Journal of Conservative Dentistry

REVIEW ARTICLE
Year
: 2021  |  Volume : 24  |  Issue : 2  |  Page : 113--123

Effect of surface treatment on the dislocation resistance of prefabricated esthetic fiber posts bonded with self-adhesive resin cement: A systematic review and meta-analysis


Shweta Elizabeth Jacob1, Sabah Mohd Zubair2, Manuel Sebastian Thomas1, Vinod Jathanna1, Ramya Shenoy3,  
1 Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Mangalore, Affiliated to Manipal Academy of Higher Education, Manipal, Karnataka, India
2 Research Assistant, Kasturba Medical College, Mangalore, Affiliated to Manipal Academy of Higher Education, Manipal, Karnataka, India
3 Department of Public Health Dentistry, Manipal College of Dental Sciences, Mangalore, Affiliated to Manipal Academy of Higher Education, Manipal, Karnataka, India

Correspondence Address:
Dr. Manuel Sebastian Thomas
Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Mangalore, Affiliated to Manipal Academy of Higher Education, Manipal - 575 001, Karnataka
India

Abstract

Background: This systematic review aimed to determine the presence of any in vitro proof to validate the utilization of surface treatments to advance the bond strength of fiber posts to intraradicular dentin with self-adhesive resin cements. Methodology: Laboratory studies that assessed the push-out or pull-out bond strength of the prefabricated esthetic posts whose surface was treated with either chemical or physical treatment or a combination and bonded using self-adhesive resin cement within root canal model were included for this systematic review. The review began after obtaining the registration number from the International Prospective Register of Systematic Reviews (PROSPERO ID-CRD42020165009). Study reporting was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Relevant articles were identified using a literature database search in Web of Science, Scopus, PubMed, and EBSCO. Besides this, handsearch was also done to ensure complete capture of the articles. Results: Fifteen articles were then selected and included in this study, out of which four were excluded for meta-analysis due to usage of the artificial substrate. It was shown that an additional step of surface treatment of esthetic fiber post did not result in significant improvement in dislocation resistance. Assessment of risk of bias categorized the available research into high risk and medium risk. The results showed heterogeneity. Conclusion: The use of additional steps such as chemical, mechanical, or a combination of post surface treatment does not have any added benefit. However, the results must be interpreted with caution due to methodological shortcomings.



How to cite this article:
Jacob SE, Zubair SM, Thomas MS, Jathanna V, Shenoy R. Effect of surface treatment on the dislocation resistance of prefabricated esthetic fiber posts bonded with self-adhesive resin cement: A systematic review and meta-analysis.J Conserv Dent 2021;24:113-123


How to cite this URL:
Jacob SE, Zubair SM, Thomas MS, Jathanna V, Shenoy R. Effect of surface treatment on the dislocation resistance of prefabricated esthetic fiber posts bonded with self-adhesive resin cement: A systematic review and meta-analysis. J Conserv Dent [serial online] 2021 [cited 2021 Nov 30 ];24:113-123
Available from: https://www.jcd.org.in/text.asp?2021/24/2/113/327860


Full Text



 Introduction



Root canal-treated teeth lacking enough crown structure require a post to retain core for definitive restoration.[1],[2] Fiber posts with their similar elastic modulus to that of dentin produce favorable stress distribution, leading to low occurrences of root fractures.[2],[3] Along with this, these colored fiber posts have several other advantages such as improved light dispersion through the root and gingival tissues, suppression of the corrosive reactions that happen with metal alloy prefabricated posts, and simple removal in case of endodontic retreatment.[4] Even though numerous studies have been performed to evaluate the adhesion of cements and fiber posts, debonding of posts remain the main reason for the failure.[5],[6],[7]

Present-day fiber posts are made up of resin matrix-embedded unidirectional fibers (carbon, quartz, or glass). The resin matrix is responsible for the resistance to compression, whereas the fibers provide the resistance against flexure and also form the surface onto which the functional monomers confined in the adhesive cements will interact.[8] Carbon fiber posts and preformed metallic posts are not indicated in the anterior region as these have shown unacceptable esthetics, hence the emergence of esthetic fiber posts usage.[9]

Resin cements are widely used for luting of indirect restorations, but their bond strength is significantly influenced by the technique used for cementation.[10],[11] For the past few years, self-adhesive resin cements have been tried for cementing fiber posts into intraradicular dentin to provide easier clinical application compared to the regular resin cements which are more technique sensitive.[3],[12] Their use eliminates etching of the post space or adhesive system usage. They are dual polymerized and used for adhesive bonding of all indirect restorations including fiber posts.[13]

