Biomechanical considerations in restoring endodontically

treated teeth
David Amif, DMD,a and Colin Gorfil, BDS (Rand)b
The Maurice and Gabriela GoldschlegerSchool of Dental Medicine, Tel Aviv University, Tel
Aviv, Israel

Various concepts for dental treatment have been established without appropriate
documentation, such as restoration of endodontically treated teeth. Some research-
ers and dentists strongly recommend including a post with the restoration to
strengthen the root. Other studies have indicated that posts may substantially
weaken the roots and should be avoided. An additional approach suggested that the
post did not improve the resistance to fracture during occlusion and did not support
the restoration. Biomechanical problems are analyzed, and a recommended clinical
approachiis presented.(J PROSTHET DENT 1994;71:565-7.)

M any dentists have successfully treated patients Dentin provides a solid base required for the restoration
by means of empiric methods that are not supported by of a tooth, and the structural strength of a tooth depends
sound longitudinal studies. All prosthodontic treatment on the quantity and inherent strength of dentin and the
without exception exacts its “biological price.” Concepts integrity of its anatomic form. After endodontic therapy
for restoring pulpless teeth have been formed from clinical there is an appreciable loss of dentin including anatomic
observation rather than valid scientific investigation. En- structures, cuspal ridges, and the arched roof of the pulpal
dodontically treated teeth present numerous problems be- chamber. This results from restorative or endodontic tech-
cause of coronal destruction from dental caries, fractures, niques that rarely preserve dentin. The fundamental
and previous restorations or endodontic techniques. The problem is the quantity of healthy dentin remaining to re-
result is loss of tooth structure and a reduction in the ca- tain the restoration.
pability of the tooth to resist a myriad of intraoral forces. An increase in the incidence or prevalence of fractures of
Most of the literature concerning restoration of endo- pulpless teeth has been observed clinically, but there have
dontically treated teeth has focused on the post-core unit. been few investigations designed to solve the problem.
The post is inserted in a root canal, and the core is retained Many dentists assume that endodontically treated teeth
by an apical extension and supports the coronal portion are weakened and more prone to fracture because of des-
that simulates a Iprepared tooth to sustain a definite cast iccation or premature loss of fluids supplied by vital pulps.
restoration.le4 This assumption is based on the research of Helfer et al.6
The traditional objective for a post was to strengthen the who reported that there was approximately 10% less col-
weakened tooth. It was assumed that there was a basic lagen-bound water in the tooth. Three years previously
change in the dentin of the pulpless tooth, and immediate Fusayama and Maedal demonstrated that there were no
steps were suggested to strengthen the tooth and improve changes in the modulus of elasticity, hardness, or fracture
resistance to occ:lusal forces. However, these techniques toughness of pulpless teeth. The direct relationship be-
commonly weaken the tooth. tween the amount of remaining coronal tooth structure and
Posts and cores are commonly advocated to (1) protect the ability of the tooth to resist occlusal forces was demon-
or strengthen the tooth against intraoral forces by equally strated in 1956 by Vale,8 followed by Larson et al9 and
distributing torquing forces within the radicular dentin to Mondelli et al.‘O As more tooth structure was removed, the
supporting tissues, thus dispersing the forces along the resistance to occlusal forces was diminished and the possi-
root, and (2) provide retention for the core that replaced bility of fracture increased.
lost coronal tooth structure and retain the restoration.3, 5 Similar results appeared in the literature relating to re-
The validity of these assumptions and the capability of the moval of dentin from a root canal in preparation for a metal
post to provide these essential functions were examined. post. Trope et al.” showed that preparation of the canal
weakened the root and decreased its ability to withstand
forces before insertion of a metal post, and the post further
increased the risk of fracture. These results explained the
Winical Professor,Section of Oral Rehabilitation. data repeated in numerous experiments, where intact
bSeniorClinical Lecturer, Section of Operative Dentistry.
Copyright @1994by The Editorial Council of THE JOURNAL OF pulpless teeth without intraradicular “strengthening” op-
PROSTHETIC DmmmY. posed occlusal forces better than teeth “strengthened” by
0022-3913/94/$3.00+0. 10/l/62792 various posts.12The increase in coronal fractures of endo-

