CH 19

Various methods of restoring pulpless teeth have been
reported for more than 200 years. In 1747, Pierre

Fauchard described the process by which roots of max-
illary anterior teeth were used for the restoration of
single teeth and the replacement of multiple teeth
(Figure 19-1).
1
Posts were fabricated of gold or silver
and held in the root canal space with a heat-softened
adhesive called mastic.
1,2
The longevity of restora-
tions made using this technique was attested to by
Fauchard: Teeth and articial dentures, fastened with
posts and gold wire, hold better than all others. They
sometimes last fteen to twenty years and even more
without displacement. Common thread and silk, used
ordinarily to attach all kinds of teeth or articial pieces,
do not last long.
1
In Fauchards day, replacement crowns were made
from bone, ivory, animal teeth, and sound natural
tooth crowns. Gradually, the use of these natural sub-
stances declined, to be slowly replaced by porcelain. A
pivot (what is today termed a post) was used to retain
the articial porcelain crown into a root canal, and the
crown-post combination was termed a pivot crown.
Porcelain pivot crowns were described in the early
1800s by a well-known dentist of Paris, Dubois de
Chemant.
2
Pivoting (posting) of articial crowns to
natural roots became the most common method of
replacing articial teeth and was reported as the best
that can be employed by Chapin Harris in The Dental
Art in 1839.
3
Early pivot crowns in the United States used sea-
soned wood (white hickory) pivots.
4
The pivot was
adapted to the inside of an all-ceramic crown and also
into the root canal space. Moisture would swell the
wood and retain the pivot in place.
2
Surprisingly,
Prothero reported removing two central incisor crowns
with wooden pivots that had been successfully used for
18 years.
2
Subsequently, pivot crowns were fabricated
using wood/metal combinations, and then more
durable all-metal pivots were used. Metal pivot reten-
tion was achieved by various means such as threads,
Chapter 19
RESTORATION OF
ENDODONTICALLY TREATED TEETH
Charles J. Goodacre and Joseph Y. K. Kan
Figure 19-1 Early attempts to restore single or multiple units. A,
Pivot tooth consisting of crown, post, and assembled unit. B, Six-
unit anterior bridge pivoted in lateral incisors with canines can-
tilevered. Crowns were fashioned from diversity of materials.
Human, hippopotamus, sea horse, and ox teeth were used, as well as
ivory and oxen leg bones. Posts were usually made from precious
metals and fastened to crown and root using a heated sticky mas-
tic prepared by gum, lac, turpentine, and white coral powder.
(Reproduced with permission from Fauchard P.
1
)
*The authors are indebted to Drs. Kenneth C. Trabert, Joseph P.
Cooney, Angelo A. Caputo, and Jon P. Standlee of the University of
California School of Dentistry, Los Angeles, who contributed so
generously the many ne illustrations, photographs, and laborato-
ry ndings found in this chapter.
pins, surface roughening, and split designs that provid-
ed mechanical spring retention.
2
Unfortunately, adequate cements were not available
to these early practitionerscements that would have
enhanced post retention and decreased abrasion of the
root caused by movement of metal posts within the
canal. One of the best representations of a pivoted
tooth appears in Dental Physiology and Surgery, written
by Sir John Tomes in 1849 (Figure 19-2).
5
Tomess post
length and diameter conform closely to todays princi-
ples in fabricating posts.
Endodontic therapy by these dental pioneers
embraced only minimal efforts to clean, shape, and
obturate the canal. Frequent use of the wood posts in
empty canals led to repeated episodes of swelling and
pain. Wood posts, however, did allow the escape of the
so-called morbid humors. A groove in the post or
root canal provided a pathway for continual suppura-
tion from the periradicular tissues.
1
Although many of the restorative techniques used
today had their inception in the 1800s and early 1900s,
proper endodontic treatment was neglected until years
later. Today, both the endodontic and prosthodontic
aspects of treatment have advanced signicantly, new
materials and techniques have been developed, and a
substantial body of scientic knowledge is available on
which to base clinical treatment decisions.
The purpose of this chapter is to answer questions
frequently asked when dental treatment involves pulp-
less teeth and to describe the techniques commonly
employed when restoring endodontically treated teeth.
Whenever possible, the answers and discussion will be
supported by scientic evidence.
914 Endodontics
SHOULD CROWNS BE PLACED ON
ENDODONTICALLY TREATED TEETH?
A retrospective study of 1,273 teeth endodontically
treated 1 to 25 years previously compared the clinical
success of anterior and posterior teeth.
6
Endo-
dontically treated teeth with restorations that encom-
passed the tooth (onlays, partial- or complete-coverage
metal crowns, and metal ceramic crowns) were com-
pared with endodontically treated teeth with no coro-
nal coverage restorations. It was determined that coro-
nal coverage crowns did not signicantly improve the
success of endodontically treated anterior teeth. This
nding supports the use of a conservative restoration
such as an etched resin in the access opening of other-
wise intact or minimally restored anterior teeth.
Crowns are indicated only on endodontically treated
anterior teeth when they are structurally weakened by
the presence of large and/or multiple coronal restora-
tions or they require signicant form/color changes
that cannot be effected by bleaching, resin bonding, or
porcelain laminate veneers. Scurria et al. collected data
from 30 insurance carriers in 45 states regarding the
procedures 654 general dentists performed on
endodontically treated teeth.
7
The data indicated that
67% of endodontically treated anterior teeth were
restored without a crown, supporting the concept that
many anterior teeth are being satisfactorily restored
without the use of a crown.
When endodontically treated posterior teeth (with
and without coronal coverage restorations) were com-
pared, a signicant increase in the clinical success was
noted when cuspal coverage crowns were placed on
maxillary and mandibular molars and premolars.
6
Therefore, restorations that encompass the cusps
should be used on posterior teeth that have interdigita-
tion with opposing teeth and thereby receive occlusal
forces that push the cusps apart. The previously dis-
cussed insurance data indicated that 37 to 40% of pos-
terior pulpless teeth were restored by practitioners
without a crown, a method of treatment not supported
by the long-term clinical prognosis of posterior
endodontically treated teeth that do not have cusp-
encompassing crowns.
7
There are, however, certain
posterior teeth (not as high as 40%) that do not have
substantive occlusal interdigitation or have an occlusal
form that precludes interdigitation of a nature that
attempts to separate the cusps (such as mandibular
rst premolars with small, poorly developed lingual
cusps). When these teeth are intact or minimally
restored, they would be reasonable candidates for
restoration of only the access opening without use of a
coronal coverage crown.
Figure 19-2 Principles used today in selecting post length and
diameter were understood and taught by early practitioners during
mid-1800s. Reproduced with permission from Tomes J.
5
Restoration of Endodontically Treated Teeth 915
Multiple clinical studies of xed partial dentures,
many with long spans and cantilevers, have determined
that endodontically treated abutments failed more
often than abutment teeth with vital pulps owing to
tooth fracture,
812
supporting the greater fragility of
endodontically treated teeth and the need to design
restorations that reduce the potential for both crown
and root fractures when extensive xed prosthodontic
treatment is required.
Gutmann reviewed the literature and presented an
overview of several articles that identify what happens
when teeth are endodontically treated.
13
These articles
provide background information important to an
understanding of why coronal coverage crowns help
prevent fractures of posterior teeth. Endodontically
treated dog teeth were found to have 9% less moisture
than vital teeth.
14
Also, with aging, greater amounts of
peritubular dentin are formed, which decreases the
amount of organic materials that may contain mois-
ture. It has been shown that endodontic procedures
reduce tooth stiffness by 5%, attributed primarily to
the access opening.
15
Tidmarsh described the structure of an intact tooth
that permits deformation when loaded occlusally and
elastic recovery after removal of the load.
16
The direct
relationship between tooth structure removed during
tooth preparation and tooth deformation under load of
mastication has been described.
17
Dentin from
endodontically treated teeth has been shown to exhibit
signicantly lower shear strength and toughness than
vital dentin.
18
Rivera et al. stated that the effort
required to fracture dentin may be less when teeth are
endodontically treated because of potentially weaker
collagen intermolecular cross-links.
19
Conclusions
Restorations that encompass the cusps of endodonti-
cally treated posterior teeth have been found to
increase the clinical longevity of these teeth. Therefore,
crowns should be placed on endodontically treated
posterior teeth that have occlusal interdigitation with
opposing teeth of the nature that places expansive
forces on the cusps. Since crowns do not enhance the
clinical success of anterior endodontically treated
teeth, their use on relatively sound teeth should be lim-
ited to situations in which esthetic and functional
requirements cannot be adequately achieved by other,
more conservative restorations (Figure 19-3).
WITH PULPLESS TEETH, DO POSTS IMPROVE
LONG-TERM CLINICAL PROGNOSIS OR
ENHANCE STRENGTH?
Laboratory Data
Virtually all laboratory studies have shown that place-
ment of a post and core either fails to increase the frac-
ture resistance of extracted endodontically treated
teeth or decreases the fracture resistance of the tooth
when a force is applied via a mechanical testing
machine.
2025
Lovdahl and Nicholls found that
endodontically treated maxillary central incisors were
stronger when the natural crown was intact, except for
the access opening, than when they were restored with
cast posts and cores or pin-retained amalgams.
20
Lu
found that posts placed in intact endodontically treat-
ed central incisors did not lead to an increase in the
force required to fracture the tooth or in the position
and angulation of the fracture line.
21
McDonald et al.
found no difference in the impact fracture resistance
of mandibular incisors with or without posts.
22
Eshelman and Sayegh
25a
reported similar results when
posts were placed in extracted dog lateral incisors.
Guzy and Nicholls determined that there was no sig-
nicant reinforcement achieved by cementing a post
into an endodontically treated tooth that was intact
except for the access opening.
23
Leary et al. measured
the root deection of endodontically treated teeth
before and after posts of various lengths were cement-
ed into prepared root canals.
24
They found no signi-
cant differences in strength between the teeth with or
without a post. Trope et al. determined that preparing
a post space weakened endodontically treated teeth
compared with ones in which only an access opening
was made but no post space.
25
Figure 19-3 Incisal view of an intact central incisor that required
endodontic treatment owing to trauma. Placement of a bonded
resin restoration in the access opening is the only treatment
required since crowns do not enhance the longevity of anterior
endodontically treated teeth. A crown would only be used when
esthetic and functional needs cannot be achieved through more
conservative treatments.
A potential situation in which a post and core could
strengthen a tooth was identied by Hunter et al. using
photoelastic stress analysis.
26
They determined that
removal of internal tooth structure during endodontic
therapy is accompanied by a proportional increase in
stress. They also determined that minimal root canal
enlargement for a post does not substantially weaken a
tooth, but when excessive root canal enlargement has
occurred, a post strengthens the tooth. Therefore, if the
walls of a root canal are thin owing to removal of
internal root caries or overinstrumentation during post
preparation, then a post may strengthen the tooth.
Two-dimensional nite element analysis was used in
one study to determine the effect of posts on dentin
stress in pulpless teeth.
27
When loaded vertically along
the long axis, a post reduced maximal dentin stress by
as much as 20%. However, only a small (3 to 8%)
decrease in dentin stress was found when a tooth with
a post was subjected to masticatory and traumatic
loadings at 45 degrees to the incisal edge. The authors
proposed that the reinforcement effect of posts is
doubtful for anterior teeth because they are subjected
to angular forces.
Clinical Data
Sorenson and Martinoff clinically evaluated endodonti-
cally treated teeth with and without posts and cores.
28
Some of the teeth were restored with single crowns,
whereas others served as either xed or removable par-
tial-denture abutments. Posts and cores signicantly
decreased the clinical success rate of teeth with single
crowns and improved the clinical success of removable
partial-denture abutment teeth but had little inuence on
the clinical success of xed partial-denture abutments.
Eckerbom et al. examined the radiographs of 200 consec-
utive patients and radiographically re-examined the same
patients 5 to 7 years later to determine the prevalence of
apical periodontitis.
29
Of the 636 endodontically treated
teeth evaluated, 378 had posts and 258 did not have posts.
At both examinations, apical periodontitis was signi-
cantly more common in teeth with posts than in
endodontically treated teeth without posts.
Mors evaluated the incidence of vertical root frac-
ture in 460 endodontically treated teeth, 266 with
posts.
30
There were 17 teeth with root fracture after a
time period of at least 3 years. Nine of the 17 fractured
teeth had posts, and 8 root fractures were in teeth with-
out posts. Mors concluded that the endodontic tech-
nique can cause vertical root fracture.
30
None of the
clinical data provide denitive support for the concept
that posts and cores strengthen endodontically treated
teeth or improve their long-term prognosis.
916 Endodontics
Purpose of Posts
Since clinical and laboratory data indicate that teeth are
not strengthened by posts, their purpose is for reten-
tion of a core that will provide appropriate support for
the denitive crown or prosthesis. Unfortunately, this
primary purpose has not been completely recognized.
Hussey and Killough noted that 24% of general dental
practitioners felt that a post strengthens teeth.
31
A 1994
survey (with responses from 1,066 practitioners and
educators) revealed some interesting but erroneous
facts.
32
Ten percent of the dentist respondents felt that
each endodontically treated tooth should receive a
post. Sixty-two percent of dentists over age 50 believed
that a post reinforces the tooth, whereas only 41% of
the dentists under age 41 believed in that concept.
Thirty-nine percent of part-time faculty, 41% of full-
time faculty, and 56% of nonfaculty practitioners felt
that posts reinforce teeth.
32
Conclusions
Both laboratory and clinical data fail to provide deni-
tive support for the concept that posts strengthen
endodontically treated teeth. Therefore, the purpose of
a post is to provide retention for a core.
WHAT IS THE CLINICAL FAILURE RATE OF
POSTS AND CORES?
Several studies provide clinical data regarding the
number of posts and cores that failed over certain time
periods (Table 19-1).
3342
When this number is divided
by the total number of posts and cores placed, the
absolute failure rate is determined. A 9% overall aver-
age for absolute failure was calculated by averaging the
absolute failure percentages from eight studies (an
average study length of 6 years). In these studies, the
absolute percent of failure ranged from 7 to 14%.
A review of more specic details from the eight
studies provides insight into the length of each study
and the number of posts and cores evaluated. The
ndings of a 5-year retrospective study of 52 posts
and cores indicated that there were 6 failures and a
12% absolute failure rate.
33
Another study found that
17 of 154 posts failed after 3 years, for an 11%
absolute failure rate.
34
An absolute failure rate of 9%
was found in three studies.
3537
A study of 138 posts
in service for 10 years or more reported a 7%
absolute post and core failure rate after 10 years or
more (9 of 138 posts failed).
38
An 8% absolute failure
rate (39 of 516 posts and cores) was published when
516 posts and cores placed by senior dental students
were retrospectively evaluated,
39
whereas another
study recorded a 14% failure rate (8 failures in 56
posts and cores) from posts and cores placed by den-
tal students.
40
Kaplan-Meier survival statistics (percent survival
over certain time periods) were presented or could be
calculated from the data in seven studies (Table
19-2).
41
The survival rates ranged from a high of 99%
after 10 years or more of follow-up to a 78% survival
rate after a mean time of 5.2 years. The percent failure
per year has also been calculated and ranged from
1.56%/year
36
to 4.3%/year.
42
Conclusions
Posts and cores had an average absolute rate of failure
of 9% (7 to 14% range) when the data from eight stud-
ies were combined (average study length of 6 years).
WHAT ARE THE MOST COMMON TYPES OF
POST AND CORE FAILURES?
Seven studies indicate that post loosening is the most
common cause of post and core failure (Figure 19-
4).
33,34,36,37,39,43,44
Turner reported on 100 failures of
post-retained crowns and indicated that post loosening
was the most common type of failure.
43
Of the 100
failures, 59 were caused by post loosening. The next
most common occurrences were 42 apical abscesses
followed by 19 carious lesions. There were 10 root frac-
tures and 6 post fractures. In another article by Turner,
he reported the ndings of a 5-year retrospective study
of 52 post-retained crowns.
33
Six posts had come loose,
which was the most common failure. Lewis and Smith
presented data regarding 67 post and core failures after
4 years.
44
Forty-seven of the failures (70%) resulted
from posts loosening, 8 from root fractures, 7 from
caries, and 4 from bent or fractured posts. Bergman et
al. found 8 failures in 96 posts after 5 years.
36
Six posts
had come loose, and 2 roots fractured. Hatzikyriakos et
al. reported on 154 posts and cores after 3 years.
34
Five
posts had come loose, 5 crowns had come loose, 4 roots
fractured, and caries caused 3 failures. Mentink et al.
identied 30 post loosenings and 9 tooth fractures
when evaluating 516 posts and cores over a 1- to 10-
year time period (4.8 years mean study length).
39
Torbjrner et al. reported on the frequency of 3 techni-
cal failures (loss of retention, root fracture, and post
fracture).
37
They did not report biologic failures. Loss
of retention was the most frequent post failure,
accounting for 45 of the 72 post and core failures
(62.5%). Root fracture was the second most common
failure cause, followed by post fracture (Figure 19-5).
Table 19-1 Clinical Failure Rate of Posts and Cores
Lead Author Study Length % Clinical Failure
Turner, 1982*
33
5 y 12 (6 of 52)
Sorenson, 1984
35
125 y 9 (36 of 420)
Bergman, 1989*
36
5 y 9 (9 of 96)
Weine, 1991*
38
10 y or more 7 (9 of 138)
Hatzikyriakos, 1992*
34
3 y 11 (17 of 154)
Mentink, 1993*
39
110 y 8 (39 of 516)
(4.8 mean)
Wallerstedt, 1984*
40
40 y 14 (8 of 56)
(7.8 mean)
Torbjrner, 1995
37
169 mo 9 (72 of 788)
Mean values

