Preparation for Restoration ‘& Harold H, Messer and Charles J. Goodacre aie aa ‘ter reading this chapter, the student should be able to: 1. Describe the main factors involved in the surval of rootilled teeth, 2, Summarize factors contributing to loss of tooth strength and describe the structural Importance of remaining tooth tissue. Explain the importance of coronal seal and how itis achieved. Describe requirements of an ackequate restoration. 5. Outline postoperative risks to the unrestored tooth. 5. Discuss the rtionale for immediate restoration CHAPTER OUTLINE LONGEVITY OF ROOT-FILLED TEETH [AND CAUSES OF TOOTH LOSS STRUCTURAL AND BIOMECHANICAL ‘CONSIDERATIONS Structural Changes in Dentin Loss of Teoth structure Biomechanical Factors Requirements for an Adequate Restoration CORONAL SEAL ‘AND TOOTH. estorability should be confirmed before root canal ‘treatment Is begun. Options for restoration are also considered then, although the final choice is often made treatment progresses. The options for restoration need careful cons dlerstion because mote endodontically Iteated fecth are lost as a result of restorative factors than as a result of failure of the root canal treatment itself.” In most cases, restoration is straightforward, but the choice must be based on sound principles if the tooth is to be retained long term as a functional unit. This chapter considers principles of restoration rather than detalled techniques, which are beyond the scope of this textbook, LONGEVITY OF ROOT-FILLED TEETH AND CAUSES OF TOOTH LOSS Root-filled teeth are expected fo function effectively for 1 prolonged period. Numerous studies investigating the survival of root-filled teeth have documented that at most 19 to 2%6 are Tost per year." A very large study of 14 million cases reported that only 2.6% of teeth were lost RESTORATION TIMING RESTORATION DESIGN Principles and Concepts Pins Planning the Definitive Restoration PREPARATION OF CANAL SPACE 7. Kdentify restorative options before commencing root canal treatment 8, Discuss advantages and disadvantages of direct and indirect restorations ‘9. Outline indications for post placement in anterior and posterior teeth. 10, Describe common post systems and advantages and disadvantages of each, 11, Describe core materials and their placement 12, Describe techniques for restoring an access opening through an existing restoration. RETENTION AND CORE SYSTEMS ‘Anterior Teeth Posterior Teeth RESTORING ACCESS THROUGH AN EXISTING RESTORATION Coronal Tooth Preparation Post Space Preparation after 6 years. A smaller but more detailed study found that root-filied teeth were 3 times as likely to be extracted as their vital, contralateral counterparts in the same patient, but 89% of root-filled tecth were retained after 8 years? Clearly, many factors contribute to loss of enddodonti- cally treated teeth. Endodontic problems (development or persistence of a periapical lesion, with accompanying signs and symptoms) are generally amenable to further management rather than extraction, Most teeth are lost for periodontal or restorative reasons (including caries)."* Many restorative varlables influence the success rate achieved in clinical practice, and much lower survival rates can De expected with inadequate restoration.”? ‘When root canal-treated teeth are restored with crowns as opposed to no crown, the tooth survival rate is, enhanced." A well-placed amalgam with adequate Ccuspal protection is also a durable restoration. Most pos- terior teeth requiring extraction are lost because of tunrestorable crown fracture, resulting from inadequate restoration that does not protect weakened cusps (Figure 16-1).7" A literature review of complications associated 287288 Chapter 16 + Preparation for Restoration Figure 161 Crown root fracture (split tooth) of a root ccanal-treated tooth restored with amalgam but lacking pro tection of undermi Colman) j, weakened cusps. (Courtesy Dr. H. vith posts and cores found an average complication rate Cf 1096 in clinical studies, with post loosening and root fracture being the mast common complications.!