Postendodontic Restoration: Endodontic Post-and-Core

or No Post At All?
Michael Naumanna / Marc Schmitterb / Gabriel Krastlc

Purpose: The objective of this systematic review was to assess the impact of endodontic post insertion on the clin-
ical performance of endodontically treated teeth (ETT).
Materials and Methods: A specific PICO question was developed and a Medline search was performed in January
2017 using relevant terms in order to identify studies comparing the success/survival of dental restorations using
endodontic posts or no posts. Additionally, the electronic databases “Opengrey”, “BBO”, “LILAC” and “IBECS”
were assessed and a hand search of cross references from original articles and reviews was performed. The meth-
odological quality of the included studies was assessed independently by three referees using (1) the critical ap-
praisal skills program (CASP) and (2) Cochrane checklist (version 5.1.0).
Results: A total of 14 studies were included, among them 11 randomized controlled trials (RCT), two prospective
clinical trials, and one retrospective clinical trial. The overall quality of the studies was good according to the CASP.
However, the Cochrane rating showed that in seven studies, the risk of bias was high in > 40% of the items, indi-
cating a relevant level of methodological flaws. Three studies showed a low risk of bias in > 80% of the items. The
majority (10 out of 14) of the clinical studies included failed to show a positive effect of post placement. A post ef-
fect is possible when no cavity wall is present.
Conclusion: There is no unequivocal clinical evidence to support or reject the use of posts even for no-wall cavi-
ties, either for direct or indirect restorations.
Keywords: post, dowel, screw, core, post-retained, no-post, post-free, endocrown, buildup, post-and-core.

J Adhes Dent 2018; 20: 19–24. Submitted for publication: 01.10.17; accepted for publication: 22.01.18
doi: 10.3290/j.jad.a39961

R estored endodontically treated teeth (ETT) are more

prone to failure compared to vital teeth. The clinical out-
come of ETT seems to be influenced by a variety of base-
line factors, including the number of proximal9 or occlusal
contacts,4,25 tooth position in the dental arch,23,30,40,43
crown placement,1,28 type of abutment,14,23 apical sta-
tus,15 hard tissue loss due to caries, trauma, previous res-
torations or endodontic access,16,24,34,44,46 as well as the
periodontal status.32,38,47
A variety of studies were performed to assess the most
suitable type of restoration after root canal filling.7 The de-
cision of whether to place a post obviously depends on the
final restoration. In particular for indirect restorations, it ap-
pears that post placement is more frequently adopted than
for direct restorations.31 Due to the fact that unequivocal
guidelines do not exist, there are no generally accepted
treatment concepts.
The aim of the present systematic review was to search
for clinical evidence on the value of endodontic post place-
ment compared to post-free restorations, and to rate the
level of evidence.
MATERIAL AND METHODS

a Professor, Department of Prosthodontics, Geriatric Dentistry and Cranioman-
dibular, Disorders, Charité – Universitätsmedizin Berlin, Berlin, Germany. Con-
cept, analysis, wrote manuscript.
b Professor, Department of Prosthodontics, University Hospital of Würzburg,
Würzburg, Germany. Concept, analysis, contributed substantially to discussion.
c Professor, Department of Conservative Dentistry and Periodontology, Center
of Dental Traumatology, University Hospital of Würzburg, Würzburg, Germany.
Concept, analysis, contributed substantially to discussion.
Correspondence: Prof. Dr. Michael Naumann, Department of Prosthodontics, Ge-
riatric Dentistry and Craniomandibular Disorders, Charité – Universitätsmedizin
Berlin, Aßmannshauser Str 4-6, 14197 Berlin, Germany. Tel: +49-175-298-0421;
e-mail: naumann@naumann-kiessling.de
Pico Question
A specific PICO question was developed by the authors.
This strategy can be used to optimize and facilitate the ap-
plication of an evidence-based approach to dental practice.
Furthermore, this method may provide a framework for a
more elaborate literature research.42
y P (patient): adults with sufficient root canal treatment
needing a restoration;
y I (intervention): any type of root canal post, followed by
any type of restoration;
y C (comparison): any type of post-free restoration;
y O (outcomes): failure rates of post/core complexes.

