Endodontic Considerations

for the Restoration of Endodontically 1

Treated Teeth

Brian D. Barsness and Samantha Harris Roach

Abstract

The aim of this chapter is to offer a guide, from the endodontist’s perspective, as
to how root canal-treated teeth should be restored, and to give some clinical
recommendations to help meet these restorative goals. The endodontic and
restorative components of treatment are typically considered as independent
phases. However, when considering the impact of each of these phases on the
long-term prognosis of the tooth, it becomes apparent that both the endodontic
and restorative plans should be considered jointly before treatment is carried out.
With so many options for the timing of treatment, endodontic and restorative
materials, and restoration design, the clinician is left with some difficult decisions
at the treatment planning phase. In this chapter, considerations for the material
characteristics, restoration design, and management of post placement
complications are presented and discussed with respect to their impact on long-
term prognosis. In addition, treatment sequencing, techniques of temporization,
and strategies to prevent coronal microleakage of endodontically treated teeth
are discussed in detail.

1.1 Introduction

The objectives of nonsurgical endodontic therapy have been described classically as

being twofold: biological and mechanical. The biological objectives of endodontic
therapy are focused on removing diseased and infected tissues, as well as eliminat-
ing bacterial products such as endotoxins, from the canal system. The successful

B.D. Barsness (*) • S.H. Roach

Division of Endodontics, Department of Restorative Sciences,
University of Minnesota, Minneapolis, MN, USA
e-mail: bars0020@umn.edu; sroach@umn.edu

© Springer International Publishing Switzerland 2016 1

J. Perdigão (ed.), Restoration of Root Canal-Treated Teeth:
An Adhesive Dentistry Perspective, DOI 10.1007/978-3-319-15401-5_1
2 B.D. Barsness and S.H. Roach

outcome of healing and function, ultimately, depends upon maintaining the coronal
and apical seal of the endodontically treated tooth.
Similarly, when determining the long-term prognosis for a tooth requiring end-
odontic therapy, it has been suggested by the results of several studies (Ray and
Trope 1995; Gillen et al. 2011) that the quality of the coronal restoration after end-
odontic therapy may be as important as the quality of the endodontic treatment
itself. These studies highlight the importance of coronal restoration after endodontic
treatment. It follows that the plan for the definitive occlusal restoration should ide-
ally be established at the time the endodontic therapy is planned. The question then
arises of how these endodontically treated teeth are best restored.
Although there has been a recent trend in endodontic research to promote conser-
vative access and canal preparation (Krishan et al. 2014), the fact remains that some
loss of tooth structure does occur even with conservative endodontic treatment tech-
niques. Additionally, the materials used during root canal therapy may also play a
role in decreasing the integrity of dentin (White et al. 2002). And in many cases,
teeth requiring endodontic therapy present with preoperative tooth structure loss
due to caries or previous restorations, thereby adding complexity to both the end-
odontic and restorative phases of treatment.
The aim of this chapter is to offer a guide, from the endodontist’s perspective, as
to how root canal-treated teeth should be restored, and to give some clinical recom-
mendations to help meet these restorative goals.

1.2 How Does the Coronal Restoration Impact

the Success of Endodontic Treatment?

It is generally accepted that a favorable outcome of endodontic treatment relates to the

technical quality of the canal disinfection and long-term seal of the obturating material.
Several prospective outcome studies (Marquis et al. 2006) have presented an expected
favorable outcome for primary root canal therapy at above 90 % in the absence of pre-
operative apical periodontitis and approximately 80 % in the presence of preoperative
apical periodontitis. These favorable outcomes decrease dramatically in the presence of
inadequate root canal fillings and apical periodontitis (de Chevigny et al. 2008).
Although an adequate coronal seal may be provided by a well-obturated root
canal system, over time an inadequate coronal restoration may allow for the ingress
of microbes and contribute to the recontamination and ultimate failure of the end-
odontic and restorative treatment. There has been debate regarding the priority of
impact regarding such an outcome. Which is more important; an adequate endodon-
tic treatment or an adequate coronal restoration? Could they be equally important?
One early study by Ray and Trope (1995) presented a thought-provoking finding, in
that the effect of the restoration on the radiographic success was statistically greater
than the effect of a good endodontic filling. Adding to the debate, Tronstad et al.
(2000) raised the counterpoint, stating that the quality of the root canal filling was
the most important factor for the outcome of endodontic treatment. If the quality of
the root filling was good, a good restoration improved on the endodontic success
1 Endodontic Considerations for the Restoration of Endodontically Treated Teeth 3

rate by more than 10 %. However, if the quality of the root canal filling was poor,
the quality of the coronal restoration was of no importance for the outcome of the
endodontic treatment.
In a systematic review published by Gillen et al. (2011), the impact of the quality of
coronal restoration and the quality of root canal fillings on success of root canal treat-
ment were considered. Their findings gave support to the notion that all aspects of
treatment have impact on outcome. The odds for healing of apical periodontitis increase
with both adequate root canal treatment and adequate restorative treatment. Poorer
clinical outcomes may be expected with adequate root filling-inadequate coronal resto-
ration and inadequate root filling-adequate coronal restoration. There seemed to be no
significant difference in the odds of healing between these two combinations.
It is difficult at best to understand the risk of unfavorable outcomes where there
exists such variation in treatment protocols and outcome measures. Large, epide-
miological studies can be useful in assessing cohorts to better interpret clinical
decision making and outcomes. One such study by Salehrabi and Rotstein (2004)
retrospectively evaluated the records of 1,126,288 patients having received an initial
endodontic treatment over a period of 8 years. Over this 8-year follow-up period,
97 % of teeth treated by nonsurgical root canal therapy were retained in the oral cav-
ity. Of the teeth requiring extraction, 85 % did not have a permanent crown placed.
So, while it becomes imperative to provide a permanent restoration on the end-
odontically treated tooth, is there an expected rate of unfavorable outcome asso-
ciated with prosthodontic failure? Vire (1991) evaluated and classified failures of
endodontically treated teeth according to prosthodontic, periodontic, and endodon-
tic categories. Teeth that had been crowned had a greater longevity (87 months) than
uncrowned teeth (50 months). Interestingly, of the 116 endodontically treated teeth,
59.4 % were prosthetic failures, primarily due to crown fracture.
Further adding to the complexity of restorative considerations, Iqbal et al. (2003)
performed a retrospective analysis of factors associated with the periapical status of
restored endodontically treated teeth. The benefit and uniqueness of this study were
that the authors explored possible associations between prosthodontic, occlusal,
endodontic, and periodontal factors with the apical health of endodontically treated
teeth. Three factors were significantly associated with the presence of an apical
radiolucency: confirmed occlusal contact, by virtue of the tooth being involved in
group function or the only contact in working side and protrusive movements, and
endodontic filling and crown margins of poor quality. Good-quality endodontic fill-
ing and crown margins improved endodontic outcome. However, occlusal contact
was shown to be associated with failing endodontic treatment, thereby increasing
the range of factors that may influence endodontic outcomes.
In support of the considerations of permanent restoration, restorative material,
and tooth position, Ng et al. (2010) performed a prospective study on the factors
affecting outcomes of nonsurgical root canal treatment. This study evaluated tooth
survival following primary and secondary root canal treatment. Five hundred
seventy-two patients receiving primary root canal treatment and 642 patients receiv-
ing secondary treatment were followed annually between 2 and 4 years. Survival
was determined as the tooth being present and potentially functional at the time of
4 B.D. Barsness and S.H. Roach

recall, whereas failure was determined to be a tooth that had been extracted. As a
result, the 4-year survival following primary and secondary root canal treatment
was 95.4 and 95.2 %, respectively. The restorative factors found to increase the
chance of tooth loss were restoration with a temporary restoration only, restoration
with a cast post and core, lack of two interproximal contacts, and a position as the
terminal tooth in the arch.
In summary, the endodontic and restorative treatment complex poses numerous
clinical considerations to the clinician. As presented, the significance of both end-
odontic and restorative measures relies on thoughtful consideration of material sci-
ence, biomechanical principles, and treatment timeframes. With proper application
of these considerations, the restored endodontically treated tooth can be expected to
serve its intended function for many years.

