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Endodontic Topics 2014, 31, 68–83 © 2014 John Wiley & Sons A/S.
All rights reserved Published by John Wiley & Sons Ltd

ENDODONTIC TOPICS
1601-1538

Restoration of endodontically
treated teeth: contemporary
concepts and future perspectives
NADIM Z. BABA & CHARLES J. GOODACRE

The concept of using a root for the restoration of a missing crown is not new. Through continuous research, our
understanding of the causes of failure has improved. Recent research on endodontically treated teeth has changed
contemporary views concerning some principles while consolidating others. Clinical success in restoring
endodontically treated teeth depends on our ability to use the latest materials available in conjunction with sound
clinical methods. A number of articles have discussed the major factors that play a key role in the long-term
survival of endodontically treated teeth and associated restorations. The purpose of this article is to identify key
principles that affect tooth and restoration survival and to present expectations regarding optimal future solutions
for the long-term retention of endodontically treated teeth.

Received 23 September 2014; accepted 2 October 2014.

Various methods and materials have been proposed occur when endodontically treated teeth are restored
over the years for restoring pulpless teeth (1–3). Root (Fig. 1) (4). Fortunately the failure rate is relatively
fractures and other difficulties encountered with these low, but it could be even lower. As professionals,
early treatments led to the development of cast post it is our obligation to do everything possible to
and cores that continue to be used today. Recently, minimize complications. Some of the post
in response to an increased demand for esthetic all- complications encountered clinically are pos
ceramic restorations, a variety of non-metallic loosening, root fracture (Fig. 2), endodontic failure
prefabricated tooth-colored post systems have been (Fig. 3), root perforation (Fig. 4), post fracture
introduced as an alternative to metal posts. Today, the (Fig. 5), caries, and periodontal failure. The most
prosthodontic and endodontic aspects of restoring common post complications have been identified as
endodontically treated teeth (ETT) have appreciably post loosening and root fracture (4). Several authors
advanced and a significant body of scientific (5–10) discussed the multifactorial origins of the
knowledge on which to base our clinical treatment causes of cracks and fractures in ETT. Loss of tooth
decisions is available. However, retaining structure, the use of endodontic irrigants and
endodontically treated teeth throughout life requires instrumentation, a reduced level of proprioception,
careful restoration and adherence to available changes in dentin, and the restorative procedures are
evidence. the main factors proposed as causes of fracture (i.e.
Although the collaboration between different post placement). In addition, different variables, such
specialties coupled with modern therapies allows as the arch position, the presence of opposing occlusal
patients to retain severely compromised teeth for contacts, periodontal tissue support, endodontic
longer periods of time, the restoration of such teeth status, and the amount of remaining dentin, play an
remains a challenge. Despite a number of innovations important role in the prognosis of ETT. A number of
and decades of research on posts, failures can still articles have discussed the major factors that play a key

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Restoration of endodontically treated teeth: contemporary concepts and future perspectives

a c

Fig. 1. (a) A separated instrument within the mesial root canal of a mandibular right second molar. (b) Perforation
of the roots of a mandibular second molar, the result of post space preparation with instruments not held parallel to
the root canals. (c) A radiograph of a fractured maxillary lateral with a prefabricated non-metallic post.

role in the long-term survival of endodontically


treated teeth and associated restorations (11,12). The
purpose of this article is to identify key principles that
affect tooth and restoration survival and to present
expectations regarding optimal future solutions for the
long-term retention of endodontically treated teeth.

Effect of endodontic treatment on


the tooth
When performing root canal therapy, the access cavity
opening causes loss of coronal tooth substance (Fig. 6)
(13,14). In addition, root canal treatment as well as
retreatment can cause damage to the root dentin. A
Fig. 2. Radiograph displaying a very short post in the study looked at the influence of retreatment
root of a maxillary first bicuspid that caused root procedures on the appearance of defects on the root
fracture.
canal walls (15). It was concluded that retreatment
caused more defects in dentin than initial treatment.
During initial treatment, craze lines and cracks can be
formed in the dentin. The latter can develop into

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Baba & Goodacre

Fig. 3. Radiograph displaying an inadequate root canal


therapy that caused a radiolucent apical lesion.
Fig. 5. Radiograph of a fractured maxillary lateral
incisor with a prefabricated screw post.

