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 Table of Contents  
RESEARCH
Year : 2022  |  Volume : 22  |  Issue : 1  |  Page : 38-47

A randomized controlled twelve month clinical study on the evaluation of success rate of endodontically treated teeth restored with metal poly-fiber posts and dentin posts


Department of Prosthodontics, K M Shah Dental College and Hospital, Sumandeep Vidyapeeth Deemed to be University, Vadodara, Gujarat, India

Date of Submission08-Apr-2021
Date of Decision08-Dec-2021
Date of Acceptance17-Dec-2021
Date of Web Publication27-Jan-2022

Correspondence Address:
Rajesh Sethuraman
No 9 Department of Prosthodontics, K M Shah Dental College and Hospital, Sumandeep Vidyapeeth Deemed to be University, Piparia, Vadodara - 391 760, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jips.jips_134_21

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  Abstract 


Settings and Design: Department of Prosthodontics, KMSDCH, SVDU, Randomised Controlled study.
Materials and Methods: Thirty-six teeth that satisfied selection criteria were randomly allocated and treated in the two intervention groups – metal fiber post with composite core and dentin post with composite core. Patient characteristics with respect to gender, tooth guidance, type of tooth, and mobility amount of tooth structure left were recorded. The primary outcome of tooth loss and the secondary outcomes of recurrent caries detected at the crown margin, de-cementation of crown, and fracture of the core, post, and root were recorded at baseline, 3, 6, and 12 month follow up.
Statistical Analysis Used: Chi Square test.
Results: Thirty-six teeth in 17 patients (10 males and 7 females) were treated using metal fiber post (18 teeth) and dentin post (18 teeth). No loss of tooth was seen at the end of 3, 6, and 12 months. The secondary outcomes also showed no recurrent caries at margin and no fracture of core, post, and root in both the groups at the end of 3, 6, and 12 months. One case of de-cementation was observed in both the groups at the 12-month period. Periodontal and periapical conditions showed no clinical and radiographic signs at any of the follow-up periods in both the groups.
Conclusion: This twelve month randomized controlled clinical study concluded a similar success rate for endodontically treated teeth restored with crowns on both metal fiber post with composite core and dentin post with composite core.

Keywords: Crown de-cementation, dentin post, endodontically treated teeth, loss of tooth, metal polyfiber post, randomized control trial, root fracture


How to cite this article:
Patel SS, Sethuraman R. A randomized controlled twelve month clinical study on the evaluation of success rate of endodontically treated teeth restored with metal poly-fiber posts and dentin posts. J Indian Prosthodont Soc 2022;22:38-47

How to cite this URL:
Patel SS, Sethuraman R. A randomized controlled twelve month clinical study on the evaluation of success rate of endodontically treated teeth restored with metal poly-fiber posts and dentin posts. J Indian Prosthodont Soc [serial online] 2022 [cited 2022 May 25];22:38-47. Available from: https://www.j-ips.org/text.asp?2022/22/1/38/336673




  Introduction Top


The best standard of care following endodontic treatment when a tooth lacks adequate structure to bond a conservative endocrown is to lute or bond a post with a composite core buildup primarily to provide adequate retention and resistance form to retain the definitive crown. Such restorations need a careful selection of the endodontic post system which has always been determined by experience and practicality of the practitioner. However, with increased clinical research, it has been that the decision to treat a tooth endodontically should be determined by the amount and nature of remaining tooth structure that would be able to support a definitive crown and in cases where a full-coverage restoration is the decision, and then, the practitioner has a choice of various post and core materials and post designs to retain an overlying crown.

The use of posts was originally only for retaining a crown in cases where reduced coronal structure remained[1] and was glorified to reinforce the remaining tooth.[2] With time, various authors hypothesized that the posts should have rigidity that be close to dentin in order to favorably dissipate the occlusal forces along the long axis of the tooth.[3],[4],[5] Metallic posts lack this unique requirement and moreover produce catastrophic fractures of roots. Posts therefore have been developed with a modulus of elasticity that mimics that of dentin. Most studies advocate the use of glass fiber posts for long-term success in restoring endodontically treated teeth as they are esthetic and resistant to corrosion and produce less unfavorable root fractures. In the past few years, material research has been directed toward obtaining materials with biomimetic properties. None of the premanufactured post systems meet all ideal biomechanical properties.