1.3 When and Why Do Endodontically Treated

Teeth Require Full Coverage?

The need for a full-coverage restoration after endodontic therapy is largely deter-
mined by tooth type, amount of tooth structure loss, and the amount of occlusal
stress on the tooth.

1.3.1 Anterior Teeth

By an in vitro study, Trabert et al. (1978) found that there was no significant differ-
ence in resistance to fracture between untreated anterior teeth and endodontically
treated anterior teeth without full-coverage restoration. In a more clinically based
retrospective study including 1273 endodontically treated teeth, Sorensen and
Martinoff (1984) found that long-term prognosis for anterior teeth, both maxillary
and mandibular, was not increased with full-coverage restoration with or without a
metal post versus simple restoration of the endodontic access. However, some cur-
rent research may indicate that bonded fiber posts may offer some reinforcement (for
more on this concept, see Chap. 6). In most cases, anterior teeth with small proximal
restorations can be restored with lingual resin restorations. To restore these teeth, the
gutta-percha should be seared off at or below the level of the cementoenamel junc-
tion, and the resin should be placed directly on top of the gutta-percha. In anterior
teeth, full coverage may only be necessary when there has been significant loss of
tooth structure prior to endodontic therapy or for esthetic reasons.

1.3.2 Posterior Teeth

In the same study by Sorensen and Martinoff (1984), it was found that full coronal
coverage did significantly improve the long-term success rate for endodontically
treated maxillary and mandibular premolars and molars. The reasoning behind
1 Endodontic Considerations for the Restoration of Endodontically Treated Teeth 5

why endodontically treated molars without cuspal coverage have a decreased

long-term prognosis can be explained by cuspal deflection. When molar teeth with
MO or MOD preparations and endodontic accesses are subjected to occlusal-type
forces, the cusps actually move more than intact teeth (Panitvisai and Messer
1995). Even when the marginal ridges are preserved, the adjacent cusps are still
significantly weakened (Linn and Messer 1994). This type of cuspal deflection
creates stress within the tooth and can lead to catastrophic coronal fractures
(Fennis et al. 2002). Based on these findings, it is suggested that all posterior teeth
receive full-coverage restorations following endodontic treatment. The only
exception to this rule may be the mandibular first premolar. In some cases, when
the lingual cusp of this tooth is underdeveloped, it may not be subject to the wedg-
ing forces of opposing cusps when restored with an occlusal repair of the end-
odontic access (Hansen et al. 1990).

1.3.3 Ferrule

If a crown is deemed necessary after root canal therapy, it is also imperative that the
dentist considers the amount of tooth structure remaining coronal to the alveolar
crest in order to respect biologic width and provide space for a crown margin on
tooth structure. The preservation of intact coronal and radicular tooth structure is
crucial in optimizing the biomechanical behavior of the restored tooth, by allowing
for incorporation of a “ferrule” feature during crown preparation. As stated by
Sorensen and Engelman (1990), a ferrule effect is created by incorporating a 360°
collar of the crown surrounding the parallel walls of the dentin extending coronal to
the shoulder of the preparation. The result is an increased resistance form of the
crown from the extension of dental tooth structure (Fig. 1.1).
Restorative considerations for endodontically treated teeth always include main-
taining an effective coronal seal, protection of the remaining tooth, and restoration
of both function and esthetics. Rosen (1961) defined the concept of extra-coronal
“bracing” as a subgingival collar or apron of gold extending as far as possible
beyond the gingival seat of the core and completely surrounding the perimeter of the
cervical portion of the tooth, serving to prevent fracturing of the root. Rosen and
Partida-Rivera (1996) tested this using 76 extracted maxillary lateral incisors
restored with gold cervical collars and coronally threaded with a post until fracture
occurred. The collar significantly reduced the incidence of root fracture. Libman
and Nicholls (1995) reported that an increased ferrule length increased the resis-
tance to fracture, while an increased post length did not. One significant consider-
ation in the ferrule design is the influence of biologic width. Fugazzotto and
Parma-Benfenait (1984) stated a minimum of at least 3 mm should be left between
the crown margin and the alveolar bone in order to avoid impingement on the coro-
nal attachment of the periodontal connective tissue. In consideration of the restor-
ative dimension then required, at least 3 mm of supra-alveolar tooth structure, in
addition to ferrule height, may be required to provide an effective restorative dimen-
sion (Fig. 1.2).
6 B.D. Barsness and S.H. Roach

Fig. 1.1 Diagram depicting an endodontically

treated tooth restored with a fiber post,
a core buildup, and a crown. Co core buildup,
Fe ferrule effect, Gp residual gutta-percha,
Fp fiber post

Occasionally, the clinician may recommend a crown lengthening procedure

on a tooth with inadequate coronal tooth structure for an effective ferrule height
and adequate biologic width. In some cases, crown lengthening may compro-
mise the supporting bone of adjacent teeth or the crown to root ratio of the tooth
in question. Orthodontic extrusion has been presented as a reasonable alterna-
tive to crown lengthening in these situations. However, this procedure may
require greater length of treatment. With the potential drawbacks of both crown
lengthening and orthodontic extrusion, the clinician may need to decide whether
or not to include a ferrule around the entire diameter of the tooth. This clinical
alternative was evaluated in a literature review of 62 articles by Juloski et al.
(2012). Their findings suggest that if the clinical situation does not allow a 360°
ferrule, an incomplete ferrule is considered to be better than the absence of a
ferrule. Additionally, including a ferrule lowers the impact of the post and core
system, luting agents, and final restoration on the performance of endodonti-
cally restored teeth. This study also found that orthodontic extrusion lead to a
better prognosis than surgical crown lengthening.
1 Endodontic Considerations for the Restoration of Endodontically Treated Teeth 7

Fig. 1.2 Biological

width. A Sulcular
epithelium, B junctional
epithelium, C connective
tissue

1.4 Alternatives to the Ideal Restoration

1.4.1 Cuspal Coverage Amalgam

Although a full-coverage crown is usually the restoration of choice in posterior

teeth, a complex amalgam restoration that covers the cusps has been suggested as a
suitable alternative (Starr 1990) (Fig. 1.3). This type of restoration may be indicated
in cases in which cost of the crown is prohibitive for the patient or if insufficient
tooth structure remains coronal to the crest of bone to maintain biologic width and
a crown ferrule. With this type of cuspal coverage restoration, all of the remaining
cusps are reduced 2 mm and rebuilt with amalgam. It has also been suggested that,
if the pulp chamber height is less than 4 mm, amalgam should be condensed 2–4 mm
into each canal to increase the fracture resistance of the amalgam restoration
(Nayyar et al. 1980; Kane et al. 1990). Although the long-term prognosis for this
type of complex amalgam restoration may not be as favorable as a full-coverage
crown (Martin and Bader 1997), Mondelli et al. (1998) found that these
8 B.D. Barsness and S.H. Roach

a b

c d

e f

g
1 Endodontic Considerations for the Restoration of Endodontically Treated Teeth 9

cusp-covering amalgam restorations increase the fracture resistance in comparison

to endodontically accessed posterior teeth without cuspal coverage. Smales and
Hawthorne (1997) also found that complex amalgam restorations had a mean sur-
vival rate of 14.6 years. Therefore, this type of restoration can serve as a good inter-
mediate restoration to protect the tooth until the patient can proceed with a crown or
crown lengthening if indicated.

