18  C H A P T E R
Esthetic Posts
George Freedman
T he increasing predictability and popularity of endodon-
tic procedures, attributable in no small measure to the
decreased discomfort associated with the process, have encour-
aged patients to treat and maintain their dentitions for their
entire lifetimes. Largely responsible is a very successful long-term
public education process by the dental profession. Increased
endodontic coverage by insurance carriers also motivates more
patients to choose restoration rather than extraction. In today’s
information-based society, patients are more aware of dental
treatment options and more actively involved in co-diagnosis
and co–treatment planning. Their concerns include the biocom-
patibility of the post-endodontic restorative materials (posts,
cores, and cements), the invasiveness of the restorative proce-
dure, and, most important, the overall functional and esthetic
result.
RELEVANCE TO ESTHETIC
DENTISTRY
Dental professionals’ experience over the past half-century has
confirmed that most, if not all, endodontically treated teeth
require a comprehensive restoration such as a full crown or onlay
to restore the tooth structure destroyed by decay, fracture, or
endodontic access. The clinical aspects of the restoration, given
the variety of post and core materials along with the remaining
tooth structure, can be a challenge. Endodontically treated teeth
seen in a dental practice have lost appreciable amounts of coronal
tooth structure to caries and/or the access preparation. The
objective of the post and core buildup is primarily to replace the
missing coronal tooth structure which will provide retention and
resistance for the crown that will ultimately restore the tooth’s
function and esthetics. Although some controversy surrounds
the absolute need for post and core treatments, the issue can be
reduced to mechanical terms. When much of the coronal tooth
structure remains, a post may be indicated but not required.
When the remaining root exhibits little or no remaining coronal
tooth structure, the foundation provided by the post and core
buildup is an absolute precondition for crown preparation. The
post anchors the restoration to the remaining radicular dentin
without necessarily strengthening the root.
The prognosis is often directly proportional to the bulk
of the remaining dentin: the greater the remaining dentin
482
thickness, the greater the fracture resistance. Posts are selected
to provide maximal retention for the overlying restoration while
minimally invading remaining dentinal tissue. Adhesively
bonded posts increase the retention of the post and core system
and improve the restored tooth’s prognosis. Bonded non-metallic
posts also tend to distribute functional stresses over larger inter-
nal radicular surfaces, decreasing the force per area of root and
thus the possibility of root fracture. The core platform is the
accessible and visible supragingival extension of the post that
supports the crown. Because the core is the physical link between
the remaining subgingival dentin and the overlying crown, its
shape and position are critical in managing the direction and
magnitude of forces transferred to the remaining tooth. The core
material may be exposed through partially translucent or ceramic
crowns, and thus the ideal core coloration is the dentinal shade.
The post-endodontic complex forms a monobloc which com-
prises the multi-layered tooth-to-restoration structure with no
inherently weak interlayer interfaces. Sequential bonding of the
dentin to the post resin cement, to the post, to the core, to the
crown resin cement, and to the crown is critical. The adhesive
strength at each interface must be greater than the bond of the
natural tooth to itself. Successful treatment offers strength and
resistance to the post-endodontic continuum from the residual
dentin to the final restoration that approach the strength and
resistance of the original non-decayed tooth.
BRIEF HISTORY OF THE CLINICAL
DEVELOPMENT AND EVOLUTION
OF POSTS AND CORES
Post and core materials are divided into three separate classes:
post material, core material, and cement. The criteria that dental
professionals must use for determining which materials to use
are based mostly on scientific data, the dentist’s clinical experi-
ence, and, to a lesser extent, patient preference. The first two
would seem to be self-evident. The material must work in the
realm of scientific predictability and it must be successful clini-
cally in terms of time spent, results achieved, and comfort of
both patient and practitioner. Patient preference is largely a
matter of esthetics. As more and more all-ceramic restorations
find their way into dental treatment, the nature of the

