journal of dentistry 41 (2013) 207–215

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Effect of ferrule and post placement on fracture resistance of

endodontically treated teeth after fatigue loading

F. Zicari a,c,*, B. Van Meerbeek b, R. Scotti c, I. Naert a

a
Leuven BIOMAT Research Cluster, Department of Prosthetic Dentistry, School of Dentistry, Oral Pathology and Maxillo-Facial Surgery,
Catholic University of Leuven, Belgium
b
Leuven BIOMAT Research Cluster, Department of Conservative Dentistry, School of Dentistry, Oral Pathology and Maxillo-Facial Surgery,
Catholic University of Leuven, Belgium
c
Department of Prosthetic Dentistry, School of Dentistry, Alma Mater Studiorum, University of Bologna, Italy

article info abstract

Article history: Objectives: To evaluate the influence of the ferrule effect (1) and the fibre-post placement (2)
Received 17 August 2011 on the fracture resistance of endodontically treated teeth subjected to cyclic fatigue loading.
Received in revised form Methods: 40 extracted single-rooted upper pre-molars were sectioned at the CEJ (groups a
15 June 2012 and b) or 2 mm above the CEJ (groups c and d), and subsequently endodontically treated.
Accepted 6 October 2012 After 24-h water storage at 37 8C, specimens were restored according to four build-up
approaches (n = 10 per group): (a) NF–NP (no ferrule, no post), (b) NF–P (no ferrule, fibre-
post), (c) F–NP (ferrule, no post) and (d) F–P (ferrule, fibre post). RelyX Posts (3M-ESPE) were
Keywords: used in groups NF–P and F–P, and were cemented with Panavia F 2.0 (Kuraray). A standard-
Fibre posts ized composite core was built, after which specimens were restored with an all-ceramic
Ferrule crown (IPS Empress CAD, Ivoclar-Vivadent) Specimens were fatigued by exposure to
Fatigue 1,200,000 cycles using a chewing simulator (Willytech). All specimens that survived fatigue
Fracture resistance loading were fractured using a universal loading device (Micro-Tester, Instron). A two-way
analysis of variance was used to determine the statistical significance of the factors ferrule
and post on fracture resistance.
Results: Only one NF–NP specimen failed under fatigue. The ferrule effect significantly
enhanced the fracture resistance of the restored teeth, regardless the use of a post
( p = 0.003). F–NP obtained the highest fracture resistance (758.52  121.89 N), which was
not significantly different from F–P (647.58  132.95 N); NF–NP presented the lowest fracture
resistance (361.52  151.69 N). For all groups, only ‘repairable’ failures were recorded.
Conclusions: Avoiding extra-removal of sound tooth structure, rather than placing a fibre
post, can protect endodontically treated teeth against catastrophic failure. However, when
any ferrule can be preserved, a fibre-post may improve the retention and fatigue resistance
of the restoration.
# 2012 Elsevier Ltd. All rights reserved.

* Corresponding author at: Leuven BIOMAT Research Cluster, Department of Prosthetic Dentistry, Catholic University of Leuven,
Kapucijnenvoer 7, B-3000 Leuven, Belgium. Tel.: +32 16 332438; fax: +32 16 332309.
E-mail address: francesca.zicari@med.kuleuven.be (F. Zicari).
