FP notes

Restoration of endodontically treated teeth

TYS QNS
M99Q2
The restora.on of endodon.cally treated teeth requires special a9en.on both in diagnosis and in clinical technique.
(a) Do all anterior and posterior endodon.cally treated teeth require a post-crown restora.on? Explain your
answer for each type of teeth.
(b) Describe the op.mum reten.on and resistance form desirable for post-cores.
(c) Describe 1 technique for the reten.on of core material in the restora.on of a posterior endodon.cally treated
tooth.
M91Q3a
One of the major reasons for the failure in post-endo treated tooth is improper restora.on. What factors would you
consider in the treatment of planning of an endo treated terminal molar abutment opposing natural den..on?
M90
Discuss the principle of post-prepara.on in a successfully endodon.cally treated tooth. List the methods by which post
and core may be constructed.
Write short notes on:
(a) Pon.c design (b) Shade selec.on
S90Q3
How would you classify post-core systems in the restora.on of an endodon.cally treated tooth? What are the factors
you should take into considera.on when designing a post-crown?

lauras notes

endodontically treated teeth have tended to focus on

Fractures in endodontically treated teeth have been
the strength of the teeth (16). A number of such studies
understood to be multifactorial in origin. The causes of
suggested that there are no major differences in
fracture in endodontically treated teeth can be broadly
FPhave
notes
the mechanical properties of teeth with vital pulp and
classified as iatrogenic and non-iatrogenic, and are
root-filled
teeth
(12,
14).
As
pointed
out
by
Kahler
outlined
in Fig. 1. In this article, the mechanisms and
WHY ENDO TX TOOTH PREDISPOSED TO
FRACTURE
et al. (17) the inference from such studies has been
risk factors for fracture predilection in endodontically
STRUCTURAL
LOSS
(coronal and
radicular .ssue
that
the apparent
brittleness
of root-filled
teethloss)
would
treated teeth are described under the following headings:
manifest
itself
as
changes
in
strength
or
modulus
of
Due to
1.The mechanisms of fracture resistance in dentine
elasticity.
should be- cnoted
that
strength
is merely the
aries &
exis.ng
restora.ons
Prior Itpathology
ability to resist deformation or show stiffness to loads,
(1.1)Biomaterial considerations of dentine substrate
Endodon,c treatment - Access prepara.ons including loss of roof of pulp chamber result in increased cuspal
measured under well-controlled situations. On the
(1.2)Biomechanical considerations in intact and post
deec.on during func.on and increase the possibility of cusp fracture and microleakage at the margins of
other hand, toughness is the ability to absorb energy
core restored teeth
restora.ons.
Instrumenta.on
of root cstiffness
anals aects
without
fracturing.
In material science,
and thickness of den.nal walls in roots
procedures properties
- Post space
prep
weakens
ooth srisk
ignicantly
(Trope
M et predilection
al 1985) in endodonti Restora,ve
toughness
are mechanical
that
cannot
be the t2.The
factors for
fracture
increased
together
Itris
inherently
cally treated
tooth indefinitely.
structure was
emoved,
the rdifficult
esistance to occlusal
forces teeth
was diminished and the possi- bility of
As more
in artificial
materials
with
very
high
initial
stiffness
fracture increased (Vale 1956, Larson 1981) => conserve as much tooth structure as possible
(strength) to accommodate a long plastic yield
(2.1)Chemical factors: effects of endodontic irrigants
(toughness) (18, 19). Natural mineralized tissues, such
and medicaments on dentine
OF PULP ORGAN
asLOSS
dentine, are a result of long-term optimization,
(2.2)Microbial factors: effects of bacteria-dentine
Reduced levels
of propriocep.on
which could
impair normal protec.ve
reexes.
controlled
by the
selection processes
of evolution.
interaction
CHANGE IN understanding
MOISTURE CONTENT:
Increased bofri9leness
o loss of moisture..
BUT
Therefore,
the mechanisms
fracturedue t(2.3)Dentine
factors:
effects of tooth structural loss
resistance
operating
in
the
dental
tissues
would
provide
(2.4)Restorative
factors:
effectstreated
of post
and
Papa
e
t
a
l.
1
994
-

i
nsignicant
d
ierence
i
n
t
he
m
oisture
c
ontent
b
etween
e
ndodon.cally
teeth
and core

betterteeth
insight
restorations
with vinto
ital pthe
ulp. risk factors that predispose
endodontically treated teeth to fracture.
(2.5)Age factors: effects of age changes in dentine
Fuayama et al 1969 - no change in modulus of elas.city, hardness or fracture toughness in pulpless teeth

Causes of fractures
in endodontically
treated teeth

Non-iatrogenic
causes

Iatrogenic causes

Tooth structural loss

Effect of chemicals
&intra-canal
medicament

Effects of restorations
& restorative
procedures

Primary causes

Secondary causes

History of recurrent
pathology

Effect of ageing of
dental tissues

Anatomical position
of the tooth

Fig. 1. Outline of the causes of fracture in endodontically treated teeth.

REQUIREMENTS WHEN RESTORING ENDO TX TEETH

58 Protects remaining tooth structure

Minimizes cuspal exure

Provide coronal seal

Sa.ses func.on and aesthe.cs

lauras notes

Tooth must have -

Good apical seal

No sensi.vity to pressure

No exudate

No stula

No apical sensi.vity

No ac.ve inamma.on

FP notes

GENERAL CONSIDERATIONS IN RESTORING ENDO TX TEETH

Pt factors

Occlusion
Parafunc.on

Tooth

Posi.on of tooth in the arch

Amt of tooth structure lej ajer caries free
Planned abutment for FPD or RPD
Shape of canal
Amount of gingival recession -> nish line more cervical -> thinner walls

Post

Type: Material
Design
Diameter
Length
Lu.ng agent

Core

Core material
How is the core a9ached? adhesive?

Crown

Coronal coverage necessary?

Ferrule
Type of crown
Determines necessary reduc.ons -> amount of tooth structure ajer prep -> do you need
post to retain core
* need to know what crown you are indica.ng -> drives what core u need
Crown design
Cervical metal collar to resist root fracture

PATIENT FACTORS

OCCLUSION
Anterior
teeth

Risk factors:

Posterior
teeth

Occlusal scheme pa9erns and cuspal heights signicantly inuence the type and direc.on of load

Deep bite situa.ons, parafunc.on and dietary habits

that is applied to each tooth

Group func.on situa.ons, especially when the buccal cusps of the maxillary teeth are long,
generate higher lateral forces, when compared to canine guidance

Importance
of occlusion

Favourable occlusal prosthesis design is probably more important for survival of structurally
compromised endodon.c treated teeth than is the type of post used
Because non-desirable forces introduced by way of an interference on the restora.on are a risk
for fa.gue fracture of teeth.

Clinical
implication

Before restoring a tooth, a thorough review of the occlusal pa9ern as well as func.onal and
parafunc.onal forces is performed, as these will inuence the success of the nal restora.on of
the par.cular tooth.

lauras notes

FP notes

TOOTH FACTORS

POSITION OF TOOTH IN THE ARCH

Source

Schwartz, Robbins Joe 2004

Post Placement and Restora:on of Endodon:cally Treated Teeth: A Literature Review
Jotkowitz & Samet 2010 - Rethinking ferrule a new approach to an old dilemma

Anterior
teeth

Loading

Non-axial loading, lateral & shearing forces

Lateral forces have a greater poten.al to damage the tooth-restora.on
interface when compared to ver.cal loads.