sub-structure that supports the crown is increasingly relevant
to the ultimate esthetics of the final restoration. If metal shows
through a tooth-colored ceramic and creates a shadow on the
surface of the restored tooth, the esthetics of the restoration will
not be acceptable. Therefore, of all the criteria for post and core
treatment, esthetics is among the most important.
Dental posts first began as gold pins inserted into teeth, pos-
sibly at considerable pain to the patients. They were used about
2500 years ago in the Etruscan lands of ancient Italy. These
retentive pins were inserted into the radicular canals, which
were probably untreated, and anchored carved ivory chunks to
restore the patient’s function and appearance. Over the past
150 years or so, cast gold has played a significant role in restor-
ing endodontically treated teeth. Gold posts were cast using a
lost wax process and fit the post space more or less accurately.
About 30 years ago, the prefabricated stainless steel post was
introduced. It was stronger and easier to fit, in some respects,
than gold. The titanium post, manufactured from an even
stronger material, was next to be used in dentistry. Subse-
quently, the carbon fiber post was introduced, noted less for its
strength than its ability to be slightly bendable. However,
carbon fibers have the black coloring of carbon and were not
esthetically acceptable. They were relatively quickly replaced by
various glass and fiber rod posts. Core materials have also pro-
gressed from gold to amalgam to glass ionomer, and finally to
composite resin materials. Cements began with zinc phosphate
materials, and have been relatively unchanged until recently,
when composite resin cements became available.
RELATING FUNCTION AND
ESTHETICS OF POSTS
Typically, the post becomes virtually invisible when it is covered
by a porcelain-fused-to-metal crown. Areas that may pose a
visible liability include around the gingival margin where a
shine-through of the metal—gold, stainless steel, or titanium—
through thin dentinal root walls and thin gingival attached
tissue covering the bone on the buccal of anteriors, can give
the entire tooth a grayish appearance. This is particularly
problematic when patients have high lip lines and tend to smile
a lot.
An esthetic post should assume the same coloration as the
underlying dentin, ideally becoming indistinguishable. Thus,
whether working with a porcelain-fused-to-metal or a ceramic
crown, there is no shine-through. The only shade that is actu-
ally visible is of the same hue as the dentin and blends into the
tooth structure. A slight discrepancy is easy to cover up with
current ceramic restoration technologies. It is also very impor-
tant to use a cement that is either dentin colored or preferably
translucent when developing the esthetics of the post and core.
Translucent cement materials allow the underlying tooth color-
ation to shine through and to blend with the ceramic margin.
Tinted cements often create the potential for an additional
color mismatch that further complicates the marginal esthetics
of the restoration.
Contemporary Esthetic Dentistry 483
The function of the post and core as the intermediate restora-
tion between the remaining root and the crown depends on a
strong adhesion among the various restored components. The
dentin adheres to the cement, the cement adheres to the post,
the post adheres to the core, and the core adheres to the crown.
All adhesive strengths exceed the natural adhesive strength of the
tooth to itself. With an adhesively retained post and core, and
subsequently an adhesively retained crown, the tooth can actu-
ally be as strong as the natural dentition prior to any decay.
Earlier cements such as zinc phosphate and polycarboxylate
provided no bonding strength to any of the substrates to which
they attached—enamel, dentin, metal, or ceramic. Resin cements
attach adhesively to all of these materials effectively.
CLINICAL CONSIDERATIONS
Indications
Esthetic posts are clinically similar to and generally more con-
servative of tooth structure than other prefabricated posts. They
can be used for virtually any post-endodontic situation. They
are more conservative and easier to place than cast metal restora-
tions and typically require one chairside appointment versus a
minimum of two sessions for indirect procedures.
Esthetic posts are made of materials that are chemically inert,
eliminating any hazard associated with sensitization or allergy in
the patient.
Contraindications
There are no known contraindications to the placement of
esthetic posts when a post (of any type) is clinically indicated.
MATERIAL OPTIONS
Posts
There are many posts available to the dental practitioner, as well
as many core materials and cements. The best way to evaluate
the most suitable material in each category is to review the sci-
entific data, check the research support, and evaluate the materi-
als. The dentist’s clinical experience, including ease of clinical
use, predictability, and ease of placement, are significant factors
as well. The patient, of course, expects and should be receiving
a long-lasting solution for their post-endodontic condition that
is essentially better, faster, and easier than the other procedures