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Naumann et al

Table 1 CASP rating for RCTs

Authors Percentage “yes” Percentage “no” Percentage “unclear”

Creugers et al (2005a) 77.8% 22.2% 0%

Creugers et al (2005b) 88.9% 11.1% 0%

Mannocci et al (2005) 77.8% 11.1% 11.1%

Ferrari et al (2007) 77.8% 11.1% 11.1%

Fokkinga et al (2007) 88.9% 11.1% 0%

Cagidiaco et al (2008) 88.9% 11.1% 0%

Fokkinga et al (2008) 88.9% 11.1% 0%

Bitter et al (2009) 88.9% 11.1% 0%

Ferrari et al (2012) 77.8% 11.1% 11.1%

Zicari et al (2011) 88.9% 11.1% 0%

Cloet et al (2017) 88.9% 11.1% 0%

The resulting question was: In patients in need of resto-
ration of a root-filled tooth, which is the most successful
treatment: insertion of a post or a post-free restoration?
Search Process and Selection of Studies
The three authors performed a Medline (via Pubmed)
search in January 2017 using the term “post” OR “posts”
OR “dowel” OR “dowels” OR “screw” OR “screws” OR
“core” OR “post-retained” OR “no-post” OR “post-free” OR
“endocrown” OR “buildup” OR “buildups” OR “build-up” OR
“build-ups” in order to identify studies comparing the suc-
cess/survival of dental restorations using posts or no
posts. To narrow the search, the limits “clinical trial” and
“dental journals” were applied.
Furthermore, the following electronic databases were as-
sessed using the search terms “posts” and “core”: Open-
grey (21), BBO, LILAC, and IBECS. Additionally, a hand
search of cross references from original articles and re-
views was performed to identify additional studies that
could not be located in the electronic databases. Finally,
the personal databases of the authors were included in the
search.
Inclusion/Exclusion Criteria
Only in vivo studies in humans comparing the success or
survival of teeth restored using posts or post-free restor-
ations were included. In vitro studies, finite-element stud-
ies, and studies assessing the survival or success of either
posts or cores were excluded.
Appraisal of the Studies Selected and Analysis
Quality assessment of the selected studies was performed
by three referees using the following standardized check-
lists: the critical appraisal skills program (CASP) and the
Cochrane checklist (version 5.1.0).
At least two of the three referees had to agree in order
to set the quality level on the selected degree. The agree-
ment was assessed using the intraclass correlation coeffi-
cient, which was calculated using SPSS, v 23.0.0.2 (SPSS;
Armonk, NY, USA).
RESULTS
From 2595 articles retrieved in Medline, 11 studies were
included in the full-text analysis. Three further studies were
identified searching the personal databases of the authors.
In LILAC, IBECS, OpenGrey, and BBO, no further relevant
references could be found. In total, 14 studies were in-
cluded, among them 11 randomized controlled trials, 2 pro-
spective clinical trials, and 1 retrospective clinical trial.
Quality Assessment
CASP in RCTs (n = 11): All three referees agreed on 91% of
the items, while on the rest of the items, at least two of the
three referees agreed. The results of the assessment is
shown in Table 1.
It must be mentioned that the item “were patients,
health workers and study personal blinded” was rated as
“no” in all studies.
CASP in other studies (n = 3): All three referees agreed
on 95.8% of the items; on one item, at least two of the
three referees agreed. The intraclass correlation coefficient
was > 0.9. The results of the assessment are shown in
Table 2.
Cochrane-based assessment (n = 11): All three referees
agreed on 71.4% of the items. In 28.6%, two of the three
authors agreed. The intraclass correlation coefficient
was > 0.7. The results of the assessment are given in
Table 3.

