Abstract
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Objectives
This systematic review aimed to investigate the fracture resistance and mode of failure of endodontically-treated permanent teeth restored with Ribbond posts (Ribbond, Inc.) compared with endodontically-treated permanent teeth restored with other post systems.
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Methods
A comprehensive, systematic literature search was carried out using several electronic databases: MEDLINE/PubMed, Google Scholar, and Cochrane Library. Two separate researchers were appointed to identify the studies meeting the eligibility criteria, and to perform the data extraction, risk of bias, and quality assessment.
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Results
Twelve studies were included in the quantitative analysis. Meta-analysis was performed with 11 of the 12 included articles. The meta-analysis showed that Ribbond posts have a fracture strength less than prefabricated metal posts, cast metal posts, and prefabricated fiber posts and greater than custom e-glass fiber posts. Mode of failure analysis revealed that Ribbond posts have the most favorable non-catastrophic fractures.
-
Conclusions
Although Ribbond posts have lower fracture resistance, their favorable mode of failure makes them potentially the most biomimetic post system.
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Keywords: Fracture strength; Post and core technique; Ribbond; Systematic review
INTRODUCTION
Restoration of endodontically-treated teeth presents a persistent clinical challenge as they are frequently structurally compromised due to a variety of reasons, including caries, restorations, and endodontic access interventions [
1]. The loss of tooth structure involving one or both marginal ridges or the loss of a facial/lingual wall of the tooth significantly increases the risk of fracture [
2]. Root-filled teeth show a greater association with fractures as compared to vital teeth [
3].
Determining the optimal type of post-endodontic restoration is influenced by the type of teeth and their position in the arch, forces of occlusion, and the remaining coronal tissue structure [
4]. The quantity of the remaining tooth structure comprises the ferrule, which is defined as “a 360° collar of the crown that surrounds the parallel walls of the dentin and extends coronally to the shoulder of the preparation” [
5]. An abundance of literature demonstrates increased fracture resistance of endodontically-treated teeth in the presence of at least 1 mm of ferrule height [
5–
7]. When the coronal structural loss is greater than 50%, the literature suggests the placement of an intraradicular post to reinforce structurally compromised teeth, increase their fracture resistance, and support the final crown restoration [
8]. Posts do not directly increase the strength of endodontically-treated teeth but rather they facilitate the core retention [
9,
10].
Cast posts and cores have conventionally been employed to reinforce pulpless teeth. Metal posts have excellent rigidity and the ability to withstand loads without undergoing deformation. They are resilient to axial stresses whose intensity is along the post’s axis. However, they have poor stress distribution ability, and they exhibit a concentration of forces at the root apex [
11,
12] since they possess a high modulus of elasticity, much different from that of dentin. This also holds true for other post and core systems with a high modulus of elasticity, such as prefabricated zirconium or prefabricated metal posts. Employing posts with an elastic modulus closer to that of dentin reduces the chances of catastrophic radicular fractures [
13]. Other than biological concerns, metal posts also present aesthetic problems, especially in anterior teeth.
This led to a shift in the trend from using more rigid posts to using prefabricated fiber posts which had greater elasticity and better esthetics [
14]. Their lower elastic modulus leads to a uniform distribution of stresses along the post-dentin interface, thus avoiding critical stress concentration and catastrophic fractures of the root [
15–
18]. Prefabricated fiber posts are cemented with a dual cure luting agent. The thickness of the resin cement used affects the strength of the restoration at the post-dentin interface [
19], thus suggesting the need for dowels that adapt to the canal anatomy and have a good intracanal fit.
Recently, custom-made fiber post and core systems that employ polyethylene fibers (Ribbond fibers; Ribbond, Inc., Seattle, WA, USA) [
20] have been introduced. Ribbond is an ultra-thin, leno-weaved, high molecular weight, reinforcement ribbon with excellent bondability and fracture toughness. Ribbond fibers are embedded in resin composite which are then condensed within the canal in the form of an endodontic post [
21]. Ribbond posts are said to be biologic posts with improved esthetics and translucency, and relative ease of manipulation. They can also be placed in a single visit without the need for a laboratory phase [
22].
Literature regarding the behavior and performance of Ribbond post and core systems in terms of their retentive ability, fracture strength, and fracture repairability as compared to that of conventional post and core systems needs further evaluation. Thus, this systematic review was undertaken to analyze the outcome of in vitro studies comparing the fracture resistance and mode of failure of Ribbond post and core systems with that of other post and core systems.
METHODS
The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocol for systematic reviews and meta-analyses was undertaken and was registered on PROSPERO (CRD42023472726). Using the PICOS (Population; Intervention; Comparison; Outcome; Study Design) framework, a review question was composed as follows: “Does the use of a Ribbond post and core system influence the fracture resistance and failure modes of endodontically-treated permanent teeth as compared to those of other post and core systems?”
Search strategy
A comprehensive, systematic literature search was carried out using several electronic databases: MEDLINE/PubMed, Google Scholar, and Cochrane Library. The following keywords or terms were employed and adjusted according to each database: ((Ribbond) OR (fiber reinforced composite) OR (polyethylene fiber)) AND ((Post) OR (Dowel) OR (endodontically-treated teeth) OR (post-core technique) OR (post and cores) OR (endodontic post)) AND ((fracture resistance) OR (fracture strength)).
Eligibility criteria
The studies were selected based on the following inclusion and exclusion criteria.
1. Inclusion criteria
• Studies published from 1990 to 2022 in peer-reviewed journals
• Studies published in the English language
• In vitro comparative studies between Ribbond post and core systems and other post and core systems
• Studies included endodontically-treated permanent teeth, restored with different types of post and core systems
2. Exclusion criteria
• In vivo and ex vivo studies, animal studies, reviews, case reports, case series
• Studies that did not include Ribbond post and the core group
• Studies that included indirect restorations
Screening and selection of studies
All the results obtained underwent title screening and abstract screening based on the eligibility criteria. After the elimination of duplicates, full-text articles were retrieved if screening data was inconclusive. Two researchers who were blinded to each other were appointed to identify the studies meeting the eligibility criteria. A third reviewer was appointed to eliminate any disagreements during the selection of studies between the two authors.
