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Title: Restoring the intraradicular space : esthetic post systems / Douglas A. Terry.

Description: Batavia, IL : Quintessence Publishing Co, Inc, [2021] | Includes bibliographical references and index. | Summary: “This book describes the biologic basis for restoring weakened teeth with post and core systems, focusing on how to do this conservatively and esthetically to maximize longevity”-- Provided by publisher.

Subjects: MESH: Post and Core Technique | Dental Restoration, Permanent | Esthetics, Dental | Root Canal Therapy

Quintessence Publishing Co, Inc
411 N Raddant Road
Batavia, IL 60510
www.quintpub.com

All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher.

3 | CLINICAL APPLICATIONS FOR RESTORING “COMPROMISED” ENDODONTICALLY TREATED TEETH

4 | CLINICAL APPLICATIONS FOR RESTORING “END STAGE” ENDODONTICALLY TREATED TEETH

There is a question I always ask myself, my students, and my colleagues: “What is our single most important responsibility as an oral health care provider?” While there may be various interpretations of our core duties, I always come to the same simple but resounding answer: “To help our patients keep their teeth as long as possible!”

To pursue this goal and preserve teeth, we have to emerge from the era of destructive dentistry, which dates back to times before resin bonding and adhesive protocols were available. Healthy tooth structure had to be sacrificed during preparation to accommodate restorative and prosthetic materials that relied solely on retention. The popularity of implant dentistry sometimes added to this destructive mindset when teeth were extracted and implants placed too early or inadequately, thereby accelerating the cascade of early tooth loss instead of following the core principle of preservation. The rush to the seemingly easiest but most destructive treatment options may lead to early tooth loss, bone and tissue resorption, peri-implantitis, and altered eruption of teeth next to implants that were placed in younger patients.

Several new studies agree that the recommended age when dental implants can be placed safely is going up and up, making a strong case to preserve even severely damaged and endodontically treated teeth as long as possible. Don’t get me wrong: I have nothing against implants, and in many cases, they are the last and absolutely best resort to provide our patients with chewing function and esthetics. However, they are the last resort when everything else fails. And the argument I often hear that “implants last longer than teeth” is not only completely wrong but not even a logical argument for erring on the side of placing implants earlier instead of exploiting all resources to try and save a natural tooth. While some of that rationale may, sadly, be driven by convenience and economic aspects, I believe that the most important factors in the treatment-planning decision-making process are proper knowledge and information.

The most difficult treatment-planning decisions are related to the severely damaged endodontically treated tooth. The amount of misinformation on this topic is simply astonishing. What is the state of the scientific evidence on endodontically treated teeth and how to restore them? When should a post be placed? And in light of this era of minimally invasive and adhesive dentistry, what are the best materials and most current protocols for post and core placement, based on the science?

Douglas, author of many groundbreaking and bestselling books, has compiled a team of the most respected researchers and clinicians to answer these questions and provide clear guidance on a topic that seems to have been widely overlooked. Restoring the Intraradicular Space: Esthetic Post Systems provides a detailed and scientific description of the evolution of post and core systems while offering a comprehensive view into all associated aspects, from general design criteria and the components of the post and core systems to post materials, adhesive bonding and luting agents, material selection, core buildup, and finally, the extracoronal restoration. The dilemma of preserving or replacing the compromised natural tooth is discussed in great detail with ample scientific support. Over 1,000 cited research studies are distilled into clear and meaningful guidelines for the clinician to select an appropriate system for the restorative management of endodontically treated teeth for each clinical situation. In well-known Douglas Terry manner, clinical protocols are illustrated meticulously and with stunning quality with over 800 photographs and figures.

To fulfill our responsibility to help patients keep their teeth as long as possible, understanding and selecting proper protocols, materials, and procedures to restore endodontically treated teeth is indispensable. While a comprehensive text on this topic was long overdue, Restoring the Intraradicular Space: Esthetic Post Systems is not only an exceptional resource for the practicing dentist but a true masterpiece in its scientific rigor and clinical excellence. The captivating writing and superb clinical documentation make this an essential piece of literature for oral health care providers at any stage of their career. Congratulations Douglas and team—I am sure that your work will inspire countless colleagues and prevent many patients from losing their teeth too early. Thank you for that!

