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Effect of MTA versus CEM apical plugs on fracture resistance of endodontically treated simulated immature teeth restored with cast metal posts: an in-vitro study

BMC Oral Health volume 21, Article number: 280 (2021) Cite this article

Abstract

Background

Endodontically treated immature teeth which are restored with cast metal posts are of the most susceptible teeth to fracture. An apical plug is usually used as root end filling in order to seal the wide apical foramen. The current study was performed to evaluate the effect of different apical plug materials (MTA and Calcium enriched mixture cement) at varied thicknesses on fracture resistance of teeth restored with cast metal posts.

Methods

A total of 40 extracted intact single-rooted human mandibular premolars (removed for orthodontic reasons) were used in the study. The coronal part of each tooth was removed and root canal preparation was performed. A size 4 Gates Glidden drill was used to enlarge the canal and was passed through the apical foramen in order to simulate an immature apex. Samples were randomly divided into 5 groups (n = 8) according to apical plug (control group: No plug, group MTA5: 5 mm MTA plug, group CEM5: 5 mm CEM plug, group MTA3: 3 mm MTA plug, group CEM3: 3 mm CEM plug). Post-space preparations were performed and cast metal post-and-cores were fabricated and cemented. Fracture resistance was assessed using a universal testing machine. Fracture thresholds were recorded and data were analyzed using One-way ANOVA and Dunnett’s T3 tests with significance level at P value < 0.05.

Results

The analysis showed a significant difference of fracture resistance between groups (P value < 0.05). The mean fracture resistance of samples in control group was significantly lower than MTA5 (P value = 0.003). There was no significant difference between other groups (P value > 0.05).

Conclusions

Within the limits of this study, the evidence indicated that placement of a 5 mm MTA apical plug increased the fracture resistance in simulated immature teeth which are restored with cast metal posts, compared to control group (gutta-percha and sealer). While the results were not as promising for a 3 mm MTA apical plug or either 3 or 5 mm CEM apical plug.

Peer Review reports

Background

Endodontic and prosthodontic treatment of immature teeth has always been challenging for practitioners. All the three factors of being endodontically treated (apexification), immaturity, and being restored with cast metal post, are among risk factors for root fracture [1,2,3,4]. Therefore, endodontically treated immature teeth which are restored with cast metal posts are of the most susceptible teeth to fracture.

Achieving an appropriate apical seal which is essential for prevention of microorganism’s ingress, is challenging in immature teeth, due to the wide apical foramen [5, 6]. Different materials have been advocated as apical plug materials, among which bioceramic-based materials such as Mineral trioxide aggregate (MTA), BioAggregate, Biodentine, Calcium enriched mixture cement (CEM) are of the most popular materials [7]. The use of bioceramic-based materials has shown to decrease the fracture susceptibility compared to calcium hydroxide paste which was traditionally used for endodontic treatment of immature teeth before introduction of bioceramic-based materials [4, 8, 9].

If an endodontically treated tooth is severely damaged, restoration of the tooth structure usually requires a post-and-core system. Currently, there are several post or post and-core systems available using different materials and techniques such as metal cast posts, metal prefabricated posts, carbon fiber posts, glass fiber posts, and zirconia posts [10, 11].

Despite better esthetic results of recently developed posts such as glass fiber posts, and zirconia posts [10, 12], cast metal post-and-core systems have been a successful treatment option for the restoration of severely damaged endodontically treated teeth -especially posterior teeth [13, 14].

The current study was performed to evaluate the effect of different apical plug materials (MTA and CEM) at varied thicknesses on fracture resistance of teeth restored with cast metal posts and to the best of our knowledge, this is the first study to do so. The null was that there was no significant difference of fracture resistance between and within experimental and control groups.

Methods

A total of 40 extracted intact single-rooted human mandibular premolars (removed for orthodontic reasons in dental clinic of Gorgan School of Dentistry and three private offices) were selected based on the inclusion criteria. Since it was the first study of its kind, sample size calculation was not applicable. Preparation of the samples was performed by a dental student (AD), guided by supervising endodontics and prosthodontics faculties (EG and LSh).

The teeth were disinfected with 5.25% NaOCl and stored in isotonic saline solution. Visual and stereomicroscope at 10× magnification (SMP-200, HP, USA) assessments were performed and teeth with a single straight root of similar length and size with no sign of crack, fracture, or carious lesion were selected.

