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Ferrule Comes First. Post Is Second!'' Fake News
Ferrule Comes First. Post Is Second!'' Fake News
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“Ferrule Comes First. Post Is Second!” Fake News and Alternative Facts? A
Systematic Review
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Abstract
Introduction: Both the role of an endodontic post and
the ferrule effect have been discussed for decades. The
clinical impact of endodontic posts compared with post-
I n contrast to vital teeth,
the complication rate of
restorations on endodonti-
Significance
Ferrule effect and maintaining cavity walls are pre-
dominant factors with regard to tooth and restoration
free restoration with or without ferrule support was not cally treated teeth (ETT)
survival of endodontically treated teeth. Consider-
systematically reviewed so far. It was assumed that the is considerably increased,
able clinical evidence to the influence of the tooth
effect of an endodontic post compared with a post-free maybe finally resulting in
type on the survival of endodontically treated teeth
restoration can be evaluated only when at the same tooth loss. Therefore, ETTs
is scarce. Most studies do not confirm a positive ef-
time a ferrule or no-ferrule situation was clinically are often judged as ‘‘less
fect of post placement for indirect restoration.
compared. Methods: The specific PICO question was valuable’’ as abutments for
as follows: Patient: adults with sufficient endodontic prosthodontic restorations
treatment needing a core or post; Intervention: post- when it comes to reliability and cost-effectiveness compared with vital teeth (1) or implants
endodontic treatment using posts with or without (2). Systematically reviewed (SR) data over 3 to 25 years showed that survival rates of res-
ferrule; Comparison: post-endodontic treatment without torations after endodontic treatment ranged between approximately 81% and 100% (3).
posts with or without ferrule; Outcomes: failure rates of Over the past decades, much research focused on the question of which post-and-
post/core complexes with or without ferrule support. A core technique/material should be used to increase ETT and restoration survival (4).
Medline search was performed via PubMed in June A wide range of post materials with different mechanical properties, such as cast gold
2017 using relevant electronic databases. Additionally, (5), stainless steel (6, 7), titanium (8), zirconia (9), or less rigid materials, such as fiber
hand search was performed. Only prospective clinical posts (10) was applied. A recent survey reported that a great variety of options is presently
studies in humans comparing the success/survival of used, also including no post placement depending on the final restoration planned (11).
teeth restored with or without posts over a minimum However, unequivocal guidelines do not exist.
time of observation of 5 years were included. Results: The aim of the present SR was to look for for high-level clinical evidence comparing
In total, 7 randomized controlled trials and 1 prospective post versus no-post placement in ferruled and unferruled teeth to distinguish between
clinical trial met inclusion criteria. Cochrane rating post and ferrule effect and to exclude the blurring impact of the latter. The null hypothesis
showed high risk of bias in 5 studies. Two of 3 studies was that post placement is superior to post-free restorations (post effect) irrespective of
support the ferrule-effect concept. Seven of 8 show no the presence of a ferrule (ie, ferrule effect) for restoration and/or tooth survival.
post effect. Clinical evidence regarding the influence
of tooth location on its survival is scarce. Conclusion: Material and Methods
Ferrule effect and maintaining cavity walls are the pre- PICO Question
dominant factors with regard to tooth and restoration
The specific PICO question was as follows:
survival of endodontically treated teeth. Most studies
P (patient): adults with sufficient endodontic treatment needing a dentin core
do not confirm a positive effect of post placement. (J En-
buildup procedure
dod 2018;44:212–219)
I (intervention): post-endodontic treatment using posts with or without ferrule
support
Key Words C (comparison): post-endodontic treatment without posts with or without ferrule
Buildup, clinical trial, core, dowel, endodontically
support
treated teeth, no-post, post-and-core, post-free, post-re-
O (outcomes): tooth and/or restoration survival
tained, screw
From the *Department of Prosthodontics, Geriatric Dentistry, and Craniomandibular Disorders, Charite–Universit€atsmedizin Berlin, Berlin, Germany; †Departments of
Prosthodontics and §Conservative Dentistry and Periodontology, University Hospital of W€urzburg, W€urzburg, Germany; and ‡Department of Operative Dentistry and
Endodontology, University of Marburg, Marburg, Germany
Address requests for reprints to Michael Naumann, Prof Dr med dent, DMD, Department of Prosthodontics, Geriatric Dentistry, and Craniomandibular Disorders,
Charite–Universit€atsmedizin Berlin, Aßmannshauser Str 4-6, Berlin 14197, Germany. E-mail address: naumann@naumann-kiessling.de
0099-2399/$ - see front matter
Copyright ª 2017 American Association of Endodontists.
