RestorativeDentistry

Jamie Dickie John McCrosson†

Post Removal Techniques Part 1

Abstract: Dismantling restorations from teeth which require endodontic re-treatment can be difficult. Many dentists are reluctant to
remove posts through fear of weakening, perforating or fracturing the remaining root structure. A variety of techniques have been
described and developed for post removal. This is the first in a series of two papers which provide an overview of these techniques. The
rationale for endodontic re-treatment, pre-operative assessment and factors affecting post removal are discussed. Techniques are illustrated
with clinical case reports.
The second paper describes the use of specific post removal devices and the removal of fibre posts.
Clinical Relevance: Endodontic re-treatment has a more successful long-term outcome than surgical treatment for failed root canal
treatment. This may involve the removal of existing post restorations or portions thereof.
Dent Update 2014; 41: 490–498

Endodontic re-treatment can be complex that, with good case selection, post removal undergone root canal treatment and
and challenging. The goal is to access the is a predictable procedure. Root fractures subsequent restoration.7 Since carrying out
pulp chamber, remove materials from the rarely occur if appropriate techniques and post removal and endodontic re-treatment
root canal space and, if present, address devices are used.3,4 is time consuming and costly, it could
deficiencies or repair defects that are No single method always be counterproductive to embark on this
pathological or iatrogenic in origin.1 This produces a successful result. In many cases, approach when the overall oral condition
may involve the removal of an existing post. a combination of various techniques may gives a poor foundation for a successful
Many dentists are reluctant be required. Therefore, familiarity with restorative outcome. Teeth of poor
to attempt post removal through fear of a variety of techniques may increase an prognosis include those with significant
weakening, perforating or fracturing the individual clinician’s chances of success. probing depths, mobility and furcation
remaining root structure.2 As a result, a involvement.8
high number of patients are referred to Additionally, some removal
specialist centres by general practitioners Endodontic re-treatment vs techniques require a degree of force to be
requesting removal or surgical treatment. apicectomy applied and it would be ill-advisable to use
However, the presence of a post should not A systematic review by these methods on teeth which are mobile
be considered as an indication in itself for Torabinejad et al found that endodontic as a result of periodontal disease.
periapical surgery.3 surgery offers more favourable initial Endodontic
Various techniques have been success, but non-surgical retreatment offers When assessing teeth for
designed and developed for post removal. a more favourable long-term outcome.5 A endodontic re-treatment, there are several
Dental practitioners should be reassured study by Naito produced similar results.6 factors that need to be considered to
This appears to suggest that determine the prognosis for successful
conservative endodontic re-treatment is the endodontic re-treatment.9 These include:
preferred choice compared with periapical  Periapical radiolucency − Teeth with an
surgery, as it is generally more successful apical lesion display have a lower success
Jamie Dickie, BDS, MFDS RCPS(Glasg), and predictable. rate compared to those without;10
Lecturer and Honorary Registrar  Size of radiolucency − Teeth with a lesion
in Restorative Dentistry and John <5 mm in diameter have a greater success
McCrosson†, BDS, FDS RCPS(Glasg),
Pre-operative assessment rate than those with a lesion >5 mm;10
Former Lecturer and Honorary Consultant Periodontal  Previous treatment factors − Poor access
in Restorative Dentistry, Glasgow Dental Tait et al stressed that cavity design, untreated, poorly cleaned
Hospital and School, 378 Sauchiehall periodontal health is critical in determining and obturated canals, instrumentation
Street, Glasgow, G2 3JZ. the long-term success of teeth that have complications (eg ledges and separated

