Received: 14 December 2021 Revised: 11 January 2022 Accepted: 17 January 2022

DOI: 10.1111/jerd.12880

CLINICAL ARTICLE

Restorative difficulty evaluation system of endodontically

treated teeth

Marco Ferrari MD, DMD, PhD1 | Denise I. K. Pontoriero DDS1 |

2 1
Edoardo Ferrari Cagidiaco DDS, PhD, MS | Fabio Carboncini DDS

1
Department of Prosthodontics and Dental
Materials, School of Dentistry, University of
Siena, Siena, Italy
2
Department of Oral Surgery, School of
Dentistry, University of Siena, Siena, Italy
Correspondence
Marco Ferrari, School of Dentistry, Policlinico
Le Scotte, Viale Bracci 14, Siena 53100, Italy.
Email: ferrarimar@unisi.it
Abstract
Objective: This article provides an updated overview of restorative procedures of
endodontically treated teeth.
Clinical considerations: The different techniques and procedures to restore an
endodontic treated tooth were considered in the last decades. While they are
generally performed using bonding procedures in combination with or without the
placement of a post into the root to build up the abutment, there has been a lack
of interest in restorative difficulties that can be faced. Failures are represented
such as debonding of the post, fracture of the root, decementation, and/or frac-
ture of the restoration, microleakage of the margins. Essentially, the presence of a
sufficient failure is considered a key point of a long prognosis. Different clinical
factors can directly influence the type of restoration and the longevity of the
treatment. The restorative difficulty evaluation system (RDES) is proposed in this
article. This new system is composed of eight different clinical factors that are
divided into six levels of difficulties. The RDES is composed of 1. Endodontic com-
plexity and outcome, 2. Vertical amount of coronal residual structure and
dimension of the pulp chamber, 3. Horizontal amount of coronal residual struc-
ture, 4. Restoration marginal seal, 5. Local interdisciplinary conditions, 6. the com-
plexity of the treatment planning, 7. Functional need, 8. Dental wear and
esthetic need.
Conclusion: This article reviews the RDES and outlines critical steps and tips for clini-
cal success.
Clinical significance: The RDES allows to any clinician to evaluate restorative difficul-
ties when an endodontic treated tooth must be restored, combines clinical aspects
that can involve from the single tooth to a full mouth rehabilitation.

KEYWORDS
bonding, build up, complex treatment, endodontic treated teeth, posts

J Esthet Restor Dent. 2022;34:65–80. wileyonlinelibrary.com/journal/jerd © 2022 Wiley Periodicals LLC 65

66
1 | I N T RO DU CT I O N
The best plan strategy for success should start with the end in mind.
Before initiating treatment, the clinician should carefully examine and
evaluate the tooth and assess it for the feasibility of endodontic treat-
ment, restorability, periodontal health, occlusal function, esthetic
needs.
Clinical diagnosis during the evaluation of the possibility to save
an endodontically involved tooth has to be based on the capability to
keep the tooth in function for a reasonable time.1–4
There is therefore the need for new baseline parameters that will
have to establish once the treatment goals to restore endodontically
treated teeth (ETT) in different clinical conditions.
Under the best of circumstances, the restorative difficulty evalua-
tion system (RDES) would be able to maintain ETT in function for
many years also to give an idea of the difficulty that the operator will
have to treat the single case.
Hence, it is apt to point out the local, tooth, and oral clinical
parameters which may serve as indicators for a new-onset.
From a clinical point of view, the maintenance of an ETT for a
long time reflects proper treatment planning for the tooth itself and
the mouth of the patient. The diagnostic process must be based on a
multifactorial approach, with a proper evaluation of each patient.
Parameters such as endodontic anatomy, complexity and out-
come of the endodontic treatment, amount of coronal residual struc-
ture, margins quality of restoration, local interdisciplinary conditions,
in particular periodontal status, type, and complexity of the treatment
planning, functional need, dental wear, and esthetic needs must be
evaluated.
Without a proper RDES, the patients are likely to experience dif-
ferent types of clinical failure of different impact on the oral health of
each patient.
The assessment of the RDES in each patient would enable the cli-
nician to determine the difficulty in maintaining and restoring the ETT
in function in a proper personalized treatment planning.
FERRARI ET AL.
The determination of such RDES would thus prevent both
undertreatment and excessive overtreatment and in a particular
type of catastrophic failure that can determine an economic
and clinical stress/lack/complications for both clinician and
patient.
2 | ENDODONTIC TREATED TEETH
D I A G N O S T I C M ET H O D O F R E S TO R A T I V E
DI FF I CUL TY
The RDES may be evaluated based on several clinical factors, local
and more generally related to the entire mouth, whereby no single
parameter displays a more paramount role.
The entire spectrum of general, local and mouth parameters
ought to be evaluated simultaneously.
For this purpose, a functional diagram has been created
(Scheme 1 and Table 1) including the following aspects:
1. Endodontic complexity and outcome,
2. Vertical amount of coronal residual structure and dimension of the
pulp chamber,
3. Horizontal amount of coronal residual structure,
4. Restoration marginal seal,
5. Local interdisciplinary conditions,
6. The complexity of the treatment planning,
7. Functional needs,
8. Dental wear and esthetic need.
Each parameter has its own scale for minor,1,2 moderate,3,4 and
high-difficulty5,6 profiles that can be visualized in the functional
diagram from inside to outside (Scheme 1). A comprehensive evalu-
ation of the functional diagram will provide individualized treat-
ment planning and determine the ETT prognosis inside its
treatment planning.
Modifications may be made to the functional diagram if additional
factors become important according to new evidence.
S C H E M E 1 The functional diagram
of restorative difficulty evaluation
system (RDES); eight clinical
parameters are included. From the
center to the boarder clinical difficulty
increases in six different level. Green
area corresponds to low risk, yellow
area to moderate risk, and red area to
high-risk category
 FERRARI ET AL.

