RESTORATIVE DENTISTRY
Evaluation of fiber posts vs metal posts for
restoring severely damaged endodontically treated teeth:
a systematic review and meta-analysis
Xiaodong Wang, MDS*/Xin Shu, MDS*/Yingbin Zhang, MDS/Bin Yang, PhD/Yutao Jian, PhD/Ke Zhao, PhD
Objectives: This review was undertaken to answer a controver-
sial clinical question with high-quality evidence: When severely
damaged teeth are restored, which type of post (metal or fiber)
demonstrates superior clinical performance? Data sources: The
meta-analysis was conducted according to the guidelines in the
Cochrane handbook. Electronic databases (MEDLINE, EMBASE,
CENTRAL) and gray literatures were screened up to January
2018. Only randomized controlled trials (RCTs) with follow-up of
at least 3 years were included. The quality of included studies
was assessed by the Cochrane Collaboration’s tool. Meta-analy-
sis compared survival, success, post debonding, and root frac-
ture incidence of teeth restored with fiber and metal posts. The
GRADE system (Grading of Recommendations, Assessment,
Development and Evaluations) was used to assess the strength
Key words: meta-analysis, post, success rate, survival rate, tooth defect
The retention of severely damaged teeth is sometimes contro-
versial, especially when the value of endodontic treatment is
limited due to a questionable prognosis. Dental implants have
been promoted as an acceptable but more non-conservative
alternative for clinicians.1 However, according to a published
systematic review, compromised but adequately treated and
maintained teeth showed long-term (over 15 years) survival
rates comparable with those of implant-supported single
crowns.2 Additional advantages of endodontic treatment and
subsequent restorations are that they are less invasive, more
psychologically acceptable, and of relatively low cost. These
may provide an opportunity for the retention of natural teeth,
even with severe hard-tissue loss, and represent a cost-effective
alternative to tooth extraction and implant placement.3
8 QUINTESSENCE INTERNATIONAL | volume 50 • number 1 • January 2019
of the evidence. Of 1,511 records, 14 full texts were obtained.
Only four RCTs with follow-up times of 3 to 7 years met the se-
lection criteria. The methodologic quality of included RCTs was
low risk of bias. Fiber posts presented significantly higher sur-
vival rates than did metal posts (RR 0.57, 95% CI: 0.33 to 0.97,
P = .04), while no difference was observed in success rates, post
debonding rates, or root fracture rates. The GRADE assessment
indicated a high quality of evidence for survival rates and a
moderate quality for success rates. Conclusion: It was con-
cluded that fiber posts displayed higher medium-term (3 to
7 years) overall survival rates than did metal posts when used in
the restoration of endodontically treated teeth with no more
than two coronal walls remaining. (Quintessence Int 2019;50:
8–20; doi: 10.3290/j.qi.a41499)
Endodontically treated teeth (ETT) are brittle and prone to
fracture.4 Therefore, post application is essential in the resto-
ration of ETT with substantial tissue loss, increasing the frac-
ture resistance of restored teeth, and providing retention for
the core material and coronal restoration.5 With proper design,
noble alloy cast posts and cores are considered the “gold stan-
dard,” due to high clinical success rates,6,7 and demonstrate a
higher fracture resistance for restored teeth compared with
fiber posts.5 Conversely, the incidence of root fracture is rela-
tively lower for fiber posts, since their elastic moduli are com-
parable with that of natural dentin.8-10 Compared with cata-
strophic vertical root fractures related to the use of cast metal
posts for restoring teeth, bevel and horizontal fractures in the
coronal aspects of the roots are reportedly the most common

