RESTORATION OF THE

ENDODONTICALLY
TREATED TOOTH
MIRANDA, MAGNEDYLLE
Presented by:
PICCIO, KRISTINE
SPECIAL FEATURES
OF ENDODONTICALLY TREATED TEETH

altered tissue physical characteristics

loss of tooth structure
possible discoloration.
 Possible Clinical
Alteration Level Specific Changes
Implication

Collagen structure Increased tooth fragility

Tooth moisture
Composition Mineral composition
Reduced adhesion to
and content substrate

Elasticity modulus and

behavior
Dentin Increased tooth
Tensile and shear
structure strength
fragility

Microhardness

Resistance to Increased tooth

Tooth deformation fragility
Macrostructure Resistance to fracture Reduced retention/
Resistance to fatigue stability of the
prosthesis
AESTHETIC CHANGES
OF ENDODONTICALLY TREATED TEETH

Discoloration (yellowish to grayish tones)

Loss of Translucency
Internal Staining
RESTORATION OF THE ENDODONTICALLY
TREATED TOOTH IS DESIGNED TO:

1. Protect the remaining tooth from fracture.

2. Prevent reinfection of the root canal system.
3. Replace the missing tooth structure.
DIRECT COMPOSITE
RESTORATIONS
Indicated when a minimal amount of coronal
tooth structure has been lost after
endodontic therapy.
A mixture of a polymerized resin network
reinforced by inorganic fillers.
When properly cured, they are highly
aesthetic, exhibit high mechanical properties
INDIRECT RESTORATIONS:
COMPOSITE OR CERAMIC ONLAYS AND OVERLAYS

Overlays incorporate a cusp or cusps by

covering the missing tissue.
Resin composite onlays are used to restore
endodontically treated teeth.
Ceramics are a material of choice for long-
term aesthetic indirect restorations
FULL CROWNS
Indicated when a significant amount of
coronal tooth structure has been lost by
caries, restorative procedures, and
endodontics.
Cementation of a post inside the root canal
is necessary to retain the core material and
the crown.
FERRULE
FERRULE
Formed by the walls and margins of the
crown, encasing at least 2 to 3 mm of sound
tooth structure.
Resists lateral forces from posts and leverage
from the crown in function
Increases the retention and resistance of the
restoration.
FERRULE
FIVE REQUIREMENTS:

1. The ferrule (dentin axial wall height)

must be at least 2 to 3 mm.
2. The axial walls must be parallel.
3. The restoration must completely
encircle the tooth.
4. The margin must be on solid tooth structure.
5. The crown and crown preparation must not invade the attachment
apparatus.
ENDODONTIC POST
Should not break
Should not break the root
Should not distort or allow movement of
the core and crown.

Resilience
Stiffness
IDEAL POST
Flexibility
Strength.
WHY ROOTS FRACTURE?

Fatigue failure
occurs when a material or
a tissue is subjected to
cyclic loading.
 LUTING CEMENTS
Generally supplied as a powder and a liquid
physical properties are highly influenced by the mixing ratio
of the components.
LUTING CEMENTS

GLASS IONOMER LUTING

CEMENTS
A mixture of glass particles and polyacids,
Classified as either conventional or resin-
modified glass ionomer cements.
LUTING CEMENTS

RESIN-BASED
LUTING CEMENTS
Rationale:
Bonding posts to root canal dentin will
reinforce the tooth and help retain the
post and the restoration.
LUTING CEMENTS

SELF-ADHESIVE
CEMENTS

Do not require any pretreatment of the tooth substrates,

Their clinical application is accomplished in a single step.
Contain multifunctional phosphoric acid methacrylates that
react with hydroxyapatite
 PRETREATMENT
EVALUATION AND
TREATMENT STRATEGY

Reporter: kristine Piccio

Endodontic Evaluation
Prerestorative examination should include an inspection of the quality of existing
endodontic treatment.

Periodontal Evaluation
The periodontal condition of the tooth must therefore be determined before the
start of endodontic therapy and restorative phase

Biomechanical Evaluation
All previous events, from initial decay or trauma to final root
canal therapy, influence the biomechanical status of the tooth
and the selection of restorative materials and procedures.
 Biomechanical Evaluation
Important clinical factors include the following:
◆ The amount and quality of remaining tooth structure
◆ The anatomic position of the tooth
◆ The occlusal forces on the tooth
◆ The restorative requirements of the tooth

Tooth Position, Occlusal Forces, and Parafunctions

Teeth are subjected to cyclic axial and nonaxial forces associated restorations
must resist these forces to limit potential damages such as wear or fracture.
Esthetic Evaluation and Requirements
Potential esthetic complications should be investigated, Anterior teeth, premolars,
and often the maxillary first molar, along with the surrounding gingiva, compose the
esthetic zone of the mouth.
Treatment Strategy
General Principles and Guidelines
The post, the core, and their luting or bonding agents form
together the foundation restoration to support the coronal restoration of
endodontically treated teeth.

