Fracture Resistance Review

Review Article
Fracture Resistance of Teeth Restored with Post-retained

Restorations: An Overview
Mahmoud Khaled AL-Omiri, BDS, PhD, FDS RCS,* Ahmad Abdelaziz Mahmoud, BDS, PhD,*
Mohammad Ramadan Rayyan, BDS, MDSc, and Osama Abu-Hammad, BDS, MSc, PhD*
Abstract
Introduction: Posts have been used efficiently to retain
restorations for badly destructed teeth. This article
critically analyzes the concerned topics related to the
fracture resistance of teeth restored with dowelretained restorations. Methods: A systematic review
of PubMed/MEDLINE, Cochrane, and Scopus databases
was completed (from 1960 to 2010). Single or combined
key words were used to obtain the most possible
comprehensive list of articles. Checking the references
of the relevant obtained sources completed the review
along with a manual search to locate related articles
on the topic. In vivo and ex vivo (laboratory,
computer-based finite element, and photoelastic stress
analysis studies) investigations related to the topic
were included. Results: Many factors have been
proposed to influence the fracture resistance of postrestored teeth. Recognizing the significance of these
factors on the fracture resistance of teeth would aid in
choosing the suitable treatment modality for every individual case. Fracture resistance was improved if tooth
structure loss was limited, a ferrule was obtained,
a post with similar physical properties to natural dentine
was used, and adhesive techniques for post luting and
coronal restoration were used. Adhesively luted resin/
fiber posts with composite cores appear to be the best
currently available option in terms of tooth fracture
and biomechanical behaviour. Conclusions: Most
guidelines were based mainly on ex vivo studies and
to a lesser extent on limited in vivo studies. The lack
of long-term controlled randomized clinical studies
was the main hindrance to reaching a conclusive and
undisputable opinion regarding endodontic posts in
terms of tooth fracture and biomechanical behaviour.
(J Endod 2010;36:14391449)
Key Words
Endodontic post, failure modes, fracture resistance,
review
ndodontically treated teeth were claimed to be weaker and more prone to fracture
than vital teeth (1). Fennis et al (2) investigated 46,000 insurance claims and reported a higher incidence of tooth fracture among endodontically treated teeth. The
loss of water and collagen cross-linking might underlie the brittleness and weakness
of enododontically treated teeth (3, 4). On the other hand, some studies reported
that tooth substance of endodontically treated teeth had comparable biomechanical
and physical properties to vital teeth (57).
The loss of structural integrity is the main reason behind the vulnerability of
endodontically treated teeth and their reduced resistance to fracture (5, 8). Most
endodontically treated teeth suffer massive reduction in their structural stability
because of the great loss of coronal dental structure caused by caries, fractures, and
access preparations.
Tang et al (9) summarized the risks that increased the potential of tooth fracture
after endodontic treatment. The risks included loss of tooth structure, stresses attributed to endodontic and restorative procedures, access cavity preparation, instrumentation and irrigation of the root canal, obturation of the root canal, post canal
preparation, post selection, coronal restoration, and inappropriate selection of tooth
abutments for prostheses.
Vertical root fractures of endodontically treated teeth prepared to receive
endodontic posts were more frequent in the teeth of older patients and when dentine
thickness was reduced (10). In their review, Dietschi et al (11) concluded that changes
in tooth biomechanical behavior, tissue composition, and moisture after the loss of
tooth vitality and proper endodontic treatment were limited and negligible. However,
they found that teeth became weaker as they lost more coronal tissue because of caries
or restorative procedures.
Another possible reason behind their inferior resistance to fracture is the reduced
proprioception of endodontically treated teeth (12). Consequently, they will be subjected to more harmful forces without a protective reflex. Because of their inherent
weakness, endodontically treated teeth need to be restored in a manner that would
provide protection for the remaining tooth structure but would also allow the restoration of esthetic and functional demands (13).
The restoration of endodontically treated teeth should aim at increasing tooth fracture resistance especially in cases with extensive tooth destruction (13). Some
researchers recommended the use of posts for support and reinforcement of remaining
tooth structure. This claim was supported by the ability of posts to distribute stress in
a favorable way that would improve the fracture resistance of restored teeth (1419).
Salameh et al (17, 20) showed that endodontically treated teeth restored with fiber
posts and ceramic crowns were more resistant to fracture and had less catastrophic
fracture patterns than the ones restored with ceramic crowns and no posts. In
another study, Salameh et al (21) used porcelain fused to metal, Empress II (Ivoclar
From the *Department of Prosthodontics, University of Jordan, Amman, Jordan; and Riyadh Colleges of Dentistry and Pharmacy, Riyadh, Saudi Arabia.
Address requests for reprints to Dr Mahmoud AL-Omiri, BDS, PhD, FDS RCS, Department of Prosthodontics, Faculty of Dentistry, The University of Jordan, Amman
11942, Jordan. E-mail address: alomirim@yahoo.co.uk.
0099-2399/$0 - see front matter
Copyright 2010 American Association of Endodontists.
doi:10.1016/j.joen.2010.06.005
JOE Volume 36, Number 9, September 2010
Fracture Resistance of Teeth Restored with Post-retained Restorations
1439
Review Article
Vivadent, Schaan, Liechtenstein), SR Adoro (Ivoclar Vivadent, Noble
Park North, Victoria, Australia), and Cercon (Dentsply Ceramco,
York, PA) crowns to restore endodontically treated maxillary incisors
and reported similar conclusions as described previously regardless
the type of used crown. Also, Cagidiaco et al (18) and Ferrari et al
(19) showed that the placement of fibre posts did improve the survival
rate of endodontically treated premolars.
Furthermore, Nam et al (22) found that the fracture resistance of
endodontically treated premolars with one to four remaining coronal
walls was significantly increased when they were restored with fiber
posts. Moreover, teeth showed better stress distribution and fracture
patterns when restored with fiber posts. However, fracture resistance
of teeth with no remaining coronal walls was not improved when fiber
posts were used. Figure 1A through D presents some fracture modes
that associate metal, glass fiber, and carbon fiber posts.
When compared with no post treatment, Nothdurft et al (23) reported better fracture resistance of premolars with class II cavity preparations after they were restored with zirconia, fiber, or titanium posts.
They concluded that posts in premolars with class II cavities would
improve tooth resistance to the extra-axial forces. In another study, Nothdurft et al (24) reported no difference in fracture resistance of premolars with class II cavities restored with crowns alone or crowns and posts
(titanium, zirconium dioxide, glass fiber, and quartz fiber posts). From
these two studies, it can be concluded that the use of crowns might
cancel the effect of posts on fracture resistance of restored teeth.
On the other hand, many studies challenged the use of posts for
support and reinforcement of remaining tooth structure and even
considered post placement as a risk factor that weakened the remaining
tooth structure and predisposed tooth fracture. These studies showed
that restoring endodontically treated teeth using cast metal, prefabricated metal, or fiber posts had negative effects on teeth fracture resistance (2530). Unlike other modes of failure, root fracture of post
restored teeth is the most catastrophic and almost always results in
extraction of the involved tooth (27, 28). A higher incidence of
vertical root fractures was reported among teeth restored with
titanium, zirconia, and prefabricated/cast metal endodontic posts (26,
28, 31, 32). This was greatly attributed to stress concentration within
the radicular dentine during post placement and, consequently, the
altered pattern of stress distribution upon loading (3234).
Fokkinga et al (35) reported that the presence or absence of
metal/fiber posts did not affect the fracture resistance and failure modes
of endodontically treated premolar teeth with resin composite crowns
and no retained coronal tooth structure. Therefore, they suggested that
posts are not necessary for the restoration of such teeth. Also, Mohammadi et al (36) found no difference in fracture resistance of premolars
restored with direct resin composite in the presence or absence of fiber
post and cusp coverage.
Furthermore, Soares et al (29) found that the loss of dentinal
structures and the presence of fibre posts caused more stress concentration in tooth and restoration and decreased the fracture resistance of
teeth. However, they found that fiber posts were associated with less
catastrophic fracture modes when there was an extensive loss of tooth
tissues.
An in vitro study by Pilo et al (30) showed that endodontic therapy
for upper bifurcated premolars caused loss of more dentine at bifurcation area of both roots in comparison to outer areas. Furthermore, the
preparation of post canals undermined root strength because it left less
than the recommended 1-mm dentine thickness around the post canal.
Buccal roots were more affected by this pitfall. Therefore, they recommended limiting the use of posts in upper bifurcated first premolars,
and when necessary the posts should be used in lingual roots rather
than the buccal ones.
1440
Khaled AL-Omiri et al.
The literature is full of controversial conclusions regarding the

