Review Article

Do Metal Postretained Restorations Result in More Root

Fractures than Fiber Postretained Restorations?
A Systematic Review and Meta-analysis
Fabr
cio Eneas Diniz Figueiredo, DDS,* Paulo Ricardo Saquete Martins-Filho, PhD,
and Andr
e Luis Faria-e-Silva, PhD*
Abstract
Introduction: Teeth requiring endodontic treatment
commonly have compromised a coronal tooth structure
that often requires the use of an intraradicular post to
retain the coronal restoration. Although usually successful, catastrophic failures requiring extraction have been
reported in the literature. The aim of this systematic review was to analyze clinical trials and cohort studies that
evaluated the incidence rate of root fractures in postretained restorations. The hypothesis was that the incidence rate related to the use of metal posts was higher
than that of fiber posts. Methods: A MEDLINE search
for clinical studies reporting the incidence of root fractures of restorations retained with fiber posts or metal
posts of endodontically treated teeth with a more than
5-year follow-up was conducted from inception to
January 2014. Seven randomized clinical trials and 7
cohort studies were included. Results: The pooled survival rate was 90% (95% confidence interval, 85.5
93.3) for metal-based posts and 83.9% (95% confidence
interval, 67.692.8) for fiber-reinforced posts. The overall incidence rate of root fractures (catastrophic failures)
was similar between metal and fiber posts. Prefabricated metal posts and carbon fiber posts had a 2-fold increase in the incidence rate of root fractures compared
with cast metal posts and glass fiber posts, respectively.
Conclusions: The results of this study did not show significant differences for root fracture incidence between
metal- and fiber posts. However, the studies included
in this review presented a high risk of bias, and further
well-designed clinical studies are required to confirm
these findings. (J Endod 2015;-:18)

Key Words
Dental restoration failure, endodontically treated teeth,
meta-analysis, post and core technique

From the Departments of *Dentistry and Health Education,

Universidade Federal de Sergipe, Sergipe, Brazil.
Address requests for reprints to Dr Andr
e Luis Faria-e-Silva,
Universidade Federal de Sergipe, Hospital Universit
ario, Departamento de Odontologia, Rua Cl
audio Batista, s/n Bairro Sanat
orio, Aracaju, Sergipe, Brazil, CEP 49060-100. E-mail
address: fariaesilva.andre@gmail.com
0099-2399/$ - see front matter
Copyright 2015 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2014.10.006

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refabricated fiber-reinforced posts have become more popular than cast posts for
clinical usage in recent years. This may be caused by enhanced esthetics and a
reduction in treatment time. Another factor may be that the elastic modulus between
fiber posts and dentin is similar, which has been related to a reduced incidence of
root fractures (1, 2). Several in vitro studies have shown that because of their high
elastic modulus, metal posts concentrate stress on the root and promote a higher
incidence of root fractures compared with fiber posts (3). In contrast, a recent study
with finite element analysis has shown that the use of fiber posts resulted in higher stress
on root structures compared with metal posts, primarily when the bonding between the
fiber posts and the root canal surface failed (ie, debonding) (4). However, the same
study showed that fiber postrestored roots were less prone to fracture because the
risk of fracture of the core and/or post is higher than that of the root.
Clinically, a reduced incidence of catastrophic failures, which does not permit the
replacement of the restoration, can be more important than the survival rate of the
restoration. However, the aim of most reviews on intraradicular posts has been to evaluate the survival rate. Thus, the aim of this systematic review was to analyze the outcome
of clinical trials and cohort studies evaluating the post-retained restorations regarding
the incidence rate of root fractures. The hypothesis is that the incidence rate of root
fractures related to the use of metal posts is higher than that of fiber posts. This study
also aimed to evaluate the clinical performance of the systems regarding their survival
rate.

Materials and Methods

A protocol of this systematic review was designed a priori and was registered in the
PROSPERO database (registration number CRD 42014007423).

