Hindawi Publishing Corporation

International Journal of Dentistry

Volume 2009, Article ID 150251, 9 pages
doi:10.1155/2009/150251

Review Article
Restoration of Endodontically Treated Teeth Review and
Treatment Recommendations

Iris Slutzky-Goldberg,1 Hagay Slutzky,2 Colin Gorfil,3 and Ami Smidt4

1 Post-Graduate Program in Endodntics, HUHSDM, Jerusalem 91120, Israel
2 Department of Community Dentistry, HUHSDM, Jerusalem 91120, Israel
3 Department of Prosthodontics, The Maurice and Gabriella School of Dental Medicine, TAU, Tel Aviv 69978, Israel
4 The Center for Graduate Studies in Prosthodontics, HUHSDM, Jerusalem 91120, Israel

Correspondence should be addressed to Iris Slutzky-Goldberg, [email protected]

Received 30 July 2009; Accepted 13 October 2009

Recommended by Nestor Cohenca

Coronal restorations and posts can positively influence the long-term prognosis of teeth following root canal therapy. Final sealing
the canal by placing an appropriate post and core will minimize leakage of oral fluids and bacteria into the periradicular area and
is recommended as soon as possible after completion of root canal filling. Glass ionomer or MTA placed over the residual root
canal filling after post space preparation may be effective to prevent bacterial leakage. A ferrule of 1-2 mm of tooth tissue coronal
to the finish line of the crown significantly improves the fracture resistance of the tooth and is more important than the type of the
material the core and post are made of.

Copyright © 2009 Iris Slutzky-Goldberg et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

1. Introduction the resultant success rate was 67.6%. They concluded that
apical periodontal health depended significantly more on
Recently, growing attention has been given to procedures the coronal restoration than on the technical quality of the
carried out after completion of the endodontic treatment endodontic treatment. The importance of a good restoration
and their impact on the prognosis of devitalized teeth. to the periapical health was confirmed in similar studies [3–
These procedures may allow the passage of microorganisms 6], even though these demonstrated that an adequate root
and their by-products to the apical region of the root and filling had a more substantial impact on the outcome of
into the alveolar bone, a potential cause of delayed failures. treatment than the quality of the coronal restoration [7].
The consequences of these “events” may be important
in determining the long-term success of the endodontic
treatment [1]. 2. Root Canal Filling Materials
Ray and Trope [2] evaluated the relationship between the
quality of the coronal restoration and the quality of the root Salivary microleakage is considered to be a major cause of
canal filling by examining the radiographs of endodontically endodontic failure due to bacteria and endotoxins pene-
treated teeth. They observed that a combination of good tration along the root canal filling [8, 9]. Contamination
restorations and good endodontic treatments resulted in of the root canal can occur through salivary microleakage
absence of periapical inflammation in 91.4% of the teeth, during post space preparation, after post cementation,
whereas poor restorations and poor endodontic treatments through temporary fillings, and through leaking margins of
resulted in the absence of periradicular inflammation in permanent restorations [1].
only 18.1% of the teeth examined. Furthermore, where The penetration of saliva through obturated root canals
poor endodontic treatments were followed by good per- increases with the longer exposure period [10] (see Figure 1).
manent restorations, that appeared radiographically sealed, Microorganisms were isolated from obturated root canals
2 International Journal of Dentistry

Figure 1: Bacterial contamination occurred after completion of Figure 2: The post space should be dressed between appointments
root canal treatment in the tooth, which remained with a temporary and irrigated before post cementation.
filling for 15 month.

