SCIENTIFIC SESSION

The ideal restoration of endodontically treated teeth structural and

esthetic considerations: a review of
the literature and clinical guidelines
for the restorative clinician
Konrad Meyenberg, DMD
Private Office for Reconstructive Dentistry
Zrich, Switzerland

Correspondence to: Konrad Meyenberg

Private Office for Reconstructive Dentistry, Rennweg 58 / Eingang Oetenbachgasse 26, 8001 Zrich, Switzerland;
E-mail: k.meyenberg@bluewin.ch; Web: www.zahnaerzte-rennweg.ch

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MEYENBERG

Moderator/Editors Introduction
One of the most challenging dilemmas

for the younger patient, then why cant

faced by todays clinician is the manage-

it be done for the older patient? On the

ment of the structurally and esthetically

other hand, perhaps it is more predict-

compromised

treated

able in a given case to remove the tooth

tooth. Certainly, in recent years there has

endodontically

and restore it with a dental implant res-

been a tendency to take the simplified

toration. These and other issues are real

approach of extraction and implant

concerns we have as practitioners and it

but this does not always prove to be as

is important to have objective as well as

simple as we would like to think. Has

the subjective criteria on which to base

the popularity of dental implantology

our decision for the choice of restorative

made the restorative dentist complacent

protocol.

in regards to the possibilities that good

Are all endodontically treated teeth

endodontic, periodontal and restorative

really less predictable than a dental

treatments can achieve? Without doubt

implant-supported restoration? Are they

the dental implant option has its place,

really more likely to fail? Do they really

and rightly so, but in many cases, I sus-

have a poor prognosis? Do implants re-

pect, the endodontic/restorative option

ally have fewer complications? Is retreat-

does not always receive its due merits.

ment as easy? Do anterior and posterior

Whenever we are faced with such a

teeth behave the same? When is the

compromised tooth, we have to con-

prognosis of the tooth unfavorable and

sider the following question: is the tooth

at what point is extraction and an im-

maintainable? If so, then this is surely

plant the best option? These and many

our primary goal. However, the question

other relevant questions are eloquently

is complicated by the context ie, is this

addressed below by our essayist and

a young patient? Is this a bridge abut-

EAED Active Member, Dr Konrad Mey-

ment? Is there an esthetic challenge, ie,

enberg. My hope is that this paper will

a dark tooth? In the younger patient, it

serve to help us to question our treat-

may be desirable to maintain a poten-

ment choices more critically in this area,

tially hopeless tooth for as long as pos-

suggest useful answers to many of the

sible in order to buy time and delay the

questions in this dilemma, provide us

day of implant placement and its subse-

with objective criteria on which to base

quent eventual failure. Retreatment of a

our judgements and finally offer solu-

tooth is, more often than not, simpler with

tions so that we can make better choices

a broader range of options than retreat-

for the treatment of our patients.

ment of a failed implant, particularly in

the esthetic zone. If this can be done

Dr Tidu Mankoo, BDS

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SCIENTIFIC SESSION

Abstract

Clinically, most of non-vital teeth must

be considered as structurally and es-

In restorative dentistry, the non-vital tooth

thetically compromised.2 The fracture

and its restoration have been extensively

rate and as a consequence the risk for

studied from both its structural and es-

tooth loss is considerably higher com-

thetic aspects.

pared to vital teeth. 

The

restoration

of

endodontically

treated teeth has much in common with

modern implantology: both must include
multifaceted biological, biomechanical

Part 1:
Structural considerations

and esthetic considerations with a profound understanding of materials and

What are the causes of fractures?

techniques; both are technique sensitive

and both require a multidisciplinary ap-

There are several causes for the in-

proach. And for both, two fundamental

creased risk of cracks in endodontically

principles from team sports apply well:

treated teeth to be considered. Cracks

firstly, the weakest link determines the

predispose the tooth immediately or af-

limits, and secondly, it is a very long way

ter some time to fracture. The following

to the top, but a very short way to failure.

four factors contribute to this predisposi-

Nevertheless, there is one major dif-

UJPO
'JHT

o


ference: if the tooth fails, there is the op-

Structural loss of tooth substance due

tion of the implant, but if the implant fails,

to pre-endodontic restorative proce-

there is only another implant or nothing.

dures or the endodontically induces

The aim of this essay is to try to an-

access cavity preparation and root

swer some clinically relevant concep-

canal enlargements.5,6

tual questions and to give some clinical

Increased brittleness by age induces

guidelines regarding the reconstructive

changes in the dentin and the loss of

aspects, based on scientific evidence

free unbound water from the root ca-

and clinical expertise.

nal lumen and the dentinal tubules in

pulpless teeth.7-11
Weakening effects by endodontic irSJHBOUT
/B0$M
&%5"

BOE
NFEJDB-

Rebuilding the ideal tooth

from an endodontically
treated tooth what does
this mean?

bacterial interactions with the dentin

Essentially, the goal is to restore the ap-

ical effects through crack inducing or

pearance and biomechanical properties

crack propagating endodontic and

comparable to those of a vital, complete-

restorative methods and instruments,

ly intact tooth. In addition, the coronal

including endodontic files.12-16

tions (CaOH2

PO
EFOUJO
FGGFDUT
PG

substrates, corrosive effects of restorative materials, and negative mechan-

restoration should prevent bacterial re-

The reduced level of proprioception

colonisation of the endodontically treat-

of non-vital teeth causes a reduced

ed root canal

system.1

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level of control of forces by the normal

MEYENBERG

Fig 1

Cracks in lower first molar due to deep cavity.

Fig 2

Fracture of first upper premolar due to deep

cavity with endodontic treatment.

Fig 3

Fracture of palatal

root of upper first molar due

Fig 4

Fracture originating from the apex of a canine due to the use of

inadequate endodontic techniques.

to endodontic treatment.

protective neuromuscular inhibition

mechanism.17

Recent research shows that dentin

has some very effective inherent properties to inhibit crack progression (fracture

Some of these factors may be influ-

UPVHIFOJOH
NFDIBOJTNT

UP
PQUJNBMMZ

enced or modified to improve the prog-

distribute local stresses and to partially

nosis, however the most important factor

repair defects, as long as a tooth is vi-

for success is to avoid any unnecessary

tal.8,9 However, a non-vital tooth will lose

loss of tooth substance in general and

some of these properties over time. A

to preserve as much as possible after

key consideration is that the amount of

removal of all decayed material.

collagen fibers in endodontically treated

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SCIENTIFIC SESSION

teeth decreases, which means that this

to dispense with posts in many indica-

dentin is much less fatigue resistant.17

tions, as they are no longer required for

In addition, even vital dentin loses some

the retention of a core build-up.

of its initial strength over its lifetime: it

However, mindful clinicians can still

shows a different fracture behavior as

observe a relatively high rate of vertical

the mineral content increases over time

root fractures despite the absence of

and causes a less favorable fracture be-

posts and even with the use of adhe-

havior because of the increased brittle-

sive techniques above all in curved

ness.18,19

and small roots; indeed some authors

report up to 20% of vertical fractures of

Restorative options:

endodontically treated teeth. Man-

what is the ideal concept?

dibular molars and maxillary premolars

are most often affected.25,26 Provided

As a consequence, any attempts to

there is enough coronal dentin structure

restore a non-vital tooth must include

NPSF
UIBO
UXPUIJSET
BWBJMBCMF

JU
TFFNT

not only the use of restorative materi-

that there is no difference between teeth

als with properties similar to the dental

restored with or without posts in this re-

components, but also the use of clinical

spect.27 Interestingly in this article, 86%

concepts that allow to compensate the

of molars with vertical root fractures had

inherent reduction of the mechanical re-

the fracture in a root without a post.

sistance of endodontically treated teeth.

A

true

so-called

biomimetic

Therefore, as long as no active posts

con-

or screws are used, which may produce

cept20 therefore does not only implicate

detrimental lateral forces on the den-

the use of particular materials similar in

tin walls,28 and as long as inadequate

their properties to dentin and enamel,

placement techniques with risk of per-

but also sometimes the use of particular

forations are not used,  posts per se

materials with different properties to re-

may not be considered as destructive.

store the incomplete tooth as a whole in

all its mechanical, biological and esthet-

When is a post indicated?

ical aspects,21 above all if the remaining

tooth structure is compromised.

The main reason to use a post today

is no longer to increase the retention

Post or no post

and resistance of a core build-up, since

are posts destructive?

there are very effective adhesive techniques available. As discussed, provid-

In the past, fractures of teeth often have

ed there is sufficient tooth structure avail-

simply been attributed to inadequate re-

able, there is no longer a need to place

storative procedures, be it by the use of

a post. In premolars with limited

inadequate core materials or the use of

amount of tooth destruction and molars

posts and screws. The introduction of ad-

where, in general, more dentin walls with

hesive techniques and their successful

greater surface area can be engaged

integration in almost all current restora-

to be bonded as compared to anterior

tive procedures has allowed the clinician

teeth, a direct bonded core build-up is

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MEYENBERG

clinically the concept of choice; it can be

not be compensated simply by adhe-

regarded clinically as well established,

sive techniques using fiber posts and

reliable and perhaps preferable to con-

composite cores. In a recent long-term

ventional post-core concepts. In addi-

study over 7 to 11 years, the mechani-

tion, by avoiding posts, the risk of cracks

cal failures reached 7 to 11% and were

due to thin residual root walls or perfora-

always related to a lack of coronal tooth

tions can be

eliminated.

structure.

For anterior teeth and heavily compro-

If anterior teeth and premolars pre-

mised premolars, however, this state-

sent with large defects that require

ment is limited to teeth that present with

crowning, however, adequate transfer

small to moderate defects and that will

of forces from the crown into the core

later not be crowned. 

build-up and from there into the root is

For posterior teeth, the best prognosis

not possible without a post. Importantly,

is achieved if in addition to a bonded

the function of the post is not only the

effect
is

cre-

increase of the retention of the core, but

ated by the final restoration. This means

also the optimization of the resistance

that full cuspal coverage is used, be it

form. In addition, the mechanical prop-

a partial or full crown. Adhesive tech-

erties of a composite core alone may

niques alone without cuspal coverage

also not be sufficient in the case of a

may still lead to catastrophic failures

narrow abutment diameter and cannot

over time (ie, untreatable long axis frac-

reduce high stresses in the critical cervi-

UVSFT

BOE
DBOOPU
CF
SFHBSEFE
BT
DMJOJ-

cal area, which in such a case, is prone

cally safe.

to horizontal fractures. A clinical study

core foundation a ferrule

It must be stated at this point that the

PWFS

UP

ZFBST
XJUI
DSPXOT
CPOEFE

ferrule effect is the most effective way of

directly to a reduced macroretention ge-

mechanical stabilization, ie, of optimiz-

ometry without posts clearly showed

ing the resistance form, of any endodon-

that the concept can work for molars

tically treated teeth.
Given the weaker

(8795% success, depending from the

structure, as previously discussed, the

BNPVOU
PG
SFTJEVBM
DBWJUZ
XBMMT

CVU
EJE

effect of the better load distribution into

not work for premolars, if there were no

the cervical zone and the avoidance of

cavity walls at all and the crown was just

any wedging effect by the post or core

bonded directly into the residual pulp

build-up into the coronal part of the root

DIBNCFS

TVDDFTT
SBUF


cannot be overemphasized. Therefore,

Therefore, the purpose of a post and

in order to provide a ferrule in situa-

core as a unit is primarily to transfer the

tions without sufficient tooth structure

loads into the root and secondly, the

above the zone of the biological width,

post is used as a reinforcing element of

orthodontic extrusion or surgical crown

the core build-up.

lengthening should be considered. A

The downside of this concept is the

ferrule length of 1.5 to 2 mm is recom-

weakening effect on the root itself; 

mended.

to compensate for this, the ferrule effect

It must also be stated that, obviously,

the lack of coronal tooth structure can-

must be incorporated into the restoration

design.

