INTRODUCTION

During the past 20 -30 years there has been an increased interest in restoring
endodontically treated teeth. This mode of treatment is complicated by the
fact that much or all of the coronal tooth structure which normally would be
used in the retention of the a restoration has been destroyed by caries ,
previous restoration , trauma and the endodontic access itself.
Restoration of endodontically treated teeth is warranted as long as
healthy adjacent teeth do not suffer from a heroic attempt to retain a tooth
with a hopeless prognosis. The benefit of restoring such a tooth must be
carefully weighed against the risks of removing it and replacing it with a
fixed or removable prostheses.
Unfortunately, fractures and perforations are common causes of failure
when endodontically treated teeth are restored. Usually these problems are
the result of improper restorative concepts of clinical misjudgement. A
thorough understanding of the proper use of posts, cores and copings will
enable the dentist to produce a final restoration that provides adequate
retention while replacing and reinforcing lost tooth structure.
MANAGEMENT OF ENDODONTICALLY TREATED TEETH
DIAGNOSIS AND TREATMENT PLANNING
Prior to performing any dental procedure, the clinician must first
examine the patient and arrive at a diagnosis. Following this process, a
treatment plan can be formulated based on the medical and dental history,
the clinical and radiographic examination, and the patients needs and chief
complaint.

Endodontic consideration
Attention must be given to the quality of the endodontic therapy.
Prior to restorative procedures, it is essential that the endodontic treatment
be successful. Predictable success in endodontic therapy requires a dense,
uniform, three dimensional obturation of the root canal system, 0.5 to 1.0
mm from the radiographic apex of the root or roots. For patients that exhibit
previous endodontic treatment, an evaluation of that treatment and its
success is necessary. Should the tooth exhibit signs or symptoms indicting
failure, retreatment procedures should be accomplished prior to restoring the
tooth. When obturation deficiencies such as incomplete root canal fillings,
poorly instrumented or condensed canals, poorly adapted silver points and
untreated canals are evident in the absence of clinical signs and symptoms
indicative failure, they also should be corrected prior to the restorative
procedures.
PROSTHETIC CONSIDERTIONS
Treatment planning for a tooth that requires endodontic therapy or a
previously endondontically treated tooth is dependent primarily on the
amount of remaining tooth structure. Additional factors affecting prognosis
are the tooth type, morphology, arch position, the occlusal and prosthetic
forces applied to the tooth and the periodontal support for the tooth.
Tooth structure may be lost for a variety of reasons caries, previous
restorative treatment, traumatic injury attrition, erosion , abrasion and
resorption may contribute to loss of coronal structure. The extent of coronal
destruction is an important determination in deciding on the restorative
technique and materials to be used in retuning the tooth to normal form and
function. Contrary to popular belief, posts do not strength the tooth. The
primary function of a post is to provide retention for the core. Posts are
indicated when there is inadequate tooth structure to retain a core for a
coronal structure. It has been demonstrated that pulp less teeth have a
significantly higher resistance to fracture as compared to teeth restored with
post and cores.
It is evident now that care should be taken to preserve as much
sound dentin during endodontic therapy and subsequent restorative
procedures.
In evaluating tooth type, the clinician must realize that each tooth
exhibits a unique morphology and structure, which will be subjected to
different degrees of stress during function. Morphologically, the
circumference of the tooth at the cementoenamel junction is of great concern
when considering a restorative procedure. In posterior teeth, the occlusal
force’s are directed more axially than in anterior teeth in which the forces
are more lateral. In addition, the direction and degree of occlusal stress can
be increased if the tooth is to be an abutment for a fixed or removable
prosthesis.

Periodontal considerations
Periodontal disease should be treated prior to placement of definitive
restorations. A healthy periodontium provides the best prognosis for the
tooth and will make procedures such as placement of margins and making of
an impression easier and more accurate.
1. Provide adequate isolation for endodontic therapy.
2. Re-establish the biologic width and
3. Provide coronal tooth structure to incorporate a ferrule into the cast
restoration.
The ferrule has been defined as a circumferential band to cast metal at the
margin of a crown which is placed on solid tooth structure. Encircling band
of cast metal acts as a reinforcing sleeve around the coronal portion of the
tooth. The encirclement of the tooth provided by the ferrule will act to
prevent splitting of the tooth when wedging forces are encountered. Ferrule
is only effective when the walls are very close to parallel and allowed a
rounded transition from ferrule wall to the preparation margins. A beveled
finish line for the over casting enhances the ferrule effect and improves the
fracture resistance of the root.
Clinical Protocol for restoring endondontically treated teeth
Anterior teeth
As a consensus, anterior teeth that exhibit intact marginal ridges, can
be restored by placement of a base over the gutta percha obturating material
and sealing the lingual access with an acid etch composite resin provided the
teeth meets the occlusal requirements and the patient is happy with the
appearance. Pulp less anterior teeth can also be conservatively restored
with a bonded composite resin restoration rather than artificial crown. A
laminate veneer offers a conservative alternative if the facial surface is intact
with moderate discolouration. Anterior teeth that exhibit mesial and distal
restoration should be restored with a post and core prior to the placement of
a crown. The loss of both marginal ridges and a lingual access opening
leaves the facial portion of the tooth unsupported.
Mandibular incisors and maxillary lateral incisors would always
require a post and core before placing an artificial crown.

Posterior teeth
The need for a core or a post and core is determined on the basis of
remaining tooth structures as well as expected occlusal and prosthetic forces
that will be applied.

Clinical consideration
The apical seal, alveolar bone support, and root morphology are all
important considerations when determining post size and depth. Anatomy
and morphology of teeth also should be considered when planning for a post.
When posts are to be used in maxillary molars, the palatal canal should be
used because of its relatively large and straight configuration. In
mandibular molars, the distal canal should be used because of the root
morphology and size of the canal. The buccal roots in maxillary molars and
the mesial root of mandibular molars are not good candidates to receive a
post because of their size, morphology and curvature. When feasible, post
placement should be carried out under the aseptic conditions provided by
rubber dam isolating the post and prevents bacterial contamination of the
radicular space by salivary leakage. In addition, it is prudent to disinfect or
sterilize the post prior to cementation.

