A Novel Approach to Fracture Resistance

Using Horizontal Posts after Endodontic

Therapy: A Case Report and Review of
Literature

Journal of Endodontics
April 2020,volume:26(3)
Pg no:545-550

GUIDED BY: PRESENTED BY :

DR.P.KARUNAKAR DR.M.RASAGNA
DR.UMRANA FAIZUDDIN PG 2ND YEAR
DR.ASHISH JAIN
CONTENTS
• Introduction
• Restorative-decision making protocol
• Aim of the study
• Case report
• Discussion
• Conclusion
• Critic analysis
• Review of literature
• Take home message
• references
INTRODUCTION
Coronal destruction
caused by caries

fractures

Previous
restorations

Endodontic
access
• In a retrospective 10-year survival study, it was shown that

91.3% of teeth that were crowned after root canal therapy survived
compared with a survival of only 76% for teeth not restored with a crown.

• Several studies have reported more constricted access openings  may limit
their ability to instrument and reach more of the canal walls.
• Several endodontists cite literature which  shows that endodontic failures are
mostly related to fracture and not due to  infection.

• In the 10-year survival study, only 7% of teeth were lost because of endodontic
failure compared with 36% that failed because of root fracture.
• Prognosis of ETT is influenced by different parameters such as 
amount of hard tissue loss,
presence of a minimum of 1.5–2.0 mm ferrule height preparation ,
 post and core material used.

• However, the type of material and restoration technique are

still controversial for endodontically treated teeth.

• Different prosthetic techniques and materials have been reported for

the restoration of ETT .
RESTORATIVE DECISION -MAKING PROTOCOL
• STEP- 1:
Assessment of the  Amount of the tooth structure loss and any
modifying factors.

• STEP-2:
Choosing a conservative treatment option for each clinical situation
Assessment of the  Amount of the tooth
structure loss and any modifying factors.
• This is an essential step because the type of  definitive
restoration  chosen to restore the tooth will be influenced by this
factor.

•  This acts as a  fundamental for an accurate assessment of the

strength of the remaining tooth structure.
MARGINAL RIDGES

• Critical in the maintenance of tooth stiffness and limiting

excessive cuspal deflection.

•  In a study done by Reeh et al, Loss of tooth stiffness was

20% -occlusal cavity 46% -one marginal ridge loss 63%-two marginal ridge loss
• In a study done by shahrbaf et al ,evaluated the effect of marginal ridges 
thickness on fracture resistance of ETT,composite restored maxillary
premolars found that

Marginal ridge thickness of >1 mm preserved the fracture

resistance of the teeth.

• Various studies have reported that

 Removal of both marginal ridges in MOD cavity preparation resulted  in

more  cuspal deflection when compared  to MO/DO cavity. 
THE BUCCAL AND PALATAL/LINGUAL AXIAL
WALLS
• The remaining wall thickness was reported to be an important factor
in the resistance to fracture under occlusal load.

• In a study done by Scotti et al,reported that an axial wall thickness of

<2mm was noted to reduce the tooth resistance to fracture in ETT
premolars.
ENDODONTIC ACCESS CAVITY
• In a study done by Panitvisai  et al, reported an increase of 2–3 folds
of cuspal deflection when an endodontic access cavity was carried
out for MO/DO and MOD cavities. 

• Depending upon the amount of tooth structure remaining,ETT were

divided into three categories
Minimally destructed ETT
Moderately destructed ETT
Severely destructed ETT
 MINIMALLY DESTRUCTED ETT

• Do not necessarily cuspal coverage.

• In One retrospective clinical study,Endodontically

treated molars with occlusal cavities restored with
intracoronal restorations reported to have 78%
survival rates over 5 yrs.

 Occulsal cavity or
Thick remaining axial
walls >2mm
MODERATELY DESTRUCTED ETT

Thin remaining axial

walls<2mm  or a MOD cavity

• Require cuspal coverage to increase the fracture resistance.

