Post-Core (Dowel or Dowel-Core)

Cast Post-Core / Custom Dowel

Restoration of Endodontically Treated Teeth

Donna N. Deines, DDS, MS Fixed Prosthodontics
Sources: Shillingburg et. al. Rosenstiel et. al.

A post which fits within the canal and retains the core, which replaces the missing coronal tooth structure. Does not reinforce endodontically treated teeth. RCT should be gutta percha

Custom cast post-core (dowel)

Pre-fabricated Post-Core

Treatment Planning: Assure Restorability

Remove all caries (before RCT) Assess adequate tooth structure. Determine periodontal health / lack of mobility Determine need for crown lengthening or extrusion.

Treatment Planning: Restorability

Role of tooth in restorative treatment

Treatment Planning: Determine success of endodontic treatment

Asymptomatic Well-filled Good apical seal No evidence of pathology

Caries extent to bone level - consider C:R after crown lengthening Evaluate bite-wing radiograph as well as PA Option for FPD or implant replacement

Usefulness for effective occlusion Abutment for prosthesis Esthetics Could the tooth be more effectively be replaced?
FPD or implant

Poor RCT Fill or Apical Seal: Re-treatment

Treatment Planning

Evidence of Pathology
Fractured root
Periapical lesion Draining fistula Pain, mobility Isolated deep pocket

Long-standing temporary filling Recurrent caries Non-restorability Contamination of RCT Re-treatment

Root Resorption

Considerations for Anterior Teeth

Anterior Teeth

Intact moderate-size anterior:

Bleach and composite resin Porcelain laminate veneer (fx tooth, discoloration) No post will weaken tooth

Extensive coronal destruction

Post-core necessary to provide crown retention Resists horizontal dislodging forces

Posterior Teeth

Molars

Greater loading vertical fracture Cuspal coverage always recommended. Full crown with high fracture risk

Large circumference: post not necessary for lateral resistance just retention of core. Pulp chamber retention / pre-fabricated post / pinretention dependent on tooth structure. Amalgam or composite resin

If a post is needed: Palatal root of maxillary molars Distal root of mandibular molars (Buccal roots of maxillary and mesial roots of mandibular molars small, concavities, curvature)

Premolars

General Considerations
Cast or Prefab PC / Pin/pulp chamber retention
Thickness of tooth structure surrounding canal Bulk / height of remaining coronal tooth structure Diameter / morphology of root Bone support Role in final restorative plan

General considerations:

Use post/core only if roots are long, bulky, straight Use post if abutment / lateral stress / height:CEJ diameter is great. Minimum 2mm axial wall covered by crown (ferrule effect).

RCT tooth as abutment for 1-pontic FPD RCT generally not indicated for free-end RPD abutment. (esp. premolars)

Preparation of clinical crown

Ferrule Effect

Ferrule Effect

Encirclement of vertical axial wall to protect against fracture by counteracting spreading forces generated by the post. Conserve tooth structure Smooth sharp angles in cast post preps to minimize cementation stress & casting accuracy.
Crown margin must be placed on solid tooth structure or risk root fracture.

Ferrule Effect

Anti-rotation

Anti-rotation features

Pins, keyways, or remaining tooth structure. Peripheral distribution of retention and resistance features of core enhance resistance of restoration.

Anti-rotation features

Canal Preparation

Post-Core Considerations

2 posts; Oval shape of pulp chamber; remaining tooth structure.

Rubber dam isolation: asepsis; protection Remove gutta percha and prepare canal in separate procedures. Ideal time to make post space is immediately after obturation.

Make post-core separately from final preparation. Marginal adaptation and fit Facilitates replacement of crown Facilitates FPD abutment preparation

Retention form of posts: geometry

Embedment: Post Length Retention: 2/3 length of root (embedded in bone) and at least the length of clinical crown

Post Length

Serrated Smooth - Threaded

Post Embedment

Threaded post / inadequate length of post fractured root

Post Embedment

Fracture resistance:

Post length should extend to at least the distance of which the root is supported in bone.

