Cagidiaco.

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Clinical Performance of Fiber Post Restorations in

Endodontically Treated Teeth: 2-Year Results
Maria Crysanti Cagidiaco, MD, DDS, PhDa/Ivana Radovic, DDS, MScb/Marco Simonetti, DDS, MSca/
Franklin Tay, BDSc, FADM, PhDc/Marco Ferrari, MD, DDS, PhDd

Purpose: This study evaluated the 2-year outcome of post-and-core restorative

procedures in endodontically treated teeth. The effect of baseline factors (tooth type,
number of residual coronal walls, and type of definitive restoration) on restoration
failure was assessed. Materials and Methods: The consecutive sample design
included 150 patients. A total of 162 teeth (57 anterior and 105 posterior) were
restored. Sixty-nine teeth had 3 or 4 residual coronal walls, while 93 teeth had 2 or
fewer walls. Crowns and direct resin composite restorations were placed in 121 and
41 teeth, respectively. After 23 to 25 months, all patients were evaluated. Logistic
regression was used to identify the joint effect of variables recorded at baseline (P <
.05). Results: The only failure modes observed were post debonding (4.3%, 2 in
anterior teeth and 5 in posterior teeth) and endodontic failure (3.0%, 2 in anterior teeth
and 3 in posterior teeth). All post debondings occurred in teeth with 2 or fewer coronal
walls that were crown covered. All endodontic failures occurred in crown-covered
teeth (1 failure in a tooth with 3 walls and the remaining 4 failures in teeth with 2 or
fewer walls). Logistic regression found no statistical significance for any of the
variables recorded at baseline. Conclusion: Restorations placed with the use of a
fiber post and core resulted in 4.3% post debondings and 3.0% endodontic failures
after 2 years of clinical service. Int J Prosthodont 2007;20:293–298.

L iterature on the performance of fiber post-and-

core systems is constantly increasing. 1,2 The
potential of these systems to reduce the incidence of
The significance of laboratory findings was con-
firmed in many clinical studies showing satisfactory
performance of endodontically treated teeth restored
nonretrievable root fractures when compared to con- with post-and-core systems. Both retrospective9–11 and
ventional cast posts has been emphasized in several prospective12–17 clinical studies have been conducted,
in vitro studies.3–8 focusing on different aspects of restorative procedures
involving placement of fiber posts. Survival rates
reported in these studies vary substantially, and this
aAssistant Professor, Department of Dental Materials and Restorative
heterogeneity can be attributed partly to different study
Dentistry, Policlinico Le Scotte, University of Siena, Italy.
designs, inclusion criteria, number of patients followed,
bPhD Student, Clinic for Pediatric and Preventive Dentistry, Faculty and observation periods. Nevertheless, valuable infor-
of Dentistry, University of Belgrade, Serbia. mation has been obtained, providing the opportunity
cResearch Scientist, Department of Oral Biology & Maxillofacial
to identify major decision-making elements in restor-
Pathology, School of Dentistry, Medical College of Georgia, Augusta,
ing endodontically treated teeth with and without post
Georgia.
dProfessor and Chairman, Department of Dental Materials and placement.2
Restorative Dentistry, Policlinico Le Scotte, University of Siena, Italy. Factors that can affect the survival of endodontically
treated teeth are numerous and diverse. An investiga-
Correspondence to: Dr Marco Ferrari, Department of Restorative
Dentistry and Dental Materials, Policlinico Le Scotte, University of
tion of the influence of proximal contacts revealed that
Siena, Viale Bracci, 53100 Siena, Italy. Fax +39 05 772 33117. teeth with no or 1 proximal contact at access were lost
E-mail: [email protected] at more than 3 times the rate of teeth with 2 proximal

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Clinical Performance of Fiber Post Restorations in Endodontically Treated Teeth

