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12 Restoration of RCT and Periodontally Weakened Teeth 2009
12 Restoration of RCT and Periodontally Weakened Teeth 2009
12 Restoration of RCT and Periodontally Weakened Teeth 2009
A post which fits within the canal and retains the core, which replaces the missing coronal tooth structure. Does not reinforce endodontically treated teeth. RCT should be gutta percha
Pre-fabricated Post-Core
Remove all caries (before RCT) Assess adequate tooth structure. Determine periodontal health / lack of mobility Determine need for crown lengthening or extrusion.
Caries extent to bone level - consider C:R after crown lengthening Evaluate bite-wing radiograph as well as PA Option for FPD or implant replacement
Usefulness for effective occlusion Abutment for prosthesis Esthetics Could the tooth be more effectively be replaced?
FPD or implant
Treatment Planning
Evidence of Pathology
Fractured root
Periapical lesion Draining fistula Pain, mobility Isolated deep pocket
Root Resorption
Anterior Teeth
Posterior Teeth
Molars
Greater loading vertical fracture Cuspal coverage always recommended. Full crown with high fracture risk
Large circumference: post not necessary for lateral resistance just retention of core. Pulp chamber retention / pre-fabricated post / pinretention dependent on tooth structure. Amalgam or composite resin
If a post is needed: Palatal root of maxillary molars Distal root of mandibular molars (Buccal roots of maxillary and mesial roots of mandibular molars small, concavities, curvature)
Premolars
General Considerations
Cast or Prefab PC / Pin/pulp chamber retention
Thickness of tooth structure surrounding canal Bulk / height of remaining coronal tooth structure Diameter / morphology of root Bone support Role in final restorative plan
General considerations:
Use post/core only if roots are long, bulky, straight Use post if abutment / lateral stress / height:CEJ diameter is great. Minimum 2mm axial wall covered by crown (ferrule effect).
RCT tooth as abutment for 1-pontic FPD RCT generally not indicated for free-end RPD abutment. (esp. premolars)
Ferrule Effect
Ferrule Effect
Encirclement of vertical axial wall to protect against fracture by counteracting spreading forces generated by the post. Conserve tooth structure Smooth sharp angles in cast post preps to minimize cementation stress & casting accuracy.
Crown margin must be placed on solid tooth structure or risk root fracture.
Ferrule Effect
Anti-rotation
Anti-rotation features
Pins, keyways, or remaining tooth structure. Peripheral distribution of retention and resistance features of core enhance resistance of restoration.
Anti-rotation features
Canal Preparation
Post-Core Considerations
Rubber dam isolation: asepsis; protection Remove gutta percha and prepare canal in separate procedures. Ideal time to make post space is immediately after obturation.
Make post-core separately from final preparation. Marginal adaptation and fit Facilitates replacement of crown Facilitates FPD abutment preparation
Embedment: Post Length Retention: 2/3 length of root (embedded in bone) and at least the length of clinical crown
Post Length
Post Embedment
Post Embedment
Fracture resistance:
Post length should extend to at least the distance of which the root is supported in bone.
Forces are directed outward along length of post Root fractures often caused by;
Too short a post Too large diameter
Remove little if any additional dentin beyond what is needed to perform the RCT
Cast Post-Core
Advantages:
Preservation of tooth structure (post fits space) Anti-rotation properties Core retention (inherent part of post)
Disadvantages:
Enlargement of canal for post at apex for fit Core retention to post can be problem Potential for rotation
Disadvantages:
# of appointments necessary Decreased retention of tapering design Wedging effect on root ???? (If no flat root face vertical stop)
Pre-fabricated Post-Core
1. 2. 3. 4.
Measure canal length Remove gutta percha (heat carrier) Enlarge canal (Peeso reamer) Drill post hole (twist-drill)
Post Cementation
Active threaded design or Passive serrated design (threaded design root fracture)
Etch; wash; dry (air and paper points) Coat post with cement Spin cement into canal with Lentulo spiral (ZnPO4) Seat using slow, finger pressure only
Place matrix band and condense amalgam; Leave slightly out of occlusion.
Plastic post pattern fitted to lubricated canal with Duralay resin. Coronal portion added w/ second mix of resin. Resin core shaped to crown preparation.
Resin pattern is invested and cast (type III gold). Vent is cut with inverted cone bur. Cementation complete crown preparation.
Post Materials
Cast metal (Type III gold; Au-Pd) Stainless steel Titanium Ceramic / zirconium Fiber (carbon / quartz) / composite
Modulus of elasticity same as dentin Post will not cause root fracture Fatigue causes fiber / composite breakdown and post fracture Use only when well-supported by sound tooth structure and lack of heavy lateral forces.
Short post in facial canal. Amalgam condensed into lingual canal (fractured).
Cast post-core: Retention / resistance from both canals. (long post facial / short lingual) Contiguous metal structure resists fracture.
Orthodontic and periodontal adjuncts to restoring damaged teeth Regaining interproximal space Extrusion Crown lengthening with osseous correction Root resection
Orthodontic movement
Core restoration placed and prepared for full crown. Acrylic provisional crown is cemented. Elastic orthodontic separator is placed.
Orthodontic movement
0.6 mm ligature wire wrapped around contact and tightened. Check / tighten at 1week intervals Adjust occlusion Add contact to provisional crown
Orthodontic movement
Adjust occlusion as tooth is tipped. Surgical crown lengthening may also be necessary. Full crown is placed.
Tooth structure lost to level of alveolar crest does not allow ferrule effect of crown to protect from root fracture.
Orthodontic Extrusion
Crown lengthening: osseous re-contour and apical re-positioning of flap (3 mm apical to crown margin).
Deep cervical margin and bone resorption result in un-esthetic difference in gingival height. Can be due to deep fracture, caries, and crown lengthening surgery.
Normal anatomic C:R for CI is 11:14 Crown lengthening for 3 mm apical fracture leaves unstable and unesthetic 14:11. Extrusion / crown lengthening 11:11 - more esthetic and stable.
Orthodontic Extrusion
Endodontics and post-core Arch wire with mid-facial loop and embedded pin in provisional crown Elastic from pin to loop Movement of 1.0 1.5 mm / week
Distance the destruction extends apical to the alveolar crest The biologic width of 2.0 mm 1.0 mm for sulcus apical to crown margin
Amount of extrusion desired 3mm Bracket placed 3mm apical to center of post-core/provisional; Arch wire placed in brackets. Incisal length adjusted as tooth moves coronally.
#10 extruded for adequate ferrule with post-core. Bone travels with root unesthetic gingival line (low).
The descended level of gingiva and bone makes clinical crown shorter. (The alveolar crest descends with the tooth.) Osseous re-contouring to level of adjacent tooth allows equal length of clinical crown.
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Shoulder finish line extended onto root surface requires excessive axial reduction: possible pulpal involvement and weakening of entire tooth
Conservative treatment: Prepare for metal-ceramic to CEJ; Long bevel or light chamfer metal collar
Furcation Flutes
The anatomic facial groove should merge with the vertical concavity extending from the furcation flute
Root Resection
Eradicate areas of tooth which cause problems in hygiene maintenance. Salvage teeth with endodontic problems. Must not have excessive bone loss. Furcation must be in coronal 1/3 and well separated roots. Must be treatable w/ endo.
Preparation finish line intersects with the vertical flutes in the root trunk. Axial surface of tooth preparation occlusal to the inversion of the gingival finish line must have a vertical concavity or flute, as will the crown. Like seating groove must parallel path of insertion.
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