RESTORATION OF ENDODONTICALLY
TREATED TEETH
DR. HUDA ABD EL-HALIM
Restoring teeth functionally and esthetically after endodontic treatment often
presents a challenge to the dentist. Typically, root canal treatment is initiated because
of deep caries or trauma, both of which often result in extensive loss of tooth
structure.
Additional tooth tissue is removed for endodontic access, cleaning and shaping of
the root canal, and post space preparation, further reducing the structural integrity of
the tooth and decreasing its resistance to fracture
Restoration of endodontically treated teeth is of importance regarding
the following:
a. Restoring the lost tooth structure
b. Improving the physical characteristics of tooth that have been altered after
the endodontic treatment.
c. Esthetics, as usually endodontically treated teeth become dull and darker
in appearance
d. Prevent tooth fracture
• Problems facing restoration of endodontically treated teeth are:
Dehydration of dentin due to decreased
dentinal fluids
Decrease in dentin ultimate strength
Increased brittleness of dentin
Decrease modulus of resilience of dentin
Factors affecting the type of restorative procedure applied:
A. Position of tooth-anterior or posterior.
B. Amount of lost tooth structure.
C. Esthetics
D. Age of patient.
E. Economic factors
Prior to going in for a restorative procedure, the operator must Confirm
whether the endodontic treatment has been successful or not how???
This can be confirmed by looking at the signs and symptoms of successful
endodontic treatment, which are as follows:
i. Absence of pain, swelling or any other sign and symptom.
ii. Proper apical seal with complete obliteration of root canals, without under-
or-overfilling.
iii. Absence of pain during percussion on the tooth.
iv. Absence of pain on pressure.
v. Absence of fistula.
RESTORATIVE DESIGN FEATURES FOR ENDODONTICALLY TREATED
TEETH
Restorative design may be planned with following considerations:
A. For posterior teeth, if marginal and crossing ridges are intact then direct restoration
with amalgam or composite material can be the final restoration.
B. If one or more marginal or crossing ridges are lost, then amalgam must act as a
foundation for cast restoration.
C. Pins and post can be used in case of badly broken down teeth.
D. All badly broken-down, endodontically treated teeth should have foundation, usually in
amalgam, under its restoration which is usually made up of cast materials.
E. In case of anterior root canal treated teeth, if any proximal surface is involved, then
build up the tooth with a foundation form to be covered with a reinforcing or protecting
restoration. Usually a ceramic or porcelain fused to cast veneer restoration is the material
of choice.
F. Ferrule feature: It is most important resistance feature in restoration for an
endodontically treated tooth. For this the cast restoration should involve sound tooth
structure at least 2 mm apical to the gingival periphery of the foundation.
By applying this feature, cast restorations encompass the tooth circumferentially, bring its
components together to resist splitting and to assure maximum reinforcement for
remaining tooth structure
TYPES OF RESTORATIONS
The following restorations are frequently indicated:
A. For anterior teeth
1. Lamination and veneering.
2. Partial crown.
3. Full crown.
B. For posterior teeth
1. Inlay.
2. Onlay covering all cusps
3. Partial cast crown.
4. Full cast crown
5. Post and core supported crown restoration
LAMINATES
Laminates are the veneer like (but thinner than veneers) restorations. They restore
the facial surface of tooth for esthetic purposes. They are made up of either
composite resins or porcelain.
Laminate bonding is indicated for a combination of mild to moderate anomalies of
color, position, and form of the teeth. As endodontically treated teeth usually
become dull and darker in shade, thus restoring anterior teeth with laminates helps
in improving the esthetics
PARTIAL JACKET CROWNS
Partial jacket crowns are the restorations covering two or
more surfaces of a tooth. The rationale is to enhance the
esthetics of the restoration and to conserve tooth structure.
They are indicated in intact tooth with average crown length
and normal anatomic crown form.
They are contraindicated in short teeth or teeth with Three-quarter crown preparation on
extensive crown restoration. maxillary canine (A) Proximal view
(B) Incisal view
TYPES OF PARTIAL JACKET CROWNS
Various types of partial jacket crowns are as follows:
1. Three quarter crown: They restore the occlusal surface and three of the four axial
surfaces not including the facial surface.