Fig. 4. Inappropriate placement of a screw post created


a perforation in the pulpal floor of the maxillary first Fig. 6. Excessive enlargement of the access cavity
molar. following root canal therapy.

fractures during retreatment and under the functional


stresses applied to the tooth during chewing and The most commonly used techniques are trans-
parafunction. Several studies (16,17) compared the illumination (Fig. 7), occlusal tests, endodontic
effect of hand files and rotary files on dentin after canal microscopes, dyes, and quantitative percussion
preparation. They concluded that rotary instruments diagnostics (18–22). Recently, cone beam computed
caused more dentinal defects, such as craze lines and tomography (CBCT) has been suggested as a tool to
cracks, which possibly could develop into fractures diagnose fractures, perforations, or suspected cracks
after restorative treatment. (23,24).
Several methods have been proposed for detecting Another factor that could affect the mechanical
cracks and fractures when they are not visible clinically. properties of dentin is the use of endodontic irrigants

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Restoration of endodontically treated teeth: contemporary concepts and future perspectives

a b

d
c

Fig. 7. (a) Clinical photo shows a crack line on the occlusal surface of a maxillary first molar. (b) The amalgam
restorations were replaced with new ones and the tooth was prepared to receive a partial coverage restoration. (c) A
trans-illumination picture shows the crack running between the amalgams across the transverse ridge. (d) Occlusal
view of the 3/4 crown showing that it encompassed the buccal cusps.

and medications (25–27). Following contact with of the demineralized collagen matrices (30). The aging
these products, chemical degradation of dentin is dentin becomes sclerotic and exhibits very limited
evident and the dentin becomes weaker because of a yielding before failure. The fracture toughness is lower,
reduction in microhardness. However, the degree of and the stress–strain response is characteristic of brittle
dentin change is related to the amount and duration of behavior (31). Most importantly, there is a reduction in
contact between products and dentin. Other irrigation the stiffness and elasticity of dentin and a reduced
agents such as mineral trioxide aggregate and bioactive resistance to crack propagation (6,13,32,33).
glass do not seem to affect the flexural strength of root These factors can affect the prognosis of the
dentin (28–29). endodontically treated tooth. As a consequence,
In addition to the use of irrigants and medications, practitioners should strive to use restorative materials
Ferrari et al. showed that 10 to 12 years after with properties similar to that of dentin, along with
endodontic treatment, there is progressive degradation sound clinical principles to counteract the changes in

