Endo Tribune Middle East & Africa No. 2, 2017
Exploring the fracture resistance of retentive pin-retained e.max press onlays in molars / XP-endo® Shaper - 3D-Shaping - Clinical Cases
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DTMEA_No.2. Vol.7_ET.indd
www.dental-tribune.me
PUBLISHED IN DUBAI
E
March-April 2017 | No. 2, Vol. 7
T
Exploring the fracture resistance of
NDO
RIBUNE
retentive
pin-retained
e.max
press
The World’s Endodontic Newspaper Middle East & Africa Edition
onlays in molars
By Dr. Les Kalman & Yasmin Joseph,
Canada
Retentive titanium dentinal pins
have been combined with indirect
restorations. Application of pins has
been used with lithium disilicate,
an indirect pressed ceramic restorative material, termed e.max. The
objective of this study was to investigate the fracture resistance of pinretained versus non pin-retained indirect e.max press restorations. Ten
human extracted teeth were used
for the control and ten for the test
group. Titanium dentinal pins were
placed and e.max press restorations
were fabricated, by a commercial laboratory, and then cemented. Fracture
resistance was assessed. Data was
collected and results were obtained.
Fracture resistance of both groups
indicated no significant difference
in values. An observation from testing illuminated that pin-reinforced
e.max benefitted from a controlled
fracture, which minimized tooth
damage. The data suggests that
pin-reinforced indirect e.max restorations offer no appreciable difference in fracture resistance. Further
testing would be required to expand
upon the sample size, explore other
strength vectors and consider a clinical in vestigation.
Introduction
The loss of tooth structure, from
disease or biomechanical stress,
requires the replacement of tooth
structure through dental restoration techniques. This may occur either directly or indirectly. Extensive
tooth restorations typically require
indirect restorations.[1] Indirect dental restorations benefit from excellent form, function, esthetics, and
strength; however, the retention of
indirect restorations can prove problematic.[1] This is primarily due to
variable technique-sensitive chemical bond of the restorative material
with the tooth.[2] The type of restoration used largely depends on the
magnitude of tooth destruction and
dictates unique preparation design
characteristics.[3]
With the increasing demand in esthetics, use of ceramics has become
more prevalent in restorative dentistry.[4] E.max, a ceramic and metalfree restorative material, has been
demonstrated to be an extremely
strong, dependable restoration with
ideal esthetics.[2] It is a highly biocompatible glass ceramic composed
of lithium disilicate.[5] E.max is also
among the most durable dental materials to date.[6] Previous studies
have concluded that e.max poses
no health risk to dental patients and
has little potential to cause irritation
or sensitizing reactions, when compared to composite or gold restorations.[2]
Although the primary retention of
an indirect restoration is based on
bond strength, secondary elements
can be introduced to further increase
surface area and retentive strength,
such as pins.[7] Traditionally, retentive pins were employed to offer significant retention to direct restorations when minimal tooth structure
remained.[8] Effective utilization of
pins required proper application of
biomechanical principles in each
clinical case.[9] Adequate dentin,
to support the pin, remains an important factor in the evaluation of
the clinical success of retentive restorations.[10] The type of pin used
also determines the success rate of
the restoration. Among the two pin
types, titanium retentive pins have
been found to be highly biocompatibility with minimal corrosive activity.[10]
Due to the sensitivity of indirect
restoration bonding and resultant retention, an investigation on
Fig. 1: No pin onlay tooth preparation
Fig. 3: Periapical radiograph verifying pin placement
whether the use of titanium retentive pins would offer an increase in
fracture resistance seemed fitting.
If there was a significant increase in
fracture resistance between the restorative material and the tooth, pin
reinforced e.max press restorations
could justify further investigation. In
addition, with advances in 3-D intraoral imaging and CAD/CAM, a digital
work flow would provide a simple
and predictable clinical alternative.
Materials and methods
Control Group (N)
Test Group (N)
3016
2277
2121
3079
2510
2258
3120
2396
2859
2222
2679
2436
1605
2606
1716
2927
3060
1575
3118
2385
Table 1: Fracture resistance values for samples (Newtons)
Fig. 2: Pin onlay tooth preparation
Human extracted molar teeth were
used for this investigation. They
were sorted and randomized. A total of 20 extracted molar teeth were
used. The control group contained
ten molar teeth. Each tooth was
prepared for a four surface onlay
restoration which did not incorporate pins. The test group included
ten molar teeth. Each tooth was prepared for a four surface onlay restoration which did not incorporate
pins. Each four surface e.max onlay
restoration preparation had either
the buccal or lingual wall remaining intact (Fig. 1) following standard
Fig. 4: Occlusal view of e.max press onlay restoration
pin-retained amalgam guidelines.
