Long term retrospective study of the clinical performance of fiber posts
Marco Ferrari, MD, DDS, Ph D, Maria Crysanti Cagidiaco, MD, DDS, Ph D, Cecilia Goracci,
DDS, MSC, Ph D, Alessandro Vichi, DDS, MSC, Ph D, Pier Nicola Mason, MD, DDS, Franklin
Tay
ABSTRACT
Purpose: To evaluate the long-term clinical performance of three fiber posts after a period of
service ranging from 7-11 yrs. Materials and Methods: 985 posts were included in the study: 615
Composiposts, 160 Aestethic Posts and 210 Aesthetic Plus Post were placed into endodontically
treated teeth. Four combinations of bonding/luting materials were used. Endodontic and
prosthodontic results were recorded. Acturial Life Table statistical analysis and Mantel-Haenszel
comparison of survival curve have been performed at 95% level of confidence. Results: a failure
rate betweem 7% and 11% was recorded for the three types of posts. 79 failures in total were noted.
39 failures were due to endodontic reasons, 1 root fracture, 1 fiber post fracture, 17 dislodgment of
the crown and 21 debonging. The mechanical failures were always related with a small amount of
coronal residual structure. No statistical significant differences were found among the three groups,
whilst a significant difference was noted related to the location of the teeth (posterior teeth had
more failures than anteriors). The results of this retrospective study indicate that fiber posts in
combination with bonding/luting materials can be used routinely for restoring endodontically
treated teeth.
CLINICAL SIGNIFICANCE
Fiber posts can be used in daily practice for restoring endodontically treated teeth. Mechanical
failure of restored teeth with fiber posts can be related with the amount of residual coronal structure.
Introduction
The progress in the technology of fiber-reinforced materials addressing structure, shape, and optical
properties of the posts has led to the development of materials that have overcome some of the
limitations of metallic posts (platiunm, alloys, titanium or porcelain materials) concerning esthetic
appearance, mode of failure, and clinical performance (1-16, Monticelli). Also, the mechanical
behavior and related mechanisms of failure of fiber posts were recently compared to those of
metallic posts (Ukon et al, 2000; Cornier et al., 2001; Reagan et al., 1999) and to endodontically
treated teeth restored without luting posts (Salameh et al., 2006; Sorrentino et al., 2006). While
metallic posts or/and no placement of fiber posts tend to produce an irreversible root fracture on
failure, if a root fracture occurs in the presence of a fiber post, it is usually located more coronally
and is more easily retreatable. This type of failure may be due to the greater amount of tooth
structure that must be removed when a metallic post is placed ( Stankiewicz et al., 2003). Also, in
case of need of retreatment ( Sakkal, 1998), fiber posts are more easily removed than metallic or
ceramic ones (Gesi et al., 2004; XXX).
Since post placement and root canal treatment are regarded as major causes of root fractures, crown
coverage has been routinely highly recommended (Sorensen and Martinoff, 1984; Fuss et al., 2001)
as a protective measure. An association between crown placement and the survival of
endodontically treated teeth was observed when the loss of tooth structure was remarkable
(Aquilino et al., 2002, Newman et al., 2003); however, the mode of failure or deflection of bonded
fiber-reinforced composite posts demonstrated that they may protect the remaining tooth structures,
particularly since fracture occurs at loads that rarely occur clinically (Paul and Scharer, 1998)
Recently several reviews on using posts for restoring endodontically treated teeth were published
(21-29 Monticelli; Monticelli et al. 2003; Grandini et al., 2005; Neuman et al., 2005a, Neumann et
al., 2005b; Creugers et al., 2005). Some retrospective and prospective clinical studies on
endodontically treated teeth restored with fiber posts are available but all of them reported data at
short term ( ). For that, long-term clinical trials were advocated for determining whether these
findings are clinically significant. The range of survival of fiber posts luted into root canal
preparation ranged from 2% to 7.7% in retrospective studies and from 1.7% to 12.8% in prospective
studies during a short period of service/observation (between 2 and 3 years) ( ).
