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Restoration of theendodontically treated

tooth

Amith BabuAmrita Dora

Ganesh O.R

Praveen J

Ourvind Singh


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CONTENTS

Introduction

History

Need for finalrestoration

Objectives

Classification

Anterior teeth

Posterior teeth

Components of finalrestoration:

I. Posts

II. CoresIII. Crowns


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The tooth as a house


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INTRODUCTION

Hence require special considerations forthe final restoration, particularly where therehas been extensive loss of tooth structure. The

special needs involve ensuring both adequateretention for the final restoration andmaximum resistance to tooth fracture.

Endodontic success depends not onlyon the quality of the root canal treatment, butalso on timely coronal restoration of thecompromised tooth.


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CONTENTS

Introduction

History


Objectives

Classification

Anterior teeth

Posterior teeth


I. Posts



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HISTORY

Various methods of restoring

pulpless teeth have been

reported for past 200 years.

In 1747 Pierre Fauchardfabricated gold and silver

posts to be placed in root

canal space.

Replacement crowns were

made from bone, ivory,

animal tooth.


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Is final restoration

after endodontictreatment important?


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LITERATUREREVIEW1In this study using radiographs they assessed the

following Good restorations + good endodontic treatments

resulted in absence of periapical inflammation in

91.4%.

Poor restorations + poor endodontic treatments

resulted in the absence of periradicular inflammation

in only 18.1%.

Poor endodontic treatment + good restorationsyielded a success rate of 67.6%.

1Periapical status of endodontically treated teeth in relation to the technical

quality of the root filling and the coronal restoration.H. A. Ray and M. TropeInternational Endodontic Journal, vol. 28, no. 1, pp. 1218, 1995.

This shows the importance of final restorationin endodontically treated teeth


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CONTENTS

Introduction

History


Objectives

Classification

Anterior teeth

Posterior teeth


I. Posts



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What are theobjectives of Final

restoration?


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GOALS

2Maintained coronal and apical seal of the root

canal treatment

Protect and preserve the remaining tooth structure

Provided a supportive and retention foundation forthe placement of definitive restoration

Restore the function and esthetics

2Colour atlas of endodontics 2 edition

William T.Johnson DDS MS

Page no 130


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What are the factorsto be considered while

planning the final

restoration?


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FACTORS

3Amount of remaining sound tooth structure

Occlusal function

Opposing dentition

Position of the tooth in the arch

Length, width and curvature of the roots

3Endodontics : Restoring of Endodontically Treated Teeth

American Association of Endodontics.1995 Dec Publication


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CONTENTS

Introduction

History


Objectives

Classification

Anterior teeth

Posterior teeth


I. Posts



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4Based on the remaining tooth

structure

Classification Description

Class I 4 walls

Class II 3 wallsClass III 2 walls

Class IV 1 wall

Class V No wall

4Restoring endodontically treated teeth with posts and coresa review

Ingrid peroz et al.Quintessence International no.9 volume 36 oct 2005.


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6Restoration of Endodontically Treated

Teeth:

An Evidence-Based Literature ReviewUniversity of Toronto, Faculty of Dentistry. Int

J Prosthodont 2008;18(1):40-1.


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FERRARI AND

OTHERS

FOKKINGA &

OTHERS

SAMPLES240 endodontically-treatedpremolars in 210

patients

307 endodontically-treated teethin 257

patients

TEST

TREATMENT

Fiber posts Cast post and core

Pre-fab metal post and

composite core

CONTROL

TREATMENT

No post Post-free composite core

DURATION

(YRS)

2 Up to 17

CONCLUSIONS

4 coronal wall remaining: no

difference in

complication rates

3 coronal walls remaining:

post placement

increases survival rates

Where substantial remaining

dentin is available, a post and

core does not perform better

than a post-free core


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8Ferrari M. Post placement affects survival of endodontically treated

premolars. JDentRes 2007;86(8):729-734.

8

Fokkinga W. Up to 17-year controlled clinical study on post-and-cores andcovering crowns. J Dent 2007;35(10):778-786.


