See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/337468821

One‐step fiber post cementation and core build‐up in endodontically treated

tooth: A clinical case report

Article  in  Journal of Esthetic and Restorative Dentistry · November 2019

DOI: 10.1111/jerd.12551

CITATIONS READS

0 1,178

5 authors, including:

Bruno Mascaro
São Paulo State University
1 PUBLICATION   0 CITATIONS   

SEE PROFILE

All content following this page was uploaded by Bruno Mascaro on 02 June 2020.

The user has requested enhancement of the downloaded file.

Received: 16 May 2019 Revised: 19 October 2019 Accepted: 24 October 2019
DOI: 10.1111/jerd.12551

CLINICAL ARTICLE

One-step fiber post cementation and core build-up in

endodontically treated tooth: A clinical case report

José Mauricio dos Santos Nunes Reis DDS, MS, PhD1 |

1
Carlos R. de Moura Oliveira DDS, MS | Erica G. J. Reis DDS, MS, PhD2 |
Bruno A. Mascaro DDS1 | Filipe de Oliveira Abi-Rached DDS, MS, PhD1
1
Department of Dental Materials and
Prosthodontics, Araraquara Dental School, Sao Abstract
Paulo State University (UNESP), Araraquara, Objective: This clinical case report addresses the step-by-step of the application of a
S~ao Paulo, Brazil
2 core-and-post system that uses a single resin composite material to fiber post cemen-
Endodontics Professor at Brazilian
Association of Dental Surgeons (ABCD), tation and core build-up in a maxillary left central incisor.
Campo Grande, Mato Grosso do Sul, Brazil
Clinical considerations: The literature reports several materials and methods for the
Correspondence restoration of endodontically treated teeth with coronal destruction that require an
José Mauricio dos Santos Nunes Reis,
intra-radicular fiber post for the core build-up. The present case report describes a
Department of Dental Materials and
Prosthodontics, Araraquara Dental School – core-and-post or “monoblock” technique. A dual resin composite (Core-X Flow;
Sao Paulo State University (UNESP), Rua
Dentsply DeTrey) highly filled material and cement was used for luting the fiber post
Humaitá, nº. 1680 Araraquara – Sao Paulo, SP,
Brazil. (Blue X-Post) and build-up the core structure in an easy application.
Email: reis@foar.unesp.br
Conclusions: The “core-and-post” technique that uses a single material system proto-
col minimizes the material interfaces, steps of procedures, and chair-time in compari-
son to conventional techniques.
Clinical Significance: The use of different materials for post cementation and core
build-up requires more steps, which increases the chair-time and number of inter-
faces among the materials. Since the “monoblock” technique uses only one material,
it can streamline the clinical procedures, thus, saving time and materials. Moreover,
techniques based on core-and-post systems are easily applied, versatile, and
esthetics, and can be applicable to posterior and anterior teeth.

KEYWORDS
core build-up, core-and-post system, restorative dentistry, tooth crown

1 | I N T RO D UC T I O N root,9,10 or vertical root fractures caused by both increased stress

concentration in the apical region of the post and a difference in the
Endodontically treated teeth that show coronal structure destruction Young's modulus between dentin and metal.1 An ideal core and post
and have undergone extensive restorations are usually rebuilt with improves the biomechanical stability of an abutment tooth preventing
post and core followed by prosthetic crown restoration.1,2 Among debonding and root fracture or fracture of the abutment.11 Therefore,
several techniques, posts, and materials for cementation and core over the last decades, prefabricated glass fiber posts have been used
build-up reported in the literature,3-6 cast post and core has been tra- as an alternative for custom metallic posts.12,13
ditionally used due to its high mechanical strength and desirable fit in Due to improvements in adhesive techniques, resin composites
7,8
the root canal. However, teeth restored by such systems may show cores and glass fiber posts have become increasingly prevalent.2 The
more frequent oblique/horizontal fractures in the middle third of the Young's modulus of resin composites, in contrast to that of the cast post