Minimal loss of tooth structure

may be restored conserva.vely with a bonded restora.on in the access opening
A post is of li9le or no benet in a structurally sound anterior tooth (neutral beam theory
And increases the chances for a non restorable failure
The same conclusion holds for an anterior tooth with a porcelain veneer
If an endodon.cally treated anterior tooth is to receive a crown, a post ojen is indicated.
Thickness of wall:
Remaining coronal tooth structure is quite thin ajer it has received root-canal treatment and
been prepared for a crown.
Anterior teeth must resist lateral and shearing types of forces, and the pulp chambers are
too small to provide adequate reten.on and resistance without a post.
The amount of remaining coronal tooth structure and the func.onal requirements of the
tooth determine whether an anterior tooth requires a post.
SUMMARY

Coronal coverage not necessary

( only when there is extensive loss of tooth structure where use of CR has
limited prognosis)
Prognosis NOT Improved
Discoloura.on consider Bleaching
(note that resorp.on may occur as a side eect of nonvital bleaching)
Posts NOT rou.nely Recommended
POSTS Mandatory
when Crown indicated (limited coronal den.ne remaining ajer reduc.on for
complete coverage)
FPD / RPD Abutment

lauras notes

FP notes

POSITION OF TOOTH IN THE ARCH

Molars

Loading

Mainly ver.cal forces, occluso-gingival direc.on

More prone to fracture because of
1) closer proximity to THA and
2) morphologic characteris.cs (cusps that can be wedged apart)

Should receive cuspal coverage,

Do not require a post in most cases
Pulp chamber (mechanical undercuts) and canals provide adequate reten.on for a core
buildup Unless the destruc.on of coronal tooth structure is extensive
Posts should be avoided in posterior teeth as the roots are ojen narrow and/or curved.
Subsequently, post-space prepara.on can lead to root perfora.on.
Removal of radicular den.ne to accommodate post will further weaken the tooth and may
lead to fracture.
Post should be placed in the largest, straightest canal
palatal canal in the maxillary molars and a distal canal in the mandibular molars
rarely, if ever, is more than one post required in a molar.

Pre-molars

Loading

More likely than molars to be subjected to lateral forces

Usually bulkier than anterior teeth, but ojen are single-rooted teeth with rela.vely small pulp
chambers.
For these reasons, they require posts more ojen than molars.
The remaining tooth structure and func.onal demands are, once again, the determining factors.
Because of the delicate root morphology present in some premolars, special care must be
exercised when preparing a post space.
Exceptions

Excep.ons to coronal coverage for posterior teeth

Mandibular premolars - Esp if marginal ridges intact
5 worse then 4
4 - Lingual cusp v reduced -> like canine -> no chance of wedging eect
Against denture occlusion no need
Against implant -> tx as normal tooth
Abutment for RPD -> crown (but evidence is weak)

lauras notes

FP notes

PLANNED ABUTMENT FOR FPD/RPD

FPD
abutment

Higher stress than single crowns

RPD
abutment

Tooth-borne vs combina.on tooth-.ssue-borne par.al dentures

In the fully tooth borne par.al denture occlusal stressesare transmi9ed to bone by way of the
periodontal ligament. It func.ons similarly to a xed par.al denture. The extension base par.al
denture, however, derives its support from two dierent .ssues, teeth and edentulous ridge each
having dierent degrees of displaceability. This ojen results in torquing stress on abutment
teeth.
Krol 1981

Study

Sorensen et al 1985, Endodon:cally treated teeth as abutments

Method

1273 teeth endodon.cally treated teeth 1 - 25 years prior to study by 9 general prac..oner in US
Type of abutment: no crown, single crown, FPD and RPD

Results

Failure rate of RPDs (22.6%) was twice that of FPDs (10.2%) and four .mes that of teeth with
crowns (5.2%)
Sta.s.cal analysis (chi square) revealed that the successrate of crowns was signicantly higher
than that of RPDs (p < .OOl) and FPDs p< .05)

POST /CORE - DEFINITION

POST

Intra radicular reten.on

Primary purpose of a post is to retain a core in a tooth with extensive loss of coronal tooth
structure

CORE

Replacement of lost tooth structure

Mimic/replace - to achieve conven.onal tooth prep -> increase axial wall height to increase
reten.on

lauras notes

FP notes

POST
Rationale: 3Rs
Ability of a post to resist ver.cal dislodging forces.
Length

increasing the length and diameter of the post can increase reten.on

Diameter

Diameter is less important than the other factors listed. Even though
reten.on can be increased slightly by enlarging the post diameter, the

RETENTION

loss of tooth structure weakens the tooth

Taper

Parallel posts are more reten.ve than tapered posts

Lu.ng cement
Ac.ve vs passive Ac.ve posts are more reten.ve than passive posts
ability of the post and tooth to withstand lateral and rota.onal forces
Inuenced by
remaining tooth structure
posts length and rigidity
presence of an.rota.on features

REISISTANCE

presence of a ferrule.
A restora.on lacking resistance form is not likely to be a long-term success, regardless
of the reten.veness of the post
NO

Sorensen et al 1984 (see below)

Trope M 1985:
In vitro study of 64 extracted maxillary central incisors placed in copper
rings lled w cement, subjected to slowly increasing compressive force .ll
fracture occur
1. The prepara.on of a post space signicantly weakened endodon.cally
treated teeth.
2. A post (steel parapets w ZnPO4 cement) did not signicantly
strengthen endodon.cally treated teeth.
3. When a post space was prepared, acid etching and restora.on with a
composite resin strengthened the teeth more than the other restora.ve
methods used.

REINFORCEMENT?
Maybe

A post and core may help prevent coronal fractures when the
remaining coronal tooth structure is very thin ajer tooth
prepara.on
When loaded ver.cally along the long axis, a post reduced
maximal den.n stress by as much as 20%
reinforcement eect of posts is doubwul for anterior teeth
because they are subjected to angular forces.
(Goodacre and Spolnik 1995 Part 1)

lauras notes

weighed carefully against the load to which the

restored tooth will be subjected.