Data extraction and synthesis
For all the selected studies, the following information was reported: authors, year, type of teeth, post type, study groups, remaining tooth structure, evaluated outcomes, mean fracture strength, mode of failure, luting agent used, thermocycling, fracture testing equipment used, statistical analysis software used, and statistical tests performed. Studies with homogeneous study populations were subjected to meta-analyses using a fixed-effect model. Only if the heterogeneity was substantial (>50%) then a random-effect model was employed.
Assessment of heterogeneity
Assessment of heterogeneity was performed using the Review Manager (RevMan) software (Cochrane Collaboration, London, UK) [
23]. The results were presented as the standardized mean difference (SMD) with a 95% confidence interval (CI). Heterogeneity was considered statistically significant if
p < 0.05. The Cochran Q test and the
I2 inconsistency tests were also performed to assess the heterogeneity of the treatment effects. A general guide to interpreting the
I2 test is as follows [
24]: 0% to 40%, heterogeneity might not be important; 30% to 60%, may represent moderate heterogeneity; 50% to 90%, may represent substantial heterogeneity; 75% to 100%, may represent considerable heterogeneity.
For risk of bias analysis, two separate reviewers were appointed to analyze each individual study. The domains used for the quality assessment were based on the reporting of items as per the modified CONSORT (Consolidated Standards of Reporting Trials) statement for
in vitro studies [
25] which were: teeth size and form standardization, teeth free of caries or restorations, sample size calculation, randomization of specimens, implementation of sequence generation, outcome, statistical methods, standardized teeth preparation, standardized and replicable methodology, material application measures followed, blinded evaluation, complete results, and funding. When a study described a domain, it was allotted ‘yes’ and if it failed to describe a domain ‘no information’ was allotted. If 10 to 13 domains were described, the study was determined to have a low risk of bias. If seven to nine domains were described, the study was determined to have some concerns or a moderate risk of bias. If less than seven domains were described, a high risk of bias was reported.
The presence of publication bias was assessed visually by the relative symmetry of individual studies around the overall estimates using Begg’s funnel plot. The funnel plots were drawn of effect size versus standard error for each subgroup analysis. Asymmetry of the funnel plots may imply publication bias.
RESULTS
Search strategy and characteristics of the studies
A total of 597 records were obtained from searching electronic databases. After the removal of duplicates, a total of 407 records remained which were then subjected to title screening and abstract reading. A total of 389 records were excluded, and 18 articles underwent full-text evaluation. Of those, 12 articles met the eligibility criteria and were included in the present systematic review and underwent quality assessment and data extraction. Meta-analysis was performed with 11 of the 12 studies included. The search strategy and process of study selection are reported in
Figure 1 along with the reasons for exclusion.
The chief characteristics of the 12 studies included are presented in
Table 1. In comparison to Ribbond posts, all 12 studies tested prefabricated glass fiber posts [
18,
26–
36], four studies tested custom glass fiber (EverStick; GC Europe N.V., Leuven, Belgium) posts [
28,
29,
31,
32], two studies tested cast metal posts [
33,
35], four studies tested prefabricated metal posts [
18,
31–
33], and one study also tested zirconia and quartz post [
27]. Nine of the 12 studies also assessed the fracture patterns in which three studies tested reattached fragment samples [
29,
32,
36] whereas the other five studies tested a composite resin core build-up [
26,
30,
31,
33,
35]. Amongst the three reattached fragment studies, two studies described the fracture patterns as repairable/nonrepairable [
32,
36] while the third study described it as a fracture at the original site/fracture at new sites [
29]. One study did not provide an adequate description of the fracture patterns [
18]. Amongst the five composite resin core studies, two studies described the fracture pattern based on restorability as favorable/unfavorable [
31] or repairable/nonrepairable [
35], while the other three studies described the fracture pattern based on fracture line propagation along the root [
26,
30,
33]. Some additional characteristics are also mentioned in
Table 2.
The risk of bias in the included studies is presented in
Table 3, along with the overall risk of bias presented in
Figure 2. All the included studies were largely comparable in methodological quality. All the included studies had a low risk of bias with all the respective domains. The highest risk of bias was seen for ‘sample size calculation,’ ‘implementation of sequence generation,’ and ‘blinded evaluation’ domains. As per the domains analyzed, all studies presented a low risk of bias.
The meta-analysis of the review was performed on 11 studies [
26–
36]. The meta-analysis of the included studies evaluating the fracture strength values is presented as forest plots in
Figure 3.
Figure 3A shows the subgroup analysis comparing Ribbond posts with endodontically-treated teeth restored without a post; the use of Ribbond posts improved the fracture strength values significantly (SMD, –6.45 [95% CI, –11.05 to –1.85];
I2 = 97%). Braga
et al. [
26], Kumar
et al. [
29], Ozcan and Valandro [
31], and Thakur and Ramarao [
34] showed higher fracture resistance in the Ribbond posts group. Jindal
et al. [
30] showed higher fracture resistance in endodontically-treated teeth without posts group. The analysis showed higher fracture resistance in the Ribbond posts group.
Figure 3B presents the subgroup analysis comparing Ribbond posts with prefabricated metal posts; fracture strength values were significantly higher with the use of prefabricated metal posts (SMD, 1.81 [95% CI, 1.12–2.50];
I2 = 18%). Ozcan and Valandro [
31], Ozcopur
et al. [
32], and Sirimai
et al. [
33] showed higher fracture resistance in the prefabricated metal posts group. The analysis showed higher fracture resistance in the prefabricated metal posts group compared to the Ribbond posts group.
Figure 3C presents the subgroup analysis comparing Ribbond posts with prefabricated fiber posts; the use of prefabricated fiber posts significantly increased the fracture strength values (SMD, 1.42 [95% CI, 0.03–2.81];
I2 = 91%). Aggarwal
et al. [
35], Batra
et al. [
27], Jindal
et al. [
30], Ozcopur
et al. [
32], Thakur and Ramarao [
34], and Ramesh
et al. [
36] showed higher fracture resistance in the prefabricated fiber posts group. Braga
et al. [
26] showed higher fracture resistance in the Ribbond posts group. The analysis showed higher fracture resistance in prefabricated fiber posts compared to the Ribbond posts group.
