MANAGEMENT OF
ENDODONTICALLY
TREATED TOOTH

www.indiandentalacademy.com
INDIAN DENTAL ACADEMY
Leader in continuing dental education

www.indiandentalacademy.com

www.indiandentalacademy.com
CONTENTS
1. Introduction.
2. Definitions
3. History
4. Review of literature
5. Changes in endodontically treated
teeth.
6....
7. Treatment planning for restoration of
endodontically treated teeth.
8. Principles of tooth preparation.
9. Basic compon...
v) Recent advances in post
b) Core
i) Desirable physical characteristics
ii) Various materials used in core
fabrication
c)...
c) Preparation of coronal tooth
structure
11) Custom cast and core
12) Provisional restoration
13) Failures
14) Summary
15...
INTRODUCTION

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A tooth that has been pulpally involved
is often given a second chance with
endodontic treatment. However, in
most instanc...
the chemical insults due to the
restorative materials, loss of
structural integrity (removal of
critical dentin during end...
Restoring such a tooth involves a
range of treatment options of
varying complexity. The loss of
tooth structure makes rete...
If the requirements of the tooth are
assessed carefully and the
treatment is planned appropriately,
it can resume full fun...
Restoration of the pulpless teeth
has been dated back to the 1740’s
where posts were fabricated of
gold or silver .Ever si...
DEFINITIONS

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Dowel : a post, usually made of metal
that is fitted into a prepared root
canal of a natural tooth. When
combined with an ...
Core : the center or base of a
structure

Post-core crown: a restoration in
which the crown and cast post is
one unit
www....
Ferrule (GPT-7):
l: a metal band or ring used to fit the
root or crown of a tooth
2: any short tube for making a tight
joi...
• Apex (GPT-7): in dentistry, the
anatomic end of a tooth root.
• Biologic width: the combined
width of connective tissue ...
HISTORY

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In 1747, Pierre Fauchard described
the process by which roots of
maxillary anterior teeth were used
for the restoration of...
A 6 unit bridge,
pivoted in lateral
incisor, with
canines cantilevered
www.indiandentalacademy.com
Posts were fabricated of gold or
silver and held in the root canal
space with a heat-softened
adhesive called “mastic” (pr...
In Fauchard’s days, replacement
crowns were made from bone,
ivory, animal teeth, and sound
natural tooth crowns. Gradually...
• A pivot (what is today termed a
post) was used to retain the
artificial porcelain crown into a
root canal, and the crown...
• Early pivot crowns used seasoned
wood (white hickory) pivots. The
pivot was adapted to the inside of
an all-ceramic crow...
• Subsequently, pivot crowns were
fabricated using wood/metal
combinations, and then more
durable all-metal pivots were us...
Metal pivot retention was achieved by
various means such as threads, pins,
surface roughening, and split designs
that prov...
REVIEW OF LITERATURE

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Hamilton et al ( JPD 1959:9;639)
In their article, Porcelain dowel
crowns, discussed about the
method of fabrication and v...
Silverstein et al ( JPD 1964: 14;372)
in their article, Reinforcement of
weakened pulpless tooth, stated
that, for the suc...
Colley et al ( BDJ 1968;124;63-69)
did a study on the effect of post
length on the retention of post and
concluded that in...
Goldrich M et al (JPD 1970;23:173)
in his article on ‘construction of
posts for teeth with existing
restorations’, mention...
H.G.Kurer et al (JPD 1977;38:515)
Did a study to assess the axial
retention of dowels. They
concluded that threaded dowels...
Guzy et al (JPD 1979:42;39) did invitro
study on the effects of post placement on
endodontically treated teeth and conclud...
• Richard W.Chan et al (JPD 1982;48:401)
Cast-gold post-core combination and
amalgam or composite resin cores used in
comb...
Gordon D. Mattison et al (JPD 1984;51:785)
Did a study to analyze the apical leakage and
effect of gutta-percha removal te...
John A. Sorensen et al ( JPD 1984;52:28) in
the article ‘ Clinically significant factors in
dowel design’ concluded that:
...
• Teeth that had a dowel length
equal to or greater than the crown
length had a success rate of 97%.

