SURVIVAL RATE OF ENDODONTICALLY TREATED TEETH WITH FIBER-POST SUPPORTED RESTORATIONS: A SYSTEMATIC REVIEW

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Alina Ismailova

5th, OF group 14

SURVIVAL RATE OF ENDODONTICALLY TREATED

TEETH WITH FIBER-POST SUPPORTED

RESTORATIONS: A SYSTEMATIC REVIEW

Master’s Thesis

Supervisor

Lecturer, Rimantas Ožiūnas

‘

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2 LITHUANIAN UNIVERSITY OF HEALTH SCIENCES

MEDICAL ACADEMY   FACULTY OF ODONTOLOGY 

ORTHOPEDIC CLINIC

SURVIVAL RATE OF ENDODONTICALLY TREATED TEETH WITH FIBER-POST SUPPORTED RESTORATIONS: A SYSTEMATIC REVIEW

Master’s Thesis

Kaunas, 2018

The thesis was done by

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EVALUATION TABLE OF THE MASTER’S THESIS  OF THE

TYPE OF SYSTEMIC REVIEW OF SCIENTIFIC LITERATURE

Evaluation:... Reviewer:...

(scientific degree. Name and surname)

Reviewing date: ...

No. MT parts MT evaluation aspects

Compliance with MT requirements and evaluation Yes Partially No 1 _Summary (0.5 point)

Is summary informative and in compliance with the

thesis content and requirements? 0.3 0.1 0

2 Are keywords in compliance with the thesis essence? 0.2 0.1 0

3

Introduction, aim and tasks

(1 point)

Are the novelty, relevance and significance of the

work justified in the introduction of the thesis? 0.4 0.2 0

4 Are the problem, hypothesis, aim and tasks formed

clearly and properly? 0.4 0.2 0

5 Are the aim and tasks interrelated? 0.2 0.1 0

6 Selection criteria of the studies, search methods and strategy (3.4 points)

Is the protocol of systemic review present? 0.6 0.3 0

7

Were the eligibility criteria of articles for the selected protocol determined (e.g., year, language, publication condition, etc.)

0.4 0.2 0

8

Are all the information sources (databases with dates of coverage, contact with study authors to identify additional studies) described and is the last search day indicated?

0.2 0.1 0

9

Is the electronic search strategy described in such a way that it could be repeated (year of search, the last search day; keywords and their combinations; number of found and selected articles according to the combinations of keywords)?

0.4 0.1 0

10

Is the selection process of studies (screening, eligibility, included in systemic review or, if applicable, included in the meta-analysis) described?

0.4 0.2 0

11

Is the data extraction method from the articles (types of investigations, participants, interventions, analysed factors, indexes) described?

0.4 0.2 0

12

Are all the variables (for which data were sought and any assumptions and simplifications made) listed and defined?

0.4 0.2 0

13

Are the methods, which were used to evaluate the risk of bias of individual studies and how this information is to be used in data synthesis, described?

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14 Were the principal summary measures (risk ratio,

difference in means) stated? 0.4 0.2 0

15

Systemization and analysis of

data (2.2 points)

Is the number of studies screened: included upon assessment for eligibility and excluded upon giving the reasons in each stage of exclusion presented?

0.6 0.3 0

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Are the characteristics of studies presented in the included articles, according to which the data were extracted (e.g., study size, follow-up period, type of respondents) presented?

0.6 0.3 0

17

Are the evaluations of beneficial or harmful outcomes for each study presented? (a) simple summary data for each intervention group; b) effect estimates and confidence intervals)

0.4 0.2 0

18 Are the extracted and systemized data from studies

presented in the tables according to individual tasks? 0.6 0.3 0

19 _Discussion

(1.4 points)

Are the main findings summarized and is their

relevance indicated? 0.4 0.2 0

20 Are the limitations of the performed systemic review

discussed? 0.4 0.2 0

21 Does author present the interpretation of the results? 0.4 0.2 0

22

Conclusions (0.5 points)

Do the conclusions reflect the topic, aim and tasks of

the Master’s thesis? 0.2 0.1 0

23 Are the conclusions based on the analysed material? 0.2 0.1 0

24 Are the conclusions clear and laconic? 0.1 0.1 0

25

References (1 point)

Is the references list formed according to the

requirements? 0.4 0.2 0

26 Are the links of the references to the text correct? Are

the literature sources cited correctly and precisely? 0.2 0.1 0 27 Is the scientific level of references suitable for _{Master’s thesis?} 0.2 0.1 0 28

Do the cited sources not older than 10 years old form at least 70% of sources, and the not older than 5 years

– at least 40%? 0.2 0.1 0

Additional sections, which may increase the collected number of points

29 Annexes Do the presented annexes help to understand the

analysed topic? +0.2 +0.1 0

30

Practical

Recommen-dations

Are the practical recommendations suggested and are

they related to the received results? +0.4 +0.2 0

31

Were additional methods of data analysis and their results used and described (sensitivity analyses, meta-regression)?

+1 +0.5 0

32

Was meta-analysis applied? Are the selected statistical methods indicated? Are the results of each meta-analysis presented?

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General requirements, non-compliance with which reduce the number of points

33

General require-ments

Is the thesis volume sufficient (excluding annexes)?

15-20 pages (-2 points) <15 pages (-5 points)

34 Is the thesis volume increased artificially? -2

points -1 point

35 Does the thesis structure satisfy the requirements of _{Master’s thesis?} -1 point -2 points

36 Is the thesis written in correct language,

scientifically, logically and laconically? -0.5 point -1 points

37 Are there any grammatical, style or computer

literacy-related mistakes?