490 DentalUpdate July/August 2014

© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 131.172.036.029 on October 1, 2017.
Use for licensed purposes only. No other uses without permission. All rights reserved.
 RestorativeDentistry

instruments) and root fillings protruding wish to compromise by having treatment marginal leakage, which can weaken the
through apices are known causes for and retaining a tooth of a questionable cement lute and facilitate removal. If this is
previous failure.11 These issues would need long-term prognosis. They would need the case, the presenting complaint can be
to be overcome for a favourable outcome; to be made aware of the prognosis and that of a foul taste or halitosis.
 Perforations − The rate of success any contingency plan(s) prior to gaining The most common factors
decreases if there is iatrogenic damage to consent for this approach.7 influencing post removal are summarized
the root canal anatomy;12 Batemen et al advocated that in Table 1.
 Pathological/microbiological factors − each case needs to be evaluated and
Radicular cysts and persistent intracanal selected appropriately, as extraction of the
and extracanal infection are potential tooth followed by replacement with bridges Accessing the post
causes of unsuccessful outcomes.11 or implants may provide a more predictable A decision on the form of
and favourable long term outcome. They temporary restoration and its method of
suggested that such consideration be given fabrication should be taken pre-operatively.
Extract and replace?
to teeth with a history of previous anatomic The coronal restoration is then removed
Heroics should be avoided to
breaches/problems, where the natural to expose the post.14,19 This paper does
retain teeth with a hopeless prognosis;
tooth has a poor prognosis and there are not focus on crown removal methods, but
however, there are clinical situations
no issues with the costs of subsequent examples include the use of a high speed
where extraction is not a preferred option
replacement teeth.13 Figure 1 shows a post bur, an excavator, an ultrasonic device, the
either. In these situations, patients may
in an UL2 which has 50% horizontal bone Safe Relax device (see below) or a sliding
loss and an UL1 with root surface calculus, hammer, all of which may coincidentally
indicating active periodontal disease. In remove the post.
order to avoid root fracture, a new post Any encasing restorative
would need to be placed beyond the bone material and cement around the post head
level, which in this case may be difficult. is then removed.14,21 For preformed posts,
A reasonable alternative to post removal, any restorative material forming the core
endodontic re-treatment and the provision should be trimmed. With custom post
of a replacement post crown would be and cores, the core should be separated
to extract and replace the UL2 with an from the root face by removing the core/
adhesive cantilever bridge from the UL3 as cement interface with an ultrasonic scaler
this may give a more predictable outcome. or long neck round bur, eg ISO size 006
(D205 LN bur, Dentsply Maillefer, Ballaigues,
Switzerland), ISO size 100 or ISO size 120
The root and post
(0197 LN bur, Komet, Rock Hill South
A well-angulated periapical
Carolina) burs (Figure 2). If cutting with a
radiograph should be used to investigate
bur is necessary, it should only be done
residual root morphology, length, width,
on the core material in order to preserve
curvature and thickness, as well as post
tooth structure. Any encircling metal collars
location, length, width and angulation.14
should also be removed to diminish the
It may also be possible to ascertain which
‘ferrule effect’.22
type of post has been used, if previously
unknown.
Clinical examination may Methods for removing posts
reveal that the post is already loose due to
Figure 1. Radiograph of an intact post and core A summary of post types, their
in UL2 with 50% horizontal bone loss. difficulty of removal and suggested removal
method(s) is provided in Table 2.

Ultrasonic scaler
Ultrasonic devices have been
suggested to facilitate post removal for
over 25 years.23 They are the most common
method used to remove posts from all
tooth types.4 The transfer of ultrasonic
energy down the length of the post/
cement/dentine interface promotes cement
failure and loosens the post. It is particularly
Figure 2. (a) LN round ISO size 120 bur; (b) LN round ISO size 100 bur. effective in cases where zinc phosphate and

July/August 2014 DentalUpdate 491

© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 131.172.036.029 on October 1, 2017.
Use for licensed purposes only. No other uses without permission. All rights reserved.
 RestorativeDentistry

Factor Observations/Findings

Post Length Posts of greater length can take longer to remove2, 15

Post Type (See Table 2)

Core Decreasing the height and width of cast cores can facilitate
removal16

Materials:
Composite cores around preformed posts can be more difficult
to remove than amalgam cores3