1.4.2 Cuspal Coverage Composite

Like the cuspal coverage amalgam restoration, a composite restoration covering

the cusps has also been suggested as an alternative to a crown for endodontically
treated posterior teeth. In a laboratory study examining the fracture resistance of
endodontically treated molars with direct or indirect cuspal coverage composite
restorations, Plotino et al. (2008) selectively covered the mesial cusps and restored
the mesial marginal ridges. They found that selectively covering cusps did not
restore the strength of the cusps to their preoperative state. However, in an ex vivo
study on endodontically treated premolars, Mondelli et al. found that restoring all
cusps with composite significantly increased the fracture resistance (Mondelli
et al. 2009). Therefore, reducing the entire occlusal surface and all cusps 2 mm
and restoring the tooth in composite may offer a suitable option for restoring end-
odontically posterior teeth especially in the premolar region where a metallic res-
toration may not be as esthetically acceptable. However, a review of the literature
indicates that amalgam is superior to composite for posterior tooth restorations in
terms of long-term survivability of the restoration (Kovarik 2009). This may again
indicate that a cuspal coverage composite may reinforce the strength of the tooth
and serve as a good transitional restoration until a crown can ultimately be placed
to protect the tooth long term.

Fig. 1.3 Cuspal coverage amalgam (Courtesy of Dr. Scott B. McClanahan, University of
Minnesota School of Dentistry). (a) Radiographic image showing tooth #19 root canal completed
and coronal temporary restoration in place. (b) Clinical image showing tooth #19 root canal
completed and coronal temporary restoration in place. (c) Temporary restoration is removed,
occlusal tooth structure is reduced 2 mm, and mesial and distal box preparations are created. (d)
Occlusal view of tooth preparation for amalgam cuspal coverage. (e) Completed amalgam cuspal
coverage restoration (occlusal). (f) Completed amalgam cuspal coverage restoration (lingual). (f)
Radiographic image showing amalgam cuspal coverage in place. Note amalgam condensed into
distal canal for retention
10 B.D. Barsness and S.H. Roach

1.5 What Are the Guidelines and Techniques

for Post Preparations?

Once it is decided that a post is indicated, the practitioner must consider the timing
of the post placement, the design (length, width, taper, etc.), and the best location to
place the post within the tooth in question.

1.5.1 Timing of Post Space Preparation

Sequencing of the restoration of endodontically treated teeth may seem straightfor-

ward until one considers implementing provisional treatment steps, all while main-
taining the integrity of the coronal and apical seals established during endodontic
treatment. One such challenge exists with post space preparation. When a post
space is determined to be necessary for restoration of the tooth (Goerig and
Mueninghoff 1983), there is considerable debate regarding the timing of post space
preparation with respect to coronal microleakage and apical seal. Immediate
removal of the coronal sections of the root canal filling may be accomplished using
heated pluggers or an electronic thermal tip. Delayed post space preparation, how-
ever, may require the use of rotary instrumentation in combination with solvent
softeners. Earlier studies by Dickey et al. (1982) suggest that immediate post space
preparation significantly increased apical leakage due to inadequate sealer setting
time. Portell et al. (1982), however, reported that the removal of gutta-percha was
more difficult with delayed post space preparation. They hypothesized that this
may have contributed to greater apical leakage with delayed post space preparation
than with immediate post space preparation in their study. More recent studies have
indicated less apical leakage associated with immediate post space preparation, as
well as immediate post and core placement (Demarchi and Sato 2002; Solano et al.
2005). With increased acceptance of contemporary obturation techniques, such as
continuous warm gutta-percha backfill and the use of resin sealers, it seems pru-
dent for the restoring clinician to consider immediate post space preparation, rather
than delayed, given the convenience and timeliness afforded by these material and
techniques.

1.5.2 Post Length

The length of the post space preparation is determined by both the mechanical
retention requirements and the need to maintain an adequate root canal filling
dimension for an apical seal. In vitro studies using pressurized dye leakage systems
have suggested caution is advised when making the assumption that a minimal api-
cal obturation dimension is equivalent to the apical seal obtained with the intact root
canal filling (Abramovitz et al. 2001). The authors of these studies reported that a
retained apical filling dimension of 5 mm was inferior to that of the intact root canal
filling. Additionally, reduction of the fillings to 3 mm resulted in an unpredictable
1 Endodontic Considerations for the Restoration of Endodontically Treated Teeth 11

Fig. 1.4 Illustration of

intracanal and orifice
barriers. (1) Represents an
endodontically treated
tooth restored with a
full-coverage crown, post
and core, and use of an
intracanal barrier (B); (2)
Represents an B
endodontically treated
tooth restored with a
cuspal coverage restoration
and an orifice barrier (B)
(Illustration adapted from
Mavec et al. (2006))
B

1 2

seal. Portell et al. (1982) found that 7 mm of remaining gutta-percha in the apical
fill resulted in less leakage than 3 mm, reaffirming the need to maintain an adequate
apical dimension of root canal filling material.
Occasionally, one is confronted with the dilemma of a short crown-root ratio
potentially limiting the apical filling dimension as a compromise to maximizing post
length retention form. A novel approach presented by Mavec et al. (2006) incorpo-
rates the use of an intracanal glass ionomer barrier to assist in the resistance to micro-
leakage resulting from an inadequate dimension of apical filling material. In this
in vitro study, for teeth requiring a post and core that allowed for only 3 mm of remain-
ing gutta-percha, a 1 mm glass ionomer barrier placed over the remaining gutta-per-
cha reduced the risk of recontamination of the apical filling material (Fig. 1.4).
In addition to maintaining adequate apical canal filling dimensions, another post
length consideration relates to the influence of post fit or “form-congruence” as
presented by Schmage et al. (2005). This concept of form-congruence aims to maxi-
mize adaptation of the post to the surrounding root canal walls, in order to facilitate
stress distribution along the canal wall. This effect was observed in studies by
Sorensen and Engelman (1990) with tapered cast post and cores and crowns luted
with zinc phosphate cement. This was not, however, observed with parallel-sided
posts and post space preparations. There may be an effect of destabilization by cre-
ating a post space that transforms a naturally conical canal space into a cylindrical
form. Kishen et al. (2004) have suggested that not only the thickness of the dentin
wall stabilizes the root but also the presence of inner dentin with a lower elastic
modulus than the more mineralized outer dentin. This is particularly important
when large diameter post space preparations are created to transform an oval canal
12 B.D. Barsness and S.H. Roach

into a cylindrical form for the purpose of circumferential post fit, thereby removing
critical dimensions of inner dentin. Selecting a post that closely approximates the
existing canal form preserves the inner dentin and elastic modulus but may be asso-
ciated with poor form-congruence. Büttel et al. (2009) reported that the fracture
resistance of teeth restored with fiber-reinforced composite posts and direct resin
composite crowns without ferrules was not influenced by post fit within the root
canal, irrespective of the post length. This implies that excessive post space prepara-
tion aimed at producing an optimal circumferential post fit is not required to improve
fracture resistance of the root.

