CLINICAL REPORT
Australian Dental Journal 2002;47:(1):57-62
Cast post and core foundation for the badly broken down
molar tooth
EV Bass*
Abstract
Background: This article addresses the difficult
clinical problem of restoration of endodontically
treated posterior teeth, where there is nothing left of
the clinical crown.
Methods: A step by step procedure, including
instrumentation and materials and a new impression
technique, is described in detail, with clinical
photographs.
Results: This technique results in the fabrication of a
robust and extremely retentive post and core on
which to place fixed prosthodontic restorations.
Conclusions: The author has placed over 600
restorations of this type over a five year period,
without any reported failures. With the ‘greying’ of
the population there are increased demands on
dentists to restore structurally compromised teeth,
and increasing expectations of the performance of
these restorations. This technique is offered as a
superior alternative to conventional post and core
constructions methods.
Key words: Cast post and core, sliding prefabricated post,
endodontically treated molars.
(Accepted for publication December 2000.)
INTRODUCTION
The restoration of a badly broken down
endodontically treated molar tooth is a challenging
task. This is evident from the vast amount of existing
literature on this subject. A comprehensive literature
review has been presented by Chiche et al.1 This traced
back to 1911 where one of the first methods was
suggested by Robin. In the same article Chiche et al.1
described his own modality, where a prefabricated
plastic post was inserted into the palatal canal of a
maxillary molar and the impression of the remaining
tooth, already prepared for a crown, was taken with
the plastic post in it. A crown was then fabricated and
a gold post cast from a plastic post was inserted
through the crown immediately following crown
cementation.
Mora and Firtell2 suggested replacing a graphite post
in the second canal with a metal post, in a technique
*Prosthodontist, HCF Dental Centre, Sydney.
Australian Dental Journal 2002;47:1.
described by Weiner3 in 1981. Chand4 developed a post
selection guide for the para post system (Whaledent
International, USA) for a pre-operative assessment of
the para post drill suitable for post hole preparation.
He also addressed the problem of post hole clearing
before cementation. More recently Sadan et al.5
suggested a similar technique to Chiche’s but for
indirect fabrication of two separate castings, first – the
post and then – the core for mandibular molars. After
cementation of this assembly a crown was
manufactured from a new impression.
Most clinicians suggested, if possible, preparation of
the dowel space to within 3-5mm of the apical seal.
This is not considered to be a requirement nowadays as
a post length equal to the length of the expected crown
is thought to be sufficient.6 However, in the author’s
opinion, in divergent roots, when two posts are utilized
even this length is not necessary. Neither is it required
to achieve a diameter of the post equal to one-third of
the root width as has been suggested by Johnson et al.7
and Trabert and Cooney.8 Indeed, as the posts are
divergent, much shorter ones should provide adequate
retention. Goldman et al.9 found posts cemented into
properly conditioned post holes, where the smear layer
has been removed, exhibit much higher retention,
especially when the luting cement is introduced by a
Lentulo spiral. The best method for removing the smear
layer in their study was rinsing with 17 per cent
ethylenediamine tetra acetic acid (EDTA) followed by
5.2 per cent sodium hypochlorite. The post holes were
dried with paper points and air. In the technique
described in this paper a similar concentration of 15 per
cent EDTA is used for this purpose with slight
modifications in the method of delivery and without
sodium hypochlorite solution.
The luting cement has been changed as the new
reinforced glass ionomer cement is claimed by the
manufacturer to adhere chemically to dentine and gold
and should provide better retention than zinc phosphate.
However, in the first hundred or so post cores
constructed using the technique described, the latter
was used with equal success.
In the technique described in this paper, isolation of
badly broken down molars was achieved by cotton
57
Products manufacturers
Product
Impression material. President: light body and putty
Crown & Bridge Burs Kit: K + B System Prep 2555
Absolute Alcohol (100% Ethanol)
EDTA 15%
Modified PD Reamers – No 1,2,3,4 – Fig 1
OP-PO titanium posts (OPT – 3)
OP-PO twist drills (OPD 001, 002 ,003)
Modified stainless steel (s/s) temporary posts
(OPTE - 3) Fig 2
Modified Barbed Broach (ISO 6) Fig 5
Modified finger plugger #40
(sides flattened with stone to grip cotton wool) Fig 4
Modified Lentulo spiral (ISO 40)
(cut to 20mm length)
Fuji Plus Luting Cement
rolls and in some cases with the addition of suction
with a tongue guard. In the author’s opinion a rubber
dam would interfere with frequent checks for occlusal
clearance and alignment with adjacent teeth. Possible
damage to the surrounding gingiva by clamps may
create a problem for finalizing the preparation and
impression taking at the same appointment.