The retrospective clinical study with the highest number of fiber posts evaluated reported a failure
rate of 3.2% of 1,304 fiber posts, due to endodontic problems such as periapical lesions at the
radiographic examination (16 teeth) or debonging (25 posts) of the post during removal of
temporary restorations during a period of clinical service ranging from 1-6 years. No root fractures
were recorded. In this clinical investigation three different types of fiber posts were luted (C-Posts,
Aesthetic Posts and Aesthetic Plus Posts) using four combinations of bonding/luting materials.
The primary goal of this study was to evaluate the clinical outcome of three fiber posts in service
for 7-11 years. The null hypothesis that the three posts were determining different results during
long term clinical service was formulated.
Materials and Methods
Between January 1994 and November 1997, 840 C-Posts were placed; then, between the end of
1997 and of April 1998 215 Aestheti Posts were used and finally, after January 1998 until
December 1998 249 Aestheti Post Plus were luted.
From each of the three dentists, 80% of the total number of patients treated with this system was
selected by simple randomization with random number tables (25). Acturial Life Table statistical
analysis and Mautel-Haeusael comparison of survival curve were performed at 95% level of
confidence (26).
A total of 719 patients treated with 850 C-Posts, 215 patients with 249 Aestheti Posts and 234
patients with 290 Aestheti Post Plus were selected for evaluation. The age of the patients ranged
from 20-84 yrs (mean 53 yrs).
Data from the dental records were available at the time of examination and the records correlated
well with examinations. As all patients had previously been included in an individual recall
program, data were also obtained from the records of the remaining patients who were unable to
participate in person.
The frequency of types of tooth treated, recalled samples at 8-10 years and length of clinical service
of the different posts are shown in Table 1.
The final restorations of the treated teeth were metal ceramic restorations (52%), ceramic crowns
(38%) and the remained restored with resin-based composite (RBC). Of the opposing occluding
teeth, 45% had fixed restorations, 20% were restored with a removable denture, 10% occluded with
unrestored teeth and 5% were not in occlusion.
At the final recall 580 patients for 615 C-Posts, 145 patients and 160 Aestheti Posts and 186
patients and 210 Aestheti Post Plus were evaluated. The age of the patients ranged from 26-79 yrs
(mean 48 yrs).
Clinical procedures
All roots were endodontically treated following lateral condensation of gutta-percha with eugenolfree sealer (b). After no less than 48 hrs from the endodontic treatment the roots were prepared for
receiving a post. In the molar roots only one post was placed, in the palatal root of maxillary and in
the distal root of mandibular teeth.
After selection of appropriate drill size, the root canal space was prepared using preshaping and
finishing drills (a) for a length of 8 mm. At least 4 mm of gutta-percha was left apically to seal the
root apex. Then the posts were tried-in and consequently shortened with a diamond bur. Finally, the
fiber posts were bonded with the selected bonding system and resin cement, strictly following
manufacturers’ instructions.
The fiber posts were bonded with different dentin bonding/resin cement combinations. The
following bonding systems were used: All Bond 2 and One-Step (a) in combination with C&B resin
cement, Scotchbond Multi-Purpose Plus (c) in combination with Opal luting composite and
Scotchbond 1 (Single-Bond)(c) with Rely X resin cement.
The combinations between adhesive materials and fiber posts are reported in Table 3.
Then the teeth were build-up with RBC. The build-up of the abutment core was performed with
different RBCs: Bis-Core (a) self-curing RBC was mainly used on C-Posts and Aestheti Posts
whilst light-curing RBC was used for build-up abutment with Aestheti Plus Posts.
Parameters
The rate of success was assessed by clinical and intraoral radiographic examinations.
