Biomechanical Effect of Ferrule on Incisors Restored with

a Fiberglass Post and Lithium-Disilicate Ceramic Crown

after Thermal Cycling and Fatigue Loading
Andréa Dolores Correia Miranda Valdiviaa / Monise de Paula Rodriguesb / Aline Aredes Bicalhoc /
Bart Van Meerbeekd / Jos Vander Slotene / Roberto Sales e Pessoaf / Carlos José Soaresg

Purpose: To evaluate the biomechanics of endodontically treated incisors restored with a fiberglass post and a
CAD/CAM lithium-disilicate ceramic crown with/without a ferrule after thermal and mechanical aging.
Materials and Methods: Twenty bovine incisors were divided into two groups (n = 10): 1. Fe, with a ferrule of
2 mm, and 2. NFe, without a ferrule. After endodontic treatment, the teeth were restored using a fiberglass post
(Exacto 3, Angelus) and composite core (Tetric Ceram, Ivoclar Vivadent). They then received a CAD/CAM lithium-di-
silicate ceramic crown (IPS e.max CAD) luted using a self-adhesive composite (RelyX Unicem 2, 3M Oral Care). All
specimens were subjected to 20,000 thermocycles and 2,400,000 simulated chewing cycles. Ceramic crown and
root dentin strains (μS) were measured using strain gauges (n = 10) during 100-N loading before and after the ther-
mal and mechanical aging, and upon fracture loading. The specimens were subsequently loaded to fracture (N).
The stress distribution was analyzed using 3D individualized finite-element models created by micro-CT of experi-
mental samples (n = 3). Strain data were analyzed using two-way ANOVA and Tukey’s HSD test. Fracture resistance
was analyzed using Student’s t-test and fracture mode was analyzed using the chi-squared test (α = 0.05).
Results: After aging, NFe exhibited significantly higher root dentin deformation (buccal: 1248.0 ± 282.8; lingual:
516.2 ± 195.0; p < 0.001) than Fe (buccal, 554.0 ± 233.8; lingual: 311.8 ± 159.0; p < 0.001). The deformation
measured on ceramic crowns was not influenced by ferrule presence or aging process. Significantly higher fracture
resistance (N) was observed for the Fe (1099.6 ± 214.8) than the NFe group (675.3 ± 113.8) (p < 0.001). The
NFe group revealed a lower fracture resistance:root strain ratio than did the Fe group. The stress levels on root
dentin and fiberglass were lower for the Fe group.
Conclusion: The NFe group showed increased root dentin strain after the aging process. The Fe group revealed
higher fracture resistance, lower stress concentration on root dentin and fewer catastrophic fractures.
Keywords: fiberglass post, ferrule, CAD/CAM ceramic crown, strain-gauge test, fracture resistance, finite element
analysis, thermal cycling, fatigue.

J Adhes Dent 2018; 20: 133–142. Submitted for publication: 04.01.18; accepted for publication: 07.03.18
doi: 10.3290/j.jad.a40305

a Dentist, Biomechanics Research Group, Department of Operative Dentistry
and Dental Materials, Dental School, Federal University of Uberlandia (UFU),
Uberlandia, MG, Brazil; Professor of Oral Rehabilitation, Faculty of Dentistry,
Autonomous University of Guadalajara, Jalisco, México. Performed the experi-
ments and finite element analysis, wrote the manuscript in partial fulfillment
of requirements for a PhD degree.
b Postgraduate Student, Biomechanics Research Group, Department of Opera-
tive Dentistry and Dental Materials, Dental School, Federal University of Uber-
landia (UFU), Uberlandia, MG, Brazil. Performed the finite element analysis.
c Professor, Health Technical School, Federal University of Uberlandia, Minas
Gerais, Brazil; Biomechanics Research Group, Department of Operative Dentistry
and Dental Materials, Dental School, Federal University of Uberlandia (UFU), Uber-
landia, MG, Brazil. Performed strain-measurement and fracture tests.
d Full Professor, KU Leuven (University of Leuven), Department of Oral Health
Sciences, BIOMAT & UZ Leuven (University Hospitals Leuven), Dentistry, Leu-
ven, Belgium. Proofread the manuscript, contributed substantially to conduct-
ing the experiments.
e Full Professor, KU Leuven (University of Leuven), Department of Mechanical
Engineering, Leuven, Belgium. Scientific advisor, proofread the manuscript.
f
Dentist, Biomechanics Research Group, Department of Operative Dentistry
and Dental Materials, Dental School, Federal University of Uberlandia (UFU),
Uberlandia, MG, Brazil. Helped with the finite element analysis, proofread the
manuscript.
g Professor and Chair, Biomechanics Research Group, Department of Operative
Dentistry and Dental Materials, Dental School, Federal University of Uber-
landia (UFU), Uberlandia, MG, Brazil. Research idea, hypothesis, performed
statistical evaluation, supervised the finite element analysis, scientific advisor,
proofread the manuscript.
Correspondence: Prof. Dr. Carlos José Soares, Av. Pará, 1720, Bloco 4L, Anexo
A, Campos Umuarama, 38400-902 Uberlândia, Minas Gerais, Brazil. Tel: +55-
34-3225-8106; e-mail: carlosjsoares@ufu.br

