CD 004623

Root canal posts for the restoration of root filled teeth
(Review)
Bolla M, Muller-Bolla M, Borg C, Lupi-Pegurier L, Laplanche O, Leforestier E
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2008, Issue 4
http://www.thecochranelibrary.com
Root canal posts for the restoration of root filled teeth (Review)
Copyright 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
AUTHORS CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ACKNOWLEDGEMENTS
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 Cast posts (type I) versus fibre posts (type III), Outcome 1 Failures after 4 years. . . .
Analysis 2.1. Comparison 2 Composite restoration versus full-coverage metal-ceramic crown (MCC: prosthodontic status),
Outcome 1 Failures after 3 years. . . . . . . . . . . . . . . . . . . . . . . . . . . .
ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
WHATS NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
INDEX TERMS
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
1
2
2
2
3
5
7
7
8
8
11
17
17
18
18
19
20
20
20
20
20
21
[Intervention Review]

Marc Bolla2 , Michele Muller-Bolla1 , Cybele Borg2 , Laurence Lupi-Pegurier1 , Olivier Laplanche3 , Eric Leforestier4
1 Sante
Publique (Public Health), Facult de Chirurgie Dentaire, Nice, France. 2 Biomatriaux Dentaires (Biomaterials), Facult de
Chirurgie Dentaire, Nice, France. 3 Prothses (Prosthetics), Facult de Chirurgie Dentaire, Nice, France. 4 Odontologie Conservatrice
- Endodontie (Conservative Dentistry), Facult de Chirurgie Dentaire, Nice, France
Contact address: Michele Muller-Bolla, Sante Publique (Public Health), Facult de Chirurgie Dentaire, 24 Rue des Diables Bleus, Nice,
06357, France. muller@unice.fr.
Editorial group: Cochrane Oral Health Group.
Publication status and date: Edited (no change to conclusions), published in Issue 4, 2008.
Review content assessed as up-to-date: 31 October 2006.
Citation: Bolla M, Muller-Bolla M, Borg C, Lupi-Pegurier L, Laplanche O, Leforestier E. Root canal posts for the restoration of root
filled teeth. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD004623. DOI: 10.1002/14651858.CD004623.pub2.
ABSTRACT
Background
The foundation for the reconstruction of endodontically-treated teeth can be provided by a metal or a non-metal post and core system
but no guidelines exist for choosing one or the other in particular clinical cases.
Objectives
To assess the effectiveness of different post and core systems for the restoration of endodontically-treated teeth. The primary objective
of this review was to compare the clinical failure rates of the different types of posts.
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2005, Issue 3), MEDLINE (from
1966 to September 2005), Scopus (from January 1985 to December 2004) and EMBASE (until December 2004). We looked through
reference lists of articles and dental conference proceedings. We contacted researchers in the field and manufacturers.
Selection criteria
Randomised or quasi-randomised clinical trials (RCTs) comparing failures on endodontically-treated permanent teeth with different
types of post. The outcomes were loss of retention, post fracture and root fracture.
Data collection and analysis
Two review authors independently assessed the quality of trials and extracted data. Study authors were contacted for additional
information.
Main results
Two trials involving 317 participants were included but only one of them, involving 200 participants, compared metal to non-metal
posts. The other answered to the secondary objective. The risk of failure was greater with metal-cast posts (9/98) compared to carbon
fibre posts (0/97) (risk ratio (RR) = 0.05 (95% confidence interval (CI) 0.00 to 0.90)) but the study was at high risk of bias. Thus
fewer failures occurred when using non-metal posts but the evidence is unreliable.
Authors conclusions
Our systematic review could not specify which type of post and core system should be used when two or three dentine walls remain.
More RCTs are needed to confirm whether fibre-reinforced post and core systems are superior and to clarify the influence of the
remaining tooth structure on the treatment outcome of the different post and core systems available. Well-defined inclusion criteria
focusing on the number of dentine walls (two or three) should be used.
PLAIN LANGUAGE SUMMARY

There is weak evidence from one trial of 200 people that carbon fibre posts have fewer failures after 4 years than metal-cast posts. More
research is needed.
Root canal posts are placed in teeth that have lost an extensive amount of tooth structure because of decay, failed fillings (restorations)
or tooth fractures. Post and core systems can be metal or non-metal and provide a way to securely anchor the filling material core to
the tooth. The core is retained by the post and the tooth can then be restored with a crown. The post is inserted into the root canal
of an endodontically-treated tooth. Thus it provides retention for the final restoration. In one study, non-metal posts induced fewer
failures. Thus more research is necessary to indicate which system should be used for different clinical cases.
BACKGROUND
The restoration of root-filled teeth remains a major concern in
dentistry (Fernandes 2001). Endodontic therapy is primarily performed on teeth with clinical crowns previously damaged by caries,
restorative failure, or fracture (Abou-Rass 1992). Moreover decay
and trauma may often induce an extensive loss of tooth structure. When a large amount of the clinical crown has been lost to
damage, it is often impossible to achieve sufficient anchorage of
a restoration in the remaining dentine (Heydecke 2002). Thus,
endodontically-treated teeth with significant tooth structure loss
have to be restored with a core as foundation for the final restoration. A post provides a way to securely anchor the filling material
to the tooth: the post is inserted into the endodontically-treated
root canal and this enables the coronal prosthetic core to be built
and retained. Post and core systems do not, however, strengthen
the root, but rather serve to improve retention of the final restoration (Bolla 1999; Ferrari 2002).
Once it has been decided to use a post system in restoring endodontically-treated teeth, countless post designs and techniques are
available (Akkayan 1998). Traditionally, posts were always metal,
and they were prefabricated or cast. Of late, carbon fibre posts,
zirconia posts and woven-fibre composite material for posts and
cores have been introduced. The modulus of elasticity of carbon
fibre posts is similar to that of dentine, whereas the rigidity of
alloys used for cast or prefabricated posts has been reported to be
much higher (Fernandes 2001). Thus these new systems are more
biologically compatible with tooth tissue. Moreover they can be

bonded to dentine.
Some authors recommend the use of cast post and core systems as a foundation for the reconstruction of endodonticallytreated teeth (Christensen 1998; Shillingburg 1982), whereas, others advice non-metal posts (Ferrari 2000; Glazer 2000; Mannocci
2001; Torbjorner 1996). To date, there is only one meta-analysis (Heydecke 2002) which takes into account both in vitro and
in vivo studies related to the performance of cast posts and cores
compared to direct cores with prefabricated posts on anterior single-rooted teeth. This review aims to identify all relevant clinical
studies irrespective of tooth type (anterior and posterior teeth) and
to compare the failure rates of different types of post and core
systems.
OBJECTIVES
Primary
The primary objective of this review was to compare the clinical
failure rate of different types of posts used for the restoration of
endodontically-treated teeth.
Metal versus non-metal posts.
Metal-cast posts versus commercial prefabricated metal

posts.
Category III: two-element system comprising a commercial

prefabricated non-metal post (fibre-reinforced post or ceramic
post) and a composite resin, a glass-ionomer cement or a resinmodified glass-ionomer core.
Secondary
Studies which compared the same category of post in different

tooth types, prosthetic status, presence/absence of ferrule, alloy
type and presence/absence of diaphragm.
Studies using zinc phosphate, zinc polycarboxylate, glass ionomer
and resin as luting cements for posts were included.
Studies registering failures of endodontic treatment were excluded.
Differences in the failure rate between post and core categories

regarding:
the presence of a ferrule;
the type of alloy (in the case of metal posts);
the presence of a diaphragm (if cast posts).
Subgroup analyses were used to compare the following.
Differences in the failure rate between post and core categories
regarding:
tooth type (incisors, canines, premolars and molars) and
location (maxilla or mandible);
prosthetic status of the tooth (single crown, fixed partial
denture abutment (FPD abutment), removable partial denture
abutment (RPD abutment) and fixed partial denture abutment
combined with a removable partial denture).
METHODS
Criteria for considering studies for this review
Types of studies
Randomised or quasi-randomised clinical trials: parallel group and
split-mouth designs.
The minimum duration for the studies was 6 months.
Types of participants
Participants with permanent teeth endodontically treated by a dental practitioner in hospital or private practice. For these teeth, a
post was clearly indicated as the means of retention for the final
restoration.
Types of outcome measures

