Endodontic Topics 2015, 33, 73–86 © 2015 John Wiley & Sons A/S.

All rights reserved Published by John Wiley & Sons Ltd

ENDODONTIC TOPICS
1601-1538

Restorative procedures: effect on

the mechanical integrity of
root-filled teeth
MICHAEL NAUMANN

Received 9 March 2015; accepted 11 October 2015.

Introduction In a prospective clinical trial over a time of

observation of 10 years, 149 teeth with post-
A systematic review dealing with the success endodontic restorations including glass fiber-
probability of root canal treatments, implant- reinforced posts and several prosthetic restorations
supported single crowns, and fixed prosthesis derived were examined (5). Factors influencing tooth survival
interesting conclusions. It shows that teeth which were evaluated. An annual failure rate of 4.6% may
were endodontically treated and restored with single be explained by the preparation design. The
crowns and implant-supported single crowns have a treatment protocol at that time only required a
comparable (short-term) success probability (1). crown margin ending in sound cervical dentin below
Interestingly, both types of restorations perform the core buildup. A ferrule height of 2 mm was not
better than fixed prosthesis (2). Thus, it provides a always realized. This may be one essential factor
strong argument to retain teeth by endodontic explaining the high failure rate. Regarding the
treatment when reasonable and possible. However, influence of prosthetic restorations on survival, the 5-
the decision to treat a tooth endodontically and to year evaluation showed a significantly higher failure
rebuild is not just influenced by the prognosis over a risk for teeth restored with single crowns or teeth as
time of 5 or 10 years, but also by the individual abutments of a combined fixed-removable partial
patient’s general health condition, smoking, caries, denture (6). Interestingly, after 10 years, the type of
patient preference, and of course economic factors restoration cannot be confirmed as a significant risk
(3). Before each endodontic treatment, it is also factor. The influence of remaining tooth structure on
important to examine the tooth and the area carefully tooth survival was also evaluated. It was shown that
in order to determine if and how the tooth can be the remaining tooth structure has an impact on
restored with a good long-term prognosis after tooth survival, and especially teeth without any cavity
completion of the endodontic treatment (Fig. 1). walls showed a higher risk of failure.
A further parameter for survival is the position of
Status of clinical trials: long-term the tooth in the dental arch. The study quoted
above shows that anterior teeth have twice the risk
results of post-endodontic
of failure compared to posterior teeth. This may be
restorations explained by the occurrence of non-axial shear forces
There are only a few long-term studies on the in the anterior region and can be evaluated as
survival of post-endodontic restorations. In addition, unfavorable biomechanical stress (7).
differences in materials, methods applied, and A randomized controlled clinical pilot study over
recorded baseline and outcome parameters 7 years evaluated the survival of 91 teeth that were
complicate an adequate assessment of these published reconstructed with adhesively luted fiber-reinforced
trials, for example by means of systematic reviews (4). composite and titanium posts (8). Prosthetic

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Fig. 1. Pre-endodontic checklist (before starting endodontic treatment).