https://doi.org/10.1016/j.joen.2017.09.020
JOE — Volume 44, Number 2, February 2018 Role of Ferrule Effect and Endodontic Post 213
214
Review Article
TABLE 1. Characteristics of Included Randomized Controlled Trials and Prospective Study Evaluated in Systematic Review
Potential
Number Number and overlaps
Naumann et al.
and 95 anterior Direct metal metal posts and survival probability (at
teeth) post + full composite cores both levels) in both
crown: 150/268 trials (P > .05). The 17-
year survival rates at
restoration level
varied from 71% to
80%, and at tooth
level from 83% to
92%.
In an endodontically
treated tooth with
substantial remaining
dentin, a post in a core
does not perform
better than a post-free
core.
Fokkinga Private Up to 17 years 87 98 teeth (25 molars, Direct metal Direct Not applicable No Post placement showed A
et al (7) practice 54 premolars, post + direct composite: 44 no influence on the
and 19 anterior composite: 53 survival probability at
teeth) either level (P > .05).
The estimated overall
survival rate at
17 years was
53% 14% at the
restoration level and
79% 11% at the
tooth level.
The results of this study
showed no difference
in survival probability
between
endodontically
treated single teeth
reconstructed with
direct composite
restorations either
with or without a
metal post.
Ferrari Private 72 months 345 360 teeth (premolars 11.9% for Glass fiber post: PFM crown: Yes, with limitation Yes Cox regression analysis C
et al (15) practice with different patients, 12.3% 120/240 Glass 120/120 for no-wall groups; revealed that fiber
amount of dentin for restorations fiber bundles: No ferrule effect: post retention
left at the coronal 120/240 hazard ratio significantly improved
level after (HR) = 12.3, tooth survival
endodontic P = .001; (P < .001). Failure risk
treatment) Ferrule effect: was lower in teeth
HR = 8.6, P = .004 restored with
prefabricated
Role of Ferrule Effect and Endodontic Post
Review Article
post vs post-free respectively (P = .57). Moreover, no
group significant differences
for success or survival
could be found among
the 4 groups (the 3 test
groups and the control
group).
(continued )
215
Review Article
(indicated by
same letter)
Potential
between
overlaps
patient
groups
retained restorations
amounted to 92.5%
No
Ferrule effect
Not applicable
composite: 60
Number and
restorations
direct composite:
restorations in
post-retained
and type of
with sufficient tooth tissue only. In these teeth, resin composite cores
Direct metal post
and crown or
and crown or
study arm
relevant
Number
cast cores (n = 11) were inserted. Sufficient tooth tissue was defined
82/248
17/325 (5.2%)
91.4%, for custom-made posts 92.1%, and 91.2% for post-free res-
torations. There was no statistically significant difference between
test and control groups, and absolute failure rate comparing ante-
rior (14%) with posterior teeth (12%) (P > .05). All post-free res-
torations were located in posterior teeth (3 absolute failures). The
325 teeth (179 molars,
no information on
81 premolars, and
48 anterior teeth;
authors concluded that the mode of root restorations did not play a
tooth type of the
characteristics
Number and
of restored
role. However, due to the limited number of teeth in the second study
baseline
teeth at
17 dropouts)
this SR (16). Survival rate of root-filled teeth was 92.5% for teeth
183
restored with titanium posts, 97.1% for those restored with cast post-
and-cores, and 94.3% for teeth without post-retained restorations
post-and-cores
4.4 (1.7) years:
restoration
years: cast
post-free
titanium
Consistency of Results
To the best of our knowledge, this is the first SR comparing impact of
post versus no-post placement on tooth and restoration survival in ferruled
Prospective clinical trials
practice
Setting
Figure 2. Minimal (left) and substantial (middle) dentin height as used by Creugers et al (12, 13) and Fokkinga et al (6, 7) to describe remaining coronal tooth
structure; typical description of defect size 0 to IV remaining cavity walls (0 to IV) (right).