The failure rate of different post and core systems assessed
by clinical and radiographic examination. Technical failures
included: loss of retention, post fracture and root fracture.
The survival time for different types of post and core
systems.
Search methods for identification of studies

In order to find relevant studies meeting the inclusion criteria, the
following was undertaken.
(1) Electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2005, Issue 3),
MEDLINE (from 1966 to September 2005), Scopus (from January 1985 to December 2004) and EMBASE (until December
2004). Search strategies are given in Appendix 1 and Appendix 2.
(2) Search for additional relevant articles on the electronic
databases.
(3) Search of reference lists from articles provided by the electronic
search.
(4) Reading of the International Association for Dental Research
(IADR) conference proceedings (from 1996 to 2005) (keywords
were Dental materials, Clinical trials, Prosthodontics, Root).
(5) Contact of IADR members to track down any unpublished
studies.
(6) Contact of manufacturers, researchers and experts known to
be involved in the field in an effort to trace unpublished studies
or published studies not found.
The searches attempted to track down all relevant studies irrespective of language. Non-English papers were translated.
Types of interventions
Studies which compared any category of post with any other.
Category I: passive metal custom-cast posts and cores
(burnt-out plastic patterns or cast-on posts).
Category II: two-element system comprising a commercial
active or passive prefabricated metal post (tapered, parallel or a
parallel-tapered combination) and a core built up from amalgam,
glass-ionomer cement, resin-modified glass ionomer or
composite resin.
Data collection and analysis

Study selection
(1) Two review authors (Michle Muller-Bolla (MMB) and Cyble
Borg (CB)) independently examined the title, keywords and abstract of reports identified from the electronic searching for evidence of three criteria.
(a) A randomised or quasi-randomised clinical trial.

(b) The use of one post system compared to another or the use of
one post system in different clinical situations.
(c) Failure assessment on endodontically-treated permanent teeth
after post cementation.
If the report fulfilled these three criteria or if one or both review
authors was not able to assess this from the title, keywords or
abstract then the full article was obtained.
(2) Screening of full-text articles, decision about eligibility and
data extraction were carried out independently by three review
authors (Marc Bolla (MB), MMB and CB). Any disagreement between the three review authors was resolved by discussion with a
fourth review author (Laurence Lupi-Pegurier (LLP), Eric Leforestier (EL) or Olivier Laplanche (OL)).
If authors had published several articles concerning the same study,
only the latest was taken into account.
The authors were contacted for additional information if necessary.
Data extraction
Two review authors (MMB, CB) used a previously-prepared data
extraction form. They independently extracted the data considering the year of publication, the posts assessed, the mean duration
of the study, outcomes, the sample size, gender and age, endodontically-treated tooth characteristics (tooth type, prosthetic status),
operator qualification. If the results were presented in a graphical
form, relevant data were extracted if possible. Otherwise the authors were contacted for clarification and if that was unsuccessful,
the study could be excluded. Any disagreement between the review authors was discussed and where necessary, two other review
authors were consulted (MB, LLP or OL). If agreement could not
be reached, the data were excluded.
MB checked the data extraction.
Quality assessment
The methodological quality of included studies was assessed using the criteria described in the Cochrane Handbook for Systematic
Reviews of Interventions 4.2.5 (Higgins 2005).
A quality assessment was carried out for all studies fulfilling the
inclusion criteria, as follows:
Was there a randomisation of the participants?
0 Not randomised
1 Inadequate
2 Unclear
3 Adequate.
Was a calculation of sample size undertaken?
0 No/not mentioned
1 Yes.
Were inclusion/exclusion criteria clearly defined?
0 Not defined
1 Poorly defined
2 Well defined.
Was follow up achieved (> or = 80%)?
0 No/not mentioned
1 Yes < 80%
2 Yes > or = 80%.
Was treatment blind to patients, operators or assessors recorded?
0 No/not possible
1 Unclear
2 Yes.
Were the outcomes of the people who withdrew described by study
group and included in the analysis (intention-to-treat (ITT) analysis)?
0 Not mentioned
1 States numbers and reasons for withdrawal by study group but
no analysis
2 Primary analysis based on all recruited cases.
Were the control and treatment groups comparable at entry?
0 Large potential for confounding or not discussed
1 Confounding small - mentioned but not adjusted for
2 Unconfounded - good comparability of groups or confounding
adjusted for.
Risk of bias was assessed according to the Cochrane Handbook for
Systematic Reviews of Interventions 4.2.5 based on three of the quality criteria, allocation concealment, blinding of outcome assessor
and follow up. After taking into account the additional information provided by the authors, studies were grouped into the following categories.
(A) Low risk of bias (plausible bias unlikely to seriously alter the
results) if all criteria are met.
(B) High risk of bias (plausible bias that seriously weakens confidence in the results) if one or more criteria are not met as described
in the Cochrane Handbook for Systematic Reviews of Interventions
4.2.5 Section 6.7.
Authors were contacted for clarification on allocation concealment, randomisation, blinding and withdrawals if these were unclear.
Data synthesis
As the response was a dichotomous outcome, risk ratios were used
and the uncertainty was expressed using 95% confidence intervals.
If future trials are found for future updates, they will be dealt
with in the following way: if the response is still dichotomous, risk
ratios will be used; for quantitative data the estimates of the effect
size (difference between two means divided by the control-group
standard deviation (SD)) will be calculated. The uncertainty will
be expressed using 95% confidence intervals.
Meta-analyses were carried out if the studies were sufficiently homogeneous. The heterogeneity of the results was assessed using
formal tests of heterogeneity and graphical display. Possible reasons for heterogeneity were specified a priori as follows: (1) study
took place in contexts of different baseline dental health, (2) studies were heterogeneous in terms of failure characteristics, (3) other
factors.
If future trials are found, subgroup analyses will be undertaken
for tooth type, location and prosthetic status. Subgroup analyses
will also be conducted to further divide the posts in groups II and
III. Type II could be subdivided into IIa (active posts: in which
retention is obtained by the threads on the post) and IIb (passive
posts: retention is ensured by a layer of luting cement between the
post surface and the radicular dentine). Passive posts in Type III
could be subdivided into two subgroups IIIa (ceramic posts) and
IIIb (fibre-reinforced posts: carbon fibre posts, carbon fibre posts
covered with quartz fibre or quartz fibre posts).
excluded studies table). The main reasons for exclusion were: trials without control (following of only one group of participants),
controlled clinical trials, studies focused on endodontic treatment,
restorative or prosthetic outcomes and studies comparing post and
core materials of the same type.
Three studies were finally eligible for inclusion in the review (Ellner
2003; Ferrari a 2000; Mannocci 2002). Of these three eligible
clinical trials, two (Ellner 2003; Ferrari a 2000) provided insufficient information. The corresponding authors were contacted
and asked to provide the missing details required to be considered
in the meta-analysis. Only one of the two authors answered and
so, finally, two randomised controlled trials (RCTs) were included
(Ferrari a 2000; Mannocci 2002). If the remaining author (Ellner
2003) responds to our request for further details, the data will be
included in future updates.
RESULTS
Characteristics of included studies
Description of studies
See: Characteristics of included studies; Characteristics of excluded
studies.
Search results
The electronic search based on all selected databases produced
altogether 16,944 records, many of which were duplicates. The
sources of these 16,944 records were the following: Scopus (from
January 1985 to December 2004) yielded 3248 records; EMBASE
(until December 2004), 1086 records; MEDLINE (from 1966
to September 2005), 12,218 records; and the Cochrane Central
Register of Controlled Trials (CENTRAL) (The Cochrane Library
2005, Issue 3) gave 392 records. Finally all electronic selected
databases produced altogether 871 records which were not duplicates. The search for additional relevant articles did not produce any others. The search of reference lists from articles identified by the electronic search yielded two more articles that were
not duplicates (Dallari 1996; Roberts 1970). The search through
dental conference proceedings (International Association for Dental Research (IADR) from 1996 to 2005) indicated 13 relevant
studies. Contacted association members gave one more reference
(Monticelli 2003) but contacted manufacturers (RTD Grenoble
and Dexter Dental Emco) did not provide any other unpublished
relevant study.
The 887 records were firstly checked on the basis of the title, keywords and abstract. Three dental congress abstracts corresponded
to published studies (Fredriksson 1998; Malferrari 2003). Thus,
only 52 records were selected. Forty-nine full-text reports were
in English, one was in French (Bolla 1995), one in Hungarian
(Fazekas 1998) and one in Italian (Lai 2002). From these 52 reports, 49 were irrelevant for this review (see Characteristics of
See Characteristics of included studies table.

