journal of dentistry 42 (2014) 582–587

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journal homepage: www.intl.elsevierhealth.com/journals/jden

Cast metal vs. glass fibre posts: A randomized

controlled trial with up to 3 years of follow up

Rafael Sarkis-Onofre 1, Rogério de Castilho Jacinto 1, Noéli Boscato 1,

Maximiliano Sérgio Cenci 1, Tatiana Pereira-Cenci *
Graduate Program in Dentistry, Federal University of Pelotas, Rua Gonçalves Chaves, 457, Pelotas, RS 96015-560,
Brazil

article info abstract

Article history: Objective: This randomized controlled trial compared the survival of glass fibre and cast
Received 21 March 2013 metal dental posts used to restore endodontically treated teeth with no remaining coronal
Received in revised form wall.
27 January 2014 Methods: Fifty-four participants (45 women) and 72 teeth were evaluated during a follow-up
Accepted 3 February 2014 period of up to 3 years. Teeth were randomly allocated to the glass-fibre and cast-metal post
groups. All teeth were restored with single metal-ceramic crowns. Survival probabilities
were analyzed using Kaplan–Meier statistics ( p  0.05).
Keywords: Results: The 3-year recall rate was 92.3% and the survival rates of glass fibre and cast metal
Fibre-reinforced post posts were similar (97.1% and 91.9%, respectively; p = 0.682). Four failures were observed:
Dowel and core two glass fibre posts in a premolar and anterior tooth debonded, one glass fibre post in a
Dental restoration premolar debonded in association with root fracture, and one root fracture occurred in a
Follow-up studies molar with a cast metal post.
Cementation Conclusions: Glass fibre and cast metal posts showed similar clinical performance in teeth
Clinical trial with no remaining coronal wall after 3 years.
Clinical Significance: Posts are used to restore most endodontically treated teeth with no
remaining coronal wall. This randomized controlled trial, one of few to compare glass fibre
and cast metal posts in such teeth, showed that post type did not significantly influence the
survival of restorations. These results can help dentists respond to the important question
of how best to rehabilitate endodontically treated teeth with no remaining coronal wall.
# 2014 Elsevier Ltd. All rights reserved.

1. Introduction preservation of at least one coronal wall is one of the most

critical factors for the success of endodontically treated and
Endodontically treated teeth may exhibit pronounced coronal restored teeth. Thus, the absence of coronal walls is a worst-
destruction,1 and the amount of residual coronal dentine can case scenario for restoration, and the use of intraradicular
influence the clinical survival of posts and restorations. The posts is the main method for retaining coronal restorative

