POST-ENDODONTIC

RESTORATION
*************************************************************
INTRODUCTION
WHY DO WE NEED TO RESTORE ENDODONTICALLY TREATED TEETH?
FUNCTIONS
WHEN DO YOU PROVIDE A POST-ENDO RESTORATION?
BASIC COMPONENTS OF A POST-ENDO RESTORATION
THE POST
THE CORE
THE FINAL RESTORATION
BIOMECHANICAL PRINCIPLES OF TOOTH PREPARATION
CLINICAL TECHNIQUES
CONCLUSION
INTRODUCTION
Root canal therapy cannot be summarized by saying, ill it, shut it, orget it!" The inal
restoration o#er an endodontically treated tooth is as important or probably e#en more
important than the actual root canal therapy itsel"
The endodontically treated tooth constitutes a uni$ue subset o teeth re$uiring
restorations because%
&irst and oremost, the tooth structure has already been 'ea(ened by pre#ious
episodes o caries, trauma, restorati#e procedures and tooth preparations"
)n accountable percentage o structural integrity is lost because o the root canal
therapy itsel due to access ca#ity preparation and canal instrumentation leading
to increased le*ing o the tooth and ultimately its racture"
+ome authors $uote an alteration in the composition o the dentin such as a
change in the collagen cross lin(ing, dehydration etc" O course, 'hether such a
change is actually detrimental to the prognosis o the treatment is $uestionable as
studies ha#e not been #ery conclusi#e about it"
,oreo#er such teeth are esthetically and physically compromised re$uiring
special (inds o restoration"
&inally and most importantly, the RC treated tooth has got an impaired
neurosensory eed- bac( mechanism because o the lac( o pulpal tissue i"e" the
protecti#e property o .proprioception/ is lost" This renders the tooth more
#ulnerable to racture under normal masticatory orces" +o, a person can un-
intentionally bite too hard on the RC treated tooth compared to a #ital tooth,
'hich can lead to its racture and ailure"
)ll these points emphasis the need o a 'isely designed, accurate and strong
restoration o#er the endodontically treated tooth, 'hich 'ould not only protect the tooth
but also pre#ent any orm o microlea(age" Coronal lea(age or orthograde contamination
#ia sali#a has no' been sited as the prime cause o endodontic ailures"
0ence the function o a post-endodontic restoration are%
- 1ro#iding a coronal seal"
- 1ro#iding protection to the remaining tooth structure"
- Restoring the esthetics and unctions o the tooth"
Treatment planning or the post-endodontic restoration should start, ideally
spea(ing, prior to the commencement o the RCT itsel" )n e*traction should be carried
out i the restorability and periodontal status o the tooth is $uestionable instead o
spending unnecessary time and e*penses on it" I this is not the case and the tooth is
sal#ageable, then the ollo'ing principles should be (ept al'ays in mind%
2" 1reser#ation o remaining tooth tissue by conser#ati#e restorati#e design
compatible 'ith acceptable aesthetics and unction"
3" Reduction o stress and its a#orable distribution 'ithin the remaining tooth tissue
by proper design and selection o materials"
No', an important $uestion beore us is !"#n to restore ater endodontic treatment" ,ost
authors agree that since the success rate o RCT is pretty high at 45-678, an arbitary
period o a couple o 'ee(s is suicient beore pro#iding a permanent restoration" )
permanent restoration may be delayed i the endodontic treatment has%
- Doubtul prognosis re$uiring possible re-treatment"
- 1resence o sinus
- Tenderness to palpation 9percussion