1.5.3 Post Placement Complications and Management

Although posts may be indicated in certain clinical situations, the creation of the
post space adds a certain degree of risk to the restorative procedure. These risks
include contamination of the root canal system, root perforation, and weakening of
root dentin leading to vertical root fracture, all of which can affect the long-term
prognosis for the tooth.
An important factor in root fracture subsequent to post placement is the reduc-
tion of root dentin thickness during post space preparation (Hunter et al. 1989). In a
clinical study, Cohen et al. (2003) found that 91 % of diagnosed vertical root frac-
tures were due to inadequately designed posts (either too wide or too long), indicat-
ing that the thickness of root dentin had been overly reduced. Therefore, it is
important that when creating a post space, the practitioner is as conservative as
possible with the removal of dentin to prevent the root weakening due to canal over-
enlargement (Tjan and Whang 1985). Using solvents, such as chloroform or heat to
remove gutta-percha, will facilitate creating a post space without removing addi-
tional dentin or affecting the apical seal as compared to rotary removal techniques
(Grecca et al. 2009). However, there is evidence that chloroform, and other solvents
used to soften gutta-percha (halothane or xylene), may decrease the microhardness
of dentin (Rotstein et al. 1999). Therefore, heat may be the safest way to remove
gutta-percha for post space preparation, as long as the practitioner is mindful of the
possible damage heat can produce on the supporting tissues if the temperature on
the external root surface is significantly raised (Eriksson and Albrektsson 1983).
Generally, however, electronic heat sources are safe to use within the canal at tem-
peratures of around 200 °C (Silver et al. 1999) and with short (4 s) intervals of heat-
ing (Buchanan 2007).
When the canal space has already been subject to overenlargement either by iatro-
genic error or by a previous provider, it may be possible to reinforce the root dentin by
using a resin-reinforced dowel system (Saupe et al. 1996). By this method, a smooth
light transilluminating post is placed into the overenlarged canal space, and resin is
compacted around it against the canal walls. The resin is cured by transmitting light
through the post pattern. The post pattern is then removed, the post space is refined
within the cured resin, and a permanent post is cemented. Saupe et al. (1996) found
this technique to increase fracture resistance in endodontically treated thin-walled
teeth. There is evidence, though that this strengthening effect may be reduced over
1 Endodontic Considerations for the Restoration of Endodontically Treated Teeth 13

time with occlusal forces and as the bond between the dentin and the resin weakens
(Heydecke et al. 2001). For more on this technique and concept, see Chap. 5.
When post-preparation burs are misdirected away from the canal space or when
large post drills are used in areas of thin root dentin, there is risk that the post drill
can perforate the root dentin and create a communication between the canal space
and the external surface of the root (Fig. 1.5). In a radiographic study, Kvinnsland
et al. (1989) observed that more than half of the perforations noted in their cases
were attributed to post-preparation procedures. The main complication that arises
from perforations is the potential for secondary inflammatory periodontal involve-
ment and loss of attachment, eventually causing tooth loss (Wong and Cho 1997).
Bacterial infection originating either from the root canal or the periodontal tissues,
or both, prevents healing and brings about inflammatory reactions in the tooth-sup-
porting tissues. Conditions such as suppurations, abscesses, sinus tracts, and bone
resorptive processes may follow (Tsesis and Fuss 2006). It follows that the goal of
repairing a perforation is to achieve a tight and permanent seal that will prevent
bacteria and their by-products in the root canal from entering the surrounding peri-
odontal tissues. As far as prognosis for the repair of perforations, the chance of
healing of the supporting tissues is improved if the perforation is small, if it occurs
below the level of the bone, and if it is repaired immediately under aseptic condi-
tions, preventing bacterial contamination (Fuss and Trope 1996).
Materials that have been used to repair perforations include amalgam (Benenati
et al. 1986; Balla et al. 1991), gutta-percha (Petersson et al. 1985; Benenati et al.
1986; Kvinnsland et al. 1989), tricalcium phosphate (Sinai et al. 1989; Balla et al.
1991), zinc oxide eugenol (Bramante and Berbert 1987), Super EBA (Bogaerts
1997), dentin chips (Petersson et al. 1985), Cavit (Sinai et al. 1989), hydroxyapatite
(Balla et al. 1991), glass ionomer cement (Fuss et al. 2000), and mineral trioxide
aggregate (MTA) (Holland et al. 2001). Currently MTA is widely used as a perfora-
tion repair material due to results of in vitro studies demonstrating its sealing ability
(Nakata et al. 1998; Daoudi and Saunders 2002) and biocompatibility (Hakki et al.
2012) and case reports demonstrating its clinical success in these types of repairs
(Arens and Torabinejad 1996; Main et al. 2004; Mente et al. 2010). Biodentine
(Septodont, USA) is a calcium silicate-based material that has been recently advo-
cated as another root perforation repair material. Although in vitro studies have
shown Biodentine to exhibit biocompatibility (Mori et al. 2014), there is a lack of
evidence supporting its clinical success as a perforation repair material at this time
(Malkondu et al. 2014). Another recently introduced perforation repair material is
Endosequence Root Repair Material (ERRM). Initial investigations have suggested
that ERRM may offer a seal superior to that created by MTA (Jeevani et al. 2014)
and provide a similar biocompatibility (AlAnezi et al. 2010). Yet again, there are
few clinical cases or long-term clinical studies that have been published using this
material as a perforation repair material. Therefore, clinical success and long-term
prognosis associated with ERRM are unknown at this time.
In some cases, especially in large perforations, it may be difficult to avoid
pushing repair materials beyond the root and into the periodontal ligament space,
possibly changing the architecture of the supporting structures and impairing the
healing process. In these cases, the use of an internal matrix using a biocompatible
14 B.D. Barsness and S.H. Roach

a b

c d

Fig. 1.5 (a) Digital radiographic image of tooth #27 showing fiber post placement mesial to canal
space. (b) Cone beam CT image showing post perforating facial aspect of root. (c) Surgical clinical
image showing fiber post perforating mesial-facial aspect of root. (d) Surgical clinical image
showing root end resection and repair of perforation (Clinical photos attributed to Dr. Cynthia
Tyler, University of Minnesota Division of Endodontics)
1 Endodontic Considerations for the Restoration of Endodontically Treated Teeth 15

