Basic ResearchTechnology

Effect of Cement Type, Relining Procedure, and Length of Cementation on Pull-out Bond Strength of Fiber Posts
Vanessa Cruz Macedo, MD, DDS,* Andre Luis Faria e Silva, PhD, MD, DDS, and Luis Roberto Marcondes Martins, PhD, MD, DDS
Abstract
Introduction: As opposed to the cementation metal posts, the cementation of ber posts has several details that can signicantly inuence the success of post retention. This study evaluated the effect of the relining procedure, the cement type, and the luted length of the post on ber posts retention. Methods: One hundred eighty bovine incisors were selected to assess post retention; after endodontic treatment, the canals were ared with diamonds burs. Post holes were prepared in lengths of 5, 7.5, and 10 mm; the ber posts were relined with composite resin and luted with RelyX ARC, RelyX Unicem, or RelyX Luting 2. All cements are manufactured by 3M ESPE (St. Paul, MN). Samples were subjected to a pull-out bond strength test in a universal testing machine; the results (N) were submitted to a three-way analysis of variance and the Tukey post hoc test (a = 0.05). Results: The improvement of post retention occurred with the increase of the post length luted into the root canal; the relining procedure improved the pull-out bond strength. RelyX Unicem and RelyX ARC showed similar values of retention, both showing higher values than RelyX Luting 2. Conclusion: Post length, the relining procedure, and the cement type are all important factors for improving the retention of ber posts. (J Endod 2010;36:15431546)

Key Words
Bond strength, ber post, resin cement

ntraradicular posts are commonly used to restore endodontically treated teeth when their remaining coronal tissue can no longer provide adequate support and retention for the restoration (1, 2). For decades, endodontically treated teeth have been restored using cast metal posts; despite their high retention and thin resulting cement lm, these conventional posts have a high elastic modulus and can lead to root fractures (3, 4). On the other hand, the similar elastic modulus of ber posts, resin cements, and dentin is considered to be advantageous for improving the performance of restorations (5, 6). In contrast to rigid posts, ber posts do not need to be inserted to a length equal to or longer than the depth of the clinical crown in order to reduce the chance of root fracture (7). This is advantageous for short roots or for roots presenting a high degree of curvature. Once the ber posts are adhesively luted into the canal, a high in-depth insertion into the root canal is not necessary to improve retention (8). This is feasible because the bonding of the cement to dentin walls is more effective in the cervical region than in the apical region (9, 10). Despite the cited advantages, the mismatch between the diameters of the post space and the ber post remains a clinical problem (11, 12); prefabricated posts do not t well into elliptical-shaped canals (13) or ared canals that result from carious extension, trauma, pulpal pathosis, or iatrogenic misadventure (11). In such cases, if the post does not t well, the layer of resin cement might be excessively thick, favoring the formation of air bubbles and predisposing the post to debonding (14). One solution for this issue is to reline the ber post with resin composite (15); customizing the post increases its adaptation to the root walls and reduces the thickness of the resin cement (14). Improving the contact between the post and the canal walls may also reduce the dependence on the bonding for retention (16). It has been shown that cements with lower bonding potential but other favorable mechanical properties may be useful in luting relined ber posts (17). Therefore, the aim of this study was to evaluate the effect of ber post relining with resin composite, cement type used for luting, and post-hole length on the pull-out bond strength of ber posts luted to root canals.

Materials and Methods

From the *Department of Dental Materials and Prosthodon tics, Sao Jose dos Campos Dental School, Sao Paulo State University, Sao Jose dos Campos, SP, Brazil; Department of Dentistry, Federal University of Sergipe, Aracaju, SE, Brazil; and Department of Restorative Dentistry, Piracicaba Dental School, University of Campinas, Piracicaba, SP, Brazil. Address requests for reprints to Andre Luis Faria e Silva, Departamento de Odontologia, Campus da Saude Prof Joao Cardoso Nascimento Junior, Rua Claudio Batista S/N, Bairro Sanatorio, Aracaju/SE, Brazil 49060-100. E-mail address: andrelfsilva@hotmail.com. 0099-2399/$0 - see front matter Copyright 2010 American Association of Endodontists. doi:10.1016/j.joen.2010.04.014

One hundred eighty recently extracted bovine incisors with similar root sizes and lengths were selected for this study. The crowns were removed above the cementumenamel junction with a low-speed diamond saw in order to obtain a remaining root height of 16 mm. For the endodontic treatment, a step-back preparation technique was used; to are the coronal and middle third of the canal, a #2 Gates Glidden drill was inserted several millimeters into the canal. This was repeated with #3 and #4 drills. Apical preparation was conducted with the nal master apical le of size 40; aring of the canal was completed with ling to size 70. All enlargement procedures were followed by irrigation with 2.5% sodium hypochlorite solution. The prepared root canals were obturated with gutta-percha cones using the lateral condensation technique and Sealer-26 resin sealer (Dentsply Ind Com Ltda, Petropolis, RJ, Brazil). The specimens were stored in 100% humidity for at least 72 hours to allow for the resin sealer to set. After the storage period, the coronal gutta-percha was removed with a hot Rhein instrument at 5-, 7.5-, and 10-mm depth. In order to obtain a standardized ared canal, the canals were enlarged using #4138 and 4137 high-speed diamond burs (KG Soren sen Ind e Com LTDA, Sao Paulo, SP, Brazil) under water irrigation. Three post space depths were prepared: 5, 7.5, and 10 mm. In order to facilitate handling, the roots

