evolution and integration of current restorative endodontic … · 2008. 5. 1. · dr. gad zyman...

Dr. Enrique Kogan

Dr. Enrique Kogan received his dental degreefrom the Universidad Tecnologica de Mexico in1978. He went on to complete a specialty pro-gram in fixed prosthodontics at the University ofMissouri-Kansas City from 1978 to 1980. From1980 to 1998 he was a professor at the Univer-sidad Tecnologica de Mexico, and from 2004 hewas a visiting professor at the Nova Southeast-ern University School of Dentistry in Ft. Lauder-dale, FL. Dr. Kogan has lectured nationally andinternationally on adhesive dentistry, cosmeticdentistry, periodontal prosthesis, implantprosthodontics, and restoration of endodonti-cally treated teeth. He is responsible for the de-sign of the PeerlessPost system. Dr. Kogan haspublished articles on different dental themes.

Dr. Sergio Rubinstein

Dr. Sergio Rubinstein received his dental degreefrom the Universidad Tecnologica de Mexico in1980. He went on to complete a specialty programin periodontal-prosthesis at the University of Illi-nois College of Dentistry from 1980 to 1982. From1980 to 1992 he was an assistant professor at theUniversity of Illinois College of Dentistry. Dr. Rubin-stein has lectured nationally and internationally onadhesive dentistry, cosmetic dentistry, periodontalprosthesis, and implant prosthodontics and hasgiven hands-on courses in bonding techniques. Dr.Rubinstein has published articles on adhesive den-tistry and implant prosthodontics.

Dr. Gad Zyman

Dr. Gad Zyman received his dental degree fromthe Universidad Tecnologica de Mexico in 2003.He went on to complete a specialty program inprosthodontics at Nova Southeastern Universityfrom 2002 to 2005. Since then he has been in

Enrique Kogan Sergio Rubinstein

private practice. Dr. Zyman has published articles onendodontic posts in conjunction with Dr. Kogan.

T he restoration of endodontically treated teeth was advocated by G.V.Black in 18691 followed by a one-unit post and crown by Richmond2

in 1878. Engineering principles indicate that structural strength onendodontically treated teeth is decreased by the removal of the roof of thepulp chamber, canal enlargement, and hence loss of integrity. The intrinsicstrength of dentin can be diminished as a result of root canal treatmentoriginated by decay, pathology, or trauma. When endodontic treatment isindicated, one must consider that the resulting anatomy and configuration ofthe canal(s) can vary according to its original anatomy, canal access, canalenlargement, and chemomechanical preparation. In addition, intrinsic dentinstrength may be adversely affected by the absence of a pulp that results in adecrease of moisture content of dentin3,4 and consequently becoming moresusceptible to fracture than vital teeth (Figure 1).5–9

SCIENTIFIC ARTICLE

Evolution and Integration ofCurrent RestorativeEndodontic ConceptsEnrique Kogan, DDS, Sergio Rubinstein,DDS, Gad Zyman, DDS, and Alan J.Nidetz, DDS

The need to provide internal supportto the endodontically treated tooth be-foreplacementofacoronal restoration isclearlydocumented,7,8,10,11 aswell as forcoronal stabilization.5 In the past it wasadvocated to conservatively restorepulpless posterior teeth with pins andamalgam. Such technique, because ofthe friction and self-threading of thepins, produced stresses and strain untothe dentin because of the wedging ac-tion, resulting in minute fracture linesandcrazing.12–16 Lovdahl17 described in1977 that endodontically treated teethwith a conservative root canal filling andintact coronal structure were found tobe stronger than root canal–filled teethwith cast-gold dowel cores or pin-retained amalgam cores.

Before restoration, a thoroughevaluation of the affected tooth or
teeth and its remaining tooth struc-
ture most be made to form an accu-rate diagnosis. This should includethe following considerations: (1) Isthe tooth restorable? (2) What is thehealth of supporting bone and peri-odontal tissues? (3) What is the mo-bility? (4) Is at least 2 mm of soundtooth structure available for a ferruleeffect? (5) Are the quadrant, arch,and entire dentition restorable? (6)What is the relation of the tooth tothe occlusal plane? (7) What is theimportance of the tooth to the over-all treatment plan? (8) Endodonticcomplications can lead to apicoec-tomy treatment; therefore, apicalseal and post reconstruction tech-niques can influence long-termprognosis. (9) What is the cost?

