CHIPPED, FRACTURED, OR ENDODONTICALLY TREATED TEETH - Daniel C.N. Chan, DMD, MS, DDS, Michael L.

Myers, DMD, Gerald M. Barrack, DDS, Ronald E. Goldstein, DDS INTRODUCTION New caries prevention and health measures and improved oral care will help more patients keep more of their teeth disease free for a lifetime. However, one thing in "dental life" is almost a certainty: teeth will continue to fracture. Although sports injuries can e greatly reduced with proper protective gear, our daily lives are conducive to all sorts of accidents causing patients to fracture their teeth. !he fre"uency of permanent incisor fractures in children is reported to range from # to $%&.$,'( !he loss of tooth su stance in these situations is likely to e more hori)ontal than vertical. *ost tooth fractures are minor and seldom involve pulp. !his chapter discusses such simple fractures, as well as treatment of teeth with pulpal and endodontic intervention +!a le ',-'-. .ne e/ample of a more serious fracture involving the pulp is also presented with an e/planation of techni"ues for handling this pro lem. 0ifficult fracture cases are usually emergencies. 1ith our population living longer and retaining most of their teeth, the incidence of cracks in teeth also seems to e increasing. A ta ulated review of cracked tooth syndrome, treatment options, and other considerations is included for easy reference +!a le ',-$-.

2onservative restorative dentistry is always the goal in treating esthetic pro lems, and the fractured tooth is no e/ception. !he most conservative treatment would o viously e cosmetic contouring, or the reshaping of the natural teeth, provided that it does not negatively alter the esthetics of the smile +3igur 4$4s',$4d es ',-'A, and ',-'5-. 0ecades ago, the full crown restoration was the treatment of choice. !oday, in addition to cosmetic contouring, the conservative solution is a choice etween direct onding with composite resin and laminating with porcelain.'','$,'6 !hese choices are ased on several factors:

3igur 4$4s',$4d e ',-'A: !his $'-year-old girl had chipped her anterior incisors when she was a teenager.

3igur 4$4s',$4d e ',-'5: 2osmetic contouring was the most conservative treatment availa le and was performed in a less than '-hour appointment.

. Amount of tooth destruction resent. 7enerally, small chips or fractures are easily restored with direct onded composite resin +3igur 4$4s',$4d es ',-$A, and ',-$5-. !he esthetic result is e/cellent and provides the patient with an economic, one-appointment solution without any anesthesia.8,'% However, if the patient continues to chip or fracture the onding, then porcelain would e a etter alternative +3igur 4$4s',$4d es ',-4A, ',45, ',-42, ',-40, ',-49 and 3-. :n the event that the enamel is severely compromised, re"uiring a more e/tensive restoration, the patient may ultimately e etter off with a porcelain laminate. !he fractured area is then replaced with the stronger and more dura le porcelain. However, it may e a wise choice to select composite resin onding as an interim restoration. !his minimi)es any further trauma to the tooth y additional preparation and allows o servation time for any pulpal pro lem; moreover, the onded solution can last for an indefinite period of time +3igur 4$4s',$4d es ',-6A and 5, ',62, ',-60 and 9, and ',-63-.'$

3igur 4$4s',$4d e ',-$A: !his teenager chipped her ma/illary front teeth.

3igur 4$4s',$4d e ',-$5: !he left central incisor was onded with composite resin.

3igur 4$4s',$4d e ',-4A: !his young lady fractured her ma/illary anterior incisors. 0espite numerous onding repairs, she continued to refracture the teeth. 5ecause she also o jected to the incisal translucency, she was treatment planned for three porcelain laminates.

3igur 4$4s',$4d e ',-45: !he initial preparations for the three porcelain laminates were done with a %.#-mm depth cutter +5rasseler <=> >ystem, 5rasseler, >avannah, 7A-.

3igur 4$4s',$4d e ',-42: !he two-grit diamond is used to reduce the enamel to the predetermined depth cut.

3igur 4$4s',$4d e ',-40: !he final preparations.

3igur 4$4s',$4d e ',-49 and 3: !hree porcelain laminates were placed on the central incisors and right lateral. !he new laminates also achieved the o jective to eliminate the incisal translucency.

3igur 4$4s',$4d e ',-6A and 5: !his '(-year-old student fractured her central incisors on the edge of a swimming pool.

3igur 4$4s',$4d e ',-62: A long evel is placed using an e/tra coarse diamond.

3igur 4$4s',$4d e ',-60 and 9: !he central incisors are onded with composite resin.

3igur 4$4s',$4d e ',-63: 3ive years later, the patient has continued to e maintained with composite resin restorations. . Lon!e"ity re#uired. :f the patient does not mind the added cost, increased longevity can e achieved with the porcelain laminate. However, the patient needs to e informed a out the limited life e/pectancy of each restorative option. ?atients must also e made aware of the periodic maintenance re"uired, proper home care, and any dietary restrictions necessary to o tain the longest life possi le.'6 . Economic considerations. Although the cost savings of direct onding might not e reali)ed if numerous repairs are considered, it still may e easier for the patient to pay lesser amounts over the many years during which the direct onded restoration can stay in place. . $cclusal factor. :f an end-to-end occlusal relationship or increased occlusal re"uirement e/ists, porcelain may again provide more dura ility, depending on the design of the laminate. :t is essential to protect the incisal edge with sufficient porcelain to resist fracture. An e/ample of this condition is seen in a patient who fractured a tooth +3igur 4$4s',$4d e ',-#A-. 0uring the clinical e/amination, this patient e/pressed his desire for a younger and righter smile. !he teeth were then prepared, and an impression was made for si/ porcelain laminate veneers. !o help protect the occlusion, porcelain was wrapped incisally to the lingual surface +3igur 4$4s',$4d e ',-#5-. 1hat egan as an emergency visit to repair a fractured tooth resulted in enhancing this patient@s entire smile +3igur 4$4s',$4d e ',-#2-.

