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Endodontic Posts: Tips for Securing Restorative Success

Because an endodontic post is part of a restorative system (crown-cement-core-post-cementtooth), its success relies on the success of the entire system and vice versa. That said, some post-specific factors can improve your chances of securing a restoration that will hold together and restore function. Post material and design, as well as preparation of the tooth for a post, including use of a ferrule, all contribute to the restorations reliability.

Beyond retention, factors like esthetics and the ability to re-treat the tooth should the restoration fail also deserve some consideration when selecting a post.

Post Material Mechanical Properties. The material a post is made ofmetal, fiber, or ceramichelps determine mechanical properties like strength and flexibility. Generally, metal and ceramic posts are stronger than fiber ones, but fiber posts offer greater flexibility and have demonstrated fewer root fractures when compared to metal or ceramic ones.[1-4] Unfortunately, there is no clear-cut guidance as to where the balance should be struck between strength and flexibility.[5,6]

Esthetics. Unless your final restoration will be a porcelain-fused-to-metal crown, post material may influence the esthetic result. When esthetics is a concern, ceramic and many fiber posts may have an advantage over metal ones. Metal posts can result in a grayish discoloration, apparent in both the restoration and the gingival margin.[7] Carbon fiber posts, likewise, are dark and may cause shine through.[5,8,9] Thus, for anterior restorations, where esthetics are especially important, consider using a ceramic or light-colored fiber post made of quartz, silicone or glass fibers.[5,8] These light-colored fiber posts have the added esthetic advantage of translucency.[8]

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Posttreatment/Re-treatment Considerations. When placing a post, you may want to weigh the importance of detecting that post on a radiograph and the ease of removing that post should the restoration fail. Post material is a factor on both counts.

Radiopacity. Metal and ceramic posts are identifiable in radiographs, but the radiopacity of fiber posts varies. In the ADA Professional Product Review, three of the seven tested fiber posts demonstrated a radiopacity that was at least equivalent to gutta percha [10]: DT Light Post, ParaPost Fiber Lux, and FRC Postec Plus.[11]

When selecting a post, ask about its radiopacity. Typically, 1 mm of dentin has a radiopacity of approximately 1.5 mm of aluminum. If the post you are considering has a radiopacity that is less than dentin, you may want to consider using a radiopaque cement.

Post Removal. Should the restoration or the root canal seal fail, removal of the post may be necessary. Ideally, the post should be retrievable without substantial loss of tooth structure or damage to the tooth. Fiber posts reportedly can be removed with conventional rotary instruments or by use of solvents, minimizing the effect on remaining dentin.[12,13] While the process may be more time-consuming or difficult, metal posts also can be removed safely,[14] typically after loosening the post with ultrasonics. Ceramic posts are considered difficult to remove, often requiring cutting with rotary instruments.[5]

Some manufacturers offer recommendations for post removal (Table). In addition, some postsystem product lines include re-treatment drills or wrenches; the experts in our panel discussion, however, were wary about the stress such systems may place on the remaining tooth structure, opting instead for ultrasonics when removing posts.[9] When considering posts, it may be beneficial to ask about removal instructions.

Post Design

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Design features like the shape of the post, the post surface, as well as post length and diameter all have been shown to influence retention. In addition, the presence of a retentive head on a post has been shown to offer significant advantages in core retention.[11,15,16]

Post Shape. Posts come in three basic shapes: parallel, tapered, and parallel-tapered (Table).

Parallel. Parallel posts are more retentive than tapered ones.[17,18] In general, they seem less likely to cause root fractures, distributing stresses evenly along their length.[19-21] However, parallel posts require removal of more tooth structure than tapered ones and, therefore, may not be suitable for roots with thin walls.[22]

Tapered. Tapered posts allow for minimal dentin removal since most roots themselves are tapered. Unfortunately, the stresses absorbed by these posts are concentrated in the apex, creating a wedging effect and increasing the risk of vertical root fracture.[23,24] Because of this increased risk when tapered posts fail, they are more likely to leave the tooth unrestorable.[25]

Parallel-tapered. The parallel-tapered post offers the advantages of both designs with few reported disadvantages. This post has a parallel shaft, tapering at the apical end. This mix achieves retention associated with parallel sides, while allowing tooth preservation at the apex.[26]