failure mode related to the use of fiber posts for restoring
teeth.11,12
A recent systematic review of randomized controlled trials
(RCTs) compared survival rates between fiber and metal posts,
but only descriptive results were reported due to the high het-
erogeneity.13 Other relevant systematic reviews were based on
observational studies, presenting a high risk of bias and a rela-
tively lower power of evidence.14,15 To the present authors’
knowledge, without a definite conclusion, selection of the
most adequate type of post for the restoration of ETT remains
controversial and a major concern in dentistry.
The amounts of residual cavity walls should be considered
as the predominant factor affecting the survival of both ETT
and the restorations.16 The survival rates increased when more
residual tooth tissue remained, for both metal- and fiber-post-
supported restorations.13 A prospective clinical study with
5-year follow-up showed that, despite the types of posts and
cores used, coronal restorations with “substantial dentin height”
appeared to have significantly higher survival rates than those
with “minimal dentin height” (98% vs 93%).17 However, post
placement did not seem to affect the survival of ETT in cases of
sufficient coronal tissue remaining.18 Results of a systematic
review showed that although post placement appeared to
have a significant influence on reducing the catastrophic failure
of ETT with severe defects, when three or four coronal walls
remained, post placement seemed to have no influence.19
Therefore, in light of the positive effects, deleterious side-ef-
fects, and extra costs of posts, only in cases of severe coronal
tissue loss should posts be used. Comparing the clinical perfor-
mance of post systems without identifying the remaining cor-
onal walls could result in substantial heterogeneity.
The aim of this systematic review was to answer the follow-
ing question: When severely damaged ETT are restored, which
type of intraradicular post (metal or fiber) demonstrates supe-
rior clinical outcomes in terms of survival and success rates?
Data sources
The meta-analysis was conducted according to the guidelines of
the Cochrane Handbook (http://handbook-5-1.cochrane.org/).
The study protocol was registered after the initial screening stage
(Prospero CRD42015017644). Slight modification was made to
the initially registered protocol. For the reasons described previ-
ously, only the clinical performance of ETT with no more than
two coronal walls was included in this systematic review.
Literature published in English and Chinese was obtained
through an electronic search of the following databases (up to
QUINTESSENCE INTERNATIONAL | volume 50 • number 1 • January 2019
Wang et al
January 2018): MEDLINE via PubMed, EMBASE via embase.com,
and CENTRAL via the Cochrane Library. The search strategy
included the following key word combinations (MeSH and free-
text terms in Title/Abstract): “Post and Core Technique [MeSH
Terms]”, “fiber*”, “fibre*”, “glass-fib*”, “quartz-fib*”, “carbon-fib*”,
“non-metal*”, “metal*”, “cast*”, “wrought”, “screw”, “titanium”, “Ti”,
“cobalt-chromium”, “Co?Cr”, “stainless”, “gold”, “alloy”, “prefabri-
cate*”, “custom”, “endodontic*”, “root canal”, “post*”, “dowel*”,
and “pin*”. Gray literature was searched for potentially suitable
unpublished clinical trials in ClinicalTrials.gov, Open Grey, and
Google Scholar. Additional relevant studies were identified by
hand-searches of the references in the retrieved articles.
Resource selection
Initially, two reviewers independently examined the titles and
abstracts according to the following inclusion criteria:
■ Patients (P): patients with endodontically treated perma-
nent teeth restored with posts and cores. For restored teeth,
residual coronal walls should ≤ 2. There was no restriction
by gender or tooth position.
■ Intervention (I): endodontically treated teeth restored with
prefabricated or custom fiber posts, followed by coverage
with indirect fixed permanent restorations (crowns or fixed
partial dentures [FPDs]).
■ Control (C): endodontically treated teeth restored with pre-
fabricated or custom metal posts, followed by coverage
with indirect fixed permanent restorations (crowns or FPDs).
■ Outcomes (O): survival and success rates of restored teeth
(primary outcomes). The survival criterion was defined as
an in situ tooth–post complex without extraction. The suc-
cess criterion was defined as both the restored tooth and
restoration being present and clinically acceptable, without
intervention or repair needed. Secondary outcomes
included incidence of complications including root fracture
and debonding of posts.
■ Study design (S): RCTs with follow-up time of at least 3 years.
The full texts were analyzed when the titles or abstracts indi-
cated that the inclusion criteria were fulfilled. When necessary,
the original author was contacted for further clarification of
missing information. Any disagreement between the two
reviewers was resolved by consensus. If the disagreement
could not be resolved, a third reviewer was involved. Two
reviewers independently extracted the data using a data col-
lection form.
9
 RESTORATIVE DENTISTRY

1 Fig 1 Flowchart of the selection of studies.

Initial electronic search results:
MEDLINE via PubMed: n = 901
EMBASE via embase.com: n = 641
CENTRAL via Cochrane Library: n = 366

Duplicates removed: n = 397

Potentially relevant publications:

n = 1,511

Handsearching and gray literature searching: Excluded by title and abstract:

n=0 n = 1,497

Potentially relevant articles for full text analysis:

n = 14

Articles excluded with reasons:

n = 10 (Table 2)

Articles included in meta-analysis:

n=4

Table 1 Characteristics of included studies

Study Study Follow-

Region Coronal wall Restorations Post cement
(year) design up
Post No.