B$ic co%&on#nt of t"# &ot-#n'o'ontic (#to($tion $(#)
- The post
- The core
- The inal restoration
+imply put, the post helps in the retention o the core, the core helps in the replacement
o the missing tooth structure and the inal restoration helps in restoring the orm and
unction o the tooth and protects the remaining tooth structure rom racture"
Not all teeth re$uire a post or a cro'n" +ome re$uire all : components 'hile some may
need ;ust an access seal"


THE POST
D#finition%
The post can be deined as a relati#ely rigid restorati#e material placed in the
canal o a non-#ital tooth"
Function%
The post has got 3 main unctions%
- Retention o core
- 1rotection o the tooth by dissipation o orces along its long a*is to the
surrounding periodontal tissues and the al#eolar bone"
I'#$* &(o&#(ti#)
- Retenti#e to the tooth and the core
- +trong and pro#ide protection to the tooth
- Radiopa$ue
- <iocompatible
- Inert
- =conomical
- =sthetic 'here#er re$uired
In'ic$tion
- =*tensi#e coronal tooth structure loss9 >758 loss o tooth structure including
important landmar(s such as marginal ridges, cingulum, reciprocating 'alls etc"
- Teeth 'hich are going to be used as abutments or &1D/s, o#erdentures etc
- Teeth e*hibiting e*tensi#e 'ear or patients ha#ing any paraunctional habits
'hich can cause e*cessi#e amounts o load on the tooth"
- Teeth that are going to become a part o a periodontal splint"
- &or the retention o a comple* restoration"
Cont($in'ic$tion)
<esides the opposites o the abo#e points, certain other contraindication include%
- =ndodontically treated teeth ha#ing a $uestionable prognosis re$uiring possible
re-treatment"
- Teeth ha#ing minimal canal dentin
- Teeth ha#ing unusual anatomy such as e*treme cur#atures and ragile roots"
C*$ific$tion)
Numerous classiications ha#e been $uoted by se#eral authors, 'hich are more or less
similar to each other" The ollo'ing is a simple 'ay o classiying posts based on their
eatures%
2" &abrication% Custom cast
1reabricated
3" ,aterials used% ,etallic
Non-metallic
:" =sthetics% =sthetic
Non-esthetic
?" Retention mode% )cti#e 9 threaded
1assi#e9 cemented
7" +hape% 1arallel
Tapered
1arallel 'ith apical taper
@" +urace coniguration% +mooth
+errated
Threaded
A"+han( coniguration% +olid
0ollo'
+plit
4" Benting% Bented
Non-#ented
6" Resiliency% Rigid
&le*ible
F#$tu(#)
The posts, as mentioned in the classiication, come in #arious diameters, lengths, tapers,
sizes, surace conigurations, shan( conigurations etc" The choice o an indi#idual post
selection is purely based on the operator/s discretion and the type o case beore him"
T+&# of &ot%
1osts can broadly be o 3 types C custom cast or preabricated" Custom cast posts are
those posts 'hich are made by ta(ing an impression o the canal space either directly or
indirectly and casting a post 'hich e*actly replicates the canal space" The preabricated
post is a#ailable commercially in predetermined dimensions, length and contours and
hence does not replicate the canal space" +ome ma;or dierences bet'een the 3 are%

The preabricated metal post can be o 3 types based on their mode o retention
- 1assi#e post or the cemented post 'hich rely on a cementing media or
their retention
- )cti#e post or the threaded post 'hich acti#ely thread into the dentin to
attain retention"
The non-metallic preabricated posts can be either esthetic posts or non-esthetic posts"

THE CORE
D#finition% The core can be deined as a restorati#e material placed in the coronal portion
o the tooth to replace the missing coronal tooth structure"