Figure 3D shows the subgroup analysis comparing Ribbond posts with custom e-glass fiber posts; the use of Ribbond posts improved the fracture strength values significantly (SMD, –1.64 [95% CI, –5.18 to 1.89];
I2 = 96%). Khurana
et al. [
28] and Ozcopur
et al. [
32] showed higher fracture resistance in the custom glass fiber posts group. Ozcan and Valandro [
31] showed no difference between the two groups. Kumar
et al. [
29] showed higher fracture resistance in the Ribbond group. The analysis showed higher fracture resistance in the Ribbond posts group compared to the custom glass fiber posts group.
Mode of failure
Table 4 shows the fracture patterns and modes of failure of different post systems as compared to those of Ribbond posts. As evident from the incidence rate of catastrophic vs non-catastrophic fractures, Ribbond posts consistently showed a favorable mode of fracture across all the included studies. Cast metal posts showed the most unfavorable fractures followed by prefabricated metal posts, prefabricated glass fiber posts, and custom e-glass fiber posts in decreasing order.
Publication bias
No significant publication bias was reported according to the funnel plots generated on subgroup analysis using the random effects model presented in
Figure 4.
DISCUSSION
Teeth are susceptible to a variety of occlusal loads in the oral cavity during masticatory functions like chewing, biting, and sometimes parafunctional habits [
37]. Endodontically-treated teeth are typically difficult to restore, and when they involve significant tissue loss, intraradicular reinforcements are sometimes required to keep the coronal restoration in place. This systematic review and meta-analysis comprised
in vitro studies that assessed the placement of Ribbond posts as compared to other intraradicular posts based on the fracture strength and fracture patterns of structurally compromised endodontically-treated teeth.
The amount of coronal structural loss a tooth experiences dictates the type of post-endodontic restoration. According to Jotkowitz and Samet [
38], the height and thickness of the remaining ferrule along with the lateral load a tooth undergoes directly affect the ‘risk of failure’ and the quality of the restoration. Dietschi
et al. [
39] recommended that weakened endodontically-treated posterior teeth can be restored functionally and aesthetically by direct and indirect adhesive techniques, avoiding an additional sacrifice of sound tissues and further stated that if there is less than half coronal residual tooth structure, post placement is indicated. The biomechanical properties of both, the remaining tooth structure and the material used for post and core, should be taken into consideration while restoring structurally compromised teeth.
Recently, Ribbond posts (custom polyethylene fiber posts) have been used to restore weakened endodontically-treated teeth [
40]. Ribbond is made of leno-woven, ultra-high molecular weight polyethylene fibers [
41]. Ribbond posts have several advantages over conventional post and core systems such as improved esthetics, excellent bondability, and a modulus of elasticity very close to that of dentin [
40]. Polyethylene fiber-reinforced composites (FRCs) alter stress patterns, providing improved stress distribution [
42]. According to a finite element analysis by Belli
et al. [
43], increased stress concentration was observed with an increase in the number of interfaces of the monoblocks created by the restorations. Ribbond fiber posts create a primary monoblock effect and thus dissipate the stresses along the long axis of the tooth [
41]. Without necessitating structural alteration, Ribbond fibers can be cut and incorporated into dental composites. They adapt closely to the internal contours of the tooth and remain adhered to one another [
40].
Traditionally, cast posts and cores have been employed due to their excellent strength and resistance to deformation [
44]. Cast posts provide an accurate fit, eliminating the need for a thicker layer of cement thus contributing to its superior strength [
44,
45]. Likewise, in the present systematic review and meta-analysis, it was seen that cast metal posts had a significantly higher fracture strength when compared to Ribbond posts, but they resulted in catastrophic nonrepairable fractures. In the study by Sirimai
et al. [
33], it was seen that cast posts had the highest fracture strength while polyethylene fiber posts had the lowest fracture strength, but there was an unmistakable difference in the failure patterns for both groups. All of the teeth restored by cast posts suffered nonrepairable root fractures; 90% had a vertical root fracture pattern whereas 10% had a horizontal root fracture pattern at the junction of the middle and apical third of the root. Whereas, in the teeth restored with polyethylene fiber posts only 10% of the samples experienced a vertical root fracture and 80% of the samples had failure limited only to the composite core. Similar findings were seen in the study by Aggarwal
et al. [
35], with the cast post group having the highest fracture strength but nine out of 10 samples had a nonrepairable fracture pattern whereas the Ribbond post group showed a repairable fracture strength for all samples despite having the lowest fracture strength. Similar results were seen in the studies evaluating prefabricated metal posts (titanium posts). Ozcan and Valandro [
31] reported that the fracture resistance of Paraposts (titanium posts; Coltene/Whaledent, Altstätten, Switzerland) was almost twice that of Ribbond posts, with no unfavorable fractures for either of the groups. The titanium post group reported core fractures whereas the Ribbond post group reported a loss of post retention. The possible reason for this could be that during the fracture test performed in the study, loading was arrested the moment core failure was observed and there was a high probability of root fracture if loading had been continued. Sirimai
et al. [
33] reported that although titanium posts have a higher fracture strength than Ribbond posts, 90% of the posts fractured with a nonrepairable fracture pattern, whereas only 10% of Ribbond posts had a nonrepairable fracture pattern. Ozcopur
et al. [
32] reported similar findings where despite a higher fracture strength, 60% of the posts fractured in a non-restorable fashion whereas Ribbond posts exhibited 100% fracture repairability. This could be attributed to the material properties that cast metal posts and prefabricated metal posts exhibit, such as high stiffness, high modulus of elasticity, and poor stress distribution ability with a critical concentration of stresses apically [
11,
12]. Due to the aforementioned properties, the posts tend to fracture at the expense of the root structure.