available.
Of the available post materials, the most common are the
cast metal, the prefabricated metal, and the resin fiber posts.
Cast metal posts (Box 18-1), whether in gold or base metal,
have certain advantages. They are laboratory fabricated, elimi-
nating chairside technique sensitivity. Cast as metal objects, they
have great transverse strength and are very unlikely to break. The
negatives of cast metal posts include difficulty taking impressions;
it is hard to place hydrophobic impression materials into the
narrow confines of the post-endodontic canal and to ensure the
484 Esthetic Posts  
BOX 18.1  Pros and Cons of Cast
Metal Post
Pros
• Lab fabricated
• Great transverse strength
• Long history
Cons
• Difficult impression
• Difficult fit
• High cost
• Does not bond
BOX 18.2 Pros and Cons of Prefab
Metal Post
Pros
• Chairside
• Good transverse strength
• Lasts 20+ years
Cons
• Poor adaptation
• Does not bond
• Poor esthetics
absence of air or water bubbles. The pour of the impression at
the dental laboratory is perhaps even more difficult; it is virtually
impossible to orient the direction of the post precisely when
pouring the stone impression, so the angulation of the post with
respect to the tooth and/or core is often slightly off the mark.
This minute discrepancy can very easily compromise the fit of
the entire post and core complex.
Most dentists will identify with the difficulty of seating the
cast metal post and core into the residual root. In fact, adjust-
ments are often needed either on the restorative material or on
the remaining tooth structure in order to actually develop an
acceptable fit. However, the great advantage of the cast metal
post is its supposedly tight fit into the remaining canal system.
Therefore, in modifying this tight fit in order to be able to seat
the restoration, the major advantage of the cast metal post is
eliminated. The increased cost of the cast metal post arises from
the expenses of the technician’s work and transportation to and
from the laboratory. If gold or similar precious metals are used,
the cost to the dentist and patient can be even higher. The great-
est problem of cast metal posts is that they are typically manu-
factured of noble or non-reactive materials and thus do not bond
to the tooth structure—either enamel or dentin. Furthermore,
these materials do not bond to the overlying crown through the
cement. All the interfaces in the cast metal post system are luting
interfaces which provide a filling of the space between materials,
but no adhesion.
Prefabricated metal posts (Box 18-2) have the advantage of
being inserted chairside, thus eliminating the need for a second
BOX 18.3 Pros and Cons of Resin
Fiber Post
Pros
• Chairside, bonds
• Excellent transverse strength
• Shock absorber
• Esthetics
Cons
• New technique
• Poor esthetics (some)
Data from Mannocci F, Ferrari M, Watson TF: Intermittent loading of teeth restored
using quartz fiber, carbon-quartz fiber, and zirconium dioxide ceramic root canal
posts, J Adhes Dent 1:153-158, 1999.
appointment and incremental laboratory and transportation
costs for the practitioner. The metal itself has good transverse
strength. Unless the prefabricated metal post is abused during
or after insertion, it is unlikely to break or bend during clinical
use. More than 30 years of clinical experience with these materi-
als have generally been very positive.
The negative aspect is that the post hole must be made to fit
the shape of the post. Because this fit is an approximation at
best, the adaptation between the remaining tooth structure and
the post itself is not precise. The intervening space is ultimately
filled by cement, typically less strong than the post. The prefab-
ricated metal does not bond to either the underlying tooth
structure or the overlying core or crown. Prefabricated metal
posts tend to have the same poor esthetics as cast metal posts.
They cast a gray shadow through esthetic restorations if there is
not enough masking material in the core cement or the ceramic
to overcome this esthetic liability.
Resin fiber posts (Box 18-3) were introduced to the dental
profession in the early 1990s. The advantages of these posts
include the fact that they are placed chairside in a single
appointment and they bond to the underlying tooth structure
whether enamel or dentin, to the overlying core, and subse-
quently to the overlying crown if suitable resin cements and
techniques are used. They have excellent transverse strength;
they are composed of many fibers that are bundled together
with BIS-GMA, the basic component of composite dentistry.
The fibers tend to bend under load rather than break. As
they bend, they also act as shock absorbers. This means that
as forces are placed on the crowned tooth, the underlying
post can actually absorb most of the shock rather than trans-
mitting it to the remaining tooth structure. Resin fiber posts
are available in a variety of colors. The earliest ones were
black (carbon fiber), very well researched, and highly regarded
by the profession but posed an esthetic liability in visible
anterior areas. The more recent ones are tooth colored, white,
or translucent, making them much more adaptable to an
esthetic objective.

