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View from the Chairside: Why I love Cast Post-Cores & You Should Too!

We are certainly very grateful to Dr. Paul Belzycki for the amount of time and effort he put in developing today’s presentation. Although you may find it long, the presentation is packed with valuable clinical information about complex cases that were restored using cast post-cores. In his hands, this technique has proven very successful at delivering restorations that continue to defy the test of time even after many years. 

Dr. Belzycki is a dental surgeon from Toronto. He graduated from the Faculty of Dentistry at the University of Toronto in 1979 and has kindly accepted to share four decades of clinical experience with our viewers in this series of clinical mentorship posts. 

My sincere thanks go to Dr. Paul Belzycki and I hope that you benefit from such great clinical insights. Be sure to share your thoughts, comments, suggestions, and questions with us at oasisdiscussions@cda-adc.ca

Until next time!

Chiraz Guessaier
CDA Oasis Manager

Dr. Belzycki’s Thoughts

This presentation is a continuation of this series of clinical mentorship posts. When I set out to develop the presentation, to my surprise, I discovered that the topic of cast post-cores is the subject of some controversy regarding their use and teaching. There exists opposing points of view from respected university-level academics.  

Undeterred, this presentation attempts to offer my own clinical perspective, based on careful observation and documentation as to what has proven successful “in my hands.” Several “demanding cases” are presented as evidence to not abandon this time-tested technique.

Watch the follow-up presentation: Why I Love Cast Post-Cores and You Should Too! The Sequel

Full Presentation (55.56″)

 

Case-by-Case Presentations

This presentation is about… Case #1
Case #2 Case #3
Case #4 Concluding Remarks…

 

12 comments

  1. The cases presented show a high degree of skill and wonderful technique. Dr. Belzycki has done an admirable job restoring these teeth and the long term results speak for themselves.

    However, I would like to comment on the consequences of cast post use. from an Endodontic perspective.

    Firstly, it is extremely important that the previous endodontic treatment be critically evaluated BEFORE these cast posts are placed. Placement of a well cemented, intimately fitting cast post (particularly an nice aesthetic restoration) virtually guarantees that Endodontic surgery will be needed, should Endodontic retreatment be necessary. In situations with large canals and/or short roots, surgerizing the case predisposes the root to fracture by further reducing its size or by having unfavorable remaining crown/root ratios. So, if you are going to use a cast post…be SURE that the endo is evaluated in 3D (cbCT) and critically assessed.

    Secondly, use of multiple posts (especially cast posts) should be discouraged. Posts require “draw”‘- and that generally means loss of dentin – NEVER a good thing. Using posts in mesial canals of mandibular molars or buccal canals of maxillary molars ignores the natural root anatomy, predisposes the tooth to perforation and cracks, is risky and unnecessary. Since Dr. Belzycki appears to be a proponent of amalgam use, many of these posterior cases can be easily (and MUCH less expensively) restored with an all amalgam (Nayyar) style core. These cores allow for use of shallow conservative orifice retention holes and chamber undercuts, which is not possible with cast posts.

    Thirdly, Endodontics has evolved since Dr. Belzycki’s training. We have much more flexible and adaptable instrumentation. Endodontic preparations have become MUCH more conservative, with much greater emphasis on restoratively driven Endo and what is LEFT after endo treatment. Routine enlargement of canals to the sizes shown are extremely rare. Most of the “size 80 minimal preparation for post” cases are either older anterior retreatment cases or non-vital traumas where the teeth have stopped developing.. Use of larger, hand driven SS files has pretty much become obsolete.

    Post use is one of the most frequently misunderstood aspects of Dentistry. Posts are used to retain cores…AND USED ONLY WHEN NEEDED. Unfortunately, there is an incentive to use “more posts” because of the way that fees are structured. (More posts = Greater Fee). We Endodontists see the results of this daily as we attempt to fix endo failures through the use of disassembly/retreatment. It is frustrating to see posts unnecessarily placed in essentially intact teeth, only to become “Intra-Dentinal Implants” that obstruct our ability to retreat the case conventionally.

    So, if you ARE going to use a post (1) make SURE you really DO need one to retain the core and (2) Try not to use more than one (its unnecessary) and (3) critically evaluate the endo over which you are restoring.

    • Dr. Paul Belzycki

      Hello Dr. Kaufman. Thank you for sharing your thoughts on my post.

      As before, I will address each point in your comment.

      Regarding “from an Endodontic perspective”. As stated, I am a GP, but one that provides endo, perio and restorative dentistry. I endeavour to bring an integrated perspective to each and every case; and I offer all my previous presentations as evidence that it is comprehensive and efficacious.

