TOPICS OF INTEREST

The Prosthodontic Management

of Endodontically Treated Teeth: A
Literature Review. Part I. Success
and Failure Data, Treatment Concepts
Charles J, Goodame, DDS, MSD, * and Kenneth J. Splnik, DDS, MSD f
Part I of this three-part l i terature revi ew discusses the incidence of endodontic t reat ment
required after prosthodontic procedures, whether crowns are needed on endodontically t reat ed
teeth, t he primary purpose of posts, the causes of post and core failure, root fracture incidence data,
and past design considerations. Perti nent questions are addressed based on t he past 25 years of
dental literature.
JProsthod 1994;3:243-250. Copyright D 1994 by the American College of Prosthodontists.
INDEX WORDS: endodontically t reat ed teeth, posts and cores, incidence data
PLETHORA OF articles have been written in
A the dental literature regarding the prosthodon-
tic management of endodontically treated teeth.
Many of these papers have discussed techniques of
fabricating posts and cores, whereas others have
presented clinical and laboratory data that help
answer difficult questions regarding the best prosth-
odontic treatment for these teeth. Thc purpose of
this report is to address some of these difficult
questions by reviewing the dental literature of the
past 25 years and proLiding a summar) opinion based
on the reviewed scientific studies.
What Is the Incidence
of Endodontic Treatment
Required After Teeth Are
Prepared for Single Crowns
and Fixed Partial Dentures?
One study] reported that the incidence of endodontic
treatment after cementation of single crowns was 3%
after 5 years. Another single crown study2 found that
the incidence was 4%after 34 months.
The incidence of fixed partial denture abutments
*Pmjssor andDean. Lorna Linda UnIniversiQ Schwl oJDentisty. Lorna
f i hoci at e Professor of Endodontics. Indiana Unicersi& School oJ
ConexpnnPact to: Charles J. Gomiacre, DDS, MSD, Loma Linda
C@ynght 0 1994 by the American College ofPro.ithodonti.sts
1059-941Xf94/0304-00II$5.W/ 0
Linda, a.
DPntisly, Indianafilb. IN
lhirmsi& LSchwl oJDentiit91, Lomn Tin& CA 92350.
requiring endodontic treatment has varied in differ-
ent studies. The results have been: 3% after 5 years?
3% after 10 years,& 6% after 2 to 6 years: 10% after
10 years: 14% after 7 year^,^and 21% after 6 years.8
The gencrally higher incidence with fixed partial
dentures is assumed to he related to the greater
tooth reduction required to align multiple teeth and
perhaps also related to the grcater occlusal forces on
some types of prostheses. These assumptions are
supported by Raridow et alg who reported an increas-
ing incidence related to the size of thc prosthesis: 7%
for 7-unit prostheses, 9% for %unit prostheses, and
23% for 10-unit prostheses.
Reuter and BroscIo found a difference between
abutments with little or no caries at the time of tooth
preparation and abutments with deep carious le-
sions. Three percent of the teeth with little or no
caries required endodontic treatment after 5 years,
whereas 10% of the teeth with deep carious lesions
required treatment. Bergenholtz and Nymanll re-
ported on thc need for endodontic treatment in
patients with advanced periodontal disease who re-
ccivcd both periodontal and prosthodontic treat-
ments. Three percent of the periodontally treated
teeth that were not prepared for fixed prostheses
required endodontic therapy 4 to 13 years after
treatment, whereas 15% of the periodontally treated
teeth that were prepared for fixed prostheses needed
endodontic treatment. There was an increase in the
need for endodontic therapy when the bone loss
exceeded one third of the root length. They also
noted that 50% of the pulpal problems occurred 7 to
Journal ofProsthodonticr. 1/01 3, No 4 (Decemh), 1!?94:j$24.7-2.50 243
244 Endonticalb Treated Teeth b Goodacre and Sfilnik
12 years after prosthesis placcment, rather than
within the first fewyears as one might expect.