Vol 20, No 2, 2018 133

Valdivia et al
E ndodontically treated teeth commonly require post-and-
core restorations for retention purposes.1,4 Posts associ-
ated with all-ceramic crowns are an option for teeth with a
severe loss of coronal structure.46 Several materials and
techniques have been advocated for restoring endodontically
treated teeth. Lithium-disilicate crowns manufactured with
CAD/CAM systems have shown good clinical performance.32
The correct choice of the post system and the presence of
a ferrule are important factors for treatment prognosis.18,20,43
Fiberglass posts have been used clinically as an alternative to
metal posts for the restoration of endodontically treated
teeth.8,11,37 The major advantage of fiberglass posts is that
they have an elastic modulus more similar to that of den-
tin,6,18,25 and are able to bond to root dentin, which may lead
to a better distribution of the occlusal loads along the
root.23,29 Failures in post-retained crowns generally occur in
the maxillary anterior region, where horizontal forces are
greater than in other regions.30 The amount of coronal and
root dentin that remains after root canal instrumentation and
post space preparation is correlated with the fracture resis-
tance, and plays an important role in the biomechanical be-
havior of endodontically treated teeth restored with fiber
posts.4,46 A recent meta-analysis suggested that the absence
of a coronal wall might increase the risk of fiber post-and-core
restoration failure, whereas the effect of a ferrule is still not
entirely understood.47 Other studies reported that the pres-
ence of a uniform ferrule surrounding the remaining tooth
structure enhanced fracture resistance4 and increased the
long-term success of anterior teeth with root posts.18,20,40
Failure of endodontically restored teeth is a result of the
interaction of multiple mechanical properties of all the re-
storative materials involved.41 To evaluate the biomechanical
behavior and the failure process of endodontically restored
teeth, destructive mechanical tests serve as an important
means of subjecting restored teeth to high-intensity load-
ing.29 However, this method does not provide enough infor-
mation about the internal structural behavior of the tooth-
restoration biomechanical unit against loading. Therefore, it
is necessary to combine destructive mechanical tests with
nondestructive methods, such as strain-gauge tests for more
precise biomechanical analysis.4,29,45,46 The strain mea-
sured during the nondestructive tests can be regarded as an
indication of the repetitive deformation that roots undergo
during functioning, resulting in structural fatigue.42 Artificial
aging of specimens using thermal cycling and cyclic mechan-
ical loading is an important in vitro method to reproduce the
physiological functions of teeth in the oral environment.10
Generally, accelerated artificial aging of dental materials is
indicated and causes a significant decrease in the mechani-
cal properties.13
The aim of this study was to evaluate the strain before
and after thermal and mechanical fatigue aging, the frac-
ture resistance and fracture mode, and the stress distribu-
tion of endodontically treated incisors that were restored
using a fiberglass post and CAD/CAM all-ceramic crown
with and without a ferrule. The null hypothesis tested was
that the biomechanical behavior would not be affected by
the amount of coronal dentin remaining.
134
MATERIALS AND METHODS
Specimen Preparation
Twenty bovine incisors were selected for this study. The in-
cisors had similar dimensions (coronal volume within 10%
of average) and roots without curvature, and were free of
cracks or defects. All external debris was removed with a
hand scaler, and the teeth were stored in distilled water at
37°C. Using a water-cooled diamond disk (no. 7020; KG
Sorensen; Barueri, SP, Brazil), the anatomic crowns of all
teeth were sectioned perpendicular to the long axis up to
15.0 mm from the apical limit for the specimens with a fer-
rule (n = 10; Fe group, Fig 1a) and up to 13.0 mm from the
apical limit for the specimens without a ferrule (n = 10; NFe
group, Fig 1b). The mean dimensions of the bovine incisor
roots were similar to human maxillary central incisors.4 The
root canals were instrumented to full extension using No. 2
and 3 Gates-Glidden drills (Dentsply Sirona; York, PA, USA).
A No. 4 Gates-Glidden drill (Dentsply Sirona) was used in
the cervical and middle thirds of the root canal. The canals
were rinsed with 1.0% sodium hypochlorite (Miyako; Guarul-
hos, SP, Brazil) and physiological saline (Avante Pharma;
Belo Horizonte, MG, Brazil), dried with paper points, and
obturated with gutta-percha (Dentsply Sirona) and calcium
hydroxide-based cement (Sealer 26; Dentsply Sirona). 34
The specimens of the Fe group were prepared with a dia-
mond rotary cutting instrument (no. 3215; KG Sorensen),
which allowed cutting a 2.0-mm-high circular ferrule with a
rounded cervical ending. The post space was initially ob-
tained with a heated instrument (M-Series Hand Pluggers;
Dentsply Sirona) and the residual gutta-percha was then
removed with Gates-Glidden drills, standardizing the post
space to 8.0 mm for the group without a ferrule and
10.0 mm for the group with a ferrule, maintaining 5.0 mm
of gutta-percha at the apex. The root canals were enlarged
with a 1.0- to 1.6-mm diameter conical drill (Exacto drill No.
3, Angelus Science and Technology; Londrina, PR, Brazil) to
8.0 mm for the group without a ferrule and to 10.0 mm for
the group with a ferrule, generating a standardized post
space for the fiberglass post.4
The roots were embedded in polystyrene resin (AM 190
resin, AeroJet; Santo Amaro, São Paulo, Brazil). The roots
without and with a ferrule were embedded 2.0 and 4.0 mm
below the cervical limit, respectively. The periodontal liga-
ment was simulated using polyether impression material
(Impregum Soft, 3M Oral Care; St Paul, MN, USA).36 Prior to
taking the impression, the root surfaces were dipped into
molten wax up to 2.0 and 4.0 mm apically from the cervical
limit for the groups without and with a ferrule, respectively.
The resulting wax layer was 0.2 to 0.3 mm thick. A radio-
graphic film with a central circular opening (IBF; Rio de Ja-
neiro, RJ, Brazil) was used to stabilize the teeth during the
embedding procedure. The roots were placed with the cervi-
cal limit facing down into the opening in a wooden board,
leaving the root in a vertical position perpendicular to the
supporting radiographic film. Then, a 20.0-mm-high,
22.0-mm-diameter plastic cylinder (PVC, Tigre; Joinville, SC,
Brazil) was placed over the root and fixed in position with
The Journal of Adhesive Dentistry

