Received: 27 February 2020 Revised: 24 March 2020 Accepted: 31 March 2020

DOI: 10.1111/jerd.12589

RESEARCH ARTICLE

Adaptable fiberglass post after 3D guided endodontic

treatment: Novel approaches in restorative dentistry

Amanda Stephanie Silva DDS | Alice Cecília Carvalho Santos DDS |

Camila de Sousa Caneschi MSc | Vinícius Carvalho Machado MSc |
Allyson Nogueira Moreira DDS, PhD | Luís Fernando dos Santos Alves Morgan DDS, PhD |
Warley Luciano Fonseca Tavares DDS, PhD

Department of Restorative Dentistry, School

of Dentistry, Federal University of Minas
Gerais, Belo Horizonte, Brazil
Correspondence
Warley Luciano Fonseca Tavares. Avenida
Antônio Carlos 6627. Departamento de
Odontologia Restauradora, Faculdade de
Odontologia, Universidade Federal de Minas
Gerais, Belo Horizonte, Minas Gerais, Brazil.
Email: warleyt@hotmail.com
Funding information
Universidade Federal de Minas Gerais
Abstract
Objective: The rehabilitation of extensively damaged teeth with great structural loss
and calcified root canals represents a challenge for dentistry. Classically, this restorative
procedure of endodontically treated teeth involves intraradicular post placement.
Retentive function post that can closely adapt to the root canal without the excessive
wear of intraradicular dentin has a fundamental importance to ensure the longevity of
the restoration.
Clinical considerations: This report presents a clinical case of 3D guided access to a
severely calcified pulp canal followed by the cementation of a fiberglass post that is
adaptable to the root canal and prosthetic rehabilitation with full ceramic crown.
Conclusions: 3D guided access allowed conservative and safe root canal treatment.
The adaptable fiberglass post meets the specific needs of the described case and has
a simple technique and low cost.
Clinical significance: Guided endodontics is a minimally invasive approach for teeth
with calcified root canals. The post used in this study meets the demands of teeth
endodontically treated with conservative techniques. The professional should not
need to adapt the anatomy of the root canal to the anatomical reality of the post.
This one adapts itself to the shape of the canal.

KEYWORDS

adaptable post, calcified canal, guided endodontics

1 | I N T RO DU CT I O N can result in deviations, perforations, inability to achieve patency and,

The deposition of mineralized tissue along the root canal walls is
1,2
related to previous traumatic processes, responses of orthodontic
3
forces due to the interference with pulpal blood supply or even
related to physiological factors in elderly patients.4 Approximately
25% of traumatized anterior teeth can develop pulp canal
5
obliteration.
Endodontic treatment of teeth with pulp calcification is a chal-
lenge even for the most experienced clinicians. Inadequate treatment
consequently, treatment failure.6 Recently, the advent of guided end-
odontics has brought a new possibility of treatment in cases of severe
pulp calcifications in both anterior and posterior teeth.7-10 A com-
puted aid implantology software matched with cone-beam computed
tomographic (CBCT) imaging and a digital scanning 3D impression
allow the virtual planning of the procedure.
The endodontic treatment of teeth with calcified root canals and
major coronary damage requires care to ensure the success of future
restorations. As an alternative to the traditional approach, guided

J Esthet Restor Dent. 2020;1–7. wileyonlinelibrary.com/journal/jerd © 2020 Wiley Periodicals, Inc. 1