Considerations
for Anterior Teeth
FP notes
Endodontically treated anterior teeth do not always
Sorensen
JA, Mar:no
JT. by placement of a complete
need
complete
coverage
A
Post
Tension
Intracoronal
Reinforcement
and crestorative
oronal coverage:
A study of Endodon:cally Treated teeth.
crown,
except
when plastic
materials
have
limited
prognosis
(e.g., if the tooth has large
Neutral axis
J Prosthet
Dent.
1984; 51:780-84.
proximal composite restorations and unsupported
Compression
tooth
structure).
otherwise intact teeth funcStudy
design Many
Retrospec.ve
B
tion satisfactorily with
a
composite
resin
restoration.
Endodon.cally treated teeth
Although it is commonly believed, it has not been
Fig. 12-5
6 den.sts
Mul.-prac.ce, that
demonstrated experimentally
endodontically
Experimental stress distributions in an endodontically treated
1273 teeth
selected
from 6than
000 pvital
a.ent records
treated teeth are weaker
or more
brittle
tooth with a cemented post. When the tooth is loaded, the
lingual surface (A) is in tension, and the facial surface (B) is in
teeth. Their moisture
content,
however,
may
be
1 to 25 year Follow-Up
compression. The centrally located cemented post lies in the
reduced.7 Laboratory testing8 has actually revealed a
and Caries failure excluded
Perio
neutral axis (i.e., not in tension or compression). (Redrawn from
resistance to fracture
similar
between untreated and
Guzy GE, Nicholls JI: In vitro comparison of intact endodontically treated teeth
of Failure
Dislodgement ; Fracture
Deni.on
endodontically treated
anterior
teeth. Nevertheless,
with and without endo-post reinforcement. J Prosthet Dent 42:39, 1979.)
clinical fracture does
occur,
andAnalysis
attempts
have
been
Survival
BUT
Retrospec.ve
Records
NOT
made to strengthen the tooth by removing part of the
Confounding Variables ??
root canal filling and replacing it with a metal post.
Cemented
may increase
further the
limit
or scomplicate
InConclusions
reality, placement
the removal
Posts of a post requires
intracoronal
reinforcement
did NOT sposts
ignicantly
clinical
uccess
endodontic re-treatment options if these are necesof additional tooth structure (Box 12-1), which is
rate (resistance to fracture
dislodgement)
f any of tdestruction
he anatomic occurs,
groups post
sary.or In
addition, if ocoronal
likely to weaken the tooth.
of endodon.cally
teeth may be necessary to provide adequate
removal
Cementing a post in an endodontically
treated treated
support
tooth is a fairly common clinical procedure,
despite
=> posts do not reinforce teeth for a future core.
For these reasons, a metal post is not recomthe paucity of data to support its success. In fact, a
10,11
coverage
Anterior
teeth
(max & m
and) - NO in
improvement
n clinical
success
mended
anterior iteeth
that
do rate
not require
and two
stress analyses
have
laboratory study9Coronal
complete coverage restorations. This view is supdetermined that no significant reinforcement
teeth (max & ported
mand) - by
YES arate
of clinical success
was
signicantly
that
did not show
retrospective
study13
results. This might be explained by Posterior
the hypothesis
any
improvement
in
prognosis
for
endodontically
that when the tooth is loaded, stressesimproved
are greatest
at
with coronal coverage
treated anterior teeth restored with a post. In
the facial and lingual surfaces of the
root and an
94% of endodon.cally treated molars and premolars that subsequently
another study, post placement did not influence the
internal post, being only minimally stressed, does
14
received of
coronal
were sor
uccessful,
while
only 56%
of occlusally
A conflictposition
angle of
radicular
fracture.
not help prevent fracture (Fig. 12-5). Results
othercoverage
8,12
ing report
suggests
that endodontically
studies, however, contradict this unprotected
assumption.endodon.cally
treated phowever,
osterior teeth
survived
treated teeth not crowned after obturation were lost
six times more frequently than teeth that were
crowned after obturation.15
Box 12-1 Disadvantages to the Routine Use of
Discoloration in the absence of significant tooth
a Cemented Post
loss may be more effectively treated by bleaching16
than by the placement of a complete crown,
Placing the post requires an additional operative
although not all stained teeth can be bleached sucprocedure.
cessfully. Resorption can be an unfortunate side
Preparing a tooth to accommodate the post entails
effect of nonvital bleaching.17 However, when loss of
removal of additional tooth structure.
coronal tooth structure is extensive or the tooth will
It may be difficult to restore the tooth later, when
be serving as an FDP or partial removable dental
a complete crown is needed, because the
prosthetic abutment, a complete crown becomes
cemented post may have failed to provide
mandatory. Retention and support then must be
adequate retention for the core material.
derived from within the canal, because a limited
The post can complicate or prevent future
amount of coronal dentin remains once the reducendodontic re-treatment that may be necessary.
tion for complete coverage has been completed.

lauras notes

FP notes

MATERIAL OF POST
1) Cast post
core

Indica.on

When a tooth is misaligned and the core must be angled in rela.on to the post to
achieve proper alignment with the adjacent teeth.
Small teeth such as mandibular incisors, when there is minimal coronal tooth
structure available for an.rota.on features or bonding

+ve

Advantages in certain clinical situa.ons.

when mul.ple teeth require posts, more ecient to make an impression and
fabricate them in the laboratory rather than placing a post and buildup in
individual teeth as a chair-side procedure
generally easy to retrieve when endodon.c retreatment is necessary.
Possible to fabricate replacement crown without need for post removal
Path of placement dierent from that selected for post and core may be selected
for crown (especially when restored tooth serves as abutment for FDP)

- ve

Require two appointments, temporiza.on, and a laboratory fee.

Less conserva.ve of tooth structure because cannot have undercuts
Biggest disadvantage - require an esthe.c temporary restora.on.
Temp post/crowns are not eec.ve in preven.ng contamina.on of the root-
canal system
When a temporary post and crown is needed, a barrier material should be
placed over the obtura.ng material, and the cast post and core should be
fabricated and cemented as quickly as possible.

2) Ceramic & +ve

zirconia post
-ve

Esthe.c, can use for translucent all ceramic restora.ons

Weaker than metal posts, so a thicker post is necessary, which may require
removal of addi.onal radicular tooth structure.
Not possible to bond a composite core material to the post, making core reten.on
a problem
Retrieval of zirconium and ceramic posts is very dicult if endodon.c retreatment
is necessary or if the post fractures.

3) Fibre/
Elastic post

Characteris

More exible than metal posts and had approximately the same modulus of

.c

elas.city (s.ness) as den.n.

Elas.c posts, the tooth, cement, and post will all deform during func.on

+ve:
Reinforcing
eect

Reinforcement abili.es of bre reinforced composite posts.

bonded posts are reported to strengthen the root ini.ally, the strengthening
eect may be lost over .me, due to uid leakage through the apical foramina
and lateral canals
bonding to radicular den.ne has been shown to be less reliable than bonding to
coronal den.ne.

lauras notes

FP notes

MATERIAL OF POST
+ve:
Favourable
failure
pa9ern

Failure will appear at the weakest point, which would be the adhesive joints at
the coreden.ne and postcement den.ne interfaces.
Hence, the mode of failure will be loss of marginal seal, core fracture, post
fracture, or loss of reten.on
The less the remaining coronal tooth structure, the greater will be the stress at
the adhesive interface
Signicantly lower load bearing values
BUT failure of this type of post seems to be protec,ve of the remaining tooth
structure by displaying a more favourable failure pa9ern, with virtually no root
fracture
Fracture of the remaining tooth structure has been shown to occur more
occlusally with bre posts, making these failures restorable vs. a more apical
posi.oned fracture occurring with metal post
When bonded in place with resin cement, it was thought that forces would be
distributed more evenly in the root, resul.ng in fewer root fractures.
In vitro studies have shown elas.c posts to have a lower tendency to cause root
fracture than posts of higher s.ness

Decision
making

Where a good ferrule is not a9ainable: bonded post rather than a metal post.
(Jotkowitz & Samet 2010)

Does it
actually
matter?

Reinforcement eect a?er cementa,on of a complete crown with ferrule eect makes the
dierence between s, and elas,c posts less obvious.
Hu YH 2003:
No signicant dierence in fracture resistance between teeth restored with four post and core
systems: serrated, parallel-sided, cast posts, and cores; prefabri- cated, stainless steel, serrated and
parallel-sided posts, and resin-composite cores; prefabricated carbon ber posts and resin-composite
cores; and ceramic posts and resin-composite cores. In this study, the teeth from each group received
endodon.c therapy and a full- coverage metal crown, which was cemented onto each tooth. The
specimens were subjected to a compressive load at a 451 angle to its axis un.l failure

DESIGN OF POST
Active vs
passive

Ac.ve posts - threaded and are intended to engage the walls of the canal
Passive posts - retained strictly by the lu.ng agent.
Ac.ve posts are more reten.ve than passive posts, but introduce more stress into the root than
passive posts
They can be used safely, however, in substan.al roots with max- imum remaining den.n.
Their use should be limited to short roots in which maximum reten,on is needed

Parallel vs
tapered

Parallel

More reten,ve than tapered posts

Induce less stress into the root, because there is less of a wedging eect, and
are reported to be less likely to cause root fractures than tapered posts
Higher success rate with parallel posts than tapered posts.

lauras notes

10

FP notes

DESIGN OF POST
Tapered

Prefab post
core

Require less den,n removal because most roots are tapered

Indicated in teeth with thin roots and delicate morphology.

typically made of stainless steel, nickel chromium alloy, or .tanium alloy

very rigid, and with the excep.on of the .tanium alloys, very strong.
Titanium posts have low fracture strength, which means they are not strong enough to be
used in thin post channels. Removal of .tanium posts can be a problem because they
some.mes break
.tanium and brass posts should be avoided, because they oer no real advantages over the
stronger metal posts.
Round - oer liBle resistance to rota,onal forces.
This is not a problem if adequate tooth structure remains, but if minimal tooth structure
remains, an.rota.on features must be incorporated into the post prepara.on with slots or
pins. A bonded material should be used for the core.