A scheme of the samples preparation steps is shown in Fig. 1. The coronal part of each tooth was removed in a way that a 16 mm root was remained. Root canal preparation was performed using rotary NiTi Protaper instruments (Dentsply Maillefer, Ballaigues, Switzerland) with shaping and finishing files (Sx, S1, S2, F1 and F2). Canals were irrigated with 2 ml isotonic saline between preparation steps. A size 4 Gates Glidden drill was used to enlarge the canal and was passed through the apical foramen in order to simulate an immature apex. Samples were randomly divided into 5 groups using the simple randomisation method (a control group and 4 experimental groups) according to apical plug materials [mineral trioxide aggregate (MTA Angelus, Soluçoes Odontologicas, Londrina, Brazil), and calcium enriched mixture (CEM, BioniqueDent, Tehran, Iran)].

  1. 1.

    Control group No plug.

  2. 2.

    Group MTA5 MTA orthograde 5 mm plug.

  3. 3.

    Group CEM5 CEM orthograde 5 mm plug.

  4. 4.

    Group MTA3 MTA orthograde 3 mm plug.

  5. 5.

    Group CEM3 CEM orthograde 3 mm plug.

Fig. 1
figure 1

Samples preparation steps

Full size image

The materials were prepared according to the manufacturer's instructions (MTA was mixed at 1 spoon of MTA powder and 1 drop of sterile water and CEM was mixed at 3 portions of CEM powder and 1 drop of CEM liquid). The plugs placed in an orthograde manner, using MTA carrier (Dentsply Maillefer, Switzerland). In experimental groups, apical plug materials (MTA or CEM) were condensed using back end of thick paper points. In case of overfilling, the excess material was removed by a sterile blade. Correct placement was confirmed with preapical radiographs (Kodak, Carestream Health, USA). A wet paper point was placed in the root canal and samples were stored in wet gauze for 24 h. All root canals were obturated using gutta-percha (Meta Biomed Co. Ltd, Korea) and AH26 sealer (Dentsply, DeTrey, Germany) using cold lateral condensation technique with accessory gutta-percha cones. The samples were then sealed by temporary cement (Cavit, ESPE, Seefeld, Germany) and were incubated for 1 week at 37 °C.

The apical 5 mm of the samples were mounted in self-curing resin blocks, using a plastic ring mold (20 mm diameter and 10 mm thickness). Samples were vertically stabilized on surveyor, using plastic cylinders filled with acrylic resin. Post-space preparations were performed using preparation drills (D.T. Light-Post Universal Drill Size #0.5 for filling removal and D.T. Light-Post Finishing Drill Size #1 for post-space shaping). A minimum of 5 mm of apical seal was retained in all groups which means remaining only MTA/CEM in MTA5 and CEM5 groups, a combination of MTA/CEM and gutta-percha in MTA3 and CEM3 groups, and gutta-percha in the control group.

Resin patterns of posts were fabricated using acrylic resin (Duralay, Reliance Dental Mfg. Co., worth, Illinois) and direct technique. A 4-mm-height resin pattern for core was fabricated for all samples, using a standard mold made by cutting a plastic tube. Patterns were spurred, invested ((Deguvest lmpuls, Degu Dent Co., Germany), and casted using Ni–Cr alloy (T-3 Ni–Cr, CMP Industries LLC, NY, USA).

The castings were cleaned, sandblasted, and adjusted into the root canal. The cast posts were visually evaluated for adaptation. The castings were cemented with resin luting cement (Panavia F2.0, Kuraray medical Inc., OsaKa, Japan), using finger pressure. Samples were stored in saline solution at 37 °C for 3 days.

Fracture resistance was assessed using a universal testing machine (Zwik/Roell 020, Ulm, Germany). A static load was applied to each sample with a 90° angle to the occlusal surface of the metal core at a crosshead speed of 0.05 mm/min until the fracture occurred. Fracture thresholds were recorded and data were analyzed using SPSS 16.0 with significance level at P value < 0.05.

