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Vol. 42. No. 2 AprilJune 2009

Case Report

The aesthetic treatment for anterior teeth with lost crown by

endorestoration
Nanik Zubaidah
Department of Conservative Dentistry
Faculty of Dentistry, Airlangga University
Surabaya - Indonesia

ABSTRACT

Background: The aesthetic has an important role in social life, especially the anterior teeth. The aesthetic abnormality of anterior
teeth i.e. discoloration, malpotition or the anterior teeth with crown damage for more than one third or all part of crown is lost due
to caries or other causes, will influence its appearance especially during smile. Purpose: The aim of this case report, therefore, is to
show how teeth with clinical crown lost or only the root left still can be treated by endorestoration treatment in order to reconstruct
the shape and function of the teeth similar to the original ones. Case: Female 52 years old with the lost crown of anterior teeth. The
patient did not want her teeth to be extracted. Case Management: The abnormality of these teeth are still able to be reconstructed
by endorestoration i.e. endodontic treatment with post and core insertion in the root canal will increase its retention and recovery by
the porcelain crown fused to metal to recover the original formation and aesthetic and thus has the normal refunction. The treatment,
it improve the confidence of the patient, and also can function normally. The patient did not feel pain. Ronsenography showed the
periapical lesion diminished, the neighbor gingival was going better in both function and color. Conclusion: Endorestoration treatment
on the anterior teeth with lost crown could recover the normal function, dental aesthetic and self confidence.
Key words: endorestoration, aesthetic, anterior teeth
Correspondence: Nanik Zubaidah, c/o: Departemen Konservasi Gigi, Fakultas Kedokteran Gigi Universitas Airlangga. Jl. Mayjend.
Prof. Dr. Moestopo No. 47 Surabaya 60132, Indonesia. E-mail: [email protected]

INTRODUCTION

Aesthetics and beauty can not be separated from

social life. Everyone even can enjoy the aesthetics
anytime since the aesthetics is part of human life. Many
patients, thus, are really concerned with their anterior teeth
because of aesthetic reason. Unfortunately, some of them
ignore the chewing function, and more concern with the
appearance.1,2
The natural and harmonious appearance, furthermore, is
one of aesthetic elements that all patients wish. The basic
principles of the treatment in dentistry are actually including
power, good function, and satisfying aesthetics. However,
the good aesthetics without being supported by the good
function and optimal power still can make the patients feel
difficult in doing their daily chewing activity. On the other
hand, though without being supported by good aesthetics,
good function and optimal power can make the patients

comfortable in doing their activities, they will still be lack

of confidence.3,4
Being able to smile with full of confidence, moreover,
is a strong indicator that indicates the person is satisfied
with himself. This condition then can improve his social
relation and support him to reach any success in business
or professional life.3 Specifically, the anterior teeth are
important element during laughing. Thus, all abnormalities
in the terms of discoloration, malposition, or the anterior
teeth with crown damage for more than one third or all part
of crown lost due to caries or other causes are the most
significant element disturbing the appearance. However,
the abnormal teeth still can be treated by endorestoration
treatment.1,5
Endorestoration treatment actually consists of endodontic
treatment and restoration. The determining process of the
restoration after endodontic treatment requires some factors
to be considered i.e: the degree of tooth damage; the quality

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Dent. J. (Maj. Ked. Gigi), Vol. 42. No. 2 AprilJune 2009: 99103

of dental supporting tissue; the present of antagonist tooth

or not; and the capacity of chewing power.5,6 The success
of a restoration, moreover, was determined by retention,
stability, and aesthetics of the teeth. Thus, the improving
process of the appearance, especially in the term of
aesthetics, is getting more important in dentistry in this
modern era.7
The aim of this case report, therefore, is to show how
teeth with clinical crown lost or only the root left still
can be treated by endorestoration treatment in order to
reconstruct the shape and function of the teeth similar to
the original ones.
The following report is about a case of anterior teeth
with crown damage for more than one third or all part of
crown lost due to caries after being treated with aesthetic
treatment by endorestoration.

