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QUINTESSENCE INTERNATIONAL

Restoring endodontically treated teeth with posts and cores—A review

Ingrid Peroz, Dr Med Dent 1 /Felix Blankenstein, Dr Med Dent 1 / Klaus-Peter Lange, Prof Dr Med Dent 2 /Michael Naumann, Dr Med Dent 3

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

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

The prognosis of endodontically treated teeth depends not only on the treatment itself, but also on sealing the canal and mini- mizing the leakage of oral fluids and bacteria

1 Associate Professor, Humboldt University of Berlin, Dental School, Department of Prosthetic Dentistry and Oral Gerontology, Berlin, Germany.

2« Professor, Humboldt University of Berlin, Dental School, «Department of Prosthetic Dentistry and Oral Gerontology, «Berlin, Germany.

3« Assistant Professor, Humboldt University of Berlin, Dental «School, Department of Prosthetic Dentistry and Oral «Gerontology, Berlin, Germany.

Reprint requests: Dr Ingrid Peroz, Zentrum für Zahnmedizin, Abteilung für Zahnärztliche Prothetik und Alterszahn- medizin, Augustenburger Platz 1, 13353 Berlin, Germany. E-mail: ingrid.peroz@charite.de

into periradicular areas by prompt placement of coronal restorations. 1 This treatment includes the decision of whether or not posts should be used. After many years of scientif- ic work involving post material, post geome- try, post length, core material, and other con- siderations, the indication for posts is re- emerging as a topic of discussion. A change of paradigm has occurred based on the advantages of adhesive restorations, which seem to make post insertion unnecessary. In addition to this development, evidence- based treatment is becoming increasingly important in dentistry. Treatment decisions and strategies should be based on the best and most-up-to-date factual evidence avail- able. Evidence-based dentistry is influencing

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Table 1

Level of evidence due to study design

Evidence level

Study design

I Meta-analysis of randomized, controlled trials

a (high)

I Single randomized, controlled trial

b

II Controlled study without randomization

a

II b

Experimental study

III

Descriptive study

IV

Estimation of experts

the evaluation and adaptation of many treat- ment methods that have been commonplace until now. Based on the design of the stud- ies, investigators categorized these treat- ments into different groups, depending on the level of evidence available (Table 1). Although these levels of evidence depend on clinical trials only, they were also used to characterize in vitro studies. The aim of this study was to create guide- lines for the reconstruction of endodontically treated teeth by posts and cores based on a review of the literature, and to assign citations to their levels of evidence.

METHODS AND MATERIALS

The literature search was done using the Grateful Med Interface for Medline (www.cbi.nlm.nih.gov), the Cochrane library (www.cochrane.org), and by manual search- es of the German journal Deutsche Zahnärztliche Zeitschrift published the last 10 years. Due to language limitations, only German or English literature was reviewed. Because the online searching process could not find meta-analysis of randomized clinical trials or single randomized trials, liter- ature was searched using key words: dental AND endodontically treated teeth AND other key words (see Table 2). The referenced articles were gathered according to subheadings relevant to treat- ment decisions concerning endodontically treated teeth.

RESULTS

Indications for using posts

In an in vitro study with matched teeth pairs (split-mouth design), Sedgley and Messer 2 were able to show that vital dentin is harder than dentin from contralateral endodontically treated teeth, but there was no significant biomechanical change that would indicate that the endodontically treated teeth had become more brittle (in vitro, level of evi- dence II b). This result is supported by anoth- er matched teeth pairs study by Papa et al, 3 which shows that there is no significant dif- ference in the moisture content between endodontically treated teeth and vital teeth. It appears that the remaining amount of tooth hard tissue influences stability, rather than the factors listed above. Whereas the preparation of a pulpal access only reduces structural stability by about 5%, loss of the circumferential integrity by mesio-occlusodis- tal (MOD) cavities reduces the stability by about 63%. 4 Panitvisai and Messer 5 have shown that the cuspal deflection increases with increasing cavity size, and is greatest fol- lowing endodontic access. The importance of the marginal ridge for the structural stabili- ty of teeth was also shown by Strand et al. 6 The use of posts, however, does not increase the fracture resistance significantly. This was shown in several comparative in vitro studies (level of evidence II b). 710 Posts are used to provide retention for the core material, so the indication for post inser- tion depends on the dental substance and extent of either destruction or viable structure seen in the teeth being considered for endo- dontic treatment. The amount of remaining tooth structure necessary to warrant post insertion, or a decision to use other methods, is not clearly defined. It is, however, based on reviews or personal clinical experience (inter- nal evidence) with a level of evidence no bet- ter than IV (review, IV). 11 There is a general lack of systematic approaches in literature published on this matter. For this reason, an attempt was made to formulate a more detailed description for the amount of remaining dental tissue because the extent of destruction cannot be evaluated metrically. This classification describes 5

