doi:10.1111/iej.
12847
REVIEW
A new classification system for the restoration of
root filled teeth
2 , G. Paolone3
M. Zarow1, A. Ram
ırez-Sebastia
2

n-Sindreu & M. Roig2
Espona , F. Dura 2
1
Private Practice, Krakow, Poland; 2Department of Restorative Dentistry and Endodontics, School of Dentistry,
Universitat Internacional de Catalunya, Barcelona, Spain; and 3Dental School, Universit

Abstract
Zarow M, Ram
ırez-Sebastia  A, Gaetano P,
de Ribot Porta J, Mora J, Espona J, Dura
n-Sindreu
F, Roig M. A new classification system for the restoration of
root filled teeth. International Endodontic Journal, 51, 318–
334, 2018.
The aim of this report is to (i) review the current liter-
ature on the status of root filled teeth, (ii) analyse the
most important factors in decision-making, (iii) dis-
cuss the current restorative concepts, and (iv) classify
both the evidence and clinical practice in a way that
Introduction
Restoration of root filled teeth is a controversial sub-
ject and a challenge because of the confusing range
of opinions presented by dentists and scientists, which
makes it difficult to select the most appropriate
restorative option (Vire 1991, Morgano et al. 1994).
The ongoing debate on whether a post is necessary
also remains controversial. The aim of this article is
to classify both the evidence and clinical practice in a
way that seeks to be clear, understandable and
helpful for clinicians.
Current status of root filled teeth
Root filled teeth are structurally and aesthetically
compromised (Morgano et al. 1994). The loss of tissue
Correspondence: Fernando Dur
an-Sindreu, Department of
Restorative Dentistry and Endodontics, School of Dentistry,
Universitat Internacional de Catalunya (UIC), Sant Cugat del
Valles, Barcelona, Spain (e-mail: fduran@uic.es).
318 International Endodontic Journal, 51, 318–334, 2018
, J. de Ribot Porta2, J. Mora2, J.
a Vita e Salute San Raffaele, Milan, Italy
seeks to be clear, understandable and helpful for clini-
cians. Restoration of root filled teeth represents a
challenge for the clinician and remains a controver-
sial subject. The guidelines describe a new classifica-
tion that is drawn from evidence presented in the
literature and also from clinical expertise-based
reviews. It describes five categories of teeth.
Keywords: dental restoration, endodontics,
post-and-core technique, root canal treatment.
Received 3 December 2015; accepted 23 August 2017
at root and crown levels leads to significant biome-
chanical changes (Cariso et al. 1987, Robbins 1990,
ogren et al. 1990, Peroz et al. 2005) resulting in a
Sj€
high incidence of fractures (Sj€ogren et al. 1990). Evi-
dence suggests that fracture of root filled teeth and, in
consequence, the risk of tooth loss are considerably
higher than that of teeth with vital pulps. Using data
from more than 46 000 patients from 28 dental prac-
tices, Fennis et al. (2002) found a positive correlation
between root filled teeth and subgingival fracture
location. Loss of internal tooth structure leads to
increased cusp deflection during occlusal function.
Deflection is more pronounced in root filled premolars
with mesial, occlusal and distal (MOD) cavities, and
by doubling the depth of the MOD cavity, the cuspal
deflection has been reported to increase by a factor of
eight (Hood 1985).
Root filled teeth are more vulnerable to tooth loss
than teeth with vital pulps due to the following risk
factors:
• Post-treatment disease following root canal treat-
ment (de Chevigny et al. 2008).
© 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd

• Loss of substantial tooth structure through caries,
previous restorative treatment and endodontic pro-
cedures (sometimes repeated over years; Trabert
et al. 1978, Mondelli et al. 1980, Pitts et al. 1983,
Reeh et al. 1989, Trope & Ray 1992, Hansen &
Asmussen 1993).
• Weakening of tooth structure through use of
endodontic chemicals (calcium hydroxide, sodium
hypochlorite, EDTA, chlorhexidine, alcohol; Niu
et al. 2002, Marending et al. 2007, Qian et al.
2011, Uzunoglu et al. 2012).
• Dehydration of dentine and transformation of col-
lagen fibre structure (age factor, loss of unbound
water from the root canal space and the dentinal
tubules in pulpless teeth (Bang & Ramm 1970,
Kinney et al. 2005, Porter et al. 2005, Bajaj et al.
2006, Bakland & Andreasen 2012).
• Reduction in the level of proprioception, which
can lead to uncontrolled occlusal forces (Loewen-
stein & Rathkamp 1955, Randow & Glantz 1986).
Additionally, other individual factors, such as gen-
der, occlusion, parafunctions, the material of the
antagonist occlusal surface (e.g. implant supported
crown), oral hygiene or saliva flow, can influence the
prognosis of restored teeth (Kishen 2006, Peutzfeldt
et al. 2008, Dias et al. 2016).
The most important factors in selecting
the restorative approach
Although patient satisfaction with root canal treat-
ment followed by tooth restoration is high (Hamasha
& Hatiwsh 2013), the procedure requires a significant
investment. Therefore, the overall treatment and
tooth structure must be assessed to ensure a good
long-term prognosis. Treatment planning should
include a careful analysis of the implications of tooth
restoration. The most important factors to consider
are as follows:
Residual crown structure
One of the most important factors influencing the suc-
cess of a restoration is the amount of remaining
supragingival tooth structure. The ferrule effect,
described as a band that encircles the perimeter of the
residual tooth, has a crucial influence on fracture
resistance, especially in decoronated teeth (Juloski
et al. 2012, 2014, Abdulrazzak et al. 2014). A prop-
erly executed ferrule reduces the incidence of frac-
tures in root filled teeth by reinforcing the external
© 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd
Zarow et al. New classification for RFT restoration
surface of the tooth and dissipating the forces that
concentrate at the narrowest circumference of the
tooth (Linde 1984, Wu et al. 1998). Increasing the
ferrule height, particularly on the palatal side,
enhances tooth resistance (Zhang et al. 2015). As lit-
tle as 1 mm of coronal dentine above the gingival
margin during crown preparation will double the
fracture resistance of preparations in which the core
terminates on a flat surface directly above the margin
(Sorensen & Engelman 1990, Milot & Stein 1992).
However, for a more predictable restoration, a prop-
erly executed ferrule must be 1.5–2 mm high, espe-
cially on the palatal and buccal walls (Helfer et al.
1972, Rivera & Yamauchi 1993, Juloski et al. 2012).
If destruction of the tooth structure renders a suffi-
cient ferrule unachievable, crown lengthening or
orthodontic extrusion should be performed (Juloski
et al. 2012).
Residual root structure
In addition to the amount of remaining coronal tooth
structure, the amount of residual root is also signifi-
cant. Although there is a dearth of evidence-based
research on the topic, the use of crown-to-root ratio
in addition to other clinical indices may offer the best
clinical predictors (Grossmann & Sadan 2005). A
1 : 1 ratio has been recommended as the minimally
acceptable necessary for resisting lateral forces when
the periodontium is healthy and the occlusion is con-
trolled (Ng et al. 2006). Long-term maintenance of a
tooth with an unfavourable crown-to-root ratio, due
to the presence of reduced alveolar bone support,
might lead to increased mobility and possible
periodontal issues (Baraban 1967).
Compromised tooth reconstruction versus value of
the tooth in the treatment plan
When a tooth is to be restored with a crown or has
to act as an abutment for a fixed/removable prosthe-
sis, the cost and the amount of work involved must
be considered, along with endodontic and periodontal
issues and patient-related factors (systemic conditions,
medication, social habits, expectations).
Loss of retention and fractures of both teeth and
restorations in fixed (Randow et al. 1986) and remov-
able (Wegner et al. 2006) prosthodontics have been
shown to be more frequent when the distal abutments
are root filled. In a retrospective clinical study com-
paring 1273 root filled teeth as abutments or crowns,
International Endodontic Journal, 51, 318–334, 2018 319
 New classification for RFT restoration Zarow et al.
the success rate related to the greater lateral func-
tional stresses was found to be higher for single
crowns (94.8%) than for fixed bridges (89.2%) and
removable prosthesis (77.4%). The amount of remain-
