110 Indian J Dent Res, 20(1), 2009

Metal-ceramic dowel crown restorations for severely damaged

teeth: A clinical report
Bulem Yzgll, !enay Canay
ABSTRACT
This clinical report describes an alternative prosthodontic treatment of a patient who had severely
damaged endodontically-treated first molar teeth in all quadrants of her mouth. The young
patients severely damaged permanent molar teeth were treated with a restoration combining the
advantage of the esthetics of dental porcelain, reinforced with the underlying cast gold dowel
crown. Using this technique, the remaining sound tooth structure was preserved with function
and esthetics accomplished. The described metal-ceramic one piece dowel crown restoration
seemed to perform without any problems for the 12 month evaluation time.
Key words: Dowel core, dowel crown, endodontic therapy, esthetics, onlay restoration
Address for correspondence:
Dr. Bulem Yzgll,
E-mail: bulemy@gmail.com
Department of Prosthodontics
Faculty of Dentistry, University
of Hacettepe 06100, Ankara,
Turkey
Received : 20-12-06
Review completed : 16-03-08
Accepted : 16-04-08
PubMed ID : 19336871
DOI: 10.4103/0970-9290.49063
CASE REPORT
The probable survival rate of an endodontically treated
tooth is directly related to the quantity and quality of the
remaining dental tissue.
[1]
The roof of the pulp chamber
provides much of the necessary support for the natural
tooth and its loss leaves the facial and lingual walls severely
weakened and without sufcient support.
[2]
Dowel-core
restorations are used in the reconstruction of coronal
structure lost due to caries, fracture, endodontic access,
abscess, or prior restorations.
[311]
The post size and shape,
the nal preparation design of the tooth, and the kind
of luting agent used inuence tooth resistance.
[5]
Dowel
posts mainly provide protection from horizontal as well
as vertical fracture and retention and stabilization to the
core.
[12,13]
Because their insertion and retention in the
prepared canal is independent of dentin elasticity, they
produce no lateral stress that can crack or fracture the root
if they have a positive seat and can not move apically beyond
this seat.
12
A tooth with more than one canal requires a
dowel of optimal length in the most desirable canal and a
shorter key-type lock post in a second canal. The key aids
in seating the dowel and prevents rotation.
[1214]
Of the various dowel-core designs available, the most widely
used can be classied into two basic types: metal posts and
cores that are custom cast as a single piece and two-element
designs comprising a commercial prefabricated post to
which a silver amalgam, resin composite, or glass-ionomer
cement core is subsequently adapted. Cast dowel-cores
are commonly advocated for teeth with little remaining
coronal structure. In such situations, the use of an alloy
with high gold content, and thus high biocompatibility,
high corrosion resistance, and low rigidity appear to be
most appropriate.
[1]
Even in the situation of minimal coronal destruction, cuspal
coverage is mandatory. The restoration can be an onlay
design instead of a complete coverage restoration.
[13]
Ceramic
onlays have become an important treatment modality in
modern dental practice because of the increased demand for
esthetic posterior restorations.
[15]
This clinical report presents
a young patient whose severely damaged permanent molar
teeth were treated with a modality combining the advantage
of esthetics of porcelain reinforced with an underlying cast
gold dowel crown.
CASE REPORT
A 21-year-old young female reported for an evaluation of
her permanent rst molar teeth. She had a dental history of
caries in all rst molars, which were consecutively treated
with amalgam llings [Figure 1]. Six months before her
treatment in the prosthodontic department, the patient had
an endodontic emergency procedure in the maxillar right
rst molar tooth. A clinical evaluation revealed an anterior
open articulator and posterior premature contacts while the
radiographic evaluation revealed unsuccessful llings. The
patient also stated that she was not fond of the black llings
on her teeth. Therefore, endodontic treatment was applied
to all of her rst molar teeth prior to prosthetic treatment.
This work has been presented as a poster presentation at the
28th Annual Conference of the European Prosthodontic
Association Conference in Ku"adas-#zmir-Turkey on the
16
th
through the 18
th
of September 2004.
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Indian J Dent Res, 20(1), 2009 111
Since the molar teeth were extremely damaged and esthetics
was an important factor, a metal-ceramic dowel crown,
which is a combination of a cast gold dowel-core with
coronal porcelain structure, was planned in this case.
