Restoration of an Endodontically treated teeth

Master class – 2021

Previously asked question from this topic

❖ Endo-Prostho Interdependancy. Discuss

❖ Management of Endodontically treated teeth.

❖ Discuss Radicular Crowns

❖ Discuss the factors affecting the selection of Restorative Treatment of

Endodontically treated tooth

❖ Compare Pre-fabricated posts vs Customized posts

❖ Role of Prosthodontist in recent concepts of multidisciplinary patient care.

Contents
▪ Introduction

▪ Review of literature

▪ Effects of Endodontics on tooth

▪ Treatment planning to restore an endodontically treated tooth

▪ Basic components used in the restoration of an endodontically treated tooth

▪ Principles for preparation of an endodontically treated tooth

a) Conservation of the tooth structure

b) Retention form

c) Resistance form
▪ Effect of ferrule on the resistance form of the tooth preparation

▪ Dowel classification

▪ Factors which effects the dowel selection

▪ Dowel materials

▪ Core and core materials

▪ Techniques for Dowel and Core fabrication

A) Removal of the Endodontic filling material

B) Preparation of the canal

C) Preparation of the coronal tooth structure

▪ Cast Dowel and Core fabrication techniques

A) Direct techniques of fabrication

B) Indirect techniques of fabrication

▪ Provisional restorations for an endodontically treated tooth

▪ Pre-fabricated post versus Cast post and Cores

▪ Summary and conclusion

▪ References

Introduction

Endodontic therapy has provided dentistry with the ability to retain the teeth,

that just a few decades ago have been extracted with out hesitation. When the

Endodontic treatment of the tooth has been completed, however question often arise

as to how to restore it to protect the tooth structure that remains. The restoration of

an endodontically treated tooth can be difficult both diagnostically and technically. It

is by the fact that much of the coronal tooth structure, which normally would be used

in the retention of the restoration, has been destroyed by caries or previous

restorations, trauma and the endodontic access preparation.

An endodontically treated tooth should have good progress. It can resume

full function and serve satisfactorily as an abutment for fixed partial denture.

Different clinical techniques have been proposed to solve these problems and

opinions differ as to the most appropriate one. Recent experimental data have

improved our understanding of the difficulties inherent in restoring an endodontically

treated tooth.

Review of literature

1) William H. Silverstein in (1964) stressed the importance of reinforcing pulp

less teeth, which have been weakened by caries, and Endodontic procedures

need the support of a post and core casting for reinforcement. The casting

should be designed to guard against horizontal as well as longitudinal

fractures of pulp less teeth.

2) Robert J. Watson in (1968) described a method of providing co9ronal bulk to

endodontically treated teeth. He used pin reinforced amalgam cores in his

technique and concluded that unlike the cast core and dowel techniques, the

splinting effect of the steel pins cemented in the dentin peripheral to the root,

tends to prevent root fracture.

3) Noah stern in (1973) evaluated the principles of preparing endodontically

treated tooth with a dowel and core and it should possess a positive seal to

prevent wedge like action of the post. The transverse and vertical shape of

the prepared root canal should follow the contour of the exterior root surface.

The dowel length should be determined by the bone support of the involved

root.

4) James L. Guthann in (1977) described the guidelines for the preparation of

endodontically treated teeth to receive a post and core restoration, which

includes.

1) Proper instrumentation.

2) Orientation to the long axis of the root.

3) Adequate length of preparation.

4) Internal shaping of the canal.

5) Albert C. Goerig in (1983) concluded that the restoration of an non-vital or

endodontically treated tooth will depends on the following criteria’s.

a) The location of the tooth in the arch.

b) Root morphology.

c) Degree of coronal destruction.

d) Amount of occlusal stress.

e) Whether the tooth will serve for an abutment for PD or RPD.

6) David J. Sokol in (1984) concluded that

 a) Endodontically treated teeth should be reinforced because tooth will

because brittle due to impaired blood supply and loss of tooth

structure.

b) b) The posts used for restoration should be long narrow, parallel sided

and threaded.

7) David J. Baraban in (1988) narrated the different techniques of restoring the

endodontically treated teeth. It was concluded that the success of restoration

depends on the proper diagnosis, selectivity of the tooth to be treated and the

skills and techniques to carryout the necessary procedure.

8) A. J. Hunter in (1989) evaluated the effect of post placement on the

endodontically treated teeth. The results suggested that enlargement of the

canal increase cervical stress, and the post placement will decrease stress in

this region. Post length appeared to be more important than post diameter in

determining the relative stress at the cervical region.

9) John A. Sorensen in (1990) evaluated the fracture resistance of pulp less

teeth with various ferrule designs and amounts of coronal tooth structure. It

was concluded that 1mm of coronal dentin above the shoulder significantly

increased the fracture resistance.

Effects of Endodontics on the tooth

The disease process and the restorative procedures that create the need of

Endodontic therapy affect much more than pulp vitality. The tooth structure that
remains after endodontic treatment has been undermined and weakened by caries,

fracture, tooth preparation and restoration.