J Esthet Restor Dent. 2020;32:5–11. wileyonlinelibrary.com/journal/jerd © 2019 Wiley Periodicals, Inc. 5

6 REIS ET AL.

and core, is more comparable to that of the dentin, which results in selection and cementation in order to facilitate the observation of
decreased stress concentration under oclusal forces and prevents cata- sound tooth structure. On the other hand, in some situations, as in this
strophic root fractures.7,14 Moreover, the larger cement layer at the clinical case report, clinical and radiographic examinations allow
post/dentin adhesive interface can absorb the oclusal forces, which
decreases the occurrence of root fractures.15 Fractures are commonly
constrained to the cervical third of the roots and cores, and, under some
clinical situations, may be repairable.9,10 Most failures related to the
fiber posts approach are caused by a debonding between post-cement
interfaces, rather than cement-dentin, or associated with a cohesive fail-
ure of cement.16 According to some authors, the incidence of fiber posts
fractures are lower and the survival and success rates are higher in com-
parison to teeth restored with no post17 or with cast post and core.18
Bulk fill composites have been an interesting alternative for the
reconstruction of teeth with extensive coronal destruction, since they
enable the use of thicker increments,19,20 which reduces clinical time
and technical sensibility.20 Furthermore, such materials show similar
or lower polymerization shrinkage in comparison to conventional
F I G U R E 1 Initial clinical condition. Extensive resin composite
and/or flowable composite resins,21 and similar fracture strength to
restoration in the maxillary left central incisor, including buccal,
nanohybrid composite resins, and can be used in restorations of end-
mesial, distal, and incisal surfaces. Note cracks in the previous
odontically treated teeth with extensive structure loss.22,23 Despite restorations and esthetic compromise
the development of novel materials and techniques over the past
years, major challenges and controversy regarding restoration of end-
odontically treated teeth still remain, mainly when the root is weak-
ened and the ferrule is either limited, or absent.14
This case report addresses the clinical use of an etch-and-rinse
core-and-post system (XP Bond + Core-X Flow; Dentsply DeTrey,
Konstanz, Germany) that employs a single material for both cementa-
tion of the fiber post and core build-up in tooth with a minimum of
2.0 mm ferrule height. A clinical case presented clarifies the technical
steps and discusses the benefits of the material in relation to the
widely used conventional procedures.

2 | CLINICAL REPORT

A 24-year-old female patient was attended in the Conventional and

Implant-Supported Fixed Prosthesis dental clinic at Araraquara Dental
School – Sao Paulo State University (UNESP), complaining about
esthetics regarding the shape and color of her maxillary left central inci-
sor. A clinical intraoral examination revealed an esthetic impairment
related to an old direct resin composite veneer with interproximal cov-
erage and full contour of the middle to incisal thirds caused by a previ-
ous fracture. The examination also detected an endodontic access
restored with resin composite, increased sensitivity to vertical percus-
sion, and good periodontal condition. The resin veneer showed inade-
quate reproduction of the chromatic aspects and marginal restoration
cracks. After clinical and radiographic examinations (Figures 1 and 2),
an endodontic retreatment was prescribed, since voids and inhomoge-
neous root canal filling were observed. The reduced amount of tooth
structure remnant in the middle/incisal thirds did not compromise the
minimum ferrule of 2.0 mm desired with the use of pre-fabricated posts
F I G U R E 2 Periapical radiograph prior to the endodontic
and recommended by the manufacturer of the material used. To deter- retreatment. Note the presence of voids, inhomogeneous root canal
mine the ferrule, the teeth should usually be prepared before post filling, and extensive resin composite restorations
REIS ET AL. 7

