CLINICAL EBOOK SERIES

POWERED BY

SPOTLIGHT ON
ENDODONTICS
AUGUST 2019

2 C E C R E D I T S C A S E R E P O R T

POST AND CORE ENDODONTIC-PERIODONTAL LESIONS

Handling Posts and Salvaging a Periodontally

Cores for Successful Compromised and
Endodontic Cases Endodontically Involved
Joseph Chikvashvili, DDS Three-Rooted Mandibular
First Molar With Cervical
Enamel Projection
J. Sylvia Western, MDS; Vivek Vijay Gupta, MDS; and Srinivas
Sulugodu Ramachandra, MDS

SUPPORTED BY AN UNRESTRICTED GRANT FROM CARESTREAM DENTAL • Published by AEGIS Publications, LLC © 2019
 The Root of the
Problem
of Continuing Education in Dentistry

T
AUGUST 2019 | www.compendiumlive.com

PUBLISHER
AEGIS Publications, LLC
his special eBook from Compendium puts the of Continuing Education in Dentistry
SPECIAL PROJECTS MANAGER
spotlight on two articles on endodontics. The first C. Justin Romano

article is a continuing education (CE) course on SPECIAL PROJECTS EDITOR

Cindy Spielvogel
how to handle posts and cores for successful cases. of Continuing Education in Dentistry
SPECIAL PROJECTS COORDINATOR
The second article is a case report on salvaging a June Portnoy
periodontally compromised and endodontically involved three- BRAND DIRECTOR
rooted mandibular first molar with cervical enamel projection. Matthew T. Ingram

The CE article describes techniques for placement of posts, MANAGING EDITOR

Bill Noone
along with explaining the equally important decision not to
CREATIVE
place a post, depending on the case. As the author explains, the Claire Novo
best option is to aim for the most conservative access, while EBOOK DESIGN
determining whether a prefabricated or fiber post is ideal. Jennifer Barlow

Clinicians should adhere to placement principles for posts for

retention of cores and strengthening of connections between
coronal buildup material and tooth structure. Successful post
placement takes under consideration the quantity and quality
of tooth structure, along with adjacent teeth, occlusion, para-
function, and future restorations. The author concludes that
providing the most optimal patient care is accomplished by
careful decision-making before, during, and after root canals
and other endodontic treatments.
The second article presents a case report on a multidisci-
plinary approach to the management of a mandibular first
COVER
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molar with an additional distolingual root (radix entomolaris)

and grade III cervical enamel projection. The diagnosis for
the case was an endodontic-periodontal lesion due to non-
vitality and associated advanced periodontal destruction.
The patient was treated with drainage of the periodontal ab-
scess with adjunct antibiotics, phase I periodontal therapy, Chief Executive Officer
Daniel W. Perkins
endodontic therapy, radiculoplasty, regenerative periodontal
President
therapy, replacement of the missing right mandibular second Anthony A. Angelini
molar, and long-term maintenance. The authors conclude Chief Operating and Financial Officer
that, with early identification and by following a multidisci- Karen A. Auiler
plinary approach, clinicians can successfully treat compro- Media Consultant, Midwest and West
Jeffrey E. Gordon
mised three-rooted mandibular molars with cervical enamel
Media Consultant, East
projection. Scott MacDonald
Compendium takes pride in offering a variety of informa- Subscription and CE information
tion on topics in dentistry. For more articles on endodon- Hilary Noden
877-423-4471, ext. 207
tics, please visit https://www.aegisdentalnetwork.com/cced/ hnoden@aegiscomm.com
endodontics/.

Sincerely,

Louis F. Rose, DDS, MD

AEGIS Publications, LLC
Editor-in-Chief 140 Terry Drive, Suite 103
lrose@aegiscomm.com Newtown, PA 18940

2 COMPENDIUM EBOOK SERIES August 2019 | Volume 40 Number 16 www.compendiumlive.com

 CONTINUING EDUCATION POST AND CORE

Handling Posts and Cores for

Successful Endodontic Cases
Joseph Chikvashvili, DDS

ABSTRACT: Techniques for placement of posts—or the equally important decision

not to place a post—depend on the particular conditions of each unique case. The best
option is to aim for the most conservative access, while determining whether a pre-
fabricated or fiber post is ideal. Clinicians should adhere to placement principles for
posts for retention of cores and strengthening of connections between coronal buildup
material and tooth structure. Successful post placement considers quantity and qual-
ity of tooth structure, along with adjacent teeth, occlusion, parafunction, and future
restorations. The rationale also takes into account patients’ goals and reasonable
possibilities for their budgets. The author concludes that providing the most optimal
patient care is accomplished by careful decision-making before, during, and after root
canals and other endodontic treatments.

LEARNING OBJECTIVES

• Explain in which situations it is • Delineate the difference • Examine case-by-case

appropriate or inappropriate to between concerns with considerations for conservative-
place a post. prefabricated and fiber posts. access placement principles for

T
posts in endodontic scenarios.

he topic of “post and core” is per- Root-Canal Access

tinent to both endodontics and Ultimately, the aim in endodontics is to pre-
general dentistry. For every cli- serve the tooth as long as possible for the pa-
nician, there is a unique way in tient. A clinician may want to do a root canal
which to do successful post-and- but must face realistic concerns, such as not
core dentistry; the field is highly complex. having enough tooth.1 Figure 1 shows a case
However, within the complexity, it is pos-
sible to focus on developing expertise in a
specific area that occurs at a high frequency
in post-and-core dentistry: prefabricated
posts. Clinicians are often curious about
which post system is best, when in fact no
post is the “best” post. The more conserva-
tive a clinician’s access, the greater the likeli-
hood of obtaining longevity from a root canal
or restoration. This article explores methods
Fig 1.
for obtaining conservative access and ensur-
ing clinical success. Fig 1. Limited access.

DISCLOSURE: The author received an honorarium for the webinar program on which this article is based.