Changes in the endodontically treated teeth

A) Loss of coronal tooth structure:

The decreased strength of endodontically treated teeth is primary due to the

loss of coronal tooth structure. Endodontic access in to the pulp chamber destroys

the structural integrity provided by the coronal dentin of the pulpal root and allows

greater flexing of the tooth structure.

B) Altered physical characteristics

The changes in the collagen cross-linking and dehydration of the dentin leads

to 14% reduction in the strength and toughness of the tooth. The internal moisture

loss has been shown to average approximately 9% and is greater in the anterior

teeth. This combined loss of structural integrity, loss of moisture, loss of dentin

toughness compromises endodontically treated teeth and necessitates special care

in the restoration of pulp less teeth.

C) Altered esthetic characteristics of residual tooth

The darkening of non-vital anterior teeth is common phenomenon, Bio-

chemically altered dentin modifies light refraction through the tooth and changes it

appearance inadequate Endodontic cleaning and shaping of the coronal area also

contributes to this discoloration by staining the dentin from degradation of vital tissue

left in the pulp horns.

Indications for restoring an Endodontically treated tooth

1) The amount of tooth structure loss is one of the most important aspects in

restoration of an endodontically treated tooth. Extensive tooth structure loss

from caries, fracture and previous restorations significantly weakens the

remaining tooth, making dowels, cores and crowns necessary.

2) A non-vital anterior tooth that has loss significant tooth structure requires post

and core restorations.

3) A non-vital anterior tooth with significant coronal tooth structure loss and

significant discoloration requires post and core restoration.

4) Posterior teeth carry greater occlusal leads than the anterior teeth. An

endodontically treated posterior tooth with significant loss of coronal tooth

structure indicates post and core restoration.

5) Endodontically treated abutments for EPD require more extensive protection

against horizontal and torquing forces. In these cases post and core returned

restorations are indicated.

Treatment planning for restoration of an endodontically

treated teeth

All of the changes that accompany root canal therapy influence the selection

of restorative procedures for endodontically treated teeth. Tooth structure loss can

range from very minimal access preparation in intact teeth to very extensive damage
that endangers the longevity of the tooth if self. Restorative treatment decision

depends on

1) The amount of remaining tooth structure

Posterior teeth are subjected to greater occlusal forces than the anterior teeth

and restorations must be planned to protect posterior teeth against fracture.

2) The functional demands that will be placed on the tooth

The horizontal and torquing forces endured by abutments for EPD or RPD

dictate more extensive and retentive fractures in the restoration.

3) Esthetic demands of the restoration

Prefabricated metal, carbon fiber, ceramic and glass fiber posts are used as

an alternatives to metal posts and these are used in conjunction with the plastic

material such as composite resin amalgam or glass ionomer.

4) The need for the tooth as an abutment in a larger restoration

Teeth with minimal remaining tooth structure are at an increased risk for fracture;

provide decreased retention for the restoration. When the decision is made to

restore the endodontically treated tooth, careful, assessment should be done for

▪ Good apical seal.

▪ No sensitivity to pressure.

▪ No exudates.

▪ No sinus.

▪ No apical sensitivity.

▪ No active inflammation.
 In adequate root fillings should be retreated and if doubt still exists, the tooth

is monitored until there is definite evidence of success or failure.

Basic components used in the restoration of an endodontically

treated teeth

There are four basic components that may utilized restoring an endodontically

treated tooth are post-pins cores and final restorations.

1) Endodontic posts or dowels are usually cemented or threaded into a prepared

canal. Their purpose is to retain the core and to equally distributes the forces

of mastication to the supporting structures the root PDL and surrounding

bone.

2) Pins are used either alone or in combination with the posts to provide

retention for the core material posts are contraindicated in teeth with extreme

root curvatures in which a perforation could result or in which non-soluble

filling materials such as resins or silver points cannot be removed.

3) The core replaced coronal tooth structure that has been lost because of

caries and previous restorations cores are formed from composite or

amalgam or reinforced glass ionomer or may be cast in precious and non-

precious alloys in combination with the post.

4) The final restoration restores external tooth contours and allows the tooth to

function harmoniously with those teeth remaining in the oral cavity.

5) A encircling band of metal, which will support the tooth externally bracing it

against fracture by the dowel which has been described as an ferrule effect,

which is about 2mm wide. It may be provided by a coping a long contra level
 on the core or the axial wall of the crown, which extend epically beyond the

margin of the dowel core.

6) A counter rotational device on the dowel is fabricated to prevent its being

twisted or rotated by horizontal forces applied to the core.

Principles for preparation of an endodontically treated

tooth

When creating a post space, one must use great care to remove only minimal

tooth structure from the canal over enlargement can perforate or weaken the tooth,

which then may split during cementation of the post or during subsequent function.

The thickness of the remaining dentin is a prime variable in the fracture resistance of

the root.

Experimental impact testing of teeth with cemented posts of different

diameters showed that teeth with thicker (1.8mm) post fractured more easily than

those with a thinner (1.3mm) one.

Photo elastic stress analysis also has shown that internal stress is reduced

with thinner posts.

A.J. Hunter et al (1989) in their photo elastic study concluded that

▪ Removal of internal tooth structure during root canal therapy is accompanied

by a proportional increase in stress at the cervical area, particularly on

tension side.