Fig 1 a: NFe cavity prepar-
ation; b: Fe cavity prepar-
ation; c: 4.0x2.0-mm strain
gauge attached buccally on a b
the ceramic crown and
1.0x1.0-mm strain gauge at-
tached at the coronal cervi-
cal limit on the buccal root
surface; d: 1.0x1.0-mm
strain gauge attached at the
coronal cervical limit on the
palatal root surface; e: strain
measurement upon 100-N
loading to simulate occlusal
loading; f: mechanical cy-
cling aging; g: strain mea-
surement upon fracture
e f
loading.
cyanoacrylate adhesive (Super Bonder, Loctite; Itapeví, SP,
Brazil) and wax. The self-curing polystyrene resin (AM 190
resin, AeroJet; Piracicaba, SP, Brazil) was manipulated ac-
cording to the manufacturer’s instructions and inserted into
the cylinder. After polystyrene-resin polymerization, the
roots were removed from the cylinder and the wax was re-
moved from both the root surface and the cylinder. Impres-
sion material (Impregum Soft, 3M Oral Care) was placed
into the resin cylinders, the roots were reinserted, and the
excess polyether material was removed with a scalpel
blade.45
Post, Core and Crown Fabrication
Prefabricated fiberglass posts (Exacto No. 3, Angelus) with
1.4-mm and 0.9-mm diameters in the coronal and apical
portions, respectively, were cleaned with a 70% alcohol so-
lution (Miyako) before the posts were immersed in 24% hy-
drogen peroxide (H2O2, Dinâmica; Diadema, SP, Brazil) for
1 min, followed by rinsing and drying.45 Afterwards, a one-
bottle silane coupling agent (Silano, Angelus) was applied
for 1 min.
For post cementation, the post spaces were rinsed with
0.9% saline solution (Indústria Farmacêutica Basa; Caxias
do Sul, RS, Brazil) and dried with paper points (Dentsply
Sirona). All posts were cemented with self-adhesive com-
posite (RelyX Unicem 2, 3M Oral Care) that was manipu-
lated according to the manufacturer’s instructions and intro-
duced into the canal. The cementation process was
standardized with a 500-g load applied to the specimens
for 5 min and at every luting step.4 The excess cement was
removed after 1 min, and after 5 min, the composite ce-
ment was light polymerized at each surface of the speci-
mens (buccal, palatal, incisal) for 40 s with an LED light-
Vol 20, No 2, 2018
Valdivia et al
c d
g
curing unit (LCU) at an output of 1200 mW cm-2 (Radii-Cal,
SDI; Bayswater, Australia).23 The composite core was fabri-
cated using 2-mm increments of composite (Tetric Ceram,
Ivoclar Vivadent; Schaan, Liechtenstein). The dentin was
etched with 37% phosphoric acid (Cond AC 37, FGM; Join-
ville, SC, Brazil); then an etch-and-rinse 3-step adhesive
(Scotchbond Multi-Purpose; 3M Oral Care) was applied, fol-
lowing the manufacturer’s instructions. The adhesive primer
was applied over the etched structures and gently dried
with an air stream for 5 s, followed by application of the
bond component and polymerization for 10 s with the LED
LCU. Each increment was light cured for 40 s with the LED
LCU. All-ceramic crown preparations, featuring 1.5 mm of
axial reduction and 6 degrees of axial convergence of the
walls, were performed with a tapered, rounded-end diamond
rotary cutting instrument (No. 4138; KG Sorensen). The
teeth of the Fe groups were prepared creating a 2.0-mm-
high ferrule. The diamond cutting instruments were dis-
carded after every fifth preparation. The cavity preparations
were finished with an extra-fine-grit diamond rotary cutting
instrument (No. 3145FF; KG Sorensen).
The specimens were restored with CAD/CAM milled all-
ceramic crowns. Each sample was scanned using Cerec 3D
software (Dentsply Sirona) and milled out of lithium-disili-
cate glass-ceramic blocks (IPS e.max CAD, size I12, Ivoclar
Vivadent) according to the manufacturer’s instructions. The
internal restoration surface was etched with 5% hydrofluoric
acid (Condac Porcelana 5%; FGM) for 20 s followed by rins-
ing and drying. A silane agent (Silano; Ângelus, Londrina,
PR, Brazil) was then applied for 1 min.23 The ceramic
crowns were cemented using self-adhesive composite
(RelyX Unicem 2; 3M Oral Care) following the same protocol
as that described for post fixation.
135
Valdivia et al
Strain Measurement
The specimens were submitted to the strain-gauge test be-
fore and after artificial aging. To measure tooth deformation,
two strain gauges with grid size 1x1 mm PA-06-038AA-120-
LEN, Excel Sensores; Embú, SP, Brazil) were placed on the
root surface 2.0 mm below the crown limit; one gauge was
placed on the buccal surface (Fig 1c), parallel to the long axis,
and the other on the lingual surface (Fig 1d).29 One strain
gauge with grid size 4x2 mm (PA-06-060CC-350-LEN; Excel
Sensores) was attached to the buccal surface of the ceramic
crown (Fig 1c). The strain gauges were bonded with a cyano-
acrylate adhesive (Super Bonder; Loctite) and connected to a
data acquisition device (ADS0500IP, Lynx; São Paulo, SP,
Brazil). In addition, a control specimen with 3 strain gauges
attached, but not subjected to loading, was mounted adjacent
to the tested tooth to compensate for ambient temperature
fluctuations or due to gauge electrical resistance.4,29,46
The specimens with strain gauges were subjected to a
nondestructive ramp load from 0 to 100 N using a mechan-
ical testing machine (EMIC DL2000, EMIC; São José dos
Pinhais, PR, Brazil) before and after artificial aging. The load
was applied at a 0.5-mm/min crosshead speed and 45-de-
gree angle along the long axis of the tooth (Fig 1e).4,26 The
data were recorded with a computer that performed the sig-
nal transformation and data analysis (AqDados 7.02 and
AqAnalysis; Lynx).
Thermocycling and Fatigue Loading
Thermal variations were induced using a thermal cycling ma-
chine (Thermo-cycler, Willytech; Munich, Germany) between
two water baths of 5°C and 55°C with a dwell time of 30 s at
each temperature. All specimens were subjected to 20,000
thermocycles in total. After the first 10,000 thermocycles,
the specimens were subjected to fatigue loading for
1,200,000 cycles. The fatigue loading was performed under
water irrigation using a chewing simulator with sliding move-
ment (Willytech, Munich, Germany), which has been claimed
to correspond to 10 years of clinical function.22 The load was
applied at 45 degrees at a frequency of 1.6 Hz. A sinusoidal
load of 0 to 50 N was applied with a stainless-steel ball-
shaped stylus to the lingual surface of the ceramic crown
(Fig 1f).48,49 The failures under fatigue loading were recorded
during the test by integrated LVDT displacement sensors,
which were able to detect a displacement of 100 μm and
were connected to software.
Strain During the Fracture Procedure (CSt-Fr),
Fracture Resistance and Fracture Mode
All specimens were loaded to fracture using the same com-
pressive loading design as in the strain gauge tests. The
force required (N) to cause fracture was recorded by a 500-
KN load cell hardwired to software (TESC; EMIC), which de-
tected any sudden load drop in its load cell during the com-
pression tests. The strains were also recorded at failure
load (St-Fr) (Fig 1g).
The fracture mode of each specimen was assigned to one
of five categories: (I) post debonding without ceramic-crown
or root dentin fracture; (II) cohesive fracture of ceramic crown
136
only; (III) cohesive fracture of ceramic crown with core in-
volved; (IV) fracture with root involvement in cervical third that
can be restored in association with periodontal surgery; (V)
root fracture in the middle or apical third, which requires ex-
traction of the tooth. The samples were evaluated for cracks
after the fracture-resistance test, helping to determine the
fracture mode.9 The images of the samples were captured at
1.5X magnification under standardized conditions (Nikon D60
and Nikkor 105 mm macro lens, Chiyoda; Tokyo, Japan)
using transillumination LED light (Photonita, P1050; Flori-
anópolis, SC, Brazil) with the optic fiber illuminator positioned
on the occlusal surface of the tooth. The fractured speci-
mens were mounted on aluminum stubs, sputter coated with
gold (Bal-Tec SCD 050; Balzers, Liechtenstein), and exam-
ined under a scanning electron microscope (EVO MA 10, Carl
Zeiss; Jena, Germany). SEM photomicrographs were obtained
at different magnifications to illustrate the failure modes.
Residual Stress Calculation and Finite-Element Analysis
The 3D finite-element models were generated using 3 sam-
ples randomly selected before thermomechanical aging for
each group (Fe and NFe). The samples were micro-CT
scanned (Model 1172; Brucker Skyscan, Kontich, Bel-
gium).14 The equipment was adjusted to scan the whole
tooth, with a beam-accelerating voltage of 100 kV, an x-ray
beam current of 100 μA, Al+Cu filter material, 10-μm image
pixel size, 2000x1048 resolution, and a 0.7-degree rotation
step to obtain 4 frames, which resulted in 2340 slices.
Using NRecon software (SkyScan 1172, Bruker-microCT;
Kontich, Belgium), 780 slices of tooth structure were se-
lected, applying the artefact-correction parameters of
Smoothing 2 and Ring 5.
The DICOM files obtained from MicroCT were identified
using an interactive medical image-control system (Mimics
16.0, Materialise; Leuven, Belgium). The segmentation of
the dental structures and restorative materials was accom-
plished based on the image-density thresholding. The
masks of dentin, composite cement, gutta-percha, fiber-
glass post, composite, and ceramic were converted into a
3D file (STL, bilinear, and interplane interpolation algorithm)
using Mimics for STL. The aspect ratio and connectivity of
the triangles in the native STLs resulted in an inappropriate
model for FEA use. Therefore, the remesh component in
Mimics software was used to reduce the number of trian-
gles and simultaneously improve the quality of the triangles
while maintaining the geometry. In addition, an advanced
STL design and meshing software (3-matic 8.0, Materialise)
was used to create the resin cylinder and simulated peri-
odontal ligament. Each STL file was treated separately be-
fore merging all parts into a single STL file, termed assem-
bly. The final assembly was then re-meshed using the
3-matic REMESH component. Self-intersecting curves were
maintained and the tolerance variation from the original
data was specified (the quality of triangles does not mean
the tolerance variation from the original data). The quality is
defined as a measure of triangle height:base ratio, so that
the file can be imported in the FEA-software package with-
out producing errors.
The Journal of Adhesive Dentistry
 Valdivia et al