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CONTENTS

Introduction

History


Objectives

Classification

Anterior teeth

Posterior teeth


I. Posts



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ANTERIOR TEETH

9Anterior teeth with

minimal loss of tooth

structure can be

restoredconservatively with a

bonded restoration in

the access opening

9Intracoronal reinforcement & coronal coverage:a study of endodontically

treated teeth. Sorensen JA, Martinoff JT. J Prosthet Dent 1984;51:7804.


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ANTERIOR TEETH

10A post is of little or no benefit in a

structurally sound anterior tooth

Increases the chances of a failure

10Fracture strength and survival rate of endodontically treated maxillary incisors

with approximal cavities after restoration with different post and core systems: an

in-vitro study. Heydecke G, Butz F, Strub JR. J Dent 2001; 29:42733.


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ANTERIOR TEETH

11In cases of extensive loss of external tooth

structure, a post is usually required for anterior

teeth, due to the predominantly shearing forces

present and the narrow tooth dimensions. Extra-coronal crown preparation combined with

endodontic access preparation significantly

weakens the cervical area of anterior teeth.

11Post Placement and Restoration of Endodontically Treated Teeth: A

Literature Review. Richard S. Schwartz, et al. Journal of

Endodontics:VOL. 30, NO. 5, MAY 2004


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Anterior Teeth

13Biomechanical considerations for the restoration of endodontically

treated teeth: A systematic review of the literature. Didier Dietschi,, Ivo

Krejci, Quintessence international Volume 39 number 2 february 2008


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Anterior Teeth

14Biomechanical considerations for the restoration of endodontically

treated teeth: A systematic review of the literature. Didier Dietschi,, Ivo

Krejci, Quintessence international Volume 39 number 2 february 2008


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CONTENTS

Introduction

History


Objectives

Classification

Anterior teeth

Posterior teeth


I. Posts



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Considerations for posterior teeth

Endodontically treated posterior teeth are subject to

greater loading than anterior teeth, because of their

position closer to the insertion of the masticatory

muscles. This, combined with their morphologiccharacteristics, makes them more susceptible to

fracture.


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Posterior teeth

15The results showed that the clinical

success rates of endodontically treated

premolars restored with fiber posts and direct

composite restorations or full coverage withmetal-ceramic crowns were highly successful

without any failures, even after 3 years of

service .

15J Prosthet Dent 2002 Sep;88(3):297-301. Three-year clinical survival of

endodontically treated premolars restored with either full cast coverage

or with direct composite restoration. Mannocci F, Bertelli E, Sherriff M,

Watson TF, Ford TR


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CASE REPORT

Post-endodontic restoration of a

deeply decayed tooth - options and

limitation Michael Bruder, DDS.

Jounal of oral science,11: 2;2007.


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Posterior teeth

16Molar teeth rarely require a post unless

there has been significant loss of tooth

structure. A coronal-radicular core buildup

with silver amalgam utilizing the pulp

chamber, and possible 2 mm canal extensions,

has proved very effective in vitro and in vivo.

16Nayyar, A., An amalgam coronal-radicular dowel and core technique

for endodontically treated posterior teeth. J Prosthet Dent, 1980. 43: p.

511.


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CASE REPORTReconstruction of Endodontically Treated

Posterior Teethwith or without Post?Maciej Zarow, Walter Devoto. The European

Journal Of Esthetic Dentistry. Volume

4,number 4,december 2009.


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Tooth fracture of an endodontically treated

maxillary molar restored with a bonded composite

restoration.


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CONTENTS

Introduction

History


Objectives

Classification

Anterior teeth

Posterior teeth


I. Posts



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COMPONENTS OF FINAL

RESTORATION

A.Posts

B. Cores

C. Crowns


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CONTENTS

Introduction

History


Objectives

Classification

Anterior teeth

Posterior teeth


I. Posts



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Role of posts

Indications

Post selection:Factors to be considered Ferrule effect

Types

Procedure

POSTS

Th R l f P t i th R t ti


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The Role of Posts in the Restoration

of Endodontically Treated Teeth

18The primary purpose for a post is to retain acore that can be used to support the final

restoration.

Posts do not reinforce endodontically treatedteeth, and a post is not necessary when

substantial tooth structure is present after a

tooth has been prepared.

18W. Cheung, A review of the management of endodontically treated teeth:

post, core and the final restoration, Journal of the American Dental

Association, vol. 136, no. 5, pp. 611619, 2005.


