Journal of

Clinical Medicine

Article
Clinical Outcomes of Endodontic Treatments and Restorations
with and without Posts Up to 18 Years
Denise Irene Karin Pontoriero 1 , Simone Grandini 2 , Gianrico Spagnuolo 3 , Nicola Discepoli 4 ,
Stefano Benedicenti 5 , Valerio Maccagnola 6 , Alberto Mosca 7 , Edoardo Ferrari Cagidiaco 1 and Marco Ferrari 1, *

1 Department of Prosthodontics and Dental Materials, University of Siena, 53100 Siena, Italy;
[email protected] (D.I.K.P.); [email protected] (E.F.C.)
2 Department of Endodontics and Restorative Dentistry, School of Dental Medicine, University of Siena,
53100 Siena, Italy; [email protected]
3 Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples
“Federico II”, 80131 Naples, Italy; [email protected]
4 Department of Periodontology, School of Dental Medicine, University of Siena, 53100 Siena, Italy;
[email protected]
5 Department of Endodontics and Restorative Dentistry, School of Dental Medicine, University of Genoa,
16121 Genoa, Italy; [email protected]
6 Department of Orthodontics, University of Padua, 35122 Padua, Italy; [email protected]
7 Private Practitioner, 25025 Brescia, Italy; [email protected]
* Correspondence: [email protected]; Tel.: +39-0577-233131; Fax: +39-0577-233117



Abstract: Background: The aim of this study was to collect long-term restorative and endodontic


outcomes of endodontically treated teeth (ETT). Methods: 298 teeth were included in the study
Citation: Pontoriero, D.I.K.;
and were recalled up to 18 years with a media of 10.2 years. At baseline, 198 sample teeth (66.44%)
Grandini, S.; Spagnuolo, G.; Discepoli,
showed symptoms and 164 (55%) had periapical radiolucency. The most frequently used obturation
N.; Benedicenti, S.; Maccagnola, V.;
techniques were warm gutta-percha in 80% of cases, and by carrier in 20%. A total of 192 ETT were
Mosca, A.; Ferrari Cagidiaco, E.;
Ferrari, M. Clinical Outcomes of
restored by direct resin composite restorations, and 106 posts were luted. Moreover, 75 (25.16%) direct
Endodontic Treatments and restorations remained as final restorations, 137 single crowns (45.97%), 42 (14.09%) partial adhesive
Restorations with and without Posts crowns, and 42 (14.09%) abutments of fixed bridges were the final treatments. Descriptive and
Up to 18 Years. J. Clin. Med. 2021, 10, inferential statistics were performed (α = 0.05). A Cox regression model was made. Results: results
908. https://doi.org/10.3390/ showed success for 92.6% of ETT up to 18 years, 2.68% (8 ETT) showed irreversible failures, and
jcm10050908 14 (4.69%) reversible complications. Four ETT (1.34%) failed because of root fracture and the other four
(1.34%) because of endodontic complications. Eight ETT (2.69%) showed non-irreversible periodontal
Academic Editor: Edgar Schäfer complications and the other six (2.01%) prosthodontic complications. Accordingly, with Kaplan–
Meier analysis, the survival rate after 18 years was 97.3% (Interval of Confidence (IC) 95.1–98.3).
Received: 22 January 2021
The presence of a short or long (at least 1 mm related to radiographic apex) quality endodontic
Accepted: 18 February 2021
filling displayed a statistically significant higher risk of complication (hazard ratio (HR) = 17.00
Published: 25 February 2021
(IC 5.68–56.84). Furthermore, a clinically detectable not precise coronal margins predicts the presence
of any clinical complication with a hazard ratio almost seven times higher than endodontically
Publisher’s Note: MDPI stays neutral
with regard to jurisdictional claims in
treated teeth with a proper margin (HR = 6.89 (IC 2.03–23.38)), while the presence of lucency at the
published maps and institutional affil- baseline did not affect the risk of complication (HR = 0.575 (IC 0.205–1.61)). The presence of post,
iations. tooth position in the arch, and the type of it did not show a high-risk rate (HR = 1.85, 1.98, and 2.24,
respectively). Conclusions: a correct filling (at the apex) of root canals combined with proper coronal
margins allow obtaining a long-term high success rate in teeth with a periapical lesion at the baseline.
The use of a post or not, when its placement is related to the residual amount of the crown, does not
Copyright: © 2021 by the authors. change the final outcome of the ETT.
Licensee MDPI, Basel, Switzerland.
This article is an open access article Keywords: build-up; clinical trial; endodontic outcomes; endodontic retreatments; posts
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).

