Restoration of the endodontically treated tooth

Amith Babu Amrita Dora Ganesh O.R Praveen J Ourvind Singh

CONTENTS

Introduction History Need for final restoration Objectives Classification

Anterior teeth Posterior teeth Components of final restoration: I. Posts II. Cores III. Crowns

The tooth as a house

INTRODUCTION
Endodontic treatment is largely performed on teeth significantly affected by caries, multiple repeat restorations and/or fracture. Already structurally weakened, such teeth are often further weakened by the endodontic procedures designed to provide optimal access and by the restorative procedures necessary to rebuild the tooth. It is therefore accepted that endodontically treated teeth are weaker and tend to have a lower lifetime prognosis.

INTRODUCTION
Hence require special considerations for the final restoration, particularly where there has been extensive loss of tooth structure. The special needs involve ensuring both adequate retention for the final restoration and maximum resistance to tooth fracture. Endodontic success depends not only on the quality of the root canal treatment, but also on timely coronal restoration of the compromised tooth.

CONTENTS

Introduction History Need for final restoration Objectives Classification

Anterior teeth Posterior teeth Components of final restoration: I. Posts II. Cores III. Crowns

HISTORY

Various methods of restoring pulpless teeth have been reported for past 200 years. In 1747 Pierre Fauchard fabricated gold and silver posts to be placed in root canal space. Replacement crowns were made from bone, ivory, animal tooth.

Is final restoration after endodontic treatment important?

LITERATURE REVIEW
1In

this study using radiographs they assessed the following Good restorations + good endodontic treatments resulted in absence of periapical inflammation in 91.4%. This shows the importance of final restoration Poor restorations + poor endodontic in endodontically treatedtreatments teeth resulted in the absence of periradicular inflammation in only 18.1%. Poor endodontic treatment + good restorations yielded 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. Trope International Endodontic Journal, vol. 28, no. 1, pp. 1218, 1995.

CONTENTS

Introduction History Need for final restoration Objectives Classification

Anterior teeth Posterior teeth Components of final restoration: I. Posts II. Cores III. Crowns

What are the objectives of Final restoration?

GOALS
2Maintained

coronal and apical seal of the root canal treatment Protect and preserve the remaining tooth structure Provided a supportive and retention foundation for the placement of definitive restoration Restore the function and esthetics

2Colour

atlas of endodontics 2 edition William T.Johnson DDS MS Page no 130

What are the factors to be considered while planning the final restoration?

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

CONTENTS

Introduction History Need for final restoration Objectives Classification

Anterior teeth Posterior teeth Components of final restoration: I. Posts II. Cores III. Crowns

4Based

on the remaining tooth structure

Description 4 walls 3 walls 2 walls 1 wall No wall

Classification Class I Class II Class III Class IV Class V

endodontically treated teeth with posts and coresa review Ingrid peroz et al.Quintessence International no.9 volume 36 oct 2005.
4Restoring

6Restoration

of Endodontically Treated Teeth:

An Evidence-Based Literature Review University of Toronto, Faculty of Dentistry. Int J Prosthodont 2008;18(1):40-1.

FERRARI AND OTHERS

SAMPLES
240 endodontically-treated premolars in 210 patients

FOKKINGA & OTHERS

307 endodontically-treated teeth in 257 patients Cast post and core Pre-fab metal post and composite core Post-free composite core

TEST Fiber posts TREATMENT CONTROL TREATMENT DURATION (YRS) 2 4 coronal wall remaining: no difference in complication rates 3 coronal walls remaining: post placement increases survival rates No post

Up to 17 Where substantial remaining dentin is available, a post and core does not perform better than a post-free core

CONCLUSIONS

8Ferrari

M. Post placement affects survival of endodontically treated premolars. JDentRes 2007;86(8):729-734.

8Fokkinga

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

CONTENTS

Introduction History Need for final restoration Objectives Classification

Anterior teeth Posterior teeth Components of final restoration: I. Posts II. Cores III. Crowns

ANTERIOR TEETH
9Anterior

teeth with minimal loss of tooth structure can be restored conservatively 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.

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.

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

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

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

CONTENTS

Introduction History Need for final restoration Objectives Classification

Anterior teeth Posterior teeth Components of final restoration: I. Posts II. Cores III. Crowns

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 morphologic characteristics, makes them more susceptible to fracture.

Posterior teeth
results showed that the clinical success rates of endodontically treated premolars restored with fiber posts and direct composite restorations or full coverage with metal-ceramic crowns were highly successful without any failures, even after 3 years of service .
15J

15The

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

CASE REPORT
Post-endodontic restoration of a deeply decayed tooth - options and limitation Michael Bruder, DDS. Jounal of oral science,11: 2;2007.

Posterior teeth
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.
16Molar

16Nayyar,

A., An amalgam coronal-radicular dowel and core technique for endodontically treated posterior teeth. J Prosthet Dent, 1980. 43: p. 511.

CASE REPORT
Reconstruction of Endodontically Treated Posterior Teethwith or without Post? Maciej Zarow, Walter Devoto. The European Journal Of Esthetic Dentistry. Volume 4,number 4,december 2009.

