POST ENDODONTIC RESTORATION

Dr. Sayak Gupta

 HISTORY
 INTRODUCTION
 STATUS OF ROOT FILLED TEETH
 VULNERABLE TO TOOTH LOSS
 SPECIFIC TISSUE MODIFICATIONS AND CLINICAL
IMPLICATIONS
 FACTORS IN SELECTING RESTORATVE
APPROACH
 RESIDUAL ROOT STRUCTURE
 FUNCTION AND TOOTH POSITION IN ARCH
 CLASSIFICATIONS
 RESTORATIVE MATERIALS
 DIRECT COMPOSITE
 INDIRECT RESTORATIONS
 ENDOCROWNS
 FULL CROWNS
 WHY TOOTH FRACTURE
 POST AND CORE
 FIBER POST
 CAST POST
 CORE MATERIALS
 COMPOSITE
 AMALGAM
 GIC
 INTERIM PESTORATIONS
 TEMPORARY
RESTORATIONS
 DEFINITIVE RESTORATIONS
 ENDODONTICS VS IMPLANTS
 RESTORATIVE ASPECTS
 CONCLUSION
 Various methods of restoring pulpless teeth have been reported for more
than 200 years. In 1747, Pierre Fauchard described the process by which
roots of maxillary anterior teeth were used for the restoration of single teeth
and the replacement of multiple teeth

 Posts were fabricated of gold or silver and held in the root canal space with
a
heat-softened adhesive called ‘‘mastic.’’

 The replacement crowns were made from bone, ivory, animal teeth, and sound
natural tooth crowns. Gradually the use of these natural substances declined,
to be slowly replaced by porcelain

 A pivot (what is today termed a post) was used to retain the artificial
porcelain crown into a root canal and the crown–post combination was
termed a ‘‘pivot crown.’’
 Early pivot crowns in the United States used seasoned wood (white hickory)
pivots. The pivot was adapted to the inside of an all-ceramic crown and also
into the root canal space. Moisture would swell the wood and retain the
pivot in place.

 Subsequently, pivot crowns were fabricated using wood/metal combinations

and then more durable all-metal pivots were used. Metal pivot retention
was achieved by various means such as threads, pins, surface roughening,
and split designs that provided mechanical spring retention
 Today, both endodontic and prosthodontic aspects of treatment have
advanced significantly, new materials and techniques have been developed,
and a substantial body of scientific knowledge is available upon which to
base clinical treatment decisions.
 Root-filled teeth are generally weakened by caries and subsequent
restorative procedures. Loss of dental tissue, due to either caries or
cavity preparation, reduces tooth stiffness and fracture strength of the
remaining tooth structure in proportion to the increase in cavity width
and depth.

 Marginal ridges are strategic for tooth strength, and their loss
considerably reduces tooth stiffness, while endodontic access appears to
exert only a modest influence on tooth strength.

 Excessive coronal flaring during root canal therapy further weakens

the tooth and predisposes the tooth to subcrestal Fractures.
 The restoration must be planned carefully to ensure that weakened cusps
are adequately protected, but at the same time the tooth is not further
weakened by excessive restorative procedures.
 Root filled teeth are structurally and aesthetically compromised .The
loss of tissue at root and crown levels leads to significant biomechanical
changes resulting in a high incidence of fractures .

 Evidence suggests that fracture of root filled teeth and, in consequence, the
risk of tooth loss are considerably higher than that of teeth with vital
pulps.

 Loss of internal tooth structure leads to increased cusp deflection during

occlusal function. Deflection is more pronounced in root filled premolars
with mesial, occlusal and distal (MOD) cavities, and by doubling the
depth of the MOD cavity, the cuspal deflection has been reported to
increase.

 The discoloration of tooth can also result because of incomplete cleaning

and shaping of the root canal system, the accumulation of sealer, debris
or filling materials left in the chamber.
 Root filled 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.

 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.
 Additionally, other individual factors, such as gender, occlusion,
parafunctions, the material of the antagonist occlusal surface (e.g. implant
supported crown), oral hygiene or saliva flow, can influence the prognosis
of restored teeth
 Residual crown structure

 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.

 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, particularly on the palatal side, enhances
tooth resistance .As little as 1 mm of coronal dentine above the gingival
margin during crown preparation will double the fracture resistance of
preparations in which the core terminates on a flat surface directly
above the margin

 However, for a more predictable restoration, a properly executed ferrule

must be 1.5–2 mm high, especially on the palatal and buccal

 If destruction of the tooth structure renders a sufficient ferrule

unachievable, crown lengthening or orthodontic extrusion should
be performed
 In addition to the amount of remaining coronal tooth structure, the
amount of residual root is also significant.