Cast gold cores - easier to reduce than cores made with non-
precious metals3

Type of Lute Posts cemented with zinc phosphate materials - easier to remove
than those cemented with resin-based lutes15,17,18

The type of lute cannot be determined without previous clinical

notes15

Position of most coronal portion of post Supracrestal – easier to remove19

Subcrestal (i.e. fractured posts) – more difficult19

Tooth type/position Anterior teeth – easier to remove post19

Posterior teeth – greater difficulty19

Diameter/adaptation of post Wider, better adapted posts – difficult19

Inappropriately adapted posts – less time to remove2

Table 1. Factors affecting post removal.

glass ionomer cements have been used,24,25 Short, intense periods of Figures 3 and 4 show the
but has little influence on resin cements.23 vibration should be applied at different removal of an intact custom post and
Removal with an ultrasonic scaler requires positions for no longer than 15 seconds1,26,28 a fractured post using an ultrasonic,
less force than the majority of post to prevent excessive heat production. Check respectively.
removal devices17 and causes minimal loss for any looseness at regular intervals. Posts
of dentine.24 However, dentine cracks,4,25 generally loosen within 10−15 minutes of
Sonic scaler
significant heat generation26 and root vibration.1 Smith suggested that it takes
Endodontic sonic instruments
perforation27 are all possible complications. a maximum of one minute per millimetre
can also be used in a similar fashion to
Piezo-electric ultrasonic of post.19 If the post remains firm, an
their ultrasonic counterparts since their
scalers21,22,27 with large, flat, parallel-sided alternative technique can be considered
elliptical pattern of oscillation can cause
tips are the most effective.22 The tip or used in conjunction with the ultrasonic
disruption of the cement lute.26 However,
should be applied, with water spray to scaler to produce a favourable result.
Buoncristiana et al concluded that sonic
the side of the post and the unit activated Any alternative methods used for posts
instruments were poor in terms of post
at full power.19 The tip should be guided cemented with zinc phosphate and glass
removal when compared to ultrasonics,29
circumferentially around the post and along ionomer cements will likely require less
whereas Cherukara reported a case where
any exposed length.28 For fractured posts, a force for removal owing to the previous
two posts were removed successfully by this
2 mm deep trough may be cut around the ultrasonic instrumentation.24
means.27
post fragment with a LN bur to allow the Ultrasonic scalers can also
scaler tip to contact the side of the post.19,22 unwind threaded active (screw) posts if
This trough needs to be kept as narrow as they are guided around the post in an
Unscrew
possible to retain tooth tissue. anticlockwise direction.20,22
Threaded active posts, examples
492 DentalUpdate July/August 2014
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 131.172.036.029 on October 1, 2017.
Use for licensed purposes only. No other uses without permission. All rights reserved.
 RestorativeDentistry

Type Removal difficulty Suggested removal method(s)

Metal

Custom Moderate20 Ultrasonic, removal devices*4 and Safe

Relax

Preformed
-Non Threaded Simple20 Ultrasonic and removal devices*20

-Threaded
-Passive
-Tapered Simple20 Ultrasonic and removal devices*22

-Parallel-sided Simple20

-Active (Screw) Simple20 Ultrasonic and removal devices*4, 22

Unscrew, 14,20,22 Ultrasonic20,22

Ruddle kit22
UPR and Masserann

Fibre Moderate20 Manufacturers removal kit, or drill out13,22

Ceramic Difficult20 Masserann20

Table 2. Types of post and their removal. *Removal devices include the Eggler, Universal Post Remover (UPR), Ruddle kit and Masserann collectively (see Part 2).

