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Identifying and

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149 views9 pages

Identifying and

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© © All Rights Reserved
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Identifying and Reducing Risks for Potential Fractures in

Endodontically Treated Teeth


Weirong Tang, DDS,* Younong Wu, DDS, MSc, PhD,*
,
and Roger J. Smales, BDS, MDS(Hons),
DDSc

Abstract
Introduction: Although long-term functional survival
rates can be high for initial endodontically treated
permanent teeth, they are generally more susceptible
to fracture than teeth with vital pulps. Tooth extraction
is often the consequence of an unfavorable prognosis
after coronal and root fractures, but their occurrence in
endodontically treated teeth might be reduced by iden-
tifying the risks for fracture associated with various
operative procedures. Methods: This article presents
an overview of the risk factors for potential tooth frac-
tures in endodontically treated teeth on the basis of liter-
ature retrieved from PubMed and selected journal
searches. Results: Postendodontic tooth fractures
might occur because of the loss of tooth structure and
induced stresses caused by endodontic and restorative
procedures such as access cavity preparation, instru-
mentation and irrigation of the root canal, obturation
of the instrumented root canal, post-space preparation,
post selection, and coronal restoration and from inap-
propriate selection of tooth abutments for prostheses.
Conclusions: Potential tooth fractures might be
reduced by practitioners being aware during dental
treatments of controllable and noncontrollable risks.
(J Endod 2010;36:609617)
Key Words
Endodontic treatment, risk factors, tooth fractures
A
lthough the long-term functional survival of initial endodontically treated perma-
nent teeth was reported as 97.1% after 8 years in a very large epidemiologic survey
(1), coronal and/or radicular tooth fractures continue to remain important reasons for
postendodontic tooth repairs and extractions (2, 3). A 5-year follow-up survey involving
857 randomly selected teeth with nonsurgical root canal treatment found that 18
(28.1%) of the total 64 tooth extractions performed by the dentists were attributed
to nonspecic tooth fractures (4). Relatively few large clinical studies from general
practices have examined the prevalence and incidence of complete and incomplete
coronal and/or radicular fractures in restored and nonrestored teeth with either vital
pulps or endodontically treated nonvital pulps and with either complete or incomplete
root formation. Most of the clinical reports have been of ndings from surveys and
retrospective studies, of which several were conducted in institutions.
Apart fromthose tooth fractures caused by sudden impact trauma, postendodontic
tooth fractures have generally been attributed to weakened tooth structure caused by
incomplete root formation, dental caries, tooth wear, and operative dentistry proce-
dures and from changes in tooth structure caused by aging, vital pulp tissue loss,
and endodontic therapy (5). These fatigue failures of tooth structure and restorative
materials in endodontically restored teeth might result from normal functional stresses
and from increased functional and parafunctional stresses.
Because increasing numbers of elderly persons want to retain their remaining
dentitions for as long as possible, increasing numbers of teeth now require endodontic
therapy. Many of these remaining teeth show the adverse effects of severe wear and
tear from previous dental conditions and/or restorative treatments, with an increased
risk for postendodontic tooth fractures. Although the causes are multifactorial, many
such fractures undoubtedly result from inappropriate treatment planning and
endodontic and restorative procedures undertaken by dental practitioners. Therefore,
the purpose of the present article is to identify and reduce the risks for potential tooth
fractures.
Methods
Publications in PubMed were initially searched by using the key words endodont*
AND tooth fracture OR root fracture. Further articles were gleaned from references
listed in the publications and related articles and from searching selected journals.
Results
Prevalence and Incidence of Tooth Fractures
After excluding tooth fracture caused by sudden impact trauma, the American Asso-
ciation of Endodontists has classied 5 variations of longitudinal tooth fracture: enamel
craze lines, fractured cusp, cracked tooth, split tooth, and vertical root fracture (6).
One 15-week study involving 11 dentists reported 543 tooth fractures, of which
85.6% were complete cusp fractures, 13.4% incomplete or suspected cusp fractures,
and 0.9% root fractures (7). Some 3% of the fractured teeth had not been restored
previously, and most of the 377 cusp fractures that were not associated with caries
occurred in teeth with vital pulps. This study also reported that during any given year
some 6% of adult patients with at least 1 posterior tooth at risk would experience
a complete posterior cusp fracture in the absence of caries, with an incidence rate
of 72.7 per 1000 person-years at risk. The noncarious fracture rate experience for ante-
rior teeth was far lower. In the subsequent 1- to 2-year follow-up study of 517 previously
From the *Department of Endodontics, College of Stoma-
tology, and

Dental Research Institute, College of Stomatology,
Nanjing Medical University, Nanjing, PR China; and

School of
Dentistry, Faculty of Health Sciences, University of Adelaide,
Adelaide, Australia.
Address requests for reprints to Professor Wu Younong,
Dental Research Institute, College of Stomatology, Nanjing
Medical University, 140 Han Zhong Road, Nanjing 210029,
PR China. E-mail address: [email protected].
