Factors determining post selection: A literature review

Aquaviva S. Fernandes, BDS, MDS,a Sharat Shetty, BDS, MDS,b and Ivy Coutinho, BDS, MDSc
Goa Dental College, Bambolim Goa, India; Kargar Dental College, Mumbai, India
Most endodontically treated teeth require a post-and-core build-up for restoring the teeth to optimum
health and function. Selection of an appropriate post-and-core system from the wide variety of those
available may be a clinical dilemma. Therefore, the purpose of this article is to review the literature to
identify the various factors that influence the selection of the post-and-core assembly. English-language
peer-reviewed articles between 1961 and 2002 were identified using MEDLINE, as well as a hand
search. The following key words were used: post, design, retention, fracture resistance, survivability,
and esthetics. Selection of a post and core system should satisfy many interrelated biologic, mechanical,
and esthetic factors to optimally restore the endodontically treated tooth to adequate form and func-
tion. This review may serve as a guide to aid the clinician in the selection of a post-and-core system.
(J Prosthet Dent 2003;90:556-62.)

T he longevity of endodontically involved teeth has

been greatly enhanced by continuing developments
made in endodontic therapy and restorative procedures.
It has been reported that a large number of endodonti-
cally treated teeth are restored to their original function
with the use of intraradicular devices.1 These devices
vary from a conventional custom cast post and core to
one-visit techniques, using commercially available pre-
fabricated post systems.2,3 In the last few decades, vari-
ous prefabricated posts systems have been developed.
The selection of post design is important, because it may
have an influence on the longevity of the tooth.4
This article reviews the literature to determine the
various factors influencing the post selection for restor-
ing an endodontically treated tooth. The English-lan-
guage literature from 1961 to 2002 was searched using
MEDLINE. This was complemented with a manual
search. The following key words were used: post, design,
retention, fracture resistance, survivability, and esthet-
ics. According to the reviewed articles, the factors influ-
encing post selection were root length, tooth anatomy,
root width, canal configuration, amount of coronal
tooth structure, torquing force, stresses, development of
hydrostatic pressure, post design, post material, material
compatibility, bonding capability, core retention, re-
trievability, esthetics, and crown material.
ROOT LENGTH
The length and shape of the remaining root deter-
mines the length of the post.5 It has been suggested that
root length should be considered for the selection of the
ideal post length.6 It has been demonstrated that the
greater the post length, the better the retention and
stress distribution.5-9 However, it may not always be
possible to use a long post, especially when the remain-
a
Lecturer, Department of Prosthodontics, Goa Dental College.
b
Lecturer, Department of Prosthodontics, Kargar Dental College.
c
Lecturer, Department of Prosthodontics, Goa Dental College.
ing root is short or curved. Several studies suggest that it
is important to preserve 3 to 5 mm of apical gutta-percha
to maintain the apical seal.10,11 When the root length is
short, the clinician must decide whether to use a longer
post or to maintain the recommended apical seal and use
a parallel-sided threaded post. On the other hand, the
result of an in vitro investigation has demonstrated that
reinforced composite luting agents may compensate for
the reduced post length.12 For molars with short roots,
the placement of more than one post will provide addi-
tional retention for the core foundation restoration.6,12
TOOTH ANATOMY
Each tooth in the arch exhibits anatomic characteris-
tics such as root curvature, mesio-distal width, and la-
bio-lingual dimension. Hence, root anatomy dictates
post selection.12 Teeth may have anatomic variations,
which may adversely affect the post placement. How-
ever, most investigators have disregarded anatomic vari-
ations such as invagination, depression, and ribbon-
shaped roots.8,10,13,14 A consideration of the root size
and length is important, because improper post space
preparation and use of large-diameter posts present the
risk of apical or lateral perforation. Moreover, an active
post can initiate cracks in the thin dentinal wall. A thor-
ough knowledge and radiographic evaluation of the root
anatomy will aid the clinician in avoiding catastrophic
damage to the roots when planning the post space. Ra-
diographs help the restorative dentist to evaluate the
root length, width, anatomic variations, canal structure,
and the surrounding hard tissue structures. Occasion-
ally, the radiographs can be misleading because of prox-
imal root concavities and the magnification factor.