6 yr 9 (196 of 2,220)
*Studies used to calculate mean study length.
Calculation made by averaging numeric data from all studies.

Table 19-2 Kaplain-Meier Survival Data (%) of
Posts and Cores
Lead Author Study Length % Survival
Roberts, 1970
42
5.2 y mean 78
Wallerstedt, 1984
40
410 y range 83
Sorenson, 1985
28
125 y range 90
Weine, 1991
38
>10 y 99
Hatzikyriakos, 1992
34
3 y 92
Mentink, 1993
39
10 y 82
Creugers, 1993
41
6 y 81 (threaded
(meta-analysis) posts), 91
(cast posts)
Figure 19-4 Mandibular molar crown that failed because the post
loosened from the distal root.
In two studies, factors other than loss of retention were
listed as the most common cause of failure.
35,38
Sorenson
and Martinoff evaluated 420 posts and cores and record-
ed 36 failures.
35
Of the 36 failures, 8 were related to
restorable tooth fractures, 12 to nonrestorable tooth frac-
tures, and 13 to loss of retention and 3 were caused by
root perforations. Weine et al. found 9 failures in 138
posts and cores after 10 years or more.
38
Three failures
were caused by restorative procedures, 2 by endodontic
918 Endodontics
treatment, 2 by periodontal problems, and 2 by root frac-
ture. No posts failed owing to loss of retention.
Four studies provided data on the incidence of tooth
fracture but did not provide information regarding
post loosening. Linde reported that 3 of 42 teeth frac-
tured,
45
Ross found no fractures with 86 posts,
46
Mors found that 10 of 266 teeth fractured,
30
and
Wallerstedt et al. identied 2 fractures with 56 posts.
40
Loss of retention and tooth fracture are the two
most common causes of failure (in that order of occur-
rence) when these studies are collectively analyzed by
averaging the numeric data from all of the studies. Five
percent of the posts placed (105 of 2,178 posts) experi-
enced loss of retention (Table 19-3). Three percent of
the posts placed (66 of 2,628 posts) failed via tooth
fracture (Table 19-4).
Conclusions
Loss of retention and tooth fracture are the two most
common causes of post and core failure.
WHICH POST DESIGN PRODUCES THE
GREATEST RETENTION?
Laboratory Data
There have been many laboratory studies comparing
the retention of various post designs. Threaded posts
provide the greatest retention, followed by cemented,
parallel-sided posts. Tapered cemented posts are the
least retentive. Cemented, parallel-sided posts with ser-
Figure 19-5 Radiograph of a fractured maxillary rst premolar
caused by a post with an excessive diameter and insufficient length,
two problems frequently seen in conjunction with fractured roots.
Table 19-3 Clinical Loss of Retention Associated with Posts and Cores
% of Posts Placed % of Failures
Lead Author Study Length That Loosened Post Form Owing To Loosening
Turner, 1982
33
5 y 9 (6 of 66) Appeared to be tapered *
Turner, 1982
33
15 y or more * Tapered 59 (59 of 100)
Sorenson, 1984
35
125 y 3 (13 of 420) Tapered and parallel 36 (13 of 36)
Lewis, 1988
44
4 y * Threaded, tapered, and parallel 70 (47 of 67)
Bergman, 1989 5 y 6 (6 of 96) Tapered 67 (6 of 9)
Weine, 1991
38
10 or more 0 (0 of 138) Tapered 0 (0 of 9)
Hatzikyriakos, 1992
34
3 y 3 (5 of 154) Threaded, parallel, and tapered 29 (5 of 17)
Mentink, 1993
39
110 y (4.8 mean) 6 (30 of 516) Tapered 77 (30 of 39)
Torbjrner, 1995
37
Mean values
5 (105 of 2,178) 59 (205 post loos-

enings of 349
total failures)
*Data not available in publication.