Structurally Sound Anterior Teeth

Anterior teeth can lose vitality as a result of a
trauma with no or minimal structural damage.
Nonvital Posterior Teeth With Minimal/Reduced Tissue Loss
loss of vitality in posterior teeth resulting from trauma, decay, or restorative
procedure does not necessarily lead to extreme biomechanical involvement and
therefore allow in certain conditions for conservative restorations.

Structurally Compromised Teeth

decision for placing a post as well as the selection of a post system (rigid or
nonrigid) depends once again on the amount and quality of remaining tooth
structure and the anticipated forces sustained by this tooth
 Structurally Compromised Anterior Teeth
nonvital anterior tooth that has lost significant tooth structure
requires restoration with a crown, supported and
retained by a core and possibly a post as well.

Structurally Compromised Posterior Teeth

Slightly decayed posterior teeth in the context of
parafunctions or significantly fragilized premolars and
molars require cuspal protection afforded by
onlay restoration, endocrown, or a full crown
Additional Procedures
Periodontal crown lengthening surgery or orthodontic extrusion can expose
additional root structure to allow restoration
of a severely damaged tooth.
CLINICAL PROCEDURE
Tooth Preparation
The most important part of the restored tooth is the tooth itself. thickness and
height of remaining dentin walls or cusps along with functional occlusal conditions
are the determining factors in choosing the most appropriate restorative solution.

Post Placement
The post is an extension of the foundation into the
root of structurally damaged teeth, needed for
the core and coronal restoration stability and retention.
Adhesive Procedures
Both self-etch and etch-and-rinse adhesive systems can be used successfully on
root dentin, both systems having a well-documented proof of efficacy.

Partial Restorations
In the case of limited to moderate coronal substance loss, the restorative strategy
for endodontically treated front teeth varies, from direct composite restoration
using the same layering or application techniques as for vital teeth
Foundation Restoration Underneath
Full Crowns
significant coronal substance loss justifies a full-tooth cover�age, the strategy for
foundation fabrication varies from:
◆ Amalgam core with/without metal post
◆ Composite core without post
◆ Composite post with fiber or ceramic post
◆ Composite with prefabricated metal post
◆ Cast gold post and core
Amalgam core with/without metal post
Composite core without post

Composite post with fiber or ceramic post

Composite with prefabricated metal post

Cast gold post and core
VITAL PULP
THERAPY
:
JAHARA PANIBON
ROSSAN MOLDEZ
V I TA L P U L P T H E R A P Y I S T H E T R E AT M E N T
I N I T I AT E D O N A N E X P O S E D P U L P T O R E PA I R
A N D M A I N TA I N T H E P U L P V I TA L I T Y
- Grossman

- exposed pulp to repair and maintain pulp vitality

- capacity of the pulp for repair in the absence of microbial contamination

- most important aspect of VTP are diagnosis of pulpal condition and case selection
How do we know if the tooth is a good candidate for VITAL PULP THERAPY?

- Without sign and symptoms of irreversible pulpitis and provoked pain of short duration that is relieved
upon removal of stimulus with analgesics or by brushing.

VTP depends on:

-age of the px
-size of the pulp chamber
-bacterial contamination

PRIMARY GOALS OF VTP:

• DENTIN BRIDGE FORMATION
• CONTINUATION OF ROOT DEVELOPMENT
 Tissue compromised by caries, trauma, or restorative procedure

A, Mandibular left first molar in a 23-year-old with minor symptoms. B, Asymptomatic maxillary right molar in a 16-
year-old. All patients were referred to the endodontist for root canal treatment based on radiographic observation.
They exhibited normal vitality with cold testing, and all were treated successfully with vital pulp therapy.
• PULPOTOMY
• APEXOGENESIS
• INDIRECT PULP CAPPING
• DIRECT PULP CAPPING
 -removal of the coronal part of the pulp or a portion of the pulp
that is indicated for:

1. cariously exposed deciduous (primary) teeth with healthy

radicular pulps.
2. traumatic or carious exposure of permanent teeth with
undeveloped roots.
3. an alternative to extraction when endodontic
treatment is not available.
4. emergency treatment in permanent teeth with acute
pulpitis

- Surgical amputation of coronal portion of an exposed pulp to protect and preserve

the remaining radicular pulp’s vitality and function
Case selection:
• Vital pulp
• Reversible pulpitis
 - defined as treatment of the vital pulp by capping in order to permit
continued growth of root and closure of the open apex and maintaining maturation of root.