3 COMPENDIUM EBOOK SERIES August 2019 | Volume 40 Number 16 www.compendiumlive.com

 CONTINUING EDUCATION
where the clinician was able to access four
canals through a zirconium crown, with
limited access. Generally, it is preferable to
err on the side of opening larger and clean-
ing out well. If the access is too small, three
problems arise: (1) clinicians may not clean
effectively; (2) there is a greater chance of
separation because there is not enough of a
straight path, and (3) canals may be missed.
Conversely, if clinicians open too large, they
can destroy the tooth. There is a happy me-
dium where the result is fine-tuned and engi-
neered perfectly. Although the perfect result
is not always possible or ideal, clinicians con-
tinue to strive for it. The best approach is to
find the canals and then open them up under
a microscope to get enough access. This gives
the clinician whatever shape is needed for
conservative access.
Types of Posts
Many teeth need to be restored with posts,
whether prefabricated metal posts, cast posts,
or fiber posts. Fiber posts are currently the
best option, but the most popular of the posts
has been the prefabricated metal post.2 It is
easier to use, cheaper, and provides more vari-
ability; clinicians can acquire many inexpen-
sive and different sizes.3 Various options offer
more flexibility, depending on the manner in
which each case presents itself. The purpose
of a post is to retain the core. Posts are used to
retain composite, metal, or amalgam cores and
help strengthen the connection between the
coronal buildup material and the remaining
tooth structure.
Principles of Post Placement
Certain principles must be accounted for to
have a successful post and core.4 These prin-
ciples can act as guidelines for the clinician:
(1) quantity of tooth structure remaining,
(2) quality of tooth structure remaining, (3)
structures adjacent to the tooth, (4) occlu-
sion and parafunctional habits, and (5) future
4 COMPENDIUM EBOOK SERIES August 2019 | Volume 40 Number 16 www.compendiumlive.com
POST AND CORE
restoration. Understanding the principles
laid out in this article will enable clinicians
to make the right decision based on the case
at hand.
Quantity of Tooth Structure
When considering quantity, in general when
more than half the tooth structure is missing,
the clinician should consider placing a post.
The issue is whether there is enough structure
for retention of the crown. It depends on the
ferrule, which can be defined as a 360-degree
metal collar of the crown surrounding the par-
allel walls of the dentine extending coronal to
the shoulder of the preparation.5 Sometimes
the clinician has a situation where there is no
ferrule, and other times the ferrule is almost
ideal. The ideal is when there is no core, just
the natural tooth functioning as the core, al-
though there are exceptions.
In the ideal situation for restoring a tooth,
3 mm of the wall is on one side and 2 mm on
the other, which indicates at least a 2-mm
ferrule.6 In this case, the clinician is going to
have a higher chance of success. Restorations
can occur in other situations, but the patient
should be warned that failure is possible in
certain scenarios.
Quality of Tooth Structure
When looking at the quality of the tooth struc-
ture, the clinician is looking for indications of
non-ideal conditions, such as discoloration,
cracks, an undercut, and concavities. The
first premolar has a concavity, but sometimes
there are concavities in molars, such as the
distal of the lower molar or the palatal of the
maxillary molar, eg, No. 3. These are teeth
that should get posts. The clinician should
aim to place the post in the straighter-path
canal. On tooth No. 5, for example, it is usu-
ally the palatal. There are times when the
straighter option could be another canal, such
as the buccal, but generally the palatal is the
best option.6
 CONTINUING EDUCATION POST AND CORE

Fig 2. Fig 3.
Fig 2. Minimal walls.

Figure 2 shows a situation where the clini-

cian excavated the tooth of a patient with decay,
and it pulped out. The buccal and lingual walls
were intact; however, the walls were minimal,
and there were still fragments of amalgam and
cracks. If the clinician prepared this tooth af-
ter building it up, the clinician would lose all
the good tooth structure that was left. This
tooth would likely need a post. Fig 4.

Adjacent Structures
If a tooth stands alone, greater forces will be
placed on it because it has no adjacent teeth
to provide support. This situation will affect
the decision-making process for placing a
post. Figure 3 shows a tooth that was on an
island and would be having three implants
placed in front of it. The tooth would take a
much greater beating than another tooth that
had support proximally. Even though it had
a good root canal, the clinician would need
Fig 5.
to account for whether the tooth would last
until the implants integrated. Figure 4 shows Fig 3. Tooth on an island. Fig 4. Case that quickly
a case that would quickly proceed to implants. would proceed to implants. Fig 5. Root tip left from
old extraction.
The patient had a less-than-ideal bridge for
over a decade, with decent endodontics and non-threaded post, there should not be excess
functionality. There was also an overhang on gutta-percha because it is not as solid as the
the premolar. The post was not ideal in this tooth and will lead to greater movement. That
case because there was one distal canal and movement on the tooth and bridge will create
not all the gutta-percha was removed from it. too much force and result in demise.
An intimate fit should be the goal with the post Figure 5 shows an interesting situation
and the walls. Whether using a threaded or where a root tip was left from an old extraction.

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 CONTINUING EDUCATION
There was an area of necrotic tooth in the pre-
molar that caused pain to the patient, who was
also a heavy smoker. She had already experi-
enced failure of three implants. When they
failed, the clinicians tried to place just one im-
plant slightly wider and thicker to resolve the
issue, but that also had failed. Removing the
bridge for an expensive treatment involving
two implants and a new bridge was not an op-
tion. The clinicians needed to find a way to save
the situation so her bite would remain optimal.
They considered removing the bridge and re-
placing it with a long bridge from the molar to
the canine adjacent to the premolar. They also
considered a partial, because she was missing
some teeth on the other side. After a lengthy
discussion, they decided to do whatever they
could to maintain her current bridge, planning
to move to partials when the bridge failed.
Figure 6 shows the successful root canal that
stopped the patient from being in pain, but she
still had some discomfort. The images did not
show anything significant; the case was com-
pleted at a time when cone-beam computed
tomography (CBCT) was not routine. The
clinicians had to trust what they saw, which
was 6-mm probing that left a chance for a
crack in the tooth. There was a buccal frac-
ture of the mesial root. There was bone apical
to it but nothing coronally, so they decided
to resect the root. They cut it out, put some
holes into the bone, and added demineralized
Fig 6.
Fig 6. Successful root canal.
6 COMPENDIUM EBOOK SERIES August 2019 | Volume 40 Number 16 www.compendiumlive.com
POST AND CORE
freeze-dried bone. They also later put a col-
lagen membrane over it and closed it.
This was not an ideal situation; the ideal
would have been to take the bridge out and
place implants, but that would not have been
possible with a patient who had already expe-
rienced four implant failures. The implants
that had failed were in the maxilla, so it was
possible they would have been better in a dif-
ferent location, but it would also have been
significantly more expensive.
The bridge that had lasted about 14 years
managed to then last another 5.5 years before
it cracked and failed. The question of whether
the delay was worth the trouble was a personal
choice only the clinician could make with the
patient based on the unique circumstances.
Because the post was not placed perfectly, it
added stress that led to the mesial root cracking.
Occlusal Considerations
Occlusion is one of the most overlooked areas
in endodontics; however, other than remain-
ing structure, it is the most important factor.7
Patients who are heavy bruxers can cause the
need for a root canal from the lateral forces.
Patients who clench pose a different challenge
with apical forces, yet the damage from both
can be the same. Figure 7 shows a patient with
bruxism. The patient had pain in response
to hot and cold stimulus, and the clinicians
needed a bitewing to determine which tooth
was causing the pain. From the periapical (PA),
it was clear that tooth No. 2 had a large prob-
lem, No. 3 had a crown, and No. 4 had a large
restoration. Any of the three may have been
the source of the problem.
With the bitewing shown in Figure 8, it be-
came clear there was gross decay in tooth No.
3 that could not be seen on the PA, and there
was a periodontal defect, a pulp stone, in No.
2. There was also a class V lesion revealing the
bruxism, flat occlusion, multiple restorations
in No. 30, a post in No. 31, and decay on No. 2
as well. The post in No. 31 was useless because
 CONTINUING EDUCATION POST AND CORE