0300-5712/$ – see front matter # 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jdent.2012.10.004
208 journal of dentistry 41 (2013) 207–215
1. Introduction
When restoring endodontically treated teeth, the majority of
failures appeared to be due to biomechanical or restorative
rather than biological reasons.1–5 The most important factor
that needs to be considered for a long-term success is the loss
of tissue at both the root6,7 and coronal levels.3,8,9 The role of
the amount of remaining tooth structure on the fracture
resistance of endodontically treated teeth has often been
emphasized in previous studies.3,10 In particular, a ‘‘ferrule
effect’’ of at least 1.5 mm has been recommended for a long
term success of post-endodontic restorations.10–14 Even more
tooth structure can be preserved by omitting the post and it is
tempting to suggest that core restorations without posts may
perform as well as restorations with posts.8 As a matter of fact,
when restoring an endodontically treated tooth with excessive
loss of dental structure, a post may be needed to improve the
retention of the core build-up material and to distribute
occlusal stresses along the remaining tooth structure. It has
been demonstrated that posts do not strengthen the tooth.15–
17
On the contrary, post space preparation procedures remove
remaining tooth structure thus weakening the tooth and
increasing the risk of root fractures.11,18,19 Restorations with
fibre posts have been shown to fail mostly because of less
tooth-threatening failures such as loss of post retention and
fracture of the post, as compared to the traditional cast post-
and-cores and metallic posts, that frequently yielded unfa-
vourable root fractures.2,20–24 However, not-repairable root
fractures of endodontically treated teeth are still faced in the
clinical practice. Moreover, the risks of root perforations and
root fractures during placement of root canal posts should not
be underestimated as well (Fig. 1).25,26
Fig. 1 – Study set-up. Endodontic treatment, (post)-and-core build-up and crown restoration of the four approaches tested.
Nowadays, thanks to the significant progress adhesive
dentistry has made, guidelines for restoration of endodonti-
cally treated teeth might be revised and the main issue should
not be which type of post performs better but rather in which
cases there is a need for a post or not. Recently, following the
concept of minimal invasiveness of adhesive restorations,
short posts have been evaluated as effective alternative to
traditionally long posts.27–30 Besides, some other studies
indicated that the amount of axial dentin surrounded by the
crown is more important than the length of the post.31 Overall,
comparing results of different studies is obviously difficult,
since different set-ups and materials have been used. In
particular, only in a few studies a fatigue test was performed
and conclusions were mostly based on static compressive
tests solely (Fig. 2).32,33
Aim of this study was to evaluate whether or not fibre-posts
adhesively cemented into the root canal can influence the
fracture resistance of endodontically treated teeth when a
ferrule is preserved. The hypotheses tested were that ferrule
effect (1) and fibre post placement (2) do not affect the fracture
resistance of endodontically treated teeth after cyclic fatigue
loading.
2. Materials and methods
Forty extracted upper pre-molars were stored in 0.5% chlora-
mine in water at 4 8C and used within 6 months after
extraction. The inclusion criteria were absence of caries or
root cracks, absence of previous endodontic treatments, posts
or crowns. Teeth with root length of 15  1 mm and similar
mesio-distal and bucco-lingual dimensions (10%) were used
for standardization. Teeth were randomly divided in 4
 journal of dentistry 41 (2013) 207–215
Fig. 2 – Study set-up. Fatigue and fracture resistance tests.
experimental groups of 10 specimens each according to four
build-up approaches (Fig. 1).
2.1. Specimens preparation (Fig. 1)
2.1.1. Endodontic treatment
Teeth were cut at the cement-enamel junction (CEJ, groups a
and b) or 2 mm above the CEJ (groups c and d) using a low-
speed diamond saw (Isomet 1000, Buehler, Lake Bluff, IL, USA).
Endodontic treatment was done following a standardized
crown-down technique using the ProTaper system (Dentsply-
Maillefer, Konstanz, Switzerland) and the X-Smart-Endo-
motor (Dentsply-Maillefer, Konstanz, Switzerland). The apical
foramen was prepared to size 30. Irrigation was performed
after every change of instrument by alternating 2.5% NaOCl
solution and 17% EDTA solution. Root canal lubricant (Glyde,
Dentsply-Maillefer, Konstanz, Switzerland) was only used
during shaping of the coronal third. Roots were dried with
alcohol and paper points and filled with Top Seal (Dentsply-
Maillefer, Konstanz, Switzerland) and tapered gutta-percha
points using the System-B continuous wave condensation
technique. The root access was temporarily filled with Clearfil
AP-X (Kuraray, Tokyo, Japan). The same composite was
applied to the apical part of the root in order to exclude
leakage through the apex.