J. Clin. Med. 2021, 10, 908. https://doi.org/10.3390/jcm10050908 https://www.mdpi.com/journal/jcm

J. Clin. Med. 2021, 10, 908 2 of 12

1. Introduction
Long-term survival of endodontically treated teeth (ETT) depends on correct and well-
sealing restoration and the principles of endodontic therapy, by outlining the biology of
the dental pulp and periradicular tissues, the etiology and pathophysiology of the disease
processes, and the measures to diagnose, prevent, and cure the different disorders that
have been established [1,2].
Different parameters were proposed to define endodontic “success” and the existing
data on endodontic therapy outcome must be carefully interpreted. Differences in the
assessment of teeth during follow-up were noted, such as the radiographic assessment
method, the radiographic criteria for success (loose and strict), the unit of outcome measure
(root and tooth), and the length of follow-up [3].
Criteria setting the threshold for success at the complete resolution of the periapical
radiolucency have been described as “strict” [4] or “stringent” [5], while choosing a mere
reduction in the size of the periapical radiolucency [6], has been described as setting a
“loose” [4] or “lenient” [5] threshold. The frequency of adoption of these two thresholds
in previous studies has been similar; the expected success rates using “strict” criteria
would be lower than those based on “loose” criteria. Regarding periapical periodontitis
in radiographs, a scoring system for registration and evaluation was proposed [7]. This
system provides an ordinal scale of five scores, ranging from healthy to severe periodontitis
with exacerbating features. It is based on radiographs with verified histological diagnosis
and can be suitable in epidemiological studies.
Another outcome measure, “functional retention”, has been introduced [5]. A root
can be considered “functional” when no clinical signs and symptoms are present, indepen-
dently from the presence or absence of periradicular radiolucency [8,9].
“Functional retention” of teeth after root canal treatment is a similar but less lenient
outcome measure than “survival”.
The “strict criteria” are based on remission of clinical signs and symptoms, and
lamina dura’s complete restitutio ad integrum [10] were followed in this clinical study.
Considering that the shortest recall in this clinical study was performed at 48 months, there
was reasonable time for complete healing of the wide majority of periapical lesions (when
present) and, in this way, “strict” criteria were followed.
Endodontic treated teeth must be restored in order to function and for esthetic pur-
poses. Restoration of ETT can be performed with or without a post [11], by direct or indirect
restoration. The best treatment is still under discussion, but it depends on the amount of
the residual crown, the anatomy of roots, etc. [12–16].
The type of restoration made on top of the endodontic treated root is another clinical
key factor to guarantee longevity to the tooth and, in particular, the precision of the coronal
margin of the restoration, independently, if an indirect or direct restoration is made [17–19].
Another important aspect is how the endodontic treated root can be built up, using or not
posts [20]. It is still an open question whether a post is needed or can be avoided [11,21,22].
In order to obtain predictable results, clinical trials are needed. Clinical trials are
considered more reliable than in vitro tests and can be retrospective or prospective [23,24].
Prospective clinical studies are usually performed in specialized centers; specific
parameters are evaluated with a limited number of samples. Retrospective studies can
collect a wider number of samples and may reflect the clinical behavior of practitioners.
The aim of this retrospective clinical study was to collect long-term restorative and
endodontic outcomes of ETT restored by different clinical procedures.
The tested null hypotheses were: (1) there was no difference in the endodontic outcome
of ETT with and without periapical lesion at the beginning of the treatment; (2) there was
no difference in the endodontic outcome between endodontic treatments with or without
precise coronal margins; (3) there was no difference between ETT restored with or without
post; (4) there was no difference between ETT restored by direct or indirect restoration.
J. Clin. Med. 2021, 10, 908 3 of 12

2. Materials and Methods

2.1. Study Population
Over a 20-year period (March 1999 to March 2019), one expert endodontist (DP)
conducted 298 endodontic treatments in 205 patients (143 men, age range: 19 to 61 years;
169 women, age range: 19 to 71 years); follow-ups were done with reference to the dental
records. Patients were in need of different endodontic therapies. Consecutive patients were
selected from the authors’ offices. Only primary endodontic treated teeth or nonsurgical
retreatments, with a follow-up of at least 18 months or longer, were included in this survey,
with patients who returned for oral hygiene recalls in 2019.
All procedures performed in this study involving human participants, were in accor-
dance with the ethical standards of the institutional committee, and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards. Informed written
consent was obtained from all individual participants included in the study. Collection and
analysis of the data were approved by the Ethical Committee of the University of Siena.
Inclusion criteria were the following: age: 42 (±7.9) years (range 19 to 71); sex: 169 F,
143 M; periodontally healthy or successfully treated patients in need of one or more
endodontic treatments.
Exclusion criteria were the following: individuals who were not yet adults (<18 years),
pregnancy, disabilities, previous prosthodontic restorations of abutment teeth, deep defects
(close to pulp, <1 mm distance), or pulp capping, heavy occlusal contacts or history of
bruxism, systemic disease or severe medical complications, allergic history concerning
methacrylates, rampant caries, xerostomia, lack of compliance.

2.2. Sample Characteristics

A total of 298 teeth were included in the study, of which, 52 were premolars (26%),
170 molars (52%), and 76 anterior teeth (21%, II e V sextant); 103 ETT belonged to the
mandible (30.68%) and 195 (69.32%) to maxillae.
Several endodontic peculiarities were analyzed. At baseline, 198 sample teeth (66.44%)
showed symptoms (tenderness/pain to percussion) and 164 (55%) had periapical radiolu-
cency. Regarding ETT with radiolucency, 90 of them (54.87%) were in coincidence with
their need for retreatment and 74 (45.13%) were necrotic teeth. The most frequently used
obturation techniques were warm gutta-percha in 80% of cases, by carrier in 20%, and hot
gutta-percha in other cases, mainly when curve canals were treated.
After being endodontically treated, 192 ETT were restored by direct resin composite
restorations, and 106 posts were luted. A total of 75 (25.16%) direct restorations remained
as final restoration, 137 single crowns (45.97%), 42 (14.09%) partial adhesive crowns, and
42 (14.09%) abutments of fixed bridges were the final treatments.

2.3. Original Endodontic Therapy Procedure

For each tooth, the following preoperative data were recorded: demographic data,
tooth location, number of root canals, previous endodontic treatment, clinical signs and
symptoms, vitality tests, and radiographic periapical status. Based on these findings, the
preoperative condition was classified as one of the following: vital (healthy or irreversibly
inflamed pulpitis), non-vital, endodontically treated, with or without periapical lesion, and
symptomatic or asymptomatic.
For each tooth, the following intra-operative data were recorded: number of treatment
sessions; inter-appointment dressing (if used); the occurrence of procedural complications
such as perforation, breakage of files and flare-up; length of canal filling (at apical level,
1 mm short or more and beyond); and temporary restoration placed. A conservative
endodontic cavity (CEC) access was performed using a long shaft round diamond bur
and endodontic dedicated ultrasonic tips. After straight-line access preparation was
obtained, root canals were negotiated with pre-curved stainless steel K-type files (Maillefer,
Bailague, Switzerland), size 0.8 or 10 ISO (International Standard Organization) to the
major apical foramen. Working length was measured using an electronic apex locator
J. Clin. Med. 2021, 10, 908 4 of 12