after 22 days of exposure to saliva. Both lateral and vertical performed using the fluid filtration technique [23, 24] and
condensations methods of obturation were evaluated in the dye penetration technique [25].
this study [11]. Additionally leakage of obligate anaerobes Some authors speculate that the expansion of hygro-
and bacterial metabolites along laterally condensed root scopic restorative materials leads to poor adaptation at the
canals was demonstrated without any significant differences restorative material-cavity walls interface [26, 27]. In an
between root canals obturated with gutta-perch cones (GP) in vitro work which examined the antibacterial effect of 4
and other root canal sealers [12–14]. temporary filling materials, IRM had a bacteriocidic effect
A novel filling system that was introduced in 2004, on the growth of S. mutans which lasted for at least 14 days,
Resilon and Epiphany, was no better than gutta-percha with whereas it had a bacteriostatic influence for 1 day on the
Roth or with epoxy resin sealers like AH Plus or MM- growth of E. faecalis, which could not be demonstrated after
seal at sealing root canals [15]. In a comparative study 7 days. The authors suggested that IRM may be selective
using a microleakage model and a new sequence detection for some bacteria but not for others, therefore allowing
assay “One Cut Event AmplificatioN (OCEAN) technique”, the growth of E. faecalis which is associated with failure of
Pasqualini et al. [16] demonstrated that canals obturated endodontic treatments [28].
with Resilon showed a greater number of microleakage
events than those obturated with gutta-percha and Zinc 4. Are Endodontically Treated Teeth
oxide eugenol sealer. On the other hand, Bodromlu et al. More Brittle?
[17] showed better results for Resilon as compared with
gutta-percha and AH-Plus, especially in delayed post space Contrary to common belief, endodontically treated teeth are
preparation. Although none of the root-canal filling mate- not more brittle [29, 30]. No difference in moisture content
rials and sealers exhibited complete apical sealing [18]. In was found between endodontically treated and vital teeth
another study, the Resilon system provided the lowest mean [31]. The access cavity in combination with an early loss of
values of apical leakage, but did not provide hermetic sealing one or both marginal ridges leaves the tooth at serious risk.
of the root canal system, furthermore, thermoplastification According to Dietschi et al. [32], the loss of vitality and a
negatively influenced the apical sealing ability of Resilon proper RCT affected tooth biomechanical behavior only to a
[19]. limited extent. The tooth strength is reduced in proportion to
coronal tissue lost, due to either carious lesions or restorative
3. Temporary Filling Materials procedures. A direct relationship exists between the amount
of remaining tooth structure and the ability to resist occlusal
Temporary fillings, in teeth undergoing root canal treatment forces [33] (see Figure 4). It is therefore important to provide
or before completion of the final restoration, must provide a restoration allowing cuspal coverage as soon as possible
an effective barrier against salivary contamination of the root after completion of the RCT [1].
canal. Intermediate Restorative Material (IRM), Cavit, and Anterior teeth with minimal access cavity can be restored
TERM are commonly used as temporary filling materials with a composite resin, and premolars and molars with
[20]. IRM, that is used due to its high compressive strength minimal access cavities or other coronal tissue loss can be
[21], has been demonstrated in bacterial leakage to be less restored with amalgam or composite resin in combination
leak proof than Cavit and TERM [20, 22]. These results with a resin bonding system. Whereas, posterior teeth
were similar to those reported by others, in experiments with large access cavities following extensive carious lesions
International Journal of Dentistry 3

transmit larger lateral forces to the remaining root structure

[46]. It was also suggested that increasing post length is more
important than post diameter for retention improvement
[47].