Eligibility Criteria
Clinical studies reporting the incidence of root fractures of restorations retained
with fiber-reinforced composite posts or metal posts of endodontically treated teeth
were considered eligible for inclusion in this systematic review. Articles were selected
if they met the following criteria: randomized clinical trials (RCTs) and cohort studies
comparing the incidence of root fractures of metallic and fiber-reinforced composite
posts, RCTs and cohort studies in which 1 arm reported the incidence of root fracture
of 1 system, and RCTs and cohort studies with a mean/median of follow-up time of
5 years.
Studies from which we were unable to extract data for the outcomes of interest,
in vitro studies, reviews, and studies with a mean/median of follow-up time of less
than 5 years were excluded. Whenever more than 1 publication reported results for
the same group of patients, we included only the report containing the most comprehensive data to avoid the duplication of information.
Search Strategy
A MEDLINE search for RCTs and cohort studies was conducted from inception (no
limit regarding the year of publication) to January 2014 using the following key terms:
(nonvital tooth OR devitalized tooth OR pulpless tooth OR endodontically

Root Fracture of Post-retained Restorations

Review Article

Figure 1. A flowchart for the selection of systematic reviews.

treated tooth) AND (fiber post OR metallic post OR cast dowel

OR dowel OR metal post OR carbon-fiber post OR glass-fiber
post OR quartz-fiber post OR fiber-reinforced post OR post
core systems OR post and core technique) AND (exp cohort studies
OR cohort OR controlled clinical trial OR epidemiologic methods OR
clinical trial). The search also included a hand search of crossreferences from original articles and reviews to identify additional
studies that could not be located in the MEDLINE database. In addition,
dissertations and theses were searched in the OpenThesis database using a search strategy similar to the one applied in MEDLINE. No language or publication year criteria were imposed.

Data Extraction and Outcomes

Two independent reviewers screened the search results and identified studies that were potentially relevant based on the article titles and
abstracts. Relevant studies were read in full and selected according to
2

Figueiredo et al.

the eligibility criteria. Data concerning cohort studies were extracted

independently by 2 reviewers. Disagreement between the 2 reviewers
was solved either by consensus or a third reviewer.
Root fracture leading to tooth extraction was considered a catastrophic failure and defined as the primary outcome. Noncatastrophic
failures were defined as the secondary outcome and included endodontic failures (ie, failures related exclusively to the root canal therapy, but
the restoration remained intact), crown dislodgement, post debonding,
and post/core fractures (5, 6).

Assessment of Risk of Bias

The Cochrane Risk of Bias Tool was used to assess the quality of
the study methodology of eligible RCTs. The study quality was assessed
independently by 2 reviewers using the following 7 criteria: random
sequence generation, allocation concealment (selection bias), blinding
of participants and personnel (performance bias), blinding of outcome
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Review Article
TABLE 1. Summary Characteristics of Included Studies
Eligible studies
No. of unique studies
Median (IQR) follow-up (y)
Participants
Total no. of participants
Median (IQR) no. of participants
% female
Post system
Metal-based posts (no. of studies)
Fiber-reinforced posts (no. of studies)
Post years of follow-up*
Outcome (no. of events)
Root fractures
Noncatastrophic failures

Randomized clinical trials

Observational cohort studies

All studies

7
6.7 (5.97.8)

7
10.0 (8.610.0)

14
8.2 (6.610.0)

874
91.0 (59.0151.0)
54.9

2328
99.0 (78.5515.0)
68.4

3202
95.0 (75.3173.8)
65.2

4
5
7427

4
3
34 294

8
8
41 721

8
54

54
413

62
467

IQR, interquartile range.

*Estimated from the number of transplanted patients and the mean follow-up time.

Several studies provided data on multiple outcomes of interest.

assessment (detection bias), incomplete outcome data (attrition bias),

selective reporting (reporting bias), and other bias (absence of
description regarding tooth location or the amount of remaining coronal structure). The response for each criterion was reported as low risk
of bias, high risk of bias, and unclear risk of bias (7).
The cohort studies were assessed using a modified version of the
Newcastle-Ottawa Scale (8) and included evaluations of the representativeness of the sample size, selection of a comparison group (whether
participants were drawn from the same source, eg, same institution or
database), ascertainment of exposure by secure records, outcome of
interest not present at the start of the study, confounders or others factors used to match or control for in analysis, outcome assessment by
clinical and radiographic examination, adequate follow-up period for
outcome of interest ($5 years), and loss to follow-up unlikely to introduce bias. These items were not merged into a quality score. Instead, the
relevant information for each domain was tabulated to allow for greater
transparency. The Newcastle-Ottawa Scale was also assessed by 2 reviewers, and disagreement was solved by consensus or a third reviewer.

