Direct or Indirect Restoration of Endodontically Treated

Maxillary Central Incisors with Class III Defects?

Composite vs Veneer or Crown Restoration

Journal of adhesive dentistry 2018

20(6):519-526
Guided by:
Dr.P.Karunakar
Presented by:
Dr.Umrana Faizuddin
M.Rasagna
Dr.Ashish jain
CONTENTS
• Introduction
• Objectives of final restoration
• Pre-treatment evaluation
• Types of post endodontic restoration
• Anterior treatment philosophy
• Class 3 defects in anterior ETT
• Aim of the study
• Materials and methodology
• Results
• Discussion
• Conclusion
• Critic analysis
• Review of literature
• Take home message
• References
INTRODUCTION
OBJECTIVES OF FINAL RESTORATION
• Maintain coronal seal of the root canal treatment
• Protect and preserve the remaining tooth structure
• Provide a supportive and retention foundation for the placement of
definitive restoration
• Restore the function and esthetics
 Restorative
Endodontic
Periodontal

PRE-TREATMENT
EVALUATION

Esthetics
Prosthetic
TYPES OF POST ENDODONTIC RESTORATIONS
• Access opening fillings
• Onlays for posteriors
• Crowns
• Core –build up
• Post and core followed by full coverage crowns
• veneers
 ANTERIOR TEETH-TREATMENT PHILOSOPHY
• Predominatly receive shear forces

• In consideration of restorative scenarios, available studies focused on

specific single defect configurations in anterior teeth with access cavities ,
class III cavities , class IV cavities, cervical cavities , or severely damaged
teeth.

• These studies evaluated how to restore anterior ETT directly with resin
composite restorations , indirectly with veneer , or crown restorations .
CLASS 3 DEFECTS IN ANTERIOR ENDODONTICALLY TREATED TEETH
• Recommendations to restore anterior ETT with Class III cavities are
underrepresented in the literature.
• A systematic review on anterior composite restorations concluded that
Class III restorations generally have lower annual failure rates than other
restorations in the anterior region.
• different treatment strategies :
• composite
• veneer
• crown
 COMPOSITE
• One treatment option to restore anterior
Class III cavities is to apply composite
restorations directly without extensive
preparation and removal of tooth
structure.

• less invasive,and,avoid time consuming

procedure.

• In a study done by Von Stein-Lausnitz et

al,Direct resin composite restoration in
endodontically treated maxillary central
incisors with access to class III defect sizes
achieve clinical acceptable load capabilities
 INDIRECT RESTORATIONS
• VENEER
• This restoration technique represents an
alternative to traditional restoration
procedures such as metal ceramic
restorations and all ceramic crown
• It preserves the remaining tooth structure,
re-establishes function, and offers good
esthetic results
• Some studies concluded that Veneering
tooth reduction might reduce tooth fracture
resistance, particularly for endodontically
treated teeth
• Veneers seem indicated only when the remaining structure of
endodontically treated teeth is relatively intact

• Some authors reported that among veneer prepared teeth, those that
were restored with fiber posts showed significantly higher mean
maximum load values when compared with those that were just
endodontically treated and with those that were not subjected to root
canal therapy.
 FULL COVERAGE CROWNS
• full coverage crown restorations on
endodontically treated teeth are
widely accepted.
• sytematic review on the restoration
of ETT showed acceptable 10-year
survival rates of 81% for ETT restored
with crowns, and found reduced
survival rates of 63% for ETT restored
with direct restorations.
 POST AND CORE

• As endodontically treated teeth often have

extensive defects, post placement is often
clinically necessary to improve core retention
• Glass-fiber-reinforced endodontic posts (GFP)
are widely used , and their usage is supported
by an increasing body of clinical evidence
• Fiber-reinforced composites(FRC) posts have
been recommended because of their dentin-
like Young’s modulus ,thus forming a adhesive
monobloc
• fewer studies described that fiber-reinforced posts increase fracture
strength of endodontically treated teeth with resin composite restorations
and decrease the risk to fail compared to restorations without a fiber post

• However, other authors have shown that the insertion of these posts has no
impact on fracture resistance of ETT with class III cavities restored with
composite resin or indirectly with a crown.
AIM OF THE STUDY
• the aim of this ex-vivo study was to evaluate the load capacity of
direct or indirect endodontically restored maxillary central incisors
,with or without glass-fiber posts
MATERIALS AND METHODOLOGY

• Seventy two maxillary central incisors ,stored in 0.5% chloramine T

solution were included in the study.
 Inclusion criteria
• Caries free and defect free.
• No coronal defects.
• Should not be endodontically treated .
• Specimens dimensions were measured from cej to apex for root
length ,as well as buccolingual and mesiodistal dimensions at cej.
• The minium required root length is 15mm.​
• Based on ratio of buccolingual and mesiodistance distance specimens were
divided into 6 groups(n=12)​.
GROUP C,DIRECT RESTORATION WITH COMPOSITE

• Gutta-percha was removed 3 mm apically to the CEJ.