www.indiandentalacad...
R.A. Oliva et al (JPD 1987;57: 554)
Did a study to investigate the dimensional
stability of silver amalgam and a
conventio...
Conventional composite used a core
material in this study was found to
be dimensionally unstable when
directly exposed to ...
Ryle A. Radke et al (JPD 1988;59:318)
Did a study to compare the retentive
values of 4 luting agents (Zinc phosphate,
glas...
Rahmat A et al
( JPD 1989:61:676-678)
did a study to examine the effect of
metal collar (with approx. 3 degree
taper) on t...
James E Haddex et al
( JPD 1990;64: 515-519)
did a study to investigate the effect of
the method of Guttapercha removal on...
Felton D.A et al (JPD 1991;65:179) did a
study on the effect of post design on
incidence of root fracture and concluded
th...
• Most of the root fractures resulting
from dowel insertion occurred on
the mesial or distal root surfaces as
a result of ...
Hemmings et al
(JPD 1991;66:325-329)
did a study and investigated the
resistance of various post and core
designs to torsi...
Anthony H.L. Tjan et al (Q Int.
1992;23:839)
• Did a study to evaluate the effect of
eugenol- containing endodontic sealer...
Irrigating the post space with alcohol
or etching with phosphoric acid gel
effectively restored the retention.
• The use o...
Daniel B et al (JPD 1994: 72;591-594)
Did a study to evaluate the retention of pre
formed posts with four different cement...
Arturo M et al
(JPD 1998;80:527)
• Did a study to compare the fracture
resistance of two types of restorations:
teeth rest...
• Significantly higher fracture threshold
values were obtained in the cast post core
group. Teeth restored with carbon fib...
• Steele et al ( J endod 1999:25;6)
did an invitro study on the fracture
strength of endodontically treated
premolars and ...
Flemming et al
( IJP 1999: 12;78-82)
did a study on the influence of post
length and crown ferrule length on
the fracture ...
Mary Rafter et al
(J Prosthet Dent 2003;89:360-7.)
Did study to compare the effect of fiberreinforced composite post syste...
M. ROSENTRITT et al (Journal of Oral
Rehabilitation 2004 31; 675–681)
• Did a study to compare the fracture
resistance and...
• The all-ceramic posts and the glass–fibrereinforced posts both provided a significant
higher fracture resistance than th...
Emine Y. et al ,(J Prosthodont 2005;14:8490.)
Did a study to compare fracture strengths of
teeth restored with cast metal ...
They concluded that In-Ceram Spinell
and IPS Empress 2 ceramic dowel and
cores may be candidates for the
restoration of en...
CHANGES IN
ENDODONTICALLY
TREATED TEETH

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1. Loss of tooth structure.
2. Altered physical characteristics.
3. Altered esthetic characteristics of the
residual tooth...
1. Loss of tooth structure.

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Reeh et al (J Endod 1989:15;512-516)
Evaluated the effects of endodontic
procedures as compared to restorative
reduction o...
Endodontic procedures reduce
tooth stiffness by only 5%

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MOD cavity decreases stiffness > 60%
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The endodontic
access into the pulp
chamber destroys the
structural integrity
provided by the
coronal dentin of the
pulpal...
When tooth structure is significantly reduced,
Fracture of
undermined cusp
Or
Fracture of tooth
in the area of
Smallest
ci...
The decreased volume
+
The effect of prior dental procedures

Significant potential for fracture of
the endodontically tre...
2. Altered physical characteristics

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Changes that takes place in
endodontically treated teeth:
a) Changes in collagen cross linking
b) Dehydration of the denti...
a) Changes in collagen cross linking
Collagen

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Structure of dentine
Rivera et al ( J Endod 1988: 14;195) did
a study on dentine collagen cross links
of root filled and normal teeth. They
con...
B) Dehydration of the dentine ( loss
of moisture)
Helfer et al ( OOO 1972: 34;661-670)
did a study to determine the moistu...
Messer et al (J. Endod. 1994:10;91-93)
did a study to measure the moisture
content of vital and endodontically
treated tee...
Stephen Cohen : Path ways of pulp: 8th
edt.)
Changes in collagen cross-linking and
dehydration of the dentin result in a
1...
C) Changes due to use of sealer
cements
May effect the properties of
endodontically treated teeth

www.indiandentalacademy...
Jonck et al (J Endod 1979; 5: 20-24)
did an analysis of the root dentine in
teeth treated endodontically with ZOE
sealers ...
• Biven et al ( BDJ 2005) in their
study showed that the eugenol
present in the eugenol containing
root canal sealers incr...
3. Altered esthetic characteristics
.

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• A) Biomechanically altered dentin
modifies light refraction through the
tooth and modifies its appearance.
• B) Inadequa...
C) Caries, restorations and secondary
calcifications modify the appearance.

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PRE TREATMENT
EVALUATION

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Before restoring, the endodontically
treated tooth should be assessed for :
• Endodontic evaluation
• Periodontal evaluati...
Endodontic evaluation

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CHECK FOR
• Apical seal
• No tenderness on
percussion
• No draining sinus.
• No mobility
• No active inflammation

www.ind...
Inadequate root fillings retreatment

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Signs of failure Retreatment

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Obturation performed with silver
cones Retreatment

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If doubt  observe until there is
definitive evidence of success or
failure.