To improve the bond strength between the post and the resin cements, several surface pretreatments of glass fiber posts (GFP) have been tried out, which can be classified into (1) physical or chemical means for exposing the inorganic glass fibers and creating surface irregularities such as silanization and sandblasting and (2) chemical treatments for increasing the micromechanical and chemical post attachments such as hydrogen peroxide (H2O2) and hydrofluoric acid (HF).[5],[14],[15],[16] In a study by Monticelli et al., it was seen that surface conditioning improved fiber post bonding.[17] Even though silanization has the advantage of being a convenient chairside operation, its effect on bond strength was questionable.[18]

Sandblasting makes the glass fibers accessible for chemical interaction by the removal of the top layer of resin. Naturally, sandblasting also roughens the surface, thereby significantly increasing the surface area and energy.[8] Other techniques of surface treatments such as aluminum oxide particle air abrasion and hydrofluoric acid etching have been previously tested with self-adhesive resin cement for bond strength improvements. These have helped improve the surface roughness (adhesive area), increase the surface free energy, and expose resin composite filler components. Similarly, hydrogen peroxide was also found to escalate the surface roughness.[19]

Despite the number of in vitro studies, it is unclear whether different surface treatments on fiber posts can improve its retention of using self-adhesive resin cements. Hence, the current study aimed to systematically establish the presence of any in vitro data to validate the use of surface treatments to advance the bond strength of fiber posts to intraradicular dentin using self-adhesive resin cements.

 Methodology



This systematic review was conducted to verify whether there is in vitro evidence to justify the application of surface treatments to increase the bond strength of the prefabricated esthetic posts using self-adhesive resin cement to intraradicular dentin. Study reporting was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The protocol was registered on the International Prospective Register of Systematic Reviews (PROSPERO) before commencing (Registration number CRD42020165009).

Search strategy

Relevant articles were identified using a literature database search in Web of Science, Scopus, PubMed, and EBSCO. Besides this, handsearch was also done by checking the bibliography of identified documents to ensure complete capture of the articles. The literature review in various databases was conducted using specific keywords and subject headings derived after scoping searches. For example, the search string used for literature review in PubMed database was ((((((((((((tooth color*) OR (translucent)) OR (glass fiber)) OR (quartz fiber)) OR (zirconia)) OR (non metal*)) OR (non-metal*)) OR (esthetic)) AND ((post) OR (dowel))) AND (((((silan*) OR (air abrasi*)) OR (etch*)) OR (adhesi*)) OR (surface treatment))) AND ((((((((self adhesive luting resin) OR (self-adhesive luting resin)) OR (self adhesive resin)) OR (self-adhesive resin)) OR (self adhesive cement)) OR (self-adhesive cement)) OR (self-adhesive luting cement)) OR (self adhesive luting cement))) AND ((((((((push out bond strength) OR (push-out bond strength)) OR (pull out bond strength))) OR (pull-out bond strength)) OR (bond strength)) OR (retenti*)) OR (dislocation resistance))) AND ((((teeth) OR (root canal)) OR (post space)) OR (dentin)) [Supplementary Table 1].[INLINE:1]

Screening and selection

In vitro studies that assessed the push-out or pull-out bond strength of the prefabricated esthetic posts whose surface was treated with a chemical, mechanical, or combined means and bonded using self-adhesive resin cement within natural or artificial substrate were included for this study. Only published articles in the English language after 2001 (year of introduction of self-adhesive resin cement) were considered.

Studies which include other posts than prefabricated esthetic posts, studies where no surface treatment of the post was carried out, studies which do not have a control group, experiments were other modes of testing than dislocation resistance was used, and those whose data were unavailable despite requesting the authors were all excluded. Title and abstract screening were done by two reviewers, and full-text screening of the articles was carried out by three reviewers. Any sort of disagreement was settled by the subject expert.

Data collection

A data extraction sheet was prepared in MS Excel, to easily identify the variables in the articles. The research team made groups to categorize the variables under the type of the prefabricated esthetic posts, surface pretreatment of the post, substrate to which post is bonded, and the push-out/pull-out bond strength values (the arithmetic average of the values of the thirds was used). All the bond strength values were expressed in megapascal. From the articles, even other relevant information such as the size and nature of the post, root canal preparation, mode of cement application, storage of samples, and a mode of failure was extracted considering the inclusion criteria.

