Review ArticleRestoration of Endodontically Treated Teeth Review andTreatment Recommendations

Amrita Dora, O.R.Ganesh Murthi, Amithbabu, Praveen J, Ourvind Singh

Post-Graduate Program in Endodontics, University of The East, Manila,Philippines

INTRODUCTION:

Recently, growing attention has been given to procedures carried out after completion of the endodontic treatment and their impact on the prognosis of devitalized teeth. These procedures may allow the passage of microorganisms and their by-products to the apical region of the root and into the alveolar bone, a potential cause of delayed failures. The consequences of these “events” may be important in determining the long-term success of the endodontic treatment[1].

Endodontic treatment is largely performed on teeth significantly affected by caries, multiple repeat restorations and/or fracture. Already structurally weakened, such teeth are often further weakened by the endodontic procedures designed to provide optimal access and by the restorative procedures necessary to rebuild the tooth. It is therefore accepted that endodontically treated teeth are weaker and tend to have a lower lifetime prognosis.

Hence require special considerations for the final restoration, particularly where there has been extensive loss of tooth structure. The special needs involve ensuring both adequate retention for the final restoration and maximum resistance to tooth fracture. Endodontic success depends not only on the quality of the root canal treatment, but also on timely coronal restoration of the compromised tooth.

Ray and Trope [2] evaluated the relationship between the quality of the coronal restoration and the quality of the root canal filling by examining the radiographs of endodontically treated teeth. They observed that a combination of good restorations and good endodontic treatments resulted in absence of periapical inflammation in 91.4% of the teeth, whereas poor restorations and poor endodontic treatments resulted in the absence of periradicular inflammation in only 18.1% of the teeth examined. Furthermore, where poor endodontic treatments were followed by good permanent restorations, that appeared radiographically sealed the resultant success rate was 67.6%.

History:

Various methods of restoring pulpless teeth have been reported for past 200 years. In

1747 Pierre Fauchard fabricated gold and silver posts to be placed in root canal space.Replacement crowns were made from bone, ivory, animal tooth.

Is final restoration after endodontic treatment important?

Root canal treated teeth are supposed to be structurally different from unrestored vital teeth. It has been suggested that endodontically treated teeth dry over time and dentin undergoes changes in collagen cross-linking.3 Therefore it has been suggested that endodontically treated teeth are more brittle and may fracture more easily than vital teeth.4-6 Fennis et al studied more than 46,000 patients from insurance claims and reported significantly more fractures in teeth with endodontic treatment. Moreover, after root canal treatment, the teeth usually presented inadequate remaining coronal structure.7-9 It is believed that it is the loss of the tooth structure from caries, trauma, or both that makes endodontically treated teeth more susceptible to fracture.10-11 Randow and Glantz12 reported that teeth have a protective feedback mechanism that is lost when the pulp is removed, which may also contribute to tooth fracture.13In this study using radiographs they assessed the following

1. Good restorations + good endodontic treatments resulted in absence of periapical inflammation in 91.4%.

2. Poor restorations + poor endodontic treatments resulted in the absence of periradicular inflammation in only 18.1%.

3. Poor endodontic treatment + good restorations yielded a success rate of 67.6%.

This shows the importance of final restoration in endodontically treated teeth.

Root Canal FillingMaterials

Salivary microleakage is considered to be a major cause of endodontic failure due to bacteria and endotoxins penetration along the root canal filling 14-15. Contaminationof the root canal can occur through salivary microleakage during post space preparation, after post cementation, through temporary fillings, and through leaking margins ofpermanent restorations 16. The penetration of saliva through obturated root canals increases with the longer exposure period 17. Microorganisms were isolated from obturated root canals after 22 days of exposure to saliva. Both lateral and vertical condensations methods of obturation were evaluated in this study 18. Additionally leakage of obligate anaerobesand bacterial metabolites along laterally condensed root canals was demonstrated without any significant differences between root canals obturated with gutta-perch cones (GP) and other root canal sealers 19-21. A novel filling system that was introduced in 2004, Resilon and Epiphany, was no better than gutta-percha with Roth or with epoxy resin sealers like AH Plus or MMseal at sealing root canals 23. In a comparative study using a microleakage model and a new sequence detection assay “One Cut Event AmplificatioN (OCEAN) technique”, Pasqualini et al. 24demonstrated that canals obturated with Resilon showed a greater number of microleakage events than those obturated with gutta-percha and Zinc oxide eugenol sealer. On the other hand, Bodromlu et al. 24 showed better results for Resilon as compared with gutta-percha and AH-Plus, especially in delayed post space preparation. Although none of the root-canal filling materials and sealers exhibited complete apical sealing 25. In another study, the Resilon system provided the lowest mean values of apical leakage, but did not provide hermetic sealing of the root canal system, furthermore, thermoplastification negatively influenced the apical sealing ability of Resilon 26.

