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Clinical Evaluation of Cast and Prefabricated Metal Post

Permanent Link: http://ufdc.ufl.edu/UFE0024434/00001

Material Information

Title: Clinical Evaluation of Cast and Prefabricated Metal Post a 5-Year Retrospective Study
Physical Description: 1 online resource (61 p.)
Language: english
Creator: Mousawi, Hassan
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2009

Subjects

Subjects / Keywords: cast, endodontically, metal, posts, prefabricated, tooth
Dentistry -- Dissertations, Academic -- UF
Genre: Dental Sciences thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: While an abundance of in vitro studies on different aspects of custom cast and prefabricated posts has been reported and discussed in the literature, few studies compared the success of clinically meaningful restorative approaches, and the materials used. It is therefore still difficult to justify a preference for cast or prefabricated post and core restorations based on in vitro studies alone. Very little clinical data are available on post and core treatment that are performed on a daily basis. The objective of this study was to evaluate the clinical survival rate of custom-fabricated cast post and cores, and prefabricated post and cores used in dental practices, and to see if there is any significant difference in their performance and longevity as influenced by the age and gender of the population, type of post material used, length of the post, amount of alveolar bone tissue supporting the roots, location of the tooth in the dental arch, the type of cement used, the effect of opposing occlusion, and the type of final prosthetic treatment received. This retrospective analysis will aim to prove that one of the methods for fabrication of post and cores is more predictable with a higher survival rate based on a large patient group over a five-year period. The study population for this study was patients who had been treated at the Undergraduate Student Clinic for Fixed and Removable Prosthodontics at the University of Florida with custom fabricated cast posts or prefabricated posts, from 2003 till 2007, and whom have been treated by third or fourth year dental student, were analyzed. And information were gathered manually and recorded for statistical analysis. Out of all the variables evaluated in this study, and their correlations to the survival of custom-fabricated cast posts and prefabricated metal posts, age of patients, post length, amount of alveolar bone supporting the root(s), and the type of final prosthetic treatment endodontically treated teeth have received, were found to be significant. Both treatment modalities can be recommended if they are applied within indications and with the necessary caution. Metallic posts continue to be the standard for most situations because they have stood the test of time.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Hassan Mousawi.
Thesis: Thesis (M.S.)--University of Florida, 2009.
Local: Adviser: Esquivel, Josephine F.
Local: Co-adviser: Clark, Arthur E.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2010-05-31

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2009
System ID: UFE0024434:00001

Permanent Link: http://ufdc.ufl.edu/UFE0024434/00001

Material Information

Title: Clinical Evaluation of Cast and Prefabricated Metal Post a 5-Year Retrospective Study
Physical Description: 1 online resource (61 p.)
Language: english
Creator: Mousawi, Hassan
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2009

Subjects

Subjects / Keywords: cast, endodontically, metal, posts, prefabricated, tooth
Dentistry -- Dissertations, Academic -- UF
Genre: Dental Sciences thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: While an abundance of in vitro studies on different aspects of custom cast and prefabricated posts has been reported and discussed in the literature, few studies compared the success of clinically meaningful restorative approaches, and the materials used. It is therefore still difficult to justify a preference for cast or prefabricated post and core restorations based on in vitro studies alone. Very little clinical data are available on post and core treatment that are performed on a daily basis. The objective of this study was to evaluate the clinical survival rate of custom-fabricated cast post and cores, and prefabricated post and cores used in dental practices, and to see if there is any significant difference in their performance and longevity as influenced by the age and gender of the population, type of post material used, length of the post, amount of alveolar bone tissue supporting the roots, location of the tooth in the dental arch, the type of cement used, the effect of opposing occlusion, and the type of final prosthetic treatment received. This retrospective analysis will aim to prove that one of the methods for fabrication of post and cores is more predictable with a higher survival rate based on a large patient group over a five-year period. The study population for this study was patients who had been treated at the Undergraduate Student Clinic for Fixed and Removable Prosthodontics at the University of Florida with custom fabricated cast posts or prefabricated posts, from 2003 till 2007, and whom have been treated by third or fourth year dental student, were analyzed. And information were gathered manually and recorded for statistical analysis. Out of all the variables evaluated in this study, and their correlations to the survival of custom-fabricated cast posts and prefabricated metal posts, age of patients, post length, amount of alveolar bone supporting the root(s), and the type of final prosthetic treatment endodontically treated teeth have received, were found to be significant. Both treatment modalities can be recommended if they are applied within indications and with the necessary caution. Metallic posts continue to be the standard for most situations because they have stood the test of time.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Hassan Mousawi.
Thesis: Thesis (M.S.)--University of Florida, 2009.
Local: Adviser: Esquivel, Josephine F.
Local: Co-adviser: Clark, Arthur E.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2010-05-31

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2009
System ID: UFE0024434:00001


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1 CLINICAL EVALUATION OF CAST AND PREFABRICATED METAL POST: A 5 YEAR RETROSPECTIVE STUDY By HASSAN MOUSAWI A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS F OR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2009

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2 2009 Hassan Mousawi

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3 To my mother; the pillar of my strength

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4 ACKNOWLEDGMENTS I would like to express my appreciation to Dr. Josephine Esquivel, my supervisory committee cha ir, for all of her support and guidance. I would also like to thank Dr. Buddy Clark, my supervisory committee cochair, for his time and effort. Special thanks go to Dr. Edgar ONeill and Dr. Lucius Battle for their insight, support, and inspiration. Tha nks also go t o Dr. Olin Tyle r II for his help with reviewing the dental charts used in this study. To my precious mother, I express much gratitude and appreciation for all the support and love she has provided to me.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS .................................................................................................................... 4 LIST OF TABLES ................................................................................................................................ 6 LIST OF FIGURES .............................................................................................................................. 7 ABSTRACT .......................................................................................................................................... 8 CHAPTER 1 INTRODUCTION AND LITERATURE REVIEW ................................................................. 10 Historical Overview of Dental Posts and Cores ........................................................................ 10 Treatment Planning ..................................................................................................................... 13 Considerations and Restorations ................................................................................................ 14 Anterior Teeth ............................................................................................................................. 15 Posterior Teeth ............................................................................................................................ 16 Best Time for Restoration ........................................................................................................... 17 Custom Casts vs. Prefabricated Posts ........................................................................................ 18 Post Space Preparation ................................................................................................................ 20 Post Cementation ......................................................................................................................... 22 Objective of Study....................................................................................................................... 25 2 MATERIALS AND METHODS ............................................................................................... 27 Study Population ......................................................................................................................... 27 Grading Codes ............................................................................................................................. 28 Statistical Approach .................................................................................................................... 28 3 RESULTS AND DISCUSSION ................................................................................................ 30 Results .......................................................................................................................................... 30 Discussion .................................................................................................................................... 34 4 SUMMARY AND CONCLUSION ........................................................................................... 54 LIST OF REFERENCES ................................................................................................................... 55 BIOGRAPHICAL SKETCH ............................................................................................................. 61

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6 LIST OF TABLES Table page 3 1 One -way ANOVA for failure by age. ................................................................................... 41 3 2 Means of age for failure ......................................................................................................... 41 3 3 Failure by gender .................................................................................................................... 42 3 4 Failure by post type. ............................................................................................................... 43 3 5 Failure by post length. ............................................................................................................ 44 3 6 Failure by percentage of root in bone. .................................................................................. 45 3 7 Failure by type of restorations material. .............................................................................. 46 3 8 Failure by cement. .................................................................................................................. 47 3 9 Failure by tooth position. ....................................................................................................... 48 3 10 Failure by type of prosthetic treatment. ................................................................................ 49 3 11 Failure by type opposing occlusion. ..................................................................................... 50 3 12 Type III tests of the significant variables. ............................................................................ 52 3 13 Post length least square means. ............................................................................................. 52 3 14 Percentage of root in bone least square means. .................................................................... 53 3 15 Type of final prosthetic treatment least square means. ........................................................ 53

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7 LIST OF FIGURES Figure page 3 1 Percentage of failure by gender. ............................................................................................ 42 3 2 Percentage of failure by post type. ........................................................................................ 43 3 3 Percentage of failure by post length. ..................................................................................... 44 3 4 Percentage of failure by % of root in bone. .......................................................................... 45 3 5 Percentage of post failure by type of restorations material. ............................................... 46 3 6 Percentage of failure by cement. ........................................................................................... 47 3 7 Percentage of failure by tooth position. ................................................................................ 48 3 8 Percentage of failure by type of tooth treatment. ................................................................. 49 3 9 Perc entage of failure by type of opposing dentition. ........................................................... 50 3 10 Percentage of total failure of all post types. ......................................................................... 51

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8 Abstract of Thesis Presented to the Graduate Schoo l of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science CLINICAL EVALUATION OF CAST AND PREFABRICATED METAL POST: A 5 YEAR RETROSPECTIVE STUDY By Hassan Mousawi May 2009 Chair: Josephi ne Esquivel Cochair: Buddy Clark Major: Dental Sciences While an abundance of in vitro studies on different aspects of custom cast and prefabricated posts has been reported and discussed in the literature, few studies compared the success of clinicall y meaningful restorative approaches, and the materials used. It is therefore still difficult to justify a preference for cast or prefabricated post and core restorations based on in vitro studies alone. Very little clinical data are available on post and core treatment that are performed on a daily basis. The objective of this study was to evaluate the clinical survival rate of custom fabricated cast post and cores, and prefabricated post and cores used in dental practices, and to see if there is any si gnificant difference in their performance and longevity as influenced by the age and gender of the population, type of post material used, length of the post, amount of alveolar bone tissue supporting the roots, location of the tooth in the dental arch, the type of cement used, the effect of opposing occlusion, and the type of final prosthetic treatment received. This retrospective analysis will aim to prove that one of the methods for fabrication of post and cores is more predictable with a higher survi val rate based on a large patient group over a five -year period.

