See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/304398919

Modern Endodontic Principles Part 7: The Restorative Interface

Article  in  Dental Update · May 2016

DOI: 10.12968/denu.2016.43.4.319

CITATION READS

1 9,722

6 authors, including:

Carly Taylor Sarra Jawad

Central Manchester University Hospitals NHS Foundation Trust Guy's and St Thomas' NHS Foundation Trust
22 PUBLICATIONS   112 CITATIONS    15 PUBLICATIONS   74 CITATIONS   

SEE PROFILE SEE PROFILE

Reza Vahid Roudsari James Darcey

The University of Manchester The University of Manchester
16 PUBLICATIONS   114 CITATIONS    43 PUBLICATIONS   434 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Modern Endodontics View project

Greater Manchester Trauma Network View project

All content following this page was uploaded by James Darcey on 31 January 2018.

The user has requested enhancement of the downloaded file.

 Endodontics

Warren Martin

Carly Taylor, Sarra Jawad, Reza Vahid Roudsari, James Darcey and Alison Qualtrough

Modern Endodontic Principles Part

7: The Restorative Interface
Abstract: The restoration of endodontically-treated teeth is a topic that has been extensively studied and yet remains controversial. The
endodontically-treated tooth can be restored with a wide range of techniques of varying complexity. This article reviews the literature
on this topic. Consideration is given to the ferrule and its importance in achieving success. Furthermore, consideration will be given
to the use of endodontically-treated teeth as abutments for fixed and removable prostheses and the challenges this presents. Clinical
recommendations are presented as guidelines to improve the predictability and outcome of treatment when restoring structurally
compromised root-filled teeth.
CPD/Clinical Relevance: The prognosis of endodontically-treated teeth depends not only on the success of the endodontic treatment, but
also on the type of reconstruction.
Dent Update 2016; 43: 319–334

Following successful endodontic therapy  To provide a coronal seal; in stiffness following preparation of
the tooth must be restored. This restoration  To restore form, occlusal stability, and an MOD cavity.4 It is now accepted
process has several justifications: adequate contact points with the that cuspal deflection and thickness
adjacent teeth; of the residual walls and cusps are
 To restore function; more important factors. As cavity size
Warren Martin, BDS, LDS, MSc, MFDS,  To protect the residual tooth structure increases, especially after endodontic
General Dental Practitioner/Clinical against further tissue loss; access, and the marginal ridges are lost,
Teaching Fellow, Greyholme Dental  To ensure health of the marginal structural stability decreases. Thus, the
Suite, Cheltenham/University Dental periodontal tissues; presence of a marginal ridge is now
Hospital of Manchester, Carly Taylor,  To provide optimal aesthetics. considered a far more influential factor
BDS, MSc, MFGDP, FHEA, Clinical Of these functions, protection upon tooth strength than an endodontic
Lecturer/Honorary Specialty Registrar of the underlying tooth structure should access cavity.5 However, it must be noted
in Restorative Dentistry, Sarra Jawad, be recognized as essential in preventing that non-vital teeth do appear to have
BDS, BSc, MFDS, Specialty Registrar/ endodontic failure. It is known that reduced tactile sensitivity and therefore
Honorary Clinical Lecturer in Restorative the longevity of a root-treated tooth have the potential to be loaded to a
Dentistry, Reza Vahid Roudsari, DDS, is directly related to the amount of greater degree before the biofeedback
MFDS, MSc, PGCert(OMFS), Clinical remaining sound tooth material1 mechanism is initiated.6
Lecturer/Honorary Specialty Registrar and there is frequently extensive
in Restorative Dentistry, James Darcey, loss of natural tooth structure in Direct restoration
BDS, MSc, MDPH, MFGDP, MEndo, endodontically-treated teeth.2 Previous If the coronal structures
FDS(Rest Dent), Consultant and Honorary beliefs that the mechanical weakening are largely intact (particularly marginal
Lecturer in Restorative Dentistry and of endodontically-treated teeth was due ridges) and loading is favourable, a
Alison Qualtrough, BChD, MSc, PhD,
to the difference in moisture content simple plastic restoration can be placed
FDS MRD, Senior Lecturer/Honorary
when compared to vital teeth has in the access cavity. Placing a bonded
Consultant in Restorative Dentistry,
been disproved.3 It has been shown restoration immediately following
University Dental Hospital of Manchester,
that endodontic access and treatment obturation whilst the rubber dam
Higher Cambridge Street, Manchester
only reduces the stiffness of teeth by remains in place is good practice
M15 6FH, UK.
5%, compared to a 63% reduction (Figure 1).
May 2016 DentalUpdate 319
 Endodontics

