Machine Translated by Google
Review Article
''Ferrule Comes First. Post Is Second!'' Fake News
and Alternative Facts? A Systematic Review
Michael Naumann, DMD,* Marc Schmitter, DMD,† Roland Frankenberger, DMD,‡
and Gabriel Krastl, DMD§
Abstract
Introduction: Both the role of an endodontic post and
the ferrule effect have been discussed for decades.
The clinical impact of endodontic posts compared
with post free restoration with or without ferrule
support was not systematically reviewed so far. It was
assumed that the effect of an endodontic post
compared with a post-free restoration can be evaluated
only when at the same time a ferrule or non-ferrule
situation was clinically compared. Methods: The
specific PICO question was as follows: Patient: adults
with sufficient endodontic treatment needing a core
or post; Intervention: post endodontic treatment using
posts with or without ferrule; Comparison: post-
endodontic treatment without posts with or without
ferrule; Outcomes: failure rates of post/core complexes
with or without ferrule support. A Medline search was
performed via PubMed in June 2017 using relevant
electronic databases. Additionally, hand search was
performed. Only prospective clinical studies in humans
comparing the success/survival of teeth restored with
or without posts over a minimum time of observation
of 5 years were included. Results: In total, 7
randomized controlled trials and 1 prospective clinical
trial met inclusion criteria. Cochrane rating showed
high risk of bias in 5 studies. Two of 3 studies support
the ferrule-effect concept. Seven of 8 show no post
effect. Clinical evidence regarding the influence of
tooth location on its survival is scarce. Conclusion:
Ferrule effect and maintaining cavity walls are the
predominant factors with regard to tooth and
restoration survival of endodontically treated teeth. Most studies do not confirm a positive effect of post placement.
(J En
dod 2017;-:1–8)
Key Words
Buildup, clinical trial, core, dowel, endodontically treated
teeth, no-post, post-and-core, post-free, post-retained, screw
From the *Department of Prosthodontics, Geriatric Dentistry, and Craniomandibular Disorders, Charite–Universit€atsmedizin Berlin, Berlin, Germany;
Prosthodontics and § Conservative Dentistry and Periodontology, University Hospital of W€urzburg, W€urzburg, Germany; and
Endodontology, University of Marburg, Marburg, Germany
Address requests for reprints to Michael Naumann, Prof Dr med dent, DMD, Department of Prosthodontics, Geriatric Dentistry, and Craniomandibular Disorders,
Charite–Universit€atsmedizin Berlin, Aßmannshauser Str 4-6, Berlin 14197, Germany. E-mail address: naumann@naumann-kiessling.de
0099-2399/$ - see front matter
Copyright ª 2017 American Association of Endodontists.
https://doi.org/10.1016/j.joen.2017.09.020
JOE — Volume -, Number -, - 2017
Significance
Inthe
contrast to vital rate
complication teeth,
of
restorations on endodonti Ferrule effect and maintaining cavity walls are predominant
factors with regard to tooth and restoration survival of
cally treated teeth (ETT) is
endodontically treated teeth. Consider able clinical evidence
considerably increased,
to the influence of the tooth
perhaps finally resulting in
type on the survival of endodontically treated teeth is scarce.
tooth loss. Therefore, ETTs
Most studies do not confirm a positive effect of post placement
are often judged as ''less
valuable'' as abutments for for indirect restoration.
prosthodontic restorations
when it comes to reliability and cost-effectiveness compared with vital teeth ( 1) or
implants (2). Systematically reviewed (SR) data over 3 to 25 years showed that survival
rates of restorations after endodontic treatment ranged between approximately 81% and 100% (3).
Over the past decades, much research focused on the question of which post-and
core technique/material should be used to increase ETT and restoration survival (4).
A wide range of post materials with different mechanical properties, such as cast gold
(5), stainless steel(6, 7), titanium(8), zirconia(9), or less rigid materials, such as fiber
posts(10) was applied. A recent survey reported that a great variety of options is presently