Does it
matter?

Dierence in fracture rate between various posts disappeared when the crowns were placed
(Kishen 2006).
Sorensen JA 1984: retrospec.ve clinical study that showed that the presence of a post had li9le
eect on the fracture rate of a crowned tooth.

LUTING AGENT OF POST

The most common lu.ng agents are zinc phosphate, resin, glass ionomer, and resin- modied glass-ionomer cements.
Resin cements
(+) increase reten.on, tend to leak less than other cements, and provide at least short-term strengthening of the root
Bonded resin cements have been recommended for their strengthening eect in roots with thin walls. Examples
include immature teeth or teeth with extensive caries. Resin may be bonded to some types of posts, so theore.cally,
the den.n/resin/post can be joined via resin adhesion into one unit, at least for a period of .me.
(-) more technique sensi.ve , require extra steps such as preparing the canal walls with acid or EDTA and placing a
den.n-bonding agent.
Contamina.on of the den.n or post can be a problem. Predictable delivery of etchants and adhesive materials deep
into the canal space also can be problema.c.
Self-cure or dual-cure cements should be used because of limited light penetra.on into the root, even with translucent
posts
(Schwartz, Robbins Joe 2004)

lauras notes

11

FP notes
Chapter
RESTORATION
OF
REATED
PREPARATIONChapter
OF CANAL
SPACE
12
ESTORATION
OF THE
THEEENDODONTICALLY
NDODONTICALLYTT
REATEDTOOTH
TOOTH

Apical
Apicalseal
seal
Minimal
Minimalenlargement
enlargement
Length
Length
Stop
Stop
Antirotation
Antirotation
Margin extension
Margin extension

AA

341
341

BB

CC

1
1
3
3
2
2

6
64
4Fig.

6
56
5

12-8
Fig.
12-8 cross-section through a maxillary central incisor
Faciolingual

Fig. 12-9
Fig.
Use
of 12-9
a prefabricated post entails enlarging the canal one or

Usefile
of sizes
a prefabricated
the canal
one or
two
to obtain apost
goodentails
fit at aenlarging
predetermined
depth.
file sizes
obtain a good
predetermined
depth.
A,two
Incorrect;
theto
prefabricated
postfitis at
tooa narrow.
B, Incorrect;
A, prefabricated
Incorrect; the post
prefabricated
is tootonarrow.
B, Incorrect;
the
does notpost
extend
the apical
seal.
prefabricated
post doespost
notisextend
to enlarging
the apicaltheseal.
C,the
Correct;
the prefabricated
fitted by
C, Correct;
canal
slightly. the prefabricated post is fitted by enlarging the
canal slightly.

Faciolingual
through
a maxillary
centraldesign
incisor
prepared for cross-section
a post and core.
Six features
of successful
prepared
for a post
and core.apical
Six features
successful canal
design
are identified:
1, adequate
seal; 2,of minimum
are
identified:(no
1, undercuts
adequate apical
seal; 3,
2, minimum
canal
enlargement
remaining);
adequate post
length; 4, positive
(to minimize3,wedging);
5, verenlargement
(no horizontal
undercutsstop
remaining);
adequate
post
tical wall
prevent
rotation (similar
a box); and
6, extension
length;
4, to
positive
horizontal
stop (toto
minimize
wedging);
5, verof the
final
margin(similar
onto sound
tooth
structure.
tical
wall
to restoration
prevent rotation
to a box);
and
6, extension
of the final restoration margin onto sound tooth structure.

Apical seal

Diameter

rately and yet passively while ensuring strength and

rately and
yet passively
while
strength
retention.
Along
the length
of a ensuring
tapered post
space,and
retention. Along
theneeds
lengthtoofexceed
a tapered
post
space,
enlargement
seldom
what
would
enlargement
seldom needs
to exceed
what would
have
been accomplished
with one
or two additional
have
been
accomplished
two
additional
file
sizes
beyond
the largestwith
size one
usedorfor
endodonticfile
treatment.
Because
the more
coronal
sizes beyond
the of
largest
size used
forposition
endodonthetreatment.
post space,
a much
file must
besused
to
Because
the more
coronal
position
picallyto
ensure
an aoflarger
dcquatc
apical
eal.
Four to 5 mm of gu9a percha should he retained ofatic
(Fig. 12-8). Excessive enlargement can perforate or
accomplish
(Fig.a 12-9).
of the postthis
space,
much larger file must be used to
When
othe
nly Excessive
3 mwhich
m or
less
present,
there post
is or
a greater
incidence
f leakage.
weaken
root,
thenis
may
split
(Fig.
12-8).
enlargement
can during
perforate
accomplish
thiso(Fig.
12-9).
Preparation of coronal tissue
cementation
or subsequent
function.
Theduring
thickness
weaken
the root,
which then
may split
post
Adequately
c
ondensed
g
u9a
p
ercha
c
an
b
e
s
afely
r
emoved
i
mmediately
ajer
cementation
Preparation oftreated
coronal
tissue
of the remaining
dentin is function.
the primeThe
variable
in
Endodontically
teeth
oftenendodon.c
have lost much
or subsequent
thickness
fracture
resistance
of
the
root.
Experimental
impact
coronal
tooth
structure
as
a
result
of caries,
a result
of
the remaining dentin is the prime variable in
Endodontically treated teeth often
haveaslost
much
treatment.
testing of
teeth with
cemented
posts of different
ofcoronal
previously
placed
restorations,
or of
in caries,
preparation
of
fracture
resistance
of
the
root.
Experimental
impact
tooth
structure
as
a
result
as a result
7
showed
that
teeth posts
with rof
a different
thicker placed
diameters
the
endodontic
cavity.canal
However,
ifpreparation
a cast core
If
a zinc
xide
ewith
ugenol
provisional
estora.on
over the placed
oaccess
bturated
ior
s einxposed
to of
testing
ofoteeth
cemented
of previously
restorations,
7
(1.8 mm) post
fracturedthat
moreteeth
easily with
than those
with
isthe
to be used, further
reduction
is needed if
toaaccomshowed
a thicker
diameters
access
cavity. However,
cast core
saliva
for (1.3
long
.me
periods
( = 3 months),
leakage
will endodontic
occur
that
ccrown
ompromises
the gu9a
percha
a thinner
mm)
one.
modate
complete
and to remove
undercuts
(1.8
mm) post
fractured
more easily than those with
is to bea used,
further
reduction
is needed
to accomPhotoelastic
stress
analysis
also
has
shown
that
from
the
chamber
and
internal
walls.
This
may
leave
aseal,
thinner
(1.3
mm)
one.should be endodon.cally retreated.
modate a complete crown and to remove undercuts
and
such
teeth
internal
stresses stress
are reduced
with
thinner
posts. The
very
coronal dentin.
Everywalls.
effortThis
should
Photoelastic
analysis
also
has shown
that
fromlittle
the chamber
and internal
may be
leave
root
can
be
compared
to
a
ring.
The
strength
of
a
ring
made
save as much of the coronal tooth structure
Goodacre
internal stresses are reduced with thinner posts. The
very tolittle
coronal dentin. Every effort should be
is proportional to the difference between the fourth
as possible, because this helps reduce stress concenroot can be compared to a ring. The strength of a ring
made to save as much of the coronal tooth structure
powers of its internal and external radii. This implies
trations at the gingival margin.21 The amount of
is proportional
to the difference between the fourth
as possible, because this helps reduce stress concenMinimal
e
nlargement
that the strength of a prepared root comes from
remaining tooth structure is probably
the most
powers of its internal and external radii. This implies
trations at the gingival margin.21 The amount of
its periphery,
notdiameter
from its interior,
and
soontrolled
a post of to pimportant
predictor
of clinical
success.
If more than
Post
a
nd
c
ore
s
hould
b
e
c
reserve
r
oot
s
tructure
s
o
t
hat
p
erfora.ons
are
that
the strength
of a not
prepared
comes
from
toothtooth
structure
is remains,
probably the
thepost
most
reasonable
size should
weakenroot
the root
signifi2remaining
mm of coronal
structure
its
periphery,
not
from
its
interior,
and
so
a
post
of
important
predictor
of
clinical
success.
If
more
than
19
less
likely
to occur, aitnd
the tooth
can resist
racture
during has
post
cementa.on
r fracture
Nevertheless,
is difficult
to enlarge
a rootroot fdesign
cantly.
probably
a limited
role in o
the
reasonable
size should
weaken
root signifi2 mm of coronal
structure
remains,
post
canal 19
uniformly
and tonot
judge
with the
accuracy
how
The the
once
resistance
of the tooth
restored
tooth.22,23
subsequent
f
unc.on
Nevertheless,
it is been
difficult
to enlarge
root
cantly.
design probably
has a limited
rolecoronal
in thereducfracture
much tooth
structure has
removed
and ahow
common
clinical practice
of routine
22,23
uniformly
and
to judge
with
accuracy
howof the
The
once
resistance
of thelevel
tooth.
Post
iameters
should
not
xceed
one
root
diameter
at restored
any
loca.on,
and
post
,p
canal
thick dthe
remaining
dentin
is. eMost
roots
arethird
nartion
to the
gingival
before
post
and
core
fabrimuch
structurethan
has faciolingually
been removedand
andoften
how
common
clinical practice
of routine
coronal (Fig.
reducrower tooth
mesiodistally
cation
is outmoded
and should
be avoided
diameter
s
hould
u
sually
b
e
1