 A 1 : 1 ratio has been recommended as the minimally acceptable

necessary for resisting lateral forces when the periodontium is healthy
and the occlusion is controlled.

 Long-term maintenance of a tooth with an unfavourable crown-to-root

ratio, due to the presence of reduced alveolar bone support, might lead
to increased mobility and possible periodontal issues
 Occlusal load is key to treatment planning for root filled teeth. It is
important for the clinician to understand whether the patient has acceptable
function or can be classified as belonging to one of three groups of
abnormal occlusal attrition: constricted path of closure, occlusal
dysfunction or parafunction.

 In the case of excessive occlusal wear, more destructive loadings are expected,
which can predispose compromised root filled teeth to fracture or other types
of failure such as post fracture ,debonding or composite core fracture.

 Occlusal forces on one tooth have been reported to be up to 10 times greater

than the maximum biting forces distributed in a balanced occlusion.Research
has demonstrated that due to progressive cuspal displacement, both time- and
load dependent, continuous loading as a result of clenching is more
destructive than chewing.
 Understanding occlusal problems and planning an appropriate
reinforcement of the tooth to be treated may help to reduce future
failure risk
 In order to decrease the magnitude of stresses, it is important to maintain occlusal
points of contact with opposing teeth rather than wider areas of occlusal contacts

 In posterior teeth, fibre posts should be used only for adhesive purposes .

 A fibre post should be inserted only in the presence of limited coronal dentine with
the aim of increasing the amount of bonded dentine .In such cases, the fibre post
is luted to increase the adhesive surface area.

 When full crowns are planned, root filled molars and premolars with limited tissue
loss can be restored without posts.

 Posts could be helpful in those teeth, particularly in premolars, if cusp protection

is not provided. In the case of a premolar with severe periodontal loss, a large
diameter post seems essential .Severe periodontal bone loss increases the length of
the tooth above the bone which significantly increases the risk of tooth fracture.


 For anterior teeth, the situation is entirely different. Whilst posterior
teeth have to support compressive loads, where elasticity is the most
important characteristic ,maxillary anterior teeth have to support
flexural stresses, where rigidity is the most important characteristic.

 In anterior teeth, fibre posts are often luted for functional rather than
adhesive reasons in order to increase rigidity
 Improved physical properties of composite resins and the introduction of adhesive
systems offer increased potential for the restoration of root filled teeth

 Mechanical interlocking of resin with peritubular/intertubular dentine and

hybrid layer formation is important for the performance of composite resin
restorations.

 Adhesive restorations promote sufficient retention and create an adhesive bridge

between the buccal and lingual cusps of the tooth. Composite resins may have the
potential to decrease deflection and fracture of cusps under occlusal load .

 In cases with sufficient remaining tooth structure, especially if intact enamel is

present, the use of indirect adhesive restorations without posts provides
alternatives to conventional treatment concepts
 Immediate dentine bond strength values do not always correlate with long-
term bond stability as degradation throughout the dentine-bonded
interface occurs in months

 Alternatives to cast posts and cores have been developed as fibre posts
have an elasticity modulus (E) closer to that of dentine (post = 20 GPa,
dentine = 18 GPa) when compared with prefabricated and cast metal
posts (E = 200 GPa) and ceramic posts (E = 150 GPa) allowing the
absorption and uniform distribution of stresses to the remaining root
structure instead of concentrating them .

 Although prefabricated metal posts have an elastic modulus greater

than that of dentine, their behaviour in the root canal is similar to fibre
posts contrary to cast posts, which concentrate the stress apically.
 The use of prefabricated posts and custom-made cores with composite
simplifies the restorative procedure, because all steps can be
completed chairside, and clinical success can be expected

 Dual-cure materials provide the most reliable option for achieving

good cement polymerization along the post length .Although it is able
to polymerize even in the complete absence of light, dual-curing resins
develop better mechanical properties when light irradiated
 Class I: 4 remaining cavity walls (access cavity)
 If all the axial walls of the cavity remain and have a thickness greater than
1 mm, it is not necessary to insert posts ,provided the tooth is not
subjected to undue occlusal forces

 Classes II and III: 2 or 3 remaining cavity walls

 Treatment in cases involving the loss of 1 or 2 cavity walls does not
necessarily require the insertion of a post, a core followed by a crown
is indicated

 Class IV: 1 remaining cavity wall

 In cases where only 1 cavity wall remains, the core material has little or
no effect on the fracture resistance.Thus post is indicated
 Class V: No remaining cavity wall
 In cases of teeth with a high degree of destruction where no cavity
wall remains, the insertion of posts appears necessary to provide for
core material retention
 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

 Teeth with less than 25% of remaining tooth structure - to be restored with
rigid posts
 Class 0 (no post – composite core build-up)

 It is possible to take advantage of the anatomy of the pulp chamber, particularly in

posterior teeth, to increase adhesive surface area and thus mechanical retention .

