24 March 2020

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Restoration of endodontically treated molar: a clinical case

Authors: Dr. Martignoni, Prof. Grandini

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The restoration of the endodontically treated molar has always been a debated topic. The clinician faces many different challenges and it is important to know how to approach every single patient depending on the different clinical situations.
 Recently, an evidence-based treatment planning for the restoration of endodontically treated molar has been proposed (reference: Evidence-based treatment planning for the restoration of endodontically treated single teeth: importance of coronal seal, post vs no post, and indirect vs direct restoration).
The importance of the coronal seal is undisputable for the long term success of the endodontic treatment.
The clinician has to decide if a particular tooth needs a post or not, if a direct or an indirect restoration is required, which material needs to be used. In cases where there is enough tooth structure left, and the patient has no parafunctional habits, direct restoration can be used to reduce the amount of tooth structure that needs to be removed for the preparation of the indirect restoration.
The following case is an example of a molar, with four sound remaining walls, that is directly restored after the root canal treatment.

The patient, 26 years old, was referred for an endodontic treatment after a pulpitis occurred on the tooth 2.6 and an emergency treatment was carried out by another dentist (rx 1)

After local anesthesia, the rubber dam is placed to isolate the operating field. The temporary restoration is clearly visible (fig 1). 
After removing it, the canal orifices are located (fig 2), including MB2 and the shaping and irrigation is performed (fig 3).
A sequence of ProTaper Gold instruments is used to shape the root canals and the endodontic space is obturated and sealed with the continuous wave of condensation technique.

Fig. 4 shows the result after the floor of the cavity preparation has been cleaned using AH Cleaner, to remove all remnants of the cement and to be prepared for the next steps of the adhesion.

Selective etching of the enamel (fig 5) is one of the possibilities we have when using a universal adhesive system. Enamel is a substrate that benefits from the etching phase, while on dentin results are quite similar in both etch and rinse and etch and dry mode.

After the Dentin Bonding Agent has been light cured, a bulk filling material (fig 6) is used to replace the missing dentin structure. Bulk fillers can be used in 4mm increments and give us a few clinical advantages, being easy to use and requiring a very limited time.

The last layer when using this “bulk and body” technique is the so called capping layer. 2mm of resin composite are used to rebuild the occlusal anatomy. Fig 7 and 8 show the modelling of the cusps, until the restoration is completed (fig 9).

A careful finishing and polishing is carried out, leading to a correct integration of the restoration in the remaining tooth substance (fig 10).