used, also including no post placement depending on the final restoration planned (11).
However, unequivocal guidelines do not exist.
The aim of the present SR was to look for high-level clinical evidence comparing
post versus no-post placement in ferrulated and unferruled teeth to distinguish between
post and ferrule effect and to exclude the blurring impact of the latter. The null hypothesis
was that post placement is superior to post-free restorations (post effect) irrespective of
the presence of a ferrule (ie, ferrule effect) for restoration and/or tooth survival.
Material and Methods
PICO Question
The specific PICO question was as follows:
P (patient): adults with sufficient endodontic treatment needing a dentin core buildup
procedure
I (intervention): post-endodontic treatment using posts with or without ferrule support
C (comparison): post-endodontic treatment without posts with or without ferrule
support
O (outcomes): tooth and/or restoration survival
†
Departments of
‡
Department of Operative Dentistry and
Role of Ferrule Effect and Endodontic Post 1
Machine Translated by Google
Review Article
The resulting question was the following:
Is the insertion of a post or a post-free restoration the most
successful treatment option in patients requiring restoration of an
endodontically treated tooth, irrespective of the presence of a ferrule?
Search Process and Selection of Studies Three of
the authors (MN, MS, GK) performed a Medline (via PubMed)
search in March 2017 using the terms (''post'' OR ''posts'' OR ''dowel''
OR ''dowels'' OR ''screw'' OR ''screws'' OR ''core'' OR ''post retained''
OR ''no-post'' OR ''post-free'' OR ''endocrown '' OR ''buildup'' OR
''buildups'' OR ''build-up'' OR ''build-ups'') to identify studies comparing
the success/survival of dental restorations using posts or no posts. In
this database, the authors used limits to narrow the search with the
options ''clinical trial'' and ''dental journals.'' Furthermore, the following
electronic databases have been analyzed using the search terms ''posts''
and '' core'': Opengrey, BBO, LILAC, and IBECS. All references cited in
the identified articles were also checked to identify other potentially
relevant articles. Finally, the personal databases of the au thors were
included in the search.
Inclusion/Exclusion Criteria
The present review included in vivo studies in humans comparing
the success or survival of teeth restored using posts and-cores and
teeth restored using cores without posts. Retrospec had clinical studies,
in vitro and finite-element studies, and studies assessing the survival or
success of either posts or cores have been excluded. Only studies
including statements of the remaining coronal tooth structure and studies
comparing post placement or post free restorations with or without
ferrule support were considered (Table 1).
Appraisal of the Studies Selected
After selection of the literature, its quality was assessed using
standardized checklists:
1. The critical appraisal skills program (CASP)
2. Cochrane checklist (version 5.1.0)
Statistical Analysis
Quality of methodology was assessed by 3 referees. Two of the 3
referees had to agree to set the quality level on the selected degree.
The agreement was assessed using the intraclass correlation coefficient,
which was calculated using SPSS (V 23.0.0.2) (IBM SPSS Statistics, IBM
Corporation, Chicago, IL).
Results In
Medline, 2595 articles were found. After screening the titles and the
abstracts of the identified studies, 8 studies were included in the full-text
analysis. In LILAC, IBECS, OpenGrey, and BBO, no further relevant
references could be found (Fig. 1). In total, 8 studies were included,
among them 7 randomized controlled trials (RCTs) and 1 prospective
clinical trial (Table 1).
Main Findings from Selected Studies Randomized
Controlled Trials. Creugers et al (12, 13) published 5-year data on post-
and-core restorations with or without covering crowns conducted between
January 1988 and June 1991.
Observations after 17 years were published by Fokkinga and co workers
(6, 7). Studies were conducted at Nijmegen University clinic and in 17
