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The official journal of the Australian Dental Association

Australian Dental Journal
Australian Dental Journal 2011; 56:(1 Suppl): 77–83 doi: 10.1111/j.1834-7819.2010.01298.x

Current perspectives on post systems: a literature review
C Goracci,* M Ferrari*
*Department of Dental Materials and Fixed Prosthodontics of Siena, Tuscan School of Dental Medicine, University of Florence and Siena, Italy.

ABSTRACT
This literature review summarizes the most recent and reliable evidence on post systems. A search was limited to review articles published over the last 10 years in dental journals with an impact factor. Papers cited in the initially retrieved review articles were also included if significant. Preservation of tooth tissue, presence of a ferrule effect, and adhesion are regarded as the most effective conditions for long-term success of post-endodontic restorations. Adhesively luted fibre-reinforced composite post restorations have demonstrated satisfactory survival rates over relatively long follow-up periods. The clinical effectiveness of such restorations has been mainly ascribed to the more biomimetic behaviour of fibre-reinforced composite posts that reduces the risk of vertical root fractures. The most common type of failure when using fibre posts is post debonding and it is generally agreed that achieving stable adhesion to intraradicular dentine is more challenging than to coronal dentine. Several factors related to endodontic treatment, root canal shape, post space preparation, post translucency, adhesive cement handling and curing may have an influence on the outcome of the luting procedure. The most reliable results in fibre post cementation are obtained by etch-and-rinse adhesives in combination with dual-cure resin cements. The use of self-adhesive resin cements has also been proposed. Simplification is an obvious advantage of these new materials. However, the durability of their bond still needs to be verified with long-term clinical studies. Several techniques for pre-treating the fibre-reinforced composite post surface have been tested with the aim of improving the bond strength at the post-core and post-cement interfaces. Silicoating followed by silanization currently appears to be the most effective and convenient method for this purpose. In conclusion, the available evidence validates the use of fibre posts as an alternative to metal posts and preferably to other tooth-coloured posts, such as zirconia dowels, in the restoration of endodontically treated teeth. Longer term clinical trials are expected to further strengthen this evidence.
Keywords: Adhesive, cement, fibre-reinforced composite, post, root dentine. Abbreviations and acronyms: FEA = finite element analysis; FRC = fibre-reinforced composite.

INTRODUCTION The primary purpose of a post is to retain the coronal restoration in an endodontically treated tooth that has suffered an extensive loss of crown structure.1 Numerous techniques and materials have been proposed for the restoration of endodontically treated teeth.2 Metallic prefabricated and cast posts have been utilized for decades. More recently, in response to the request for tooth-coloured posts, several non-metallic dowels have been marketed. Among them, epoxy resin posts reinforced with carbon fibres, epoxy or methacrylate resin posts reinforced with quartz or glass fibres, zirconia posts, and polyethylene fibre-reinforced posts can be distinguished.3 The objective of this literature review was to summarize the most recent and reliable evidence on post systems. An electronic search of pertinent, English language, peer-reviewed literature was conducted in the
ª 2011 Australian Dental Association