0099-2399/$0 - see front matter
Copyright 2010 American Association of Endodontists.
doi:10.1016/j.joen.2009.12.002
Review Article
JOE Volume 36, Number 4, April 2010 Risks for Potential Fractures in Endodontically Treated Teeth 609
restored and mainly vital noncarious fractured posterior teeth, the
lingual cusps of mandibular molars, the mesiobuccal and distolingual
cusps of maxillary molars, and the buccal cusps of maxillary premolars
fractured most frequently (8). Some 25%of the fractures extended onto
root surfaces, and another 24%extended belowthe gingival margin, but
only 3% of all fractures involved exposure of the dental pulp. Another
very large 3-month study involving 28 general practitioners reported
238 instances of complete cusp fracture, with an incidence rate of
20.5 per 1000 person-years at risk and with similar tooth and cusp frac-
ture distributions to previous reports (9). Teeth restored on 3 or more
surfaces were at particular risk for fractures, and endodontically treated
teeth were associated signicantly with more frequent subgingival frac-
ture locations.
A retrospective study of 1639 endodontically treated amalgam-
restored posterior teeth without cuspal overlays found that 62%of teeth
with mesio-occlusodistal (MOD) restorations and 26% of teeth with
mesio-occlusal or disto-occlusal (MO/DO) restorations had fractured
over 20 years (2). One much smaller retrospective study reported the
survival estimates for endodontically treated premolar teeth restored
with either 181 MOD amalgam or 40 MOD self-cure resin composite
restorations placed without bonding agents after enamel etching
(10). Although during the rst 3 years there were signicantly more
cusp fractures reported with the amalgam restorations, during the
subsequent 7 years the cuspal fracture rates associated with both
restorative materials were very similar. According to the survival esti-
mates, after 10 years approximately 55% of the teeth with amalgams
and 20% of the teeth with resin composites had fractured cusps.
However, when nonendodontically treated teeth also were included
in a large institutional study, only 1.8% of 1450 Class II amalgam-
restored teeth showed cusp fractures at 10 years (11). Similarly, the
prevalence of complete cusp fractures in 1 general practice survey
also was very low at 1.9% for amalgam restorations and 2.3% for resin
composite restorations (12). The prevalence of cusp fractures in-
creased signicantly with the number of restored surfaces present and
the ages of the patients, in particular after the age of 55 years. Failure
to replace interim (temporary/provisional) restorations with more
permanent restorations after endodontic treatment resulted in very
high tooth losses of 65.5%during a mean follow-up time of 3 years (13).
Despite the many publications concerning cracked and split teeth,
there is scant information on their prevalence and incidence. A survey of
543 tooth fractures reported 13.4% as being incomplete or suspected
cusp fractures (7). From a sample of 763 teeth present in 51 new
patients during an 18-month survey in a private practice, 278
(36.4%) cracked teeth were diagnosed with the assistance of 3.25
loupes. Signicant predictors of cracks were Class I and II restorations,
excursive interferences, and parafunction (14). During a 6-year period,
examination of 8175 patients referred to a specialist endodontic prac-
tice found that the diagnosis of cracked tooth was made in 9.7% of all
teeth evaluated (15). A 15-month general practice survey of 62 cracked
teeth reported that 24% had occlusal, 37% had MO/DO, and 39% had
MOD (amalgam?) restorations (16). An early study of 102 cracked
teeth collected during a period of 10 years reported 27.5%with occusal,
33.3% with MO/DO, and 32.4% with MOD amalgam restorations (17).
By contrast with these studies, a 1-year dental hospital survey reported
that 60.4% of 154 cracked teeth were identied in nonrestored intact
posterior teeth of patients who were usually referred by general practi-
tioners and examined by endodontists (18). Most cracked teeth
involved previously restored molars in older patients (1719).
Although not mentioned in most of the above studies, similar cracked
teeth also might occur in nonvital and root-lled teeth.
A retrospective survey of 460 single-rooted and multi-rooted
endodontically restored teeth that had been functioning for at least 3
years reported that 3.7% had vertical root fractures (20). Other surveys
of vertical root fractures in endodontically restored teeth have reported
4% in MO/DO and MOD amalgam-restored teeth without cuspal over-
lays (2) and 2.7%where post cores were present in predominately ante-
rior teeth (21). However, difculties have been experienced in the
accurate clinical diagnosis of vertical root fractures. A retrospective
study involving the direct examination of 547 extracted endodontically
treated teeth found 8.8%to have vertical root fractures; these were more
frequent in mandibular than in maxillary rst molars (3). A similar
study of extracted endodontically treated teeth found that 10.9% had
vertical root fractures (22). A recent study of extracted human teeth
(40 premolars, 40 molars) showed an overall higher accuracy for
cone beam computed tomography scans (0.86) than periapical radio-
graphs (0.66) for detecting vertical root fractures, with or without root
canal llings (23). A 13-year retrospective study of 315 conrmed
vertical root fractures in 274 Chinese patients found that 60% occurred
in endodontically treated teeth, mainly in younger age groups, and 40%
occurred in nonendodontically treated teeth, mainly in men and in
older age groups. Vertical root fractures were highest in rst molars,
and most of the fractures involved the mesiobuccal roots of maxillary
molars and the mesial roots of mandibular molars (24).
In conclusion, in general practice the occurrence of tooth frac-
tures is usually low, with few vital pulp exposures, and mainly involves
older patients with complete cusp fractures in molars and maxillary
premolars. Extensive amalgam and resin composite restorations
without cuspal overlays increase the long-term risks for tooth fracture
in both vital and endodontically treated teeth. Vertical root fractures
occur mainly in endodontically treated molar teeth and are underdiag-
nosed clinically. High tooth losses occur in endodontically treated teeth
with interim rather than more permanent restorations.
