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

Restoring endodontically treated teeth

with posts and cores—A review
Ingrid Peroz, Dr Med Dent1/Felix Blankenstein, Dr Med Dent1/
Klaus-Peter Lange, Prof Dr Med Dent2/Michael Naumann, Dr Med Dent3

Objective: The prognosis of endodontically treated teeth depends not only on the suc-
cess of the endodontic treatment, but also on the type of reconstruction. These considera-
tions include the decision of whether or not to use posts. Methods and materials: A liter-
ature review has been performed to create guidelines for the reconstruction of endodonti-
cally treated teeth by posts and cores. Results: Posts should only be used for the reten-
tion of core material in cases where little dental substance remains, ie, one or no cavity
walls. A ferrule of 2 mm has to be provided, by surgical means if necessary. The post
length is limited by the necessary apical seal of 4 to 6 mm. In cases of short posts, adhe-
sive fixation is preferred. Ceramic posts show a higher risk of fracture than fiber posts
which are retrievable. Composites have proven to be a good core material. Posts should
be inserted if endodontically treated teeth are used as abutments for removable partial
dentures. Conclusion: These guidelines are based mainly on in vitro studies with an evi-
dence level of II a or II b, as there is a lack of randomized clinical studies available. The
remaining tooth structure is an important factor influencing the indication of posts and
cores, yet it is not sufficiently recognized in clinical studies and in vitro. Therefore, further
prospective clinical studies are needed. (Quintessence Int 2005;36:737–746)

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

The prognosis of endodontically treated into periradicular areas by prompt placement

teeth depends not only on the treatment
itself, but also on sealing the canal and mini-
mizing the leakage of oral fluids and bacteria
1
Associate Professor, Humboldt University of Berlin, Dental
School, Department of Prosthetic Dentistry and Oral
Gerontology, Berlin, Germany.
2«
Professor, Humboldt University of Berlin, Dental School,
«Department of Prosthetic Dentistry and Oral Gerontology,
«Berlin, Germany.
3«
Assistant Professor, Humboldt University of Berlin, Dental
«School, Department of Prosthetic Dentistry and Oral
«Gerontology, Berlin, Germany.
Reprint requests: Dr Ingrid Peroz, Zentrum für Zahnmedizin,
Abteilung für Zahnärztliche Prothetik und Alterszahn-
medizin, Augustenburger Platz 1, 13353 Berlin, Germany.
E-mail: ingrid.peroz@charite.de
of coronal restorations.1 This treatment
includes the decision of whether or not posts
should be used. After many years of scientif-
ic work involving post material, post geome-
try, post length, core material, and other con-
siderations, the indication for posts is re-
emerging as a topic of discussion. A change
of paradigm has occurred based on the
advantages of adhesive restorations, which
seem to make post insertion unnecessary.
In addition to this development, evidence-
based treatment is becoming increasingly
important in dentistry. Treatment decisions
and strategies should be based on the best
and most-up-to-date factual evidence avail-
able. Evidence-based dentistry is influencing