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Table 2

Number of references found using study designs and key words

 
 

AND

endodontically

AND

AND

AND

treated

AND

OR

AND

AND

AND

ferrule

fiber

metal

AND

Study type

teeth

post

core

diameter

length

abutment

effect

post

post

cementation

Meta-analysis of RCT

0

0

0

0

0

0

0

0

0

0

RCT

0

0

0

0

0

0

0

0

0

0

Controlled clinical trial

0

0

0

0

0

0

0

0

0

0

Prospective study

6

1

1

0

0

0

0

1

1

1

Follow-up study

35

10 (4)*

10 (4)*

0

0

0

0

3

2 (1)*

1

Longitudinal study

50

13

13

0

0

0

0

4

3

2

Cohort study

51

13

13

0

0

0

0

4

3

2

Clinical trial

1

0

0

0

0

0

0

0

0

0

Comparative study

125

61

59

2

6

1

1

9

27

11

* Upon reading abstracts of these studies, many had to be eliminated. Only those in parentheses are valid.

classes, depending on the number of remain- ing axial cavity walls. 12 Class I describes the

access preparation with all 4 axial cavity walls remaining. Class II describes loss of 1 cavity wall, commonly known as the mesio-occlusal (MO) or the disto-occlusal (DO) cavity. Class

III represents an MOD cavity with 2 remaining

cavity walls. Class IV describes 1 remaining cavity wall, in most cases the buccal or oral wall, and Class V describes a decoronated tooth with no cavity wall remaining.

The minimal thickness of the cavity wall as

a determining factor for the resistance to func-

tional loads of the crown-root complex is con- sidered 1 mm. Hard tissue with thicknesses below this level cannot be prepared for crowns without the loss of all remaining substance, leaving no dental tissue. A thickness greater than 1 mm provides an amount of hard tissue sufficient to stabilize the core material even after crown preparation. Therefore, a cavity wall with less than 1 mm thickness cannot be taken into consideration. 13 The minimal height of a cavity wall capa- ble of providing a sufficient ferrule effect is 2 mm. This aspect is described in further detail below.

Class I: 4 remaining cavity walls (access cavity)

If all the axial walls of the cavity remain and

have a thickness greater than 1 mm, it is not necessary to insert posts (Fig 1). In these cases, any type of definitive restoration can be considered. This judgment is based on several in vitro studies, which can be

assigned to evidence level II b, depending on their comparable study design. 7,10,14

Classes II and III: 2 or 3 remaining cavity walls

Treatment in cases involving the loss of 1 or 2 cavity walls does not necessarily require the insertion of a post, as the remaining hard tissue provides enough surface for the use of other methods, in particular, for cores using adhesive systems (Fig 1). An in vitro study by Steele and Johnson 15 showed that compos- ites or amalgam restorations with 3 surfaces (MOD), increase fracture resistance. There was no significant difference between the experimental groups, which included unal- tered teeth or those with access only 15 (in vitro, II b). The comparison between different adhesive systems for the reconstruction of root canal-treated premolars with MOD cavi- ties have shown that dentin-bonding systems stabilize teeth particularly well, such that their fracture resistance was comparable to intact teeth 16 (in vitro, II b). Furthermore, anterior teeth with proximal cavities do not benefit from post insertion 17 (in vitro, II b). Two clinical studies assigned to evidence level III, (due to retrospective methods), show that teeth with extensive MOD cavities with- out reconstruction and with crowns have a higher risk. 18 Anterior teeth do not seem to benefit from restoration with crowns. 19

