SURENDERA DENTAL COLLEGE AND RESEARCH

INSTITUTE

CASE PRESENTATION

ON

REHABILITAtION OF FRACTURED MAXILLARY INCISOR

WITH CUSTOM POST /CORE: A CASE REPORT

PRESENTED BY
DR. ADITYA BANSAL
PG STUDENT

GUIDED BY
DR. YOGESH KUMAR
DIRECTOR PRINCIPAL AND HEAD
DEPARTMENT OF CONSERVATIVE DENTISTRY
AND ENDODONTICS.

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Contents

1. Introduction
2. Case Report
3. Discussion
4. Conclusion
5. References

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1. INTRODUCTION

 Post or dowel: The dowel is a post or other relatively rigid, restorative material placed in
the root of the non-vital teeth. The foremost purpose of the dowel is to provide retention
for the core and coronal restoration.
 Core: Is defined as properly shaped and wall restored substructure which replaces
missing coronal structure and retain the final restoration.
 The longevity of endodontically involved teeth has been greatly enhanced by continuing
developments made in endodontic therapy and restorative procedures. It has been
reported that alarge number of endodontically treated teeth are restored to their original
function with the use of intraradicular devices. These devices vary from a conventional
custom cast post and core to onevisit techniques, using commercially available
prefabricated post systems. In the last few decades,various prefabricated posts systems
have been developed. The selection of post design isimportant, because it may have an
influence on the longevity of the tooth (Sorensen JA et al1990).
 Anterior endodontically treated teeth are restored with posts more often than posterior
teeth. Laboratory studies suggest (Guzy GE et al; 1979, Robbins JW et al; 1993, and
Trope M et al; 1985) that the post does not provide increased fracture resistance to the
root and may, in fact weaken the tooth.
 The primary purpose of a post is to retain a core in a tooth with extensive loss of coronal
tooth structure.The decision to place a post is dictated by the amount of coronal
remaining tooth structure after the crown preparation is completed and the functional
requirements of the restored tooth.Cast metal posts were traditionally used for
intraradicular retention and have shown high survival rates after 10 years.

 Advantages of Custom Post and Core

1. They are custom fit to the root configuration.

2. Provide a better geometric adaptation to excessively flared, elliptical, tapered, noncircular
or irregular shape canals.
3. Excellent core retention.

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4. Greater strength in the sections.
5. This two-step procedure improves the marginal adaptation and allows for a variation in
the path of insertion of the crown.
6. It almost always requires minimum tooth structure removal
7. Custom cast post and cores adapt well to extremely tapered canals or those with a non-
circular cross-section or irregular shape, and roots with minimal remaining coronal tooth
structure

 Disadvantagesof Custom Post and Core

1. Root fractures - the modulus of elasticity of cast metal is 10 times greater than that of
dentin leading to greater stress concentration and subsequent root fracture.
2. The transmission of occlusal forces thorugh the metal cores can focus stresses at specific
regions of the root, causing root fracture
3. Aesthetics – metal post alter the light transmission through the tooth and may show
through the root especially where the gingiva is thin and Metal core will also alter the
optical properties of overlying ceramic restoration.
4. This method requires two-appointment visits and a laboratory fee.

 The present report highlights the management of broken down endodontically treated
anterior tooth with the use of cast post/core system.

2. CASE REPORT
 A 25- year old male patient reported to the department of Conservative Dentistry and
Endodontics with a chief complaint of broken upper front teeth. Patient gave the history
of road traffic accident 6 months back. There was no history of nausea, vomiting and loss
of consciousness after trauma.
 Intraoral examination revealed Ellis class III fracture irt 21 (Fig. 1) and the tooth was non
tender to percussion.

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 On thermal testing the tooth no 21 gave no response to cold and heat test and even high
amount of current cannot elicit response to electric pulp tester.

Fig 1: Preoperative View

 Radiographic examination revealed Ellis class III fractures irt 21 with involvement of
pulp space ( Fig 2).

Fig 2: Preoperative IOPA

 The final diagnosis established was Ellis Class III fracture with chronic irreversible
pulpitisirt 21.
 The treatment plan decided was root canal treatment irt 21 followed cast post and core
followed by crown.
 After getting the written consent from the patient, the endododntic treatment started.
 The access cavity was made irt21and working length was established apex locator (Ray-
pex) which was confirmed with digital radiograph (Digora Optime). Biomechanical

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 preparation was done with k files till MAF 30 # k file. Copious irrigation was done with
normal saline, hydrogen peroxide. Calcium hydroxide was placed as an
intracanalmedicament and the access cavities was temporized.
 The patient was recalled after 7 days. On the next visit, the teeth were asymptomatic. The
Calcium hydroxide intracanal medicament was removed from the canals with the help of
H- files and normal saline. Master cone wasselected corresponding to the size of master
apical file (50 no) and obturation was done using lateral compaction technique (Fig 3).