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TABLE 1. Description of Cements Used in This Study and the Application Protocols Cement
RelyX ARC

Classication
Resin cement

Application protocol
The canal walls were etched with 35% phosphoric acid for 15 seconds, rinsed for 15 seconds, and gently air dried. Excess water was removed from the post space with absorbent paper points. The Scotchbond Multipurpose Plus Activator (3M ESPE, St Paul, MN) was applied into the root canal with a microbrush of compatible size and air dried for 5 seconds. Afterwards, the Scotchbond Multipurpose Plus Primer (3M ESPE) and also air dried. The dual-cured resin cement RelyX ARC was mixed and placed over the posts, which was inserted into the root canal with light pressure. The excess of luting material was removed and light activation was performed for 40 seconds. The root canal walls were rinsed with water using a syringe and then gently dried with paper points. The cement capsule was activated for 2 seconds and mixed automatically in a high-speed triturator for 10 seconds. Afterwards, the resin cement was applied into the root canals by means of Elongation Tip (3M ESPE). The post was then seated in the root canal; the excess resin was subsequently removed. The light activation was performed for 40 seconds. The root canal walls are cleaned and dried as described for RelyX Unicem. The cement was mixed for 10 s inserted into the canal with 50 K-le. The post was inserted into the canal with light pressure and stabilized during 2 min. Then, the excess material was removed.

RelyX Unicem

Self-adhesive resin cement

RelyX Luting

Resin-modied glass ionomer

were embedded in polystyrene resin blocks. Parallelism between the post and resin block was obtained using a parallel meter. The prepared root canals received either relined or nonrelined ber posts; a 1.5-mm diameter glass ber-reinforced epoxy post system (Reforpost; Angelus, Londrina, Brazil) was used. The Adper Single Bond 2 adhesive system (3M ESPE, St Paul, MN) was applied and light cured over the previously silanized post before the cementation procedure. For the relining procedure, the ber post was treated as previously described. Afterwards, the canal walls were lubricated with a hydrosoluble gel; the ber post was covered with resin composite Filtek Z250 (3M ESPE) and inserted into the canal. The resin composite was light cured for 20 seconds, the relined ber post was removed, and the resin composite was light cured again for 20 seconds. Copious rinsing removed the lubricant gel from the root canal. The cements used for cementation and the details of the luting procedures are described in Table 1. The specimens were stored in 100% humidity at 37 C for 24 hours before testing. The pull-out test was performed parallel to the long axis of both the post and the tooth at a cross-head speed of 0.5 mm/min using a universal testing machine (Model 4411; Instron Inc, High Wycombe, UK). The force required to dislodge each post was then recorded in newtons. The independent variables tested in this study were the post relining, the cement type, and the depth of luting. Statistical analysis was performed by applying a three-way analysis of variance followed by the Tukey post hoc test at a 95% condence level.

Tukey test are shown in Tables 2 and 3. Because statistical signicances were detected only for the factors observed individually, comparisons were performed only for the pooled average. Relined posts presented signicantly higher pull-out bond strengths than nonrelined posts. Regarding the depth of post cementation, posts that were luted at a 10-mm depth presented the highest values followed by those luted at a 7.5-mm depth. RelyX ARC and RelyX Unicem showed similar results for retention, both showing signicantly higher bond strengths compared with RelyX Luting 2.

Discussion
When restoring root-lled teeth, clinicians are opting for materials that have an elastic modulus similar to that of dentin, that are capable of creating homogenous stress distribution, and that are able to decrease the incidence of catastrophic root fractures (18, 19). Fiber posts have elastic moduli similar to that of dentin and have the ability to bond to this substrate by the use of adhesive cements. Thus, it has been shown that it is not necessary to increase the depth of ber post cementation in order to improve fracture resistance (7). However, the results of the current study show that, irrespective of the type of cement used, increasing the depth of cementation is benecial to improve the post retention. Several studies have shown that the bond strength of resin cements to root canals is effective in the cervical third but weak in the apical third (11, 2022). Thus, it is reasonable to assume that the bond to the cervical third of the root canal could be enough to promote proper post retention. Regardless of the low bond strength in the apical regions, the frictional retention in these areas contributes to the dislocation resistance of the ber post (23, 24). Frictional retention is directly proportional to the contact area (the larger the contact surfaces, the better the retention). This explains the results of this