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Q U I N T E S S E N C E I N T E R N AT I O N A L
Peroz et al
Ta b l e 1 Level of evidence due to
study design
Evidence level Study design
I a (high) Meta-analysis of randomized,
controlled trials
Ib Single randomized, controlled trial
II a Controlled study without
randomization
II b Experimental study
III Descriptive study
IV Estimation of experts
the evaluation and adaptation of many treat-
ment methods that have been commonplace
until now. Based on the design of the stud-
ies, investigators categorized these treat-
ments into different groups, depending on
the level of evidence available (Table 1).
Although these levels of evidence depend on
clinical trials only, they were also used to
characterize in vitro studies.
The aim of this study was to create guide-
lines for the reconstruction of endodontically
treated teeth by posts and cores based on a
review of the literature, and to assign citations
to their levels of evidence.
METHODS AND MATERIALS
The literature search was done using the
Grateful Med Interface for Medline
(www.cbi.nlm.nih.gov), the Cochrane library
(www.cochrane.org), and by manual search-
es of the German journal Deutsche
Zahnärztliche Zeitschrift published the last
10 years. Due to language limitations, only
German or English literature was reviewed.
Because the online searching process
could not find meta-analysis of randomized
clinical trials or single randomized trials, liter-
ature was searched using key words: dental
AND endodontically treated teeth AND other
key words (see Table 2).
The referenced articles were gathered
according to subheadings relevant to treat-
ment decisions concerning endodontically
treated teeth.
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738
RESULTS
Indications for using posts
In an in vitro study with matched teeth pairs
(split-mouth design), Sedgley and Messer2
were able to show that vital dentin is harder
than dentin from contralateral endodontically
treated teeth, but there was no significant
biomechanical change that would indicate
that the endodontically treated teeth had
become more brittle (in vitro, level of evi-
dence II b). This result is supported by anoth-
er matched teeth pairs study by Papa et al,3
which shows that there is no significant dif-
ference in the moisture content between
endodontically treated teeth and vital teeth.
It appears that the remaining amount of
tooth hard tissue influences stability, rather
than the factors listed above. Whereas the
preparation of a pulpal access only reduces
structural stability by about 5%, loss of the
circumferential integrity by mesio-occlusodis-
tal (MOD) cavities reduces the stability by
about 63%.4 Panitvisai and Messer5 have
shown that the cuspal deflection increases
with increasing cavity size, and is greatest fol-
lowing endodontic access. The importance
of the marginal ridge for the structural stabili-
ty of teeth was also shown by Strand et al.6
The use of posts, however, does not
increase the fracture resistance significantly.
This was shown in several comparative in
vitro studies (level of evidence II b).7–10
Posts are used to provide retention for the
core material, so the indication for post inser-
tion depends on the dental substance and
extent of either destruction or viable structure
seen in the teeth being considered for endo-
dontic treatment. The amount of remaining
tooth structure necessary to warrant post
insertion, or a decision to use other methods,
is not clearly defined. It is, however, based on
reviews or personal clinical experience (inter-
nal evidence) with a level of evidence no bet-
ter than IV (review, IV).11 There is a general
lack of systematic approaches in literature
published on this matter.
For this reason, an attempt was made to
formulate a more detailed description for the
amount of remaining dental tissue because
the extent of destruction cannot be evaluated
metrically. This classification describes 5
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Q U I N T E S S E N C E I N T E R N AT I O N A L
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Ta b l e 2 Number of references found using study designs and key words

AND
endodontically AND AND AND
treated AND OR AND AND AND ferrule fiber metal AND
Study type teeth post core diameter length abutment effect post post cementation

Meta-analysis of RCT 0 0 0 0 0 0 0 0 0 0
RCT 0 0 0 0 0 0 0 0 0 0
Controlled clinical trial 0 0 0 0 0 0 0 0 0 0
Prospective study 6 1 1 0 0 0 0 1 1 1
Follow-up study 35 10 (4)* 10 (4)* 0 0 0 0 3 2 (1)* 1
Longitudinal study 50 13 13 0 0 0 0 4 3 2
Cohort study 51 13 13 0 0 0 0 4 3 2
Clinical trial 1 0 0 0 0 0 0 0 0 0
Comparative study 125 61 59 2 6 1 1 9 27 11
* Upon reading abstracts of these studies, many had to be eliminated. Only those in parentheses are valid.

classes, depending on the number of remain- assigned to evidence level II b, depending on