TABLE 1 The restorative difficulty evaluation system (RDES) reported in a table. Green area corresponds to low-risk scores, yellow area to moderate risk, and red area to high-risk scores

Score 1 2 3 4 5 6

Parameters
Endodontic complexity Vital tooth Necrotic single root with Necrotic multi-root with Complex anatomy Retreatment Complex retreatment
and outcome a periapical lesion a periapical lesion (calcified and/or (with modification of
additional canals, etc.) the root anatomy)
Vertical amount of Four coronal residual Three coronal residual Two coronal residual One coronal residual One coronal residual No ferrule
coronal residual walls walls walls wall wall
structure and
dimension pulp
chamber
Horizontal amount of Absence of cervical A slight cervical lesion, Cervical lesion requiring Absence of cervical A slight cervical lesion, Cervical lesion requiring
coronal residual lesions or excessive not requiring restoration and lesions and presence not requiring restoration and
structure internal structure restoration, and absence of excessive of excessive internal restoration, and presence of excessive
removal absence of excessive internal structure structure removal presence of excessive internal structure
internal structure removal internal structure removal
removal removal
Restoration marginal seal Margins in the enamel Margins partially in the Margins in dentin and Margins placed iuxta- Margins placed into the Margins placed deeply
and completely supra- enamel and dentin supra-gengivally gingival sulcus into the sulcus
gengivally placed and iuxta-gengivally placed
placed
Local interdisciplinary No need for Loss of attachment Need for crown Need for ortho extrusion Need for ortho extrusion Need for periodontal
conditions interdisciplinary without the need for lengthening (single and crown and crown surgical therapy
treatment (single periodontal treatment, tooth) lengthening (single lengthening (single (bridge)
tooth) (single tooth) tooth) tooth)
The complexity of the A single tooth in a virgin A single tooth in a Tooth as the abutment Tooth as the terminal Tooth as the abutment Tooth as the distal
treatment planning quadrant quadrant with other of a multiunit bridge distal abutment of a of a full arch terminal abutment of
restored teeth multiunit bridge rehabilitation a full arch
rehabilitation
Functional need Free-standing Free-standing Short/medium (up to Short/medium (up to Long span bridge in the Long span bridge in the
restoration in the restoration in the 20 mm) span bridge in 20 mm) span bridge in favorable occlusal unfavorable occlusal
favorable occlusal unfavorable occlusal the favorable occlusal the unfavorable environment environment
environment environment environment occlusal environment
Dental wear and esthetic No dental wear and no Slight esthetic need and Esthetic needs and mild High-esthetic need and High-esthetic need and Compromised function
need esthetic needs slight dental wear dental wear heavy dental wear severe dental wear due to dental wear
67
68
FIGURE 1 A vital second molar in need to be endodontically
treated
F I G U R E 3 A necrotic single root premolar with a periapical lesion
before the endodontic treatment (ET)
3 | F A I L U R E OF ET T
Failure of ETT is usually related to endodontic and restorative
reasons.1–3
The most common reason for extraction was for prosthetic issues
followed by periodontal ones, non-restorable cusp/tooth fracture,
non-restorable caries, vertical root fracture, endodontic failure, and
perforation/stripping was the least common reason. The mandibular
first molars were the most frequently extracted teeth and in general
4
posterior teeth were extracted more frequently than anterior ones.
Nonsurgical root canal treatment often fails when adequate standards
are not achieved (insufficient preparation and irrigation and short/long
root canal filling length).5,6
For the mentioned clinical aspects related to ETT failures, the
application of Endodontic Treated Teeth Diagnostic Method (ETTDM)
can be useful for clinicians.
FERRARI ET AL.
FIGURE 2 Same tooth at 5 years recall
FIGURE 4 Same tooth at 5 years recall
3.1 | Endodontic complexity and outcome
Endodontic complexity and outcome parameter are placed first
because they are first because the first steps in the treatment of a
tooth when needed. Also, the endodontic treatment must be per-
formed reliably to foresee its long-term success.
The relationship between endodontic case complexity and treat-
ment outcomes was pointed out by different authors.9–12