SEVERELY DESTRUCTED ETT

Tooth structure loss

beyond an MOD cavity

• Would definitely require cuspal coverage.

• Cuspal coverage in these clinical cases would also facilitate the
reestablishment of the lost occlusal anatomy.
CHOOSING A CONSERVATIVE TREATMENT  OPTION FOR 
EACH CLINICAL SITUATION
• Flowchart for the decision making process for restoration of posterior ETT using
adhesively retained restorations
• The substantial loss of ETT structures during preparation might worsen the
situation when endodontic treatment is associated with MOD cavities. 

• From this point, adhesive restorations, with the potential to reinforce

weakened tooth structure seem to have an advantage over crowns.

• The clinical outcomes of direct or indirect  resin composite restorations,

represent a less invasive approach , are variable in the literature, ranging
from catastrophic to acceptable.
 CLASSIFICATION OF
POSTS
POSTS

NON-METALLIC
METALLIC POSTS POSTS

Carbon-fibre posts
Custom cast posts Fibre reinforced posts
Ceramic posts
Prefabricated posts Zirconia posts
 FIBRE REINFORCED
POSTS

Chair sided Prefabricated

fabricated FRC FRC posts
POST

Carbon Glass Quartz

Polyethylene fibre fiber fibre
woven fiber posts posts posts
tapes
• Usually,fiber post placement is indicated if the coronal tooth structure is
insufficient to support a core buildup.

• ADVANTAGES OF FIBER POSTS:

Favorable physical properties

Elastic modulus similar to dentin

Their bond strength is equivalent to adhesively or conventionally luted gold post

Reduce the risk of tooth fracture

Display higher survival rates than teeth restored with rigid zirconia posts
• Placement of fibre posts within the radicular dentin have some
limitations:
Weakening of the radicular structure during post space preparation.
poor bonding strength in the apical areas of the post space.

• Also,treatment using posts should be used only for retention of a core

within the remaining tooth structure but not for aiming to strengthen the
tooth
• Therefore, the application of horizontal fiber posts in MOD cavities has
come into question.

• Several studies have shown that a horizontal fiber reinforcement of the

ETT might enhance the fracture resistance of these teeth in MOD cavities.

• This technique is primarily indicated for teeth in which no subsequent

crown is planned, and there could be an esthetic compromise.
• Studies done by Beltrao et al and Favero et al advocated that transfixing
posts with composite restorations.

• Enhanced the fracture resistance of the tooth when compared with

restorations with no post transfixed.

• Until now, there have been no clinical cases reported using horizontal
posts
 AIM OF THE STUDY

• The aim of this case report was to describe a technique for reinforcing the
coronal tooth structure with horizontal fiberglass posts running buccolingually
embedded in a composite resin core after endodontic therapy.
CASE REPORT
• A 40-year-old Hispanic man presented with a chief complaint of
spontaneous sharp pain in the maxilla of 4 days duration that radiated
to the right ear.

• No thermal sensitivity, pain was worse at night, prevented him from

sleeping.

• On oral examination no lesions 

Floor of the mouth
Borders of the tongue
Hard/soft palate
Mucosa or gingiva.
• On clinical examination, upper right  first molar was sensitive to
palpation and percussion.
• Probing depths were within normal limits.
• Based on the findings,diagnosis was  pulp necrosis with symptomatic
apical periodontitis.

Pre-op radiograph irt #3 showing

periapical  radiolucency with
coronally radioopaque filling was
seen.
 • Root canal therapy was advised  irt to that tooth.
•  Later, two horizontal posts to reinforce was suggested as treatment plan as
pt could not afford for crown.
• Root canal treatment was performed in two appointments.