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Baba & Goodacre

mechanical properties of dentin as well as the loss of 775 ETT in 508 patients and found a higher survival
tooth structure following root canal treatment (RCT). rate for teeth restored within 2 weeks.
A systematic review investigated tooth survival after If immediate restoration of the tooth is not possible,
RCT (34); 14 studies met the inclusion criteria. Four it is recommended to protect the root canal system by
key factors were identified as enhancing the survival sealing the orifice of the canals and the floor of the
of teeth after RCT: the presence of interproximal pulp chamber with intracoronal barriers (43–45).
contacts, no plans for using the treated teeth as Among the suggested materials to be used are flowable
abutments for fixed or removable partial dentures, composite resin, mineral trioxide aggregate (MTA),
tooth type, and crown restoration. glass ionomer, fissure sealant, and conventional
The restorative dentist plays an important role in the restorative composite resin. This type of treatment has
success and failure of endodontic treatment. Before mostly been suggested to protect the root canal system
endodontic treatment is contemplated, the restorative from contamination during the provisionalization
dentist should: (i) have an overall treatment plan period.
for the patient based on their chief complaint The use of digital impressions and CAD/CAM
and desires; (ii) assess the restorability of the tooth, fabrication can help the restorative dentist to seal the
which may involve the removal of all existing filled root canal system and protect the tooth as soon
restorations and/or caries to determine the tooth’s as possible, either with a provisional or definitive
restorability, and examine the tooth for the presence of restoration.
cracks; and (iii) evaluate the need for any periodontal
treatment and appraise the periodontal prognosis of
Principles that enhance success
the tooth to be restored. After endodontic treatment
has been performed, the dentist should minimize
when restoring endodontically
recontaminating the root canal system.
treated teeth
A study by Balto et al. (35) found that all of the The prognosis of ETT does not depend solely on the
provisional materials they tested in post-prepared root quality of the RCT or the quality and time required
canals failed to prevent coronal leakage when used for for definitive restoration (38,46). Survival of the
an average of 30 days. Similarly, delayed placement of restoration also depends on several basic principles
the definitive restoration had an impact on the that affect tooth and restoration survival.
prognosis of ETT. These teeth had a higher success
rate when they were restored with a definitive
Cuspal coverage
restoration than with a provisional coronal access
restoration (36). An in vitro study looking at bacterial ETT can benefit from the placement of crowns. An
penetration of coronally unsealed endodontically epidemiological study in a large patient population
treated teeth found that defective restorations could found that while 97% of teeth were retained in the oral
cause reinfection of the root canal system within 19 cavity 8 years after initial non-surgical endodontic
days (37). A combination of poor endodontic treatment, an analysis of the teeth that were extracted
treatment and poor restoration caused a high failure (< 3%) revealed that 85% of them had no full coronal
rate for ETT (38). In comparing endodontic coverage (47). Aquilino & Caplan reported that ETT
treatment quality with restoration quality, Tronstad with cuspal coverage had a six times greater rate of
et al. (39) found that the quality of root canal survival than those without cuspal coverage (48).
treatment is more crucial than that of the coronal Another prospective study (49) of the factors affecting
restoration for the survival of ETT. outcomes of non-surgical RCT found that ETT which
A well-fitting provisional restoration followed by a were restored with a crown had a better survival rate
post and core and a definitive coronal restoration than those that were not. Vire (50), in a study of failed
should be planned and cemented in as short a time as teeth, demonstrated that ETT without crowns were
possible. Avoiding reinfection of the root canal and lost after an average time of 50 months whereas ETT
preventing mechanical failures such as fractures with crowns were lost after an average of 87 months.
enhances the survival of ETT (40,41). In a In a systematic review, Stavropolou & Koidis (51)
retrospective study, Willershausen et al. (42) evaluated concluded that ETT restored with crowns had a

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Restoration of endodontically treated teeth: contemporary concepts and future perspectives

higher long-term survival rate compared to those not Several studies (54–56) indicated that ETT with
restored with crowns (Figs. 8 and 9). A retrospective intact coronal surfaces (except for the access opening)
cohort study found that the 5-year survival rate of can be successfully restored using composite resin
teeth without cuspal coverage was 36% (52). However, restorations. However, the survival rate of ETT will
while crowns significantly improved the success of likely be lower when ETT have lost excessive amounts
endodontically treated posterior teeth, they did not do of tooth structure. Sedgley & Messer (57) concluded
so for anterior teeth (53). Intact endodontically that the loss of axial dentin walls weakens the teeth.
treated anterior teeth only require a crown when they Composite resin is a popular core buildup material
are weakened by large or multiple existing restorations because of its ease of use, and the possibility of
or when they require significant changes to their form preparing and finishing it immediately (46). Some
or color that are not manageable by conservative clinicians consider composite resin as an esthetic
restorations. replacement for cuspal coverage crowns. Composite
resin appears to be an acceptable core material when
substantial coronal tooth structure remains but a poor
choice when a significant amount of tooth structure is
missing (56,58,59). The authors believe that if less
than 50% of the coronal tooth structure of an
endodontically treated tooth remains, a post should be
used to retain the core material. The choice of buildup
material depends on the remaining adjacent teeth,
occlusion, and the planned definitive restoration. One
disadvantage of composite resin is that it is
dimensionally unstable (60). The setting shrinkage
during polymerization causes stress on the adhesive
bond resulting in cuspal strain with a disruption of the
bond, and gap formation that might contribute to
long-term bond failure followed by microleakage and
Fig. 8. Occlusal view showing the fractured buccal cusp
recurrent caries (54,55). The amount of shrinkage is
of an endodontically treated mandibular left first molar
without cuspal coverage. related to the amount of filler content in the
composite resin. A reduced amount of filler will cause
greater shrinkage. For this reason it is necessary to
avoid using flowable composite resins as buildup
materials because of their low filler content and their
reduced mechanical properties (61).
A recent systematic review looking at the effects of
the restoration of ETT by crowns versus conventional
filing materials concluded that there is no evidence to
support or refute the effectiveness of crowns over
filling materials for the restoration of ETT (46).
After considering the available contrasting data, the
authors acknowledge the potential benefits of using
composite resin to restore posterior teeth that are
intact except for a conservative access opening.
However, when occlusal wear, heavy forces, or para-
functional habits are present in the mouth, more
clinical data are required to determine the long-term
Fig. 9. Fracture of the palatal cusp of a maxillary right
first molar with significant amount of tooth structure
survival of these teeth when large composite resin
missing restored with a composite resin and without restorations are present. For this reason, we
cuspal coverage. recommend that endodontically treated teeth which

