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Contemporary Restoration of TREATED TEETHEvidence-Based Diagnosis and Treatment Planning Nadim Z. Baba, dmd, msdProfessor of Restorative DentistryDirectorHugh Love Center for Research and Education in TechnologyLoma Linda University School of DentistryLoma Linda, California Quintessence Publishing Co, IncChicago, Berlin, Tokyo, London, Paris, Milan, Barcelona, Beijing,Istanbul, Moscow, New Delhi, Prague, São Paulo, Seoul, Singapore, and Warsaw Foreword viiPreface viiiContributors ix Part I: Treatment Planning for Endodontically Treated Teeth Impact of Outcomes Data on Diagnosis and Treatment Planning 3 1 Charles J. Goodacre and W. Patrick Naylor Treatment Planning Considerations for Endodontically Treated Teeth 19 2 Robert A. Handysides and Leif K. Bakland Treatment Options and Materials for Endodontically Treated Teeth 33 3 Nadim Z. Baba and Charles J. Goodacre Part II: Methods of Restoration for Endodontically Treated Principles for Restoration of Endodontically Treated Teeth 61 4 Nadim Z. Baba, Charles J. Goodacre, and Fahad A. Al-Harbi Cementation of Posts and Provisional Restoration 75 5 Faysal G. Succaria and Steven M. Morgano Tooth Whitening and Management of Discolored Endodontically 6 Treated Teeth 91 Part III: Management of Severely Damaged Endodontically Crown Lengthening 107 7 Nikola Angelov Preprosthetic Orthodontic Tooth Eruption 115 8 Joseph G. Ghafari Intra-alveolar Transplantation 127 9 Antoanela Garbacea, Nadim Z. Baba, and Jaime L. Lozada Autotransplantation and Replantation 137 10 Leif K. Bakland and Mitsuhiro Tsukiboshi Osseointegrated Dental Implants 149 11 Juan Mesquida, Aladdin J. Al-Ardah, Hugo Campos Leitão, Jaime L. Lozada, and Aina Mesquida Part IV: Treatment of Complications and Failures Repair of Perforations in Endodontically Treated Teeth 167 12 George Bogen, C. John Munce, and Nicholas Chandler Removal of Posts 181 13 Ronald Forde, Nadim Z. Baba, and Balsam Jekki Removal of Broken Instruments from the Root Canal System 195 14 David E. Jaramillo Endodontic Treatment of a Tooth with a Prosthetic Crown 201 15 Mathew T. Kattadiyil Retrofitting a Post to an Existing Crown 207 16 Nadim Z. Baba, Tony Daher, and Rami Jekki It is an honor to have been invited to write the foreword Dentists encountering treatment planning dilemmas, such for Dr Nadim Baba's text on the restoration of endodonti- as determining when to extract a compromised tooth and cally treated teeth. The last book on this topic, published by when to retain it and restore it, can find the answers to most Quintessence, was authored by Shillingburg and Kessler in of their questions in this first-rate text. Traditional principles 1982. Three decades later, this new book is much needed and techniques are reviewed and reinforced, along with and long overdue.
modern materials and methods, all with a firm foundation Dr Baba's interest in the restoration of pulpless teeth in the best available scientific evidence and with an em- dates back to his graduate-school days. I served as his phasis on clinical studies. Many of the chapters provide program director and his principal research advisor during comprehensive, step-by-step descriptions of technical pro- his studies at Boston University in the postdoctoral pros- cedures with accompanying illustrations to guide the read- thodontic program, where the title of his master's project er through all aspects of restoring pulpless teeth, including and thesis was "The Effect of Eugenol and Non-eugenol fabrication of various foundation restorations, cementation Endodontic Sealers on the Retention of Three Prefabricated techniques, and methods of provisionalization of endodon- Posts Cemented with a Resin Composite Cement." Dr Baba tically treated teeth. Preprosthetic adjunctive procedures, certainly has come a long way since receiving his certifi- such as surgical crown lengthening, repair of perforations, cate of advanced graduate study and master of science in and orthodontic measures, are also described and illus- dentistry degree in 1999. He is now a Diplomate of the American Board of Prosthodontics and a full professor at Dr Baba has assembled a group of renowned experts on Loma Linda University School of Dentistry, and he is about various topics related to the restoration of pulpless teeth, to publish this comprehensive book on the restoration of and these experts have collectively produced this outstand- endodontically treated teeth. ing text, which will remain a definitive reference for years This new text has a wealth of evidence-based information to come. The profession as a whole is very fortunate to on all facets of restoration of endodontically treated teeth have this text. Many thanks must go to Dr Baba for under- and will serve as an indispensable reference not only for taking this monumental task and to all contributing authors dentists involved in the restoration of pulpless teeth, such for their time and efforts in helping Dr Baba produce this as general practitioners and prosthodontists, but also for new book on such a very important subject.
dentists who do not place restorations but are engaged in planning treatment for structurally compromised teeth, such as endodontists, periodontists, and oral surgeons. With Steven M. Morgano, dmd the well-documented success of osseointegrated implant- Professor of Restorative Sciences and Biomaterials supported fixed restorations, combined with a better un- Director, Division of Postdoctoral Prosthodontics derstanding of the factors that can influence the prognosis Boston University Henry M. Goldman School of Dental of severely broken down teeth, the profession's approach to planning treatment for these teeth has evolved, and this Boston, Massachusetts text offers a well-balanced, contemporary approach to the topic of treatment planning.
My interest in the restoration of endodontically treated teeth dates back to my graduate-school days at Boston Uni- versity. When working on my master's project and thesis and later while studying for the American Board of Pros- I wish to express my appreciation and indebtedness to thodontics exam, I realized that very few books dealt with all my friends and colleagues who contributed chapters, the restoration of pulpless teeth. The first book on that topic sections of chapters, or clinical cases in specific areas in was published by Quintessence in 1982; two decades which they are experts. Without them the book would not later, three books were published but all were somewhat have been possible.
limited in their scope. They dealt mainly with fiber posts, I would like to take the opportunity to thank Leif Bakland, their characteristics, and their clinical applications. Zouheir Salamoun, W. Patrick Naylor, and the dean of This book is primarily intended to be a manuscript that my school, Loma Linda University, Charles J. Goodacre, reviews the basic principles of diagnosis and treatment for their counsel and help during the preparation of the planning and describes numerous treatment options and the techniques recommended for contemporary treatment Most importantly, I extend my special thanks to Ms Lisa of endodontically treated teeth. The purpose of this book is Bywaters and the staff of Quintessence Publishing for their to provide general dentists, endodontists, prosthodontists, professionalism and guidance in bringing my book to life. and dental students (postgraduate and predoctoral) with a I also would like to acknowledge my teachers and men- comprehensive review of the literature and evidence-based tors who had a great impact on my visions, attitude, and information for the treatment of endodontically treated career: Pierre Boudrias, Hideo Yamamoto, Steven M. Mor- teeth, keeping in mind the integration of systematic assess- gano, David Baraban (deceased), and Charles J. Goodacre. ments of clinically relevant scientific evidence. They remind me of the Lebanese-American poet and writer Four major themes are discussed. The first part focuses Gibran Khalil Gibran, who said: "The teacher who is indeed on treatment planning, treatment options, and materials wise does not bid you to enter the house of his wisdom but used for the restoration of endodontically treated teeth. The rather leads you to the threshold of your mind." second part reviews the principles and methods of restora- I feel blessed, lucky, and proud to have had the chance tion along with cementation, provisional restoration, and to know and work with each one of these people in various management of discolored endodontically treated teeth. stages of my professional career.