Metal polyfiber posts (SpirapostPFS, DMG, NJ, America) and dentin posts are two novel post types that have been innovated but less used in clinical scenarios. The metal polyfiber post is made up of stainless steel wires of surgical grade twisted around natural colored biocompatible polyfiber strands. Being self-adaptive, these innovative metal polyfiber posts fit the canals as if they are customized for the case. They adapt easily even in cases with curvatures, involve very less of dentin removal, and make a mechanically strong structure. Further, the coronal part of the post can be angulated according to the need of the long axis of the tooth to provide unhindered core buildup and adequate resistance form. The manufacturers claim 100% biocompatibility and ease of remove if retreatment is necessary.[6] Munoz et al. in 2007[7] evaluated the effect of cyclic loading on teeth restored with metal fiber posts and concluded that the new fiber metal post was able to resist functional and parafunctional forces when subjected to a loading force and in fact able to resist higher fatigue forces. Therefore, metal polyfiber post presents a clinical alternative to conventional rigid posts. Mastoras et al. inferred that the metal polyfiber system provided significantly increased post retention when compared with the fiber post.[8]

Biological dentin posts made from natural, extracted teeth present a feasible option for the strengthening of the root canal, thus presenting the potential advantages of low dentin stress, along with preservation of dentin walls. These posts being adhesively bonded to tooth dentin show greater retention compared to premanufactured posts and provide an economical option for restoring endodontically treated teeth. Case reports on the use of dentin posts to restore endodontically treated teeth exist in literatures.[9],[10] Kathuria et al. concluded that teeth restored with dentin posts exhibited better fracture resistance than those restored with fiber-reinforced composite posts.[11]

In vitro studies indicate that the metal fiber post and dentin post are better than other post systems. Being lately introduced clinical behavior and success rates of the metal polyfiber post and dentin post are still lacking. Hence, there existed a need for a randomized control clinical study to evaluate the fracture resistance of these two post and core systems in endodontically treated teeth for a 12-month clinical observation period. The null hypothesis proposed in the study is that both the posts (metal polyfiber post and dentin post) do not differ in the success rates as compared with the primary and secondary outcomes for an observation period of 1 year.


  Methodology Top


The study was conducted in the Department of the Prosthodontics and Crown and Bridge. Ethical approval for the study was granted by the Institutional Ethics Committee, SV vide no SVIEC/ON/DENT/BN-PG12/012116. All the patients who reported to the Department of Prosthodontics and Crown and Bridge for post endodontic rehabilitations were screened for the need of post and core restorations. The endodontically treated teeth were evaluated for inclusion and exclusion criteria which were set for the study. All eligible participants were informed of the nature of the study using the participant information sheet in their own language. A signed informed consent form in a language that the patient understood was obtained. The basic information recording patient details, operatory details, and primary and secondary outcomes at 3, 6, and 12 months was recorded in a pro forma.

On the basis of data values obtained from the study done by Naumann et al.,[12] a sample size was obtained by using nMaster software (version 2.0) at 95% confidence interval and 80% power. A total sample size of 30 was arrived at which was divided equally into 15 in each group. Further considering a 20% dropout in the study, a final sample size of 36 was achieved.

The patients who reported to the Department of Prosthodontics in the period extending for 9 months (January to September) were screened and recruited in the study. This study was done on the 17 participants and 36 endodontically treated teeth adhering to the following inclusion and exclusion criteria. All patients received post and core treatment followed by crown placement as indicated for the case and were on a period of observation of 3, 6, and 12 months.

Inclusion criteria

  1. Any teeth with an adequate root filling with no evidence of endodontic failure
  2. Two or more cavity walls remaining
  3. Symptom-free canal filling with a minimum apical seal of 4 mm
  4. Healthy periodontium with no evidence of bleeding on probing with at least 75% periodontal support as seen on radiograph
  5. Teeth with a minimum of 2 mm of coronal healthy tooth structure above gingiva or if lesser than that should be increased by a crown-lengthening procedure to get 2 mm of healthy crown structure
  6. Residual root canal thickness at the orifice of more than 1 mm
  7. Willingness to return at the intervals of at least 1-year evaluation.