Fig 7. Fig 9.

Fig 8. Fig 10.

Fig 7. Bruxism. Fig 8. Bitewing revealed decay and

other problems.

when a post is placed, it must be the right length,

width, and size. If the post is too short, there will
be a greater fulcrum and the tooth will break. If
it is too long, the clinician can break it by wedg-
ing it. If it is too short, it will not hurt the tooth,
but it will not provide any valuable function. It is
overall preferable to do posts in teeth having just
single restorations rather than abutments for
bridges because those teeth are already under
Fig 11.
greater force. If the technique is not performed
correctly, iatrogenic issues may result. Fig 9. Significant bleeding and other problems
resulted from this case. Fig 10. Repair was initially
successful. Fig 11. The repair lasted 8.5 years.
Consideration of Future Restorations
Figure 9 shows a situation on tooth No. 12 that be learned from this case is that a solution
may have been presumed to be easily resolv- does not have to look pleasant for it to work.
able. However, the dentist experienced prob- Functionally, the repair shown in Figure 10
lems, including significant bleeding. It was due was successful because the clinician was able
either to irreversible pulpitis or a perforation. to fix the whole wall with mineral trioxide ag-
Judging by the PA, something detrimental was gregate (MTA) and was able to find the ca-
occurring with the distal. A lesson that can nal. The clinician also put in the post for the

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 CONTINUING EDUCATION POST AND CORE

general dentist and closed it. Later, the general thickness of the walls and what the canal will al-
dentist took the post out and replaced it with a low. In this case, it was done under a rubber dam,
post that was larger and shorter than would be which was beneficial; often clinicians will see
recommended. Interestingly, the result lasted teeth that have good endodontics, but multiple
8.5 years, as shown in Figure 11. years later, radiolucency will appear because
The clinician took the path described be- when the post was placed, saliva seeped in.
cause the patient initially came in with some The rules for placement of a post depend
sensitivity on the tooth, but the issue quickly on good retention: the greater the length, the
progressed to the need for a root canal and the greater the retention.3 Also, two-thirds of the
possibility of losing the tooth because her gen- length of the root is ideal, but 4 to 5 mm of api-
eral dentist had inadvertently destroyed the cal gutta-percha is essential because anything
wall. Unfortunately, the story does not have less than that will disrupt the seal.8 Figure 14
a happy ending: at 9.25 years, the repairs fi- shows a case where a patient had a post, core,
nally broke. Yet the case is important because and crown. The threaded post was shorter
it shows that a resolution for even a “terrible” than ideal because the tooth was longer. Not
case can last almost 10 years and be to some
extent a success. When the right principles
are maintained, there can still be a successful
outcome. The reason this case in particular
succeeded was because of a factor that was
barely visible: above the perforation repair
was 2 mm of ferrule and, therefore, coronal
tooth structure. The perforation was not only
below the gum but also the bone, which is gen-
erally a more ideal location for a perforation.
Figure 12 shows an example of a post that
was too long. Although it was a pleasant-
looking threaded post, there was about a mil-
limeter of gutta-percha, where ideally 4 to 5
mm of gutta-percha would be used.8 This was Fig 12.
also an iatrogenic problem where the referring
dentist put a post directly into the furcation.
This type of problem can be fixed by removal
and repairing with MTA. However, because
there was not much tooth structure, the tooth
became far more compromised.
Figure 13 shows an example where there was
likely a good root canal that was absorbed. The
way to avoid this type of problem is that the per-
son who does the root canal should do the post.
This is not always possible, and some general
dentists like to do the restorative work them-
Fig 13.
selves, but the advantage of having the same per-
son do both is that the person is familiar with the Fig 12. The post was too long. Fig 13. A good root
curve of that canal. That clinician also knows the canal may have been absorbed.

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 CONTINUING EDUCATION POST AND CORE

visible was the mental foramen underneath.

The patient did not have the financial resourc-
es to have the case redone. However, when the
post would be removed, the clinician would
need to trephine or use an ultrasonic around
it, making the access bigger than an ideal con-
servative access. Potentially, the crown would
come off. The patient did not have finances
for re-treating the tooth and could not have
an apicoectomy because the mental foramen
was directly under the tooth. Fig 14.
The options, therefore, were to extract it and
put a bridge or an implant in later when funds
were acquired, or, as was done in this case, per-
form an intentional replant. The clinician ex-
tracted the tooth, cut it, placed MTA, and then
put it back under occlusion using sutures—al-
though the clinician would normally put com-
posite in each corner to maintain it and would
not etch. Usually after 2 weeks, there is stabil-
ity. Figure 15 shows the postoperative radio-
graph, and Figure 16 shows a radiograph 4.5 Fig 15.
years later. The patient’s probing went from 3
to 4 mm, but overall it was a success because
something is always lost coronally, whether
the case is a replant or an implant.

