Q U I N T E S S E N C E I N T E R N AT I O N A L

Restoring endodontically treated teeth with posts and coresA review

Ingrid Peroz, Dr Med Dent1/Felix Blankenstein, Dr Med Dent1/ Klaus-Peter Lange, Prof Dr Med Dent2/Michael Naumann, Dr Med Dent3
Objective: The prognosis of endodontically treated teeth depends not only on the success of the endodontic treatment, but also on the type of reconstruction. These considerations include the decision of whether or not to use posts. Methods and materials: A literature review has been performed to create guidelines for the reconstruction of endodontically treated teeth by posts and cores. Results: Posts should only be used for the retention of core material in cases where little dental substance remains, ie, one or no cavity walls. A ferrule of 2 mm has to be provided, by surgical means if necessary. The post length is limited by the necessary apical seal of 4 to 6 mm. In cases of short posts, adhesive fixation is preferred. Ceramic posts show a higher risk of fracture than fiber posts which are retrievable. Composites have proven to be a good core material. Posts should be inserted if endodontically treated teeth are used as abutments for removable partial dentures. Conclusion: These guidelines are based mainly on in vitro studies with an evidence level of II a or II b, as there is a lack of randomized clinical studies available. The remaining tooth structure is an important factor influencing the indication of posts and cores, yet it is not sufficiently recognized in clinical studies and in vitro. Therefore, further prospective clinical studies are needed. (Quintessence Int 2005;36:737746)

Key words: endodontically treated teeth, post and core, reconstruction, review

The prognosis of endodontically treated teeth depends not only on the treatment itself, but also on sealing the canal and minimizing the leakage of oral fluids and bacteria

Associate Professor, Humboldt University of Berlin, Dental School, Department of Prosthetic Dentistry and Oral Gerontology, Berlin, Germany.

Professor, Humboldt University of Berlin, Dental School,

Department of Prosthetic Dentistry and Oral Gerontology, Berlin, Germany.

3

Assistant Professor, Humboldt University of Berlin, Dental

School, Department of Prosthetic Dentistry and Oral Gerontology, Berlin, Germany. Reprint requests: Dr Ingrid Peroz, Zentrum fr Zahnmedizin, Abteilung fr Zahnrztliche Prothetik und Alterszahnmedizin, Augustenburger Platz 1, 13353 Berlin, Germany. E-mail: ingrid.peroz@charite.de

into periradicular areas by prompt placement of coronal restorations.1 This treatment includes the decision of whether or not posts should be used. After many years of scientific work involving post material, post geometry, post length, core material, and other considerations, the indication for posts is reemerging as a topic of discussion. A change of paradigm has occurred based on the advantages of adhesive restorations, which seem to make post insertion unnecessary. In addition to this development, evidencebased treatment is becoming increasingly important in dentistry. Treatment decisions and strategies should be based on the best and most-up-to-date factual evidence available. Evidence-based dentistry is influencing

COPYRIGHT 2005 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
VOLUME 36 NUMBER 9 OCTOBER 2005

737

Q U I N T E S S E N C E I N T E R N AT I O N A L
Peroz et al

Ta b l e 1

Level of evidence due to study design

Study design

RESULTS
Indications for using posts
In an in vitro study with matched teeth pairs (split-mouth design), Sedgley and Messer2 were able to show that vital dentin is harder than dentin from contralateral endodontically treated teeth, but there was no significant biomechanical change that would indicate that the endodontically treated teeth had become more brittle (in vitro, level of evidence II b). This result is supported by another matched teeth pairs study by Papa et al,3 which shows that there is no significant difference in the moisture content between endodontically treated teeth and vital teeth. It appears that the remaining amount of tooth hard tissue influences stability, rather than the factors listed above. Whereas the preparation of a pulpal access only reduces structural stability by about 5%, loss of the circumferential integrity by mesio-occlusodistal (MOD) cavities reduces the stability by about 63%.4 Panitvisai and Messer5 have shown that the cuspal deflection increases with increasing cavity size, and is greatest following endodontic access. The importance of the marginal ridge for the structural stability of teeth was also shown by Strand et al.6 The use of posts, however, does not increase the fracture resistance significantly. This was shown in several comparative in vitro studies (level of evidence II b).710 Posts are used to provide retention for the core material, so the indication for post insertion depends on the dental substance and extent of either destruction or viable structure seen in the teeth being considered for endodontic treatment. The amount of remaining tooth structure necessary to warrant post insertion, or a decision to use other methods, is not clearly defined. It is, however, based on reviews or personal clinical experience (internal evidence) with a level of evidence no better than IV (review, IV).11 There is a general lack of systematic approaches in literature published on this matter. For this reason, an attempt was made to formulate a more detailed description for the amount of remaining dental tissue because the extent of destruction cannot be evaluated metrically. This classification describes 5

Evidence level

I a (high) Ib II a II b III IV

Meta-analysis of randomized, controlled trials Single randomized, controlled trial Controlled study without randomization Experimental study Descriptive study Estimation of experts

the evaluation and adaptation of many treatment methods that have been commonplace until now. Based on the design of the studies, investigators categorized these treatments into different groups, depending on the level of evidence available (Table 1). Although these levels of evidence depend on clinical trials only, they were also used to characterize in vitro studies. The aim of this study was to create guidelines for the reconstruction of endodontically treated teeth by posts and cores based on a review of the literature, and to assign citations to their levels of evidence.