material has been advocated to help maintain repair materials inside the tooth and
preserve the health and structure of the supporting bone and periodontal ligament.
This technique, as described by Bargholz (2005), involves placing pieces of resorb-
able collagen membrane through the perforation and into the defect in bone. The
collagen serves to recreate the outer surface of the root. MTA or another perforation
repair material can then be layered against the collagen barrier without great risk of
extruding the repair material beyond the root surface. After the perforation is
repaired, the collagen membrane will be resorbed within a few weeks.
In the case of a large perforation, a perforation as a result of resorption, a perfora-
tion that does not heal after nonsurgical repair, or a perforation that is inaccessible
from an orthograde approach, surgical repair of the root perforation may be an
option (Tsesis and Fuss 2006). Generally this surgical repair consists of a reflecting
the gingival tissue, accessing the area of the perforation via osteotomy if necessary,
removing any inflammatory tissue around the site of perforation, and repairing the
perforation with a perforation repair material, such as MTA, to create a permanent
seal. It has also been suggested that guided tissue regeneration, by the use of a bone
allograft and a membrane, may promote healing in surgical perforation repair sites
where a significant amount of bone was lost due either to the inflammatory process
or the osteotomy created to access the perforation area (Dean et al. 1997).
The risk of creating thin root dentin or root perforation is higher in certain teeth
or roots where anatomic considerations, such as dentin thickness, canal shape and
size, and external root shape are a factor (Sathorn et al. 2005). Mandibular incisors
generally have a ribbon-shaped root, with more thickness of dentin in the buccal
lingual dimension and very thin dentin in the mesial-distal dimension. With a round
post space preparation, therefore, there is risk of thinning or even perforating the
mesial or distal root dentin (Gluskin et al. 1995). Maxillary premolars with two
roots also present an area of thin dentin on the furcal aspect of the buccal root
(Lammertyn et al. 2009), making the palatal root the more ideal location for a post.
Similarly, when a post is necessary in a maxillary molar, it is suggested that it be
placed in the palatal root due to greater bulk of tooth structure in that root (Schwartz
and Robbins 2004); however, the operator must also take into consideration the api-
cal curvature of the palatal root (Bone and Moule 1986). Rigid post drills and posts
will not follow root curvatures, so there is risk of perforating at the inner aspect of
the curvature if the post drill used beyond the point of curvature. In the mandibular
molar, the “danger zone” for perforation is on the distal aspect of the mesial root,
just below the furcation (Berutti and Fedon 1992). Therefore, it is generally recom-
mended to place posts in the distal root in these teeth (Schwartz and Robbins 2004).
However, recent studies have shown that the furcal aspect of both the mesial and
distal roots in the mandibular first molar can present areas of extremely thin dentin
(Harris et al. 2013), so again it is advisable to remove as little tooth structure as pos-
sible when creating post space in this tooth, even in the distal root.
Additionally, post design can contribute to the risk for root fracture. Active
threaded posts induce more stress into the dentin and carry with them a higher risk
of root fracture (Felton et al. 1991). Threaded posts, therefore, should only be used
in teeth with substantial remaining root thickness (Schwartz and Robbins 2004).
16 B.D. Barsness and S.H. Roach

1.6 Coronal Microleakage

1.6.1 Orifice Barriers

Due to time constraints or patient scheduling conflicts, it may not always be possi-
ble to place a permanent coronal restoration immediately after root canal obturation.
However, in order to provide an environment conducive to healing following root
canal therapy, great care must be taken to ensure adequate sealing of coronal and
apical structures. If the canal space is not sealed adequately, then microbial organ-
isms, or their toxins, may induce an inflammatory response and lead to persistent
disease. Obturated root canal systems may be recontaminated with microbes, or
toxins, in various ways. A delay in placing a permanent coronal restoration follow-
ing root canal treatment may allow coronal microleakage of the temporary filling
material to occur. While oxide eugenol materials, such as Cavit (3M ESPE), have
good sealing properties, there is a limit to the duration of their effectiveness.
Fracturing of the coronal restoration, or tooth, resulting in exposure of the endodon-
tic filling material and preparation of a post space in which the resulting dimension
of apical filling material is less than adequate to maintain a seal are additional means
of microleakage. The factor that the clinician has the most control over in regard to
preventing recontamination of the root canal system is the use of a rubber dam dur-
ing post space fabrication and coronal restoration. In a recent retrospective study by
Goldfein et al. (2013), it was reported that when no rubber dam was used during
post placement, 73.6 % of cases were considered successful at follow-up. 93.3 % of
cases were considered successful when a rubber dam was used, and this difference
was found to be statistically significant.
The impact of coronal microleakage as it relates to clinical outcome is not new.
Allison et al. (1979) suggested the possibility that a poor coronal seal might contrib-
ute to clinical failure. In the following years, in vitro dye leakage studies by Swanson
and Madison (1987) suggested that a significant amount of coronal microleakage is
evident after only 3 days of exposure of gutta-percha to artificial saliva. The extent
of microleakage in that study was similar at 3 days and 8 weeks, implying that coro-
nal microleakage may be a rapid and significant event. Further studies have rein-
forced the significance of coronal microleakage. Torabinejad et al. (1990) found that
50 % of single-rooted teeth were contaminated with bacteria along the whole length
of the root after 19 days or 42 days, depending on the contaminating microbial spe-
cies introduced. In another study, Magura et al. (1991) assessed salivary penetration
through obturated root canals and found that gutta-percha exposed coronally for up
to 3 months should be retreated prior to placement of the definitive restoration. So,
while the critical timeframe of coronal microleakage may be debated, the significant
impact of adequate coronal seal in preventing microleakage is clearly evident.
As an ever-increasing range of restorative materials for post and core restorations
are made available, it becomes a challenge to assess which materials will best pro-
tect the integrity of the sealed crown-root complex. Earlier studies by Bachicha
et al. (1998) aimed to measure the microleakage of a stainless steel post system and
a carbon-fiber post system luted with a range of cements, including zinc phosphate,
1 Endodontic Considerations for the Restoration of Endodontically Treated Teeth 17

glass ionomer, Panavia-21 (Kuraray Noritake), and C&B Metabond (Parkell Inc.).
Statistical analysis of this fluid filtration study model showed that there was signifi-
cantly more microleakage associated with the zinc phosphate cement than those
cemented with dentin bonding cements. In a different study approach, Freeman
et al. (1998) evaluated the number of mechanical load cycles required to cause pre-
liminary failure of full cast crown restorations having standardized minimal ferrule
height and three different post systems, including passive stainless steel ParaPost
(Coltene) and dentin bonding composite core, threaded #2 Flexi-Post (Essential
Dental Systems Inc.) and dentin bonding composite, and a custom cast post and
core luted with zinc phosphate cement. Their findings suggest that in teeth restored
with a post and core, the occurrence of preliminary failure is clinically undetectable,
yet it allows leakage between the restoration and tooth that may extend down the
prepared post space. None of the post and core systems used in their study surpassed
the others in preventing or delaying preliminary failure. Increased ferrule length,
however, greatly improved resistance to cyclic loading when an additional
10,000 cycles had been applied.
The use of intracoronal orifice barriers to prevent recontamination of the canal
system is a restorative consideration with much support in the literature. Not only as
an adjunctive measure against failure of a temporary restoration but also in consid-
eration of canal morphology of multi-canal teeth. As Saunders and Saunders (1994)
reminded us, it is very important to adequately seal the coronal part of the root canal
system, due to the fact that molars have accessory canals that can be present in the
floor of the pulp chamber. This could cause bacterial leakage into the furcation
region. Excess sealer and gutta-percha should be removed to the level of the canal
orifices and the pulp chamber sealed with a restorative material. In an in vitro bacte-
rial leakage study by Chailertvanitkul et al. (1997), a 1 mm layer of Vitrabond
(resin-modified glass ionomer liner, currently known as Vitrebond, 3M ESPE)
placed over canal orifices of endodontically treated multi-rooted teeth that had been
stored at 100 % humidity for 2 years was evaluated. Teeth that had been sealed with
Vitrabond showed significantly less leakage of two types of bacteria apically
through the gutta-percha obturant than those without a barrier after just 60 days. In
another study by Maloney et al. (2005), the authors took into consideration the
effect of thermocycling on a 1 or 2 mm glass ionomer intracoronal barrier in pre-
venting coronal microleakage. A significant reduction in coronal microleakage was
observed with the use of either a 1 or 2 mm intracoronal barrier.