Therefore, use of a grid is recommended while a radio-
graph is made so that the length, diameter, and design of
the post can be correctly determined.15
Gutmann16 reviewed the anatomic considerations in
some detail and stated that roots of maxillary centrals

556 THE JOURNAL OF PROSTHETIC DENTISTRY VOLUME 90 NUMBER 6

FERNANDES, SHETTY, AND COUTINHO
and laterals, and also mandibular premolars, have suffi-
cient bulk to accommodate most post systems. This
knowledge aids the dentist in determining the post suit-
able for a given root.
POST WIDTH
Preserving tooth structure, reducing the chances of
perforation, and permitting the restored tooth to resist
fractures are criteria in selection of the post width.17,18
Tilk et al19 evaluated maxillary and mandibular teeth,
and recommended a range of post widths. Various in-
vestigators19-21 have recommended different ap-
proaches regarding the selection of the post diameter.
These approaches were summarized by Lloyd and
Palik22 into 3 categories, conservationist (13 propo-
nents), preservationist (7 proponents), and proportion-
ist (6 proponents) approaches. Stern and Hirshfeld23
suggested that post width should not be greater than 1
third of the root width at its narrowest dimension. This
proportionist approach was advocated with the intent of
preserving sufficient tooth structure. Other investigators
have proposed the preservationist approach where in the
post should be surrounded by a minimum of 1mm of
sound dentin.24 Others, including Pilo and Tamse,21
advocated minimal canal preparation and maintaining as
much residual dentin as possible, thereby suggesting
restriction of the post diameter in an effort to conserve
the remaining tooth structure (conservationist ap-
proach).
The influence of post width on its retention and frac-
ture resistance has also been studied. It was shown that
an increase in post width has no significant effect on its
retention.8 The tooth restored with larger diameter
posts is reported to provide the least resistance to frac-
ture with a decrease in the width of the remaining den-
tin.18
CANAL CONFIGURATION AND POST
ADAPTABILITY
Canal configuration aids in making a choice between
a custom-designed post and a prefabricated post.14,25 If
the selected post closely fits or conforms to the canal
shape and size, it may be a more conservative option
because less dentin removal is required, thus enhancing
fracture resistance of the tooth, as well as retention of
the post.4,26
Often, a dilemma arises in funnel-shaped canals,
whether to use a parallel-sided post and fill the remain-
ing post space with cement or to use a tapered post that
closely adapt to the canal wall. A third option is to use
large prefabricated parallel-sided posts by removing ad-
ditional tooth structure, so that an intimate contact be-
tween the canal and post is attained. It has been sug-
gested that if a canal requires extensive preparation, a
well-adapted cast post and core restoration will be more
DECEMBER 2003
THE JOURNAL OF PROSTHETIC DENTISTRY
retentive than a prefabricated post that does not match
the canal shape.27 In addition, root reinforcement with
composite is suggested for wide canals.28 In vitro stud-
ies4,29 have demonstrated that a well-adapted tapered
post provided increased resistance to fracture. However,
on fracture, it resulted in an extensive loss of tooth struc-
ture compared with teeth restored with well-adapted,
passively cemented parallel-sided posts.
Recently, Morgano and Milot30 questioned the re-
sults of an in vivo study,31 which concluded that close
adaptation of a post causes more catastrophic failure.
Morgano and Milot30 stated that 44% of the cast posts
were less than one half to one quarter the length of the
clinical crown and that the failure rate reported was the
result of compromised length rather than post type. A
recent investigation regarding custom-cast posts re-
ported a success rate of more than 90% after 5 years in
function.30
CORONAL STRUCTURE
The amount of remaining coronal tooth structure is
also a critical factor in determining the post selection.
The bulk of the tooth above the restorative margin
should be at least 1.5 to 2 mm to achieve resistance
form.32 It was found that teeth restored with carbon
fiber posts had inferior strength compared with those
restored with metal posts when subjected to forces sim-
ulating those in a clinical setting.33,34 The use of cast
post and cores in restoring endodontically treated teeth
with moderate to severe coronal tooth loss has demon-
strated a success rate of 90.6% after 5 years of service.35
The results of in vitro33,34 and in vivo studies35 indi-
cate that nonmetal posts, such as a carbon fiber post
system, can be used when ample coronal dentin remains
and the crown is well supported by remaining tooth
structure35; otherwise, cast post and core may be used
when there is moderate to severe tooth loss.
