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Ferrule Effect: A Literature Review

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Ferrule Effect: A Literature Review
Jelena Juloski, DDS,* Ivana Radovic, DDS, MSc, PhD,† Cecilia Goracci, DDS, MSc, PhD,*
Zoran R. Vulicevic, DDS, MSc, PhD,† and Marco Ferrari, MD, DDS, PhD*
Abstract
Introduction: Preserving intact coronal and radicular
tooth structure, especially maintaining cervical tissue
to create a ferrule effect, is considered to be crucial
for the optimal biomechanical behavior of restored
teeth. The ferrule effect has been extensively studied
and still remains controversial from many perspectives.
The purpose of this study was to summarize the results
of research conducted on different issues related to the
ferrule effect and published in peer-reviewed journals
listed in PubMed. Methods: The search was conducted
using the following key words: ‘‘ferrule’’ and ‘‘ferrule
effect’’ alone or in combination with ‘‘literature review,’’
‘‘fracture resistance,’’ ‘‘fatigue,’’ ‘‘finite element anal-
ysis,’’ and ‘‘clinical trials.’’ Results: The findings from re-
viewed articles were categorized into three main
categories: laboratory studies, computer simulation,
and clinical trials. Laboratory studies were further classi-
fied into subchapters based on the main aspect investi-
gated in relation to the ferrule effect. Conclusions: The
presence of a 1.5- to 2-mm ferrule has a positive effect
on fracture resistance of endodontically treated teeth. If
the clinical situation does not permit a circumferential
ferrule, an incomplete ferrule is considered a better
option than a complete lack of ferrule. Including a ferrule
in preparation design could lead to more favorable frac-
ture patters. Providing an adequate ferrule lowers the
impact of the post and core system, luting agents, and
the final restoration on tooth performance. In teeth
with no coronal structure, in order to provide a ferrule,
orthodontic extrusion should be considered rather
than surgical crown lengthening. If neither of the alter-
native methods for providing a ferrule can be performed,
available evidence suggests that a poor clinical outcome
is very likely. (J Endod 2012;38:11–19)
Key Words
Endodontically treated teeth, ferrule effect, post and
core, review
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 ª 2012 American Association of Endodontists.
doi:10.1016/j.joen.2011.09.024
JOE — Volume 38, Number 1, January 2012
Review Article
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-
ture and the functional requirements (1). Frequently, the remaining tooth structure is
not sufficient, and a post is indicated to provide retention for crown restoration (1–
3). Cast post and core systems were the standard for many years. However, demands
for simpler procedures and esthetic restorations led to the development of
prefabricated posts, initially made from metal and more recently from ceramics
and fiber-reinforced composites (FRCs) (1, 4, 5).
A successful clinical outcome of endodontically treated teeth depends on
adequate root canal treatment as well as on adequate restorative treatment per-
formed afterwards (6). Therefore, research has focused on finding the most prom-
ising post and core system (7–9), luting agent (10–12), and crown type (13, 14).
Even though a strengthening effect of the post is desirable and very often needed, it
was questioned in the literature (1). Despite extreme efforts to reinforce endodon-
tically treated teeth, biomechanical failures still represent a critical issue (4, 15).
The lack of a protective feedback mechanism after pulp removal may be
a contributing factor to frequent tooth fractures (16). However, beside noncontrol-
lable risk factors, the high occurrence of fractures may be attributed to various
operative procedures, such as access cavity preparation and restoration, root canal
preparation, irrigation and obturation, post space preparation, and final coronal
restoration (15, 17).
Preserving intact coronal and radicular tooth structure and maintaining cervical
tissue to create a ferrule effect are considered to be crucial to optimize the biomechan-
ical behavior of the restored tooth (17, 18). A ferrule effect is defined as a ‘‘360 metal
collar of the crown surrounding the parallel walls of the dentine extending coronal to
the shoulder of the preparation. The result is an elevation in resistance form of the
crown from the extension of dentinal tooth structure’’ (19). More precisely, parallel
walls of dentin extending coronally from the crown margin provide a ‘‘ferrule,’’ which
after being encircled by a crown provides a protective effect by reducing stresses within
a tooth called the ‘‘ferrule effect’’ (20) (Fig. 1).
Growing attention has been given to the prognosis of endodontically treated
teeth, and, generally, the ferrule effect is considered necessary to stabilize restored
tooth (1, 3, 17, 21–24). 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
would be desirable, it should not be provided at the expense of the remaining
coronal or root structure (25, 26). However, it is important to bear in mind
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
Ferrule Effect 11
Review Article
Figure 1. A schematic drawing of endodontically treated tooth restored with
post and core system and a crown. Co, core; Cr, crown; F, dentin extending
coronal from crown margin providing a ferrule; G, remaining gutta-percha;
P, post.
(22). This topic has been extensively studied and yet remains
controversial from many perspectives. Therefore, this literature
review aimed at summarizing research conducted on different issues
related to the ferrule effect.