Data Synthesis and Analysis

The incidence rate of root fractures and noncatastrophic failures
was calculated by dividing the number of events by the period of risk for
all included posts during the study period per 1000 post years of followup. If the total number of posts years was not reported, it was calculated
by multiplying the number of posts under follow-up by the mean duration of follow-up. Confidence intervals (CIs) were based on the normal
approximation and calculated using the number of posts and post years
of follow-up. A constant 0.5 continuity correction was used for studies
with 0 events (9).
A meta-analysis of the crude survival rates with no adjustment for
the follow-up duration was performed by dividing the number of surviving posts by the total number of posts included during the study period.
A Kaplan-Meier analysis could not be performed because most of the
reports did not provide a precise follow-up period for each patient.
CIs were calculated using normal approximation. When the crude survival rate in a study was reported to be 100%, we used a continuity
correction with the crude survival rate set to 99%.
Statistical heterogeneity was investigated using the Cochran Q test
and I2 index. For the Q statistic, a P value <.10 was used as an indication
of interstudy variability (10). I2 was interpreted as the proportion of total variation across studies caused by the variability, and a value >75%
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was considered a measure of high heterogeneity (11). Subgroup analyses according to the study design (RCT  cohort), sample size
(<100 posts  $100 posts), and post system (metal postrestored
roots  cast metal postrestored roots, reinforced carbon fiber
postrestored roots  reinforced glass fiber postrestored roots)
were conducted to explore any potential source of heterogeneity between studies. For a meta-analysis of the survival rate, a stratified analysis according to the follow-up time was performed.
The pooled estimate of the rates was calculated using the
fixed-effects or random-effects models depending on the betweenstudy heterogeneity. In the absence of high heterogeneity, a fixedeffects model using the Mantel-Haenszel method was selected to pool
the data, assuming that there was a common effect size and that the differences between single results were caused by chance. When high heterogeneity was observed, the pooled estimates and the corresponding
95% CIs were calculated based on the random-effects model using the
DerSimonian-Laird method. In the random-effects meta-analysis model,
the rates for individual studies were assumed to vary around pooled estimates (12). The forest plot was used to present the pooled estimates and
the 95% CIs graphically. Each study was represented by a square in the
plot that was proportional to the studys weight in the meta-analysis. Twosided P values <.05 were considered statistically significant.
A funnel plot was created by plotting the individual estimates in log
units against the standard error. To assess publication bias, contourenhanced funnel plots were examined, and their symmetry was tested
using the Begg and Mazumbar rank correlation with continuity correction (13). Leave-one-out sensitivity analysis was conducted by omitting 1 study at a time and examining the influence of each individual
study on the pooled effect size (14).

Results
Search Results and Study Characteristics
The literature search resulted in 255 articles, 20 of which were
defined as potentially relevant to the current analysis. Of these, 9
were excluded in the subsequent detailed assessments for the reasons
shown in Figure 1. No dissertation or thesis was retrieved from the
OpenThesis database. Three other articles were included after searching the references and adding these articles to the remaining 11 studies,
resulting in a total of 14 studies (6, 1527) that met our eligibility
criteria and were included in the meta-analysis. The 14 studies (7
RCTs and 7 cohort studies) included in the present analysis were
Root Fracture of Post-retained Restorations

Review Article
TABLE 2. Risk of Bias of Included Studies
Quality of cohorts using the Newcastle-Ottawa quality scale
Outcome

Selection

Cohort, year

Representative
sample size

Naumann et al, 2012

mez-Polo et al, 2010
Go
Hikasa et al, 2010
Jung et al, 2007
Ferrari et al, 2007
m et al, 2006
Segerstro
Weine et al, 1991

+
+
+
+
+
+
+

Selection of
a comparison
group

Ascertainment
of exposure by
secure records

Outcome not
present at
beginning
of study

+
+
+

+
+
+
+
+
+
+

+
+
+
+
+
+
+

Confounders
and other
factors

Assessment
of outcome

Was follow-up
long enough?

