1
Jyothis Jose Thannippara
2021, V year, Group 12
PREVALENCE OF COMPLICATIONS IN TEETH,
RESTORED WITH GLASS FIBER POST COMPARED
WITH METAL CAST POST, SYSTEMATIC REVIEW.
Master’s ThesisSupervisor
Dr. Tadas Venskutonis
2 MEDICAL ACADEMY
FACULTY OF ODONTOLOGY CLINIC
DEPARTMENT OF DENTAL AND ORAL PATHOLOGY
PREVALENCE OF COMPLICATIONS IN TEETH, RESTORED WITH GLASS FIBER POST COMPARED WITH METAL CAST POST, SYSTEMATIC REVIEW.
Master’s Thesis
The thesis was done
by student ... Supervisor ...
(signature) (signature)
... ...
(name surname, year, group) (degree, name surname)
... 20…. ... 20….
(day/month) (day/month)
3
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: ...
Compliance with MT
No. MT parts MT evaluation aspects 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 point s)
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)?
4
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 0.2 0.1 0
information is to be used in data synthesis, described?
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
16
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
5
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
recommendations
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?
+2 +1 0
General requirements, non-compliance with which reduce the number of points
33
General requirements
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
6
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 subsections 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.
7
TABLE OF CONTENTS
ABBREVIATIONS ... 8 ABSTRACT ... 9 SANTRAUKA ... 10 1.INTRODUCTION ... 112.SEARCH METHODS AND STRATEGY ... 13
2.1 Protocol and registration ... 13
2.2 Types of publications ... 13
2.3 Data collection ... 13
2.4 Literature search and screening ... 14
2.5 Selection of articles ... 14
2.6 Inclusion and exclusion criteria ... 14
3.SYSTEMATIZATION AND ANALYSIS OF DATA ... 16
3.1 Search Results ... 16
3.2 Characteristic of research ... 18
3.3 Risk of Bias ... 23
4.DISCUSSION ... 25
5.CONCLUSION ... 28
6.ACKNOWLEDGMENT AND DISCLOSURE STATEMENT ... 28
7.PRACTICAL RECOMMENDATIONS ... 28
8
ABBREVIATIONS
AFR- Annual failure rate
ETT – Endodontically treated teeth. CI – Confidence intervals
RCT- Randomized control trials RR – Risk Ratio
9
ABSTRACT
Objectives: to review complications which are presented when the tooth is restored with glass
fiber post compared with metal cast post.
Search Methods and Strategy: A literature search was performed on Medline (Pub Med)
and Cochrane Library, databases from 2010 to December 2021. The keywords used for the search are as follows; Glass fiber posts, Metal Cast posts, Root Canal Fracture and
Complications.
Results: A total of 1453 articles were obtained after the initial search and after analysis and
elimination, 4 articles were enrolled in this systemic review. Two types of posts; glass fiber posts and metal cast posts were analysed and compared with each other. The evaluation revealed that a total number of 335 teeth were treated which was also observed with follow up period in all 4 articles. Overall, there was a total number of 41 failed posts, in which 21 were glass fiber posts and 17 were metal cast posts. Also, 13 teeth which were treated with post and core were revealed to have root fractures as a form of complication. The 4 articles extracted shows that both types of posts had similar clinical performance.
Conclusion: The study presented limited number of studies in which to investigate the topic
matter. The sample size has a greater influence on the reliability of the study as the studies presented showed minor to no differences between the complications of metal cast and glass fiber posts. The results of this present systematic review are based on RCT and clinical trials. It conferred that glass fiber posts had a greater failure rate than metal cast posts, however the results are not sufficient as more clinical trials should be conducted to conclude a potential statistically significant difference between the metal cast and glass fiber posts.
10
SANTRAUKA
Tikslai: apžvelgti komplikacijas, kurios atsiranda, kai dantis atstatomas stiklo pluošto kaiščiu,
palyginti su metaliniu lietu įklotu.
Paieškos metodai ir strategija: Literatūros paieška buvo atlikta „Medline“ („Pub Med“) ir
Cochrane'o bibliotekoje, duomenų bazėse nuo 2010 m. Iki 2021 m. Gruodžio mėn. Raktiniai žodžiai: Stiklo pluošto kaištis, metalinis lietas įklotas, šaknies kanalo lūžis ir komplikacijos.
