Restorative Considerations in

Deciding Whether to Restore or Remove

CE
Endodontically Treated Teeth

Abstract:
The interdisciplinary team is often confronted with the decision of whether to retain or remove ques-
tionable teeth that have already been treated endodontically. The purpose of this article is to review the
restorative criteria that must be met in order for these teeth to be predictable over the long term. In many
instances, the decision of whether to restore or remove a tooth is quite clear. Untreatable periodontal
conditions, untreatable endodontic conditions, unmanageable root resorption, or root fractures make
the decision to remove a tooth an easy one. For the purpose of this article the author is going to assume
that the teeth in question are treatable endodontically as well as periodontally and focus specifically on
the issues of restorative predictability.

T here are essentially three major as-

pects to discuss when considering
whether to restore or remove a question-
era, the typical goal in describing an
adequate tooth preparation was 3 mm
of vertical height with 6° of taper.1 The
able tooth that is biologically healthy. ability to bond a restoration has altered
The first is structural—is it possible to those requirements to some degree, al-
restore the tooth in such a manner that though it is difficult to identify specif-
a good long-term prognosis exists? The ically how little tooth structure is an
second is esthetic—is it possible to create acceptable amount for both retention
Frank M. Spear, DDS, MSD
Founder and Director
a pleasing final appearance and maintain and resistance form when bonding is
Seattle Institute for Advanced the tooth? And the final area is value— used. There is, however, a significant
Dental Education
Seattle, Washington
what will the cost be both financially amount of clinical research that identi-
Affiliate Assistant Professor and in time and energy to maintain the fies the method of failure of endodon-
University of Washington tooth as opposed to removing it? tically treated teeth when inadequate
School of Dentistry
Seattle, Washington tooth structure was available and the
Private Practice Structural Issues tooth had been restored with a post
Seattle, Washington The structural issues of whether to and core.2 The most common failure is
retain or remove a tooth relate to the a loss of retention of the post, the core,
amount of remaining tooth structure. and the crown, with the result that the
Learning Objectives If the tooth has had endodontic therapy, patient arrives at the office with the
has the majority of its coronal form re- restoration in their hand. The second
After reading this article, the maining, and is endodontically and perio- most common method of failure is a
reader should be able to: dontally healthy, there is little question in fracture of the post with the crown and
• discuss the criteria that must most cases about whether to remove or core now in the patient’s hand, but the
be met during the restorative restore the tooth. post still cemented in the tooth. And
decision-making process to Making the decision to restore or re- finally, the third most common method
ensure long-term predictability move teeth that are biologically healthy of failure is the root of the tooth split-
of teeth that have already been but missing the majority of their coronal ting vertically.
treated endodontically. form is not always clear. In these teeth, All of these methods of failure have
• identify the three major aspects which often are fractured, the challenge been linked to a lack of tooth structure
to consider when deciding is getting the necessary tooth structure or, more specifically, what is known as
whether to restore or remove a to make a predictable restoration. It is a lack of ferrule.3 Ferrule is defined as
tooth that is biologically healthy. helpful at this point to discuss how much the amount of tooth structure between
tooth structure is necessary. the margin of the restoration and the
• describe the major causes in
Classically, prior to the era of adhe- margin of the build-up (Figure 1). To
the failure of restored teeth that
sive bonding, the geometry of the tooth understand how ferrule plays a role in
had been previously treated
preparation was solely responsible for failure, it is helpful to consider how forces
endodontically.
retention and resistance form. In that are applied during function.