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SCIENTIFIC SESSION

The ferrule effect may also compen-

#BTJDBMMZ
UIFSF
BSF
UXP
DPOGMJDUJOH
JT-

sate unexpected breakdown of adhe-

sues causing some disagreements on

sion after bonding and luting proce-

the ideal material of a post.2 From a me-

dures in unqualified dentin conditions.

chanical standpoint, it is evident that a

A safe clinical concept always implies

post stiffer than dentin can take up more

the incorporation of a belt and braces

load but induces more stress in some api-

approach to offset routes of potential

cal parts of the root, which can increase

failure.

the risk of a vertical root fracture. Con-

A special indication for a post is the

versely, a post that has an elastic modu-

immature root, presenting with a large

lus closer to dentin will, in fact, induce

root canal.

less stress concentration apically in the

Obviously neither gutta-percha nor

root, but more in the cervical region.

MTA nor composite have a significant

In addition, the interface between

reinforcing effect. In this instance, the

post and core and between core and

only

is

dentin is also subjected to stress, so one

achieved with a post. This is in line with

can expect to see more root fractures

the clinical observation of increased risk

JSSFQBSBCMF
GSBDUVSFT

XJUI
TUJGGFS
QPTUT

of fracture in immature teeth left without

made from metallic or ceramic materi-

post and core-build up after endodontic

als, whereas more flexible posts would

treatment.

show more post fractures, debonding of

significant

reinforcing

effect

core materials and loss of retention (pos-

If a post is indicated:

TJCMZ
SFQBJSBCMF

XJUI
TVCTFRVFOU
QSPC-

what post concept should be

lems of leakage and caries. The latter

used: stiff or flexible?

may lead to endodontic reinfection and

catastrophic coronal destruction of tooth

If something can break, it will break, and

substance, thus leveling out the poten-

it will always break at the weakest point

tial advantage of this latter concept over

this basic finding and classic rule for

the first one.

construction is also true for this applica-

The dilemma for the clinician is the

tion and may explain the significant con-

meaningful interpretation of the litera-

troversies regarding what would be the

ture, as countless studies have been

best of all the available concepts. The

published in this field, most of them being

question may be not whether something

in vitro studies with questionable clinical

will break, but rather where it will break.

potential relevance. Numerous theoreti-

Almost all dental materials have been

cal studies using finite element analysis

used clinically for posts. Still clinically

have also been performed, which would

relevant today are gold-alloys, chrome-

all need to be verified according to clas-

cobalt, titanium, zirconia and glass fib-

sic engineering principles in a real mod-

er posts. Carbon fiber posts have no

el, but only a minority of the in vitro stud-

clinical significance due to poor clinical

ies have been performed with dynamic

performance and disastrous potential;

or fatigue loading under a simulated

therefore they will not be discussed in

oral environment. Another difficulty is

this article.

that study results are also influenced by

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MEYENBERG

the structural condition, various types of

tablishment of proper bonding be-

natural teeth utilized and the respective

tween all substrates is of paramount

loading pattern.

importance.51 If bonding fails, much

One of the more clinically relevant in

less favorable stress patterns occur

vitro studies compared cast posts and

both in the root, above all in the critical

DPSFT
UJUBOJVN
5J

QPTUT
XJUI
DPNQPT-

cervical area, and in the post and core

ite cores, zirconia posts with composite

itself.52 As a clinical consequence,

cores and zirconia posts with ceramic

loss of retention of the core and post

cores, using, in all groups, adhesive

is still unfortunately the major compli-

techniques and a ferrule of 1 to 2 mm

cation.

on central incisors where all teeth were

crowned. The most favorable results

Most of the clinical studies are difficult

JO
UFSNT
PG
GSBDUVSF
TUSFOHUI


/

BOE

to interpret in their outcome, since the

TVSWJWBM
SBUF


DPVME
CF
BDIJFWFE

amount of tooth loss and the condition

with the stiffest concept (zirconia posts

of the remaining dentin (pre-existing

XJUI
B
DFSBNJD
DPSF

BOE
UIF
MFBTU
GB-

cracks, aging, endodontic treatment

vorable with the cast post and core sys-

NPEBMJUJFT

BSF
OPU
LOPXO
BOE
NBZ
IBWF

UFN


/




influenced the choice of the concept.

In contrast to this study with ideal tooth

The scientific dilemma is very nicely

substrate, another study compared dif-

expressed in a systematic review about

ferent degrees of tooth destruction, us-

the simple final question, whether a

ing fiber posts and composite cores or

crown or a filling is more effective in the

premolars.

clinical performance for an endodonti-

It was shown that posts had a significant

cally treated tooth. The authors con-

positive effect on fracture strength if only

clude There is insufficient evidence

1 or 2 cavity walls were left, whereas no

to support or refute the effectiveness

EJGGFSFODF
DPVME
CF
GPVOE
JG

PS

DBWJUZ

of conventional fillings over crowns for

walls were left. However, if a completely

the restoration of root filled teeth. Until

flat profile without any substance above

more evidence becomes available cli-

the preparation line is used, most likely

nicians should continue to base deci-

the post will debond as predominant

sions on how to restore root filled teeth

mode of failure.

on their own clinical experience, whilst

composite cores alone on

Two facts are of special importance in

taking into consideration the individual

the judgment of studies comparing dif-

circumstances and preferences of their

ferent concepts:

patients.

The results of these in vitro studies

This statement shows not only the

largely depend on the presence or

complexity of the topic, but also that

BCTFODF
PG
B
GJOBM
SFTUPSBUJPO
DSPXO


clinical multifactorial reality does not al-

Principally, differences in materials of

low clear definition of one simple gener-

posts and cores level out from the mo-

ally valid concept.

ment where a crown is

placed. 

Nevertheless, there is still a need

If metal-free post and core concepts

for clear clinical guidelines, based on

are to be successfully used, the es-

scientific evidence paired with clinical

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SCIENTIFIC SESSION

expertise. Only this combination finally

with different concepts of build-ups. All

leads to clinical evidence.

teeth were finally crowned with porcelain

As a conclusion from numerous clini-

GVTFE
UP
NFUBM
1'.

DSPXOT
"O
PWFSBMM

cal studies, it must be stated that there is

failure rate in this 6-year survival study of

OP
TVQFSJPS
DPODFQU
JO
BMM
SFTQFDUT
#PUI


XBT
SFQPSUFE
8IFO
POMZ
B
DJSDVMBS

direct and indirect concepts and gold,

ferrule of 2 mm or less was left, the fail-

Ti, fiber and zirconia posts work well if

ure rate increased to nearly 90 to 100%

the respective concepts are properly ex-

GPS
UIF
OP
QPTU
DPODFQU
UP

UP

GPS

ecuted. The single most important point

prefabricated posts, and to around 70%

is to preserve as much remaining tooth

for the customized post concept.

structure as

possible.  

Two additional arguments may require

The results clearly suggest that prefabricated

fiber

posts

are

superior

consideration for the reconstructive cli-

to customized fiber posts (glassfiber

nician: a) fiber posts offer the highest

CBOE
SFTJO
JNQSFHOBUFE

PS
DPNQPTJUF

potential for reintervention due to their

cores without any posts, if there are only

relative ease of removal, however their

2 walls or less remaining. However, even

successful use clinically is much more

if in addition to the bonded core a pre-

technique sensitive,58 and b) post and

fabricated fiber post is used, the con-

cores with a high modulus of elasticity

cept obviously fails to be convincingly

NFUBM
PS
[JSDPOJB

PGGFS
B
IJHIFS
GSBD-

successful in cases with extended tooth

ture resistance as a foundation of the

destruction.

crown,50 which may be of significance

*O
DPOUSBTU
UP
UIJT

PWFSBMM
GBJMVSF

for the long-term success of all-ceramic

rate over 6 years of non-metallic posts

crowns.59,60

and build-ups, a 10-year report of prefabricated metal posts and cast metal

What about bonding a post into

QPTUT
BOE
DPSFT
SFTVMUFE
JO
B

BOE

the root canal space? Does bond-


PWFSBMM
GBJMVSF
SBUF

ing help in cases with extended

amount of tooth destruction?

Retention
The almost doubled overall failure rate

What is the ideal surface condi-

of fiber posts and the surprisingly high

tioning of fiber posts?

debonding rate must raise the question

Looking at the results of a recent clini-

about the effectiveness and efficiency

cal 10-year fiber post study, a surpris-

of this concept in general practice. Per-

JOHMZ
IJHI
BOOVBM
GBJMVSF
SBUF
PG

JT

haps it is unsurprising given the inher-

reported and an overall failure rate of

ently more technique-sensitive concept


XJUI

GJCFS
QPTU
GSBDUVSFT
BOE

of the required adhesive techniques and

11% post debondings.61 The highest

the lack of a simple clear user protocol.

probability of a failure was reported for

anterior teeth with no cavity walls.