(Root ZX Morita, Tokyo, Japan), established at electronic 0 and, in most cases, checked
with an intraoperative X-ray. Due to the long period of time that has been taken into
consideration in this study, different shaping techniques and instruments have been used.
From 1999 to 2003 a crown-down approach was utilized to give correct shaping to the
canals; pre-flaring was performed with a manual pre-curved stainless steel K-file with a
#25 tip 0.02 taper, then the shaping was performed with a Ni-Ti rotary file system, which
had tip size #25 for all instruments and a different taper (QANTEC Kerr, Kerrville, TX,
USA From 2003 to 2013, a simultaneous technique was introduced in the clinical procedure,
utilizing Ni-Ti rotary files with different tip sizes and different tapers (Mtwo, Sweden e
Martina, Italy). From 2013 to 2019, a mixed technique was adopted: pre-flaring and glide
path were performed to length with a nickel-titanium #10 tip size and 0.04 taper rotary
file, followed by a nickel-titanium #15 tip size and 0.05 taper rotary file (Mtwo, Sweden e
Martina, Italy). All canals were shaped with the M-Wire alloy rotary instrument ProTaper
Next (Maillefer, Bailague, Switzerland) to a length of up to a #25 tip size and a variable
taper. The apical diameter was measured (apical gauging) using nickel-titanium manual
K-type files, NiTi Flex (Maillefer, Bailague, Switzerland), and the shaping of the apical
third was refined, where needed. Irrigation was copious and frequent using heated 5.25%
sodium hypochlorite NiClor (NiClor, Ogna, Bologna, Italy) deposited with side-vented
30-G needles. After instrumentation, the root canals were irrigated with 17% EDTA solution
Tubuliniclean (Ogna, Bologna, Italy), for 3 min, followed again by several 1-min irrigations
with heated 5.25% sodium hypochlorite solution.
The canals were dried with dedicated sterile paper points, filled with dedicated
gutta-percha cones ProTaper Next (Maillefer, Bailague, Switzerland), and zinc oxide-based
endodontic sealer (Pulp Canal Sealer, Kerr, Germany) using a continuous wave of con-
densation technique (80%) or a carrier-based technique (Thermafil, Dentsply, Konstanz,
Germany) in roots with curve canals, depending on the root canal anatomy. A post was
placed when the remaining coronal structure was less than 50% [25]. A temporary restora-
tion was performed using zinc oxide based cement placed on the pulp chamber floor
covered by a layer of glass ionomer cement (GCem, GC Co., Tokyo, Japan).
The post space was prepared using the drill provided by the manufacturer. Fiber-
reinforced composite post was adapted to the anatomy of the root. Post length was adapted
to the length of the post space. The post surface was cleaned with phosphoric acid and
treated with a silane-coupling agent. For adhesive cementation, the dentinal surface was
etched with phosphoric acid for 10 s and pretreated with a dual-cure adhesive before
the post was cemented with a dual-cure resin. Aesthetic Plus fiber posts in combination
with the All Bond 2 bonding system and proprietary C&B resin cement (Bisco) were used
between 1999 and 2008. GC fiber posts, in combination with Gradia Core (GC), were used
from 2009 to 2018. Porcelain to fused metal crowns were cemented with Fuji Cem (GC)
until 2015, whilst more recently, zirconia full crowns were luted with G-Cem adhesive
cement (GC). When direct restorations were placed, cuspal coverage was made, and the
restorations were made using resin composite materials in combination with proprietary
bonding systems. From 1999 to 2010, Gradia (GC) resin composite in combination with
G-Bond (GC) was used. After 2010, a combination between G-aenial resin composite (GC)
and G-Bond Plus (GC) was used. More recently (from 2016), the same resin was used in
combination with GPremio bond (GC).

2.4. Follow-Up
For each tooth, the following postoperative data were recorded: the treatment and
recall period, the presence or absence of signs and symptoms, the presence or absence
of apical lesion, the presence and type of restoration, and the type of build-up with or
without a post. Only primary endodontic treated teeth or nonsurgical retreatments with
a follow-up of at least 18 months or longer were included in this survey with a media
of 10.2 years. The follow-up sessions were performed with patients who returned to the
offices during oral hygiene recalls during 2019. Among all patients who returned for a
J. Clin. Med. 2021, 10, 908 5 of 12

recall, 298 teeth were selected for this survey. All of the recorded information from the
files were transferred to a computerized database. The clinical follow-up examinations
were performed by the primary author (D.P.). For teeth examined more than once, only the
findings of the final examination during 2019 were considered. Traumatized teeth, injured
with luxation, intrusion, extrusion, avulsion, or horizontal fractures, and teeth requiring
endodontic surgery, were excluded from this study.

2.5. Criteria of Evaluation

When only the endodontic treatments were evaluated, the following criteria of the
European Society of Endodontology 1994 [25] were used to judge the success rate of
root canal therapy: (1) clinical examination: the absence of pain, swelling, and other
symptoms, no sinus tract, and no loss of function; and (2) radiographic examination:
the periodontal ligament space was normal on the original diagnostic radiograph, and
it remained unchanged on recall radiographs, or healing of a radiolucent area visible on
the original preoperative radiograph was observed and the periodontal ligament space
returned to normal. For radiographic examination, PAI (Peri Apical Index) scores were
used [7].
Therefore, cases were considered as failures in the presence of pain, swelling, and sinus
tract. Radiographically, failures were identified when a lesion appeared after endodontic
treatment, when a preexisting lesion increased in size, and when a lesion remained the
same or only diminished in size. Multi-rooted teeth were assessed according to the root
that appeared the worst.
Debonding of the post was registered when the crown dislodged or/and moved.
Loss of retention was registered when mobility was detected between the crown and the
abutment, when saliva was expressed at the margin of the crown when pressure was
applied, or when an explorer could easily be inserted between the tooth and the crown.
Coronal fracture of the direct restoration was registered when visible.
Carious lesions were recorded when a dental explorer could penetrate the dentin at
the cervical margin of the crown or the direct restoration as assessed through radiographs
and/or clinically.
Ceramic fractures (chipping) were registered clinically and from photographs.
Possible “marginal leakage” was clinically evaluated with a sharp explorer along the
margins and radiographically.
Periodontal involvement was recorded when a periodontal disease (not existing at the
baseline) was visible around the sample tooth according to periodontal parameters [26].
The two examining operators (A.M. and V.M.) were calibrated before the examination.
Calibration was done in 30 cases. The two examiners made their own evaluations. In case
they disagreed, the single cases were reevaluated and an agreement was found.
In this clinical study, the endodontic and restorative treatments made for each tooth
were evaluated in a single sample. For that, when the global treatments were considered, it
was decided to avoid misunderstanding between the definitions of success and survival.
Success was defined by the percentage of endodontic treatments and restorations that
remained in situ without any modification. Survival was defined by the percentage of
endodontic treatments and restorations that remained in situ, with modifications, but still
under clinical acceptability. Failure was defined by the percentage of teeth that needed to
be replaced [27].
Data were collected based on predetermined criteria. Percentages of teeth with or
without apical periodontitis were recorded, as well as adequate root canal treatment (AE),
inadequate root canal treatment (IE), adequate seal of the restoration (AR), and inadequate
seal of the restoration (IR).

