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Juloski 2012 - Ferrule Effect Literature Review PDF
Juloski 2012 - Ferrule Effect Literature Review PDF
Abstract
Introduction: Preserving intact coronal and radicular
tooth structure, especially maintaining cervical tissue
to create a ferrule effect, is considered to be crucial
T he restoration of endodontically treated teeth involves a variety of treatment
options and still represents a challenging task for clinicians. Whether a tooth
requires a post or not is determined by the amount of remaining coronal tooth struc-
for the optimal biomechanical behavior of restored ture and the functional requirements (1). Frequently, the remaining tooth structure is
teeth. The ferrule effect has been extensively studied not sufficient, and a post is indicated to provide retention for crown restoration (1
and still remains controversial from many perspectives. 3). Cast post and core systems were the standard for many years. However, demands
The purpose of this study was to summarize the results for simpler procedures and esthetic restorations led to the development of
of research conducted on different issues related to the prefabricated posts, initially made from metal and more recently from ceramics
ferrule effect and published in peer-reviewed journals and fiber-reinforced composites (FRCs) (1, 4, 5).
listed in PubMed. Methods: The search was conducted A successful clinical outcome of endodontically treated teeth depends on
using the following key words: ferrule and ferrule adequate root canal treatment as well as on adequate restorative treatment per-
effect alone or in combination with literature review, formed afterwards (6). Therefore, research has focused on finding the most prom-
fracture resistance, fatigue, finite element anal- ising post and core system (79), luting agent (1012), and crown type (13, 14).
ysis, and clinical trials. Results: The findings from re- Even though a strengthening effect of the post is desirable and very often needed, it
viewed articles were categorized into three main was questioned in the literature (1). Despite extreme efforts to reinforce endodon-
categories: laboratory studies, computer simulation, tically treated teeth, biomechanical failures still represent a critical issue (4, 15).
and clinical trials. Laboratory studies were further classi- The lack of a protective feedback mechanism after pulp removal may be
fied into subchapters based on the main aspect investi- a contributing factor to frequent tooth fractures (16). However, beside noncontrol-
gated in relation to the ferrule effect. Conclusions: The lable risk factors, the high occurrence of fractures may be attributed to various
presence of a 1.5- to 2-mm ferrule has a positive effect operative procedures, such as access cavity preparation and restoration, root canal
on fracture resistance of endodontically treated teeth. If preparation, irrigation and obturation, post space preparation, and final coronal
the clinical situation does not permit a circumferential restoration (15, 17).
ferrule, an incomplete ferrule is considered a better Preserving intact coronal and radicular tooth structure and maintaining cervical
option than a complete lack of ferrule. Including a ferrule tissue to create a ferrule effect are considered to be crucial to optimize the biomechan-
in preparation design could lead to more favorable frac- ical behavior of the restored tooth (17, 18). A ferrule effect is defined as a 360 metal
ture patters. Providing an adequate ferrule lowers the collar of the crown surrounding the parallel walls of the dentine extending coronal to
impact of the post and core system, luting agents, and the shoulder of the preparation. The result is an elevation in resistance form of the
the final restoration on tooth performance. In teeth crown from the extension of dentinal tooth structure (19). More precisely, parallel
with no coronal structure, in order to provide a ferrule, walls of dentin extending coronally from the crown margin provide a ferrule, which
orthodontic extrusion should be considered rather after being encircled by a crown provides a protective effect by reducing stresses within
than surgical crown lengthening. If neither of the alter- a tooth called the ferrule effect (20) (Fig. 1).
native methods for providing a ferrule can be performed, Growing attention has been given to the prognosis of endodontically treated
available evidence suggests that a poor clinical outcome teeth, and, generally, the ferrule effect is considered necessary to stabilize restored
is very likely. (J Endod 2012;38:1119) tooth (1, 3, 17, 2124). Then again, the cost of getting this support in teeth with
no coronal dentin is the additional loss of tooth tissue, and although a ferrule
Key Words would be desirable, it should not be provided at the expense of the remaining
Endodontically treated teeth, ferrule effect, post and coronal or root structure (25, 26). However, it is important to bear in mind
core, review that a ferrule effect is just one part of the restored endodontically treated tooth
that represents a complex system. The clinical performance of the entire
complex is also affected by several other factors including the post and core
material, the luting agent, the overlying crown, and functional occlusal loads
From the *Department of Fixed Prosthodontics and Dental Materials of Siena, Tuscan School of Dental Medicine, University of Florence and Siena, Siena, Italy; and
Clinic for Pediatric and Preventive Dentistry, Faculty of Dentistry, University of Belgrade, Belgrade, Serbia.