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9 The study population for this study was patients who had been treated at the Undergraduate Student Clinic for Fixed and Removable Prosthodontics at the University of Florida with custom f abricated cast posts or prefabricated posts, from 2003 till 2007, and whom have been treated by third or fourth year dental student, were analyzed. And information were gathered manually and recorded for statistical analysis. Out of all the variables ev aluated in this study, and their correlations to the survival of custom -fabricated cast posts and prefabricated metal posts, age of patients, post length, amount of alveolar bone supporting the root(s), and the type of final prosthetic treatment endodontic ally treated teeth have received, were found to be significant. Both treatment modalities can be recommended if they are applied within indications and with the necessary caution. Metallic posts continue to be the standard for most situations because the y have stood the test of time.

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10 CHAPTER 1 INTRODUCTION AND LIT ERATURE REVIEW Historical Overview of Dental Posts and Cores The restoration of endodontically treated teeth is an important aspect of dental practice that involves a range of treatment options of varying complexity. An endodontically treated tooth should have a good prognosis. It can resume full function and serve satisfactorily as an abutment for a fixed dental prosthesis or a removable partial dental prosthesis. However, special techn iques are needed to restore such a tooth. Usually a considerable amount of tooth structure has been lost because of caries, trauma, endodontic treatment, and the placement of previous restorations. The loss of tooth structure makes retention of subsequent restorations more problematic and increases the likelihood of fracture during function. The challenge may be complicated by substantial loss of coronal tooth structure and the ability to predict restorative success. Cast posts and cores are often used t o provide retention and stability for final restorations of endodontically treated teeth (Robbins 1990). The use of posts in the root canal space to retain an overlaying restoration has a history of at least 300 years (Ring 1985). In the 1700s Fauchard inserted wooden dowels in canals of teeth to aid in crown retention (Fauchard 1746). Over time the wood would expand in the moist environment to enhance retention of the dowel unit, unfortunately, the root would often fracture vertically (Shillingburg 1997). In 1871 Harris Chapin recommended a post or a pivot to retain an artificial crown in a root with an extirpated pulp (Harris C 1871). Additional efforts to develop crowns retained with posts or dowels in the 1800s were limited by the failure of the endodontic therapy of that era. Several of the 19th century versions of dowels also used wooden pivots, but some dentists reported the use of metal posts favored by Black (Black 1869) in which a porcelain -faced crown was secured by a screw passing into gold -lined root canal.

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11 The Richmond crown was introduced in 1878 and incorporated a threaded tube in the canal with a screw -retained crown (Richmond 1878). The glossary of prosthodontic terms 8th edition defined the Richmond crown as an artificial crow n consisting of a metal base that fits the prepared abutment of the natural tooth and carries a post or pivot for insertion into the endodonticaly treated root canal: a porcelain facing reinforces the metal backing (Glossary of Prosthodontics 2005). The Richmond crown was later modified to eliminate the threaded tube and was redesigned as a 1 -piece dowel and crown (Hampson 1958, Demas 1957). In 1911 the Davis crown was introduced; a dental restoration supported by a dowel in root canal over which was cem ented a porcelain tube tooth in direct contact with the root face of the tooth (Davis 1916). A later modification of the Davis crown involved a gold casting that improved the fit between the root and artificial tooth (Davis 1916). One -piece dowel and crown became unpopular because they were not practical. This was evident when divergent paths of insertion of the post -space and remaining tooth structure existed, especially for abutments to fixed dental prosthesis. One -piece dowel restorations also present ed problems when the crown or fixed partial denture required removal and replacement. These difficulties led to the development of a post and -core restoration as a separate entity with an artificial crown cemented over core and remaining tooth structure ( Morgano 1999). With the major advances in endodontic therapy that occurred in this century, the challenges increased for restorative dentistry. Teeth that were commonly extracted without hesitation were successfully treated with predictable endodontic th erapy, and a satisfactory restorative solution was necessary, especially for teeth with severe damage. Cast post and cores became routine methods for restoration of endodontically treated teeth (Morgano 1999).

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12 The development of cast dowel cores was a logical evolution from the Richmond and Davis crowns. An alternative method using prefabricated metal posts and composite resin or amalgam as a core material was introduced around the 1970s and has been used ever since on a large scale (Baraban 1972, Spal ten 1971). Individually cast posts and cores are normally cast from metal alloy (gold alloy type III, type IV). As for prefabricated posts, these are either metallic posts such as stainless steel, titanium alloy, and non -metallic posts such as posts of z irconia and carbon fiber or glass fiber reinforced resin composite. Traditional thought has gone from one extreme to another and back again. While Fauchard in late 1700s, used wooden posts to retain crowns (Fauchard 1746). Radke and Eismann suggested i n 1991 that one function of the post is to provide reinforcement of the tooth (Cohen 1991). A cast restoration that extended at least 2 mm apical to the junction of the core and the remaining tooth structure was recommended. It was suggested that encirclem ent of the root with this ferrule effect would protect the pulpless tooth against fracture by counteracting spreading forces generated by the post. The most current literature, however, seems to dispute the reinforcement potential of posts. Trope et a l. evaluated fracture resistance of restored endodontically treated teeth; they found that preparation of post space significantly weakened endodontically treated teeth and that a post did not significantly strengthened treated teeth (Trope 1985). Posts h ave one purpose, or one main indication and that is to retain the core material that can be used to support the final restoration. The decision regarding post placement should be made based on the amount of coronal remaining tooth structure. Thus, if adequ ate retention for the core can be derived from the use of natural undercuts in the pulp chamber and canal

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13 entrances, a post is not indicated. Cast post and core can help to change axial inclination of crowns to improve alignment. Post placement requires th e removal of additional tooth structure, and this will likely weaken the tooth further and create an area of stress concentration at the terminus of the post channel (Whitwortth 2002). There is compelling evidence that they do not strengthen teeth (Trope 1 985, Sorensen 1984, Guzy 1979, Assif 1993) and a post is not necessary when substantial tooth structure is present after a tooth has been prepared. In actuality, placing a post can predispose a tooth to fracture. The use of certain post designs can predispose them to catastrophic failure, as shown by Sorensen and Engelman (Sorensen 1984). In response to the discovery that posts do not strengthen teeth; they only serve to retain the core, research into design, shape, diameter, and length of posts now focuse s on issues of retention. Treatment Planning When a decision is made to treat the tooth endodontically, consideration must have been given to its subsequent restoration. Before being restored, teeth that have been endodontically treated must be carefully evaluated for the following: good apical seal, no sensitivity to pressure, no exudates, no fistula, no apical sensitivity, and no active inflammation (Rosenstiel 2001). Using a post system to retain a core, over which a crown can be placed, is often neces sary when inadequate coronal tooth structure remains. A unique balance exists between maximizing retention of the post and maintaining resistance to root fracture. Resistance to root fracture is directly related to he thickness of remaining dentin walls (Stockton 1999). The amount of alteration, the location of the tooth in the dental arch, its current morphology, the opposing

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14 contacts, and the manner in which it is restored, all will affect the degree to which dentin is susceptible to fracture (Hunter 1 989). Considerations a nd Restorations Multiple factors must be considered in choosing a final restoration. E ssential considerations include the amount of remaining sound tooth structure, occlusal function, opposing dentition, and position of the tooth in t he arch, as well as length, width and curvature of the root(s). It is also important to understand that changes occur in the dentin of endodontically treated teeth; affect its function under stress. In an in vitro study with matched teeth pairs, Sedgley and Messer were able to show that vital dentin is harder that dentin from contralateral endodontically treated teeth, but there was no significant biomechanical change that would indicate that the endodontically treated teeth had become more brittle (Sedgl ey 1992). This result was supported by another study by Papa et al, which showed that there was no significant difference in the moisture content between endodontically treated teeth and vital teeth (Papa 1994). It appears that the remaining amount of tooth hard tissue influences stability. Where as the preparation of pulpal access only reduces structural stability by about 5%, loss of circumferencial integrity by mesio -occlusodistal cavities reduces the stability by about 63% (Reeh 1989). The weakness is primarily caused by loss of tooth structure due to caries, previous restorations, fractures, or endodontic access procedures Therefore, the strongest tooth is the one in which the most sound dentin and enamel can be retained and used to rebuild the tooth. The use of posts, however, does not increase the fracture resistance significantly. This was shown in several comparative in vitro studies (Guzy 1979, Baratieri 2000, Mcdonald 1990)

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15 Anterior Teeth Crowns placed on anterior teeth do not make teeth inh erently stronger (Sorensen 1984, Sidoli 1997). Laboratory testing demonstrated a comparable resistance to fracture between sound and endodontically treated anterior teeth (Trabert 1978). Placement of a lingual or palatal dentin bonded composite resin is t he treatment of choice for a nterior teeth with intact marginal ridges, cingulum and incisal edges. Placement of a crown on an anterior tooth is indicated when there is extensive coronal destruction or the need for occlusal change, or for esthetic reasons. In such situations, the mechanical and esthetic properties of all ceramic, metal -ceramic, or modified resin crowns offer advantages over large composites (McLean 1998). Some anterior teeth may require complete coronal coverage along with posts and cores This is common when large proximal restorations are present, caries has undermined the remaining marginal ridges, or the majority of the incisal edge has been lost due to trauma. Current research indicates that when an enamel -bonded porcelain veneer is being placed on an endodontically treated tooth, there is no need for post (Baratieri 2000). Because the maxillary lateral incisor and the mandibular incisors are smaller teeth, a post is commonly indicated before crown placement (Morgano 1999). In maxill ary central incisor and canine teeth, however, the decision should be made after crown preparation. If the dentist believes there is adequate remaining tooth structure to provide adequate resistance to fracture, a bonded composite is placed in the access preparation. If, in the judgment of the dentist, there is insufficient remaining coronal tooth structure to resist the functional forces, a post is placed (Robbins 2002).