METHODS AND MATERIALS

The literature search was done using the Grateful Med Interface for Medline (www.cbi.nlm.nih.gov), the Cochrane library (www.cochrane.org), and by manual searches of the German journal Deutsche Zahnrztliche Zeitschrift published the last 10 years. Due to language limitations, only German or English literature was reviewed. Because the online searching process could not find meta-analysis of randomized clinical trials or single randomized trials, literature was searched using key words: dental AND endodontically treated teeth AND other key words (see Table 2). The referenced articles were gathered according to subheadings relevant to treatment decisions concerning endodontically treated teeth.

COPYRIGHT 2005 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

738

VOLUME 36

NUMBER 9

OCTOBER 2005

Q U I N T E S S E N C E I N T E R N AT I O N A L
Peroz et al

Ta b l e 2

Number of references found using study designs and key words

AND endodontically treated AND teeth post AND ferrule effect AND fiber post AND metal post

Study type

OR core

AND diameter

AND length

AND abutment

AND cementation

Meta-analysis of RCT RCT Controlled clinical trial Prospective study Follow-up study Longitudinal study Cohort study Clinical trial Comparative study

0 0 0 6 35 50 51 1 125

0 0 0 1 10 (4)* 13 13 0 61

0 0 0 1 10 (4)* 13 13 0 59

0 0 0 0 0 0 0 0 2

0 0 0 0 0 0 0 0 6

0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 1

0 0 0 1 3 4 4 0 9

0 0 0 1 2 (1)* 3 3 0 27

0 0 0 1 1 2 2 0 11

* Upon reading abstracts of these studies, many had to be eliminated. Only those in parentheses are valid.

classes, depending on the number of remaining axial cavity walls.12 Class I describes the access preparation with all 4 axial cavity walls remaining. Class II describes loss of 1 cavity wall, commonly known as the mesio-occlusal (MO) or the disto-occlusal (DO) cavity. Class III represents an MOD cavity with 2 remaining cavity walls. Class IV describes 1 remaining cavity wall, in most cases the buccal or oral wall, and Class V describes a decoronated tooth with no cavity wall remaining. The minimal thickness of the cavity wall as a determining factor for the resistance to functional loads of the crown-root complex is considered 1 mm. Hard tissue with thicknesses below this level cannot be prepared for crowns without the loss of all remaining substance, leaving no dental tissue. A thickness greater than 1 mm provides an amount of hard tissue sufficient to stabilize the core material even after crown preparation. Therefore, a cavity wall with less than 1 mm thickness cannot be taken into consideration.13 The minimal height of a cavity wall capable of providing a sufficient ferrule effect is 2 mm. This aspect is described in further detail below.

assigned to evidence level II b, depending on their comparable study design.7,10,14

Classes II and III: 2 or 3 remaining cavity walls

Treatment in cases involving the loss of 1 or 2 cavity walls does not necessarily require the insertion of a post, as the remaining hard tissue provides enough surface for the use of other methods, in particular, for cores using adhesive systems (Fig 1). An in vitro study by Steele and Johnson15 showed that composites or amalgam restorations with 3 surfaces (MOD), increase fracture resistance. There was no significant difference between the experimental groups, which included unaltered teeth or those with access only15 (in vitro, II b). The comparison between different adhesive systems for the reconstruction of root canal-treated premolars with MOD cavities have shown that dentin-bonding systems stabilize teeth particularly well, such that their fracture resistance was comparable to intact teeth16 (in vitro, II b). Furthermore, anterior teeth with proximal cavities do not benefit from post insertion17 (in vitro, II b). Two clinical studies assigned to evidence level III, (due to retrospective methods), show that teeth with extensive MOD cavities without reconstruction and with crowns have a higher risk.18 Anterior teeth do not seem to benefit from restoration with crowns.19

Class I: 4 remaining cavity walls (access cavity)

If all the axial walls of the cavity remain and have a thickness greater than 1 mm, it is not necessary to insert posts (Fig 1). In these cases, any type of definitive restoration can be considered. This judgment is based on several in vitro studies, which can be