CASE

The patient is a fifty two year old woman. The clinical

crown of her anterior teeth was lost, or only the root of the
teeth was left due to carries. Nevertheless, the patient did
not want to have an extraction for her teeth. The patient
wanted a treatment for her anterior teeth so that she could
get the normal shape and the dental aesthetics similar to
her original ones.
During the intra oral examination on the teeth
number 12, 11, 21, 22 and 23 (Figure 1), moreover, it
was found that the clinical crown was lost or the root left
was strongly inside socket and alveolar bone. Thus, for
conducting diagnosis and treatment plan, panoramic and
local radiographic photos must be taken first. The photo
result showed radiolucency around periapical area on teeth
number 12, 11, 21, 22 and 23. The condition of her teeth
was also non vital with a clinical diagnosis of necrotic pulp
followed by periapical lesion.

Figure 1. The condition of the teeth number 12, 11, 21, 22 and
23 before treatment.

This endorestoration treatment plan, moreover, consisted

of intracanal endodontic treatment with restoration like
porcelain jacket crown fused to metal. This treatment also
needed retention like pin dowel and core.

CASE MANAGEMENT

Intracanal endodontic treatment was carried out on the

teeth number 12, 11, 21, 22, and 23 with some visitation
treatment. After that, the root canal of the teeth treated by
endodontic treatment was duplicated with elastomers in
order to make retention like pin dowel and core as well as to
make restoration like a temporary jacket crown appropriate
with the normal position in good dental curvature. The aim
of the making of the temporary jacket crown was to protect
posts and core inserted during the treatment and to describe
the normal position of the anterior teeth appropriate with the
good dental curvature with normal overbite and overjet.
The insertion of pin dowel and core was carried out
one by one into the root canal of the teeth number 12, 11,
21, 22, and 23 (Figure 2). Afterwards, with phosphate zinc
cements the preparation of pin dowel and core inserted
was carried out to obtain appropriate position and parallel
construction so that the setting of the porcelain jacket crown
fused to metal could be done easily and created good dental
curvature.

Figure 2. Insertion of posts and core into the teeth number 12,
11, 21, 22, and 23.

The next stage, the duplicating of the teeth number 12,

11, 21, 22, and 23 was carried out with double impression
materials. The biting mold was also made in order to make
the position of the teeth similar to the original position.
The teeth were then set with the temporary jacket crown
which was not only appropriate with the shape but also
harmonious with the aesthetics. Afterwards, the duplicating
result of upper and lower jaw models was sent to dental
laboratories in order to make the porcelain jacket crown
fused to metal.
The final stage of the treatment, the porcelain jacket
crown fused to metal was set on the teeth number 12, 11,
21, 22 and 23. Since the condition of the initial fit was
good, the shape and the color were normal, and there was
no premature contact, the permanent insertion was carried
out with glass ionomer cement, luting type (Figure 3). The
patient was then asked to do 1 week, 3 months, 7 months,
and 1 year visit treatment.

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Zubaidah: The aesthetic treatment for anterior teeth

Figure 3. The condition of the teeth number 12, 11, 21, 22 and
23 after treatment.

CASE

with normal overbite and overjet. The making of pin dowel

and core, thus, must be taken place in dental laboratory.
The next stage was insertion of pin dowel and core
made of phosphate zinc cement (Figure 2). First, the
preparation of post was carried out in order to obtain not
only the appropriate position and parallel construction,
but also the good and harmonious dental curvature, which
then was duplicated with double impression materials.
Afterwards, the insertion of temporary crown appropriate
with the harmonious and aesthetic dental curvature was
carried out. The duplicating result then was sent to dental
laboratories in order to make the porcelain jacket crown
fused to metal.

The patient is thirty two year old woman. Her number

33 tooth crown was lost due to carries (Figure 1). Thus,
the patient used to feel ashamed whenever she smiled.
However, the patient did not want to have an extraction
for her tooth. She wanted her tooth to be treated and kept.
She wished that her tooth could have had normal function
again similar to her original ones.
During the intra oral examination, it was found that the
condition of the root left on 33 tooth was still strong inside
socket and alveolar bone. The result of the roentgen photo
showed that there was periapical lesion. The condition of
the teeth was non vital with a clinical diagnosis of total
necrotic pulp.