[11] Titanium pins with a diameter of
0.6 mm were used (Stabilok; Fairfax
Dental Inc.). Two pins were placed
in each tooth at the appropriate line
angles; pin 1 was placed on the mesial side whereas pin 2 was placed on
the distal side of each molar tooth
(Fig. 2). Pins were inserted to a 2 mm
depth. The top 1mm was sheared off
and smoothed.[8] Pin length was
slightly variable among the teeth.
Radiographs were taken in a buccolingual and mesiodistal fashion
to verify pin placement (Fig. 3). All
tooth specimens were packaged and
sealed in a moisture controlled container and shipped to a dental laboratory (DentUSA) for restoration fabrication with e.max press (IPS e.max
Press; Ivoclar Vivadent). Specimens
were returned in the same manner
along with the e.max onlay restorations (Figs. 4 & 5). Tooth specimens
and restorations were prepared and
bonded (Fig. 6) using Multilink adhesive cementation system (Multilink
Automix; Ivoclar Vivadent) following manufacturing recommendations.[12]
Cement flash was removed and the
restorations were polished following
standard Schulich Dentistry protocols. The prepared tooth was fixed
with ortho resin (Fig. 7) (acrylic resin,
DENTSPLY Caulk) in the stabilization ring (Fig. 8). A universal loading
machine (Instron laboratory testing unit: ITW) was utilized to apply
an axial load to the tooth until the
tooth fractured (Fig. 9). The machine
applied pressure at a maximum
crosshead speed of 0.5 mm/min.
Tooth fracture was assessed visually
and measured in Newtons for all the
teeth in the control and test groups
(Fig. 10).
Results
The force (Newtons) required to
cause fracture of either the restoration or tooth, or a combination of the
two, was extremely variable (Table
1). The test group suggested greater
variability among the values and
the highest fracture resistance value.
There was no significant difference
ÿPage A2
[2] =>
DTMEA_No.2. Vol.7_ET.indd
A2
ENDO TRIBUNE
Dental Tribune Middle East & Africa Edition | 2/2017
◊Page A1
Conclusions
Fig. 5: Internal view of e.max press onlay restoration
Fig. 6: Cemented e.max press restoration
Fig. 7: Tooth sample embedded into ortho resin
This study explored combining retentive titanium pins with indirect
e.max press onlay restorations in
extracted human molar teeth. Teeth
were then subjected to axial loading in a universal loading machine.
There was no statistical difference in
fracture resistance between the two
groups. However, the highest fracture resistance was displayed from a
pin-retained e.max onlay. This may
be related to the increased surface
area and subsequent bond strength.
Observationally, pin-retained e.max
onlays fractured in a manner that
seemed more controlled than non
pin-retained onlays.
Digital dentistry could simplify this
potential alternative by providing
the clinician with the tools required
to acquire the digital impression,
design and fabricate the final restoration. Although pin-retained was
termed for the investigative restorations, perhaps pin-reinforced would
seem more logical. Further investigations are required to substantiate
the research and identify whether
this approach may be considered as
a clinical alternative.
Fig. 8: Tooth sample secured in stabilization ring with Instron bearing
Fig. 9: Axial loading in Instron unit
Fig. 10: Tooth fracture/onlay failure
Conflict of Interest
Research was supported by the Schulich Dentistry Summer Research Project and by Research Driven Inc. Les
Kalman is the co-owner and President of Research Driven Inc.
Acknowledgements
The authors thank Victoria Yu, a dental summer student, who assisted
with aspects of the methodology,
and Dr. Amin Rizkalla, BSc, MEng,
PhD, Associate Professor & Chair of
the Division of Biomaterials Science,
who facilitated the testing.
Fig. 11: Fracture resistance averaged for each group with
standard deviation: graphical.
in the fracture resistance between
the non pin-retained e.max press
restorations and the pin-retained
e.max press restorations (Fig. 11). An
unpaired t-test result using P < .05
was P = .4443 in this assessment. Data
were obtained by using an analysis
of variance (ANOVA). Significant differences were set at a .05 level (Fig. 11).