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INDICATIONS

19Post placement is indicated ifboth of the

following clinical conditions exist:

The remaining coronal tooth structure is

inadequate for the retention of a restoration.

When there is sufficient root length to

accommodate the post while maintaining an

adequate apical seal.

19Stockton LW.Factors affecting retention of post systems:

A literature review. J Prosthet Dent 1999;81:380385.


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FACTORSTOCONSIDER

Post length

Post diameter

Post design




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Post length21

Guidelines:1. The post should more than the incisocervical

or occlusocervical dimension of the crown.

2. The post should be longer than the crown.3. The post should be 1 1/3 the length of the

crown.

4. The post should end halfway between thecrestal bone and the root apex.




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Ideal tooth

preparationfor post

placement


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Post Size and Length

22Post length is unique and individualized for each

case. The clinician should have a thorough

knowledge of root morphology before placing a post.

The longer the post, the greater the retention. Aguideline of one half to three quarters of the root

length is often followed but may not be reasonable

for extremely long, short, narrow, or curved roots

22Retention of endodontic dowels: effects of cement, dowel length, diameter, and

design. Standlee JP, Caputo AA, Hanson EC: J Prosthet Dent 39:401, 1998.

The effect of the embedded depth of posts on

retentive capacity has been shown to be

significant


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Post diameter

23The diameter of the post is dictated by

the root canal anatomy.

A minimal dentin thickness of 1 mm around

the post should be provided.

23Lloyd PM, Palik JF. The philosophies of dowel diameter preparation: A

literature review. J Prosthet Dent 1993;69:3236.


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The diameter of the post is dictated by the remaining root

substance and root canal space: (A) too narrow; (B) optimum

size post; (C) too large.

P t d i


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Post design

24

Posts can be serrated,smooth, roughened or

threaded.

Parallel, serrated posts

are cemented into thecanal passively. They are

retentive and produce less

stress in the root dentine

than threaded systems


Literature Review. Richard S. Schwartz, et al. Journal of

Endodontics:VOL. 30, NO. 5, MAY 2004

F l Eff t


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Ferrule Effect

25The ferrule is the circumferential ring ofsound tooth structure that is enveloped by

the cervical portion of the crown

restoration. A minimum sound dentineheight of 1.5-2 mm is required between the

core and crown margins.

25Sorensen JA and Engelman MJ. Ferrule design and fracture resistance of

endodontically treated teeth. J Prosthet Dent 1999;63:529-536.


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Importance of ferrule

The ferrule provides bracing or casing action

to protect the integrity of the root.

26Eff t f f l th f t


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26Effect of a crown ferrule on the fracture

resistance of endodontically treated teeth

restored with prefabricated posts STATEMENT OF PROBLEM: Root fracture is

one of the most serious complications following

restoration of endodontically treated teeth

Fifty freshly extracted canines were

endodontically treated. The teeth were randomly

divided into groups of 10 and prepared according

to 5 experimental protocols

The results of this study showed that an increased

amount of coronal dentin (ferrule) significantly increasesthe fracture resistance of endodontically treated teeth.

26Effect of a crown ferrule on the fracture resistance of endodontically treated

teeth restored with prefabricated posts.

Pereira JR, de Ornelas F, Conti PC, do Valle AL

J Prosthet Dent. 2006 Jan;95(1):50-4.


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27An incomplete crown ferrule is

associated with greater variation in load capacityand, despite high fracture values, inclines to

fracture.

27Effect of incomplete crown ferrules on load capacity of endodontically

treated maxillary incisors restored with fiber posts, composite build-ups, and

all-ceramic crowns: an in vitro evaluation after chewing simulation.

Naumann M, Preuss A, Rosentritt M.

Acta Odontol Scand. 2006 Feb;64(1):31-6.

27CHARACTERISTICS OF AN


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CHARACTERISTICS OF AN

IDEAL POST: Minimum preparation. Resistance to fatigue.

Elastic modulus similar to dentin.

Non corrosive.

Retentive (post & Head).

Easy to adjust and fit.

Radiopaque.

Adequate material Easy Removal

27Factors determining post selection: A literature Review.

Fernandes A., Shetty Sh., Coutinho I.-

J Prosth. Dent. Dec. 2003.