2 ADVANCED ESTHETICS & INTERDISCIPLINARY DENTISTRY MARCH 2007— VOLUME 3, NUMBER 1

 likely the post is to potentially fatigue author was not directly involved with
and fracture, resulting in the loss of the any of this research, but because he grad-
crown and core or, worse, a vertical frac- uated from the same program 25 years
ture of the root of the tooth. ago, he is very aware of how each article
One of the major goals in making evaluates a specific variable in the fatigue
the decision to restore or remove an resistance of the restoration of endodon-
endodontically treated tooth is to deter- tically treated teeth. At the heart of this
mine if adequate tooth structure exists series of articles is the concept that
to prevent the types of failures described fatigue resistance is the critical element
previously, and if not, determining if in the long-term predictability of endo-
could it be created. Knowing how much dontically treated teeth. Success requires
tooth structure is necessary, and where it a tooth be able to accept repeated forces
Figure 1—The concept of ferrule, the amount of necessary, is a key part of this decision- at a lower level to succeed long term
tooth between the margin of the build-up and making process. rather than be resistant to one maximal
the margin of the restoration. traumatic event. This varies significant-
Literature Review ly from the common methodology of
Using a maxillary anterior tooth as To answer these questions, the author using an Instron machine and increasing
an example, loading during excursive is going to reference a series of research the load until a traumatic failure occurs
movements or during the incising of projects that have evaluated the influence as a way of in vitro testing different
food creates a compressive force on the of the amount of tooth structure, type restorative variables.
facial margin of the restoration and a ten- of build-up, type of post, and the method In the first study, Libman compared
sile force attempting to open up the lin- of luting to the fatigue resistance of the the amount of remaining ferrule and its
gual margin of the restoration (Figure 2). final result. And while many research influence on when preliminary failure
Normally, the stiffness of the dentin, articles have been published on this occurred.4 Preliminary failure is defined
combined with the quality of the restora- topic, the author is going to use a spe- as the moment the restoration margin
tion, prevents any kind of failure under cific series of articles done by students opens up, loses its integrity and begins
load. Compare the loading of a tooth from the University of Washington post- the microleakage process (Figure 4). But
that is fractured level with the gingival graduate prosthodontics program. The because the restoration is still cemented
tissue to the retention and resistance of
the entire restoration supported by a post
and core, and one can understand how,
under loading, the management of any
forces depends on the quality of the post
and core because there is no natural tooth
structure to which the crown is cemented
(Figure 3). The more flexible the post,
the more likely the lingual margin is to
open up because of the tension that
Figure 2—An illustration of the distribution of Figure 3—An illustration showing that when the
occurs with the occlusal forces. compressive and tensile forces on a normal tooth is even with the gingival level, all of the
Once the lingual margin has opened, restoration. resistance to force is borne by the post and core.
it is now possible for leakage to enter the
gap between the crown and the tooth
and start working its way toward the
post and apically in the canal. When the
leakage moves far enough in an apical
direction that there is an inadequate
amount of post still cemented to retain
the core, then the post, core, and the
crown all fall out. This entire event is
often preceded for months and some-
times years by the patient presenting
with a complaint of a bad taste or offend-
ing odor around the questionable tooth.
And yet, at each appointment the margin
of the restoration seemed intact because
the crown was still cemented to the core
CE

and the post was still cemented in the Figure 4—The concept of preliminary failure, when the margin of the restoration is no longer
canal. The more rigid the post, the more cemented to the root of the tooth.

