ENDODONTOLOGY Original Research

Clinical and radiological evaluation of cast metal and

quartz fibre posts in endodontically restored teeth

SHASHIKALA K * #
SONALI SHARMA ** ##

ABSTRACT
Forty one maxillary anterior teeth indicated for post and core and patients of either sex between the age group of
18-25 years who fulfilled the selected criteria were involved in this study. All the selected teeth were endodontically
treated and the post space preparations were performed by rotary instruments. Patients were randomly divided
into two groups: Cast Metal Posts [MP] group which served as control and Quartz Fibre Post [FP] the test group.
After cementation of the posts in both groups as per standard procedure, ceramic restorations were placed.
Periodic evaluation was carried out at 3, 6 and 9 months. The clinical parameters assessed were debonding at
post-core and tooth interfaces, core fracture, crown fracture, periodontal status and aesthetics. The radiological
parameters assessed were root fracture, post fracture, periapical status and post adaptation in the root canal. The
data was tabulated and statistically analyzed. Survival analysis by Kaplan Meier and median survival time methods
were compared using Wilcoxon Test. Results suggest Fibre post and core group showed only one failure whereas
cast metal group exhibited three failures. However, there was no statistical significant difference between the
groups.
Key words: Quartz fibre posts; Cast metal post, Pre fabricated post.

INTRODUCTION significant reduction in the capability to resist a

The most important reason for the emergence myriad of functional forces.3
of endodontics to the forefront of clinical dentistry
Successful restoration of root filled teeth
is a perfect balance between the understanding of
requires an effective coronal seal, protection of
the basic scientific principles and evolving
remaining tooth, restoration of function and
technologies. The restoration of endodontically
acceptable esthetics.3 The final restoration will
treated teeth is an important aspect of dental
include a combination of dowel/post and core and
practice that involves a range of treatment options
coronal restoration.4 Endodontic posts have been
of varying complexities.1 The successful restoration
classified in various ways, the preformed and
of an endodontically treated teeth is an ongoing
custom cast, metallic and non-metallic, stiff and
challenge for a restorative dentist.2 Present day
flexible, aesthetic and non aesthetic.4 Posts are
clinicians are well aware that “The naturally
required for supporting a core foundation when
retained root is the ultimate dental implant.” The
there is insufficient clinical crown remaining.1 The
endodontically treated teeth with extensive loss of
choice of dowel /post design should be in
tooth substance have numerous problems due to

* Prof &Head, ** Senior Lecturer, Dept of Conservative Dentistry& Endodontics, # R.V. Dental College & Hospital, Bangalore, ## A.C.D.S, Secunderabad.