* STRUCTURAL AND BIOMECHANICAL CONSIDERATIONS. Teeth function in a challenging environment, with heavy ‘occlusal forces and repeated loading at a frequency of more than ane million cycles per yeat, over many years Of clinical life, Caries, restorative procedures, and occlusal wear add to the risk of serious damage to teeth during normal function, and root-filled teeth are at greater risk than intact teeth, Restorative fallures commonly Include cusp fractures ‘or some form of coronal fracture (split tooth) (see Figure 16-1)? It is important to understand the basis for this fracture susceptibility when designing restorations. Access preparation superimposed on an extensively catious or restored tooth leads to further loss of tooth structure. Unsupported cusps (particularly those without an adja- cent intact marginal rldge) associated with a large access, opening are more prone to fracture. Excessive preparation of the canal space for a post further weakens the root and Introduces significant stress areas." Structural Changes in Dentin ‘The clinical perception persists that root canal-treated teeth become brittle, supposedly losing resilience as the moisture content of dentin declines after pulp loss, This, perception has only limited experimental support. Few studies have compared physical properties of endodonti~ cally tyeated versus untreated human teeth with vital pulps. The moisture content of endodonitically treated teeth was not reduced, even after 10 years." Also, com= paring vital and roct-filled teeth revealed only very minor differences in. strength, toughness, and hardness. of Figure 16-2 Teeth requiting root canal treatment have commonly been structurally compromised by caries and restorative procedures. dentin." Thus susceptibility to fracture cannot be atttlb- tuted only to structural changes in dentin after loss of pulp vitality. The loss of dentinal fluid, which may play a role in steess distribution and stress relief, could contribute to changes in the response of rooted teeth to occlusal stresses.” Loss of Tooth Structure ‘Teeth are measurably weakened even by occlusal cavity preparation; greater loss of tooth structure further com: promises strength. Loss of one or both marginal ridges is a major contributor to reduced cuspalstifines (strength), which predisposes to fracture (Figure 16-2). Access has only a minor effect on decreasing cuspal strength when the access cavity is surrounded by solid walls of dentin. In a tooth already seriously compromised by caries, trauma, or large restorations, the access cavity is more significant, particularly If the adjacent marginal ridge has been lost: Excessive coronal flaring results in greater susceptibility to cusp fractures?” Biomechanical Factors ‘The occlusal loads to which teeth are subjected during normal function generate large stresses in teeth, which, are capable of causing cusp fracture and even vertical root, fracture in intact vital teeth.” Cuspal flexure (movement under loading) will weaken premolars and molars over time." As cavity preparations become larger and deeper, ‘unsupported cusps become weaker and show more deflec- tion under occlusal loads. Greater cuspal flexure leads to cyclic opening of margins between the tooth and the restorative material, Fatigue is also a factor; cusps become progressively weaker with repetitive flexing, Thus the res- {oration must be designed to minimize cuspal flexure to protect against fracture and marginal leakage.Requirements for an Adequate Restoration Based on these concepts, the definitive restoration must (2) protect remaining tooth structure, (2) minimize cuspal, flexure, (3) providea coronal seal, and (4) satisfy function, and esthetics. Care must be taken to ensure that esthetic demands do not lead to the weakening of teeth by exces- sive removal of remaining tooth structure. CORONAL SEAL Eliminating bacteria from the canal space and preventing reentty are crucial to healing, The coronal seal is an essen- tial component of bacterial control, both during and after treatment. ‘The restoration (both temporary and denint tive) provides the coronal seal. Coronal leakage is a major cause of failure?2" Even & ‘well-obturated canal with appropriate use of sealer cement does not provide an enduring barter to bacterial penetta- tion2%* Exposure of obturating matetials to oral fluids through @ lost restoration, marginal discrepancy, or recur rent caries leads eventually to sealer disintegration and bacterial contamination of the canal system, with subse quent apical pathosis ‘The restoration must provide the coronal seal either as f separate step (@g., placing a barrier over canal orl- fices)”* or more commonly as ant integral part of the restoration by virtue ofits marginal sealing ability. Posts (particularly prefabricated posts) and cores do not create 4 seal until the own Is placed. Lack of an intact sealing restoration is an important factor in the persistent cr developing perizpical lesion, Fortunately, this is usually correctable by endodontic and restorative retreatment Another concem is inadequate temporary seal, both during treatment and after treatment Is complete but before definitive restoration. There is not sufficient infor ration to know how much exposure time to oral fluids mandates retreatment because the time required to develop substantive leakage has varied between 3 and 90 days in experimental studies." In a clinical study in ‘which root canal t:eatment was