STRESS
Post and core–restored endodontically treated teeth
are subjected to various types of stresses: compression,
tensile, and shear. Of these stresses, shear stress is most
detrimental to the restored tooth.36 Holmes et al5 have
demonstrated that the variation in post dimension
greatly influences shear stresses. An increase in the post
length with diameter kept to a minimum will help to
reduce shear stresses and preserve tooth structure. Thus,
the vulnerability of the endodontically treated tooth to
fracture is decreased.5
TORSIONAL FORCE
Intraorally, post and core–restored teeth are sub-
jected to various types of forces. Torsional forces on the
post-core-crown unit may lead to loosening and dis-
placement of the post from the canal, causing failure of
557
THE JOURNAL OF PROSTHETIC DENTISTRY
the system.37-39 Therefore, the ability of the selected
post design to resist torsional forces will play a key role in
stabilizing and retaining the post-core and crown
unit.37-39
Burgess et al37 demonstrated the importance of an
antirotational feature in the post design and concluded
that resistance to torsional forces is integral to the sur-
vival of the post-core-crown unit. An investigation into
torsional resistance of several post systems revealed that
active post designs provide greater torsional resistance
than a passive post.38,39
ROLE OF HYDROSTATIC PRESSURE
Cementation plays a significant role in enhancing re-
tention, stress distribution, and sealing irregularities be-
tween the tooth and the post.40 During cementation, an
increase in stress within the root canal has been reported
because of the development of hydrostatic pressure.41
This pressure affects the complete seating of the post
and may also cause fracture of the root.41,42 Fortunately,
there is evidence that the fitting stresses can be reduced
by careful placement of the post and by using a proper
post design with a cement vent to permit escape of the
luting agent and thus reduce the hydrostatic pressure.36
Tapered posts, however, are self-venting and will permit
the cement to flow out along the entire surface. Pressure
development is also dependent on the viscosity of the
cement. The more viscous the cement, the greater the
development of the hydrostatic pressure.43
Zinc phosphate cement has been successfully used for
the cementation of posts for many years. Recently, resin
luting agents have been used, although they are tech-
nique-sensitive and more difficult to manipulate.44,45
Care must be taken when using resin luting agents that
polymerize anaerobically because they may polymerize
prematurely, thus preventing complete seating of the
post. Slow-polymerizing dual polymerizing luting
agents are recommended in these situations.12
POST DESIGN
The available post designs can be classified according
to their shapes and surface characteristics. They may be
parallel, tapered, or parallel-and-tapered combination.
According to their surface characteristics, the posts are
active or passive.46 The active post mechanically engages
the dentin with threads, whereas the passive post de-
pends on the cement and its close adaptation to the canal
wall for its retention.
