Title Clinical Case Reports

Title
Author(s)
Clinical case reports
Mahindre, Prajakta Prakash
Citation
Issued Date
URL
Rights
2010
http://hdl.handle.net/10722/133493
Creative Commons: Attribution 3.0 Hong Kong License
Clinical Case Reports

Submitted in partial fulfillment of the requirements for the degree of
Advanced Diploma in Endodontics

at The University of Hong Kong
August 2010
by
Prajakta Prakash Mahindre

BDS (Maharashtra University of Health Sciences, India)
MDS (The University of Hong Kong, Hong Kong)
Preface
Preface
Clinical Case Reports
Submitted by Prajakta Prakash Mahindre (2007969396)
As partial fulfillment of the requirements for the degree of Advance Diploma in
Endodontics, at the Faculty of Dentistry, the University of Hong Kong in August 2010.
In this case report, all patients received endodontic treatments during the course
of Advanced Diploma Dental Surgery from September 2009 to July 2010. Treatments
were performed at the Endodontic Clinic, Floor 3A, Prince Philip Dental Hospital, 34
Hospital Road, Hong Kong, China.
Supervision was done by Dr. G.S.P. Cheung
(Postgraduate Programme Director in Endodontics), Dr. Robert Ng, Dr Chengfei Zhang,

Dr. Yiu Fai Mak, Dr. Siu Fai Leung, Dr Jeffrey Chang, Dr. Angela Ho, Dr. Alex Chan
and Dr. Rachel Tan.
Treatments were classified as endodontic treatment on multiple teeth, nonsurgical endodontic treatment (RCT), non-surgical endodontic retreatment (re-RCT),
and surgical endodontic treatment.
Treatments with more than one tooth were
considered as multiple endodontic treatments. Endodontic treatments of teeth whose

pulps or canals were accessed by another dentist were considered to be non-surgical
endodontic retreatment. A total of 27 patients were treated during the year, where RCT
and Re-RCT were performed on 45 teeth, surgical treatment was done for 5 teeth, one
implant was placed and 7 CMC were cemented.
Lignocaine (2 %) with 1:80,000 epinephrine (Brand name: Xylestesin-A) was
used as local anesthetic for all patients. Teeth were isolated by rubber dam. An
orthodontic band was cemented on the posterior teeth if necessary. After the access
cavity was prepared, root canals were prepared using the step-down technique. Sodium
hypochlorite solution (3%) and ethylene-diamine-tetra-acetic acid (EDTA 17%) were
used as irrigants. The coronal third of the canal was prepared before the apical third of
i
Preface
the canal was accessed. Radiographs and electronic apex locator (Root ZX Apex
Locator, J Morita Corporation, Kyoto, Japan) were used to determine the working
length of the root canal. File-Eze (Ultradent, South Jordan, Utah, USA) was used as a
canal lubricant.
Teeth were temporized between appointments with a calcium
hydroxide dressing (Calasept, JS Dental MFG INC, Ridgefield, Connecticut, USA) in

the canal, and a combination of cotton pellets, Cavit (3M ESPE, Seefeld, Germany)
and IRM (Dentsply, Caulk, Milford, Delaware, USA) in the access cavity. Obturation
was achieved by warm vertical compaction of gutta percha with AH Plus (Dentsply,
DeTrey, Konstanz, Germany). A layer of IRM with 1 to 2 mm thick was placed on top
of the gutta percha, before the placement of final restoration. A post and core, or
bonded corono-radicular amalgam with All-BOND 2 cement (Bisco, Schaumberg,
Illinois, USA), or composite resin.
ii
Table of Contents
Table of Contents
Preface
Table of Contents
iii
Acknowledgements
List of Abbreviations, Equipment and Materials
viii
Case Synopsis
Non-Surgical Root Canal Treatment
PPDH No: 237463
PPDH No: 184923
Non-Surgical Root Canal Retreatment

PPDH No: 268936
PPDH No: 247457
PPDH No: 167162
PPDH No: 214456
PPDH No: 250900
10
PPDH No: 263016
12
PPDH No: 252723
14
PPDH No: 253557
16
PPDH No: 270912
18
PPDH No: 242859
20
iii
Table of Contents
PPDH No: 200007
22
PPDH No: 249871
24
PPDH No: 266857
26
PPDH No: 229260
28
PPDH No: 37765
30
Surgical Root Canal Treatment

PPDH No: 270912
32
PPDH No: 259311
37
PPDH No: 254213
41
PPDH No: 154144
47
PPDH No: 250888
50
Multiple Treatments
PPDH No: 257056
57
PPDH No: 269196
59
PPDH No: 260029
63
PPDH No: 246472
66
PPDH No: 246760
68
iv
Acknowledgements
Acknowledgements
It is an honor for me to have an opportunity to work and learn under the valuable
guidance and supervision of Dr Gary Cheung, Dr Robert Ng, Dr Sui Fai Leung,
Dr Chengfei Zhang, Dr Yiu Fai Mak, Dr Angela Ho, Dr Jeffrey Chang, Dr Alex Chan
and Dr Rachel Tan during my clinical training.
Their expertise in the field of
endodontics improved my clinical knowledge immensely and also provided me with a

clear understanding of the subject. I would also like to thank them for their insightful
and helpful comments through these years.
I express my deepest gratitude Dr Gary Cheung for his constant support and
guidance from the initial to the final level which enabled me to develop an
understanding of the subject. He has broadened my knowledge not only to the field of
endodontics, but also other areas in clinical dentistry. He has supported me throughout
the years with his patience and knowledge whilst allowing me the room to work in my
own way. I would also like to acknowledge his tolerance and patience while correcting
my drafts inspite of all the repetitive typo errors and limited knowledge about computer
functions.
I would also like to thank Dr Robert Ng, my idol for his valuable guidance, his
great efforts to explain things clearly and simply during the entire course. His
enthusiasm and passion towards endodontics is motivational and contagious as well. I
would like to appreciate all his contribution of time and ideas to make my clinical
training more productive and stimulating. In his own small ways, encouraged me,
helped in channelizing and moulding my thought process about the specialty, which was
supported with sound reasoning from the literature and self-experience.
Dr Siu-Fai Leung, I would like to express my deepest appreciation to you for not
only sharing your clinical expertise, but also giving me a chance to try alternative
v
Acknowledgements
treatment modalities. I would like to thank you for lending me your books to read.
Dr. Yiu Fai Mak, the clinical expertise shared by you and also various question
answer sessions during the clinics, was helpful and I really learnt a lot from them.
I am thankful to Dr Danny Low for giving me a chance to teach in the sim-lab
when I needed it the most and for sharing their clinical experience.
Dr Jeffrey Chang, I am deeply indebted to you for caring, extending your help
whenever needed, understanding and giving me the right advise always. Your gesture, of
giving me a chance to help you in your research is deeply appreciated. Thank you so
much for patiently listening to me and also encouraging throughout these three years.
Special thanks to Dr Angela Ho, for not only teaching me but also for letting me
know about my flaws and helping me to overcome them.
I would like to express my gratitude to Dr Chengfei Zhang for all his help &
guidance, especially for sharing his expertise stem cells and its relation to dentistry. I am
also thankful to Dr Alex Chan for teaching me and guiding me as well.
I am indebted to my colleagues Dr Angeline Lee, Dr Catherine Chia, Dr Helen
Liang, Dr Michael Tse, Dr Irwan Soo, Dr Bonnie Chiu and Dr Willis Wei who have
made available their support in a number of ways. They have also been a source of good
advice and for providing a stimulating and fun environment to learn and grow. I would
like to thank them for being my friends, understanding me and standing by me
throughout the course.
Special appreciation goes to my Karen Leung, Waimea Lau and Mandy Chan
my dental surgery assistants for co-operating, being helpful and supporting me through
these years. I especially appreciate them for helping me get acclimatized to the new
vi
Acknowledgements
clinical set-up in this hospital and also make this entire learning experience productive
and joyous. I deeply appreciate Waimea for standing by me whenever needed.
Lastly, I would like to say special thanks to my family members, especially my
father, Dr Prakash Mahindre and my mother, Dr Priya Mahindre for encouraging me to
pursue this degree. The continuous and endless love and support provided by my
parents, sister (Poonam Mahindre), brother (Capt. Pritish Mahindre) and friends
especially Michelle, Sandeep, Shweta, Vaish, Parth, Sagar, Robert & Sadia throughout
these three years is priceless and without their encouragement and help this would not
be possible.
vii
List of Abbreviations, Materials and Equipment

Abbreviations
BDS
Bachelor of Dental Surgery
Buccal
Ca (OH) 2
Calcium hydroxide
CMC
Ceramic metal crown
CR
Composite resin
Distal
E/O
Extra-oral
EDTA
Ethylene-diamine-tetra-acetic acid
GDP
General dental practitioner
GIC
Glass ionomer cement
GP
Gutta percha
I/O
Intra-oral
Lingual
JHDO
Junior Hospital Dental Officer
Mesial
MDS
Master of Dental Surgery
MTA
Mineral Trioxide Aggregate
Occlusal
Palatal
PA
Periapical
Post-Op
Post-operative
PPDH
Prince Philip Dental Hospital
Materials and Equipment

AH Plus
Dentsply DeTrey, Konstanz, Germany

viii

ALL-BOND 2
Bisco, Schaumburg, Illinois, USA
Calasept
JS Dental, Ridgefield, Connecticut, USA
Cavit
3M ESPE, Seefeld, Germany
Corsodyl
SmithKline Beecham Consumer Healthcare, Maidenhead, UK
Esthet-X
Dentsply Caulk, Milford, Delaware, USA
File-Eze
Ultradent, South Jordon, Utah, USA
FlexoFiles
Dentsply Maillefer, Ballaigues, Switzerland
Fuji II TM LC
GC Corporation, Tokyo, Japan
Geitstlich Bio-Gide Geistlich Pharma AG, Bahnofstrasse , Wolhusen, Switzerland