Table 1 Mechanical properties of materials used for dentin and restorative materials

Dentin and restorative Elastic modulus Poisson ratio Tensile Compressive strength Reference
materials (GPa) strength (MPa) (MPa) No.
Dentin 18.60 0.31 98.7 297.0 27

Composite 17.10 0.31 45.5 277.0 34

Lithium-disilicate glass ceramic 13.50 0.31 271.0 360.0 7

Polystyrene resin 13.50 0.31 39

Gutta-percha 0.69 0.45 15

Composite cement 8.10 0.30 26

Polyether 50 0.45 39

As a specific approach for better model generation, the Table 2 Orthotropic properties, tensile strength and
STL models were imported to MSC.Patran 2010r2 (MSC. compressive strength of the fiberglass post43
Software; Santa Ana, CA, USA) and meshed. Tetrahedral
elements were used to ensure smooth contact at all model Properties Fiberglass Tensile Compres-
post unit strength sive
interfaces. The volumetric meshes of all model components
(MPa) strength
were created based on the standard triangulated language (MPa)
(STL) descriptions of the optimized surface. The meshes
were imported into an FEA-software package (Marc/Mentat, EX (MPa) 37000 40 250
MSC.Software) for the attribution of material properties to EY (MPa) 9500
the other model components (ie, bone, periodontal liga-
ment, enamel, dentin, composite cement, gutta-percha, fi- EZ (MPa) 9500
berglass post, and composite). The elastic moduli of the ηXY 0.34
restorative materials and dental structure are listed in Ta-
bles 1 and 2. To simulate the interface among model com- ηYZ 0.27
ponents, precisely bonded contacts were held. The nodes ηXZ 0.34
on the base of the bone-model structure were rigidly fixed in
the x-, y- and z-dimensions, to simulate the experimental Gxy (MPa) 3544.8
set-up tests. The loading conditions were simulated using Gxz (MPa) 1456.7
nodal-point load with the same load intensity used experi-
mentally (100 N applied at 45 degrees to the lingual sur- Gxz (MPa) 3544.8
face of the crown). The load was applied in a coronal-apical ηXY, ηYZ, and ηXZ: Poisson ratios in the orthogonal planes (xy, yz, and
direction in relation to the tooth’s longitudinal axis. The as- xz); Gxy, Gxz, and Gxz: shear moduli.
sessment and post-processing were performed for each
model using modified von Mises and equivalent von Mises
stresses by means of Marc/Mentat 2010r3 software. RESULTS

Statistical Analysis Fatigue Loading

The ceramic crown and root dentin strains (μS) as well as
fracture resistance (N) data were tested for normal distribu-
tion (Shapiro-Wilk, p > 0.05) and equality of variances (Lev-
ene’s test), followed by parametric statistical tests. Two-
way ANOVA followed by Tukey’s post-hoc test were used to
compare the effect of ferrule presence, aging procedure,
and their interaction for ceramic crown and root dentin
strain data. Fracture resistance was analyzed using Stu-
dent’s t-test. Fracture mode was analyzed using the chi-
squared test. All tests used an α = 0.05 significance level
and all analyses were carried out using Sigma Plot version
13.1 (Systat Software; San Jose, CA, USA). The light emis-
sion spectra were analyzed qualitatively.
Only one NFe specimen failed during fatigue loading be-
cause of post debonding after 1,200,000 cycles. All other
specimens survived 2,400,000 fatigue cycles.
Tooth Structure and Ceramic Strain
The ceramic crown and root dentin strains (μS) during the
simulation of 100-N loading before and after aging are
shown in Fig 2. The ceramic crown revealed lower deforma-
tion than root dentin, irrespective of ferrule presence. For
ceramic crown deformation, no difference was found be-
tween the FE and NFE groups, irrespective of aging proced-
ures. Root dentin revealed higher deformation than did the
ceramic crown, irrespective of ferrule presence or aging.

