A core is the term used to describe the
restoration that is placed in order to build up a broken down tooth before
receiving an indirect restoration. In some cases it may not be necessary to
place a separate core, but an indirect restoration may be constructed to
replace all of the missing tooth structure. Typical examples of this include root-filled
teeth in which an integral corono-radicular restoration and core may be placed,
or for teeth that have suffered cusp fracture where placement of a traditional
restoration would leave very little tooth structure (e.g. premolars with a
previous mesio-occlusodistal restoration and one lost cusp, a ‘one-piece’ onlay
may be the treatment of choice). However, for most teeth requiring an indirect restoration,
a core restoration will need to be provided.
The exact nature of any particular core
will depend on the degree to which the tooth in question is broken down and how
much coronal dentine remains. When attempting to understand the rationale for choice
of core restoration, it is helpful to consider the concept of extremes, from a
simple space-filling core to a structural core (Fig. 5.3) and relate the
different functions to the materials available.
Core Build up Video
Space-filling core
When much coronal dentine
remains, the role of a core is simply to fill out any undercuts and give an
appropriate shape that will provide adequate retentive and resistance form
(described later). The restorative material simply acts to prevent or ‘block
out’ any undercuts to the path of insertion of the intended indirect
restoration. This situation commonly arises when an intra-coronal restoration (i.e.
an inlay) is planned to replace a previous direct restoration. The preparation
will have to be modified to eliminate the undercuts; extending the preparation
would be unnecessarily destructive compared with placement of a core material
to block out the undercuts. Similarly, the same approach can be taken to give
smooth axial walls when an extra-coronal restoration such as a full coverage
crown is planned.
In the above example, the
functional demands and stresses encountered by the core material will be minimal.
The mechanical properties of a core material in this situation are not critical,
and the material choice is largely determined by secondary factors such as
ability to bond to tooth structure, cariostatic properties and ease of handling
(e.g. command set).
Types of core
restorations, (a) structural and (b) space-filling.
Structural core
When a large amount of coronal
dentine has been lost, it is more likely that an extra-coronal full-coverage restoration
will be planned. The core material will replace a substantial part of the
clinical crown and will form the bulk of the final preparation. In this case,
the core material will be subjected to significant functional demands and
stresses, particularly in molar teeth, and must therefore have adequate mechanical
properties to resist these. Although a full-coverage crown may afford some
protection to the core if the margins are extended gingivally beyond the core6,
this protection is limited. The strongest materials available at present are
amalgam (for a direct core) or a cast metal such as gold (for an indirect core
in an endodontically treated tooth).
Essentially, there are four
types of direct core material available; amalgam, resin composite, glass ionomer
or hybrid materials such as light-cured resin-modified glass-ionomer cement
(RmGIC).
Amalgam
Amalgam has perhaps the best
track record when used for substantial posterior core build-ups. Amalgam has
good contrast with tooth substance and is easy to prepare. The long time to
full set may predispose to early fracture, which is unfortunate, as the
preparation cannot usually be prepared at the same visit, although newer
high-copper amalgam alloys have high strength within a short time and may be prepared
at the same visit after a short delay. The thermal expansion of amalgam is
quite dissimilar to dentine, and this factor may predispose to failure after a
period of time. In addition, amalgam cannot be bonded to tooth substance
without resorting to proprietary products for amalgam bonding.
Resin composite
The use of resin composite as
a core material has advantages and disadvantages. The composite does not
require a two-visit crown preparation technique and, when necessary, the crown
preparation can be commenced immediately. However, against this, the resin composite
is difficult to prepare to the correct form because it may be difficult to
differentiate between tooth tissue and core substance, though resin composites
of contrasting colour are available. Lightcured resin composites should be used
with caution, as full depth of cure may not be achieved in substantial core
build-ups. Chemicalcure or dual-cure resin composites (the latter having the
advantage of ‘command set’) have an advantage in that those portions of the material
not exposed to the curing light will still undergo polymerization due to the
chemical cure. However, they may undergo increased discoloration (due to the
tertiary amine activator7) compared with light-cured resin composites and thus
should be used with caution in anterior teeth in which non-opaque aesthetic restorations
are planned. Some resin composites are marketed specifically for core build-up,
are coloured and have advantages over tooth-coloured composites. It has been
suggested that because of water sorption and expansion, additional die relief
should be provided during construction, or impression taking should be delayed
after preparation to prevent discrepancy between the working die and the prepared
tooth.
Glass ionomers and
resin-modified glass-ionomer cement
Traditional glass-ionomer
cements are only suitable for use as a space-filling core, where they will not
be subjected to any stresses, as they are inherently weak materials. Several
glass-ionomer materials are marketed specifically for use as a core build-up
material such as RmGIC. They bond to dentine, release fluoride, have comparable
thermal behaviour to dentine, can be made a contrasting colour to tooth (e.g.
blue) and are easy to prepare, although the long-term behaviour of these
materials is not well documented. Water sorption and expansion are higher with these
materials than with resin composites and, for this reason, after preparation
there should be a delay before impression taking. At present, their use as a
structural core may be questionable. However they may eventually become the materials
of choice with further developments.
Choice of core material
The choice of core material
depends on several clinical variables. The role of the core material with
regard to a space-filling or functional role is critical and the degree to which
the core will be subjected to stress and the amount of bracing provided by
remaining coronal dentine should be considered when selecting the material.
Amalgam alloy should not be used beneath anterior full-veneer crown
restorations as corrosion products from the amalgam core may stain the dentine
peripheral to the restoration and result in poor aesthetics.
Similarly, an amalgam core
underneath a three-quarter crown may shine through the remaining tooth and be
unaesthetic. Restoration of the endodontically treated tooth is covered in
detail in later posts, though points of particular relevance are repeated here.
In most situations the general principles above apply. When little tooth
structure remains it is usual to place a post-retained core, although molar
teeth may successfully be restored with an amalgam dowel core (Nayyar core). If
a direct intra-radicular post has been placed in order to retain a core, then
care should be taken to ensure that the properties of the core material are not
mismatched to those of the post (e.g. avoid glass-ionomer cement or
resin-composite cores with metal intra-radicular posts), although some studies
suggest that fibre posts (with a relatively low modulus of elasticity) perform
better with a rigid metal core.
In general terms, when there
is sufficient coronal dentine remaining to provide some support to the core
material, then resin-based restorative materials are the core materials of
choice. However, for a tooth that has lost much coronal tooth structure then a
stronger core material (amalgam or cast metal if root treated) should be
placed.
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