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16 Posterior Teeth Posterior teeth present a different set of restorative needs due to th eir structure and the occlusal forces placed on them during function. Posterior teeth receive predominantly vertical rather than shear forces. Contemporary thought, in both research and clinical practice, supports the placement of a protective restoratio n with full cuspal coverage on these teeth (Sorensen 1984, Hoag 1982). This is easily accomplished with a crown or onlay when sufficient tooth structure remains. Full coverage restorations prevent the fractures that can result from occlusal forces separat ing cusp tips during function. Many endodontically treated molars do not require a post because they have more tooth substance and a larger pulp chamber to retain a core buildup (Kane 1991). When a post is required as a result of extensive loss of natura l tooth substance, it should be placed in the largest and straightest canal to avoid weakening the root too much during post space preparation and root perforation in curved canals. The distal canal of mandibular molars and the palatal canal of maxillary m olars usually are the best canals for post placement. When core retention still is insufficient after a single post is inserted, placement of pins can be considered for additional retention (Kane 1991). Unless a large percentage of coronal tooth structu re is missing, posts are rarely required in endodontically treated molars (Robbins 2002). More conservative methods of core retention can be used. Premolars have less tooth substance and smaller pulp chambers to retain a core buildup after endodontic trea tment than do molars, and posts are required more often in premolars. In addition to root taper and curvature, many pre -molar roots are thin mesiodistally, and some have proximal root invaginations. Furthermore, the clinical crown of the mandibular first p remolar

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17 often is inclined lingually in relation to its root. These anatomical characteristics must be considered carefully during post space preparation to avoid perforating the root. However, complete coronal coverage may not always be necessary in cases of posterior teeth opposing partial or complete dentures. In these cases, the forces of mastication and cuspal interdigitation may be significantly reduced, thus minimizing chance of fracture (Shillingburg 1997). Best Time for Restoration Because modern en dodontic therapy achieves a predictably high success rate, postponing restoration for extended periods of time to be certain of endodontic success is unnecessary and could place the tooth at risk. Bishop and Biggs (Bishop 1995) reiterated the need for prom pt restoration immediately following completion of endodontic therapy to protect the treated tooth from microbial contamination (Safavi 1987, Vire 1991). In addition, when immediate preparation of the post space after the endodontic filling was compared to delayed preparation (after at least 24 hours), neither method proved to be consistently superior (Portell 1982). Ideally, post space preparation is completed at the appointment when the root canal is filled (Whitworth 2002). At this time, the clinician is most familiar with the canal system and reference points. He/she is also able to prepare the post space with the rubber dam in place to minimize microbial entry, and can further condense the apical segment of the root filling after the coronal gutta pe rcha has been removed (Abramovitz 2000). When a tooth had a periradicular lesion, some practitioners commonly waited months for radiographic evidence of healing prior to restoration. If a final restoration cannot be placed within a few weeks of endodont ic treatment, a strong, leak -resistant, protective, provisional

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18 restoration is indicated. A well-processed temporary crown or bridge, glass ionomer, or acid etched composite build up may be considered for the minimum time possible, as can a properly fitted and cemented orthodontic band (Abramovitz 2000). Custom Casts v s Prefabricated Posts Custom cast post and core restorations have had a long history of successful use in restorative dentistry, especially when a coronal ferrule is provided. Its advantages include rigidity, better fit and more uniform thickness of cement. One six -year retrospective study reported a success rate of 90.6 percent using a cast post and core as a foundation restoration (Bergman 1989). Cast gold alloy type III or IV is an inert ma terial with modulus of elasticity (stiffness of 14.5 x 106 psi) and coefficient of thermal expansion ( 15 [C1] x 106) similar to those of dentin, and yet it has good compressive strength that can withstand normal occlusal forces (Cheung 2005) The main disadvantage of the cast post and core placement procedure is that it requires two visits and laboratory fabrication. In general, custom cast post and core restorations are indicated in teeth with elliptical or excessively flared canals. It is also indica ted where alignment of the proposed crown is significantly different from the inclin ation of the canal, which is often the case with anterior teeth. With most anterior, and some bicuspid teeth, there is also inadequate room for sufficient bulk of buildup material around the post to provide a solid unit. Thus for most anterior teeth and small bicuspid teeth requiring a post, the choice is a cast post core design. When used, a cast post core should utilize a high -strength type III or IV gold alloy or a simi lar high -strength non -precious alloy. The main disadvantage of the cast post and core placement procedure is that it requires two

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19 visits and laboratory fabrication. Preformed posts with an amalgam build up are often more conservative of tooth structure t han cast gold especially in posterior teeth. They are generally less expensive and quicker and easier to fabricate. In recent years, there has been a considerable increase in the number of post systems available. An alternative to the custom cast post is a prefabricated post that can be adjusted and inserted in a single visit. Many types of prefabricated posts (in terms of shape, design, material) are available. Stainless steel, titanium and titanium alloys, gold -plated brass, ceramic and fiber reinforced polymers have been used as materials for prefabricated posts. The ideal post and core material should have physical properties such as modulus of elasticity, compressive strength and coefficient of thermal expansion that are similar to those of dentin (ch eung 2005). In addition, prefabricated posts should not be corrosive and should bond easily and strongly to dentin inside the root using suitable cement so that the entire assembly of a post and core resembles the original tooth. Stainless steel has been u sed for a long time in prefabricated posts. However, it contains nickel, and nickel sensitivity is a concern, especially among female patients. Stainless steel and brass have problems with corrosion. Pure titanium has slightly lower physical properties suc h as compressive and flexural strength than alloys, but it is the least corrosive and most biocompatible material (Monaghan 1992). Titanium posts, however, have low fracture strength and tend to break more easily compared with stainless steel posts during removal in re treatment cases (Cheung 2005). Furthermore, most titanium alloys used in posts have a density similar to that of gutta percha when seen on radiographs, which makes them more difficult to detect.

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20 In general, prefabricated posts are indicated with small circular canals. The prefabricated post and core remains the most widely used system. Prefabricated posts with a direct build up work very well in posterior teeth where there is room for sufficient bulk of buildup material. Canal angulations ar e infrequently a problem. Custom cast posts are indicated when a prefabricated post cannot be properly fitted (Shillingburg 1997). In regard to conservation of tooth structure, the use of tapered posts requires removing less dentin because root canal spaces are cleaned and shaped in a tapered fashion. Although parallel posts and screw posts are more retentive in the root canal, more dentin removal is required in their post space preparation. This can be undesirable, especially in post space preparation for parallel posts, as more dentin is removed from the thinner apical and middle aspects of the root canal walls. From the point view of the conservation of tooth structure alone, it seems that the use of anatomical custom posts would provide for a stronger t ooth than would prefabricated posts, which require removal of additional tooth structure to adapt the canal space to the post. Post Space Preparation Knowing the root anatomy of different teeth is important before attempting to prepare any canal space for post installation. Clinicians must be aware that root diameter may differ in the facial lingual and mesio distal dimensions. To determine the appropriate post length and width to avoid root perforation, clinicians must consider conditions such as root ta per, proximal root invaginations, root curvatures and angle of the crown to the root during the mechanical preparation of a post space (Cohen1991). Gutmann gave a good review of anatomical and biological considerations in restoring endodontically treated teeth (Gutmann 1992). Studies have shown that as the post length increases, so does retention (Ruemping 1979, Kurer 1977, Standlee 1978). While longer posts demonstrate increased retention, their position

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21 in the root may lead to clinical problems. In thi n or curved roots, long posts can cause perforations or fractures. In short roots, they may disrupt the apical seal (Sorensen and Martinoff 1984). M any formulae for recommended lengths have been proposed. It is rational to prepare a post channel as long as it is consistent with anatomical limitations while maintaining 4 to 5 mm of apical gutta percha seal (Kvist 1989). Acceptable guidelines for determining the post length include the following: The post length should be equal to the clinical crown lengt h (Rosen 1961, Silverstein 1962) The post length should be equal to one half to two -thirds of the length of the remaining root (Baraban 1967, Bartlett 1968). The post should extend to one -half the length of the root that is supported by bone (Stern 19 73). Clinical success rates support post length equal to or greater than the crown length of the tooth. In a study of 1,273 teeth restored a minimum of one year, Sorensen and Martinoff showed a 97% success rate for any post crown restoration in which the post length was equal or exceeded the crown length. Another recommendation was that the post length should be between one half and three quarters the length of the root (Sorensen and Martinoff 1984). As was stated previously, root anatomy varies from toot h to tooth and even within the same tooth in different patients. Clinicians must consider these variations along with the guidelines. Each clinical situation is unique, so the preparation of the post space must be evaluated carefully and planned for accordingly. Most endodontic texts and researchers advocate ma intaining a 4 5 mm apical seal (Mattison1984). However, if a post is shorter than the coronal height of the clinical crown, the prognosis is considered unfavorable, because stress is distributed over a smaller surface area,

