Tech. for immediate core build up in endo treated teeth/ dental implant courses

Techniques for immediate core buildup ofTechniques for immediate core buildup of
endodontically treated teethendodontically treated teeth
INDIAN DENTAL ACADEMYINDIAN DENTAL ACADEMY
Leader in continuing Dental EducationLeader in continuing Dental Education
www.indiandentalacademy.comwww.indiandentalacademy.com

 IntroductionIntroduction
 Historical developmentHistorical development
 Need for restoration of endodontically treated teethNeed for restoration of endodontically treated teeth
 Important questionsImportant questions
 Treatment planTreatment plan
 Successful designSuccessful design
 Ideal propertiesIdeal properties
 Materials usedMaterials used
 Core materialCore material
 Article properArticle proper

 History :History :
• 1747,1747, Pierre FauchardPierre Fauchard –fabricated posts of gold /–fabricated posts of gold /
silver & held in the root canal with a heat softenedsilver & held in the root canal with a heat softened
adhesive called “Mastic”.adhesive called “Mastic”.
• Crowns used were made up of bone, ivory, animalCrowns used were made up of bone, ivory, animal
teeth,& sound natural tooth crowns – slowly replacedteeth,& sound natural tooth crowns – slowly replaced
by porcelain.by porcelain.
• Pivot (post) crown –Pivot (post) crown –Dubous de ChemantDubous de Chemant
• Seasoned wood (white hickory) pivots –Seasoned wood (white hickory) pivots – ProtheroProthero
• Metal – threads, pins, surface roughening.Metal – threads, pins, surface roughening.
• No cements available to enhance these posts.No cements available to enhance these posts.
• Sir John Tomes (1849)- post length & diameter.Sir John Tomes (1849)- post length & diameter.

 Need for restoration :Need for restoration : J.Prostho Dent 1992;67:458-67J.Prostho Dent 1992;67:458-67
• Moisture control;Moisture control;
-moisture content of coronal dentin > radicular dentin-moisture content of coronal dentin > radicular dentin
((↓ tubules , greater inorganic substrate)
-Battistone & Burnett stated moisture loss from
endodontically treated teeth is irreversible.
2) Architectural changes;
-substantial dentin removal – doesn’t weaken the
tooth (prep for post does)
-tooth stiffness is compromised, due to the result of
alteration in the coronal area.

3)3) Biomechanical behavior ;Biomechanical behavior ;
-Acc. to Tidmarsh, intact tooth is a hollow, laminated structure-Acc. to Tidmarsh, intact tooth is a hollow, laminated structure
that deforms under load, the structure may shorten, its sidethat deforms under load, the structure may shorten, its side
may bulge, & its cusps may be wedged apart by opposingmay bulge, & its cusps may be wedged apart by opposing
cusps.cusps.
-physiologic loading recovery is possible but excessive load may-physiologic loading recovery is possible but excessive load may
lead to permanent deformation.lead to permanent deformation.
4)4) Dentinal toughness ;Dentinal toughness ;
-elastic modulus for dentin – 1.90 x 10-elastic modulus for dentin – 1.90 x 1066
psipsi
-average tensile strength – 7.0 x 10-average tensile strength – 7.0 x 1033
psipsi
-compressive / breaking strength – 43.0 x 10-compressive / breaking strength – 43.0 x 1033
psipsi
-fracture toughness depends on tubule orientation, angle & force-fracture toughness depends on tubule orientation, angle & force
of load, nature of the collagen fibrils.of load, nature of the collagen fibrils.
-as it exhibits considerable plastic deformation, so it is a weak,-as it exhibits considerable plastic deformation, so it is a weak,
biologic ductile material which vary in strength & toughness.biologic ductile material which vary in strength & toughness.

5)5) Collagen alteration ;Collagen alteration ;
-collagen forms the organic matrix of the dentin, with-collagen forms the organic matrix of the dentin, with
inorganic calcium phosphate salts impregnated in theinorganic calcium phosphate salts impregnated in the
matrix.matrix.
-changes in the cross links b/w the fibers – brittleness-changes in the cross links b/w the fibers – brittleness
of the pulpless teeth.of the pulpless teeth.

Which post design produces the greatest retentionWhich post design produces the greatest retention ??
• Classification:Classification:
I)I) a. custom madea. custom made
b. prefabricatedb. prefabricated
II)II) a. activea. active
b. passiveb. passive
III)III) a. metala. metal
b. carbonb. carbon
c. fiber reinforced compositec. fiber reinforced composite
d. ceramicd. ceramic
e. thermoplastice. thermoplastic

IV)IV) PrefabricatedPrefabricated
a) i. smootha) i. smooth
ii. Serratedii. Serrated
iii. Threadediii. Threaded
b) i. parallelb) i. parallel
ii. Taperedii. Tapered
c) i. solidc) i. solid
ii. Spilt shank.ii. Spilt shank.
 Threaded parallel > serrated parallel > cemented tapered.Threaded parallel > serrated parallel > cemented tapered.

