RESEARCH AND EDUCATION

Accuracy of cast posts fabricated by the direct and the indirect

techniques
Mohammad R. Rayyan, BDS, MDS,a Roa’a A. Aldossari, BDS,b Sarah F. Alsadun, BDS,c and
Fatimah R. Hijazy, BDSd

Most endodontically treated ABSTRACT

teeth undergo a significant loss Statement of problem. Patterns for custom cast posts and cores can be fabricated either by the
of coronal structure because of direct or the indirect technique. Which technique is more accurate is unknown.
caries, fractures, and access
Purpose. The purpose of this in vitro study was to investigate the effect of pattern fabrication
preparation. To restore the
technique on the accuracy of post fit.
integrity of these teeth, end-
odontic posts have been suc- Material and methods. Ten intact extracted premolar teeth with a single canal and similar di-
cessfully used over many years mensions received root canal treatment. The teeth were sectioned 2 mm above the cementoe-
1 namel junction. A total of 20 cast post and core patterns, 2 for each tooth, were fabricated, 10 with
to retain coronal restorations.
the direct technique and 10 with the indirect technique. Patterns were cast to produce 20 cast post
Posts can be custom made and cores. Each tooth was scanned using a microcomputed tomography (mCT) system with a
or prefabricated. Custom-made resolution of 14.5 mm, once with the post of the direct technique and once with the post of the
post and cores have long been indirect technique. Ct analyzer software was used to calculate the overall space between the post
considered the gold standard and canal walls and the space areas in 3 different standardized sections. The Student paired t test
for the rehabilitation of severely was used to determine any significant difference in the scores of the groups.
damaged endodontically treated Results. The overall space between the canal walls and posts made with the direct technique
teeth. They conforms better to ranged between 7.86 and 17.39 mm3, with a mean value of 12.25 mm3, whereas with the indirect
the shape of the canal and technique, the space ranged between 6.68 and 18.02 mm3, with a mean of 11.92 mm3. No sig-
provide maximum retention nificant differences were found between the results of either technique (P>.05).
and support for the coronal Conclusions. Within the limitations of this study, neither the indirect nor direct pattern fabrication
restoration.2 technique influenced the accuracy of post fitting. (J Prosthet Dent 2016;-:---)
Other advantages of cast
post and cores include their high strength, durability, are still favored in many clinical situations, especially
and the strong union between the core and the post. where multiple teeth or misaligned teeth require post
However, cast posts and cores have been associated placement.5 Cast post and cores can also offer an
with more unfavorable deep root fractures, perhaps advantage over other post systems for teeth with
because of their relatively high modulus of elasticity.1 extensive tooth damage, partial fixed dental prosthesis
Moreover, the evolution of nonmetal post systems, abutments, and bruxism and other heavy occlusion
including fiber-reinforced resin posts, has led to situations. A number of surveys have shown that a
improved esthetics and more favorable stress distri- good percentage of dentists still prefer the cast post
bution patterns.3,4 Nevertheless, cast posts and cores and core system.6-9

a
Assistant Professor, Prosthodontic Department, College of Dentistry, Riyadh Colleges of Dentistry and Pharmacy, Riyadh, Saudi Arabia.
b
General Dentist, Security Forces Polyclinic, Ministry of Interior, Riyadh, Saudi Arabia.
c
General Dentist, Graduate of Riyadh Colleges of Dentistry and Pharmacy, Riyadh, Saudi Arabia.
d
Private practice, Al Khobar, Saudi Arabia.

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morphology, root canal therapy, root canal volume and