Vol 20, No 2, 2018 137

Valdivia et al

1200 Bb
the cervical third of the root involving cervical dentin demon-
Before aging strated that dentin remained adhered to the ceramic crown
1000 (Fig 5c). The SEM photomicrographs of post-detached sam-
After aging
Tooth strain (μS)

800 ples demonstrated several bubbles and voids in the com-

Ba
600 Ba
400
200
Aa Aa Aa Aa
0
Fe NFe Fe
Ceramic crown Root surface
Fig 2 Tooth strain (μS) measured by strain gauges (n = 10) upon
100 N loading before and after aging. Different uppercase letters
compare the aging effect for each strain measurement. Lowercase
letters compare ferrule presence (Fe) and absence (NFe) for each
strain measurement (p < 0.05).
The NFe group resulted in root dentin deformation similar to
that of the Fe group before aging, but the NFe group re-
vealed higher root dentin deformation than did the Fe group
after aging. The aging process had no effect on root dentin
strain for the Fe group, but significantly increased the root
dentin strain for the NFe group (Table 3).
The ceramic crown and root dentin strains (μS) at the max-
imum fracture loading are shown in Fig 3. The ceramic crown
revealed a lower deformation than root dentin, irrespective of
ferrule presence. For ceramic crown deformation, no differ-
ence was found between Fe and NFe. The Fe group resulted in
higher root dentin deformation than the NFe group.
Fracture Resistance
The mean fracture resistance (N) and standard deviation
are shown in Table 3. The Student’s t-test showed a signifi-
cantly higher resistance to fracture for Fe than NFe.
The fracture-mode distribution is presented in Table 3.
The chi-squared showed a significant difference between Fe
and NFe (p = 0.004). The Fe group produced fractures in-
volving only the ceramic crown or associated with core frac-
ture. NFe revealed more fractures involving root dentin and
post debonding. The typical fracture modes for Fe and NFe,
examined with the transillumination method, are shown in
Fig 4. SEM showed that ceramic crown fractures (Fig 5a)
and composite-core fractures (Fig 5b) are always accompa-
nied by crown-dentin detachment. The fracture located at
Ba posite cement (Fig 5d).
The ratio between the maximum resistance and root den-
tin deformation at the moment of fracture is shown in
Table 4. The NFe group revealed a higher root- strain:fracture
resistance ratio than did the Fe group (p < 0.001).
NFe
Finite-Element Analysis
The modified von Mises stress distributions are summa-
rized in Figs 5 and 6. The highest stress concentration was
located on the external surface of root dentin (Fig 5). The
stress on the lingual surface was higher than that on the
buccal root dentin. The stress levels on the fiber posts and
composite were lowest for the Fe model (Fig 5). The highest
stress concentration is located at the composite-core inter-
face with root dentin (Fig 6). The stress is more concen-
trated at the lateral surface and at the lingual surface of
the cervical margin of the ceramic crown (Fig 6).
DISCUSSION
The aim of this study was to test the hypothesis that the
presence of a ferrule on anterior endodontically treated inci-
sors restored with a fiberglass post/composite core/CAD/
CAM ceramic crown influences the biomechanical perfor-
mance, as expressed by crown and root dentin strains, frac-
ture resistance, fracture mode, and stress distribution. The
results of the present study confirmed that the presence of
a ferrule improved the integrity of the restorative materials
and root dentin, with the same root deformation after
aging. Additionally, a reduction in stress concentration in
root dentin, an increase in fracture resistance, and a reduc-
tion in number of root fractures of endodontically treated
incisors restored with fiberglass post were observed. There-
fore, the null hypothesis was rejected.
This study used bovine incisors instead of human inci-
sors. Bovine dentin is often used for in vitro tests and is
generally considered similar to human dentin in terms of
composition, properties, and geometric root configura-
tion.9,33 The increased availability of bovine teeth made it
possible to standardize the sample size and shape.29,37
Standardization was essential for obtaining comparable re-

Table 3 Mean strain values (μS) before and after aging loaded to 100N

Aging Buccal crown strain Buccal root strain Lingual root strain

Fe NFe Fe NFe Fe NFe

Before 13.8 (5.4)Aa 12.8 (5.2)Aa 437.8 (178.1)Aa 611.1 (282.8)Aa 221.4 (81.7)Aa 236.7 (59.7)Aa

After 13.4 (4.0)Aa 16.8(3.1)Aa 554.0 (233.8)Ab 1248.0 (282.8)Bb 311.8 (159.0)Ab 516.2 (195.0)Bb

Different superscript uppercase letters indicate significant differences in aging. Different superscript lower case letters indicate significant differences for the
ferrule factor within each strain mode (p < 0.05).

138 The Journal of Adhesive Dentistry

 Valdivia et al

a b c d

Fig 3 Prevalent fracture modes. a: NFe

group, type I post debonding; b: NFe group,
type IV root fracture in the cervical third. c:
Fe group, type II cohesive fracture of the
restoration; d: Fe group, type III cohesive
fracture of the restoration with core involve-
ment.

a b

Fig 4 SEM photomicrographs of speci-

mens. a: fracture mode type I showing sev- c d
eral bubbles and voids; b: fracture mode
type II showing a ceramic crown fracture
and complete detachment of the ceramic
crown from root dentin; c: fracture mode
type III showing a ceramic and composite-
core fracture and detachment of the com-
posite core from dentin; d: fracture mode
type IV showing a root dentin fracture lo-
cated at the cervical third of root dentin ad-
hered to the ceramic crown.

Sample 1 Sample 2 Sample 3

a b a b a b
MPa
Fe – with ferule

50

25
NFe – without ferule

Fig 5 Modified von Mises stress distribu-

tions of the external root dentin of the Fe 0
and NFe models. a: on the buccal surface;
b: on the lingual surface.

