Enhanced post crown retention in resin compositereinforced, compromised, root-fiiied teeth: A case report

Joo Looin Lui, BDS, MSc, FADM*

The introduction of an intraradicuiar composite reinforang technique, in conjunction with the reestabtishment ot matching post canal spaces, has aiiowed compromised, root-tilled teeth to be restored with functional, esthetic post crowns. This ciinicai case report suggests that reconstituted post canais. in accurateiy adapting to passive, parallel-sided, matching, and well-fitting posts, can enhance the retention of post crowns. Other factors of ciinicai importance reiating to the resin-reintorced technique are discussed, induding fracture resistance, depth of poiymerization. dentin adhesion, polymerization shrinkage, and coronal microleakage. {Qumlessence Int 1999:30:601-606) Key words: crown, endodonticaily treated tooth, light-transmitting post, re info roe ment, resin composite, retention

he futictional and esthetic rehabilitation of compromised, root-filled teeth presents a difficult restorative problem for the practicing dentist. Loss of tooth substance in these affected teeth may result in little or no remaining crown structure and weakened, thin-walled roots with widely flared canals. In this situation, placement of a retentive pin is not possible because of the lack of dentin substance at the coronal portion of the root, and placement of a conventional cast post will exert wedging forces at the already thin and weakened portions of the root. The geometry of the flared canal will also result in a very wide, tapered, and un retentive post. In 1987, Lui' introduced a reinforcement technique involving the reconstitution of lost intraradicuiar dentin in conjunction with the creation of a sizematched post canal of predetermined length to support a functional post crown. This technique involved acid etching of the internal radicular dentin in combination with adhesive honding and lining of the thin canal walls with autocuring resin composite. The bonded resin composite, besides acting as a reinforcing substitute for dentin, also reconstructed a new post canal that could accommodate a size-matched, passive, parallel-sided, well-fitting post. This technique reestab-

'Professor. Department ot Consen/ative Dentistry, Faculty of Dentistry, University ot Maiaya, Kuala Lumpur, Malaysia. Reprint requests: Dr J. L Lui, Professor, Department of Conservative Dentistfy, Faculty ol Denlistry, University of Malaya, 50603 Kuala Lumpur, Maiaysia. Fax: 603-759-4533.

lished the continued serviceability of badly damaged nonvital teeth that were previously deemed unrestorable and consequently condemned for extraction. The use of autocurirtg resin composite can be difficult because the dentist has no control once the rapidly polymerizing resin is placed in the root canal, especially in deep radicular defects. In such situations, the use of light-curing resin composite is preferred because it has better handling characteristics and the on-demand set allows sufficient time and control for proper placement in the root canal. However, lightcuring resin composite only has a depth of cure of 4 to 5 mrn, because of the limited transmission of light through the composite. The introduction of lighttransmitting plastic posts has subsequently solved this problem and the technique has now been clinically used to reinforce teeth compromised by caries,^ trauma,'' developmental anomalies,' internal rsorption,^ iatrogenic causes,^'' and various situations of thin-walled, flared canals.^'* In severely compromised teeth, where little or no crown structure remains, the treated, reinforced roots have been finally restored with post crowns.''^*' Posts are placed not for tbe purpose of strengthening tbe root"^ but for the provision of retention of the core and crown.'"" When post diameters were evaluated as a factor in root fractures, smaller diameters showed greater resistance to root fracture than did larger diameters.'^ To strengthen the weakened root, it is important that the selected post be as smalt as the prepared apical portion of the obturated, flared root canal. This would ensure that the reinforced root 601

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Fig 1 Paired teeth right centrai incisoi with a no^mai-sized oanal and left centrai incisor with a fiared canai

Fig 2 Flared canai in the maxillary left central incisor reinforoed with resin composite.

would have a sufficient thickness of reinforcing composite.' A post should be parallel-sided, because tapered posts act as wedges and can concentrate forces at the coronal portion of the post canal.''"'= Tapered posts are also less retentive.'^ This simple composite bonding technique, by reconstituting the lost dentin in thin-wallcd roots, not only reinforces severely compromised teeth but also creates post canals of predetermined lengths. These essentially parallel-sided post canals are retentive to their corresponding matching posts. The following case report illustrates the enhancement of post crown retention in composite-reconstituted, flared canals of compromised teeth.
CASE REPORT