general practices around Nijmegen.
2 Naumann et al.
The first article including 5-year observations reported 249 patients
with ETT requiring 1 covering crown. Three types of restorations were
included in that trial: (1) cast post-and-core, (2) direct metal post and
resin composite core restoration, and (3) post-free all-resin composite
core restoration. Teeth were divided in 2 expected dentin heights after
crown preparation with (#1 called trial S, substantial dentin height, 201
teeth) > 75% of circumferential dentin height, and thickness was 1 mm
or more above gingival level (ie, a ferrule of 1 to 2 mm was achievable),
and (#2, trial M, minimal dentin height, 118 teeth) < 75% as described in
(Fig. 2) ( 6 , 7, 12, 13). Thus, in the latter, no appropriate ferrule was
achieved.
Effect of Ferrule. After 5 years of observation, restorations with ferrule in
subgroup S survived significantly better (98% 2%) than in subgroup M
without ferrule (93% 3%) (P = .04). However, after 17 years, comparison
of survival probability between the ferrule sub group (trial S, S = 0.84)
and no-ferrule subgroup (trial M, S = 0.71) differed significantly only for
prefabricated post with resin composite cores and crowns (P = .03).
Effect of Post. After 17 years, 28% (computed by authors: n = 89 teeth)
of all restorations were available. Type of post-and-core had no significant
influence in both trials (P > .05). Survival rate at rest ration level varied
from 71% to 80%, and at tooth level from 83% to 92%.
Effect of Post (Effect of Ferrule Not Applicable). A second subsequent
article of this working group (12) reports 5-year observations of direct
restorations in patients (n = 87) not able or willing to receive a single
crown in the same setting as described previously.
After random allocation in this trial, 99 direct restorations were formed
with (n = 53) or without (n = 46) prefabricated posts. After 5 years of
observation, all post-free restorations survived (survival 98% 2%). No
significant difference between groups was found (P > .05).
Overall estimated survival rate after 17 years of restoration was
53% (14%), and for the teeth 79% (11%). Post placement had no
influence (P > .05) on survival probability. Caries was the predominant
reason for absolute failure.
Effect of Post (Effect of Ferrule Not Applicable). Mannocci et al (14)
compared the 5-year clinical performance of 219 endodontically treated
premolars with Class II cavities restored with either amalgam (n = 109)
compacted in the coronal third of the root canal to increase retention or
direct resin composite restorations ( n = 110). At 5 years, 9 of 100
amalgam and 10 of 97 resin composite restorations failed (no significant
difference, P = .81).
Ferrari et al (15) reported 6-year data (15, 18) of 345 patients
divided into 6 groups of 60 premolars each (maximum 2 teeth per
patient). Four groups were divided according to the remaining cavity
walls (1 to 4). Additionally, in another group (group 5), the coronal tooth
structure provided adequate ferrule, whereas in group 6 no ferrule was
present. Within each group, teeth were randomly divided into 3 subgroups.
Subgroup A did not receive a post, in subgroup B prefabricated fiber-
reinforced composite posts were inserted, and in subgroup C customized
fiber-reinforced composite posts were used.
Effect of Post. The overall survival rate was 94.1% (lost to follow-up
12.3%), 99.1% for prefabricated posts, 97.2% for customized posts, and
85.9% for no posts. The 6-year recall did not exhibit interactions between
the type of restoration and the amount of remaining coronal dentin (ie,
cavity walls) (P > .05).
Cloet et al (16) reported results of 143 patients in a 5-year recall.
All subjects received all-ceramic crowns after root canal treatment in 203
teeth in a university setting (29 operators). The comparison of
restorations with and without posts was performed in a second study arm
JOE — Volume -, Number -, - 2017
 Machine Translated by Google
Post-
Ferru
Effec
End
Role TABLE 1. Characteristics of Included Randomized Controlled Trials and Prospective Study Evaluated in Systematic Review

