12 RESTORATION OF THE ENDODONTICALLY TREATED TOOTHmic PDF

12
RESTORATION
OF THE
ENDODONTICALLY
TREATED TOOTH
Two factors influence the choice of technique:

KEY TERMS the type of tooth (whether it is an incisor, canine,
canal shape post length premolar, or molar) and the amount of remaining
ferrule prefabricated posts coronal tooth structure. The latter is probably the
multipiece cast cores root most important indicator in determining the
post shape root diameter prognosis.
post removal stress distribution A number of different clinical techniques have
post type surface texture been proposed to solve these problems, and opinions
post and core vary about the most appropriate one. Experimental
data have improved the understanding of the diffi-
culties inherent in restoring endodontically treated
teeth. This chapter offers a rational and practical
approach to the challenge.
n endodontically treated tooth should have a
A good prognosis. It can resume full function

and serve satisfactorily as an abutment for a
fixed dental prosthesis (FDP) or a removable partial
TREATMENT PLANNING
Because of extensive caries or periodontal disease,
dental prosthesis. However, special techniques are removal of a tooth may be more sensible than
needed to restore such a tooth. Usually a consider- endodontically treating it, although a severely
able amount of tooth structure has been lost because damaged tooth occasionally can be restored after
of caries, endodontic treatment, and the placement orthodontic repositioning or root resection (Fig.
of previous restorations. The loss of tooth structure 12-1; see also Fig. 16-7). This should be done if loss
makes retention of subsequent restorations more of the tooth will significantly jeopardize the patient’s
problematic and increases the likelihood of fracture occlusal function or the total treatment plan, partic-
during functional loading. ularly if dental implants are not an option. When the
336
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Chapter 12 RESTORATION OF THE ENDODONTICALLY TREATED TOOTH 337
A B,C
D E,F
Fig. 12-1
A to D, A severely damaged tooth can sometimes be retained after orthodontic extrusion (see Chapter 6). E and F, Plaque control
around periodontally compromised teeth may be improved after hemisectioning (see Chapter 5). (E and F, Courtesy of Dr. H. Kahn.)
decision is made to treat the tooth endodontically,

consideration must have been given to its subse-
quent restoration. Before being restored, teeth that
have been endodontically treated must be carefully
evaluated for the following1:
• Good apical seal B
• No sensitivity to pressure A
• No exudate
• No fistula
• No apical sensitivity
• No active inflammation
Inadequate root fillings should be re-treated
before fixed prosthodontic treatment is begun. If
doubt remains, the tooth should be observed for
several months until there is definite evidence of
success or failure.
If the coronal structures are largely intact and
loading is favorable, as on anterior teeth that are C D
farther removed from the fulcrum (see Chapter 4), a
simple filling can be placed in the access cavity (Fig.
12-2A). However, if a substantial amount of coronal
structure is missing, a cast post and core is indi-
cated instead (Fig. 12-2B). Molars are often restored
with amalgam or a combination of one or more Fig. 12-2
cemented posts and amalgam or composite resin A, An anterior tooth with an intact clinical crown can be pre-
(Fig. 12-2C and D). dictably restored with a composite restoration in the access
Although one-piece post-crowns were once made, cavity. B, When most coronal tissue is missing, a cast post and
such prostheses are of only historical interest. Supe- core is indicated to obtain optimal tooth preparation form. C,
In mandibular molars, an amalgam foundation is retained by a
rior results are obtained with a two-step technique
cemented prefabricated post in the distal canal. D, In maxillary
(Fig. 12-3) consisting of initial placement of a post molars, the palatal canal is most often used.
and core foundation followed by placement of a
338 PART II CLINICAL PROCEDURES: SECTION 1
slightly larger to achieve optimal seating (see

Chapter 7). Thus, it is easier to achieve a satisfactory
marginal adaptation because the expansion rate of
the two castings can be controlled individually. An
added benefit is that it is possible to fabricate a
replacement crown, if necessary, without the need
for post removal, which may jeopardize the progno-
sis of the tooth. Finally, a path of placement different
from the one selected for the post and core may be
selected for the crown. This is often helpful when the
tooth is restored to serve as an abutment for an FDP.
Fig. 12-3 Clinical Failure

The first molar and second premolar have been restored with
post and cores. Note the margins, optimally located on sound Morphologic and functional differences between
tooth structure, cervical to the castings. anterior teeth and posterior teeth necessitate that
they be treated differently after endodontic therapy,
mainly because different loading considerations
apply.
In one retrospective analysis4 involving 638
patients, investigators evaluated 788 post and cores:
456 custom cast post and cores and 332 foundations
with ParaPosts. Four to five years after cementation,
reported failure rates in male patients were signifi-
cantly higher than in female patients, and failure
rates after age 60 were three times as high as failure
rates for younger patients. Maxillary failure rates
(15%) were three times as high as mandibular failure
rates (5%) and more prevalent in lateral incisors,
Fig. 12-4 canines, and premolars than in central incisors and
The second premolar has been restored with a cast post and molars. Failure rate under FDPs was significantly
core, before a metal-ceramic crown. (Courtesy of Dr. R. Webber.) lower than under single crowns. The latter finding
may have been caused by load reduction resulting
from bracing by the FDP. No correlation was appar-
separately fabricated crown. Most often a metal post ent between failure and reduced marginal height
is used, which provides the necessary retention for of the encasing bone. Custom cast post and cores
the core. The core replaces any lost coronal tooth exhibited slightly higher failure rates than did
structure, allowing optimal tooth preparation geom- amalgam foundations. This observation was also
etry to be achieved. Thus, the shape of the residual made by Sorensen and Martinoff.5 However,
coronal tooth structure, combined with the core, Torbjörner and colleagues4 suggested that custom
should result in an ideal shape for the preparation cast post and cores tend to be used more often in
(Fig. 12-4). teeth that already have considerably weakened root
Prefabricated metal, carbon fiber, ceramic, and structure. Thus, regardless of the technique selected
glass fiber posts are available. The last two options for subsequent restoration, the teeth themselves are
provide esthetic alternatives to metal posts.2,3 Typi- already more prone to failure. Distal cantilevers
cally, prefabricated posts are used in a two-step appear to contribute to post and core failure in
procedure: first the post is cemented, after which a endodontically treated abutment teeth that support
plastic core material such as composite resin, the cantilever.
amalgam, or glass ionomer is applied. After shaping Most of the failures just discussed are influenced
of the core and remaining tooth structure to optimal by load. In general, as loading increases, failure rates
crown preparation form, a crown is fabricated in the appear to increase concomitantly. Failure has been
conventional manner. shown to occur at lower loads as teeth are loaded less
A cast post and core needs to be slightly under- parallel to their long axes,6 which suggests that
sized compared with the canal to achieve optimal clinical failure occurs more readily under lateral
internal seating, whereas the crown needs to be loading.
In the planning of the restoration of endodonti-

Load
cally treated teeth, the practitioner must account for Post
A
the strength of the remaining tooth structure,
weighed carefully against the load to which the
restored tooth will be subjected. B
Considerations for Anterior Teeth

Endodontically treated anterior teeth do not always
need complete coverage by placement of a complete Post A
crown, except when plastic restorative materials Tension
have limited prognosis (e.g., if the tooth has large Neutral axis
proximal composite restorations and unsupported
tooth structure). Many otherwise intact teeth func- Compression
B
tion satisfactorily with a composite resin restoration.
Although it is commonly believed, it has not been Fig. 12-5
demonstrated experimentally that endodontically Experimental stress distributions in an endodontically treated
treated teeth are weaker or more brittle than vital tooth with a cemented post. When the tooth is loaded, the
teeth. Their moisture content, however, may be lingual surface (A) is in tension, and the facial surface (B) is in
reduced.7 Laboratory testing8 has actually revealed a compression. The centrally located cemented post lies in the
resistance to fracture similar between untreated and neutral axis (i.e., not in tension or compression). (Redrawn from
endodontically treated anterior teeth. Nevertheless, Guzy GE, Nicholls JI: In vitro comparison of intact endodontically treated teeth
with and without endo-post reinforcement. J Prosthet Dent 42:39, 1979.)
clinical fracture does occur, and attempts have been
made to strengthen the tooth by removing part of the
root canal filling and replacing it with a metal post.
In reality, placement of a post requires the removal Cemented posts may further limit or complicate
of additional tooth structure (Box 12-1), which is endodontic re-treatment options if these are neces-
likely to weaken the tooth. sary. In addition, if coronal destruction occurs, post
Cementing a post in an endodontically treated removal may be necessary to provide adequate
tooth is a fairly common clinical procedure, despite support for a future core.
the paucity of data to support its success. In fact, a For these reasons, a metal post is not recom-
laboratory study9 and two stress analyses10,11 have mended in anterior teeth that do not require
determined that no significant reinforcement complete coverage restorations. This view is sup-
results. This might be explained by the hypothesis ported by a retrospective study13 that did not show
that when the tooth is loaded, stresses are greatest at any improvement in prognosis for endodontically
the facial and lingual surfaces of the root and an treated anterior teeth restored with a post. In
internal post, being only minimally stressed, does another study, post placement did not influence the
not help prevent fracture (Fig. 12-5). Results of other position or angle of radicular fracture.14 A conflict-
studies, however, contradict this assumption.8,12 ing report however, suggests that endodontically
treated teeth not crowned after obturation were lost
six times more frequently than teeth that were
crowned after obturation.15
Box 12-1 Disadvantages to the Routine Use of Discoloration in the absence of significant tooth
a Cemented Post loss may be more effectively treated by bleaching16
than by the placement of a complete crown,
Placing the post requires an additional operative
although not all stained teeth can be bleached suc-
procedure.
cessfully. Resorption can be an unfortunate side
Preparing a tooth to accommodate the post entails
effect of nonvital bleaching.17 However, when loss of
removal of additional tooth structure.
coronal tooth structure is extensive or the tooth will
It may be difficult to restore the tooth later, when
be serving as an FDP or partial removable dental
a complete crown is needed, because the
prosthetic abutment, a complete crown becomes
cemented post may have failed to provide
mandatory. Retention and support then must be
adequate retention for the core material.
derived from within the canal, because a limited
The post can complicate or prevent future
amount of coronal dentin remains once the reduc-
endodontic re-treatment that may be necessary.
tion for complete coverage has been completed.
It takes some practice to

estimate remaining wall
thickness after preparation
for the future extracoronal
restoration.
A
B
Weak area
Fig. 12-6
Cross section through a central incisor. The dotted line indicates
the original tooth contour before preparation for a metal-
ceramic restoration. Even with minimum reduction for the
extracoronal restoration, the facial wall is weakened and would
not be able to support a prosthesis successfully. The sharp C
lingual wall complicates pattern fabrication.
Coupled with the loss of internal tooth structure