1.7 Indications for the Use of Temporary Materials

in Endodontics

1.7.1 Physical and Chemical Differences of the Temporary

Restorations Used in Endodontics

The temporization of an endodontically treated tooth is a critical and fundamental

step during the course of both treatment and restoration. The quintessential goal of
18 B.D. Barsness and S.H. Roach

temporization is to maintain a favorable environment for continued healing while

allowing for efficient re-accessing of the chamber space. This is accomplished most
commonly by using one or more temporary restorative materials in conjunction
with a sterile cotton pellet or endodontic sponge barrier over the canal orifices.
Three of the more commonly used temporary materials are IRM (Dentsply Caulk),
Cavit (3M ESPE), and T.E.R.M (Dentsply Maillefer). The choice of materials and
considerations of remaining tooth structure, as well as anticipated restorative time-
frame, become essential decisions prior to temporization.
Intermediate restorative material (IRM) consists of a powder containing zinc
oxide and polymethacrylate mixed with a eugenol liquid. The addition of polymeth-
acrylate to the zinc oxide eugenol mixture provides the material with improved
compressive strength, abrasion resistance, and hardness (Naoum and Chandler
2002). These attributes make IRM a strong enough material to restore marginal
ridges and to withstand occlusal forces. However, the seal against coronal leakage
provided by IRM is less effective than some of the other temporary materials avail-
able (Barkhorder and Stark 1990).
Cavit consists of zinc oxide, calcium sulfate, zinc sulfate, glycolacetate, polyvi-
nyl acetate resins, polyvinyl chorine acetate, triethanolamine, and pigments. Cavit
sets and expands upon contact with moisture providing an efficient fluid seal which
may be easily removed for continued treatment. The required thickness of Cavit to
provide an efficient fluid seal was evaluated by Pisano et al. (1998). In their bacterial
leakage study, it was determined that a minimum thickness of 3.5 mm Cavit pro-
vided an adequate microbial barrier for 90 days in 85 % of the study samples. In
comparison, the same thicknesses of IRM and Super EBA provided an adequate
microbial barrier in only 65 % of the samples. One obvious limitation to Cavit is
with its relatively poor wear characteristics and fracture resistance when needing to
restore marginal ridges.
Taking advantage of both the effective sealing properties of Cavit and the supe-
rior wear characteristics of IRM, the use of a “sandwich” technique combining both
materials has been advocated (Hagemeier et al. 1990). By this technique, 3.5 mm
Cavit is placed above the cotton pellet to seal off the chamber from leakage, and
IRM is then placed on top of the Cavit to provide the resistance fracture and wear
(Fig. 1.6).
T.E.R.M., a temporary endodontic restorative material, is one of the newer
options for temporization of the endodontic access. T.E.R.M. is a predosed visible
light-cured resin containing urethane dimethacrylate polymers, inorganic radi-
opaque fillers, organic pre-polymerized filler, pigment, and initiators. As reported
by Hansen and Montgomery (1993) in a 5-week thermocycling and leakage study,
T.E.R.M. performed better than IRM. At 1, 2, and 3 mm thicknesses, T.E.R.M.
maintained as tight a seal as at 4 mm, suggesting the usefulness when 4 mm is not
obtainable when considering other materials such as Cavit or IRM.
While in vitro studies are often compelling, the inability to truly model condi-
tions in vivo may call into question the appropriateness of their findings. A higher
level of evidence is provided by clinical studies, such as with a study by Beach et al.
1 Endodontic Considerations for the Restoration of Endodontically Treated Teeth 19

Fig. 1.6 Temporary

restoration, “sandwich”
technique. (1) IRM 1
(Dentsply), (2) Cavit (3M
ESPE), approximately
3.5 mm, (3) cotton spacer
2

(1996) comparing Cavit, IRM, and T.E.R.M. restorative materials for bacterial leak-
age in a human clinical study. The access openings of 51 endodontically treated
teeth were randomly sealed with a 4 mm thickness of one of the three materials.
Following 3 weeks from placement, microbial sampling was conducted both aerobi-
cally and anaerobically. Positive growth occurred in 4 of 14 T.E.R.M. samples and
in 1 of 18 IRM samples. Cavit did not demonstrate leakage in any of the teeth
sampled. In this study, Cavit provided a significantly better seal than T.E.R.M. over
the study period.

Conclusion
The long-term prognosis for an endodontically treated tooth depends not only on
the disinfection of the root canal space but continued protection of that space
from bacterial contamination with a high-quality coronal restoration. Whether or
not full coronal coverage or a post is indicated or if temporization is necessary
prior to definitive restoration, it is important to consider techniques for protecting
the root canal system from infection, all while preserving crown and root dentin,
to insure the best enduring health and strength of the tooth.
20 B.D. Barsness and S.H. Roach

References
Abramovitz S, Lev R, Tamse A, Metzger Z (2001) The unpredictability of seal after post space
preparation: a fluid transport study. J Endod 27:292–295
AlAnezi AZ, Jiang J, Safavi KE, Spangberg LSW, Zhu Q (2010) Cytotoxicity evaluation of endo-
sequence root repair material. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
109:e122–e125
Allison DA, Weber CR, Walton RE (1979) The influence of the method of canal preparation on the
quality of apical and coronal obturation. J Endod 10:298–304
Arens D, Torabinejad M (1996) Repair of furcal perforations with mineral trioxide aggregate: two
case reports. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 82:84–88
Bachicha WS, DiFiore PM, Miller DA, Lautenschlager EP, Pashley DH (1998) Microleakage of
endodontically treated teeth restored with posts. J Endod 24:703–708
Balla R, Lomonaco C, Skribner J, Lin L (1991) Histological study of furcation perforations treated
with tricalcium phosphate, hydroxylapatite, amalgam and Life. J Endod 17:234–238
Bargholz C (2005) Perforation repair with mineral trioxide aggregate: a modified matrix concept.
Int Endod J 38:59–69
Barkhorder RA, Stark MM (1990) Sealing ability of intermediate restorations and cavity design
used in endodontics. Oral Surg Oral Med Oral Pathol 69:99–101
Beach C, Calhoun J, Bramwell D, Hutter J, Miller G (1996) Clinical evaluation of bacterial leak-
age of endodontic temporary filling materials. J Endod 22:459–462
Benenati FW, Roane JB, Biggs JT, Simon JH (1986) Recall evaluation of iatrogenic root perfora-
tions repaired with amalgam and gutta-percha. J Endod 12:161–166
Berutti E, Fedon G (1992) Thickness of cementum/dentin in mesial roots of mandibular first
molars. J Endod 18:545–548
Bogaerts P (1997) Treatment of root perforations with calcium hydroxide and SuperEBA cement:
a clinical report. Int Endod J 30:210–219
Bone J, Moule AJ (1986) The nature of curvature of palatal canals in maxillary molar teeth. Int
Endod J 19:178–186
Bramante CM, Berbert A (1987) Root perforations dressed with calcium hydroxide or zinc oxide
and eugenol. J Endod 13:392–395
Buchanan LS (2007) Continuous wave of condensation technique for enhanced precision. Endod
Ther 7:23–24
Büttel L, Krastl G, Lorch H, Naumann M, Zitzmann NU, Weiger R (2009) Influence of post fit and
post length on fracture resistance. Int Endod J 42:47–53
Chailertvanitkul P, Saunders WP, Saunders EM, MacKenzie D (1997) An evaluation of microbial
coronal leakage in the restored pulp chamber of root-canal treated multi-rooted teeth. Int Endod
J 30:318–322
Cohen S, Blanco L, Berman L (2003) Vertical root fractures clinical and radiographic diagnosis.
J Am Dent Assoc 134:434–441
Daoudi MF, Saunders WP (2002) In vitro evaluation of furcal perforation repair using mineral
trioxide aggregate or resin modified glass ionomer cement with and without the use of the
operating microscope. J Endod 28:512–515
de Chevigny C, Dao TT, Basrani BR, Marquis V, Farzaneh M, Abitbol S, Friedman S (2008) Treatment
outcome in endodontics: the Toronto study–phase 4: initial treatment. J Endod 34:258–263
Dean JW, Lenox RA, Lucas FL, Culley WL, Himel VT (1997) Evaluation of a combined surgical
repair and guided tissue regeneration technique to treat recent root canal perforations. J Endod
23:525–532
Demarchi MGA, Sato EFL (2002) Leakage of interim post and cores used during laboratory
fabrication of custom posts. J Endod 28:328–329
Dickey DJ, Harris GZ, Lemon RR, Luebke RG (1982) Effect of post space preparation on apical
seal using solvent techniques and Peeso reamers. J Endod 8:351–354
1 Endodontic Considerations for the Restoration of Endodontically Treated Teeth 21