All rst molar teeth canals were obturated with gutta percha
and were asymptomatic. Isolation of the severely damaged
molar teeth were achieved by cotton rolls, suction, and a
tongue guard (HiandDri-Drident, Microplus Inc., Clinton,
MA) because a rubber dam would have interfered with
frequent checks for occlusal clearance and alignment with
adjacent teeth. After the existing provisional restorations
were removed, all unsupported dentin and enamel were
removed using a horizontally approaching rotary cutting
instrument (Diatech Dental AG, Heerbrugg, Switzerland)
so that sound residual tooth structure had a minimum
wall thickness of 1 mm. With a bur, the pulp chamber
was rendered free of luting cement, gutta percha, and
provisional restorative material. The gingival margins were
left supragingivally for easier access. The preparation was
made with a 1 mm wide chamfer and a counterbevel to
achieve the ferrule effect. Dowel spaces were prepared in the
distal canals of the mandibular molar teeth and the palatinal
canals of the maxillar molar teeth. Before the enlargement
of the canals, the Peeso reamers (Dentsply, Ballalgues,
Switzerland) length was chosen by measuring against the
radiographs so that at least 34 mm in length of the gutta
percha was left in the apex to prevent dislodgement and
leakage. After the dowel spaces were prepared, orices of
the mesial canals of the mandibular molar teeth and mesial-
distal canals of the maxillar molar teeth were prepared as
the key-locks using a bur (Diatech Dental AG, Heerbrugg,
Switzerland). The length of each key-lock was 34 mm
[Figures 2a, 2b, and 3]. The preparations were washed, dried,
and lubricated with a water-soluble lubricant (Panavia

F
Oxyguard II, Kuraray Medical Inc., Okayama, Japan).
The cast dowel crowns were fabricated using the direct
impression technique. Solid plastic sprues (Williams Dental,
Buffalo, NY) were trimmed to t loosely in the canals.
Hard inlay wax (Almore International Inc., Portland, OR)
was softened and applied on the sprue and was seated in
the canals. When the wax had achieved an initial set, the
pattern was moved in and out of the canal to ensure that
it would not be locked into any undercuts. The core and
the key-lock preparations were waxed around the dowel
impression. The dowel crown was then sprued and cast
from a gold alloy (Degudent G; DeguDent GmbH, Hanau,
Germany). After casting, removal, and cleansing, the dowel
crowns were adapted and seated to the teeth [Figure 4].
With four cast dowel crowns in place, a new complete-arch
impression was made using a vinyl polysiloxane impression
paste (Speedex; Coltene Whaledent, Mahwah, NJ). The new
casts, with the cast dowel crowns in place, were transferred
to an articulator (Whip Mix Corp; Louisville, KY) for the
fabrication of the porcelain (Ceramco 3; Dentsply Ceramco,
PA) part of the restoration. After the completion of the
porcelain superstructure on the cast dowel crowns, the
restorations were tried and checked for marginal integrity,
proximal and occlusal relations, and color [Figure 5,
Figure 6]. Between the tooth margins and the porcelain
part, there was a 11.5 mm cast collar. The cast part of
the restorations was airborne-particle abraded with 50
aluminum oxide abrasive (Microetcher Model Er Precision
Sandblaster; Danville Engineering, Inc., U.S.A.). Dual-cure
resin cement (Panavia F; Kuraray Medical, Inc.) was used
as a luting agent [Figure 7]. After applying the alloy primer
(Alloy Primer; Kuraray Medical, Inc.) on the cast dowel
parts, ED Primer II A and B (ED Primer II A, B; Kuraray
Medical, Inc.) were mixed and applied to the coronal and
dowel parts on the tooth structure. Thirty seconds later, the
tooth was air dried and the excess primer was removed with
paper points. Panavia F pastes A and B (Panavia F; Kuraray
Medical, Inc.) were dispensed in equal amounts, then the
mixed cement was applied to coat the cast dowel parts of the
restoration. The manufacturers instructions were followed
Dowel crown restorations Yzgll and Canay
Figure 1: Pretreatment radiographs of rst molar teeth Figure 2: Schematic diagram of dowel crown restorations a, Mandibular
b, Maxillar rst molar tooth
a b
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112 Indian J Dent Res, 20(1), 2009
for all aspects of the seating procedure. The excess cement
on the margins was cleaned. The restoration margins were
light cured for 20 seconds on each surface and the restoration
was left for self cure by applying Oxyguard II (Oxyguard
Dowel crown restorations Yzgll and Canay
II, Kuraray Medical, Inc.) for 3 minutes. The margins were
burnished so that the gold alloy and tooth were on the same
plane. The panoramic radiograph of the patient was made
after 12 months [Figure 8]. The described metal-ceramic
Figure 5: Dowel crown restorations after porcelain application
Figure 7: Intraoral view of restorations
Figure 6: Dowel crown restorations on casts
Figure 8: Panaromic radiograph of 12-mouth recall
Figure 3: Intraoral view of the dowel preparations Figure 4: Try-in of metal frameworks in mouth
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Indian J Dent Res, 20(1), 2009 113
one-piece dowel crown restoration seemed to perform
without any problems for the 12-month evaluation time.
