RESD 515 Lecture 11 Restoration of Endodontically Treated Teeth

RESTORATION OF ENDODONTICALLY TREATED TEETH
RESD 515
Lecture 11
Dr. Swapna Munaga
1
Lecture Learning Outcomes
Know how to restore endodontically treated teeth.

Know different type of restoration.
Know the indication and contraindication for each type.
Know the advantages and disadvantages for each type.
RESD 515 LECTURE 11 – RESTORATION OF ENDODONTICALLY TREATED TEETH

Vulnerable to tooth loss
Endodontically treated teeth are more vulnerable to tooth loss than teeth with vital pulps due to the
following risk factors:
Post-treatment disease following root canal treatment.
Loss of substantial tooth structure through caries, previous restorative treatment and
endodontic procedures
Weakening of tooth structure through use of endodontic chemicals (calcium hydroxide, sodium
hypochlorite, EDTA, chlorhexidine, alcohol.)

Vulnerable to tooth loss
Dehydration of dentine and transformation of collagen fibre structure (Age factor, loss of
unbound water from the root canal space and the dentinal tubules in pulpless teeth.)
Reduction in the level of proprioception, which can lead to uncontrolled occlusal forces.

Tooth structural loss
Primary Secondary
Effect of chemical & Intra Effect of ageing of dental

canal medicaments H/o recurrent pathology
tissues
Effect of restorations & Anatomical position of

procedures tooth
( Anil Kishen,Et al,2006)

Restoration of endodontically treated tooth
Restorations of endodontically treated teeth are designed to:-
(1) Protect the remaining tooth from fracture.

(2) Prevent reinfection of the root canal system.
(3) Replace the missing tooth structure.

Factors in selecting restorative approach

Amount of tooth structure loss:

Amount of tooth structure loss: Minimal loss of tooth structure
Marginal , incisal & crossing ridges are intact with conservative access cavity
preparation signifies Minimal loss of tooth structure.
• GP should be cleared off the access cavity with hot instruments or GG drills.
• All traces of sealer must be removed to prevent discoloration of the crown
• Posterior teeth can be restored with amalgam , modified GIC or composite resin
• The core must extend 1 mm into the canal orifices.

Amount of tooth structure loss: Moderate loss of tooth structure
Anterior teeth
Loss of one marginal ridge and or incisal margin (signifies moderate loss of tooth
structure).
Management options are :
• simple core restoration or
• post and core

Amount of tooth structure loss: Moderate loss of tooth structure
Posterior teeth
loss of one or both marginal ridges additional to tooth lost in access preparation
(signifies moderate loss of tooth structure).
• Amalgam or composite cores extending 1-2 mm into the canals,
• post and core with compulsory cuspal coverage.

Amount of tooth structure loss: Extensive loss of tooth structure
Little or no coronal tooth structure is remaining signifies extensive loss of tooth

structure.
• Crown lengthening, forced eruption followed by cast post,core & crown with a
ferrule.
• Crown lengthening, forced eruption followed by pre-fabricated post,core and

crown.

Ferrule effect
One of the most important factors influencing the

success of a restoration is the amount of remaining
supragingival tooth structure.
The ferrule effect, described as a band that encircles

the perimeter of the residual tooth, has a crucial influence
on fracture resistance, especially in decoronated teeth

Ferrule effect
No Ferrule
Ferrule of adequate height

Ferrule effect
A properly executed ferrule reduces the incidence of fractures in

root filled teeth by reinforcing the external surface of the tooth and
dissipating the forces that concentrate at the narrowest
circumference of the tooth.
Increasing the ferrule height, enhances tooth resistance.
For a more predictable restoration, properly executed ferrule must

be 2 mm high, especially on the palatal and buccal.
RESD 515 LECTURE 11 – POST ENDODONTIC RESTORATIONS

Adequate Less/no
ferrule height ferrule height
Metal core
Resin core
Ceramic
core
no ferrule

Classification of endodontically treated teeth- by Cohen
According to Cohen, choice of post endodontics restoration depends upon the amount
of the remaining coronal tooth structure.
Teeth with minimal tooth loss – coronal restorations
Teeth more than 50% of remaining coronal structure - restored with crowns
Teeth with 25 to 50 % of remaining tooth structure – restored with non – rigid posts
followed by crown
Teeth with less than 25% of remaining tooth structure - to be restored with rigid
posts followed by crown
Diagnosis and treatment plan