 Unless the destruction of coronal tooth structure is extensive, the pulp chamber and
canals provide adequate retention for a core build-up .Given these anatomical
features, root filled molars and some anterior teeth may not require posts.

 However, occlusal relationships should be carefully evaluated in anterior teeth. The

possibility of restoring anterior and posterior teeth without the use of a post is an
advantage because more tooth substance is preserved and the clinical procedure is
easier to achieve

 .According to Magne et al. (2017), fibre posts are always detrimental to the failure
mode, and should be avoided in incisors when a ferrule is present.
(a) Temporary restoration in tooth 26 prior to root canal treatment. (b) Tooth 26 following removal of the temporary
restoration. (c) Direct reconstruction of tooth 26 without using a post. (d) Final restoration of tooth 26. (e) Final
periapical radiograph of tooth 26.
Preoperative image of anterior teeth. (b) Tooth 11 and 21. Class 0: >50% of coronal structure remaining without
the necessity of fibre post placement. (c) Rubber dam isolation on teeth 11 and 21. (d) Direct restorations on teeth
11 and 21 (e) Final radiographs of teeth 11 and 21.
 Post placement is recommended in anterior teeth and premolars with
compromised tooth structure (<50% structure; Meyenberg 2013, Guldener et al.
2017).

 Structurally compromised teeth have less than 50% of remaining

coronal structure. The placement of a post is indicated when two or fewer
walls are present in anterior teeth and premolars .

 Premolars, unlike molars, often have less tooth substance and smaller pulp
chambers to retain a core build-up after root canal treatment .Premolars are also
more likely to be subjected to lateral forces during mastication .

 It has been well documented that the fracture resistance of a tooth depends on the
angle of the applied load, with oblique forces being more detrimental .In
retrospective clinical reports ,premolars were found to be the most frequently
fractured teeth. For these reasons, they may require posts more often than molars.
 Fibre post placement significantly reduced failure risk for root
filled premolars.

 In particular, fibre posts appeared to play a protective role against

root fracture .

 In the case of molars, there is no need for a post, except in cases of

totally
missing coronal tooth tissue and insufficient pulp chamber surface .

 Anterior maxillary teeth have to support flexural stresses, and fibre posts
are often luted for functional reasons to increase biomechanical
properties. Additionally, applying fibre posts with highly fluorescent
characteristics is purported to improve the final aesthetic outcome of the
restoration.
 Post placement cannot compensate for total or partial ferrule loss.

 A fibre post might be placed only after orthodontic or surgical crown

lengthening. This decision should be based on the position of the tooth in the
arch: for molars, surgical crown lengthening, and for premolars and anteriors,
orthodontic extrusion is reported to be preferable.

 In general, crown lengthening involves a number of significant

disadvantages.
From the patient’s perspective, these include treatment delay (especially for
wound healing or orthodontic extrusion), discomfort and the considerable
added cost to an already expensive sequence of procedures.

 Initiation of final prosthetic treatment should wait at least 3 months and

possibly up to 6 months for aesthetically important areas, as the free gingival
margin requires a minimum of 3 months to establish its final vertical position
 In the anterior zone, surgical crown lengthening of a single tooth has a
negative aesthetic impact, particularly in medium and high smiles, making
forced tooth eruption via orthodontic extrusion the technique of choice
when clinical crown lengthening is needed in isolated teeth in the anterior
zone.

 Biomechanically, the disadvantages include an increased crown-to-root ratio,

especially in surgical crown lengthening, and loss of tooth structure
resulting from apical relocation of the preparation finish line

 Surgical crown lengthening inevitably increases the tooth length above the
bone level, and the more height of tooth structure above the bone level the
greater is the risk of failure of root filled teeth. Orthodontic extrusion is a
predictable procedure and combined with a fiberotomy and gingival
recontouring allows an optimal relation between the gingiva and the
margin of the restoration to be created
(a) Tooth 11 Class 2: <50% of structure remaining without ferrule effect. (b) Rapid orthodontic extrusion on tooth
11 with fiberotomy. (c) Image of tooth 11 after orthodontic extrusion. (d) Image of tooth 11 after orthodontic
extrusion.
 Teeth with no ferrule effect may fail and root fracture may result. If a ferrule is not
possible (either periodontally or orthodontically), but the patient still prefers to save the
tooth, a gold cast could provide a possible alternative .