Address requests for reprints to Dr Jelena Juloski, Department of Fixed Prosthodontics and Dental Materials of Siena, Policlinico Le Scotte, Viale Bracci, 53 100 Siena,
Italy. E-mail address: jelenajuloski@gmail.com
0099-2399/$ - see front matter
Copyright 2012 American Association of Endodontists.
doi:10.1016/j.joen.2011.09.024
then teeth without a ferrule (36, 37), and, therefore, it was suggested resistant to fracture than teeth with prefabricated posts when the ferrule
that a 2-mm ferrule should be provided at least on the buccal and effect was not provided (30, 4143) as well as in the presence of a 2-
lingual wall. Irrespective of the ferrule design, the predominant mode mm ferrule (42, 43, 45). On the contrary, in the presence of a ferrule,
of failure was an oblique fracture from the lingual margin to the vestib- teeth restored with prefabricated titanium posts and composite cores
ular tooth surface (36). had higher fracture resistance compared with cast post and core and
Few studies assessed the impact of particular ferrule design on prefabricated quartz-FRC posts (44). Still, for a sudden impact, cast
tooth resistance (19, 31, 39). The inclusion of interproximal grooves post and core was more effective, but under cyclic fatigue testing teeth
when there is a 1-mm or more coronal dentinal extension decreased restored with carbon-FRC posts outperformed cast post and cores (48).
the failure loads and therefore should be avoided. Furthermore, with Furthermore, among the 1-mm, 1.5-mm, and 2-mm ferrule length
a 1-mm or 2-mm ferrule preparation, there was no difference in frac- specimens, higher fracture loads were observed in teeth restored
ture resistance regardless of whether a butt joint or a 1-mm-wide con- with a quartz-FRC post compared with teeth restored with glass-FRC,
trabevel configuration existed at the tooth-core junction (19, 39). zirconia enriched glassFRC, and zirconia posts (32).
Type of Post and Core System and Final Restoration. The After subjecting the specimens only to mechanical loading, there
effectiveness of different procedures for restoring the function of was no difference in the survival rate (100%) among teeth with a 1.5-
endodontically treated teeth subjected to static (13, 30, 32, 4046) mm ferrule restored with zirconia, FRC, or titanium post (47). After
or fatigue loading (4752) has been widely investigated. cycling loading, specimens were exposed to an oblique, static load
Combinations of different ferrule designs and various post and core until failure, and, likewise, all systems showed statistically equivalent
systems and final restorations were tested in an attempt to find the fracture strength values and modes of failure. However, when speci-
best treatment option that would provide the highest fracture mens were subjected to thermomechanical fatigue loading, there was
resistance and the most favorable fracture pattern of severely a lower percentage of survival (49, 50). Both studies (49, 50)
compromised teeth. However, the results were controversial. Some investigated the following combinations of materials in the presence
research reported that changes in stiffness and design associated with of a 2-mm-high dentine ferrule and under the same fatigue condi-
post and core material did not significantly influence fracture tions: titanium post and composite core, zirconia post and ceramic
resistance as long as sufficient dentine structure remained (13, 41, core, zirconia post and composite core, and cast gold post and
47, 49, 52), whereas other studies pointed out that post type may core system. Heydecke et al (49) found no statistically significant
have an impact (32, 4245, 50). differences in survival rates, fracture loads, and modes of failure
The vast majority of literature data suggests that the presence of among groups, but all ceramic posts and cores were recommended
a ferrule is a significant factor in improving resistance to fracture for as an esthetic alternative to cast post and cores because all specimens
different types of posts: cast post and core (13, 33, 36, 4043, 48, remained intact during thermomechanical loading, the higher fracture
53), all ceramic post and core (40), prefabricated metallic posts (30, strengths, and the number of restorable fractures observed among
34, 41), and prefabricated fiber-reinforced composite (FRC) posts specimens from that group. Conversely, Butz et al (50) found a lower
(13, 29, 46, 48, 54). Conversely, two studies reported that the survival rate and fracture strength for ceramic post/composite core
additional use of ferrule preparation had no benefit in terms of combination and suggested that this should be avoided in clinical use.
