Paper Endodoncia Bla

SCIENTIFIC SESSION
The ideal restoration of endodonti-

cally treated teeth – structural and
esthetic considerations: a review of
the literature and clinical guidelines
for the restorative clinician
Konrad Meyenberg, DMD

Private Office for Reconstructive Dentistry
Zürich, Switzerland
Correspondence to: Konrad Meyenberg

Private Office for Reconstructive Dentistry, Rennweg 58 / Eingang Oetenbachgasse 26, 8001 Zürich, Switzerland;
E-mail: [email protected]; Web: www.zahnaerzte-rennweg.ch
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Moderator/Editor’s Introduction
One of the most challenging dilemmas for the younger patient, then why can’t
faced by today’s clinician is the manage- it be done for the older patient? On the
ment of the structurally and esthetically other hand, perhaps it is more predict-
compromised endodontically treated able in a given case to remove the tooth
tooth. Certainly, in recent years there has and restore it with a dental implant res-
been a tendency to take the simplified toration. These and other issues are real
approach of “extraction and implant” concerns we have as practitioners and it
but this does not always prove to be as is important to have objective as well as
simple as we would like to think. Has the subjective criteria on which to base
the popularity of dental implantology our decision for the choice of restorative
made the restorative dentist complacent protocol.
in regards to the possibilities that good Are all endodontically treated teeth
endodontic, periodontal and restorative really less predictable than a dental
treatments can achieve? Without doubt implant-supported restoration? Are they
the dental implant option has its place, really more likely to fail? Do they really
and rightly so, but in many cases, I sus- have a poor prognosis? Do implants re-
pect, the endodontic/restorative option ally have fewer complications? Is retreat-
does not always receive its due merits. ment as easy? Do anterior and posterior
Whenever we are faced with such a teeth behave the same? When is the
compromised tooth, we have to con- prognosis of the tooth unfavorable and
sider the following question: is the tooth at what point is extraction and an im-
maintainable? If so, then this is surely plant the best option? These and many
our primary goal. However, the question other relevant questions are eloquently
is complicated by the context – ie, is this addressed below by our essayist and
a young patient? Is this a bridge abut- EAED Active Member, Dr Konrad Mey-
ment? Is there an esthetic challenge, ie, enberg. My hope is that this paper will
a dark tooth? In the younger patient, it serve to help us to question our treat-
may be desirable to maintain a poten- ment choices more critically in this area,
tially hopeless tooth for as long as pos- suggest useful answers to many of the
sible in order to “buy time” and delay the questions in this dilemma, provide us
day of implant placement and its subse- with objective criteria on which to base
quent eventual failure. Retreatment of a our judgements and finally offer solu-
tooth is, more often than not, simpler with tions so that we can make better choices
a broader range of options than retreat- for the treatment of our patients.
ment of a failed implant, particularly in
the esthetic zone. If this can be done Dr Tidu Mankoo, BDS
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Abstract Clinically, most of non-vital teeth must

be considered as structurally and es-
In restorative dentistry, the non-vital tooth thetically compromised.2 The fracture
and its restoration have been extensively rate and as a consequence the risk for
studied from both its structural and es- tooth loss is considerably higher com-
thetic aspects. pared to vital teeth.
The restoration of endodontically
treated teeth has much in common with
modern implantology: both must include Part 1:
multifaceted biological, biomechanical
Structural considerations
and esthetic considerations with a pro-
found understanding of materials and What are the causes of fractures?
techniques; both are technique sensitive
and both require a multidisciplinary ap- There are several causes for the in-
proach. And for both, two fundamental creased risk of cracks in endodontically
principles from team sports apply well: treated teeth to be considered. Cracks
firstly, the weakest link determines the predispose the tooth immediately or af-
limits, and secondly, it is a very long way ter some time to fracture. The following
to the top, but a very short way to failure. four factors contribute to this predisposi-
Nevertheless, there is one major dif- UJPO 'JHTo

ference: if the tooth fails, there is the op- Structural loss of tooth substance due
tion of the implant, but if the implant fails, to pre-endodontic restorative proce-
there is only another implant or nothing. dures or the endodontically induces
The aim of this essay is to try to an- access cavity preparation and root
swer some clinically relevant concep- canal enlargements.5,6
tual questions and to give some clinical Increased brittleness by age induces
guidelines regarding the reconstructive changes in the dentin and the loss of
aspects, based on scientific evidence free unbound water from the root ca-
and clinical expertise. nal lumen and the dentinal tubules in
pulpless teeth.7-11
Weakening effects by endodontic ir-
Rebuilding the ideal tooth SJHBOUT /B0$M &%5"
BOE NFEJDB-
tions (CaOH2
PO EFOUJO FGGFDUT PG
from an endodontically
bacterial interactions with the dentin
treated tooth – what does
substrates, corrosive effects of restor-
this mean? ative materials, and negative mechan-
Essentially, the goal is to restore the apical effects through crack inducing or
pearance and biomechanical properties crack propagating endodontic and
comparable to those of a vital, complete- restorative methods and instruments,
ly intact tooth. In addition, the coronal including endodontic files.12-16
restoration should prevent bacterial re- The reduced level of proprioception
colonisation of the endodontically treat- of non-vital teeth causes a reduced
ed root canal system.1 level of control of forces by the normal
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MEYENBERG
Fig 1 Cracks in lower first molar due to deep cavity. Fig 2 Fracture of first upper premolar due to deep
cavity with endodontic treatment.
Fig 3 Fracture of palatal Fig 4 Fracture originating from the apex of a canine due to the use of
root of upper first molar due inadequate endodontic techniques.
to endodontic treatment.
protective neuromuscular inhibition Recent research shows that dentin

mechanism.17 has some very effective inherent proper-
ties to inhibit crack progression (fracture
Some of these factors may be influ- UPVHIFOJOH NFDIBOJTNT
UP PQUJNBMMZ
enced or modified to improve the prog- distribute local stresses and to partially
nosis, however the most important factor repair defects, as long as a tooth is vi-
for success is to avoid any unnecessary tal.8,9 However, a non-vital tooth will lose
loss of tooth substance in general and some of these properties over time. A
to preserve as much as possible after key consideration is that the amount of
removal of all decayed material. collagen fibers in endodontically treated
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SCIENTIFIC SESSION
teeth decreases, which means that this to dispense with posts in many indica-
dentin is much less fatigue resistant.17 tions, as they are no longer required for
In addition, even vital dentin loses some the retention of a core build-up.
of its initial strength over its lifetime: it However, mindful clinicians can still
shows a different fracture behavior as observe a relatively high rate of vertical
the mineral content increases over time root fractures despite the absence of
and causes a less favorable fracture be- posts and even with the use of adhe-
havior because of the increased brittle- sive techniques – above all in curved
ness.18,19 and small roots; indeed some authors
report up to 20% of vertical fractures of
Restorative options: endodontically treated teeth. Man-
what is the ideal concept? dibular molars and maxillary premolars

are most often affected.25,26 Provided
As a consequence, any attempts to there is enough coronal dentin structure
restore a non-vital tooth must include NPSFUIBOUXPUIJSETBWBJMBCMF
JUTFFNT
not only the use of restorative materi- that there is no difference between teeth
als with properties similar to the dental restored with or without posts in this re-
components, but also the use of clinical spect.27 Interestingly in this article, 86%
concepts that allow to compensate the of molars with vertical root fractures had
inherent reduction of the mechanical re- the fracture in a root without a post.
sistance of endodontically treated teeth. Therefore, as long as no active posts
A true so-called biomimetic con- or screws are used, which may produce
cept20 therefore does not only implicate detrimental lateral forces on the den-
the use of particular materials similar in tin walls,28 and as long as inadequate
their properties to dentin and enamel, placement techniques with risk of per-
but also sometimes the use of particular forations are not used, posts per se
materials with different properties to re- may not be considered as destructive.
store the incomplete tooth as a whole in
all its mechanical, biological and esthet- When is a post indicated?
ical aspects,21 above all if the remaining
tooth structure is compromised. The main reason to use a post today
is no longer to increase the retention
Post or no post – and resistance of a core build-up, since
are posts destructive? there are very effective adhesive tech-

niques available. As discussed, provid-
In the past, fractures of teeth often have ed there is sufficient tooth structure avail-
simply been attributed to inadequate re- able, there is no longer a need to place
storative procedures, be it by the use of a post. In premolars with limited
inadequate core materials or the use of amount of tooth destruction and molars
posts and screws. The introduction of ad- where, in general, more dentin walls with
hesive techniques and their successful greater surface area can be engaged
integration in almost all current restora- to be bonded as compared to anterior
tive procedures has allowed the clinician teeth, a direct bonded core build-up is
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clinically the concept of choice; it can be not be compensated simply by adhe-