2.1.2. Post luting procedures
Specimens were divided in 4 groups of 10 specimens each,
according to the following four build-up approaches: (a) NF–NP
(no ferrule, no post), (b) NF–P (no ferrule, fibre-post), (c) F–NP
(2 mm ferrule, no post) and (d) F–P (2 mm ferrule, fibre-post).
After 24-h water storage at 37 8C, gutta-percha was removed
using no. 2, 3, 4 Gates-Glidden burs up to 5 mm into root canal
in NF–P and F–P groups. The post space was then prepared
with a low-speed bur provided by the post manufacturer. The
prepared root canal was finally flushed with 2 ml NaOCl
solution (2.5%), after which it was dried with paper points.
Double-tapered translucent glass-fibre RelyX Fiber Posts (3M
ESPE, Seefeld, Germany) of 1.6 mm diameter (size n. 2) were
tried in, cleaned with alcohol and cemented with Panavia F 2.0
and ED Primer II, strictly following the manufacturer’s
instructions (Table 1). The accompanied adhesive was applied
209
with ‘extra-small’ micro-brushes in roots and the cement was
applied with a Centrix syringe. The cement was polymerized
from the top of the post with an Optilux 500 device (Demetron/
Kerr, Danbury, CT, USA) with a light output not less than
550 mW/cm2 for 60 s. Posts did not receive any pre-treatment.
In NF–NP and F–NP groups, in which any post was planned to
be placed, gutta-percha was seemingly removed up to 2 mm
into the root canal for retention and filled-up with the
composite used for core build-up.
A standardized core of 5 mm and 68 taper was built with
Optibond FL (Kerr Corporation, Orange, CA) and Supreme-XT
(3M-ESPE) composite using CoreForms for upper premolars
(Kerr) with layers of maximum 2 mm. Each layer was
polymerized from each side for 40 s with Optilux 500. All
teeth were prepared for all-ceramic crowns restorations with a
1 mm shoulder finishing line with a rounded internal angle. In
teeth belonging to F–NP and F–P groups, a circumferential
dentinal wall was preserved with a minimum thickness of
1 mm.
Finishing and polishing were performed immediately after
polymerization of the composite core with fine diamond burs
and finishing discs.
Specimens were restored with all ceramic crowns (IPS
Empress CAD Multi, Ivoclar-Vivadent) that were cemented
with Panavia F 2.0. The actual thickness of the crowns ranged
between 1 and 1.5 mm along the axial walls whereas was kept
of 1.5 mm on the occlusal surface and 2 mm on the cusps.
2.2. Mechanical loading (Error! Reference source not
found)
2.2.1. Fatigue loading
Specimens were embedded in methacrylate resin (Technovit
4004, Hereus-Kultzer) at 2 mm from the CEJ to simulate the
bone level and submitted to a fatigue load of 1,200,000 cycles
under water irrigation using a chewing simulator with sliding
movement (Willytech, Germany), simulating 5 years of clinical
function.34,35 Load was applied at 458 at a frequency of 1.6 Hz.
A sinusoidal load of 0–50 N was applied with a stainless-steel
ball-shaped stylus in the centre of the occlusal area of the
crown. Failures under fatigue loading were recorded during
testing by means of integrated LVDT displacement-sensors,
210 journal of dentistry 41 (2013) 207–215

Table 1 – List of materials used: composition and application procedures.

Material (Batch no.) Composition Adhesive Substrate pre-treat- Application procedures
strategy ment
Panavia F2.0/ED  ED Primer II A: HEMA, 10- Self-etch Mix one drop each of Mix paste A and paste B for
Primer II (Kuraray, MDP, 5-NMSA, water, Primers EDII-A and EDII- 20 s. Apply the mixed paste
Tokyo, Japan) (41298) accelerator B. Apply the mixture to and seat the post (into the
 ED Primer II B: 5-NMSA, the root canal; leave it in root canal) or the crown.