2.6. Radiographic Method and Evaluation

When evaluating treatment results, the first clinical and radiographic examination
was performed by the primary author (D.P.) when the 298 followed cases were randomly
 2.6. Radiographic Method and Evaluation
When evaluating treatment results, the first clinical and radiographic examination
J. Clin. Med. 2021, 10, 908 was performed by the primary author (D.P.) when the 298 followed cases were randomly 6 of 12
selected from patient files, recorded by handwriting, and the recorded information was
transferred to a computerized database. The final evaluation was done together with two
other observers after calibration (A.M. and V.M.). For radiographic examination, PAI
selected
scores werefrom
usedpatient
[7]. files, recorded by handwriting, and the recorded information was
transferred to a computerized database. The final evaluation was done together with two
other
2.7. observers
Statistical after calibration (A.M. and V.M.). For radiographic examination, PAI scores
Analysis
wereDescriptive
used [7]. and inferential statistics were performed using the Stata 15 IC statistical
package, and the significance level was set at α = 0.05. The minimum, mean, and maxi-
2.7. Statistical
mum follow-ups Analysis
were calculated for all endodontic treatments. The overall failure inci-
dence Descriptive
rate was according to the totalstatistics
and inferential failure events
were (tooth extraction)
performed usingand
thetoStata
the presence
15 IC statistical
of any complication
package, (free of thelevel
and the significance event) divided
was set at by
α =the total
0.05. Thetooth-years
minimum,during
mean,the andtotal
maximum
follow-up
follow-ups period;
werethe 95% confidence
calculated for all intervals (95%treatments.
endodontic CI) were estimated according
The overall to the
failure incidence
Poisson
rate was distribution.
according Both
to thethe cumulative
total survivals
failure events performed
(tooth wereand
extraction) recorded
to theusing the of any
presence
Kaplan–Meier
complication analysis. Coxevent)
(free of the regression
dividedanalysis
by thewas used
total to examineduring
tooth-years the riskthe
factors
totalfor
follow-up
any
period; the 95% confidence intervals (95% CI) were estimated according to ratio
clinical event during the follow-up period. The results were presented as hazard the Poisson
(HR) with 95% confidence intervals (CI).
distribution. Both the cumulative survivals performed were recorded using the Kaplan–
Meier analysis. Cox regression analysis was used to examine the risk factors for any clinical
3. Results
event during the follow-up period. The results were presented as hazard ratio (HR) with
Results showed that 92.61% of ETT did not have any complications up to 18 years
95% confidence intervals (CI).
(Figures 1–3).
Regarding the quality of root filling, 264 teeth (88.59%) showed good filling (Figures
3. Results
1–3) (gutta-percha at the radiologic apex), 22 roots (7.38%) short filling (shorter than 1 mm
Results
from the showedapex),
radiographic that 92.61% of ETTlong
and 12 (4.03%) did not have
filling any than
(longer complications
1 mm of theup to 18 years
radio-
(Figures
graphic 1–3).
apex).

(a) (b) (c)

Figure
Figure1.1.(a)(a)
Upper central
Upper incisor
central with with
incisor periapical lesion. lesion.
periapical (b) The (b)
rootThe
afterroot
being endodontically
after being endodontically
treated. A second root was filled by warm gutta-percha technique. A direct resin composite resto-
treated. A second root was filled by warm gutta-percha technique. A direct resin composite
J. Clin. Med. 2021, 10, x FOR PEER REVIEW 7 of 12 restora-
ration was used to restore the coronal part of the tooth. (c) The root after 3 years of clinical service.
tion was used to restore
A complete healing is evident.the coronal part of the tooth. (c) The root after 3 years of clinical service. A
complete healing is evident.

(a) (b) (c)

Figure
Figure2.2.(a)(a)
AAlower bicuspid
lower in need
bicuspid to beto
in need endodontically treatedtreated
be endodontically becausebecause
of necrosis of the pulp
of necrosis of the pulp
and periapical lesion; (b) The tooth after being endodontically treated. Two canals were found,
and periapical lesion; (b) The tooth after being endodontically treated. Two canals were found,
cleaned and filled; (c) The tooth at 2 years recall. The periapical lesion completely disappeared.
cleaned and filled; (c) The tooth at 2 years recall. The periapical lesion completely disappeared.
 (a) (b) (c)
Figure 2. (a) A lower bicuspid in need to be endodontically treated because of necrosis of the pulp
J. Clin. Med. 2021,and periapical lesion; (b) The tooth after being endodontically treated. Two canals were found,
10, 908 7 of 12
cleaned and filled; (c) The tooth at 2 years recall. The periapical lesion completely disappeared.

(a) (b) (c)