The core Amalgam  Proven track record

Core is the term used to  Retentive features require additional preparation
describe a restoration that is placed in  Good contrast with tooth substrate hence easy to prepare
order to build up a broken down tooth  Cannot usually be prepared at same visit (newer high copper
before receiving an indirect restoration. alloys may be prepared after short delay)
The role of a core is reliant upon how  Cannot be bonded to tooth without resorting to intermediary
much coronal dentine remains. For the products
majority of pulpless teeth a structural
core material is required as this will Resin Composite  Bonding negates the need for additional retentive features
form the bulk of the final preparation.  Crown preparation can be commenced immediately
Consequently, it will be subjected to  Difficult to differentiate from tooth tissue (some ‘core
significant functional stresses and must composites’ have contrasting colour)
therefore exhibit adequate mechanical  Technique sensitive
properties to resist these. There are  Chemical/dual cure undergo greater discoloration (due to
essentially four types of direct core tertiary amine activator) and should be used with caution where
material available: aesthetics is critical
1. Amalgam;  Water sorption and expansion means impression taking should
2. Resin composite; be delayed following preparation
3. Glass ionomer; and
Glass Ionomer and  Bonds to dentine
4. Hybrid materials, ie resin-modified
RmGIC  Release fluoride
glass-ionomer cements (RmGIC).
 Water sorption and expansion higher than resin composite
The relevant properties of these are
 Inherently weak
summarized in Table 1.  Long-term behaviour of materials not well documented
Endodontically-treated teeth Not suitable as a structural core material but may be used to
typically lack sufficient coronal dentine in remove undercuts
which retentive features can be prepared
to retain a core without compromising Table 1. Properties of core materials.
the strength of the remaining tooth
structure. Where a large pulp chamber
exists, extension of amalgam/composite
into this space alone may be sufficient.
Where the pulp chamber is small or there
is more significant tooth loss, the Nayyar
technique should be used:7 2−3 mm of
the coronal root filling is removed and
an amalgam or composite core placed
to fill the coronal preparation, the pulp
chamber and the extension into the roots
(Figure 2). This technique has been widely
adopted for premolars as well as molars
and a core of this type will function well
even when there is as little as one sound
cusp remaining. Given bonded cores do
not require additional retentive features,
clinicians should consider resin composite
cores, where possible, to preserve tooth
structure.

Ferrule
A key component in
the predictability of restoration of
endodontically-treated teeth is the ‘ferrule’.
The ferrule is that part of the crown that
Figure 1. Elective endodontics was performed on LR6 to allow internal access to an external cervical
encircles the remaining tooth structure
resorptive lesion. With sound coronal tooth tissue including intact marginal ridges, the clinician can
(Figure 3). The ferrule binds the remaining
have confidence in the long-term success of direct plastic restoration with composite.
tooth together, simultaneously preventing
320 DentalUpdate May 2016
 Endodontics

a b

Figure 2. (a, b) Following endodontic treatment, removal of the coronal 3 mm of GP from the canals and the placement of a Nayyar core in amalgam or
composite provides both excellent coronal seal and a sound foundation for future indirect restoration.

3. Number of walls and ferrule location

Although studies have
demonstrated the superiority of a uniform
full 360° ferrule over one that varies in
different parts of the tooth, the concept
of a partial ferrule should not be ruled
out.12 Having a good palatal ferrule only
on upper incisors is as effective as having
a complete ‘all around’ ferrule, as this will
resist the forces applied in function to the
palatal surface.13

4. Type of tooth and the extent of lateral load

Lateral forces have a greater
potential to damage the tooth-restoration
interface when compared with vertical
loads.14 Hence, a differential approach
needs to be adopted when it comes to the
restoration of anterior and posterior teeth.
If there is no ferrule, the tooth
should be viewed as compromised and
the patient informed accordingly. It
Figure 3. The ferrule is that portion of the crown that encircles the remaining dentine.
should not, however, be considered an
absolute contraindication to treatment,
rather an important prognostic feature
root fracture and providing resistance better the fracture resistance provided. to be included in the consent process
form to prevent dislodgement of the A ferrule height of 2 mm or more is (Figure 5). With minimal or absent ferrule,
crown during function8 (Figure 4). predictive of improved outcomes.10 the clinician becomes dependent upon
Four factors which directly influence 2. Ferrule width intraradicular aids (eg Nayyar cores and
the ferrule have previously been Clinically, it is generally posts) to retain the coronal restoration.
identified.9 accepted that walls are considered ‘too Crown lengthening and/or orthodontic
thin’ when they are less than 1 mm in extrusion may be considered in cases
1. Ferrule height thickness, such that the minimal ferrule where the tooth is of strategic importance
The greater the height height is only of value if the remaining or planned as an abutment, therefore
of remaining tooth structure above dentine has a minimal thickness of demanding improved mechanical
the margin of the preparation, the 1 mm.11 characteristics.
May 2016 DentalUpdate 323
 Endodontics

