Introduction

One of the biggest assets of a person is a smile that shows beautiful and
natural teeth. Children and adolescents are now sensitive to the appearance of
unattractive teeth. When a tooth discolorated, deformed, bent, or missing, they will
try to hide his teeth and consciously try not to smile. Performing dental care
aesthetically can produce a changes in their appearance, which often increase a
confidence, personality and social life.1
A color is one of the basic artistic elements in conservative aesthetic
dentistry. Color plays an important role in the success or failure of aesthetic tooth
restoration.1 Discoloration of teeth, especially anterior teeth, can be a serious
aesthetic problem. Discoloration can occur in teeth with pulp necrosis. In addition,
non-vital teeth that have been analyzed for canals will be weaker because of their
structure caused by caries, cavity preparation, and root canal formation.2 Anterior
teeth with minimal removal of tooth structure can be conservatively restored with
bonding restoration. Meanwhile, the anterior teeth with extensive coronal tooth loss
require posts, cores and crown sheaths.3 Posts are needed as additional retention
because the pulp space and single root canal are not adequate for core retention.2 In
addition, posts also have a role as a seal at the coronal root canal.4
The newest concept of dental care is minimally invasive treatment. The
most favorable treatment options in the views of tooth reduction are cantilever fixed
partial denture or maryland fixed partial denture.5,6 Treatment or restoration that is
performed will produce restorations with adequate shape, good in function and
aesthetic. It could give physiological integrity of teeth both in the hard and soft
tissue with around them. A good restoration will improve dental health and general
health of patients.7
This case report will discuss a management of the crown in anterior teeth
that damage and require core post and modified crown sheath (crown) due to the
edentoulus area next to it.

Objective
The objective of this case report is to show that teeth that have posts and
crowns but their crowns were damage and have applied root canal treatment can be
given aesthetic restoration treatment by core posts and crowns replacements. The
crown was modified to give prosthesis to the next area with missing teeth.

Case Operation Procedure

A 52-year-old woman came to the Dental Conservation Specialist Clinic at
the Dental and Oral Hospital of Airlangga University in Surabaya complaining that
her artificial teeth were shaked and dicolored. Patients asked to replace her dentures
because she felt less confident. The dental history has been treated and the dentures
placed since 1 year ago. But the patient feels dissatisfied with the results because
its color did not suitable. There are currently no pain complaints.
On objective examination, the crown of teeth 11 and pontics in area 21 with
normal gingival are obtained. After removing crowns and pontics, the remaining
tissue in tooth 11 is less than 1/3 of the crown. Percussion and palpation
examination are negative. Normal overbite and overjet of 2mm. Radiographic
examination revealed that tooth 11 contained gutta-percha and prefabricated metal
posts in the root canal. The roots in normal limits and there is no radiolucency in
the apical region.
From some of those examinations the diagnosis of tooth 11 was pulp
necrosis after root canal treatment. Their treatment plan is posts and crown damage
replacement with fixed restoration in the form of a modified crown with porcelain
fused to metal in tooth 11 and edentulous area 21 with internal retention of tooth
11 in the form of fabricated metal posts (NiCr) and metal rest on the tooth palate
22.
The first stage of treatment is a diagnostic, intra-oral (digital), and periapical
x-ray. Removed posts and crown sheath that has been damaged. The patient's upper
and lower jaw then were imprinted with an irreversible hydrocolloid (alginate)
molding material for the temporary crown making. Determination of tooth color
includes cervical color A3 Vitalumin vacuum and incisal A2 Vitalumin vacum.
Next by the installation of the old crown sheath using temporary cement
(freegenol).
In the second stage, gutta-percha point (working length of 12 mm) was
taken using a penetration drill and calibration drill. X-rays of gutta-percha points
were taken, followed by crown decaputation and seat making. The post casts in
elastomer for fabricated post and cast the maxilla with double impression of the
lower jaw using alginate. Then the temporary crown is reinserted with temporary
cement (freegenol) and the working model is sent to the dental laboratory.
In the next step, try installing fabricated posts and X-ray posts. After
checking and getting good results, fabricated post insertion is carried out using glass
ionomer cement (GIC) luthing. After that the teeth are prepared for preparation.
Firstly, gingival management is carried out with a retraction cord to determine the
limit of the preparation end. Then the post core preparation on the 11th tooth. After
that, the maxillary molding was done with a double impression technique using
elastomer because this material has high accuracy and sufficient flexibility. Before
the patient discharge, bite registration is performed initially and the temporary
crown is reinserted with a temporary cement (freegenol). The working model is
sent to the dental laboratory to make a modified crown with the color that was
adjusted.
On the next visit, when the modified crown was processed by the dental lab,
a modified porcelain fused to metal crown was tested. Once declared good, the
modified crown is inserted into the teeth using glass ionomer cement (GIC) luthing
and the remaining material were cleaned with instruments and dental floss. After
insertion the patient is instructed to check it on the next visit.
At the last stage or on the last visit, patient showed no complaint. Extra oral
examination no abnormalities found. Examination of intra oral crown is good,
tightly closed, gingiva around normal and percussion examination is normal. After
that periapical X-ray was taken and the normal results were obtained.