Researchers have indicated that carbon fiber posts and glass
fiber posts with composite resin cores are less likely to cause root
fractures than stainless steel posts with composite resin cores.
Cores
Over the years, a number of core materials (Box 18-4) have
been used to fabricate post and core restorations. They include
cast metal, amalgam, glass ionomer, cermet, and composite
resin.
The advantages of the cast metal core (Box 18-5) are that it
is laboratory fabricated and involves little chairside work for the
dentist. The thickness of the core provides great transverse
strength to this part of the restoration. It is extremely unlikely
to ever fracture. The cast metal post and core are actually cast as
a single unit, together providing a very strong substructure for
restorations. The major disadvantage of the cast metal core is its
esthetic appearance under ceramic crowns. The bright yellow of
the gold metal core or the darkness of the base metal shine
through ceramic restorations and making esthetic results rather
difficult. The color is quite intense and the porcelain thickness
is limited. Masking cements are difficult to use when the discol-
oration is intense, so acceptable esthetics are unlikely if a ceramic
restoration is placed over a cast metal core. Because cast metal
cores are laboratory fabricated and require two appointments,
their cost is higher, particularly when gold is used. The cast metal
also does not bond either to the underlying tooth structure or
to the overlying crown. The luting cement will provide stability
but no chemical or mechanical adhesion.
The amalgam core (Box 18-6) is inexpensive, very easy to
place (most dentists are familiar with its use), and has good
adaptation to the internal anatomy of the pulp chamber.
However, amalgam forms no chemical bond to the tooth struc-
ture even when “amalgam bonding” materials are used. It has a
very poor transverse strength; any significant horizontal pressure
BOX 18.4 Types of Core Materials
• Cast metal
• Amalgam
• Glass ionomer or cermet
• Composite resin
BOX 18.5 Pros and Cons of Cast Metal
Core
Pros
• Lab fabricated
• Great transverse strength
• Long history
Cons
• Esthetics under ceramic crowns
• Cost
• Does not bond
Contemporary Esthetic Dentistry 485
or force on the amalgam core is likely to fracture it. Its dark
coloration also offers very poor esthetics. The dark gray of the
amalgam (which turns black when it is corroded by time and
saliva) definitely shows through ceramic crowns or at the margins
of overlying restorations. The other disadvantage of amalgam is
that it tends to leech into the surrounding dentinal and soft
tissues, creating amalgam tattoos. Even when it is not directly
visible to the viewer, its effects can be seen as a gray silver pallor
of the soft or hard tissues.
Glass ionomer cores (Box 18-7) were proposed in the mid-
1980s because they release fluoride, and this was viewed as a
distinct advantage. Although there is no doubt that glass iono-
mers do release fluoride, the amount of fluoride absorption by
the remaining tooth structure is debatable. There is little evi-
dence to indicate that the remaining non-vital tooth structure
actually absorbs fluoride from an adjacent polymerized restor-
ative material. Glass ionomer also has a weak bond to the tooth
structure, about 6 to 10 MPa. This is considered a strength by
some, but a weakness by most clinicians. Glass ionomer cores
have poor compressive strength and tend to fail.
Cermets are glass ionomer materials that have metal filings
added to their chemistry. These materials are supposed to be
somewhat stronger than traditional glass ionomers. In fact, they
have stronger compressive strength but tend to be even weaker
overall than glass ionomers. They also have the esthetic liability
of amalgam-like coloration.
Composite cores (Box 18-8) are very strong. They are
made of the same restorative materials that were developed mid-
century and have been used clinically since the 1970s. They form
a strong bond to tooth structures, both enamel and dentin, as
well as to all the dental cements in use today. The composite cores
are bondable to the ceramics and metals of overlying crowns.
They are placed onto the tooth in a flowable state and thus have
an excellent adaptation to the anatomy of the chamber, the canal,
and underneath the crown, as they create a monobloc.
BOX 18.6 Pros and Cons of Amalgam
Core
Pros
• Inexpensive
• Easy
• Good adaptation
Cons
• No chemical bond
• Poor transverse strength
• Poor esthetics
BOX 18.7 Disadvantages of Glass
Ionomer Core
• Poor compressive strength
• Weak bond
• Tends to fail
486 Esthetic Posts  
BOX 18.8 Pros and Cons of Composite
Core
Pros
• Strong bond to tooth, porcelain
• Excellent adaptation
• Creates monobloc
Con
• Change in clinical technique
Cements
A number of materials are available for cementing posts into the
radicular tooth structure. These include zinc phosphate and
polycarboxylate luting materials, glass ionomer, compomer, and
composite cements, some requiring a distinct etching step while
others do not, as they are self-etching.
Clinically, it must be questioned whether cements are really
necessary as a separate step? After all, there is little difference
between adhesive resin cement and core buildup materials. They
are typically quite similar in terms of chemistry, characteristics,
and application mode. The major difference is that the core
material is somewhat more filled. If, however, a suitable com-
promise can be found between the core material and the resin
cement, it makes sense that the same material can be used for
both applications. In fact, this has been common practice since
the late 1990s. Using the same material for cementation and
core buildup eliminates the waiting time for the polymerization
of the cement inside the post space—a chairside gain of 7 to
10 minutes.
Zinc phosphate cements have a long history in dentistry.
They are effective luting materials but do not adhere to enamel,
dentin, metal, or ceramic and therefore provide no incremental
strength to the restoration. With respect to the overall scheme
of the monobloc, they provide an interface that offers absolutely
no adhesion of the component materials. They are highly irritat-
ing to vital tooth structures due to their application acidity
(pH ~2.0) and their long term acidity once set (pH ~4.5-5.0).
Polycarboxylate cements have been available since the
1970s. They were widely used because they exhibited lower
postoperative sensitivity. Their lower acidity is less irritating to
tissues. In the post-endodontic situation, this is not an impor-
tant consideration because the removal of the nerve means that
there is no sensitivity possible in the tooth. Polycarboxylate, like
zinc phosphate, does not bond to enamel, dentin, metal, or
ceramic. In fact, it is not as strong as zinc phosphate and there-
fore has even less application in the post cementation field at
the present time.
Glass ionomer cements have the inherent advantage of
releasing fluorides. However, they provide a weak bond to the
tooth and are slowly soluble in oral fluids. As previously men-
tioned, there is no evidence that the fluoride released by the
adjacent glass ionomer is actually picked up by the remaining
dentinal tissues. Although the fluoride can act as a local antibac-
terial, it has little, if any strengthening effect on surrounding
BOX 18.9 Pros and Cons of Compomer
Cement
Pros
• Releases fluoride
• Very high bond strength
Con
• May fracture overlying ceramic restorations
BOX 18.10 Pros and Cons of Resin
Cement
Pros
• High bond strength to tooth, metal, ceramic
• Easy and predictable
Con
• New techniques
dentinal tissue. Glass ionomer cement proponents are satisfied
with the weak bond to the tooth structure, typically 6 to 10 MPa,
but it makes more sense for a post and core system to be
cemented into place with a stronger bond to the tooth structure,
specifically by using resin cements with bond strengths of
20 MPa or higher. Glass ionomer solubility in oral fluids is
particularly critical at the restorative margins where salivary
fluids and dietary acids corrode the cement. If a margin is
exposed, the acid can ultimately dislodge the entire post and
core complex.
Compomer cements (Box 18-9) are resin-reinforced glass
ionomers, and have considerable bond strength to tooth struc-
ture, on the order of 50 MPa and higher. They also release
fluoride. These properties would make them seem the ideal
cementation materials for post and core systems. However, com-
pomer cements tend to absorb water after they set, and this
causes them to expand. Even a small coefficient of linear expan-
sion translates into a very large volumetric expansion with water
sorption. As a result, compomer cements have been reported to
fracture overlying ceramic restorations. Theoretically, when used
as post cements, they can also fracture the remaining radicular
root structure. It is not possible to predict the actual direction
in which the compomer cement will expand after setting. These
materials should not be used for post cementation.
Resin cements (Box 18-10) entered common use in the early
1990s. Their advantages include a high bond strength to tooth
structures, both dentin and enamel, as well as to metal and
ceramic. They are easy to use and very predictable in their lon-
gevity. Resin cements may or may not release fluoride but are
virtually insoluble in oral fluids. It is therefore expected that they
will remain as placed for very long periods of time. The bond
strength of resin cement to tooth structures and metal or ceramic
is typically over 20 MPa. Thus the resin cement provides the
ideal interface among the various components of the post-
endodontic restorative monobloc. It can be used to cement every
interface securely and predictably.