of high quality (maximal obturation), periapical lesions did not develop even several years after the coronal seal was lost" Because the {quality of obturation is often uncertain, a commonly accepted guideline is 2 to 3 months." ‘The unrestored, temporized, root canal-treated tooth ‘without definitive restoration is a candidate for problems. Unless there ate specific reasons for delay, definitive res ‘oration Is completed as soon as practical." The tooth is at its weakest after access and remains so until itis appropriately restored. The temporary will not provide complete protection against occlusal forces even when the tooth is out oF occlusion or is splinted with an orth odontic band, Practure during or soon after treatment all oo common (Figure 16-3). Most temporary restorative ‘materials have low wear and fracture resistance; substan- tial occlusal wear or material fracture may occur within ‘weeks, It is unnecessary to wait for radiographic evidence of healing before the final restoration is placed, Even in Chapter 16 + Preparation for Restoration 289. Figure 16-3 Unrestorable fracture during root canal treat~ ment. The lack of cuspal protection combined with deep anatomic grooves led to fracture within days of endodontic access. ‘many cases with a guarded prognosis, prompt definitive restoration may improve the prognosis because of the better protection. ‘Almost the only reason to delay the definitive restora tion is a questionable prognosis where fallure woutd lead, to extraction, The prognosis for procedural problems, such as perforation, has been so greatly improved with newer repair materials, such as mineral trioxide aggregate (MTA), that few endodontic indications justify a delay. ‘With a guarded prognosis, the rationale for postponing definitive restoration is based on the nature of further management if failure occurs. Decision making for man- aging failure is covered in Chapter 19, Retreatment is, usually possible through the restoration; if correction, requires surgery, there Is no reason to delay restoration, If definitive restoration is delayed, the temporary must last as long as necessary (up to a year). It must protect, seal, and meet functional and esthetic demands, A good long-term posterior provisional restoration is an amalcore that encompasses (onlays) weakened cusps, thus provid- ing functional and sealing protection. The definitive crown preparation can be completed later without remov- ing the core (Figure 16-4). Comparable anterior «estora- tions are more challenging because of esthetic factors and, difficulties with coronal seal. A provisional post may be susceptible to flexion and loosening, thereby compromis- ing an adequate seal.” It is preferable to place a definitive post and core immediately (which provides a better ‘coronal seal) when a provisional crown is indicated." RESTORATION DESIGN ae Principles and Concepts “Three practical principles for function and durability are the following: 1, Conservation of tooth structure. Most teeth requiting, treatment are already compromised structurally; further dentin removal should be minimized. On,290 Chapter 16 * Preparation or Restoration Figure 16-4 Chamber and canal orfices retain an amalgam core, taking advantage of natural undercuts. The teeth can be prepared for crowns without removing the amaicore, or the amalgams may be definitive restorations if the cusps are adequately protected. (Courtesy Dr. P. Parashos.) the other hand, cuspal reduction and crown place- ment may be necessary to encompass remaining tooth structure, thereby preventing fracture and preserving the tooth, Routinely decoronating and rebuilding an endodontically treated tooth is nei- ther desirable nor in keeping with contemporary 2. Retention. The coronal restoration is retained by the core and remaining dentin. If the core requires retention, then the pulp chamber and root canal system can be used, with provision of a post. A post weakens and may perforate the root and should be placed only when needed to retain the core."** 3. Protection of remaining tooth structure. In postetior teeth, this applies to protecting weakened cusps by minimizing fexure and fracture. The restoration, designed to transmit functional loads through the tooth to the suspensory apparatus. Planning the Det ‘The choice of definitive restoration can be clecided only after caries and any existing restoration are removed and the access Is prepared. Visualizing the restorative prepara- /e Restoration tion in advance ensures that structural requirements of © the core will be preserved. Increasingly, esthetic demands are leading to the use of tooth-colored materials for both direct and indirect cestorations. These materials may have Jess favorable functional properties than metallic restora- tions