Vol 20, No 2, 2018 139

Valdivia et al
Table 4 Fracture resistance (N), mode of fracture and the ratio between root dentin deformation and fracture resis-
tance, as measured using an axial compression test (n = 10)
Group n Fracture resistance
(N)
With ferrule 10 1099.6 (214.8)A
Without ferrule 10 675.3 (113.8)B
Different superscript letters indicate a significant difference between the fracture resistance of the restorative techniques (p < 0.05).
Sample 1 Sample 2
a b a b
Fe – with ferule
NFe – without ferule
sults, because deformation and fracture load depend on
geometry. The dimensions and geometry of the selected
bovine root dentin had dimensions similar to those of maxil-
lary human incisors. In this investigation, a force of 100 N
was chosen to simulate chewing strain and for stress
analysis, because physiological biting forces during eating
were found to be between 20 and 160 N.5,31 The tooth root
was embedded in polystyrene resin with an elastic modulus
similar to that of bone tissue, and the periodontal ligament
was simulated using an elastomeric material, by which the
in vitro experimental design approximated the oral environ-
ment.31 The combination of destructive and nondestructive
methods on the same sample, such as strain gauge mea-
surements, fracture resistance, and fracture mode analysis,
permitted a sequential understanding of the failure pro-
cess. Having measured the deformation before fracture
may have contributed to a better understanding of the en-
tire fracture process from initiation to ultimate rupture.42
However, it is not possible to determine stress experimen-
tally, as the use of finite-element analysis with simulation
parameters in more realistic conditions is still necessary.3
During oral function, teeth are subjected to dynamic
masticatory and thermal loading. This subcritical loading
may lead to a slow process of incremental structural degra-
dation, often referred to as fatigue.17 In this study, the
specimens were subjected to 20,000 thermal cycles and
2,400,000 mechanical cycles prior to the tests to simulate
aging during 10 years of clinical service.13,22,44,42,45,48,49
140
Fracture mode Strain:fracture
resistance ratio
I II III IV V
0 4 5 1 0 3.85A
4 0 1 5 0 5.88B
Sample 3
a b MPa
50
25
Fig 6 Modified von Mises stress distribu-
0
tions of the ceramic crown of the Fe and
NFe models. a: on the buccal surface; b:
on the lingual surface.
Only one sample in the NFe group failed during fatigue load-
ing, with the post debonding after 1,200,000 cycles, which
is the most common failure type observed clinically in pa-
tients.40 However, these failures can be easily corrected by
re-cementation, prolonging the function of the restor-
ation.8,40
The current results show that the strain gauges attached
to the buccal and palatal surfaces were able to detect dif-
ferences between groups.4,45 It has been demonstrated
that when a single-root tooth is subjected to loading applied
along the tooth’s long axis, the greatest tensile stress oc-
curs at the lingual root surface of the coronal third of the
root.12,24 The bond integrity is decisive for stress/strain
transfer; if the fiberglass post detaches from the root den-
tin, the stress tends to concentrate at the interfaces
(Fig 4). The large number of bubbles and voids in the com-
posite cement layer may increase stress concentration, fa-
voring failure at the interface (Fig 4). Improving the methods
of composite cement insertion into the root canal can be an
important strategy to create a more homogeneous compos-
ite cement layer. Although the stress concentration at the
buccal surface of the ceramic crown, where the strain
gauge was attached, was lower, several failure modes in-
volving fracture of the ceramic crown were recorded in the
NFe group. The stress concentrated at the intaglio surface
of the ceramic may contribute to the high stress level of the
ceramic crown and result in fracture. The strain values re-
corded in this study before and after aging demonstrated
The Journal of Adhesive Dentistry