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22 thereby increasing the probability of radicular fracture. A Short root and tall clinical crown present the clinician with the dilemma of having to compromise the mechanics, apical seal or both. Under such circumstances, an apical seal of 3 mm is considered acceptable (Rosenstiel 2001). It is accepted widely that the post diameter makes little difference in the retention of the post. An increase in the posts width, on the other hand, will increase the risk of root fracture (Stan dlee 1978, Caputo 1987). In general, the post width should not exceed one -third of the root width at its narrowest dimension, and clinicians should bear in mind that most roots are not perfectly rounded (Morgano 1996). An experimental impact testing with cemented posts of different diameters showed that teeth with thicker 1.8mm posts fractured more easily than those with thinner 1.3mm ones (Helfer 1972). A minimum of 1 mm of sound dentin should be maintained circumferentially, especially in the apical ar ea where the root surface usually becomes narrower and functional stresses are concentrated (Caputo 1976). In choosing a post size, the practitioner must consider that root diameter decreases apically and that concavities in the root can be invisible radi ographically. These anatomical factors can contribute to thin dentinal walls that are subject to fracture during the initial post cementation or during occlusion if the post is too wide. The cleaning and shaping procedures used in modern endodontic treat ment are aggressive in the removal of dentin within the root canal space; therefore, removal of more dentin from the canal wall in the preparation of the post space should be kept to a minimum to preserve tooth substance and minimize root fracture. Post Ce mentation Dental cements lute the post to radicular dentin and properties such as compressive strength, tensile strength, and adhesion of the cement are commonly described as predictors for

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23 success of a cemented post. Other factors such as potential for plastic deformation, microleakage, water imbibition, behavior of cement during the setting process, and handling characteristics cab also influence the survival rate of a cemented post. Cements for posts and core restorations have been investigated extens ively (Chapman 1985, Young 1985, Radke 1989, Burgess 1992). All posts, whether cast or prefabricated, are cemented inside the root canal. The cementing medium enhances retention, aids in stress distribution, and, ideally, seals microgaps between the tooth and the post. Among the most commonly used dental cements are zinc phosphate, polycarboxylate, glass ionomer cement, resin -based composite and the hybrid of resin and ionomer cements. Zinc phosphate has had the longest history of success, and remains the standard of comparison. Historically, zinc phosphate was the cement of choice, yielding higher retentive values than polycarboxylate or standard resin cements. In addition to having an extended working time, it is compatible with zinc oxide eugenol (ZO E), which is contained in most root canal sealers. In the case of an endodontic failure, a metal post that is cemented in the canal space with zinc phosphate is easier to remove and has a lower risk of root fracture compared with a metal post that is bonde d strongly with a resin -based composite cement in the root canal space (Cheung 2005). Both zinc phosphate and glass ionomer have similar properties and are commonly used because of their ease of use, coupled with their history of clinical success (Radke 1989, Ertugrul 2005). Z inc phosphate and resin modified glass ionomer cements such as vitremer luting, offer adequate retention and resistance to leakage and simplify post removal. Pure glass ionomer cements should work as well but are sensitive to mois ture or the lack of it in a canal when

PAGE 24

24 setting. The use of resin cements should be reserved for cases outside of these criteria where adequate post length and retention are not available. Many current in vitro studies have shown more favorable results w ith adhesive cements (Balbosh 2005, Mendoza 1994, Tjan 1987, Cohen 2000). These studies have shown a significant increase in post retention and increase in fracture resistance with adhesive resin cements compared with other cements. However, it must a lways be borne in mind that, despite improved retention in some laboratory studies, especially if the post has a poor fit within the canal (Mendoza 1994), none of the cements can overcome the inadequacies of a poorly designed post, and, ultimately, the choice of luting agent seems to have little effect on post retention (Chapman 1985) or the fracture resistance of dentine (Dreissen 1997). With regard to cements, the practitioner must keep in mind that coronal leakage is a major factor in endodontic failure. All contemporary cements are susceptible to dissolution in the presence of saliva. Therefore, the importance of close marginal adaptation of crown to tooth for protection of the cementing medium cannot be over emphasized. Venting is a means for cement to escape must always be provided to reduce the intraradicular hydrostatic pressure created during cementation of the post. This factor is of profound importance especially with the custom cast post (Gross 1983). Most prefabricated posts have a venting mechanism incorporated in their design. A vent may be incorporated in the custom cast post with a bur prior to cementation or it may be incorporated in the wax pattern before. Methods of cementation include placement of the cement with the post, or cement p lacement with a lentulo spiral, a paper point, or an endodontic explorer. Investigations of these

PAGE 25

25 methods have shown that the lentulo spiral is the superior instrument for cement placement (Goldman 1984, Nathanson 1993, Goldstein 1986). Another method for cement placement is using a needle tube, taking care to insert the tip of the tube all the way to the bottom of the canal space and provided that cement extrudes from the tip as it slowly is removed from the canal. After cement placement, the post is coa ted with the cement and is inserted (Schwartz 1996). Objective of Study While an abundance of in vitro studies on different aspects of custom cast and prefabricated posts has been reported and discussed in the literature, few studies compared the success o f clinically meaningful restorative approaches, and the materials used. It is therefore still difficult to justify a preference for cast or prefabricated post and core restorations based on in vitro studies alone. Very little clinical data are available on post and core treatment that are performed on a daily basis. Based on these facts, the objective of this study was to evaluate the clinical survival rate of custom fabricated cast post and cores, and prefabricated post and cores used in dental practices and to see if there is any significant difference in their performance and longevity as influenced by the age and gender of the population, type of post material used, length of the post, amount of bone supporting the roots, location of the tooth in the arch, the type of cement used, the effect of opposing occlusion, and the type of final prosthetic treatment received. The following specific aims are proposed: 1 To test the hypothesis that age and gender has no effect on the clinical survival rate of custo m fabricated cast posts, or prefabricated posts. 2 To test the hypothesis that cast posts made of Type III gold alloy will exhibit higher clinical survival rates than prefabricated posts made of titanium alloy (Parapost XH Whaledent USA).

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26 3 To test the hypothe sis that a longer post will exhibit higher clinical survival rates in cast and prefabricated metal posts. 4 To test the hypothesis that clinical survival rates for cast and prefabricated posts are affected by the amount of bone supporting the roots. 5 To test the hypothesis that dental posts used in endodontically treated teeth that performed as abutments for removable or fixed partial dentures will exhibit a lower survival rate than those performed as abutments for single crowns. 6 To test the hypothesis that endodontically treated tooths position in the arch affects the survival rate of custom fabricated cast posts and prefabricated metal posts. 7 To test the hypothesis that metal posts cemented with resin reinforced cements will exhibit a higher survival rate. 8 To the test the hypothesis that opposing occlusion is related to survival rates in custom fabricated cast posts and prefabricated metal posts. This retrospective analysis will aim to prove that one of the methods for fabrication of post and cores is m ore predictable with a higher survival rate based on a large patient group over a five -year period.

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27 CHAPTER 2 MATERIALS AND METHOD S Study Population This retrospective study was approved by the Institutional Review Board at the University of Florida (approval number: 390 2007), to use six hundreds and thirty nine patient files who had received a cast fabricated post and core buildup or a prefabricated post and either a composite or amalgam buildup at the Undergraduate Student Clinic for Fixed and Removabl e Prosthodontics at the University of Florida, between January 2003 and December 2007, to be evaluated and acquire data relevan t for the results of the study. These patients had been treated by the third and fourth year den tal students with either cast (g old type III alloy) fabricated pos ts, or prefabricated (titanium parapost XH, Whaledent ) posts. A computer query was done using Quick Recovery and Medical Manager Programs to identify the number of cast and prefabricated post and cores made at the Univer sity of Flori da College of Dentistry between 2003 2007. The codes D2952 was entered for cast post and cores and D2954 for prefabricated post and cores. This allowed us with the identification of the number of cast and prefabricated post and cores along with the chart numbers associated with the procedures. A pilot study consisted of ten charts that were selected randomly, two charts from each year, starting w ith 2003 and ending with 2007, was conducted in order to calibrate the investigators that were participating in the study. The patient files were analyzed using grading codes, which helped collecting the needed information to be recorded for statistical analysis. A manual search of the charts was conducted. Data were g athered mainly from the studen t doctors treatment notes, and from exam ining patients dental radiographs attached in their charts.

