Restoration of Esthetics and

Function of A Fractured Maxillary

Anterior Tooth With Custom
Made Post and Core- A Case Report

Nadeem Yunus
Department of Prosthodontics, Faculty of Dentistry, Jamia Millia Islamia,
New Delhi, India.
Email: nadeemyunus2@yahoo.com, Phone: +91-9971027660

ABSTRACT
There may be different causes of fracture upon the remaining tooth structure. If
of the maxillary anterior teeth. The crown of a tooth is severely damaged and
primary aim of managing a fractured height of the remaining crown is, less it
anterior tooth should always be to preserve would not be able to provide adequate
the remaining tooth structure and restore retention to the crown prosthesis. Hence, it
esthetics and function adequately. People should be restored by a post and core where
now a days have become more conscious post provide the retention to the core
about their esthetics and expect restoration portion and core provide the protection to
of their esthetics immediately after trauma. the remaining structure of tooth crown and
There are different treatment modalities retention to the crown prosthesis.
for a fractured anterior tooth which depend

Key words : Post and core, esthetics, multidisciplinary management, endodontic treatment,
Ferrule effect.

Introduction
Majority of the dental trauma in permanent dentition comprises of
the crown fractures. 26-76% cases of dental injuries involve crown fractures
while 0.3-5% of the cases involve crown-root fractures.1 Fracture of the
anterior teeth not only causes esthetic and functional problems but also
causes psychological breakdown of the patient. Hence it is always advised
to restore the fractured anterior teeth as early as possible. Treatment
modalities of the fractured anterior tooth depend on the level of the
fracture. An Ellis class I fracture can be restored by composite restoration;
and restoration of Ellis class II fracture can be done either by composite
 Nadeem Yunus

restoration and crown fabrication or combination of both. As far as Ellis

class III fracture is concerned it usually requires a multidisciplinary
approach. Treatment of this class depends on the gingival level of the
fracture line3. If the fracture line is supra-gingival there are two possibilities
of the treatment. First treatment possibility is endodontic treatment and
crown prosthesis and the second possibility is endodontic treatment, post
and core and crown fabrication. In case the fracture line is sub-gingival
the treatment becomes quite complicated. A combined effort of endodontist,
periodontist, orthodontist and prosthodontist is generally required in this
situation. In case of sub-gingival fracture, gingivectomy, surgical and
orthodontic extrusion of the tooth is usually required to bring sub-gingival
fracture line to supra-gingival level2. In case of fractured permanent
anterior teeth if pulp is extensively involved with complete root formation,
post-core and crown fabrication after root canal treatment is
recommended3.
In this article a case of fractured maxillary anterior tooth is presented
which was restored with custom made cast post and core followed by
porcelain fused to metal crown prosthesis.

Case Report
A 14 years old boy reported to our department with chief complaint
of fractured upper front tooth (Fig. 1); he wanted his tooth to be restored.
Patient gave history of trauma to his front tooth by a fall while running 10
days back. He told that he could not find any piece of his fractured tooth.
Patient’s medical and dental history was not significant. Extra oral
examination was unremarkable while intra oral examination revealed
fracture of maxillary left central incisor (Tooth no. 21, FDI notation) with
exposure of pulp i.e. Ellis class III
fracture 4 (or type VI according to
Garcia-Godoy classification) Fracture
line was sub-gingival on mesio-palatal
aspect of the crown involving cementum
also. Adjacent teeth and mandibular
anterior teeth were also examined for
any trauma by pulp testing and
radiographic evaluations. All these teeth
were found normal.
Fig. 1 : Frontal view of the patient.

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Restoration of Esthetics and Function of A Fractured

Diagnosis and Treatment Planning

Based on the clinical and radiological findings a diagnosis of
irreversible pulpitis was made. Endodontic treatment and gingivectomy
on the mesio-palatal aspect of tooth 21 followed by fabrication of cast
post & core and porcelain fused metal crown prosthesis was planned.

Treatment
After anesthetizing fractured tooth 21, the pulp was extirpated.
Working length was established with the help of intraoral periapical
radiograph and thorough debridement was done. Cleaning and shaping
of the root canal was performed by step back technique which was
accompanied with copious irrigation with sodium hypochlorite. On the
next appointment obturation of the canal was done with gutta-percha
and zinc oxide eugenol (Fig. 2). Gingivectomy of tooth 21 was performed
on the mesio-palatal aspect to expose the fracture line and the patient
was recalled after 10 days.