* Corresponding author at: R. Gonçalves Chaves 457, Pelotas, RS 96015-560, Brazil. Tel.: +55 5332256741x134; fax: +55 5332256741x134.
E-mail addresses: rafaelonofre@terra.com.br (R. Sarkis-Onofre), rogeriocastilho@hotmail.com (R.C. Jacinto), noeliboscato@gmail.com
(N. Boscato), cencims@gmail.com (M.S. Cenci), tatiana.cenci@ufpel.tche.br (T. Pereira-Cenci).
1
Tel.: +55 53 3225 6741; fax: +55 53 3225 6741.
http://dx.doi.org/10.1016/j.jdent.2014.02.003
0300-5712/# 2014 Elsevier Ltd. All rights reserved.
 journal of dentistry 42 (2014) 582–587
material.2–4 Cast metal posts were traditionally used for
intraradicular retention and have shown high survival rates
after 10 years.5 As metal posts have been hypothesized to have
high elastic moduli in comparison with that of dentine, which
could increase the risks of root fracture and catastrophic
failure,6 glass fibre posts were introduced as an alternative. As
the mechanical properties of these posts are similar to that of
dentine, the risk of catastrophic failure is reduced2 and most
failures related to their use involve post debonding.7 In
addition to post failure per se, the failure of intraradicular
posts can be related to tooth position; failures in post-retained
crowns generally occur in the maxillary anterior region, where
horizontal forces are greater than in other areas.8 However,
few studies have compared the use of glass fibre and cast
metal posts to restore endodontically treated teeth with no
remaining coronal wall.
Given this lack of clinical evidence regarding the best post
to use for the restoration of teeth without coronal walls, the
aim of this study was to evaluate the survival of glass fibre and
cast metal posts in such teeth. The hypothesis tested was that
the survival of endodontically treated teeth would not differ
according to the type of post used.
2. Materials and methods
2.1. Experimental design
This prospective, double-blinded (patient and evaluator),
parallel-group randomized controlled trial (RCT) was regis-
tered at ClinicalTrials.gov (NCT01461239). The study was
approved by the local research and ethics committee (protocol
122/2009) and followed the CONSORT recommendations.
Participants’ oral health was assessed, and they provided
written informed consent before enrollment in the study.
Inclusion criteria were: good oral health (no caries or period-
ontal disease), the presence of one or more endodontically
treated anterior or posterior teeth with no coronal wall or the
enamel portion of one wall with no dentinal support (ferrule
height, 0–0.5 mm) requiring intraradicular retention and a
single metal-ceramic crown, and bilateral posterior occlusal
contact. Exclusion criteria were: presence of one or more
endodontically treated teeth with periodontal or occlusal
problems, and presence of a large prosthesis (Kennedy class I
or II) in the antagonist(s) of the tooth or teeth to be restored.
Participants were recalled for clinical and radiographic
examinations over a 3-year follow-up period. The main
outcome evaluated was post debonding.
2.2. Sample size calculation
Considering that some studies have shown no difference in
survival between post types,1,9–11 sample size calculation was
performed based on the equivalence of treatments. Under the
assumption of no difference between standard and experi-
mental treatments, this calculation determined that 64
participants were required to be 90% sure that the limits of
a two-sided 90% confidence interval would exclude a
difference of more than 18% between the standard and
experimental treatment groups.
583
2.3. Randomization
A randomization sequence was generated with a computer-
ized random number generator. For treatment randomization,
a person not involved in the study wrote post types (glass fibre
and cast metal) on slips of paper and inserted them into plain
brown envelopes. For participants randomly assigned to
receive glass fibre posts, a second randomization was
performed to determine whether regular or self-adhesive
resin cement would be used. The randomization process took
tooth group into account to minimize bias due to anatomical
variation.
2.4. Clinical procedures
Between July 2009 and May 2012, 159 participants with
endodontically treated teeth requiring crowns were screened
in the Department of Operative Dentistry. Ninety-five parti-
cipants were excluded because they did not meet the inclusion
criteria or declined to participate.
All procedures were performed under rubber dam isolation
and all materials were used according to the manufacturers’
instructions. Initially, all teeth included in the study received
endodontic treatment using the crown down technique and
irrigation with 2.5% NaOCl solution. Teeth were filled using the
lateral condensation technique and Grossman cement (Endo-
Fill; Dentsply Maillefer, Petrópolis, Brazil) and gutta-percha
cones (Dentsply Maillefer). Then, 2/3 of the filling was removed
from the root canal with #5 Gates Glidden burs (Dentsply
Maillefer). Before glass fibre post cementation, root canals
were prepared with the reamer from the fibre post system.
Glass fibre posts (White Post DC; FGM, Joinville, Brazil) were
cleaned with ethanol and pretreated with silane (ProSil; FGM).
Cast metal posts (CoCr) were previously done directly in
acrylic resin (Duralay II Lab Pattern Resin; Polidental, Cotia,
Brazil).
For glass fibre posts secured with regular resin cement
(RelyX ARC; 3M ESPE, St. Paul, MN, USA), post spaces were
etched with 37% phosphoric acid (Condac; FGM) and adhesive
was applied (Single Bond or Scotchbond Multi-Purpose; 3M
ESPE), which includes an activator, primer, and catalyst). The
resin cement was applied to the root canal using a Centrix
syringe (DFL Indústria e Comércio S.A., Rio de Janeiro, Brazil)
and the post was seated. Digital pressure was applied for
5 min, excess cement was removed, and the preparation was
light-polymerized for 40 s/surface. For glass fibre posts
secured with self-adhesive resin cement (RelyX U100; 3M
ESPE), all steps with the exception of adhesive application
were performed as described for regular resin cement. For
both resin cements, cores were made using adhesive and
composite resin (Scotchbond Multi-Purpose primer and
adhesive and Z250; 3M ESPE). Cast metal posts were luted
with the self-adhesive resin cement following the same steps
as for glass fibre posts. After post luting, radiographs were
taken to check the success of the procedure.
All teeth received single metal-ceramic restorations. The
teeth included had a ferrule height of 0–0.5 mm. Under-
graduate and graduate students who had attended 12 h of
lectures and training in restorative dentistry performed the
procedures.
584 journal of dentistry 42 (2014) 582–587

2.5. Evaluation parameters

Participants were recalled 6, 12, 24, and 36 months after post

cementation (baseline) for clinical and radiographic exam-
inations. Periapical radiographs were taken using a film
packet holder. Two calibrated independent examiners who
had participated in previous clinical studies12–16 performed
the evaluation according to FDI criteria.17 Initially, a blinded
examiner performed the crown evaluation and another
person not involved in the study performed the radiographic
examination. To ensure blinded clinical evaluation, radio-
graphs were evaluated after initial crown evaluation.
Periodontal status (probing depth and clinical attachment
level), pain occurrence, antagonist status, and occlusion
pattern were evaluated. The occurrence of the following
events was recorded: radiographic alteration (periapical
lesion, secondary caries); post and/or crown debonding; and
fracture of the restoration, core, post, and/or root. All
failures recorded were considered to be complete. When a
patient returned for examination with a tooth lacking a post,
the timing of failure (post debonding) was based on his/her
self-report.