ing axial cavity walls.12 Class I describes the
access preparation with all 4 axial cavity walls
remaining. Class II describes loss of 1 cavity
wall, commonly known as the mesio-occlusal
(MO) or the disto-occlusal (DO) cavity. Class
III represents an MOD cavity with 2 remaining
cavity walls. Class IV describes 1 remaining
cavity wall, in most cases the buccal or oral
wall, and Class V describes a decoronated
tooth with no cavity wall remaining.
The minimal thickness of the cavity wall as
a determining factor for the resistance to func-
tional loads of the crown-root complex is con-
sidered 1 mm. Hard tissue with thicknesses
below this level cannot be prepared for crowns
without the loss of all remaining substance,
leaving no dental tissue. A thickness greater
than 1 mm provides an amount of hard tissue
sufficient to stabilize the core material even
after crown preparation. Therefore, a cavity
wall with less than 1 mm thickness cannot be
taken into consideration.13
The minimal height of a cavity wall capa-
ble of providing a sufficient ferrule effect is
2 mm. This aspect is described in further
detail below.
Class I: 4 remaining cavity walls
(access cavity)
If all the axial walls of the cavity remain and
have a thickness greater than 1 mm, it is not
necessary to insert posts (Fig 1). In these
cases, any type of definitive restoration can
be considered. This judgment is based on
several in vitro studies, which can be
their comparable study design.7,10,14
Classes II and III: 2 or 3 remaining
cavity walls
Treatment in cases involving the loss of 1 or
2 cavity walls does not necessarily require
the insertion of a post, as the remaining hard
tissue provides enough surface for the use of
other methods, in particular, for cores using
adhesive systems (Fig 1). An in vitro study by
Steele and Johnson15 showed that compos-
ites or amalgam restorations with 3 surfaces
(MOD), increase fracture resistance. There
was no significant difference between the
experimental groups, which included unal-
tered teeth or those with access only15 (in
vitro, II b). The comparison between different
adhesive systems for the reconstruction of
root canal-treated premolars with MOD cavi-
ties have shown that dentin-bonding systems
stabilize teeth particularly well, such that their
fracture resistance was comparable to intact
teeth16 (in vitro, II b). Furthermore, anterior
teeth with proximal cavities do not benefit
from post insertion17 (in vitro, II b).
Two clinical studies assigned to evidence
level III, (due to retrospective methods), show
that teeth with extensive MOD cavities with-
out reconstruction and with crowns have a
higher risk.18 Anterior teeth do not seem to
benefit from restoration with crowns.19
Class IV: 1 remaining cavity wall
In cases where only 1 cavity wall remains, the
core material has little or no effect on the frac-

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Q U I N T E S S E N C E I N T E R N AT I O N A L
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Class I– III Class IV

Two to 4 One cavity
cavity walls wall remaining
remaining

Post No Post Fiber Fiber/metal

Core Adhesive Core Adhesive Adhesive/cast
Definitive restoration Any Definitive Crown Onlay/crown
restoration

Fig 1 No post is needed in cases with at least 2 axial cavity walls remain-
ing. A thickness of the cavity wall
1 mm and a height of
2 mm are pre-
conditions. If these conditions cannot be fulfilled, the cavity wall must be
considered as missing.
Fig 2 A post should be inserted if only 1 cavity wall is
remaining. Fiber posts are preferable in anterior teeth, but in
posterior teeth, fiber or metal posts can be used. The core can
be made of composite or as a cast post and core. The defini-
tive restorations should be crowns in anterior teeth and
crowns, onlays, or overlays in posterior teeth.

Class V: No remaining cavity wall

Class V
No cavity walls
remaining
Post
Fiber/metal
Core Adhesive/cast
Definitive restoration Crown
Fig 3 A post must be inserted if there is no cavity wall remaining. A ferrule
of 2 mm is needed to provide a lower risk of root fracture.
ture resistance of the endodontically treated
teeth20 (in vitro, II b). If the tooth has to be
used as an abutment for fixed or removable
partial dentures, crown preparation will fur-
ther decrease fracture resistance.21 There-
fore, the present concept suggests using
posts in such cases of reduced remaining
tooth structure. For esthetic reasons, non-
metal posts are preferred for treatment of
anterior teeth. In posterior teeth, both metal
posts and nonmetal posts are acceptable
treatment options (Fig 2).
In cases of teeth with a high degree of
destruction where no cavity wall remains, the
insertion of posts appears necessary to pro-
vide for core material retention (Fig 3).
Additionally, the ferrule effect has a great
influence on fracture resistance, especially in
decoronated teeth. A ferrule, defined as a cir-
cumferential area of axial dentin superior to
the preparation bevel, should have a height
of 1.5 to 2.5 mm.22–24 Various in vitro studies
with evidence level II b have shown that frac-
ture resistance can be significantly increased
by the use of a ferrule; the post length or
design (whether they are parallel-sided or
tapered) are of secondary importance for
fracture resistance if a sufficient ferrule can
be provided.22–24
If deep destruction of the teeth renders a
sufficient ferrule impossible, a surgical crown
lengthening can be performed. This provides
a crown ferrule resulting in a reduction of
static load failure25 (in vitro II b). Bolhuis et
al26 postulated that the crown ferrule is more
important than a post and core, or a core
reconstruction with adhesive fillings only.
The researchers examined decoronated,
root-treated premolars. These were rebuilt by
core build-up without an endodontic post or
by core build-up with an endodontic post (a
cast post and core, and a composite with a