There are two kinds of resin cements currently available. One
involves the typical etching, bonding, and resin process wherein
the tooth structures are etched, rinsed, and then bonded with
the adhesive components either mixed or used in sequence. The
other, more advanced option involves single-step, self-etching,
self-adhesive cements applied directly into the moist prepared
tooth. These materials are injected (after auto-mixing) either
into the post space or onto the post. The post is then securely
cemented into the tooth. These self-curing cements are light
initiated and can be used for the core buildup as well.
The ideal post system (Figure 18-1) for the post-endodontic
tooth is a fiber post that is adhered into the remaining prepared
radicular structure with a resin cement that bonds to both the
post and the root structure. This resin cement, which is the same
material as a core buildup material, is used to build up the
form and function of the core that will be prepared to receive
the crown.
OTHER CONSIDERATIONS
Time and convenience are important chairside factors in post
and core fabrication. The major advances in post development
in the latter part of the twentieth century included changes in
post delivery, post cementation, and core buildup. The advent
of the single-appointment, single-step post and core procedure
has made this process much easier for the dental practitioner; it
is also far more practical and more easily financially attainable
for the patient.
Post cementation has become considerably more predict-
able, as well. Adhesive cements have replaced luting cements,
enabling the development of the adhered monobloc rather than
the cemented restoration, which was readily dislodged by force,
trauma, or vibration. Adhesive cements also have the advantage
of distributing the load of forces over the entire radicular
surface rather than focusing the forces to two areas, typically at
the fulcrum and the point of a post. The most recent
FIGURE 18-1  Ideal post system.
Contemporary Esthetic Dentistry 487
development in post delivery is the utilization of the cement as
a core buildup material and vice versa. Using the same material
for both functions eliminates the 7- to 10-minute waiting time
for cement polymerization, allowing the practitioner to proceed
immediately after having placed the cement and light curing.
This permits the practitioner to accomplish the post and core
procedure in far less time and far more efficiently than ever
before.
INNOVATIVE ELEMENTS
Scientific Elements
Among the scientific innovations in current post techniques
are the self-adhesive, dual-cure resin cements. These materials
eliminate the multiple steps needed to prepare the tooth struc-
ture for the resin cement. Previously, the radicular structure
had to be cleansed, etched, bonded with several materials
(accurately mixed or sequentially applied), and light cured,
hopefully to the bottom of the post space. The cement had
to be mixed and inserted. Placing the self-adhesive cements is
far easier. The entire sequence of steps—etching, priming,
bonding, and cementing—is accomplished in the single step
of inserting the auto-mixed cement into the post space and
inserting the post. In this manner, 7 to 10 minutes of prepara-
tion requiring four or six hands (the dentist plus one or two
dental assistants) has been reduced to a procedure that can
be readily accomplished by the solo practitioner in 30 seconds
or less.
Technical Elements
The technological advances in post technology center upon the
move away from cast and prefabricated metals to carbon and
glass fibers. The benefit is that the metal, whether cast or pre-
fabricated, tended to transmit most of the occlusal and lateral
forces that were applied to the crown directly to the remaining
tooth structure (Figure 18-2). In fact, the cast metal post trans-
mits about 88% of all forces that are applied to it to the fulcrum
areas and the apical tip of the post. This places a tremendous
amount of stress on the remaining radicular tooth structure and
occasionally causes root fracture. Prefabricated posts, because
they do not typically fit as well as the cast posts and have the
cushion of the cement between the post and the tooth to absorb
some of the pressure, transmit only about 62% of the crown
forces to the fulcrum and apical tip areas. These loads can also
cause root fractures but are somewhat less likely to do so than
the cast metal posts. The bonded fiber post actually tends to
bend. All the individual fibers, which are held together by
BIS-GMA or polyurethane adhesives, bend and flex slightly
under pressure. Thus they tend to absorb most of the forces
placed on the crown; only 28% is transmitted to the remaining
tooth structure. Furthermore, the fiber post is bonded to the
entire remaining radicular tooth structure; this relatively small
residual force is actually spread out over the entire remaining
radicular tooth structure, not concentrated on the fulcrum or
post apical tip areas.
488 Esthetic Posts  