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Periodontal evaluation:

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In addition to performing a routine
periodontal evaluation (pocket
depth, bleeding on probing etc), the
effect of the plan...
Attempts to place the restorative
margins on solid tooth structure
Invade the biological attachment zone.
In such cases,
C...
Restorative evaluation

Comprises of estimating the
strategic importance of the tooth

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Need extensive treatment

Most Distal tooth

Long span bridge

Avoid DEB RPD

Intermediate abutment

www.indiandentalacade...
• Reliability of tooth after restoration
should be considered.
• Tooth must be able to withstand
functional forces placed ...
Esthetic evaluation

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• Thin gingiva may transmit a
shadow of dark root color through
the tissue.
• Metal or dark, carbon fiber dowels
or amalga...
• The translu-cency of all-ceramic crowns
must be considered in the selection of
dowel and buildup materials.
• Tooth-colo...
TREATMENT PLANNING FOR
RESTORATION OF
ENDODONTICALLY TREATED
TEETH

www.indiandentalacademy.com
Important considerations are:
• The amount of remaining tooth
structure
• The anatomic position of the tooth
• The functio...
1. The amount of remaining tooth
structure

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The amount of tooth structure
damage is one of the most
important aspects in restoration of
the endodontically treated too...
Christensen et al (JADA1998:129:96)
Teeth with more
than half of the
tooth structure
intact can be
restored
Conservatively...
• Teeth with extensive tooth structure loss
 weak making dowels, cores, and
crowns necessary.

www.indiandentalacademy.c...
Teeth with minimal remaining
tooth structure present several
problems :

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The amount of remaining dentin is
far more significant to the longterm prognosis of the restored
tooth than is the selecti...
• Additional dentine at
the marginal area, when
encased by the crown
margin or ferrule
provides greater
protection than do...
Treatment planning requires use of
dental specialties
• to obtain the necessary sound tooth
structure
• to design the dowe...
2. The anatomic position of the
tooth

www.indiandentalacademy.com
Anterior teeth
• Intact, nonvital,
anterior teeth
minimal risk
for fracture.
• Restorative treatment sealing of the
acces...
significant loss of
tooth structure

crown supported
and retained by
the dowel and
core.

www.indiandentalacademy.com
• Hunter et al ( JPD 1992:68;421) and Guzy et
al (JPD 1979:42;39) did invitro study on the
effects of post placement on en...
www.indiandentalacademy.com
Disadvantage of routine use of
cemented post in intact anterior teeth:
• Requires additional operative procedure
• Removes...
• May be difficult to restore the teeth
later when crown is needed, because
this post may fail to provide adequate
retenti...
Warren et al (J Endod 1990:16;570)
Discoloration in the absence of
significant tooth loss may be more
effectively treated ...
When extensive tooth loss or tooth
will be serving as abutment for
FPD or RPD  complete coverage
is must.

www.indiandent...
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Posterior teeth
•Subjected to greater loading than anterior
•More susceptible to fracture
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Should receive cuspal coverage to
prevent fracture

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Significant loss of tooth structure
post and core

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• Steele et al ( J endod 1999:25;6) did an
invitro study on the fracture strength of
endodontically treated premolars and
...
3. Functional load of the tooth

www.indiandentalacademy.com
teeth as abutments for fixed or removable
partial dentures

bear more horizontal and torquing forces

need more extensive ...
www.indiandentalacademy.com
Abutment teeth for long-span fixed
bridges and DEB RPD absorb
greater transverse loads and require
more pro-tection than d...
Teeth that exhibit extensive wear
from bruxism, heavy occlusion
require the full complement of
dowel-core-crown

www.india...
4. Esthetic requirements of the tooth

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Anterior teeth, premolars, and often
the maxillary first molar come in
the esthetic zone of the mouth.
Alterations to the ...
• Careful selection of restorative
materials .
• Restorative materials include:
Tooth colored dowels,
Tooth colored compos...
Thank you
www.indiandentalacademy.com
Leader in continuing dental education

www.indiandentalacademy.com
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Managment of endodontically treated tooth /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.


Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
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Transcript of "Managment of endodontically treated tooth /certified fixed orthodontic courses by Indian dental academy "