2.6. Statistical analysis

Statistical analyses were performed using SigmaStat software

(version 3.5; Systat, Richmond, CA, USA). Descriptive analyses
were used to characterize the teeth included in the study and
the reasons for failure. Survival curves were created using the
Kaplan–Meier method and the log-rank test was used to
examine differences between groups according to post and
cement types ( p < 0.05). Fig. 1 – Flowchart of trial phases.

3. Results
inappropriate in one crown and absent in three crowns; these
3.1. Participants contacts were corrected during examinations.

Of 64 participants included in randomization, three did not 3.2. Failures

receive the intervention because they declined participation
(n = 2) or the tooth was already fractured (n = 1). A total of 78
posts were cemented. Six participants were lost during follow
up due to study withdrawal (n = 5) or metal allergy (n = 1;
Fig. 1). Thus, 54 participants (9 men, 45 women; mean age,
42.7  11.2 years) were ultimately included in the study. In
total, 72 posts in 40 anterior and 32 posterior teeth (37 glass
fibre posts in 21 anterior and 16 posterior teeth; 35 cast metal
posts in 19 anterior and 16 posterior teeth) were evaluated. The
recall rate for the 3-year study period was 92.3% (Fig. 1); those
who were not reevaluated (7.7%) were lost after treatment and
did not return for the first examination at 6 months. The mean
observation times for glass fibre and cast metal posts were
19.2  7.84 and 15.02  7.04 months, respectively. Seventy-two
teeth were evaluated at 6 months, 53 at 12 months, and 26
teeth were evaluated at 36 months.
No evaluated tooth showed a periodontal problem and no
patient reported endodontic-related pain. Three antagonist
teeth had resin composite restorations; all others were sound
natural teeth. Evaluation revealed that occlusal contact was
Four debonding failures were observed: two glass fibre posts
luted in a maxillary anterior tooth and a premolar with regular
resin cement (RelyX ARC + Single Bond) debonded after 8 and
26 months, respectively; and two root fractures occurred in a
premolar with a glass fibre post luted with self-adhesive resin
cement (RelyX U100) and a molar with a cast metal post after
15 and 20 months, respectively. The debonded glass fibre posts
were replaced with the same post type and the two fractured
teeth were extracted. All observed failures occurred in female
participants.
Estimated mean survival times of glass fibre and cast metal
posts were 30.1 (95% confidence interval [CI], 28.1–32.2)
months and 32.3 (95% CI, 29.1–35.5) months, respectively.
The 3-year survival rates of cast metal and glass fibre posts
were 97.1% and 91.9%, and those of posts in anterior and
posterior teeth were 97.5% and 90.6%, respectively. Survival
rates did not differ according to post type ( p = 0.682), cement
type for glass fibre posts ( p = 0.691), or tooth position
( p = 0.217; Fig. 2).
 journal of dentistry 42 (2014) 582–587
Fig. 2 – Kaplan–Meier survival curves for (A) glass fibre and cast metal posts and (B) anterior and posterior teeth.
4. Discussion
This RCT was conducted based on the assumed equivalence of
the interventions. Its aim was to demonstrate that the new
intervention (glass fibre posts) is not worse, in terms of the
primary response variable, than the standard (cast metal
posts) using a predefined margin (Friedman).18 This approach
was used because the majority of clinical studies have not
produced results favouring any particular post available in the
market. The results of the present study indicate that the
survival of glass fibre and cast metal posts was similar. Cast
metal posts have shown high survival rates,5 and the similar
rates observed for glass fibre posts in this study indicate that
these posts can be a reliable alternative because of their
mechanical and aesthetic properties. The patients were
followed for up to 3 years, with 92.3% of patients evaluated
at least once during this period and an overall mean survival
time of 17.2  7.72 months documented. The follow-up period,
however, constitutes one limitation of this study; longer
follow up could lead to the detection of possible differences
between post systems over time, and is a goal for our future
studies.
This RCT showed that severely destroyed teeth restored with
glass fibre and cast metal posts performed similarly, with
similar survival rates after 3 years of clinical service. These
results are aligned with those of two systematic reviews,19,20
which found no evidence to support a ‘‘best way’’ to restore
endodontically treated teeth. Given the availability of several
treatment options utilizing a variety of posts and other
materials to restore the coronal portions of teeth with extensive
and distinct degrees of destruction, controlled comparative
studies are needed to provide the best clinical evidence.
A systematic review21 comparing the clinical and in vitro
performance of cast metal and prefabricated posts verified
that no evidence favoured any particular post. However, few
studies have been well designed to comparatively evaluate
585
post survival, mainly because the methodologies of RCTs
entail a great amount of work and high costs.22 Our study
compared the survival rates of cast metal and glass fibre posts,