best post to use for the restoration of endodontically treated teeth.
This article critically analyzes the concerned topics and controversy
related to the fracture resistance of teeth restored with dowelretained restorations.
Methods
A systematic review of PubMed/MEDLINE (from 1960 to 2010),
Cochrane, and Scopus databases (to 2010) was completed. Single or
combined key words (fracture resistance, endodontic post and core,
fiber posts, adhesive luting, and endodontically treated teeth) were
used to obtain the most possible comprehensive list of articles. Checking the references of the relevant obtained sources completed the review
along with a manual search to locate the most relevant articles on the
topic. In vivo and ex vivo (laboratory, computer-based finite element,
and photoelastic stress analysis studies) investigations related to the
topic were included in this review. Because the number of long-term
randomized controlled clinical trials (RCTs) was limited in this field,
retrospective, prospective, descriptive, review, and RCT studies were
included. Studies describing post and core systems to restore endodontically treated teeth and their mechanical and physical properties were
included. Also, articles investigated fiber posts, ceramic posts, cast
posts, and prefabricated metal posts, and different core systems were
included. Furthermore, articles studied failure modes and fracture
resistance of teeth restored with different post and core systems were
included.
Results
Methods Used to Assess Stress Distribution and Fracture
Resistance of Post-Restored Teeth
Few RCT studies have investigated the fracture resistance of teeth
restored with post and core restorations. This might be attributed to the
difficulties encountered in controlling related factors clinically such as
force magnitude and direction, teeth geometry, and remaining tooth
structure (13). In vitro studies, on the other hand, are easier to control
and conduct, but their recommendations should be interpreted with
caution because of their limitations and conflicting results.
It is impossible to accurately simulate intraoral conditions by
in vitro studies (13). However, attempts were made to investigate fracture resistance of endodontically treated teeth restored with posts and
cores experimentally (37). Three methods have been frequently used
for this purpose including laboratory experiments, photoelastic analysis, and finite element analysis (13, 37).
Although most mechanical laboratory studies were aimed at investigating the failure loads and modes of restored teeth, photoelastic and
finite element analysis studies were used to investigate stresses within
restored teeth upon loading and the effect of post placement on stress
values and distribution (13).
Laboratory Experiments
Many mechanical studies were conducted to investigate the effect
of post placement and related factors on the fracture resistance of
endodontically treated teeth (38-43). Extracted teeth, especially
incisors and premolars, were used in these studies. Static loading at
a constant angle was applied to restored teeth in some studies (41,
44). However, actual masticatory forces are multidirectional and
repeatedly applied on larger areas (13). In order to mimic such conditions, cyclic loading was also applied in some studies (42, 43, 45).
Hayashi et al (46) applied simultaneous static and cyclic loading to
restored teeth in both horizontal and vertical directions and reported
that teeth restored with fiber posts and composite cores were more
Review Article
Figure 1. A catastrophic coronal dentine-core-root vertical fracture. (A) A catastrophic horizontal root fractureassociated prefabricated metal post. (B) A favorable core fracture-associated fiber post. (C) A catastrophic core and root fractureassociated carbon fiber post. (D) A prepared post canal for a glass fiber post.
(E) Note the oval shape of the root canal cross-section and the rounded cross-section of the post canal. There was no need for further preparation of the canal to
improve post fitting.
resistant to fracture than those restored with metallic posts (46). Also,
Hu et al (47) applied static and cyclic loading to teeth restored with cast
metal posts, resin composite posts, and carbon fiber posts and found
that teeth restored with carbon fiber posts were resistant to more
load cycles, whereas cast metal posts required the highest fracture
loads. However, resin composite posts were associated with favorable
root fractures, whereas all cast metal posts and carbon fiber posts
were associated with unfavorable root fractures (47).
Strain gauges were used to calculate stresses within examined teeth
models. However, this method may need complex mathematical calculation and is limited by the number of gauges that can be placed on the
model (48). Experimental studies in general have many limitations. The