Impregum TM
IRM
KetacCem
Micro-Opener
Obtura II
Obtura Spartan, Fenton, MO, USA
OPMI PROrgo operating microscope Ziesus Surgical, Oberkochen, Germany

ParaPost XP TM
Coltne/Whaledent Inc., Ohio, USA
PIEZON Master 400 EMS SA, Nyon, Switzerland

Poly F cement
Dentsply DeTrey, Konstanz, Germany
ProRoot TM MTA
ProFile
ProTaper
ProPexII TM
Apex Locator Dentsply Maillefer, Ballaigues, Switzerland
Radix Fiber Post
RelyX Fiber Post
RelyX TM Unicem
Self-Adhesive Universal Resin Cement

ix

Root ZX
J. Morita, Irvine, California, USA
TempBond TM NE
Kerr, Romulus, Michigan, USA
Touchn Heat 5004
SybronEndo, Orange, California, USA
Trim
Bosworth, Skokie, Illinois, USA
Ubistesin TM forte
Xylestein-A
Non-Surgical Endodontic Treatment
Non-Surgical Endodontic
Treatment
PPDH No. 237463 (Male, 64 years old)

Reason for referral: Persistent draining sinus with of 24 and 25
Medical History: Nil relevant
Working diagnosis: Chronic suppurative apical periodontitis associated with non-vital
pulp of tooth 24
Treatment provided: Non-Surgical RCT for 24
Prognosis: Good
Summary of treatment
Date
Treatment provided
13/01/2010 Consultation and examination

25/01/2010 RCT commenced for tooth 24
Working length determined
26/02/2010 Instrumentation completed for tooth 24
05/03/2010 Obturation of tooth 24
19/03/2010 24 restored with fiber-post and composite core foundation
12/07/2010 4 month review
Tooth 24
Fig. 1 Pre-operative (13/01/2010)
Fig. 2 Working Length (25/01/2010)

Fig. 3 Master Cone (05/03/2010)
Fig. 4 Post-obturation (05/03/2010)
Fig. 5 4 month review (12/07/2010)
* For tooth 24, there is a void between the root filling and the post. Another large void is present between
the coronal restoration and the root fillng. The standard of the root canal treatment is technically
unsatisfactory and better treatment could be done.
PPDH No. 184923 (Female, 35 years old)

Reason for referral: Blocked canal and discolored 11
Medical History: Patient had a pervious episode of allergic reaction in 07 and was
given steroids for the same. Patient informed that she was allergic to caffeine &
synthetic hydrotalcite. On the day of consultation she did not report about any other
allergies including penicillin upon questioning. However, after prescribing Amoxicillin
for a procedural error (Hypochlorite accident) that occurred during the treatment, the
patient developed an allergic reaction to it. When she reported to the hospital, she was
again questioned about any allergies and then she informed that she was allergic to
penicillin and aspirin. The patient was then referred to Queen Mary hospital to the E&D
department for further care.
Working diagnosis: Chronic apical periodontitis associated with nonvital pulp of tooth
11
Treatment provided: Non-surgical RCT for 11
Prognosis: Good
Date
Treatment provided

Size #25 K-file reached the apex un-obstructed
Instrumentation completed
29/01/2010 Hypochlorite accident occurred during treatment
Patient had I/O mild swelling extending from 12-22
E/O mild swelling was seen over the upper lip region
Patient was prescribed medication (Note: No allergies to any
antibiotics admitted)
Tab Amoxicillin 500mg (2tabs) TDS x 5days
Tab Ibuprofen 200mg TDS x 3days
Post-Op instructions were given
Patient reported after a couple of hours about swelling around her eyes
on further questioning she revealed that she was allergic to Penicillin
and Aspirin. She was instructed to immediately stop the medication
and report to the A&E department at Queen Mary Hospital to insure
appropriate management.
02/02/2010 Review examination
3

E/O Oedema seen around the eyes and the mild swelling around the
upper lip area had decreased
I/O 11 was tender to percussion
Swelling in the labial vestibule had decreased
Tooth 11 restored with composite resin
Tooth 11
Non-Surgical Endodontic Retreatment
Non-Surgical Endodontic
Retreatment
PPDH No: 268936 (Female, 39 years old)

Reason for referral: Ledged/Blocked canals with 48
Working diagnosis: Chronic apical periodontitis of 48 complicated with ledged canals
Treatment provided: Non-surgical re-RCT for 48
Prognosis: Good
Date
Treatment provided

01/03/2010 Working length determined; Instrumentation completed
Tooth 48 restored with a bonded amalgam core foundation
Tooth 48
Fig.3 Master Cone (26/03/2010)

Reason for referral: Persistent symptoms with 25
Medical History: Patient is hypertensive and on medication for the same
Working diagnosis: Chronic apical periodontitis of 25
Prognosis: Good
Date
Treatment provided

Working length determined; Instrumentation completed
23/04/2010 Tooth 25 obturated and restored with a fiber-post and composite resin
core foundation
*Patient did not come back for a follow-up
Tooth 25

Reason for referral: 24 persistent mild pain secondary caries beneath the CMC
Medical History: Patient is hypertensive and on medication for the same
Working diagnosis: Chronic apical periodontitis and secondary caries of 24
Prognosis: Good
Date
Treatment provided

RCT commenced for tooth 24
20/04/2010 Tooth 24 obturated and restored with a fiber-post and composite resin
core foundation
Tooth 24

Reason for referral: RCT of 46 due to blocked canals and pulp stone present
Working diagnosis: Chronic apical periodontitis of 46 complicated with blocked
canals
Treatment provided: Re-RCT for 46
Prognosis: Good
Date
Treatment provided
31/03/2010
Consultation and examination

Pulp stone seen in the pulp chamber and removed
28/04/2010
MB canal blocked and unable to achieve patency
04/06/2010
Working Length determined
07/06/2010
08/02/2010
Obturation of tooth 46
Tooth 46


Reason for referral: Radiographically under-extended root filling and the tooth
required a full coverage restoration.
Treatment provided: Non surgical re-RCT for 36
Prognosis: Good
Date
Treatment provided

13/04/2010 Tooth 36 obturated and restored with bonded amalgam core
foundation
13/07/2010 3 months review
Patient is on the waitlist for crown in the BDS pool.
Tooth 36
10

11
PPDH No: 263016 (Male, 79 years old)

Reason for referral: Perforated MB canal with 36
Working diagnosis: Chronic apical periodontitis of tooth 36 complicated with a
perforation at the MB aspect of the pulpal floor
Prognosis: Guarded for 36 due to the time lapsed after perforation and loss periodontal
support
Date
Treatment provided

01/04/2010 Working length determined
16/04/2010 Perforation sealed with GIC
Tooth 36 restored with a bonded amalgam restoration
Tooth 36
12
Fig. 3 Perforation Sealed (16/04/2010)
13

Reason for referral: Patient has been referred as the root canal had a C shaped
morphology
Prognosis: Good
Date
Treatment provided

Tooth 37 restored with bonded amalgam core foundation
Patient is pending for bridge cementation by BDS student
Tooth 37
14

15

Reason for referral: Leaking restoration and secondary caries associated with 37
Working diagnosis: Chronic apical periodontitis of 37 associated with secondary caries
Treatment provided: Removal of silver points and non-surgical re-RCT for 37
Prognosis: Fair, patency could not be achieved in the mesial canal as the canal was
obliterated
Date
Treatment provided

Silver points retrieved from the distal & mesial canals
Mesial canal was blocked
Tooth 37 restored with a bonded amalgam foundation
17/03/2010 Tooth 37 prepared for a CMC
Rubber based impression taken
11/05/2010 Try-in, then cementation of CMC for tooth 37
16/07/2010 3 months review
16

Tooth 37
Fig. 4 Silver point retrieved (07/12/2009)
17

Reason for referral: Recurrent swelling and pus drainage associated with 11
Working diagnosis: Chronic suppurative apical periodontitis of 11
Prognosis: Fair
Date
Treatment provided

28/04/2010 Obturation of tooth 11 with MTA
17/05/2010 Tooth 11 restored with a bonded composite core foundation
* Patient was unable to come for the review
Tooth 11
18

Fig. 3 MTA Obturation (28/04/2010)
19

Reason for referral: On and off tenderness form tooth 15
Working diagnosis: Chronic apical periodontitis of 15 associated with technically
incomplete root canal treatment
Prognosis: Good
Date
Treatment provided

15/01/2010 Instrumentation completed with tooth 15
Tooth 15 restored with fiber-post and composite core foundation
Tooth 15
20

21

Reason for referral: Failed RCT for tooth 11
Medical History: Diet controlled diabetes mellitus
Working diagnosis: Chronic apical periodontitis of 11 associated with incomplete root
canal treatment
Prognosis: Good
Date
Treatment provided

14/12/2009 RCT commenced for tooth11
Pin retrieved from the canal
Patient referred back to the BDS for post and crown
*Radiographically it was noted that the direction of post placement
was deviated away from the original path of the canal
Tooth 11
22
Fig. 4 Post-obturation (04/01/2010)*
*Radiograph was damaged in the re-fixing machine
23

Reason for referral: Blocked canals
Working diagnosis: Chronic apical periodontitis of 36 complicated with blocked
canals
Prognosis: Good
Date
Treatment provided

Distal Canal negotiated up to estimated WL
08/01/2008 ML canal located
Patient did not return for treatment for a very long time. She came back
for treatment when her temporary restoration dislodged and she
experienced mild pain with the tooth. Patient had gone to a GDP for
treatment and returned back as she had pain
09/10/2009 Examination Done
C/O- Dislodged restoration and pain in relation to 36
Root canal treatment was commenced
11/11/2009 Instrumentation completed
Tooth 36 restored with Bonded amalgam core foundation
18/01/2010 CMC preparation done with tooth 36
08/02/2010 CMC try-in done and cemented for tooth 36
24

Tooth 36
25

Reason for referral: Blocked/Ledged canals with 26
Working diagnosis: Chronic Apical periodontitis of 26 complicated with ledged canals
Treatment provided: Non-surgical re- RCT for 26
Prognosis: Good
Date
Treatment provided