Materials and Methods
A literature search was conducted based on the following criteria:
articles retrieved in PubMed using the following key words: ‘‘ferrule’’
and ‘‘ferrule effect’’ alone or in combination with ‘‘literature review,’’
‘‘fracture resistance,’’ ‘‘fatigue,’’ ‘‘finite element analysis,’’ and ‘‘clinical
trials’’; English language; and publication date range from 2000 to
2011. This search strategy identified 59 articles. Articles that were
not found to be significant to the subject of the review based on the
abstract were excluded. Conversely, noteworthy articles cited in the
selected pertinent articles were included as well as some of the classic
literature. Finally, the web sites of relevant dental journals were
explored in the search for in press papers. Sixty-two articles, 13 review
and 49 original articles, were found to meet the mentioned inclusion
criteria and became the object of the present review.
Results
The findings from all articles were categorized into three main
categories: laboratory studies, computer simulation (finite element
analysis), and clinical trials.
Laboratory Studies
The majority of published articles are laboratory studies that used
static load tests to simulate single high-force application that might
12 Juloski et al.
occur with trauma or as a result of parafunctional habits. All reviewed
articles used single-rooted human or bovine teeth and constant load
was applied at an angle to the long axis until fracture of the specimen
occurred. Maximum loads that teeth could withstand and fracture
patterns were analyzed and compared. However, the clinical signifi-
cance of results obtained from in vitro static testing has been ques-
tioned (27–29) because a monostatic load does not represent the
clinical situation in which repetitive mechanical loading and thermal
changes are characteristics. Therefore, in order to acquire more
clinically relevant data with regards to the ferrule effect, in some of
the reviewed studies, mechanical, thermal, or thermomechanical
fatigue testing were performed, and endurance of the specimens was
measured.
Results of all laboratory studies that investigated the ferrule effect
were further classified into following subchapters based on the main
aspect that was investigated in relation to the ferrule effect: ferrule
height/ferrule design, type of post and core system and final restoration,
post length, luting techniques, and crown lengthening versus ortho-
dontic extrusion (Table 1).
Ferrule Height/Ferrule Design. The necessary ferrule height
required to provide the protective effect was frequently investigated
(19, 29–35). When crowned bovine teeth were subjected to cycling
loading until the crown or post was dislodged or the post or root
fractured, the resistance increased significantly with an increasing
ferrule height (34). Similarly, the number of load cycles required to
induce failure in cement layer (preliminary failure) was higher for
human teeth with higher ferrule (29, 33). Teeth with no ferrule
survived only few fatigue cycles, and 0.5-mm and 1-mm ferrule groups
showed a significantly higher number of cycles before failure (29). Even
though between these two groups there was no statistically significant
difference, the authors recommended a 1-mm-high ferrule because
of a large standard deviation in the 0.5-mm ferrule test group. One milli-
meter of coronal dentin was also found to be enough to significantly
increase the fracture strength when exposed to static loading (19).
On the contrary, two studies reported no statistically significant differ-
ence in failure loads between teeth with a 1-mm ferrule and those with
no remaining coronal tooth structure (30, 31). In another study, teeth
with a 0.5-mm and 1-mm ferrule failed at a significantly lower number
of load cycles than the 1.5-mm and 2-mm ferrule groups (33). Ferrule
heights required to significantly improve fracture resistance when
exposed to static loading were 2 mm (31, 32) and 3 mm (30). Addi-
tionally, during chewing simulation, teeth with a 1-mm ferrule had
a higher percentage of preliminary failure and lower ultimate loads
before fracture when compared with a 2-mm high design (35). The
mode of fracture was highly dependent on the ferrule height: for resto-
rations with a ferrule height of a 1-mm post/core/crown complex was
usually decemented, whereas for teeth with 2-mm ferrule fractures
starting on the remote side were most common (35).