of which include Dentatus (Dentatus a c

AB, Hagersten, Sweden) or Radix Anker
(Dentsply, Weybridge, UK), can simply
be ‘unscrewed’ anticlockwise using the
corresponding tool supplied by the
manufacturer for their placement. If the tool
no longer fits due to post damage, cotton
wool can be placed over the post to provide
a better fit.20,22
Alternatively, fine forceps can
be used for unscrewing (see below). If a
groove (pre-existing or cut by a bur) is b d
present coronally,30 a flat instrument (such
as an enamel chisel or flat plastic) or small
screwdriver can be inserted and turned
anticlockwise to unthread the post (Figure 5).
Care should be taken when
removing active posts as they can become
locked in the canal due to the flow of luting
cement into the grooves present along the
post shaft. Removal of such posts should
never be forced.20,22 Figure 3. (a) A post-retained metal ceramic crown with poor marginal adaption on UL1. (b) The
exposed core after removal of the coronal restoration. Note the existing separation between the core
and at the labial root face. (c) A piezo-electric ultrasonic scaler being applied. (d) The removed post
Safe Relax − Anthogyr and core.
The Safe Relax system by Anthogyr
July/August 2014 DentalUpdate 495
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 131.172.036.029 on October 1, 2017.
Use for licensed purposes only. No other uses without permission. All rights reserved.
 RestorativeDentistry

(Sallanches, France) is an automated device may increase the risk of root fracture, a
primarily used to remove crown and although no evidence of this has been
bridgework. However, it can also be used for published at present. Manual sliding
tapered and parallel non-active posts with hammers are also available; however, the
their respective cores intact. It comprises a authors’ opinion is that this is a dangerous
series of hooks and cables that can be used option and would not be recommended.
for various restorations. These attach to the Figures 7 (a−h) show a custom post being
system’s handpiece device which is connected removed using the Safe Relax system.
to the dental unit’s air motor (Figure 6).
If a point of application does
Forceps
not exist prior to use, one can be established
Stieglitz forceps19 (Claudius
by separating the core from residual root
Ash, Potters Bar, Hertfordshire, UK) and
face with an ultrasonic scaler or LN bur.
other fine forceps (eg upper roots) (Figure
One of the systems hooks is attached to the b
8) can be used to grip and unthread
handpiece and its tip positioned at the point
screw posts in an anticlockwise direction.
of application. Traction is applied by pulling
Sufficiently loose parallel and tapered
the device in a coronal direction before
posts can also be removed if they are
pressing the motor pedal to initiate a series of
round/circular in shape. Small, gentle,
ultra-fast micro-strokes in an axial direction to
alternating rotations should be used along
withdraw the post. These micro-strokes will
with adequate finger support buccally/
not start unless the initial traction is applied.
labially and palatally to help detect any
The device operates at a recommended speed
tooth movement. If any resistance is met,
range between 5,000 and 25,000 rpm and the
the forceps should not be forced further
intensity and frequency of the micro-strokes
and an alterative method of removal must
can be altered.31
be adopted. Excessive force could lead to
This method can result in
root fracture, rupture of the periodontal
sudden removal of the post. Therefore,
ligament fibres or extraction of the tooth. c
care should be taken to ensure that there
Therefore, forceps should only be used if
is adequate patient airway protection to
the post is already loose within the canal.
prevent aspiration. The sudden movement

a c

Figure 5. (a) Radiograph showing two active

threaded (screw) posts in an UL6 with a peri-api-
cal radiolucency tracked by a gutta-percha point.
b d (b) The exposed posts. (c) The removed posts
after unscrewing with an enamel chisel.

Figure 4. (a) A fractured post in UL2. Note the pin holes of a previous restoration and residual gut-
ta-percha. (b) Use of a LN bur to create a 2 mm space around the post fragment. (c) A piezo-electric
ultrasonic being circumferentially applied to the side of the post, as well as up and down the exposed
length. (d) The removed post fragment. Figure 6. Safe Relax handpiece and hook inserts.

496 DentalUpdate July/August 2014

© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 131.172.036.029 on October 1, 2017.
Use for licensed purposes only. No other uses without permission. All rights reserved.
 RestorativeDentistry

a e

b f Figure 8. (a) Upper fine root forceps; (b) Stieglitz

forceps.