Post Diameter, Texture,

and Material
Post diameter and texture are other important
concerns. Achieving less than one-third of the
diameter of the root is ideal, and at least a mil-
limeter of dentin should be achieved circum-
ferentially. Without that, the clinician would
be looking for a fracture. One millimeter is
the minimum, with one-and-a-half millime-
ters being ideal. With regard to texture, ser-
rated and roughened posts provide greater
retention because they provide more surface
area. Similarly, the clinician can sandblast.
Additionally, the cement that is used is impor-
tant. Luting agents are not all equal. Resin and
glass-ionomer cements are generally superior
to others.9 Custom cast post and core is more
prudent for use in large canals or very oval
Fig 16.
Fig 14. The post was shorter than ideal. Fig 15.
Postoperative radiograph. Fig 16. Radiograph
after 4.5 years.
canals in some maxillary anterior teeth, such
as No. 8, No. 9, and No. 10.
Prefabricated posts are better for circular ca-
nals and are less expensive, but there are defi-
nitely times when clinicians would want to do
the cast and core, especially if they do not have
a lot of tooth structure; it will be significantly

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 CONTINUING EDUCATION
Fig 17.
Fig 17. A case with a good fiber post on the lateral
that could be longer.
better for the retention of the tooth.10 The canal
diameter dictates the size of the post, not the
root diameter. Sometimes with big oval canals,
the post and core can spin around, especially
on a cast post and core. Adding a keyway in the
bulkiest part of the remaining tooth structure
will help to resist rotational forces.
As to which material to use, the literature
indicates fiber is better because it has greater
flexibility and is less likely to allow for vertical
fractures.2,3 It also has better esthetics, which is
significant for both anterior and posterior teeth.
The problem with fiber posts is that they can
snap off and pull out. When they snap off, they
are difficult to remove. A tapered diamond bur
or ultrasonic can be used, but it must be done
very carefully. Depending on the circumstances,
metal can also be difficult, but metal is often
serrated or threaded and can be unwound with
an ultrasonic. However, fiber is significantly
10 COMPENDIUM EBOOK SERIES August 2019 | Volume 40 Number 16 www.compendiumlive.com
POST AND CORE
more flexible because it has a better modulus of
elasticity, which should be as close to the den-
tin’s elasticity as possible. On the radiograph,
it can be difficult to see. Figure 17 shows a case
with a good fiber post on the lateral that could
be longer. The central should definitely be
longer than it is. Because the clinician thought
the posts and crowns were well done with good
seals, when the patient had pain and apical ra-
diolucencies, they were treated with apicoec-
tomies. This was easier and less invasive than
dismantling the previous structure.
Other Considerations
In deciding whether to use a post, the clinician
must take the unique factors involved in each
case into consideration. Figure 18 shows a case
where the post was essentially useless and not
congruent with the walls of the tooth. Figure
19 shows what the tooth looked like without
the post. There was some decay, but the clini-
cian was still able to save the tooth. Figure 20
shows the postoperative radiograph; Figure
21 was taken 6 months later. The clinician had
told the patient that healing would need to be
checked 6 months postoperatively to deter-
mine whether she could get a crown. There
were two options for the tooth: (1) doing what
the clinician did, which was to build internally
as well as from mid-root with composite, or (2)
use a fiber post. Several fiber posts could have
been placed in the tooth as a better option, but
this patient did not want to spend much and
was unsure about the crown.
Another time when a post cannot be placed
is when there is internal or external resorp-
tion. In the case shown in Figure 22, internal
resorption occurred. Today it would be much
easier to ascertain with CBCT. Here, the cli-
nician filled the resorption with gutta-percha,
and then above the gutta-percha, the mid-
root coronal section was filled with compos-
ite. Because of how weakened the tooth was
already, the clinician wanted to do whatever
was possible to prevent it from weakening
 CONTINUING EDUCATION POST AND CORE

Fig 18. Fig 19.

Fig 20. Fig 21.

Fig 18. A case where the post was essentially useless and not congruent with the walls of the tooth. Fig 19.
The tooth without the post. Fig 20. Postoperative radiograph. Fig 21. Radiograph 6 months later.

further. Figure 23 shows the postoperative
radiograph, and Figure 24 shows the 2-year
checkup. The only post that could be placed
would have been a fiber post.
When considering cores, the clinician has
many good options. Cores today are excep-
tional. The best quality core mimics the hard-
ness of dentin. Clinicians must simply ensure
that whatever they use to etch and bond is
compatible with the core.
Finally, it is important to think in the 3-di-
mensional (3D). Most observers may believe
the case in Figure 25 looks good, ignoring the
root-canal access. From Figure 26, one can see
that the situation actually is not ideal—about
20% may be filled, meaning that 100% is not
clean. When viewing radiographs, it is com-
mon to consider them from the incomplete
perspective shown in Figure 25. If a patient
is experiencing sensitivity seemingly inexpli-
cably, it may be useful to view the tooth in 3D
with CBCT—the true dimensions of the tooth
should be considered.
Conclusion
Techniques for placement of posts—or the
equally important decision not to place a post—
depend on the particular conditions of each
unique case. The best option is to aim for the
most conservative access, while determining
whether a prefabricated or fiber post is ideal.
Clinicians should adhere to post placement
principles for retention of cores and strength-
ening of connections between coronal buildup
material and tooth structure. Successful post
and core cases consider quantity and quality

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 CONTINUING EDUCATION POST AND CORE

Fig 22. Fig 23. Fig 24.