What are the objectives of Final restoration?

27 1. Maintained coronal and apical seal of the root canal treatment

2. Protect and preserve the remaining tooth structure

3. Provided a supportive and retention foundation for the placement of definitive

restoration

4. Restore the function and esthetics

Temporary FillingMaterials

Temporary fillings, in teeth undergoing root canal treatment or before completion of the final restoration, must provide an effective barrier against salivary contamination of the root canal. Intermediate Restorative Material (IRM), Cavit, and TERM are commonly used as temporary filling materials 28. IRM, that is used due to its high compressive strength 29, has been demonstrated in bacterial leakage to be less leak proof than Cavit and TERM 28-30. These results were similar to those reported by others, in experiments. The post space should be dressed between appointments and irrigated before post cementation. performed using the fluid filtration technique 31-32 andthe dye penetration technique33. Some authors speculate that the expansion of hygroscopic restorative materials leads to poor adaptation at the restorative material-cavity walls interface34. In an in vitro work which examined the antibacterial effect of 4 temporary filling materials, IRM had a bacteriocidic effect on the growth of S. mutans which lasted for at least 14 days,whereas it had a bacteriostatic influence for 1 day on the growth of E. faecalis, which could not be demonstrated after 7 days. The authors suggested that IRM may be selective for some bacteria but not for others, therefore allowing the growth of E. faecalis which is associated with failure of endodontic treatments 35.

Classification:

Class I: 4 remaining cavity walls(access cavity)

If all the axial walls of the cavity remain and have a thickness greater than 1 mm, it is not necessary to insert posts (Fig 1). In these cases, any type of definitive restoration can be considered. This judgment is based on several in vitro studies, which can be assigned to evidence level II b, depending on their comparable study design.36,37,38

Classes II and III: 2 or 3 remainingcavity walls

Treatment in cases involving the loss of 1 or 2 cavity walls does not necessarily require the insertion of a post, as the remaining hard tissue provides enough surface for the use of other methods, in particular, for cores using adhesive systems (Fig 1). An in vitro study bySteele and Johnson39 showed that composites or amalgam restorations with 3 surfaces(MOD), increase fracture resistance. There was no significant difference between theexperimental groups, which included unaltered teeth or those with access only39 (invitro, II b). The comparison between different adhesive systems for the reconstruction ofroot canal-treated premolars with MOD cavities have shown that dentin-bonding systemsstabilize teeth particularly well, such that their fracture resistance was comparable to intactteeth16 (in vitro, II b). Furthermore, anterior teeth with proximal cavities do not benefitfrom post insertion17 (in vitro, II b).

Two clinical studies assigned to evidence level III, (due to retrospective methods), show that teeth with extensive MOD cavities without reconstruction and with crowns have a higher risk.40 Anterior teeth do not seem to benefit from restoration with crowns.41

Class IV: 1 remaining cavity wall

In cases where only one cavity wall remains, the core material has little or no effect on the frac ture resistance of the endodontically treated teeth42 (in vitro, II b). If the tooth has to be used as an abutment for fixed or removable partial dentures, crownpreparation will further decrease fracture resistance43 Therefore, the present concept suggests using posts in such cases of reduced remaining tooth structure. For esthetic reasons, nonmetal posts are preferred for treatment of anterior teeth. In posterior teeth, both metalposts and nonmetal posts are acceptable treatment options (Fig2)

