Review Article Int J Clin Prev Dent 2014;10(1):45-50ㆍhttp://dx.doi.org/10.15236/ijcpd.2014.10.1.

45
ISSN (Print) 1738-8546ㆍISSN (Online) 2287-6197

Prosthodontic Management of Endodontically Treated

Teeth: A Literature Review
Cecil Williams1, Manish Kumar2, Manas Bajpai3, Deshant Agarwal3
1
Department of Prosthodontics, Including Crown and Bridge, and Implantology, Daswani Dental College and Hospital, Kota,
2
Department of Prosthodontics, Including Crown and Bridge, and Implantology, 3Department of Pathology and Microbiology,
NIMS Dental College and Hospital, Jaipur, India

The restoration of endodontically treated teeth is one of the most challenging situations of the dentist’s clinical practice, be-
cause it involves procedures related to several areas, such as endodontics, operative dentistry, and prosthetic dentistry. The re-
storation of endodontically treated teeth is a topic that is extensively studied and yet remains controversial from many
perspectives. This article reviews the major pertinent literature on this topic, with an emphasis on major decision-making ele-
ments in proper post selection and restoration of endodontically treated teeth. Most endodontically treated teeth require a post
and core build-up for restoring the teeth to optimum health and function. Selection of an appropriate post-and-core system
from the wide variety of those available may be a clinical dilemma. Selection of a post and core system should satisfy many
interrelated biologic, mechanical, and esthetic factors to optimally restore the endodontically treated tooth to adequate form
and function. It is also important to remember that the prognosis of endodontically treated teeth depends not only on endo-
dontic treatment success itself, but also on the amount of remnant tooth tissue and the definitive restoration that will be placed
onto the dental element. This review may serve as a guide to aid the clinician in the selection of a post and core system.

Keywords: endodontically treated teeth, posts and cores, cement, restoration

Introduction large number of endodontically treated teeth are restored to their

The longevity of endodontically involved teeth has been great-
ly enhanced by continuing developments made in endodontic
therapy and restorative procedures. It has been reported that a
Corresponding author Manish Kumar
Department of Prosthodontics, Including Crown and Bridge,
and Implantology, NIMS Dental College and Hospital,
Jaipur, Rajasthan 302004, India. Tel: +91-09610-395532,
Fax: +91-0141-266235, E-mail: drmanishagarwalmds@
gmail.com
Received November 1, 2013, Revised March 15, 2014,
Accepted March 17, 2014
original function with the use of intraradicular devices [1].
These devices vary from a conventional custom cast post and
core to one-visit techniques, using commercially available pre-
fabricated post systems. In the last few decades, various pre-
fabricated posts systems have been developed. The primary
purpose of a post is to retain the coronal restoration in an endo-
dontically treated tooth that has suffered an extensive loss of
crown structure. The selection of post design is important, be-
cause it may have an influence on the longevity of the tooth.
Coronal restorations and posts can positively influence the
long-term prognosis of teeth following root canal therapy. Final
sealing the canal by placing an appropriate post and core will
minimize leakage of oral fluids and bacteria into the peri-
radicular area and is recommended as soon as possible after

Copyright ⓒ 2014. Korean Academy of Preventive Dentistry. All rights reserved.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/
by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