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740 VOLUME 36 • NUMBER 9 • OCTOBER 2005
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silica post), and an additional group was not
provided with a core at all. No significant dif-
ference in fracture strength among the differ-
ent groups could be demonstrated.26
Several criteria must be taken into account
with respect to the indication for post inser-
tion. These criteria will be presented later.
Post length
Reviews of evidence presented in level IV
studies state that the post length should
reach two-thirds of the entire root length. A
crown-length/post-length ratio of at least 1:1
should be provided.11,27.
Post length influences the stress load
along the root. Whereas the enlargement of
the canal increases cervical stress, post
placement will decrease stress in this region.
Short, wide posts lead to elevated stress con-
centrations in the cervical region. Post place-
ment beyond two-thirds of root depth does
not further decrease cervical stress, but
tends to increase stress in the apical region28
(in vitro, II b).
The selection of post length, however,
depends on many criteria. It has been shown
that the post length is less important for fracture
resistance than the ferrule effect23 (in vitro, II b).
The type of fixation used for posts also
has an influence on the required length of
the post. Nissan et al29 were able to show that
adhesive fixation can compensate for
reduced retention due to the use of a shorter
parallel-sided or tapered post29 (in vitro, II b).
Testori et al18 demonstrated there is no sig-
nificant difference in the retention of adhe-
sive fixed posts 5 mm or 8 mm in length (clin-
ical trial and review, III). These results, how-
ever, are less because they were ascertained
with a very limited number of samples.
Whereas the studies cited above paid
special attention to the correlation between
post length and post retention, other studies
tended to evaluate the remaining root filling
after post-space preparation, especially with
respect to leakage. It was shown that leak-
age increases with post-space preparation,
and a remaining apical filling of less than 3
mm results in an unpredictable seal.30,31 Post
insertion and adhesive fixation can compen-
sate for this leakage. Nevertheless, the need
for a remaining apical root filling of 4 to 6
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Q U I N T E S S E N C E I N T E R N AT I O N A L
Peroz et al
mm was also found.30,31 Considering the
need for both a sufficient ferrule effect and
the remaining apical sealing, the postulated
post length of two-thirds of the root length
may be impossible in many clinical situa-
tions. As previously stated, shorter posts
should be fixed with luting composite.29
Post diameter
There is little evidence (level IV) for an opti-
mal post diameter. A diameter of one-third of
the root diameter is postulated in many
reviews. A minimal dentin thickness of 1 mm
around the post should be provided.11,32 Due
to the stability of the post itself, Lambjerg-
Hansen and Asmussen33 postulated a post
diameter of at least 1.3 mm. In the present
study, a diameter of ISO 90 or 1.25 mm,
respectively, is proposed.
Post fixation
Adhesive systems seem to be able to stabi-
lize the tooth. Reeh et al4 have shown that
composite restorations with dentin enamel
etching provide a stability similar to that of
the intact tooth (in vitro, controlled trial: II b).
The use of composite in the entrance of the
root canal stabilizes the root-filled tooth,
whereas an additional post is unable to con-
tribute further stabilization.34 Paul and
Schärer11 state in their review that the adhe-
sive fixation of a post and core may stabilize
the tooth. It was demonstrated in several in
vitro studies with an evidence level of II b, that
roots in which the posts were adhesively
cemented were significantly more fracture
resistant than those using zinc phosphate
cement35,36 (in vitro II b). Based upon this evi-
dence, the present study recommends adhe-
sive fixation for any kind of post.
Post design
Post design also influences the success of
the restoration. Torbjoner et al37 published a
prospective study with an evidence level of II
a, comparing failure rates and failure charac-
teristics of tapered and parallel-sided posts.
They found the cumulative failure rate of
tapered posts was 15% higher than the fail-
ure rate for parallel-sided posts (8%). Loss of
retention was listed as the most frequent rea-
son for failure for both types of posts.37
741
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Parallel-sided posts and those surround-
ed by large amounts of cement had lower
fracture rates than tapered posts or tapered
posts with maximal adaptation in the root
canal.38 Further studies also show that the
post design has to be considered in combi-
nation with other aspects of posts. In this