m
m
o
r
l
ess.
thick
the remaining
dentin
Most roots
areonnartion to Extension
the gingival
beforewall
postofand
fabrihave proximal
concavities
thatis.cannot
be seen
a
12-10).
of level
the axial
thecore
crown
mesiodistally
than
faciolingually
often resistance
cationto isthe
outmoded
and structure
should be
avoided
(Fig.
standard
periapical
radiograph.
Experimentally,
apical
missing
tooth
provides
what
increasing
post diameter
decreases
tand
he tooths
to
fracture.
rower
have
concavities
that
cannot
seen on a
of thewith
axial
wall of which
the crown
most proximal
root fractures
originate
from
thesebe
concavities,
is12-10).
known Extension
as a restoration
a ferrule,
is
standard
periapical
radiograph.
apical to
missing
structure
what
because the
remaining
dentin Experimentally,
thickness is
defined
as the
a metal
bandtooth
or ring
used toprovides
fit the root
most
root20fractures
originate
fromd
these
concavities,
is crown
knowniof
atooth,
restoration
with ao
which
Therefore,
the root
canal
minimal.
as
opposed
toferrule,
crown
that is
The
thickness
of the
remaining
en.n should
is the be
prime vorariable
n asfaracture
resistance
f tahe
root.
because
the enough
remaining
dentin
thickness
defined
as a metal
or ring
to fitThis
the is
root
enlarged only
to enable
the post
to fit accu-is
merely
encircles
coreband
material
(Fig.used
12-11).
20
Root
canal should
be enlarged
nly enough
post
t accurately
and to
yet a pcrown
assively
Therefore,
the root ocanal
shouldto
beenable
minimal.
orthe
crown
ofto
a tooth,
as opposed
that
enlarged only enough to enable the post to fit accumerely encircles core material (Fig. 12-11). This is

while ensuring strength and reten.on.

lauras notes

12

FP notes

PREPARATION OF CANAL SPACE

Length

post length seems more important than diameter in determining cervical stresses, stress in the
tooth generally increases as the post diameter increases
post length is the most important reten.ve factor and that post diameter was a secondary
factor
Goodacre and Spolnik 1995

Guideline: 3/4 root length (Goodacre and Spolnik 1995)

Minimum post length that ideally should be used is 9 mm.
posts that were three fourths or more of the root length were 20% to 30% more reten,ve
than posts that were one half of the root length or equal in length to the crown.
three fourths of the length of the root oered the greatest rigidity and least root deec,on
(bending)
But this dimension is not achievable without compromising the apical seal on many teeth
Clinically, each tooth must be individually evaluated for root length and amount of remaining
guBa percha before establishing the desired post length.
long-rooted teeth: achieving a length as close as possible to three fourths of the root length
is desirable
whereas many teeth will have posts that are equal in length to the crown because of
limited root length and the need to retain 4 to 5 mm of apical gu9a percha.

Vertical stop

lauras notes

Provides a posi.ve seat -> prevents wedging eect -> spilt root

13

FP notes

CORE
GIC/RMGIC

AR

(-) lack adequate strength as a

(+) good physical and mechanical
buildup material and should not be
proper.es
used in teeth with extensive loss of (-) crown prepara.on must be
tooth structure.
delayed to permit the material
.me to set.
When there is minimal loss of
tooth structure and a post is not
(-) esthe.cs
needed, glass-ionomer materials
work well for block-out, such as
ajer removal of an MOD
restora.on.

CR
currently the most widely used
buildup material.
can be bonded to many of the
current posts and to the remaining
tooth structure to increase
reten.on
not a good choice, however, with
minimal remaining coronal tooth
structure, par.cularly if isola.on is
a problem.

NAYYARS TECHNIQUE: ONE-PIECE AMALGAM POST-CORE

Used when there is sucient coronal tooth structure, at least 3 walls
Adequate reten.on and resistance form from pulp chamber
Procedure
Removal of 2-3mm of GP from all canals
Amalgam/CR used as posts as well as core material
Select high early strength amalgam
Condense into root canals
Same visit crown prep possible
MODIFIED NAYYARS TECHNIQUE:
Prefab post used to provide addi.onal reten.on

POST-CORE RESTORED - BIOMECHANICAL CONSIDERATIONS

In a postcore-restored tooth, the post, core, crown, and the remaining tooth structure respond to bi.ng forces as a
single func.onal unit
Key dierences between intact tooth and tooth restored using postcore are
(1) Occurrence of regions of stress concentra.on and
(2) Increase in the tensile stresses produced within the remaining tooth structure of a postcore restored tooth.
The intensity of stress concentra,on and tensile stresses will depend upon
(1) The material proper.es of the crown, post, and core material
(2) The shape of the post
(3) The adhesive strength at the crowntooth, coretooth, and core post, posttooth interfaces
(4) The magnitude and direc.on of occlusal loads
(5) The amount of available tooth structure
(6) The anatomy of the tooth.
When bi,ng loads are angled away from the long axis of the tooth:
stress concentra.on intensity and tensile stresses have been noted to increase signicantly because
(1) the greater s,ness of the endodon.c post and core restora.on,
(2) The angula,on of the post with respect to the line of ac.on of occlusal load, and
(3) Increased exure of the remaining reduced tooth structure.
lauras notes

