Restoration

of pulpless teeth: Application

principles
in present and future contexts
Steven
Boston

M. Morgano,
University,

of traditional

DMDa

Goldman

School

of Graduate

Dentistry,

Boston,

Mass.

Posts
were
recommended
more
than
100 years
ago to retain
artificial
crowns.
Recent
studies
suggest
that posts
can weaken
teeth;
therefore
restorative
procedures
that
help preserve
pulpal
vitality
and eliminate
the need for posts are desirable.
If
endodontic
therapy
is unavoidable,
conservation
of remaining
tooth
structure
is most
important.
When
a post is required
to retain
a core for an artificial
crown,
a custom
cast post is the most
effective
means
of conserving
tooth
structure.
The length
of the
post should
not be compromised,
although
4 to 5 mm of apical
gutta-percha
must
be
maintained.
The restorative
prognosis
is improved
if the width
of the post does not
exceed
one half the width
of the root,
and the cemented
artificial
crown
should
extend
apical
to the core to provide
a 1.5 to 2 mm ferrule.
Complex
procedures
have
allowed
the dentist
to restore
extensively
damaged
teeth.
However,
extraction
and replacement
with
implant-supported
prosthodontics
may be more
prudent
with
severely
compromised
teeth.
(J PROSTHET
DENT 1996;75:375-SO.)

M
ethods of restoring pulpless teeth were described
more than 100 years ago. In 1871 Harrisi recommended
a
post or pivot to retain an artificial
crown in a root with
an extirpated
pulp, although endodontic
techniques were
crude at that time. Major advances in endodontic therapy
that occurred in this century have significantly
altered the
practice of dentistry.
Teeth that were once considered
nonrestorable
and extracted are commonly treated endodontically
and restored to function. The post or dowel that
was originally
designed merely to retain the coronal restoration when there was inadequate
remaining
tooth structure2 was later viewed as a method of reinforcement
of the
pulpless tooth.3 The rigid post or dowel has been assumed
to prevent horizontal
fracture of the tooth by directing
functional
and parafunctional
forces through the center of
the root.4

CONCEPTS

OF REINFORCEMENT

Data from an in vitro investigation

by Kantor and Pines5
reported that an intraradicular
post doubled the fracture
resistance of a root. Nevertheless,
other studies have indicated that transmission
of occlusal forces intraradicularly
predisposed
the root to vertical fracture.6, 7 Eissman and
Radke3 recommended
a cast restoration
that extended at
least 2 mm apical to the junction
of the core and the
remaining
tooth structure
and suggested that encirclement of the root with this ferrule effect would protect the
pulpless tooth against fracture by counteracting
spreading
forces generated
by the post.

Presented
before the Annual
Meeting
dontics,
Tucson,
Ark.,
May 1995.
AssociateProfessor
ofProsthodontics,
Sciences.
Copyright
0 1996 by the Editorial
PROSTHETIC

0022-3913/96/$5.00

APRIL1996

DENTISTRY.

+ 0 10/l/70207

of the Academy
Department
Council

of THE

of ProsthoofRestorative
JOURNAL

OF

Fig. 1. Rigid post and core can prevent horizontal

fracture of clinical crown; however, occlusal forces (OF) are
transmitted
to root as spreading
forces (SF). If artificial
crown extends 2 mm apical to junction
of core and tooth,
ferrule effect (FE) will resist spreading
forces and help
prevent vertical fracture. Post and core in combination
with artificial crown provide coronoradicular
stabilization.
Others have advocated this cast ferrule,s, and the combination of a post-core restoration
with an overcasting
to
act as a ferrule is commonly accepted today as a rational
approach to coronoradicular
stabilization
for a pulpless
tooth (Fig. 1). Nevertheless,
a recent nationwide
survey of
dentists philosophies
and techniques of restoring pulpless
teeth indicated major differences in treatment
approaches
and beliefs concerning
reinforcement.rO
Approximately
50% of the respondents
to the survey believed that a post
will reinforce an endodontically
treated tooth.rO There are
few in vivo reports of restored endodontically
treated teeth,