strength of dentine varies according to age, pulpal condition before
extraction, and the storing media, which may affect the fracture patterns
(13). Resins and stones are commonly used for mounting teeth during
testing (4951). They set by the exothermic reaction, which may affect
the dental structures (52). Moreover, despite researchers attempts to
reproduce the resiliency of periodontal ligament and bone, they could
not provide the correct actual resiliency of these structures. Some
experimental studies applied forces directly on the post head or the
core, which is commonly not the case clinically (49, 50, 53). This
may produce misleading and contradictory results. Naumann et al
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Review Article
(54) highlighted the lack of standardization of test parameters applied
for in vitro studies of fracture resistance of teeth restored with
endodontic posts. They found that 95% of studies used static loading,
and only 15% of the studies used thermocycling and mechanical loading
to test fracture resistance of teeth restored with endodontic posts.
Furthermore, different studies used different teeth, and 57% of the
studies used upper incisors only. Also, most studies used specimens
without crowning. Therefore, the different test parameters and standards might be the reason behind the controversy surrounding the issue
of fracture resistance of teeth restored with endodontic posts.
Photoelastic Stress Analysis

Photoelastic models were used to study the effect of post placement and related factors on the patterns of stress distribution within
endodontically treated teeth (5557). Photoelasticity is the property
of transparent materials to exhibit colorful patterns known as
fringes when stressed under polarized light (55). A transparent
double-refraction plastic sheet is used to fabricate specimens for
two-dimensional photoelastic stress analysis (57). Stress concentration
areas can be identified according to the sequence of color bands of the
fringes. Three-dimensional photoelastic models are less frequently used
because of the difficulty of their construction and their high cost (55).
Photoelastic methods provide visual evidence of stress patterns
within tested models. However, the properties of photoelastic materials
are different from those of tooth structure, and the modeling of objects
made of more than one material is technically difficult (13).
Finite Element Method
The finite element method (FEM) has been frequently used for
stress analysis in many aspects of dentistry. Many studies used the
FEM to investigate the effect of post placement and related parameters
on the stress picture within dowel-restored teeth (34, 5865).
Models are simulated using a computer and subdivided into a finite
number of smaller divisions termed elements. Material properties,
boundary conditions, and loads are then assigned for the elements.
Stress analysis is then performed by solving differential equations of
elements to quantify stresses generated within these elements.
FEM offers the advantages of easy simulation of nonhomogenous
models and easy changing of parameters like material properties and
loading conditions (58). However, material properties, loading conditions, and boundaries simulated do not represent the absolute clinical
situation that constitutes a limitation for the application of this method
(13).
Stress Distribution Within Post-Restored Teeth and Its
Relation to Fracture Resistance
Viscoelastic properties of a tooth structure affect stress distribution within the tooth. If viscoelastic properties are undermined, the
tooth will be mechanically compromised in terms of stress distribution,
values, and concentration. Root canal treatment and post and core
restorations are examples of conditions in which tooth viscoelasticity
is reduced and this might be the reason why teeth are more liable to
fracture (66). Post insertion alters the pattern of stress distribution
within root dentine (37). Different posts affect the stress picture in
post-restored teeth differently, which will be discussed in the following
sections. Upon loading, teeth restored without post insertion show
a concentration of stresses at the circumference of the tooth with
uniform stress distribution within the root canal (67). Post insertion
results in a nonuniform distribution of dentinal stresses within the
root (68). Upon functional loading, critical stress concentration areas
are produced at the post-dentine interface that precipitates microcracks
1442
within the root. These microcracks grow and propagate to cause fatigue
failure and unrestorable root fractures (32, 63). The coronal third of
the root has been reported as the main site of stress concentration
(69, 70).
The inner dentine of the root is usually less mineralized and
possesses more water content than the outer dentine (71). Therefore,
the inner dentine has a higher potential for plastic deformation and
crack formation. Using experimental and clinical investigations, Kishen
et al (72) examined fractured post and core restored teeth using laser
scanning confocal microscopy and scanning electron microscopy and
observed numerous microcracks within the inner dentine material
adjacent to the endodontic post. They also used FEMs of dentine to
relate crack formation and root fractures to tensile stresses generated
within dentine. High strains were generated within the inner dentine
substance upon tensile loading. They, among other researchers,
concluded that crack formation and fracture progression in postrestored teeth were initiated from the inner region of dentine (72
74). Thickness of the inner dentine and factors related to the postdentine interface seem to play a major role in stress distribution and
fracture resistance of endodontically treated teeth. Therefore, the
removal of inner dentine during post placement should be minimized
as much as possible to maintain adequate fracture resistance of
dowel-restored teeth (72).
Factors That Affect the Fracture Resistance of PostRestored Teeth