accelerator, water, initiator place for 30 s. Remove Remove the excess, light-
 Panavia cement catalyst: 10- excess primer with cure for 60 s
MDP, hydrophobic aromatic paper points. Dry with
and aliphatic gentle air flow
photoinitiator, dibenzoyl
peroxide dimethacrylate,
hydrophilic dimethacrylate,
silanized silica
 Panavia cement base:
hydrophobic aromatic and
aliphatic dimethacrylate,
sodium aromatic
sulphinate, N,N diethanol-
p-toluidine, functionalized
sodium fluoride, silanized
barium glass
Optibond FL (Kerr, Primer: ethyl alcohol, alkyl Etch-and-rinse 37% phosphoric acid Place etchant on enamel
Orange CA, USA) dimethacrylate resins and and dentin for 15 s
(2930285) water
Bonding: uncured
methacrylate ester,
monomers, triethylene
glycol, dimethacrylate,
ytterbium trifluoride, inert
mineral fillers,
photoinitiators, and
stabilizers
Rinse with water
approximately15 s
Gently air dry
Apply OptiBond FL Prime
over enamel and dentin
uniformly for 15 s. Gently
air dry and light cure for
20 s
Supreme XT BIS-GMA, UDMA. Bis-EMA,
(3M-ESPE, TEG-DMA, PEGDMA, silica
Seefeld, and zirconia filler
Germany) (7EE)
IPS Empress CAD Ceramic ingots made of: IPS ceramic etching gel: Apply to the crown surface
Multi (Ivoclar-Vivadent, >98% SiO2, BaO, Al2O3, CaO, aqueous solution of for 90 s
Shaan, Liechtenstain) CeO2, Na2O, K2O, B2O3 < 2% hydrofluoric acid (<5%) Rinse and dry
(L06020) TiO2 and pigments
Clearfil ceramic primer: Dispense into a well of the
3-MTS, 3-MDP, ethanol mixing dish immediately
before application. Apply to
the adherent surface with a
brush tip. Dry by blowing
mild dry air
Relyx Posts n. Glass fibre, epoxy resin, No treatment
2 (078210803) zirconia filler

which were able to detect displacements of 100 mm and
connected to a PC-software.
2.2.2. Fracture resistance
After fatigue loading, each specimen was immediately
subjected to a fracture resistance test using a universal
loading device (5848 MicroTester1, Instron, Norwood, MA,
USA). Each test was performed at a cross-head speed of
0.5 mm/min and load was applied at 458 using the same
specimen holder and stainless-steel ball-shaped stylus used
for fatigue loading. The maximum failure load was recorded in
Newton (N).
 journal of dentistry 41 (2013) 207–215 211

Table 2 – Mean fracture resistance according to the processing of failures under fatigue loading.
Fatigue failures/number Fracture strength (N) Fracture strength (N)
of tested specimens Fatigue failures included Fatigue failures not included
NF–NP 1/10 361.5 (151.7) C 396.13 (111.4) C
NF–P 0/10 577.0 (104.9) B 577.00 (104.9) B
F–NP 0/10 758.5 (121.9) A 758.52 (121.9) A
F–P 0/10 647.6 (132.9) AB 647.58 (132.9) AB
Superscript letters indicate statistical groups. Means belonging to the same statistical group are not significantly different (two-way ANOVA
followed by Tukey multiple comparison, p < 0.05).

Failures were classified in: Overall, the ferrule effect has been found to significantly
affect the fracture resistance of endodontically treated teeth
( p < 0.0001), by which the first hypothesis has been rejected.
