Clinical Research
Long-term Clinical Outcomes of Endodontically
Treated Teeth Restored with or without Fiber
Post–retained Single-unit Restorations
Kevin A. Guldener, med dent,* Carla L. Lanzrein, med dent,†‡
Beatrice E. Siegrist Guldener, Dr med. dent., MS,*§ Niklaus P. Lang, Prof Dr med dent, MS,*k
Christoph A. Ramseier, PD, Dr med dent, MAS,* and Giovanni E. Salvi, Prof Dr med dent, DMD*
Abstract
Introduction: The aim of the present study was to
evaluate both survival and failure rates of endodonti-
cally treated teeth restored with or without fiber post–
retained restorations after a mean observation period
of at least 5 years. Methods: A total of 144 single-
rooted and multirooted teeth in 100 subjects were
B ecause of the increasing
endodontically treated following a predetermined
aseptic protocol and restored with either a fiber post
and a composite core or a composite filling without in-
traradicular retention. A fiber post was cemented when
the teeth presented with only 1 wall and/or less than
one third of the remaining height of the clinical crown.
After a comprehensive treatment plan, the teeth were
restored with either a direct composite restoration or a
single-unit crown. Endodontically treated teeth support-
ing fixed and removable dental prostheses and tele-
scopic crowns were excluded from the analysis.
Success was defined as tooth survival without any treat-
ment of biological and/or technical complications.
Results: The overall tooth survival rate was 89.6% after
a mean observation time of 8.8  2.3 years. The survival
rate of teeth with a fiber post amounted to 94.3%, and
for teeth without a post, it was 76.3% (P < .001). The
main reason for tooth loss was root fracture (9.7%).
No loss of post retention was observed. Successfully
treated teeth without any biological and/or technical
complications and requiring no additional treatment
during the entire observation period amounted to
79.9%. Conclusions: Endodontically treated teeth
restored with fiber posts and either a direct composite
restoration or a single-unit crown yielded higher survival
and success rates compared with teeth restored without
fiber posts. Vertical fractures of roots not containing a
post represented a frequently encountered and serious
problem. (J Endod 2016;-:1–6)
From the*Department of Periodontology, School of Dental Medicine, University of Bern, Bern, Switzerland; †Private Practice, Thun, Switzerland; ‡Private Practice,
Fribourg, Switzerland; §Private Practice, Bern, Switzerland; and kCenter for Dental Medicine, University of Z€urich, Z€urich, Switzerland.
Address requests for reprints to Dr Giovanni E. Salvi, Freiburgstrasse 7, 3010 Bern, Switzerland. E-mail address: giovanni.salvi@zmk.unibe.ch
0099-2399/$ - see front matter
Copyright ª 2016 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2016.10.008
JOE — Volume -, Number -, - 2016
Key Words
Fiber post, restoration, root canal treatment, root filling, root fracture, single-unit crown
popularity of implant
dentistry, the decision
Significance
Endodontic therapy is predictable and reliable.
Long-term outcomes of endodontically treated
whether to treat or extract
teeth compare favorably with those of implant-
severely compromised teeth
supported restorations. Therefore, prophylactic
affected by pulpal and/or
extractions of endodontically treated and restored
periapical disease and
teeth being replaced with dental implants cannot
considerable loss of coro-
be recommended.
nal tooth substance be-
comes more challenging.
Thorough assessment of the patient’s health and periodontal condition and a careful eval-
uation of the remaining tooth substance facilitated by magnification devices are important
prerequisites in the decision-making process. High-standard nonsurgical endodontic treat-
ment completed by a quality restoration and single-tooth implants both represent viable
treatment modalities (1). Both treatment options have risks, advantages, and disadvantages,
and patients need to be informed, enabling them to participate in the choice of the proper
treatment.
For single-tooth implants, a higher incidence of postoperative complications
requiring additional treatment interventions has been reported (2), whereas in
most endodontic studies detailed information on the restoration is lacking. Root
canal–treated teeth reconstructed with a good restoration show higher success rates
(3, 4), and patients prefer keeping their own teeth whenever possible (5).
