SYSTEMATIC REVIEW

Influence of the ferrule effect on the failure of fiber-reinforced

composite post-and-core restorations: A systematic review and
meta-analysis
Victor Eduardo de Souza Batista, DDS, PhD,a Sandro Basso Bitencourt, DDS, MSc,b
Natália Almeida Bastos, DDS, MSc,c Eduardo Piza Pellizzer, DDS, PhD,d Marcelo Coelho Goiato, DDS, PhD,e and
Daniela Micheline dos Santos, DDS, PhDf

The restoration of endodonti- ABSTRACT

cally treated teeth often requires
Statement of problem. The survival and/or success of post-retained restorations is influenced by
the use of post-and-core tech- the amount of residual coronal structure, known as the “ferrule effect.”
niques to restore esthetics and
function.1,2 In this context, end- Purpose. The purpose of this systematic review and meta-analysis was to evaluate whether the
presence or absence of the ferrule effect influences the failure rate of fiber-reinforced composite
odontic posts are widely used in
post-and-core restorations.
teeth with insufficient coronal
structure to provide retention for Material and methods. A comprehensive review of the literature was performed using the
restorations.3 Different mate- PubMed/Medline, Embase, Scopus, and Cochrane Library databases for articles published up to May
2018. The risk ratio with 95% confidence interval was estimated using the Mantel-Haenszel method.
rials are used to fabricate these
Potentially eligible studies were selected based on the reading of the abstracts and full text of
posts, which can be metallic prospective clinical trials, randomized clinical trials, or prospective randomized studies, all with a
(gold and nongold alloys) or minimum of 10 participants in each group, with a follow-up period longer than 6 months, and
nonmetallic (glass fiber, carbon published in English.
fiber, and zirconia among Results. Of the 380 studies retrieved, 4 were included in this meta-analysis. A total of 297 teeth were
others).4-6 evaluated, 157 with a ferrule and 140 without a ferrule. The mean survival rate was 88.35% in the
Fiber-reinforced composite ferrule group and 78.05% in the nonferrule group. No statistically significant difference was noted in
(FRC) posts have emerged as the general failure analysis (risk ratio: 0.71 [95% confidence interval: 0.47 to 1.06]; P=.09), although a
an alternative to traditional higher number of failures occurred in nonferrule restorations. More controlled and randomized
cast or prefabricated metal clinical trials are needed to establish a clinical protocol for the use of post-retained restorations.
posts. Esthetic advantages and Conclusions. Despite the limited number of available studies, the results of this meta-analysis
the short clinical treatment suggest that the ferrule effect does not significantly reduce the failure rate in fiber-reinforced
timedbecause laboratory steps composite post-and-core restorations. (J Prosthet Dent 2019;-:---)
are not necessarydmake FRC
the material of choice for post-and-core restorations.2 endodontic post restorations.1,7,8 Therefore, different
However, different failure rates have been reported for clinical factors are clearly related to the success and

This work was presented at the Academy of Dental Materials 2018 Annual Meeting in Porto de Galinhas, Pernambuco, Brazil, October 4-6, 2018.
a
Professor, Department Prosthodontics, Presidente Prudente Dental School, University of the West of São Paulo (UNOESTE), Presidente Prudente, Brazil.
b
Doctoral student, Department of Dental Materials and Prosthodontics, Sao Paulo State University (UNESP), Araçatuba, Brazil.
c
Doctoral student, Department of Operative Dentistry, Endodontics and Dental Materials, Bauru School of Dentistry, University of São Paulo (USP), Bauru, Brazil.
d
Professor, Department of Dental Materials and Prosthodontics, Sao Paulo State University (UNESP), Araçatuba, Brazil.
e
Professor, Department of Dental Materials and Prosthodontics, Sao Paulo State University (UNESP), Araçatuba, Brazil.
f
Professor, Department of Dental Materials and Prosthodontics, Sao Paulo State University (UNESP), Araçatuba, Brazil.