Rezultatai: Iš viso po pradinės paieškos buvo gauti 1453 straipsniai ir iš viso 4 straipsniai
buvo įtraukti į šią pateiktą sisteminę apžvalgą. Dviejų tipų kaiščiai: stiklo pluošto kaiščiai ir metalinis lietas įklotas buvo analizuojami ir lyginami tarpusavyje. Vertinimas parodė, kad iš viso buvo gydomi 335 dantys, kurie taip pat buvo stebimi visuose 4 straipsniuose. Iš viso buvo 41 nesėkmingas kaištis, iš kurių 21 kaištis buvo stiklo pluošto ir 17 kaiščių buvo metaliniai. Be to, iš 13 dantų buvo atstatyti kaiščiai, buvo nustatyta šaknies lūžiai. Analizuotuose 4 straipsniuose duomenis rodo panašią klinikinę sėkme.
Išvada: Tyrime buvo rastas ribotas skaičius tyrimų, kuriuose buvo analizuota tiriama tema.
Imties dydis turi didesnę įtaką tyrimo patikimumui, nes pateikti tyrimai parodė, kad tarp metalinių lietų ir stiklo pluošto kaiščių komplikacijų nėra jokių skirtumų. Šios sisteminės apžvalgos rezultatai yra pagrįsti randomizuotais klinikiniais ir klinikiniais tyrimais. Joje nustatyta, kad stiklo pluošto kaiščiai turėjo daugiau komplikacijų nei metaliniai lieti kaiščiai, tačiau rezultatų nepakanka, nes reikėtų atlikti daugiau klinikinių tyrimų, kad būtų galima rasti statistiškai reikšmingą skirtumas tarp metalinių ir stiklo pluošto kaiščių.
Raktiniai žodžiai: Stiklo pluošto kaištis, Metalinis lietas įklotas, Komplikacijos, Šaknų
11
1. INTRODUCTION
The main function of a post and core is to provide retention for the core and facilitate full sealing of the coronal sections of the root canal. Metal cast posts are often used; however, they do not meet the requirements needed for modern dental medicine. Many factors could contribute to this drawback such as colour of teeth, possible corrosion and high modulus of elasticity which can lead to root fracture [1]. Dentists frequently place post and core to build-up endodontically treated crown abutments on teeth which have bridge restoration that may have suffered excessive material loss [2, 3]. The most common complications in teeth which are restored with a post, are vertical root fractures (VRF) [4]. VRF is characterized as a longitudinal fracture of the root that originates on the internal canal wall and spreads through the root dentine towards the external root surface [5]. VRF is common and often a highly damaging result to the structure and functionality of the tooth. After identifying the VRF, the treatment plan is uncomplicated; if it is a single rooted tooth, the tooth is recommended to be either extracted or if it is a molar tooth it is recommended for root amputation, or a hemi-section should be performed.
According to the American Association of Endodontists’ Glossary of Endodontic terms, the VRF is an incomplete fracture in the root that may happen buccolingually or mesiodistally; this then may cause periodontal defects and may be evident radiographically. VRF can be also described as being confined to the root. It can be classified as either complete or incomplete [6]. Major functions of post and core is to serve stability to restored tooth and to protect the tooth by evenly distributing and spreading mastication forces along the tooth. Metal post and core have been used since 1980 and currently are still being used till this day, as a form of restoration for endodontically treated tooth. However, in modern odontology, there is an increase demand for a more aesthetic and greater physical properties which has led to the popularity of glass fiber post [7].
Considering the treatment for endodontically treated teeth (ETT), having no residual coronal walls could potentially cause difficulty in restoring the tooth. Therefore, coronal walls are important for such treatments. The use of posts and its association with crowns are essential factors to consider when restoring ETT. The use of intraradicular post is an essential method for retaining coronal restorative material [8, 9,10]. Usually, posts can be classified based on their elastic modulus. Metal posts (metal cast or prefabricated post), ceramic posts and carbon fiber post, have high values of elastic modulus. However, glass fiber posts presents low elastic modulus. Depending on the material in which the posts are fabricated , it can present different mechanical behaviours [11, 12].