20 The Journal of Adhesive Dentistry

 Naumann et al

Table 2 CASP rating for other studies

Authors Percentage “yes” Percentage “no” Percentage “unclear”

Willershausen et al (2005) 37.5% 62.5% 0%

Salvi et al (2007) 87.5% 12.5% 0%

Guldener (2016) 100% 0% 0%

Table 3 Cochrane rating for RCTs

Authors High risk of bias Low risk of bias unclear

Creugers et al (2005a) 42.9% 42.9% 14.2%

Creugers et al (2005b) 42.9% 42.9% 14.2%

Mannocci et al (2005) 28.6% 57.1% 14.3%

Ferrari et al (2007) 57.1% 28.6% 14.3%

Fokkinga et al (2007) 42.9% 57.1% 0%

Cagidiaco et al (2008) 42.9% 57.1% 0%

Fokkinga et al (2008) 42.9% 57.1% 0%

Bitter et al (2009) 14.3% 85.7% 0%

Ferrari et al (2012) 57.1% 42.9% 0%

Zicari et al (2011) 14.3% 85.7% 0%

Cloet et al (2017) 14.3% 85.7% 0%

Main Findings from Selected Studies
Randomized controlled trials
Creugers et al11,12 published 5-year data on post-retained
and post-free restorations with or without covering crowns.
The 17-year observations of these trials were published by
Fokkinga et al.19,20 The first study included 249 patients
with ETT in need of one covering crown. After 5 years, no
statistical differences were found between the survival of
teeth with and without posts. However, due to shortcom-
ings in the treatment allocation procedure, “high-risk teeth”
were underrepresented in the post-free group. Thus, a di-
rect comparison between crowned teeth with and without
posts is biased. Comparable results were obtained after
17 years. Obviously, a post in a core did not perform better
than a post-free core, provided that sufficient coronal tooth
structure remained after crown preparation.19
A second clinical investigation11 re-evaluated direct res-
torations in patients (n = 87) not able or willing to receive a
single crown in the same setting as described above. In
this trial, 99 direct restorations were performed with
(n = 53) or without (n = 46) prefabricated posts. After
5 years, all post-free restorations had survived. No signifi-
cant difference between groups was found (p > 0.05). After
17 years, post placement had no influence on survival prob-
ability, neither at the restoration nor at the tooth level.
Mannocci et al29 compared the 5-year clinical perfor-
mance of 219 endodontically treated premolars with class II
cavities restored with either amalgam (n = 109) or direct
composite restorations (n = 110). In the composite group,
carbon fiber posts were used, while amalgam restorations
were placed without posts. At 5 years, no significant differ-
ence was observed between the two groups. Considering
the type of failure, significantly more fractures occurred in
the amalgam group, while significantly more secondary car-
ies was observed in the composite group.
Bitter et al6 reported on 120 teeth restored with full
crowns, partial crowns or direct composite in 90 patients
over an observation period ranging from 6 to 56 months
(mean: 32.4 ± 13.7 months). Three groups were defined
according to the number of walls extending > 2 mm above
gingival level: two or more walls (n = 40), one wall (n = 39),
and no wall (n = 41). For each group, teeth were randomly
assigned to two subgroups: teeth in subgroup “post” re-
ceived a prefabricated glass-fiber post, while composite
was placed to a depth of 3 mm from the root canal orifice
in subgroup “no post”. The overall failure rate after 3 years
was 8% (subgroup “no post” 10%, n = 6; subgroup “post”
7%, n = 3; no significant difference, p = 0.32). A significant
effect of post placement on survival rate was observed only
for the no-wall group (p = 0.03).