Fig 22. Internal resorption. Fig 23. Postoperative radiograph. Fig 24. Radiograph at 2-year checkup.

of tooth structure, along with adjacent teeth, ABOUT THE AUTHOR

occlusion, parafunction, and future restora-
tions. It also takes into account patient goals
and reasonable possibilities for their budgets.
In the end, providing the most optimal patient
care is accomplished by careful decision-mak-
ing before, during, and after root canals and
other endodontic treatments.
Fig 25. Fig 26.
Fig 25. The case at first may appear satisfactory.
Fig 26. A further look shows the situation is more
complex.
Joseph Chikvashvili, DDS
Private Practice, West Orange, New Jersey
Queries to the author regarding this course may be submitted
to authorqueries@aegiscomm.com.
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2. Mohan SM, Gowda EM, Shashidhar MP. Clinical
evaluation of the fiber post and direct composite
resin restoration for fixed single crowns on end-
odontically treated teeth. Med J Armed Forces India.
2015;71(3):259-264.
3. Adanir N, Belli S. Evaluation of different post lengths’
effect on fracture resistance of a glass fiber post sys-
tem. Eur J Dent. 2008; 2(1):23-28.
4. Cheung W. A review of the management of end-
odontically treated teeth. Post, core and the final res-
toration. J Am Dent Assoc. 2005;136(5):611-619.
5. Sorensen JA, Engelman MJ. Ferrule design and
fracture resistance of endodontically treated teeth. J
Prosthet Dent. 1990;63(5):529-536.
6. Hargreaves KM, Berman LH. Cohen’s Pathways of
the Pulp. 11th ed. Mosby; 2015.
7. Yu CY. Role of occlusion in endodontic management:
report of two cases. Aust Endod J.2004;30(3):110-115.
8. Rahimi S, Shahi S, Nezafati S, et al. In vitro compari-
son of three different lengths of remaining gutta-per-
cha for establishment of apical seal after post-space
preparation. J Oral Sci. 2008;50(4):435-439.
9. Ingle JI, Bakland LK. Endodontics. 5th ed. BC Deck-
er; 2002.
10. Uniyal S, Aeran H, Kwatra B, Nautiyal A. Post & core:
an easy and effective treatment modality for severely
damaged teeth. International Journal of Oral Health
Dentistry. 2015;1(2):99-104.

12 COMPENDIUM EBOOK SERIES August 2019 | Volume 40 Number 16 www.compendiumlive.com

 CONTINUING EDUCATION QUIZ
Handling Posts and Cores for Successful Endodontic Cases
TAKE THIS FREE CE QUIZ BY CLICKING HERE: COMPENDIUMLIVE.COM/GO/SPOTLIGHTENDO1
ENTER PROMO CODE: ENDOSL1
1. The more conservative a clinician’s access,
the greater the likelihood:
A. of using a cast metal post.
B. of using a prefabricated metal posts.
C. of using a nonmetallic post.
D. of obtaining longevity from a root canal or
restoration.
2. If endodontic access is too small, which
problem may arise?
A. Clinicians may not clean effectively.
B. There is a greater chance of separation
because there is not enough of a straight
path.
C. Canals may be missed.
D. all of the above
3. The best approach when finding the canals is
to do what to get enough access?
A. Open them under a microscope.
B. Use a number 4 round bur for access.
C. U se one of a number of special endodontic
access burs.
D. Make sure to use distilled water to
frequently rinse during access.
4. The purpose of a post is to:
A. strengthen the tooth.
B. retain the core.
C. provide additional tooth stability vertically.
D. provide additional tooth stability
horizontally.
5. In general, when more than how much of the
tooth structure is missing should the clinician
consider placing a post?
A. 10%
B. a third
C. half
D. three quarters
Course is valid from 8/1/2019 to 8/31/2022. Participants
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6. What is the minimum ferrule that is
considered ideal for restoring a tooth?
A. 1 mm
B. 2 mm
C. 3 mm
D. 4 mm
7. Patients who are heavy bruxers can cause the
need for a root canal from:
A. the resultant internal enamel crazing.
B. the lateral forces.
C. excessive periodontal mobility.
D. excessive periodontal pocketing.
8. If the post is too short, the tooth will break
because:
A. there will be too much surface area for the
cement.
B. o  f the risk for recurrent decay around the
post.
C. there will be a greater fulcrum.
D. of the increased brittle nature of the short
post.
9. What is the ideal length of a post in the root?
A. one-fourth
B. one-third
C. one-half
D. two-thirds
10. How much apical gutta-percha is essential
because anything less than that will disrupt
the seal?
A. 1 to 2 mm
B. 2 to 3 mm
C. 3 to 4 mm
D. 4 to 5 mm
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| Volume 40 Number 16 www.compendiumlive.com
 CASE REPORT ENDODONTIC-PERIODONTAL LESIONS

Salvaging a Periodontally
Compromised and Endodon-
tically Involved Three-Rooted
Mandibular First Molar With
Cervical Enamel Projection
J. Sylvia Western, MDS; Vivek Vijay Gupta, MDS; and Srinivas Sulugodu Ramachandra, MDS

ABSTRACT: This case report describes the management of a mandibular first mo-
lar with an additional distolingual root (radix entomolaris) and grade III cervical
enamel projection through a multidisciplinary approach. Diagnosis for the case was
endodontic-periodontal lesion due to non-vitality and associated advanced periodon-
tal destruction. The patient was treated with drainage of the periodontal abscess with
adjunct antibiotics, phase I periodontal therapy, endodontic therapy, radiculoplasty,
regenerative periodontal therapy, replacement of the missing right mandibular second
molar, and long-term maintenance. Follow-up of the patient up to 9 months has been
uneventful. Cases of advanced periodontal destruction typically show some degree of
tooth mobility, which was absent in this case. The article discusses the tripod effect as
well as the increased surface area for periodontal attachment provided by the addi-

A
tional root contributing to the non-mobility of the involved tooth.

major anatomical variant of the
two-rooted mandibular first
molar is an additional distolin-
gual root, referred to as the ra-
dix entomolaris (RE).1 The sci-
entific literature has extensive reports on
three-rooted mandibular molars and their
prevalence among different races. 2-5 The
prevalence of these three-rooted mandibu-
lar first molars appears to be less than 3%
in African populations, no more than 4.2%
in Caucasians, less than 5% in Eurasian
populations, and more than 5% (even up
to 40%) in populations with Mongolian
traits.2-5 Scientific literature also includes
occurrence of endodontic mishaps due to
DISCLOSURE: The authors reported no conflicts of interest associated with this work.
failure to identify the third root 6,7 and inci-
dence of advanced periodontal attachment
loss attributed to the presence of the ad-
ditional third root.8 Advanced periodontal
disease may prompt the clinician to advise
amputation of the RE or extraction of the
involved tooth.1
Perhaps the most commonly occurring ana-
tomic factor related to RE is cervical enamel
projection (CEP), which is associated with
attachment loss in the furcation areas of mo-
lars.9 Scientific literature supports the high-
est prevalence of CEP among the Taiwanese
population and in mandibular second molars.9
Coexistence of RE and CEP in a mandibular
molar and the management of this condition