that ferrule presence is important for stress/strain transfer
from the crown to root dentin. The higher stress concentra-
tion at the root limit of the composite core/post interface
and the absence of the ferrule protection may explain the
post debonding, which was responsible for more type I and
IV failures in the NFe group. Ferrule effect and maintaining
cavity walls are predominant factors with regard to tooth
and restoration survival of endodontically treated teeth. The
absence of a ferrule significantly increased the strain after
aging, but the strain was stable when a ferrule was present.
The strain gauges were attached near sites where fractures
were expected to start.4,45 However, this study was limited by
the location of the strain gauges. Future studies should con-
sider affixing the strain gauge on the proximal root dentin
close to the crown limit, because most of the fracture lines
are located in this region. Ceramics have high elastic moduli
and a low strain capacity, so they tend to concentrate stress
inside the body of the restoration, resulting in low deforma-
tion.32 The stiffness of the lithium-disilicate glass-ceramic may
explain the lower strain values observed at the buccal surface
of the crown. Moreover, the finite-element models demon-
strated that the stress concentration at the buccal surface of
the loaded incisor is insignificant when compared with the
stress located at the inner and proximal surfaces.
Failure by fracture is a direct consequence of stress and
strain magnitude and distribution. The teeth without a fer-
rule revealed a significantly lower fracture resistance than
did the teeth with a ferrule. The absence of a ferrule in-
creased stress at the root dentin/cement/fiberglass post
interfaces. Theoretically, initial interface debonding occurs
when either the normal stress exceeds the tensile strength,
or the tangential stress overtakes the shear-bond
strength.19 Fiberglass posts are typically involved in these
circumstances, and if the post detaches while remaining in
the root canal, the risk-of-fracture index in the root in-
creases significantly.28 Consequently, the root dentin strain
increased after thermomechanical aging, probably because
the interfaces between restorative material and root dentin
presented detachment. Therefore, the lower fracture resis-
tance of the teeth without a ferrule is a consequence of
both aspects, namely increased root dentin stress and
strain as well as more detaching sites at the interfaces.
Similar results were observed in several other stud-
ies.4,16,29,41,46 However, using a thermomechanical aging
process in association with the strain-gauge test, the pres-
ent study clearly demonstrates that root dentin strain and
specific finite-element models expressed the stress-distri-
bution principles that ferrules exhibit to protect endodonti-
cally treated teeth restored with fiberglass posts.
The stress concentrations observed at root dentin and
the fiberglass post were higher for the NFe group than for
the Fe group. The stress concentrations at the lateral sur-
face of the ceramic crown and at the lingual surface of the
root were highly correlated with the failure mode of the NFe
group. The higher stress concentration at the root limit of
the composite core/post may explain the post debonding
recorded during thermomechanical aging as well as the high
percentage of failure modes involving post detachment from
Vol 20, No 2, 2018
Valdivia et al
the root canal. Although the behavior was similar for both
the Fe and NFe models, the use of different specific finite-
element models was important to demonstrate the effect of
ferrule geometry and that the external shape of the root can
influence the stress magnitude. Different root shapes and
volumes of dentin directly reflect the magnitude of the
stress concentrated at root dentin. Simplified finite-element
analysis using generalized models is commonly used to
study the effect of ferrule presence; however, the use of
individualized models generated by MicroCT, such as those
used in this study, can better explain the patient-to-patient
variability of clinical restorative procedures.
In this study, we also calculated the ratio between the
maximum resistance and root dentin deformation at the mo-
ment of fracture. The NFe group revealed a higher root
strain/fracture resistance ratio than did the Fe group. Teeth
without a ferrule deformed more with lower fracture resis-
tance, demonstrating that a ferrule is an important biomech-
anical parameter for anterior teeth endodontically treated
and restored with fiberglass posts and ceramic crowns. The
results of this study could be interpreted in general for bio-
mechanical aspects, such as the stress/strain complex, but
failures due to the loss of adhesive should not be directly
transferred to human teeth. Clinical studies analyzing the di-
mension and configuration of ferrules in anterior teeth are
necessary to confirm the results of the present study.
CONCLUSION
The presence of a ferrule contributed to the prevention of fi-
berglass-post detachment from the root dentin and restorative
materials, maintaining the same level of root dentin strain
after thermomechanical aging. The absence of a ferrule re-
sulted in increased root dentin strain after the aging process.
The incisors with a 2.0-mm ferrule restored with a CAD/CAM
ceramic crown exhibited higher fracture resistance, lower
stress concentration at root dentin, and fewer fracture modes
involving root failure than did incisors without a ferrule.
ACKNOWLEDGMENTS
This study was supported by a PhD grant from PDSE CAPES Founda-
tion (Grant number 7100/13-2) and grant from FAPEMIG (Research
Support Foundation of the State of Minas Gerais).
REFERENCES
1. Bateman G, Ricketts DN, Saunders WP. Fibre-based post systems: a re-
view. Br Dent J 2003;195:43-48.
2. Belli R, Petschelt A, Hofner B, Hajtó J, Scherrer SS, Lohbauer U. Fracture
rates and lifetime estimations of CAD/CAM all-ceramic restorations. J
Dent Res 2016;95:67-73.
3. Bicalho AA, Valdivia AD, Barreto BC, Tantbirojn D, Versluis A, Soares CJ.
Incremental filling technique and composite material – part II: shrinkage
and shrinkage stresses. Oper Dent 2014;39:E83-92
4. da Silva NR, Raposo LH, Versluis A, Fernandes-Neto AJ, Soares CJ. The
effect of post, core, crown type, and ferrule presence on the biomechan-
ical behavior of endodontically treated bovine anterior teeth. J Prosthet
Dent 2010;104:306-317.
141
Valdivia et al
5. De Boever JA, McCall WD Jr, Holden S, Ash MM Jr. Functional occlusal
forces: an investigation by telemetry. J Prosthet Dent 1978;40:326–333.
6. Dietschi D, Duc O, Krejci I, Sadan A. Biomechanical considerations for
the restoration of endodontically treated teeth: a systematic review of the
literature – part 1. Composition and micro- and macrostructure altera-
tions. Quintessence Int 2007;38:733-74.
7. Dong XD, Darvell BW. Stress distribution and failure mode of dental ceram-
ics structures under hertzian indentation. Dent Mater 2003;19:542-551.
8. Ferrari M, Cagidiaco MC, Goracci C, Vichi A, Mason PN, Radovic I, Tay F.
Long-term retrospective study of the clinical performance of fiber posts.
Am J Dent 2007;20:2872-2891.
9. Fonseca RB, Haiter-Neto F, Carlo HL, Soares CJ, Sinhoreti MA, Puppin-
Rontani RM, Correr-Sobrinho L, Correr-Sobrinho. Radiodensity and hard-
ness of enamel and dentin of human and bovine teeth, varying bovine
teeth age. Arch Oral Biol 2008;53:1023-1029.
10. Geminiani A, Lee H, Feng C, Ercoli C. The influence of incisal veneering
porcelain thickness of two metal ceramic crown systems on failure resis-
tance after cyclic loading. J Prosthet Dent 2010;103:275-282.
11. Goracci C, Ferrari M. Current perspectives on post systems: a literature
review. Aust Dent J 2011;56:77-83.
12. Gresnigt MM, Özcan M. Fracture strength of direct versus indirect lami-
nates with and without fiber application at the cementation interface.
Dent Mater 2007;23:927-933.
13. Hahnel S, Henrich A, Bürgers R, Handel G, Rosentritt M. Investigation of