Etiology of Tooth Fractures
The causes of tooth fracture have been variously ascribed to
sudden impact trauma resulting from falls, ghts, motor vehicle acci-
dents, epileptic ts, and laryngoscope misuse (25) and to fatigue failure
of tooth structure resulting from repeated stress overloading. Normal
functional stresses might result in coronal and/or radicular tooth frac-
tures in instances of reduced mechanical properties, from reduced
tooth structure caused by incomplete root formation, caries, tooth
wear, and operative dentistry procedures, and from changes in tooth
structure caused by aging, vital pulp tissue loss, and endodontic therapy
(5). Parafunctional stresses and increased functional stresses on the re-
maining teeth after posterior tooth extractions and prosthodontic treat-
ments further increase the risks of tooth fracture and might even result
in coronal and/or radicular fractures in intact vital teeth (26).
Noncontrollable Risk Factors
Although these factors are largely beyond the control of the dental
practitioner, they should be considered carefully as part of endodontic
and concomitant restorative treatment planning.
The reduced mechanical properties of tooth structure arising from
physiologic and pathologic processes and conditions have been exten-
sively reviewed (5). The modulus of elasticity and, importantly, the frac-
ture toughness of teeth might be reduced not only by incomplete root
development and losses of hard tooth substance but also by changes
in the moisture content of dentin with aging and with the loss of vital
pulp tissue. Increased amounts of physiologic and pathologic translu-
cent dentin also occur with aging, which, with the associated loss of
moisture, leads to an increased risk for brittle fracture (27). The tensile
strength of dentin is far lower than the compressive strength (28). In the
conned environment of the vital pulp and adjacent dentinal tubules,
Review Article
610 Tang et al. JOE Volume 36, Number 4, April 2010
the presence of free water results in increased dentin viscoelasticity and
also facilitates the absorption and distribution of energy before tooth
fracture occurs (5). Differing coronal and radicular tooth forms, sizes,
anatomical locations, and root numbers result in the teeth being subject
to extremely variable functional and parafunctional occlusal forces,
whose eccentric loading effects might be increased further in non-
mobile teeth with long clinical crowns and short roots.
Controllable Risk Factors
Most of the controllable risk factors mentioned in the present
article are attributed to iatrogenic risks associated with various opera-
tive procedures.
Immature Teeth with Incomplete Root Formation. Many
immature permanent teeth with incomplete root formation and
requiring endodontic treatment are severely weakened because of
wide, ared canal spaces and thin dentin walls that might lead to coronal
and/or radicular tooth fractures during normal functional stresses.
Apexication and root reinforcement might counter the reduced
mechanical properties resulting from incomplete root formation.
Apexication induces apical closure by the formation of mineral-
ized tissue. A non-setting aqueous suspension of calcium hydroxide
has been traditionally recommended for this treatment (29). However,
the calcium hydroxide paste must be changed every 36 months until
a calcic barrier can be detected (30). The time taken for apical closure
varies, ranging from 519 months (31), and requires multiple visits
during a long period. Because root canal obturation cannot be per-
formed until apical closure, the canal is susceptible to reinfection
because of its temporary seal, and the tooth is also liable to fracture
(32). By contrast, once any initial infection is treated, mineral trioxide
aggregate (MTA) is able to form an immediate apical seal rather than
having to wait months for apexication (3234). After the placement
of an MTA plug, the canal might be obturated with gutta-percha and
the access cavity restored, with the expectation of the resolution of any
periapical lesion and the continued development of the root end (35).
After apexication, the dentin walls might still be thin, but the risk
of subsequent tooth fracture might be reduced by root reinforcement;
this is essential if a post core is required. Placing a thick layer of dentin-
bonded intracanal resin composite around a ber post, or a metal post
when required, signicantly improved the fracture resistance of thin-
walled roots (3641).
Endodontic Access Cavity Preparation. An in vitro investiga-
tion found that the loss of structural tooth integrity associated with
endodontic access preparation might lead to a higher occurrence of
fractures in endodontically treated teeth (42). However, compared
with intact teeth, 3.0-mm access cavity preparations in sound extracted
maxillary central incisors resulted in minimal increased tooth deforma-
tion when using a light force. Tooth deformation increased progres-
sively after root canal preparation and obturation and in particular
after tapered and parallel post-space preparations (43). When
comparing the effect on fracture resistance of either labial or palatal
access cavity location, another in vitro study of maxillary central and
lateral incisors found no signicant difference in failure loads among
all tested groups (44). Obviously, existing large carious lesions and in-
tracoronal tooth preparations would decrease the fracture resistance of
the teeth. Care should be taken during the preparation of access cavities
through ceramic restorative materials to avoid brittle cracking.
Root Canal Preparation. Tooth type, canal wall thickness and
root canal diameter and cross-sectional shape, root canal preparation
instruments and preparation methods, and the size of the master apical
le might all be involved in the increased risk for tooth fracture during
and subsequent to endodontic therapy.
Tooth type signicantly affects the risk of tooth fracture after root
canal instrumentation. In a study of 76 extracted mandibular premolars
and canines, the force required to fracture the instrumented premolars
was 30% lower than that required to fracture their noninstrumented
counterparts, whereas the force required for the instrumented canines
was only 2% lower than for their noninstrumented counterparts (40).