Because of limited clinical evidence on the influence of restorative procedures on
root canal–treated teeth, principles for restorative work have to be mainly derived from
laboratory studies. A considerable lack of coronal tooth substance, the presence of a
dentin ferrule, careful selection of luting agents for post cementation, and coronal
restoration may all influence clinical outcomes (6–10).
In a clinical study following a protocol for high-quality root canal treatment and
standardized restoration procedures, the 5-year survival rate of endodontically treated
teeth amounted to 92.5% for teeth restored with titanium posts, 97.1% for those
restored with cast post and cores, and 94.3% of teeth without post-retained restorations
(11). The most frequent complications included root fracture (6.2%), recurrent caries
(1.9%), development of periapical pathology (1.6%), and loss of retention (1.3%).
Similar cumulative survival rates and frequency of root fractures, increased probing
Fiber Post–retained Single-unit Restorations 1
Clinical Research
depths, increased tooth mobility, caries, periapical lesions, and loss of
retention were reported for endodontically treated teeth restored with
either indirect cast post and cores or direct composite buildups with
titanium posts after a mean observation period of 8.56 years (11).
Moreover, outcomes of a recent systematic review indicated sim-
ilarities between the incidences of root fractures among metal and fiber
post–retained restorations after an observation period of at least 5 years
(12). However, the studies included in the systematic review (12) pre-
sented a high risk of bias without being able to formulate clear guide-
lines for the selection of metallic versus fiber posts.
Today, fiber-reinforced, resin-based composite posts with a
modulus of elasticity similar to dentin are supposed to significantly
reduce the risk of vertical root fractures. Most common causes of failure
associated with fiber posts are post debonding, secondary caries, and
restorable cervical fractures (13–15), with post debonding being the
major role of failure (16). Laboratory studies have identified debonding
being caused by difficulties in regarding dentin hybridization (17).
Removal of the thick smear layer produced during post space prepara-
tion is critical for a good retention of adhesively luted posts (18). In
most clinical studies, detailed information on post space preparation
and bonding procedures is missing.
Aware of the advantages of fiber posts and the inherent problems
regarding debonding of adhesively luted reconstructions, endodonti-
cally treated teeth included in the present study were restored according
to a protocol respecting available evidence of laboratory work (19).
For the purpose of the present study, success was defined as tooth
survival without any treatment of biological and/or technical complica-
tions. Therefore, the aim of the present study was to assess success, sur-
vival, and failure modes of endodontically treated teeth restored with or
without fiber posts and either direct composite restorations or single-
unit crowns after an observation period of at least 5 years.
Material and Methods
Null Hypothesis
The null hypothesis of the present investigation was that no differ-
ences in survival and success rates of endodontically treated teeth
restored with or without a fiber post would be observed.
Study Design
No preliminary data were available for this study. Hence, it was not
possible to perform a sample size calculation with respect to the differ-
ence in outcome variable. This study was designed and conducted as a
longitudinal retrospective evaluation of endodontically treated and
restored teeth with an observation period of at least 5 years. The end-
odontic and restorative procedures were performed by 1 specialist in
periodontology and endodontology (B.E.S.G.) in a private practice in
Bern, Switzerland, as part of standard dental care. A standardized pro-
tocol was followed in order to optimize endodontic and restorative pro-
cedures. The study was conducted observing the guidelines for clinical
research in the Declaration of Helsinki.
Inclusion criteria were as follows:
1. Subjects without relevant medical conditions;
2. Completion of periodontal treatment with a full-mouth plaque score
#30% and a full-mouth bleeding score #30%;
3. Regular compliance with a supportive periodontal therapy program;
4. Possibility to check the restored abutment teeth with respect to bio-
logical (ie, recurrent caries, recurrent periodontitis, and periapical
pathology) and/or technical (ie, loss of retention, post fracture, and
root fracture) complications, respectively; and
2 Guldener et al.
5. Single- and multirooted teeth serving as abutments for either a
single-unit metal ceramic crown or a direct composite crown.
