MANAGEMENT OF

ENDODONTICALLY
TREATED TOOTH
BY:
JANSEN HAZEL GALBAN
JOYCE RAYRAY
INTRODUCTION
• Endodontic treatment is largely performed on
teeth significantly affected by caries, multi
restorations and/or fracture.

• Some of the basic, yet important, concepts in the

management of ET teeth are micro leakage, the
ferrule effect and biological width.
• It generally is agreed that the successful
treatment of a badly broken down tooth with
Restoration of teeth
pulpal disease depends not only on good
after endodontic
endodontic therapy, but also on good prosthetic
treatment
reconstruction is becoming
of the tooth after endodontic
therapy an
is completed.
integral part of the
restorative practice in
dentistry.
Diagnosis and Treatment Planning
ENDODONTIC PROSTHETIC
CONSIDERATION CONSIDERATION
1. Good apical seal 1. Extent of coronal
2. No sensitivity to pressure destruction
3. No exudates 2. Tooth type
4. No fistula 3. Position in arch,
5. No apical sensitivity morphology, circumference
6. No active inflammation of tooth, occlusal and
prosthetic forces applied to
7. Retreatment should occur if
tooth, periodontal support
there are signs and
symptoms indicating failure
ESTHETIC CONSIDERATION

1. Thin gingiva may transmit a dark shadow of the root through the
tissue

2. Metal or dark carbon fiber placed in the canal can result in

unacceptable gingival discoloration from the underlying root

3. Endodontic and restorative materials in these esthetically critical

cases must be selected so as to provide the best health service
with the minimum of esthetic compromise.
• Post (dowel) – refers to a cylindrical or tapered
object that fits into the prepared root canal of a
tooth.

• Core - refers to a build up restoration usually

amalgam/ composite placed in a badly broken
down tooth to restore the bulk of the coronal
portion of the tooth to facilitate subsequent
restoration by means of an indirect extra coronal
restoration
USE OF A POST
• Do posts strengthen ET teeth?
▫ It has been suggested that ET teeth dry out over
time and that the dentin in ET teeth undergoes
changes in collagen cross-linking. Therefore, it has
been suggested that ET teeth are more brittle and
may fracture more easily than non-ET teeth.
In other words, the
▫ Some studies,
mainhowever,
functionpoint
of aout that posts do not
post
strengthen isteeth,
the but instead that
retention of the
a preparation
of a post space
core andto thesupport
placementtheof a post can
weaken the root and
coronal may lead to root fracture.
restoration.
When to use a post?
• the evaluation of whether a post is needed is
based on how much natural tooth substance
remains to retain a core buildup and support the
final restoration after caries removal and
endodontic treatment are completed.
INDICATIONS
ANTERIOR TEETH
• Anterior teeth with minimal loss of
tooth structure may be restored
conservatively with a bonded
restoration in the access opening.
• A post and core is only indicated
when the tooth is weakened by
the presence :
▫ Large or multiple coronal restorations
▫ Undermined marginal ridges
▫ Require form or color changes that cannot be affected by
bleaching, resin bonding or laminate veneers
• Mandibular incisors and maxillary lateral incisors
receiving crowns
• Abutments for FPD and RPD
POSTERIOR TEETH
A. MOLARS
• Endodontically treated, molar
teeth should receive cuspal
coverage, but in most cases, do
not require a post.
• Post are indicated in molars when
large percentage of coronal
structure is missing and teeth are
at risk of fracture
• If it is placed in molars, the distal
canal of mandibular molars and
the palatal canal of maxillary
molars usually are the best canals
for post placement.
B. PREMOLARS
• premolars are usually bulkier
than anterior teeth, but often
single-rooted teeth with
relatively small pulp chambers
and are more likely than molars
to be subjected to lateral forces
during the mastication = it
requires post than molars.
• Post may be required if it will
function as abutment for RPD or
suffers from an attachment loss
• Post system must require
minimal reshaping and
enlargement of canal space due
to the canal anatomy of
premolars
PRINCIPLES FOR POST AND CORE
1. Preservation of tooth structure
1. Preparation of canal
2. Preparation of coronal tissue

