Practical considerations and technical post-retained restorations

Gabriel R. Zuckerman, DDSa

procedures

for

East Northport,

N. Y.
dependable treatment structure. Manufactured will provide a simple, a cast tapered post. which a post-retained option for post Ipatterns reliable, and The cast tapered restoration is

Post-retained restorations are a practical and restoring teeth with insufficient coronal tooth combined with an effective clinical procedure economic method to produce restorations with post can be used for all clinical applications in indicated. (J PROSTHET DENT 1996;%:135-9.)

c onsiderable . dental treatment is performed to repair and restore teeth damaged by caries, attrition, abrasion, erosion, and fractures caused by trauma or masticatory stress. Restorations may be as simple as a class I amalgam or as complex as a complete veneer crown. Sometimes teeth with insufficient coronal tooth structure to support a crown must be restored and require a foundation. This foundation is often a post-retained core on which a complete veneer crown is placed. Making a post and core can be a time-consuming process. In the past the post and core were traditionally cast as one piece. After the post and core were cemented, the crown preparation was completed, and an impression was made to fabricate the restoration. To reduce time and cost manufacturers have introduced a wide variety of prefabricated post systems (PPS). One major dental supplier1 offers 16 prefabricated post systems. These systems are available in as many as 20 sizes and require accessories for their placement and additional materials for their cementation and core buildup. The use of these systems requires a considerable inventory and a substantial investment for the dentist. The latest issue of one trade journal2 contained advertisements for seven PPS and related materials and a technical article for the use of new, retrievable PPS. It is obvious that PPS represent a considerable economic opportunity for the manufacturers and suppliers of these products. A post-retained restoration (PRR) may fail for any of the following reasons: caries, endodontic failure, periodontal disease, root fracture, post dislodgment, post core separation, and crown core separation. Thayer3 expresses concern that post core separation is more likely to occur when composite resin cores are used with PPS. Mechanical failures from post core and crown core separation are under the direct control of the operator and should not occur. A plethora of published reports is focused on the retention of post systems. This inordinate attention would seem to indicate that an excessively high failure rate exists for

Fig.

1.

Gutta-percha

is removed

from canal with

hot in-

strument PRRs and that these failures result from post dislodgment. The few studies published in the literature report a rather low failure rate for all types of PRRs. Schwartz et a1.4 reported a 2.7% failure rate for dowel-supported crowns but do not provide reasons for these failures. Their report was published in 1970, before prefabricated post systems became widely avatilable. Hatzikyriakos et al! reported that 11% of post-retained restorations failed after 3 years of service. The causes for these failures were root fracture, caries, root-post separation, and crown core separation. Only 3.2% of these failures were caused by root-post separation. Crown core separation accounted for an additional 3.2% of the failures. A good post system should be universally adaptable for all PRRs, require minimum chair time to use, require a minimum inventory of supplies and special equipment,

aPrivate practice. Copyright 0 1996 by The Editorial

PROSTHETIC DENTISTRY. 0022-3913/96/$5.00 + 0. 10/l/69030

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Fig. 2. After canal is shaped with reamer, occlusal end of post space is flared, and bevel is made around circumference of root face..

Fig.

4. Completed

die and resin transfer

coping.

Fig. 3. Compound and tube impression pattern in post space.

is made with post

Fig. 5. Drawing of prosthesis made in two segments different path of insertion for each segment.

with

and produce effective and reliable retention. PPS do not fulfill these requirements. Prefabricated posts cannot be used for the retention of a root cap restoration with stud and bar attachments for overdenture retention. Smith6 stated that laboratory charges may be lower when preformed posts and cores are used, but any savings is more than outweighed by the extra clinical time taken to fit most of them. A cast tapered post system used in conjunction with an effective clinical procedure can fulfill all of these requirements. With the procedure presented the same post system can be used for any PRR. It can be used to make cast post and cores and crowns, crowns with posts as part of the crown, and root cap restorations with attachments for overdentures. Any of these restorations can be accom-

plished in the same amount of chair time with the same number of appointments with the same procedure with the same post system. The same post-retained provisional restoration can be used throughout the entire treatment procedure. This article presents an alternative to a post and core to retain a complete veneer crown. This restoration has a post made as an integral part of the crown. When the post and crown are made as one unit, no chance exists for the post and core to separate or for the crown to separate from the core. Restorations made in this manner are more easily made in the laboratory and require less chair time for cementation. These factors reduce the cost of the restoration and provide a better service to the patient. The only clinical situation for which this design is contraindicated

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Fig. 6. Abutment

teeth prepared

for prosthesis.

Fig. 7. Maxillary

cast with removable

dies used to make prosthesis.

Fig. 8. Prosthesis

made as two interlocking

segments.

occurs when the path of insertion of the post is not compatible with the path of insertion of the restoration, which is most likely to occur when the post and crown are to be used as a retainer for a fmed partial denture. This design should be used in situations where the retention of a core is questionable because of insufficient core height created by occlusal restrictions.