Class IV: 1 remaining cavity wall

In cases where only 1 cavity wall remains, the core material has little or no effect on the frac-

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Class I– III

Class IV

Two to 4 cavity walls remaining

Two to 4 cavity walls remaining One cavity wall remaining Fiber Fiber/metal Adhesive Adhesive/cast Crown
Two to 4 cavity walls remaining One cavity wall remaining Fiber Fiber/metal Adhesive Adhesive/cast Crown
Two to 4 cavity walls remaining One cavity wall remaining Fiber Fiber/metal Adhesive Adhesive/cast Crown
Two to 4 cavity walls remaining One cavity wall remaining Fiber Fiber/metal Adhesive Adhesive/cast Crown
Two to 4 cavity walls remaining One cavity wall remaining Fiber Fiber/metal Adhesive Adhesive/cast Crown
Two to 4 cavity walls remaining One cavity wall remaining Fiber Fiber/metal Adhesive Adhesive/cast Crown

One cavity

wall remaining

Fiber Fiber/metal Adhesive Adhesive/cast Crown Onlay/crown
Fiber
Fiber/metal
Adhesive
Adhesive/cast
Crown
Onlay/crown

Post

No

Post

Core

Adhesive

Core

Definitive restoration

 

Any

Definitive

 

restoration

Fig 1 No post is needed in cases with at least 2 axial cavity walls remain- ing. A thickness of the cavity wall 1 mm and a height of 2 mm are pre- conditions. If these conditions cannot be fulfilled, the cavity wall must be considered as missing.

Class V

No cavity walls remaining Post Fiber/metal Core Adhesive/cast Definitive restoration Crown
No cavity walls
remaining
Post
Fiber/metal
Core
Adhesive/cast
Definitive restoration
Crown

Fig 3

of 2 mm is needed to provide a lower risk of root fracture.

A post must be inserted if there is no cavity wall remaining. A ferrule

ture resistance of the endodontically treated teeth 20 (in vitro, II b). If the tooth has to be used as an abutment for fixed or removable partial dentures, crown preparation will fur- ther decrease fracture resistance. 21 There- fore, the present concept suggests using posts in such cases of reduced remaining tooth structure. For esthetic reasons, non- metal posts are preferred for treatment of anterior teeth. In posterior teeth, both metal posts and nonmetal posts are acceptable treatment options (Fig 2).

Fig 2 A post should be inserted if only 1 cavity wall is remaining. Fiber posts are preferable in anterior teeth, but in posterior teeth, fiber or metal posts can be used.The core can be made of composite or as a cast post and core. The defini- tive restorations should be crowns in anterior teeth and crowns, onlays, or overlays in posterior teeth.

Class V: No remaining cavity wall

In cases of teeth with a high degree of destruction where no cavity wall remains, the insertion of posts appears necessary to pro- vide for core material retention (Fig 3). Additionally, the ferrule effect has a great influence on fracture resistance, especially in decoronated teeth. A ferrule, defined as a cir- cumferential area of axial dentin superior to the preparation bevel, should have a height of 1.5 to 2.5 mm. 2224 Various in vitro studies with evidence level II b have shown that frac- ture resistance can be significantly increased by the use of a ferrule; the post length or design (whether they are parallel-sided or tapered) are of secondary importance for fracture resistance if a sufficient ferrule can be provided. 2224 If deep destruction of the teeth renders a sufficient ferrule impossible, a surgical crown lengthening can be performed. This provides a crown ferrule resulting in a reduction of static load failure 25 (in vitro II b). Bolhuis et al 26 postulated that the crown ferrule is more important than a post and core, or a core reconstruction with adhesive fillings only. The researchers examined decoronated, root-treated premolars. These were rebuilt by core build-up without an endodontic post or by core build-up with an endodontic post (a cast post and core, and a composite with a