Results

The mean, standard deviation, minimum, and maximum fracture resistance for each group is presented in Table 1. The values were normally distributed across all groups (Kolgomorov–Smirnov test, P > 0.05), so one-way ANOVA was used to identify the significant difference among the groups. Assumption of homogeneity of variance was rejected (Leven’s test, P < 0.05) and Dunnett’s T3 test was used for multiple comparisons.

Table 1 Mean and standard deviation of fracture resistance of values in 5 groups
Full size table

Using One-way ANOVA it was determined that there was a significant difference of fracture resistance between groups (P value < 0.05). The Dunnett’s T3 tests showed that the mean fracture resistance of samples in control group was significantly lower than MTA5 (P value = 0.003), and there was no significant difference between other groups (P value > 0.05) (Table 2). Figure 2 shows the comparison of fracture resistance values among groups.

Table 2 Intergroup comparison of fracture resistance (Dunnett test)
Full size table
Fig. 2
figure 2

Comparison of fracture resistance values among groups

Full size image

Discussion

While endodontic treatment by itself increases the risk of root fracture [1], immature endodontically treated teeth are at an even higher risk of root fracture because of their thin dentinal walls [4, 5]. The situation becomes more complicated, if placement of an endodontic post is the treatment plan.

Traditionally, the long‐term use of calcium hydroxide has been the treatment of choice for induction of apexification in non-vital immature teeth [15]. However, the introduction of MTA in 1993 [16] provided a successful alternative with advantages including establishment of an instant apical barrier, setting ability in wet environment, promising sealing ability, provision of a shorter treatment period, improving patient compliance, ease of handling, and possibly increased fracture resistance of immature teeth [17,18,19,20,21]. CEM which was introduced in 2006 [22], has shown features comparable to those of MTA such as fracture resistance [4] and sealing ability [23]. CEM has even shown some superior results such as higher antibacterial effect [24], significantly shorter setting time, easier handling, and no tooth discoloration [25].

Although recently developed posts such as zirconia posts, carbon posts and glass fiber posts have offered better esthetic results than cast metal posts [5, 26], the superiority of success rate is controversial. Some studies have reported reduced chair-side and laboratory time of the new post systems [10, 12, 26], while others reported the advantages of cast metal posts such as higher retention [14] or superiority of results in special circumstances such as when multiple teeth need post systems or in case of tooth mal-alignment, and in small teeth with minimal dental tissue [27].

Overall, cast metal posts are still one of the most used systems, especially for the posterior teeth [28, 29]. Unfortunately, caries of young permanent teeth is still highly prevalent among children and adolescents in many countries [30,31,32]; and excessive tooth destruction due to dental caries is still a major reason tooth loss in these age groups [33, 34]. In case of severe tooth destruction, cast metal posts are still regarded as the gold standard for restoration [35], but previous studies concerning fracture resistance of endodotically treated immature teeth only focused on fiber post restorations [4, 36, 37]. Fiber posts have elastic modulus similar to that of the dentin [38], hence the results cannot be generalized to other post systems including cast metal posts.

In the present study, the effect of type and thickness of apical plug materials (MTA vs CEM/ 3 mm vs 5 mm) on fracture resistance of endodontically treated immature teeth restored with cast metal posts was assessed. Several studies have shown that a full canal obturation or an apical plugging by bio-ceramics, increases the fracture resistance of either mature or simulated immature teeth compared to the roots which were instrumented but were not filled, or were filled only with gutta-percha and sealer [8, 39, 40]. Full canal obturation by bio-ceramics is not indicated when placement of an endodontic post is the treatment plan, because further removal of the material for post-space preparation might not be easy [41], and also the material is more expensive than gutta-percha and sealer. Therefore, in such cases, MTA or CEM are used as apical plugs and the rest of the root canal is filled with gutta-percha and sealer [42, 43].

The results of the current study showed that the fracture resistance of samples in all experimental groups were higher than the control group (gutta-percha and sealer). However, the superiority was not statistically significant except for teeth filled with a 5 mm MTA apical plug.