Moreover, because the clinical situation does not always permit
preparation of the circumferential ferrule of uniform height, the effect
of incomplete ferrule on tooth resistance has been studied (36–38). A
ferrule of nonuniform height, varying between 0.5-mm proximal and 2-
mm buccal and lingual, was less effective in preventing failure under
static loading than a uniform 2-mm ferrule (36). Similarly, differences
in resistance after thermomechanical loading were present when a 360
circumferential 2-mm ferrule was compared with a 2-mm ferrule
present just on the palatal or facial aspect or with the ferrule interrupted
by biproximal cavitation (38). Yet, one study reported no change in
resistance between teeth with a uniform ferrule and a ferrule that incor-
porated only the buccal and/or lingual wall (37). Nonetheless, teeth
with a nonuniform ferrule length were still more fracture resistant
JOE — Volume 38, Number 1, January 2012
 Review Article
TABLE 1. A List of the Reviewed Laboratory Studies According to the Main Aspects Investigated in Each Study
Type of post and Crown lengthening
Type Ferrule height/ core system and Luting vs orthodontic
of test ferrule design final restoration Post length techniques extrusion
Static load Sorensen and Zhang et al (40) Nissan et al (59) al-Hazaimeh and Gegauff (66)
testing Engelman (19) da Silva et al (13) Gutteridge (55) Meng et al (70)
Pereira et al (30) Pereira et al (30) Mezzomo et al (53) Meng et al (69)
Cho et al (31) Pereira et al (41)
Akkayan (32) Zhi-Yue and
Tan et al (36) Yu-Xing (42)
Dikbas (37) Sendhilnathan
Kutesa-Mutebi and Nayar (43)
and Osman (39) Akkayan (32)
al-Hazaimeh and Massa et al (44)
Gutteridge (55) Qing et al (45)
Ng et al (54) Lima et al (46)
Fatigue Ma et al (29) Xible et al (47) Schmitter et al (35) Dorriz et al (56)
testing Isidor et al (34) Hu et al (48) Isidor et al (34) Goto et al (28)
Libman and Heydecke et al (49) Buttel et al (60) Naumann et al (61)
Nicholls (33) Butz et al (50) Aykent et al (63)
Schmitter et al (35) Sahafi et al (51) Hsu et al (62)
Naumann et al (38) Naumann et al (52) Schmitter et al (65)
Dorriz et al (56) Schmitter et al (35)
Junge et al (64)

then teeth without a ferrule (36, 37), and, therefore, it was suggested
that a 2-mm ferrule should be provided at least on the buccal and
lingual wall. Irrespective of the ferrule design, the predominant mode
of failure was an oblique fracture from the lingual margin to the vestib-
ular tooth surface (36).
Few studies assessed the impact of particular ferrule design on
tooth resistance (19, 31, 39). The inclusion of interproximal grooves
when there is a 1-mm or more coronal dentinal extension decreased
the failure loads and therefore should be avoided. Furthermore, with
a 1-mm or 2-mm ferrule preparation, there was no difference in frac-
ture resistance regardless of whether a butt joint or a 1-mm-wide con-
trabevel configuration existed at the tooth-core junction (19, 39).
Type of Post and Core System and Final Restoration. The
effectiveness of different procedures for restoring the function of
endodontically treated teeth subjected to static (13, 30, 32, 40–46)
or fatigue loading (47–52) has been widely investigated.
Combinations of different ferrule designs and various post and core
systems and final restorations were tested in an attempt to find the
best treatment option that would provide the highest fracture
resistance and the most favorable fracture pattern of severely
compromised teeth. However, the results were controversial. Some
research reported that changes in stiffness and design associated with
post and core material did not significantly influence fracture
resistance as long as sufficient dentine structure remained (13, 41,
47, 49, 52), whereas other studies pointed out that post type may
have an impact (32, 42–45, 50).
The vast majority of literature data suggests that the presence of
a ferrule is a significant factor in improving resistance to fracture for
different types of posts: cast post and core (13, 33, 36, 40–43, 48,
53), all ceramic post and core (40), prefabricated metallic posts (30,
34, 41), and prefabricated fiber-reinforced composite (FRC) posts
(13, 29, 46, 48, 54). Conversely, two studies reported that the
additional use of ferrule preparation had no benefit in terms of
resistance to fracture of teeth restored with cast post and core
(43) and prefabricated metallic post (55).
When teeth with a 2-mm ferrule were restored with a custom-
fabricated all-ceramic or metal post and core, resistance to fracture
was similar (40). Metal cast post-and-core-restored teeth were more
resistant to fracture than teeth with prefabricated posts when the ferrule
effect was not provided (30, 41–43) as well as in the presence of a 2-
mm ferrule (42, 43, 45). On the contrary, in the presence of a ferrule,
teeth restored with prefabricated titanium posts and composite cores
had higher fracture resistance compared with cast post and core and
prefabricated quartz-FRC posts (44). Still, for a sudden impact, cast
post and core was more effective, but under cyclic fatigue testing teeth
restored with carbon-FRC posts outperformed cast post and cores (48).
Furthermore, among the 1-mm, 1.5-mm, and 2-mm ferrule length
specimens, higher fracture loads were observed in teeth restored
with a quartz-FRC post compared with teeth restored with glass-FRC,
zirconia enriched glass–FRC, and zirconia posts (32).
After subjecting the specimens only to mechanical loading, there
was no difference in the survival rate (100%) among teeth with a 1.5-
mm ferrule restored with zirconia, FRC, or titanium post (47). After
cycling loading, specimens were exposed to an oblique, static load
until failure, and, likewise, all systems showed statistically equivalent
fracture strength values and modes of failure. However, when speci-
mens were subjected to thermomechanical fatigue loading, there was
a lower percentage of survival (49, 50). Both studies (49, 50)
investigated the following combinations of materials in the presence
of a 2-mm-high dentine ferrule and under the same fatigue condi-
tions: titanium post and composite core, zirconia post and ceramic
core, zirconia post and composite core, and cast gold post and
core system. Heydecke et al (49) found no statistically significant
differences in survival rates, fracture loads, and modes of failure
among groups, but all ceramic posts and cores were recommended
as an esthetic alternative to cast post and cores because all specimens
remained intact during thermomechanical loading, the higher fracture
strengths, and the number of restorable fractures observed among
specimens from that group. Conversely, Butz et al (50) found a lower
survival rate and fracture strength for ceramic post/composite core
combination and suggested that this should be avoided in clinical use.