Class V: No remaining cavity wall

In cases of teeth with a high degree of destruction where no cavity wall remains, the insertion of posts appears necessary to provide for core material retention (Fig 3). Additionally, the ferrule effect has a great influence on fracture resistance, especially indecoronated teeth. A ferrule, defined as a circumferential area of axial dentin superior tothe preparation bevel, should have a height of 1.5 to 2.5 mm.22–24 Various in vitro studieswith evidence level II b have shown that fracture resistance can be significantly increasedby the use of a ferrule; the post length or design (whether they are parallel-sided ortapered) are of secondary importance for fracture resistance if a sufficient ferrule canbe provided.44

If deep destruction of the teeth renders a sufficient ferrule impossible, a surgical crown lengthening can be performed. This provides a crown ferrule resulting in a reduction of static load failure45 (in vitro II b). Bolhuis et al46 postulated that the crown ferrule is more important than a post and core, or a core reconstruction with adhesive fillings only. The researchers examined decoronated, root-treated premolars. These were rebuilt by core build-up without an endodontic post or by core build-up with an endodontic post (a cast post and core, and a composite with a silica post), and an additional group was not provided with a core at all. No significant difference in fracture strength among the differentgroups could be demonstrated.46 Several criteria must be taken into account with respect to the indication for post insertion. These criteria will be presented later.

Fig 1 No post is needed in cases with at least 2 axial cavity walls remaining.A thickness of the cavity wall _ 1 mm and a height of _ 2 mm are preconditions.If these conditions cannot be fulfilled, the cavity wall must beconsidered as missing

Fig 2 A post should be inserted if only 1 cavity wall isremaining. Fiber posts are preferable in anterior teeth, but inposterior teeth, fiber or metal posts can be used.The core canbe made of composite or as a cast post and core. The definitiverestorations should be crowns in anterior teeth and

crowns, onlays, or overlays in posterior teeth.

Fig 3 A post must be inserted if there is no cavity wall remaining. A ferruleof 2 mm is needed to provide a lower risk of root fracture

Literature Review:

47 Restoration of Endodontically Treated Teeth:

An Evidence-Based Literature Review

University of Toronto, Faculty of Dentistry. Int J Prosthodont 2008;18(1):40-1.

Studies pertaining to the clinical performance of post and core and non-post and core retained full coverage crowns. The aim was to locate research, appraise and communicate the evidence found from scientific studies pertaining to the clinical performance of post and core and non-post and core retained full coverage crowns in order to determine which system would minimize post-operative complications and furnish long term prognoses.

Outcome Measures and Rates

(1) Re-cementation of crown is not considered a failure (data is censured instead)

(2) Extraction due to periodontal reasons is not considered a failure (data is censured instead).

Includes tooth loss due to fracture of crown/root, periradicular disease, caries, trauma, or other reasons)

ANTERIOR TEETH

With only a conservative access opening, anterior teeth can be restored with a resin restoration. Placement of a post is not necessary when a complete coverage restoration is not indicated. Post installation may inhibit attempts to bleach a discolored endodonticallytreated tooth. Moreover, a post does not strengthen the root. A retrospective study by Sorensen and Martinoff48 showed no improvement in prognosis for endodontically treated anterior teeth restored with a post. Lovdahl and Nicolls" found that endodontically treated maxillary central incisors with intact natural crowns exhibiting access openings were stronger than teeth restored with cast posts and cores or pin-retained amalgams. Large interproximal restorations, incisal edge fractures, or esthetic concerns may necessitate the placement of a post and core, as well as full corona' coverage.49

POSTERIOR TEETH

A significant improvement is noted in the clinical success of endodontic treatment of maxillary and mandibular premolars and molars when coronal coverage restorations are present. Full-coverage crowns prevent fracture when occlusal forces act to separate the cusp tips.48 Crowns should generally be used on all endodontically treated posterior teeth.50-51 If significant tooth structure has been retained, a crown may be all the coverage required. If minimal structure remains, a post may be necessary to help retain a foundation before crown placement. If a crown cannot be placed because of a patient's financial limitations, the clinician should provide some other form of cuspal coveragesuch as an amalgam onlay.

