POST-RETAINED CROWN (Restoration of the Endodontically Treated Tooth) Cemented Dowel Crown Cemented dowel crown (radiographic view)

Treatment Planning Endodontically treated tooth need to be assessed carefully for the following: 1. Good apical seal 2. No sensitivity to pressure 3. No exudates 4. No fistula 5. No apical sensitivity 6. No active inflammation Disadvantages to the routine use of a cemented post:  Placing the post require an additional operative procedure  Preparing a tooth to accommodate the post removes additional tooth structure The use of a parallel-sided post in a tapered canal requires considerable enlargement of the post space, which can weaken the root significantly.  It may be difficult to restore the tooth later, when a complete crown is needed, because the cemented post may have failed to provide adequate retention for the core material.  The post can complicate or prevent future endodontic retreatment if this becomes necessary.

2 Methods of Removing Gutta Percha:  With a warmed condenser  With a rotary instrument (sometimes used with a chemical agent such as chloroform) Steps: (using a warmed condenser) 1. Before removing gutta percha, calculate the appropriate length of the post. 2. Avoid the apical 5mm if possible. 3. To prevent aspiration of an endo. instrument, apply a rubber dam before preparing the post space. 4. Select an endo. condenser large enough to hold heat well but not so large that it binds against the canal walls. 5. Mark it at the appropriate length, heat it, and place it in the canal to soften the gutta percha. 6. When the gutta percha has been removed to the appropriate depth, shape the canal as needed. ENLARGEMENT OF THE CANAL For Prefabricated Posts 1. Enlarge the canal one to two sizes with a drill, endo file and reamer that matches the configuration of the post 2. Use a prefabricated post that matches standard endo instruments 3. Be especially careful not to remove more dentin at the apical extent of the post space than is necessary For Custom-made Posts 1. Use custom-made posts in canals that have a noncircular cross section or extreme taper. Enlarging canals to conform to a preformed post may lead to perforation. 2. Be most careful on molars to avoid root perforation. PREPARATION OF THE CORONAL TOOTH STRUCTURE  Ignore any missing tooth structure and prepare the remaining tooth as though it were undamaged.  Be sure that the facial surface of the tooth is adequately reduced for good esthetics.  Remove all undercuts that would prevent withdrawal of the pattern  Remove any unsupported tooth structure, but be careful to preserve as much of the crown as possible.  Be sure that part of the crown is prepared perpendicular to the post.  Complete the preparation by eliminating sharp angles and establishing a smooth finish line. Post Fabrication: a. Prefabricated Posts -One advantage of using prefabricated posts is the simplicity of the technique -A post is selected to match the dimensions of the canal, and only minimum adjustment is needed for seating it to the full depth of the post space -Coronal half of the post may have an inadequate fit because the root canal has been flared, this is corrected by adding material when the core is made b. Custom-made Posts -Can be cast from direct pattern or an indirect one -Direct technique utilizes autopolymerizing resin and is indicated for single canals whereas an indirect technique is more appropriate for multiple canals

Requirements for traditional core and dowel construction:  Ideally the length of post should be equal to, at least, the length of the estimated clinical crown.  The post must have an occlusal stop to prevent displacement apically. This is of vital importance since displacement toward the apex commonly results in fracture of the prepared root.  Included in this construction should be resistance to rotational forces.  Posts should be of sufficient thickness to resist displacement and assist stabilization. PREPARED TOOTH for DOWEL CROWN Principle of Post Support (Retention)  Minimum post length should equal restored crown length or engage 2/3 of natural root  Cylindrical posts are more retentive than similarly size tapered posts  Wrought (bent/twisted/formed) gold alloy posts are two to four times stronger than cast gold alloy posts of equal diameter  Serrated posts are 30% to 40% more retentive than are smooth posts 3 Stages in Tooth Preparation 1. Removal of the root canal filling material to the appropriate depth 2. Enlargement of the canal 3. Preparation of the coronal tooth structure REMOVAL OF THE ENDO FILLING MATERIAL

Core Fabrication: -The core replaces missing coronal tooth structure, and thereby forms the shape of the tooth preparation. -It can be shaped in resin or wax and added to the post pattern before the assembly is cast into metal. -The core can also be cast onto most prefabricated post systems. -A third alternative is to make the core from a restorative material such as amalgam, GI or composite resin. Available Post and Core System:

Amalgam

RECOMMENDED USE Molars with adequate coronal tooth structure Teeth with minimum tooth structure missing same Elliptical or flared canal

PRECAUTION Not recommended in teeth under lateral load (anteriors) Not recommended in teeth under lateral load same Care to remove nodules before try in

GI

Composite Resin Custom cast Post & Core Wire post & Cast core

Amalgam

GI

ADVANTAGE Conservative of tooth structure Straightforward technique same

DISADVANTAGES Low tensile strength Corrosion with base metal Difficult condensation Low strength Low strength Continued polymerization Microleakage Less stiff than wrought Time-consuming Complex procedure Corrosion of base metal Pt-Au-Pd wire expensive

Small circular canal

Care to avoid perforation during prep.

Composite Resin

same

Tapered prefabricated post

same Not recommended for excessively flared canals

Custom cast Post & Core Wire post &

High strength Better fit than prefabricated High High strength stiffness

Sided prefabricated post Threaded post

same

Care during prep

Only when maximum retention is essential

care to avoid fracture during seating

Cast core Tapered prefabricated post Sided prefabricated post

Conservative of tooth Structure High strength & stiffness High strength Good retention Comprehensive system

Less retentive than sided or threaded system Precious-metal post expensive Corrosion of SS Less conservative of tooth structure

Removal or retrieval can be facilitated by using an adhesive to attach a hollow tube extractor or by using a threaded extractor. Maxillary incisor with a fractured post inside the canal (A and B). The diameter of the post is gauged with a sizing tool. The selected trephine is carefully rotated counterclockwise to create a narrow channel around the post. When the instrument has removed sufficient material, the post is recovered. The fractured crown and post after removal.

  

Threaded post

High retention

Stresses generated in the canal may lead to fracture Not conservative of coronal and radicular tooth structure

 

Tapered threaded post (jacket crown) Tapered threaded post (fixed bridge) Post Removal by High Speed Bur  A post that has fractured within the root canal cannot be removed with a post puller or forceps. The post can be drilled out, but great care is needed to avoid deviation. This technique is best limited to relatively short fractured posts. Masseran Technique  Uses special hollow end-cutting tubes or trephines to prepare a thin trench around the post. 

Cementation of Post and Core  A rotary (lentulo) paste filler or cement tube is used to fill the canal with cement.   The post is first coated with cement. It is important that the luting agent fill all dead spaces within the root canal system. The post and core is inserted gently to reduce hydrostatic pressure, which could cause root fracture. It is recommended that a groove be placed along the side of the post to allow excess cement to escape, if a parallel-sided post is being used.