Cloet RCT 5y 68 anterior (28 fiber, Fewer than 2 dentin Single crowns Dual-curing 65 prefabricated 91
et al20 40 metal*); 123 walls (≥ 2 mm) with adhesive cement fiber posts (Parapost
(2017) posterior (63 fiber, wide pulp chambers (Panavia F 2.0) FibreLux); 26
60 metal*) custom-made glass
fiber posts
(EverStick)

Sarkis- RCT 3y 40 anterior (21 fiber, No remaining Metal-ceramic single Regular resin cement Glass fiber post 37
Onofre 19 metal); 32 coronal wall, or the crowns (RelyX ARC) or (White Post DC)
et al21 posterior (16 fiber, enamel portion of self-adhesive resin
(2014) 16 metal) one wall with no cement (RelyX U100)
dentinal support
(ferrule height, 0–0.5
mm)
Sterzenbach RCT 7y 27 incisors (15 fiber, Two or fewer cavity 52 single crowns (24 Self-adhesive resin Glass fiber post 45
et al22 12 metal); 17 canines walls remaining fiber, 28 metal); 23 cement (RelyX (Fiberpoints Root
(2012) (7 fiber, 10 metal); 37 FPDs (13 fiber, 10 Unicem) Pins Glass)
premolars (18 fiber, metal); 4 single
19 metal); 10 molars crown-RPDs (1 fiber,
(5 fiber, 5 metal) 3 metal); 8 FPD-RPDs
(3 fiber, 5 metal)
Schmitter RCT 5y Anterior and Coronal tooth Crowns, FPDs, Metal post: zinc Fiber-reinforced 50
et al23 posterior (sample destruction ≥ 40% crowns integrated phosphate cement posts (ER dentin
(2011) size unclear) into RDPs (Harvard Dental). post)
Fiber post:
composite cement
(Variolink II)
*About 90% (90/101) of the samples in the metal post group had insufficient (≤ 2 coronal walls) tooth tissue remaining, and therefore, the study was included in the analysis.
†
”Absolute failure” refers to catastrophic complications (root fracture, post fracture in root canal, caries, endodontic failure, and periodontal failure) that resulted in tooth extraction.
“Relative failure” refers to repairable complications (loss of retention of the post, endodontic failure, and post fracture requiring post replacement).

10 QUINTESSENCE INTERNATIONAL | volume 50 • number 1 • January 2019

 Wang et al

Review included studies. To test the reliability of evidence, outcomes of

Assessment of risk of bias and evidence quality
Methodologic qualities of retrieved studies were evaluated inde-
pendently by two reviewers according to the guidance provided
by the Cochrane Collaboration. The following domains were as-
sessed: sequence generation, allocation concealment, blinding,
incomplete outcome data, selective outcome reporting, and
other sources of bias. Additionally, quality of the body of evi-
dence and strength of recommendation were assessed accord-
ing to the GRADE approach by GRADEprofiler 3.6.1 (McMaster
University and Evidence Prime).
Statistical analysis
Pooled data from all outcomes were subjected to meta-analysis to
estimate the risk ratio (RR) and 95% confidence intervals (CI) using
the Review Manager (Ver. 5.3). For each outcome, Cochrane’s Q
test was applied for analysis of the heterogeneity among
fixed-effects and random-effects models were compared, but
only random-effects estimates were reported to be more con-
servative. If the heterogeneity of outcomes was higher than
40%, sensitivity analysis was carried out by subgroup analysis,
testing for excess studies with significant results. If heterogeneity
could not be eliminated, meta-analysis was abandoned and nar-
rative analysis was applied instead. Additionally, publication
bias could not be assessed due to the limited number of studies.
Search results
An electronic search identified 1,511 potentially relevant arti-
cles. The evaluation of titles and abstracts led to the selection
of 14 articles, and finally, only four articles met the inclusion
criteria. The search strategy is described in Fig 1.
Characteristics of included studies
The characteristics of included studies are detailed in Table 1.

Fiber post Metal post

Survival Survival
Drop- Drop-
Failure (success) Post No. Failure (success)
out out
rate rate

Unclear Absolute failure†: 6 prefabricated 91.21% Gold alloy-based 101* 5* Absolute failure†: 14 (6 anterior, 86.14%
fiber posts (1 anterior, 5 (80.22%) wrought posts and cast 8 posterior). Relative failure†: 10 (76.24%)
posterior); 2 custom fiber posts cores (Parapost and (6 anterior, 4 posterior)
(2 anterior). Relative failure†: Medior 3 Centres +
7 prefabricated fiber posts Métaux)
(3 anterior, 4 posterior); 3 custom
fiber posts (3 anterior)
2 2 debonded (1 premolar, 1 97.30% Co-Cr metal post 41 4 1 root fracture (molar) 97.56%
anterior); 1 debonded with root (91.89%) (97.56%)
fracture (premolar)