Tooth 26
Fig. 2 Working Length (13/11/2009
26

27

Reason for referral: A new radiolucency was detected radiographically with tooth 21
Working diagnosis: Technically inadequate root canal filling and secondary caries of
21
Treatment provided: Non surgical re-RCT for 21
Prognosis: Good
Date
Treatment provided

15/04/2010 CMC cemented for tooth 21
*Patient did not return for a review
Tooth 21
28
29

Reason for referral: Perforation with 16 during RCT
Working diagnosis: Chronic apical periodontitis of 16 complicated with pulpal floor
perforation
Treatment provided: Non- surgical re-RCT for 16
Prognosis: Guarded due to the time lapsed from perforation and pre-existing
compromised periodontal support
Date
Treatment provided

25/01/2010 Perforation site located in the floor of the pulp and temporarily sealed
with Cavit and GIC
19/03/2010 Perforation site sealed with MTA
09/04/2010 Tooth 16 restored with bonded amalgam core foundation
Tooth 16
30
31
Surgical & Multiple Endodontic Treatment
Surgical & Multiple

Endodontic Treatment
Surgical & Multiple Root Canal Treatment

Reason for referral: Recurrent swelling and pus drainage form the 11, 12
Working diagnosis: Radicular cyst of 11, 12
Chronic apical periodontitis of 21, 22
Treatment provided: Re-RCT for 11, 12, 21, 22
Apicectomy for 11 and 12.
Prognosis: Fair for 21, 22, 11, 12
Date
Treatment provided

Continuous yellowish serous discharge seem to be oozing out from
tooth 11
12/05/2010 Working length determined for teeth 11, 12; Instrumentation
completed (Unable to completely dry the canal for tooth11)
20/05/2010 Obturation of tooth 12 with MTA
Unable to completely dry the canal for tooth 11 as there was
continuous serous discharge through the canal
RCT commenced for teeth 21, 22
28/05/2010 Obturation of teeth 21, 22 with MTA
31/05/2010 Tooth 12 restored with fiber-post and composite core foundation
01/06/2010 Apicectomy done for teeth 11, 12
11 treated with a through and through approach and obturated with
MTA
The bony defect was filled with bone substitute and covered with a
membrane and the flap was sutured back
08/06/2010 Sutures removed
14/07/2010 21, 22 restored with fiber-post and composite core foundation
32

Teeth 11, 12, 21 and 22
Fig. 1 Pre-operative
(22/04/2010)
Fig. 2 Pre-operative
(22/04/2010)
Fig. 3 Working Length

(12/05/2010)
Fig. 4 Working Length

(12/05/2010)
Fig. 5 Obturation 12 and

Working Length 21, 22
Fig. 6 Post-obturation
21, 22 (28/05/2010)
Fig. 7 Post-obturation 12
(31/05/2010)
Fig. 8 Apicectomy 11, 12

(01/06/2010)
Fig. 9 Post-operative
(17/07/2010)
33

*Tooth 21 was obturated with MTA, since the Apical size was #100 K file. After
Obturation, MTA was extruded periapically- probably while packing the material into
the canal and due to a difficulty in obtaining a satisfactory apical stop. MTA has been
demonstrated to be a highly biocompatible material (Kettering & Torabinejad 1995;
Asrari & Lobner 2003; Torabinejad et al 1995; Tunca et al 2007) adverse tissue reaction
would be considered minimal, if at all. Extrusion could be minimized henceforth by
placing a barrier (e.g. Surgicel, calcium sulfate etc) towards the apical end to act as an
apical plug.
Clinical Pictures (Surgical)

Fig. 12 Intra-operative (08/02/2010)
34

(2x2 cm fibrous tissue mass excised)

(Bone-substitute Bio-Oss)

(Membrane Bio-Gide placed)

(Sutures Placed)
Fig. 18 Post suture removal (14/07/2010) Fig. 19 Post suture removal (14/07/2010)
35
Appendix
36

Reason for referral: Persistent pain with 24
Working diagnosis: Chronic apical periodontitis of 24 complicated with buccal
fenestration of the root tip
Treatment provided: Non surgical re-RCT followed by apicectomy for 24
Prognosis: Fair
Date
Treatment provided

25/11/2009 Perforation present on the buccal canal at the apical-third.
27/01/2010 Instrumentation completed
17/03/2010 Obturation palatal canal obturated with GP and AH Plus sealer
Buccal canal Obturated with a MTA
14/04/2010 Tooth 24 restored with a bonded amalgam core foundation
09/06/2010 Apicectomy done with tooth 24
14/06/2010 Suture removal
Tooth 24
37

Fig. 3 Obturation of Palatal with GP
(17/03/2010)
Fig. 4 Obturation of buccal with MTA

and followed by bonded amalgam
restoration (17/03/2010)
Clinical Pictures
38

Fig. 9 Resected root tip (09/06/2010)
(09/06/2010)
Fig. 10 Methylene blue staining

(09/06/2010)
Fig. 11 Retero-preparation (09/06/2010)
Fig. 12 MTA retero-filling (09/06/2010)
Fig. 13 Post-operative radiograph

(09/06/2010)
Fig. 14 After suture removal

(23/06/2010)
39

Fig. 14 After Suture removal (23/06/2010)
40

Reason for referral: Blocked Canals
Working diagnosis: Chronic apical periodontitis of 16, 24
Carious 36 with blocked /ledged canals
Treatment provided: Non-surgical re-RCT for 16, 24
36 surgical extraction followed by 38 auto-transplantation into
the 36 extraction socket
Prognosis: Good 16
Fair for tooth 24: canal perforation on 26 apical third
Guarded for tooth 38: The tooth is just like an avulsed tooth thus, may have
chances of replacement resorption , but considering that the extraction was
performed under sterile conditions and tooth has been placed into the
socket within 15 minutes it could have an improved prognosis
Date
Treatment provided

03/02/2010 Re-RCT commenced for tooth 24
Perforation noted in the buccal canal
27/01/2010 Obturation of tooth 24 with GP and AH Plus; buccal canal over the
down pack a 2mm layer of MTA was placed to seal the perforation.
29/01/2010 Tooth 24 restored with fiber-post and composite resin core
The MB2 was located and merged into the MB canal
26/04/2010 Tooth 16 obturated and restored with a bonded amalgam core
foundation
02/06/2010 RCT commenced for 36
On caries excavation from the floor of the chamber the floor appeared
very thin and the restorability was doubtful
The prognosis was poor thus extraction was recommended for tooth 36
41

21/07/2010 Auto-transplantation was done with 38 as the donor tooth to replace the
extracted 36
28/07/2010 Suture removal for 38
04/08/2010 Tooth 38 no signs or symptoms
RCT commenced with tooth 38
11/08/2010 Obturation of tooth 38 with GP and AH Plus
Tooth 28 restored with bonded amalgam restoration
Splint removal
Tooth 24
42

Tooth 16
Tooth 36 & 38
43

Fig. 11 Auto-transplanted 38
(21/07/2010)
Fig. 14 Post-operative (11/08/2010)
44

Clinical pictures
Fig. 14 36 Extraction Socket

(21/07/2010)
Fig.15 36 Extraction Socket

(21/07/2010)
Fig. 16 Extracted 36 (21/07/2010)
Fig. 17 Extracted 38 (21/07/2010)
45

Fig. 18 Transplanted 36 (21/07/2010)
Fig. 19 Splinted 38 (21/07/2010)
Fig. 20 Suture Removal for 38 (28/07/2010)
46
PPDH No. 154144 (Male, 57 years old )

Reason for referral: Transportation of the canal with 25
Working diagnosis: Chronic apical periodontitis of 25 complicated with apical
transportation of the canal
Treatment provided: Apicectomy with through and through tooth preparation for 25
Prognosis: Fair, due to compromised periodontal support
Date
Treatment provided
15/04//2010 Consultation and examination

Continuous oozing of serous yellowish fluid noted through the canal
Canal dressed with Calcium Hydroxide
27/04/2010 Working Length determined
Unable to dry the canal
Yellowish serous fluid seen oozing through the canal and unable to
dry the canal
25/06/2010 Unable to dry the canal
Yellowish serous fluid seen oozing through the canal and unable to
dry the canal
Canal dressed with Calcium Hydroxide
21/07/2010 Apicectomy done with 25
through and through preparation of tooth 25
Tooth 25 obturated with MTA
28/07/2010 Suture removal
30/07/2010 Tooth 25 restored with fiber- post and composite core foundation.
47

Tooth 25
Fig. 1 Pre-operative from the referring
GDP (15/04/2010)

(15/04/2010)

(15/04/2010)
Fig. 4 Apicectomy with MTA

Obturation (21/07/2010)
48

Clinical Pictures
Fig. 13 Suture Removal (28/07/2010)
49

Reason for referral: Incomplete RCT with 46
Apical periodontitis and under-extended root fillings with 14, 23
and 26
Chronic apical periodontitis and apical strip perforation of 14
Chronic apical periodontitis with furcation perforation of 26
Treatment provided: Non-surgical re-RCT for 46, 26, 23
Non-surgical re-RCT followed by apicectomy for 14
Single tooth implant with 16
Prognosis: Good 46, 23
Fair 14, 26
Date
Treatment provide

27/01/2010 Obturation of 46 done
Instrumentation completed with 26
Furcation perforation sealed with MTA
21/04/2010 Obturation of 26
Obturation of 23
Obturation of 14 done with MTA
50

01/06/2010 Apicectomy done for 14
Implant placed in the area of 16
08/06/2010 Post-surgical review; Sutures removed
21/06/2010 Tooth 14 restored with fiber-post and composite core foundation
14/07/2010 Crown preparation done for 26 (CMC)
02/08/2010 CMC cementation for 14, 26 and 46
6 month review for tooth 46; 3 month review tooth 26
Tooth 46
51