A recent study compared the retention of different fiber posts with different

This is confirmed by another clini-

surface conditionings (performed ac-

cal study62 where premolars of varying

cording to the manufacturers recom-

degrees of destruction were restored

NFOEBUJPOT

BOE
MVUJOH
BHFOUT
JO
EFO-

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MEYENBERG

tin Ti-posts luted with conventional zinc

etching

phosphate-cement served as the con-



NJO
PS
NFUIZMFOF
DIMPSJEF
GPS


T

trol group. The control Ti-post showed,

or micromechanical treatments (sand-

together with some combinations of the

CMBTUJOH

PS
B
DPNCJOBUJPO
PG
CPUI
IBWF

test group, the highest pull-out strength,

been proposed. Surprisingly, sand-

whereas some combinations of the test

blasting seems to not affect the mechan-

group showed surprisingly low values.

ical properties of the fiber posts.75 Sand-

This is in line with another study, where

blasting with silanization is, therefore, an

adhesively luted fiber posts were not

efficient, simple and predictable way of

superior to gold posts either adhesively

surface conditioning a fiber post before

luted or conventionally cemented with

bonding.77,78 However, fiber posts are

glass ionomer cement.65

susceptible to water degradation, and

with

hydrogen

peroxide

for

damaging the surface will increase this

Adhesion to radicular dentin

phenomenon. Thus, a predictable bond-

Adhesively luting a post into root den-

ing procedure that completely seals the

tin is a controversial issue. Conflicting

post surface and avoids any voids is of

results have been published about the

paramount importance to preserve frac-

efficacy of bonding to radicular dentin.

ture resistance.79 Some manufacturers

Probably due to the structural differenc-

now use a coating on their posts to fur-

es in radicular dentin, bond strengths

ther simplify and improve the bonding.80

improve from the apical to the coronal

Nevertheless, care should be taken to

section. Comparing the use of compli-

consider both the manufacturers rec-

cated separated dentin bonding and lut-

ommendations and their scientific basis.

ing procedures with simpler self-etching

cements, it seems clinically more relia-

Mechanical properties

ble to use self-etching and self priming

Major differences in the mechanical

cements taking into account the poten-

properties of different brands of posts

tially somewhat lower bond strength to

is another critical point. Since there

dentin.66-71

Inadequate ability to cure

are now countless brands of posts on

the luting agents precludes the use

the market with a sometimes-unknown

of light-curing materials. Dual-cure or

origin, a proper selection based on in-

chemically curing materials should be

dependent scientific investigations is

used instead, since different fiber posts

imperative to avoid basic mechanical

indeed differ in their light transmitting

failures.81,82 Using a fatigue resistance

properties, however posts with optimal

test, a difference of roughly 7,000 cy-

mechanical

allow

cles until fracture for the worst and up

enough light penetrating all over the

to 2,000,000 cycles for the best post in

whole length of the post to sufficiently

UIJT
SFTQFDU
FRVJWBMFOU
UP
OP
CSFBLBHF

properties

polymerize light-cured

do

not

materials.72

could be shown. The quality of the manufacturing processes including type of

Adhesion to post surface

fiber and matrix, pre-tensioning of fibers,

To improve bond strength to the pre-

bond between fibers and matrix, among

fabricated fiber posts, chemical (silane,

other factors, play an important role.

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SCIENTIFIC SESSION

Fig 5

Case 1: initial radiograph of non-vital cen-

tral incisors with different degree of remaining tooth

Fig 6

Case 1: initial clinical situation, large com-

posite build-ups, discolorations.

substance, final radiograph of build-ups with short

GJCFS
QPTUT
QMBDFE
PVUMJOFE
GPS
CFUUFS
WJTJCJMJUZ


Fig 7

Case 1: abutment teeth after removal of ex-

Fig 8

isting composite cores.

ing.

Fig 9

Fig 10

Case 1: build-ups of abutment teeth com-

Case 1: abutment teeth after internal bleach-

Case 1: build-ups of abutment teeth com-

pleted with fiber posts and composite core, buccal

pleted with fiber posts and composite core, occlusal

view.

view.

Therefore, both a sensitive indication

and technique is mandatory for the successful use of the concept of fiber posts
combined with composite cores (Figs 5
Fig 11

Case 1: final clinical result.

248
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
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UP



MEYENBERG

Fig 12

Case 2: initial radiograph of second lower

premolar with fiber post and PFM crown.

Fig 13

$BTF

SBEJPHSBQI

ZFBST
BGUFS
UIFSBQZ

showing post fracture, composite core debonding

and crown dislodgement.

Fig 14

Case 2: clinical view showing fractured

fiber post and extensive caries destruction underneath debonded composite core.

Concluding remarks regarding

the structural aspects

Materials with potential of corrosion

TUBJOMFTT
TUFFM
CSBTT

NBZ
JOEVDF

fractures of materials and dentin and

The following statements regarding the

structural aspects may be made:
Where a crown is fabricated and a
proper ferrule effect is created, neither
the material (Ti, gold alloys, zirconia,
HMBTT
GJCFS

OPS
UIF
TIBQF
BOE
MFOHUI

therefore should not be used.

Adhesive cementation of fiber posts
is mandatory.
Adhesive

cementation

of

metallic

posts is not mandatory.

Core build-ups should always be

of the post are a significant influence,

bonded, even if a metal post is not

as long as clinically reasonable con-

bonded.

cepts are used.

Conversely, insufficient coronal tooth

Regarding the clinical reality, the fol-

structure will always lead to an in-

lowing additional statements must be

creased failure rate independent of

made:

the concept of restoration.

$FSBNJD
QPTUT
[JSDPOJB

DBOOPU
CF

Increasing the coronal diameter of the

removed after luting, offer no potential

post helps to reduce the fracture risk

for reintervention and should therefore

of all posts, however the residual den-

be used in selected cases only.

tin wall thickness needs to be considered.

For abutment teeth presenting large

defects and requiring crowning, or

Huge differences in the quality of fib-

longer span bridges, or in general

er posts require a careful selection to

heavy loads, metallic posts are pref-

avoid post fractures.

FSBCMF
PWFS
GJCFS
QPTUT
'JHT


UP



249
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
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SCIENTIFIC SESSION

References, Part 1


2.





5.

6.

7.

8.

9.



11.

.BOOPDDJ
'
#IVWB
#

Stern S. Restoring teeth
following root canal re-treatment. Endodontic Topics
2011;19:125152.
Kishen A. Mechanisms and
risk factors for fracture predilection in endodontically
treated teeth. Endodontic
5PQJDT
o
(IFS
.&
+S
%VOMBQ
3.

Anderson MH, Kuhl LV.
Clinical survey of fractured
teeth. J Am Dent Assoc
o
$IBO
$1
-JO
$1
5TFOH
4$

Jeng JH. Vertical root fracture in endodontically versus
nonendodontically treated
UFFUI
B
TVSWFZ
PG


cases in Chinese patients.
Oral Surg Oral Med Oral
Pathol Oral Radiol Endod
o
Reeh ES, Messer HH,
Douglas WH. Reduction in
tooth stiffness as a result
of endodontic and restorative procedures. J Endod
1989;15:512516.
Asundi A, Kishen A. Digital
photoelastic investigations
on the tooth-bone interface.
+
#JPNFE
0QU
o

Jantarat J, Palamara JE,
Lindner C, Messer HH.
Time dependent properties
of human root dentin. Dent
.BUFS


o
Kishen A, Asundi A. Experimental investigation on the
role of water in the mechanical behavior of structural
EFOUJO
+
#JPNFE
.BUFS
3FT

"
o
Kruzic JJ, Nalla RK, Kinney JH, Ritchie RO. Crack
blunting, crack bridging and
resistance-curve fracture
mechanics in dentin: effect
PG
IZESBUJPO
#JPNBUFSJBMT

o
(BMF
.4
%BSWFMM
#8
%FOUJO

permeability and tracer
tests. J Dent 1999;27:111.
Jameson MW, Hood JA,
5JENBSTI
#(

5IF
FGGFDUT
PG

dehydration and rehydration on some mechanical

properties of human dentin.
+
#JPNFDI
o
1065.
12. Grigoratos D, Knowles
J, Ng YL, Gulabivala K.
Effect of exposing dentin
to sodium hypochlorite and
calcium hydroxide on its
flexural strength and elastic
modulus. Int Endod J
o


(PMETNJUI
.
(VMBCJWBMB

K, Knowles JC. The effect
of sodium hypochlorite irrigant concentration on tooth
surface strain. J Endod
2002;28:575579.


4BMFI
""
&UUNBO
8.


Effect of endodontic irrigation solutions on microhardness of root canal dentin. J
%FOU
o


4PV[B
#JFS
$"
4IFNFTI

H, Tanomaru-Filho H,
Wesselink PR, Wu M. The
ability of different nickeltitanium rotary instruments
to induce dentinal damage
during canal preparation. J
&OEPE
o
16. Ferrari M, Mason PN,
Goracci C, Pashley DH, Tay
FR. Collagen degradation
in endodontically treated
teeth after clinical function.
+
%FOU
3FT
o

17. Randow K, Glanz PO.
On cantilever loading of
vital and non-vital teeth.
An experimental clinical
study. Acta Odontol Scand
o


#BKBK
%
4VOEBSBN
/
/B[ari A, Arola D. Age, dehydration and fatigue crack
HSPXUI
JO
EFOUJO
#JPNBUFSJals 2006;27:25072517.
19. Viguet-Carrin S,Garnero
P,Delmas PD. The role
of collagen in bone
strength. Osteoporos Int
o
20. Magne P, Douglas WH.
Rationalization of esthetic
restorative dentistry based
on biomimetics. J Esthet
Dent 1999;11:515.

250
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
70-6.&

t
/6.#&3

t
46..&3


21. Ni CW, Chang CH, Chen TY,

Chuang SF. A multiparametric evaluation of postrestored teeth with simulatFE
CPOF
MPTT
.FDI
#FIBW

#JPNFE
.BUFS
o

22. Tsesis I, Rosen E, Tamse A,
Taschieri S, Kfir A. Diagnosis of vertical root fractures
in endodontically treated
teeth based on clinical and
radiographic indices: a
systematic review. J Endod
o

'VTT
;
-VTUJH
+
5BNTF
"

Prevalence of vertical root
fractures in extracted endodontically treated teeth. Int
&OEPE
+
o


$PQQFOT
$3.
%F.PPS

RJG. Prevalence of vertical
root fractures in extracted
endodontically treated teeth.
*OU
&OEPE
+

25. Tamse A, Fuss Z, Lustig J,
Kaplavi J. An evaluation
of endodontically treated
vertically fractured teeth. J
Endod 1999;25:506508.
26. Vire DE. Failure of endodontically treated teeth: classification and evaluation. J
&OEPE
o
27. Salvi GE, Siegrist Guldener
#&
"NTUBE
5
+PTT
"
-BOH

NP. Clinical evaluation of
root filled teeth restored
with or without post-andcore systems in a specialist
practice setting. Int Endod J
o
28. Kishen A, Kumar GV, Chen
NN. Stressstrain response
in human dentin: rethinking
fracture predilection in postcore restored teeth. Dent
5SBVNBUPM
o
29. Zarow M, Devoto W, Saracinelli M. Reconstruction
of endodontically treated
posterior teeth with or
without post? Guidelines for
the dental practitioner. Eur J
&TUIFU
%FOU
o


4PV[B
&.
EP
/BTDJNFOUP

LM, Maia Filho EM, Alves
CM. The impact of post
preparation on the residual
dentin thickness of maxil-

MEYENBERG

lary molars. J Prosthet Dent

o


,SFKJ
*
%VD
0
%JFUTDIJ
%
EF

Campos. Marginal adaptation, retention and fracture
resistance of adhesive composite restorations on devital
teeth with and without posts.
0QFS
%FOU
o


'PLLJOHB
8"
-F
#FMM
".