The third part describes the different aspects of the man- agement of severely damaged pulpless teeth. In the final part, treatment of complications and failures is reported.
Aladdin J. Al-Ardah, dds, ms
Nicholas Chandler, bds, msc, phd
Assistant Professor Associate Professor of Endodontics Advanced Education Program in Implant Dentistry University of Otago School of Dentistry Loma Linda University School of Dentistry Dundin, New Zealand Loma Linda, California Tony Daher, dds, msed
Fahad A. Al-Harbi, bds, msd, dscd
Associate Professor of Restorative Dentistry Dean and Assistant Professor Loma Linda University School of Dentistry College of Dentistry Loma Linda, California University of Dammam Dammam, Saudi Arabia University of California at Los Angeles Nikola Angelov, dds, ms, phd
Los Angeles, California Professor and Director Predoctoral Program in Periodontics Ronald Forde, dds, ms
Loma Linda University School of Dentistry Chair and Assistant Professor of Restorative Dentistry Loma Linda, California Loma Linda University School of Dentistry Loma Linda, California Nadim Z. Baba, dmd, msd
Professor of Restorative Dentistry Antoanela Garbacea, dds
Hugh Love Center for Research and Education in Technology Santa Rosa, California Loma Linda University School of Dentistry Loma Linda, California Joseph G. Ghafari, dmd
Head and Professor Leif K. Bakland, dds
Division of Orthodontics and Dentofacial Orthopedics Ronald E. Buell Professor of Endodontics Department of Otolaryngology, Head and Neck Surgery Loma Linda University School of Dentistry American University of Beirut Medical Center Loma Linda, California George Bogen, dds
Professor of Orthodontics Private practice limited to endodontics Lebanese University School of Dentistry Los Angeles, California Adjunct Professor of Orthodontics New York University College of Dentistry New York, New York Charles J. Goodacre, dds, msd
Aina Mesquida, dds
Dean and Professor of Restorative Dentistry Loma Linda University School of Dentistry Advanced Education Program in Implant Dentistry Loma Linda, California Loma Linda University School of Dentistry Loma Linda, California Robert A. Handysides, dds
Chair and Associate Professor of Endodontics Juan Mesquida, dds
Loma Linda University School of Dentistry Assistant Professor Loma Linda, California Advanced Education Program in Implant Dentistry Loma Linda University School of Dentistry David E. Jaramillo, dds
Loma Linda, California Clinic Director and Associate Professor of Endodontics Loma Linda University School of Dentistry Steven M. Morgano, dmd
Loma Linda, California Professor of Restorative Sciences and Biomaterials Balsam F. Jekki, bds
Division of Postdoctoral Prosthodontics Assistant Professor of Restorative Dentistry Boston University Henry M. Goldman School of Dental Loma Linda University School of Dentistry Loma Linda, California Boston, Massachusetts Rami Jekki, dds
C. John Munce, dds
Assistant Professor of Restorative Dentistry Assistant Professor of Endodontics Loma Linda University School of Dentistry Loma Linda University School of Dentistry Loma Linda, California Loma Linda, California Mathew T. Kattadiyil, dds, mds, ms
Assistant Professor of Endodontics Associate Professor of Restorative Dentistry University of Southern California Ostrow School of Advanced Specialty Education Program in Prosthodontics Los Angeles, California Loma Linda University School of Dentistry Loma Linda, California W. Patrick Naylor, dds, mph, ms
Hugo Campos Leitão, dmd, msd
Advanced Dental Education Assistant Professor in Periodontics Professor of Restorative Dentistry Universitat Internacional de Catalunya Loma Linda University School of Dentistry Loma Linda, California Yiming Li, dds, msd, phd
Faysal G. Succaria, dds, msd
Professor of Restorative Dentistry Chair and Assistant Professor Department of Prosthodontics Center for Dental Research Boston University Institute for Dental Research and Loma Linda University School of Dentistry Loma Linda, California Dubai, United Arab Emirates Jaime L. Lozada, dmd
Mitsuhiro Tsukiboshi, dds, phd
Professor and Director Advanced Education Program in Implant Dentistry Tsukiboshi Dental Clinic Loma Linda University School of Dentistry Loma Linda, California



Treatment Planning for Endodontical y Treated Teeth Impact of Outcomes Data on 1. Diagnosis and Treatment Planning Treatment Planning Considerations 2. for Endodontically Treated Teeth3. Treatment Options and Materials for Endodontically Treated Teeth


2 Treatment Planning Considerations for Endodontically Treated Teeth Fig 2-4 (a) The complexity of the root canal system is well illustrated in these sections of maxillary molars. Note the variety of canal configurations
in the mesiobuccal roots and in particular the location of the second mesiobuccal canal in the molar on the right. (b) A radiograph of a maxillary molar seems to show two palatal roots (arrows). (c) On the patient's request, the tooth was extracted; two palatal roots were identified (arrows).
In addition, Schilder12 named four biologic objectives for Assessment of other conditions
these preparations: 1. Treatment procedures are confined to the roots.
2. Necrotic debris is not forced beyond the apical foram- Fracture lines involving cusps of teeth have been a prob- lem in dentistry, probably throughout human history. The 3. All pulp tissues are removed from the root canal space.
pain associated with such fracture lines was described by 4. Sufficient space exists for intracanal medicaments and Gibbs,16 who termed it cuspal fracture odontalgia. Every dentist has probably had a patient who complains about pain on chewing and later shows up with the broken-off These objectives provide a basis for assessing the qual- cusp, usually from a premolar tooth. Whether or not the ity of the endodontic procedure prior to restoration of the pulp is directly involved (by exposure), it is usually neces- tooth. Deviation from the original canal shape is referred to sary to complete RCT before the tooth is restored. Diagno- as transportation of the canal. The greater the transporta- sis of a fracture line under a cusp, before it breaks off, can tion, the greater the likelihood of a poor endodontic out- be a challenge and will be discussed in the next section on come, resulting in the need for either endodontic retreat- ment or extraction of the tooth.