Assessment of risk of bias

Assessment of the quality of the articles was done following Sarkis-Onofre et al. and Moraes et al. that classifies potential risk of bias as being high, moderate, and low risk.[3],[5] The quality assessment was based on (a) intact human or bovine teeth, (b) similar canal size of the specimen, (c) sample size calculation, (d) randomization of the samples, (e) size of post and post space and cleansing step, (f) treatment by single operator, (g) manufacturer's instruction followed, (h) aging done, and (i) blinding of the operator. Letter “Y” (yes) was denoted when the parameter was present in the article and if not then “N” (no) was denoted under the parameter which was prepared for the risk of bias assessment. The total number of Y for each article determines the grading of risk of bias and was performed by four reviewers. Grading was done as follows: 1–3, high risk of bias; 4–6, moderate risk of bias; and 7–9, low risk of bias.

Statistical analysis

Review Manager (RevMan, Australian Cochrane Centre, 2008) Version 5.3 was used to perform the meta-analysis. Subgroup analysis was performed by type of prefabricated esthetic posts used as well as the type of post surface treatment performed (chemical treatment, physical treatment, or a combination). We have calculated the weighted average, heterogeneity, and confidence interval for the mean difference between groups by applying the random-effects model. Statistical heterogeneity between surface treatments among the included studies was assessed using the I2 statistic. Based on Z-test, P < 0.05 was considered statistically significant.

 Results



Results from the literature search, screening, and selection

The results from the above search terms obtained are as follows: PubMed, 174; Scopus, 83; Web of Science, 56; EBSCO, 32; and handsearch, 29 articles. Articles that appeared in more than one database were removed as duplication, resulting in 199 articles. From this, 165 were excluded after abstract screening, bringing the number to 34 studies [Figure 1].{Figure 1}

Characteristics of the excluded studies

Few of the studies had adhesive applied to post spaces instead of the post surface.[20],[21],[22],[23],[24],[25] In others, cements other than self-adhesive cements were used.[26],[27],[28] A study by Faria-e-Silva et al. did not have any surface treatments done on the post, whereas some had no control group.[27],[29],[30],[31],[32],[33],[34] Few of them displayed incomplete datasets.[8],[23],[24],[25],[35] Hence, a total of 19 were excluded from our study.

Characteristics of included articles

RelyX Unicem (3M ESPE) was the most used self-adhesive resin cement. Among the various posts used such as GFP and quartz fiber posts (QFP) (transparent and opaque), surface pretreatment done with silane did not demonstrate a statistically significant difference between treated and non-treated groups.[36],[37],[38],[39],[40] Among other studies, sandblasting or sandblasting combined with silanization showed significantly higher bond strength.[8],[18],[19],[41],[42] Most of the failures demonstrated were adhesive in nature between the post and the root dentin.

Risk of bias

Out of all the evaluated studies, nine of them showed a high risk of bias [Table 1].[18],[36],[37],[40],[41],[42],[43],[44],[45] None of the studies had blinding of the operator and a few of them were conducted by multiple operators.[4],[38],[19] Strict adherence to the manufacturer's instructions was followed by all except in a few studies.[18],[41],[44],[45] It was also found out that only two articles showed sample size calculation.[19],[47]{Table 1}

Meta-analysis results

Meta-analysis was carried out by combining 11 in vitro studies to assess the effect of surface treatment on the dislocation resistance of prefabricated esthetic posts bonded with self-adhesive resin cement. Only studies carried out on natural teeth were included for meta-analysis. The features of all the studies included are summarized in [Table 2]. As shown in the forest plot, there was no significant difference in the dislocation resistance of silanated and nonsilanated GFP [Figure 2]a as well as QFP [Figure 2]b when bonded with self-adhesive resin cement. Even air abrasion with and without silanization showed no significant increase in dislocation resistance as compared to the control group [Figure 2]c and [Figure 1]d. As for the GFP, none of the other chemical post- and pretreatments also proved better than the untreated posts [Figure 3]. This was substantiated with P > 0.05 for the Z test. However, since the I2 >50% in almost all the forest plots, the pooled statistics need to be interpreted with caution because of the presence of significant statistical heterogeneity.{Figure 2}{Figure 3}{Table 2}

 Discussion



Due to the growing demand for esthetics, metallic posts have been replaced by tooth-colored metal-free post systems such as GFP, zirconia posts, and QFP, out of which GFP are most used in this study. Even though metal posts are rigid and strong, their main shortcomings include discoloration, chances of the post and root fracture, and risk of corrosion.[48] Prefabricated GFP help in uniform stress distribution across the root due to its low modulus of elasticity and flexibility.[22] One of the major disadvantages shown by the prefabricated fiber posts is the highly cross-linked less reactive polymer matrix of the post material, making bonding to resin luting agents and tooth difficult.[49] Among the different posts used, GFP were commonly used. This is due to their excellent esthetic property, great strength, stiffness, elastic modulus comparable to dentin, and weaker fracture resistance.[29]

Self-adhesive cements are the latest addition to the resin category. They are dual cured and show a greater bond to dentin surfaces. Unlike other resin cements, a separate adhesive bonding agent is not needed, thus time-saving and shortening the procedure.[12] RelyX Unicem, commonly used cement in this study, along with its multifunctional monomers and phosphoric acid groups demineralizes and infiltrates enamel and dentin creating micromechanical retention and chemical bonding to hydroxyapatite.[3],[13] This chemical interaction is due to calcium ion chelation by the acidic groups of self-adhesive cements.[22] Therefore, the bonding mechanism is mainly due to chemical adhesion and micromechanical retention. Additional benefits include long-term stability, high moisture tolerance, and reduced risk of postoperative sensitivity.