Table 1 Distribution of Treated Teeth, No. of Residual endodontically treated teeth and patients in whom en-
Coronal Walls, and Crown Placement dodontic treatment was needed prior to the restoration
No. of walls Anterior Posterior Total were both included. A total of 162 teeth were restored
by 2 operators. If the teeth had already been endo-
No walls dontically treated, inclusion criteria of a symptom-free
Crown 26 30 56
1 wall root canal filling with a minimum apical seal of 4 mm
Crown 4 10 14 had to be met. Only teeth that had been previously
No crown 3 – 3 endodontically treated by 1 of the 2 operators were
2 walls
Crown – 13 13 included in the study. The age of the patients ranged
No crown 7 – 7 from 18 to 75 years (mean: 56 years). Seventy-nine
3 walls restorations were placed by the first operator and 83
Crown – 15 15
No crown – 13 13 by the second operator. The assignment of each patient
4 walls to one of the operators was decided by tossing a coin.
Crown 5 18 23 Both anterior (n = 57) and posterior (n = 105) teeth with
No crown 12 6 18
varying degrees of hard tissue loss were included in the
study. The following data were collected at the base-
line examination: patient age and gender, tooth type
(anterior or posterior), number of residual coronal walls
(0 to 4), size of the post placed, and type of restoration
contacts. 18 A strong association was also found (crown or direct resin composite restoration).
between crown placement and the survival of Distribution of treated teeth, number of residual
endodontically treated teeth.19 coronal walls, and presence of crowns are shown in
However, studies that specifically identify tooth- Table 1. Sixty-nine teeth had 3 or 4 residual coronal
related factors as possible failure predictors of fiber walls, while 93 teeth had 2 or fewer walls. In the molar
post restorations in endodontically treated teeth are roots, only 1 post was placed, either in the palatal root
missing in the literature. In prospective studies, only 1 of maxillary teeth or the distal root of mandibular teeth.
type of tooth has been included.12,15 Various retro- The restorations of 121 teeth were metal-ceramic and
spective studies provided information on both maxil- all-ceramic crowns. The remaining teeth were restored
lary and mandibular anterior and posterior teeth, but with direct resin composite restorations.
the number of baseline factors recorded varied and
their correlation with the restoration performance was Clinical Procedures
not investigated.9–11 In the only study that evaluated risk
factors for fiber post restoration failure, tooth type, In teeth that needed endodontic treatment prior to
type of definitive restoration, and the presence of restoration, the roots were endodontically treated using
adjacent teeth were found to be significant predictors a step-back technique with FlexMasters nickel-titanium
of failure.17 instruments (VDW), Gates-Glidden drills (nos. 1 to 3,
The aim of the present study was to evaluate the Union Broach), and 2.5% sodium hypochlorite irriga-
2-year outcome of restorative procedures involving the tion. The canals were obturated with thermoplasticized
placement of fiber posts in endodontically treated teeth. injectable gutta-percha (Obtura, Texceed) and a resin
The null hypothesis tested was that tooth type, num- sealer (AH-Plus, DeTrey). No less than 48 hours after
ber of residual coronal walls, and placement of a crown endodontic treatment, the roots were prepared to
do not significantly influence failure of a fiber post receive a post.
system placed in an endodontically treated tooth. DT Light Posts (RTD) were used (nos. 1 to 3 based on
the size and shape of the roots). After selection of the
Materials and Methods appropriate drill size, the root canal space was pre-
pared using preshaping and finishing drills provided by
The study population comprised 150 consecutive the manufacturer to a length of 8 mm. At least 4 mm of
patients that needed restoration of endodontically gutta-percha was left apically to seal the root apex. The
treated teeth between February and July 2003 at the posts were tried in and consequently shortened with a
Department of Restorative Dentistry of the University diamond bur. The cementation procedure was per-
of Siena, Italy. The study protocol was reviewed and formed according to the manufacturers’ instructions.
approved by the Ethical Committee of the University of Prime & Bond NT Dual Cure adhesive system (Dentsply
Siena. All patients needing restoration of endodontically Caulk) was used in combination with dual-cure resin
treated teeth were included until 150 patients were col- cement (Calibra, Dentsply Caulk). The post space was
lected. Patients that presented with previously rinsed and thoroughly dried using air and paper points.