MEDLINE database, accessed through PubMed. The following query terms were entered: non-metal post, non metal post, prefabricated post, fiber post, zirconia post, polyethylene fiber post, post-endodontic restoration*, restor* of endodontically treated teeth. The search was limited to review articles published over the last 10 years in dental journals with an impact factor. Papers cited in the initially retrieved review articles were also included if significant. Additionally, the websites of relevant dental journals were explored in the search for in press papers. REVIEW According to the conclusions of a recent review by Dietschi et al.,4 in the restoration of endodontically treated teeth the approach has evolved from a totally empirical level to the current application of biomechanical concepts to guide the decision-making process.
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results from randomized controlled clinical trials.C Goracci and M Ferrari Primarily.9.20 Moreover. stainless steel and zirconia have elastic moduli (110 GPa.8 Since fibre posts are passively retained into the root canal. Fibre density. the use of an ultrasonic oval-shaped tip has been suggested for a more conservative post space preparation (Fig 3A). in the presence of the less rigid fibre posts.24 For ovoid-shaped canals. the effectiveness of the adhesive cement and the luting procedure plays a relevant role in the overall clinical performance of the restorations.4–6 Specifically. Such stress conditions are more reliably simulated in fatigue tests.10 Specifically.4. Three-dimensional FEA simulations have pointed out the relevance of preserving the ferrule effect.9.8. 200 GPa.1.22 FRC post shape FRC posts are available in different shapes: cylindrical. due to the negative influence of several intervening factors. respectively) well above that of dentine (18 GPa). Nevertheless. double-tapered (Table 1.4. RC Prep. fibre posts are relatively easy to remove by boring through 78 the middle of the post with an ultrasonic or a rotary instrument.23.11–13 Owing to a greater similarity in elastic properties with dentine. as well as of fatigue studies. preservation of tooth tissue.18 In addition to the favourable biomechanical behaviour. stress is transmitted internally and concentrates towards the apical level. Among them.21 The adhesion between quartz or glass fibres and resin matrix is enhanced by fibre silanization prior to embedding. However. such as sodium hypochlorite.8. thus increasing the risk for vertical root fracture. presence of a ferrule effect. There are indications in the literature that parallel-sided posts are more retentive than tapered dowels.4 These findings are in agreement with the results of static fracture resistance tests. Oval-shaped glass fibre posts were recently introduced for better adaptation into ovoid-shaped canals (Fig 3A and 3B).21 FRC post composition FRC posts are made of carbon. cylindroconical. depending on the post type.8 The clinical effectiveness of such restorations has been mainly ascribed to the more biomimetic behaviour of FRC posts.8. particularly at the apical level.17 Static fracture resistance tests mimic stresses such as those transmitted in trauma. thus limiting the amount of dentine tissue to be removed in post space preparation.9 Some marketed posts exhibit a coronal head or serrations for retentive purposes (Fig 2). provide evidence to support the use of FRC posts for the restoration of endodontically treated teeth.19. Additionally. the number of fibres per mm2 of post cross-sectional surface. A strong interfacial bond enables load transfer from the matrix to the fibres and is essential for an effective use of the reinforcement properties.3 Double-tapered posts better adapt to the shape of the endodontically treated canal. other advantageous properties of fibre posts have contributed to their rapid diffusion among clinicians.e. embedded in a matrix of epoxy or methacrylate resin (Table 1.25 Adhesive luting of fibre posts Several clinical studies have pointed out that the most frequent failure mode of fibre post retained restorations is post debonding. Fig 1). hydrogen peroxide.4.4 Besides laboratory test outcomes. titanium.15 for a more favourable performance of the restored teeth under stress.16. and restorable failures.6. the analyses using three-dimensional (3-D) models are considered more reliable.9.3 Fibres are oriented parallel to the post longitudinal axis and their diameter ranges between 6 and 15 lm. endodontic irrigants. achieving stable adhesion to intraradicular dentine.4.26 Among them. such as post debonding. varies between 25 and 35.7. and adhesion are regarded as the most effective conditions for long-term success of the restorative procedure.9 Conversely. are more likely to occur.14 and using restorative materials with elastic properties similar to dentine. quartz or glass fibres. both prospective and retrospective. no evidence was found that posts can actually reinforce the roots. failures in the oral cavity more commonly occur due to functional loads or parafunctional forces repeated over a long period of time. that represents a catastrophic failure. quartz or glass fibre posts offer the most favourable optical properties for reproducing the natural aspect of the restored tooth. FRC posts allow for a relatively uniform stress distribution to the tooth and the surrounding tissues. such as resin composites. remains a clinical challenge. in case endodontic retreatment is needed.1. thus yielding a protective effect against root fracture. Fig 2). to abutments of removable dentures. conical. in a tranverse section of the post 30–50% of the area is occupied by fibres. Fibre posts simplify the post-endodontic restoration procedure in comparison with the use of cast posts.11. EDTA. by eliminating the laboratory step. i. In the presence of rigid posts.13 A visualization of stress distribution within the restored teeth has been provided by several finite element analysis (FEA) studies. root fractures are very rare.4. 300 GPa.4. Therefore.4. as well as calcium hydroxide and eugenol of medicaments and sealers ª 2011 Australian Dental Association . contemporary adhesively luted fibre-reinforced composite (FRC) post restorations have manifested satisfactory survival rates over relatively long follow-up periods.4 Conversely.7.3.4. or when removing a temporary crown.