Fiber post Cast post Pre-fab post

Healthy Low-modulus High-modulus High-modulus

A tooth B restoration C restoration D restoration

FIGURE 18-2  The healthy tooth (A) is subjected to various forces, vertical, lateral, and diagonal. The natural enamel and dentin
are particularly well suited to absorbing and distributing these forces. The low-modulus fiber post restoration (B) is bonded to
the remaining dentin and the core. This relationship absorbs the majority of stresses on the crown bonded to the core, and dis-
tributes them over the entire remaining radicular structure. The high–modulus cast post restoration (C) ideally fits snugly into
the post space, held in place with a luting, non-adhesive cement. Forces on the cemented crown transmit and focus the majority
of the forces to two specific areas, the juncture of the post and the core and the apical tip of the post. This is where most of the
root fractures observed with cast posts occur. The high–modulus pre-fabricated post restoration (D) fits less snugly than the cast
post; the cement acts as a shock absorber, transmitting less force from the crown than the cast post, but much more than the
fiber post. The pre-fabricated post also focuses and transmits forces to the juncture of the post and the core and the apical tip of
the post. Because they are less efficient in transmitting forces, pre-fabricated posts are less likely to fracture roots than cast posts.

TREATMENT PLANNING Sequence

There are a number of options for post placement in endodon-
tically treated teeth. The fundamental issue is whether a post is
actually required as part of the post-endodontic treatment
plan. The literature is divided roughly half and half in this
area. There is agreement, however, among all concerned that
when there is little or no supragingival tooth structure left, the
only method for developing the core that can accept crown
placement is to anchor one or more posts in the remaining
radicular tooth structure, and then to develop the occlusal
end(s) into a core that protrudes above the gingival margin
such that the crown can, in fact, be secured. Thus, if there is a
lot of tooth structure left, it is arguable whether or not a post
should be placed. If there is little or no coronal tooth structure
left, there is no argument—there simply is no other method to
affix a crown.
In most cases, the time the dentist invests in developing the
post and core restoration in an endodontically treated tooth is
far less costly and troublesome than the alternative of treating a
tooth that has suffered the loss of a crown due to a post-less core
that has fractured off at the gingival margin. Therefore this
author recommends that a post be placed as a retentive and a
protective device in all post-endodontically treated teeth.
The post and core complex can be placed only after the end-
odontic treatment has been successfully completed. It must be
securely in place before the crown preparation can start. If the
endodontic procedure is not successful or not yet comfortable
for the patient, it does not make sense to seal the endodontic
access opening with a post and core that obstructs further end-
odontic intervention. Typically the practitioner should wait
until all sensitivity has dissipated and the patient is comfort-
able enough to proceed with the post and core procedure
without any need for local anesthesia. Should problems develop
after the post has been placed, the bonded post is rather diffi-
cult to remove, and the tooth might require an apical end-
odontic procedure, or apicoectomy, directly through the buccal
or lingual; this approach is certainly an option but a secondary
one at best.
Treatment Considerations
In preparing the post hole, the practitioner should follow the
gutta percha root filling material into the canal. To avoid perfo-
rations, the position of the reamer with respect to the gutta

