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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
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INTRODUCTION
Root canal therapy cannot be summarized by saying, “fill it, shut it, forget it”. The final
restoration over an endodontically treated tooth is as important or probably even more
important than the actual root canal therapy itself.
The endodontically treated tooth constitutes a unique subset of teeth requiring
restorations because:
First and foremost, the tooth structure has already been weakened by previous
episodes of caries, trauma, restorative procedures and tooth preparations.
An accountable percentage of structural integrity is lost because of the root canal
therapy itself due to access cavity preparation and canal instrumentation leading
to increased flexing of the tooth and ultimately its fracture.
Some authors quote an alteration in the composition of the dentin such as a
change in the collagen cross linking, dehydration etc. Of course, whether such a
change is actually detrimental to the prognosis of the treatment is questionable as
studies have not been very conclusive about it.
Moreover such teeth are esthetically and physically compromised requiring
special kinds of restoration.
Finally and most importantly, the RC treated tooth has got an impaired
neurosensory feed- back mechanism because of the lack of pulpal tissue i.e. the
protective property of ‘proprioception’ is lost. This renders the tooth more
vulnerable to fracture under normal masticatory forces. So, a person can un-
intentionally bite too hard on the RC treated tooth compared to a vital tooth,
which can lead to its fracture and failure.
All these points emphasis the need of a wisely designed, accurate and strong
restoration over the endodontically treated tooth, which would not only protect the tooth
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but also prevent any form of microleakage. Coronal leakage or orthograde contamination
via saliva has now been sited as the prime cause of endodontic failures.
Hence the functions of a post-endodontic restoration are:
- Providing a coronal seal.
- Providing protection to the remaining tooth structure.
- Restoring the esthetics and functions of the tooth.
Treatment planning for the post-endodontic restoration should start, ideally
speaking, prior to the commencement of the RCT itself. An extraction should be carried
out if the restorability and periodontal status of the tooth is questionable instead of
spending unnecessary time and expenses on it. If this is not the case and the tooth is
salvageable, then the following principles should be kept always in mind:
1. Preservation of remaining tooth tissue by conservative restorative design
compatible with acceptable aesthetics and function.
2. Reduction of stress and its favorable distribution within the remaining tooth tissue
by proper design and selection of materials.
Now, an important question before us is when to restore after endodontic treatment. Most
authors agree that since the success rate of RCT is pretty high at 80-95%, an arbitary
period of a couple of weeks is sufficient before providing a permanent restoration. A
permanent restoration may be delayed if the endodontic treatment has:
- Doubtful prognosis requiring possible re-treatment.
- Presence of sinus
- Tenderness to palpation /percussion
Basic components of the post-endodontic restoration are:
- The post
- The core
- The final restoration
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Simply put, the post helps in the retention of the core, the core helps in the replacement
of the missing tooth structure and the final restoration helps in restoring the form and
function of the tooth and protects the remaining tooth structure from fracture.
Not all teeth require a post or a crown. Some require all 3 components while some may
need just an access seal.
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THE POST
Definition:
The post can be defined as a relatively rigid restorative material placed in the
canal of a non-vital tooth.
Function:
The post has got 2 main functions:
- Retention of core
- Protection of the tooth by dissipation of forces along its long axis to the
surrounding periodontal tissues and the alveolar bone.
Ideal properties:
- Retentive to the tooth and the core
- Strong and provide protection to the tooth
- Radiopaque
- Biocompatible
- Inert
- Economical
- Esthetic wherever required
Indications
- Extensive coronal tooth structure loss/ >50% loss of tooth structure including
important landmarks such as marginal ridges, cingulum, reciprocating walls etc.
- Teeth which are going to be used as abutments for FPD’s, overdentures etc
- Teeth exhibiting extensive wear or patients having any parafunctional habits
which can cause excessive amounts of load on the tooth.
- Teeth that are going to become a part of a periodontal splint.
- For the retention of a complex restoration.