Prefabricated fiber posts have been gradually replacing metal posts due to their improved aesthetic properties, low modulus of elasticity, and greater dissipation of stresses [
14]. Since fiber posts are prefabricated, a layer of luting cement surrounds the post, serving as the weakest point of the tooth-post-core complex [
19,
46]. This creates a secondary monoblock as opposed to the primary monoblock that Ribbond posts provide, thus the stress dissipation is lesser than in custom-made fiber posts [
43]. The advantage of having primary monoblock over secondary monoblock is that the homogeneity of the tooth-post-core complex achieved in the former is greater, thus opposing forces as a single unit [
43]. All studies comparing prefabricated fiber posts with Ribbond posts in the present meta-analysis showed that the former had a fracture resistance greater than that of the latter. The mode of fracture analysis revealed that in four out of the five studies [
32,
34–
36], Ribbond posts had 100% fracture repairability whereas in one study [
30] the fracture repairability was 75%. Prefabricated fiber posts had a fracture repairability of 80% or less in all studies, with one study showing fracture repairability even as low as 60%. Although prefabricated fiber posts have higher fracture resistance than Ribbond posts, the fracture mode is not exceedingly favorable, resulting in nonrepairable root fractures significantly more often than Ribbond posts. Depending on the thickness of the cement layer, a large portion of the prefabricated fiber post and core restoration comprises the luting cement. Thus, the quality of the luting cement has a direct influence on the biomechanical properties of the post and core restoration. Furthermore, prefabricated fiber posts require post space preparation which results in additional root dentin removal, whereas custom fiber posts do not necessitate the need for root dentin removal since they adopt the canal anatomy [
40].
With a deeper understanding of the biomechanics of the tooth system and improved material science and bonding protocols, aesthetic custom fiber posts have started coming into the limelight [
28]. Custom FRC posts adapt to the internal anatomy of the canal system. They have a modulus of elasticity very close to that of dentin, which is advantageous due to excellent dissipation of stresses, with reduced incidence of root fractures [
32]. Since custom fiber posts create a primary monoblock, stresses experienced during function and mastication get distributed more homogenously, thus avoiding critical stress concentration [
32]. EverStick is a custom glass fiber post impregnated in unpolymerized resin which is pliable and can be condensed into the canal in the form of a post [
47]. In the present meta-analysis, EverStick posts showed marginally higher fracture strength than Ribbond posts. This could possibly be attributed to the silanization of glass FRC posts which provides better adherence of the glass fibers to the resin, whereas the inherent difficulty to achieve silanization with polyethylene fibers leads to somewhat weaker adherence with the resin [
28]. However, the mode of failure evaluation of EverStick posts when compared to Ribbond posts revealed that Ribbond posts have a higher fracture repairability than EverStick posts. This could be attributed to the differences in fiber orientation and intracanal adaptation. EverStick posts are unidirectional and congregate in the middle of the post space with a layer of resin cement around them, whereas polyethylene fibers are multidirectional and show close adaptation to the canal wall, minimizing the resin cement interface, possibly resulting in variations in the mode of failure [
29].
Ribbond posts also present some added advantages over prefabricated fiber posts. Erkut
et al. [
48] studied the microleakage in overflared canals restored with adhesively luted posts and stated that Ribbond had the least amount of microleakage. Furthermore, custom Ribbond fiber posts have no shape memory and thus do not experience a “rebound” phenomenon once placed in the canal, whereas prefabricated glass fiber posts exhibit a significant memory and tend to revert to their original “straight” position. This gives Ribbond posts an edge while being placed in curved canals [
49].
Clinical studies evaluating the survival rates of Ribbond posts are scarce. Despite having lower fracture resistance values, clinical survival rates of Ribbond posts have been promising, as seen in a clinical study performed by Piovesan
et al. [
50] which reported high survival rates of Ribbond posts after the 97-month follow-up period. This suggests that Ribbond posts may be advocated for long-term restorations.
Besides their lower fracture resistance, Ribbond posts also present another discernible drawback. They transfer stresses to the cervical third of the root [
32], which could affect the retention of the post when there is a lack or absence of ferrule. The primary purpose of intraradicular post placement is not just retention of the core but to prevent the dislodgement of the tooth-core-post complex from the root at a level that is non-restorable [
51]. When teeth are severely structurally compromised, with a ferrule of less than 2 mm, the need for a biologic post that does not compromise the tooth structure further or cause catastrophic failures is essentially heightened. Nilavarasan
et al. [
52] conducted a study on primary teeth with the remaining ferrule of only 1 mm and stated that Ribbond posts had a better fracture strength than prefabricated glass fiber posts. Further studies should be undertaken to evaluate the role of Ribbond posts in restoring severely structurally compromised teeth, with inadequate ferrule.
Although in vitro studies provide better standardization in terms of sample preparation and evaluation, well-designed randomized clinical trials with a long follow-up period are needed to eliminate the difference between in vitro and in vivo environments and reach a conclusive clinical opinion regarding the behavior and in vivo effectiveness of the Ribbond post and core system.
CONCLUSIONS
The focus of restoring teeth with compromised structure should shift to prevent the tooth from any harm during function in the long term. As seen within the limitations of the present systematic review, although Ribbond posts have less fracture resistance when compared to other contemporary post and core systems, they present the most favorable mode of failure. The fracture mode is almost never at the cost of the tooth-core-post complex, resulting in repairable non-catastrophic fractures. This makes Ribbond posts a suitable biomimetic restorative alternative for rehabilitating structurally compromised teeth.
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CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was reported.
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FUNDING/SUPPORT
None.
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AUTHOR CONTRIBUTIONS
Conceptualization, Formal analysis, Project administration: Vartak MA, Fanibunda U. Data curation, Funding acquisition: Vartak MA. Investigation: Vartak MA, Hegde SR, Fanibunda U. Methodology: Vartak MA, Hegde SR. Resources, Software, Visualization: Vartak MA, Fanibunda U. Supervision: Fanibunda U, Hegde VR. Validation: Fanibunda U. Writing - original draft: Vartak MA. Writing - review & editing: Vartak MA, Fanibunda U. All authors read and approved the final manuscript.