Tooth fracture of an endodontically treated maxillary molar restored with a bonded composite restoration.

CONTENTS

Introduction History Need for final restoration Objectives Classification

Anterior teeth Posterior teeth Components of final restoration: I. Posts II. Cores III. Crowns

COMPONENTS OF FINAL RESTORATION

A. Posts

Cores C. Crowns
B.

CONTENTS

Introduction History Need for final restoration Objectives Classification

Anterior teeth Posterior teeth Components of final restoration: I. Posts II. Cores III. Crowns

POSTS
Role

of posts Indications Post selection:Factors to be considered Ferrule effect Types Procedure

The Role of Posts in the Restoration of Endodontically Treated Teeth

18The

primary purpose for a post is to retain a core that can be used to support the final restoration. Posts do not reinforce endodontically treated teeth, 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.

INDICATIONS
19Post

placement is indicated if both 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.

FACTORS TO CONSIDER
Post length Post diameter Post design

20Stockton

LW.Factors affecting retention of post systems: A literature review. J Prosthet Dent 1999;81:380385.

Post length
21Guidelines:

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 the crestal bone and the root apex.
21Stockton

LW.Factors affecting retention of post systems: A literature review. J Prosthet Dent 1999;81:380385.

Ideal tooth preparation for post placement

Post Size and Length

22Post

length is unique and individualized for each case. The clinician should have a thorough The effect of the embedded before depth of posts a on knowledge of root morphology placing post. retentive capacity has been shown to be The longer the post, the greater the retention. A significant guideline 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.

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.

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.

Post design
24Posts

can be serrated, smooth, roughened or threaded. Parallel, serrated posts are cemented into the canal passively. They are retentive and produce less stress in the root dentine than threaded systems
24Post

Placement and Restoration of Endodontically Treated Teeth: A Literature Review. Richard S. Schwartz, et al. Journal of Endodontics:VOL. 30, NO. 5, MAY 2004

Ferrule Effect
25The

ferrule is the circumferential ring of sound tooth structure that is enveloped by the cervical portion of the crown restoration. A minimum sound dentine height 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.

Importance of ferrule
The ferrule provides bracing or casing action to protect the integrity of the root.

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 The results of this study showed that an increased restoration of endodontically treated teeth amount of coronal dentin (ferrule) significantly increases Fifty freshly extracted canines were the fracture resistance of endodontically treated teeth. endodontically treated. The teeth were randomly divided into groups of 10 and prepared according to 5 experimental protocols
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.

incomplete crown ferrule is associated with greater variation in load capacity and, despite high fracture values, inclines to fracture.

27An

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

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.

28TYPES OF POSTS METALLIC

Stainless Steel Titanium Titanium Alloy Gold-Plated brass

NON-METALLIC

Carbon Fibre Ceramic Glass-fibre reinforced Composite 28Fundamental of fixed prosthodontics 3 editions
Herbert T. shillingburg Page no 345

Types of Posts

Prefabricated posts

Custom made posts

Direct Technique Indirect Technique

Wax pattern before casting.

Custom cast post and core

Advantages:

Disadvantages:

Preservation of maximum Less stiff than wrought tooth structure Provision of anti-rotational Time consuming, complex procedure properties Core retention Recommended Use: Less chances of vertical Elliptical canals fractures during preparation Flared canals High strength

29Prefabricated

Tapered Post
Disadvantages:

Advantages:

Low retention Conserves tooth structure Longitudinal splitting of High strength and Recommended Use: remaining root stiffness 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 Smooth Post

Disadvantages:

Advantages:

Excellent clinical retention Minimal stress production within root Ease of placement Superior rating
30Color

Precious material post expensive Corrosion of stainless-steel Less conservative of tooth structure

Atlas of Endodontics. , 2nd edition William T.Johnson, page no 133-134.

31Prefabricated

Threaded Posts
Disadvantages:
Stresses generated in canal may lead to fracture Does not conserve coronal and radicular tooth structure

Advantages:

High retention

Recommended Use: Only when maximum retention is essential

31Color

Atlas of Endodontics. , 2nd edition William T.Johnson, page no, 133-134.

32Carbon

Fiber Post
Disadvantages:

Advantages:
Dentin bonding Easy removal

Recommended Use: Can be used in posteriors with moderate loss of coronal structure
32Post

Low strength (compared to metal) Lack of radiopacity Carbon color presents an esthetic problem

Placement and Restoration of Endodontically Treated Teeth: A Literature Review. Richard S. Schwartz, et al. Journal of Endodontics:VOL. 30, NO. 5, MAY 2004

33Fiber

Reinforced Post
Disadvantages:

Advantages:

Esthetic

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

34Zirconia

Ceramic Post
Disadvantages:

Advantages:

Esthetics High stiffness High modulus of elasticity

Expensive Uncertain clinical performances

Recommended Use: High esthetic demands

Procedure

Textbook of Endodontology 2 editions Preben Hrsted-Bindslev Page no 326

A review of the studies done on the various post systems suggests that the fiber posts are the most reliable!!!