regarded clinically as well established, sive techniques using fiber posts and
reliable and perhaps preferable to con- composite cores. In a recent long-term
ventional post-core concepts. In addi- study over 7 to 11 years, the mechani-
tion, by avoiding posts, the risk of cracks cal failures reached 7 to 11% and were
due to thin residual root walls or perfora- always related to a lack of coronal tooth
tions can be eliminated. structure.
For anterior teeth and heavily compro- If anterior teeth and premolars pre-
mised premolars, however, this state- sent with large defects that require
ment is limited to teeth that present with crowning, however, adequate transfer
small to moderate defects and that will of forces from the crown into the core
later not be crowned. build-up and from there into the root is
For posterior teeth, the best prognosis not possible without a post. Importantly,
is achieved if – in addition to a bonded the function of the post is not only the
core foundation – a ferrule effectis cre- increase of the retention of the core, but
ated by the final restoration. This means also the optimization of the resistance
that full cuspal coverage is used, be it form. In addition, the mechanical prop-
a partial or full crown. Adhesive tech- erties of a composite core alone may
niques alone without cuspal coverage also not be sufficient in the case of a
may still lead to catastrophic failures narrow abutment diameter and cannot
over time (ie, untreatable long axis frac- reduce high stresses in the critical cervi-
UVSFT
BOEDBOOPUCFSFHBSEFEBTDMJOJ- cal area, which in such a case, is prone
cally safe. to horizontal fractures. A clinical study
It must be stated at this point that the PWFS UP ZFBST XJUI DSPXOT CPOEFE
ferrule effect is the most effective way of directly to a reduced macroretention ge-
mechanical stabilization, ie, of optimiz- ometry without posts clearly showed
ing the resistance form, of any endodon- that the concept can work for molars
tically treated teeth.Given the weaker (87–95% success, depending from the
structure, as previously discussed, the BNPVOUPGSFTJEVBMDBWJUZXBMMT
CVUEJE
effect of the better load distribution into not work for premolars, if there were no
the cervical zone and the avoidance of cavity walls at all and the crown was just
any wedging effect by the post or core bonded directly into the residual pulp
build-up into the coronal part of the root DIBNCFS TVDDFTTSBUF

cannot be overemphasized. Therefore, Therefore, the purpose of a post and
in order to provide a ferrule in situa- core as a unit is primarily to transfer the
tions without sufficient tooth structure loads into the root and secondly, the
above the zone of the biological width, post is used as a reinforcing element of
orthodontic extrusion or surgical crown the core build-up.
lengthening should be considered. A The downside of this concept is the
ferrule length of 1.5 to 2 mm is recom- weakening effect on the root itself;
mended. to compensate for this, the ferrule effect
It must also be stated that, obviously, must be incorporated into the restoration
the lack of coronal tooth structure can- design.
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SCIENTIFIC SESSION
The ferrule effect may also compen- #BTJDBMMZ UIFSF BSF UXP DPOGMJDUJOH JT-
sate unexpected breakdown of adhe- sues causing some disagreements on
sion after bonding and luting proce- the ideal material of a post.2 From a me-
dures in unqualified dentin conditions. chanical standpoint, it is evident that a
A safe clinical concept always implies post stiffer than dentin can take up more
the incorporation of a ‘belt and braces’ load but induces more stress in some api-
approach to offset routes of potential cal parts of the root, which can increase
failure. the risk of a vertical root fracture. Con-
A special indication for a post is the versely, a post that has an elastic modu-
immature root, presenting with a large lus closer to dentin will, in fact, induce
root canal. less stress concentration apically in the
Obviously neither gutta-percha nor root, but more in the cervical region.
MTA nor composite have a significant In addition, the interface between
reinforcing effect. In this instance, the post and core and between core and
only significant reinforcing effect is dentin is also subjected to stress, so one
achieved with a post. This is in line with can expect to see more root fractures
the clinical observation of increased risk JSSFQBSBCMF GSBDUVSFT
XJUI TUJGGFS QPTUT
of fracture in immature teeth left without made from metallic or ceramic materi-
post and core-build up after endodontic als, whereas more flexible posts would
treatment. show more post fractures, debonding of
core materials and loss of retention (pos-
If a post is indicated: TJCMZSFQBJSBCMF
XJUITVCTFRVFOUQSPC-
lems of leakage and caries. The latter
what post concept should be
may lead to endodontic reinfection and
used: stiff or flexible?
catastrophic coronal destruction of tooth
“If something can break, it will break, and substance, thus leveling out the poten-
it will always break at the weakest point” tial advantage of this latter concept over
– this basic finding and classic rule for the first one.
construction is also true for this applica- The dilemma for the clinician is the
tion and may explain the significant con- meaningful interpretation of the litera-
troversies regarding what would be the ture, as countless studies have been
best of all the available concepts. The published in this field, most of them being
question may be not whether something in vitro studies with questionable clinical
will break, but rather where it will break. potential relevance. Numerous theoreti-
Almost all dental materials have been cal studies using finite element analysis
used clinically for posts. Still clinically have also been performed, which would
relevant today are gold-alloys, chrome- all need to be verified according to clas-
cobalt, titanium, zirconia and glass fib- sic engineering principles in a real mod-
er posts. Carbon fiber posts have no el, but only a minority of the in vitro stud-
clinical significance due to poor clinical ies have been performed with dynamic
performance and disastrous potential; or fatigue loading under a simulated
therefore they will not be discussed in oral environment. Another difficulty is
this article. that study results are also influenced by
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the structural condition, various types of tablishment of proper bonding be-

natural teeth utilized and the respective tween all substrates is of paramount
loading pattern. importance.51 If bonding fails, much
One of the more clinically relevant in less favorable stress patterns occur
vitro studies compared cast posts and both in the root, above all in the critical
DPSFT UJUBOJVN 5J
QPTUTXJUIDPNQPT- cervical area, and in the post and core
ite cores, zirconia posts with composite itself.52 As a clinical consequence,
cores and zirconia posts with ceramic loss of retention of the core and post
cores, using, in all groups, adhesive is still unfortunately the major compli-
techniques and a ferrule of 1 to 2 mm cation.
on central incisors where all teeth were
crowned. The most favorable results Most of the clinical studies are difficult
JOUFSNTPGGSBDUVSFTUSFOHUI /
BOE to interpret in their outcome, since the
TVSWJWBMSBUF
DPVMECFBDIJFWFE amount of tooth loss and the condition
with the stiffest concept (zirconia posts of the remaining dentin (pre-existing
XJUI B DFSBNJD DPSF
BOE UIF MFBTU GB- cracks, aging, endodontic treatment
vorable with the cast post and core sys- NPEBMJUJFT
BSFOPULOPXOBOENBZIBWF
UFN /
influenced the choice of the concept.
In contrast to this study with ideal tooth The scientific dilemma is very nicely
substrate, another study compared dif- expressed in a systematic review about
ferent degrees of tooth destruction, us- the simple final question, whether a
ing fiber posts and composite cores or crown or a filling is more effective in the
composite cores alone on premolars. clinical performance for an endodonti-
It was shown that posts had a significant cally treated tooth. The authors con-
positive effect on fracture strength if only clude “There is insufficient evidence
1 or 2 cavity walls were left, whereas no to support or refute the effectiveness
EJGGFSFODFDPVMECFGPVOEJGPSDBWJUZ of conventional fillings over crowns for
walls were left. However, if a completely the restoration of root filled teeth. Until
flat profile without any substance above more evidence becomes available cli-
the preparation line is used, most likely nicians should continue to base deci-
the post will debond as predominant sions on how to restore root filled teeth
mode of failure. on their own clinical experience, whilst
Two facts are of special importance in taking into consideration the individual
the judgment of studies comparing dif- circumstances and preferences of their
ferent concepts: patients”.
The results of these in vitro studies This statement shows not only the
largely depend on the presence or complexity of the topic, but also that
BCTFODFPGBGJOBMSFTUPSBUJPO DSPXO
clinical multifactorial reality does not al-
Principally, differences in materials of low clear definition of one simple gener-
posts and cores level out from the mo- ally valid concept.
ment where a crown is placed. Nevertheless, there is still a need
If metal-free post and core concepts for clear clinical guidelines, based on
are to be successfully used, the es- scientific evidence paired with clinical
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SCIENTIFIC SESSION
expertise. Only this combination finally with different concepts of build-ups. All
leads to clinical evidence. teeth were finally crowned with porcelain
As a conclusion from numerous clini- GVTFEUPNFUBM 1'.
DSPXOT"OPWFSBMM
cal studies, it must be stated that there is failure rate in this 6-year survival study of
OPTVQFSJPSDPODFQUJOBMMSFTQFDUT#PUI XBTSFQPSUFE8IFOPOMZBDJSDVMBS
direct and indirect concepts and gold, ferrule of 2 mm or less was left, the fail-
Ti, fiber and zirconia posts work well if ure rate increased to nearly 90 to 100%
the respective concepts are properly ex- GPSUIFOPQPTUDPODFQU UPUPGPS
ecuted. The single most important point prefabricated posts, and to around 70%
is to preserve as much remaining tooth for the customized post concept.
structure as possible. The results clearly suggest that pre-
Two additional arguments may require fabricated fiber posts are superior
consideration for the reconstructive cli- to customized fiber posts (glassfiber
nician: a) fiber posts offer the highest CBOE SFTJOJNQSFHOBUFE
PSDPNQPTJUF
potential for reintervention due to their cores without any posts, if there are only
relative ease of removal, however their 2 walls or less remaining. However, even
successful use clinically is much more if in addition to the bonded core a pre-
technique sensitive,58 and b) post and fabricated fiber post is used, the con-
cores with a high modulus of elasticity cept obviously fails to be convincingly
NFUBM PS [JSDPOJB
PGGFS B IJHIFS GSBD- successful in cases with extended tooth
ture resistance as a foundation of the destruction.
crown,50 which may be of significance *ODPOUSBTUUPUIJTPWFSBMMGBJMVSF
for the long-term success of all-ceramic rate over 6 years of non-metallic posts
crowns.59,60 and build-ups, a 10-year report of pre-
fabricated metal posts and cast metal
What about bonding a post into QPTUTBOEDPSFTSFTVMUFEJOBBOE
PWFSBMMGBJMVSFSBUF
the root canal space? Does bond-
ing help in cases with extended
Retention
amount of tooth destruction?
The almost doubled overall failure rate
What is the ideal surface condi- of fiber posts and the surprisingly high
tioning of fiber posts? debonding rate must raise the question
Looking at the results of a recent clini- about the effectiveness and efficiency
cal 10-year fiber post study, a surpris- of this concept in general practice. Per-
JOHMZIJHIBOOVBMGBJMVSFSBUFPGJT haps it is unsurprising given the inher-
reported and an overall failure rate of ently more technique-sensitive concept
XJUIGJCFSQPTUGSBDUVSFTBOE of the required adhesive techniques and
11% post debondings.61 The highest the lack of a simple clear user protocol.
probability of a failure was reported for A recent study compared the reten-
anterior teeth with no cavity walls. tion of different fiber posts with different
This is confirmed by another clini- surface conditionings (performed ac-
cal study62 where premolars of varying cording to the manufacturer‘s recom-
degrees of destruction were restored NFOEBUJPOT
BOE MVUJOH BHFOUT JO EFO-
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tin Ti-posts luted with conventional zinc etching with hydrogen peroxide for
phosphate-cement served as the con- NJO PS NFUIZMFOF DIMPSJEF GPS T