percha should be verified every 1-2 millimeters. Where direct
light visibility is difficult, additional lighting can be used to
identify that the gutta percha is, in fact, in the center of the post
space that is being reamed with the drill. The restorative proce-
dure should use fourth generation adhesives (followed by resin
cements) or preferably the more simplified single-step self-
adhesive cements.
Finishing
There is little surface finishing involved, and polishing is cer-
tainly not required. Essentially, the crown preparation consti-
tutes the finishing procedure for the post and core.
EVIDENCE-BASED PRINCIPLES
The materials, technologies, and techniques described for the
esthetic post and core procedures have been in use since the early
1990s. There is an abundent amount of scientific data on the
materials and steps used in this procedure.
CLINICAL CONSERVATION
CONCEPTS
The driving factor in this area is that as little remaining radicu-
lar tooth structure as possible should be removed. Therefore,
sized posts that are closely adapted to the post endodontic
canal diameter should be used. Most manufacturers produce a
variety of post sizes and size-mated reamers. Fortunately, there
is a wide variety of choices in the products available for this
kind of restoration. Generally speaking, the gutta percha
should be removed initially with the smallest reamer available.
The reamer should be sized up to ensure that all post space
preparation is located in relatively strong, healthy dentin. Once
that has been achieved, the post is tried for fit and depth, and
the procedure is continued.
NEAR-FUTURE DEVELOPMENTS
The current techniques for posts and cores are clinically
simpler—much better, much faster, and much easier than at
any time in the past. The materials are such that it is readily
conceivable that the entire post and core procedure can be
accomplished in no more than 15 minutes as part of the post-
endodontic crown fabrication procedure. It is difficult to see
how much faster and how much easier this process could be.
One possibility is the self-adherent post, a post that has a self-
etching, self-adhesive cement pre-applied to its surface such
that it can be placed into the prepared post space without
additional steps. Alternatively, posts that could be polymerized
or otherwise light initiated to adhere mechanically and possibly
chemically to the surrounding dentinal walls may be
Contemporary Esthetic Dentistry 489
developed. The cement would actually be a component of the
post, either surrounding it in the form of a gel cement cover-
ing, or a substance that is sound or light activated to release
cement from its structure such that it adheres to the surround-
ing surfaces.
CLINICAL TECHNIQUES
The post-endodontic tooth is first isolated (Figure 18-3, A) and
the reamer is used to shape and define the post space inside the
tooth (Figure 18-3, B). Note the flecks of tooth structure and
gutta percha. It is very important during the reamer preparation
to keep the gutta percha centered in the canal with frequent
verification. This avoids inadvertent perforation of the radicular
structure. When the post space reaming is completed, the post
is tried in it (Figure 18-3, C ).
The remaining radicular structure is etched (Figure 18-3,
D). Etching should take no more than 15 seconds. The etch
is washed away completely (Figure 18-3, E ) both on the
surface and inside the post space. The bonding agent is then
applied to the tooth structure (Figure 18-3, F ). In this case
a dual-curing fifth-generation bonding agent, DenTASTIC
UNO-DUO (Pulpdent Corporation, Watertown, Massachu-
setts) is applied to the tooth structure (Figure 18-3, G ). This
material is self-curing and will be light initiated and continue
to completion on its own. All the excess bonding agent must
be blown away with an air syringe until there are no droplets
scattering across the surface (Figure 18-3, H). At this point,
the adhesive is cured (Figure 18-3, I ). The curing light will
not be effective for more than 2 or 3 mm into the canal or
into the post space, but the dual-cure nature of the adhesive
ensures that even in the deepest unlit portions of the post
space there will be a self-cure within a minute. The auto-
mixing resin cement or resin core material is bled onto a pad
(Figure 18-3, J , inset) to ensure the quality of the material,
then injected directly into the post space (Figure 18-3, J ),
preferably from the deepest portions out; once the post space
has been filled with the resin cement, the post is inserted into
the canal (Figure 18-3, K ). It is placed into the canal pas-
sively, but the pressure of the post on the still-fluid core mate-
rial eliminates any voids or air bubbles that might exist.
The post is inserted to its total depth into the still-fluid core
material. The core material is Spee-Dee (Pulpdent Corporation)
(Figure 18-3, L ). After the post has been inserted, the core
material is used to fill in any voids that may be visible (Figure
18-3, M), then the whole complex is light cured. It is then pos-
sible to continue building up the core immediately without
waiting for the cement to set (Figure 18-3, N ); each successive
layer is cured separately. The process can be continued immedi-
ately after each curing step.
Once the buildup procedure has been completed, the excess
post length is removed with a high-speed bur (Figure 18-3, O ).
The post and core are now ready for preparation into the crown
abutment. Figures 18-3, P and Q show the prepared abutment
from the occlusal and the buccal aspects.
490 Esthetic Posts  