Results
Analysis of variance revealed statistically signicant differences for all factors (p < 0.01); however, there was no signicant effect for any interaction between the factors (p > 0.05). Comparisons using the

TABLE 2. Bond Strength Means (Standard Deviations) for All Cements and Post Types (N) Cements Post type
Non-relined post Relined post Pooled average

RelyX ARC
245.1 (74.5) 336.7 (91.6) 290.9 (94.8) A

RelyX Unicem
208.4 (83.8) 362.4 (87.8) 285.4 (115.2) A

RelyX Luting 2
101.7 (57.0) 147.1 (71.0) 124.4 (67.8) B

Pooled average
185.1 (94.3) B 282.1 (127.3) A

For the pooled averages, means followed by distinct letters are signicantly different (Tukey test, 95% condence level).

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TABLE 3. Bond Strength Means (Standard Deviations) for All Post Lengths and Post Types (N) Post length Post type
Non-relined post Relined post Pooled average

Cement
RelyX ARC RelyX Unicem RelyX Luting RelyX ARC RelyX Unicem RelyX Luting

5 mm
199.9 (72.3) 146.6 (46.5) 44.1 (10.8) 318.3 (67.6) 304.8 (57.9) 78.0 (23.9) 181.9 (116.1) C

7.5 mm
254.4 (65.1) 213.2 (91.0) 110.3 (34.3) 300.3 (36.4) 387.5 (84.1) 173.5 (48.0) 239.9 (108.6) B

10 mm
281.1 (67.8) 265.8 (65.0) 150.8 (52.2) 391.5 (126.4) 394.9 (94.1) 189.8 (72.4) 279.0 (122.2) A

Overall for cement by post type

245.1 (74.5) A 208.4 (83.8) A 101.7 (57.0) B 336.7 (91.6) A 362.4 (87.8) A 147.1 (71.0) B

Pooled average
185.1 (94.3) B 282.1 (127.3) A

For the pooled averages, means followed by distinct letters are signicantly different (Tukey test, 95% condence level).

study; ber posts luted deeper provided the highest pull-out bond strengths. In addition to the contact area, closer contact between cement type and dentin is also important in order to improve the frictional retention of the post. In this study, the relining procedure increased the post retention to the root canal. A higher post-to-root canal adaptation increases the sustained pressure during cementation (16). The application of sustained pressure results in better contact between the cement/post assembly and the dentin (25). This results in higher frictional retention compared with nonrelined posts and consequently in increased pull-out bond strengths. Furthermore, a higher sustained pressure during cementation reduces blister formation in the cement (25); blisters can act as aw-initiating sites during pull-out testing, interfering with the bond strength. Based on these results, it seems that the relining procedure increases the ber post retention by improving the contact between the cement and the adhesive rather than by reducing the defects observed in thin cement layers. Regarding the cement, the RelyX Luting 2 presented the lowest values of pull-out bond strength. This is a resin-modied glass ionomer, exhibiting lower bond strengths than other evaluated cements (26). The low bond strength is probably related to the application over the smear layer because no acid solution is applied before cementation. Thus, the retention provided by RelyX Luting 2 is more dependent on frictional retention than on its bonding to dentin. Because the mechanical properties of this cement are poorer compared with the resin cements, it is expected that this cement will have the lowest retention (27). Conversely, RelyX Unicem is a self-adhesive resin cement and interacts very supercially with the substrate, resulting in poor bond strength (28). However, it appears that RelyX Unicem has good chemical interaction with the calcium in hydroxyapatite, improving their mechanical properties (29). Furthermore, self-adhesive resin cements appear to have low shrinkage because of their viscoelastic properties, leading to better intimate contact of the resin cement with the root canal walls and higher frictional resistance (30). RelyX ARC is a conventional dual-cured resin cement that generates higher bond strength to dentin than the other cements evaluated (27). However, its high polymerization shrinkage and the resulting stress could impair the bonding to the root dentin (31). This increases the dependency on mechanical properties of cement for improving the post retention. Despite being a dual-cured material, deeper portions of cement are inaccessible to light, rendering the material dependent on the chemical curing. This can reduce the degree of conversion of the cement and consequently affect its mechanical properties. However, the use of a primer that is activated before insertion of the cement may improve the conversion. The primer contains sodium and sulnic acid salts that react with the primers acidic resin monomers to produce free radicals that would enhance the polymerization reaction of the cement (32, 33). Thus, the approach indicated by the manufacturer

of RelyX ARC improves both the mechanical properties of the cement and post retention. Although ber post retention seems to be derived predominantly from frictional retention, the luted length of the post is just as important to improve their retention. Relining the ber post reduces the thickness of the cement layer and also improves the frictional retention. The reduction of resin thickness may also reduce the polymerization stress because the stress development increases associated with increased volume of the resin cement (34). In conclusion, the use of cement with proper mechanical properties is essential for adequate post retention.

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