Titelblatt
Copyright-Seite
Foreword
Preface
Further Reading
Acknowledgements
Contributors
Chapter 1 The First Step: the Endodontic Treatment
Aim
Outcome
Introduction
Stages of Root Canal Treatment
Preoperative Assessment and Preparation
Preparation of the Root Canal Space
Access cavity preparation
Instrumentation and disinfection of the root canal space
Sealing the Root Canal Space
How Do Endodontically Treated Teeth Differ From Vital Teeth?
Why and When to Restore the Root Canal Treated Tooth
When Is Endodontic Retreatment Required?
How Successful Is Endodontic Treatment?
Conclusion
Further Reading
Chapter 2 Adhesion and the Root-filled Tooth
Aim
Outcome
Background to Contemporary Adhesive Systems
Three-step Systems
Two-step Systems
One-step Systems
Anatomical Considerations in Adhesion to Root Canal Dentine
Potential Interferences with Dentine Bonding Caused by Endodontic Materials
Sodium Hypochlorite
Chelating Agents
Calcium Hydroxide
Endodontic Sealers and Gutta-Percha
Adhesive Restorations for Root Canal Treated Teeth
Restorative Materials for Root-filled Teeth
Build-up of an Adhesive Composite Core Without Using a Post
Further Reading
Chapter 3 Crowning Root Canal Treated Teeth
Aim
Outcome
Introduction
Anterior Teeth
Restorative Options for Anterior Teeth
Composite filling
Ceramic or composite veneer
Metal-ceramic crowns
Captek Auro Galva Crown, Sintercast
All-ceramic crowns
Gold-resin crowns
Resin crowns
Posterior Teeth
Clinical Choices for Posterior Teeth
Amalgam restoration
Direct composite
Gold onlays
Composite and ceramic onlays
Metal-ceramic crowns
All-ceramic crowns
Success of the Root Filling
Teeth Without Apical Periodontitis
Teeth With Apical Periodontitis
Indications for Crowning
Anterior Teeth
Posterior Teeth
Crown Preparation
Tooth Reduction
Finishing Lines for Single Crowns
The Preparation for Bridge Abutments
Crown Cementation
Further Reading
Chapter 4 Fibre Posts
Aim
Outcome
Introduction
Fibre Posts
Mechanical Properties
Adhesion to Composite
Clinical Studies
Cementation of Fibre Posts
Single-rooted Teeth
Multi-rooted Teeth
Debridement
Re-access and Preparation
Post Length
Isolation
The Use of Matrices
Bonding
Composite Cement
Insertion of the composite into the root canal
Insertion of the Post
The Composite Core Build-up
Clinical Sequence of Post Cementation and Crown Build-up (Fig 4-11a-l)
Further Reading
Chapter 5 Problem Solving in the Restoration of Teeth with Fibre Posts
Aim
Outcome
Introduction
Customising Fibre Posts
IPN Fibre Posts
Clinical Case
Further Reading
Chapter 6 Understanding the Failure of Adhesive Restorations in Root Canal Treated Teeth
Aim
Outcome
Failures
Post-core Decementation
How to minimise the risks of post-core decementation
Procedure for the management of post-core decementations
Detachment of the Composite Core-crown
Fibre Post Fracture
The risk of post fracture may be minimised by:
Management of a fractured fibre post
Root Fracture
The risk of root fracture may be minimised in a number of ways including:
Treatment of root fractures
Failure of Intracoronal Restorations
The Risk of Secondary Caries May Be Reduced By:
Chipping
Fracture of the Root
Further Reading
Chapter 7 Endodontic Retreatment of Teeth Restored with Adhesive Techniques and Fibre Posts
Aim
Outcome
Introduction
Diagnosis
Armamentarium
Working with magnification
Principles of Post Removal
Rotary instruments
Ultrasonic devices
Procedure
Further Reading
Chapter 8 The Restorability of Broken Down Teeth: the Decision-making Process
Aim
Outcome
Objectives of Restoring a Severely Compromised Tooth
Restoration of Compromised Teeth
Prognosis
Prosthodontic Prognosis
Remaining Coronal Tooth Structure
Presence of Fractures
Crown Fracture
Crown Fracture
Symptoms
Clinical features
Diagnosis
Clinical
Radiographic
Management
Root Fracture
Root Fracture
Symptoms
Clinical features
Clinical diagnosis
Radiographic diagnosis
Management
Protection against Fracture
Coronal Seal
Ferrule Effect
Suitability for a post
Occlusal Factors
Aesthetic Factors
Periodontal Prognosis
Crown Lengthening
Perio-endo Lesions
Endodontic Prognosis
Determinants of Endodontic Success
Iatrogenic Factors
General Factors
Alternative Options
Extraction
Implant Placement
Limitations of implants
Bridges
Conventional fixed bridge
Minimal preparation resin-bonded bridgework
Removable Partial Denture
Conclusion
Further Reading
Quintessentials of Dental Practice – 40
Endodontics – 4
British Library Cataloguing in Publication Data
Mannocci, Francesco
Adhesive restoration of endodontically treated teeth. – (Quintessentials of dental practice; v. 40)
1. Dentistry, Operative 2. Root canal therapy
3. Prosthodontics
I. Title II. Cavalli, Giovanni III. Gagliani, Massimo
617.6′9
ISBN: 1850973210
Copyright © 2008 Quintessence Publishing Co. Ltd., London
All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without the written permission of the publisher.