Recently I read a comment by a dentist saying “every root has a chance.” This statement resonated with my philosophy because it is not only the tooth but also the alveolar and soft tissue architecture and the patient that deserve a chance. Over the last decade I have witnessed patients presenting with fractured teeth that were referred for removal and implant placement. Upon discussion with them, it became clear that not everyone was given proper informed consent; some were offered only the one treatment option. So I would explain the how’s and why’s of every option, and then the patient could make the proper choice for their oral health. Individuals make better decisions when they are given all the potential options and the consequences of each.

A recent conversation with a young periodontist on my team further underscored this problem. He told me that his referring dentists do not try and save a given tooth with a post and core. In discussing this with my friend and colleague Dr Konrad Meyenberg in Switzerland, we considered that perhaps the reason was the lack of confidence clinicians have in the endodontic therapy and in their knowledge of proper adhesive protocol. This extraction-oriented, reconstructive mentality may be based on the clinicians’ misconception that endodontically treated teeth are considered inferior to implants in regard to long-term stability and retention. However, it has been demonstrated that endodontic and implant therapies have equivalent results when the treatments are appropriately chosen and performed at a high level of expertise on well-maintained patients.

Throughout these chapters, I would like the reader to direct their attention to modern applications in the fields of endodontics, restorative dentistry, periodontics, and orthodontics. In the past two decades, dentistry has seen a paradigm shift in philosophy that has been guided by a greater understanding of science. Advancements in endodontic technology with the use of modern instruments and new equipment, biocompatible filling materials, and microsurgical techniques have allowed the clinician to visualize, identify, and treat complexities they could not have fathomed a decade before. Correspondingly, advancements in restorative material formulations, adhesive technology, and a better understanding of the methods to achieve a biologically stable, dentogingival interface through periodontal and orthodontic concepts have expanded the treatment possibilities for the patient, clinician, and technician. Furthermore, clinicians should not make treatment decisions based on their skill level alone but should refer or adopt an interdisciplinary approach when required for the management of more complex clinical scenarios.

These advances in all disciplines in the 21st century have increased the myriad opportunities available to discriminating patients and provided solutions to many of the endodontic, restorative, and esthetic challenges faced by the restorative team. This changing technology has allowed the clinician to treat many clinical challenges through simpler, more conservative, and more economical methods. This evolution in philosophy and science has resulted in a change in the trend for dental treatment. Thus, an awareness in the evolution of different disciplines in dentistry combined with the common occurrence of misinformed patients coming for another opinion stimulated my team and me to develop this book. This philosophy of choosing the least invasive procedure and moving to a more invasive one if required over time is an ethical one. I hope the concepts in this book direct the clinician and technician to consider possibilities they had not imagined.

The text provides a detailed and scientific description of the evolution of the post and core system and the significance of the adhesive design concept when restoring the intraradicular post space. A detailed presentation is provided of the various applications and restorative techniques that I use on a daily basis with my patients for restoring the post space. The scientific data and microscopic illustrations are intertwined to provide clarity and evidence for these procedures. In addition, chapter 2 provides a detailed description of the light-curing unit (by Dr Richard Price) and the significance of understanding its mechanism for proper selection and use, which play an integral role in the adhesive design concept for achieving an optimal bonded interface. The third chapter demonstrates the information presented in the early chapters through illustrated case presentations while providing clinical applications for retaining the compromised tooth. The last chapter demonstrates clinical scenarios for the replacement and restoration of the nonrestorable endodontically treated tooth or the “end stage” tooth, while providing various treatment considerations and the critical factors that may play a role in the selection, outcome, and predictability of each of these treatment modalities.

As always, the inspiration for writing this book and sharing photographs of these procedures can be attributed to my dear patients, colleagues, and students around the world who have directed me on this journey. Compilation of this information would not have been possible without the dedication, persistence, and relentless hard work and long hours of my dear friend and personal assistant, Melissa Nix. My mother’s great ability to persuade patients to return for follow-up photographs along with her support and delicious dinners and desserts for the team have certainly been crucial for completing this project. Furthermore, this book would not have seen the light of day without the dedication, attention to detail, and organization and imagination of the Quintessence team. I would also like to express my gratitude to my team members who are my true friends—Dr John Powers, Dr John Burgess, Dr Ruhani Cheema, Dr Markus Blatz, Dr Susana Paoloski, Dr Gamid Nasuev, Alex Schueger, Olivier Tric, and Dr Richard Price. Also, I would like to thank my wonderful patients, without whom this project would not have been possible. Finally, I give special thanks to my Creator who instills passion in my life for everything I do and who makes me realize that teeth are simple in His hands but so complex in mine.