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silica post), and an additional group was not

mm

was also found. 30,31 Considering the

provided with a core at all. No significant dif- ference in fracture strength among the differ-

need for both a sufficient ferrule effect and the remaining apical sealing, the postulated

ent groups could be demonstrated. 26

post

length of two-thirds of the root length

Several criteria must be taken into account

may

be impossible in many clinical situa-

with

respect to the indication for post inser-

tions. As previously stated, shorter posts

tion. These criteria will be presented later.

should be fixed with luting composite. 29

Post length

Post diameter

Reviews of evidence presented in level IV studies state that the post length should reach two-thirds of the entire root length. A

crown-length/post-length ratio of at least 1:1 should be provided. 11,27 . Post length influences the stress load along the root. Whereas the enlargement of

the canal increases cervical stress, post

placement will decrease stress in this region. Short, wide posts lead to elevated stress con-

centrations in the cervical region. Post place- ment beyond two-thirds of root depth does

not further decrease cervical stress, but

tends to increase stress in the apical region 28 (in vitro, II b). The selection of post length, however, depends on many criteria. It has been shown that the post length is less important for fracture

There is little evidence (level IV) for an opti- mal post diameter. A diameter of one-third of the root diameter is postulated in many reviews. A minimal dentin thickness of 1 mm around the post should be provided. 11,32 Due to the stability of the post itself, Lambjerg- Hansen and Asmussen 33 postulated a post diameter of at least 1.3 mm. In the present study, a diameter of ISO 90 or 1.25 mm, respectively, is proposed.

Post fixation

Adhesive systems seem to be able to stabi- lize the tooth. Reeh et al 4 have shown that composite restorations with dentin enamel etching provide a stability similar to that of

the intact tooth (in vitro, controlled trial: II b). The use of composite in the entrance of the

resistance than the ferrule effect 23 (in vitro, II b). The type of fixation used for posts also

root

whereas an additional post is unable to con-

canal stabilizes the root-filled tooth,

has

an influence on the required length of

tribute further stabilization. 34 Paul and

the post. Nissan et al 29 were able to show that adhesive fixation can compensate for reduced retention due to the use of a shorter

Schärer 11 state in their review that the adhe- sive fixation of a post and core may stabilize the tooth. It was demonstrated in several in

parallel-sided or tapered post 29 (in vitro, II b). Testori et al 18 demonstrated there is no sig- nificant difference in the retention of adhe-

vitro studies with an evidence level of II b, that roots in which the posts were adhesively cemented were significantly more fracture

sive

fixed posts 5 mm or 8 mm in length (clin-

resistant than those using zinc phosphate

ical

trial and review, III). These results, how-

cement 35,36 (in vitro II b). Based upon this evi-

ever, are less because they were ascertained

dence, the present study recommends adhe-

with

a very limited number of samples.

sive fixation for any kind of post.

Whereas the studies cited above paid special attention to the correlation between

after post-space preparation, especially with

Post design

post length and post retention, other studies

Post

design also influences the success of

tended to evaluate the remaining root filling

respect to leakage. It was shown that leak-

the restoration. Torbjoner et al 37 published a prospective study with an evidence level of II a, comparing failure rates and failure charac-

age

increases with post-space preparation,

teristics of tapered and parallel-sided posts.

and

a remaining apical filling of less than 3

They found the cumulative failure rate of

mm

results in an unpredictable seal. 30,31 Post

tapered posts was 15% higher than the fail-

insertion and adhesive fixation can compen-

ure rate for parallel-sided posts (8%). Loss of

sate

for this leakage. Nevertheless, the need

retention was listed as the most frequent rea-

for a remaining apical root filling of 4 to 6

son for failure for both types of posts. 37

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Parallel-sided posts and those surround- ed by large amounts of cement had lower fracture rates than tapered posts or tapered posts with maximal adaptation in the root canal. 38 Further studies also show that the post design has to be considered in combi- nation with other aspects of posts. In this regard, the ferrule effect seems to be more important for fracture resistance than the post design. 22 Adhesive fixation of posts is also more relevant for post retention than the post design itself 11,29 (review, IV; in vitro, II b) (review, IV).