While this is the first study to compare the effect of MTA and CEM apical plugs on fracture resistance of teeth restored with cast metal posts, effect of the two materials on fracture resistance of teeth has been compared in other circumstances and controversial results were reported. Evren et al. [4] compared the fracture resistance of simulated immature human teeth using 4 mm apical plugs (MTA, CEM, and Biodentine), with fiber post and composite resin restoration. They reported no statistically significant difference of fracture resistance between the experimental groups, which is in accordance with the results from the current study. Evren et al. also reported that fracture resistance values for all experimental groups were significantly higher than the control group, while in the current study, the difference was only significant for MTA5 group. The difference between the results regarding the comparison of the experimental and control groups may be explained by methodological differences between studies (i.e., preparations of the control groups, thickness of the plugs, type of post systems, and restorative materials).

Sarraf et al. [44] compared the fracture resistance of immature bovine teeth completely filled with MTA, CEM, and Biodentine with no post-space preparation and placement. They reported that MTA and Biodentine showed superior results over CEM. These results seem to be inconsistent with the results of the current study which showed similar fracture resistance values for both CEM and MTA. However, these differences could also be explained by methodological differences between studies, particularly in using full canal obturation or apical plug. Sarraf et al. also reported that the fracture resistance was not different for CEM, gutta-percha and sealer, and control (dried cotton wool filling) groups. The difference between results regarding the comparison of the experimental and control groups in the two studies can also be explained by different preparations of control groups and the thickness of obturations.

Milani et al. [8] also compared the fracture resistance of simulated immature human incisors filled with MTA, CEM, and MTA plus composite resin with negative control (untreated teeth) and positive control (unfilled teeth) groups. The results of this study showed no significant differences among three experimental groups, which appears to be in consistent with the present study. Milani et al. also reported no significant difference among MTA plus Composite and CEM groups with positive and negative control groups. While MTA group had significantly higher strength values than positive control. Difference in results regarding the comparison of the experimental and control groups in the two studies is observed; which can be related to different preparations of the control groups and use of post systems.

The current study also showed no statistically significant difference of fracture resistance regarding the thickness of the apical plugs (3 mm or 5 mm). Although several studies have been performed to compare the effect of using different thicknesses of apical plugs on root- end sealing ability [45,46,47,48], the studies assessing the effect of thickness on the apical of mechanical properties are rare. Madani et al. [48] compared the fracture resistance of simulated immature teeth, filled with 3 and 5 mm apical plugs of MTA and CEM with a control group (5 mm gutta-percha). Teeth were restored with glass fiber post and composite resin. As consistent with the current study, Madani et al. reported no statistically significant difference of fracture resistance between the experimental groups. However, unlike the present study, no significant differences from the control group was found; which can be attributed to the fact that the studies used different post systems and restorations.

The effect of thickness on surface micro-hardness of MTA and CEM has also been evaluated in several studies. A study performed by Tabrizizadeh et al. [49] showed no statistical difference of surface micro-hardness between 4 and 8 mm MTA and CEM plugs. Login et al. [50] also reported no statistic difference of surface micro-hardness between 4 and 6 mm MTA plugs, while 10 mm plugs were significantly harder that 4 and 6 mm plugs. Although the results of both mentioned studies appear to be in consistent with the present study, testing variable mechanical properties (i.e., surface micro-hardness and fracture resistance), prevents accurate comparison.

Root-end sealing ability, in addition to mechanical resistance and hardness, should be noticed while comparing different apical plug materials and thicknesses. Adel et al. [45] who compared the root-end sealing ability of different thicknesses of MTA and CEM, reported a significantly higher sealing ability of 5 mm apical plugs compared to 3 mm apical plugs of both materials. Valois et al. [46] and Gosh et al. [47], also reported a higher root-end sealing ability of 4 mm MTA plugs compared to lower thicknesses. Thus, decisions for clinical use of apical plugs should not be made only on the basis of mechanical properties. And comprehensive in-vitro and in-vivo studies of various factors influencing the clinical outcome of endodontics and prosthodontic treatment of immature teeth is required.

Overall, the results of most studies on fracture resistance are not comparable to each other, because of the great methodological variations regarding sample type (e.g. bovine/human teeth, premolars/incisors), sample preparations (e.g. immaturity simulation, root canal preparation and obturation techniques, post-space preparation, post systems), obturations (e.g. full canal/ apical plug, material thickness), coronal restorations (e.g. composite resins, metal cores or crowns), testing machine (fatigue/static load, speed, angle) and several other factors. Hence, there is a need to standardize the methods, in order to perform fair comparisons and interpretations.