14

FP notes

What happens when lateral forces are applied:

Lateral forces -> high stress concentra.ons in radicular den.n at the coronal one third of the root.
Rota,onal axis of the tooth: at the crest of alveolar bone
Forces are greatest on the circumference of the root, lowest within the root canal.
The center of the root or canal is a neutral area with regard to force concentra.on.
This force distribu.on explains the suscep.bility of teeth to fracture at the cementoenamel junc.on when lateral
forces are exerted on the coronal por.on of the tooth. The contribu.on of the post inserted in the root canal or
area of zero forces is negligible because the post absorbs only minimal forces in this posi.on
A post does not no.ceably reduce forces at the margins of a crown and does not cause a more equal distribu.on
or dispersion of forces along the length of the root. (Assif et al 1989)
Fracture predilection in endodontically treated teeth
Fracture predilection in endodontically treated teeth
LD
LD

60
60

0
0

Crown
Crown
AF
AF

Core
Core
Dentine
Dentine

NA
NA

TS
TS

Post
Post

CS
CS

TL
TL
SC
SC
TA
TA

LR
LR
CZ
CZ

LD-Load
CS-Compressive stress
LD-Load stress
CS-Compressive
stress
TS-Tensile
NA-Neutral
axis along
which stress is zero
TS-Tensile stresszone
NA-Neutral
axis along which stress is zero
CZ-Compressive
AF-Axis
of force
CZ-Compressive
zonethe reactant stresses
AF-Axisproduced
of force by the initial contact of
LR-Line
resulting from
LR-Line
from
the reactant stresses produced by the initial contact of
tooth
withresulting
supporting
bone.
tooth with supporting bone.

Fig. 8. Schematic illustration of bending stress distribuFig. 8. Schematic illustration of bending stress distribution within tooth (15).
tion within tooth (15).

CL
CL
SC
SC
CA
CA
SC
SC

CL-Compressive stress concentration regions for axial loads (0)

CL-Compressive stress concentration regions for axial loads (0)
CA-Compressive stress concentration for loads at 60 lingual to
CA-Compressive
the
long axis of thestress
tooth concentration for loads at 60 lingual to
the long axis of the tooth
TL-Tensile stress concentration for axial loads (0)
TL-Tensile stress concentration for axial loads (0)
TA-Tensile stress concentration for loads at 60 lingual to the
TA-Tensile
stress
concentration for loads at 60 lingual to the
long
axis of the
tooth
long axis of the tooth
SC-Regions of stress concentrations
SC-Regions of stress concentrations

Fig. 9. Schematic diagram illustrating stress concentraFig. 9. Schematic diagram illustrating stress concentration regions in postcore restored teeth (16).
tion regions in postcore restored teeth (16).

in the remaining tooth structure. Stress concentrations

in the remaining tooth structure. Stress concentrations
at the cervical region are mostly because of the
at the cervical region are mostly because of the
increased flexure of the compromised tooth structure,
crack, or a geometric notch such as a sharp corner,
increased flexure of the compromised tooth structure,
crack, or a geometric notch such as a sharp corner,
while stress concentrations at the apical region are
thread, hole, etc,. (2) tensile stress: the tensile stress
while stress concentrations at the apical region are
thread, hole, etc,. (2) tensile stress: the tensile stress
generally due to taper of the root canal and charactermust be of a magnitude high enough to provide
generally due to taper of the root canal and charactermust be of a magnitude high enough to provide
istics of the post. The regions of high stressTHEconcentramicroscopic
plastic deformation at the tip of the stress
JOURNAL
OF PROSTHETIC
DENTISTRY
ASSIF
AND GORFIL
istics of the post. The regions of high stress concentramicroscopic
plastic deformation at the tip of the stress
tion are also associated with the apical termination of
concentration. The tensile stress need not be an applied
tion
are
also
associated
with
the
apical
termination
of
concentration.
The
tensile
stress
need
not
be
an
applied
2 most common
occurrence:

the post
(16). Imperfections
such as a notch, ledge, or
stress on the structure, but may be a residual stress
the post (16). Imperfections such as a notch, ledge, or
stress on the structure, but may be a residual stress
crack
created
in
the
during root canal preparainside the structure. It should be understood that
1) Loosening crack
of the
post in the dentine
created
dentine during root canal preparainside the structure. It should be understood that
tion or sharp threading from a post or a pin will also
material properties such as yield strength and tensile
tion or sharp threading from a post or a pin will also
material properties such as yield strength and tensile
2) Tooth fractures
give rise to localized stress concentration regions that
strength have virtually no bearing on the vulnerability
give rise to localized stress concentration regions that
strength have virtually no bearing on the vulnerability
can
befailure:
the locus for a potential fatigue failure (Fig. 10)
of a material to crack extension and fracture. The
Other reasons
for
can be the locus for a potential fatigue failure (Fig. 10)
of a material to crack extension and fracture. The
(47). A smooth root canal shape is therefore recomincrease in magnitude of tensile stresses and concentra(47). a
And
smooth
root canal shape is therefore recomincrease in magnitude of tensile stresses and concentra Apical lesions
caries
mended to eliminate stress concentration sites.
tion of stresses will render the remaining tooth
mended to eliminate stress concentration sites.
tion of stresses will render the remaining tooth
Fractured/loose
crowns
Fracture
from a biomechanical perspective is a very
structure prone to fracture. Close congruence
noAnal stress has
a0 been
Fracture from a biomechanical perspective is a very
structure prone to fracture. Close congruence
has been
complex process that involves the nucleation and
reported between the regions Iof stress concentration
complex process that involves the nucleation and Fig. reported
between the
regions
of stress
concentration
1.
Stress
distribution
across
root
in
tooth
under
load.
F,
Force in
applied on lingual
growth of micro and macro cracks. Knowledge of
observed in photoelastic models and oblique fracture
of tooth.inFulcrum
(lower vertical
arrow)
on buccalfracture
surface and
growth of micro and macro cracks. Knowledge of surface
observed
photoelastic
models
andisoblique
in corresponds to
Root fractures
cracks are formed and grow within materials is crestextracted
how
teeth
subjected
to
in
vitro
fracture
resistance
of alveolar bone. T, tensile stresses; C, compressive stresses. C and T are maximal at
how cracks are formed and grow within materials is external
extracted
teeth
subjected
to
in
vitro
fracture
resistance
surface
root and decrease
to zero at
center of root
or canal (only
important
to funderstand
a structureto
fractures.
(16).ofBesides,
the tensile
strength
of dentine
is available place
and core
ailures are how
a9ributable
root for tests
3-10%of post
important
to understand
how
a structure fractures.
testsinsertion).
(16). Besides,
theortensile
post
Center of root
canal is strength
neutral areaof
withdentine
regard toisforce concentraEven microscopic cracks can grow over time, eventually tion,much
its compressive
strength
(47).
Finiteand inlower
its giventhan
position,
post receives minimal
stresses
under
occlusal load and conEven microscopic cracks can grow over time, eventually sequently
muchdoes
lower
than its compressive
strength (47). Finitefractures . resulting
little to reinforce
root under
such atoload.
in the fracture of the structure. Therefore,
element
analyses
(FEA) was
also used
study the stress
resulting in the fracture of the structure. Therefore,
element analyses (FEA) was also used to study the stress
structures
with
cracks
that
are
not
superficially
visible
distribution
pattern
in
teeth
restored
using
ost forms
are cracks
the mthat
ost are
likely
to cause visible distribution pattern in teeth restored usingaapostcore
Threaded pstructures
with
not superficially
postcore
could fail catastrophically. For fracture todontically
occur in
a teeth
system.
FEA
similar
treated
resultedThe
from the
loss studies
of substan-have highlighted
Therefore
the post
design has limited influence on resiscould
fail
catastrophically.
For
fracture
to
occur
in
a
system.
The
FEA
studies
have
highlighted
similar
root fracture
and split, and threaded exible posts
do that
not included
reduce
tress
concentra.on
during