+
+

+
+
+
+
+
+
+

+
+
+

Follow-up
rate $90%

+
+

Quality of RCTs using Cochrane risk of bias tool

Selection
Randomized clinical
trial, year

Random
sequence
generation

Sterzenbach et al, 2012

Ferrari et al, 2012
Signore et al, 2009
Creugers et al, 2005
Mannocci et al, 2005
Ellner et al, 2003
King et al, 2003

Unclear risk
Unclear risk
High Risk
Unclear risk
Unclear risk
High risk
Unclear risk

Performance

Detection

Attrition

Reporting

Allocation
concealment

Blinding of
participant
and personnel

Blinding of
outcome
assessment

Incomplete
outcome data

Selective
reporting

Other

Unclear risk
Unclear risk
Low Risk
Unclear risk
Unclear risk
Unclear risk
Unclear risk

High risk
High risk
High risk
High risk
High risk
High risk
High risk

Low risk
High risk
High risk
Unclear risk
High risk
Unclear risk
High risk

High risk
High risk
High risk
Unclear risk
High risk
Low risk
High risk

Low risk
Low risk
Low risk
Low risk
Low risk
Low risk
Low risk

Low risk
Low risk
High risk
High risk
Low risk
High risk
High risk

published between 1991 and 2012. The pooled population was

composed of 3202 participants and 4752 posts, with a follow-up
time of 41,721 post years. Sixty-two root fractures and 467 noncatastrophic failures were diagnosed during the study period (Table 1).

Risk of Bias
Randomization and allocation concealment procedures were
inadequate or unclear in the trials included in the systematic review.
Failures in randomization and allocation concealment allow the clinician to predict the upcoming treatment allocation, thereby leading to
selection bias. In addition, except in the study performed by Sterzenbach et al (26), neither the patients nor the investigators were blinded
to the treatment received, and the trials were classified as having a high
risk of performance and detection bias. Only 1 study (16) had no attrition bias, and a low risk of reporting bias was observed for all trials. The
absence of descriptions regarding the amount of coronal remaining
and/or tooth location was also considered a bias. The quality assessment of the included trials is shown in detail in Table 2.
The risk of bias among cohort studies is reported in Table 2. The
sample size was considered representative in all cohort studies, but in
only 3 studies (17, 19, 20) was a comparison group selected. The
ascertainment of exposure through secure records and demonstration
that the outcome of interest was not present at the start of the study
were observed for all cohorts. The methods used to control for
confounding were not described, and a high risk of performance bias
was observed. However, outcome assessment by clinical and
radiographic examination was described for most studies. Although
the follow-up time was long enough to produce root fractures and noncatastrophic failures, only 2 cohort studies (19, 24) described that a loss
to follow-up was unlikely to introduce bias.
Incidence Rate of Root Fracture
Data on the incidence rate of root fractures for metal-based posts
were extractable from 4 RCTs (15, 16, 21, 26) and 4 cohort studies
4

Figueiredo et al.

(1820, 27). The pooled event rate per 1000 post years was 5.13
(95% CI, 4.056.21), but important heterogeneity was observed
across studies (P < .001, I2 = 99.8%). For fiber-reinforced posts,
data on the incidence rate of root fractures were extractable from 5
RCTs (6, 21, 22, 25, 26) and 3 cohort studies (17, 23, 24). The
pooled estimate per 1000 post years was 4.78 (95% CI, 4.285.27).
Moreover, interstudy heterogeneity was high (P < .001, I2 = 100%)
(Fig. 2).
The incidence rate of root fractures for prefabricated metal posts
and carbon fiber posts was 2-fold higher compared with cast metal
posts and glass fiber posts (Figs. 2 and 3). However, subgroup
analysis failed to define the reasons for heterogeneity (Table 3). There
was no evidence of publication bias, as suggested by visual inspection of
the funnel plot and the Begg and Mazumbar rank correlation (P = .063
for metal-based posts, P = .107 for fiber-reinforced posts). The sensitivity analysis showed that the pooled event rate for both systems did not
change substantially with the exclusion of any one study, thereby indicating that the meta-analyses were not compromised in any way.

Incidence Rate of Noncatastrophic Failures

Data on the incidence rate of noncatastrophic failures for metalbased posts were extractable from 4 RCTs (15, 16, 21, 26) and 3
cohort studies (19, 20, 27). Using a random-effects model (heterogeneity: P < .001, I2 = 100%), we found that the overall incidence rate of
noncatastrophic failures for metal-based posts was 12.69 (95% CI,
7.9017.48) per 1000 post years. For fiber-reinforced posts, important
heterogeneity was also observed (P < .001, I2 = 100%), and the pooled
effect size was 19.39 (95% CI, 13.2125.57) (Fig. 3).
The incidence rate of noncatastrophic failures was increased 2fold in cast metal posts and carbon fiber posts compared with prefabricated metal posts and glass fiber posts, respectively. The reasons for
heterogeneity were also not defined by subgroup analysis (Table 3). The
robustness of the pooled effect size was examined by sequentially
removing each study and reanalyzing the remaining data sets. For
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Review Article