Contraindications:
Besides the opposites of the above points, certain other contraindication include:
- Endodontically treated teeth having a questionable prognosis requiring possible
re-treatment.
- Teeth having minimal canal dentin
- Teeth having unusual anatomy such as extreme curvatures and fragile roots.
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Classification:
Numerous classifications have been quoted by several authors, which are more or less
similar to each other. The following is a simple way of classifying posts based on their
features:
1. Fabrication: Custom cast
Prefabricated
2. Materials used: Metallic
Non-metallic
3. Esthetics: Esthetic
Non-esthetic
4. Retention mode: Active / threaded
Passive/ cemented
5. Shape: Parallel
Tapered
Parallel with apical taper
6. Surface configuration: Smooth
Serrated
Threaded
7.Shank configuration: Solid
Hollow
Split
8. Venting: Vented
Non-vented
9. Resiliency: Rigid
Flexible
Features:
The posts, as mentioned in the classification, come in various diameters, lengths, tapers,
sizes, surface configurations, shank configurations etc. The choice of an individual post
selection is purely based on the operator’s discretion and the type of case before him.
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Types of posts:
Posts can broadly be of 2 types – custom cast or prefabricated. Custom cast posts are
those posts which are made by taking an impression of the canal space either directly or
indirectly and casting a post which exactly replicates the canal space. The prefabricated
post is available commercially in predetermined dimensions, length and contours and
hence does not replicate the canal space. Some major differences between the 2 are:
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The prefabricated metal post can be of 2 types based on their mode of retention
- Passive post or the cemented post which rely on a cementing media for
their retention
- Active post or the threaded post which actively thread into the dentin to
attain retention.
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The non-metallic prefabricated posts can be either esthetic posts or non-esthetic posts.
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THE CORE
Definition: The core can be defined as a restorative material placed in the coronal portion
of the tooth to replace the missing coronal tooth structure.
The core can be anchored to the tooth either via its extension onto the
coronal aspect of the tooth or via an endodontic post.
Ideal properties:High compressive strength
- Dimensional stability
- Should not deform plastically under loading
- Retentive to post, tooth and if possible to the overlying crown as well
- Should be easy to manipulate and place
- Should set rapidly
- Biocompatible
- Inert
- Economical
- Esthetic wherever indicated
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Core materials: Advantages Disadvantages
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Cast core High strength
No concern regarding
delamination from the post
Expensive
Time consuming
Casting inaccuracies
Amalgam High compressive strength
High modulus of elasticity
Easy manipulation and
placement
Stable to thermal and
functional stresses
Unesthetic
Cannot be bonded to
Tendency to discolour
adjacent gingiva
Tendency to corrode
Low early strength –
preparations cannot be done
immediately
Composite Esthetic
Bondable
Adequate strength
Command set- preparation
can be done immediately
Microleakage due to
polymerization shrinkage
Dimensionally unstable
Tendency to deform
plastically and thus cannot
be used in high stress areas
GIC Chemically adhesive to the
tooth
Anticariogenic
Low fracture resistance
Early moisture sensitivity
MMGIC -----------//-----------------
Used when>50% of tooth
structure is intact
Very brittle
RMGIC Properties lie in between
composites and GIC
Anticariogenic
More adhesive than GIC
Decreased moisture
sensitivity
Decreased microleakage
Tendency to expand in
presence of moisture- can
lead to fracture of overlying
all-ceramic crowns.
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Pin-retained cores:
At times posts cannot be placed in the root due to anatomical factors or
due to the non-irretrievability of a silver cone obturation. In such situations, pins can be
used to gain an adequate amount of retention. Sometimes pins can also be used along
with a post to gain an auxiliary mode of retention.
Amalcore:
Nayyar and Walton have described a technique wherein the coronal 2mm of gutta-
percha is removed and amalgam condensed into it to attain adequate amount of retention
for the core. Studies have shown favorable results with this type of technique.