• A bulk-fill composite was filled into the first 3 mm of the root canal and light cured for 20 s.
• Access and Class III cavities were incrementally filled with a composite followed by light
curing in increments(20 s each) and a final polishing procedure.
GROUP CP,DIRECT RESTORATION WITH ENDODONTIC GLASS
FIBER POST AND COMPOSITE
• Preparation of cavities was performed as described for group C.
• gutta-percha was applied 10 mm apically to the mesial CEJ to leave post
space open, ensuring at least 4 mm of gutta-percha for apical sealing.
• Glass-fiber posts were tried in to verify a passive fit and correct length of
post space.
GROUP V,VENEER RESTORATION

• Cavity preparation and composite restoration was performed as

described for group C.
• Specimens were fixed with the root into a polyether impression
material
• A pre-scan of the clinical crown was performed with an intraoral
scanner before veneer preparation.
• Teeth were prepared considering a long-wrap veneer removing
proximal contact points.
• Facial preparation-0.6mm,incisal-1.5mm,interproximal –
1mm,cervical-0.4mm,palatal chamfer preparation.
GROUP VP,VENEER RESTORATION AND ADDITIONAL GLASS FIBER
POST
• Cavity preparation, post placement and restorative procedure
with composite were performed as described for group CP.
• Veneers were fabricated and luted as described for group V.
GROUP CR,CROWN RESTORATION

• Cavity preparation was performed as described for group C.

• Teeth were fixed with the root into a polyether impression material.
• A pre-scan of the clinical crown was performed with an intraoral scanner
before crown preparation.
GROUP CRP,CROWN RESTORATION AND ADDITIONAL GLASS
FIBER POST
• Cavity preparation, post placement, and restorative procedure with
composite and endodontic post were performedas described for
group CP.
• Crown fabrication and placement were performed as described for
group C.
EMBEDDING OF SPECIMENS

• roots were coated with a thin layer of wax and blocked out with wax
2.5 mm below the CEJ, simulating biological width.
• Teeth were retained parallel to tooth axis and mounted in an acrylic
resin block with a parallelometer.
• After polymerization, teeth were removed and cleaned.
• Roots were coated with a thin layer of acrylic resin and an
adhesive was applied on the acrylic resin layer.
• A polysiloxane soft lining material was inserted into the root space of
the acrylic block.
• Specimens were finally placed back into the acrylic block.
LOADING OF SPECIMENS

• Thermo mechanical loading (TML) was performed with following

parameters: 3.000 thermal cycles.
• between 5/55 °C for 2 min each cycle in distilled water and 1.2 x 106
mastication cycles of 1 and 50 N at a loading angle of 135 degrees to
the horizontal.
• After TML, surviving specimens were loaded at 135° in a universal
testing machine 2 mm below the incisal edge until failure occurred
failure detection was defined at 10% loss of maximum force.
ANALYSIS OF FAILURE MODES

• Fracture of crown or veneer restoration.

• combined crown-tooth fracture at the anatomic crown level (located
coronal to the CEJ)
• Fracture diagonal at crown-root level including first 2 mm of the root
• fracture diagonal at crown-root level including more than 2 mm of the
root
• root fracture more than 2 mm below the CEJ
• root fracture in the cervical third
STASTICAL ANALYSIS

• Non-parametric Kruskal-Wallis and the post-hoc Mann-Whitney U-

test with Bonferroni-Holm correction were applied for analysis of
maximum load capacity(Fmax).
• Differences in the frequency of the failure modes(re-restorable and
catastrophic) between the groups and impact of post material were
evaluated by by Pearson’s chi-squared test (p = 0.05).
RESULTS
 DISCUSSION
• Indirect veneer-restored teeth showed a significantly higher load
capacity after dynamic and subsequent linear loading compared to teeth
directly restored with composite.

• There was no post effect, either for direct or for indirect restorative
approaches.

• The results show that anterior ETT with Class III defects restored with
composite present no differences in load capacity compared to indirect
ceramic crown restorations.

• this supports direct restoration as equivalent treatment compared to

crown restorations of this defect size.
• In a study done by Valdivia et al, Endodontically treated incisors with
composite restorations with or without GFP showed higher fracture
resistance compared to crown restorations.

• This behavior can be explained by the fact that composite resin restorations
bonded to dentin and enamel showed a mechanical behavior much closer to
that of an intact sound tooth and that maximal preservation of healthy
tooth structure is important for longevity of the tooth-restoration complex.
• However, only linear loading was performed in the study

• Earlier studies demonstrated that dynamic loading by TML prior to

linear loading is crucial.

• since this linear loading approach does not consider fatigue or aging,
which are essential parameters during intraoral biodegradation of
restorations of all kinds
• The present study showed that the veneer, a less invasive treatment
option, is as loadable as a crown restoration.