ing tooth structure and presence of appropriate cor-
ono-radicular anchorage that serve as abutments are
even more critical for root filled teeth (Dua et al.
2016).
When, on the other hand, a questionable tooth is
part of a wider restoration, especially if in a strategic
position, extraction and implant options should be
considered (Zitzmann et al. 2010).
In cases where implants are already planned and
the tooth under consideration is between them, its
strategic value could be reduced, and even teeth with
a questionable to good prognosis may be considered
for extraction (Zitzmann et al. 2009, 2010). However,
this approach should be considered only in selected
cases, and the preservation of the specific tooth/teeth
should always be considered first (Patzelt et al. 2014).
Function and tooth position in the arch
Occlusal load is key to treatment planning for root
filled teeth. It is important for the clinician to under-
stand whether the patient has acceptable function or
can be classified as belonging to one of three groups
of abnormal occlusal attrition: constricted path of clo-
sure, occlusal dysfunction or parafunction (true brux-
ism; Jayne 2006).
In the case of excessive occlusal wear, more
destructive loadings are expected, which can predis-
pose compromised root filled teeth to fracture or other
types of failure such as post fracture (Mehta & Millar
2008, Peutzfeldt et al. 2008), debonding or composite
core fracture (Dietschi et al. 2006).
Occlusal forces on one tooth have been reported to
be up to 10 times greater than the maximum biting
forces distributed in a balanced occlusion (Hidaka
et al. 1999). Research has demonstrated that due to
progressive cuspal displacement, both time- and load-
dependent, continuous loading as a result of clench-
ing is more destructive than chewing (Larson 2006).
Understanding occlusal problems and planning an
appropriate reinforcement of the tooth to be treated
may help to reduce future failure risk (Trushkowsky
2014).
On the other hand, the clinician must be certain
that the restored root filled tooth does not play a
strategic functional role in the occlusion. In the case
of compromised root filled tooth reconstruction, not
320 International Endodontic Journal, 51, 318–334, 2018
only can post placement be planned, but appropriate
design of the occlusal surface should also be per-
formed (Lynch et al. 2004, T€ orbjorner & Fransson
2004b, Faria et al. 2011, Dammaschke et al. 2013,
Liu et al. 2014). In order to decrease the magnitude
of stresses, it is important to maintain occlusal points
of contact with opposing teeth rather than wider
areas of occlusal contacts (Wiskott & Belser 1995,
Costa et al. 2014). Considering that parafunctional
loads can be six times the normal chewing force, pos-
sible occlusal interferences must be identified and
adjusted, as they may be potentially damaging (Was-
sell et al. 1998). Horizontal forces caused by para-
function may increase the risk of endodontic failure
(Eliyas et al. 2015) although nothing could be found
in the literature related to parafunctions and failure
of root filled teeth.
The position of the tooth in the arch is important
in treatment planning. Maxillary posterior teeth are
more likely to fail than similar mandibular teeth (Fer-
rari et al. 2007a, Ghavamnasiri et al. 2011). Consid-
erable differences exist between anterior and posterior
teeth in the indications for fibre posts (Naumann et al.
2008, 2012). In posterior teeth, fibre posts should be
used only for adhesive purposes (Zarow et al. 2009,
Ferrari et al. 2012). A fibre post should be inserted
only in the presence of limited coronal dentine with
the aim of increasing the amount of bonded dentine
(Bergman et al. 1989). In such cases, the fibre post is
luted to increase the adhesive surface area. When full
crowns are planned, root filled molars and premolars
with limited tissue loss can be restored without posts.
Posts could be helpful in those teeth, particularly in
premolars, if cusp protection is not provided (Aurelio
et al. 2016). In the case of a premolar with severe
periodontal loss, a large diameter post seems essential
(Wang et al. 2016). Severe periodontal bone loss
increases the length of the tooth above the bone
which significantly increases the risk of tooth frac-
ture. Increasing the length of posts increases the resis-
tance to fracture and strength of teeth (Standlee et al.
1972, Akkayan 2004, Santos-Filho et al. 2008, Du
et al. 2011); however, the biomechanical effect of post
diameter seems to be more important than that of
post length (Asmussen et al. 2005, Okamoto et al.
2008, Wang et al. 2016). This is because post diame-
ter contributes more than length in resisting the
bending mode (Wang et al. 2016).
For anterior teeth, the situation is entirely different.
Whilst posterior teeth have to support compressive
loads, where elasticity is the most important
© 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd

characteristic (Pedrollo Lise et al. 2017), maxillary
anterior teeth have to support flexural stresses, where
rigidity is the most important characteristic (Magne &
Douglas 2000). In anterior teeth, fibre posts are often
luted for functional rather than adhesive reasons in
order to increase rigidity (Helfer et al. 1972, Creugers
et al. 1993, Youngson 2005, Ramirez-Sebastia et al.
2014).
Restoration concepts
Improved physical properties of composite resins and
the introduction of adhesive systems offer increased
potential for the restoration of root filled teeth (Assif
& Gorfil 1994). Mechanical interlocking of resin with
peritubular/intertubular dentine and hybrid layer for-
mation is important for the performance of composite
resin restorations (Pashley & Carvalho 1997). Adhe-
sive restorations promote sufficient retention and cre-
ate an adhesive bridge between the buccal and
lingual cusps of the tooth (Ausiello et al. 1997). Com-
posite resins may have the potential to decrease
deflection and fracture of cusps under occlusal load
(Magne & Belser 2003). In cases with sufficient
remaining tooth structure, especially if intact enamel
is present, the use of indirect adhesive restorations
without posts provides alternatives to conventional
treatment concepts (Scotti et al. 2013). Enamel is pre-
ferred over dentine for bonding (Tezvergil et al. 2003,
Van Meerbeek et al. 2003). Marginal discolouration,
poor adaptation and loss of retention occur when the
dentine/adhesive interface is exposed to the oral cav-
ity. Discoloration, poor marginal adaptation and sub-
sequent loss of retention of the restoration (Mjor &
Gordan 2002, Mjor et al. 2002) are frequent clinical
findings. Even though several studies revealed excel-
lent immediate and short-term bonding effectiveness
of dental adhesives (van Dijken 2002), the durability
and stability of resin-bonded interfaces on dentine cre-
ated by some bonding systems remain questionable
(Carrilho et al. 2005, Tay et al. 2005, Bitter et al.
2012, Marchesi et al. 2013). Major concerns have
been expressed regarding interfacial ageing due to
degradation of the hybrid layer, related to water sorp-
tion, hydrolysis of the resin and disruption of the col-
lagen network (Breschi et al. 2008). These studies
highlighted that immediate dentine bond strength val-
ues do not always correlate with long-term bond sta-
bility (De Munck et al. 2005) as degradation
throughout the dentine-bonded interface occurs in
© 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd
Zarow et al. New classification for RFT restoration
months (Carrilho et al. 2005, Tay et al. 2005, Breschi
et al. 2008).
As root filled teeth are often structurally compro-
mised, root canal-retained restorations were proposed
to achieve sufficient anchorage of a restoration
(Shillingburg et al. 1997).
For many years, the cast gold post and core was
regarded as the ‘gold standard’ due to its superior
success rate (Bergman et al. 1989, Creugers et al.
1993). Alternatives to cast posts and cores have been
developed as fibre posts have an elasticity modulus (E)
closer to that of dentine (post = 20 GPa, dentine = 18
GPa) when compared with prefabricated and cast
metal posts (E = 200 GPa) and ceramic posts
(E = 150 GPa) allowing the absorption and uniform
distribution of stresses to the remaining root structure
instead of concentrating them (Linde 1984, Bergman
et al. 1989, Robbins 1990, Creugers et al. 1993, Fer-
rari et al. 2000). Although prefabricated metal posts
have an elastic modulus greater than that of dentine,
their behaviour in the root canal is similar to fibre
posts contrary to cast posts, which concentrate the
stress apically. That could be explained by the pres-
ence of resin composite around the post preventing its
contact with the root canal walls (Kainose et al.
2015).
The use of prefabricated posts and custom-made
cores with composite simplifies the restorative proce-
dure, because all steps can be completed chairside,
and clinical success can be expected (Sahafi et al.
2004, Monticelli et al. 2006, Vano et al. 2006, Fer-
rari et al. 2007b, Cagidiaco et al. 2008, Stewardson
et al. 2010) if all adhesive procedures are followed.
Composite alone cannot reduce high stresses in the
critical cervical area, especially in the case of a nar-
row abutment diameter, which is prone to horizontal
fractures in such cases (Glockner et al. 1999). How-
ever, disregard of the specific indications and con-
traindications can lead to failure of fibre post
reconstructions. According to the results of a 10-year
clinical study, an unexpectedly high annual failure
rate of 4.6% and an overall failure rate of 37% were
reported, with 11% accounting for fibre post fractures
and 11% for post debondings (Naumann et al. 2012).
The highest probability of failure was reported for
anterior teeth with no cavity walls. A similar mode of
failure of fibre posts was observed in another study
with premolars, in which the fibre post concept failed
in cases with extensive tooth destruction (L€ uthy &
Gauckler 1993).
International Endodontic Journal, 51, 318–334, 2018 321