FINAL RESTORATION :
The final component of a post-endodontic restoration is the final or the definitive
restoration. As mentioned before, the final restoration helps to
Protect the remaining tooth structure from fracture
Protect the entire unit from microleakage
Restore the esthetics and functions of the tooth
Posterior teeth:Because of the vertical forces experienced by a posterior tooth, as a
general rule all endodontically treated posterior teeth require a full occlusal coverage
restoration. This could be a metal / a ceramo-metal crown or it could be an onlay.
Anterior tooth:Anterior teeth usually experience shear forces. Depending on the
structural integrity and the amount of discolouration of the tooth of the tooth, a
permanent restoration for an anterior tooth can take any of the following forms:
Teeth with posts = Jacket crowns-all-ceramic/ ceramo-metal
Teeth without posts but discolored = Laminate veneer /JC
Intact teeth with no discoloration = Composite for the access seal
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PREPARATION PROCEDURES
Biomechanical principles governing placement of post-endodontic restorations:
CONSERVATION OF TOOTH STRUCTURE
Canal: Care should be taken to remove minimum amount of tooth structure from
within the canal space to prevent the fracture of the root either during cementation
or function. If the cross section of the tooth is considered as a ring, then the
strength of the ring is directly proportional to R4 – r4 where R= radius of the tooth
and r= radius of canal i.e the strength is drastically effected by a substantially
sized post. Thus, the canal should be enlarged just enough so as to seat a post
passively yet accurately at the same time ensuring retention and rigidity for the
post. Ideally, the post diameter= 1/3 the diameter of the tooth or the post should
have a minimum of 1mm of sound dentin surrounding it.
Coronal tooth structure: As much of the coronal tooth structure should be
preserved to avoid any kind of stress build-up especially at the narrowest
circumference of the tooth which is the cervical 1/3 of the tooth. This prevents
any chance of a fracture, which can occur during function.
Time and again, it is emphasized that a minimum of 2mm of tooth structure is
compulsory for the success of a post endodontic restoration. Why is this so? It is because;
this remaining vertical height of tooth is necessary to accommodate the ferrule or the
extra-coronal brace, which is going to be provided by the subsequent full coverage metal
crown/coping.
What is a ferrule?
A ferrule is defined as a 3600 metal collar of the crown or coping
surrounding the parallel walls of the dentin extending coronal to the cervical line of the
preparation resulting in an elevation of resistance form for the tooth.
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Stresses in radicular dentin get concentrated at the narrowest circumference of the tooth.
If no ferrule is provided then constant forces on the tooth can lead to a vertical splitting of
the root during function. Providing an encasement of binding of the gingival 2mm of the
axial walls of the preparation reduces the incidence of fracture of the tooth by
reinforcement and dissipation of forces that concentrates at the narrowest circumference
of the tooth. Thus, a ferrule:
- Helps to bind the remaining tooth structure together
- Prevents root fracture during function
- Prevents stress concentration at gingival margin
To be successful, the ferrule must encircle a minimum of 2mm of vertical wall of sound
tooth structure between the cervical finish line and gingival extent of the core. In case the
remaining tooth structure is inadequate, then periodontal crown lengthening surgery or
orthodontic extrusion is necessary.
This effect can easily be understood by a simple example :
When a nail is hammered into a wooden peg, the latter tends to split along its long axis. If
a metal ring is placed to brace the impact, no such splitting occurs.
According to Wein and Ingle, if adequate tooth structure is present, a 450 bevel can be
placed in the occlusal aspect of the preparation to allow for an extension of the core
around the axial walls. This extra metal collar of the core gives extra resistance
to fracture and also acts as a stop against over seating / wedging action of the post and
core.
If inadequate, crown lengthening surgery or orthodontic extrusion should be done.
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RETENTION FORM :
Post retention can be defined as the ability of a post to resist vertical dislodging
forces.
This is affected by:
- Preparation design
For circular canals = parallel walls
For elliptical canals = restricted taper of 60-80
- Post design:
Active > passive parallel> passive tapered
- Post length:
ore the length, more the retention
Ideally, length of post = Crown Length or at least 2/3-3/4 the
length of root
- Post diameter:
ore the diameter more is the retention but more is the fracture
susceptibility as well.