Fig 3: IOPA after Obturation

 On next visit, the post space was prepared with pesso reamers till size # 4 irt 21, leaving 5
mm guttapercha for apical seal and the post space was confirmed radiographically. (Fig
4).

Fig. 4 IOPA showing Post space

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 Tooth preparation was done for PFMcrown and ferrule was made irt 21 (Fig. 5).

Fig.5Tooth preparation irt 21

 The direct wax pattern fabrication was done. The tooth was temporized and patient was
recalled on very next day for cementation of cast metal post/ core.
 The investment and casting procedure was carried out and cast post and core was
finished, polished and then checked in the mouth for fit, alignment. Then the fit of cast
post and core was confirmed radiographically.
 Post and core cementation was done using luting GIC (GC Fuji America) (Fig 6, 7).

Fig. 6 Intra oral view after Cast post and core cementation

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 Fig. 7 IOPA showing Cast Post and core

 This was followed by final prosthetic phase including PFM crown irt 21 (Fig. 8, 9).

Fig. 8 Post- operative intra-oral view

Fig. 9 Final post- operative IOPA

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3. DISCUSSION
 The customized cast post and core possessuperior adaptation to the root canal, associated
with little or no stress with installation and high strength in comparison to the
prefabricated post. On the other hand custom cast posts is considered time consuming
complex procedure. Its recommended use is with elliptical or flared canals while
prefabricated posts function best in teeth with small circular canal.
 The decision making for placing a post and type of post system depends upon the amount
of remaining tooth structure.
 According to clinical protocols for restoring non-vital teeth with full prosthetic
restorations – when there is a loss of more than half of the coronal tooth structure with
sufficient ferrule height and remaining dentin thickness of 1 mm is preserved after tooth
preparation, custom metal cast post/core is recommended.(Cohen- 10thedi.)
 Studies on the cast post/core retention have shown that the cast post fit the prepared root
canal as closely as possible. When ferrule is present, custom cast posts and cores exhibit
a higher fracture resistance compared to composite cores built on prefabricated metallic
or carbon posts.
 The incorporation of the concept of ‘ferrule’ or ‘the ferrule effect’ has been accepted as
one of the foundations of the restoration of the endodontic treated tooth. The origin of the
term is thought to come from the Latin terms ‘ferrum’ - iron, and ‘viriola’ - bracelet, such
that the ferrule is an encircling band of cast metal around the coronal surface of the tooth.
 The rule established is that a 1.5-2 mm ferrule height directly above the margin improves
long-term survival of endodontic treated teeth with a post and core.
 The cast restoration encircles the remaining parallel walled tooth structure with a metal
band thereby ‘bracing’ the tooth, providing resistance to dislodgement and preventing
fracture.Cohen et al (1976) concluded that a metal margin should surround and protect
the rootfrom vertical fracture (the ferrule effect)

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 4. CONCLUSION

Although the quest for the ideal material to restore lost tooth structure continues to be a focus of
modern dental research but with proper treatment planning and technique the custom cast post
and core systems still considered as gold standard to restore the broken down endodontically
treated teeth.

5. REFERENCES
1. John Ingle-“Periapical Pathology”-“Endodontics”, 6th Edition.
2. Cohen-“Structure and Functions of Dentine and Pulp Complex”-“Pathways of the Pulp”,
10th edition.
3. Louis Grossman-“Endodontic Practice”, 12th Edition.
4. Contemporary Fixed Prosthodontics- Stephen F. Roesensteil
5. Held eresteves, Andre Correia, Filipe Araujo. Classification of extensively damaged teeth
to evaluate prognosis; JCDA; 2011:77;b105\
6. Krasteva K. Clinical application of a fiber-reinforced post system. J Endod2001; 27: 132-
133.
7. De Rijk W G. Removal of fiber posts from endodontically treated teeth. Am J Dent 2000;
13(Spec No): 19B-21B.
8. Quintas A F, Dinato J C, Bottino M A. Aesthetic posts and cores for metal-free
restoration of endodontically treated teeth. Pract Periodontics Aesthet Dent 2000; 12:
875-884; quiz 886.
9. Brown D. Fibre-reinforced materials. Dent Update 2000; 27: 442-448.
10. Freedman G A. Esthetic post-and-core treatment. Dent Clin North Am 2001 103-116.
11. Sorensen J A, Martinoff J T. Clinically significant factors in dowel design. J\ Prosthet
Dent 1984; 52: 28-35.
12. Christensen G J. Posts and cores: state of the art. J Am Dent Assoc1998; 129: 96-97.

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