THE JOURNAL OF PROSTHETIC DENTISTRY 1

2 Volume
Clinical Implications
The ferrule effect has been a controversial issue. A
tooth with a ferrule and more dental structure does
not appear to be the main factor in failure
prevention. The results of this study may help the
clinician decide how to restore an endodontically
treated tooth with extensive tissue loss because the
ferrule effect may not be the critical factor in
optimal biomechanical behavior.
survival of these restorations, such as the type and po-
sition of the tooth, its relation to the antagonist, the
presence of proximal contacts, the type of definitive
restoration, and, primarily, the amount of residual coro-
nal structure.1,7,8
The presence of at least 2 mm of dentin in the coronal
portion has been reported to be one of the most
important factors increasing restoration fracture resis-
tance in the final restoration and is known as the “ferrule
effect”.1,8 This remaining dentin can support better
biomechanical performance and, consequently, longevity
in post-and-core restorations.4 However, a consensus
regarding these advantages is lacking because mechani-
cal and clinical trials have yielded inconsistent re-
sults.1,2,8-10
Considering this controversy, the search for a clinical
protocol for endodontically treated teeth is further
hampered by the conflicting results of biomechanical
trials10-12 and published clinical studies.2,8 Therefore, the
purpose of this systematic review and meta-analysis was
to evaluate whether the presence or absence of a ferrule
influences the failure rate in FRC post-and-core resto-
rations. The null hypothesis was that teeth with and
without a ferrule would demonstrate the same risk for
failure.
MATERIAL AND METHODS
This review was structured in conformity with the
Preferred Reporting Items for Systematic Reviews and
Meta-Analyzes (PRISMA) checklist.13 Initially, the
methods of this study were recorded on the PROSPERO
(International Prospective Register of Systematic Re-
views) platform under the number CRD42018092904.
The literature search was carried out by 2 indepen-
dent researchers (S.B.B., N.A.B.) using the PubMed/
Medline, Embase, Scopus, and Cochrane Library data-
bases for studies published up to May 2018. A combi-
nation of the following terms was used: "Ferrule or
Ferrule effect and Post and Core Technique" - search
details: Ferrule[All Fields] OR (ferrule[All Fields] AND
effect[All Fields] AND ("post and core technique"[MeSH
Terms] OR ("post"[All Fields] AND "core"[All Fields]
THE JOURNAL OF PROSTHETIC DENTISTRY
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Table 1. Studies excluded and reasons for exclusion
Author, Year of Publication Reason
Naumann et al, 20127 No direct comparison between teeth with
ferrule and without ferrule
Sterzenbach et al, 201220 No direct comparison between teeth with
ferrule and without ferrule
Signore et al, 201124 Retrospective study
Setzer et al, 201123 Retrospective study
Naumann et al, 200721 No direct comparison between teeth with
ferrule and without ferrule
Schmitter et al, 200722 No direct comparison between teeth with
ferrule and without ferrule
AND "technique"[All Fields]) OR "post and core tech-
nique"[All Fields])).
In addition, a manual search of the topic was con-
ducted in relevant journals: Journal of Dentistry, Dental
Materials, Journal of Prosthetic Dentistry, Journal of Oral
Rehabilitation, Journal of Prosthodontics, International Jour-
nal of Prosthodontics, American Journal of Dentistry, Journal
of Endodontics, and International Endodontic Journal.
The corresponding author was contacted when the
full content of the studies could not be accessed. An
interexaminer test (Kappa) was performed at different
stages of study selection to verify agreement between the
researchers.
Potentially eligible studies were selected according to
previously determined inclusion and exclusion criteria
(described elsewhere in this article) and after reading the
abstracts and full text. If needed, a discussion with a third
examiner (D.M.S.) was carried out to reach consensus.
This procedure was applied to all stages of the selection
process.
To be eligible, studies were required to be one of the
following: a prospective clinical trial, a randomized clin-
ical trial, or a prospective randomized study. In addition,
studies were required to compare the rehabilitation of
teeth with and without remaining dentin (ferrule), to
have a minimum of 10 participants in each group and a
follow-up period longer than 6 months, and to be pub-
lished in English. Studies that did not compare the
rehabilitation of teeth with and without a ferrule, litera-
ture reviews, in vivo studies, in vitro studies, finite
element analyses, retrospective studies, case reports, and
studies published in languages other than English were
excluded.
The review was conducted according to the PRISMA
recommendations for which the Participant, Interven-
tion, Comparison, Outcome (PICO) question was “Can
the ferrule effect reduce the failure rate in fiber-reinforced
composite post-and-core restorations?” “Participants”
were those with endodontically treated teeth requiring
FRC post-and-core restorations, “Intervention” was
teeth without coronal tooth remaining (without ferrule),
“Comparison” was teeth with coronal tooth remaining
Batista et al
- 2019 3