What is the proper length for a postWhat is the proper length for a post ??
1)1) ¾ th root length for long rooted teeth.¾ th root length for long rooted teeth.
2)2) For average length – 5mm apical sealFor average length – 5mm apical seal
3)3) Post –at least 4 mm apical to bone crest to reducePost –at least 4 mm apical to bone crest to reduce
dentin stress.dentin stress.
4)4) Molar post should not be extended > 7mm into theMolar post should not be extended > 7mm into the
root canal apical to base of the pulp chamber.root canal apical to base of the pulp chamber.

How much gutta-percha should be removed to retainHow much gutta-percha should be removed to retain
apical sealapical seal ??
 Mattison et al (1984);Mattison et al (1984);
3mm – 7mm apical GP (av. 5mm)3mm – 7mm apical GP (av. 5mm)
 Nixon et al (1991)Nixon et al (1991)
4mm – 7mm apical GP (av.6mm)4mm – 7mm apical GP (av.6mm)

Can GP be removed immediately & post spaceCan GP be removed immediately & post space
preparedprepared ??
 adequate GP condensation can be removed.adequate GP condensation can be removed.
What instruments remove GP without disturbing theWhat instruments remove GP without disturbing the
apical sealapical seal ??
 Gate-Glidden burGate-Glidden bur
 Paeso reamerPaeso reamer
 Warm pluggerWarm plugger
 GPX bur (Brassler,Georgia)GPX bur (Brassler,Georgia)

Does the use of a cervical ferrule (circumferential bandDoes the use of a cervical ferrule (circumferential band
of metal) that engages tooth st. help prevent tooth #of metal) that engages tooth st. help prevent tooth # ??
Ferrule – Brown (1993)Ferrule – Brown (1993)
Iron (Ferrum) & Bracelets (Viviola)Iron (Ferrum) & Bracelets (Viviola)
““it is a metal ring / cap used to strengthen the end of ait is a metal ring / cap used to strengthen the end of a
stick / tube”stick / tube”
Dental ferrule is an encircling band of cast metalDental ferrule is an encircling band of cast metal
around the coronal surface of the tooth.around the coronal surface of the tooth.
Two types;Two types;
a) crown ferrule imp. for # resistancea) crown ferrule imp. for # resistance
b) core ferruleb) core ferrule
-effectiveness-effectiveness ↑ by grasping larger amounts of tooth st.
-best- 2mm or more of tooth st.is covered as a ferrule.www.indiandentalacademy.comwww.indiandentalacademy.com

 Treatment planning :Treatment planning :
• Good apical sealGood apical seal
• No sensitivity to pressureNo sensitivity to pressure
• No exudateNo exudate
• No fistulaNo fistula
• No apical sensitivityNo apical sensitivity
• No active inflammationNo active inflammation
• Selection of restorative procedureSelection of restorative procedure
-remaining tooth st.-remaining tooth st.
-anatomic position of the tooth-anatomic position of the tooth
-functional load on the tooth-functional load on the tooth
-esthetic requirement-esthetic requirement

 Six features for a successful design :Six features for a successful design :
• Apical sealApical seal
• Minimal enlargementMinimal enlargement
• LengthLength
• StopStop
• AntirotationAntirotation
• Margin designMargin design

 Core material used :Core material used :
-Material should posses ;-Material should posses ;
• High compressive strengthHigh compressive strength
• Dimension stabilityDimension stability
• Ease manipulationEase manipulation
• Short setting timeShort setting time
• An ability to bond to both tooth & postAn ability to bond to both tooth & post
a)a) Cast core;Cast core;
- metal- metal ↑ root #
- ceramic to zirconia dowels- ceramic to zirconia dowels

b) Amalgam coreb) Amalgam core
c) Composite resin corec) Composite resin core
d) Glass ionomer;d) Glass ionomer;
-significant sound dentin-significant sound dentin
-with additional retention pins-with additional retention pins
-moisture control is assured-moisture control is assured
-caries control-caries control
e) Resin modified GICe) Resin modified GIC

Techniques for immediate core buildup ofTechniques for immediate core buildup of
endodontically treated teethendodontically treated teeth
Reviews the ;Reviews the ;
a)a) Microbiologic emphasizing on chair sideMicrobiologic emphasizing on chair side
b)b) Prosthetic restorative materials.Prosthetic restorative materials.
c)c) MechanicalMechanical
d)d) Periodontal aspectsPeriodontal aspects
 Materials used are ;Materials used are ;
a)a) AmalgamAmalgam
b)b) Resin compositeResin composite
c)c) Glass ionomer.Glass ionomer. www.indiandentalacademy.comwww.indiandentalacademy.com