2. Reverse three quarter crown: They restore all the surfaces except the lingual surface.
They are usually indicated on the mandibular molars with severe inclination.
3. Seven-eighth crown: They are extensions of the three quarter crown to include major
portion of facial surface. They are generally indicated for maxillary molars and premolars
where mesial surface of tooth is sound, but the distal surface is extensively destroyed by
caries.
4. Mesial half crown: It is actually a three-quarter crown rotated 90 degrees, preserving
the distal surface of the tooth, while veneering the remaining surfaces.
FULL JACKET CROWN
They restore and cover all the surfaces of the clinical
crown. The restorative material may be all metal, all
porcelain (ceramic) or a metal ceramic combination.
Types of Crowns
Complete Metal Veneer Crown
They are made up of cast metal alloys and are usually
indicated in the areas where there are heavy occlusal
forces and esthetics are not of much importance.
Porcelain-fused-to-metal Crown
Porcelain-fused-to-metal crown consists of a cast metal
substructure of a special alloy to which porcelain is
fused. Usually gold is used as a substructure, but nowa-
days use of base-metals is increasing. In the cervical
area, it is often difficult to mask the metal, and in some
cases metal is left exposed, especially in the posterior
areas
Feldspathic Porcelain Jacket Crown
These are translucent porcelain crowns which can be altered to match natural teeth
in shade by appropriate blending of standard porcelain powders. The desired shape
and contour is usually fabricated on a platinum matrix that has been adapted to a die
representing the abutment preparation. They are indicated for anterior teeth, they
have superior esthetic quality, but they are easily subjected to fracture.
Aluminous Porcelain Jacket Crown
The core of this crown is composed of approximately 50% high-strength alumina
and 50% dental porcelain. Such type of core increases the strength of restoration.
Since alumina is an opaque material, this type of jacket crown does not have a
translucency exhibited by the feldspathic crown.
Cerestore Crown
This shrink-free ceramic material essentially consists of Al2O3 and MgO mixed with a
Barium glass frits. On firing crystalline transformation produces Magnesium aluminate
spinel, which occupies a greater volume than the original mixed oxides compensates for the
conventional firing shrinkage.
Advantages:
Good dimensional stability
Better accuracy of fit and marginal integrity.
Esthetics enhanced due to the lack of metal coping.
Biocompatible .
Low thermal conductivity, Low coefficient of thermal expansion
the only disadvantage is its complex technique for fabrication.
Acrylic Jacket Crown
They can be heat-cured or self-cured and are available in numerous shades for color
matching. These crowns are fabricated directly on the die by using tinfoil as a matrix.
Usually they do not last more than three to five years.
Dicor Crown
This crown is truly castable ceramic restoration that has sufficient strength for use for
posterior teeth. It is translucent and offers superior esthetics. The advantage of this
type of crown is that occlusion and anatomy can be predetermined in wax pattern on
an articulated cast.
POST AND CORE
Post and core can be built up in order to replace the lost crown structure and may be used as a
foundation under the restoration. The core replaces the lost coronal tooth structure and provides
bulk, cementing surface, support and retention for the crown.
The dowel (post) provides support and retention for the core and should be designed so as to
minimize the potential for root fracture from forces which may act on the crown.
Post and core are radicular retained restorations consisting of a post or dowel with an attached
core that obtains its retention and resistance to displacement from the prepared root portion of an
endodontically treated tooth.
While the root preparation retains the post, the core establishes retention and resistance for
complete veneer crowns that restore the pulpless tooth to normal form and function. Core is built
up with silver amalgam or composite resins.
Root canal treated maxillary anterior tooth restored
with one piece post and core
1. Apical seal is preserved with 4 to 5 mm of gutta percha.
2. Root canal post.
3. Periodontal ligament.
4. Remaining natural crown structure.
5. Core replacing missing coronal tooth structure and
providing retention to artificial crown
6. Artificial crown.
WHAT HAPPENS TO ENDODONTICALLY TREATED TEETH?
◼ Endodontically treated teeth are more susceptible to biomechanical failure due to:
1. Coronal destruction from caries, fractures, previous restorations, endodontic
access cavity, and root canal chemo-mechanical preparation.
2. Loss of mechano-receptors after endodontic therapy increases the threshold of
pressure receptors in periodontium leading to functional overload and fracture.