Post length
The length of apical seal remaining after post preparation and the
degree to which it was disturbed during post hole preparation can influence
the long term success of the restoration. When ever mechanical preparation
of the post hole is required, 4-5 mm of undisturbed apical gutta percha
should remain after post preparation.
Additionally, the height of the alveolar bone surrounding the root and
the root morphology are equally important considerations in the restorative
equation.
Traditional view of post length have advocated that the post be
a. Equal to the height of the clinical crown.
b. One and one half times the length of the clinical crown and
c. Two third the length of the remaining root.

Post Width
The size of a post is dependent on the root width and canal
morphology. In general, the width of a post should not be larger than one
third of the root width at its narrowest dimension. In addition, the post
should be surrounded by at least 1 mm of sound dentin. This point is
especially critical in the apical area where the root narrows and stresses are
concentrated. Small diameter posts provide greater resistance to fracture as
compared with larger diameter posts, and evidence exists indicating that the
post diameter has no significance effect on retention.

Classification
Posts generally are classified either by their shape (tapered versus
parallel sided) or by their mechanism of placement (non-threaded versus
threaded). These characteristics have great influence over the retention of
the post and its ultimate selection for a given clinical situations.

2. FOUNDATION RESTORATIONS FOR PULPLESS TEETH

Historical perspectives
The concept of using the root of a tooth for retention of a crown is not
new. In the 1700s Fauchard inserted wooden dowels in canals of teeth to aid
in crown retention. Overtime the wood would expand in the moist
environment to enhance retention of the dowel until, unfortunately, the root
would often fracture vertically. Additional efforts to develop crowns
retained with posts or dowels in the 1800s were limited by the failure of the
“endodontic” therapy of the era. Several of the 19 th century versions of
dowels also used wooden “pivots,” but some dentists reported the use of
metal posts favored by Black in which a porcelain-faced crown was
secured by a screw passing into a gold-lined root canal. A device developed
by Clark in the mid-1800s was extremely practical for its time because it
included a tube that allowed drainage from the apical area or the canal.
The Richmond crown was introduced in 1878 and incorporate a
threaded tube in the canal with a screw retained crown. The Richmond
crown was later modified to eliminate the threaded tube and was redesigned
as a 1-piece dowel and crown. One –piece dowel crowns became unpopular
because they were not practical. This was evident when divergent paths of
insertion of the post-space and remaining tooth structure existed, especially
for abutments to fixed partial dentures (FPDs). One-piece dowel-crown
restorations also presented problems when the crown of FPD required
removal and replacement. These difficulties led to development of a post-
and-core restoration as a separate entity with an artificial crown cemented
over a core and remaining tooth structure.

FACTORS AFFECTING RETENTION OF POST SYSTEMS

Variables reported to affect retention include length, diameter and design
of the post, canal shape and preparation, luting medium, method of
cementation, and location in the dental arch.

a. Post Length
1. The post should equal the incisocervical or occlusocervical dimension
of the crown.
2. The post should be larger than the crown.
3. The post should be 1 1/3 the length of the crown.
4. The post should be a certain fraction of the length of the root such as
one half, two thirds, or four fifths.
 5. The post should end halfway between the crestal bone and the root
apex.
6. The post should be as long as possible without disturbing the apical
seal.
The length of the post has a significant effect on its retention and in most
instances, the more deeply the post is placed, the more retentive it becomes.
Leary et al. also found that posts with a length of at least 3- quarters of the
length of the root offered the greatest rigidity and least root deflection
(bending) when compared with posts that were a half or a quarter the root
length. Short posts are especially dangerous and have a much higher failure
rate.

b. Post Diameter
Increasing the diameter of the post does not provide a significant
increase in the retention of the post, however, it can increase the stiffness of
the post at the expense of the remaining dentin and the fracture resistance of
the root.
Therefore post diameter must be controlled to preserve radicular
dentin, reduce the potential for perforations, and permit the tooth to resist
fracture. Goodacre suggested that post diameters should not exceed one third
of the root diameter at any location.

C. Post Design
6 basic commercial systems available as follows:
1. Tapered, smooth-sided posts.
2. Parallel-sided, serrated, and vented posts.
3. Tapered, self-threaded posts.
 4. Parallel-sided, threaded, split-shank posts.
5. Parallel-sided, threaded posts.
6. Carbon-fiber posts.
Of the first 5 systems, the parallel-sided, serrated, vented post produced
stresses that were distributed most uniformly along its length and appeared
best able to protect the dentin. Retention must be weighed against
distribution. Tapered self-threaded screws are the most likely to cause stress
fracture and are not recommended. Parallel-sided threaded posts that are
tapered may be considered when additional retention is needed.
Posts systems
a. Tapered post, Non threaded
A tapered post is less retentive than a parallel post. Tapered posts
generally will have a wedging action on the root and have a relatively low
retention rate. These posts also have been shown to be less successful than
placement of no post at all. For these reasons, this type of post is only
recommended for very tapered canals in which parallel sided posts would
require excessive tooth preparation.

b. Parallel sided posts, Threaded or Non threaded and inactive.