▪ Minimal enlargement of the root canal for a moderately sized post does not

substantially weaken the tooth.

 ▪ If a considerable enlargement of the root canal has occurred, a post with a

moderate diameter and length substantially reinforces the tooth.

It is difficult to enlarge the root canal uniformly and to guage the accuracy how much

structure has been removed and how thick the remaining dentin will be present.

Thus if recommended that the root canal be enlarged to enable the post to fit snugly

for strength and retention. The length of the post space, enlargement seldom needs

to exceed one or two additional file sizes beyond that used for endodontic treatment.

Preparation of coronal tissue

Endodontically treated teeth often have lost much coronal tooth structure as a

result of caries, of previously placed restorations or in preparation of the endodontic

access cavity. Further reduction is needed to accommodate a complete crown and

remove intra-coronal undercuts if a cast core is used, which may leave very little

coronal dentin. As much of the coronal tooth structure should be conserved as

possible because if helps to reduce stress concentration at the gingival margin.

The mount of remaining tooth structure is probably the single most important

predictor of clinical success. Extension of the axial wall of the crown apical to the

missing tooth structure provide a “ferrule”, which help to bind the remaining tooth

structure together preventing root fracture during function.

B) Retention form

Anterior Teeth
 Dislodgement of post retained anterior crown is frequent seen clinical and is

due to inadequate retention form of the prepared post. Retention of the post mainly

affected by the preparation geometry, the post length post diameter, surface texture

of the post and the luting agent.

a) Preparation Geometry

Some canals, particularly in maxillary central incisors have nearby a circular

cross section. These can be prepared to give cavity with parallel walls or minimum

taper allowing the use of preformed post of corresponding configurations. The

canals with elliptical cross section are prepared with a restricted amount of taper to

ensure adequate retention. Retention increases rapidly as taper is reduced.

J.P. Standle et al (1978) concluded that, the threaded parallel sided post are most

retentive and serrated parallel sided post cemented in cylindrical canals exhibited

intermediate retention and smooth sided tapered post are least retentive.

Several laboratory tests confirmed that parallel-sided posts are more retentive

than taped posts and threaded posts are most retentive of all. But these

comparisons are relevant only if the post fits the post canal properly serve the

retention is proportional to the total surface area.

b) Post length

Studied have shown that as post length increases, retention increases, but

the relationship is not necessarily linear. A post will too short will fail in retention and

may cause root fracture from stresses generated by occlusal forces Fig 12-16(1).

Absolute guidelines for optimal post length are difficult to define ideally the post
should be as long as possible without jeopardizing the apical seal or the strength or

integrity of the remaining tooth structure.

K.D. Desort (1983) stated that leaving at least 3-5mm of apical seal and extending

the post to atleast half the length of the root will enhance the retention of the

restoration Fig 12 JPD 1983 (204).

Shillinagburg et al (1970) recommended that the post leave a minimum of 3mm of

root canal filling at the radiographic apex to maintain the integrity of root canal seal.

c) Post diameter

Increasing the post diameter in an attempt to increase retention is not

recommended since it may unnecessarily weaken the remaining root.

David J. Sokol in (1984) suggested that, increasing the post diameter beyond the

required to produce intimate contact between the dowel and the dentin walls for

optimum retention results in unnecessary removal of dentin and weakens the root.

d) Post surface texture

A serrated or roughened post is more retentive than a smoother one Grooving

of the post and the root canal considerably increases the retention of the tapered

post.

Johnson et al (1976) found that a parallel-sided serrated dowel post increased the

retention 41/2 times over that of tapering sided post. They also found that an

increase in post length or diameter yielded 30-40% increase in the retention.

David J. Sokol in (1984) stated that reinforcement post should be parallel sided

rather than tapered to o\provide retention and minimization of stress. They also

suggested that serrated post increase retention but are totally dependent on cement

bond, while threaded post increase retention but also increase the stress in the

restoration.

e) Luting Agent

When considering traditional cements the choice of luting agent seems to

have little effect on post retention or the fracture resistance of dentin.

The adhesive resin luting agents have the potential to improve the

performance of post and core restorations and these cements are indicated if a post

becomes dislodged.

Thomas Junge et al (1998) conducted an invitro study to compare the load fatigue

of endodontically treated teeth using 3 luting agents. They concluded that the resin

cement samples has a higher number of load cycles to preliminary failure when

compared to zinc phosphate and resin modified glass ionomer.

Rodke R.A et al (1988) conducted an in-vitro study to compare the retention of

Endodontic posts using 4 luting agents and they concluded that, zinc phosphate and

glass ionomer cements were found to be more retentive than polycarboxylate and

composite resin cement.

Moody C.R et al (1989) compared the bond strength of zinc phosphate and

polycarboxylate cements in cementing cast gold crowns to composite resin cores

under varied storage and thermo cycling conditions. They concluded that ZnPo 4 is

the recommended cement for use with the composite resin core buildups.
Posterior teeth

Relatively long post with a circular cross-section provides good retention and

support in the anterior teeth but should be avoided in the posterior teeth, which often

have carried roots and elliptical or ribbon shaped canals. For these teeth, retention is

better provided by two or more relatively short posts in the divergent canals.