Kreulen CM, Lassila LV,
Vallittu PK, Creugers NH.
Ex vivo resistance of direct
composite complete crowns
with and without posts on
maxillary premolars. Int
&OEPE
+
o


(V[Z
(&
/JDIPMT
+*
*O

vitro comparison of intact
endodontically treated teeth
with and without endo-post
reinforcement. J Prosthet
%FOU
o


4PV[B
&.
EP
/BTDJNFOUP

LM, Maia Filho EM, Alves
CM. The impact of post
preparation on the residual
dentin thickness of maxillary molars. J Prosthet Dent
o



)FZEFDLF
(
#VU[
'
4USVC

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
%FOU
o


'FSSBSJ
.
$BHJEJBDP
.$

Grandini S, De Sanctis M,
Goracci C. Post placement
affects survival of endodontically treated premolars. J
%FOU
3FT
o


4UBOLJFXJD[
/3
8JMTPO

PR. The ferrule effect: a
literature review. Int Endod J

o


+VMPTLJ
+
3BEPWJD
*

Goracci C, Vulicevic ZR,
Ferrari M. Ferrule effect: a
literature review. J Endod
o


4PSFOTFO
+"
.BSUJOPGG
+5


Intracoronal reinforcement
and coronal coverage: a
study of endodontically
treated teeth. J Prosthet
%FOU
o



'FSSBSJ
.
$BHJEJBDP
.$

Goracci C, Vichi A, Mason
PN, Radovic I, Tay F. Longterm retrospective study
of the clinical performance
of fiber posts. Am J Dent
2007;20:287291.


1JFSSJTOBSE
-
#PIJO
'

3FOBVMU
1
#BSRVJOT
.
$PSono-radicular reconstruction
of pulpless teeth: a mechanical study using finite element analysis. J Prosthet
%FOU
o


#JOEM
"
3JDIUFS
#
.SNBOO

WH. Survival of ceramic
computer-aided design/
manufacturing crowns
bonded to preparations with
reduced macroretention
geometry. Int J Prosthodont
o


4BUIPSO
$
1BMBNBSB
+&

Palamara D, Messer HH.
Effect of root canal size and
external root surface morphology on fracture susceptibility and pattern: a finite
element analysis. J Endod
o


#PMIVJT
)1#
%F
(FF
"+

Feilzer AJ, Davidson CL.
Fracture strength of different
core build-up designs. Am J
%FOU
o


)FZEFDLF
(
#VU[
'
)VTsein A, Strub JR. Fracture
strength after dynamic loading of endodontically treated
teeth restored with different
post-and-core systems. J
1SPTUIFU
%FOU
o



4DINPMEU
4+
,JSLQBUSJDL
5$

Rutledge RE, Yaccino JM.
Reinforcement of simulated
immature roots restored with
composite resin, mineral
trioxide aggregate, guttapercha, or a fiber post after
thermocycling. J Endod
o


.BOHPME
+5
,FSO
.
*OGMVence of glass-fiber posts on
the fracture resistance and
failure pattern of endodontically treated premolars with
varying substance loss:
An in vitro study. J Prosthet
%FOU
o



/H
$$
%VNCSJHVF
)#

"M#BZBU
.*
(SJHHT
+"

Wakefield CW. Influence
of remaining coronal tooth
structure location on the
fracture resistance of
restored endodontically
treated anterior teeth. J Prosthet Dent 2006;95:290296.



)FZEFDLF
(
1FUFST
.$

The restoration of endodontically treated, single-rooted
teeth with cast or direct
posts and cores: a systematic review. J Prosthet Dent

o
50. Dietschi D, Duc O, Krejci
*
4BEBO
"
#JPNFDIBOJcal considerations for the
restoration of endodontically
treated teeth: a systematic
review of the literature, Part
II (Evaluation of fatigue
behavior, interfaces, and in
WJWP
TUVEJFT

2VJOUFTTFODF

*OU
o
51. Krejci I, Duc O, Dietschi
D, de Campos E. Marginal
adaptation, retention and
fracture resistance of adhesive composite restorations
on devital teeth with and
without posts. Oper Dent.
o


4BOUPT
"'
.FJSB
+#
5BOBLB

$#
9BWJFS
5"
#BMMFTUFS

RY, Lima RG, Pfeifer CS,
Versluis A. Can fiber posts
increase root stresses and
reduce fracture? J Dent Res
2010;89:587591.


3BTJNJDL
#+
8BO
+
.VTJLBOU
#-
%FVUTDI
"4
"

review of failure modes in
teeth restored with adhesively luted endodontic
dowels. J Prosthodont
o


'FEPSPXJD[
;
$BSUFS
#

de Souza RF, de Andrade
Lima Chaves C, Nasser M,
4FRVFJSB#ZSPO
1
4JOHMF

crowns versus conventional
fillings for the restoration of
root filled teeth. Cochrane
Database Syst Rev
2012:16:CD009109.
55. Fokkinga WA, Kreulen CM,
#SPOLIPSTU
&.
$SFVHFST

NH. Up to 17-year controlled

251
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
70-6.&

t
/6.#&3

t
46..&3


SCIENTIFIC SESSION

clinical study on post-andcores and covering crowns.

+
%FOU
o


4JHOPSF
"
#FOFEJDFOUJ
4

,BJUTBT
7
#BSPOF
.
"OHJero F, Ravera G. Long-term
survival of endodontically
treated, maxillary anterior
teeth restored with either
tapered or parallel-sided
glass-fiber posts and fullceramic crown coverage.
+
%FOU
o
57. Jung RE, Kalkstein O, Sailer
I, Roos M, Hmmerle CH.
A comparison of composite
post buildups and cast gold
post-and-core buildups for
the restoration of nonvital
teeth after 5 to 10 years. Int J
1SPTUIPEPOU
o


'FSSBSJ
.
#SFTDIJ
-
(SBOdini S. Fiber posts and
endodontically treated teeth:
a compendium of scientific
and clinical perspectives,
ed 1. Wendywood, South
Africe: Modern Dentist
Media. Wendywood, 2006.
59. Malament KA, Socransky
SS. Survival of Dicor glassceramic dental restorations
over 20 years: Part IV. The
effects of combinations of
variables. Int J Prosthodont

o
60. Malament KA, Socransky
SS, Thompson V, Rekow D.
Survival of glass-ceramic
materials and involved
clinical risk: variables
affecting long-term survival.
Pract Proced Aesthet Dent
4VQQMo
61. Naumann M, Koelpin M,
#FVFS
'
.FZFS-VFDLFM
)


10-year survival evaluation
for glass-fiber-supported
postendodontic restoration:
a prospective observational clinical study. J Endod
o
62. Ferrari M, Vichi A, Fadda
GM, Cagidiaco MC, Tay
'3
#SFTDIJ
-
1PMJNFOJ
"

Goracci C. A randomized
controlled trial of endodontically treated and restored
premolars. J Dent Res
2012;91:72S78S.



(NF[1PMP
.
-MJE
#

Rivero A, Del Ro J, Celemn
A. A 10-year retrospective
study of the survival rate of
teeth restored with metal
prefabricated posts versus
cast metal posts and cores.
+
%FOU
o


8SCBT
,5
,BNQF
.5

Schirrmeister JF, Altenburger MJ, Hellwig E. Retention
of fiber posts dependent
on different resin cements.
Schweiz Monatsschr ZahnNFE
o
65. Kremeier K, Fasen L, KlaibFS
#
)PGNBOO
/
*OGMVFODF

of endodontic post type
(glass fiber, quartz fiber or
HPME

BOE
MVUJOH
NBUFSJBM
PO

push-out bond strength to
dentin in vitro. Dent Mater
o
66. Ferrari M, Mannocci F, Vichi
"
$BHJEJBDP
.$
.KS

*"
#POEJOH
UP
SPPU
DBOBM

structural characteristics of
the substrate. Am J Dent
o


$BMJYUP
-3
#BOEDB
.$

Clavijo V, Andrade MF, Vaz
LG, Campos EA. Effect of
resin cement system and
root region on the push-out
bond strength of a translucent fiber post. Oper Dent
o
68. Huber L, Cattani-Lorente M,
4IBX
-
,SFKDJ
*
#PVJMMBHVFU

S. Push-out bond strengths
of endodontic posts bonded
with different resin-based
luting cements. Am J Dent
2007;20:167172.
69. Monticelli F, Ferrari M,
Toledano M. Cement system
and surface treatment
selection for fiber post luting. Med Oral Patol Oral Cir
#VDBM
&o


#BSBCBOUJ
/
.BEJOJ
-

Krokidis A, Acquaviva
PA, Cerutti F, Cerutti A.
Polymerization degree and
cementation methods of two
different self-adhesive luting cements used for glass
fiber post cementation.
Minerva Stomatol 2012;61:
o

252
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
70-6.&

t
/6.#&3

t
46..&3


71. Sterzenbach G, Karajouli G,

/BVNBOO
.
1FSP[
*
#JUUFS

K. Fiber post placement
with core build-up materials
or resin cements An evaluation of different adhesive
approaches. Acta Odontol
4DBOE
o
72. Radovic I, Corciolani G,
Magni E, Krstanovic G,
Pavlovic V, Vulicevic ZR,
Ferrari M. Light transmission
through fiber post: the effect
on adhesion, elastic modulus and hardness of dualcure resin cements. Dent
.BUFS
o


.POUJDFMMJ
'
0TPSJP
3
4BEFL

FT, Radovic I, Toledano
M, Ferrari M. Surface
treatments for improving
bond strength to prefabricated fiber posts: a literature review. Oper Dent
o


:FOJTFZ
.
,VMVOL
4


Effects of chemical surface treatments of quartz
and glass fiber posts on
the retention of a composite resin. J Prosthet Dent
o
75. Radovic I, Monticelli F,
Goracci C, Cury AH,
Coniglio I, Vulicevic ZR,
Garcia-Godoy F, Ferrari M.
The effect of sandblasting
on adhesion of a dualcured resin composite to
methacrylic fiber posts:
microtensile bond strength
and SEM evaluation. J Dent
o
76. Soares CJ, Santana FR,
Pereira JC, Araujo TS,
Menezes MS. Influence of
airborne-particle abrasion
on mechanical properties and bond strength of
carbon/epoxy and glass/
bis-GMA fiber-reinforced
resin posts. J Prosthet Dent
o
77. Valandro LF, Yoshiga S,
de Melo RM, Galhano GA,
Mallmann A, Marinho CP,
#PUUJOP
."
.JDSPUFOTJMF

bond strength between a
quartz fiber post and a resin
cement: effect of post sur-

MEYENBERG

face conditioning. J Adhes

Dent 2006;8:105111.
78. Zicari F, De Munck J, Scotti
R, Naert I, Van Meerbeek
#
'BDUPST
BGGFDUJOH
UIF

cement-post interface. Dent
Mater 2012;28:287297.
79. Vano M, Carvalho C, Sedda
M, Gabriele M, GarcaGodoy F, Ferrari M. The influence of storage condition
and duration on the resistance to fracture of different
fiber post systems. Am J
%FOU
o

80. Schmage P, Nergiz I, Markopoulou S, Pfeiffer P. Resistance against pull-out force

of prefabricated coated
FRC posts. J Adhes Dent
o
81. Cheleux N, Sharrock PJ.
Mechanical properties of
glass fiber-reinforced endoEPOUJD
QPTUT
"DUB
#JPNBUFS

o
82. Grandini S, Goracci C,
Monticelli F, Tay FR, Ferrari
M. Fatigue resistance and
structural characteristics

of fiber posts: three-point

bending test and SEM
evaluation. Dent Mater
2005;21:7582.


