Review Article

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 analysis,’’ and ‘‘clinical trials.’’ Results: The findings from reviewed articles were categorized into three main categories: laboratory studies, computer simulation, and clinical trials. Laboratory studies were further classified into subchapters based on the main aspect investigated 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 fracture 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 alternative 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)

T

Key Words
Endodontically treated teeth, ferrule effect, post and core, review

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 structure 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 performed afterwards (6). Therefore, research has focused on finding the most promising 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 endodontically 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 noncontrollable 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 biomechanical 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

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

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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 significance of results obtained from in vitro static testing has been questioned (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 orthodontic 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 millimeter 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 difference 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). Additionally, 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 restorations 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 2mm 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 incorporated only the buccal and/or lingual wall (37). Nonetheless, teeth with a nonuniform ferrule length were still more fracture resistant

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

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TABLE 1. A List of the Reviewed Laboratory Studies According to the Main Aspects Investigated in Each Study Type of test
Static load testing

Ferrule height/ ferrule design
Sorensen and Engelman (19) Pereira et al (30) Cho et al (31) Akkayan (32) Tan et al (36) Dikbas (37) Kutesa-Mutebi and Osman (39) al-Hazaimeh and Gutteridge (55) Ng et al (54) Ma et al (29) Isidor et al (34) Libman and Nicholls (33) Schmitter et al (35) Naumann et al (38)

Type of post and core system and final restoration
Zhang et al (40) da Silva et al (13) Pereira et al (30) Pereira et al (41) Zhi-Yue and Yu-Xing (42) Sendhilnathan and Nayar (43) Akkayan (32) Massa et al (44) Qing et al (45) Lima et al (46) Xible et al (47) Hu et al (48) Heydecke et al (49) Butz et al (50) Sahafi et al (51) Naumann et al (52) Dorriz et al (56)

Post length
Nissan et al (59)

Luting techniques
al-Hazaimeh and Gutteridge (55) Mezzomo et al (53)

Crown lengthening vs orthodontic extrusion
Gegauff (66) Meng et al (70) Meng et al (69)

Fatigue testing

Schmitter et al (35) Isidor et al (34) Buttel et al (60)

Dorriz et al (56) Goto et al (28) Naumann et al (61) Aykent et al (63) Hsu et al (62) Schmitter et al (65) 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 vestibular 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 fracture resistance regardless of whether a butt joint or a 1-mm-wide contrabevel 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 customfabricated all-ceramic or metal post and core, resistance to fracture was similar (40). Metal cast post-and-core-restored teeth were more
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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 2mm 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 1.5mm 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 specimens 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 conditions: 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 controversial. Some studies reported that the direct technique was appropriate because more severe root fractures were found in cast post-andcore-restored teeth (30, 41, 56); others did not observe differences in fracture pattern between teeth restored with cast post and core 13

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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 cementation failure (30). When prefabricated posts were made from quartzFRC, 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 resistance 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, glassFRC, 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 structure 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 guttapercha, 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 fracture under static load was unaffected by the post length (59). Besides, 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 performance 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 3mm 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 established 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 1mm 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 2mm-high ferrule, there was no difference in bonded and nonbonded core groups (63).

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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 significant differences between zinc-phosphate and resin-modified glassionomer 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). Therefore, if a 1.5-mm ferrule is to be achieved, at least 4.5 mm of supraalveolar 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 difference 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, fractures 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 biomechanical 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 extraction significantly improved the fracture strength of the tooth, and
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 reconstruction 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

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TABLE 2. List of FEA Studies Investigating the Ferrule Effect, the Study Design, and the Most Important Findings Amount of coronal dentin (ferrule)
No ferrule 2-mm ferrule

Author, year
Pierrisnard et al, 2002 (74)

Tooth model
Monoradicular tooth with simulated bone base

Post (cement for post)/core/ final restoration (cement for final restoration)
1. NiCr cast post-and-core/NiCr crown 2. NiCr post/composite/NiCr crown 3. Carbon-FRC/composite/NiCr crown 4. No post/composite/NiCr crown Cement layers considered insignificant Metal cast post-and-core/metal crown

Most important findings
Regardless of the model, the greatest stress in the cervical region. Post placement reduced cervical stress. Absence of ferrule resulted in increased stress levels. Ferrule eliminated effect of core material on cervical stress. Crown lengthening did not decrease tooth resistance. Displacement potential of a crown is reduced with increasing ferrule height. Restoration without ferrule failed primarily because of debonding and subsequently root fracture. Stress values were lower for both post systems when ferrule was present. Stress values were lower for glassFRC post. Increase of the elastic modulus of the post material increased the dentin stress. Post length had a minor effect on force distribution when ferrule was present. FRC posts do not contribute to load transfer as long as the bonding between the tooth and composite core is intact.

