Post-and-Core Restoration of Severely Damaged

Permanent Posterior Teeth in Young Adolescents

Nili Tickotsky, DMD, MSc, MEd1/Roy Petel, DMD2/Yael Haim, DMD3/
Maysa Ghrayeb, DMD3/Moti Moskovitz, DMD, PhD4

Purpose: This retrospective study evaluated the survival rates of postendodontic severely
decayed posterior permanent teeth in young adolescents. Materials and Methods: A total
of 48 teeth (patient age range: 8.8–16.9 years) restored with a Kurer post-and-core system
(Anchor System, Kurer K4) were assessed. Follow-up appointments 1 to 6 years posttreatment
included radiographs and a clinical examination. Results: A total of 5 teeth (10.4%) were
extracted, and 13 restorations (27%) required repair. Average restoration-to-failure time was
27 months (SD 12.2 months). Conclusion: In view of these findings, clinicians should consider
post-and-core restorations an alternative to extractions of endodontically treated severely
damaged teeth in adolescents. Int J Prosthodont 2017;30:458–460. doi: 10.11607/ijp.5243

E ndodontically treated severely decayed permanent

posterior teeth in young patients present the den-
tist with a restorative challenge. Little intact dentin
predicts a less than optimal prognosis,1–3 and per-
manent crowns are not recommended until full teeth
eruption.3 Permanent teeth extractions in adolescents
might result in various complications, such as posteri-
or bite collapse, loss of alveolar bone height, and tooth
migration with subsequent space closure.4,5
The present retrospective study aimed to evaluate
the survival rates of postendodontic severely dam-
aged posterior teeth in adolescents restored with
posts and cores.
Materials and Methods
The study protocol was approved by the Institutional
Human Subjects Ethics Committee of the Hebrew
University Hadassah School of Dental Medicine,
Jerusalem, Israel. Dental records of 74 patients with
89 endodontically treated teeth restored with a Kurer
1Researcher, Bar Ilan University, Ramat Gan, Israel.
2Senior
Member, Department of Pediatric Dentistry, Hebrew University,
Hadassah School of Dental Medicine, Jerusalem, Israel.
3Private Practice, Jerusalem, Israel.
4Senior Lecturer and Director of Postgraduate Program, Department
of Pediatric Dentistry, Hebrew University, Hadassah School of Dental
Medicine, Jerusalem, Israel.
Correspondence to: Dr Moti Moskovitz, Department of Pediatric
Dentistry, Hadassah School of Dental Medicine, PO Box 12272,
Jerusalem 9112102, Israel. Fax: 972-2-6431747.
Email: motim@md.huji.ac.il
©2017 by Quintessence Publishing Co Inc.
post-and-core system (Anchor System, Kurer K4)
were assessed. A total of 48 teeth in 31 females and 17
males with at least 1 year of follow-up and that had not
been restored with a crown were included in the study.
All teeth had poor prognoses, with less than 50%
of the crowns’ peripheries present. Mean age at time
of treatment was 13.88 years (range: 8.8–16.9 years).
The same dentist (P.K.) performed all restorations us-
ing the Kurer Anchor System, a cylindrical, threaded
post system1,2 (Fig 1). A total of 13 teeth were restored
with amalgam, which was bonded to the tooth us-
ing Amalgambond PLUS (Parkell), and 35 teeth were
restored with composite resins of various brands, as
listed in Table 1.
Follow-up appointments that included bitewing
radiographs, a periapical radiograph, and a clinical
examination were conducted 1 to 6 years posttreat-
ment. Follow-up time ranged from 12.7 to 72.8 months
(1.06–6.07 years) with a mean follow-up of 26.9 ± 12.3
months. Restorations were independently evaluated
by two board-certified pediatric dentists (M.M. and
R.P.) who had not performed the restorations. Failures
were divided into two categories: irreversible failures,
resulting in tooth extraction (eg, post fracture, root
fracture, periapical lesions), and reversible failures,
requiring a new coronal restoration (ie, core failure).
Statistical Analyses
Data were analyzed using SPSS software version 20
(SPSS). Analyses consisted of chi-square analysis
with significance level set at P ≤ .05. Kaplan-Meier
analysis with log-rank test was used to test the vari-
able restoration core type for its influence on the sur-
vival probability, with a cutoff value of P = .05.