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Baba & Goodacre

have been previously restored and weakened by prior a favorable mode of failure when ETT with no buildup
tooth structure removal be restored with a crown that material are used. These crowns were found to be
encompasses the cusps. Conversely, it may be possible more resistant to failure than teeth that had been
to avoid crowns on some previously restored posterior restored with a post, composite resin core, and a
teeth with only a conservative access opening and ceramic crown (69,70). It is unknown whether this
little-to-no wear present that would indicate the type of conservative restoration will produce the same
presence of detrimental occlusal forces. problems as the one-piece crown–post combinations
It is highly recommended that a rubber dam be made using metal. Also, the impact of their subsequent
placed when a composite resin is used as the core removal upon structure integrity is unknown.
buildup material. Composite resin is a technically
demanding material that requires careful adherence to
Tooth preservation
material-handling protocols. To ensure success, the
use of low-shrinkage composite resin (62), the buildup Maximum preservation of coronal and radicular tooth
of the core in small increments (63), and the use of structure is a guiding principle for the restoration of
liners (64) has been advocated. ETT. As clinicians we should preserve intact tooth
The high demand for esthetic restorations, the need structure whenever possible in order to maintain an
for an occlusal material stiffer than dentin, and the adequate retention and resistance form of the final
benefit of covering the cusps has caused some restoration. The position of the tooth in the arch,
clinicians to use all-ceramic onlays and crowns as a the presence of opposing occlusal contacts, the
conservative and effective treatment modality to periodontal tissue support, the endodontic status, and
restore ETT (65–67). A suggested conservative the amount of remaining dentin aids in selecting
technique to restore ETT is the use of an endocrown the appropriate material for the definitive restoration.
(68–70). This restoration consists of an onlay or The authors believe that gold onlays or crowns are
crown with the core material in a single unit (Fig. 10). excellent restorations where esthetics is not of major
The core material engages in a cavity prepared into the concern, on teeth with limited interocclusal space, and
pulp chamber. A study by Magne et al. (68) found that when restoring heavy bruxers.
an endocrown fabricated from a resin nanoceramic has

Cervical ferrule
A ferrule can be established by the crown
encompassing sound tooth structure (Fig. 11) (71–
76). The data indicates that cervical ferrules increase
the tooth’s resistance to fracture (71,72,77). In spite
of the data supporting the benefit of cervical ferrules,
not all practitioners recognize their value. A survey
published by Morgano et al. (78) evaluated the
percent of respondents who felt that a ferrule increased
a tooth’s resistance to fracture: 56% of general dentists,
67% of prosthodontists, and 73% of board-certified
prosthodontists felt that core ferrules increased a
tooth’s fracture resistance.
Different lengths and forms of the ferrule have been
studied (71,73,74,79) and are essential factors for
the success of the “ferrule effect.” When possible,
encompassing 2.0 mm of intact tooth structure
around the entire circumference of a core creates an
optimally effective crown ferrule. Grasping larger
Fig. 10. All-ceramic restoration consisting of a crown amounts of tooth structure further enhances ferrule
with a core material in a single unit. effectiveness. The amount of tooth structure engaged

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Restoration of endodontically treated teeth: contemporary concepts and future perspectives

