In restorative dentistry, the non-vital tooth and its restoration have been extensively studied from both its structural and esthetic aspects. The restoration of endodontically treated teeth has much in common with modern implantology: both must include multifaceted biological, biomechanical and esthetic considerations with a profound understanding of materials and techniques; both are technique sensitive and both require a multidisciplinary approach. And for both, two fundamental principles from team sports apply well: firstly, the weakest link determines the limits, and secondly, it is a very long way to the top, but a very short way to failure. Nevertheless, there is one major difference: if the tooth fails, there is the option of the implant, but if the implant fails, there is only another implant or nothing. The aim of this essay is to try to answer some clinically relevant conceptual questions and to give some clinical guidelines regarding the reconstructive aspects, based on scientific evidence and clinical expertise.

The clinical concepts regarding the restoration of root canal treated teeth are not clear today and often based on conjecture due to a lack of sound empirical data. The diversity of published opinions is confusing and may lead to less-than-optimal treatment selections. There is also emerging debate whether or not a post is necessary. The purpose of the present article is to organize this topic in evidence-based principles and provide dental practitioners with clear guidelines about restorative therapy for premolar and molar teeth. Two clinical reports are presented, to exemplify the different clinical situations. The first case highlights a conservative restoration of an endodontically treated molar, maintaining an adequate quantity of healthy residual tissue and only covering the cusp with restoration material, which was not sustained by healthy dentin. In the second case, the fact that the premolar was so badly damaged by carious pathology meant that it was necessary to use a pin to anchor the composite material, and the cusp was covered completely. Based on the two presented clinical reports and a literature review, the concept of fiber post application is explained. Searches by hand and MEDLINE were employed to identify peer-reviewed articles on reconstruction of endodontically treated posterior teeth. A total of 70 articles published between 1967 and 2008 were reviewed.

A review of the literature was done to determine when posts are required for restoring endodontically treated teeth and to give guidance on preparation of post space, design of posts, and use of luting agents. Posts were deemed to be unnecessary when adequate coronal tooth structure was present to retain a core. It was found that tooth structure should not be removed to construct a stronger post. The thinnest post with adequate strength was recommended. For best retention, it was found that post surfaces should not be smooth. When resin reinforced glass ionomer cements were used, they were found to be potentially harmful to restored teeth. Remaining coronal tooth structure was found to have the highest correlation in regard to success of the final restoration of endodontically treated teeth.

In post and core research, little attention has been given to the tooth with minimal bulk and mesialdistal width. The purpose of this in vitro study was to investigate retention and fracture characteristics of lower incisors restored with variable dowel designs. Fifty freshly extracted mandibular incisors were endodontically treated. Four groups of 10 teeth, decoronalized and dowel- and core-restored, were tested for retention characteristics and fracture resistance. One group of 10 teeth restored with composite resin in intact natural crown acted as controls. Dowel variables included a prefabricated round cross-sectional design and a morphologic dowel that reproduced the canal space. A universal testing machine created tensile and transverse loads, and failure was measured and recorded. Results showed no difference in resistance to transverse loading between morphological and standardized dowels (p > 0.05). However, when analyzing modes of failure, ferruled morphological post and core design was less likely to result in a catastrophic root or post fracture. In addition, morphological dowels were significantly more retentive than standardized round dowels in teeth with narrow cross-sections (p = 0.007). This study also reaffirmed the findings of previous investigations, that the intact natural crown of an endodontically treated tooth provides maximum resistance to root fracture.

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Much confusion exists in the dental community regarding the restoration of endodontically treated teeth; few review articles present succinct guidelines for the restoration of these teeth. This article reviews the literature and presents guidelines for restoration of endodontically treated teeth.