With regard to fracture modes, the findings were also controver-
sial. Some studies reported that the direct technique was appropriate
because more severe root fractures were found in cast post-and-
core-restored teeth (30, 41, 56); others did not observe differences
in fracture pattern between teeth restored with cast post and core

JOE — Volume 38, Number 1, January 2012 Ferrule Effect 13

Review Article
or prefabricated metallic or FRC posts (13, 40, 45, 48). Also, no
difference was present between ferruled teeth restored with different
types of FRC posts (32). However, among teeth with prefabricated metal
posts and composite cores, with no ferrule, and a 1-mm to 3-mm
ferrule, different fracture patterns were present; nonferruled specimens
failed because of core fracture and ferruled teeth because of cementa-
tion failure (30). When prefabricated posts were made from quartz-
FRC, teeth without a ferrule mainly failed as a result of debonding,
and in the presence of a ferrule, the most common mode of failure
was root fracture (54).
When a ferrule was provided, several studies reported that the
placement of a post did not significantly improve fracture resistance
compared with teeth restored only with composite core and no canal
retention (39, 41, 44, 46). However, leaving the specimens empty,
without post and without core buildup, regardless of the presence of
a 2-mm-high ferrule led to the lowest fracture resistance, suggesting
that a ferrule is only one key element in the complex (52). A significant
increase in load capability was observed when only composite core was
placed, which was contributed to an increase in retentive surface to
withstand static loading (52).
Furthermore, when a ferrule was not provided, fracture resistance
to static loading of teeth restored with posts was comparable with teeth
with composite buildups alone (46). Then again, a positive impact of
post placement on fracture resistance was found (41). In terms of resis-
tance to cyclic loading, no difference was found between teeth restored
only with a composite core without post and teeth restored with post and
core systems, irrespective of the type of post (51, 52). On the other
hand, the shape of the post did have an impact: parallel-sided cast posts
showed a higher resistance than the ones restored with tapered posts
(51). Surface treatment of prefabricated posts (ie, titanium, glass-
FRC, and zirconium), which consisted in air abrasion, followed by
silane coating significantly increased the resistance (51). However, it
was anticipated that the presence of a ferrule may have resulted in
higher resistance and overshadowed the effect of post-related factors
that could have given different results.
Regarding the failure pattern, specimens that were left empty had
more restorable than catastrophic fractures, whereas the group with
only core buildup had an equal number of both types of failure (52).
Specimens restored with posts and cores had more catastrophic failures
when a ferrule was present, irrespective of post material, but when an
FRC post was used, less catastrophic failures were observed compared
with titanium posts (52).
Only one study aimed to investigate the impact of different crown
types and the ferrule effect on tooth deformation and fracture resistance
(13). The effect of alumina-reinforced ceramic and metal crowns was
assessed, and it was reported that mechanical behavior is primarily
determined by the presence of a ferrule and crown type and the effect
of post and core system was considered secondary (13). The use of
a ceramic crown overcame the disadvantage of ferrule absence, and
a ceramic crown with glass-FRC post was recommended as the best
choice for restoring endodontically treated incisors. When a ferrule
cannot be provided, authors recommended metal crowns and cast
post and cores (13).
Post Length. As stated earlier, the preservation of sound root struc-
ture is of utmost importance. Minimizing the loss of root dentin tissue
during post space preparation can be realized by using reduced-length
posts. Besides, it could ensure the preservation of 4 to 5 mm of gutta-
percha, which is necessary to provide a reliable apical seal (57, 58).
When a 2-mm ferrule was designed and prefabricated metal posts
were luted with a titanium-reinforced composite, the resistance to frac-
ture under static load was unaffected by the post length (59). Besides,
14 Juloski et al.
only fractures of teeth with reduced-length posts were considered
restorable (59). Likewise, the post length had no significant influence
on failure during chewing stimulation or on ultimate loads when human
premolars with a 1-mm or 2-mm ferrule were restored with 2-mm and
7-mm long glass-FRC posts (35).
No difference in fracture resistance occurred when bovine teeth
with no ferrule, a 1.25-mm ferrule, and a 2.5-mm ferrule were restored
with 5-mm, 7.5-mm, and 10-mm long prefabricated titanium posts and
subjected to cyclic mechanical loading (34). Conversely, the perfor-
mance of teeth without a ferrule restored with an FRC post and direct
composite crown was different when different post lengths were used
(60). After thermomechanical loading, specimens restored with a 3-
mm post length yielded significantly lower fracture values than with
a post inserted 6 mm.