3igur 4$4s',$4d e ',-#A: !his A#-year-old man had fractured his right central incisor. 5ecause he desired a younger and righter looking smile, si/ porcelain laminates were treatment planned.

3igur 4$4s',$4d e ',-#5: !his patient had an end-to-end ite, which re"uired additional incisal edge reinforcement.

3igur 4$4s',$4d e ',-#2: Note the improvement in this man@s smile with a lighter shade and teeth that are more proportionate to each other.

:n the final analysis, although direct onding will generally e the method most often selected, there are definite situations for which porcelain laminate will e the techni"ue of choice. !he advantages and disadvantages of direct onding, laminating, and crowns are outlined in !a les ',-4, ',-6, and ',-# for comparison.'$

CHIPS OR FRACTURES WITHOUT PULPAL INVOLVEMENT

Conservative Bon in! Te"#ni$%es &or Lon!'Ter( Res%)ts PROBLEM* A $(-year-old male presented with fractured ma/illary central incisors involving the incisal edges +3igur 4$4s',$4d e ',-AA-. 5ecause the patient preferred not to reduce the tooth structure, a onded composite resin was the material of choice to restore the fractured edges.

3igur 4$4s',$4d e ',-AA: !his $(-year-old man fractured his ma/illary central incisors. TREATMENT* >ince the left central incisor overlapped the right one, the mesial surface of the left central was reshaped slightly to reduce the amount of overlapping in an attempt to create an illusion of straightness +3igur 4$4s',$4d e ',-A5-. !hese fractures were old and not sensitive, so no protective ase was re"uired. :n a new fracture or pulp e/posure, the fracture site would have een protected first with glass ionomer liner. A large particle composite restoration was used for strength and to help lend in translucency. !he restorations were finished with conventional composite resin finishing techni"ues +see 2hapter '4, Esthetics in Dentistry, =olume ', $nd 9dition-.

3igur 4$4s',$4d e ',-A5: After light cosmetic contouring to the left central incisor, oth central incisors were onded with a large particle composite resin. 3ourteen years later, the patient came in with a small fracture in the onding material of the central incisor +3igur 4$4s',$4d e ',-A2-. !he teeth were reveneered with hy rid composite resin to improve his smile once more +3igur 4$4s',$4d e ',-A0-. Although this patient may well e the e/ception to the rule of an average life e/pectancy of # to , years, his case does point out the fact that many patients would have preferred the restoration replaced long efore the slight discoloration took place. However, careful maintenance, including good oral hygiene and prudent dietary ha its, helped account for the e/tended life of these restorations. !he tooth can always e laminated or crowned if onding does not work, ut once the enamel is reduced for a full crown, it can never e onded or laminated. :n the future, etter onding and laminating materials will, no dou t, ecome availa le.

3igur 4$4s',$4d e ',-A2: 3ourteen years later, this patient fractured the onding on the right central incisor.

3igur 4$4s',$4d e ',-A0: !he central incisors were reveneered and the left lateral was also onded to achieve an even more attractive smile. Bon in! Ori!ina) Toot# Fra!(ent >imonsen first suggested that fractured original tooth segments could e onded ack together.$A :f the patient has a "clean" reak and rings in the fractured piece of enamel, it is entirely possi le and many times advisa le to attempt reattachment y acid etching oth the tooth itself and the fragment. <ight polymeri)ed tooth-colored resin cement is applied to oth pieces and the fracture piece is carefully fit and polymeri)ed ' minute la ially and ' minute lingually. Additional modifications have taken place, and there are newer techni"ues that are variations on the original philosophy.$( 3or instance, 2roll advocated attaching the two segments together, first with a glass ionomer light polymeri)ed liner +=itre ond, 4* 9>?9, >t. ?aul, *N- and then reinforcing la ially and lingually with composite resin.A *any variations of such onding are reported in the literature.$,',,4',4$,44 5onding the original tooth fragment is not limited to the anterior region. ?osterior teeth fractures, especially in the case of premolars, can e successfully onded together. !he long-term survival of such repairs is reported to e in the #-year range.$,$6 However, in these cases, the onded teeth are est viewed as a temporary restoration awaiting partial or full crown coverage. <ie en erg reported using resin- onded partial-coverage ceramic restorations to treat incomplete fractures.$$,$4 CHIPS OR FRACTURES WITH PULPAL INVOLVEMENT :n the event that the pulp is e/posed, two choices e/ist: . %ul otomy. :f the root ape/ is open, this is the preferred treatment according to several