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Naumann et al
In 2007, Ferrari et al17 published the 2-year RCT data of
210 individuals with 240 premolars restored with full
crowns. Six groups were defined based on the amount of
dentin left at the coronal level. In each group, half of the
teeth received a prefabricated glass-fiber post. The survival
rate was 92.5% for teeth with prefabricated posts and 70%
for the “no post” group. Premolars without posts had a
4.9-fold (p < 0.001) increased risk of failure compared to
teeth with post support. The amount of remaining coronal
dentin significantly influenced the prognosis, leading to a
significantly higher failure risk for teeth that had lost all
coronal walls, particularly when no ferrule was present.
Comparable data were provided by Cagidiaco et al8 after
3 years and Ferrari et al18 after 6 years. Besides post-re-
tained crowns using prefabricated posts and post-free
crowns, a further subgroup was included where fiber bundles
were adapted directly into the post space to create a custom-
ized post. On all teeth, single unit metal-ceramic crowns were
placed. Survival rates after 3 years were highest for prefabri-
cated posts (90.9%), followed by customized posts (76.6%),
and no post (62.5%). Findings of 6-year recall were similar
compared to 3-year recall, indicating that the presence of a
post was a significant factor for restoration survival.
The results of 143 patients having received all-ceramic
crowns after root canal treatment in 203 teeth were re-
ported by Zicari et al49 in a 3-year interim analysis and
Cloet et al10 in a 5-year analysis. An adequate ferrule was
always present. Comparison of restorations with and with-
out posts was performed in one of the two study arms of
the investigation, including only teeth with at least two walls
exceeding 2 mm of dentin thickness. In these teeth, com-
posite cores without posts (n = 13) or with gold-alloy-based
wrought posts and cast cores (n = 11) were inserted. After
3 years49 and 5 years,10 no statistically significant differ-
ence could be detected between post-retained and post-
free restorations regarding their survival rate.
Prospective controlled trials
Two nonrandomized, prospective clinical studies compar-
ing post-retained and post-free restorations were included
in this systematic review. Both clinical trials were pub-
lished by the same group.22,35 After a mean observation
period of at least 4 years, the survival rate of root-filled
teeth was 92.5% for teeth restored with titanium posts,
97.1% for those restored with cast post-and-cores, and
94.3% for teeth without post-retained restorations.35 No
significant difference was found between these groups. The
second clinical trial revealed survival rates of 94.3% and
76.3% for teeth with a fiber post and teeth without a post,
respectively, after a mean observation period of
8.8 years.22 In contrast to the first study, significant differ-
ences were observed. However, nonrandomized allocation
of the teeth to the different intervention groups and possi-
ble bias arising from overlapping patient samples in the
post-free groups should be considered. It appears that no
significant differences between post-retained and post-free
restoration can be observed when no crown is placed, ie,
no ferrule effect is present.
22
Retrospective clinical trials
The only study with a retrospective design included in this
review revealed a mean survival of 66 months for teeth with
posts and 93 months for teeth without post insertion.48
Again, allocation bias must be considered, since posts
were only inserted in the case of insufficient tooth structure
and retention, while post-free restorations were performed
when the amount of residual coronal hard tissue was
judged as being adequate to provide sufficient retention.
Thus, no reliable conclusion may be drawn from this study.
Agreement Between Referees
In the Cochrane-based assessment (n = 11), all three refer-
ees agreed on 71.4% of the items. Two of the three authors
agreed on 28.6% of the items. The intraclass correlation
coefficient was > 0.7, which is good. For CASP in all other
studies (n = 3), all three referees agreed on 95.8% of the
items, and at least two of the three referees agreed on one
item. The intraclass correlation coefficient was excellent
(> 0.9).
DISCUSSION
The present systematic review of randomized, prospective,
and retrospective clinical trials comparing post-supported
and post-free restoration of ETT could not provide unequivo-
cal evidence to support or reject the use posts, even for
no-wall cavities, either for direct or for indirect restorations.
The majority (10 out of 14) of the clinical studies included
failed to show a positive effect of post placement. Rather,
the extension of the coronal tooth defect seemed to influ-
ence the survival of ETT. However, it is beyond the scope of
this paper to systematically analyze the impact of the re-
maining coronal tissue and its morphology on the prognosis
of the affected teeth. The present results are in accordance
with a recent review demonstrating that the survival of teeth
with substantial coronal tissue is not influenced by the use
of posts.3
Already in the 1980s, doubt existed that an endodontic
post reinforces the tooth.39,46 Since then, a consensus has
arisen that an endodontic post cannot play a reinforcing
role due its position in the tooth center as an area without
force application2 – at least when the outer surface of the
tooth is intact.36 However, it is generally accepted that a
post creates additional retention for the core build-up.
One study included in the present systematic review
compares post-retained composite restorations and post-
free amalgam fillings in class II cavities with intact cusp
structure. No benefit of post placement was found.29 How-
ever, due to the different types of coronal restoration – ad-
hesive approach with post vs nonadhesive approach with-
out post – in the two experimental groups, the real impact
of post placement cannot be verified. Nevertheless, the
study was included because the trial met the predefined
inclusion criteria.
The larger the defect size, the more valuable becomes
the placement of an endodontic post.6,17,18 At least, the
The Journal of Adhesive Dentistry

