Clinical Conservation: by mohammed ali

Treatment planning

In general, post is indicated when there is a little or no coronal

tooth structure after endodontic treatment.

When there is a lot of remaining coronal structure, placing a post

become arguable, some some dentists prefer placing post even if the
coronal structure is preserved, to prevent cervical fracture.

Placing post and core system should be done on successful

endodonticlly treated tooth.

The position of the reamer should be centered in the root canal

filling material to avoid perforation.

Pretreatment Evaluation:

1- Quality of the endodontic treatment:

The endodontic treatment should be properly done.

Retreatment should be considered if tooth exhibits any clinical

signs of inflammation, a periapical pathology exists, or inappropriate
endodontic filling material was used ( silver pointes).

2- Periodontal condition:

This is important for long-term success of teeth.

Weak teeth should be extracted.

A mutilated tooth in which the restorative treatment would

violate the junctional epithelium or the attachment level (e.g.
extensive caries, perforations, external root resorption) should be
considered for crown- lengthening surgery or orthodontic extrusion.
4- The amount of remaining coronal tooth structure:

More than half conservative treatment with coronal restorations

without posts.

minimal post, core, and definitive restoration.

The functional load on the tooth:

The post, core, and crown system is indicated, when more extensive
protective and retentive features are required in the restoration:

1 Bruxism and heavy occlusion.

2 Abutment teeth for long-span

fixed bridges.

3 Abutment teeth for free end

removable partial denture.

5- Esthetic zone (Anterior teeth, premolars, and often 1 st

molar) requires:

2 Careful selection of restorative

materials.

3 Careful handling of the tissues.

4 Timely endodontic intervention to

prevent darkening of the root as it
looses vitality.

Considerations for anterior teeth

Anterior teeth do not always need complete coverage,

except when plastic restorative materials would have
limited prognosis in view of the extent of coronal
destruction. Many function with composite resin
.restorations

when the tooth is loaded, stresses are greatest at the

facial and lingual surfaces of the root and an internal post,
being only minimally stressed, does not help prevent
fracture

considerations for posterior teeth

Endodontically treated posterior teeth are subject to

greater loading than anterior teeth are because of their
position closer to the insertion of the masticatory muscles.
This, combined with their morphologic characteristics,
.makes them more susceptible to fracture

Complete coverage is recommended on teeth with a high

risk of fracture, especially maxillary premolars, because
complete coverage gives the best protection against
fracture

Post Length

Since 5 mm of gutta-percha should be retained apically to

ensure a good seal (as measured radiographically), posts
should be extended to that length in all teeth except
.molars
With molars, posts should be placed in the primary roots
(palatal root of maxillary molars and distal roots of
mandibular molars) and should not be extended more
than 7 mm apical to the origin of the root canal in the
base of the pulp chamber. Extension beyond this length
can lead to root perforation or only very thin areas of
.remaining tooth structure

?WHAT IS THE PROPER LENGTH FOR A POST

A wide range of recommendations have been made

:regarding post length, which includes the following
 The post length should equal the incisocervical or (1)
.occlusocervical dimension of the crown
.The post should be longer than the crown (2)
.The post should be one and one-third the crown length (3)
.The post should be half the root length (4)
.The post should be two-thirds the root length (5)
.The post should be four-fifths the root length (6)
The post should be terminated halfway between the (7)
.crestal bone and root apex

:Short posts

lead to greater stress at the coronal aspect of the canal

and are more susceptible to dislodgement or root fracture.
Very short posts, those ending in the cervical third of the

canal, are associated with a high number of vertical root

fractures

The diameter of the post

should be kept to a minimum, consistent with the rigidity

.required and the width of the endodontic obliteration

Preservation of natural root structure will maintain

maximum tooth strength. It is also essential to maintain

the integrity of the endodontic obliteration

Custom made posts considered more conservative that ready-

made post, but when they are made of extremely rigid materials such
zirconia, they endanger the root specially weakened one.