- This procedures are primarily used

to treat younger patients and typically
focus on immature permanent teeth
that have not fully developed.

Thin dentin in obturated canals of immatured roots and open apex are prone to fracture
A)Traumatic injury to young permanent teeth B) Calcium hydroxide apexogenesis is
done C) Continued growth with maintenance of vitality
 Moldez, Rossan

PULP CAPPING
- a dental procedure aimed at
preserving the vitality of the pulp
that is exposed due to caries or
trauma, but is still healthy and
capable of healing

TWO (2) TYPES OF PULP CAPPING:

(1) Indirect
(2) Direct
INDIRECT PULP CAPPING
-a procedure where a biocompatible material covers the deepest layer of
affected dentin to prevent pulp exposure and trauma
Purpose: To protect the pulp from further injury and to permit healing and repair.
R AT I O N A L E :
INDIRECT PULP CAPPING
INDICATIONS
Pain History:
• Mild pain associated with eating
• Negative history of spontaneous
extreme pain
Clinical Examination:
• Deep carious lesion near the pulp
• Minimal pulp inflammation; definite
layer of affected dentin remains after
removing infected dentin.
Radiographic Examination:
• Normal lamina dura and PDL space
• No radiolucency in bone and
periapically
CONTRAINDICATIONS
Pain History:
• Sharp, penetrating pain
• Prolonged night pain
Clinical Examination:
• Tooth mobility
• Discoloration of tooth
• Negative reaction the electric
pulp testing
Radiographic Examination:
• Definite pulp exposure
• Interrupted lamina dura
• Widened PDL space
radiolucency
 TECHNIQUE:

1st appointment:

(1) Anesthesia & rubber dam isolation

(2) Removal of caries
(3) No pulpal exposure and no signs of irrev.
pulpitis
(4) Remaining affected dentin covered w/
Ca(OH)2; place base of IRM
(5) Wait for 3-8 weeks
 T E C H N I Q U E:

2nd appointment:

(1) After 3-8 weeks; patient

asymptomatic
(2) Temporary filling is removed
(3) Careful further excavation &
clinically confirm the change in
color & hardness of affected dentin
(4) Hard set Ca(OH)2 followed by
RMGIC base & a bonded
composite restoration/amalgam
DIRECT PULP CAPPING
- Placement of medicament directly over pulp at site of exposure
- Mechanical/Iatrogenic exposure
- Pin point exposure
DIRECT PULP CAPPING
DIRECT PULP CAPPING

INDICATIONS CONTRAINDICATIONS
• Asymptomatic vital young • Severe pain at night
permanent or permanent • Spontaneous pain
teeth • Tooth mobility
• Small exposure • Large pulp exposure
(<0.5mm “true pin point • Excessive bleeding
lesion) • Serous exudate
• Little or no bleeding at • Presence PA
exposure site lesion/root resorption
• Mechanical > carious • Presence of
swelling/fistula
DIRECT PULP CAPPING

Factors affecting prognosis:

- Area of exposure
- Size of exposure
- Carious? Mechanical?
- Bacterial contamination
- Duration of exposure before the treatment
- Microleakage
- Duration of the hemorrhage
PROCEDURE
(1) Anesthesia & rubber dam application
(2) Disinfect the area with chlorhexidine
solution
(3) Rinse w/ anesthetic or sterile saline
(4) Sterile cotton pellet to control bleeding
(5) Mix capping agent
(6) Apply to exposure site
(7) Base/liner then restore

TECHNIQUES:
Calcium hydroxide technique: MTA technique: (2)
(1)Ca(OH)2
(1)MTA
(2)RMGIC
(2)RMGIC
(3)Final restoration
(3)Final restoration
(composite/amalgam)
Calcium hydroxide (Ca(OH)2)
- Stimulates dentin repair and forms a protective dentin bridge,
sealing off the pulp from irritants and bacteria. It's known for
promoting healing and having antimicrobial properties.