Figure 4. The post crown in the UL1 was

Figure 6. Vertical root fracture of an upper canine
removed to allow endodontic access. It is clear
following restoration with a post-retained crown.
that this tooth has sufficient coronal dentine
to permit a ferrule effect and thus predictable
restoration following re-treatment.
3. There is an increased risk of iatrogenic
perforation.19
As such, the decision whether
to use a post must be made judiciously b
and currently there appears to be a
definite trend towards reduced post
usage. Without clear guidelines from
definitive research, specific factors for
the individual tooth and clinical situation
require careful consideration. Ultimately,
the evaluation of whether a post is
needed is based on how much natural
tooth substance remains to retain a core
build-up and support the final restoration
after caries removal and endodontic
treatment are completed. It is sensible to
Figure 5. The LR4 has no coronal dentine consider placement of a post only if there
remaining and therefore no ferrule is possible. is such significant loss of coronal tooth
The bonded fibre composite post must be relied tissue that a core cannot be retained.
on for retention and resistance form. Practically, the divergent roots and
pulp chamber space of molars should Figure 7. Following an incompetent attempt to
mean posts should not be required, but achieve optimum length on these cast posts, the
Posts anteriorly these features are not present. clinician has perforated apically on both UR1 and
Therefore, for structurally compromised UL1. The extent of perforation UL1 is visible on
The primary function of a
anterior teeth, post-retained cores remain the post-extraction images. (Images courtesy of
post is to retain a core in a tooth with Dr Niall Quigley.)
an essential part of restorative dentistry.
extensive loss of coronal tooth structure.15
If the decision is made to
Posts are associated with three significant
place an intra-radicular post, there are
drawbacks16 (Figures 6 and 7):
several aspects to consider, including posts of choice have been direct or cast
1. Preparation may disturb the seal of the
the type of post, size and shape of post, metal posts. These have several drawbacks:
root canal filling, which may lead to
conservation of tooth structure and the
microleakage and failure;17  They are not tooth coloured;
creation of the post space.
2. Removal of sound tooth structure,  The mechanical properties of metals
thereby weakening the root which may differs from natural tooth; and
result in premature loss due to root Non-metal post systems  Failure of metal posts tends to be
fracture;18 Traditionally, the principal catastrophic root fracture.10,20
324 DentalUpdate May 2016
 Endodontics