For several years cast post and coreswere used to rebuild missing tooth
structure, either with an indirect tech-

EVOLUTION AND INTEGRATION OF CURRENT RESTORATIVE ENDODONTIC CONCEPTS

Alpha Omegan • Volume 100 • Number

nique when an impression is takenand a wax pattern is created and castin type 3 gold or semidirect techniquein which the pattern is created in themouth (Figure 2). In either case, criti-cal steps include the creation of a waxor acrylic pattern to be completedwith proper control of volumetricchanges and compensation from allmaterials used, such as impressionmaterial, stone, wax, or acrylic, invest-ment, casting technique, and alloyused. It is of utmost importance thatthe attained result creates a post andcore with a passive fit onto the root ortooth. Otherwise, undesirable stresswill be immediately transferred intothe root, which could lead to eventualvertical fracture and loss of the tooth.

CURRENT CONCEPTS FORRESTORATIVE SUCCESS WITHENDODONTIC-TREATED TEETH

Once endodontic success is deter-mined,18 current concepts are to re-

Figure 1. Vertically fractured root withprefabricated stainless steel post.

inforce such teeth with a bonding

3

protocol as the lost tooth structure isbeing replaced with a proper fittingand passive post which includes aself-retentive head to support acore.19

Fiber posts have been used in therestoration of endodontically treatedteeth since their introduction in thelate 1980s (COMPOSIPOST/C-POST; Recherches Techniques Den-taires, Grenoble, France).20

These fiber posts have showngood clinical behavior in differentstudies: 99% success rate in 236 pa-tients after 2 to 3 years,21 99% in 94teeth after 1 year,22 95% in 1304cases between 1 and 6 years,23 and200 cases in 4 years,24 99% in 180posts after 18 months,25 and 89.6%in 52 teeth after 6 to 48 months.26

No catastrophic failures (root frac-tures) were reported.

One author’s (E.K.) personal clin-ical data showed 95.4% success ratein 454 fiber posts placed over a pe-riod of 6 years (February 2000 to

Figure 2. Semidirect technique for fab-rication of an acrylic pattern to be castedin type 3 gold. (A) Gold cast post ce-mented with a modified resin glassionomer cement. Dentistry by SergioRubinstein, DDS.

Dr. Alan Nidetz

Dr. Alan Nidetz received his dental degree fromLoyola University School of Dentistry in 1981. Heserved as an assistant professor in the Depart-ment of Removable Prosthetics. Dr. Nidetz haslectured nationally on various subjects related toprosthetic and restorative dentistry, as well asadult orthodontics. He has given hands-oncourses in provisional restoration fabrication aswell as removable prosthetic fabrication. Dr. Ni-detz has published articles on adhesive dentistryand implant prosthodontics.

January 2006). The posts placed

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were 14 C-Post (RTD-Bisco) (case 1;Figures 3-9), 8 DT Light-Post (RTD-Bisco) (case 2; Figures 10-15), 216ParaPost Fiber-White (Coltene/Whaledent) (case 3; Figures 16-22),and 216 of the new Peerless Post(SybronEndo) (case 4; Figures 23-30). Of the 21 failures (4.6%), 8 (4Fiber-White and 4 Peerless Post)were de-bonded and 13 (6 Fiber-White and 7 Peerless Post) were postfractures.

A review of the literature of cur-rently marketed post systems,along with our own clinical expe-

Figure 3. Fracture upper first premolar.

Figure 4. Pre-op x-ray.

Figure 5. Carbon fiber posts (C-Post
-Bisco, Inc) and respective drills.
122

rience and the effect that post de-sign has on clinical success, alllend themselves to a rationale for anew post design: The PeerlessPostsystem by SybronEndo.

With current evidence-based re-search, this article describes the sim-plicity, efficiency, and safety aspectsof the Peerless Post system.

IDEAL POST DESIGNThe ideal post system or design

must consider endodontic as well asrestorative principles and includethe following.27–31

Figure 6. Carbon fiber post in place.

Figure 7. Composite core build-up.

Figure 8. Final ceramic restoration.

Alpha

Anatomical form similar to the lostdental volume

The overall, essential shape of thepost is tapered, to mimic the rootcanal treatment (Figure 31).

Figure 9. Postoperative x-ray, showingnonradiopaque post. Dentistry by En-rique Kogan, DDS.

Figure 10. Clinical view of destroyedcentral incisors.

Figure 11. Preoperative x-ray.

Omegan • Volume 100 • Number 3


Minimal (conservative) preparationThe post can be placed in the ca-

nal without further preparation afterthe endodontic therapy.

Figure 12. Fiber post (DT-Light, BiscoInc) in place.

Figure 13. Post-op x-ray after post ce-mentation.