T E C H N I QU E
The procedure described is for a lower molar.
Existing restorations are removed and the tooth is
roughly prepared for a crown, with a chamfer at the
gingival level. All unsupported/thin enamel and dentine
are removed using a horizontally approaching
diamond, so that sound residual tooth structure has a
minimum wall thickness of 1mm. With an ultrasonic
scaler and #6 round long shank bur the pulp chamber
is rendered free of luting cement, gutta percha (GP),
and temporary restorative material. The orifices of the
canals are prepared with a #4 round long shank bur to
a depth of 1-2mm.
A dowel space is prepared in the distal canal using a
No 2 Produits Dentaires (PD) reamer with very light
pressure. GP shavings should be observed coming out
alongside the reamer. If there are no GP shavings
Fig 1. Modified PD reamers (#2 and #3) are on the right with distance
pieces removed, guiding tips cut off and depth indicating grooves
marked at 10mm and 15mm.
58
Manufacturer
Coltene/Whaledent, New Jersey, USA
Meisinger, Germany
Colgate – Orapharm
Produits Dentaires – SA Vevey Suisse
Optident, West Yorkshire, England
Kerr, USA
United Dental Manufacturers, USA
GC Corporation, Japan
present, look into the dowel preparation to ensure that
the GP root filling is in the middle of the dowel space.
This is done with a front surface mirror. If GP is not in
the middle you might be going sideways. If obstruction
to the advancement of the reamer is felt, go to a depth
of no more than 6-8mm from the canal orifice.
Depending on the size and shape of the canal either a
No 2 or No 3 PD reamer could now be used, with
lateral pivoting movements so that the walls of the
dowel preparation are shaved to conform to the cross-
sectional shape of the root; in this case (distal root) it is
oval in shape therefore a bucco-lingual movement is
used. At this stage ensure that the dowel space walls are
completely free of extraneous material, and smooth; it
is not possible to achieve this result with a parallel-
sided post drill, which is not side-cutting. Now the
mesio-lingual canal is prepared using OP-PO (Optident,
West Yorkshire, England) drills consecutively from No 1
(white) to No 3 (pink) to a depth of 4-5mm from the
orifice (in curved roots it can be shorter), again
observing GP shavings as in the distal dowel
preparation.
The preparations are now washed and dried.
The PD reamer with the shank cut off is placed in the
distal canal dowel preparation (No 2 or No 3
Fig 2. A modified s/s OPTE-03 temporary post at the bottom. It has
been adjusted in length at its smooth end so that when in the dowel
space it is clear of the opposing dentition.
Australian Dental Journal 2002;47:1.
Fig 3. Preparation of the mesial wall of the pulp chamber to be
parallel with the distal dowel space. A PD reamer has been cut off at
the shank and placed in the distal dowel space as a guild to ensure
parallelism of the preparation.
depending on the size of the dowel preparation) so it
fits snugly and the inclination of it in relation to the
opposing wall of the pulp chamber, i.e., the mesial wall,
is visualized. The mesial wall of the pulp chamber is
now prepared with a No 3 or No 4 PD reamer to have
the same path of insertion as the dowel in the distal
canal. This is done using the shortened reamer which is
positioned in the distal dowel space as a guide (Fig 3).
A wisp of cotton wool is gently rolled around the finger
plugger (No 40) to make a thin coat; this is done by
rotating the finger plugger in a thin wisp of cotton wool
held between the fingers. It is then dipped in 15 per cent
EDTA and placed into the dowel preparation with a
pumping action. A bubbling effect may be observed
(Fig 4). This is repeated two or three times using a new
wisp each time. The procedure is repeated with 100 per
cent alcohol and then a dry wisp.
At this stage ensure that you have washed your
gloves in soap and water to remove powder. The stain-
less steel (OPTE-03) temporary post is modified by
shortening it sufficiently so that it is clear of the
opposing occlusion when it is placed in the mesio-
lingual dowel space. The three grooves of the post
Fig 4. Distal dowel preparation is cleaned with EDTA on a cotton
wisp wrapped around a #40 modified finger plugger; the bubbling
effect of the EDTA is clearly seen.
Australian Dental Journal 2002;47:1.
