ENDODONTIC-PROSTHODONTIC RELATIONSHIP

 Our objective should be the perpetual preservation of what remains than the meticulous
restoration of what is missing. – M.M. De Van.
 A successful endodontic treatment has to be complemented with an adequate
postendodontic restoration to make the pulpless tooth function indefinitely as an integral
part of the oral masticatory apparatus.
 Endodontically treated teeth fail principally due to one of the following two reasons:
1. Persistent intraradicular infection
2. Postendodontic restorative difficulties

ANATOMICAL, BIOLOGICAL AND MECHANICAL CONSIDERATIONS IN RESTORING

ENDODONTICALLY TREATED TEETH

Endodontically treated teeth are associated with unique structural and functional
challenges. They are-
1. The role of moisture loss and the nature of dentin.
2. Alterations in strength caused by architectural changes in the morphology of teeth.
3. Concepts of biomechanical behaviour of tooth structure under stress.
4. Biological width.
5. Protecting the remaining coronal tooth tissue- creating the ferrule.

CHANGES IN ENDODONTICALLY TREATED TOOTH

1. LOSS OF TOOTH STRUCTURE- decreased strength, destroys structural integrity, and allows
greater flexing of tooth under function
2. ALTERED PHYSICAL CHARACTERISTICS-
 Changes in collagen cross-linking- RC Treated tooth has more immature cross linked collagen
fiber… brittleness of non-vital teeth
 Dehydration of dentin- loss of moisture
 Changes due to use of sealer cements- affects properties
3. ALTERED ESTHETIC CHARACTERISTICS-
 Altered dentin modifies light refraction, and modifies its appearance
 Caries, restorations and secondary calcifications modify the appearance

Considering criteria’s-

A. BIOLOGIC WIDTH
 To have a healthy gingival attachment apparatus, room is required between the margin of
the restoration and the crest of bone.
 This means that there should be an absolute minimum of 2.5- 3mm between the
restoration margin and the crest of bone.
 An adequate bulk of tooth coronal to the restoration margin is required to restore the tooth.
 The amount of coronal tooth structure, along with the position of the tooth in the arch, will
dictate: the type of build-up indicated;
 whether a preformed post, or a cast post and core are indicated; and
 whether a crown is needed.

CLINICAL NOTE- RESTORATION MAGIN SHOULD NOT IMPINGE ONTO THE BIOLOGIC WIDTH AS IT
WOULD CAUSE PERIODONTAL BREAKDOWN.
 B. REMAINING CORONAL TOOTH TISSUE – CREATING THE FERRULE
 A ferrule is defined as a band of extracoronal material at the cervical margin of a crown
preparation that encompassess the tooth and provides resistance form to the tooth. This is
usually provided by the crown that is placed over the post and core system.
 It is of paramount importance that as much coronal or supragingival tooth tissue is
preserved as possible, as this significantly improves the prognosis of the tooth and
restoration.
 One to two millimetres of tooth tissue coronal to the finish line of the crown preparation
significantly improves the fracture resistance of the tooth and is more important than the
type of core and post material
 The ferrule effect occurs because of the crown bracing against the remaining supragingival
tooth tissue.
 The height of the ferrule at differing locations around the circumference of the tooth may
also be important due to functional occlusal loading.
 PURPOSE OF FERRULE-
 Improves structural integrity by counteracting –
1. Functional lever forces
2. Wedging effects of tapered dowels
3. Lateral forces expected during insertion of dowel
 Thus prevents root fracture
 CLINICAL NOTE-
 A 1.5 mm ferrule can be recommended labially and lingually whereas a shorter 1 mm
ferrule could be accepted mesially and distally due to decreased stress in these direction.
 Maxillary incisor- longer ferrule on the palatal aspect
 Mandibular incisor- longer ferrule on the labial aspect.

PRE-TREATMENT EVALUATION
1. Endodontic evaluation –
 apical seal, TOP, draining sinus, mobility, inflammation, inadequate root filling
2. Periodontal evaluation-
 pocket depth, BOP
 Attempts to place restorative margin on solid tooth structure
 if the biological attachment zone is invaded- in such cases crown lengthening or
orthodontic extrusion
3. Restorative evaluation-
 reliability of tooth after restoration,
 able to withstand functional forces,
 large amount of missing tooth structure- replaced by post and core and crown.
4. Esthetic evaluation-
 metal carbon fiber dowels or amalgam in canal- unacceptable gingival discoloration from
root
 Transluscency of all-ceramic crowns- to be considered in selection of dowel and buildup
materials
 In esthetic areas- tooth colored carbon fiber posts or zirconia posts
 In estheic areas- tooth colored composite core materials used.

RESTORATIVE TREATMENT PLANNING OF NON-VITAL TOOTH

Restorative treatment decisions depend on the following-

1. Amount of the remaining tooth structure

2. Functional demands that will be placed on the tooth
3. Anatomic position of the tooth
4. Need for the tooth as a abutment in a larger restoration

CORE
 The core consists of restorative management of the coronal portion of a tooth after the
completion of endodontic treatment.
 The most widely used core materials are-
i. Resin based composites
ii. Silver amalgam
iii. Cast gold
iv. Glass ionomer cement ( type II)

EVALUATION OF TEETH

Anterior and posterior teeth function much differently, therefore, they must be evaluated
separately.