DI SCUSSI ON
As alternatives to cast dowel-cores, the use of prefabricated
posts and custom-made buildups with amalgam, resin
composites, and glass-ionomer cements simplifies the
restorative procedures.
[3]
Composite cores are more prone
to recurrent caries and bacterial adhesion. Amalgam cores
main disadvantage is that even the fastest setting amalgam
requires 20 to 30 minutes before sufficient strength is
achieved for preparation. Other disadvantages are concerns
about mercury, discoloration of gingival tissues, and esthetic
problems when certain all-ceramic crowns are used.
[6]
The cast gold dowel-core has been regarded as the gold
standard in post and core restorations due to its superior
success rates.
[3]
Cast post and core assemblies were reported
to yield higher fracture strengths than direct buildups
with prefabricated posts and amalgam.
[4]
According to the
research by Reagan, et al.,
[6]
two different prefabricated
posts used with either amalgam or composite core material
and a cast post and core performed equally well. Sorensen
and Martinoff
[7]
concluded that 94% of endodontically
treated molars and premolars that subsequently received
coronal coverage were successful, while only 56% of
occlusally unprotected endodontically treated posterior
teeth survived.
Porcelain is most satisfying for the patients quest for natural
color and esthetics. The stable metal base concept with
overlying porcelain has been widely recognized for inlays
and onlays.
[811]
Using a high gold content metal as a base
allows easier burnishing for the sealing of the margins and
adaptation of the dowel to the preparation.
[11]
The restoration described in this article meets the
requirements of esthetics with the porcelain veneer and at
the same time the cast substructure provides the strength
needed to withstand occlusal loading. Also, conventionally
there is a need for complete occlusal coverage for severely
damaged and endodontically treated teeth. With the
Dowel crown restorations Yzgll and Canay
described method, there has been no more necessity for the
fabrication of a crown.
REFERENCES
1. Martinez-Insua A, Da Silva L, Rilo B, Santana U. Comparison of the
fracture resistance of pulpless teeth restored with a cast post and
core or carbon-fiber post with a composite core. J Prosthet Dent
1998;80:527-32.
2. Starr CB. Amalgam crown restorations for posterior pulpless teeth. J
Prosthet Dent 1990;63:614-619.
3. Heydecke G, Butz F, Hussein A, Strub J. Fracture strength after dynamic
loading of endodontically treated teeth restored with different post-
and-core systems. J Prosthet Dent 2002;87:438-445.
4. Plasmans PJ, Visseren LG, Vrijhoef MM, Kyser AF. In vi t ro comparison
of dowel and core techniques for endodontically treated molars. J
Endodon 1986;12:382-7.
5. Mezzomo E, Massa F, Libera SD. Fracture resistance of teeth restored
with two different post-and-core designs cemented with two different
cements: An i n vi t ro study. Part I. Quintessence Int 2003;34:301-6.
6. Reagan SE, Fruits TJ, Van Brunt CL, Ward CK. Effects of cyclic loading
on selected post-and-core systems. Quintessence Int 1999;30:61-7.
7. Sorensen JA, Martinoff JT. Intracoronal reinforcement and coronal
coverage: A study of endodontically treated teeth. J Prosthet Dent
1984;51:780-4.
8. Wirz J, Jaeger K. Modern alternatives to amalgam: Cementable
restorations and inlays. Quintessence Int 1999;30:551-6.
9. Esquivel-Upshaw JF, Anusavice KJ, Reid M, Yang MC, Lee RB. Fracture
resistance of all-ceramic and metal-ceramic inlays. Int J Prosthodont
2001;14:109-14.
10. Garber DA, Goldstein RE. Porcelain and composite inlays and onlays:
Esthetic posterior restorations. Quintessence Publishing Co., Inc.;
1994.
11. Sewitch T. Resin-bonded metal-ceramic inlays: A new approach. J
Prosthet Dent 1997;78:408-11.
12. Johnson JK, Schwarz N, Blackwell RT. Evaluation and restoration of
endodontically treated posterior teeth. J Am Dent Assoc 1976;93:597-
605.
13. Sadan A, Elliot R, Raigrodski AJ. Treatment planning extensively broken-
down mandibular molars for post-and-core fabrication. Quintessence
Int 1998;29:351-5.
14. Shillingburg HT, Fisher DW, Dewhirst RB. Restoration of endodontically
treated posterior teeth. J Prosthet Dent 1970;24:401-8.
15. Roulet JF, Herder S. Bonded Ceramic Inlays. Chicago: Quintessence
Publishing Co., Inc.; 1991.
How to cite this article: Yzgll B, Canay S. Metal-ceramic dowel crown
restorations for severely damaged teeth: A clinical report. Indian J Dent Res
2009;20:110-3.
Source of Support: Nil, Conict of Interest: None declared.
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