Buccal view of horizontal Fibre glass posts and 

Occlusal view of root
space preparation double tapered Light post
canal treated teeth
drill
Cementation of horizontal Placement of compactible
posts with flowable composite resin in the pulp
composite resin chamber around the horizontal Final restoration
posts
Post-op radiograph with 17 mnths  follow-up
clinical pic 17 mnths post- op
horizontal posts radiograph
 DISCUSSION
• One of the endodontist’s challenges is to convince the patient that
immediate restoration after root canal therapy  as the  tooth is
vulnerable to fracture.

• Immediate placement of horizontal posts after endodontic therapy

may reduce the possibility of developing a fracture.

•  This technique is primarily for teeth in which no subsequent crown is

planned, and there could be an esthetic compromise.
• Relatively fast, simple procedure.

• The only prerequisite is that the buccal and lingual walls remain standing.

• The cost effectiveness of this procedure outweighs the alternatives  such

as extraction and implant or post-core and crown build-up.

• In a  vitro study done by Scotti et al , salameh et al reported 

•   When compared with a direct composite restoration , a composite

restoration reinforced with glass fibers significantly increased fracture
resistance.
• In an vitro study done by Karzoun et al,reported that a composite resin core
buildup with a single horizontal fiberglass post running buccolingually
doubled the fracture resistance.

•  These findings reveal that the extension of these  horizontal glass fiber post
through the buccal and palatal cusps.

• They strengthens the composite resin filling and through adhesion reinforces
the cusps and enhances the fracture resistance of ETPs. 
• In a simliar  study done by bromberg et al on molars,reported that the teeth
restored with direct composite resin with  2 TFP showed higher fracture
resistance by 60%.

• One possible explanation would be the reduction of cusp deflection caused

by anchoring of the buccal and lingual walls of the cavity preparation
• Similar results were found in the following studies.

• In a study done by Beltrao et al, observed a 29% fracture resistance recovery

with direct composite restorations and 62% with the same technique with
TFPs. 

• In a study done by Favero et al,showed a 78% to 80% recovery of resistance

by using 2 fiberglass posts with different diameters and 46% without the
posts.
• Though ,majority of articles stated a significant  increase in  fracture
  resistance  when the tooth was restored with horizontal fiberglass posts.

• This statement  did not follow through  with  fracture location.

• In a study done by Mergulhao et al,evaluating  the resistance and patterns

of fracture of endodontically treated maxillary premolars (ETPs) restored
with different methods.
80% of restorations with
horizontal fiber posts are
30% being repairable
repairable(above
when the restoration
stimulated bone level)
is a conventional
composite resin
without horizontal
posts.

Facture mode  was based on

the classification given zicari et
al.
• Scotti et al, used  the cementoenamel junction as the determinant of
catastrophic fracture.

•  Karzoun et al  uses the cervical third of the root as a reference point.

• Bromberg  , Beltrao et al, and Favero et al  define it as a crack in the pulpal
floor.

• The concept of repairable has not been finalized as restorative treatment

plan  is a  very subjective issue between doctor and patient.
 Summaries of In Vitro Studies Using Horizontal Posts
Author Total number Number Unrepairable Mean Mean % fracture Significance
of teeth in and type of fracture fracture fracture resistance
the study teeth with location resistance resistanc increases with
HP (N) with HP e (N) HP+ CR
CR  with CR relative to CR
only only

Beltrao et al, 75 15 molars Floor of the 2645 1225 100 Transfixing

2009 pulp chamber: cavity
20% preparations
unrepairable  with fiberglass
posts was a
conservative
low-cost
technique to
treat ETT
Karzoun 60 12 premolars Cervical third 961 482 100 The fracture
of roots: 75% resistance of ET
et al, unrepairable upper premolars
2015 restored with
direct CR was
increased when
reinforced with
horizontal fiber
glass posts.