Background: Post design and material has very important effects on dentinal stress distribution since the post placement can create stresses that lead to 35Fiber posts show more root fracture. Materials: homogeneous stress distribution 4 metallic posts (ParaPost XH, ParaPost XT, metallic and posts. ParaPost XP,than and Flexi-Flange) 1 fiberglass post (ParaPost Fiber Lux) were used.

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

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 and zirconia 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. 36

Good allow strength Fractures repair

Resistance to fracture of endodontically treated teeth restored with different post systems. Akkayan B, Gulmez T. J Prosthet Dent. 2002;87:431437.

Conclusion: The fiber posts evaluated provided an advantage over a conventional post that showed a higher number of irretrievable post and unrestorable root Readily retrievable 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.

PURPOSE: This retrospective study evaluated treatment outcome of cast post and core and Composipost systems after 4 yrs of clinical service. Better than cast post The results of this retrospective study indicated system in the long term that the Composipost(95% success) system(fiberreinforced 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.

PURPOSE: This study aggregated literature data on in vitro failure loads and failure modes of prefabricated fiber-reinforced composite (FRC) post systems and to compare them to those of prefabricated metal, customcast, 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.

More favourable

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.

MECHANICAL PROPERTIES
Material Flexural strength Gpa Tensile Strength MPa Elastic Modulous GPa

Stainless Steel Titanium Alloy Zirconium Oxide C-Post (64% Carbon)

40Evolving

800
1000 820

n/a
n/a n/a

200
110 200

1100

2900

17.8

Technology in Endodontic Posts. Pitel M., Hicks N Comp. Of Cont. Educ. in Dent. January 2003.

CONTENTS

Introduction History Need for final restoration Objectives Classification

Anterior teeth Posterior teeth Components of final restoration: I. Posts II. Cores III. Crowns

CORES
Indications Principles Types of core build up Procedure

INDICATIONS
Core restorations are indicated if any 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 Herbert T. shillingburg Page no 367

MATERIALS USED FOR CORE

BUILD UP
DIRECT PLACEMENT:
1. 2. 3.

Composite resin Amalgam Glass ionomer resin

INDIRECT PLACEMENT:

Casting
42Fundamental

of fixed prosthodontics 3 editions Herbert T. shillingburg Page no 369

Composite resin core

Advantages:

Disadvantages:

Good compressive strength Easy to manipulate Rapid polymerization Dentin bonding

Polymerization shrinkage Poor dimensional stability

Recommended Use: Excellent build-up material for posterior and anterior teeth if isolation assured

Amalgam core
Advantages:

Disadvantages:

Reduced marginal leakage Better dimensional stability Better compressive strength Better modulus of elasticity

Mercury sensitivity Low tensile strength Corrosion with base metal

Recommended Use: Molars with adequate coronal tooth structure

Glass Ionomer resin core

Advantages:

Disadvantages:

Anticariogenic Adhesive Easy to manipulate

Recommended Use: Teeth with minimum tooth structure missing

Low resistance to fracture Low retention to preformed post Sensitive to moisture

So which is the best material for core buildup???

The modulus of elasticity of amalgam is significantly higher than all other material tested and is closer to that of dentin Prepared core build-ups in a hybrid composite material provided the highest fracture 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.

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.

Tensile strength and modulus of elasticity of glass ionomer cements are significantly Based on the stated lower than dentin andabove amalgam evidence, composite seems to be Glass ionomers are relatively slow-setting the best choice as a core build up and their early resistance to moisture is poor

material.

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.

CONTENTS

Introduction History Need for final restoration Objectives Classification

Anterior teeth Posterior teeth Components of final restoration: I. Posts II. Cores III. Crowns

CROWNS

Indications Advantages Disadvantages Types

CROWN PLACEMENT
INDICATIONS Better esthetics Situations in which the structural integrity of natural crown is compromised CONTRAINDICATIONS Anterior teeth have only have conservative access opening
49Textbook

of Endodontology Gunnar Bergenholtz Page no 317

CROWNS
Advantages:

Disadvantages:

Durable Good esthetics Restoring dental function Good Form Protection of tooth
50Textbook

Loss of tooth structure Expensive

of Endodontology Gunnar Bergenholtz Page no 317

METAL-CERAMIC CROWNS

It consists of a ceramic layer bonded to a thin cast metal coping that fits over the tooth preparation. It combines the strength and accurate fit of a cast restoration with the esthetic effect of a ceramin crown. Less tooth preparation required compared to all ceramic crowns.

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

Cast metal crown is a full crown restoration which is 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

CROWNS
Partial 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

Temporary crowns are used to protect a tooth that has 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.

Conclusion

Anterior Tooth

Class I - III Class IV

Class V

Complete Coverage is not required

Complete Coverage is required

Complete Coverage is required

Conservative Trt Resin composite

Prefabricated fiber post with composite core full ceramic crown

Posterior Tooth

Class I-III Class IV

Class V

Conservative Trt Onlay

Composite Core Fiber post Metal Ceramic Crown

Pre-fabricated fiber post Composite Core Metal Ceramic crown

Thank You