One of the most prevalent methods for restoring an endodontically treated tooth (ETT) with inadequate remaining structure is to use dowel post and core complex. The concept of using a root canal to provide retention for core material was the first expressed in 1700s by Pierre Fauchard,¹,² who suggested to use metallic “tenons” posts screwed into root canal.³ In 1800s, several researches focused on increasing crown retention by posts application.¹ Posts, generally, could be classified to prefabricated or custom-made, and metallic or nonmetallic with their related subcategories. Prefabricated metallic posts, the oldest version of intracanal posts, had some limitation in esthetic zone,⁴ as well as the risk of toxicity, the possibility of corrosion, and allergic reactions;⁵,⁶ nonmetallic posts were introduced to overcome these deficiencies.⁷ However, several failures in the treatment of endodontically treated teeth in the current century¹ put a significant question mark in front of the applications of dowel post. Some studies claimed posts could concentrate stress, and lead to root fracture.⁸,⁹,¹⁰,¹¹ Other reported gingivitis,¹²,¹³ periodontal disease,¹⁴ fracture of core,¹² fracture of post,¹² loss of retention,¹⁴,¹⁵ and caries¹⁴,¹⁶ as the complications of post-based treatment, and introduced gingivitis,¹² and root fracture¹⁵ as the most prevalent complications.

Although some treatment alternative namely “Richmond crown”¹,¹⁷ and “Endocrown” were introduced in 19^th and 20^th centuries, post-based restorative options are still among the most prevalent treatment options used in every day dentistry. The improvement in scientific criteria resulted in an ever-increasing introduction of different materials and methods for post fabrication to maximize the profits, and minimize the potential risks. However, long-term successful results, and predictable retention without stress concentration inside the remaining root structure mainly return to appropriate cement selection. Considering the varieties of available cements with special characteristics Table 1, the present review focuses on comparing different types of dental cement, according to their selection and application criteria for different types of posts.{Table 1}

An electronic search was carried out (1970 to 2020) through Medline, PubMed, Scopus, and Google Scholar. The following keywords were searched in title, abstract, or keywords with different combinations: ETT, root canal therapy, dental post, post and core, prefabricated post, custom post, dental cement, resin cement, cement selection, cement*, adhesive resin cement. Using reference management software (Endnote X8, Thomson Reuters), duplicated studies were eliminated, and the most relevant articles were chosen based on inclusion criteria: English articles focusing on different types of posts and dental cements, and selecting appropriate cement for each type of post. The studies addressed extra canal posts, or other characteristics of intracanal posts were excluded, as well as studies on other direct or indirect restorations.

The numbers of search results for the selected keywords were 1580 (PubMed), 18,000 (Google scholar) and 3105 (Scopus). After duplicate removal and title/abstract analysis, 317 studies were selected for full-text review. Finally, 146 studies met the requirement of inclusion/exclusion criteria and were included to be discussed.

Dental cements provide retention for indirect restorations by chemical or mechanical bonding, or simply, filling the space between the restoration and tooth structure, physically.²⁶ Intra canal posts provide retention for core materials; however, its own retentiveness should be passively provided by dental cements. Different dental cements are available with varieties of properties to be used:

Zinc phosphate cement (ZP), introduced in 1800s, is the oldest luting cement.¹⁹,²⁷ Low tensile strength,¹⁸,¹⁹ high degree of solubility (0.36%),¹⁹ high compressive strength, and elastic modulus,¹⁸ low cost, and early strength are among the properties. After 1 h, ZP has the lowest PH (about 1.2),¹⁸,¹⁹ that increases to 5.5 after 24 h.¹⁸ In patients with acid reflux problems, and in vital teeth with low residual dentin thickness, this cement should be used carefully.

Zinc polycarboxylate cement (ZPC), introduced in 1968,²⁸ was the first cement that exhibited chemical bond to tooth structure, and according to increasing pH after mixing, it was very biocompatible.²² However, weak bond to enamel and dentin,¹⁸ and low compressive and tensile strength,¹⁸,²⁰ make it inappropriate for single-unit restorations or long-span fixed partial dentures.¹⁸

Glass ionomer cement (GI) was introduced in 1969 under the name of aluminosilicate polyacrylic acid.¹⁹ Enamel and dentin adhesion, fluoride release, low bonding strength, moderate compressive strength, low tensile strength, and high solubility are among the properties.¹⁸,¹⁹ GI could be indicated in varieties of restoration namely all-metal/PFM crowns, short span fixed partial denture, alumina/zirconium-based all-ceramic restorations, and Metal post and core.