Leave 4-5 mm apical seal Without endangering root thickness

1/3 diameter of root at its narrowest 1 mm surround of sound dentin at mid-root and beyond

A cylindrical post with near perforation of mesial aspect of distal canal

Safe removal of gutta percha

Cutting instruments NO!

Forces are directed outward along length of post Root fractures often caused by;
Too short a post Too large diameter

Heat Carrier - yes

Peeso reamer Round bur Twistdrill

Perforations can be caused by any cutting instrument

Perforation of palatal root maxillary molar

Improper angulation from access preparation. Facial curvature hidden on radiograph.

Remove little if any additional dentin beyond what is needed to perform the RCT

General guidelines for post design:

Conserve: remove little if any additional dentin beyond what is needed to perform the RCT Retain a minimum of 4-5 mm gutta-percha apically. An adequate ferrule of minimum 2 mm vertical height and 1 mm dentin thickness. Use a post designed to incorporate mechanical features that resist rotational forces. Post length: place the post to extend apical to the crest of the bone at least = height of clinical crown.

Modification of a cylindrical post

Modification of post space by adding core material or casting to cylindrical post

Cast Post-Core
Advantages:
Preservation of tooth structure (post fits space) Anti-rotation properties Core retention (inherent part of post)

Cylindrical Pre-fabricated Post-Core

Advantages:
Increased retention w/in root Ease of placement

Disadvantages:
Enlargement of canal for post at apex for fit Core retention to post can be problem Potential for rotation

Disadvantages:
# of appointments necessary Decreased retention of tapering design Wedging effect on root ???? (If no flat root face vertical stop)

Cast post-core using cylindrical serrated post

Technique: Pre-fabricated Post-Core

Pre-fabricated Post-Core

1. 2. 3. 4.

Measure canal length Remove gutta percha (heat carrier) Enlarge canal (Peeso reamer) Drill post hole (twist-drill)

Fit the post; correct length; x-ray

Note post #11 is not fully seated due to coronal contact

Place anti-rotation features, if necessary (grooves, pins)

Vlock Post Retentive Head

Post Cementation

Pre-fabricated Post Composite Core

Active threaded design or Passive serrated design (threaded design root fracture)

Etch; wash; dry (air and paper points) Coat post with cement Spin cement into canal with Lentulo spiral (ZnPO4) Seat using slow, finger pressure only

Pre-Fabricated Post Composite Core

Pre-fabricated Post Amalgam Core

Cast Post-Core: Preparation

Retentive head requires resin core.

Resin must present contrast in posterior teeth.

Place matrix band and condense amalgam; Leave slightly out of occlusion.

Internal walls must diverge (no

undercut).

No sharp internal angles.

Cast Post-Core: Pattern

Cast Post-Core: pattern cast in gold

Provisional restoration for cast post-core

Plastic post pattern fitted to lubricated canal with Duralay resin. Coronal portion added w/ second mix of resin. Resin core shaped to crown preparation.

Resin pattern is invested and cast (type III gold). Vent is cut with inverted cone bur. Cementation complete crown preparation.

Internal wire or temporary post

Provisional crown matrix combines acrylic resin with post.

Post Materials
Cast metal (Type III gold; Au-Pd) Stainless steel Titanium Ceramic / zirconium Fiber (carbon / quartz) / composite

Metal Dowel darkened root

Translucent posts: Ceramic / Composite Resin

Cast metal core to pre-fab post Pressed ceramic to ceramic post

Root discoloration often caused by internal debris, corrosion or microleakage.

Ceramic post composite core Resin cementation of post

Ceramic Post - Composite Core

Translucent post-core with all-ceramic crown

Reinforced Composite Resin Post

Inadequate post depth & retention Dissimilar metals - corrosion

Brass post amalgam core corrosion

Modulus of elasticity same as dentin Post will not cause root fracture Fatigue causes fiber / composite breakdown and post fracture Use only when well-supported by sound tooth structure and lack of heavy lateral forces.