Post material/core material

Due to the biomaterial aspects in cases where metal posts are used, the definitive restoration should be made with either the same or analog alloys. The present study suggests cast-on posts and cores made of a gold Au-alloy, a cobalt-based alloy, or titani- um. This suggestion is based on internal evi- dence only (evidence level IV). Screws should not be used, as a higher incidence of root fractures lowers their sur- vival rate significantly 39,40 (retrospective clini- cal trial, III; meta-analysis over clinical trials, II a). Fiber posts tested by in vitro studies show a great variability in fracture resistance when compared to metal posts or ceramic posts. Cormier et al 41 identified fiber posts as having the lowest fracture resistance, whereas Akkayan and Gulmez 42 found comparable fracture resistance values between zirconium oxide and fiber posts. In cases of fractures, the fiber posts produced more restorable fractures than other post materials (in vitro, II b). 4143 Taking into account that in vitro tests involve higher fracture loads than those occurring during mastication, fiber posts pro- vide sufficient fracture thresholds. In an in vitro study (evidence level II b) performed on structurally weakened central incisors with thin cavity walls of 0.5 to 0.75 mm, Saupe et al 44 demonstrated that the resistance to a simulated masticatory load of a fiber post and core system was sig- nificantly greater than that of a morphologic post and core procedure. Under these con- ditions, a ferrule provides no additional ben- efit with respect to retention and fracture resistance.

If fiber posts are used, they should be fixed by adhesive material. Vichi et al 45 described the types of adhesive structures between the resin cement and dentin (in vivo, III). Ferrari et al 46 were able to show, by microscopic examinations, that Excite dual- cured bonding agent produced a resin- dentin interdiffusion zone higher than that seen in samples with Excite light-cured bond- ing agent or a one-step bonding system (in vitro, II b). The biomaterial disadvantages of fiber posts, which are based on decreased 3-point bending test values due to the water storage of these posts, can be avoided by adhesive fixation because they were isolated to saliva 47 (in vitro, II b). Ceramic posts show survival rates and fracture strength comparable to cast posts and cores 48 (in vitro, II b). Zirconia posts and ceramic cores, as well as chair-side proce- dures with zirconia posts with composite cores, are recommended 49 (in vitro, II b). Comparisons of fiber and ceramic posts show a higher risk of fracture with ceramic posts due to cracks within the posts 50,51, (in vitro, II b). Fiber posts show an additional advantage in that they are readily retrievable after failure. 52 The results of a retrospective in vivo study (evidence level III) indicate that fiber posts are superior to the conventional cast post and core systems after 4 years of clinical service. 53 The use of metal posts is justified by stud- ies showing that the fracture resistance of teeth restored by metal posts is superior to other systems. 54 The morphologic cast post and core systems appear to be of secondary importance compared to direct metal posts and composite cores. Direct posts and cores comprised 70% of the cases in root fractures after loading and 30% of the core fractures. The cast posts involved the root of all cases of fracture. 43 Surfaces of metal posts should be rough to provide the best retention in the root canal 5560 (in vitro studies, II b). Metal posts can be cemented by zinc phosphate cement or by adhesive resin systems. Because adhe- sive cementation results not only in lower microleakage, but also in higher retention, it is preferred. 61.62

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The comparison between cast and direct post-and-core systems revealed no signifi- cant differences that would justify recom- mending the use of one over the other. 63 This statement is based on one of the rare meta- analyses made by a systematic review of in vitro and in vivo studies. 64 However, due to the lack of randomized, controlled studies, the assigned evidence level is II a. Direct posts and cores should use (inde- pendent of the post material) composites as core material. After amalgam, composites show both the lowest defect and failure rates, and the best fracture resistance (evidence level IIb to IV). 49,6570