outcomes, the reported post and root fractures were

Identification

Records identified Additional records

through database identified through tabulated and evaluated as a dichotomous outcome. The
searching other sources relative risk (RR) and 95% confidence interval (CI) using
(n=380) (n=0) a random-effects model were applied16 (a=.05 for RR
values). Review Manager 5 (Cochrane Group) was used
for the meta-analysis and elaboration of the funnel chart.
Records after An asymmetric funnel chart may indicate publication
duplicates removed
bias or other biases related to sample size, although
(n=276)
asymmetry may also show a true relationship between
Screening

experimental size and effect size.17 The heterogeneity

Records screened Records excluded
was significant at P<.1 and was evaluated using the Q
(n=10) (n=266) (c2) method and the I2 value. The results were dichoto-
mized as good and poor. An I2<60% was the limit for
data homogeneity.18 The survival rate of FRC post-and-
Full-text articles Full-text articles core restorations was calculated using the Kaplan-Meier
assessed for eligibility excluded, with reasons method, considering the dentin remaining (with and
Eligibility

(n=10) (n=06) without ferrule). The failure rate was determined by the
percentage of failed restorations in relation to the num-
ber of restorations performed in each study.
Studies included in
qualitative synthesis
(n=04) RESULTS
The literature search retrieved 380 studies. After the
removal of duplicates, the titles and abstracts of 276
Included

Studies included in studies were read. Ten studies were selected,1,2,7,8,19-24

quantitative synthesis
(meta-analysis)
(n=04)
Figure 1. Search strategy according to PRISMA statement. PRISMA,
Preferred Reporting Items for Systematic Reviews and Meta-Analyzes.
(with ferrule), and “Outcome” was related to failure
reporting (decementation, post fracture, root fracture,
coronary portion fracture, endodontic failure, and crown
displacement).
Important data were extracted from the included
studies and tabulated. The information collected from
these studies included the following: name of the first
author, year of publication, type of study, total number of
participants, total number of teeth with ferrule, total
number of nonferrule teeth, rehabilitated teeth, type of
endodontic post material, commercial brand of post, type
of cement used, type of rehabilitation, follow-up, survival
rate, and reported failures. The quality of the included
studies was graded according to the Jadad14 scale, with
scores ranging from 0 to 5, in which a score greater than
3 was classified as an appropriate study.
The meta-analysis was based on the Mantel-
Haenszel method.15 For evaluation of the primary
outcome, decementation, post fracture, root fracture,
coronary portion fracture, endodontic failure, and crown
displacement were considered general failures and eval-
uated as a dichotomous outcome. As secondary
and their full texts were read. Six studies7,20-24 were
subsequently excluded for reasons described in Table 1.
Only 4 studies met the pre-established selection
criteria1,2,8,19 for inclusion in the systematic review
(Fig. 1). Of the 4 studies selected, 3 were randomized
controlled trials and 1 was a prospective investigation.
The details of these studies are described in Table 2. A
total of 297 teeth were evaluated, including 157
teeth with ferrule (47.1%) and 140 without ferrule
(52.9%), with follow-up duration ranging from 36 to 72
months, with a mean of 45 months. The interexaminer
(Kappa) tests were performed using the selected titles
and abstracts to obtain a concordance test value of 100%
(Kappa=1).
The restorations included metal-ceramic and metal-
free prostheses, both complete- and partial-coverage
restorations, mainly in the premolars. Clinical examina-
tion of the restorations at the follow-up visit was per-
formed by the same examiner in 1 study8 and by 2
examiners in the other 3 studies.1,2,19 All studies used
radiographic examination as an evaluation criterion, with
image magnifications of ×3,8 ×4.5,19 and ×5.1,2 Two
studies1,2 varied the type of FRC used: prefabricated
(everStick POST; GC Corp) and custom (D.T. Light-Posts;
BISCO, Inc). One study19 used the D.T. Light-Posts, and
another study8 used the Snowpost (Abrasive Technology
Ltd). The survival rate varied from 72.5% to 95% in the
ferrule groups (mean 88.35%) and from 62.5% to 95.2% in