5. Microleakage after Post Space Preparation

Figure 3: Best outcome found in teeth where the post was in contact During post space preparation a small volume of obturation
with the gutta percha. material remains in the root canal. This residual filling at
the apical region serves as the last barrier against microbial
penetration along the root canal, which may in time cause
periapical inflammation. The consequences of these events
carry greater occlusal loads and therefore require protection
are contamination of the canal and colonization of bacterial
against possible fracture [34, 35]. Notwithstanding, the use
species at the walls of the apical portion of the root canal
of posts does not reinforce endodontically treated teeth and
[48–50]. The length of GP fill remaining in the root canal
some reports even show that teeth which were restored
has a major effect on the apical seal. There is a consensus that
without a post and core are less susceptible to fracture than
a longer filling provides a better seal [51, 52]. It was observed
teeth with post and core [36].
that when only the apical 4 mm of root canal filling (RCF)
Several materials are available for core buildup: gold,
remained, the leakage was significantly greater than when the
amalgam, resin composites, and reinforced glass ionomers
original full-length filling was examined [53]. DeCleen [51]
[36]. In a study that compared the use of amalgam,
stated that 3 mm of remaining GP is the absolute minimum
resin composite, and glass ionomer in combination with a
and that preferably 6 mm should be left in the root canal.
prefabricated post in extracted teeth subjected to masticatory
The methods of canal obturation, post space prepara-
forces, it was found that amalgam had the lowest failure
tion, and timing of post space preparation may influence
rate, and that glass ionomer core buildup materials caused
future microleakage. Haddix et al. [54] compared heated
the greatest number of failures [37]. Some studies supported
pluggers, gates-glidden drills, or GPX instruments as post
the use of amalgam dowels in the root canals to increase
space preparation tools. The remaining length of apical GP
the retention of the restoration when the remaining wall
fillings was 3 or 5 mm. At these levels, significantly less
thickness was less than 4 mm [38, 39]. Nonetheless, Tamse
leakage was observed when the heated plugger technique
et al. [40] compared 49 mesial roots extracted due to vertical
was used. This may be explained by the additional effect of
fractures with 52 mesial mandibular roots without fractures,
vertical condensation achieved by using heated pluggers [1].
and found that 67.3% of the vertically fractured roots had
Using a fluid transport device, Fan et al. [55] found more
an amalgam dowel in the coronal part (1-2 mm) of the
leakage after delayed post preparation than after immediate
root. The authors suggested that the removal of more dentin
preparation. The root canals were obturated with laterally
from the coronal part of a susceptible to fracture root
condensed GP cones and either AH26 or Pulp Canal Sealer,
and condensing amalgam with an expansion potential into
noting no significant difference between the sealers. Wu et al.
an already weakened root contributes to vertical fracture
[53] suggested that leakage following removal of the coronal
development.
portion of the RCF during post space preparation may be
In an in vitro study by Pilo et al. [41], comparing resin-
compensated for by the cemented post. In an SEM analysis
based composite, amalgam, and cast gold as core materials
of the canal walls after post space preparation, large areas
under a crown in endodontically treated teeth, no significant
were covered by smear layer, debris, and sealer/gutta-percha
difference in fracture and failure characteristics was found
remnants. Thus, the post space may not be available for
among these materials, provided a 2-mm ferrule existed on
adhesive bonding and resin cementation of fiber posts [56].
the margin of healthy tooth substance. These findings are
in accordance with Hoag and Dwyer [42] who suggested
that 1-2 mm of tooth tissue coronal to the finish line of 6. Post Cementation
the crown significantly improves the fracture resistance of
the tooth. The ferrule reduced vertical root fracture by one The influence of the gap between the post and the residual
third, and when failure occurred, it is usually in the form of gutta-percha on the clinical outcome of endodontically
horizontal root fracture—thus, leaving the teeth more likely treated teeth was studied from records of patients treated by
to be retrievable. Nonetheless, following enlargement of the dental students. 3 groups of teeth were compared according
cavity size, especially after endodontic access, the tooth is to the gap between the post and the residual gutta-percha.
subjected to an increased cuspal deflection and a potential The best outcome was found in teeth where the post was in
fracture [43]. contact with the gutta-percha (83.3%); when this gap was 0–
A post should be used only when there is insufficient 2 mm a satisfactory outcome was found in 53.6% of the teeth,
tooth substance remaining to support the final restoration and a gap larger than 2 mm resulted in an inferior outcome,
[44]. Post length should be as long as the clinical crown where only 29.4% of the teeth were defined satisfactory
height. The post should end halfway between the crestal bone [57] (see Figure 3). A fluid filtration system was used to
and the root apex [45]. Short posts have poor retention and examine the effect of cementation of stainless-steel post and
4 International Journal of Dentistry

(a) (b)

Figure 4: The access cavity in combination with an early loss of both marginal ridges due to caries (a) or trauma (b) leaves the tooth at
serious risk of fracture.