Eriksson AR, Albrektsson T (1983) Temperature threshold levels for heat-induced bone tissue
injury: a vital-microscopic study in the rabbit. J Prosthet Dent 50:101–107
Felton DA, Webb EL, Kanoy BE, Dugoni J (1991) Threaded endodontic dowels: effect of post
design on incidence of root fracture. J Prosthet Dent 65:179–187
Fennis WM, Kuijs RH, Kreulen CM, Roeters FJ, Creugers NH, Burgersdijk RC (2002) A survey
of cusp fractures in a population of general dental practices. Int J Prosthodont 15:559–563
Freeman MA, Nicholls JI, Kydd WL, Harrington GW (1998) Leakage associated with load
fatigue-induced preliminary failure of full crowns placed over three different post and core
systems. J Endod 24:26–32
Fugazatto PA, Parma-Benfenait S (1984) Pre-prosthetic periodontal considerations. Crown length
and biologic width. Quintessence Int 12:1247–1256
Fuss Z, Abramovitz I, Metzger Z (2000) Sealing furcation perforations with silver glass ionomer
cement: an in vitro evaluation. J Endod 26:466–468
Fuss Z, Trope M (1996) Root perforations: classification and treatment choices based on prognos-
tic factors. Endod Dent Traumatol 12:255–264
Gillen BM, Looney SW, Gu LS, Loushine BA, Weller RN, Loushine RJ, Pashley DH, Tay FR
(2011) Impact of the quality of coronal restoration versus the quality of root canal fillings on
success of root canal treatment: a systematic review and meta-analysis. J Endod 37:895–902
Gluskin AH, Radke RA, Frost SL, Watanabe LG (1995) The mandibular incisor: rethinking guide-
lines for post and core design. J Endod 21:33–37
Goerig AC, Mueninghoff LA (1983) Management of the endodontically treated tooth. Part II:
technique. J Prosthet Dent 49:491–497
Goldfein J, Speirs C, Finkelman M, Amato R (2013) Rubber dam use during post placement influ-
ences the success of root canal-treated teeth. J Endod 12:1481–1484
Grecca FS, Rosa AR, Gomes MS, Parolo CF, Bemfica JR, Frasca LC, Maltz M (2009) Effect of
timing and method of post space preparation on sealing ability of remaining root filling
material: in vitro microbiological study. J Can Dent Assoc 75:583
Hagemeier MK, Cooley RL, Hicks JL (1990) Microleakage of five temporary endodontic restor-
ative materials. J Esthet Dent 2:166–169
Hakki SS, Bozkurt SB, Ozcopur B, Purali N, Belli S (2012) Periodontal ligament fibroblast response to
root perforations restored with different materials – a laboratory study. Int Endod J 45:240–248
Hansen EK, Asmussen E, Christiansen NC (1990) In vivo fractures of endodontically treated pos-
terior teeth restored with amalgam. Endod Dent Traumatol 6:49–55
Hansen SR, Montgomery S (1993) Effect of restoration thickness on the sealing ability of TERM.
J Endod 9:448–452
Harris SP, Bowles WR, Fok A, McClanahan SB (2013) An anatomical investigation of the man-
dibular first molar using micro-computed tomography. J Endod 39:1374–1378
Heydecke G, Butz F, Strub JR (2001) Fracture strength and survival rate of endodontically treated
maxillary incisors with approximal cavities after restoration with different post and core
systems: an in-vitro study. J Dent 29:427–433
Holland R, Filho JA, de Souza V, Nery MJ, Bernabe PF, Junior ED (2001) Mineral trioxide aggre-
gate repair of lateral root perforations. J Endod 27:281–284
Hunter AJ, Feiglin B, Williams JF (1989) Effects of post placement on endodontically treated
teeth. J Prosthet Dent 62:166–172
Iqbal MK, Johansson AA, Akeel RF, Bergenholtz A, Omar R (2003) A retrospective analysis of
factors associated with the periapical status of restored, endodontically treated teeth. Int
J Prosthodont 16:31–38
Jeevani E, Jayaprakash T, Bolla N, Vemuri S, Sunil CR, Kalluru RS (2014) Evaluation of sealing
ability of MM-MTA, endosequence, and biodentine as furcation repair materials: UV
spectrophotometric analysis. J Conserv Dent 17:340–343
Juloski J, Radovic I, Goracci C, Vulicevic ZR, Ferrari M (2012) Ferrule effect: a literature review.
J Endod 38:11–19
22 B.D. Barsness and S.H. Roach

