DOI: 10.7860/JCDR/2017/24669.

9675
Original Article

Effect of Different Ferrule Length on

Dentistry Section

Fracture Resistance of Endodontically

Treated Teeth: An In vitro Study

Sushil Kar1, Arvind Tripathi2, Chavi Trivedi3

ABSTRACT with prefabricated glass fibre posts (Reforpost, Angelus) and

Introduction: A ferrule has been described as a key element composite resin (Filtek™ Z250xt). Standardized preparation
of tooth preparation when using a post and a core. It is a was done on each specimen to receive a cast metal crown. The
vertical band of tooth structure at the gingival aspect of crown specimens were thermocycled and compressive static load at a
preparation. It lessens the stress transmission to the root which crosshead speed of 1 mm/min was applied at an angle of 30° on
is due to forces from posts or bending during seating of the post. lingual incline of buccal cusp of the crown until failure occurred.
The incorporation of a ferrule can help to withstand the forces The load (N) at failure and mode of failure were recorded.
of occlusion, preserve the hermetic seal of the luting cement, Statistical analysis was performed with Kruskal Wallis test.
and minimize the concentration of stresses at the junction of
post and core. Result: Fracture resistance values among the groups was found
to be statistically significant (p<0.001). The 3 mm ferrule group
Aim: To evaluate and compare the effect of ferrule length on
had significantly higher failure load (971.99+133.07) compared
fracture resistance of endodontically treated mandibular premolar
teeth, restored with prefabricated glass fiber post luted with resin to 2 mm (848.84+109.60), 1 mm (714.64+133.89) and 0 mm
cement, composite core and a full coverage metal crown. ferrule groups (529.36+119.95). More favourable failure modes
were observed in almost all groups.
Materials and Methods: Forty freshly extracted mandibular
premolars were treated endodontically. They were randomly Conclusion: The results of this study showed that fracture
divided into four groups according to their ferrule height: 3 mm, resistance of endodontically treated teeth increases as ferrule
2 mm, 1 mm and 0 mm (no ferrule). All specimens were restored length increases.

Keywords: Occlusal load, Polymerization, Thermocycle

INTRODUCTION Therefore, the aim of this study was to evaluate and compare the
Prosthetic rehabilitation of endodontically treated teeth has been effect of ferrule length on fracture resistance of endodontically
a challenge to dental practitioners. Following endodontic therapy, treated mandibular premolar teeth restored with prefabricated
substantial amount of tooth structure is lost due to caries, glass fiber post luted with resin cement, composite core and a full
trauma and endodontic procedures and it becomes a hollow coverage metal crown.
calcified laminated structure with deficient collagen cross linking
and reduced modulus of resiliency with increased fracture sus­ MATERIALS AND METHODS
ceptibility. Survival of such teeth is directly related to the quality as The present in vitro study was conducted in Department of
well as quantity of the remaining tooth structure [1]. Conservation Prosthodontics, Saraswati Dental College and Hospital, Lucknow,
of sound coronal dentin permits placement of margin on Uttar Pradesh, India in collaboration with Central Institute of Plastic
remaining tooth structure which influences the fracture resistance Engineering and Technology, Lucknow. Forty extracted, human
of crowned endodontically treated teeth [2]. Reinforcement of permanent mandibular premolars of approximately same dimensions
fiber posts in endodontically treated teeth with insufficient coronal were selected for the study which was measured using an electronic
tooth structure produces a stress field similar to that of natural
digital Vernier's calliper (Mitutoyo/Digimatic, Japan) to make sure
teeth because of same elastic modulus as that of dentine, thus
that they satisfy the following inclusion criterias: Mesio-Distal (M-D)
restoring the tooth to function [3].
dimensions: 5 mm±1, Bucco-Lingual (B-L) dimensions: 7 mm±1,
Incorporation of a ferrule when restoring an endodontically treated root length atleast 15 mm [Table/Fig-1a,b]. Additionally, periapical
tooth with a post-core and a crown always enhance the prognosis B-L and M-D radiographic views were taken to ensure the presence
of the tooth. A ferrule has been defined as a circumferential metal
of straight, single canal orifice, and completely formed apices. The
collar of the crown surrounding the parallel walls of the dentine
teeth were inspected to exclude any defects or cracks, restorations
extending coronal to the margin of the preparation [4]. The ferrule
or caries and previous endodontic restorations. Disinfection of the
improves biomechanical stability of the tooth by improving resistance
specimens was done using 0.5% chloramine T aqueous solution at
to dynamic occlusal loading and integrity of the cement seal of the
prosthesis. Studies have validated the use of atleast 1.5 mm ferrule 4°C for one week. Subsequently the selected teeth were stored in
as most effective in resisting fracture under load [5-7]. Many studies normal saline throughout the procedure to prevent desiccation.
investigating the ferrule effect have used cast post and core and A reference line was marked with graphite pencil at the Cemento-
generally on anterior teeth [8-12], but there is little information as to Enamel Junction (CEJ) of the experimental group specimens.
whether ferrule length has an added advantage along with fiber post The marking was based on digital vernier calliper measurements.
and composite core in premolar tooth. Sectioning the coronal tooth structure, at the reference lines, was
done perpendicular to the long axis of the teeth using a diamond