Fiber posts and endodontically treated teeth: a compendium of scientific and clinical perspectives. produce a thick ‘secondary’ smear layer. France Macrolock Illusion Post RTD. part of the dentine possibly altered by canal irrigants. Therefore.Post systems Table 1.27 As far as the utilization of eugenol-containing root canal sealers is concerned. Residues of unset sealer might indeed be displaced from the apical portion of the canal by Fig 1. Wallingford. medicaments. France Radix Fiber Post Dentsply Maillefer. by altering dentine structure or interfering with resin polymerization. Switzerland DT Light Safety Lock VDW. HDDMA Epoxy Shape Double tapered Tapered Glass Quartz Quartz Quartz Zirconium enriched glass Pre-conditioned quartz Glass Zirconia-rich glass Glass Glass Carbon Double tapered Double tapered Double tapered Tapered. USA Composipost RTD. a careful debridement of the post space walls should be performed prior to cementation. Liechtenstein GC Fiber Post Tokyo. France Fibres Glass Glass Resin matrix Resin UDMA. USA FRC Postec Plus Ivoclar-Vivadent. Japan DT Light Post Illusion RTD. Munich.) ª 2011 Australian Dental Association 79 . CT. highly dispersed silicon dioxide Methacrylate Epoxy Epoxy Epoxy Epoxy Epoxy Epoxy Epoxy Bis-GMA Bis-GMA.4. bar = 10 lm). Wendywood: Modern Dentistry Media 2008. Schaan. (From: Ferrari M with Breschi L and Grandini S. Lewis Center. MN. Chemical composition and shape of several marketed fibre posts Post RelyX Fiber Post 3M ESPE. circumferential head grooves. Ytterbium trifluoride. TEGDMA. Londrina.26 When preparing the post space. acting under the far from ideal irrigation possible inside the root canal. PR. (b) A higher magnification of the same section shows diameter and density of reinforcing fibres embedded into the resin matrix (x1550. Grenoble. France DT Light Post RTD Grenoble. USA Reforpost Angelus. including remnants of plasticized gutta-percha and sealer. St Paul. Such contaminants hinder chemical interaction and penetration of the luting agent. rotary instruments. Ballaigues. Lemgo. and sealers is obviously removed. Germany Dentin Post X Komet. Brasil FibreKleer Serrated Post Jeneric ⁄ Pentron. modified. spiral head serrations Double tapered Double tapered Tapered with a retentive head Cylindrical with long apical cone Serrated Serrated Two-stage parallel were found to negatively affect the adhesion of luting agents. Grenoble. UDMA. Germany Snowpost Abrasive Technology. (a) Low magnification scanning electron microscope image of the cross-section of a fibre post (x30). Grenoble. the clinical indication emerging from several laboratory studies is to refrain from proceeding with post luting immediately after root canal obturation. Ohio. in order to (a) (b) enhance post retention. However.26 The use of ultrasonic instrumentation in association with EDTA has been suggested for this purpose.