Luting Techniques
Post luting. Two studies reported that the additional use of ferrule
preparation had no benefit in terms of the resistance to fracture when
resin cement was used for post cementation (53, 55). However, when
conventional zinc-phosphate cement was used, the presence of a ferrule
did provide improvement in metal cast post-and-core-restored teeth
(53). Although there was no difference in fracture strength between
the ferrule and nonferrule groups, the modes of failure differed. Teeth
with a ferrule underwent a mostly oblique fracture, whereas in teeth
without a ferrule vertical root fracture was the predominant failure
mode (55). Moreover, a higher resistance to the preliminary failure
of teeth with a 1.5-mm ferrule was shown when resin cement was
used for luting an FRC post in comparison with cast post and core luted
with conventional zinc-phosphate cement (28). In the same study, teeth
with titanium posts luted with zinc-phosphate cement and adhesively
bonded composite cores showed an intermediate level of resistance.
It was concluded that a stronger union between the post and core es-
tablished using adhesive bonding may significantly influence crown
cement failure (28). Bonding metal cast posts to the tooth structure
by the application of an opaque porcelain layer to post surface before
cementation with resin cement increased the survival rate and fracture
strength and compensated for the lack of a ferrule (56). In terms of
fracture patterns, more favorable failure modes were seen for teeth
restored with a glass-FRC post and composite cores than for teeth
restored with cast post and core (56).
One study evaluated the performance of teeth with excessively
flared root canals restored with FRC posts luted with resin cements
(61). Results showed that, after a simulated 5-year period of service
by thermomechanical loading, flared unferruled teeth did not exhibit
load capability that could be recommended for clinical use when luted
with self-adhesive resin cement. However, when ferrule existed and
posts were adhesively luted, irrespective of the type of resin cement
(self-adhesive or in combination with an adhesive), clinically acceptable
mean values for the load capability were revealed. Another two studies
used the same self-adhesive resin cement for luting FRC and metal posts
and reported similar fracture resistance in the presence of ferrule,
regardless of the post type (13, 52). Within the no ferrule groups,
fracture resistance was unaffected by the post type (13), but also higher
load values were measured for metallic post compared with FRC (52).
Composite cores that were bonded to a tooth structure with a 1-
mm ferrule compared with nonbonded composite cores provided
significantly stronger crown retention under fatigue loading (62).
Also, the bonding of silver amalgam cores significantly improved the
fracture resistance of teeth previously subjected to thermal cycling
only when a ferrule was not present, whereas in the presence of a 2-
mm-high ferrule, there was no difference in bonded and nonbonded
core groups (63).
JOE — Volume 38, Number 1, January 2012

Crown luting. It was reported by Ma et al (29) that using resin
cement to lute crowns in their study resulted in a higher cycle count
compared with zinc-phosphate cement used by Libman and Nicholls
(33). These conclusions are consistent with findings from other
studies (35, 64, 65). When the ferrule was present, the resin luting
agent for bonding crowns increased the number of cycles needed to
cause premature failure (35, 64) and the ultimate loads that the
complex could withstand afterwards (35, 65) in comparison with
a glass-ionomer cement. A higher bond strength of resin-bonded
restorations and the ability to transfer tensile stresses at crown/dentine
interface were the possible explanations of the results (35). No signif-
icant differences between zinc-phosphate and resin-modified glass-
ionomer cement were found (64). The preparation design had an
important effect on fracture resistance when crowns were cemented
with glass-ionomer cement (ie, more retentive preparation and greater
wall thickness led to the greater fracture resistance), whereas it did
not influence fracture strength when crowns were cemented with resin
cement (65).
Crown Lengthening versus Orthodontic Extrusion. The
restoration of severely damaged teeth, with no clinical crown present,
represents a particularly important issue. In such a clinical situation,
an adequate ‘‘biologic width’’ and distance between crown margin
and alveolar crest should be ensured (25, 66). Biological width was
defined as ‘‘the dimension of the junctional epithelial and connective
tissue attachment to the root above the alveolar crest’’ (67), and it
has been recommended that at least 3 mm between the crown margin
and the alveolar crest should be left to avoid impingement on the
coronal attachment of the periodontal connective tissue (68). There-
fore, if a 1.5-mm ferrule is to be achieved, at least 4.5 mm of supra-
alveolar tooth structure is required (25). In a situation in which enough
tooth structure does not exist, the clinician may consider two options:
surgical crown lengthening or orthodontic extrusion (19, 25, 66).
The effects of apical placement of a ferrule on the resistance to
static load failure after crown lengthening (66, 69, 70) or forced
tooth eruption (69) were investigated. Composite analogs of a premolar
without crown lengthening and without a ferrule with the crown finish
line located at the cement-enamel junction showed a significantly
greater load resistance than crown-lengthened specimens prepared
with a 2-mm ferrule and the finish line moved 2 mm apically from
the cement-enamel junction (66). The results were in accordance
with another study that used human premolars (70). Both of the studies
restored the specimens with cast post and cores. However, that differ-
ence in fracture strength was not present between teeth with an apically
positioned ferrule and teeth without a ferrule when restored with
carbon-FRC posts and composite cores (69, 70). Moreover, most
failures for cast post and core systems were catastrophic, such as
vertical root fractures and oblique root fractures located below the
cervical third of the roots and, for prefabricated carbon-FRC posts, frac-
tures were less severe and located at or above the cervical third of the
root (70). On the other hand, the presence or absence of a ferrule did
not influence the root fracture pattern, irrespective of the post and core
system used (70).