Many factors influence the fracture resistance of post-restored
teeth. Some factors are directly related to the post-core system including
post length, post diameter, post design, post material, post fitting, core
material, ferrule effect, and luting cement (13). Other factors are
related to the restored tooth and include cuspal coverage, remaining
coronal tooth structure, loading conditions, and alveolar bone support
(13, 15). The effect of these factors on the fracture resistance of dowelrestored teeth will be discussed in details throughout the following
sections.
Post Length
Stress analysis studies showed better stress distribution within
dentine when longer metal, fiber, or zirconia posts were used (65,
75). Similarly, increased fracture resistance was associated with
increased post length (15, 76). Longer posts provide greater rigidity
and less root bending than short posts (13). An endodontic post should
extend beyond the level of alveolar bone to provide better root support
(77).
Davy et al (75) reported a decrease in cervical stresses when the
post length was increased up to two thirds of the root length. However,
increasing the post length beyond two thirds of the root may cause stress
concentration at apical area of the root meanwhile provide no additional support for the cervical region (78). Burns et al (79) reported
minimal effects of the post length on stress distribution within dentine.
Other studies supported this finding and found no effect of the post
length on fracture resistance of restored teeth (45, 80, 81). Giovani
et al (82) found no effect of post length on the fracture resistance of
teeth restored with metal cast post and core. However, they showed
significantly higher fracture resistance for teeth restored with longer
glass fiber posts (10-mm long) when compared with shorter ones
(6-mm long). On the other hand, Cecchin et al (83) found that longer
fiber posts (12- or 8-mm long) were associated with higher fracture
resistance of teeth when compared with shorter ones (4-mm long).
However, they concluded that too much preparation to get the longest
post space was not essential for better fracture resistance of postJOE Volume 36, Number 9, September 2010
Review Article
restored teeth. In their study, posts that were just above half of root
length (8-mm long) were enough to improve the root fracture resistance and were similar to posts that were two thirds of the root length
(12-mm long). Adhesive fixation of the post and ferrule incorporation
might decrease the effect of post length on the fracture resistance of
dowel-restored teeth (45, 81, 84).
In conclusion, the optimum post length depends on several factors
including root length, crown height, level of bone support, and technique of cementation. Adhesive cements, ferrule effect, and full coronal
restoration may reduce the effect of post length on the tooth fracture
resistance (77, 84).
Post Diameter
A smaller post diameter is recommended to retain more dentine
during preparation of post channel, which enhances the fracture resistance of dowel-restored teeth (39, 85). The ability of a tooth to resist
fracture is directly related to the amount of remaining dentine
around the post (39, 86). Increased radicular dentinal stresses were
observed when a post diameter was increased (58, 87). The larger
the post diameter the less the fracture resistance of a dowel-restored
tooth (39).
Recommendations regarding the adequate amount of radicular
dentine around a post vary among researchers. One third of the root
width was recommended as the higher limit for the post diameter
(52). Some researchers suggested the preservation of 1 mm of sound
dentine around the post channel (25). Halle et al (88) recommended
the preservation of more radicular dentine and suggested that 1.75 mm
retained dentine around the post was sufficient to resist fracture of the
tooth. In order to reduce failures and fractures, Mou et al (89) recommended that the optimum post to root diameter ratio should be approximately 1:4.
Post Design
Tapered metal posts cause greater cervical stress concentration
than parallel-sided posts (75, 90). This was attributed to the wedging
effect introduced by tapered posts. Apical stresses, on the other
hand, tend to be higher when parallel-sided posts are used (91).
This was attributed to the sharp angles and reduced tooth structure
at the apical area. A higher incidence of root fracture was reported
when tapered posts were used (50).
Threaded metal posts were associated with stress concentration at
the dentine-thread interface. Such areas can predispose crack formation and jeopardize the fracture resistance of dowel-restored teeth
(92). Decreasing the number of threads and increasing the spaces
between them produces less harmful stresses (93). Prethreading the
post cavity and slight counter rotation of the post after engagement
may also reduce the harmful stresses produced by threads (48). There
are no clinically available threaded fiber posts. However, Uddanwadiker
et al (94) proposed a finite model of threaded fiber post and found
increased stress concentration because of this post, which reduced
the fracture resistance.
Among various post designs, tapered threaded metal posts were
reported as the most hazardous to the fracture resistance of dowelrestored teeth. Likewise, parallel serrated posts were the most favorable
in this regard (14). Silva et al (95) compared four different metal posts
to glass fiber posts and found better stress distribution within the teeth
restored with glass fiber post. Furthermore, they found more stress
concentration at the coronary portion of metal posts. They concluded
that post material was more important for stress distribution than the
external characteristics of the post. On the other hand, Signore et al
(96) found that the survival rate of parallel-sided glass fiber posts
was more than that recorded for tapered ones over up to 8 years of function.
Post Material
The mechanical properties of materials used for post construction
as well as their biocompatibility may influence the fracture resistance of
restored teeth. Posts with higher modulus of elasticity like metals are
associated with higher failure loads (52, 97103). However, they
tend to cause catastrophic and irreparable root fractures when they
fail (97, 98, 100, 101, 104106). Being more rigid than the tooth,
high modulus elasticity posts produce stress concentration at critical
areas of the root and cause more fractures (58, 63). Unlike rigid
posts, posts with a similar modulus of elasticity to dentine (eg, fiber
posts) can distribute stresses more evenly along the post-dentine interface and cause less root fractures (56, 58, 63, 107).
Materials with a low modulus of elasticity bend more under load