Tooth 26
Fig. 8 Perforation sealed with MTA

(14/04/2010)

(14/04/2010)
52

Tooth 23
Tooth 14
53

Fig. 19 Obturation with MTA
(26/05/2010)
Fig. 20 Apicectomy 14 (01/06/2010)

(01/06/2010)
16 Implant Placement
Fig. 22 Implant placement (01/06/2010)
Fig. 23 Implant placement (01/06/2010)
54

Clinical Pictures (Pre-operative)
Surgical clinical pictures

Fig. 28 Apicectomy with 14 (01/06/2010)
55

Fig. 29 16 Implant (01/06/2010)
(01/06/2010
Fig. 30 16 Implant placement

(01/06/2010)
Fig. 33 Post-operative
56
Surgical endodontic treatment
Multiple endodontic
treatment
Multiple Root Canal Treatments

Reason for referral: Persistent sinus with 21
Working diagnosis: Chronic suppurative apical periodontitis of 21
Chronic apical periodontitis of 17
Non-surgical treatment for 21
Prognosis: Good for tooth 21
Guarded for tooth 17, due to compromised periodontal support
Date
Treatment provided

Tooth 21 restored with composite core foundation
Patient informed that he needed to get restorations done, but he
insisted that he would get it done later after the treatment
22/02/2010 Working length determined; Instrumentation completed for tooth 17
Tooth 17 restored with bonded amalgam restoration
*Patient did not trun up for a review
Tooth 21
57

Tooth 17
58

Reason for referral: Recurrent abscess associated with 12 &13
Chronic apical periodontitis of 12, 13 and 14 associated
technically inadequate filling
Treatment provided: Non-surgical re- RCT for 12, 13 & 14
Non-surgical RCT for 15
Prognosis: Good, for 13, 14, 15
Date
Treatment provided
02/03//2010 Consultation and examination

Cast-post removed
Perforation detected on the labial aspect of the canal at the apical third
30/03/2010 Another perforation detected on the palatal aspect of the canal at the
apical third
Cast-post removed
Tooth 12 had a poor prognosis and thus extraction was recommended
Obturation done for 13
18/05/2010 Tooth 13 restored with a para-post and composite core foundation
11/06/2010 Extraction done for tooth 12
Cast-post removed
59

16/07/2010 Working length determined for tooth 14 (Palatal canal was not treated
by the previous operator)
B canal was perforated in the apical third; Instrumentation completed
B canal obturated with MTA (Apical third)
P canal Obturated with GP and AH Plus
27/07/2010 B canal obturated with GP (Backfill)
Tooth 14 restored with fiber-post and composite core foundation.
Tooth 12 and 15
Fig. 1 Pre-operative 12 (02/03//2010)
Fig. 2 Pre-operative 15 (02/03//2010)
60

Tooth 13
Fig. 6 Pre-operative (02/03//2010)
Fig. 9 Obturation and Post Try-in

(29/04/2010)
*The post-operative radiograph was lost in the fixing machine
61

Tooth 14
Fig. 10 Pre-operative (02/03//2010)
Fig. 13 Obturation (23/07/2010)
Clinical Pictures
Fig. 10 Post removed from 13
(29/04/2010)
Fig. 11 Post removed from 14

(16/07/2010)
62

Reason for referral: Persistent abscess with 16
Medical History: Hypertensive and on medication for the same
Working diagnosis: Chronic suppurative apical periodontitis of 16, 45
Chronic apical periodontitis of 44
Treatment provided: For tooth 16 - place MTA plug over the MB root with an
orthograde approach sealing the DB, P root canal orifices with
IRM and restore 16 with a bonded amalgam core foundation,
Crack line was seen during the surgery thus tooth 16 was
extracted
Non-surgical RCT for 25
Non-surgical re-RCT for 24
Prognosis: Fair for tooth 44, 45
16 Extracted
Date
Treatment provided

MTA plug placed for MB and IRM for DB and P canals.
16 restored with bonded amalgam core foundation
09/12/2009 PA surgery done by reflecting a flap.
Crack line seen extending from the furcation area to the middle-third
of the DB root. Patient referred for extraction of tooth 16
Tooth 45 restored with fiber-post and composite resin core foundation
Instrumentation completed for tooth 44
44 restored with fiber-post and composite resin core foundation
63

Tooth 16
(09/11/2009)
Fig. 2 MTA plug at the distal root

(09/11/2009)
Teeth 44 and 45
Fig. 3 Pre-operative 44, 45 (05/11/2009)
Fig. 4 Pre-operative 44, 45 (05/11/2009)
Fig. 5 Working Length 45 (23/11/2009)
Fig. 6 Master Cone 45 (03/02/2010)
64

Fig. 7 Post-obturation 45 (03/02/2010)
Fig. 8 Working Length 44 (03/02/2010)
Fig. 9 Master Cone 44 (01/03/2010)
Fig. 10 Post-operative 44 (01/03/2010)
65

Reason for referral: 12, 22 were obturated with silver points 10 yrs back and became
symptomatic
Treatment provided: Removal of silver points and non-surgical re-RCT for 12, 22
Prognosis: Good
Date
Treatment provided

Silver point retrieved
Silver point retrieved
25/11/2009 Obturation of teeth 12, 22
15/12/2009 Fiber-post cementation and core build up for teeth 12, 22
Teeth 12, 22 restored with composite restoration.
Teeth 12 and 21
66

67

Reason for referral: Under-extended root filling with 13, 16, 14, 24
and need for a full coverage coronal restoration
Medical History: Not relevant
Working diagnosis: Technically incomplete RCT of 13, 14, 16, 24
Treatment provided: Non-surgical re-RCT for 13, 14, 16, 24
Prognosis: 13, 14, 16, 24 Good
Date
Treatment provided

MB2 located and it merged into the MB
19/04/2010 RCT commenced for teeth 13, 14
21/04/2010 Obturation of 13, 14
13, 14 restored with fiber-post and composite core foundation
Instrumentation completed for 24
23/07/2010 6 month review for tooth 16
3 month review for teeth 13 & 14
68

Tooth 16
Fig. 4 6 month Review (23/07/2010)
Teeth 13 & 14
69

Tooth 24
70
Some Aspects of Push-out bond strength of

Adhesive luting cements
Submitted in partial fulfillment of the requirements for the degree of
Advanced Diploma in Endodontics

at The University of Hong Kong
August 2010
By
Prajakta Mahindre
BDS (Maharashtra University of Health Sciences, India)
MDS (The University of Hong Kong, Hong Kong)
PREAMBLE
This research project entitled Micro-push-out bond strength and the modes of failure
for a fiber-reinforced resin-post system cemented using four adhesive luting cements,
which was submitted to the University of Hong Kong as a partial requirement of the
Masters of Dental Surgery in Endodontics, 2007-2009.
These papers were written during the course of study 2009-2010. The first paper is
under review with Hong Kong Dental Journal. The second paper has been submitted
to Quintessence International, for review and publication.
Acknowledgement
Acknowledgement
I would like to express my gratitude to Dr Gary Cheung, my supervisor for this
guidance, advice and patience from the initial phase of my research. I also would like to
acknowledge him for showing patience and tolerance for proofreading the write-ups for
the thesis as well as the papers.
I would like to thank Dr Jeffrey Chang for his guidance and especially for
lending us his idea of the loading machine, without which the second part of the study
would not be possible.
Dr Robert Ng, my sincere thanks for your constant guidance, help and advice
through-out.
I am deeply indebted to my friends Parth Arya and Bhomik Chandana for being
patient, giving me their time and especially for helping me with the excel sheets,
calculations and helping me format my documents.
I would like to extend my acknowledgement to Mr. Tony Yip, Mr. Shadow
Yeung and Mr. Chiu Ying-Yip of the Dental Materials Science laboratory of Faculty of
Dentistry, The University of Hong Kong for preparation of the materials and equipment
needed for the research project. Special thanks to Mr. Shadow Yeung for helping me
with the statistics.
ii
Table of Contents
Table of Contents
Preamble
Acknowledgements
ii
Table of Contents
iii
Paper I
The effect of cyclic loading to fiber-reinforced resin post retention:
push-out bond strength
Abstract
Introduction
Material and Methods
Results
11
Discussion
12
Conclusion
14
References
15
Tables and Figures
22
Paper II
Flowable composite not a good substitute for the placement of fiber
reinforced resin post
iii
Table of Contents
Abstract
25
Introduction
26
Material and Methods
27
Results
32
Discussion
33
Conclusion
34
References
35
Tables and Figures
39
iv
The effect of cyclic loading to fiber- reinforced resin post retention:

push-out bond strength
P.P. Mahindre, G.S.P. Cheung
Area of Endodontics, Comprehensive Dental Care, Faculty of Dentistry, The University of Hong Kong,
HKSAR, China
Abstract
Objective: To compare the micro-push-out bond strength and mode of failure of a
fiber-reinforced resin post cemented with a dual-cured resin cement in extracted
human teeth, with and without simulated occlusal loading.
Materials and Methods: Single-rooted, extracted human teeth were root canal treated
and divided into two groups (n=16 each) by stratified, random sampling. The teeth
were decoronated, and a prefabricated fiber-reinforced resin post (Radix, Dentsply
Maillefer) was cemented in each using Panavia F 2.0 (Kuraray). A layer of silicone
sealant was painted over the root surface to about 2mm below the CEJ to simulate the
periodontal ligament. Then, the tooth was embedded into an acrylic resin and secured
in a jig so that it formed an angle of 135 degrees with a loading stylus (inter-incisal
angle). The specimens were cyclically loaded up to 70 N for a total of 120,000 cycles.
Then, the roots were retrieved and sectioned into slices of about 1 mm thick. Push-out
tests were performed at a cross-head speed of 1mm/min in a universal testing machine
(Instron), and the data was analyzed using one-way ANOVA and two-sample t-test,
where appropriate, at = 0.05.
Results: No significant difference was found in the micro-push-out bond strength at
various levels of the root canal for loaded and unloaded groups (ANOVA, p 0.05).
The loaded group demonstrated a significantly lower bond strength (5.2 3.0 MPa),
compared with the non-loaded specimens (12.9 5.0 MPa) (t-test, p < 0.05).
Conclusion: The micro-push-out bond strength of a fiber-reinforced resin post