▪ When amalgam used as the core material, it can be condensed either around

cemented metal posts or directly into short prepared post spaces. It more

than 3-4mm of coronal tooth structure remains, use of root canals for

retention is not necessary and this avoids chance of perforation.

▪ An alternative preparation method for posterior tooth is to select the canals

that are widest normally the palatal canals of maxillary molars and distal

canals of mandibular molars are used for the major posts and other canals

were prepared for short auxiliary post spaces in other canals with same path

of the withdrawal.

▪ If a cast dowel core is made, it can be made in sections that have different

paths of withdrawal.

C) Resistance form

One of the functions of post and core is to improve resistance to laterally

directed forces by distributing them over as large an area as possible.

Stress distribution

An excessive internal preparation of the root weaken the root and possibility

of failure in the restoration will increases. The post design should distribute stresses

as evenly as possible.

The influence of post design on stress distribution has been tested using

photo elastic materials; strain gauges and finite element analysis form these

laboratory studies the following conclusions have been drawn.

1) The greatest stress concentrations are found at the shoulder particularly inter-

proximally and all the apex. Dentin should be considered in these areas if

possible.

2) Stresses are reduced as post length increases.

3) Parallel-sided posts may distribute stresses more evenly than tapered posts,

which may have wedging effect. However parallel sided posts generate high

stresses at the apex.

4) Sharp angles in the preparation should be avoided because they produce

high stresses during loading.

5) High stress can be generated during insertion particularly with smooth parallel

sided that have no vent for cement escape.

6) The threaded posts can produce high stress concentration during insertion

and loading, but they have been shown to distribute stress evenly if the posts

are backed off a half farm.

7) The cement layer results in a more even stress distribution to the root with les

stress concentrations.
Rotational Resistance

It is important that a post with a circular cross section not rotate during

function. When sufficient coronal tooth structure remains, this should not present a

problem since rotation is prevented by core.

▪ If coronal dentin is completely lost, a small groove placed in the canal can

serve, anti-rotational element. The groove is normally placed where the canal

is bulkiest, usually on the lingual aspect.

▪ Rotation can be prevented by an auxiliary pin in the root face.

▪ Rotation of the threaded post also can be prevented by preparing a small

cavity half in the post and half in the root and condensing amalgam into it

after cementation of the post.

▪ Rotation can be prevented by placing additional cemented post in multicoated

teeth.

▪ Rotation can be prevented by proper extension of the casting margins apical

to the core.

Effect of Ferrule on Resistance form

“A ferrule can be defined as a metal ring or cap put around the end of a tool,

cane etc to provide added strength”. This effect used in the dowel preparation in the

form of a circumferential contra bevel. This contra bevel reinforces the coronal
aspect of the dowel preparation, aids in effecting a positive occlusal seat, and acts

as an anti-rotational device.

▪ Extension of axial wall of the crown apical to the missing tooth structure will

help in binding the remaining tooth structure together and prevents root

fracture during function.

▪ Ferule effect can be also used where these is little or no clinical crown

remaining by placing a large contra bevel on the root surface, with the finish

lines of the final crown preparation apical to the post and core unit.

▪ Lue Zhi-Yue et al (2003) concluded that 2mm dentin ferrule more effectively

enhanced the fracture strength of custom cast post-core restored

endodontically treated tooth.

▪ Flemming Isidor et al (1999) concluded that ferrule length was more

important than post length in increasing fracture resistance of an

endodontically treated tooth.

Dowel classification

Dowels can be categorized into two major categories.

1) Custom cast dowels.

2) Preformed dowel systems.

Preformed dowel system can be further categorized by their geometric shape as

1) Tapered dowels.

2) Parallel dowels.
 These may be further classified by their surface configuration as

1) Serrated dowels.

2) Smooth dowels.

3) Threaded dowels.

Factors which affects the Dowel selection

(1) Dowel length

As mentioned earlier, dowel retention is proportional to the dowel length. The

dowel should be long enough to satisfy clinical requirements with out jeopardizing

the root integrity. The standard parameters for dowel length in a tooth with normal

periodontal support range between

1) Two thirds of the length of the canal.

2) The coronal length of the root.

3) Half the bone supported length of the root.

▪ Root morphology plays a great role in the determining dowel length. The

root should have at least 1mm of tooth structure remaining around the

dowel in all directions in order to resist fracture or perforation. Root

curvature reduces the dowel length as the greater the curve of the root

and more coronally located, the shorter is the dowel.

▪ The need to maintain adequate obturation is the major factor, which

limits the dowel length. Retaining the last 3-5mm filling material at the

apex is sufficient for the Endodontic seal.

2) Dowel shape

Placement of parallel-sided dowel with in the canal improves both retention

and force distribution of the dowel parallel-sided dowels are 2-4 times as retentive as

tapered dowels. They also distribute functional loads to the root passively and

therefore indicated for the majority of the cases photoelectric studies have

demonstrated that tapered dowels act like a wedge to exert significant lateral forces

on the tooth structure. These forces may ultimately result in a vertical root fracture.