rations are more retentive than cemented, smooth-
sided parallel posts.
Clinical Data
There is clinical support for these laboratory studies.
Torbjrner et al. reported signicantly greater loss of
retention with tapered posts (7%) compared with par-
allel posts (4%).
37
Sorenson and Martinoff determined
that 4% of tapered posts failed by loss of retention,
whereas 1% of parallel posts failed in that manner.
35
Turner indicated that tapered posts loosened clinically
more frequently than parallel-sided posts.
43
Lewis and
Smith also found a higher loss of retention with
smooth-walled tapered posts than parallel posts.
44
Bergman et al.
36
and Mentink et al.
39
evaluated only
tapered posts, and both studies reported that 6% of
tapered posts failed via loss of retention, values higher
than those recorded by Torbjrner et al.
37
and
Sorenson and Martinoff
35
for parallel posts.
Contrasting results were reported by Weine et al.
38
They found no clinical failures from loss of retention
with cast tapered posts. Hatzikyriakos et al. studied
tapered threaded posts, parallel cemented posts, and
tapered cemented posts.
34
The only posts that loosened
from the root were parallel cemented posts.
Conclusions
Tapered posts are the least retentive and threaded
posts the most retentive in laboratory studies. Most of
the clinical data support the laboratory ndings.
IS THERE A RELATIONSHIP BETWEEN
POST FORM AND THE POTENTIAL FOR
ROOT FRACTURE?
Laboratory Data
Using photoelastic stress analysis, Henry determined
that threaded posts produced undesirable levels of
stress.
47
Another study used strain gauges attached to
the root and compared four parallel-sided threaded
posts with one parallel-sided nonthreaded post.
48
Two
of the threaded posts produced the highest strains,
Table 19-4 Clinical Tooth Fractures Associated with Posts and Cores
% of Teeth Restored
with Posts That % of Failures Owing
Lead Author Study Length Fractured Post Form(s) Studied To Fracture
Turner, 1982
33
5 y 0 (0 of 66) Appear to be tapered *
Turner, 1982
33
15 y or more * Tapered, parallel, and threaded 10 (10 of 100)
Sorenson, 1984
35
Linde, 1984
45
210 y (5 y, 8 mo) 7 (3 of 42) Threaded 38 (3 of 8)
mean
Lewis, 1988
44
4 y * Threaded, tapered, and parallel 12 (8 of 67)
Bergman, 1989
36
5 y 3 (3 of 96) Tapered 33 (3 of 9)
Ross, 1980
46
5 y or more 0 (0 of 86) Tapered, parallel, and threaded 0 (0 of 86)
Mors, 1990
30
3 y at least 4 (10 of 266) Threaded and parallel *
Weine, 1991
38
10 y or more 1 (2 of 138) Tapered 50 (2 of 4)
Hatzikyriakos, 1992
34
3 y 3 (4 of 154) Threaded, parallel, and tapered 3 (4 of 17)
Mentink, 1993
39
110 y (4.8 mean) 2 (9 of 516) Tapered 23 (9 of 39)
Wallerstedt, 1984
40
7.8 y 4 (2 of 56) Threaded 25 (2 of 8)
Torbjrner, 1995
37
16 y 3 (21 of 788), Parallel and tapered 29 (21 of 72)
3% mean
Mean values
3 (66 of 2,628) 17 (74 tooth frac-

tures of 446
total failures)
*Data not available in publication.