cemented with Panavia F 2.0 was not influenced by the depth of the post space, but
the value decreased after simulated occlusal loads.
Introduction
Endodontically treated teeth have a clinical impression of being more brittle
(i.e. more prone to fracture) than vital teeth (1). The strength of these teeth are often
jeopardized by preexisting loss of tooth structure due to caries, trauma, or other
conditions nessitating root canal therapy. Root canal posts often are required for their
restoration. This is also an area where the endodontists meet the prosthodontists in
their fight for space to optimize treatment success. The aims of this article were to
provide a brief summary of concerns for post-endodontic restorations and to examine
the effect of occlusal loading on the retention of post-and-cores with a dual-cured,
dentin adhesive cement.
Strength of a tooth
It has been shown that the loss of one or more marginal ridges would lead to
the reduction of the fracture strength for posterior teeth (2). On the other hand,
endodontic procedures on an otherwise intact premolar would result in a 5% reduction
in the cuspal stiffness, which in contrast to a greater reduction for a MOD cavity
preparation that averaged 63% loss in stiffness (3).
The dentin itself had been considered to be weakened due to the loss of water
content following pulp extirpation (4), although others failed to confirm a loss of
moisture content of dentin after endodontic treatment to any significant degree
(5).The loss of collagen cross-linking (6), probably a result of the release and the of
the action of the metallo-proteinase enzymes that are released after disintegration of
the pulpal soft tissue (7, 8). The loss of neural stimuli from the pulp might alter the
sensory input to occlusal loads, so that the root canal-treated teeth could become
overloaded and fracture before the patient perceives the excess load placed on the
tooth (9).
Chemical agents used during root canal treatment can have an impact on the
physical properties of dentin. Ethylene-diamine-tetraacetic acid (EDTA) could deplete
the inorganic content of dentin (10), while calcium hydroxide and sodium
hypochlorite would digest the organic content (11). The alternate use of NaOCl and
EDTA would progressively cause removal of the organic and inorganic materials of
the root dentin substrate, reducing its micro-hardness (12). The flexural strength of
dentin may be reduced by the use of calcium hydroxide or 3 to 5% sodium
hypochlorite (11). This calls for a judicious use of concentrated irrigating agents and
extra-long term use of calcium hydroxide dressing.
Root canal post
A root canal post will be required for the teeth with remaining dentin being
insufficient to provide resistance or retention for the final restoration. Posts are
available in various shapes, configurations and dimensions. Traditionally, they were
metallic, either pre-fabricated or cast, and were cemented with either zinc-phosphate
or glass ionomer cements. There are esthetic concerns with metallic posts, as well as
an un-restorable mode of fracture if this should happen (13, 14). Nowadays, fiberreinforced resin posts (or simply known as fiber-reinforced resin posts) are gaining
popularity. Having a modulus of elasticity similar to that of dentin is advocated as an
advantage for fiber-reinforced resin posts, allowing them to flex slightly and
mimicking the tooth movement upon functional loading (15). Another often-quoted
advantage of fiber-reinforced resin posts is the ability to bond to dentin with adhesive
resin cement. This is thought to mediate a union between the fiber-reinforced resin
post and the tooth substance, providing reinforcement to the root and reducing the
chance of root fractures (16). Clinically, a reduced amount of tooth and/or root
fracture has been reported when the tooth is restored with a fiber-reinforced resin post,
compared to those similarly restored teeth without a post. Should fracture occur, the
fiber-reinforced resin post tends to break leaving the remaining root intact (17).
In addition to providing retention, root canal posts should play a role in
preventing microleakage by limiting any micromovement at the margins of the
coronal restoration due to occlusal loads; such micromovement is considered as a
precursor to coronal leakage (18). Re-infection of the root canal system through a
breakdown of coronal seal can lead to failure of endodontic treatment (19). Thus, the
flexible nature of fiber-reinforced resin posts is considered a disadvantage by some
authors (20, 21).
Cavity configuration factor (C-factor), being the ratio of the area of the bonded
to that of the unbonded surface of a cavity is an important consideration for dentin
adhesion (22). During polymerization of the resin cement, material at the unbonded
surface can move and flow, thereby relieving the shrinkage stresses. However, as the
unbonded surface area becomes small, there is insufficient stress relief and a high
probability for one or more bonded surface to debond, succumbing to the shrinkage
stress developed in the material. For the root canal, the C-factor is extremely high that
could exceed a value of 200 (23, 24, 25, 26). To reduce the effect of the problem, the
use of a slower-setting material may be advantageous. This concept was supported by
the result of a study showing that two chemically cured cements (C & B Meta Bond Parkell INC and Fuji Plus - GC America INC) with a longer setting time than dual-
cure cement, showed a lower incidence of spontaneous cementation failure during

specimen preparation (25).
The luting procedure is an important and a critical aspect in the use of fiberposts. Majority of the clinical failures of teeth restored with fiber reinforced resin
posts occur by debonding (27). The application technique used and the viscosity of
the cement are important factors that may affect the bond strength values and the
complete setting of the post in the canal (28). It was previously reported that a
uniform and favorable distribution of the cement layer could be obtained by using the
lentulo spiral (29).Voids and bubbles formed during the application of the luting
cement, could impede the proper cementation of the post, which may cause debonding
as a sequel (30). Several authors recommended the use of a lentulo spiral or the use of
an injection technique for application of the cement into the post space (16, 29, 31).
The use of injection technique followed by the use of lentulo spiral for 4 s has been
recommended by other authors as it exhibited increased retention of the post (32, 33).
Whereas, DArcangelo et al. (2007) exhibited no difference in the retention of fiber
reinforced resin post system despite of the application techniques used (34).
From a review of literature there seems to be a conflict between the desire for
a flexible post and the wish to maintain a crown margin that is free of micromovement
(and hence microleakage) during the function (35). There is a scarcity of reports of the
effect of functional loads on the retention provided by adhesively cemented fiberreinforced resin posts. With that in mind, an experiment was devised to examine the
retention of a tooth-colored fiber-reinforced resin post retained with a chemically
cured adhesive cement and the effect of simulated occlusal loads.
Materials and Methods
One hundred and twenty recently extracted, single-rooted human maxillary and
mandibular teeth, including central and lateral incisors, canines and second premolars
were collected and stored in 1% Chloramine T solution. Teeth with root caries,
hypoplasia, non-carious cervical cavities, any pre-existing restorations, root canal
treatment, calcified canal, presence of crack line (examined under an operating
microscope), open apices and resorptive defects were discarded. Only those with an
oval to round canal were chosen. For this study a total number of thirty-two teeth
were included. They were immersed in 6% sodium hypochlorite (Clorox, Oakland,
CA, USA) solution for 3 minutes to facilitate removal of the organic remnants from
the root surfaces. An ultrasonic scaler was used to remove any hard deposits. The
mesio-distal and bucco-lingual diameters at the cemento enamel junction (CEJ) for
each tooth were measured using a pair of calipers (Digimatic caliper; Mitutoyo, Hants,
UK) and radiographs were exposed in these two directions for each. The specimens
were divided into two groups (n=16), using a stratified random sampling method so
that the two groups had similar overall dimensions.
Selected teeth were decoronated using a diamond disc (Horico; Hopf, Berlin,
Germany) under continuous air-water spray cooling at a level 1.5 mm coronal to the
cemento-dentinal junction (CEJ). Root canal treatment was performed at a working
length which was 1 mm short of the canal length (distance at which the tip of a size 10
K-file was seen at the apical foramen) using the ProTaper rotary system (Denstply
Maillefer, Ballaigues, Switzerland) at 250 rpm up to the F4 instrument. Canals were
irrigated with 6% sodium hypochlorite and patency checked after the use of each
rotary file. The final rinse consisted of 3 ml of 17% EDTA followed by 3 ml of
deionized water. All irrigants were delivered into the root canals using a 28-gauge
end-exiting needle in a 3 ml syringe. All canals were obturated using the warm
vertical compaction of gutta-percha with AH Plus sealer (Denstply Maillefer,

Ballaigues, Switzerland)
A post space of approximately 9 mm deep was left after the down-pack. After
24 hours the post space was refined using proprietary drills of a fiber-reinforced resin
post system (Radix fiber post; Denstply Maillefer, Ballaigues, Switzerland). The post
was pre-fitted according to the manufacturers recommendation. After try-in, it was
wiped with alcohol and air dried. Then, the post hole was thoroughly rinsed with 3 ml
6% sodium hypochlorite, followed by 3 ml deionized water and then 3 ml
chlorhexidine, before it was dried with paper points.
The procedures for cementation of the post were same for both groups. Equal
amounts of ED Primers A and B (Panavia F 2.0; Kuraray: Okayama, Japan) were
mixed in a dappen dish with a micro-brush. Two consecutive coats were applied on
the post and into the post space. Excess primer was removed from the post hole using
a paper point, followed by a gentle flow of air from a 3-in-one syringe directed
horizontally across the incisal/occlusal surface. Then, equal amounts of paste A and B
(Panavia F 2.0) were mixed according to the manufacturers recommendations and
applied into the post hole using a lentulo spiral and onto the post. The post was
inserted in a smooth, steady motion and held in position with a firm finger pressure
for 5 minutes. Excess cement was removed using a no. 15 scalpel blade (Paragon,
Sheffield, England) and a curing light was directed from the top of the post for 40 s. A
core build-up was performed using a dentin adhesive (All-Bond 2; BISCO,
Schaumburg, IL, USA) and a composite resin material (Estheti-X; Denstply DeTrey,
Konstanz, Germany). The composite material, in not more than 2mm-thick increment,
was syringed directly around the post and adapted to shape with a plastic instrument.
Each increment was light cured for 20 s. The final height of the core build up was
5mm with a stepped platform (2 mm wide and 2 mm tall) on the palatal surface,
which would be the site for load application for the loaded group.
Simulated occlusal loading