Figure
Figure 3. (a) 3. (a)
A first A first
lower molarlower molar
with with periapical
periapical lesion andlesion and
in need toin
beneed to be retreated.
retreated. (b) The
(b) The molar molar
immediately after being
immediately after being endodontically treated. Four canals (one in a radix entomolaris)
endodontically treated. Four canals (one in a radix entomolaris) were detected and treated. (c) The molar afterwere de- 4 years. The
good healthtected and
of the treated. areas
periapical (c) The molar
can after 4The
be noted. years. Thewas
crown good health with
restored of thean
periapical
adhesiveareas canonlay.
esthetic be
noted. The crown was restored with an adhesive esthetic onlay.
Regarding the quality of root filling, 264 teeth (88.59%) showed good filling (Figures 1–3)
There were(gutta-percha
no statisticallyatsignificant differences
the radiologic apex), among
22 rootsoutcomes of vital
(7.38%) short root (shorter
filling and than 1 mm
necrotic and retreatment with radiolucency.
from the radiographic apex), and 12 (4.03%) long filling (longer than 1 mm of the radio-
At the recall, 284 (94.42%)
graphic apex). ETT showed good coronal margin, 11 (4.38%) not-so good
margins (margin wasThere filledwere
non-precise with thesignificant
no statistically sharp explorer), and 3among
differences (1.2%) clear open-of vital root and
outcomes
ing of the margins radiographically.
necrotic and retreatment with radiolucency.
Success was recorded
At thein 276 ETT
recall, (92.6%), 2.68%
284 (94.42%) (8 ETT)good
ETT showed showed irreversible
coronal margin,failures,
11 (4.38%) not-so good
and 14 (4.69%) reversible complications.
margins (margin was filled non-precise with the sharp explorer), and 3 (1.2%) clear opening
Four ETT (1.34%) failed because
of the margins of root fracture and the other four (1.34%) because
radiographically.
of endodontic complications.
Success was recorded in 276 ETT (92.6%), 2.68% (8 ETT) showed irreversible failures,
Eight ETT (2.69%) showedreversible
and 14 (4.69%) non-irreversible periodontal complications and the other
complications.
six (2.01%) prosthodontic complications.
Four ETT (1.34%) failed because of root fracture and the other four (1.34%) because of
The placement or not ofcomplications.
endodontic a post did not show different outcomes.
Sixteen failures Eight
were ETTfound (2.69%)
when showed non-irreversible
a full crown was cemented periodontal
on the ETT.complications
Failures and the other
were recorded in sixthree
(2.01%)
casesprosthodontic
in combination complications.
with direct restorations, in one case with a
partial crown, and two Thecases
placement or not of aofpost
as the abutment did not show different outcomes.
a bridge.
The survival rateSixteen failures were
of both “failure” found
and “free when
of the a full
event” crown was cemented
of endodontically on the ETT. Failures
treated teeth,
determined by the were recorded inanalysis
Kaplan–Meier three cases
overinancombination
18-year period, with direct restorations,
is shown in Figures 4 and in one case with a
partial
5. The survival rate crown,
after andwas
18 years two97.3%
cases as the abutment
(Interval of a bridge.95.1-98.3). All of
of Confidence(IC)
the extractions, except The survival
one, occurredrateduring
of boththe“failure”
first 2 and
years“free of the event”
of service. of endodontically treated
The cumulative
survival to any complication displays that they occurred in the vast majority duringperiod,
teeth, determined by the Kaplan–Meier analysis over an 18-year the is shown in
Figures 4 and 5. The survival rate after 18 years was 97.3% (Interval of Confidence (IC)
95.1–98.3). All of the extractions, except one, occurred during the first 2 years of service. The
cumulative survival to any complication displays that they occurred in the vast majority
during the first 5 years of service. Notwithstanding after 18 years of observation, the
success rate was 92.6% (IC 90.1–94.71).

Cox Regression Analysis

A Cox regression model was built to verify the predictive potential for survival data
to any complication of clinical and radiographic variables. The independent variables were
evaluated in terms of the hazard ratio (Table 1). The final model obtained by the command
“all sets” (Stata 15 IC displays a risk of any complication five times higher for the presence
of a full crown as a final restoration (HR = 5.03 (IC 1.39–18.20)) in comparison to any
other restorative procedure. The presence of a non-perfect quality of the endodontic filling
(short or long) displayed a statistically significant higher risk of complication (HR = 17.00
(IC 5.68–56.84). Furthermore, clinically detectable non-precise margins predict the presence
of any clinical complication with a hazard ratio almost 7 times higher than endodontically
treated teeth with proper coronal margins (HR = 6.89 (IC 2.03–23.38), while the presence of
lucency at the baseline did not affect the risk of complication (HR = 0.575 (IC 0.205–1.61).
J.J.Clin.
J.
Clin.Med.
Clin. Med. 2021,
Med. 2021,
10, 908
2021, 10,
10, xx FOR
FOR PEER
PEER REVIEW
REVIEW 8 of 128 of 12
8 of 12

The
firstpresence ofofservice.
post, tooth position in the arch,
18and type did not showthe
high-risk
success rate
first 55 years
years of service. Notwithstanding
Notwithstanding after
after 18 years
years of observation,
of observation, the success rate was
rate was
(HR = 1.85, 1.98, and
92.6% (IC 90.1–94.71). 2.24, respectively).
92.6% (IC 90.1–94.71).

00
00
00
00
00

Figure4.4.
Figure
Figure 4.The
Thesurvival
The survival
survival rate
rate
rate after
after 18
18 18
after years
years was
waswas
years 97.3%97.3% (Interval
(Interval
97.3% of Confidence
Confidence
of Confidence
(Interval of (IC) 95.1–98.3).
95.1–98.3).
(IC) 95.1–98.3).
(IC) All of
All of the
All of
the extractions,
extractions, except,
except,
the extractions, one occurred
one occurred
except, during
duringduring
one occurred the
the firstthe first
2 years 2 years
first 2ofyears of
service. service.
of service.
00
00
00