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28TYPESOFPOSTS

METALLIC NON-METALLIC

Stainless Steel Titanium

Titanium Alloy

Gold-Platedbrass

Carbon Fibre

Ceramic

Glass-fibrereinforced

Composite28Fundamental of fixed prosthodontics 3 editions

Herbert T. shillingburg

Page no 345


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Types of Posts


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Prefabricated posts


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Custom made posts

Direct Technique

Indirect Technique

Wax pattern before casting.


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Custom cast post and core

Advantages: Preservation of maximum

tooth structure

Provision of anti-rotational

properties

Core retention

Less chances of vertical

fractures during preparation

High strength

Disadvantages: Less stiff than

wrought

Time consuming,

complex procedure

Recommended Use:

Elliptical canals

Flared canals


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29Prefabricated Tapered Post

Advantages: Conserves tooth

structure

High strength and

stiffness

Disadvantages: Low retention

Longitudinal

splitting of

remaining rootRecommended Use:

Small circular canals or

Very tapered canals

29Post placement and restoration of endodontically treated teeth: A

literature review.

Schwartz. R, Robbins. J.

J Endodon 2004, 30: 289-301.

30Prefabricated Parallel - Sided


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Prefabricated Parallel Sided

Smooth Post

Advantages: Excellent clinical

retention

Minimal stress

production within

root

Ease of placement

Superior rating

Disadvantages: Precious material

post expensive

Corrosion of

stainless-steel

Less conservative of

tooth structure

30Color Atlas of Endodontics. , 2ndedition

William T.Johnson, page no 133-134.

31P f b i t d Th d d P t


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31Prefabricated Threaded Posts

Advantages: High retention

Disadvantages: Stresses generated in

canal may lead to

fracture

Does not conserve

coronal and radicular

tooth structure

Recommended Use:

Only when maximum

retention is essential

31Color Atlas of Endodontics. , 2ndedition

William T.Johnson, page no, 133-134.


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32Carbon Fiber Post

Advantages: Dentin bonding

Easy removal

Disadvantages: Low strength

(compared to metal)

Lack of radiopacity

Carbon color

presents an esthetic

problem

Recommended Use:

Can be used in posteriors

with moderate loss of

coronal structure


Literature Review. Richard S. Schwartz, et al.

Journal of Endodontics:VOL. 30, NO. 5, MAY 2004


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33Fiber Reinforced Post

Advantages: Esthetic

Disadvantages: Low strength

High failure rate

Recommended Use:

Should not be used where remaining

tooth structure is less than ideal or where

high occlusal forces are present.

33Aesthetic posts and cores for metal free restoration of

endodontically treated teeth. Adriana Quintas, Jose Dinato. Pract

Periodont Aesthet Dent; 12(9): 875-884


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34Zirconia Ceramic Post

Advantages: Esthetics

High stiffness

High modulus of

elasticity

Disadvantages: Expensive

Uncertain clinical

performances

Recommended Use:

High esthetic demands

Procedure


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Procedure

Textbook of Endodontology 2 editions

Preben Hrsted-Bindslev

Page no 326


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A review of the studies doneon the various post systems

suggests that the fiberposts are the most reliable!!!


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Background: Post design and material has very

important effects on dentinal stress distribution sincethe post placement can create stresses that lead to

root fracture.

Materials:

4 metallic posts (ParaPost XH, ParaPost XT,

ParaPost XP, and Flexi-Flange) and 1 fiberglass post

(ParaPost Fiber Lux) were used.

35Fiber posts show more

homogeneous stress distributionthan metallic posts.

35Influence of different post design and composition on stress distribution in

maxillary posterior teeth. Finite element analysis.

Natercia R Silva, Carolina G Castro, Paulo CF Santos-Filho.

Indian journal of dental research 2009 vol 20

P Thi i it t d d th ff t f


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Purpose. This in vitro study compared the effect of

titanium, quartz fiber, glass fiber, and zirconia posts

systems on the fracture resistance and fracture patterns

of crowned, endodontically treated teeth

Results. Teeth restored with quartz fiber posts

exhibited significantly higher resistance to fracture than

the other 3 groups. Teeth restored with glass fiber andzirconia posts were statistically similar.