Teeth may develop cracks and fracture for a number of reasons, including trauma, excessive masticatory forces, Root canal systems and iatrogenic incidents. Regardless of etiology, when cracks or fractures develop in dental hard tissues it is not The root canal system is complex (Fig 2-4), and its anatomy possible to repair them, except for a short period of time has been studied extensively for many years. Of special with bonding agents. In contrast, bone and cartilage rou- interest in the current context, Weine et al13 called atten- tinely undergo repair following fracture. Although tooth tion to the frequent presence of two canals in the mesio- fractures and cracks cannot be healed, it is possible in buccal roots of maxillary molars. Pineda and Kuttler14 many cases to maintain such teeth for various periods of and Vertucci15 developed classification systems for canal time following identification and diagnosis.
configurations in individual roots. Research in root canal For convenience in discussing cracks and fractures, three morphology has led to descriptions of more than 20 canal categories will be used: enamel craze lines, infractions, and vertical root fractures (VRFs).
These considerations are important for the evaluation of a tooth that has undergone RCT. They also point to the chal- Enamel craze lines. Craze lines are small cracks that are
lenges inherent to treating teeth with endodontic disease confined to the enamel of teeth (Fig 2-5). They are not typi- prior to restoration to full function. Achieving full function cally visible unless light rays highlight them incidentally. requires that the treatment-planning process be a teamwork They develop over time, so they probably can be found in process: RCT can be performed on almost any tooth, but most teeth eventually. Occasionally they will show stains restorability must be determined prior to the endodontic from exposure to liquids such as coffee and red wine. Be- component of treatment. Communication among the vari- cause these cracks are confined to enamel, they have no ous treating dentists before, during, and after RCT offers pulpal impact, and no treatment is necessary, except op- the best possibility of an optimal outcome.


Diagnosis and Treatment Planning Fig 2-5 Enamel craze lines (arrow) are common and pre-
Fig 2-6 (a) Infractions (arrow) can be identified visually with the help of dyes, in
sent no particular problem other than their potential for this case a red dye. Infractions usually run in a mesiodistal direction; they may be asymptomatic or associated with pain on chewing and cold stimuli. (b) A tooth extracted because of symptoms associated with an infraction shows the presence of the infraction (arrow). They typically originate in the crown of the tooth and pro- gress in an apical direction. (c) On rare occasions, infractions run in a faciolingual tional bleaching if they are stained. There is no evidence that can mimic trigeminal neuralgia; chronic orofacial pain that craze lines progress to involve more than enamel.
can also develop. The wide range of pain experiences is probably why Cameron18 used the term syndrome to de- Infractions (cracked teeth). The term cracked tooth is com-
scribe this dental situation. The etiology of infractions is monly used to describe a tooth that has developed an probably in most cases related to occlusal forces, whether infraction, which is defined as "a fracture of hard tissue from regular daily chewing or isolated trauma such as in which the parts have not separated"17 (Fig 2-6). Cam- blows to the underside of the mandible.19–25 eron18 incorrectly defined this condition as cracked tooth It is likely that teeth with infractions become symptomatic syndrome; the use of syndrome is not appropriate for pain when the infractions become invaded by bacteria26 (Fig associated with fractures in teeth. It is, however, a situation 2-7). Bacteria stimulate inflammation in the pulp, whether with a variety of symptoms, and diagnosis can be very or not the infraction communicates directly with the pulp tis- sue. The inflamed tissue is responsible for the exaggerated Mandibular molars and maxillary molars and premo- cold response. It is also likely that the tooth will become lars are the teeth most frequently associated with infrac- sensitive to biting when the infraction progresses from the tions. The teeth usually have vital pulps and the infractions tooth crown to the root, and the bacteria that will soon typically run in a mesiodistal direction. They begin in the occupy the infraction then stimulate an inflammatory re- crowns of teeth and progress in an apical direction. Not all sponse in the adjacent periodontal ligament (PDL).
teeth with infractions are symptomatic, but when symptoms Diagnosis of infractions is complicated by many factors. develop they can range from pain on chewing, to an exag- Because infractions are usually located in a mesiodistal di- gerated response to cold stimuli, to severe pain episodes rection in the crown, they are not visible on radiographs. 3 Treatment Options and Materials for Endodontically Treated Teeth Fig 3-17 (a and b) A provisional fixed dental prosthesis is fabricated in resin composite material. The restoration has proper contours, thickness,
proximal contacts, and adequate occlusal contacts. (c) Gutta-percha is removed from the orifice of the canals to aid in retention of the core. (d) A carbide rotary cutting instrument is used to make an occlusal access opening on the provisional prosthesis, toward the center of the foundation. (e) The FPD is cemented, and the amalgam is condensed in the prepared post spaces. (f and g) A tapered rotary cutting instrument is used carefully to make a vertical groove in the lingual surface in order to section the provisional prosthesis. (h and i) The amalgam foundation is refined for the definitive tooth preparation, and a final impression is taken.
3. Remove 1 to 2 mm of gutta-percha from the orifice of endodontic plugger. Fill the remaining pulp chamber the canals to aid in retention of the core. This is only with amalgam up to the occlusal surface of the pro- necessary when the pulp chamber is smaller than 3 visional FPD to ensure an adequate seal, and make mm in depth (Fig 3-17c).
occlusal adjustments as needed (Fig 3-17e).
4. Use a carbide rotary cutting instrument to make an oc- 9. At the following appointment, carefully section the pro- clusal access opening in the abutment retainer toward visional FPD by using a tapered rotary cutting instru- the center of the foundation. ment to make a vertical groove in the buccal surface 5. Place the modified provisional FPD on the remaining (Figs 3-17f and 3-17g).
tooth structure, and confirm adequate access to the 10. Refine the amalgam foundation for the definitive tooth cavity for ideal amalgam placement and condensation preparation, and take the definitive impression (Figs (Fig 3-17d).
3-17h and 3-17i).
6. Confirm proper fit and marginal adaptation of the pro- 11. Fabricate and cement a new provisional FPD with pro- visional FPD.
visional cement.
7. Cement the modified provisional FPD with a small amount of provisional cement placed only on the mar- The same procedure is used when a provisional crown is gins of the provisional FPD.
used as a matrix for an amalgam core buildup (Fig 3-18).