“What is truth” is a question that has been asked by philosophers, scientists, and religious prophets for centuries.

Truth can be defined as that which conforms to facts, reality, and actuality. But this definition has a broad latitude of interpretation and application. If we say truth can be relative or absolute, this may differentiate and lead to a better understanding and application. Relative truth conforms to logic and reality and can be interpreted differently by every person based upon their culture, religion, and life experiences. However, absolute truth requires each of us to search and discover something greater than ourselves.

God is the true essence of being and the absolute truth. The Bible describes the ultimate expression of truth in John 14:6: “I am the way, the truth, and the life.”

For over 250 years, clinicians have written about the placement of posts in the roots of teeth to retain restorations.1^,2 As early as 1728, Pierre Fauchard described the use of “tenons,” or metal posts screwed into the roots of teeth to retain bridges.1^,3^–6 In the mid 1800s, wood replaced metal as the post material, and the “pivot crown” became popular among dentists; this was a wooden post fitted to an artificial crown and the canal of the root.1^,2^,7 Often these wooden posts would absorb fluids and expand, frequently causing root fractures.4^,7 In the late 19th century, the “Richmond crown,” a single-piece post-retained crown with a porcelain facing, was engineered to function as a bridge retainer.2^,7 During the 1930s, the custom-cast post and core was developed to replace the one-piece post crowns. This procedure required casting a post and core as a separate component from the crown.7 This two-step technique improved marginal adaptation, allowed variation in the path of insertion of the crown,1 and provided a better alignment of the core when the tooth being restored was flared or overlapped the adjacent tooth. In the 1990s, tooth-colored fiber posts debuted as an alternative to these conventional metal post systems.8^–17

From the past to the present, the rationale for the utilization of a post system has metamorphosed. The concepts of the past were designed with the belief that endodontically treated teeth (ETT) were brittle from a loss of moisture18^,19 and required a post to strengthen the weakened tooth.20^–26 Although there is a reduction in moisture content after endodontic treatment, current concepts refute this postulate.18^,19^,27^–36 Current concepts supported by evidence-based research indicate that the primary objective of any post and core system is to replace missing coronal tooth structure, to retain the core,37^–44 and to provide sufficient retention41^,43^,45^–54 and resistance form to the final restoration to restore original form and function.37^–39^,55^–69 Today, clinicians can choose from a variety of user-friendly post and core systems29^,70^–81 for different endodontic, restorative, and esthetic requirements. These systems and methods are well documented in the literature.23^–25^,29^,40^,42^,80^–99 However, no single post system meets the demands for favorable biomechanical compatibility65^,80^,100^–102 or provides the perfect restorative solution for every clinical circumstance, and each situation requires an individual evaluation.82

Furthermore, the reconstruction of ETT can present restorative and esthetic challenges for the technician and the clinician.9^,80^,103^–105 The failure of these post-retained systems has been documented in numerous clinical studies.22^,39^,45^,51^,66^–68^,101^,106^–150 Many of these studies indicate that the failure rate of restorations on pulpless teeth with posts and cores is higher than that for restorations of vital teeth106^,151^–163 because of their structural differences and the significant loss of tissue.36 Several main causes of failure of post-retained restorations have been identified, including recurrent caries,164^,165 endodontic failure,165 periodontal disease,165 post dislodgment,165 cement failure,166 post-core separation,165 crown-core separation,165 loss of post retention,40^,164 core fracture,152 loss of crown retention,40^,164 post distortion,164 post fracture,40^,152^,164^,166 tooth fracture,152^,166 root perforation,40 and root fracture.40^,152^,164^,167^,168 Also, corrosion of metal posts has been proposed as a cause of root fracture.152 A post and core system fabricated with dissimilar metals can cause galvanic corrosion that occurs between the two dissimilar materials.19^,169 This gradual destructive process involves the electrical interaction of at least two different metals or nonmetallic conductors in an environment (ie, microleakage) that accelerates the corrosion of at least one of them, while the least noble metal corrodes the most (for more information, see the section entitled “Lack of corrosiveness” later in this chapter).

