The restoration of teeth with extensive structural damage is an important clinical procedure in

dental practice. However, despite the availability of a variety of materials, techniques and studies
in the scientific literature, the criteria for selection of such teeth for restoration need clarification.
The approach to severely compromised teeth should be based on consistent scientific evidence to
reduce dental error and improve the prognosis. If restoration is indicated, it must conserve and
protect the remaining tooth structure. In this article, we develop and suggest clinical criteria and
guidelines that clinicians may use to identify and classify extensively damaged teeth to help in
the diagnosis, treatment plan and prognosis.

Introduction
A tooth with extensive damage is one that has lost substantial structure as a result of caries,
previous restoration failures, fractures or even procedures related to endodontic treatment. The
restoration of such teeth with endodontic treatment is an important clinical procedure in dental
practice; however, various studies have taken different perspectives on this issue. 1,2 The loss of
dental tissue and the weakening of the remaining structure present a challenge in terms of
prosthetic rehabilitation. Although the current success rate of dental implants is high, 3 the
clinician must be able to assess the probability of restoring severely damaged teeth successfully. 410
The dimensions of the remaining tooth tissues as well as several biological and occlusal factors
must be properly assessed to establish the correct treatment plan.
The aim of this article is to present clinical guidelines to help the clinician easily diagnose and
establish a treatment plan for the rehabilitation of severely damaged teeth.
Assessing the Probability of Successful Restoration
Remaining Tooth Tissues
The extent of the remaining tooth structure is among the most important and critical factors in
determining the prognosis for restoration of a damaged tooth. Evidence indicates that the
dimensions of the crown dentin are important.4 Some studies11,12agree that a dentin thickness <
1 mm increases the risk of failure. This minimum thickness is more often achieved in buccal or
palatal/lingual than interproximal areas after endodontic treatment and tooth preparation.4,1315
The ferrule effectthe need for a 360 collar 2 mm in height (1.5 mm minimum)was
described by Sorensen and Engelman11 in 1990. Smaller dimensions are associated with a greater
risk of failure.4,6,9,16-22
A post should be used only when there is insufficient tooth substance remaining to support core
material or the final restoration. The height of the post should always be the same or greater than
that of the future crown, and its width should be established by the width of the canal after root

canal treatment. Increasing post diameter in an effort to increase retention is not recommended,
as this creates unnecessary weakening of the remaining tooth structure.1,9,23-25
Biologic Considerations
Caries, previous restorations and fractures can affect the biologic width of the remaining
structure and lead to accumulation of bacteria, inflammation, increased probing depth, gingival
recession or a combination of these problems. When sulci are normal (23 mm) and healthy and
bands of attached gingiva are adequate, margins can be placed up to 0.5 mm inside the sulcus.
When tooth structure is insufficient to allow adequate soft tissue attachment, other procedures
(such as surgical crown lengthening or orthodontic extrusion) may be necessary to achieve
optimal results.26-34
In preparing a root canal for a post, the main barrier against reinfection of the periapical region is
the endodontic obturation material. The length of the remaining apical seal after post preparation
can influence the long-term success of the restoration. 4,5,10,35-38 There is some evidence for leaving
35 mm of undisturbed apical endodontic obturation material after post preparation. Only some
teeth have a 1-mm thick layer of dentin 5 mm from the apex. At distances less than 3 mm from
the apex, there is unlikely to be 1 mm of sound dentin surrounding the apical end of the post.4,10,39
Occlusal Factors
Occlusal load is also an important consideration in estimating the chances of successful
restoration of a damaged tooth. In a retrospective study, Sorensen and Martinoff 40 found that,
although the success rate for single-unit crowns was 94.8%, it was 89.2% for fixed partial
denture abutments and only 77.4% for removable partial denture abutments. Nyman and
Lindhe41 found that fractures in abutment teeth occurred more frequently in root-treated teeth.
Hatzikyriakos and colleagues42 reported a failure rate for endodontically treated teeth used as
abutments for fixed and removable partial dentures that was more than twice that for such teeth
not used as abutments.
Some conclusions can be drawn from these studies. Extensively damaged teeth cannot be
considered reliable as abutments for fixed or removable dentures (especially long-span fixed
bridges and distal extensions of removable dentures) or cantilevers or for patients with severe
bruxism and clenching habits.4,8,9,11,41,42
Clinical Protocol for Diagnosing Extensively Damaged Teeth
For a severely damaged tooth, some elements of a treatment plan are mandatory:

Removal of all caries and old restorations to achieve access to the remaining tooth
structure.
Elimination of all periodontal infection and control of plaque.
Predetermination of the value of the tooth, e.g., is it important for occlusion or esthetics?

The following criteria should then be assessed in this sequence: ferrule effect, relation between
root and crown length, endodontic condition.

Criterion 1 Ferrule Effect

The ferrule effect is determined from vertical and horizontal intraoral measurements. The vertical
measurement is from the top of the gingival margin to the top of the remaining tooth wall at 4
points: mesial, distal, buccal and lingual or palatine. This can be easily assessed using a
periodontal probe with a stop and an endodontic ruler. Values are positive if the top of the
remaining tooth is above the gingival margin (Fig. 1) or negative if it is below (Fig 2).
The horizontal measurement is the thickness of the remaining tooth walls at the level of the
future crown margin at 4 points: mesial, distal, buccal and lingual or palatine (Fig. 3). This can
be easily measured with calipers, which are commonly used to measure framework thickness of
fixed prosthodontics (Fig. 4). If space does not permit the use of calipers, a periodontal probe
(with a stop) can be used instead (Fig. 5).

