RESEARCH AND EDUCATION

Influence of remaining coronal tooth structure on fracture

resistance and failure mode of restored endodontically treated
maxillary incisors
Domingo Santos Pantaleón, DDS, MSD, PhD,a Brian R. Morrow, MS,b David R. Cagna, DMD, MS,c
Cornelis H. Pameijer, DMD, MScD, DSc, PhD,d and Franklin Garcia-Godoy, DDS, MS, PhDe

ABSTRACT
Statement of problem. Limited information is available on the effect of an incomplete ferrule because of the varying residual axial wall
heights and the volume of residual tooth structure on the fracture resistance of endodontically treated and restored maxillary incisors.
Purpose. The purpose of this in vitro investigation was to examine the effect of varying residual axial wall heights, residual coronal tooth
structure, and the absence of 1 proximal axial wall on the fracture resistance and failure mode of endodontically treated teeth restored with
metal posts.
Material and methods. Sixty intact human maxillary central incisors were divided into 6 groups (n=10): no ferrule (NF), 2-mm complete
ferrule (CF2), 2-mm (IF2), 3-mm (IF3), and 4-mm (IF4) incomplete ferrules missing a single interproximal wall, and a control group that
had a 6-mm incomplete ferrule (IF6). Cast metal post-and-cores were placed in all experimental specimens except for controls. Control
specimens received 1 interproximal cavity preparation extending to the root canal access and a composite resin restoration. Complete
metal crowns were then cemented on all specimens. Completed specimens were subjected to thermocycling (6000 cycles, 5 C/55 C)
followed by the immediate testing of fracture resistance. Failed specimens were sectioned buccolingually and evaluated to identify the
failure mode. The data were analyzed with an analysis of variance (ANOVA) and the Student-Newman-Keuls multiple comparison test (a=.05).
Results. An incomplete ferrule (IF2) with 1 interproximal wall missing had significantly reduced fracture resistance (697 N) compared with a
complete ferrule (932 N). An increase of 3 to 4 mm of remaining wall height improved fracture resistance, from 844 N (IF3) to 853 N (IF4).
Partial decementation was noticed in 8 NF and 5 IF2 specimens. IF3 and IF4 had no decementations. Radicular fractures and cracks (cata-
strophic failure) were observed in all IF2, IF3, and IF4, 9 CF2, and 6 NF specimens. In 7 specimens without posts (IF6, control), composite resin
foundation and/or coronal dentin fracture were observed and the failure was considered repairable.
Conclusions. The results of this in vitro study indicated that specimens with a 2-mm ferrule of uniform height were more resistant to fracture
than specimens with a 2-mm ferrule and 1 missing interproximal wall. An increased wall height of 3 or 4 mm was associated with a significant
increase in fracture resistance and can compensate for the missing interproximal wall. (J Prosthet Dent 2018;119:390-6)

Endodontically treated teeth are often more susceptible and the endodontic treatment itself.1,2 The choice of an
to fracture than are vital teeth because of the loss of appropriate restorative technique for endodontically
structural integrity secondary to the loss of enamel and treated maxillary incisors is determined by the amount of
dentin caused by caries, fractures, previous restorations, dental structure remaining, and by esthetic and

Partially funded by the Dominican Republic Ministry of Higher Education Science and Technology (National Fund for Innovation, Scientific and Technological
Development; code 2014-2A4-010).
a
Adjunct Professor, School of Dentistry, Autonomous University of Santo Domingo, Santo Domingo, Dominican Republic.
b
Research Associate, Department of Bioscience Research, College of Dentistry, University of Tennessee Health Science Center, Memphis, Tenn.
c
Professor and Associate Dean for Postgraduate Affairs, Director of the Advanced Prosthodontics Program, Department of Prosthodontics, College of Dentistry,
University of Tennessee Health Science Center, Memphis, Tenn.
d
Professor Emeritus, Department of Reconstructive Sciences, University of Connecticut, Farmington, Conn.
e
Professor and Senior Executive Associate Dean for Research, College of Dentistry, University of Tennessee Health Science Center, Memphis, Tenn; and Honorary
Professor, School of Dentistry, Autonomous University of Santo Domingo, Santo Domingo, Dominican Republic.