Both included studies were conducted in Italy. The combined total
number of participants included in the trials was only 317. The
number of withdrawal patients was 13 after a 36-month follow-up
period (Mannocci 2002) and five more after a 48-month followup period (Ferrari a 2000) i.e. a total of 18 (5.6%). The age range
of participants was not specified for one study (Ferrari a 2000);
it varied from 35 up to 55 years (mean age of 48 years) in the
Mannocci 2002 study.
The type of post and core varied: non-metal carbon fibre posts
(Composipost system) versus type III gold alloy cast posts (type I
post and core system) (Ferrari a 2000) and non-metal carbon fibre
posts (type III post and core system) covered with a composite
filling versus the same post type covered with a full-cast crown
(Mannocci 2002). Thus only one study (Ferrari a 2000) met the
primary objective of this systematic review and the other study,
one of the secondary objectives (Mannocci 2002).
These two RCTs had one inclusion criteria in common; in both
studies, the participant had to have at least one permanent tooth
with significant tooth structure loss that needed root canal treatment and a root canal post for the final restoration. Both studies
provided a clear description of the intervention.
In the study by Ferrari a 2000, 200 patients were divided into
two groups of 100 endodontically-treated teeth: group 1 received
Composipost systems (type III post and core system) and group
2 received cast posts and cores (type I). In the study by Mannocci
2002, 117 subjects were included in the trial: one tooth was treated
per subject and all teeth were restored with a type III post-and-core
system (Composipost). Then the selected subjects were randomly
assigned to one of the two following experimental groups: 60 in
group 1 corresponding to final restoration with composite, and
57 in group 2 with full-coverage metal-ceramic crowns. There was
only one operator.
Characteristics of excluded studies

See Characteristics of excluded studies table.
The table of excluded studies presents the main reasons for exclusion of studies which did not fulfil either of the inclusion criteria in the review. The reasons for exclusion were varied and
in many studies there were several reasons for exclusion. The
randomised clinical trial conducted by Monticelli 2003 did not
correspond to the objectives (for this study comparison of three
type III posts corresponding to different brands). In 13 studies the only reason for exclusion was that the studies were designed as non-randomised controlled clinical trials (Amakawa
1999; Bergman 1989; Grandini 2002; Hatzikyriakos 1992; King
2003; Lai 2002; Malferrari 2002; Malferrari 2003; Mentink a
1993; Mentink b 1993; Ottl 1998; Paul 2004; Torbjrner 1995).
Seventeen trials without control (following one group of participants) were also excluded (Bolla 1995; Dallari 1996; Edelhoff
2000; Fazekas 1998; Ferrari b 2000; Fredriksson 1998; Gher
1987; Glazer 2000; Hedlund 2003; Hochman 2003; Kakehashi
1998; Krantz-Schfers 2003; Linde 1984; Rovatti 1994; Tidehag
2004; Wallerstedt 1984; Walter 2003). Three retrospective studies were excluded (Aquilino 2002; Llena-Puy 2001; Weine 1991).
Ten studies focusing on endodontic, restorative or prosthetic outcomes were excluded (Antonoff 1978; Bass 2002; Goodacre 2003;
Grieve 1993; Krasteva 2001; Lewis 1988; Libby 1997; Owall
2000; Priest 1996; Roberts 1970). Two literature reviews (Burke
1992; Morgano 1993), one in vitro study (Akkayan 1998) and
one commentary of a randomised clinical study focusing on posts
(Basrani 2004) were excluded as well as one clinical trial which
evaluated the influence of metal posts (type II) on fracture resistance of pulpless bleached teeth (Francischone 2003). One randomised clinical trial whose author has been contacted for further information had to be excluded as no reply was given after 6
months (Ellner 2003).
Characteristics of studies awaiting assessment

Friedel et al (Friedel 2002) have been contacted for further information on their trial in order to decide about study eligibility.
Characteristics of outcomes measures

In the included randomised clinical trials, the rate of success was
assessed by clinical and intraoral radiographic examinations: root
fracture, post fracture and loss of retention were evaluated. Both
registered secondary caries but this was not included in this review
because it was not an indicate of technical failure concerning the
post and core system. If the secondary caries is due to a microleakage concerning only the post and core system, it could also be related to microleakage of the coronary restoration (crown or direct
restoration). Lastly, a temporary augmentation of the individual
caries risk could be evocated. In the cases of endodontic infection
that was only considered by Ferrari a 2000 as another failure, the
reasoning is the same. The post and core system is not the only
aetiologic factor. It would be another bias. Economic costings were
not included because the organization of the systems of care, the
type of social protection, the environmental and cultural factors
differed according to the countries in which the studies had been
carried out.
Risk of bias in included studies

See Additional Table 1.
The agreement between the review authors (Cybele Borg (CB) and
Michele Muller-Bolla (MMB)) was generally good with Kappa
values for eligibility of reports (0.8), allocation concealment (0.7),
and adequacy of reporting and handling of attrition (0.9). Any
disagreement between CB and MMB was discussed with another
review author.
No information concerning allocation concealment was given in
either trial. The generation of randomisation sequence was adequate for Mannocci 2002 (tossing a coin) and unclear for Ferrari
a 2000. No more information concerning the allocation concealment was given.
The calculation of sample size was not mentioned. The inclusion
and exclusion criteria were well (Mannocci 2002) and poorly defined (Ferrari a 2000).
Neither randomised controlled trial (RCT) permitted blinding
(patients, operators or assessors) because clinical protocols are different according to the type of post. As radiographic examination
shows the type of post, outcomes blind to assessors was also not
possible.
Withdrawals were adequately reported.
The reported drop-out rates are shown in the Characteristics of
included studies table. The reasons for withdrawal were specified
but analysis in both RCTs remained unmodified.
In the Ferrari a 2000 study some confounds were mentioned but
not adjusted for, whereas there was good comparability of groups
in the Mannocci 2002 study.
In the only study focusing on our primary objective (Ferrari a
2000), it is unknown if the two groups were comparable: the only
comparison between the two groups at baseline concerned tooth
location but the distribution of tooth type treated in each group is
unknown. Moreover the sex and age of the included participants
were not mentioned; and the teeth included in both groups are
quoted as tooth with important loss of structure without any
precise details such as the number of remaining dentine walls.
Lastly the number of operators was not indicated. Thus, both
studies were assessed as at high risk of bias.
Effects of interventions
Comparison of cast posts and fibre-reinforced posts

failures (Comparison 1)
Concerning our primary objective, only one study (Ferrari a 2000)
was included. This showed that the Composipost system (type III:
0/97 failures) resulted in fewer failures than the conventional cast
post and core system (type I: 9/98 failures) after 4 years of clinical
service (risk ratio (RR) = 0.05, 95% confidence interval (CI) 0.00
to 0.90). The only failure type that occurred was root fracture in
the cast post and core group.
Prosthetic status of the tooth (Comparison 2)