Parallel sided post design offer increased retention over tapered
design. Parallel sided post have excellent clinical retention and failures are
caused most often by dislodgement. Prefabricated parallel sided posts are an
excellent choice for many clinical situations and offer the advantages of ease
of placement, minimal stress production within the root, and good retention,
as well as offering the added advantage of allowing final tooth preparation
during the same appointment.
c. Parallel sided posts, Threaded, Active.
They rely on some form of mechanical engagement of cutting flute
into dentin to gain increased retention. These are the most controversial type
of post category. Posts in this group have been shown to induce increased
stresses with in the root, which may later lead to root fracture.
If a threaded post is selected for use, there must be an attempt to
minimize internal stresses from thread placement. The thread in the root
must be formed prior to post placement and there should be no resistance to
the post as it is finally placed. These systems use either a tap or the post
itself to perform the thread and this must be done in conjunction with
diligent debridement of the canal preparation. This category of posts is
indicated only for very short root in which use of a nonthreaded post would
result in failure due to lack of length for retention.

d. Amalgam Coronal – Radicular Dowel Core

It is not an absolute requirements that an endodontically treated tooth
should have a dowel placed in the root. As already pointed out, this decision
should be made after careful evaluation of the previously described criteria
of remaining tooth structure, tooth type and morphlogy arch position,
occlusal forces, and periodontal status. When it is evident that a significant
amount of sound dentin remains, as is often the case when restoring molars
the dentist must choose to use the chamber space and a short extension of 2
to 4 mm into one or more of the canals to build the foundation entirely of
amalgam. Auxillary pins should be employed with this technique only if
additional retention is deemed absolutely necessary.
d. Luting Agents
Luting agents, including zinc phosphate, polycarboxylate, glass
ionomer, and filled and unfilled resin cements. . Posts are cemented into
the preparation to achieve a seal along the canal and to aid in post retention.
The choice of dental cement for post cementation is essentially one of
operator preference. Glass ionomer, resin, and zinc phosphate cements all
have been shown to the acceptable for post placement. Recommended
portions and mixing techniques must be followed to assure successful
results.
The cementation of custom cast or prefabricated dowel and core
foundations must be carried out in an isolated environment to minimize
entry of bacteria into the prepared canal and aid to moisture control. This is
best accomplished using a rubber dam on the prepared tooth. The canal is
washed with water and dried with indirect air and paper points. Any
moisture remaining in the prepared canal will significantly diminish
retention of the post.
In an effort to study ways to increase post retention, researchers
examined the internal dentin surface of prepared canals. By examining
selected endodontically treated teeth with scanning electron microscopy,
they were able to detect a familiar smear layer, presumably the result of the
canal preparation process. Their effort focused on removal of the smear
layer with 17’7’’ ethylene diamine tetracetic acid (EDTA) and 5.25% NaCI
and comparison of zinc oxyphosphate cement, polycarboxylate cement and
unfilled resin cement for cementation efficiency. Results indicated that
removal of the smear layer and use of unfilled resin cement was significantly
more retentive than zinc oxyphosphate cement.
 The selected cement is mixed and taken on the blade of a plastic
filling instrument and held over the canal orifice. A Lentulo spiral paste
filler is rotated through the cement carrying it into the canal. The dowel
itself also is coated and inserted into the canal using slow finger pressure,
thus allowing excess cement to escape. A dowel should never be forced into
position because of the potentially dangerous hydraulic forces being created
which may result in stress fracture.

e. Canal Shape
Because the predominant canal shape is ovoid and the walls of
prefabricated posts are commonly parallel, the majority of luted
prefabricated posts are unlikely to adapt well along their entire interface with
the canal walls. As a result, the post may not fit the preparation closely, and
the luting agent may not totally fill the interface.

f. Preparation Of The Canal Space And Tooth

When necessary, gutta percha should be removed with an endodontic
heat carrier until the desired length is reached. A minimum of 4 to 5 mm of
gutta percha must remain to preserve the apical seal. Preservation of the
apical gutta percha should be confirmed radiographically before the post is
cemented. After gutta percha removal, root canal reamers can be used to
widen the canal space by a reaming action to ensure a relatively round
preparation. For each prefabricated post system, the accompanying twist
drills are then used to shape the canal following the direction and depth
created by the hand instruments. These twist drills should not be used to
remove filling materials. Twist drills also should not be forced but should
passively follow the course of the previously established canal. Stops should
be placed on engine-mounted drills at the desired depth as an added
precaution. Drills can gouge the dentin and cause undesirable vertical
angulation of the preparation or perforate the root. The goal should be to
choose the prefabricated system consistent with the smallest possible canal
diameter to preserve the inherent strength of the root.

g. Location in the dental arch

The location of the tooth in the dental arch necessitates different
restorative requirements to ensure the longevity of endodontically treated
teeth. Several in vitro studies have confirmed the greater fracture resistance
of minimally damaged endodontically treated maxillary anterior teeth when
compared with post-core crown restored maxillary central incisors. Thus
coronal coverage should be selected only when large restorations exist, or
for esthetics. Nevertheless, cuspal coverage is commonly recommended for
posterior endodontically treated teeth.
Clinically, a post in a maxillary anterior tooth is subjected to
compressive, tensile, shear, and torquing forces. At the dentin-post interface,
the forces that tend to dislodge the post are predominately labially inclined
shear forces, and studies have suggested resistance form can be increased
with the use of a beveled preparation. The maxillary anterior region is
considered to be a high risk area for failure, which may be due in part as a
result of unfavourable directional loading during function.
All endodontically treated maxillary premolars and most mandibular
second premolars should receive cuspal coverage to protect the remaining
cusps during occlusion. Lateral excursive forces can shear the remaining
cusp or cause vertical root fracture. Full crowns are preferred to three
quarter crowns or onlays to prevent fractures. The metal in partial veneer
restorations can flex, thereby exerting forces against the cusps and causing
fractures. When onlays are used fractures of the cusps may be prevented by
incorporating a wide reverse bevel at the cuspal margins to provide
mechanical locking with a minimum of 1.5 to 2 mm of metal on the cusps to
reduce the flexing of the metal. Lower first premolar may be treated as
anterior teeth. Endodontically treated molars in which there has been
minimal access with limited proximal wall , destruction by caries may be
restored with an alloy with high copper content. If buccal or lingual walls
are thin , thet are reduced and restored with amalgam or cast metal
coverage.when a molar is badly broken down, the missing coronal
substructure should be restored with a coronal – radicular amalgam post and
core before placing a full crown. If more than 60% of the remaining tooth
structure is missing, a post in addition to the pins should be placed in the
largest canal to replace the amalgam core. When the molar is used to be
used as an abutment tooth, a post is commonly used.