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Cagidiaco et al

Caulk 34% Tooth Conditioner Gel (34% phosphoric acid, Endodontic problems requiring retreatment were also
Dentsply Caulk) was applied to the post space through noted; however, the primary goal of the study was to
a needle and completely rinsed off after 15 seconds with assess factors related to the success/failure of the
water carried into the canal using an endodontic syringe. fiber post restorative procedure rather than the
Excess water was removed from the post space with a endodontic treatment. Further, since endodontic fail-
gentle air blast. Paper points were used to remove resid- ures cannot be directly attributed to the post-and-core
ual moisture without desiccating the etched dentin sur- system, they were not included in the statistical analy-
face. One to 2 drops of Prime & Bond NT adhesive were sis. Clinical examinations were carried out indepen-
placed into a clean plastic mixing well and immediately dently by the 2 operators, and the examiner was always
mixed with an equal number of drops of self-cure acti- the operator who did not place the restoration.
vator for 1 to 2 seconds with a clean, unused brush tip.
The adhesive/activator mixture was applied to the post Statistical Analysis
preparation with a microbrush, and care was taken to
apply generous amounts to the preparation orifice. The To aid in the analysis, the dependent variable (outcome
contact of the adhesive/activator with the tooth struc- of fiber post restorative procedure) was dichotomized
ture was maintained for 20 seconds. The post prepara- (success/failure). The chi-square test was applied to
tion was dried with an air syringe, and the excess investigate whether the 2-year outcome of the restora-
adhesive/activator solution was absorbed from the post tive procedure presented with significant differences
space with a paper point. A single coat of mixed adhe- between the 2 operators. A logistic regression model
sive/activator was applied to the post with the same was used to identify the joint effect of variables
brush, followed by gentle air drying. If any non-shiny recorded at baseline that could have modified the oc-
areas appeared on the treated post, the mixed adhe- currence of restoration failure. The level of significance
sive/activator was reapplied and immediately air dried was set at P < .05. Calculations were performed using
for 5 seconds. Resin cement components were mixed SPSS 13.0 software (SPSS).
and spread on the surface of the post and into the post The data obtained in the study were also used to per-
preparation with a lentulo spiral. The post was seated form a power analysis to determine how many subjects
immediately, and the excess cement was removed. Light would be necessary to show the statistical significance
curing was performed on the post for 10 seconds with of baseline parameters when various response rates of
a high-power light-emitting diode curing light (950 the dependent variable were assumed, given the stan-
mW/cm2, SmartLite PS, Dentsply Caulk). Buildup of the dard values of power (80%) and type I (5%) and type
abutment cores prior to crown coverage was performed II (20%) errors. These calculations were handled by
using flowable resin composite (X-Flow, Dentsply Caulk) PASS Power Analysis Software (NCSS).
and microhybrid resin composite (CeramX, Dentsply
Caulk). The same resin composites were used for Results
placing direct resin composite restorations.
In teeth restored with crowns, care was taken to pre- Results of the 2-year recall are summarized in Table 2.
pare a 2-mm-high ferrule. However, in several teeth, No root or post fractures and no failures of the core
nonuniform ferrules had to be prepared because of a buildup were recorded. The only failure mode observed
loss of tooth structure. In these cases, the achieved was post debonding (7 cases, 4.3%). Three debondings
ferrule height was never below 1 mm. All-ceramic occurred in teeth restored by the first operator, and 4
crowns were fabricated using the IPS Empress System in teeth restored by the second operator. In all cases,
(Ivoclar Vivadent). post debonding occurred in crown-covered teeth. Two
post debondings were recorded for anterior teeth, both
Evaluation Parameters in cases where the restored tooth had no remaining
coronal walls prior to treatment. In posterior teeth,
After 23 to 25 months, all patients were recalled for a 5 post debondings occurred, also in cases with a
follow-up evaluation. The success rate was assessed considerable amount of tooth-structure loss.
by clinical and intraoral radiographic examinations. No statistically significant differences were found
Radiographs of each fiber post were taken with the in the number of restoration failures between the 2
long-cone technique using ultraspeed film. A modified operators. Logistic regression analysis found no sta-
parallel technique was used. The radiographs were tistical significance for any of the variables recorded at
examined at approximately 5⫻ magnification. Failure baseline. Therefore, no factors were identified as pos-
was defined as the need for a new restoration sible predictors for fiber post failure. All restorations
because of post debonding, post fracture, vertical or that failed as a result of post debonding were replaced
horizontal root fracture, or a failure of the core buildup. in the same manner as previously described.