With CASP in RCTs (n = 7), all 3 referees agreed in 91% of the Clinical observation periods varied from 5 to 17 years in the
items, whereas in the rest of the items at least 2 of the 3 referees selected studies. We chose 5 years as the cutoff for minimum time of
agreed. observation, because it was shown that this is the minimum time to
For CASP in the prospective study (n = 1), all 3 referees agreed. show different behavior (21). It is positive that for the present SR
that 17-year data were available.
Methodological Quality of Studies The longer the observation time, the higher was the dropout rate.
The methodological quality of the studies was heterogeneous. There are no unequivocal guidelines of how many dropouts are still
In 3 RCTs only, the risk of bias was judged to be low for most items. acceptable after a certain recall time (22). After 17 years, approximately
In contrast, the risk of bias was judged to be high for several items in 3 to 4 of 10 patients were still willing or able to be recalled (6, 7); after
the other studies. 6 years, 9 of 10 (12.3%). Only Cloet et al (16) stated that an a priori
formal power calculation based on existing literature data resulted in a
sample size of 800 teeth to reach a power of 80% (P = .05). Similar
Incorporation of Evidence into the Algorithm results were found earlier (23).
In the authors’ assessment, remaining coronal tooth structure is If a tooth loses its clinical crown (ie, no cavity wall remains),
the predominant factor with regard to tooth and restoration survival mid- to long-term data (6, 7, 12, 13) show that an almost
of ETT. For single crowns, the ferrule effect has a supportive value circumferential (>75% of the circumference) ferrule preparation
over a mid-term time of observation in all evaluated studies. This pos- of 1.5 to 2.0 mm is essential, resulting in a 5% increase of
itive effect could not be found for posts. survival probability. Ferrule might be interpreted as a defect with
4 remaining walls, but with insufficient coronal height. During
Discussion function, both compression and tension forces are maximal at the
This SR involving randomized and prospective clinical trials external root surface at the crestal bone level and decrease to ‘‘0’’
comparing post-supported and post-free restoration of ETT high- in the tooth center (24). This may be compensated by a dentin
lights the importance of the remaining coronal tooth structure as ferrule (25). However, over a long period (17 years), ferrule was
a predicting factor of both restoration and tooth survival. For beneficial only for prefabricated titanium posts with composite
most authors, it appears easy to count the number of remaining cav- core buildups. Hence, based on the clinical evidence, the ferrule ef-
ity walls from 4 (ie, access cavity only) to no wall, as described fect can be described as a mid-term phenomenon. The remaining
earlier (19), probably derived from the configuration factor (C-fac- dentin wall thickness of this ferrule should be 1 mm (26) to have
tor) (20) (Fig. 2). a functional, supportive value. In the present SR, only clinical studies
JOE — Volume 44, Number 2, February 2018 Role of Ferrule Effect and Endodontic Post 217
Review Article
TABLE 2. Overview of Included and Evaluated Publications Showing Ferrule maxillary anterior region. There is a lack of considerable clinical evi-
and Post Effect, Respectively dence with regard to the influence of the location of the tooth in the
Ferrule Post dental arch on the survival of ETT, either with direct or indirect resto-
effect effect rations.
Trials Yes No Yes No
Prospective trials Acknowledgments
Salvi 2007 (17) — — x This research did not receive any specific grant from funding
Randomized controlled trials agencies in the public, commercial, or not-for-profit sectors.
Cloet 2017 (16) — — x
Ferrari 2012 (15) x x* The authors deny any conflicts of interest related to this
Mannocci 2005 (14) — — x study.
Fokkinga 2007 (6) (x)† (x) x
Fokkinga 2008 (7) — — x
Creugers 2005 (12) — — x References
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†
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JOE — Volume 44, Number 2, February 2018 Role of Ferrule Effect and Endodontic Post 219
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