 There are several long-term clinical studies that report high success rates with cast gold
posts .From the endodontist’s perspective, cast gold posts are easily removed for
retreatment.

 Silver–palladium alloys can be used as an alternative to gold. These posts are easy to
adjust at the chairside, demonstrate acceptable casting accuracies and have properties
similar to those of gold casting alloys.

 With minimal residual tooth structure and absence of a ferrule effect, newer options such
as fibre-reinforced posts and cores have a reduced longevity .Under mechanical stress
and high temperatures, they undergo greater deformation. Absorption of liquid also has a
negative effect on the three-dimensional stability of composite build-ups leading to a
tendency towards the development of microleakage caries and post-treatment endodontic
disease
 Laboratory studies report a higher frequency of core failure for composite
cores than for metal cores. Mechanical qualities of the core material play a
more important role, particularly in cases where less residual dentine is present

 Teeth restored with a cast post and core support a greater compressive load in
comparison with fibre posts, but when they fail they fracture in a
catastrophic manner .

 A stiff post, in the case of minimal residual coronal dentine, distributes the
forces along the post into the root. Failures caused by fatigue would occur
at higher stress levels and after a considerably longer time compared with
fibre posts, but the risk of an irreparable root fracture would be increased
 Other drawbacks to cast posts include the clinical time required, the
need for an additional appointment, the need to place a temporary
crown ,the higher cost and the risk of bacterial contamination during
temporization.

 After post space preparation, the clinician’s main concern is the small
amount of filling material that remains in the root canal.

 This most apical portion serves as the only barrier against penetration
of microorganisms that may cause periapical inflammation .

 To reduce the risk of contamination of the canal and colonization of

bacterial species on the walls of the apical portion of the root canal, it
may be preferable to restore the tooth immediately
 In some cases, treatment and restoration of the compromised root filled tooth
can be too complex (no ferrule, retreatment, ortho- or perio-crown
lengthening, post, crown) and time-consuming with no predictable outcome
 Tooth 25 (Class 4) Given the lack of ferrule and poor coronal
structure, implant therapy was proposed.
 Restorations of endodontically treated teeth are designed to

 (1) protect the remaining tooth from fracture,

 (2) prevent reinfection of the root canal system, and

 (3) replace the missing tooth structure.

 Although the use of a crown built on post and core is a traditional

approach, others have advocated the use of direct composite resins for
restoring small defects in endodontically treated teeth.

 More recently, indirect restorations such as overlays or endocrowns made

of composite resins or ceramics have also been used.
 When a minimal amount of coronal tooth structure has been lost after
endodontic therapy, a direct resin composite restoration may be indicated

 Unfortunately, the shrinkage that accompanies polymerization of

contemporary composite resin remains a significant problem to the
long- term success of these restorations.

 Direct composite restorations have been placed in anterior teeth that have
not lost tooth structure beyond the endodontic access preparation. In
such cases, the placement of a direct composite restoration offers an
immediate sealing of the tooth, which prevents coronal leakage and
recontamination of the root canal system with bacteria

 They are contraindicated when more than a third of coronal tissue has
been lost.
 Ceramic or resin composite onlays and endocrowns can also be used to
restore endodontically treated teeth. Whereas overlays incorporate a
cusp or cusps by covering the missing tissue, endocrowns combine the
post in the canal, the core, and the crown in one component.

 Both onlays and endocrowns allow for conservation of remaining

tooth structure, whereas the alternative would be to completely
eliminate cusps and perimeter walls for restoration with a full crown.

 Ceramics are a material of choice for long-term esthetic indirect

restorations because their translucency and light transmission
mimic enamel.
 Onlays, overlays, and endocrowns can also be fabricated from
resin composites processed in the laboratory.

 Using various combinations of light, pressure, and vacuum, these

fabrication techniques are claimed to increase the conversion rate of
the polymer and consequently the mechanical properties of the
restorative material.
 Endocrown-type restorations are single prostheses fabricated from
reinforced ceramics that can be acid etched, indicated for
endodontically treated molar teeth that have significant loss of coronal
structure.

 Endocrowns are formed from a monoblock containing the coronal por

tion integrated into the apical projection that fills the pulp chamber space,
and possibly the root canal entrances.