-2

points -1 points 38 Is text consistent, integral, and are the volumes of its

structural parts balanced? -0.2 point -0.5 points

39 Amount of plagiarism in the thesis. >20% (not evaluated)

40

Is the content (names of sections and sub- sections and enumeration of pages) in compliance with the thesis structure and aims?

-0.2 point -0.5 points

41

Are the names of the thesis parts in compliance with the text? Are the titles of sections and sub-sections distinguished logically and correctly?

-0.2 point -0.5 points

42 Are there explanations of the key terms and

abbreviations (if needed)? -0.2 point -0.5 points

43 Is the quality of the thesis typography (quality of

printing, visual aids, binding) good? -0.2 point -0.5 points

*In total (maximum 10 points):

*Remark: the amount of collected points may exceed 10 points.

Reviewer’s comments: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

Reviewer’s name and surname Reviewer’s signature

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6 Annex No. 4

SUMMARY

Aim: To analyze clinical data about the survival rate of endodontically treated teeth with fiber-post

supported restorations in order to see if it can be better alternative treatment to metal posts.

Material and methods: A systematic review was carried out to identify relevant studies reporting data about survival of endodontically treated teeth with fiber-post supported restorations applied in restorative dentistry. This systematic review was done according to PRISMA-P criteria. The data was extracted from the selected 12 research articles. The search was performed through electronic databases such as ScienceDirect, ResearchGate, PubMed and WileyOnline and was restricted to publications from 2008- 2018.

Results: Based on all 12 analyzed articles with the observational periods in the range of 1-11 years,

the survival rate of endodontically treated teeth with fiber-post supported restorations was ranging from 55% to 100% but with prevalence in the range 70% – 100%. While in most cases the value of the success rate was ranging from 85-95%.

Conclusion: Based on analyzed literature, can be concluded that the survival rate of endodontically

treated teeth with fiber post supported restorations is high enough to expect a good prognosis. Uniquely clinical key factors as the presence of at least one remaining cavity wall or presence of ferrule increases the success and survival rate of endodontically treated teeth with fiber-reinforced posts compared to its absence. But even with all its advantages it couldn’t be told that fiber posts are better than metal, as the clinical studies’ results show as well good outcomes of teeth restored with metal posts.

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INTRODUCTION

Generally speaking, teeth with severe caries destruction, suffered from the trauma, or underwent non-conservative endodontic treatment tend to have a loss of coronal hard tissue [1]. This in its turn leads to the lack of retention for the tooth´s coronal restoration as well as the loss of mechanical strength of tooth itself making the tooth more fragile [2]. Hence, the usage of post and core systems is indicated to compensate the mechanical retention between the tooth and the restoration, as well as strengthening the endondotically weakened teeth, providing fracture resistance to these compromised teeth [3, 4].

So, during the last decades, the post and core system for the reinforcement of endodontically treated teeth has been a much disscussed topic which has been reported in many studies [3, 5, 6].

Starting as metal post systems which later has been replaced to a certain level by metal-free posts systems gained more popularity. This evolution into fiber-post type is not something recent but rather goes back to 1989 with the first introduction in clinical use in France. While first scientific article was published 1990 by Duret where he described carbon-fiber reinforced posts [7]. With all its advantages, such as high tensile strength and elastic modulus that is similar to dentine, but it had lack of radiopacity and it was in black color that not corresponds to high aesthetics’ demands [8]. So later, this problem was solved with invention of silica-fiber posts which are translucent and whitish. These posts are made from glass -or quartz-fibers. This system´s improvement added high aesthetics property to its many advantages same as in carbon fiber posts, such as an easy clinical manipulation, shorter chair-time, and elastic modulus that is similar to the dentin preventing creation of undesirable stress within the remaining tooth structure and thus preventing a root fracture [8, 9, 10, 11, 12].

It is known that intact teeth compare to endodontically treated teeth have different biomechanics. In intact teeth dentin structure and its composition is the key for proper distribution of functional stresses from tooth to surrounding tissues. While as the tooth become pulpless its biomechanics are changing, the dentine tissue become dehydrated and it contributes to the reduction in the mechanical integrity of endodontically treated teeth [13]. If the tooth has a need to be restored with post, core and crown it also changing its biomechanics and it is again dissimilar to that of an intact tooth. The teeth restored using a post-core system has different regions of stress concentration and increased tensile stresses in the remaining root dentin. One from the factors that is responsible for undesirable stress distribution within the remaining tooth structure in a post-core restored tooth is the greater stiffness of the endodontic post than stiffness of the dentine tissue [14]. So in generally

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9 it is believed that use of posts with similar elastic modulus to the dentine is less damaging to the remaining dentine structure because when it flexes it deforms together with remaining dentine and cement interface [6]. Thus in this case maximum stress concentration and the weakest point will be at the level of cervical region in cement interface between post and dentine or between core and dentine. Hence it has prognosis for more favorable failures such as post debonding and post or core fracture. While for stiffer metal posts, maximum stress concentration is observed around the posts apex that lead to higher risk for unfavorable failures such as vertical root fracture making the tooth irreparable [14, 6, 15]. This in its turn would enhance survival rate of the non-vital tooth.

Anyways elasticity positive effect has been controversially debated since on the other hand some clinical studies based of study results don’t support the benefits of the elastic modulus stated above [16, 17]. So as in one of the study results showed that difference between metal and fiber posts is not so obvious if the tooth had proper ferrule and covered with complete crown [18].

As dentistry is evolving towards metal free restorations as in ceramic crowns instead of PFM crowns, or composite fillings instead of amalgam, we also noticed it in post and core systems in form of fiber post systems, which are becoming very popular among not only new dentists but also the experienced ones [19].