The complexity endodontic indices that were proposed by many
have one thing in common: the ability to assign a cumulative numeri-
cal value, which increases with the degree of complexity while the
restorative index of treatment need (RIOTN) system of grading the
complexity of root canal treatment was found to be incomplete, with
moderate to poor reproducibility.11
However, endodontic complexity that will reflect on the outcome,
is based on root canal anatomy and clinical preexisting situations; root
FERRARI ET AL.
F I G U R E 5 A necrotic multi-root lower molar with a periapical
lesion before the endodontic treatment (ET)
F I G U R E 7 A central upper incisor with complex anatomy before
the endodontic treatment (ET)
canal anatomy factors are related to original root canals such as tight
canals, calcified canals, apical bifurcation, complex anatomy, internal
and/or external resorption, short root, and iatrogenic alterations of
69
FIGURE 6 Same tooth at 4 years recall
the anatomy such as stripping and perforation. Clinical preexisting sit-
uations factors are related to apical seal and root filling, periapical
lesions, crack syndrome, age of the patients, preexisting post, degra-
dation of collagen material. All these factors can directly influence the
decision-making on the type and materials to be sued for the buildup,
and the final restoration.
Far from identifying an ideal Complexity index, it can be stressed
that each tooth/root(s) has its difficulty to be treated and that can be
related to the knowledge and skill of the single operator. Also, a big
number of endodontic treatments are performed by General Clinicians
(GCs) that also do the restorative procedures in the same ETT. This
practical aspect reinforces the need for ETTDM.
In order to be easily used by GCs, the grade of Endodontic Com-
plexity was organized in 6 degrees, from the most simple to the most
difficult: 1. Vital tooth (Figures 1 and 2), 2. Necrotic single root with a
periapical lesion (Figures 3 and 4), 3. Necrotic multi-root with a peri-
apical lesion (Figures 5 and 6), 4. Complex anatomy (calcified canals,
additional canals, etc.) (Figures 7–9), 5. Retreatment (Figures 10 and
11), 6. Complex retreatment (with modification of the root anatomy)
(Figures 12 and 13). Individuals with vital teeth to be treated for the
first time have relatively high predictability while those in need of
retreatment have the lowest.
3.2 | Coronal residual structure (vertical)
The amount of residual structure of ETT is the main described param-
eter in the literature.13,14
It is well known how a tooth becomes weaker and weaker as it is
progressively loses part of its coronal structure.13 The amount of cor-
onal residual structure is often described as the number of residual
walls15 but also as percentage of the remained residual structure as
well16 to point out the need to place a post or not.17–23 The concept
of “ferrule” was pointed out as the main parameter to be evaluated in
ETT.24
70
FIGURE 8 Working length of the two root canals
F I G U R E 1 0 A lower molar in need of retreatment before
endodontic treatment (ET)
The residual amount of coronal residual dentin can be evaluated
horizontally and vertically. Here is the description of vertical coronal
residual dentin: 1. Four coronal residual walls, 2. Three coronal
FERRARI ET AL.
FIGURE 9 Same tooth at 7 years recall
residual walls, 3. Two coronal residual walls, 4. One coronal residual
wall, 5. Ferrule, 6. No ferrule.
The first two grades, four or three remaining residual walls sug-
gest to build up without post-placement and to use a direct restora-
tion (mainly on anterior teeth) or a partial crown to cover cusps
(Figures 14–17).14,25
Grade 3 and 4 might consider placing a post or not to hold the
core, relating the other parameters. Grade 5 and 6 usually need a post
for the build-up. However, grade 6 shows a clinical condition in which
is indicated to use the tooth as an abutment for a single crown or,
after crown lengthening and/or extrusion of the root for a bridge.15
Also, still in the vertical direction, the depth and shape of the pulp
chamber must be evaluated: when is rather wide and deep and sound
the tooth structure is coronal, the build-up material can be retained
inside the pulp chamber, avoiding placement of any posts.14
3.3 | Coronal residual structure (horizontal)
The residual coronal structure must also be evaluated “horizontally,”
considering the presence or not of a cervical lesion,26–31 and how
FERRARI ET AL. 71