14 COMPENDIUM EBOOK SERIES August 2019 | Volume 40 Number 16 www.compendiumlive.com

 CASE REPORT
Fig 1. Fig 2.
Fig 3.
Fig 4.
Fig 1. Periodontal abscess seen in relation to the
mandibular right first molar. Fig 2. A pocket depth
of more than 10 mm was revealed in the mid-
buccal area. Fig 3. Intraoral periapical radiograph
of mandibular right first molar. Presence of radio-
lucency around the third root, or RE, can be noted.
Fig 4. Master cone radiograph of mandibular right
first molar after endodontic therapy.
has not yet been documented. This article re-
ports the successful management of a man-
dibular first molar with RE and a buccal grade
III CEP through a multidisciplinary approach.
Case Report
A 45-year-old male patient of Chinese ori-
gin reported to SEGi Oral Health Center,
15 COMPENDIUM EBOOK SERIES August 2019 | Volume 40 Number 16 www.compendiumlive.com
ENDODONTIC-PERIODONTAL LESIONS
Malaysia, with a chief complaint of suppu-
ration discharge in the right lower posterior
tooth region. The patient was under medica-
tion for diabetes mellitus for the past 10 years.
Past dental history revealed extraction of the
mandibular right second molar (tooth No. 31)
and mandibular left first molar (tooth No. 19).
Extraction of tooth No. 31 was precipitated by
caries, whereas removal of tooth No. 19 was
due to periodontal reasons. Intraoral exami-
nation of the soft tissues revealed a sinus tract
in the buccal alveolar mucosa in relation to
the mandibular right first molar (tooth No.
30) (Figure 1). Although sinus tracing with
gutta-percha is usually indicated to identify
the source of infection, whether endodontic or
periodontal, in this case clinical judgment and
radiographic findings identified the source of
infection in tooth No. 30 as being of both pulp-
al origin and periodontal origin, and therefore
sinus tract tracing with gutta-percha was not
needed. Hard-tissue examination revealed
the presence of a large composite restoration
in the occlusal aspect and an amalgam resto-
ration on the buccal aspect of tooth No. 30
(Figure 2).
Basic periodontal examination scores for
the patient were 3, 2, 3 (right to left) for the
maxillary sextants and 4, 2, 2 (right to left)
for the mandibular sextants. Detailed peri-
odontal examination divulged a periodontal
pocket of 10 mm at both distobuccal and dis-
tolingual aspects of the mandibular right first
molar with drainage of pus from the sulcus
(Figure 2). Probing at the furcal region using
a Nabers probe revealed a grade II furcation
involvement. The mandibular first molar was
nonmobile. The tooth was nonresponsive to
cold and electric pulp sensitivity tests indicat-
ing non-vitality.
The intraoral periapical radiograph of the
mandibular right first molar (tooth No. 30)
showed radiolucency around the periapex with
severe bone loss (Figure 3). Careful observa-
tion of this radiograph showed the presence of
 CASE REPORT
This article reports the successful management of a
mandibular first molar with radix entomolaris and a
buccal grade III cervical enamel projection through
a multidisciplinary approach.
an additional distolingual root in relation to
this tooth. The radiograph showed radiolucen-
cy in the furcation area with inter-radicular
bone loss extending up to the apex of the dis-
tal and distolingual roots. Endodontically, the
diagnosis was chronic apical abscess associ-
ated with necrotic pulp. Due to the associated
advanced periodontal destruction, this lesion
was classified as an endodontic-periodontal
lesion. The formulated treatment plan con-
sisted of drainage of the periodontal abscess
with adjunctive antibiotics, phase I periodon-
tal therapy (scaling and root surface debride-
ment), endodontic therapy, and radiculoplasty,
followed by regenerative periodontal therapy
and replacement of the missing right man-
dibular second molar.
Informed consent was obtained from the pa-
tient after the formulated treatment plan, its
advantages and disadvantages, and the progno-
sis for the involved tooth were explained to him.
Treatment Procedures
Drainage of the periodontal abscess through
the sulcus using area-specific curettes and
prescription of adjunctive antibiotics (tablet
amoxicillin and clavulanic acid 625 mg three
times daily for 5 days) constituted the emer-
gency treatment. One week later, phase I ther-
apy was initiated, which included supra- and
subgingival scaling and root surface debride-
ment. In the subsequent appointment, an en-
dodontist initiated nonsurgical endodontic
therapy in tooth No. 30. Pain control during
endodontic and periodontal procedures at
16 COMPENDIUM EBOOK SERIES August 2019 | Volume 40 Number 16 www.compendiumlive.com
ENDODONTIC-PERIODONTAL LESIONS
different time periods throughout this treat-
ment was achieved by performing inferior
alveolar nerve block by administering one
cartridge of 2% lignocaine with 1:100,000 epi-
nephrine. Access opening was performed un-
der rubber dam isolation using an endodontic
access bur. Initially, the prepared access cavity
was triangular, and the mesiobuccal, mesiolin-
gual, and distal root canal orifices were located
using an endodontic explorer.
Based on observations from the preopera-
tive radiographs, the root canal orifice cor-
responding to the RE root was anticipated to
be just lingual to the distal root canal orifice.
Further, the access cavity was modified to a
trapezoidal shape to locate the fourth canal.
A glide path was established using #08 and
#10 size K-files. The working length of the ca-
nals was determined electronically using an
apex locator and confirmed radiographically.
Canals were then cleaned and shaped using
rotary nickel-titanium files and a crown-down
technique under copious irrigation using 3%
sodium hypochlorite, 2% chlorhexidine, and
17% ethylenediaminetetraacetic acid (EDTA).
Canal disinfection was carried out by placing
non-setting calcium hydroxide as an intraca-
nal medicament for 7 days.
In the subsequent visit, the patient was asymp-
tomatic. Clinically, there was no tenderness on
percussion and no active pus drainage from the
sinus tract, and the canal was dry. The periodon-
tal status, however, remained unaltered. A mas-
ter cone radiograph was taken (Figure 4) and
obturation was completed using a single-cone
 CASE REPORT ENDODONTIC-PERIODONTAL LESIONS

Fig 5. Fig 6.

Fig 7. Fig 8.