In the current study, no crowns were placed on the cores, as in some other studies [51, 52], in order to avoid the confounding effect of assemblage of several adhesively bonded parts. Although use of crowns could be more similar to the clinical situation, and the researchers could limit the confounding effect by considering the mode of failure. Evaluation of the mode of failure of the specimens could also bring more information about the mechanisms and reasons of failures. Therefore, not assessing the failure mode is noted as a limitation of the current study and it can be suggested to the future researchers to conduct the assessment. Findings of the current study is based on a relatively small sample size which can also be considered as a limitation. Other limitations of the study are that exact same post-space dimensions could not be achieved because of operator dependency of the preparations and slight anatomic differences. However, size of the apical opening could be measured which can be considered in future researches. And finally, the limitations of an in-vitro, static fracture resistance test are understood.

Conclusions

Within the limits of this study, the evidence indicated that placement of a 5 mm MTA apical plug increased the fracture resistance in simulated immature teeth which are restored with cast metal posts, compared to control group (gutta-percha and sealer). While the results were not as promising for a 3 mm MTA apical plug or either 3 or 5 mm CEM apical plug.

Availability of data and materials

The datasets used during the current study are available from the corresponding author on reasonable request.

References

  1. Tang W, Wu Y, Smales RJ. Identifying and reducing risks for potential fractures in endodontically treated teeth. J Endod. 2010;36(4):609–17.

    Article  PubMed  Google Scholar 

  2. Corsentino G, Pedullà E, Castelli L, Liguori M, Spicciarelli V, Martignoni M, Ferrari M, Grandini S. Influence of access cavity preparation and remaining tooth substance on fracture strength of endodontically treated teeth. J Endod. 2018;44(9):1416–21.

    Article  PubMed  Google Scholar 

  3. Bayram E, Bayram HM. Fracture resistance of immature teeth filled with mineral trioxide aggregate, bioaggregate, and biodentine. Eur J Dent. 2016;10(2):220–4.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Evren OK, Altunsoy M, Tanriver M, Capar ID, Kalkan A, Gok T. Fracture resistance of simulated immature teeth after apexification with calcium silicate-based materials. Eur J Dent. 2016;10(2):188–92.

    Article  PubMed Central  Google Scholar 

  5. Figueiredo FE, Martins-Filho PR, Faria-e-Silva AL. Do metal post–retained restorations result in more root fractures than fiber post–retained restorations? A systematic review and meta-analysis. J Endod. 2015;41(3):309–16.

    Article  PubMed  Google Scholar 

  6. Nagmode PS, Satpute AB, Patel AV, Ladhe PL. The effect of mineral trioxide aggregate on the periapical tissues after unintentional extrusion beyond the apical foramen. Case Rep Dent. 2016;2016:3590680.

    PubMed  PubMed Central  Google Scholar 

  7. Abusrewil SM, McLean W, Scott JA. The use of Bioceramics as root-end filling materials in periradicular surgery: a literature review. Saudi Dent J. 2018;30(4):273–82.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Milani AS, Rahimi S, Borna Z, Jafarabadi MA, Bahari M, Deljavan AS. Fracture resistance of immature teeth filled with mineral trioxide aggregate or calcium-enriched mixture cement: an ex vivo study. Dent Res J. 2012;9(3):299–304.

    Google Scholar 

  9. Andreasen JO, Munksgaard EC, Bakland LK. Comparison of fracture resistance in root canals of immature sheep teeth after filling with calcium hydroxide or MTA. Dent Traumatol. 2006;22(3):154–6.

    Article  PubMed  Google Scholar 

  10. Theodosopoulou JN, Chochlidakis KM. A systematic review of dowel (post) and core materials and systems. J Prosthodont. 2009;18(6):464–72.

    Article  PubMed  Google Scholar 

  11. Ricketts DN, Tait CM, Higgins AJ. Post and core systems, refinements to tooth preparation and cementation. Br Dent J. 2005;198(9):533–41.

    Article  PubMed  Google Scholar 

  12. Dikbas I, Tanalp J. An overview of clinical studies on fiber post systems. Sci World J. 2013;2013:171380.

    Article  Google Scholar 

  13. Morgano SM, Milot P. Clinical success of cast metal posts and cores. J Prosthet Dent. 1993;70(1):11–6.

    Article  PubMed  Google Scholar 

  14. Türker SA, Özçelik B, Yilmaz Z. Evaluation of the bond strength and fracture resistance of different post systems. J Contemp Dent Pract. 2015;16:788–93.