FIGURE 11 Same tooth at 7 years recall

F I G U R E 1 2 A complex retreatment in a central incisor with

modification of root anatomy (perforation due to screw post) before
endodontic treatment (ET)

FIGURE 13 Same tooth at 2 years recall

much tooth structure was removed during the opening of the root
canal system13,32,33 (Figures 18–20).
Here is the description of horizontal coronal residual structure:
1. Absence of cervical lesions or excessive internal structure removal
F I G U R E 1 4 A upper premolar endodontic treatment (ET) with
three remained residual walls and build-up without post-placement
and a partial crown to cover cusps. The upper bicuspid still has three
residual walls
72 FERRARI ET AL.

FIGURE 15 A partial crown was prepared

FIGURE 16 The lithium disilicate partial crown at 4 years recall

FIGURE 17 Radiographic view at 4 years recall

due to endo or previous condition, 2. A slight cervical lesion, not

requiring restoration, and absence of excessive internal structure
removal due to endo or previous condition, 3. Cervical lesion requiring
restoration and absence of excessive internal structure removal due
to endo or previous condition, 4. Absence of cervical lesions and pres-
ence of excessive internal structure removal due to endo or previous
condition, 5. A slight cervical lesion, not requiring restoration, and
presence of excessive internal structure removal due to endo or previ-
ous condition, 6. Cervical lesion requiring restoration and presence of
excessive internal structure removal due to endo or previous
condition.
Grades 3, 4, 5 e 6 represent rising difficulty clinical situations, till
complete loss of buccal wall because there is no dentin left.
To make the restoration, grade 6 suggests crown lengthening
while grades 3, 4, and 5 remaining coronal residual structure in the
F I G U R E 1 8 The residual coronal structure is also evaluated
vertical direction must be evaluated to build up the abutment with or
“horizontally,” considering the presence or not of a cervical lesion,
without a post and for possible need of crown lengthening. In case and how much tooth structure was removed during the opening of
the abutment grade 6 can be part of a bridge, sufficient residual root canal system
FERRARI ET AL. 73

F I G U R E 1 9 After being
restored different amount of
sound tooth might remain

F I G U R E 2 0 When crown is
made, the restorations can be part
of the abutments

coronal structure should be guaranteed by crown lengthening and/or When risk ratio analysis was performed, restoration with a proper
orthodontic extrusion. quality of obturation and a good marginal coronal seal were significant
factors to get long-term high-quality outcomes. These findings were
in all studies (same above).
3.4 | Restoration marginal seal Moreover, the margins of direct and indirect restoration made to
restore an ETT can be placed in the enamel,37 partially in enamel and den-
In the last years, the importance of the marginal seal of restorations tin such as a partial crown14 or completely in dentin such as a full crown.
34–36
on ETT was demonstrated. The type of restoration made on top Also, the margins can be related to periodontal tissues and can be
of the endodontic treated root is another clinical key factor to guaran- placed iuxta-gingival,38 slightly into the sulcus39,40 or deeply into the
tee longevity to the tooth and in particular the quality of the coronal sulcus.41 The deeper the margin is, the more difficult it will be to keep
seal of the restoration, whether or not an indirect or direct restoration it clean for the patient and consequently the prognosis more
was made. uncertain.42
74 FERRARI ET AL.