      As a GP, most of the teeth I restore are those where I have provided the endodontic therapy with hand instrumentation. With this technique, I become intimate with the anatomy of each canal and therefore can judge accordingly, which ones will accommodate a #80 to “a given length” as not to transport the canal nor weaken remaining tooth structure. “Antiquated” as this may seem, the results speak for themselves. I do not see how Endodontics has changed all that much since my graduation. Of course, other than for the toys. What of it? The core concepts are still the same. Clean and seal a canal as best as possible with as little damage to the canal system as possible. I use my muscles to turn an instrument, others use electricity. Over the course of my career, I have seen far more excess dentine removed as a result of rotary instrumentation, because doing so with an electric motor is physically easier. Protocols such as Crown-Up, Crown-Down, Crown-Sideways, come and go. The pendulum does swing.

      Regarding the issue of multiple posts in molar teeth. I said quite plainly that I had rarely used this approach in molars. Note the molar I presented did service as a distal abutment for a bridge that lasted decades until the patient’s passing. This case was done back in the early 80’s. It is shown to aid younger clinicians as to what a multi-sectioned cast post-core looks like, in the event that they were not exposed to this technique. Yes, I use pins and prefabricated posts in molars. The combination of those retentive elements is determined by what solid tooth structure is remaining and the canal anatomy; and never by financial concerns. In fact, I rarely use prefabricated posts, if I can gain retention with retentive pins and engagement of the upper 2 mm. of canal space with amalgam. This has been made clear in several of my previous presentations.

      Given all the above, I could still make a case for multiple-section cast post-cores in molars. They work fine, but must be prepared, designed and fabricated with care. As you claimed, removing excess tooth structure for the sake of draw is never a good idea. Doing so is not proper technique nor did I advocate it. I stated in my summation that recommendations on treatment are not made in a vacuum. One must assess the case in totality, taking into account, if a given tooth anatomy could justify such an undertaking. Multiple-section posts can be feasible but must be mated with the right tooth and the final restorative endeavor. This does not mean it is my first and only treatment option. It remains a tool in my Tool-Box. I do not discard old tools, because one never knows when they may be needed.

      Regarding the need for 3D scanning. In my opinion, this is not necessary, I have never done it despite the fact that I have placed many posts. I see no reason to subject a patient to unnecessary radiation when a good periapical film will suffice; and then one can decide if further investigation is warranted. Common sense and standards of care would dictate that all teeth scheduled for any form of restoration, would have adequate radiographic assessment. Further, as an endodontist, you would routinely see post failures because the ones that are just fine and dandy do not present to you. Perhaps, this bias sample is the source for your opinion. And to spice up the conversation, I was told by an Oral Surgeon that root-end procedures do not work because he extracts all the failures. We informed him that he may have come to that erroneous conclusion because the vast majority of successfully treated teeth do not present to him.

      This presentation is not designed to be a step-by-step instructional guide. One would need several days for such a task in order to elucidate all the do’s and don’ts. Because I have not stated these in the presentation, due to time constraints, it does not mean I am unaware of them. My primary intention in these mentorship posts is to whet the appetite for learning and humbly provide a role model of a dentist that continues to practice with joy and passion in the pursuit of excellence and one who puts the needs of patients above all else.

      Thank you again,
      Dr. Paul Belzycki, DDS

  2. Thank you for your presentation Dr. Belzycki.
    I have been very fortunate to get my dental education at the University of Saskatchewan where my Prosthodontics Professor, Dr. Moulding, taught us Cast Post Core. I have been using cast post core for all single canal teeth and premolars and some molars with great success for the last 11 years. I, too, am an advocate of this method! I am not sure if cast post core is taught presently at University of Saskatchewan. I hope they still teach it.
    Respectfully,
    Shahram Rahmani, BSC, DMD

    • Dr. Paul Belzycki

      Dr. Rahmani, thanks for your comment. I am curious. What technique were you taught and what do you use today? Do you take impression as I do, or direct technique with Duralay? Or both depending on circumstance.

      Just want to know.
      Seems there is controversy here as well.

      Good to hear from all across Canada.
      This forum amazes me.
      I now communicate with more dentists across the country than my own city.

      • Thank you for your reply Dr. Belzycki! I was taught both direct technique utilizing Dursley as well as taking impression. I use impression. I combine the cast post core and crown impression and ask the lab to fabricate cast post core and and a crown in conjunction with that. However, the cast post core and crown are not attached.
        When the case comes back, they are cemented in one appointment.
        I have not used direct technique except during my training at Dental School.
        Regards,
        Shahram Rahmani, BSc., DMD

        • Good to know.
          I just use impression technique as shown.
          I will always insert post and core first, then take a second impression.
          In my mind, too many variables with doing it all together.
          My own hang-up.

          Many thanks for your contribution and thoughts.

  3. It may be easier to resolve the gun debate in the US, then the post debate in Dentistry.

    I presently teach and practice. Having graduated from Rutgers in 78, and practice in south Florida since 80, I have seen many sides of this coin.