The core can be anchored to the tooth either #ia its e*tension onto the
coronal aspect o the tooth or #ia an endodontic post"
I'#$* &(o&#(ti#)0igh compressi#e strength
- Dimensional stability
- +hould not deorm plastically under loading
- Retenti#e to post, tooth and i possible to the o#erlying cro'n as 'ell
- +hould be easy to manipulate and place
- +hould set rapidly
- <iocompatible
- Inert
- =conomical
- =sthetic 'here#er indicated
Co(# %$t#(i$*) A',$nt$-# Di$',$nt$-#
C$t co(# 0igh strength
No concern regarding
delamination rom the post
=*pensi#e
Time consuming
Casting inaccuracies
A%$*-$% 0igh compressi#e strength
0igh modulus o elasticity
=asy manipulation and
placement
+table to thermal and
unctional stresses
Unesthetic
Cannot be bonded to
Tendency to discolour
ad;acent gingi#a
Tendency to corrode
Do' early strength C
preparations cannot be done
immediately
Co%&oit# =sthetic
<ondable
)de$uate strength
Command set- preparation
can be done immediately
,icrolea(age due to
polymerization shrin(age
Dimensionally unstable
Tendency to deorm
plastically and thus cannot
be used in high stress areas
.IC Chemically adhesi#e to the
tooth
)nticariogenic
Do' racture resistance
=arly moisture sensiti#ity
MM.IC -----------99-----------------
Used 'hen>758 o tooth
structure is intact
Bery brittle
RM.IC 1roperties lie in bet'een
composites and EIC
)nticariogenic
,ore adhesi#e than EIC
Decreased moisture
sensiti#ity
Decreased microlea(age
Tendency to e*pand in
presence o moisture- can
lead to racture o o#erlying
all-ceramic cro'ns"
Pin-(#t$in#' co(#)
)t times posts cannot be placed in the root due to anatomical actors or
due to the non-irretrie#ability o a sil#er cone obturation" In such situations, pins can be
used to gain an ade$uate amount o retention" +ometimes pins can also be used along
'ith a post to gain an au*iliary mode o retention"
A%$*co(#%
Nayyar and Falton ha#e described a techni$ue 'herein the coronal 3mm o gutta-
percha is remo#ed and amalgam condensed into it to attain ade$uate amount o retention
or the core" +tudies ha#e sho'n a#orable results 'ith this type o techni$ue"

FINAL RESTORATION %
The inal component o a post-endodontic restoration is the inal or the deiniti#e
restoration" )s mentioned beore, the inal restoration helps to
1rotect the remaining tooth structure rom racture
1rotect the entire unit rom microlea(age
Restore the esthetics and unctions o the tooth
Pot#(io( t##t")<ecause o the #ertical orces e*perienced by a posterior tooth, as a
general rule all endodontically treated posterior teeth re$uire a ull occlusal co#erage
restoration" This could be a metal 9 a ceramo-metal cro'n or it could be an onlay"
Ant#(io( toot"))nterior teeth usually e*perience shear orces" Depending on the
structural integrity and the amount o discolouration o the tooth o the tooth, a
permanent restoration or an anterior tooth can ta(e any o the ollo'ing orms%
Teeth 'ith posts G Hac(et cro'ns-all-ceramic9 ceramo-metal
Teeth 'ithout posts but discolored G Daminate #eneer 9HC
Intact teeth 'ith no discoloration G Composite or the access seal
PREPARATION PROCEDURES
<iomechanical principles go#erning placement o post-endodontic restorations%
CONSERVATION OF TOOTH STRUCTURE
Canal% Care should be ta(en to remo#e minimum amount o tooth structure rom
'ithin the canal space to pre#ent the racture o the root either during cementation
or unction" I the cross section o the tooth is considered as a ring, then the
strength o the ring is directly proportional to R
?
C r
?