Figure 2. A forest plot and funnel plot for the incidence rate of root fractures according to the post system.

metal-based posts, omitting the cohort study of Jung et al (20) resulted

in a significant reduction in the incidence rate of noncatastrophic failures (7.27; 95% CI, 3.3611.18), whereas the other studies had no
substantial effect on the pooled results. However, there was no obvious
evidence of publication bias in this meta-analysis (Begg test, P = .548).
For fiber-reinforced posts, the results were not compromised by the
one-by-one study removals, and no obvious publication bias was found
(Begg test, P = .548) (Fig. 3).

Survival Rate of Post Systems

Figure 4 shows the study-specific and summary survival rates of the
post systems. The pooled survival rate for metal -based posts was 90.0%
(95% CI, 85.593.3), and statistically significant heterogeneity among
studies was observed (P = .008, I2 = 63%). For fiber-reinforced posts,
the pooled survival rate was 83.9% (95% CI, 67.692.8), and important
heterogeneity (P < .001, I2 = 97.3%) was also observed.
To explore the sources of heterogeneity, we considered performing a stratified analysis based on the follow-up periods according to the

subgroups of post systems (Table 4). The stratified analysis showed a

reduction in the overall survival rate of post systems over time. We
did not observe statistical heterogeneity between studies of prefabricated metal posts, but significant changes in heterogeneity were noted
in the overall analysis of survival when cast metal posts were added. For
the fiber post system, heterogeneity was analyzed in 3 follow-up periods
(4.16 years, 6.18 years, and 8.110 years). Severe statistical heterogeneity was observed during the 6.1- to 8-year follow-up, but the variability in the individual study results was not related to the type of fiber
post. In addition, there was no evidence for a difference in the summary
estimates by adjusting the results for the study design (results not
shown). However, further analysis suggested that heterogeneity could
be primarily attributed to 2 studies (17,25) because of variations in
the sample sizes. After excluding these studies, the heterogeneity tests
showed no statistically significant differences (P = .547, I2 = 0.0%)
in the remaining studies.
Visual inspection of the funnel plot and the Begg and Mazumbar
rank correlation showed no potential for publication bias in any of
the meta-analyses. The leave-one-out method showed that the survival

Figure 3. A forest plot and funnel plot for the incidence rate of noncatastrophic failures according to the post system.

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Root Fracture of Post-retained Restorations

Review Article
TABLE 3. Subgroup Analysis to Investigate Differences between Studies Included in the Meta-analysis for Incidence Rate (/1000 post years) of Root Fracture and
Noncatastrophic Failures
Root fracture
Pooled estimates
Source
Metal-based posts
Study design
RCT
Cohort
Sample size
<100 posts
$100 posts
Post-system
Prefabricated
metal post
Cast metal post
Fiber-reinforced posts
Study design
RCT
Cohort
Sample size
<100 posts
>100 posts
Post system
Glass fiber
Carbon fiber

Noncatastrophic failures
Tests of
heterogeneity

Pooled estimates

Tests of
heterogeneity

No. of
studies

IR

95% CI

P value
(Q test)

I2 (%)

No. of
studies

IR

95% CI

P value
(Q test)

I2 (%)

4
4

5.01
5.25

2.287.74
3.896.60

<.001
<.001

99.7
99.9

4
3

6.93
20.35

3.1110.75
12.4328.26

<.001
<.001

99.9
100

5
3

4.66
5.92

2.946.35
4.377.48

<.001
<.001

99.6
99.9

5
2

14.60
7.93

4.1125.09
2.3313.52

<.001
<.001

100
100

5.52

4.386.66

<.001

99.9

12.80

9.1316.48

<.001

100

3.39

0.61 to 7.39

<.001

99.9

22.09

7.3936.79

<.001

100

5
3

2.91
8.19

1.674.16
3.2013.18

<.001
<.001

99.9
100

5
3

15.98
25.08

6.4425.53
6.8943.27

<.001
<.001

100
100

3
5

10.89
1.31

0.8920.88
0.961.66

<.001
<.001

100
99.9

3
5

24.35
16.43

5.2843.41
9.0023.86

<.001
<.001

100
100

3
5

3.58
5.69

0.626.54
3.467.91

<.001
<.001

100
100

3
5

14.17
22.56

4.86 to 33.20
15.0430.08

<.001
<.001

100
100

CI, confidence interval; IR, incidence rate; RCT, randomized clinical trial.

rate for the adjusted and unadjusted data sets did not change substantially with the exclusion of any one study. The results of the sensitivity
analysis exclude the possibility of bias and confirm the robustness of
effect sizes.