45
International Journal of Clinical Preventive Dentistry
completion of root canal filling. Glass ionomer or prorootMTA
(Dentsply, York, PA, USA) placed over the residual root canal
filling after post space preparation may be effective to prevent
bacterial leakage. A ferrule of 1-2 mm of tooth tissue coronal
to the finish line of the crown significantly improves the fracture
resistance of the tooth and is more important than the type of
the material from which post and core are made. Ray and Trope
[2] evaluated the relationship between the quality of the coronal
restoration and the quality of the root canal filling by examining
the radiographs of endodontically treated teeth. They observed
that a combination of good restorations and good endodontic
treatments resulted in absence of periapical inflammation in
91.4% of the teeth, whereas poor restorations and poor endo-
dontic treatments resulted in the absence of periradicular in-
flammation in only 18.1% of the teeth examined. Furthermore,
where poor endodontic treatments were followed by good per-
manent restorations, that appeared radiographically sealed, the
resultant success rate was 67.6%. They concluded that apical
periodontal health depended significantly more on the coronal
restoration than on the technical quality of the endodontic
treatment. The importance of a good restoration to the peri-
apical health was confirmed in similar studies [3] even though
these demonstrated that an adequate root filling had a more sub-
stantial impact on the outcome of treatment than the quality of
the coronal restoration. Devitalized teeth due to endodontic
treatment show some different features compared with vital
teeth. This occurs because these teeth, generally, present pre-
vious history of carious lesions (small or very extensive), pre-
viously performed restorative treatment, eventual fractures and
traumas, as well as the endodontic therapy itself. To plan and
perform the restorative treatment of endodontically treated
teeth, properly, it is important that the dentist know these alter-
ations and their effects, predicting possible intercurrences and
planning the most correct approach for each case treatment.
Restorative treatment of endodontically treated teeth may vary,
ranging from a relatively small direct restoration to more com-
plex indirect restorations involving the placement of an intra-
radicular post and core and the indirect restoration itself [4].
Some factors may directly influence on the option for the restora-
tion type, e.g., the amount of coronal remnant after endodontic
treatment and patient’s prosthetic need. Also, the clinician
should verify whether the tooth would be used as a removable
or fixed partial denture abutment. It should be clear that, the re-
storative treatment planning of tooth undergoing endodontic
therapy must be carefully executed.
Materials and Methods
An electronic search of pertinent, English language, peer-re-
46 Vol. 10, No. 1, March 2014
viewed literature was conducted in the medline database, ac-
cessed through Pubmed. The following query terms were en-
tered: metal post, prefabricated post, fiber post, zirconia post,
restoration of endodontically treated teeth. Selected articles
were studied and concluded for review.
Restoration of Endodontically Treated
Teeth
According to the conclusions of a recent review by Dietschi
et al. [5] in the restoration of endodontically treated teeth the
approach has evolved from a totally empirical level to the cur-
rent application of biomechanical concepts to guide the deci-
sion-making process. Primarily, preservation of tooth tissue,
presence of a ferrule effect, and adhesion are regarded as the
most effective conditions for long-term success of the re-
storative procedure. Contamination of the root-canal system by
saliva, often referred to as ‘coronal leakage’ or ‘coronal micro-
leakage’, is a potential cause of endodontic failure [6]. In addi-
tion, recurrent caries or fractured restorations may lead to re-
contamination of the root canal system. Contamination of the
root-canal system with bacteria must be prevented during and
after endodontic treatment. Aseptic treatment techniques
should be used. Once root-canal treatment is completed, imme-
diate restoration of the tooth is recommended whenever
possible. When the tooth is restored with a permanent restora-
tion, bonded restorations should be used as much as possible
to minimize microleakage [7]. Some studies support the inter-
pretation that it is the loss of structural integrity associated with
the access preparation, rather than changes in the dentin, that
lead to a higher occurrence of fractures in endodontically treat-
ed teeth compared with vital teeth [8]. Access preparations re-
sult in increased cuspal deflection during function [9] and in-
crease the possibility of cusp fracture and microleakage at the
margins of restorations. In most endodontically treated teeth,
there also is missing tooth structure caused by caries or existing
restorations. Randow and Glantz [10] reported that teeth have
a protective feedback mechanism that is lost when the pulp is
removed, which also may contribute to tooth fracture. Fennis
et al. [11] studied more than 46,000 patients from insurance
claims and reported significantly more fractures in teeth with
endodontic treatment. Taken together, these studies indicate
that restorations that enhance structural integrity would be ex-
pected to increase the prognosis of endodontically treated teeth
exposed to heavy masticatory loading forces. The quality of the