necessary for endodontic treatment, the remaining
walls become thin and fragile (Fig. 12-6), which Fig. 12-7
often necessitates their reduction in height. A, Mandibular premolar and hemisected molar restored with
cast post and cores. B, Waxed three-unit fixed dental prosthe-
sis (FDP). C, The FDP cemented in place. (Courtesy of Dr. F. Hsu.)
Considerations for Posterior Teeth
Posterior teeth are subject to greater loading than are
anterior teeth because of their closer proximity to restoration. However, when a metal-ceramic crown
the transverse horizontal axis. This, combined with is to be used, considerable tooth reduction is
their morphologic characteristics (having cusps that required, which results in further weakening of the
can be wedged apart), makes them more susceptible remaining tooth structure. In general, when signifi-
to fracture. Careful occlusal adjustment reduces cant coronal tooth loss has occurred, a cast post and
potentially damaging lateral forces during excursive core (Fig. 12-7) or an amalgam foundation restora-
movements. Nevertheless, endodontically treated tion is needed.
posterior tooth should receive cuspal coverage to
prevent biting forces from causing fracture. Possible PRINCIPLES OF TOOTH PREPARATION
exceptions are mandibular premolars and first
molars with intact marginal ridges and conservative Many of the principles of tooth preparation dis-
access cavities not subjected to excessive occlusal cussed in Chapter 7 apply equally to the preparation
forces (i.e., posterior disclusion in conjunction with of endodontically treated teeth, although certain
normal muscle activity). additional concepts must be understood in order to
Complete coverage is recommended on teeth avoid failure.
with a high risk of fracture. This is especially true for
maxillary premolars, which have been shown to Conservation of Tooth Structure
have fairly high failure rates if restored with two or
three surface amalgam restorations.18 Complete Preparation of the canal
coverage gives the best protection against fracture, In creating post space, great care must be used to
because the tooth is completely encircled by the remove only minimal tooth structure from the canal
• Apical seal
• Minimal enlargement
• Length
• Stop
• Antirotation
• Margin extension
A B C
2
Fig. 12-9
Use of a prefabricated post entails enlarging the canal one or
two file sizes to obtain a good fit at a predetermined depth.
A, Incorrect; the prefabricated post is too narrow. B, Incorrect;
the prefabricated post does not extend to the apical seal.
6
6 5
C, Correct; the prefabricated post is fitted by enlarging the
4 canal slightly.
Fig. 12-8
Faciolingual cross-section through a maxillary central incisor
prepared for a post and core. Six features of successful design
are identified: 1, adequate apical seal; 2, minimum canal rately and yet passively while ensuring strength and
enlargement (no undercuts remaining); 3, adequate post retention. Along the length of a tapered post space,
length; 4, positive horizontal stop (to minimize wedging); 5, ver- enlargement seldom needs to exceed what would
tical wall to prevent rotation (similar to a box); and 6, extension have been accomplished with one or two additional
of the final restoration margin onto sound tooth structure. file sizes beyond the largest size used for endodon-
tic treatment. Because of the more coronal position
of the post space, a much larger file must be used to
(Fig. 12-8). Excessive enlargement can perforate or accomplish this (Fig. 12-9).
weaken the root, which then may split during post
cementation or subsequent function. The thickness Preparation of coronal tissue
of the remaining dentin is the prime variable in Endodontically treated teeth often have lost much
fracture resistance of the root. Experimental impact coronal tooth structure as a result of caries, as a result
testing of teeth with cemented posts of different of previously placed restorations, or in preparation of
diameters7 showed that teeth with a thicker the endodontic access cavity. However, if a cast core
(1.8 mm) post fractured more easily than those with is to be used, further reduction is needed to accom-
a thinner (1.3 mm) one. modate a complete crown and to remove undercuts
Photoelastic stress analysis also has shown that from the chamber and internal walls. This may leave
internal stresses are reduced with thinner posts. The very little coronal dentin. Every effort should be
root can be compared to a ring. The strength of a ring made to save as much of the coronal tooth structure
is proportional to the difference between the fourth as possible, because this helps reduce stress concen-
powers of its internal and external radii. This implies trations at the gingival margin.21 The amount of
that the strength of a prepared root comes from remaining tooth structure is probably the most
its periphery, not from its interior, and so a post of important predictor of clinical success. If more than
reasonable size should not weaken the root signifi- 2 mm of coronal tooth structure remains, the post
cantly.19 Nevertheless, it is difficult to enlarge a root design probably has a limited role in the fracture
canal uniformly and to judge with accuracy how resistance of the restored tooth.22,23 The once
much tooth structure has been removed and how common clinical practice of routine coronal reduc-
thick the remaining dentin is. Most roots are nar- tion to the gingival level before post and core fabri-
rower mesiodistally than faciolingually and often cation is outmoded and should be avoided (Fig.
have proximal concavities that cannot be seen on a 12-10). Extension of the axial wall of the crown
standard periapical radiograph. Experimentally, apical to the missing tooth structure provides what
most root fractures originate from these concavities, is known as a restoration with a ferrule, which is
because the remaining dentin thickness is defined as a metal band or ring used to fit the root
minimal.20 Therefore, the root canal should be or crown of a tooth, as opposed to a crown that
enlarged only enough to enable the post to fit accu- merely encircles core material (Fig. 12-11). This is
R A
A B
Fig. 12-10 C
A, It is preferable to maintain as much coronal tooth structure
as possible, provided it is sound and of reasonable strength.
B, Extensive caries has resulted in the loss of all coronal tooth R B
structure. This is less desirable than the situation in A, because
greater forces are transmitted to the root.
C
R
Fig. 12-12
Effect of apical preparation on crown/root ratio. A, Schematic
of extensively damaged premolar tooth. Apical extension of the
A B gingival margin would encroach on the biologic width (Chapter
Fig. 12-11 5). This preparation has no ferrule. C, crown length; R, root
Extending a preparation apically creates a ferrule and helps pre- length. B, Creating a ferrule with orthodontic extrusion (see Fig.
vents fracture of an endodontically treated tooth during func- 6–21) reduces root length (R′), whereas crown length remains
tion. A, Preparation with a ferrule (arrows). B, Preparation unchanged. C, Surgical crown lengthening also reduces root
without a ferrule. length (R′) but increases crown length (C′). This results in a
much less favorable crown/root ratio, which may, in fact,
weaken the restoration. (Courtesy of Dr. A. G. Gegauff. From Gegauff AG:
thought to help bind the remaining tooth structure Effect of crown lengthening and ferrule placement on static load failure of
together, simultaneously preventing root fracture cemented cast post-cores and crowns, J Prosthet Dent 84:169, 2000.)
during function.24–26 Although there is evidence that
preserving as much coronal tooth structure as
possible enhances prognosis, it is less clear whether
the prognosis is improved by creation of a ferrule in root is effectively shortened, the crown is not length-
an extensively damaged tooth through a surgical ened (see Fig. 12-12B).
crown-lengthening procedure. In this latter circum-
stance, although the crown lengthening allows fab- Retention Form
rication of a crown with a ferrule, it also leads to a
much less favorable crown/root ratio and therefore Anterior teeth
to increased leverage on the root during function Simultaneous dislodgment of an anterior crown with
(Fig. 12-12). the post and core that retains it is frequently seen
One laboratory study showed that creating a clinically and results from inadequate retention
ferrule through surgical crown lengthening resulted form of the prepared tooth.13,28 The normal faciolin-
in a weaker, rather than a stronger, restored tooth.27 gual convergence of anterior teeth, coupled with
In comparison, creating a ferrule with orthodontic smaller tooth size, complicates achieving such
extrusion may be preferred, because even though the retention form. Post retention is affected by the
preparation geometry, post length, post diameter, erably enlarged, which would significantly weaken
post surface texture, and the luting agent. the root unnecessarily (Fig. 12-14).
Preparation geometry Post length
Some canals, particularly in maxillary central inci- Studies29,31,32 have shown that as post length
sors, have a nearly circular cross-section (see Table increases, so does retention. However, the relation-
12-3). These can be prepared with a twist drill or ship is not necessarily linear (Fig. 12-15). A post that
reamer to provide a cavity with parallel walls or is too short will fail (Fig. 12-16), whereas one that is
minimal taper, allowing the use of a preformed post too long may damage the seal of the root canal fill or
of corresponding size and configuration. Conversely, risk root perforation if the apical third is curved or
canals with elliptical cross-sections must be pre- tapered (Fig. 12-17). Absolute guidelines for optimal
pared with a restricted amount of taper (usually 6 to post length are difficult to define. Ideally, the post
8 degrees) to ensure adequate retention and elimi- should be as long as possible without jeopardizing
nate undesired undercuts. This is analogous to an the apical seal or the strength or integrity of the
extracoronal preparation (see Chapter 7). With remaining root structure. Most endodontic texts
extracoronal preparations, retention increases advocate maintaining a 5-mm apical seal. However,
rapidly as vertical wall taper is reduced (see Chapter if a post is shorter than the coronal height of the clin-
7). Although retention can be further increased by ical crown of the tooth, the prognosis is considered
use of a threaded post, which screws into dentin, this unfavorable, because stress is distributed over a
procedure is not recommended because of residual smaller surface area, thereby increasing the proba-
stress in the dentin. If the procedure is used, bility of radicular fracture. A short root and a tall
however, threaded posts must be “backed off ” to clinical crown present the clinician with the
ensure passivity; otherwise, the root will fracture. dilemma of having to compromise the mechanics,
In accordance with this explanation, laboratory the apical seal, or both. Under such circumstances,
testing29–31 has confirmed that parallel-sided posts an apical seal of 3 mm is considered acceptable.
are more retentive than tapered posts and that Post diameter
threaded posts are the most retentive (Fig. 12-13). Increasing the post diameter in an attempt to
However, these comparisons are relevant only if the increase retention is not recommended because the
post fits the root canal properly, because retention is results are minimal retentive gain and unnecessary
proportional to the total surface area. weakening of the remaining root. Although one
Circular parallel-sided post systems are effective group of investigators33 reported that increasing the
only in the most apical portion of the post space, post diameter increased retention, other reports do
because the majority of prepared post spaces not confirm this.29,30 Empirical evidence suggests
demonstrate considerable flare in the occlusal half. that the overall prognosis is good when post diame-
Similarly, when the root canal is elliptical, a parallel-
sided post is not effective unless the canal is consid-
1200
1000
800
Force (N)
600
400
200
0
Tapered ParaPost Radix Flexi-Post Kurer
Length 8 mm; diameter 1.5-1.65 mm
cemented with zinc phosphate
Fig. 12-13
Comparison of forces needed to remove different prefabricated Fig. 12-14
post systems. (Redrawn from Standlee JP, Caputo AA: The retentive and The use of a parallel-sided post in a tapered canal requires con-
stress distributing properties of split threaded endodontic dowels. J Prosthet siderable enlargement of the post space, which can weaken the
Dent 68:436, 1992.) root significantly. (Courtesy of Dr. R. Webber.)
1000
Embedment depth
5 mm
750
8 mm
Force (N)
500
250
Unitek Whaledent Kurer

(tapered) (parallel) (threaded)
Diameter 1.8 mm cemented with zinc phosphate
Fig. 12-15
Effect of the depth of embedding a post on its retentive capacity. (Data from Standlee JP, et al: Retention of endodontic dowels: effects of cement,
dowel length, diameter, and design. J Prosthet Dent 39:401, 1978.)
ter does not exceed one third of the cross-sectional

root diameter.
Post surface texture
R A serrated or roughened post is more retentive than
a smooth one,30 and controlled grooving of the post
Short posts are and root canal34 (Fig. 12-18) considerably increases
A
more likely to the retention of a tapered post.
result in root
fracture.
Luting agent
R In considering traditional cements, the choice of
luting agent seems to have little effect on post
retention35,36 or the fracture resistance of dentin.37
However, adhesive resin luting agents (see Chapter
F
31) have the potential to improve the performance
of post and core restorations; laboratory studies have
shown improved retention.38,39 Resin cements may
be indicated if a post becomes dislodged. Resin
cements are affected by eugenol-containing root
canal sealers, which should be removed by irrigation
with ethanol or etching with 37% phosphoric acid if
R the adhesive is to be effective.40 Zinc phosphate and
B glass ionomer have comparable retentive properties,
whereas polycarboxylate and composite resin
R cements have slightly less.41 Some resin and glass
ionomer cements have demonstrated significantly
higher retention than resin-ionomer cements,42
although the choice of luting agent may become
F
more important if the post has a poor fit within the
canal.43 A post and core should be remade if any
Fig. 12-16
Faciolingual longitudinal sections through a maxillary central
rotation or wobble is present.
incisor. A, With a post of the correct length, a force (F) applied
Posterior teeth
near the incisal edge of the crown generates a resultant couple
(R). B, When the post is too short, this couple is greater (R¢), Relatively long posts with a circular cross-section
which leads to the increased possibility of root fracture. provide good retention and support in anterior teeth
B C
Fig. 12-17
A, Correct post length. B, The post is too short; the consequences are inadequate retention and increased risk of root fracture.
C, These posts are too long, jeopardizing the apical seal.
600
NS (p<0.05)
400
Failure load (N)
200
0
Cast Cast Cast Cast Parallel
tapered tapered tapered and tapered and sided
(zinc (composite grooved (zinc grooved (Whaledent)
phosphate) resin) phosphate) (composite
resin)
Fig. 12-18
Effect of horizontal grooving on the retention of tapered posts. NS, Not significant. (Modified from Wood WW: Retention of posts in teeth with
nonvital pulps. J Prosthet Dent 49:504, 1983.)
because of the missing tooth structure. In mandibu-