Aim: To analyze clinical data about the survival rate of endodontically treated teeth with fiber post–

supported restorations in order to see if it can be better alternative treatment to metal posts.

Tasks:

1. To collect information about survival rate of endodontically treated teeth with fiber post supported restorations.

2. To collect and discuss clinical data/clinical key factors that can influence on success and survival rate of endodontically treated teeth restored with fiber post system.

3. To discuss possible complications related to fiber post-systems.

4. To compare outcomes of endodontically treated teeth restored with fiber post and metal post system.

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1. SELECTION CRITERIA OF STUDIES. SERARCH METHODS AND

STRATEGY

1.1. Selection criteria of studies

This systematic review was done according to PRISMA-P (Preferred Reporting Items for Systematic review and Meta-Analysis Protocols) criteria, to analyze survival rate of endodontically treated teeth with fiber-post supported restoration that can be influenced by different clinical key factors (annex 5.). Moreover, inclusion and exclusion criteria and filters covered the following statements.

Inclusion criteria including for selection were the following:

1) scientific articles of randomized clinical trials and (prospective and retrospective) observational clinical studies,

2) articles are not older than 10 years, 3) published in English,

4) studies performed on humans, 5) in vivo.

Furthermore articles and studies were selected that involved following exclusion criteria such as:

1) studies in vitro, 2) studies on animals, 3) abstracts, 4) case reports, 5) author debates, 6) summaries and 7) systematic reviews. 1.2. Search methods

The systematic review was done by one investigator during the period December 2017 - April 2018. The electronic search included multiple web databases naming: ScienceDirect, ResearchGate,

PubMed and WileyOnline. So search was performed by combining keywords as teeth, survival,

fiber post, glass fiber post, clinical trial, endodontically treated teeth. All those electronic

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11 Science´s EZproxy. The search was focused on finding randomized clinical trials and (prospective and retrospective) observational clinical studies about survival rate of endodontically treated teeth with fiber post supported restorations. The collected studies along with their clinical data were then manually reviewed and double checked by supervisor (Rimantas Ožiūnas) to finally select the adequate articles for the systematic analysis.

1.3. Study selection

Combinations of keywords used for the search strategy in electronic databases were chosen according to the above mentioned topic. During the search identification phase each database was accessed. Following 3 keywords combinations were used in each database: 1) teeth AND fiber

post, 2) Endodontically treated teeth AND fiber post AND survival, 3) clinical trial AND survival AND glass fiber post. That can be seen in tables (1-7) below.

Then articles were selected from the titles and abstracts that met following inclusion and exclusion criteria and were relevant to the aim of this systematic review.

In database SienceDirect the first used keyword’s combination were “teeth AND fiber post”. They showed 721 results. When using the filter “Research articles”, 445 results were shown. After adding the time filter “10 years”, 321 hits were filtered. By changing the time filter “10 years”, into “5 years”, 170 scores appeared (Table 1). But because the results were too wide with two keywords it was decided to use later minimum three keywords in combination.

Table 1. ScienceDirect database with date of search 2018.03.02.

Keywords Filters Results

Teeth AND fiber post

No filter 721

Research articles 445

Research articles,10 years 321

Research articles, 5 years 170

After completing the first search, with only two general keywords, the extent of found articles was too immense, to elaborate an accurate search. Further searches were initiated by using a third keyword (at least), to overcome this problem. So in further search it was decided to use minimum

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12 keywords. The filter “Research articles” remained for the further research, since only research articles were relevant for that analysis.

In the next step, the keywords as “Endodontically treated teeth AND survival” were added, limited the research articles, 88 results were shown. When narrowing the research down, by using the filter “10 years”, 54 scores were manifested, whereas 37 scores were offered while using the filter “5 years” (Table 2).

Table 2. ScienceDirect database with date of search 2018.03.02.

Endodontically treated teeth AND fiber post AND survival

Research articles, 10 years

54

Research articles, 5 years

37

The next search contained the combination of keywords “clinical trial AND survival AND glass fiber post”. The filter “Research articles” was repeatedly left intact for this search. 19 results were found. Again the filter “10 years” which showed 18 results whereas the filter “5 years” showed 11 results modified the research (Table 3).

Table 3. ScienceDirect database with date of search 2018.03.02.

Clinical trial AND survival AND glass fiber post

Research articles, Open access, 10 years

18

Research articles, Open access, 5 years

11

Then articles were searched in ResearchGate database according the same three keywords combinations but were screened only manually due to absence of filters. Finally 4 new articles were chosen according selected inclusion criteria.

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13 Combinations of keywords used for the search strategy in PubMed database were the same as above used in SienceDirect and ResearchGate databases but some filters were different according database possibilities and selected inclusion critaria. Results are seen below in tables 4, 5.

Table 4. PubMed database with date of search 2018.03.02.

Clinical Study, Clinical Trial, Human, English

18

Clinical Study, Clinical Trial, Human, English, 10 years

12

5

Table 5. PubMed database with date of search 2018.03.02.

Clinical Study, Clinical Trial, Human, English

9

7

3

Again the same combinations of keywords were used in WileyOnline database as above in previous databases but some filters were different according database possibilities and selected inclusion criteria. Results can be seen in tables 6, 7.

Table 6. WileyOnline database with date of search 2018.03.02.

Journals, Open access content, Journals , 10 years

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Table 7. WileyOnline database with date of search 2018.03.02.

Journals, Open access content, Journals, 10 years

63

The initial electronic search from all used databases resulted in 1106 publications. Records after using at least 3 keywords in combination, with filter “10 years” showed 342 papers and then 270 records were excluded at title/abstract screening. The remaining 72 screened articles were checked for duplicates (49 excluded duplicates). Then the 23 articles left, were assessed for eligibility, 11 of them were excluded (due to lack of relevant data and studies in vitro). Finally, 12 articles were included for this qualitative analysis (Figure 1).

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Figure 1. A flowchart for the article selection.

Records identified through databases Searching (1106): SienceDirect: 828 PubMed: 27 WileyOnline: 247 ResearchGate: 4 S cr ee n in g In clu d ed E li gib il it y Id en tif icat ion

Records after using at least 3 keywords in combination, with filter “10 years”

(n = 342) Records screened (n = 72) Records excluded at title screening (n = 270) Full-text articles assessed for eligibility

(n = 23) (n = 94)

Records after duplicates removed  (n =49) Studies included in qualitative synthesis (n = 12) (n = 25) 11 articles excluded:

Due to lack of relevant data and studies in vitro

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1.4. Data extraction

The main data were extracted from each selected study and displayed in tables (8) and (9): authors and year of publication, study design, number of participants, number of teeth, types of teeth, type of post, mean observation period, remaining cavity walls, presence/absence of ferrule, type of luting agents, type of core build up material used, type of final restoration, survival rate, success rate. Data regarding mode of failure were also recorded for studies that evaluated this outcome. In some studies survival rate was calculated according existing parameters.

1.5. Study variables

In this systematic analysis, the main two variables were success and survival rate of the of endodontically treated teeth with fiber post supported restorations which directly or indirectly are influenced by different clinical factors such as presence or absence of ferrule, number of remaining cavity walls, follow-up period, final restorations and failure modes.

According the studies, definition of survival rate is defined as the outcome in the absence of

absolute failure, for example in the absence of root fracture which was regarded as a catastrophic

failure, since it committed the tooth to extraction [20].

While definition of success rate is defined as the outcome rate in absence of absolute and relative

failures (relative failures: endodontic failure, post debonding and fracture, core fracture, final

restoration failure; absolute: root fracture) [20].

1.6. Risk of bias in studies

Unfortunately, among other limitations, the risk of bias has not been paid attention in few of studies selected for this paper, which in its turn could or not cause higher risk of bias that should be taken in consideration while reading this systematic review. In other words, the selected studies can give an overestimation of survival of endodontically treated teeth with fiber post supported restoration, which might be not be closer to clinical truth. However, this doesn’t mean that the fiber post restorations as treatment method has misleading prognosis, especially if professional judgment is based on randomized clinical trials.

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2. SYSTEMIZATION AND ANALYSIS OF DATA

All gathered data deemed important has been illustrated on table (8) and (9).

First of all, table (8) shows data from the selected articles which were in form of randomized clinical trials (10 studies) and observational clinical studies including prospective and retrospective types (2 studies). The mean number of patients involved was 97 per study (ranging from 47 to 199). Including a total of 1590 teeth with the mean 151 treated teeth with posts per study (ranging from 57 to 526) from which 809 teeth were anterior teeth and 781 were posterior.

Speaking about post-systems, few types has been mentioned and evaluated starting from the most common which was prefabricated glass fiber post (1195), quartz fiber post (266), prefabricated titanium post (94), and the least which was cast metal post (37).

Concerning the coronal tooth structure, the number of remaining cavity walls was also considered. Starting from presence of four walls until zero walls of tooth´s crown, most common were teeth with one or two present walls (n-985), then teeth with zero present walls (n-343), and then teeth with three or four (n-329) present walls. Hence, the most common scenario was teeth with one or two present walls (in 12 studies), then second common was teeth with zero present wall (in 9 studies) and least common with three or four present walls (in 5 studies).

Another factor mentioned was presence or absence of ferrule as well as the size of ferrule created. Ferrule´s height was reported in 9 studies (1.5-2 mm), absent in 3 studies (0-0.5mm), and no data was reported in 2 studies. Ferrule height most commonly was 2 mm (8 studies), then 1.5mm (5 studies).

Next clinical key factor was final restoration for post-core restored teeth which included the most commonly used porcelain fused to metal crowns (9 studies), bridge construction (4 studies), abutment crown for fixation of partial removable denture (4 studies), as well as direct resin composite restorations (2 studies), and least used ceramic crown (1 studies).

When it comes to observation period, the mean was 5.2 years (ranging from 1.5 to 11.8 years). During which several complications have developed such as most commonly endodontic complications reaching 130 teeth which were reported in 8 studies, 59 post debonding of the post-core reported 8 studies, 37 post fractures reported in 6 studies, 31 root fractures mentioned in 10 studies, 19 core fractures documented in 5 studies, 16 final crown displacements reported in 2 studies, and finally 12 recurrent/secondary caries documented in 4 studies.

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18 Last but not least, speaking about the main variables in this systematic review which are the survival and success rates. Starting with survival rate, it was ranging from 55% to 100%. The survival rate of glass fiber post 55% in the observational period of 11 years was in the group of teeth with one/two walls and without any remaining cavity walls. The survival rate with more than 90% was mainly in teeth with ferrule or more than one remaining cavity walls. Survival rate which was basically defined as the presence of the tooth during the follow-up period with treated complications if present, giving a maximum rate of 100% was present in 5 studies, and high rate ranging from 70 – 98% in all 12 studies in different groups, only 58% in the remaining 1 study in one group.

In most cases the value of the success rate in the groups and subgroups was ranging from 85-95% (9 studies), in 6 studies success rate was varying from 95-100%, then 4 studies varied from 70-85%, while 7 studies included success rate from 28-70%.