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THE JOURNAL OF PROSTHETIC DENTISTRY ASSIF AND GORFIL

noAnal stress a0
I
Fig. 1. Stress distribution across root in tooth under load. F, Force applied on lingual
surface of tooth. Fulcrum (lower vertical arrow) is on buccal surface and corresponds to
crest of alveolar bone. T, tensile stresses; C, compressive stresses. C and T are maximal at
external surface of root and decrease to zero at center of root or canal (only available place
for post insertion). Center of root or canal is neutral area with regard to force concentra-
tion, and in its given position, post receives minimal stresses under occlusal load and con-
sequently does little to reinforce root under such a load.

dontically treated teeth resulted from the loss of substan- Therefore the post design has limited influence on resis-
tial dentin that included the roof of the pulpal chamber. tance of the tooth to fracturing, and it is not as critical as
Cracks or fractures of roots occurred after endodontic a complete cast crown to brace healthy tooth structure
treatment, especially in those teeth “strengthened” by apical to the core margin.21-25
posts after tooth structure was removed from the cana1.13-17 The metal crown concentrates forces at its margins dur-
Metal posts concentrate unbalanced forces to walls of the ing occlusal loading because of pressure of the crown on the
root. finish line of the tooth preparation when the margin design
The main factor endangering the survival of pulpless is a butt joint type and because of sharp angles that con-
teeth after restoration is loss of dentin during endodontic centrate forces when stressed.26In the metal crown, forces
treatment, while preparing the accesscavity with excessive are concentrated in an area of sharp margins, exerting
widening and additional loss of dentin from post prepara- much pressure on the coronal one third of the root. In the
tion. Therefore it is not necessary to strengthen the tooth, transitional area between a rigid and a less rigid material,
but it is essential not to weaken it unnecessarily! Conser- there is concentration of high stress with increased forces,
vation of dentin is mandatory, and restorations that sup- especially lateral forces. The rigid material or the crown
port this concept are preferable. absorbs more forces and transfers them to the less rigid
Considerable controversy surrounds the need for using material or the tooth.27
coronal-radicular stabilization. There are three basic phi- A post does not noticeably reduce forces at the margins
losophies: (1) Some dentists advocate posts in each tooth of a crown and does not cause a more equal distribution or
after root canal treatment because posts supposedly dispersion of forces along the length of the root.24 There-
strengthen the tooth against occlusal forces.18Tlg (2) Others fore it is questionable whether a post resolves the special
discourage the use of posts claiming that the tooth prepa- needs of the endodontically treated tooth.
ration of the root canal and the insertion of the post results Cylindrical posts have sharp angles at their apical ends,
in substantial weakening of the tooth.l’* I232o (3) A third where forces are concentrated. These posts exert compres-
group believes there is no appreciable improvement in re- sive forces on the root apical to the sharp angles and can
sistance of the tooth to occlusal forces. Use of posts should create dentinal cracks from the tip of the post to the cir-
be avoided when they are not required to provide retention cumference of the root. The preparation of the canal for
for a core.3 this post leaves a thin dentinal wall at the apex of the
Studies conducted directly on post systems are ques- preparation, where concentration of forces is greatest, and
tionable because they do not reflect specific clinical condi- also increases the risk of perforation. Tapered posts exhibit
tions. The core is commonly covered by a complete crown lower concentrations of stress in the apical portion, prob-
with a 2 mm margin on healthy tooth structure, and this 2 ably because of the absence of sharp angles and conserva-
mm bracing provides a ferrule effect that protects the root tion of tooth structures in this area.24,28
against fractures at gingival margins. Lateral forces result in high stress concentrations in
Studies have shown that artificial crowns alter the radicular dentin at the coronal one third of the root.24 The
distribution of forces to roots, and post systems lose signif- rotational axis of the tooth is located at the crest of alve-
icance when the tooth is covered by a complete cast crown. olar bone and the forces are greatest on the circumference

566 VOLUME 71 NUMBER 6

ASSIF AND GORFIL THE JOURNAL OF PROSTHETIC DENTISTRY

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