Prior to loading, a layer of silicone sealant was painted over the root surfaces
to about 2 mm below the CEJ (on the buccal aspect), to imitate the periodontal
ligament (17). The root portion was then embedded in a self-cured acrylic resin
(Rapid Repair; Denstply DeTrey) to the same level of the silicone sealant to simulate
the crestal bone. The embedded tooth was secured in a holder to produce an interincisal angle of 135 degrees with the loading stylus (35) (Fig. 2). ). Each specimen
was cyclically loaded up to 70 N for a total of 120,000 cycles, at a frequency of 2-3
Hz after the core build-up after the post cementation. After the cyclic loading, each
specimen was inspected for the silicone layer intactness and under magnification
(2.5X) with the aid of a sharp probe for signs of root fracture; the specimen would be
discarded if such signs were evident. For all the specimens the silicone layer was
intact and no breakdown or deformation was noted.
Micro-push-out bond strength

All specimens of were embedded in an acrylic resin (Rapid Repair) and then
sectioned horizontally into slices of approximately 1 mm thickness, with a microtome
(SP-1600; Leica Microsystems, Wetzlar, Germany) using a 340 m-thick blade. The
specimens were fed at a rate of about 50 m per minute to avoid disruption of the
cement lute. The first cut was made at the junction of the ferrule and the core material,
i.e. top of the post hole. Depending on the length of the post, some 5 to 6 slices were
obtained, from the top of the ferrule until the entire length of the post was included.
The coronal side of each slice was marked with an indelible marker for identification.
For each specimen, the diameter of the post along the buccal-lingual (X-axis)
and mesial-distal (Y-axis) direction on both the coronal-facing and the apical-facing
surfaces were measured under a travelling microscope (Laour-Lux 12 MES, Leitz,
Wetzlar, Germany). The thickness of the luting cement was similarly measured at the
locations where it was noted to be the thickest and the thinnest. The thickness of each
slice was measured using a digital caliper to a precision of 0.01 mm. Then each slice
was placed, in turn, on the platform of a universal testing machine (Instron;
Testometric, Rochdale, Lancashire, UK) with the coronal surface facing down.
Plungers were custom made to be 0.2 mm smaller in diameter than the post for the
various slices. Care was taken to center the plunger on to each cross section to avoid
contacting the surrounding dentinal wall. Force was applied, with a cross-head speed
of 1 mm/min, until the post was completely disloged from the tooth substance.
All debonded specimens were inspected under the travelling microscope
(Laour-Lux 12 MES) to determine the mode of failure, based on a classification
described by some authors (32, 37).
Type 1 Adhesive failure between the post and the luting material
Type 2 Adhesive failure between dentin and the luting material
Type 3 Cohesive failure of the luting material
Type 4 Cohesive failure of the post
Type 5 Mixed type, a combination of any two or more failures types mentioned
above
Data Analysis
10
The surface area (A) was determined for the post (A1) and the root canal space
(A2) allowing for the thickness of the cement, using the general formula (38)
Where, D1 and D2 are the diameter on the coronal and apical surface, respectively, and
h the thickness of the section. For the purpose of calculating the shear bond strength ,
the effective adhesive surface area A was taken as the average of A1 and A2, so that
Fmax was the maximum load when dislodgement of the post occurred (32). The pushout-bond strengths among various horizontal levels (coronal to apical) of the root
were first examined for any difference using one-way analysis of variance (ANOVA)
at a significance level of p = 0.05. If a significant difference was noted, post hoc
multiple comparison tests were carried out at = 0.01 (Bonferroni correction). Then,
difference between the non-loaded and loaded group was examined at = 0.05 using
a parametric or non-parametric test were appropriate.
Results
The core build-up for all the specimens was intact after loading and no
debonding, defects or fractures were observed in the tested samples. It has been
shown that the teeth restored with fiber reinforced resin post, core and a crown show
micromovement after loading leading to leakage (35). Thus in this study the loads
were directly applied to the cores to determine whether the loading affected the
integrity of the core build-up itself (36).
11
Mean bond strength values

The mean bond strength values for various horizontal slices with and without
loading are given in Table 1. There was no significant difference in bond strength at
different levels of the canal, although the value tended to be greater for the coronal
than the apical sections (Fig. 1). The data was pooled for examining the difference
between the groups. The loaded group demonstrated a significantly lower mean bond
strength than for the non-loaded group (t- test; p < 0.001). Adhesive failures (type 1 or
2) were the most often mode of failure observed (Table. 2). There seemed to be a
slight shift towards more Type 4 and 5 failures after simulated occlusal loading but
the difference was not statistically significant (Chi-square Test, p 0.05) (Table 2).
Discussion
A variety of experimental set-ups, including the pull-out, micro-tensile and
micro-shear (push-out) test, have been used for determining the bond strength for root
canal posts to the root dentin. For the pull-out technique, the post is clamped and a
tensile stress is applied to dislodge it along the path of insertion. This method is liable
to give rise to non-uniform stress distribution along the lengthy area of adhesive
interface (39). Micro-tensile test allows for a more even distribution of stresses, due to
the use of smaller-sized specimens (40, 41). However, testing the bond strength of
endodontic posts using the micro-tensile technique is sensitive to the process of
specimen preparation. The root has to be horizontally sectioned, and then trimmed
into small slices of uniform dimensions. The application of micro-tensile tests
therefore is, limited. A high incidence of premature failures has been noted during
12
specimen preparation. Micro-push-out test appears able to eliminate most of the

problems that occur with the micro-tensile technique for testing the retention of root
canal posts (42). It outclasses the (macroscopic) pull-out test by eliminating the nonuniform stresses at the adhesive interface that develop in a thick section (43). A
compressive stress is applied on the apical end of the post, which is equivalent to
pulling the post in the coronal direction, such an experimental set-up can be controlled
much more easily.
Panavia F 2.0 is a resin based, dual-cured cement that has a long track record.
It
contains
phosphate-based
functional
monomer,
10-MDP
(10
Methacryloyloxydecyl dihydrogen phosphate). This molecule has been shown to

chemically interact with hydroxyapatite that remains after dentin conditioning (44).
Due to the low solubility of the MDP-calcium salt in water, this bond is expected to
be stable in aqueous environment (45).This cement mediates a bond of similar
strength at various levels of the root canal, an observation also reported by others (46).
In contrast, some reported significant higher bond strength values in the coronal than
apical sections for RelyX Unicem and Panavia F (25, 47). Higher density of dentinal
tubules and, hence, longer and greater number of resin tags in the coronal area (48, 49)
and a better accessibility during the bonding procedure are considered as factors
contributory to a higher bond strength in the coronal regions (25, 50, 51). The lack of
difference in the bond strength at different depths of the canal in this present study
may be related to an effective bonding technique.
It may not be surprising that the retention of fiber-reinforced resin post
decreases after repeated (functional) loading. Cyclic loads may cause microcracks to
develop at the resin-dentin interface (52). While the origin of the crack is largely
unknown, it might be related to a break in the integrity (of part) of the perimeter of the
13
post due to the high C-factor. When a post-and-core retained restoration is subjected
to an oblique load (for an anterior tooth), stresses are concentrated in the coronal
aspect of the post hole (53, 54) and micro-movements at the restoration margin
(especially on the palatal aspect) can occur. The result would be an increased amount
of leakage that can be demonstrated by dye penetration or with other molecules (35).
Other investigators have tested some metallic posts (pre-fabricated stainless
steel vs. cast), both cemented with Panavia F (Kuraray), but failed to find an effect on
the bond strength due to cyclic loading (55) but some authors exhibited vice versa in
their study ( 56, 57).
Analysis of the failure mode revealed that adhesive failure was more common
than the cohesive or mixed mode. A similar finding has been reported by other studies
(32, 46). Of the two adhesive interfaces present for root canal posts, a greater amount
of failure was observed between the post and the luting cement (Type 1; see Fig. 2).
Pre-treatment of the fiber-reinforced resin posts aiming to improve the union with the
resin cement should improve their retention in the root canal space (58, 59). In
summary, the results of our study indicated a deteriorating effect on the bond between
a fiber-reinforced resin post and dual-cured resin cement.
Conclusion
Within the limited scope of this research, it was concluded that
1) The bond strength mediated by dual cured adhesive cement (Panavia F 2.0)
is not affected by its location in the root canal.
2) Cyclic loading can have a significant influence on the bond strength
between the fiber-reinforced resin post and the root canal dentin.
3) Adhesive failure is the most prevalent reason for loss of retention for fiberreinforced resin post cemented with this brand of adhesive cement.
14
However, more research would be required in testing the specimens restored with
crowns under situations to simulate actual clinical occlusal function (including both
lateral and protrusive excursion).
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21
Figures and Tables

Figure 1 Comparison of the bond strengths for the cyclically loaded and nonloaded groups
Coronal
Apical
22
Figure. 2 Illustrative photograph of the rested sample
2 mm
Loading
Platform
1350 Interincisal
angle
23
Table 1 Micro-push-out bond strength at different horizontal levels

Non-loaded (Group 1)
Sections
Loaded (Group 2)
Mean (MPa)
S.D
Mean (MPa)
S.D
15.25
5.43
5.63
3.26
12.78
4.48
6.71
3.45
11.26
4.09
5.48
2.36
12.37
4.65
4.30
2.10
(Most apical) E
13.44
6.24
3.43
2.80
(Most coronal) A
P > 0.05
P > 0.05
Table 2 Modes of failure after micro-push-out test