(SBOEJOJ
4
$IJFGGJ
/

Cagidiaco MC, Goracci C,
Ferrari M. Fatigue resistance
and structural integrity of
different types of fiber posts.
Dent Mater J 2008;27:687


Part 2:
Esthetic considerations

or is largely addressed with full crowns,

Introduction

structions that require optimal stabiliza-

since endodontically treated posterior

teeth present mostly with large recontion by full or partial crowns.

In addition to the numerous issues dis-

In the anterior zone, however, esthet-

cussed in part 1 of this paper, non-vital

JDT
DBO
CF
TUSPOHMZ
EJTUVSCFE
CZ

OFHB-

teeth are frequently esthetically com-

tive effects:

promised. This frequently presents sig-

Discolouration of the clinical crown.

nificant and special challenges when it

Discolouration of the cervical region.

comes to meeting the demand for nat-

Discolouration of the gingiva and mu-

ural-looking, esthetically pleasing teeth

cosa.

sought by our patients today.

The aim of the second part of this pa-

There are various causes of these en-

per is to try to answer several clinically

dodontically induced intrinsic discolora-

relevant conceptual questions and to

tions:

provide some clinical guidelines regard-

Intrapulpal haemorrhage.

ing the management of the esthetic as-

Pulpal necrosis.

pects, based on scientific evidence and

Incomplete removal of pulp tissue

clinical expertise.

during the endodontic treatment.

Endodontic

irrigants,

medications

Why are most endodontically

and root canal filling material (root

treated teeth dark?

BOE
DFSWJDBM
[POF


The

discoloration

of

Restorative materials (cervical zone

endodontically

BOE
DSPXO


treated teeth is a common observation.

Coronal leakage.

In the posterior region, this phenom-

Dentin sclerosis.

enon is seldom esthetically disturbing

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SCIENTIFIC SESSION

Unfortunately almost all root canal seal-

the tooth are heavily discolored and do

ers including Zinc Oxide-Eugenol and

not respond to the bleaching procedure.

")

UP
B
MFTTFS
FYUFOU

MFBE
UP
EJTDPMPSBUJPO
BCPWF
BMM
JO
UIF
DFSWJDBM
[POF

Do bleaching procedures lead to

Also the use of MTA, be it grey or white,

external resorption?

will ultimately lead to a greyish appearance or darkening of the root.5,6

Cervical root resorption is a serious

Furthermore, the calcification pro-

complication that is difficult to treat11,12

cess in the dentin through obliteration

and ultimately can lead to tooth loss.

of the dentinal tubules and changes in

There are various reasons for this phe-

the free water content before and after

nomenon. Orthodontic treatment and

endodontic treatment and through ag-

tooth trauma are the most common pre-

ing processes, contributes to an altered

disposing factor. Internal bleaching may

optical appearance in addition to the in-

increase the combinatory risk, however

creased

brittleness.7-10

it seems to be limited to cases where

extensive concentrations of H2O2 com-

How can we improve the color of

bined with heat (the thermo-catalytic

UIF
UPPUI
TVCTUBODF
#MFBDIJOH

NFUIPE

XBT
VTFE  The presence

or replacing discoloured coronal

dentin?

of defects at the cemento-enamel junction seem to play a major role, allowing

the bleaching agent to penetrate into the

Although some of the above mentioned

negative factors can be clinically modi-

periodontal space.15
The

recommendations

today

are

fied, it is evident that a non-vital tooth

therefore not to heat the bleaching agent

inevitably loses some esthetic qualities

in the access cavity, to seal the residual

in terms of the color. As a matter of prin-

root filling well before application of the

ciple, replacing discolored dentin to cor-

bleaching agent and to generally use

rect the color is not the preferable op-

less aggressive bleaching chemicals

tion from a structural viewpoint. In part 1,

instead of high concentrations of H2O2.

the mechanical aspects to support this

The best clinical compromise of ef-

axiom have already been extensively

fect, side-effects, risks and long-term

discussed.

experience is in the use of the so called

existing

walking bleach technique16 where,

substance is always the better option,

classically, sodium perborate is mixed

if we agree on the principle that hav-

with water.

Therefore,

bleaching

the

ing a discolored tooth is preferable to

In the authors long-term experience,

having no tooth. Most discolorations

this is clinically as efficient as other more

are bleachable except those caused by

aggressive chemicals, provided a cor-

metal ions (amalgam, or silver and other

rect cervical and coronal seal of the

IFBWZ
NFUBM
DPOUBJOJOH
NBUFSJBMT

2 So

bleaching cavity have been realized.

the only indication to remove discolored

The cervical seal is preferably achieved

dentin may be if small spots that do not

with a modified glass ionomer cement,

contribute to the structural resistance of

classically applied at the level of the con-

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MEYENBERG

nective tissue attachment, whereas the

further compromise the strength of the

coronal seal is achieved with adhesively

residual tooth structure. This is an im-

luted composite to ensure an optimal

portant consideration particularly if ad-

penetration of the bleaching agent into

ditional reconstructive measures are to

the dentin. Hence, leaving the access

be executed26 and if the potential for re-

cavity open and using at-home tech-

intervention is taken into account.

advisable.17

Second, as mentioned, bleaching

Success largely depends from the ap-

agents themselves lead to a weakening

plication duration of the bleaching agent

of the tooth structure through the chemi-

o
EBZT
o
UJNFT

BOE
CZ
GBS
PVUQFS-

cal modification of the dentin.27,28 A re-

forms alternative quick in-office tech-

cent publication supported the use of

niques in the long run.18 In a recent study

sodium perborate mixed with water in

it could also be shown that this concept

this respect, since this combination led

compares very favorably to more ag-

to a significantly smaller additional open-

gressive mixtures of chemicals in terms

ing of the dentinal tubules compared to

of H2O2 leakage at different root locations

all other bleaching agents. Interestingly

niques with open trays is not

with and without external

defects.19,20

Since cervical defects are difficult to


DBSCBNJEF
QFSPYJEF
DBVTFE
UIF

worst effect.29

detect with conventional radiographs

Another important consideration is

and require cone beam computed to-

the influence of bleaching on dentin

NPHSBQIZ
$#$5

UFDIOJRVFT 21 the use

bonding. As emphasized in part 1, the

of this less-aggressive concept makes

quality of the internal reconstruction af-

additional sense in avoiding added un-

ter endodontic therapy is of key impor-

known risks while producing good es-

tance in reconstituting the resistance to

thetic results.

fracture. Using an adhesive approach is

advisable but technique sensitive and,

Do bleaching procedures weaken

in general, all bleaching agents lead to

the tooth or may dark roots also

reduced bond strengths and increased

microleakage. Consequently, the use

be bleached?

of antioxidants has been advocated to

that

counteract this effect (eg, sodium ascor-

bleaching chemicals weaken tooth sub-

CBUF

BOEPS
EFMBZJOH
UIF
CPOEJOH
QSP-

stance.

cedure for at least 10 days after washing

Recent

research

clearly

shows

Since the endodontic treatment itself

out the bleaching agent The antioxi-

already weakens the dentin consider-

dant is especially necessary and should

ably through chemical and mechanical

be mandatory if bonding with simplified

effects
CZ

UP

JO
TUSFOHUI 25

single bond dentin adhesives, or if de-

additional care must be taken if a bleach-

layed bonding is not warranted or pos-

ing procedure is being considered.

sible.

First of all, internal removal of dis-

However, good dentin adhesion can be

colored dentin should be avoided. It

achieved if: a) sodium perborate mixed

does not lead to better results with the

with water is used to bleach, b) the tooth

described bleaching technique and will

is left with saline solution for 7 days after

255
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SCIENTIFIC SESSION

Fig 16

$BTF

JOJtial radiographic situation. A carbon composite post had been
placed.
Fig 15

$BTF

EJTDPMPSFE
OPOWJUBM
SJHIU
DFOUSBM

incisor with PFM crown, initial clinical situation.

removal of the bleaching agent, and c)

conditions owing to unfavorable ovoid

a scientifically and clinically well estab-

root canal configurations and dentin mi-

lished self-etching 2-step dentin bonding

crostructure in the deeper parts of the

TZTUFN
FH
$MFBSGJM
4&
CPOE

JT
VUJMJ[FE

root canal the root should not be

For enamel, the same principle of waiting

further compromised by using bleach-

after washing off the bleaching agent is a

ing techniques inside the root canal.

simple and successful strategy. Recent

As long as the intracoronal bleaching

proposals for new resin formulations that

is performed within the access cavity

are supposed to allow immediate bond-

reaching to the level where the connec-

ing after bleaching have not proved as

tive tissue attachment ends coronally,

effective.

the results constitute a sufficient com-

Since adhesion within the root remains

promise esthetically,26 even in the criti-

a challenge even in ideal experimental

DBM
DFSWJDBM
[POF
'JHT

o


Fig 17

$BTF

BCVUNFOU
UPPUI
BGUFS
DSPXO
BOE

Fig 18

$BTF

IPMMPX
DPNQPTJUF
CVJMEVQ
GPS
JOUFS-

post removal.

nal bleaching of coronal part of the abutment tooth.

256
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MEYENBERG

Fig 19

$BTF

DPNQMFUFE
CVJMEVQ
PG
BCVUNFOU

Fig 20

$BTF

HMBTT
DFSBNJD
DSPXO
MBZFSJOH

tooth with bonded fiber post and core, after internal

technique.

bleaching with sodium perborate and water.

Fig 21

$BTF

GJOBM
DMJOJDBM
SFTVMU

Fig

22

$BTF

GJOBM
SBEJPHSBQI

showing good adaptation of the short

fiber post and bonded core to the denUJOBM
XBMMT
MJHIU
DVSFE
NBUFSJBMT
VTFE


257
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SCIENTIFIC SESSION

Internal bleaching is a techniquesensitive

approach.

Potential

rea-

sons for failures are numerous, with

coronal or apical leakage being the
most frequent, and short-cut treatment protocols are more likely to have
QSPCMFNT
#PUI
UIF
DPSPOBM
BOE
UIF

apical-cervical seal, along with the
optical quality of the access restoration, account for success or failure.
The prognosis of the bleaching procedure is more prone to recurrence
of discoloration if the tooth became
rapidly discolored after the endodontic treatment.
Subjective and objective satisfaction
of the dentist or the patient may differ
substantially.
Fig 23

Limited light conducting properties of fib-

er posts with good mechanical properties preclude

The potential for intervention and the

the use of long posts, if light-cured materials are to

concept of a progressive (conserva-

be used.