11 1 cervical root fracture 91.11% Titanium post 46 11 3 endodontic failures (2 incisors, 93.48%
(premolar); 1 middle root fracture (91.11%) (Fiberpoints Root Pins 1 molar) (93.48%)
(incisor); 1 enhanced tooth mobil- Titanium)
ity (canine); 1 core fracture
(premolar)

11 6 extracted (post core-crown
loosened and severe decay); 2
post core-crown dislodgement
and recemented; 2 crowns
cracked or severely chipped; 1
apical alteration
88.00% Titanium screw post 50 8 17 extracted (root fracture or 66.00%
(78.00%) (BKS) perforation); 1 post dislodgement (58.00%)
and recemented; 1 crown
dislodgement and recemented; 1
core-crown complex loosened
and restored; 1 apical alteration

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 RESTORATIVE DENTISTRY

Table 2 Characteristics of excluded studies and reasons for exclusion

Fiber post Metal post

Remaining
Study Study Reasons for
coronal
(year) design Drop- Failures Drop- Failures exclusion
wall Post information No. Post information No.
outs (n) (n) outs (n) (n)

Naumann RCT (11 y) ≤ 2 cavity Glass fiber posts 45 16 12 Titanium posts 46 19 7 Multiple
et al24 walls reports
(2017)
Naumann RCT (3 y) ≤ 2 cavity Glass fiber posts 45 4 0 Titanium posts 46 0 0 Multiple
et al25 walls reports
(2007)
Zicari et RCT (3 y) < 2 cavity 65 prefabricated 91 Unclear 2 Gold alloy-based 88 Unclear 1 Multiple
al26 (2011) walls fiber posts; 26 wrought posts reports
(height ≥ 2 custom-made and cast cores
mm) glass fiber posts
Qian et RCT (2 y) Unclear Custom-made 48 Unclear 0 Co-Cr alloy cast 49 Unclear 5 No description
al27 (2017) glass fiber posts posts-cores of coronal
destruction
Gbadebo RCT (0.5 y) ≥ 2 mm Glass fiber posts 20 2 0 Stainless steel 20 4 0 Coronal
et al28 ferrule posts destruction is
(2014) inconsistent
with our PICO
King et Prospec- Unclear Carbon fiber 16 2 0 Wrought precious 11 2 0 Non-RCT
al29 (2003) tive (80 to posts alloy
100 mo)
Ma et al30 Retro- Unclear Glass fiber posts 73 Unclear 2 Cast titanium 40 Unclear 5 Non-RCT
(2013) spective posts-cores
(> 5 y)
Aquilino Retro- Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear Unclear Non-RCT
et al31 spective
(2002)
Turker et Prospec- Unclear Polyethylene 42 Unclear 0 NA NA NA NA Non-RCT;
al32 (2007) tive (10 to fiber ribbon-rein- “No metal
73 mo) forced posts posts” group
Ellner et RCT (10 Unclear NA NA NA NA Cast tapered 50 Unclear 3 “No fiber
al33 (2003) years) posts; Prefabri- posts” group
cated posts; Cast
posts and cores;
Threaded
titanium posts
NA, not applicable.

All four included studies were RCTs (parallel design) with fol-
low-up of 3 to 7 years.20-23 Characteristics and reasons for exclu-
sion of 10 studies are listed in Table 2.24-33
For the same clinical trial with multiple publications, only
the most recent was included in the analysis. Initially, a study
by Naumann et al24 was included in the survival rate calcula-
tion, and resulted in marked heterogeneity of meta-analysis
(P = .06, I2 = 59%). Sensitivity analysis indicated the following
possible reasons: first, the dropout rate of this RCT was as high
as 49.4%, which is not acceptable in analysis. In addition, it was
the only long-term (11-year) RCT, and the author reported that
the survival rates for severely damaged ETT decreased signifi-
cantly after 8 years, leading to a significantly higher failure rate
and heterogeneity compared with results of other included
studies. Therefore, the 11-year long-term results were excluded,
and data from the 7-year report for the same study were
included instead.22
Risk of bias
The quality assessments are presented in Fig 2. Generally, most
studies showed relatively low risk of bias, except for selection
bias, since half of the included studies did not conceal alloca-
tion. Sarkis-Onofre et al21 and Sterzenbach et al22 mentioned
the blinding of participants and personnel or outcome assess-
ment. However, the objective outcome was not likely to be
influenced by lack of blinding; therefore, low risk of both per-
formance bias and detection bias was determined.