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DATA SHARING STATEMENT
The datasets are not publicly available but are available from the corresponding author upon reasonable request.
Figure 1.PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart showing search strategy and selection of studies.
Figure 2.Overall summary of the risk of bias assessment.
Figure 3.Meta-analysis comparing fracture resistance of the Ribbond post (Ribbond, Inc., Seattle, WA, USA) groups and other experimental groups. (A) Ribbond posts and endodontically-treated teeth (ETT) without posts. (B) Ribbond posts and prefabricated metal posts. (C) Ribbond posts and prefabricated fiber posts. (D) Ribbond posts and custom e-glass fiber posts. CI, confidence interval; SD, standard deviation; SMD, standardized mean difference.
Figure 4.Begg’s Funnel plot with 95% confidence intervals demonstrating symmetric distribution with the absence of systematic heterogeneity of individual study compared with the standard error (SE) of each study, indicating an absence of any publication bias. SMD, standardized mean difference.
Table 1.Main characteristics extracted from selected studies
|
Study (year) |
Type of teeth |
Post type |
Study group |
Remaining structure |
Evaluated outcome |
Mean Fracture strength |
Mode of failure (catastrophic) |
|
Sirimai et al. (1999) [33] |
Maxillary central incisors (N = 60, n = 10) |
· Cast metal post |
· Group 1: CPC |
Decoronated at the level of the most incisal point of the CEJ |
Fracture resistance and mode of failure |
· Group 1 (CPC): 288.61 ± 51.74 N |
·Group 1: 100% |
|
· Prefabricated metal post |
· Group 2: VPT |
· Group 2 (VPT): 254.70 ± 55.66 N |
·Group 2: 60% |
|
· Polyethylene fiber post |
· Group 3: PWFH |
· Group 3 (PWFH): 127.01 ± 26.85 N |
·Group 3: 10% |
|
· Group 4: PWFH-VPT |
· Group 4 (PWFH-VPT): 218.34 ± 20.48 N |
·Group 4: 40% |
|
· Group 5: PWFH-PP |
· Group 5 (PWFH-PP): 233.63 ± 42.92 N |
·Group 5: 20% |
|
· Group 6: PP |
· Group 6 (PP): 201.39 ± 29.1 N |
·Group 6: 80% |
|
Newman et al. (2003) [18] |
Maxillary central incisors (N = 90, n = 10) |
· Prefabricated glass fiber post |
Control: |
Decoronated 2 mm incisal to the CEJ of the buccal surfaces |
Fracture resistance and mode of failure |
|
|
|
· Prefabricated metal post |
· 1,4: Parapost XH 1.5 mm |
· 1,4: 18.33 ± 3.27 kg |
·1,4: 30% |
|
· Polyethylene fiber post |
Narrow canals: |
|
|
|
· 1,1: Fiberkor fiber post 1.5 mm |
· 1,1: 9.79 ± 1.29 kg |
|
|
· 1,2: Luscent fiber post 1.6 mm |
· 1,2: 12.90 ± 1.64 kg |
·1,1: 0% |
|
· 1,3: Ribbond 1.6 mm |
· 1,3: 4.55 ± 1.49 kg |
·1,2: 0% |
|
· 1,5: Ribbond nonstandardized 2 mm |
· 1,5: 24.91 ± 11.53 kg |
·1,3: 0% |
|
Flared canals: |
|
·1,5: 0% |
|
· 2,1: Fiberkor fiber post 1.5 mm |
· 2,1: 9.04 ± 1.76 kg |
|
|
· 2,2: Luscent fiber post 1.6 mm |
· 2,2: 12.87 ± 2.69 kg |
·2,1: 0% |
|
· 2,3: Ribbond 1.6 mm |
· 2,3: 12.87 ± 3.54 kg |
·2,2: 0% |
|
· 2,5: Ribbond nonstandardized 2 mm |
· 2,5: 31.95 ± 11.98 kg |
·2,3: 0% |
|
|
|
·2,5: 0% |
|
Ozcan and Valandro (2009) [31] |
Maxillary canines (N = 70, n = 10) |
· Prefabricated metal post |
· Group 1: Titanium posts (ParaPost) + Silano-Pen (Bredent) + silane |
2 mm above the buccal CEJ |
Fracture resistance and mode of failure |
· Group 1: 521 ± 153 N |
No catastrophic |
|
· E-glass fiber post |
· Group 2: Titanium posts + 30 μm CoJet-Sand (3M ESPE) + silane |
· Group 2: 525 ± 91 N |
fractures for |
|
· Polyethylene fiber post |
· Group 3: Titanium posts + 50 μm Al2O3 + V-primer (Sun Medical) |
· Group 3: 550 ± 149 N |
any group |
|
· Group 4: Titanium posts + 50 μm Al2O3 + Alloy primer (Kuraray) |
· Group 4: 408 ± 122 N |
|
|
· Group 5: E-glass FRC post (EverStick) |
· Group 5: 321 ± 131 N |
|
|
· Group 6: Polyethylene fiber (Ribbond) + resin impregnation |
· Group 6: 267 ± 108 N |
|
|
· Group 7: Resin composite core only, with no posts |
· Group 7: 175 ± 70 N |
|
|
Ozcopur et al. (2010) [32] |
Single rooted teeth (N = 80, n = 10) |
· Prefabricated metal post |
Sound roots: control |
Decoronated keeping a root length of 12 mm |
Fracture resistance and mode of failure |
Sound roots: control |
Sound roots: |
|
· Prefabricated glass fiber post |
· Unicore |
• Unicore: 1,472.78 ± 195.29 N |
control |
|
· E-glass fiber post |
· EverStick |
• EverStick: 1,265.94 ± 81.46 N |
·Unicore: 80% |
|
· Polyethylene fiber post |
· Ribbond |
• Ribbond: 976.74 ± 103.7 N |
·EverstickEverStick: 40% |