'here RG radius o the tooth
and rG radius o canal i"e the strength is drastically eected by a substantially
sized post" Thus, the canal should be enlarged ;ust enough so as to seat a post
passi#ely yet accurately at the same time ensuring retention and rigidity or the
post" Ideally, the post diameterG 29: the diameter o the tooth or the post should
ha#e a minimum o 2mm o sound dentin surrounding it"
Coronal tooth structure% )s much o the coronal tooth structure should be
preser#ed to a#oid any (ind o stress build-up especially at the narro'est
circumerence o the tooth 'hich is the cer#ical 29: o the tooth" This pre#ents
any chance o a racture, 'hich can occur during unction"
Time and again, it is emphasized that a minimum o 3mm o tooth structure is
compulsory or the success o a post endodontic restoration" Fhy is this soI It is becauseJ
this remaining #ertical height o tooth is necessary to accommodate the errule or the
e*tra-coronal brace, 'hich is going to be pro#ided by the subse$uent ull co#erage metal
cro'n9coping"
Fhat is a erruleI
) f#((u*# is deined as a :@5
5
metal collar o the cro'n or coping
surrounding the parallel 'alls o the dentin e*tending coronal to the cer#ical line o the
preparation resulting in an ele#ation o resistance orm or the tooth"
+tresses in radicular dentin get concentrated at the narro'est circumerence o the tooth"
I no errule is pro#ided then constant orces on the tooth can lead to a #ertical splitting o
the root during unction" 1ro#iding an encasement o binding o the gingi#al 3mm o the
a*ial 'alls o the preparation reduces the incidence o racture o the tooth by
reinorcement and dissipation o orces that concentrates at the narro'est circumerence
o the tooth" Thus, a errule%

- 0elps to bind the remaining tooth structure together
- 1re#ents root racture during unction
- 1re#ents stress concentration at gingi#al margin
To be successul, the errule must encircle a minimum o 3mm o #ertical 'all o sound
tooth structure bet'een the cer#ical inish line and gingi#al e*tent o the core" In case the
remaining tooth structure is inade$uate, then periodontal cro'n lengthening surgery or
orthodontic e*trusion is necessary"
This eect can easily be understood by a simple e*ample %
Fhen a nail is hammered into a 'ooden peg, the latter tends to split along its long a*is" I
a metal ring is placed to brace the impact, no such splitting occurs"
)ccording to Fein and Ingle, i ade$uate tooth structure is present, a ?7
5
be#el can be
placed in the occlusal aspect o the preparation to allo' or an e*tension o the core
around the a*ial 'alls" This e*tra metal collar o the core gi#es e*tra resistance
to racture and also acts as a stop against o#er seating 9 'edging action o the post and
core"
I inade$uate, cro'n lengthening surgery or orthodontic e*trusion should be done"
RETENTION FORM %
1ost retention can be deined as the ability o a post to resist #ertical dislodging
orces"
This is aected by%
- 1reparation design
&or circular canals G parallel 'alls
&or elliptical canals G restricted taper o @
5
-4
5
- 1ost design%
)cti#e > passi#e parallel> passi#e tapered
- 1ost length%
ore the length, more the retention
Ideally, length o post G Cro'n Dength or at least 39:-:9? the
length o root
- 1ost diameter%
ore the diameter more is the retention but more is the racture
susceptibility as 'ell"
Ideally d K
2
9
:
cross- sectional d o root
- +urace%
Rough, serrated, abraded, notched, groo#ed or threaded posts pro#ide more
retention than smooth" )ccording to Nergiz, roughening the canal surace #ia
notching or groo#ing 'ill enhance the retention o the preabricated posts"
Duting cements% +tudies ha#e sho'n that resin cements are the most retenti#e
ollo'ed by Ln 1O
?