Abou-RassL2 coined the term stressed pulp and
proposed the concept to help identify those teeth
that have a greater potential for developing pulpal
disease after prosthodontic treatment (Figs 1 and 2).
He reported that stressed pulps are vital pulps that
have been subjected to repeated injury, including
accidental trauma, operative procedures, prosthodon-
tic tooth preparation, or other dental procedures.
Abou-Rass suggests that endodontic treatment should
be considered before pulpally traumatic dental proce-
dures are performed on teeth with pulps that have
already been stressed on multiple occasions.
Summary
The incidence of endodontic treatment required
after tooth preparation has ranged from 3% to 23%.
Fixed partial dentures and complex prostheses had
higher incidence rates than single crowns. It has been
assumed that the higher rates are because of the
greater tooth reduction sometimes required to align
multiple teeth. The incidence is higher when the
prepared teeth have deep carious lesions and when
Figure 1. The maxillar): central incisors have been
prepared for ceramic restorations. The right central incisor
has a distal pulp blush from excessive reduction. The
arrow indicates the area that appeared clinically red. A
tooth with this type of injury has a greater chance of
needing endodontic treatment from the excessive stress of
tooth preparation.
Figure 2. Pulpal blush occurred over the mesial pulp
horns ofboth central incisors at the time of tooth prepara-
tion. Provisional resin crowns were cemented, and 3 weeks
later, dark areas (arrows) are noted where the pulpal
blush had occurred. The authors experience indicates
serious pulpal stress has occurred when dark areas are
noted after a pulpal blush. Teeth with stressed pulps
should be treated before complex prosthodontic treatment
is completed.
periodontal disease has resulted in considerable bone
loss. Many pulpal problems occur after several years
rather than in the first few years, and one study
showed that 50% of the pulpal problems occurred
after 7 to 12 years. It has been suggested that
stressed pulps are more prone to developing pulpal
disease after prosthodontic treatment.
Do Endodontically Treated Teeth
Need Crowns?
Sorensen and Martinoff l 3 reported the results of a
retrospective study of 1,273 teeth that had been
endodontically treated 1 to 25 years before the study.
Endodontically treated teeth with coronal coverage
restorations (onlays, partial or complete metal crowns,
and metal ceramic crowns) were compared with
endodontically treated teeth with no coronal cover-
age restorations. Coronal coverage did not signifi-
cantly improve the success of endodontically treated
anterior teeth (Fig 3). This finding supports the
placement of only resin in the access openings of
otherwise intact anterior teeth. However, some inci-
sors and canines may need complete coverage crowns
because of the presence of large and/or multiple
previous restorations or because of esthetic condi-
tions that cannot be adequately addressed with more
conservative forms of treatment.
Decembm 1994, Voolume.3, Number 4 245
Figure 3. The maxillary left central incisor suffered a
traumatic injury that necessitated endodontic therapy.
The tooth is intact except for a conservative access open-
ing. Because the tooth is not facially discolored and is intact
except for the access opening, a resin restoration can be
placed in the access opening as the definitive treatment.
This same study13 found a significant improve-
ment in the clinical success of maxillary and mandibu-
lar premolars and molars when coronal coverage
restorations were present. This finding supports the
placement of crowns on posterior teeth that cover
sufficient coronal tooth structure to prevent fracture
when occlusal forces attempt to separate the cusp
tips.
G~trnann ~ has very aptly summarized the special
needs of endodontically treated teeth by reviewing
several interesting articles. Pulpless dog teeth were
found15 to have 9% less moisture than vital teeth.
With aging, greater amounts of peritubular dentin
are dcposited, which decreases the amount of or-
ganic materials that may contain moisture.15 Reeh et
all6 showed that endodontic procedures reduce tooth
stiffness by 5%, attributed primarily to the access
opening. Tidmarshl described the structure of an
intact tooth that allows it to deform under loading
and still exhibit elastic recovery after removal of the
load. Grirnaldi* discussed the direct relationship
between tooth structure lost during tooth prepara-
tion and the deformation of the tooth under load.