restorations were single crowns and fixed partial significantly improves fracture resistance compared
dentures of metal ceramics and combined fixed- to post alone or post and core buildup (17).
removable partial dentures. The results showed that It has been shown that the aim of the
when a ferrule design is ensured (in 13 cases by reconstruction of endodontically treated teeth is
surgical crown lengthening before the restoration the reinforcement of the outer surface (instead of the
was started), a survival rate of 92% is possible, inner endodontic space) of a respective tooth (12,18).
irrespective of the post material. The type of The translation of this insight was named “ferrule”
prosthetic restoration did not prove to be a and its effect became popular with the phrase “ferrule
statistically relevant factor (8). effect,” which will be discussed later in more detail.
Meanwhile, it is a generally accepted statement that
a post only needs to be placed in order to create
Indication of endodontic post
additional retention for the core buildup. Due to the
placement
increasing abilities of adhesive techniques and
To answer the question of when to place a post, one materials, this statement must be proven in the future
needs to be aware of the aim of post placement. (19). Perhaps posts can soon be avoided. Of greater
Even 30 years ago there were doubts that an importance is the amount of hard tissue remaining,
endodontic post reinforces an endodontically treated which significantly influences the structural integrity
tooth (9,10). Nevertheless, this approach still of the tooth. While preparation of an access cavity
garners broad approval from dentists (11). A recent decreases structural stability by about 5%, preparation
survey indicates that there has only been a slight of an MOD cavity leads to a reduction of about 60%
change in this opinion. Endodontic posts are (20). Panitvisai & Messer (21) showed that the
preferably inserted due to their ascribed “reinforcing deflection of the cusps increases with increasing cavity
effect” to reduce the risk of fracture. But this is not size (occlusal cavity to MO or MOD cavity). This
the case! The endodontic post is not able to act in a increase is highest when the first endodontic
reinforcing manner because of its position within the treatment step—preparing the access cavity—was
tooth center as an area without force application performed (21). Another study demonstrated the
(12). Hence, an endodontic post itself does not importance of maintaining the marginal ridge for
significantly increase the fracture resistance of a post- tooth stability (22). Lang and co-workers (23) were
restored tooth (13–16). The effect of every able to impressively show the impact of gradual
restorative step on fracture resistance was seen restorative steps starting with access preparation and
in vitro. It was shown that the combination of post, ending with post space preparation for tapered and
adhesive core buildup, and crown with ferrule design parallel prefabricated posts on tooth flexibility, i.e.

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rigidity of endodontically treated upper central The first time a classification based on defect
incisors. It can be concluded that minimally invasive, extension was published was in 2003 (25). Two
hard tissue-saving types of therapy should be given years later it was part of a systematic review (26). In
priority. This will increase the mechanical stability of 2007 this approach was adopted by other authors
a tooth and thus its prognosis. and correlated to a prognostic clinical judgement
Hence, we suggested a concept to classify (27). An essential criterion for the type of
endodontically treated teeth by the defect extension restoration is the number of remaining cavity walls.
with (24) and without (25) exactly measuring hard A cavity wall of a remaining thickness less than 1
tissue loss. It is recommended that classification be millimeter is defined as missing because an
done according to both the defect size and the inadequate mechanical stability is assumed (29).
tooth type in order to determine when post Figure 2 provides an overview of the restorative
placement is indicated. It has been shown to be concept.
practical to distinguish between the five classes of - Class I: A Class I tooth shows an access cavity with
defect dimensions presented hereafter (Fig. 2). four intact cavity walls. An adhesive core buildup is

Fig. 2. Defect extension and respective treatment recommendation for front teeth, premolars, and molar teeth.