Carbon, zirconia and reliance on dual-cured materials; minimal.33 Therefore, the root canal
fibre composite posts have all been  Problems posed by certain endodontic should be enlarged only enough to
introduced as alternatives to metal materials − both sodium hypochlorite enable the post to fit accurately and yet
posts. These systems are deemed more and eugenol can interfere with passively whilst ensuring strength and
biologically compatible with tooth tissue.1 bonding.29 retention.
Furthermore, if amalgam is phased out The dental literature relating
of dentistry, clinicians must become to the different types of posts presents Retention form
confident with resin-based technology. too many variables to enable a true
Simultaneous dislodgement
The more aesthetic glass and comparison between all available post
of an anterior crown with its retaining
quartz fibre post have now replaced types. The profession lacks long-term
post and core is a frequent occurrence
carbon fibre posts. Moreover, they clinical results, with a high level of
and results from inadequate retention
can be bonded to dentine. Zirconium evidence pertaining to survival data for
form of the prepared tooth.34 Post
posts cannot be etched, therefore, it is the various post systems.30 The presence retention is affected by the following
not possible to bond a composite core of a ferrule of 1.5−2 mm sound coronal factors.
material to the post, making core retention tooth structure between the core and
a problem.21 Retrieval of zirconium and the finish line is more important in
ceramic posts is very difficult if endodontic Preparation geometry
fracture resistance than the post design
retreatment is necessary, or if the post Some canals have a near
or type.31 Nonetheless, there is a growing
fractures. Some ceramic materials can be circular cross-section. These can be
understanding of the benefits of resin-
removed by grinding away the remaining prepared with a twist drill or reamer
bonded fibre-composite post systems.
post material with a bur, but this is a to provide a cavity with parallel walls
Given the more predictable and less
tedious and dangerous procedure. It is minimal taper, allowing the use of a
catastrophic mode of failure, we would
impossible to grind away a zirconium post. preformed post of corresponding size
advocate these in conjunction with
For these reasons, ceramic and zirconium and configuration. Conversely, canals
composite cores wherever possible.
posts should not be used. with elliptical cross-sections must be
However, no one system
The main advantage of using prepared with a restricted amount of
has universal application. Parallel-
a fibre post is that the modes of failure taper to ensure adequate retention and
sided or tapering pre-fabricated posts
are generally more retrievable than those eliminate undesired undercuts.
are recommended for conservatively
of metal post systems. The use of fibre prepared root canals in teeth with roots
posts reduces the risk of root fracture of circular cross-section. Excessively Post length
significantly as the modulus of elasticity of flared canals are most effectively If a post is shorter than the
these posts is closer to that of dentine.22 managed by a traditional custom cast coronal height of the clinical crown of
Fibre posts provide greater elastic support post. In vitro studies have confirmed that the tooth, the prognosis is considered
to the core of a tooth than metal posts23 parallel-sided posts are more retentive unfavourable, because stress is
(Figure 8). than tapered posts and that threaded distributed over a smaller surface area. As
The most common causes of posts are the most retentive.32 Threaded post length increases, so does retention.32
failure associated with fibre post systems posts which screw into dentine are not Most endodontic texts advocate
are post de-cementation and secondary recommended as they generate residual maintaining a 5 mm apical seal, whilst 3
caries.24 Of these, post de-cementation stress in the dentine, which may result in mm is considered the absolute minimum.
has been suggested as the most frequent root fracture.
complication.25 There are many challenges
to successful bonding in the root canal
that may explain this mode of failure: Conservation of tooth
 Polymerization shrinkage and the structure
unfavourable geometry for resin In creating post space, care
bonding within the root canal − a high must be used to remove only minimal
configuration factor or C-Factor (the tooth structure from the canal. Excessive
ratio of bonded to unbonded resin enlargement can perforate or weaken the
surfaces);26 root, which may then split during post
 Deterioration of the resin bond with cementation or subsequent function.
time;27 Most roots are narrower mesio-distally
 Incompleteness of resin infiltration into than facio-lingually and often have
the demineralized dentine;28 proximal concavities that cannot be
 Performing the bonding steps is more seen on standard periapical radiographs. Figure 8. Greater than 50% of tooth structure
difficult deep in the root canal system; Experimentally, most root fractures was lost and there was minimal ferrule distally
on the LR5. A fibre post was placed followed by a
 Penetration with a curing light is limited originate from these concavities, because
composite core.
in the root canal system, resulting in a the remaining dentine thickness is
May 2016 DentalUpdate 325
 Endodontics

Post diameter presence of a ferrule effect. restorations preserve more sound tooth
Increasing the post diameter Figure 9 demonstrates six structure than does a full coverage
in an attempt to increase retention is key features of post design, placement crown, while at the same time providing
not recommended because the results and subsequent preparation that may all cuspal coverage to protect weakened
have minimal retention advantage and contribute to long-term success of the cusps40 (Figure 10). If it is anticipated
unnecessary weakening of the remaining endodontically-treated and extensively that after crown preparation the buccal
root. Empirical evidence suggests that compromised tooth. and/or lingual walls will have less than
the overall prognosis is good when post
1 mm remaining dentine thickness, a
diameter does not exceed one third of the
cross-sectional root diameter.35
Indirect restorations partial coverage restoration should be
The overwhelming majority considered.
of reports in the literature supports the Whatever the evidence
Post surface texture suggests, the patient must be involved
need for cuspal coverage restorations of
A serrated or roughened post is in the decision-making process. Though
endodontically-treated posterior teeth,
more retentive than a smooth post.36 best practice indicates indirect restoration
and a strong association between the
success of endodontically-treated teeth of many endodontically-treated teeth,
Luting agent and crowned teeth has been shown.38 many patients do not want or cannot
Using adhesive resin luting However, no consensus exists regarding afford this ideal. It is imperative in
agents have the potential to improve the preferred type of final restoration these circumstances that the core is
performance of post and core restorations: for endodontically-treated teeth.39 More placed to the best possible standard
laboratory studies have shown improved recently, partial restorations such as and consideration given to providing
retention.37 indirect onlays are advocated as these cuspal coverage with the chosen plastic

Resistance form
The resistance to lateral
Clinical Examination
displacement largely stems from the
 Tooth type, alignment, drifting, over-eruption
 Length and location of edentulous span
 Existing restoration size and quality
 Periodontal support
 Clinical crown height
 Inter-occlusal clearance
 Assessment of opposing dentition or prosthesis

Occlusal Examination

 Evidence of parafunction
 Static contacts
 Dynamic contacts
 Presence of interferences (working and non-working side, RCP-ICP, protrusive)