Resin-modified GI (RMGI) was introduced to overcome GI sensitivity to early moisture contamination and high solubility rate. In this combination of resin and conventional GI,²¹ adhesion to tooth structure was improved as well as compressive/tensile strength, solubility, and post-cementation sensitivity.²⁹ RMGI has a wide range of applications; however, in traditional feldspathic or pressable ceramic restorations should be used with caution.¹⁸

Resin cement (RC) was introduced in mid-1970s as an acid-base reaction cement.³⁰ High compressive, tensile, and bonding strength, esthetics, and low solubility, candidate this cement for esthetic or compromised situations.³¹ RCs could be classified to conventional, self-etch, and self-adhesive types Figure 1.⁷,³² In conventional (total etch or etch-and-rinse) RC, etching process happens as a separate stage, and after rinsing, adhesive, or primer-adhesive is applied on tooth structure before cement application. Self-etch primer, used in self-etch RC, is a combination of acidic monomers, phosphate esters, and primer. These cements might be used in 2 or 3 steps. Self-adhesive (all-in-one) RC combined all the steps in one tube to reduce the technical sensitivity, and facilitate the process. However, the research reported lower bond strength for this type.³³,³⁴,³⁵,³⁶Figure 1

Resin cements classification.

Selecting a proper dowel post depends on various factors namely the amount of remaining tooth structure, tooth anatomy, position, functional requirements, root length, width, and configuration, potential torquing force, dowel post design and material, bonding capability, esthetics, and restoration type.⁷¹,⁷²

Prefabricated posts and recommended cements

Prefabricated posts are indicated when sufficient width and length of root structure has been preserved, the root has circular cross-section, and severe root canal undercuts prevent cast posts application.⁷³ Metallic prefabricated posts could be routinely cemented by conventional cements.⁷³,⁷⁴,⁷⁵,⁷⁶ However, dual-cure RCs have been recommended for nonmetallic types,⁶⁷,⁷⁷ or when higher retention is desired.

Metallic post has been using during the past 20 years, and divides into three subgroups based on material type: titanium, stainless steel, or brass. Conventional permanent cement (ZP and GI) could be used for these posts.⁷³ However, there are controversies in comparison between ZP and RC. Some studies reported better retention for RC,⁷⁸ while the others gave more priority to ZP in these posts;⁷⁴,⁷⁵,⁷⁶ there are other studies not recommend RC for clinical application in posts.⁷³

Stainless steel and brass posts are rigid and strong, and are not appropriate when minimal tooth structure remains.⁷ They might form corrosion products, and lead to root discoloration⁷⁹

Titanium post, introduced to reduce the possibility of corrosion,⁷ has low fracture strength (that make it contraindicated in thin root canal), and close radiodensity to gutta-percha.⁷

Nonmetallic posts are either made from ceramics (zirconia or alumina),⁸⁰ or a combination of resin matrix and reinforcing fibers (carbon, glass, or quartz).⁸¹ They were introduced to provide more favorable esthetics,⁸² or close elastic modulus to dentine compared to metallic dowel posts⁸¹ to reduce the risk of root fracture and increase the survival rate.⁸³

Zirconia post, composed of zirconium oxide, is an all-ceramic post with high flexural strength, elastic modulus,⁸⁴ and toughness.⁸⁵,⁸⁶,⁸⁷ It could be indicated in esthetic area;³²,⁸⁸ however, inherent brittleness, limitates its application.⁸⁹ There is inherent deficiency in retention of these posts considering the smooth surface,⁷⁸ and insufficient bonding to RCs.⁹⁰,⁹¹,⁹²,⁹³,⁹⁴ However, RC provides higher bond strength compared to GI cement,⁹⁵ and the RC with phosphate monomer content, proved to be more reliable for bonding zirconia⁹⁶