2 SILVA ET AL.
endodontic is minimally invasive11-14 and emphasize the importance
of dentin preservation in the pericervical region to increase the suc-
11
cess rates of restorative treatments.
Classically, rehabilitation of endodontically treated teeth involves
the placement of an intraradicular post for the retention of direct or
indirect final restoration.15-17 From a prosthetic standpoint, restora-
tion should be designed to preserve as much healthy dental structure
as possible, thus reducing the risk of teeth fracture.18
The use of formatting drills in the additional preparation for
intraradicular post can increase the loss of dentin substance to 50% or
19,20
more. Thus, the choice of the post and the intraradicular prepara-
tion is a fundamental step to ensure that there is no wear or tear
beyond the endodontic preparation previously performed.21
Consistent with the concepts of minimizing root tooth wear dur-
ing root canal shaping, new types of posts have been introduced. The
current proposal is based on the fact that the professional should not
need to adapt the anatomy of the root canal to the anatomical reality
of the post. The post must adapt itself to the shape of the canal. It is
in this line that the adaptive post (Taper, Angelus, Londrina, Brazil)
was developed with a conical sleeve that is adaptable to the shape of
the canal.
The aim of this report is to present a clinical case of 3D guided
access to a severely calcified pulp canal and the cementation of a
fiberglass post that is adaptable to the root canal and prosthetic reha-
bilitation with full ceramic crown.
2 | CASE REPORT
A 57-year-old female patient sought dental care at the integrated
clinic of the School of Dentistry, complaining of coronary loss of the
left upper lateral incisor without pain. After anamnesis and clinical
F I G U R E 1 A, Initial smile aspect. B, Frontal intraoral view of the tooth without the restoration. C, Incisal view of the tooth without the
restoration. Note the severe loss of coronal structure
evaluation, a temporary crown was found in this tooth (Figure 1).
According to the patient's report, an unsuccessful attempt to access
the root canal was performed. Radiographic examination revealed a
severely calcified root canal without endodontic treatment and a pin-
like metal structure. A cone beam computed tomography (CBCT)
examination was requested, and the result confirmed the presence of
severe calcification of the canal.
After analysis and discussion of the case between the dental team
and the patient, it was decided to perform the guided endodontic
access to the calcified canal, a prefabricated root canal adaptable post
and then a pure ceramic total crown. The patient received and signed
an informed consent after careful explanations of the methods to be
employed, risks and benefits.
To generate the 3D access guide to the root canal, the patient's
upper arch was scanned (3Shape R700 Scanner; Holmens Kanal,
Copenhagen, Denmark), and the image was then aligned and
processed with that of CBCT using SimPlant software (Version 11;
Materialize Dental, Leuven, Belgium). A virtual copy of the drill used
with a diameter of 1.3 and 20 mm in length (Neodent Drill for
Tempimplants, Ref: 103179; JJGC Ind and Dental Materials Trade SA,
Curitiba, Brazil) was superimposed over the scanned images in a posi-
tion that allowed them to be scanned, with access to the visible canal
in the apical third of the root (Figure 2). Then, a 3D guide was printed
as described by Tavares et al.9
After verifying the perfect fit of the guide in the mouth, access
was made with a low-speed handpiece using a drill with a diameter of
1.3 mm and a length of 20 mm set to 10 000 rpm. Drilling was per-
formed with pumping movements to penetrate through the calcified
part of the root canal under copious irrigation with saline. Successive
saline irrigations were performed to avoid root microcracks. After the
patent canal was reached by the drill according to the planning and
3D guide, a rubber dam was placed. A #10 K file was inserted into the
SILVA ET AL. 3

FIGURE 2 A, Initial radiography. Note the absence of root canal space. B, 3D virtual planning of guided endodontics

FIGURE 3 A, Check of the template fit in the mouth. B and C, Guided drilling. D, Root canal instrumentation. E, Post-operative radiography

root canal, and the working length was electronically confirmed using
an apex locator (FinePex; Schuster Medical Equipment and Dental,
Santa Maria, Rio Grande do Sul, Brazil) and radiographic examination
(Figure 3).
Root canal instrumentation was performed using the ProTaper
NEXT system (Denstply, Ballaigues, Switzerland) until X2 file and
irrigation with 2.5% sodium hypochlorite. The irrigating solution was
agitated with XP-endo Finisher (FKG Dentaire, La Chaux-de-Fonds
Switzerland) at 1000 rpm for 60 seconds. After drying the canal,
obturation was performed with Tagger's hybrid technique and AH
Plus Sealer (Dentsply DeTrey GmbH, Konstanz, Germany). A new pro-
visional restoration was made.
In the following session, the absolute isolation of the operative
field was performed for intracanal space preparation and cementation
of post. After planning the length of the post within the root canal, a
Largo #1 drill was used in accordance with the principles of apical
sealing maintenance (working length minus 5 mm). Then, Largo
No. 2 and 3 drills were used to clear and shape the root canal only in
the region with guided access with its specific drill, that is, in the mid-
dle and cervical third of the root.
Next, the post was selected as a super thin cylindrical fiberglass
intracanal post that has a conical fiberglass sleeve (Figure 4). This
sleeve fits into the post moving along its longitudinal axis. The post
system was selected according to the endodontic preparation using
4 SILVA ET AL.