A B

C D

E F

FIGURE 18-3  A, Isolated post endodontic tooth. B, Post space inside the tooth defined and shaped using a reamer. Flecks of
tooth structure and gutta percha noted. C, Post tried in after the completion of post space reaming. D, Radicular structure etched.
E, Etch completely washed away on the surface and inside the post space. F, Bonding agent applied to tooth structure.
 Contemporary Esthetic Dentistry 491

G H

I J

K L

M N

FIGURE 18-3, cont’d  G, DenTASTIC UNO-DUO bonding agent is applied to tooth structure. H, Excess bonding agent blown
away with an air syringe until there are no droplets scattering across the surface. I, The adhesive being cured. J, Resin cement
bleed on pad (inset photo) and resin cement injected into the post space. K, Post inserted into the canal after it is filled with the
resin cement. L, Spee-Dee core material. M, Core material used to fill in any visible voids. N, Core can be built up immediately
without waiting for post cement to polymerize. Continued
492 Esthetic Posts  

O P

FIGURE 18-3, cont’d  O, The core is built up and excess post length is removed. P and Q, Prepared abutment, occlusal (P) and
buccal (Q) views. (G and L, Courtesy Pulpdent Corporation, Watertown, Massachusetts.)

C A S E 1  Post and Core Restoration of an Endodontically Treated Tooth

Figure 18-4, A, shows a temporarily restored endodontically treated tooth. The provisional material is removed
(without local anesthetic) using a Great White #557 bur (SS White Burs, Lakewood, New Jersey) (Figure 18-4,
B), and the two canals are filled with gutta percha (Figure 18-4, C). Figure 18-4, D, shows the suitable-sized
reamer used to clean out the gutta percha to the appropriate depth (Figure 18-4, E). It is important to note the
direction of the reamer so that the posts can be inserted and cemented in the same direction. The canals are
ready for adhesive procedures. The two posts are tried into the canal to ensure there is no interference as they
are inserted (Figure 18-4, F), which may cause problems during the cementation with the access of one or the
other post. The post spaces and the pulp chamber are cleaned out thoroughly (Figure 18-4, G); the entire post
and core space is etched (Figure 18-4, H), and bonded. Note that the bonding procedures cannot be shown
because the flash from the camera will cure the adhesive inside the canal. Silane is placed on the post to increase
its adhesion to the composite (Figure 18-4, I inset). The core material is inserted into the two post spaces at
the same time, and the posts are placed to their full depths (Figure 18-4, I). The core is light cured (Figure 18-4,
J). After curing and successive layer buildup, the final step is the placement of the core all the way to the occlusal
surface (Figure 18-4, K). The excess post length is removed with a bur (Figure 18-4, L). Both diamonds and
carbides can be used. The occlusal surface of the tooth is polished (Figure 18-4, M). This tooth is now ready for
function or preparation for a crown. After the rubber damn has been removed, the post-treatment view of the
tooth can be seen (Figure 18-4, N), with the pretreatment view on the inset.
 Contemporary Esthetic Dentistry 493

C A S E 1  Post and Core Restoration of an Endodontically Treated Tooth (cont’d)

A B

C D

E F

FIGURE 18-4  A, Temporarily restored endodontically treated tooth. B, Provisional material removed using a Great
White bur. C, Two canals filled with gutta percha. D, The reamer used to clean out the gutta percha for the
appropriate depth. E, Canals reamed to the appropriate depth and ready for adhesive procedures. F, Two posts tried into
the canal.
Continued on next page
494 Esthetic Posts  

C A S E 1  Post and Core Restoration of an Endodontically Treated Tooth (cont’d)

G H

I J

K L

FIGURE 18-4, cont’d  G, Post spaces and the pulp chamber thoroughly cleaned. H, Entire post and core space etched
and bonded. I, Silane is placed on the post (inset photo) and core material inserted into the two post spaces. The posts are
placed to their full depths. J, The core is light cured. K, Placement of the core all the way to the occlusal surface. L, Excess
post length removed with a bur after final layer is cured.

C A S E 1  Post and Core Restoration of an Endodontically Treated Tooth (cont’d)
M N
FIGURE 18-4, cont’d  M, Occlusal surface of the restoration is polished. N, Post-treatment view of the tooth, comparing
it to the pretreatment view (inset).
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