COMPONENTS OF FINAL RESTORATION

A. Posts

B. Cores

C. Crowns

POSTS

Most in vitro laboratory studies that have tested endodontically treated teeth by applying force with a mechanical testing machine have shown that placement of a post and core does not increase fracture resistance. Researchers are in general agreement that posts do not reinforce endodontically treated teeth and actually weaken the root.52-56 The primary purpose of a post is to retain a core that is used to retain the definitive restoration

Indications

57Post placement is indicated if both of the following clinical conditions exist:

The remaining coronal tooth structure is inadequate for the retention of a restoration.

When there is sufficient root length to accommodate the post while maintaining an adequate apical seal.

Factors to consider

1. Type of post

2. Post length

3. Post diameter

4. Post design

Types of Posts

Posts can be made of a variety of materials (Figure 4). Prefabricated posts are generally made of stainless steel, platinum-gold-palladium, or titanium, but newer compositions include ceramic and carbon fiber. Cast custom posts are usually cast from Type II or III gold alloy. Posts can be categorized by mode of retention (active or passive) or shape (parallel or tapered). Laboratory studies indicate that threaded (active) posts are the most retentive, followed by cemented, serrated, parallel-sided posts.58 Cemented, tapered posts are the least retentive. Although threaded posts are the most retentive, they place insertion stress on the root and can cause root fracture. The tapered post has a wedging effect that also places stress on the root. Parallel serrated posts have the advantage of good retention with uniformly distributed functional stresses.' A study by Felton," however, demonstrated no statistical effects of post design on the potential for root fracture and concluded that the amount of remaining dentin and existing root morphology may be determining factors for fracture resistance during dowel placement in endodontically treated teeth. Although retention is often evaluated in comparisons of post and core systems, clinical experience indicates that

a post placed to adequate length is not likely to fail regardless of the design. Intact, adequately placed posts are difficult to remove when necessary.

FIGURE 4 Posts can be made from various materials such asstainless steel (A), esthetic carbon fiber (B), carbon fiber (C), andceramic (D).

Post Size and Length

Post length is unique and individualized for each case. The clinician should have a thorough knowledge of root morphology before placing a post. The effect of the embedded depth of posts on retentive capacity has been shown to be significant.59 The longer the post, the greater the retention. A guideline of one half to three quarters of the root length is often followed but may not be reasonable for extremely long, short, narrow, or curved roots. At a minimum, research has established that the post length should be equal to or greater thanthe crown length of the restored tooth. Retrospective clinical data on 1273 endodontically treated and restored teeth demonstrated few failures for posts that were as long as the crown or longer.'° At least4 to 5 mm of gutta-percha should be left in the apical portion of the canal to ensure an adequate seal. If this guideline cannot be followed and the post is shorter than the crown, extraction should be considered. The width of the post should not be greater than one third of the width of the root at any point along the dowel. Maintaining a minimum of 1 mm of sound dentin around the post is also advisable. Tjan 60 demonstrated that root Valls with 2 or 3 mm of buccal dentin were less likely to fracture than those having only 1 mm. Because of the

two-dimensional nature of radiographs, buccal-lingual dimensions cannot be assessed and therefore the actual amount of dentin present in the mesio-distal direction may be smaller than the amount perceived. The clinician should keep this in mind and carefully consider teeththat have roots with fluting or depressions along the mesial and distal surfaces. Smaller posts not only conserve tooth structure, but also provide increased resistance to fracture compared with larger posts. 61

Post length:

62Guidelines:

1. The post should more than the incisocervical or occlusocervical dimension of the crown.

2. The post should be longer than the crown.

3. The post should be 1 1/3 the length of the crown.

4. The post should end halfway between the crestal bone and the root apex.

Fig 5 Ideal tooth preparation for post placement

Fig 6 A ideal length of post. B. short post are more likely to fracture

Ferrule Effect

The ferrule effect is achieved by encircling the remaining tooth structure with a cast band of metal. This effect has been shown to significantly increase the fracture resistance of an endodontically treated tooth by counteracting functional stresses such as lever forces and wedging effects (Figure 7).63 Opinions vary regarding the amount of ferrule needed, 64 but 1.5 to 2 mm should be considered the clinical minimum.63 Surgical crownlengthening is often used to increase ferrule. This option should be considered with caution. Gegauff 37 demonstrated that decoronated premolar teeth that received surgical crown lengthening to provide a 2-mm ferrule were more likely to fracture because of the alteredcrown-to-root ratio than teeth receiving no crown lengthening.