trol group. The control Ti-post showed, or micromechanical treatments (sand-
together with some combinations of the CMBTUJOH
PSBDPNCJOBUJPOPGCPUIIBWF
test group, the highest pull-out strength, been proposed. Surprisingly, sand-
whereas some combinations of the test blasting seems to not affect the mechan-
group showed surprisingly low values. ical properties of the fiber posts.75 Sand-
This is in line with another study, where blasting with silanization is, therefore, an
adhesively luted fiber posts were not efficient, simple and predictable way of
superior to gold posts either adhesively surface conditioning a fiber post before
luted or conventionally cemented with bonding.77,78 However, fiber posts are
glass ionomer cement.65 susceptible to water degradation, and
damaging the surface will increase this
Adhesion to radicular dentin phenomenon. Thus, a predictable bond-
Adhesively luting a post into root den- ing procedure that completely seals the
tin is a controversial issue. Conflicting post surface and avoids any voids is of
results have been published about the paramount importance to preserve frac-
efficacy of bonding to radicular dentin. ture resistance.79 Some manufacturers
Probably due to the structural differenc- now use a coating on their posts to fur-
es in radicular dentin, bond strengths ther simplify and improve the bonding.80
improve from the apical to the coronal Nevertheless, care should be taken to
section. Comparing the use of compli- consider both the manufacturers’ rec-
cated separated dentin bonding and lut- ommendations and their scientific basis.
ing procedures with simpler self-etching
cements, it seems clinically more relia- Mechanical properties
ble to use self-etching and self priming Major differences in the mechanical
cements taking into account the poten- properties of different brands of posts
tially somewhat lower bond strength to is another critical point. Since there
dentin.66-71 Inadequate ability to cure are now countless brands of posts on
the luting agents precludes the use the market with a sometimes-unknown
of light-curing materials. Dual-cure or origin, a proper selection based on in-
chemically curing materials should be dependent scientific investigations is
used instead, since different fiber posts imperative to avoid basic mechanical
indeed differ in their light transmitting failures.81,82 Using a fatigue resistance
properties, however posts with optimal test, a difference of roughly 7,000 cy-
mechanical properties do not allow cles until fracture for the worst and up
enough light penetrating all over the to 2,000,000 cycles for the best post in
whole length of the post to sufficiently UIJTSFTQFDU FRVJWBMFOUUPOPCSFBLBHF

polymerize light-cured materials.72 could be shown. The quality of the man-
ufacturing processes including type of
Adhesion to post surface fiber and matrix, pre-tensioning of fibers,
To improve bond strength to the pre- bond between fibers and matrix, among
fabricated fiber posts, chemical (silane, other factors, play an important role.
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SCIENTIFIC SESSION
Fig 5 Case 1: initial radiograph of non-vital cen- Fig 6 Case 1: initial clinical situation, large com-
tral incisors with different degree of remaining tooth posite build-ups, discolorations.
substance, final radiograph of build-ups with short
GJCFSQPTUTQMBDFE PVUMJOFEGPSCFUUFSWJTJCJMJUZ

Fig 7 Case 1: abutment teeth after removal of ex- Fig 8 Case 1: abutment teeth after internal bleach-
isting composite cores. ing.
Fig 9 Case 1: build-ups of abutment teeth com- Fig 10 Case 1: build-ups of abutment teeth com-
pleted with fiber posts and composite core, buccal pleted with fiber posts and composite core, occlusal
view. view.
Therefore, both a sensitive indication

and technique is mandatory for the suc-
cessful use of the concept of fiber posts
combined with composite cores (Figs 5
Fig 11 Case 1: final clinical result. UP

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Fig 12 Case 2: initial radiograph of second lower

premolar with fiber post and PFM crown.
Fig 13 $BTFSBEJPHSBQIZFBSTBGUFSUIFSBQZ
showing post fracture, composite core debonding
Fig 14 Case 2: clinical view showing fractured
and crown dislodgement.
fiber post and extensive caries destruction under-
neath debonded composite core.
Concluding remarks regarding Materials with potential of corrosion

the structural aspects TUBJOMFTT TUFFM CSBTT
NBZ JOEVDF
fractures of materials and dentin and
The following statements regarding the therefore should not be used.
structural aspects may be made: Adhesive cementation of fiber posts
Where a crown is fabricated and a is mandatory.
proper ferrule effect is created, neither Adhesive cementation of metallic
the material (Ti, gold alloys, zirconia, posts is not mandatory.
HMBTTGJCFS
OPSUIFTIBQFBOEMFOHUI Core build-ups should always be
of the post are a significant influence, bonded, even if a metal post is not
as long as clinically reasonable con- bonded.
cepts are used.
Conversely, insufficient coronal tooth Regarding the clinical reality, the fol-
structure will always lead to an in- lowing additional statements must be
creased failure rate independent of made:
the concept of restoration. $FSBNJD QPTUT [JSDPOJB
DBOOPU CF
Increasing the coronal diameter of the removed after luting, offer no potential
post helps to reduce the fracture risk for reintervention and should therefore
of all posts, however the residual den- be used in selected cases only.
tin wall thickness needs to be consid- For abutment teeth presenting large
ered. defects and requiring crowning, or
Huge differences in the quality of fib- longer span bridges, or in general
er posts require a careful selection to heavy loads, metallic posts are pref-
avoid post fractures. FSBCMFPWFSGJCFSQPTUT 'JHTUP

