Intermittent Loading of Teeth Restored

Using Quartz Fiber, Carbon-Quartz Fiber,

and Zirconium Dioxide Ceramic Root
Canai Posts
Francesco MannocciVMarco Ferraris/Timothy F. Watson^

Purpose: The purpose ofthe investigation was to compare the performances of teeth restored with quartz
fiber, carbon-quartz fiber, and zirconium-dioxide posts covered with all-ceramic crowns when subjected to
a cyclic ioading test performed in a wet environment.
Materlais and Methods: Forty single-rooted human lower premoiars having similar dimensions were endodonticaliy treated and mounted in acrylic resin blocks with a simuiated pericdontal iigament. The teeth
were divided into three experimental groups ahd one controi group. Post holes 8 mm Icng were prepared
in the roots of the exprimentai groups in which quartz fiber, carbon-quartz fiber, and zirconium dioxide
posts were cemented. In the controi group, no posts were used. The crown buildup was made with composite resin. The teeth were covered with ali-ceramic crowns and intermittently loaded at an angie of 45
degrees to the long axis of the tooth at a frequency of two loads per second.
Results; Only one faiiure (root fracture + post fracture) was observed in each of the fiber post groups,
while in the zirconium dioxide post group, six failures were otjserved (one crown fracture and 5 root fractures + post fractures]. The Kaplan-Meier analysis of the three experimental groups showed that the survival rate of zirconium dioxide posts was significantly lower than that of both types of fiber post, Aii the
exprimentai groups showed a survival rate higher than that of the control group.
Conclusion; Fiber posts reduced to a minimum the risk of root fractures of teeth restored with composite
cores and Empress crowns under the present exprimentai conditions (intermittent ioading in a wet environment],
J Adhesive Dent 1999:2:153-158

SubmitteO for puOlication: 06.10.98: accepted for publication:

ost systems are used to restore endodonticaliy

treated teeth n many different clinical situations.3'19 Clinical retrospective studies have siiown
tiiat posts cannot strengthen teeth and that post-

' Cfm(Ml Professor, Department of EndoOontics. University of Siena.

Itaiy, also affiliated with the Researc/t Center or Dentistry, Livorno.
Italy.
' Professor, University of Siena, italy, ano Associate Clinicai
Professor, Tufts University. Boston MA: also afTtiiated mth the Research
Center for Dentistry, Livorno, Itaiy.
'

Senior Lecturer, Consultant, Guy's + St Thomas' Dental School of

King's Coiiege. London Bridge. SEI 9RT. London. UK.

Reprint requests: Dr Francesco Mannocci. MD. DDS. Research Center for Dentistry, Piazza Attias 19. Livorno, italy 57120.
Tel; 1^390-586-892283, Fax; +390-586-898305

V e i l , Nn

12.11.98

core restorations may result in root fractures or perforations, post fractures, and post dislodgement,^
Therefore, ideal posts shouid impart minimal stress
to the tooth, provide adequate retention to the core,
and be easiiy removable to permit endodontic retreatment.
Carbon fiber posts (Composiposts, RTD, St Egreve,
France] were introduced on the market in order to
fulfill these requirements,i^ These posts are fabricated from continuous, unidirectional carbon fibers
approximately 8 pm in diameter, embedded in an
epoxy resin matrix. The fiexurai moduius of carbon
fiber posts was found to be similar to that of metai
posts in two different studiesi'^^i in which threepoint bending tests were performed. In these studies, the load was applied with a direction of 90

153

Mannocci et al

manufacturers have explored the potential of developing metal-free all-ceramic restorations.ii''.i6 Allceramic crowns provide superior esthetic results
compared to conventional porcelain-fused-to-metal
restorations. Unfortunately, the esthetic results of
all-ceramic restorations are influenced by several
factors, such as post-core materials and luting cement color and shade.^ Light transmission is impeded by metallic posts; therefore, they may not be
indicated for the crown buildup of endodohtically
treated teeth in need of an all-ceramic restoration.
These teeth are often built up with white posts
made of zirconium dioxide partially stabilized by the
addition of yttrium oxide. The use of these white
posts Is intended to allow light transmission
through the post structure.