ISBN: 1-85097-321-0
Adhesive materials and techniques, together with advances in fibre posts, have revolutionised the restoration of root canal treated teeth. This revolution offers many new exciting opportunities, but has created new challenges. Adhesive restoration of endodontically treated teeth – the latest, keenly awaited addition to the widely acclaimed Quintessentials of Dental Practice series, provides a concise, highly practical overview of modern principles and procedures for the restoration of root canal treated teeth in clinical practice. The information and guidance included in this volume is of immediate practical relevance.
If you are still using traditional approaches to restore root canal treated teeth, apply bonding procedures, but in a limited range of situations, or wish simply to better understand where, when and how to use fibre posts and associated materials, then this book should be a priority on your “must read” list.
For those who have already purchased and read volumes in the Quintessentials series, the format will be familiar – easy to read, authoritative text, accompanied by numerous high-quality illustrations, with each chapter concluding with carefully selected suggestions for further reading. All of this condensed into a book which takes only a few hours to read, with the prospect of a huge return for your time and effort. For many, the restoration of root canal treated teeth will never be the same again.
Another carefully crafted, well-illustrated volume, further expanding and enhancing the Quintessentials series – one of the most efficient and effective ways to learn about, understand and apply modern concepts and procedures in clinical practice.
Congratulations to the authors for a job well done.
Nairn Wilson
Editor-in-Chief
The restoration of root canal treated teeth has changed considerably in recent years. Dentine bonding systems, composite resins and fibre posts have largely replaced amalgam cores and cast metal posts; all-ceramic and composite crowns have superseded metal-ceramic crowns in the management of aesthetic problems. Many universities across the world are now teaching the use of fibre posts and composite as the principal means of restoring root-filled teeth.
Key advantages of contemporary adhesive techniques include:
Immediate post-endodontic placement of a post and core build-up.
Design and construction of the post-endodontic restoration under the direct control of the dentist.
Securing an immediate and enhanced post-endodontic coronal seal.
Provision of restorations with improved aesthetics.
Ability to preserve and bond to tooth tissue which would be removed in conventional, non-adhesive techniques.
This is a book on adhesive restorations. As a consequence, other techniques are not considered in any detail. This does not mean that non-adhesive restorations such as Nayyar cores and cast metal posts are no longer valid modalities of treatment, but the evidence supporting the use of fibre posts and composite exceeds the evidence in favour of metal posts and cores.
The aim of this book is to provide the general practitioner with principles and techniques for the adhesive restoration of root canal treated teeth. Most of the techniques described in this book have been used and refined by the authors over the past 12 years; most of them have also been tested in two clinical studies published in peer-reviewed journals. As this is a practical book, the scientific evidence supporting our work is not described in detail. The reading lists contain references to relevant clinical and scientific data.
In addition to considerations of restoration placement, consideration is given to retreatment, including the removal of fibre posts, which may present special challenges for the general practitioner.
Discussion of the restorative decision-making processes is included in the concluding chapter, to be read subsequent to the description of the adhesive restorative options for the restoration of root canal treated teeth.
Francesco Mannocci
Giovanni Cavalli
Massimo Gagliani
Mannocci F, Qualtrough AJ, Worthington HV, Watson TF, Pitt Ford TR. Randomized clinical comparison of endodontically treated teeth restored with amalgam or with fibre posts and resin composite: five-year results. Oper Dent 2005;30:9–15.
Mannocci F, Bertelli E, Sherriff M, Watson TF, Ford TR. Three-year clinical comparison of survival of endodontically treated teeth restored with either full cast coverage or with direct composite restoration. J Prosthetic Dent 2002;88:297–301.
Many thanks to Nairn Wilson and Tom Pitt Ford for their continuing support and encouragement.
Special thanks to John Whitworth. This book would not exist without his help.
We would like to thank Luca Boschian, Andrea Felloni and Dario Mezzanzanica for their invaluable support, together with Riccardo Cantoni for his outstanding technical support in respect of the crown and bridgework illustrated in this book.
