A new classification system for the restoration of

root filled teeth

 CONTENTS

 Introduction
 Changes occurring in an endodontically treated teeth
 Important factors in selecting the restorative approach
1. Residual crown structure
2. Residual root structure
3. Compromised tooth reconstruction versus value of the tooth in the treatment plan
4. Function and tooth position in the arch

 New classification
 Discussion
 Conclusions
 References
 INTRODUCTION
• Endodontic treatment is largely performed on teeth significantly affected by caries, multiple repeat
restorations and/or fracture.

• Already structurally weakened, such teeth are often further weakened by the endodontic
procedures designed to provide optimal access and by the restorative procedures
necessary to rebuild the tooth.

• Hence it is accepted that these teeth tend to have a lower lifetime prognosis.

• They require special considerations for the final restoration, particularly where there has been
extensive loss of tooth structure.

• The special needs involve ensuring both adequate retention for the final restoration and
maximum resistance to tooth fracture. Which can be collectively termed as anchorage

• Endodontic success depends not only on the quality of the root canal treatment, but
also on timely coronal restoration of the compromised tooth
Is final restoration after endodontic treatment important

• Good restorations + good endodontic treatments

resulted in absence of periapical inflammation in 91.4%.
• Poor restorations + poor endodontic treatments
resulted in the absence of periradicular inflammation in
only 18.1%.

• Poor endodontic treatment + good restorations yielded

a success rate of 67.6%.

1Periapical status of endodontically treated teeth in relation to the technical

quality of the root filling and the coronal restoration.H. A. Ray and M. Trope
International Endodontic Journal, vol. 28, no. 1, pp. 12–18, 1995.
Changes occurring in an endodontically treated teeth

The major changes in the endodontically treated teeth include

• loss of tooth structure

• altered physical characteristics (functional loss)

• altered esthetic characteristics of the residual tooth

 Loss of tooth structure:

 The loss of tooth structure is always not a direct result of endodontic treatment
 In most cases it is the previous episode of caries, fracture, tooth preparation,
restorations.
 Gutmann (1992) showed that endodontic access into the pulp chamber destroys the
structural integrity of the coronal dentin—> greater flexing of the tooth under occlucsal
loading
 Altered physical characteristics:

 Several studies have proposed that the dentin in endodontically treated teeth is
substantially different than dentin in teeth with “vital'’'' pulps
 It was thought that the dentin in endodontically treated teeth was more brittle
because of water loss and loss of collagen cross-linking.
 Huang et al. (1991) compared the physical and mechanical properties of dentin
specimens from teeth with and without endodontic treatment at different levels of
hydration.
 They concluded that neither dehydration nor endodontic treatment caused
degradation of the physical or mechanical properties of dentin
 Thus it is the loss of structural integrity that plays a major role in fracture of endodontically treated teeth.

• Access preparations result in increased cuspal deflection during function and increase the
possibility of cusp fracture and microleakage at the margins of restorations. ( Panitvisai P,
Messer HH. 1995)

Randow and Glantz (1992)

reported that teeth have a protective feedback mechanism is lost when the pulp is
removed, which also may contribute to tooth fracture
 Altered aesthetic characteristics:
 Biochemically modified dentine modifies light refraction through the tooth and modifies its appearance

 Improper endodontic cleaning and shaping of the coronal area contribute to discoloration by degradation of
vital tissues left in the pulp chamber
.

 Medicaments and restorative materials used during the treatment

 Important factors in selecting the restorative approach

Residual crown structure

• One of the most important factors influencing the success of a restoration is the amount of
remaining supragingival tooth structure

• vertical band of tooth structure at the gingival aspect of a crown preparation.

• The ferrule should be a minimum of 1 – 2 mm high, have parallel axial walls, completely encircle the
tooth, end on sound tooth structure and not invade the attachment apparatus of the tooth.