Exclusion criteria were as follows:
1. Subjects with untreated periodontal conditions and
2. Endodontically treated teeth supporting removable dental prosthe-
ses, telescopic crowns, and fixed dental prostheses.
Endodontic and Restorative Procedures
Root canal treatment or retreatment was performed on all teeth
after rubber dam isolation (Ivory; Heraeus Kulzer GmbH, Hanau,
Germany) and standardized chemical (ie, irrigations with 0.5% sodium
hypochlorite) and mechanical disinfection with hand (ie, FlexoFiles;
Dentsply Maillefer, Ballaigues, Switzerland) and rotating instruments
(Lightspeed LS1; Lightspeed Technology, San Antonio, TX, and Pro-
Taper Universal; Dentsply Maillefer, Ballaigues, Switzerland). Root ca-
nal obturation was performed by means of lateral condensation with
gutta-percha points and a root canal sealer (AH Plus; Dentsply DeTrey
GmbH, Konstanz, Germany). The use of an additional light source and
magnifying loupes (3.5; Zeiss, Feldbach, Switzerland) or a micro-
scope (Global Surgical Corporation, St Louis, MO) was part of the stan-
dardized endodontic and restorative protocol. To minimize the risk of
recontamination, permanent closure of the access cavity was performed
under rubber dam isolation and within 2 to 3 weeks after root canal
obturation. In teeth with only 1 wall and/or less than one third of the
remaining height of the clinical crown according to Peroz et al’s class
IV and V (20), a fiber post (Easy Post and Easy Post Lux, Dentsply Mail-
lefer) was cemented in the strongest root (eg, the distal root of the lower
molars or the palatal root of the upper molars).
After initial post space preparation to a depth of 8 mm from the
canal entrance by means of a Largo Peeso Bur (Dentsply Maillefer, Bal-
laigues, Switzerland) with a noncutting tip to avoid root perforation, the
precision drills were used by hand, and, if necessary, a matrix band was
placed. In case of short roots, care was taken to leave an apical seal of at
least 3- to 4-mm root filling, and, if necessary, a shorter post was used.
The smear layer in the post space and the access cavity was removed
with a rotating brush (Curaden, Kriens, Switzerland) and a chelating so-
lution (Tubulicid; Dental Therpeutics AB, Saltsj€o–Boo, Sweden). Etching
of the access cavity and post space with 36% phosphoric acid for 30 sec-
onds (Blue Etch; La Maison Dentaire SA, Balzers, Lichtenstein) was fol-
lowed by rinsing with water for 60 seconds and air drying. Irrigation with
alcohol, air drying, and visual inspection for cleanliness using a micro-
scope were followed by dentin conditioning (Syntac Primer, Syntac Ad-
hesive) and application of bonding resin (Heliobond). Excess material
was removed from the post space by means of sterile paper points.
The post was cleaned with alcohol, and silane (Monobond S/
Monobond Plus; Ivoclar Vivadent, Schaan, Lichtenstein) was applied
for 60 seconds. After application of bond resin to the post, a thin layer
of cement was brought into the canal space using a Lentulo spiral
(Dentsply Maillefer) and on the post before insertion. The core was
built with adding composite material in increments according to the
manufacturer’s instructions (Saremco ELS, Rebstein, Switzerland).
Biological Complications
Biological complications of abutment teeth were recorded as end-
odontic failure, recurrent caries, or recurrent periodontitis.
Technical Complications
Technical complications of abutment teeth were recorded as loss
of retention or root fracture.
JOE — Volume -, Number -, - 2016
 Clinical Research
TABLE 1. Mean Observation Time  Standard Deviation (SD), Median, and Range with Respect to Retention and Restoration Type
Fiber post, n (%) No fiber post, n (%)
n = 106/144 (73.6%) n = 38/144 (26.4%)
DCR SUC Total DCR SUC Total Total, n (%)
n = 65 (45.1%) n = 41 (28.5%) n = 106 n = 33 (22.9%) n = 5 (3.5%) n = 38 N = 144 (100%)
Mean  SD (y) 10.3  1.8 8.1  2.1 8.6  1.9 9.2  3.0 10.5  2.6 9.4  2.9 8.8  2.3
Median (years) 9.3 7.6 8.8 8.3 10.5 8.5 8.7
Range (years) 5.5–12.1 5.1–12.9 5.1–12.9 5.3–15.3 7.8–12.3 5.3–15.3 5.1–15.3
DCR, direct composite restoration; SUC, single-unit crown.