4. PREFABRICATED POSTS.
Post and Core Material
Posts are usually made of either stainless steel, nickel chromium, pure
titanium, titanium alloy, or non oxidizing noble alloy. Recent additions
include carbon fibre, fibre reinforced composite, ceramic composite and
zirconia post. The stainless steel posts are of a proven strength but recent
interest about nickel sensitivity and inclusion of other metals have prompted
many practitioners to opt for titanium or its alloy, both of which are more
inert. With regard to preformed stainless steel post they are stronger than
titanium post and they are more radiopaque. This radiopacity is an
advantage, it making a post easier to identify clinically. Nearly pure
titanium is slightly weaker than its alloy but the strength differences and
fatigue resistance differences are not clinically significant. The recent trend
seems to favour the use of the titanium and titanium alloys. Most
prefabricated post systems are available in both stainless steel and titanium
or titanium alloy. Carbon fibre post has gained ground in recent year as a
preferred mode of treatment. These posts consists of bundles of stretched
aligned carbon fibres embedded in an epoxy matrix. Ease of removal, a
modulus of elasticity close to natural tooth which decreases the risk of stress
concentration and a high level of retention because the post bonds to the
resin system used to retain it in the root.
Prefabricated posts have become more popular, and there is a variety
of systems available.

Carbon fiber reinforced epoxy resin posts.

Most prefabricated posts are metallic, but there are several newer
nonmetallic system available. A post fabricated from a carbon fiber
reinforced epoxy resin was developed in France by Duret and Renaud, and
became commercially available in Sweden in 1992. Carbon fiber reinforced
epoxy resin is a recently introduced dental restorative material composed of
unidirectional carbon fibers that are 8 μm in diameter embedded in a resin
matrix. The material is radiolucent and appears to be biocompatible
In vitro studies have indicated that these carbon fiber posts possessed
inferior strength compared to metal posts. These posts are used with
composite cores and resin luting agents. Nevertheless their ability to bond
to adhesive dental resins appears unremarkable, and their bond can be
improved with mechanical retention such as serrations.
 Because of the parallel arrangement of the reinforcing carbon fibers,
these posts displayed anisotropic behavior whereby their physical properties
differ depending on the loading angles. Furthermore, even if the elastic
modulus of the post were comparable to human dentin, this property will not
ensure similar clinical behaviour for the post and radicular dentin. The root
is essentially a hollow tube surrounded by an intervening layer of composite
resin luting agent. The radically different configuration of the root
compared with the post combined with the interposed composite resin luting
material suggest that the flexibility of the post will not match the flexibility
of the root. Another in vitro study indicated that the form of the post would
influence its rigidity and reported that smooth posts were less flexible than
serrated posts.
A flexible post can be detrimental especially when there is little remaining
natural tooth structure between the margin of the core and the gingival
extension of the artificial crown. When the ferrule is absent or extremely
small, occlusal loads may cause the post to flex with eventual micro-
movement of the core, and the cement seal at the margin of the crown may
fracture is a short time. Marginal leakage with recurrent dental caries will
ensue, but the deterioration will be unnoticed until substantial destruction of
tooth structure occurs.

Zirconia posts.
With recent advances in ceramic technology, the all ceramic crown has
become more popular. However, restoring a pulp less tooth with a metal
post and core in combination with an all ceramic crown is a challenge. The
underlying metal from the post and core can alter the optical effects of a
translucent all ceramic crown and compromise the esthetics.
 The response to the need for a post that possesses optical properties
compatible with an all ceramic crown, an all ceramic post has been
developed. This post is composed of zirconium oxide. Studies have
indicated stability after long term aging to this ceramic material without
evidence of degradation. The post is made from fine grain, dense tetragonal
zirconium poly-crystals (TZP), and the zirconia post has been reported to
possess high flexural strength and fracture toughness. This radiopaque
material is biocompatible with some physical properties similar to steel. The
zirconia post was designed for use with an adhesive resin cement.
These posts were also designed for use with a composite core material, but a
large composite core may not be sufficiently rigid to support a brittle all
ceramic crown. Sorensen described a method of combining this post with
IPS Empress pressed glass technology to compensate for the disadvantages
of a composite core for an all ceramic restoration. A custom glass ceramic
core was formed over the prefabricated zirconia post to develop a post and
core that was entirely ceramic.
Clinical trails are lacking with this new all ceramic post and the ability
of these posts to resist intra oral forces are unknown. Ceramics are tough
materials with high compressive strengths, but are brittle when subjected to
shearing forces. An alternative t this all ceramic post is a cast post and core
made form a metal ceramic alloy. Opaque porcelain can be fused to core
portion to provide a durable post and core that will disguise the graying
effect that can occur with conventional cast metal posts and cores when
combined with all ceramic crowns.
Woven fiber composite materials
The manufacturer of a cold glass plasma treated polyethylene woven
fiber has suggested this material in a resin composite to provide
coronaradicular stabilization for pulp less teeth. The fibers are multi
directional and developers of the material have suggested a number of uses.
An in vitro study of this material with extracted human teeth indicated that
woven fiber composite posts and core were significantly weaker than cast
metal posts and cores. Nevertheless, when this woven fiber composite was
reinforced with a smaller diameter prefabricated post, the strength of the
system increased significantly. These prefabricated posts embedded in the
woven fiber composite were not as strong as cast posts and cores, but were
less likely to cause fracture of the roots when subjected to failure loads.