sources.6,# 9hrmann descri ed the procedure eginning with coronal pulp removal, which will allow root maturation to proceed only with closure of the ape/ then taking place., 3ollowing closure, a radicular pulpectomy is done and is usually followed y endodontic therapy plus construction of a post and core. . %artial ul otomy. Another view has een e/pressed y 2vek, who suggested a partial pulpotomy in permanent incisors with comple/ root fractures, regardless of whether the ape/ was open.( 5asically, the techni"ue consists of a $-mm-depth removal of the coronal pulp with sterile saline eing used to control leeding. Ne/t, a calcium hydro/ide pulp liner +0ycal 2aulk, 09N!>?<BC2aulk, *ilford, 09- is used and is covered with a composite resin. 9hrmann concluded that this latter techni"ue seems to e the method of choice, citing fewer traumas and preserving most of the pulp as two advantages., He reported that of 4# cases, 44 were successful and retained their vitality, with the longest follow-up eing , years. !he consideration for a chipped or fractured tooth is whether the pulp is damaged. :f it has een e/posed, the tooth should e protected with a pulp-capping material +calcium hydro/ide- and covered with a tooth-colored restorative material for at least A weeks. A recommended techni"ue after pulp capping is onding with a composite resin. Danca reported the success of a case with a #-year follow-up.$% !he responsi ility of the dentist is to preserve the natural dentition. :n some circumstances, this is impossi le, ut it is an ideal for which to aim. !o achieve this goal, it may e necessary to call on colleagues for assistance. 1ho is credited with the result is unimportant. 1hat is important is for the patient to receive the est possi le treatment and advice. !his point is well illustrated y the actual treatment of a patient with fractures of the ma/illary central incisors that e/tended lingually eneath the crest of the one and e/posed the pulps. !he patient@s dentist consulted an oral surgeon who recommended endodontic treatment. 5efore final restorative therapy was chosen, consultations were held with an oral surgeon, a pediatric dentist, and two general practitioners. !he case that follows involved consultation with other dental specialists and shows an esthetic result that was worth the effort.'# Preservation o& Fra"t%re Ma+i))ar, Centra) In"isors t#ro%!# Inter is"i-)inar, T#era-, PROBLEM* A general practitioner saw a '$-year-old girl who had een in an accident. He referred her to an oral surgeon for removal of oth ma/illary permanent central incisors, which had een fractured hori)ontally and vertically, e/posing the pulps. !he oral surgeon thought that the teeth might e saved and referred the patient to an endodontist. After endodontic therapy on oth teeth +3igur 4$4s',$4d es ',-(A and 5-, the patient returned to the general practitioner, who consulted the pediatric dentist. !he two agreed that someone skilled in cosmetic restorative procedures should e called on for the reconstruction.

3igur 4$4s',$4d e ',-(A and 5: Although this '$-year-old girl was referred to an oral surgeon for a postaccident e/traction of oth fractured central incisors, he wisely referred the patient to an endodontist in an attempt to save the teeth. TREATMENT* 5ecause saving teeth was a step- y-step procedure involving endodontic treatment, periodontal surgery, and reconstructive techni"ues, the treatment plan could e changed if one of the suggested treatments failed. 9ndodontic therapy had already een completed on oth central incisors. !hese surgical procedures were performed ne/t: removal of the tooth fragments that were fractured vertically, la ial and lingual gingivectomy and gingivoplasty, palatal ostectomy, and la ial frenectomy +3igur 4$4s',$4d e ',-(2-. Appro/imately # mm of palatal plate was removed to e/pose new margins on the fractured teeth +3igur 4$4s',$4d e ',-(0-. After the tissue healed, gold posts were constructed and cemented on the two ma/illary incisors +3igur 4$4s',$4d es ',-(9 to H-. 3inal preparations were made, and impressions for aluminous porcelain crowns were made. !he two crowns were seated +3igur 4$4s',$4d es ',-(: and E-. 3igur 4$4s',$4d e ',-(D is a radiograph of the teeth at the end of treatment.

3igur 4$4s',$4d e ',-(2 and 0: 3ollowing endodontic therapy and removal of the fractured tooth fragments, periodontal surgery to lengthen the e/posed crowns was performed.

3igur 4$4s',$4d e ',-(9 to H: Ne/t, two posts and cores were constructed for the endodontically treated teeth.

3igur 4$4s',$4d e ',-(: and E: !wo aluminous porcelain crowns were constructed and inserted on the central incisors.

3igur 4$4s',$4d e ',-(D: ?ost-treatment radiograph of the two fractured and restored central incisors. !he parents have een told that these crowns will pro a ly have to e replaced when the patient is older ecause the margins may e e/posed. However, they might last longer ecause of the higher marginal attachment. 5ecause of the age of the child, the anticipated cost of the treatment, and the presumed lack of dental knowledge of the parents, the pediatric dentist and the general practitioner who were to do the treatment e/plained the reconstruction procedures at length. Although the endodontic therapy had een completed, the father informed the two dentists that he had decided to have " oth teeth pulled and a plate put in." A su se"uent conference convinced the parents that this would not e the wisest course to follow if restorative procedures could e performed. !heir e/pression of thanks at the end of the treatment justified the time spent persuading the family to accept the outlined treatment plan. RESULT* 0entists sometimes assume, incorrectly, that ecause a tooth is fractured eneath the periodontal ligament and into the one, it cannot e saved. ?roper surgical and reconstructive techni"ues can save these roots for many years, sometimes indefinitely. 0entists may also assume, again incorrectly, that ecause of the e/pense or difficulty of treatment, a patient or his or her family would prefer to sacrifice a tooth. Not knowing what value the patient places on a tooth, the dentist should give the patient the opportunity to decide. :t is almost always etter to save a tooth. !he patient can clean it more easily with floss, and the root support helps share occlusal load. !he purpose of this case is not to show the skill of the operator ut to call attention to the

fact that, even though e/traordinary measures are needed, it may e possi le to preserve the natural dentition. !o do so may involve multiple referrals and consultations, ut the good result +3igur 4$4s',$4d e ',-(<- and the knowledge that possi ilities e/ist should e considered efore a patient is allowed to lose a tooth. !he function of dentistry is to maintain the integrity of the dental arch and to preserve the dentition. 3or this patient, at least, this goal was achieved.