whereas two other threaded posts caused strains com-
parable to the nonthreaded post. Standlee et al., using
photoelastic methods, indicated that tapered, threaded
posts were the worst stress producers.
49
When three
types of threaded posts were compared in extracted
teeth, Deutsch et al. found that tapered, threaded posts
increased root fracture by 20 times that of the parallel
threaded posts.
50
Laboratory testing of split-threaded posts has pro-
vided varying results, but more research groups have
concluded that they do not reduce the stress associated
with threaded posts. Thorsteinsson et al. determined
that split-threaded posts did not reduce stress concen-
tration during loading.
51
In another study, split, thread-
ed posts were found to produce installation stresses
comparable to other threaded posts.
52
Greater stress
concentrations than some other threaded posts were
reported under simulated functional loading.
5355
Rolf
et al. found that a split, threaded post produced compa-
rable stress to one type of threaded post and less stress
than a third threaded post design.
56
Ross et al. deter-
mined that a split-threaded post produced less root
strain than two other threaded posts and comparable
strain to a third threaded post and a nonthreaded post.
48
Another research group concluded that the split, thread-
ed design reduced the stresses caused during cementa-
tion compared with a rigid, threaded post design.
57
Multiple photoelastic stress studies concluded that
posts designed for cementation produced less stress
than threaded posts.
47,49,56
When parallel-sided cemented posts have been com-
pared with tapered cemented posts, photoelastic stress
testing results have generally favored parallel-sided
posts. Using this methodology, Henry found that par-
allel-sided posts distribute stress more evenly to the
root.
47
Finite-element analysis studies produced simi-
lar results.
58,59
Two additional photoelastic studies con-
cluded that parallel posts concentrate stress apically
and tapered posts concentrate stress at the post-core
junction.
51,54
Also, using photoelastic testing, Assif et
al. found that tapered posts showed equal stress distri-
bution between the cementoenamel junction and the
apex compared with parallel posts, which concentrated
the stress apically.
60
When fracture patterns in extracted teeth were used
to compare parallel and tapered posts, the evidence
favoring parallel posts is less favorable. Sorenson and
Engelman determined that tapered posts caused more
extensive fractures than parallel-sided posts, but the
load required to create fracture was signicantly high-
er with tapered posts.
61
Lu, also using extracted teeth,
found no difference in the fracture location between
920 Endodontics
prefabricated parallel posts and cast posts and cores.
21
Assif et al. tested the resistance of extracted teeth to
fracture when the teeth were restored with either paral-
lel or tapered posts and complete crowns.
62
No signi-
cant differences were noted, and post design did not
inuence fracture resistance.
In analyzing the stress distribution of posts, it was
noted that tapered posts generate the least cementation
stress and should be considered for teeth that have thin
root walls, are nearly perforated, or have perforation
repairs.
54
Clinical Data
There are several clinical studies that provide data
related to the incidence of root fracture associated with
different post forms. Some of these studies provide a
comparison of multiple post forms, whereas other
studies evaluated only one type of post. Combining all
of the root fracture data for each post form from both
types of studies reveals some interesting trends (Table
19-5). Five studies present data regarding root fractures
and threaded posts,
30,35,40,45,46
four regarding fracture
associated with parallel-sided cemented posts,
30,35,37,46
and seven related to tapered, cemented posts.
30,3539,46
If the total number of threaded posts evaluated in the
ve studies is divided into the total number of fractures
found with threaded posts, a percent value can be
determined that represents the average incidence of
tooth fracture associated with threaded posts in the ve
studies. The same data can be calculated for parallel
cemented and tapered cemented posts, permitting a
comparison of the root fracture incidences associated
with these three post forms.
Combining the ve studies that reported data rela-
tive to threaded posts produced a mean fracture rate of
7% (11 fractures from 169 posts). The four clinical
studies that contain fracture data from parallel-sided
cemented posts produced a mean fracture incidence of
1% (9 fractures from 687 posts). From the seven stud-
ies reporting root fracture with tapered posts, there is a
mean fracture rate of 3%(50 root fractures from 1,553
posts). These combined study data support the previ-
ously cited photoelastic laboratory stress tests, indicat-
ing that the greatest incidence of root fractures
occurred with threaded posts and that the lowest per-
centage of root fracture was associated with parallel
cemented posts. In a meta-analysis of selected clinical
studies, Creugers et al. calculated a 91% tooth survival
rate for cemented cast posts and cores and an 81% sur-
vival rate for threaded posts with resin cores.
41
Although the combined data from all of the studies
for each type of post revealed certain trends, analysis of
individual studies (where multiple post forms were
compared in the same study) produced less conclusive
results. One study of threaded and cemented posts
determined that teeth with threaded posts were lost
more frequently than teeth with cast posts.
29
In three
other clinical comparisons of threaded and cemented
posts, no tooth fracture differences were noted between
threaded and cemented posts.
30,34,46
In addition to the
comparisons of threaded and cemented posts, four
clinical studies provide data comparing the tooth frac-
ture incidences associated with parallel-sided and
tapered posts. In comparing parallel and tapered posts
by reviewing dental charting records, a higher failure
rate was reported with tapered posts than parallel posts
in two studies,
35,37
and the failures were judged to be
more severe with tapered posts. Two other clinical
studies determined that there were no differences
between tapered and parallel-sided posts.
34,46
Hatzikyriakos et al. found no signicant differences
between 47 parallel cemented posts and 44 tapered
cemented posts after 3 years of service.
34
Ross evaluat-
ed 86 teeth with posts and cores that had been restored
at least 5 years previously.
46
No fracture differences
were found between 38 tapered cemented posts and 39
parallel cemented posts.
Unfortunately, the total number of clinical studies
that compared multiple post forms in the same study is
limited. Also, several factors may have affected the nd-
ings of available studies. Two of the articles that con-
tained a comparison of multiple post forms covered
sufficiently long time periods (10 to 25 years) that the
tapered cemented posts may have been in place for
much longer time periods than the parallel-sided
cemented posts (owing to the later introduction of par-
allel posts into the dental market).
35,37
The mean time
since placement for each post form was not identied in
these studies. Also, both of these studies were based on
reviews of patient records (rather than clinical exami-
nations) and depended on the accuracy of dental charts
in determining if and when posts failed, as well as the
cause of the failure. Another factor that affected the
results of many of the referenced clinical studies was the
length of the posts. For instance, in Sorenson and
Martinoff s study, 44% of the tapered cemented posts
had a length that was half (or less than half) the
incisocervical/occlusocervical dimension of the crown
whereas only 4% of the parallel cemented posts were
that short.
35
Since short posts have been associated with
higher root stresses in laboratory studies, the difference
in post length may have affected their ndings in which
tooth fractures occurred with 18 of 245 tapered posts
compared with no fractures with 170 parallel posts.
Conclusions
When evaluating the relationship between post form
and root fracture, laboratory tests generally indicate
that all types of threaded posts produce the greatest
potential for root fracture. When comparing tapered
and parallel cemented posts using photoelastic stress
analysis, the results generally favor the parallel cement-
ed posts. However, the evidence is mixed when the
comparison between tapered and parallel posts is based
on fracture patterns in extracted teeth created by apply-
ing a force via a mechanical testing machine.
When evaluating the combined data from multiple
clinical studies, threaded posts generally produced the
highest root fracture incidence (7%) compared with
tapered cemented posts (3%) and parallel cemented
Table 19-5 Post Form and Tooth Fracture
Clinical Data (% of Post and Cores Studied That Failed via Tooth Fracture)
Threaded Posts (Lead Author) Parallel-Sided Posts (Lead Author) Tapered Posts (Lead Author)
40 (2 of 5) (Sorenson
35
) 0 (0 of 170) (Sorenson
35
) 7 (18 of 245) (Sorenson
35
)
0 (0 of 10) (Ross
46
) 2 (5 of 332) (Torbjner
37
) 4 (16 of 456) (Torbjner
37
)
4 (2 of 56) (Wallerstedt
40
) 0 (0 of 39) (Ross
46
) 1 (2 of 138) (Weine
38
)
7 (3 of 42) (Linde
45
) 3 (4 of 146) (Mors
30
) 2 (9 of 516) (Mentink
39
)
7 (4 of 56) (Mors
30
) 3 (3 of 96) (Bergman
36
)
0 (0 of 38) (Ross
46
)
3 (2 of 64) (Mors
30
)
7% Mean
*
(11 of 169) 1% Mean* (9 of 687) 3% Mean* (50 of 1,553)
*Calculation made by averaging numeric data from all studies.
posts (1%). Analysis of individual clinical studies as
opposed to the combined data produces less conclusive
results. Additional comparative clinical studies would
be benecial, including designs that have not yet been
evaluated in comparative studies.
WHAT IS THE PROPER LENGTH FOR A POST?
A wide range of recommendations have been made
regarding post length, which includes the following: (1)
the post length should equal the incisocervical or
occlusocervical dimension of the crown
6370
; (2) the
post should be longer than the crown
71
; (3) the post
should be one and one-third the crown length
72
; (4)
the post should be half the root length
73,74
; (5) the post
should be two-thirds the root length
7579
; (6) the post
should be four-fths the root length
80
; (7) the post
should be terminated halfway between the crestal bone
and root apex
8183
; and (8) the post should be as long
as possible without disturbing the apical seal.
47
A
review of scientic data provides the basis for differen-
tiating between these varied guidelines.
Although short posts have never been advocated, they
have frequently been observed during radiographic
examinations (Figure 19-6). Grieve and McAndrew
found that only 34% of 327 posts were as long as the
incisocervical length of the crown.
84
In a clinical study of
200 endodontically treated teeth, Ross determined that
only 14% of posts were two-thirds or more of the root
length and 49% of the posts were one-third or less of the
root length.
46
A radiographic study of 217 posts deter-
mined that only 5% of the posts were two-thirds to three-
quarters the root length.
85
In a retrospective clinical study
of 52 posts, Turner radiographically compared the length
922 Endodontics
of the post with the maximum length available if 3 mm
of gutta-percha were retained.
33
Posts that came loose
used only 59% of the ideal length, and only 37% of the
posts were longer than the proposed minimum length.
Nine millimeters were proposed as the ideal length.
Sorensen and Martinoff determined that clinical
success was markedly improved when the post was
equal to or greater than the crown length.
35
Johnson
and Sakumura determined that posts that were three-
quarters or more of the root length were up to 30%
more retentive than posts half of the root length or
equal to the crown length.
86
Leary et al. indicated that
posts with a length at least three-quarters of the root
offered the greatest rigidity and least root bending.
87
These data indicate that post length would appro-
priately be three-quarters that of root length. However,
some interesting results occur when post length guide-
lines of two-thirds to three-quarters the root length are
applied to teeth with average, long, and short root
lengths. It was determined that a post approaching this
recommended length range is not possible without
compromising the apical seal by retaining less than
5 mm of gutta-percha.
88
When post length was half
that of the root, the apical seal was rarely compromised
on average-length roots. However, when posts were
two-thirds the root length, many of the average- and
short-length roots would have less than the optimal
gutta-percha seal. Shillingburg et al. also indicated that
making the post length equal the clinical crown length
can cause the post to encroach on the 4.0 mm safety
zone required for an apical seal.
89
Abou-Rass et al. proposed a post length guideline for
maxillary and mandibular molars based on the inci-
dence of lateral root perforations occurring when post
preparations were made in 150 extracted teeth.
90
They
determined that molar posts should not be extended
more than 7 mm apical to the root canal orice.
When teeth have diminished bone support, stresses
increase dramatically and are concentrated in the
dentin near the post apex.
91
A recent nite-element
model study established a relationship between post
length and alveolar bone level.
92
To minimize stress in
the dentin and in the post, the post should extend more
than 4 mm apical to the bone.
Conclusions
Reasonable clinical guidelines for length include the fol-
lowing: (1) Make the post approximately three-quarters
the length of the root when treating long-rooted teeth;
(2) when average root length is encountered, then post
length is dictated by retaining 5 mm of apical gutta-per-
cha and extending the post to the gutta-percha (Figure
Figure 19-6 Radiograph showing a very short post in the distal root
of the rst molar that has loosened and caused prosthesis failure.
19-7); (3) whenever possible, posts should extend at
least 4 mm apical to the bone crest to decrease dentin
stress; and (4) molar posts should not be extended
more than 7 mm into the root canal apical to the base
of the pulp chamber (Figure 19-8).
HOW MUCH GUTTA-PERCHA SHOULD BE
RETAINED TO PRESERVE THE APICAL SEAL?
It has been determined that when 4 mm of gutta-per-
cha are retained, only 1 of 89 specimens showed leak-
age, whereas 32 of 88 specimens (36%) leaked when
only 2 mm of gutta-percha were retained.
93
Two stud-