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SCIENTIFIC SESSION
References, Part 1 dehydration and rehydra- 21. Ni CW, Chang CH, Chen TY,
tion on some mechanical Chuang SF. A multipara-
.BOOPDDJ' #IVWB# properties of human dentin. metric evaluation of post-
Stern S. Restoring teeth +#JPNFDIo restored teeth with simulat-
following root canal re-treat- 1065. FECPOFMPTT.FDI#FIBW
ment. Endodontic Topics 12. Grigoratos D, Knowles #JPNFE.BUFSo
2011;19:125–152. J, Ng YL, Gulabivala K.
2. Kishen A. Mechanisms and Effect of exposing dentin 22. Tsesis I, Rosen E, Tamse A,
risk factors for fracture pre- to sodium hypochlorite and Taschieri S, Kfir A. Diagno-
dilection in endodontically calcium hydroxide on its sis of vertical root fractures
treated teeth. Endodontic flexural strength and elastic in endodontically treated
5PQJDTo modulus. Int Endod J teeth based on clinical and
(IFS.&+S %VOMBQ3. o radiographic indices: a
Anderson MH, Kuhl LV. (PMETNJUI. (VMBCJWBMB systematic review. J Endod
Clinical survey of fractured K, Knowles JC. The effect o
teeth. J Am Dent Assoc of sodium hypochlorite irri- 'VTT; -VTUJH+ 5BNTF"
o gant concentration on tooth Prevalence of vertical root
$IBO$1 -JO$1 5TFOH4$ surface strain. J Endod fractures in extracted endo-
Jeng JH. Vertical root frac- 2002;28:575–579. dontically treated teeth. Int
ture in endodontically versus 4BMFI"" &UUNBO8. &OEPE+o
nonendodontically treated Effect of endodontic irriga- $PQQFOT$3. %F.PPS
UFFUIBTVSWFZPG tion solutions on microhard- RJG. Prevalence of vertical
cases in Chinese patients. ness of root canal dentin. J root fractures in extracted
Oral Surg Oral Med Oral %FOUo endodontically treated teeth.
Pathol Oral Radiol Endod 4PV[B#JFS$" 4IFNFTI *OU&OEPE+
o H, Tanomaru-Filho H, 25. Tamse A, Fuss Z, Lustig J,
5. Reeh ES, Messer HH, Wesselink PR, Wu M. The Kaplavi J. An evaluation
Douglas WH. Reduction in ability of different nickel- of endodontically treated
tooth stiffness as a result titanium rotary instruments vertically fractured teeth. J
of endodontic and restora- to induce dentinal damage Endod 1999;25:506–508.
tive procedures. J Endod during canal preparation. J 26. Vire DE. Failure of endodon-
1989;15:512–516. &OEPEo tically treated teeth: clas-
6. Asundi A, Kishen A. Digital 16. Ferrari M, Mason PN, sification and evaluation. J
photoelastic investigations Goracci C, Pashley DH, Tay &OEPEo
on the tooth-bone interface. FR. Collagen degradation 27. Salvi GE, Siegrist Guldener
+#JPNFE0QUo in endodontically treated #& "NTUBE5 +PTT" -BOH
teeth after clinical function. NP. Clinical evaluation of
7. Jantarat J, Palamara JE, +%FOU3FTo root filled teeth restored
Lindner C, Messer HH. with or without post-and-
Time dependent properties 17. Randow K, Glanz PO. core systems in a specialist
of human root dentin. Dent On cantilever loading of practice setting. Int Endod J
.BUFSo vital and non-vital teeth. o
8. Kishen A, Asundi A. Experi- An experimental clinical 28. Kishen A, Kumar GV, Chen
mental investigation on the study. Acta Odontol Scand NN. Stress–strain response
role of water in the mechani- o in human dentin: rethinking
cal behavior of structural #BKBK% 4VOEBSBN/ /B[- fracture predilection in post-
EFOUJO+#JPNFE.BUFS3FT ari A, Arola D. Age, dehy- core restored teeth. Dent
"o dration and fatigue crack 5SBVNBUPMo
9. Kruzic JJ, Nalla RK, Kin- HSPXUIJOEFOUJO#JPNBUFSJ- 29. Zarow M, Devoto W, Sara-
ney JH, Ritchie RO. Crack als 2006;27:2507–2517. cinelli M. Reconstruction
blunting, crack bridging and 19. Viguet-Carrin S,Garnero of endodontically treated
resistance-curve fracture P,Delmas PD. The role posterior teeth – with or
mechanics in dentin: effect of collagen in bone without post? Guidelines for
PGIZESBUJPO#JPNBUFSJBMT strength. Osteoporos Int the dental practitioner. Eur J
o o &TUIFU%FOUo
(BMF.4 %BSWFMM#8%FOUJO 20. Magne P, Douglas WH. 4PV[B&. EP/BTDJNFOUP
permeability and tracer Rationalization of esthetic LM, Maia Filho EM, Alves
tests. J Dent 1999;27:1–11. restorative dentistry based CM. The impact of post
11. Jameson MW, Hood JA, on biomimetics. J Esthet preparation on the residual
5JENBSTI#(5IFFGGFDUTPG Dent 1999;11:5–15. dentin thickness of maxil-
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lary molars. J Prosthet Dent 'FSSBSJ. $BHJEJBDP.$ /H$$ %VNCSJHVF)#

o Goracci C, Vichi A, Mason "M#BZBU.* (SJHHT+"
,SFKJ* %VD0 %JFUTDIJ% EF PN, Radovic I, Tay F. Long- Wakefield CW. Influence
Campos. Marginal adapta- term retrospective study of remaining coronal tooth
tion, retention and fracture of the clinical performance structure location on the
resistance of adhesive com- of fiber posts. Am J Dent fracture resistance of
posite restorations on devital 2007;20:287–291. restored endodontically
teeth with and without posts. 1JFSSJTOBSE- #PIJO' treated anterior teeth. J Pros-
0QFS%FOUo 3FOBVMU1 #BSRVJOT.$PS- thet Dent 2006;95:290–296.
'PLLJOHB8" -F#FMM". ono-radicular reconstruction )FZEFDLF( 1FUFST.$
Kreulen CM, Lassila LV, of pulpless teeth: a mechani- The restoration of endodon-
Vallittu PK, Creugers NH. cal study using finite ele- tically treated, single-rooted
Ex vivo resistance of direct ment analysis. J Prosthet teeth with cast or direct
composite complete crowns %FOUo posts and cores: a system-
with and without posts on #JOEM" 3JDIUFS# .ÚSNBOO atic review. J Prosthet Dent
maxillary premolars. Int WH. Survival of ceramic o
&OEPE+o computer-aided design/ 50. Dietschi D, Duc O, Krejci
(V[Z(& /JDIPMT+**O manufacturing crowns * 4BEBO"#JPNFDIBOJ-
vitro comparison of intact bonded to preparations with cal considerations for the
endodontically treated teeth reduced macroretention restoration of endodontically
with and without endo-post geometry. Int J Prosthodont treated teeth: a systematic
reinforcement. J Prosthet o review of the literature, Part
%FOUo 4BUIPSO$ 1BMBNBSB+& II (Evaluation of fatigue
4PV[B&. EP/BTDJNFOUP Palamara D, Messer HH. behavior, interfaces, and in
LM, Maia Filho EM, Alves Effect of root canal size and WJWPTUVEJFT
2VJOUFTTFODF
CM. The impact of post external root surface mor- *OUo
preparation on the residual phology on fracture suscep- 51. Krejci I, Duc O, Dietschi
dentin thickness of maxil- tibility and pattern: a finite D, de Campos E. Marginal
lary molars. J Prosthet Dent element analysis. J Endod adaptation, retention and
o o fracture resistance of adhe-
)FZEFDLF( #VU[' 4USVC #PMIVJT)1# %F(FF"+ sive composite restorations
JR. Fracture strength and Feilzer AJ, Davidson CL. on devital teeth with and
survival rate of endodon- Fracture strength of different without posts. Oper Dent.
tically treated maxillary core build-up designs. Am J o
incisors with approximal %FOUo 4BOUPT"' .FJSB+# 5BOBLB
cavities after restoration )FZEFDLF( #VU[' )VT- $# 9BWJFS5" #BMMFTUFS
with different post and core sein A, Strub JR. Fracture RY, Lima RG, Pfeifer CS,
systems: an in vitro study. J strength after dynamic load- Versluis A. Can fiber posts
%FOUo ing of endodontically treated increase root stresses and
'FSSBSJ. $BHJEJBDP.$ teeth restored with different reduce fracture? J Dent Res
Grandini S, De Sanctis M, post-and-core systems. J 2010;89:587–591.
Goracci C. Post placement 1SPTUIFU%FOUo 3BTJNJDL#+ 8BO+ .VTJ-
affects survival of endodon- LBOU#- %FVUTDI"4"
tically treated premolars. J 4DINPMEU4+ ,JSLQBUSJDL5$ review of failure modes in
%FOU3FTo Rutledge RE, Yaccino JM. teeth restored with adhe-
4UBOLJFXJD[/3 8JMTPO Reinforcement of simulated sively luted endodontic
PR. The ferrule effect: a immature roots restored with dowels. J Prosthodont
literature review. Int Endod J composite resin, mineral o
o trioxide aggregate, gutta- 'FEPSPXJD[; $BSUFS#
+VMPTLJ+ 3BEPWJD* percha, or a fiber post after de Souza RF, de Andrade
Goracci C, Vulicevic ZR, thermocycling. J Endod Lima Chaves C, Nasser M,
Ferrari M. Ferrule effect: a o 4FRVFJSB#ZSPO14JOHMF
literature review. J Endod .BOHPME+5 ,FSO.*OGMV- crowns versus conventional
o ence of glass-fiber posts on fillings for the restoration of
4PSFOTFO+" .BSUJOPGG+5 the fracture resistance and root filled teeth. Cochrane
Intracoronal reinforcement failure pattern of endodonti- Database Syst Rev
and coronal coverage: a cally treated premolars with 2012:16:CD009109.
study of endodontically varying substance loss: 55. Fokkinga WA, Kreulen CM,
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clinical study on post-and- (ØNF[1PMP. -MJEØ# 71. Sterzenbach G, Karajouli G,