The purpose of a ferrule

• improve the structural integrity of the pulp less tooth

• It increases the mechanical resistance of a
post/core/crown restoration by reducing the potential
for displacement

Consequences of Inadequate Ferrule

• root fracture
• Cement failure and post loosening
• Post fracture
insufficient ferrule length, even where
margins are placed subgingivally
 Residual root structure

crown-to-root ratio

• 1 : 1 ratio has been recommended as the minimally acceptable necessary for resisting lateral forces
when the periodontium is healthy and the occlusion is controlled

• Long-term maintenance of a tooth with an unfavourable crown-to-root ratio, due to the presence of
reduced alveolar bone support, might lead to increased mobility and possible periodontal issues
 Compromised tooth reconstruction versus value of the tooth in the
treatment plan

• When a tooth is to be restored with a crown or has to act as an abutment for a fixed/removable
prosthesis, the cost ,amount of work involved must be considered, along with endodontic and
periodontal issues

• Loss of retention and fractures of both teeth and restorations in fixed and removable
prosthodontics have been shown to be more frequent when the distal abutments are root
filled.

• In a retrospective clinical study comparing 1273 root filled teeth as abutments or crowns,
the success rate related to the greater lateral functional stresses was found to be higher for
single crowns than for fixed bridges, removable prosthesis
 Function and tooth position in the arch
• Occlusal load is key to treatment planning for root filled teeth

• In the case of excessive occlusal wear, more destructive loadings are expected

• Understanding occlusal problems and planning an appropriate reinforcement of the

tooth to be treated may help to reduce future failure risk

• The position of the tooth in the arch is important in treatment planning

• Maxillary posterior teeth are more likely to fail than similar mandibular teeth

• Considerable differences exist between anterior and posterior teeth in the indications for
fibre posts
The aim of this new classification was to help the clinician to select the most appropriate
treatment plan for restoring root filled teeth
 Class 0 (no post – composite core build-up)

• Unless the destruction of coronal tooth structure is extensive,the pulp chamber and canals provide
adequate retention for a core build-up

Class 0: >50% of coronal structure remaining advantage

• tooth substance is preserved and the clinical

procedure is easier to achieve
 Class 1 (fibre post)

• Post placement is recommended in anterior teeth and premolars with compromised tooth structure (<50%

• The placement of a post is indicated when two or fewer walls are present in anterior teeth and premolars

• over a 2-year observation period, concluded that fibre post placement significantly reduced failure risk for
root filled premolars

• In the case of molars, there is no need for a post, except in cases of totally missing coronal tooth
tissue and insufficient pulp chamber surface

<50% of remaining coronal structure

 Class 2 (pre-restorative procedures are needed:
orthodontic extrusion or crown lengthening)

• Post placement cannot compensate for total or partial ferrule loss.

• A fibre post might be placed only after orthodontic or surgical crown lengthening

disadvantages.

• treatment delay
• patient discomfort
• Additional cost
• Increased crown root ratio
 Class 3 (gold cast post)

• If a ferrule is not possible (either periodontally or orthodontically), but the patient

still prefers to save the tooth, a gold cast could provide a possible alternative

• There are several long-term clinical studies that report high success
rates with cast gold posts

drawbacks

Additional cost and Clinical time required

need to place a temporary crown
risk of bacterial contamination during temporization
Class 4 (extraction)

In some cases, treatment and restoration of the compromised

root filled tooth can be too complex (no ferrule,
retreatment, ortho- or perio-crown lengthening,
post, crown) and time-consuming with no predictable
 Discussion
 The purpose of this review is to present a classification for the restoration of root filled teeth, which
seeks to be clear, understandable and helpful for the clinician.

Dietschi et al. (2008) published

recommendations for the treatment of root filled
teeth, with a classification according to the clinical
situation.
Peroz et al.
(2005) conducted a literature review based on in
vitro studies to draw up guidelines for post and core
root filled teeth reconstruction
 Conclusions

 the decision-making process in the restoration of root filled teeth is complex and should
consider the following factors

 amount and quality of tooth structure,

 tooth position in the arch and
 anatomy and function

 All these clinical situations can be classified in order to guide the clinician in the
decision-making process.
 References
 M. Zarow, A. Ramırez-Sebastia (2017)A new classification system for the restoration of root
filled teeth : a review

 Dietschi D, Duc O, Krejci I, Sadan A (2008) Biomechanicalconsiderations for the restoration

of endodontically treated teeth: a systematic review of the literature,

 Peroz I, Blankenstein F, Lange KP, Naumann M (2005) Restoring endodontically treated teeth
with posts and cores–a review

 Cohen – Pathways of the pulp

 Schwartz: Post Placement and Restoration of Endodontically Treated Teeth: A Literature

Review JOE Vol. 30, no. 5, May 2004
Thank You