THEJOURNALOFPROSTHETICDENTISTRY

375

THE JOURNAL

OF PROSAIC

DE~TR~

but poorer successrates for pulpless teeth can be expected

compared with teeth with vital pulps.rla la Endodontically
treated teeth that serve as abutments to fixed or removable
prostheses have been reported to be most prone to failure,i3, l4 and several retrospective studies of f=ed partial
dentures (FPDs) with cantilever pontics suggested an inordinate failure rate for pulpless abutment teeth.15-i7 A
comprehensive retrospective study by Sorensen and Martinoffrs rs of 1273 endodontically treated teeth in the practices of nine general dentists found the custom-tapered
cast post and core more often associated with irreversible
damage to the tooth, and post placement did not increase
resistance to fracture of the tooth or dislodgment of the artificial crown. These investigators reported the highest
success rate with the parallel-sided serrated post.ls, I9
FAILURES
It is often assumed that the higher incidence of failure
observed for restored endodontically treated abutments is
primely related to the fragility of the sparse remaining
tooth structure.2Q However, mechanical weakness may not
be the only reason for the higher failure rate of pulpless
teeth. An in vivo investigation of the pressoreceptive function of endodontically treated teeth has indicated reduced
tactile sensation with these teeth.21 This altered pressoreceptive capacity may affect the patients ability to detect
functional overload and could be a significant contributing
factor to the higher fracture rate reported for pulpless
teeth.

Numerous features of posts have been implicated as

causes of failure. Tapered posts were claimed to produce
wedging stresses in the root, which can predispose the root
to fracture, and parallelism of the post has been suggested
as a method to reduce unwanted stresses.22s23An additional advantage of parallelism is improved retention, so
the post is less likely to be dislodged.24a25 Threaded posts
that actively engage tooth structure provide maximal rem
tention but have also been criticized for generating stresses
within the radicular dentin. 26,27 Guidelines at this time
are still confusing because of the lack of well-controlled in
vivo studies and the conflicting results of many in vitro investigations.
The studies of Sorensen and Martinoff18, I9 of 1273 endodontically treated teeth implied an inordinate failure rate
with cast metal posts. However, the data indicated that
almost one half the cast posts in their study were one half
or less the length of the clinical crowns. When the length
of the posts equaled the length of the clinical crowns, the
success rate was 97.5%. It appears that a limitation of the
investigations by Sorensen and Martinoffls ig was the lack
of control of the clinical procedures performed by the nine
dentists in the study.
Preliminary data from a retrospective study in progress
by Milot and Morgan0 conducted at the University of
Montreal School of Dental Medicine have indicated an im376

pressive success rate for custom-cast metal posts and

cores. More than 900 patients with pulpless teeth treated
by predoctora1 dental students restored with cast posts
were studied, and the overall success rate was approximately 96%. The one variable that appeared to have the
greatest influence on success was the width of the post.
When the radiographic width of the post exceeded one half
the width of the root, the success rate was considerably
poorer.
RECOMMENDATIONS
Indications

FOR THE

FUTURE

for posts

Posts do not reinforce endodontically treated teeth, but

they are indicated when there is inadequate tooth structure to retain a core for a coronal restorationZg Frequently,
pulpless anterior teeth can be conservatively restored with
a bonded composite resin restoration rather than an artificial crown.3o When significant coronal tooth structure
remains and preparation of the pulpless tooth is conservative, an artificial crown can often be placed without a post.
Nevertheless, because of their small diameter, mandibular
incisors and maxillary lateral incisors will commonly
require a post and core if an artificial crown is indicated.
If an anterior pulpless tooth will be restored with a complete crown and must serve as an abutment to a prosthesis; omission of the post may not be prudent regardless of
the amount of remaining coronal tooth structure. Also, a
post alone is not enough because the complete crown
retainer must include a ferrule that is 1.5 to 2 mm long. The
ferrule can improve resistance to dynamic occlusal loading,
help maintain the integrity of the cement seal of the artificial crown retainer, and reduce the potential for stress
concentration at the junction of the core and the post.31
When the ferrule is absent, occlusal forces must be resisted
exclusively by the post, which may eventually fracture.17
Molars can often be restored with a coronoradicular silver amalgam build-up followed by a complete veneer crown
or partial coverage cast restoration.32 This method is best
applied to molars with slight-to-moderate destruction of
coronal tooth structure where there is adequate depth to
the pulpal chamber and can occasionally be used with premolars.33 The coronoradicular amalgam post and core is
not as suitable when the molar has lost all tooth structure
above the gingival crest and the roots are well spaced with
a shallow pulpal chamber. Prefabricated posts are usually
indicated to augment the retention of the amalgam core
when the pulpa chamber is shallow. Dental amalgam
bonding agents such as 4-methac~lo~ethyl~mellitate
anhydride (4-META) resin can bond a silver amalgam core
to the tooth structure and augment conventional mechanical retention. If prefabricated posts are used, a 4-META
resin will also bond the silver amalgam to the posts. The
longevity of the resinous bond to the silver amalgam in the
oral cavity is upon,
but this approach appears promising.