• This due to its an entirely non-prepared cervicopalatal part of the tooth

acts as reinforcing structure can be left untouched and seems beneficial
as it is less invasive.

• The current findings are in accordance with Valdivia et al, showing higher
load capacities for veneer restorations compared to crown restorations.
• An in vitro study by D’Arcangelo et al investigated load capacity and
deflection of ETT restored with composite and porcelain veneers, with and
without GFPs.

• the authors concluded that veneer restorations appear to be an optimal

treatment option for anterior ETT since they allow a vestibular reinforcing
effect .

• In the present study ,ceramic veneers were used ,the present authors
assume that composite veneers can achieve values similar to those of
ceramic veneers.
• In a study done by d’Arcangelo et al on composite and ceramic veneers,
and found no statistically significant difference between the two
material types of veneers.

• In contrast, one study evaluating anterior ETT with composite and

ceramic veneer restorations showed that the placement of a GFP
significantly increased the load capacity with porcelain veneers.

• crown restorations, ten of twelve failures were defined as catastrophic

in contrast to five catastrophic failures in the post-free group with
crown restorations
• This is in accordance with a previous study done by Hydecke et al
evaluating metal crowns, where fewer catastrophic failures without
posts were reported.
• In the present study, there was no significant effect of a post either
for direct or indirect restoration tested.
• it was in accordance with the study done by valdivia et al ,where no
effect of glass fiber posts was shown for ETT with class 3 cavities
restored with direct composite and veneer restoration.
• because although the incisors were structurally compromised by the
endodontic treatment and 2 large class 3 restorations they still
retained sufficient dentin to maintain similar stress-strain complex
to that of intact teeth.
CONCLUSION
• Endodontically treated maxillary central incisors with
Class III defects restored with direct composite restorations
present load capacities comparable to indirect crown
restorations.
• Veneer restorations seems to be more advantageous than
crowns.
• Placement of glass fiber posts has no positive effect.
CRITIC ANALYSIS

MERITS DEMERITS

Tested the load Study is limited by moderate

capacity of dimension of class 3
endodontically treated defects,from the clinical
teeth with both direct perspective ,a simulated
and indirect higher loss of coronal hard
restorations tissue would be beneficial
Endodontically treated maxillary central incisors with cavity sizes up to bi-proximal class
III may be successfully directly restored with resin composite. Post placement shows no
additional effect except for decoronated endodontically treated incisor
A fiber post restoration can be suggested when endodontic treatment is associated
with veneer restoration. Veneer restorations seem to be an optimal choice also for
endodontically treated teeth
The presence of glass fiber posts did not increase the fracture resistance of
endodontically treated incisors. Conservative composite resin restorations showed
higher fracture resistance values
Within the limitations of this in vitro study, placement of a fiber post did not affect
the fracture resistance of endodontically treated maxillary central incisors with 2
Class III restorations
 TAKE HOME MESSAGE
• In Endodontically treated incisors with Class III defects it was concluded
that direct composite restorations are they are less invasive and more time
saving and economical
• Veneers enable hard tissue conservation, and are a highly esthetic and has
strenghtening effect under funtional loading condition
• Crown restorations involve the highest amount of hard tissue removal
during tooth preaparation and show load capacities similar to that of direct
restorations
• Thus,they may only play a role only as a third-line intervention when
restoring anterior ETT with Class III cavities.
• Endodontic post does not seem necessary always.
REFERENCES
• von Stein-Lausnitz M, Bruhnke M, Rosentritt M, Sterzenbach G, Bitter K,
Frankenberger R, Naumann M. Direct restoration of endodontically treated
maxillary central incisors: post or no post at all? Clin Oral Investig 2018.
• Valdivia AD, Raposo LH, Simamoto-Junior PC, Novais VR, Soares CJ. The effect
of fiber post presence and restorative technique on the biomechanical
behavior of endodontically treated maxillary incisors: an in vitro study. J
Prosthet Dent 2012;108:147-157.
• D’Arcangelo C, De Angelis F, Vadini M, D’Amario M, Caputi S. Fracture
resistance and deflection of pulpless anterior teeth restored with composite
or porcelain veneers. J Endod 2010;36:153-156.
• Dammaschke T, Nykiel K, Sagheri D, Schafer E. Influence of coronal
restorations on the fracture resistance of root canal-treated premolar and
molar teeth: a retrospective study. Aust Endod J 2013;39:48-56.
• Koelpin M, Sterzenbach G, Naumann M. Composite filling or
singlecrown? The clinical dilemma of how to restore endodontically
treated teeth. Quintessence Int 2014;45:457-466.
• Naumann M, Sterzenbach G, Proschel P. Evaluation of load testing of
postendodontic restorations in vitro: linear compressive loading,
gradual cycling loading and chewing simulation. J Biomed Mater Res B
Appl Biomater 2005;74:829-834.
• Color atlas of endodontics 2nd edition William T. Johnson DDS MS