8. Condense the first increments of amalgam into the pre- pared post spaces using a periodontal probe or an Types of Posts and Cores Fig 3-18 (a) The mandibular right first molar was endodontically treated and presented with enough remaining coronal tooth structure and adequate
depth of the pulpal chamber. (b) Tooth preparation is finished, and the post space is prepared in the distal canal to receive a prefabricated metallic post. (c) The provisional crown is fabricated using resin material with proper contours, thickness, proximal contact, and adequate occlusal contacts. (d) An occlusal access opening in the provisional crown is made so only a peripheral shell of resin is retained using a carbide rotary cutting instrument. The provisional crown is cemented with a luting agent. The length of the prefabricated post is adjusted to the appropriate height, and the post is cemented with zinc phosphate cement. (e) The amalgam is condensed into the prepared post space. (f and g) After the amalgam has hardened or at a subsequent appointment, the provisional crown is sectioned carefully by making a vertical groove in the labial surface using a tapered rotary cutting instrument. (h) The amalgam foundation is refined for the definitive tooth preparation, and a final impression is taken. (Courtesy of Dr Carlos E. Sabrosa, Rio de Janeiro, Brazil.) Composite resin Oliva and Lowe255 found that composite resin cores were not dimensionally stable when exposed to moisture. How- Composite resin is a popular core material because it is ever, Vermilyea et al257 found that the use of a well-fitting easy to use and satisfies esthetic demands. Certain proper- provisional restoration will provide the composite resin ties of composite resins are inferior to those of amalgam core with some degree of moisture protection. Hygroscopic but superior to glass-ionomer materials.234,247 Kovarik et al234 expansion of composite resin cores and cements in layered showed that composite resin is more flexible than amal- structures with an overlying ceramic layer can generate sig- gam. It adheres to tooth structure, may be prepared and nificant stresses that have the potential to cause extensive finished immediately, and has good color under all-ceramic cracking in the overlying ceramic layer. Clinically, this im- crowns. Composite resin appears to be an acceptable plies that all-ceramic crown performance may be compro- core material when substantial coronal tooth structure re- mised if the crowns are luted to composite cores that have mains235,248–253 but a poor choice when a significant amount undergone hygroscopic expansion.258 of tooth structure is missing.234,254 Another disadvantage is that composite resin is dimen- One disadvantage of composite resin cores is the insta- sionally unstable (setting shrinkage). Shrinkage during po- bility of the material in oral fluids (water sorption).255,256 lymerization causes stress on the adhesive bond, resulting





CH 12 Repair of Perforations in Endodontically Treated Teeth Fig 12-8 (a) Mandibular left first molar with a mesial root periapical radiolucency in a 13-year-old asymptomatic girl. The molar exhibits both strip
and apical perforations from previous root canal treatment. (b) Strip perforation visible under the DOM at the furcal side of the mesial root (arrow). (c) Working length determination after removal of previous obturation material. (d) White MTA canal obturation to the level of the pulpal floor. (e) Final radiograph of obturation and the fiber post and bonded core. (f) Radiograph at 7 years, showing the complete-coverage restoration and complete periradicular healing. The patient is asymptomatic with the molar in full function. (Courtesy of Dr Marga Ree, Amsterdam.) Fig 12-9 (a) Maxillary left second premolar in a symptomatic 24-year-old man with a suspected post perforation to the mesiobuccal root aspect.
Note the well-circumscribed periradicular radiolucency adjacent to the perforation. (b) Completed access through the metal-ceramic crown. The coronal aspect of the post has been uncovered. (c) Post following removal. (d) Chamber after debridement of the perforation site and preparation for MTA placement. (e) Immediate postoperative radiograph following MTA perforation repair and subsequent completion of nonsurgical endodon- tic retreatment. (f) Ten-month radiographic review showing complete resolution of the periradicular pathosis. The patient is asymptomatic. (Courtesy of Dr Ryan M. Jack, Colorado Springs, CO.) Management of Perforations Fig 12-10 (a) Mandibular left first molar in a symptomatic 32-year-old man. Note the presence of a separated file at the mesial root apex and
concomitant transportation and perforation of the mesial root canal during previous treatment. (b) Identification of the perforation site. (c) Canal obturation with gray MTA. (d) Surgical resection of the mesial roots, removal of the separated file, and MTA retrofill. (e) Nine-month radiographic review. (f) Three-year recall radiograph showing complete remineralization of the osteotomy site.
calcium hydroxide followed by placement of gutta-percha Retrograde management of perforations
as a perforation repair and filling technique.5,128–132 MTA can be placed with or without a matrix barrier; however, The goal of surgical repair of root perforations is to pro- root-end resection may be indicated if the original canal vide a reliable seal so that bacteria and their by-products is not accessible after the repair.11 Where apical surgery are prevented from entering the periodontium through the is not an option, advanced techniques can also provide root canal system. This procedure should encourage an dedicated channels for conventional obturation after MTA environment that promotes regeneration of the damaged placement and hardening.
periodontal tissues and maintains immune cell surveillance. Hemorrhage at the perforation site can be challenging The indications for surgical treatment include excessive ex- when nonobservable subcrestal perforations are being pre- trusion of the repair material, combination (orthograde and pared apically or beyond the view of the DOM. Once the retrograde) therapies, perforations inaccessible by nonsur- perforation is identified, 1.25% to 6.0% NaOCl provides gical means, and failure of nonsurgical repairs3,5,15,23,106 an environment that removes inflammatory tissue, controls (Fig 12-10). The location of the perforation is the prime hemorrhage, disinfects the perforation site, and conditions determinant in the strategy and material used in the surgi- the surrounding dentin.133–137 However, the solution must cal approach.144 not be propelled into perforation areas because this can According to Gutmann and Harrison,106 certain aspects often cause severe tissue damage and paresthesia.138–143 of the case must be considered before surgical treatment Sodium hypochlorite should always be delivered passively, can be initiated: using pipette carriers or cotton pellets, or placed in the pulp chamber and gently transported along the main canal us- • The amount of remaining bone and any surrounding os- ing hand files, avoiding penetration at the wound site. The solution may also be delivered by inserting a small suction • The overall periodontal status cannula into the canal beyond the perforation and then • The duration and size of the defect placing the liquid in the chamber to be passively drawn • The surgical accessibility into the canal to beyond the defect. If the perforation does • The soft tissue attachment level not include the main canal, then NaOCl is gently brought • The patient's oral hygiene and medical status to the limit of the defect interface and frequently replen- • The surgeon's soft tissue management expertise ished until hemostasis is achieved.