, Type II EIC, R,EIC and inally polycarbo*ylate cements
- Number o posts% In multiple rooted teeth, more than 2 post can be used to
increase retention and retain core especially in se#erely bro(en do'n teeth"
+ome considerations or posterior teeth%
- Relati#ely long 9 circular posts are to be a#oided in cur#ed ribbon shaped canals"
+hort posts in di#ergent canals pro#ide better retention"
- ) cast core can be made in sections Msplit castingN 'ith dierent paths o 'ith
dra'l
- The 'idest canal is selected or the ma;or post and short au*iliary post spaces are
prepared in the other canals 'ith same path o 'ithdra'l

RESISTANCE FORM%
It is deined as the ability o the post tooth to 'ithstand lateral and rotational
orces"
Resistance to stresses % is pro#ided by -
2" &errule eect
3" ,inimum internal preparation
:" Conser#ation o dentin apicaly and cer#ically as these are high stress
zones
?" Increase in post length
7" )#oiding sharp angles
@" 1reerring parallel o#er tapered posts as the ormer distributes stresses
more e#enly
A" 1reerring #ented parallel posts o#er smooth parallel posts Mtapered posts
are sel -#entingN
4" +tresses induced by threaded posts can be reduced by bac(ing o O a turn
6" Cement layer results in more e#en stress distribution"
Rotational Resistance % is pro#ided by -
- I suicient coronal tooth structure is present by the #ertical 9 a*ial 'all"
- I insuicient then C
) groo#e 9 notch at the oriice o canal in the region o ma* bul( is placed" Then
is called as anti-rotational notch9groo#e 9 element or (ey'ay"
)n au*illary can be placed
) ca#ity can be prepared in the post and ad;acent tooth and amalgam can be
condensed
In posterior teeth a post in another canal can be used to pro#ide resistance to
rotation"
CLINICAL TECHNIQUES)
1. Removal of endodontic filling material
> +il#er cone
C Remo#e and reobturate 'ith E1
- =arlier sectional sil#er cone obturation 'as suggested done by pre-
notching :mm abo#e the cone and t'isting o the coronal portion
ater placement" This should be clearly a#oided as chances o
dislodgement and apical lea(age is #ery high
> Eutta-percha
The timing or remo#al o E1 is still contro#ersial" It 'as pre#iously belie#ed
that 3? hours to a 'ee( delay 'as re$uired to a#oid disturbing the seal" Recent reports
re#eal that ade$uately condensed E1 can be remo#ed immediately"
aN Non-c$((i#( /$#' o/tu($tion Mlat9'arm #ertical9 in;ectableN% E1 can be remo#ed
#ia %
- 0eat using pluggers 9 system < 9Touch .n heat"
- Chemical using sol#ents li(e chloroorm, *ylene, halothane turpentine etc"
- ,echanical using rotary instruments li(e EE drills, 1eeso reamers, 1arapost drills
NiTi rotary Cinstruments"
O all these methods, astest, saest and easiest method is the mechanical method" I
immediately remo#al is needed, then heat is the preerred method to a#oid
distributing the seal"
bN I a c$((i#( /$#' o/tu($tion li(e Thermail 'as planned, then pre-notching o
carrier :-?mm abo#e the apical e*tent can be done and the coronal portion t'isted o
ater insertion"
) radiograph is ta(en to conirm ade$uate remo#al o E1"
3" Post selection% as mentioned beore depends on root morphology remaining
coronal tooth structure, occlusal orces and esthetic concerns"
:" Enlargement of canal% Is done to remo#e undercuts and prepare the canal to
recei#e an appropriately sized post" )s mentioned beore the enlargement should
not be more than 29:
rd
the diameter o the root 'ith at least 2mm o sound dentin
surrounding the canal"
4. Coronal tooth structure preparation
- Remo#e undermined enamel
- 1repare as though tooth 'as undamaged
- 1repare inish line at-least 3mm gingi#al to core to attain ade$uate errule design
- ) contra be#el can be placed at ;unction o uture core and tooth to pro#ide an
additional metal collar rom the core" This helps to%
<race tooth against racture
1ro#ides a #ertical stop against o#erseating
Reduces 'edging eect
- )t times because o e*cessi#e laring 9 then dentinal 'alls due to caries e*tension a
post can be cemented prior to cro'n preparation to protect the 'ea(ened tooth
structure
)nother approach is to ill the canal space 'ith composite around a Dumine* light
transmitting post, 'hich transers light to the composite but does not bond to it" The