Number and
characteristics of
Number

and type of post-

retained restorations
Number and type

of post-
free
Potential

overlaps
between

patient

Review
Number of restored teeth in relevant study arm restorations in groups
and
patients at at baseline relevant study Post (indicated by same
Study Setting Follow-up baseline Dropout, % arm Ferrule effect effect Main findings letter)
Randomized controlled trials
Creugers Private 60 months 87 99 teeth (27 molars, 54 Direct metal Direct Not applicable None of the post-free restorations A

Article
et al (12) practice and premolars, and post + direct composite: 46 failed (100% survival).
18 anterior teeth) composite: 53 Two restorations with
university posts failed after almost 5
years (survival 96%
2%). Survival
difference was not
statistically significant.

The present study does not

support the need for
posts for
structurally
compromised and
endodontically
treated teeth restored with
composite
constructions and
of
not covered by
cast crowns.
Creugers Private 60 months 249 319 teeth (115 Post-and-core cast PFM crown: 42 Yes (substantial No No difference was found B
et al (13) practice molars, 103 + PFM crown: vs minimal between the survival
and premolars, and 127/277 dentin height) of the different types of
university 101 anterior Direct metal restorations.
teeth) post + PFM Overestimation of the
crown: 150/277 survival of the post
free core restorations
(98%) because ''high
risk teeth'' are
underrepresented in
this group. Direct
comparison between
core restorations with and
without posts is thus
biased and
therefore not allowed.
Mannocci Private 5 years 219 219 teeth (premolars Carbon fiber Amalgam: 109 Not applicable No No statistically significant
et al (14) practice with Class II post + direct difference was found
lesions and intact composite: between the
cusp structure) 110/110 proportion of failed
teeth in the 2
experimental groups.
Fiber posts and
composite were found to
be more effective than
amalgam in
preventing root
fractures but less
effective in preventing
secondary caries.
Fokkinga Private 15–17 years 257 307 teeth (113 Cast post-and-core + Full crown: 39 No/Yes only No Type of post-and-core B
et al (6) practice molars, 99 full crown: in combination restoration showed no
premolars, 118/268 with prefabricated influence on the
3

(continued)
 Machine Translated by Google
Number alt
N
e4

TABLE 1. (continued)

Potential
Number Number and
Volume
overlaps
Number and and type of post- type of between
characteristics of retained post-free patient
Number of restored teeth restorations in restorations in groups
patients at at baseline relevant relevant study Post (indicated by
Study Setting Follow-up baseline Dropout, % study arm arm Ferrule effect effect Main findings survival same letter)
and 95 anterior Direct metal metal posts and probability (at both
teeth) post + full composite colors levels) in both trials
crown: 150/268 (P > .05). The 17-year
survival rates at
restoration level
ranged from 71% to
80%, and at tooth
level from 83% to
92%.
In an endodontically
treated tooth with
substantial remaining
JOE
dentin, a post in a core
does not perform
better than a post-free
core.
Fokkinga Private Up to 17 years 87 98 teeth (25 molars, Direct metal Direct Not applicable No Post placement showed no A
et al (7) practice 54 premolars, post + direct composite: 44 influence on the
and 19 anterior composite: 53 survival probability at
teeth) either level (P > .05).
The estimated overall
survival rate at
17 years was
53% 14% at the
restoration level and
—

79% 11% at the

tooth level.
The results of this study
showed no difference in
survival probability
-,

between
endodontically
-

treated single teeth

reconstructed with
direct composite
restorations either
with or without a
metal post.
Ferrari Private 72 months 345 360 teeth (premolars 11.9% for Glass fiber post: PFM crown: Yes, with limitation Yes Cox regression analysis W

et al (15) practice with different patients, 12.3% 120/240 Glass 120/120 for no-wall groups; revealed that fiber
amount of dentin for restorations fiber bundles: No ferrule effect: post retention
left at the coronal 120/240 hazard ratio significantly improved
-2017

level after (HR) = 12.3, tooth survival

endodontic P = .001; (P < .001). Failure risk
treatment) Ferrule effect: was lower in teeth
HR = 8.6, P = .004 restored with
prefabricated
(P = .001) than with
customized posts
(P = .009).
Cloet university 5.8 y (range, 143 205 teeth in total Restoration Prefabricated 13/24 direct Not applicable No Lifetime curves did not show D
et al (16) 0.5–7.2 y) but only 24 teeth recall rates wrought post composite any significant
with sufficient at 1, 3, and and cast core buildups and differences between
tooth tissue, 5 years were and all-ceramic the test and control
Machine Translated by Google