|
· Parapost |
• Parapost: 1,342.29 ± |
·Ribbond: 0% |
|
Reattached fragments |
370.13 N |
·Parapost: 60% |
|
· Unicore |
Reattached fragments |
|
|
· EverStick |
• Unicore: 1070.77 ± |
Reattached |
|
· Ribbond |
178.42 N |
fragments |
|
· Parapost |
• EverStick: 1042.23 ± |
·Unicore: 58% |
|
|
147.06 N |
·EverstickEverStick: 47% |
|
|
• Ribbond: 995.32 ± 88.75 N |
·Ribbond: 25% |
|
|
• Parapost: 1318.3 ± 240.9 N |
·Parapost: 68% |
|
Aggarwal et al. (2012) [35] |
Uni-radicular mandibular premolar teeth (N = 50, n = 10) |
· Cast metal post |
· Group I/CD: cast dowel |
Decoronated |
Fracture resistance and mode of failure |
· Group I/CD: 484 ± 41 N |
·Group I/CD: 90% |
|
· Prefabricated glass fiber post |
· Group II/FD: single glass fiber dowel |
· Group II/FD: 338 ± 28 N |
·Group II/FD: 20% |
|
· Polyethylene fiber post |
· Group III/AFD: glass fiber-reinforced resin dowel with accessory fiber dowels |
· Group III/AFD: 352 ± 34 N |
·Group III/AFD: 30% |
|
· Group IV/DL: relined glass fiber-reinforced resin dowel |
· Group IV/DL: 368 ± 24 N |
·Group IV/DL: 30% |
|
· Group V/RRR: dowels formed with the help of polyethylene fiber ribbon-reinforced resin composite |
· Group V/RRR: 256 ± 22 N |
·Group V/RRR: 0% |
|
Jindal et al. (2012) [30] |
Maxillary incisors (N = 75, n = 15) |
· Prefabricated glass fiber post |
Control group |
Decoronated 2 mm above CEJ |
Fracture resistance and mode of failure |
Control: 437.87 ± 32.81 N |
Glass fiber post |
|
· Polyethylene fiber post |
Glass fiber post |
Glass fiber post |
·10 mm: 0% |
|
· 10 mm |
· 10 mm: |
·5 mm: 30% |
|
· 5 mm |
740.21 ± 29.87 N |
Ribbond fiber post |
|
Ribbond fiber post |
· 5 mm: |
·10 mm: 40% |
|
· 10 mm |
425.18 ± 42.73 N |
·5 mm: 30% |
|
· 5 mm |
Ribbond fiber post |
|
|
|
· 10 mm: |
|
|
|
216.93 ± 53.39 N |
|
|
|
· 5 mm: |
|
|
|
299.62 ± 53.42 N |
|
|
Kumar et al. (2013) [29] |
Mandibular premolars (N = 60, n = 15) |
· E-glass fiber post |
· Group 1: Only dual cure resin cement |
Decoronated root length: 10 mm |
Fracture resistance and mode of failure |
· Group 1: 181.26 ± 2.90 N |
·Group 1: 73% |
|
· Polyethylene fiber post |
· Group 2: Ribbond |
· Group 2: 279.56 ± 0.80 N |
·Group 2: 0% |
|
· Group 3: EverStick |
· Group 3: 224.09 ± 3.43 N |
·Group 3: 60% |
|
(vertical fractures simulated in all three groups) |
· Group 4: 328.14 ± 1.06 N |
|
|
· Group 4: Unfractured control group |
|
|
|
Braga et al. (2015) [26] |
Maxillary premolars (N = 100, n = 10) |
· Prefabricated glass fiber post |
· Group 1: sound teeth (positive control) |
Class II MOD cavities,1m above CEJ on both sides, with palatal extension cusps reduced to dimension 3 mm thick and 3.5 mm in height |
Fracture resistance and mode of failure |
· Group 1: 0.83 ± 0.15 N |
· Group 1: 0% |
|
· Prefabricated polyfiber post |
· Group 2: unrestored (negative control) |
· Group 2: 0.14 ± 0.05 N |
· Group 2: 50% |
|
· Polyethylene fiber post |
· Group 3:MR |
· Group 3: 0.43 ± 0.09 N |
· Group 3: 50% |
|
· Group 4:FR+ MR |
· Group 4: 0.53 ± 0.07 N |
· Group 4: 40% |
|
· Group 5: glass fiber post (Reforpost) + MR |
· Group 5: 0.41 ± 0.12 N |
· Group 5: 0% |
|
· Group 6: Reforpost + FR + MR |
· Group 6: 0.48 ± 0.13 N |
· Group 6: 10% |
|
· Group 7:polyethylene fiber (Ribbond) + MR |
· Group 7: 0.50 ± 0.17 N |
· Group 7: 50% |
|
· Group 8: Ribbond + FR + MR |
· Group 8: 0.54 ± 0.14 N |
· Group 8: 10% |
|
· Group 9: polyfiber post (Spirapost) + MR |
· Group 9: 0.79 ± 0.16 N |
· Group 9: 30% |
|
· Group 10: Spirapost + FR + MR |
· Group 10: 0.84 ± 0.11 N |
· Group 10: 20% |
|
Ramesh et al. (2016) [36] |
Reattached maxillary central incisor fragments (N = 60, n = 30) |
· Prefabricated glass fiber post |
Group 1: labiopalatal fracture |
Group 1: 2 mm palatally, 6 mm labially |
Fracture resistance and mode of failure |
Group 1: |
Group 1: |
|
· Polyethylene fiber post |
· Subgroup 1: prefabricated fiber post |
Group 2: 6 mm palatally, 2 mm labially |
· Subgroup 1: 568.4 ± 18.65 N |
·subgroupSubgroup 1: 20% |
|
· Subgroup 2: Ribbond post |
|
· Subgroup 2: 519.7 ± 22.36 N |
·subgroupSubgroup 2: 0% |
|
Group 2: palatolabial fracture |
|
Group 2: |
|
|
· Subgroup 1: prefabricated fiber post |
|
· Subgroup 1: 533.4 ± 19.62 N |
Group 2: |
|
· Subgroup 2: Ribbond post |
|
· Subgroup 2: 488.1 ± 34.41 N |
·subgroupSubgroup 1: 13.3% |
|
|
|
· Subgroup 2: 488.1 ± 34.41 N |
·subgroupSubgroup 2: 0% |
|
Thakur and Ramarao (2019) [34] |