Radiographic Examination (consider horizontal parallax views for multi-rooted

teeth)

 Root length, configuration

 Quality of endodontic treatment
 Presence of periapical disease
 Crown:root ratio
 Canal curvature, preparation taper
Figure 9. Six features of successful design.  Periodontal bone levels
1 − adequate apical seal; 2 − minimal canal
enlargement (not beyond the original shaping); Clinical Investigation
3 − adequate post length (within 3−5 mm of the
apex); 4 − extension of final restoration margin  Removal of existing restorations and carious tissue
onto sound tooth tissue; 5 − vertical wall to  Examination for the presence of cracks on the pulpal floor
prevent rotation and allow ferrule incorporation  Assessment of remaining coronal tooth tissue
into crown; 6 − positive vertical stop (to promote
axial loading). Table 2. Factors to consider when assessing the favourability of a tooth to act as an abutment.

326 DentalUpdate May 2016

 Endodontics

restoration (Figure 11). Figures 12 and 13 Prosthodontic interface any planned restorations being particularly
demonstrate algorithms that may help important. This involves careful assessment
Abutment tooth assessment
clinicians decide upon optimum strategy for not only of clinical crown height, but also
Endodontically-treated teeth
restoring the root-filled tooth. the thickness of remaining dentine. In order
are often required as abutments for fixed
to do this, all existing restorations and
and removable prostheses. With this
carious tissue must be removed and the
a comes a very specific set of problems
amount of tissue removal for any planned
that must be recognized when planning
restoration also needs to be visualized.
restorative treatment and getting patients
This can be particularly challenging when
to consent to the likely success of such
abutments are planned to be restored with
treatment plans.
crowns incorporating milled guide surfaces,
Posterior teeth are
which require extra tissue removal (Figure
predominantly exposed to axially directed
14).
forces. When such a tooth acts as an
It is advisable to remove any
abutment, it is now also exposed to
remaining tooth tissue which will be less
greater non-axial forces. This is especially
than 1 mm thick, as this will be prone to
true if we consider cantilever bridges and
fracture. Once this has been undertaken,
the terminal abutment for a Kennedy
the clinician can now better assess
Classification I partial denture. In such
the suitability of the tooth to act as an
situations, extra consideration needs to
abutment and if extra retention from the
be given to the amount of remaining
root canal will be required in order to retain
tooth tissue, with the resistance form of
a restoration or core. Location and span
of the prosthesis will also be important, as
b different forces will be exerted on anterior
a and posterior abutments. Anticipation of
the forces which the tooth will be subjected
to require assessment of any parafunctional
activity and the opposing dentition.
Obviously, this is only a small part of the
abutment tooth assessment and the factors
that need consideration are presented in
Table 2.

Prosthesis design
Once careful consideration of
the factors outlined in Table 2 has been
undertaken, the feasibility of a fixed or
b
c removable option can be considered.

Abutments for fixed prostheses

Abutment teeth requiring a
post-retained restoration should not be
used as the sole abutment for a fixed
prosthesis (cantilever design) as there
is a significant risk of root fracture and
de-cementation16 (Figure 15). When fixed-
fixed designs are planned, the clinician
needs to consider the different support
which can be offered by the two abutments
Figure 10. (a–c) Minimal preparation adhesive if only one is root-filled. Although tempting,
onlays are an excellent strategy for protecting utilizing double abutments can result in
remaining tooth structure whilst minimizing Figure 11. (a, b) Following RCT LL6, cuspal further problems and should be avoided.
additional tooth removal. Gold can be heat-treated coverage was achieved with direct composite. Such restorations are more difficult for
to form an oxide layer permitting cementation The clinician should aim for 1.5−2 mm thickness
patients to clean and for maintenance of
with bi-functional resins such as Panavia. (Images of composite (or amalgam) as otherwise this may
periodontal health. Additionally, the forces
courtesy Professor Julian Satterthwaite.) necessitate additional cuspal reduction.
generated during function can cause
May 2016 DentalUpdate 329
 Endodontics

the most distal retainer to de-cement,

resulting in microleakage and recurrent
caries.
Other options for managing
such situations include the use of a
fixed-moveable design (Figure 16).
Fixed moveable bridges theoretically
allow less transmission of force to
the weaker abutment by allowing
some independent movement of
abutments and facilitating removal of
the compromised abutment without
destroying the prosthesis. Clinicians
must be aware that joints only allow
movement in a vertical direction, so may
have limited use when lateral forces are
considered. In addition, joints may require
additional destruction of tooth structure
and consideration should be given to the
positioning of the joint.