Review Article

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with sufficient tooth tissue only. In these teeth, resin composite cores (n =
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11) were inserted. Sufficient tooth tissue was defined as at least 2 dentin
walls of $2-mm dentin thickness and with wide pulp chambers. After 5 years,
the recall rate was 87.2%.
Effect of Post. Overall survival was 91.5%, for prefabricated posts 91.4%,
for custom-made posts 92.1%, and 91.2% for post-free restorations. There
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and absolute failure rate comparing anterior (14%) with posterior teeth
(12%) (P > .05). All post-free restorations were located in posterior teeth (3
absolute failures). The authors concluded that the mode of root restorations
did not play a role. However, due to the limited number of teeth in the second
study arm comparing restorations with and without posts, the results should
be interpreted with caution.
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Prospective Controlled Trial: Effect of Post (Effect of Ferrule Not Applicable).

One nonrandomized clinical study comparing post-retained and post-free
381

restorations was included in this SR (16). Survival rate of root-filled teeth

was 92.5% for teeth restored with titanium posts, 97.1% for those restored
with cast post and cores, and 94.3% for teeth without post-retained
restorations (17) . No significant difference was computed between these
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Consistency of Results To the

best of our knowledge, this is the first SR comparing impact of
postversus no-post placement on tooth and restoration survival in ferrulated
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and/or unferruled teeth over a time of observation of 5 years or more.

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Agreement Between Referees In