The traditional custom-cast dowel core provides a better geometric adaptation to excessively flared or elliptical canals and almost always requires minimal removal of tooth structure.1 Custom-cast posts and cores adapt well to extremely tapered canals or those with a noncircular cross section and/or irregular shape and roots with minimal remaining coronal tooth structure.82^,89 Patterns for custom-cast posts can be formed either directly in the mouth or indirectly in the laboratory. Regardless, this method requires two appointment visits and a laboratory fee. Also, because it is cast in an alloy with a modulus of elasticity that can be as high as 10 times greater than that of natural dentin,55 this possible incompatibility and rigidity can create stress concentrations in the less rigid root, resulting in post separation or failure.170^–172 Additionally, the transmission of occlusal forces through the metal core can focus stresses at specific regions of the root, causing root fracture55 (Fig 1-1). Furthermore, upon esthetic consideration, the cast-metal post can result in discoloration and shadowing of the gingiva and the cervical aspect of the tooth173 (Fig 1-2).

An alternative and currently more popular method is the prefabricated post and core system. Prefabricated post and core systems are classified according to their geometry (ie, shape and surface configuration) and method of retention. The methods of retention are designated as active or passive. Active posts engage the dentinal walls of the post space preparation during cementation, whereas passive posts do not engage the dentin but rely on cement for retention.1^,174 The basic post shapes and surface configurations are tapered serrated, tapered smooth-sided, tapered threaded, parallel serrated, parallel smooth-sided, and parallel threaded. While active or threaded posts are more retentive175^–178 than passive posts, active posts create high stress concentrations in root dentin at each thread during placement.177^,179^–184 These stresses have the potential to create cracks185^,186 that can increase the susceptibility of root fracture127^,184 when occlusal forces are applied.10 Thus, a significant cause of failure with an active post system is root fracture.52^,184^,187^,188 More recent modern designs provide a collar that limits insertion, flexible tips (FlexiPost), and stress-reducing thread design. Metal screws have a survival rate of 78%127^,184 after 1 year and 50% after 5 years.184 Parallel-sided serrated posts are the most retentive of the passive prefabricated posts, and the tapered smooth-sided posts are the least retentive of all designs.7

Traditional prefabricated metal posts are made of platinum-gold-palladium, brass, nickel-chromium (stainless steel), pure titanium, titanium alloys, and chromium alloys.7^,37^–39^,164 Although stainless steel is stronger, the potential for adverse tissue responses to the nickel has resulted in the use of a biocompatible titanium alloy.189^,190 Also, contributing factors to root fracture such as excessive stiffness (modulus of elasticity)191^–193 and post corrosion7^,121 (Fig 1-3) from many of these metal posts have generated concerns about their use. In addition, prefabricated metal posts can negatively affect the esthetic result.

Nonmetallic prefabricated posts have been developed as alternatives,194 including ceramic (white zirconia) posts, carbon-fiber posts, and fiber-reinforced resin posts. Zirconia posts have a high flexural strength and are biocompatible as well as corrosion resistant.195 This material, however, is difficult to section intraorally with a diamond bur and difficult to remove from the canal for retreatment.164 Carbon-fiber posts are made from unidirectional carbon fibers held together with an epoxy resin and ceramic. They exhibit strength and relatively high flexibility and can be retrieved from the canal preparation with ease for retreatment. However, their black color has a negative effect on the final esthetic result of all-ceramic crowns.189 New advances with next-generation tooth-colored posts, which are identical in design to conventional carbon-fiber posts, reduce this esthetic challenge. There are several methods for the fabrication of the direct fiber-reinforced resin system that include a bondable polyethylene woven reinforcement fiber (Ribbond-THM, Ribbond; Construct, Kerr/Sybron), a prefabricated fiber-reinforced composite post system, a direct anatomical formed fiber-reinforced composite post system,105^,195^,196 a direct/indirect anatomical formed fiber-reinforced composite post system, and an indirect anatomical formed fiber-reinforced composite post system (see the section entitled “Direct Fiber-Reinforced Post and Core System” later in this chapter).