    Article  PubMed  Google Scholar 

  15. Rafter M. Apexification: a review. Dent Traumatol. 2005;21(1):1–8.

    Article  PubMed  Google Scholar 

  16. Torabinejad M, Hong CU, McDonald F, Ford TP. Physical and chemical properties of a new root-end filling material. J Endod. 1995;21(7):349–53.

    Article  PubMed  Google Scholar 

  17. Chala S, Abouqal R, Rida S. Apexification of immature teeth with calcium hydroxide or mineral trioxide aggregate: systematic review and meta-analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;112(4):36–42.

    Article  Google Scholar 

  18. Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod. 1999;25(3):197–205.

    Article  PubMed  Google Scholar 

  19. Holden DT, Schwartz SA, Kirkpatrick TC, Schindler WG. Clinical outcomes of artificial root-end barriers with mineral trioxide aggregate in teeth with immature apices. J Endod. 2008;34(7):812–7.

    Article  PubMed  Google Scholar 

  20. Witherspoon DE, Small JC, Regan JD, Nunn M. Retrospective analysis of open apex teeth obturated with mineral trioxide aggregate. J Endod. 2008;34(10):1171–6.

    Article  PubMed  Google Scholar 

  21. Hatibović-Kofman Š, Raimundo L, Zheng L, Chong L, Friedman M, Andreasen JO. Fracture resistance and histological findings of immature teeth treated with mineral trioxide aggregate. Dent Traumatol. 2008;24(3):272–6.

    Article  PubMed  Google Scholar 

  22. Asgary S, Eghbal MJ, Parirokh M, Torabzadeh H. Sealing ability of three commercial mineral trioxide aggregates and an experimental root-end filling material. Iran Endod J. 2006;1(3):101–5.

    PubMed  PubMed Central  Google Scholar 

  23. Milani AS, Shakouie S, Borna Z, Deljavan AS, Jafarabadi MA, Azar FP. Evaluating the effect of resection on the sealing ability of MTA and CEM cement. Iran Endod J. 2012;7(3):134–8.

    PubMed  PubMed Central  Google Scholar 

  24. Asgary S, Kamrani FA, Taheri S. Evaluation of antimicrobial effect of MTA, calcium hydroxide, and CEM cement. Iran Endod J. 2007;2(3):105–9.

    PubMed  PubMed Central  Google Scholar 

  25. Utneja S, Nawal RR, Talwar S, Verma M. Current perspectives of bio-ceramic technology in endodontics: calcium enriched mixture cement-review of its composition, properties and applications. Restor Dent Endod. 2015;40(1):1–13.

    Article  PubMed  Google Scholar 

  26. Goracci C, Ferrari M. Current perspectives on post systems: a literature review. Aust Dent J. 2011;56:77–83.

    Article  PubMed  Google Scholar 

  27. Schwartz RS, Robbins JW. Post placement and restoration of endodontically treated teeth: a literature review. J Endod. 2004;30(5):289–301.

    Article  PubMed  Google Scholar 

  28. Ahmed SN, Donovan TE, Ghuman T. Survey of dentists to determine contemporary use of endodontic posts. J Prosthet Dent. 2017;117(5):642–5.

    Article  PubMed  Google Scholar 

  29. Girotto LP, Dotto L, Pereira GK, Bacchi A, Sarkis-Onofre R. Restorative preferences and choices of dentists and students for restoring endodontically treated teeth: a systematic review of survey studies. J Prosthet Dent. 2020. https://doi.org/10.1016/j.prosdent.2020.07.005.

    Article  PubMed  Google Scholar 

  30. Soltani MR. Dental caries status and its related factors in Iran: a meta-analysis. J Dent. 2020;21(3):158–76.

    Google Scholar 

  31. Kazeminia M, Abdi A, Shohaimi S, Jalali R, Vaisi-Raygani A, Salari N, Mohammadi M. Dental caries in primary and permanent teeth in children’s worldwide, 1995 to 2019: a systematic review and meta-analysis. Head Face Med. 2020;16(1):1–21.