12 The aim of this systematic review is to analyse the outcomes of the randomized controlled trials (RCT), clinical trials and cohort studies evaluating the post and core materials; metal cast post and glass fiber post. This review also analyses the failure of the treatment during the follow up periods, which allows for a better perception on the clinical performance of the glass fiber posts and metal cast posts regarding its success rate. The hypothesis concludes that there will be more tooth failures on metal cast posts in comparison to glass fiber posts. Aim of the work:
1. To evaluate failures and complications regarding metal cast and glass fiber posts. 2. To analyse the success rates regarding clinical performance of metal cast and glass
13
2. SEARCH METHODS AND STRATEGY
2.1 Protocol and registration
The systematic review has been presented according to PRISMA STATEMENT (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, which was specified prior to analysis of the studies included.
Clinical questions were separated and organized using the PICO strategy. Table 1. PICO table
Component Description
Population Patients who have completed endodontic
treatment along with placement of post and core.
Intervention Fiber Glass Posts after root canal treatment
Comparison/ Control Metal cast post after root canal treatment
Outcome The frequency of post and core failures and
the success rate.
2.2 Types of publications
The systematic review is based on the selection and identification of main information sources and literature studies performed from electronic databases. The review included studies based on human, and which was published in English language.
2.3 Data collection
The information and articles were gathered from two electronic online databases: Pub Med and Cochrane Library. The citations were read and verified, and the articles related to the topic were qualified.
14
2.4 Literature search and screening
The protocol for this systematic review was carried out according to the PRISMA guidelines within, Pub Med and Cochrane Library database using various combinations of the keywords listed in Table 2.
Table 2. Summary of keywords combinations
Name of database and last search dates
Keywords used Results
Pub Med ((((glass fibre post) AND
(metal cast post)) OR (complications[MeSH Terms])) OR (root canal fracture[MeSH Terms])) OR (root canal[MeSH Terms])
3135
Cochrane Library All text: glass fibre post Or: root canal
Or: root canal fracture And: Metal Cast Post
234
2.5 Selection of articles
The literature chosen for this review was selected in several stages. The first stage was the identification of articles according to keywords as mentioned above (Table 2). Then any duplicates between the databases were removed. Additional filters were also applied such as: last 10 years, human studies, English language and fell-text available. The last stage after the full-text analysis was to further evaluate the articles by assessing their relevance and
adherence to the selection criteria and those that fit the criteria were included in this systematic review.
2.6 Inclusion and exclusion criteria
The search engine of PubMed and Cochrane Library databases were searched. The final stage of screening involved articles from the respective databases involving full text review.
15 Thorough evaluation of the articles was done to certify study eligibility upon the inclusion and exclusion criteria presented down below:
Inclusion criteria
• Articles written in the English language.
• Articles that have been published in the last 10 years. • Studies about Glass fiber posts
• Studies about Metal cast posts • Articles involving root fractures
• Studies performed on human patients only
Exclusion criteria
• Publications older than 10 years
• Publications in languages other than English • Studies performed on animals
• Studies that do not include vertical root fractures • Reviews
16
3.SYSTEMATIZATION AND ANALYSIS OF DATA
3.1 Search Results
There was an initial total of 3369 articles found to review of the subject. The software Zotero (George Mason University, USA) [13]was used to manage the articles and identify any studies that was duplicated while doing the search. 144 articles were found to be duplicates and hence was rejected. From the remaining 3225 articles, 105 articles were excluded due to the language not being English and 2809 articles were also excluded as it was non-clinical trials. 311 full-text articles were assessed for eligibility. Of the 311, 307 full-text articles were further excluded as they were not relevant to the topic of study for this systematic review. After reviewing and analysing the remaining full-text articles according to the inclusion and exclusion criteria, 3 studies were selected to be included. A manual search was also conducted to find the additional resources related to the study. In the manual search, 1 extra article was found that was included. The whole article selection procedure was done according to the PRISMA method and can be seen depicted as a flow chart in Figure 1.
