Post and Core
Post and Core
Post and Core
Key words: endodontically treated teeth, post and core, reconstruction, review
The prognosis of endodontically treated teeth depends not only on the treatment itself, but also on sealing the canal and minimizing the leakage of oral fluids and bacteria
Associate Professor, Humboldt University of Berlin, Dental School, Department of Prosthetic Dentistry and Oral Gerontology, Berlin, Germany.
School, Department of Prosthetic Dentistry and Oral Gerontology, Berlin, Germany. Reprint requests: Dr Ingrid Peroz, Zentrum fr Zahnmedizin, Abteilung fr Zahnrztliche Prothetik und Alterszahnmedizin, Augustenburger Platz 1, 13353 Berlin, Germany. E-mail: ingrid.peroz@charite.de
into periradicular areas by prompt placement of coronal restorations.1 This treatment includes the decision of whether or not posts should be used. After many years of scientific work involving post material, post geometry, post length, core material, and other considerations, the indication for posts is reemerging as a topic of discussion. A change of paradigm has occurred based on the advantages of adhesive restorations, which seem to make post insertion unnecessary. In addition to this development, evidencebased treatment is becoming increasingly important in dentistry. Treatment decisions and strategies should be based on the best and most-up-to-date factual evidence available. Evidence-based dentistry is influencing
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Ta b l e 1
RESULTS
Indications for using posts
In an in vitro study with matched teeth pairs (split-mouth design), Sedgley and Messer2 were able to show that vital dentin is harder than dentin from contralateral endodontically treated teeth, but there was no significant biomechanical change that would indicate that the endodontically treated teeth had become more brittle (in vitro, level of evidence II b). This result is supported by another matched teeth pairs study by Papa et al,3 which shows that there is no significant difference in the moisture content between endodontically treated teeth and vital teeth. It appears that the remaining amount of tooth hard tissue influences stability, rather than the factors listed above. Whereas the preparation of a pulpal access only reduces structural stability by about 5%, loss of the circumferential integrity by mesio-occlusodistal (MOD) cavities reduces the stability by about 63%.4 Panitvisai and Messer5 have shown that the cuspal deflection increases with increasing cavity size, and is greatest following endodontic access. The importance of the marginal ridge for the structural stability of teeth was also shown by Strand et al.6 The use of posts, however, does not increase the fracture resistance significantly. This was shown in several comparative in vitro studies (level of evidence II b).710 Posts are used to provide retention for the core material, so the indication for post insertion depends on the dental substance and extent of either destruction or viable structure seen in the teeth being considered for endodontic treatment. The amount of remaining tooth structure necessary to warrant post insertion, or a decision to use other methods, is not clearly defined. It is, however, based on reviews or personal clinical experience (internal evidence) with a level of evidence no better than IV (review, IV).11 There is a general lack of systematic approaches in literature published on this matter. For this reason, an attempt was made to formulate a more detailed description for the amount of remaining dental tissue because the extent of destruction cannot be evaluated metrically. This classification describes 5
Evidence level
I a (high) Ib II a II b III IV
Meta-analysis of randomized, controlled trials Single randomized, controlled trial Controlled study without randomization Experimental study Descriptive study Estimation of experts
the evaluation and adaptation of many treatment methods that have been commonplace until now. Based on the design of the studies, investigators categorized these treatments into different groups, depending on the level of evidence available (Table 1). Although these levels of evidence depend on clinical trials only, they were also used to characterize in vitro studies. The aim of this study was to create guidelines for the reconstruction of endodontically treated teeth by posts and cores based on a review of the literature, and to assign citations to their levels of evidence.
