Fiber post adhesion to radicular dentin: The use of acid etching prior to a one-step self-etching...

VOLUME 43 7 JULY/AUGUST 2012 615

QUINTESSENCE INTERNATIONAL

fiber posts in combination with luting agents

and adhesive systems.3–7 Fiber-reinforced

posts are luted to radicular dentin using

composite resin along with adhesive sys-

tems. The fundamental requirement is to

achieve an effective bond between the

composite resin and root canal dentin, as

well as with the composite resin matrix of

the fiber post.8 However, the goal is not only

to achieve a high retentive bond strength of

the fiber post, but also to avoid any microbi-

ologic leakage along the root canal or post

and to avoid degradation of the fiber post

structure.9 In fact, the most frequent cause

of failure is adhesive or cohesive debond-

ing of the post, which occurs primarily at

the cementodentin interface due to incom-

plete removal of canal-filling materials.10–12

Dentin walls after post space preparation

are usually covered by a thick smear layer

containing rough debris and remnants of

gutta-percha and sealer, which may inter-

fere with effective dentin bonding.11 The

bonding mechanism of adhesive systems

to root dentin is based on hybridization of

The postendodontic restoration has a con-

siderable impact on the long-term success

of both root canal treatment1 and the surviv-

al of endodontically treated teeth, which are

more susceptible to fracture.2 The introduc-

tion of adhesive systems and the improved

physical properties of composite resins and

fiber-reinforced posts offer new potential

for the restoration of endodontically treated

teeth. Several in vitro and in vivo studies

have indicated the favorable properties of

1 Assistant Professor, Department of Cariology and Operative

Dentistry, Dental School Lingotto, University of Turin, Turin,

Italy.

2 Lecturer, Department of Cariology and Operative Dentistry,

Dental School Lingotto, University of Turin, Turin, Italy.

3 Associate Professor, Department of Public Health and

Microbiology, University of Turin, Turin, Italy.

4 Professor, Department of Endodontics, Dental School Lingotto,

University of Turin, Turin, Italy.

5 Dean and Professor, Department of Endodontics, Dental School

Lingotto, University of Turin, Turin, Italy.

Correspondence: Dr Nicola Scotti, c.so Vittorio Emanuele II,

25–10125 Torino, Italy. Email: [email protected]

Fiber post adhesion to radicular dentin: The use of acid etching prior to a one-step self-etching adhesive

1 2/Marco Scansetti, DDS2/Giuseppe Migliaretti, Prof3/Damiano Pasqualini, DDS4/

5

The aim of this study was to evaluate the bond strength of fiber posts luted with a one-step self-etching adhesive with the push-out test after phosphoric acid conditioning of the root dentin. Thirty-six single-rooted teeth were endodontically treated. Teeth were sectioned perpendicularly to the cementoenamel junction, and a 10-mm post space was prepared with a calibrated bur. Specimens were then divided into three groups according to the

acid conditioning and self-etch one step. Fiber posts were luted with self-curing resin-based cement. Teeth were cut in 1-mm slices and pushed until failure with an Instron

(P < .05). Two additional specimens from each group were examined under the scanning electron

strength of fiber posts luted with self-etch adhesives (P < .05). SEM analysis showed a

(Quintessence Int 2012;43:615–623)

Key words: bond strength, fiber post, phosphoric acid, push-out, self-etch

616 VOLUME 43 7 JULY/AUGUST 2012


Scotti et al

the demineralized surface, resin tags, and

adhesive lateral branch formation.13 Many

studies showed the difficulty in effectively

removing the smear layer to obtain a post

space and dentin surface cleaned and

suitable for resin adhesion, above all in the

middle and apical level of the post space.11

In vitro studies evaluated different adhesive

techniques for the reliable bonding of the

steps total-etch adhesive systems showed

better bond strengths if compared with

two-step total-etch and self-etch adhesive

systems.14–17 However, the use of self-etch

systems is increasing and has been strong-

ly proposed even for fiber post cementa-

tion.18,19 Furthermore, it has been reported

that the bond strength to root canal dentin

of self-etch systems is not strongly affected

by the post space region.18,20,21 However,

the self-etching systems’ infiltrating efficien-

cy of the thick smear layer on post space

dentin remains a concern. Several studies

reported that etching,22 chemical irrigation,8

and ultrasonic treatment23 are effective in

the removal of the smear layer on end-

odontically treated dentin. However, these

procedures have not been deeply investi-

gated in conjunction with self-etch systems.

-

pose of this in vitro study was to evaluate

the effect of etching on the bond strength

of fiber posts in different root regions with

a one-step self-etching system. The null

hypothesis tested in this study was that post

acid before the application of one-step self-

etching adhesive could improve the bond

strength of the fiber post.