The thinner the root dentin, the more likely is the tooth to fracture. On
the basis of mandibular incisors, a nite element analysis study with
mid-root regions with circular canal diameters from 0.52.0 mm
and corresponding dentin wall thicknesses from 1.00.25 mm found
that reduction in dentin wall thickness was an important factor for
increased fracture susceptibility (45). Another nite element analysis
study, also based on mandibular incisors, found that circular canals
had lower and more uniform stress distributions than oval canals in
which greater stresses were recorded at the labial and lingual canal
extensions and at the cervical and middle thirds (46).
An in vitro fracture resistance study of 39 mandibular molars
with mesiobuccal root canals prepared by using either stainless steel
hand les (K-les; Mani Inc, Nakaakutsu, Japan) or 2 nickel-titanium
rotary les (Lightspeed; Lightspeed Technology, Inc, San Antonio, TX;
and Greater Taper; Tulsa Dental Products, Tulsa, OK) found that
the greater apical enlargement achieved with Lightspeed les and
the increased canal taper achieved with Greater Taper les did not
signicantly increase root fracture susceptibility compared with
conventional step-back K-le preparations (47). However, in another
study in which canals had been enlarged with SystemGT (Dentsply-
Maillefer, Ballaigues, Switzerland) les, the roots were signicantly
weaker than those instrumented with either lower taper nickel-
titanium FlexMaster (VDW GmbH, Munich, Germany) rotary les or
hand K-les (48). A recent study of 260 mandibular premolars
compared the incidence of dentinal defects (craze lines and fractures)
after canal preparation with different nickel-titanium rotary les. No
defects were found in the unprepared root canals and those prepared
with hand K-les and S-ApeX (FKG, Dentaire, La Chaux-de-Fonds,
Switzerland) rotary les, but ProTaper (Dentsply-Maillefer), ProFile
(Dentsply-Maillefer), and SystemGT rotary le preparations resulted
in craze lines and partial cracks in 16%, 8%, and 4% of teeth, respec-
tively (49). Such defects might increase the risks for future root
fractures.
With 40 mandibular premolars with straight root canals, a recent
study examined the effect of root canal preparation methods on the
development of apical cracks. No signicant difference was found
when using stainless steel hand les with either step-back or crown-
down techniques, but apical cracks were more likely to appear when
the working length was the root canal length, rather than when it was
1.0 mm less than the root canal length (50). The recommendation
has been made that the size of the master apical le should be only
23 numbers larger than the size of the initial hand le that binds
slightly at the dentinocemental junction in mature teeth after straight-
line access (51).
In conclusion, overinstrumentation of root canals with excessive
removal of dentin and the presence of noncircular canals and thin canal
walls, particularly with certain tooth types, increase the risk for root
fracture. The effect of various nickel-titanium rotary les is somewhat
controversial, with some studies reporting an increased risk for craze
lines and dentin cracks and reduced root fracture resistance compared
with using hand les.
Root Canal Irrigation. Apart from destroying intracanal microor-
ganisms, root canal irrigants are also used to remove pulp remnants and
the smear layer formed after root canal preparation and to open the
dentinal tubules so as to clean the root canal thoroughly and obtain
a superior situation for adhesion and canal obturation.
Review Article
JOE Volume 36, Number 4, April 2010 Risks for Potential Fractures in Endodontically Treated Teeth 611
Sodium hypochlorite (NaOCl) and ethylenediaminetetraacetic
acid (EDTA) are common endodontic irrigants. However, their pro-
longed use at high concentrations has adverse effects on the physical
properties of root canal dentin, such as signicantly reduced exural
strength, elastic modulus, and microhardness (5254), which might
increase the risk for root fractures. Sequential use of 17% EDTA for
10 minutes and 5% NaOCl was associated with erosion of the root canal
dentin (55), and the mean shear strength of dentin specimens treated
with NaOCl for a prolonged period of 5 weeks was reduced by 59%
(56). Microhardness testing of root canal dentin after using EDTA, eth-
yleneglycoltetraacetic acid (EGTA), EDTA plus Cetavlon (EDTAC), and
NaOCl found that the single and combined use of EDTA decreased mi-
crohardness signicantly more than all other treatment regimens, and
that all combined treatment regimens decreased microhardness signif-
icantly compared with their single-treatment versions (57). Changes in
the physical properties of root canal dentin occurred because of the
removal of both organic and inorganic components. Other in vivo
studies have shown that the bonding of resin-based adhesives to dentin
is also adversely affected by many common irrigants, medicaments, and
gutta-percha solvents (5).
In conclusion, the prolonged use of high concentrations of EDTA
and NaOCl canal irrigants, particularly in combination, might increase
the risk for root fracture. The irrigants should be eliminated completely
from the root canals before endodontic obturation and before using
resin-based adhesives.
Root Canal Obturation. Until relatively recently, the choice of
materials for root canal sealers and root canal llings was very limited.
Ideally, the materials should be radiopaque and easily placed and
removed, have antimicrobial properties, and form a stable adhesive
seal with and reinforce the root canal dentin walls.
Gutta-percha is a long-established root canal lling material, but it
does not adhere to the root canal walls, and its elastic modulus is only
approximately 79 MPa (58), which is much lower than that of dentin at
approximately 17,400 MPa (54). Resilon (Resilon Research LLC, Mad-
ison, CT) performs in a similar way to gutta-percha with the same
handling properties and might also be heat softened or dissolved
with solvents such as chloroform for retreatment purposes (59).