Summary
This paper has highlighted
different techniques that may be appropriate
in different situations and that all techniques
may be difficult to execute. It gives the reader
c g some insight into which technique may
work effectively, depending on the clinical
circumstances.
The use of conservative methods
before more destructive methods is
recommended (ie those which cause greater
dentine loss or increase the risk of root
fracture).
Ultrasonic devices are very
beneficial when it comes to post removal
d h procedures as they are the least destructive
method of removal and can also facilitate the
use of other techniques/devices.
The next paper in this series
covers the use of devices specifically designed
for retrieving posts as well as the removal of
fibre posts.

References
Figure 7. (a) A custom post and core in UL1 (after crown removal). (b) Ultrasonic separation of the
1. Ruddle CJ. Nonsurgical retreatment.
core from root face. (c) The core now separated from root face. (d) Selection of the Safe Relax hook
insert. (e) Application of the hook between core and root face, along with traction in a coronal direc- J Endod 2004; 30(12): 827−845.
tion (arrow). (f). The dislodged post after a series of automated micro-strokes. (g) The post space after 2. Peciuliene V, Rimkuviene J, Maneliene R,
removal. (h) The removed post and core. Pletkus R. Factors influencing the removal
of posts. Stomatologija 2005; 7(1): 21−23.
3. Abbott PV. Incidence of root fractures
and methods used for post removal. Int
Burs post space and the authors would advocate Endod J 2002; 35(1): 63−67.
LN burs can be used to aid with that this approach should not be considered 4. Castrisos T, Abbott PV. A survey of
the removal of short posts (5 mm or less) of unless all other options have been exhausted. methods used for post removal in
thin diameter. High speed burs should never If a tungsten carbide bur is specialist endodontic practice. Int Endod J
be used.22 The bur should be worked around applied to fragments of 2 mm (or less), it can 2002; 35(2): 172−180.
the post circumference (keeping it as close to occasionally bind to the post. As a result, 5. Torabinejad M, Corr R, Handysides R,
the post as possible) to destroy the cement withdrawal of the bur from the root canal also Shabahang S. Outcomes of nonsurgical
lute interface or the post itself completely. removes the post fragment. This outcome retreatment and endodontic surgery: a
This can lead to widening of the root canal/ obviously damages and sacrifices the bur. systematic review. J Endod 2009; 35(7):

July/August 2014 DentalUpdate 497

© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 131.172.036.029 on October 1, 2017.
Use for licensed purposes only. No other uses without permission. All rights reserved.
 RestorativeDentistry