Radiographs were taken of each fiber post with the long-cone technique and ultraspeed film (e). A
modified parallel technique was used. The radiographs were examined with approximately x5
magnification. The outcome was considered successful if the post and core were in situ, without
clinical or radiographic signs of technical failures, loss of retention, root fracture or post fracture.
During the prosthetic treatment, the stability of the resin core and the possible dislodgment of the
posts during debonding procedures of temporary restorations.
The clinical examinations, in the practice of the two dentists, were carried out independently by the
two operators. The observers were not blinded in the clinical examination as this was not possible.
To obtain the maximum unbiased comparison, observers were calibrated.
Results
The duration in service of the C-Posts dowels varied from 8-11 years (mean 10.2). The Aestheti
Posts remained in place for a period between 7 and 7.9 years (mean 7.5) and the Aestheti Post Plus
between 7 and 7.5 (mean 7.2) years.
79 failures were recorded respectively 43 of C-Posts, 13 Aestheti Posts and 23 Aestheti Posts Plus.
Of the 985 recalled posts of 911 patients, 21 showed failures due to debonding of the post with
dislodgment of the crowns under clinical service. In one case a root fracture was observed of an
abutment of a partially debonded bridge. In 17 cases, only dislodgment of the crown, with total or
partial fracture of the core abutment were noted. All debonded posts were originally bonded to teeth
between with less than 2 mm of coronal remained dentin and 2 residual walls. In 2 cases, a partial
debonding of the crown/bridge determined a deep leakage below the restorations with consequent
decay of the abutment. The other 39 failures were due to endodontic periapical lesions. 35
endodontic failures were discovered during radiographic examination; these teeth showed an
asymptomatic periapical lesion; the other 4 of endodontic failures showed clinical signs and were
observed during emergency.
The total amount of failures was 79. The results showed no statistically significant difference
among the four groups and the three tested fiber posts (Table X). There was a statistically
significant difference between failures observed in posterior teeth than those recorded anteriorly:
that was due to the main posterior location of endodontic failures. No difference were found in the
frequency of failures recorded in upper and lower teeth.
Only one root fracture was found; the tooth was a premolar with a very small amount of root dentin
at his coronal 1/3; The root fractured between the coronal and medium 1/3 and consequently was
extracted.
The debonding failures were almost equally distributed among the four bonding/resin cement
systems used in this clinical trial (Table 3).
Figs xx-xx show representative cases from this study(vedi controlli attuali 4-8 e 9-11).
Discussion
Some retrospective studies on the clinical performace of fiber posts have appeared in the literature
(Frederikson et al., 1998; Ferrari et al., 2000; Ferrari et al., 2000; Dallari and Rovatti, 1996; Ellner
et al., 2003). As the present clinical report, the retrospective studies are often unable to ensure an
adequate control of all the variables that might come into play under clinical conditions. However,
all other clinical reports on fiber posts performances have the major limitation in the relatively
small size (Dallari and Rovatti, 1996; Frederikson el all 1998; Glazer, 2000; Ferrari et al., 2000;
Mannocci et al., 2002; Malferrari et al., 2003) whilst in this study a considerable amount of
restorations are recalled after a long term clinical service, and consequently some useful
information can come also from retrospective study like this report.
In any case, the results of the present clinical trial were not completely in line with the findings of
previous retrospective studies (Frederikson et al., 1998; Ferrari et al., 2000; Ferrari et al., 2000;
Dallari and Rovatti, 1996; Ellner et al., 2003) which also reported a survival rate of the tested posts
at the 94-97%; in this study the survival rate was between 89% and 93% and the data was related to
the number of restorations and in particular to the frame time of their clinical service: longer the
clinical service of the posts, higher the number of clinical failures.