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recommended and can be applied as a definitive mechanical characteristics close to dentin shows a
filling using hybrid composite resins. strengthening effect on excessively flared teeth (35).
- Class II: An access cavity and three remaining In theory, fiber-reinforced composite posts in
cavity walls result in an adhesive core buildup, which general should allow the post to flex under load, thus
can be applied as a definitive filling. enabling improved distribution of stress between post
- Class III: When an access cavity and two remaining and dentin (36). The risk of fracture should therefore
cavity walls are present, an adhesive core buildup is be reduced (37). Also the Young’s modulus was
recommended. The restoration can be applied in a identified as important for the evaluation of a cement
direct or indirect manner e.g. laboratory restoration. used for post cementation. Based on finite element
Therefore, an adhesive treatment concept is analysis (FEA), it was stated that, with a decreased post
recommended. rigidity (low Young’s modulus), the stress leveling
- Class IV: The access cavity and one remaining cavity effect of the cement itself is less important (38).
wall indicate the need for supporting retention of the However, a higher stress concentration was found
core buildup by an assembled endodontic post or the between the cement and post, leading to a loss of post
fabrication of a cast post-and-core buildup. For retention (39). Root fractures were attributed to
anterior teeth, a solely directly adhesive core buildup extreme differences between post and dentin rigidity,
may be an option. However, sound scientific evidence with a stress concentration within the root (39). In
is scarce. Preparation for a crown may optimize the this connection, a compensation of stress-induced root
esthetic appearance, but it results in additional loss of fractures by Young’s modulus was postulated (40). In
tooth structure. contrast to this, FEA shows that post-related stress
- Class V: This is an access cavity with four missing reduces with increasing Young’s modulus in the order
cavity walls, i.e. the tooth is decoronated. An glass fiber, titanium, and zirconia (41). In addition,
adhesive core buildup in combination with an with more rigid post materials, a gentler, hard tissue-
assembled endodontic post is indicated. saving post space preparation is possible because the
Alternatively a casted post-and-core may be an post diameter can be reduced (28,42). Materials that
option. The latter needs to eliminate undercuts are more rigid prevent deformation of the entire post-
before manufacturing; however, this may result in and-core complex, which reduces the risk of secondary
additional hard tissue loss. For definitive restoration, caries by preventing a cement joint opening (43).
a single crown restoration is recommended. A Table 1 shows the Young’s modulus of different
ferrule height of at least 2 mm is key. Orthodontic dental materials in the post-endodontic complex.
extrusion or surgical crown lengthening may be The discussion above shows that to date there is
required beforehand. no consistent concept. Therefore we will not go
In addition to defect extension, the following through the pros and cons of (gold alloy) casted
aspects need to be briefly highlighted. post-and-cores, prefabricated posts made from
zirconia, carbon, glass, or quartz fiber, or even screw
posts because this has already been done in
Young’s modulus of posts numerous inconclusive articles. Thus, other crucial
A hypothesis in regard to the Young’s modulus or clinical aspects will be highlighted below.
the rigidity of an endodontic post is that it should
be similar or close to that of dentin (18,28,29). In
in vitro studies, the number of re-restorable failures
Load capability
are regarded as an expression of the optimal Young’s The advantage of decreased stress when loading
modulus. This is the case when fiber-reinforced fiber-reinforced posts is offset by reduced load
composite posts are tested against metallic posts capability compared to metallic posts (44). A
(30). Comparing post materials such as dental systematic review (30) demonstrated that fiber-
ceramics or metal alloys, Young’s modulus of fiber- reinforced posts were significantly less loadable
reinforced composite posts is closer to that of compared to casted post-and-cores. The load
dentin. This is defined as their major advantage (31– capability was similar compared to prefabricated
34). One study pointed out that a post with metal posts and significantly higher than that of

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 Restorative procedures and mechanical integrity

Table 1: Young’s modulus of a variety of important fail but in a restorable manner. However, there is a
materials in the post-endodontic complex trend toward choosing fiber posts (5).
Material Young’s modulus

Titanium 110 GPa [Torbjorner & Ability of re-entry and re-restoration

Fransson 2004]
Another aspect influencing post choice is re-
Glass fiber-reinforced 30 GPa (manufacturer’s
treatability. Fiber posts are superior to metal and
composite post information ER DentinPost,
Gebr. Brasseler, Lemgo, ceramics, in particular when cemented adhesively.
Germany) to 56 GPa Corresponding drills have been developed in order to
(manufacturer’s information destroy the compound between the composite resin
Fiberpoints Root Pins Glas,
matrix and fibers (45–47). However, the removal of
Sch€utz Dental Group,
Rosbach, Germany) fiber posts is not that problematic when using a round
diamond drill. By applying intermittent movements
Carbon fiber-reinforced 75 GPa to 215 GPa
with and without water cooling—to control whether
composite post [Torbjorner & Fransson
2004] one is still within the post material—the fiber post can
be removed within minutes. There is no efficient
Zirconium 200 GPa (manufacturer’s
method to do this with titanium and zirconia posts
information ER CeraPost,
Gebr. Brasseler) (48,49). As well, there is an increased risk of
perforation or provoking dentin flaws and cracks (50).
Core buidup composite 12.5 GPa to 25 GPa [Ausiello
resin et al. 2002, Braem et al.
1986, Pegoretti et al. 2002, What is the best post length?
Torbjorner & Fransson 2004]