Kane JJ, Burgess JO, Summitt JB (1990) Fracture resistance of amalgam coronal-radicular restora-
tions. J Prosthet Dent 63:607–613
Kishen A, Kumar GV, Chen NN (2004) Stress-strain response in human dentine: rethinking frac-
ture predilection in postcore restored teeth. Dent Traumatol 20:90–100
Kovarik RE (2009) Restoration of posterior teeth in clinical practice: evidence for choosing amal-
gam versus composite. Dent Clin N Am 53:71–76
Krishan R, Paqué F, Ossareh A, Kishen A, Dao T, Friedman S (2014) Impacts of conservative
endodontic cavity on root canal instrumentation efficacy and resistance to fracture assessed in
incisors, premolars, and molars. J Endod 40:1160–1166
Kvinnsland I, Oswald RJ, Halse A, Gronningsaeter AG (1989) A clinical and roentgenological
study of 55 cases of root perforation. Int Endod J 22:75–84
Lammertyn PA, Rodrigo SB, Brunotto M, Crosa M (2009) Furcation groove of maxillary first
premolar, thickness and dentin structures. J Endod 35:814–817
Libman WJ, Nicholls JI (1995) Load fatigue of teeth restored with cast post and cores and com-
plete crowns. Int J Prosthodont 8:155–161
Linn J, Messer HH (1994) Effect of restorative procedures on the strength of endodontically
treated molars. J Endod 20:479–485
Magura ME, Kafrawy AH, Brown CE, Newton CW (1991) Human saliva coronal microleakage in
obturated root canals: an in vitro study. J Endod 17:324–331
Main C, Mirzayan N, Shabahang S, Torabinejad M (2004) Repair of root perforations using min-
eral trioxide aggregate: a long-term study. J Endod 30:80–83
Malkondu Ö, Karapinar Kazandağ M, Kazazoğlu E (2014) A review on biodentine, a contempo-
rary dentine replacement and repair material. Biomed Res Int 2014:160951
Maloney SM, McClanahan SB, Goodell GG (2005) The effect of thermocycling on a colored glass
ionomer intracoronal barrier. J Endod 31:526–528
Marquis VL, Dao T, Farzaneh M, Abitbol S, Friedman S (2006) Treatment outcome in endodon-
tics – the Toronto study. Phase III: initial treatment. J Endod 32:299–306
Martin JA, Bader JD (1997) Five-year treatment outcomes for teeth with large amalgams and
crowns. Oper Dent 22:77–78
Mavec JC, McClanahan SB, Minah GE, Johnson JD, Blundell RE (2006) Effects of an intracanal
glass ionomer barrier on coronal microleakage in teeth with post space. J Endod 32:120–122
Mente J, Hage N, Pfefferle T, Koch MJ, Geletneky B, Dreyhaupt J, Martin N, Staehle HJ (2010)
Treatment outcome of mineral trioxide aggregate: repair of root perforations. J Endod 36:
208–213
Mondelli RF, Barbosa WF, Mondelli J, Franco EB, Carvalho RM (1998) Fracture strength of
weakened human premolars restored with amalgam with and without cusp coverage. Am
J Dent 11:181–184
Mondelli RF, Ishikiriama SK, de Oliveira FO, Mondelli J (2009) Fracture resistance of weakened teeth
restored with condensable resin with and without cusp coverage. J Appl Oral Sci 17:161–165
Mori GG, Teixeira LM, de Oliveira DL, Jacomini LM, da Silva SR (2014) Biocompatibility evalu-
ation of biodentine in subcutaneous tissue of rats. J Endod 40:1485–1488
Nakata TT, Bae KS, Baumgartner JC (1998) Perforation repair comparing mineral trioxide aggre-
gate and amalgam using an anaerobic bacterial leakage model. J Endod 24:184–186
Naoum HJ, Chandler NP (2002) Temporization for endodontics. Int Endod J 35:964–978
Nayyar A, Walton RE, Leonard LA (1980) An amalgam coronal-radicular dowel and core tech-
nique for endodontically treated posterior teeth. J Prosthet Dent 43:511–515
Ng Y-L, Mann V, Gulabivala K (2010) Tooth survival following non-surgical root canal treatment:
a systematic review of the literature. Int Endod J 43:171–189
Panitvisai P, Messer HH (1995) Cuspal deflection in molars in relation to endodontic and restor-
ative procedures. J Endod 21:57–61
Petersson K, Hasselgren G, Tronstad L (1985) Endodontic treatment of experimental root
perforations in dog teeth. Endo Dent Traumatol 1:22–28
1 Endodontic Considerations for the Restoration of Endodontically Treated Teeth 23

Pisano DM, DiFiore PM, McClanahan SB, Lautenschlager EP, Duncan JL (1998) Intraorifice sealing
of gutta-percha obturated root canals to prevent coronal microleakage. J Endod 24:659–662
Plotino G, Buono L, Grande N, Lamorgese V, Somma F (2008) Fracture resistance of endodonti-
cally treated molars restored with extensive composite resin restorations. J Prosthet Dent 99:
225–232
Portell FR, Bernier WE, Lorton L, Peters DD (1982) The effect of immediate versus delayed dowel
space preparation on the integrity of the apical seal. J Endod 8:154–160
Ray HA, Trope M (1995) Periapical status of endodontically treated teeth in relation to the techni-
cal quality of the root filling and the coronal restoration. Int Endod J 28:12–18
Rosen H (1961) Operative procedures on mutilated endodontically treated teeth. J Prosthet Dent
11:973–986
Rosen H, Partida-Rivera M (1996) Iatrogenic fracture of roots reinforced with a cervical collar.
Oper Dent 11:46–50
Rotstein I, Cohenca N, Teperovich E, Moshonov J, Mor C, Roman I, Gedalia I (1999) Effect of
chloroform, xylene, and halothane on enamel and dentin micro- hardness of human teeth. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 87:366–368
Salehrabi R, Rotstein I (2004) Endodontic treatment outcomes in a large population in the USA:
an epidemiological study. J Endod 30:846–850
Sathorn C, Palamara JEA, Palamara D, Messer HH (2005) Effect of root canal size and external
root surface morphology on fracture susceptibility and pattern: a finite element analysis.
J Endod 31:288–292
Saunders WP, Saunders EM (1994) Coronal leakage as a cause of failure in root canal therapy:
a review. Endod Dent Traumatol 10:105–108
Saupe WA, Gluskin AH, Radke RA (1996) A comparative study of fracture resistance between
morphological dowel and cores and a resin reinforced dowel system in the intraradicular
restoration of structurally compromised roots. Quintessence Int 27:483–491
Schmage P, Ozcan M, McMullan-Vogel C, Nergiz I (2005) The fit of tapered posts in root canals
luted with zinc phosphate cement: a histological study. Dent Mater 21:787–793
Schwartz RS, Robbins JW (2004) Post placement and restoration of endodontically treated teeth:
a literature review. J Endod 30:289–301
Silver GK, Love RM, Purton DG (1999) Comparison of two vertical condensation obturation
techniques: Touch‘n Heat modified and System B. Int Endod J 32:287–295
Sinai IH, Romea DJ, Glassman G, Morse DR, Fantasia J, Furst ML (1989) An evaluation of trical-
cium phosphate as a treatment for endodontic perforations. J Endod 15:399–403
Smales RJ, Hawthorne WS (1997) Long-term survival of extensive amalgams and posterior
crowns. J Dent 25:225–227
Solano F, Hartwell G, Appelstein C (2005) Comparison of apical leakage between immediate
versus delayed post space preparation using AH Plus Sealer. J Endod 31:752–754
Sorensen JA, Engelman MJ (1990) Ferrule design and fracture resistance of endodontically treated
teeth. J Prosthet Dent 63:529–536
Sorensen JA, Martinoff JT (1984) Intracoronal reinforcement and coronal coverage. J Prosthet
Dent 51:780–784
Starr CB (1990) Amalgam crown restorations for posterior pulpless teeth. J Prosthet Dent
63:614–619
Swanson K, Madison S (1987) An evaluation of coronal microleakage in endodontically treated
teeth. Part 1. Time periods. J Endod 13:56–59
Tjan AHL, Whang SB (1985) Resistance to root fracture of dowel channels with various thick-
nesses of buccal dentin walls. J Prosthet Dent 53:496–500
Torabinejad M, Ung B, Kettering JD (1990) In vitro bacterial penetration of coronally unsealed
endodontically treated teeth. J Endod 16:566–569
Trabert KC, Caput AA, Abou-Rass M (1978) Tooth fracture–a comparison of endodontic and
restorative treatments. J Endod 4:341–345
24 B.D. Barsness and S.H. Roach

Tronstad L, Asbjornsen K, Doving L, Petersen I, Eriksen HM (2000) Influence of coronal restora-

tions on the periapical health of endodontically treated teeth. Endod Dent Traumatol
16:218–221
Tsesis I, Fuss Z (2006) Diagnosis and treatment of accidental root perforations. Endod Topics
13:95–107
Vire DE (1991) Failure of endodontically treated teeth: classification and evaluation. J Endod
17:338–342
White JD, Lacefield WR, Chavers LS, Eleazer PD (2002) The effect of three commonly used
endodontic materials on the strength and hardness of root dentin. J Endod 28:828–830
Wong R, Cho F (1997) Microscopic management of procedural errors. Dent Clin N Am
41:455–480