The only secondary objective fulfilled concerned the prosthetic
status of the tooth and only one clinical trial addressing this subject was included. Mannocci 2002 reported that no statistically
significant difference was found between the clinical success rates
of endodontically-treated premolars restored with fibre posts and
direct composite restorations compared to a similar treatment and
a full-coverage with metal-ceramic crowns after 3 years of service.
Post-dislodgement only occurred in both groups at 24 months of
follow up (RR = 1.85, 95% CI 0.17 to 19.8).
DISCUSSION
Only one study including 200 subjects showed the superiority of
type III post and core systems compared to cast post and core system. However the quality assessment indicated a high risk of bias
(see Additional Table 1). This was due to the method of randomisation being unclear. Perhaps confounding existed. Some inclusion criteria were poorly defined and more particularly, the tooth
to treat with a post and core system (Ferrari a 2000). The expression severe loss of tooth structure did not indicate the number
of residual dentine walls. This lack of definition is a problem and
could distort results. In 2003, the National Authority for Health
(HAS) in France published recommendations regarding restoration of endodontically-treated teeth with a post and core system
(HAS 2003). These recommendations were made by professional
agreement because the literature did not allow precise indications.
Ferrari a 2000 study was not considered. However, HAS also advocated important loss of tooth structure without any definition
of this to contra-indicate type III post and core systems. On the
contrary, the French National Academy of Dentistry (Ac Dentaire
2004) clearly specifies, by agreement of eight French dental experts, which type of post and core should be used according to
the number of the remaining dentine walls: -when the amount
of the remaining dentine walls equals or exceeds three: a type III
post and core system is required; -when this is lower than two: a
type I post and core system has to be used. When two or three
dentine walls remain, both types of post and core systems could
be used. However, it should be noted that no methodology and
no references were given in these National Academy of Dentistry

recommendations. Our systematic review and, more particularly
the study by Ferrari a 2000, did not demonstrate the superiority
of one system within these precise clinical conditions i.e. according to the number of remaining dentine walls. Thus, randomised
controlled trials (RCTs) with precise dental anatomic inclusion
criteria are necessary.
The studies included in this review did not fulfil our secondary objectives. Only one study involving 117 subjects compared restorative treatment (direct composite restorations) and prosthetic treatment (metal ceramic crowns) of endodontically-treated premolars
first restored with fibre posts. Thus the failure rate of non-metal
posts was not evaluated regarding the prosthetic status of the tooth
(single crown, fixed partial denture (FPD) or removable partial
denture (RPD) abutments).
AUTHORS CONCLUSIONS
Implications for practice
The introduction of carbon fibre post and tooth coloured post and
core systems should change our clinical practice but there are not
enough published randomised clinical trials (RCTs) focusing on
these systems to set up recommendations.
Only one study fulfilled the primary objective. However, although
this study indicated that type III post and core systems led to statistically significantly less failure than type I, the implications for
practice must be interpreted cautiously. This study was considered
to be at high risk of bias because the criteria were poorly defined,
and more particularly the clinical indications of the post and core
systems. Indication concerned endodontically-treated teeth with
significant loss of structure but the importance of the dental loss
of structure was not clearly defined. Therefore our systematic review could not specify which post and core system should be used
according to the number of residual dentine walls and more particularly when two or three dentine walls remained. Besides, the
fewer failures with type III post and core systems cannot be extended to all non-metal posts, as this study only dealt with carbonfibre posts. As far as metal posts are concerned, only gold-alloy
cast posts were taken into account. Thus, again, the results cannot
be generalised to all the cast metal-posts. On the other hand, no
evidence of a difference between a metal crown and composite was
found in endodontically-treated teeth with intact cusps.
Implications for research

More RCTs are needed to confirm the superiority of the fibrereinforced post and core system and to clarify the influence of
the remaining tooth structure on the treatment outcome of the
different post and core systems available.
These RCTs should be parallel group studies comparing cast posts

to non-metal posts including information on the tooth type and
the prosthodontic status of the tooth. Inclusion criteria should be
very well defined and described such as the number of dentine
walls (two or three). These RCTs should have good allocation concealment, be adequately powered and they should have a follow
up of at least 3 years. Lastly, operators should have adequate experience and training for all interventions.
ACKNOWLEDGEMENTS
We would like to thank Professor Helen Worthington for her
expert help. We would also like to thank Mrs Sylvia Bickley at
the Cochrane Oral Health Group (OHG) in Manchester, UK, for
her help in searching the literature and Ms Emma Tavender, also
at the Cochrane OHG, for her help. We would like to thank the
reviewers Paul Brunton and Lee Hooper for their help. We would
like to thank Jane Fenner-Magnaldo, University of Nice Sophia
Antipolis, for writing assistance and manuscript review in English.
REFERENCES
References to studies included in this review

Ferrari a 2000 {published data only}
Ferrari M, Vichi A, Garcia-Godoy F. Clinical evaluation of
fiber-reinforced epoxy resin posts and cast post and cores.
American Journal of Dentistry 2000;13(Spec No):15B18B.
Mannocci 2002 {published data only}
Mannocci F, Bertelli E, Sherriff M, Watson TF, Ford TR.
Three-year clinical comparison of survival of endodontically
treated teeth restored with either full cast coverage or with
direct composite restoration. The Journal of Prosthetic
Dentistry 2002;88(3):297301.
References to studies excluded from this review

Akkayan 1998 {published data only}
Akkayan B, Caniklioglu B. Resistance to fracture of crowned
teeth restored with different post systems. The European
Journal of Prosthodontics and Restorative Dentistry 1998;6(1):
138.
Bergman 1989 {published data only}

Bergman B, Lundquist P, Sjogren U, Sundquist G.
Restorative and endodontic results after treatment with cast
posts and cores. The Journal of Prosthetic Dentistry 1989;61
(1):105.
Bolla 1995 {published data only}
Bolla M, Medioni E, Muller M, Rocca JP. Composipost
system: clinical trial and critical analysis [Le systme
Composipost : tude clinique et analyse critique].
Information Dentaire 1995;7:499504.
Burke 1992 {published data only}
Burke FJ. Tooth fracture in vivo and in vitro. Journal of
Dentistry 1992;20(3):1319.
Creugers 2005 {published data only}
Creugers NH, Mentink AG, Fokkinga WA, Kreulen CM.
5-year follow-up of a prospective clinical study on various
types of core restorations. The International Journal of
Prosthodontics 2005;18(1):349.
Amakawa 1999 {published and unpublished data}

Amakawa Y, Fukushima S, Tsubota Y. An 11-year clinical
evaluation of post and cores. Journal of Dental Research
1999;78(IADR Abstracts):222 (Abs 933).
Dallari 1996 {published data only}

Dallari A, Rovatti L. Six years of in vitro/in vivo experience
with Composipost. Compendium of Continuing Education
in Dentistry. Supplement 1996, (20):S5763.
Antonoff 1978 {published data only}

Antonoff SJ, Gulker IA, Kaufman EG. A survey of post and
core designs for endodontically treated teeth. Quintessence
International, Dental Digest 1978;9(4):7983.
Edelhoff 2000 {published and unpublished data}

Edelhoff D, Spiekermann H, Junge LM, Sorensen JA,
Yildirim M. Clinical results of an all-ceramic post and core
system. Journal of Dental Research 2000;79(Special Issue):
542 (Abs 3185).
Aquilino 2002 {published data only}

Aquilino SA, Caplan DJ. Relationship between crown
placement and the survival of endodontically treated teeth.
The Journal of Prosthetic Dentistry 2002;87(3):25663.
Basrani 2004 {published data only}
Basrani B, Matthews D. Survival rates similar with full cast
crowns and direct composite restorations. Evidence Based
Dentistry 2004;5(2):45.
Bass 2002 {published data only}
Bass EV. Cast post and core foundation for the badly broken
down molar tooth. Australian Dental Journal 2002;47(1):
5762.
Ellner 2003 {published data only}

Ellner S, Bergendal T, Bergman B. Four post-and-core
combinations as abutments for fixed single crowns: a
prospective up to 10-year study. The International Journal of
Prosthodontics 2003;16(3):24954.
Fazekas 1998 {published data only}
Fazekas A, Menyhart K, Bodi K, Jako E. Restoration
of root canal treated teeth using carbon fiber posts
[Gykrkezelt fogak rekonstrukcioja sznszalas muanyag
csapok alkalmazasaval]. Fogorvosi Szemle 1998;91(6):
16370.
Ferrari b 2000 {published data only}

Ferrari M, Vichi A, Manocci F, Mason PN. Retrospective
study of the clinical performance of fiber posts. American
Journal of Dentistry 2000;13(Spec No):9B13B.
Francischone 2003 {published and unpublished data}
Francischone CE, Henostroza Quintans N, Francischone
AC, Lauris JRP. Long-term clinical trial of pulpless bleached
teeth restored with and without metallic posts and composte
resins. Journal of Dental Research 2003;82(Special Issue B):
B-340 (Abs 2636).
Fredriksson 1998 {published and unpublished data}
Fredriksson M, Astback J, Pamenius M, Arvidson K.