Figure 14. Composite build-up.

Alpha Omegan • Volume 100 • Number

Adequate materialPrestressed fibers are homog-

enously distributed in a resin matrixto avoid structure defibration anddeterioration (Figure 32).32

Resistance to fatigueTesting indicates that posts with

higher content (more than 60%) ofprestressed quartz or glass fibers re-sist cyclic fatigue better than postswith less fiber (less than 50%).33 ThePeerlessPost has more than 60% ofGlass Fibers.

Figure 15. Final ceramic restorations.Dentistry by Enrique Kogan, DDS.

Figure 16. Destroyed lower left first pre-molar.

Figure 17. Pre-operative x-ray.

3

Elastic modulus similar to dentinThe elastic modulus should be 15

to 40 GPa.

NoncorrosiveUnlike base casting metals and

stainless steel, fiber post materialcannot corrode.

Retentive (post and head)The design should offer a self-

retentive body and a self-retentive,antirotation head (Figure 33).

Easy to adjust and fitThe post should allow adjust-

ments in the apical area as well as the

Figure 18. Fiber Glass posts (Coltene-Whaledent, Inc) and respective drills.

Figure 19. Fiber post in place.

Figure 20. Composite core build-up.

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coronal area, at the clinician’s dis-cretion and without compromisinglateral adaptation in the canal. Be-cause of the mechanical propertiesof the fiber posts and the reliabilityof adhesive cementation techniquesand materials, the depth of a fiberpost can be equal to or slightlygreater than the length of the clinicalcrown (Figure 34).34

Figure 21. Temporary restorations fororthodontic treatment.

Figure 22. Postoperative x-ray. Dentistryby Enrique Kogan, DDS.

Figure 23. Lateral view showing theamount of core or clinical crown to be
rebuilt.
124

Radiographically detectableThe post should be detectable by

radiography (Figure 35).

VersatileWe need different lengths, diame-

ter, and tapers to fit most clinical sit-uations (Figure 36).

Figure 24. PeerlessPost Kit (SybronEndo)

Figure 25. Prefabricated post can bemodified on either end without affect-ing the fit of the post and still maintain
retention for the core.
Alpha

Easily removableThe removal of posts can be a ma-

jor obstacle in the retreatment ofteeth that have recurrent disorders.The use of fiber posts offers the ad-vantage of an easy removal.35

CONCLUSIONSModern dental restorative treat-

ment of endodontically treated teethmust consider the preservation ofdental tooth structure. It is necessarythat from the beginning (root canaltreatment), we must use techniques

Figure 26. Lower premolar isolated withthe rubber dam.

Figure 27. Prefabricated post tried withproper isolation.

Figure 28. Occlusal view of rebuilt
tooth.

ifying interocclusal clearance.

Rubinstein, DDS.

tween the post and the prepared canal.

Figure 32. Cross-section showing fibers.

self-retentive, antirotation head.

port to withstand forces during function.

Figure 35. Radiopaque fiber posts.


Alpha Omegan • Volume 100 • Number 3

that do not remove much additionaldentinal tissue, use posts that fromits nonrigid nature reduce the risk offractures both in the root and in thepost itself, and that the adhesive ce-mentation procedure be as simple aspossible to obtain a final restorationwith a high success rate. The Peer-lessPost system is a new alternativeto the fiber post concept that offerscharacteristics not found in anyother systems.

References1. Black GV. A method of grafting artificial

crowns on roots of teeth. Mo Dent J.1869;1:233.

2. Tylman SD. Theory and practice ofcrown and bridge. Prosthodontics. 5thed. St. Louis, MO: CV Mosby Co, 1965.

3. Helfer AR, Melnick S, Schilder H. Deter-mination of the moisture content of vitaland pulpless teeth. J Oral Surg 1972;34:661.

4. Nayyar A. Walton RE, Leonard LA. Anamalgam coronal-radicular dowel andcore technique for endodonticallytreated posterior teeth. J Prosthet Dent1980;43:511–515.

5. Weine FS. Endodontic therapy. 1st ed.St Louis, MO: CV Mosby Co, 1972.

6. Johnson JK, Schwartz NL, Blackwell RT.Evaluation and restoration of endodon-tically treated posterior teeth. J Am DentAssoc 1976;93:597–605.

7. Ingle JI. Endodontics. 1st ed. Philadel-phia, PA: Lea & Febiger, 1965.

8. Rosen H. Operative procedures on mu-tilated endodontically treated teeth. JProsthet Dent 1961:11:973.

Figure 36. Color coded for easy identifi-cation of diameter and taper.