An investigation is ongoing at the Faculty of Dentistry, University of Malaya, where paired root-filled teeth indicated for post-and-core crown restorations are studied. Patients included in the study have 1 compromised root-filled tooth with a flared canal and a control tooth with a more normal-sized canal (Fig 1). A 24-year-old man presented at tbe Conservative Dentistry Clinic for post crowns following endodontic treatment of both maxillary central incisors. The patient had fallen, fracturing both incisors, 5 years before 602

he sought dental treatment. He suffered no pain at the time of the trauma and only sought treatment when swelhng and pain developed. Post crowns were indicated following completion of root canal therapy. It was found that the canal of his left central incisor was flared compared to that of the right tooth. It was decided to reinforce the left compromised incisor first by using the Luminex system (Dentatus) to reconstitute the lost intraradicular dentin and by creating a patent, size-matched post canal with a suitable lightcuring hybrid composite (Prisma TPH, Caulk/ Dentsply) (Fig 2). This reinforcement technique has been described in detail in the literature.^"*'^ Following polymerization and removal of the Luminex light-transmitting post, the excess composite at the root face of the reinforced left central incisor was trimmed, and an antirotational cavity was prepared in the resin composite reinforcement. The root canal of the right central incisor was prepared to receive a conventional, customized, cast post. The coronal root faces of both incisors were finally prepared for restoration with post crowns (Fig 3}. Direct post-and-core waxups were obtained. For the reinforced left central incisor, the core waxup was made on a matching Luminex grooved burnout casting post. Both post-and-core castings were checked for fit and then cemented into their respective preparations with Fuji I glass-ionomer cement (GC). A radiVolume 30, Number 9, 1999

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Fig 3 Final looth preparation for post crown Fig 4 Cemented posts and cores. Note the Fig 5 Immediate postoperative view ol cerestoration. Right central incisor prepared to conventional tapered cast post in the right mented metal-ceramio crowns on both maxreceive customized post and core and left central incisor canal and the composite rein- illary central incisors. incisor reinforced to receive Luminex matoh- toroement supporting a parallel post in the ing post and core left central incisor.

Fig 6 Maxillary right central incisor tollowing post crown debonding.

Fig 7 Maxillary right central incisor ready for reinforcement,

Fig 8 Maxillary right central incisor immediately after resin composite reinforcement.

ographic record was made of the cemented posts and cores (Fig 4), Finally, functional, esthetic metalceramic crowns were cemented in place (Fig 5), Four months later, the patient returned, complaining that the post crown on the maxillary right central incisor had become dislodged (Fig 6), This was carefuHy examined; after removal of the old cemetit and cleaning, the debonded post crown was recemented with Fuji I glass-ionomer cement. Five months later, the patient returned again, complaining that the maxillary right post crown had once more dehonded.
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It was then decided to line and reinforce the maxillary right central incisor with the same technique (Figs 7 and 8), A cast post and core, using a matching burnout casting post, was fabricated (similar to that of the left central incisor) and cemented in place with Fuji I (Fig 9). A new metal-ceramic crown was constructed at the patient's request (Fig 10), The new post crown has now been in place for 3 years. Periodic follow-up examination of both the post crowns for 3 years revealed that the crowns were functional and the roots were in good condition.
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Fig 9 (ieft) Composite reinforcement ot the maxiliary right centrai incisor, supporting the new post crcwn.