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JOE — Volume -, Number -, - 2017 Role of Ferrule Effect and Endodontic Post 5
Machine Translated by Google
Review Article
Figure 2. Minimal (left) and substantial (middle) dentin height as used by Creugers et al (12, 13) and Fokkinga et al (6, 7) to describe remaining coronal
tooth structure; typical description of defect size 0 to IV remaining cavity walls (0 to IV) (right).
With CASP in RCTs (n = 7), all 3 referees agreed in 91% of the
items, whereas in the rest of the items at least 2 of the 3 referees
agreed.
For CASP in the prospective study (n = 1), all 3 referees agreed.
Methodological Quality of Studies The
methodological quality of the studies was heterogeneous.
In 3 RCTs only, the risk of bias was judged to be low for most items.
In contrast, the risk of bias was judged to be high for several items in
the other studies.
Incorporation of Evidence into the Algorithm
In the authors' assessment, remaining coronal tooth structure is
the predominant factor with regard to tooth and restoration survival of
ETT. For single crowns, the ferrule effect has a supportive value over
a mid-term time of observation in all evaluated studies. This post itive
effect could not be found for posts.
Discussion This
SR involving randomized and prospective clinical trials comparing
post-supported and post-free restoration of ETT high lights the
importance of the remaining coronal tooth structure as a predicting
factor of both restoration and tooth survival. For most authors, it
appears easy to count the number of remaining cavity walls from 4
(ie, access cavity only) to no wall, as described earlier (19), probably
derived from the configuration factor (C-fac tor) (20 ) (Fig. 2).
6 Naumann et al.
Clinical observation periods varied from 5 to 17 years in the
selected studies. We chose 5 years as the cutoff for minimum time of
observation, because it was shown that this is the minimum time to
show different behavior (21). It is positive that for the present SR that
17-year data were available.
The longer the observation time, the higher was the dropout rate.
There are no unequivocal guidelines of how many dropouts are still
acceptable after a certain recall time(22). After 17 years, approximately
3 to 4 of 10 patients were still willing or able to be recalled (6, 7); after
6 years, 9 of 10 (12.3%). Only Cloet et al (16) stated that an a priori
formal power calculation based on existing literature data resulted in a
sample size of 800 teeth to reach a power of 80% (P = .05). Similar
results were found earlier (23).
If a tooth loses its clinical crown (ie, no cavity wall remains), mid-
to long-term data (6, 7, 12, 13) show that an almost circumferential
(>75% of the circumference) ferrule preparation of 1.5 to 2.0 mm is
essential, resulting in a 5% increase of survival probability. Ferrule
might be interpreted as a defect with 4 remaining walls, but with
insufficient coronal height. During function, both compression and
tension forces are maximum at the external root surface at the crestal
bone level and decrease to ''0'' in the tooth center (24). This may be
compensated by a dentin ferrule (25). However, over a long period (17
years), ferrule was beneficial only for prefabricated titanium posts with
composite core constructions. Hence, based on the clinical evidence,
the ferrule effect can be described as a mid-term phenomenon. The
remaining dentin wall thickness of this ferrule should be 1 mm (26) to
have a functional, supportive value. In the present SR, only clinical
studies
JOE — Volume -, Number -, - 2017
Machine Translated by Google
TABLE 2. Overview of Included and Evaluated Publications Showing Ferrule
and Post Effect, Respectively
Ferrule
effect
Trials Yes At the Yes
Prospective trials
Salvi 2007 (17) —— x
Randomized controlled trials
Cloet 2017 (16) —— x
Ferrari 2012 (15) x x*
Mannocci 2005 (14) —— x
Fokkinga 2007 (6) (x)† (x)
Fokkinga 2008 (7) ——x
Creugers 2005 (12) ——x
Creugers 2005 (13)
Yes/no x 3/3 0/3 1/8
—, not applicable, because direct restorations did not present a ferrule, no unferruled control, or
non–no-wall defect; x, fully applicable; (x), partially applicable.
*Only premolars investigated.
†
Only for prefabricated titanium posts.
that present data on ferrulated and unferruled ETT with or without
post support were considered to distinguish a possible ferrule effect
from a post effect. Two of 3 studies confirm a ferrule action, whereas
the third one limits it to titanium post-and-cores. Failure risk in creases with the
number of missing cavity walls. Maybe 1 remaining
cavity wall substitutes a ferrule and its positive effect. For direct restorations (ie, no
ferrule effect is present per definition), half of all
teeth failed during 17 years of observation. Thus, placing crowns
on ETT might be beneficial.
Adhesively or nonadhesively directly restored small cavities as Class II
(3 remaining cavity walls) do not benefit from post placement(14). Preparation of an
access cavity (4 remaining cavity walls) does not justify the
insertion of a post, as demonstrated by the 6-year RCT results (15). The
same is true for 4-, 3-, and 2-wall defects and resin composite core
buildups with or without posts restored with single crowns (15, 27). A
short-term prospective study showed that already 1 remaining cavity
wall may substitute a post effect (28), in accordance with findings of an
earlier SR (29). Thus, only teeth presenting large coronal defects without
remaining cavity walls might benefit from post placement. The number of
failures in post-free groups are not significantly higher, which makes intuitive sense;
however, unequivocal statements for post placement cannot
be given. As reported in a 17-year follow-up study (7), there seems to
be no benefit of a post for direct composite resin restorations. Only
when no ferrule is present do teeth benefit from prefabricated posts
with composite core, being covered by a single crown. It is noteworthy
that 8 of 10 restored teeth are still in function after 17 years.
The ferrule and its effect are well to evaluate when (1) a no-wall
defect is present and (2) ferrule and no-ferrule preparation in post
and/or no-post groups are compared to ascribe a specific effect exclusively to 1 of
both factors (ie, post or ferrule). It means a ferrule might
blur the effect of a post. Surprisingly, although a ferrule effect was shown
in 2 of 3 studies eligible for evaluation, only 1 of 8 studies show a positive post effect
for premolars (Table 2)! It is remarkable that after
5 years and more of observation clinically generally accepted positive
effects of a post are not as obvious as one might expect.
Conclusion
Most studies fail to show a post effect, whereas a ferrule may have a
supportive effect on indirect restorations. Biomechanical considerations
suggest different behavior of anterior teeth, premolars, and molars due to
different load direction with a higher risk of mechanical failure in the
JOE — Volume -, Number -, - 2017
Review Article
anterior maxillary region. There is a lack of considerable clinical evidence with
regard to the influence of the location of the tooth in the
dental arch on the survival of ETT, either with direct or indirect rest rations.
Post
effect
At the
Acknowledgments
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
The authors deny any conflicts of interest related to this
study.
x
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Role of Ferrule Effect and Endodontic Post 7
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Review Article
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JOE — Volume -, Number -, - 2017