Exclusion criteria

  1. Potential abutments for fixed or removable prosthesis
  2. Lack of adequate posterior support, defined as the absence of all molar teeth
  3. Any obvious occlusal interference or fremitus affecting the tooth to be restored
  4. Missing teeth in opposite arch
  5. Patients with parafunctional habit (bruxism)
  6. Patient who refuse crown-lengthening procedure
  7. Pregnant patient.


The study being a randomized control design, the cases included were randomized using a computer-generated sequence of random numbers to the intervention group of metal fiber and control group of dentin posts. The generated randomized sequence was as follows 2 1 2 2 2 1 2 2 2 1 1 1 2 1 1 1 1 2 2 1 1 1 2 2 1 1 2 1 1 2 1 2 1 1 1 1 with “1” being metal polyfiber post group and “2” being dentin post group. The allocation details were sealed in an opaque envelope which was only opened after the period of 1-year evaluation prior to tabulating data for statistical evaluation. The group assignment for every tooth in the patients as decided by the sequence of random numbers was maintained by the department sister. The patient was also blinded to the groups under which their teeth were being treated.

In the study recruitment period of 9 months, 49 patients who were candidates for post and core restorations were screened for the inclusion and exclusion criteria. Of these, 13 cases were excluded, of which 9 did not satisfy inclusion criteria and 4 patients refused to participate. The remaining 36 cases were randomized for equal distribution into metal polyfiber post group and dentin post group (18 each). The summary of this study design is presented as a CONSORT flow diagram in [Figure 1].
Figure 1: CONSORT flow diagram of the study design and flow of participants in various phases of the study

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At the baseline, a routine examination was performed to record demographic details, tooth type, tooth mobility,[13] functional status on the basis of degree of attrition,[14] type of tooth guidance as combined anterior/canine guidance, canine guidance, and group function. Prior to the post placement, impressions were made of each tooth to document the amount of hard tissue loss according to the tooth restorability index.[15] Need for crown lengthening for ferrule was evaluated using a periodontal probe. A circumferential 2-mm ferrule was considered favorable, otherwise a surgical crown-lengthening procedure was done. Post space preparation was done using routine protocols of instrumentation, radiography, and principles of restoration of endodontically treated teeth.

For preparing dentin posts, the following method was followed to ensure standardization. In a clear acrylic block, three different post space preparations were done with the help of number 1, 2, and 3 Peeso drill (Hi-Rem over fiber post system, Italy). Dentin posts were prepared from healthy maxillary and/or mandibular canine or single-rooted premolar teeth which were freshly exacted for periodontal or orthodontic reasons or dis-impaction which were noncarious and had no evidence of cracks. Patients whose teeth were used for the study purpose provided consent to use their teeth for research purpose. The teeth were kept in 10% formaldehyde for 7 days and then sterilized in a Class B autoclave at 121°C for 15 min as per CDC guidelines[16] and decoronated after sterilization. Debris and soft tissue were removed from the extracted tooth and sectioned longitudinally into two halves along the root canal with the high-speed air rotor [Figure 2]. The pulp tissue was removed from the canal. Dentin block was prepared out of each section and shaved with the flat taper fissure bur [Figure 3] to closely fit the shape of the previously prepared post spaces prepared using different sizes of Peeso reamers in the plexiglass block [Figure 4] and [Figure 5]. Dentin post thus prepared was of the size of Peeso reamer, and these were used as per requirement of diameter and length in patients. Posts thus prepared were sterilized using autoclave cycle of 121°C for 15 min and kept ready before use in patients.
Figure 2: Sectioning of tooth

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Figure 3: Shaving of dentin to prepare post

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Figure 4: Plexiglass with different post spaces prepared

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Figure 5: Dentin posts made of different sized custom fit to the plexiglass post spaces