17
Figure 1. PRISMA flow diagram
Records identified through database searching (Pub Med
and Cochrane Library. (n =3369)
Scree
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In
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ib
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it
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Records after duplicates removed (n =3225) Records screened (n =3225) Records excluded: • Not in English: (n= 105) • Non-Clinical Trial = (n= 2809) Full-text articles assessed for eligibility
(n =311)
Full-text articles excluded, with reasons:
• Content not relevant: (n = 307) Studies included in qualitative synthesis (n = 4) Manual search (n = 1)
18
3.2 Characteristic of research
Table 3. Characteristics of included studies.
Researcher Study design
Sample size Coronal wall Study group Gender Age group Observatio n period R.Sarkis-Onotre et al (2020) [14] RCT 119 patients 183 teeth: Anterior:90 Posterior:93
Anterior/ posterior ETT without coronal wall or 1 wall in enamel without dentine support (Ferrule height, 0-0.5 mm) Metal cast: 72 Glass fiber: 111 23 males 96 females 45.1+-11.8 12 months 62 months Olaide S. Gbadebo et al (2014) [15] RCT 30 patients 40 teeth Anterior: 29 Posterior: 11 Minimum of 2 mm coronal tooth structure Group 1- Metal cast: 20 Group 2 -Glass fiber: 20 - 38.2+-16.8 1 month 6 months R.Sarkis-Onotre et al (2014) [16] RCT 54 patients 72 teeth Anterior: 40 Posterior: 32
No remaining coronal wall or Enamel portion of one wall with no dentinal support (ferrule height, 0-0.5 mm) Metal cast: 35 Glass fiber: 37 9 males 45 females 42.7 +- 11.2 6 months 12 months 24 months 36 months
19 Table 3 presents study characteristics such as: authors, study design, sample size, coronal wall, study group, gender, age group and observation period of all the RCT and clinical study of glass fiber and metal cast post.
Roshan Uthappa et al (2015) [17] Clinical study 40 root canals treated. Anterior: 14 Posterior: 26 - Group 1- Metal cast: 20 Group 2 - Glass fiber: 20 - 18-25 6 months
20
Table 4. Summary of glass fiber post and metal cast post failures - randomized controlled the trial.
In the study conducted by R.Sarkis-Onotre et al [14] a total of 119 patients was presented. Of which, 111 cases were glass fiber posts and 72 cases were presented with metal cast posts which were evaluated after 9 years of follow-up. Larger number of glass fiber posts was seen on patients compared to metal cast posts. In this study, 23 patients were male and 96 were female. Kaplan- Meier graph was used in determining the success and survival of both posts.
Authors Clinical evaluation of the tooth R.Sarkis-Onotre et al (2020) [14] Olaide S. Gbadebo et al (2014) [15] R.Sarkis-Onotre et al (2014) [16] Roshan Uthappa et al (2015) [17]
Crown debonding Glass fiber: 6 Metal cast: 0 Glass fiber: 0 Metal cast: 0 Glass fiber: 0 Metal cast: 0 Glass fiber: 0 Metal cast: 0 Root fracture Glass fiber: 7
Metal cast: 3 Glass fiber: 0 Metal cast: 0 Glass fiber: 2 Metal cast: 1 Glass fiber: 0 Metal cast: 0 Post debonding Glass fiber: 2
Metal cast: 1 Glass fiber: 0 Metal cast: 0 Glass fiber: 0 Metal cast: 0 Glass fiber: 0 Metal cast: 0 Crown & post
debonding Glass fiber: 1 Metal cast: 1 Glass fiber: 0 Metal cast: 0 Glass fiber: 2 Metal cast: 2 Glass fiber: 0 Metal cast: 0 Secondary caries Glass fiber: 1
Metal cast: 0 Glass fiber: 0 Metal cast: 0 Glass fiber: 0 Metal cast: 0 Glass fiber: 0 Metal cast: 0 Endodontic failure Glass fiber: 1 Metal cast: 0 Glass fiber: 0 Metal cast: 0 Glass fiber: 0 Metal cast: 0 Glass fiber: 0 Metal cast: 0 Mobility of the crown Glass fiber: 0 Metal cast: 0 Glass fiber: 1 Metal cast: 1 Glass fiber: 0 Metal cast: 0 Glass fiber: 0 Metal cast: 3 Marginal integrity Glass fiber: 0
Metal cast: 0 Glass fiber: 1 Metal cast: 1 Glass fiber: 0 Metal cast: 0 Glass fiber: 0 Metal cast: 2 Failure of core Glass fiber: 0
Metal cast: 0 Glass fiber: 0 Metal cast: 0 Glass fiber: 0 Metal cast: 0 Glass fiber: 0 Metal cast: 2
21 The log-rank test for both analysed results did not show or present any statistically significant difference for the survival rate and success. In the results, the cox regression model was also presented. All the variables tested was found to show no statistically significant variance. The ARF (annual failure rate) of both glass fiber posts and metal cast posts after 5 years was 1.5%, in which metal cast posts presented AFR of 1.2% and glass fiber posts presented AFR of 1.7%. The anterior and posterior teeth presented AFR of 0.5% and 2.5% respectively. Table 4 presents the failure of both posts by clinical evaluation of the teeth. In the article of R.Sarkis-Onotre et al [14] 23 post failures were observed. There were 17 failures observed which were associated with glass fiber posts and 6 that were associated with metal cast posts. Majority of the failures were found in the posterior teeth. 16 failures were presented within the 23 teeth which was treated. Out of the 23 posts, 10 posts had root fractures. 7 of which were glass fiber posts and only 3 of which was metal cast posts.