Discussion
There was no statistical difference
between the control group (non pinretained restorations) and the test
group (pin-retained restorations) in
Fig. 12: Digital impression of a pin-augmented substructure.
fracture resistance. The results indicated that the test group exhibited
greater variability. This could be due
to pin location, pin length, differences in pin angulations or variations
in the width of the onlay preparation margin. The highest fracture
resistance value was a pin-retained
e.max onlay, which could be related
to the increased surface area and
subsequent bond strength.[13] Pinretained e.max onlays had a tendency to fracture in a very controlled
manner, with much of the tooth-restoration complex remaining intact.
Fig. 13: Milled e.max restoration with pin-bore holes.
Conversely, non pin-retained e.max
onlays typically fractured in such a
violent manner that the tooth-restoration complex was destroyed.
Due to the degree of variability, further laboratory testing would be
warranted with a larger sample size.
A clinical investigation, highlighting
the procedural aspects, would also
be an ideal extension of the research.
Further studies should isolate variables and establish a greater sample
size. With advances in technology,
the digital workflow of records, de-
sign and output could be easily implemented for pin-retained restorations. It has been previously shown
that digital impressions have the
ability to capture all aspects of a pinaugmented substructures (Fig. 12).
[14] It has also been demonstrated
that CAD/CAM technology has the
precision and accuracy to mill (Fig.
13) the subsequent pin-bored restoration from an e.max CAD block.[14]
A digital approach seems to represent a simple and predictable chairside alternative for the clinician.
Editorial note: A complete list of references is available from the publisher.
This article was published in CAD/
CAM international magazine of digital dentistry No. 04/2016.
Dr Les Kalman, DDS
Assistant Professor, D epartment of Restorative Dentistry, Schulich School of
Medicine and Dentistry; and Chair of
Dental Outreach Community Service
program, Western University, London, Ontario, Canada.
Yasmin Joseph, BSc
Undergraduate Student, Faculty of Science, Western University, London, Ontario, Canada.
XP-endo® Shaper - 3D-Shaping - Clinical Cases
By FKG
Technological advances and manufacturing processes are allowing the
practitioner the ability to get closer
to ideal root canal therapy. The “perfect” file should touch all the walls of
the canal without changing its shape
while still allowing room for disinfecting irrigation solutions. The aim
is to achieve optimal disinfection in
a minimally invasive fashion. Thus
both aims of root canal therapy can
be achieved ; a healthy surrounding
periodontium and a strong root with
maximal resistance to fracture. FKG
aims to develop advanced endodontic instruments that provide dentists
with the best shaping ability, even in
curved or oval canals.
The XP-endo® Shaper is the latest instrument of the FKG’s range of 3D instruments. It is the epitome of what
incremental innovation can create
for modern dentistry; it features the
combination of a dual technology
and a unique expertise.
Firstly, the exclusive MaxWire® alloy provides the instrument with
an exceptional flexibility and an extreme resistance to cyclic fatigue. It
allows the XP-endo® Shaper to shape
and to progress inside the root canal
with agility, whilst expanding and
contracting its shape, adapting itself
to the specific morphology of each
canal.
In addition, the Booster Tip, thanks
to its six cutting edges, guides the
instrument easily toward the apical
terminus and enables to start the
shaping at an ISO diameter of 15,
then gradually to increase its working scope to reach an ISO diameter
30.
CLINICAL CASE n°1
Pulpectomy on a first upper right
molar A 62 years-old caucasian female presented a symptomatic pulpitis on tooth 16.
After a glide path of 15/.02 with a
hand file, the canals were shaped using the XP-endo® Shaper. For each
canals, the instrument was used
by applying 5 light up-and-down
movements and then removed and
cleaned.
Pre-Op
After irrigating the canal, 5 more
up-and-down movements were applied and the final size was verified
using a Gutta Percha 30/.04. Finally,
the canals were obturated with TotalFill® BC Points™ and TotalFill® BC
Sealer™.
Post-Op
Dr. Kleber K. T. Carvalho
He has completed his graduate course
in Dentistry, specialization and Master’s
degree in Endodontics at Universidade
Metodista de São Paulo – Brazil. He is the
coordinator of a specialization course at
Funorte – Santo André, São Paulo, Brazil.