Batista et al THE JOURNAL OF PROSTHETIC DENTISTRY

4 Volume - Issue -

Table 2. Demographic data of all studies included

Total Total
Number Number
Total of Teeth of Teeth Number of Follow-
Type of Number of with without Teeth Type of Commercial Cement Type of up Survival
Author Study Participants Ferrule Ferrule Restored Post Brand Used Restoration (mo) Type of Failure Rate (%)
Bitter et al, RCT 100 40 21 Anterior: 15 Fiber- DT Light Post CLEARFIL Ceramic 36 With ferrule: With
200919 Premolar: 20 reinforced (VDW) Core partial loss of post ferrule: 95
Molar: 25 composite crowns/ retention, 1; Without
complete root fracture: 1 ferrule:
crowns Without ferrule: 95.2
post fracture, 1
Ferrari RCT 345 PFP: 18; PFP: 18; Premolar Fiber- PFP: D.T. PFP: Calibra; Single-unit 72 With ferrule: With
et al, 20121 CP: 14 CP: 19 reinforced Light-Posts CP: BisCore metal- post fracture, 4; ferrule:
composite (RTD); CP: ceramic Endodontic 92.6
everStick crown failures, 4; Without
fibers decementation, ferrule:
4; displacement 80.7
of the crown, 4
Without ferrule:
root fractures,
4; endodontic
failures, 6; post
fracture, 6;
decementation,
4; displacement
of the crown, 4
Mancebo Prospective 87 45 42 Incisors: 34; Zircon-rich Snowpost; RelyX; Metal- 36 * With
et al, 20108 study canine: 12; glass fiber Carbotech Unicem ceramic/ ferrule:
premolar: 16; metal-free 93.33
molar: 1 Without
ferrule:
73.8
Cagidiaco RCT 345 PFP: 20; PFP: 20; Premolar Fiber- PFP: D.T. PFP: Calibra; Single-unit 36 * With
et al, 20082 CP: 20 CP: 20 reinforced Light-Posts CP: BisCore metal- ferrule:
composite (RTD); CP: ceramic 72.5
everStick crown Without
fibers ferrule:
62.5

CP, custom post; PFP, prefabricated post; RCT, randomized controlled trial. *Not reported.

with Ferrule without Ferrule Risk Ratio Risk Ratio

Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI M-H, Random, 95% CI

Bitter et al, 2009 2 40 1 21 3.0% 1.05 [0.10, 10.92]

Mancebo et al, 2010 3 45 11 42 10.5% 0.25 [0.08, 0.85]
Cagidiaco et al, 2008 11 40 15 40 30.4% 0.73 [0.39, 1.39]
Ferrari et al, 2012 17 32 24 37 56.1% 0.82 [0.55, 1.23]

Total (95% CI) 157 140 100.0% 0.71 [0.47, 1.06]

Total events 33 51
Heterogeneity: τ2=0.04; χ2=3.64, df=3 (P=.30); I2=18% 0.01 0.1 1 10 100
Test for overall effect: Z=1.67 (P=.09)
Favors [with Ferrule] Favors [without Ferrule]

Figure 2. Comparison of teeth with and without ferrule. Outcome: failure in general. CI, confidence interval.

the nonferrule group (mean 78.05%). The failures occur-
ring in each study are described in Table 2.
No statistically significant difference was found in the
general failure analysis (RR: 0.71 [95% CI: 0.47 to 1.06];
P=.09), although a higher number of failures occurred in
nonferrule restorations (Fig. 2). The intrastudy hetero-
geneity measure (c2) was 3.64; the interstudy heteroge-
neity (I2) was 18%. For the secondary outcome, 2 studies
reported the number of post and root fractures in the
presence or absence of ferrule,1,19 also demonstrating no
statistically significant difference (RR: 0.65 [95% CI: 0.21
to 1.94]; P=.44 and RR: 0.42 [95% CI: 0.03 to 5.15]; P=.50,
respectively; Fig. 3). The funnel chart displays evident
symmetry between differences in the means for the
studies evaluated with absence of bias (Fig. 4). The risk of
bias in each study according to the Jadad scale demon-
strated that only 1 study,19 with a score of 3, was
appropriate (Table 3).

THE JOURNAL OF PROSTHETIC DENTISTRY Batista et al

- 2019 5

with Ferrule without Ferrule Risk Ratio Risk Ratio

Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI M-H, Random, 95% CI

Bitter et al, 2009 0 40 1 21 12.1% 0.18 [0.01, 4.21]

Ferrari et al, 2012 4 32 6 37 87.9% 0.77 [0.24, 2.49]

Total (95% CI) 72 58 100.0% 0.65 [0.21, 1.94]

Total events 4 7
Heterogeneity: τ2=0.00; χ2=0.73, df=1 (P=.39); I2=0%
Test for overall effect: Z=0.78 (P=.44) 0.01 0.1 1 10 100
Favors [with Ferrule] Favors [without Ferrule]
A

with Ferrule without Ferrule Risk Ratio Risk Ratio

Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI M-H, Random, 95% CI

Bitter et al, 2009 1 40 0 21 46.7% 1.61 [0.07, 37.88]

Ferrari et al, 2012 0 32 4 37 53.3% 0.13 [0.01,2.29]

Total (95% CI) 72 58 100.0% 0.42 [0.03, 5.15]

Total events 1 4
Heterogeneity: τ2=0.92; χ2=1.38, df=1 (P=.24); I2=28%
0.01 0.1 1 10 100
Test for overall effect: Z=0.68 (P=.50)
Favors [with Ferrule] Favors [without Ferrule]
B
Figure 3. Comparison of teeth with and without ferrule. A, Outcome: post fracture. B, Outcome: root fracture. CI, confidence interval.