A retrospective study of 236 patients with teeth restored
by carbon fiber-reinforced epoxy resin posts. Journal of
Prosthetic Dentistry 1998;80(2):1517.
Fredriksson M, Astbck J, Pamenius M, Arvidson K.
Composipost treated teeth: a retrospective study. Journal of
Dental Research 1996;75(Special Issue):286 (Abs 2145).
Segerstrm S, Astbck J, Ekstrand K. A retrospective longterm study of teeth restored by carbon-fiber-reinforced
epoxy resin posts. Journal of Dental Research 2003;82
(Special Issue B):B-115 (Abs 820).
Gher 1987 {published data only}
Gher ME Jr, Dunlap RM, Anderson MH, Kuhl LV. Clinical
survey of fractured teeth. Journal of American Dental
Association 1987;114(2):1747.
Glazer 2000 {published data only}
Glazer B. Restoration of endodontically treated teeth with
carbon fibre posts: a prospective study. Journal of the
Canadian Dental Association 2000;66(11):6138.
Goodacre 2003 {published data only}
Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY.
Clinical complications in fixed prosthodontics. Journal of
Grandini 2002 {published and unpublished data}
Grandini S, Ferrari M, Balleri P, Vichi A. Clinical trial of
fiber posts luted with self-curing Excite in combination with
an experimental resin cement. Journal of Dental Research
2002;81(Special Issue A):A-52 (Abs 198).
Grieve 1993 {published data only}
Grieve AR, McAndrew R. A radiographic study of postretained crowns in patients attending a dental hospital.
British Dental Journal 1993;174(6):197201.
Hatzikyriakos 1992 {published data only}
Hatzikyriakos AH, Reisis GI, Tsingos N. A 3-year
postoperative clinical evaluation of posts and cores beneath
existing crowns. Journal of Prosthetic Dentistry 1992;67(4):
4548.
(FPDs) prepared by dental school students: a retrospective

study. Journal of Oral Rehabilitation 2003;30(2):16570.
Kakehashi 1998 {published data only}
Kakehashi Y, Luthy H, Naef R, Wohlwend A, Scharer P. A
new all-ceramic post and core system : clinical, technical,
and in vitro results. The International Journal of Periodontics
and Restorative Dentistry 1998;18(6):58693.
King 2003 {published data only}
King PA, Setchell DJ, Rees JS. Clinical evaluation of a
carbon fibre reinforced carbon endodontic post. Journal of
Oral Rehabilitation 2003;30(8):7859.
Krantz-Schfers 2003 {published and unpublished data}
Krantz-Schfers C, Schfers F. Clinical results of a zirconium
oxide post after 4 years. Journal of Dental Research 2003;82
(Special Issue B):B-118 (Abs 849).
Krasteva 2001 {published data only}
Krasteva K. Clinical application of a fiber-reinforced post
system. Journal of Endodontics 2001;27(2):1323.
Lai 2002 {published data only}
Lai V, Luglie PF, Chessa G. In vivo evaluation of carbon
fiber posts [Valutazione dellaffidabilita clinica dei perni
di terza generazione]. Minerva Stomatologica 2002;51(5):
22530.
Lewis 1988 {published data only}
Lewis R, Smith BG. A clinical survey of failed post retained
crowns. British Dental Journal 1988;165(3):957.
Libby 1997 {published data only}
Libby G, Arcuri MR, LaVelle WE, Hebl L. Longevity of
fixed partial dentures. Journal of Prosthetic Dentistry 1997;
78(2):12731.
Linde 1984 {published data only}
Linde LA. The use of composites as core material in rootfilled teeth. II. Clinical investigation. Swedish Dental
Journal 1984;8(5):20916.
Llena-Puy 2001 {published data only}
Llena-Puy MC, Forner-Navarro L, Barbero-Navarro I.
Vertical root fracture in endodontically treated teeth: a
review of 25 cases. Oral Surgery, Oral Medicine, Oral
Pathology, Oral Radiology and Endodontics 2001;92(5):
5535.
Malferrari 2002 {published and unpublished data}
Malferrari S, Baldissara P, Arcidiacono A. Translucent quartz
fibers posts: a 20 months in vivo study. Journal of Dental
Research 2002;81(Special Issue A):A-333 (Abs 2656).
Hedlund 2003 {published data only}

Hedlund SO, Johansson NG, Sjogren G. A retrospective
study of pre-fabricated carbon fibre root canal posts. Journal
of Oral Rehabilitation 2003;30(10):103640.
Malferrari 2003 {published and unpublished data}
Malferrari S, Monaco C, Scotti R. Clinical evaluation

of teeth restored with quartz fiber-reinforced epoxy resin
posts. The International Journal of Prosthodontics 2003;16
(1):3944.
Scotti R, Malferrari S, Monaco C. Clinical evaluations of
quartz fiber posts: a 30 months results. Journal of Dental
Hochman 2003 {published data only}

Hochman N, Mitelman L, Hadani PE, Zalkind M. A
clinical and radiographic evaluation of fixed partial dentures
Mannocci 2005 {published data only}

Mannocci F, Qualtrough AJ, Worthington HV, Watson
TF, Pitt Ford TR. Randomized clinical comparison of
endodontically treated teeth restored with amalgam or with

fiber posts and resin composite: five-year results. Operative
Dentistry 2005;30(1):915.
Mentink a 1993 {published data only}
Mentink AG, Meeuwissen R, Kayser AF, Mulder J. Survival
rate and failure characteristics of the all metal post and
core restoration. Jounal of Oral Rehabilitation 1993;20(5):
45561.
Mentink b 1993 {published data only}
Mentink AG, Creugers NHJ, Meeuwissen R, Leempoel
PJ, Kayser AF. Clinical performance of different post and
core systems - results of a pilot study. Journal of Oral
Rehabilitation 1993;20(6):57784.
Monticelli 2003 {published data only}
Monticelli F, Grandini S, Goracci C, Ferrari M. Clinical
behavior of translucent-fiber posts: a 2-year prospective
study. The International Journal of Prosthodontics 2003;16
(6):5936.
Morgano 1993 {published data only}
Morgano SM, Milot P. Clinical success of cast metal posts
and cores. Journal of Prosthetic Dentistry 1993;70(1):116.
Naumann 2005 {published data only}
Naumann M, Blankenstein F, Dietrich T. Survival of glass
fibre reinforced composite post restorations after 2 years an observational clinical study. Journal of Dentistry 2005;33
(4):30512.
Ng 2004 {published data only}
Ng CC, al-Bayat MI, Dumbrigue HB, Griggs JA, Wakefield
CW. Effect of no ferrule on failure of teeth restored with
bonded posts and cores. General Dentistry 2004;52(2):
1436.
Ottl 1998 {published data only}
Ottl P, Lauer HC. Success rates for two different types of
post-and-cores. Journal of Oral Rehabilitation 1998;25(10):
7528.
Owall 2000 {published data only}
Owall B, Cronstrom R. First two-year complications of fixed
partial dentures, eight units or more. Swedish Guarantee
Insurance claims. Acta Odontologica Scandinavica 2000;58
(2):726.
Paul 2004 {published data only}
Paul SJ, Werder P. Clinical success of zirconium oxide
posts with resin composite or glass-ceramic cores in
endodontically treated teeth: a 4-year retrospective study.
The International Journal of Prosthodontics 2004;17(5):
5248.
Priest 1996 {published data only}
Priest GF. Failure rates of restorations for single-tooth
replacement. The International Journal of Prosthodontics
1996;9(1):3845.
Roberts 1970 {published data only}
Roberts DH. The failure of retainers in bridge prostheses.
An analysis of 2,000 retainers. British Dental Journal 1970;
128(3):11724.
Rovatti 1994 {published data only}