restorative dentistry performed after root-canal treatment di-
rectly impacts the prognosis of the endodontically treated tooth
[12].
 Cecil Williams, et al：Prosthodontic Management of Endodontically Treated Teeth
Indications for a Post
The primary purpose of a post is to retain a core in a tooth with
extensive loss of coronal tooth structure [13]. However, prepa-
ration of a post space adds a certain degree of risk to a restorative
procedure. The need for a post varies greatly between the ante-
rior and posterior teeth.
Anterior Teeth
Anterior teeth with minimal loss of tooth structure may be re-
stored conservatively with a bonded restoration in the access
opening. A post is of little or no benefit in a structurally sound
anterior tooth and increases the chances for a nonrestorable fail-
ure [14]. If an endodontically treated anterior tooth is to receive
a crown, post often is indicated. In most cases, the remaining
coronal tooth structure is quite thin after it has received root-ca-
nal treatment and been prepared for a crown. Anterior teeth must
resist lateral and shearing types of forces, and the pulp chambers
are too small to provide adequate retention and resistance with-
out a post. The amount of remaining coronal tooth structure and
the functional requirement of the tooth determine whether an
anterior tooth requires a post.
Molars
Endodontically treated molar teeth should receive cuspal cov-
erage but in most cases, do not require a post. Unless the destruc-
tion of coronal tooth structure is extensive, the pulp chamber
and canals provide adequate retention for a core buildup [15].
Molars must resist primarily vertical forces. In those molars that
do require the post, the post should be placed in the largest,
straightest canal, which is the palatal canal in the maxillary mo-
lars and a distal canal in the mandibular molars.
Premolars
Premolars are usually bulkier than anterior teeth, but often are
single rooted teeth with relatively small pulp chambers. For
these reasons, they require posts more often than molars.
Premolars are more likely than molars to be subjected to lateral
forces during mastication. The remaining tooth structure and
functional demands are, once again, the determining factors.
Types of Posts
1. Active versus passive posts
Most active posts are threaded and are intended to engage the
walls of the canal, whereas passive posts are retained strictly
by the luting agent. Active posts are more retentive than passive
posts, but introduce more stress into the root than passive posts.
Their use should be limited to short roots in which maximum
retention is needed.
2. Parallel versus tapered posts
Parallel metal posts are more retentive than tapered posts and
this also is reported to be true for fiber posts [16]. Parallel post
induces less stress into the root, because there is less of wedging
effect, and is reported to be less likely to cause root fracture than
tapered posts. In a retrospective study, Sorensen and Martinoff
[17] reported a higher success rate with parallel posts than ta-
pered posts. Tapered posts are primarily indicated in teeth with
thin roots and delicate morphology.
3. Custom cast post and cores
Custom-fabricated, cast post and cores are still regarded as the
established technique or gold standard for restoring extensively
damaged teeth. Ellner et al. [18] recorded a success rate of 100%
for the group with custom-fabricated post and cores with an ex-
cellent success probability in the observation period of 10 years.
Custom cast post and cores offer advantages in certain clinical
situations. For example, when multiple teeth require posts, it is
sometimes more efficient to make an impression and fabricate
them in the laboratory rather than placing a post and buildup in
individual teeth as a chair-side procedure. A cast post and core
may be indicated when a tooth is misaligned and the core must
be angled in relation to the post to achieve proper alignment with
the adjacent teeth. Cast post and cores also may be indicated in
small teeth such as mandibular incisors, when there is minimal
coronal tooth structure available for antirotation features or
bonding. Cast post and cores are generally easy to retrieve when
endodontic retreatment is necessary. Perhaps the biggest dis-
advantage for cast post and cores is in areas that require an es-
thetic temporary restoration. Temporary post/crowns are not ef-
fective in preventing contamination of the root-canal system
[19]. When a temporary post and crown needed, a barrier mate-
rial should be placed over the obturating material, and the cast
post and core should be fabricated and cemented as quickly as
possible.
4. Prefabricated post and cores
Prefabricated posts are typically made of stainless steel, nickel
chromium alloy, or titanium alloy. They are very rigid, and very
strong with the exception of the titanium alloys. Because they
are round, they offer little resistance to rotational forces. This
is not a problem if adequate tooth structure remains, but if mini-
mal tooth structure remains, antirotation features must be in-
www.ijcpd.org 47
International Journal of Clinical Preventive Dentistry
corporated into post preparation with slots or pins. A bonded
material should be used for the core. Titanium posts were in-
troduced because concerns about corrosion. Most of the tita-
nium alloys used in post has radiodensity similar to gutta-percha
and sealer.
Titanium posts have low fracture strength, which means they
are not strong enough to be used in thin post channels. Removal