MARCH 2007— VOLUME 3, NUMBER 1 ADVANCED ESTHETICS & INTERDISCIPLINARY DENTISTRY 3

to the build-up and the post is still 1.5-mm ferrule, the teeth were separated 40,511 cycles to reach failure, which is
cemented in the canal, the restoration into three groups: in Group 1 the cast- very similar to the number from Goto’s
appears clinically sound. Libman’s focus gold crowns were cemented with zinc- study using identical methods for plac-
was to use standardized-length, cast- phosphate cement; in Group 2 the crowns ing the posts, core, and crown.
gold post cores cemented with zinc phos- were cemented with a resin-modified, In analyzing the results from these
phate into extracted central incisors. The glass-ionomer cement; and in Group 3 three studies, several things become
length and dimensions of the tooth the crowns were placed with an adhe- obvious. First, the type of cement used
preparations were kept as identical as sive resin cement. Again, each tooth was to retain the crown over the post and
possible. The only variable was the dif- mounted in an acrylic block with a strain core has an enormous impact on fatigue
ference in the ferrule length for each of gauge cemented to the lingual margin resistance, with adhesive resin being dra-
the samples, varying from a control with and placed into the device for fatigue matically better than zinc phosphate or
no post core, up to a 2-mm ferrule, in testing. The load used in Junge’s study resin-modified glass ionomer. The same
0.5-mm increments. A cast-gold crown was different then that used in Libman’s, dramatic change can also be seen when
was cemented using zinc phosphate on therefore, a direct correlation of the comparing the different methods of
top of the preparation and build-up. numerical values required to achieve fail- luting the post in the canal, with adhe-
The complete restoration and extracted ure cannot be made between the two sive resin being the clear choice. Two
root was embedded in an acrylic block studies. However, Junge used zinc phos- questions, however, remain unanswered.
and prepared for fatigue testing. A strain phate cement as one of his variables, so First, is it necessary to have a ferrule
gauge was cemented over the lingual mar- the impact of the different cements on circumferentially around the tooth? And
gin of the restoration to act as a chart the number of cycles required to reach second, is it necessary to have a 1.5-mm
recorder. This recorder was able to read preliminary failure can be easily seen. ferrule if adhesive resin is used to place
any change occurring at the lingual mar- In Group 1, failure occurred at 5,646 the post core and the crown?
gin under tension from repeated loading cycles. In Group 2, failure occurred at Wong was interested in whether a
or fatigue. The results showed that it 6,795 cycles. In Group 3, failure was not circumferential ferrule was necessary.7
took only 213 cycles to produce prelim- recorded because the machine was shut Using the fatigue apparatus described
inary failure when a 0.5-mm ferrule was off at 100,000 cycles and none of the
previously with extracted natural teeth,
present; 1,140 cycles when a 1-mm fer- teeth had yet failed.
bonded fiber posts, composite cores,
rule was present; 71,651 cycles when a This study clearly shows the impor-
and cementing the crowns with a resin-
1.5-mm ferrule was present; 70,045 tance of using adhesive resins in cement-
modified glass ionomer, his study was
cycles when a 2-mm ferrule was pres- ing the final restoration over any post
separated into two major groups. Group
ent; and 91,208 cycles for the control and core build-up. And yet it leaves sev-
1 had a 2-mm circumferential ferrule.
natural tooth. eral unanswered questions. Would the
Group 2 had the margin of the prepara-
The data from this study clearly show- results be the same if the ferrule was less
tions scalloped to provide 2 mm of fer-
ed that at least a 1.5-mm ferrule for pre- than 1.5 mm? Would the results be the
rule on the buccal and lingual surfaces,
dictable fatigue resistance is required. same if a different post-and-core system
The challenge of Libman’s original mod- had been used? How would the results but none interproximally. The findings
el is that the materials and techniques vary if the ferrule was not the same were very conclusive in that the critical
used—namely cast-gold post cores and height circumferentially around the location for the ferrule is on the buccal
zinc phosphate cement—are not used as tooth? To answer these questions it will and lingual surfaces, and whether any
commonly today. It was therefore neces- be necessary to complete another series ferrule was present interproximally did
sary to create a series of research studies of studies looking at different variables. not affect the outcome. This is quite
using the same methodology as Libman Thu did exactly that, also using three easy to understand when the distribu-
but altering specific variables to see groups as Junge, except that he used tion of force to the restoration during
their impact. In evaluating the variables resin cement to place all of the posts loading is evaluated, with the facial sur-
that must be controlled when restoring and cores, followed by glass-ionomer face being compressed while the lingual
endodontically treated teeth, the cement cement to place the crowns over the surface experiences tension but the mid-
used to retain the post, the cement used posts and cores.6 Like the others, a cir- interproximal is essentially a zone of no
to retain the restoration, the type of post cumferential 1.5-mm ferrule was used stress (Figure 5). The final question re-
used, and the type of build-up material for each tooth. Comparing the results maining is whether it is, in fact, neces-
used must all be considered. of Thu’s research to Goto’s is quite sary to have a 1.5-mm or 2-mm ferrule
Junge modeled his research after astounding given that the only changed if adhesive resin is being used to place
Libman’s using extracted central inci- variable was the cement used to place the post core and the crown.
sors, cast-gold post cores cemented with the posts. Group 1 (cast-gold post core) Ma developed a study8 where the vari-
zinc phosphate cement, and a 1.5-mm required 163,326 cycles to reach failure; able to be altered was the actual height of
circumferential ferrule, but he altered Group 2 (the stainless steel para-post the ferrule, again using a similar method-
the cement used to place the cast-gold with a bonded core) required 244,315 ology to the previous studies. Each
crown.5 After cementation of the cast- cycles to reach failure; and Group 3 group consisted of a fiber post and com-
gold post cores and the creation of the (fiber post with composite core) required posite core, both bonded to place, and an
4 ADVANCED ESTHETICS & INTERDISCIPLINARY DENTISTRY MARCH 2007— VOLUME 3, NUMBER 1
all-ceramic crown also bonded to place.
The variables were: Group 1, no ferrule;
Group 2, a 0.5-mm circumferential fer-
rule; and Group 3, a 1-mm circumfer-
ential ferrule. An analysis of the results
shows how critical the adhesive resin
cement is to success, but also points to
the necessity of having some ferrule pres-
ent. Group 1 failed in only 213 cycles;
Group 2 failed at 155,137 cycles; and
Group 3 failed at 262,872 cycles.
Clearly the fatigue resistance and
long-term predictability of an endodon-
tically treated tooth are affected by the
amount of ferrule, the cement used to
retain the crown, and the cement used
to place the post and core. At this point
it is difficult to identify how much Figure 5—An illustration showing a lack of compressive or tensile force at the mid-interproximal,
importance the post/core system used eliminating the need for an interproximal ferrule.