 Presented three clinical cases using three differentPresented three clinical cases using three different
techinques ;techinques ;
For short chair side time for crown fabricationFor short chair side time for crown fabrication
In first two cases with provosional acrylic resinIn first two cases with provosional acrylic resin
shells :shells :
a) custom made used to house amalgam coronala) custom made used to house amalgam coronal
b) prefabricated -radicular dowel coreb) prefabricated -radicular dowel core
Third case :Third case :
-copper band was used for a composite post & core-copper band was used for a composite post & core
build upbuild up

Microbiologic , prosthetic , & mechanical aspect :Microbiologic , prosthetic , & mechanical aspect :
a)a) Coronal microleakage leads to endodontic failure, inCoronal microleakage leads to endodontic failure, in
cases of inadequate marginscases of inadequate margins
b)b) Pulpless teeth have weak buccal & lingual walls,Pulpless teeth have weak buccal & lingual walls,
lacking adequate supportlacking adequate support
c)c) Reduced amount of dentin, damage to the anatomicReduced amount of dentin, damage to the anatomic
st. leads to loss of internal strengthst. leads to loss of internal strength→ prone to #prone to #
d)d) If wall after preparation is 1mm or less, it should beIf wall after preparation is 1mm or less, it should be
removedremoved

e)e) Lost tooth core, retention means are;Lost tooth core, retention means are;
i) pulp chamber wallsi) pulp chamber walls
ii) coronal-radicular spaceii) coronal-radicular space
iii) undercutsiii) undercuts
iv) parapulpar pinsiv) parapulpar pins
v) postsv) posts
 Tooth strength following endo treatment is directlyTooth strength following endo treatment is directly
proportional to the remaining dentin.proportional to the remaining dentin.
 2-3mm of prepared dentin beyond finish line2-3mm of prepared dentin beyond finish line
provides essential ferrule effect (avg 1.5mm byprovides essential ferrule effect (avg 1.5mm by
Lenchner &Lenchner)Lenchner &Lenchner)www.indiandentalacademy.comwww.indiandentalacademy.com

Biologic width :Biologic width :
- it a mandatory rule to maintain the width- it a mandatory rule to maintain the width
- violation may result in irreversible damage to the- violation may result in irreversible damage to the
attachment apparatus.attachment apparatus.
ac-alveolar crestac-alveolar crest
bw-biologic widthbw-biologic width
dd-deepest destructiondd-deepest destruction
fcm-final crown marginfcm-final crown margin
fcb-final bottom of sulusfcb-final bottom of sulus

Materials used in the study ;Materials used in the study ;
a)a) AmalgamAmalgam
b)b) Resin compositesResin composites
c)c) Resinmodified glass ionomers.Resinmodified glass ionomers.
Kovarik et al;Kovarik et al;
-amalgam –highest compressive strength (65,000 psi)-amalgam –highest compressive strength (65,000 psi)
-bulk of amalgam contributes to retention & resistance-bulk of amalgam contributes to retention & resistance
when using the amalgam coronal-radicular dowel &when using the amalgam coronal-radicular dowel &
core technique. (particular to molars)core technique. (particular to molars)
-Nayyar et al & kane et al ;this technique is ideal when-Nayyar et al & kane et al ;this technique is ideal when
dealing with 3-4 walls with min thickness of 1mmdealing with 3-4 walls with min thickness of 1mm
after preparationafter preparation
-can be bonded to improve marginal seal & core reten.-can be bonded to improve marginal seal & core reten.www.indiandentalacademy.comwww.indiandentalacademy.com

 Resin composites, compressive strength- 45,000 psiResin composites, compressive strength- 45,000 psi
-tendency to absorb liquids, including saliva & the-tendency to absorb liquids, including saliva & the
microorganisms it containsmicroorganisms it contains
-requires moisture control-requires moisture control
-application of bonding-application of bonding
-curing in layering & stages-curing in layering & stages
-reliable curing device-reliable curing device
 GIC- compressive strength- 25,000 psiGIC- compressive strength- 25,000 psi
-due its fluoride content, its restorations prevents-due its fluoride content, its restorations prevents
secondary caries.secondary caries.
-isolated & clean working area-isolated & clean working area

Use of posts for immediate core restorations :Use of posts for immediate core restorations :
Factors effecting the retention of prefabricated post;Factors effecting the retention of prefabricated post;
a)a) Post lengthPost length
b)b) Post diameterPost diameter
c)c) Luting agentLuting agent
d)d) Canal formCanal form
e)e) Canal & tooth mode of preparationCanal & tooth mode of preparation
f)f) Position of the tooth in the archPosition of the tooth in the arch