Diagnosis and treatment- Endodontic considerations
Good apical seal

No sensitivity
No exudate
No fistula
No apical sensitivity
No active inflammation
Retreatment should occur if there are signs or symptoms indicating failure

Diagnosis and treatment- Periodontal considerations
Extent of underlying periodontal disease
Adequate biologic width
In cases with extensive coronal destruction crown lengthening can be considered.
Presence of enough coronal tooth structure to incorporate ferrule into cast restoration
RESD 515 LECTURE 11 RESTORATION OF ENDODONTICALLY TREATED TEETH

Diagnosis and treatment- Prosthetic considerations
Extent of coronal destruction
Tooth type (Anterior vs. Posterior)
Position in arch, Morphology, Circumference of tooth, Occlusal and prosthetic forces
applied to tooth, Periodontal support

Diagnosis and treatment- Esthetic consideration
Metal or dark carbon fiber placed in the canal can result in unacceptable gingival
discoloration from the underlying root.
Endodontic and restorative materials in these esthetically critical cases must be selected
with care so as to provide the best health service with the minimum of esthetic
compromise.

COMPONENTS OF FINAL RESTORATION
POST
CORE
CROWNS
COMPONENTS OF POST ENDODONTICS RESTORATION
Core
Post
Down pack/
remaining GP/
apical plug

“A post is a restorative dental material placed in the
root of a structurally damaged tooth in which
additional retention is needed for the core and
coronal restoration”
POSTS

Requirement of a tooth to accept a post and core
Optimal apical seal

Absence of fistula or exudate
Absence of active inflammation
No sensitivity to percussion
Absence of associated periodontal disease
Sufficient bone support around the root
Sound tooth structure coronal to alveolar crest
Absence of any fracture of root

Contraindications of placing post
Presence of sign of endodontics failure like poor apical seal, active inflammation,
presence of fistula or sinus tract
tenderness on percussion
If adequate retention of core can be achieved by natural undercut
If there is horizontal crack in the coronal portion of the teeth
When tooth is subjected to exessive occlusal stress like lateral stress of bruxism or
heavy incisal guidance.

Classification of posts
According to type of alloy.
1. Gold alloy
2. Chrome-Cobalt alloy
3. Nickel-Chromium alloy

Classification of posts
According to the method of fabrication
Post
Custom made Pre-fabricated
Metal
Metal
Carbon
FRC
Ceramic
Ceramic
I. According to Taper
• Tapered
• Parallel
• Parallel Tapered
II. According to surface character

• Smooth
• Serrated
• Self threading
III. According to fit

• Passive (retention with luting)
• Active (threaded)
IV. According to material
1. Metallic
• Titanium
• Stainless steel
• Brass
2. Non-Metallic
i) Non-Esthetic
Carbon fibre post
Carbon fibre post
ii) Esthetic Post
• Polyethelene fibre
• Glass fibre
• Quartz Ceramic post
• Ceramic
glass fibre post
V. According to light transmission
• Light transmitting – eg: light transmitting glass fibre posts, Luminex
• Non-Light transmitting

Advantages
VI. According to Monoblock formation (Meaning a single unit)

Monobloc formation – eg: fiber reinforced composite (FRC) posts
No Monobloc formation- eg: metal post
Singh SV, Chandra A, Pandit IK. A new classification of post and core. Ind J Rest Dent 2015;4(3):56-58
Monobloc
DESIGN FEATURES OF POST & CORE RESTORATIONS
1.Post length
2.Post diameter/width
3.Post shape
4.Surface texture
5.Post material
6.Core retention

Post length
Greater the post length, better the retention an stress distribution

Recommendations
3-5 mm of GP in the apical region to maintain apical seal.
Equal to crown length
Longer than crown length
At least 2/3rds root length
At least ½ the length of the root in bone (from crestal bone
to root apex)
As long as possible without disturbing apical seal