METHOD AND MATERIALS

Sample preparationThirty-six extracted intact human single-

rooted teeth with similar root lengths were

selected. After debriding the root surfaces

with Gracey curettes (Hu-Friedy), speci-

tooth was sectioned at the cementoenamel

axis of the tooth, using a cylindric diamond

rotary cutting instrument (Intensiv 314;

diameter, ISO 014; length, 8.0 mm;

Intensiv). Samples were endodontically

instrumented using Pathfiles no. 1, no. 2,

and no. 3 (Dentsply Maillefer) and ProTaper

S1-S2-F1-F2-F3 (Dentsply Maillefer) to the

working length, enlarging the apex to size

30, 0.09 taper. The working length was

established under 10! magnification (Pro

file became visible at the apical foramen.

(EDTA) (Tubuliclean, Ogna), using a 2-mL

syringe and a 25-gauge needle. Specimens

were obturated with gutta-percha using the

DownPack heat source (Hu-Friedy) and

Obtura II system (Analytic Technologies).

After 24 hours, the dowel space was

prepared to a depth of 10 mm, mea-

sured from the sectioned surfaces using

dedicated handpieces (Dentsply Maillefer).

Specimens were then randomly assigned to

one of three groups (each n = 12) by means

of a random numbers table. The groups dif-

fered according to the adhesive protocol.

Group A. Samples were treated with a

seconds, washed with a water syringe and

endodontic needle, and gently air dried with

an air syringe. Excess water was removed

from the post space using paper points,

without allowing the dentin to become dehy-

mixed, and three coats of the primer and

adhesive material were applied into the root

canals with a small brush. Excess primer

adhesive solution was removed with a gen-

tle stream of air. A layer of prebonding resin

was then applied and gently air dried. The

excess was removed with a paper point.

Group B. Samples were treated with a

The adhesive system was employed fol-

lowing the manufacturer instructions. Post

spaces were washed with a water syringe

and then gently air dried with an air syringe.

Excess water was removed from the post

space using paper points, without allowing

the dentin to become dehydrated. Three



Scotti et al

brush along the post space walls and gen-

tly air dried. The adhesive material was light

Heraeus Kulzer) by placing the light source

at the coronal end of the sample.

Group C. Samples were treated with the

experimental adhesive protocol. The root

air drying of the etching gel was performed

Fiber posts were luted with a self-curing

Post ISO 100s (Dentsply Maillefer) were

cemented to full depth in the prepared post

spaces. Specimens were then stored in

physiologic solution for 7 days.

Specimen preparation for the push-out strength testThirty specimens were assigned to the

push-out bond-strength test (n = 10 per

group). Each specimen was sectioned per-

pendicularly to the post axis using a low-

under water cooling to obtain five to six

1-mm root slices. Each section was marked

on its coronal side with an indelible marker.

The push-out test was performed by apply-

ing an axial load to the post at a crosshead

speed of 0.5 mm/min, using an Instrom

Machine I model 10/D (Sintech, MTS). The

most coronal portion was always turned

downward (the load direction was from api-

cal to coronal). The maximum failure load

to megapascal (MPa).

Scanning electron microscopy (SEM) analysisTwo specimens for each group were pre-

pared and sectioned as described for the

push-out bond-strength test. The root sec-

were subsequently rinsed with 20 mL of

0.1 M sodium cacodylate buffer at pH 7.4

for 1 hour with three changes, followed

by distilled water for 1 minute. After being

dehydrated in ascending grades of etha-

nol, the sections were then demineralized

-

rite for 10 minutes to visualize the hybrid

layer. The specimens were then dried and

mounted on aluminum stubs (Ted Pella)

with adhesive carbon disks (Ted Pella)

and colloidal quick-drying silver paint (Ted

Pella). The specimens were finally sputter-

coated with gold-palladium in an E-5100

sputter-coater (Polaron) at 20 mA for 90

seconds. They were observed with an SEM

magnifications (250! to 5,000!).

Statistical analysisThe measurements of push-out bond

strength were considered independent sta-

tistical units within each group for the three

regional portions of the root canal dentin

(coronal, middle, and apical thirds). The

normal distribution of the push-out strength

data was first checked and verified using

the Kolmogorov-Smirnov test. The differ-

ences among the groups were evaluated

through a one-way analysis of variance

As variances were homogeneous,

Differences were considered significant at

P < .05. The data were analyzed with SPSS

RESULTS

Mean push-out bond-strength (± standard

deviation [SD]) for each adhesive protocol

is as follows. The mean bond strength was

7.51 ± 4.27 MPa for group A, 5.64 ± 2.95

-

phoric acid was employed, showed a sig-

nificantly higher mean bond strength than

P = .012, f = 4.61).