 New classification for RFT restoration Zarow et al.
Other concerns were difficulty in luting a post to
the canal wall and the mechanical properties of the
various brands of fibre posts. Luting a post is a tech-
nically demanding procedure, and failure of the adhe-
sion to the dentine has been reported (Grandini et al.
2004, Yoldas et al. 2005).
Adhesion to canal walls may be affected by several
factors such as the presence of smear layer, the post
space preparation method (Serafino et al. 2004, Gor-
acci et al. 2005), adverse clinical factors, gutta-percha
solvents (Erdemir et al. 2004), the use of disinfectant
solutions such as sodium hypochlorite in concentra-
tions over 2% or in combination with EDTA or intra-
canal medicaments such as calcium hydroxide (Saleh
& Ettman 1999, Grigoratos et al. 2001, Morris et al.
2001, Ari et al. 2003, Ozturk & Ozer 2004), the use
of eugenol-based materials (Bayindir et al. 2003, Car-
valho et al. 2007), the use of bleaching agents (Elkha-
tib et al. 2003, Arcari et al. 2007), the influence of
root canal retreatment (Erdemir et al. 2004) and geo-
metric factors, for example unfavourable C-factor and
greater polymerization shrinkage due to the canal
configuration (Bouillaguet et al. 2003, Tay et al.
2005) and the filler content of the cement (Ferrari
et al. 2009).
The structural differences in root dentine result in
improved bond strengths from the apical to the coro-
nal portion (Naito 2010, Balto 2011).
Proper polymerization of the bonding agent is
critical to achieve a solid and lasting post adhesion
(Wu et al. 2009). New adhesives have been intro-
duced with the aim of simplifying the luting proto-
col. However, care must be taken when using etch-
and-rinse and single-step self-etch adhesives (Suh
et al. 2003), due to incompatibility with self-cure
and dual-cure cements; thus, the application of a
chemical initiator for polymerization is indicated
(Suh et al. 2003).
The use of light-cured materials is not advised
because the light cannot penetrate along the length
of the post (Wu et al. 2009). Dual-cure materials pro-
vide the most reliable option for achieving good
cement polymerization along the post length (Goracci
et al. 2008). Although purportedly able to polymerize
even in the complete absence of light, dual-curing
resins develop better mechanical properties when light
irradiated (Caughman et al. 2001).
The load-bearing ability of teeth with nonvital
pulps may be improved by the application of high-fil-
ler-content composite resins, suitable both for cores
and for post cementation. Its use simplifies the clinical
322 International Endodontic Journal, 51, 318–334, 2018
protocol and results in a more mechanically homoge-
neous restoration (Putignano et al. 2007, R€ odig et al.
2010, Panitiwat & Salimee 2017). However, from a
research perspective, it is important to note that the
increased percentage of filler in these materials
needed for core build-up leads irreversibly to higher
stress during polymerization, ultimately resulting in
lower bond strength values (Ferrari et al. 2009).
Fibre posts that fit accurately in the root canal pos-
sess higher bond strength and fewer gaps than do
posts with an inaccurate fit (Penelas et al. 2016).
Prospective and retrospective clinical studies have
indicated that fibre post displacement occurs with
greater frequency with a thicker cement layer (Fre-
driksson et al. 1998, Ferrari et al. 2000). Thus, the
restoration of weakened roots with extensive tissue
destruction resulting from carious lesions, previous
restorations with excessive post and core diameters,
canal overinstrumentation, incomplete physiological
root development, internal resorption, developmental
anomalies or even oval-shaped root canals present a
challenge to dentists (Chersoni et al. 2005, Baba
et al. 2009).
The evidence suggests that cuspal coverage should
be provided for posterior root filled teeth. Sorensen &
Martinoff (1984) concluded in their retrospective
evaluation of 1273 root filled teeth that the presence
of cusp coverage was the only significant restorative
variable to predict long-term success.
New classification
Restoration of root filled teeth has an important role
in clinical practice. The use of posts in the restorative
phase following root canal treatment was thought in
the past to strengthen teeth (Trope et al. 1985).
Indeed, this concept is still considered relevant by
many dentists (Naumann et al. 2006a). Interestingly,
the use of posts is strongly influenced by the country
or even region where the dentist practises (Hussey &
Killough 1995, Naumann et al. 2006a, 2016, Kon
et al. 2013, Akbar 2015) and by the postgraduate
education received (Sarkis-Onofre et al. 2015). Whilst
in the United States both board-certified prosthodon-
tists (43%) and general dentists (59%) were of the
opinion that a post reinforces a root filled tooth (Mor-
gano et al. 1994), only 29% of dentists surveyed in
Sweden shared this opinion (Eckerbom & Magnusson
2001). Clearly, there is a need of a classification that
guides the dentist in the restorative process of root
filled teeth.
© 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd

The aim of this new classification was to help the
clinician to select the most appropriate treatment plan
for restoring root filled teeth when choosing between
a composite core alone, a composite core reinforced
by fibre post, a gold cast post or implant treatment.
Class 0 (no post – composite core build-up)
It is possible to take advantage of the anatomy of the
pulp chamber, particularly in posterior teeth, to
increase adhesive surface area and thus mechanical
retention (Rocca et al. 2013, Sedrez-Porto et al. 2016,
Belleflamme et al. 2017, Hayes et al. 2017). Unless
the destruction of coronal tooth structure is extensive,
the pulp chamber and canals provide adequate reten-
tion for a core build-up (Sokol 1984). Given these
anatomical features, root filled molars and some ante-
rior teeth may not require posts (Assif et al. 2003,
Ramirez-Sebastia et al. 2013, Belleflamme et al.
2017). However, occlusal relationships should be
carefully evaluated in anterior teeth. The possibility of
restoring anterior and posterior teeth without the use
of a post is an advantage because more tooth sub-
stance is preserved and the clinical procedure is easier
to achieve (Figs 1a–e and 2a,b,c,e). According to
Magne et al. (2017), fibre posts are always detrimen-
tal to the failure mode, and should be avoided in inci-
sors when a ferrule is present.
Class 1 (fibre post)
Post placement is recommended in anterior teeth and
premolars with compromised tooth structure (<50%
structure; Meyenberg 2013, Guldener et al. 2017).
Structurally compromised teeth have less than 50%
of remaining coronal structure. The placement of a
post is indicated when two or fewer walls are present
in anterior teeth and premolars (Ferrari et al. 2012).
Premolars, unlike molars, often have less tooth sub-
stance and smaller pulp chambers to retain a core
build-up after root canal treatment (Sorrentino et al.
2007). Premolars are also more likely to be subjected
to lateral forces during mastication (Sorrentino et al.
2007). It has been well documented that the fracture
resistance of a tooth depends on the angle of the
applied load, with oblique forces being more detrimen-
tal (Assif & Gorfil 1994). In retrospective clinical
reports (Abramovitz et al. 2001, Heydecke et al.
2001), premolars were found to be the most fre-
quently fractured teeth. For these reasons, they may
require posts more often than molars. Ferrari et al.
© 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd
Zarow et al. New classification for RFT restoration
(2000), over a 2-year observation period, concluded
that fibre post placement significantly reduced failure
risk for root filled premolars. In particular, fibre posts
appeared to play a protective role against root frac-
ture (Ferrari et al. 2000). In the case of molars, there
is no need for a post, except in cases of totally missing
coronal tooth tissue and insufficient pulp chamber
surface (Sorrentino et al. 2007).
Anterior maxillary teeth have to support flexural
stresses, and fibre posts are often luted for functional
reasons to increase biomechanical properties (D’Arcan-
gelo et al. 2008, 2010, Salameh et al. 2008). Addition-
ally, applying fibre posts with highly fluorescent
characteristics is purported to improve the final aes-
thetic outcome of the restoration (Fig. 3a–e; Paolone
et al. 2013).
Class 2 (pre-restorative procedures are needed:
orthodontic extrusion or crown lengthening)
Post placement cannot compensate for total or partial
ferrule loss. A fibre post might be placed only after
orthodontic or surgical crown lengthening. This deci-
sion should be based on the position of the tooth in
the arch: for molars, surgical crown lengthening, and
for premolars and anteriors, orthodontic extrusion is
reported to be preferable (Abdulrazzak et al. 2014,
Juloski et al. 2014, Magne et al. 2017; Figs 4 and 5).
In general, crown lengthening involves a number of
significant disadvantages. From the patient’s perspec-
tive, these include treatment delay (especially for
wound healing or orthodontic extrusion), discomfort
and the considerable added cost to an already expen-
sive sequence of procedures. Initiation of final pros-
thetic treatment should wait at least 3 months and
possibly up to 6 months for aesthetically important
areas, as the free gingival margin requires a minimum
of 3 months to establish its final vertical position
(Hempton & Dominici 2010). In the anterior zone, sur-
gical crown lengthening of a single tooth has a nega-
tive aesthetic impact, particularly in medium and high
smiles, making forced tooth eruption via orthodontic
extrusion the technique of choice when clinical crown
lengthening is needed in isolated teeth in the anterior
zone (Camargo et al. 2007, Hempton & Dominici
2010). Biomechanically, the disadvantages include an
increased crown-to-root ratio, especially in surgical
crown lengthening, and loss of tooth structure result-
ing from apical relocation of the preparation finish line
(Juloski et al. 2012). Meng et al. (2009) found in a lab-
oratory study that increased apical ferrule preparation
International Endodontic Journal, 51, 318–334, 2018 323
 New classification for RFT restoration Zarow et al.
(a)
(c)
(e)
Figure 1 (a) Temporary restoration in tooth 26 prior to root canal treatment. (b) Tooth 26 following removal of the temporary
restoration. (c) Direct reconstruction of tooth 26 without using a post. (d) Final restoration of tooth 26. (e) Final periapical
radiograph of tooth 26.
lengths resulted in significantly increased fracture resis-
tance for simulated forced tooth eruption, but not for
simulated crown lengthening. Surgical crown length-
ening inevitably increases the tooth length above the
bone level, and the more height of tooth structure
above the bone level the greater is the risk of failure of
root filled teeth (Naumann et al. 2006b, Wang et al.
2016). Orthodontic extrusion is a predictable proce-
dure and combined with a fiberotomy and gingival
recontouring allows an optimal relation between the
gingiva and the margin of the restoration to be created
(Malmgren et al. 1991). Orthodontic extrusion is easier
to achieve in maxillary teeth than in the mandible
(Malmgren et al. 1991).
Class 3 (gold cast post)
Teeth with no ferrule effect may fail and root fracture
may result (Abdulrazzak et al. 2014, Magne et al.
2017). If a ferrule is not possible (either periodontally
or orthodontically), but the patient still prefers to save
324 International Endodontic Journal, 51, 318–334, 2018
(b)
(d)
the tooth, a gold cast could provide a possible alterna-
tive (Maroulakos et al. 2015, Sarkis-Onofre et al.
2017). There are several long-term clinical studies
that report high success rates with cast gold posts
(Bergman et al. 1989, Ellner et al. 2003, Raedel et al.
2015, Cloet et al. 2017). From the endodontist’s per-
spective, cast gold posts are easily removed for
retreatment. Silver–palladium alloys can be used as
an alternative to gold. These posts are easy to adjust
at the chairside, demonstrate acceptable casting accu-
racies and have properties similar to those of gold
casting alloys (Oilo et al. 1985, Stokes & Hood 1989).
With minimal residual tooth structure and absence
of a ferrule effect, newer options such as fibre-rein-
forced posts and cores have a reduced longevity
(Magne et al. 2017). Under mechanical stress and high
temperatures, they undergo greater deformation
(Kovarik et al. 1992). Absorption of liquid also has a
negative effect on the three-dimensional stability of
composite build-ups (Huysmans et al. 1993) leading to
a tendency towards the development of microleakage
© 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd

(a)
(c)
(e)
Figure 2 (a) Preoperative image of anterior teeth. (b) Tooth 11 and 21. Class 0: >50% of coronal structure remaining without
the necessity of fibre post placement. (c) Rubber dam isolation on teeth 11 and 21. (d) Direct restorations on teeth 11 and 21.
(e) Final radiographs of teeth 11 and 21.
(Chang et al. 2012), caries and post-treatment
endodontic disease (Freeman et al. 1998). When a
fibre-reinforced restorations loosens, it may be unno-
ticeable to the patient and may lead to caries and, even-
tually, to tooth extraction (Schmitter et al. 2011).
Laboratory studies report a higher frequency of
core failure for composite cores than for metal cores.
Mechanical qualities of the core material play a more
important role, particularly in cases where less resid-
ual dentine is present (Hoag & Dwyer 1982, Akkayan
& Gulmez 2002, Pilo et al. 2002). One proposed
guideline is that a direct technique with a composite
build-up may offer an alternative in which more than
one-third of the coronal dentine remains (T€orbjorner
& Fransson 2004a).
© 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd
Zarow et al. New classification for RFT restoration
(b)
(d)
A cast post may also provide an option when the
axis of the root filled teeth needs to be corrected;
when compromised root filled teeth will serve as an
abutment for a longer span bridge (Figs 12–14), pre-
cise attachment or telescopic crown; or when compro-
mised root filled teeth are subjected to extensive
occlusal forces (Meyenberg 2013).
The clinician must be aware that teeth restored
with a cast post and core support a greater compres-
sive load in comparison with fibre posts, but when
they fail they fracture in a catastrophic manner
(Franco et al. 2014). A stiff post, in the case of mini-
mal residual coronal dentine, distributes the forces
along the post into the root. Failures caused by fatigue
would occur at higher stress levels and after a
International Endodontic Journal, 51, 318–334, 2018 325
 New classification for RFT restoration Zarow et al.