Fig. 11. A ferrule will be created by the overlying crown


engaging tooth structure. The final restoration is at least
2 mm apical to the junction core/tooth.

by the overlying crown appears to be more important


than the length of the post in increasing a tooth’s
resistance to fracture.
If insufficient cervical tooth structure remains to
develop a ferrule, surgical crown lengthening or
orthodontic extrusion should be considered to expose
more tooth structure. Fig. 12. Post and crown loosened from maxillary canine
In some situations where teeth have been extensively a few months after placement. (a) Both the post/
restored, have been subject to trauma, or have prefabricated post and the crown came off. (b) Clinical
photo shows the absence of cervical tooth structure
substantial caries, it will be difficult to obtain a ferrule.
(ferrule) for retention of the crown.
In such cases it may be prudent to extract the tooth
and replace it with an implant and crown. Extraction
of ETT may also be required when crown lengthening or crowns with the fracture resistance of teeth restored
would create an unacceptable esthetic environment or with posts and cores and crowns. Maxillary incisors
produce a furcation defect, or when a short root is without posts resisted higher failure loads than the
present that would not permit an appropriate post other groups with posts and crowns (82) and
length to be developed (80). mandibular incisors with intact natural crowns
Studies have shown that a uniform ferrule produces exhibited greater resistance to transverse loads than
significantly greater fracture resistance than a non- teeth with posts and cores (83). These studies have
uniform ferrule (74,76,81), with the greatest variation shown no evidence of a strengthening reinforcement
in failure load associated with the absence of portions effect of posts. However, several studies showed a
of the crown ferrule. The presence of a 2-mm ferrule relatively high failure rate of endodontically treated
on the facial, lingual, distal, and mesial surfaces of the teeth that were restored with a composite resin filling
tooth produces the most favorable resistance to tooth without a post (84–86). The failures occurred when
fracture and decreases the weakening effect of a post the teeth had small and curved roots. A study by Salvi
(Fig. 12) (76). et al. (87) evaluated ETT restored with and without
post and cores in a specialist practice. They concluded
Need for a post
that there was no significant difference between teeth
Studies have compared the fracture resistance of restored with or without posts provided that at least
endodontically treated extracted teeth without posts two-thirds of the dentin remained. They also found

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Baba & Goodacre

a b

Fig. 13. (a) Radiograph of a broken mesial root of an endodontically treated mandibular right molar restored with
a crown and no post. (b) Extracted tooth showing the fractured mesial root.

that 11 out of 13 failures in mandibular molars were


due to fractures (Fig. 13).
a
Clinical studies have failed to provide definitive
support for the concept that posts strengthen
endodontically treated teeth (53,85,87). An analysis of
data from multiple clinical studies noted that 3% of
teeth with posts fractured with no evidence that posts
enhanced the survival of teeth (88). Posts have had
little enhancing effect on the clinical survival of fixed
partial denture abutments, but they did improve
the clinical survival of removable partial denture
abutments compared to endodontically treated
abutments where no posts were used (53).
Because clinical and laboratory data indicate teeth
are not strengthened by posts, their purpose is for the
retention of a core that will provide adequate retention b
and support for the definitive crown or prosthesis.
When enough tooth structure is present in an
endodontically treated molar, there is absolutely no
need for a post (Fig. 14). The presence of adequate
dentin coupled with no preparation of a post space
helps avoid weakening the tooth, eliminates the risk of
perforation during post preparation, and aids in
preventing the development of cracks that could be
detrimental to the ETT. In endodontically treated
molars, buildup materials usually have sufficient
retention from the pulp chamber, divergent coronal
portions of the root canals, and undercuts created in
Fig. 14. (a) Occlusal view of a maondibular second
the pulp chamber during removal of caries and RCT. molar showing the presence of enough tooth structure
For endodontically treated anterior teeth and to retain the core. (b) Radiograph of the root canal
premolars, if sufficient tooth structure remains to treatment.

