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Baba 2014
Baba 2014
Restoration of endodontically
treated teeth: contemporary
concepts and future perspectives
NADIM Z. BABA & CHARLES J. GOODACRE
The concept of using a root for the restoration of a missing crown is not new. Through continuous research, our
understanding of the causes of failure has improved. Recent research on endodontically treated teeth has changed
contemporary views concerning some principles while consolidating others. Clinical success in restoring
endodontically treated teeth depends on our ability to use the latest materials available in conjunction with sound
clinical methods. A number of articles have discussed the major factors that play a key role in the long-term
survival of endodontically treated teeth and associated restorations. The purpose of this article is to identify key
principles that affect tooth and restoration survival and to present expectations regarding optimal future solutions
for the long-term retention of endodontically treated teeth.
Received 23 September 2014; accepted 2 October 2014.
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Fig. 1. (a) A separated instrument within the mesial root canal of a mandibular right second molar. (b) Perforation
of the roots of a mandibular second molar, the result of post space preparation with instruments not held parallel to
the root canals. (c) A radiograph of a fractured maxillary lateral with a prefabricated non-metallic post.
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The most commonly used techniques are transillumination (Fig. 7), occlusal tests, endodontic
microscopes, dyes, and quantitative percussion
diagnostics (1822). Recently, cone beam computed
tomography (CBCT) has been suggested as a tool to
diagnose fractures, perforations, or suspected cracks
(23,24).
Another factor that could affect the mechanical
properties of dentin is the use of endodontic irrigants
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d
c
Fig. 7. (a) Clinical photo shows a crack line on the occlusal surface of a maxillary first molar. (b) The amalgam
restorations were replaced with new ones and the tooth was prepared to receive a partial coverage restoration. (c) A
trans-illumination picture shows the crack running between the amalgams across the transverse ridge. (d) Occlusal
view of the 3/4 crown showing that it encompassed the buccal cusps.
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Cuspal coverage
ETT can benefit from the placement of crowns. An
epidemiological study in a large patient population
found that while 97% of teeth were retained in the oral
cavity 8 years after initial non-surgical endodontic
treatment, an analysis of the teeth that were extracted
(< 3%) revealed that 85% of them had no full coronal
coverage (47). Aquilino & Caplan reported that ETT
with cuspal coverage had a six times greater rate of
survival than those without cuspal coverage (48).
Another prospective study (49) of the factors affecting
outcomes of non-surgical RCT found that ETT which
were restored with a crown had a better survival rate
than those that were not. Vire (50), in a study of failed
teeth, demonstrated that ETT without crowns were
lost after an average time of 50 months whereas ETT
with crowns were lost after an average of 87 months.
In a systematic review, Stavropolou & Koidis (51)
concluded that ETT restored with crowns had a
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Tooth preservation
Maximum preservation of coronal and radicular tooth
structure is a guiding principle for the restoration of
ETT. As clinicians we should preserve intact tooth
structure whenever possible in order to maintain an
adequate retention and resistance form of the final
restoration. The position of the tooth in the arch,
the presence of opposing occlusal contacts, the
periodontal tissue support, the endodontic status, and
the amount of remaining dentin aids in selecting
the appropriate material for the definitive restoration.
The authors believe that gold onlays or crowns are
excellent restorations where esthetics is not of major
concern, on teeth with limited interocclusal space, and
when restoring heavy bruxers.
Cervical ferrule
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Fig. 13. (a) Radiograph of a broken mesial root of an endodontically treated mandibular right molar restored with
a crown and no post. (b) Extracted tooth showing the fractured mesial root.
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Future directions
In the future, we foresee that the advancement of
CAD/CAM technology, milling, and laser printing
along with an improvement in digital impression
technology will make it possible to more easily and
accurately fabricate customized post and cores from
several different materials. In addition, more
conservative endodontic treatment procedures are
likely to emerge and reduce the need for posts and
crowns. Pulpal regeneration procedures may even
eliminate or substantially reduce the need for the use
of crowns and posts and cores.
In future studies of ETT and new technologies, we
believe in vitro studies should be performed using
fatigue loading and chewing simulation conditions.
Summary
Based on this review of available evidence, the
following clinical recommendations are proposed:
1. When performing root canal therapy, the tooth
needs to be evaluated for the presence of cracks and
craze lines using several of the diagnostic tools
available. The restorability of the tooth needs to be
assessed along with the periodontal prognosis.
2. Following root canal therapy, the tooth needs to be
restored with a definitive restoration in as short a
time as possible. If immediate restoration is not
possible, it is recommended to seal the orifice of the
canals and the floor of the pulp chamber with
intracoronal barriers.
3. Crowns are not needed on many endodontically
treated posterior teeth to enhance their long-term
survival because their structural integrity is often
compromised. There is some data indicating
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References
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2. Harris CA. The Dental Art. Baltimore: Armstrong and
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3. Richardson J. A Practical Treatise on Mechanical
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148149, 152153.
4. Goodacre CJ, Baba NZ. Restoration of endodontically
treated teeth. In: Ingle JI and Bakland LK, eds.
Endodontics, 6th edn. Toronto, Canada: BC Decker
Inc., 2008.
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