Composite resin cement

An in vitro study showed that even quite short posts
low Young’s modulus 7.0 GPa [Lanza et al. 2005, may be an option (5, 8, and 10 mm post length and
Li et al. 2006] similar retentive values) when placed adhesively (51).
high Young’s modulus 18.6 GPa [Lanza et al. 2005, For conventional cementation, the longer the post,
Li et al. 2006]
the higher the retentive values (5 mm < 8 mm < 10
Self-adhering universal ~ 9 GPa (manufacturer’s mm) (52). The post choice may be influenced by
composite resin information, 3M ESPE, criteria more relevant than post length. For example,
Seefeld, Germany)
it has been shown that post length is less important
Zinc phosphate cement 12.6 GPa (internal data for fracture resistance than the ferrule effect (53).
(powder to liquid = provided by 3M ESPE) This aspect will be discussed below.
1.5)
In our own preclinical and clinical studies, we aim
All-ceramic crown 120 GPa [Pegoretti et al. 2002] to place posts at a length of 8 mm within the root
(glass ceramic) canal as long as 4 mm of root canal filling remains.
Dentin 12 GPa [Kinney et al. 2003]; This is important in order to maintain the apical seal
15 GPa [Torbjorner & because it has been shown that bacteria are able to
Fransson 2004];
penetrate the post space. A remaining apical root
19 GPa [Gutmann 1992,
Ko et al. 1992] to 25 GPa filling of only 3 mm causes an unpredictable apical
[Kinney et al. 2003] seal. In essence, a remaining apical root filling of
4–6 mm and a similar post length appears advisable
(54,55).

ceramic core-and-posts. However, this analysis

contains the methodological shortcoming inherent
Post diameter
in all in vitro studies and thus must be interpreted As mentioned above, a study by Lang et al. (23)
with caution. Overall, the choice is between a more assessed tooth rigidity and the deformation of teeth
loadable metallic post, which likely fails unrestorable, during different steps of endodontic preparation
and a less loadable fiber post, which is more likely to using Speckle pattern interferometry. It was shown

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that every single treatment step, starting with access

preparation, followed by endodontic preparation
until tapered, and then parallel-sided post space
preparation, causes gradual tooth destabilization.
Thus, when post placement is indicated, it is
advisable to use a post of the minimum diameter
with a sufficient inherent mechanical stability.
Therefore, in our own studies, we choose a post
diameter of 1.2 mm (56–58) as standard, even when
a post of greater diameter is possible. This is in
accordance with Lambjerg-Hansen & Asmussen,
who postulate that a post diameter of 1.3 mm is
necessary (59). Statements that post diameter should
be one-third of tooth diameter can also be found in
prosthodontic textbooks. However, good evidence
to justify a specific diameter is scarce.
The remaining dentin wall is a more essential
factor. More than 1 mm should be ensured (60,61)
because at least 0.3 to 0.5 mm of hard tissue will be
removed via crown preparation, which leaves at least
a thin dentin wall of >0.5 mm in thickness (Fig. 3).
Additional details are discussed below.

Key to success: the “ferrule effect”

Since it was shown for the first time in vitro (62),
the importance of the “ferrule effect” and its
meaning for the load capability of post-endodontic
restorations has been confirmed many times (63,64).
It works as a metal ring around a windlass, keeping
it together. The final restoration embraces the tooth
at the level of the crown margin. Thus, it increases Fig. 3. Example of an excessively flared tooth. When
the remaining dentin wall is thinner than 1 mm, a
the load capability and marginal integrity of the final
ferrule preparation is not possible. The risk of failure
restoration. A wedge action during occlusal loading increases.
will be leveled (62,63). Hence, the ferrule is the key
factor to clinical success. Therefore, it appears
justified to say that, compared to the “ferrule
effect,” the choice of post material is of minor
impact in regard to the mechanical stability of the
post-endodontic complex.
A ferrule height of 1 mm doubles the load
capability compared to non-ferruled specimens
(ferrule height 0 mm) (62). A minimum ferrule
height of 1.5 to 2 mm should be ensured (63,65–
67) (Fig. 4). If this is not possible per se because the
tooth is for example fractured at the gingival level,
surgical crown lengthening is indicated or—a bit
more exotic—one tries to enlarge the supra-gingival Fig. 4. Clinical example of correct ferrule preparation
abutment height by orthodontic extrusion (62,68). of 2 mm in height.