Carter et allq indicated that dentin from endodonti-
cally trcated teeth shows significantly lower shear
strength and toughness than dentin from vital teeth.
Rivera et alZ0 stated that the degree ofwork required
to fracture dentin may be less in endodontically
treated teeth because the collagen intermolecular
cross-links may be weaker.
Summary
Crowns should generally be used on endodontically
treated posterior teeth but are not necessary on
relatively sound anterior teeth.
Do Posts Reinforce
Endodontically Treated Teeth?
Most laboratory studies have shown that placement
of a post and core does not increase the fracture
resistance of endodontically treated extracted teeth
when a force is applied via a mechanical testing
machine. Lovdahl and Nicholls* found that endodon-
tically treated maxillary central incisors were stron-
ger when the natural crown was intact cxcept for the
access opening than when they were restored with
cast posts and cores or pin-retained amalgams. I,uz2
found that posts placed in intact endodontically
treated central incisors did not lead to an increase in
the force required to fracture the tooth nor in the
position and angulation of the fracture line. Guzy
and Ni~holls2~ determined that there was no signifi-
cant reinforcement achieved by cementing a post
into an endodontically treated tooth that was intact
except for the access opening. Lcary et alZ4 measured
the root deflection of endodontically treated tooth
before and after posts of various lengths were ce-
mented into prepared root canals. They found no
significant differences in strength between the teeth
with or without a post. Trope et alZ5 determined that
preparing a post space weakened endodontically
trcated teeth compared with ones in which only an
access opening was made, but no post space. They
also found that cemented Paraposts (Coltenel
Whaledent Inc, New York, NY) did not increase the
fracture resistance.
Kantor and Pinesz6 determined that cementing a
stainless steel rod into prepared post spaces of teeth
that had also been prepared for complete coverage
crowns increased the fracture resistance compared
with teeth that were only prepared for complete
crowns but had no post. Using photoelastic stress
analysis, Hunter el al* determined that removal of
internal tooth structure during endodontic therapy is
accompanied by a proportional increase in stress.
They also determined that minimal root canal en-
largement for a post does not substantially weaken a
tooth. However, if considerable root canal enlarge-
ment has occurred, a post substantially reinforces the
tooth.
246 Endonticalb Treated 'I'Peth Go:oodacreand Spolnik
One study2* used two-dimensional finite element
analysis to study the effect of posts on dentin stress in
pulpless teeth. When loaded vertically along the long
axis, a post reduced rnaximal dentin stress by as
much as 20%. However, only a small (3% to 8%)
decrease in dentin stress was found when a post was
present and when the teeth were subjected to masti-
catory and traumatic loadings at 45" to the incisal
edge. KO et a12* determined that the reinforcement
effect of posts is doubtful for anterior teeth because
they are subjected to angular forces.
In a clinical study of endodontically treated teeth,
Sorensen and Martinoff 29 found that post placement
was associated with a significantly decreased success
rate for single crowns, produced no significant change
in the success of fixed partial denture abutments,
and significantly improved the success or removable
partial denture abutment teeth.
Summa y
The primary purpose of a post is to retain a core that
can be used to retain the definitive prosthesis. Posts
do not reinforce endodontically treatcd teeth and are
not necessary when substantial tooth structure is
present after teeth have been prepared (Fig 4). A
post and core may help prevent coronal fractures
when the remaining coronal tooth structure is very
thin after tooth preparation (Figs 5 and 6).
Figure 4. No post and core was used in the mandibular
second molar abutment because substantial tooth struc-
ture was present after endodontic treatment was com-
plete.