has in the fatigue-resistance process.

From Thu’s work, when resin-modified,
glass-ionomer cement was used to retain
the crown, the stainless-steel post bonded
in place with a composite core required
the most cycles to failure, followed by
a bonded cast post core and the weak-
est of the three, the bonded fiber core.
However, we do not have research that
compares the three post/core systems
to each other when the crown also was Figure 6—Facial view of a fractured endodon- Figure 7—The same tooth in Figure 6, showing
tically treated tooth with minimal facial ferrule. minimal lingual ferrule.
bonded, but it would appear that the
choice of post may be the least impor-
tant decision one has to make in how to
restore an endodontically treated tooth.
In using the previous research as
part of the decision-making process for
whether an endodontically treated tooth
should be restored or removed, it is
obvious that the ability to get a 1-mm
ferrule on both the buccal and lingual
surfaces is critical to long-term success.
And, any restorations done where no Figure 8—After minor palatal crown lengthen- Figure 9—The completed restoration.
ing and the placement of a tooth-colored post
ferrule is present regardless of the adhe- and core, it is possible to gain 1.5 mm to 2 mm
sive or the post used is doomed to ear- of palatal ferrule.
ly failure. In addition to the height of
the ferrule, it is also important to note restore or remove an endodontically (Figure 6 through Figure 9).9,10 The
that the thickness of the remaining walls treated tooth is whether or not a ferrule second is to use orthodontic extrusion
of the tooth will have an impact on the can be created on the tooth in question to erupt the tooth to a more coronal
success of the ferrule. That is, a 1-mm- without long-term negative implications level, followed by apically positioning
tall ferrule that has only a few tenths of for the patient. the tissue to expose the required tooth
a millimeter of wall thickness is proba- In general, two methods exist to cre- structure.11-14 In some cases this ortho-
bly inadequate. ate a ferrule when one is absent. The dontic extrusion can be done quite
Unfortunately, the author is unaware first is surgical in nature, apically posi- rapidly, attempting to pull the tooth
of any research that has evaluated the tioning the gingival tissues either through out of the attachment and avoid the
thickness of the remaining walls on gingivectomy or osseous surgery to ex- secondary surgery. Whether surgery or
CE

long-term success. Another important pose more of the tooth, allowing a ferrule orthodontic extrusion is attempted to
question in determining whether to to be created when the tooth is prepared obtain a ferrule the net effect will always