3igur 4$4s',$4d e ',-(<: A total team approach was necessary to save this young lady@s ma/illary incisors. 5oth she and her parents appreciated the enefits of interdisciplinary care. LIFE E.PECTANCY WITH COMPOSITE RESINS Although the average life e/pectancy is 4 to , years, the fact is that some patients may e/perience a much longer and more useful restoration life +see 3igur 4$4s',$4d es ',AA, ',-A5, ',-A2, and ',-A0-.'6 !hese restorations are, for the most part, noninvasive, and the onded restoration offers a good measure of protection to the tooth while odonto lastic activity is taking place at the damage site. !hey can also continue to e reveneered rather than replaced for an indefinite period of time +3igur 4$4s',$4d es ',,A, ',-,5 and 2, and ',-,0 and 9-. 1hen replacement is necessary, if full crown coverage is the treatment of choice, it can e done with less chance of pulp involvement.

3igur 4$4s',$4d e ',-,A: !his A-year-old girl fractured her ma/illary central incisors in an accident.

3igur 4$4s',$4d e ',-,5 and 2: !he two central incisors were eveled and onded with composite resin.

3igur 4$4s',$4d e ',-,0 and 9: !en years later, the patient still retains her original onding, although reveneering has een done to maintain appearance POSTERIOR RESTORATIONS

:n these areas, it is even more important to place a protective ase and use the etching techni"ue on enamel walls and dentin. *arginal leaks can e minimi)ed y this techni"ue. :n addition, patients must e advised of the possi ility of replacing the restorations every 4 to , years. >everal methods of restoring the simple fracture have een shown in this chapter, although all seem to arrive at the same conclusion: the final measure of success is how these onds respond to oral fluids. 1ith further investigation, stronger materials and stronger onds will e developed that may warrant reinserting restorations as improved materials ecome availa le. !hus, in certain cases, it may e to the patient@s advantage not to destroy tooth structure for full-coverage procedures at present. However, when small pieces reak off of posterior teeth, onding can e used either as an interim or the final restoration if it is not in an occluding area where it may e under too much stress. :f it is, then porcelain may e the est choice +3igur 4$4s',$4d es ',-8A, ',-85, and ',82-. :n the final analysis, the full crown remains a via le option, especially if esthetic changes are to e made that may not e possi le with a more conservative treatment. Also, some patients prefer the long-lasting enefit that the full crown provides.'4

3igur 4$4s',$4d e ',-8A: !his A%-year-old woman fractured the ucco-occlusal surface of her mandi ular right second icuspid. 5ecause the fracture was in an occluding area and was previously repaired with composite resin onding, the patient opted for the longer lasting protection of a full crown.

3igur 4$4s',$4d e ',-85: 3ull shoulder margins are prepared with a !?9 diamond +>hofu, *enlo ?ark, 2A- or !79 diamond +?remier, Ding of ?russia, ?A-.

3igur 4$4s',$4d e ',-82: !he final crown shows how well ceramics can mimic the natural tooth and esthetically lend with the e/isting dentition. RESTORATION OF ENDODONTICALLY TREATED FRACTURED TEETH Prin"i-)es !he philosophy for the restoration of endodontically treated teeth has changed significantly in recent years. !raditional concepts were that nonvital teeth were so weakened y root canal therapy that they re"uired a post to reinforce the root in the same manner that concrete is reinforced with steel rods. 3urther, it was elieved that these teeth also needed to e crowned to protect the tooth from fracture. 2linical e/perience and research studies have, in some cases, produced a dramatic shift in the way endodontically treated teeth are restored.',$,'8,$',$# 9ndodontically treated teeth have certain characteristics that are well known y clinical dentists. 3irst, the loss of vitality results in a change in color over time. !his can result in an unaccepta le esthetic result. !hese teeth are structurally compromised due to the access opening re"uired to

accomplish root canal therapy. Additionally, these teeth often have e/tensive restorations or caries, further compromising their strength and structural integrity. 9ndodontically treated teeth also seem to e rittle ecause of the loss of vitality. 2linical e/perience has shown that these teeth seem to have an increased risk of fracture. !here is no large ody of in vivo scientific literature to determine how to est restore endodontically treated teeth. However, there are several good retrospective studies that provide some guidance. 3rom these studies, it is clear that anterior teeth have different characteristics and re"uire a different clinical approach than posterior teeth. Another conclusion that can e made is that endodontically treated anterior teeth do not automatically re"uire restoration with a crown. :n fact, most endodontically treated anterior teeth will have the same longevity whether or not they have een crowned. >o, the clinical options for restoration of an anterior tooth are dictated y the condition and the functional and esthetic re"uirements of the tooth. :f the tooth is relatively intact, it should simply e restored with a composite resin restoration. :f it has changed color, then leaching of the tooth would also e indicated. :f the e/isting restorations or caries are moderate in si)e or include the incisal edge, then a porcelain veneer could e the appropriate choice for treatment. :n many instances, leaching of the endodontically treated tooth prior to restoration with composite resin or a porcelain veneer will provide a etter esthetic result. !hree major reasons for using crowns are +'- if the tooth is adly roken down, +$- a significant change in tooth contour is desired, or +4- if the tooth is to e used as an a utment for a fi/ed or remova le partial denture. *ost anterior teeth in this condition have little sound remaining tooth structure and will re"uire a post and core restoration to support and retain the crown. !his concept is supported y most studies. >uch a patient can e seen in 3igur 4$4s',$4d es ',-'%A, ',-'%5 to 7, and ',-'%H. ?ost restorations used in anterior teeth fall into two road types: +'- the prefa ricated post with a core material to replace the missing coronal tooth structure and +$- the cast metal post and core that is custom made for the tooth +3igur 4$4s',$4d e ',-'%:-.