Post width
3 theories
THE CONSERVATIONIST THE PRESERVATIONIST THE PROPORTIONIST
suggests the narrowest It advocates that at This advocates that post

diameter that allows the least 1 mm of sound width should not
fabrication of a post to dentin should be exceed one third of the
the desired length. maintained root width at its
teeth with narrower post circumferentially to resist narrowest dimensions to
exhibit greater the fracture resist fracture
resistance to fracture
Post width
Recommendations
0.6mm –mandibular incisors
1mm- maxillary central incisors, maxillary and mandibular canines, palatal root of
maxillary first molar
0.8mm –other teeth
An increase in post width has no significant effect on its retention.
Post length is a significant factor in retention than post diameter.

Surface texture
Posts can be serrated, smooth, roughened or threaded. Order of retention:
threaded> serrated>smooth
Cast posts are smooth

Surface texture
Serrated posts have negative recesses in them and give more retention than
smooth posts
The parallel sided, serrated posts were found to exert the least amount of stress
They produce less stress in the root dentine than threaded systems.
Threaded posts actively engage dentin and produce more stresses.

Post shape
tapered post- wedging effect, stress concentration at the coronal portion of

the root, and lower retentive strength
parallel post- increase retention and produce uniform stress distribution

along the post length. stress concentration at the apex of the post in a narrow
and tapering root end can occur
Parallel tapered post- the post is parallel throughout its length except for the
most apical portion, where it is tapered. It permits preservation of the dentin
at the apex and also achieves sufficient retention because of parallel design
Post material
The ideal post material should match dentin in its physical

properties.
Elastic modulus of cast posts is much higher than dentin.

When stressed, cast post does not flex with dentin, predisposing to
root fracture
FRC or glass fiber post has least tendency to predispose root

fracture as their elastic modulus is near to dentin.

Core retention
Cast Post and Core is fabricated as a single unit–excellent core

retention
Prefabricated Post and Core of GIC/composite resin – the

junction is a weak point

CORES
“The core replaces carious, fractured, or missing

coronal structure and helps to retain the final
restoration”

Ideal requisites of a core material
High compressive strength Short setting time.
High tensile strength. An ability to bond to both tooth and dowel.
High modulus of elasticity (rigidity). Biocompatible
High fracture toughness Natural tooth color, when indicated.
Dimensional stability Low plastic deformation.
Ease of manipulation Low cost

CLASSIFICATION OF CORE MATERIALS
core for custom Core for prefabricated

made post
post
(Cast core)
Metal Amalgam
Ceramic Composite
Glass ionomer
Resin modified glass

ionomer
CORES- CAST CORE
Type III / IV Gold alloys, base metal alloys, silver palladium alloys are used for making cores.
Advantages
• High strength
• Avoids dislodgement of core
Disadvantages
• More root fracture
• Casting inaccuracies
• Time consuming
• Expensive
CORES- AMALGAM CORE
Dental amalgam is a traditional core buildup material with a long history of clinical success
Advantages:
• High compressive strength
• High modulus of elasticity
• Easy manipulation and placement
• Stable to thermal and functional stresses
Disadvantages:
• Unesthetic
• mercury toxicity
• Tendency to discolor adjacent gingiva
• Tendency to corrode
• Low early strength –preparations cannot be done immediately

CORES- COMPOSITE RESIN CORE
Composite core materials take a number of strategies to enhance their strength and resistance.
Metal may be added, filler levels may be increased, or faster setting ionomers may be added.
Advantages:
Disadvantages:
• Esthetic
• Microleakage due to polymerization shrinkage
• Bondable
• Tendency to deform plastically
• Adequate strength
• needs strict Isolation
• Command set

CORES- GIC CORE
The rationale for using glass ionomer materials is based on their cariostatic effect resulting
from fluoride release
Advantages:
• Anti cariogenic
• Chemically adhesive to the tooth
• used for small buildups/ to level undercuts
Disadvantages:
• Low fracture resistance
• Low early strength
• Low retention to prefabricated posts