Group
Type 1
Type 2
Type 3
Type 4
Type 5
Non-loaded
57
26
52
27
18
15
(n = 97)
Cyclically loaded
(n = 112)
Value for type 3 was eliminated for the Chi-square test. Other groups showing
a non significant difference in the amount of various modes of failures
between the two groups.
24
Flowable composite not a good substitute for the placement of

fiber reinforced resin post
P.P. Mahindre, G.S.P. Cheung
Area of Endodontics, Comprehensive Dental Care, Faculty of Dentistry, The University of Hong Kong,
HKSAR, China
Aim: To evaluate the push-out bond strength and the modes of failure for a fiberreinforced resin post system cemented with four adhesive luting cements.
Material and methods: Sixty four extracted single-rooted human teeth, each with a
single root canal, were decoronated and root canal treated, and then randomly divided
into 4 groups (n=16). A fiber post (Radix fiber-post; Dentsply, Maillefer) was cemented
in each tooth using one of the four adhesive luting cements: Panavia F (PVF), RelyX
Unicem (RXU), SmartCem2 (SC2) and CoreX Flow (CXF), followed by a core buildup with resin composite. All specimens were stored at 100% RH at room temperature
for 2-3 days to ensure complete polymerization before they were embedded and serially
sectioned into slices of about 1mm thickness. Push-out test was performed at a crosshead speed of 1 mm/min in a universal testing machine (Instron). Data was analyzed
statistically at = 0.05.
Results: Significant differences were evident in the bond strength values between
groups (ANOVA, p < 0.05). SC2 group exhibited the highest mean bond strength value
(14.87 6.49MPa), which was comparable to RXU (14.33 5.67 MPa) (p 0.05). PVF
(12.91 4.97 MPa) and CXF (11.87 3.83 MPa) were similar to each other, both
values being significantly lower than that of SC2 (ANOVA; p < 0.05). The most
common mode of failure was adhesive, either at the post-cement or dentin-cement
interface.
Conclusions: The retention of fiber-reinforced resin post is influenced by the type of
luting cement used. Adhesive failures at bonding interfaces were most common.
25
Keywords: Fiber posts, resin cement, micro-push-out bond strength, root canal dentin,
dentin adhesive.
Introduction
The need for restoring the missing coronal structures of endodontically treated
teeth is obvious. The final restoration should also be designed to distribute the
mastication forces arising from occlusal function (1). For maxillary anterior and many
premolar teeth, a post-and-core is often placed, over which a full coverage crown is
cemented. Depending on the relative location of the post and the alveolar support, the
functional and parafunctional loads acting on the coronal restoration would borne by the
root, with some being spread to the supporting structures (2, 3).
Fiber-reinforced resin composite posts, or simply known as fiber posts were
introduced in the early 1990s, as an alternative to the metallic post (4). Fiber posts have
a modulus of elasticity similar to that of dentin, which is claimed to allow a more even
distribution of occlusal stresses to the remaining tooth structure than the rigid metallic
posts, mediating a higher fracture resistance for the restored unit (5 8). Other oftenquoted advantages of fiber posts are the ability to bond to dentin with adhesive cement,
absence of corrosion and aesthetic appeal (6, 9, 10). Thus, the combined use of a dentin
adhesive cement and a fiber-post not only may reinforce the remaining tooth structure,
but also enhance the esthetics of the final tooth-colored restoration (11).
Various factors can affect the retention of root canal post to dentin, which
include: the type of dentin i.e. normal vs sclerotic (12); region of dentin - apical vs
middle vs coronal (12, 13); and type of adhesive system i.e. light vs chemical vs dual
cured (14 20). In addition, the durability of the bond may deteriorate with time (17).
The efficacy of dentin bonding agents at the apical region of the canal has remained
controversial, with some reporting higher bond strength at the apical (21), while others
26
showed greater bond strength at the coronal region (15). Controversial results with
respect to the retention of fiber posts to the root canal dentin by different luting cements
have also been reported (16 20).
With the advances in the resin composite technology, materials of various filler
contents, and flow characteristics have been marketed. Most of them can be used in
conjunction with a dentin adhesive to achieve bonding. It is tempting to use a flowable
composite to cement the fiber-reinforced resin post in place, and then continue using the
flowable material to build up the (most of) core foundation.
The purpose of this study was to compare the bonding efficacy of three adhesive
cements and one flowable composite for cementing a fiber-reinforced resin post system.
The evaluation means was a push-out test.
Materials and Methods

Recently extracted, single-rooted human maxillary and mandibular teeth
(including central and lateral incisors, canines and mandibular second premolars) were
collected and stored in 1% Chloramine T solution. They were soaked in sodium
hypochlorite, cleaned and examined under an operating microscope and with
radiographs. Teeth with root caries, hypoplasia, non-carious cervical cavities, preexisting restoration, or root canal fillings, calcified canals, cracks, open apices and
resorptive defects were excluded from the selection. Sixty-four teeth were selected, and
randomly divided into four groups (n=16 each), using a stratified sampling method for
similar cervical diameters and root lengths in each. All teeth were decoronated using a
diamond disc (Horico, Hopf, Berlin, Germany) at a level 1.5 mm coronal to the
cemento-enamel junction (CEJ). The working length was established at 0.5mm from the
apical foramen and the canal was prepared using the ProTaper rotary system (Dentsply
27
Maillefer, Ballaigues, Switzerland) to the size F4 instrument. Patency was ascertained

after every instrument and the canal was irrigated with 6% sodium hypochlorite. The
final rinse comprised 3 mL of 17% EDTA, followed by 3 mL of deionized water. All
irrigants were delivered into the canal using a 28-gauge safe-ended needle (Monoject;
TYCO Healthcare, Mansfield, MA, USA). Canals were obturated with gutta-percha and
AH Plus sealer (Dentsply Maillefer, Ballaigues, Switzerland) using the warm vertical
compaction technique (22).
A post space of 9 mm deep was left after the down pack. The post space was
then refined using proprietary drills of a selected fiber post system (Radix fiber-post;
Dentsply Maillefer, Ballaigues, Switzerland). All post spaces were thoroughly rinsed
with 3 mL 6% sodium hypochlorite, followed by 3 mL deionized water and then 3 mL
chlorohexidine before drying with paper points for the bonding procedure. The fiber
post was wiped with alcohol, air dried, and cemented with one of the following adhesive
cements (Table 1), according to the manufacturer instructions.
PVF (Panavia F):

The post space was first etched with 30% phosphoric acid, and rinsed. Then, equal
amounts of ED Primers A and B (Panavia F 2.0; Kuraray, Okayama, Japan) were mixed
in a dappen dish. Two consecutive coats were applied with a micro-brush on the post
and into the post space. Excess primer was removed from the space by inserting a paper
point into the space, then gently blowing air from a 3-in-one syringe across the
incisal/occlusal surface. After that, equal amounts of pastes A and B were mixed and
applied into the post hole using a Lentulo spiral and onto the post. The post was inserted
in a smooth steady motion and held in position with firm finger pressure. Excess cement
was removed and a curing light was applied, directed from the top of the post for 20 s.
28
Then, a bonding agent (All Bond 2; BISCO, Schaumburg, IL, USA) was applied and a
resin restorative composite (Esthet-X, Dentsply DeTrey, Konstanz, Germany) was
syringed directly around the post and shaped to form a core. Several increments, of
about 2 mm thick, were added and light cured for 20 s each.
RXU (RelyX Unicem):

This is a self-etched, dual-cured adhesive dual-cured, cement for which dentin
conditioning is required. The encapsulated form of the RelyX Unicem cement (3M
ESPE, Platz, Seefield, Germany) was used. The capsule was mixed in an automatic
mixer (RotoMix; 3M ESPE) for 10 s and then injected directly into the post space. The
post was similarly inserted and held in position for 2 min. Excess cement was removed
and curing light was applied over the top of the post for 40 s. A core was built up with
the same material and procedure as in the previous group.
SC2 (SmartCem2):
SmartCem2 (Dentsply DeTrey, Konstanz, Germany) is another self-etch, self-adhesive
resin composite cement. After mixing, it was applied on the post, as well as into the post
hole with a Lentulo spiral. The post was inserted into the post space and held in place
for 3 minutes (for initial set), according the manufacturer. Excess cement was removed
and curing light was applied for 40 s. The core build-up was performed in a similar
fashion described above.
CXF (CoreX Flow):

The post space in this group was first etched with 37% phosphoric acid for 15 s
according to the manufacturers instructions. It was then treated with XP BOND
29
Universal Total-Etch Adhesive (Dentsply DeTrey, Konstanz, Germany) with equal