is the durability of their bond to tooth substrates. be pointed out that the achievement of a valid bond depends on the accuracy of each step in the adhesive handling procedure. In this regard it is worth mentioning that. self-adhesive resin cements demonstrated a limited potential to demineralize and penetrate beyond the smear layer. the current evidence indicates that the most reliable results in fibre post cementation are obtained by etch-and-rinse adhesives in combination with dual-cure resin cements.34. easy-to-use materials for fibre post luting.32 The same trend toward simplification has led to the introduction of selfadhesive resin cements. verified that the eugenolbased sealer had no significant influence on post retention when adhesive cementation was performed one week after root filling.28 Kurtz et al.36 Conversely. and be spread over the post space walls. still under verification for self-adhesive resin cements. However. Mazzitelli et al. and the application of a co-initiator of chemical polymerization should be ensured. Both at coronal and intraradicular level. while it increased the bond strength of another luting agent of the same category.31 With the intention to simplify the handling. reported that thermocycling did not affect the post retentive strength of two self-adhesive resin cements. (b) Double tapered. These newer systems that do not contain a separate bonding agent have been readily accepted as alternative. achieve bond strengths to dentine inferior to those of etch-and-rinse luting agents. (b) Scanning electron microscope image of the cross-section of an oval post (x40. their incompatibility with self-cure and dual-cure cements must be taken into consideration. reported only an incremental increase in the retentive strength of dowels luted with a self-adhesive resin cement after ageing of post-retained restorations through thermocycling. modified.33–35 A clinically relevant issue. with time. could compromise their retentive and sealing ability.) 80 ª 2011 Australian Dental Association . (c) Serrated. and established a rather superficial interaction with dentine. then interfering with cement polymerization. (From: Ferrari M with Breschi L and Grandini S.26 It should.38 To sustain the concern about bond stability is the consideration that if self-adhesive resin cements do not completely shift to neutrality and hydrophobicity with curing.37 No significant change in retention and seal was observed for the etch-and-rinse luting agent tested as a control. found a significant reduction in retention and an increase in interfacial nanoleakage for posts luted with two self-adhesive cements after 40 000 thermal cycles.35 (a) (b) Fig 3. they would remain potentially exposed to hydrolytic degradation phenomena that.4. the use of paper points in post space drying and microbrushes in adhesive application is advisable.C Goracci and M Ferrari (a) (b) (c) Fig 2. In order to clarify these aspects. Marketed fibre posts exhibit various shapes and may differ largely in translucency. Bitter et al. as selfadhesive resin cements have only been recently introduced into the market. paper points or microbrushes. that rely on acidic monomers for simultaneous substrate demineralization and infiltration. Fiber posts and endodontically treated teeth: a compendium of scientific and clinical perspectives. The limited access to the post space represents an additional complication.30. based on the outcome of bond strength tests and microscopic observations. the use of simplified adhesives has been proposed. long-term clinical investigations are desirable. self-adhesive cements. when utilizing etch-and-rinse two-step and single-step self-etch adhesives. that may become quite complex with three-step bonding systems. However. Wendywood: Modern Dentistry Media 2008. (a) Tapered with retentive coronal head. however. Such evidence is in fact still largely missing. (a) The ultrasonic tip for post space preparation in ovoid canals and the oval posts indicated for such canals. bar 500 lm). Mazzoni et al.29 With regard to luting agents.