  1. 1. MANAGEMENT OF ENDODONTICALLY TREATED TOOTH www.indiandentalacademy.com
  2. 2. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  3. 3. CONTENTS 1. Introduction. 2. Definitions 3. History 4. Review of literature 5. Changes in endodontically treated teeth. 6. Pretreatment evaluation. www.indiandentalacademy.com
  4. 4. 7. Treatment planning for restoration of endodontically treated teeth. 8. Principles of tooth preparation. 9. Basic components used in restoration of endodontically treated tooth. a) Dowel i) Ideal properties ii) Classification iii) Retentive, protective and esthetic qualities iv) Materials used for fabrication www.indiandentalacademy.com
  5. 5. v) Recent advances in post b) Core i) Desirable physical characteristics ii) Various materials used in core fabrication c) Coronal coverage 10) Procedure for tooth preparation of endodontically treated teeth a) Guttapercha removal b) Post space prepration www.indiandentalacademy.com
  6. 6. c) Preparation of coronal tooth structure 11) Custom cast and core 12) Provisional restoration 13) Failures 14) Summary 15) Conclusion 16) References www.indiandentalacademy.com
  7. 7. INTRODUCTION www.indiandentalacademy.com
  8. 8. A tooth that has been pulpally involved is often given a second chance with endodontic treatment. However, in most instances endodontically treated teeth have been exposed to a variety of insults ranging from caries, the operative procedures that follow, www.indiandentalacademy.com
  9. 9. the chemical insults due to the restorative materials, loss of structural integrity (removal of critical dentin during endodontic procedures) and finally dehydration of the tooth structure. www.indiandentalacademy.com
  10. 10. Restoring such a tooth involves a range of treatment options of varying complexity. The loss of tooth structure makes retention of the subsequent restoration more problematic and increases the likelihood of fracture during function. www.indiandentalacademy.com
  11. 11. If the requirements of the tooth are assessed carefully and the treatment is planned appropriately, it can resume full function and serve satisfactorily as an abutment for a fixed or removable partial denture. www.indiandentalacademy.com
  12. 12. Restoration of the pulpless teeth has been dated back to the 1740’s where posts were fabricated of gold or silver .Ever since then a variety of techniques and materials have been introduced to reinforce the endodontically treated tooth. www.indiandentalacademy.com
  13. 13. DEFINITIONS www.indiandentalacademy.com
  14. 14. Dowel : a post, usually made of metal that is fitted into a prepared root canal of a natural tooth. When combined with an artificial crown or core, it provides retention and resistance for the restoration (GPT-7) www.indiandentalacademy.com
  15. 15. Core : the center or base of a structure Post-core crown: a restoration in which the crown and cast post is one unit www.indiandentalacademy.com
  16. 16. Ferrule (GPT-7): l: a metal band or ring used to fit the root or crown of a tooth 2: any short tube for making a tight joint www.indiandentalacademy.com
  17. 17. • Apex (GPT-7): in dentistry, the anatomic end of a tooth root. • Biologic width: the combined width of connective tissue and epithelial attachment superior to the crestal bone www.indiandentalacademy.com
  18. 18. HISTORY www.indiandentalacademy.com
  19. 19. 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. www.indiandentalacademy.com
  20. 20. A 6 unit bridge, pivoted in lateral incisor, with canines cantilevered www.indiandentalacademy.com
  21. 21. Posts were fabricated of gold or silver and held in the root canal space with a heat-softened adhesive called “mastic” (prepared by gum, turpentine and white coral powder). www.indiandentalacademy.com
  22. 22. In Fauchard’s days, replacement crowns were made from bone, ivory, animal teeth, and sound natural tooth crowns. Gradually, the use of these natural substances declined, and were replaced by porcelain. www.indiandentalacademy.com
  23. 23. • 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.” • In the early 1800s Dubois de Chemant described Porcelain pivot crowns. www.indiandentalacademy.com
  24. 24. • Early pivot crowns 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. www.indiandentalacademy.com
  25. 25. • Subsequently, pivot crowns were fabricated using wood/metal combinations, and then more durable all-metal pivots were used. www.indiandentalacademy.com
  26. 26. Metal pivot retention was achieved by various means such as threads, pins, surface roughening, and split designs that provided mechanical spring retention. www.indiandentalacademy.com
  27. 27. REVIEW OF LITERATURE www.indiandentalacademy.com
  28. 28. Hamilton et al ( JPD 1959:9;639) In their article, Porcelain dowel crowns, discussed about the method of fabrication and various advantages and disadvantages of porcelain as restorative material www.indiandentalacademy.com
  29. 29. Silverstein et al ( JPD 1964: 14;372) in their article, Reinforcement of weakened pulpless tooth, stated that, for the success of the restoration, the post selected should be longer than the crown www.indiandentalacademy.com
  30. 30. Colley et al ( BDJ 1968;124;63-69) did a study on the effect of post length on the retention of post and concluded that increasing the length of post in teeth increases the retention of post. www.indiandentalacademy.com
  31. 31. Goldrich M et al (JPD 1970;23:173) in his article on ‘construction of posts for teeth with existing restorations’, mentioned that the post length should equal the incisocervical or occlusocervical dimension of the crown. www.indiandentalacademy.com