    Article  Google Scholar 

  32. Quan JK, Wang XZ, Sun XY, Yuan C, Liu XN, Wang X, Feng XP, Tai BJ, Hu Y, Lin HC, Wang B. Permanent teeth caries status of 12-to 15-year-olds in China: findings from the 4th National Oral Health Survey. Chin J Dent Res. 2018;21(3):181–93.

    PubMed  Google Scholar 

  33. Candan M, Mavi E, Buldur B. Causes and patterns of permanent tooth loss among 9–15 years old children in the Central Anatolia Region. JOHOE. 2020;9(4):203–8.

    Google Scholar 

  34. Sahibzada HA. Pattern and causes of tooth extraction in patients reporting to a teaching dental hospital. J Islamabad Med Dent College. 2016;5(4):172–6.

    Google Scholar 

  35. de Moraes AP, Neto VP, Boscato N, Pereira-Cenci T. Randomized clinical trial of the influence of impression technique on the fabrication of cast metal posts. J Prosthet Dent. 2016;116(1):47–51.

    Article  PubMed  Google Scholar 

  36. Brito-Júnior M, Pereira RD, Veríssimo C, Soares CJ, Faria-e-Silva AL, Camilo CC, Sousa-Neto MD. Fracture resistance and stress distribution of simulated immature teeth after apexification with mineral trioxide aggregate. Int Endod J. 2014;47(10):958–66.

    Article  PubMed  Google Scholar 

  37. Sivieri-Araujo G, Tanomaru-Filho M, Guerreiro-Tanomaru JM, Bortoluzzi EA, Jorge ÉG, Reis JM. Fracture resistance of simulated immature teeth after different intra-radicular treatments. Braz Dent J. 2015;26(3):211–5.

    Article  PubMed  Google Scholar 

  38. Zicari F, Coutinho E, Scotti R, Van Meerbeek B, Naert I. Mechanical properties and micro-morphology of fiber posts. Dent Mater. 2013;29(4):e45-52.

    Article  PubMed  Google Scholar 

  39. Ballal NV, Rao S, Yoo J, Ginjupalli K, Toledano M, Husain NA, Özcan M. Fracture resistance of teeth obturated with two different types of mineral trioxide aggregate cements. Braz Dent Sci. 2020;23(3):1–9.

    Google Scholar 

  40. Darak P, Likhitkar M, Goenka S, Kumar A, Madale P, Kelode A. Comparative evaluation of fracture resistance of simulated immature teeth and its effect on single visit apexification versus complete obturation using MTA and biodentine. J Family Med Prim Care. 2020;9(4):2011–5.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Boutsioukis C, Noula G, Lambrianidis T. Ex vivo study of the efficiency of two techniques for the removal of mineral trioxide aggregate used as a root canal filling material. J Endod. 2008;34(10):1239–42.

    Article  PubMed  Google Scholar 

  42. Moradi S, Disfani R, Ghazvini K, Lomee M. Sealing ability of orthograde MTA and CEM cement in apically resected roots using bacterial leakage method. Iran Endod J. 2013;8(3):109–13.

    PubMed  PubMed Central  Google Scholar 

  43. Tabrizizade M, Asadi Y, Sooratgar A, Moradi S, Sooratgar H, Ayatollahi F. Sealing ability of mineral trioxide aggregate and calcium-enriched mixture cement as apical barriers with different obturation techniques. Iran Endod J. 2014;9(4):261–5.

    PubMed  PubMed Central  Google Scholar 

  44. Sarraf P, Nekoofar MH, Sheykhrezae MS, Dummer PM. Fracture resistance of immature incisors following root filling with various bioactive endodontic cements using an experimental bovine tooth model. Eur J Dent. 2019;13(2):156–60.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Adel M, Nima MM, Shivaie Kojoori S, Norooz Oliaie H, Naghavi N, Asgary S. Comparison of endodontic biomaterials as apical barriers in simulated open apices. ISRN Dent. 2012;2012:359873.

    PubMed  PubMed Central  Google Scholar 

  46. Valois CR, Costa ED Jr. Influence of the thickness of mineral trioxide aggregate on sealing ability of root-end fillings in vitro. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004;97(1):108–11.