lar molars, the larger distal canal is recommended
for post placement. In maxillary molars, the palatal
canal is used (see Fig. 12-2C and D).
Although it is possible to restore a severely com-
promised molar with three or more missing cusps
with multiple posts and amalgam, the tooth’s overall
importance must be assessed, as the prognosis
of such teeth is often guarded. If retaining the tooth
is crucial and optimal strength is needed, a multip-
iece cast core can be used (made in sections
that have different paths of withdrawal) (Fig. 12-20).
Fig. 12-19 An alternative preparation method for a posterior
When preparing posterior teeth for intracoronal retention, the tooth is selecting the canals that are widest (normally
practitioner must be careful to avoid perforation, especially on the palatal of maxillary molars and the distal
the distal surface of mesial roots and the mesial surface of distal of mandibular molars) for the major post and
roots, where residual tooth structure is normally thinnest and then preparing short auxiliary post spaces in the
where concavities are often present (arrows). other canals with the same path of withdrawal
(Fig. 12-21).
but should be avoided in posterior teeth, which often

have curved roots and elliptical or ribbon-shaped Resistance Form
canals (Fig. 12-19). For these teeth, retention is
better provided by two or more relatively short posts Stress distribution
in the divergent canals. One of the functions of a post and core is to improve
When amalgam is used as the core material, it can resistance to laterally directed forces by distributing
be condensed either around cemented metal posts them over as large an area as possible. However,
or directly into short, prepared post spaces. If a rea- excessive internal preparation of the root weakens it,
sonable amount of coronal tissue remains, use of a and the risk of failure increases. The post design
single metal post that is cemented in the largest should distribute stresses as evenly as possible.
canal can provide adequate retention for the core The incidence of radicular fracture increases with
material. When more than 3 to 4 mm of coronal the use of threaded posts that actively engage
tooth structure with reasonable wall thickness radicular dentin, and threaded flexible posts do
remains, use of a post in the root canals for retention not appear to reduce stress concentrations during
is not necessary, and this reduces the risk of function.
perforation.44 When a post is not used, the chamber The influence of post design on stress distribu-
must provide adequate retention for the core mate- tion has been tested with photoelastic materi-
rial. It may then be advantageous to prepare several als,20,32,46–48 strain gauges,49,50 and finite element
short divergent post spaces into which the core analysis.51,52 From these laboratory studies, the fol-
material extends. Use of the canals for retention can lowing conclusions have been drawn:
provide good results,45 although once a complete 1. The greatest stress concentrations are found at
crown has been provided, the strength of the tooth is the shoulder, particularly interproximally, and at
not dramatically influenced by differences in tech- the apex. Dentin should be conserved in these
nique. areas if possible.
Mandibular premolars and molars with a reason- 2. Stresses are reduced as post length increases.
able amount of remaining coronal tooth structure, 3. Parallel-sided posts may distribute stress more
when coupled with a circumferential cervical band evenly than do tapered posts, which may have a
of tooth structure with restricted taper of about wedging effect. However, parallel-sided posts
2 mm, can often be restored with amalgam directly generate high stresses at the apex.
condensed into the chamber. Core buildups in 4. Sharp angles should be avoided because they
molars with one or more missing cusps benefit from produce high stresses during loading.
one or more cemented posts around which the 5. High stress can be generated during insertion,
amalgam can be condensed. The posts provide the particularly with smooth, parallel-sided posts that
additional retention, which was compromised have no vent for cement escape.
A B,C
D E,F
Fig. 12-20
A to F, Cast cores for posterior teeth can be made in interlocking sections, with each section having its own path of withdrawal.
Medial Distal
A B C
Lingual
Lingual
Buccal Buccal
D E,F
Fig. 12-21
Single-piece castings can be made by selecting the larger-diameter canal and extending a second post for a limited distance into
the smaller canal. A, A maxillary first premolar. B, A maxillary first molar. C, A mandibular first molar. D to F, Post and core provided
for a maxillary first premolar by the indirect technique.
Removal of the Endodontic Filling Material

The root canal system should first be completely
filled; space should then be made for a post, thus
ensuring that lateral canals are sealed. A post cannot
be placed if the canal is filled with a full-length silver
point, so these must be removed and the tooth
retreated with gutta-percha. It is not advisable to
shorten previously cemented silver points, because
leakage will result even if only a short portion is
removed.53,54
There are two commonly used methods to remove
gutta-percha (Fig. 12-23): (1) using a warmed
endodontic plugger, and (2) using a rotary instru-
ment, sometimes in conjunction with chemical
Fig. 12-22
Rotational resistance in an extensively damaged tooth can be agents. Although more time consuming, the warmed
obtained by preparing a small groove in the root canal. This endodontic plugger is preferred because it elimi-
must be in the path of placement of the post and core. nates the possibility that the rotary instrument will
inadvertently damage the dentin. If it is more con-
venient, the gutta-percha can be removed with a
warmed condenser immediately after obturation.
6. Threaded posts can produce high stress concen- This does not disturb the apical seal.55,56 This
trations during insertion and loading, but they method offers the additional advantage of allowing
have been shown to distribute stress evenly if the the operator to work in an area where the root canal
posts are backed off a half-turn and when the anatomy is still familiar.
head contact area is of sufficient size.38 1. Before removing gutta-percha, calculate the
7. The cement layer results in a more even stress dis- appropriate length of the post. It should be ade-
tribution to the root with less stress concentrations. quate for retention and resistance but not long
enough to weaken the apical seal. As a guide,
Rotational resistance make the post length equal to the height of the
To minimize the risk of dislodgment, it is important anatomic crown (or two-thirds the length of the
that preparation geometry prevents a post with a cir- root), but leave 5 mm of apical gutta-percha. On
cular cross-section from rotating during function short teeth, it is not possible to meet both these
(Fig. 12-22). This usually does not present a problem restrictions, and a compromise must be made. An
when sufficient coronal tooth structure remains, absolute minimum of 3 mm of apical fill is
because rotation is prevented by a vertical coronal needed. If this cannot be achieved without having
wall. Where coronal dentin has been completely a very short post, the tooth’s prognosis is seriously
lost, a small groove placed in the canal wall can serve impaired.
as an antirotational element. The groove is normally 2. Avoid the apical 5 mm if possible. Curvatures and
located where the root is bulkiest, usually on its lateral canals may be found in this segment.
lingual aspect. Alternatively, rotation can be pre- Average values for crown and root length are
vented by an auxiliary pin in the root face. Rotation given in Table 12-1. If the working length of the
of a threaded post can also be prevented31 by prepar- root canal is known, the length of the post space
ing a small cavity (half in the post, half in the root) can be easily determined. Therefore, the incisal
and condensing amalgam into it after the post is or occlusal reference point must not be lost as a
cemented. result of premature removal of coronal tooth
structure.
3. To prevent the patient’s aspiration of an endodon-
PROCEDURES tic instrument, apply a rubber dam before prepar-
Tooth preparation for endodontically treated teeth ing the post space.
can be considered a three-stage operation: 4. Select an endodontic condenser large enough to
1. Removal of the root canal filling material to the hold heat well but not so large that it binds
appropriate depth. against the canal walls.
2. Enlargement of the canal. 5. Mark it at the appropriate length (normally
3. Preparation of the coronal tooth structure. endodontic working length minus 5 mm), heat
A B
Length is NEVER gained with

end-cutting twist drills! Instead,
a safe tipped instrument such as
a Peeso-Reamer or Gates Glidden
C drill is used. The twist drill is
D
only used to parallel the walls
of the post space.
Fig. 12-23
Gutta-percha can be removed from the canal with a heated endodontic plugger. (A and B), a non–end-cutting bur (C) (e.g., a Gates
Glidden drill). A ParaPost drill (D) can be used to parallel the post space wall (with a rubber stop to ensure accuracy of the prepa-
ration depth). (A and B, Courtesy of Dr. D. A. Miller.)
Table 12-1 AVERAGE CROWN AND ROOT LENGTHS (IN MILLIMETERS)