CH 13 Removal of Posts Fig 13-3 (a) Schematic of a cast post and core that requires removal
for endodontic retreatment. (b) A rotary instrument is used to reduce the diameter of the core. (c) The core is further reduced with a Gonon bur. (d) The core is threaded with a Gonon trephine bur. (e) A mandrel with a washer and cushions in place is threaded on the post, and then the knurled knob is turned to remove the post. (Courtesy of Dr Nadim Z. Baba, Loma Linda, CA.) 31-mm-long Endodontic Cariesectomy Bur Endodontic Shallow shaft (0.7 mm) on the #1/4, #1/2, & #1 Fig 13-4 Gonon post puller device.
Fig 13-5 Munce Discovery Burs (CJM Engineering).
Mechanical Devices Fig 13-6 (a) Radiograph of a maxillary right lateral incisor with an apical lesion requiring the
removal of a cast post and core and endodontic retreatment. (b) The cast post and core is isolated with rubber dam. (c) The cast post and core is shaped into a roughly cylindric shape. (d) A Munce Discovery Shallow Troughers (CJM Engineering) is used to remove the cement around the post. (e) A special bur is used to thread the head of the cast post and core. (f) Application of counterclockwise rotational force using the wrench. (g) Gonon post in place and ready to be used. (h) The screw is turned to open the jaws and create an extraction force. (i) Removal of post and preservation of the tooth structure. (j) Postoperative radiograph showing the endodontically retreated root canal and the definitive restoration. (Courtesy of Dr Marga Ree, Amsterdam.) post to protect the tooth from the lifting action of the pliers (Fig 13-6). Should the post be successfully removed at this point, the retreatment of the tooth may proceed following inspection of the root to verify its integrity. The Gonon post removal system is less invasive then the Masserann Kit and the LGPP and requires less removal of tooth structure.11,38 Page numbers followed by "f" indicate fig- ures; those followed by "t" indicate tables; Bacteria, 24f, 139 cast post and core, 80–82, 80f–82f those followed by "b" indicate boxes Balanced forces technique, 195 ferrule effect on, 84 Base metal alloy, 36 fiber-reinforced resin post, 82–83, 83f intraradicular disinfection, 78, 78b Abutment teeth, 4 description of, 127, 169 Acrylic resin provisional restorations, 84–85 implant placement and, 124f post surface treatment, 79 Aluminum oxide, 79 orthodontic forced eruption and, 116, provisional restorations, 86–87 Alveolar ridge, 123, 150–152 radicular dentin, 78–79 Amalgam cores, 48–50, 49f–50f surgical crown lengthening and, 108–109 Amalgam restorations tooth fracture effects on, 111f techniques of, 78–84, 80f–83f complete-crown restoration versus, 6 treatment modalities for maintaining, voids created during, 79, 79f discoloration caused by, 92 mercury release from, after tooth bleaching, Bis-acryl composite resin, 85 Cervical root resorption Bite test, 24, 24f intracoronal tooth bleaching as cause of, Amelogenesis imperfecta, 93 Bleaching. See Tooth bleaching.
Bond strength, extracoronal bleaching effects invasive, 29f, 29–30 Ankylosis-related root resorption, 28f, 29, Cervical tooth structure, for ferrule, 68–69 Broken instruments Chairside extracoronal bleaching, 100 Anterior teeth. See also specific teeth. illustration of, 196f Combined endodontic-periodontal anchorage for, 118 prevalence of, 196 conditions, 26–27 endodontically treated removal of, 181, 196–199 Complete-crown restoration, 6 complete coronal coverage in, 7 Complex amalgam restorations, 6 description of, 6–7 Composite resin cores, 51–52 restorations for, 8, 34–35 Calcium hydroxide-containing sealer, 77–78 Composite resin restorations discoloration caused by, 92 Apical lesions, 20 Carbamide peroxide, 94–95 endodontically treated teeth, 5–6 Apical perforations, 169, 173 Carbon fiber–reinforced epoxy resin posts, fracture resistance of, 35 Apical seal, 10, 63, 67 41–43, 41f–43f, 42t At-home extracoronal bleaching, 100, 102 Cast posts and cores. See Custom cast posts time until failure with, 5–6 Computer-aided design/computer-assisted antibiotics use in, 139 definition of, 137 glass-ionomer, 76b, 76–77 Cone beam computed tomography, 141 dietary considerations, 139 polycarboxylate, 76 Core ferrules, 68 examples of, 137–138, 138f post type and, 76b, 77 Cores. See Posts and cores.
general principles of, 139–141 properties of, 75, 76b–77b Coronal teeth preparation, 66 molars, 141f–142f, 141–143 resin, 77, 79, 82–84 Coronal-coverage crowns premolars, 143f, 143–144 resin-modified glass-ionomer, 77 anterior teeth, endodontically treated, 34 prognosis after, 140–141 ultrasonic post removal affected by, 191 posterior teeth, endodontically treated, 34 root resorption concerns, 139–140, 140f zinc phosphate, 76, 76b Cracked teeth, 22–26 Avulsed tooth, 138f, 144, 145f Craze lines, 22–23, 23f, 70, 70f Crestal perforations, 169, 171, 173, 174f cuspal deflection of, 7–8 for orthodontic tooth movement, 121 flexibility of, 7 Forced eruption, orthodontic. See crown-root ratio, 116–117, 124 fracture of, 4–5 Orthodontic forced eruption. See also Orthodontic extrusion.
length of, post length correlation with, moisture content in, 7, 35 root. See Root fracture.
prosthetic. See Prosthetic crown.
physical properties of, 7–8 tooth. See Tooth fractures.
Crown lengthening, surgical. See Surgical posterior teeth. See Posterior teeth.