In the article which is conducted by Olaide et al [15] there were significantly fewer number of patients who had post and core treatment. This randomized clinical study is presented in Table 3. The study evaluated 153 patients, out of which only 30 patients had met the inclusion criteria with 40 teeth evaluated overall. Majority of the teeth (72.5%) within this study were located in the anterior teeth and 10% of which were located in the molars.
The results were divided into two groups; group 1 included metal cast posts and group 2 consisted of glass fiber posts. There were two follow-up periods which was recorded, the first one was after 1 month after the treatment and the second follow up was after 6 months. Out of the 40 teeth clinically evaluated, only 38 teeth were observed at the 1 month follow up.
At the end of the 6-month period, a total of 10% and 5.6% marginal failure was observed in both group 1 and 2 respectively. However, there was no significance shown statistically with the difference in the marginal integrity of the teeth in both groups. Contrary to R.Sarkis-Onotre et al (14), in this study, there was no presence of root fracture occurring within the 40 teeth treated with either metal cast or glass fiber posts.
In the study done by Olaide et al [15], the Kaplan – Merier survival graph was used to record the survival rate of both types of post and core. Investigating the survival of both post and core, showed that there was no statistical difference of survival after 6 months. The Kaplan-Merier curves demonstrated that the two groups have parallel results for a 6-month period. During this period, it was revealed that both metal cast and glass fiber posts behaved equally indicating that there was no significant difference in survival rate.
22 Within another study by R.Sarkis-Onotre et al [16], there were 54 patients of which 9 were male and 45 were female. A total of 72 posts were placed, 40 of which were placed in the anterior teeth and 32 were placed in the posterior teeth. The 72 posts were divided according to the type, which were glass fiber and metal cast posts. 37 glass fiber posts were placed, of which 21 was placed on the anterior teeth and 16 placed on the posterior teeth. The remaining 35 metal cast posts consisted of 19 posts that were placed on the anterior teeth and 16 posts placed on the posterior teeth. After the 6 months follow up period, all 72 teeth were evaluated. However, only 53 were evaluated after 12 months and 26 teeth were observed after 36
months.
In this randomized control trial, there were 4 teeth which were observed with de-bonding failure. Two glass fiber posts which were placed in the anterior maxillary teeth and two placed in the premolars de-bonded after 8 and 26 months respectively. In table 4, there were 2 root fractures presented, which had occurred on the premolar tooth with glass fiber post and on a molar tooth with metal cast post. This complication occurred after 15 months for the premolar tooth and 20 months for the molar tooth.
The clinical study conducted by Roshan Uthappa et al [17] evaluated 40 teeth which were treated by root canal treatment. 20 teeth were treated with metal cast posts and the remaining 20 were treated with glass fiber posts. A total of 11 posts were placed in the incisors, 3 placed in the canine, 23 placed in the premolars and 3 placed in the molars. The observation period for this clinical study was 6 months and a further follow up was conducted afterwards.
When the clinical evaluation was completed (refer to table 4), 3 patients that were treated with metal cast posts showed mobility of crown, 2 metal cast posts showed marginal integrity and 2 metal cast posts showed a failure of core after 6 months of observation. After examination of glass fiber posts’ treatment outcomes, there was no complications recorded.