 The endocrown is a total porcelain crown fixed to a depulped posterior

tooth, which is anchored to the internal portion of the pulp chamber and to
the cavity margins, thus obtaining macromechanical retention (provided
by the pulpal walls), and microretention (by using adhesive cementation).
 Endocrowns are especially indicated in cases of molars with short,
obliterated, dilacerated, or fragile roots.

 They may also be used in situations of excessive loss of coronal dental

tissue and limited interocclusal space, in which it is not possible to attain
adequate thickness of the ceramic covering on the metal or ceramic
substructures.
 When a significant amount of coronal tooth structure has been lost by
caries, restorative procedures, and endodontics, a full crown may be
the restoration of choice.

 To be successful, the crown and crown preparation together must meet

five requirements:
 1. The ferrule (dentin axial wall height) must be at least 2 to 3 mm.
 2. The axial walls must be parallel.
 3. The restoration must completely encircle the tooth.
 4. The margin must be on solid tooth structure.
 5. The crown and crown preparation must not invade the attachment
apparatus.
 Structures subjected to low but repeated forces can appear to fracture
suddenly for no apparent reason. This phenomenon, also known as
fatigue failure, occurs when a material or a tissue is subjected to cyclic
loading.

 Fatigue may be characterized as a progressive failure phenomenon

that proceeds by the initiation and propagation of cracks

 Fatigue failure of nonvital teeth restored with a post is more catastrophic

because it may result in a complete fracture of the root. A post placed into
a dentin root will function physically like any structural rod anchored in
another material.

 This means that the forces applied on the post are transmitted to the root
dentin with characteristic patterns depending on the modulus of elasticity of
both the post and the dentin. If the post has a higher modulus than the
dentin, the stress concentration is adjacent to the bottom of the post
 When the stiffness of the endodontic post is similar to that of dentin,
stresses are not concentrated in the dentin adjacent to the apex of the
post but rather dissipated by both the coronal and the root dentin
 Post
 It is relatively rigid restorative material placed in the root of a nonvital
tooth. It extends coronally to anchor the core material which supports
the crown.
 Core
 Core is the supragingival portion which replaces the missing coronal tooth
structure and forms the center of a new restoration. In other words it acts
as a miniature crown

 Post Mainly Serves Two Functions

 • Helps in retaining the core
 • Helps in favorable distribution of the stresses through the radicular
dentin portion of the teeth to apex
 Retention and the Resistance Form
 Post retention refers to the ability of
post to resist vertical dislodging
forces. Post resistance
refers to the ability of the post and the
tooth to withstand the lateral and
rotational forces

 Factors affecting post retention

 • Post length
 • Post diameter
 • Post taper and design
 • Luting agent
 • Luting method
 • Canal shape
 • Post position in dental arch.
 Factors affecting post resistance
 • Post length
 • Rigidity
 Accepted Guidelines for Determining Post
Length

 These include:

 • Post should be equal to clinical crown length.

 • Post should be equal to one-half to two-thirds of the length of

the remaining root.

 • Post should end halfway between the crestal bone and the root
apex.

 • Post should be as long as possible without disturbing the apical seal.

Since root anatomy varies from tooth to tooth, so post space should
be evaluated and planned accordingly.
 Presently there are three different theories/philosophies regarding the
post diameter in literature. these are:

 The conservationist: It suggests the narrowest diameter that allows the

fabrication of a post to the desired length. It allows minimal
instrumentation of the canal for post space preparation According to
this, teeth with smaller dowels exhibit greater resistance to fracture.

 The preservationist: It advocates that at least 1 mm of sound dentin

should
be maintained circumferentially to resist the fracture

 The proportionist: This advocates that post width should not exceed one-
third of the root width at its narrowest dimensions to resist fracture The
guideline for determining appropriate diameter of post involves
mesiodistal width of the roots.
 Advantage of the cast post/core system is that the core is an integral
extension of the post, and that the core does not depend on
mechanical means for retention on the post.

 This construction prevents dislodgment of the core from the post and
root when minimal tooth structure remains.

 However, the cast post/core system also has several disadvantages. Valuable
tooth structure must be removed to create a path of insertion or
withdrawal. Second, the procedure is expensive because two appointments
are needed, and laboratory costs may be significant. The laboratory phase
is technique sensitive.

 Metal casting of a pattern with a large core and a small-diameter post can
result in porosity in the gold at the post/core interface. Fracture of the
metal at this interface under function results in failure of the restoration.

 Most important, the cast post/core system has a higher clinical rate of
root fracture than preformed posts.
 Studies on cast post retention have shown that the post must fit the prepared
root canal as closely as possible to be perfectly retained.