of titanium posts can be a problem because they sometimes
break when force is applied with a post removal instrument. For
these reasons, titanium post should be avoided, because they of-
fer no real advantages over the stronger metal posts.
5. Ceramic and zirconium posts
One factor that has reduced the use of metal posts is esthetics.
Metal posts are visible through the more translucent all-ceramic
restorations and even with less translucent restorations may
cause the marginal gingiva to appear dark. These concerns have
led to the development of posts that are white and/or translucent.
Among the materials used for, ‘esthetic’ posts are zirconium
and other ceramic materials. These posts will work clinically,
but have several disadvantages. As, a group, they tend to be
weaker than metal posts, thicker post is necessary, which may
require removal of additional radicular tooth structure.
Zirconium posts can not be etched therefore; it is not possible
to bond a composite core material to the post, making core re-
tention a problem [20]. Retrieval of zirconium and ceramic
posts is very difficult if endodontic retreatment is necessary or
if the post fractures. For these reasons ceramic and zirconium
posts should be avoided.
6. Fiber posts
Fiber posts are available, including carbon fibers, quartz fi-
bers, glass fibers and silicon fiber posts. Their main advantage
was that they were more flexible than metal posts and had ap-
proximately the same modulus of elasticity (stiffness) as dentin.
Original carbon fiber posts were dark, which was a potential
problem when considering post-restorative esthetics. More re-
cent versions quartz fibers, glass fibers and silicon fiber posts
are white. Specifically, contemporary adhesively luted fi-
bre-reinforced composite (FRC) post restorations have man-
ifested satisfactory survival rates over relatively long follow-up
periods [21]. The clinical effectiveness of such restorations has
been mainly ascribed to the more biomimetic behaviour of FRC
posts [5]. Specifically, in the presence of the less rigid fibre
posts, root fractures are very rare, and restorable failures, such
as post debonding, are more likely to occur. Owing to a greater
similarity in elastic properties with dentine, FRC posts allow
for a relatively uniform stress distribution to the tooth and the
surrounding tissues, thus yielding a protective effect against
48 Vol. 10, No. 1, March 2014
root fracture [5]. Three-dimensional finite element analysis
simulations have pointed out the relevance of preserving the fer-
rule effect, and using restorative materials with elastic proper-
ties similar to dentine, such as resin composites, for a more fa-
vourable performance of the restored teeth under stress [22].
Results from randomized controlled clinical trials, both pro-
spective and retrospective, provide evidence to support the use
of FRC posts for the restoration of endodontically treated teeth
[5]. In addition to the favourable biomechanical behaviour, oth-
er advantageous properties of fibre posts have contributed to
their rapid diffusion among clinicians. Fibre posts simplify the
post-endodontic restoration procedure in comparison with the
use of cast posts, by eliminating the laboratory step.
Additionally, fibre posts are relatively easy to remove by boring
through the middle of the post with an ultrasonic or a rotary in-
strument, in case endodontic retreatment is needed. Moreover,
quartz or glass fibre posts offer the most favourable optical
properties for reproducing the natural aspect of the restored
tooth [22].
The Ferrule Effect
The ‘ferrule effect’ is important to long-term success when a
post is used. A ferrule is defined as a vertical band of tooth struc-
ture at the gingival aspect of a crown preparation. It adds some
retention, but primarily provides resistance form and enhances
longevity [23]. A ferrule with 1 mm of vertical height has been
shown to double the resistance to fracture versus teeth restored
without a ferrule [24]. Other studies have shown maximum ben-
eficial effects from a ferrule with 1.5 to 2 mm of vertical tooth
structure [25].
Luting Cements
The most common luting cements are zinc phosphate, resin,
glass ionomer, resin cements and resin modified glass-ionomer
cements. Recent trend has been toward resin cements, because
they increase retention tend to leak less than other cements, and
provide at least short-term strengthening of the root [23]. A
study by Bachicha et al. [26] reported less leakage when resin
cement was used with stainless-steel and carbon fiber compared
with zinc phosphate or glass-ionomer cements. Similar results
were reported by Junge et al. [27] reported that posts cemented
with resin cements were more resistant to cyclic loading than
those cemented with zinc phosphate or resin modified
glass-ionomer cement. Bonded resin cements have been rec-
ommended for their strengthening effect in roots with thin
walls. Examples include immature teeth or teeth with extensive
caries. Resin may be bonded to some types of posts; so theoret-
 Cecil Williams, et al：Prosthodontic Management of Endodontically Treated Teeth
ically, the dentin/resin/post can be joined via resin adhesion
unit, at least for a period of time. Unfortunately resin cements
have some disadvantages. Resin cements are more ‘technique
sensitive’ than most of the other luting cements. They require
extra steps such as preparing the canal walls with acid or etylene
diamine tetra acetic acid and placing a dentin-bonding agent.