2. Retention

3. Resistance
Preservation of tooth structure
a. Preparation of the canal
-coronal and radicular tooth
structure should be conserved
-preparation of a post space
should require minimal removal
of additional radicular dentin
beyond the requirements for
root canal treatment
-enlargement only weakens
the root
Six Important Features For
Successful Design
1. Adequate apical seal
2. Minimal canal enlargement
3. Adequate post length
4. Positive horizontal stop (to
minimize wedging)
5. Vertical walls to prevent
rotation
6. Extension of the final
restoration margin onto
sound tooth structure
Preservation of tooth structure
a. Preparation of the canal
b. Preparation of coronal tissue
-If more than 2mm of the coronal
tooth structure remains, then the
post and design plays a little role in
the fracture resistance of restored
tooth
-Extension of axial wall of the
crown apical to the missing tooth
structure provides what is known as
ferrule and helps to bind the
remaining tooth structure together,
preventing root fracture during
function
Retention
• Post retention refers to the ability of a post to
resist vertical dislodging forces
• Retention is influenced by the
▫ Canal shape and preparation of canal space
▫ Post’s length
▫ Post diameter and taper
▫ Post design
▫ Tooth location in dental arch
▫ The luting agent and luting method
Resistance
• Refers to the ability of the post and tooth to
withstand lateral and rotational forces
• It is influenced by the:
▫ Remaining tooth structure
▫ The post’s length and rigidity
▫ The presence of anti-rotation features
▫ The presence of ferrule
Rotational resistance
• Areas where coronal dentin
has been completely lost, a
small groove placed in the
canal can serve as an anti-
rotational element
• The groove is normally located
where the root is bulkiest =
lingual aspect
The Ferrule Effect
• A ferrule is defined as a vertical band of tooth structure
at the gingival aspect of a crown preparation.

• The ferrule should be a minimum of 1-2 mm high, have parallel

axial walls, completely encircle the tooth, end on the sound tooth
structure and not invade the attachment apparatus of the tooth.
Ferrule = ferrum (iron) + vairiola (bracelets)
It is a metal band that encircles the external surface of residual tooth
Two types of Ferrule
1. Core Ferrule- part of a cast metal core
-for cast post and core a contrabevel is given
collar of metal that encircles the tooth and
serves as secondary ferrule-independent of
crown ferrule.

2. Crown Ferrule- the ferrule created by the

overlying crown engaging the tooth structure
-the ferrule must encircle a vertical wall of sound
tooth structure above the margin and must not
terminate on restorative materials
• The purpose of ferrule is to improve the structural integrity of the
pulp less tooth by counteracting functional lever forces, wedging
effect of tapered dowels and lateral forces exerted during insertion
of the dowel

• It increases the mechanical resistance of the post/core/crown

restoration by reducing the potential for displacement (labial
and axial rotation) and compressive stresses within labial dentin
and canal wall
Consequences of inadequate ferrule
• Catastrophic / extreme root fracture
• Cement failure and post loosening
• Post fracture
Post selection
1. Root length 9. Post design
2. Tooth anatomy 10. Post material
3. Post width 11. Material
4. Canal configuration compatibility
5. Amt of coronal tooth 12. Bonding capability
structure 13. Core retention
6. Torquing force 14. Retrievability
7. Stresses 15. Esthetics
8. Development of 16. Crown material
hydrostatic pressure
Root length
• Determines the length of the
post
• Greater the post length, better
the retention and stress
distribution
• Parallel sided threaded post of
reinforced composite luting
agent can compensate for
reduced post length
• For short rooted molars more
that one post will provide
additional retention for core
• the post should be equal the
incisocervical or occlusocervical
dimension of the crown.
• The post should be longer than
the crown
• The post should be 1 1/3 the
length of the crown
• The post should end halfway
between the crestal bone and the
root apex
• The post should be as long as
possible without disturbing the
epical seal
Tooth anatomy
• Tooth anatomy such as root
curvature, mesiodistal width and
labio-lingual dimension, canal
structure, proximal root
concavities, anatomic variation –
all these factors should be
considered in order to avoid any
risk of apical or lateral perforation.
• Clinically, a post in maxillary
anterior tooth is subjected to
compressive, tensile, shear and
torquing forces.
Post width
• Post with must be controlled to
▫ Preserve radicular dentin
▫ Reduce the potential for perforations
▫ Permit the tooth to resist fracture
1. Proportionist approach suggest the post width should not
be greater than one third of the root width at its narrowest
dimension
2. Preservationist approach suggest that the post should be
surrounded by a minimum of 1 mm of sound dentin
3. Consevationist approach advocated minimal canal
preparation and maintaining as much residual dentin as
possible
Canal configuration
• Canal configuration determines whether to use
custom designed or perforated post
• Post should:
▫ Fit closely
▫ Apply conform to canal shape and size
▫ Less dentin removal
▫ Enhance fracture resistance
1. Circular canals- prepared to have
parallel walls (parallel
prefabricated posts)
2. Elliptical canals/ excessively
flared canals- cannot be prepared
to give parallel walls - taper
restricted to 6-8 degrees (custom
cast posts or tapered prefabricated
posts
Amount of coronal tooth structure
• The bulk of the restoration above the restorative
margin should be atleast 1.5mm to 2mm to
achieve resistance form