MARCH 2007— VOLUME 3, NUMBER 1 ADVANCED ESTHETICS & INTERDISCIPLINARY DENTISTRY 5

 be that there will be less root in the
bone after treatment than there was
before treatment; surgery will often
remove bone and increase the crown-
to-root ratio, and eruption pulls the
root out of the bone, again reducing the
crown-to-root ratio, although not as
severely as surgery alone (Figure 10).
As a general rule, whether using sur-
gery or forced eruption and surgery, it
will be necessary to have at least 4 mm
of tooth exposed above the bone on
both the buccal and lingual surfaces.
This allows for a 1.5-mm ferrule to be
prepared while maintaining the margin
2.5 mm from the underlying bone. In
Figure 10—An illustration comparing the different methods of obtaining a ferrule on a fractured addition to determining how much tooth
tooth, eruption vs crown lengthening. Note the differences in crown-to-root ratio between the structure needs to extend coronally to
different techniques.
the bone, one must consider the amount
of root that will remain in the bone
when determining whether the tooth
should be retained or removed.
Classically, clinicians have spoken of
wanting to maintain a 1:1 crown-to-root
ratio when deciding to retain a tooth or
to remove it.15 The challenge, of course,
is that all clinicians have seen patients
with significantly less than a 1:1 ratio
and yet completed a very successful res-
Figure 11—A patient with a severely fractured Figure 12—A radiograph showing that the
toration. It is necessary for clinicians to
maxillary right central incisor. Endodontic therapy, extent of the fracture on the right central incisor, decide how much root is believed to be
a post and core, and a temporary crown have from the most apical portion of the fracture to necessary to choose restoration vs re-
been placed. the apex of the tooth, is 12 mm and the decision
was made to erupt the tooth to obtain a ferrule.
moval. For a maxillary anterior tooth, if
the author can retain 8 mm to 9 mm of
root in the bone he will generally con-
sider retaining the tooth. Because 4 mm
of tooth structure is needed coronal to
the bone, this means that the tooth must
be 12 mm to 13 mm long to have 8 mm
to 9 mm of root in the bone and 4 mm
coronal to the bone. If these dimen-
Figure 13—The extent of the lingual fracture Figure 14—Because it will be necessary to
sions cannot be met it is difficult to
going 0.5 mm below the palatal crest of bone. expose 4 mm of tooth above the crest of bone, predict long-term success and removal
the orthodontics has been set up to erupt the should be considered (Figure 11 through
tooth 4.5 mm; in addition, a fiberotomy was
performed to the crest of bone.
Figure 17).

Figure 15—The tooth after the orthodontic Figure 16—Following three months of healing Figure 17—The completed smile view of the
extrusion. Note the gingival levels have remained note the gingival health and a 1.5 to 2 mm fer- patient seen in Figures 11 through 16. Note the
the same but the margin of the restoration is rule apical to the margin of the buildup. maintenance of gingival levels and interproximal
now exposed. papilla because eruption was used to obtain the
ferrule rather than surgery.