and tend to fail before causing root fracture (108110). This
constitutes a protective mechanism for the tooth structure. Many
studies showed high clinical survival and success rates for teeth
restored with fiber posts (111113). The vast majority of failures
were attributed to causes other than catastrophic tooth fracture.
Cagidiaco et al (110) concluded that fiber posts outperform metal posts
in treatment of root canal treated teeth. However, in a randomized
controlled clinical pilot study; Naumann et al (114) compared the clinical performance of titanium and fiber posts for 2 years and reported
similar successful clinical outcomes for both treatments.
Many studies showed better fracture resistance of teeth restored
with fiber-reinforced resin posts (which had a similar rigidity to
dentine) when compared with metal or zirconia posts (which had
a much higher modulus of elasticity than dentine) (45, 82, 98, 106,
115117). Cast posts and cores were frequently associated with deep
catastrophic root fractures (27, 28, 97, 118).
Nevertheless, Newman et al (119) and Toksavul et al (120) reported that less fracture resistance and more catastrophic root fractures
were associated with glass fiber posts when compared to zirconium
posts. Stockton and Williams (121) suggested that fiber post flexibility
might cause stress redirection toward the post-tooth interface and thus
increase the failure rate. Furthermore, some studies reported no significant difference in fracture resistance of restored teeth when fiberreinforced resin or metal posts were used (118, 122, 123).
Moreover, Fokkinga et al (123) found similar fracture patterns and
behaviors of premolars restored with metal crowns when either metal
or fiber posts were used. Also, Nothdurft et al (23) reported no difference in fracture modes and patterns when either titanium, quartz fiber,
glass fiber, or zirconium dioxide posts were used to restore premolars
with class II cavity. Furthermore, Toman et al (124) found that teeth
restored with resin cemented silica-coated titanium posts and
composite cores had higher fracture resistance than teeth restored
with resin-cemented zirconia or glass fiber posts (with or without silica
coating) and composite cores.
Corrosion resistance of post material may influence the fracture
resistance of restored teeth. Metal posts were found to corrode overtime
(125). It was proposed that corrosion products could migrate through
the dentinal tubules and build up intratubular pressure, which predisposed root fractures (13). Titanium posts have high corrosion resistance when compared with other metal alloys. Brass alloys, on the
other hand, have very low corrosion resistance (13).
The storage of fiber posts in saline water reduces their fracture
strength and causes voids between the resin matrix and fibers (126).
However, this does not occur if fiber posts are stored at in a condition
in mineral oil or in human teeth in saline water. This finding might
1443
Review Article
explain some of the controversy found in the literature because different
storage conditions used in different studies might affect fiber post fracture strength differently and thus affect the results.
Post Fitting
Goracci et al (127) concluded that sliding friction was the main
factor that affected resistance to dislocation of resin-bonded fiber posts.
Also, the use of dentine adhesive did not improve dislocation resistance
when compared with the use of resin cement without dentine adhesive.
The presence of interfacial gaps and the incomplete removal of smear
layer might be the reason for these findings.
Poorly fitted posts might create levers within the root canal,
making the tooth more liable to fracture (128). Close adaptation of
posts to the canal walls was found to increase the fracture resistance
of restored teeth significantly (50). Santos et al (129) showed that lacking effective bonding between the root and posts with different elastic
modulus was associated with a higher risk of vertical root fracture in
upper premolars. Schmitter et al (81) concluded that when fiber
post-restored teeth were crowned, centrally positioned fiberreinforced posts did not contribute to load transfer as long as the
bond between the tooth and composite core was intact and resin cement
was used to bond the fiber post.
Buttel et al (76) found that the fracture resistance of teeth restored
with fiber posts and composite crowns without ferrules was not affected
by post fit within the root canal. Therefore, excessive post canal preparation to achieve optimal circumferential post fit is unjustifiable
because it will not increase fracture resistance of teeth. Figure 1E presents adequate post canal preparation when the cross-section of the root
is oval.
Core Material
Less stiff cores are expected to deform under occlusal loads and
thus reduce the stress concentration within the dentine (108).
Composite resins were reported to fracture under loads lower than
those necessary to fracture the tooth (130). This is considered as
a protective mechanism for tooth structure. Cast metal posts and cores
were associated with more root fractures than prefabricated posts and
amalgam or composite cores (131). However, crown placement with
adequate ferrule can mask the effect of core build ups on the fracture
resistance of restored teeth (132135). This was attributed to the fact
that a crown restoration could favourably distribute stresses and
redirect them toward the root (90,134).
Coating zirconia posts with tribochemical silica coating and silanization increases their fracture resistance and the bond strength to
composite resin (136). When compared with no airborne particle abrasion of the post surface, better long time bond strength to composite
cores was recorded when zirconia posts were abraded using airborne
particle abrasion and received primer and silane coupling agent to their
surface (137).
Fiber post surface can be treated by silane coupling agents or
bonding agents to improve their bond to composite resins (138). Better
bond strength was recorded when silane coupling agents were used.
Treatment of the fiber post surface with hydrogen peroxide before silanization increases the bond strength to composite cores more than
using silane coupling agent alone (139). This might be caused by the
dissolution of epoxy resin matrix of the post, which enhances better
surface characteristics.
Monticelli et al (140) concluded that surface conditioning
enhanced fiber post bonding properties. Also, the bond strength of pretreated fiber posts to composite cores was satisfactory. However, thermocycling reduces the bond strength between fiber posts and
1444
composite cores regardless of the pretreatment of the post surface