ies found no leakage at 4 mm, whereas another study
found that 1 of 8 specimens leaked at 4 mm.
94,95
Portell
et al. found that most specimens with only 3 mm of
apical gutta-percha had some leakage.
96
When the leak-
age associated with 3, 5, and 7 mm of gutta-percha was
compared, Mattison et al. found signicant leakage dif-
ferences between each of the dimensions.
97
They pro-
posed that at least 5 mm of gutta-percha are required
for an adequate apical seal. Nixon et al. compared the
sealing capabilities of 3, 4, 5, 6, and 7 mm of apical
gutta-percha using dye penetration.
98
The greatest
leakage occurred when only 3 mm were retained, and it
was signicantly different from the other groups. They
also noted that a signicant decrease in leakage
occurred when 6 mm of gutta-percha remained. Kvist
et al. examined radiographs from 852 clinical
endodontic treatments.
99
Posts were present in 424 of
the teeth. Roots with posts in which the remaining root
lling material was shorter than 3 mm showed a signif-
icantly higher frequency of periapical radiolucencies.
Conclusions
Since there is greater leakage when only 2 to 3 mm of
gutta-percha are present, 4 to 5 mm should be retained
apically to ensure an adequate seal. Although studies
indicate that 4 mm produce an adequate seal, stopping
precisely at 4 mm is difficult, and radiographic angula-
tion errors could lead to retention of less than 4 mm.
Therefore, 5 mm of gutta-percha should be retained
apically (see Figure 19-7).
DOES POST DIAMETER AFFECT RETENTION
AND THE POTENTIAL FOR TOOTH FRACTURE?
Studies relating post diameter to post retention have
failed to establish a denitive relationship. Two studies
determined that there was an increase in post retention
as the diameter increased,
89,100
whereas three studies
found no signicant retention changes with diameter
variations.
101103
Krupp et al. indicated that post length
was the most important factor affecting retention and
post diameter was a secondary factor.
104
A more denitive relationship has been established
between post diameter and stress in the tooth. As the
post diameter increased, Mattison found that stress
increased in the tooth.
105
Trabert et al. measured the
impact resistance of extracted maxillary central inci-
sors as post diameter increased and found that increas-
ing post diameter decreased the tooths resistance to
fracture.
106
Deutsch et al. determined that there was a
sixfold increase in the potential for root fracture with
every millimeter the tooths diameter was decreased.
50
However, two nite-element studies failed to nd high-
er tooth stresses with larger-diameter posts.
58,59
Figure 19-7 Five millimeters of gutta-percha were retained in the
maxillary premolar and the post extended to that point.
Figure 19-8 Distal post in the mandibular molar was extended to
a maximal length of 7 mm.
Conclusions
Laboratory studies relating retention to post diameter
have produced mixed results, whereas a more denitive
relationship has been established between root fracture
and large-diameter posts (Figure 19-9).
WHAT IS THE RELATIONSHIP BETWEEN
POST DIAMETER AND THE POTENTIAL
FOR ROOT PERFORATIONS?
In a literature review of guidelines associated with post
diameter, Lloyd and Palik indicated that there are three
distinct philosophies of post space preparation.
107
One
group advocated the narrowest diameter for fabrication
of a certain post length (the conservationists). Another
group proposed a space with a diameter that does not
exceed one-third the root diameter (the proportionists).
The third group advised leaving at least 1 mm of sound
dentin surrounding the entire post (the preservationists).
Based on the proportional concept of one-third the
root diameter, three articles measured the root diame-
ters of extracted teeth and proposed post diameters
that would not exceed that proportion.
89,90,108
Tilk et
al. examined 1,500 roots.
108
They measured the nar-
rowest mesiodistal dimension at the apical, middle, and
cervical one-thirds of the teeth except the palatal root
of the maxillary rst molar, which was measured faci-
olingually. Based on a 95% condence level that post
width would not exceed one-third the apical width of
the root, they proposed the following post widths
(Table 19-6): small teeth such as mandibular incisors,
about 0.6 to 0.7 mm; large-diameter roots such as max-
illary central incisors and the palatal root of the maxil-
924 Endodontics
lary rst molar, about 1.0 mm; and for the remaining
teeth, about 0.8 to 0.9 mm.
Shillingburg et al. measured 700 root dimensions to
determine the post diameters that would minimize the
risk of perforation.
89
Also based on not exceeding one-
third the mesiodistal root width, they recommended
the following post diameters (see Table 19-6):
mandibular incisors, 0.7 mm; maxillary central incisors
or other large roots, 1.7 mm, which was the maximal
recommended dimension; post tip diameter, at least 1.5
mm less than root diameter at that point; and post
diameter at the middle of the root length, 2.0 mm less
than the root diameter.
Post spaces were prepared in 150 extracted maxillary
and mandibular molars using different instrument
diameters, and the resulting incidences of perforations
were recorded.
90
The authors determined that the mesial
roots of mandibular molars and the buccal roots of
maxillary molars should not be used for posts owing to
the higher risk of perforation on the furcation side of the
root. For the principal roots (mandibular distal and
maxillary palatal), they determined that posts should not
be extended more than 7 mm into the root canal (apical
to the pulp chamber) owing to the risk of perforation.
Regarding instrument size, they concluded that post
preparations can be safely completed using a No. 2 Peeso
instrument, but perforations are more likely when the
larger No. 3 and 4 Peeso (Dentsply/Maillefer North
America; Tulsa, Okla.; Moyco/Union Broach; York, Pa.)
instruments were used.
Raiden et al. evaluated several instrument diameters
(0.7, 0.9, 1.1, 1.3, 1.5, and 1.7 mm) to determine which
Figure 19-9 Excessive post diameters. A, A large-diameter post placed in the palatal root of the maxillary molar. B, A large-diameter thread-
ed post caused fracture of the maxillary second premolar. The radiographic appearance of the bone is typical of a fractured roota teardrop-
shaped lesion with a diffuse border.
A
B
one(s) would preserve at least 1 mm of root wall thick-
ness following post preparation in maxillary rst pre-
molars.
109
They determined that instrument diameter
must be small (0.7 mm or less) for maxillary rst pre-
molars with single canals because the mesial and distal
developmental root depressions restrict the amount of
available tooth structure in the centrally located single
root canal. However, when there are dual canals, the
instrument can be as large as 1.1 mm because the
canals are located buccally and lingually into thicker
areas of the roots.
Conclusions
Instruments used to prepare posts should be related in
size to root dimensions to avoid excessive post diameters
that lead to root perforation (Figure 19-10). Safe instru-
ment diameters to use are 0.6 to 0.7 mm for small teeth
such as mandibular incisors and 1 to 1.2 mm for large-
diameter roots such as the maxillary central incisor.
Molar posts longer than 7 mm have an increased chance
of perforations and therefore should be avoided even
when using instruments of an appropriate diameter.
CAN GUTTA-PERCHA BE REMOVED
IMMEDIATELY AFTER ENDODONTIC
TREATMENT AND A POST SPACE PREPARED?
Several studies indicate that there is no difference in the
leakage of the root canal lling material when the post
space is prepared immediately after completing
endodontic therapy.
94,110112
Bourgeois and Lemon
found no difference between immediate preparation of a
post space and preparation 1 week later when 4 mm of
gutta-percha were retained.
110
Zmener found no differ-
ence in dye penetration between gutta-percha removal
after 5 minutes and 48 hours.
111
Two sealers were tested,
and 4 mm of gutta-percha were retained apically. When
lateral condensation of gutta-percha was used, Madison
and Zakariasen found no difference in the dye penetra-
tion between immediate removal and 48-hour
removal.
94
Using the chlorpercha lling technique,
Table 19-6 Post Space Preparation Widths (in mm)
Maxillary Mandibular
Tilk et al.
108
Shillingburg et al.
89
Tilk et al.
108
Shillingburg et al.
89
Central incisor 1.1 1.7 0.7 0.7
Lateral incisor 0.9 1.3 0.7 0.7
Canine 1.0 1.5 0.9 1.3
First premolar
(B) 0.9 0.9
(L) 0.9 0.9
Second premolar 0.9 1.1 0.9 1.3
First molar
(MB) 0.9 1.1 (MB) 0.9 1.1
(DB) 0.8 1.1 (ML) 0.8 0.9
(L) 1.0 1.3 (D) 0.9 1.1
Second molar
(MB) 1.1 (MB) 0.9
(DB) 0.9 (ML) 0.9
(L) 1.3 (D) 1.1
Figure 19-10 The excessive post diameter in the maxillary second
premolar created a perforation in the mesial root concavity. Note
the distinct border and round form of the radiolucent lesion, char-
acteristics indicative of a root perforation.
Schnell found no difference between immediate removal
of gutta-percha and no removal of gutta-percha.
112
By
contrast, Dickey et al. found signicantly greater leakage
with immediate gutta-percha removal.
113
Kwan and Harrington tested the effect of immediate
gutta-percha removal using both warm and rotary
instruments.
114
There was no signicant difference
between the controls and immediate removal using
warm pluggers and les. Compared to the controls, there
was signicantly less leakage with immediate removal of
gutta-percha when using Gates-Glidden (Dentsply/
Maillefer North America; Tulsa, Okla.; Moyco/Union
Broach; York, Pa.) drills.
Karapanou et al. compared immediate and delayed
removal of two sealers (a zinc oxideeugenol sealer and
a resin sealer).
115
No difference between immediate
and delayed removal was noted with the resin sealer,
but delayed removal of the zinc oxideeugenol sealer
produced signicantly greater leakage.
Portell et al. found that delayed gutta-percha
removal (after 2 weeks) caused signicantly more leak-
age than immediate removal when only 3 mm of gutta-
percha were retained apically.
96
Fan et al. found more
leakage from delayed removal of gutta-percha.
116
Conclusions
Adequately condensed gutta-percha can be safely
removed immediately after endodontic treatment.
WHAT INSTRUMENTS REMOVE GUTTA-PERCHA
WITHOUT DISTURBING THE APICAL SEAL?
Multiple studies have determined that there is no differ-
ence in leakage between removing gutta-percha with hot
instruments and removing it with rotary instru-
ments.
93,97,117
Suchina and Ludington
117
and Mattison et
al.
97
found no difference between hot instrument
removal and removal with Gates-Glidden burs. Camp
and Todd found no difference between Peeso reamers,
Gates-Glidden burs, and hot instruments.
93
Hiltner et al.
compared warm plugger removal with two types of
rotary instruments (GPX burs; Brassler, Savannah,
Georgia, and Peeso reamers).
118
There were no signi-
cant differences in dye leakage between any of the groups.
Contrasting results were found by Haddix et al.
119
They
measured signicantly less leakage when the gutta-percha
was removed with a heated plugger than when either a
GPX instrument or Gates-Glidden drills were used.
Conclusions
Both rotary instruments and hot hand instruments can
safely be used to remove adequately condensed gutta-
percha when 5 mm are retained apically.
926 Endodontics
CAN A PORTION OF A SILVER POINT BE
REMOVED AND STILL MAINTAIN THE
APICAL SEAL?
In one study, all of the specimens leaked when 1 mm of
a 5-mm-long silver point was removed using a round
bur.
111
Neagley found that removal of the lling materi-
al coronal to the silver point with a Peeso reamer caused
no leakage.
95
However, when all of the lling material
and 1 mm of the silver point were removed, complete
dye penetration occurred in eight of nine specimens.
Conclusions
The removal of a portion of a silver point during post
preparation causes apical leakage.
DOES THE USE OF A CERVICAL FERRULE
(CIRCUMFERENTIAL BAND OF METAL) THAT
ENGAGES TOOTH STRUCTURE HELP PREVENT
TOOTH FRACTURE?
Survey data indicate the percentage of respondents
who felt that a ferrule increased a tooths resistance to
fracture.
32
Fifty-six percent of general dentists, 67% of
prosthodontists, and 73% of board-certied prostho-
dontists felt that core ferrules increased a tooths frac-
ture resistance. To investigate this concept, several
research studies have been performed. Some of the
studies indicate that ferrules are benecial, whereas
others found no increase in fracture resistance.
The results appear indecisive until three differ-
ences between study designs are analyzed. First, some
of the studies tested ferrules that were part of a cast
metal core (core ferrules),
120124
whereas other stud-
ies evaluated the effectiveness of ferrules created by
the overlying crown engaging tooth structure.
125128
One study evaluated both core and crown ferrules.
129
Second, there were differences in the form of the fer-
rule and therefore the manner by which the metal
engaged tooth structure (beveled sloping surface ver-
sus extension over relatively parallel prepared tooth
structure). Third, there were variations in the
amount of tooth structure encompassed by the fer-
rules. Table 19-7 provides a comparison of the stud-
ies and the effectiveness of the various core and
crown ferrules.
The data generally indicate that ferrules formed as
part of the core are less effective than ferrules created
when the overlying crown engages tooth structure. In
four of the six core ferrule studies, they were found to
be ineffective.
121,122,124,129
Also, in one of the two stud-
ies in which the core ferrule was effective, the ferrule
form was a 2 mm parallel extension of the core over
tooth structure
120
as opposed to a bevel. In the other
study in which core ferrules were found to be effec-
tive,
123
a torsional force was used as opposed to an
angular lingual force.
In the crown ferrule studies, most of the ferrules
effectively increased a tooths resistance to fracture.
Only when the crown ferrule was of minimal dimen-
sion
125
or a sloping form
129
was it found to be ineffec-
tive. In support of these studies, Rosen and Partida-
Rivera found that a 2 mm cast gold collar (not part of
the post and core) was very effective in preventing root
fracture when a tapered screw post was intentionally
threaded into roots so as to induce fracture.
130
Assif et
al. found no difference in the tooth fracture patterns of
parallel posts, tapered posts, and parallel posts with a
tapered end when they were covered by a crown that
grasped 2 mm of tooth structure.
62
The data also support the concept that ferrules that