I. ANTERIOR TEETH
CLINICAL NOTE-

 A full coverage crown is not mandatory for every endodontically treated anterior
tooth.
 The clinical decision is based on the extent of loss of tooth structure and
esthetics.
i. Only access cavity preparation with no discoloration---- etched resin composite
core buildup restoration
ii. Loss of one or both the proximal walls and/ or significant discoloration that
cannot be managed by bleaching …. Etched resin composite core builup
restoration followed by full coverage crown
iii. Extensive loss of tooth structure---- post and core followed by full coverage
crown.

II. POSTERIOR TEETH-

CLINICAL NOTE
 Endodontically treated posterior teeth should receive cuspal coverage to prevent
fracture, but in most cases does not require a post.
 Post is indicated in a posterior tooth only when other conservative retention and
resistance features cannot be used for the core.
 It is indicated when the tooth is to serve as an abutment for a rpd/fpd – coronal
reinforcement would be required.
 In posterior teeth, posts are most commonly placed in –
 Palatal canal of maxillary molars
 Distal canal of mandibular molars
 Palatal canal of maxillary premolars
 POSTS

 The primary function of a post is to provide retention of the core material.

 A post does not strengthen or increase the fracture resistance of a tooth.

An ideal post system should have the following features:

 Provide maximal retentiveness to the core

 Physical properties compatible to dentin
 Maximum retention with minimal removal of dentin
 Even distribution of functional stresses along the root surface
 Esthetic compatibility with the definitive restoration and surrounding tissue
 Minimal stress during placement and cementation
 Resistance to displacement
 Easy retrievability
 Material compatibility with core
 Ease of use, safety, and reliability
 Reasonable cost

The principles which are to be taken into consideration during treatment planning for a post
and core restoration are as follows:

I. Post length
II. Tooth anatomy
III. Post width
IV. Canal configuration and post adaptability
V. Post design
VI. Luting cement

Principles of tooth preparation

a. CONSERVATION OF TOOTH STRUCTURE

b. RETENTION FORM
c. RESISTANCE FORM

A. CONSERVATION OF TOOTH STRUCTURE

1. PREPARATION OF THE CANAL
 Remove only minimal tooth structure
 Excessive enlargement can perforate or weaken the root, which then may
split during post cementation or subsequent function.
 Root canal should be enlarged only enough to enable the post to fit
accurately and yet passively while ensuring strength and retention.
2. PREPARATION OF THE CORONAL TISSUE
 Every effort should be made to save as much of the coronal tooth structure
as possible, provided it is sound and of reasonable strength…. because this
helps reduce stress concentration at the gingival margin.
  Extending preparation apically creates a ferrule and helps prevents fracture
during function.
 If more than 2mm of coronal tooth structure remains, the post design has
probably has a limited role in the fracture resistance of the restored tooth.
 LOCATION WHERE FERRULE CAN BE GIVEN-
a. Crown ferrule- created by overlying crown engaging the tooth structure
b. Core ferrule- ferrule is part of cast metal post

CLINICAL POINTS

 Ferrule that grasp larger amount of tooth structure are more

effective than small amount
 Sloping ferrule- ferrule are more effective when encompasses
relatively parallel prepared tooth structure than when it engages
sloping tooth structure.

B. RETENTION FORM
1. Anterior teeth
Post retention factors-
1. Preparation geometry
2. Post length
3. Post diameter
4. Post surface texture
5. Luting agent
PREPARATION GEOMETRY-
 Parallel-sided posts are more retentive than tapered posts and that
threaded posts are the most retentive
POST LENGTH-
 Ideally, the post should be as long as possible without jeopardizing the
apical seal or the strength or integrity of the remaining root structure.
 Most endodontic texts advocate maintaining a 5mm apical seal.
 However, if a post is shorter than the coronal height of the clinical crown of
the tooth, the prognosis is considered unfavourable, because stress is
distributed over a smaller surface area, thereby increasing the probability of
radicular fracture. Under such circumstances, an aical seal of 3mm is
considered acceptable
POST DIAMETER –
 Increasing the post diameter in an attempt to increase retention is not
recommended because there is minimal retentive gain and unnecessary
weakening of the remaining root.
POST SURFACE AREA-
 A serrated post is more retentive than a smooth one.
LUTING AGENT –
 choice of cement has little effect on retention / fracture resistance of dentin
 however, resin luting agents- have potential to increase the performance of
post and core restorations
 resin cements are affected by eugenol containing root canal sealers, which
should be removed by ethanol/ etching by 37% phosphoric acid
 2. POSTERIOR TEETH
 Long posts should be avoided in posterior teeth.
 For these teeth, retention is better provided by two or more relatively short
posts in the divergent canals.
 When 3-4mm coronal structure with reasonable wall thickness--- use of post
is not necessary.

C. RESISTANCE FORM
1. ROTATIONAL RESISTANCE
2. STRESS DISTRIBUTION

Rotational resistance-
 Circular post should not rotate during function
 If sufficient tooth structure – rotation is prevented by vertical coronal wall.
 Where coronal dentine wall is completely lost, a small groove placed in the
canal wall can serve as an antirotaional element.

Stress distribution