3igur 4$4s',$4d e ',-'%A: !his young lady fractured her left central and lateral incisors in an accident. 5ecause the original teeth had protruded efore fracturing, the patient re"uested that the restoration e accomplished with an improved appearance in the most permanent treatment availa le.

3igur 4$4s',$4d e ',-'%5 to 7: 3ollowing endodontic therapy, two cast posts were constructed and cemented to place in the prepared incisors.

3igur 4$4s',$4d e ',-'%H: !he final all-ceramic crowns were onded to place. Note the natural result of oth the shade and te/ture of the crowned teeth.

3igur 4$4s',$4d e ',-'%:: .ptions for post and core restorations.

As previously mentioned, posterior teeth re"uire a different treatment approach than is

indicated for anterior teeth. ?osterior teeth usually have a greater ulk of remaining tooth structure than anterior teeth. Also, the occlusal forces on posterior teeth are significantly greater than anterior teeth. Fetrospective studies of posterior teeth that have had root canal therapy indicate that these teeth are much more likely to fracture if they are not crowned. !herefore, conclusions from research indicate that posterior teeth that have had root canal therapy should always e restored with a restoration that provides coronal coverage. !he asic principle for posterior teeth is that the restoration should provide for cuspal coverage or protection. !his can e accomplished with a crown +either full or partial coverage- or even an onlay. !he only e/ception to this rule might e for a premolar that has a minimal endodontic access and at least one intact marginal ridge. :n this instance, if the occlusion is favora le +ie, canine disclusion-, a small two-surface onded composite could e considered. Gnlike anterior teeth, which almost always re"uire a post to retain the core, posterior teeth seldom need a post. !he retention for the core or foundation can usually e o tained y taking advantage of the undercuts present in the pulp cham er, especially in molars. >o if amalgam is used for the core, it is simply condensed into the pulp cham er. :f a composite resin core material is used, it can e retained oth y dentin onding and the pulp cham er. :f the tooth has hardly any coronal tooth structure +ie, level with the gingival margin-, a cemented, prefa ricated post can e used to provide the re"uired retention for the core restoration. >mall premolars are more likely to need a post restoration ecause there may not e sufficient retention for the core. :n summary, endodontically treated anterior teeth do not always need to e crowned; when they are to e crowned, a post may or may not e re"uired. ?osterior teeth always need a crown +ie, cuspal coverage- ut rarely re"uire a post. !he purpose of a post is to retain the core; it does not reinforce the root.$8,4% Post Desi!n >everal principles must e considered in post selection and design. !hese principles apply for either prefa ricated or cast posts. 0esign characteristics include length, diameter, shape, surface configuration or te/ture, method of attachment, and material. *any of these characteristics have een studied e/tensively y in vitro studies. :n addition, several retrospective studies give guidance concerning optimum factors for post selection and design. Fetention of a post increases with increasing length. !he post should at least e e"ual in length to the clinical crown or two-thirds of the root length, whichever is greater +3igur 4$4s',$4d e ',-'%E-. At least 6 mm of gutta-percha should e left in the ape/ of the root to maintain the apical seal. :n contrast to post length, post diameter has little influence on retention. :n fact, increasing post diameter re"uires removal of additional tooth structure and simply weakens the tooth, increasing the risk of a vertical root fracture. !herefore, the post should not e any larger in diameter than is a solutely necessary. !he general guidelines are that the post should not e greater than one-third of the diameter of the root at the cement-enamel junction and that at least ' mm of dentin thickness should e

maintained at all levels of the root. 7enerally, it is est not to enlarge the post space any greater than the space created during root canal therapy. !oo aggressive flaring of the canal during root canal therapy or enlargement of the canal space for a post will surely compromise the tooth. :n the same vein, the shape of the post should e parallel rather than tapered. A tapered post design creates a wedging force within the root of the tooth. 2onversely, parallel posts produce less stress and fewer vertical root fractures.

3igur 4$4s',$4d e ',-'%E: .ptimum post length. !he surface configuration or te/ture has a significant influence on post retention. A smooth-surface or polished post is less retentive than a te/tured +eg, sand lasted- post. ?ost designs that are serrated or crosshatched or have some other retentive design e/hi it the est resistance to dislodgment. .ne other design parameter is the mode of attachment. A post can have a passive fit in the tooth root and e retained y cement, or it can e actively retained +threaded like a screw- and retention gained y virtue of the threads +with or without the aid of cement-. However, threaded posts create the potential for a significant wedging force within the

tooth root and should e avoided. ?arallel posts with proper length and a retentive surface design can o tain more than ade"uate retention. :n situations when it is not possi le to o tain the optimum length or shape, the re"uired retention is much etter and gained more safely y using a stronger cement +ie, resin- than y using a threaded post. !here are several different materials that can e used for posts, including stainless steel, titanium, )irconium +tooth colored-, ceramic, and polymers +!a le ',-A-. !he material used for the post is much less important than the design and si)e of the post +ie, preservation of tooth structure- unless esthetics ecomes a consideration. :f so, a toothcolored post should e considered.