390 THE JOURNAL OF PROSTHETIC DENTISTRY

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March 2018
Clinical Implications
A ferrule missing a single interproximal axial wall
can be compensated for if more than 3 mm of the
height of the remaining walls can be preserved. This
increases the fracture resistance of endodontically
treated maxillary central incisors.
functional considerations.3-7 Because endodontically
treated teeth may have insufficient residual coronal
structure, the placement of a post-and-core is often
indicated.8-13 An important function of the post-and-core
is to retain the coronal restoration and favorably
distribute applied forces to the residual tissues.14-18 Peroz
et al19 conducted a systematic review and concluded that
the amount of residual tooth structure was more critical
than the post length in preventing tooth fracture.
Traditionally, the presence of a ferrule on sound tooth
structure has been suggested.19,20 The ferrule effect is
developed by preparing residual coronal tooth structure
to near-parallel axial walls traversing the circumference
of the tooth. In so doing, placement of the definitive
complete crown is said to provide resistance to the
development of internal stress upon loading that can lead
to catastrophic failure.20 An appropriately developed
ferrule may reduce the stress within the tooth structure,
thus helping to maintain the integrity of the sealing
cement and also reducing the stress between the cement
and the post-and-core.21
The need for a design for a complete ferrule has been
postulated,8,20 but there is no consensus regarding the
height of the axial walls. Most studies recommend a height
of 2 mm,19 while others suggest a minimum of 1.5 mm.22
However, 1 study suggested a height of 1 mm if the core is
made of composite resin and a metal-free ceramic crown is
adhesively placed.23 Another study showed that the
higher the ferrule (3 mm), the higher the fracture resis-
tance.24 In clinical practice, attaining a complete ferrule of
even 2 mm of dentin is not always possible because of the
extent of a carious lesion or fracture. Orthodontic extrusion
or crown lengthening to produce a complete ferrule is not
always possible either. Both of these methods have dis-
advantages because they may compromise periodontal
support and because lengthening the clinical crown can
affect esthetics by producing gingival margins at different
levels. Additionally, these treatments increase treatment
time, patient discomfort, and treatment cost.
Information is sparse regarding the number and
height of the remaining walls of a partial ferrule and the
influence they both have on the successful restoration of
severely compromised maxillary incisors.25 The few lab-
oratory and clinical studies available have shown incon-
sistent results. Al-Wahadni and Gutteridge26 evaluated a
Santos Pantaleón et al
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391
partial ferrule with only the facial wall and concluded that
a ferrule of 3 mm or more improved the fracture resis-
tance compared with the control group with no ferrule.
Goto and Swift27 in unpublished research found no dif-
ference in crown fracture resistance with or without
ferrule in the proximal walls. However, Naumann et al28
reported that when the height of the incomplete ferrule
was 2 mm in the groups examined (buccal, proximal, and
lingual), the lowest fracture resistance was recorded in the
group with ferrule and no proximal walls. Tan et al,29 in a
study in which the heights and configurations of the
ferrule were varied, noticed that in specimens with a 2-
mm buccal and lingual height and proximal walls of 0.5
mm, statistically significant lower fracture resistance was
recorded. However, Ng et al30 studied a partial 180 de-
grees in tooth circumference (buccal, proximal, and
lingual) with 2-mm residual walls. The group with the
proximal ferrule showed lower fracture resistance. Yang
et al31 suggested that more studies are needed to eluci-
date the relationship between the exact numbers of cor-
onal walls in relation to restoration failures and concluded
that the role of a ferrule is not totally understood.
This study evaluated the effect of a partial ferrule with 1
missing interproximal axial wall and varying heights of the
remaining walls on the fracture resistance of the tooth and
also the failure mode in maxillary central incisors restored
with cast metal post-and-cores. The first null hypothesis
was that the fracture resistance and the failure mode would
not be affected if a ferrule of 2 mm in height was present in
3 walls with 1 interproximal wall missing. The second null
hypothesis was that increasing the height of the remaining
coronal walls to 3 or 4 mm would not be enough to
compensate for the 1 missing interproximal wall.
MATERIAL AND METHODS
Sixty intact periodontally compromised and recently
extracted maxillary central incisors were stored in 0.9%
physiologic saline with 1% thymol at room temperature.
The project received authorization from the National
Council of Bioethics in Health of the Dominican Re-
public. The teeth were examined under ×4 magnification
and cleaned to remove all tissues and debris. Radio-
graphs were obtained to verify the absence of fractures,
internal root resorption, and endodontic filling material.
The root lengths (approximately 13.40 mm) and bucco-
lingual diameters (approximately 6.54 mm) at the
cementum-enamel junction (CEJ) were measured with
digital calipers (Mitutoyo). The teeth were divided into 6
experimental groups of 10 teeth each (n=10). All teeth
received conventional endodontic treatment involving
manual instrumentation with files of up to no. 40 K
(Dentsply Sirona), irrigation with 3% sodium hypochlo-
rite (ChloridCid; Ultradent Products, Inc), lateral
condensation filling with gutta percha (Dentsply Sirona),
THE JOURNAL OF PROSTHETIC DENTISTRY
392 Volume 119 Issue 3