mechanical properties of modern dental composites after artificial aging
for one year. Oper Dent 2010;35:412-419.
14. Jaecques SV, Van Oosterwyck H, Muraru L, Van Cleynenbreugel T, De
Smet E, Wevers M, Naert I, Vander Sloten J. Individualised, micro CT-
based finite element modelling as a tool for biomechanical analysis re-
lated to tissue engineering of bone. Biomaterials 2004;25:1683–1696.
15. Joshi S, Mukherjee A, Kheur M, Mehta A. Mechanical performance of
endodontically treated teeth. Finite Elem Anal Des 2001;37:587-601.
16. Juloski J, Apicella D, Ferrari M. The effect of ferrule height on stress dis-
tribution within a tooth restored with fibre posts and ceramic crown: a fi-
nite element analysis. Dent Mater 2014;30:1304-1315.
17. Ma PS, Nicholls JI, Junge T, Phillips KM. Load fatigue of teeth with differ-
ent ferrule lengths, restored with fiber posts, composite resin cores, and
all-ceramic crowns. J Prosthet Dent 2009;102:229-234.
18. Marchionatti AME, Wandscher VF, Rippe MP, Kaizer OB, Valandro LF.
Clinical performance and failure modes of pulpless teeth restored with
posts: a systematic review. Braz Oral Res 2017;31:e64.
19. Murakami N, Wakabayashi N. Finite element contact analysis as a critical
technique in dental biomechanics: a review. J Prosthodont Res
2014;58:92-101.
20. Naumann M, Schmitter M, Frankenberger R, Krastl G. „Ferrule Comes
First. Post Is Second!” Fake news and alternative facts? A systematic re-
view. J Endod 2018;44:212-219.
21. Naumann M, Sterzenbach G, Rosentritt M, Beuer F, Frankenberger R. In
vitro performance of self-adhesive resin cements for post-and-core build-
ups: influence of chewing simulation or 1-year storage in 0.5% chlora-
mine solution. Acta Biomater 2010;6:4389-4395.
22. Nawafleh N, Hatamleh M, Elshiyab S, Mack F. Disilicate restorations fa-
tigue testing parameters: a systematic review. J Prosthodont
2015;25:116-126.
23. Newman MP, Yaman P, Dennison J, Rafter M, Billy E. Fracture resistance
of endodontically treated teeth restored with composite posts. J Prosthet
Dent 2003;89:360-367.
24. Özcan M, Mese A. Fracture strength of indirect resin composite lami-
nates to teeth with existing restorations: an evaluation of conditioning
protocols. J Adhes Dent 2009;11:391-397.
25. Pedrollo Lise D, Van Ende A, De Munck J, Umeda Suzuki TY, Cardoso Vie-
ira LC, Van Meerbeek B. Biomechanical behavior of endodontically
treated premolars using different preparation designs and CAD/CAM ma-
terials. J Dent 2017;59:54-61.
26. Pereira RD, Valdívia AD, Bicalho AA, Franco SD, Tantbirojn D, Versluis A,
Soares CJ. Effect of photoactivation timing on the mechanical properties
of resin cements and bond strength of fiberglass post to root dentin.
Oper Dent 2015;40:E206-221.
27. Rees JS, Jacobsen PH, Hickman J. The elastic modulus of dentine deter-
mined by static and dynamic methods. Clin Mater 1994;17:11-15.
28. Santos AF, Meira JB, Tanaka CB, Xavier TA, Ballester RY, Lima RG,
Pfeifer CS, Versluis A. Can fiber posts increase root stresses and reduce
fracture? J Dent Res 2010;89:587-591.
29. Santos-Filho PC, Castro CG, Silva GR, Campos RE, Soares CJ. Effects of
post system and length on the strain and fracture resistance of root filled
bovine teeth. Int Endod J 2008;41:493-501.
142
30. Sarkis-Onofre R, Jacinto RC, Boscato N, Cenci MS, Pereira-Cenci T. Cast
metal vs. glass fibre posts: a randomized controlled trial with up to
3 years of follow up. J Dent 2014;42:582-587.
31. Schwindling FS, Hartmann T, Panagidis D, Krisam J, Rues S, Schmitter M.
In vitro investigation on extensively destroyed vital teeth: is fracture force a
limiting factor for direct restoration? J Oral Rehabil 2014;41:920-927.
32. Signore A, Benedicenti S, Kaitsas V, Barone M, Angiero F, Ravera G.
Long-term survival of endodontically treated, maxillary anterior teeth re-
stored with either tapered or parallel-sided glass-fiber posts and full-ce-
ramic crown coverage. J Dent 2009;37:115-121.
33. Soares CJ, Barbosa LM, Santana FR, Soares PB, Mota AS, Silva GR.
Fracture strength of composite fixed partial denture using bovine teeth as
a substitute for human teeth with or without fiber-reinforcement. Br Dent
J 2010;21:235-240.
34. Soares CJ, Bicalho AA, Tantbirojn D, Versluis A. Polymerization shrinkage
stresses in a premolar restored with different composite resins and dif-
ferent incremental techniques. J Adhes Dent 2013;15:341-350.
35. Soares CJ, Martins LR, Fonseca RB, Correr-Sobrinho L, Fernandes Neto
AJ. Influence of cavity preparation design on fracture resistance of pos-
terior Leucite-reinforced ceramic restorations. J Prosthet Dent
2006;95:421-429.
36. Soares CJ, Pizi EC, Fonseca RB, Martins LR. Influence of root embed-
ment material and periodontal ligament simulation on fracture resistance
tests. Braz Oral Res 2005;19:11-16.
37. Soares CJ, Santana FR, Silva NR, Preira JC, Pereira CA. Influence of the
endodontic treatment on mechanical properties of root dentin. J Endod
2007;33:603-606.
38. Soares CJ, Soares PV, Pereira JC, Fonseca RB. Surface treatment proto-
cols in the cementation process of ceramic and laboratory-processed
composite restorations: a literature review. J Esthet Restor Dent
2005;17:224-235.
39. Soares CJ, Soares PV, de Freitas Santos-Filho PC, Castro CG, Magalhaes
D,Versluis A. The influence of cavity design and glass fiber posts on bio-
mechanical behavior of endodontically treated premolars. J Endod
2008;34:1015-1019.
40. Soares CJ, Valdivia AD, da Silva GR, Santana FR, Menezes Mde S. Longi-
tudinal clinical evaluation of post systems: a literature review. Br Dent J
2012;23:135-140.
41. Soares PV, Santos-Filho PC, Gomide HA, Araujo CA, Martins LR, Soares
CJ. Influence of restorative technique on the biomechanical behavior of
endodontically treated maxillary premolars. Part II: strain measurement
and stress distribution. J Prosthet Dent 2008;99:114-122.
42. Soares PV, Santos-Filho PC, Martins LR, Soares CJ. Influence of restora-
tive technique on the biomechanical behavior of endodontically treated
maxillary premolars. Part I: fracture resistance and fracture mode. J Pros-
thet Dent 2008;99:30-37.
43. Stankiewicz NR, Wilson PR. The ferrule effect: a literature review. Int
Endod J 2002;35:575–581.
44. Stappert CF, Özden U, Gerds T, Strub JR. Longevity and failure load of ce-
ramic veneers with different preparation designs after exposure to masti-
catory simulation. J Prosthet Dent 2005;94:132-139.
45. Valdivia AD, Raposo LH, Simamoto-Júnior PC, Novais VR, Soares CJ. The
effect of fiber post presence and restorative technique on the biomechan-
ical behavior of endodontically treated maxillary incisors. J Prosthet Dent
2012;108:147-157.
46. Veríssimo C, Simamoto Júnior PC, Soares CJ, Noritomi PY, Santos-Filho
PC. Effect of the crown, post, and remaining coronal dentin on the bio-
mechanical behavior of endodontically treated maxillary central incisors. J
Prosthet Dent 2014;111:234-246.
47. Yang A, Lamichhane A, Xu C. Remaining coronal dentin and risk of fiber-
reinforced composite post-core restoration failure: a meta-analysis. Int J
Prosthodont 2015;28:258-264.
48. Zicari F, Van Meerbeek B, Scotti R, Naert I. Effect of ferrule and post
placement on fracture resistance of endodontically treated teeth after fa-
tigue loading. J Dent 2013;41:207-215.
49. Zicari F, Van Meerbeek B, Scotti R, Naert I. Effect of fibre post length and
adhesive strategy on fracture resistance of endodontically treated teeth
after fatigue loading. J Dent 2012;40:312-321.
Clinical relevance: A ferrule placed in anterior endodonti-
cally treated teeth reduced strain in root dentin and in-
creased fracture resistance. The presence of a ferrule
remains an important factor for a favorable prognosis of
endodontically treated teeth restored with a ceramic crown.
The Journal of Adhesive Dentistry
Copyright of Journal of Adhesive Dentistry is the property of Quintessence Publishing
Company Inc. and its content may not be copied or emailed to multiple sites or posted to a
listserv without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.