Definitive restoration

The indication for post insertion depends not only on the amount of remaining tooth struc- ture but also on the planned prosthetic reconstruction. The prognosis of an endo- dontically treated tooth is best if in a com- plete dental arch because of stabilizing mesial and distal proximal contacts. 71 Sorensen and Martinoff 72 demonstrated in their clinical, retrospective study (evidence level III) that post insertion brings no advan- tage to the survival rate of an endodontically treated tooth if it is restored by a crown or fixed partial denture. However, in cases where such a tooth is needed as an abut- ment for removable partial dentures, the post insertion has a significant positive effect for treatment success. 72 Nevertheless, a tooth treated by root canal within a removable par- tial denture poses a higher risk for treatment failure 72,73 (in vivo studies, evidence level III). Testori et al 18 have shown that the pain threshold of an endodontically treated tooth used as a distal abutment is twice as high as that of a vital tooth These results influenced the present study, in which endodontically treated teeth were not included as abutment teeth for tele- scopes apart from cases in which all cavity walls remain. If a tooth treated with a root canal has to be included as an abutment tooth for cantilever fixed partial dentures or as the distal abutment of fixed partial den- tures, or combined with a removable partial denture, the patient must be informed about the higher risk of failure.

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DISCUSSION

Peroz et al

The present concept for the restoration of endodontically treated teeth by posts and cores aims to draw its guidelines from the evidence present in recent literature. The cited literature is assigned a level of evidence showing the reliability of the sources upon which decisions are based. The review of the literature shows that there is a lack of in vitro, and especially, clin- ical studies, correlating the amount of remaining tooth structure to the indication for posts. As such, it would be worthwhile to examine whether it is possible or recom- mendable not to use posts even for teeth with no remaining cavity walls. The limited number of prospective clinical studies is notable. Therefore, a prospective clinical study documenting cases meeting specific criteria (tooth within a complete dental arch, single tooth restoration, retention by remain- ing pulp chamber) in which posts are not used, is necessary. There is also a lack of prospective clinical studies in which the amount of remaining tooth structure is documented and the sur- vival rate of several post materials is tested. The remaining tooth structure should be evaluated by a designed index system. 74

CONCLUSIONS

The literature review reveals:

1. There is a lack of prospective clinical stud- ies with well-documented inclusion crite- ria for endodontically treated teeth, remaining coronal hard tissue, and flaring.

2. The 2-mm ferrule has a very important role for the survival rate of endodontically treated teeth that have been restored with crowns.

3. Post length is limited by the necessary api- cal seal of 4 to 6 mm. Remaining tooth structure is more important than post length in avoiding tooth fracture.

4. Adhesive fixation is preferable, as it pro- duces a higher fracture resistance in com-

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parison to cemented posts and cores, as well as offers a higher leakage resistance.

5. Composites are a good core material.

6. Posts should be inserted if endodontically treated teeth are used as abutments for removable partial dentures.

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Prosthodontist

Department of Comprehensive Care Case Western Reserve University School of Dental Medicine Cleveland, OH

The Department of Comprehensive Care at Case Western Reserve University School of Dental Medicine invites applications for a full-time tenure track faculty position at the assistant/associate professor level. Responsibilities include didactic and clinical teaching and research. Participation in the CWRU Dental Faculty practice is available. Candidates must have a DMD/DDS degree or equiv- alent, and advanced training in prosthodontics or equivalent. Research and clinical interest and/or experience in fixed and implant prosthodontics and adhesive dentistry is desired. Salary and rank commensurate with qualifications and experience.

and rank commensurate with qualifications and experience. Case Western Reserve University is an equal

Case Western Reserve University is an equal opportunity/affirmative action employer.

Applicants should send a curriculum vitae, and names of three references to:

Avishai Sadan, DMD, Chairman Department of Comprehensive Care Case Western Reserve University School of Dental Medicine 10900 Euclid Avenue Cleveland, OH 44106-4905

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