3. Irrigating solutions and medicaments during the preparation of root canals
decrease mechanical properties of root dentin and can cause fracture.
4. Dehydration occurs in RCT teeth which leads to a decrease in dentin plasticity and
increased stiffness.
FACTORS AFFECTING ADHESION OF POST TO RADICULAR
DENTIN
Smear layer in RCT teeth Irrigating solutions used in RCT
Endodontic sealers Cavity configuration (C-factor)
Burs selection Accessibility and visibility
Humidity and operative area Type of adhesive system
control
Prepared root canal wall completely covered
by smear layer occluding all dentinal tubules
SMEAR LAYER
◼ Smear layer is any debris, calcific in nature, produced by reduction or instrumentation of
dentin, enamel or cementum OR as a contaminant that precludes interaction with the
underlying pure tooth tissue.
◼ The coronal smear layer reflects the substructure of the dentin matrix composition (HA+
denaturated collagen), while the endodontic smear layer contains inorganic, organic
substances that also include fragments of odontoblastic process, microorganisms and necrotic
tissues.
❖ Etch-and rinse approach: The use of etching followed by rinsing, removes the smear layer
prior to bonding.
❖ Self-etch approach: the smear layer is only modified and is incorporated within the hybrid
layer complex.
SMEAR LAYER
SMEAR LAYER
◼ From endodontic point of view, it is preferable to remove the smear layer
completely as it may be infected and may protect the bacteria already present
in the DT. Also, The penetration depth within DT of different sealers increases
once the smear layer is removed.
◼ From adhesive point of view, it is recommended to remove the smear layer to
increase dentin permeability that allows better diffusion of adhesive mononors
between demineralized collagen fibers.
SMEAR LAYER
◼ Secondary smear layer: It is an additional thicker layer resulting from the preparation of post space using
post drills. It is composed of debris and sealer/gutta-percha remnants that significantly affect the adhesion of
fiber posts.
◼ How to deal with it?
❖ Phosphoric acid? It was reported that the use of phosphoric acid after post-space preparation resulted in
discontinuous areas of deep intertubular demineralization, alternating with areas of opened DT and other
areas covered by a smear layer as the result of an incomplete chemical dissolution during the etching
process.
❖ Chelating agent and Sodium hypochlorite. Combination (EDTA+NaOCl) affect the dissolution and
antibacterial ability of NaOCl. Etidronic acid can be used in combination to NaOCl as an alternative.
❖ Ultrasonic instrumentation along with Ethylenediaminetetraacetic acid (EDTA) before the bonding
process to decrease debris and open DT.
IRRIGATING SOLUTIONS USED IN RCT
◼ NaOCl:
❖ Has antibacterial action. It dissolves vital or necrotic tissue and organic components of the smear layer.
❖ Disadvantages: 1) It Can inhibit the polymerization of resin-based cements due to strong oxidizing properties
which impair adhesion. 2) It affects the mechanical properties such as microhardness, elastic modulus,
resistance to flexion, and fatigue.
◼ EDTA:
❖ It is an acid with chelating action (reacts with calcium and forms soluble calcium chelates).
❖ NaOCl + EDTA (17%) can be used for 1 minute only to avoid dentin erosion and decreased microhardness.
❖ A study (9) reported that the irrigation of root canals with 10 ml of 17% EDTA solution for 1 min followed by 10
ml of 5% NaOCl was effective in removing the smear layer in root canals.
◼ CHx (2%):
❖ Antimicrobial, inhibit matrix metalloproteinase (MMP) that degenerates collagen fibers and degrades the
hybrid layer.
❖ Disadvantages: Unable to dissolve the organic content of the smear layer.
◼ Complete removal of the smear layer,
which contains microorganisms and
infectious deteriorated dentin, is essential for
a successful prognosis in root canal therapy.
Effective methods for removing smear
layers have been widely investigated.
However, recent studies have reported the
negative effects of endodontic irrigants on
bond strengths of resinous materials to
dentin.
◼ The study has demonstrated that the effects
of endodontic irrigation on the bonding of
resin cement to radicular dentin depended
on the dentin bonding system used.