MATERLALS
This procedure can be used to make any PPR with a cast tapered post. Two post systems are currently available for use with this procedure: Preci-post (Preat Corp., San Mateo, Calif.) and Colorama Endo (Degussa Corp., S. Plainfield, N. J.). Each system is available in post kits that have burnout patterns for tapered posts in two or more sizes and

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Fig.

9. Posterior

segment

is cemented

on second premolar

and canine.

Fig. 10. Anterior segment prosthesis is completed.

is cemented

over the core on cuspid and central

incisor,

and

post space reamers of an equivalent size for each pattern. Accurate reproduction of the post space in the die is ensured, because the pattern is used as part of the impression for the die.

PROCEDURE
Fig. 1 illustrates a single-rooted tooth that has no remaining coronal tooth structure. Endodontic treatment has been completed, and the canal has been obturated with gutta-percha. 1. Remove the gutta-percha to the apical third of the root with a hot instrument (Fig. 1). 2. Enlarge the canal with gates glidden drills to expose clean dentin along the canal walls. The drills are stepped to produce a tapered post hole. Gates glidden drills have a side cutting head, a flexible shaft and a contra-angle shank. These drills will follow the canal and reduce the chance of creating lateral root perforations. 3. Size the canal with one of the contra-angle reamers included in the post kit. 4. Flare the occlusal2 to 3 mm of the post space in an elliptic shape to strengthen the post where it will join the rest of the restoration and to prevent rotation of the post within the post space. 5. Make a bevel around the circumference of the root face

to accommodate the metal collar of the casting. Fig. 2 illustrates the completed root preparation. 6. Select a plastic post pattern that corresponds to the reamer used to form the post space. 7. Mushroom the end of the plastic post pattern with a hot spatula to create retention for the post pattern in the impression. 8. Place the post pattern into the prepared post space and make an impression. The post pattern will remain in the impression, creating a precise post space in the die made from the impression. The impression can be made with any crown and bridge impression materials. Post patterns are particularly well suited for use with compound and tube impressions. Fig. 3 illustrates a compound and tube impression fabricated to make the die. The compound impression containing the post pattern is copper-plated, and the die stem is formed with autopolymerizing acrylic resin. The plastic post pattern can be removed from the die by pulling it straight out with a pair of pliers. Fig. 4 illustrates a completed die and a resin transfer coping. Details for making dies and resin transfer copings are described in a previously published article.7 When the casts with the dies are articulated, the entire restoration may be completed in the laboratory.

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A post and crown may be made as one unit, or a post and core with a separate complete veneer crown can be completed at this time. For overdentures, a post and coping pattern can be made with a plastic pattern for a stud or bar retainer, and it can be cast as one unit.

cisor, and a complete veneer crown retainer for the central incisor. The core on. the canine was made with a path of insertion compatible,with the path of insertion of the retainer on the right central incisor.

CONCLUSION CLINICAL APPLICATION

Figs. 5 through 10 illustrate the practical application of a cast post and core used as an intermediate retainer for a fixed partial denture that replaces the maxillary right first premolar and the right lateral incisor teeth. The abutments for this five-unit ceramometal fixed partial denture are the maxillary second premolar, the canine, and central incisor teeth. The canine did not have a clinical crown and was prepared for a cast post and core foundation. The second premolar was prepared for a complete veneer crown retainer with a path of insertion compatible with the post preparation in the canine. The right central incisor was prepared for a complete veneer crown retainer with a path of insertion in the long axis of the tooth. The extreme labial inclination of the right central incisor made it necessary to construct the prosthesis in two interlocking segments, each with a different path of insertion. The posterior thrlee-unit segment of the prosthesis has a path of insertion determined by the post in the canine. Therefore the posterior three-unit segment consists of a complete veneer crown on the second premolar, a pontic for the first premolar, and a cast post and core retainer for the canine. The anterior three-unit segment of the prosthesis consists of a complete veneer crown that telescopes over the post and core retainer on the canine, a pontic for the lateral inPost-retained restorations are a practical and reliable treatment option. Cast tapered posts, when made correctly, will provide ,areliable foundation for PRRs. The cast tapered post is a versatile, universally adaptable method of achieving retention for all types of PRRs. The procedure described will produce a post-retained restoration in the same time required to make a complete veneer crown. REFERENCES
1. Henry Schein Dental Catalog. Fall 9mint.w 95. 2. Dental Products Report. November, 1994. 3. Thayer KE. Fixed prosthodontics. Chicago: Year Book Medical Publishers, 1984:282. 4. Schwartz NL, Whitsett LO, Berry TG, Stewart JL. Unserviceable crowns and fixed partial dentures: life span and causes for loss of serviceability. J Am Dent Assoc 1970;81:1395-401. 5. Hatzikyriakos AH, IReisis GI, Tsingos N. A three year postoperative clinical evaluation ofposts and cores beneath existing crowns. J PROSTHET DENT 1992;67:454-8. 6. Smith BG, Dental crowns and bridges. Chicago: Year Book Medical Publishers, 1986:31. 7. Zuckerman GR. Dies with resin copings for accurate registrations. J FROSTHET DENT 1992;67:37-40.

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DR. GABRIEL R. ZUCKEKMAN 1199 FIFTH AVE. EAST NORTHPORT, NY 11731

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