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 Tickotsky et al

Fig 1  Maxillary left first molar re-

stored with post and core restoration
using the Kurer Anchor System and
Filtek P60 Posterior Restorative (3M
ESPE).

Table 1   Characteristics of Failed and Damaged Restorations

Time from
Patient age Time from endodontic
at time of Tooth treatment treatment to Total
Patient treatment number to failure post and core follow-up
sex (y) (FDI) Restoration type Reason for failure (y) restoration (mo) period (y)
Female 8.8 36 Amalgam + SSC Marginal inadequacy 2.48 0.3 8.65
Male 15.4 26 Amalgam Restoration broke 2.42 0.6 6.3
Female 10.8 46 Amalgam Secondary caries 2.7 0.6 6.15
Female 9.8 36 Amalgam Lingual wall broke 5.7 0.6 5.7
Male 16.4 36 Composite Alveolar bone loss + 6.3 2 6.3
coronal material loss
Female 14.6 47 Composite Clearfill Secondary caries 6.25 6.0 6.25
Male 9.5 46 Composite Clearfill + SSC Secondary caries 3.25 6.0 4.7
Female 13.25 25 Composite Restoration broke 3.33 2 4.53
Female 11.1 46 Composite Heliomolar Secondary caries 3.04 3 3.04
Male 14.1 16 Composite P60 Secondary caries 2.75 50.5 2.75
Male 15.0 46 Composite P60 Inadequate distal 2.37 2.0 2.37
margins
Female 10.7 46 Composite Alveolar bone loss 2.33 29.2 2.33
Male 15.0 46 Composite P60 Inadaquate restoration 1.74 21.6 1.74
Female 10.9 25 Composite Secondary caries 1.41 0.3 1.41
Male 16.1 36 Amalgam Periapical inflammation 5.6 3 5.6

Female 15.2 16 Composite Qglass Periapical 1.8 24.9 2.64

inflammation
Female 13.6 36 Composite Heliomolar Fistula 0.47 – 0.47
Female 14.5 14 Composite + temporary Vertical root fracture 2.1 3.95 2.1
acrylic crown
Mean 13.0 3.1 11 4.057
Extracted teeth are bold. SSC = stainless steel crown.

Results Pearson chi-square test showed no statistically sig-

Of the 48 teeth followed, 5 (10.4%) were extracted. A
total of 13 core restorations (27%) showed dental car-
ies or marginal incompatibility and had to be repaired.
Average time from restoration to extraction/core dam-
age was 27.06 months (SD 12.2 months). Extracted
teeth and damaged restorations are described in Table
1. Kaplan-Meier curve of core survival according to
restoration material is shown in Fig 2. Log-rank test
showed no statistically significant difference in survival
rate for amalgam and composite restorations (P = .778)
or for females and males (P = .857).
nificant correlation between success rate and (1) type
of restoration (P = .189, df = 1), (2) time from endodon-
tic treatment to restoration (P = .96, df = 5), (3) patient
age (P = .76, df = 4), or (4) tooth type (molar/premolar)
(P = .0583, df = 9).
Discussion
The Kurer anchor system showed a relatively high
survival rate, with only ~10% of the treatments re-
sulting in irreversible failures. Survival curves indi-
cate that at 4 years posttreatment most restorations

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Post and Core for Permanent Young Teeth

Conclusions
1.00 +
+++
++
++
+
+++++
+
Cumulative survival (%)