F I G U R E 4 A, Cylindrical fiberglass intracanal post with conical fiberglass sleeve (Taper, Angelus, Londrina, Brazil). B, Operatory field with the
use of a rubber dam and special clamp for gingival tissue retraction. C, Preparation of the root post's space whit Largo No. 1, 2, and 3 drills. D
and E, Proof of the adaptive fiber glass post in the prepared canal

low-speed handpiece cylindrical drill. The post system employed is
consisted of six different sizes concerning the post and sleeve diame-
ters. The post space in this case had a 10 mm total length. When the
sleeve is inserted together with the post, it allows an intimate adapta-
tion to root canal walls. The post selected to this case was number
2, which presented the diameter of 0.6 in the apical portion and
1.3 mm in the sleeve. The post was positioned in the root canal at the
10 mm depth and the sleeve was inserted onto the post by moving it
as apically as possible with slight digital pressure. Horizontal markings
on the sleeve helped to determine the amount of penetration in the
root canal through the post. The post and sleeve assembly was then
removed for surface treatment utilizing alcohol swabs followed by
silane (Monobond S, Ivoclar Vivadent, Liechtenstein) on the surface of
the post and the sleeve, both internally and externally, with the use of
an extrafine disposable brush (Cavibrush, FGM, Brazil). Intracanal irri-
gation with physiological saline solution, aspiration with endodontic
cannula and humidity control with absorbent paper cones were
performed.
To cement the post, the root canal was cleaned with saline and
dried with absorbent paper points. A dual self etching, self adhesive
resin cement (SeT PP, SDI, Australia) was used and inserted into the
root canal with the aid of an extra thin Centrix tip and applied over
the post and the glove surfaces. The post-glove system was inserted
into the root canal with light pressure guided by the horizontal mark-
ings on the gloves. The excess of cement was then removed around
the post with the aid of a disposable brush, followed by photo-
activation for 40 seconds (Radii-cal, SDI, Australia). Then, the adhesive
procedures were performed on the enamel, dentin and coronary por-
tion of the post, followed by the insertion of the resin composed of
the incremental technique for building a filler core (Filtek Z350 XT,
3M). After this step, and after the initial setting time of the cement,
the post was cut at the planned occlusal height with the aid of a dia-
mond spherical tip under refrigeration. A periapical radiograph was
taken to confirm the successful adaptation of the post after cementa-
tion (Figure 5).
In subsequent sessions, clinical and laboratory steps were per-
formed to receive a definitive ceramic disilicate crown. Internally in the
crown, adhesive procedures involved the sandblasting with aluminum
oxide, etching rinse with 10% hydrofluoric acid for 20 seconds and
37% phosphoric acid for 60 seconds, followed by silane and gentle air-
drying. The dental/core substrate was cleaned with prophylactic
brushes and dried.
Direct facets using resin composite (Z350 XT, 3M) were per-
formed in teeth 11 and 21. The adhesive procedures involved
etching with 37% phosphoric acid on enamel surfaces and a self-
adhesive system (Adper Single Bond Universal, 3M). The
SILVA ET AL. 5

F I G U R E 5 A, Cement insertion with Centrix tip into the root canal and application over the post and the glove surfaces. B, Excess cement
removal with the aid of a disposable brush. C, Photoactivation for 30 seconds. D, A filling core was made using restorative resin composite. E, The
post was cut at the planned incisal height. F, Intraoral view after core preparation and provisional restoration. Note the good cervical
adaptation. G, Periapical radiograph after post cementation, core reconstruction and provisional restoration. H, One year follow up aspect after
cementation of the ceramic crown in tooth 22 and direct resin veneers in teeth 11 and 21