a. repairable (including adhesive failures and crown fractures) Placing a post into the root canal has not been found to be less
when the fracture line was above the simulated bone level beneficial to increase the fracture resistance of endodontically
and treated teeth ( p = 0.21), by which the second hypothesis has
b. not-repairable (including root fracture) when the fracture been accepted. Besides, the interaction between ‘‘ferrule
line was below the simulated bone level. effect’’ and ‘‘post placement’’ was also found to be significant
( p = 0.003, Error! Reference source not found and Tables 2 and
Loss of post retention that occurred under fatigue test was 3). The highest fracture resistance was recorded for F–NP
included as repairable failure. (758.52  121.89 N), which was not significantly different from
F–P (647.58  132.95 N). The lowest fracture resistance was
2.3. Statistical analysis observed for NF–NP (361.52  151.69 N).
Analysis of failures showed a prevalence of repairable
Statistical analysis was performed using the software package failures in all groups, although a higher number of not-
Statistica (StatSoft 9.1, OK, USA). repairable failures were observed in groups NF–NP and F–P
Analysis of variance (two-way ANOVA) with Tukey-HSD for (Fig. 4). Retention loss of the core in NF–NP during fatigue
post hoc comparison was used to analyse the fracture loading was considered as repairable failure.
resistance test results. A significance level of 5% was used.
Statistical analysis was performed either excluding teeth that
failed during the fatigue test or including them as the lowest 4. Discussion
loading value (50 N).
In this study, we focused on the influence of a ferrule and the
fibre-posts placement on fracture resistance of endodontically
3. Results treated teeth after being subjected to fatigue loading. The
hypothesis that a 2 mm circumferential ferrule does not affect
3.1. Fatigue loading the fracture resistance of endodontically treated teeth has
been rejected. The hypothesis that placing a fibre-post does
Only one NF–NP specimen failed during fatigue loading not affect the fracture resistance of endodontically treated
because of loss of core retention. All the other specimens teeth has been accepted.
survived the 1,200,000 fatigue cycles. Overall, it appeared that preserving a ferrule is beneficial to
increase the fracture resistance of endodontically treated
3.2. Fracture resistance test teeth ( p < 0.0001). When a ferrule cannot be preserved, placing
a post also increases the fracture resistance ( p = 0.0003).
The statistical outcome did not vary when excluding speci- However, when a cervical collar of dentin (ferrule) can be
mens failed under fatigue loading or when including them as preserved, a post seems not to be necessary and it might even
the lowest measured value (50 N), as shown in Table 2. decrease the strength of the restored tooth. Teeth with a 2 mm
ferrule and restored without a post (F–NP) obtained the highest
fracture resistance. The mean values obtained by the F–NP
group were significantly higher than those obtained by all
Table 3 – ANOVA table representing effective decom- other groups, except for teeth with ferrule and restored with a
position of main variables and their interaction. post (F–P).
This outcome corroborates results of previous studies, in
SS DF MS p-Value
which a ferrule of at least 1.5 mm has been reported to be
Ferrule 546,565 1 546,565 <0.0001
efficacious for the long-term survival of restorations of
Post 27,321 1 27,321 0.21
endodontically treated teeth.9,10,12,36,37 Nevertheless, the
Ferrule  post 266,386 1 266,386 0.0003
Error 598,898 36 16,636 configuration of the ferrule has recently been stressed. Some
earlier findings reported that a uniform ferrule height of 2 mm
SS, sums of squares; DF, degrees of freedom; MS, mean squares.
led to higher fracture resistance than a ferrule height varying
212 journal of dentistry 41 (2013) 207–215
between 0.5 and 2 mm, in particular when approximal cavities
are not involved.38 Besides, some other studies indicated that
the higher the number of remaining cavity walls, the better the
biomechanical performance of endodontically treated
teeth.8,39–42 Naumann et al., for instance, reported that
Fracture Resistance (N)
preserving a ferrule, along with a stabilizing effect of a fibre
post, can enhance the load capability of excessively flared
endodontically treated teeth as well, thus balancing the loss of
tissue at the root level.14 However, to provide an adequate
clinical crown length and ferrule height, orthodontic extrusion
or surgical crown lengthening have been suggested
in situations of insufficient remaining coronal tissue.9,43
However, when dealing with the restoration of teeth that lost
hard tissue considerably, creation of a ferrule may be made at
the expense of the remaining tooth structure, thus further
potentially weakening the tooth. Hence, nowadays, thanks to
the significant developments that adhesive techniques have
made, alternative approaches, including inlay and onlay
restorations without posts, should be considered as less
invasive and viable alternative.44–46 Therefore, clinical trials
that evaluate adhesive partial restorations on the long-term
should be encouraged.