 When a ferrule is present, custom cast posts and cores exhibit a

higher fracture resistance compared to composite cores built on
prefabricated metallic posts or carbon posts.

 Cast posts are also known to exhibit the least amount of retention and
are associated with a higher failure rate compared to prefabricated parallel-
sided posts.
 The core replaces carious, fractured, or missing coronal structure and helps
to retain the final restoration. Desirable physical characteristics of a core
include
 (1) high compressive and flexural strength,
 (2) dimensional stability,
 (3) ease of manipulation,
 (4) short setting time, and
 (5) the ability to bond to both tooth and post.

 Core materials include composite resin, cast metal or ceramic, amalgam, and
sometimes glass ionomer materials. The core is anchored to the tooth by
extension into the coronal aspect of the canal or through the endodontic
post.
 The importance of retention between the post, the core, and the tooth
increases as remaining tooth structure decreases.
 Composite core materials take a number of strategies to enhance their strength
and resistance; metal may be added, filler levels may be greater, or faster
setting ionomers may be used.

 Composite core materials have been shown to exhibit slightly

better mechanical values than conventional materials, but
improvements are negligible.

 However, they appear to be superior to silverglass- ionomer cement and

amalgam. The advantages of composite core resins are adhesive bonding to
tooth structure and many posts, ease of manipulation, rapid setting, and
translucent or highly opaque formulations.

 Composite cores have been shown to protect the strength of all-ceramic crowns
equally to amalgam cores.
 Bond strength of composite cores to dentin depends on a complete
curing of the resin materials, so dentin bonding agents must be
chemically compatible with composite core materials. Self-cure
composite resins require self-cure adhesives and are mostly
incompatible with lightactive cure adhesives.

 However, no adhesive has been shown to completely

eliminate microleakage at the margins of the restoration.

 A degradation of the resin core or the marginal integrity of the crown

can result in invasion of oral fluids.

 Therefore, as with all buildup materials for decimated teeth, more than
2 mm of sound tooth structure should remain at the margin for optimal
composite resin core function.
 Composite core materials can be used in association with metallic, fiber,
or zirconia posts. This is frequently observed in the presence of
structurally compromised teeth.

 They may provide some protection from root fracture in teeth restored
with metal posts compared with amalgam or gold cores.

 Loosening of the post, core, and crown with composite core can occur,
but composite cores have been shown to fail more favorably than
amalgam or gold
 Dental amalgam is a traditional core buildup material with a long history of
clinical success. Although there are many variations in the alloy’s
composition, more recent formulations have high compressive strength
(400 MPa after 24 hours), high tensile strength, and a high modulus of
elasticity.

 High-copper alloys tend to be stiffer (60 GPa) than lowcopper alloys.

 Amalgam can be used with or without a post.

 With the amalcore technique, amalgam is compacted into the pulp chamber
and 2 to 3 mm coronally of each canal. The following criteria were
considered for the application of this technique: the remaining pulp chamber
should be of sufficient width and depth to provide adequate bulk and
retention of the amalgam restoration, and an adequate dentin thickness
around the pulp chamber was required for the tooth-restoration continuum
rigidity and strength.
 The fracture resistance of the amalgam coronal-radicular restoration
with four or more millimeters of chamber wall was shown to be
adequate, although the extension into the root canal space had little
influence.

 Amalgam can also be used in combination with a prefabricated metallic

post when the retention offered by the remaining coronal tissue needs to be
increased.

 Amalgam cores are highly retentive when used with a preformed metal
post in posterior teeth; they require more force to dislodge than cast posts
and cores.

 Significant disadvantages of amalgam cores are the “nonadhesive nature”

of the material, the potential for corrosion, and subsequent discoloration of
the gingiva or dentin. Amalgam use is declining worldwide because of
legislative, safety, and environmental issues.
 Glass ionomer and resin-modified glass ionomer cements are adhesive
materials useful for small buildups or to fill undercuts in prepared
teeth.

 The rationale for using glass ionomer materials is based on their

cariostatic effect resulting from fluoride release. However, their low
strength and fracture toughness result in brittleness, which contraindicates
the use of glass ionomer buildups in thin anterior teeth or to replace
unsupported cusps.

 They may be indicated in posterior teeth in which

 (1) a bulk of core material is possible,
 (2) significant sound dentin remains, and
 (3) caries control is indicated.
 Resin-modified glass ionomer materials are a combination of glass ionomer
and composite resin technologies and have properties of both materials.
Resin-modified glass ionomers have moderate strength, greater than
glass ionomers but less than composite resins.