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All root canals receiving metal polyfiber and dentin posts were minimally prepared to allow passive insertion of the posts [Figure 6]. Fit and extension of the posts were confirmed radiographically. The selected posts were disinfected with a glutaraldehyde disinfectant and cemented using flowable dual-cure Duolink composite luting cement (Bisco Inc., Schaumburg, Illinois, US) [Figure 7] and [Figure 8]. Light-cure composite buildup was done using Bis-Core core buildup dual-cure composite (Bisco Inc., Schaumburg, Illinois, US) [Figure 9]. All teeth received full-coverage crowns luted with resin-modified GIC luting cement [Figure 10]. Maintenance instruction was given to each patient, and they were placed on a regular checkup and follow-up. A baseline intraoral periapical radiograph was taken once the crown was cemented [Figure 11]. The patient was recalled at 3-, 6-, and 12-month interval to evaluate the primary and secondary outcomes of post endodontic restoration [Figure 12], [Figure 13], [Figure 14]. The primary endpoint was loss of tooth for any reason and the secondary endpoints were recurrent caries detected at the crown margin,[17] de-cementation of crown, fracture of the core, fracture of the post, and fracture of the root.
Figure 6: Post space preparation

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Figure 7: Cemented metal polyfiber post

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Figure 8: Cemented dentin post

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Figure 9: Composite core buildup

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Figure 10: Baseline radiograph

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Figure 11: Luted metal-ceramic crowns

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Figure 12: Three-month observation

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Figure 13: Six-month observation

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Figure 14: Twelve-month observation

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During every follow-up, the clinical examination was performed by one calibrated blinded examiner (RS). However, blinding for radiographic interpretation could not be done. Follow-up examinations were performed with a dental probe and mirror to detect marginal gap formation of the restorations. Fracture of core in case of de-cementation of crown was evaluated clinically. Radiograph was taken in every recalled interval time to exclude the possibility of radiographic symptoms of root and post failure and periodontal and periapical lesions. Codes were assigned according to the outcomes by the examiner. The collected data were entered in the Excel sheets and tabulated and subjected to statistical analysis using Graph Pad Prism 9 Software, San Diego, California, America.


  Results Top


The demographic details of the patients included in the study and tooth characteristics are summarized in [Table 1]. A total of 36 patients with a mean age of 39 years for the metal polyfiber post group and 47 years for the dentin post group were recruited in the randomized control trial. Most of these teeth were incisors (38.88%) followed by premolars (33.33%) and an equal number of canines and molar teeth (13.15%). Majority of these teeth were restored with metal-ceramic crowns (72.22%). Metal restorations were around 25%, and all-ceramic crowns were 0.02%. All the patients were available for follow-up at 3-, 6-, and 12-month follow-up. The observations made for the primary and secondary outcomes are summarized in [Table 2]. None of the teeth in either group at all the three time intervals showed loss of tooth, recurrent caries detected at the crown margin, and fracture of the core or post or root. Two cases of crown de-cementations were reported at the end of 12 months, one in each group though. No post or core or root fracture was seen, and re-cementation after evaluating dynamic occlusion was done. Results of the Chi-square test for de-cementation using GraphPad Prism 9 software [Table 3] showed a statistically insignificant difference between the groups at different time intervals. Radiographic interpretations were not a part of outcome analysis but were done as protocol to evaluate the presence or absence of root fracture and development and/or progress of periodontal and periapical lesion if any. Nevertheless, radiographic assessments also did not show any new or change in periapical or periodontal tissues at the end of the time intervals. No symptoms of pain or any form of discomfort were reported by the patients. As there was no difference in the primary and secondary outcomes, any statistical evaluation of these observations was not done. On the basis of these results, the null hypothesis was accepted, indicating that there was no clinical or statistical difference in the success rate of endodontically treated teeth receiving restorations over either dentin post or metal polyfiber post.
Table 1: Demographic and tooth characteristics for the two groups

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Table 2: Primary and secondary outcomes in the two groups

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Table 3: Result of the Chi-square test for de-cementation of the crown

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  Discussion Top


Pulpless teeth survive the brunt of masticatory load if the access cavity opening has been conservative, and/or loss of tooth structure due to caries and resorption is minimal. In spite of these, evidence does exist to demonstrate pulpless teeth to be more prone to fracture than vital teeth.[18],[19] It has also been observed that posterior teeth are more prone to cervical third and unfavorable fractures due to the nature of oblique stresses that act on them.[20] Engineering principles indicate that natural teeth with integral coronal and radicular structures perform best clinically. With endodontically treated teeth, these forms are affected and hence they may not perform to their fullest extent as a vital tooth may. Protection of such a weakened tooth is enhanced by an extra-coronal restoration. Many a time, the remaining tooth structure may not be adequate enough to retain a crown, thus indicating a post and core for long-term success. A post and core system is primarily needed to provide adequate structure to give retention to the crown. However, it should be done such that the load-bearing ability of the endodontically treated teeth is not jeopardized and thus failures are not invited. The adequacy and clinical efficiency of restorations post endodontic treatment have dictated the long-term success and survival of nonvital teeth.