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Length
Every effort should be made to ensure maximal length
of the post while maintaining
4 to 5 mm of apical guttapercha sea1.35 When roots are unusually
short or curved,
the post must often be shorter than desired and retention
will be less predictable. 36 In addition, greater leverage is
exerted when the post is shorter than the clinical crown
length, and this unfavorable
leverage can also predispose
to fracture of the root.36 Commonly the dentist will resort
to a threaded post that actively engages radicular
dentin
to compensate
for the limited retention
of a short post.
However, an active post is least desirable. A 4-META resinous cement can provide retention
that rivals a threaded
post but does not produce the unfavorable
stresses that occur when tooth structure is actively engaged.37 There are
no long-term
clinical trials on the effects of repeated mechanical loading and thermocycling
on the integrity of the
bond of this resinous cement. Therefore the in vitro retention reported
with a 4-META
cement may fatigue with
time as a result of plastic deformation
from normal intraoral forces.38
When the design of the post follows traditional
guidelines, conventional
cements are probably
the preferred
luting agents. Most resinous cements are relatively
expensive, technique sensitive, and difficult to manipulate,3g
whereas traditional
cements are less complicated,
more
cost effective, and have a long history of success. Also, unlimited retention is not necessarily the goal with any post.
If a post fractures, it must be removed from the root to
permit
retreatment.
4o The remnant
of a post that is
bonded to the root may require mechanical removal with
a high-speed handpiece and surgical-length
round bur-an
arduous task that can result in perforation
and loss of the
tooth. Furthermore,
it is preferable
that a post and core
dislodge because of cement failure rather than fracture the
root if the restoration
is subjected to excessive force.

Conservation

of tooth

structure

Conservation
appears to be the most critical factor for
success, although
the dentist should also strive for suffcient length of the post. 41 Because any prefabricated
post
system requires the dentist to instrument
the root to fit the
stock post, a custom-fitted
cast post is potentially
more
conservative
of tooth structure. With narrow single-rooted
teeth such as mandibular
incisors preservation
of tooth
structure
is especially important,
and custom-cast
posts
have been reported to offer better retention and resistance
to fracture compared with parallel-sided
serrated posts.42
Not all cast posts are made conservatively.
Strict adherence to the guideline of parallelism
of the post space may
result in overpreparation
of the apical one third of the post
channel. There will also be a sharp line angle at the apical
termination
of the post preparation
that can concentrate
stresses where the radicular
dentin is thinned and weakened (Fig. 2).43

AFRIL

1996

Fig. 2. A, From facial view it appears that there is

adequate thickness of dentin in apical one third of root for
parallel-sided
post (arrows). B, Proximal
view of root
reveals sparse remaining
facial and lingual dentin. Sharp
line angles (arrows) predispose to stress concentration
at
apical termination
of post.
Slightly tapered posts are easier to prepare and more
conservative
because most roots are tapered. The dentist
can remove the gutta-percha
to the desired depth and then
eliminate
any undercuts or residual endodontic
sealer on
the walls of the root canal. The post can then be designed
to fit the available space. The resultant
slightly tapered
post could theoretically
generate stresses at the coronal
one third of the root22; however, these stresses can be effectively counteracted
with a ferrule design to the overcasting.3 A tapered post is also less retentive than a perfectly parallel post is, 25 but sufficient length should provide
adequate retention
so long as the taper is kept to a minimum.44

Enhancing

the ferrule

effect

A beveled finish line for the overcasting can enhance the

ferrule effect and increase the fracture resistance of the
root. Bevels were once considered
desirable for all cast
restorations
by many prosthodontists
because of the geometric advantage or slip effect that facilitated
marginal
closure.45 Numerous studies have challenged this assumption that a cavosurface bevel will improve marginal
adaptation.46-4g The contemporary
approach to tooth preparations for complete crowns has tended to eliminate
cavosurface bevels, which require a potentially
unesthetic

377

TEZE JOUBNAL

OF PRO~~TI~

DE~ISTRY

MORGAN0

graph may curve dramatically in the third plane, and rigid

engine reamers can perforate the root when carried apitally to remove gutta-percha (Fig. 3). Shillingburg and
Kesslers5 also advocated extremely large Peeso reamers
for canal preparation, and a No. 6 reamer has been
suggested for maxillary central incisors. Because of the inherent risk of failure with excessively wide posts, these
recommendations should be revised.