Figure 5. After preparation of the maxillar). left central
incisor for a ceramic restoration, only a thin layer ot
coronal tooth structure was rrmaining periapical to the
cndodontic access opening anti pulp chamber. Note the
white blotchy areas (arrow) visible through the thin facial
tooth structure, which is the provisional cement placed in
the pulp chamber. If a crown was cemented over this
prepared tooth, the remaining thin coronal tooth structure
could fracture when occlusal forces were applicd to thc
crown, resulting in fdure. A post and core could prevent
the fracturc of this thin coronal tooth structurc.
What Are the Most Common
Types of Post and Core Failures?
There are only a limited number or clinical studies
that contain data relative to post and core failures.
Turner3') reported on 100 failures of post-retained
crowns and indicated that post loosening was the
most common type of failure. Of the 100 failures, 59
wcre caused by post loosening. Apical lesions and
caries were the next most common occurrences,
followed by fracturcd or loose crowns. There were 10
fractured roots and 6 fractured posts. In another
paper, TurneI-3' reported the findings of a 5-year
retrospective study d 52 post-retained crowns. Six
posts had come loose, and there were no tooth
fractures. Bergman et a13* reported that he found 8
failures in 96 posts after 5 years. Six posts had come
loose, and there were 2 root fractures.
Sorenson and Martinoff 13329 evaluated 1,273 end-
dontically treated teeth, 420 of which had posts and
cores. There were 36 post and core failures. Thirteen
of the 36 failures were caused by post dislodgement,
8 wcre related to restorable tooth fractures, 12 were
related to nonrestorable tooth fractures, and 3 were
related to post perforations. Weine et al" found 9
December 1994, Volume 3, Number 4
247
Figure 6. A post and core was not placed in the maxillary
canine, and the thin coronal tooth structure fractured
causing failure of the two-unit splint. Note the fracture line
visible on the mesial surface of the canine apical to the
margin.
failures in 138 posts and cores after 10 years or more.
There were 3 failures related to restorative proce-
dures, 2 related to the endodontic therapy, and 2
related to periodontal causes. Two roots had frac-
tured, and no posts had come loose.
Hatzikyriakos et aP4 reported the 3-year resiilts of
154 posts and cores. Five posts had come loose, 5
crowns had come loose, 4 roots had fractured, and 3
roots had caries.
Summary
Although there are many types of post and core
failures, loosening of the post and tooth fractures
were two of the most common occurrences. Three
papers reported that post loosening occurred more
often than tooth fractures. Two studies found slightly
higher incidences of tooth fracture than post loosen-
ing, and one study found comparable incidences of
post loosening and tooth fracture.
Which Post Design I s the Most
Retentive?
There have been many laboratory studies on post
design and retention. Parallel-sided, threaded posts
have been found to be the most r~tenti ve?~-~ Ce-
mented, parallel-sided posts have been found to be
more retentive than cemented tapered po ~t s . ~~, ~~ ~
Cemented, parallel-sided posts with serrations are
more retentive than cemented, smooth-sided paral-
Clinically, Weine et a133 reported no retention
problems when they evaluated their experience with
cemented, tapered posts over 10 years or more. In a
clinical study of cemented tapered posts placed by
dental students, Bergman et a132stated that this
design can be strongly recommended.
lel posts,35,375%4(1
Summary
From a retention standpoint, the laboratory evidence
indicates that threaded posts are the most retentive
followed by cemented, parallel-sided posts. Serra-
tions increase post retention. Cemented, tapered
posts are the least retentive, but some clinicians
reported that they have successfully used this design
and did not have retention problems.
What Data Is Available Regarding
Root Fractures From Posts?
One clinical studja4 reported that 2.6% of post and
core failures were because of root fracture, whereas
another report30 indicated that 10% of post and core
failures were attributable to root fracture. In a study4
of crown and fixed partial denture failures from all
causes, tooth fractures accounted for 3.9% of the
failures, In this study, fractures werefurther subdi-
vided into coronal fractures and root fractures. Ap-
proximately three quarters of the fractures were
coronal with the rest being root fractures. Only 4 of
the I3 coronal fractures occurred on endodontically
treated teeth, whereas all of the root fractures were
found in endodontically treated teeth. Ross4 evalu-
ated 200 endodontically treated teeth at least 5 years
after treatment: 134 with no posts and 86 with posts.