Finally, table (9) illustrates what types of luting agents as well as core build up materials. The posts used in these studies were luted/cemented with resin cements, which were sub-categorized into self-adhesive (5 studies), dual-cured (5 studies), and chemical cured (1 study). The main material used for building up the core was resin composite in different types including dual cured, chemical cured, flowable, micro-hybrid and special composite core build up material.

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Table 8. Clinical key factors and study variables of systematic analyses

Study reference Study design # of partici-pants # of teeth (n) Type of teeth (n) Type of post (n) Mean observa-tional period (y.) Remained cavity walls (n) Ferrule (mm) Final restoration (n)

Failure modes (n) Survival

rate Success rate Sterzenbach G. et al, 2012 RCT 87 87 IN 27 CA 17 PR 37 MO 10 GFP 41, 5.9 ±1.8 2 (22) 1 (23) 0 (46) 2 PFMcr, FPD RPD GFP: 3 RoFr, 1 CoFr 90.2 - TP 47 TP: 3 EnFl 93.2 Naumann M. et al, 2017 RCT 87 87 IN 27 CA 17 PR 37 MO 10 GFP 41, 8.4 ± 3.4 2 (22) 1 (23) 0 (46) 2 PFMcr, FPD+RPD PMFcr+RPD

GFP: 4 RoFr, 1 ToFr, 2-EnFl, 1 CoFr, 1ReC, 1 Mobility degree-3, 2 changes in treatment plan.

58.7 -

TP 47 TP: 5 EnFl, 1 RoFr,1 extraction for

other reason 74.2 Signore A. et al, 2008 RCT 192 526 ANT 526 GFP 5.3 3 4 (80) FCcr 5 PoDe 1 PoFr 1 CoFR 8 CrFr 100 100 1 2 (446) 2 or 1 96.9 96.9 Sarkis-Onofre R. et al, 2014 RCT 54 72 ANT 40 POST 32 GFP 35, 1.4 ± 0.6 1 0 0-0.5 PFMcr GFP: 1 RoFr,2 PoDe 97.1 - Cast metal post 37

Cast metal post: 2 PoDe, 1 RoFr

91.9

Juloski J. et al, 2014

RCT 120 120 PR 120 GFP 4 3,4 (60) PFMcr 4 EnFl, 1 PoFr, 3 PoDe,

2 RoFr

100 90

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20 Ferrari M. et al, 2012 RCT 199 (Prefab QFP+ CM GFP) 107 PR 107 Prefab QFP 107 6 4 (36) PFMcr 0 100 100 3 (34) 1 PoDe 100 94.1 2 (36) 1 EnFl, 1 PoFr 100 88.9 1 (34) 3 PoDe, 1 EnFl 100 77.8

0 (32) ≥2 1 PoFr, 2 EnFl, 4 PoDe 100 61.1

0 (37) <2 1 RoFR, 3 EnFl, 3 PoCoFr, 4 PoDe 94.4 38.9

Guldener KA. et al, 2016 RCT 106 106 IN,CA 27 PR-34 MO-45

GFP 8.8 ± 2.3 1 - DCR 2 EnFl, 1 ReC, 6 RoFr 93.8 83

PFMcr 95.1 90.2

Cagidiaco MC. et al, 2008

RCT 120 120 PR-120 Prefab GFP 3 - RoFr, CrDis:

4 (20) 0 100 100 3 (20) 0 100 100 2 (20) 0 100 100 1 (20) 1 98 95 0 (20) ≥2 4 95 80 0 (20) ≤2 6 88 70 Bitter K. et al, 2009 RCT 60 60 ANT-15 PR-20 MO-25 QFP 2.7 ± 1.1 2 ( 20) - 0 100 100 1 (20) 1 RoFr, 1 PoCo De 95 90 0 (20) 2 1 PoFr 100 95

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21 Parisi C. et al, 2015 ROCS 61 99 ANT-63 POST-70 QFP 5.88 ± 1.37 4 3 2 1 0

≥1.5 9 PoDe, 2 ReC, 3 EnFl 98 88

Crown 54 8 Bridge 39 3 94.8 RPD’s abut-ment cr. 6 3 50 Skupien JA. et al, 2015 RCT 47 57 ANT-14 PR-21 MO-22 GFP 4.9 ± 5 1 0

1.5 DCR 30 1 RoFr, 7 ReFr, 2 ReC 95 40

PFMcr 27 1 CrFl 100 95 Naumann M. et al, 2012 POCS 119 149 ANT 63 POST 86

GFP 6.2 ± 3.6 0-2 55: PoFr, PoDe, EnFl; 55 46

0 (62) 39 ≥1 (87) 16 Single crown79 32 Bridge 40 11 Combined fixed removable 30 12

Study design: ROCS- Retrospective observational clinical study,POCS- prospective observational clinical study, RCT- randomized clinical trial. Type of teeth: INC-incisors, CA- canines, PR- premolars, MO- molars.

Type of post: GFP- glass fiber posts, QFP- quartz fiber posts, TP- titanium posts, CM- customized, Prefab- prefabricated, cr- crown, Gr.-group. Final restoration: PFM- porcelain fused to metal crowns, FC- full ceramic crowns, DCR- direct composite restorations, RPD- removal partial

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Table 9. Luting agents and core build up materials for fiber posts.