 As a core material, they are adequate for moderate-sized buildups, but

hygroscopic expansion can cause fracture of ceramic crowns and
fragilized roots.

 The bond to dentin is close to that of dentin-bonded composite resin and

significantly higher than traditional glass ionomers.

 Today, resin composites have replaced glass ionomer materials for core
fabrication.
 Interim restorations are those that provide structural integrity to the
tooth while the tooth is undergoing endodontic treatment.

 An interim restoration is expected to remain in situ providing a good seal

until the endodontic treatment is completed and a definitive restoration can
be provided. These interim restorations should help provide support for
weakened cusps preventing fracture between appointments as well as a
good coronal seal.

 Where the tooth’s coronal structure is severely compromised or a crack is

suspected, copper rings or orthodontic bands may act as interim
restorations
.Some have advocated the use of stainless steel orthodontic bands as
interim
restorations citing reduced cusp flexure often in premolar teeth and
recommended that if one or more cusps are missing a band should
be placed.
 When metal bands are used, it is prudent to use chemically curing cements
as well as ensure that the margins allow optimum oral hygiene and that the
restoration is in keeping with the occlusion. It is not always possible to use
metal bands around teeth in smile line such as premolars due to aesthetic
considerations, although using a tooth coloured material to mask the
buccal surface of the metal band have been described

Using copper bands Using orthodontic bands

 Temporary restorations are those that occupy the access cavity and provide a
good coronal seal between appointments. The overriding requirement is
that they should provide an effective and durable seal between
appointments.

 Other desirable properties include ease of removal at the next

appointment, inexpensive and having inferior aesthetic properties, thus
making it more obvious at the time of removal so that additional tooth
structure is not removed at the subsequent re-entry appointment.

 An array of potential materials are available, including zinc-oxide/ calcium-

sulphate-based materials (Cavit, Coltosol – Coltene Whaldent, Mahwah, NJ,
USA), zinc-oxide-based reinforced intermediate restorative materials (IRM
– Dentsply Caulk, Milford, USA), GIC, resin modified GIC (RMGIC),
reinforced GIC (Ketac Fil and Ketac Silver – 3M ESPE, Seefeld, Germany),
composite (TERM – Dentsply Maillefer Switzerland), amalgam
 The combination of Cavit and IRM have been recommended for
various reasons including cost, ease of use and the fact that used
together better dentine adaptation was seen when compared with IRM
alone

 Cavit and IRM provided as good a seal as the original restoration

when placed in access cavities through interim IRM restorations,
amalgam fillings and gold or metal ceramic crowns
 The definitive restoration should be placed as soon as possible after completion of
root canal treatment

 Chugal (2007) found that 40% of teeth with temporary restorations failed when
compared with 21% failure of those with definitive restorations

 Chugal found no difference in endodontic failure rates between crowns,

amalgams
or composites

 Residual endodontic sealers can also adversely affect bonding and a total etch
procedure is recommended. GIC must be sticky to form a bond with tooth structure,
yet also be packed down into the canal orifices.

Composite can also be used, although air blows easily occur and
adequate drying and curing to the depth of the canal orifice may be
difficult to achieve
 Anterior teeth are loaded non-axially. Posterior teeth are loaded occlusally and
therefore axially. The options for anterior teeth are direct composite
restorations or replacement crowns with or without a post. The options for
premolars is similar although these teeth are often loaded axially and may be
loaded horizontally if they are involved in lateral guidance and cuspal
coverage should be considered where marginal ridges are compromised.

 Molars can be restored with simple composite or amalgam restorations in the

access cavity if the marginal ridges are intact or complex amalgams/composite
providing cuspal coverage, onlays/overlays in gold (Fig. 5), indirect
composite or porcelain, or full coverage crowns in metal, metal ceramic or all
ceramic if marginal ridges are compromised.
 When crowns are considered, the need for a ferrule is mandatory for
a more predictable restoration

 Ferrules must be on sound tooth structure (not the core) and axial walls
must be parallel and minimum thickness of 1 mm. The longer the
ferrule the better with minimum of 1 mm height suggested by some.

 Ferrules should not invade periodontal attachment and therefore must be

more than 0.4 mm from the base of the gingival crevice, although the
depth of the gingival crevice may vary from patient to patient with the
average biological width being approximately 2 mm
 Nayyar cores are useful in posterior teeth as amalgam can be packed 2-3 mm
into the canal orifice avoiding the need for a post and providing an orifice
seal.