12 QUINTESSENCE INTERNATIONAL | volume 50 • number 1 • January 2019

 Wang et al

2 0.78, 95% CI: 0.48 to 1.27, P = .31) with low heterogeneity

Blinding of participants and personnel (performance bias)

(P = .27, I2 = 23%) (Fig 4).
Studies from Sarkis-Onofre et al21 (3 years) and Schmitter et
al23 (5 years) were included in comparisons of post debonding

Blinding of outome assessment (detection bias)

Random sequence generation (selection bias)
rates. The results indicated that fiber posts and metal posts

Incomplete outcome data (attrition bias)

showed no differences in rates of post dislodgement (RR 1.64,

Allocation concealment (selection bias)

95% CI: 0.33 to 8.28, P = .55) (Fig 5). No heterogeneity was

Selective reporting (reporting bias)

detected between the two studies (P = .34, I2 = 0%).
Sarkis-Onofre et al21 (3 years) and Sterzenbach et al22 (7 years)
reported the incidence of root fracture. Meta-analysis pre-
sented no statistical significance between fiber and metal posts
(RR 2.21, 95% CI: 0.29 to 16.75, P = .44) (Fig 6). No heterogeneity
was detected (P = .46, I2 = 0%).

Chloet et al20
Sarkis-Onofre et al21
Schmitter et al23
22
Sterzenbach et al
Fig 2 Risk of bias summary.
? ?
+ –
+ –
+ +
Other bias
GRADE assessment
+ + ? + ? SoF (summary of findings) tables were generated with GRADE-
+ + + + ? profiler. Among the six outcomes analyzed in this review, over-
all survival rates showed high quality of evidence (Fig 7); ante-
+ + + + ?
rior and posterior tooth survival rates and success rates (Fig 8)
+ + + + ? showed moderate quality of evidence (all downgraded one
level for imprecision), but incidences of post debonding and
root fracture showed low quality of evidence (downgraded two
levels for imprecision).

Discussion
Data synthesis
In the present meta-analysis, all the included studies were
Comparison of survival rates All four studies were included well-designed RCTs with low risk of bias, resulting in satisfac-
in the analysis of survival rates with follow-up times from 3 to tory quality of evidence for the primary outcomes.
7 years.20-23 As meta-analysis showed (Fig 3a), fiber posts pre- A published descriptive systematic review comparing fiber
sented significantly higher overall survival rates than did metal and metal posts did not conduct a meta-analysis of RCTs
posts (RR 0.57, 95% CI: 0.33 to 0.97, P = .04). No heterogeneity because of high heterogeneity.13 In any exploration of the ori-
was detected among the studies (P = .40, I2 = 0%). gin of heterogeneity, residual coronal walls are expected to be
Two studies (Fig 3b) were included for the analysis of sur- one of the determinant factors. A previous systematic review
vival rates of anterior teeth (5 to 8 years),20,22 and three studies showed that the high variation in success/survival rates of ETT
(Fig 3c) were included in posterior tooth survival rate analysis crowns with the absence of a ferrule or only one coronal wall
(3 to 7 years).20-22 The results of meta-analysis indicated that no ranged between 0% and 97%, while higher success/survival
statistical significance was detected in the anterior zone (RR rates with lower variation between 66.7% and 100% were pres-
0.80, 95% CI: 0.27 to 2.32, P = .68) or the posterior zone (RR 0.76, ent for the three- and four-wall groups.34 Based on the guide-
95% CI: 0.31 to 1.89, P = .56), with no heterogeneity in both line for the type of reconstruction for ETT according to the
groups (anterior, P = .77, I2 = 0%; posterior, P = .62, I2 = 0%). residual coronal wall, it is recommended that with two to four
remaining coronal walls, a post would not be necessary. But
Comparison of success, post debonding, and root fracture with no or one remaining wall, the core material could provide
rates The same four studies were also included in the analysis limited retention as well as fracture resistance, and a post is
of 3- to 7-year success rates.20-23 No statistically significant differ- required.35 Consequently, studies on ETT with fewer than two
ence was observed between fiber posts and metal posts (RR walls were included in the current meta-analysis, and very low

QUINTESSENCE INTERNATIONAL | volume 50 • number 1 • January 2019 13

 RESTORATIVE DENTISTRY

3a

Chloet et al20
Sterzenbach et al22

P
P

Fig 3a Comparison of survival rates.

3b

Chloet et al20
Sarkis-Onofre et al21
Schmitter et al23
Sterzenbach et al22

P
P

Fig 3b Comparison of survival rates of anterior teeth.