Mineral Trioxide Aggregate (MTA)

- Biocompatible material that sets in moisture, forming a tight
seal and promoting tissue repair. MTA is favored for its superior
sealing ability, biocompatibility, and potential for enhanced tissue
regeneration.
 Endodontic-Periodontal
Lesions

Content:
●Introduction
●Pathway connectiong endodontic and periodontal tissue
●Etiology of Endo-Perio Lesions
●Classification Of Endo-Perio Lesion
 Introduction

• Conditions where there is a combination of both endodontic and

periodontal involvement.

• Result from various factors such as dental trauma, periodontal disease, or

complications from previous dental procedures

• The pathway of bacteria into the periodontal tissue

 Pathway Connecting Endodontic and
Periodontal Tissue
2 Pathway
Anatomical Pathway Non-Physiological Pathway
• Periodontal Pocket • Traumatic Injuries
• Apical Migration • Iatrogenic Factors
• Dentinal Tubules • Dental Plaque and Calculus
• Foreign Body Ingress
 Etiology of Endo-Perio Lesions
• Microbial Factors
• Bacterial invasion of the dental pulp and periodontal tissues
• Inflammatory Response
• Inflammation in the dental pulp (pulpitis) and periodontal tissues (gingivitis,
periodontitis) Which then contributes to tissue destruction and breakdown.
• Anatomical Factors
• Anatomical variations in the tooth structure, such as accessory canals, lateral
canals, and apical deltas, can create pathways for bacteria
• Systemic Factors:
• Systemic health conditions, such as diabetes, immunodeficiency disorders, or
hormonal changes
• Traumatic Injuries
• Iatrogenic Factors
 Classification Of Endo-Perio Lesion

1. Primary Endodontic Lesion

2. Primary Endodontic Lesions With Secondary Periodontal
Involvement
3. Primary Periodontal Lesions
4. Primary Periodontal Lesions With Secondary Endodontic
Involvement
5. True Combined Lesion
 Primary Endodontic Lesion
• Disease processes of the dental pulp usually involve inflammatory changes
by Caries, restorative procedures, and traumatic injuries.
• Inflammatory in the periodontium
• Resorb bone apically and laterally and destroy the attachment apparatus
adjacent to a nonvital tooth.
• Suppurative process results to a sinus tract along the periodontal ligament
space
• Endo testing shows Pulp degeneration
Treatment
• Resolution is usually nonsurgical
endodontic therapy without any periodontal treatment.
• Sinus tract disappears if necrotic pulp is removed and canals are sealed
well
 Primary Endodontic Lesions With Secondary
Periodontal Involvement

• Untreated Primary Endodontic Lesion

• Continuation Of Pathosis
• Destruction of alveolar bone
• Necrotic Root Canal
• Plaque or Calculus Accumulation
• Radiograph will show generalized periodontal disease with defects at the initial
site of the endodontic involvement
Treatment
• Treatment of both condition is required
 Primary Periodontal Lesions
• Periodontal disease have Progressive nature
• Starts in sulcus and migrates to apex
• Progress along root surface
• Commonly due to accumulation of plaque, calculus and deep pockets
• Loss of clinical attachment and formation of a periodontal abscess
• Bony lesion is usually more widespread and generalize
• Treatment
• Depends on the extent of the periodontitis
and on the patient’s ability to comply with
potential long-term treatment and
maintenance therapy
 Primary Periodontal Lesions With Secondary
Endodontic Involvement
• exhibits deep pocketing, with a history of extensive periodontal
disease and, possibly, past treatment
• bacteria and inflamatory products could gain access to the pulp via
accessory root canal
• Pulp may become necrotic

Treatment
• Depends on continuing periodontal
treatment subsequent to endodontic therapy
 True Combined Lesion
• Pulpal and periodontal disease may occur independently or
concomitantly in and around the same tooth
• Occurs when endodontic lesion progresses coronally and joins the
infected periodontal pocket apically
• Necrotic pulp or a failing endodontic treatment, plaque, calculus, and
periodontitis is present
• If sinus tract is present, it may necessary to open a flap
• Treatment
• Surgery like amputation, Hemisection or bicuspidization
• Molar teeth root resection can be done
Concomitant Pulpal and Periodontal Lesions
• The presence of two separate and distinct entities
• No clinical evidence that either disease state has influenced the other

Treatment
• Treatment is rendered to only one of the diseased tissues hoping that
the other will respond favorably.
• Both disease processes must be treated concomitantly
Treatment and Prognosis