Surface Features. Surface features of the post also can influence retention. Threaded posts engage the walls of the tooth canal, like a screw. These posts are said to be active and are very well retained. However, active posts may introduce stress to the tooth and are associated with increased risk of root fracture.[27-30] Because of these drawbacks, participants in the ADAs expert panel discussion on endodontic posts opted for passive posts.[9]

By contrast, passive posts are retained solely with a luting agent. Although they are less retentive, they are not associated with the increased stress and root fracture reported for active

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posts.[5] In addition, manufacturers have added some surface features, like serrations, that seem to aid in retention (Table).[31] Smooth posts seem to be less retentive than those with textured surfaces.[32,33]

Length and Diameter. Post retention improves with increases in post length, rather than diameter.[9,17,26,34] An increase in post length with a minimum diameter preserves tooth structure and reduces shear stresses and risk of fracture.[35] See the section below on tooth preparation for more specific tips on post length.

Diameter is important for strength and resistance to post fracture. A variety of philosophies exist regarding post diameter,[36] but generally speaking, preservation of tooth structure is a key consideration when preparing a canal for a post. Ideally, the post space should require minimal removal of radicular dentin.[9,37] Further enlargement weakens the root.[38,39] Sequential use of post twist drills, starting with narrowest and working up to the desired post diameter, can be useful in minimizing tooth loss during post-space preparation.[40]

Preparation of the Tooth

Above all, professional judgment and individual case consideration will determine how you prepare the tooth for a post, but the dental literature does offer some guidance in this area.

With regard to length, for example, one rule of thumb suggests that posts should be as long, if not longer than, the clinical crown height and should end apically beyond the crestal bone.[25,39,41] It also is generally recommended that at least 3-5 mm of gutta percha should be retained for the apical seal[42-45]; although some researchers suggest 4-5 mm, citing unreliability of a 3 mm gutta percha seal.[43,46]

In addition, use of a ferrule has been shown to offer advantages to a post-retained restoration.[47] A ferrule is a collar-like band of restorative material that extends around the tooth

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1-2 mm gingival to the core build-up material. The ferrule is created by extending the margin of the crown preparation gingivally onto the tooth structure and helps achieve resistance, enabling the restoration to withstand lateral and rotational forces. [20,47-50]

Sorensen and Engelman report that teeth restored with a ferrule of 1 mm had twice the fracture resistance of those restored without a ferrule.[20] Beyond a reduced incidence of fracture, Barkhordar noted that, when the restoration failed, the ferrule seemed to offer an advantage, leaving teeth that were able to be re-treated.[48]

Conclusion

The number of choices offered in endodontic posts can make it easy to lose sight of the forest for the trees. It may help to remember that the post is only one part of a system, which becomes one element in a functional dental arch.

We hope the above discussion helps clarify what the literature says about various post features and how those features might influence the restoration. Achieving restorative success ultimately rests on the use of scientific information like that provided here, individual patient factors, and your clinical judgment.

REFERENCES 1. Newman MP, Yaman P, Dennison J, Rafter M, Billy E. Fracture resistance of endodontically treated teeth restored with composite posts. J Prosthet Dent 2003;89(4):360-7. 2. Akkayan B, Gulmez T. Resistance to fracture of endodontically treated teeth restored with different post systems. J Prosthet Dent 2002;87(4):431-7. 3. 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(1):26-36. 4. 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(Spec No):15B-18B. 5. Schwartz RS, Robbins JW. Post placement and restoration of endodontically treated teeth: a literature review. J Endod 2004;30(5):289-301.