Study reference Luting agents Core build up

Sterzenbach G. et al, 2012 resin cement (self-adhesive) resin composite

Naumann M. et al, 2017 resin cement (self-adhesive) resin composite

Signore A. et al, 2008 resin cement (dual-cure) dual-cure resin composite and hybrid light-cure composite

Sarkis-Onofre R. et al, 2014 resin cement -

J Juloski J. et al, 2014 resin cement (self-adhesive, dual-cured) -

Ferrari M. et al, 2012 resin cement (dual-cure) flowable composite and microhybrid composite

Guldener KA. et al, 2016 - cement composite material

Cagidiaco MC. et al, 2008 resin cement (dual-cure) flowable composite and microhybrid composite

Bitter K. et al, 2009 composite core build-up material (chemical-cure) composite core build-up material (chemical-cure)

Parisi C. et al, 2015 resin cement (self-adhesive) composite resin

Skupien JA. et al, 2015 resin cement (self-adhesive) resin composite

Naumann M. et al, 2012 resin cement (dual-cure) composite (chemical-cure)

Failure modes: PoFr- post fracture, PoDe- post debonding, RoFr- root fracture, EnFl- enododontic failure, CoFr- core fracture, ToFr- tooth fracture,

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3. DISSCUSSION

The data collected in the result´s section of this systematic review shows an interesting variation in both success and survival rate of endodontically treated teeth with fiber-reinforced post systems during an observation period ranging from 1 – 11 years. Giving the table (8) the survival rate had a range from 55% to 100%, while success rate had a range from 38% to 100%. The success rate 38% was in the group of teeth with a prefabricated fiber posts, without remaining cavity walls but with the absence of the ferrule. While in group with presence of ferrule survival rate has increased till 61%.

This big interval/range of percentage can be directly or indirectly related to several clinical key factors. Anyways during analysis of current studies it should be considered some limitations, such as big difference in the observational periods and different practical skills of people who performed the treatment, as they were experienced dentists and also odontology students.

Influence of a type of tooth on the survival rate

Starting talk with the types of teeth that restored with post and core systems, according to analyzed studies, opinion that there is the influence of tooth type on survival rate is controversial. In many studies was found the correlation that maxillary teeth especially anterior teeth have higher risk failure rate due to higher functional horizontal forces acting compared with a more perpendicular compressive force vector for posterior teeth [21, 22]. But other studies showed results that there is no significant difference between type of tooth, showing nearly same results between maxillary and mandibular teeth, and between anterior and posterior teeth [23, 24].

3.2. Influence of the amount of remaining cavity walls on the survival rate

Speaking about the type of tooth influence, one must mention tooth´s crown structure itself. Meaning the remaining tooth´s crown substance, such as cavity walls presence at the time of post-core restoration. In few studies it has been shown that teeth with three or four walls receiving post and core restoration had up to 96 - 100 % survival rate within in 3-6 years period, which in its turn coincides with survival rate of pulpless teeth with same amount of walls but without post retention [25, 20]. Besides, in other studies, the teeth with one or two remaining walls were giving us a survival rate in a range of 55 – 100% [17, 21, 26, 27]. Where the lowest survival rate 55% was in group of teeth one and more walls or without remaining walls, where from 62 teeth without walls

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24 39 teeth had a failure [21]. While the groups of teeth with one or two walls have showed higher survival rate with the lowest survival rate 86% in 4 years [17, 20, 21, 25, 26, 27, 28, 29]. Anyway some other groups of teeth without walls but with ferrule showed good results, with survival rate 95% in 6 years, 100% in 6 years, and 100% in 2.7 years [25, 20, 28].

So the studies that had clinical trials with six group of teeth (from 0 remaining cavity wall to 4) have concluded that post space should not be prepared in endodontically treated tooth with three and especially four walls unless necessary, and a root canal post should only be used when needed for retention of a coronal restoration [20, 25].

3.3. Influence of the presence/absence of ferrule on the survival rate

Another key factor concerning tooth structure is ferrule which in its turn can be subdivided into ferrule presence/absence and ferrule size. Starting with its presence, in some vitro studies was reported that teeth with ferrule even at a very small size of 0.5mm provided higher strength resistance than teeth without ferrule [30, 31, 32]. However, in other studies clinical data showed that teeth with ferrule had no significant difference compared to the ones lacking ferrule, which was explained by the loss of ferrule structure and its effect during preparation for a final crown [20, 25]. Anyways we can see in table 8 that the survival rates of teeth with ferrule in higher than in groups of teeth without it. When it comes to the ferrule’s size, the bigger ferrule’s length the higher is the fracture resistance of the endodontically treated teeth which were restored with the fiber-post system [33]. Besides, the longevity of endodontically treated teeth with post and core system increases depending on adequate ferrule’s length which is considered 1.5 – 2mm (between crown margin and core) [34].

3.4. Influence of the final coronal restoration on the survival rate

Once the endodontically treated tooth has received post and core restoration, a final coronal restoration should be carried out as early as possible. According A. Vichi’s study both success and survival rate of endodontically treated teeth are directly proportional to both endodontic treatment and subsequent final coronal restoration. Meaning that only after receiving a coronal final restoration, a tooth can be considered as properly treated endodontically [35]. In other words, the shorter time-span between these two moments the lesser the risk of bacterial infection, and thus higher percentage of success and survival rate of the tooth. And the reason for an early definitive coronal seal is to prevent micro-leakage and bacterial reinfection into the root canal system which increased by 3% every additional month until the final coronal seal is delivered [36]. So by B.

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25 Willershausen was concluded that: “The coronal seal achieved by the restoration may be considered as important for the success of endodontic treatment” [36].