Figure 5. The cumulative survival to any complication displays that they occurred in the vast ma-
Figure5.5.The
The cumulative survival to any complication displays thatoccurred
they occurred in the vast ma-
Figure
jority duringcumulative
jority during the first
the
survival
first 55 years
years of to
of
any
service.
service.
complication displays
Notwithstanding,
Notwithstanding,
that they
after
after 18 years
18 years of in the vast
of observation,
observation, majority
the success
the success
during
rate wasthe92.6%
first 5(IC
years of service. Notwithstanding, after 18 years of observation, the success rate
90.1–94.71).
rate was 92.6% (IC 90.1–94.71).
was 92.6% (IC 90.1–94.71).
Cox Regression Analysis
Cox Regression Analysis
Table 1. Considered independent variables. (FullC = full crown; FilQuality = quality of endodontic
ASymt
filling;A Cox= regression
presence
Cox regression model was
was
of symptoms;
model built
Seal to verify
verify
= quality
built to the predictive
predictive
of restoration
the potential for
margins).
potential for survival
survival data
data
to any
to any complication
complication of of clinical
clinical and
and radiographic
radiographic variables.
variables. The The independent
independent variables
variables
_t
were evaluated Hazard
evaluated in Ratio
in terms
terms of Std.
of the Err.
the hazard
hazard ratio z
ratio (Table P
(Table 1).> |z|
1). The
The final (95%
final model Conf. Interval)
model obtained
obtained by by the
the
were
Post
command “all 1.444597
sets” (Stata 15 1.288705
IC displays a0.41
risk of any0.680
complication 0.251421
five 8.300259
times higher for
command “all sets” (Stata 15 IC displays a risk of any complication five times higher for
the presence
theFullC of a full
presence of a2.361482 crown as a final
full crown as2.034491 restoration (HR =
1.00 (HR =0.319
a final restoration 5.03 (IC 1.39–18.20)) in comparison
0.4363625 12.77973
5.03 (IC 1.39–18.20)) in comparison
to any other restorative procedure. The presence of a non-perfect quality
to any other restorative procedure. The presence of a non-perfect quality of the endodontic
FilQuality 11.0516 8.10662 3.28 0.001 2.624511of the endodontic
46.53742
filling
filling (short or long) displayed a statistically significant higher risk of complication (HR
Symt(short or0.7417658
long) displayed a statistically
0.5672379 −0.39significant
0.696higher risk of complication
0.1657075 3.320409 (HR
= 17.00
= 17.00 (IC 5.68–56.84). Furthermore, clinically detectable non-precise margins predict the
Seal (IC 5.68–56.84).
4.425534 Furthermore,
4.166967clinically1.58 detectable
0.014non-precise margins
0.6990313 predict the
28.01785
presence of
presence of any
any clinical
clinical complication
complication with with aa hazard
hazard ratio
ratio almost
almost 77 times
times higher
higher than
than en-
en-
dodontically treated teeth with proper coronal margins (HR = 6.89
dodontically treated teeth with proper coronal margins (HR = 6.89 (IC 2.03–23.38), while (IC 2.03–23.38), while
the presence
the presence ofof lucency
lucency at at the
the baseline
baseline did did not
not affect
affect the
the risk
risk of
of complication
complication (HR (HR == 0.575
0.575
J. Clin. Med. 2021, 10, 908 9 of 12

4. Discussion
The long-term survival and success rates of ETT are similar and/or better than those
of implants available in the literature [28–30]. For that, it is mandatory to safe natural teeth
as many as possible. High success and survival rates of ETT are mainly related to the
quality of the endodontic treatment and the restorative procedure used to save the tooth in
clinical services [31].
In this clinical study, many parameters were collected and statistically evaluated on
a long-term basis. The clinical samples were followed up to 18 years and failures were
observed mainly within the first years of clinical service. This finding showed that when
root fracture was avoided by covering cusps with the crown or the direct restoration,
the teeth were protected from occlusal loading [32]. Moreover, when partial or complete
healing of the periapical lesion was achieved, the restored root remained in clinical service
without any clinical sign or symptom. These findings were in agreement with previous
reports [8,33–35].
The presence of signs and symptoms—including the presence of periapical lucency—
did not influence the final outcomes. In fact, around half of ETT showed a radiolucency
visible at the baseline, and of them, approximately 50% were present in teeth in need of
retreatment, whilst the others were necrotic teeth. No differences were found in the final
outcomes among teeth with radiolucency at the baseline (necrotic and roots in need of
retreatment) and those without (vital teeth). For that, the first null hypothesis—that there
was no difference in the endodontic outcome of ETT, with or without periapical lesions at
the beginning of the treatment—was accepted
The numbers of failures due to tooth fractures, endodontic, periodontal, or prosthodon-
tic reasons, were limited to 22 of 298 ETT. Of the recorded failures, 14 were reported as
repairable; eight were catastrophic failures and, consequently, needed root extraction. The
success rate was around 92% (Figures 1–3), the survival rate around 4.69%, and only less
than 2.69% were irreversible failures. The success and survival rates of this clinical study
were a little higher than several others [36–38]. Another important aspect related to the
failure was the fact that irreversible failures mainly took over in the first two years and
within the first 5 years, when cumulated as reversible and irreversible failures. It can be
speculated that “biological” complications can come out rather quickly, and periodontal
and prosthodontic complications in a longer time, but after 5 years of clinical service, it can
be expected that an ETT can stay in clinical service for many more years.
One-third of the restored ETT were in the mandible and two-thirds in the maxilla, but
no statistically significant differences were found in the outcome.
The endodontic standardized procedures used in this study were strictly followed,
which could be considered other important factors that determine high-quality outcomes.
At the baseline (immediately after endodontic treatment was completed) a precise root
filling at the radiographic apex of root canals was recorded (approximately 92%), while
in less than 5% the root filling was short, and in less than 4% too long. The quality of
endodontic treatment, and in particular of root filling, could be an important factor used to
predict a positive outcome [17–19].
From the result of this clinical study, there was no difference between final outcomes of
vital teeth and second root canal treatments. It was expected that the presence of periapical
translucency, teeth already endodontically treated, and/or necrotic teeth can determine
lower success and survival rates. These data can be related to the high-quality root canal
fillings and bacteria-tight post-endodontic restorations that were made in this clinical
study [39,40].
Regarding the survival and success rates of the restoration made on ETT, several
aspects can be pointed out. First, the presence (or not) of the post did not make statistically
significant differences. For that, the null hypothesis—that there was no difference between
ETT restored with or without a post—was accepted. This might be because posts were
placed when clinically indicated. This study is in agreement with other authors [20].
J. Clin. Med. 2021, 10, 908 10 of 12

The type of restoration was evaluated in relation to success, survival, and failure rates.
Statistically, there were no differences between the different types of restorations.
However, accordingly, with Cox regression analysis evaluating the high-risk ratio,
the placement of a crown on the ETT raises the risk of failure, five times more than any
other type of restoration. This could partially be because nearly 75% of ETT were restored
with a full or partial crown, or abutment of the bridge, raising the number of possible
failures combined with crowns. A wider number of samples should be evaluated in order
to confirm these findings.
It should note that, in this study, the clinician performing the work was an expert
endodontist. The variable “operator” could be considered one of the most important factors
concerning the outcomes in dentistry [41]. Experience, knowledge, and skill of the operator
can justify the high rate of success and survival for up to 18 years.
When risk ratio analysis was performed, restoration with a proper quality of obtu-
ration, and a good marginal coronal seal, were significant factors to obtain long-term
high-quality outcomes. These findings are in agreement with several other studies [17–19].
For that, the null hypothesis—that there was no difference in endodontic outcome
between endodontic treatments, with or without precise coronal margins—was rejected.
Several limitations of this study can be pointed out. First, the limited number of ETT
should be expanded; moreover, the outcomes are mainly related to the skill and knowledge
of one expert operator, and it would be interesting to enlarge the number of operators.
The study findings should be confirmed by other (similar) multi-center clinical trials,
possibly prospectively made.