Several studies47,48 have implicated the active post
design as a cause of failure of the post and core–restored
teeth. Of the designs studied, the tapered post conforms
to the natural root form and canal configuration, thus
permitting optimal preservation of tooth structure at the
post apex. However, this design is reported to produce a
wedging effect, stress concentration at the coronal por-
558
FERNANDES, SHETTY, AND COUTINHO
tion of root, and lower retentive strength.48-50 Parallel-
sided post designs have been shown to increase reten-
tion and produce uniform stress distribution along the
post length.9 Concentration of stress has been reported
to occur at the apex of the post, especially in a narrow
and tapering root end.9 This stress is considered to be
caused by unnecessary removal of tooth structure at the
apical end of the root and sharp angles of the post.51,52
In the parallel-tapered design, the post is parallel
throughout its length except for the most apical portion,
where it is tapered. This design permits preservation of
the dentin at the apex and at the same time achieves
sufficient retention because of parallel design.51
The surface characteristics of the post also change the
retentive and fracture resistance values. The highest re-
tention is observed in the threaded post, followed by the
post with a serrated surface. The least retention is seen
with smooth surface posts.19,48 Unfortunately, the
threaded post engages in dentin and may lead to in-
creased undesirable stresses within the root. To avoid
placement stresses caused by threads, the following pro-
cedures have been recommended: pretapping post chan-
nels, limiting the number of threads, counter-rotating
the post by one half turn after full engagement, and
incorporating a spilt-shank mechanism.53 However, an
analysis of the available clinical studies suggests that the
performance of a threaded post is inferior to that of a
custom-cast post.54 Of all the designs studied, the
threaded tapered screw post exerts a greater amount of
stress and was considered the least desirable.48,49 The
parallel-sided, serrated, and vented posts were found to
exert the least amount of stress.55
POST MATERIAL
To achieve optimum results, the material used for the
post should have physical properties similar to that of
dentin, be bonded to the tooth structure, and be bio-
compatible in the oral environment.56 It should also act
as a shock absorber by transmitting only limited stress to
the residual tooth structure.57 Unfortunately, the mate-
rials used for post and cores, as well as luting agents,
have distinct physical properties different from dentin
and exhibit fundamentally different fatigue behavior.36
Traditionally, posts were made of metal alloys. Re-
cently, nonmetallic posts have been introduced. Several
studies 58-60 have examined post and cores made of var-
ious alloys and other materials with different rigidity and
demonstrated that rigid materials resisted greater forces
without distortion. Therefore, there may be a potential
danger in using highly rigid posts.
Recently introduced carbon fiber posts are purported
to have mechanical properties that closely match those
of the tooth.33,61 The presence of the parallel fibers in
the resin of carbon fiber posts enable them to absorb and
dissipate stresses.33,61 In vitro studies,33,34 however,
VOLUME 90 NUMBER 6
FERNANDES, SHETTY, AND COUTINHO
have demonstrated that carbon fiber posts have inferior
strength compared with metal posts when subjected to
forces simulating those in the oral cavity.
Zirconium ceramic, which is presently used for posts,
has a high modulus of elasticity, and therefore the forces
are assumed to be transmitted directly from the post to
the tooth interface without shock absorption.62 The
stiffer ceramic post may cause more root fractures com-
pared with the carbon fiber post. Asmussen et al61 have
demonstrated that fracture of endodontically restored
teeth is less extensive with carbon fiber posts than with
ceramic posts.
Although various claims are made with regard to
nonmetallic posts, there is a need for long term clinical
evaluation of both metallic and nonmetallic post systems
to allow a definitive recommendation of either of them.
Until such time, metallic posts continue to be the stan-
dard for most situations because they have stood the test
of time.
MATERIAL COMPATIBILITY
Corrosion of the post and fracture of the root has
been reported in the dental literature.63 Ideally, post and
cores are made of the same alloy. Dissimilar alloys may
create galvanic action, which can lead to corrosion of the
less noble alloy.64 Corrosion of the post may be initiated
because of the access of an electrolyte to the post surface,
through cementum and dentin, through microleakage
around the coronal restoration, through the accessory
canals, which may be opened during post space prepa-
ration, or through undiagnosed root fracture.42,65
These corrosion products cause a change in volume that
has been postulated to cause the root fracture.63
Of the various alloys used for posts, titanium alloys
are the most corrosion resistant.43 Alloys containing
brass have lower strength and lower corrosion resistance
and, hence, are less desirable.66 Noble metal alloys are
corrosion resistant, but their cost is higher. With the
availability of nonmetallic post materials, the corrosion
factor is eliminated.