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6. Asmussen E, Peutzfeldt A, Heitmann T. Stiffness, elastic limit, and strength of newer types of endodontic posts. J Dent 1999;27(4):275-8. 7. Fernandes AS, Shetty S, Coutinho I. Factors determining post selection: a literature review. J Prosthet Dent 2003;90(6):556-62. 8. Bateman G, Ricketts DN, Saunders WP. Fibre-based post systems: a review. Br Dent J 2003;195(1):43-8; discussion 37. 9. American Dental Association. A Look at Posts from a Different Perspective: Educators, Researchers Weigh In. ADA Professional Product Review (Online version) Expert Panel Discussion. Available at www.ada.org/goto/ppr. 10. International Organization for Standardization. ISO 6876: Dental root canal sealing materials. Geneva: ISO 2001 11. ADA Council on Scientific Affairs. Endodontic Posts. ADA Professional Product Review 2006;I(Spring):2. Available at www.ada.org/goto/ppr. 12. de Rijk WG. Removal of fiber posts from endodontically treated teeth. Am J Dent 2000;13(Spec No):19B-21B. 13. Freedman GA. Esthetic post-and-core treatment. Dent Clin North Am 2001;45(1):103-16. 14. Abbott PV. Incidence of root fractures and methods used for post removal. Int Endod J 2002;35(1):63-7. 15. Chang WC, Millstein PL. Effect of design of prefabricated post heads on core materials. J Prosthet Dent 1993;69(5):475-82. 16. Cohen BI, Pagnillo MK, Newman I, Musikant BL, Deutsch AS. Retention of a core material supported by three post head designs. J Prosthet Dent 2000;83(6):624-8. 17. Standlee JP, Caputo AA, Hanson EC. Retention of endodontic dowels: effects of cement, dowel length, diameter, and design. J Prosthet Dent 1978;39(4):400-5. 18. Qualtrough AJ, Chandler NP, Purton DG. A comparison of the retention of tooth-colored posts. Quintessence Int 2003;34(3):199-201. 19. 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(5):527-32. 20. Sorensen JA, Engelman MJ. Ferrule design and fracture resistance of endodontically treated teeth. J Prosthet Dent 1990;63(5):529-36. 21. Isidor F, Brondum K. Intermittent loading of teeth with tapered, individually cast or prefabricated, parallel-sided posts. Int J Prosthodont 1992;5(3):257-61. 22. Raiden G, Costa L, Koss S, Hernandez JL, Acenolaza V. Residual thickness of root in first maxillary premolars with post space preparation. J Endod 1999;25(7):502-5. 23. Standlee JP, Caputo AA, Collard EW, Pollack MH. Analysis of stress distribution by endodontic posts. Oral Surg Oral Med Oral Pathol 1972;33(6):952-60.-60; 24. Standlee JP, Caputo AA, Holcomb J, Trabert KC. The retentive and stress-distributing properties of a threaded endodontic dowel. J Prosthet Dent 1980;44(4):398-404. 25. Sorensen JA, Martinoff JT. Clinically significant factors in dowel design. J Prosthet Dent 1984;52(1):28-35.

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26. Cooney JP, Caputo AA, Trabert KC. Retention and stress distribution of tapered-end endodontic posts. J Prosthet Dent 1986;55(5):540-6. 27. Felton DA, Webb EL, Kanoy BE, Dugoni J. Threaded endodontic dowels: effect of post design on incidence of root fracture. J Prosthet Dent 1991;65(2):179-87. 28. Burns DA, Krause WR, Douglas HB, Burns DR. Stress distribution surrounding endodontic posts. J Prosthet Dent 1990;64(4):412-8. 29. Standlee JP, Caputo AA. The retentive and stress distributing properties of split threaded endodontic dowels. J Prosthet Dent 1992;68(3):436-42. 30. Deutsch AS, Musikant BL, Cavallari J, Silverstein L, Lepley J, Ohlen K, Lesser M. Root fracture during insertion of prefabricated posts related to root size. J Prosthet Dent 1985;53(6):786-9. 31. Nergiz I, Schmage P, Platzer U, Ozcan M. Bond strengths of five tapered root posts regarding the post surface. J Oral Rehabil 2002;29(4):330-5. 32. Tilk MA, Lommel TJ, Gerstein H. A study of mandibular and maxillary root widths to determine dowel size. J Endod 1979;5(3):79-82. 33. Standlee JP, Caputo AA, Holcomb J, Trabert KC. The retentive and stress-distributing properties of a threaded endodontic dowel. J Prosthet Dent 1980;44(4):398-404. 34. Krupp JD, Caputo AA, Trabert KC, Standlee JP. Dowel retention with glass-ionomer cement. J Prosthet Dent 1979;41(2):163-6. 35. Holmes DC, Diaz-Arnold AM, Leary JM. Influence of post dimension on stress distribution in dentin. J Prosthet Dent 1996;75(2):140-7. 36. Lloyd PM, Palik JF. The philosophies of dowel diameter preparation: a literature review. J Prosthet Dent 1993;69(1):32-6. 37. Pilo R, Tamse A. Residual dentin thickness in mandibular premolars prepared with gates glidden and ParaPost drills. J Prosthet Dent 2000;83(6):617-23. 38. Heydecke G, Butz F, Strub JR. Fracture strength and survival rate of endodontically treated maxillary incisors with approximal cavities after restoration with different post and core systems: an in-vitro study. J Dent 2001;29(6):427-33. 39. Hunter AJ, Feiglin B, Williams JF. Effects of post placement on endodontically treated teeth. J Prosthet Dent 1989;62(2):166-72. 40. Ricketts DN, Tait CM, Higgins AJ. Tooth preparation for post-retained restorations. Br Dent J 2005;198(8):463-71. 41. Goodacre CJ, Spolnik KJ. The prosthodontic management of endodontically treated teeth: a literature review. Part III. Tooth preparation considerations. J Prosthodont 1995;4(2):122-8. Review. 42. Mattison GD, Delivanis PD, Thacker RW Jr, Hassell KJ. Effect of post preparation on the apical seal. J Prosthet Dent 1984;51(6):785-9. 43. Goodacre CJ, Spolnik KJ. The prosthodontic management of endodontically treated teeth: a literature review. Part II. Maintaining the apical seal. J Prosthodont 1995;4(1):51-3. 44. Madison S, Zakariasen KL. Linear and volumetric analysis of apical leakage in teeth prepared for posts. J Endod 1984;10(9):422-7.