clinicians testify the remaining sound dental structure, mainly in the 2.1 | Technical steps
cervical third. Despite the limitations of bidimensional images in show
2.1.1 | Step 1: Root canal preparation
the width of the tooth structure, periapical/interproximal radiographs
are important to observe the extension of previous restorative treat- After the endodontic retreatment (Figure 3), the root canal was
ments. In conjunction to the clinical examination (decisive and para- accessed by heated Rhein root canal pluggers (Golgran Ind., S~ao Paulo,
mount exam), and considering the anamnesis data in which was related SP, Brazil). Gutta-percha was removed with #2 Largo Peeso Reamer
the tooth fracture in the middle to incisal third, we decide to select and of the system and the apical sealing was preserved. Finally, the root
cement the fiber post prior to the dental preparation, since the ferrule canal was prepared by a #3 post drill (Figure 4).
presence was predictable. This facilitates the endodontic and adhesive
procedures under rubber dam isolation.
The tooth coronal third was reconstructed by a core-and-post sys- 2.1.2 | Step 2: Fiber post selection and preparation
tem (XP BOND/Self Cure Activator + Blue X-Post #3 + Core-X Flow; for adhesive luting
Dentsply DeTrey, Konstanz, Germany), followed by an all-ceramic
crown. After adhesion procedures, the fiber post was cemented into After gutta-percha removal and root canal preparation, a periapical

the root canal and the core was made using the single Core-X Flow, radiograph was employed to check the preparation quality and to

which is a dual-cure highly filled (70 wt%) resin composite delivered in select the fiber post size, according to the anatomical dimensions of
a dual-barreled syringe, which favors direct and accurate intraoral the root canal. The selected fiber post (Blue X-Post #3) was demar-
applications. The tooth was subjected to dental preparation with cated (Figure 5), reduced to an adequate length by a high-speed dia-
rounded shoulder margin. The all-ceramic crown was made with pres- mond bur under water-cooling and cleaned with alcohol. It was
sable lithium disilicate ceramic (IPS e.max Press, Ivoclar Vivadent, completely wetted by an XP BOND/Self Cure Activator (Dentsply
Schaan, Liechtenstein), veneered with nano-fluorapatite veneering DeTrey, Konstanz, Germany) mixture bonding system and the solvent
porcelain (IPS e.max Ceram; Ivoclar Vivadent, Schaan, Liechtenstein). was removed by a gentle blow with an air syringe for at least

FIGURE 3 Periapical radiograph after root canal retreatment FIGURE 4 Root canal preparation by Maillefer Precision Drill #3
8 REIS ET AL.

FIGURE 5 Fiber post (Blue X-Post #3) try-in and demarcation for
cutting

FIGURE 7 Root canal and coronal walls filling with Core-X Flow

FIGURE 6 XP BOND/Self Cure Activator application

(Figure 7), and the fiber post was immediately placed into the final

5 seconds. The X-post was protected from light until the cementation position and stabilized. It was light-cured for 40 seconds by a

procedure. 1200 mW/cm2 curing light output (Radii, SDI, Victoria, Australia). The
material excess was removed with diamond bur and a periapical radio-
graph was taken to confirm the fiber post adaptation and root sealing
2.1.3 | Step 3: Root canal adhesive procedures (Figure 8).

The root canal dentin walls were etched with 36% phosphoric acid for
15 seconds. The acid was then removed with water sprayed for 2.1.5 | Step 5: Dental preparation, impression, and
20 seconds and the root walls were carefully dried with absorbent full crown cementation
paper points prior to bonding procedures. The XP BOND/Self Cure
The tooth was prepared to receive a veneered lithium disilicate crown
Activator self-cure bonding system was actively applied into the root
(Figures 9 and 10). A two-step putty-wash impression with polyvinyl
canal walls (Figure 6) for 20 seconds. The adhesive excesses were
siloxane was performed (Figure 11). The crown (Figure 12) was luted
removed with absorbent paper points and the solvent was evaporated
with self-adhesive resin cement (RelyX U200, 3M ESPE AG, Seefeld,
by gentle air blowing for 5 seconds.
Germany).