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28 Grading Co des Grading codes were carried out for all patients files fulfilling the needed information as follows: 1 ) Age 2 ) Gender Female = 0 Male = 1 3 ) Post Type Prefab = 0 Cast = 1 4 ) Post Length up to 1/2 root = 0 more than 1/2 root = 1 5 ) % Root in Bone < 50% = 0 50 75% = 1 > 75% = 2 6 ) Type of Restoration Build up = 0 PFM = 1 Gold = 2 Temporary = 3 7 ) Cement Zinc Phosphate = 0 Other = 1 Not available = 2 8 ) Tooth Position Anterior tooth = 0 Posterior tooth = 1 9 ) Free Standing ( not an abutment for FPD or RPD ) Yes = 0 FPD abutment = 1 RPD abutment = 2 10) Opposing Dentition Natural = 0 FPD = 1 RPD or CD = 2 11) Failure Yes = 0 No = 1 Statistical Approach A sprea dsheet was made to identify the birth year of the patients, the gender, post type (prefabricated or cast), post length, percentage root in bone, the type of restoration, cement used, tooth position within the arch, whether the tooth is free standing (not a n abutment for the fixed

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29 partial denture or removable partial denture, the opposing dentition, failure, and if there is inadequate information to determine any of the preceding data Data and information were analyzed using the Statistical Analysis System (SAS), and were subjected to determine the survival rate for both cast and prefabricated post and cores. To ascertain if ten of the possible variables are correlated to post failure a two -step process was performed. In the first, unviariate tests of cor relation were performed to test for correlation between post failure and the variables. Since nine of the variables were categorical, a Chi squared test was performed and the one -way ANOVA was used for the one continuous variable age (Weaver 2008). A P -v alue less than 0.05 was considered as significant. The second step was to look at the multivariate correlation between significant variables and failure. Because failure is a binary variable, logistic regression was used (Weaver 2008). The process to fi nd the best model was to start with all significant variables and their first order interactions, and then remove parameters till only significant variables at the 0.05 level remained.

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30 CHAPTER 3 RESULTS AND DISCUSSI ON Results The one -way ANOVA for the c ontinuous variable age is shown in Table 3 1 with the probability level set at 0.05 for statistical significance, and its corresponding means in Table 3 2. The study shows that age is significant and the mean age for failure for female showed to be 59 yea rs of age, while the mean age for failure for males showed to be 52 years of age. Ten pair wise tables and their corresponding Chi squared test results are shown in Table 3 3 through 3 11, and also, ten plots with their corresponding percent of row freque ncies are shown in Figure 3 1 through 3 9. Table 3 3 and Figure 3 1 show that male patients treated with metal posts performed slightly better than female patients. Failure was recorded in 24 patients out of total 261 female patients, compared to 29 fail ed cases out of 378 male patients treated with post and core in the clinic. This difference was not statistically significant with P>0.05. Figure 3 1 illustrate s 90% survival r ate of metal posts for female patients and 91% survival rate of metal post s fo r male patients. Therefore, gender had no statistical significance with post failures. Table 3 4 and Figure 3 2 show ed the effect of post type used and if it had any significance with the failure rate of post treatment. From the table we found 9 failed c ases out 1 29 prefabricated post treatment and 44 failed cases out of 510 custom fabricated cast post treatment. Figure 3 2 illustrated the percentages of the survival rate of both types of posts used in the undergraduate clinic with 92% survival rate for prefabricated posts, and 91.5% for custom cast posts. The difference was not statistical ly significant to the study P>0.05. Table 3 5 and Figure 3 3 indicated that post length had a significant influence on the survival probability of the post and core tre atment. Shorter posts demonstrated larger number of

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31 failure than longer posts. Post spaces prepared to more than half of the root length had higher survival rate than post spaces prepared up to or less than half the length of the root with failure rates of 5% and 16.5%, respectively. 26 failed posts were found in 159 patients treated with prefabricated metal posts, and 27 failed cases were documented in 480 patients treated with custom fabricated cast posts. The Chi -square test resulted in a statistical sign ificance of post length related to metal posts survivability P<0.05. Table 3 6 and Figure 3 4 illustrated the effect of th e amount of bone remained supporting roots of endodontically treated teeth with metal prefabricated or custom fabricated posts. A total of 43 patients were treated with metal posts in teeth that had less than 50% of roots embedded by bone, 16 posts failure were documented. The other group was 185 teeth that had 5075% of bone supporting roots of the treated teeth. Thirteen cases of this group had failed. The last group of this category of testing was teeth that had more than 75% of bone supporting roots of the treated teeth. There were 24 cases documented as failure out of total 411 teeth treated with metal posts. In Figure 3 4 there was shown how poorly the treatment outcome was for teeth that had less than 50% bone supporting the roots with percentage of failure of 38%. Teeth with more than 75% of bone supporting their roots had only 6% of failure. Statistically this varia ble has shown to be very significant on how well metal posts performed and survived P<0.05. Table 3 7 and Figure 3 5 illustrated the influence of material of restorations were used to treat teeth that had metal posts performed on them. Different type of r estorations was used and varied from build up restorations, PFM materials, gold, and temporary restorations. Statistical tests have shown a little influence between each group in the survival probability of metal posts, however there was not a statistical significant difference of the type of material used to restore endodontically treated teeth with percentage of failure recorded.

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32 Table 3 8 and Figure 3 6 showed the influence of different type of cement used on the survival probability of teeth treated with metal posts. The statistical tests compared the use of zinc phosphate cements to other type of cements used in the Undergraduate Clinic for Removable and Fixed Prosthodontics at the University of Florida. No statistical significant difference P>0.05 was found with different type of cements used to the percentage of survival of metal posts in endodontically treated teeth. Over 90% survival of metal posts were recorded with all type of cements documented. In Table 3 9 and Figure 3 7 an illustration of the importance of tooth position in the dental arch to the survival probability of teeth treated with metal posts was tested. It was shown that no statistically significant differences were ascertained between anterior and posterior endodontically tre ated teeth in the dental arch with the percentages of survival of metal posts. Table 3 10 and Figure 3 8 demonstrated the influence of final treatment type of the endodontically treated teeth to their probability of survival of metal posts used. It was re corded that endodontically treated teeth with metal posts that were not splinted by other teeth as part of a fixed partial denture prosthesis or a removable partial denture prosthesis had a larger percentages of survival probability of metal posts used. F igure 3 8 illustrated the percentages of failure for teeth that performed as an abutment for removable partial denture prosthesis to be 18%, while it was 9% for teeth that performed as an abutment for fixed partial denture prosthesis, and 6% for teeth that performed as un-splinted single crowns. This variable appeared to be of a great statistical significance to the probability of survival of metal posts P<0.05. Table 3 11 and Figure 3 9 represent the influence of opposing dentition on the survival probabil ity of metal posts in endodontically treated teeth. From the data collected it was made clear that teeth with metal posts performed a little better when opposed natural teeth with 8%

PAGE 33

33 failure of row frequency. Teeth that opposed fixed and removable prostheses performed relatively well in comparison. No statistically significant differences were determined between the different types of opposing occlusion on the survival probability of metal posts in endodontically treated teeth P>0.05. Figure 3 10 demonst rates the total percentage of failure of both types of metal posts documented in this study. It exhibited 92% survival probability of prefabricated and custom fabricate metal posts combined. At a significance level of 0.05, four variables were shown to be correlated with failure, they are age, post length, percentages of root in the bone, and whether the tooth treated with post was a free standing crown or an abutment for fixed or removable partial denture prosthesis. The final model of significant variables was shown to be models of post length, percentage of roots in bone, and the type of final prosthetic treatment. All these variables were significant at < 0.001. The type III tests for these effects are shown in table 12. To illustrate how these vari ables affect failure the adjusted least square means are shown in Table 1315. The mean represents the average probability that a patient with metal post treatment would experience a failure. Table 3 13 illustrates the probability of survival of metal po sts in relation to the post length. It was found out that when metal posts are prepared to more than half the length of the roots to have a probability of survival of 91%. While the probability of survival dropped to 72% when posts were to be prepared to less than half of the length of the roots. Table 3 14 represents the probability of survival of metal posts in relation to the amount of bone remained supporting the roots. It was found out that when teeth were supported 5075% or more by bone tissue, had a survival probability of 90%, 92% respectively. When endodontically

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34 treated teeth had less than 50% of bone supporting the roots, the survival probability of metal posts treatment was only 56.8%. Table 3 15 brings clear the relationship between the survival probability of metal posts performed in endodontically treated teeth and the type of final treatment associated with those teeth. It showed that the probability of survival of metal posts performed in teeth that are unsplinted single crowns, or teeth that presented as abutments for fix partial denture prostheses, was 89%. The probability of survival of metal posts dropped significantly in teeth that acted as abutments for removable partial denture prosthesis to 69%. Discussion The design of t his study was specifically meant to assess variables that might influence the survival of 2 different metal post systems that were used for endodontically treated teeth in the Undergraduate Clinic of Fixed and Removable Prosthodontics at the University of Florida. As regards age, older patients were reported to have less survival of metal posts than younger patients. A significant difference was recorded and illustrated in Table 3.1. Our findings could be attributed to the fact that elderly patients tak e various medications that might cause xerostomia, which could be a major cause of developing root caries. Another significant correlation was the fact that teeth that have been treated with metal posts were abutments for some type of removable partial de nture prostheses. Many geriatric studies showed that alterations in nature of pulp sensitivity, higher risk of developing root caries, and poor oral hygiene, had a significant influence on the survival of metal posts. Pulp and dentin, like other connective tissues, undergoes changes with time. Some of these changes are natural, whereas others may be a result of injury such as caries, periodontal disease, trauma, or restorative dental procedures. Regardless of the cause changes in pulp and dentin appearanc e and function do occur (Waton R 2002). A deeply entrenched clinical perception persists that root canal treated