Fractures that would allow repair of the tooth were

observed in quartz fiber and glass fiber , whereas

unrestorable, catastropic fractures were observed in

titanium and zirconia post groups.36Resistance to fracture of endodontically treated teeth restored with different

post systems.

Akkayan B, Gulmez T.

J Prosthet Dent. 2002;87:431437.

Fractures allow repairGood strength


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Conclusion: The fiber posts evaluated

provided an advantage over a conventionalpost that showed a higher number of

irretrievable post and unrestorable root

fractures. The fiber posts were readily

retrievable after failure, whereas the

remaining post systems tested were non

retrievable.

37In vitro comparison of the fracture resistance and failure mode of fiber,

ceramic, and conventional post systems at various stages of restoration.

Cormier CJ, Burns DR, Moon P.

J Prosthodont. 2001;10:2636.

Readily retrievable


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PURPOSE: This retrospective study evaluated

treatment outcome of cast post and core and

Composipost systems after 4 yrs of clinical

service.

The results of this retrospective study indicated

that the Composipost(95% success) system(fiber-reinforced epoxy resin posts) was superior to the

conventional cast post and core system(84%

success) after 4 yrs of clinical service.

38Clinical evaluation of fiber-reinforced epoxy resin posts & cast post & cores.

Ferrari M, Vichi A, Garcia-Godoy F.

Am J Dent. 2000;13:15B18B.

Better than cast post

system in the long term


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PURPOSE: This study aggregated literature data on in

vitro failure loads and failure modes of prefabricated

fiber-reinforced composite (FRC) post systems and tocompare them to those of prefabricated metal, custom-

cast, and ceramic post systems.

RESULTS: Custom-cast post systems showed higher

failure loads than prefabricated FRC post systems,whereas ceramic showed lower failure loads.

Significantly more favourable failures occurred with

prefabricated FRC post systems than with prefabricated

and custom-cast metal post systems.39A structured analysis of in vitro failure loads and failure modes of fiber, metal,

and ceramic post-and-core systems.

Fokkinga WA, Kreulen CM, Vallittu PK, Creugers NH.

Int J Prosthodont. 2004;17(4):476482.

More favourable

MECHANICAL PROPERTIES


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Material Flexural

strengthGpa

Tensile

StrengthMPa

Elastic

ModulousGPa

Stainless

Steel

800 n/a 200

TitaniumAlloy

1000 n/a 110

Zirconium

Oxide

820 n/a 200

C-Post(64% Carbon)

1100 2900 17.8

40Evolving Technology in Endodontic Posts.

Pitel M., Hicks N

Comp. Of Cont. Educ. in Dent. January 2003.


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CONTENTS

Introduction

History


Objectives

Classification

Anterior teeth

Posterior teeth


I. Posts

II. Cores

III. Crowns


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Indications

Principles

Types of core build up

Procedure

CORES

I


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INDICATIONS

Core restorations are indicated ifany of the

following clinical conditions exist:

The replacement of missing coronal tooth

structure is necessary.

When the enhanced retention and resistance

to displacement of the final restoration is

necessary.

41Fundamental of fixed prosthodontics 3 editions


Page no 367

MATERIALS USED FOR CORE


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MATERIALSUSEDFORCORE

BUILDUP

DIRECT PLACEMENT:

1. Composite resin

2. Amalgam

3. Glass ionomer resin

INDIRECT PLACEMENT:

Casting

42Fundamental of fixed prosthodontics 3 editions


Page no 369

C it i


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Composite resin core

Advantages: Good compressive

strength

Easy to manipulate

Rapid

polymerization

Dentin bonding

Disadvantages: Polymerization

shrinkage

Poor dimensional

stability

Recommended Use:Excellent build-up material

for posterior and anterior

teeth if isolation assured

A l


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Amalgam core

Advantages: Reduced marginal

leakage

Better dimensional

stability

Better compressive

strength

Better modulus of

elasticity

Disadvantages: Mercury sensitivity

Low tensile strength

Corrosion with base

metal

Recommended Use:Molars with adequate

coronal tooth

structure

Gl I i


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Glass Ionomer resin core

Advantages: Anticariogenic

Adhesive

Easy to manipulate

Disadvantages: Low resistance to

fracture

Low retention to

preformed post

Sensitive to moisture

Recommended Use:Teeth with minimum

tooth structure missing


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So which is the bestmaterial for core

buildup???