Fig 5. The shortened OPTE-03 s/s temporary post is in the mesio-
lingual dowel space and the #40 modified barbed broach (part of the
handle has been cut off and the shortened barbed broach has been
folded over) is in the distal dowel space. They are clear of each other
and clear of the opposing occlusion.
facing the occlusion will engage the impression material
(Fig 5). A No 40 barbed broach is prepared for the
impression by cutting off part of the plastic head
leaving 2mm; then part of the apical barbed end is cut
off and it is folded to half its length. This should fit
loosely into the distal dowel preparation to the full
working length and be clear of the occlusion. The cut-
off plastic handle of this broach is clear of the stainless
steel post in the mesio-lingual dowel preparation, and
clear of the occlusion (Fig 5). The barbed broach is now
removed, the preparation is dried and a thin retraction
cord is placed into the gingival crevice.
With the stainless steel No 3 temporary post
remaining in the mesio-lingual preparation, President
light body impression material is injected around this
post and into the distal dowel preparation. It is spun
into the distal dowel preparation with a No 40 Lentulo
spiral shortened to 20mm, so that the dowel
preparation is filled. Immediately after the barbed
broach is placed into the distal dowel space it is further
injected to fill the pulp chamber and periphery of the
preparation. A light coat is also applied on the
Fig 6. Dual arch impression for cast metal post/core. The s/s OPTE-
03 post has been reinserted into the impression until all three grooves
are engaged.
59
Fig 7. The impression in Fig 6 sectioned mesio-distally. The #40
folded barbed broach supporting the impression of the distal dowel
space and the OPTE-03 post in the mesio-lingual post hole are
exposed.
opposing occlusion. The index finger and thumb of the
gloved right hand are wetted with 70 per cent alcohol
or glycerine and a President putty ball (made with a
quarter scoop of catalyst and base by the assistant) is
held with these two fingers is placed on the tooth
preparation with pressure applied by a thumb of the
left hand to ensure close adaptation around the tooth.
The patient is then asked to bite down and keep firmly
shut until impression material sets.
After the impression material has set the patient is
asked to open their mouth and the impression is gently
removed. Often the stainless steel No 3 post may stay
in the mesio-lingual dowel preparation; in this case it is
removed gently and relocated into the impression
making sure the three clicks of the relocation grooves
are heard and felt when they engage the impression
(Fig 6, 7). A cotton pellet is placed into the pulp
chamber and the cavity is temporized with the material
of choice, which should be easily removed by ultrasonic
scaler to avoid altering the shape of the preparation at
the next appointment.
When the cast gold (Type IV) post/core is received
from the laboratory and checked in the mouth for fit, a
short sprue is notched by a carborundum disk leaving
only thin metal attached to the core. This ‘handle’ will
help during cementation and could easily be broken off
Fig 8. A titanium #3 serrated and sand-blasted OPT-3 post, is fitted
through the cast gold core.
60
Fig 9. The cast gold post/core is checked for fit in the mouth. The
shortened sprue and the OPT-3 post have been notched with a
carborundum disk level with the occlusal surface of the core.
later. A serrated and sand-blasted titanium OPT-3 post
is now checked to ensure it can easily slide through the
core (Fig 8). It is now marked on the model level with
the core and checked in the mouth. If this was
successful it is notched with a carborundum disk so it
can easily be broken off during cementation (Fig 9).
The dowel preparations are now cleaned with 15 per
cent EDTA and 100 per cent alcohol, and dry cotton
wool, as previously described. Powder from gloves
should be removed by soap and water before cotton
wisps are wound around a No 40 modified finger
plugger. This prevents contamination of dowel spaces
by glove powder and also presents an opportunity to
check gloves for possible microholes and leakage. It is
best to wash gloved hands at the commencement of the
appointment.
In the author’s opinion the luting cement of choice is
Fuji Plus. The working time for this cement is relatively
short, the cast metal post core and titanium post are
held by their tags with locking tweezers in a comfort-
able position for fast insertion into the preparation.
After the cement is mixed it is introduced into both the
dowel spaces and pulp chamber by a modified No 40
Lentulo spiral. Immediately the cast gold post and core
Fig 10. The case gold post/core with OPT-3 post fitted through the
core have been cemented and are ready for the final impression for a
crown.
Australian Dental Journal 2002;47:1.