2.1.4 | Step 4: Fiber post cementation and core

3 | DISCUSSION
build-up
The cap of the Core-X Flow syringe was removed and a small amount The “monoblock” or core-and-post technique simplifies the post and
of material was discarded. The Core-X Flow was directly applied onto core restoration, since it can be used for post cementation and core
the treated fiber post surface and into the canal and pulp chamber build-up.24,25 Over the past decades, resin composites reinforced with
REIS ET AL. 9

F I G U R E 1 0 Note the dentin in the cervical third guaranteeing the

adequate ferrule height (black arrows) and the limits of the resin composite
in the transition of the cervical to middle third (red dashed line)

F I G U R E 8 Periapical radiograph after fiber post cementation and

coronal filling

FIGURE 11 Impression mold

F I G U R E 9 Maxillary left central incisor after crown preparation

with rounded shoulder margin design

inorganic particles have been developed and used, and sometimes FIGURE 12 Veneered lithium disilicate crown after cementation
recommended by manufacturers to be used as cementing materials
and core filling.25 The protocol followed in this case report demon- that require post cementation and core build-up. Therefore, the use
strated a predictable and easy way to restore endodontically treated of only one material for two indications enables the creation of a
teeth. The entire system works in harmony toward reinforcing teeth “monoblock” bond interface between the post-dentin-cores, which
10 REIS ET AL.

results in a cohesive reconstruction of impressive strength and sturdi- for the core build-up, and the present technique can also be used
ness over time. jointly with the conventional ones, since some clinicians resist the
Bitter et al.26 evaluated the push-out bond strength and the resin- application of novel protocols and materials.
dentin interface morphology by confocal laser scanning microscopy of
different core-and-post systems. Core-X Flow showed similar bond
4 | C O N CL U S I O N S
strength to MultiCore Flow (Ivoclar-Vivadent) and lower than
Luxacore Z (DMG) and Rebilda DC (Voco). However, the authors con-
1. The “monoblock” technique based on core-and-post materials/sys-
cluded that all systems showed homogeneous hybrid layer formation
tems uses only one material for post cementation and core build-up.
and penetration into dentinal tubules, hence, an effective and suc-
2. Since a single material is used, clinical steps are easily, and
cessful adhesion to the root canal walls and satisfactory clinical per-
quickly performed with minimal technical sensibility.
formance. They also highlighted unlike conventional systems that use
3. Clinicians can minimize their chair time for fiber post cementa-
one material for post cementation and another for core build-up, the
tion and core build-up, choosing a system that reduces steps and
use of only one manufactured core-and-post system can eliminate
materials with predictable success.
possible incompatibilities among different materials and provide full
potential of each system. Sterzenbach et al.27 observed that the bond
strength of fiber posts adhesively luted to root canal dentin was sig- DISCLOSURE OF INTEREST
nificantly higher when either self-adhesive resin cements, or the
Core-X Flow etch-and-rinse core-and-post material were used, in The authors do not have any financial interest in the companies

comparison to the DentinBond/DentinBuild (Komet) etch-and-rinse whose materials are included in this article.