Disadvantages of surgical crown lengthening treatment are an
increase in crown/root ratio caused by the reduced effective root
length and the increased effective crown length and reduced volume
of root dentine that remains (66, 69, 70). An alternative approach
to treatment could be an orthodontic extrusion. From the bio-
mechanical point of view when orthodontic extrusion is performed,
bone support reduces, but the coronal lever arm does not change.
The preparation of a 1-mm ferrule after simulated forced tooth extrac-
tion significantly improved the fracture strength of the tooth, and
JOE — Volume 38, Number 1, January 2012
Review Article
a 2-mm ferrule design was associated with an even higher fracture
resistance (69).
Computer Simulation: Finite Element Analysis
Finite element analysis (FEA) is the method that evaluates stress
distribution within complex structures and provides results without
variation (71). The accuracy of the results depends on the extent to
which the model approaches reality (35, 71). Because of the large
variability of the results obtained from in vitro studies, different
concerns related to the ferrule effect have been investigated based on
FEA (35, 72–74). Study designs and most important findings of each
study are reported in Table 2. The distribution of compressive and
tensile stress (73, 74) and stress combination, known as equivalent
von Mises stresses (72), were studied on 3-dimensional models of
monoradicular tooth under static oblique load.
It was reported that the cervical region of the tooth is exposed to
the greatest stress, irrespective of the type of coronoradicular recon-
struction and preparation design (74), and that compressive stress
is larger than tensile stress (73, 74). However, it was stated that the
presence of a ferrule decreases stress levels (72, 74). Furthermore,
the cervical stress level seems to be lower in the presence of root
canal post than when no post is used (74). The distribution and values
of stress were different between glass-FRC and zirconium oxide
ceramic posts; an increase of the elastic modulus of the post material
increased the dentin stress but shifted the maximum stress location
from the dentin surface adjacent to the post to the post material
(72). In the absence of ferrule, posts with a high modulus of elasticity
(metallic posts) generated greater cervical stress than a carbon-FRC
post, which represented the most significant contributory factor in
increasing the risk of fracture (74). Nonetheless, metallic post in
combination with a rigid core material (cast post and core) generated
significantly lower tensile stress in comparison with a combination of
metallic post and composite core, whereas in the presence of a ferrule,
core material had no impact on the stress level (74).
There are two main changes in stress distribution with an increase
in ferrule height: a decrease in compressive stress in labial cervical
dentine and an increase in tensile stress in palatal cervical dentin
with an increased area of palatal dentine under stress (73). Authors
also suggested that these tensile stress values were approaching the
tensile strength of dentine and produced favorable conditions for
a crack to nucleate, which would run apically and obliquely along
the palatal root dentine from the internal to external root surface.
Therefore, the ferrule height should be determined individually based
on the buccolingual cervical diameter of the tooth. Moreover, higher
displacement values of a simulated metallic crown (labial and axial
rotation) were shown in teeth without a ferrule, what makes them
more prone to failure because of debonding, and subsequently vertical
root fracture through the lever action of the loose post or fracture of the
post in the cervical portion (73). However, displacement potential is
reduced with an increasing ferrule height up to 1.5 mm, over which
there was no difference (73). Additionally, this study did not assess
the influence of the cement material. Because the simulated intact state
of the dentin-crown interface when cemented with glass-ionomer
cement was considered analogous to the debonding state when the
crown was adhesively luted with a resin cement, it was proposed by
another study that crowns with small ferrule heights should be resin
bonded (35).
FEA does not support the notion that crown lengthening may result
in a tooth with less ability to withstand load because patterns and stress
values of tensile and compressive stress did not differ between standard
and crown-lengthened models (73). With regards to post length, the
Ferrule Effect 15
Review Article
TABLE 2. List of FEA Studies Investigating the Ferrule Effect, the Study Design, and the Most Important Findings
Post (cement for post)/core/
Amount of coronal final restoration (cement for
Author, year Tooth model dentin (ferrule) final restoration) Most important findings
Pierrisnard et al, Monoradicular No ferrule 1. NiCr cast post-and-core/NiCr Regardless of the model, the
2002 (74) tooth with 2-mm ferrule crown greatest stress in the cervical
simulated 2. NiCr post/composite/NiCr region.
bone base crown Post placement reduced cervical
3. Carbon-FRC/composite/NiCr stress.
crown Absence of ferrule resulted in
4. No post/composite/NiCr increased stress levels.
crown Ferrule eliminated effect of core
Cement layers considered material on cervical stress.
insignificant
Ichim et al, Maxillary No ferrule Metal cast post-and-core/metal Crown lengthening did not
2006 (73) central 0.5-mm ferrule crown decrease tooth resistance.
incisor with 1-mm ferrule Displacement potential of
simulated 1.5-mm ferrule a crown is reduced with
periodontal 2-mm ferrule increasing ferrule height.
ligament Thickness 1 mm Restoration without ferrule failed
With and without primarily because of
crown debonding and subsequently
lengthening root fracture.