Novel approaches to bridge design

If multiple edentulous areas
are present and the remaining teeth are
endodontically-treated, then provision of
multiple cantilever bridges may not be a
sensible option. In such circumstances,
consideration can be given to the use of
copings. Each tooth is prepared to receive
a coping with milled surfaces. These
teeth can then be used as abutments for
a tooth- and tissue-supported prosthesis
or one which is entirely tooth-supported.
The latter can be cemented with
temporary cement. This essentially creates
a ‘weak link’ in the prosthesis, so that it is
easily retrievable if problems arise.

Endodontics as an adjunct to
prosthodontic treatment
In rare circumstances,
Figure 12. An algorithm to aid restorative treatment planning of anterior teeth following endodontic endodontic treatment may be
treatment. provided electively in order to facilitate
prosthodontic reconstruction (Table
3). Elective devitalization of a tooth
 To provide simple overdenture abutments which support the prosthesis, enhance bone should not be undertaken lightly and
preservation and improve proprioception a meticulous assessment of the risks
 To allow placement of intra-coronal precision attachments to facilitate support and and benefits must be undertaken and
retention of a removable prosthesis and improve aesthetics thoroughly discussed with the patient.
 To allow retention of a restoration where insufficient coronal tooth tissue remains by The clinician must have a realistic
placing a post in the root canal perspective of his/her own capabilities
 When teeth have significantly over erupted, in order to re-establish the occlusal plane and that the canal morphology is
as part of a comprehensive prosthodontic rehabilitation favourable for a positive outcome.
Moreover, the clinician needs to be
confident that the resultant restoration
Table 3. Indications for elective endodontics.
will have the best chance of success and
330 DentalUpdate May 2016
 Endodontics

Figure 14. Milling crowns requires more

extensive palatal reduction.

Figure 15. When planning the replacement of

this bridge, ‘like-for-like’ may be replaced, but
it may be preferable to convert this to a fixed-
movable design with a joint acknowledging the
differential support of the abutments.

Figure 13. An algorithm to aid restorative treatment planning of posterior teeth following endodontic Figure 16. A joint incorporated into the pontic
treatment. LL6 to allow for the differential support of the LL7
and LL5.

this needs to be carefully planned before with a single crown.16 In addition to this,
endodontic treatment is instigated (Table prosthodontic treatment may also result
on the compromised abutment whilst not
4). Despite this, when used appropriately, it in the need for subsequent endodontic
disturbing the rest of the prosthesis. If a
can significantly enhance the outcome of treatment. The risk of pulpal necrosis
partial removable prosthesis is planned,
prosthodontic treatment. associated with crown preparation has
it is sensible to distribute retentive
been reported to be significantly higher
components across other teeth should the
Complications in those teeth which act as a bridge
abutment.41 Such factors need to be root-treated tooth fail. Furthermore, the
The literature would suggest that chrome framework should be extended to
the use of root-filled teeth as abutments carefully considered and articulated to
patients during the consent process. the abutment to facilitate the addition of a
are associated with a higher incidence of
tooth if necessary.
failure. Studies have reported a significantly
higher failure rate of endodontically-treated Planning for failure
teeth serving as bridge and partial denture If used, joints should be Conclusions
abutments compared with those restored placed to facilitate removal of the retainer Patients are not well served if
May 2016 DentalUpdate 331
 Endodontics