While the importance of preserving sound coronal tissue
seems to be well proven, the use of a post is controversial. In
this study, placing a fibre post did not enhance the fracture
resistance of premolars restored with all ceramic crowns
where a ferrule was preserved. However, post placement
appeared to enhance the fracture resistance of premolars
without a ferrule, which is in line with findings of a
randomized clinical trial that revealed that fibre post
placement was efficacious to reduce failures of post-endodon-
tic restorations only for teeth with no residual coronal walls.4
Regrettably, controversial data have been reported by earlier
studies in which the fracture resistance and the mode of
failure of endodontically treated teeth restored with or
without posts were investigated. Recently, some studies
revealed that, in vitro, teeth restored with fibre posts exhibited
a higher fracture resistance and more restorable failures as
compared to teeth restored without posts.2,39,40 Other studies
showed that fibre post placement could be effective to reduce
the occurrence of unrestorable root fractures only when
restoring teeth with one or two residual coronal walls. On the
contrary, other studies concluded that the insertion of fibre
posts did not improve the fracture resistance of endodonti-
cally treated teeth11,36,44,45 and did not reduce the occurrence
of catastrophic failures.44 Heydecke et al., for instance,
showed that post insertion does not add any beneficial effect
to intact teeth, even in the anterior region where higher
tension stress due to more horizontal forces develops during
function.8 Post insertion has also been shown not to improve
marginal adaptation, retention and fracture resistance of
adhesive composite restorations on endodontically treated
premolars.45
In this study, only single-rooted upper premolars were
used because they have been shown to be more susceptible to
root fractures when submitted to occlusal loading after
endodontic treatment.47,48 Moreover, load was applied at
458, thus inserting extra-axial forces on the restored tooth,
which are associated with bending moments and unfavour-
able stress distribution during function. This configuration
1000
900
800
700
600
500
400
300
200
100
No post
0
No ferrule Ferrule Post
Fig. 3 – Interaction plot for fracture resistance of teeth
according to the 4 build-up approaches. Vertical bars
denote 0.95 confidence intervals (two-way ANOVA,
p = 0.0003).
appeared to be the ‘‘worst case scenario’’ with regard to the
fracture resistance of endodontically treated teeth and
considered suitable for evaluating the behaviour of restora-
tions with or without fibre posts after fatigue loading.9,49,50
Furthermore, in this study, a fatigue test has been carried
out before subjecting specimens to a fracture load, in order to
avoid false conclusions due to the application of a compressive
load only.51 Fatigue failures are defined as fractures of a
material caused by cyclic or repeated sub-critical loads,52
whereby a structure eventually fails after being repeatedly
subjected to loads that are so small that one application
apparently is not detrimental to the component.53 For dental
applications, fatigue tests should be performed for a minimum
of 106 cycles. A total of 1,200,000 cycles have been performed in
this study, in order to simulate 5 years of clinical function.34
Obviously, a large number of variables are involved when
simulating clinical loading, e.g. loading force, direction and
frequency of load, temperature and humidity of the test
chambers, teeth conditions and materials used. Moreover,
several studies only applied static load to evaluate fracture
resistance of endodontically treated teeth. For this reason,
overall, results appear difficult to be compared.
In the literature, in particular in studies dealing with micro-
tensile bond strength, the correct handling of samples that
failed before they could be tested is still up to debate.54,55 By
omitting the failures under fatigue loading, only the non-failed
samples that exhibit the highest fracture resistance are
counted in, which will lead to a bias towards a higher fracture
resistance results (Table 2 and Fig. 3). On the other hand, if
failures under fatigue loading were included as 0 N, judgement
would have been too severe, since it is known that specimens
were subjected to a cyclic loading of 50 N. Therefore, statistical
analysis was also performed including failures under fatigue
loading with the lowest measured values of 50 N. In this study,
this resulted in no statistical differences, due to the fact that
only one NF–NP specimen prematurely failed under fatigue
loading.
 journal of dentistry 41 (2013) 207–215
F-P
F-NP
NF-P
NF-NP Repairable
Not-repairable
0 2 4 6 8 10
Fig. 4 – Analysis of failures. A prevalence of repairable
failures was observed in all experimental groups.