Discussion
The results of this systematic review show similarities between the
incidences of catastrophic failures among metal and fiber postretained
restorations. There was a higher incidence of noncatastrophic failures
for fiber postrestored roots, but the survival rate was similar for both

types of posts. This systematic review included both clinical trials and
observational cohort studies, resulting in high levels of heterogeneity
among studies. Few studies evaluating metal and fiber posts were found
in the literature. Thus, considering the necessity of comparing these
types of posts, the 1-arm design for data analysis was performed.
Even the subgroup analyses did not identify the sources of heterogeneity, and the use of the 1-arm design for data analysis could explain the
high heterogeneity observed in the meta-analyses in the present study.
Interestingly, the survival rate analysis showed that the type of metal post
(cast or prefabricated) partially explained the interstudy heterogeneity
in this group. The same was not observed between the types of fiber

Figure 4. A forest plot and funnel plot for the survival rate of post systems.

Figueiredo et al.

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Review Article
TABLE 4. Stratified Analysis Based on Periods of Follow-up according to the Post Systems*
Period of follow-up
Post-system/study
Metal post
Prefabricated metal post
Sterzenbach et al, 2012

mez-Polo et al, 2010
Go
Hikasa et al, 2010
Jung et al, 2007
Creugers et al, 2005
Ellner et al, 2003
King et al, 2003
Weine et al, 1991
Subgroup survival rate
Heterogeneity (Q test; I2)
Cast metal posts

mez-Polo et al, 2010
Go
Hikasa et al, 2010
Jung et al, 2007
Ellner et al, 2003
Subgroup survival rate
Heterogeneity (Q test; I2)
Overall survival rate
Heterogeneity (Q test; I2)
Fiber post
Carbon fiber
Ferrari et al, 2007
m et al, 2006
Segerstro
Mannocci et al, 2005
King et al, 2003
Subgroup survival rate
Heterogeneity (Q test; I2)
Glass fiber
Sterzenbach et al, 2012
Naumann et al, 2012
Ferrari et al, 2012
Signore et al, 2009
Subgroup survival rate
Heterogeneity (Q test; I2)
Overall survival rate
Heterogeneity (Q test; I2)

02 y

2.14 y

4.16 y

6.18 y

8.110 y

10.115 y

99.3 (98.899.6)

100.0 (76.2100.0)

99.3 (98.799.6)
P = .217; 34.5%

97.0 (96.197.7)

100.0 (71.7100.0)

97.0 (96.197.7)
P = .814; 0.0%

93.5 (81.797.9)

94.2 (93.095.3)

96.0 (85.999.0)

100.0 (71.7100.0)

94.2 (93.195.2)
P = .939; 0.0%

91.4 (90.092.6)

89.0 (55.098.2)

91.4 (90.092.6)
P = .778; 0.0%

84.6 (66.994.9)
86.6 (84.988.1)
93.5 (92.394.6)

92.0 (67.599.6)
89.0 (55.098.2)
93.5 (88.0-96.6)
87.0 (85.588.5)
P = .893; 0.0%

78.7 (76.880.6)

89.0 (56.199.4)

78.7 (76.880.6)
P = .417; 0.0%

97.0 (94.998.4)

97.0 (94.998.4)
NA
98.3 (94.299.5)
P = .001; 84.8%

93.7 (91.095.9)

93.7 (91.095.9)
NA
96.2 (95.397.0)
P = .010; 78.4%

89.6 (86.192.3)

89.6 (86.192.3)
NA
93.0 (89.495.4)
P = .027; 63.6%

82.5 (78.486.1)

82.5 (78.486.1)
NA
87.9 (77.793.7)
P < .001; 92.2%

82.6 (73.589.5)
75.5 (71.079.7)
90.2 (78.196.8)
100.0 (80.7100.0)
82.0 (72.588.7)
P = .073; 56.9%
87.0 (81.691.0)
P < .001; 77.9%