F I G U R E 2 1 Marginal seal can be more effective when margins

are placed in enamel as when a partial crown is made

F I G U R E 2 2 When a full crown is made and margins are placed in

F I G U R E 2 3 An interdisciplinary case in which orthodontic dentin, the marginal seal can be less effective
extrusion and crown lengthening were needed to recreate a ferrule
and restore the tooth

The following degrees description was made: 1. Margins in the

enamel and completely supra-gengivally placed, 2. Margins partially in
the enamel and iuxta-gengivally placed in dentin (Figure 21), 3. Mar-
gins in dentin and supra-gengivally placed, 4. Margins placed iuxta-
gingival (Figure 22), 5. Margins placed into the sulcus, 6. Margins
placed deeply into the sulcus.

3.5 | Local interdisciplinary conditions

Local periodontal conditions are another important factor to be evalu-

ated. Interdisciplinary considerations should be made to assess how
much sound remaining tooth structure versus restorative material will
be available at the end of the treatment before final impressions.43
An endodontically treated tooth might present an intact periodontium, or
a loss of attachment but without the need for periodontal therapy.
In other cases, it might be necessary a periodontal surgical ther-
39,44,45
apy, to eliminate pockets or to restore mucogingival tissues.
advanced perio-prosthetic cases the need for parallelism between
FIGURE 24 Periodontal surgery for crown lengthening
some prepared teeth with loss of periodontal support may challenge
the ETT restoration.
Crown lengthening is one of the most common surgical therapy
needed as pretreatment in prosthodontic cases.46 In some cases,
In crown lengthening can be combined or not with orthodontic root
extrusion.47 Furthermore, teeth or roots bound to crown lengthening
FERRARI ET AL. 75

FIGURE 26 The final abutment with a high ferrule

FIGURE 25 The premolar after being restored

procedure, with or without ortho extrusion, should be thoroughly

examined and previsualized as they could appear after the completion
of the treatment to decide the best pre-prosthetic option.
In some other cases, molars might present furcation involvement,
and the treatment can be based on restoring the tooth after endodon-
tic treatment thinking of every single root like a single tooth as for
retention of the restorative material.47
The following degrees description was therefore conceived: 1. No
need for interdisciplinary treatment (single tooth), 2. Loss of attach-
ment without the need for periodontal treatment, (single tooth) 3. Need
for crown lengthening (single tooth), 4. Need for ortho extrusion and
FIGURE 27 The final crown in place
crown lengthening (single tooth) (Figures 23–27), 5. Furcation involve-
ment (tooth). 6. Need for periodontal surgical therapy (bridge).
Quite often, ETT of a young patient are positioned in a quadrant
without restored teeth and with normal occlusion. In this case, if a
3.6 | Complexity of the treatment certain amount of coronal residual structure remained, a direct resto-
ration or a partial adhesive crown might be indicated.48
Another important clinical factor to be evaluated is the complexity of Sometimes the endodontically treated tooth is in a quadrant with
the treatment. other restored teeth and the patient might need to restore the full
76 FERRARI ET AL.

F I G U R E 2 8 This patient in
2005 was in good general and
periodontal health and was
classified as a heavy bruxer
(clenching) with an unfavorable
occlusal environment (deep and
close anterior bite, probably
responsible for the functional
wear of the lower front teeth).
The occlusal environment would
become favorable after VDO
increase, even if this would not
have changed the patient's
clenching habit

F I G U R E 2 9 Clinical and
radiographic situation of third
sextant. A root diagram for each
tooth in the sextant, which
seemed to be the most critical
area was made