resistance to fracture of teeth restored with cast post and core With regard to fracture modes, the findings were also controver-
(43) and prefabricated metallic post (55). sial. Some studies reported that the direct technique was appropriate
When teeth with a 2-mm ferrule were restored with a custom- because more severe root fractures were found in cast post-and-
fabricated all-ceramic or metal post and core, resistance to fracture core-restored teeth (30, 41, 56); others did not observe differences
was similar (40). Metal cast post-and-core-restored teeth were more in fracture pattern between teeth restored with cast post and core
results of FEA suggested that it has a minor effect on force distribution for the prognosis of restored endodontically treated molars (75). It
when a 1-mm or 2-mm-high ferrule is present (35), which is in agree- was commented that judgment on a preexisting ferrule is difficult to
ment with the results from in vitro testing (34, 35, 59). obtain retrospectively and should be evaluated by a model study or
One study aimed to combine the advantages of in vitro tests and cone-beam tomography to get a 3-dimensional rather than two-
FEA (35). The results obtained from both methods were compared with dimensional picture of the prerestorative condition. However, the
agreement. In order to evaluate distribution of the external forces finding was in line with the results of a prospective clinical trial (77)
among different internal substructures, virtual models of intact teeth that investigated 1-year survival of teeth restored with FRC posts and tita-
and models of teeth with different damage levels were investigated. nium screw posts. The short-term clinical performance of FRC posts
The results indicated that for intact restoration forces were exclusively was superior to that of titanium screw posts, but the ferrule height
transferred at the dentine-crown interface, and the post did not did not have an influence on the survival of neither post type. However,
contribute to load transfer until the bond between the composite one should bear in mind that the mean ferrule height in the study was
core and the dentine failed (35). more than 3 mm in both groups, and survival rates after 1 year were
93.5% and 75.6% for FRC and titanium post, respectively.
Furthermore, no impact of the post material on the clinical
Clinical Trials outcome after 2 years was found in the presence of a ferrule (78). Teeth
One retrospective (75) and few prospective (7680) clinical were restored with either a titanium or glass-FRC post; all the teeth
studies have so far specifically addressed whether and to what extent received a 2-mm ferrule preparation; and, if necessary, surgical crown
the presence of ferrule has an influence on the clinical behavior of lengthening was performed. It was concluded that both posts can be
endodontically treated and restored teeth. All studies with study highly successful in postendodontic restorations when used with
design and most important findings are reported in Table 3. a self-adhesive resin cement and composite core.
Two studies evaluated the influence of various preoperative The effect of the remaining tooth structure on the survival of teeth
factors, including the ferrule height, on the clinical performance of restored with a cast post and core system, a direct metal post, or no post
endodontically treated and restored teeth (75, 77). The amount of was also studied (76). The expected dentin height remaining after tooth
tooth structure available for a ferrule calculated retrospectively from preparation was predicted preoperatively and categorized as substantial
bitewing radiographs was not the preoperative parameter significant (a 1-mm or 2-mm ferrule could be achieved) or minimal (a ferrule
could not be achieved). Over a 5-year follow-up period, teeth with crown preparation, which varied from full chamfer with a bevel
a substantial dentin height performed significantly better than teeth interproximally and lingually, to a feather finish, depending on the
with less remaining tooth structure, whereas the type of restoration height and thickness of the remaining dentine. All teeth were
did not have an influence. restored with a single-unit porcelain fused to metal crown. Over
Two studies evaluated the clinical behavior of endodontically a 2- (79) or 3-year (80) observation period, the post placement
treated premolars with varying degrees of coronal tissue loss that provided a significant contribution to the survival of restored teeth.
were restored with FRC post and composite cores or without any Nevertheless, irrespective of the restorative procedure, the preserva-
root canal retention (79, 80). In both studies, posts were luted tion of at least one coronal wall significantly reduced the failure risk.
inside the root canal with composite cement in combination with When all coronal walls were missing, similar failure risks existed
an appropriate adhesive system. The amount of dentin left at the regardless of the presence or absence of 2-mm-high ferrule retention
coronal level was assessed before composite abutment buildup and (79, 80).