0
being the only study that used molar teeth. This fact may
have promoted a positive effect for the group without a
Standard Error (log [RR])

0.5 ferrule. However, a meta-analysis25 that analyzed

1 that the absence of a coronal wall may increase the risk
1.5
2 Failures such as crown decementation and detachment
0.01 0.1 1 10
RR
Figure 4. Funnel chart indicating evident symmetry between differences
in means for studies evaluated with absence of bias. RR, relative risk;
SE, standard error.
DISCUSSION
Although restorations performed in the presence of a
ferrule demonstrated a higher survival rate (88.35% with
ferrule versus 78.05% without ferrule), no statistically
significant difference was found regarding general failure
of post and root fracture. Therefore, the null hypothesis
that teeth with and without ferrule would exhibit the
same risk for failure was accepted. These data agree with
a clinical study1 that reported no statistical differences
between the presence and absence of a ferrule, even
though there was a difference in the survival of the res-
torations. However, 1 included study19 did not show a
tangible difference in survival between the 2 groups,
whether and how coronal dentin loss would affect the
failure rate of FRC post-and-core restoration suggested
for restoration failure.
Biomechanical studies have reported that the
cementation line and the adhesive interface are the re-
gions most susceptible to failure in FRC restorations.12,26
100 were reported for both groups in the studies included.
Therefore, a correct cementation technique according to
manufacturer’s recommendations is necessary to achieve
an adequate adhesive interface. The presence of a ferrule,
however, could preclude the direct exposure of the
cement area and, consequently, reduce the risk of injury
during mastication and the possibility of microleakage.8
Regarding the possibility of fracture of the root and
post-and-core restorations with or without remaining
dentin, the presence of a ferrule increased FCR resis-
tance.27 The ferrule confers a protective effect, which
resists functional forces, the wedge effect of the conical
posts, and the lateral forces generated during post
insertion.8 In this context, patients should be informed of
the possibility of root and post fracture when little or no
dentin remains. The studies by Ferrari et al1 and Cagi-
diaco et al2 reported numerous crown dislodgements and
all root fractures occurred in teeth, with the remaining
coronal tooth structure reduced to 1 or 2 walls before
abutment. However, damage to any ferrule appeared to

Batista et al THE JOURNAL OF PROSTHETIC DENTISTRY

6 Volume
Table 3. Quality assessment of selected studies
Quality Criteria Bitter et al, 2009
1. Was the study described as random? Yes
2. Was the randomization scheme described and appropriate? Yes
3. Was the study described as double-blind? No
4. Was the method of double blinding appropriate? No
5. Was there a description of dropouts and withdrawals? Yes
Jadad score 3 2
Quality of study High
place the restored tooth under a higher risk of failure
than when one or more coronal walls were present.2
Although systematic reviews reporting this issue have
been published,25,28 the present review aimed to update
the literature and presents a differential and isolated
analysis of FRC and root fracture as the data about this
are not yet available in the literature. The few clinical
studies addressing the subject have limited the analyses
of post and root fracture. It is possible to find several
studies that evaluated the ferrule effect, but most were
in vitro or involved biomechanical tests.10-12
Despite the low number of included studies, the
heterogeneity was verified using c2 and I2 statistics and
was considered low. However, some specific character-
istics of the included studies were found, such as the use
of a custom fiber post,2 and 3 of the 4 studies included
had 36 months of follow-up. However, an analysis of the
risk of bias demonstrated that only 1 study19 was
considered appropriate. Thus, studies with all the criteria
of quality assessment were difficult to find because some
points, such as double blinding, are impossible to achieve
in studies of this type. More controlled and randomized
clinical trials are needed to establish a clinical protocol for
the use of post-and-core restorations and to provide
more data for future relevant systematic reviews.
CONCLUSIONS
From the results of the present meta-analysis, the
following conclusion was drawn:
1. The ferrule effect does not appear to reduce the
failure rate of FRC post-and-core restorations
significantly when compared with its absence.
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