    Article  PubMed  Google Scholar 

  47. Ghosh C, Kundu GK, Zahir S, Sarkar S, Bazmi BA, Kar S. A comparative evaluation of ideal apical sealing material for open apex single rooted permanent tooth: an in vitro study. SRM J Res Dent Sci. 2015;6(3):145–9.

    Article  Google Scholar 

  48. Madani ZS, Harandi A, Geraily E, Bijani A, Gharekhani S. Fracture strength of teeth restored with fiber post and apical plug. Casp J Dent Res. 2017;6(2):15–22.

    Google Scholar 

  49. Tabrizizadeh M, Dabbagh MM, Badrian H, Davoudi A. Microhardness properties of mineral trioxide aggregate and calcium-enriched mixture cement plugs at different setting conditions. J Int Oral Health. 2015;7(9):36–9.

    PubMed  PubMed Central  Google Scholar 

  50. Slutzky-Goldberg I, Sabag L, Keinan D. The influence of mineral trioxide aggregate (MTA) thickness on its microhardness properties—an in vitro study. Endod Pract US. 2014;7(2):26–30.

    Google Scholar 

  51. Fráter M, Forster A, Jantyik Á, Braunitzer G, Nagy K, Grandini S. In vitro fracture resistance of premolar teeth restored with fibre-reinforced composite posts using a single or a multi-post technique. Aust Endod J. 2017;43(1):16–22.

    Article  PubMed  Google Scholar 

  52. Özcan M, Valandro LF. Fracture strength of endodontically-treated teeth restored with post and cores and composite cores only. Oper Dent. 2009;34(4):429–36.

    Article  PubMed  Google Scholar 

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Acknowledgements

Not applicable.

Funding

The study is funded by the Golestan University of Medical Sciences.

Author information

Authors and Affiliations

  1. Department of Edndodontics, Gorgan School of Dentistry, Golestan University of Medical Sciences, Gorgan, Golestan, Iran

    Ensieh Grayli

  2. Gorgan School of Dentistry, Golestan University of Medical Sciences, Gorgan, Golestan, Iran

    Abbas Dashtban

  3. Department of Prosthodontics, Gorgan School of Dentistry, Golestan University of Medical Sciences, Gorgan, Golestan, Iran

    Leyla Shadan

  4. Department of Biostatics and Epidemiology, Health Management and Social Development Research Center, Golestan University of Medical Sciences, Gorgan, Golestan, Iran

    Naser Behnampour

  5. Department of Pediatric Dentistry, Gorgan School of Dentistry, Golestan University of Medical Sciences, Gorgan, Golestan, Iran

    Elham Afshari

Authors
  1. Ensieh Grayli
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  2. Abbas Dashtban
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  3. Leyla Shadan
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  4. Naser Behnampour
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  5. Elham Afshari
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Contributions

EG conceived, and designed the study, supervised and contributed to the endodontic procedures. AD carried out the major part of endodontic and prosthodontic procedures. LSh supervised and contributed to the prosthodontic procedures and contributed to the manuscript preparation. NB contributed to the data analysis, data interpretation and manuscript preparation. EA contributed to data interpretation and manuscript preparation. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Elham Afshari.

Ethics declarations

Ethics approval and consent to participate

Ethical approval for this study was obtained from the Ethics Committee of Golestan University of Medical Sciences (code: IR.GOUMS.REC.1397.191). All methods were carried out in accordance with relevant guidelines and regulations. The permission to utilize the teeth samples was granted by The Ethics Committee of Golestan University of Medical Sciences based on the recorded proposal (research code: 19-110580, ethics code: IR.GOUMS.REC.1397.191). The permission is also approved by Iran National Committee for Ethics in Biomedical research (https://ethics.research.ac.ir/IndexEn.php).

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Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Grayli, E., Dashtban, A., Shadan, L. et al. Effect of MTA versus CEM apical plugs on fracture resistance of endodontically treated simulated immature teeth restored with cast metal posts: an in-vitro study. BMC Oral Health 21, 280 (2021). https://doi.org/10.1186/s12903-021-01641-w

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  • DOI: https://doi.org/10.1186/s12903-021-01641-w

Keywords

  • Fracture resistance
  • Cast metal
  • Endodontic post
  • Bioceramics
  • MTA
  • CEM

BMC Oral Health

ISSN: 1472-6831

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