Clinical Implications surface area, enamel and dentin thickness, and 3D
The fitting accuracy of cast posts produced by the modeling.18,19 Kim et al20 compared the accuracy of mCT
measurements with 3D scanners, direct measurements,
direct technique was similar to that produced by
and photography and concluded that mCT scanning is a
the indirect technique.
reliable method of measuring distances and volumes and
of observing internal and external tooth structures.
The purpose of this study was to investigate the fitting
Many factors may affect the prognosis of teeth
accuracy of cast posts made with 2 different techniques,
restored with cast posts, including the length of the post,
the direct technique and the indirect technique using
taper angle, type of cement used, and post fitting within
mCT imaging.
the canal.1,10,11
The adaptation of tapered posts to root canals has
MATERIAL AND METHODS
been identified as the main factor associated with the
failure threshold of restored teeth.12 The passive fit of the Before conducting the study, ethical committee approval
endodontic post and the presence of a homogenous was obtained from the research center in the Riyadh
cement layer surrounding it can prevent harmful torque Colleges of Dentistry and Pharmacy (IRP/2012/009). Two
and levers on the tooth structure that might predispose it sets of cast post and cores were obtained for the same
to fracture.10 teeth, using 2 different techniques: the direct and indirect
Two main techniques have been described and used technique. The accuracy of post fit was evaluated using
for cast post and core fabrication: the direct and the in- mCT to determine which technique provided more ac-
direct technique. For the indirect technique, an elasto- curate results.
meric impression of the post space is made and poured in Forty-four extracted premolar teeth were collected
stone to allow the fabrication of a post and core pattern and cleaned of deposits and calculus by hand scaling. The
in the dental laboratory.13,14 For the direct technique, the teeth were then examined visually and by radiographs.
pattern is fabricated in the prepared canal with an acrylic Only teeth with a patent single root canal, complete
resin.15 apex, no cracks, and no root resorption were considered.
Few studies have compared the accuracy of these 2 Finally, 10 teeth with similar root morphology, length,
techniques in terms of post retention and root fracture and width were included. Using statistical software
resistance. Al-Omari and Zagibeh16 investigated the ef- (G*power v3.1; Faul, Erdfelder, Lang, & Buchner)21 this
fect of technique and cement type on the retention of sample size was able to achieve 0.8 power analysis
custom cast posts and reported no significant influence of assuming a=.05.
the post fabrication technique on the post retention. The teeth were then sectioned with a diamond disk,
However, they reported a significant effect of cement leaving 2 mm above the cementoenamel junction. All
type and cementation process on the post retention. In pulp tissue was removed, and the canals were cleaned
another study, Pitigoi-Aron et al17 examined the accuracy and shaped in the conventional manner.16 Obturation
of cast posts made with both techniques. By measuring was carried out using gutta percha and sealer (AH26;
the weight of the impression material which occupied the Dentsply DeTrey). Any excess coronal to the canal orifice
space between the post and the canal, the accuracy of was removed with a warm plugger.
post fit was obtained and compared. They found that the After 24 hours, 12 mm of the obturation was removed
indirect technique significantly provided better post fit with Gates Gliddens drills size 2 and 3. The post spaces
and therefore recommended this technique, especially for where finalized with RelyX post drills (3M ESPE) sizes 1
multiple posterior teeth or cases with limited interarch and 2. The canals were then irrigated before the roots
space. were mounted in acrylic resins.
Different methods have been used to evaluate the ac- For each tooth, 2 patterns were made, 1 with the
curacy of fit of dental restorations, including endodontic direct technique and 1 with the indirect technique. The
posts. One of the methods recently adopted in dental patterns were cast to produce 20 custom cast post and
research is microcomputed tomography (mCT). The mCT cores, which were divided into 2 groups. group (D) had
system uses microfocal spot x-ray sources and detectors the 10 posts fabricated with the direct technique, and
with high resolution to produce 3-dimensional (3D) group (ID) had the 10 posts fabricated with indirect
reconstructed images with voxels approximately 1 000 000 technique.
times smaller in volume and thus with higher spatial res- For the indirect technique, a sectional plastic tray
olution than computed tomography imaging. mCT analysis (COE spacer tray; GC Corp) was loaded with polyvinyl
now has many applications in medical and dental research siloxane putty impression material (Express STD; 3M
and has been successfully used to study root canal ESPE) while injecting the light body polyvinyl siloxane

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Table 1. Spaces recorded with each technique

Technique/Measurement Mean ±Standard Deviation
Direct group (D)
Overall space (mm3) 12.25 2.97
Space area in section A (mm2) 1.18 0.63
Space area in section B (mm2) 1.20 0.48
Space area in section C (mm2) 0.88 0.53
Space at end of post (mm3) 0.61 0.63
Indirect group (ID)
Overall space (mm3) 11.92 3.38
Space area in section A (mm2) 1.65 0.62
Space area in section B (mm2) 1.29 0.57
Space area in section C (mm2) 0.98 0.49
Space at end of post (mm3) 0.55 0.57
Figure 1. Two-dimensional slice showing 5 space measurements.