• In cases of endodontically treated teeth with

moderate to severe coronal tooth loss cast post
and cores were more successful whereas, in
cases where ample coronal dentin remain non-
metal posts such as carbon fiber post were
deemed successful.
Torquing forces
• Torsional forces on the post-
core-crown unit lead to
loosening and displacement of
the post from the canal
• Active post designs provide
greater torsional resistance than
a passive post
Stresses
• Post and core- restored endodontically treated teeth are
subjected to various types of stresses: compression,
tensile, and shear.
• Of these stresses, shear stress is most detrimental to the
restored tooth.
• An increase in the post length with diameter kept to a
minimun will help to reduce shear stresses and preserve
tooth structure, thus, the vulnerability of the
endodontically treated tooth to fracture is deacreased.
Post material
• Wagnild et al (2002) summarixed the ideal
physical properties of a post that include:
1. maximum protection of the root
2. Adequate retention within the root
3. Biocompatible / noncorrosive
4. Maximum retention of the core and crown
5. Maximum protection of the crown margin
cement seal
6. Pleasing esthetics
7. Radiopeque
• According to construction:
▫ Custom made
▫ Preformed
• According to nature of fit:
▫ Passive
▫ Active
• According to shape:
▫ Parallel
▫ Tapered
• According to surface configuration:
▫ Smooth
▫ Serrated
▫ Threaded
 Types of a posts
• There are two main categories of 2. Prefabricated post and
posts: custom-fabricated and core crown is a type of dental
prefabricated. restoration required where
1. Custom-fabricated cast gold there is an inadequate amount
post and core has been used of sound tooth tissue
for decades as a foundation remaining to retain a
restoration to support the final conventional crown.
restoration in ET teeth. 1. Metal
1. Gold alloy 1. Stainless steel
2. Chrome-cobalt alloys 2. Titanium
3. Brass
3. Nickel-chromium alloys
2. Non-metal
1. Carbon-fiber
2. Fiber-reinforced
1. Glass fiber
2. Quatz fiber
3. Woven polyethelyne fiber
3. Ceramic and zirconia
Prefabricated post and core system
• Eliminate weaker residual walls, clean up the
cavity, preserving all healthy dentin.
• Prepare the root canal according to your usual
procedure
• The post is chosen according to the canal’s
diameter not to the root’s diameter
• Prepare the composite bonding cement, coat the
post
• Insert it immediately into the canal
• Fit the core form boxing system
• Fill up with the core composite while pressing
and polymerize
• Advantage
▫ Less expensive
▫ Less no. of appointments
• Disadvantage
▫ dislodgement
▫ Chemical reaction
▫ Difficult to retrieval of active post
Custom cast post system
• Direct technique

• Indirect technique
Direct technique
• Remove any weak, thin,
and unsupported tooth
structure
• Using progressively larger
diameter Pesso reamers
remove the gutta percha
into the predetermined
initial depth
• Repeat this process as
necessary leaving 4-5 mm
of gutta percha as an
apical seal.
• Add a keyway to resist rotation of post/core.
• Place the keyway in the bulkiest part of the
remaining tooth structure.
• Try-in the performed
plastic post and be
sure it goes all the way
down the prepared
canal w/o binding
(totally passive fit)
• Trim it as necessary.
• Measure the post
relative to the depth of
the canal with a
periodontal probe
• Lubricate the canal
▫ Using the bead brush
technique, fill the canal
completely with resin.
▫ Use the bristles of a brush
(bent at a 45 degree angle
for easier access) to force
acrylic down the canal
and express any trapped
air
• Immediately, dip the
plastic post in acrylic
liquid ( to soften post
and enhance bond of
acrylic) and seat it in
the canal for its full
depth
• Move the post up and
down in the canal 1-2
mm to avoid getting it
“locked in”
• Using hemostats,
carefully remove the
post pattern and
inspect it to be sure it
is fully formed = with
no voids