Although Resilon can chemically bond to the root canal dentin walls,
the bond strength is very low at approximately 0.5 MPa (60), as is
the elastic modulus of approximately 87 MPa (58). ZnO/TPU is a poly-
urethane-based composite composed of zinc oxide (ZnO) and thermo-
plastic polyurethane (TPU). It can be bonded to the root canal walls,
and its elastic modulus is approximately 138 MPa (61). However, its
clinical application is not documented. Resin composites have a similar
elastic modulus to dentin and can be bonded to root canal dentin walls,
but the material is very difcult to remove when either endodontic
retreatment or placement of a post is required.
Many in vitro studies have examined the effect on the fracture
resistance of endodontically treated teeth of various root canal obtura-
tion materials. A study of 60 endodontically treated immature maxillary
teeth reported that no signicant differences were found among any of
the treatment groups when comparing the reinforcement and strength-
ening ability of gutta-percha, Resilon, and a self-cure owable resin
(62). Another similar study of 72 mandibular sheep incisors evaluated
the fracture resistance achieved by obturating the root canals of
simulated immature teeth with MTA and then gutta-percha, Resilon,
or self-cure owable and hybrid resin composites. The hybrid resin
composite was the only material that showed signicantly more
fracture resistance than when the canals contained only MTA plugs
(63). A further study of 67 single-rooted endodontically treated teeth
investigated gutta-percha with a ZnO sealer, GuttaFlow paste (Colte ne/
Whaledent, Altsta tten, Switzerland), Resilon with RealSeal sealer
(Pentron Clinical Technologies, Wallingford, CT), and a resin-coated
gutta-percha EndoRez with Endorez sealer (Ultradent, South Jordan,
UT). The mean forces to vertical root fracture for Resilon and EndoRez
were signicantly higher than for gutta-percha and GuttaFlow but less
than for the intact control root canals (64). However, another study of
50 endodontically treated maxillary central incisors reported no signif-
icant differences in fracture resistance among Resilon (in conjunction
with either a bonding or a nonbonding endodontic sealer), EndoRez,
and gutta-percha obturation materials (65).
In vitro studies have also examined the effect of various obturation
placement techniques on the fracture resistance of endodontically
treated teeth. In one study, much greater wedging effects occurred
during lateral condensation, warmvertical compaction, and thermome-
chanical compaction of gutta-percha, compared with the minimal effects
associated with Thermal (Dentsply-Maillefer) condensation (66).
Another study of 50 maxillary incisor teeth found that during cold lateral
compaction of gutta-percha the use initially of a nger spreader larger
than size 25 caused a signicantly decreased vertical fracture resistance
of the roots (67). Using a ne nger spreader and standard loads during
lateral compaction resulted in craze lines in all 34 maxillary incisor
tooth specimens and root fractures when the root canal diameters
were enlarged to 40%50% of the total root widths (68).
In conclusion, stable adhesion to root canal dentin walls and an
elastic modulus similar to dentin are 2 key factors for root lling mate-
rials to improve the fracture resistance of endodontically treated teeth.
Although these criteria might be partly satised by highly lled resin
composites, they are not ideal root canal obturation materials. Other
nonadhesive/weakly adhesive and/or less stiff materials fail to reinforce
signicantly the roots. Care should be observed during cold lateral
compaction of root lling materials to avoid potential fractures of
thin-walled roots.
Endodontic Access Cavity Restoration. An in vitro study of
12 extracted human maxillary premolars with large MOD and access
cavity preparations found that improved cuspal stiffness achieved by
a conventional glass ionomer cement base was very small compared
with a resin composite base. However, after placement of the nal resin
composite and ceramic restorations there was no longer a signicant
difference between teeth with different base materials (69). The original
in vitro retention values for cemented metal crowns on molars were
exceeded after the amalgam repair of endodontic access cavity prepa-
rations (70). However, intracoronal and extracoronal restorations that
have been severely weakened or extensively damaged during access
cavity preparations might require replacement rather than repair.
When coronal tooth structure loss is minimal and the marginal ridges
are intact, then restoration of the access cavity with a bonded resin
composite is all the treatment that is required.
Post Space Preparation. A post or dowel is placed in the root
canal of a structurally damaged tooth only when additional retention
is needed for a core (foundation) and coronal restoration. Placement
of posts does not usually improve the strength of the remaining tooth
structure, and in many instances, excessive post-space (post-channel)
preparations might result in reduced strengths and compromised apical
endodontic seals and the risk of root perforations in premolar and
mandibular incisor teeth in particular. In many instances posts are
not required for the retention of radicular cores in molar teeth. If
required, then a short post might be placed in the palatal canal of maxil-
lary molars and in the distal canal of mandibular molars.
Maintenance of the obturation seal is critical to resist bacterial mi-
croleakage in endodontically treated teeth. To avoid violation of the
apical seal, at least 45 mm of apical gutta-percha should be retained
(71, 72). A recent study of 126 extracted single-rooted maxillary ante-
rior teeth with intact apices reported that the optimum apical seal after
Review Article
612 Tang et al. JOE Volume 36, Number 4, April 2010
post-space preparation was associated with 6 mm of remaining gutta-
percha (73). Ideally, the post core should be placed immediately after
obturation to reduce the effects of canal contamination resulting from
a leaking interim post and articial crown.