BONDING ABILITY
Cores may be bonded to the post and tooth structure
so that the tooth-post-core-crown system may function
as a unit which, as previously mentioned, may be diffi-
cult because of the difference in the physical properties
of the materials and tooth structure. Of the cements
available, zinc phosphate cement is the one that has been
time tested. Newer adhesive resin luting agents are ad-
vocated for the luting of posts because they are reported
to bond the post to the tooth structure in comparison to
the traditional cements, which produce only frictional
resistance.67 Moreover, a composite core material can
also be bonded to the tooth structure and post with
bonding agents.43
DECEMBER 2003
THE JOURNAL OF PROSTHETIC DENTISTRY
The bonding of a post to the tooth structure should
improve the prognosis of the post-core restored tooth
by increasing post retention68 and by reinforcing the
tooth structure.28 It has been postulated that reinforce-
ment of the tooth is due to the stress distribution char-
acteristics of the bonding materials.28
Recently, the importance of bonding on the reten-
tion of posts has been demonstrated.69 It was reported
that resin luting agents showed good adhesion to carbon
fiber posts and glass fiber posts.69 The adhesion to zir-
conia posts was found to be unsatisfactory.69 It was also
observed that to improve retention, the carbon fiber
post did not require any surface treatment as compared
with the zirconia post. In spite of the creation of micro-
retention on zirconia posts, the adhesion between the
post and resin luting agent was not uniform, thus indi-
cating that the nature of post material was responsible
for the bonding of the post to the tooth structure.69
CORE RETENTION
The primary reason for using a post is to retain the
core that substitutes the missing coronal tooth struc-
ture. Therefore, the post head design is an important
factor.70 The post head should provide adequate reten-
tion and resistance to displacement of the core material.
Studies30,71 have reported that prefabricated metal
posts with direct cores made of glass ionomer, compos-
ite, or amalgam are less reliable than a one-piece cast
post and core because of the interface between the post
and the core. As the number of interfaces increase, the
potential for failure also increases.72 Thayer73 has ex-
pressed concern that post and core separation is more
likely to occur when composite is used as core material.
In an effort to avoid this, posts with various head designs
are available. Designs vary and include crenellated, flat,
and spherical.74 Bonding techniques are advocated to
reinforce the retention of the core.75 Some investiga-
tors74,75 have concluded that the post head design is
crucial and that the lack of retentive features of the post
head may reduce post to core retention.
RETRIEVABILITY
Ideally, the post system selected should be such that if
the endodontic treatment fails or the post fractures, it is
easy for the clinician to retrieve the post without sub-
stantial loss of tooth structure.71 Unfortunately, the re-
trievability of a metal post, especially the cast post and
core system is difficult and involves removal of tooth
structure around the post, which could further weaken
the tooth. Carbon fiber posts have an advantage over
metallic and ceramic posts in that the removal is rela-
tively easy, rapid, and predictable.76 Post removal can be
performed by means of conventional rotary instruments
and solvents,76 which assist in the preservation of the
residual dentin and minimize the chances of perforation.
559
THE JOURNAL OF PROSTHETIC DENTISTRY
Removal of zirconia posts has been found to be more
difficult.69
Certain post systems facilitate easy removal of the
post by providing a milled head, a wrench, or a consec-
utive series of retreatment drills.77,78 Other commer-
cially available systems to remove posts include the
Messeran Kit (Medidenta International Inc, Woodside,
New York, NY), Post Removal System (SybronEndo;
Orange, Calif), and Endodontic extractors (Brasseler
Inc, Savannah, Ga).44 In addition, an ultrasonic unit
(Cavi-Endo, Dentsply Intl, Inc, York, Pa), Roto-Pro bur
(Ellman International, Hewlett, NY), and a combina-
tion of tube extractors with cyanoacrylate, will aid in
post removal by breaking up the cement.44
ESTHETICS
The post and core material should be esthetically
compatible with the crown and the surrounding tis-
sues.79 Several authors have emphasized the need to
have the color of the foundation restoration as close to
that of natural dentin.76,80 However, in clinical situa-
tions in which the root has extensive damage or exhibits
immature development, the use of a custom cast post
would compromise esthetics as the gray tint of the metal
may show through the thin root wall. The overlying
gingival tissue would also appear darker or grayish.28
This esthetic concern has led to the development of
esthetic posts made from reinforced resins or ceramics in
an effort to eliminate the color deficiency.