Abutment Tooth Survival
Abutment tooth survival was defined as teeth surviving without any
treatment needs and teeth surviving after treatment of biological and/or
technical complications.
Abutment Tooth Success
Abutment tooth success was defined as teeth surviving without any
treatment of biological and/or technical complications.
Statistical Analysis
Descriptive statistics are presented as mean  standard deviations
and ranges with intervals. The tooth was used as the statistical unit.
Chi-square and Fisher exact tests were applied to detect statistically sig-
nificant differences between groups. A P value <.01 was considered sta-
tistically significant. Statistical analysis was performed with a
commercially available software package (SAS Institute Inc, Cary, NC).
Results
Eighteen of 144 teeth (12.5%) in 15 patients were lost to follow-up
because of the following reasons: lack of radiographs at follow-up
(n = 10), relocation (n = 6), and treatment plan change (n = 2).
The mean observation time was 8.8 years with a median of 8.7 years
and a range of 5.1–15.3 years (Table 1).
Table 2 shows the frequency distribution of restorations with
respect to retention and tooth type. The percentage of teeth restored
with a fiber post included 25.5% incisors and canines (n = 27),
32.1% premolars (n = 34), 21.7% maxillary molars (n = 23), and
20.8% mandibular molars (n = 20), respectively. Teeth without
post-retained restorations included 28.9% incisors and canines
(n = 11), 15.8% premolars (n = 6), 31.6% maxillary molars
(n = 12), and 23.7% mandibular molars (n = 9), respectively.
The overall tooth survival rate was 89.6%. The survival rate was
94.3% for teeth with a fiber post and 76.3% for teeth without a post,
respectively (Table 3). As shown in Table 3, 106 teeth (73.6%) were
restored with a fiber post and either a single-unit crown (SUC) or a
direct composite restoration (DCR). Teeth without a post (n = 38,
26.4%) were restored either with an SUC or a DCR. Teeth restored
TABLE 2. Frequency Distribution with Respect to Retention and Tooth Type
Fiber No fiber
post, n (%) post, n (%)
n = 106/144 n = 38/144
Incisors + canines 27 (25.5) 11 (28.9)
Premolars 34 (32.1) 6 (15.8)
Maxillary molars 23 (21.7) 12 (31.6)
Mandibular molars 22 (20.8) 9 (23.7)
Total 106 (100) 38 (100)
with a fiber post yielded a statistically significantly (P < .001) higher
survival rate compared with teeth restored without a post, irrespec-
tive of the restoration type. Similarly, teeth restored with a fiber post
yielded a statistically significantly (P < .001) higher success rate
compared with that of teeth restored without a post, irrespective
of the restoration type (Table 3).
With respect to the survival and complication rates, no statistically
significant differences (P > .05) were observed comparing non-
crowned teeth (ie, with DCRs) with and without a fiber post with
crowned teeth (ie, with SUCs) with and without a fiber post (Table 3).
In teeth with post-retained restorations, no loss of post retention
and no post fracture were observed, irrespective of the restoration type.
In 9.7% (14/144) of all teeth, vertical root fracture was the reason for
tooth loss. In 4.9% (7/144) of all teeth, vertical root fractures were
observed in maxillary and mandibular molars subsequently treated
with root amputations (Table 4).
As shown in Table 5, of a total of 21 (14.6%) vertical root frac-
tures, only 1 fracture occurred in a root containing a post. Of all the
vertical root fractures, 52.4% (11/21) were observed in the mesial
roots of mandibular molars without a post.