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 Sushil Kar et al., Effect of Different Ferrule Length on Fracture Resistance of Endodontically Treated Teeth www.jcdr.net

disc with low speed straight handpiece. The resultant coronal tooth Statistical analysis
surface was flat, rather than following the undulations of the CEJ The data was analysed using Statistical Package for Social
under constant water irrigation. To standardize the specimen’s Sciences, version 15.0, distributions were checked for normality
length, the crowns of the selected teeth were removed according to using Kolmogorov Smirnov test and failure mode was recorded
ferrule heights; Group A: no ferrule; Group B: 1 mm ferrule; Group and statistically analysed with Kruskal Wallis test.
C: 2 mm ferrule; Group D: 3 mm ferrule.
Standardized endodontic procedure was carried out on all
specimens using Protaper® (Dentsply Maillefer, Ballaigues), canals
were irrigated with 3% NaOCl and obturated with F2 ProTaper
guttapercha cones (Dentsply Maillefer, Ballaigues) using AH Plus
Sealer (Dentsply Maillefer, Switzerland). Finally to ensure full setting
of the seal, the teeth were stored in a 100% humid environment at
37°C for 24 hours.
Guttapercha removal was performed with Gates Glidden drills (3#)
taking care to preserve 4 mm apical seal. Radiographs were taken
to evaluate the adequacy of the remaining dentine structure around
the post space preparation. For standardized orientation of all
specimens into resin filled moulds, dental surveyor was used [Table/
Fig-1c]. Root surfaces were marked 3 mm below the CEJ. To simulate
the periodontal ligament, the root surfaces were covered with two
layers of 0.075 mm thick heat-resistant polytetrafluoroethylene
adhesive tape and coated with petroleum jelly. Silicone impression
material (Alphasil®, Germany) was mixed and injected around tooth
to produce a standardized silicone layer of 0.15 mm to simulate [Table/Fig-2]: a) Tooth was prepared using a high speed rotary handpiece mounted
in a dental surveyor; b) Specimen placed on UTM (Instron 3382) for loading.
periodontal ligament.
Prefabricated glass fiber post (Reforpost, Angelus) of 0.9 mm
diameter at their apical section and 1.3 mm diameter at their coronal
section were selected for the study [Table/Fig-1d]. The dual-cure
resin cement RelyXTM U200 was used for post cementation. The
specimens were left undisturbed for 15 minutes prior to storage
in 100% humidity environment at 37°C for 24 hours. Composite
resin (for core build up) was placed in increments with 40 seconds
of polymerization. Standardized preparation was done in each
specimen using a high speed rotary handpiece [Table/Fig-2a].
[Table/Fig-3]: a) Favourable fracture; b) Unfavourable fracture.
Crowns were luted with glass ionomer cement.
Distilled water was selected to store the specimens at a temperature
of 37°C with 100% humidity for 24 hours. Subsequently the
RESULTs
The mean value of fracture resistance, standard deviation and inter­
specimens were thermocycled for 500 times from 5° to 55°C using
group comparison was recorded and statistically analysed using
30 second dwell times. The mounted specimens were aligned with
Kruskal Wallis test [Table/Fig-4]. The specimens (n=40) had a mean
the long axis of the tooth at 30° to the loading rod tip. This jig was
fracture resistance of (766.21+204.91 N) with values ranging from
secured to the lower compartment of a Universal Testing Machine
a minimum of 364.66 N to a maximum of 1253.67 N. Fracture
(UTM) (Instron 3382). A flat steel tip with compressive head was
resistance was found to be lowest for Group A (529.36±119.95 N)
used to apply the load on lingual incline of buccal cusp. It was fixed
followed by Group B (714.64±133.89 N), Group C (848.84±109.60 N)
to the moving upper compartment of the testing machine [Table/
and highest for Group D (971.99±133.07 N) [Table/Fig-4]. Difference
Fig-2b]. The compressive load was applied at a crosshead speed
in fracture resistance values among the groups was found to be
of 1 mm/min until failure occurred. The failure mode was evaluated
statistically significant (p<0.001).
by visual examination of the specimens to classify its type [13].
Then a stereomicroscope (Olympus, U-CMAD3, Japan) was used Though fracture was found to be favourable in higher proportion
for further evaluation of the mode of failure. The failure mode of Group D (90.0%) as compared to Group B (80.0%), Group C
was classified as either favourable (restorable) or unfavourable (80.0%) and Group A (70.0%) [Table/Fig-5], they were not statistically
(catastrophic) [Table/Fig-3a,b]. Favourable failure modes are those significant.
that take place above the level of acrylic resin which simulate the
bone level. They include either partial or complete post-core- DISCUSSION
crown debonding or post-core-tooth complex fracture above Advancements in the field of restorative dentistry have markedly
acrylic resin block. Unfavourable failure occurs below the level of increased the probabilities of successful restoration of severely
the acrylic resin. It includes fracture of the post-core-root complex, damaged endodontically treated teeth. The preservation of tooth
cracks in the roots or vertical root fractures. structure in endodontically treated tooth improves its prognosis
because it provides protection against fracture under occlusal
loads. A ferrule, in respect to the teeth, is a band that encircles the
external dimension of residual tooth structure.
In the present study, influence of ferrule length on fracture resistance
and failure pattern of endodontically treated crowned mandibular
premolars reinforced with composite core and fiber post was
[Table/Fig-1]: a) Dimension of crown measured using an electronic digital Vernier's
caliper; b) Dimension of root measured using an electronic digital Vernier's caliper;
investigated. The decision to place a post in endodontically treated
c) Specimens mounted into resin filled moulds; d) Length of the post (standardized) tooth depends upon amount of loss of tooth structure and also the
using an electronic digital Vernier's caliper. amount of functional forces on tooth [14,15]. Many investigators