Contamination of the dentin or post can be a problem.
Predictable delivery, of etchants and adhesive materials deep
into the canal space also can be problematic. The post should
be cemented with auto cure or dual-cure resin cement that is
mixed and placed with the post [28]. These steps must be per-
formed quickly and carefully to assure that the post is com-
pletely seated.
Core Materials
The purpose of the post is to retain the core, which in turn helps
retain the crown. With cast post and cores, the core is formed
on the post directly on the tooth or indirectly on a cast. The gen-
eral shape and orientation of the core is developed during
fabrication. Prefabricated posts are used in combination with
a restorative build-up material which is formed after cementa-
tion of the post. The choices are amalgam, composite resin, or
glass-ionomer materials. The glass-ionomer materials, includ-
ing resin-modified glass ionomer, lack adequate strength as a
buildup material and should not be used in teeth with extensive
loss of tooth structure [29]. Amalgam has been used as a buildup
material, with well recognized strengths and limitations. It has
good physical and mechanical properties and works well in
high-stress areas [30]. Amalgam can cause esthetic problems
with ceramic crowns and sometimes makes the gingiva look
dark. Currently, composite resin is the most popular core mate-
rial and has some characteristics of an ideal buildup material.
It can be bonded to many of the current posts and to the remain-
ing tooth structure to increase retention. It has high tensile
strength and the tooth can be prepared for a crown immediately
after polymerization. It is tooth colored’ and can be used under
translucent restorations without affecting the esthetic result. On
the negative side, composite shrinks during polymerization,
causing gap formation in the areas in which adhesion is weakest.
It absorbs water after polymerization, causing it to swell and un-
dergoes plastic deformation under repeated loads [31].
Discussion
Post and cores contribute in providing predictable restorative
options for endodontically treated teeth. After reviewing the lit-
erature, it appears that an ideal post system should have the fol-
lowing features: (a) physical properties similar to dentin, (b)
maximum retention with little removal of dentin, (c) dis-
tribution of functional stresses evenly along the root surface, (d)
esthetic compatibility with the definitive restoration and sur-
rounding tissue, (e) minimal stress during placement and ce-
mentation, (f) resistance to displacement, (g) good core re-
tention, (h) easy retrievability, (i) material compatibility with
core, (j) ease of use, safety and reliability, and (k) reasonable
cost. Therefore, the clinician should be knowledgeable in se-
lecting the right type of post and core systems to meet the bio-
logical, mechanical, and esthetic needs for each individual
tooth. This review identified the proper selection of the
post-and-core system and offers the following clinical recom-
mendations: (1) conserve as much remaining tooth structure as
possible during the post space preparation; (2) custom-cast post
and cores are recommended for noncircular root canals and
when coronal tooth structure loss is moderate to severe; (3) par-
allel-sided, passive, serrated, self-venting prefabricated posts
are recommended for small circular canals; (4) posts with an an-
tirotational feature should be used in situations with circular ca-
nals; (5) adequate apical seal must be maintained without com-
promising the length of the post; (6) more than one post may
be used for multirooted short teeth; (7) passive parallel posts are
advocated for adequate retention but when the apical thickness
of dentin is minimal, a parallel-tapered combination post design
may be preferred; (8) retentive qualities of the post head may
facilitate firm retention of core material; (9) the post should en-
sure material compatibility, bonding ability, adequate rigidity,
and esthetic compatibility with permanent restoration; (10) re-
trievability in the event of failure should be considered; and (11)
the system should be easy to use and cost effective. Although
newer prefabricated post systems have been introduced, but
published long-term clinical data are not available. In addition,
the claim that the nonmetallic post systems provide excellent
esthetics has yet to be demonstrated through clinical research.
Future research evaluating clinical success of the newer post
systems on teeth with varying degree of tooth loss is
recommended.
Conclusions
The available laboratory and clinical evidence validates the
utilization of fibre posts as an alternative to metal posts and pref-
erably to other tooth-colored posts, such as zirconia dowels, in
post-retained restorations. Preservation of coronal dental tis-
sue, the use of dowels with elastic properties similar to dentine,
and effective post adhesion are the most critical factors for the
successful clinical performance of restored endodontically
treated teeth. With such a wide variety of materials and post de-
signs available for the restoration of endodontically treated
www.ijcpd.org 49
International Journal of Clinical Preventive Dentistry
teeth, the clinician should be selective in choosing the post sys-
tem that best fits the individual needs of each tooth. The criteria
and factors presented in this review may help guide the clinician
in selecting the most desirable post system for each tooth.
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