Class IV: 1 remaining cavity wall

In cases where only 1 cavity wall remains, the core material has little or no effect on the frac-

COPYRIGHT 2005 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
VOLUME 36 NUMBER 9 OCTOBER 2005

739

Q U I N T E S S E N C E I N T E R N AT I O N A L
Peroz et al

Class I III
Two to 4 cavity walls remaining

Class IV
One cavity wall remaining

Post Core Definitive restoration

No Adhesive Any

Post Core Definitive restoration

Fiber Adhesive Crown

Fiber/metal Adhesive/cast Onlay/crown

Fig 1 No post is needed in cases with at least 2 axial cavity walls remaining. A thickness of the cavity wall 1 mm and a height of 2 mm are preconditions. If these conditions cannot be fulfilled, the cavity wall must be considered as missing.

Fig 2 A post should be inserted if only 1 cavity wall is remaining. Fiber posts are preferable in anterior teeth, but in posterior teeth, fiber or metal posts can be used. The core can be made of composite or as a cast post and core. The definitive restorations should be crowns in anterior teeth and crowns, onlays, or overlays in posterior teeth.

Class V: No remaining cavity wall

In cases of teeth with a high degree of destruction where no cavity wall remains, the insertion of posts appears necessary to provide for core material retention (Fig 3). Additionally, the ferrule effect has a great influence on fracture resistance, especially in decoronated teeth. A ferrule, defined as a circumferential area of axial dentin superior to the preparation bevel, should have a height of 1.5 to 2.5 mm.2224 Various in vitro studies with evidence level II b have shown that fracture resistance can be significantly increased by the use of a ferrule; the post length or design (whether they are parallel-sided or tapered) are of secondary importance for fracture resistance if a sufficient ferrule can be provided.2224 If deep destruction of the teeth renders a sufficient ferrule impossible, a surgical crown lengthening can be performed. This provides a crown ferrule resulting in a reduction of static load failure25 (in vitro II b). Bolhuis et al26 postulated that the crown ferrule is more important than a post and core, or a core reconstruction with adhesive fillings only. The researchers examined decoronated, root-treated premolars. These were rebuilt by core build-up without an endodontic post or by core build-up with an endodontic post (a cast post and core, and a composite with a

Class V
No cavity walls remaining

Post Core Definitive restoration

Fiber/metal Adhesive/cast Crown

Fig 3 A post must be inserted if there is no cavity wall remaining. A ferrule of 2 mm is needed to provide a lower risk of root fracture.

ture resistance of the endodontically treated teeth20 (in vitro, II b). If the tooth has to be used as an abutment for fixed or removable partial dentures, crown preparation will further decrease fracture resistance.21 Therefore, the present concept suggests using posts in such cases of reduced remaining tooth structure. For esthetic reasons, nonmetal posts are preferred for treatment of anterior teeth. In posterior teeth, both metal posts and nonmetal posts are acceptable treatment options (Fig 2).

COPYRIGHT 2005 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

740

VOLUME 36

NUMBER 9

OCTOBER 2005

Q U I N T E S S E N C E I N T E R N AT I O N A L
Peroz et al

silica post), and an additional group was not provided with a core at all. No significant difference in fracture strength among the different groups could be demonstrated.26 Several criteria must be taken into account with respect to the indication for post insertion. These criteria will be presented later.

mm was also found.30,31 Considering the need for both a sufficient ferrule effect and the remaining apical sealing, the postulated post length of two-thirds of the root length may be impossible in many clinical situations. As previously stated, shorter posts should be fixed with luting composite.29

Post length
Reviews of evidence presented in level IV studies state that the post length should reach two-thirds of the entire root length. A crown-length/post-length ratio of at least 1:1 should be provided.11,27. Post length influences the stress load along the root. Whereas the enlargement of the canal increases cervical stress, post placement will decrease stress in this region. Short, wide posts lead to elevated stress concentrations in the cervical region. Post placement beyond two-thirds of root depth does not further decrease cervical stress, but tends to increase stress in the apical region28 (in vitro, II b). The selection of post length, however, depends on many criteria. It has been shown that the post length is less important for fracture resistance than the ferrule effect23 (in vitro, II b). The type of fixation used for posts also has an influence on the required length of the post. Nissan et al29 were able to show that adhesive fixation can compensate for reduced retention due to the use of a shorter parallel-sided or tapered post29 (in vitro, II b). Testori et al18 demonstrated there is no significant difference in the retention of adhesive fixed posts 5 mm or 8 mm in length (clinical trial and review, III). These results, however, are less because they were ascertained with a very limited number of samples. Whereas the studies cited above paid special attention to the correlation between post length and post retention, other studies tended to evaluate the remaining root filling after post-space preparation, especially with respect to leakage. It was shown that leakage increases with post-space preparation, and a remaining apical filling of less than 3 mm results in an unpredictable seal.30,31 Post insertion and adhesive fixation can compensate for this leakage. Nevertheless, the need for a remaining apical root filling of 4 to 6

Post diameter
There is little evidence (level IV) for an optimal post diameter. A diameter of one-third of the root diameter is postulated in many reviews. A minimal dentin thickness of 1 mm around the post should be provided.11,32 Due to the stability of the post itself, LambjergHansen and Asmussen33 postulated a post diameter of at least 1.3 mm. In the present study, a diameter of ISO 90 or 1.25 mm, respectively, is proposed.