Free radicals, 95, 100 crown lengthening.
posts and cores effect on, 36 Furcation perforations, 169, 173 Crown-root fractures proprioception of, 8 diagnosis of, 128 prosthetic crown, 201–205, 203f–204f incidence of, 132 provisional restorations in, 87 Gates Glidden instruments, 11, 64 proximal contact of, 4 shear strength of, 8 augmentation of, 123 sound tooth structure, 14 excessive display of, 109f Cuspal deflection, 7–8 survival rates for, 4, 20 irritation of, from tooth bleaching, 101 Cuspal fracture odontalgia, 22 time until failure, 5–6 postrestorative recession of, 155f Custom cast posts and cores ultrasonic vibration effects on, 192 treatment planning for. See Treatment Gingival connective tissue, 192 cementation of, 80–82, 80f–82f Glass fiber–reinforced epoxy resin posts, direct fabrication technique for, 37–38, vital teeth versus, 4 43f, 43–45, 44t, 45f Epoxy resin posts indications for, 37 carbon fiber–reinforced, 41f–43f, 41–43 core buildup material use of, 52 indirect fabrication technique for, 38–41 glass fiber–reinforced, 43f, 43–45, 44t, silver alloys added to, 52 lost-wax technique, 36, 37f Glass-ionomer cement, 76b, 76–77, 191 for posterior teeth with divergent roots, Extracoronal bleaching resin-modified, 77 at-home, 100, 102 surface treatment of, 79 Gonon post removal system, 183, 184f zinc phosphate cementation of, 80–82, dental professionals' role in, 101–102 enamel effects of, 101 apical seal and, 10, 63, 67 gingival irritation secondary to, 101 condensation of, 67f in-office, 99f, 99–100 immediate versus delayed removal of, restorations and, 101 risks associated with, 100–102 instruments for removal of, 67 Dental fluorosis, 93–94 tooth sensitivity secondary to, 100–101 removal of, 66–67, 67f craze lines in, 70 orthodontic. See Orthodontic extrusion.
surgical. See Intra-alveolar transplantation.
post diameter effects on, 64 Hereditary hypophosphatemia, 93 residual thickness of, 11, 70–71 H O . See Hydrogen peroxide.
Hydrogen peroxide, 94–96, 100–102 thickness of, 11, 70–71 intra-alveolar transplantation for improving, Dentogingival junction, 108 Idiopathic root resorption, 30, 30f restoration retention affected by, 68f, Immediate implant placement. See Osseointegrated implants, immediate Direct core materials, 48–52 surgical crown lengthening consideration placement of.
Discoloration of teeth. See Tooth osseointegrated. See Osseointegrated Distofacial root, 13 cementation of, 77, 82–83, 83f description of, 14–15 biologic width considerations, 124 self-adhesive resin cement for, 82–83, 83f complications of, 159–160 Eggler post removal, 186, 187f–188f surface treatment of, 79 in growing patients, 124, 125f immediate, 123. See also decalcification of, 93 Osseointegrated implants, immediate extracoronal bleaching effects on, 101 Fixed partial dentures placement of.
hypocalcification of, 93 provisional, modification into matrix for hypoplasia of, 93 amalgam core buildup, 49–50, 50f nerve injuries during, 159–160 Enamel craze lines, 22–23, 23f survival rates for, 4–5 orthodontic extrusion effects on, 124 Endodontically treated teeth Flapless crown lengthening, 112 postextraction, 117, 118f anterior teeth, 6–7 Incisors, 12–13 characteristics of, 7–8 for forced eruption, 118, 119f Indirect fabrication, of custom cast posts and endodontically treated description of, 35 Occlusal forces, 6 Indirect provisional restorations, 85–86 provisional crown as matrix for amalgam Orthodontic extraction, 123 Infection-related root resorption, 27–28, core buildup in, 50, 51f Orthodontic extrusion crown-root ratio improvements through, Infractions, 23–25 infraction risks, 23 In-office extracoronal bleaching, 99f, root morphology of, 13 implant placement benefits of, 124 intra-alveolar transplantation advantages Instrument Removal System, 199 Mandibular premolars infraction risks, 23 mechanical application guidelines for, broken. See Broken instruments.
post placement in, 14 diameter of, root fracture and perforation root morphology of, 13 periodontal advantages of, 123 Masserann Kit, 185–186, 186f success factors, 116 intra-alveolar transplantation, 129 Masserann Micro Kit, 196 Orthodontic forced eruption. See also post space preparation using, 11, 64 Maxillary canines, 12 rotary. See Rotary instruments.
Maxillary first molars advantages of, 125 Intentional replantation, 138, 138f, 176 post diameter excess in, 65 Interdentin cracks, 182 root morphology of, 12–13 application of, 118–121, 119t–120t Internal resorption, 28, 28f Maxillary first premolars biologic width and, 116, 124f Interproximal papillae, 124 post placement in, 14 biology of, 121–122 root morphology of, 12 brackets and wires for, 118, 120 adjunctive procedures, 128–129 two-rooted, 12, 14 coronal restoration goals of, 116–117 advantages of, 132 Maxillary incisors crown fracture and, 116 case report of, 129, 130f–131f endodontically treated esthetics of, 123 complications of, 132–133 canal filling material in access cavity of, contraindications for, 132 goals of, 116–117 disadvantages of, 132 with natural crowns, 35 guidelines for, 120t esthetics affected by, 132 forced eruption of, 120f indications for, 116 ferrule effect improved through, 132 post placement in, 14 maxillary incisors, 120f fixation after, 131 root morphology of, 12 mechanics of, 118–120, 119f–120f, histologic evaluation of outcome of, infraction risks, 23 modalities of, 119t palatal roots in, 71, 71f orthodontic considerations, 123 indications for, 132 root morphology of, 12–13 instruments used in, 129 periodontal considerations, 123, 123f outcomes of, 131–133 Maxillary premolars principles of, 118, 119f periodontal healing after, 131 endodontically treated, 35 progression of, 115–116 prognosis after, 133 infraction risks, 23 surgical technique of, 128–129 root morphology of, 12 research considerations, 124–125 Intracoronal tooth bleaching, 96–99, scope of, 123–125 Intrapulpal hemorrhage, 92, 93f Mesio-occlusal restorations, 6 Intraradicular disinfection, 78, 78b Orthodontic tooth movement, 121, 123 Intrusive luxation, 132 Mineral trioxide aggregate, 171–173, 172f Orthodontic wire, 39f Irreversible pulpitis, 20, 24 Moisture content, 7, 35 Orthopedic force, 118 Orthopedic implant site preservation or autotransplantation of, 137, 141f–142f, Lasers, for crown lengthening, 112 Osseointegrated implants Little Giant Post Puller, 183, 183f advantages of, 149 Loosening of posts, 9–10, 15 infraction risks, 23 buccolingual positioning of, 157f Lost-wax technique, 36, 37f mandibular. See Mandibular molars.
complications of, 159–160 Luting agents, 75–77. See also Cement.
maxillary. See Maxillary molars.