To increase the retentive strength of the post, pretreatments are done such as chemo/mechanical conditioning, which eliminates or dissolves the epoxy matrix of posts, exposing the fibers that get activated and react with resinous cement.[37] Silanization is, without doubt, the most common treatment done on fiber post surface. Silane solutions are organic–inorganic hybrid compounds that cause adhesion between different matrices.[35] Silane agents provide retention of the fiber posts by a chemical reaction between silicon oxide present on the surface layer and the adhesive matrix.[39] On the application of H2O2, spaces are created between the fibers which favor the micromechanical interlocking between the post and cement.[46] Sandblasting with aluminum oxide particles leads to plastic deformation and improved surface roughness of the fiber post, leading to an increased surface area for bonding. This helps in increasing the contact angle of the polymer surface.[37] Hydrofluoric acid etching demonstrates fractured fibers and exposes the resin matrix helping in micromechanical retention.[18] The effect of silanization on the retention of posts by the bond between the resin cement and the post surface has been widely debated. Even though many studies show no change in bond strength after silanization, Aksornmuang et al. and Goracci et al. in their studies demonstrated increased bonding after silanization to surfaces of quartz and GFP.[50],[51] However, this study shows that there is not much significant difference seen in post retention in any of the above-mentioned surface treatment on fiber post surface.

Retention of the post to root structure is most measured using push-out bond strength test, which produces shear stress at post cement interface similar to clinical conditions.[44] Various factors influencing the bond strength are length, diameter, shape, surface treatment of post as well as root dentin, canal regions, type of posts, and luting agents used.[18] Micro push-out bond strength test demonstrates bond strength at coronal, middle, and apical levels of the root dentin. Higher bond strength is seen in the coronal third compared to the middle and apical thirds. This can be due to decreased penetration of the curing light till apex, difficulties in moisture control in the apical third, incomplete infiltration and distribution of resin cement leading to the formation of bubbles and voids in the apical region, and formation of a thick smear layer throughout the post space.[4],[44] Pull-out tests have shown to be more advantageous than push-out tests as they efficiently measure simultaneously shear as well as tensile bond strength. They also eliminate the chance of a fractured post segment being left behind in the root canal.[39]

Adhesive failures occurring between root dentin and resin cement are frequently seen. The flexural strength property of fiber posts is used to evaluate the fracture resistance. Posts demonstrating higher values of flexural strength are more resistant to fracture than those showing the least value.[4] Mode of failures is not influenced by silane or other surface treatments as the stresses were distributed uniformly and post surface area revealing exposed glass/quartz fibers were limited.[36] A higher percentage of cohesive failures (i.e. failures within the cement itself), was seen in self-adhesive cements as they showed higher bond strengths.[18]

Most of the studies investigated here show a high risk of bias, leading to high heterogeneity. This is because the variables that could influence this result were not controlled by the researchers. Even though the studies simulated clinical conditions, being in vitro does not wholly replicate oral conditions. For better clinical results, randomized control trial with longer follow-up periods or in vitro studies with a robust experimental design are required to get a better insight into the influence of post surface treatment and bond strength. Furthermore, further studies are to be conducted to evaluate the effect of sealers and obturation, the technique of post space preparation, and canal cleansing strategy on the bonding of self-adhesive resin cement.

 Conclusion



GFP are the commonly tested prefabricated esthetic fiber post. Among the various treatments on the surface of different prefabricated posts, silane treatment was the commonly researched modality. However, analysis of included in vitro studies demonstrated no significant improvement in bond strength of self-adhesive resin cement to fiber post subjected to surface treatment, when compared to the nontreated posts. Thus, the use of an additional step to assist in improving the adhesion could be a futile exercise. Nonetheless the results of this systematic review should be interpreted with caution as most of the considered studies were having a high risk of bias. Therefore, further studies with a low risk of bias are required to further validate the results.

Acknowledgment

We would like to thank Dr. Prasanna Mithra, Associate Professor, Department of Community Medicine, Kasturba Medical College, Mangalore, for his advice and guidance in conducting this systematic review.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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