Post fixation
Adhesive systems seem to be able to stabilize the tooth. Reeh et al4 have shown that composite restorations with dentin enamel etching provide a stability similar to that of the intact tooth (in vitro, controlled trial: II b). The use of composite in the entrance of the root canal stabilizes the root-filled tooth, whereas an additional post is unable to contribute further stabilization.34 Paul and Schrer11 state in their review that the adhesive fixation of a post and core may stabilize the tooth. It was demonstrated in several in vitro studies with an evidence level of II b, that roots in which the posts were adhesively cemented were significantly more fracture resistant than those using zinc phosphate cement35,36 (in vitro II b). Based upon this evidence, the present study recommends adhesive fixation for any kind of post.

Post design
Post design also influences the success of the restoration. Torbjoner et al37 published a prospective study with an evidence level of II a, comparing failure rates and failure characteristics of tapered and parallel-sided posts. They found the cumulative failure rate of tapered posts was 15% higher than the failure rate for parallel-sided posts (8%). Loss of retention was listed as the most frequent reason for failure for both types of posts.37

COPYRIGHT 2005 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
VOLUME 36 NUMBER 9 OCTOBER 2005

741

Q U I N T E S S E N C E I N T E R N AT I O N A L
Peroz et al

Parallel-sided posts and those surrounded by large amounts of cement had lower fracture rates than tapered posts or tapered posts with maximal adaptation in the root canal.38 Further studies also show that the post design has to be considered in combination with other aspects of posts. In this regard, the ferrule effect seems to be more important for fracture resistance than the post design.22 Adhesive fixation of posts is also more relevant for post retention than the post design itself11,29 (review, IV; in vitro, II b) (review, IV).

If fiber posts are used, they should be fixed by adhesive material. Vichi et al45 described the types of adhesive structures between the resin cement and dentin (in vivo, III). Ferrari et al46 were able to show, by microscopic examinations, that Excite dualcured bonding agent produced a resindentin interdiffusion zone higher than that seen in samples with Excite light-cured bonding agent or a one-step bonding system (in vitro, II b). The biomaterial disadvantages of fiber posts, which are based on decreased 3-point bending test values due to the water storage of these posts, can be avoided by adhesive fixation because they were isolated to saliva47 (in vitro, II b). Ceramic posts show survival rates and fracture strength comparable to cast posts and cores48 (in vitro, II b). Zirconia posts and ceramic cores, as well as chair-side procedures with zirconia posts with composite cores, are recommended49 (in vitro, II b). Comparisons of fiber and ceramic posts show a higher risk of fracture with ceramic posts due to cracks within the posts50,51, (in vitro, II b). Fiber posts show an additional advantage in that they are readily retrievable after failure.52 The results of a retrospective in vivo study (evidence level III) indicate that fiber posts are superior to the conventional cast post and core systems after 4 years of clinical service.53 The use of metal posts is justified by studies showing that the fracture resistance of teeth restored by metal posts is superior to other systems.54 The morphologic cast post and core systems appear to be of secondary importance compared to direct metal posts and composite cores. Direct posts and cores comprised 70% of the cases in root fractures after loading and 30% of the core fractures. The cast posts involved the root of all cases of fracture.43 Surfaces of metal posts should be rough to provide the best retention in the root canal5560 (in vitro studies, II b). Metal posts can be cemented by zinc phosphate cement or by adhesive resin systems. Because adhesive cementation results not only in lower microleakage, but also in higher retention, it is preferred.61.62

Post material/core material

Due to the biomaterial aspects in cases where metal posts are used, the definitive restoration should be made with either the same or analog alloys. The present study suggests cast-on posts and cores made of a gold Au-alloy, a cobalt-based alloy, or titanium. This suggestion is based on internal evidence only (evidence level IV). Screws should not be used, as a higher incidence of root fractures lowers their survival rate significantly39,40 (retrospective clinical trial, III; meta-analysis over clinical trials, II a). Fiber posts tested by in vitro studies show a great variability in fracture resistance when compared to metal posts or ceramic posts. Cormier et al41 identified fiber posts as having the lowest fracture resistance, whereas Akkayan and Gulmez42 found comparable fracture resistance values between zirconium oxide and fiber posts. In cases of fractures, the fiber posts produced more restorable fractures than other post materials (in vitro, II b).4143 Taking into account that in vitro tests involve higher fracture loads than those occurring during mastication, fiber posts provide sufficient fracture thresholds. In an in vitro study (evidence level II b) performed on structurally weakened central incisors with thin cavity walls of 0.5 to 0.75 mm, Saupe et al44 demonstrated that the resistance to a simulated masticatory load of a fiber post and core system was significantly greater than that of a morphologic post and core procedure. Under these conditions, a ferrule provides no additional benefit with respect to retention and fracture resistance.