 Fig 11. A porcelain fused to metal crown has been issued.
are seated, followed by the titanium post. As soon as
the titanium post is inserted through the cast gold core
into the dowel space in the mesio-lingual canal, the tag
end is broken off and the remaining post is further
advanced into the dowel space by applying pressure
with an amalgam plugger.
While it is in a jelly state the excess cement is
removed with a probe two to three minutes after
Fig 12. Upper left 5, 6 and 7 after completion of RCT and removal
of weak and unsupported coronal tissue present a restorative
challenge.
Fig 13. The same teeth shown in Fig 12 (25, 26, 27) have been
successfully restored with cast gold post/cores. 26 and 27 have sliding
OPT-3 posts cemented through the cores. All three teeth are ready for
final impression for crowns.
Australian Dental Journal 2002;47:1.
Fig 14. Root filled 46 and 47 ready for restoration. Nothing of the
clinical crowns remains.
Fig 15. Two cast gold post/cores with titanium posts sliding through
the cores. Note that the posts and the sprues have been notched level
with the occlusal table of the cores to facilitate breaking them off at
cementation.
Fig 16. 46 and 47 with post/cores cemented ready for crowns to be
issued. The gingival margins of the preps have been conditioned with
trichloroacetic acid. This prevents contamination with seepage from
the gingival crevice.
cementation. The finishing of the shoulder/chamfer and
refining of the axial walls should be delayed by about
10 minutes to allow for full initial set to occur. At this
time the notched sprue on the core is broken off and the
small protruding part of the titanium post is smoothed
(Fig 10). An impression for a crown is now taken using
the ‘Dual Arch Impressions’10,11 technique and a crown
61
is cemented with the same Fuji Plus luting cement
(Fig 11). A similar technique for post/core preparation
could be used for upper molars. The only difference is
the palatal canal is prepared for a cast post and the
disto-buccal for a prefabricated one. Difficult restorations
of upper molars may be salvaged successfully using this
method (Fig 12, 13). This is also the case for badly
broken down lower molars (Fig 14, 15, 16).
CONCLUSION
In this article another technique is described for
restoration of mandibular molars after endodontic
treatment, where very little is left of the clinical crown.
Preparation of two post holes in divergent roots using
specific slightly modified instruments has been
presented in this paper. A new impression technique for
cast post and core restoration, for single unit and short
span bridges as well as the preparation of the post holes
for cementation with a modern luting cement are also
described.
AC K N OW L E D G E M E N T S
The author would like to thank Mr Ian Burrell for his
excellent technical assistance. Dr S Dracopoulos and Dr
S Bender for their help in preparing this manuscript.
The administration staff of HCF Dental Centre,
Sydney, for encouragement and support in this project.
There was no commercial, government or any other
grant offered for the work described in this paper.
REFERENCES
1. Chiche G, Weaver C, Pinault A. Divergent post and tube and
screw systems for the short crown preparation. Quintessence Int
1990;10:813-820.
62
2. Mora AF, Firtell DN. Cast post and core for nonparallel canals.
J Prosthet Dent 1984;52:235-237.
3. Weiner AL. A nonparallel cast post and core technique for teeth
with divergent canals. J Prosthet Dent 1981;46:240-242.
4. Chan RW. Restoration of endodontically treated teeth: Part II –
Selection and insertion of posts. Aust Prosthodont J 1988;2:67-
79.
5. Sadan A, Elliot R, Raigrodski AJ. Treatment planning extensively
broken-down mandibular molars for post-and-core fabrication.
Quintessence Int 1998;29:351-355.
6. State-of-art post and core use from global dental literature. CRA
Newsletter 1998;22:2.
7. Johnson JK, Schwartz NL, Blackwell RT. Evaluation and restora-
tion of endodontically treated posterior teeth. J Am Dent Assoc
1976;93:597-605.
8. Trabert RC, Cooney JP. The endodontically treated tooth.
Restorative concepts and technique. Dent Clin North Am
1984;28:923-951.
9. Goldman M, De Vitre R, Tenca J. Cement distribution and bond
strength in cemented posts. J Dent Res 1984;63:1392-1395.
10. Bass EV, Kafalias MC. Dual-arch impressions. Aust Dent J
1992;37:1-5.
11. Bass EV, Kafalias MC. Dual-arch impressions. J Dent Assoc
South Africa 1992;47:428-431.
Address for correspondence/reprints:
Dr EV Bass
HCF Dental Centre
Level 3, 403 George Street
Sydney, New South Wales 2000
Email: sbender@hcf.com.au
Australian Dental Journal 2002;47:1.