Tapered posts are most conservatives but they have inferior

retention and stress distribution properties, parallel posts are less
conservative at apical part and case stress concentration at this area,
parallel side with tapered end posts considered the best design
 The new customized ready-made fiber posts like (everstick) have
the conservative and adaptive advantages of custom posts and the
favored stresses of fiber posts

preparation-

a. Radicular preparation

-minimal root canal enlargement

-over enlargement can weaken the root

b. Coronal preparation

-maintain the coronal tooth structure as much as possible

-only caries and undermined enamel should be removed

Preparation should be started with smaller reamer size

available and gradually sized up

The position of the reamer should be centered in the root canal

filling material to avoid perforation

The Ferrule

placed on a tooth with optimal ferrule, the crown and root

function as one It is a 360 degree circumferential ring of
sound tooth structure that is enveloped by the cervical
portion of the crown restoration. A minimum sound
dentine height of 1.5-2 mm apically to the junction
between the core and the remaining part of the tooth
. structure

When a crown is integrated unit and occlusal forces are

transmitted in normal physiological fashion to the
periodontium. Where inadequate ferrule exists, occlusal
stresses are transferred directly to the core and/or post
with high likelihood of tooth, root or post fracture or post
. dislodgement due to the effect of the tapered post
In such cases adequate circumferential tooth structure
:can best be gained by

.a) Forced orthodontic eruption

. b) Surgical crown lengthening

c) sub-gingival preparation and prolonged

temporization( in selected cases ) to allow reestablishment
.of the biological width

The orthodontic extrusion in case of no sound tooth

structure is accessible is the preferred procedure more
than the surgical lengthening that affect the crown root
. ratio

: So the ferrule to be formed it should be

1. Minimum of 1.5 2 mm in height.

2. Have parallel walls .
3. Completely encircle the tooth .

The ferrule must not be less than 1.5 -2 mm in labial

and palatal surfaces because of high forces directed in the
. labio-palatle direction while it can be limited to 0.5mm

Importance of ferrule

1. Antirotation effect.
2. Decrease risk of fracture without ferrule..improve the
pognesis .

Binds the tooth structure together

Consequences of Inadequate Ferrule

Catastrophic root fracture

Cement failure and post loosening

Post fracture
Effect of ferrule and post placement on fracture resistance of
endodontically treated teeth after fatigue loading (j o u r n a l o
f d e n t i s t r y 4 1 ( 2 0 1 3 ) 2 0 7 2 1 5(

Objectives: To evaluate the influence of the ferrule effect (1)

and the fibre-post placement (2) on the fracture resistance of

endodontically treated teeth subjected to cyclic fatigue loading

Methods:

40 extracted single-rooted upper pre-molars were sectioned at

the CEJ (groups a and b) or 2 mm above the CEJ (groups c and
d), and subsequently endodontically treated. After 24-h water
storage at 37 8C, specimens were restored according to four
build-up approaches (n = 10 per group):

(a) NFNP (no ferrule, no post),

(b) (b) NFP (no ferrule, fibrepost),

(c) (c) FNP (ferrule, no post) and

(d) FP (ferrule, fibre post)

RelyX Posts (3M-ESPE) were

used in groups NFP and FP, and were cemented with Panavia F
2.0

(Kuraray).

A standardized composite core was built, after which specimens

were restored with an all-ceramic crown (IPS Empress CAD,
Ivoclar-Vivadent)

Fatigue loading

Specimens were embedded in methacrylate resin at 2 mm from

the CEJ to simulate the bone level and submitted to a fatigue
load of 1,200,000 cycle under water irrigation using a chewing
simulator with sliding movement (Willytech, Germany),
simulating 5 years of clinical function.

Load was applied at 458 at a frequency of 1.6 Hz. A sinusoidal

load of 050 N was applied with a stainless-steel ball-shaped
stylus in the centre of the occlusal area of the crown.

Failures under fatigue loading were recorded during testing by

means of integrated LVDT displacement-sensors

Specimens were fatigued by exposure to 1,200,000 cycles using

a chewing simulator (Willytech). All specimens that survived
fatigue loading were fractured using a universal loading device
(Micro-Tester, Instron)

Results
Fatigue loading

Only one NFNP specimen failed during fatigue loading

because of loss of core retention. All the other specimens

survived the 1,200,000 fatigue cycles

Overall, the ferrule effect has been found to significantly affect

the fracture resistance of endodontically treated teeth

Placing a post into the root canal has not been found to be less
beneficial to increase the fracture resistance of endodonticallyt
reated teeth by Besides,

Analysis of failures showed a prevalence of repairable

failures in all groups, although a higher number of notr epairable

failures were observed in groups NFNP and FP

(Retention loss of the core in NFNP during fatigue

loading was considered as repairable failure

Conclusions

It can be concluded that:

Endodontically treated teeth with a circumferential ferruleof 2

mm height and restored without a post may survive fatigue
loading as well as teeth restored with a fibre post.