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Ta b l e 2
Study type
OR core
AND diameter
AND length
AND abutment
AND cementation
Meta-analysis of RCT RCT Controlled clinical trial Prospective study Follow-up study Longitudinal study Cohort study Clinical trial Comparative study
0 0 0 6 35 50 51 1 125
0 0 0 1 10 (4)* 13 13 0 61
0 0 0 1 10 (4)* 13 13 0 59
0 0 0 0 0 0 0 0 2
0 0 0 0 0 0 0 0 6
0 0 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0 1
0 0 0 1 3 4 4 0 9
0 0 0 1 2 (1)* 3 3 0 27
0 0 0 1 1 2 2 0 11
* Upon reading abstracts of these studies, many had to be eliminated. Only those in parentheses are valid.
classes, depending on the number of remaining axial cavity walls.12 Class I describes the access preparation with all 4 axial cavity walls remaining. Class II describes loss of 1 cavity wall, commonly known as the mesio-occlusal (MO) or the disto-occlusal (DO) cavity. Class III represents an MOD cavity with 2 remaining cavity walls. Class IV describes 1 remaining cavity wall, in most cases the buccal or oral wall, and Class V describes a decoronated tooth with no cavity wall remaining. The minimal thickness of the cavity wall as a determining factor for the resistance to functional loads of the crown-root complex is considered 1 mm. Hard tissue with thicknesses below this level cannot be prepared for crowns without the loss of all remaining substance, leaving no dental tissue. A thickness greater than 1 mm provides an amount of hard tissue sufficient to stabilize the core material even after crown preparation. Therefore, a cavity wall with less than 1 mm thickness cannot be taken into consideration.13 The minimal height of a cavity wall capable of providing a sufficient ferrule effect is 2 mm. This aspect is described in further detail below.
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Class I III
Two to 4 cavity walls remaining
Class IV
One cavity wall remaining
No Adhesive Any
Fig 1 No post is needed in cases with at least 2 axial cavity walls remaining. A thickness of the cavity wall 1 mm and a height of 2 mm are preconditions. If these conditions cannot be fulfilled, the cavity wall must be considered as missing.
Fig 2 A post should be inserted if only 1 cavity wall is remaining. Fiber posts are preferable in anterior teeth, but in posterior teeth, fiber or metal posts can be used. The core can be made of composite or as a cast post and core. The definitive restorations should be crowns in anterior teeth and crowns, onlays, or overlays in posterior teeth.
Class V
No cavity walls remaining
Fig 3 A post must be inserted if there is no cavity wall remaining. A ferrule of 2 mm is needed to provide a lower risk of root fracture.
ture resistance of the endodontically treated teeth20 (in vitro, II b). If the tooth has to be used as an abutment for fixed or removable partial dentures, crown preparation will further decrease fracture resistance.21 Therefore, the present concept suggests using posts in such cases of reduced remaining tooth structure. For esthetic reasons, nonmetal posts are preferred for treatment of anterior teeth. In posterior teeth, both metal posts and nonmetal posts are acceptable treatment options (Fig 2).
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silica post), and an additional group was not provided with a core at all. No significant difference in fracture strength among the different groups could be demonstrated.26 Several criteria must be taken into account with respect to the indication for post insertion. These criteria will be presented later.