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45. Kvist T, Rydin E, Reit C The relative frequency of periapical lesions in teeth with root canalretained posts. J Endod 1989;15(12):578-80. 46. Abramovitz L, Lev R, Fuss Z, Metzger Z. The unpredictability of seal after post space preparation: a fluid transport study. J Endod 2001;27(4):292-5. 47. Stankiewicz NR, Wilson PR. The ferrule effect: a literature review. Int Endod J 2002;35(7):575-81. 48. Barkhordar RA, Radke R, Abbasi J. Effect of metal collars on resistance of endodontically treated teeth to root fracture. J Prosthet Dent 1989;61(6):676-8. 49. Hoag EP, Dwyer TG. A comparative evaluation of three post and core techniques. J Prosthet Dent 1982;47(2):177-81. 50. Mezzomo E, Massa F, Libera SD Fracture resistance of teeth restored with two different post-and-core designs cemented with two different cements: an in vitro study. Part I. Quintessence Int 2003;34(4):301-6.

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Table. Characteristics of Posts Evaluated for ADA Professional Product Review.*

Brand CeraPost DT Light Post FibreKleer FRC Postec Plus Material Ceramic Fiber Retentive Head Design No No Shape, Surface Tapered, Smooth ParallelTapered, Smooth Parallel, Smooth ParallelTapered, Smooth Post Removal Instructions None provided. Post removal kit available from Bisco (800/247-3368) None provided. Use a diamond rotary instrument to drill a preliminary hole, using an extra-long rose bur (0.6 mm diameter). Use FRC Postec Plus reamer. Instructions available from Ivoclar Vivadent (800/5336825). None provided. Use the Kodex Twist drill to initially drill through the post. Use the Tenax end cutting drills to drill through the depth of the post. Finish with the standard ParaPost drills. Instructions available from Coltene/Whaledent (800/221-3046). Use the Kodex Twist drill to initially drill through the post. Use the Tenax end cutting drills to drill through the depth of the post. Finish with the standard ParaPost drills. Instructions available from Coltene/Whaledent (800/2213046). None provided.

Fiber Fiber

Yes No

Luscent Anchors ParaPost Fiber Lux

Fiber Fiber

No Yes

Tapered, Smooth Parallel, Serrated

ParaPost Fiber White

Fiber

Yes

Parallel, Serrated

Twin Luscent Anchors IntegraPost

Fiber

No

Tapered, Smooth

Parallel, None provided. Roughened Metal No Parallel, None provided. ParaPost Serrated Plus Metal Yes Parallel, None provided. ParaPost XH Serrated * ADA Council on Scientific Affairs. Endodontic Posts. ADA Professional Product Review. 2006; I(Spring):2. Tapered post also available. No retentive head design, but serrations present on the head.

Metal

Yes