Definitive Restorations

DEFINITIVE RESTORATIONS - Crowns
Anterior teeth are loaded non-axially. The options for anterior teeth are direct composite
restorations or replacement crowns with or without a post.
Premolars & molars- are often loaded axially. So cuspal coverage should be
considered where marginal ridges are compromised. onlays/overlays in gold, indirect
composite or porcelain, or full coverage crowns in metal, metal ceramic or all ceramic
are indicated.
When crowns are considered, the need for a ferrule is mandatory for a more
predictable restoration
Types of crowns:
• ceramic
• metal ceramic
• cast metal crown with acrylic or composite facing
• Fibre-reinforced composite crowns
• Endocrowns
DEFINITIVE RESTORATIONS - endocrowns
Endo crown is a one piece ceramic crown with apical projection that fills the pulp
chamber space, and possibly the root canal entrances.
It gains its retention and stability from anchoring to the internal part of the pulp chamber
and on the cavity margins which provides a macro-mechanical retention
the micro-mechicanal retention is achieved by the concept of acid etching and usage of
adhesive cementation.
Can be made from acid etchable ceramic or indirect resins.

Indications :
Excessive loss of coronal dental tissue and limited inter-occlusal
space
Succesfully root treated molar.
Short clinical crown molars
Contraindications :
Para Functional habits
Depth of pulp chamber less than 3mm
If adhesion can’t be assured
Cervical Margin less than 2 mm wide

Advantages :
take advantage of the pulp chamber to promote mechanical retention , stability
and also to increase the available adhesive surface.
Preserves sound coronal and radicular tooth structures
Avoids additional intra radicular preparation for post retention-
Allows supra gingival margins and preserves health of periodontium.
Disadvantages :
Risk of debonding
Still under research to be usedin centrals and premolars

Fiber reinforced composite post restoration

Removal of GP
Gates glidden drills are most commonly employed for removal of guttapercha.
Use of GP solvent is highly discouraged

Post Space Preparation
4 mm
Peso reamers are used for creating post space preparation.

Most of the companies give a corresponding drill with the fiber posts

Conditioning of the Post
Space
Etch canal and
coronal dentin Rinse all residue Dry canal with
Try in the post with phosphoric acid of etching gel paper points
15s

Space
Apply dual cure Remove excess
bonding agent or self With paper points
etch resin cement
10s

Place the post and fully

Mix dual cure or self etch Coat the cement on FRC seat it
resin cement Post Remove excess

Direct Core Build-up
Build up core with

Light cure for direct composite in Prepare tooth
60 sec increments for crown
60s 40s

CAST POST
Fabrication of wax/resin post investing wax/resin post Casting procedure
Indirect method Direct method

CAST POST
Indications
• Moderate to severe loss of tooth structure
• Best for single rooted teeth
• Proclined teeth - Need to change the angulation of the core with
respect to the post
• Tapered canals
• Multiple post and cores in the same arch
Contraindications
• Minimal tooth loss
• Short roots, thin roots
• Flared canals
• Esthetics is a major concern

CAST POST
Advantages
• High strength
• Minimal alteration of canal anatomy
• Fits to canal shape as it is customised
• Core is an integral part of the post
• Change in core angulation possible
Disadvantages
• Multiple visits, additional cost involved
• Unesthetic appearance
• Temporization is difficult
• Difficult to retreive
• Rigidity of a cast post can predispose to root fracture
• Tapered shape creates wedging effect

CAST POST
Indirect method
Fabrication of cast post
Direct method
Indirect method
• An impression of the post space and adjacent teeth and gingiva needs to
be taken.
• Impression material is injected into the post space and a rigid object (wire,
tooth pick, paper clips, plastic sprues) is inserted in the canal before the
initial set of impression material.
• The impression is then used to construct a suitable post in the dental

laboratory.
• The indirect method conserves chair time by delegating the pattern for the
post and core to a dental laboratory. RESD 515 LECTURE 11 – RESTORATION OF ENDODONTICALLY TREATED TEETH
CAST POST
Direct method
direct fabrication of the pattern can be done using any of the below:
wax with a plastic rod as a carrier
acrylic resin with a solid plastic sprue
acrylic resin with an endodontic file coated with wax that adapted to the prepared
canal

Reference
Pathways of pulp by Stephen Cohen; 11 th edition
fundamentals of operative dentistry: a contemporary approach

james b. summitt. 4th edition

RESD 515 Lecture 11 Restoration of Endodontically Treated Teeth - Dr. Munuga

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RESTORATION OF ENDODONTICALLY TREATED TEETH

Dr. Swapna Munaga

Know how to restore endodontically treated teeth.

