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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 15  |  Issue : 1  |  Page : 52-59

Rehabilitation of compromised permanent incisors with anatomically adjustable fiber post


Department of Pedodontics, Faculty of Dentistry, Kafr El-Sheikh University, Kafr El-Sheikh, Egypt

Date of Submission05-Dec-2017
Date of Acceptance28-Feb-2018
Date of Web Publication4-Apr-2018

Correspondence Address:
Talat M Beltagy
Department of Pedodontics, Faculty of Dentistry, Kafr El-Sheikh University, Kafr El-Sheikh
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tdj.tdj_55_17

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  Abstract 

Purpose
To evaluate clinically and radiographically the rehabilitated compromised upper permanent central incisors with the everStick post.
Patients and methods
Thirty-six children patients aged from 10 to 16 years were divided into three equal groups (12 patients each). Group I, flared root canals of the patients were rehabilitated with the everStick post. Group II, flared root canals were rehabilitated with EasyPost/composite, and group III (control), unflared root canals were rehabilitated with EasyPost/core. The clinical parameters included the reinforced tooth, mucosa, temporary crown, and reinforcing system. The radiographical parameters were the periapical status, periodontal ligament condition, root fracture or resorption, and changes at the interfaces of the reinforcing system. All patients were followed up clinically and radiographically at 3, 6, 12 and 18 months.
Results
Both everStick and control group showed 100% clinical success, while EasyPost/composite group showed debonding of the reinforcing system in one patient with a clinical success rate of 91.7%, and the difference was not statistically significant (P > 0.05). Radiographic assessment showed no evidence of root fracture or external root resorption and no periodontal or periapical pathology that require crown removal for clinical interference. The radiographic findings showed 100% success rate for all studied groups.
Conclusion
The use of direct anatomical everStick posts in the rehabilitation of flared canals functioned well for 18 months with favorable clinical, radiographical, and aesthetic results.

Keywords: anatomically adjustable fiber post, compromised permanent incisors, root canal reinforcement


How to cite this article:
Beltagy TM. Rehabilitation of compromised permanent incisors with anatomically adjustable fiber post. Tanta Dent J 2018;15:52-9

How to cite this URL:
Beltagy TM. Rehabilitation of compromised permanent incisors with anatomically adjustable fiber post. Tanta Dent J [serial online] 2018 [cited 2018 Oct 18];15:52-9. Available from: http://www.tmj.eg.net/text.asp?2018/15/1/52/229248


  Introduction Top


The esthetic and functional rehabilitation of structurally compromised teeth presents a unique challenge to the restorative dentists. The compromised tooth may arise from carious extension, trauma to young permanent teeth, developmental anomalies, internal resorption, inappropriate root canal preparation, endodontic retreatment, and iatrogenic cause [1],[2],[3]. The compromised teeth with thin-walled roots are weak to withstand normal biting forces and so susceptible to fractures, which complicate the restorative procedure [4].

The traditional placement of retentive pins in a compromised tooth is impossible due to lack of dentinal support at the coronal portion of the root. For decades, the cast posts were used for the management of such teeth, but they compromised the aesthetics 'shine throughphenomena', demonstrated a high risk of root fractures due to the marked difference in modulus of elasticity between metal post and dentin, and the coronal wedging forces at the already weakened root [5],[6].

Endodontically-treated teeth with less than 2 mm thickness of dentin should be ideally rehabilitated before post placement. Several researchers showed that the use of dentin bonding agents, glass ionomer and composites can strengthen the tooth and produce leak-free restorations [2],[7],[8].

The fiber posts have a superior alternative to the metal posts due to their favorable biomechanical properties with less stress concentration and good optical properties [9],[10]. However, it is difficult to place a single fiber post closely fitted in the flared canal, so the cement thickness increases that affect its physicochemical properties [11]. Furthermore, the bonding strength, core stabilization, and the retention are affected [12] which may compromise the long-term prognosis. Therefore, the direct anatomic post is used as an alternative approach in restoring the flared canal to overcome these disadvantages. In this technique, the fiber posts may be relined with composite resin that reproduces the morphology of root canals, reduces the cement thickness, increases the retention and prevents the adhesive failure [13],[14].