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35 teeth become more brittle, assumingly, losing resilience as the moisture content of dentin declines after pulp loss. This perception is unsup ported experimentally (Walton 2002). Few studies have compared physical properties of endodontically treated versus non treated human teeth with vital pulp. The moisture content of endodontically treated teeth was not reduced, even after 10 years (Papa 1 994). Also, a comparison of these two groups revealed no significant differences in strength, toughness and hardness of dentin (Huang 1992, Sedgley 1992). Thus, susceptibility to failure cannot be reliably attributed to structural changes in dentin after loss of pulp vitality or after root canal tr eatment (Walton 2002). It is more attributed to the type of final treatment the endodontically treated teeth are receiving and other factors mentioned previously. Post length was shown to have a significant in fluence on the survival of both types of metal post systems evaluated. In this clinical study it was illustrated that endodontically treated teeth that had longer posts; extending to more than half of the root length while maintaining the necessary apical seal; to have significantly greater survival than teeth treated with shorter metal posts. Table 3.13 shows a clear presentation of the importance of post length. It was shown that post spaces that were prepared up to half the length of the roots had a s urvival probability of 72.8%. While posts spaces that were prepared for more than half of the root length had a survival probability of 91.5%. An abundance of reports and documentations support our findings (Santos Filho 2008, Asmussen 2005, Caputo 1987, Colley 1968, Cooney 1986, Holmes 1996, Sorensen 1984). Fernandes concluded in his study, that posts needed to be long enough to prevent excessive internal stresses in the roots (Fernandes 2001). The length of metal post plays an important role in its re tention. Various investigators have demonstrated a significant relationship between vertical resistance to displacement and length of the post. Posts should be as long as possible with 3 5 mm of root filling left at the apex for seal (Baraban 1988, Colma n

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36 1979). Research suggests that longer the post, greater is the retention and less is the stress (Standlee 1978). One of the significant variables that were investigated in this study was the amount of bone present to support the roots of the endodonti cally treated teeth. It was cleared out in this examination that the survival of metal posts was significantly reduced in endodontically treated teeth that had less than 50% of bone tissue surrounding their roots. It was exhibited in Table 3.14 that when endodontically treated teeth had more than 75% of bone tissue support present, the survival probability of metal posts treatment was 92%. While the survival probability had significantly dropped to 56.8% when less than half of the roots were supported by alveolar bone tissue. Metal post should extend to at least half the length of the root contained in the remaining alveolar bone (Jacoby 1976). It has demonstrated in this clinical investigation the importance of proper treatment planning prior to endodo ntic therapy of teeth. The amount of alveolar bone present with respect of the necessary apical seal should be always taken into consideration. It was apparent that teeth with good overall prognosis and adequate periodontal support as measured clinically and radiographically, would have illustrated higher survival probability of metal posts treatment assuming the proper maintenance by the clinician and patient (Walton 2002). Another important variable examined was the different types of final prosth etic restorations that endodontically treated teeth with metal posts have received. It was brought clear in Table 3.15 that teeth that were used as abutments for single crowns, and abutments for fixed partial denture prostheses have demonstrated the highe st survival probabilities when compared to teeth that were used as abutments for removable partial dentures prostheses, with survival probabilities of 89.4%, 89.1%, and 69.3%, recorded respectively. Many reports support

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37 our findings. A retrospective cli nical study by Wegner aimed to evaluate the survival rate of teeth that were endodontically treated and restored with endodontic posts and prosthodontic restorations. In her study, the calculated survival rates of the abutments were found to be significan tly different for fixed partial dentures and for removable partial dentures with survival rate of 92.7% and 51% respectively (Wegner 2006). Endodontically treated teeth used as removable partial denture abutments have a five times greater failure than si ngle teeth (Sorensen 1990). Endodontically treated teeth that serve as abutments for fixed or removable prostheses have been reported to be most prone to failure (Palmqvist 1994). A study by Kantor recommended the use of cast metal post and core for rest oring endodontically treated teeth that are used as abutments for removable partial dentures (Kantor 1977). One of our main objectives in this study was to compare clinically the cumulative survival rate of custom fabricated cast posts to prefabricate metal post used in endodontically treated teeth. Figure 3.10 demonstrated the cumulative survival rate of both types of posts used and was found to be 92% during the observation period of 5 years. 510 custom fabricated posts were documented and exhibited 9 1% survival, and 129 prefabricated posts were used with a survival rate of 92% reported. Few in vivo studies illustrated similar results, but did not evaluate large patient collectives and possible covariates that may affect the risk of failure. Bergman e xamined the success rate of cast post and cores over 6 years with 96 posts cases. The failure rate was established in relation to the type of prosthetic restoration (crown, bridge), type of tooth (anterior, premolar, molar), the jaw (maxillary, Mandibular ). There was a 10% failure rate after 6 years (Bergman 1989). Ellner et al. in his prospective study of 50 posts in 31 patients recorded a success rate of 100% for the group with custom -fabricated post and cores with an excellent success probability in the observation period of 10 years. The patient collective was, however,

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38 highly selective and had only been treated with single crowns (Ellner 2003). Ferrari et al. compared in their study custom -fabricated post and cores with fiber posts. After 4 years in service, custom -fabricated post and cores showed a failure rate of 14% (Ferrari 2000). Hatzikyriakos et al. examined the failure rate with 154 post and cores involving prefabricated, screw retained, custom -fabricated, cemented post and cores under crowns, bridges and removable dentures. The cumulative failure rate was 9.1%for custom -fabricated post and cores after a period of 3 years. The number of cases in each group was, however, too small to draw any further conclusions from findings (Hatzikyriakos 1992). Sorensen and Martinoff examined the failure rate with 1273 root teeth in relation to the postendodontic treatment (no post and core versus different post systems). In this study, the majority of teeth 65.4% had not been treated with a post and core and only 19.2% had been treated with a cast post and core. The failure rate recorded for the latter group was 12.7%, but no information was provided about the time in situ (Sorensen 1985). Torbjorner et al examined the success rate of two different post designs paraposts versu s custom -fabricated cast posts in a 6 years study. The 456 cast posts and cores exhibited a failure rate of 10.5 % during the observation period (Torbjorner 2004). Balkenhol et al. examined the survival time of custom -fabricated cast post and core, and evaluated different variables, which influenced the risk of failure over a period of 10 years. They have concluded that custom -fabricated post and core have a good long-term prognosis, and reported a cumulative failure rate of 11.2%, and an average survi val time of 7.3 years (Balkenhol 2007). In this study gender was found not to have a significant influence on the survival of neither of the 2 metal post systems used. Figure 3.1 demonstrated clearly the effect of gender on the survival of metal posts and showed relatively close percentages. A study conducted in Denmark

PAGE 39

39 have illustrated different results (Peutzfeldt 2007); where they found males to have less survival probability of metal posts, and they have related their findings to the fact that men ex erted greater bite forces than women. It was shown in this retrospective study that there were no significant differences between types of materials used for the coronal coverage of endodontically treated teeth. It was reported that most endodontically tr eated posterior teeth had full coronal coverage, metal or porcelain fused to metal coverage. Both type of materials performed relatively equally as demonstrated in Figure 3.5. Anterior teeth on the other hand, were found to be treated either with composi te restorations, or porcelain fused to metal crowns. A slight advantage of anterior teeth that were treated with full coronal coverage had been recorded over teeth that had only filling restorations. However the difference in survival of both types of me tal posts with different types of materials of coronal coverage used in anterior teeth was not significant. Type of cements used in the clinic for retaining metal posts was another variable that has been evaluated and found to be of no significance to s urvival of metal posts in endodontically treated teeth. The majority of cases examined have documented the use of zinc phosphate with a survival rate greater than 90%. However, metal posts that were retained using other type of cements available in the c linic also reported relatively similar values. There was no significant difference in the survival rate of metal posts retained by different type of permenant cements considering the proper post space preparation, amount of osseos bone present, and the type of final prosthetic restoration. Neither tooth position in the arch, nor the type of opposing occlusion showed to have a significant influence on the survival probability of metal posts with endodontically treated teeth in this study. Other studies al so produced this result (Bergman 1989, Dammaschke 2003). On

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40 the other hand, a few studies recorded a prevalence of failures in the upper jaw, generally in the anterior region (Mentink 1993, Torbjorner 1995). The data of the study were acquired using a re trospective, longitudinal study design. A typical problem with retrospective studies is the availability of analyzable, consistent data. This did not, however, pose a problem with this retrospective study, as the clinical findings had been recorded in th e department of prosthodontics since the beginning of 2003 according to a standardised procedure. Operators lack of completed training was not likely to be a disadvantage, because there was extensive treatment plan and treatments were closely supervised. It can therefore be assumed that the recorded data are representative and comparable. It would have been more practical, if the average observation period had been much longer than 5 years. Dentists should evaluate the root length. If the root is too s hort, or the crown to root ratio is unfavorable, the tooth may be unsuitable as an abutment for removable partial denture prostheses. If the osseos support and the root length are inadequate, the dentist should relate to the patient that the prognosis is poor. These considerations, in addition to minimal coronal tooth structure, make the prognosis questionable for a compromised tooth. Pulpless teeth are commonly avoided as abutments for removable partial dentures, especially if the terminal abutment is f or a distal extension (Sorensen 1990). Limitations of the study varied from sometimes lack of documentation of all investigated variables, the uncertainty of amount of ferrule remained and number of dentinal walls maintained, and unavailability of documenting posts width preparations. Future clinical studies should focus on evaluating different prefabricated non-metallic posts to custom fabricated posts, and for a longer period of observation time.