Eraslan et al, Maxillary No ferrule 1. Glass-FRC/composite/ Stress values were lower for both
2009 (72) central 1-mm ferrule ceramic crown post systems when ferrule was
incisor with 2-mm ferrule 2. Zirconium oxide ceramic present.
simulated post/composite/ceramic Stress values were lower for glass-
periodontal crown FRC post.
ligament and Increase of the elastic modulus of
alveolar bone the post material increased the
dentin stress.
Schmitter et al, Premolar 1-mm ferrule 1. Glass-FRC: 2-mm and 7-mm Post length had a minor effect on
2010 (35) 2-mm ferrule long (resin)/composite/ force distribution when ferrule
metal crown (resin) was present.
2. Glass-FRC: 2-mm and 7-mm FRC posts do not contribute to
long (resin)/composite/ load transfer as long as the
metal crown (glass-ionomer) bonding between the tooth
and composite core is intact.
FRC, fiber-reinforced composite; NiCr, nickel-chromium.

results of FEA suggested that it has a minor effect on force distribution
when a 1-mm or 2-mm-high ferrule is present (35), which is in agree-
ment with the results from in vitro testing (34, 35, 59).
One study aimed to combine the advantages of in vitro tests and
FEA (35). The results obtained from both methods were compared with
agreement. In order to evaluate distribution of the external forces
among different internal substructures, virtual models of intact teeth
and models of teeth with different damage levels were investigated.
The results indicated that for intact restoration forces were exclusively
transferred at the dentine-crown interface, and the post did not
contribute to load transfer until the bond between the composite
core and the dentine failed (35).
Clinical Trials
One retrospective (75) and few prospective (76–80) clinical
studies have so far specifically addressed whether and to what extent
the presence of ferrule has an influence on the clinical behavior of
endodontically treated and restored teeth. All studies with study
design and most important findings are reported in Table 3.
Two studies evaluated the influence of various preoperative
factors, including the ferrule height, on the clinical performance of
endodontically treated and restored teeth (75, 77). The amount of
tooth structure available for a ferrule calculated retrospectively from
bitewing radiographs was not the preoperative parameter significant
for the prognosis of restored endodontically treated molars (75). It
was commented that judgment on a preexisting ferrule is difficult to
obtain retrospectively and should be evaluated by a model study or
cone-beam tomography to get a 3-dimensional rather than two-
dimensional picture of the prerestorative condition. However, the
finding was in line with the results of a prospective clinical trial (77)
that investigated 1-year survival of teeth restored with FRC posts and tita-
nium screw posts. The short-term clinical performance of FRC posts
was superior to that of titanium screw posts, but the ferrule height
did not have an influence on the survival of neither post type. However,
one should bear in mind that the mean ferrule height in the study was
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
outcome after 2 years was found in the presence of a ferrule (78). Teeth
were restored with either a titanium or glass-FRC post; all the teeth
received a 2-mm ferrule preparation; and, if necessary, surgical crown
lengthening was performed. It was concluded that both posts can be
highly successful in postendodontic restorations when used with
a self-adhesive resin cement and composite core.
The effect of the remaining tooth structure on the survival of teeth
restored with a cast post and core system, a direct metal post, or no post
was also studied (76). The expected dentin height remaining after tooth
preparation was predicted preoperatively and categorized as substantial
(a 1-mm or 2-mm ferrule could be achieved) or minimal (a ferrule

16 Juloski et al. JOE — Volume 38, Number 1, January 2012

 Review Article
TABLE 3. The List of Clinical Trials Investigating the Ferrule Effect, the Study Design, and the Most Important Findings
Type of study; Tooth type; amount Post (cement for post)/core/final
follow-up of coronal dentin restoration (cement for final
Author, year period (ferrule) restoration) Most important findings
Setzer et al, Retrospective Molars Endodontically treated molars Amount of tooth structure
2011 (75) study Ferrule with subsequent crown available for ferrule was not
4 years Could not be observed restoration the preoperative parameter
>1.5 mm significant for the
1-1.5 mm prognosis.
<1 mm
Schmitter et al, Prospective Anterior (20%), 1. Glass-FRC (resin)/composite/ Ferrule did not have an
2007 (77) randomized posterior (80%) crown, FPD or crown integrated influence on the survival of
controlled Mean ferrule >3 mm in RPD (no information) neither post type.
trial 2. Ti post (zinc phosphate)/ Performance of FRC posts was
1 year composite/crown, FPD or crown superior to that of metal
integrated in RPD (no posts.
information)
Ferrari et al, Prospective Premolars 1. Quartz-FRC (resin)/composite/ Post placement reduced the
2007 (79) clinical trial All coronal walls PFM crown (no information) risk of failure.
2 years 3 coronal walls 2. No root canal retention/ Preservation of at least one
2 coronal walls composite/PFM crown (no coronal wall reduced the
1 coronal wall information) failure risk.
2-mm ferrule Teeth missing all coronal walls
No ferrule had similar failure risks
regardless of the presence
or absence of ferrule.