Discussion
The present study assessed the survival and success rates of
endodontically treated teeth restored with or without fiber posts and
either DCRs or SUCs over a mean observation time of 8.8 years. The
results indicated that endodontically treated teeth restored with fiber
post–retained restorations yielded statistically significantly higher sur-
vival and success rates compared with those of teeth without a post.
Moreover, the fact that endodontically treated teeth with and without
a fiber post were crowned did not improve the prognosis when
compared with that of noncrowned teeth. Thus, based on these out-
comes, the null hypothesis was rejected.
The results of the present study are corroborated by findings of a
randomized clinical trial indicating that the placement of a prefabri-
cated or customized fiber post contributed significantly to the survival
of endodontically treated premolars restored with an SUC over an
observation period of 6 years (15). In contrast with the outcomes of
the study by Ferrari et al (15), no operator variability, post debondings,
or post fractures were observed in the present study. It has to be noted
that all the endodontic treatments were rendered by the same specialist
in endodontology and periodontology under a strict standardized pro-
Total, tocol. However, additional differences were observed when comparing
n (%) the protocol of the present study with that of Sterzenbach et al (8) in
N = 144 which only teeth with a dentin ferrule of at least 2 mm were used as abut-
38 (26.4) ments for SUCs and fixed and removable dental prostheses. Hence,
40 (27.8) based on the fact that different endodontic and restorative protocols
35 (24.3) were adopted among studies, a full comparison with the study outcomes
31 (21.5) by Ferrari et al (15) and Sterzenbach et al (8) must be exercised with
144 (100)
caution.

JOE — Volume -, Number -, - 2016 Fiber Post–retained Single-unit Restorations 3

Clinical Research
TABLE 3. Survival, Success, and Tooth Loss with Respect to Retention and Restoration Type
Fiber post, n (%) No fiber post, n (%)
n = 106/144 n = 38/144
DCR SUC DCR SUC Total, n (%)
n = 65 (45.1%) n = 41 (28.5%) Fiber post total n = 33 (22.9%) n = 5 (3.5%) No post total N = 144 (100%)
Survival 61 (93.8) 39 (95.1) 100 (94.3)* 25 (75.8) 4 (80.0) 29 (76.3)* 129 (89.6)
Success 54 (83.1) 37 (90.2) 91 (85.8)† 21 (63.6) 3 (60.0) 24 (63.2)† 115 (79.9)
Tooth loss 4 (6.2) 2 (4.9) 6 (5.7) 8 (24.2) 1 (20.0) 9 (23.7) 15 (10.4)
DCR, direct composite restoration; SUC, single-unit crown.
*94.3% statistically significantly different from 76.3% (P < .001).
†
85.8% statistically significantly different from 63.2% (P < .001).

Nevertheless, despite the fact that endodontically treated teeth
were restored adopting different protocols, the outcomes reported in
the present study and in those discussed previously (8, 15) yielded
favorable survival rates of approximately 90% after an observation
period of 6 to 9 years. As such, endodontic therapy has to be
accepted as being predictable and reliable. A survival rate of
endodontically treated teeth of approximately 90% compares
favorably with that of 95.2% of implants supporting SUCs after
10 years (21). Furthermore, in a study assessing the quality of life of
patients with either endodontically treated teeth or implant-supported
restorations, all participants expressed a clear message toward the
retention of their natural dentition (5). Thus, prophylactic extractions
of endodontically treated and restored teeth being replaced with dental
implants cannot be recommended.
Bonding to root canal dentin is challenging and influenced by mul-
tiple factors (19, 22, 23). Dowel debonding appears to be a frequently
reported mode of failure in previously published clinical trials on
adhesively luted fiber posts (7, 14, 16, 24). In contrast to the
findings of the studies mentioned previously, no loss of post retention
was observed in the present study, corroborating the results of a
study reporting on the long-term survival rate of endodontically treated
maxillary incisors restored with fiber posts and SUCs (25). As in the pre-
sent study, post space preparation and post placement were performed
under a rubber dam; special attention was given to careful removal of
the smear layer and cementation. Because of the heterogeneity of treat-
ment protocols and the lack of detailed information on the clinical pro-
cedures applied, reasons for the controversial results can only be
speculated on. Nevertheless, the presence of a special smear layer ex-
isting after post space preparation (26) has to be given appropriate
attention.