3c

Chloet et al20
Sarkis-Onofre et al21
Sterzenbach et al22

P
P

Fig 3c Comparison of survival rates of posterior teeth.

heterogeneity was detected. Therefore, it is suggested that in
comparisons of the application and performance of different
post and core systems, consideration of remaining coronal
walls should be regarded as a prerequisite.
Besides remaining coronal walls, a ferrule is another import-
ant factor,36 since ETT restored with ferrules showed survival
rates superior to those of ETT restored without ferrules during
5-year observation.16 Unfortunately, most included studies did
not report detailed information on ferrules and the height of
remaining coronal walls. Therefore, the relationship between
ferrules and survival/success rates could not be clarified by sub-
group analysis. It is suggested that the influence of the ferrule

14 QUINTESSENCE INTERNATIONAL | volume 50 • number 1 • January 2019

 Wang et al

Chloet et al20
Sarkis-Onofre et al21
Schmitter et al23
Sterzenbach et al22

P
P

Fig 4 Comparison of success rates.

Sarkis-Onofre et al21
Schmitter et al23

P
P

Fig 5 Comparison of post debonding rates.

Sarkis-Onofre et al21
Sterzenbach et al22

P
P

Fig 6 Comparison of root fracture rates.

effect should be based on relatively sufficient support from
coronal walls. The results of a 6-year RCT demonstrated that, for
restored teeth without coronal walls, failure risks were similar,
regardless of the presence or absence of ferrules.37
Differences in remaining dental tissue, post depth and
preparation, materials, and processing techniques for posts/
cores, as well as cement selection, etc, resulted in survival rates
with a large variation among included studies (88%23 to 97.3%21
for fiber posts, 66%23 to 97.6%21 for metal posts). Therefore, for
comparisons of clinical performance of different post systems,
meta-analysis with only RCTs is the best choice to minimize pos-
sible influencing factors. The results showed that fiber posts pres-

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 RESTORATIVE DENTISTRY

Fiber posts compared to metal posts for severely damaged ETT 7

Patient or population: patients with severely damaged ETT

Settings: University
Intervention: Fiber posts
Comparison: Metal posts
Outcomes Illustrative comparative risks* (95% CI) Relative No. of participants Quality of the Comments
Assumed risk Corresponding risk effect (studies) evidence
(GRADE)
Metal posts Fiber posts
Survival Study population RR 0.57 (0.33 461 (4 studies) ++++ high
147 per 1,000 84 per 1,000 (49 to 143) to 0.97)
Moderate
103 per 1,000 59 per 1,000 (34 to 100)
*The basis for the assumed risk (eg, the median control group risk across studies) is provided in footnotes.
The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its
95% CI).
(CI, confidence interval; RR, relative risk).
GRADE Working Group grades of evidence

High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the
estimate.
Very low quality: We are very uncertain about the estimate.

Fig 7 Summary of findings for survival rates.

Fiber posts compared to metal posts for severely damaged ETT 8

Patient or population: patients with severely damaged ETT

Settings: University
Intervention: Fiber posts
Comparison: Metal posts
Outcomes Illustrative comparative risks* (95% CI) Relative No. of participants Quality of the Comments
Assumed risk Corresponding risk effect (studies) evidence
(GRADE)
Metal posts Fiber posts
Survival Study population RR 0.78 (0.48 461 (4 studies) +++− moderate†
206 per 1,000 161 per 1,000 to 1.27)
(99 to 261)
Moderate
153 per 1,000 119 per 1,000
(73 to 194)
*The basis for the assumed risk (eg, the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is
based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). (CI, confidence interval; RR, relative
risk).
GRADE Working Group grades of evidence

High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the
estimate.
Very low quality: We are very uncertain about the estimate.
†
Downgraded one level for imprecision (total sample size [461] is relatively small).

Fig 8 Summary of findings for success rates.