grasp larger amounts of tooth structure are more effec-
tive than those that engage only a small amount of
tooth structure. In both the core and crown ferrule
studies, the tooths resistance to fracture was increased
when a substantive amount of tooth structure was
engaged (2 mm in the core ferrule studies and 1 to 2
mm in the crown ferrule studies). Libman and Nicholls
found the 0.5 to 1.0 mm crown ferrule to be ineffec-
tive,
125
whereas a 1.5 to 2.0 mm crown ferrule was
effective. Isidor et al. determined that increasing crown
ferrule length signicantly increased the number of
Table 19-7 Core Ferrules
Was Ferrule
Study Ferrule Form Effective? Materials/Type of Test
Barkhordar, 1989 2 mm parallel extension of core Yes Extracted teeth/angular lingual force applied
over the tooth to p and c (no overlying crown)
Sorensen, 1990 1 mm wide 60-degree bevel at No Extracted teeth/angular lingual force applied
the tooth-core junction to p and c (with overlying crown)
Tjan, 1985 60-degree bevel at the No Extracted teeth/angular lingual force applied
tooth-core junction to p and c (no overlying crown)
Loney, 1990 1.5 mm parallel extension of No Photoelastic teeth/angular lingual force
core over the tooth applied to p and c (no overlying crown)
Hemmings, 1991 45-degree bevel Yes Extracted teeth/torsional force applied to
p and c (no overlying crown)
Saupe, 1996 2 mm parallel extension of core No Extracted teeth/angular lingual force applied
over thin dentin wall to p and c (no overlying crown)
(0.50.75 mm thick)
Sorensen, 1990 130-degree sloping nish line No Extracted teeth/p and c with crown
12 mm of tooth grasped by crown Yes Extracted teeth/p and c with crown
Libman, 1995 0.51 mm of prepared tooth No Extracted teeth/p and c with crown/cyclic
grasped by crown loading
1.52 mm of prepared tooth Yes Extracted teeth/p and c with crown/cyclic
grasped by crown loading
Milot, 1992 1 mm wide 60-degree bevel Yes Plastic analogies of teeth/p and c with
grasped by crown crowns
Isidor, 1999 1.25 mm of prepared tooth Yes Bovine teeth/cyclic angular load/p and c
grasped by crown with crown
2.5 mm of prepared tooth Yes, but more Bovine teeth/cyclic angular load/p & c
grasped by crown effective than with crown
1.25 mm
Hoag, 1982 12 mm of prepared tooth Yes Extracted teeth/p and c with crown
grasped by crown
p and c = post and core.
cyclic cycles required to cause specimen failure.
127
They
compared no ferrule with 1.25 and 2.55 mm crown fer-
rules and concluded that ferrule length was more
important than post length in increasing a tooths
resistance to fracture under cyclic loading.
The form of the prepared ferrule also appears to
affect a tooths fracture resistance in the previously cited
studies. Only one beveled/sloping ferrule was effective
in enhancing a tooths fracture resistance, and that was
when a torsional force was applied to the tooth.
Conclusions
Differences of opinion exist regarding the effectiveness
of ferrules in preventing tooth fracture. Ferrules have
been tested when they are part of the core and also when
the ferrule is created by the overlying crown-engaging
tooth structure. Most of the data indicate that a ferrule
created by the crown-encompassing tooth structure is
more effective than a ferrule that is part of the post and
core (Figure 19-11). Ferrule effectiveness is enhanced by
grasping larger amounts of tooth structure. The
amount of tooth structure engaged by the overlying
crown appears to be more important than the length of
the post in increasing a tooths resistance to fracture.
Ferrules are more effective when the crown encompass-
es relatively parallel prepared tooth structure than
when it engages beveled/sloping tooth surfaces.
POST AND CORE PLACEMENT TECHNIQUES
Pretreatment Data Review
When it has been determined that a post and core is
required to properly retain a denitive single crown or
xed partial denture, the following characteristics should
be determined prior to beginning the clinical procedures
associated with fabrication of a post and core:
1. Post length
2. Post diameter
3. Anatomic/structural limitations
4. Type of post and core that will be used (prefabricat-
ed post and restorative material core or anatomical-
ly customized cast post and core)
5. Root selection in multirooted teeth
6. Type of denitive restoration being placed and its
effect on core form and tooth reduction depths.
Post Length
Since 5 mm of gutta-percha should be retained apical-
ly to ensure a good seal (as measured radiographically),
posts should be extended to that length in all teeth
except molars. With molars, posts should be placed in
928 Endodontics
the primary roots (palatal root of maxillary molars and
distal roots of mandibular molars) and should not be
extended more than 7 mm apical to the origin of the
root canal in the base of the pulp chamber. Extension
beyond this length can lead to root perforation or only
very thin areas of remaining tooth structure.
Post Diameter
A frequently used and clinically appropriate guideline
for post diameter is to not exceed one-third the root
diameter. It has been determined that when a root
canal is prepared for a post and the diameter is
increased beyond one-third of the root diameter, the
tooth becomes exponentially weaker. Each millimeter
of increase (beyond one-third the root diameter) caus-
es a sixfold increase in the potential for root fracture.
50
Based on measuring the root dimensions of 1,500 teeth
(125 of each tooth) and using the guideline that the
post should be one-third the root diameter, optimal
post diameter measurements have been determined to
be about 0.6 mm for mandibular incisors and 1.0 mm
for maxillary central incisors, maxillary and mandibu-
lar canines, and the palatal root of the maxillary rst
molar.
108
The recommended post diameter for the
other teeth was 0.8 mm.
108
Another study of 700 teeth
recommended that post diameter should range from
0.7 mm for mandibular incisors to a maximum of 1.7
mm for maxillary central incisors.
89
Anatomic/Structural Limitations
The practitioner who completed the endodontic treat-
ment is ideally suited to identify characteristics of the
Figure 19-11 Types of ferrules. A, Tooth prepared for a post and
core. B, A post and core has been cemented into the tooth. The
arrows note how the core has created a ferrule around the tooth
(core ferrule). C, A metal ceramic crown has been cemented over
the core. The arrows show how the crown encompasses the tooth
cervically, establishing a crown ferrule.
A B C
pulp chamber, the anatomy of the root canal(s), and
completed endodontic lling that should be reviewed
before placing a post and core. These characteristics
include the presence and extent of dentinal craze lines,
identication of teeth for which further root prepara-
tion (beyond that needed to complete endodontic
instrumentation) will result in less than 1 mm of
remaining dentin or a post diameter greater than one-
third the root diameter area, information regarding
areas in which the remaining tooth structure is thin, and
the point at which signicant root curvature begins.
Craze Lines
Craze lines in dentin are areas of weakness where fur-
ther crack propagation may result in root fracture and
tooth loss. The patient should be informed of their
presence with appropriate chart documentation of
crack location. It is prudent to avoid post placement, if
possible, in favor of a restorative material core. If a post
is required, it should passively t the canal, and the
denitive restoration should entirely encompass the
cracked area, whenever possible, by forming a ferrule.
Dentin Thickness After Endodontic Treatment
Following normal and appropriate endodontic instru-
mentation, teeth can possess less than 1 mm of dentin,
indicating that there should be no further root prepa-
ration for the post. When these teeth are encountered,
it is best to fabricate a post that ts into the existing
morphologic form and diameter rather than addition-
ally preparing the root to accept a prefabricated type of
post. This characteristic is one of the primary indica-
tions for use of a custom cast post and core. One study
determined that canines (maxillary and mandibular),
maxillary central and lateral incisors, and the palatal
root of maxillary rst molars possessed more than 1
mm of dentin after endodontic cleaning and shap-
ing.
131
All other teeth had roots with less than 1 mm of
remaining dentin following endodontic treatment.
With the goal of preserving 1 mm of remaining dentin
lateral to posts, it has been determined that single-
canal maxillary rst premolars should have posts that
are 0.7 mm in diameter or less.
109
Mandibular premo-
lars with oval- or ribbon-shaped canals should not be
subjected to any preparation of the root canal for a
post since this will result in less than 1 mm of
dentin.
132
Preparation of the mesial root canals in
mandibular molars and the buccal root canals in max-
illary molars can result in perforation or only thin
areas of remaining dentin. Based on measurements of
residual dentin thickness, it is recommended that
posts not be placed in these roots if possible.
Root Curvature
When root curvature is present, post length must be lim-
ited to preserve remaining dentin, thereby helping to
prevent root fracture or perforation. Root curvature
occurs most frequently in the apical 5 mm of the root.
Therefore, if 5 mm of gutta-percha are retained apically,
curved portions of the root are usually avoided. As dis-
cussed previously under post length, molar posts should
not exceed 7 mm in the primary roots because of the
potential for perforation owing to root curvature and
the presence of developmental root depressions. Molar
roots are frequently curved, and the post should termi-
nate at the point where substantive curvature begins.
Type of Post and Core
Posts or dowels can be generally classied as
cement/bonded posts or threaded posts. Cemented
posts depend on their close proximity to prepared
dentin walls and the cementing medium. Examples are
custom-cast posts and cores (Figure 19-12) and a vari-
ety of prefabricated designs (Figure 19-13). The pre-
fabricated designs include parallel-sided metal posts,
such as the Para-Post (Coltene/Whaledent, Mahwah,
New Jersey) (Figure 19-14) or different types of thread-
ed posts. Threaded posts depend primarily on engaging
the tootheither through threads formed in the
dentin as the post is screwed into the root or through
threads previously tapped into the dentin (eg, the
Kurer post; Marie Reiko, Inc, Reno, Nevada). Examples
of threaded posts include the Kurer post (Figure 19-
15), the Dentatus (Dentatus USA, New York, New
York) post, and the Flexi-Post (Essential Dental, South
Hackensack, New Jersey) (Figure 19-16).
Recently, posts made of carbon ber (C-Post, Aesthetic
Post, and Light Post, Bisco, Inc, Schaumburg, Illinois),
ceramic materials (Cerapost, Brasseler, Savannah,
Georgia; Cosmopost, Ivoclar-Vivadent, Amherst, New
York), and ber-reinforced polymers (Ribbond, Ribbond,
Inc, Seattle, Washington; Fibrekor Post System,
Jeneric/Pentron, Wallingsford, Connecticut) have been
introduced. Carbon ber posts are made of unidirection-
al carbon bers embedded in an epoxy matrix.
133138
Esthetic versions of this post have a quartz exterior that
makes the post tooth colored. Ceramic posts are made
from zirconium dioxide.
139142
Fiber-reinforced posts are
made of a woven polyethylene ber ribbon that is coated
with a dentin bonding agent and packed into the canal,
where it is then light polymerized in position.
143
Research indicates that carbon ber posts possess
adequate rigidity,
134
are not prone to produce tooth
fracture,
135,136,138
and have been shown to be clinically
successful.
137
It is reported that carbon ber posts can
930 Endodontics
Figure 19-12 Custom-cast post and core. A, Wax pattern form
around plastic post on a cast. B, Pattern removed from the cast. C,
Casting has been nished and seated on the cast.
A
B C
Figure 19-13 Prefabricated post designs. A, Tapered, smooth. B,
Parallel, serrated. C, Tapered, self-threading. D, Parallel, threaded.
Note that the post ts into pretapped threads in the dentin. E,
Parallel, serrated, tapered end.
Figure 19-14 Whaledent, parallel-sided, vented, serrated post
(right). The canal is enlarged with a Peeso reamer (left) and the nal
channel preparation is made with a matched twist drill (center).
be removed from the tooth. Ceramic posts have very
high exual strengths and are very hard.
139,141
When
polyethylene ber-reinforced posts were compared
with metal posts in the laboratory, the ber-reinforced
posts reduced the incidence of vertical root fracture.
143
The authors prefer to use posts designed for cemen-
tation whenever possible. However, when post retention
is a critical success factor and available root length is
limited, threaded designs are appropriate and necessary.
For teeth with large and/or round roots with sub-
stantial remaining root thickness after endodontic
treatment is completed, either a prefabricated post or
custom cast post can be used. If root preparation
required to accommodate a prefabricated (round) post
form will reduce dentin thickness to less than a mil-
limeter, then a custom-cast post becomes the safest
type of post.
Root Selection for Multirooted Teeth
When posts and cores are needed in molars, posts are
best placed in roots that have the greatest dentin thick-
ness and the smallest developmental root depressions.
The most appropriate roots (the primary roots) in
maxillary molars are the palatal roots, and in mandibu-
lar molars, they are the distal roots. The buccal roots of
maxillary molars and the mesial root of mandibular
molars should be avoided if at all possible. If these
roots must be used in addition to the primary roots,
then the post length should be short (3 to 4 mm) and a
small-diameter instrument should be used (no larger
than a No. 2 Peeso instrument, which is 1.0 mm in
diameter). When 7 mm long posts were placed in the
mesial root of mandibular molars, 20 of the 75 tested
teeth had only a thin layer of remaining dentin or were
perforated.
90
Type of Denitive Restoration
It is important to know the type of single crown or
retainer (all-metal, all-ceramic, metal ceramic) that will
be used as the denitive restoration for each endodon-
tically treated tooth that requires a post and core. This
knowledge permits the tooth to be reduced in accor-
dance with the reduction depths and form recom-
mended for each type of crown/retainer.
TECHNICAL PROCEDURES
Coronal Tooth Preparation
Post and core fabrication can often best be done after
the coronal tooth preparation has been completed
(Figure 19-17). The amount of tooth structure that
needs to be removed is related to the type of crown to