Fig 10 (beiow) New post crown tor tiie ma^iliary rigiit central inCiSOf

DISCUSSION

Dislodgment is considered one of the main failures in post-and-core crown restoration, and cariy or premature post crown debonding does not bode well for the practicing dentist. It is important, therefore, that post crowns he designed to have good retention. Conventional customized posts provide a very accurate adaptation of the post's surface to the canal walls, but the nature of their fabrication determines that they conform to a tapered shape. Johnson and Sakumura'^ determined that parallel-sided posts are 4.5 times more effective in resisting tensile forces than are tapered posts. In the composite lining and reinforcement technique, the intraradicular composite, on polymerization, adapts very accurately to the parallel-sided post, thus establishing a patent post canal that accurately matches its intended post.' In the Luminex system, the light-transmitting plastic post, except for the pointed tip, is essentially parallel sided. This ease report suggests that post-and-core crowns placed in reinforced roots with reconstituted parallelsided post canals may he retained better than the customized east post and crown. Besides post taper, other factors contribute to post retention, including post length, post diameter, grooving on the post and/or canal walls, and the type of luting cement. The use of the grooved burnout casting posf also contributes to overall retention. For post crown construction, it had been recommended that there be at least 1 mm of sound dentin
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around the circumference of the post canal.^ Tjan and Whang'" found that when 1 mm of dentin remains after canal preparation, the root is more prone to fracture, even when a metal collar is incorporated in the cast post and core. Endodontically treated teeth are not, therefore, strengthened by fhe placement of prefabricated or customized posts. When such a root-filled tooth is compromised, the use of resin composite to line and strengthen the weakened canal walls actually reinforces the root and creates a post canal that is accurate, retentive, and sufficiently strong to support a post crown in the weakened root.' Saupe et ai" found that compromised, root-filled teeth reinforced with the Luminex system are 50% more resistant to fracture than are those restored with a conventional cast post and core. Similarly, Linden'^ found fhat the composife reinforcement technique increases the flexural strength of compromised feefh by about 50% when Luminex grooved and titanium posts are used. Thus, compromised, rootfilled teeth can be adequately reinforced, through intraradicular composite reconstitution, to retain functional, esthetic posf crowns. In taking advantage of light-curing resin composite in the rehabilitation of compromised, root-filled teeth, Lui^" stressed that it is important that the composite be adequately polymerized within the root canal if it is to eftectively reconstitute and reinforce a weakened, defective root. Several reporfs have demonstrated adequate depth of polymerizafion of infraradicular resin composife with the use of the Luminex light-transmitVciume 30, Number 9, 1999

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ting plastic posts,'-22 j ^ ^aggg where the root canals are exceptionally deep, dual-curing resin composites, in which the polymerization is initiated hy light and then completed hy autocuring, can be used. After removal of the smooth, light-transmitting post, a corresponding-sized Luminex grooved post can be inserted in the newly created post canal to transmit light radially, in the lateral direction, toward the root canal walls. Morphologically, there is no human root with a defect so large that the curing light cannot reach in the radial direction. In fact, the curing is so complete that Tjan et a!" found that the retentive value of the composite reinforcement bonded to the root canal wall is significantly higher than that of a custom cast post luted to the root canal wall with zinc phosphate cement. It has been stated that the intraradicular composite undergoes polytnerization shrinkage in the direction of the bonded surface away from the Hght-transmitdng post,^* Other authors, including Tjan et al,^^ believe that al! light-curing resins shrink toward the curing light, away from the dentin wall, and, in this situation, toward the plastic post. They added that the use of dentin bonding systems eliminates or reduces the undesirable contraction gap at the resin-dentin interface. There is some concern regarding coronal microleakage in endodontically treated teeth^''"^^ because neither gutta-percha^'^* nor cemented prefabricated and custom posts and cores'^ can effectively prevent crowndown leakage from the oral environment. The removal of the smear layer^" and the adhesion of resin materials to the root canal walP"^ have been shown to decrease leakage, Intraradicular resin composite reconstitution of a compromised, root-filled tooth may reduce or eliminate leakage at the coronal end of the root. In this case, glass-ionomer cement was used to lute the post and core in the resin-reinforced root, because this same cement was used for luting the conventional, customized cast post in the prepared control canal.