Rovatti L, Mason PN, Dallari A. New research on
endodontic carbon-fiber posts. Minerva Stomatologica 1994;
43(12):55763.
Tidehag 2004 {published and unpublished data}
Tidehag P, Lundstrm J, Larsson B, Molin M. A 7-year
retrospective study of Composipost root canal posts. Journal
of Dental Research 2004;83(Special Issue A):(Abs 4080).
Torbjrner 1995 {published data only}
Torbjorner A, Karlsson S, Odman PA. Survival rate and
failure characteristics for two post designs. Journal of
Wallerstedt 1984 {published data only}
Wallerstedt D, Eliasson S, Sundstrom F. A follow-up study
of screwpost-retained amalgam crowns. Swedish Dental
Journal 1984;8(4):16570.
Walter 2003 {published and unpublished data}
Walter C, Groten M. The clinical performance of allceramic post reconstructions over several years. Journal of
Dental Research 2003;82(Special Issue B):B-117 (Abs 844).
Weine 1991 {published data only}
Weine FS, Wax AH, Wenckus CS. Retrospective study of
tapered, smooth post systems in place for 10 years or more.
Journal of Endodontics 1991;17(6):2937.
Willershausen 2005 {published data only}
Willershausen B, Tekyatan H, Krummenauer F, Brisemo
Marroquin B. Survival rate of endodontically treated teeth
in relation to conservative vs post insertion techniques - a
retrospective study. European Journal of Medical Research
2005;10(5):2048.
References to studies awaiting assessment

Friedel 2002 {published and unpublished data}
Friedel W, Wegner SM, Kern M. Survival rate of abutment
teeth restored with posts and cores. Journal of Dental
Additional references
Abou-Rass 1992
Abou-Rass M. Post and core restoration of endodontically
treated teeth. Current Opinion in Dentistry 1992;2:99107.
Ac Dentaire 2004
Acadmie Dentaire, Paris, France. Using of preprosthetic
post and core systems [Rapport sur lutilisation des
reconstitutions coronaires prprothtiques ancrage
radiculaire]. www.academiedentaire.org/ANCD/
rapports.php3 (2004).
Bolla 1999
Bolla M, Bennani V. La reconstitution corono-radiculaire
prprothtique des dents dpulpes. Guide clinique. Paris:
CDP, 1999.
Christensen 1998
Christensen GJ. Posts and cores: state of the art. Journal of
the American Dental Association 1998;129(1):967.
10
Fernandes 2001
Fernandes AS, Dessai GS. Factors affecting the fracture
resistance of post-core reconstructed teeth: a review. The
International Journal of Prosthodontics 2001;14(4):35563.
Ferrari 2000
Ferrari M, Vichi A, Garcia-Godoy F. Clinical evaluation of
fiber-reinforced epoxy resin posts and cast post and cores.
American Journal of Dentistry 2000;13(Spec No):15B18B.
Ferrari 2002
Ferrari M, Scotti R. Fiber post systems: mechanical properties
and clinical applications. Milano: Masson Ed, 2002.
FNAD 2004
French National Academy of Dentistry. Consensus
concerning pre-prosthetic post and core systems [Rapport sur
lutilisation des reconstitutions coronaires pr prothtiques
ancrage radiculaire]. http://www.academiedentaire.org/
ANCD/rapports.php3. Paris (France), 2004.
HAS 2003
Haute Autorit de Sant, Paris, France. Indications
and contra-indications of direct or indirect post and
core systems [Indications et contreindications des
reconstitutions coronoradiculaires couls et insrs en pahse
plastique]. www.anaes.fr/anaes/anaesparametrage.nsf/Page?
ReadForm&Section=/anaes/SiteWeb.nsf/wRubriquesID/
APEH-3YTFUH?OpenDocument&Defaut=y& (2003).
Heydecke 2002
Heydecke G, Peters MC. The restoration of endodontically
treated, single-rooted teeth with cast or direct posts and
cores: a systematic review. The Journal of Prosthetic Dentistry
2002;87(4):3806.
Higgins 2005
Higgins JPT, Green S, editors. Cochrane Handbook for
Systematic Reviews of Interventions 4.2.5 [updated May
2005]. The Cochrane Library 2005, Issue 3. Chichester,
UK: John Wiley & Sons, Ltd.
Mannocci 2001
Mannocci F, Sherriff M, Watson TF. Three-point bending
test of fiber posts. Journal of Endodontics 2001;27(12):
75861.
Shillingburg 1982
Shillingburg HT, Kessler JC. Restoration of endodontically
treated teeth. Chicago: Quintessence Publishing Company,
1982.
Torbjorner 1996
Torbjorner A, Karlsson S, Syverud M, Hensten-Pettersen
A. Carbon fiber reinforced root canal posts. Mechanical
and cytotoxic properties. European Journal of Oral Sciences
1996;104(5-6):60511.
Indicates the major publication for the study
11
CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]

Ferrari a 2000
Methods
RCT.
Parallel group study.
Follow-up time: 48 months.
Type of post and core randomised.
Participants
200 patients were randomly assigned to 1 of the 2 groups of endodontically-treated teeth (Type I or type III post and
core system).
To be included, subjects had to have at least 1 tooth with severe loss of tooth structure. All teeth were endodonticallytreated with lateral condensation of gutta-percha and eugenol-free sealer; after no less than 48 hours after endodontic
treatment, the roots were prepared to receive a post. In the molar roots, only 1 post was placed.
Drop-out rate: 2.5% at 48 months follow up.
Interventions
Type III gold alloy cast posts (type I post and core) versus non-metal carbon fibre posts (type III)
Outcomes
- Post dislodgement.
- Post fracture.
- Root fracture.
Notes
- Core type: cast core in a type III gold alloy or composite core.
- Cast posts and cores were cemented with zinc-phosphate cement.
Non-metal posts were bonded with resin cement.
- All teeth received a porcelain-fused-to-metal crown as the final restoration
Mannocci 2002
Methods
RCT.
Parallel group study.
Follow-up time: 36 months.
The selected subjects were randomly assigned to 1 of the 2 experimental groups by tossing a coin
Participants
117 patients (57 men, 63 women aged from 35 to 55 years) were randomly assigned to group 1 (n = 60) or group 2
(n = 57).
To be included, subjects had to have 1 maxillary or mandibular premolar for which endodontic treatment and crown
build up was indicated. 1 tooth per patient was treated. Only teeth without previous endodontic treatment with Class
II carious lesions and preserved cusp structure were included. The selected teeth needed to be in occlusal function
after restoration and were not used as abutments for fixed or removable partial dentures.
Drop-out rate: 1.7% at 24 months and 14.53% at 36 months follow up
Interventions
Non-metal carbon fibre posts (type III) covered with a composite filling versus non-metal carbon fibre posts (type
III) covered with a full-cast crown.
Single operator.
2 examiners other than the operator.
12
Mannocci 2002
(Continued)
Outcomes
- Post dislodgement.
- Post fracture.
- Root fracture.
Notes
- Core type: composite core.