The everStick Post (GC Europe NV, Finland) is introduced to avoid the large root preparation. It is a soft, flexible, minimally invasive and resin-impregnated unpolymerized fiber post with unique interpenetrating polymer network. The post can be individually precision-shaped and cured in-situ to an atypical anatomic shape of any root canal and to maximize the adhesive surface before light-activation while offering high micromechanical bonding and flexural strength after polymerization [15],[16],[17].

EverStick post allows equal distribution of occlusal stresses along the root surface and has an elastic modulus nearly similar to the dentin, thus minimizing the risk of the root fracture [18]. Furthermore, the everStick post does not result in metal corrosion or allergic reactions and can be easily removed from a root canal in case of endodontic failures [19],[20].

To date, there is still no consensus on the best material and technique for management of structurally compromised teeth with flared canals [21]. Therefore, this study aimed to evaluate in-vivo the rehabilitatation of compromised upper permanent central incisors using everStick post in children.


  Patients and Methods Top


Patient selection

Thirty-six patients in this controlled clinical trial aged from 10 to 16 years (mean age 12.83 + 2 years) were selected from Out-patient Clinic of Pedodontic Department, Faculty of Dentistry, Tanta University. Twenty-four patients had structurally compromised upper central incisors with nearly similar degrees of flaring) measured from radiographs) that exceed the size of #130 file and indicated for rehabilitation. Twelve patients had upper central incisors with normal canal indicated for endodontic treatment with fiber post/core restoration. All children patients were free from any systemic diseases, or any parafunctional activities.

The protocol of the present study has been approved by the Ethical Committee of the Faculty of Dentistry, Tanta University, and a written consent was obtained from the children's parents who were thoroughly informed of the objective, procedures of the research and publishing its results. Child's ascent was also taken.

Apical obturation of the flared root canal

A preoperative radiograph was taken for each patient and isolation was achieved using cotton rolls. Caries, debris, necrotic tissues and soft dentin were removed by #130 K-files and Dentatus Classic Reamers (Dentatus, USA) The root canal was irrigated alternatively with 0.9% saline and 2.5% sodium hypochlorite solution (NaOCl) and then was dried. Eugenol-free root canal sealer (AH26; Dentsply, Switzerland) was used with gutta-percha for root canal obturation and a postoperative periapical radiograph was taken to check the obturation accuracy.

Root canal preparation for the post

Gutta-percha filling was removed with heated instruments and gates glidden drills leaving a minimum of 3–5 mm apical seal. Intermittent rinsing was performed by 2.5% NaOCl and dried carefully with large paper points. For accurate determination of the desired post length, the depth of the prepared canal and the height of the coronal structure were measured using an endodontic instrument.

According to the degrees and causes of flaring, and the rehabilitating system used, the children patients were divided into two groups (12 patients each):

  1. Group I: the flared canals of the patients were rehabilitated with the everStick posts
  2. Group II: the flared canals of the patients were rehabilitated with fiber posts (EasyPost, Dentsply, Maillefer, Switzerland) and nanofilled composite resin, (Filtek Z350 XT, 3M ESPE, USA) while the control group (group III) contained 12 patients who their unflared root canals were indicated for endodontic therapy with EasyPost/core reinforcement.


Group I (everStick group)

Each everStick post 1.5 mm diameter (LOT: 1410081) was adjusted 2 mm short of estimated crown height, trial fitted, shaped, laterally adapted in the canal using endodontic plugger, and initially light-cured for 20 s. If the post does not reach the full depth, the end of the post was tapered with a sharp scissor. The post was then removed from the canal and again thoroughly light-cured on all sides for 40 s. The desired length of the post was confirmed by a periapical radiograph.

Additional everStick posts were bonded with a thin film of light-cure enamel bonding agent Stick Resin (GC Europe NV) closely adapted to the main post, and then light-cured for 10 s. The posts were removed from the canal and protected from the light before cementation. The surface of the posts was activated thoroughly using stick resin.

After etching the canal with 37% phosphoric acid gel and bonding it with Adper Single Bond Plus (3M ESPE, USA) the dual-cured resin cement (RelyX, 3M ESPE; Unicem, USA) was dispensed into the canal space following the manufacturer's instruction. The post was slowly inserted into the canal space with locking tweezer; the excess cement was removed and light-activated for 40 s.