coronoapical positioning of, 157f perforation of, 172f, 174f–175f description of, 125 post and core placement in, 71 immediate placement of Mandibular canines, 13–14 Mottled tooth, 93–94 advantages of, 155 Mandibular fractures, 160 alveolar wall gap effects on, 158 Mandibular incisors Mucoperiosteal flap, 153 contraindications for, 155–156 endodontically treated Multiple idiopathic root resorption, 30, 30f definition of, 154 with natural crowns, 36 dehiscence effects on, 158–159 post avoidance in, 14 factors that affect, 156–159 root morphology of, 13 Nickel-titanium files, 195–196 fenestration effects on, 158–159 Mandibular molars indications for, 155–156 distal roots in, 71, 71f periapical pathosis effects on, 159 primary stability during, 158 timing of repair, 168–169 tooth fracture secondary to, 182 scientific validation for, 154–155 tooth retention affected by, 167–168 ultrasonic devices for, 190–192 surgical protocols, 156 Periapical pathosis, 159 tooth position effects on, 156 Periodontal disease, 26, 124 instruments used to create, 11, 64 tridimensional position effects on, 156– Periodontal ligament, 121, 139, 143–144 root fracture risks, 13 Periradicular lesions, 27 Post space preparation mesiodistal positioning of, 157f Peritubular dentin, 35 definitive restoration placement after, Peroxides, for tooth bleaching, 94–96 contraindications, 152 Pivot crowns, 33–34 gutta-percha removal and, 66–67 description of, 149–150 PMMA. See Polymethyl methacrylate.
provisional restoration placement after, 88f in healed sites, 152–154, 153f–154f Polycarboxylate cement, 76 root perforation caused during, 27f, 170 immediate loading of, 154 Polyethylene fiber–reinforced posts, 45f, immediate provisionalization, 153–154 amalgam, 48–50, 49f–50f indications for, 152 carbon fiber–reinforced epoxy resin, 41– nonsubmerged technique, 153 acrylic resin provisional restorations, 84 scientific validation for, 152 eugenol effects on, 78 complications of, 9–14 submerged technique, 153 shrinkage during, 51 composite resin, 51–52 Osseointegration, 152 Polymethyl methacrylate, 84–86 custom cast. See Custom cast posts and cementation of. See Cement; Cementation.
description of, 41 Palatal canal, 71f depth of, 11–12 direct materials, 48–52 Passive eruption, 108, 109f diameter of, 11, 64, 65f for endodontic treatment of tooth under a fiber. See Fiber posts.
glass fiber–reinforced epoxy resin, 43f, classification of, 170, 170b guidelines for, 9 43–45, 44t, 45f combined endodontic-periodontal laboratory data findings regarding, 8–9 glass ionomer, 52 conditions caused by, 27 length of. See Post length.
in molars, 71, 71f crestal, 169, 171, 173, 174f loosening of, 9–10, 15, 191 in multirooted teeth, 71, 71f definition of, 167 materials for, 14–15 polyethylene fiber–reinforced posts, 45f, description of, 9 diagnosis of, 168–170 misconceptions about, 8 prefabricated. See Prefabricated posts.
prefabricated, 14 factors that affect, 10–13 provisional, 87–88 removal of. See Post removal.
furcation, 169, 173 purpose of, 35–36 retrofitting of, to existing crown, 207–211 hemorrhage at site of, 175 removal of. See Post removal.
tooth strengthening benefits of, 36 retrofitting of, to existing crown, 207–211 types of, 36–52 illustration of, 27f sealer effect on retention of, 77–78 zirconia, 46f, 46–47 instrument diameter and, 11 Posterior teeth. See also specific teeth. intentional replantation for, 176 surface treatment of, 79 anchorage for, 118 endodontically treated management of, 172–176 crown restoration of, 34 mineral trioxide aggregate for, 171–173, crown length and, 62–63, 71 custom cast posts and cores for, 40–41 excessive, 62–63 restorations for, 8, 34–35 molars, 172f, 174f–175f fiber posts, 14–15 survival rate of, 34 orthograde management of, 172–175 guidelines for, 63–64 Prefabricated posts post length excess as cause of, 62, 63f post loosening affected by, 10 cementation or bonding of, 47, 48f post space preparation as cause of, 27f retentive ability and, correlation between, description of, 14 premolar, 168f–169f, 173f–174f prevention of, 13–14, 170–171 root curvature effects on, 71 types of, 41–47 prognostic factors for, 168–170, 170b, root fracture risks and, 11, 62–63 autotransplantation of, 143f, 143–144 pulpal floor, 168 infraction risks, 23 repair materials for, 171–172 endodontist referral for, 181 retrograde management of, 175f, 175– factors that affect, 181 illustration of, 184f–185f perforation of, 168f–169f, 173f–174f risk factors for, 14 mechanical devices for, 182–188, post and core placement in, 71 root fracture and, differentiation of, 64 two-rooted, 12, 14 signs and symptoms of, 168 post characteristics that affect, 181 Pressure-related root resorption, 29, 29f risks associated with, 182 Primary roots, 64 subcrestal, 173–175, 174f root fracture secondary to, 182 Proprioception, 8 supracrestal, 169, 171, 173 rotary instruments for, 188–190, surgical management of, 175f, 175–176 access cavity through, 203, 204f amalgam cores under, 49 endodontic treatment of tooth with, 201– amalgam. See Amalgam restorations.
anterior teeth, 8, 34–35 maxillary, 12–13 posterior teeth, 34 composite resin. See Composite resin Root perforations. See Perforations.
retrofitting of post to, 207–211 Root resorption, 27–30, 139–140, 140f, sound tooth structure amount necessary for, extracoronal bleaching effects on, 101 factors that affect Root surface conditioning agents, 176 time until failure with, 5–6 anatomical and structural, 70–71 Rotary instruments Provisional fixed partial dentures, 49–50, craze lines, 70, 70f broken, 199f. See also Broken instruments.
dentin thickness, 11, 70–71 description of, 66 Provisional restorations ferrule effect, 68f, 68–69, 84 post removal using, 188–190, 189f–191f acrylic resin, 84–85 post diameter, 64, 65f cementation of, 86–87 post length, 61–64, 62f–64f, 84 characteristics of, 84, 85b provisional restorations, 67–68, 68f composite resin, 85 root canal preparation, 66–68 immediate versus delayed removal of, 67 computer-aided design/computer-assisted posterior teeth, 8, 34–35 post retention affected by, 77–78 manufacture of, 86 provisional. See Provisional restorations.