Fig 1 A carbon fiber post {center), a carbon-quartz fiber

(right), and a quartz tiber post (ieft).

degrees to the long axis of the tooth. The elastic

modulus of carbon fiber posts was reported to be
close to that of root dentin when the load was applied at ca. 35 degrees to the long axis of the tooth,
thus reducing the risk of root fractures.^^ A recent
cyclic loading test of post-core restorations in
bovine teeth covered with metal crowns showed
that carbon fiber post-composite core restorations
were less likely to cause root fractures than stainless steel post-composite core systems.^^ The retreatment of teeth built up with fiber posts is simple
because the fiber post structure can be easily destroyed with any low- or high-speed bur.
The clihical performances of carbon fiber posts
were found promising In a recent retrospective 2- to
3-year recall study, in which no root or post fractures were observed.^^
Because of the Increasing demand from patients
ahd clinicians for esthetic replications of the natural dentition, researchers and dental materials
154

A potential disadvantage of carbon fiber posts is

that their black color might show through when allceramic crowns are employed, especially in anterior
teeth. For this reason, white fiber posts (AesthetiPlus, RTD) ("quartz fiber" posts, according to the
manufacturer) and quartzflber-coated carbon fiber
posts (Aestheti-Post, RTD) with a design very similar
to that of carbon fiber posts (Fig 1) were recently introduced on the market. The epoxy resin matrix is
the same for both the new fiber and carbon fiber
posts.
After luting the all-ceramic restoration, the crown
and the post transmit occlusal loading to the root;
in this manner, the fracture resistance of the root
might be related to the type of post used.
The aim of the present investigation was to compare the fracture resistance of teeth restored using
quartz fiber, carbon-quartz fiber, and zirconium dioxide posts covered with ail-oeramic crowns when
subjected to cyclic loading in a wet ehvironment.

MATERIALS AND METHODS

Forty extracted single-rooted human lower premolars were selected for this study. The teeth were
kept moist with saline solution during all procedures.
The roots were divided into four groups of teh
teeth each. The crowns of the teeth were cut off
with a carbide bur mounted on a turbine handpiece,
so that the length ofthe roots was 14 mm.
The root canals were prepared chemomechahically and filled by lateral condensation of gutta-percha and an epoxy-resin-based root canal sealer (AH
26, De Trey, Konstanz, Germany). Using Largo drills
The Journal of Adhesive Dentistry

Mailiefer, Baillagues, Switzerland), 8 mm of the

gutta percha fjIMng was removed. The curvature of
the canals was examined with S c h n e i d e r ' s
method^^: all the roots included in the experiment
showed a oanal curvature cf less than 10 degrees
in the coronal 10 mm. After the root canal preparation, the buccolingual and mesicdistal diameters of
the teeth were measured. The measurements for
each tooth were multiplied together to give an approximate value for the root size. Teeth were ranked
according to size and placed into groups using a
stratified sampling method. In this way, the three
experimental groups and the control group included
teeth of approximateiy the same size.
In all groups, the root canal walls were enlarged
with the low-speed burs provided by the manufacturer; the depth of the post hole preparation was 8
mm. The root canal walis were etched with 38%
phosphoric acid (Bisco, Itasca IL, USA) for 30 seconds, rinsed with water spray and then gently air
dried. Aii Bond 2 Primer A and B (Bisco) were mixed
and applied into the canais.
All Bond 2 Pre-Bond resin was appiied into the
canal, then C&B cement (Bisco) base and cataiyst
were mixed according to manufacturer's instructions. The cement was appiied to the surface of # 1
quartz fiber posts (Aestheti Plus, RTD, lot 2SQ
9710A) (group 1) and # 1 carbon-quartz fiber posts
(Aestheti Post RTD, lot 2SH9710A) (group 2). The
fiber posts employed are shown in Fig 1. The posts
were inserted into the canai. The cement was allowed to set and crown buiidup was performed with
Bis Core self-poiymerizing composite resin (Bisco).
In group 3. zirconium dioxide posts (# 232L12, 090
Cerapost, Gebr Brasseler, Lemgo, Germany, Lot
197194) were used. Foiiowing manufacturer's instructions, the posts of this group were cleaned
with alcohoi, etched for 3 minutes with 8% hydrofluoric acid, silanJzed for 4 minutes with Monobond
S {Vivadent, Schaan, Lichtenstein), and gentiy air
dried. The posts were then cemented and the
crown buiidup performed using the same techniques described for the previous two groups.
In group 4, the controls, no-post hoie preparation
was performed. Oniy 3 mm of the coronal part of the
gutta-percha root canai filling were removed using a
size 3 Largo drill, and the crown buildup was performed as described for the previous groups. After
etching, priming, and application of the adhesive,
the coronal part of the canal was filled with Bis
Core composite resin (Bisco). The core buiidup was
completed with the same composite resin.