After, when we speak about the type of final coronal restoration, what is the best for endodontically treated tooth that is restored with the fiber-reinforced post, we can rely on results from many studies. In this paper, according to Kevin´s study, the survival and success rate for restored teeth with direct composite was 93.8% and 83% respectively, while the survival and success rate for metal-ceramic crowns was 95.1% and 90.2% respectively [37]. This proves no significant difference between the two coronal restorations [37, 48]. While Skupein´s study reported a survival and success rate of glass fiber post restored with direct composite restorations of 95 % and 40% respectively. While with metal-ceramic crowns was 100% and 95% respectively. According made log-rank test it was stated that there was no significant difference for survival according to the type of restoration, unlike for success rates which were higher in metal-ceramic crowns and only 45% in case of direct composite restorations what lead to more endodontic and prosthetic retreatments procedures [47]. In conclusion, restorations placed on endodontically treated teeth presented acceptable survival rates. However it was concluded by J. A. Skupien that: “An indirect restorations provided higher acceptable clinical performance and lower need for re-intervention” [47].

Also according to results, we can see that when endodontically treated teeth with post core system as abutment for fixed partial denture/bridge demonstrated significantly lower failure rate than when it is abutment for single crowns. Finally, the least success shows abutments for removable partial dentures [22, 38].

Another clinical key factor that should be considered, as the influence on survival of endodntically treated teeth with fiber post-core system, is the influence of luting agent. Nowadays these posts typically are bonded with resin luting cement and utilize composite for cores, that we can see in many clinical trials. (tab.9)

3.5. Influence of the elastic modulus of posts on the survival rate

Another factor as the elastic modulus of posts in combination with cement was considered as the threat for failure. As glass and quartz fiber posts are more flexible than both metal and carbon-fiber postsin some aspect it reported as a disadvantage [39]. In case of greater flexure it is producing micro- movement of the core and cement breakdown that leads to microleakage and failure, but from other hand reducing the possibility of catastrophic root fracture [40].

To appreciate the fiber post-system, a brief comparison with metal post-systems (stainless steel & titanium) should be drawn. Starting with fatigue or fracture resistance, which is among principle

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26 causes of structural failure of any restoration. This main benefit of fiber post-systems, whose elastic modulus is similar to the dentin, allows it to flex slightly if necessary and preventing breakage of itself and/or root structure and in case of maximum stress its concentration and the weakest point will be at the level of cervical region in cement interface between post and dentine or between core and dentine. (41, 42, 14]. Besides, even in case of post-fracture or endodontic retreatment, unlike the metal post system, the fiber post can be easily removed without any trauma or invasive removal of the surrounding tooth structure [40, 43].

But according to the analyzed papers it is seen still metal post shouldn’t be considered as a worse treatment option. The longest observational period was 11 years in Michael Naumann clinical trial [44]. Michael’s study is comparing survival of severely damaged endodontically treated teeth with prefabricated glass fiber post and metal post. Where the teeth had not more than two remaining cavity walls with 2 mm ferrule’s presence [44]. If we look at results in 8 years, it is high enough for both groups [17]. After 11 years it observed 58.7 % of survival rate in teeth with the use of prefabricated glass fiber posts when in teeth with titanium posts it is 74.2% but without significant difference between the groups, and still shows favorable survival rates. So these studies concluded that tooth survival is not influenced by post rigidity [17, 44, 29]. Also, they explain that probably it is more important the presence of ferrule in severely damaged endodontically treated teeth than the type of post. The same result can be seen in another study where the survival rate didn’t have a significant difference between the groups of glass fiber post and cast metal posts, both with high survival rates in 3-years (97.1%, 91.9%) [16]. Even the absence of cavity walls and minimal size of ferrule or its absence didn’t reduce survival rate. But because it was only 3 year follow-up, longer observation periods was needed to detect possible differences and complications [16]. Some other studies also can prove that rigidity- the elastic modulus of the post doesn’t influence the survival of teeth. A result of Miguel Go´mez-Polo’s study approves it with the high survival rate of both prefabricated and cast metal posts in 10 years in retrospective study [32]. This is also comparable with the results reported in other studies [45]. Like in one of the retrospective study where 516 teeth were restored with a cast post and core build-ups and were followed from 1970 till 1990, the survival rate was found to be 82% after 10 years for post and cores in the anterior region [46].

3.6. Failures of endodontically treated teeth with post- core supported restorations

As any restoration, fiber post reinforced teeth can have complications. So what are the most common failures we can see in 12 analyzed clinical studies? Success rate results have a big range of analyzed clinical studies’ results. Above was mentioned that success rate is defined as the outcome rate in absence of absolute and relative failures (relative failures: endodontic failure, post debonding

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27 and fracture, core fracture, final restoration failure; absolute: root fracture). Totally about 312 failures out of the 1812 teeth occurred in these studies (tab. 8). From all 12 analyzed studies can be seen that survival rate stays high because teeth restored with glass fiber posts dominantly had relative failures (59 post debonding of the post-core, 37 post fractures, 19 core fractures, 16 final crown displacements and 12 recurrent/secondary caries) , also called favorable failures. Also nicely illustrated in B. Willershausen’s study that endodontic problem is the most common complication [36]. Only about 9 % of all failures were root fractures that were followed by tooth extraction and had decreased the survival rate. But if to compare with more results of metal posts studies, they don’t show a significantly higher rate of absolute failures; like in M. Go´mez-Polo’s study root fractures also have the lowest rate from all failures [32].

3.7. Drop-out rates in clinical studies

In consideration should be taken that it was found that not so many clinical studies with long observational period exist, probably due to great difficulty in performing standardized studies in

vivo [44]. Also, many studies told that they had high drop-out rates of posts restorations from

follow-ups. So drop-out rates were reported by 7 studies, being 29.3 % in glass fiber group and 41.3 % in titanium post group in M. Naumann’s study (2017), 2.3 % from A. Signore’s study, 7.7 % from R. Sarkis-Onofre’s study, 12.3 % from M. Ferrari’s trial, and 12.5% from KA. Guldener’s trial, 12.2 % from K. Bitter’s trial, 5.1 % from M. Naumann’sclinical study (2012) [44, 27, 16, 20, 37, 28, 21]. These patients had either died or could not be found because they changed their home address or their name, or no compliance the call, or they no longer were interested in participating.