RESD 515 LECTURE 11 – RESTORATION OF ENDODONTICALLY TREATED TEETH

Post-treatment disease following root canal treatment.

RESD 515 LECTURE 11 – RESTORATION OF ENDODONTICALLY TREATED TEETH

RESD 515 LECTURE 11 – RESTORATION OF ENDODONTICALLY TREATED TEETH

Effect of chemical & Intra Effect of ageing of dental

Effect of restorations & Anatomical position of

( Anil Kishen,Et al,2006)

Restorations of endodontically treated teeth are designed to:-

(1) Protect the remaining tooth from fracture.

RESD 515 LECTURE 11 – RESTORATION OF ENDODONTICALLY TREATED TEETH

RESD 515 LECTURE 11 – RESTORATION OF ENDODONTICALLY TREATED TEETH

RESD 515 LECTURE 11 – RESTORATION OF ENDODONTICALLY TREATED TEETH

• All traces of sealer must be removed to prevent discoloration of the crown

• The core must extend 1 mm into the canal orifices.

RESD 515 LECTURE 11 – RESTORATION OF ENDODONTICALLY TREATED TEETH

Management options are :

• simple core restoration or

• post and core

RESD 515 LECTURE 11 – RESTORATION OF ENDODONTICALLY TREATED TEETH

(signifies moderate loss of tooth structure).

Management options are :

• Amalgam or composite cores extending 1-2 mm into the canals,

• post and core with compulsory cuspal coverage.

RESD 515 LECTURE 11 – RESTORATION OF ENDODONTICALLY TREATED TEETH

Little or no coronal tooth structure is remaining signifies extensive loss of tooth

Management options are :

• Crown lengthening, forced eruption followed by pre-fabricated post,core and

RESD 515 LECTURE 11 – RESTORATION OF ENDODONTICALLY TREATED TEETH

One of the most important factors influencing the

The ferrule effect, described as a band that encircles

RESD 515 LECTURE 11 – RESTORATION OF ENDODONTICALLY TREATED TEETH

Ferrule of adequate height

RESD 515 LECTURE 11 – RESTORATION OF ENDODONTICALLY TREATED TEETH

A properly executed ferrule reduces the incidence of fractures in

Increasing the ferrule height, enhances tooth resistance.

For a more predictable restoration, properly executed ferrule must

RESD 515 LECTURE 11 – POST ENDODONTIC RESTORATIONS

RESD 515 LECTURE 11 – RESTORATION OF ENDODONTICALLY TREATED TEETH

of the remaining coronal tooth structure.

Teeth with minimal tooth loss – coronal restorations

RESD 515 LECTURE 11 – RESTORATION OF ENDODONTICALLY TREATED TEETH

Good apical seal

RESD 515 LECTURE 11 – RESTORATION OF ENDODONTICALLY TREATED TEETH

Extent of underlying periodontal disease

Adequate biologic width

In cases with extensive coronal destruction crown lengthening can be considered.

Extent of coronal destruction

Tooth type (Anterior vs. Posterior)

Position in arch, Morphology, Circumference of tooth, Occlusal and prosthetic forces

applied to tooth, Periodontal support

RESD 515 LECTURE 11 – RESTORATION OF ENDODONTICALLY TREATED TEETH

RESD 515 LECTURE 11 RESTORATION OF ENDODONTICALLY TREATED TEETH

RESD 515 LECTURE 11 – POST ENDODONTIC RESTORATIONS

RESD 515 LECTURE 11 – RESTORATION OF ENDODONTICALLY TREATED TEETH

Optimal apical seal

RESD 515 LECTURE 11 – RESTORATION OF ENDODONTICALLY TREATED TEETH

RESD 515 LECTURE 11 – RESTORATION OF ENDODONTICALLY TREATED TEETH

According to type of alloy.

RESD 515 LECTURE 11 – RESTORATION OF ENDODONTICALLY TREATED TEETH

Custom made Pre-fabricated