There are numerous types of post materials available. Metal alloy
posts include custom-fabricated cast post cores and prefabricated
wrought posts. Non-alloy posts include custom-fabricated resin
composite and ceramic post cores and prefabricated ceramic and
ber-reinforced polymer posts. The latter are being used increasingly
as light-transmitting glass and quartz ber-reinforced posts for use
with dual-cure resin-based luting cements. Included in the many advan-
tages of ber-reinforced posts when compared with metal alloy posts is
that the former more closely match the modulus of elasticity of dentin,
allowing more even distribution of occlusal stresses in the root dentin
(74), which usually leads to fewer and less severe in vitro root fracture
failures that might be reparable (7578). The fracture resistance of
resin composite restored mandibular molars, with or without ber-re-
inforced posts, was directly related to the number of residual cavity
walls remaining (76). Another in vitro study of endodontically treated
and resin composite restored mandibular premolars found that
although a glass ber-reinforced post did not improve fracture resis-
tance, it reduced the incidence of catastrophic fracture types when there
was a large loss of tooth structure such as in a MOD cavity preparation
with two-thirds occlusal-cervical cusp loss (79). Two other in vitro
studies showed that ber-reinforced posts could contribute signicantly
to the strengthening of crowned endodontically treated maxillary
incisor and premolar teeth (77, 78).
Fiber-reinforced post failures usually occur from exure, with de-
bonding at lower forces than stiffer metal alloy posts that tend to with-
stand higher loads before bending to result in more instances of
catastrophic root fractures (80). However, the inclusion of ferrules
in articial complete crowns largely negated any in vitro root fracture
resistance differences between these 2 post materials (81) and between
different post designs. The optimumpost to root diameter ratios needed
to minimize the occurrence of both post and root failures for different
post materials requires further investigation (82).
There are also numerous designs of posts available, variously clas-
sied as morphologic or nonmorphologic, tapered or parallel-sided
(including double-stepped post diameters), active or passive, and
smooth or roughened/serrated. Morphologic, tapered, and double-
stepped posts preserve dentin in the apical region of the post-space
preparation, reducing the risks for root perforation (83). This is impor-
tant for teeth with small tapered roots, such as maxillary lateral incisors
and mandibular incisors (84). Teeth with short roots, large funnel-
shaped root canal orices, and thin dentin walls present problems
for post retention and the avoidance of root fractures, which morpho-
logic cast posts cannot solve satisfactorily. A thick articial dentin sand-
wich of resin composite encircling a narrow ber-reinforced or metal
alloy post might be provided to increase the fracture resistance of the
root and to improve the retention of the post.
Posts are retained in the prepared post spaces with dental luting
cements. The earlier more soluble, low-strength zinc phosphate, poly-
carboxylate, and conventional glass ionomer luting cements were
originally marketed for use with rigid metal alloy posts. Newer resin-
modied glass ionomer and resin-based luting cements used with
dentin bonding agents are more appropriate for the less rigid ber-
reinforced posts (85). Problems regarding the potential for fracture
of low-strength all-ceramic crowns and thin roots with posts, cemented
by using earlier resin-modied glass ionomer cements, have been
resolved (86). Care should be taken to remove all traces of eugenol-
containing endodontic sealers during post-space preparations because
eugenol inhibits the cure of resin-containing luting cements (87).
However, as discussed at length elsewhere (88), because of the many
less than optimal factors present during post-core placement, the reten-
tion of cemented ber-reinforced posts might depend largely on fric-
tional sliding resistance to dislodgement rather than to the relatively
low micromechanical and chemical adhesion achieved by currently
popular simplied resin-based dentin bonding agents. A recent nite
element study of maxillary second premolar models conrmed that
the lack of an effective adhesive bond between root dentin and post
also increased the risk for vertical root fracture. (89). Many of the
factors concerning post materials, designs, and luting cements have
been described in a recent publication (90).
In conclusion, posts do not usually strengthen roots, and the post-
space preparations for their placement might actually weaken further
the remaining tooth structure and also lead to apical microleakage
when insufcient root canal obturation seal remains. The use of
ber-reinforced posts and resin-based luting cements has resulted clin-
ically in fewer severe root fracture failures than occurred previously
with rigid metal alloy posts.
Coronal Restoration. Subsequent coronal restoration of the tooth
must be considered carefully even before endodontic therapy begins. All
too often after successful endodontic treatments, teeth have to be ex-
tracted because of preexisting unsatisfactory periodontal and restor-
ability situations. All caries and existing dubious restorations must be
removed before endodontic treatment to allow inspection for tooth
cracks and the location of sound cavity margins. Restorative materials,
cusp coverage, and articial crowns with ferrules are factors that might
inuence signicantly the subsequent fracture resistance of endodonti-
cally treated teeth. Many details relevant to the restoration of endodon-
tically treated teeth have been discussed elsewhere (91, 92).