COPYRIGHT 2005 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

742

VOLUME 36

NUMBER 9

OCTOBER 2005

Q U I N T E S S E N C E I N T E R N AT I O N A L
Peroz et al

The comparison between cast and direct post-and-core systems revealed no significant differences that would justify recommending the use of one over the other.63 This statement is based on one of the rare metaanalyses made by a systematic review of in vitro and in vivo studies.64 However, due to the lack of randomized, controlled studies, the assigned evidence level is II a. Direct posts and cores should use (independent of the post material) composites as core material. After amalgam, composites show both the lowest defect and failure rates, and the best fracture resistance (evidence level IIb to IV).49,6570

DISCUSSION
The present concept for the restoration of endodontically treated teeth by posts and cores aims to draw its guidelines from the evidence present in recent literature. The cited literature is assigned a level of evidence showing the reliability of the sources upon which decisions are based. The review of the literature shows that there is a lack of in vitro, and especially, clinical studies, correlating the amount of remaining tooth structure to the indication for posts. As such, it would be worthwhile to examine whether it is possible or recommendable not to use posts even for teeth with no remaining cavity walls. The limited number of prospective clinical studies is notable. Therefore, a prospective clinical study documenting cases meeting specific criteria (tooth within a complete dental arch, single tooth restoration, retention by remaining pulp chamber) in which posts are not used, is necessary. There is also a lack of prospective clinical studies in which the amount of remaining tooth structure is documented and the survival rate of several post materials is tested. The remaining tooth structure should be evaluated by a designed index system.74

Definitive restoration
The indication for post insertion depends not only on the amount of remaining tooth structure but also on the planned prosthetic reconstruction. The prognosis of an endodontically treated tooth is best if in a complete dental arch because of stabilizing mesial and distal proximal contacts.71 Sorensen and Martinoff72 demonstrated in their clinical, retrospective study (evidence level III) that post insertion brings no advantage to the survival rate of an endodontically treated tooth if it is restored by a crown or fixed partial denture. However, in cases where such a tooth is needed as an abutment for removable partial dentures, the post insertion has a significant positive effect for treatment success.72 Nevertheless, a tooth treated by root canal within a removable partial denture poses a higher risk for treatment failure72,73 (in vivo studies, evidence level III). Testori et al18 have shown that the pain threshold of an endodontically treated tooth used as a distal abutment is twice as high as that of a vital tooth These results influenced the present study, in which endodontically treated teeth were not included as abutment teeth for telescopes apart from cases in which all cavity walls remain. If a tooth treated with a root canal has to be included as an abutment tooth for cantilever fixed partial dentures or as the distal abutment of fixed partial dentures, or combined with a removable partial denture, the patient must be informed about the higher risk of failure.

CONCLUSIONS
The literature review reveals: 1. There is a lack of prospective clinical studies with well-documented inclusion criteria for endodontically treated teeth, remaining coronal hard tissue, and flaring. 2. The 2-mm ferrule has a very important role for the survival rate of endodontically treated teeth that have been restored with crowns. 3. Post length is limited by the necessary apical seal of 4 to 6 mm. Remaining tooth structure is more important than post length in avoiding tooth fracture. 4. Adhesive fixation is preferable, as it produces a higher fracture resistance in com-

COPYRIGHT 2005 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
VOLUME 36 NUMBER 9 OCTOBER 2005

743

Q U I N T E S S E N C E I N T E R N AT I O N A L
Peroz et al

parison to cemented posts and cores, as well as offers a higher leakage resistance. 5. Composites are a good core material. 6. Posts should be inserted if endodontically treated teeth are used as abutments for removable partial dentures.