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The modulus of elasticity of amalgam is

significantly higher than all other materialtested and is closer to that of dentin

Prepared core build-ups in a hybrid

composite material provided the highestfracture resistance

46Fracture resistance of five pinretained core buildup materials on teeth

with and without extracoronal preparation.

Burke, FJT, Shaglouf, AG, Combe, EC, Wilson, NHF.

Operative Dentistry 2000; 25: 388-394.


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This study showed that the tensile and

flexural strengths of composite are

significantly higher than that of amalgam

and glass ionomer.

47Kovarik, Robert E., Breeding, Larry C., Caughman, W. Franklin. Fatigue

life of three core materials under simulated chewing conditions.

The Journal of Prosthetic Dentistry Oct 1992; 68(4): 584-589.


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Tensile strength and modulus of elasticity

of glass ionomer cements are significantlylower than dentin and amalgam

Glass ionomers are relatively slow-setting

and their early resistance to moisture is poor

48Mechanical properties of direct core buildup materials.

Combe, E.C., Shaglouf, A., Watts, D.C., Wilson, N.H.F.

Dental Materials 1999; 15: 158-165.

Based on the above stated

evidence, composite seems to be

the best choice as a core build upmaterial.


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CONTENTS

Introduction

History


Objectives

Classification

Anterior teeth

Posterior teeth


I. Posts

II. Cores

III. Crowns


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CROWNS

Indications

Advantages

Disadvantages

Types

CROWN PLACEMENT


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CROWNPLACEMENT

INDICATIONS

Better esthetics

Situations in which the structural integrity

of natural crown is compromised

CONTRAINDICATIONS

Anterior teeth have only have conservativeaccess opening

49Textbook of Endodontology

Gunnar Bergenholtz Page no 317

CROWNS


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CROWNS

Advantages:

Durable

Good esthetics

Restoring dental

function

Good Form Protection of tooth

Disadvantages:

Loss of tooth structure

Expensive

50Textbook of Endodontology

Gunnar Bergenholtz Page no 317


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51PORCELAIN JACKET CROWN


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51PORCELAIN JACKET CROWN

It consists of a crown entirely made up of ceramic.

Superior esthetics and excellent translucency.

Good tissue response even with subgingival

margins.

But is has reduced strength and is the least

conservative of all tooth preparation.

51Endontics Problem-Solving in Clinical Prctice

TR Pitt Ford, BDS, PhD

Page No.161

52FULL CAST METAL CROWNS


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52FULL CAST METAL CROWNS

Cast metal crown is a full crown restoration whichis cast with dental alloy.

It had high strength, is long lasting and requires

the least amount of tooth preparation. Cannot be used in areas where esthetics is of

prime concern.

52Endodontics Problem-Solving in Clinical Practice

First published in the United Kingdom in 2002

ISBN 1-85317-695-8

TR Pitt Ford, BDS, PhD Page no 161,

53PARTIAL CAST METAL


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CROWNSPartial cast metal crowns may be used when the

buccal surface of the tooth is intact. They are more

conservative of tooth tissue than complete crowns,

but they are more demanding technically both for

clinician and in the laboratory

53Color Atlas of Endodontics.

William T.Johnson, 2nd edition, 133-134.

54TEMPORARY CROWNS


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54TEMPORARY CROWNS

Temporary crowns are used to protect a tooth thathas been prepared for a permanent crown while

the patient waits for the permanent crown to be

fabricated by the dental lab.

Types:

i. Polycarbonate

ii. acrylic temporary

iii. Custom-cast temporaries

iv. Composite resin

54Color Atlas of Endodontics.

William T.Johnson, 2nd edition, 133-134.


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Conclusion

Anterior Tooth


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Class IVClass I - III

Complete Coverage

is required

Prefabricated fiber post with

composite core

full ceramic crown

Complete

Coverage is

not required

Conservative Trt

Resin composite

Class V

Complete Coverage

is required

Posterior Tooth


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Class IV

Class I-III

Conservative TrtOnlay

Class V

Composite Core

Fiber post

Metal Ceramic

Crown

Pre-fabricated fiber

post

Composite Core

Metal Ceramic

crown


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Thank You

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