Tapered dowel forms

These are generally reserved for the significant tapered canal systems where

uses of parallel-sided dowel necessitate attention of the radicular dentin walls. The

limitations of these forms of dowels include low retentive capacity and potential for

wedging during function.

Dowel Diameter

The dowel must be of sufficient diameter to resist the functional forces.

Larger diameter gives little or no improvement in the dowel-to-root retention but

significantly reduces the resistance of the tooth to fracture.

Surface configuration of Dowels

 The surface of dowel can be serrated smooth or threaded serrated surfaces

provide mechanical undercuts for cement and significantly increase retention of

parallel dowels that of smooth surfaces. Serrations can be horizontal with a single

vertical vent channel or fluted so that the serration form a series of vents that

reduces hydraulic forces generated during cementation.

Dowel materials

Materials used in the dowel construction must be able to withstand functional

stress and resist corrosion and must not be harmful to the patient. Importantly

physical requirements of dowel include adequate stiffness high yield stress and

favorable fatigue properties.

▪ Insufficient stiffness results in stress concentration as the dowel repeatedly

deforms and springs back under function. This stress concentration can

ultimately cause fracture and failure of the tooth or restoration.

▪ Yield strength is a measure of resistance to permanent deformation. Low

yield strength materials deform under lesser loads and transfer stress to the

other portions of the restoration.

▪ Dowels possessing unfavorable fatigue properties are subject to premature

failure when exposed to repetitive stresses of oral function, which will result in

a fracture of dowel and may lead to tooth fracture.

▪ Dowel materials should be selected that are inert or highly resistant to

corrosive effects of oral fluids. The most significant corrosion occurs in the

stainless. dowels that have been invested heated and allowed to cool.
 Custom cast dowels are fabricated form gold alloys and other conventional

fixed prosthodontic metals. These metals are generally non reactive and

custom dowels are cast and not wrought, the chances of corrosion from heal

treatment is eliminated.

▪ The prefabricated parallel sided post are made of platinum-gold-palladium,

nickle-chromium and cobalt-chromium Eg: C-post Aestheti-post

▪ A Berrated post comes in either stainless stell or gold alloys. Eg: para post,

parapost XP para post XH.

▪ Tapered posts are available in Pt-Au-Pd and Ni-Cr alloys. Eg: Cerapost, C-I

Post.

▪ Recent concern about the potential for sensitivity and allergy production by

nickle alloys can overcome biocompatible titanium preformed dowels, which

are less allergic than Ni-Cr alloys. The disadvantage of using titanium post or

dowel is their less radio opacity, which is similar to gutta-purcha and other

cutting agents.

▪ Carbon fiber posts have increased in popularity during recent years. These

posts consist of bundles of stretched aligned carbon fibers embedded in the

epoxy matrix. The resultant post will be strong but has significantly lower

stiffness and strength. The chief disadvantage of a carbon fiber post is its

black appearance, which presents an esthetic problem. Eg: UM C-post,

Aesthti post,
 ▪ Manufacturers have developed high strength ceramic posts (Zirconia posts)

and ceramic co9mposite and woven fiber (polyethylene) posts and all are

having excellent esthetic properties. Eg: ER cerapost,

Koutays et al (2003) concluded that all ceramic posts and cores cemented with

adhesive technology can be used in combination with all ceramic crowns because

they contribute to better light transmission and reflectance, provide natural

translucency to the all ceramic restoration and offer excellent biocompatibility.

Core and core materials

The core consists of restorative material placed in the coronal area of the

tooth. The material replaces carious fractured or otherwise missing coronal

structure and retains the final coronal restoration.

The core is anchored to the tooth by a direct connection of the core into canal

or through Endodontic dowel. The attachment between tooth, dowel and core

mechanical chemical or both.

The remaining tooth structure can be altered to enhance retention of the core

or to provide resistance to core rotation under function. In most of the cases

irregular nature of the residual coronal tooth structure and normal morphology of the

pulp chamber and canal orifices eliminate the need for these tooth alterations.

Using restorative materials that bond to the tooth structure enhance retention and

resistance with put necessitating removal of valuable dentin.

Desirable physical properties of a core material should include

 ▪ High compressive strength.

▪ Dimensional stability.

▪ Ease of manipulation.

▪ Short setting time.

Cast core

A cast core forming a one-piece dowel and core is a traditional and proven

method of restoring endodontically treated teeth.

Advantages

▪ As the core is an integral extension of the dowel, the cast core does not

depend on the mechanical means for retention to the dowel.

▪ Selection of the dental alloys used in the casting allows control of core

properties. Noble metals provide a non-corrosive final restoration. Increased

stiffness and associated decreased dentin deformation can be obtained by

casting type IV gold.

Disadvantages

▪ The numbers of appointments required are more.

▪ The laboratory expense, in time and materials may be significant.

▪ The laboratory phase may also be technique sensitive in the core fabrication

process casting a large core in contact with a small diameter dowel pattern

can result in porosity at the dowel core interface.

Amalgam core

Dental amalgam has many characteristics advantages for core fabrication.

Advantages

▪ Amalgam is very stable to thermal and functional stresses.

▪ Amalgam also presents a corrosion barriers that seals tooth alloy junction,

which inhibits recurrent caries corrosion of the restoration.