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41 Table 3 1. One -way ANOVA for failure by age. Source DF Sum of Squares Mean Square F Value Pr > F Model 1 2117.7758 2117.7758 9.22 0.0025 Error 637 146364.1678 229.7711 Corrected Total 638 148481.9437 Table 3 2. Means of age for failure Failure Age LSMEAN 0 59.3773585 1 52.7764505

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42 Table 3 3. Failure by gender Gender Failure Frequency 0 1 Total 0 24 237 261 1 29 349 378 Total 53 586 639 Statistic DF Value Prob Chi Square 1 0.4711 0.4925 Figure 3 1 Percentage of failure by gender.

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43 Table 3 4. Failure by pos t type. Post Type Failure Frequency 0 1 Total 0 9 120 129 1 44 466 510 Total 53 586 639 Statistic DF Value Prob Chi Square 1 0.3688 0.5436 Figure 3 2. Percentage of failure by post type.

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44 Table 3 5. Failure by post length. Post Length Failure F requency 0 1 Total 0 26 133 159 1 27 453 480 Total 53 586 639 Statistic DF Value Prob Chi Square 1 18.0692 <.0001 Figure 3 3. Percentage of failure by post length.

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45 Table 3 6. Failure by percentage of root in bone. Percentage Root in Bone Failure Frequency 0 1 Total 0 16 27 43 1 13 172 185 2 24 387 411 Total 53 586 639 Statistic DF Value Prob Chi Square 2 50.9123 <.0001 Figure 3 4. Percentage of failure by % of root in bone.

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46 Table 3 7. Failure by type of restorations material. Restora tion Failure Frequency 0 1 Total 0 3 51 54 1 38 419 457 2 12 90 102 3 0 26 26 Total 53 586 639 Statistic DF Value Prob Chi Square 3 4.4994 0.2123 Figure 3 5. Percentage of post failure by type of restorations material.

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47 Table 3 8. Failure by c ement. Cement Failure Frequency 0 1 Total 0 36 412 448 1 13 120 133 2 4 54 58 Total 53 586 639 Statistic DF Value Prob Chi Square 2 0.5714 0.7515 Figure 3 6. Percentage of failure by cement.

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48 Table 3 9. Failure by tooth position. Tooth Position Failure Frequency 0 1 Total 0 30 393 423 1 23 193 216 Total 53 586 639 Statistic DF Value Prob Chi Square 1 2.3770 0.1231 Figure 3 7. Percentage of failure by tooth position.

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49 Table 3 10. Failure by type of prosthetic treatment. Final Treatment Failure Frequency 0 1 Total 0 22 367 389 1 11 123 134 2 20 96 116 Total 53 586 639 Statistic DF Value Prob Chi Square 2 15.7705 0.0004 Figure 3 8. Percentage of failure by type of tooth treatment.

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50 Table 3 11. Failure by type opposing occlusion. Opposing Dentition Failure Frequency 0 1 Total 0 28 373 401 1 12 75 87 2 13 138 151 Total 53 586 639 Statistic DF Value Prob Chi Square 2 4.3853 0.1116 Figure 3 9. Percentage of failure by type of opposing dentition.

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51 Figure 3 10. Percentage of total failure of all post types.

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52 Table 3 12. Type III tests of the significant variables. Effect Num DF Den DF F Value Pr > F Percentage Root in Bone 2 633 15.76 <.0001 Post Length 1 633 18.79 <.0001 Free Standing 2 633 7.68 0.0005 Table 3 1 3. Post length least square means. Post Length Mean Standard Error Mean 0 0.7288 0.04844 1 0.9154 0.01732

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53 Table 3 14. Percentage of root in bone least square means. Percentage Root in Bone Mean Standard ErrorMean 0 0.5683 0.08235 1 0.9086 0.02468 2 0.9230 0.01638 Table 3 15 Type of final prosthetic treatment least square means. Type of Final Treatment Mean Standard Error Mean 0 0.8942 0.02295 1 0.8915 0.03330 2 0.6932 0.05960

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54 CHAPTER 4 SUMMARY AND CONCLUSI ON Within the limitations of this clinical study, multiple variables have been evaluated for their influence on survival probability of custom -fabricated cast post and prefabricated metal posts used in endodontically treated teeth. Multiple hypotheses were fabricated and the conclusions were drawn to be: 1 Age of patients did influence the survival rate of both treatment modalities, and was found that older patients exhibited less survival rate than younger patients. 2 Metal posts that were prepared for more than half of the root length while maintaining the necessary apical seal shown to have greater survival probability. 3 The percentage of alveolar bone remain to support the endodontically treated teeth was found to influence the survival probability of both treatment modalities signi ficantly. 4 The type of final prosthetic restoration fitted has a significant effect on the survival probability. Posts under single crowns and fixed partial denture prostheses have the highest survival probability. 5 The clinical survival of custom -fab ricated cast posts and prefabricated metal posts were not affected by patients gender, type of cements used to retain posts, types of opposing occlusion, and the position of the endodonticaly treated teeth in the dental arches. Very little clinical data are available on metal posts treatments that are performed on a daily basis. This fact, combined with the inconsistency of the clinical data that have been published we could not conclude the preference of custom -fabricated cast posts over prefabricated m etal posts. Both treatment modalities can be recommended if they are applied within indications and with the necessary caution. Metallic posts continue to be the standard for most situations because they have stood the test of time.

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55 LIST OF REFERENCES Abramovitz I, Tagger M, Tamse A, Metzger Z. The effect of immediate vs. delayed post space preparation on the apical seal of root canal filling: a study in an increased -sensitivity pressure driven system. J Endod 2000;26:435439. Asmussen E, Peutzfeldt A, Sahafi A. Finite element analysis of stresses in endodontically treated, dowel restored teeth. J Prosthet Dent 2005;94:321 329 Assif D, Bitenski A, Pilo R, Oren E. Effect of post design on resistance to fracture of endodontically treated teeth with comple te crowns. J Prosthet Dent 1993;69:3640. Balbosh A, Ludwig K, Kern M. Comparison of titanium dowel retention using four different luting agents. J Prosthet Dent 2005;94:227233. Balkenhol M, Wostmann B, Rein C, Ferger P. Survival time of cast post and cor es: A 10 -year retrospective study Journal of dentistry 2007;35:5058. Baraban D. Immediate restoration of pulpless teeth. J Prothet Dent 1972;28:607612. Baraban D. The restoration of endodontically treated teeth -An update. J Prosthet Dent 1988;59:553558. Baratieri L, De Andrada M, Arcari G, Ritter A. Influence of post placement in the fracture resistance of endodontically treated incisors veneered with direct composite. J Prosthet Dent 2000;84:180184. Bartlett S. Construction of detached core crowns for pulpless teeth in only two sittings. JADA 1968;77:843 845. Bergman B, Lundquist P, Sjgren U, Sundquist G. Restorative and endodontic results after treatment with cast posts and cores. J Prosthet Dent 1989;61:10 5 Bishop K. and Biggs P. Endodontic failure -A problem from top to bottom. Br Dent J 1995; 179: 3536. Black G. A method of grafting artificial crowns on roots of teeth. Mo Dent J 1869;1:233236. Burgess J, Summitt J, Robbins J. The resistance to tensile, compression, and torsional forces provided by four post systems. J Prosthet Dent 1992;68:899903. Caputo A, Standlee J. Pins and posts: why, when and how. Dent Clin North Am 1976;20:299 311. Caputo A, Standlee J. Restoration of endodontically involved teeth. In: Biomechanics in clinical dentistry. C hicago: Quintessence 1987;P:185. Chapman K, Worley J, von Fraunhofer J. Retention of prefabricated posts by cements and resins. J Prosthet Dent 1985;54:649652.