  32. 32. H.G.Kurer et al (JPD 1977;38:515) Did a study to assess the axial retention of dowels. They concluded that threaded dowels appear to have better resistance to axial displacement than other types. www.indiandentalacademy.com
  33. 33. Guzy et al (JPD 1979:42;39) did invitro study on the effects of post placement on endodontically treated teeth and concluded that when the tooth is loaded, stresses are greatest at the facial and lingual surfaces of the root ( lingual surface is in tension, while facial surface is in compression), while the centrally located post lies in the neutral axis (ie only minimally stressed) and thus, does not help prevent fracture www.indiandentalacademy.com
  34. 34. • Richard W.Chan et al (JPD 1982;48:401) Cast-gold post-core combination and amalgam or composite resin cores used in combination with cemented steel post have been examined. Cast gold specimens required less force before failure occurred. All of the cast post core foundations showed displacement from original cemented position and most teeth showed evidence of root fracture. Amalgam and composite resin specimens commonly exhibited fracture of the core but showed less evidence of post core dislodgement and root fracture. www.indiandentalacademy.com
  35. 35. Gordon D. Mattison et al (JPD 1984;51:785) Did a study to analyze the apical leakage and effect of gutta-percha removal technique (hot instrument, mechanical rotary instrument and chemical solvent) on apical seal. They concluded that mechanical method is most desirable for gutta-percha removal in post preparation. As the level of gutta-percha increased to 7 mm the degree of leakage decreased. At least 5 mm of gutta-percha is necessary for an adequate apical seal. www.indiandentalacademy.com
  36. 36. John A. Sorensen et al ( JPD 1984;52:28) in the article ‘ Clinically significant factors in dowel design’ concluded that: • The cast parallel-sided serrated dowel and core and the parallel-sided serrated dowel with an amalgam or composite resin core recorded the highest success rate. • The tapered cast dowel and core display a higher failure rate than teeth treated without intracoronal reinforcement. www.indiandentalacademy.com
  37. 37. • Teeth that had a dowel length equal to or greater than the crown length had a success rate of 97%. www.indiandentalacademy.com
  38. 38. R.A. Oliva et al (JPD 1987;57: 554) Did a study to investigate the dimensional stability of silver amalgam and a conventional composite used as core material. Result of this study indicates that silver amalgam used as a core material is dimensionally stable when exposed to moisture. Seating of crowns fabricated for silver amalgam cores was not affected by exposing the cores to moisture. www.indiandentalacademy.com
  39. 39. Conventional composite used a core material in this study was found to be dimensionally unstable when directly exposed to moisture. Seating of crowns fabricated to fit the composite cores was significantly affected by the dimensional instability of the resin core material www.indiandentalacademy.com
  40. 40. Ryle A. Radke et al (JPD 1988;59:318) Did a study to compare the retentive values of 4 luting agents (Zinc phosphate, glass ionomer , polycarboxylate cement and a composite resin ) for ability to retain posts in prepared root canals of extracted teeth. Zinc phosphate and glass ionomer cements were found to be more retentive than polycarboxylate cements and composite resins. www.indiandentalacademy.com
  41. 41. Rahmat A et al ( JPD 1989:61:676-678) did a study to examine the effect of metal collar (with approx. 3 degree taper) on the resistance of endodontically treated roots to fracture. They concluded that reinforcement with metal collar is necessary to enhance resistance to root fracture. www.indiandentalacademy.com
  42. 42. James E Haddex et al ( JPD 1990;64: 515-519) did a study to investigate the effect of the method of Guttapercha removal on apical seal. They concluded that heated pluggers should be used to remove guttapercha. Although rotary instruments remove guttapercha faster, they seem to disturbe apical seal to a greater extent. www.indiandentalacademy.com
  43. 43. Felton D.A et al (JPD 1991;65:179) did a study on the effect of post design on incidence of root fracture and concluded that: • There were no statistically significant differences in the incidence of root fracture among any of the dowel systems evaluated regardless of shape, taper or presence or absence of threads. www.indiandentalacademy.com
  44. 44. • Most of the root fractures resulting from dowel insertion occurred on the mesial or distal root surfaces as a result of reduced thickness of dentin and the presence of external depressions (flutes) on these surfaces. www.indiandentalacademy.com
  45. 45. Hemmings et al (JPD 1991;66:325-329) did a study and investigated the resistance of various post and core designs to torsional forces and concluded that cervical collar form design was the most favorable design, embracing resistance and decreasing tooth fractures. www.indiandentalacademy.com
  46. 46. Anthony H.L. Tjan et al (Q Int. 1992;23:839) • Did a study to evaluate the effect of eugenol- containing endodontic sealer on retention of prefabricated pots luted with adhesive composite resin cement. They concluded that: • Eugenol significantly reduced the retention of parapost dowels luted with panavia composite resin cement. www.indiandentalacademy.com