When prefabricated posts are used, the core build up should be either
in amalgam, glass ionomer, or composite resin. The optimal build up
material should have adequate strength, be biocompatible exhibit a high
level of resistance of bacterial leakage and be dimensionally stable in the
presence of oral fluids. In addition, a foundation restoration that supports a
transluscent all ceramic crown should not adversely affect the esthetic
qualities of the final restoration.
1. Composite resin
Composite resin cores are commonly used in the anterior region. The
final strength of these cores ranges from good to excellent and they offer the
option of preparation immediately after placement. They do not, however
have the cariostatic properties of the glass ionomers and have dissimilar
expansion and contraction values with the tooth. They also lead to water
sorption. Which results in core breakdown. This expansion of composites
due to water is a potential concern due to generation of internal stresses. It
is further seen that mechanical properties of composite degrade with
thermocycling and exposure of water. Their use may include single tooth
build ups or abutments for short span or multiple unit fixed partial dentures.
They are inferior to amalgam and cast gold as a core material.
2. Amalgam
The most commonly used core material with prefabricated posts is
amalgam. Amalgam is relatively easy to use, provides a corrosion interface
with the tooth, and has an excellent final strength. Its coefficient of thermal
expansion is almost double of that of dentin and it is relatively stable in the
presence of water. Amalgam is classified as to the shape of its particles.
1. Spherical
2. Spheroidal, or
3. A blending of the two types known as an admix. Fast setting
amalgam is necessary if the practitioner wants to prepare for
the final restoration at the same appointment, and the spherical
alloys best meet this requirement. This type of amalgam gains
strength rapidly and will allow careful preparation after 15 to
20 minutes.
Amalgam is recommended for general use in restoring single
posterior tooth and for short span and long span multiple abutment fixed
partial dentures.
3. Glass Ionomer : Increased use of glass ionomer has been reported
recently to restore the endodontically treated teeth. The major drawback to
their use is the question of adequate strength to support the final restoration.
They also require good isolation for placement. Which may present a
clinical challenge. Their use is indicated primarily for blocking out small
undercut areas for crown preparation or for single posterior teeth to be
crowned, or for short span fixed partial denture abutments with minimal
strength requirements.
4. Cast Post and Core : Cast post and core can be fabricated by direct and
indirect methods. Customs post and core patterns should be casted in Type
III and Type IV gold alloys or high noble alloys. They possess adequate
strength and minimize corrosion. If a patient is not allergic to nickel, then
nickel chromium alloys should be used. Although the nickel chromium
alloys offer an acceptable strength component, they also exhibit low
resilience to loading and may undergo corrosive change, making them less
desirable as gold substitutes. Cast post and core resistance to leakage is
derived from the luting agent. It does not absorb water and has a coefficient
of thermal expansion very close to that of dentin. It is the build up material
of choice.

. Advantages of the cast post and core include

i. Preservation of the maximum tooth structure as the post is
fabricated to fit the radicular space.
ii. Provision of antirotational properties and
iii. Core retention, because the core is an inherent part of post
and does not need to be retained by the post.
Disadvantages include
i. The appointments necessary to fabricate a pattern and then seat the
post.
ii. The decreased retention of the tapering design, and
iii. The wedging effect exerted on the root.
Advantages to the proprietary post system are
1. These posts rely principally on cement for retention.
2. Ease of placement.

Disadvantage include
i. Removal of existing tooth structure to accommodate the post
ii. Decrease core retention to the post, and the potential for rotation.
iii. Lack of cementatin groove to vent the hydrostatic pressures
developed during cementation.
The threaded post systems, although exhibiting the greatest retention,
generally are contra indicated as restoring endodontically treated teeth
because of the production of stress within the root. Stresses produced
during channel preparation and during installation procedures can lead to
vertical root fracture.

ROLE OF THE FERRULE EFFECT

A post and core in a pulpless tooth can transfer occlusal forces
intraradicularly with resultant predisposition to vertical fracture of the root.
The role of the final cast restoration in protection of the dowel-restored pulp-
less tooth has been discussed for decades. In 1959 Frank indicated the
importance of protective coronal coverage of pulp-less teeth, and Rosen
suggested that the “hugging action” of a subgingival collar of cast metal
provided extracoronal bracing that could prevent fracture of tooth structure.
Eissman and Radke used the term ferrule effect to describe this 360-degree
ring of cast restoration at least 2mm apical to junction of the core and
remaining tooth structure.
REVIEW OF LITERATURE
In vitro studies by Barkhorder et al and Hemming et al reported an
improved resistance to fracture when encircling collars or ferrules were use
with posts. Assif et al examined in vitro the effect of post design on the
fracture resistance to fracture if the core was covered with a complete cast
crown that extended 2 mm apical to the finish line of the core. An in vitro
study by Isidor et al evaluated the effects of post length and ferrule length
on the resistance to dynamic loading of bovine teeth restored with artificial
crowns. Resistance to failure was greatest for the group restored with a
combination of the longest posts (10mm) and the longest ferrules (2,5mm).
Libman and Nicholls evaluated in vitro the effects of ferrules on the
integrity of the cement seal of cast crowns, and reported improved resistance
to fatigue failure of the cement seal of a crown when the crown margin
extended at least 1.5mm apical to the margin of the core. Another study
indicated that failure of the cement seal of the artificial crown occurred first
on the tension side of the tooth, especially when the ferrule was small and
the post was off-center. Loss of the cement seal of the coronal restoration is
insidious and clinically undetectable initially. Nevertheless, leakage will
occur between the crown margin and the tooth surface and may extend into
the post space, which could lead to dental caries and potential loss of the
tooth. Torbjorner et al retrospectively evaluated the survival and failure
characteristics of teeth restored with posts and artificial crowns, and their
results indicated a higher potential for fracture of the post when the
cemented crowns did not provide a ferrule effect.