Fig 5. One month after endodontic therapy and following completion of root surface debridement.
Arrows indicate the presence of CEP. Fig 6. Partial penetration of the Nabers probe in the furcation area.
Obstruction of thorough probing could be due to the presence of RE. Fig 7. Clinical image after degran-
ulation. Note the bone defects and bone loss up to the apical one-third of the root surface. Fig 8. Clinical
image after placement of bone graft in the furcation defect.

technique and a mineral trioxide aggregate
(MTA)-based root canal sealer. Restoration of
the coronal access cavity was done using glass-
ionomer cement followed by direct composite.
Case Re-evaluation
One month after endodontic therapy, the case
was re-evaluated. At the re-evaluation visit, the
patient presented with exposure of the buccal
furcation in relation to tooth No. 30 due to gin-
gival recession (Figure 5), revealing a grade III
CEP (indicated by the arrows in Figure 5). The
presence of deep periodontal pockets on both
the buccal and lingual aspects with bleeding on
probing indicated residual infection (Figure 6).
The clinicians conveyed to the patient the need
for further periodontal surgery to eliminate
the residual infection in relation to tooth No.
30 and obtained his informed consent.
After administration of intraoral anesthesia,
placement of a crevicular incision extending
from tooth No. 28 to tooth No. 30 and a crestal
incision in relation to the edentulous area be-
tween teeth Nos. 30 and 32 marked out the
surgical area. A full-thickness mucoperiosteal
flap was elevated. Removal of the tissue tags
and granulation tissue provided access to and
visibility of the bony defects and root surfaces
(Figure 7). Elimination of the root roughness
was accomplished by thorough root surface
debridement. The CEP was smoothened by
radiculoplasty. Bony architecture in the furca-
tion area revealed a definite horizontal com-
ponent, with the vertical component extend-
ing up to and beyond the root apex of the RE.
After complete debridement, synthetic
bone graft (CompactBone S, Dentegris
International GmbH, dentegris.eu) was placed
to fill the bony defect in the furcation area
(Figure 8). Placement of the mucoperiosteal
flaps to their original position was followed by
placement of interrupted sutures and covering
of the surgical area with periodontal dress-
ing. The patient was given a prescription of

17 COMPENDIUM EBOOK SERIES August 2019 | Volume 40 Number 16 www.compendiumlive.com

 CASE REPORT ENDODONTIC-PERIODONTAL LESIONS

Fig 9.

Fig 11.
Fig 10.

Fig 12. Fig 13.

Fig 9. Buccal view at 6-month follow-up. Fig 10. Occlusal view at 6-month follow-up showing fixed
prosthesis using mandibular right first and third molars as abutments. Fig 11. Buccal view at 9-month
follow-up. Fig 12. View of soft tissue on the lingual side of tooth No. 30 at 9-month follow-up. Fig 13.
Intraoral periapical radiograph of tooth No. 30 at 9-month follow-up. Radiopacity around the disto-
lingual root of tooth No. 30 showed continued bone formation/bone fill.

analgesics for pain control and postsurgical
instructions after the surgery.
One week later the patient was recalled for
suture removal. Grade I mobility was noticed
during the 1-month follow-up. A temporary
bridge was placed to replace the missing
tooth No. 31, using teeth Nos. 30 and 32 as
abutments. After 2 months, the patient was re-
viewed again. There was no mobility observed
after removal of the temporary bridge. With
teeth Nos. 30 and 32 as abutments, a three-
unit metal-ceramic bridge was placed to re-
place the missing tooth No. 31.
Follow-up
Follow-up of the patient at 3 months, 6
months (Figure 9 and Figure 10), and 9
months (Figure 11 and Figure 12) was un-
eventful. Grade I mobility had been detected
at 1 month. Oral prophylaxis done at three