tial dentin
the sroof
of the
pulpal chamber.
offunc.on.
the tooth
to fracturing,
and it is not as critical as
material, the following factors must be
present
altered
stress
distribution
patterns tance
in tooth
structure
material, the following factors must Cracks
be present
patternsa in
toothcast
structure
or fractures altered
of roots stress
occurreddistribution
after endodontic
complete
crown to brace healthy tooth structure
simultaneously: (1) stress concentrator: this
can
be
a
after
the
placement
of
post,
core,
and
crown
(4850).
treatment,
in those
strengthened
apicalcrown
to the core
margin.21-25
simultaneously: (1) stress concentrator: this
can beespecially
a
after
the teeth
placement
of post,bycore, and
(4850).

POST CORE FAILURES

lauras notes

posts after tooth structure was removed from the cana1.13-17

Metal posts concentrate unbalanced forces to walls of the
root.
The main factor endangering the survival of pulpless
teeth after restoration is loss of dentin during endodontic
treatment, while preparing the accesscavity with excessive
widening and additional loss of dentin from post preparation. Therefore it is not necessary to strengthen the tooth,

The metal crown concentrates forces at its margins during occlusal loading because of pressure of the crown on the
finish line of the tooth 65
preparation when the margin design
65because of sharp angles that conis a butt joint type and
centrate forces when stressed.26In the metal crown, forces
are concentrated in an area of sharp margins, exerting
much pressure on the coronal one third of the root. In the
transitional area between a rigid and a less rigid material,

15

FP notes
tapered, threaded posts were the worst stress producers, increased the incidence of root fracture in extracted
teeth by 20 .mes that of
the parallel threaded post
Cemented posts produce the least root stress.
Increasing post length increases the resistance of a root to fracture
increasing post diameter decreases the resistance of a root to fracture.

Kishen

(1)
Initial signs of interfacial failure at the
crown tooth interface. This can lead to
loosening of the crown.
This failure depends on the adhesive
strength of the crown-tooth interface.

(3)
The interfacial failure at the
crown-tooth interface may
progress as interfacial failure at
the core-tooth interface.
This failure depends on the
adhesive strength of the coretooth interface.

(2)
The interfacial failure
approaching the core may
cause core fracture.
The fracture of the core would
depend upon the mechanical
properties of the core material.

(5)
The interfacial failure at
the core-tooth interface
may progress as
interfacial failure at the
post-tooth interface.
This failure depends on
the adhesive strength of
the post-tooth interface

(4)
The interfacial failure approaching
the post may cause post fracture.
The fracture of the post would
depend upon the mechanical
properties of the post material

(6)
The post-core restored tooth behaves as a single
unit to functional forces. As the interfacial failures
progresses, the response of the post-core unit and
the remaining tooth structure becomes distinctly
different. And this will lead to the fracture of tooth.
The location and nature of tooth fracture will
depend upon the mechanical properties and shape
of the post, anatomy of the tooth, direction of the
external force and the amount and nature of
remaining tooth structure.

Fig. 17. Schematic diagram showing the progression of interfacial failures and fractures in postcore restored tooth.

Age factors: effects of age changes on

dentine
Alteration of normal dentine to form transparent
dentine is a common age-induced process. Physiologic
transparent (or sclerotic) dentine appears to form
without trauma or caries attack as a natural consequence of aging, whereas pathologic transparent
dentine is often seen subjacent to caries. The dentinal
lauratubules
s notes in transparent dentine are gradually filled up
with a mineral phase over time, beginning at the apical

end of the root and often extending into the coronal

dentine. The large intratubular mineral crystals deposited within the tubules in transparent dentine are
chemically similar to intertubular mineral. It was
suggested that a dissolutionreprecipitation mechanism is responsible for its formation (131). In the past, it
was believed that transparency required a vital pulp
(132). This belief has been largely discounted. It now
appears that endodontically restored teeth have the
same or a greater rate of transparent dentine formation 16
as teeth with vital pulp (133). The elastic properties of

FP notes

CROWN

CROWNS VS DIRECT RESTORATIONS

Study

A.F. Stavropoulou, P.T. Koidis

A systema:c review of single crowns on endodon:cally treated teeth
Journal of den:stry 35 (2007) 761767

Method

Systema.c review of 1609 references, of which 10 survived

Single crowns, n not stated
failure of the RCTRs is dened as: fracture of the tooth, fracture of the restora.on, post fracture, post
decementa.on, dislodgment of the restora.on, marginal leakage of the restora.on and tooth loss. The
outcome of the study was chosen to be success of RCTRs and none of the above failure criteria should exist
for the restora.on to be considered successful.
Data pooled and cumula.ve Life Table Survival Curves

2 to 10 year Follow-Up
Conclusions
Crown vs No

RCT covered with crowns have a higher long-term survival rate (81% ajer 10
years) than RCT without crown coverage (63 % ajer 10 years)
Survival rate for RCT without crown coverage is quite sa.sfactory for the
rst 3 years (84 ! 9%), while there is a signicant decrease in the survival

crown

of RCT ajer this period.

3-year survival rate of resin- restored teeth is markedly be9er than that of
amalgam- restored teeth.
AR unacceptable for restora.on of endodon.cally treated posterior teeth,
whether amalgam is used as a temporary or permanent restora.ve

AR vs CR

material.
Enamel-bonded resin is an alterna.ve treatment op.on for teeth that are in
the need of a temporary restora.on and have limited loss of tooth structure

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FP notes
Study

Fokkinga WA, Kreulen CM, Bronkhorst WM, Creugers NH. Up to 17- year controlled clinical study
on post-and-cores and covering crowns.
J Dent 2007; 35:778-786.

Method

Controlled Clinical Trial

Single crowns
Mul.-prac.ce, 18 operators
257 pa.ents, 307 core restora.ons
RPD abutments excluded
15 to 17 year Follow-Up
Survival Analysis Kaplan Meier, dropouts, censored date
Deni.on of Survival Restora.on, Tooth
Treatment Alloca.on ?? (The disadvantage of the general prac.ce se}ng appeared
some.mes to be the lack of compliance of the operators regarding the treatment assignment)
>75% of the circumferen.al den.n wall has minimal 1mm thickness and at
Substan.al

least a height of 1mmabove gingival level;

den.ne height Less than 25% of the circumference has less than 1mm above the gingiva,
But a ferrule of 12mm could be achieved.
Minimial
den.ne height
CONCLUSION

WHICH TYPE
OF CORE TO
USE? IS CPC

<75% of the circumferen.al den.n wall has at least 1 mm above gingival level;
More than 25% of the circumference has less than 1 mm above the gingiva,
Or no ferrule of 12mm could be achieved.
The results of this study showed NO dierence in survival probabili,es
among dierent core restora,ons under a covering crown of
endodon.cally treated teeth.

ALWAYS

No dierence in restora.on-survival was found between these two

NECESSARY?

types of post-and-cores for teeth with minimal den.n height. Thus,

one should be careful to conclude that in the situa.on of a tooth with
minimal den.n height always a cast post-and-core is preferred.