- Fibre posts were bonded with resin cement.
- Teeth were restored with either metal-ceramic crown or with direct composite restoration
RCT: Randomised Clinical Trial
Characteristics of excluded studies [ordered by study ID]
Study
Reason for exclusion
Akkayan 1998
This in vitro study examined the effect of 4 different post systems (type I and type II) on the fracture resistance
of crowned endodontically-treated teeth
Amakawa 1999
This non-randomised controlled clinical trial evaluated the influence of metal posts (type II) on fracture
resistance of pulpless bleached teeth
Antonoff 1978
Survey of post and core design for endodontically-treated teeth focused on a questionnaire sent to the
departments of Prosthodontics and Restorative Dentistry of all the dental schools in the United States
Aquilino 2002
A retrospective cohort design and multivariate proportional hazards regression were used to develop explanatory models for the loss of root canal treated teeth. This study tested the hypothesis that crown coverage is
associated with improved survival of endodontically-treated teeth when pre-access, endodontic, and restorative factors are controlled
Basrani 2004
Commentary of the randomised clinical trial of Mannocci focusing on posts
Bass 2002
Description of a step-by-step procedure for the restoration of a badly broken-down endodontically-treated

molar tooth
Bergman 1989
Non-randomised controlled clinical trial focused on restorative and endodontic results after treatment with
type III gold-alloy cast posts and cores (type I post and core)
Bolla 1995
Description of the Composipost system (type III) and following of 1 group of participants for 2 to 3 years
Burke 1992
Litterature review focused on the incidence, causes and methods of investigating tooth fracture
Creugers 2005
2 controlled clinical trials were mixed comparing cast post and core, prefabricated metal post and resin core
and only resin core (1st RCT) or cast post and core and prefabricated metal post and resin core (2nd RCT).
Participation to 1 or the other depended of the expected dentin height levels; and within each trial, the type
of restoration was assigned by balanced drawing
13
(Continued)
Dallari 1996
Description of the Composipost system (type III) and following of 1 group of participants
Edelhoff 2000
The purpose of this study is to evaluate the clinical performance of zirconia posts (type III) and a corresponding
heat-pressed core material by following 1 group of participants
Ellner 2003
This prospective study evaluated the clinical outcome of 4 different post and core combinations (type I, type
II) over a period up to 10 years
Fazekas 1998
This study evaluated the treatment outcomes with the Composipost system (type III) after 24 months by
following 1 group of participants
Ferrari b 2000
This study evaluated the treatment outcomes of different fibre-reinforced post and core systems, all corresponding to the same type of post and core system (type III)
Francischone 2003
The objective of this clinical trial was to evaluate the influence of metal posts (type II) on fracture resistance
of pulpless bleached teeth. Teeth with no marginal ridges were restored with a post and composite resin
whereas teeth with intact marginal ridges were restored with composite resin only
Fredriksson 1998
This study evaluated the treatment outcomes of the Composipost system (type III) after 2, 3 and 7 years by
Gher 1987
This clinical survey evaluated reasons for endodontically-treated tooth fractures by following 1 group of
participants
Glazer 2000
This prospective study evaluated the success of a carbon-fibre post system (type III) used to retain an
intracoronal foundation to restore endodontically-treated teeth by following 1 group of participants
Goodacre 2003
The purpose of this study was to identify the incidence of complications and the most common complications
associated with single crowns, fixed partial dentures, all-ceramic crowns, resin-bonded prostheses, and posts
and cores
Grandini 2002
The aim of this non-randomised controlled clinical trial was to evaluate the effectiveness of a self curing
one-bottle adhesive system on bonding fibre-reinforced posts (type III)
Grieve 1993
This study was undertaken in order to examine different aspects of the quality of post-retained crowns,
including potential causes of failures
Hatzikyriakos 1992
Non-randomised controlled clinical trial focused on the evaluation of posts and cores (type I and type II)
beneath existing crowns
Hedlund 2003
This study evaluated the quality of prefabricated carbon-fibre root canal posts (type III) placed in patients
who regularly visited a general practice (1 group of participants)
Hochman 2003
The aim of this study was to provide insights into the survival rates of fixed partial dentures prepared by
dental school students and to evaluate the causes of failure by following 1 group of participants
14
(Continued)
Kakehashi 1998
Clinical (1 group of participants), technical and in vitro results with an all-ceramic post and core system are
presented
King 2003
This study is a non-randomised controlled clinical trial comparing cast posts (type I) versus non-metal
prefabricated posts (type III). Study combines split-mouth and parallel-group designs
Krantz-Schfers 2003
The purpose of this study was to examine the clinical results of the Cerapost posts (type III) after 4 years by
Krasteva 2001
The objective of this article is to describe the endodontic procedures for post and core system preparation
using a fibre-reinforced post in patients with destroyed tooth structure
Lai 2002
Non-randomised controlled clinical trial focused on the evaluation of carbon fibre-reinforced post systems
(type III)
Lewis 1988
Case report of failed post-retained crowns.
Libby 1997
This study determined the reasons for failure and length of service for fixed partial dentures delivered with
specific clinical, radiographic, and laboratory procedures
Linde 1984
The aim of this prospective study was to determine the success and the failure of the use of composite cores
under gold crowns by following 1 group of participants
Llena-Puy 2001
Cases study that examined the clinical conditions under which 25 endodontically-treated teeth suffered
vertical root fracture
Malferrari 2002
The purpose of this non-randomised controlled clinical trial was to evaluate the clinical behaviour of 84
endodontically-treated teeth restored with translucent quartz fibre posts (type III)
Malferrari 2003
Non-randomised controlled clinical trial which evaluated the acceptability of quartz fibre-reinforced epoxyresin posts (type III) used in endodontically-treated teeth over a 30-month period
Mannocci 2005
Randomised controlled clinical trial which compared restoration with post and without post. The restored
teeth were never covered by a crown
Mentink a 1993
Non-randomised controlled clinical trial focused on the survival rate and failure characteristics of the allmetal post and core restoration (type I)
Mentink b 1993
Non-randomised controlled clinical trial focused on the clinical performance of different post and core
systems (all type II)
Monticelli 2003
This non-randomised controlled clinical trial evaluated the clinical performance of 3 types of translucent
posts over a follow-up period of 2 to 3 years
Morgano 1993
Litterature review focused on the clinical success of cast-metal posts and cores (type I)
Naumann 2005
Cohort study comparing comparing post and core materials of the same type
15
(Continued)
Ng 2004
Non-randomised controlled clinical trial focused on the clinical performance of bonded fibre post and resin
core between the ferrule and non-ferrule groups
Ottl 1998
Non-randomised controlled clinical trial focused on the success rate for 2 different types of post and cores
(type I and type II)
Owall 2000
This study is an analysis of fixed partial dentures that failed or suffered severe complications within the first
2 years after cementation
Paul 2004
This non-randomised controlled clinical trial evaluated the treatment outcomes of zirconium oxide posts
(type III) with either direct resin composite cores or indirect glass-ceramic cores after several years of clinical
service and compared clinical and radiographic long-term results of such posts with historically available
long-term data on metal posts
Priest 1996
Failure rates of traditional fixed partial dentures, resin-bonded protheses, and implant restorations for the
replacement of a single tooth are compared in this literature review
Roberts 1970
An analysis of bridges is described in this article.
Rovatti 1994
Several clinical studies on the Composipost system (type III) are reviewed and discussed
Tidehag 2004
The purpose of this study was to evaluate the clinical performance of Composipost root canal posts (type
III) within the regular dental care system of Sweden by following 1 group of participants
Torbjrner 1995
Non-randomised controlled clinical trial focused on the survival rate and failure characteristics for 2 castpost designs (type I)
Wallerstedt 1984
Prospective study focused on amalgam crowns retained with brass screwposts (type II). 1 group of participants
Walter 2003
This study evaluated the clinical success of adhesively-luted zirconium-oxide posts (type III) by following 1
group of participants
Weine 1991
Retrospective study of smooth tapered post systems (type II). 1 group of participants
Willershausen 2005
Non-randomised cohort study which compared restoration with post and without post
16
DATA AND ANALYSES
Comparison 1. Cast posts (type I) versus fibre posts (type III)
Outcome or subgroup title

1 Failures after 4 years
No. of
studies
No. of
participants
195
Statistical method
Effect size
Risk Ratio (M-H, Fixed, 95% CI)
0.05 [0.00, 0.90]
Comparison 2. Composite restoration versus full-coverage metal-ceramic crown (MCC: prosthodontic status)
Outcome or subgroup title

1 Failures after 3 years
No. of
studies
No. of
participants
104
Statistical method
Effect size
Risk Ratio (M-H, Fixed, 95% CI)
1.85 [0.17, 19.80]
Analysis 1.1. Comparison 1 Cast posts (type I) versus fibre posts (type III), Outcome 1 Failures after 4 years.
Review:
Comparison: 1 Cast posts (type I) versus fibre posts (type III)

Outcome: 1 Failures after 4 years
Study or subgroup
Fibre posts
Cast posts
n/N
n/N
Risk Ratio
Weight
Ferrari a 2000
0/97
9/98
100.0 %
0.05 [ 0.00, 0.90 ]
Total (95% CI)
97
98
100.0 %
0.05 [ 0.00, 0.90 ]
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI
Total events: 0 (Fibre posts), 9 (Cast posts)