  47. 47. Irrigating the post space with alcohol or etching with phosphoric acid gel effectively restored the retention. • The use of alcohol (ehtyl alcohol/ethanol) as a canal irrigant or etching with 37% phosphoric acid gel was found to be effective in restoring the resistance to dislodgement of post. Irrigation with alcohol produced a more consistant and reliable result. www.indiandentalacademy.com
  48. 48. Daniel B et al (JPD 1994: 72;591-594) Did a study to evaluate the retention of pre formed posts with four different cements • Panavia (Kuraray), • All- Bond 2 ( Bisco), • C&B Meta bond (parkel) and • Ketac-Cem (ESPE-Premier). They concluded that C&B Meta bond was most retentive, while no difference in retention was found between Ketac-Cem and Panavia cements. All- Bond 2 was the least retentive cement. www.indiandentalacademy.com
  49. 49. Arturo M et al (JPD 1998;80:527) • Did a study to compare the fracture resistance of two types of restorations: teeth restored with pre fabricated carbon fiber posts and composite cores to cast dowel-core restored teeth. They concluded that www.indiandentalacademy.com
  50. 50. • Significantly higher fracture threshold values were obtained in the cast post core group. Teeth restored with carbon fiber post and composite cores typically showed failure of the post core interface before the fracture of the tooth occurred. This failure occurred in response to acceptably high loads. By contrast, teeth restored with cast post and core typically showed fracture of the tooth. www.indiandentalacademy.com
  51. 51. • Steele et al ( J endod 1999:25;6) did an invitro study on the fracture strength of endodontically treated premolars and concluded that premolars with access openings or conservative MOD preparations can be restored to nearly normal cusp fracture values with dentine bonding and composite resin systems, but this strengthening may only be temporary. www.indiandentalacademy.com
  52. 52. Flemming et al ( IJP 1999: 12;78-82) did a study on the influence of post length and crown ferrule length on the fracture resistance of post and concluded that an increase in ferrule length is more important than post length. www.indiandentalacademy.com
  53. 53. Mary Rafter et al (J Prosthet Dent 2003;89:360-7.) Did study to compare the effect of fiberreinforced composite post systems on the fracture resistance and mode of failure of endodontically treated teeth. Results show that the load to failure of the stainless steel posts were significantly stronger than all the composite posts studied. However, the mode of failure or deflection of the fiberreinforced composite posts is protective to the remaining tooth structure. www.indiandentalacademy.com
  54. 54. M. ROSENTRITT et al (Journal of Oral Rehabilitation 2004 31; 675–681) • Did a study to compare the fracture resistance and marginal adaptation of allceramic incisor crowns with all-ceramic posts, glass–fibre-reinforced posts and titanium posts as well as a control without any post. • The results showed that the restored teeth without posts showed no significantly different fracture strength compared with teeth with the titanium system. www.indiandentalacademy.com
  55. 55. • The all-ceramic posts and the glass–fibrereinforced posts both provided a significant higher fracture resistance than the teeth without posts. • The greatest marginal gap was found with the titanium system at the interface cementcrown and with the all-ceramic posts at the transition between cement-tooth. • Regarding fracture resistance and the marginal adaptation, the all-ceramic and FRC posts may be considered as an alternative to the commonly used titanium post restorations. www.indiandentalacademy.com
  56. 56. Emine Y. et al ,(J Prosthodont 2005;14:8490.) Did a study to compare fracture strengths of teeth restored with cast metal and ceramic dowel and cores supporting all-ceramic crowns. The comparison between metal and ceramic dowel and cores did not reveal significant differences in spite of the fact that In-Ceram Spinells had lower mean fracture values. The fracture strength of all groups was remarkably higher than forces applied to anterior Teeth. www.indiandentalacademy.com
  57. 57. They concluded that In-Ceram Spinell and IPS Empress 2 ceramic dowel and cores may be candidates for the restoration of endodontically treated anterior teeth, as the fracture strengths of these restorations are above the maximum occlusal forces of natural dentition. www.indiandentalacademy.com
  58. 58. CHANGES IN ENDODONTICALLY TREATED TEETH www.indiandentalacademy.com
  59. 59. 1. Loss of tooth structure. 2. Altered physical characteristics. 3. Altered esthetic characteristics of the residual tooth. www.indiandentalacademy.com
  60. 60. 1. Loss of tooth structure. www.indiandentalacademy.com
  61. 61. Reeh et al (J Endod 1989:15;512-516) Evaluated the effects of endodontic procedures as compared to restorative reduction of tooth. They concluded that endodontic procedures reduce tooth stiffness by only 5% (attributed primarily to the access opening), while restorative procedures causes appreciable loss of tooth stiffness www.indiandentalacademy.com
  62. 62. Endodontic procedures reduce tooth stiffness by only 5% www.indiandentalacademy.com
  63. 63. MOD cavity decreases stiffness > 60% www.indiandentalacademy.com
  64. 64. The endodontic access into the pulp chamber destroys the structural integrity provided by the coronal dentin of the pulpal roof and allows greater flexing of the tooth under function. www.indiandentalacademy.com