Dr. Carvalho has authored one book in
Endodontics and 8 book chapters. He runs
a private practice limited to Endodontics.
ÿPage A3
[3] =>
DTMEA_No.2. Vol.7_ET.indd
Dental Tribune Middle East & Africa Edition | 2/2017
A3
ENDO TRIBUNE
Join
Hands-On Training in Dubai
Post-endodontic-treatment: Should we place posts,
do crowns or just composites and onlays?
Tutor: Dr. Eduardo Mahn, Chile
Date: 05 May 2017
Time: 09:00 - 18:00
Venue: InterContinental Hotel Festival City, Dubai, UAE
Target Audience: Dentists
7 CE Credits
Hands-On Training
05 May 2017 am
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www.cappmea.com/ca
DUBAI
Course objectives
1. Understand the importance of proper planning and
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2. Understand the last improvements in material science
and the treatment possibilities with glass fiber posts.
3. Understand the biomechanics involved when teeth are prepared.
4. Decide when to make a hybrid stump or place a post.
5. Understand the importance of the ferrule effect.
6. Indicate an endocrown and learn how to prepare it.
◊Page A2
CLINICAL CASE n°2
Treatment (ex-vivo) of a first upper right premolar.
Endodontic treatment of a first upper right premolar (Tooth 14), extracted for orthodontic reasons. The
aim of this procedure was to assess the ability of XPendo® Shaper to instrument irregularities of the canal system and prepare it for the filling.
After preparing a glide path to 20/.02, the canals were
shaped thanks to the XP-endo® Shaper to the desired
final size 30/.04. The XP-endo® Shaper could get to
canal irregularities, and maintained the original
shape of the canal.
Finally, the canals were obturated with TotalFill® BC
Points™ and TotalFill® BC Sealer™.
Radiograph showing
the bucco-lingual aspect of the maxillary
first premolar
Cross-section at 1 mm from the apex
Cross-section at 4 mm from the apex
Cross-section at 7 mm from the apex
Dr. Hubert Gołąbek
Dr. Gołąbek graduated from the Medical University of Warsaw. He is a PhD student at the Department of Comprehensive Dentistry of the Medical University of
Warsaw and an International Resident of the Continuing Education International Program in Endodontics at the University of Pennsylvania. He deals mostly with
Endodontics and endodontic microsurgery.
CLINICAL CASE n°3
A 42 years-old caucasian male presented a symptomatic pulpitis.
After preparing a glide path to 20/.02, the mesial canals were
shaped thanks to the XP-endo® Shaper to the final size 30/.04. The
distal canals initially larger than the mesial canals were also shaped
with the XP-endo® Shaper creating a space to adapt a size 40/04
TotalFill® BC points™.
After shaping, disinfection was completed with the XP-endo®
Finisher for all canals. The obturation was carried out with TotalFill®
BC points™ and TotalFill® BC sealer™.
These technical advantages combined with high-speed continuous
rotation and minimum torque, minimise the stresses exerted onto
the canal walls and prevent debris compaction in the dentinal tubules, they also promote the creation of micro-debris which can be
easily eliminated thanks to the turbulence generated by the instrument. It provides the patient with a non-aggressive, conservative
treatment.
This instrument is an amazing new single file system from FKG. It
allows faster treatment in the majority of the root canals. With its
enhanced flexibility compared to instruments of the same size and
its high cyclic fatigue resistance, shaping becomes a simple, safe
and quick process.
This high-tech instrument helps the dentists to perform their procedures with reproducible success.
Dental Tribune International
Pre-op
Microscopic view
(12x) of 3 mesial
canals after instrumentation
and
cleaning thanks
to XP-endo instruments
Post-op
Microscopic view
(12x) of 3 mesial
canals after obturation with TotalFill®
C Points™ 30/.04
and TotalFill® BC
Sealer™.
Dr. Gilberto Debelian
He has completed his specialization in Endodontics from the University of
Pennsylvania, School of Dental Medicine, USA in 1991. He obtained his PhD
at the University of Oslo, Norway in 1997. He is an Adjunct Visiting Professor
at the post-graduate program in Endodontics, University of North Carolina
and University of Pennsylvania, USA. Dr. Debelian has authored 3 chapter
books, one book in Endodontics and written more than 60 scientific and
clinical papers.
ESSENTIAL
DENTAL MEDIA
www.dental-tribune.com
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