Se$%en"e o& Treat(ent &or Posterior Teet# /Mo)ars an Lar!e Pre(o)ars0 !he core uild-up for a posterior tooth should e placed prior to crown preparation. A sufficient amount of time should have elapsed since completion of the root canal therapy to e confident that it has een successful. !he tooth should e asymptomatic and not sensitive to percussion. 3ollowing root canal therapy, the typical molar will have a large e/isting restoration. All restorative materials and caries should e removed. !he guttapercha should e removed from the pulp cham er. !he gutta-percha can e removed ' to $ mm into the canal orifices to increase retention +3igur 4$4s',$4d e ',-''-. :f there is at least one cusp remaining and the pulp cham er has walls of $ to 4 mm in depth, a post is not re"uired for retention of the core. !he core may e either amalgam or composite resin +!a le ',-(-.

3igur 4$4s',$4d e ',-'': Amalgam or composite resin core.

!he advantage of composite resin is that it may e prepared immediately. 2omposite resin also offers the advantage of dentin onding and a relatively simple techni"ue for core placement. !he main disadvantage of composite resin is that it is su ject to water a sorption and microleakage. :t should only e used in posterior applications when it is possi le to place the crown margins at least $ mm eyond +ie, apical to- the resin-tooth interface. A composite resin core material of contrasting color should e used to minimi)e the risk of inadvertently preparing the preparation margin on composite resin. 3or an amalgam core, a metal matri/ and or copper and can e used as a retainer. :f the crown preparation needs to e completed the same day the core is placed, a fast-setting amalgam can e used. After '# minutes, the core is hard enough to egin the crown preparation. !he crown margin should e e/tended ' mm apical to the amalgam-tooth interface +3igur 4$4s',$4d es ',-'$A, ',-'$5, ',-'$2, ',-'$0, ',-'$9, and ',-'$3-.

3igur 4$4s',$4d e ',-'$A: ?eriapical radiograph showing tooth H4% after successful root canal treatment.

3igur 4$4s',$4d e ',-'$5: 5itewing radiograph showing tooth H4% with amalgam core uild-up completed. Note that the core material e/tends appro/imately $ mm into the canal orifices for increased retention.

3igur 4$4s',$4d e ',-'$2: !ooth H'6 after successful root canal treatment.

3igur 4$4s',$4d e ',-'$0: Femoval of temporary restorative material and remaining amalgam. 7utta-percha from the pulp cham er was removed for core retention.

3igur 4$4s',$4d e ',-'$9: 2ompleted core uild-up on tooth H'6.

3igur 4$4s',$4d e ',-'$3: 2ompleted crown preparation on tooth H'6. 3or molars, if there is little remaining tooth structure or the pulp cham er is shallow, then a post should e used to provide retention for the core +3igur 4$4s',$4d e ',-'4A-. Gsually, only one post is needed. A prefa ricated post should e cemented into the largest canal. :n mandi ular molars, this will typically e the distal canal. No attempt should e made to place a post in the mesial canal of a mandi ular molar as the distal wall of the mesial root is thin and easily perforated. 3or ma/illary molars, a single post in the lingual canal is ade"uate. 5ecause the direction of the post is divergent from the pulp cham er, it creates e/cellent retention for the core +3igur 4$4s',$4d es ',-'45, ',-'42, ',-'40, ',-'49, and ',-'43-.

3igur 4$4s',$4d e ',-'4A: ?refa ricated post with core.

3igur 4$4s',$4d e ',-'45: !ooth H4 after successful root canal treatment.

3igur 4$4s',$4d e ',-'42: :nade"uate pulp cham er wall height and lack of remaining tooth structure evident after removal of previous restorative materials. Additional retention with prefa ricated post is indicated.

3igur 4$4s',$4d e ',-'40: 2ompleted core uild-up on tooth H4.

3igur 4$4s',$4d e ',-'49: 2ompleted crown preparation on tooth H4. Note that the preparation margin e/tends apical to the core-tooth interface.

3igur 4$4s',$4d e ',-'43: 2omposite resin may also e used as core material. Se$%en"e &or Anterior Teet# 3or anterior teeth, the decision to use a prefa ricated post versus a cast post and core is est made after the crown preparation is completed +!a le ',-,-. !he appropriate amount of incisal and a/ial reduction should e created. !hen the amount of remaining sound tooth structure can e evaluated to make the decision a out the post type. !he prefa ricated post and core is indicated when there is a moderate amount of remaining tooth structure or there are significant undercuts in the canal or pulp cham er that would re"uire e/cessive removal of tooth structure. :t should also allow the preparation of the crown margin at least $ mm eyond the core to minimi)e the risk of water a sorption. !he advantage of this techni"ue is that it conserves tooth structure, decreases the risk of root fracture, and is less e/pensive and time consuming. !here are several disadvantages with the prefa ricated post techni"ue. !he core of a prefa ricated post and core is not as strong as a cast post and core. !here is a risk of mechanical failure of the core since the composite resin core materials do not ond to the cemented posts, and, as previously mentioned, the resin core is suscepti le to water a sorption. :t is also not indicated when the long a/is of the root is significantly different from the long a/is of the core.

!he cast post and core is indicated when there is a minimal amount of remaining tooth structure or the core will e very close to the crown margin +less than ' mm-. :t may also e needed when the core does not align with the root or there is a deep vertical overlap resulting in minimal occlusal clearance. !he advantage of the cast post and core is that it is strong and will fit irregular or flared canals. !he major disadvantages are that it is e/pensive, time consuming, and less conservative +re"uires more tooth reduction to eliminate undercuts or for canal enlargement-.