6 ADVANCED ESTHETICS & INTERDISCIPLINARY DENTISTRY MARCH 2007— VOLUME 3, NUMBER 1

 The one exception to these rules is the over the long term than removing bone
young patient who has not completed and gingiva and leaving the patient in
growth. In these patients, the mainte- a less desirable situation for future tooth
nance of a root—no matter how weak or replacement (as well as dealing with a
how inadequate the ferrule—is a better less pleasing esthetic result after the
choice than removing the tooth at a current treatment). Not doing heroic
young age and dealing with the conse- treatment to save an isolated single
quences later. It is far better to attempt anterior tooth also makes sense because
to maintain the tooth, knowing that it of the predictability of tooth replace-
will eventually fail, but getting the patient ment for single missing anterior teeth. Figure 18—A patient with an extremely high
through the critical period of growth A large part of this predictability is that lip line and a fractured right central incisor.
and then determining how to ultimate- the presence of adjacent teeth ensures
ly replace the tooth. good interproximal bone height with
Another structural factor that must acceptable interproximal papilla heights,
be taken into account when determin- unless prior bone loss has already oc-
ing whether to consider restoring a tooth curred. As a general rule, if the tooth to
or removing it is to consider whether the be removed has no periodontal disease,
tooth will have excessive forces placed it is possible to replace it very predictably
on it. Does the patient have a history of using a single-tooth implant and get a
severe parafunction or bruxism? If so, it very pleasing esthetic result, largely due
is extremely important that the tooth to retaining the adjacent natural teeth
meet the ideal requirements of ferrule
(Figure 18 through Figure 21).
height and wall thickness if it is to suc-
There are times, however, when there
ceed. If that is not possible, it is prob-
may be multiple questionable teeth and
ably in the best interest of the patient
the clinician must decide whether to
to remove the tooth and consider some
remove all of them or retain some of
form of replacement. The same is also
them. If none of them can be managed
true if the tooth is to be a terminal abut-
structurally, the decision would typi-
ment for a complex fixed prosthesis.
The opposite of these circumstances also cally be to remove them all and replace Figure 19—The adjacent teeth are periodon-
applies. If the patient has no history of them prosthetically. In certain instances, tally healthy and it would be virtually impossible
however, the ability to retain one or two to save the root of the right central and have the
tooth wear and the tooth is to be a single- restoration be predictable.
unit restoration, particularly in the ante- maxillary anterior teeth can greatly
rior, it may be possible to have less than enhance the final esthetic outcome of
the ideal ferrule height or wall thick- the restoration because of their ability
ness and still be successful, albeit less to retain interproximal bone.
predictable, than if more tooth struc- For example, retaining one maxil-
ture was present. lary central incisor and the opposite
maxillary lateral incisor has the ability
Esthetic Issues to maintain the papilla heights across
In addition to the structural require- all of the maxillary anterior teeth if
ments described previously concerning implants are used to replace the miss-
whether a tooth should be restored or ing teeth. The retained maxillary cen- Figure 20—A photograph following the removal
tral will maintain the papilla between of the root placement of an implant and five
removed, there are other considerations months of healing. Note the excellent papilla
that have to be taken into account, the opposite central and the lateral due to the maintenance of the adjacent teeth.
specifically the impact of retaining or incisor implant on the side of the re-
removing the tooth on esthetics. There tained central. The retained lateral inci-
are situations where it would be possi- sor will maintain the papilla between it
ble to create an acceptable ferrule on and the maxillary central that is replaced
a maxillary anterior tooth and have by the implant on its side, and also will
adequate root length in bone, but the maintain the papilla between it and the
resulting gingival esthetics would be canine that is replaced by an implant
completely unacceptable because of the on the same side. Treatment planning
surgical procedure necessary to expose to maintain some isolated maxillary
adequate tooth structure. In these cases, anterior teeth is especially helpful in
removal of the tooth and replacing it patients who are very esthetically con-
CE

Figure 21—A four year recall photograph of the

with either an implant or a fixed pros- scious and have a high lip line. There patient seen in Figures 18 through 20.
thesis would better serve the patient are many cases where esthetics need to

MARCH 2007— VOLUME 3, NUMBER 1 ADVANCED ESTHETICS & INTERDISCIPLINARY DENTISTRY 7

Figure 22—A patient presenting for esthetic enhancement with an endo- Figure 23—As the tooth is prepared it is also obvious the root is moder-
dontically treated maxillary right central incisor with a large access cavity. ately discolored.

Figure 24—An incisal view shows how thin the walls of the remaining Figure 25—The solution was to utilize thin bonded ceramic crowns with
tooth structure are; a normal 1.2 mm reduction on the facial would remove a zirconium oxide and pressed ceramic post and core minimizing the
the entire facial wall. amount of facial reduction that had to be performed.

Figure 26—Internal bleaching was performed on the right central incisor Figure 27—A six year recall photograph of the final restorations in place.
minimizing the need for a thick restoration to mask the discolored root.

be considered in addition to the struc- is value, specifically, what are the costs the potential costs, the potential risks,
tural condition of the tooth when decid- vs the benefits to the patient when and what it will mean if there is early
ing if the patient is better served by comparing the retention of the tooth failure of the retained tooth. Before the
retaining and restoring the tooth or vs the removal and replacement of the evolution of implants, it was rare to
removing and replacing it (Figure 22 tooth. And value is something that only not consider going through heroic means
through Figure 29). the patient can determine. It is not up to retain a tooth. In fact, it was com-
to the clinician to determine whether mon to consider endodontic therapy, a
The Value Aspect maintaining a tooth, even if it only lasts cast post core, crown-lengthening sur-
The final area that must be evaluat- 2 more years, is worth it, but rather it gery, and the final restorations as a nec-
ed with regard to restoration vs removal is up to the patient to be informed of essary part of treatment planning to