Fiber reinforced posts show high success rate with reduced risk of root fracture by their close toughness to dentine.⁹⁷ Self-adhesive RC has been suggested as the cement of choice for fiber posts with high bond strength.⁹⁷ However, other researches proved better results using etch-and-rinse dual curing adhesive system, compared to self-adhesive or self-etch RC or GI cements.⁹⁸,⁹⁹,¹⁰⁰,¹⁰¹,¹⁰² A company have suggested dual-cure flowable hybrid composite for cementation of fiber posts.¹⁰³

Fiber reinforced resin-based composite (FRC) post reduces the risk of toxicity,³¹,¹⁰⁴ and by their close modulus of elasticity to dentine,¹⁰⁵,¹⁰⁶,¹⁰⁷ reduces the possibility of root fracture. Moreover, FRC posts can be removed easily for retreatment if necessary.⁸⁸,⁸⁹,⁹⁰,⁹¹,⁹²,⁹³,⁹⁴,⁹⁵,⁹⁶,⁹⁷,⁹⁸,⁹⁹,¹⁰⁰,¹⁰¹,¹⁰²,¹⁰³,¹⁰⁴,¹⁰⁵,¹⁰⁶,¹⁰⁷,¹⁰⁸ Bonding with tooth structure causes good distribution of occlusal forces.¹⁰⁹ However, FRC post has low physical strength. The most reliable cement for this group of posts is etch-and-rinse dual-cure RCs.¹¹⁰

Polyethylene fiber post (PFP), introduced as an alternative to stainless steel and zirconia posts with less micro-leakage,¹¹¹ is made from ultrahigh molecular weight polyethylene woven fiber ribbons.¹¹² Tooth structure protection, and reduced risk of root fracture have been mentioned as advantages.¹⁰⁶ Eskitaşcioğlu et al. reported minimum stress within PFP compared to cast post and core system; and suggested these posts for restoration of apically resected teeth¹¹³

Carbon fiber posts (CFP), introduced in 1998,¹¹⁴ was the first nonmetallic postintroduced. CFP consists of bundle of stretched carbon fibers embedded into an epoxy matrix.⁷²,⁷³,¹¹⁵

Glass fiber (GF) post is made from silicate glass (electrical, or high-strength glass), or quartz fibers,¹¹⁶,¹¹⁷ and different types of matrices (polymethylmethacrylate or epoxy resin).¹¹⁸ Silicate glass ceramic post has better esthetic, that could even be enhanced by using epoxy resin as matrix.⁸⁸ Quartz (Glass) fiber post could be preferred over CFP for ease of application and removing, and clinicians preferred to use them because of their esthetic biocompatibility.¹¹⁹ Self-adhesive RCs have been recommended by some companies¹²⁰ One study claim that RMGI could be indicated for GF posts.³⁷ Table 3 summarizes the recommendations of different companies for selecting proper type of cement for each type of posts.

{Table 3}

Custom posts

Custom posts are indicated when moderate-to-severe coronal structure has been lost, root canal has noncircular cross section,⁷² the core has different angle to the post, core retention on post is compromised duo to tooth size, and when multiple post and core are to be made in the same patient.⁷² A company recommended self-adhesive RC for metallic customize posts;¹³⁴ however, considering the adaptation of these types of posts to the root canal, all types of cements could be used for custom posts.²²,¹³⁵ One study found ZP and GI to be more retentive than ZPC or even RC.⁷⁵ Another study claimed that GI is inappropriate for casted intracanal posts considering the insufficient strength.¹³⁶

Metallic custom post is a very strong and retentive choice especially for small tooth, as the core is an inherent part of the component. Poor esthetics, risk of corrosion and fabrication inaccuracy, and difficult retrieval could be mentioned as disadvantages.⁷³

Precious alloy post contains silver, palladium, and gold,¹³⁷ is corrosion resistant, highly biocompatible, and suitable for hypersensitive patients.¹³⁸