As the clinician continues the search for optimal functional and esthetic success with a post-retained crown system, the current selection of restorative materials and techniques may prove overwhelming. While no single system provides the ideal restorative solution for every clinical circumstance, understanding both general design criteria and the components for the various post and core systems available allows the clinician to appropriately select the method and materials compatible with the existing tooth structure and desired result. A system is defined as any set of components working together for the overall objective of the whole.1 Selecting the proper post and core system for a specific clinical situation requires an evaluation of the various components and interfaces of the system.197^,198 The components of the direct fiber-reinforced composite resin post system are the surface of the root dentin, the intraradicular post, the core buildup, the luting cement, and the final restoration199 (Fig 1-4). The system can be analyzed in four regions: (1) at the intraradicular surface (dentin surface), (2) at the post-tooth interface, (3) within the core, and (4) intracoronally. For the successful rehabilitation of the ETT, it is imperative to understand the disparity and complexity of the interrelationship of these interfaces with various restorative materials.55 The failures of each system provide us with design principles that can be utilized with any post-retained crown system. These specific design principles bring us to higher levels of understanding potential problem areas in any restorative situation. Therefore, the following design principles should be considered when using any post-retained crown system. An evaluation of the direct fiber-reinforced resin post system with these design principles is provided.

Dislodgment and tooth fracture are causes for failure of post and core restorations. The majority of clinical failures involving fiber-reinforced post systems occur through debonding.15^,29^,45^,80^,100^,119^,120^,124^–126^,200^–215 Core stability and post retention are important in preventing these failures in the restoration of ETT51^,105^,164^,166^,168^,177^,193^,216^–218 (Fig 1-5). The ideal post system should replace lost tooth structure while providing adequate retention and resistance for the core and final restoration while transferring occlusal forces during function and parafunction to prevent root fracture. Adhesive post systems allow conservative minimally invasive preparations that preserve sound tooth structure and strengthen the remaining tooth. However, meticulous adhesive protocols are required for reliable bonding and effective adhesion. Improving the quality of the adhesive interface and the long-term adhesion of fiber-reinforced post systems to dentin requires improving resin impregnation into dentin,212^,219^–227 enhancing the strength of the polymer formed by the adhesive system,212^,228^–252 and increasing the resistance of collagen fibrils to enzymatic degradation.212^,253^–273 Because the root canal anatomy can impose limitations to achieving a quality hybrid layer, modified clinical protocols have been suggested. Studies indicate that various methods and materials can improve the stability of the resin-dentin bond.

Numerous studies suggest methods and materials to improve resin impregnation into dentin. One study indicates that diamond bur preparation of the post channel in comparison to a carbide bur allows the etching procedure to remove the smear layer more efficiently with more open dentinal tubules and with fewer smear layer remnants. Thus, the acid-resistant smear layer produced by the manufacturer’s carbide bur for post space preparation can be removed with a similar-diameter diamond bur, and the replaced smear layer will be more susceptible to phosphoric acid dissolution.212^,220 Other studies indicate that liquid phosphoric acid applied with an endodontic needle improved the removal of the smear layer better than gel etchants and that higher bond strengths to the dentin were achieved when an etch-and-rinse adhesive system was utilized.212^,226^,227 Several studies indicate that vigorous rubbing of the adhesive may improve the permeability of the etchant into the dentin collagen network.223^,224 Other studies indicate that the application of multiple layers of simplified etch-and-rinse adhesives and self-etch adhesives to coronal dentin yield higher immediate bond strengths.221^,222 However, this modified protocol should be applied with caution to prevent post seating because of the increase in thickness of the hybrid layer. It is suggested that paper points or a vacuum capillary tip adapter (Luer Vacuum Adapter, Ultradent) can be utilized to absorb the excess solvent.212