(a) (c)

(d)

(b)

(e)

Figure 3 (a) Tooth 22. Class 1: <50% of remaining coronal structure. (b) Radiograph of tooth 22 prior to post placement.
(c) Fibre post placement on tooth 22. (d) Fibre post in tooth 22 before reconstruction. (e) Postoperative image of tooth 22.

Figure 4 Radiographic sequence of crown lengthening on tooth 27. Endodontic treatment, crown lengthening, build-up and
indirect restoration (overlay).

considerably longer time compared with fibre posts,
but the risk of an irreparable root fracture would be
increased (Freeman et al. 1998, Martinez-Insua et al.
1998). De Backer et al. (2007) confirmed significantly
more failures after the use of post and core abutments
for bridges with more than 3 units and cantilever
bridges.
Other drawbacks to cast posts include the clinical
time required, the need for an additional appointment,
the need to place a temporary crown (Baba et al.
2009), the higher cost and the risk of bacterial
contamination during temporization (Heling et al.
2002, Fokkinga et al. 2007). After post space prepara-
tion, the clinician’s main concern is the small amount
of filling material that remains in the root canal. This
most apical portion serves as the only barrier against
penetration of microorganisms that may cause periapi-
cal inflammation (Heling et al. 2002). To reduce the
risk of contamination of the canal and colonization of
bacterial species on the walls of the apical portion of
the root canal, it may be preferable to restore the tooth
immediately (Fox & Gutteridge 1997).

326 International Endodontic Journal, 51, 318–334, 2018 © 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd
 Zarow et al. New classification for RFT restoration

(a) (b)

(c)
(d)

Figure 5 (a) Tooth 11 Class 2: <50% of structure remaining without ferrule effect. (b) Rapid orthodontic extrusion on tooth
11 with fiberotomy. (c) Image of tooth 11 after orthodontic extrusion. (d) Image of tooth 11 after orthodontic extrusion.

Figure 6 Tooth 25 (Class 4) Given the lack of ferrule and poor coronal structure, implant therapy was proposed.

studies to draw up guidelines for post and core root

Class 4 (extraction)
In some cases, treatment and restoration of the com-
promised root filled tooth can be too complex (no fer-
rule, retreatment, ortho- or perio-crown lengthening,
post, crown) and time-consuming with no predictable
outcome (Fig. 6).
Discussion
The purpose of this review is to present a classifica-
tion for the restoration of root filled teeth, which
seeks to be clear, understandable and helpful for the
clinician.
Several studies have proposed different classifications
for the restoration of root filled teeth. Peroz et al.
(2005) conducted a literature review based on in vitro
filled teeth reconstruction. Dietschi et al. (2008) pub-
lished recommendations for the treatment of root filled
teeth, with a classification according to the clinical sit-
uation.
This review identified five categories for restoring root
filled teeth and is a new classification for dentist.
Choosing between a composite core, a composite core
reinforced by fibre post, a gold post or implant
treatment must be based on residual crown and root
structure, function and tooth position in the arch.
Because clinical studies rarely provide the necessary
information about the initial biomechanical status of
a tooth and do not meet strict research protocols,
they fail to contribute any meaningful information
about the relative indication and performance of the
many materials and techniques used to restore root

© 2017 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 51, 318–334, 2018 327
 New classification for RFT restoration Zarow et al.
filled teeth (Sequeira-Byron et al. 2015). The decision
about whether to cover a cusp or not can only be
made after a multifactorial analysis, which includes
cavity dimensions and the resulting biomechanical
status, as well as occlusal and aesthetic factors
(Dietschi et al. 2008). Clinicians must integrate essen-
tial clinical elements into the equation that cannot be
evaluated in vitro and that are rarely taken into con-
sideration in clinical trials (uncontrolled variables) on
root filled teeth. Elements specific to each patient are
caries risk, occlusion determinants (canine or group
guidance, type of occlusion, overjet and overbite) and
the presence or absence of parafunctions.
Treatment planning must consider the possibility of
restoring the tooth and its implications, and must
require a careful analysis of residual tooth structure
at both the coronal and the root levels.
Conclusions
Within the limitations of the literature cited and
clinical expertise-based reviews, it can be concluded
that the decision-making process in the restoration
of root filled teeth is complex and should consider
the following factors: amount and quality of tooth
structure, tooth position in the arch and anatomy
and function. According to the literature reviewed,
in many root filled teeth there is no need for post
placement. Fibre posts are recommended in anterior
teeth and premolars with compromised tooth struc-
ture (<50%) and/or with high tooth length over
bone crest (either for periodontal defect or surgical
crown lengthening). A ferrule is highly beneficial for
the prognosis of root filled teeth. In case of total or
partial loss of ferrule, fibre posts can be placed, but
only after orthodontic or surgical crown lengthening.
If a ferrule cannot be provided and the patient still
prefers to save the tooth, a gold cast could be a pos-
sible option. In cases where treatment and restora-
tion of the compromised root filled tooth are too
complex with poor prognosis and/or the tooth inter-
feres in a large restorative reconstruction, extraction
followed by implants or FPD might be a valuable
treatment option. All these clinical situations can be
classified in order to guide the clinician in the
decision-making process.
Conflict of interest
The authors have stated explicitly that there are no
conflict of interests in connection with this article.
328 International Endodontic Journal, 51, 318–334, 2018
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