23
3.3 Risk of Bias
Table 5. Risk of bias assessment
The Cochrane risk of bias tool (18) was used to assess the risk of bias of the 3 articles listed on Table 5. All studies are included except for Roshan Uthappa et al (2015) [16] since it is a cohort study, therefore the JBI critical appraisal (19) was used as seen in Table 6.
Author/year Random sequence generation Allocation concealment Blinding of participants and personnel Blinding of outcome assessment Incomplete outcome data Selective reporting Other sources of bias R.Sarkis-Onotre et al (2020) [14]
Low risk Low risk Low risk Low risk Low risk Low risk Low risk
Olaide S. Gbadebo et al (2014) [15]
Low risk High risk Unclear risk Unclear risk Low risk Unclear risk Low risk
R.Sarkis-Onotre et al (2014) [16]
24
Table 6. Risk of bias assessment continued
JBI CRITICAL APPRAISAL CHECKLIST FOR COHORT STUDIES
Author/year
Roshan Uthappa et al (2015) [17]
Were the two groups similar and recruited from the same population? Yes Were the exposures measured similarly to assign people to both
exposed and unexposed groups?
Yes
Was the exposure measured in a valid and reliable way? Yes
Were confounding factors identified? Not Applicable
Were strategies to deal with confounding factors stated? Not Applicable Were the groups/participants free of the outcome at the start of the
study (or at the moment of exposure)?
Yes
Were the outcomes measured in a valid and reliable way? Yes Was the follow up time reported and sufficient to be long enough for
outcomes to occur?
Yes
Was follow up complete, and if not, were the reasons to loss to follow up described and explored?
Yes
Were strategies to address incomplete follow up utilized? Yes
25
4. DISCUSSION
In the systematic review presented, all the studies were well-designed, randomized control trials with low risk of bias (refer to Table 5 and 6) resulting in satisfactory quality of evidence for the primary outcome.
In the 4 articles [14-17] used in this systematic review, a total number of 335 teeth were analysed with regard to the treatment and observed with follow-ups. Within the 335 teeth which was treated, 41 teeth presented with failure of treatment by the exhibited complications. Additionally, of those 41 teeth that had showed signs of treatment failure, 24 were glass fiber posts and 17 were metal cast posts failures. The accuracy of the results presented in this review is supported through a recent systematic review study [20] that established that glass fiber posts showed higher medium-term (3 to 7 years) overall survival rates (RR 0.57, 95% CI:0.33 to 0.97, P=.04) when compared with metal cast posts.
An observational clinical study was organised in 2005 by Naumann et al. [21] about the survival of composite posts reinforced by glass fiber after 2 year follow up. There were a total number of 83 patients and in this study, there were 105 glass fiber reinforced posts that were placed among the patients. A failure rate of 3.8% of the posts after 12 months and 12.8% after 24 months was found to be the evaluated results.
One of the main complications observed during these studies was root fractures. Table 6 shows the summary of glass fiber and metal cast posts failures. As shown in the table, the most recurring complication observed was root fracture. There were 13 root fractures that were identified as a complication throughout the 4 articles used for the study. 9 root fractures occurred due to placement of glass fiber posts and another 4 root fractures occurred due to the placement of metal cast posts.
A systematic review and meta-analysis [22] explored the findings of Figueiredo et al. and it revealed a similar occurrence of root fracture when comparing both metal and fiber posts to prefabricated metal cast and carbon fiber posts. These studies presented the conclusion that prefabricated metal cast and carbon fiber posts had a two-fold increase in the rate of root fracture when compared to metal cast post and glass fiber post.