Filtek Z350 XT was used to build the core build-up of the coronal structure of the rehabilitated tooth [Figure 1] and [Figure 2].
Figure 1: A 15-years girl showed compromised right maxillary central incisor indicated for intra-radicular rehabilitation with the everStick post- Extensive coronal destruction at the right maxillary central incisor caused by carious extension into old traumatized teeth (a). Trial fit of a pre-cut everStick post (b). Additional posts were closely adapted and bonded together (c). EverStick posts before and after cementation (d, e). Coronal reduction of the rehabilitated tooth to receive a temporary crown (f). The completed case (g).

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Figure 2: A 10-years boy showed traumatized left maxillary central incisor indicated for intra-radicular rehabilitation using everStick post (a). EverStick posts were closely fitted intra-radicular (b). The posts form atypical anatomic shape of the root canal (c). Core building-up from the composite resin (d). Coronal reduction for temporary crown restoration (e). Final restoration (f).

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Group II (EasyPost/composite group)

The etching and adhesive application to the root dentinal surfaces were carried out in a similar process as mentioned in group I. The root canal space was filled with Filtek Z350 XT composite using a delivery tip placed in Compule Tips Gun.

A vasolenized Luminex smooth light-transmitting plastic post #6 (Luminex, Dentatus, Weissman Technology) was then centrally seated within the filled root canal up to its full depth and the excess composite was removed by plastic instrument.

The composite was then light-cured for 40 s, and thereafter, the Luminex post was removed from the canal leaving a rehabilitated root with an internal post space.

The post space was reamed-out and refined using the same size of Dentatus Classic Reamer #6 and then the canal was etched, rinsed off and dried.

A prefabricated EasyPost #4 (Dentsply, Maillefer, Switzerland) was prepared, cut to the desired length and cemented by RelyX Unicem according to manufacturer's instruction.

After the complete set of the post, the polyester crown forms were used to complete the core building-up from Filtek Z350 XT [Figure 3].
Figure 3: Permanent central incisor (a&b). Intraradicular injection of composite resin using a delivery tip placed in Compule Tips Gun (c). Intraradicular polymerization using a Lumenix post (d). A matching internal post space after polymerization and removal of the Lumenix post (e). Trial insertion of EasyPost before cementation (f). Composite core building-up (g). Coronal reduction for temporary crown restoration (h). Final restoration with the temporary acrylic jacket crown (i).

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Group III (normal canal/Easy post): (control group)

Children patients had upper central incisors with unflared normal canals that indicated for root canal therapy with post/core reinforcement were selected. After conventional endodontic therapy and maintained a 3–5 mm gutta-percha apical seal, Dentatus Classic Reamers were used for root canal shaping to receive EasyPost #4. The etching, adhesive application, post cementation, and core building-up were carried out in a similar process as mentioned in the previous groups.

The coronal structures of all treated teeth were prepared to receive temporary acrylic jacket crowns and cemented with adhesor carbofine (SpofaDental, Czech Republic).

The patients and/or the parents were directed to maintain the presence of the temporary restoration till the age of 18 years.

A postoperative periapical radiograph was taken for the completed case and considered as a baseline for follow-up [Figure 4].
Figure 4: A 13-years boy showed trauma to maxillary central incisors and the right central incisor indicated for Post/core reinforcement (control group) (a). EasyPost after cementation at the right central incisor (b). Core building-up from the composite resin (c). Coronal reduction for temporary crown restoration (d). The case after final restoration (e).

Click here to view


The clinical parameters included the evaluation of the rehabilitated tooth for mobility and fracture; mucosa for inflammation, swelling, and fistula or sinus tract. The temporary crown for color stability, fracture, and displacement. The fiber post and rehabilitating material were evaluated for the fracture or displacement.

The radiographic assessment parameters included the periapical status, periodontal ligament condition, root fracture, root resorption, and any changes from the baseline at the interfaces between the reinforcing material-cement-post and dentin were evaluated [22].

Follow-up

All patients were directed to maintain good oral hygiene and were followed up clinically and radiographically at 3, 6, 12 and 18 months postoperative. The rate of success was assessed by the clinical and radiographic evaluation.

The outcome was considered successful if the rehabilitating systems were in-situ with no detachment or displacement, no core, post fracture, vertical/horizontal root fracture, no external root resorption or periodontal/periapical pathology requiring crown removal for clinical interference [23],[24].