▪ High compressive strength and high tensile strength and high modulus of

elasticity are the ideal properties of amalgam.

▪ Amalgam demonstrates superior mechanical retention to the tooth and dowel

undercuts.

▪ Bonded amalgam procedures enhance retention and further reduce micro

leakage by incorporating a layer of resin that chemically bonds to both dentin

and metal.

Disadvantages

▪ Potential for corrosion with base metals and discoloration of gingival and

remaining dentin.

Composite Resin core

▪ Composite core material is easy to manipulate and sets very rapidly

preparation for the final restoration is readily accomplished during the core

placement session.
 ▪ Additional retention and anti-rotation mechanisms are also easily achieved

with auxiliary pins, dentin preparations and dentin bonding materials.

Disadvantages

▪ Polymerization shrinkage and contraction away from the tooth structure can

result in core tooth marginal opening and microcracks.

▪ Dimensional stability of these materials is unfavorable.

▪ Co-efficient of thermal expansion is 2-10 times greater than that of tooth

structure, which can affect the luting integrity and micro leakage under the

restoration.

▪ Low modulus of elasticity allows deformation of composite under degradation

of cement seals and allows unacceptable load transfers to the dowel

materials.

▪ These materials should not be used in teeth extensive structural damage.

Glass Ionomer core

▪ High viscosity glass ionomers and glass ionomer silver cements are core

materials employ adhesion to dentin. The chemical union improves retention

of restoration and reduces the marginal leakage.

▪ The major advantage of these materials is anti-cariogenic quality derived from

the fluorides present in the chemical composition.

Disadvantages

▪ Adhesive failure can result from contamination of the tooth surface.

▪ The glass ionomer core materials are technique sensitive and deviation from

the manufacturers recommendations can lead to failure of the core and of the

final crown.

▪ The tensile strength and flexural strength of GIC core materials are lower than

that of either amalgam or composite.

Coronal Radicular core

As an alternative to the traditional cast dowel and core for posterior teeth the

direct coronal radicular restoration. This restoration consist of a core that replaces a

coronal tooth structure and extends 2-4mm into the coronal portion of the canals.

▪ The coronal radicular core utilizes conventional restorative materials,

including amalgam, composite or reinforced glass ionomer silver.

▪ The coronal radicular core is indicated for posterior teeth that have large pulp

chambers and multiple canals for preparation.

Disadvantages

▪ The ease of manipulation and rapid set of above-mentioned materials is an

advantage.

▪ The build up can be placed and prepared for final coronal restoration in one

visit.
 ▪ Single homogenous materials used for entire restoration.

Techniques of Dowel and core fabrication

Tooth preparation for endodontically treated teeth can be considered a 3-

stage operation, which include.

1) Removal of the root canal filling material to the appropriate depth.

2) Enlargement of the canal.

3) Preparation of the coronal tooth structure.

Removal of Endodontic filling material

The first step for all types of dowel and core restorations in the removal of the

gutta percha from the dowel space. The amount of gutta percha to be removed is

dictated by the desired dowel length, the bone height and the root morphology.

There are commonly used methods to remove gutta percha.

1) Using warmed Endodontic plugger.

2) Using rotary instrument.

▪ A root canal plugger or electronic heating device can be safety be used to

remove gutta percha.

▪ Rotary instrumentation for gutta percha removal carry the risk of straying

from the canal and cutting the excess radicular dentin which results in

weakening of root structure and could result in lateral perforation.

 ▪ The pesos Reamers and gates glidden drills are commonly used they are

designed to center themselves within the confines of the gutta percha fill.

▪ These drills gradually increase the size of the canal, remove natural

undercuts, and shape the canal to correspond with the provided dowel or

dowel pattern. The diameters of these drills and associated dowel forms

are incremented from 0.7-1.7mm for peeso reamers and 0.6-1.5mm for

Gates-Glidden drills.

Steps in removal of Gutta percha

▪ Before removing gutta percha the appropriate length of the post should be

calculated. It should be adequate for retention and resistance but not so long

as to weaken the apical seal. An absolute 3-5mm apical fill is needed for better

apical seal.

▪ Avoid the apical 5mm it possible curvatures and lateral canals may be found in

this segment. It the working length, of the tooth canal is known the length of

the post space can be easily determined. There it is important not be loose

incisal or occlusal reference points through premature removal of coronal tooth

structure.

▪ An Endodontic condenser of large size is selected but not so large that it binds

against the canal walls.

▪ Appropriate length should marked (Endodontic working length-5mm) on

instrument and then heated and placed in the canal to soften the gutta percha.
▪ If the gutta percha is old and has last its thermoplasticity use a rotary

instrument to remove the filling.

▪ If using a rotary instrument, which is choosed to be, slight narrower than the

canal.

▪ The instrument should follow the center of the gutta percha and should not cut

the dentin often only a part of root canal fill need to be removed with rotary

instrument and remaining will be removed with heated condenser.

▪ A rotary instrument should not be used immediately after obturation, because if

may disturb the apical seal.

▪ When gutta percha has been removed to the appropriate depth shape the canal

as needed. This can be accomplished with Endodontic hand instruments or a

low speed drill. The purpose is to remove undercuts and prepare the canals

receive an appropriately sized post without excessively enlarging the canal.