Ideally d < 1/3 cross- sectional d of root
- Surface:
Rough, serrated, abraded, notched, grooved or threaded posts provide more
retention than smooth. According to Nergiz, roughening the canal surface via
notching or grooving will enhance the retention of the prefabricated posts.
Luting cements: Studies have shown that resin cements are the most retentive
followed by Zn PO4, Type II GIC, RMGIC and finally polycarboxylate cements
- Number of posts: In multiple rooted teeth, more than 1 post can be used to
increase retention and retain core especially in severely broken down teeth.
Some considerations for posterior teeth:
- Relatively long / circular posts are to be avoided in curved ribbon shaped canals.
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Short posts in divergent canals provide better retention.
- A cast core can be made in sections (split casting) with different paths of with
drawl
- The widest canal is selected for the major post and short auxiliary post spaces are
prepared in the other canals with same path of withdrawl
RESISTANCE FORM:
It is defined as the ability of the post tooth to withstand lateral and rotational
forces.
Resistance to stresses : is provided by -
1. Ferrule effect
2. Minimum internal preparation
3. Conservation of dentin apicaly and cervically as these are high stress
zones
4. Increase in post length
5. Avoiding sharp angles
6. Preferring parallel over tapered posts as the former distributes stresses
more evenly
7. Preferring vented parallel posts over smooth parallel posts (tapered posts
are self -venting)
8. Stresses induced by threaded posts can be reduced by backing off ½ a turn
9. Cement layer results in more even stress distribution.
Rotational Resistance : is provided by -
- If sufficient coronal tooth structure is present by the vertical / axial wall.
- If insufficient then –
A groove / notch at the orifice of canal in the region of max bulk is placed. Then
is called as anti-rotational notch/groove / element or keyway.
An auxillary can be placed
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A cavity can be prepared in the post and adjacent tooth and amalgam can be
condensed
In posterior teeth a post in another canal can be used to provide resistance to
rotation.
CLINICAL TECHNIQUES:
1. Removal of endodontic filling material
> Silver cone
– Remove and reobturate with GP
- Earlier sectional silver cone obturation was suggested done by pre-
notching 3mm above the cone and twisting off the coronal portion
after placement. This should be clearly avoided as chances of
dislodgement and apical leakage is very high
> Gutta-percha
The timing for removal of GP is still controversial. It was previously believed
that 24 hours to a week delay was required to avoid disturbing the seal. Recent reports
reveal that adequately condensed GP can be removed immediately.
a) Non-carrier based obturation (lat/warm vertical/ injectable): GP can be removed
via :
- Heat using pluggers / system B /Touch ‘n heat.
- Chemical using solvents like chloroform, xylene, halothane turpentine etc.
- Mechanical using rotary instruments like GG drills, Peeso reamers, Parapost drills
NiTi rotary –instruments.
Of all these methods, fastest, safest and easiest method is the mechanical method. If
immediately removal is needed, then heat is the preferred method to avoid
distributing the seal.
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b) If a carrier based obturation like Thermafil was planned, then pre-notching of
carrier 3-4mm above the apical extent can be done and the coronal portion twisted off
after insertion.
A radiograph is taken to confirm adequate removal of GP.
2. Post selection: as mentioned before depends on root morphology remaining
coronal tooth structure, occlusal forces and esthetic concerns.
3. Enlargement of canal: Is done to remove undercuts and prepare the canal to
receive an appropriately sized post. As mentioned before the enlargement should
not be more than 1/3rd the diameter of the root with at least 1mm of sound dentin
surrounding the canal.
4. Coronal tooth structure preparation
- Remove undermined enamel
- Prepare as though tooth was undamaged
- Prepare finish line at-least 2mm gingival to core to attain adequate ferrule design
- A contra bevel can be placed at junction of future core and tooth to provide an
additional metal collar from the core. This helps to:
Brace tooth against fracture
Provides a vertical stop against overseating
Reduces wedging effect
- At times because of excessive flaring / then dentinal walls due to caries extension a
post can be cemented prior to crown preparation to protect the weakened tooth
structure
Another approach is to fill the canal space with composite around a Luminex light
transmitting post, which transfers light to the composite but does not bond to it. The
post space thus created is treated routinely using peeso or low speed drills.