Heterogeneity: not applicable
Test for overall effect: Z = 2.03 (P = 0.042)
0.001 0.01 0.1

Favours fibre posts
10 100 1000
Favours cast posts
17
Analysis 2.1. Comparison 2 Composite restoration versus full-coverage metal-ceramic crown (MCC:
prosthodontic status), Outcome 1 Failures after 3 years.
Review:
Comparison: 2 Composite restoration versus full-coverage metal-ceramic crown (MCC: prosthodontic status)
Outcome: 1 Failures after 3 years
Study or subgroup
Metal-ceramic crown
Composite
n/N
n/N
Risk Ratio
Weight
Mannocci 2002
2/54
1/50
100.0 %
1.85 [ 0.17, 19.80 ]
Total (95% CI)
54
50
100.0 %
1.85 [ 0.17, 19.80 ]
M-H,Fixed,95% CI
Risk Ratio
M-H,Fixed,95% CI
Total events: 2 (Metal-ceramic crown), 1 (Composite)

Heterogeneity: not applicable
Test for overall effect: Z = 0.51 (P = 0.61)
0.001 0.01 0.1

Favours MCC
10 100 1000
Favours composite
ADDITIONAL TABLES
Table 1. Quality assessment
Quality assessment
Ferrari a 2000
Mannocci 2002
Allocation concealment (0 Not defined, 1 0

Poorly defined, 2 Well defined)
Randomisation of the participants (1 Inad- 2

equate, 2 Unclear, 3 Adequate)
Calculation of sample size (0 No/not men- 0

tioned, 1 Yes)
Inclusion/exclusion criteria (0 Not defined, 1

1 Poorly defined, 2 Well defined)
Follow-up achievement (0 No/not men- 2

tioned, 1 Yes < 80%, 2 Yes > 80%)
Blind outcome assessment (0 No/not pos- 0

sible, 1 Unclear, 2 Yes)
ITT analysis (0 Not mentioned, 1 States 2

numbers and reasons for withdrawal by
study group but analysis unmodified, 2 Primary analysis based on all recruited cases)
18
Table 1. Quality assessment
(Continued)
Control and treatment groups compara- 1

ble (0 Large potential for confounding or
not discussed, 1 Confounding small - mentioned but not adjusted for, 2 Unconfounded - good comparability of groups or
confounding adjusted for)
APPENDICES
Appendix 1. CENTRAL search strategy
#1 TOOTH NONVITAL/
#2 ((root next fill*) AND (teeth OR tooth))
#3 devital* NEAR/6 tooth OR endodontically treated teeth OR endodontically treated tooth
#4 devital* NEAR/6 teeth
#5 (pulpless NEAR/6 teeth
#6 ((pulpless NEAR/6 tooth) OR tooth pulp disease
#7 #1 Or #2 Or #3 Or #4 Or #5 OR #6
#8 POST AND CORE TECHNIQUE/
#9 post* NEAR/6 core*
#10 ((fiber NEAR/6 post*) OR (fibre NEAR/6 post*) OR (fiber NEAR/6 core*) OR (fibre NEAR/6 core*)
#11 ((root NEXT canal NEAR/6 post*) OR (root canal NEAR/6 core*))
#12 ((endodontic NEAR/6 post*) OR (endodontic NEAR/6 core*))
#13 stainless steel post* OR glass fiber post* OR glass fibre post*
#14 cast NEAR/6 post*
#15 parapost* OR dentatus dowel*
#16 crown and core*
#17 non-metallic NEAR/6 post*
#18 #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17
#19 #7 AND #18
Appendix 2. Scopus, MEDLINE, EMBASE search strategy

#1 tooth nonvital
#2 root fill teeth AND root fill tooth
#3 devital tooth OR endodontically treated teeth OR endodontically treated tooth
#4 devital teeth
#5 pulpless teeth
#6 pulpless tooth
#7 (#1 OR #2 OR #3 OR #4 OR #5 OR #6)
#8 post and core technique
#9 post and core
#10 fiber post OR fibre post OR fiber core OR fibre core
#11 root canal post OR root canal core
19
#12 endodontic post OR endodontic core

#13 endodontic post OR endodontic core OR endodontic dowel
#14 stainless steel post OR glass fibre post OR glass fiber post
#15 cast post
#16 parapost OR dentatus dowel
#17 crown AND core
#18 non-metallic post
#19 (#8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18)
#20 (#7 AND #19)
WHATS NEW
Last assessed as up-to-date: 31 October 2006.
Date
Event
Description
31 July 2008
Amended
Converted to new review format.
HISTORY
Protocol first published: Issue 1, 2004
Review first published: Issue 1, 2007
CONTRIBUTIONS OF AUTHORS
Marc Bolla conceived the idea for the review and is the guarantor for the review. Michle Muller-Bolla wrote the protocol and the
review. Cyble Borg wrote letters to the authors. Michle Muller-Bolla and Cyble Borg independently assessed the eligibility of the
trials, extracted data and assessed the quality of the trials.
DECLARATIONS OF INTEREST
None known.
SOURCES OF SUPPORT
20
Internal sources
Laboratoire Surface Interface en Odontologie (LASIO), France.
External sources
No sources of support supplied
INDEX TERMS
Medical Subject Headings (MeSH)
Dental
Restoration Failure; Post and Core Technique; Root Canal Therapy; Randomized Controlled Trials as Topic
MeSH check words

Humans
21

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Root canal posts for the restoration of root filled teeth

Root canal posts for the restoration of root filled teeth

PLAIN LANGUAGE SUMMARY

biologically compatible with tooth tissue. Moreover they can be

Metal-cast posts versus commercial prefabricated metal

Category III: two-element system comprising a commercial

Studies which compared the same category of post in different

Differences in the failure rate between post and core categories

Criteria for considering studies for this review

Types of outcome measures

Search methods for identification of studies

Data collection and analysis

(a) A randomised or quasi-randomised clinical trial.

See Characteristics of included studies table.

Characteristics of excluded studies

Characteristics of studies awaiting assessment

Characteristics of outcomes measures

Risk of bias in included studies

Comparison of cast posts and fibre-reinforced posts

Prosthetic status of the tooth (Comparison 2)

no references were given in these National Academy of Dentistry

Implications for research

These RCTs should be parallel group studies comparing cast posts

References to studies included in this review

References to studies excluded from this review

Bergman 1989 {published data only}

Amakawa 1999 {published and unpublished data}

Dallari 1996 {published data only}

Antonoff 1978 {published data only}

Edelhoff 2000 {published and unpublished data}

Aquilino 2002 {published data only}

Ellner 2003 {published data only}

Ferrari b 2000 {published data only}

Fredriksson M, Astback J, Pamenius M, Arvidson K.

(FPDs) prepared by dental school students: a retrospective

Hedlund 2003 {published data only}

Malferrari 2003 {published and unpublished data}

Malferrari S, Monaco C, Scotti R. Clinical evaluation

Hochman 2003 {published data only}

Mannocci 2005 {published data only}

endodontically treated teeth restored with amalgam or with

Rovatti 1994 {published data only}

References to studies awaiting assessment

Indicates the major publication for the study

Characteristics of included studies [ordered by study ID]

- Core type: composite core.

RCT: Randomised Clinical Trial

Characteristics of excluded studies [ordered by study ID]

Reason for exclusion

Commentary of the randomised clinical trial of Mannocci focusing on posts

Description of a step-by-step procedure for the restoration of a badly broken-down endodontically-treated

Case report of failed post-retained crowns.

An analysis of bridges is described in this article.

DATA AND ANALYSES

Comparison 1. Cast posts (type I) versus fibre posts (type III)

Outcome or subgroup title

Risk Ratio (M-H, Fixed, 95% CI)

0.05 [0.00, 0.90]

Outcome or subgroup title

Risk Ratio (M-H, Fixed, 95% CI)

1.85 [0.17, 19.80]

Root canal posts for the restoration of root filled teeth

Comparison: 1 Cast posts (type I) versus fibre posts (type III)

0.05 [ 0.00, 0.90 ]