and require greater removal of tooth structure. Care rust be taken to ensure that structural strength is not ‘compromised. For anterior teeth, the choice of final restoration is somewhat limited. Wherever possible, restoration of the access (eg, ackd-ech composite) is used; this fs sufficient for teeth that are otherwise largely Intact. For more exten- sively damaged teett (trauma, large proximal restora- tions), complete coronal coverage supported bya posticore is indicated. The choices for premolars and molars are more varie. Figure 16-5 Resin composite restorations are more esthetic than amalgam and are increasingly used when cost Is a cconcem, The procedure is technique sensitive and recurrent proximal caries needs to be monitored carefully Direct Restorations Restorations inserted directly into the prepared cavity (amalgam or composite) may be conservative, but a requirement is that the restoration protects against coronal fracture. Indications include the following: 1. Minimal tooth structure has been lost before and during root canal treatment. A conventional access cavity ina tooth with intact marginal ridges is restored without further preparation, 2, Prognosis is uncertain, requiring a durable semiper- manent restoration. 3, Ease of placement and cost. Many posterior teeth may be restored with amalgam if itis esthetically acceptable and if unsupported. cusps ate adequately protected. A conventional class IL ‘amalgam will not achieve this and ordinarily should not be used.” At a minimum, cusps adjacent to a lost mar al ridge should be onlayed with sufficient thickness of amalgam (a least 3 to 4 mm) to resist occlusal forces. The amalgam should extend into the pulp chamber and canal orifices to ald retention. The amalgam may subsequently serve asa core for indirect cast restoration if indicated (see Figure 16-4). Bonded amalgamis have also been used, but their clinicil performance in root-illed teetin has’ not been documented, and bond failure is likely to be cata- strophic for otherwise unsupported cusps ‘There can besubstantial esthetic deficits whenamalgam Is used in visible teeth, and the need fora tooti-colored, restoration has led to expanded use of bonded composite resin restorations. The use of bonding continues to esca- Jate as materials and techniques improve, and good results, have been reported in a long-term prospective clinical study of resin composite restorations (Figure 16-5). Recutrent proximal caries remains a concern, Indirect Restorations Cast restorations (onlays and three-quarter_and_ full crowns) provide the greatest occlusal protection and are optimal if there is extensive loss of tooth structure, TheChapter 16 + Preparation for Restoration — 291 Figure 16-6 A, Cast gold onlay incorporates a reverse bevel for additional protection against cuspal flexure, but may not satisfy esthetic requirements for many patients. B, A full crown Is estheticaly more acceptable but involves greater tooth reduction than an onlay. attractiveness of onlays is that the cavity design usually requires little additional tooth tissue removal other than. for the cusp onlays (Figure 16-6). The access cavity should be sealed with an amalcore or glass ionomer, which forms a base for the casting, The strength of gold allows conser- vative tooth reduction and @ reverse bevel for effective cusp reinforcement. ‘A full crown isa reliable, strong restoration that pro- tects against crown-root fracture.’*” Root canal treat- ment coupled with tooth reduction may result in the removal of substantial coronal tooth structure, necessitat- ing placement of a core and occasionally @ post to retain the core. To plan the core shape, these must be complete exposure of the finish line. Gingival retraction cord and electrosurgery are useful for exposure and also prevent undersized cores being made because of incomplete view- ing of the finish line. Complete crowns should be used only when there is insufficient coronal tooth structure present for a moce conservative restoration or if func- tional or parafunctional stresses require the splinting effect of complete coronal coverage. PKEPARATION OF CANAL SPACE AND TOOTH Coronal Tooth Preparation Post Selection A post retains the core; the neet! for a post is dictated by theamount of remaining coronal tooth structure. A major disadvantage Is that posts do not reinforce the tooth but further weaken it by additional removal of dentin and by creating stresses that predispose to root fracture "2" A post system should be selected that fits the require ments of the tooth and restoration, The tooth and resto- ration should no: be prepared and adapted to the post, system; rather, the post system and preparation design should be selected as appropriate to the situation, ‘The debate