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 Restorative procedures and mechanical integrity

Studies comparing these approaches with regard to prosthetic restoration is planned, as shown by a
the mechanical integrity of the post-endodontic survey, dentists tend to frequently place posts more
complex are not yet available. or less for “safety reasons” (1). In contrast, when
An in vitro study using a 5-year simulation of asked whether every endodontically treated tooth
functional loading by thermo cycling and mechanical needs a post, only a small group answered “yes.”
loading of all-ceramic crown-restored post- Overall, the results of this survey show an extreme
endodontic restorations of upper central incisors uncertainty in identifying the need for post
impressively shows the effect of a ferrule (69). Even placement, in particular when a costly prosthetic
teeth which were left empty, i.e. no posts or cores restoration is involved. The available evidence with
were placed, showed an acceptable load capability regard to the interaction of the chosen final
during the course of functional loading. This restoration and post-endodontically treated teeth as
indicates that clinical survival over 5 years appears abutments will be discussed below.
likely. Compared to teeth that received a post and a
core but no ferrule preparation (ferrule height
Filling versus crown for single-
0 mm), no significant difference was found. An
tooth restoration
adhesive core buildup without post support and with
a 2 mm ferrule height increases load capability. One central finding is that endodontically treated
However, only teeth with a post and a 2 mm ferrule teeth have the best prognosis when situated within a
height were significantly more loadable, irrespective complete arch. Mesial and distal contact points show
of the post material (glass fiber or titanium post) a splinting action (70). A paradigm in dentistry
(Fig. 5). Thus, to date combining a post with an today is to save hard tissue as much as possible.
adequate ferrule height of at least 2 mm is Direct restorations facilitate a minor loss of tooth
recommended. The post material itself is of minor structure, reducing treatment time and costs. But
importance with regard to the mechanical properties what about the clinical success, in particular when an
of the post-endodontic complex. adhesive approach was not followed (Fig. 5)?
A working group compared the 6–8 year survival
of endodontically treated and vital teeth after
Post-endodontic restored teeth as placement of a composite restoration (71). It was
abutments shown that the survival of endodontically treated
The amount of remaining hard tissue is the decisive teeth was 86% after 6 years, somewhat lower
factor in terms of the mechanical integrity of an compared to vital teeth (93%). For Class III defects
endodontically treated tooth, and it is also key to (access cavity and two remaining cavity walls), there
identifying the need to place a post. But when a are two possibilities for treatment: (i) with an
adhesive multi-layered composite resin filling; or (ii)
preparing the tooth for a single-crown restoration.
More than 30 years ago, a study group asked
whether the clinical success of endodontically treated
teeth depends on their position in the dental arch or
the insertion of an endodontic post, and if there is a
dependent relationship to overlaying restorations
(72). In a retrospective study design, they showed
that clinical success is not gradable in anterior teeth
by capping a tooth. In contrast to that, a significant
effect for crowning posterior teeth was concluded. If
a post was placed, no advantage with regard to
survival was found for crowned teeth (abutments for
single crown or fixed-partial dentures). In a
Fig. 5. Often the remaining cavity wall fractures literature review, Goodacre & Spolnik (73)
instead of the filling. highlighted the positive influence of indirect cuspid