37
ENDODONTOLOGY
accordance with the biomechanical requirements
of the remaining tooth structure. 3
Various methods of restoring pulp less teeth
have been reported for more than 200 years. In
1747, Pierre Fauchard described the process by
which roots of maxillary anterior teeth were used
for restoration of single teeth and the replacement
of multiple teeth. Posts were fabricated of gold or
silver and held in the root canal space with a heat
softened adhesive called mastic.5
In 1990 Duret et al described a non metallic
material for the fabrication of posts based on carbon
reinforcement principle. Carbon fibres posts are
black in colour and do not lend themselves to
aesthetic restorations with all ceramic units. This
led to the introduction of the silica fibre posts which
are translucent and more tooth coloured. These
posts are also called glass fibre and quartz fibre
posts. 6
One of the functions of a post and core is to
improve resistance to laterally directed forces by
distributing them over as large an area as possible.7
when two or more components are placed in
contact with one another, the components and
interfaces created will be subjected to considerable
clinical and functional demands. Components with
higher elastic-modulus (cast post/core) will transfer
functional stresses to the lower elastic-modulus
components (dentin) and ultimately result in
endodontic or restorative failure. When all
components have similar elastic-moduli there is a
uniform stress distribution and lowered interfacial
stress and failure. This phenomenon has been
coined “monobloc.” “Monobloc” requires that all
components of a tooth restoration have similar
elastic moduli to dentin to allow the components
38
SHASHIKALA K, SONALI SHARMA
to move, flex, and stresses one assembly. This
phenomenon is incorporated in fibre posts.8
Accumulation of metallic corrosion
byproducts also weakens the dentin and the
interface between the post and the canal. The newer
fibre-reinforced post systems preserve tooth
structure, are non corroding, and have a similar
elastic modulus compared to dentin making them
more compatible than their metal counterparts.8
The retention of metal posts can be affected
by shape, post-surface area, and type of cement
used. Parallel posts need too much tooth structure
to be removed. Tapered, cemented posts need
retentive characteristics (grooves, threads) for
sufficient retention. The newer post systems (fibre-
reinforced) use bonding instead of cementing for
increased retention. With a bonded post, it is
unnecessary for retention to come mainly from its
design or surface features.8
Fibre posts are ready to use whereas
construction of a cast metal post and core is more
time consuming and demands extra clinic and
laboratory time. 11 One of the major clinical
advantages of fibre-reinforced post is the ability to
remove them expediently and without trauma. Fibre
posts are not retrieved in one piece like a cast or
prefabricated post, but are removed from the canal
by drilling down directly through them. Metal post
systems have a much higher potential for causing
allergic reactions and other adverse biologic effects.
Carbon fibre/quartz-glass fibre posts have a lower
allergenic potential and are generally considered
to be more biocompatible.8
Research on biomechanics of post and cores
over the past decade has replaced many of our
traditional ideas with data as to how and when to
ENDODONTOLOGY CLINICAL AND RADIOLOGICAL EVALUATION OF CAST METAL AND QUARTZ FIBRE POSTS IN ENDODONTICALLY RESTORED TEETH
best restore these teeth. Success can only be
achieved when the technique choice best meets
the needs of the individual, specifically the needs
of the individual diseased tooth and the clinical
use for which it is intended.9
MATERIALS AND METHODS
METHOD OF COLLECTION OF DATA
Forty one maxillary anterior teeth, indicated
for post and core were selected for the study. The
patients of either sex between the age group of 18-
25 years and who fulfilled the selection criteria
referred to Department of Endodontics, were
included in the study. After approval from Ethical
Committee Board, the written informed consent
were obtained from all the individual participants
involved in the study.
INCLUSION CRITERIA
Non vital, discolored, single rooted maxillary
anterior teeth with cervical and middle third crown
fracture were included. Teeth with healthy
periodontal status and occlusion with sufficient over
jet and over bite were included. Teeth with
complete root formation and without any anatomic
variation were taken in to consideration.
Endodontically treated teeth, Patients willing to give
written informed consent and agreeing for regular
follow up were selected.
EXCLUSION CRITERIA
Non-vital multirooted teeth, Patient aged less
than eighteen years, Teeth with poor periodontal
status / with large persistent periapical lesion.
Malocclusion with deep bite, edge-to-edge bite and
cross bite.
PROCEDURE
After clinical and radiological examination and
confirmation of eligibility criteria the selected cases
39
were randomly divided into two groups; Cast Metal
Post [MP] Group served as control and Quartz Fibre
Post [FP] Group as the test group.
MP Group - Twenty anterior root treated teeth
were restored with the conventional custom-made
cast metal posts prepared by direct wax pattern
technique, invested and casting procedure were
carried with nickel chrome alloy using induction
casting machine.
FP Group - Twenty one anterior root treated
teeth were restored with the prefabricated quartz
fibre posts.
Endodontic treatment was completed for all
the involved teeth as per standard procedure using
gutta-percha/zinc oxide sealer as obturating
material/lateral compaction technique. After no less
than 48 hours from the endodontic treatment, the
involved teeth were prepared for receiving the
posts. Leaving 4 millimetres of gutta percha in the
apical third of root canal, the remaining gutta
percha was removed by hand instruments. The
direct wax pattern was taken in group MP and
invested. Casting procedure was carried out in
induction casting machine [Bego-Germany]. The
custom made post and core was then cemented in
the root canal using glass ionomer luting cement
[GC]. Later, the ceramic crowns [Cera Bond] were
fabricated and cemented.
In cases of group FP, after selection of
appropriate drill size provided with the
prefabricated post kit, the root canal space was
prepared leaving at least 4 mm of gutta percha
apically. The prefabricated posts Mirafit – White
[Kuraray America] were tried in the canal as per
the manufacturer’s instructions. All the root canals
ENDODONTOLOGY SHASHIKALA K, SONALI SHARMA