Vol 1, No 2 , 1 9 9 9

Twenty-four hours after the crown buildup, the

teeth were prepared for a crown. The finishing line
used was a 90-degree shoulder. The height of the
preparations was 5 mm; the width ofthe shouider
was 1.5 mm. The impressions were taken with Permadyne (ESPE, Seefeld, Germany).
Empress crowns (Ivoclar, Schaan, Liechtenstein )
were prepared by the same technician.
The surfaces of the preparations were etched
with a semi-gel of 32% phosphoric acid (Bisco) for
20 seconds, rinsed, and gently dried with compressed air. The Empress crowns were etched for 2
minutes with an 8% hydrofluoric acid gel (Bisco);
siiane was then appiied to the Empress crowns for
4 minutes and gentiy air dried. The crowns were
then cemented with Ail Bond 2 dentai adhesive
(Bisco) and C&B cement (Bisco) according to manufacturer's instructions. The cement was allowed to
set, and then the crowns were kept in water for 4
weeks. The exprimentai modei used was that described by Isidor^^ with some modifications: a smaii
bail of composite (ZIOO, 3M, St Paul, MN, USA)
was piaced on the root tip and a thin layer of silicone was appiied aiong the root surface to simulate
a periodontai ligament.
The roots were mounted in acryiic resin biocks,
with 6 mm of tooth extending beyond them. The
specimens were then ioaded intermittently at a frequency of 2 cycles per second, with a peak load of
250 N. The load was appiied by a custom-made machine to the buccal surface of the premolars (45
degrees to the long axis of the tooth). Loading was
automatically discontinued upon indication that the
restorative system had faiied. Root fractures, ceramic crown fractures, post fractures, and post and
crown deoementation were considered causes of
faiiure.
The location of post-root fracture (above or below
the resin block margin) was also evaiuated. The machine was stopped after 400,000 impacts if no failure had occurred. During the loading procedure, the
teeth were submerged in water.
The survivai rates of the three groups were statistically compared with a Kapian-lVleier analysis.

RESULTS
The resuits obtained are shown in Table 1. All the
root fractures observed both in the experimental
groups and in the control group were located above
the resin block margin. Only one failure (root frac-

155

Mannocci tal

Table 1 Post failures and faiiure modes of the various groups

Root fracture +
pest
decementation

root fracture * rcct fracture

pest fracture

Quartz fiber posts

n = 10 (group 1)

1
226780 loads

Carbcn-quartz
fiber posts
n = 10 (grcup 2)

1
157111 loads

Zirconium dioxide
n = 10 (gnDup 3)

5
25 leads
28341 loads
152156 loads
252000 leads
257833 leads

No-post grcup (ccntrol)

n = 10 (group 4)

ture + post fracture] was observed in each of the

fiber post groups, while in the zirconium dioxide
post group, six failures were observed; one crown
fracture and 5 root fractures + post fractures. All
the teeth included in the control group faiied because of root fractures. The survival rate of the
teeth of the control group was found to be significantiy iower than that of the experimental groups
(P < 0.05), No statistically significant difference (P >
0.05) was found between the Kapian-Meier curves
for groups 1 and 2, neither was any difference
found between the different types of failures of the
two groups.
Both quartz fiber and carbon-quartz fiber posts
had statistically significantly (P < 0,05) higher survival rates than zirconium dioxide posts group 3),
The comparison of the survivai curves of the experimental groups and ofthe control groups is shown in
Fig 2,