Figure 2. Insertion of post and core on the 33 tooth.

The final stage of the treatment was setting porcelain

jacket crown fused to metal on the 33 tooth. Since the initial
fit was good, the shape and the color were appropriate, and
there was no premature contact, permanent insertion then
was carried out with glass ionomer cements with luting
type, insertion of porcelain jacket crown fused to metal
(Figure 3). The patient then only needed some visits, 1
week, 3 months, 7 months, and 1 year visit treatment.

Figure 1. The condition of the 33rd tooth before treatment.

CASE MANAGEMENT

The tooth number 33 could be treated by intracanal

endodontic treatment only with one visit treatment. Then,
retention like pin dowel and core could be set. A temporary
crown which must be fit with the normal position in the
good dental curvature could also be made. This aim of these
procedures was to protect the core post inserted during
the treatment and to describe the position of the normal
anterior teeth appropriate with the good dental curvature

Figure 3. The condition of the 33 tooth after treatment.

DISCUSSION

In these cases, the patients needed an aesthetic treatment

of anterior teeth since their anterior teeth have got crown

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Dent. J. (Maj. Ked. Gigi), Vol. 42. No. 2 AprilJune 2009: 99103

damage for more than one third or all part of the crown due
to caries, which then have made the patient feel ashamed
and less confident during their smiling. On teeth number
12, 11, 21, 22, and 23 (Case 1) and number 33 (Case 2),
moreover, the tooth vitalities were non vital with a clinic
diagnosis, necrotic pulp. Those teeth, however, still could
be treated concerning with the condition of root left which
was still appropriate in the terms of length, thickness, and
depth of their rooting in the socket and alveolar bone. Thus,
this condition could probably be treated by endorestoration
treatment, which was by intracanal endodontic treatment
with supporting pin dowel and core (Case 1) and (Case 2)
in order to improve the tooth retention as well as to make
restoration of porcelain jacket crown fused to metal. In
other words, this condition is the same as Shillingburgs
opinion6 which said that the condition of teeth with the
crown damage or the heavy oclusal pressure has an indicator
that the crown is with pin dowel.
Similarly, Tohiroh8 and Kamizar,9 also said that teeth
with short clinic crown condition or without any clinic
crown, but still having appropriate roots in the terms of
length, thickness, and depth of their rooting in alveolar
bone, can be treated well with posts. This treatment,
however, is also depend on the condition of the teeth
whether the comparison between root and crown follows
the requirement, in which the length of posts inserted into
root canal at least is the same as the length of the crown.
Therefore, the selection of post and core design as
supporting in root canal must be appropriate with the size of
the crown left concerning with the height of oclusal pressure
(chewing power), diameter of root canal and tooth location
as well as the health of periodontal tissue as supporting to
post crown.10 It means that the consideration in selecting
kind of post crown can not be separated with how the
posts will be designed. The procedures of design selection
and root canal preparation, furthermore, must carefully be
carried out in order not to cause the weakening of the tooth
tissue left and the removing of posts.11
In case 1 (teeth number 12, 11, 21, 22, and 23) and case 2
(tooth number 33), for example, those teeth used pin dowel
since the posts have some advantages, like that the posts and
the core can not only become unity but can also follow the
root canal preparation, so they can be retentive and stable
and do not need additional retention like pin.8
Then, the setting of pin dowel and core on teeth 12, 11,
21, 22, and 23 (Case 1) was done in the same time but one
by one. The aim of this procedure is to get an appropriate
construction and size based on both the normal size of each
and the curvature of the anterior teeth with normal overbite
and overjet so that the good and harmonious aesthetics can
be created.
The principle of the tooth treatment after the endodontic
treatment, moreover, is to carry out the restoration of root
and crown with post crown and core which is retentive and
stable so that it can not only easily remove but can also be
used for long in the mouth cavity like the original teeth.