930−937. time required for cast post removal by

6. Naito T. Surgical or nonsurgical treatment ultrasound: an in vitro study. Appl Oral Sci
for teeth with existing root fillings? Evid 2009; 17(3): 145−149.
Based Dent 2010; 11(2): 54−55. 19. Smith BJ. The removal of fractured post
7. Tait CME, Ricketts DNJ, Higgins AJ. fragments in general dental practice
Restoration of the root-filled tooth: pre- using ultrasonic vibration. Dent Update
operative assessment. Br Dent J 2005; 2002; 29(10): 488−491.
198: 395−404. 20. Rhodes JS. Disassembly techniques to
8. Ekuni D, Yamamoto T, Takeuchi N. gain access to pulp chambers and root
Retrospective study of teeth with a canals during non-surgical root canal
poor prognosis following non-surgical re-treatment. Endod Topics 2011; 19:
periodontal treatment. J Clin Periodontol 22−32.
2009; 36(4): 343−348. 21. Chong BS. Problems with endodontic
9. Pitt Ford TR, Rhodes JS. Root canal treatment. In Harty’s Endodontics in
retreatment: 1. Case assessment and Clinical Practice 6th edn. London:
treatment planning. Dent Update 2004; Churchill Livingstone, 2010: pp260-261.
31: 34−39. 22. Chong BS. Disassembling the coronal
10. Ng YL, Mann V, Gulabivala K. Outcome restoration. In Managing Endodontic
of secondary root canal treatment: a Failure in Practice. 1st ed. London:
systematic review of the literature. Int Quintessence Publishing, 2004. 65−88.
Endod J 2008; 41(12): 1026−1046. 23. Krell KV, Jordan RD, Madison S, Aquilino
11. Roda RS, Gettleman BH. Nonsurgical S. Using ultrasonic scalers to remove
retreatment. In Cohen’s Pathways of the fractured root posts. J Prosthet Dent 1986;
Pulp. 10th edn. St Louis, Mo: Elsevier 55: 46−49.
Mosby, 2010: pp890−952. 24. Gomes APM, Kubo CH, Santos RAB,
12. Gorni FG, Gagliani MM. The outcome of Santos DR, Padilha RQ. The influence of
endodontic retreatment: a 2-yr follow-up. ultrasound on the retention of cast posts
J Endod 2004; 30(1): 1−4. cemented with different agents. Int Endod
13. Bateman G, Barclay CW, Saunders J 2001; 34: 93−99.
WP. Dental dilemmas: Endodontics or 25. Satterthwaite JD, Stokes AN. Dentinal
dental implants? Dent Update 2010; crack incidence following ultrasonic
37(9):579−590. vibration to intra-radicular posts.
14. Ingle JI, Bakland LK, Baumgartner JC. N Z Dent J 2004; 100: 105−109.
Retreatment of non-healing endodontic 26. Dominici JT, Clark S, Scheez J, Eleazer
therapy and management of mishaps. PD. Analysis of heat generation using
In Ingle’s Endodontics 6th edn. USA: ultrasonic vibration for post removal.
Peoples Medical Publishing House, 2007: J Endod 2005; 31: 301−303.
pp1088−1161. 27. Cherukara GP, Pollock GR, Wright PS. Case
15. Garrido AD, Oliveira AG, Osório JE, Silva- report: removal of fractured endodontic
Sousa YT, Sousa-Neto MD. Evaluation of posts with a sonic instrument. Eur J
several protocols for the application of Prosthodont Rest Dent 2002; 10(1): 23−26.
ultrasound during the removal of cast 28. Dixon EB, Kaczkowski PJ, Nicholls JI,
intraradicular posts cemented with zinc Harrington GW. Comparison of two
phosphate cement. Int Endod J 2009; ultrasonic instruments for post removal. J
42(7): 609−613. Epub May 2009. Endod 2002; 28: 111−115.
16. Chandler NP, Qualtrough AJ, Purton DG. 29. Buoncristiani J, Seto BG, Caputo AA.
Comparison of two methods for the Evaluation of ultrasonic and sonic
removal of root canal posts. Quintessence instruments for intraradicular post
Int 2003; 34(7): 534−536. removal. J Endod 1994; 20(10): 486−489.
17. Alfredo E, Garrido AD, Souza-Filho CB, 30. Carrotte P. Endodontic problems. Br Dent J
Correr-Sobrinho L, Sousa-Neto MD. In 2005; 198: 127−133. Epub Feb 2005.
vitro evaluation of the effect of core 31. Author unknown. Safe Relax. Anthogyr
diameter for removing radicular post [internet] 2011. URL: http://www.
with ultrasonic. J Oral Rehabil 2004; 31: anthogyr.com/upload/wysiwyg/
590−594. Extranet/Brochures/product_
18. Soares JA, Brito-Júnior M, Fonseca DR instrument/safe_relax/Leaflet_
et al. Influence of luting agents on Saferelax_GB_150dpi_0911.pdf
498 DentalUpdate July/August 2014
P13840 DNA POC_Dental Update_60x255.indd 1 22/07/2014 15:28
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 131.172.036.029 on October 1, 2017.
Use for licensed purposes only. No other uses without permission. All rights reserved.