0.80 +
++
0.60
0.40
0.20 Amalgam
Average
0 Composite
0 1 2 3
Time postrestoration (y)
Fig 2  Kaplan-Meier survival curves according to the restoration
material.
were still intact, suggesting that crowning the teeth
at that time (or earlier) may improve long-term sur-
vival.3 These results are interesting in light of the lack
of studies on the prognosis of post-and-core resto-
rations for adolescents. To the best of the present
authors’ knowledge, the present study considers the
lowest age range studied yet.
Although the Kurer post system uses an invasive
dentin threading procedure that can contribute to
root fracture in young teeth with wider pulp resulting
in thin radicular dentin walls after endodontic treat-
ment, only two teeth in this cohort experienced root
fracture.
Study limitations include a rather small sample size,
a follow-up period that is less than optimal, and lack
of a control group in the form of a different post sys-
tem due to the study being retrospective. Another in-
herited disadvantage is that teeth were not isolated
with a rubber dam prior to composite core buildup,
which might have compromised restoration durability.
Although the study’s limitations prevent drawing defi-
nite conclusions, the fact that most restorations were
++++ +
still intact 4 years posttreatment should encourage
clinicians to consider post-and-core restorations as
+ an alternative to extractions of severely damaged per-
manent teeth in adolescents.
4 5 6 Acknowledgments
This study is based on a DMD thesis submitted to the Hebrew
University Hadassah School of Dental Medicine, Jerusalem, Israel.
The authors would like to thank Dental Volunteers for Israel (www.
dental-DVI.co.il) clinic for the use of the database for the study.
Dr Kurer is the inventor of Kurer K-4 Anchor System. He donated
the post and volunteered as a dentist, treating the patients of the
Dental Volunteers for Israel clinic from adolescence to the age of
18 years, three times per annum since 2003. The authors reported
no conflicts of interest related to this study.
References
  1. Fokkinga WA, Kreulen CM, Bronkhorst EM, Creugers NH. Up
to 17-year controlled clinical study on post-and-cores and cov-
ering crowns. J Dent 2007;35:778–786.
  2. Nagasiri R, Chitmongkolsuk S. Long-term survival of endodon-
tically treated molars without crown coverage: a retrospective
cohort study. J Prosthet Dent 2005;93:164–170.
 3. Schwartz RS, Robbins JW. Post placement and restoration
of endodontically treated teeth: A literature review. J Endod
2004;30:289–301.
  4. Craddock HL, Youngson CC, Manogue M, Blance A. Occlusal
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Literature Abstract

Pilot Randomized Controlled Trial of Titrated Subcutaneous Ketamine in Older Patients with Treatment-Resistant Depression

The purpose of this study was to assess the efficacy and safety of subcutaneous ketamine for geriatric, treatment-resistant depression,
and secondary aims were to examine whether repeated treatments were safe and more effective at inducing or prolonging remission than
a single treatment. In this double-blind, controlled, multiple-crossover study with a 6-month follow-up (randomized controlled trial [RCT]
phase), 16 participants (≥ 60 years of age) with treatment-resistant depression who relapsed after remission or did not remit in the RCT
were administered an open-label phase. Up to five subcutaneous doses of ketamine (0.1, 0.2, 0.3, 0.4, and 0.5 mg/kg) were administered in
separate sessions (≥ 1 week apart), with one active control (midazolam) randomly inserted (RCT phase). Twelve ketamine treatments were
given in the open-label phase. Hemodynamic and psychotomimetic outcomes, as well as mood, were assessed by blinded raters. Remit-
ters in each phase were followed for 6 months. Of the 14 patients who completed the RCT phase, 7 remitted with ketamine treatment, and
5 remitted at doses below 0.5 mg/kg. Doses ≥ 0.2 mg/kg were significantly more effective than midazolam. Ketamine was well tolerated.
Repeated treatments resulted in higher likelihood of remission or longer time to relapse. These results provide preliminary evidence for
the efficacy and safety of ketamine in treating elderly depression patients. Dose titration is recommended for optimizing antidepressant
and safety outcomes on an individual basis. Subcutaneous injection is a practical method for giving ketamine. Repeated treatments may
improve remission rates (clinicaltrials.gov; NCT01441505).

George D, Gálvez V, Martin D, et al. Am J Geriatr Psychiatry 2017 [Epub ahead of print]. References: 29. Reprints: Colleen Loo, School of Psychiatry,
University of New South Wales, Sydney NSW 2052, Australia. Email: colleen.loo@unsw.edu.au —Steven Sadowsky, USA

460 The International Journal of Prosthodontics

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