a carbon-fiber post system on microleakage. Both posts, A recent systematic review of post and core materials
when cemented with dentin-bonding resin cements (C & B conducted by Theodosopoulou and Chochlidakis [65] was
Metabond and Panavia-21), exhibited less microleakage than based on articles found in an electronic search of MEDLINE
when the posts were cemented with non-dentin-bonding from 1966 to 2008, and a Cochrane and EMBASE search
cements (glass ionomer and zinc phosphate) [58]. It was from 1945 to 2008. It was aimed to determine which post
demonstrated that significantly greater leakage occurred in and core system is the most successful when used in vivo
temporary restorations than in cast post and cores cemented to restore endodontically treated teeth. Failures were con-
with zinc phosphate cement or prefabricated posts and cores sidered as cases with root fracture, dowel fracture, periapical
cemented with a composite luting cement [59]. These results radiographic change/lesion, and/or dowel dislodgment. The
were advocated by another study which demonstrated, in following conclusions were made: Carbon fiber in resin
addition, that the use of dentin-bonding cements resulted in matrix dowels (Composiposts) are significantly better than
less microleakage than with traditional, non-dentin-bonding precious alloy cast dowels. Glass fiber dowels are significantly
cements, and that the adaptation of the post to the canal may better than metal screw dowels, and moderately better
be more important than the cement used [60]. than quartz fiber dowels. and glass fiber reinforced dowels
Fogel [61] compared microleakage of five post sys- (Postec) are better than quartz fiber dowels (AEsthetiplus).
tems using the fluid filtration system: stainless steel posts Glass fiber-reinforced dowels are moderately worse than
cemented with (a) zinc phosphate cement, (b) polycarboxy- titanium dowels. Furthermore, quartz fiber dowels (DT) and
late cement, (c) a composite resin, (d) composite resin after glass fiber-reinforced dowels (Postec) show the same results
use of a dentin bonding agent, and (e) composite resin after when compared to each other.
use of a dentin conditioner and a dentin bonding agent.
The results showed that none of the post-cement systems 7. Permanent Restoration
tested were capable of consistently achieving a fluid-tight
seal. Usumez et al. [62] compared the sealability of stainless Friedman and Mor [66] stated that endodontic treatment is
steel dowels (ParaPost), (2) glass fiber dowels (Snowpost), a predictable procedure with long-term tooth retention rate,
(3) resin-supported polyethylene fiber (Ribbond) dowels, or and that asymptomatic teeth, in spite of having a periapical
(4) zirconia dowels (Cosmopost). Resin-supported polyethy- lesion, may be considered functional. Indeed, Salehrabi and
lene fiber dowels and glass fiber dowels tested exhibited Rotstein [67] checked the records following initial root canal
less microleakage compared to zirconia dowel systems. treatments of 1,462,936 teeth from 1,126,288 patients and
The use of various types of fiber-reinforced posts and found that 97% of the teeth remained in the oral cavity
resin cement is becoming more popular. Among different after an evaluation period of 8 years. The 3% remaining
types of adhesively-luted fiber-reinforced dowels evaluated: were subjected to apical surgeries, extractions, and so forth,
DT Light Post (LP), Glassix (GL), Ribbond (RB), and most of which occurred within 3 years from completion
StickTech Post (ST), the individually shaped polyethylene- of treatment. Complications occurred in teeth without any
reinforced dowel (Ribbond) showed the least overall leakage coronal coverage in 85% of the cases. In another study,
[63]. In microleakage study of 200 endodontically treated endodontically treated teeth not crowned after obturation
teeth restored with prefabricated dowels and tooth-colored were lost 6 times more often than teeth crowned after
restoratives as core materials with and without the use of a obturation [68]. A 10-year prospective clinical trial, showed
flowable composite liner, the use of flowable liners reduced 94% survival rate of metal post-and-cores with a crown
microleakage. Z-100 both with and without flowable liner [69]. Another 17-year controlled prospective study showed
demonstrated better resistance to leakage as compared with that the type of core restorations under the crowns had
Solitaire, Admira, and Filtek P60 [64]. no effect on the survival rate of 307 endodontically treated
International Journal of Dentistry 5

