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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

SD

f

Part

I of

th is th ree-par t l i te ra tu re rev iew d iscusses the inc idence

of

endodont ic t rea tment

requ i red a f te r p ros thodont ic p rocedures wh ether c row ns a re needed on endodont ica l ly t rea ted

tee th the p r imary purpose of posts the causes

of

pos t and core fa i lure roo t f racture incid ence data

and p as t des ign cons idera t ions . Per t inen t ques t ions a re addressed based on th e p as t

25

years

of

dent al l i terature.

JPros thod 1994;3:243 250. Copyri ght D

1994

b y the American College of Prosthodontists.

INDEX WORDS: endodont ica l ly t rea ted teeth pos ts and cores inc idence da ta

PLETHORA

OF articles have been written in

A

he 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 5years. Another single crown study2found that

the incidence was 4% after 34 months.

The incidence of fixed partial denture abutments

PmjssorandDean. Lorna Linda UnIniversiQ

Schwl

oJDentisty.

Lorna

fihoc iate

Professor o

Endodontics. Indiana

Unicersi& School o

ConexpnnPact to: Charles

J.

Gomiacre, DDS, MSD oma Linda

C@ynght

994 by

the

American College

ofPro.ithodonti.sts

1059-941Xf94/0304-00II$5.W/0

Linda,a

DPntisly,

Indianafilb.

IN

lhirmsi

LSchwl

JDentiit91, omn

Tin&

CA 92350.

requiring endodontic treatment has varied in differ-

ent studies. The results have been: 3% after 5years?

3 after 10years,&

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 trea tment . 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

43



244

Endonticalb

Treated Teeth Goodacre

and Sfilnik

12 years after prosthesis placcment, rather than

within the first fewyears as one might expect.”

Abou-RassL2 oined 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 tha t “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 centra l 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 centra l 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 Vo‘olume.3,

Number

4

45

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 ~ t r n a n n ’ ~as 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.15Reeh 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 tha t dentin from endodonti-

cally trcated teeth shows significantly lower shear

strength and toughness than dentin from vital teeth.

Rivera et alZ0 tated tha t 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 PostsR e i n f o r c e

E n d o d o n t i c a l l y T r e a t e d T e e t h ?

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*’ ound 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 cent ral 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~etermined 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 alZ4measured

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 tee th

with or without a post. Trope et alZ5 etermined 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 Pinesz6determined 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.



46

Endonticalb Treated 'I'Peth Go oodacreand polnik

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 dent in 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.

Summay

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 fd ur e. A post and core could prevent

the fracturc of this thin coronal tooth structurc.

What re 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') eported 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 o r 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 3329 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

Volume3,

Number

4

247

Figure

6 .

A

post and corewas 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 138posts and cores after 10 years or more.

The r e 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

eported 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~tentive?~-~’e-

mented, parallel-sided posts have been found to

be

more retentive than cemented tapered p o ~ 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 the ir experience with

cemented, tapered posts over 10 years or more. In a

clinical study of cemented tapered posts placed by

dental students, Bergman et a132 stated 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

t ha t

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 ndicated tha t 10% of post and core

failures

were

attributable to root fracture. I n a study4

of crown and fixed partial denture failures from all

causes, tooth fractures accounted for

3.9%

of the

failures, In this study, f ractures w‘ere fur ther 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: 134with no posts and 86 with posts.

None of the tee th 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 ound that tapered, threaded posts

were the

worst

stress producers. In comparing three

threaded prefabricated posts, Deutsch et a P ound



24

8

k;ndonti culb 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 a p ~ 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 a P 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 ound that cemented posts produced less

stress than threaded posts.

Traber t ct aF9 indicated tha t 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 oot 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 at tributable 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

L e s s

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 ca t

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.

In 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* ound that parallel-

sided posts distribute stress more evenly to the root

than to the tapered posts. Two finite element analy-

sis

s t ~ d i e s j ~ . ~ ~ound similar results.

Two

photoelastic

studies ,5q found that parallel posts concentrate

stress apically, whereas tapered posts concentrate

stress at the post-to-core unction.

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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