Discussion
Based on the case described above, the patient requires replacement of post
and crown restorations in the anterior teeth that have been treated by the root canal
but the crown have damaged. In the vitality test, the tooth is non vital. On the
radiographic picture, there is a good filler in the root canal which means the tooth
has been treated by the root canal. From dental examination, found that 11th tooth
diagnosis with pulp necrosis after root canal treatment.8 Based on this examination,
the treatment plan was to replace a modified crown restoration with an internal
retention of tooth 11 in the form of a fabricated post.
Replacement of crown restoration on the patient's teeth is done because the
crown is discolorated. According to Ascheim and Dale, the principle of restorations
in teeth that have been treated with root canals is returned to its function, aesthetics
and even distribution of chewing load, so that it can be used and stayed in the oral
cavity for a long time.9 So if there is a discoloration, it will interfere the aesthetic
function of the restoration. In most studies, the success of root canal treatment is
determined by the absence of radiolucent features and the absence of clinicals sign
and symptoms.10 So that in this case, root canal retreatment is unnecessary.
In this case the post is used as internal retention which will form a nucleus
to replace lost or damaged dentine. Posts are used because the teeth do not have
sufficient coronal structures for a core but still have enough coronal structures to
make a ferrule effect.11 The ferrule effect is a 3600 metal collar of crowns that
surrounds the parallel walls of the dentine and extends to the edge of the preparation
ending which serves to proceed pressure, thereby increasing tooth resistance to
fractures.12 Fabricated metal (NiCr) posts are chosen because they have several
advantages, which are preventive to hard tooth tissue because they adjust to the root
canal diameter and they also have core components that are already part of the post.
This also relates to the purpose of giving posts as additional retention for
restoration.2,11 When the remaining tooth structure cannot provide support and
retention for restoration, endodontically treated teeth usually require a post.12
The final restoration used is a modified crown with porcelain fused to metal.
Modified crowns were made of sheathed crowns with intra-coronal core post
retention in tooth 11 and pontic crowns in the edentulous area 21 as well as the
addition of metal rest on the palate of tooth 22 to increase stabilization. This
crowning is adjusted to the ante law which reads "the periodontal membrane surface
area of the supporting tooth must be equal to or exceed the surface area of the tooth
to be replaced."14 The use of the crown on the anterior region has greater success
than the posterior because it has a lower compressive force . In addition, these teeth
also have normal horizontal and vertical relations.15 The choice of porcelain fused
to metal material is to benefit from a combination of the strength of the metal
structure and the aesthetic quality of porcelain. It also considers the patient's
socioeconomic factors.10
In the final stage of treatment, the control was performed 2 months after
insertion of the modified crown. At the time of control, patient presented no
complaint and was satisfied with the results of the treatment. Extra oral examination
showed no abnormalities. Intra oral examination of the modified crown is tightly
closed, either, the gingiva is around normal and there is no abnormal percussion.
The success of a treatment can be achieved if the treatment plan and all
treatments are carried out well, thus affecting the achievement of a good prognosis
in the long term. In addition good cooperation and communication between the
dentist and the patient is also needed.16

Conclusion
Based on the explanation above, it can be concluded that the anterior teeth
with posts and crowns had restored but its crown are damage and the root canal
treatment was done, restoration treatment by replacing them with modifying crowns
could be performed to get retentive and stability of the restoration, taking into
account the state of the remaining dental tissue, the state of the periodontal tissue
and periapex tissue. The treatment is carried out to achieve good restoration results
and can improve dental and oral health and general health of the patient.