mm was also found.30,31 Considering the need for both a sufficient ferrule effect and the remaining apical sealing, the postulated post length of two-thirds of the root length may be impossible in many clinical situations. As previously stated, shorter posts should be fixed with luting composite.29
Post length
Reviews of evidence presented in level IV studies state that the post length should reach two-thirds of the entire root length. A crown-length/post-length ratio of at least 1:1 should be provided.11,27. Post length influences the stress load along the root. Whereas the enlargement of the canal increases cervical stress, post placement will decrease stress in this region. Short, wide posts lead to elevated stress concentrations in the cervical region. Post placement beyond two-thirds of root depth does not further decrease cervical stress, but tends to increase stress in the apical region28 (in vitro, II b). The selection of post length, however, depends on many criteria. It has been shown that the post length is less important for fracture resistance than the ferrule effect23 (in vitro, II b). The type of fixation used for posts also has an influence on the required length of the post. Nissan et al29 were able to show that adhesive fixation can compensate for reduced retention due to the use of a shorter parallel-sided or tapered post29 (in vitro, II b). Testori et al18 demonstrated there is no significant difference in the retention of adhesive fixed posts 5 mm or 8 mm in length (clinical trial and review, III). These results, however, are less because they were ascertained with a very limited number of samples. Whereas the studies cited above paid special attention to the correlation between post length and post retention, other studies tended to evaluate the remaining root filling after post-space preparation, especially with respect to leakage. It was shown that leakage increases with post-space preparation, and a remaining apical filling of less than 3 mm results in an unpredictable seal.30,31 Post insertion and adhesive fixation can compensate for this leakage. Nevertheless, the need for a remaining apical root filling of 4 to 6
Post diameter
There is little evidence (level IV) for an optimal post diameter. A diameter of one-third of the root diameter is postulated in many reviews. A minimal dentin thickness of 1 mm around the post should be provided.11,32 Due to the stability of the post itself, LambjergHansen and Asmussen33 postulated a post diameter of at least 1.3 mm. In the present study, a diameter of ISO 90 or 1.25 mm, respectively, is proposed.
Post fixation
Adhesive systems seem to be able to stabilize the tooth. Reeh et al4 have shown that composite restorations with dentin enamel etching provide a stability similar to that of the intact tooth (in vitro, controlled trial: II b). The use of composite in the entrance of the root canal stabilizes the root-filled tooth, whereas an additional post is unable to contribute further stabilization.34 Paul and Schrer11 state in their review that the adhesive fixation of a post and core may stabilize the tooth. It was demonstrated in several in vitro studies with an evidence level of II b, that roots in which the posts were adhesively cemented were significantly more fracture resistant than those using zinc phosphate cement35,36 (in vitro II b). Based upon this evidence, the present study recommends adhesive fixation for any kind of post.
Post design
Post design also influences the success of the restoration. Torbjoner et al37 published a prospective study with an evidence level of II a, comparing failure rates and failure characteristics of tapered and parallel-sided posts. They found the cumulative failure rate of tapered posts was 15% higher than the failure rate for parallel-sided posts (8%). Loss of retention was listed as the most frequent reason for failure for both types of posts.37
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Parallel-sided posts and those surrounded by large amounts of cement had lower fracture rates than tapered posts or tapered posts with maximal adaptation in the root canal.38 Further studies also show that the post design has to be considered in combination with other aspects of posts. In this regard, the ferrule effect seems to be more important for fracture resistance than the post design.22 Adhesive fixation of posts is also more relevant for post retention than the post design itself11,29 (review, IV; in vitro, II b) (review, IV).
If fiber posts are used, they should be fixed by adhesive material. Vichi et al45 described the types of adhesive structures between the resin cement and dentin (in vivo, III). Ferrari et al46 were able to show, by microscopic examinations, that Excite dualcured bonding agent produced a resindentin interdiffusion zone higher than that seen in samples with Excite light-cured bonding agent or a one-step bonding system (in vitro, II b). The biomaterial disadvantages of fiber posts, which are based on decreased 3-point bending test values due to the water storage of these posts, can be avoided by adhesive fixation because they were isolated to saliva47 (in vitro, II b). Ceramic posts show survival rates and fracture strength comparable to cast posts and cores48 (in vitro, II b). Zirconia posts and ceramic cores, as well as chair-side procedures with zirconia posts with composite cores, are recommended49 (in vitro, II b). Comparisons