Ichim et al, 2006 (73)

Maxillary central incisor with simulated periodontal ligament

No ferrule 0.5-mm ferrule 1-mm ferrule 1.5-mm ferrule 2-mm ferrule Thickness 1 mm With and without crown lengthening No ferrule 1-mm ferrule 2-mm ferrule

Eraslan et al, 2009 (72)

Maxillary central incisor with simulated periodontal ligament and alveolar bone Premolar

1. Glass-FRC/composite/ ceramic crown 2. Zirconium oxide ceramic post/composite/ceramic crown

Schmitter et al, 2010 (35)

1-mm ferrule 2-mm ferrule

1. Glass-FRC: 2-mm and 7-mm long (resin)/composite/ metal crown (resin) 2. Glass-FRC: 2-mm and 7-mm long (resin)/composite/ metal crown (glass-ionomer)

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 agreement 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
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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 twodimensional 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 titanium 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
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; follow-up period
Retrospective study 4 years

Author, year
Setzer et al, 2011 (75)

Tooth type; amount of coronal dentin (ferrule)
Molars Ferrule Could not be observed >1.5 mm 1-1.5 mm <1 mm Anterior (20%), posterior (80%) Mean ferrule >3 mm

Post (cement for post)/core/final restoration (cement for final restoration)
Endodontically treated molars with subsequent crown restoration

Most important findings
Amount of tooth structure available for ferrule was not the preoperative parameter significant for the prognosis. Ferrule did not have an influence on the survival of neither post type. Performance of FRC posts was superior to that of metal posts. Post placement reduced the risk of failure. Preservation of at least one coronal wall reduced the failure risk. Teeth missing all coronal walls had similar failure risks regardless of the presence or absence of ferrule. Post placement, irrespective of post type, provided a significant contribution to teeth survival. The contribution was more effective for prefabricated FRC post than for customized fiber post. Teeth with substantial dentin height performed better than teeth with less remaining tooth structure. Type of restoration did not influence.

Schmitter et al, 2007 (77)

Prospective randomized controlled trial 1 year

1. Glass-FRC (resin)/composite/ crown, FPD or crown integrated in RPD (no information) 2. Ti post (zinc phosphate)/ composite/crown, FPD or crown integrated in RPD (no information) 1. Quartz-FRC (resin)/composite/ PFM crown (no information) 2. No root canal retention/ composite/PFM crown (no information)

Ferrari et al, 2007 (79)

Prospective clinical trial 2 years

Premolars All coronal walls 3 coronal walls 2 coronal walls 1 coronal wall 2-mm ferrule No ferrule

Cagidiaco et al, 2008 (80)

Prospective clinical trial 3 years

Premolars All coronal walls 3 coronal walls 2 coronal walls 1 coronal wall 2-mm ferrule No ferrule

1. Prefabricated quartz-FRC (resin)/composite/PFM crown (no information) 2. Customized fiber post (resin)/ composite/PFM crown (no information) 3. No root canal retention/ composite/PFM crown (no information) 1. Cast post and core (zincphosphate or glass-ionomer)/ PFM crown (zinc-phosphate or glass-ionomer) 2. Prefabricated metal post (zincphosphate or glass-ionomer)/ composite/PFM crown (zincphosphate or glass-ionomer) 3. No root canal retention/ composite/PFM crown (zincphosphate or glass-ionomer) 1. Titanium post (self-adhesive resin)/composite/crown, FPD or crown integrated in RPD (no information) 2. Glass-FRC post (self-adhesive resin)/composite/crown, FPD or crown integrated in RPD (no information)

Creugers et al, 2005 (76)

Prospective clinical trial 5 years

Incisors, canines, premolars, molars Substantial or minimal dentin height

Naumann et al, 2007 (78)

Randomized controlled clinical pilot trial 2–3 years

Incisors, canines, premolars, molars 2-mm ferrule Surgical crown lengthening performed if necessary

Both posts resulted in successful treatment outcome after 2 years.

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
JOE — Volume 38, Number 1, January 2012

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 preservation 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). 17

Ferrule Effect

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 expected 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 methodologies 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 structure, 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, clinicians may take in consideration tooth extraction followed by appropriate 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 treatment 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 importantly, 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.
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Acknowledgments
The authors deny any conflicts of interest related to this study.

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Ferrule Effect

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