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overlaying restorations in the area of posterior teeth ceramic crowns (75). After 3 years, there was no
on long-term survival. statistically significant difference with respect to
In a retrospective study, 400 endodontically clinical success rates. To date, no long-term follow-
treated teeth were examined with respect to the effect up of this study has been published. Thus, based on
of coronal restorations over a 2-year period (74). The scientific clinical evidence, no particular therapy
authors identified statistically increased survival rates approach can be recommended.
for teeth restored with crowns compared to teeth The same group evaluated endodontically treated
restored with amalgam and composite resin. This premolars with Class II defects with amalgam fillings
publication gives no information about defect (76). After 5 years, amalgam-restored teeth showed
extensions. Teeth with post-and-core buildup more root fractures than adhesively restored teeth,
without cavity walls and also teeth with certain but fewer secondary caries lesions. After 5 years, 91%
remaining tooth structure may have been included, of the premolars restored with amalgam fillings and
which in turn would affect the results. 90% of the teeth restored with posts and crowns
Another of the few prospective clinical trials survived, respectively. The authors recommend
evaluated direct composite resin and glass fiber post- avoiding crowns for endodontically treated
supported restorations in endodontically treated premolars with the aim of protecting sound tooth
premolars compared to restorations with metal structure (Fig. 6).
The limitations of the presented studies are
summarized in a systematic review as follows: “There
is insufficient evidence to support or refute the
effectiveness of conventional fillings over crowns for
the restoration of root-filled teeth” (77).

Fixed partial dentures and cantilever

fixed partial dentures
A literature review showed that endodontically
treated teeth are suitable anchors for fixed partial
dentures (78). However, compared to vital teeth,
survival rates are lower. This was shown in an
investigation by Walton (79,80). Resulting failure
rates were 21% for endodontically treated teeth and
5% for vital teeth. A 10-year prospective clinical
Fig. 6. Worst-case scenario: vertical root fracture. study demonstrated lower failure risks for teeth

Fig. 7. Fracture of a cast post-and-core as part of a combined fixed-removable partial denture.

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 Restorative procedures and mechanical integrity

restored with endodontic posts after root canal effect on treatment success (89). Nevertheless, a
filling as anchors of fixed partial dentures than for post-endodontically treated tooth as an abutment for
single crowns and removable partial dentures (6). a combined fixed-removable partial denture does
A literature review shows that the distal anchor of a have an increased risk of failure (89,90), in particular
cantilever fixed partial denture (FPD) should be a vital for abutment fracture (Fig. 7). A prospective clinical
tooth because survival decreases for endodontically study found that 154 endodontically treated teeth
treated teeth due to mechanical failure (78). An actual observed over a time of 3 years had a higher risk of
in vitro investigation analyzed 2-unit cantilever fixed failure when used as an abutment for a fixed-
partial dentures on maxillary anterior teeth after a removable partial denture (90).
chewing simulation of 10 years (81). It was shown that A retrospective clinical study was conducted to
the amount of remaining tooth structure and insertion evaluate the survival rate of teeth that were
of a post had no statistically significant influence on endodontically treated and restored with endodontic
survival. The realization of a ferrule design within the posts and either fixed partial or combined fixed-
study is an important approach to explain the results.
Another in vitro investigation on endodontically
treated premolars shows that teeth with cast post-and-
core reconstructions exhibit unfavorable biomechanical
properties for a prosthetic restoration as the cantilever
fixed partial denture (82). A systematic review
calculated a survival rate for cantilever fixed partial
dentures of 81% after 10 years (83). It is necessary to
mention that the results of that study included both
vital teeth and endodontically treated teeth.
In a clinical study by Landolt & Lang (84),
exclusively cantilever FPDs were evaluated. If
abutment teeth were endodontically treated and
restored by cast post-and-core or screws, the
proportion of technical problems (framework fracture,
chipping, loss of retention) rose up to 35%, while only
7% of vital teeth failed due to loss of retention of FPDs
or framework fractures. The insights over the past
years show that building up endodontically treated
teeth with conventional cemented cast post-and-cores,
screws, or prefabricated metal posts as used in the
clinical studies mentioned above increases the risk of
marginal leakage (85) and root fractures (12,86,87).
One reason might be that the force necessary to
provoke discomfort or even pain must be three times
that of vital teeth (51). In contrast, a recently
published study doubted the validity of this
explanation because both vital and non-vital teeth
showed similar tactile sensitivity (88).