core-and-post system and the self-etch adhesive/resin cement ED-

Primer II/Panavia F 2.0 (Kuraray Medical Inc.). According to the
OR CID
authors Sterzenbach et al.,27 the filler content seemed to exert a slight
impact in relation to the bond strength performance for those mate- José Mauricio dos Santos Nunes Reis https://orcid.org/0000-0002-
rials. Marigo et al.28 evaluated the push-out bond strength of two 1910-2360
self-adhesive and two etch-and-rinse luting systems after artificial
aging and observed significant differences in the total bond strength
RE FE RE NCE S
among the cements. Core-X Flow produced the highest mean values,
followed by Cement-One (Dentalica) and Axia Core Dual (Dentalica). 1. Okamoto K, Ino T, Iwase N, et al. Three-dimensional finite element
SmartCem 2 (Dentsply) produced the lowest results. No significant analysis of stress distribution in composite resin cores with fiber posts
of varying diameters. Dent Mater J. 2008;27(1):49-55.
differences were detected among the cements in the medium or api-
2. Ishikawa Y, Komada W, Inagaki T, et al. The effects of post and core
cal areas; however, in the middle zone, Core-X Flow showed the material combination on the surface strain of the 4-unit zirconia fixed
highest values and SmartCem 2 provided the lowest ones. Axia Core partial denture margins. Dent Mater J. 2017;36(6):798-808.
Dual and Core-X Flow showed more homogeneous bonding strengths 3. Hikita K, Van Meerbeek B, De Munck J, et al. Bonding effectiveness
of adhesive luting agents to enamel and dentin. Dent Mater. 2007;23:
across the different anatomical sites (cervical, middle, and apical).
218-225.
Mazzoni et al.29 investigated the influence of thermocycling on the 4. Zicari F, De Munck J, Scotti R, et al. Factors affecting the cement-post
bond strength of fiber posts cemented by different luting approaches. interface. Dent Mater. 2012;28(3):287-297.
Thermocycling significantly affected the bond strength of both self- 5. Skupien JA, Sarkis-Onofre R, Cenci MS, et al. A systematic review of
factors associated with the retention of glass fiber posts. Braz Oral
etch adhesive/resin cement (Panavia F 2.0) and self-adhesive cement
Res. 2015;29(1):1-8.
(RelyX Unicem; 3M ESPE) in comparison to control specimens incu- 6. Soejima H, Takemoto S, Hattori M, et al. Effect of adhesive system on
bated in artificial saliva for the same period of time. Although the retention in posts comprising fiber post and core resin. Dent Mater J.
etch-and-rinse system (XP Bond/Core-X Flow) showed a slight 2013;32(4):659-666.
7. Fraga RC, Chaves BT, Mello GS, et al. Fracture resistance of endodon-
decrease in the bond strength, no significant difference was detected
tically treated roots after restoration. J Oral Rehabil. 1998;25(11):
in comparison with the control. Moreover, Core-X Flow showed 809-813.
higher bond strength than Panavia F 2.0 and RelyX Unicem after arti- 8. Rezaei Dastjerdi M, Amirian Chaijan K, Tavanafar S. Fracture resis-
ficial aging (40,000 cycles), which, according to the authors, repre- tance of upper central incisors restored with different posts and
sents an approximately 4-year clinical function. cores. Restor Dent Endod. 2015;40(3):229-235.
9. Qing H, Zhu Z, Chao Y, Zhang WQ. In vitro evaluation of the fracture
The technique described in this report can be replicated without
resistance of anterior endodontically treated teeth restored with glass
additional steps or materials, which enables clinicians to perform their fiber and zircon posts. J Prosthet Dent. 2007;97(2):93-98.
procedures with less chair-time and effort. The dispensing syringe 10. Ni CW, Chang CH, Chen TY, et al. A multiparametric evaluation of
delivery by the system provides favorable mixing properties and a post-restored teeth with simulated bone loss. J Mech Behav Biomed
Mater. 2011;4(3):322-330.
long and narrow-shaped root canal mixing tip. Therefore, the system
11. Mamoun J. Post and core build-ups in crown and bridge abutments:
can be directly applied into the root canal, which avoids hand mixing bio-mechanical advantages and disadvantages. J Adv Prosthodont.
and minimize bubble formation. Several philosophies can be applied 2017;9(3):232-237.
REIS ET AL. 11