Post Pre-aration After the decision has een made for either a cast post and core or a prefa ricated post and core, the canal preparation should e initiated. !he gutta-percha may e removed with either a hot instrument +plugger- or with a rotary instrument. !he rotary instrument is more convenient, and there is no risk of urning the patient. A noncutting drill +7ates 7lidden, *ilte/, Bork, ?A, or ?eeso reamer, *ilte/- is the proper instrument for this step. !he noncutting drill should e smaller in diameter than the e/isting canal space so that it only removes gutta-percha. A high-speed ur or an end-cutting drill from a prefa ricated post kit should never e used to remove the gutta-percha ecause the risk of perforation is too great. !he tooth is measured on a radiograph, a reference point is esta lished on the tooth, and the gutta-percha is carefully removed to the desired depth, leaving a minimum of 6 mm for the apical seal. :deally, a minimum of '% mm of length should e o tained. !he canal preparation should e the same at this point regardless of the type of post that is planned. No attempt should e made at this time to enlarge the canal; the goal of this step is to esta lish the proper post length. !he post space length and preservation of gutta-percha in the apical portion of the root can e verified with a radiograph at this time. 0igital radiographs are a distinct advantage as they save considera le time and re"uire much less radiation, thus allowing the operator to take multiple views during the entire procedure. 2om ined with digital radiography, the use of an intraoral camera or surgical microscope can provide an e/cellent view of the canal and an inherent safety factor in preventing perforation. Ne/t, the canal should e shaped with the drills provided with the post system. 9nlargement of the canal should e

kept to a minimum, remem ering that the tooth ecomes weaker as more tooth structure is removed. !he canal should not e enlarged any greater than is necessary to accommodate the post +3igur 4$4s',$4d e ',-'6-. !he typical ma/illary lateral incisor should not e enlarged to more than %.%6% inches in diameter. *a/illary central incisors may e enlarged to a diameter of %.%#% inches. :f the coronal portion of the canal is flared, the canal should not e enlarged to achieve parallel walls as this will unnecessarily weaken the root. :n this case, it would e etter to use a tapered, prefa ricated post design or a cast post and core in com ination with a resin cement.

3igur 4$4s',$4d e ',-'6: :mproper post and core techni"ue leading to clinical failure.

!he choice of material type is pro a ly less significant than adhering to accepted design principles +ie, ade"uate length, parallel shape-. !he most commonly used prefa ricated post types are stainless steel, titanium, or titanium alloy. !he prefa ricated post can e cemented with any accepta le cement, including glass ionomer or )inc phosphate cement. :f the post is shorter than desired or the canal is tapered, a resin cement should e considered. 3or the core, composite resin has the necessary strength, provides dentin onding, and is the material of choice to use with prefa ricated posts in anterior teeth. 3igur 4$4s',$4d es ',-'#A, ',-'#5, ',-'#2, ',-'#0, ',-'#9, ',-'#3, and ',-'#7 show two e/amples of the use of post and composite resin uild-up.

3igur 4$4s',$4d e ',-'#A: ?eriapical radiograph showing tooth H( after post space preparation.

3igur 4$4s',$4d e ',-'#5: !ry-in of prefa ricated posts. !he post should e at least e"ual in length to the clinical crown or two-thirds of the root length.

3igur 4$4s',$4d e ',-'#2: ?refa ricated post cut to length and cemented.

3igur 4$4s',$4d e ',-'#0: !eeth H, and H'% restored with composite core uild-up material and prepared to receive porcelain-fused-to-metal crowns.

3igur 4$4s',$4d e ',-'#9: :n another patient, tooth H, with a prefa ricated post cut to length and cemented.

3igur 4$4s',$4d e ',-'#3: !ooth H, restored with composite core uild-up material.

3igur 4$4s',$4d e ',-'#7: *irror view of the lingual surface of tooth H,. Note the ferrule design with ' to $ mm of vertical tooth structure eyond the restorative margin. :f a cast post and core is indicated, the pattern can e made either y a direct or indirect techni"ue +3igur 4$4s',$4d e ',-'A-. 3or the direct techni"ue, undercuts in the canal or pulp cham er must e locked out. !hen a direct pattern can e made using the appropriate-si)e plastic post from the post system and making the core with autopolymeri)ing acrylic resin. 1ith the indirect techni"ue, an impression of the tooth is o tained using a plastic post to record the post space. !he post can e cast in either a no le or non-no le metal +3igur 4$4s',$4d e ',-'(-. 3or smaller-diameter posts, a type ::: gold alloy is inadvisa le as it does not provide ade"uate strength. !he use of a nonno le alloy +Ni-2r-5e- provides the potential for resin onding of the post to the dentin surface of the canal. !his may e desira le for short posts or for tapered canals.

3igur 4$4s',$4d e ',-'A: 2ast post and core.