of fiber and ceramic posts show a higher risk of fracture with ceramic posts due to cracks within the posts50,51, (in vitro, II b). Fiber posts show an additional advantage in that they are readily retrievable after failure.52 The results of a retrospective in vivo study (evidence level III) indicate that fiber posts are superior to the conventional cast post and core systems after 4 years of clinical service.53 The use of metal posts is justified by studies showing that the fracture resistance of teeth restored by metal posts is superior to other systems.54 The morphologic cast post and core systems appear to be of secondary importance compared to direct metal posts and composite cores. Direct posts and cores comprised 70% of the cases in root fractures after loading and 30% of the core fractures. The cast posts involved the root of all cases of fracture.43 Surfaces of metal posts should be rough to provide the best retention in the root canal5560 (in vitro studies, II b). Metal posts can be cemented by zinc phosphate cement or by adhesive resin systems. Because adhesive cementation results not only in lower microleakage, but also in higher retention, it is preferred.61.62
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The comparison between cast and direct post-and-core systems revealed no significant differences that would justify recommending the use of one over the other.63 This statement is based on one of the rare metaanalyses made by a systematic review of in vitro and in vivo studies.64 However, due to the lack of randomized, controlled studies, the assigned evidence level is II a. Direct posts and cores should use (independent of the post material) composites as core material. After amalgam, composites show both the lowest defect and failure rates, and the best fracture resistance (evidence level IIb to IV).49,6570
DISCUSSION
The present concept for the restoration of endodontically treated teeth by posts and cores aims to draw its guidelines from the evidence present in recent literature. The cited literature is assigned a level of evidence showing the reliability of the sources upon which decisions are based. The review of the literature shows that there is a lack of in vitro, and especially, clinical studies, correlating the amount of remaining tooth structure to the indication for posts. As such, it would be worthwhile to examine whether it is possible or recommendable not to use posts even for teeth with no remaining cavity walls. The limited number of prospective clinical studies is notable. Therefore, a prospective clinical study documenting cases meeting specific criteria (tooth within a complete dental arch, single tooth restoration, retention by remaining pulp chamber) in which posts are not used, is necessary. There is also a lack of prospective clinical studies in which the amount of remaining tooth structure is documented and the survival rate of several post materials is tested. The remaining tooth structure should be evaluated by a designed index system.74
Definitive restoration
The indication for post insertion depends not only on the amount of remaining tooth structure but also on the planned prosthetic reconstruction. The prognosis of an endodontically treated tooth is best if in a complete dental arch because of stabilizing mesial and distal proximal contacts.71 Sorensen and Martinoff72 demonstrated in their clinical, retrospective study (evidence level III) that post insertion brings no advantage to the survival rate of an endodontically treated tooth if it is restored by a crown or fixed partial denture. However, in cases where such a tooth is needed as an abutment for removable partial dentures, the post insertion has a significant positive effect for treatment success.72 Nevertheless, a tooth treated by root canal within a removable partial denture poses a higher risk for treatment failure72,73 (in vivo studies, evidence level III). Testori et al18 have shown that the pain threshold of an endodontically treated tooth used as a distal abutment is twice as high as that of a vital tooth These results influenced the present study, in which endodontically treated teeth were not included as abutment teeth for telescopes apart from cases in which all cavity walls remain. If a tooth treated with a root canal has to be included as an abutment tooth for cantilever fixed partial dentures or as the distal abutment of fixed partial dentures, or combined with a removable partial denture, the patient must be informed about the higher risk of failure.
CONCLUSIONS
The literature review reveals: 1. There is a lack of prospective clinical studies with well-documented inclusion criteria for endodontically treated teeth, remaining coronal hard tissue, and flaring. 2. The 2-mm ferrule has a very important role for the survival rate of endodontically treated teeth that have been restored with crowns. 3. Post length is limited by the necessary apical seal of 4 to 6 mm. Remaining tooth structure is more important than post length in avoiding tooth fracture. 4. Adhesive fixation is preferable, as it produces a higher fracture resistance in com-
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parison to cemented posts and cores, as well as offers a higher leakage resistance. 5. Composites are a good core material. 6. Posts should be inserted if endodontically treated teeth are used as abutments for removable partial dentures.
