Indication to the type of restoration

O.R.GaneshMurthi M.Sc.D Endo student

The tooth as a house

Introduction
Teeth that require endodontic treatment are often severely broken down and can be vulnerable to fracture; they often require extensive (and expensive) restoration following root canal treatment. A high fracture rate has been found in root-filled teeth that have mesial Occlusal distal (MOD) amalgam restorations, and it is often good practice to place some form of cusp coverage restoration to prevent destructive flexure during mastication.

Fluids

No Fluids

Endodontically treated teeth are usually weak 

loss of tooth structure 

loss of moisture in the dentin

Sealing the Access Cavity
There is good evidence from scientific studies that the quality of coronal seal affects the prognosis of root canal treatment. It takes a relatively short time for the root-filled tooth to become reinfected if it is left exposed to the oral cavity.

treatment planning 
     

Existing endodontically treated teeth need to be assessed care-fully for the following: Good apical seal No sensitivity to pressure No exudate No fistula No apical sensitivity No active inflammation

objectives of restoration endodontically treated tooth
Stated as µ3R¶s 
 

Reinforcement Replacement Retention

Reinforcement  

Reinforcement of the remaining tooth structure is achieved with dowel and coping DOWEL ± post extending approximately 2/3rd the length of the root canal

A - Dowel

Replacement
Replacement of missing tooth structure is achieved with the core CORE ± is the coronal extension of the dowel that provide optimal retention for final Restoration.

B - CORE

Retention
Is supplied by
1.

Dowel for core Core for final restoration

2.

Considerations for anterior teeth
Anterior teeth do not always need complete coverage, except when plastic restorative materials would have limited prognosis in view of the extent of coronal destruction. Many function with composite resin restorations. when the tooth is loaded, stresses are greatest at the facial and lingual surfaces of the root and an internal post, being only minimally stressed, does not help prevent fracture

protection of anterior teeth?
Coronal coverage does not significantly improve the success of Anterior RCT.

Minimal coronal damage
a.I tact ar i al ri What is the final rest rati n f this ty e f .I tact ci case ? ( all access l ening) Rest re access ening with a composite c.Intact incisal edge resin d. - small r imal lesi ns/rest rati ns

significant coronal damage
What is the final restoration of this type of case ? Post/core -small circular canal acceptable to use prefab post + resin(must have at least 2mm of tooth  loss of incisal edge structure apical to resin core); however, cast post and core best treatment  coronal fracture/esthetically -elliptical/flared canal custom cast post/core 
undermined

marginal ridges

unacceptable
Full coverage crown

do all RCT teeth need ³protection´?
Anteriors No, But may need post/core to restore tooth Posteriors YES !!!!!!!!!! (unless not in occlusion)

Considerations for posterior teeth
Endodontically treated posterior teeth are subject to greater loading than anterior teeth are because of their position closer to the insertion of the masticatory mus-cles.

Parts of prosthodontic reconstruction compared with chain links

Resin restoration in access opening
Indication
Intact anterior tooth with only an access opening or very small class III restoration

Contraindications
Numerous or large restoration in tooth resulting in extensive desturction most posterior teeth

Resin restoration in access opening
Advantages 
  

1 appointment Cost Preserve tooth structure Esthetics

Disadvantages 

Potential for microleakage

Amalgam core foundation
Indication
Posterior teeth that are to receive crowns cuspal coverage can be considered for strength as an option to crown

Contraindication
Teeth in which a bulk of amalgam cannot be obtained

TYPES OF POSTS
METALLIC 
  
Stainless Steel Titanium Titanium Alloy Gold-Plated brass

NON-METALLIC 
Carbon Fibre  Ceramic  Glass-fibre reinforced  Composite

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 Less chances of vertical Recommended Use: fractures during preparation Elliptical canals High strength Flared canals

Prefabricated Tapered Post
Advantages: 


Disadvantages: 


Conserves tooth structure High strength and stiffness

Low retention Longitudinal splitting of remaining root

Recommended Use: Small circular canals or Very tapered canals

Prefabricated Parallel - Sided Smooth Post
Advantages: 
  

Disadvantages: 
 

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

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

Prefabricated Threaded Posts
Advantages: 

Disadvantages: 

Stresses generated in canal may lead to fracture  Does not conserve coronal and radicular Recommended Use: Only when maximum tooth structure retention is essential High retention

Fiber Reinforced Post
Advantages: 

Disadvantages: 


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.

Zirconia Ceramic Post
Advantages: 
 

Disadvantages: 


Esthetics High stiffness High modulus of elasticity

Expensive Uncertain clinical performances

Recommended Use: High esthetic demands

Cast metal post and core
Indication
Teeth in which minimal tooth structure remains a tooth that is to be used as an abutment for fixed partial denture.