incremental insertion and stratification technique of the resin com-
posite were used to create the definitive restoration. The first layer
was performed with a dentin resin (A1D), followed by body opacity
(A2B in cervical third and A1B in medium and incisal thirds) and
enamel resin (A2E in cervical third and A1E in medium and incisal
thirds). The final layer was performed with a translucent resin (AT).
Each increment was photo activated for 20 seconds with a final
activation of 40 seconds after the last increment. The ultimate
polishing of the restorations was performed 21 days after comple-
tion of the restoration using multi-laminated burs, polishing discs
(Soft-lex, 3M) and rubbers (Jiffy, Ultradent, Germany). At the 1-year
follow-up clinic session, the integrity of the treatment was
evaluated.
3 | DISCUSSION
The prognosis of teeth that are indicated for endodontic treatment is
often linked to the anatomical aspects of the tooth. Root canal anat-
omy suggests the pattern of stress concentration in different areas
not detected on radiography.19 Therefore, observing this anatomy
and understanding its importance regarding fracture susceptibility and
risk of perforation are very important elements in the successful
19,21
placement of an intraradicular post system.
This step is also necessary to ensure the restorability of the dental
element by assessing factors such as the thickness of the remaining
dentin, which in turn determines the ability of the future restored set
to withstand chewing loads. Substantial loss of tooth structure can
thus predict treatment success. It is therefore essential to evaluate
and customize the clinical root canal related to this aspect even before
endodontic treatment is initiated.22
In the case of calcified canals, attempting to locate the canals
through a traditional approach can result in a greater loss of tooth
structure and deviations in canal orientation, leading to perforations
that can occur even under the care of the most experienced practi-
tioners.6 Thus, the traditional technique becomes risky for the treat-
ment of calcified canals, especially in teeth that also present a great
loss of coronary structure.6,9,22
Preparing the root canal with the use of 3D guides has shown
promise in relation to traditional approaches. According to an
observational study by Bruchgreitz et al,23 on 50 single-rooted
teeth, it was consistently observed that guided endodontic prepara-
tion provides efficient accuracy regardless of the degree of root
canal obliteration. Thus, it can be said that the technique presented
here provides a reduction in iatrogenesis when accessing calcified
root canals and leads to biomechanical benefits in the preservation
of the dental structure because it is a more conservative
approach.9,23
After the endodontic treatment has been carried out, we move
to the rehabilitation stage where the focus is to ensure the retention
of future restorative material.24 The use of prefabricated
intraradicular post as additional retainers has been the first choice.
Fiberglass posts stand out due to their desirable esthetics and chem-
ical adhesion to resinous materials.25,26 In addition, fiberglass posts
have the advantage of having a modulus of elasticity close to that of
the dental structure, aiding stress distribution and minimizing the
6 SILVA ET AL.
chance of fracture, especially when dealing with teeth with a great
loss of healthy structure.27 However, despite stress reduction using
fiberglass posts, it is difficult to completely undo the stress under
load conditions or to recreate a stress distribution equal to that
found in healthy teeth. This is quite valid in anterior teeth, such as
the case in question, where transverse forces play an important
role.27,28
It is important to add that the post design is defined by several
different parameters, including the length or diameter and the longitu-
dinal root canal shape.29 The effect of these parameters on the final
performance has been examined in several studies.30,31 Recommenda-
tions on post length have been reported; for example, many studies
recommend diameter limits, since a larger post diameter suggests the
elimination of a larger amount of dentin.32,33
Therefore, the post used in this study was developed to meet the
demands of teeth endodontically treated with conservative tech-
niques (an extra thin main post and a conical sleeve adaptable to dif-
ferent conduit diameters). In addition, this post is available in different
diameters, making it possible to select a post according to the taper of
the cone and instrument used during obturation. By using a super
thin, tapered, adaptable, tapered-shaped intraradicular post, it is possi-
ble for the root canal to receive a retainer without additional wear in
the space preparation for the post. Thus, the post fits into the canal
and not the other way around.19 The particularity of the system pres-
ented here is in the extra thin post and the glove, as juxtaposition of
the post allows a better adaptation along the entire length of the canal
space, from the apical portion to the medium and cervical third
regions.
4 | C O N CL U S I O N S
It was concluded that 3D guided access allowed conservative and safe
root canal treatment. The adaptable fiberglass post meets the specific
needs of the described case and has a simple technique and low cost.
However, further studies are needed to verify the long-term retained
effects.
ACKNOWLEDGMENTS
The authors want to thanks the Department of Restorative Dentistry
at the School of Dentistry of Universidade Federal de Minas Gerais
(UFMG) and Pró- Reitoria de Pesquisa da UFMG (PRPq). The authors
deny any conflicts of interest related to this study.
CONF LICT OF IN TE RE ST
The authors deny any conflicts of interest related to this study.
ORCID
Camila de Sousa Caneschi https://orcid.org/0000-0002-9580-2561
Vinícius Carvalho Machado https://orcid.org/0000-0002-3089-
5138
Warley Luciano Fonseca Tavares https://orcid.org/0000-0003-
2077-927X
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How to cite this article: Silva AS, Carvalho Santos AC, de
Sousa Caneschi C, et al. Adaptable fiberglass post after 3D
guided endodontic treatment: Novel approaches in restorative
dentistry. J Esthet Restor Dent. 2020;1–7. https://doi.org/10.
1111/jerd.12589