• Cut off the top of thee

plastic post so that
your patient can close
completely
• Using a large diameter
coarse diamond, shape
the pattern to ideal
preparation form on the
tooth.

• Using hemostats, remove

the pattern from the
tooth. The pattern
should not be removed
until it is completed.
• There is the risk of
breakage each additional
time the pattern is
removed.
Indirect technique
• The tooth is prepared
prior to the pattern
fabrication.
• A heated endodontic
condensor is used to
safely remove the gutta
percha
• The minimum length of
the post is equal to the
length of the clinical
crown
• The recommended
length is 2/3 the length
of the root in bone while
maintaining 5mm of
gutta percha at the apex
▫ Remember chances of
perforation increases as
the length of the post
approaches the apex of
the tooth
• The prefabricated post
are inserted into the
canals. In this case a
precious metal post is
being used in the
lingual canal because
the canal diameter is
only equivalent to a
brown sized parapost.
• The precious metal
post are issued from
the dispensing window,
and require an
additional fee
• The assistant hold the
powder, liquid ans
suction- while the core
portion is made in resin
• 1st lubricate the
remaining tooth
structure with a water
soluble lubricant then
apply the resin.
• The assistant may
remove the suction near
the resin, evaporating
monomer from its
surface
• The completed resin core
is allowed to polymerize
– then it is prepared to
the shape of the ideal
crown preparation

• Using conventional
diamond instruments,
water and suction, the
resin core is prepared in
the same manner as a
conventional preparation
• The preparation is
completed to ideal form
and in this case its path
of insertion is aligned
with the preparation of
tooth #11

• The completed post and

sore patternnsubmitted
to the laboratory for
investing and casting in
gold alloy
• The casting is cleaned
and sandblasted with
alumina oxide in
preparation for try-in,
shaping and
cementation.
• The canals are dried
and the casting
inserted using light
pressure
• Small shiny marks on
the casting indicate
where adjustment
should be made
• The completed post is cemented
Material compatibility
• Dissimilar alloys of the post and the core may create
galvanic action, which can lead to corrosion of the
less noble alloy.
• These corrosion products cause a change in volume
that has been postulated to cause the root fracture
• Titanium alloys are the most corrosion resistant.
Alloys containing brass have lower strength and
lower corrosion resistance and hence are less
desirable noble metal alloys are corrosion resistant,
but their cost is higher.
• But with the availability of nonmetallic post
materials, the corrosion factor is eliminated.
Bonding capability
• The bonding of the post should improve the
prognosis of post-core restored tooth by
increasing post retention and by reinforcing the
tooth structure.
• Resin luting agents have good adhesion to
carbon fiber post and glass fiber post
• The adhesion to zirconia post was found to be
unsatisfactory.
Core retention
• Prefabricated metals posts with direct cores
made of glass ionomer, composites, or amalgam
are less reliable than a one-piece cast post and
core because of the interface between the post
and the core.

Retrievability
• Carbon fiber post have an advantage over
metallic , ceramic, zirconia post in that the
removal is relatively easy, rapid and predictable.
Esthetic
• Custom cast post would compromise esthetics as the
gray tint of the metal may show through the thin
root wall. The overlying gingival tissue would also
appear darker or grayish.
• With prefabricated metal post, the core material can
be composite, which may aid in masking the metallic
color of the post depending on the thickness of the
composite.
• A ceramic crown with an opaque substructure may
be necessary in situations where complete masking
is difficult.
Crown material
• The metal ceramic crown will permit the
clinician to use any post and core material
• All ceramic crowns are translucent and allow
metal to show through.
• When crown thickness is reduced, the color of
foundation restoration shows through a
nonopaque thin crown.