The cast metal post and core is extremely strong but stiff and increases the possibility of a nonvital tooth to be fractured.[21] In addition, the esthetics and time-consuming techniques are added disadvantages. Hence, prefabricated metallic post systems, which are less stiff and more practical to use, came up which eventually were replaced by fiber-reinforced posts, with claims made that the glass, quartz, and carbon fiber post have properties close to dentin.

This study was planned as a randomized control design with inclusion criteria set as periodontally healthy teeth with successful endodontic treatment, adequate bone support with presence of at least 2 mm of ferrule tooth structure above the gingiva with 2 or more cavity walls, and with thickness of 2 mm dentin after tooth preparation.[22] These criteria ensure better prognosis and long-term success of the post and core treatment, strength of the root, and reduction of root fracture. The concept that remaining dentin needs to be preserved is a very vastly researched topic. Most studies conclude at least 1.5 mm to 2 mm of ferrule height and 1 mm of axial healthy dentin with or without crown lengthening as minimum requirements for adequate ferrule effect and resistance to fracture.[23],[24]

Success rate of endodontically treated teeth as abutments is reported to be 95% for single crowns, 89% for fixed partial denture and 77% for removable partial denture.[25],[26],[27] These stresses lead to fracture of teeth which are weakened by endodontic therapy and post placement. Vertical fractures occur in root-filled teeth fitted with posts, especially in those functioning as terminal abutments or as abutments for fixed or removable partial denture.[25],[28] Hence, abutment teeth and patients in whom past or present history of bruxism and/or excessive attrition were also not included in the study due to excessive masticatory loads and presence of little remaining coronal dentin.[3],[29]

Metal polyfiber and dentin posts were included in this trial as there are only in vitro studies that exist that evaluate the strength of teeth restored with them. Metal polyfiber posts were used as provided by the manufacturer. Commercial production of dentin post is not available, hence either they have to be produced manually or through CAD-CAM technology. The possibility of using CAD-CAM to produce dentin post was evaluated. However, there was not much success and feasibility found in the same. Hence, the manual method of preparing dentin post was adopted. The method was devised to produce high-quality sterilized and standardized dentin post. Sterilization guidelines followed were such that bond strength and physical properties of dentin were not affected.[30]

The luting resin also acts as a force buffer allowing favorable stress distribution. Dual-cure resin cement produces a hybrid layer that is essential to ensure good sealing for the post and core restoration and also to enhance post retention.[31],[32],[33] Good compressive strength, esthetic and adhesive properties similar elastic modulus were reasons to use composite resin as the core buildup material.[34],[35],[36] The methodology used to evaluate the outcomes was similar to those followed in previous well conducted clinical trials and retrospective studies.[37]

Results revealed that there was 100% success with respect to performance of both post and core systems for the primary outcome over 1-year period of evaluation. No tooth in both the groups showed tooth loss. In the absence of similar studies clinical on metal polyfiber post and Dentin post available in the literature, a strict comparison with other studies is not possible. However, similar primary outcome measures have been reported with other post and core systems in other studies.[22],[37] These studies concluded that glass fiber post and core systems show a high success rate in restoration of endodontically treated teeth. They attribute such performance to the properties of post to be similar in modulus of elasticity and biomechanical behavior similar to dentin. On similar lines, it can be deciphered from the results of the present study that the use of metal fiber post and dentin post would not result in tooth loss for a period of 1 year when careful selection and treatment of endodontically treated teeth is done.