Need for realistic

Fig. 3. From facial view palatal root of maxillary molar

appears relatively straight (A); however, root curves dramatically in third plane (E) and engine reamer such as
Pees0 reamer can perforate root.
metal m~~n.50 Nevertheless, for endodontically treated
teeth it appears that the beveled finish line is beneficial
and desirable when esthetics will permit. Milot and Stein51
have reported the results of an in vitro study that used
standardized plastic analogs to investigate the influence of
the cavosurface bevel on the fracture resistance of the root.
These investigators found a statistically significant increase in resistance to root fracture with three different
post systems for a beveled preparation compared with a
nonbeveled preparation.
Shillingburg et a1.52have advocated a contrabevel in the
preparation for the cast core to act as an additional ferrule
that is independent of the cast crown; however, Sorensen
and Engleman53 found no advantage to this contrabevel.
Also, a 1 mm beveled finish line for a complete crown
preparation without additional tooth structure coronal to
the bevel did not improve fracture resistance of the root.53

Conservative,
controlled
removal of gutta-percha

approach

to

A safe, rapid technique for removal of the gutta-percha

is the use of a heated instrument.54 The Touch h Heat
controlled heat inst~ent
(Analytic Technology Corp.,
Redmond, Wash.) is convenient for this purpose and virtually eliminates the potential to perforate the root. Peeso
reamers can then be used to remove the endodontic sealer
only. Rarely is a size larger than a No. 2 Peeso reamer necessary. Shillingburg and Kessler55 have recommended the
Peeso reamer for removal of the gutta-percha. However, a
root that appears straight on the two-dimensional radio-

378

treatment

planning

The philosophy of retaining severely compromised teeth

regardless ofthe cost of treatment or the prognosis also requires reevaluation. Commonly teeth that are carious to
the gingival margin are treated with surgical crown
len~he~ng or o~hodontic extrusion. A core is then retained with an intraradicular post, and the tooth is
restored with an artificial crown. The literature has
described numerous approaches to restoring compromised
pulpless molars with resected roots.56 Complex state-ofthe-art dental procedures have allowed the dentist to
restore teeth that are technically nonrestorable, but what
is the prognosis of these resurrected teeth? In the past
these relatively fragile teeth were treated similar to sound,
vital teeth. Often they were expected to serve as abutments
to cantilever FPDs, but failure was inordinately high.i5
Endodontically treated teeth with resected roots were also
commonly used as key abutments to FPDs, often as a
method to avoid a removable partial prosthesis.56 Nevertheless, a failure rate ranging from 32% to 38% has been
reported for resected pulpless teeth.57J 58 Root resective
procedures are technically demanding, and a high percentage of failures appears to be the result of faulty resections.5g

New treatment

options

Advances in endodontics altered the practice of dentistry

in the 1950s and provided the dentist with many more
treatment options. The reported predictability of implant
dentistry has further enhanced the dentists treatment alternatives.6065 It is now difficult for the contemporary
dentist to justify the use of questionable teeth as abutments to complex prosthetic restorations. Severely compromised teeth can often be extracted and replaced with
implant-supported FPDs or single crowns for comparable
costs and with a better prognosis.
Finally, the best approach to avoiding the problem of the
endodontically treated tooth is to avoid the need for endodontics. Wee-mean~g recommendations of very aggressive tooth preparations for artificial crowns that provide
the laboratory technician with more than enough room to
ensure favorable esthetics can jeopardize the vitality of
healthy pulps. A more conservative tooth preparation
might challenge the ingenuity of the laboratory technician
who is striving for optimal esthetics, but preservation of
sound, vital tooth structure will improve the long-term

VOLUME

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MORGAN0

prognosis of the tooth. Traditional guidelines for tooth

preparations should be reemphasized where tooth reduction is conservative but adequate for the planned restorative material and esthetic concerns are realistic. A fragile masterpiece with a guarded prognosis is not necessarily in the best interest of the patient or the dentist.@

SUMMARY
Endodontically treated teeth present unique problems;
therefore conservative restorative techniques that avoid
endodontic treatment are highly desirable. If endodontic
therapy is unavoidable, conservation of tooth structure
becomes even more important. A post may be required to
support a core, but the length of the post should not be
compromised and the width should be minimal. Slightly
tapered posts are more conservative and easier to prepare
than parallel-sided posts. The dentist must also develop a
ferrule for teeth restored with posts. When the length ofthe
post must be compromised because of anatomic limitations, a 4-META resinous cement can be used and is probably preferable to an active post. For severely compromised
teeth extraction and replacement with conventional or implant-supported prosthodontics should be considered because this treatment approach may be more predictable.

THE JOURNAL

16.

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21.

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23.
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25.
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61. Zarb GA, Schmitt A. The longitudinal

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62. Zarb GA, Schmitt A. The longitudinal
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Reprint requests to:
DR. STEVEN M. MORGANO
BOSTON UNIVERSITY
GOLDMAN SCHOOL OF GRADUATE DENTISTRY
DEPARTMENT OF RESTORATIVE SCIENCES, ROOM 612
100 E. NEWTON ST.
BOSTON, MA 02118

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