were treated with the bonding system ED primer
(Kuraray America) supplied with the kit. The fibre
posts were then cemented with dual- cure adhesive
resin cement Panavia F 2.0 ( Kuraray America). The
core was built up with photo core build up material,
clearfil photo core (Kuraray America), provided by
the manufacturer. The ceramic crowns were
fabricated later and cemented [figure 1]. All the
treated cases were recalled at an interval of 3, 6
and 9 months for clinical and radiological
evaluation. The clinical parameters of evaluation
were debonding at the post / core and the tooth
inter phase, mobility of the tooth, crown fracture,
periodontal status and aesthetics. The Radiological
evaluation parameters were root fracture, crown
fracture, periapical status, and adaptation of the
posts in the root canal.
METHODS OF STATISTICAL ANALYSIS
The Exceland SPSS (SPSS Inc, Chicago)
software packages were used for data entry and
Analysis, the unit of analysis was the tooth and teeth
were referred to as cases. Statistical analysis was
done by Kaplan Meier analysis for survival analysis,
Wilcoxon test was done for evaluating median
survival time and Chi square test of significance
was done for proportion analysis. At the bivariate
levels, the following independent variables were
assessed: patient’s sex and age, post type, tooth
type and their location. Variables were created for
tooth type, event status (i.e., post failure vs. non-
failure), and time to event, and were assigned
numerical values. Time-to-event was defined as the
time, in months, between the date of insertion of
the post and the date of failure of the restoration.
Censored observations were cases for which failure
did not occur during the observation period.
However, censored observations contributed time
to the analysis.

A B C

D E

Figure1: Clinical steps in Fibre post placement in tooth 11 and 21; A) Preoperative photograph. B) Fibre- post placement. C) Application of
oxygaurd to offset oxygen inhibition. D) Core build-up. E) Cementation of ceramic crowns.

40
ENDODONTOLOGY CLINICAL AND RADIOLOGICAL EVALUATION OF CAST METAL AND QUARTZ FIBRE POSTS IN ENDODONTICALLY RESTORED TEETH

Figure 2: Distribution of
failures by post type

NATURAL CAST METAL FIBRE

TOOTH POST POST

Figure3. Stress pattern generated on application of inclined load of 70 N.

41
ENDODONTOLOGY SHASHIKALA K, SONALI SHARMA

TABLE – II : LIFE TABLE OF CAST METAL POST

Interval Number Number Number Number of Proportion Proportion Cumulative Hazard
Start Time Entering this Withdrawn Exposed to Terminal Terminating Surviving Proportion Rate
Interval during Risk Events Surviving at
interval End
0 20 0 20 1 0.05 0.95 0.95 0.0017
30 19 0 19 0 0 1 0.95 0
60 19 0 19 0 0 1 0.95 0
90 19 0 19 0 0 1 0.95 0
120 19 0 19 0 0 1 0.95 0
150 19 0 19 0 0 1 0.95 0
180 19 0 19 1 0.0526 0.9474 0.9 0.0018
210 18 0 18 0 0 1 0.9 0
240 18 0 18 1 0.0556 0.9444 0.85 0.0019
270 17 17 8.5 0 0 1 0.85 **
The median survival time for these data is 270.00

TABLE – III : LIFE TABLE OF FIBER POST

Number Number Number Number of Proportion Proportion Cumulative Hazard
Entering this Withdrawn Exposed to Terminal Terminating Surviving Proportion Rate
Interval during Risk Events Surviving at
interval End
21 0 21 0 0 1 1 0
21 0 21 0 0 1 1 0
21 0 21 0 0 1 1 0
21 0 21 0 0 1 1 0
21 0 21 0 0 1 1 0
21 0 21 0 0 1 1 0
21 0 21 0 0 1 1 0
21 0 21 0 0 1 1 0
21 0 21 1 0.0476 0.9524 0.9524 0.0016
20 20 10 0 0 1 0.9524 **