be used, and that, in turn, determines the extent of core
fabrication. For instance, if some of the remaining
tooth structure is very thin after the coronal prepara-
tions, it is better to remove that part of dentin and
replace it as part of the core.
Pulp Chamber Preparation
The pulp chamber should be cleaned of any lling mate-
rial prior to post space preparation (Figure 19-18). If a
Figure 19-15 Kurer posts. A, Standard anchor. B, Crown saver. Figure 19-16 Flexi-post. Note the split in the apical portion of
the post that permits some exion to occur during placement.
A B
prefabricated post is to be used, undercuts and irregular-
ities in the pulp chamber will help retain the core mate-
rial. If a custom-cast post is indicated, the undercuts in
the chamber should be blocked out with lling material
or eliminated by removing tooth structure.
932 Endodontics
Root Canal Preparation
The best time to prepare the post space is at the time
the root canal treatment is completed. If the post space
needs to be prepared later, the gutta-percha can be
removed using either a warm endodontic plugger or an
endodontic le or a slow-speed rotary instrument such
as a Gates-Glidden drill (Figure 19-19) or a Peeso drill
(Figure 19-20). It is always prudent to isolate the tooth
with a rubber dam during these procedures. The root
canal lling material should be removed incrementally
until the desired post space depth is achieved (Figure
19-21). A periodontal probe is well suited for measur-
ing preparation depth.
Prefabricated Cemented or Bonded Post/Restorative
Material Core (see Figures 19-22, 19-23, 19-24)
1. The root canal lling material is removed using a
warm endodontic plugger or a small-diameter
rotary instrument until the desired post depth is
achieved (Figure 19-24, A).
2. The canal is enlarged in size using the rotary instru-
ment that corresponds to the nal dimension of the
selected post. Selected post dimensions should cor-
respond to those previously recommended post
diameters for specic teeth (Figure 19-24, B). The
post should t passively into the post space without
substantial movement (Figure 19-24, C).
3. At least the apical half of the post should t closely
to the preparation. The coronal half of the post
may not t as well because of root canal aring.
However, this lack of adaptation can be corrected
when the core material is placed around the
cemented post.
4. If the root canal cannot be prepared to conform to
the round shape of the post and have adequate
Figure 19-17 Coronal tooth preparation. A, Existing crown being
removed on an endodontically treated tooth. B, Initial reduction of
the tooth has been completed to permit assessment of the integrity
of the remaining coronal tooth structure.
A
B
Figure 19-18 Pulp chamber preparation. A, Incisal view showing presence of provisional material sealing the coronal access. B, Rotary
instrument being used to remove provisional material.
A B
approximation to the root canal walls, then a cus-
tom-cast post may be preferable.
5. Care must be taken not to remove more dentin at
the apical extent of the post space than is necessary.
6. Radiographic conrmation is important to ensure
proper seating and length of the post.
7. The incisal/occlusal end of the post is shortened
(Figure 19-24, D) so that it does not interfere with
the opposing occlusion, but it must provide sup-
port and retention for the restorative core materi-
al (2 to 3 mm).
8. When metal posts are used, they can be bent coro-
nally, if necessary, to align them within the core
material (Figure 19-25). Post bending is done out-
side the mouth with orthodontic pliers.
9. The post is cemented into the root canal using
resin bonding procedures (Figure 19-24, E).
10. If there is little or no remaining coronal tooth
structure to provide resistance to core rotation, an
auxiliary threaded pin (TMS pins, minimum or
regular; Coltene/Whaledent; Mahwah, N.J.) should
be placed into the remaining tooth structure
(Figure 19-24, F).
Figure 19-19 Two different diameters of Gates-Glidden drills. Figure 19-20 Set of six Peeso reamers.
Figure 19-21 Root canal preparation. A, Rotary instrument being
used to prepare post space in a root canal. Note the rubber ring
around the instrument to identify the appropriate apical extension
of the post preparation. B, Post space preparation completed. C,
Periodontal probe being used to measure post space depth.
A
C
B
934 Endodontics
Figure 19-22 Placement of parallel-walled Para-Post and composite resin core in an anterior tooth. A, Endodontic treatment completed
and initial crown preparation formed on remaining coronal tooth structure. B, Gutta-percha removed. C, Post space being formed using a
Peeso instrument. D, Post space being rened using a Para-Post drill. E, Trial placement of the post to verify adequate approximation to post
space without binding. F, The post has been shortened so that it does not interfere with occlusal closure and there will be space for fabrica-
tion of the crown. The post was cemented after shortening. G, The tooth has been etched and a bonded composite resin core formed and
then shaped using rotary instruments.
Figure 19-23 Placement of Para-Post and restora-
tive material core in a molar. A, Endodontic treat-
ment completed. B, Provisional restorative material
in the pulp chamber has been removed and gutta-
percha removed from the distal root. C, Post space
formed with a drill. D, Trial placement of the post.
E, The post has been shortened and cemented. A
restorative material core has been formed. F, The
core has been prepared, an impression made, and
the denitive crown cemented. G, If there will be an
extended time delay between placement of the core
and preparation of the tooth for a crown, the core
can be built to full tooth contour to serve as the
interim restoration.
A B C
D E F G
A B C
D E F G
Figure 19-24 Placement of a carbon ber post and composite
resin core. A, Post preparation completed to the desired form and
depth. Note the antirotation notch prepared into the dentin. B,
Carbon ber post. C, Post placed into the canal to verify adequate
adaptation and passivity. D, Post being shortened using a diamond
instrument so that there is adequate occlusal clearance. E, The post
has been bonded into the root canal. F, Diagram showing place-
ment of a threaded pin because there was a lack of coronal tooth
structure to augment core retention. G, The composite resin core
has been bonded to the dentin. The tooth preparation can now be
completed by decreasing the total occlusal convergence, rening the
nish line, and smoothing the surfaces.
A B
D C
E
F
G
11. Restorative material is then condensed around
the post or bonded to the post and remaining
tooth structure. A slight excess of material is
placed, and this is removed during crown prepa-
ration (Figure 19-24, G).
12. The denitive tooth preparation is then complet-
ed (Figure 19-26), and an impression is made for
the crown.
Prefabricated Threaded Post/
Restorative Material Core
1. The root canal lling material is removed as
described.
2. The canal is sequentially enlarged using the manu-
facturers provided rotary instruments until the
desired diameter is achieved.
3. The Kurer post system uses a root facer to prepare a
at area on the coronal surface of the root against
which the incorporated metal core can seat (Figure
19-27). Other threaded posts (such as the Flexi-post)
use a restorative material for the core (Figure 19-28)
and therefore do not need such an instrument.
4. Either the root is threaded using a hand tap (Kurer)
or the post is threaded into the canal (Flexi-post).
5. The core is formed by either reshaping the attached
metal core (Kurer) or building a restorative materi-
al core to the desired dimensions and then prepar-
ing it for the denitive crown.
Custom-Cast Post and Core
This procedure for making a custom-cast post and core
is illustrated in Figure 19-29:
1. The root canal lling material is removed as
described. It is not necessary or desirable to make
the post space round.
936 Endodontics
2. Since most custom-cast posts and cores will possess a
slightly tapered form, a at area should be prepared
in the remaining coronal tooth structure if there is
not one already present in existing morphology. This
at area (formed perpendicular to the long axis of
the post) will serve as a positive stop during cemen-
tation of the post and during subsequent application
of occlusal forces, thereby helping to minimize any
tendency for the post to wedge against the tooth.
3. The custom-cast post and core can either be made
indirectly on a cast obtained from an impression or
fabricated from a pattern made directly on the
tooth. The indirect process is often the technique of
choice for teeth with difficult or limited access.
Direct Procedure
1. Select a plastic post that ts within the connes of
the post preparation without binding (Figure 19-
30, A). Leave the post sufficiently long that it can be
easily grasped.
2. Lightly lubricate the canal (using a water-soluble
lubricant such as die lubricant helps ensure that all
lubricant can be subsequently removed, thereby
not interfering with cement retention).
3. Place notches on the side of a plastic post pattern if
the post is smooth and seat it to the depth of the
prepared canal.
4. Use the bead-brush technique to apply resin to the
prepared canal and the body of the plastic post.
Seat the post into the full depth of the canal.
5. Do not allow the resin to completely harden within
the canal. Remove and reseat the post and attached
resin several times while the resin is still in its rub-
bery stage so that the pattern does not inadvertent-
ly become locked into the canal (Figure 19-30, B).
Figure 19-25 Coronal portion of posts are bent prior to cementa-
tion to place them more strategically within core. A, For contain-
ment inside preparation contour. B, For a more central location in
core material.
Figure 19-26 Denitive tooth preparations. Composite resin core
and remaining coronal tooth structure of a maxillary central inci-
sor have been prepared for a denitive all-ceramic crown.
A B
6. Remove the polymerized pattern and inspect the
resin for integrity and lack of voids. Reseat the post
and test for adaptation and passivity.
7. Add additional coronal resin to form the desired
dimensions of the core (Figure 19-30, C). Remove
and reseat the pattern as previously described to pre-
vent it from becoming locked into the coronal tooth
structure (Figure 19-30, D). A slight excess of core
resin is added (Figure 19-30, E) so that the hardened
core can be prepared with a high-speed diamond and
water spray to the desired form (Figure 19-30, F).
8. The core is then removed, invested, and cast.
9. The post and core are trial placed, adjusted, and
then cemented. The denitive tooth preparation
can then be completed.
10. A pattern can also be developed using wax rather
than resin.
Indirect Procedure
1. Nonaqueous elastomeric impression materials
make accurate impressions of the prepared root
canal, but some method of supporting the impres-
sion material prevents distortion/displacement of
the set material during removal from the mouth
and pouring of the cast.
Figure 19-27 Placement of a prefabricated, threaded Kurer post. A, Completed endodontic therapy. B, Gutta-percha removed. C, Initial
preparation of the root canal. D, Final diameter established, which also determines the size of the tap and the post that will be used. E,
Preparing countersink using a Root Facer instrument (Kurer, Kerr Corporation, Orange. California). F, Hand tap being used to create threads
in the root. G, Trail placement of a post to determine how much of the post must be shortened. H, Shortened post in place. I, The prefabri-
cated metal core has been prepared to a form that represents the shape of a prepared tooth and will provide appropriate space for fabrica-
tion of a crown.
Figure 19-28 Flexi-post has been
placed into the root and a compos-
ite resin material built around the
post.
A B C D
E F G H I
938 Endodontics
Figure 19-29 Custom-cast post and core. A, Traumatically fractured central incisor after endodontic treatment and post space preparation.
B, Cast post and core seated in the tooth.
Figure 19-30 Fabrication of a direct pattern for a custom-cast post and core. A, Plastic post selected that ts passively into the prepared
post space. B, Resin has been placed into the prepared root canal and the plastic post seated to the depth of the canal. Note that the plastic
post is being removed before the resin completely hardens to ensure that the resin post does not become locked into the prepared post space.
C, Additional unlled resin is being applied using a bead-brush technique to build a core. D, The core buildup is being removed before it
completely hardens to again prevent the resin from becoming locked into position. E, Excess core material has been applied. F, Initial prepa-
ration of the resin core has been completed. The pattern can now be removed and cast and the nal tooth preparation completed after the
post and core are cemented.
A B
D C
F
E
2. Several methods of support are available. A metal
wire that returns to its original shape when slight-
ly distorted is desirable. Safety pins (Figure 19-31, A)
and orthodontic wire have been used for this pur-
pose. Metal wire such as a paper clip can be bent
on impression removal and be permanently dis-
torted. Plastic posts are also used to support the
impression material (Figure 19-32, C). They can
be exed in slightly curved canals or if they con-
tact coronal tooth structure. Subsequent removal
of the post after the impression material sets
allows straightening of the plastic post to occur,
resulting in distortion. Only use plastic posts when
they are totally passive and do not bind on any
tooth structure.
3. When a safety pin or orthodontic wire is selected as
the means of supporting the impression material,
the coronal portion of the wire should be bent over
to form a handle and to help retain it in the
impression material (Figure 19-31, B).
4. Notch the wire and coat it with adhesive (see
Figure 19-31, B).
5. Fill the prepared canal with impression material
using a slowly rotating lentulo spiral instrument
(Dentsply Maillefer North America, Tulsa, Ok)
(Figure 19-31, C) accompanied by an up and down
motion (Figure 19-31, D).
6. Alternately, an anesthetic needle can be placed to
the depth of the post space (to serve as an air
escape channel) and impression material syringed
down the canal (Figure 19-32, A and B).
7. Seat the wire or plastic post through the impres-
sion material to the full depth of the canal (Figure
19-31, E), syringe additional impression material