Shllingburg et al have advocated a contra bevel in the tooth

preparation for a cast post and core to produce a core with a collar that
serves as a secondary ferrule, independent of the ferrule provided by the cast
crown. However, Sorensen and Engleman reported no advantage to this
contra bevel and collar when a crown was cemented over the core. Their
results indicated that the ferrule effect was obtained from nearly parallel
walls of intact tooth structure coronal to the finish line for the artificial
crown and not from the contra bevel on the core preparation. They also
reported that a 1 mm beveled finish line for a complete crown preparation
without additional tooth structure coronal to the bevel did not improve the
fracture resistance of the root.
Loney et al conducted an analysis of stresses developed in
photoelastic resin models of maxillary canines restored with cast cores. Half
the specimens contained cores with a 1.5 mm collar to provide a ferrule as a
component of the cores with a 1.5 mm collar to provide a ferrule as a
component of the core itself, and half omitted this collar. Their results
indicated substantially higher mean stresses with the collared cores and
suggested that incorporation of a ferrule with a cast core may be undesirable.
Current knowledge has confirmed that as much coronal tooth structure
as possible should be retained when preparating pulpless teeth for complete
crowns to maximize the ferrule effect. A minimal height of 1.5 to 2mm of
intact tooth structure above the crown margin for 360 degrees around the
circumference of the tooth preparation appears to be a rationale guidelines
for this ferrule effect. Surgical crown lengthening or orthodontic extrusion
should be considered with severely damaged teeth to expose additional tooth
structure to establish a ferrule. If these provisions for developing a ferrule
are impractical, extraction of the tooth and replacement with conventional or
implant supported prosthodontics should be considered.
Corrosion
Recommendation have been made that the post and core, and possibly
the crown, be fabricated of the same metal as the prolonged electrolytic
reaction between dissimilar post and core metals (stainless steel, silver, or
brass posts reacting with the tin in the amalgam core) may result in
longitudinal and oblique root fractures. The products of this reaction,
deposit in the root canal, induce volumetric changes and cause root fracture.

Criteria for cast post and core design

Many cast posts resist rotational forces because they are oblong in cross
section. However, the cast post for round canals, such as the maxillary
incisors, requires locking notches or keyways incorporated into the canal to
resist rotational movements. Prefabricated round posts require pins and
notches to resist these torquing forces.
The post should closely approximate the walls of the canals without a
wedging effect. If the fit is too tight the forces of cementation may be
sufficient to fracture the root. The cast post is roughened prior to
cementation with a sandpaper disk to remove the oxide layer of the casting
and increase the retention. This removal also helps the casting to fit
passively in the canal. The post is vented by flattening a small portion of the
buccal or lingual post along the length allow cement to escape and reduce
the hydraulic pressure
PROCEDURES
Tooth preparation for endodontically treated teeth can be considered
as a three stage operation.
1. removal of the root canal filing material to the appropriate depth.
2. enlargement of the canal and
 3. Preparation of the coronal tooth structure.

Removal of the endodontic filling material

It is recommended that the root canal system first be completely
obturated and then space made for a post. This will ensure that lateral canals
are sealed.
There are two commonly used methods for removing gutta percha -
with a warmed endodontic plugger and with a rotary instrument. Of these
techniques, the warmed condenser is preferred because it eliminates the
possibility of the rotary instrument’s inadvertently damaging the dentin.
1. Before removing gutta percha, calculate the appropriate length of
the post. As a guide, make the post length equal to the height of the
anatomic crown (or two thirds the length of the root ) but leave 5
mm of apical gutta percha.
2. Select and endodontic condenser large enough to hold heat well but
not so large that it binds against the canal walls.
3. Mark it at the appropriate length (normally endodontic working
length minus 5 mmm) heat it, and place it in the canal to soften the
gutta percha.
4. If the gutta percha is old and has lost its thermoplasticity, use a
rotary instrument, making sure that the instrument follows the gutta
percha and does not engage dentin (lest it cause a root perforation).
Special post preparation instruments are available. Gates glidden drill.
Para Post drill. A rotary instrument should not be used immediately
after obturation, for it may disturb the apical seal.
5. When the gutta percha has been removed to the appropriate depth,
shape the canal as needed.
 This is accomplished with endodontic hand instruments or a low
speed drill. The purpose is to remove undercuts and prepare the canal
to receive an appropriately sized post without excessively enlarging
the canal.

Enlargement of the canal

Prior to enlargement of the canal, a decision must be made regarding
the type of post system that will be used for fabrication of the post and core.
Parallel sided prefabricated posts are recommended for conservatively
prepared root canals in teeth with roots of circular cross section. Excessively
flared canals, as may be found in young persons or following retreatment of
an endodontic failure, are best managed with a custom post.

For prefabricated posts

1. Enlarge the canal one or two sizes with a drill, endodontic file, or
reamer that matches the configuration of the post. In the case of a
threaded post, the appropriate drill is followed by a tap.
2. Use a prefabricated post that matches standard endodontic
instruments.
For custom made posts
1. Use custom made posts in canals that have a non-circular cross
section or extreme taper. Enlarging canals to conform to a preformed
post may lead to perforation. Often very little preparation will be
needed for a custom made post. However, undercuts within the canal
should be removed and some additional shaping usually is necessary.
2. Be most careful on molars to avoid root perforation.
Preparation of the coronal tooth structure
After the post space has been prepared, the coronal tooth structures is
reduced for the extra coronal restoration.
1. Ignore any missing tooth structure (from previous restorative
procedures. Caries, fracture, or endodontic access) and prepare the
remaining tooth as though it were undamaged.
2. Remove all under cuts that would prevent withdrawal of the pattern.
3. Remove any unsupported tooth structure, but be careful to preserve
as much of the crown as possible.
4. Be sure also that part of the crown is prepared perpendicular to the
post.
This will create a positive stop to prevent overseating and possible
splitting of the tooth. Similarly rotation of the post must be prevented by
preparing a flat surface parallel to the post. If sufficient tooth structure for
this feature remains, an antirotation groove should be placed in the canal.
5. Complete the preparation by eliminating sharp angles and
establishing a smooth finish line.

