Restoration of pulpless teeth: Application of traditional

principles in present and future contexts

Steven M. Morgano, DMDa
Boston University, 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 compro-
mised 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 endo-
dontically and restored to function. The post or dowel that
was originally designed merely to retain the coronal resto-
ration when there was inadequate remaining tooth struc-
ture2 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 Fig. 1. Rigid post and core can prevent horizontal frac-
reported that an intraradicular post doubled the fracture ture of clinical crown; however, occlusal forces (OF) are
transmitted to root as spreading forces (SF). If artificial
resistance of a root. Nevertheless, other studies have indi-
crown extends 2 mm apical to junction of core and tooth,
cated that transmission of occlusal forces intraradicularly ferrule effect (FE) will resist spreading forces and help
predisposed the root to vertical fracture.6, 7 Eissman and prevent vertical fracture. Post and core in combination
Radke3 recommended a cast restoration that extended at with artificial crown provide coronoradicular stabilization.
least 2 mm apical to the junction of the core and the
remaining tooth structure and suggested that encircle-
Others have advocated this cast ferrule,s, ’ and the com-
ment of the root with this “ferrule effect” would protect the
bination of a post-core restoration with an overcasting to
pulpless tooth against fracture by counteracting spreading
act as a ferrule is commonly accepted today as a rational
forces generated by the post.
approach to coronoradicular stabilization for a pulpless
tooth (Fig. 1). Nevertheless, a recent nationwide survey of
Presented before the Annual Meeting of the Academy of Prostho- dentists’ philosophies and techniques of restoring pulpless
dontics, Tucson, Ark., May 1995. teeth indicated major differences in treatment approaches
“AssociateProfessor ofProsthodontics, Department ofRestorative and beliefs concerning reinforcement.rO Approximately
Sciences.
Copyright 0 1996 by the Editorial Council of THE JOURNAL OF
50% of the respondents to the survey believed that a post
PROSTHETIC DENTISTRY. will reinforce an endodontically treated tooth.rO There are
0022-3913/96/$5.00 + 0 10/l/70207 few in vivo reports of restored endodontically treated teeth,

APRIL1996 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 fail-
ure,i3, l4 and several retrospective studies of f=ed partial
dentures (FPDs) with cantilever pontics suggested an in-
ordinate failure rate for pulpless abutment teeth.15-i7 A
comprehensive retrospective study by Sorensen and Mar-
tinoffrs rs of 1273 endodontically treated teeth in the prac-
tices 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 ar-
tificial 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 func-
tion of endodontically treated teeth has indicated reduced
tactile sensation with these teeth.21 This altered pressore-
ceptive capacity may affect the patient’s 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 addi-
tional 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 in-
vestigations.“”
The studies of Sorensen and Martinoff18, I9 of 1273 end-
odontically 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 im-
376
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 approxi-
mately 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 FOR THE FUTURE
Indications for posts
Posts do not reinforce endodontically treated teeth, but
they are indicated when there is inadequate tooth struc-
ture 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 arti-
ficial crown.3o When significant coronal tooth structure
remains and preparation of the pulpless tooth is conserva-
tive, 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 com-
plete crown and must serve as an abutment to a prosthe-
sis; 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 arti-
ficial 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 sil-
ver 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 pre-
molars.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 mechan-
ical 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 prom-
ising.
VOLLME 75 NCJMRER 4
 THE JOURNAL OF PROSTHETIC DENTISTRY

Length
Every effort should be made to ensure maximal length
of the post while maintaining 4 to 5 mm of apical gutta-
percha 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 res-
inous cement can provide retention that rivals a threaded
post but does not produce the unfavorable stresses that oc-
cur when tooth structure is actively engaged.37 There are
no long-term clinical trials on the effects of repeated me-
chanical loading and thermocycling on the integrity of the
bond of this resinous cement. Therefore the in vitro reten-
tion reported with a 4-META cement may fatigue with
time as a result of plastic deformation from normal intra-
oral forces.38
When the design of the post follows traditional guide-
lines, conventional cements are probably the preferred
luting agents. Most resinous cements are relatively ex- Fig. 2. A, From facial view it appears that there is
pensive, technique sensitive, and difficult to manipulate,3g adequate thickness of dentin in apical one third of root for
whereas traditional cements are less complicated, more parallel-sided post (arrows). B, Proximal view of root
cost effective, and have a long history of success. Also, un- reveals sparse remaining facial and lingual dentin. Sharp
limited retention is not necessarily the goal with any post. line angles (arrows) predispose to stress concentration at
If a post fractures, it must be removed from the root to apical termination of post.
permit retreatment. 4o The remnant of a post that is
“bonded” to the root may require mechanical removal with
Slightly tapered posts are easier to prepare and more
a high-speed handpiece and surgical-length round bur-an
conservative because most roots are tapered. The dentist
arduous task that can result in perforation and loss of the
can remove the gutta-percha to the desired depth and then
tooth. Furthermore, it is preferable that a post and core
eliminate any undercuts or residual endodontic sealer on
dislodge because of cement failure rather than fracture the
the walls of the root canal. The post can then be designed
root if the restoration is subjected to excessive force.
to “fit the available space.” The resultant slightly tapered
post could theoretically generate stresses at the coronal
Conservation of tooth structure one third of the root22; however, these stresses can be ef-
Conservation appears to be the most critical factor for fectively counteracted with a ferrule design to the over-
success, although the dentist should also strive for suff- casting.3 A tapered post is also less retentive than a per-
cient length of the post. 41 Because any prefabricated post fectly parallel post is, 25 but sufficient length should provide
system requires the dentist to instrument the root to fit the adequate retention so long as the taper is kept to a mini-
stock post, a custom-fitted cast post is potentially more mum.44
conservative of tooth structure. With narrow single-rooted
Enhancing the ferrule effect
teeth such as mandibular incisors preservation of tooth
structure is especially important, and custom-cast posts A beveled finish line for the overcasting can enhance the
have been reported to offer better retention and resistance ferrule effect and increase the fracture resistance of the
to fracture compared with parallel-sided serrated posts.42 root. Bevels were once considered desirable for all cast
Not all cast posts are made conservatively. Strict adher- restorations by many prosthodontists because of the geo-
ence to the guideline of parallelism of the post space may metric advantage or “slip effect” that facilitated marginal
result in overpreparation of the apical one third of the post closure.45 Numerous studies have challenged this assump-
channel. There will also be a sharp line angle at the apical tion that a cavosurface bevel will improve marginal adap-
termination of the post preparation that can concentrate tation.46-4g The contemporary approach to tooth prepara-
stresses where the radicular dentin is thinned and weak- tions for complete crowns has tended to eliminate cavo-
ened (Fig. 2).43 surface bevels, which require a potentially unesthetic