around the supporting device as well as the pre-
pared tooth (Figure 19-31, F), and seat the impres-
sion tray (Figure 19-31, G).
8. Remove the impression (Figure 19-31, H), evaluate
it, and pour a cast.
9. Make an interocclusal record and obtain an oppos-
ing cast and appropriately sized plastic post to be
used in forming a wax pattern (Figure 19-33, A).
10. Lightly lubricate the canal of the working cast with
die lubricant (Figure 19-33, B).
11. Place notches on the side of a plastic post that seats
to the full depth of the canal preparation.
12. Apply a very thin layer of sticky wax to the plastic
post and then add soft inlay wax in small incre-
ments, fully seating the plastic post after each
increment of wax is added (see Figure 19-33, B).
13. Ensure that the pattern is well adapted but passive
(Figure 19-33, C).
14. After the post pattern has been fabricated, the wax
core is added (Figure 19-33, D) and shaped, and then
the pattern is cast in metal (see Figure 19-33, E).
15. The cast post and core are then cemented in the
tooth and the denitive tooth preparation com-
pleted (Figure 19-33, F).
PREPARATION FOR OVERDENTURES
An overdenture is a complete denture supported by
retained teeth and the residual alveolar ridge.
144
Because the retained teeth are shortened, contoured,
and altered to be covered, they need to be endodonti-
cally treated (Figure 19-34).
In 1969, Lord and Teel coined the term overden-
ture and described the combined endodontic-peri-
odontic-prosthodontic technique applied thereto.
145
As early as 1916, however, Prothero had referred to the
use of root support, stating, Oftentimes two or three
widely separated roots or teeth can be utilized for sup-
porting a denture.
2
It should also be noted that much
earlier, in 1789, George Washingtons rst lower den-
ture, constructed of ivory by John Greenwood, was in
part supported by a left mandibular premolar.
146
Retaining roots in the alveolar process is based on the
proven observation that as long as the root remains, the
bone surrounding it remains (Figure 19-35). This over-
comes the age-old prosthetic problem of ridge resorp-
tion. Ideally, then, retaining four teeth, two molars and
two caninesone each at the four divergent points of
an archshould provide good balance and long lifeto
a full overdenture (Figure 19-36). Unfortunately,
patients requiring prostheses seldom present just these
ideal conditions, and the dentist must make do with the
best that can be devised from the dentition remaining.
One situation to be warned against, however, is the
diagonal cross-arch arrangement a molar abutment
on one side, for example, and a canine on the opposite
side. The rocking and torquing action set up by this
arrangement leads to problems and loss of one or both
abutments. The molar abutment alone is preferable to
the diagonal cross-arch situation.
If the selected abutment teeth are reduced to a short
rounded or bullet shapeliterally tucking the abut-
ments inside the denture basethe crown-root ratio of
the tooth is vastly improved, especially when periodon-
tally involved teeth have lost some alveolar support. As
shortened teeth, however, they can serve quite well as
abutments for full overdentures.
Indications and Advantages
The indications for overdentures include the psychic
support some patients receive from not being totally
940 Endodontics
Figure 19-31 Post and core impression using safety pin wire and a spiral instrument
for placing impression material. A, A safety pin that will be sectioned. B, The safety pin
has been sectioned and bent so that the point extends to the depth of the post prepa-
ration and the bent portion projects above the tooth. The bent portion serves as a han-
dle and also as a means of helping retain the wire in the impression material. Note that
notches have been ground into the wire to facilitate retention of the impression mate-
rial. The wire will now be coated with impression material adhesive. C, A lentulo spi-
ral instrument that will be used to spin impression material to the apical portion of
the post preparation. The corkscrew form of the instrument, when slowly rotating
toward the root apex in a slow-speed handpiece, spirals the impression material to the
depth of the prepared post space. D, A small portion of mixed impression material is
picked up with the spiral instrument and placed into the prepared post space. The spi-
ral instrument is being slowed rotated by the handpiece and moved up and down in
the canal to place the impression into all aspects of the prepared post space. E, A sec-
tion of the safety pin has been fully seated into the prepared post space.
A B
D E
C
Figure 19-31 (Continued) F, Additional impression material has
been syringed over the prepared tooth. G, Impression tray being
seated. H, Completed impression.
F
G
H
Figure 19-32 Post and core impression using an anesthetic needle,
impression syringe, and poly (vinyl siloxane) impression material.
A, An anesthetic needle seated to the base of a prepared post space
and an impression syringe tip in position. B, Impression material
being syringed down the prepared canal. C, A plastic post that ts
passively into the canal is fully seated through impression material.
A B
C
942 Endodontics
Figure 19-33 Indirect post fabrication on a working cast. A, Working cast with plastic post around which a wax pattern will be formed. The
apical portion of the post has good approximation to the cast but is passive. B, The cast has been lubricated, a thin layer of wax applied to
the plastic post, and the post fully seated into the cast while the wax is soft. C, A plastic post removed from the cast so that the wax adapta-
tion can be evaluated. D, Wax added to the adapted post to form a core. The core will now be carved to the nal form and then invested and
cast. E, Casting seated on the working cast. The cast can be hand articulated with the opposing cast to establish the required occlusal clear-
ance. F, Cast post and core cemented and preparation completed.
A B
C D
E
F
Figure 19-34 Overdenture abutment, well obturated and restored
with amalgam. Note excellent bony support. (Courtesy of Dr. David
H. Wands.)
Figure 19-35 Dramatic demonstration of alveloar bone remaining around retained canines but badly resorbed under full upper and oste-
rior lower partial dentures. Reproduced with permission from Lord JL and Teel S.
144
Figure 19-36 Mirror view of four retained abutments providing
ideal support for an overdenture. Reproduced with permission
from Brewer AA and Morrow RM.
149
edentulous. Even more important is the preservation of
the alveolar ridge and the shielding of the ridge from
stress provided by rm abutment teeth. One should
also be aware that vertical dimension is better pre-
served if ridge height is maintained. A bonus to all of
these advantages is the support, stability, and retention
derived from rm abutments.
Contraindications
Overdentures are contraindicated when remaining alve-
olar support is so lacking that no tooth can be retained
for very long. Overdentures are also contraindicated if
the remaining natural teeth are adequate to restore the
mouth with xed or removable partial dentures.
Abutment Tooth Selection
A healthy abutment tooth for an overdenture must
have minimal mobility, a manageable sulcus depth, and
an adequate band of attached gingiva.
145
If these pre-
requisites are lacking, the pocket depth can be reduced
and the attached gingiva developed by proper peri-
odontal procedures.
Abutment Tooth Location
The ideal teeth to retain are those located where
occlusal forces wreak greatest destruction on the ridges.
Opposite a natural dentition, the canine teeth are ideal
to retain. In edentulous patients, the anterior portion
of the arches is particularly susceptible to resorption, so
canines and premolars are again the rst choice to be
saved, with incisors the second choice. It is especially
important to save mandibular teeth because of difficul-
ties encountered in retaining lower dentures. Even sav-
ing a single tooth, a molar in particular, may contribute
greatly to long-term denture success.
Technique
After the selection of the proper abutment teeth, the
key to successful overdenture construction is simplicity
of technique. If an immediate denture is to be placed,
the endodontic therapy, extractions, and periodontal
treatment may all be done at the denture placement
appointment. The teeth to receive root canal llings are
anesthetized, and a rubber dam is placed. The crowns
of these teeth are then amputated 3 to 4 mm above the
gingival level. The length of the remaining tooth is
established radiographically, and the pulps are
removed. The canals are then properly cleaned, shaped,
and obturated with gutta-percha by means of the lling
technique appropriate to the canal anatomy. The coro-
nal 3 to 5 mm of the gutta-percha lling are then
removed, the preparation is undercut, and a well-con-
944 Endodontics
densed amalgam lling is placed to cap the canal obtu-
ration. At this time as well, the abutments should be
properly shaped to rise 2 to 3 mm above the tissue and
to be rounded or bullet shaped with a slope back from
the labial surface to accommodate the denture tooth to
be set above it. They should then be highly polished
(Figure 19-37). The abutments must not be too short
or the tissue will grow over them as a lawn grows over
a sidewalk,
144
nor should they be too long, compro-
mising the denture contour and placing greater stress
on the supporting teeth (Figure 19-38).
The denture is relieved over the abutment until it ts
securely on the tissue without touching the abutment
teeth. It is then related to the abutment teeth with a
small amount of self-curing acrylic. This proper rela-
tionship of denture to tissue and tooth is important for
denture stability and to keep the stresses on the teeth
within physiologic limits.
This entire operation is neither complex nor time
consuming. Removing the crown from the tooth great-
ly simplies and speeds the endodontic therapy. Some
candidates for overdenture abutment teeth may not
need root canal therapy. The pulpless teeth may already
have been successfully treated. Other teeth may be so
abraded that the pulp has receded to a level where the
tooth only needs shortening, proper contouring, and
polishing (Figure 19-39).
If the abutment teeth are involved periodontally or
are not surrounded by a good collar of attached gin-
giva, periodontal therapy will be needed to correct
these aberrations.
Figure 19-37 Mandibular canines that have served as overdenture
abutments for years. Reproduced with permission from Fenton A,
Brewer A. Dent Clin North Am 1973;17:723.
Problems
A number of problems have arisen with overdentures,
most of them related to poor patient selection and lack
of patient cooperation.
The most serious problems are associated with
dental caries and periodontal disease. One must
remember that, throughout their lives, candidates for
complete dentures have usually been neglectful of
their teeth and supporting structures and have a his-
tory of extensive dental disease. That is why they have
reached this sad point (Figure 19-40). In recommend-
ing overdentures, the dentist takes an obvious chance
that the patients habits will change and that he will
become motivated and adept at oral hygiene to retain
the vestiges of this dentition. That some do not
should come as no surprise (Figure 19-41). The
importance of good home care must be emphasized
to the overdenture patient.
Other challenges related to the use of endodontical-
ly treated teeth include wear of the dentin and the need
for retention.
Possible Solutions to the Problems
Quite naturally, the prime solution to the caries-peri-
odontal problem is better patient cooperation in home
care. A special 0.4% stannous uoride gel has been
introduced to be placed in the well in the base plate
to remineralize the dentin.
147,148
This, of course, will
do nothing for periodontal disease, which can be con-
trolled only by plaque removal and by proper and equal
force placed on the abutments. More frequent denture
relines may also be required.
Coverage of the dentin surfaces is recommended for
those situations wherein severe abrasion of the tooth
has occurred (Figures 19-42 and 19-43). Bruxism
would be the principal etiologic factor. Even gold may
eventually be worn through,
149
but it takes a much
longer time.
A possible solution to inadequate denture retention
or to the rotational problem centering around the sin-
gle anterior abutment tooth may be with mechanical
attachments. There are a number on the market, and
Figure 19-38 Improperly contoured overdenture abutments.
Square edge invites grip by overdenture and torquing action.
Prominent buccal contour and extra height comprised the contour
of the overdenture. (Courtesy of Dr. David H. Wands.)
Figure 19-39 A, Vital teeth with severe abrasion and receded pulpsideal overdenture abutments. B, Incisor overdenture abutment not
requiring therapy owing to pulp recession. The calcied pulp area should be carefully explored for the pulp horn. (Courtesy of Dr. David H.
Wands.)
946 Endodontics
Figure 19-40 A, Rather typical neglect by many denture patients. Caries and periodontal disease forecast probable lack of future patient
cooperation. B, Mirrow view of lingual gingiva of two possible overdenture abutments. Because it is virtually impossible to develop attached
gingiva in the lingual area, use of these teeth as abutments is contraindicated. (Courtesy of Dr. David H. Wands.)
Figure 19-41 Two-year recall reveals advanced caries and peri-
odontal disease of abutments. The patient did not remove the den-
ture for days at a time. (Courtesy of Dr. David H. Wands.)
Figure 19-42 Severe abrasion (arrow) caused by bruxism. For
long-term overdenture success, such an abutment needs post and
coping. Reproduced with permission from Robbins JW. J Am Dent
Assoc 1980;100:858.
Figure 19-43 A, Cast post and
copings, properly contoured
and polished to restore abut-
ment teeth. B, Two-year recall
shows a healthy response to this
ideal, albeit expensive, restora-
tive method. Reproduced with
permission from Lord JL and
Teel S.
145
A B
A B
they include ball and socket type of attachments, o-
rings, and magnets.
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Various methods of restoring pulpless teeth have been

reported for more than 200 years. In 1747, Pierre

Calculation made by averaging numeric data from all studies.

5 (105 of 2,178) 59 (205 post loos-

Calculation made by averaging numeric data from all studies.

3 (66 of 2,628) 17 (74 tooth frac-

Calculation made by averaging numeric data from all studies.

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