Fig. 2 : Intraoral peri-apical radiograph of the patient after endodontic treatment

The coronal portion of the gutta-percha was removed using peeso
reamer leaving the apical 5-6 mm gutta-percha intact. Then the coronal
portion of the fractured crown was prepared to fabricate the pattern of
cast post and core. Margins of the prepared crown were given a bevel of
about 2 mm to get the ferrule effect5.
A wooden sick was used to take the impression of the root canal.
Stick was made thin so that it might go inside the root canal completely

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 Nadeem Yunus

up to the prepared length. Petroleum jelly was applied inside the canal
and the coronal portion of the affected tooth using as a separating medium.
Inlay casting wax was applied on the stick and stick was immediately
inserted into the canal. Enough time was given for the setting of the wax
before stick was removed and inspected for any discrepancy in detail of
reproduction. If there was shortage of the wax some wax was again applied
on the stick and inserted into the canal. This process was repeated till we
found complete impression of the canal. In this way we got a pattern of
the post (dowel) portion of the post and core. Once the post pattern was
ready the core portion was built on the coronal part of the same stick with
wax. The core was prepared like a prepared natural abutment tooth. The
post and core pattern was removed from the mouth and casting was done
(Fig. 3).

Fig. 3 : Cast post and core.

After finishing of the post and core it was cemented into the patient’s
mouth with glass ionomer cement (Fig. 4) and impressions for porcelain
fused to metal (PFM) crown were made using polyvinyl siloxane. The
PFM crown was delivered on the next appointment (Fig. 5).

Fig. 4 : Cast post and core after cementation. Fig. 5 : Final restoration with PFM
crown

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Restoration of Esthetics and Function of A Fractured

Discussion
Satisfactory restoration of a traumatically fractured anterior tooth is
a difficult and challenging task. Various treatment modalities are available
to restore a fractured anterior tooth. Andreasen et al.3 (2007) recommended
that a fractured permanent tooth with fully developed root and extensive
pulpal exposure should be treated with post and core and crown
restoration.
There are various types of post and core systems which can be broadly
divided into pre-fabricated and custom made cast post and core categories.
Examples of pre-fabricated posts are metal posts, ceramic posts, fiber posts
etc.
Creugers et al.6 (1993) performed a study on durability of different
types of post and core and concluded that survival rate of prefabricated
metal screw posts is quite low due to higher rate of root fractures.
Mannocci et al.7 (1999) did a study to compare the properties of quartz
fiber, carbon quartz fiber and zirconium dioxide ceramic root canal posts
and concluded that the ceramic posts show a higher risk of fracture due
to presence of cracks within the posts.
Cormier et al.8 (2001) compared fracture resistance and failure mode
of fiber, ceramic and conventional post systems at various stages of
restoration and told that fiber posts have the lowest fracture resistance as
compared to the other post systems.
Peroz I et al.9 (2005) reviewed different post and core systems and
recommended the custom made cast post and core to restore an
endodontically treated tooth.
Also, Tsurumachi et al.10 (2012) presented a case report in which they
managed a deep crown-root fracture of a maxillary central incisor. They
used cast palladium post and core in this case. In our case we also used a
custom made cast post and core for better prognosis and long lasting
successful treatment.

Conclusion
Fracture of an anterior tooth may impose a psychological trauma to
the patient. Hence it is always recommended to manage this type of cases
as early as possible to restore the esthetics and function. Achieving the
satisfactory results for such cases has always been challenging for
clinicians. Treating these cases with custom cast post and cores provide
long term success.

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 Nadeem Yunus

References
1. Olsburgh S, Jacoby T, Krejci I. Crown fractures in the permanent dentition:
pulpal and restorative considerations. Dent Traumatol. 2002 Jun;18:103-15.
2. Krastl G, Filippi A, Zitzmann NU, Walter C, Weiger R. Current aspects of
restoring traumatically fractured teeth. Eur J Esthet Dent. 2011 summer;6:124-
141.
3. Andreasen JO, Andreasen FM, Tsukiboshi T. Crown-root fractures: Textbook
and color atlas of traumatic injuries to the teeth. 4th ed. Oxford: Blackwell;
2007. 314-336 p.
4. Ellis RG. The classification and treatment of injuries to the teeth of children.
4th ed. Chicago: Year Book Publishers Inc; 1960.
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2012 Jan;38:11–19.
6. Creugers NH, Mentink AG, Kayser AF. An analysis of durability data on post
and core restorations. J Dent.1993 Oct;21:281-284.
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quartz fiber, carbon quartz fiber and zirconium dioxide ceramic root canal
posts. J Adhes Dent. 1999;1:153-158.
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stages of restoration. J Prosthodont. 2001 Mar; 10(1):26-36.
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treated teeth with posts and cores-A review. Quintessence Int. 2005 Oct;
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10. Tsurumachi T, Matsumoto S, Kobayashi Y, Ohara K et al. Esthetic and
endodontic management of a deep crown-root fracture of a maxillary central
incisor. J Oral Science. 2012; 54(4):359-362.

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