The mean ± SD push-out bond strengths

of different root regions are listed in Table 1.

All groups showed a progressive reduction

in bond strength values from coronal to api-

cal. The highest push-out strength values

were observed in the coronal third of the

root canal among all the groups, indicating a



Scotti et al

significant effect of the root region on the

bond strength (P < .05). Statistical analysis

showed that the coronal third of group A

showed the highest push-out strength, while

reported the highest push-out bond-strength.

SEM analysis showed different hybrid

layers among different areas of the post

space and among different adhesive tech-

niques. Different magnifications revealed

the homogeneity and continuity of the hybrid

layer along the entire adhesive interface. At

the highest magnifications (5,000!), the

density and progression of the resin tags

and lateral branches, as well as the pres-

ence of debris in the hybrid layer, could be

detected.

In the coronal third, the total-etch tech-

nique (group A) showed a homogeneous

hybrid layer characterized by long, dense,

and frequent resin tags, without significant

debris between them. The middle third was

characterized by a hybrid layer where areas

with thinner resin tags, but still in a great

portion and with a considerable length,

alternate with areas in which the presence

of debris prevented the adhesive resin from

infiltrating into the tubules (Fig 1).

Table 1 The mean push-out test values of different root regions (MPa/mm2)

Root region Group Mean ± SD bond strength

A 11.86 ± 4.23a

7.54 ± 3.18b

9.32 ± 3.83b

Middle A 5.46 ± 2.98c

5.21 ± 3.06c

7.87 ± 2.81b

Apical A 5.21 ± 2.54c

4.18 ± 1.78c

6.44 ± 3.10b

SD, standard deviation. Different superscript letters indicate statistical differences (P < .05).

Fig 1 SEM micrographs of the hybrid layer of group A at the (a) coronal, (b) middle, and (c) apical level.

a

c

b



Scotti et al

showed the presence of hybrid layers,

denoting the dissolution of the smear layer

with a low intratubular infiltration of the den-

tin substrate. The images of the coronal third

report a ghost hybrid layer.17 In this area,

resin tags were not very frequent, and if

present, they were mixed with debris whose

shapes were pressed into the resin plugs.

Many resin plugs are broken because of

the degradation of debris embedded dur-

ing the adhesive procedures and then

removed during the preparative procedures

of the specimens undergoing SEM analysis.

appeared inadequate toward the tip and

become thinner before completely disap-

pearing at the apical third (Fig 2).

tags and lateral branches in the coronal

third that were less dense and shorter

compared with those produced by the

total-etch technique, but still superior to the

ones with self-etch. Similarly to the previous

showed a ghost hybrid layer where the

shapes of the debris embedded in the

hybrid layer and then removed during the

preparative procedures of the specimens

undergoing SEM analysis are imprinted

on the resin plugs. In the middle third and

layer that was more homogenous and had

fewer fractured areas; further magnifica-

tions showed resin plugs that were shorter

and less dense than in the coronal third.

These plugs were mixed with smear layer

debris left after the post space cleaning

and etching, which was incorporated with

the self-etch adhesive (Fig 3).

Fig 2 SEM micrographs of the hybrid layer of group B at the (a) coronal, (b) middle, and (c) apical level.

a

c

b



Scotti et al

DISCUSSION

Significant differences in bond strength

was employed in conjunction with one-step

self-etch systems. Thus, the null hypothesis

tested was accepted.

In this in vitro study, the fiber post bond

strength was tested with the push-out test.

This method is considered to be the most

appropriate for measuring the retention of

posts,24 even if the dislodging forces can-

not be directly compared with the functional

stresses the post needs to withstand during

clinical service.

The results of this study showed a

decrease in fiber post bond strength values

proceeding from the coronal third to the

apical third of the post space. Several stud-

ies are in accordance with this outcome.25–27

Different clinical factors could be respon-

sible for this phenomena: no visibility in

deeper areas of the post space resulting in

a less predictable post space cleaning and

therefore in higher amounts of rough debris

that occlude dentin tubules not available for

adhesion11,12; less distribution and density

of dentinal tubules in the apical portion of

the root canal system28,29; apical sclerosis30;

the cavity configuration factor of the post

space31; and difficulty of access to the api-

cal part of the post space and consequent

restrictions in adhesive cement flow to this

portion.32 Another clinical factor that could

affect the fiber post adhesion is the increas-

ing distance from curing light proceeding

from coronal to apical.33,34 For this reason,

in this study, a self-curing adhesive cement

was used.

the results of the current study, some stud-

ies showed higher bond strengths in the

Fig 3 SEM micrographs of the hybrid layer of group C at the (a) coronal, (b) middle, and (c) apical level.

a

c

b



Scotti et al

apical third than in the other parts of the root

canal,35 whereas other studies suggested

that the root canal region does not influ-

ence adhesion of the post to canal dentin.36

These conflicting results could be attributed

to the different luting cements employed

or the differences in sample preparation

procedures.