The median survival time for these data is 270.00

Comparison of survival experience using the

Wilcoxon (Gehan) statistic
statistic df. Prob.
1.357 1 0.244

42
ENDODONTOLOGY CLINICAL AND RADIOLOGICAL EVALUATION OF CAST METAL AND QUARTZ FIBRE POSTS IN ENDODONTICALLY RESTORED TEETH
RESULTS
In this in vivo study the clinical and
radiological performance of quartz fiber post [FP
Group] was compared to cast metal post [MP
Group] at a time interval of 3, 6 and 9 months.
Both the groups were equally distributed in the
study. It was observed that the mean age group in
this study was 37.17 years. The final outcome of
the study was not affected by age or gender nor
tooth type specific. The failure rate of FP Group
was 4.8 % as compared to 15 % in MP Group. In
FP Group there was only one failure, due to
debonding of the post at post tooth interface. In
MP Group three failures were seen, one biological
that resulted in periapical breakdown, one crown
fracture and one failure in post adaptation in the
canal [figure2]. The probability of survival of MP
Group was 85 % and that of FP Group was 95 %.
The median time of survival in each group was 270
days (Tables II and III). Though FP Group performed
better than MP Group, the results, however were
not statistically significant.
DISCUSSION
Endodontic treatment has progressed
significantly over the last two decades leading to
greater knowledge, clinical success and
concomitant cost of endodontic treatment. Failure
in teeth that have been root canal treated is more
likely to be the result of failure of the restoration
that has been placed, rather than the endodontic
treatment itself.10
Many retrospective studies on the clinical
performance of fibre posts have been published.
However, most of them were unable to ensure an
adequate control of all variables that might come
into play under clinical conditions. On the other
43
hand, in a prospective study design many of the
variables possibly involved are already controlled
at the stage of case selection, and experimental
groups can be made homogenous in all but the
variable under study. Thus, the variables under
study which are the different materials used for post
and core restoration, became the factors most
crucially responsible for the variability in the
clinical performance of the teeth over time.11
The cast metal post and core has been the
traditional and time honoured method of restoring
endodontically treated teeth. However, there are
some disadvantages associated with conventional
post and core systems such as poor retention of
the post, greater incidence of root fracture, and risk
of corrosion when different metals are used in the
system.12 Fabrication of cast metal post and cores
can be time consuming and involves additional
laboratory cost. The laboratory procedure itself may
introduce errors within casting and thus increase
risk of failures. This drawback of cast metal alloy
post system has also been observed and
experienced in this study.
A growing interest in aesthetic dental
restorations and adhesive dentistry has led to
development of innovative post materials and
techniques for restoration of endodontically treated
teeth. These newer systems, like quartz fibre post
have focused on physical properties, such as
modulus of elasticity, that are closely matched to
dentin to decrease stress concentration within the
root canal and reduce the incidence of fracture.
Most of the fibre posts can be removed from a root
canal with ease and predictability when necessary,
without compromising core retention in cases of
endodontic retreatment.13 In the present study there
ENDODONTOLOGY SHASHIKALA K, SONALI SHARMA

were no failures necessitating re-treatment in fibre adaptation to the canal walls also represents an
group. important element in biomechanical performance
of the restoration.10 In MP Group there was one
Impact of the periodontal status on the survival
failure with respect to post adaptation. The failure
of endodontically treated teeth was discussed by
was statistically censored on the day of post
Naumann et al. 14 Periodontal failures of
insertion. But for academic interest the case was
endodontically treated teeth were the second most
evaluated for a total of 9 months. It was observed
frequent cause of failure [32 %] after crown fractures
that with respect to treated tooth, the patient
[60 %]. Increased reduction of the bone support
developed a discharging sinus indicating a
lead to a marked decrease of the load capability of
biological failure. Biological failure is defined as
a post -retained post -endodontic restoration.14 In
the presence of any pathology due to caries or
the present study the exclusion criteria have been
periodontal disease or endodontic failure.
very stringent, the periodontal status as well as
Mechanical failure was debonding of any part of
periapical status has been assessed preoperatively.
the tooth -post- core- crown complex or presence
Thus cases with doubtful periodontal status, which
of fracture.16 In an in vivo study it was observed
might affect the prognosis, have not been included
that more biological failures occur in premolars
in the study and probably in this study no cases
than anterior owing to complex root anatomy.16 In
with any deterioration in periodontal status were
the present study true biological failure was
reported.
observed in one case in MP Group, which showed
Recent studies by Tait et al have demonstrated a periapical lesion at end of the study. The FP Group
that placement of a post can create stresses that did not show any case of periapical breakdown
lead to root fracture during post placement or [figure 2].
function and that the strength of endodontically
In a retrospective study by Ferrari et al, it was
treated tooth was directly related to remaining
observed that the main cause of failure in fibre post
internal tooth structure .15 In the present study, no
system was due to debonding.17 This is usually the
fracture of the root or abutment was seen and no
result of an adhesive failure at the interface between
crown debonding or decementation occurred in
dentin and resin cement.11 In the present study in
both the groups. In FP Group, the post was bonded
fibre post Group the failure consisted of only one
in the canal in the same sitting as that of post
post debonding, which was ascribed to a loss of
preparation, hence it could have reduced chances
integrity at the adhesive interface between dentin,
of root fracture as compared to MP Group, wherein
adhesive, resin cement, and post. The debonding
the post was cemented in the subsequent
failure could be retreated as there was sufficient
appointment. The adhesive post-placement
coronal tooth structure remaining.
preparation might reduce the negative side effects
of post placement preparation by stabilizing the Over the years, the first-generation carbon fibre
root in terms of inner splinting. 10
posts have been replaced by quartz-coated carbon
fibres and glass fibres that are amenable to silane
In a study by Tait et al it was found that post