14. Attin T, Hellwig E, Hilgers R-D. Der Einflu verstrkender Wurzelstifte auf die Frakturanflligkeit endodontisch versorgter Zhne. Dtsch Zahnrztl Z 1994;49:586589. 15. Steele A, Johnson BR. In vitro fracture strength of endodontically treated premolars. J Endod 1999;25: 68. 16. Ausiello P, De Gee AJ, Rengo S, Davidson CL. Fracture resistance of endodontically treated premolars adhesively restored. Am J Dent 1997;10:237241. 17. Strub JR, Pontius O, Koutayas S. Survival rate and fracture strength of incisors restored with different post and core systems after exposure in the artificial mouth. J Oral Rehabil 2001;28:120124. 18. Testori T, Badinio M, Castagnola M. Vertical root fractures in endodontically treated teeth: A clinical survey of 36 cases. J Endod 1993;19:8791. 19. Sorensen JA, Martinoff JT. Intracoronal reinforcement and coronal coverage: A study of endodontically treated teeth. J Prosthet Dent 1984;51:780784. 20. Foley J, Saunders E, Saunders WP. Strength of core build-up materials in endodontically treated teeth restored by the post and core technique. Am J Dent 1997;10:166172. 21. Burke FJ, Shaglouf AG, Combe EC, Wilson NH. Fracture resistance of five pin-retained core buildup materials on teeth with and without extracoronal preparation. Oper Dent 2000;25:388394. 22. Assif D, Bitenski A, Pilo R, Oren E. Effect of post design on resistance to fracture of endodontically treated teeth with complete crowns. J Prosthet Dent 1993;69:3640. 23. Isidor F, Brondum K, Ravnholt G.The influence of post length and crown ferrule length on the resistance to cyclic loading of bovine teeth with prefabricated titanium posts. Int J Prosthodont 1999;12:7882. 24. Sorensen JA, Engelman MJ. Ferrule design and fracture resistance of endodontically treated teeth. J Prosthet Dent 1990;63:529536. 25. Gegauff AG. Effect of crown lengthening and ferrule placement on static load failure of cemented cast post-cores and crowns. J Prosthet Dent 2000;84: 169179. 26. Bolhuis HPB, De Gee AJ, Feilzer AJ, Davidson CL. Fracture strength of different core build-up designs. Am J Dent 2001;14:286290. 27. Stockton LW. Factors affecting retention of post systems: A literature review. J Prosthet Dent 1999;81: 380385. 28. Hunter AJ, Feiglin B, Williams JF. Effects of post placement on endodontically treated teeth. J Prosthet Dent 1989;62:166172. 29. Nissan J, Dimitry Y, Assif D.The use of reinforced composite resin cement as compensation for reduced post length. J Prosthet Dent 2001;86:304308. 30. Abramovitz L, Lev R, Fuss Z, Metzger Z. The unpredictability of seal after post space preparation: A fluid transport study. J Endod 2001;27:292295.

REFERENCES
1. Heling I, Gorfil C, Slutzky H, Kopolovic K, Zalkind M, Slutzky-Goldberg I. Endodontic failure caused by inadequate restoration procedures: Review and treatment recommendations. J Prosthet Dent 2002; 87:674678. 2. 3. Sedgley CM, Messer HH. Are endodontically treated teeth more brittle? J Endod 1992;18:332335. Papa J, Cain C, Messer HH. Moisture content of vital vs endodontically treated teeth. Endod Dent Traumatol 1994;10:9193. 4. Reeh ES, Douglas WH, Messer HH. Stiffness of endodontically treated teeth related to restoration technique. J Dent Res 1989;68:15401544. 5. Panitvisai P, Messer HH. Cuspal deflection in molars in relation to endodontic and restorative procedures. J Endod 1995;21:5761. 6. Strand GV, Tveit AB, Gjerdet NR, Bergen GE. Marginal ridge strength of teeth with tunnel preparations. Int Dent J 1995;45:117123. 7. Guzy GE, Nicholls JI. In vitro comparison of intact endodontically treated teeth with and without endo-post reinforcement. J Prosthet Dent 1979;42: 3944. 8. Heydecke G, Butz F, Strub JR. Einflu des endodontischen Aufbaus auf die Frakturfestigkeit berkronter Frontzhne. Dtsch Zahnrztl Z 1999;54:637640. 9. Baratieri LN, De Andrada MA, Arcari GM, Ritter AV. Influence of post placement in the fracture resistance of endodontically treated incisors veneered with direct composite. J Prosthet Dent 2000;84: 180184. 10. McDonald AV, King PA, Setchell DJ. In vitro study to compare impact fracture resistance of intact roottreated teeth. Int Endod J 1990;23:304312. 11. Paul SJ, Schrer P. Plastische Aufbauten in der Kronen- und Brckenprothetik. Quintessenz 1996; 47:15191531. Blankenstein 12. F, Lange von Naumann KP. Vorschlag In-vitro M, zur

Standardisierung

Belastbarkeit-

suntersuchungen an endodontisch behandelten Zhnen. Dtsch Zahnrztl Z 2002;57:554557. 13. Pilo R, Tamse A. Residual dentin thickness in mandibular premolars prepared with Gates Glidden and ParaPost drills. J Prosthet Dent 2000;83:617623.