teeth [70]. This was confirmed in another study, which in the inflammation rate between the group without plugs
showed that the type of post and core was not relevant with (89%) and those with IRM (38%) or composite orifice
respect to survival. However, the longevity of a post-and- plug (39%) were statistically significant. In their study even
core restoration was influenced by the amount of remaining when only gutta-percha (without sealer) was used for filling,
dentin height after preparation [71]. the placement of an orifice plug significantly prevented
the occurrence of inflammation. The results of this study
demonstrate that the placement of an orifice plug after
8. Timing root canal filling is beneficial to delay and prevent coronal
microleakage. It may be assumed that the placement of an
The dilemma of whether to place a permanent restoration
intraorifice barrier establishes an immediate coronal seal.
immediately after completion of the endodontic treatment
Outcomes of studies underscore the importance of a
or to wait for the resolution of the rarefying osteitis exists
sound coronal seal with respect to the overall success of root
among dental practitioners. Safavi et al. [72] examined
canal treatment. Pisano et al. [78] tested whether Cavit, IRM,
the influence of delaying coronal permanent restorations
or Super-EBA as intraorifice filling materials can prevent
on the prognosis of endodontically treated teeth, 464
coronal microleakage of human saliva and its components in
endodontically treated teeth were evaluated, using follow up
the absence of a coronal restoration. At the end of a 90-day
radiographs. Higher success rate was found in teeth with
test period, 15% of the Cavit-filled orifices leaked, whereas
permanent restorations (amalgam, composite resin filling, or
35% of the IRM and Super-EBA-filled orifices leaked.
cast crowns with or without a post and core) than in teeth
The gutta-percha obturated root canals that received an
with temporary fillings (IRM or Cavit).
intraorifice filling material leaked significantly less than the
Although the difference was not significant, they sug-
obturated unsealed control group, all of which leaked in less
gested that an appropriate and prompt permanent restora-
than 49 days. Another study evaluated the effect of glass
tion after completion of endodontic treatment should be
ionomer used as an intracoronal barrier for the prevention of
carried out. It showed significantly more leakage after placing
microleakage by using the fluid transport model. Following
a temporary filling than following placement of a permanent
root canal treatment 30 teeth received 0–2 mm intracoronal
restorative material to seal access cavities [26]. The authors
barrier of “Triage” glass ionomer. 1 or 2 mm of Triage
suggested that it may be more prudent to use permanent
significantly reduced coronal microleakage in thermocycled
restorative materials for provisional restorations in order
endodontically treated teeth as compared with no barrier
to prevent inadequate canal sealing and the resulting risk
[80].
of fluid penetration. Another study compared the amount
A study which compared coronal microleakage between
of dye leakage after post space preparation along root
Resilon with Epiphany primer and sealer and gutta-percha
canals obturated with GP with either AH26 or a zinc oxide
with 2-mm of Triage intraorifice barrier using a fluid
eugenol (ZOE) based sealer. The post space was prepared
filtration model found significantly less leakage for the gutta-
immediately after obturation or one week later. The only
percha/glass-ionomer intraorifice barrier group than the
significant difference was that in the delayed preparation
Resilon alone group [81].
group in which ZOE based sealer was used; there was greater
Mineral trioxide aggregate (MTA) was also suggested
leakage [73].
for use as a coronal barrier, in a study that compared the
effectiveness of grey MTA, white MTA, and Fuji II LC cement
9. Coronal Barrier as coronal barriers to bacterial leakage. A dual chamber
leakage model utilizing salivary microbes was used for the
Metzger et al. [74] compared remaining gutta-percha after evaluation of the microleakage. Leakage did not occur until
post space preparation of 3, 5, 7, or 9 mm and found that day 52 with Fuji II, day 56 with gray MTA, and day 59 with
the seal of 3, 5, and 7 mm remaining Gutta-percha was white MTA. There was no statistically significant difference
inferior to an intact filling of 14 mm. Microbial leakage of in leakage between the materials tested at 30, 60, or 90
E. faecalis after post space preparation in teeth filled in vivo days [82]. Another study showed that after 10 months,
with RealSeal versus Gutta-percha was examined in teeth in there were no demonstrable differences between periapical
which 5 mm of apical filling material was left. RealSeal-filled inflammation in dog teeth with conventional root fillings
teeth showed leakage after 3.5 days and Gutta-percha-filled and those coronally augmented by MTA [83]. Mavec et
teeth showed a mean leakage of 10 days [75]. al. [84] suggested that in clinical situations of teeth with
Since the gutta-percha remaining after post space prepa- compromised crown-root ratio that require a post and core,
ration does not provide a seal equivalent to the intact 1 mm of Vitrebond over 2 or 3 mm remaining gutta-percha
root canal filling [1], several materials and techniques have could reduce the risk of recontamination of the apical gutta-
been suggested to address the shortcomings of gutta-percha. percha.
Numerous studies have shown that the use of intraorifice
barriers in canals filled with gutta-percha significantly
decreases coronal microleakage [76–78]. Yamauchi et al. [79] 10. Discussion and Recommendations
demonstrated substantial reduction in apical periodontitis
in dogs’ teeth after placement of a coronal barrier using Bacteria harbored the oral cavity can cause periapical
IRM or dentin bonding/composite resin. The differences inflammation by penetrating the root canal not only before
6 International Journal of Dentistry

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