Failure to replace interim restorations with more permanent
restorations after endodontic treatment resulted in very high tooth los-
ses of 65.5% during a mean follow-up time of 3 years (13). In 2 long-
term retrospective studies the cusps of endodontically treated poste-
rior teeth with MOD amalgam restorations fractured far more
frequently than teeth with MO/DO amalgam restorations (2), and there
were fewer short-term cuspal fractures in endodontically treated
premolar teeth with MOD resin composite restorations than with
MOD amalgam restorations (10). An in vitro study of 50 maxillary
premolars found that the short-term fracture resistance of the teeth
was completely regained when MOD preparations were restored
with resin composite and partially regained when MOD preparations
associated with endodontic treatment were restored in the same way
(93). In a 5-year clinical study of endodontically treated premolars,
110 Class II preparations restored by using ber-reinforced posts
and resin composite showed fewer root fractures but more caries
than 109 similar preparations restored with amalgam (94).
The importance of cusp coverage in weakened non-endodonti-
cally treated posterior teeth has been stressed in many publications
(9597). A recent in vitro study of maxillary premolars with wide
MOD cavity preparations also conrmed the importance of cusp
coverage, even when using bonded resin composite restorations
extended into the pulp chambers, for signicantly increasing the frac-
ture resistance of weakened endodontically treated posterior teeth
(98). In contrast, another study of endodontically treated extracted
maxillary premolars restored with MOD bonded resin composites re-
ported no signicant differences in fracture resistance for teeth treated
with/without ber posts/cusp coverage combinations (99). A retro-
spective cohort study of 220 endodontically treated molars without
crowns and restored in 89% of instances with resin composites found
that 101 teeth with identied failures had overall survival estimates at 1,
2, and 5 years of 96%, 88%, and 36%, respectively. Survivals were 78%
at 5 years where minimal tooth structure had been lost (100).
Review Article
JOE Volume 36, Number 4, April 2010 Risks for Potential Fractures in Endodontically Treated Teeth 613
A large retrospective study for up to 25 years found that the success
rate for endodontically treated single teeth with articial crowns was
94.8% and without articial crowns was signicantly lower at 75.8%
(101). Another retrospective cohort study of 203 endodontically
treated teeth reported that after 10 years, teeth without articial
complete crowns were lost at 6.0 times the rate of teeth with such
crowns (which all survived), when tooth type and the presence of caries
were controlled (102). However, for premolar teeth with Class II
carious lesions and in which ber-reinforced posts had been placed,
there was no signicant difference between intracoronal resin
composite restorations and the additional placement of metal-ceramic
crowns in the low 3-year failure rates (103). Irrespective of using
a metal post or not, very low 5-year failure rates also were reported
for metal-ceramic crowns placed over both cast post cores and direct
resin composite cores (104). A recent systematic review of single resto-
rations in endodontically treated teeth reported that the estimated
survivals were 81% for crowned teeth and 63% for direct restorations
(resin composites, amalgams, cements) at 10 years (105). An up to 17-
year controlled clinical trial of 98 endodontically treated teeth restored
by using direct resin composite core-crowns found no signicant
survival differences between teeth with and without prefabricated metal
posts for either the restorations or the teeth. Overall survival estimates at
17 years were 53% for the restorations and 79% for the teeth (106).
Although not mentioned in most studies, the occlusion should be care-
fully evaluated and occlusal adjustments made to prevent high stresses
occurring in the restored teeth. The presence of parafunctional habits
also should be assessed.
A signicant feature to reduce catastrophic root fractures with
cast post cores in particular is the inclusion in an articial crown
of a ferrule or metal/ceramic collar encircling minimally tapered walls
of dentin that extend approximately 1.52.0 mm coronal to the
shoulder of the crown preparation at the cementoenamel junction
(CEJ) (107). The height of the ferrule appears to be less signicant
in endodontically treated teeth restored with ber-reinforced posts
and resin composite cores because these materials have a similar
elastic modulus to dentin (108). However, clinical crown lengthening
with apical extension of the shoulders 2.0 mm below the CEJ for
ferrule placement in anterior teeth with either cast metal alloy or
ber-reinforced posts might actually lead to a decreased in vitro frac-
ture resistance of the roots because of the increased clinical crown to
root ratios and the reduced dentin volume of the tapered roots (109).
This adverse situation might be avoided by forced anterior tooth erup-
tion before the placement of either 1.0 mm or 2.0 mm high ferrules
(110). The in vitro root fracture resistance of 50 endodontically
treated maxillary anterior teeth restored with ber-reinforced posts
and metal crowns and subjected to palatal loading was directly related
to the circumferential extent and the sites of the 2.0 mm high ferrule
preparations in coronal dentin. The highest fracture resistance load-
ings were found for complete circumferential and palatal sited ferrule
preparations and the lowest for no preparations (111). A nite
element analysis study suggested that a ferrule increases the mechan-
ical resistance of a post/core/crown restoration in maxillary incisors
by reducing the potential for labial displacement and compressive
stresses within the labial dentin and root canal wall. However, the
ferrule also creates a larger area of palatal dentin under tensile stress,
which might favor crack development on the palatal aspect of the
root (112). Earlier literature on the ferrule effect is reviewed
elsewhere (113).