  65. 65. When tooth structure is significantly reduced, Fracture of undermined cusp Or Fracture of tooth in the area of Smallest circumference (Frequently CEJ) www.indiandentalacademy.com
  66. 66. The decreased volume + The effect of prior dental procedures Significant potential for fracture of the endodontically treated teeth. www.indiandentalacademy.com
  67. 67. 2. Altered physical characteristics www.indiandentalacademy.com
  68. 68. Changes that takes place in endodontically treated teeth: a) Changes in collagen cross linking b) Dehydration of the dentine c) Changes due to use of sealer cements. www.indiandentalacademy.com
  69. 69. a) Changes in collagen cross linking Collagen www.indiandentalacademy.com Structure of dentine
  70. 70. Rivera et al ( J Endod 1988: 14;195) did a study on dentine collagen cross links of root filled and normal teeth. They concluded that the root canal treated teeth have more immature and fewer mature crosslinked collagen fibers. Thus leading to decrease in tensile strength. These changes in cross links may contribute to brittleness of nonvital teeth. www.indiandentalacademy.com
  71. 71. B) Dehydration of the dentine ( loss of moisture) Helfer et al ( OOO 1972: 34;661-670) did a study to determine the moisture content of vital and pulpless teeth and concluded that there was 9% less moisture in calcified tissues of pulpless teeth than in vital teeth. This moisture loss may increase brittleness. www.indiandentalacademy.com
  72. 72. Messer et al (J. Endod. 1994:10;91-93) did a study to measure the moisture content of vital and endodontically treated teeth and concluded that there was no statistically significant difference in moisture content of both. www.indiandentalacademy.com
  73. 73. Stephen Cohen : Path ways of pulp: 8th edt.) Changes in collagen cross-linking and dehydration of the dentin result in a 14% reduction in strength and toughness of endodontically treated molars. www.indiandentalacademy.com
  74. 74. C) Changes due to use of sealer cements May effect the properties of endodontically treated teeth www.indiandentalacademy.com
  75. 75. Jonck et al (J Endod 1979; 5: 20-24) did an analysis of the root dentine in teeth treated endodontically with ZOE sealers and concluded that in sealers containing ZOE, free Zinc competes with calcium binding sites on the surface of hydroxyapatite crystals. But it is not clear whether Zinc causes changes in physical properties of dentine. www.indiandentalacademy.com
  76. 76. • Biven et al ( BDJ 2005) in their study showed that the eugenol present in the eugenol containing root canal sealers increases the microhardness of dentine. www.indiandentalacademy.com
  77. 77. 3. Altered esthetic characteristics . www.indiandentalacademy.com
  78. 78. • A) Biomechanically altered dentin modifies light refraction through the tooth and modifies its appearance. • B) Inadequate endodontic cleaning and shaping of the coronal area  staining the dentine from degradation of vital tissue left in the pulp horns. www.indiandentalacademy.com
  79. 79. C) Caries, restorations and secondary calcifications modify the appearance. www.indiandentalacademy.com
  80. 80. PRE TREATMENT EVALUATION www.indiandentalacademy.com
  81. 81. Before restoring, the endodontically treated tooth should be assessed for : • Endodontic evaluation • Periodontal evaluation: • Esthetic evaluation • Restorative evaluation www.indiandentalacademy.com
  82. 82. Endodontic evaluation www.indiandentalacademy.com
  83. 83. CHECK FOR • Apical seal • No tenderness on percussion • No draining sinus. • No mobility • No active inflammation www.indiandentalacademy.com
  84. 84. Inadequate root fillings retreatment www.indiandentalacademy.com
  85. 85. Signs of failure Retreatment www.indiandentalacademy.com
  86. 86. Obturation performed with silver cones Retreatment www.indiandentalacademy.com
  87. 87. If doubt  observe until there is definitive evidence of success or failure. www.indiandentalacademy.com
  88. 88. Periodontal evaluation: www.indiandentalacademy.com
  89. 89. In addition to performing a routine periodontal evaluation (pocket depth, bleeding on probing etc), the effect of the planned restoration on the attachment apparatus must be considered. www.indiandentalacademy.com
  90. 90. Attempts to place the restorative margins on solid tooth structure Invade the biological attachment zone. In such cases, Crown lengthening orthodontic extrusion www.indiandentalacademy.com
  91. 91. Restorative evaluation Comprises of estimating the strategic importance of the tooth www.indiandentalacademy.com
  92. 92. Need extensive treatment Most Distal tooth Long span bridge Avoid DEB RPD Intermediate abutment www.indiandentalacademy.com
  93. 93. • Reliability of tooth after restoration should be considered. • Tooth must be able to withstand functional forces placed on it. • Large amount of missing tooth structure must be replaced by post n core and crown. www.indiandentalacademy.com
  94. 94. Esthetic evaluation www.indiandentalacademy.com
  95. 95. • Thin gingiva may transmit a shadow of dark root color through the tissue. • Metal or dark, carbon fiber dowels or amalgam placed in the canal can result in unacceptable gingival discoloration from the underlying root. www.indiandentalacademy.com
  96. 96. • The translu-cency of all-ceramic crowns must be considered in the selection of dowel and buildup materials. • Tooth-colored carbon fiber post, glass fiber, or zirconia posts can be used in esthetic areas. • Tooth-colored, rather than opaque, composite core material should be selected for the esthetic case. www.indiandentalacademy.com