Also the types of failures changed in this report when they are compare to those found in the
previous report (Ferrari et al., 2000) and other published clinical trials ( ); in the past, the failure of
fiber posts was never due to a root fracture ( ) but the most frequent cause of failure of luted fiber
posts were debonding and endodontic problems. The debonding mainly occurred during the
removal of provisional crowns and in teeth with less than 2 mm of dentin structure left at the
coronal level. In the present report, recorded debonding of the final restorations were noted during
their clinical service and was still in combination with a small amount of coronal residual dentin
remained after the endodontic treatment. Also, 17 dislodgment of the crowns, fracture of the post in
one case and fracture of the root were recorded. The dislodgment of crowns were always in
combination with a partial or total fracture of the abutment, with a small amount of coronal residual
structure and with natural opposite dentition and heavy occlusion: it can be speculated that lateral
occlusal forces can cause this type of failure. The case of post fracture was due to overloading of a
restored tooth with a crown and extracoronal attachment for a partial denture whilst the fracture of
the root was due to a very weak root canal wall remained after the endodontic treatment: both these
fractures can not be related to mechanical properties of the posts but mainly to the operator.
Recently it was reported the 12.8% of failures after 24 months of clinical service mainly (9%) due
to post fractures (Naumann et al., 2005, J Dent. The type of posts used in this clinical study were
FibreKor and Luscent Anchors, two type of posts that, when loaded laterally, can fail after a limited
number of cylces under three bending machine otherwise the three types of posts tested in this study
never showed fractures after 2.000.000 of three bending cycles (Grandini et al., 2005).
As no statistical significant differences were found among the three types of fiber posts with four
different types of adhesive/luting material combinations, if follows that the selection of the post and
adhesive/luting materials basicly becomes a matter of personal preference of the clinician based on
experience and habits.
The endodontic failures were mainly noted in posterior teeth and this fact can be related with the
higher difficulties on treating molars and premolars than monoradicular teeth.
As it was pointed out in several clinical report, the mechanical failures were strictly related with a
small amount of coronal residual structure: during removal of the provisional crown debonding can
occur and then, during long term clinical service, debonding of the post and dislodgement of the
crown were recorded; the role of a ferrule structure coronally is well known (Trabert et at., 1978;
Sorensen and Engelmann, 1990; Morgano and Brackett, 1999; Gegauff, 2000; Nicholls, 2001;
Stankiewicz and Wilson, 2002; Zhi-Yue et al., 2003) and recently also its non-uniform ferrule
circumferential height on fracture resistance was pointed out (Tan et al., 2005). In the present
clinical study it was noted that dislodgement and debonding were always combined with less than 2
residual walls coronally and natural dentition as opposite teeth. The results of this study confirmed
once more the key role of the ferrule structure, and suggested to preserve as much as possible all the
coronal residual dentin at the time of the post placement.
The cause if the debonding of the posts during the clinical service might be due also to the recently
pointed out limitations on getting a high bond strength to root dentin essentially related to type of
dentin (Cagidiaco et al., 2003; Mjor, XXX), and bonding procedures into root canal space (Chersoni
et al., 2004; Tay et al., 2005). Because the bond strength to root canal dentin is pretty low (Goracci
et al., 2004; Sadek et al., 2005 Vano et al., 2006) when compared to coronal dentin (Ferrari et al.,
2006), and the thickness of resin cement can be in some area thick (Grandini et al., 2005), under
occlusal loading a disruption at the bonding interface and/or a cohesive failure of the luting material
can occur and determine the debonding of the post and the crown.
During the first recall (Ferrari et al., 2000) all debonding failures were restored again with a fiber
post: in 50% of the cases the post was replaced, whils in the others the same post was reluted;
during the recalls of this report, in 4 cases of debonding, and in the case of root fracture,
accordingly with the patient it was decide to build a new more complex treatment planning and
extract the root and replace it with an implant.
The null hypothesis tested in this study was not confirmed: There was no significant difference in
the clinical service yielded by the three types of posts. Prospective clinical studies is currently in
progress for clarifying the performances of endodontically treated teeth restored with and without
posts and porcelain crowns.