regard, the ferrule effect seems to be more
important for fracture resistance than the
post design.22 Adhesive fixation of posts is
also more relevant for post retention than the
post design itself11,29 (review, IV; in vitro, II b)
(review, IV).
Post material/core material
Due to the biomaterial aspects in cases
where metal posts are used, the definitive
restoration should be made with either the
same or analog alloys. The present study
suggests cast-on posts and cores made of a
gold Au-alloy, a cobalt-based alloy, or titani-
um. This suggestion is based on internal evi-
dence only (evidence level IV).
Screws should not be used, as a higher
incidence of root fractures lowers their sur-
vival rate significantly39,40 (retrospective clini-
cal trial, III; meta-analysis over clinical trials, II
a). Fiber posts tested by in vitro studies show
a great variability in fracture resistance when
compared to metal posts or ceramic posts.
Cormier et al41 identified fiber posts as having
the lowest fracture resistance, whereas
Akkayan and Gulmez42 found comparable
fracture resistance values between zirconium
oxide and fiber posts. In cases of fractures,
the fiber posts produced more restorable
fractures than other post materials (in vitro, II
b).41–43 Taking into account that in vitro tests
involve higher fracture loads than those
occurring during mastication, fiber posts pro-
vide sufficient fracture thresholds.
In an in vitro study (evidence level II b)
performed on structurally weakened central
incisors with thin cavity walls of 0.5 to
0.75 mm, Saupe et al44 demonstrated that
the resistance to a simulated masticatory
load of a fiber post and core system was sig-
nificantly greater than that of a morphologic
post and core procedure. Under these con-
ditions, a ferrule provides no additional ben-
efit with respect to retention and fracture
resistance.
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742 VOLUME 36
If fiber posts are used, they should be
fixed by adhesive material. Vichi et al45
described the types of adhesive structures
between the resin cement and dentin (in
vivo, III). Ferrari et al46 were able to show, by
microscopic examinations, that Excite dual-
cured bonding agent produced a resin-
dentin interdiffusion zone higher than that
seen in samples with Excite light-cured bond-
ing agent or a one-step bonding system (in
vitro, II b).
The biomaterial disadvantages of fiber
posts, which are based on decreased 3-point
bending test values due to the water storage
of these posts, can be avoided by adhesive
fixation because they were isolated to saliva47
(in vitro, II b).
Ceramic posts show survival rates and
fracture strength comparable to cast posts
and cores48 (in vitro, II b). Zirconia posts and
ceramic cores, as well as chair-side proce-
dures with zirconia posts with composite
cores, are recommended49 (in vitro, II b).
Comparisons of fiber and ceramic posts
show a higher risk of fracture with ceramic
posts due to cracks within the posts50,51, (in
vitro, II b). Fiber posts show an additional
advantage in that they are readily retrievable
after failure.52 The results of a retrospective in
vivo study (evidence level III) indicate that
fiber posts are superior to the conventional
cast post and core systems after 4 years of
clinical service.53
The use of metal posts is justified by stud-
ies showing that the fracture resistance of
teeth restored by metal posts is superior to
other systems.54 The morphologic cast post
and core systems appear to be of secondary
importance compared to direct metal posts
and composite cores. Direct posts and cores
comprised 70% of the cases in root fractures
after loading and 30% of the core fractures.
The cast posts involved the root of all cases
of fracture.43
Surfaces of metal posts should be rough
to provide the best retention in the root
canal55–60 (in vitro studies, II b). Metal posts
can be cemented by zinc phosphate cement
or by adhesive resin systems. Because adhe-
sive cementation results not only in lower
microleakage, but also in higher retention, it
is preferred.61.62
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The comparison between cast and direct
post-and-core systems revealed no signifi-
cant differences that would justify recom-
mending the use of one over the other.63 This
statement is based on one of the rare meta-
analyses made by a systematic review of in
vitro and in vivo studies.64 However, due to
the lack of randomized, controlled studies,
the assigned evidence level is II a.
Direct posts and cores should use (inde-
pendent of the post material) composites as
core material. After amalgam, composites
show both the lowest defect and failure rates,
and the best fracture resistance (evidence
level IIb to IV).49,65–70
Definitive restoration
The indication for post insertion depends not
only on the amount of remaining tooth struc-
ture but also on the planned prosthetic