on how the post should interact with the tooth under Joad is whether the post material should be similar in stiffness to root dentin (carbon fiber, qua fiber), somewhat stiffer (titanium and gold), or much stiffer (stainless steel and cobalt-chromium alloys). Stiffer posts may lead to tooth fracture, whereas the more flexible posts deform with the tooth and tend to fall ‘without fracturing the tooth. Bonding between the post and the tooth may allow the restored tooth to deform more with loading, compared with the conventional approach of the indirect restoration being much more rigid than the tooth, Long-term clinical trials will deter- mine how posts should interact with teeth and what ddegice of stiffness functions best. Carbon fiber and quartz fiber posts appear to be advantageous in relation to root, fracture potential. Fewer fractures have been recorded in laboratory stuclies compated to metal posts." However, these types of posts have been less retentive than metal posts in laboratory tests indicating the need for optimal retentive post length. Clinical results provide favorable data regarding longevity, post retention, and low fre quency of fracture (Figure 16-7). Tt has been determined in the laboratory that threaded posts create stress in the root of a tooth.** Additionally, a meta-analysis of clinical studies indicates the survival rate for threaded posts Is 81%, whereas.it is 919 for cemented posts.” Post Space Preparation ‘When a post is required for core retention, the minimum post space (length, diameter, and taper) should be pre: pared consistent with that need, Preparation consists of removing gutta-percha to the required length, followed by enlargement and shaping to receive the post (Figure 16-8). Caution is required; removing excess gutta-percha results in a defective apical seal.*"** Also, excessive dentin removal seriously weakens the root, which may predis- pose to root fracture. A perforation may occur if the ‘cutting instrument deviates from the canal or If the prep- aration is too large or extends beyond the straight portion of the canal. Radiographs may be deceptive as a guide to292 Chapter 16 * Preparation far Restoration Figure 16-7 A and B, Carbon fiber posts are increasingly used for anterior teeth, with excellent esthetic results. €, The post Is radiolucent. root curvature and diameter by disguising root concavi- ties and faciolingual curves. Asa general rule, post diam- eter should be minimal, particularly apically, and not more than one third of the root diameter.™ Tapered post preparation prevents the risk of creating a siep at the apical post space, which may predispose to wedging and, root fracture, Removal of Gutta-Percha Whenever possible, gutta-percha is removed immediately after obturation to ensure the most predictable apical seal, At this stage, the dentist is most familiar with the canal features, including shape, length, size, and curva- ture, Depending on the obturation technique, the canal may be filled only to the desired length or gutta-percha may be removed to length using a hot instrument. The remaining gutta-percha is then vertically condensed in the apical canal before the sealer has set. ‘The obturation radiograph will confirm that sufficient gutta-percha remains (4 to 5mm). Studies have shown that canal leakage occurs when only 2 or 3mm of gutta-percha is retained apically; however, little or no leakage occurs \when there is 4 mm or more.**** Therefore 4 mm of gutta- percha provides an appropriate apical seal. However, because of variation in the angulation of clinical radi graphs, It may be prudent to retain § mm or more of radiographic gutta-percha, Guita-percha removal ata subsequent appointment is satisfactory“ A safe procedure is the use of a heated instrument. Gutta-percha Is removed in increments to the desired length, using a heat carsier or heated plugger. Any instrument that penetrates to the desired depth can be uscd, as long as it has sufficient heat capacity. Alterna tive means of removal include solvents and mechanical, Problems with solvents, such as chloroform, xylene, ot cucalyptol, include messiness and unpredictable depth of penetration, Use of rotary instruments, especially Peeso reamers, requires cautlon because of thelr tendency to diverge ‘and perforate or at least seriously damage the root. They may also "grab" and displace the apical gutta- percha. Specially designed rotary nickel-titantum instru- ‘ments rotating at lovr speeds may be more effective, but hhave little evidence to recommend theit use. Finishing the Post Space ‘The post space is then further refined, If gutta-percha has been adequately removed, use of rotary instruments for final canal shaping should not be a problem, ‘The bulk of the canal preparation has been achieved