- If anti-rotational key way is required, a fracture 170 bur is used to make a groove /
notch extending 4mm into the canal to a depth of 0.6mm at the canal orifice at its
bulkiest portion
- Eliminate all sharp angles
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5. Post Fabrication:
Custom –cast:
a) Direct Procedures
- Select sprue formers [wood/ plastic], which slide easily into canal till apical end
without binding.
- After lubricating the canal, coat sprue former with inlay wax, place in canal and
acquire a with inlay wax, place in canal and acquire a proper impression of the
canal space.
- Form a core with additional wax in the shape of the final tooth preparation
- This procedure can be done using cold cure acrylic instead of wax.
b) Indirect Procedures:
- An orthodontic ‘J’ shaped wire is verified for loose fit full length in the canal and
coated with an adhesive
- Canal is lubricated.
- Fill canal with elastomeric impression material
Using a lentulospiral
- Seat the wire and syringe in more impression material and seat the tray
- Pour the cast and fabricate the post and core on the cast done in the direct method
Investing and Casting:
Some important points to remember is:
- 1-2 cc of extra water is added to the investment a liner is omitted. This is done to
increase the casting shrinkage, which would result in a slightly smaller post that
does not bind to the canal and provides space for the cement. A tight fit could
cause root fracture.
A provisional restoration: Made of an orthodontic wire within the canal a temporary
acrylic JC should be provided to the patient.
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CEMENTATION:
- All temporary materials are removed
- Canal is dried irrigation with EDTA and NaOCl
- Fit of post and core is checked with light pressure
- If it binds air abrade the post, reinsert, check for shiny spots and relieve them.
- Finish polish the core
- Place vertical groove if needed on the post to serve as an escape vent for the
cement
- Coat as canal with cement using a lentulo spiral
- Coat post with cement and slowly place the post and core into place.
For a prefabricated post, an appropriate post with adequate length and diameter is
selected. The length is adjusted so as to leave 2-3mm of it supragingival for core
retention. The core is built up over this.
If cementation is done resin cement is planned then the method is:
- Mix and place primer in dried canal
- Mix resin cement and coat the post with it
- Do not place paste in canal as it will set almost instantly an contacting primer
- Place post in canal and apply pressure for one-minute light cure it.
- Apply oxyguard for 3 minutes and wash it off
An advancement in the fiber reinforced post system is the poly ethylene woven ribbon
fibers or the Ribbond fiber post. Developed by Frielich, it involves the packing of several
strips of resin saturated Ribbond fibers into a conditional and primed post space along
with dual-cure resin cement. A core of composite is fabricated over this.
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The all ceramic post and core are fabricated by:
Slip casting
Copy milling
Two piece technique = Zr post + copy milled ceramic core
Heat pressed technique = Zr post + pressed glass ceramic core
Even though endodontically treated teeth with their restorations have excellent prognosis
failures do occur a failure rate of 5-17% has been sited for post and core restry. These are
mainly due to:
1. Root fracture
2. Post fracture
3. Secondary caries
4. Periodontal disease
Careful case selection, adherence to Biomechanical principles, appropriate post selection
and meticulous maintenance of oral hygiene can prevent these problems.
CONCLUSION:
“ SO NEAR…BUT YET SO FAR”
From a simple piece of wire in 352AD, to the wooden post of the 18 th century to the
esthetic post of today, history has borne witness to the relentless efforts made to secure an
artificial tooth to the root. Judging by the pace at which research is moving, combining
material science and understanding with dental relevance, that day is not far when one
can provide an accurate and complete dental rehabilitation to an endodontically treated
tooth in minimal chair-side time with maximum satisfactory results. Here’s looking
forward to a 100% success rate for endodontics.