FIGURE 7 Key features of an endodontically treated incisorrestored with a crown include antirotation, ferrule, positive stop,and a minimum of 5 mm of remaining gutta-percha

FIGURE 8 Antirotation effect

65Effect of a crown ferrule on the fracture resistance of endodontically treated teeth restored with prefabricated posts

STATEMENT OF PROBLEM: Root fracture is one of the most serious complications following restoration of endodontically treated teeth

Fifty freshly extracted canines were endodontically treated. The teeth were randomly divided into groups of 10 and prepared according to 5 experimental protocols

The results of this study showed that an increased amount of coronal dentin (ferrule) significantly increases the fracture resistance of endodontically treated teeth.

66An incomplete crown ferrule is associated with greater variation in load capacity and, despite high fracture values, inclines to fracture.

66Characteristics of an ideal post:

Minimum preparation.

Resistance to fatigue.

Elastic modulus similar to dentin.

Non corrosive.

Retentive (post & Head).

Easy to adjust and fit.

Radiopaque.

Adequate material

Easy Removal

Custom made posts:

1. Direct Technique

2. Indirect Technique

Advantages:

Preservation of maximum tooth structure

Provision of anti-rotational properties

Core retention

Less chances of vertical fractures during preparation

High strength

Disadvantages:

Less stiff than wrought

Time consuming, complex procedure

Recommended Use:

Elliptical canals

Flared canals

67Prefabricated Tapered Post

Advantages:

Conserves tooth structure

High strength and stiffness

Disadvantages:

Low retention

Longitudinal splitting of remaining root

Recommended Use:

Small circular canals or

Very tapered canals

68Prefabricated Parallel - Sided Smooth Post

Advantages:

Excellent clinical retention

Minimal stress production within root

Ease of placement

Superior rating

Disadvantages:

Precious material post expensive

Corrosion of stainless-steel

Less conservative of tooth structure

69Prefabricated Threaded Posts

Advantages:

High retention

Disadvantages:

Stresses generated in canal may lead to fracture

Does not conserve coronal and radicular tooth structure

Recommended Use:

Only when maximum retention is essential

70Carbon Fiber Post

Advantages:

Dentin bonding

Easy removal

Disadvantages:

Low strength (compared to metal)

Lack of radiopacity

Carbon color presents an esthetic problem

Recommended Use:

Can be used in posteriors with moderate loss of coronal structure

71Fiber Reinforced Post

Advantages:

Esthetic

Disadvantages:

Low strength

High failure rate

Recommended Use:

Should not be used where remaining tooth structure is less than ideal or where high occlusal forces are present.

72Zirconia Ceramic Post

Advantages:

Esthetics

High stiffness

High modulus of elasticity

Disadvantages:

Expensive

Uncertain clinical performances

Recommended Use:

High esthetic demands

A review of the studies done on the various post systems suggests that the fiber posts are the most reliable!!!

I. 73Fiber posts show more homogeneous stress distribution than metallic posts.

Background: Post design and material has very important effects on dentinal stress distribution since the post placement can create stresses that lead to root fracture.

Materials:

4 metallic posts (ParaPost XH, ParaPost XT, ParaPost XP, and Flexi-Flange) and 1 fiberglass post (ParaPost Fiber Lux) were used.

Results: The stress distribution was most homogenous in fiber posts compared to all other posts.

II. Good strength & Fractures allow repair

Purpose. This in vitro study compared the effect of titanium, quartz fiber, glass fiber, and zirconia posts systems on the fracture resistance and fracture patterns of crowned, endodontically treated teeth

Results. Teeth restored with quartz fiber posts exhibited significantly higher resistance to fracture than the other 3 groups. Teeth restored with glass fiber and zirconia posts were statistically similar.

Fractures that would allow repair of the tooth were observed in quartz fiber and glass fiber , whereas unrestorable, catastropic fractures were observed in titanium and zirconia post groups.