cores and covering crowns. Rivero A, Del Río J, Celemín /BVNBOO. 1FSP[* #JUUFS
+%FOUo A. A 10-year retrospective K. Fiber post placement
4JHOPSF" #FOFEJDFOUJ4 study of the survival rate of with core build-up materials
,BJUTBT7 #BSPOF. "OHJ- teeth restored with metal or resin cements – An evalu-
ero F, Ravera G. Long-term prefabricated posts versus ation of different adhesive
survival of endodontically cast metal posts and cores. approaches. Acta Odontol
treated, maxillary anterior +%FOUo 4DBOEo
teeth restored with either 8SCBT,5 ,BNQF.5 72. Radovic I, Corciolani G,
tapered or parallel-sided Schirrmeister JF, Altenburg- Magni E, Krstanovic G,
glass-fiber posts and full- er MJ, Hellwig E. Retention Pavlovic V, Vulicevic ZR,
ceramic crown coverage. of fiber posts dependent Ferrari M. Light transmission
+%FOUo on different resin cements. through fiber post: the effect
57. Jung RE, Kalkstein O, Sailer Schweiz Monatsschr Zahn- on adhesion, elastic modu-
I, Roos M, Hämmerle CH. NFEo lus and hardness of dual-
A comparison of composite 65. Kremeier K, Fasen L, Klaib- cure resin cements. Dent
post buildups and cast gold FS# )PGNBOO/*OGMVFODF .BUFSo
post-and-core buildups for of endodontic post type .POUJDFMMJ' 0TPSJP3 4BEFL
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teeth after 5 to 10 years. Int J HPME
BOEMVUJOHNBUFSJBMPO M, Ferrari M. Surface
1SPTUIPEPOUo push-out bond strength to treatments for improving
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dini S. Fiber posts and o cated fiber posts: a lit-
endodontically treated teeth: 66. Ferrari M, Mannocci F, Vichi erature review. Oper Dent
a compendium of scientific " $BHJEJBDP.$ .KÚS o
and clinical perspectives, *"#POEJOHUPSPPUDBOBM :FOJTFZ. ,VMVOL4
ed 1. Wendywood, South structural characteristics of Effects of chemical sur-
Africe: Modern Dentist the substrate. Am J Dent face treatments of quartz
Media. Wendywood, 2006. o and glass fiber posts on
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SS. Survival of Dicor glass- Clavijo V, Andrade MF, Vaz ite resin. J Prosthet Dent
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o cent fiber post. Oper Dent Garcia-Godoy F, Ferrari M.
60. Malament KA, Socransky o The effect of sandblasting
SS, Thompson V, Rekow D. 68. Huber L, Cattani-Lorente M, on adhesion of a dual-
Survival of glass-ceramic 4IBX- ,SFKDJ* #PVJMMBHVFU cured resin composite to
materials and involved S. Push-out bond strengths methacrylic fiber posts:
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Pract Proced Aesthet Dent luting cements. Am J Dent o
4VQQMo 2007;20:167–172. 76. Soares CJ, Santana FR,
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#FVFS' .FZFS-VFDLFM) Toledano M. Cement system Menezes MS. Influence of
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for glass-fiber-supported selection for fiber post lut- on mechanical proper-
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a prospective observa- #VDBM&o carbon/epoxy and glass/
tional clinical study. J Endod #BSBCBOUJ/ .BEJOJ- bis-GMA fiber-reinforced
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62. Ferrari M, Vichi A, Fadda PA, Cerutti F, Cerutti A. o
GM, Cagidiaco MC, Tay Polymerization degree and 77. Valandro LF, Yoshiga S,
'3 #SFTDIJ- 1PMJNFOJ" cementation methods of two de Melo RM, Galhano GA,
Goracci C. A randomized different self-adhesive lut- Mallmann A, Marinho CP,
controlled trial of endodonti- ing cements used for glass #PUUJOP.".JDSPUFOTJMF
cally treated and restored fiber post cementation. bond strength between a
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face conditioning. J Adhes 80. Schmage P, Nergiz I, Marko- of fiber posts: three-point
Dent 2006;8:105–111. poulou S, Pfeiffer P. Resist- bending test and SEM
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R, Naert I, Van Meerbeek of prefabricated coated 2005;21:75–82.
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Mater 2012;28:287–297. 81. Cheleux N, Sharrock PJ. Ferrari M. Fatigue resistance
79. Vano M, Carvalho C, Sedda Mechanical properties of and structural integrity of
M, Gabriele M, García- glass fiber-reinforced endo- different types of fiber posts.
Godoy F, Ferrari M. The influ- EPOUJDQPTUT"DUB#JPNBUFS Dent Mater J 2008;27:687–
ence of storage condition o
and duration on the resist- 82. Grandini S, Goracci C,
ance to fracture of different Monticelli F, Tay FR, Ferrari
fiber post systems. Am J M. Fatigue resistance and
%FOUo structural characteristics
Part 2: or is largely addressed with full crowns,

since endodontically treated posterior
Esthetic considerations
teeth present mostly with large recon-
structions that require optimal stabiliza-
Introduction
tion by full or partial crowns.
In addition to the numerous issues dis- In the anterior zone, however, esthet-
cussed in part 1 of this paper, non-vital JDTDBOCFTUSPOHMZEJTUVSCFECZOFHB-
teeth are frequently esthetically com- tive effects:
promised. This frequently presents sig- Discolouration of the clinical crown.
nificant and special challenges when it Discolouration of the cervical region.
comes to meeting the demand for nat- Discolouration of the gingiva and mu-
ural-looking, esthetically pleasing teeth cosa.
sought by our patients today.
The aim of the second part of this pa- There are various causes of these en-
per is to try to answer several clinically dodontically induced intrinsic discolora-
relevant conceptual questions and to tions:
provide some clinical guidelines regard- Intrapulpal haemorrhage.
ing the management of the esthetic as- Pulpal necrosis.
pects, based on scientific evidence and Incomplete removal of pulp tissue
clinical expertise. during the endodontic treatment.
Endodontic irrigants, medications
Why are most endodontically and root canal filling material (root
treated teeth dark? BOEDFSWJDBM[POF

Restorative materials (cervical zone
The discoloration of endodontically BOEDSPXO

treated teeth is a common observation. Coronal leakage.
In the posterior region, this phenom- Dentin sclerosis.
enon is seldom esthetically disturbing
253
70-6.&t/6.#&3t46..&3
SCIENTIFIC SESSION
Unfortunately almost all root canal seal- the tooth are heavily discolored and do
ers including Zinc Oxide-Eugenol and not respond to the bleaching procedure.
") UPBMFTTFSFYUFOU
MFBEUPEJTDPM-
PSBUJPO BCPWFBMMJOUIFDFSWJDBM[POF Do bleaching procedures lead to
Also the use of MTA, be it grey or white, external resorption?
will ultimately lead to a greyish appear-
ance or darkening of the root.5,6 Cervical root resorption is a serious
Furthermore, the calcification pro- complication that is difficult to treat11,12
cess in the dentin through obliteration and ultimately can lead to tooth loss.
of the dentinal tubules and changes in There are various reasons for this phe-
the free water content before and after nomenon. Orthodontic treatment and
endodontic treatment and through ag- tooth trauma are the most common pre-
ing processes, contributes to an altered disposing factor. Internal bleaching may
optical appearance in addition to the in- increase the combinatory risk, however
creased brittleness.7-10 it seems to be limited to cases where
extensive concentrations of H2O2 com-
How can we improve the color of bined with heat (the thermo-catalytic
UIFUPPUITVCTUBODF #MFBDIJOH NFUIPE