UJWF

BQQSPBDI
EVSJOH
UIF
MJGFUJNF
PG

a discolored tooth are essential. Aggressive

What about the predictability and

stability of bleaching procedures?

reconstructive

concepts

based just on esthetic considerations

and early crowning can lead to premature tooth loss. Therefore, bleaching

There has been some debate about the

instead of removing tooth substance

predictability and long-term effective-

is the preferable treatment, both for

ness of internal bleaching,  with de-

non-reconstructive and reconstruc-

scribed esthetic success rates of around

tive cases.26

90% after 2 years, 75% after 5 years and

60% after 16 years. The potential causes

May crowns or veneers

for the recurrence of discoloration have

compensate darkened coronal

been suggested as: a) the same substances as those having caused the ini-

tooth structure?

tial discoloration, or b) penetration of pig-

First of all it is important to understand

ments from the oral cavity, or c) bacterial

the concept of illumination of the oral tis-

reinfection of the root canal system with

sues.  The tooth with its clinical crown

subsequent infiltration into the cervical

and root, the gingiva, the bone and the

and coronal dentin.1

periodontium form an optical unit. Light

From long-term studies and clinical

is transmitted by diffuse reflection into

observations, the following can be con-

the tissues. It is therefore critical not to

cluded:

disturb this delicate system with discol-

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MEYENBERG

orations or by the introduction of inad-

nates and all-ceramic partial crowns,

equate opaque or dark restorative ma-

as a wide variety of all-ceramic crown

terials. Of particular importance in this

systems exist today with excellent opti-

respect is a soft color transition from the

cal properties and long-term survival, in

cervical third of the clinical crown into

particular, the new generation of glass-

the adjacent gingival tissues.

ceramic materials. In addition, these

Since the mid 1960s, dental techni-

materials allow the provision of bonded

cians and prosthodontists tried to imple-

full coverage veneer type crowns with

ment this concept in order to improve

SFEVDFE
QSFQBSBUJPO
TJNJMBS
UP
EF-

the esthetics of full crown margins. In the

HSFF
WFOFFS
QSFQBSBUJPO
'JHT

o


1980s, PFM crowns without metal collars

Consequently, the management of

were introduced, using shoulder and ve-

discolored

neering porcelains with better light con-

increasingly important. It should be re-

ducting properties to illuminate the adja-

membered that all attempts to mask out

cent

tissues.

tooth

substrate

becomes

Despite these efforts,

discolored tooth substance will invari-

the results were never completely sat-

ably end up with increased opacity and

isfying when the underlying tooth struc-

therefore unnatural reflection of the light

ture was dark, or if there were vital and

instead of a diffuse reflection inside the

rather translucent teeth to be matched.

materials. This is of particular importance

Hence the search and development of

when veneering a tooth with a discolored

true light conducting materials as frame-

cervical zone, as the fine veneer margins

works with lower opacity than metal or

cannot create the appropriate color tran-

the pre-existing all-ceramic

cores.

sition from the tooth crown into the gin-

Today, in the case of vital teeth with

giva. If a full crown is provided in such a

adequate tooth substance, more con-

case, a pleasing result can be achieved

servative bonded porcelain restorations,

by using opaque all-ceramic framework

such as veneers and anterior partial all-

materials, provided that adjacent struc-

ceramic crowns, are increasingly the

tures are also more opaque and the gin-

treatment of choice as compared to full

gival tissue is thick, but this is rather the

crowns, due to esthetic, technical and

exception than the rule.57,58 The same is

biological

advantages.

It is impor-

tant to understand that the success of

true if opaque cements are used to cover

dark underlying substance.

these restorations is largely based on

Above all, trying to mask out dis-

the esthetic and mechanical advantag-

colored teeth should not result in over-

es of the natural uncompromised tooth

preparation:59 the mission statement of

substrate as the foundation of the resto-

Hippocrates primum nihil nocere (first

ration rather than an artificial substrate.

EP
OP
IBSN

TIPVME
BMTP
CF
UIF
HVJEJOH

As a consequence of this success, the

QSJODJQMF
IFSF
'JHT

BOE



concept has been extended to endo-

Thus the clinical concept for man-

dontically treated teeth, with the idea be-

agement of discolored tooth substance

hind to convert darkened tooth structure

should always consider internal bleach-

into vital looking tissues.   Naturally

ing as first option, even if the result will

this is not only relevant to bonded lami-

not be absolutely perfect.

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SCIENTIFIC SESSION

Fig 24

$BTF

EJTDPMPSFE
BCVUNFOU
UFFUI
XJUI

Fig 25

$BTF

GJOBM
QJDUVSF
XJUI
1'.
DSPXOT
%VF

cast post and cores, leading to a disturbance in the

to the symmetry of the case, the suboptimal color

illumination of the adjacent tissues.

transition from the abutment margins into the gingival tissues fortunately does not disturb too much
in this case.

If the tooth needs an additional indirect restoration, a veneer or full cover-

is similar to what can be observed within

the enamel of natural teeth.

age veneer-crown is an attractive and

One drawback certainly is if the dis-

less invasive solution. In the authors

colored tooth has already been restored

own experience over the last 15 years

with a post. If removal of the post without

from when the concept first was used,

risk of damage to the root is viable, then

long-term results for esthetics and sur-

the internal bleaching can be performed

vival rates in both types of restorations

before a new post and core is fabricat-

are comparable to all-ceramic crowns.

ed. If this is considered too risky, metallic

However, in the literature there are only

posts and cores can at least be masked

studies with vital teeth available at the

with a tooth-colored opaquer and com-

moment, which show a survival rate of

posite to avoid to improve the substrate


PWFS

ZFBST
GPS
WFOFFST
BOE

color for an all-ceramic framework.

100% for extended veneers over 5

This leads to the next question: Can

years.60,61 The observation of small su-

tooth-colored posts enhance the color

perficial cracks not influencing survival

of dark roots?
Tooth-colored posts have long been
advocated in esthetic dentistry. Since
early trials around 1965 by John McLean
with Alumina posts, the concept has
been further developed to mechanically
more reliable posts, with the introduction of the first Zirconia posts in 1995 

and the first fiber posts in 1990.
The proposed reasons for tooth-colored posts for esthetics in root treated
teeth are:

Fig 26

Case 5: left central incisor with polished

To illuminate the root and cervical re-

cast post and core, right lateral incisor with tooth-

gion and thus brighten up darkened

colored post and core.

tooth substance.

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MEYENBERG

To prevent any darkening effect of a post

by photospectroscopic studies67 and

on non-discolored tooth substance.

may lead to incorrect clinical recom-

To create a tooth-colored basis for the

mendations in specific cases.

However, given the clinical and sci-

core and the crown.

entific evidence, there is actually little

While the first reason has already been

reason to take out existing well adapted

disputed early on by experienced cli-

and luted cast post and cores if the re-

nicians not being able to see any dif-

maining dentin itself is not discolored

ference in the color between a metallic

and does not require bleaching. It is

post and a tooth-colored post put into

clinically sufficient to mask the buccal

the same dark root under natural light

part of the metal with a tooth-colored

conditions, the second two points are

opaquer. If space and residual thick-

good arguments for tooth-colored posts.

ness of a gold alloy post and core do

In fact a recent study showed that there

not allow to do this, another smart ap-

is no difference in the cervical color of

proach is to polish the buccal part of

abutment teeth between white and me-

the exposed metal to a high gloss, thus

tallic posts, however tooth-colored posts

creating total reflection of the light at the

and cores were beneficial for the overall

core surface.68 This concept has been

color of the all-ceramic

crowns.65

This

widely used by the author for years with

is in line with observations of clinicians

no adverse effects regarding the reten-

aware of these subtle

differences.66

UJPO
PG
UIF
MVUFE
DSPXOT
'JHT

o


Some care must be taken when trying

In conclusion, it can be stated that

to translate in vitro studies about color

the color of the remaining tooth sub-

influences into clinical practice. Some

strate is of much greater importance

subtle components of the color, such as

than the color of the post and cannot

the quality of the internal diffuse reflec-

be influenced positively by the post in

tion depending on the intensity of light

the cervical and apical region, however

and the softness of the transition into the

having a tooth-colored post is beneficial

marginal gingiva cannot be measured

for the core.

Fig 27

Fig 28

Case 5: final picture showing the good

reflection properties of the polished metal part of the

Case 6: abutment teeth with various de-

grees of discolorations.

left central abutment tooth.

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SCIENTIFIC SESSION

sue. In oral implantology, however, some

studies have been performed looking at
the influence of various abutment materials on the color of the existing soft
tissues, and how variations in the soft
tissue thickness can modify the overall
color resulting from abutment and covering soft tissue. Since these abutments
all have a subgingival component and a
titanium implant base, this would appear
to offer a situation well in line with a discolored root. Comparing zirconia, polished gold alloys and machined titanium
in a pig model, a visible difference was
Fig 29

Case 6: layered glass ceramic crowns

with internal opaquer and varying opacities of

frameworks.

always present if the tissue thickness

XBT
CFMPX


NN
#FUXFFO

UP


NN

in thickness, only zirconia (regardless of
BOZ
WFOFFSJOH

EJE
OPU
JOEVDF
B
DIBOHF

Can soft tissue thickening

*G
UIF
UIJDLOFTT
XBT


NN
PS
NPSF
UIF

compensate darkened cervical

material itself had no influence.69 In a

root structure?

human study, comparing metal abutments and PFM crowns with all-ceramic

A soft color transition from the crown

abutments and crowns, the latter be-

into the soft tissue is essential for an

haved better, but there was still a visible

esthetically pleasing result. In the pre-

difference for both groups compared

ceding pages, the focus was placed

to the adjacent teeth.70

Another study

results,71

on the root and crown of the tooth and

presented similar

how negative effects can be managed.

correlation between the thickness of the

However, if discolorations are still pre-

mucosa and the respective amount of

sent in the critical cervical supra- and

discoloration could be found.

although no

subgingival zone, it makes sense to

In essence, the fiber content and the

consider influencing the soft tissue

degree of keratinization may play a more

characteristics.

important role for the masking ability

The margin of the soft tissue cover-

than the soft tissue thickness alone. In

ing the cervical part of the root plays

this respect, the use of a connective tis-

an important role as a curtain to hide

sue graft taken from the palate with its

unpleasing structures. In addition, the

higher content of collagen fibers is the

buccal bone plate has also some mask-

most promising approach using an en-

ing effect over a discolored root. A thick

velope technique to improve the esthetic

bone plate can virtually completely mask

integration of the augmented tissue. 

out the root discoloration. In periodontol-

Some modifications in the technique, in-

ogy, there is little information available

cluding a microsurgical approach, have

about the masking effect of the soft tis-

been introduced to further decrease

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MEYENBERG

Fig 30

Case 6: final picture of the four anterior

Fig 31

Case 6: final picture of the right side,

teeth, showing an acceptable color transition be-

showing an acceptable color transition between the

UXFFO
UIF
QPOUJD
SJHIU
MBUFSBM
JODJTPS

BOE
UIF
PUIFS

QPOUJD
MBUFSBM
JODJTPS

UIF
WJUBM
DBOJOF
BOE
UIF
OPO

abutment teeth.

vital discolored central incisor.

healing complications and unesthetic

tissue contours and preventing further

tissue scars. 

exposure of discolored root surfaces.

An additional benefit of this approach

is the easier tissue handling during the
reconstructive phase and the prevention of post-reconstructive recessions
over time, which may expose further discolored root parts. Indeed, since many

Final consideration:
at what point should we
give up and extract?

of the discolored teeth exhibit some cer-

It is fair to state that a tooth should be

vical tissue loss over time anyway, this

saved as long as there is a predictable

procedure can also be considered as a

way to functionally and biologically do

preventive treatment of a cervical reces-

so with a reasonable prognosis. This

sion,76

dealing not primarily with health,

2-part article has shown various possi-

but with stable, esthetic tissue levels. It

bilities to overcome classic biomechani-

may also serve to counteract the loss in

cal and esthetic problems with respect

cervical tissue height that occurs by tis-

to minimizing reconstructive risks. The

sue modeling during the aging process,

basis for reconstructive survival in the

which is more noticed around discolor-

context of this article, however, is the

ed roots and is independent of the pres-

quality of the endodontic treatment as

ence or absence of dental restorations.

the starting point.