The secondary outcomes included in this study were those that could directly or indirectly be an outcome of post placement. The biomechanical behavior of the post and core influences the behavior of cement, the cement bond to the tooth structure and to the crown. If a post is similar in properties to dentine, it is bonded to the remaining tooth forming a monoblock making it more favorable for the biomechanical behavior of the crown and luting agent. Thus, inadequate post and core properties and a biomechanical disadvantage if present in the system can manifest as loss of marginal integrity if the luting agent in the cervical margin, post or core or root fracture, cement microcracks, and crown de-cementation. Results of the secondary outcomes of recurrent caries detected at the crown margin, fracture of the core, fracture of the post, fracture of the root are similar to results obtained from Preethi et al.[37] and Grandini et al.[38] Although these studies did not evaluate the post type used in the present study, similarity in results could have been accorded as the post properties were similar, especially with glass fiber post. Grandini et al.[38] in their prospective study reported 9% of the crowns to have been de-cemented over 12-month period. However, no plausible reason for the same has been mentioned. In the present study, crown de-cementation was observed in around 5.55% of the cases which is lesser to that in previous studies.[37],[38]

Ancillary analysis like multivariate analysis could have been done if different success rates would have been observed. Difference in the success rate was not observed in 1-year period, in spite of multiple confounding factors such as tooth location, tooth type, tooth guidance, tooth restorability index, need for crown lengthening for ferrule and final restoration type. Hence, the effect of these confounders on the results was not evaluated.

On analysis of results and after extrapolating the possible reasons for the specific outcomes, it can be concluded that both metal polyfiber post and dentin post behave in the same manner with respect to the primary and secondary outcomes when observed for period of 1 year. Both metal polyfiber and dentin post have similar biomechanical behavior and properties close to dentin. Metal polyfiber post has a structure like interproximal brushes that entangle with the resin cement in the post space. Contrasting a classic post, the metal polyfiber post does not have 2 separable or discrete interfaces between the post, cement, and dentin. The resin cement mechanically interlocks at different planes around the polyfiber strands, thus creating a metal and fiber-reinforced post which is which adheres to the root dentin.[8]

Teeth restored with solid dentin posts exhibit biomechanical properties similar to dentin. The microstructure of dentin is complex with a modulus of 13–18 GPa that differs according to locations and directions. The unique structure of dentin, it's ability to absorb shock and distribute stress uniformly provides a mechanism that inhibits crack propagation.[39] The resemblance in structure and properties of dentin post to radicular dentin may permit similar biomechanical behavior. It lets the tooth to exhibit similar movements and flexion under stress. It functions as a shock absorber and conducts only a small load to the dentinal walls. Therefore, this similarity between post dentin and root dentin coupled with good adhesion shall increase the fracture resistance of the tooth.[8],[9]

This study was planned as a randomized control trial with stringent design, evaluation criteria, and internal validity. Being a randomized controlled trial conducted on Indian patients, the result of the study bears good external validity for clinical application to restore endodontically treated teeth that need post and core restorations. However, adequate consent and information of the entire procedure should be provided to the patients, especially when dentin posts are used. However, there were limitations in the study. The observation period was kept as 12 months. This observation period may not be considered as an optimum time for follow-up. Although, it is also not too less an observation period in a randomized control trial. Previous studies do exist where observation period has been limited to 12 months.[40] Furthermore, systematic reviews do include studies that have been observed for a minimum period of 12 months.[41],[42] Furthermore, the use of dentin from extracted teeth may be unacceptable to patients. This can be resolved through adequate sterilization protocols, adequate consents, and standardized manufacture of preformed dentin posts. Future long-term studies should be planned to evaluate the clinical behavior of metal polyfiber post and dentin post. Endocrowns have today become a viable treatment possibility with advances in material and adhesion sciences.[43],[44] Future comparison of metal polyfiber posts and CAD-CAM dentin posts with endocrowns shall help us come out with better clinical recommendations.

This study is an efficacy study in contrast to an effectiveness study proving equal efficacy of metal polyfiber post and dentin post over 1-year observation. An effectiveness study can also be planned in the future to determine the versatility of the post with respect to patient preference, dentist convenience, and cost analysis.


  Conclusion Top


It can be concluded from this randomized controlled study that both the posts, metal polyfiber and dentin post in conjunction with composite cores, exhibit a high 1-year success rate in restoration of endodontically treated teeth.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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