into the post space. A plastic dowel (Pattern Resin LS; space areas between the post and canal walls in 3
GC Corp) was fitted into the post space, and the different sections (A, B, and C). Section A was made at
impression was made. The material was poured in dental the post-core junction, section B was made in a middle
stone (Elite Master; Zhermack) after 60 minutes. Post location of the post space, and section C was made 2 mm
and core patterns were made using inlay wax (GC Corp). shorter than the apical end of the post (Fig. 1). Each
Cores were standardized to 2 mm in height with a flat measurement was repeated twice to ensure the repro-
occlusal table. ducibility of the results. A paired t test of the scores was
For the direct technique, pattern acrylic resin (Pattern made with software (IBM SPSS Statistics v20.0; IBM
Resin LS; GC Corp) was used to fabricate post and core Corp) package to determine the significance of difference
patterns. Petroleum jelly was applied to the post space in the post fitting between the 2 techniques.
with an endodontic K file. The resin was then mixed and
inserted into the post space using a syringe with a small
RESULTS
nozzle. A plastic post was then placed to support the
resin in the canal, and the core was completed using the Mean ±standard deviation values of the 5 space mea-
same acrylic resin material. The cores were made 2 mm in surements are summarized in Table 1. The overall space
height and had a flat occlusal table. All patterns were volume between the post and prepared canal walls for
invested in phosphate bonded investing material (Bel- group D ranged between 7.86 and 17.39 mm3 with a
lavest SH; Bego) and cast in a centrifugal casting machine mean value of 12.25 mm3. For group ID, the space vol-
with beryllium-free nickel chromium alloy (MEAlloy; ume ranged between 6.68 and 18.02 mm3 with a mean
Dentsply Intl). value of 11.92 mm3. No significant differences were
The fit of the posts was verified visually and radio- found in the results of either technique (P>.05).
graphically by 2 independent examiners to ensure proper The space area measured in section A between canal
fit. The teeth were then scanned using a Skyscan 1173 at walls and posts in group D ranged between 0.02 and 1.92
high resolution and energy mCT (Skyscan; Kartuizersweg mm2 with a mean value of 1.18 mm2 , whereas in group
3B) at 95 kV and 85 mA with a resolution of 14.5 mm, ID, the space area ranged between 1.11 and 3.21 mm2
using a brass 0.25-mm-thick filter and 52% beam- with a mean value of 1.65 mm3. The space area measured
hardening reduction. Each tooth was fixed and scanned in section B between canal walls and posts in group D
twice, once with the post of the direct technique and ranged between 0.34 and 1.91 mm2 with a mean value of
once with the post of the indirect technique. After image 1.20 mm2 , whereas in group ID, the space area ranged
reconstruction, 2D virtual slices were acquired in the axial between 0.64 and 2.59 mm2 with a mean value of 1.29
plane. Each slice series was examined coronoapically to mm3. The space area measured in section C between
determine the respective analysis area in the root canal. canal walls and posts in group D ranged between 0.28
Software (Skyscan CT Analyser; Bruker Corp) was used and 1.53 mm2 with a mean value of 0.88 mm2, whereas
to calculate the areas and volume of space between each in group ID, the space area ranged between 0.44 and 1.50
post and the root canal. mm2 with a mean value of 0.98 mm3. The Student paired
Five measurements were made for each post. The first t test revealed significant difference between the results
measurement was the overall space volume existing be- of both techniques only in section A (P=.042).
tween the post and prepared canal walls; the second was The space measured between the remaining gutta
the space between the end of the post and the remaining percha and the end of posts in group D ranged between
gutta percha. The remaining 3 were measurements of 0.08 and 2.12 mm3 with a mean value of 0.61 mm3, while

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in group ID, the space ranged between 0.02 and 1.75 successfully to study root canal configurations and
mm3 with a mean value of 0.55 mm3. The paired t test measure the dimensions of different root canal systems.
revealed no significant difference in the results of the Because of its high resolution and very low voxel volume,
techniques (P>.05). it has been considered more accurate than other imaging
techniques.19,20
DISCUSSION In vitro experiments using extracted teeth are limited
in their ability to replicate the clinical situation. However,
Although most dental prostheses are fabricated indirectly
with proper standardization and control of the variables,
in the dental laboratory, which is more convenient for
they can provide valuable results which sometimes
both the dentist and the patient, many practitioners
cannot be obtained by clinical trials.16,17
prefer the direct technique for post pattern fabrication
One of the study’s limitations is that the accuracy of
because they assume it provides a more accurate fit.
only 1 direct technique was compared with only 1 indi-
Results of the current study revealed no significant
rect technique. Other direct and indirect techniques
differences between overall accuracy of fit of posts made
could render different results.
with the direct technique and that of posts made with the
Although the prior power analysis indicated that the
indirect technique. The first measurement obtained by
sample size was adequate, the mean values showed
mCT in the current study was the overall space between
relatively high standard deviation, which reduced the
each post and the respective root canal walls, which can
effect size and the power of the statistical significance.
be considered the main indicator of the overall accuracy
Although similar studies used a similar sample size,16,17 a
of post fit.17 Measurements of the horizontal space sur-
larger sample size is necessary to obtain more conclusive
face area in sections A, B, and C indicate the relative post
results.
fit at the post-core interface, the middle of the post space
preparation, and the apical part of the post respectively.
CONCLUSIONS
Space between the post and the remaining gutta percha
is also an important indicator of post fit and was Within the limitations of this in vitro study, the use of
measured for all posts. either a direct or indirect post pattern fabrication tech-
Because post fitting is known to be crucial in post nique does not affect the accuracy of cast post and core
retention, these results support the results of Al-Omari fit. When proper procedures are conducted in the clinic
and Zagibeh,16 who found no effect of the fabrication and the dental laboratory, the indirect technique could
technique on the retention of cast posts. However, the save chair side time and be more convenient to both
results of the current study are contradicted by the patient and dentist while also producing accurately fitted
findings of Pitigoi-Aron et al,17 who reported that the posts.
indirect technique provided better fit and accuracy than
the direct technique. The source of this controversy could REFERENCES
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