Figure 1. Groups showing ferrule preparation, cast metal post-and-cores, and crown. A, Group NF No ferrule. B, Group CF2 2-mm-high complete ferrule.
C, Group IF2 2-mm-high incomplete ferrule missing proximal axial wall. D, Group IF3 3-mm-high incomplete ferrule missing proximal axial wall. E, Group
IF4 4-mm-high incomplete ferrule with 3-mm-high lingual wall and missing proximal axial wall. F, Group IF6 (control) 6-mm-high incomplete ferrule
missing proximal axial wall (no post).

and use of a sealing cement (AH26; Dentsply Sirona).
The teeth were prepared by hand with rotary high-speed
diamond instruments (no. 6878-014; Brasseler) under
copious water irrigation. The anatomic crowns were
reduced according to the predetermined height for the
experimental groups. For the interproximal cavities, a
coarse, round-end diamond rotary instrument (no. 6856-
012; Brasseler) was used to prepare the 3-mm buccolin-
gual width while establishing a coronal surface parallel to
the CEJ. The CEJ served as the circumferential reference
for the linear measurement of the remaining coronal
heights for each specimen.32 Specimens were then
divided into the following 6 experimental groups (Fig. 1):
NF (no ferrule), CF2 (2-mm-high complete ferrule), IF2
(2-mm-high incomplete ferrule missing an interproximal
axial wall), IF3 (3-mm-high incomplete ferrule missing
an interproximal axial wall), IF4 (4-mm-high incom-
plete ferrule missing an interproximal axial wall and a
3-mm-high lingual wall; the 3-mm-high lingual wall was
used to represent residual tooth structure realistically
after endodontic access), and IF6 (control; 6-mm-high
incomplete ferrule missing an interproximal axial wall).
All specimens received post-and-cores except for
those in the control group, and all specimens received
complete metal crowns. Post space preparation in the NF
group was accomplished with a drill (no. 2 Peeso
Reamer; Union Broach Co), removing 8 mm of gutta
percha as measured from the coronal remaining tooth
structure. In other groups with 2-, 3-, and 4-mm-high
incomplete ferrules, 10, 11, and 12 mm of gutta percha
were removed. This preparation routine permitted the
fabrication of 8-mm posts for all specimens. Post spaces
were then gradually enlarged using no. 3 and 4 Peeso
Reamers (Union Broach Co). A direct technique was used
to fabricate post-and-core patterns. Post space contours
were directly captured using plastic dowels with