(141).
Radovic et al (142) found that sandblasting increased the microtensile bond strength between composite cores and fiber posts. Furthermore, they reported no benefit from further chairside treatment (ie,
application of silane or bonding agent) of the sandblasted post surface
because this was associated with a reduction rather than an improvement of bond strength. The use of fiber posts improved the flexural
properties of core composite resin regardless of the fiber direction
in the fiber post (143).
When the post surface was treated with bonding agents before the
addition of the composite core, Artopoulou et al (144) recorded less
adhesive failures between fiber posts and composite cores than that
between composite cores and a titanium or stainless steel post.
However, the lack of pretreatment of the post surface was associated
with better retention between metal posts and composite cores than
between fiber posts and composite cores.
Core materials on titanium posts had better resistance to torsional
forces when the post surface is treated with chemical surface conditioning techniques such as silica coating (145). The bond between
core material and the fiber post is chemical, and this increases the
retention of cores when fiber posts are used. For stability, a reliable
bond between the core material and the post should be generated.
Schmitter et al (81) concluded that centrally positioned fiberreinforced posts did not contribute to load transfer as long as the
bond between the tooth and composite core was intact.
Ferrule Effect
The ferrule concept was proposed by Rosen (146) in 1961. He
recommended the use of a metal collar extension beyond the gingival
margin of the core to encircle the tooth. The ferrule effect in association
with post and core treatment was investigated by many researchers (47,
147-150). Most of the previous studies were performed in vitro and
generally have accepted that ferrules incorporated within cores or
final crowns might increase the fracture resistance of restored teeth
by reinforcing their external surfaces to resist stresses accompanied
by functional lever forces. Ferrules also help to maintain the integrity
of cement seal around the restoration (151).
Opinions vary regarding the optimum height and design of
adequate ferrule. However, most researchers recommended
a minimum 1- to 2-mm of ferrule height of almost parallel dentine walls
at the whole circumference of the tooth (47, 152). The higher the
ferrule the greater the fracture resistance (151). A uniform height of
the ferrule at the whole tooth circumference was recommended
because it was found more effective in supporting the tooth than
a nonuniform height (150). Al-Omiri and Al-Wahadni (99) reported
that retaining coronal dentine did increase the fracture resistance of
teeth. However, they found that increasing the amount of retained
dentine more than 2 mm did not improve the tooth fracture resistance
any further. Schmitter et al (81) concluded that increased ferrule height
and resin bonding of the crown resulted in higher fracture loads of
teeth. They recommended the use of resin-bonding agents with crowns
that had a small ferrule height. Also, Dorriz et al (153) recommended
the use of ferrule or bonding with an opaque porcelain layer (if cast
metal post was used) to improve the fracture resistance of grossly
destroyed teeth.
Despite the large number of studies that supported the use of
ferrules, some researchers questioned the benefit of ferrules because
they did not provide additional support for restored teeth (50, 104,
135, 154, 155). Saupe et al (104) and Al-Hazaimeh and Gutteridge
(154) concluded that the use of resin cements in their studies might
Review Article
have cancelled the effect of ferrule on the fracture resistance of restored
teeth. These findings were also supported by Mezzomo et al (155) who
reported no significant difference in fracture resistance of nonferruled
specimens restored with resin-cemented posts and ferruled ones. When
zinc phosphate cement was used, ferruled specimens showed significantly higher fracture resistance than nonferruled ones. Moreover,
Ng et al (156) reported a higher incidence of root fracture among teeth
restored with bonded posts and cores when ferrules were incorporated.
Also, Naumann et al (157) found that incomplete ferrules (that does not
encircle 360 of the tooth) were associated with better tooth fracture
resistance when compared with ferrules that totally encircle the tooth.
They concluded that tooth structure preservation is more important for
the fracture resistance of post-treated teeth. The findings of these studies
underlie that the incorporation of ferrules in conjunction with resincemented posts for the sake of tooth reinforcement might constitute
an unjustifiable insult to the remaining tooth structure.
The invasion of the biological width during tooth preparation
should be avoided (5). This creates a dilemma in cases in which no
adequate height of tooth structure is remained above the crestal bone
for the incorporation of a ferrule. Surgical crown lengthening and
orthodontic extrusion of the tooth may help in the establishment of
adequate ferrules in such cases (151). Besides patient discomfort, extra
cost and time are required for such procedures. Moreover, surgical
crown lengthening is accompanied by the reduction of the effective
root length, which affects the crown:root ratio negatively. Gegauff
(158) investigated the effect of crown lengthening for ferrule purposes
on the failure loads of simulated analog teeth restored with post- and
core-retained crowns impeded within simulated periodontal ligament
and alveolar bone. He reported significantly lower failure loads of teeth
that received crown lengthening and ferrules. The reduction of supporting tissues combined with the altered crown:root ratio seemed to
weaken the restored teeth even with the incorporation of ferrules.
The literature lacks retrospective and prospective clinical studies
that investigated the ferrule effect. Torbjorner et al (27) reviewed
records of 72 failed metal posts and observed more post fractures in
cases in which a ferrule was not incorporated. However, Cagidiaco et
al (18) and Ferrari et al (19) found no role for ferrule effect on the
survival of premolar teeth restored with fiber posts and composite
cores. This could be caused by the effect of resin cements used for
the cementation of fiber posts and the close similarity between the
values of the elastic modulus of fiber posts/resin cements and the elastic
modulus of dentine and thus obtain favorable stress distribution. Crown
coverage might also explain these results because it directs the load to
tooth finish line and bypasses the post-core assembly and thus directs
stress towards the outer surface of the tooth and prevent tooth fracture.
More controlled clinical follow-ups are required to reach sound
conclusions regarding the ferrule effect and its proposed benefits.
Nevertheless, the available literature favors the incorporation of a ferrule
for final restorations. However, this should be in balance with the
remaining tooth structure and crown:root ratio (11, 151).
Luting Cement
The luting cement provides a buffer zone between the post and the
dentine, which might affect stress distribution upon loading (1). Brittle
conventional cements like zinc phosphate may disintegrate upon functional loading and cause levers that concentrate stresses at the apical
root portion and cause root fracture (159). Using adhesive cements
allows even stress distribution over the entire bonded surfaces. Consequently, a post can absorb functional stresses and then direct them
toward the long axis of root and thus make them more favourable
(118). Spazzin et al (107) found that cements with a higher elastic
modulus caused higher stress concentration within the cement layer.