None of the teeth with or without posts showed any
clinical or radiographic ekidence of fracture.
In a photoelastic study, Hen@ found that screw
posts produced undesirable levels of root stress.
Standlee et a143 found that tapered, threaded posts
were the worst stress producers. In comparing three
threaded prefabricated posts, Deutsch et a P found
24 8 k;ndonticulb Treated Teeth Goodume and Spolnik
that tapered, threaded posts increased the incidence
of root fracture in extracted teeth by 20 times that of
the parallel threaded post. Stancllee and C ap~t o ~~
found that split, threaded posts (Flexi-posts; Essen-
tial Dental Systems, New York, NY) caused high
internal stresses during loading like other threaded
posts. Thorsteinsson et aP also found that split,
threaded posts did not reduce thr stress concentra-
tion during loading when compared with other
threaded designs. One showed that split,
threaded posts reduced the stress created during
cementation compared with a rigid, threaded post.
Rolf et a P found that cemented posts produced less
stress than threaded posts.
Trabert ct aF9 indicated that increasing post
length increases the resistance of a root to fracture
(Fig 7 ) , and increasing post diameter decreases the
resistance ofa root to fracture.
Figure 7. (A) The maxillary first premolar has short
posts extending into both the facial and linLpaI root canals.
Short posts can cause high stresses in roots. (B) The
maxillary first premolar root fractured vertically.
Figure 8. A mandibular molar post and core caused
multiple root fractures and displacement of the fractured
root segments.
Summa y
Three percent to ten pcrccnt of post and corc failures
are attributable to root fractures (Fig 8). Threaded
post forms are the most likely to cause root fracture
and split, and threaded flexible posts do not reduce
stress concentration during function. Cemented posts
produce the least root stress.
Are Parallel-Sided Posts Less
Likely to Cause Root Fracture
Than Tapered Posts?
In a laboratory study of extracted teeth, Sorensen
and Engelmanj" found that tapered posts caused
more extensive tooth fractures than parallel-sided
posts, but one of the tapered post groups required a
much higher load to initiate root fracturc than the
parallel post group. From a retrospective clinical
study, Sorensen and Martinoff 51 determined that
the highest success occurred with parallel-sided,
serrated posts, and they found that tapered cast
posts and corm showed a higher failure rate. They
also rcportcd that tapered cast posts and corm
caused more catastrophic failures. Bergman ct aP2
found 2 root fractures in 96 teeth 6 years after
placement of tapered posts and cores by dental
students. They concluded that this design of the cat
post and core can be strongly recommended. In a
retrospective study of tapered posts in place for 10
years or more, Weine et aP3 found 2 root fractures in
December 1994. Volume 3, Number 4
249
(1.4%). They reported that this design offers safe and
desirable results. Turne$' performed a 5year rctro-
spective evaluation of 52 posts and cores and found
that many of the posts were short and 6 were loose,
but there were no root fractures.
I n a study of 30 extracted teeth, Lu2? found no
difference in the fracture location between prefabri-
cated and custom cast posts and cores. In a photoelas-
tic stress analysis study, Henry4* found that parallel-
sided posts distribute stress more evenly to the root
than to the tapered posts. Two finite element analy-
sis st~di esj ~. ~~ found similar results. Two photoelastic
studies",5q found that parallel posts concentrate
stress apically, whereas tapered posts concentrate
stress at the post-to-core junction.
summary
Although there are several laboratory studies and
some clinical data that indicates that parallel-sided
posts are less likely to cause root fracture, other
clinical studies have shown good success with tapered
posts. It seems that additional clinical studies of a
prospective nature are required to resolve this issue.
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