XBT VTFE The presence
of defects at the cemento-enamel junc-
or replacing discoloured coronal
tion seem to play a major role, allowing
dentin?
the bleaching agent to penetrate into the
Although some of the above mentioned periodontal space.15
negative factors can be clinically modi- The recommendations today are
fied, it is evident that a non-vital tooth therefore not to heat the bleaching agent
inevitably loses some esthetic qualities in the access cavity, to seal the residual
in terms of the color. As a matter of prin- root filling well before application of the
ciple, replacing discolored dentin to cor- bleaching agent and to generally use
rect the color is not the preferable op- less aggressive bleaching chemicals
tion from a structural viewpoint. In part 1, instead of high concentrations of H2O2.
the mechanical aspects to support this The best clinical compromise of ef-
axiom have already been extensively fect, side-effects, risks and long-term
discussed. experience is in the use of the so called
Therefore, bleaching the existing “walking bleach technique”16 where,
substance is always the better option, classically, sodium perborate is mixed
if we agree on the principle that “hav- with water.
ing a discolored tooth is preferable to In the author‘s long-term experience,
having no tooth”. Most discolorations this is clinically as efficient as other more
are bleachable except those caused by aggressive chemicals, provided a cor-
metal ions (amalgam, or silver and other rect cervical and coronal seal of the
IFBWZ NFUBM DPOUBJOJOH NBUFSJBMT
2 So bleaching cavity have been realized.
the only indication to remove discolored The cervical seal is preferably achieved
dentin may be if small spots that do not with a modified glass ionomer cement,
contribute to the structural resistance of classically applied at the level of the con-
254
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nective tissue attachment, whereas the further compromise the strength of the
coronal seal is achieved with adhesively residual tooth structure. This is an im-
luted composite to ensure an optimal portant consideration particularly if ad-
penetration of the bleaching agent into ditional reconstructive measures are to
the dentin. Hence, leaving the access be executed26 and if the potential for re-
cavity open and using at-home tech- intervention is taken into account.
niques with open trays is not advisable.17 Second, as mentioned, bleaching
Success largely depends from the ap- agents themselves lead to a weakening
plication duration of the bleaching agent of the tooth structure through the chemi-
oEBZT oUJNFT
BOECZGBSPVUQFS- cal modification of the dentin.27,28 A re-
forms alternative quick in-office tech- cent publication supported the use of
niques in the long run.18 In a recent study sodium perborate mixed with water in
it could also be shown that this concept this respect, since this combination led
compares very favorably to more ag- to a significantly smaller additional open-
gressive mixtures of chemicals in terms ing of the dentinal tubules compared to
of H2O2 leakage at different root locations all other bleaching agents. Interestingly
with and without external defects.19,20 DBSCBNJEF QFSPYJEF DBVTFE UIF
Since cervical defects are difficult to worst effect.29
detect with conventional radiographs Another important consideration is
and require cone beam computed to- the influence of bleaching on dentin
NPHSBQIZ $#$5
UFDIOJRVFT 21 the use bonding. As emphasized in part 1, the
of this less-aggressive concept makes quality of the internal reconstruction af-
additional sense in avoiding added un- ter endodontic therapy is of key impor-
known risks while producing good es- tance in reconstituting the resistance to
thetic results. fracture. Using an adhesive approach is
advisable but technique sensitive and,
Do bleaching procedures weaken in general, all bleaching agents lead to
the tooth – or may dark roots also reduced bond strengths and increased
microleakage. Consequently, the use
be bleached?
of antioxidants has been advocated to
Recent research clearly shows that counteract this effect (eg, sodium ascor-
bleaching chemicals weaken tooth sub- CBUF
BOEPSEFMBZJOHUIFCPOEJOHQSP-
stance. cedure for at least 10 days after washing
Since the endodontic treatment itself out the bleaching agent The antioxi-
already weakens the dentin consider- dant is especially necessary and should
ably through chemical and mechanical be mandatory if bonding with simplified
effects CZ UP JO TUSFOHUI 25 single bond dentin adhesives, or if de-
additional care must be taken if a bleach- layed bonding is not warranted or pos-
ing procedure is being considered. sible.
First of all, internal removal of dis- However, good dentin adhesion can be
colored dentin should be avoided. It achieved if: a) sodium perborate mixed
does not lead to better results with the with water is used to bleach, b) the tooth
described bleaching technique and will is left with saline solution for 7 days after
255
70-6.&t/6.#&3t46..&3
SCIENTIFIC SESSION
Fig 16 $BTF JOJ-

tial radiographic situ-
ation. A carbon com-
posite post had been
placed.
Fig 15 $BTFEJTDPMPSFEOPOWJUBMSJHIUDFOUSBM

incisor with PFM crown, initial clinical situation.
removal of the bleaching agent, and c) conditions – owing to unfavorable ovoid

a scientifically and clinically well estab- root canal configurations and dentin mi-
lished self-etching 2-step dentin bonding crostructure in the deeper parts of the
TZTUFN FH$MFBSGJM4&CPOE
JTVUJMJ[FE root canal – the root should not be
For enamel, the same principle of waiting further compromised by using bleach-
after washing off the bleaching agent is a ing techniques inside the root canal.
simple and successful strategy. Recent As long as the intracoronal bleaching
proposals for new resin formulations that is performed within the access cavity
are supposed to allow immediate bond- reaching to the level where the connec-
ing after bleaching have not proved as tive tissue attachment ends coronally,
effective. the results constitute a sufficient com-
Since adhesion within the root remains promise esthetically,26 even in the criti-
a challenge even in ideal experimental DBMDFSWJDBM[POF 'JHTo

Fig 17 $BTF BCVUNFOU UPPUI BGUFS DSPXO BOE Fig 18 $BTFIPMMPXDPNQPTJUFCVJMEVQGPSJOUFS-
post removal. nal bleaching of coronal part of the abutment tooth.
256
70-6.&t/6.#&3t46..&3
MEYENBERG
Fig 19 $BTFDPNQMFUFECVJMEVQPGBCVUNFOU Fig 20 $BTF HMBTT DFSBNJD DSPXO MBZFSJOH
tooth with bonded fiber post and core, after internal technique.
bleaching with sodium perborate and water.
Fig 21 $BTFGJOBMDMJOJDBMSFTVMU Fig 22 $BTF GJOBM SBEJPHSBQI

showing good adaptation of the short
fiber post and bonded core to the den-
UJOBMXBMMT MJHIUDVSFENBUFSJBMTVTFE

257
70-6.&t/6.#&3t46..&3
SCIENTIFIC SESSION
Internal bleaching is a technique-

sensitive approach. Potential rea-
sons for failures are numerous, with
coronal or apical leakage being the
most frequent, and “short-cut” treat-
ment protocols are more likely to have
QSPCMFNT #PUI UIF DPSPOBM BOE UIF
apical-cervical seal, along with the
optical quality of the access restora-
tion, account for success or failure.
The prognosis of the bleaching pro-
cedure is more prone to recurrence
of discoloration if the tooth became
rapidly discolored after the endodon-
tic treatment.
Subjective and objective satisfaction
of the dentist or the patient may differ
substantially.
Fig 23 Limited light conducting properties of fib-
The potential for intervention and the
er posts with good mechanical properties preclude
the use of long posts, if light-cured materials are to concept of a progressive (conserva-
be used. UJWF
BQQSPBDI EVSJOH UIF MJGFUJNF PG
a discolored tooth are essential. Ag-
gressive reconstructive concepts
What about the predictability and based just on esthetic considerations
and early crowning can lead to prema-
stability of bleaching procedures?
ture tooth loss. Therefore, bleaching
There has been some debate about the instead of removing tooth substance
predictability and long-term effective- is the preferable treatment, both for
ness of internal bleaching, with de- non-reconstructive and reconstruc-
scribed esthetic success rates of around tive cases.26
90% after 2 years, 75% after 5 years and
60% after 16 years. The potential causes May crowns or veneers
for the recurrence of discoloration have compensate darkened coronal
been suggested as: a) the same sub-
tooth structure?
stances as those having caused the ini-
tial discoloration, or b) penetration of pig- First of all it is important to understand
ments from the oral cavity, or c) bacterial the concept of illumination of the oral tis-
reinfection of the root canal system with sues. The tooth with its clinical crown
subsequent infiltration into the cervical and root, the gingiva, the bone and the
and coronal dentin.1 periodontium form an optical unit. Light
From long-term studies and clinical is transmitted by diffuse reflection into
observations, the following can be con- the tissues. It is therefore critical not to
cluded: disturb this delicate system with discol-
258
70-6.&t/6.#&3t46..&3
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orations or by the introduction of inad- nates and all-ceramic partial crowns,

equate opaque or dark restorative ma- as a wide variety of all-ceramic crown
terials. Of particular importance in this systems exist today with excellent opti-
respect is a soft color transition from the cal properties and long-term survival, in
cervical third of the clinical crown into particular, the new generation of glass-
the adjacent gingival tissues. ceramic materials. In addition, these
Since the mid 1960s, dental techni- materials allow the provision of bonded
cians and prosthodontists tried to imple- full coverage “veneer type” crowns with
ment this concept in order to improve SFEVDFE QSFQBSBUJPO TJNJMBS UP EF-
the esthetics of full crown margins. In the HSFFWFOFFSQSFQBSBUJPO 'JHTo