III. Readily retrievable

Conclusion: The fiber posts evaluated provided an advantage over a conventional post that showed a higher number of irretrievable post and unrestorable root fractures. The fiber posts were readily retrievable after failure, whereas the remaining post systems tested were non retrievable.

IV. Better than cast post system in the long term

PURPOSE: This retrospective study evaluated treatment outcome of cast post and core and Composipost systems after 4 yrs of clinical service.

The results of this retrospective study indicated that the Composipost(95% success) system(fiber-reinforced epoxy resin posts) was superior to the conventional cast post and core system(84% success) after 4 yrs of clinical service.

V. More favourable

PURPOSE: This study aggregated literature data on in vitro failure loads and failure modes of prefabricated fiber-reinforced composite (FRC) post systems and to compare them to those of prefabricated metal, custom-cast, and ceramic post systems.

RESULTS: Custom-cast post systems showed higher failure loads than prefabricated FRC post systems, whereas ceramic showed lower failure loads. Significantly more favourable failures occurred with prefabricated FRC post systems than with prefabricated and custom-cast metal post systems.

Mechanical Properties:

Material Flexural strength

Gpa

Tensile Strength

MPa

Elastic Modulous

GPa

Stainless Steel 800 n/a 200

Titanium Alloy 1000 n/a 110

Zirconium Oxide 820 n/a 200

C-Post

(64% Carbon)

1100 2900 17.8

core

So which is the best material for core buildup???

74The modulus of elasticity of amalgam is significantly higher than all other material tested and is closer to that of dentin

Prepared core build-ups in a hybrid composite material provided the highest fracture resistance

75This study showed that the tensile and flexural strengths of composite are significantly higher than that of amalgam and glass ionomer.

76Tensile strength and modulus of elasticity of glass ionomer cements are significantly lower than dentin and amalgam. Glass ionomers are relatively slow-setting and their early resistance to moisture is poor

Based on the above stated evidence, composite seems to be the best choice as a core build up material.

Discussion

The number of endodontic procedures has increased steadily in the past decade with highly predictable results. Therefore, restoration of teeth after endodontic treatment is becoming an integral part of the restorative practice in dentistry. Proper restoration of endodontically treated teeth begins with a good understanding of their physical and biomechanical properties, anatomy, and a sound knowledge of the endodontic, periodontal, restorative and occlusal principles. Although many new restorative materials

have become available over the past several years, some basic concepts in restoring endodontically treated teeth remain the same.

In this article, we reviewed the principles in the use of posts and the various types of posts that are available. A thorough understanding of posts is necessary to make the right selection, as there are so many choices available. Finally, the choice of core material and the final restoration are important in

achieving long-term clinical success.

As a result of this review, we have concluded that posts do not strengthen endodontically treated teeth and should not be used in them routinely. The main function of a post is for the retention of a core if

there is insufficient tooth substance left to support the coronal final restoration.

The reason that many different types of posts with different designs and materials are available is because they all have certain strengths and weaknesses. Selection criteria should include adequate strength, modulus of elasticity, retention, biocompatibility, esthetics and retrievability. The new fiber-reinforced posts offer impressive results, but clinical evaluation is necessary over a longer term.

Post space preparation requires good understanding and knowledge of tooth anatomy to avoid unnecessary mishaps. Cementation of posts with resin cement seems to offer better retention, less

microleakage and higher resistance to tooth fracture. However, cementing a post with resin cement must be performed meticulously, as this procedure is technique-sensitive

Gold, amalgam and resin-based composite are acceptable core materials, and each has its advantages and disadvantages. However, the use of glass ionomer cement as a core material should be avoided, owing to its low strength, low stiffness, poor bonding characteristics and high solubility.

Although many promising new materials are available and there are definite indications for their use, long-term clinical evaluations are needed. Clinicians must keep this fact in mind when selecting these materials.

CONCLUSION:

Anterior Tooth

Class IVClass I - III

Complete Coverage is required

Prefabricated fiber post with composite core

full ceramic crown

Complete Coverage is not required

Conservative TrtResin composite

Class V

Complete Coverage is required

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