12. Marchi GM, Mitsui FH, Cavalcanti AN. Effect of remaining dentine 23. Kemaloglu H, Emin Kaval M, Turkun M, et al. Effect of novel restora-
structure and thermal mechanical aging on the fracture resistance of tion techniques on the fracture resistance of teeth treated endodonti-
bovine roots with different post and core systems. Int Endod J. 2008; cally: an in vitro study. Dent Mater J. 2015;34(5):618-622.
41(11):969-976. 24. Panitiwat P, Salimee P. Effect of different composite core materials
13. Zogheib LV, Pereira JR, do Valle AL, et al. Fracture resistance of on fracture resistance of endodontically treated teeth restored with
weakened roots restored with composite resin and glass fiber post. FRC posts. J Appl Oral Sci. 2017;25(2):203-210.
Braz Dent J. 2008;19(4):329-333. 25. Bitter K, Schubert A, Neumann K, Blunck U, Sterzenbach G,
14. Silva GR, Santos-Filho PC, Simamoto-Júnior PC, et al. Effect of post Rüttermann S. Are self-adhesive resin cements suitable as core build-
type and restorative techniques on the strain and fracture resistance up materials? Analyses of maximum load capability, margin integrity,
of flared incisor roots. Braz Dent J. 2011;22(3):230-237. and physical properties. Clin Oral Investig. 2016;20(6):1337-1345.
15. Zhou L, Wang Q. Comparison of fracture resistance between casts 26. Bitter K, Gläser C, Neuman K, et al. Analysis of resin-dentin interface
posts and fiber posts: a meta-analysis of literature. J Endod. 2013;39 morphology and bond strength evaluation of core materials for one
(1):11-15. stage post-endodontic restorations. PLoS ONE. 2014;9(2):e86294.
16. Kulkarni K, Godbole SR, Sathe S, et al. Evaluation of the mode 27. Sterzenbach G, Karajouli G, Naumann M, Peroz I, Bitter K. Fiber post
failure of glass fiber oosts: an in vitro study. Int J Sci Stud. 2016;3(12): placement with core build-up materials or resin cements-an evalua-
34-39. tion of different adhesive approaches. Acta Odontol Scand. 2012;70
17. Guldener KA, Lanzrein CL, Guldener BES, et al. Long-term clinical out- (5):368-376.
comes of endodontically treated teeth restored with or without fiber 28. Marigo L, D'arcangelo C, De Angelis F, Cordaro M, Vadini M, Lajolo C.
post-retained single-unit restorations. J Endod. 2017;43(2):188-193. Evaluation of in vitro push-out bond strengths of different post-luting
18. Wang X, Shu X, Zhang Y, Yang B, Jian Y, Zhao K. Evaluation of fiber systems after artificial aging. Minerva Stomatol. 2017;66(1):20-27.
posts vs metal posts for restoring severely damaged endodontically 29. Mazzoni A, Marchesi G, Cadenaro M, et al. Push-out stress for fibre
treated teeth: a systematic review and meta-analysis. Quintessence posts luted using different adhesive strategies. Eur J Oral Sci. 2009;
Int. 2019;50(1):8-20. 117(4):447-453.
19. Alrahlah A, Silikas N, Watts DC. Post-cure depth of cure of bulk fill
dental resin-composites. Dent Mater. 2014;30(2):149-154.
20. Li X, Pongprueksa P, Van Meerbeek B, et al. Curing profile of bulk-fill
resin-based composites. J Dent. 2015;43(6):664-672. How to cite this article: Reis JMdosSN, Oliveira CRdeM,
21. Ilie N, Hickel R. Investigations on a methacrylate-based flowable com- Reis EGJ, Mascaro BA, Abi-Rached FO. One-step fiber post
posite based on the SDR technology. Dent Mater. 2011;27(4):348-355. cementation and core build-up in endodontically treated
22. Atalay C, Yazici AR, Horuztepe A, et al. Fracture resistance of end-
tooth: A clinical case report. J Esthet Restor Dent. 2020;32:
odontically treated teeth restored with bulk fill, bulk fill flowable,
fiber-reinforced, and conventional resin composite. Oper Dent. 2016; 5–11. https://doi.org/10.1111/jerd.12551
41(5):131-140.

View publication stats