3.8. Benefits of glass and quartz fiber posts restorations

Speaking about less invasive removal, the fiber post also respect the conservative and minimally invasive post space preparation, since it benefits from both micro- and macro-retention which enables it to be seated to only a half root depth to acquired proper bonding, unlike metal post that needs deeper space preparation with macro-retention such as ridges and grooves [49].

Lastly, among many benefits, is the aesthetics which is standard norm especially in the esthetic zone, which the fiber post-systems fulfill, unlike metal ones. [50, 51].

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CONCLUSION

Based on analyzed randomized clinical trials and prospective/retrospective observational clinical studies, those are not older than 10 years and with short and medium observational periods, can be concluded:

1. Survival rate of endodontically treated teeth with fiber post supported restorations is high enough to expect a good prognosis, which ranges from 55% to 100% in the period till 11 years, but with the prevalent range from 86 % to 100%.

2. Uniquely is determined that clinical key factors as the presence of at least one remaining cavity wall or presence of ferrule increase the success and survival rate of endodontically treated teeth with fiber-reinforced posts compared with its absence.

3. In case of complications of endodontically treated teeth with fiber post supported restorations, the most failures are relative failures such as endodontic failure, post debonding and its fracture, core fracture, and final restoration failure. These relative failures can be fixed and in order this increases the survival rate.

4. But even with all its advantages, it couldn’t be told that fiber posts are better than metal, as the clinical studies’ results showed as well good outcomes of teeth restored with metal posts. Anyways glass or quartz fiber posts are good alternatives to the metal post.

PRACTICAL RECOMMENDATIONS

If we rely on conclusions of clinical trials best recommendations for the fiber post restorations are:

1. To make first of all a precise diagnosis. 2. To follow indications such as

- need for an aesthetic translucency,

- the remaining of coronal tooth structure is inadequate for retention of the restoration, - preparation of at least 1.5 mm of a ferrule.

3. Cementation of final coronal restoration as soon as possible in order to prevent the risk of bacterial infection, with the preference for the indirect restoration.

4. According to patient financial possibilities and desire, to choose the best treatment plan and during treatment follow the protocol for the particular treatment.

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31 26. Juloski J, Fadda GM, Monticelli F, Fajó-Pascual M, Goracci C, Ferrari M. Four-year Survival of Endodontically Treated Premolars Restored with Fiber Posts. J Dent Res. 2014; 93(7 Suppl):52S-58S.

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32 38. Parisi C, Valandro LF, Ciocca L, Gatto MR, Baldissara P. Clinical outcomes and success rates of quartz fiber post restorations: A retrospective study. J Prosthet Dent. 2015; 114(3):367-72.

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33 50. Savi A, Manfredi M, Tamani M, Fazzi M, Pizzi S. Use of customized fiber posts for the aesthetic treatment of severely compromised teeth: a case report. Dent Traumatol. 2008; 24(6):671-5.

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34 Annex No. 1

Protocol for systematic review according to PRISMA-P

TITLE Survival rate of endodontically treated teeth with fiber post–supported restorations: a systematic review.

INTRODUCTION

Aim - to analyze clinical data about the survival rate of endodontically treated

teeth with fiber post–supported restorations in order to see if it can be better alternative treatmeant to metal posts.

Tasks - To collect information about survival rate of endodontically treated teeth

with fiber post supported restorations

- To collect and discuss clinical data/clinical key factors that can influence on success and survival rate of endodontically treated teeth restored with fiber post system.

- To discuss possible complications related to fiber post-systems.

- To compare outcomes of endodontically treated teeth restored with fiber post and metal post system

METHODS

Eligibility criteria PICOS:

o P- Participants: patients that have or need endodontic treatment o I- Intervention: post core system intervention;

o C- Group of treatment: anterior and posterior endodontically treated teeth with different amount of remaining cavity walls

o O- Success / Survival rate outcomes;

o S- Study design selection: clinical trials and studies Inclusion criteria:

1. scientific articles of randomized clinical trials and observational clinical studies,

2. articles are not older than 10 years, 3. published in English,

4. studies performed on humans, 5. in vivo. Exclusion criteria: 1. studies in vitro, 2. studies on animals, 3. abstracts, 4. case reports, 5. author debates, 6. summaries 7. systematic reviews

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Information sources

. Electronic databases: SienceDirect, ReasearchGate, Pubmed, WileyOnline.

. Key words: glass fiber post, endodontically treated teeth, survival, and clinical trial.

. Time frame: December 2017 – April 2018

Study selection . Searching by entering the key words in few combinations and according chosen including criteria.

. Screening with excluding duplicates;

. Eligibility according exclusion criteria: studies in vitro, studies on animals, abstracts, case reports, author debates, summaries, systematic reviews and lack of relevant details.

. Double-checking articles that were included in systematic review by supervisor (Rimantas Ožiūnas).

Outcomes and prioritization

. Assessing success and survival rates of endodontically treated teeth with fiber post–supported restorations in relation to different clinical key factors (type of tooth, remaining cavity walls, presence of ferrule, coronal final restoration, etc.).

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SURVIVAL RATE OF ENDODONTICALLY TREATED TEETH WITH FIBER-POST SUPPORTED RESTORATIONS: A SYSTEMATIC REVIEW

Alina Ismailova