post space thus created is treated routinely using peeso or lo' speed drills"
- I anti-rotational (ey 'ay is re$uired, a racture 2A5 bur is used to ma(e a groo#e 9
notch e*tending ?mm into the canal to a depth o 5"@mm at the canal oriice at its
bul(iest portion
- =liminate all sharp angles
7" Post Fabrication%
Cuto% 0c$t)
aN Direct 1rocedures
- +elect sprue ormers P'ood9 plasticQ, 'hich slide easily into canal till apical end
'ithout binding"
- )ter lubricating the canal, coat sprue ormer 'ith inlay 'a*, place in canal and
ac$uire a 'ith inlay 'a*, place in canal and ac$uire a proper impression o the
canal space"
- &orm a core 'ith additional 'a* in the shape o the inal tooth preparation
- This procedure can be done using cold cure acrylic instead o 'a*"
bN Indirect 1rocedures%
- )n orthodontic .H/ shaped 'ire is #eriied or loose it ull length in the canal and
coated 'ith an adhesi#e
- Canal is lubricated"
- &ill canal 'ith elastomeric impression material

Using a lentulospiral
- +eat the 'ire and syringe in more impression material and seat the tray
- 1our the cast and abricate the post and core on the cast done in the direct method
Investing and Casting%
+ome important points to remember is%
- 2-3 cc o e*tra 'ater is added to the in#estment a liner is omitted" This is done to
increase the casting shrin(age, 'hich 'ould result in a slightly smaller post that
does not bind to the canal and pro#ides space or the cement" ) tight it could
cause root racture"
) provisional restoration% ,ade o an orthodontic 'ire 'ithin the canal a temporary
acrylic HC should be pro#ided to the patient"
CEMENTATION)
- )ll temporary materials are remo#ed
- Canal is dried irrigation 'ith =DT) and NaOCl
- &it o post and core is chec(ed 'ith light pressure
- I it binds air abrade the post, reinsert, chec( or shiny spots and relie#e them"
- &inish polish the core
- 1lace #ertical groo#e i needed on the post to ser#e as an escape #ent or the
cement
- Coat as canal 'ith cement using a lentulo spiral
- Coat post 'ith cement and slo'ly place the post and core into place"
&or a preabricated post, an appropriate post 'ith ade$uate length and diameter is
selected" The length is ad;usted so as to lea#e 3-:mm o it supragingi#al or core
retention" The core is built up o#er this"
I cementation is done resin cement is planned then the method is%
- ,i* and place primer in dried canal
- ,i* resin cement and coat the post 'ith it
- Do not place paste in canal as it 'ill set almost instantly an contacting primer
- 1lace post in canal and apply pressure or one-minute light cure it"
- )pply o*yguard or : minutes and 'ash it o
)n ad#ancement in the iber reinorced post system is the poly ethylene 'o#en ribbon
ibers or the Ribbond iber post" De#eloped by &rielich, it in#ol#es the pac(ing o se#eral
strips o resin saturated Ribbond ibers into a conditional and primed post space along
'ith dual-cure resin cement" ) core o composite is abricated o#er this"
The all ceramic post and core are abricated by%
+lip casting
Copy milling
T'o piece techni$ue G Lr post R copy milled ceramic core
0eat pressed techni$ue G Lr post R pressed glass ceramic core
=#en though endodontically treated teeth 'ith their restorations ha#e e*cellent prognosis
ailures do occur a ailure rate o 7-2A8 has been sited or post and core restry" These are
mainly due to%
2" Root racture
3" 1ost racture
:" +econdary caries
?" 1eriodontal disease
Careul case selection, adherence to <iomechanical principles, appropriate post selection
and meticulous maintenance o oral hygiene can pre#ent these problems"
CONCLUSION)
+O N=)RS<UT T=T +O &)R!
&rom a simple piece o 'ire in :73)D, to the 'ooden post o the 24
th
century to the
esthetic post o today, history has borne 'itness to the relentless eorts made to secure an
artiicial tooth to the root" Hudging by the pace at 'hich research is mo#ing, combining
material science and understanding 'ith dental rele#ance, that day is not ar 'hen one
can pro#ide an accurate and complete dental rehabilitation to an endodontically treated
tooth in minimal chair-side time 'ith ma*imum satisactory results" 0ere/s loo(ing
or'ard to a 2558 success rate or endodontics"