In conclusion, after endodontic treatment, permanent coronal
restorations should replace interim restorations as soon as possible
to prevent subsequent tooth fractures. When adequate sound dentin-
supported enamel is present, then intracoronal bonded resin
composite restorations might demonstrate a better clinical perfor-
mance in preventing tooth fractures in endodontically treated teeth
than similar amalgam restorations. When posterior tooth cusps have
been weakened, then cuspal coverage with bonded resin composite,
amalgam, cast metal alloy, or high-strength ceramic materials is essen-
tial to prevent tooth fractures. Extensive coronal tooth structure loss
requires the placement of either directly fabricated core crowns or
indirectly fabricated complete crowns that are usually retained with
post cores or radicular cores in molars. When articial complete
crowns are required, then the incorporation of 1.52.0 mm high
circumferential coronal ferrules might reduce substantially the occur-
rence of subsequent root fractures. As has been stated, The placement
of a well-constructed coronal restoration has a greater effect on
endodontic success than the quality of the endodontic obturation,
and also appears more important than the type of core/foundation
or post employed (102).
Endodontically Treated Teeth as Abutments. Some
endodontically treated teeth will be used as abutments for xed and
removable prostheses that are subject to large horizontal and torquing
forces during function, such as long-span and distal-cantilevered xed
partial dentures (FPDs) and distal-extension base removable partial
dentures (RPDs), which place the teeth at higher risk for fracture.
The suitability of endodontically treated teeth as abutments for FPDs
and RPDs has been reviewed recently (114).
Fractures were reported more frequently in endodontically treated
than in vital FPD abutment teeth and primarily in those teeth with posts
that were terminal abutments (115). A large retrospective study for up
to 25 years found that the failures for endodontically treated tooth abut-
ments were 10.8% for FPDs and 22.6% for RPDs in both tooth-borne
and distal-extension designs (116). One other prospective 3-year study
reported that the failures for endodontically treated teeth used as abut-
ments for FPDs and RPDs were 16.4% and 9.1%, respectively,
compared with 5.5% for similar teeth not used as abutments (117).
A longitudinal study for up to 15 years of 515 metal-ceramic FPDs found
that endodontically treated abutment teeth had failure rates of 8% after
510 years and 21% after 1015 years compared with 2% and 5%,
respectively, for vital abutment teeth. This study also found that the
most common reason for FPD retreatment was tooth fracture (38%),
followed by periodontal breakdown (27%), and caries (11%) (118,
119). A recent retrospective study for up to 20 years of 236 short-
span FPDs placed at a dental school reported signicantly different
survival estimates of 82.4% for vital and 60.4% for endodontically
treated abutment teeth (120). By contrast, a longitudinal study for up
to 25 years at another dental school of single or FPD abutment teeth
found similar survival rates for both crowned vital and crowned high-
quality endodontically treated teeth with cast post cores (121).
A short-term retrospective clinical study of endodontically treated
teeth reported that post-core restored teeth also had a high risk for
failure when used as abutments for conical double-crown retained
RPDs (122). A large retrospective study of 2 post designs 45 years after
placement showed that FPD abutments demonstrated a signicantly
lower failure rate than single crowns and RPDabutments, and that distal
abutment teethwith cantilevered extensions demonstrated a signicantly
higher failure rate than other FPD abutments (21). During a period of
18 years, signicantly more failures of cantilevered FPDs also occurred
with endodontically treated compared with vital tooth abutments (123).
In conclusion, the use of endodontically treated teeth can be con-
dently advocated for single crowns, and with slightly less condence,
endodontically treated teeth can be recommended as abutments for
FPDs. However, the use of endodontically treated teeth to support
a precision attachment RPD, a distal-extension base RPD, or a posterior
cantilevered FPD cannot be considered to be highly predictable (114).
Review Article
614 Tang et al. JOE Volume 36, Number 4, April 2010
Conclusions
Although much of the literature available is from in vitro studies,
this review of identifying and reducing the risks for potential tooth frac-
tures in endodontically treated teeth supports the following conclusions:
(1) Immature teeth with incomplete root formation require apexica-
tion before root canal obturation. After the initial control of any
infection by using calciumhydroxide, MTA is the material of choice
to promote apical closure. After apical canal obturation, a light-
conducting ber-reinforced post encircled by a thick layer of
dentin bonded resin composite might be placed for reinforcement
of the root canal walls to enhance their fracture resistance.
(2) Mature teeth with complete root formation require minimal
removal of remaining sound tooth structure during access cavity
preparation, instrumentation of the root canal, post-space prepa-
ration, and coronal restoration. Prolonged use of high concentra-
tions of several commonly used root canal irrigants signicantly
compromise the mechanical integrity of the root canal dentin,
and high obturation compaction forces might fracture thin-walled
weakened tooth roots.
(3) Posts should be placed only when they are essential for the reten-
tion of cores and permanent restorations. Care must be taken to
avoid root perforations and destroying the apical canal seal. The
consequences of root fracture are less severe with ber-reinforced
posts than with metal alloy posts. The incorporation of a 1.52.0
mm high coronal ferrule in articial complete crowns enhances
the fracture resistance of endodontically restored teeth. However,
extending ferrule preparations apically onto narrower roots might
decrease their fracture resistance because of the reduced dentin
volume and the increased clinical crown to root length ratio.
(4) It is essential to seal all endodontic access cavities and to cover
weakened cusps with permanent bonded restorative materials as
soon as possible after endodontic treatment, both to prevent micro-
bial contamination of the root canal and to prevent tooth fractures.
Endodontically treated teeth have a signicantly higher risk for frac-
ture than vital teeth when used as abutments for precision attach-
ment and distal-extension base RPDs, and posterior cantilevered
FPDs in particular. Occlusal loads and parafunctional habits are
important factors to consider in restorative treatment planning.
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