Enlargement of the root canal

Before enlargement of the canal, the type of post system to be used for the

fabrication of the post and core must be chosen. The knowledge of root canal cross

section is an important actor in the selection of prefabricated post

A wide range of prefabricated post is available in many shapes and sizes.

Parallel-prefabricated posts are recommended for conservatively prepared root

canals with roots of circular cross section. Excessively flared canals are most

effectively managed with a custom post. However situations should be evaluated on

individual basis.
Prefabricated posts

▪ Enlarge canal one or two sizes with a drill or endodontic file or reamer that

matches the configuration of the post. In case of a threaded post, the

appropriate drill is followed by a tap that pre-threads the internal walls of the

post space.

▪ Use a prefabricated post that matches the standard endodontic instruments.

A tapered post will conform better to the canal than a parallel sided post and

requires less removal of dentin to achieve an adequate fit.

▪ Should be careful not to remove dentin at the apical extent of the post space.

Cast Dowel and Core fabrication technique

A custom made post and core can be cast from a direct pattern fabricated in

the patients mouth or on indirect technique can be fabricated in dental laboratory. A

direct technique using autopolymerizing or light polymerizing resin is recommended

for single canals. Whereas an indirect procedure is more appropriate for multiple

canals.

Direct Technique

▪ The direct custom dowel is made by fabricating a resin or wax pattern in the

prepared tooth.
▪ The prepared canal is lightly lubricated and notched with a loose fitting plastic

dowel, which should extent to the full depth of prepared canal.

▪ A bead brush technique is used to add resin to the dowel and seat it in the

prepared canal. This procedure done in two steps 1) Resin is added to canal

orifice first, 2) Rein is mixed and roll into thin cylinder, which is introduced into

the canal and pushed to into the canal with a monomer moistened plastic

dowel.

▪ Not to allow the resin to harden fully with in the canal loosed and reseat it

several times while still it will be rubbery.

▪ Once the resin has polymerized, the pattern is removed.

▪ Apical portion is formed by adding additional resin and reseating and removal

is done care should be taken not lock if inside the canal.

▪ If these are any undercuts can be trimmed away using a scalpel.

▪ More resin is added to the coronal portion of the pattern to provide bulk for

the core.

▪ The coronal portion of the pattern is shaped into a crown preparation for the

final restoration.

▪ The finish line of the final crown should be an the tooth structure and not on

the core.

▪ After completing finishing of the dowel and core pattern is cast, in gold or

nickel-chrome alloy.

▪ The core portion of the casting should be smoothened to a satin or matt

finish.
 ▪ Using a carbide a V-shape cement escape vent is fabricated on the side of

the dowel. This groove should help greatly to prevent damaging and

hydraulic pressure lateral stresses during cementation.

▪ A thin mix of cement is introduced into the prepared canal with the help of

lentulospiral more amount of cement is applied to the orifices of the canal.

▪ The finished dowel is coated with thin cement and inserted into the canal.

▪ The dowel is seated slowly with the finger pressure so that close fitting

hydraulic chamber formed by the dowel moving through the viscous liquid.

▪ When the cement has set, the axial surfaces of the core and tooth structure

with a fine grit diamond to remove any minor undercuts in the axial region.

▪ The portion of the coronal tooth form that has been built up with a core can be

treated as though it were tooth structure when the final restoration is

fabricated.

Indirect Technique

An elastomeric material will make an accurate impression of the root canal if

wire reinforcement is placed to present distortion.

▪ The orthodontic wire is cut into pieces to a length and shape them like the

letter.

▪ Fit of the each wire is verified in the prepared canal. It should fit loosely and

extent to the full depth of the post space.

▪ Wire should be coated with the tray adhesive and the canals are lubricated

with a die-lubricant.
 ▪ Using lentulo-spiral, the canals are filled with the elastomeric impression

material. Before loading the impression syringe, verify that the lentulo will

spiral material in the apical direction.

▪ Wire reinforcement will be should in each post space the full depth, the

elastomeric material is syringed around the prepared teeth and loaded

impression tray is inserted into the mouth.

▪ Impression is removed and evaluated and working cast is prepared.

▪ Once the cast is prepared, a loose fitting plastic post or a plastic tooth pick is

roughened and inserted into the prepared canal.

▪ A thin coat of sticky wax is applied to the plastic post and soft inlay wax is

added in increments from the most apical area. The post should be correctly

oriented as it is seated to adapt the wax. When the post pattern is completed,

the wax core can be added and shaped.

▪ Margins of the core is finished with a warm burnisher to produce a well fitting

casting as possible.

Preparation of the coronal tooth structure

After the post space has been prepared the coronal tooth structure is reduced

for the extra coronal restoration.

▪ Any missing tooth structure due to various restorative procedures, caries,

fracture or endodontic access are ignored and the remaining tooth structure is

prepared as though it was undamaged.

▪ Facial tooth structure is adequately reduced for the good esthetics.

 ▪ All internal and external undercuts are removed, which will prevent with drawl

of the pattern.

▪ Any unsupported tooth structure if present is removed and care should be

taken to preserve as much of the crown as possible.