Figure 29. Buccal view in occlusion ver-

Figure 30. Radiographic view, showingexcellent fit of post. Dentistry by Sergio

Figure 31. Section of a post in place,showing the intimate adaptation be-

Figure 33. Self-retentive body and a

Figure 34. Post is measured to deter-mine length of head for ideal core sup-

9. Silverstein WH. The reinforcement of

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weakened pulpless teeth. J ProsthetDent 1964;14:372.

10. Frank AL. Protective coronal coverageof the pulpless tooth. J Am Dent Assoc1959;59:895.

11. Federick DR, Serene TP. Secondary in-tention dowel and core. J Prosthet Dent1975;34:41–47.

12. Standlee JP, Collard EW, Caputo AA.Dentinal defects caused by some twistdrills and retentive pins. J Prosthet Dent1970;24:185–192.

13. Dilts WE, Welk DA, Laswell HR, GeorgeL. Crazing of tooth structure with place-ment of pins for amalgam restoration.J Am Dent Assoc 1970;81:387–391.

14. Trabert KC, Caputo AA, Collard EW,Standlee JP. Stress transfer to the den-tinal pulp by retentive pins. J ProsthetDent 1973;30:808–815.

15. Chan KC. Comparison of dentinal craz-ing ability of retention pins and machin-ist taps. J Dent Res 1973;52:178.

16. Standlee JP, Caputo AA, Collard EW,Pollard MH. Stress distribution by end-odontic posts. J Oral Surg 1972;33:952.

17. Lovdahl PE, Nicholls JI. Pin-retainedamalgam cores vs. cast gold dowelcores. J Prosthet Dent 1977;38:507–514.

18. Bender IB, Seltzer S, Saltanoff W. End-odontic success—a reappraisal of crite-ria. Oral Surg 1966;22:780.

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20. Brown PL, Hicks NL. Rehabilitation ofendodontically treated teeth using theradiopaque fiber post. Comp Cont EducDent 2003;24:4.

21. Fredriksson M, Astback J, Pamenius M,Arvidson K. A retrospective study of236 patients with teeth restored by car-bon fiber-reinforced epoxy resin posts. JProsth Dent 1998;80:151–157.

22. Mannocci F. Fiber posts: clinical andlaboratory studies. Proceedings fromthe 3rd International Symposium. Ad-hesion and Reconstruction in ModernDentistry. 1999.

23. Ferrari M, Vichi A, Mannocci F, MasonPN. Retrospective study of the clinicalperformance of fiber posts. Am J Dent2000;13(special issue):9–13.

24. Ferrari M, Vichi A, Garcia-Godoy F.Clinical evaluation of fiber-reinforcedepoxy resin posts and cast post andcores. Am J Dent 2000;13(specialissue):15–18.

25. Scotti R, Monaco C, Malferrari S. Pre-prosthetic rebuildings using quartz fiberposts: clinical experience after 18months. ATTI del IV Simposio Interna-zionale, Odontoiatria Adesiva e Rico-struttiva, 2000.

26. Glazer B. Restoration of endodonticallytreated teeth with carbon fiber posts: aprospective Study. J Can Dent Assoc2000;66:613–618.

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cos. Revista Academia Brasileira DeOdontologia, 1999.

28. Kogan E. Postes flexibles de fibra de vid-rio (tecnica directa) para restauracion dedientes tratados endodonticamente. RAsoc Dent Mex Ene, Feb 2001.

29. Fernandes A, Shetty SH, Coutinho I.Factors determining post selection: a lit-erature review. J Prosth Dent 2003;90:556–562.

30. American Association of Endodontists.Endodontics Colleagues for ExcellenceNewsletter. Spring/Summer 2004.

31. Christensen G. Post concepts are chang-ing. J Am Dent Assoc 2004;135:1308–1310.

32. Ferrari M, Scotti R Final considerations.In: Ferrari M, Scotti R, eds. Fiber posts.Characteristics and clinical applica-tions. Milan, Italty: Masson, 2002:chap-ter 13.

33. Grandini S, Goracci C, Monticelli F,Borracchini AF, Ferrari M. An evalua-tion, using a “three-point bending”test, of the fatigue resistance of certainfiber posts. II Dentista ModernoMarch 2004.

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35. Gesi A, Magnolfi S, Goracci C, FerrariM. Comparison of two techniques forremoving fiber posts. J Endod 2003;29:

2006;Feb:66–67. intrarradiculares adesivos nao metali- 580–582.

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evolution and integration of current restorative endodontic … · 2008. 5. 1. · dr. gad zyman...

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