Cagidiaco et al, Prospective Premolars 1. Prefabricated quartz-FRC Post placement, irrespective of
2008 (80) clinical trial All coronal walls (resin)/composite/PFM crown post type, provided
3 years 3 coronal walls (no information) a significant contribution to
2 coronal walls 2. Customized fiber post (resin)/ teeth survival.
1 coronal wall composite/PFM crown (no The contribution was more
2-mm ferrule information) effective for prefabricated
No ferrule 3. No root canal retention/ FRC post than for
composite/PFM crown (no customized fiber post.
information)
Creugers et al, Prospective Incisors, canines, 1. Cast post and core (zinc- Teeth with substantial dentin
2005 (76) clinical trial premolars, molars phosphate or glass-ionomer)/ height performed better
5 years Substantial or minimal PFM crown (zinc-phosphate or than teeth with less
dentin height glass-ionomer) remaining tooth structure.
2. Prefabricated metal post (zinc- Type of restoration did not
phosphate or glass-ionomer)/ influence.
composite/PFM crown (zinc-
phosphate or glass-ionomer)
3. No root canal retention/
composite/PFM crown (zinc-
phosphate or glass-ionomer)
Naumann et al, Randomized Incisors, canines, 1. Titanium post (self-adhesive Both posts resulted in
2007 (78) controlled premolars, molars resin)/composite/crown, FPD or successful treatment
clinical pilot 2-mm ferrule crown integrated in RPD (no outcome after 2 years.
trial Surgical crown information)
2–3 years lengthening 2. Glass-FRC post (self-adhesive
performed if resin)/composite/crown, FPD or
necessary crown integrated in RPD (no
information)
FRC, fiber-reinforced composite; FPD, fixed partial denture; NiCr, nickel-chromium; PFM, porcelain fused to metal; RPD, removable partial denture; Ti, titanium.

could not be achieved). Over a 5-year follow-up period, teeth with
a substantial dentin height performed significantly better than teeth
with less remaining tooth structure, whereas the type of restoration
did not have an influence.
Two studies evaluated the clinical behavior of endodontically
treated premolars with varying degrees of coronal tissue loss that
were restored with FRC post and composite cores or without any
root canal retention (79, 80). In both studies, posts were luted
inside the root canal with composite cement in combination with
an appropriate adhesive system. The amount of dentin left at the
coronal level was assessed before composite abutment buildup and
crown preparation, which varied from full chamfer with a bevel
interproximally and lingually, to a feather finish, depending on the
height and thickness of the remaining dentine. All teeth were
restored with a single-unit porcelain fused to metal crown. Over
a 2- (79) or 3-year (80) observation period, the post placement
provided a significant contribution to the survival of restored teeth.
Nevertheless, irrespective of the restorative procedure, the preserva-
tion of at least one coronal wall significantly reduced the failure risk.
When all coronal walls were missing, similar failure risks existed
regardless of the presence or absence of 2-mm-high ferrule retention
(79, 80).

JOE — Volume 38, Number 1, January 2012 Ferrule Effect 17

Review Article
Conclusions
Based on the evidence from in vitro and in vivo studies reviewed,
the presence of ferrule has a positive effect on fracture resistance of
endodontically treated teeth. More successful prognosis could be ex-
pected if healthy dentin extending 1.5 to 2 mm coronal to the margin
of the crown is provided circumferentially. If the clinical situation
does not permit a 360 circumferential ferrule because of extensive
caries lesions, previous restorations, or fractures, an incomplete ferrule
is still considered a better option than complete absence of a ferrule.
Moreover, including a ferrule in the preparation design could possibly
lead to more favorable fracture patters. With regard to the effect of
different restorative procedures on tooth resistance, literature data
are often controversial, probably because of the different methodolo-
gies and study designs used. However, it could be generally concluded
that providing an adequate ferrule lowers the impact of the post and
core system, luting agents, and the final restoration on the performance
of endodontically restored teeth.
When it comes to severely damaged teeth with no coronal struc-
ture, in order to provide space for a ferrule, orthodontic extrusion
should be considered rather than surgical crown lengthening. This
approach preserves more tooth structure and ensures more favorable
biomechanical behavior. If neither of the alternative methods for
providing a ferrule can be performed, currently available evidence
suggests that poor treatment outcome is very likely. Therefore, clini-
cians may take in consideration tooth extraction followed by appro-
priate surgical and/or prosthetic rehabilitation.
However, in all laboratory and FEA studies, single-rooted teeth
were investigated and, therefore, the influence of the ferrule effect on
multirooted teeth remains an area for further research. Also, current
literature lacks the information on optimal ferrule thickness. It is
directly related to the tooth structure remaining after endodontic treat-
ment and the amount of dentin that needs to be removed during crown
preparation, which depends on the design of the finish line and crown
type. However, this topic has not been investigated so far. More impor-
tantly, long-term prospective clinical trials with precise assessment of
remaining tooth structure after crown preparation and uniform study
design are needed in order to provide more reliable conclusions.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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