All collected data were organized, tabulated and statistically analyzed using SPSS, version 19 (IBM, Illinois, Chicago, USA). For each variable, the number and percentage were calculated, and differences between groups were tested using Kruskal–Wallis test. The level of significance was adopted at P value of less than 0.05.


  Results Top


Clinical evaluation

The rate of success was 100% for all groups at 3, 6 and 12 months of recall time, while at 18 months recall, the rate of success was 100, 91.7 and 100% for everStick, EasyPost/composite, and EasyPost/normal canal (control group), respectively.

There were no baseline changes in any of clinical parameters in all groups at 3 and 6 months of study period, while at 18 months recall; EasyPost/composite group showed debonding of the reinforcing system in one case (8.3%) [Figure 5], and the difference was not significant among them (P > 0.05).
Figure 5: Debonding the rehabilitating system in a case of EasyPost/composite group.

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The temporary crowns showed color changes in two (16.7%) cases for each group; one case was at 12 and the other at 18 months.

No crown dislodgement was observed in all groups during the study period, only one case of EasyPost/composite group showed crown fracture at 12 months of recall time.

The mucosa showed the absence of swelling, abscess, fistula or sinus formation, however, at 18-month follow-up, mild gingivitis was reported in two (16.7%) cases for each group. The results of clinical assessment during the recall time are shown in [Table 1].
Table 1: Clinical results of the study groups at recall time intervals 12 and 18 months

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Comparison between the study groups showed no significant differences statistically in all variables with P value of more than 0.05.

Radiographical evaluation

The radiographic assessment in this study revealed favorable radiographic success of 100% for all groups during patients recall [Figure 6], [Figure 7],[Figure 8], [Figure 9]. The results showed no periapical changes from the baseline during the evaluation period for all groups that also presented with healthy periodontal conditions. Additionally, failures such as root fracture or external root resorption were not recorded. The defects in reinforcing system adaptation like closed pores, lacunae or tracks were not observed within the bulk of the reinforcing material or between the interfaces of the reinforcing system and the intra-radicular dentin.
Figure 6: Preoperative periapical radiograph showed traumatized upper right central incisor indicated for intra-radicular rehabilitation (a). Gutta-percha 5 mm apical seal (b). The tooth rehabilitated with the everStick post (c). Coronal reduction (d). The completed case after the temporary acrylic crown cementation (e).

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Figure 7: Preoperative radiograph showed traumatized right central incisor indicated for rehabilitation with EasyPost/composite (a). The remaining 5 mm apical seal (b). The rehabilitated tooth after removal of a Luminex post (c). The tooth after rehabilitation (d). Coronal reduction (e). The rehabilitated tooth after temporary crown cementation (f).

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Figure 8: Preoperative radiograph of upper central incisors showed old gutta perch filling that indicated for rehabilitation (a). The remaining 5 mm apical seal (b). The lift central rehabilitated with everStick post and right central rehabilitated with the composite and before EasyPost cementation (c). Coronal reduction of both reinforced central incisors (d). The completed case after crown cementation (e).

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Figure 9: Preoperative radiograph showed traumatized right central incisor indicated for rehabilitation with EasyPost (control group) with remaining 5 mm apical seal (a). The tooth after rehabilitation with EasyPost (b). Coronal reduction (c). The completed case after crown cementation (d).

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  Discussion Top


Failures in root canal therapy in teeth with flared canals are commonly due to failures in the reinforcing system rather than the endodontic therapy itself. Recently, several types of cosmetic posts used in the management of compromised teeth are available with different materials, shape, mechanical and esthetic properties. All glass fiber posts, composite reinforced fiber posts, and ceramic posts are among the available post types [25]. Fiber posts are preferred due to their modulus of elasticity closely matching to that of dentin and facilitate the dissipation of occlusal stresses all over the roots, thus, minimizing the incidence of root fractures, which were often unrepairable [26].