Short post in facial canal. Amalgam condensed into lingual canal (fractured).

Cast post-core: Retention / resistance from both canals. (long post facial / short lingual) Contiguous metal structure resists fracture.

Orthodontic and periodontal adjuncts to restoring damaged teeth Regaining interproximal space Extrusion Crown lengthening with osseous correction Root resection

Long-standing carious lesion on proximal surface: migration of adjacent tooth

Orthodontic movement to create space

Orthodontic movement
Core restoration placed and prepared for full crown. Acrylic provisional crown is cemented. Elastic orthodontic separator is placed.

Orthodontic movement
0.6 mm ligature wire wrapped around contact and tightened. Check / tighten at 1week intervals Adjust occlusion Add contact to provisional crown

Orthodontic movement
Adjust occlusion as tooth is tipped. Surgical crown lengthening may also be necessary. Full crown is placed.

Extensive loss of tooth structure

Tooth structure lost to level of alveolar crest does not allow ferrule effect of crown to protect from root fracture.

Surgical crown lengthening

Orthodontic Extrusion

Crown lengthening: osseous re-contour and apical re-positioning of flap (3 mm apical to crown margin).

Deep cervical margin and bone resorption result in un-esthetic difference in gingival height. Can be due to deep fracture, caries, and crown lengthening surgery.

Normal anatomic C:R for CI is 11:14 Crown lengthening for 3 mm apical fracture leaves unstable and unesthetic 14:11. Extrusion / crown lengthening 11:11 - more esthetic and stable.

Orthodontic Extrusion

How much movement is necessary?

Endodontics and post-core Arch wire with mid-facial loop and embedded pin in provisional crown Elastic from pin to loop Movement of 1.0 1.5 mm / week

Distance the destruction extends apical to the alveolar crest The biologic width of 2.0 mm 1.0 mm for sulcus apical to crown margin

Amount of extrusion desired 3mm Bracket placed 3mm apical to center of post-core/provisional; Arch wire placed in brackets. Incisal length adjusted as tooth moves coronally.

Eruption of tooth and crestal bone

Facial tissue recontouring with periodontal surgery

#10 extruded for adequate ferrule with post-core. Bone travels with root unesthetic gingival line (low).

The descended level of gingiva and bone makes clinical crown shorter. (The alveolar crest descends with the tooth.) Osseous re-contouring to level of adjacent tooth allows equal length of clinical crown.

Extract or Restore #13?

Unfortunate clinical scenario Patient desires FPD replacement of #13.

Mesial perforation of root #12

Over-reduction and over-convergence of MF wall #12 pulp exposure necessitates RCT.

Near exposure on mesial #14 later needed RCT.

Improper angulation of access preparation near perforation of mesial concavity.

10

Preparations for Periodontally Weakened Teeth

Shoulder finish line extended onto root surface requires excessive axial reduction: possible pulpal involvement and weakening of entire tooth

Conservative treatment: Prepare for metal-ceramic to CEJ; Long bevel or light chamfer metal collar

Furcation Flutes

The anatomic facial groove should merge with the vertical concavity extending from the furcation flute

Root Resection
Eradicate areas of tooth which cause problems in hygiene maintenance. Salvage teeth with endodontic problems. Must not have excessive bone loss. Furcation must be in coronal 1/3 and well separated roots. Must be treatable w/ endo.

Preparation finish line intersects with the vertical flutes in the root trunk. Axial surface of tooth preparation occlusal to the inversion of the gingival finish line must have a vertical concavity or flute, as will the crown. Like seating groove must parallel path of insertion.

The facial convexity should not be replicated in the restoration.

DF and MF Root Resection on Maxillary Molars

Mesial / Distal Root Resection on Mandibular Molars

Mesial root resection #30

11

Cast post-core distal root and FPD #29-30

Metal framework and metal ceramic FPD #29-#30

Facial and palatal root resections on maxillary molars

12