  97. 97. TREATMENT PLANNING FOR RESTORATION OF ENDODONTICALLY TREATED TEETH www.indiandentalacademy.com
  98. 98. Important considerations are: • The amount of remaining tooth structure • The anatomic position of the tooth • The functional load on the tooth • The esthetic requirements for the tooth www.indiandentalacademy.com
  99. 99. 1. The amount of remaining tooth structure www.indiandentalacademy.com
  100. 100. The amount of tooth structure damage is one of the most important aspects in restoration of the endodontically treated tooth. www.indiandentalacademy.com
  101. 101. Christensen et al (JADA1998:129:96) Teeth with more than half of the tooth structure intact can be restored Conservatively with coronal restorations and without dowels inside the roots. www.indiandentalacademy.com
  102. 102. • Teeth with extensive tooth structure loss  weak making dowels, cores, and crowns necessary. www.indiandentalacademy.com
  103. 103. Teeth with minimal remaining tooth structure present several problems : www.indiandentalacademy.com
  104. 104. The amount of remaining dentin is far more significant to the longterm prognosis of the restored tooth than is the selection of artificial dowel, core, or crown materials. www.indiandentalacademy.com
  105. 105. • Additional dentine at the marginal area, when encased by the crown margin or ferrule provides greater protection than dowel and core considerations. www.indiandentalacademy.com
  106. 106. Treatment planning requires use of dental specialties • to obtain the necessary sound tooth structure • to design the dowel-core-crown complex for atraumatic retention and • also recognize when the prognosis is poor . www.indiandentalacademy.com
  107. 107. 2. The anatomic position of the tooth www.indiandentalacademy.com
  108. 108. Anterior teeth • Intact, nonvital, anterior teeth minimal risk for fracture. • Restorative treatment sealing of the access cavity. www.indiandentalacademy.com
  109. 109. significant loss of tooth structure crown supported and retained by the dowel and core. www.indiandentalacademy.com
  110. 110. • Hunter et al ( JPD 1992:68;421) and Guzy et al (JPD 1979:42;39) did invitro study on the effects of post placement on endodontically treated teeth and concluded that when the tooth is loaded, stresses are greatest at the facial and lingual surfaces of the root (lingual surface is in tension, while facial surface is in compression), while the centrally located post lies in the neutral axis (ie only minimally stressed) and thus, does not help prevent fracture www.indiandentalacademy.com
  111. 111. www.indiandentalacademy.com
  112. 112. Disadvantage of routine use of cemented post in intact anterior teeth: • Requires additional operative procedure • Removes additional tooth structure for post space preparation. www.indiandentalacademy.com
  113. 113. • May be difficult to restore the teeth later when crown is needed, because this post may fail to provide adequate retention for the core material. • Post can complicate or prevent further endodontic re treatment if it becomes necessary. www.indiandentalacademy.com
  114. 114. Warren et al (J Endod 1990:16;570) Discoloration in the absence of significant tooth loss may be more effectively treated by bleaching than by placing complete crown. www.indiandentalacademy.com
  115. 115. When extensive tooth loss or tooth will be serving as abutment for FPD or RPD  complete coverage is must. www.indiandentalacademy.com
  116. 116. www.indiandentalacademy.com
  117. 117. Posterior teeth •Subjected to greater loading than anterior •More susceptible to fracture www.indiandentalacademy.com
  118. 118. Should receive cuspal coverage to prevent fracture www.indiandentalacademy.com
  119. 119. Significant loss of tooth structure post and core www.indiandentalacademy.com
  120. 120. • Steele et al ( J endod 1999:25;6) did an invitro study on the fracture strength of endodontically treated premolars and concluded that premolars with access openings or conservative MOD preparations can be restored to nearly normal cusp fracture values with dentine bonding and composite resin systems, but this strengthening may only be temporary. www.indiandentalacademy.com
  121. 121. 3. Functional load of the tooth www.indiandentalacademy.com
  122. 122. teeth as abutments for fixed or removable partial dentures bear more horizontal and torquing forces need more extensive protective and retentive features in the restoration. www.indiandentalacademy.com
  123. 123. www.indiandentalacademy.com
  124. 124. Abutment teeth for long-span fixed bridges and DEB RPD absorb greater transverse loads and require more pro-tection than do abutments of smaller bridges or tooth supported removable partial dentures. www.indiandentalacademy.com
  125. 125. Teeth that exhibit extensive wear from bruxism, heavy occlusion require the full complement of dowel-core-crown www.indiandentalacademy.com
  126. 126. 4. Esthetic requirements of the tooth www.indiandentalacademy.com
  127. 127. Anterior teeth, premolars, and often the maxillary first molar come in the esthetic zone of the mouth. Alterations to the color or translucency  negative impact on the esthetics of this zone. www.indiandentalacademy.com
  128. 128. • Careful selection of restorative materials . • Restorative materials include: Tooth colored dowels, Tooth colored composite resin or ceramic cores, Tooth colored cements and Ceramic crowns. www.indiandentalacademy.com
  129. 129. Thank you www.indiandentalacademy.com Leader in continuing dental education www.indiandentalacademy.com

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