However, in teeth where a ferrule is not preserved, a post may

eventually improve retention of the restoration.

Avoiding extra-removal of sound tooth structure rather than

using a fibre posts does protect endodontically treated teeth
against catastrophic failures,
 since only endodontically treated teeth with a 2 mm ferrule and
restored without fibre posts did not show not-repairable root
fractures

Inserting a fibre post seems not to be necessary to improve

the fracture resistance of endodontically treated teeth in

which a ferrule is preserved, whereas is effective in teeth

without any ferrule

What monoblock

It is the ability of every component of tooth and restorative

material to act as one unit.

it is achieved by

adhesion

modulus of elastisity

coefficient of thermal expansion

The combined use of a core material and a cement/sealer in

contemporary endodontic obturations and fiber post adhesion introduces

additional interfaces into a monoblock. Monoblocks are those that have

two circumferential interfaces, one between the cement and dentin, the

.other between the cement and the core material

Monoblock is to function successfully as a mechanically

homogenous unit. First, the materials that constitute a monoblock should

have the ability to bond strongly and mutually to one another, as well as
to the substrate with which the monoblock is intended to reinforce.

Second, these materials should have moduli of elasticity that are similar

to the substrate. With the increase of the moduli of elasticity of the

different cements , the stress concentrations in the root dentin decreased

from 24.5 MPa to 20.8 MPa. When Panavia F , a heavily filled resin

cement with an elastic modulus 18.3 GPa was used that was similar to

the modulus of elasticity of dentin, the respective stress concentrations

in the root dentin were lower (20.9 MPa and 20.8 MPa). This is because

some of the stresses were redistributed to the cement layer . On the

contrary, when Superbond C&B cement (elastic modulus 1.8 GPa) and a

glass ionomer cement (elastic modulus 4.0 GPa) were used for

cementation, high stress concentrations were found in the root dentin

( stress 24.5 MPa and 23.6 MPa, respectively). These stresses were

directly transferred to the root dentin as the stress concentrations within

. the cement layers were low

Important conclusions could be derived with respect to the

interaction between dentin adhesion and elastic moduli of the materials
.employed

Although zinc phosphate cement demonstrated push out

strengths comparable with other resin cements for the cementation of
titanium or fiber posts , (its elastic modulus was close to that of dentin
and its stress concentrations in dentin were low), posts cemented with
zinc phosphate cements often failed because of the cements relatively
great elastic modulus, fragility and low bonding potential to the root
. dentin and the post surfaces

This explains why roots reinforced with posts that were cemented
with dentin adhesives are more fracture resistant than those cemented
. with zinc phosphate cements

Likewise, the lower modulus of elasticity of glass ionomer cements

also explains why they are less efficient than dentin adhesives and
composites in strengthening immature roots and roots bonded with
. quartz-coated carbon fiber posts

The first implied existence of a mechanically homogeneous

monoblock in the root canal space was reported with the bonding of
. epoxy resin-based, carbon fiber-reinforced posts to root dentin

The carbon-fiber posts, having a modulus of elasticity very similar

to the modulus of elasticity of dentin, can achieve a tooth-post-core
monoblock instead of an assembly of heterogeneous materials. This
should help to distribute masticatory loads homogeneously and reduce
.stresses during function

The epoxy resin embedding matrix in older generations of fiber

posts is also replaced with highly cross-linked, oxygen inhibition layer-
free methacrylate resin matrices that, theoretically, have the potential to
. bond to methacrylate-based resin cements
Different modalities of surface treatments of posts are also
available to render these newer generations of fiber posts more
conducive to bonding to methacrylate-based resins. Although the use of
these newer generations of fiber posts has not yet attained the scientific
rigor of an ideal monoblock. This is probably due to the similarity in the
.moduli of elasticity between fiber posts and root dentin

-: Ideal monoblock

resin cement + resin fiber post + Resin Core Material and

crown