16 QUINTESSENCE INTERNATIONAL | volume 50 • number 1 • January 2019


ent higher 3- to 7-year overall survival rates compared with metal
posts for ETT with severe coronal damage. Among the included
studies, four different metal post systems were involved (gold-
alloy-based wrought posts,20 Co-Cr casting posts,21 titanium pre-
fabricated pin posts,22 and titanium screw posts23), three of which
demonstrated comparable survival rates without statistically
significant differences compared with fiber post groups (86.14%
[metal] vs 91.21% [fiber] for 5 years;20 97.56% [metal] vs 97.30%
[fiber] for 3 years;21 93.48% [metal] vs 91.11% [fiber] for 7 years22).
In contrast, in the study by Schmitter et al,23 it was found that the
failure rate of prefabricated screw titanium posts was signifi-
cantly higher than that of fiber posts (88.00% vs 66.00% for
5 years). Interestingly, all six failures in the fiber post group were
due to post core-crown loosening and severe decay, while the 14
teeth in the metal post group were extracted because of root
fracture or perforations. Root canals were enlarged and tapped
by means of a tapper (Brasseler), followed by insertion of paral-
lel-sided screw posts, and root fractures or perforation were
observed subsequently.23 It has been proved that threaded metal
posts represent a high risk of root fracture,38 since tapping inside
the root exerts more stress on the tooth.39 Moreover, clinicians
should pay more attention to parallel threaded posts, which dis-
played two times greater root strain and stress concentration
compared with tapered threaded posts.40 In summary, the use of
parallel-sided screw metal posts should be avoided if possible.
According to methodology, although titanium parallel-sided
screw posts demonstrated much lower survival rates, there is
insufficient evidence to exclude them from the meta-analysis,
especially when heterogeneity is negligible. Additionally, accord-
ing to a published systematic review, no statistically significant
difference was detected between the 5-year success rates of pre-
fabricated titanium and those of cast posts.13
Further, it was found that ETT restored with metal posts
were extracted more often due to endodontic failure. The elas-
tic modulus mismatch between roots and metal posts led to a
stress concentration at the bonding interface between the post
and the luting material,41 which therefore resulted in microgaps
and could increase bacterial colonization as well as risk for api-
cal periodontitis.22 An in-vitro study reported that glass fiber
posts and resin-supported polyethylene fiber posts exhibited
less microleakage compared with stainless steel posts and zir-
conia posts.42 With no access to root canal retreatment, teeth
restored with a cast post-and-core restoration but with a peri-
apical lesion present are very likely to be extracted.43
Three studies reported survival rates of anterior and poste-
rior teeth, but only two studies were included in anterior tooth
analysis, because, in the study by Sarkis-Onofre et al,21 no failure
QUINTESSENCE INTERNATIONAL | volume 50 • number 1 • January 2019
Wang et al
was found in the anterior zone for both groups (both-arm-0-
event, BA0E). Also, the study by Schmitter et al23 was excluded,
since detailed information for anterior and posterior teeth was
unclear. With the limited number of included studies and mod-
est sample size, no statistical significance was detected between
fiber and metal posts for both anterior and posterior teeth.
Reported reasons for failure were similar for anterior and poste-
rior teeth, including root fracture, core fracture in fiber posts, and
endodontic failure, as well as root fracture for metal posts.20-22
Debonding was considered the most common type of fail-
ure with post-retained restorations.44,45 Only two studies were
included in the meta-analysis,21,23 since the other two studies
did not report the incidence of debonding.20,22 No statistically
significant difference was found when fiber and metal posts
were compared, but in the study by Sarkis-Onofre et al,21 dis-
lodgement was observed in two of a group of 37 prefabricated
fiber posts, compared with none in a group of 43 cast Co-Cr
posts. Post retention was determined by micromechanical
interlocking, chemical bonding, and sliding friction. Therefore,
perhaps the types of fabrication rather than the materials
should count for the retention of posts. This was supported by
an in-vitro study showing that cast metal posts had greater
retention than fiber and zirconia posts because of superior fit-
ting.46 Similarly, customized fiber posts also showed superior
bond strength compared with prefabricated metal or fiber
posts.47,48 The above results could be explained by cement thick-
ness, since thicker cement might lead to increased polymeriza-
tion stress and decreased bending strength.48 Simultaneously,
with a lack of direct visualization and control of adhesive proce-
dures, the predictability of cement could be further jeopar-
dized.48 For some prefabricated posts, since their adaptation to
root canal anatomy was not always good (eg, oval canal), lateral
compaction of smaller accessory posts was required after place-
ment of a master post. A well-prepared root canal for post space
and the selection of post taper/diameter are essential to acquire
initial friction retention during a prefabricated post try-in, which
will contribute to the prevention of post debonding.
In the studies by Cloet et al20 and Schmitter et al,23 the exact
number of root fractures is unclear. No statistically significant
differences were found in the incidence of fracture between
the two post systems in meta-analysis of the remaining two
studies.21,22 In accordance with these results, a previous review
indicated that root fracture incidence for metal posts was
5.13% per year, which is comparable with that reported for
fiber posts (4.78% per year).14 Actually, root fractures are usually
more unfavorable and catastrophic with metal posts,14,23 since
potential fracture locations are expected to be apical with
17
 RESTORATIVE DENTISTRY