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Clinical Performance of Fiber Post Restorations in Endodontically Treated Teeth

Table 2 Outcome of the 2-Year Evaluation of Placed Table 3 Outcome of the 2-Year Evaluation of Placed
Restorations: Post Debonding Restorations: Endodontic Failures

Anterior Posterior Total Anterior Posterior Total

No walls No walls
Crown Crown
Debonding 2 2 4 Failure 1 – 1
Success 24 28 52 Success 25 30 55
1 wall 1 wall
Crown Crown
Debonding – 2 2 Failure 1 2 3
Success 4 8 12 Success 3 8 11
No crown No crown
Success 3 – 3 Success 3 – 3
2 walls 2 walls
Crown Crown
Debonding – 1 1 Success – 13 13
Success – 12 12 No crown
No crown Success 7 – 7
Success 7 – 7 3 walls
3 walls Crown
Crown Failure – 1 1
Success – 15 15 Success – 14 14
No crown No crown
Success – 13 13 Success – 13 13
4 walls 4 walls
Crown Crown
Success 5 18 23 Success 5 18 23
No crown No crown
Success 12 6 18 Success 12 6 18

In cases of endodontic failure (5 cases, 3.0%), the Also, 83 (68.6%) crown-covered teeth had 2 or fewer
teeth presented with asymptomatic periapical lesions. coronal walls prior to treatment, and all post debond-
Two failures were recorded for anterior teeth and 3 for ings occurred in teeth with these characteristics.
posterior teeth (Table 3). All endodontic failures The percentage and nature of failures are in accor-
occurred in crown-covered teeth (1 failure in a tooth dance with a previous retrospective study in which all
with 3 walls and 4 failures in teeth with 2 or fewer debondings occurred in cases where posts were
walls). After retreatment, the restorations were bonded to teeth with less than 2 mm of remaining coro-
replaced and the teeth remained in service. nal dentin.11 A higher failure rate (7.7%) was recorded
Power analysis revealed that for the observed per- in a prospective study in which all the included teeth
centage of failures (4.3%), a sample size of 82 patients had lost more than 50% of their coronal structure.14 On
is needed to detect the statistical significance of base- the other hand, a failure rate of 12.8% was reported
line variables. When the calculations were performed in a prospective study after 24 months. 16
assuming a higher percentage of failures, the sample Nevertheless, the most common failure observed in
size increased as the assumed percentage of failures that study was post fracture, which may be related to
increased. The analysis indicated that the sample size the rather low fatigue resistance of the posts used.20
of 151 patients would be sufficient to detect statistical Interestingly, the majority of failures occurred in teeth
significance if the percentage of failures was 30%. that had no vertical cavity walls (12 of 16) or 1 wall
(3 of 16) at the time of restoration placement,
Discussion although statistical analysis failed to show the sig-
nificance of this finding. Conversely, the satisfactory
None of the variables recorded at baseline were found fatigue resistance20 of posts used in the present study
to have a significant influence on fiber post restora- may partly explain the difference in clinical behavior,
tion failure, which led to acceptance of the null including the lower percentage of failures in general
hypothesis. and complete absence of post fractures. DT Light
All 7 post debondings occurred in teeth that were Posts also showed favorable 2-year results in a
restored with crowns, while no failures were seen in prospective clinical study that included premolars
teeth restored with fiber posts and direct resin com- with 2 coronal walls.15 The percentage of debondings
posite restorations. However, the majority of teeth in and endodontic failures was in accordance with the
this study were restored with crowns (121, 74.7%). present study.