◼ Complete removal of the smear layer
facilitated the penetration of resin tags into
dentinal tubules and contributed to high
bond strengths when using an etch and
rinse bonding system. Conversely,
excessive smear layer removal caused by
endodontic irrigation should be avoided
when constructing a resin–dentin interface
treated with self-etching adhesives.
ENDODONTIC SEALERS
◼Eugenol-based sealers:
❖ They interfere with the polymerization of resin-based materials. The Hydroxyl group of eugenol
blocks the reactivity of free radicals formed during polymerization of resin leading to a decrease
of mononor conversion.
❖ It is recommended to use alcohol &/or phosphoric acid to clean the walls of intra-radicular
preparations.
◼Calcium hydroxide:
❖ They replace eugenol-based sealers and can be used before adhesive resin-cements.
❖ Disdvantages: they have low adhesive strength and should be used immediately after obturation.
(10)
◼Epoxy-based sealers (AH-Plus) :
❖ Can be used when pre-fabricated posts will be bonded with resin cement.
CAVITY CONFIGURATION (C-FACTOR)
◼ C-factor is the ratio between bonded and unbonded dentin surface area in the cavity.
◼ When C-factor is <5:
1. Decrease failure of adhesive interface
2. Decrease cracks and spaces at the resin interface.
3. Decrease detachment of resin from the substrate.
◼ Intraradicular preparation has a high C-factor (200-500), so dissipation of stresses generated by
polymerization shrinkage of the adhesive resin cement is more difficult, leading to the formation of cracks
along the entire length of the adhesive interface. Gaps between the adhesive and substrate and
eventually failure occur.
◼ High polymerization shrinkage stresses have been reported in resin cements because of the high C-
factor.
BURS SELECTION FOR INTRARADICULAR PREPARATION
◼Carbide Burs:
❖ Produce endodontic smear layer much more resistant to removal by water or
phosphoric acid.
❖ Studies have shown that after acid conditioning of root dentin prepared by carbide burs
produced discontinuous areas of intertubular demineralization, areas of opened DT, and
areas with smear layer present
❖ Diamond stones:
❖ Produce endodontic smear layer much easier to remove.
VISIBILITY AND ACCESSIBILITY OF INTRARADICULAR
PREPARATION
◼ Due to the difficult accessibility of intraradicular preparation, dual or
chemical cure adhesives should be used to ensure effective polymerization
as light can’t reach deeper apically.
◼ Magnification can be used for better visibility.
Humidity and operative area control
◼ Adhesive resin cementation is a moisture-sensitive technique.
◼ Pulpless teeth require the same isolating procedures as vital teeth
during adhesive procedures.
ADHESIVE SYSTEMS
◼ In order to guarantee efficient adhesion of the post to the root dentin, three aspects must be considered:
❑ The surface treatment:
The treatment of the dentin surface initially implies efficient removal of the root smear layer , followed by the infiltration of the
adhesive monomers. Etch-rinse (ER) systems are the most commonly used adhesive systems for the treatment of root dentin,
because, in addition to promoting a more effective removal of the smear layer, a more uniform demineralization pattern is
obtained.
❑ The selection of the adhesive resin system
Dual or chemically activated adhesive resin cements are the most suitable for cementation of fiberglass posts, since, with a longer
working time, they allow better control of the adaptation of the post
❑ The polymerization of the cement
In photoactivated systems, the light from the photopolymerizing device does not reach the most apical areas, even in the
presence of translucent fiber posts, as these posts have limited light transmission. Furthermore, the use of photoactivated
cements can result in a low degree of conversion of resin monomers as it approaches the apical areas, compromising the integrity
of the adhesive interface.
RECOMMENDATIONS
◼ The best choice is to use total etch adhesives with dual cure resin cement, with adequate light curing unit
(over 1000 mW/cm2).
◼ Due to good adhesion to coronal dentin and decreased in deeper canal portions, adhesively luted posts
do not need to be extended deeply as posts conventionally cemented.
◼ Direct restorative materials (composite resin), were proved to be successful in restoration of
endodontically treated teeth in teeth with minimal loss of tooth structure and conservative access
cavities.
◼ The use of 1 to 2 mm of resin modified glass ionomer cement to cover root canal obturation is
recommended to decrease stress inside the pulp chamber and furcation area.
◼ The use of bulk fill composite was recommended in many studies to decrease cusp deflection and stress
concentration.