 Post length – root length & its curvature should notPost length – root length & its curvature should not
exceed more than 3/4exceed more than 3/4thth
of the root length or violate theof the root length or violate the
apical 4-5mm of GP.apical 4-5mm of GP.
 Post should be adapted to the longitudinal axis of thePost should be adapted to the longitudinal axis of the
toothtooth
 of minimal dia to preserve the remaining dentinof minimal dia to preserve the remaining dentin
There is no ideal post capable of providing optimumThere is no ideal post capable of providing optimum
retention in all clinical situation.retention in all clinical situation.

 Case -1Case -1 : custom – made provisional acrylic resin: custom – made provisional acrylic resin
crown for an immediate amalgam restorationcrown for an immediate amalgam restoration

 Presence of two thick walls & significant pulpPresence of two thick walls & significant pulp
chamberchamber
 Occusal portion of provisional crown is removedOccusal portion of provisional crown is removed

 Shell is placed on the tooth & cemented withShell is placed on the tooth & cemented with
temporary cement (internal cervical margins)temporary cement (internal cervical margins)
 Wedge can also placed for more retention whileWedge can also placed for more retention while
condensationcondensation
 2-3mm of GP removed & cavity conditioner2-3mm of GP removed & cavity conditioner
(polyacrylic acid was applied) & amalgam condensed(polyacrylic acid was applied) & amalgam condensed

 Occlusion adjusted & several days the shell isOcclusion adjusted & several days the shell is
removed by placing a vertical groove.removed by placing a vertical groove.

 Tooth reprepared, the shell was relined & fitted to theTooth reprepared, the shell was relined & fitted to the
toothtooth
 Tooth is ready for final preparationTooth is ready for final preparation

 Final preparationFinal preparation

 Case 2Case 2 – use of prefabricated provisional acrylic-resin– use of prefabricated provisional acrylic-resin
crown for an immediate amalgam restoration.crown for an immediate amalgam restoration.

 Used polycarbonate crown (3M)Used polycarbonate crown (3M)
 Screw post (Surtex)Screw post (Surtex)
 Occlusal adjustmentOcclusal adjustment

 Separation of crownSeparation of crown
 Tooth prepared & provisional crown relined & fittedTooth prepared & provisional crown relined & fitted

 Impression was taken for fabrication of a porcelain –Impression was taken for fabrication of a porcelain –
fused –to metal crown.fused –to metal crown.

 Case 3Case 3 : use of copper band for an immediate: use of copper band for an immediate
composite build-up restoration :composite build-up restoration :
-followed by # of a large restoration-followed by # of a large restoration
-a copper band was made as a frame for core build up-a copper band was made as a frame for core build up

 Canal was prepared to receive a reinforced fiberglassCanal was prepared to receive a reinforced fiberglass
post (Fibrekor)post (Fibrekor)
 Root dentin etched for 15 secs ,washed, dried & aRoot dentin etched for 15 secs ,washed, dried & a
bonding agent was used & cured for 10 secsbonding agent was used & cured for 10 secs

 The post was fitted & cemented with a resin basedThe post was fitted & cemented with a resin based
adhesive (Rely X ARC,3M) & light cured for 40 secsadhesive (Rely X ARC,3M) & light cured for 40 secs
from occlusal aspect.from occlusal aspect.
 The buccal wall of the band was cut by a tungsten drillThe buccal wall of the band was cut by a tungsten drill

 Additional curing of 40 secsAdditional curing of 40 secs
 Restored tooth was prepared & fabrication of finalRestored tooth was prepared & fabrication of final
crown.crown.

 ConclusionConclusion ::
• Amalgam without post – molarsAmalgam without post – molars
- with provisional crown shell ;- with provisional crown shell ;
a)a) Simple techniqueSimple technique
b)b) Prevents insult to the attachment apparatusPrevents insult to the attachment apparatus
c)c) Enables initial prep of tooth,thereby determiningEnables initial prep of tooth,thereby determining
kind of post & core restoration, possible to removekind of post & core restoration, possible to remove
thin & weak walls for adequate build up.thin & weak walls for adequate build up.
d)d) Allows the pt to function with the provisional crownAllows the pt to function with the provisional crown
till the amalgam reaches its max strength.till the amalgam reaches its max strength.
e)e) Maintains contact points & prevents intra &Maintains contact points & prevents intra &
intermaxillary occlusal changes.intermaxillary occlusal changes.
f)f) Reduces gingival staining.Reduces gingival staining.

Tech. for immediate core build up in endo treated teeth/ dental implant courses

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