Favero et al, 84 14 molars Floor of the 2989 1783 68 Fiberglass posts

2015 pulp with resin
chamber: composite
43% significantly
unrepairable 
increased the
fracture strength
of endodontically
treated molars.No
effect on fracture
location.
Bromberg et 50 10 molars Floor of the 2693 1680 60 Fracture resistance
al, 2016 pulp of ET molars
chamber: restored with
70% direct CR plus
unrepairable  horizontal fiber
glass posts
increased
significantly

Scotti et al, 60 10 molars Below 582 364 60 The fracture

2016 cementoena resistance of
mel junction: endodontically
100% treated molars
unrepairable restored with
direct CR was
increased when
reinforced with
horizontal fiber
glass posts.
Mergulhao 50 10 molars Below the 935 1000 Not CR
et al, 2019 simulated statistically restorations
bone level: significant reinforced
20% with
unrepairable  horizontal
fiberglass
posts had a
dramatic
decrease in
unrepairable
fractures.
• From mechanical perspective,class design of   restoration with  vertical  post
and core followed by crown has some disadvantages.

• The vertical stresses which are  created during  preparation and  seating of
vertical posts can lead to root fracture.

• They may cause incipient craze or fracture lines  that may develop into a
full-blown catastrophic root fracture leading to  extraction.
• In addition ,during the post –space preparation removal of dentin in the
cervical area of tooth, weaken the tooth even further and subject it to
horizontal fracture.

• Sometimes it also causes strip perforation.

• Use of this horizontal posts provides a short-term benefit  for the pt by
increasing the fracture resistance.

• when the pt wants to  for a full-coverage restoration, the horizontal post-
core buildup can provide sufficient retention. 

• Vertical posts can be placed in a tooth with horizontal posts  with no

damage to previous tooth structure .
CONCLUSION
• The following case report has presented a simple ,relatively easy
placement of horizontal posts  intraorally within the ETT before a full
coverage crown can be placed.

• This horizontal posts usually provides a short benefit  of increasing the

fracture resistance of the ETT.
ADVANTAGES DISADVANTAGES

ü First clinical case to report the  Does not validate the long-term
intraoral placement of  use of horizontal post-core
   Horizontal posts . buildup as a permanent
replacement of a full-coverage
restoration after root canal
therapy

Relatively less cost when

compared to vertical post and
core which can be performed
in underserved communities
or service –working class ppl.
• Within the limitations of the study , it was concluded that
• Endodontically treated molars restored with TFP plus CR had fracture
resistance similar to those restored with ON, which was higher than that
for IN or CR only.
• Within the limitations of the study ,it was concluded that
• Usage of horizontal post or occlusal Ribbond usage increased the
fracture resistance of root canal‑treated premolars with MOD cavities
TAKE HOME MESSAGE
• From the present study,we can note that these horizontal  glass fibre
posts  can serve as alternative to other restorative techinques.

• By providing  , short term benefit of increasing the fracture resistance

of the tooth.

• Based on the positive results  seen in the in vitro studies  as well as in

the  case report, a prospective clinical trial is warranted to test the
validity of the horizontal post technique
 REFERENCES
• Bromberg et al . (2016). Fracture resistance of endodontically treated molars restored with
horizontal fiberglass posts or indirect techniques. The Journal of the American Dental
Association. 147. 10.1016/j.adaj.2016.08.001. 

• Karzoun et al.(2015). Fracture Strength of Endodontically Treated Maxillary Premolars Supported

by a Horizontal Glass Fiber Post: An In Vitro Study. Journal of Endodontics, 41(6), 907–912.

• Motasum Abu-Awwad (2019).A modern guide in the management of endodontically treated

posterior teeth.Review article.Eur J Dent,8930,63-70.

• Scotti et al (2016). Effects of fiber-glass-reinforced composite restorations on fracture resistance

and failure mode of endodontically treated molars. Journal of Dentistry, 53, 82–87.
• Aslan et al(2018).Evaluation of Fracture Resistance in Root Canal-Treated Teeth Restored Using
Different Techniques.Niger J Clin Pract.21(6),795-800.