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Cagidiaco et al

Direct resin composite restorations were placed in 41 reported in the literature. A tendency of failure to occur
teeth. Thirty-one (75.6%) direct restorations were in teeth with a high degree of tissue loss at baseline
placed in teeth with 3 or 4 walls remaining prior to treat- was noticed in this study, and this finding is in accor-
ment, which may explain the favorable results. Good dance with the findings of Naumann et al.16,17 Although
clinical performance of endodontically treated teeth a statistically significant influence was not found, the
restored with fiber posts and direct resin composite authors of the present study believe that this topic de-
restorations was reported in a prospective 30-month serves further investigation, along with other possible
study. 21 In a retrospective study, Nagasiri and risk factors present prior to the placement of post-and-
Chitmongkolsuk22 investigated the survival of en- core restorations.
dodontically treated molars without crown coverage. It The inability of the applied statistical test to identify
was shown that survival probability increased when a any significant effect may be predominantly related to
greater amount of coronal tooth structure remained. the relatively rare occurrence of failures and the short
Molars with maximum tooth structure (4 coronal walls) observation period. With the present distribution of
had a survival rate of 78% at 5 years, and direct resin baseline and dependent variables, the sample size was
composite restorations demonstrated better clinical sufficient for finding statistical significance; however,
performance than amalgam. Also, in endodontically 2 years is a relatively short period from a clinical stand-
treated premolars with limited loss of tooth structure point. Assuming that the percentage of failures would
(only teeth with Class II cavities and preserved cusp increase after a longer observation period, it may be
structure were included) fiber posts with direct resin speculated that the outcome of the statistical analysis
composite restorations showed clinical results compa- would be different when examining possible risk
rable to those of full-crown coverage after 3 years of factors. Also, a study with a larger sample size and
service.12 longer observation period may allow evaluation and
The results of the present study differ from the results identification of the main reasons for restoration
reported in a retrospective study comparing fiber-re- failure, thus providing important information for treat-
inforced epoxy resin posts to cast posts and cores.10 No ment planning and decision making. Future studies
failures attributed to the post-core procedure were ob- must also assess the significance of additional base-
served at a 4-year recall, although teeth included in the line characteristics, particularly ferrule height, as
study had a severe loss of tooth structure. Similarly, no predictors of the success of fiber post restorations.
failures related to the post-core system were reported
in a retrospective study that investigated the use of car- Conclusion
bon fiber posts.9 However, that study did not provide in-
formation on the amount of coronal dentin at baseline. Restorations placed using a fiber post and core resulted
In accordance with a number of studies showing the in 7 cases (4.3%) of post debonding and 5 cases (3.0%)
importance of ferrule effect,23 Tan et al24 reported that of endodontic failure after 2 years of clinical service.
a nonuniform ferrule results in lower fracture resistance
than a uniform 2-mm-high ferrule. Although ferrule References
height was not one of the factors recorded at baseline
in the present study, the authors speculate that the oc- 1. Schwartz RS, Fransman R. Adhesive dentistry and endodontics:
Materials, clinical strategies and procedures for restoration of
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The amount of remaining coronal dentin prior to the
placement of post-and-core restorations is rarely

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Literature Abstract

Insertion torque and resonance frequency analysis of dental implant systems in an animal model with loaded implants

This study aimed to compare the insertion torque and resonance frequency analysis of different implant systems. Three types of
Brånemark implants (machined Mk III, TiUnite Mk III, TiUnite Mk IV) and 2 types of Straumann implants (Sand-blasted, large-grit,
acid-etched [SLA] and titanium plasma-sprayed [TPS]) were studied. A total of 160 implants, 32 of each type, were placed in healed
premolar extraction sites in 16 beagle dogs. One implant of each type was placed in each jaw in a randomized premolar site, result-
ing in equal distribution between the maxilla and mandible. All implants had a length of 8 mm and a mean standard diameter of 3.8 ±
0.3 mm. The insertion torque was recorded using a torque driver. After a healing period of 8 weeks, the implants were loaded for 3
months, and the animals were then sacrificed. Resonance frequency analysis was performed and implant stability quotients (ISQs)
were recorde at placement, after healing, and at the end of the loading phase. All self-tapping implants recorded higher median
torque values than the non-self-tapping. No difference was seen between the Brånemark and Straumann implants on the basis of
ISQ values at placement. Torque values were classified as high (> 40 Ncm), medium (30 to 40 Ncm), or low (< 30 Ncm). No statisti-
cally significant differences in ISQ values were found between the 3 classes. For all implant systems, a significant decrease in me-
dian ISQ was observed. ISQ values for self-tapping implants remained stable after loading, whereas the ISQ values for non-self-tap-
ping cylinders decreased. The maximum insertion torque values for failed and successful implants were not significantly different.
Significantly higher ISQ values at placement were seen for successful implants (P = .003). Based on this model for ISQ, a threshold
of 65.5 was identified, with a sensitivity of 83% and specificity of 61% for prediction of implant loss. ISQ values at the start of loading
were not predictive of implant loss in the loading period. The authors concluded that caution should be used when judging implant
systems on the basis of resonance frequency analysis and torque measurement.

Al-Nawas B, Wagner W, Grotz KA. Int J Oral Maxillofac Implants 2006;21:726–732. References: 44. Reprints: Dr Bilal Al-Nawas, Oral and
Maxillofacial Surgery, J Gutenberg University Hospital Mainz, Augustusplatz 2, D-55131 Mainz, Germany. Fax: +49 6131 17 6602. E-mail: al-
[email protected]—Tapan N. Koticha, National University of Singapore Faculty of Dentistry, Singapore

298 The International Journal of Prosthodontics

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ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER