TBU #27 How To Choose The Restoration For Endo Treated TeethNov 12, 2022
New Issue of The Biomimetic Uprising
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Endo teeth. Ugh. Sometimes restoring these are a slam dunk while other times they can be the thing that brings our day down. Often times endo treated teeth are beat up and damaged. Maybe they are missing a cusp, severely fractured, or deep decay that requires extra steps to restore with a Deep Margin elevation.
So what do we do with these teeth? Do they all get crowns? Do they need cuspal coverage? Metal posts vs glass fiber posts vs no posts are also something to consider. Can a direct restoration be 'good enough' ?
I'll tell you what tho, I can be looking at a some of these cases and think, there is no way I can get a crown on this thing. Its been said that a crown prep typically cuts around 60-70% of healthy natural tooth structure. So then if we're trying to cut a crown that just had the core of it removed from the Endo access, there's going to be nothing left to hold the crown up!
Im here to tell you that you can do a direct composite, inlay, onlay or any variation of those three to restore your ETT. The technique has to be good, but for our avid readers and club members I know it is!
Giovanni Rocca and Ivo Krejci in 2015 wrote an article on this very topic that is helpful to start thinking differently on this topic. There is tons of evidence or research papers showing that crowns are outdated. This is just another supporting piece of literature.
Some of the deciding factors of what final restoration should be done include:
- geometry of the cavity
- tooth location in the mouth
Other secondary concerns are
- parafunctional habits
- age of tooth
- periodontal prognosis
When analyzing the existing prep geometry, keeping the marginal ridge intact should be at the top of our priorities when treated any tooth and especially these. The marginal ridge helps limit cuspal deflection.
Then we consider that the parapulpal dentin has also been removed, we have a pretty compromised tooth. Its ideal if we can have at least a 1mm wall thickness. This becomes important as we analyze the occlusion and see if there is group function or if we have a true canine guidance. If we have group function, the stress of the chewing load will accumulate on side near the gums, potentially leading to further fractures if a crown would have been prepped.
When it comes to basic Class I configurations, a stress reduced direct composite works best and there is no need to extend the outline to make room for an onlay of some sort.
An MOD type configuration potentially creates more problems. We should be careful en extending to the marginal walls and not include them if possible. The marginal walls help prevent catastrophic failures. However, when we are faced with these cases, its best to cover the cusps. This creates a better occlusal dynamic and has better morphology. A slight bit of caution, use common sense and make a judgment to see if that would be best. Cusps that are 2-3mm at the base are strong and typically dont need coverings. Not all MOD preps are the same. Its always better to preserve the enamel whenever possible.
So for the 1 actionable tip? Dont do full coverage crowns on ETT if you have previously been doing so. Fig 5 shows a good guide on how to reduce the cusps for a common prep design. On Monday if your faced with an ETT, push yourself to restore with a stress reduced direct composite or minimal inlay if the case allows.
Here is a bonus guide (Download now) based of the article and goes along with the pictures.
(Articles are given in the newsletter)
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