However, it must be noticed that teeth which have been

treated by the endodontic treatment are relatively more
fragile and can easily fracture compared to the healthy teeth
since there is an organic and biological changes because
of the death of pulp, the reduction of dental internal tissue,
and the weakening linkage between enamel and dentin
due to the scraping of dentin tissue during the root canal
preparation causing the change of the tooth color. For those
reasons, comprehensive protection is needed by using
supporting pins and core as well as by making restoration
of porcelain jacket crown fused to metal in order to prevent
the teeth from fracture.8,10
The making of porcelain jacket crown fused to metal,
thus, is a good treatment for reconstructing the esthetics,
especially the anatomy construction and the color of the
teeth which is appropriate with their original color and
can function naturally. Similarly, Hume12 also states that
porcelain jacket crown is the best solution to carry out
the restoration of the first sensitive tooth with optimal
aesthetics. According to Qualthrough and Burke, 13
moreover, from 956 patients there are only 63% who feel
satisfied with their outlooks when one of their anterior teeth
using dressing crown, and there are 79% who feel satisfied
with their outlooks when four or more of their anterior teeth
using porcelain jacket crown.
The final treatment result of Case 1 and 2, however,
could be obtained with one week, three month, seven
month, and one year visit treatment after the insertion of
the porcelain jacket crown fused to metal.
Visit I (1 week after the treatment): The patients did not
complain again about feeling painful (either shooting or
sharp painful) on their treated teeth; they also got percussion
and unpainful pressure; their gingiva color was still normal;
they did not get any inflammation around the tissue; their
radiographic photo result was good since their abnormal
radiolucent image of periapical on the teeth number 12, 11,
21, 22 and 23 (Case 1) and number 33 (Case 2) was rather
decreasing; and their recovery process was also good.
Visit II (3 months after insertion and treatment): The
condition of porcelain crown jacket was good enough;
there was no pain around the tissue; the color of the gingiva
around was normal; and based on the roentgen photo the
radiolucent image around periapical area was getting
smaller either in Case 1 or Case 2.
Visit III (7 months after insertion): The patients
did not feel painful, either hooting or sharp painful, or
discomfortable around the teeth number 12, 11, 21, 22, and
23 (Case 1) and number 33 (Case 2) which had been set with
the porcelain jacket crown fused to metal; the abnormality
of periapical lesion on their teeth was getting smaller; the
color of the gingival around was normal; and the patients
were satisfied with their daily outlook as well as they could
laugh without feeling lack of confidence anymore.
Visit IV (one year after treatment): The patients
did not feel painful, either hooting or sharp painful, or
discomfortable, so they could do their activities again with

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Zubaidah: The aesthetic treatment for anterior teeth

full of confidence. The roentgen result even showed that the

condition around the teeth was good and the color of them
was also normal (either in Case 1 or Case 2).
Therefore, criteria used in determining the success of
the endodontic treatment are not only based on radiograph
of periapex tissue but based on the clinic condition of the
teeth as well. In other words, a treatment can be determined
whether it is successful or not based on the conditions that
are no complaint from the patient about the treated teeth
and the successful effort in treating the abnormality in the
periapex tissue after one year treatment.14
In addition, Ingle15 reports that the success of the
treatment in elderly group is better than that of the treatment
in other age groups. The reason may be because one third
of the apex area of other age groups has been completely
closed since there is secondary cement or ramification of
root canal which has been declined.
Based on those explanations above, it can be concluded
that the anterior teeth either in upper jaw or lower jaw which
hadlost their clinical crown due to caries or fracture does
not need to have extraction since they still can probably
be treated with endorestoration, intracanal endodontic
treatment, by inserting posts inside root canal (intrapulp)
and core, in order to make them retentive and stable as well
as to make porcelain jacket crown fused to metal. Thus,
they finally can reconstruct the shape and function of the
teeth as well as the dental aesthetics, so the construction of
the teeth can become normal again similar to the original
construction of the teeth.

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