root fracture of dowel channels with

 Peri-apical radiographs utilizing horizontal parallax for multi-rooted teeth. Assessment
various thicknesses of buccal dentin
of canal morphology, periodontal bone levels
walls.
 The final prosthesis and restoration needs to be designed
J Prosthet Dent 1985; 53(4): 496−500.
 Assessment of remaining tooth tissue by removing existing restorations and visualizing 12. Morgano S, Brackett S. Foundation
amount of tissue removal needed for the restoration/trial preparation on a model of the restorations in fixed prosthodontics:
unrestored tooth current knowledge and future needs.
 Articulated study models and wax trial/diagnostic wax-up to assess inter-occlusal J Prosthet Dent 1999; 82: 643−657.
clearance 13. Ng CC, Dumbrigue HB, Al-Bayat
 Single visit endodontic treatment to minimize the risk of canal contamination MI et al. Influence of remaining
 Careful planning of how the tooth will be temporized to minimize the risk of bacterial coronal tooth structure location on
contamination when indirect restorations are planned the fracture resistance of restored
endodontically treated anterior teeth.
Table 4. Factors to be considered when planning elective endodontics. J Prosthet Dent 2006; 95(4): 290−296.
14. Arunpraditkul S, Saengsanon S,
Pakviwat W. Fracture resistance of
endodontically treated teeth: three
the endodontic treatment is successful 355−363. walls versus four walls of remaining
but the coronal restoration fails. Long- 2. Robbins JW. Restoration of the coronal tooth structure. J Prosthodont
term success of endodontic treatment is endodontically treated tooth. Dent 2009; 18(1): 49−53.
highly dependent upon the restorative Clin North Am 2002; 46(2): 367−384. 15. Goodacre CJ, Spolnik KJ. The
treatment that follows. There is not 3. Sedgley CM, Messer HH. Are prosthodontic management of
one post, core, or final restoration that endodontically treated teeth more endodontically treated teeth: a
can be used in all clinical situations. brittle? J Endod 1992; 18(7): 332−335. literature review. Part I. Success and
Clinicians must consider the functional 4. Reeh ES, Messer HH, Douglas WH. failure data, treatment concepts.
Reduction in tooth stiffness as a J Prosthodont 1994; 3(4): 243−250.
and aesthetic endpoints for each tooth
result of endodontic and restorative 16. Sorensen J, Martinoff J.
when considering the restorative
procedures. J Endod 1989; 15(11): Endodontically treated teeth as
protocol. Clinicians must also be aware
512−516. abutments. J Prosthet Dent 1985; 53:
that endodontically-treated teeth present
5. Pantvisai P, Messer HH. Cuspal 631−636.
challenges when used as abutments. deflection in molars in relation 17. Balto H, Al-Nazhan S, Al-Mansour K
An awareness of these is essential in to endodontic and restorative et al. Microbial leakage of Cavit, IRM,
restorative treatment planning. The procedures. J Endod 1995; 21(2): and Temp Bond in post-prepared root
restoration process is a delicate balance 57−61. canals using two methods of gutta-
between preserving and sacrificing 6. Randow K, Glantz P-O. On cantilever percha removal: an in vitro study.
tooth structure. Whatever the clinical loading of vital and non-vital teeth. J Contemp Dent Pract 2005; 6(3):
scenario, certain key philosophies must An experimental clinical study. Acta 53−61.
be remembered: Odontol Scand 1986; 44(5): 271−277. 18. Hunter A, Feiglin B, Williams J. Effects
 The clinician must strive to protect 7. Nayyar A, Walton R, Leonard L. of post placement on endodontically
tooth structure wherever possible; An amalgam coronal-radicular treated teeth. J Prosthet Dent 1989;
 Posts are simply a means of retaining dowel and core technique for 62(2): 166−172.
a core; if the core can be retained endodontically treated posterior 19. Kuttler S, McLean A, Dorn S et al. The
without posts they should not be teeth. J Prosthet Dent 1980; 43: impact of post space preparation
used; 511−515. with Gates-Glidden drills on residual
 Using bonded core materials 8. Sorensen J, Engelman M. Ferrule dentin thickness in distal roots of
helps minimize unwanted tooth design and fracture resistance of mandibular molars. J Am Dent Assoc
removal. Furthermore, with the endodontically treated teeth. 2004; 135(7): 903−909.
systematic phasing out of amalgam, J Prosthet Dent 1990; 63: 529−536. 20. Ferrari M, Cagidiaco M, Grandini S et
practitioners must become proficient 9. Jotkowitz A, Samet N. Rethinking al. Post placement affects survival of
ferrule − a new approach to an old endodontically treated premolars.
with resin-based alternatives.
dilemma. Br Dent J 2010; 209(1): J Dent Res 2007; 86(8): 729−734.
If there is no ferrule, the
25−33. 21. Butz F, Lennon AM, Heydecke G,
prognosis becomes guarded for that
10. Akkayan B. An in vitro study Strub JR. Survival rate and fracture
tooth. evaluating the effect of ferrule strength of endodontically treated
length on fracture resistance of maxillary incisors with moderate
References endodontically treated teeth restored defects restored with different post-