Various studies suggest methods and materials to enhance the strength of the polymer formed by the adhesive system. Studies indicate that the use of a hydrophobic coating after the application of a simplified self-etch adhesive and an etch-and-rinse adhesive system provides a thicker and more uniform adhesive layer with lower concentrations of water and solvent and thus a significant reduction in fluid flow rate.235^,240 This procedure transforms a simple-layer adhesive into a multilayer adhesive. This method ensures that the hydrophilic layer is photoactivated prior to the application of the hydrophobic, non-solvated bonding resin. This allows for the simplified adhesive layer to be more concentrated with hydrophobic monomers from the additional coating.212^,232^,241 Thus, by reducing the concentration of unreacted monomers between the primed and bonded layers, a more compacted and stable resin-dentin interface can be achieved.212^,235 However, this modified protocol should be applied with caution to prevent a thick adhesive layer that could interfere with post seating.212 Numerous studies suggest that the application of ethanol to replace water in acid-etched collagen will allow hydrophobic resins to infiltrate the demineralized dentin and create a hydrophobic hybrid layer.231^,239^,242^,252 Because endogenous matrix metalloproteinases (MMPs) become inactive in the absence of water, one study suggests that the application of ethanol is a potential mechanism for increasing the longevity212^,250 and durability274^–276 of resin-dentin bonds. However, several authors indicate that ethanol wet bonding yielded higher immediate bond strengths and resulted in lower nanoleakage in root canals.237^,246 Although there are differences in the suggested protocol in regard to concentration and time of application, a recent study suggested a simple higher concentration (50%) of ethanol for 60 seconds.266 Others indicate that using a high-intensity light-curing unit and/or increasing the irradiation time for the adhesive systems and resin cements will improve the adhesion of these systems to the canal wall dentin.228^,230^,244^,249 One paper indicated that increasing the light-curing time improved bond strengths to root dentin.229

A myriad of studies suggests methods and materials for increasing the longevity of hybridization by improving the resistance of collagen fibrils to enzymatic degradation.207^,277^,278 Several studies suggest the application of chlorhexidine (CHX) as a protease inhibitor for MMPs261 and cysteine cathepsins270 to preserve the hybrid layer from degradation. Furthermore, several studies indicate that a 2% CHX or a CHX-containing phosphoric acid for etch-and-rinse adhesive systems may be an excellent method for increasing the long-term stability of collagen fibrils in the hybrid layer by inhibiting endogenous MMPs and cathepsins.268^,269

It has been demonstrated that the use of ethylenediaminetetraacetic acid (EDTA) inhibits MMP-2 and MMP-9 when applied for 1 to 5 minutes,260^,272 while one in vitro study indicated an application of EDTA preserved the dentin-adhesive interface.266 Thus, the use of EDTA has been indicated as a dentin pretreatment for dentin adhesives.212^,266 However, one study demonstrated that prolonged rinsing with water removes the EDTA and there may be no residual EDTA to inhibit the degradation by endogenous MMPs.260 Several studies indicate that an increase in the extent of cross-linking of the collagen fibrils prior to adhesive application may increase the potential for durability, while other studies indicate that cross-linkers enhance the mechanical properties of these substrates. Cross-linking agents have been purported to have anti-MMP properties,253^,257 thus reducing enzymatic degradation.273 However, the application time for desirable therapeutic effect is not feasible,279^,280 and modification into a simplified protocol using proanthocyanidins incorporated into etchants and adhesives is recommended.254^,256^,258^,259 Several studies indicate the use of benzalkonium chloride (BAC) or BAC-containing acid or adhesives to inhibit the activity of the endogenous MMPs.264^,271 Because the root canal anatomy can impose limitations to achieving a quality hybrid layer, modified clinical protocols may have positive implications for improving the quality of the adhesive interface and the long-term adhesion of fiber-reinforced post systems to dentin. This in turn can improve the structural integrity of the remaining radicular dentin and increase the retention and resistance to displacement55^,168^,281 while dissipating and reducing functional stresses along the entire adhesive interface, thus providing maximum post retention and core stability.

Numerous in vitro studies support evidence that conservation of sound tooth structure is the most important factor to the successful management of structurally compromised ETT.47^,51^,216^,282^–288 It is well supported in the literature that the longevity of an ETT is directly related to the amount of remaining sound tooth structure.29^,43^,289 However, traditional-cast post systems and prefabricated post systems often require the removal of undercuts for a proper path of insertion and adaptation to the canal wall. This enlargement of the post-endodontic channel throughout biomechanical preparation during and after the endodontic procedure removes dentin during cleaning and shaping of the canal. The removal of additional dentin to accommodate placement of a larger post diameter significantly weakens the remaining tooth structure175^,285^,290 (Fig 1-6). This widening of the canal decreases the thickness of the root wall, which can lead to a diminished wall stiffness that results in increased stress levels291^,292 and can compromise long-term success.293^,294 It is widely accepted that 1 mm of dentin wall thickness is required to prevent root fracture and to properly support the core.159^,295

Table 1-1 General guidelines for post placement300^,337^–339

This table indicates anatomical root canal variations in Asian and non-Asian populations. However, anatomical variations exist in different subpopulation groups. The table provides the necessary information for post preparation and placement. During post channel preparation, the preservation of 4 to 5 mm of gutta-percha is necessary to provide an adequate apical seal.201^,296^–307

*If there are two numbers, the first number is the prevalence for that number of roots for a given tooth, and the second number is the prevalence for that number of canals for said tooth among the population groups studied.