8 ADVANCED ESTHETICS & INTERDISCIPLINARY DENTISTRY MARCH 2007— VOLUME 3, NUMBER 1

 periodontal attachment to allow the
use of a thinner, more translucent crown.
This could be followed by a zirconium
oxide post core with a pressed-ceramic
core bonded with resin cement, which
has been very successful for the author
over the long term. Finally, the author
hopes that this material stimulates the
thought process for the clinician to pres-
ent the concept of value in terms of cur-
rent expenses for treatment vs long-term
potential expenses for treatment so that
Figure 28 and Figure 29—Comparative frontal smile photographs pre- and post-treatment.
the patient can make an educated deci-
sion in determining whether or not a
provide patients with a fixed restoration. Conclusion tooth should be restored or removed,
Today, however, with the predictability The purpose of this article has been as opposed to the clinician feeling the
of implants and the high cost of endo- to identify, as specifically as possible, pressure of having to make that deci-
dontic therapy, the post core, perio- what criteria are necessary at this point sion alone.
dontal surgery, and final restorations, in time to be able to restore an endodon-
it has become increasingly important tically treated tooth and have that restora- References
1. Shillingburg HT, et al. Fundamentals of Fixed
to educate patients on the relative value tion be both esthetic and lasting. The Prosthodontics. 3rd ed. Quintessence Pub-
of removing a questionable tooth and most structurally important of these lishing Co. Inc; 1997.
restoring it by means that are more pre- criteria is the presence of at least a 1-mm 2. Schwartz RS, Robbins JW. Post placement
and restoration of endodontically treated
dictable. The biggest challenge that the tall ferrule on both the buccal and lingual teeth: A literature review. J Endodont. 2004;
author personally sees in this process is surfaces. In addition, the use of adhe- 30(5):289-301.
that often the questionable tooth ends sive resin cements for the post and core 3. Nicholls JI. The dental ferrule and the endo-
dontically compromised tooth. Quintessence
up being treated endodontically before as well as the final restoration is critical. Int. 2001;32(2):171-173.
a definitive treatment plan is complet- A brief review of the procedures that can 4. Libman WJ, Nichols JI. Load fatigue of teeth
ed. This usually occurs because the tooth enhance the presence of a ferrule has also restored with cast post cores and complete
crowns. Int J Prostho. 1995;11:311-324.
fractured and to get the patient com- been presented, specifically the use of 5. Junge T, Nicholls JI, Phillips KM, Libman WJ.
fortable endodontics was necessary. Now crown lengthening or forced eruption. Load fatigue of compromised teeth: a com-
the patient has already paid for the endo- One final comment on maintaining parison of 3 luting cements. Int J Prosthodont.
dontic therapy and the clinician is in a 1998;11(6):558-564.
a ferrule: it is not uncommon to see an 6. Thu K. Fatigue life of restored teeth with
bind of how to tell the patient that they anterior tooth that may have had endo- three bonded post and core systems. Unpub-
may be better served by removing that dontic therapy with a very large access lished data.
tooth. And yet, in the long term, if the 7. Wong Y, et al. Effect of proximal ferrule length
opening and a significant amount of
on the fatigue life of endodontically treated
tooth is not predictable, the patient internal tooth structure removed. If the teeth. Unpublished data.
will go on to pay for the post core and tooth is now prepared for a traditional 8. Ma SC. Load fatigue of teeth with different
for the crown only to ultimately have crown with 1.2 mm of facial reduction, ferrule lengths, restored with fiber posts,
composite cores, and all-ceramic crowns.
to pay for the removal of the tooth and there may be no remaining ferrule. One Unpublished data.
its replacement. It is for these reasons solution is to use a bonded all-ceramic 9. Rosenburg ES, Garber DA, Evian CI, et al.
that it is critical before performing endo- crown without any internal core, either Tooth lengthening procedures. Compendium.
1980;1:161-172.
dontics on questionable teeth to con- pressed or powder and liquid, and keep 10. Bragger U, Laachenauer D, Lang NP.
sider both the structural and esthetic the facial reduction at 0.5 mm to 0.7 mm Surgical lengthening of the clinical crown.
ramifications of whether that tooth can to retain a significant amount of tooth J Clin Periodontol. 1992;19:58-63.
11. Ingber JS. Forced eruption. Part II: Method
be predictably restored before moving structure. If the root is dark, it may of treating non-restorable teeth—periodontal
forward with the decision to retain it. be bleached internally coronal to the and restorative considerations. J Periodontal.
1976;47:203-216.
12. Lemon RR. Simplified esthetic root extrusion
techniques. Oral Surg Med Oral Pathol. 1982;
54:93-99.
Present the concept of value in terms of current expenses 13. Berglundh T, Marinello CP, Linde J, et al.
Periodontal tissue reactions to orthodontic
for treatment vs long-term potential expenses for extrusion. J Clin Periodontal. 1991;18:330-336.
14. Pontoriero A, Celenza F Jr, Ricci G, Carnevale
treatment so that the patient can make an educated G. Rapid extrusion with fiber resection: A
combined orthodontic-periodontic treatment
decision in determining whether or not a tooth modality. Int J Perio Rest Dent. 1987;5:31-43.
15. Penny RE, Kraal JH. Crown-to-root ratio: its
should be restored or removed. significance in restorative dentistry. J Prosthet
Dent. 1979;42(1):34-38.