However, more not-repairable failures were observed in
specimens without ferrule and restored without fibre
posts (NF–NP) and specimens with ferrule and restored
with fibre posts (F–P). Any not-repairable failure was
observed in specimens with ferrule and restored without
fibre posts (F–NP).
Besides the high fracture resistance, as measured by load
capability, success of a restoration has to be regarded as the
chance of re-intervention and preservation of the restored
tooth when failure has happened. It may be more favourable
that failure occurs at a lower load but in a way that it
maintains the tooth restorable. In this study, specimens
mostly failed because of repairable failures, regardless of the
build-up approach. The specimen that did not survive fatigue
loading failed because of debonding of the restoration, which
may be ascribed to a low retention of the build-up, where no
ferrule was preserved and no post was placed. Regarding
failures under fracture test, a prevalence of repairable failures
was observed in all groups (Fig. 4). Because tension develops
palatally and compression facially,56 a typical fracture pattern
extended from the palatal cervical area to the facial area above
the simulated bone level was observed. However, it should be
mentioned that only premolars with a ferrule and restored
without a post did not show not-repairable root fractures,
which again emphasize the importance of a ferrule. Interest-
ingly, 40% of teeth with a ferrule (F–NP and F–P) failed because
of crown fractures, which did not involve the core or the tooth
structure, regardless of the use of a post. A few not-repairable
failures were observed in teeth restored with posts, which
fractured closer to tip of the post itself. This finding
corresponds to the outcomes of earlier studies, that reported
the area surrounding the post tip is an area of high stress
concentration,57,58 which can initiate cracks propagation and
inclines towards fracture.
Root fractures have been attributed to large variations of
rigidity between post material and root dentin, which yielded
areas of stress concentration into the root.59,60 Fibre posts,
whose elastic modulus is in the same range of that of dentin,
are claimed to preserve teeth from catastrophic failures.
Notwithstanding, in spite of the use of fibre posts, a few
catastrophic failures were observed in this study. Unfortu-
nately, a few not-repairable fractures occurred in both teeth
213
restored with posts or without ferrule. Although this outcome
is difficult to be interpreted, it confirms that extra-removal of
sound tooth structure may weaken the tooth and lead to a
lower fracture resistance.4,61 Nonetheless, alterations of the
natural geometry of the root canal may cause destabilization
of endodontically treated teeth.62 Therefore, since it is known
that insertion of fibres in a restoration, may help in
distributing occlusal forces,46,63 one can speculate that post
placement should every time be balanced against tooth tissue
removal, in order to select the more suitable build-up
approach.
5. Conclusions
It can be concluded that:
 Endodontically treated teeth with a circumferential ferrule
of 2 mm height and restored without a post may survive
fatigue loading as well as teeth restored with a fibre post.
However, in teeth where a ferrule is not preserved, a post
may eventually improve retention of the restoration.
 Inserting a fibre post seems not to be necessary to improve
the fracture resistance of endodontically treated teeth in
which a ferrule is preserved, whereas is effective in teeth
without any ferrule.
 Avoiding extra-removal of sound tooth structure rather than
using a fibre posts does protect endodontically treated teeth
against catastrophic failures, since only endodontically
treated teeth with a 2 mm ferrule and restored without
fibre posts did not show not-repairable root fractures.
Acknowledgements
This study was partially supported by a Research Grant of the
Fund for Research Flanders (F.W.O.-G.0281.05). We thank the
following manufacturers for the donation of materials: Kerr
(Kerr Corporation, Orange, CA), Ivoclar-Vivadent (Schaan,
Lichtenstein), 3M ESPE (Seefeld, Germany) and Kuraray
(Osaka, Japan).
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