In two of the RCT studies evaluated by R.Sarkis-Onotre et al (14) (16), two of the complications was crown and post de-bonding. Although there was no difference found between different post types, 11 of the 15 failures involving de-bonding was of glass fiber posts. Adhesive failure is one of the most common reasons of de-bonding and can lead to
26 failures in tooth restoration using adhesive luted endodontic posts. [23] It is commonly
associated with adhesive technique problems such as inadequate polymerization. Most of the time failures associated with de-bonding can result in root fractures. [24] In both studies all the post and cores was luted with self-adhesive resin cement, which has been used widely, since it is easy to handle along with having good moisture tolerance. [25] Therefore, it does not require acid etching or adhesive step. [26]
On the other hand, in the study by Olaide S. Gbadebo et al [15] there were no mention of any failures of crown and posts de-bonding. In this study the usage of self-etch primer (Bond boost: Premier Co.,Ltd) was applied in the canal and also dentin adhesive was applied both inside the canal and on the surface of the post which was solidified using a light cure. The 3 randomized control trials and 1 clinical trial [14-17] showed both glass fiber and metal cast posts performed similarly. These results are supported by Fedorowicz et al and Bolla M et al systematic reviews, [27, 28] which observed no suggestion of any other methods that is used to restore a tooth that has been treated endodontically. In the study conducted by
Heydecke et al [29], comparison of treatments in both clinical and in vitro execution of metal cast and prefabricated posts confirmed that there were no evidence indicating any favour to any post. Nevertheless, there are only few studies which has been well designed to evaluate post survival. Primarily, it is due to the method of analysis used for the randomized control trail. It can be concluded that a great amount of work is needed and such studies can be expensive to conduct. [30]
In the systematic review conducted, all the 4 articles had a follow up period between 1 month up to 9 years. A conclusion can be formed that ETT restored with different types of posts could have the possibility of different mechanical behaviours. The articles mentioned within the study show that metal cast and glass fiber posts show similar clinical performance but glass fiber posts had slightly more chance of complications.
In the study undertaken by Roshan Uthappa et al, [17] the ferrule setting was not mentioned hence there could possibility of clinical discrepancy. The results of Skupien et al., revealed that in a recent meta-analysis review, the effects of the ferrule can influence the survival of ETT. [31] Within the study, it was found that teeth without a ferrule enhanced lower fracture resistance. Whereas the higher the height of ferrule, the greater the fracture resistance. In another study regulated by Fontana PE et al, it refers to the effect of ferrule thickness and on how it has an impact on fracture resistance when the tooth is being restored with glass fiber posts and cast posts. This study concluded that a thicker ferrule had a significant increase in
27 fracture resistance. This is only applicable when the ferrule thickness is at least 1mm for cast post and core. To reduce the chances of unwanted failures and complications, the ferrule thickness should also be considered when choosing which kinds of post and core is best suited for the patient. If there is an absence of desired ferrule thickness, the usage of a metal cast post and core can have occurrence of more failures. The best clinical results are demonstrated whilst there is presence of 1mm thickness of ferrule when using glass fiber post [32].
28
5. CONCLUSION
The results of the present systematic review are based on RCT and clinical trials. It is conferred that glass fiber posts had more failures than metal cast posts. Nonetheless, both posts showed reliable clinical performance. There are a limited number of studies which investigates this topic of matter. The sample size has great influence on the reliability of the study as the studies presented showed minor to no differences between the complications of metal cast and glass fiber posts.
The hypothesis concluded that there will be more tooth failures on metal cast posts in comparison to glass fiber posts. In this review it showed the results presented otherwise but without a statistically significant difference so therefore a greater number of clinical trials should be conducted in order to prove or disprove that there is a potential difference
statistically between the failures of metal cast and glass fiber posts. Depending on the clinical case presented, analysis of success rate and evaluation of complications can lead to further understanding of which type of posts should be used as there are different variables affecting each treatment protocol.
6. ACKNOWLEDGMENT AND DISCLOSURE STATEMENT
The author declares that there are no financial or other conflicts of interests related to this systematic review. I would like to express my deep appreciation to Dr Tadas Venskutonis for all the expert guidance and relentless support. I would also like to thank my Mum and Dad for the great support that they have given me throughout my dental studies. Also, my deepest gratitude to my sister Sharon Maria Jose for believing in me and keeping me motivated throughout the process of writing this thesis.7. PRACTICAL RECOMMENDATIONS
The results throughout the 4 studies used in this systematic review are the same between both metal cast and glass fiber post. There is no statistically significant difference between metal cast and glass fiber posts which concluded that data is inconclusive to decide. Furthermore, analysis of success rate and evaluation of complications can lead to further understanding of which type of post and core (metal cast or glass fiber) needs to be considered for each patient.
29
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