Additionally, during post channel preparation, the preservation of 4 to 5 mm of gutta-percha is necessary to provide an adequate apical seal.201^,296^–307 Several techniques for preparing the post channel and the effect of each technique on the apical seal have been investigated and include the use of rotary instruments, heated instruments, and solvents.175^,299^,304^,308^–310 An improper access preparation with too wide an enlargement when performing endodontic therapy can result in an excessive loss of sound coronal tooth structure20^,40^,311^,312 and increase the occurrence of fractures43^,206^,291^,313 (Fig 1-7). In addition, endodontic access on a tooth with loss of one or both marginal ridges increases the potential for fracture.29^,44^,314^–317 Investigators have reported that rotary instruments caused more dentinal defects, such as craze lines and partial cracks, which have the potential to develop into fractures after endodontic and restorative treatment.318^–320 However, no defects were observed with hand file instrumentation.318 Furthermore, overpreparation of the post space and the utilization of larger posts decrease the resistance to fracture.51^,285^,287 This reduction in the amount of dentin weakens the structural integrity of the tooth216 and can be responsible for horizontal and vertical root fracture.291^,321^–326 To prevent overpreparation during the endodontic or restorative procedure, it is recommended that the root morphology be considered for each tooth type prior to treatment. Mandibular incisors, maxillary second premolars, and the distal root of mandibular molars have mesiodistal concavities and may be narrower mesiodistally than they appear in the radiograph.327 A CBCT image can provide a 3D visualization of these anatomical features in cross section and reduce the potential for a weakened structural integrity or root perforations328 by providing a view of the tooth anatomy. Because of the wide range in anatomical variation in regard to number and shape of roots and root canals for each tooth type,329^–335 a comprehensive knowledge of root morphology179^,336 and an understanding of external root anatomy can provide insight for selecting the teeth and roots that are most appropriate for post placement with less potential for thinning and root fracture300 (Table 1-1; for further information, see section entitled “Guidelines for Restoring the Intraradicular Space”300^,337^–339).

Improvements in composite materials, adhesive technology, and endodontic procedures and technology have resulted in a more conservative design concept.9 This minimally invasive concept preserves intact tooth structure, reducing the potential for failure209 while providing adequate retention and resistance form for the final restoration.40

One method of the direct fiber-reinforced resin post system (see section entitled “Direct Fiber-Reinforced Post and Core System”) allows preservation of the canal structure and can be utilized in the treatment of irregular canal configurations. This procedure does not require a converging path of insertion and can be used with minimal preparation because it utilizes the undercuts and surface irregularities to increase the surface area for bonding (see Fig 1-9). This conservation of dentin reduces the possibility of tooth fracture during function or in the event of traumatic injury.287

Conventional luting cements such as zinc phosphate only fill the void between the restorative interfaces without attaching to either surface.55 Dual-cured resin luting agents mechanically and chemically interact with the resin of fiber-reinforced composite resin posts and the dentin, which bonds and seals the adhesive interface. Previous methods of cementation have been investigated that include placement of the cement onto the post and/or placing the cement with paper points, an endodontic explorer, and lentulo spiral.175^,340^,341 The lentulo spiral was considered the superior method of placement, providing a uniform thickness of cement with no voids.341 The author prefers placement of the adhesive resin cement onto the post and injection of the material with a needle tube placed at the base of the prepared post space, slowly removing the syringe tip to prevent the formation of air voids196 (Fig 1-8). The use of composite resin cements between the adhesive system and the reinforcement material ensures a more intimate contact with the dentin bonding agent because of lower viscosity that results in enhanced adaptation.342 One study claims that low–elastic modulus composite acts as an elastic buffer that compensates for polymerization shrinkage stress by flow, minimizing gap formation and reducing microleakage343; however, there is no evidence that flowable-lined composite restorations have improved margins or reduced leakage. If the elastic modulus is low, the composite will flex as the tooth bends, thus minimizing fracture. Also, lower-viscosity resin cements enhance post and dentin wetting, improving the interfacial internal adaptation and reducing void formations that contribute to reduced post retention and increased microleakage.344 Therefore, the use of a resin luting cement to line and strengthen the canal walls actually reinforces the root and supports the tooth-restorative complex166^,345 (Fig 1-9).