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Restoration of endodontically treated teeth: contemporary concepts and future perspectives

retain the core, the use of a post is not required; a


bonding a core buildup material to dentin is sufficient.
However, if a substantive amount of tooth structure is
missing in these teeth, a post is needed in order to
retain the core and optimize the resistance form. The
best prognosis is obtained when a 2-mm ferrule
encompasses intact tooth structure around the entire
circumference of the core no matter what type of post
is used. Because posts do not reinforce a tooth, they
should only be used when the core cannot be retained
by some other means.

Types and properties of posts


b
In recent years, prefabricated posts have become quite
popular and a wide variety of systems are now
available. In response to a need for tooth-colored
posts, several non-metallic posts such as zirconia, glass
fiber-reinforced epoxy resin (GFR), and ultra-high
polyethylene fiber-reinforced posts are available; early
data indicates that they can be acceptable alternatives
to metallic posts. However, gold alloys, titanium, and
chrome–cobalt are still clinically viable and are widely
used.
Among the non-metallic posts, GFR posts are the
most popular. They are available in different shapes:
cylindrical, cylindroconical, or conical. An in vitro
assessment of several GF post systems indicated that
Fig. 15. (a) A radiograph of a fractured mandibular
parallel-sided GF posts are more retentive than tapered
second premolar with a prefabricated non-metallic post.
GFR posts (89). These posts could be made from glass (b) Crown with broken post.
or silica fibers (white or translucent) but the most
commonly used fibers are silica based. The matrix
for this post is an epoxy resin. The fibers are in the
vicinity of 14 μm in diameter and uniformly likely to produce root fracture, post removal may
embedded in the epoxy resin matrix. The fibers are damage the root, and the cost to the patient versus
stretched before injection of the resin matrix to time of service before failure is a concern.
maximize the physical properties of the post. When In contrast, metallic posts are stiffer than dentin and
compared to metallic posts, GFR posts have a low can take more load than GFR posts. Their stiffness can
modulus of elasticity and are more flexible (90). This induce more stress apically, causing catastrophic root
flexibility induces more stress cervically, which, in the fractures (Fig. 16). Similarly to GFR posts, metal posts
case of minimal or no ferrule, causes a higher risk of also undergo a process of cement failure during cyclic
post fracture, debonding of the core, and loss of loading (93). Metal posts have a longer lifespan than
retention of the post followed by microleakage and GFR posts and they fracture less; but when they fail,
secondary caries (Fig. 15). Several studies (91,92) the failure is non-restorable (94).
have determined that there is a 40% decrease in the A comprehensive review of the English literature was
strength of GFR posts after thermocycling and cyclic conducted on evaluating the clinical performance of
loading. In addition, contact of the post with oral GFP in order to seek evidence for the treatment of
fluids (short- and long-term) reduced their flexural teeth with non-metallic posts (95). Clinical research
strength. While failure with fiber posts might be less articles showed that non-metallic posts have favorable