With prefabricated metal posts, the core material can
be composite, which may aid in masking the metallic
color of the post. However, masking will depend on the
thickness of the composite core. A ceramic crown with
an opaque substructure may be necessary in situations
where complete masking is difficult.80 These solutions
may not have an effect on the soft tissues unless a white-
colored post is also used. Therefore, the type of crown
material used will affect the post selection. The metal-
ceramic crown will permit the clinician to use any post
and core material.76 All ceramic crowns are translucent
and allow metal to show through.80 The influence of
nonmetallic carbon fiber and zirconia post systems on
all-ceramic crowns depends on the substructure and
thickness of crown.80 When crown thickness is reduced,
the color of foundation restoration shows through a
nonopaque thin crown.80
Another alternative to an esthetic post and core sys-
tem is the use of opaque porcelain fused to the core
portion of cast post and core in order to eliminate the
grayish effect of cast metal.81 Also, the use of ceramic
core material such as IPS Empress cosmo core (Ivoclare-
Vivadent, New York, NY) is advocated . The availability
of different cement shades permits minor esthetic cor-
rections under all-ceramic crowns.80
560
FERNANDES, SHETTY, AND COUTINHO
DISCUSSION
Post and cores contribute in providing predictable
restorative options for endodontically treated teeth.
After reviewing the literature, it appears that an ideal
post system should have the following features: (a)
physical properties similar to dentin, (b) maximum
retention with little removal of dentin, (c) distribu-
tion of functional stresses evenly along the root sur-
face, (d) esthetic compatibility with the definitive res-
toration and surrounding tissue, (e) minimal stress
during placement and cementation, (f) resistance to
displacement, (g) good core retention, (h) easy re-
trievability, (i) material compatibility with core, (j)
ease of use, safety and reliability, and (k) reasonable
cost. Therefore, the clinician should be knowledge-
able in selecting the right type of post and core sys-
tems to meet the biological, mechanical, and esthetic
needs for each individual tooth.
This review identified factors that influence the selec-
tion of the post-and-core system and offers the follow-
ing clinical recommendations: (1) conserve as much re-
maining tooth structure as possible during the post
space preparation, (2) custom-cast post and cores are
recommended for noncircular root canals and when
coronal tooth structure loss is moderate to severe, (3)
parallel-sided, passive, serrated, self-venting prefabri-
cated posts are recommended for small circular canals,
(4) posts with an antirotational feature should be used in
situations with circular canals, (5) adequate apical seal
must be maintained without compromising the length
of the post, (6) more than one post may be used for
multirooted short teeth, (7) passive parallel posts are
advocated for adequate retention but when the apical
thickness of dentin is minimal, a parallel-tapered combi-
nation post design may be preferred, (8) retentive qual-
ities of the post head may facilitate firm retention of core
material, (9) the post should ensure material compati-
bility, bonding ability, adequate rigidity, and esthetic
compatibility with permanent restoration, (10) retriev-
ability in the event of failure should be considered, and
(11) the system should be easy to use and cost effective.
Although newer prefabricated post systems have been
introduced, published long-term clinical data are not
available. In addition, the claim that the nonmetallic
post systems provide excellent esthetics has yet to be
demonstrated through clinical research. Future research
evaluating clinical success of the newer post systems on
teeth with varying degree of tooth loss is recommended.
SUMMARY
With such a wide variety of materials and post designs
available for the restoration of endodontically treated
teeth, the clinician should be selective in choosing the
post system that best fits the individual needs of each
tooth. The criteria and factors presented in this review
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FERNANDES, SHETTY, AND COUTINHO
may help guide the clinician in selecting the most desir-
able post system for each tooth.
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Reprint requests to:
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69. Mannocci E, Ferrari M, Watson TF. Intermittent loading of teeth restored SEBASTIAN VILLA
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root canal posts. J Adhes Dent 1999;1:153-8. PO QUEPEM
70. Cohen BI, Condos S, Deutsch AS, Musikant BL. Fracture strength of three GOA 403705
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posts. Int J Prosthodont 1994;7:178-82. FAX: ⫹91-832-2459816
71. Lewis R, Smith BG. A clinical survey of failed post retained crowns. Br E-MAIL: aquag@rediffmail.com
Dent J 1988;165:95-7.
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3. Cores. Aust Dent J 1989;34:115-21. Dentistry.
73. Thayer KE. Fixed prosthodontics. Chicago: Mosby; 1984 p. 284. 0022-3913/2003/$30.00 ⫹ 0
74. Chang WC, Millstein PL. Effect of post design of prefabricated post heads
on core materials. J Prosthet Dent 1993;69:475-82. doi:10.1016/j.prosdent.2003.09.006

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