Nonprecious alloy posts include the posts fabricated from nickel–chrome, chrome-cobalt, and nonprecious gold color alloy (NPG). Nickel–chrome alloy might be electrolytically etched to enhance micro-mechanical bonding for RCs.¹³⁹ NPG alloy with its golden color has been introduced as an alternative for precious alloys with lower cost.²⁶ It has been claimed to have acceptable durability and thermal resistance, excellent fit, good biocompatibility, and easy adjustability, soldering, and finishing capacity.²⁶ However, it shows high corrosion susceptibility,²⁵ that might lead to significant discoloration, and potential cell toxicity.⁸⁰

Nonmetallic all-ceramic custom post, made from high-toughness ceramic materials such as alumina or zirconia, is very biocompatible, does not exhibit galvanic corrosion, and provides significantly enhanced esthetic; but it has low fracture strength and toughness.⁸⁰ Dual-cure adhesive RCs have been recommended for this type of posts.¹³¹ Self-curing RC and conventional cements (ZP, GI, RMGI) could also be used for ceramic custom posts.¹³¹ Self-adhesive RC has been suggested for these posts; with higher bond strength compared to conventional cements.¹²⁶,¹³⁴,¹⁴⁰ Table 4 summarizes the characteristics of different types of post.

{Table 4}

Cement selection criteria

Dental cement in indirect restorations could be considered as an important determining factor affects retention, stability, survival, esthetic, and also patient satisfaction. The selection of appropriate cement could even be more important in intracanal posts; as in post-based restorations, not only the durability of intracanal posts but also the survival and durability of restorative treatments depend on post retention. There are a wide range of prefabricated or custom posts types/materials introduced in an ever-increasing manner in the last decade. The same varieties exist in available cements, especially when it comes to resin luting cements.

Conventional or resin cements?

In general, when an intracanal post has high degrees of adaptation in the root prepared canal (custom post), or the strength of post is not affected by bonding to tooth structure (e.g., metallic post), or esthetic is not a determining factor, conventional cements namely GI and ZP might provide acceptable retention.⁸,¹⁹,²⁹ RMGI could provide higher retention,⁸,¹⁵,³⁷ and ZPC cement could be indicated for situations where retrievability is predicted in dowel post-based treatments.⁷,¹⁸ These conventional well-known cements with a long history of application, are easily accessible, less expensive, and less technique sensitive that candidate them for routine dental applications.³⁷ However, there are situations where higher retention, strength, or esthetic call for the application of RCs. Considering the variety of types and characteristics of these cements, conscious selection is important to guarantee the long-lasting success.

Which type of resin cements?

Some RC proved to provide higher and more durable retention (total etch cements),⁵¹ while the others could facilitate the cement application in cementing a dowel post intra root canal (self-adhesive cements),¹⁵³ or control the acid penetration or dentin desiccation during cementing process (self-etch cements).⁵¹ Some RC provide immediate and predictable complete polymerization (light-cure RC), while the others could be used when full light penetration is not assured (dual- or self-cure RC).⁵¹ The selection between these cement types call for knowing the characteristic of different dowel posts, and clinical requirements.

The present review tried to provide a document-based information to select an appropriate cement based on dowel post material/type classifications. Long-term studies focused on the changes that occur in cement characteristics over the time, and the behavior of different cements under challenging conditions (e.g., short roots, abnormal dentin structure, excessive applied forces, or potential material deteriorations) are suggested to provide sound and reliable choice of cements for different types of dowel posts. Table 5 summarizes outcomes of studies on different cements.{Table 5}

Considering the limitation of this review, the following conclusions could be derived:

Conventional cements could be used safely for metallic prefabricated posts; in nonmetallic posts, or in situations with extensive coronal destruction, or higher retentive demands, dual-cure RCs have been recommended as appropriate alternative

Etch-and-rinse RC provides higher retention with predictable durability, but the retention provided by self-etch or self-adhesive RCs could still be acceptable in normal clinical situations

RCs containing functional phosphate monomer are the most appropriate adhesive cement for zirconia prefabricated or custom posts

Considering the perfect adaptation, all types of cements could be used for custom posts; however, conventional cements are preferred for metallic, and adhesive resin for ceramic posts.

Financial support and sponsorship

Nil.

Conflicts of interest

The authors of this manuscript declare that they have no conflicts of interest, real or perceived, financial or nonfinancial in this article.

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