Contraindications
Teeth requiring some types of very translucent all ceramic crowns

Cast metal post and core
Advantages
Strength post and core one unit Relative easy to incorporate anti rotation feature

Disadvantages
Numerous appointments Cost More tooth removal

Ceramic post and core
Indication
Teeth requiring some type of very translucent all ceramic crowns

Contraindication
Teeth for which a metal ceramic crown is planned

Ceramic post and core
Advantages
Esthetics

Disadvantages
Numerous appointment Cost Long term data are limited Ceramic materials may have a tendency to fracture

Crown placement
Indication
Enhancement of esthetic outcome situation in which existing restoration combined with the endodontic access under mine the structure if crown

Contraindication
Anterior teeth that have only a conservative endodontic access opening

Crown placement
Advantages
Protection of reaming tooth structure by encirclement

Disadvantages
Removal of more tooth structure cost

Crown placement
Indication
Enhancement of esthetics out come situation in which existing restorations combined with the endodontic access undermine the structure integrity of the natural crown

Contraindications
Anterior teeth that have only a conservative endodontic access opening

metalmetal-ceramic crowns
Metal-ceramic crowns are very strong and resist occlusal loads well. Minimal preparation (0.5 mm) is required on the palatal and approximal surfaces. This may be beneficial in a root-filled tooth with little remaining coronal tooth substance

metalmetal-composite crowns
Metal-composite crowns are often used as long-term provisional restorations. The composite discolours with time

metalmetal-free crowns -porcelain jacket crown
Porcelain jacket crowns require a buccal tooth reduction of between 0.8 and 1.3 mm, and can therefore be more conservative on tooth substance than a metal-ceramic crown. Stained dentine and metal posts affect the aesthetic appearance of a porcelain jacket crown. Excessive occlusal loading may be a problem and can result in unpredictable fracture.

Mesio-occlusal cavities esioPlastic Restorative Techniques
The best method of restoring a root-treated tooth with an existing proximal box depends on the size and depth of the box and on the occlusal stresses that are applied during mastication. In a case with a shallow box and no evidence of occlusal loading, an amalgam restoration could be used

conservative cuspal coverage restorations
A bevelled margin of I mm depth is prepared around the circumference of the tooth. Base metal alloys can be bonded to the etched occlusal surface of the tooth using a silane bonding system. Extra retention will be provided by the internal contours of the access cavity, the majority of which is packed with IRM.

Plastic restoration
The cusps are reduced in height and the entire occlusal surface is rebuilt in amalgam. The technique is technically demanding since the correct occlusal contacts are difficult to achieve, and the material must be thick enough to withstand occlusal forces (2-3 mm). Direct light cured composite materials are not really suitable for use in this situation, and indirect composite or porcelain restorations

Cast restorations
If a metal-ceramic crown is required, significantly more tooth substance will need to be removed (at least 1-1.5 mm). The clinician needs to be sure that sufficient tooth substance will remain after preparation for retention of the restoration to avoid an unnecessarily weakened tooth.

Core Materials - Amalgam
It is strong and easy to use. Added retention can be gained by packing the amalgam into irregularities and undercuts in the pulp chamber and by using grooves, slots and pits in the cavity walls. Self-tapping dentine pins are rarely needed, and they may impart unwanted stresses within the dentine.

The Nayyar core
The Nayyar core is a useful means of restoring a molar tooth after root treatment when there is sufficient remaining tooth substance to support the core. Amalgam is packed into the root canals to a depth of approximately 3 mm and into the pulp chamber to give mechanical retention. An adhesive can be used to give extra retention

Composite
Composite cores have the advantage that they can be built up and prepared at the same visit. Chemically activated materials such as Ti Core, have been shown to perform well. There is some concern in the literature that there may be risk of microleakage between the composite core and dentine

Cermets
Although cermets have been recommended as core materials they are not as durable as amalgam or composite. Cermets are easy to use and bond to tooth substance. They should not be used when strength is required, but they could be used as a space filler to reduce the amount of alloy required in a cast restoration

Crowns for Posterior Teeth
Cast Metal Crowns
High noble metal alloys are considered to be best since they have the greatest resistance to corrosion and tarnishing and are easy to work with. Metal crowns are excellent in situations where the patient is not concerned with the appearance of metal. Significantly less reduction in the tooth is required

Partial 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

Full Cast Metal Crowns
The preparation for a full cast metal crown is more conservative than for a metal ceramic crown (0.5-1.0 mm compared with 1.0-2.0 mm).

MetalMetal-Ceramic Crowns
Metal-ceramic crowns are generally used when a patient requires a more aesthetic restoration. Porcelain can be used on the visible surfaces, such as the buccal and occlusal surfaces of mandibular teeth. If the clinical crown height is small, then retention grooves are cut in the core to provide added retention

Ceramic Crowns
Occasionally it is reasonable to use a castable or high-strength ceramic crown on a posterior tooth, if occlusal factors are not inhibitive. The amount of tooth reduction is more than with a metal-ceramic crown (occlusal reduction of 2 mm) and may compromise retention, especially in teeth with a short crown height

Temporary crowns
For anterior
Polycarbonate and acrylic temporary crown forms Custom-cast temporaries.

For posterior teeth
Metal shell crown forms ‡ Custom-cast temporaries ‡ Long-term temporaries, metal-acrylic and metal-composite crowns

Full metal veneer crown
Advantages
1. 2. 3. 4. 5.

Strong, rigid and wear resistant High resistance & retention Fairly conservative prep Uncomplicated preparation & margins High degree of occlusal accuracy in casting

Disadvantages 
Esthetics

± Some patients dislike and will strongly object to the full metal cover ± May be limited to upper and lower molars and lower premolars 
Galvanic

action

± With other opposing metals (rare)

Advantages of composite fiber post 
   

Can bonded to the tooth with resin cement Modulus of elasticity similar to dentin Ease of removal for retreatment Excellent esthetics Non corrosive

The Role of Posts in the Restoration of Endodontically Treated Teeth
The 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.

INDICATIONS
Post 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.

Ideal tooth preparation for post placement

Ferrule Effect
The 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.