Setting shrinkage, 51–52 coronal access, 67–68 selection guidelines for, 8 Shear strength, 8 in endodontically treated teeth, 87 Retrofitting of post to existing crown, 207– Shrinkage, 51–52 fabrication of, 85–86, 86b, 86f Silver alloys, added to glass ionomer, 52 indirect, 85–86 Reversible pulpitis, 20, 21f, 24 Silver-palladium alloy, 36 luting of, 86–87 Single-tooth implants materials for, 84–85 crown-root ratio, 116–117, 124 contraindications, 152 description of, 149–150 post and core, 87–88 perforation of. See Perforations.
in healed sites, 152–154, 153f–154f surgical crown lengthening and, 111 immediate loading of, 154 Proximal contact, 4 Root canal preparation, 66–68 immediate provisionalization, 153–154 indications for, 152 instruments used to increase, 47 nonsubmerged technique, 153 overenlargement of, 13 scientific validation for, 152 Root canal system submerged technique, 153 Pulpal disease, 26, 26f broken instruments in. See Broken Pulpal necrosis, 26f, 92, 93f, 128 Sodium hypochlorite, 78 Pulpitis, 20, 21f, 24 description of, 22, 22f Sodium perborate, 94 Pulpless teeth. See Endodontically treated smear layer created during cleaning and Soft tissue crown lengthening, 110 Sound tooth structure, 14 Root canal therapy. See also Endodontically S.S. White Post Extractor, 183 treated teeth.
Structural tooth defects, 93–94 Radicular dentin, 78–79 anatomical considerations, 21–22 Subcrestal perforations, 173–175, 174f Radicular invaginations/grooves, 27 factors that affect, 20 Subgingival fractures, 4, 128 inadequately performed, 20f Supracrestal perforations, 169, 171, 173 antibiotics use in, 139 Surgical crown lengthening of avulsed tooth, 138, 138f, 144, 145f root canal preparation for, 21–22 in anterior areas, 108, 109f dietary considerations, 139 survival rates for, 20 biologic width considerations, 108–109 extraction and, 145–147, 146f treatment planning for. See Treatment description of, 69, 107 general principles of, 139–141 esthetic concerns, 108, 109f, 112 intentional, 138, 138f, 176 vertical root fractures versus, 25 factors that affect, 110 prognosis after, 140–141 ferrule considerations, 109–110 root resorption concerns, 139–140, 140f crown fracture and. See Crown-root Research, 124–125 Resin bonding, 78–79 factors that affect, 10–13 indications for, 107, 110, 111f glass fiber–reinforced epoxy resin posts description of, 77, 79 provisional restorations used with, 111 fiber-reinforced resin post cementation instrument diameter and, 11 recommendations for, 112–113 using, 82–83, 83f orthodontic extrusion contraindications, restorative procedures after, 111 indications for, 84 ultrasonic post removal affected by, 191 post diameter and, 11, 65 in subgingival preparation margins, 110, Resin-based sealer, 77–78 post removal as cause of, 182 Resin-modified glass-ionomer cement, 77 prevention of, 13–14 technique of, 110–112, 111f residual dentin thickness effects on, 11 root perforation and, differentiation of, 64 endodontically treated teeth, 4 root. See Root resorption.
threaded posts as risk factor for, 10 fixed partial dentures, 4–5 vertical, 25–26, 26f pulpal status assessments, 20, 21f Tetracycline-related tooth stains, 92–93, 93f events after, 150–151 Tetragonal zirconium polycrystals, 46 healing after, 150f tooth fractures, 22–26 Thermocatalytic method, for intracoronal implant replacement after, 117, 118f vertical root fractures, 25–26, 26f tooth bleaching, 98 Threaded posts, 9–10 replantation and, 145–147, 146f Tissue engineering, 123 resorption after, 151 Ultrasonic devices, for post removal, 190– ridge preservation after, 150–152 autotransplantation for. See socket defects, 158–159, 159f Ultrasonic tips, 198–199 for vertical root fracture, 25–26 Ultraviolet photo-oxidation technique, for description of, 137 intracoronal tooth bleaching, 98 Tooth avulsion, 138f biologic width affected by, 111f Urea hydrogen peroxide, 94 in endodontically treated teeth, 4–5 Urethane dimethacrylate, 85 carbamide peroxide for, 94–95 post removal as cause of, 182 definition of, 93 types of, 22–26 extracoronal. See Extracoronal bleaching.
Vertical root fractures, 25–26, 26f causes of, 5, 137 Vital teeth, endodontically treated teeth hydrogen peroxide for, 94–96, 100–102 data analysis of, 5 intracoronal, 96–99, 97f–99f fracture-related, 5 outcome of, 101–102 Tooth movement, orthodontic, 121, 123 over-the-counter products for, 94, 100 Tooth sensitivity, 100–101 Walking bleach, 96–98, 97f peroxides for, 94–96 Tooth stains, 92–94 residual oxygen produced during, 99 Tooth stiffness, 35 sodium perborate for, 94 Tooth structure loss, 116 Yttrium-stabilized tetragonal polycrystalline Tooth whitening, 93. See also Tooth Tooth discoloration aging-related, 92 calcific metamorphosis, 92 Transplantation. See Autotransplantation; Zinc oxide–eugenol-based sealer, 77–78 diseases that cause, 93 Intra-alveolar transplantation; Zinc phosphate cement extrinsic causes of, 92 cast post and core cementation using, intrapulpal hemorrhage, 92, 93f Transportation of the canal, 22 80–82, 80f–82f intrinsic causes of, 92–94 Trauma-related root resorption, 27 description of, 76, 76b pulpal necrosis, 92, 93f Treatment planning provisional restoration cementation using, structural tooth defects that cause, 93–94 combined endodontic-periodontal tetracycline-related, 92–93, 93f problems, 26–27 ultrasonic post removal affected by, 191 cracked teeth, 22–26 Zirconia posts, 46f, 46–47 forced. See Orthodontic forced eruption.
enamel craze lines, 22–23, 23f normal process of, 121 infractions, 23–25

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The Gender Politics of Criminal Insanity: "Order-in-Council" Women in British Columbia, 1888–1950 DOROTHY E. CHUNN* Between 1888 and 1950, 38 women were confined for indeterminate periods toBritish Columbia's psychiatric system under executive "Orders-in-Council".Enlisting clinical, organizational, and government records, the authors explore thepsychiatric practices of control through which a male medico-legal establishmentstrove to comprehend and discipline these "criminally insane" women. Theauthoritative discourses and activities that shaped these women's forensic careersreflected a gendered conception of social order that was hegemonic during thisperiod. Such discourses helped to fashion the images of women, crime, and madnessthat continue to permeate public and official culture.

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Le coût du hadj sera annoncé la semaine prochaine Lire en page 3 N° 5152 - MERCREDI 22 AVRIL 2015 QUALIFIÉE DE MASCARADEPAR LES PROCHES DU CHEIKH La statue de Benbadis«évacuée» du centre Lire en page 7 Enlèvement de la marchandise prohibée du port sec Anisfer de Rouiba NEUF DOUANIERS SOUS MANDAT DE DÉPÔT Le juge d'instruction de la deuxième chambre près le tribunal de Sidi-M'hamed (Alger), a ordonné hier, la mise en détention préventive de