Also, cement thickness did not affect stress distribution within the
post, dentine, or cement layer.
Previous studies concluded that resin-based cements could
increase the fracture resistance of dowel-restored teeth (49, 104,
154, 155, 160). Teeth restored with posts luted with resin cements
were found more resistant to fracture than teeth restored with posts
luted with zinc phosphate or glass ionomer cements (49, 155, 161).
According to these studies, the favorable behaviour of fiberreinforced resin posts might be related to the resin cements frequently
used to lute them rather than to the post material itself.
In order to obtain favorable stress distribution, the monoblock
type of restoration was recommended for the restoration of pulpless
teeth (162). This treatment involves restoring the tooth with post,
core, and crown using biomechanically homogenous bonded materials
and adhesive techniques. However, it proved difficult to predict or
achieve this because it is difficult to clean the smear layer from the
root, to remove the water droplets and moisture from the root, and
to use post and cement materials that do not shrink and have moduli
of elasticity that match the dentine (163). The technique of cementation
might also affect the fracture resistance of restored teeth (13). Residues
within a post space, bubbles within the cement layer, and excessive
seating pressure can cause stress concentration within the root and
predispose fracture (13).
Dietschi et al (164) recommended the use of specific combinations of adhesives and cements to overcome the problems of ovoid canal
shape and dentine moisture that might reduce the efficacy of adhesion
between the tooth and the post. Also, Kivanc and Gorgul (117)
concluded that self-etching adhesives were better to use than etch
and rinse adhesives for luting endodontic posts. An increased ferrule
height and resin bonding of a crown resulted in higher fracture loads
of post-restored teeth (81). Finally, Hammad et al (165) concluded
that the obturation of roots with resin-based obturation materials
increased the resistance of teeth to vertical root fracture.
Coronal Coverage
Crowning endodontically treated posterior teeth and badly
damaged anterior teeth increases their resistance to fracture, whereas
crowning endodontically treated anterior teeth with intact coronal
structure does not improve their fracture resistance (13, 166, 167).
Artificial crowns alter the distribution and transmission of stresses
into a post-root complex (90, 134, 168). Providing a crown with
adequate ferrule has more influence on the fracture resistance of
dowel-restored teeth than factors related to post and core materials
and designs (134, 169). DArcangelo et al (170, 171) suggested the
use of fiber posts when veneer restorations were used to restore
endodontically treated teeth because they found that fiber posts
increased the fracture resistance of endodontically treated teeth
prepared for or restored with composite or porcelain veneers.
Remaining Coronal Tooth Structure
Some studies suggested that fracture resistance of post-restored
teeth would be reduced if more coronal dental structures were lost
(13, 73, 172, 173). In a retrospective long-term clinical study, Ferrari
et al (112) concluded that the mechanical failure of teeth restored with
fiber posts was related to the remaining coronal tissues. Similar results
were reported in a follow-up clinical trial by Cagidiaco et al (110).
Nam et al (22) found that the fracture resistance of endodontically
treated premolars with one to four remaining coronal walls was significantly increased when they were restored with fiber posts. Moreover,
teeth showed better stress distribution and fracture patterns when
1445
Review Article
restored with fiber posts. However, fracture resistance of teeth with no
remaining coronal walls was not improved when fiber posts were used.
However, the relation between remaining coronal dentine and fracture
resistance has been questioned by other researchers especially when
coronal coverage was provided because this might mask the effect of
the retained tooth structure (104, 154, 174).
Loading Conditions
The magnitude and direction of functional loads play a major role
in stress concentration within dowel-restored teeth. Higher occlusal
forces, like in cases of parafunctional habits, were associated with
higher failure rates of such teeth (175177). Horizontal loads cause
a significantly higher stress concentration within dentine than loads
more parallel to the long axis of the tooth (64, 90, 91, 148, 168,
178181). The effect of load direction on maximum stresses
generated within restored teeth was found to be more significant than
the effect of post design and dimensions (64, 90). Because of their
inclination, anterior teeth are most likely subjected to more
horizontally directed loads (13, 177). Post insertion would magnify
stresses produced within dentine upon such loads (64). This is the
reason behind the conception that the preservation of the coronal tooth
structure of endodontically treated anterior teeth is more effective for
tooth support than post insertion (13).
Meira et al (182) found that the effect of the elastic modulus of
a post on concentration, magnitude, and direction of dentinal stress
was dependent on load direction. They showed that when highmodulus posts were modeled, horizontal loads caused more stress
on the apical area of roots and such a load suggested a vertical root fracture. On the other hand, they found that forces at 45 and 90 caused
more stress on the cervical area when low-modulus posts were
modeled; such loads suggested debonding of the post.
Alveolar Bone Support