    1-Having the tool in your box to fabricate a cast post and core is essential. I learned this technique after dental school: I take a metal ParaPost, and build-up pattern resin (GC) around it. I may have to reline the inside if not retentive. Then my lab will cast to the metal. Period. Fit is always snug, and I know the post will not wedge the canal. I like this technique since I leave the maximum amount of dentin which is crucial generally, and most specifically if a cast post is indicated. I can also retro-fit posts with this technique.

    2-I do agree that for older root canals, it is essential to have a protocol to determine if the endo is adequate first. I do use CBCT, and have found many areas around mostly upper molars on 3D that would be impossible to find on 2D. I have an interest in TMD, doing practice-based research funded by NIH, and have seen many patients that have TMD with non-diagnosed infections..cracks, failing endo, and resorption that is confirmed with CBCT. I take a Q-tip (cotton tip applicator) and palpate the individual root apices to assess the relative discomfort of all endo teeth. This is not 100% full-proof for a problem, but it gets me thinking.

    3-Its best if no post is needed….but unfortunately, I have seen a surprising number of endo teeth that the general dentist left the cotton pellet for the permanent restoration. I think amalgam is likely the best material for a core, with pins as needed, but I don’t have amalgam in my office. I use bonded composite, but if my core is close to the prep, I obsess about dropping the bone/tissue to get a sealed margin. Unfortunately, many endos fail due to inadequate occlusal seal. But on the other hand, we sometimes under-treat teeth that should have post/cores, that instead fail due to a large core that fails and comes out with the crown. I have saved many teeth that other would have extracted, but the price we pay is that it doesn’t always work out.

    Seems like we can’t always win..

    4-I can personally vouch for Dr. Paul Belzycki, as we have shared patients, and I have seen his work, and attention to detail. You can take to the bank that what he does works for him.

    Sincerely,

    Alan Slootsky

    • Dr. Paul Belzycki

      Thank you Dr. Slootsky for your input.

      Well, even a handful of responses reveals diverse opinions on this topic. Even when there is agreement on the use of cast post-cores, methods of impression taking, fabrication and design vary.

      Hence my comments at the end of the presentation are more pertinent.

      When I hear posts fail, or cause the fracture of teeth, I want to know, who did it, what was their technique, how well was that technique accomplished, was the lab phase done properly, what was the final restoration…etc…etc.

      Was the protocol provided with Brinksmanship?

      So, even the label cast post-cores refers to several design concepts.

      This was a most interesting exercise. I hope it motivates good, constructive thought in the minds of the viewers.

      Dr. Paul Belzycki, DDS

  4. Dr Elizabeth Newman

    Hi Paul

    Thank you for another superb video presentation! I really enjoyed watching it.

    I am concerned to learn that some dental schools may not be teaching students how to use cast cores and posts.It is such a proven and successful technique to restore badly broken down endodontically treated teeth.

    Like you, I am “old school” and use cast cores and posts in anterior teeth and bicuspids as I was taught at the University of Toronto.

    Like you, in molars, I prefer to put a cemented well fitted parapost down the distal canal in lower molars or the lingual canal in upper molars— and place several pins and do a bonded amalgam core build-up—although on very rare occasions, I have placed posts and a core in molars . And they are still there decades later.

    Like the anonymous dentist, I also cement my cast cores and posts and then take a second impression. I find that there has less hassles that way.

    My compliments to you again on the excellent restorative work that you provide to your patients. Most impressive.

    Please keep these excellent videos coming. Our profession is benefiting from them.

    Kind Regards

    Liz

    • Dr. Paul Belzycki

      Dear Liz.

      I told you to move to my office, but you didn’t listen.

      On a serious note, many thanks for your encouragement. These presentations do take time and effort.
      Rewarding to know that some of my friends are watching.

      Dr. Paul Belzycki, DDS

  5. Vasant Ramlaggan

    Thanks for the presentation and the great discussion from all.

    I’m currently using Carbon Fibre posts which don’t require as much or sometimes no dentin removal. I like using them because of the ability to place multiple and bond to the tooth structure when a tooth might otherwise be unsalvageable; probably even with cast cores. They don’t require the same draw, can be adjusted chairside before seating and limit the number of visits. I haven’t used a pin for over 15 years or more now with no issues and less stress over perforations, etc.

    I have seen almost no post specific failures and most of those are due to poor hygiene even after crown placement and not specifically due to the posts. Some of the failures I’ve seen are due to retention of old materials instead of completely removing them before post placement.

    Currently, the younger dentists are being taught that ANY post is bad or so I’ve been told. I don’t agree with that and have seen crowns fracture off occasionally without underlying core support.

    I’m sure, as always, different materials work better in some hands versus other hands.

    Thanks again!

  6. Thanks for the video presentation.

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