 It is also possible to place 3 mm of IRM or Cavit in the canal before the

placement of an amalgam restoration. Bonded amalgam restorations have
been shown to have strength almost comparative to unrestored teeth, and
strengths higher than bonded composite restorations although no statistical
significance was found between the two groups.

 Composite used for cuspal coverage in endodontically treated premolars

has been shown to give fracture resistance similar to untreated teeth and
higher fracture resistance compared to intracoronal composite restorations.
 More recent studies on root filled teeth have also shown direct restorations to
have lower ten-year survival rates than crowns (81% for crowns vs. 63% for
amalgam, composite, cements).

 it was concluded that endodontically treated teeth were six times more likely to
be lost if a crown was not provided and the outcomes were better if two
proximal contacts existed

 Where a crown was not provided, tooth extractions were 4.8 times higher in
anteriors, 5.8 times higher in premolars and 6.2 times higher in molars
compared to teeth with crowns. A statistically significant difference (p <0.001)
was found between teeth with a crown and those without.

 It must be remembered that endodontically treated teeth have an endodontic

access cavity and any further preparation for an extracoronal restoration
may leave a very thin band of dentine, prone to fracture. Minimal
preparation restorations are ideal to preserve tooth structure .
 Gold onlays with a 1-2 mm chamfer margin on worn teeth have shown a
survival of 89% at five years when 50 micron alumina abraded copper
containing type III cast gold alloy was used and cemented with Panavia
(Kuraray Noritake Dental Inc. Okayama, Japan) Not enough evidence
exists yet for the use of these restorations in the outcome of
endodontically treated teeth.
 Fracture resistance studies have shown that while gold onlays had
improved fracture resistance when compared to glass ceramic and resin
composite onlays, all onlay systems improve the fracture resistance when
compared to unrestored teeth. Indirect composite onlays have been
shown to have good medium term survival (96% at 2-4years) in
posterior teeth
 According to the view of the specialists, good long-term prognosis and
greater flexibility in clinical management indicate that RCT and even
retreatment should be performed first in most instances unless the tooth is
judged to be untreatable when implants are considered.

 As soon as other compromising factors or risks exist, such as insufficient

coronal tooth structure and/ or moderate to severe periodontal involvement,
the time and cost efforts engaged with the RCT may be questionable.

 When deciding if an impaired tooth with a questionable prognosis is

maintained or extracted and possibly replaced by an implant, several different
aspects have to be taken into account. These aspects comprise site-specific
factors, the entire oral situation and patient-related factors
 Multiple factors need to be evaluated such as site-specific and patient-
related factors in making an overall decision. Each case should be evaluated
individually with thorough treatment planning.

 The evidence presented clearly indicates that the extraction of a natural

tooth without any consideration of its health will result in a failure to
recognize risks and complications that may possibly arise with implant
treatment.

 Multiple risk factors tend to indicate tooth extraction and possible

replacement by an implant, particularly in the posterior region when
aesthetics are not crucial. Priority should always be given to preserving
natural dentition to the highest possible function, as this is in the
primary goal in periodontal therapy.
 Restoration of the root-filled tooth Nessrin A Taha, Harold H Messer Prim
Dent J. 2016;5(2): 29-35

 A new classification system for the restoration of root filled teeth M. Zarow1,
A. Ramırez-Sebastia2 , G. Paolone3 , J. de Ribot Porta2, J. Mora2, J. Espona2,
F. Duran-Sindreu2 & M. Roig2 International Endodontic Journal

 Restoration of the root canal treated tooth S. Eliyas,*1 J. Jalili2 and N.

Martin3 BRITISH DENTAL JOURNAL VOLUME 218 NO. 2 JAN 23
2015

 Endodontics or implants? A review of decisive criteria and guidelines for single

tooth restorations and full arch reconstructions N. U. Zitzmann, G. Krastl, H.
Hecker, C. Walter & R. Weiger International Endodontic Journal, 42, 757–
774, 2009
 Should retention of a tooth be an important goal of dentistry? How do you
decide whether to retainand restore a tooth requiring endodontic treatment or
to extract and if possible replace the tooth? Jessica J. Zachar, BDSc, fifth-year
student, Aust Endod J 2015; 41: 2–6

 Restoring endodontically treated teeth with posts and cores—A review Ingrid
Peroz, Dr Med Dent1/Felix Blankenstein, Dr Med Dent1/ Klaus-Peter Lange, Prof
Dr Med Dent2/Michael Naumann, Dr Med Dent3 VOLUME 36 • NUMBER 9 •
OCTOBER 2005

 Ingle 6 th edition

 Cohen south asian first edition

Thank You !