5. Conclusions
From the findings of this clinical study, the following conclusion can be drawn: a
correct filling (three-dimensional obturation) of root canals, which is the final result of a
proper treatment protocol, combined with a good coronal marginal seal, allows obtaining a
long-term high success rate in teeth with a periapical lesion at the baseline.
The presence of a periapical lesion at the baseline does not decrease the quality of the
final outcome.

Author Contributions: Conceptualization, S.G., S.B. and M.F.; data curation, S.G., N.D. and A.M.;
formal analysis, N.D.; funding acquisition, V.M. and M.F.; investigation, D.I.K.P., S.B., V.M. and
E.F.C.; methodology, D.I.K.P., S.G., S.B., E.F.C. and M.F.; resources, A.M.; software, N.D. and E.F.C.;
supervision, S.G.; validation, G.S.; visualization, G.S.; writing—original draft, D.I.K.P., S.G., S.B.,
E.F.C. and M.F.; writing—review and editing, G.S. and M.F. All authors have read and agreed to the
published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted according to the guidelines of the
Declaration of Helsinki and approved by the Institutional of Ethical Committee of University of Siena
(protocol code PR001; date of approval 21 October 2019).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the
study. Written informed consent has been obtained from the patients to publish this paper.
Conflicts of Interest: The authors declare no conflict of interest.

References
1. Torabinejad, M.; Bahjri, K. Essential elements of evidence-based endodontics: Steps involved in concluding clinical research. J.
Endod. 2005, 31, 563–569. [CrossRef]
2. Berghenholtz, G.; Kvist, T. Evidence-base endodontics. Endod. Top. 2014, 31, 3–18. [CrossRef]
3. Boucher, Y.; Matossian, L.; Rilliard, F.; Machtou, P. Radiographic evaluation of the prevalence and technical quality of root canal
treatment in a French subpopulation. Int. Endod. J. 2002, 35, 229–238. [CrossRef]
4. Friedman, S.; Mor, C. The success of endodontic therapy healing and functionality. J. Calif. Dent. Assoc. 2004, 32, 493–503.
5. Bender, I.B.; Seltzer, S.; Soltanoff, W. Endodontic success of a reappraisal of criteria. I. Oral Surg. Oral Med. Oral Pathol. 1966, 22,
780–789. [CrossRef]
J. Clin. Med. 2021, 10, 908 11 of 12