55.4 (50.360.4)

55.4 (50.360.4)
NA
72.7 (50.287.6)
P < .001; 97.6%

93.8 (72.899.7)
93.8 (72.899.7)
NA

85.7 (60.397.5)
85.7 (60.397.5)
NA

90.0 (82.894.4)
78.6 (52.194.2)
88.1 (81.192.8)
P = .192; 41.2%

92.0 (90.193.6)
65.0 (55.173.7)

71.0 (45.487.8)
79.5 (48.194.2)
P < .001; 96.7%

71.0 (45.487.8)
71.0 (45.487.8)
NA

NA

NA
NA
93.8 (72.899.7)
NA

NA
NA
85.7 (60.397.5)
NA

90.2 (77.596.1)

90.2 (78.196.8)
NA
89.1 (83.293.0)
P = .514; 0.0%

71.0 (64.976.4)
98.5 (97.099.3)
92.6 (33.299.7)
P < .001; 98.6%
86.0 (67.694.7)
P < .001; 97.3%

46.0 (38.254.0)

46.0 (38.154.7)
NA
54.6 (31.076.2)
P = .118; 49.2%

NA
NA
NA
NA

NA, not applicable.

*Data reported as survival rate followed by the 95% confidence interval in parentheses.

posts (carbon or glass fiber) when the survival rate was analyzed,
thereby stratifying the period of follow-up.
Despite the heterogeneity, meta-analyses of the outcomes were
performed. According to Dwyer et al (28), the decision to combine
the results of individual studies in the presence of heterogeneity depends on the aim of the particular overview that is being undertaken.
If the aim is to identify the direction of a possible association, as performed in the present study associating the type of posts and the incidence of failures, then even with observational data, a meta-analysis
appears to be appropriate.
A recent meta-analysis of in vitro studies (3) evaluating the fracture strength of roots restored with metal or fiber posts showed higher
values for metal posts, whereas the use of this last type of post resulted in
more catastrophic failures. Higher fracture strength can indicate longer
longevity under clinical function. The results of our meta-analysis of
clinical studies showed a higher survival rate for metal posts than for
fiber posts, primarily for longer periods of follow-up. However, the results of the present meta-analysis regarding the incidence rate of catastrophic failure contradict those observed for in vitro studies. In
contrast to the in vitro studies, a similarity in the incidence rate of catastrophic failures was observed among metal and fiber posts. Interestingly, when only clinical trials are analyzed, metal posts showed a
higher incidence rate of catastrophic failures. The opposite was
observed for cohort studies. Another interesting observation on subgroup analysis was the tendency to reduce catastrophic failures and increase noncatastrophic failures when cast posts (for metal based) and
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glass fiber posts (for fiber reinforced) were used. Regardless of the CI,
no significant difference was observed.
Only studies using follow-up periods longer than 5 years were
included in the present meta-analysis. A recent recommendation for
conducting controlled trials on dental materials (29) advised an observational period of longer than 5 years for indirect restorations in clinical
studies. All studies included in this systematic review used indirect
restoration to restore the tooth that received the post, requiring
follow-up periods longer than 5 years to assess the success of the restorative procedure. Furthermore, some clinical studies that were excluded
because of shorter follow-up periods were older publications of
included studies that reported on the same patients.
Some limitations should be acknowledged in this meta-analysis.
First, almost all of the observational studies that met the inclusion criteria
were retrospective cohort studies, which have less control over the subject selection and measurements and the risk for confounding. However,
cohort studies often include more subjects and have a longer follow-up
time. In addition, in regard to assessing harm, such as the incidence of
failures, these types of studies are a good source of data. Second, studies
that suffer from a high risk of bias were not excluded from the metaanalysis. This decision was made because of the lack of unbiased studies
that met the inclusion criteria for this review. Finally, we were unable to
explore the risk factors for the outcomes of interest, such as the amounts
of coronal remaining, the presence of a ferule effect, the location of the
tooth, and occlusion features. Unfortunately, these risk factors were not
described in most of the included studies.

Root Fracture of Post-retained Restorations

Review Article
In conclusion, the results of the present systematic review based
on clinical studies do not support the indication of fiber-reinforced
posts based on a reduction of catastrophic failures. However, this review
also showed the need for further well-designed clinical studies evaluating intraradicular posts.

Acknowledgments
The authors deny any conflicts of interest related to this study.

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