A lower fracture resistance was reported among roots of periodontally compromised teeth reconstructed with posts and cores
(183). Naumann et al (184) concluded that the reduction of the level
of bone support would reduce the fracture resistance of fiber posts
restored teeth.
Alveolar bone level is considered a critical factor for stress
concentration and tooth fracture (185). Finite element studies reported
massive increase in dentinal stresses as the alveolar bone level was
diminished (91, 180). The loss of alveolar support will lower the
level of the mechanical fulcrum, which in turn will jeopardize the
fracture resistance of post restored teeth (158, 186).
In order to obtain adequate fracture resistance, at least 1:1
crown:root ratio should be ensured and the post should extend beyond
the level of alveolar bone (77). Surgical crown lengthening can reduce
the crown:root ratio and predispose tooth fracture. Gegauff (158) reported significantly lower failure loads of teeth that had crown lengthening even with the presence of a ferrule.
Conclusions
The fracture resistance of post-restored teeth has been investigated
thoroughly in the literature. Previously, the argument was in favor of reinforcing the teeth by endodontic posts. Nowadays, there is a general
agreement among researchers that posts per se do not offer reinforcement for restored teeth; on the contrary, their insertion involves procedures that usually sacrifice tooth structure and reduce the fracture
resistance of teeth. Unrepairable root fractures have been frequently reported as the most catastrophic mode of failure that was associated with
post placement, especially when rigid posts were used.
1446
The last 2 decades have witnessed a shift toward studying the effect
of different post and core systems on the fracture resistance of dowelrestored teeth. Variety of available posts and introduction of new
non-metal post systems have greatly contributed to the large number
of available studies that handled this topic. Recently, a new shift occurs
again in favour of using such posts as they are believed to even improve
the fracture resistance of endodontically treated teeth when compared
with no post treatment. However, this new tendency lacks enough
evidence from long term randomized controlled clinical studies to set
this trend as the standard of future treatment of endodontically treated
teeth.
In order to avoid weakening of teeth by post placement, many post
features were thoroughly investigated. Because of the lack of long-term
controlled clinical trials and the contradictory results of in vitro
studies, the optimum post features are not yet clearly determined.
It is important to keep in mind that the restoration of teeth using
posts does involve a system that consists of post, core material, and
luting cement. The overlying crown and functional occlusal loads are
added to this system because they all influence the success of the whole
treatment. Therefore, it is less realistic to test fracture resistance of postrestored teeth without including the effect of coronal coverage, the
direction and magnitudes of masticatory forces, and the cyclic nature
of functional loads. Failing to consider all this might be the reason
behind the contradiction regarding the best post core luting agent to
use in order to reduce tooth fracture or even strengthen the endodontically treated tooth.
The treatment of endodontically treated teeth using posts might be
more successful if tooth structure loss is limited, a ferrule is obtained,
a post with similar physical properties to natural dentine is used, and
adhesive techniques for post luting and coronal restoration are used.
Therefore, when the advantages and disadvantages of different luting
agent-post-core systems and materials are considered, the adhesively
luted resin/fiber posts with composite cores appear to be the best
offered luting agent-post-core system currently available in terms of
tooth fracture and biomechanical behaviour.
It is essential to keep in mind that these guidelines are based
mainly on ex vivo studies and to a lesser extent on limited in vivo
studies. A lack of long-term controlled randomized clinical studies is
the main hindrance to reaching a conclusive and undisputable opinion
regarding endodontic posts in terms of tooth fracture and biomechanical behavior.
Acknowledgment
The authors thank Mrs AbdelAziz for all her help during the
preparation of this manuscript.
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Review Article

Fracture Resistance of Teeth Restored with Post-retained

JOE Volume 36, Number 9, September 2010

Fracture Resistance of Teeth Restored with Post-retained Restorations

Khaled AL-Omiri et al.

The literature is full of controversial conclusions regarding the

JOE Volume 36, Number 9, September 2010

model (48). Experimental studies in general have many limitations. The

Fracture Resistance of Teeth Restored with Post-retained Restorations

Photoelastic Stress Analysis

Khaled AL-Omiri et al.

Factors That Affect the Fracture Resistance of PostRestored Teeth

Khaled AL-Omiri et al.

composite cores regardless of the pretreatment of the post surface

modulus caused higher stress concentration within the cement layer.

Khaled AL-Omiri et al.

JOE Volume 36, Number 9, September 2010

JOE Volume 36, Number 9, September 2010

Fracture Resistance of Teeth Restored with Post-retained Restorations

Khaled AL-Omiri et al.

102. Ozcan M, Valandro LF. Fracture strength of endodontically-treated teeth restored

JOE Volume 36, Number 9, September 2010

JOE Volume 36, Number 9, September 2010

Fracture Resistance of Teeth Restored with Post-retained Restorations

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