45.49 While some tests reported a significant increment in cement bond strength following fibre post silanization. the auto-cure mode would be advantageous for the purpose of curing stress relief. However. zirconia has revealed some major limitations. their curing resulted in a lower stress to the just established adhesive bond and seal.49 Particularly in the presence of a post with epoxy resin matrix. In consideration of the influence of filler load on resin composites’ mechanical properties.46 The woven fibres have a modulus of elasticity similar to that of dentine. The cement curing stress is also affected by filler load. Even more importantly.46 It should.46 As the fibres adapt to the root canal.30 Among the chairside procedures.44 Polyethylene fibres Ultra-high molecular weight polyethylene fibres coated with a dentine bonding agent are used to build-up endodontic posts and cores.42 Nevertheless.3. the zirconia post falls short of the requirement to ª 2011 Australian Dental Association be easily removable in case endodontic retreatment is needed. high fracture toughness. be considered that in the latter investigation only anterior teeth in patients aged between 8 and 12 years were considered. post surface pre-treatment with 10% hydrogen peroxide for 20 minutes is a simple and effective method to enhance the fibre post-resin composite adhesion. Adhesion to fibre post surface Research has also been directed at enhancing the adhesion to post surface of the resin composite for cementation or core build-up.3. when used for endodontic posts. post push-out strength and interfacial nanoleakage expressed by experimental resins with different filler loads (10. In such a scenario. In the clinical trial by Turker et al.43 The resins with greater filler content exhibited higher contraction stress. dual-cure materials provide the most reliable option for achieving proper cement polymerization all along the dowel space.3. the amount of light reaching the apical third of the dowel space may not be sufficient to effectively cure the cement at that level. To gain a deeper insight into the current.46 1 out of 42 dowels debonded over a three-year follow-up period.49 Among the various treatments proposed to improve adhesion to the fibre post surface.39 It was recently demonstrated that even in the presence of translucent posts (Fig 2). Owing to the lower elastic modulus of the less filled resins. but also significantly reduced in glass fibre posts marketed as being translucent.4. the methacrylate-based resin of the cement or the abutment interacts with a highly cross-linked polymer with limited sites available for copolymerization.44 Also.40 Although purportedly able to polymerize even in the complete absence of light. canal enlargement is not required according to the manufacturer. 30.48. 1 out of 87 posts loosened in the prospective study by Ayna et al.40 The disclosed variability in optical properties of the dowels should therefore be taken into due consideration. It should indeed be considered that the C-factor of a thin resin cement film polymerizing within the boundaries of the post space is adverse to stress dissipation.46 Only two clinical studies of polyethylene fibre posts are available. lower bond strength and more defective interfaces. market-driven trend toward the use of highly-filled resin composites also suitable for core build-up. Zirconia posts High flexural strength. 70 wt%). In relation to its rigidity. silanization of quartz and glass fibre posts has been assessed in several laboratory studies.31. however. It is in fact practically impossible to grind off a luted zirconia post. a recent research paper assessed contraction stress.1. During the same observation period.41. due to the difficulty in getting the light to fully penetrate the post space. Silanization is not effective on resin posts reinforced by carbon fibres that do not present a sufficient number of hydroxyl groups on their surface.48. dual-curing resins develop better mechanical properties if light-irradiated. and are claimed to create a dentine-post-core mono-block allowing for a more favourable stress distribution along the root.30 Adhesive application after post silanization does not significantly add to the bond strength of a core material to a fibre post with a methacrylate-based matrix.48. clinical studies are currently ongoing in order to verify whether lowfilled resins are adequate for the long-term clinical service of post-retained restorations.48. without providing any conclusive evidence. 50.31 Silane application would promote adhesion by increasing the post surface wettability. the use of light-cure materials is not advised in post luting. light-curing has been suggested also with dual-cure cements. to the point that resin cement curing would be affected. Therefore.44 zirconia posts are more prone to cause root fractures than fibre posts.Post systems Concerning the curing mode of the cement.. biocompatibility and favourable optical properties are advantageous characteristics of zirconia as a restorative material.49 By removing a superficial layer of 81 . the surface of zirconia posts does not bond to resin composite materials. chemical stability. Chemical reactions are alternatively possible between the resin cement or core material and fibres exposed on the post surface.40 In the same investigation it was demonstrated that light transmission was not only prevented in carbon fibre posts. as well as by chemically bridging methacrylate groups of the resin and hydroxyl groups of quartz and glass fibres. according to other investigations the procedure did not contribute any substantial clinical benefit.

A systematic review of dowel (post) and core materials. Lupi-Pegurier L. Salameh Z. in post-retained restorations. hydrogen peroxide exposes to silanization a larger surface area of fibres. Nonmetallic prefabricate dowels: a review of compositions. An in vitro study into the effect of the ferrule preparation on the fracture resistance of crowned teeth incorporating prefabricated post and composite core restorations. Dent Mater 2007. Borg C. Fiber posts and endodontically treated teeth: a compendium of scientific and clinical perspectives. 2008:9–13. Dennison J. While etch-and-rinse adhesives in combination with dual-cure resin cements ensure reliable results in fibre post cementation. Ferrari M. Fernandes AS. such as zirconia dowels. Duc O.38:733–743. Ferrari M. and effective post adhesion are the most critical factors for the successful clinical performance of restored endodontically treated teeth. Billy E. followed by silanization. and in vivo studies). 9. Apicella D. 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