Mean Mean Two-Thirds Root Length
Crown Length* Root Length* Root Length (to 4 mm from apex)
MAXILLARY TEETH
Central incisor 10.8 ± 0.7 12.5 ± 1.6 8.3 8.5
Lateral incisor 9.7 ± 0.9 13.1 ± 1.4 8.7 9.1
Canine 10.2 ± 0.8 15.8 ± 2.1 10.5 11.8
First premolar 8.6 ± 0.8 12.7 ± 1.7 8.5 8.7
Second premolar 7.5 ± 0.6 13.5 ± 1.4 9.0 9.5
First molar 7.4 ± 0.5 MF 12.5 ± 1.2 8.3 8.5
DF 12.0 ± 1.3 8.0 8.0
L 13.2 ± 1.4 8.8 9.2
Second molar 7.4 ± 0.5 MF 12.8 ± 1.5 8.5 8.8
DF 12.0 ± 1.4 8.0 8.0
L 13.4 ± 1.3 8.9 9.4
MANDIBULAR TEETH
Central incisor 9.1 ± 0.5 12.4 ± 1.4 8.3 8.4
Lateral incisor 9.4 ± 0.7 13.0 ± 1.5 8.7 9.0
Canine 10.9 ± 0.9 14.3 ± 1.4 9.5 10.3
First premolar 8.7 ± 0.7 13.4 ± 1.3 8.9 9.4
Second premolar 7.8 ± 0.6 13.6 ± 1.7 9.1 9.6
First molar 7.4 ± 0.5 M 13.5 ± 1.3 9.0 9.5
D 13.4 ± 1.3 8.9 9.4
Second molar 7.5 ± 0.5 M 13.4 ± 1.2 8.9 9.4
D 13.3 ± 1.3 8.9 9.3
Data from Shillingburg HT, et al: Root dimensions and dowel size. Calif Dent Assoc J 10(10):43, 1982.
n = 50 for each tooth.
*SD listed after mean length.
D, distal; DF, distofacial; L, lingual; M, mesial; MF, mesiofacial.
it, and place it in the canal to soften the gutta- heat can be generated by these rotary instru-
percha. ments, especially during the ParaPost preparation
6. If the gutta-percha is old and has lost much of its stage.58
thermoplasticity, use a rotary instrument, making Of importance: End-cutting instruments should
sure that it follows the gutta-percha and does not never be used to gain length because root perforation
engage dentin (this causes a root perforation). For will result!
this reason, high-speed instruments and conven- 7. If using a rotary instrument, choose it to be
tional burs are contraindicated. Special post slightly narrower than the canal.
preparation instruments are available (Fig. 8. Make sure the instrument follows the center of the
12-24). Peeso-Reamers and Gates Glidden drills gutta-percha and does not cut dentin. Often, only
are often used for this purpose. The football a part of the root canal fill needs to be removed
shape of the cutting head of the Gates-Glidden with a rotary instrument, and the remainder can
drill often results in small concavities in the wall be removed with the heated condenser.
of the post space. These are avoided with the 9. When the gutta-percha has been removed to the
more cylindrically shaped Peeso-Reamer. Both appropriate depth, shape the canal as needed.
are considered “safe-tip” instruments because This can be accomplished by using an endodon-
they are not end-cutting burs. The friction gener- tic file or a low-speed drill. This procedure
ated between the fill and the tip of these burs removes undercuts and prepares the canal to
softens the gutta-percha, allowing the rotary receive an appropriately sized post without exces-
instrument to track the canal with reasonable pre- sively enlarging the canal. Files are a conservative
dictability. In one comparison of rotary instru- approach to shaping the canal walls and enable
ments,57 investigators concluded that the Gates simultaneous removal of any small residual
Glidden drill conformed to the original canal undercuts in the chamber. If a parallel-sided post
more consistently than did the ParaPost drill, is desired, a matching-size low-speed twist drill
which is an end-cutting instrument. The latter that is set to the same length as the most recently
is a twist drill and should be used only to used Peeso-Reamer can be used.
parallel the walls of the post space. Considerable
A B
Fig. 12-24
Commonly used instruments for gutta-percha removal and canal enlargement. A, Endodontic pluggers, two sizes of Peeso-Reamers
with corresponding twist drills, and endodontic file. Note attached floss as a safety precaution. B, The ParaPost twist drill corre-
sponds in size to an aluminum post used to fabricate interim restorations, a plastic post for patterns, and a stainless-steel or tita-
nium post. (Courtesy of Dr. J. A. Nelson.)
The post should be no more than one-third the cross-section also is significant in post selection.
root diameter,1,59 with the root and walls at least Prefabricated posts are circular in cross-section, but
1 mm thick. Obviously, for deciding on appropriate many root canals are elliptical, which makes
post diameters, a knowledge of average root dimen- uniform reduction with a drill impossible. Canal
sions is important. These have been calculated60 and shapes are summarized in Table 12-3.
are presented in Table 12-2. Knowledge of root canal
Table 12-2 AVERAGE ROOT DIAMETERS AND RECOMMENDED POST SIZES (IN MILLIMETERS)*
Diameter
4 mm from Recommended
CEJ Furcation† Midpoint Apex‡ Post Diameter
MAXILLARY TEETH
Central incisor MD 6.3 ± 0.5 — 5.2 ± 0.5 3.8 ± 0.4 1.5
FL 6.4 ± 0.4 — 5.8 ± 0.4 4.3 ± 0.4
Lateral incisor MD 4.9 ± 0.5 — 4.0 ± 0.5 3.2 ± 0.5 1.3
FL 5.7 ± 0.5 — 5.4 ± 0.5 4.2 ± 0.4
Canine MD 5.4 ± 0.5 — 4.4 ± 0.5 3.3 ± 0.5 1.5
FL 7.7 ± 0.6 — 7.2 ± 0.6 4.8 ± 0.6
First premolar MD 4.1 ± 0.3 Facial MD 3.6 ± 0.4 2.6 ± 0.4 0.9
FL 8.1 ± 0.7 — FL — 3.4 ± 0.4 2.4 ± 0.4
Lingual MD 3.3 ± 0.3 2.5 ± 0.4 0.9
— FL — 3.3 ± 0.4 2.4 ± 0.5
Second premolar MD 4.9 ± 0.3 — 3.8 ± 0.4 3.2 ± 0.6 1.1
FL 7.9 ± 0.5 — 7.0 ± 0.7 5.0 ± 0.7
First molar MD 7.7 ± 0.4 Mesio- MD 3.1 ± 0.3 2.9 ± 0.4 1.1
FL 10.5 ± 0.5 3.4 ± 0.3
Facial FL 5.8 ± 0.7 4.8 ± 0.7
6.8 ± 0.5
Disto- MD 2.8 ± 0.3 2.6 ± 0.4 1.1
3.1 ± 0.2
Facial FL 4.4 ± 0.5 3.8 ± 0.5
5.0 ± 0.4
Lingual MD 5.0 ± 0.5 4.4 ± 0.5 1.3
5.7 ± 0.5
FL 4.3 ± 0.4 3.7 ± 0.4 3.3 ± 0.4
Second molar MD 7.3 ± 0.4 Mesio- MD 3.1 ± 0.3 2.7 ± 0.4 1.1
FL 10.4 ± 0.6 3.4 ± 0.3
Facial FL 5.6 ± 0.7 4.5 ± 0.7
6.6 ± 0.5
Disto- MD 2.8 ± 0.3 24 ± 0.4 0.9
3.1 ± 0.4
Facial FL 3.8 ± 0.4 3.2 ± 0.4
4.3 ± 0.4
Lingual MD 4.2 ± 0.5 3.6 ± 0.5 1.3
4.9 ± 0.5
FL 4.5 ± 0.4 3.9 ± 0.4 3.1 ± 0.4
MANDIBULAR TEETH
Central incisor MD 3.3 ± 0.3 — 2.7 ± 0.3 2.1 ± 0.2 0.7
FL 5.5 ± 0.5 5.6 ± 0.4 4.3 ± 0.6
Lateral incisor MD 3.6 ± 0.3 — 2.7 ± 0.4 2.0 ± 0.2 0.7
FL 5.9 ± 0.4 5.7 ± 0.5 4.3 ± 0.5
Table 12-2—cont’d
Diameter
4 mm from Recommended
CEJ Furcation† Midpoint Apex‡ Post Diameter
Canine MD 5.2 ± 0.6 — 4.0 ± 0.5 3.2 ± 0.7 1.5
FL 7.8 ± 0.8 7.3 ± 0.6 5.0 ± 0.5
First premolar MD 5.1 ± 0.4 — 4.0 ± 0.4 3.2 ± 0.4 1.3
FL 6.6 ± 0.4 6.0 ± 0.5 4.3 ± 0.5
Second premolar MD 5.3 ± 0.3 — 4.3 ± 0.3 3.5 ± 0.5 1.3
FL 7.0 ± 0.5 6.0 ± 0.6 4.4 ± 0.5
First molar MD 8.9 ± 0.6 Mesio- MD 3.2 ± 0.3 2.8 ± 0.3 1.1
3.7 ± 0.2
FL 8.3 ± 0.6 Facial FL 3.1 ± 0.3 2.8 ± 0.4
3.4 ± 0.3
Mesio- MD 2.9 ± 0.3 2.5 ± 0.3 0.9
3.4 ± 0.3
Lingual FL 3.2 ± 0.3 2.7 ± 0.4
3.5 ± 0.4
Distal MD 2.8 ± 0.4 2.7 ± 0.4 1.1
3.5 ± 0.4
FL 7.6 ± 0.8 6.6 ± 1.2 5.4 ± 0.8
Second molar MD 9.3 ± 0.7 Mesio- MD 3.1 ± 0.3 2.6 ± 0.3 0.9
FL 8.3 ± 0.7 3.6 ± 0.3
Facial FL 2.8 ± 0.3 2.4 ± 0.4
3.2 ± 0.3
Mesio- MD 3.0 ± 0.4 2.5 ± 0.4 0.9
3.6 ± 0.4
Lingual FL 2.8 ± 0.4 2.3 ± 0.4
3.2 ± 0.5
Distal MD 3.5 ± 0.4 3.0 ± 0.4 1.1
4.1 ± 0.4
FL 6.8 ± 0.8 5.9 ± 0.9 4.7 ± 0.7
Data from Shillingburg HT, et al: Root dimensions and dowel size. Calif Dent Assoc J 10(10):43, 1982.
*N = 50 for each tooth.
†
Furcation distance from the CEJ: maxillary first molar, 4.1 mm; maxillary second molar, 3.2 mm; mandibular first molar, 3.1 mm;
mandibular second molar, 3.3 mm.
‡
Because of greater root length, the mean distance from the apex on maxillary canine measurements is 5.1 mm.
CEJ, cementoenamel junction; FL, faciolingual; MD, mesiodistal.
Table 12-3 ROOT CANAL CONFIGURATIONS

CIRCULAR ELLIPTICAL
Buccolingual Mesiodistal
Maxillary central incisor Maxillary lateral incisor
Maxillary canine
Mandibular incisors
Mandibular canine
Maxillary first premolar (two roots) Maxillary first premolar
(single root)
Mandibular first premolar
Mandibular second premolar Maxillary second premolar
Maxillary molars (distobuccal roots) Maxillary molars Maxillary molars (palatal roots)
(mesiobuccal roots)
Mandibular molars (mesial
and distal roots)
From Weine FS: Endodontic Therapy, 4th ed, pp 225–269. St. Louis, Mosby, 1989.
Enlargement of the Canal

Before enlargement of the canal, the type of post
system to be used for fabrication of the post and core
must be chosen.
The advantages and disadvantages of different
post types are summarized in Table 12-4. A B C D E F
Because no system has universal application, being
familiar with more than one technique is a signifi- Fig. 12-25
Classification of prefabricated posts. A, Tapered smooth posts.
cant advantage. A wide range of prefabricated
B, Tapered serrated posts. C, Tapered threaded posts. D, Paral-
posts are available. They come in many shapes and
lel-sided smooth posts. E, Parallel-sided serrated posts. F, Par-
sizes and have varying radiopacity that may assist in allel-sided threaded posts. (Redrawn from Shillingburg HT, Kessler JC:
their identification (Table 12-5 and Figs. 12-25 and Restoration of the Endodontically Treated Tooth. Chicago, Quintessence Pub-
12-26). lishing, 1982.)
A B,C
1 2 3 4 5 6 7 8 9
D E,F
G H
Fig. 12-26
The various endodontic posts encountered in clinical practice present with varying degrees of radiopacity. Dentists accustomed to
seeing traditional stainless steel and titanium posts may be deceived by more recently introduced systems. A, Nine representative
posts: (1) ParaPost stainless steel (Coltène/Whaledent); (2) ParaPost titanium (Coltène/Whaledent); (3) FRC Postec Plus (Ivoclar
Vivadent); (4) Glass Fiber Post (Ellman International); (5) Glass Fiber C-I Post (Parkell); (6) D. T. Light-Post (Bisco); (7) Twin Luscent
Anchors (Dentatus USA); (8) Unicore (Ultradent Products); (9) PeerlessPost (SybronEndo). The pure carbon fiber posts (not included
in A) are completely radiolucent. The type of cement that is used plays a role in the radiopacity of the post (see Fig. 31-6). B to I,
Radiographs of the six categories: B, Endowel (Star Dental), tapered and smooth sided. C, Unimetric (DENTSPLY), tapered and
serrated. D, Surtex (Dentatus USA), tapered and threaded. E, CTH Beta Post (CTH), parallel-sided and smooth. F, ParaPost
(Coltène/Whaledent) (two sizes), parallel-sided and serrated. G, Flexi-Post (Essential Dental Systems) (in the right maxillary first
molar), parallel-sided and threaded (note the split shank). H, ParaPost Fiber Lux (Coltène/Whaledent) cemented with RelyX Luting
(3M ESPE). Note the radiolucency of the post in comparison with the radiopacity of the gutta-percha endodontic fill. (B, Courtesy of Dr.
D. A. Miller and Dr. H. W. Zuckerman; C, courtesy of Dr. I. A. Roseman; D, courtesy of Dr. F. S. Weine and Dr. S. Strauss; E, courtesy of Dr. J. F. Tardera; F, courtesy
of Dr. J. L. Wingo; G, courtesy of Dr. L. R. Farsakian; H, courtesy of Dr. D. A. Miller and Dr. G. Freebeck.)
Text continues on page 358
Table 12-4 AVAILABLE POST AND CORE SYSTEMS
Recommended
Advantages Disadvantages Use Precautions
Amalgam Conservative of Low tensile strength Molars with Not recommended
tooth structure Corrosion with base adequate in teeth under
Straightforward metal coronal tooth lateral load
technique structure (anteriors)
Glass Conservative of Difficult Teeth with Not recommended
ionomer tooth structure condensation minimum in teeth under
Straightforward Low strength tooth structure lateral load
technique missing
Composite Conservative of Low strength Teeth with Not recommended
resin tooth structure Continued minimum in teeth under
Straightforward polymerization tooth structure lateral load
technique Microleakage missing
Custom cast High strength Less stiff than Elliptical or Care to remove
post and Better fit than wrought flared canals nodules before
core prefabricated Time consuming, try-in
complex
procedure
Wire post High strength Corrosion of base Small circular Care to avoid
and cast High stiffness metal canals perforation
core Pt-Au-Pd wire during
expensive preparation
Tapered Conservative of Less retentive than Small circular Not recommended
prefabricated tooth structure parallel-sided or canals for excessively
post High strength threaded systems flared canals
and stiffness
Parallel-sided High strength Precious metal post Small circular Care during
prefabricated Good retention expensive canals preparation
post Comprehensive Corrosion of
system stainless steel
Less conservative of
tooth structure
Threaded post High retention Stresses generated Only when Care to avoid
in canal may lead maximum fracture during
to fracture retention is seating
Not conservative of essential
coronal and
radicular tooth
structure
Carbon fiber Dentin bonding Low strength Minimal missing Not recommended
post Easy removal Microleakage tooth structure for teeth under
Black color Uncertain lateral load
endodontic
prognosis
Zirconia Esthetics Uncertain clinical High esthetic
ceramic High stiffness performance demand
posts
Woven fiber Esthetics Low strength High esthetic Not recommended
posts Dentin bonding Uncertain clinical demand for teeth under
performance lateral load
Glass fiber Esthetics Low strength High esthetic Not recommended
posts Dentin bonding Uncertain clinical demand for teeth under
performance lateral load
Pt-Au-Pd, platinum-gold-palladium.
Table 12-5 CURRENTLY AVAILABLE PREFABRICATED POSTS*
SHANK
Example† Product (vendor) Composition‡ Characteristics Diameter (mm)§

TAPERED SMOOTH-SIDED POSTS
FibreKleer Post System (Pentron) GF (unidirectional, LT) Flat tip 1.2 to 1.5
FRC Postec Plus (Ivoclar Vivadent) GF (unidirectional, LT) Flat tip 1.5 to 1.7
Glass Fiber Post (Ellman International) GF (unidirectional, LT) Flat tip 0.9 to 2.0
Fibio (Dental Anchor Systems) GF (unidirectional) Flat tip 1.2 to 1.5
ER Casting Post (Brasseler USA) PB Flat tip 1.1 to 1.7
Endodontic Post (Sterngold) PB Blunt tip 1.7 and 1.8
Plastic Sprue Post (Miltex) PB Blunt tip 1.4 and 1.7
C-I Plastic Pattern Post (Parkell) PB Blunt tip 1.3 and 1.6
Stress-Free Post (Denovo) SS Blunt tip, ISO|| sizes: 50 to 130 0.7 to 1.5
Filpost (Filhol Dental USA) Ti Blunt tip 1.3 and 1.6
Cerapost (Brasseler USA) ZrO2 Blunt tip 1.1 to 1.7
C-I White Glass Fiber Post (Parkell) GF (braided) Blunt tip 1.3 and 1.6
D. T. Light-Post (Bisco) QF (unidirectional, LT) Blunt tip 1.0 to 1.6
Luscent Anchors (Dentatus USA) GF (unidirectional, LT) Blunt tip 1.1 to 1.6
Twin Luscent Anchors (Dentatus USA) GF (unidirectional, LT) Tappered tip, hourglass shape 1.4 to 1.8
Unicore (Ultradent Products) QF (unidirectional, LT) Pointed tip 1.1 to 1.7
Endowel (Star Dental) PB Pointed tip, ISO|| sizes: 80 to 140 1.0 to 1.6
TAPERED SERRATED POSTS

PeerlessPost (SybronEndo) GF (unidirectional) Inverse ledges, flat tip 1.1 to 1.2
C-I Stainless Steel Post (Parkell) SS Shallow narrow grooves, flat tip 1.3 and 1.6
NuBond (Ellman International) SS Shallow narrow grooves, blunt tip 0.9 to 2.0
Tri-R Post System (Miltex) SS Spiraling grooves, pointed tip 1.0 to 1.6
TAPERED THREADED POSTS

Surtex (Dentatus USA)¶ Ti, SS, Brass Tightly threaded 1.1 to 1.8
Ancorex (E. C. Moore)¶ Ti Tightly threaded 1.1 to 1.8
PARALLEL SMOOTH-SIDED POSTS

FibreKleer Post System (Pentron) GF (unidirectional, LT) Flat tip 1.0 to 1.5
IntegraPost System (Premier) Ti alloy Fine diamond shape grooves, flat tip 0.9 to 1.5
CTH Beta Post (CTH) SS Vertical grooves, flat tip 1.1 to 1.6
Table 12-5—cont’d
SHANK
Example† Product (vendor) Composition‡ Characteristics Diameter (mm)§
CTH R Series (CTH) SS Vertical grooves, flat tip 1.1 to 1.6

GT Post (Dentsply Tulsa Dental) SS Flat tip 0.9 to 1.7
ProPost (Dentsply Tulsa Dental) SS Tapered apical end, flat tip 0.8 to 1.4
CosmoPost (Ivoclar Vivadent) ZrO2 Tapered apical end, flat tip 1.4 and 1.7
CarboPost (Danville Materials) CF Tapered apical end, blunt tip 1.0 to 1.6
Snowlight (Danville Materials) GF (unidirectional, LT) Tapered apical end, blunt tip 1.0 to 1.6
Snowpost (Danville Materials) GF (unidirectional) Tapered apical end, blunt tip 1.0 to 1.6
Core-Post (Den-Mat) GF (unidirectional), CF Pointed tip 1.0 to 2.0
Mirafit White and Black (Hager Worldwide) GF (braided), CF Pointed tip 1.2 to 1.5
GF Glass Fiber Post (J. Morita USA) GF (braided) Blunt tip 1.1 to 1.6
CF Carbon Fiber Post (J. Morita USA) CF Blunt tip 1.1 to 1.6
Vario Cast Passive Post (Brasseler USA) PB Blunt tip 1.2 to 1.6
PARALLEL SERRATED POSTS

PermaPost (Ultradent Products) Ti alloy Numerous shallow grooves, blunt tip 0.9 to 1.5
ParaPost (Coltène/Whaledent) Ti alloy, PB, SS Numerous shallow grooves, flat tip 0.9 to 1.8
ParaPost XP (Coltène/Whaledent) Ti alloy, PB, SS Diamond shape grooves, flat tip 0.9 to 1.8
Unity (Coltène/Whaledent) Ti alloy, PB Diamond shape grooves, flat tip 0.9 to 1.8
ParaPost XH (Coltène/Whaledent) Ti alloy Diamond shape grooves, flat tip 0.9 to 1.8
ParaPost Plus (Coltène/Whaledent) Ti alloy, SS Inverse ledges, flat tip 0.9 to 1.8
ParaPost Fiber Lux (Coltène/Whaledent) GF (unidirectional, LT) Inverse ledges, flat tip 1.1 to 1.5
ParaPost Fiber White (Coltène/Whaledent) GF (unidirectional) Inverse ledges, flat tip 1.1 to 1.5
FibreKor Post System (Pentron) GF (unidirectional) Inverse ledges, flat tip 1.0 to 1.5
Achromat (Axis Dental) GF (unidirectional, LT) Wide grooves, flat tip 1.3 and 1.6
Achromat—HP (Axis Dental) GF (unidirectional, LT) Wide grooves, flat tip 1.1 to 1.6
Vario Passive Post (Brasseler USA) Ti alloy Wide grooves, flat tip 1.2 to 1.6
Vlock Passive Post (Brasseler USA) Ti alloy Wide grooves, flat tip 1.2 to 1.6
Luminex (Dentatus USA) PB Wide grooves, tapered tip 1.1 to 1.8
SB Post (J. Morita USA) SS Shallow grooves, tapered tip 0.8 to 1.6
AccessPost (Essential Dental Systems) SS Deep spiraling groove, flat tip 0.8 to 1.6
AccessPost Overdenture (Essential Dental SS Deep spiraling groove, flat tip 1.1 to 1.6
Systems)
ERA Direct Overdenture (Sterngold) SS Numerous shallow grooves, flat tip 1.4 and 1.7
Locator attachment (Zest Anchors) SS Numerous shallow grooves, flat tip 1.8
PARALLEL THREADED POSTS

Surtex (Dentatus USA)¶ Ti, SS, Brass Tightly threaded, threaded tapered tip 1.1 to 1.8
¶
Ancorex (E. C. Moore) Ti Tightly threaded, threaded tapered tip 1.1 to 1.8
AZtec (Dentatus USA) Ti Tightly threaded, smooth tapered tip 1.5 to 1.8
Boston Post (Roydent Dental Products) Ti Tightly threaded, pointed tip 1.0 to 1.6
Titanium Screw Post (E. C. Moore) Ti Tightly threaded, pointed tip 1.1 to 1.8
Golden Screw Post (E. C. Moore) Brass Tightly threaded, pointed tip 1.1 to 1.8
Compo-Post (Sullivan-Schein) Brass Tightly threaded, pointed tip 1.1 to 1.8
Obturation Screws (Miltex) SS Tightly threaded, pointed tip 1.3
Kurer K4 Ready Core Anchor (Marie Reiko) SS, Ti alloy Tightly threaded, flat tip 1.6 to 2.0
Kurer K4 Universal Anchor (Marie Reiko) SS, Ti alloy Tightly threaded, flat tip 1.5 to 2.0
Kurer K4 Custom Core Anchor (Marie Reiko) SS, Ti alloy Tightly threaded, flat tip 1.7 to 2.0
Kurer K4 Denture Anchor (Marie Reiko) SS, Ti alloy Tightly threaded, flat tip 1.8 to 2.0
Europost, Headless (Dental Anchor Systems) Ti alloy Sparsely threaded, blunt tip 1.1 to 1.8
Europost, Headed (Dental Anchor Systems) Ti alloy Sparsely threaded, blunt tip 1.1 to 1.8
Vlock Active Post (Brasseler USA) Ti alloy Sparsely threaded, blunt tip 1.3 to 1.8
Vario Active Post (Brasseler USA) Ti alloy Sparsely threaded, blunt tip 1.3 to 1.8
Vario ELO Active Post (Brasseler USA) Ti alloy Sparsely threaded, flat tip 1.3 to 1.8
Radix-Anchor (Dentsply Maillefer) Ti alloy Sparsely threaded, flat tip 1.2 to 1.6
ParaPost XT (Coltène/Whaledent) Ti alloy Sparsely threaded, grooves, flat tip 0.9 to 1.5
Flexi-Post (Essential Dental Systems) Ti alloy, SS Sparsely threaded, split shank 1.0 to 1.9
Flexi-Flange (Essential Dental Systems) Ti alloy, SS Sparsely threaded, split shank 1.1 to 1.9
Flexi-Overdenture (Essential Dental Systems) Ti alloy, SS Sparsely threaded, split shank 1.4 to 1.9
Cytco-K (Dentsply Maillefer) Ti alloy 4 coronal threads, long tapered tip 0.9 and 1.2
*Posts are categorized by their radiographic silhouette from the apical 8 mm of the shank.
†
Posts are not photographed to scale.
‡
Composition key: Brass, alloy of copper and zinc (brass posts are gold plated); CF, carbon fibers bound by resin matrix; GF, glass fibers bound by resin matrix (glass fibers are either braided or
unidirectional in orientation); LT, light transmission through the post; PB, plastic burnout for a cast post; QF, quartz fibers bound by resin matrix (quartz fibers are unidirectional in
orientation); SS, stainless-steel; Ti, titanium (Ti indicates approximately 99% pure titanium, Ti alloy indicates a content of approximately 90% titanium); ZrO2, zirconium oxide or zirconia.
§
Shank diameter includes the threads of relevant posts; diameters of tapered posts are taken 8 mm from the apical tip.
||
ISO indicates that the post corresponds to standardized file sizes (set by the International Standards Organization).
¶
Surtex and Ancorex post categorization is dependent on the length of the post: the medium and longer sizes are parallel-sided threaded posts; the shorter sizes are tapered threaded posts.
The diameters of popular prefabricated posts are the canal sufficiently to provide adequate reten-
given in Table 12-6. Parallel-sided prefabricated tion for the post; in that case, a tapered custom-
posts are recommended for conservatively prepared made post is preferred.
root canals in teeth with roots of circular cross- 2. Use a prefabricated post (Fig. 12-27C) that
section. Excessively flared canals (e.g., those found in matches standard endodontic instruments. A
young persons or in individuals after re-treatment of tapered post conforms better to the canal than a
an endodontic failure) are most effectively managed parallel-sided post and requires less removal of
with a custom post. However, situations should be dentin to achieve an adequate fit. However, it is
evaluated on an individual basis. slightly less retentive and causes greater stress
concentrations, although retention may be im-
Prefabricated posts proved by controlled grooving.34
1. Enlarge the canal one or two sizes with a drill, 3. Be especially careful not to remove more dentin
endodontic file, or reamer that matches the con- at the apical extent of the post space than is nec-
figuration of the post (Fig. 12-27A and B). When essary (see Figs. 12-14 and 12-27).
using rotary instruments, alternate between the Of importance: If careful measurement techniques
Peeso-Reamers and twist drills that correspond in have been followed, radiographs are not normally
size. In the case of a threaded post, the appropri- necessary to verify the post space preparation.
ate drill is followed by a tap that prethreads the Most of the time, a preformed parallel-sided post
internal wall of the post space. Parallel-sided fits only in the most apical portion of the canal. Mod-
posts are more retentive and distribute stresses ified posts are available with tapered ends, and these
better than do tapered posts, but they do not conform better to the shape of the canal, although
conform well to the shape of a canal that has been they have slightly less retention than parallel-sided
flared to facilitate condensation of gutta-percha. posts do, particularly when restoring shorter roots.32
In this situation, it may not be possible to enlarge In the absence of a vertical stop on sound tooth struc-
Table 12-6 DIAMETERS OF EIGHT COMMONLY USED PREFABRICATED POSTS (IN MILLIMETERS)
Post 0.80 0.90 0.95 1.00 1.05 1.15 1.20 1.25 1.35 1.40
Boston* X X
Surtex* X X X
Flexi-Post* X X X
Stress-free post † ‡
size 70
K4 Universal
Anchor
ParaPost X X X
Radix* X X
Vlock Passive Post X X
1.45 1.50 1.60 1.65 1.75 1.80 1.85 1.90 2.00
Boston* X
Surtex* X X X
Flexi-Post* X X
Stress-free post
size 70
K4 Universal X X X X X
Anchor
ParaPost X X
Radix* X X
Vlock Passive Post X
*Diameter includes threads.
†
5 mm from tip.
‡
10 mm from tip.
A B,C
Fig. 12-27
A to C, Enlargement of the root canal for a prefabricated post.
ture, such posts can also create an undesirable

wedging effect.
Custom-made posts
1. Use custom-made posts (Fig. 12-28) in canals that
have a noncircular cross-section or extreme taper.
Enlarging canals to conform to a preformed
post may lead to perforation. Often very little
preparation is needed for a custom-made post.
However, undercuts within the canal must be
removed, and some additional shaping usually is Fig. 12-28
necessary. Custom-made posts are indicated for teeth with root canals
whose cross-section is not circular or is extremely tapered.
2. Be most careful on molars to avoid root perfora-
Further enlargement of the root canal is often not necessary on
tion. In mandibular molars, interradicular root
these teeth.
concavities make the distal wall of the mesial
root and the mesial wall of the distal root. partic-
ularly susceptible. In maxillary molars, the cur-
vature of the mesiobuccal root makes mesial or
distal perforation more likely61 (Fig. 12-29).
Therefore, neither post size nor length should be
excessive.
Preparation of the Coronal Tooth Structure

A B
After the post space has been prepared, the remain-
ing coronal tooth structure is reduced for the extra-
coronal restoration. Specific reduction depends on
the type of crown that is planned. When esthetic
requirements apply, as for anterior teeth, metal-
ceramic crowns or all-ceramic crowns are indicated.
(see Chapters 9, 11, 24, and 25).
1. Ignore missing coronal tissue (from previous Fig. 12-29
restorative procedures, caries, fracture, or A and B, Distal root curvature contributed to this mesial per-
endodontic access) and prepare the remaining foration (arrow) of a mandibular molar and necessitated
tooth structure as if the crown is intact. Meeting removal of the distal root segment. (Courtesy of Dr. J. Davila.)
the same specifications that would be applied able in Au-Pt, Ni-Cr, and titanium alloys. All these
otherwise (i.e., if a metal-ceramic crown with a posts have a high modulus of elasticity and an elon-
porcelain labial margin is planned, a facial shoul- gated grain structure, which contribute to their more
der and lingual chamfer are placed). The pre- suitable physical properties in comparison to cast
pared walls are the starting point for the core posts. Essentially, they are more rigid.
materials, and ensuring that the configuration is Failure of posts cast in type III gold when loaded
correct facilitates achieving correct preparation at a 45-degree angle has been attributed to
form in the core. bending.62 Although posts cast in stiffer (type IV)
2. Be sure that the facial structure of the tooth is gold or Ni-Cr alloys can be expected to resist
adequately reduced for good esthetics. bending better, prefabricated posts should possess
3. Remove all internal and external undercuts that even more desirable physical properties, although
will prevent withdrawal of the pattern. their properties can deteriorate when a core is cast
4. Remove any unsupported tooth structure, but to a wrought post.63
preserve as much of the crown as possible. Fiber composite posts have increased in popular-
Because tooth structure has been removed inter- ity. These posts consist of bundles of stretched
nally and externally, the remaining walls often are aligned glass or carbon fibers* embedded in a resin
thin and weakened. Defining absolute measure- matrix. The resulting post is strong but has signifi-
ments for the dimensions of the residual coronal cantly less stiffness and strength than do ceramic
walls is difficult, but ideally they should probably and metal posts.64 Preliminary retrospective study
be at least 1 mm wide. Wall height is reduced of the carbon fiber system appears promising65
proportionally to the remaining wall thickness, (Fig. 12-30). However, in a laboratory study in
because tall, thin walls have a tendency to frac- which teeth restored with carbon fiber posts and
ture when the interim restoration is removed and composite-resin foundations were compared with
during evaluation and seating of the casting. teeth restored with custom post and cores cast
5. In addition, be sure that part of the remaining in type III alloy, there were significantly higher
coronal tissue is prepared perpendicular to the fracture thresholds for the cast post and cores.66 One
post (see step 4 in Fig. 12-8), because this creates advantage of a fiber composite posts is their ease of
a positive stop to minimize wedging and subse- its removal for re-treatment. The preferred tech-
quent splitting of the tooth. Similarly, rotation of nique involves drilling in an apical direction. The
the post must be prevented by preparing a flat very strong carbon fibers prevent the drill from
surface parallel to the post (see step 5 in Fig. 12- tracking laterally, avoiding penetration of the dentin
8). If insufficient tooth structure for this feature and preventing the post from shattering easily into
remains, an antirotation groove should be placed small fragments (Fig. 12-31).
in the canal (see Fig. 12-22). Manufacturers have developed high-strength
6. Complete the preparation by eliminating sharp ceramic67,68 (zirconia) posts† (Fig. 12-32) and
angles and establishing a smooth finish line. ceramic composite‡ (Fig. 12-33) and woven fiber
(e.g., polyethylene) posts,§ all of which have excellent
esthetic properties (see also Chapters 25 and 27).
Post Fabrication Ceramic is very strong and rigid; woven fiber is less
strong and more flexible.69 Because the systems are
Prefabricated posts relatively new, judging how well the foundations will
Technique simplicity and treatment expediency are perform in clinical practice is difficult, but they
advantages of prefabricated posts. A post is selected should be considered when esthetic demands are
to match the dimensions of the canal, and only high.
minimum adjustment is needed to seat it to the full Corrosion resistance
depth of the post space. The coronal part of the post Several reports70–72 have linked root fracture to
may have an inadequate fit because the root canal corrosion of base metal prefabricated post and core
has been flared. This can be corrected by adding systems. In one study,67 a report on 468 teeth with
material when the core is made. vertical or oblique root fracture, investigators attrib-
Available materials (see Table 12-5) uted 72% of these failures to electrolytic action of
Prefabricated parallel-sided posts are made of plat-
inum-gold-palladium (Pt-Au-Pd), nickel-chromium
*C-Posts, Bisco Co., Schaumburg, Illinois.
(Ni-Cr), cobalt-chromium (Co-Cr), or stainless steel †
CosmoPost, Ivoclar Vivadent, Amherst, New York.
wire. Serrated posts come in stainless steel, titanium, ‡
Æstheti-Post, Bisco Co., Schaumburg, Illinois.
or nonoxidizing noble alloy. Tapered posts are avail- §
FibreKor, Jeneric/Pentron Inc., Wallingford, Connecticut.
A B,C
D E,F
G H,I
Fig. 12-30
Fiber composite posts. A and B, The ParaPost Fiber Lux system is available in various sizes. C, Gutta-percha is removed with hot
instruments or a Gates Glidden drill. The canal is prepared sequentially with the drills provided by the manufacturer. D, The post
is seated in the canal. E, The canal is prepared by etching and priming according to the manufacturer’s recommendations. F, The
luting resin is introduced into the canal with a paper point. G, The post is coated with resin luting agent, seated and the resin poly-
merized (H). The translucent post allows light transmission to the luting agent. I, The core is built up with the recommended core
resin. J, The preparation is finalized. (Courtesy of Coltène/Whaledent AG, Altstatten, Switzerland.)
dissimilar metals used for the post and the core Further study is needed to answer the question
(reaction occurring between tin in the amalgam core conclusively. However, in the meantime, avoiding
and stainless steel, German silver, or brass in the the use of potentially corrodible dissimilar metals for
post). The authors suggested that volume changes post, core, and crown is recommended.
produced by corrosion products split the root.
Although possible fracture mechanisms have been Custom-made posts
suggested,68,69 these studies are confusing cause with A custom-made cast post and core can be cast from
effect: The corrosion may have occurred after root a direct pattern fabricated in the patient’s mouth, or
fracture rather than causing it. an indirect pattern can be fabricated in the dental
A,B C,D
Fig. 12-31
A, Maxillary canine requires fiber post removal for endodontic re-treatment B, Composite resin core is removed first. C, Gates Glidden
drill used to remove the fiber post. D, Endodontically re-treated tooth before fabrication of new post and core and extracoronal
restoration. If concern exists about the long-term prognosis of an endodontically treated tooth, a carbon fiber post should be con-
sidered. The chief disadvantage of a carbon fiber post is its black appearance, which presents an esthetic problem (as can metal
posts). (Courtesy Dr. D.A. Miller.)
2. Use the bead-brush technique (Fig. 12-34B) to

add resin to the dowel (Fig. 12-34C) and seat it in
the prepared canal. This should be done in two
steps: Add resin only to the canal orifice first. An
alternative is to mix some resin and roll it into a
thin cylinder. This is introduced into the canal
and pushed into place with the monomer-
moistened plastic dowel.
3. Do not allow the resin to harden fully within the
canal. Loosen and reseat it several times while it
is still rubbery.
4. Once the resin has polymerized, remove the
Fig. 12-32 pattern (Fig. 12-34D).
Zirconia posts, such as the CosmoPost, shown with the corre- 5. Form the apical part of the post by adding addi-
sponding rotary instruments, are esthetic and strong. tional resin and reseating and removing the post,
Special pressable ceramics are available to form the core (com- taking care not to lock it in the canal.
posite resin can also be used). (Courtesy of Ivoclar Vivadent, Amherst, 6. Identify any undercuts that can be trimmed away
New York.) carefully with a scalpel.
The post pattern is complete when it can be
inserted and removed easily without binding in the
canal. Once the pattern has been made, additional
resin or light-polymerized resin* is added for the
laboratory. A direct technique with autopolymeriz- core.
ing or light-polymerized resin is recommended for Pattern fabrication with thermoplastic resin.
single canals with good clinical access, whereas an (Fig. 12-35)
indirect procedure is more appropriate for multiple 1. Fit the plastic rod to the prepared post space.
canals or when access is more problematic. As an Trim the rod until the bevel area is approximately
alternative to autopolymerizing resin, thermoplastic 1.5 to 2 mm occlusal to the finish line for the
resin can be used. core.
Direct procedure
1. Lightly lubricate the canal and notch a loose-
fitting plastic dowel (Fig. 12-34A). It should *LX Gel, Dentatus, New York, New York; Palavit G LC, Heraeus Kulzer, Inc.,
extend to the full depth of the prepared canal. South Bend, Indiana.
B C
Fig. 12-33
Ceramic composite post. A, The D.T. LIGHT-POST system uses quartz fibers in an epoxy resin matrix. Cross-sectional (B) and
longitudinal (C) sections of the fiber composite. (Courtesy of Bisco, Inc., Schaumburg, Illinois.)
A,B C,D
Fig. 12-34
A to D, Fabrication of an acrylic resin pattern for a custom-made post. (Courtesy of Dr. R. Webber.)
2. Lubricate the canal with a periodontal probe and post pattern for completeness and, with a scalpel
petroleum jelly. blade, remove any projections that result from
3. Heat the thermoplastic resin over a flame until undercuts in the canal.
the material turns clear, or heat the resin in a low- 6. For the direct technique, fabricate the core
temperature glue gun.* with conventional autopolymerizing resin, using
4. Apply a small amount of the heated resin to the the brush-bead technique, or use a syringe to
apical end of the rod to cover two thirds of the apply a light polymerized pattern resin (an easier
anticipated length of the post pattern. technique).
5. Fully insert the rod into the prepared post space. 7. If the indirect technique is preferred, pick up
Lift after 5 to 10 seconds and reseat. Inspect the the pattern with an elastomeric impression mate-
rial, which can be poured in the conventional
manner. Soak the cast in warm water to help
release the pattern. Reseat the post pattern, and
*Thermogrip, Black & Decker, Inc., Towson, Maryland. wax the core.
A B
C D
E F
Fig. 12-35
The Merritt EZ Cast Post system. A, The canal is lubricated and excess lubricant removed with paper points. The post was previ-
ously trimmed until its beveled portion protruded about 1.5 to 2 mm above the tooth preparation. B, A stick of the thermoplastic
material is heated. C, The plastic rod is covered for about two thirds of the anticipated post length. D, The coated post is inserted
and can be removed in 5 to 10 seconds. E, After any protrusions have been removed, the core is built from autopolymerizing resin
and trimmed to ideal tooth preparation form. F, The completed custom post and core. (From Rosenstiel SF, et al: Custom-cast post
fabrication with a thermoplastic material. J Prosthet Dent 77:209, 1997.)
8. Invest and cast the post and core. Phosphate- 3. Coat the wire with tray adhesive. If subgingival
bonded investment is recommended because of margins are present, tissue displacement may be
its higher strength. helpful. Lubricate the canals to facilitate removal
Indirect procedure of the impression without distortion (die lubri-
Any elastomeric material will make an accurate cant is suitable).
impression of the root canal (Fig. 12-36A) if a wire 4. Using a lentulo spiral, fill the canals with elas-
reinforcement is placed to prevent distortion. tomeric impression material. Before loading the
1. Cut pieces of orthodontic wire to length and impression syringe, verify that the lentulo will
shape them like the letter J (Fig. 12-36B). spiral material in an apical direction (clockwise).
2. Verify the fit of the wire in each canal. It should Pick up a small amount of material with the
fit loosely and extend to the full depth of the post largest lentulo spiral that fits into the post space.
space. If the fit is too tight, the impression mate- Insert the lentulo with the handpiece set at low
rial will strip away from the wire when the rotational speed to slowly carry material into the
impression is removed. apical portion of the post space. Then increase
All of the elastomeric

impression materials
require some form of
reinforcement when
A making a post space
impression.
Impression
material
Impression
B tray
Wire
reinforcement
D E
Fig. 12-36
A to E, Indirect procedure for post-and-cores.
handpiece speed and slowly withdraw the lentulo most apical and make sure that the post is cor-
from the post space. This technique prevents the rectly oriented as it is seated to adapt the wax.
impression material from being dragged out. When this post pattern has been fabricated, the
Repeat until the post space is filled. wax core can be added and shaped.
5. Seat the wire reinforcement to the full depth of 9. Use the impression to evaluate whether the wax
each post space, use a syringe to fill in more pattern is completely adapted to the post space.
impression material around the prepared teeth,
and insert the impression tray (see Fig. 12-36C).
Core Fabrication
6. Remove the impression (see Fig. 12-36D), evalu-
ate it, and pour the definitive cast (see Fig. 12- The core of a post and core restoration replaces
36E) as usual (see Chapter 17). missing coronal tooth structure and, combined with
Access for waxing is generally adequate with- the remaining coronal tissue, forms the shape of the
out placement of dowel pins or sectioning of the optimal tooth preparation. It can be shaped in resin
cast. or wax and added to the post pattern before the
7. Roughen a loose-fitting plastic post (a plastic assembly is cast in one piece. It is cast directly onto
toothpick is suitable) and, using the impression as a prefabricated post. Some concern arises that the
a guide, make sure that it extends into the entire casting process may unfavorably affect the physical
depth of the canal. properties of wrought metal posts. A third alternative
8. Apply a thin coat of sticky wax to the plastic post is to make the core from a plastic restorative mate-
and, after lubricating the stone cast, add soft inlay rial, such as amalgam, or from composite resin or
wax in increments (Fig. 12-37). Start from the glass ionomer.
matrix application (particularly on badly

damaged teeth).
Amalgam cores are suitable for restoring posterior
teeth, particularly when some coronal structure
remains. The procedure described by Nayyar and
A associates,45 with amalgam also used for the posts,
is conservative of tooth structure. The cores are
placed during the same appointment as the root
canal obturation, because then the teeth are still iso-
lated by the rubber dam, the practitioner is still
familiar with the root canal structure, and the cores
can serve as a support for the interim restoration
(Fig. 12-38).
Step-by-step procedure for amalgam (see also
Chapter 6)
1. Apply the rubber dam and remove gutta-percha
B from the pulp chamber, as well as 2 to 4 mm
into each root canal, if less than 4 mm of coronal
height remains. Use a warmed endodontic
instrument.
2. Remove any existing restoration, undermined
enamel, or carious or weakened dentin. Establish
Fig. 12-37 the cavity form, using conventional principles of
A and B, Post and core patterns made by adding wax to pre- resistance and retention form. Even if cusps are
fabricated plastic posts. missing, pins are not normally required, because
adequate retention can be gained by extending
the amalgam into the root canals.
3. If it is suspected that the floor of the pulp
Plastic filling materials chamber is thin, protect it from condensing pres-
The advantages of amalgam, glass ionomer, or sures with a cement base.
resin62,73,74 include the following: 4. Fit a matrix band. Where lack of tooth structure
1. Maximum tooth structure can be conserved, makes the application of a conventional matrix
because undercuts do not need to be removed. system difficult, an orthodontic or annealed
2. Treatment requires one fewer patient visit. copper band may be used.
3. There are fewer laboratory procedures. 5. Condense the first increments of amalgam (select
4. Testing generally shows good resistance to fatigue a material with high early strength) into the root
testing75 and good strength characteristics,76 canals with an endodontic plugger.
possibly because of the good adaptation to tooth 6. Fill the pulp chamber and coronal cavity in the
structure. However, these plastic restorative conventional manner.
materials, especially the glass ionomers, have 7. Carve the alloy to shape. The impression can be
lower tensile strength than do cast metals. made immediately. Alternatively, the amalgam
Disadvantages include the following: can be built up to anatomic contour and later
1. Long-term success may be affected by corrosion prepared for a complete crown. Under these cir-
of amalgam cores, the low strength of glass cumstances, the patient must be cautioned to
ionomer,77 or the continued polymerization78 and avoid forces that would fracture the tooth or the
high thermal expansion coefficients of composite newly placed restoration.
resin cores.
2. Microleakage with temperature fluctuations
(thermocycling) is greater under composite resin Cast metal
and amalgam cores than under conventional Cast metal cores have the following advantages:
crown preparations79 (however, the extent of 1. They can be cast directly onto a prefabricated
leakage under cast cores has yet to be post, providing a restoration with good strength
determined). characteristics.
3. Difficulty may be encountered with certain 2. Conventional high noble-metal content alloys can
operative procedures such as rubber dam or be used.
Crown
Amalgam
Root canal fill

A B,C
D E
Fig. 12-38
A to E, Retention for an amalgam core can be obtained from the root canal system, preserving as much tooth structure as possible.
(B to D, Courtesy Dr. M. Padilla.)
3. An indirect procedure can be used, making core with auxiliary posts is used, as opposed to the
restoration of posterior teeth easier. multisection core recommended for indirect poste-
Direct procedure for single-root teeth rior cast post and cores. The core is cast directly onto
Direct patterns can be formed by combining a pre- the post of one canal. (The other canals already have
fabricated post with autopolymerizing resin. Alter- prefabricated posts that pass through holes in the
natively, a thermoplastic material can be used to core.)
create a post pattern,80 and the core portion can be The procedure is simple, as long as smooth paral-
developed in autopolymerizing resin, light polymer- lel-sided or tapered posts are used:
ized resin, or wax. 1. Fit prefabricated posts into the prepared canals.
Pattern fabrication with autopolymerizing resin One post is roughened; the others are left smooth
1. Use a prefabricated metal or custom acrylic resin and lubricated. All posts should extend occlusally
post. beyond the eventual core.
2. Add resin by the “bead” technique, dipping a 2. Build up the core with autopolymerizing resin,
small brush in monomer and then into polymer using the bead technique.
and applying it to the post. Alternatively, light- 3. Shape the core to final form with carbide finish-
cured resin can be used to facilitate this step.81 ing burs.
3. Slightly overbuild the core and let it polymerize 4. Grip the smooth, lubricated posts with hemosta-
fully (Fig. 12-39A). tic forceps, and remove them.
4. Shape the core with carbide finishing burs or dia- 5. Remove, invest, and cast the core with the rough-
monds (Fig. 12-39B). Use water spray to prevent ened single post. When this has been done, the
overheating of the acrylic resin. Correct any small holes for the auxiliary posts can be refined with
defects with wax. the appropriate twist drill.
5. Remove the pattern (Fig. 12-39C); sprue and 6. After verifying the fit at evaluation, cement the
invest it immediately. core and auxiliary posts to place.
Direct pattern for multiroot teeth Indirect pattern for posterior teeth (Fig. 12-41)
A direct pattern (Fig. 12-40) can be used for multi- 1. Wax the custom-made posts as described
root posterior teeth, although limited access may previously.
make the indirect approach easier. A single-piece 2. Build part of the core around the first post.
A B
A
Fig. 12-40
A direct post and core for posterior teeth can be made by
cementing a prefabricated post through a casting. Here the
two buccal canals (A and B) had a common path of withdrawal
and could be incorporated into the core casting. More typi-
cally, only one canal has a fixed post, and the others are
cemented through the core.
B
Thus, if definitive restoration of the tooth is

delayed, it is appropriate to etch and seal the access
cavity with an adhesive resin to reduce the risk of
microleakage. However, teeth in the esthetic zone
often require a well-adapted interim restoration.
Such interim restorations prevent drifting of the
tooth itself and of opposing or adjacent teeth after
C completion of endodontics (Fig. 12-42). Of particu-
lar importance are good proximal contacts to prevent
tooth migration that leads to unwanted root proxim-
ity. If a cast post and core is made, the tooth will
require an interim restoration while the post and
core is being fabricated. This can be retained by
Fig. 12-39 fitting a wire (e.g., a paper clip or orthodontic wire)
A to C, Direct pattern for a single-root tooth. into the prepared canal. The restoration is then con-
veniently fabricated with autopolymerizing resin by
the direct technique.
Investing and Casting

3. Remove any undercuts adjacent to other post
holes and cast the first section. A cast post and core should fit somewhat loosely in
4. Wax additional sections and cast them. the canal. A tight fit may cause root fracture. The
Using dovetails to interlock the sections makes casting should be slightly undersized, which can be
the procedure more complicated and is probably of accomplished by restricting expansion of the invest-
limited benefit, especially because the final buildup ment (i.e., by omitting the usual ring liner or casting
is held together by the fixed cast restoration. at a lower mold temperature [see Chapter 22]). An
accelerated casting technique may facilitate the lab-
oratory phase.83 The casting alloy should have suit-
Interim Restorations (see Chapter 15)
able physical properties. Extra-hard partial dental
To reduce the need for endodontic re-treatment, prosthetic gold (American Dental Association type
endodontically treated teeth should be restored as IV) or Ni-Cr alloys have high moduli of elasticity and
soon as practical after completion of the endodontic are suitable for cast posts (see Chapter 19). A sound
procedure. Zinc oxide–eugenol (ZOE) luting materi- casting technique is essential because any unde-
als have been used for many years to achieve a seal tected porosity could lead to a weakened casting that
before initiation of prosthetic treatment, However, might fail in function (Fig. 12-43).
such ZOE materials have been shown to leak at the Casting a core onto a prefabricated post avoids
dentin-material interface.83 such problems of porosity, but the preheating tem-
A B
C D
E F
G H
Fig. 12-41
A to D, Multipiece post and cores can be made by the indirect technique, waxing each section to ensure that no undercuts are
created. E to H, Alternatively, interlocking sections can be made, but this complicates the laboratory phase.
It is not essential that the reline

material extend all the way down
the post space. By engaging the
apical portion of the post space,
the wire will enhance resistance
of the provisional.
Reinforcing
wire
Fig. 12-43
Fractured post. (Courtesy of Dr. D. Francisco.)
Autopolymerizing
resin
Preformed
crown
A B
Fig. 12-44
A, The fitting surface of the casting must be carefully evaluated.
B, Nodules, as can be seen here, could easily lead to root frac-
ture and tooth loss.
C post; otherwise, root fracture will result. Post and

cores should be inserted with gentle pressure.
However, the marginal fit of a cast foundation is not
as crucial as that of other cast restorations, because
the margins will be covered by the final casting. Air-
Fig. 12-42 abrading the surface to a matte finish may help
A to C, Interim restorations made for endodontically treated
teeth by lining a polycarbonate crown with autopolymerizing
detect interferences at try-in (Fig. 12-44).
resin. The post is made of metal wire (orthodontic wire or a The shape of the foundation is evaluated and
paper clip; see Chapter 15). (A, From Taylor GN, Land MF: Restoring adjusted as necessary.
the endodontically treated tooth and the cast dowel. In Clark JW, ed: Clinical
Dentistry, vol 4. New York, Harper & Row, 1985.)
Cementation
perature of the investment mold should be restricted The luting agent must fill all dead space within
if recrystallization of the wrought post84 is to be the root canal system (Fig. 12-45). Voids may be a
avoided. The latter would adversely affect its physi- cause of periodontal inflammation via the lateral
cal properties. canals.
A rotary (lentulo) paste filler or cement tube (Fig.
12-46) is used to fill the canal with cement. The post
Evaluation and core is inserted gently to reduce hydrosta-
The practitioner must be particularly careful that tic pressure, which could cause root fracture. If a
casting defects do not interfere with seating of the parallel-sided post is being used, a groove should be
placed along the side of the post to allow for

improved escape of excess cement. Use of venting
procedures has also been shown to reduce the nec-
essary seating force, although the latter is probably
cement specific.85
Removal of Existing Posts

On occasion, an existing post and core must be
removed (e.g., for re-treatment of a failed root canal
filling). Patients must understand in advance that
post removal is a risky process and occasionally
results in radicular fracture. If sufficient length of
post is exposed coronally, the post can be retrieved
with thin-beaked forceps. Vibrating the post first
with an ultrasonic scaler weakens brittle cement and
Fig. 12-45 facilitates removal. A thin scaler tip or special post
Residual voids after cementation can cause inflammation. removal tip is recommended (Fig. 12-47). Although
(Courtesy of Dr. D. Francisco.) histologic examination with animal models reveals
A B
C D
Fig. 12-46
A, Lentulo rotary paste fillers or a cement tube are used to fill the post space completely. B, The post is first coated with cement.
C, The canal is filled with cement. D, To avoid the risk of fracture, the post and core is very gently seated. A small cement line
is not usually significant, because dissolution is prevented by the presence of the definitive restoration. (B to D, Courtesy of Dr. M.
Padilla.)
A B
C D
Fig. 12-47
Post removal by ultrasonic device. A, Preoperative radiograph of the left maxillary first premolar with a parallel-sided threaded post
that had to be removed for endodontic retreatment. B, After the coronal portion of the post has been well isolated, the tip of the
ultrasonic device is placed against it, and energy is applied to disrupt the cement interface. Note the suction tip, which removes
water spray used with the ultrasonic handpiece. C, After a time, the post becomes loose within the canal and can be retrieved by
forceps. D, Radiograph of the premolar after post removal. (Courtesy of Dr. L. L. Lazare.)
no harmful effect in the periodontal tissues,86 ultra-

sonic removal is slower than other methods and may
result in an increased number of canal and
intradentin cracks.87 Alternatively, a post puller can
be used.88 This device consists of a vise to grip the A B
post and legs that bear on the root face. A screw acti-
vates the vise and extracts the post.
A post that has fractured within the root canal
cannot be removed with a post puller or forceps. The
post can be drilled out, but great care is needed to
avoid perforation. The technique is best limited to
relatively short fractured posts (Fig. 12-48).
Another means of handling an embedded frac-
tured post (described by Masserann89 in 1966) is to C D
use special hollow end-cutting tubes (or trephines)
to prepare a thin trench around the post (Fig. 12-49).
This technique has shown success.90 Retrieval can be
facilitated by using an adhesive to attach a hollow
tube extractor91 or by using a threaded extractor92 Fig. 12-48
(Fig. 12-50). Post removal by high-speed bur. A, Preoperative radiograph of
the right maxillary lateral incisor, in which both the crown and
part of a post have been fractured off. A portion of the Kurer-
SUMMARY type, parallel-sided, threaded post remains within the canal.
B, Because of the large diameter of the post and its position
Although the restoration of endodontically treated within the canal, a high-speed handpiece was chosen to drill it
teeth has been rationalized considerably by labora- out. C, Radiograph to verify the correct orientation of the bur’s
tory research data, information from controlled long- progress inside the canal. With this method of post removal,
term clinical trials is still necessary and difficult to the operator must be extremely careful not to let the high-
obtain. Different clinical procedures have been advo- speed bur contact the canal wall, which would seriously com-
cated, many of which are successful if properly used. promise tooth structure. D, Radiograph of the incisor after post
Where the crown is preserved and circumferentially removal and re-treatment. (Courtesy of Dr. D. A. Miller.)
A B
C D
E F
Fig. 12-49
Masserann technique for the removal of fractured posts. A and B, Maxillary incisor with a post that has fractured inside the canal.
C, The diameter of the post is gauged with a sizing tool. D, The selected trephine is carefully rotated counterclockwise to create a
narrow channel around the post. E, When the instrument has removed sufficient material, the post is recovered. F, The fractured
crown and post after removal.
largely intact, an anterior tooth can be safely restored endodontic plugger to remove the gutta-percha.
with a plastic filling. To prevent fracture of posterior Anterior teeth, particularly those with flared or ellip-
teeth, cast restorations providing cuspal coverage are tical canals, should be built up with a custom cast
recommended. post and core, which offers great strength, although
Preserving as much tooth structure as possible is prefabricated posts can be used successfully when
important, particularly within the root canal, in adequate retention and resistance form for the
which the amount of remaining dentin may be diffi- plastic material can be obtained. Esthetic post mate-
cult to assess. rials should be considered if a dark post would
A post and core is used to provide retention and prevent fabrication of an esthetic restoration.
support for a cast restoration. It should be of ade- Amalgam core material can be used satisfactorily on
quate length for good stress distribution but not so posterior teeth when one or more cusps have been
long that it jeopardizes the apical seal. The safest lost, although a casting may be preferred if substan-
method to create post space is to use a heated tial coronal tooth structure is missing.
A B,C
D E,F
G H,I
Fig. 12-50
Post removal by extractor. A, The Thomas (Gonon) post-removing system. It includes pliers, trephine burs, mandrels, and washers.
B, Preoperative radiograph of the left maxillary lateral incisor with a post. C, Note the flared shape of the post in this preoperative
view and the height of the surrounding tooth structure. D, A high-speed bur is used to free the post from coronal tooth structure
and parallel its sides. (Note: An ultrasonic device may be used at this point to disturb the cement interface.) E, A trephine bur
machines the post to the correct diameter and places threads for the mandrel. F, The mandrel is threaded onto the post with special
washers, which distribute the forces from the extractor evenly over the tooth. G, The beaks of the pliers are fitted onto the mandrel;
the knob of the pliers is then rotated, which separates the beaks, and the post is extruded from the tooth. H, The removed post,
still attached to the mandrel and pliers. I, Radiograph of the lateral incisor after post removal. (Courtesy of Dr. D. A. Miller.)
?
STUDY QUESTIONS
1. What must be determined to ensure that an endodontically treated tooth is ready for subsequent restorative
treatment?
2. What six features must be incorporated in the tooth preparation for a cast post and core?
3. Discuss five variables that have an impact on retention form for cast post and cores.
4. Discuss four different post and core systems, their advantages and disadvantages, and typical indications and
precautions.
5. Which canal configurations are circular? Which are elliptical?
6. Describe recommended step-by-step procedures for the following: (1) Custom-made direct procedure post
and core pattern fabrication for a maxillary second premolar. (2) Amalgam post and core on a mandibular
molar.
7. How is an interim restoration fabricated for a mandibular second premolar that has been prepared for a cast
post and core?
rad·ic·u·lar \ră-dı̆-kyōō¢lar\ adj (1830): pertaining to the

GLOSSARY* root of a tooth
anatomic crown \ăn¢a-tŏm¢ı̆k kroun\: the portion of a res·in \rĕz¢ı̆n\ n (14c): 1: any of various solid or semisolid
natural tooth that extends coronal from the cementoe- amorphous natural organic substances that usually are
namel junction—called also anatomical crown transparent or translucent and brown to yellow; usually
an·nu·lar \ăn¢ya-ler\ n (1571): a term used to describe a formed in plant secretions; are soluble in organic sol-
ring like anatomic structure vents but not water; are used chiefly in varnishes, inks,
plastics, and medicine; and are found in many dental
apex \ā¢pĕks¢\ n, pl apex·es or api·ces (1601): 1: the impression materials 2: a broad term used to describe
uppermost point; the vertex 2: in dentistry, the anatomic natural or synthetic substances that form plastic materi-
end of a tooth root als after polymerization. They are named according
autopolymerizing resin \ô¢tō-pŏl-a-mĕr-ı̄¢zing rĕz¢ı̆n\: a to their chemical composition, physical structure, and
resin whose polymerization is initiated by a chemical means for activation of polymerization—see AUTOPOLY-
activator MERIZING R., COPOLYMER R.
avul·sion \a-vŭl¢shun\ n (1622): a forcible separation or root \rōōt, rŏŏt\ n (bef. 12c): the portion of the tooth apical
detachment, as in a tearing away of a body part surgi- to the cementoenamel junction that is normally covered
cally or accidentally by cementum and is attached to the periodontal liga-
ment and hence to the supporting bone
dow·el \dou¢al\ n, obs (13c): a post usually made of metal
that is fitted into a prepared root canal of a natural tooth. stress \strĕs\ n (14c): force per unit area; a force exerted
When combined with an artificial crown or core, it pro- on one body that presses on, pulls on, pushes against, or
vides retention and resistance for the restoration—See tends to invest or compress another body; the deforma-
POST tion caused in a body by such a force; an internal force
that resists an externally applied load or force. It is nor-
e·las·tic \ı̆-lăs¢tı̆k\ adj (1653): susceptible to being mally defined in terms of mechanical stress, which is the
stretched, compressed, or distorted and then tending to force divided by the perpendicular cross sectional area
resume the original shape over which the force is applied—see COMPRESSIVE S.,
elastic modulus \ı̆-lăs¢tı̆k mŏj¢a-lus\: the stiffness or flexi- SHEARING S., TENSILE S.
bility of a material within the elastic range. Within the wax pattern \wăks păt¢urn\: a wax form that is the posi-
elastic range, the material deforms in direct proportion tive likeness of an object to be fabricated
to the stress applied as represented by Hooke’s law
ex·po·sure \ı̆k-spō¢zher\ n (1606): 1: the act of laying
open, as a surgical or dental exposure 2: in radiology, a REFERENCES
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The Glossary of Prosthodontic Terms, 8th Edition, pp. 10–81, © 2005,
fracture resistance of teeth restored with cast post
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12

Two factors inﬂuence the choice of technique:

A good prognosis. It can resume full function

decision is made to treat the tooth endodontically,

slightly larger to achieve optimal seating (see

Fig. 12-3 Clinical Failure

In the planning of the restoration of endodonti-

Considerations for Anterior Teeth

It takes some practice to

Coupled with the loss of internal tooth structure

Unitek Whaledent Kurer

ter does not exceed one third of the cross-sectional

because of the missing tooth structure. In mandibu-

but should be avoided in posterior teeth, which often

Removal of the Endodontic Filling Material

Length is NEVER gained with

Table 12-1 AVERAGE CROWN AND ROOT LENGTHS (IN MILLIMETERS)

Table 12-3 ROOT CANAL CONFIGURATIONS

Enlargement of the Canal

Text continues on page 358

Example† Product (vendor) Composition‡ Characteristics Diameter (mm)§

TAPERED SERRATED POSTS

TAPERED THREADED POSTS

Ancorex (E. C. Moore)¶ Ti Tightly threaded 1.1 to 1.8

PARALLEL SMOOTH-SIDED POSTS

Example† Product (vendor) Composition‡ Characteristics Diameter (mm)§

CTH R Series (CTH) SS Vertical grooves, ﬂat tip 1.1 to 1.6

PARALLEL SERRATED POSTS

PARALLEL THREADED POSTS

ture, such posts can also create an undesirable

Preparation of the Coronal Tooth Structure

2. Use the bead-brush technique (Fig. 12-34B) to

All of the elastomeric

matrix application (particularly on badly

Root canal fill

Thus, if deﬁnitive restoration of the tooth is

Investing and Casting

It is not essential that the reline

C post; otherwise, root fracture will result. Post and

placed along the side of the post to allow for

Removal of Existing Posts

no harmful effect in the periodontal tissues,86 ultra-

rad·ic·u·lar \ră-dı̆-kyōō¢lar\ adj (1830): pertaining to the

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