The influence of the smear layer thick-

ness on the bond strength of self-etch-

ing adhesive systems is uncertain, and a

deeper understanding of the role of the

smear layer is important to achieving effec-

tive dentin bonding.8 It has been report-

ed that the thickness of the smear layer

did not influence the adhesive capacity of

self-etch adhesive systems.37 The smear

layer hybridized by self-etching adhesive

is a weak bonding area, with the top of

the hybrid layer containing disorganized

collagen fibrils that degrade over time.38

phosphoric acid removes the endodon-

tic smear layer (produced by endodontic

instruments) or the secondary smear layer

(produced during post space preparation

with dedicated handpieces). The phos-

phoric acid role consists of opening dentin

tubules and exposing collagen fibrils to

allow adhesive infiltration.

study were comparable with values obtained

in other similar studies.39,40 Actually, higher

bond strength values were obtained in the

coronal third with the total-etch technique.

In the middle and apical thirds, group

SEM analysis on samples not submitted

to push-out tests showed hybrid layers

obtained with the three different adhesive

techniques. In each group, from the coronal

to the apical third, there was a decrease

in the percentage of areas with resin tags,

while there was an increase in the areas

with debris and gutta-percha remnants, as

observed by Perdigão et al.25 The group

hybrid layer, even in the middle and api-

deeper areas were shorter and had a lower

density compared with those in the coronal

third, but they were present and combined

with smear layer. Debris remained after

post space cleaning and etching, incorpo-

rated in the hybrid layer with the self-etch

adhesive. This can explain the push-out

values, showing higher bond strength in the

middle and apical thirds of the post spaces

etch adhesive systems.

The self-etch approach is favored by the

general practitioner because it is alleged to

be more user-friendly and less technique-

sensitive than the total-etch approach,

thereby resulting in a clinically reliable

performance.41 Therefore, self-etch adhe-

sive systems are not extensively tested in

fiber post cementation. Moreover, the use

of phosphoric acid prior to self-etching

adhesive systems in fiber post luting proce-

dures is poorly investigated in the literature.

The increase in bond strength, above all in

the middle and apical regions of the post

space, was also reported by a study con-42 One reason for

this may be that the root canal dentin is of a

different configuration, with more sclerosis,

which affects acid treatment and bonding

compared with the flat coronal dentin. The

thick smear layer produced by sequential

endodontic treatment and post prepara-

tion on the canal walls may be another

reason why etching with phosphoric acid

significantly improved the apical push-out

strengths of one-step self-etching systems. Some in vitro studies showed the incom-

patibility between one-step self-etching

adhesive systems and dual-cured resin

cements.25 The interaction produced a

bond strength reduction to radicular dentin,

the result of an adverse chemical inter-

action between catalytic components of

chemically cured composites and one-step

self-etching adhesives.43 For this reason,

in this study, a self-curing adhesive resin

cement was employed.

Our results are in contrast with other

studies reporting higher bond strength val-

ues for self-etch adhesives compared with

a total-etch approach.44 The great variabil-

ity between the performances of different

self-etch adhesives systems can in part be

ascribed to the use of different functional

monomers with different properties regard-

ing acidity, hydrolytic stability, and chemi-

cal interaction capacity.45



Scotti et al

CONCLUSION

we can conclude that post space cleaning

is less predictable when proceeding from

the coronal third to the apical third, result-

ing in a lower post bond strength in deeper

areas of the post space. Also, the appli-

cation of a self-etching adhesive in post

cementation following the classical protocol

cannot ensure predictable bond strength

phosphoric acid before the application of a

self-etch adhesive could be considered an

alternative technique in fiber post cemen-

tation, especially for the general dental

practitioner who can easily improve the

performance of a one-step self-etch adhe-

sive by adding to its clinical procedure 30

seconds of phosphoric acid etching. In this

way, it is easily possible to obtain higher

bond strength values.

Long-term bond strength should be

tested, and further studies on aged sam-

ples should be performed because some

studies showed that self-etching adhesives

increased collagenolytic activity in radicular

dentin.46

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Fiber post adhesion to radicular dentin: The use of acid etching prior to a one-step self-etching...

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