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Restorative considerations for endodontically treated teeth . ADA Meeting 19 July 2011. www.endodonticpractice.co.nz. Endodontics.

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restorative considerations for endodontically treated teeth

Restorative considerations for endodontically treated teeth.

ADA Meeting

19 July 2011

www.endodonticpractice.co.nz

endodontics
Endodontics
  • The branch of dentistry that deals with maintaining healthy dental pulp in a state of health and the treatment of diseased dental pulp to promote healing and restoring the health of the tooth and the surrounding peri-radicular tissues to maintain the function and aesthetics of the teeth.
the consultation
The Consultation

- History

- Exam

- Diagnosis

- Treatment plan

- Treatment

- Recall

the plan
The Plan

Coronal Restoration

- Remaining tooth structure

- Periodontium

- Strategic importance

- Occlusion

- Material(s)

- Additional Retention

- Nayyar technique

- Posts?

- PINS

Root Canal Treatment

- Non-surgical

- Surgical

posts
Posts

Posts DO NOT strengthen root filled tooth

They retain the core

NO POST is the best option

However……….

posts7
Posts
  • Type - Prefabricated not cast post
posts8
Posts
  • Shape – Parallel sided not tapered
posts9
Posts
  • Length – Long not short

The Crowbar Effect

posts10
Posts
  • Diameter – Debatable α material
posts11
Posts
  • Material – Rigid and not flexible

Gold, fibre such as carbon, glass, or even zirconia, or stainless steel, or titanium

posts12
Posts
  • Design – Serrated (not smooth or screw type)

Screw

Serrated

Smooth

posts13
Posts
  • Cement – Type and amount

Whatever type of cement that is used for the post it t must fit loosely in the canal. If you are a getting a tug back with your post, you have a problem.

clinical guidelines
Clinical Guidelines
  • Prefabricated
  • Long
  • Thick
  • Serrated
  • Parrallel
  • Rigid
  • Cement
final restoration core
Final Restoration/Core

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direct restoration
Direct restoration
  • Amalgam
  • Advantages
  • - Proven track record
  • - Quick and easy to place
  • - Relatively Inexpensive
  • - Good coronal seal
  • Disadvantages
  • - Mercury
  • - Colour
  • - Does not bond to teeth
  • - Require retentive features
direct restoration19
Direct restoration
  • Composite
  • Disadvantages
  • - Technique sensitive
  • - Coronal leakage
  • Advantages
  • - Matches tooth colour
  • - Less toxic
  • - Minimal preparation
  • - Bonds to teeth
slide20

Direct restoration

  • Glass Ionomer
  • Disadvantages
  • - Technique sensitive
  • - Weak
  • Advantages
  • - Matches tooth colour
  • - Less toxic
  • - Minimal preparation
  • - Moisture tolerant
  • - Releases flouride
slide21

In-direct restoration

  • Indirect CAD/CAM – CD4, Cerec
  • Advantages
  • - Matches tooth colour
  • - Less toxic
  • - Quick turn-around
  • - Bonds to teeth
  • Disadvantages
  • - Technique sensitive
  • - Brittle
  • - Cost - set up
      • - patients
slide22

In-direct restoration

  • Indirect lab based – Gold, PFM, PJC, Zirconia
  • Advantages
  • - Matches tooth colour
  • - Less toxic
  • - Good seal
  • - Restores tooth resistance
  • Disadvantages
  • - Time consuming
  • - Brittle – (Porcelain)
  • -Cost
  • - Delayed
slide24

A virgin tooth is prestressed where the cusps are in constant tension pushing towards each other to allow for the flexing occlusal forces.

  • Occlusalfilling – 20 %. I will happily replace this with amalgam or composite.
  • MO or DO – 40 % I would restore them with amalgam or composite. However as soon as you roughly lose just over 2/3(M-D) x 1/3 (B-L) of the tooth I would seriously consider cusp capping with amalgam or composite
  • MOD – 60 % At this stage, I will do a full coverage restoration with amalgam or composite
  • If a cusp is missing then the ability to withstand fracture reduces even further.
  • When restoring a tooth, one must look at the remaning tooth structure and then decide what filling they will do. This is the primary determining factor.
  • The aim of the game to restore the tooth to as close to its original state.
do all root filled teeth require crowns
Do all root filled teeth require crowns?
  • The routine use of posts and cores in anterior teeth is not required unless there is gross loss of coronal tooth structure. In fact there is lesser leakage with a bonded composite that a post core and crown. If you are going to make a veneer, you are better off making a crown. Generally too much tooth structure is lost to make a nice veneer so crown the tooth especially if it is heavily filled
  • Root canal treated posterior teeth, usually needs a crown when they are cusp capped. As a general rule, It can increase the chances of success by 6-11 fold.
  • In any case the core material that is used does not matter if there is sufficient tooth structure to provide a ferrule effect.
the ferrule
The Ferrule

When using a core build up in either anterior or posterior teeth, ideally there must be at least 2 mm of sound tooth structure above the free gingival margin for the placement of a crown. This is the ferrule. This increases the resistance of teeth to fracture and also allows for the margins from getting plaque accumulation and subsequent secondary decay. 1mm ferrule double the resistance to fracture. Uneven ferrule is better than no Ferrule. So don’t pick up that bur and trim the last remaining millimetre of supra-gingival tooth just so that your cast post is easier to fit.

crown l engthening surgery
Crown Lengthening Surgery
  • 1.0 mm cemetal-fibrous interface,
  • 1.0 mm epithelial attachment,
  • 1.0 mm sulcus
  • 1.0 mm finishing margin

= 4.0 mm above crestal bone

Orthodontic extrusion is better than CLS

how long before a crown
How long before a crown
  • Review in 6 months to check for healing. If no change. Review in another six months.
  • Crown when healing visible at the recall.
  • If crowning will reduce the chances of leakage such post core crown for anteriors. Crown immediately after RCT.
the coronal seal
The Coronal Seal

The coronal seal is NO more important than the root filling itself.

Coronal seal

Adequate root filling

clinical guidelines31
Clinical Guidelines
  • Timing of final restoration
  • Tooth fracture prior to final restoration;
  • Inadequate final restoration
    • lacks ideal marginal integrity
    • forces of occlusalfunction
    • deterioration
  • Recurrent decay
pathway to success
Pathway to success
  • Correct diagnosis

www.endodonticpractice.co.nz

pathway to success36
Pathway to success
  • Rubber dam isolation

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pathway to success37
Pathway to success
  • Adequate Access
pathway to success38

MB 2 is Not a Myth!!

Pathway to success
  • Locate all the canals

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pathway to success39
Pathway to success
  • Thorough chemo-mechanical preparation
pathway to success40
Pathway to success
  • Well constructed provisional restoration
pathway to success41
Pathway to success
  • Unidentified Iatrogenic damage

Perforation

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pathway to success42
Pathway to success
  • Produce an acceptable root filling and construct a good coronal seal
outcomes
Outcomes
  • Favourable - Healing

- Pre-operative PA area 73%-97%

- More than 2 roots 84%

- No pre-operative PA area 88%-97%

- Single rooted teeth 93%

  • Overall
      • Healing 41% - 86%
conclusion
Conclusion
  • Each case must be treated on its own merit
  • There is no “recipe” to ensure success
  • Ensure correct informed consent
  • Refer if unsure

“Do or do not... there is no try.” – Yoda

www.endodonticpractice.co.nz