As a conclusion, soft tissue thicken-

It can also be stated that today too

ing may not completely solve the prob-

many teeth are extracted in favor of im-

lem of the discolored cervical hard and

plants, with insufficient regard for the

soft tissue zone, but it can improve the

extensive reconstructive options avail-

overall result by at least stabilizing soft

able to maintain them. Furthermore, the

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SCIENTIFIC SESSION

short- and long-term biologic, esthetic

previous studies and may produce less

and technical complications of implants

successful results than expected or than

appreciated.77

Unfortu-

achieved with the classic concepts of

nately, poor endodontic treatment is still

experienced endodontic specialists. A

a major factor in premature tooth loss.

MPOHUFSN
TUVEZ
PWFS

ZFBST
DPOEVDU-

However, if performed correctly, results

ed in a private practice by a specialist,

are at least as good as replacement with

documented an overall success rate of

implants for single units.77 It is striking

91.5%.80 Initial endodontic treatments

that despite this fact, today a tendency

IBE
B
IJHIFS
TVDDFTT
SBUF


DPN-

towards a more extraction-oriented re-

pared to the non-surgical retreatment

constructive concept can be observed

HSPVQ


5IJT
TIPXT
WFSZ
DMFBSMZ

in practice. There are two main reasons

how important the quality of the first en-

for this.

dodontic treatment is for the long-term

are not fully

The first reason is that in clinical de-

success. In addition, the coronal resto-

cision-making, the predictability of the

ration has a significant influence in the

whole procedure is of primary impor-

success of the endodontic treatment.

tance in respect of complications and

Thus, to strive in every respect for an

cost. Obviously there is some pessimism

optimal restoration is as essential as an

among clinicians regarding the progno-

optimal endodontic treatment alone.81

sis of endodontic treatments in general

The second reason is that measures

and this is not completely unfounded.

to potentially save a compromised tooth

The combined failure rate of endodonti-

can later preclude the placement of

cally treated teeth in general practice is

an implant or make it very demanding.

higher than described in earlier reports:

Therefore, if an endodontic retreatment

PWFS

ZFBST
B
DVNVMBUJWF
GBJMVSF
SBUF
PG

due to recurrent apical pathology is

up to 20% is documented.78 In general,

considered, above all, careful diagnos-

the outcome of endodontic treatments

tic steps including soft and hard tissue

may have been overestimated in previ-

probing and radiographs are required.

ously published reviews because of the

Conventional radiographs do not allow

general lack of correct apical diagnosis.

proper analysis and interpretation of the

*G
IJHISFTPMVUJPO
$#$5
JT
OPU
VTFE
PGUFO

root and remaining bone housing around

the endodontic status cannot correctly

the root. The possible causes for the

be analyzed. The authors of a current

endodontic failure (eg, crack, fracture,

review state: In conclusion, the serious

perforation, insufficient root filling or ac-

limitations of longitudinal clinical studies

DFTTPSZ
SPPU
DBOBMT

DBOOPU
CF
QSPQFSMZ

restrict the correct interpretation of root

established without a high-resolution

canal treatment outcomes. Systematic

$#$5
BOE
DPOTFRVFOUMZ
UIF
QSPHOPTJT

reviews reporting the success rates of

and appropriate treatment approach

root canal treatment without referring

can only be determined based on an

to these limitations may mislead read-

accurate diagnosis.

ers.79

Therefore, the trend towards sim-

Periapical microsurgery should be

plified endodontic protocols may also

performed exclusively if non-surgical

be based on incorrect interpretations of

endodontic retreatment is not viable,

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MEYENBERG

and if the remaining bone housing is suf-

tal tooth-supported restorations, there is

ficient. The surgical approach seems to

no clear winner in terms of sustainabil-

be more successful in the short term, but

JUZ
FTUIFUJDT
CJPMPHZ
BOE
GVODUJPO
#PUI

MFTT
TP
JO
UIF
MPOH
UFSN

PWFS

UP

solutions require a perfect synergy of all

6 years for the non-surgical approach,

the fields of specialties involved and the

WFSTVT

PWFS
NPSF
UIBO

ZFBST
GPS

treatment steps to achieve the optimal

the surgical

approach.82

In addition, the

result for the individual patient.

added bone loss caused by the surgical

access osteotomy and incomplete heal-

Acknowledgements

ing can make the placement of an im-

The author would like to thank Dr Tidu Mankoo for

plant after a potential failure and eventful

the systematic and thorough editing of the whole esTBZ
%S
'SBOL
1BRV
GPS
IJT
TVQQPSU
JO
UIF
EJTDVTTJPO

extraction very difficult.

of the endodontic aspects, and Walter Gebhard and

Ultimately, when we examine the treatment outcome of implant versus non-vi-

References, Part 2
1.

Arens D. The role of

bleaching in esthetics. Dent Clin North Am
o


1MPUJOP
(
#VPOP
-
(SBOEF

NM, Pameijer CH, Somma F.
Nonvital tooth bleaching: a
review of the literature and
clinical procedures. J Endod
o


;JNNFSMJ
#
+FHFS
'
-VTTJ

"
#MFBDIJOH
PG
OPOWJUBM

teeth. A clinically relevant
literature review. Schweiz
Monatsschr Zahnmed
o

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.
"M)BWWB[
")

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#
*O
WJUSP
DPNputer analysis of crown discolouration from commonly
used endodontic sealers.
"VTU
&OEPE
+
o
119.


#PVUTJPVLJT
$
/PVMB
(

Lambrianidis T. Ex vivo
study of the efficiency of two
techniques for the removal
of mineral trioxide aggregate used as a root canal
filling material. J Endod
o

6.

Nic Pietrobon for their contribution in creating the

dental ceramics.

Jacobovitz M, de Lima RK.

Treatment of inflammatory
internal root resorption with
mineral trioxide aggregate:
a case report. Int Endod J
o
7.
Porter AE, Nalla RK, Minor
A, Jinschek JR, Kisielowski
C, Radmilovic V, Kinney
JH, Tomsia AP, Ritchie RO.
A transmission electron
microscopy study of mineralization in age-induced
USBOTQBSFOU
EFOUJO
#JPNBUFrials 2005;26:76507660.


#BOH
(
3BNN
&
%FUFSmination of age in humans
from root dentin transparency. Acta Odontol Scand
o
9.
Kinney JH, Nalla RK, Pople
+"
#SFVOJH
5.
3JUDIJF
30

Age-related transparent
root dentin: mineral concentration, crystallite size,
and mechanical properties.
#JPNBUFSJBMT
o



#BKBK
%
4VOEBSBN
/
/B[BSJ

A, Arola D. Age, dehydration
and fatigue crack growth
JO
EFOUJO
#JPNBUFSJBMT

2006;27:25072517.



#BLMBOE
-,
"OESFBTFO
+0

Will mineral trioxide aggregate replace calcium hydroxide in treating pulpal and
periodontal healing complications subsequent to dental
trauma? A review. Dent
5SBVNBUPM
o
12. Schwartz RS, Robbins JW,
Rindler E. Management of
invasive cervical resorption:
observations from three private practices and a report
of three cases. J Endod
o


)FJUIFSTBZ
(4
%BIMTUSPN

SW, Marin PD. Incidence of
invasive cervical resorption
in bleached root-filled teeth.
"VTU
%FOU
+
o


3PUTUFJO
*
5PSFL
:
-FXJOstein I. Effect of bleaching
time and temperature on
the radicular penetration of
hydrogen peroxide. Endod
Dent Traumatol 1991;7:196
198.
15. Rotstein I, Torek Y, Misgav
R. Effect of cementum
defects on radicular penFUSBUJPO
PG

)2O2 during
intracoronal bleaching. J
&OEPE
o

265
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
70-6.&

t
/6.#&3

t
46..&3


SCIENTIFIC SESSION

16. Spasser HA . A simple

bleaching technique using
sodium perborate. New York
4UBUF
%FOU
+
o

17. Liebenberg WH. Intracoronal lightening of discolored pulpless teeth: a
modified walking bleach
UFDIOJRVF
2VJOUFTTFODF
*OU

1997;28:771777.
18. Dietschi D. Nonvital bleaching: general considerations
and report of two failure
cases. Eur J Esthet Dent
2006;1:5261.
19. Sharma DS, Sharma S, Natu
SM, Chandra S. An in vitro
evaluation of radicular penetration of hydrogen peroxide from bleaching agents
during intra-coronal tooth
bleaching with an insight
of biologic response. J Clin
1FEJBUS
%FOU
o

20. Palo RM, Valera MC,
Camargo SE, Camargo
CH, Cardoso PE, Mancini
MN, Pameijer CH. Peroxide
penetration from the pulp
chamber to the external
root surface after internal bleaching. Am J Dent
o

21. Kamburog lu K , Kurs un S,
Yksel S, Oztas
#
0CTFSWFS

ability to detect ex vivo
simulated internal or external cervical root resorption.
+
&OEPE
o
22. Tamse A. Vertical root
fractures in endodontically
treated teeth: diagnostic
signs and clinical management. Endodontic Topics
o


(SJHPSBUPT
%
,OPXMFT

J, Ng YL, Gulabivala K.
Effect of exposing dentin
to sodium hypochlorite and
calcium hydroxide on its
flexural strength and elastic modulus. Int Endod J
o


1FSF[
'
3PVRVFZSPM1PVSDFM

N. Effect of a lowconcentration EDTA solution on root
canal walls: a scanning

electron microscopic study.

Oral Surg Oral Med Oral
Pathol Oral Radiol Endod
o
25. White JD, Lacefield WR,
Chavers LS, Eleazer PD.
The effect of three commonly used endodontic
materials on the strength
and hardness of root dentin.
+
&OEPE
o
26. Meyenberg KH. Nonvital
teeth and porcelain laminate veneers a contradiction? Eur J Esthet Dent
2006;1:192206.
27. Vieira C, Silva-Sousa YT,
Pessarello NM, Rached-Junior FA, Souza-Gabriel AE.
Effect of high-concentrated
bleaching agents on the
bond strength at dentin/
resin interface and flexural
TUSFOHUI
PG
EFOUJO
#SB[
%FOU

+
o
28. de Oliveira DP, Teixeira
EC, Ferraz CC, Teixeira
'#
&GGFDU
PG
JOUSBDPSPOBM

bleaching agents on dentin
microhardness. J Endod
o
29. Maleknejad F, Ameri H,
Kianfar I. Effect of intracoronal bleaching agents on
ultrastructure and mineral
content of dentin. J Conserv
%FOU
o


"UUJO
5
)BOOJH
$
8JFHBOE

A, Attin R. Effect of bleaching on restorative materials
and restorations a systematic review. Dent Mater
o


,IPSPVTIJ
.
'FJ[
"

Khodamoradi R. Fracture
resistance of endodontically-treated teeth: effect of
combination bleaching and
an antioxidant. Oper Dent
o


,JNZBJ
4
7BMJ[BEFI
)


Comparison of the effect of
hydrogel and a solution of
sodium ascorbate on dentincomposite bond strength
after bleaching. J Contemp
Dent Pract 2008;1;9:105
112.