44
ENDODONTOLOGY CLINICAL AND RADIOLOGICAL EVALUATION OF CAST METAL AND QUARTZ FIBRE POSTS IN ENDODONTICALLY RESTORED TEETH

coupling. The epoxy resin embedding matrix in
older generations of fibre posts is also replaced with
highly cross-linked, oxygen inhibition layer–free
methacrylate resin matrices that, theoretically, have
the potential to bond to methacrylate-based resin
cements. Different modalities of surface treatments
of posts are also available to render these newer
generations of fibre posts more conducive to
bonding to methacrylate-based resins. Although the
use of these newer generations of fibre posts has
not yet attained the scientific rigor of an ideal
monobloc, they are reported to have performed
well in vivo. This is probably due to the similarity
in the modulus of elasticity between fiber posts and
root dentin. 18
To improve adhesion Zakereyya S et al
contended that luting posts with Panavia 21 or
Calibra after etching the dentin with phosphoric
acid for 15 seconds produced significantly higher
retention values than treating dentin for 30 seconds
or with ED Primer, only. 19
The conventional non
adhesive post cementation is less reliable to
withstand simulated functional forces compared to
adhesive approaches. 20
Light curing resins are not recommended for
fibre posts cementation because of inadequate
depth of cure in the apical portions of the root,
even if translucent posts are used. Therefore, dual-
cured and self-cured resin cements have been
advised for fibre post cementation. It was reported
that in the absence of light some dual-cured
cements may not reach an adequate degree of
conversion. Therefore, light curing was
recommended for dual-cured resin cements. 21
In a finite element analysis study on post
systems by the authors, [figures 3], it was seen that
rigid Cast metal post - core produced highest
internal stresses as compared to fiber post 22. This is
in conformation with results obtained in a classical
study by Pegrotti .23
In an in vivo study by Ibrahim et al24 it was
found the average survival rate of cast metal post
was 7.7 years and failure rate was 11.2 %. The
most common complication was loss of retention
of post and core.24The restoration was deemed
successful if the complete crown was still cemented
to the underlying tooth-core complex at follow up.
In the present study MP Group showed one crown
fracture at the end of nine months follow up. In a
clinical study it was observed that the survival rate
of fibre post was 96 %.1 7 In this study the probability
of survival of fibre post Group is 95 % and failure
percentage is 4.8 % as compared to 85 % and
15% respectively of cast metal post Group [Table1].
There was no statistically significant difference
[p value >0.05] in the clinical performance of both
the groups.
In a recent systematic review analysis and
evaluation by Charles J. Good acre suggested that
fibre posts may be more successful than cast metal
posts, but there were not enough random clinical
trials to warrant a definitive recommendation.25
However, in this study the fibre post showed
a lesser failure rate than cast metal post. The
probability of survival of fibre post was more than
that of cast metal post and this did not depend on
the tooth type, nor age or gender specific. Cast
metal post and core fabricated using standardized
technique is still considered as traditional time
honoured method of restoring endodontically
treated teeth. Fibre post and core technique offers
the advantage of reducing chair side time, and

45
ENDODONTOLOGY
obviates the need of arduous time-consuming, error
prone laboratory procedures and expensive
equipment. They possess inherent flexibility as of
natural dentin, allowing the post to absorb stress
and prevent root fracture. Other advantages of fibre
post, like aesthetics, corrosion resistance,
biocompatibility, modulus of elasticity being similar
to that of dentin, could not be embraced in this
study.
In the light of the limitations of this study
design, fibre post and core system show promising
results and appears to be a better alternative to the
rigid cast metal post in clinical practice. However,
long-term clinical evaluation is required to
authenticate this conclusion.
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