Custom made posts

A custom made post can be cast from a direct pattern or an indirect
one. A direct technique utilizing autopolymerizing resin is recommended
for single canals whereas an indirect procedure is more appropriate for
multiple canals
Direct procedure
1. Lightly lubricate the canal and notch a loose fitting plastic dowel. It
should extend to the full depth of the prepared canal.
 2. Add resin to the dowel and seat it in the prepared canal. This is best
done in two steps; Add resin only to the canal orifice first. An
alternative is to mix some resin and roll it into a thin cylinder. This
is introduced into the canal and pushed to place with the monomer-
moistened plastic dowel.
3. Do not allow the resin to harden fully within the canal. Loosen and
reseat it several times while it is still rubbery.
4. Once the resin has polymerized, remove the pattern.
5. Form the apical part of the post by adding additional resin and
reseating and removing the post, taking care not to lock it in the
canal.
6. Identify any undercuts that can be trimmed aware carefully with a
scalpel.
The post pattern is complete when it can be inserted at removed easily
without binding in the canal. Once if pattern has been made, additional resin
is added for a core.
Indirect procedure
Any elastomer material will make an accurate impression of the root
canal if a wire reinforcement is placed to prevent distortion.
1. Cut pieces of orthodontic wire to length and shape them like the
letter.
2. Verify the fit of the wire in each canal. It should fit loosely and
extend to the full depth of the post space.
3. Coat the segment with tray adhesive.
If sub gingival margins are present, tissue displacement may be
helpful. Lubricate the canals the facilitate removal of the impression
without distortion (die lubricant is suitable)
 4. Using a lentulo, fill the canals with elastomeric impression material
5. Seat the wire reinforcement to the full depth of each cavity, syringe in
more impression material around the prepared teeth, and insert the
impression tray.
6. Remove the impression, evaluate it, and pour the final cast.
7. Roughen a loose fitting plastic post ( a plastic tooth pick is suitable)
and using the impression as a guide, make sure that it extends into the
entire depth of the canal.
8. Apply a thin coat of sticky was to the plastic post and add soft in lay
wax in increments.
It is best to start from the most apical and make sure that the post is
correctly oriented as it is seated to adapt the wax. When this post
pattern has been fabricated, the wax core can be added and shaped.
9. Use the impression to evaluate whether the wax pattern is completely
adapted to the post space.

Core fabrication
The core of a post-and –core restoration replaces missing coronal
tooth structure, and thereby forms the shape of the tooth preparation. It can
be shaped in resin or wax and added to the post pattern before the assembly
is cast in metal. Or the core from a plastic restorative material such as
amalgam, glass ionomer, or composite resin.

Plastic filling materials. The advantages of amalgam, glass ionomer or

resins are that (1) maximum tooth structure can be conserved because
undercuts do not need to be removed, (2) treatment requires one less patient
visit, (3) there are fewer laboratory procedures, and (4) testing generally
shows good strength characteristics, possibly because of the good adaptation
to tooth structure.

Step-by-step procedure for amalgam

1. Apply the rubber dam and remove gutta-percha from the pulp
chamber as well as 2to4mm into each root canal if less than 4mm
of coronal height remains. Use a warmed endodontic instrument.
2. Remove any existing restoration, undermined enamel, or carious or
weakened dentin. Establish the cavity form using conventional
principles of resistance and retention form.
Even if cusps are missing, pins are not normally required
because adequate retention can be gained by extending the amalgam
into the root canals.
3. If you suspect that the floor of the pulp chamber is thin, protect it
from condensing pressures with a cement base.
4. Condense the first increments of amalgam into the root canals with
an endodontic plugger.
5. Carve the alloy to shape. The impression can be made
immediately.

Direct pattern for multirooted teeth

A direct pattern can be used for multirooted posterior teeth, although
limited access may make the indirect approach easier. A single-piece core
with auxiliary posts is used as opposed to the multisection core
recommended for indirect posterior cast post-and cores. The core is cast
directly onto the post of one canal. (The other canals already have
prefabricated posts that pass through holes in the core).
 The procedure is simple, as long as smooth parallel sided or tapered
posts are used.
1. Fit prefabricated posts into the prepared canals. One post is
roughened; the others are left smooth and lubricated. All posts should
extend beyond the eventual preparation.
2. Build up the core with autopolymerizing resin by the bead technique.
3. Shape the core to final form with carbide finishing burs.
4. Grip the smooth lubricated posts with forceps and remove them.
5. Remove, invest, and cast the core with the roughened single post.
When this has been done, the holes for the auxiliary posts can be
refined with the appropriate twist drill.
6. After verifying the fit at try –in, cement the core and auxiliary posts to
place.

Indirect pattern for posterior teeth

1. Wax the custom-made posts as described previously.
2. Build part of the core around the first post.
3. Remove any undercuts adjacent to other postholes and cast the
first section.
4. Wax additional sections and cast them.
The use of dovetails to interlock the sections makes the
procedure more complicated and is probably of limited benefit,
especially because the final buildup is held together by the
fixed cast restoration.
Investing and casting
A cast post-and –core should fit somewhat loosely in the canal. A
tight fit may cause root fracture. The casting should be slightly undersized,
which can be accomplished by restricting expansion of the investment (e.g.,
by omitting the usual ring liner or casting.
Casting a core onto a prefabricated post avoids problems of porosity,
but the preheating temperature of investment mold should be restricted if
recrystalizat of the wrought post53 is to be avoided.

They can be further subdivided on the basis of shape into blade form
plateform) and root form(cylindrical). Blades are wedge shaped or
rectangular in cross section and are generally 2.5mm wide, 8 to15mm deep,
and 15 to 30mm long. Cyclinders are3 to 5mm in diameter and7 to20mm
long , sometimes with external threads. Endosteal implants are also
catergorized as one-stage or two-stage.

Plate implants (blades)

Blades were the first dental implant to enjoy reasonable success in a
large number of patients. All the original studies on blades used one-stage
systems, but the success rates were well below those of current root-form
implants. It has been suggested4 that many of the problems of blade
implants can be traced to the high temperature at which the bone sites were
prepared and the routine immediate loading of this type of implant. Both
these practices have been linked to the fibrous encapsulation that occurred
with many of the original blade implants. Consequently , submergible
titanium blades are now available, and more recent blade studies5 have
reported success rates above 80% for 5 years. However, the drawbacks to
blade implants remain-difficulty of preparing precision slots for blade
placement compared to placing holes accurately for root-form implants, and
the disastrously large circumferential areas of the jaw that can be affected
when a blade fails.