156

crown fracture

1
169852 loads

10
11453 leads
12342 loads
12345 loads
12568 loads
13452 loads
23421 loads
23567 loads
25300 loads
29546 loads
337S9 loads

DISCUSSION
The resuits of the present investigation show that
quartz fiber and carbon-quartz fiber posts were
able to reduce to a minimum the risk of root fractures of teeth restored with composite cores and
Empress crowns under these experimental conditions (cyclic ioading in a wet environment). Aii the
root fractures observed were located above the
resin biocks, in the experimental model used, the
resin block simulated the level o f t h e gingival margin. The locations of the fractures were thus considered favorable because, in a ciinicai situation, they
would have simpiified the re-preparation of the
tooth.
The load applied (250 N) exceeded normal biting
forces. It was used in order to allow a comparison
with a previous study^^ n which carbon fiber posts
were tested with cyclic loading.
The Journal of Adhesive Dentistry

Rg 2 Kaplan-Meier curves of the experimental groups and of the controi

group: 1-quartz fiber posts, 2-carbon quartz fiber posts. 3-zirconium dioxide posts, 4-no-post group controi).

Findings by Dietschi et ai^ may heip expiain the

results of the present investigation. Those authors
found poor adaptation of experimental zirconium
oxide posts (Ceremetric, prototype, Dentsply-Maiiiefer)tothe root canal wails after cyclic loading, while
good adaptation of carbon fiber posts was found.
The difference between the elastic modulus of
zirconium dioxide and dentin might expiain the
higher fracture rate observed in the zirconium dioxide post group. Carbon fiber compounds have
been found to be biocompatible and mechanically
satisfactory in many dentai and surgicai applicatiOnS.2.4, 6,7.8

Unfortunately, an aqueous environment might induce corrosion effects in the surface of the fibers
resuiting from water diffusing through the poiymer
matrix. In a recent study, a wet storage period of 4
months and wet thermocyciing produced a significant reduction ofthe flexural strength values of carbon fiber posts.21 The same fiexural strength test
was performed comparing carbon fiber posts in
bovine teeth submerged in water for 4 months with
carbon fiber posts stored under dry conditions: no
significant difference of the flexural strength values
was reported,^5 It can be speculated that, when a
post is cemented into the root canai and covered
with dental adhesive, the composite cement, the
composite core, and the ceramic crown, iittle or no
contact of the post with tissue fluids can occur,
thus eliminating the risk of weakening the epoxy
resin matrix.

Vol 1, No 2,1999

The mechanical behavior of the quartz fiber and

quartz-carbon fiber posts was found to be similar to
that of carbon fiber posts in a recent investigation.^^
The no-post control group exhibited more fractures than the experimental groups, thus proving
the need for a radicular support for the core materials when the entire coronal structure of endodontically treated teeth has been lost.
The esthetic advantage of white posts should be
evident when ali-ceramic crowns are employed, but
recent spectophotometrical studies have ciearly
shown that when the thickness of the ceramic
crowns is adequate to resist chewing forces, carbon
fiber posts are not detectabie.^^ However, the use
of tooth-colored materiais for post construction
might be useful when buildups of endodonticaliy
treated anterior teeth are performed with composite resins without crown coverage.
Regrettably, no prospective clinical studies regarding post and core behavior have as yet been rep o r t e d , and caution must be exercised when
extrapoiating clinicai recommendations from a work
of a pureiy in vitro nature. iHowever, since the results of the in vitro studies are promising, controiied ciinicai studies comparing these new fiber
posts to metal ones are indicated.

157

Mannocci tal
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The Journal of Adhesive Dentistry