The results of the present study are in agreement with those of
Mannocci et al (27), who reported similar survival rates of teeth
restored with a fiber post and direct composite restorations compared
with crowned teeth (SUC) with a fiber post and a composite core.
However, it has to be noted that the observation time of the study by
Mannocci et al was 3 years, whereas the observation time of the present
study amounted to 10.3 years for DCRs and 8.1 years for SUCs. Also,
when comparing DCRs with SUCs, no statistically significant difference
in survival rates was observed for teeth restored without a fiber post,
supporting the hypothesis of Mannocci et al that full-crown coverage
does not result in better clinical performance, even after observation
periods of 8 to 10 years.
Recently, a systematic review on the effect of post placement on the
restoration of endodontically treated teeth was published (28). Based
on 2 studies (15, 29), the authors concluded that post placement
appears to have a significant influence in reducing the failure rate
leading to extraction of endodontically treated teeth. In agreement
with these findings, the data of the present study show that teeth
restored with fiber posts yielded significantly less tooth loss than
teeth restored without a post, irrespective of the presence or absence
of an SUC.
Focusing on complications, 14.6% of vertical root fractures
defined according to the American Association of Endodontics
(30) accounted for the most frequent events observed. The occur-
rence of vertical root fractures has been reported with a range
from 3.1% up to 20% (31).
The fact that, in the present study, only 1 of these fractures
occurred in a root containing a post (Table 5) deserves special atten-
tion. Most fractures were diagnosed in mesial roots of mandibular and
mesiobuccal roots of maxillary molars not containing a post. This is in
disagreement with many studies published on this topic. In fact, reasons
held responsible for vertical root fractures and of which the operator
was well aware were lack of residual tooth substance, obturation
methods (32), chemical influence of irrigation solutions, intracanal
medications (33), and excessive occlusal forces (34). In order to pre-
vent excessive occlusal forces, patients of the present study were in-
structed to report on potential occlusal prematurities, and the
situation was immediately corrected.

TABLE 4. Biological and Technical Complications with Respect to Presence/Absence of a Fiber Post
Fiber post, n (%) No fiber post, n (%)
n = 106/144 (73.6%) n = 38/144 (26.4%)
Total, n (%)
Tooth loss No tooth loss Tooth loss No tooth loss N = 144 (100%)
Endodontic failure 0 (0) 2 (1.9) 0 (0) 2 (5.3) 4 (2.7)
Recurrent caries/periodontitis 0 (0) 1 (0.9) 0 (0) 2 (5.3) 3 (2.1)
Abutment fracture 0 (0) 0 (0) 1 (2.6) 0 (0) 1 (0.7)
Loss of retention 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
Vertical root fracture 6 (5.7) 6 (5.7) 8 (21.1) 1 (2.6) 21 (14.6)
Post fracture 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
Total 6 (5.7) 9 (8.5) 9 (23.7) 5 (13.2) 29 (20.1)

4 Guldener et al. JOE — Volume -, Number -, - 2016

 Clinical Research
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In conclusion and within the limits of the present study, the data 19. Goracci C, Ferrari M. Current perspectives on post systems: a literature review. Aust
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21. Jung RE, Zembic A, Pjetursson BE, et al. Systematic review of the survival rate and the
teeth of patients enrolled in regular maintenance care yielded incidence of biological, technical, and aesthetic complications of single crowns on
good long-term survival rates, irrespective of the presence or implants reported in longitudinal studies with a mean follow-up of 5 years. Clin Oral
absence of an SUC; Implants Res 2012;23 Suppl 6:2–21.
2. Fiber posts did not weaken the roots of endodontically treated teeth; 22. Boschian Pest L, Cavalli G, Bertani P, Gagliani M. Adhesive post-endodontic resto-
3. Vertical fractures of roots not containing a post were the most rations with fiber posts: push-out tests and SEM observations. Dent Mater 2002;
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expert statistical assistance. study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:381–7.
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