DO YOU
ALWAYS NEED
A POST

No dierence in the survival probability between restora.ons with and

without posts in teeth with substan.al den.n height lej => cannot be
recommended to rou.nely use a post preceding a crown in an
endodon.cally treated tooth
-> in an endodon.cally treated tooth with substan.al remaining den.n a
post in a core does not perform be9er than a post-free core

WHY IS
FERRULE IMPT

The preserva.on of substan.al remaining coronal tooth structure seems to

be cri,cal to the long-term survival of endodon,cally treated crowned
teeth.
survival probability of post-and-core reconstructed teeth with substan.al
den.n height (Trial 1) was signicantly higher than that of teeth with
minimal den.n height (Trial 2)

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FP notes

FERRULE EFFECT
Definition

An encircling band of metal that embraces the coronal surface of the tooth structure
A ferrule is dened as a ver.cal band of tooth structure at the gingival aspect of a crown
prepara.on.(Schwartz et al 2004)
It should be clear that the term ferrule is ojen misinterpreted. It is ojen used as an expression
of the amount of remaining sound den.ne above the nish line. It is in fact not the remaining
tooth structure that is the 'ferrule' but rather the actual bracing of the complete crown over the
tooth structure that cons.tutes the ferrule eect, ie the protec.on of the remaining tooth
structure against fracture. (A. Jotkowitz & N Samet 2010)
Teeth prepared with adequate ferrule eec.vely resist func.onal forces and enhances the
fracture strength of postcore restored endodon.cally treated teeth.

Advantages

Increase

YES

fracture

A ferrule with 1 mm of ver.cal height has been shown to double the

resistance to fracture versus teeth restored without a ferrule

resistance

(JA Sorensen et al 1990)

NO
No dierence in fracture resistance with or without a 2-mm ferrule using
prefabricated posts and resin cement
(al-Hazaimeh and Gu9eridge, 2001)
No dierence in fracture resistance of teeth with bonded posts with or
without a ferrule
(WA Saupe, 1996)

Consideratio
ns

Fracture

Fracture pa9erns were more favorable when a ferrule was present

pa9ern

(al-Hazaimeh and Gu9eridge, 2001)

Biological width The ferrule length obtained will be inuenced by the biologic width, which is
the dimension of the junc.onal epithelial and connec.ve .ssue a9achment to
the root above the alveolar crest.
It is generally accepted that if unpredictable bone loss and inamma.on are
to be avoided, the crown margin should be at least 2mm, from the alveolar
crest.
Recommended that at least 3 mm should be lej to avoid impingement on the
coronal a9achment of the periodontal connec.ve .ssue
Therefore, at least 4.5 mm of supra-alveolar tooth structure may be required
to provide an eec.ve ferrule
Crown

may result in a poorer crown to root ra.o (and therefore to increased leverage

lengthening

on the root during func.on) , compromised aesthe.cs, loss of the inter-dental

papilla and a poten.al compromise of the support of the adjacent teeth

Ortho extrusion crown to root ra.o may s.ll be compromised and it adds signicant .me and an
addi.onal fee
Ferrule is desirable, but should not be provided at the expense of the remaining tooth/root
structure(Stankiewicz & Wilson )

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FP notes
Jotkowitz & Samet 2010 - Rethinking ferrule a new approach to an old dilemma
4 direct factors
(Influence ferrule)

2 indirect factors
(Affects functionality of ferrule)

A) Ferrule height

E) Type of post

B) Ferrule width

F) Core material

C) Number of walls & ferrule loca.on

D) Type of tooth & extent of lateral load
A) Ferrule
height

Maximum benecial eects from a ferrule with 1.5 to 2 mm of ver.cal tooth structure
Tan P L, Aquilino S A, Gracon D G et al 2005:
The mean fracture strengths of endodon.cally treated maxillary central incisors restored
with a crown without a dowel and endodon.cally treated maxillary central incisors restored
with a cast dowel and core and crown with a uniform 2-mm ferrule were not signicantly
dierent.
Greater the height of remaining tooth structure above the margin of the prepara.on, the be9er
fracture resistance

B) Ferrule
width

Walls are considered too thin when they are less than 1 mm in thickness
minimal ferrule height is only of value if the remaining den.ne has a minimal thickness of 1
mm.
No consensus regarding contra-bevel ferrule designs, or the incorpora.on of a cervical collar and
therefore these designs are not widely accepted.

C) Number
of walls and
ferrule
loca,on

Common for a par.al ferrule to remain ajer crown prep due to

Caries free -proximal
Erosion/abrasion - buccal wall
Tooth prep to achieve max esthe.cs - thin and low buccal walls
Uniform all around ferrule > ferrule that varies in dierent parts of the tooth.
Non-uniform ferrule is s.ll superior to no ferrule at all.
(Paper quoted Al-Wahadni et al. in 2002 to jus.fy, but in actual fact the in vitro study did not cement crowns over
the cast post core restored teeth because they did not want to incorporate the ferrule eect. Anyhow quote.)

Tan P L, Aquilino S A, Gracon D G et al 2005

In vitro study inves.gated the resistance to sta.c loading of 50 endodon.cally treated max
incisor teeth with uniform (2mm all round) and nonuniform (2 mm buccal and lingual, 0.5
mm proximal) ferrule congura.on. (Restored with cast post core crown)
=> A tooth with a non-uniform ferrule is more eec,ve at resis,ng fracture than a tooth
with no ferrule, but not as eec.ve as a tooth with a uniform 2-mm ferrule.
Mandibular premolar: buccal wall more crucial
Maxillary premolar: buccolingual ferrule more crucial

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FP notes
LOCATION of sound tooth structure to resist occlusal forces that is more important than having
360 of circumferen.al axial wall den.ne.
Ng CC et al 2006
In vitro study on maxillary incisors with bonded bre posts and resin cores -
good palatal ferrule only is as eec.ve as having a complete all around ferrule, as this
tooth structure will resist the forces applied in func.on to the palatal surface of the
maxillary incisor.
a maxillary incisor that is only missing the palatal wall despite the presence of three
other favourable walls shows poor fracture resistance and is at greater risk of failing
than some condi.ons with fewer walls remaining
when the palatal wall is missing, the non-axial load from the palatal side in a maxillary
anterior crown challenges the post/core/root junc.on.
D) Type of

Anterior vs posterior teeth:

tooth &

2 dis.nguishing factors: rela.ve size and direc.on of loads they need to withstand

extent of

anterior teeth are loaded non-axially and posterior teeth in normal func.on have the majority of

lateral load

the load in an occluso-gingival direc.on. Lateral forces have a greater poten.al to damage the
tooth-restora.on interface when compared to ver.cal loads
(Refer to previous segment on Pa.ent factors: occlusion)

CROWN
Crown
design

Metal collar enhance Barkhordar RA et al 1989

resistance to root

In vitro study examined the eect of a metal collar with approximate 3

fracture

degrees of taper on the resistance of 20 endodon.cally treated maxillary

central incisor roots to fracture.
Teeth in the group with 2 mm cervical metal collar required a higher force to
aect failure then those without

Margin
design

Avoid buB joint &

sharp angles

Metal crown concentrates forces at its margins during occlusal loading

because of pressure of the crown on the nish line of the tooth
prepara.on
when margin design is a bu9 joint type and because of sharp angles
that concentrate forces when stressed.
Forces are concentrated in an area of sharp margins, exer.ng much
pressure on the coronal one third of the root.
In the transi.onal area between a rigid and a less rigid material, there is
concentra.on of high stress with increased forces, especially lateral
forces. The rigid material or the crown absorbs more forces and transfers
them to the less rigid material or the tooth

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