by the end- odontic treatment, requiring ony small refinements.oe Be Parallel-sided drills generate significant temperature Increase; final shaping can be performed using hand manipulation of the cutting instrument because only small amounts of tooth need to be removed. Ferrule “The use of cervical ferrule (circumferential band of metal) that encompasses tooth structure helps prevent tooth fracture. Ferrules formed by the crown extending cervi Chapter 16 * Preparation for Restoration 293 Figure 16-8 A and B, Post space preparation showing adequate reten- fon of gutta-percha to provide an enduring apical seal. €, The post (here a Parapost) is fitted so that no gap ‘occurs between the past and remain- ing gutta-percha, and a resin compos- ite core is built up. D, The crown in place, cally so it engages tooth structure apical to the cote ate effective in helping teeth resist fracture, whereas fercules created by the core encompassing tooth structure ate generally not effective.** Crown ferrules that encompass more than 1 mm of tooth structure are the most effective in helping teeth resist fracture.” Ferrules that encompass 2mm of tooth structure around the entire circumference ofa tooth produce greater fracture resistance than ferrules that engage only part ofthe tooth circumference.!#294 Chapter 16 * Preparation for Restoration Figure 16-9 A, Resin composite core buildup, with a ferrule incorporated into the preparation. B, Full crown as the definitive restoration. RETENTION AND CORE SYSTEMS Anterior Teeth “These teeth must withstand lateral forces from mandibu- Jat excursive movements, which if transmitted via a post, tend to split the rot. Consideration should be given to the occlusal scheme. Where possible, the excursive load should be limited, with more force being borne by adja- cent, more structurally sound teeth, Kither a prefabricated post with direct core buildup or a cast post and core will funetion effectively, A prefabricated post with direct core buildup can be used for an antericr tooth (Figures 16-8 and 16-9). I'used, a preformed post should be passive to minimize wedging forces, Also, passive fit facilitates removing the post If retreatment is necessary. Screw-retained posts are contra. wdicated—they predispose to vertical root fracture and are difficult to remove. ‘A cast metal post and core is fabricated asa single uni ‘The post portion provides unit strength and retention, and the core cannot separate from the post. Custom fitting of the post and core permits minimal dentin removal both from the canal space and coronally, plus maximum ferrule effect without crown lengthening. Importantly, core shape should conform to the remaining coronal tooth Structure, rather than machining the tooth, for a standard core or technique. Posterior Teeth Premolars with substantial Joss of coronal structure, par ticularly maxillary premolars, aze best restored with a cast post and core (Figure 16-10), Natrow mesiodistal root width and substantial developmental root depressions coupled with tapered roots may resultin excessive removal of root structure when preparing the tooth for a prefab ricated post. Additionally, the mesiodistal thinness of the tooth may not permit adequate core thickness in association with < prefabricated post. Minimal enlarge- ment during post space preparation Is essential to pre- serve suficient dentin thickness." In maxillary premolars Figure 16-10 Acast post and core provides the best founda- tion for restoring maxillary premolars, with two roots, only the palatal canal should be used for the post; the buccal furcation groove and narrow root preclude use of the buccal root“ A small, short 2 to 3mm) post, in the buccal canal provides some retenitlon and antirotation. Molars, which have larger pulp chambers, permit lect core options; the volume of the core is greater and the chamber shape provides retention, Most molars are restored with the direct core only, without a post However, with minimal remaining coronal tooth struc ‘ture and’ small pulp chamber, a post may be placed in cone canal for additional retention. Posts are rarely neces- sary in molars and should be considered only when essen- tially no coronal tooth structure remains. ‘The longest and straightest canal is preferred for the post, usually the palatal canal of maxillary molars and the ‘istal canal of mandibular molars.