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Table I Clinical distribution of the posts
Incisors
Maxilla
65
C-Posts
Mandible 53
Total
Canines
68
Premolars
68
Molars
71
Total
334
49
38
70
61
281
615
Maxilla
16
Aesth P
Mandible 15
Total
18
12
15
22
83
13
6
25
17
77
160
Maxilla
APP
25
15
21
25
108
29
Laterals
62
Mandible 18
Total
21
14
36
24
102
210
Table IIa baseline
C-Posts (n=840)
AP
(n=215)
APP
(n=249)
Tot
(n=1304)
age interval and average (months)
(18-68m; m= 46 m)
(18-12m; m= 14 m)
(16-12m; m= 13m)
n. of patients
719
201
234
1168
Table IIb actual data
Failures
n
age interval and average
C-Posts (n=615) 43 (7%) (8-10aa, m=10,2)
AP
(n=160) 13 (8%) (7aa, m=7,3)
APP
8n=210) 23 (11%) (7aa, m=7,1)
Tot
79
(7-10aa, m=7,9)
n. of patients
580
145
186
911
Table III
Combination between bonding system and fiber posts related to failures
CPost
AP
APP
Total
AB2
480
34
20
534
SBMPP
41
12
6
59
SB1
50
52
99
201
OS
44
62
85
191
Total
615
160
210
985
Failures
43
13
23
Failures
24
17
18
20
79
79
Table IV Type of failures
Fract/root
Debonding
C-P
/
13
AP
/
3
APP
1*
8
Total
1
21
*Abutment of a debonded bridge
Dislodg/crown
10
1
3
17
Endo
19
9
11
39
Fract/post
1
/
/
1
Table V Type of failures per type of teeth
Maxilla
C-P
Mandible
Inc (5/4) Lat (5/5) Can (5/5)
2/1
2/1
1/2
Prem (12/14) Mol (13/11) Total 40 Rest/39 Endo
4/3
4/3
2/1
2/2
2/1
4/1
3/2
Maxilla
AP
Mandible
-/1
1/-
-/-
1/3
1/1
1/-
-/1
-/1
-/1
1/-
Maxilla
APP
Mandible
-/1
-/-
1/-
2/4
2/3
-/-
-/1
1/1
1/2
2/2
NB 39 failures were endodontic and 40 were related to the restoration.
NB 5 teeth were extracted for being replaced with implants
Count
POST
C-Post
OUTCOME success
failure
Total
Aestheti Post
OUTCOME success
failure
Total
Aestheti Post Plus OUTCOME success
failure
Total
anterior
316
19
335
76
5
81
110
5
115
posterior
256
24
280
71
8
79
77
18
95
Total
572
43
615
147
13
160
187
23
210
79 (8.3%)
Count
OUTCOME success
failure
Total
anterior posterior
502
404
29
50
531
454
Total
906
79
985
success
f ailure
posterior
anterior
0%
25%
50%
75%
100%
posterior
anterior
0%
25%
50%
75%
success
f ailure
100%
anterior
posterior
Aestheti Post Plus
Aestheti Post
C-Post
0%
7-year recall
failure
25%
50%
75%
100%
C-Post
Aestheti
Post
Aestheti Post
Plus
Count
43
13
23
%
7%
8,1%
11%
700
600
500
400
300
100
failure
0
success
C-Post
Aestheti Post Plus
Aestheti Post
POST
failure
40
debonding
crow n dislodg.
root f racture
post f racture
30
endo tx
Count
Count
200
20
10
C-Post
Aestheti Post
Aestheti Post Plus
Root
Debonding Crown
Endodontic Post
Total
fracture
dislodgement failure
fracture
C-Post
13
10
19
1
Aestheti
Post
3
1
9
13
Aestheti 1
Post
Plus
Total 1
5
6
11
23
21
17
39
1
43
79