COPYRIGHT 2005 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

744

VOLUME 36

NUMBER 9

OCTOBER 2005

Q U I N T E S S E N C E I N T E R N AT I O N A L
Peroz et al

31. Wu M-K, Pehlivan Y, Kontakiotis EG, Wesselink PR. Microleakage along apical root fillings and cemented posts. J Prosthet Dent 1998;79:264269. 32. Lloyd PM, Palik JF. The philosophies of dowel diameter preparation: A literature review. J Prosthet Dent 1993;69:3236. 33. Lambjerg-Hansen H, Asmussen E. Mechanical properties of endodontic posts. J Oral Rehabil 1997;24: 882887. 34. Trope M, Maltz DO,Tronstad L. Resistance to fracture of restored endodontically treated teeth. Endod Dent Traumatol 1985;1:108111. 35. Mendoza DB, Eakle WS, Kahl EA, Ho R. Root reinforcement with a resin-bonded preformed post. J Prosthet Dent 1997;78:1014. 36. Utter JD, Wong BH, Miller BH. The effect of cementing procedures on retention of prefabricated metal posts. J Am Dent Assoc 1997;128:11231127. 37. Torbjorner A, Karlsson S, Odman PA. Survival rate and failure characteristics for two post designs. J Prosthet Dent 1995;73:439444. 38. Sorensen JA, Engelman MJ. Effect of post adaptation on fracture resistance of endodontically treated teeth. J Prosthet Dent 1990;64:419424. 39. Eckerbom M, Magnusson T, Martinsson T. Prevalence of apical periodontitis, crowned teeth and teeth with posts in a Swedish population. Endod Dent Traumatol 1991;7:214220. 40. Creugers NH, Mentink AG, Kayser AF. An analysis of durability data on post and core restorations. J Dent 1993;21:281284. 41. Cormier CJ, Burns DR, Moon P. In vitro comparison of the fracture resistance and failure mode of fiber, ceramic, and conventional post systems at various stages of restoration. J Prosthodont 2001;10:2636. 42. Akkayan B, Gulmez T. Resistance to fracture of endodontically treated teeth restored with different post systems. J Prosthet Dent 2002;87:431437. 43. Sirimai S, Riis DN, Morgano SM. An in vitro study of the fracture resistance and the incidence of vertical root fracture of pulpless teeth restored with six post-and-core systems. J Prosthet Dent 1999;81: 262269. 44. Saupe WA, Gluskin AH, Radke RA Jr. A comparative study of fracture resistance between morphologic dowel and cores and a resin-reinforced dowel system in the intraradicular restoration of structurally compromised roots. Quintessence Int 1996;27:483491. 45. Vichi A, Grandini S, Ferrari M. Clinical procedure for luting glass-fiber posts. J Adhes Dent 2001;3: 353359. 46. Ferrari M, Vichi A, Grandini S, Goracci C. Efficacy of a self-curing adhesive-resin cement system on luting glass-fiber posts into root canals: An SEM investigation. Int J Prosthodont 2001;14:543549. 47. Mannocci F, Sherriff M, Watson TF. Three-point bending test of fiber posts. J Endod 2001;27: 758761.

48. Butz F, Lennon AM, Heydecke G, Strub JR. Survival rate and fracture strength of endodontically treated maxillary incisors with moderate defects restored with different post-and-core systems: An in vitro study. Int J Prosthodont 2001;14:5864. 49. Heydecke G, Butz F, Hussein A, Strub JR. Fracture strength after dynamic loading of endodontically treated teeth restored with different post-and-core systems. J Prosthet Dent 2002;87:438445. 50. Mannocci F, Ferrari M, Watson TF. Intermittent loading of teeth restored using quartz fiber, carbonquartz fiber, and zirconium dioxide ceramic root canal posts. J Adhes Dent 1999;1:153158. 51. Martinez-Gonzalez A, Amigo-Borras V, Fons-Font A, Selva-Otaolaurruchi E, Labaig-Rueda C. Response of three types of cast posts and cores to static loading. Quintessence Int 2001;32:552560. 52. Cormier CJ, Burns DR, Moon P. In vitro comparison of the fracture resistance and failure mode of fiber, ceramic, and conventional post systems at various stages of restoration. J Prosthodont 2001;10:2636. 53. Ferrari M,Vichi A, Garcia-Godoy F. Clinical evaluation of fiber-reinforced epoxy resin posts and cast post and cores. Am J Dent 2000;13:15B18B. 54. Martinez-Insua A, da Silva L, Rilo B, Santana U. Comparison of the fracture resistances of pulpless teeth restored with a cast post and core or carbon-fiber post with a composite core. J Prosthet Dent 1998; 80:527532. 55. Lewis R, Smith BG. A clinical survey of failed post retained crowns. Br Dent J 1988;165:9597. 56. Nergiz I, Schmage P, Platzer U, McMullan-Vogel CG. Effect of different surface textures on retentive strength of tapered posts. J Prosthet Dent 1997;78: 451457. 57. Cohen BI, Penugonda B, Pagnillo M, Schulman A, Hittelman E. Torsional resistance of crowns cemented to composite cores involving three stainless steel endodontic post designs. J Prosthet Dent 2000;84:3842. 58. Rosin M, Fleissner P, Welk A, Steffen H, Heine B. The influence of surface configuration on the retention of posts designed for use with a cast-on technique. Quintessence Int 2001;32:119130. 59. Standlee JP, Caputo AA. Effect of surface design on retention of dowels cemented with a resin. J Prosthet Dent 1993;70:403405. 60. Cohen BI, Pagnillo M, Newman I, Musikant BL, Deutsch AS. Retention of four endodontic posts cemented with composite resin. Gen Dent 2000; 48:320324. 61. Bachicha WS, DiFiore PM, Miller DA, Lautenschlager EP, Pashley DH. Microleakage of endodontically treated teeth restored with posts. J Endod 1998;24: 703708. 62. Tjan AHL, Tjan AH, Sun JC. Retention of Luminex post system. Oral Health 1997;87:3135.