1980s, PFM crowns without metal collars Consequently, the management of
were introduced, using shoulder and ve- discolored tooth substrate becomes
neering porcelains with better light con- increasingly important. It should be re-
ducting properties to illuminate the adja- membered that all attempts to ‘mask out’
cent tissues. Despite these efforts, discolored tooth substance will invari-
the results were never completely sat- ably end up with increased opacity and
isfying when the underlying tooth struc- therefore unnatural reflection of the light
ture was dark, or if there were vital and instead of a diffuse reflection inside the
rather translucent teeth to be matched. materials. This is of particular importance
Hence the search and development of when veneering a tooth with a discolored
true light conducting materials as frame- cervical zone, as the fine veneer margins
works with lower opacity than metal or cannot create the appropriate color tran-
the pre-existing all-ceramic cores. sition from the tooth crown into the gin-
Today, in the case of vital teeth with giva. If a full crown is provided in such a
adequate tooth substance, more con- case, a pleasing result can be achieved
servative bonded porcelain restorations, by using opaque all-ceramic framework
such as veneers and anterior partial all- materials, provided that adjacent struc-
ceramic crowns, are increasingly the tures are also more opaque and the gin-
treatment of choice as compared to full gival tissue is thick, but this is rather the
crowns, due to esthetic, technical and exception than the rule.57,58 The same is
biological advantages. It is impor- true if opaque cements are used to cover
tant to understand that the success of dark underlying substance.
these restorations is largely based on Above all, trying to mask out dis-
the esthetic and mechanical advantag- colored teeth should not result in over-
es of the natural uncompromised tooth preparation:59 the mission statement of
substrate as the foundation of the resto- Hippocrates primum nihil nocere (first
ration rather than an artificial substrate. EPOPIBSN
TIPVMEBMTPCFUIFHVJEJOH
As a consequence of this success, the QSJODJQMFIFSF 'JHTBOE

concept has been extended to endo- Thus the clinical concept for man-
dontically treated teeth, with the idea be- agement of discolored tooth substance
hind to convert darkened tooth structure should always consider internal bleach-
into vital looking tissues. Naturally ing as first option, even if the result will
this is not only relevant to bonded lami- not be absolutely perfect.
259
70-6.&t/6.#&3t46..&3
SCIENTIFIC SESSION
Fig 24 $BTF EJTDPMPSFE BCVUNFOU UFFUI XJUI Fig 25 $BTFGJOBMQJDUVSFXJUI1'.DSPXOT%VF
cast post and cores, leading to a disturbance in the to the symmetry of the case, the suboptimal color
illumination of the adjacent tissues. transition from the abutment margins into the gin-
gival tissues fortunately does not disturb too much
in this case.
If the tooth needs an additional indi- is similar to what can be observed within
rect restoration, a veneer or full cover- the enamel of natural teeth.
age veneer-crown is an attractive and One drawback certainly is if the dis-
less invasive solution. In the author’s colored tooth has already been restored
own experience over the last 15 years with a post. If removal of the post without
from when the concept first was used, risk of damage to the root is viable, then
long-term results for esthetics and sur- the internal bleaching can be performed
vival rates in both types of restorations before a new post and core is fabricat-
are comparable to all-ceramic crowns. ed. If this is considered too risky, metallic
However, in the literature there are only posts and cores can at least be masked
studies with vital teeth available at the with a tooth-colored opaquer and com-
moment, which show a survival rate of posite to avoid to improve the substrate
PWFS ZFBST GPS WFOFFST BOE color for an all-ceramic framework.
100% for extended veneers over 5 This leads to the next question: Can
years.60,61 The observation of small su- tooth-colored posts enhance the color
perficial cracks not influencing survival of dark roots?
Tooth-colored posts have long been
advocated in esthetic dentistry. Since
early trials around 1965 by John McLean
with Alumina posts, the concept has
been further developed to mechanically
more reliable posts, with the introduc-
tion of the first Zirconia posts in 1995
and the first fiber posts in 1990.
The proposed reasons for tooth-color-
ed posts for esthetics in root treated
teeth are:
To illuminate the root and cervical re-
Fig 26 Case 5: left central incisor with polished
cast post and core, right lateral incisor with tooth- gion and thus brighten up darkened
colored post and core. tooth substance.
260
70-6.&t/6.#&3t46..&3
MEYENBERG
To prevent any darkening effect of a post by photospectroscopic studies67 and

on non-discolored tooth substance. may lead to incorrect clinical recom-
To create a tooth-colored basis for the mendations in specific cases.
core and the crown. However, given the clinical and sci-
entific evidence, there is actually little
While the first reason has already been reason to take out existing well adapted
disputed early on by experienced cli- and luted cast post and cores if the re-
nicians not being able to see any dif- maining dentin itself is not discolored
ference in the color between a metallic and does not require bleaching. It is
post and a tooth-colored post put into clinically sufficient to mask the buccal
the same dark root under natural light part of the metal with a tooth-colored
conditions, the second two points are opaquer. If space and residual thick-
good arguments for tooth-colored posts. ness of a gold alloy post and core do
In fact a recent study showed that there not allow to do this, another smart ap-
is no difference in the cervical color of proach is to polish the buccal part of
abutment teeth between white and me- the exposed metal to a high gloss, thus
tallic posts, however tooth-colored posts creating total reflection of the light at the
and cores were beneficial for the overall core surface.68 This concept has been
color of the all-ceramic crowns.65 This widely used by the author for years with
is in line with observations of clinicians no adverse effects regarding the reten-
aware of these subtle differences.66 UJPOPGUIFMVUFEDSPXOT 'JHTo

Some care must be taken when trying In conclusion, it can be stated that
to translate in vitro studies about color the color of the remaining tooth sub-
influences into clinical practice. Some strate is of much greater importance
subtle components of the color, such as than the color of the post and cannot
the quality of the internal diffuse reflec- be influenced positively by the post in
tion depending on the intensity of light the cervical and apical region, however
and the softness of the transition into the having a tooth-colored post is beneficial
marginal gingiva cannot be measured for the core.
Fig 27 Case 5: final picture showing the good Fig 28 Case 6: abutment teeth with various de-
reflection properties of the polished metal part of the grees of discolorations.
left central abutment tooth.
261
70-6.&t/6.#&3t46..&3
SCIENTIFIC SESSION
sue. In oral implantology, however, some

studies have been performed looking at
the influence of various abutment ma-
terials on the color of the existing soft
tissues, and how variations in the soft
tissue thickness can modify the overall
color resulting from abutment and cov-
ering soft tissue. Since these abutments
all have a subgingival component and a
titanium implant base, this would appear
to offer a situation well in line with a dis-
colored root. Comparing zirconia, pol-
ished gold alloys and machined titanium
in a pig model, a visible difference was
Fig 29 Case 6: layered glass ceramic crowns always present if the tissue thickness
with internal opaquer and varying opacities of XBT CFMPX NN #FUXFFO UP NN
frameworks.
in thickness, only zirconia (regardless of
BOZWFOFFSJOH
EJEOPUJOEVDFBDIBOHF
Can soft tissue thickening *GUIFUIJDLOFTTXBTNNPSNPSF UIF
compensate darkened cervical material itself had no influence.69 In a
human study, comparing metal abut-
root structure?
ments and PFM crowns with all-ceramic
A soft color transition from the crown abutments and crowns, the latter be-
into the soft tissue is essential for an haved better, but there was still a visible
esthetically pleasing result. In the pre- difference for both groups compared
ceding pages, the focus was placed to the adjacent teeth.70 Another study
on the root and crown of the tooth and presented similar results,71 although no
how negative effects can be managed. correlation between the thickness of the
However, if discolorations are still pre- mucosa and the respective amount of
sent in the critical cervical supra- and discoloration could be found.
subgingival zone, it makes sense to In essence, the fiber content and the
consider influencing the soft tissue degree of keratinization may play a more
characteristics. important role for the masking ability
The margin of the soft tissue cover- than the soft tissue thickness alone. In
ing the cervical part of the root plays this respect, the use of a connective tis-
an important role as a “curtain” to hide sue graft taken from the palate with its
unpleasing structures. In addition, the higher content of collagen fibers is the
buccal bone plate has also some mask- most promising approach using an en-
ing effect over a discolored root. A thick velope technique to improve the esthetic
bone plate can virtually completely mask integration of the augmented tissue.
out the root discoloration. In periodontol- Some modifications in the technique, in-
ogy, there is little information available cluding a microsurgical approach, have
about the masking effect of the soft tis- been introduced to further decrease
262
70-6.&t/6.#&3t46..&3
MEYENBERG
Fig 30 Case 6: final picture of the four anterior Fig 31 Case 6: final picture of the right side,
teeth, showing an acceptable color transition be- showing an acceptable color transition between the
UXFFOUIFQPOUJD SJHIUMBUFSBMJODJTPS
BOEUIFPUIFS QPOUJD MBUFSBMJODJTPS
UIFWJUBMDBOJOFBOEUIFOPO
abutment teeth. vital discolored central incisor.
healing complications and unesthetic tissue contours and preventing further