When esthetics is of primary concern, the selection of appropriate restorative materials becomes an important consideration. The purpose of selecting tooth-colored posts for enhancing esthetics in ETT is to aid in the creation of a natural-looking restoration. An esthetic post prevents the dark showthrough that so often is observed with a metal post.346 The light-transmission properties of traditional prefabricated or cast-metal posts differ from natural teeth where light is reflected, absorbed, or transmitted through the tooth. The incidental light is completely blocked by the metal post, which causes the characteristic shadow at the submarginal zone.347 When using an all-ceramic restoration, the color and opacity of the metal post may lead to discoloration and shadowing at the gingiva and cervical region of the tooth.173^,348

The secondary optical properties (eg, translucency, opacity, opalescence, iridescence, and fluorescence) of the composite allow light to pass through the natural tooth and the restorative material to reflect, refract, absorb, and transmit according to the optical densities of the hydroxyapatite crystals, enamel rods, and the dentinal tubules.349 Composite fiber-reinforced post systems made of quartz and glass provide these secondary optical properties for reproducing the various optical characteristics that are observed through the enamel and the dentin.42^,173 Therefore, in creating optimal esthetic harmony with the surrounding dentition, the underlying restorative material directly influences the final restoration (Fig 1-10; for more information, see chapter 3).

Root fracture is another reason for failure of the post and core system.127^,152^,164^,184 The primary goal of restoring ETT is to develop a design that distributes occlusal stress uniformly while preserving the tooth structure if the restoration fails during occlusal stress or dental trauma. Traditional cast posts (ie, stainless steel, chrome cobalt) have a modulus of elasticity as high as 10 times greater than that of natural dentin55^,350; however, an exception is titanium. This possible incompatibility can create stress concentrations in the less rigid root, resulting in post separation or failure.170^–172^,206^,351^–353 Additionally, the transmission of occlusal forces through the metal core can focus stresses at specific regions of the root and have been implicated in the high incidence of vertical root fracture55^,185^,354 (Fig 1-11). The fiber-reinforced composite post consists of fibers embedded in a polymeric matrix, and this combination creates a stiffness behavior for the post system that is similar to root dentin (elastic modulus of 18 GPa), which preserves the natural flexibility of the tooth. In addition, this similarity in elastic modulus between the fiber post and dentin reduces stress concentrations and restores stress distributions that are similar to the sound tooth.185 In the sound tooth, stress is more uniform.20^,355^,356 Because fiber posts exhibit a modulus of elasticity similar to that of root dentin,206^,357 the applied forces are more evenly distributed along the length of the post,206^,358 which minimizes the stress concentrations and reduces the potential risk for catastrophic root fracture.29^,95^,206^,359^–366 Numerous stress analysis studies conclude that ETT restored with fiber-reinforced composite posts have lower and more favorably distributed stresses than do teeth with metal posts.111^,355^,367^–372 Therefore, the fiber-reinforced composite post has a negligible incidence of root fracture118^,201^,356^,361^,373^,374; however, only laboratory tests show a difference in root fracture when metal or zirconia posts are used compared to fiber posts. The adhesive interface with different elastic moduli, such as with a metal post system and dentin, represents the weakest point of the restorative system.351^,356^,375^,376 Thus, fiber posts with mechanical properties similar to root dentin induce lower stresses than metal posts at the interface,114^,206 and their clinical performance is considered more favorable because of their favorable fracture mode69^,201 and reduced root fracture.361^,365^,377^–379

Fractures in ETT with fiber-reinforced posts usually occur in the cervical region, whereas metal posts have demonstrated a more apically positioned fracture.111^,361^,362^,366^,379 One study of different post systems reported that teeth restored with posts had properties similar to those of sound tooth structure. Glass fiber posts demonstrated favorable fractures, whereas those restored with zirconia and titanium posts demonstrated catastrophic fractures.353380356381382383