10 ADVANCED ESTHETICS & INTERDISCIPLINARY DENTISTRY MARCH 2007— VOLUME 3, NUMBER 1

 Continuing Education Quiz
Tufts University School of Dental Medicine provides 1 hour of Continuing Education credit for this article for those who wish
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1. What are the three major aspects to discuss 7. In general, how many methods exist to create
when considering whether to restore or a ferrule?
remove a questionable tooth that is a. 1
biologically healthy? b. 2
a. esthetic, periodontal, time c. 3
b. structural, esthetic, value d. 4
c. structural, periodontal, functional
d. esthetic, functional, time 8. As a general rule, it will be necessary to have
at least how much tooth exposed above the
2. The structural issues of whether to retain or bone on both the buccal and lingual surfaces?
remove a tooth relate to the amount of: a. 2 mm
a. gingival inflammation. b. 3 mm
b. periodontal health. c. 4 mm
c. remaining tooth structure. d. 5 mm
d. the patient’s facial anatomy.
9. Classically, clinicians have spoken of wanting
3. Prior to the era of adhesive bonding, the to maintain what crown-to-root ratio when
typical goal in describing an adequate tooth deciding to retain a tooth or to remove it?
preparation was: a. 0:1
a. 1 mm of vertical height with 2º of taper. b. 1:1
b. 2 mm of vertical height with 4º of taper. c. 1:2
c. 3 mm of vertical height with 6º of taper. d. 2:1
d. 4 mm of vertical height with 8º of taper.
10. Because 4 mm of tooth structure is needed
4. The most common failure is a loss of coronal to the bone, the tooth must be how
retention of: long to have the needed dimensions for
a. the post and the core long-term success?
b. the post and the crown a. 10 mm to 11 mm
c. the core and the crown b. 11 mm to 12 mm
d. the post, the core, and the crown c. 12 mm to 13 mm
d. 13 mm to 14 mm
5. In a maxillary anterior tooth, loading during
excursive movements creates a compressive
force on what aspect of the restoration?
a. facial margin
b. lingual surface Tufts University
c. gingival margin
d. labial surface
School of Dental Medicine
is an ADA CERP and ACDE
6. Because of the tension that occurs with the recognized provider.
occlusal forces, the more flexible the post,
the more likely which of the following is to
open up?
a. the gingival margin
b. the lingual margin Association
c. the facial margin for Continuing
d. the biologic width Dental Education

12 ADVANCED ESTHETICS & INTERDISCIPLINARY DENTISTRY MARCH 2007— VOLUME 3, NUMBER 1