COPYRIGHT 2005 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
VOLUME 36 NUMBER 9 OCTOBER 2005

745

Q U I N T E S S E N C E I N T E R N AT I O N A L
Peroz et al

63. Reagan SE, Fruits TJ, Van Brunt CL, Ward CK. Effects of cyclic loading on selected post-and-core systems. Quintessence Int 1999;30:6167. 64. Heydecke G, Peters MC. The restoration of endodontically treated, single-rooted teeth with cast or direct posts and cores: A systematic review. J Prosthet Dent 2002;87:380386. 65. Gateau P, Sabek M, Dailey B. Fatigue testing and microscopic evaluation of post and core restorations under artificial crowns. J Prosthet Dent 1999; 82:341347. 66. Kovarik RE, Breeding LC, Caughman WF. Fatigue life of three core materials under simulated chewing conditions. J Prosthet Dent 1992;68:584590. 67. Cohen BI, Pagnillo MK, Condos S, Deutsch AS. Four different core materials measured for fracture strength in combination with five different designs of endodontic posts. J Prosthet Dent 1996;76: 487495. 68. Cohen BI, Pagnillo M, Newman I, Musikant BL, Deutsch AS. Retention of core material supported by three post head designs. J Prosthet Dent 2000; 83:624628.

69. Cohen BI, Pagnillo MK, Newman I, Musikant BL, Deutsch AS. Pilot study of the cyclic fatigue characteristics of five endodontic posts with four core materials. J Oral Rehabil 2000;27:8392. 70. Krejci I, Mueller E, Lutz F. Effects of thermocycling and occlusal force on adhesive composite crowns. J Dent Res 1994;73:12281232. 71. Caplan DJ, Kolker J, Rivera EM, Walton RE. Relationship between number of proximal contacts and survival of root canal treated teeth. Int Endod J 2002;35:193199. 72. Sorensen JA, Martinoff JT. Endodontically treated teeth as abutments. J Prosthet Dent 1985;53: 631636. 73. Hatzikyriakos AH, Reisis GI, Tsingos N. A 3-year postoperative clinical evaluation of posts and cores beneath existing crowns. J Prosthet Dent 1992;67: 454458. 74. Blankenstein F, Naumann M, Lange K-P. berlebenswahrscheinlichkeit endodontisch behandelter ZhneVorschlag zur klinischen Erfassung des Erhaltungsgrades. Dtsch Zahnrztl Z 2002;57: 558561.

Prosthodontist
Department of Comprehensive Care Case Western Reserve University School of Dental Medicine Cleveland, OH
The Department of Comprehensive Care at Case Western Reserve University School of Dental Medicine invites applications for a full-time tenure track faculty position at the assistant/associate professor level. Responsibilities include didactic and clinical teaching and research. Participation in the CWRU Dental Faculty practice is available. Candidates must have a DMD/DDS degree or equivalent, and advanced training in prosthodontics or equivalent. Research and clinical interest and/or experience in fixed and implant prosthodontics and adhesive dentistry is desired. Salary and rank commensurate with qualifications and experience.
Case Western Reserve University is an equal opportunity/affirmative action employer.

Applicants should send a curriculum vitae, and names of three references to: Avishai Sadan, DMD, Chairman Department of Comprehensive Care Case Western Reserve University School of Dental Medicine 10900 Euclid Avenue Cleveland, OH 44106-4905

COPYRIGHT 2005 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

746

VOLUME 36

NUMBER 9

OCTOBER 2005