AF’RIL 1996 377

TEZE JOUBNAL OF PRO~~TI~ DE~ISTRY
Fig. 3. From facial view palatal root of maxillary molar
appears relatively straight (A); however, root curves dra-
matically 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 in-
crease 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 approach to
removal of gutta-percha
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 virtu-
ally 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 nec-
essary. 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
MORGAN0
graph may curve dramatically in the third plane, and rigid
engine reamers can perforate the root when carried api-
tally 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 in-
herent risk of failure with excessively wide posts, these
recommendations should be revised.
Need for realistic treatment planning
The philosophy of retaining severely compromised teeth
regardless ofthe cost of treatment or the prognosis also re-
quires 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 re-
tained 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-of-
the-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 Never-
theless, 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 per-
centage of failures appears to be the result of faulty resec-
tions.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 dentist’s treatment al-
ternatives.60‘65 It is now difficult for the contemporary
dentist to justify the use of questionable teeth as abut-
ments to complex prosthetic restorations. Severely com-
promised 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 end-
odontics. Wee-mean~g recommendations of very aggres-
sive 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 75 NLJMRER 4
MORGAN0 THE JOURNAL OF PROSTHETIC DENTISTRY

prognosis of the tooth. Traditional guidelines for tooth lous patients using cantilever bridges: a retrospective study. Int J Pe-
riodont Rest Dent 1989;9:364-75.
preparations should be reemphasized where tooth reduc- 16. Karlsson S. Failures and length of service in fmed prosthodontics after
tion is conservative but adequate for the planned restor- long-term function: a longitudinal clinical study. Swed Dent J 1989;
ative material and esthetic concerns are realistic. A frag- 13:185-92.
17. Torbjomer A, Karlsson S, Cdman PA. Survival rate and failure char-
ile masterpiece with a guarded prognosis is not necessar- acteristics for two post designs. J PROSTHET DENT 1995;73:439-44.
ily in the best interest of the patient or the dentist.@ 18. Sorensen JA, Martinoff JT. Clinically significant factors in dowel
design. J PROSTHET DENT 1984;52:28-35.
19. Sorensen JA, Martinoff JT. Intracoronal reinforcement and coronal
SUMMARY coverage: a study of endodontically treated teeth. J PROSTHET DENT
Endodontically treated teeth present unique problems; 1984;51:780-4.
20. Gutmann JL. The dentin-root complex: anatomic and biologic consid-
therefore conservative restorative techniques that avoid erations in restoring endodontically treated teeth. J PROSTHET DENT
endodontic treatment are highly desirable. If endodontic 1992;67:458-67.
therapy is unavoidable, conservation of tooth structure 21. Randow K, Glantz PO. On cantilever loading of vital and non-vital
teeth: an experimental clinical study. Acta Odontol Stand 1986;
becomes even more important. A post may be required to 44:271-7.
support a core, but the length of the post should not be 22. Standlee JP, Cap&o AA, Collard EW, Pollack MH. Analysis of stress
compromised and the width should be minimal. Slightly distribution by endodontic posts. Oral Surg Oral Med Oral Pathol
1972;33:952-60.
tapered posts are more conservative and easier to prepare 23. Cooney JP, Caputo AA, Trabert KC. Retention and stress distribution
than parallel-sided posts. The dentist must also develop a of tapered-end endodontic posts. J PROSTHET DENT 1986;55:540-6.
ferrule for teeth restored with posts. When the length ofthe 24. Standlee JP, Caputo AA, Hanson EC. Retention of endodontic dowels:
effects of cement, dowel length, diameter, and design. J PROSTHET DENT
post must be compromised because of anatomic limita- 1978;39:400-5.
tions, a 4-META resinous cement can be used and is prob- 25. Johnson JK, Sakumura JS. Dowel form and tensile force. J PROSTHET
ably preferable to an active post. For severely compromised DENT 1978;40:645-9.
26. Standlee JP, Caputo AA, Halcomb J, Trabert KC. The retentive and
teeth extraction and replacement with conventional or im- stress-distributing properties of a threaded endodontic dowel. J PROS-
plant-supported prosthodontics should be considered be- THET DENT 1980;44:398-404.
cause this treatment approach may be more predictable. 27. Deutsch AS, Musikant BL, Cavallari J, et al. Root fracture during in-
sertion of prefabricated posts related to root size. J PROSTHET DENT
1985;53:786-9.
28. Morgan0 SM, Milot P. Clinical success of cast metal posts and cores. J
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