and the results are in agreement with previous reports. A
previous RCT9 comparing two posts with different elastic
moduli luted with self-adhesive resin cement documented
high 3-year survival rates for both posts. Piovesan et al.15
reported a 97-month survival rate of 90.2% for fibre-reinforced
custom posts, and Gomez-Polo et al.5 reported a 10-year
survival rate of 82.6% for cast metal posts. An RCT comparing
the clinical performance of cast metal and glass fibre posts
showed that the probability of success at 3 years was 91.7% in
all groups.11 Another RCT4 and a prospective observational
study23 reported good clinical performance of glass fibre posts.
Some studies have shown that the presence of substantial
remaining coronal tooth structure reduces the risk of fail-
ure.4,24 In the present study, the survival of posts luted in teeth
without remaining coronal walls was evaluated. Although cast
metal and glass fibre posts showed similar survival probabil-
ities, corroborating the results of previous retrospective and
prospective studies,5,11,15,23 four failures occurred after 3
years, probably because of the difficulty of restoring teeth
with very little remaining coronal structure. In contrast to
previous reports, three of these failures occurred in posterior
teeth and one occurred in an anterior tooth, with no difference
between treatment groups. Force directions differ in the
anterior and posterior teeth, and the maxillary region is
considered to be a high-risk area for technical failures because
of greater horizontal forces.8 Thus, most failures in post-
retained crowns occur in the maxillary anterior region.25 The
different results obtained in the present study could be
explained by the absence of remaining coronal walls, which
may have led to similar responses in the posterior and anterior
teeth.
Although no difference was found between post types, two
of the four failures involved the debonding of glass fibre posts.
586 journal of dentistry 42 (2014) 582–587
Adhesive failure is the most common mode of failure in teeth
restored with adhesively luted endodontic posts,7 and are
directly associated with adhesive technique problems (e.g.,
insufficient polymerization). However, such failure may also
be an early indicator of root fracture, the absence of the
ferrule effect, or association of all factors. Furthermore, root
fracture may be correlated with unobserved tooth structure
defects, such as pre-existing root cracks. In addition, some
studies have shown that the elastic modulus of posts is
related to the risk of root fracture26–29 due to the influence of
different physical material properties; however, this hypoth-
esis remains to be tested, and no difference between groups
was observed in the present study. All failures recorded in this
study were considered to be complete and pooled for analysis,
although post debonding could be classified as a partial
failure. We did not classify the need for re-intervention as a
failure.
In this study, both post types were luted with self-adhesive
resin cement, which has been used widely because it is
considered to be easy to handle and have good moisture
tolerance30 and does not require acid etching or an adhesive
step.31 Given the absence of a difference between glass fibre
posts luted with regular and self-adhesive resin cements, all
glass fibre posts were grouped in the analysis in this study.
Most participants in this study were women. Failure rates
of post-retained crowns are expected to be higher in men due
to their greater occlusal strength. One study showed that
failure rates were correlated with patient sex and age,25
whereas others have found no evidence to support a sex-based
difference in the failure rate of post-retained crowns.19,32,7,33
However, given the poor reporting of possible sex-based
differences in these papers, this issue remains to be tested. We
did not expect the sex of patients to direct affect our results, as
treatment with different post types was well distributed
between men and women.
All teeth evaluated in this study received final single metal-
ceramic restorations, which have shown high 10-year survival
rates.32 The use of the same final restoration for all teeth
allowed us to assess the real effects of the posts on the survival
of the tooth-restoration complex. Furthermore, the status of
antagonist teeth and occlusion patterns of the crowns were
evaluated because any problem related to these factors, such
as incorrect occlusal contact, could generate a failure
unrelated to the posts.
The above-mentioned comparisons with previous studies
should be interpreted with caution due to differences in design
(retrospective vs. prospective) and comparisons of different
posts, cements, degrees of coronal destruction, and final
restorations. Thus, we strongly recommend that future
research be based on well-designed and -conducted RCTs
following the CONSORT Statement.
5. Conclusion
After 3 years of follow up, glass fibre and cast metal posts
showed good and similar clinical performance, regardless of
tooth location. However, longer follow-up periods are needed
to detect possible differences between post systems over time.
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©2014 Elsevier