Fixed-removable partial denture

(FRPD) and telescopic crown-
supported FRPDs
If a tooth is an abutment for removable partial Fig. 8. Abutment fracture (telescopic crown) in an
dentures, post placement has a significant positive extremely reduced dentition.

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Naumann

Fig. 9. When the occlusal load decreases, the shear forces increase from the molar to the front region. Front teeth
are the high-risk area for technical failures (8).

failure rate of abutments of fixed-removable partial

dentures compared to single crowns (92). Another
retrospective study over more than 6 years of
observation with 385 abutment teeth retaining 117
fixed-removable partial dentures showed that
endodontically treated teeth as anchors for double
crown-retained partial dentures have a more than
3-fold increased risk of tooth loss and increased
fracture rates compared to vital abutments (93).
However, our own results of a randomized clinical
study comparing titanium and glass fiber-supported
abutment teeth found no significant differences
between fixed and combined fixed-removable partial
dentures (9).
Fig. 10. Tooth vs. implant? While the post-endodontically A prospective clinical study on telescopic abutment
restored tooth maintains a thin bone support distally,
prostheses in patients with severely reduced dentitions
bone loss is obvious around dental implants in this
case. (one to three remaining teeth per arch) delivered
much better results with an 81% success rate over 60
removable partial dentures (telescopic crowns). A months. Success was significantly influenced by tooth
total of 864 teeth in 360 patients served as vitality, i.e. failure occurred with endodontically
abutments. The calculated survival rates of the treated abutment teeth (94) (Fig. 8).
abutments were statistically significantly different for In conclusion, in terms of mechanical integrity,
fixed partial dentures and for fixed-removable partial there is a need to carefully evaluate the degree of
dentures, with survival rates of about 93% and 51% destruction, for example by the number of
after 60 months, respectively. The authors remaining cavity walls, before endodontic therapy.
concluded that teeth restored with post-and-cores Thus, the type of prosthetic restoration should
present a high risk of failure when used as already be determined at this stage and the benefit-
abutments for fixed-removable partial dentures (91). to-risk ratio should be discussed with the patient.
A retrospective study with cast post-and-cores over However, there is no restorative therapy that can be
up to 10 years of observation revealed a higher regarded as absolutely risk-free. The realization of a

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 Restorative procedures and mechanical integrity

Fig. 11. Post-endodontic checklist.

ferrule design with a minimum height of 1.5 to 2 5. Naumann M, Koelpin M, Beuer F, Meyer-Lueckel H.
mm is mandatory in cases of damaged teeth with 10-year survival evaluation for glass fiber-supported
post-endodontic restoration: a prospective observational
two or fewer cavity walls. This applies in particular
clinical study. J Endod 2012: 38: 432–435.
for maxillary anterior teeth, which have a higher 6. Naumann M, Blankenstein F, Kiessling S, Dietrich T.
failure risk under the impact of non-axial shear Risk factors for failure of glass fiber-reinforced
forces (Fig. 9). The combination of “single crown” composite post restorations: a prospective observational
clinical study. Eur J Oral Sci 2005: 113: 519–524.
and “anterior teeth” is considered the “post-
7. Torbjorner A, Fransson B. Biomechanical aspects of
endodontic worst-case scenario.” With regard to the prosthetic treatment of structurally compromised
mechanical integrity of an endodontically treated teeth. Int J Prosthodont 2004: 17: 135–141.
abutment tooth, for more complex prosthetic 8. Sterzenbach G, Franke A, Naumann M. Rigid versus
restorations it appears beneficial to stick to fixed flexible dentine-like endodontic posts—clinical testing
of a biomechanical concept: seven-year results of a
restorations as long as possible; otherwise mechanical randomized controlled clinical pilot trial on
failures become more likely. endodontically treated abutment teeth with severe
hard tissue loss. J Endod 2012: 38: 1557–1563.
9. Trope M, Maltz DO, Tronstad L. Resistance to
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