6. Bender, I.B.; Seltzer, S.; Soltanoff, W. Endodontic success of a reappraisal of criteria. II. Oral Surg. Oral Med. Oral Pathol. 1966, 22,
790–802. [CrossRef]
7. Orstavik, D.; Kerekes, K.; Eriksen, H.M. The periapical index: A scoring systems for radiographic assessment of apical periodonti-
tis. Endod. Dent. Traumatol. 1986, 2, 20–34. [CrossRef] [PubMed]
8. Farzaneh, M.; Abitbol, S.; Friedman, S. Treatment outcome in endodontics: The Toronto study. Phases I and II: Orthograde
retreatment. J. Endod. 2004, 30, 627–633. [CrossRef]
9. Friedman, S.; Abitbol, S.; Lawrence, H.P. Treatment outcome in endodontics: The Toronto Study. Phase 1: Initial treatment. J.
Endod. 2003, 29, 787–793. [CrossRef]
10. Ng, Y.L.; Mann, V.; Rahbaran, S.; Lewsey, J.; Gulabivala, K. Outcome of primary root canal treatment: A systematic review of the
literature—Part 2. Influence of clinical factors. Int. Endod. J. 2008, 41, 6–31. [CrossRef] [PubMed]
11. Ferrari, M.; Ferrari Cagidiaco, E.; Goracci, C.; Sorrentino, R.; Zarone, F.; Grandini, S.; Joda, T. Posterior partial crowns out of
lithium disilicate (LS2) with or without posts: A randomized controlled prospective clinical trial with a 3-year follow up. J. Dent.
2019, 83, 12–17. [CrossRef] [PubMed]
12. Martino, N.; Truong, C.; Clark, A.E.; O’Neill, E.; Hsu, S.M.; Neal, D.; Esquivel-Upshaw, J.F. Retrospective analysis of survival
rates of post-and-cores in a dental school setting. J. Prosthet. Dent. 2020, 123, 434–441. [CrossRef]
13. Schwartz, R.S.; Robbins, J.W. Post placement and restoration of endodontically treated teeth: A literature review. J. Endod. 2004,
30, 289–301. [CrossRef] [PubMed]
14. Juloski, J.; Radovic, I.; Goracci, C.; Vulicevic, Z.R.; Ferrari, M. Ferrule effect: A literature review. J. Endod. 2012, 38, 11–19.
[CrossRef]
15. Juloski, J.; Apicella, D.; Ferrari, M. The ferrule height on stress distribution within a tooth restored with fiber posts and ceramic
crown: A finite element analysis. Dent. Mater. 2014, 30, 1304–1315. [CrossRef] [PubMed]
16. Vallittu, P.K. Are we misusing fiber posts? Guest editorial. Dent. Mater. 2016, 32, 125–126. [CrossRef] [PubMed]
17. Trope, M.; Ray, H.L. Resistance to fracture of endodontically treated teeth. Oral Surg. Oral Med. Oral Pathol. 1992, 73, 99–102.
[CrossRef]
18. Tronstad, L.; Asbjornsen, K.; Doving, I.; Pedersen, I.; Ericksen, H.M. Influence of coronal restorations on the periodical health of
endodontically treated teeth. Endod. Dent. Traumatol. 2000, 16, 218–221. [CrossRef] [PubMed]
19. Gillen, B.M.; Looney, S.W.; Gu, L.S.; Loushine, B.A.; Weller, R.N.; Loushine, R.J.; Pashley, D.H.; Tay, F.R. Impact of the quality
of coronal restoration versus the quality of root canal fillings on success of root canal treatment: A systematic review and
meta-analysis. J. Endod. 2011, 37, 895–902. [CrossRef]
20. Zicari, F.; Van Meerbeek, B.; Debels, E.; Lesaffre, E.; Naert, I. An up to 3-Year Controlled Clinical Trial Comparing the Outcome of
Glass Fiber Posts and Composite Cores with Gold Alloy-Based Posts and Cores for the Restoration of Endodontically Treated
Teeth. Int. J. Prosthodont. 2011, 24, 363–372.
21. Ploumaki, A.; Bilkhair, A.; Tuna, T.; Stampf, S.; Strub, J.R. Success rates of prosthetic restorations on endodontically treated teeth;
a systematic review after 6 years. Long-term Clinical Outcomes of Endodontically Treated Teeth Restored with or without Fiber
Post–retained Single-unit Restorations. J. Oral Rehabil. 2013, 40, 618–630. [CrossRef]
22. Guldener, K.A.; Lanzrein, C.L.; Guldener, B.E.S.; Lang, N.P.; Ramseier, C.A.; Salvi, G.E. Long-term Clinical Outcomes of
Endodontically Treated Teeth Restored with or without Fiber Post–retained Single-unit Restorations. J. Endod. 2017, 43, 188–193.
[CrossRef] [PubMed]
23. Morimoto, S.; Rebello de Sampaio, F.B.; Braga, M.M.; Sesma, N.; Özcan, M. Survival Rate of Resin and Ceramic Inlays, Onlays,
and Overlays: A Systematic Review and Meta-analysis. J. Dent. Res. 2016, 95, 985–994. [CrossRef] [PubMed]
24. Zhang, X.; Pei, X.; Pei, X.; Wan, Q.; Chen, J.; Wang, J. Success and Complication Rates of Root-Filled Teeth Restored with Zirconia
Posts: A Critical Review. Int. J. Prosthodont. 2019, 32, 411–419. [CrossRef] [PubMed]
25. Sorrentino, R.; Goracci, C.; Zarone, F.; Tay, F.R.; Garciía-Godoy, F.; Ferrari, M. Effect of post-retained composite restorations and
amount of coronal residual structure on the fracture resistance of endodontically-treated teeth. Am. J. Dent. 2007, 20, 269–274.
26. European Society of Endodontology. Quality guidelines for endodontic treatment: Consensus report of the European Society of
Endodontology. Int. Endod. J. 2006, 39, 921–930. [CrossRef] [PubMed]
27. Loe, H.; Silness, J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta. Odontol. Scand. 1963, 21, 533–551. [CrossRef]
28. Anusavice, K.J. Standardizing failure, success, and survival decisions in clinical studies of ceramic and metal-ceramic fixed dental
prostheses. Dent. Mater. 2012, 28, 102–111. [CrossRef]
29. Iqbal, M.K.; Kim, S. For teeth requiring endodontic treatment, what are the differences in outcomes of restored endodontically
treated teeth compared to implant- supported restorations? Int. J. Oral Maxillofac. Implant. 2007, 22, 96–116.
30. Doyle, S.L.; Hodges, J.S.; Pesun, I.J.; Law, A.S.; Bowles, W.R. Retrospective cross sectional comparison of initial nonsurgical
endodontic treatment and single-tooth implants. J. Endod. 2006, 32, 822–827. [CrossRef] [PubMed]
31. Gatten, D.L.; Riedy, C.A.; Hong, S.K.; Johnson, J.D.; Cohenca, N. Quality of life of endodontically treated versus implant treated
patients: A university-based qualitative research study. J. Endod. 2011, 37, 903–909. [CrossRef] [PubMed]
32. Buvha, B.; Giovarruscio, M.; Rahim, N.; Bitter, K.; Mannocci, F. The restoration of root filled teeth: A review of the clinical
literature. Int. Endod. J. 2020. [CrossRef]
J. Clin. Med. 2021, 10, 908 12 of 12

33. Dias, M.C.R.; Martins, J.N.R.; Chen, A.; Quaresma, S.A.; Luis, H.; Carames, J. Prognosis of indirect Composite Resin Cuspal
Coverage on Endodontically Treated Premolars and Molars: An In Vivo Prospective Study. J. Prosthodont. 2018, 27, 598–604.
[CrossRef]
34. Sundqvist, G.; Fidgor, D.; Persson, S.; Sjögren, U. Microbiologic analysis of teeth with failed endodontic treatment and the
outcome of conservative retreatment. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 1998, 85, 86–93. [CrossRef]
35. Ørstavick, D.; Qvist, V.; Stoltze, K. A multivariate analysis of the outcome of endodontic treatment. Eur. J. Oral Sci. 2004, 112,
224–230. [CrossRef]
36. Imura, N.; Pinheiro, E.T.; Gomes, B.P.F.A.; Zaia, A.A.; Ferraz, C.C.R.; Souza-Filho, F.J. The outcome of endodontic treatment: A
retrospective study of 2000 cases performed by a specialist. J. Endod. 2007, 33, 1278–1282. [CrossRef]
37. Ng, Y.L.; Mann, V.; Gulabivale, K. Tooth survival following non-surgical root canal treatment: S systematic review of the literature.
Int. Endod. J. 2010, 43, 171–189. [CrossRef]
38. Dammaschke, T.; Steven, D.; Kaup, M.; Ott, K.H.R. Long-term survival of root canal treated teeth: A retrospective study over 10
years. J. Endod. 2003, 10, 638–643. [CrossRef]
39. Dammaschke, T.; Nykiel, K.; Sagheri, D.; Schafer, E. Influence of coronal restorations on the fracture resistance of root canal-treated
premolar and molar teeth: A retrospective study. Austr. Endod. J. 2013, 39, 48–56. [CrossRef]
40. Kirkevang, L.L.; Vaeth, M.; Horsted-Bindslev, P.; Wenzel, A. Longitudinal study of periodical and endodontic status in a Danish
population. Int. Endod. J. 2006, 39, 100–107. [CrossRef]
41. Estrela, C.; Holland, R.; Rodrigues, C.; Alencar, A.H.G.; Sousa-Neto, M.D.; Pecora, J.D. Characterization of Successful Root Canal
Treatment. Braz. Dent. J. 2014, 25, 3–11. [CrossRef] [PubMed]
Reproduced with permission of copyright owner. Further reproduction
prohibited without permission.