We would also like to thank Dr Keith Cohen for providing the implant images of Chapter 9.
Bhavin Bhuva BDS, MFDS, RCS (Eng), MClinDent student in Endontology, King’s College London Dental Institute at Guy’s, King’s College and St Thomas’s Hospitals London, UK.
Giovanni Cavalli MDS, private practice, Brescia, Italy.
Laura Figini DDS, private practice, Milan, Italy.
Massimo Gagliani MD, DDS, Associate Professor of Endodontics and Restorative Dentistry, University of Milan, Italy.
Fabio Gorni DDS, private practice, Milan, Italy.
Francesco Mannocci MD, DDS, PhD, Senior Lecturer in Endodontology/Honorary Consultant in Restorative Dentistry, King’s College London Dental Institute at Guy’s, King’s College and St Thomas’s Hospitals London, UK.
Shanon Patel BDS, MSc, MClinDent, MFDS RCS (Eng), MRD RCS (Edin), Specialist Endodontist, King’s College London Dental Institute at Guy’s, King’s College and St Thomas’s Hospitals London, UK, and private practice, London, UK.
To describe the principles of root canal treatment and their impact on the subsequent restoration of the tooth.
After reading this chapter, the reader should have a clearer understanding of the role of microbial infection in periapical disease, the rationale for each stage of root canal treatment, and the importance of a suitable post-endodontic restoration. The reader should also appreciate the impact of each stage of root canal treatment on the subsequent restoration of the tooth.
The purpose of root canal treatment is to prevent apical periodontitis in teeth with irreversible pulpitis and to heal apical periodontitis in teeth with infected, necrotic pulp spaces. Root canal treatment allows teeth to remain in healthy, pain-free function in the dental arch, and to justify confidence and expenditure in respect of a definitive long-term restoration.
The dentine-pulp complex is protected by a hard, impermeable outer casing of enamel. Once these barriers are breached by, for example, caries, operative dentistry, tooth surface loss or trauma, the underlying permeable dentine-pulp complex becomes susceptible to microbial, chemical and/or physical injury. Injury may occur as a result of noxious stimuli reaching the pulp indirectly via patent dentinal tubules, or directly if the pulp becomes exposed to the mouth. The pulp tissue within the root canal space will become inflamed and ultimately necrotic, allowing microbial infection to progress. Eventually, this will lead to the development of periapical disease.
Patients with pain of dental origin may present with signs of pulpitis or apical periodontitis. Once a diagnosis of irreversible pulpitis or apical periodontitis has been made, the tooth should be assessed according to the guidelines in Chapter 8, and the treatment options of extraction versus root canal treatment and subsequent restoration discussed with the patient. When discussing treatment options, it is essential to advise that root canal treatment is not an end in itself, and that post-endodontic restorative treatment will be required to restore the tooth back to function and aesthetics. It should be stressed that the timing, nature and quality of the coronal restoration may have a critical bearing on endodontic success and tooth survival. Only then can an informed decision be made on the most suitable treatment for the tooth in question.
Root canal treatment can be broken down into stages:
preoperative assessment and preparation
preparation of the pulp space (including access and instrumentation/ disinfection)
sealing the pulp space
provision of a sealing and protective coronal restoration.
Restoration should be considered as an integral element in the package of endodontic care.
The prognosis of endodontic treatment is dependent on a systematic approach. Each stage must be successfully completed before embarking on the next if consistently predictable results are to be achieved.
Once the diagnosis has been confirmed, it is essential that the prognosis of the tooth is determined. Restorability must first be established, taking into account both the quantity, quality and location of coronal tissue, and the periodontal status. Carefully “walking” a periodontal probe around the gingival margin of the tooth will highlight the presence of significant features such as vertical fractures, which may have a serious impact on restorability and treatment planning. It is common for teeth that require endodontic treatment to be heavily restored or broken down and infected. Caries must be removed to prevent leakage and minimise the risk of microbe-laden carious dentine entering the root canal space during treatment (Fig 1-1).
Fig 1-1 Radiographic signs of caries at the distal margin of a lower molar crown. The crown must be removed to fully excavate caries and assess restorability before root canal treatment can commence.
Ideally, there should be a minimum of 2 mm of sound supragingival tooth tissue around the circumference of the tooth for subsequent restoration with a cuspal coverage restoration (Fig 1-2). If there is any doubt in respect to the prosthodontic restorability (see Chapter 8), the existing restoration should be completely removed to reveal the extent and location of residual sound tooth tissue (Fig 1-3). It is essential to inform the patient and secure their consent prior to embarking on this type of exploratory treatment. If the tooth is found to be unrestorable, an informed decision should be made to extract rather than attempt a heroic restoration.
Fig 1-2