volumes of the Self Cure Activator (A and B; Dentsply DeTrey) that had been mixed
for 1-2 s. Two layers of the mixture was applied to wet all surfaces of the post space and
left undisturbed for 20 s. Excess solvent was removed by gentle air drying for about 5 s
and the surface was left undisturbed for a uniformly glossy appearance. A layer of the
adhesive/activator mixture was applied to the post, air dried for 5 s, and light cured for
20 s. The post was then luted with a flowable composite (CoreX Flow; Dentsply Caulk,
Milford, DE, USA) by inserting it in position, holding for 40 s and curing for 20 s (as
was recommended by the manufacturer). The core built with the same material using an
incremental technique, by directly injecting on top and molding with a plastic
instrument.
Push-out bond strength: All specimens of were embedded in an acrylic resin (Rapid
Repair; Dentsply DeTrey) and then sectioned horizontally into slices of approximately 1
mm thick, in a microtome (SP-1600; Leica Microsystems, Wetzlar, Germany) with a
340 m-thick blade. The specimen was fed at a rate of about 50 m per minute, to avoid
disrupting the cement lute. The first cut was made at the junction of the ferrule and the
core material, i.e. at the top of the post hole. Some 5 to 6 slices were obtained, for the
entire length of the post. The coronal side of each slice was labelled with an indelible
marker for identification.
For each section, the diameters of the post along the buccal-lingual (X-axis) and
mesial-distal (Y-axis) direction on both the coronal-facing and the apical-facing surface
were measured under a travelling microscope (Laour-Lux 12 MES; Leitz, Weltzer,
Germany). The thickness of the cement layer was also measured, at the locations where
it was noted to be the thickest and the thinnest. Each slice was measured for its
30
thickness using a digital caliper to a precision of 0.01 mm, before it was positioned on
the platform of a universal testing machine (Instron; Testometric, Rochdale, Lancashire,
UK) with the coronal surface facing down for the push-out test. Plungers were custom
made to be about 0.2 mm smaller in diameter than that of the post for the various slices.
Care was taken to center the plunger on to the cross section of the post to avoid
stressing the surrounding dentinal wall directly. Force was recorded, with the cross-head
running at a speed of 1 mm/min, until the post was completely disloged from the tooth
slice.
All debonded specimens were inspected under the travelling microscope (LaourLux 12 MES) to determine the mode of failure, based on a classification described by
DArcangelo (2008) and Kececi et al. (2008): Type 1 Adhesive failure between the
post and the luting material; Type 2 Adhesive failure between dentin and the luting
material; Type 3 Cohesive failure of the luting material; Type 4 Cohesive failure of
the post; and Type 5 Mixed mode, with a combination of any two or more failure
types.
Data Analysis
The surface area (A) was determined for the bond surface of the post (A1) and
the root canal space (A2) using the general formula (20):
A=
where, D1 and D2 are the mean diameters on the coronal and apical surface,
respectively, and h the thickness of the slice. The effective adhesive surface area A
was taken as the average of A1 and A2. The shear bond strength was determined by
the ratio of the maximum load, Fmax when dislodgement of the post occurred, to the
31
effective bonded area A (17). Differences in the bond strength between various
horizontal root levels (coronal to apical) and between the cement groups were examined
using a two-way analysis of variance (ANOVA) at a significance level of p = 0.05. If a
significant difference was noted, post hoc multiple comparison tests were carried out at
= 0.05. One-way ANOVA test was performed to compare the pooled bond strength
values between various groups (PVF, RXU, SC2 and CXF) at a significance of p = 0.05.
Results
Push-out bond strengths: Statistically significant differences were evident for the bond
strength value for various coronal to apical slices between the groups (Two-way
ANOVA, p < 0.05) (Fig. 1). Within the same group, there was no difference in the bond
strength at various levels of the root canal for the PVF, RXU and SC2 cement (ANOVA,
p 0.05), except for the CXF group (p < 0.05). Multiple comparisons revealed a
significant difference between the more coronal (A, B) and the more apical levels (C, D,
E) for the CXF group (p < 0.05). When all values of each material were pooled for
comparison of the overall bond strength, the four cements showed a statistically
significant difference between each other (ANOVA, p < 0.05). Both RelyX Unicem
(14.33 5.67 MPa) and Panavia F (12.91 4.95 MPa) were comparable to SmartCem2
(14.87 6.49MPa) or CoreX Flow group (11.87 3.83 MPa), but the latter two groups
(SC2 vs CXF) were significantly different from each other (p < 0.01) (Table. 2).
Mode of failure: Adhesive failures (Type 1 or 2) were the most common modes of
failure after the test (Table 3). There were no significant differences between groups for
the distribution of the various failure modes observed.
32
Discussion
From the present findings, the null hypothesis that the bond strength is similar for
various luting cements used has to be rejected. The push-out test was performed on the
thin slices in this study to avoid the development of non-uniform stresses at the
adhesive interfaces when the test was done on thick sections (23, 24). It also allows the
examination of regional bond strength relative to the depth of the root canal. Indeed, one
particular group (CoreX Flow, a flowable resin composite with a dentin bonding agent)
showed a better bond at the coronal than the apical sections. Similar results of unequal
bond strengths between coronal and apical root dentin have been reported (14, 15).
However, such trend was not demonstrated by the other three materials (PVF, RXU and
SC2), nor by some other authors (17, 22). This may be related to the CoreX Flow
material that is primarily a flowable resin composite, instead of being designed as a
luting agent. Perhaps, its viscosity or filler characteristics might have jeopardized the
flow of the material or ability to relieve the polymerization shrinkage stresses. The need
for additional bonding procedures and these extra steps may increase its susceptibility to
operational variability. Thus our results indicated that flowable composite may not be a
good substitute to a resin luting agents specifically for cementation purpose.
The two self-etching adhesive cements (RXU and SC2) exhibited a higher bond
strength, compared to Panavia F, a self-cured system. The self-etching systems are
based on the use of acidic monomers that demineralize and infiltrate the tooth substrate
simultaneously to create a micromechanical union. For RelyX Unicem, there might be
some chemical adhesion to the underlying hydroxyapatite (25). Some authors
speculated that the moisture tolerance of the cement (as stated by the manufacturer for
RXU) may aid in the development of a high bond strength (26).
33
Analysis of the failure modes revealed that adhesive failures were much more
common than cohesive (within the post, or the resin cement layer) or the mixed mode of
failure, a finding that corroborated with other reports (20, 27). It should be noted that, as
the load was applied on the post during the (push-out) bond strength measurement, this
experimental set-up might promote cohesive failures of the post (28). The high
proportion of adhesive failures that occurred at the interface between the post and the
luting material, as was reported by many authors (20, 27 30), has led to the proposal
for pre-treatment of the post to improve the overall retention of the post.
Conclusion: Within the limitations of this study, it can be concluded that the pushout bond strength is influenced by the type of cement used. Flowable composite may
not be a good substitute to resin cements for luting of fiber-reinforced resin posts in
place. Adhesive resin cements seem insensitive to the depth of the post hole with regard
to the push-out bond strength. Debonding at the post-cement or cement-dentin interface
was the most common reason of loss of retention for fiber posts.
34
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Quintessence Int 2008; 39: 117-29.
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10) Cheung W. A review of management of endodontically treated teeth. Post, core

and the final restoration. J Am Dent Assoc 2005; 136: 611- 9
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MH, Pashley DH. Regional bond strengths of bonding agents to cervical
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19) DArcangelo C, DAmario M, Vadini M, Zazzeroni S, DeAngelis F, Caputi S.

The evaluation of luting agent application technique on fiber-post retention. J
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filled dentin bonding systems. Oper Dent 2001; 26: 44-7.
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1: 299-309.
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38
Tables and Figures

Table 1 Adhesive cements and build-up materials used for the four
groups
Group
PVF
Treatment for
post space
Acid etch, ED
Primer
Bonding
agent for
core buildup
Composite Core
Panavia F
All Bond 2
Esthet-X
Luting cement
RXU
Nil
RelyX Unicem
All Bond 2
Esthet-X
SC2
Nil
SmartCem2
All Bond 2
Esthet-X
CXF
Acid etch , XP
BOND with Self CoreX Flow
Cure Activator
Not required
CoreX Flow
Table 2 Mean bond strengths for various groups

Group
Mean*/ MPa
S.D.
Panavia F
82
12.91 (a, b)
4.95
RelyX Unicem
72
14.33 (a, b)
5.67
SmartCem2
76
14.87 (a)
6.49
CoreX Flow
77
11.57 (b)
3.83
Total
307
13.42
5.44
*Note: Groups with the same superscript letter were not significantly different from
each other (ANOVA, p 0.05)
39
Table 3 Modes of failure as observed after the push-out test
Group
Type 1
Type 2
Type 3
Type 4
Type 5
Total
PVF (Panavia F)
57
26
97
( 9%)
(27%)
(3%)
(6%)
(7%)
(100%)
30
46
88
(34%)
(53%)
(6%)
(7%)
(100%)
RXU(RelyX
47
31
10
92
Unicem)
(51%)
(34%)
(11%)
(4%)
(100%)
SC2 (SmartCem2)
41
34
83
(49%)
(41%)
(6%)
(4%)
(100%)
175
137
26
21
360
(7.2%)
(5.8%)
(100%)
CXF (Core X Flow)
Sub total
(48.6%)
(38.05%) (0.02%)
40
Figure . 1 Mean push-out strengths for each group at different levels of the post space
Bond
Strength
(MPa)
41

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Clinical case reports

Mahindre, Prajakta Prakash

Creative Commons: Attribution 3.0 Hong Kong License

Clinical Case Reports

Advanced Diploma in Endodontics

Prajakta Prakash Mahindre

Supervision was done by Dr. G.S.P. Cheung

(Postgraduate Programme Director in Endodontics), Dr. Robert Ng, Dr Chengfei Zhang,

Treatments with more than one tooth were

considered as multiple endodontic treatments. Endodontic treatments of teeth whose

Teeth were temporized between appointments with a calcium

hydroxide dressing (Calasept, JS Dental MFG INC, Ridgefield, Connecticut, USA) in

List of Abbreviations, Equipment and Materials

PPDH No: 184923

Non-Surgical Root Canal Retreatment

PPDH No: 247457

PPDH No: 167162

PPDH No: 214456

PPDH No: 250900

PPDH No: 263016

PPDH No: 252723

PPDH No: 253557

PPDH No: 270912

PPDH No: 242859

PPDH No: 249871

PPDH No: 266857

PPDH No: 229260

PPDH No: 37765

Surgical Root Canal Treatment

PPDH No: 259311

PPDH No: 254213

PPDH No: 154144

PPDH No: 250888

PPDH No: 269196

PPDH No: 260029

PPDH No: 246472

PPDH No: 246760

Their expertise in the field of

endodontics improved my clinical knowledge immensely and also provided me with a

List of Abbreviations, Materials and Equipment

List of Abbreviations, Materials and Equipment

Bachelor of Dental Surgery

Ceramic metal crown

General dental practitioner

Glass ionomer cement

Junior Hospital Dental Officer

Master of Dental Surgery

Mineral Trioxide Aggregate

Prince Philip Dental Hospital

Materials and Equipment

Dentsply DeTrey, Konstanz, Germany

List of Abbreviations, Materials and Equipment

Bisco, Schaumburg, Illinois, USA

JS Dental, Ridgefield, Connecticut, USA

3M ESPE, Seefeld, Germany

SmithKline Beecham Consumer Healthcare, Maidenhead, UK

Dentsply Caulk, Milford, Delaware, USA

Ultradent, South Jordon, Utah, USA