quadrant; in this case, a quadrant of adhesive partial crowns can be
indicated to better stabilize the occlusion. When partial crowns are
made, the build-up of the tooth will be performed with or without
post related to the coronal residual structure and the need to retain
the core material.14
When an endodontically treated tooth is the abutment of a
bridge, the tooth will be prepared for a full crown and it must be
kept in mind that if a post is placed only in one abutment of the
three/four-unit bridge, in case of debonding of the post, the risk of
root fracture will be higher than in single restored tooth with a full
crown.15 When the endodontically treated tooth is the distal abut-
ment of a multiunit bridge, the bridge with cantilever(s) must not be
extended to avoid the risk of root fracture whether a post is used or
not.50,51
When ETT is part of full arch or/and full mouth rehabilitation ETT
must be carefully evaluated with a global view of the mouth.
The following degrees' description was therefore made (Figure 8):
1. A single tooth in a virgin quadrant, 2. A single tooth in a quadrant
with other restored teeth, 3. Tooth as the abutment of a multiunit
bridge, 4. Tooth as the terminal distal abutment of a multiunit bridge,
5. Tooth as the abutment of a full arch rehabilitation, 6. Tooth as the
distal terminal abutment of a full arch rehabilitation.
3.7 | Length of the edentulous area
The length of the span (edentulous area) is another impact factor
related to the type of occlusion.
It will be important to evaluate if there is the possibility to make a
freestanding restoration, a short/medium (up to 20 mm) span bridge
or longer, and the type of favorable or unfavorable environment.
A favorable occlusal environment is a condition in which the
occlusal forces are equally distributed to the entire arches through
bilaterally simultaneous occlusal contacts in maximal intercuspation
position, and the excursive movements are made easy and not trau-
matic for the teeth by the presence of smooth lateral (canine or group
function) and anterior guidance.50 In presence of steep anterior guid-
ance, due to excessive overbite and minimal overjet (severe Angle's II
class/II division), lack of anterior guidance due to excessive overjet
(severe Angle's II class/I division),51 inverted vertical and horizontal
FERRARI ET AL.
F I G U R E 3 0 Tooth 24 was classified as irrational to treat because
of difficult endo retreatment due to perforation, presence of apical
radiolucency, no ferrule and risk of furcation involvement in case of
crown lengthening, excessive internal structure removal and presence
of clenching habit. The diagnosis is coherent with the root diagram
(several parameters in the high-risk category). Retreatment (5); no
ferrule (6); slight cervical lesion, not requiring restoration, and
presence of excessive internal structure removal due to endo or
previous condition (5); margins placed into the sulcus (5); need for
ortho extrusion and crown lengthening (5); single tooth in a quadrant
with other restored teeth (2); free-standing restoration in favorable
occlusal environment (after prosthetic treatment) (1); high-esthetic
need and heavy dental wear4
F I G U R E 3 2 Tooth 27 was diagnosed in the moderate risk
category: it had to be endodontically treated because of a deep
carious lesion discovered under an occlusal filling after removal of the
previous crown. This diagnosis is coherent with root diagram (two
parameters in the moderate risk category, six in the low risk). Vital
tooth (1); four coronal residual walls (1); absence of cervical lesions or
excessive internal structure removal due to endo or previous
condition (1); margins placed iuxta-gingival (4); no need for
interdisciplinary treatment (1); single tooth in a quadrant with other
restored teeth (2); free-standing restoration in favorable occlusal
environment (after prosthetic treatment) (2); high-esthetic need and
heavy dental wear (4)
overlap and inverted posterior relationship (Angle's III class), the
occlusal forces distribution could be unfavorable and may stress
too much the prosthetic abutments, especially in case of ETT. In
these situations, orthodontic pre-prosthetic treatment and/or a
prosthetic reorganized approach (with Vertical Dimension
77
F I G U R E 3 1 Tooth 26 was diagnosed doubtful: this tooth had just
been endodontically treated, it was impossible to go further
instrumenting the mesio-buccal root and the endo surgery was
unpredictable for this root. A root amputation was done. Retreatment
(5); ferrule (5); absence of cervical lesions and presence of excessive
internal structure removal due to endo or previous condition (4);
margins placed iuxta-gingival (4); furcation involvement (6); single
tooth in a quadrant with other restored teeth (2); free-standing
restoration in favorable occlusal environment (after prosthetic
treatment) (2); high-esthetic need and heavy dental wear (4).
However, the diagnosis from doubtful became good after the pre-
prosthetic phase, but this was not coherent with the negative root
diagram (three parameters in the high-risk category). The tooth
fractured after 10 years and was extracted
F I G U R E 3 3 Tooth 35 and 36 were evaluated as following.
Retreatment (5); two coronal residual walls (3); absence of cervical
lesions or excessive internal structure removal due to endo or