Figure 1: Measurement of the remaining buccal wall of tooth 15 with a

periodontal probe and stop. The value is positive as the top of the remaining tooth is above the
gingival margin.

Figure 2: Measurement of the remaining buccal wall of tooth

22 with a periodontal probe and stop. The value is negative as the tooth wall is below the
gingival margin.

Figure 3: Location of horizontal intraoral measurements.

Figure 4: Measurement of
the remaining buccal wall of a damaged tooth with calipers (1.4 mm).

Figure 5: Measurement of the remaining distal wall of a

damaged tooth using a periodontal probe.

Criterion 2 Relation of Crown to Root Length

This factor is important in predicting the retention of the future restoration. As noted above, to
promote retention of the crown, a post should be at least the same length as the future crown.
Future crown length may be measured from the top of the supposed tooth to the hypothetical
margin, intraorally or using a model (Fig. 6).

Root length may be measured radiographically (Fig. 7).

If needed, on a buccal (Fig. 8), palatine or lingual face, it is possible to measure the distance of
the reference level to the top of the remaining tooth and transfer this measure to the radiograph
(see d on Fig. 8). Then measure the root length from this level to the apex on the radiograph
(see r on Fig. 8). Using the ratio of d to d, calculate the real dimension of the root, r, from r.

Figure 6: Measurement of an extensively damaged tooth 22

from the supposed top of the tooth to the hypothetical margin with a periodontal probe.

Figure 7: Radiograph showing crown and root measurements.

Figure 8: Determination of root length at the buccal face of

tooth 12.

Criterion 3 Endodontic Condition

The remaining tooth should be evaluated related to the extent of endodontic treatment required:
can treatment be performed without predictable complications, are complications likely and,
thus, treatment outcome is uncertain or are complications irreversible and cannot be resolved
with endodontic treatment.
Classification of Teeth with Extensive Endodontic Damage
Class I

Ferrule effect: Height of remaining tooth 2 mm at 4 locations (mesial, distal, buccal,

palatine or lingual) and thickness of remaining tooth walls 2.2 mm for an esthetic
restoration or 1.6 mm for non-esthetic restorations

Remaining root length: At least as long as the future crown height plus 5 mm for the
apical seal

Endodontic condition: Endodontic treatment may be performed without predictable

complications

Prognosis: Good
Class II

Ferrule effect: Height of remaining tooth 0.52 mm or width of remaining tooth walls
1.62.2 mm with visible margins or 1.21.6 mm with non-visible margins

Remaining root length: Less than crown height plus 5 mm but equal or greater than
crown height plus 3 mm
Endodontic condition: Without predictable complications or with uncertain results
Prognosis: Moderate

Note: A tooth in this class should not be used as an abutment. A new evaluation should be
performed after endodontic treatment in cases where pretreatment prognosis is uncertain.
Class III

Ferrule effect: Height of remaining tooth < 0.5 mm or width of remaining tooth wall <
1.2 mm at future margin level

Remaining root length: Less than crown height plus 3 mm

Endodontic condition: With irreversible complications

Prognosis: Poor
Note: A tooth in this class is not a candidate for treatment; it should be extracted and replaced by
a prosthesis.
The clinical record form below may be used to evaluate severely damaged teeth using these
criteria. Each parameter is evaluated and individually classified as I, II or III. Final classification
is the highest class for any parameter, i.e., a tooth rated I, II, I for the 3 parameters, is Class II.
Clinical record form for scoring teeth with extensive damage
Class I,
prognosis good

Ferrule
effect

Root length

Class II,
prognosis moderate

Height 2mm

Height 0,52 mm

Width 2.2 mm
(esthetic)

Width 1.62.2 mm
(visible margins)

1.6 (nonesthetic)

1.21.6mm (nonvisible margins)

Class III,
prognosis poor

Height < 0.5mm

Width < 1.2 mm

crown height +
5 mm

< crown height + 5

mm

< crown length +

3 mm

crown height + 3 mm
Endodontic

Without

Without predictable

With irreversible

condition

predictable
complications

complications or
uncertain treatment
results

complications

Final classification _________________________

Additional Clinical Considerations

Pre-prosthetic treatment may affect the initial classification.

Concern about special stress patterns (bruxism, abutments for a removable partial
denture, cantilevers, extensive bridges or secondary abutments) raises the class level from
I to II or from II to III.

Class level also increases by 1 if there are esthetic concerns.

In cases where there is no antagonist, no occlusal issues, the antagonist is a removable

denture or there is clinical evidence of small to no loads over the remaining tooth, the class
level decreases by 1.

For patients with poor oral hygiene, uncontrolled periodontal disease or caries, an
extensively damaged tooth should be considered Class III.
Conclusion
Clinical guidelines help the dentist arrive at the correct diagnosis and treatment plan, avoid
errors, increase the predictability of dental treatment and increase the quality of service.
Although the literature describes the rehabilitation of teeth with extensive endodontic damage,
no clinical guidelines have been published. Our goal in this article is to provide the clinician with
such guidelines for selection of extensively damaged teeth for rehabilitation.