Mandibular first premolars (N = 90, n = 10) |
· E-glass fiber post |
Post length 2/3rd of the canal: |
Decoronated at CEJ, root length 15 mm |
Fracture resistance |
· Subgroup 1A: 179.75 ± 33.52 N |
Not applicable |
|
· Polyethylene fiber post |
· Subgroup 1A: custom polyethylene post |
· Subgroup 1B: 166.84 ± 33.11 N |
|
· Subgroup 1B: custom glass fiber post |
· Subgroup 1C: 250.33 ± 15.40 N |
|
· Subgroup 1C: prefabricated polyethylene post |
· Subgroup 1D: 201.39 ± 41.44 |
|
· Subgroup 1D: prefabricated glass fiber post |
|
|
Post length 1/2 of the canal: |
· Subgroup 2A: 146.44 ± 13.53 N |
|
· Subgroup 2A: custom polyethylene post |
· Subgroup 2B: 159.97 ± 34.06 N |
|
· Subgroup 2B: custom glass fiber post |
· Subgroup 2C: 224.2 ± 32.9 N |
|
· Subgroup 2C: prefabricated polyethylene post |
· Subgroup 2D: 204.07 ± 29.63 N |
|
· Subgroup 2D: prefabricated glass fiber post |
|
|
Control group: core without post |
Control group: 57.34 ± 14.03 N |
|
Khurana et al. (2021) [28] |
Maxillary incisors (N = 60, n = 15) |
· E-glass fiber post |
Group A: labiopalatal fracture |
Labiopalatal: 2 mm palatally, 6 mm labially |
Fracture resistance |
Group A: |
Not applicable |
|
· Polyethylene fiber post |
· A1: Ribbond |
Palatolabial: 6 mm palatally, 2 mm labially |
· A1: 517.4 ± 72.0 N |
|
· A2: EverStick |
|
· A2: 725.5 ± 59.6 N |
|
Group B: palatolabial fracture |
|
Group B: |
|
· B1: Ribbond |
|
· B1: 423.2 ± 80.5 N |
|
· B2: EverStick |
|
· B2: 617.0 ± 81.8 N |
|
Batra et al. (2022) [27] |
Mandibularfirst premolars (N = 48, n = 12) |
· Zirconia post |
· Group I: Zirconia post, |
Not mentioned |
Fracture resistance |
· Group I: 463.5 ± 14.3 N |
Not applicable |
|
· Prefabricated glass fiber post |
· Group II: Glass fiber post, |
· Group II: 425.2 ± 23.5 N |
|
· Polyethylene fiber post |
· Group III: polyethylene -woven fiber posts, |
· Group III: 410.4 ± 18.6 N |
|
· Quartz post |
· Group IV: Quartz post |
· Group IV: 385.2 ± 14.2 N |
Table 2.Additional characteristics extracted from selected studies
|
Study (year) |
Material used to form custom polyethylene fiber posts |
Luting cement used |
Thermocycling |
Fracture testing equipment |
Statistical analysis software |
Statistical tests performed |
|
Sirimai et al. (1999) [33] |
Variolink, Ivoclar |
· Group 1 and 2: Zinc phosphate cement |
Not performed |
Instron Universal Testing Machine 4202 |
SAS program |
· One-way ANOVA |
|
· Group 3, 4, 5 and 6: Variolink, Ivoclar |
· Student Newman-Keuls grouping |
|
· 2 × 2 chi-square analysis |
|
Newman et al. (2003) [18] |
Flow-it, Pentron Clinical Technologies |
· 1,1; 1,2; 1,4: Cement-it, Pentron Clinical Technologies |
Not performed |
Instron Universal Testing Machine 5655 |
SYSTAT |
· Two-way ANOVA |
|
· 2,1; 2,2: Flow-it Self, Pentron Clinical Technologies |
· ANOVA test |
|
· 1,3; 1,5; 2,3; 2,5: Flow-it, Pentron Clinical Technologies |
· Independent Student t-test |
|
· Tukey test |
|
Ozcan and Valandro (2009) [31] |
Panavia F 2.0, Kuraray |
Panavia F 2.0, Kuraray |
Subjected to thermocycling for 6,000 cycles between 5° and 55°C |
Zwick ROELL Z2.5MA Universal Testing Machine |
SAS program |
· One-way ANOVA |
|
· Tukey test |
|
Ozcopur et al. (2010) [32] |
Variolink II, Ivoclar |
Variolink II, Ivoclar |
Not performed |
Instron Universal Testing Machine |
Not mentioned |
· One-way ANOVA |
|
· Independent t-test |
|
Aggarwal et al. (2012) [35] |
RelyX ARC, 3M ESPE |
· Group I/CD: Zinc phosphate, SS White |
Not performed |
Zwick Instron Universal Testing Machine |
Not mentioned |
· One-way ANOVA |
|
· Group II/FD: RelyX ARC, 3M ESPE |
· Fischer exact test |
|
· Group III/AFD: RelyX ARC, 3M ESPE |
|
|
· Group IV/DL: Filtek Z350, 3M ESPE |
|
|
· Group V/RRR: RelyX ARC, 3M ESPE |
|
|
Jindal et al. (2012) [30] |
Monocem, Shofu |
Monocem, Shofu |
Not performed |
LR 100 K digital Instron Universal Testing Machine |
SPSS version 11.0 |
· One-way ANOVA and post hoc test |
|
Kumar et al. (2013) [29] |
RelyX U100, 3M ESPE |
RelyX U100, 3M ESPE |
Not performed |
Universal Testing Machine |
Not mentioned |
· One-way ANOVA |
|
· Tukey post hoc test |
|
· Kruskall-Wallis and Mann-Whitney test |
|
Braga et al. (2015) [26] |
RelyX ARC, 3M ESPE |
RelyX ARC, 3M ESPE |
Not performed |
Instron Universal Testing Machine 4444 |
SPSS version 17 |
· Kolmogorov-Smirnov test |
|
· One-way ANOVA |
|
· Tukey post hoc test |
|
Ramesh et al. (2016) [36] |
ParaCore, Coltene |
ParaCore, Coltene |