preparation of an access cavity (4 remaining cavity walls)
does not justify the insertion of a post, as demonstrated by
the 6-year results of a RCT.18 Already one remaining cavity
wall appears to provide a substitute for a post effect.6 This
is in accordance with findings of an earlier systematic re-
view.41 Thus, only teeth presenting larger coronal defects
might benefit from post placement. However, studies report-
ing shorter observation periods conclude that post place-
ment may be beneficial and advisable for indirect single-
crown restorations.6,8,17,18 As reported in a 17-year
follow-up study, there seems to be no benefit of a post for
direct composite resin restorations. It is noteworthy that
8 out of 10 restored teeth are still in function after 17 years.
All studies in the present review reported vertical root frac-
tures. It is remarkable that teeth with posts are more likely
to suffer from root fractures. Additionally, post placement
itself is accompanied by the risk of root perforation.
A shortcoming of all studies included in this review is the
lack of focus on anterior teeth. Particularly in the maxillary
anterior region, teeth are subjected to high shear forces.
Biomechanical considerations suggest different behaviors
of front teeth, premolars, and molars, due to a different
load direction with a higher risk in the anterior region.
Oblique loading makes the maxillary anterior region a high-
risk area for mechanical failure.45 Very short-term results of
a RCT support this assumption.27 Lang et al26 demon-
strated that in maxillary central incisors, tooth stability de-
creased already starting with the preparation of the end-
odontic access cavity. Further significant destabilization
occurred after post space preparation. Only Cloet et al10
stated that twice as many relative failures, such as post
dislodgement, occurred in anterior teeth. However, due to
the limited number of teeth in the study arm comparing
restorations with and without posts, the results should be
interpreted with caution. Thus, avoiding post placement and
instead performing minimally invasive endodontic treatment
may contribute to tooth stability. Summing up, the findings
of the present review might not be applicable to anterior
teeth. There is an urgent need for clinical studies assessing
the influence of the tooth type on the survival of ETT.
It is remarkable that all studies were performed in pri-
vate practices and only to a small extent in a university
clinical setting. There are two opposing sides to this study
design: on the one hand, the generalizability of the results
might be better, but on the other hand it may introduce
some bias (eg, several dentists, less standardized treat-
ment protocols). However, large sample sizes, which im-
prove the power of a study, can be achieved either by mul-
ticentric university-based studies or by including private
practitioners.
Endocrowns represent an alternative post-free treatment
approach for teeth with insufficient coronal tooth structure.
With anchorage in the pulp chamber, core and crown are
combined in one component. The preparation design for
endocrowns is associated with considerably reduced tooth
structure removal compared to conventional indirect restor-
ations.37 Due to a lack of clinical studies comparing endo-
crowns with conventional post-and-core retained crowns,
Vol 20, No 1, 2018
Naumann et al
this treatment approach could not be included in this sys-
tematic review. However, favorable data from three retro-
spective clinical trials suggest that endocrowns may repre-
sent a promising treatment option, particularly for posterior
teeth.5,13,33 Thus, future studies including endocrowns are
warranted.
It was not within the scope of this review to summarize
the evidence from in vitro studies regarding the research
question. A recent structured review3 based on laboratory
studies concluded that posterior teeth with limited tissue
loss can be restored without posts, especially if total cover-
age is performed. The evidence on whether root-filled inci-
sors benefit from a post remained controversial.3
CONCLUSION
There is no unequivocal clinical evidence to support or re-
ject the use posts, even for no-wall cavities, either for direct
or for indirect restorations. A positive effect of post place-
ment was shown by 4 out of 11 RCTs when no cavity wall is
present. Three additional clinical studies demonstrated no
post effect. Clinical evidence is lacking on the influence of
tooth location in the dental arch on the survival of post-re-
tained and post-free post-endodontic restorations.
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Clinical relevance: While post placement is only recom-
mendable for decoronated teeth, mechanical support
by a ferrule always appears advisable.
The Journal of Adhesive Dentistry