14. Attin T, Hellwig E, Hilgers R-D. Der Einflu verstrkender Wurzelstifte auf die Frakturanflligkeit endodontisch versorgter Zhne. Dtsch Zahnrztl Z 1994;49:586589. 15. Steele A, Johnson BR. In vitro fracture strength of endodontically treated premolars. J Endod 1999;25: 68. 16. Ausiello P, De Gee AJ, Rengo S, Davidson CL. Fracture resistance of endodontically treated premolars adhesively restored. Am J Dent 1997;10:237241. 17. Strub JR, Pontius O, Koutayas S. Survival rate and fracture strength of incisors restored with different post and core systems after exposure in the artificial mouth. J Oral Rehabil 2001;28:120124. 18. Testori T, Badinio M, Castagnola M. Vertical root fractures in endodontically treated teeth: A clinical survey of 36 cases. J Endod 1993;19:8791. 19. Sorensen JA, Martinoff JT. Intracoronal reinforcement and coronal coverage: A study of endodontically treated teeth. J Prosthet Dent 1984;51:780784. 20. Foley J, Saunders E, Saunders WP. Strength of core build-up materials in endodontically treated teeth restored by the post and core technique. Am J Dent 1997;10:166172. 21. Burke FJ, Shaglouf AG, Combe EC, Wilson NH. Fracture resistance of five pin-retained core buildup materials on teeth with and without extracoronal preparation. Oper Dent 2000;25:388394. 22. Assif D, Bitenski A, Pilo R, Oren E. Effect of post design on resistance to fracture of endodontically treated teeth with complete crowns. J Prosthet Dent 1993;69:3640. 23. Isidor F, Brondum K, Ravnholt G.The influence of post length and crown ferrule length on the resistance to cyclic loading of bovine teeth with prefabricated titanium posts. Int J Prosthodont 1999;12:7882. 24. Sorensen JA, Engelman MJ. Ferrule design and fracture resistance of endodontically treated teeth. J Prosthet Dent 1990;63:529536. 25. Gegauff AG. Effect of crown lengthening and ferrule placement on static load failure of cemented cast post-cores and crowns. J Prosthet Dent 2000;84: 169179. 26. Bolhuis HPB, De Gee AJ, Feilzer AJ, Davidson CL. Fracture strength of different core build-up designs. Am J Dent 2001;14:286290. 27. Stockton LW. Factors affecting retention of post systems: A literature review. J Prosthet Dent 1999;81: 380385. 28. Hunter AJ, Feiglin B, Williams JF. Effects of post placement on endodontically treated teeth. J Prosthet Dent 1989;62:166172. 29. Nissan J, Dimitry Y, Assif D.The use of reinforced composite resin cement as compensation for reduced post length. J Prosthet Dent 2001;86:304308. 30. Abramovitz L, Lev R, Fuss Z, Metzger Z. The unpredictability of seal after post space preparation: A fluid transport study. J Endod 2001;27:292295.
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Prosthodontist
Department of Comprehensive Care Case Western Reserve University School of Dental Medicine Cleveland, OH
The Department of Comprehensive Care at Case Western Reserve University School of Dental Medicine invites applications for a full-time tenure track faculty position at the assistant/associate professor level. Responsibilities include didactic and clinical teaching and research. Participation in the CWRU Dental Faculty practice is available. Candidates must have a DMD/DDS degree or equivalent, and advanced training in prosthodontics or equivalent. Research and clinical interest and/or experience in fixed and implant prosthodontics and adhesive dentistry is desired. Salary and rank commensurate with qualifications and experience.
Case Western Reserve University is an equal opportunity/affirmative action employer.
Applicants should send a curriculum vitae, and names of three references to: Avishai Sadan, DMD, Chairman Department of Comprehensive Care Case Western Reserve University School of Dental Medicine 10900 Euclid Avenue Cleveland, OH 44106-4905
COPYRIGHT 2005 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
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VOLUME 36
NUMBER 9
OCTOBER 2005