18 COMPENDIUM EBOOK SERIES August 2019 | Volume 40 Number 16 www.compendiumlive.com

 CASE REPORT
With early identification and by following a
multidisciplinary approach, clinicians can successfully
treat compromised three-rooted mandibular molars with
cervical enamel projection.
monthly intervals and a prescription of in-
terdental cleaning aids has helped the patient
maintain oral hygiene. At the 9-month follow-
up, probing depth at tooth No. 30 was 3 mm
buccally and 4 mm lingually. Radiographs
at 9 months (Figure 13) showed radiopacity
around the distolingual root, and evidence of
continued hard-tissue healing.
Discussion
This patient was of Chinese origin. Considered
to be an Asiatic trait, prevalence of RE is
around 5% to 31.5% in the Chinese popula-
tion.4 Therefore, the finding of RE in patients
of Chinese origin is not rare. With a huge
Chinese population spread across the world,
dental clinicians may very well encounter a
case of RE when treating patients who are
Chinese. Scientific literature reports more
common occurrence of three-rooted man-
dibular molars among males and on the right
side.2,3,10 In the present case, the patient was
male and the involved molar was on the right
side. Previous extraction of the mandibular
left first molar was due to periodontal reasons.
Therefore, it is possible that a three-rooted
mandibular first molar may also have existed
on the left side and was subsequently extract-
ed, though further discussion on this would
be speculative.
The patient was suffering from chronic
generalized periodontitis with moderate
periodontitis throughout the mouth. Severe
periodontitis with deep pockets up to 10
19 COMPENDIUM EBOOK SERIES August 2019 | Volume 40 Number 16 www.compendiumlive.com
ENDODONTIC-PERIODONTAL LESIONS
mm was seen around the right mandibular
first molar on both the buccal and lingual as-
pects. Presence of RE results in higher prob-
ing depths and additional loss of attachment,
particularly at the distolingual site.8 Presence
of CEP on the buccal side could have pre-
cipitated furcation involvement resulting
in a deep periodontal pocket.11,12 According
to the classification of CEP by Masters and
Hoskins,13 the present case can be classified
as grade III CEP, as the enamel projection
in tooth No. 30 extended from the cemen-
toenamel junction to the furcation. Presence
of swollen gingiva and periodontal abscess
masked the presence of CEP on the buccal
side. CEP was noticed following shrinkage
and recession of the gingiva, which led to
exposure of the furcation area on the buccal
side. Presence of diabetes mellitus also could
have contributed to additional attachment
loss and bone loss.
Despite the presence of advanced peri-
odontitis as evidenced by deep pockets and
significant bone loss noticed on radiographs,
there was no mobility before treatment.
Grade I mobility was noticed 1 month after
periodontal surgery. This transient mobility
subsided and the tooth was firm at 3, 6, and
9 months’ follow-up. The presence of the RE
increases the surface area for attachment of
the periodontal apparatus and acts as a tripod,
increasing the firmness of the tooth. Due to
these factors, attempts should be made to save
such compromised teeth. The most common
 CASE REPORT
method used to identify the presence of RE is
to take intraoral periapical radiographs at two
different angles. Advances in radiography in
the form of cone-beam computed tomogra-
phy have heightened the chances of clinicians
identifying RE earlier and more accurately.14,15
Identification of RE in the initial stages of
periodontal disease could aid the clinician in
treating the disease in a more minimally in-
vasive manner.
In many instances diagnosing the case as
either primarily periodontally involved or
primarily endodontically involved may be
difficult.16 The existence of a large composite
restoration that has been present for many
years could result in the secondary carious
process encroaching the pulp, resulting in pri-
mary endodontic involvement. Deep pocket-
ing and advanced bone loss around the disto-
lingual root or on the buccal side could result
in primary periodontal involvement. Effective
treatment of endodontic-periodontal lesions
and treatment of compromised teeth with RE
is challenging.17 Successful treatment of these
teeth requires a multidisciplinary approach
consisting of two stages: elimination of the
endodontic infection and regeneration of the
periodontal structures.17
In the present case, the treatment plan
indeed involved endodontic therapy and
regenerative surgical periodontal therapy.
Endodontic-periodontal lesions and peri-
odontal abscesses consist of anaerobic
microorganisms, which necessitates the
inclusion of adjunctive antibiotics.18 A com-
bination of amoxicillin and clavulanic acid
is effective in most odontogenic infections.
The shape of the access cavity for a mandib-
ular first molar with three canals is triangu-
lar. In the presence of RE, the access cavity
is made trapezoidal to gain straight-line ac-
cess.1 Therefore, to gain straight-line access
to the fourth canal the access cavity in this
case was made trapezoidal. Identification
of the root canal orifice corresponding to
20 COMPENDIUM EBOOK SERIES August 2019 | Volume 40 Number 16 www.compendiumlive.com
ENDODONTIC-PERIODONTAL LESIONS
the third root is crucial for successful man-
agement of these cases. Attempting to lo-
cate the RE root canal orifice without ad-
equate knowledge of the internal anatomy
of pulp space may result in iatrogenic furcal
perforations.6,7
Periodontal surgery and complete degran-
ulation exposed the CEP and bony defects.
Despite the advanced amount of bone de-
struction, presence of the additional root
converted the defect into a “cul-de-sac”-like
defect. Presence of the additional root could
help in preventing dislodgement of bone
grafts from the lingual side.19 The decision
to place bone graft without guided tissue re-
generation membrane was based on the pres-
ence of buccal gingival recession. Despite
the advanced periodontal destruction, the
successful outcome of this case could be
due to endodontic therapy, the firmness
of the tooth (due to increased surface area
for attachment and tripod effect), regular
follow-ups, and optimal maintenance of oral
hygiene by the patient.
Conclusion
With early identification and by following a
multidisciplinary approach, clinicians can
successfully treat compromised three-rooted
mandibular molars with CEP. Patients also
need to sustain good oral hygiene and be com-
pliant with regular maintenance visits.
ABOUT THE AUTHORS
J. Sylvia Western, MDS
Lecturer, Faculty of Dentistry, SEGi University, Malaysia
Vivek Vijay Gupta, MDS
Senior Lecturer, Faculty of Dentistry, SEGi University,
Malaysia
Srinivas Sulugodu Ramachandra, MDS
PhD Student, school of Dentistry, University of Queensland,
Australia; Faculty of Dentistry, SEGi University, Malaysia,
at time of writing
Queries to the author regarding this course may be submitted
to authorqueries@aegiscomm.com.
 CASE REPORT
REFERENCES
1. De Moor RJ, Deroose CA, Calberson FL. The radix
entomolaris in mandibular first molars: an endodontic
challenge. Int Endod J. 2004;37(11):789-799.
2. Curzon ME. Three-rooted mandibular permanent
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3. Quackenbush LE. Mandibular molar with three distal
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population. J Endod. 1993;19(9):471-473.
5. Jones AW. The incidence of the three-rooted lower
first permanent molar in Malay people. Singapore Dent
J. 1980;5(1):15-17.
6. Srinivasan R, Bhagabati N, Rajput A, Akhtar S. Non
surgical repair of iatrogenic furcal perforation of radix
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2):S422-S424.
7. Mirikar P, Shenoy A, Mallikarjun GK. Nonsurgical
management of endodontic mishaps in a case of ra-
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lingual root: a consideration in periodontal therapy. J
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mini-review. J Periodontol. 2010;81(5):789-795.
10. Somogyi-Csizmazia W, Simons AJ. Three-rooted
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11. Zee KY, Bratthall G. Prevalence of cervical enamel
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in eskimos dry skulls. Swed Dent J. 2003;27(1):43-48.
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13. Masters DH, Hoskins SW Jr. Projection of cer-
vical enamel into molar furcations. J Periodontol.
1964;35(1):49-53.
14. Silva EJ, Nejaim Y, Silva AV, et al. Evaluation of root
canal configuration of mandibular molars in a Brazilian
population by using cone-beam computed tomogra-
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15. Zhang R, Wang H, Tian YY, et al. Use of cone-beam
computed tomography to evaluate root and canal
morphology of mandibular molars in Chinese individu-
als. Int Endod J. 2011;44(11):990-999.
16. Al-Fouzan KS. A new classification of endodontic-
periodontal lesions. Int J Dent. 2014;2014:919173. doi:
10.1155/2014/919173.
17. Grudianov AI, Makeeva MK. Endo-perio lesions
prevalence and awareness of dentists about di-
agnostics and treatment. Stomatologiia (Mosk).
2014;93(3):11-14.
18. Grudianov AI, Makeeva MK, Piatgorskaia NV. Mod-
ern concepts of etiology, pathogenesis and treatment
approaches to endo-perio lesions. Vestn Ross Akad
Med Nauk. 2013;(8):34-36.
19. Sachdeva S, Phadnaik MB. Three-rooted mandibu-
lar first molar: a consideration in periodontal therapy.
J Indian Soc Periodontol. 2012;16(2):286-289.
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