previous condition (1); margins placed iuxta-gingival (4); no need for
interdisciplinary treatment (1); single tooth in a quadrant with other
restored teeth (2); free-standing restoration in favorable occlusal
environment (after prosthetic treatment) (1); high-esthetic need and
heavy dental wear (4)
Occlusion (VDO) increase or decrease, and involvement of both
arches sometimes) should help establish a more favorable occlusal
environment contributing to a more stress-free situation for the
ETT. In addition, a worn dentition (see point 8.) can configure as an
unfavorable occlusal environment after the erasure of a stable max-
imal intercuspal position and preexisting guidance.
78
As not all the patients can afford or want to undergo pre-
prosthetic orthodontic treatments or extensive prosthetic rehabilita-
tions, it happens to treat cases where the occlusal environment is not
favorable and extra attention must be paid to the evaluation of the
ETT's restoration. Needless to say, the stress involved is different also
depending on the length of the bridge span.
The following degrees description was therefore created: 1. Free-
standing restoration in the favorable occlusal environment, 2. Free-
standing restoration in the unfavorable occlusal environment,
3. Short/medium (up to 20 mm) span bridge in the favorable occlusal
environment, 4. Short/medium (up to 20 mm) span bridge in the unfa-
vorable occlusal environment, 5. Long span bridge in the favorable
occlusal environment, 6. Long span bridge in the unfavorable occlusal
environment.
3.8 | Dental wear and need of esthetics
The degree of dental wear and the need for esthetic are other impor-
tant clinical factors to be evaluated.52,53
Dental wear can be associated with esthetic need because ante-
rior teeth can be shorter.
However, dental wear might be of different degrees, from no
dental wear to compromise function.54,55
In case of severe wear, the rehabilitation is mainly motivated by
esthetic reasons with the opening of vertical dimension,56 psychologi-
57
cal needs of the patient, a high limitation of function, but not to
solve TMJ symptoms.58 In case of heavy or severe wear, ETT already
FERRARI ET AL.
F I G U R E 3 4 The recall of the
patient after 15 years of clinical
service
lost a wide part of coronal structure and more often the placement of
a post can be needed.
The following degrees description was therefore created: 1. No
dental wear and no esthetic needs, 2. Slight esthetic need and slight
dental wear, 3. Esthetic needs and mild dental wear, 4. High-esthetic
need and heavy dental wear, 5. High-esthetic need and severe dental
wear, 6. Compromised function due to dental wear.
4 | CONC LU SIONS
The RDES consists on calculating the patient's individual restorative
difficulty and is proposed to focus the attention of GCs on some
important aspects and to make easier and more reliable the treatment
planning of patients having different clinical situations
(Figures 28–34). It is always important to consider both general
aspects of each patient and then to evaluate those more related to
the tooth and its local environments such as endodontics, coronal
residual structure, restoration margin seal, and periodontal tissues
around.9,10
Several mentioned factors are intercorrelated such as those
related to the tooth (from 1 to 5) and of the mouth and patient (from
6 to 8) as well. The factors included in RDES are those that are mainly
recognized in the literature as the most important to be clinically
evaluated.1–58
However, based on the eight parameters specified above, a
multifunctional diagram was made and the clinical situation of each
tooth can be visualized from the easier to the most difficult one.
FERRARI ET AL.
A low-RDES tooth has all parameters within the low-risk catego-
ries or, at the most, one parameter in the moderate risk category.
A moderate RDES tooth has at least two parameters in the mod-
erate category, but no one parameter in the high-risk category
(Figures 32 and 33).
A high-RDES tooth has at least one parameter in the high-risk
category (Figures 30 and 31).
The diagram of each tooth must be considered a static represen-
tation of the actual clinical situation that can be dynamically improved
by periodontal therapies. While all first parameters cannot be changed
and improved, the local interdisciplinary conditions can be changed
better through crown lengthening and/or orthodontic extrusion,
gaining more coronal residual structure, and creating a ferrule. Conse-
quently, RDES can be also useful to reevaluate the treated tooth at
the end of therapies and at each recall. The possibility to use RDES at
each recall can increase knowledge about prognosis of ETT after being
restored improving quality of dental treatments as well.14–16,22,23
From the other side, RDES is time consuming and need a sort of learn-
ing curve to be used.
DISCLOSURE
The authors do not have any financial interest in the companies
whose materials are included in this article.
ORCID
Marco Ferrari https://orcid.org/0000-0001-5375-076X
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How to cite this article: Ferrari M, Pontoriero DIK, Ferrari
Cagidiaco E, Carboncini F. Restorative difficulty evaluation
system of endodontically treated teeth. J Esthet Restor Dent.
2022;34(1):65-80. doi:10.1111/jerd.12880