tissue scars. exposure of discolored root surfaces.
An additional benefit of this approach
is the easier tissue handling during the
reconstructive phase and the preven- Final consideration:
tion of post-reconstructive recessions
at what point should we
over time, which may expose further dis-
give up and extract?
colored root parts. Indeed, since many
of the discolored teeth exhibit some cer- It is fair to state that a tooth should be
vical tissue loss over time anyway, this saved as long as there is a predictable
procedure can also be considered as a way to functionally and biologically do
preventive treatment of a cervical reces- so with a reasonable prognosis. This
sion,76 dealing not primarily with health, 2-part article has shown various possi-
but with stable, esthetic tissue levels. It bilities to overcome classic biomechani-
may also serve to counteract the loss in cal and esthetic problems with respect
cervical tissue height that occurs by tis- to minimizing reconstructive risks. The
sue modeling during the aging process, basis for reconstructive survival in the
which is more noticed around discolor- context of this article, however, is the
ed roots and is independent of the pres- quality of the endodontic treatment as
ence or absence of dental restorations. the starting point.
As a conclusion, soft tissue thicken- It can also be stated that today too
ing may not completely solve the prob- many teeth are extracted in favor of im-
lem of the discolored cervical hard and plants, with insufficient regard for the
soft tissue zone, but it can improve the extensive reconstructive options avail-
overall result by at least stabilizing soft able to maintain them. Furthermore, the
263
70-6.&t/6.#&3t46..&3
SCIENTIFIC SESSION
short- and long-term biologic, esthetic previous studies and may produce less
and technical complications of implants successful results than expected or than
are not fully appreciated.77 Unfortu- achieved with the classic concepts of
nately, poor endodontic treatment is still experienced endodontic specialists. A
a major factor in premature tooth loss. MPOHUFSNTUVEZPWFSZFBST DPOEVDU-
However, if performed correctly, results ed in a private practice by a specialist,
are at least as good as replacement with documented an overall success rate of
implants for single units.77 It is striking 91.5%.80 Initial endodontic treatments
that despite this fact, today a tendency IBEBIJHIFSTVDDFTTSBUF
DPN-
towards a more extraction-oriented re- pared to the non-surgical retreatment
constructive concept can be observed HSPVQ
5IJT TIPXT WFSZ DMFBSMZ
in practice. There are two main reasons how important the quality of the first en-
for this. dodontic treatment is for the long-term
The first reason is that in clinical de- success. In addition, the coronal resto-
cision-making, the predictability of the ration has a significant influence in the
whole procedure is of primary impor- success of the endodontic treatment.
tance in respect of complications and Thus, to strive in every respect for an
cost. Obviously there is some pessimism optimal restoration is as essential as an
among clinicians regarding the progno- optimal endodontic treatment alone.81
sis of endodontic treatments in general The second reason is that measures
and this is not completely unfounded. to potentially save a compromised tooth
The combined failure rate of endodonti- can later preclude the placement of
cally treated teeth in general practice is an implant or make it very demanding.
higher than described in earlier reports: Therefore, if an endodontic retreatment
PWFSZFBSTBDVNVMBUJWFGBJMVSFSBUFPG due to recurrent apical pathology is
up to 20% is documented.78 In general, considered, above all, careful diagnos-
the outcome of endodontic treatments tic steps including soft and hard tissue
may have been overestimated in previ- probing and radiographs are required.
ously published reviews because of the Conventional radiographs do not allow
general lack of correct apical diagnosis. proper analysis and interpretation of the
*GIJHISFTPMVUJPO$#$5JTOPUVTFE PGUFO root and remaining bone housing around
the endodontic status cannot correctly the root. The possible causes for the
be analyzed. The authors of a current endodontic failure (eg, crack, fracture,
review state: “In conclusion, the serious perforation, insufficient root filling or ac-
limitations of longitudinal clinical studies DFTTPSZSPPUDBOBMT
DBOOPUCFQSPQFSMZ
restrict the correct interpretation of root established without a high-resolution
canal treatment outcomes. Systematic $#$5BOEDPOTFRVFOUMZ UIFQSPHOPTJT
reviews reporting the success rates of and appropriate treatment approach
root canal treatment without referring can only be determined based on an
to these limitations may mislead read- accurate diagnosis.
ers”.79 Therefore, the trend towards sim- Periapical microsurgery should be
plified endodontic protocols may also performed exclusively if non-surgical
be based on incorrect interpretations of endodontic retreatment is not viable,
264
70-6.&t/6.#&3t46..&3
MEYENBERG
and if the remaining bone housing is suf- tal tooth-supported restorations, there is
ficient. The surgical approach seems to no clear winner in terms of sustainabil-
be more successful in the short term, but JUZ FTUIFUJDT CJPMPHZBOEGVODUJPO#PUI
MFTTTPJOUIFMPOHUFSNPWFSUP solutions require a perfect synergy of all
6 years for the non-surgical approach, the fields of specialties involved and the
WFSTVTPWFSNPSFUIBOZFBSTGPS treatment steps to achieve the optimal
the surgical approach.82 In addition, the result for the individual patient.
added bone loss caused by the surgical
access osteotomy and incomplete heal- Acknowledgements
ing can make the placement of an im- The author would like to thank Dr Tidu Mankoo for
plant after a potential failure and eventful the systematic and thorough editing of the whole es-
TBZ %S'SBOL1BRVÏGPSIJTTVQQPSUJOUIFEJTDVTTJPO
extraction very difficult.
of the endodontic aspects, and Walter Gebhard and
Ultimately, when we examine the treat- Nic Pietrobon for their contribution in creating the
ment outcome of implant versus non-vi- dental ceramics.
References, Part 2 6. Jacobovitz M, de Lima RK. #BLMBOE-, "OESFBTFO+0

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SCIENTIFIC SESSION

The ideal restoration of endodonti-

Konrad Meyenberg, DMD

Correspondence to: Konrad Meyenberg

E-mail: [email protected]; Web: www.zahnaerzte-rennweg.ch

Abstract Clinically, most of non-vital teeth must

protective neuromuscular inhibition Recent research shows that dentin

what is the ideal concept? dibular molars and maxillary premolars

are posts destructive? there are very effective adhesive tech-

clinically the concept of choice; it can be not be compensated simply by adhe-

the structural condition, various types of tablishment of proper bonding be-

Therefore, both a sensitive indication

Fig 12 Case 2: initial radiograph of second lower

Concluding remarks regarding Materials with potential of corrosion

lary molars. J Prosthet Dent 'FSSBSJ. $BHJEJBDP.$ /H$$ %VNCSJHVF)#

clinical study on post-and- (ØNF[1PMP. -MJEØ# 71. Sterzenbach G, Karajouli G,

Part 2: or is largely addressed with full crowns,

treated teeth dark? BOEDFSWJDBM[POF

UIFUPPUITVCTUBODF #MFBDIJOH NFUIPE

Fig 16 $BTF  JOJ-

Fig 15 $BTFEJTDPMPSFEOPOWJUBMSJHIUDFOUSBM

removal of the bleaching agent, and c) conditions – owing to unfavorable ovoid

Fig 21 $BTFGJOBMDMJOJDBMSFTVMU Fig 22 $BTF  GJOBM SBEJPHSBQI

Internal bleaching is a technique-

orations or by the introduction of inad- nates and all-ceramic partial crowns,

To prevent any darkening effect of a post by photospectroscopic studies67 and

sue. In oral implantology, however, some

healing complications and unesthetic tissue contours and preventing further

References, Part 2 6. Jacobovitz M, de Lima RK.  #BLMBOE-, "OESFBTFO+0

16. Spasser HA . A simple electron microscopic study. 4PV[B(BCSJFM"& 7JUVTTJ

)PMNTUSVQ( 1BMN". 'SBEFBOJ. "RVJMBOP" compatible Materials Sys-

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Concluding remarks regarding Materials with potential of corrosion

lary molars. J Prosthet Dent 'FSSBSJ. $BHJEJBDP.$ /H$$ %VNCSJHVF)#

clinical study on post-and- (ØNF[1PMP. -MJEØ# 71. Sterzenbach G, Karajouli G,

Fig 16 $BTF JOJ-

Fig 15 $BTFEJTDPMPSFEOPOWJUBMSJHIUDFOUSBM

Fig 21 $BTFGJOBMDMJOJDBMSFTVMU Fig 22 $BTF GJOBM SBEJPHSBQI

Internal bleaching is a technique-

To prevent any darkening effect of a post by photospectroscopic studies67 and

References, Part 2 6. Jacobovitz M, de Lima RK. #BLMBOE-, "OESFBTFO+0

16. Spasser HA . A simple electron microscopic study. 4PV[B(BCSJFM"& 7JUVTTJ

)PMNTUSVQ( 1BMN". 'SBEFBOJ. "RVJMBOP" compatible Materials Sys-