3igur 4$4s',$4d e ',-'(: >imilar case restored with cast post and core. !he decision etween restoring a tooth with a prefa ricated post or cast post and core depends on how much intact tooth structure is remaining. 3or cementation of the post, a groove or vent should e created along the length of the post to allow for e/cess cement. :f using )inc phosphate or glass ionomer cements, a <entulo spiral drill +09N!>?<BC2aulk- should e used to place the cement into the canal. !his will result in the ma/imum retention for the post. After the cement has set, the e/cess is removed, and the core material is placed +prefa ricated post- or the impression procedures are initiated +cast post and core-. 3or resin cement, the instructions for the onding and cementation procedures for the cement should e followed. !his may include placing cement on the post rather than into the canal to prevent overly rapid set of the cement. .ne advantage of using resin cement is that the core material can e placed immediately after the post is seated. !hen the cement and core resin can set simultaneously and ond together. !his techni"ue works especially well when retrofitting a post to an e/isting crown +reverse post crown repair-. Se$%en"e &or Pre(o)ars !he type of foundation restoration for a premolar is determined y the amount of availa le tooth structure. !his re"uires making an estimation of the amount of tooth structure that will remain after the crown preparation. :f there is a moderate amount of tooth structure, the tooth can e restored like a molar using amalgam or composite as the core material. >imilar to a molar, the retention for the core would e gained y either mechanical retention andCor dentin onding. :f there is minimal tooth structure, it is est to use the same treatment se"uence as descri ed for an anterior tooth. 3irst, the tooth is prepared for the indicated crown. !hen the amount of remaining tooth structure is evaluated. :f the premolar has two roots, prefa ricated posts can e cemented in the two canals +3igur 4$4s',$4d es ',-',A, and ',-',5-. :t is usually not possi le or even necessary to make these posts very long ecause of canal curvature. However, ecause the canals are usually not parallel, following placement of the core, the posts and core are virtually impossi le to dislodge. 3or a small premolar, composite resin is a etter core

material than amalgam ecause the prefa ricated posts weaken the amalgam. :f there is minimal or no coronal tooth structure, a cast post should e considered, especially for a single rooted premolar.

3igur 4$4s',$4d e ',-',A: ?refa ricated post for additional core retention.

3igur 4$4s',$4d e ',-',5: ?refa ricated posts in the two canals of a premolar prior to core placement. :t is usually not possi le to make these posts very long ecause of canal curvature. 5ecause canals are usually not parallel to each other, the core is well retained y posts. Prin"i-)es &or Cro1n Pre-aration !he proper preparation of the tooth after completion of the post and core restoration is very important. 9ven with the ideal canal preparation and post restoration, the post has a tremendous potential to act as a wedge in the tooth root. !his can result in initiation of a vertical root fracture and su se"uent loss of the tooth. !he est way to protect the tooth +ie, the root- against this wedging force is y the creation of a ferrule design in the crown preparation on the tooth.4,'A,',,$',$, !he ferrule design is the encirclement of ' to $ mm of

vertical tooth structure y the crown. !his encirclement, like metal ands on a arrel, helps protect the tooth from fracture. :t resists the wedging forces that would e transmitted to the post from the occlusion. !o create an ade"uate ferrule, the margin usually must e prepared further apical. .ften, this re"uires a crown-lengthening procedure to gain sufficient tooth length to prepare the ferrule +3igur 4$4s',$4d e ',-'8-. !his principle of creating a ferrule around the tooth is pro a ly the single most important principle in the restoration of endodontically treated teeth +3igur 4$4s',$4d es ',-$%A, ',-$%5, and ',-$%2-. :f an ade"uate ferrule is o tained, the type, material, and design of the post and core ecome much less important. 2onversely, if a ferrule is not o tained, then the tooth is at risk of fracturing no matter what type of post and core is used. !his is especially true for teeth that are e/pected to carry a heavy load such as a remova le partial denture or fi/ed partial denture a utment or in patients who e/hi it e/cessive wear or ru/ism.

3igur 4$4s',$4d e ',-'8: 3errule design resists wedging force of post.

3igur 4$4s',$4d e ',-$%A: ?roper ferrule design on preparation for porcelain-fused-tometal crown.

3igur 4$4s',$4d e ',-$%5: Fadiograph showing cast post and core after cementation. Note that the post is more than one-third of the diameter of the root at the cement-enamel junction and is tapered. !ooth preparation did not e/hi it ferrule design.

3igur 4$4s',$4d e ',-$%2: >ame clinical case as in 3igur 4$4s',$4d e ',-$%5 after , years. Note the o li"ue root fracture. >uch a fracture could e prevented y a more conservative post in com ination with proper ferrule design in the crown preparation. REFERENCES '. Andreasen E., Andreasen 3*. 9ssentials of traumatic injuries to the teeth. 2openhagen: *unksgaard, '88%. $. Andreasen 3*, Noren E7, Andreasen E., et al. <ong-term survival of fragment onding in the treatment of fractured crowns: a multicenter clinical study. Iuintessence :nt '88#;$A:AA8-,'. 4. Assif 0, 5itenski A, ?ilo F, .ren 9. 9ffects of post design on resistance to fracture of endodontically treated teeth with complete crowns. E ?rosthet 0ent '884; A8:4A-6%. 6. 5ader E0, >hugars 0A, Fo ertson !*. Gsing crowns to prevent tooth fracture. 2ommunity 0ent .ral 9pidemiol '88A;$6:6(-#'. #. 2avalleri 7, Jerman N. !raumatic crown fractures in permanent incisors with immature roots: a follow-up study. 9ndodont 0ent !raumatol '88#;'':$86-A. A. 2roll !?. Fapid reattachment of fractured crown segment: an update. E 9sthet 0ent '88%;$:'-#. (. 2vek *A. A clinical report on partial pulptomoy and capping with calcium hydro/ide in permanent incisors with complicated crown fracture. E 9ndod '8(,;6:$4$-(. ,. 9hrmann 9H. Festoration of a fractured incisor with e/posed pulp using original tooth

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