REFERENCES Lui JL. A technique to reinforce weakened roots with post canals. Endod Dent Traumatoi 1987:3:310-314. Lui JL. Composite resin reinforcement of flared canals using light-transmitting plastic posts. Quintessence Int 1994:25: 313-319. Freedman G, Novak IM, Serota KS, Glassman GD. Intraradicular rehabilitation: A clinical approach. Pract Periodont Aestbet Dent 1994:6:33-39. 4. Godder B, Zhukovsky L, Bivona PL, Epelboym D. Rehabilitation of thin-walled roots with light-activated composite resin: A case report, Compend Contin Educ Dent 199415:52-57 Diekerson WG, The flexibie trans-iiluminating aesthetic post. Dent Today 1994:13:13-15, Trushkowsky RD, Estabiisbing an ideai post space in compromised teeth Dent Econ 1995,85:68-69. Sorenson JA, Engelman MJ, Effect of post adaptation on fracture resistance of endodonticaliy treated teeth. J Prosthet Dent 1990:64:419-424. Milot P, Stein RS. Root fracture in endodontieally treated teeth related to post selection and crown design. ] Prosthet Dent 1992:68:428-448, Caputo AA, Standlee JP. Pins and posts-Why, when and how. Dent Clin North Am 1976:20:299-312. Johnson JK, Schwartz NL, Blackwell RT Evaiuation and restoration of endodontically treated posterior teeth, ] Am Dent Assoc 1976:93:597-605, Standlee JP, Caputo AA, Hanson EC. Retention of endodontie dowels: Effects of cement, dowel length, diameter and design. I Prosthet Dent 1978:39:401-405. Trabert KC, Caputo AA, Abou-Rass M. Tooth fractureA comparison of endodontie and restorative treatments, J Endod 1978:4:341-345. Zmener O, Adaptation of threaded dowels to dentin. J Prosthet Dent 1980:43:530-555. Davy DT, Dilley GL, Krejci RF. Determination of stress patterns in root-filled teeth incorporating various dowel designs, J Dent Res 1981:60:1301-1310. Deutsch AS, Cavaliari J, Musikant BL, Silvestein L, LepleyJ, Petroni G. Root fracture and the design of prefabricated posts, J Prosthet Dent 1985:53:637-640, Johnson JK, Sakumura JS, Dowel form and tensile lorce, J Prosthet Dent 1978:40:645-649, Tjan AHL, Wbang SB. Resistance to root fracture of dowel channels with various thicknesses of bueeal dentin walls. J Prostbet Dent 1985:53:496-500 Saupe WA, Gluskin AH, Radke RA Jr. A comparative study of fracture resistance between morphologic dowel and cores and a resin-reinforced dowel system in the intraradicular restoration of structurally compromised roots. Quintessence Int 1996:27:483-491, Linden L. Fiexural strength of Luminex-treated roots. Presented at the European Society of Endodontology, 8th Congress, Gothenburg, Sweden, 12-14 June 1997 20, Lui JL. Deptb of composite polymerization within simulated root canals using light-transmitting posts, Oper Dent 1994; 19:165-168. 21, Anooshiravani D, Nathanson D. Efficacy of transilluminating posts for intraradicular composite curing [abstract], J Dent Res 1996:75:138,

SUMMARY

The resin-reinforcement technique, which reconstitutes iost intraradicular dentin in compromised, rootfilled teeth, can establish a new post canal suitable for post crown support. This case report suggests that such reinforced roots can accommodate passive, parallel-sided, well-fitting posts and ensure enhanced retention of post crowns in otherwise unretentive, flared root canals. This technique may increase the potential for salvaging severely compromised teeth and allow their continued serviceability as retentive, functional, esthetic post crowns.
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 Lui 22. Strassler HE, Coletti P, Hutter J. Composite polymerization within simulated root canals using iight-transmitting posts [abstract 551]. J Dent Res 1997;7e;82, 23. Tian AHL, Tjan AH, Sun JC. Retention of Luminex post system. Oral Health 1997;S7;3t-35, 24. Swanson KS, Madison S. An evaluation of coronal microleakage in endodonticaily treated teeth. Part i. Time periods. J Endod 1987:13:56-59 25. Madison S, Swanson KS, Chiles S An evaluation of coronal microleakage in endodonticaliy treated teeth. Part II. Sealer types. J Endod 1987:13:109-112 26. Madison S, Wilcox L. An evaluation of coronal microleakage in endodonticaliy treated teeth. Part III. In vivo study. J Endod 1988;14:455-458. 27. Torabinejad M, Ung B, Kettering JD. In vitro bacterial penetration of coronally unsealed endodonticaily treated teeth. I Endod 1990:16.566-569. 28. Magura ME, Kafrawy AH, Brown CE Jr, Newton CW. Human saliva coronal microleakage in obturated root canals: An in vitro study. J Endod 1991;17:324-331. 29. Freeman MA, Nicholls JI, Kydd WL, Harrington GW. Leakage associated with load fatigue-induced preliminary failure of full crowns placed over three different post and core systems. J Endod 1998;24:26-32. 30. Taylor JK, Jeansonne BG, Lemon RR. Caronal leakage: Effects of smear layer, obturation technique and sealer. J Endod 1997:23:508-512. 31. Wennberg A, Ostravik D. Adhesion of root canal sealers to bovine dentin and gutta-percha. Int Endod J 1990;23:13-19. 32. Tjan AHL, Grant BE, Dunn JR Microleakage of composite rasin cores treated witb various dentin bonding agents. J Prosthet Dent 1991;66.24-29.

^i?^ Answers to Ql 6/99 Questions

^
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1. 2. 3. 4.

B A D B

5. 6. 7. 8.

C B A C

9. 10. 11. 12.

C B D B

13. 14. 15. 16.

C B D D

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