50 Journal of Clinical and Diagnostic Research. 2017 Apr, Vol-11(4): ZC49-ZC52

www.jcdr.net Sushil Kar et al., Effect of Different Ferrule Length on Fracture Resistance of Endodontically Treated Teeth

No. of Minimum Maximum Mean Statistical significance

Group S.D. Median Mean Rank
specimens (Newton) (Newton) (Newton) H p
Group A 10 364.66 698.40 529.36 119.95 522.16 7.20
Group B 10 594.77 984.67 714.64 133.89 658.23 16.80
25.665 <0.001
Group C 10 693.00 1018.14 848.84 109.60 810.01 26.20
Group D 10 854.74 1253.67 971.99 133.07 925.39 31.80
Total 40 364.66 1253.67 766.21 204.91 767.58
[Table/Fig-4]: Inter groups comparison of compressive load (Kruskal Wallis test: Non-Parametric ANOVA).

proportion of Group D (90.0%) as compared to Group B, Group

Group A Group B Group C Group D
(n = 10) (n = 10) (n = 10) (n = 10) C (80.0% each) and Group A (70.0%) but this difference was not
found to be significant.
No. % No. % No. % No. %
Favourable 7 70.0 8 80.0 8 80.0 9 90.0
Although the design of the current study attempted to simulate
clinical situations such as ferrule preparation, periodontal ligament
Unfavourable 3 30.0 2 20.0 2 20.0 1 10.0
and cast crown, it is difficult to implement these results directly for
[Figure/Fig-5]: Favourability of fracture among the groups. the clinical practice because it is an in vitro study which could not
fully replicate oral conditions. Besides the type of test used, that is,
have reported that post placement affects fracture resistance and a static load which does not represent the oral condition. The study
increases the potential risk of root fracture and root fracture was also evaluated the mandibular premolar and therefore, the results
reported with the use of metallic posts [16,17]. Fiber posts were can be applied only to that group of teeth.
investigated to have modulus of elasticity which was similar to that
of dentine, and thus producing a stress field similar to that of natural CONCLUSION
teeth. It was thought that fiber posts lowered the interfacial stress Under the limitation of this study, the following conclusions were
and reduced the chances of failure [18]. Since the physiological drawn: Increasing the ferrule length can significantly increase
properties of a periodontal ligament in teeth under load potentially the fracture resistance of the endodontically treated mandibular
affects the results, periodontal ligament simulation was done premolars restored with a glass fibre post luted with RelyX™ U200
to be as close as possible to the clinical situation. To mimic the self adhesive resin cement, composite core and metal crown. All the
clinical oral conditions mandibular premolars were stored in normal intergroup differences, except between Group C and Group D were
saline at 37°C and they were loaded at an angle in UTM which statistically significant. The following order of fracture resistance
corresponded to the loading angulation of mandibular premolar in was observed among the different groups: Group A< Group B <
natural dentition. Group C < Group D. Almost all the subgroups had favourable type
In the present study, the fracture resistance of teeth was tested under of failures.
static load to stimulate forceful clenching. The results confirmed
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PARTICULARS OF CONTRIBUTORS:
1. Professor, Department of Prosthodontics, Saraswati Dental College, Lucknow, Uttar Pradesh, India.
2. Professor and Head, Department of Prosthodontics, Saraswati Dental College, Lucknow, Uttar Pradesh, India.
3. Junior Resident, Department of Prosthodontics, Saraswati Dental College, Lucknow, Uttar Pradesh, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Sushil Kar,
Professor, Department of Prosthodontics, Saraswati Dental College,
Date of Submission: Oct 07, 2016
Tiwari Ganj, Faizabad Road, Lucknow-227105, Uttar Pradesh, India.
E-mail: drsushil_kar@yahoo.co.in Date of Peer Review: Dec 10, 2016
Date of Acceptance: Feb 01, 2017
Financial OR OTHER COMPETING INTERESTS: None. Date of Publishing: Apr 01, 2017

52 Journal of Clinical and Diagnostic Research. 2017 Apr, Vol-11(4): ZC49-ZC52