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Baba & Goodacre

Post debonding could be due to the polymerization


shrinkage of the composite resin cement, the
technique-sensitive cementation process, the difficult
access and visibility during cementation, the lack of a
clear and universal cementation protocol, the lack of
ferrule effect, or an inadequate choice in the type of
post for the given clinical situation and tooth. The
wide range of failure percentages reported with GFR
posts may also be indicative of variations amongst
clinicians and differences in their experiences/
restorative techniques. It appears that more long-term
clinical data is needed in order to determine the
Fig. 16. A radiograph of a fractured maxillary second efficacy of fiber-reinforced posts.
premolar with a metallic prefabricated post. A 10-year retrospective study of the survival rate of
teeth restored with metal prefabricated posts and cast
metal posts and cores found that their overall failure
mechanical and physical properties and the studies rate was 15.4% and 17.4%, respectively (106). When
presented with a wide range of reported failure we compare these results to the high overall failure rate
percentages, from 0% after a mean of 2.3 years to of non-metallic post, the authors believe that the GFR
11.4% after 2 years. Post debonding, post fracture, posts are not superior to metallic or cast posts.
crown debonding, and root fracture were the most There are challenges related to the use of cylindrical
commonly reported complications. Post debonding prefabricated posts when restoring teeth with ovoid,
was reported in 16 of the 23 studies. A 10-year wide, or particularly tapered canals. The lack of
prospective study on GFR posts found that the overall intimate adaptability of these posts to the tooth
failure rate of these posts was 37%, of which 11% were structure compromises their retention in the canal.
due to post debonding (96). From these results, it can In addition, the low success rate of GFR posts
be concluded that the failure might be due to encouraged researchers to look for alternative
weaknesses in the bonding of composite resin to materials to restore ETT. Polyethylene fiber-reinforced
the post and/or to the dentin. Studies (97–99) (PFR) posts made out of ultrahigh-molecular weight
demonstrated that radicular dentin is different from polyethylene woven fiber ribbon (Ribbond, Seattle,
coronal dentin. It contains fewer tubules and forms a WA) have been proposed. It is not a post and core in
thinner hybrid layer than coronal dentin. The efficacy the traditional sense. It is a polyethylene woven fiber
of bonding to radicular dentin could be compromised. ribbon that is coated with a dentin bonding agent and
It is strongly recommended that chemical or dual-cure packed in the canal, where it is then light polymerized
composite resin cement be used to ensure complete into position (107). Another proposed material is a
polymerization of the cement in the canal. customized glass-fiber post (108,109). Costa et al.
Another reason for post debonding could be the lack (108) compared the root fracture strength of single-
of retention between the composite resin cement and rooted premolars restored with GFR posts to the ones
the surface of the GFR post. Studies have shown that restored with customized GFR posts. They concluded
there is a low bond strength (5 to 6 MPa) between the that the customized GFR posts did not show
GFR posts and composite resin (100,101). Differences improved fracture resistance or differences in failure
exist among brands of GFR posts in term of structural patterns when compared to GFR posts. Some authors
characteristics and fatigue resistance (102,103). GFR suggested combining PFR with a customized GFR
posts could present with voids and irregularities within post to restore ETT (110). Custom-milled zirconia
the resin and discontinuity at the interface between the posts have also been suggested as an alternative
fibers and the matrix. It is recommended to condition material to GFR posts in anterior teeth where the use
the surface of GFR posts prior to cementation with of a custom post is indicated. An in vitro study
soft air abrasion (2 bars) and the application of silane comparing a one-piece milled zirconia post and core
(104,105). to different core systems concluded that the mean

78
Restoration of endodontically treated teeth: contemporary concepts and future perspectives

load-bearing capacity of the one-piece milled zirconia posterior teeth that are intact except for the access
post and core was comparable to that of a cast gold opening can be satisfactorily restored with
post and core (111). One explanation as to why composite resin rather than a crown. However, the
these post behaved similarly to cast post and core is the long-term success of this more conservative
absence of an interface between the post and the core, treatment is not known in the presence of heavy
which eliminates the debonding of the core evidenced occlusal forces.
with GFR posts and cores. 4. Posts weaken teeth and they should only be used
The authors believe that until more long-term when the core cannot be adequately retained by
clinical data becomes available, fiber-reinforced resin some other means.
posts should be used with caution because of the wide 5. When crowns are placed on endodontically treated
range of reported failure rates in available clinical teeth, they should encompass 2.0 mm of tooth
studies. structure apical to the core whenever possible since
crown ferrules increase the resistance of teeth to
fracture.
Future directions
6. Until more long-term clinical data becomes
In the future, we foresee that the advancement of available, fiber-reinforced resin posts should be
CAD/CAM technology, milling, and laser printing used with caution due to the wide range of
along with an improvement in digital impression reported failure rates in available clinical studies.
technology will make it possible to more easily and 7. Procedures will become available that preserve or
accurately fabricate customized post and cores from regenerate pulp vitality and may reduce or even
several different materials. In addition, more eliminate the need for restorations. For those teeth
conservative endodontic treatment procedures are that need RCT, even more conservative endodontic
likely to emerge and reduce the need for posts and procedures will be developed; and when combined
crowns. Pulpal regeneration procedures may even with new materials it may not be necessary to place
eliminate or substantially reduce the need for the use crowns on these teeth. When posts are needed due
of crowns and posts and cores. to tooth condition, digital technologies will make it
In future studies of ETT and new technologies, we possible to fabricate customized posts and cores
believe in vitro studies should be performed using from a variety of materials.
fatigue loading and chewing simulation conditions.

References
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