However, the use of a single fiber post in the reinforcement of flared canal required a great amount of luting cement to fill up space between the dentinal wall and the loosely fitting post, leading to post debonding and adhesive failure [9]. Furthermore, the attempt to reduce the intra-canal space in cases of deep radicular defects; is sometimes difficult to use reinforcing materials with trans-illuminating posts to provide adequate polymerization that affects the properties of reinforcing materials [27]. Another potential problem is the possibility of polymerization shrinkage of the composite towards the plastic posts leaving a gap at the dentine/composite interface [28], centralization of the post within the overflared canal is sometimes difficult, and moreover the liability of microbubbles, voids, lacunae and tracks entrapments within the bulk of the reinforcing material or between the reinforcing system and the intra-radicular dentin [29],[30].

Recent protocol suggests that in spite of the use of accessory posts to reduce the space between the canal and fiber post, the cement did not significantly reduced at the contrary to expectations and still remain empty spaces between the post and the canal wall, thus the incidence of air inclusions in the cement is high that compromising the adhesive effect of the technique [31],[32]. Therefore, this study was conducted to use the direct morphologically adapted fiber reinforced everStick post in the rehabilitation of compromised upper permanent central incisors in children.

In this study, eugenol-free root canal sealer was used to avoid the adverse effect of eugenol on the adhesion between fiber posts, resin cement and dentin surfaces [33]. It is recommended for post cementation in children with thin-walled roots due to their potential to increase the fracture resistance of reinforced teeth [34]. It improves the post adhesion capacity, shows better toughness and durability, minimum microfiltration, and less solubility as compared with the other traditional luting cement [35].

The fracture of the temporary crown in this study was due to the low fracture strength and low hardness value with plastic deformation of acrylic resin [36], moreover, the over eruption of lower teeth due to the extensive coronal destruction of opposing for a long time may lead to local deep bite, that may increase the risk of the thin lingual aspect of the acrylic crown to fracture [37].

The color change of temporary crowns recorded in two cases of each group was probably due to the presence of microscopic pores that can hold microorganisms and the coupled beverages and food dye solution with the water absorption and adsorption characteristic of the acrylic resin material [38],[39].

According to Löe's Gingival Index measurement [40], the mild gingivitis observed at 18 months in this study may be explained by inadequate oral hygiene of children especially between the ages of 10 and 12 years [41]. Also, the continued slow eruption of treated teeth in response to growth and development increase the length of the clinical crown thus placing the crown margins a little away from the gingival margin leading to food accumulation [42].

In this study, no root or post/core fractures or detachment. Failure only related to debonding of the reinforcing system in a case of EasyPost/composite group. This may be due to the reinforcing system which is subjected clinically to multiforces during mastication as compressive torque, lateral, shear and tensile forces. Both compressive and tensile forces subject the postcement/reinforcing material-dentin interfaces to shear stress leading to adhesive failure and debonding of the post and or the reinforcing system [37],[43],[44].

In the current study, although there were no statistically significant differences in the rehabilitating system among all groups, everStick post group recorded 100% clinical success as the control. This finding might be explained by the function of bulk fibers impregnated with the composite of the everStick post are mainly filler support for the composite layers and acting as a crack stopper. The essential rehabilitating effect of the fibers to the fillers depends on the stress transmission from the polymer matrix to the fibers and also on the crack stopper effect of individual fibers, especially if the fibers have an equal length or exceed the critical fiber length that varies between 0.5 and 1.6 mm [45],[46],[47].

In this direct post technique, everStick posts are closely adapted together within the flared canals, replacing the luting cement or the reinforcing materials with the cement forming a monoblock dentin-post-core system that exhibits better mechanical and physical properties [41],[48]. The clinical 100% success of everStick in this study is in agreement with the findings of Monticelli et al. [43] who reported a close success rate 96%.

Some potential limitations of this study were that the presence of several uncontrolled variables with the patient selection that needs restriction to a minimal, everStick post is highly technically sensitive, the posts need for an adhesive protocol and operator experience.

In spite of these limitations, adjustable everStick technique appeared to be promising and well-accepted alternative to the other rehabilitating system because it has several advantages such as biocompatibility, minimally invasive, high flexural strength, and close modulus of elasticity to dentin and anatomically adjustable to any intra-radicular form with highly micromechanical bond to the luting cement and composite core build-up.


  Conclusion Top


Anatomical everStick posts could be a promising and efficient alternative to the traditional reinforcing systems for management of compromised upper permanent incisors, with favorable functional and aesthetic outcomes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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