▪ The remaining part of the coronal tissue is prepared perpendicular to the post

because this will create a positive stop to prevent over seating and splitting of

the tooth. The rotation of the post must be prevented by preparing a flat

surface parallel to the post. If insufficient tooth structure for this features

remains, an anti rotation groove should be placed in the canal.

▪ The coronal preparation is completed by eliminating all sharp angles and

establishing a smooth finish line.

Pin Retained Amalgam Restorations

A pin-retained restoration may be defined as any restoration requiring the

placement of one or more pins in the dentin to provide adequate resistance and

retention forms to the restoration.

Advantages

▪ These restorations can be completed in one appointment.

▪ Resistance and retention forms may be significantly increased by using pins.

▪ Compared to cast restorations pin retained amalgam restoration is a relatively

inexpensive restorative procedure.

Disadvantages

▪ Drilling pinholes and placing pins may create craze lines as well as # and

internal stresses in the dentin.

▪ Pins do not reinforce amalgam and therefore they do not increase its

strength.

▪ Pin retention increases the risk of perforating into the pulp or the external

tooth surface.

▪ The self threaded and friction lock pins are contra indicated in endodontically

treated tooth due to lack of resiliency of dentin.

Surgical management of an endodontically treated tooth

Restoration of an endodontically treated teeth becomes more complex as the

teeth or supporting structures are becomes increasingly diseased. The compromises

created by extensive loss of tooth structure after the restorative procedures and

affect the longevity of the tooth and the prosthesis.

▪ Endodontic treatment can also become a form of adjunctive therapy to

facilitate treatment of periodontally compromised teeth. Portions of teeth that

otherwise may be candidates for extraction can sometimes be retained with

the hemi section or root amputation procedures.

▪ Periodontally guarded anterior teeth can be shortened and roots used as

over denture abutments. Dowel, core and coronal restorations must also be

designed for the new shape and functions of the altered, endodontic teeth.
 ▪ When pre-restorative RCT is indicated for elongated, periodontally involved

teeth, it is extremely important to retain as much radicular dentin as possible.

Dowel placement may be needed for the retention of the core. However

conventional dowel guidelines do not apply in the restoration of the severely

periodontally compromised tooth. The dowel is rarely as long as the clinical

crown and will not reach the alveolar crest.

Provisional restorations for an endodontically treated

tooth

A temporary restoration commonly plays an important role in the successful

restoration of a tooth. It is true that normally essential role of pulpal protection is not

a concern in the treatment of an endodontically treated teeth.

Functions:

▪ Esthetic role.

▪ Protects teeth from further damage.

▪ Prevents migration of adjacent contacting teeth.

▪ Provides occlusal function.

A number of different crown formers and dowels are used in various

combinations.

1) polycarboxylate crowns have been relined with acrylic.

2) Plastic dowels are relined with acrylic resin.

Prefabricated post versus cast post and core

 Prefabricated posts are becoming increasing popular became of their case of

placement and the ability to restore a tooth for immediate crown preparation.

Although prefabricated post have their advantages, the customized cast post and

core possesses superior adaptation to the root canal.

The canal is altered to fit the prefabricated post, but customized costing is

made to fit the tooth.

The prefabricated posts rely principally on cement for retention. Because of

cylindrical shape of prefabricated posts they are best suited for circular canals,

rather than teeth with wide buccolingual root canals.

Ommell et al (1970) recommended that the post and core and possibly the

crown be fabricated in same material to prevent prolonged electrolytic reaction which

is caused by dissimilar materials.

Summary and conclusion

Although the restoration of endodontically treated teeth has been rationalized

considerably recently available laboratory research data, information from controlled

long-term clinical traits is still needed and may be more difficult to obtain.

It is clear that recent advances in material science have a significant impact

on the restoration of an endodontically treated tooth. The ability to bond multiple

restorative materials to each other and to tooth structure will continual to

revolutionize this relationship in further.

It is important to pressure as much as tooth structure. With in the root canal,

where cement of dentin remaining may be difficult to assess. A post and core is

used to provide retention and support for cast restoration. If should be adequate

length for good stress distribution but should not be SV long as to jeopardize the

apical seal.

References

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and composite resin core. JPD 1981; 45: 526-8.

2) Miller A.W: Post and core systems which one is best. JPD 1982; 48: 27-38.

3) Chan R.W: Post and core foundations for endodontically treated posterior

tooth. JPD 1982; 48: 401-406.

4) Desort K.D: The prosthodontic use of endodontically treated teeth: Theory

and Biomechanics of post preparation. JPD 1983; 49: 203-206.

5) Georig A.C: Management of endodontically treated tooth part-I concepts for

restorative designs. JPD 1983; 49: 340-5.

6) David J.S: Effective use of current core and post concepts. JPD 1984; 52:

231-234.

7) Trabert K.C: Restoration for an endodontically treated tooth. DCNA 1984; 24:

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10) Moody C.R, Dewald J.P: Comparative study of luting agents with composites

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JPD 2001; 14: 142-5.

12) Stephen Cohon: Pathways of pule 8th Edn.

13) Lous-Grossman: Endodontic practice 11th Edn.

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