reconstruction. The prognosis of an endo-
dontically treated tooth is best if in a com-
plete dental arch because of stabilizing
mesial and distal proximal contacts.71
Sorensen and Martinoff72 demonstrated
in their clinical, retrospective study (evidence
level III) that post insertion brings no advan-
tage to the survival rate of an endodontically
treated tooth if it is restored by a crown or
fixed partial denture. However, in cases
where such a tooth is needed as an abut-
ment for removable partial dentures, the post
insertion has a significant positive effect for
treatment success.72 Nevertheless, a tooth
treated by root canal within a removable par-
tial denture poses a higher risk for treatment
failure72,73 (in vivo studies, evidence level III).
Testori et al18 have shown that the pain
threshold of an endodontically treated tooth
used as a distal abutment is twice as high as
that of a vital tooth
These results influenced the present
study, in which endodontically treated teeth
were not included as abutment teeth for tele-
scopes apart from cases in which all cavity
walls remain. If a tooth treated with a root
canal has to be included as an abutment
tooth for cantilever fixed partial dentures or
as the distal abutment of fixed partial den-
tures, or combined with a removable partial
denture, the patient must be informed about
the higher risk of failure.
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DISCUSSION
The present concept for the restoration of
endodontically treated teeth by posts and
cores aims to draw its guidelines from the
evidence present in recent literature. The
cited literature is assigned a level of evidence
showing the reliability of the sources upon
which decisions are based.
The review of the literature shows that
there is a lack of in vitro, and especially, clin-
ical studies, correlating the amount of
remaining tooth structure to the indication for
posts. As such, it would be worthwhile to
examine whether it is possible or recom-
mendable not to use posts even for teeth
with no remaining cavity walls. The limited
number of prospective clinical studies is
notable. Therefore, a prospective clinical
study documenting cases meeting specific
criteria (tooth within a complete dental arch,
single tooth restoration, retention by remain-
ing pulp chamber) in which posts are not
used, is necessary.
There is also a lack of prospective clinical
studies in which the amount of remaining
tooth structure is documented and the sur-
vival rate of several post materials is tested.
The remaining tooth structure should be
evaluated by a designed index system.74
CONCLUSIONS
The literature review reveals:
1. There is a lack of prospective clinical stud-
ies with well-documented inclusion crite-
ria for endodontically treated teeth,
remaining coronal hard tissue, and flaring.
2. The 2-mm ferrule has a very important
role for the survival rate of endodontically
treated teeth that have been restored with
crowns.
3. Post length is limited by the necessary api-
cal seal of 4 to 6 mm. Remaining tooth
structure is more important than post
length in avoiding tooth fracture.
4. Adhesive fixation is preferable, as it pro-
duces a higher fracture resistance in com-
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parison to cemented posts and cores, as
well as offers a higher leakage resistance.
5. Composites are a good core material.
6. Posts should be inserted if endodontically
treated teeth are used as abutments for
removable partial dentures.
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Slutzky-Goldberg I. Endodontic failure caused by
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87:674–678.
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Prosthodontist
Department of Comprehensive Care
Case Western Reserve University School of
Dental Medicine Cleveland, OH

The Department of Comprehensive Care at Case

Case Western Reserve University is an
Western Reserve University School of Dental equal opportunity/affirmative action employer.
Medicine invites applications for a full-time tenure
track faculty position at the assistant/associate Applicants should send a curriculum vitae,
professor level. Responsibilities include didactic and and names of three references to:
clinical teaching and research. Participation in the
CWRU Dental Faculty practice is available. Avishai Sadan, DMD, Chairman
Candidates must have a DMD/DDS degree or equiv- Department of Comprehensive Care
alent, and advanced training in prosthodontics or Case Western Reserve University
equivalent. Research and clinical interest and/or School of Dental Medicine
experience in fixed and implant prosthodontics and 10900 Euclid Avenue
adhesive dentistry is desired. Salary and rank Cleveland, OH 44106-4905
commensurate with qualifications and experience.

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746 VOLUME 36 • NUMBER 9 • OCTOBER 2005