1. Fernandes AS, Dessai GS. Factors with fiber-reinforced and zirconia and-core systems: an in vitro study. Int
affecting the fracture resistance of dowel systems. J Prosthet Dent 2004; J Prosthodont 2001; 14(1): 58−64.
post-core reconstructed teeth: a 92(2): 155−162. 22. Asmussen E, Peutzfeldt A, Heitmann
review. Int J Prosthodont 2001; 14(4): 11. Tjan AH, Whang SB. Resistance to T. Stiffness, elastic limit, and strength
332 DentalUpdate May 2016
 Endodontics
DELIVER
COMFORTABLE
INJECTIONS NOW of newer types of endodontic posts.
takes 2.2ml J Dent 1999; 27(4): 275−278.
& 1.8ml 23. Mannocci F, Cavalli G, Gagliani M. Fibre Posts, Adhesive
cartridges Restorations of Root Canal Treated Teeth. Berlin: Quintessence,
Special Offer! 2008.
SAVE 15% 24. Mannocci F, Qualtrough A, Worthington H et al. Randomized
(or 10% with clinical comparison of endodontically treated teeth restored
Interest Free
Credit)* with amalgam or with fiber posts and resin composite: five-
year results. Oper Dent 2004; 30(1): 9−15.
25. Monticelli F, Grandini S, Goracci C et al. Clinical behavior
translucent-fiber posts: a 2-year prospective study.
Int J Prosthodont 2003; 16(6): 593−596.
26. Tay FR, Loushine RJ, Lambrechts P et al. Geometric factors
affecting dentin bonding in root canals: a theoretical modeling
approach. J Endod 2005; 31(8): 584−589.
27. De Munck J, Van Meerbeek B, Yoshida Y et al. Four-year water
degradation of total-etch adhesives bonded to dentin. J Dent
Res 2003; 82(2): 136−140.
28. Sano H, Takatsu T, Ciucchi B et al. Nanoleakage: leakage within
Position your practice as a calm and friendly environment the hybrid layer. Oper Dent 1994; 20(1): 18−25.
with CALAJECT, a great practice-builder that helps you to 29. Lai S, Mak Y, Cheung G et al. Reversal of compromised bonding
deliver comfortable injections. CALAJECT automatically to oxidized etched dentin. J Dent Res 2001; 80(10): 1919−1924.
30. Torbjörner A, Fransson B. A literature review on the prosthetic
controls the flow rate for each programme setting to prevent
treatment of structurally compromised teeth.
the pain often caused by the speed of the injection and the Int J Prosthodont 2004; 17(3): 369−376.
resultant pressure in the tissue. 31. Isidor F, Brøndum K, Ravnholt G. The influence of post length
and crown ferrule length on the resistance to cyclic loading
• User-friendly and simple to use
of bovine teeth with prefabricated titanium posts. Int J
• Can be used for all types of local anaesthesia
Prosthodont 1999; 12(1): 78−82.
• Cost-effective as used with standard needles and 32. Standlee JP, Caputo AA, Holcomb J et al. The retentive and
cartridges. No other consumables are needed stress-distributing properties of a threaded endodontic dowel.
• IPC (Intelligent Pressure Control) to control J Prosthet Dent 1980; 44(4): 398−404.
injection pressure 33. Felton D, Webb E, Kanoy B et al. Threaded endodontic dowels:
• Automatic aspiration when pressure on the foot control effect of post design on incidence of root fracture.
is released J Prosthet Dent 1991; 65(2): 179−187.
34. Sorensen JA, Martinoff JT. Intracoronal reinforcement and
• Acoustic signal indicates actual flow rate
coronal coverage: a study of endodontically treated teeth.
• Optional safe-sheathing system
J Prosthet Dent 1984; 51(6): 780−784.
35. Caputo A, Standlee J. Pins and posts − why, when and how.
“CALAJECT gives me the confidence of knowing my Dent Clin North Am 1976; 20(2): 299−311.
injections will always be delivered at a constant rate 36. Ruemping DR, Lund MR, Schnell RJ. Retention of dowels
and at a speed appropriate for the procedure. This subjected to tensile and torsional forces. J Prosthet Dent 1979;
greatly enhances patient satisfaction. As many people 41(2): 159−162.
reject treatment they need because of fear of the
37. O’Keefe K, Powers J, McGuckin R et al. In vitro bond strength
dental injection, taking away this concern is not only
of silica-coated metal posts in roots of teeth. Int J Prosthodont
1992; 5(4): 373−376.
a relief for them but also improves my number of
38. Aquilino S, Caplan D. Relationship between crown placement
accepted treatment plans.“
and the survival of endodontically treated teeth. J Prosthet
Philip Lewis BDS, Avenue Road Dental Practice Dent 2002; 87: 256−263.
39. Cobankara F, Unlu N, Cetin A et al. The effect of different
restoration techniques on the fracture resistance of
For more information Freephone endodontically-treated molars. Oper Dent 2008; 33(5):
0500 321111 or visit calaject.co.uk 526−533.
40. Murphy F, McDonald A, Petrie A et al. Coronal tooth structure in
root‐treated teeth prepared for complete and partial coverage
restorations.
J Oral Rehabil 2009; 36(6): 451−461.
41. Cheung G, Lai S, Ng R. Fate of vital pulps beneath a metal-
*Terms and conditions apply. Offer ends 31st July 2016. Please contact Evident for full details. E&OE.
ceramic crown or a bridge retainer. Int Endod J 2005; 38(8):
521−530.
334 DentalUpdate May 2016
View publication stats