Not performed |
Instron Universal Testing Machine |
Excel and SPSS |
· Student t-test |
|
· Chi-square test |
|
Thakur and Ramarao (2019) [34] |
Luxa core Z, DMG |
Luxa core Z, DMG |
Not performed |
Hounsfield Universal Testing Machine, S-series |
Not mentioned |
· One-way and two-way ANOVA |
|
· Bonferroni adjustment test |
|
Khurana et al. (2021) [28] |
Solocem, Coltene |
Solocem, Coltene |
Not performed |
Instron Universal Testing Machine |
SPSS version 23 |
· One-way ANOVA and post hoc test |
|
Batra et al. (2022) [27] |
Panavia F 2.0, Kuraray |
Panavia F 2.0, Kuraray |
Not performed |
Universal Testing Machine |
SPSS |
· One-way ANOVA |
|
· Bonferroni post hoc test |
Table 3.Risk of bias assessment based on reporting of items according to the modified CONSORT guidelines for in vitro studies
|
Study |
Specimens’ set-up
|
Sample size calculation |
Randomization
|
Outcome |
Statistical methods |
Materials and methods
|
Evaluation and results
|
“Funding had no influence” |
Risk of bias
|
|
Teeth size and form standardization |
Teeth free of caries or restorations |
Randomization of specimens |
Implementation of sequence generation |
Standardized teeth preparation |
Standardized and replicable methodology |
Material application measures were followed |
Blinded Evaluation |
Complete results |
|
Ramesh et al. [36] |
Yes |
Yes |
No information |
Yes |
No information |
Yes |
Yes |
Yes |
Yes |
Yes |
No information |
Yes |
Yes |
Low |
|
Ozcan and Valandro [31] |
Yes |
Yes |
No information |
Yes |
No information |
Yes |
Yes |
Yes |
Yes |
Yes |
No information |
Yes |
Yes |
Low |
|
Braga et al. [26] |
Yes |
Yes |
No information |
Yes |
No information |
Yes |
Yes |
Yes |
Yes |
Yes |
No information |
Yes |
Yes |
Low |
|
Aggarwal et al. [35] |
Yes |
Yes |
No information |
Yes |
No information |
Yes |
Yes |
Yes |
Yes |
Yes |
No information |
Yes |
Yes |
Low |
|
Jindal et al. [30] |
Yes |
Yes |
No information |
Yes |
No information |
Yes |
Yes |
Yes |
Yes |
Yes |
No information |
Yes |
Yes |
Low |
|
Sirimai et al. [33] |
Yes |
Yes |
No information |
Yes |
No information |
Yes |
Yes |
Yes |
Yes |
Yes |
No information |
Yes |
Yes |
Low |
|
Ozcopur et al. [32] |
Yes |
Yes |
No information |
Yes |
No information |
Yes |
Yes |
Yes |
Yes |
Yes |
No information |
Yes |
Yes |
Low |
|
Newman et al. [18] |
Yes |
Yes |
No information |
Yes |
No information |
Yes |
Yes |
Yes |
Yes |
Yes |
No information |
Yes |
Yes |
Low |
|
Khurana et al. [28] |
Yes |
Yes |
No information |
Yes |
No information |
Yes |
Yes |
Yes |
Yes |
Yes |
No information |
Yes |
Yes |
Low |
|
Kumar et al. [29] |
Yes |
Yes |
No information |
Yes |
No information |
Yes |
Yes |
Yes |
Yes |
Yes |
No information |
Yes |
Yes |
Low |
|
Batra et al. [27] |
Yes |
Yes |
No information |
Yes |
No information |
Yes |
Yes |
Yes |
Yes |
Yes |
No information |
Yes |
Yes |
Low |
|
Thakur and Ramarao [34] |
Yes |
Yes |
No information |
Yes |
No information |
Yes |
Yes |
Yes |
Yes |
Yes |
No information |
Yes |
Yes |
Low |
Table 4.Incidence rates of Modes of Failure (catastrophic vs non-catastrophic fractures) of Ribbond posts vs other post systems
|
Source |
% of non-catastrophic fractures (repairable/favorable) |
|
Ribbond vs ETT without posts |
ETT without posts |
Ribbond posts |
|
Ozcan and Valandro (2009) [31] |
100% |
100% |
|
Kumar et al. (2013) [29] |
27% |
100% |
|
Braga et al. (2015) [26] |
100% |
90% |
|
Ribbond posts vs cast metal posts |
Cast metal posts |
Ribbond posts |
|
Sirimai et al. (1999) [33] |
0% |
90% |
|
Aggarwal et al. (2012) [35] |
10% |
100% |
|
Ribbond posts vs prefabricated metal posts |
Prefabricated metal posts |
Ribbond posts |
|
Sirimai et al. (1999) [33] |
20% |
90% |
|
Newman et al. (2003) [18] |
70% |
100% |
|
Ozcopur et al. (2010) [32] |
40% |
100% |
|
Ribbond posts vs prefabricated glass fiber posts |
Prefabricated glass fiber posts |
Ribbond posts |
|
Newman et al. (2003) [18] |
100% |
100% |
|
Ozcopur et al. (2010) [32] |
20% |
100% |
|
Aggarwal et al. (2012) [35] |
80% |
100% |
|
Jindal et al. (2012) [30] |
70% |
70% |
|
Braga et al. (2015) [26] |
100% |
90% |
|
Ramesh et al. (2016) [36] |
80% |
100% |
|
Ribbond vs custom e-glass fiber posts |
Custom e-glass fiber posts |
Ribbond posts |
|
Ozcopur et al. (2010) [32] |
60% |
100% |
|
Kumar et al. (2013) [29] |
40% |
100% |
|
Braga et al. (2015) [26] |
100% |
100% |
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