* Other canals are nar- rower and more citrved and ate in weaker roots with surface concavities. These should be used only (and cau tiously) if other factors preclude placement in the largercanals, Core retention is supplemented by extending the core material 1 to 2mm into the remaining canal orifices ‘A wide variety of passively seated prefabricated posts {s available, Parallel-sided posts provide greater retention than tapered posts and do not wedge. They require more post space preparation; matching post size to canal size Js important to minimize dentin removal. The post need not contact dentin throughout its Tength to achieve ade- quate retention (this is important in distal canals of man- dibular molars, which areoften broad cervically). Threaded screw posts should not be used. Molar core design is simple and placement of the core requires little removal of tooth structure, A coronoradicu- lar core of amalgam (amalcore) condensed into the chamber and slightly into canal orifices is preferred and provides a passive, strong core (see Figure 16-4). With fastsetting amalgam, the crown may be prepared at the same vist, although preparation is easier when the mate- nial is fully set. A widely used alternative Is resin compos- ite, with comparable fracture resistance to amalgam and more favorable frecture patterns if failure occurs. However, composite resin has the advantage of allowing immediate crown preparation."® Glass ionomer cements do not have sufficient shear strength. Pins ‘There is no need for retentive pins. The stresses and. ilcrofractures generated in dentin and the risk of perfo- ration by pins outweigh any potential gain in retention. of the restoration, Pins have been suggested for antirota- tion of the post/core, but this is best achieved by other ‘means such as a slightly out-of-round preparation. RESTORING ACCESS THROUGH AN EXISTING RESTORATION Occasionally, pulps undergo irteversible puipitis or necro- sis after placement of a crown, requiring root canal treat- ment (Figure 16-1138 Access through the restoration, ‘with subsequent definitive repair of the opening, Is often preferred. For the restoration to remain functional, three condi- tions must be met: (1) the interface between the restora- tion and the repair material must provide @ good coronal seal; (2) retention of the restoration must not be compro- mised; and (3) the final core structure must support the restoration against functional or minor traumatic stresses ‘Access, particularly if overextended, may leave only a thin shell of dentin, especially in anterior teeth and pre- molars, Retention then depends almost entitely on the repair material. Fortunately, the chamber and canal are available to create a core that provides adequate retention and support in most instances, Flacement of a dowel ot post through an access or through an existing restoration adds no support and little retention and is rarely indicated ‘The repair matetial should have high compressive and shear strength, In most situations, amalgam is preferred, It improves retention, maintains and even improves its seal with time, and is easily condensed into the entire Chapter 16+ Preparation for Restoration 295 Figure 16-11 Pulp necrosis several years after preparation and placement of a fullcoverage festoration. Root canal treatment is now required through the crown, with atten- dant risks of perforation or loss of retention, chamber and access cavity as a single unit. Amalgam also functions well in anterior teeth with metal-ceramic resto- rations. Composite resins are usually the material of choice in tooth-colored crowns.” Glass ionomer cements and glass cermets do not have the requisite shear strength. Chapter Review Questions available in Appendix B or on the DVD REFERENCES 1, Sjogren U, Hagglund B, Sundgvist G, Wing K: Factors affect- Ing the long-term results of endodontic treatment, J Endod 16:498, 1990, 2, Vire DE: Failure of endodontically treated teeth: clasiica: tion anid evaluation, J Endod 17:338, 1991, 3, Lazatski M, Walker W 31d, Flores C, et al: Epldemiological evaluation of the outcomes of nonsurgical root canal treat- ‘ment in a large cohort of insured dental patients, J Endod 27:791, 2001 4, Salehrabi R, Rotsten I: Endodontic treatment outcomes in 2 layge patient population in the USA: an epidemiological study, f Fido 30:846, 2004. 5. Doyle SL, Hodges JS, Pesan Uf, et al: Retrospective cross sectional comparison of intial nonsuagical endodontic teat rent and single tooth implants, J Endod 32:822, 2006, 6. Caplan Dj, Cal, Yin G, White BA: Root canal filed versus nnon-root cana filled teeth: 2 retrospective comparison of ‘survival times, J Public Health Dent 68:90, 2008. 7. Sorensen JA, Martinoff JT: Intracoronal reinforcement and coronal coverage: a study of endodontically Leated teeth, J Prosthet Dent 31:780, 1984, 8, Hansen Ek, Asmussen E, Christiansen NC: In vivo fractures fof endodontically tneated posterior teeth restored with amalgarn, Endod Dent Traumatol 6:49, 1990. 9, Goodacre CJ, Spolnik Kl: The prosthodontic management of endodontically treated teeth: a literature review. Part J Success and falluce data, eatment concepts, J Prosthodont 3, 1994.