266
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
70-6.&

t
/6.#&3

t
46..&3




4PV[B(BCSJFM
"&
7JUVTTJ

LO, Milani C, Alfredo E,
Messias DC, Silva-Sousa YT.
Effect of bleaching protocols
XJUI

IZESPHFO
QFSPYJEF

and post-bleaching times on
EFOUJO
CPOE
TUSFOHUI
#SB[

%FOU
+
o


5JNQBXBU
4
/JQBUUBNBOPO

C, Kijsamanmith K, Messer
HH. Effect of bleaching
agents on bonding to pulp
chamber dentin. Int Endod J
o


$BO,BSBCVMVU
%$
,BSBCVMVU
#
*OGMVFODF
PG
BDUJvated bleaching on various
adhesive restorative systems. J Esthet Restor Dent
o


%JFUTDIJ
%
%VD
0
,SFKDJ

*
4BEBO
"
#JPNFDIBOJcal considerations for the
restoration of endodontically
treated teeth: a systematic
review of the literature, Part
II (Evaluation of fatigue
behavior, interfaces, and in
WJWP
TUVEJFT

2VJOUFTTFODF

*OU
o


"CCPUU
1
)FBI
4:

*OUFSOBM

bleaching of teeth: an analysis of 255 teeth. Aust Dent J.
o


"NBUP
.
4DBSBWJMMJ
.4

Farella M, Riccitiello F.
#MFBDIJOH
UFFUI
USFBUFE

endodontically: long-term
evaluation of a case series.
+
&OEPE
o


"CPV3BTT
.

-POHUFSN

prognosis of intentional
endodontics and internal
bleaching of tetracyclinestained teeth. Compend Contin Educ Dent
o


'SJFENBO
4
*OUFSOBM
CMFBDIing: long-term outcomes
and complications. J Am
Dent Assoc 1997;128
Suppl:51S55S.


(MPDLOFS
,
)VMMB
)
&CFMeseder K, Stdtler P. Fiveyear follow-up of internal
CMFBDIJOH
#SB[
%FOU
+

1999;10:105110.

MEYENBERG
.&:&/#&3(



)PMNTUSVQ
(
1BMN
".

Lambjerg-Hansen H.
#MFBDIJOH
PG
EJTDPMPSFE

root canal treated teeth.

BOE
ZFBS
QPTUPQFSBUJWF

results. Tandlaegebladet
o


.D-FBO
+8

5IF
4DJFODF

and Art of Dental CeramJDT
$IJDBHP
2VJOUFTTFODF

Publishing, 1979.


.FZFOCFSH
,
%FOUBM

esthetics a European
perspective. J Esthet Dent
o


(FMMFS
8
%BSL
BOE
TIBEowed zones: an important
aspect of the creative shadJOH
UFDIOJRVF
2VJOUFTTFODF

%FOU
5FDI
o


(FMMFS
8
8FDITFMXJSLVOH

von Licht und Schatten. In:
3BMG
4VDLFSU
FE

'VOLtionelle Frontzahn-Aesthetik.
Mnchen: Neuer Merkur
7FSMBH o


(PPEBDSF
$+
7BO
3PFLFM

/#
%ZLFNB
38
6MMNBOO

3#
5IF
DPMMBSMFTT
NFUBM
ceramic crown. J Prosthet
%FOU
o


(FMMFS
8
,XJBULPXTLJ
4+


The Willis glas crown: a
new solution in the dark and
shadowed zones of esthetic
porcelain restorations.
2VJOUFTTFODF
%FOU
5FDIOPM

o


.BHOF
1
%PVHMBT
8)


Additive contour of porcelain veneers: a key element
in enamel preservation,
adhesion, and esthetics for
aging dentition. J Adhes
Dent 1999;1:8192.


.BHOF
1
#FMTFS
6
#POEFE

Porcelain Restorations in the
"OUFSJPS
%FOUJUJPO
"
#JPNJNFUJD
"QQSPBDI
#FSMJO

2VJOUFTTFO[

51. Magne P, Magne M. Treatment of extended anterior
crown fractures using Type
IIIA bonded porcelain restorations. J Calif Dent Assoc
o
52. Setien VJ, Roshan S, Nelson
PW. Clinical management of
discolored teeth. Gen Dent
o



'SBEFBOJ
.
"RVJMBOP
"

#BSEVDDJ
(
"FTUIFUJD

restoration of endodontically treated teeth. Pract
Periodontics Aesthet Dent
1999;11:761768.


'SBEFBOJ
.
3FEFNBHOJ
.


An 11-year clinical evaluation of leucite-reinforced
glass-ceramic crowns: a
SFUSPTQFDUJWF
TUVEZ
2VJOUFTTFODF
*OU
o
55. Gehrt M, Wolfart S, Rafai N,
Reich S, Edelhoff D. Clinical
results of lithium-disilicate
crowns after up to 9 years
of service. Clin Oral Investig
o


&EFMIPGG
%
#SJY
0
"MM
ceramic restorations in
different indications: a case
series. J Am Dent Assoc.

4VQQM
4o4
57. Fabbri G, Mancini R,
.BSJOFMMJ
7
#BO
(

"OUFSJPS

discolored teeth restored
with procera all-ceramic restorations: a clinical evaluation of the esthetic outcome
based on the thickness of
the core selected. Eur J
Esthet Dent 2011;6:7686.
58. Volpato CA, Monteiro S Jr,
de Andrada MC, Fredel MC,
Petter CO. Optical influence
of the type of illuminant,
substrates and thickness
of ceramic materials. Dent
.BUFS
o


5PVBUJ
#
1SFQBSBUJPO
PS

excessive reduction. Pract
Proced Aesthet Dent




#FJFS
64
,BQGFSFS
*

#VSUTDIFS
%
%VNGBISU
)


Clinical performance of porcelain laminate veneers for
up to 20 years. Int J Prosthodont 2012;25:7985.
61. Guess PC, Stappert CF.
Midterm results of a 5-year
prospective clinical investigation of extended ceramic
veneers. Dent Mater.
o
62. Lthy H, Schrer P, Gauckler L. New materials in
dentistry: zirconia posts.
Abstract IV-2 of The Monte
7FSJU
$POGFSFODF
PO
#JP-

compatible Materials SysUFNT
#.4

0DUPCFS
o




.FZFOCFSH
,)
-UIZ
)

Schrer P. Zirconia posts: a
new all-ceramic concept for
nonvital abutment teeth. J
&TUIFU
%FOU
o


%VSFU
#
3FZOBVE
.
%VSFU

F. New concept of coronoradicular reconstruction: the
Composipost [in French].
$IJS
%FOU
'S
o

65. Sailer I, Thoma A, Khraisat
A, Jung RE, Hmmerle CH.
Influence of white and gray
endodontic posts on color
changes of tooth roots, composite cores, and all-ceramJD
DSPXOT
2VJOUFTTFODF
*OU

o
66. Paul SJ, Schrer P. Post
and core reconstruction for
fixed prosthodontic restoration. Pract Periodontics AesUIFU
%FOU
o
67. Vichi A, Ferrari M, Davidson
CL. Influence of ceramic
and cement thickness on
the masking of various types
of opaque posts. J Prosthet
%FOU
o
68. Carossa S, Lombardo S,
Pera P, Corsalini M, Rastello
ML, Preti PG. Influence of
posts and cores on light
transmission through different all-ceramic crowns:
spectrophotometric and
clinical evaluation. Int J
1SPTUIPEPOU
o
69. Jung RE, Sailer I, Hmmerle
CH, Attin T, Schmidlin P. In
vitro color changes of soft
tissues caused by restorative materials. Int J Periodontics Restorative Dent
2007; 27:251257.
70. Jung RE, Holderegger C,
Sailer I, Khraisat A, Suter
A, Hmmerle CH. The
effect of all-ceramic and
porcelain-fused-to-metal
restorations on marginal
peri-implant soft tissue
color: a randomized controlled clinical trial. Int J
Periodontics Restorative
%FOU
o

267
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
70-6.&

t
/6.#&3

t
46..&3


SCIENTIFIC SESSION

71. Bressan E, Paniz G, Lops

D, Corazza B, Romeo E,
Favero G. Inuence of abutment material on the gingival color of implant-supported all-ceramic restorations:
a prospective multicenter
study. Clin Oral Implants
Res 2011;22:631637.
72. Langer B, Langer L. Subepithelial connective tissue
graft technique for root
coverage. J Periodontol
1985;56:715720.
73. Raetzke PB. Covering localized areas of root exposure
employing the envelope
technique. J Periodontol
1985;56:397402.
74. Burkhardt R, Lang NP. Coverage of localized gingival
recessions: comparison of
micro- and macrosurgical
techniques. J Clin Periodontol 2005;32:287293.
75. Burkhardt R, Hrzeler MB.
Utilization of the surgical
microscope for advanced
plastic periodontal surgery.
Pract Periodontics Aesthet
Dent 2000;12:171180.

76. Allen EP, Winter RR. Interdisciplinary treatment of

cervical lesions. Compend
Contin Educ Dent 2011;32
Spec No 5:1620.
77. Ricci G, Ricci A, Ricci C.
Save the natural tooth or
place an implant? Three
periodontal decisional
criteria to perform a correct therapy. Int J Periodontics Restorative Dent
2011;31:2937.
78. Bernstein SD, Horowitz AJ,
Man M, Wu H, Foran D,
Vena DA, Collie D, Matthews
AG, Curro FA, Thompson
VP, Craig RG. Outcomes
of endodontic therapy in
general practice: A study by
the Practitioners Engaged
in Applied Research and
Learning Network. J Am
Dent Assoc 2012;143:478
487.
79. Wu MK, Shemesh H, Wesselink PR. Limitations of
previously published systematic reviews evaluating
the outcome of endodontic treatment. Int Endod J
2009;42:656666.

268
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
70-6.&

t
/6.#&3

t
46..&3


80. Imura N, Pinheiro ET, Gomes

BP, Zaia AA, Ferraz CC,
Souza-Filho FJ. The outcome of endodontic treatment: a retrospective study
of 2000 cases performed
by a specialist. J Endod
2007;33:12781282.
81. Balto K. Root-lled teeth
with adequate restorations and root canal treatment have better treatment
outcomes. Evid Based Dent
2011;12:7273.
82. Naito T. Surgical or nonsurgical treatment for teeth with
existing root lings? Evid
Based Dent 2010;11:5455.
83. Torabinejad M, Anderson
P, Bader J, Brown LJ, Chen
LH, Goodacre CJ, Kattadiyil
MT, Kutsenko D, Lozada J,
Patel R, Petersen F, Puterman I, White SN. Outcomes
of root canal treatment and
restoration, implant-supported single crowns, xed
partial dentures, and extraction without replacement: a
systematic review. J Prosthet Dent 2007;98:285311.