Root- form implants (cylinders)

Two stage surgical procedures with cylindrical root-form dental
implants are considered to represent state-of –the –art implant dentistry. The
advantages include adaptability to multiple intraoral locations, uniformly
precise implant-site preparation, and a cost of failure similar to that
experienced with a tooth is lost. Most cylinders are made of titanium alloy
with or without hydroxyapatitie coating materials that are perceived to have
the highest biofunctionality . Both threaded and nonthreaded designs are
available and are quite popular.

Treatment Planning For The Implant Patient

A combined surgical and restorative treatment plan must be devised
for prospective implant patients. Feasible nonimplant alternatives should be
presented so an informed decision can be made as to whether to proceed.
Patients need to be evaluated preoperatively and assessed as to their ability
to tolerate the procedure. The predictable risks and expected benefits should
be weighed for each person. Although the placement of dental implants does
entail some risks, these are relatively minor. Absolute contraindications,
based on immediate surgical and anesthetic risks, are limited to persons who
are acutely ill, persons with uncontrolled metabolic disease, and pregnant
women-contraindications that apply to virtually all elective surgical
procedures.
Local and systemic contraindications that thrreate long-term retention
of the implants must also be evaltated. Implants may be contraindicated in
patients wit abnormal bone metabolism, poor oral hygiene, and previous
radiation to the implant site. Most patients wh present for implant placement
became edentulous(partially edentulous from caries and periodontal disease
resulting from poor oral hygiene. Suspicion that inadequate hygiene is likely
to continue is a relative contraindication to implant placement. Patients must
be motivated and educated in oral hygiene techniques as part their
preparation for implants. Some patients may no from paralysis of the arms,
debilitating arthritis, cerebratrainidiacted in these patients unless adequate on
hygiene will be provided by care- givers. A summary contraindications to
implant placement is present.

Anterior maxilla. The anterior maxilla must be evaluated for proximity to

the nasal cavity. A minimum of 1.0 mm bones should remain between the
apex of the implant and the nasal vestibule. Due to resorption of the anterior
maxilla, the incisive foramen may be located near the residual ridge,
especially in patients who edentulous maxilla has been allowed to function
against a natural mandibular anterior dentition. Anterior maxillary implants
should be located slightly off midline, on either side of the incisive foramen.

Posterior maxilla. Implant placement in the posterior maxilla poses two

specific concerns:
First, the bone of the posterior maxilla is less dense than that of the
posterior mandible. It has larger marrow spaces and thinner cortex, and this
can affect treatment planning since increased time must be allowed for
integration of the implants and additional implants may be needed.
Generally a minimum of 6 months is needed for adequate integration of
implants placed in the maxilla. Additionally, one implant for every tooth that
is being replaced is normally recommended, especially in the posterior
maxilla.
 SUMMARY AND CONCLUSION
Although restoration of endodontically treated teeth has been rationalized,
information from controlled long term clinical trials is still needed.
As much tooth structure must be preserved as possible and post and core
is basically used to provide retention and support for a cast restoration.
There is not one post , core or final restoration that can be used in all –
clinical situations. So we have to learn with these variables and understand
the basic concepts of how to use them to maximum advantage.
 REVIEW OF LITERATURE

King PA, Setchell DJ, Rees JS.(2003) suggested that post-retained crowns
utilizing a CFRC material and a composite resin luting agent do not perform
as well as conventional wrought precious alloy posts.

Chandler NP, Qualtrough AJ, Purton DG. (1992) did a study to compare
the application of ultrasound with the use of an engine-driven trephine bur to
remove parallel-sided root canal posts and concluded that resin composite
cement could be removed from around the posts with the trephine bur but
with considerable difficulty.

Goss JM, Wright WJ Jr, Bowles WF 3rd.(2003) Eight luting materials

were compared to determine which of them obscured the radiographic image
of a cemented titanium alloy prefabricated post and concluded that glass
ionomer cements obscured the outline more than composite resin cements
but less than zinc phosphate or polycarboxylate cements.

Hedlund SO, Johansson NG, Sjogren G.(2002) : When zirconium oxide

ceramic posts are luted with resin composites the bonding between the
ceramic and resin composite seems to be weak.

Gallo JR 3rd, Miller T, Xu X, Burgess JO. This study compared the

tensile retentive strength of composite fiber-reinforced dowels luted with a
resin cement to stainless steel dowels luted with zinc phosphate cement and
concluded that under the conditions of this study, the stainless steel dowel
luted with zinc phosphate cement provided significantly greater retention.
Akkayan B, Gulmez T.(2001) concluded that higher failure loads were
recorded for root canal treated teeth restored with quartz fiber posts.
Fractures that would allow repeated repair were observed in teeth restored
with quartz fiber and glass fiber posts.

Theresa m. Hofstede( 2002) suggested an indirect technique for the

fabrication of post and core wax pattern.

Joe M. Goss et al (1985) concluded that titanium alloy prefabricated post

and gutta percha have similar radiopacity and that certain cements obscure
the radiographic image of titanium alloy prefabricated posts. They also
demonstrated that the radiopacity of cements is dependant on their thickness
and density. Since minimal space for cement remains in an adequately
prepared channel for a prefabricated post, luting agents advertised as radio-
opaque might not perform as expected because the radio-opacity is due
primarily to the post.

John A.Sorenson (1985) concluded that abutments for FPD and RPD that
were endodontically treated had significantly higher failure rates than single
crowns. Coronal – radicular stabilization had a variable effect on abutment
teeth. Dowel placement was associated with a significantly decreased
success rate in single crowns, and a significantly higher success rate in RPD
abutment teeth.

Allan S. Deutsh et al(1985) concluded that the conical threaded post

fractured roots more often and at lower torque than parallel posts.
R.M. Pillar et al (1989) concluded that threaded endodontic posts resulted
in the greater shear strength at the cement interface when axial forces were
applied to the post.