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56 Chapman K, Worley J, von Fraunhofer J. Retention of prefabricated posts by cements and resins. J Prosthet Dent 1985;54:649652. Cheung W. A review of the management of endodontically treated teeth. J Am Dent 2005;6:611619. Cohen B, Pagnillo M, Newman I, Musikant B, Deutsch AS. Retention of four endodontic posts cemented with composite resin. Gen De nt 2000;48:320324. Cohen S, Burn RC. Pathway of The Pulp, ed 6. St. Louis, MO:CV Mosby, 1991:641. Colley I, Hampson E, Lehman M. Retention of post crowns. An assessment of the relative efficiency of posts of different shapes and sizes. Br Dent J 1968;124:63 69. Colman H. Restoration of endodontically treated teeth. Dent Clin North Am 1979;23:647 662. Cooney J, Caputo A, Trabert K. Retention and stress distribution of tapered -end endodontic posts. J Prosthet Dent 1986;55:540 546. Dammaschke T, Steven D, K aup M, Ott K. Long -term survival of root -canal treated teeth: a retrospective study over 10 years. Journal of Endodontics 2003;29:638 643. Davis W. Essentials of Operative Dentistry, ed 2. St. Louis, MO:CV Mosby, 1916:23. Demas N. Direct impression for c ast Richmond crown using acetate crown forms. Dental Dig 1957;63:258259. Driessen C, Marais J, de Villers D, Nel J. The effect of bonded and non -bonded posts on the fracture resistance of dentine. J Dent Assoc S Afr 1997;52:393398. Ellner S, Bergendal T, Bergman B. Four post and -core combinations as abutments for single crowns: a prospective up to 10-year study. International Journal of Prosthodontics 2003;16:249 254. Ertugul Z, Ismail Y. An in vitro comparison of cast metal dowel retention using various luting agents and tensile loading. J Prosthet Dent 2005;93:546451. Fauchard P. The Surgeon Dentist or Treatise on The Teeth, ed 2. London:Butterworth, 1746:31. Fernandes A, Rodrigues S, SarDessai G, Mahta A. Retention of endodontic post -A review. Endodontology 2001;13: 1118. Ferrari M, Vichi A, Garcia Godoy F. Clinical evaluation of reinforced epoxy resin posts and cast post and cores. American Journal of Dentistry 2000;13:8B 15B. Goldman M, DeVitre R, Tenca J. Cement distribution and bond strength in cemented posts. J Dent Res 1984;63:13921395

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57 Goldstein G, Hudis S, Weintraub D. Comparison of four techniques for cementation of posts. J Prosthet Dent 1986;55:209211. Gross M, Turner C. Intra radicular hydrostatic pressure changes during the cementation of post retained crowns. J Oral Rehabil 1983;10:237249. Gutmann J. The dentin-root complex: anatomic and biologic considerations in restoring endodontically treated teeth. J Prosthet Dent 1992;67:458 67. Guzy G, Nicholls J. In vitro comparison of intact endodontically treated teeth with and without endo-post reinforcement. J Prosthet Dent 1979;42:3944. Hampson E, Clark J. The post retained crown. Dent Pract Dent Rec 1958;8:130135. Harris C. The Principles and Practice of Dentistry, ed 2. Philadelphia:Lindsay and Blackiston, 1871:87. Hatzikyriakos AH, Reisis GI, Tsingos N. A 3 ye ar postoperative clinical evaluation of posts and cores beneath existing crowns. J Prosthet Dent 1992;67:454 458. Helfer A, Melnick S, Schilder H. Determination of moisture content of vital and pulpless teeth. Oral Surg Oral Med Oral Pathol 1972;34: 661670. Hoag E, Dwyer T. Comperative evaluation of three post and core techniques, J Prosthet Dent 1982;47:177181. Holmes D, Diaz -Arnold A, Leary J. Influence of post dimension on stress distribution in dentin. J Prosthet Dent 1996;75:140 147. Huang T, Schilde r H, Nathanson D. Effects of moisture content and endodontic treatment on some mechanical properties of human dentin. J Endod 1992;18:209. Hunter A, Feiglin B, Williams J. Effects of post placement on endodontically treated teeth. J Prosthet Dent 1989;62:166 72. Jacoby W. Practical technique for the fabrication of a direct pattern for a post -core restoration. J Prosthet Dent 1976;35:357360. Kane J, Burgess J. Modification of the resistance form of amalgam coronal -radicular restorations. J Prosthet Den t 1991;65:470 474. Kantor M, Pines M. A comparative study of restorative technique for pulpless teeth. J Prosthet Dent 1977;38:405412. Kurer H, Combe E, Grant A. Factors influencing the retention of dowels. J Prosthet Dent 1977;38:515525. Kvist T, Rydin E, Reit C. The relative frequency of periapical lesions in teeth with root canal retained posts. J Endod 1989;15:578 580

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58 Mattison G, Delivanis P, Thacker R, Hassell K. Effect of post preparation on the apical seal. J Prosthet Dent 1984;51:785789. Mcdonald A, King P, Setchell D. In vitro study to compare impact fracture resistance of intact root treated teeth. J Endodont 1990;23:304312. McLean A. Predictably restoring endodontically treated teeth. J Can Dent Assoc 1998;64:782 787. Mendoza D, Eakle W. Ret ention of posts cemented with various dentinal bonding cements. J Prosthet Dent 1994;72:591594. Mentink AG, Meeuwissen R, Kayser AF, Mulder J. Survival rate and failure characteristics of the all metal post and core restoration. Journal of Oral Rehabilita tion 1993;20:455 461. Monaghan P, Roh L, Kim J. Corrosion behaviour of selected implant alloys. J Dent Res 1992;71:253. Morgano S, Brackett SE. Foundation restorations in fixed prosthodontics: current knowledge and future needs. J Prosthet Dent 1999;82:643 657. Morgano S. Restoration of pulpless teeth: application of traditional principles in present and future contexts. J Prosthet Dent 1996;75:375 380. Nathanson D. New views on restoring the endodontically treated tooth. Den Econ 1993;83:4850. Organizati on participating in the Eighth Edition of The Glossary of Prosthodontic Terms. J Prosthet Dent 2005;94:71. Palmqvist S, Soderfeldt B. Multivariate analyses of factors influencing the longevity of fixed partial dentures, retainers, and abutments. J Prosth et Dent 1994;71:245250. Papa J, Chain C, Messer H. Moisture content of vital vs. endodontically treated teeth. Endod Dent Traumatol 1994;10:9193. Peutzfeldt A, Sahafi A, Asmussen E. A survery of failed post -retained restorations. Clin Oral Invest 2008;12:37 44. Portell F, Bernier W, Lorton L, and Peters D. The effect of immediate versus delayed dowel space preparation on the integrity of the apical seal. J Endod 1982;8:154160. Radke R, Barkordar R, Podesta R. Retention of cast endodontic posts: Comparis on of cementing agents. J Prosthet Dent 1988;59:318320. Reeh E, Douglas W, Messer H. Stiffness of endodontically treated teeth related to restoration technique. J Dent Res 1989;68:15401544.

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59 Richmond C. New method of attaching gold crowns to natural roots of teeth. Am J Dent Sci 1878;12:425. Ring M. Dentistry: An Illustrated History, ed 2. St Louis, MO:CV Mosby, 1985:91. Robbins J. Guidelines for the restoration of endodontically treated teeth. J Am Dent Assoc 1990;120:558566. Robbins J. Restoration of the endodontically treated teeth. Dent Clin N AM 2002;46:367387. Rosen H. Operative procedures on mutilated endodontically treated teeth. J Prosthet Dent 1961;11:973 986. Rosenstiel S, Land M, Fujimoto J, Contemporary Fixed Prosthodontics, ed 2. St. Louis MO:CV Mosby, 2001:255. Ruemping D, Lund M, Schnell R. Retention of dowel subjected to tensile and torsional forces. J Prosthet Dent 1979;41:159162. Safavi K, Dowden W, Langeland K. Influence of delayed coronal permanent restoration on endodontic prognosis. Endod Dent Traumatol 1987;3:187191. Santos -Filho P, Castro C, Silva G, Campos R, Soares C. Effects of post system and ength on the strain and fracture resistance of root filled bovine teeth. Intern Endod J 2008;41:493501. Schwartz R, Summitt J, Rob bins J. Fundamental of Operative Dentistry: A Contemporary Approach, ed 2. Chicago:Quintessence, 1996:321. Sedgley C, Messer H. Are endodontically treated teeth more brittle? J Endod 1992;18:332335. Shillingburg H, Keesler J. Restoration of The Endodontic ally Treated Tooth, ed 1. Chicago:Quintessence, 1982:13. Sidoli G, King P, Setchell D. An in vitro evaluation of a carbon fiber -based post and core system. J Prosthet Dent 1997;78:59. Silverstein W. The reinforcement of weakened pulpless teeth. J Prosthet Dent 1964;14:372 381. Sorensen J, Engelman M. Ferrule design and fracture resistance of endodontically treated teeth. J Prosthet Dent 1990;63:529536. Sorensen J, Martinoff J. Clinically significant factors in dowel design. J Prosthet Dent 1984;52; 2835. Sorensen J, Martinoff J. Intracoronal reinforcement and coronal coverage: A study of endodontically treated teeth. J Prosthet Dent 1984;51:7804. Spalten R. Composite resins to restore mutilated teeth. Oper Dent 1971;25:323326.

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61 BIOGRAPHICAL SKETCH The author, Hassan Mosuawi, was born in 1978 in Malta. He grew up in Kuwait City, Kuwait. Graduated from Salah Aldeen High School in Kuwait City in June1996. In August of 1996, he enrolled at the University of Missouri -Kansas City as a dental student where he joined the six -year -combined program of Bachelor of Art and Science. In 200 3, Mousawi graduated from the University of Missouri -Kansas City School of Dentistry, with a Doctor of Dental Surgery degree. The author returned home to Kuwait and worked for the public health system of Kuwait from 2003 to 2006 before deciding to pursue a dental specialty degree in the United States. In July 2006, he enrolled in the Graduate prosthodontics program at the University of Florida. After graduation with a Master of Science in dental sciences with a specialization in prosthodontics from the U niversity of Florida in May of 2009, he plans to return to Kuwait and work for the public health system for the betterment of the dental service of his beloved country. This is the beginning of the rest of his life.