metal posts, but coronal (cervical) with fiber posts.49 In addition
to similar elastic moduli and better stress dissipation in ETT
restored with fiber posts, a thick cement layer can also act as
stress absorption under functional loading, reducing the possi-
bility of root facture.5 Finite Element Analysis indicated that the
use of a post-and-core material with a lower elastic modulus
and a cement with a higher elastic modulus could result in high
stress concentrations in the cement layer, leading to a reduc-
tion in stress and deformation in the residual root.50 However, it
must be kept in mind that the placement of a post, regardless
of its composition, produces a potential risk to the integrity of
the tooth. Filling the root canal space with a material with stiff-
ness that varies from that of pulp will make it impossible to
replicate the stress distribution of the original tooth, thus
increasing the incidence of root fracture.50
In the inclusion criteria, the follow-up time was stipulated to
be at least 3 years, since observation of less than 3 years was
generally regarded as a short-term investigation.51 Although the
quality of evidence was relatively high and credible, it should be
noted that all the results of the present review were based on
medium-term studies (3 to 7 years), and the conclusions should
not be extrapolated to long-term situations. Long-term prospec-
tive controlled clinical trials are very rare because they are diffi-
cult to conduct and have high dropout rates. Up to now, only
one long-term RCT could be found on this topic, in which cumu-
lative survival probability for glass-fiber posts (58.7%) was sig-
nificantly lower than that for metal posts (74.2%) after 11 years’
observation.24 Failure reasons for fiber posts were root fracture
(4/29), endodontic failure (2/29), core fracture (1/29), tooth frac-
ture (1/29), secondary caries (1/29), and tooth mobility (1/29)
after 11 years’ follow-up, while failures for metal posts were
attributed to endodontic failure (5/27) and root fracture (1/27).
Apart from the high dropout rate (approximately 50%), an inter-
esting trend found in this study was that, for severely damaged
teeth (defects in more than two walls), the Kaplan-Meier curve
dropped rapidly after 8 years for both groups.24 Long-term sur-
vival of ETT with extensive coronal tissue loss is highly uncertain
and could be quite different from medium-term results.
Conclusions
Based on the high level of evidence from RCTs, fiber posts display
higher medium-term (3 to 7 years) survival rates than do metal
posts in the restoration of ETT with fewer than two coronal walls
remaining. With the limited included studies and sample sizes, no
differences are evident between fiber and metal posts in anterior
teeth, posterior teeth, post debonding, and root fracture.
Acknowledgment
This work was supported by the National Natural Science Foun-
dation of China under grant No. 81470767 and No. 81600907.

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19
 RESTORATIVE DENTISTRY

Xin Shu* Staff Dentist, Department of Stomatology, Baoan Ma-

Xiaodong Wang Xin Shu
Xiaodong Wang* Clinical Assistant Professor, Department of
Prosthodontics, Guanghua School of Stomatology, Sun Yat-sen
University, Guangdong Provincial Key Laboratory of Stomatology,
Guangzhou, China.
ternal and Child Health Hospital, Jinan University, Baoan District,
Shenzhen, China.
Yingbin Zhang Staff Dentist, The 1st Clinical Division, Hospital
of Stomatology, Peking University, Xicheng District, Beijing, China.
Bin Yang Clinical Assistant Professor, Department of Restorative
Dentistry, University of Illinois at Chicago, Chicago, IL, USA.
Yutao Jian Associate Professor, Institute of Stomatological Re-
search, Guangdong Provincial Key Laboratory of Stomatology, Sun
Yat-sen University, Guangzhou, China.
Ke Zhao Professor, Department of Prosthodontics, Guanghua
School of Stomatology, Sun Yat-sen University, Guangdong Provin-
cial Key Laboratory of Stomatology, Guangzhou, China.
*These authors contributed equally to the study.

Correspondence: Dr Ke Zhao, Department of Prosthodontics, Guanghua School of Stomatology, Sun Yat-sen University, Guangdong
Provincial Key Laboratory of Stomatology, 54 Ling-yuan West Street, Guangzhou, China 510055. Email: zhaoke@mail.sysu.edu.cn;
dr.zhaoke@aliyun.com;
Dr Bin Yang, Department of Restorative Dentistry M/C 555, 801 South Paulina Street, Room 204j, Chicago, IL 60612, USA.
Email: yangbin@uic.edu;
Dr Yutao Jian, Institute of Stomatological Research, Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-sen University, Zhong-
shan Er Road 74, Guangzhou, China 510080. Email: jianyt@mail.sysu.edu.cn.

20 QUINTESSENCE INTERNATIONAL | volume 50 • number 1 • January 2019