THE JOURNAL OF PROSTHETIC DENTISTRY Santos Pantaleón et al

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March 2018 393

autopolymerizing acrylic resin (DuraLay; Reliance Dental

Mfg Co), and a core was added. The patterns were
invested and cast in nickel-chromium alloy (VeraBond II;
AalbaDent), finished with rotary tungsten carbide
instrumentation (no.190 040; Komet), and airborne 50-
mm alumina particles at 410 kPa pressure. If casting de-
ficiencies were noted, new specimens were fabricated.
The post-and-cores were cemented with a self-adhesive
resin cement (Rely X U200 Automix; 3M ESPE)
following the manufacturer’s instructions. The post
spaces were irrigated with 3% sodium hypochlorite
(ChloridCid; Ultradent Products, Inc), followed by
distilled water, and dried with paper points (Coltène).
The cement was introduced into the post space using
dispensing tips provided by the manufacturer. The post-
and-cores were placed using slight repetitive torsional
movements to reduce hydraulic pressure and prevent air
entrapment. Constant finger pressure consistent with
clinical practice was applied until the initial setting
occurred, followed by at least 6 minutes of further bench
set to permit complete polymerization. Excess cement
was removed with a scaler. In the IF6 group, the cavity Figure 2. Failure modes based on Fokkinga et al33: (1) complete
walls were etched with 37% phosphoric acid (Prime decementation of post-and-core and crown, (2) partial decementation
Dental) for 15 seconds, rinsed with an air/water spray, of post-and-core and/or crown, (3) fracture composite resin
and gently air-dried. A thin layer of adhesive (Single foundation-coronal dentin, (4) dislodgement of lingual cervical margin
crown, (5) oblique fracture, (6) horizontal fracture, (7) propagation
Bond Universal; 3M ESPE) was applied with a micro-
fracture subosseous, and (8) propagation fracture supra-osseous. Level
brush, air-dispersed, and light-polymerized for 40 sec-
of bone indicated with asterisk.
onds (VALO Cordless; Ultradent Products, Inc). The
cavity was then incrementally filled with a composite cementation, all specimens were thermocycled in distilled
resin (Z350 Filtek; 3M ESPE), and each increment was water (6000 cycles; 5 C/55 C, 2-minute dwell time) to
light-polymerized for 20 seconds. simulate approximately 5 years of service in the oral
The coronal contours were refined using diamond cavity.28 The roots were embedded in autopolymerizing
rotary instruments (no. 6878-014; Brasseler) under acrylic resin (SamplKwich; Buehler) leaving 2 mm of the
copious water irrigation, resulting in the following coronal coronal root surface exposed to imitate osseous support.
preparation parameters: a preparation height of 6 mm, Each specimen was tested for fracture resistance using
chamfer finish line at the CEJ, 1.5-mm buccal reduction, a universal testing machine (5567; Instron). Compressive
1.0-mm interproximal and lingual reductions, and 2-mm force was applied to the stop on the lingual surface of the
incisal reduction. After 1 layer of die spacer (Die Spacer; crowns and directed at a 45-degree angle to the longi-
Keystone Industries), a complete contour wax pattern was tudinal axis of the tooth at a crosshead speed of 0.5 mm/
created directly on 1 specimen. This pattern was 8 mm min until fracture. This loading geometry simulated the
high and had a circumferential thickness of approximately potential occlusal forces in a Class I occlusion.32
1 to 1.5 mm. A rectangular-shaped stop with a central The failure mode of the specimens was evaluated by
concavity was added 2 mm apical to the incisal edge on embedding the fractured specimens in autopolymerizing
the lingual surface. This stop facilitated loading during acrylic resin (SamplKwich; Buehler), followed by
fracture resistance testing. The completed crown pattern sectioning in a buccolingual direction with a low-speed
was used to generate a mold (Putty Normal Set, Elite HD; diamond wafering blade under water irrigation (IsoMet
Zhermack), which was used to fabricate replica crown 5000; Buehler). The sections were photographed with a
patterns in wax for all specimens. The wax patterns were stereomicroscope (Discovery.V8; Carl Zeiss) at ×15
invested, eliminated, and cast in nickel-chromium alloy magnification. Based on Fokkinga et al,33 the mode of
(VeraBond II; AalbaDent). The castings were inspected failure (Fig. 2) was characterized as follows: complete
under ×4 magnification for defects and a new one fabri- decementation of the post-and-core and crown; partial
cated if deficiencies were observed. The castings were decementation of the post-and-core and/or crown; frac-
finished and cemented with zinc phosphate cement ture of the composite resin foundation-coronal dentin;
(Fleck’s; Mizzy), mixed according to the manufacturer’s dislodgement of the lingual cervical margin crown; trajec-
instructions, and held under finger pressure.22 After tory of root fracture (oblique or horizontal); propagation

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394
Table 1. Fracture load (N) of different groups
Group
NF No ferrule
CF2 2-mm-high complete ferrule 932 ±236a,b
IF2 2-mm-high incomplete ferrule missing proximal axial wall 697 ±165a,b
IF3 3-mm-high incomplete ferrule missing proximal axial wall
IF4 4-mm-high incomplete ferrule with 3-mm-high lingual wall
and missing proximal axial wall
IF6 6-mm-high incomplete ferrule missing proximal axial wall
a,b
Statistically significant differences (P<.05).
of fracture (subosseous, supra-osseous); favorable
outcome (failure permits restoration of the tooth); and
unfavorable outcome (failure does not permit predictable
restoration). The data were analyzed with ANOVA and the
Student-Newman-Keuls multiple comparison test
(a=.05).
RESULTS
Fracture resistance data recorded for each group is
illustrated in Table 1. One-way ANOVA revealed a sta-
tistically significant difference (P<.05) among the groups.
The Student-Newman-Keuls multiple comparison sta-
tistical tests indicated statistically significant differences
between CF2 and IF2 (P<.05) also NF and all other
treatment groups CF2 (P<.05), IF2 (P<.05), IF3 (P<.05),
IF4 (P<.05), and IF6 (P<.05). Significant differences were
not identified between the other group combinations.
Means and standard deviations are listed in Table 1.
Regarding failure mode, the researchers identified
partial decementation of the post-and-core and/or crown
in 8 specimens in NF, partial decementation of the post-
and-core in 1 specimen in CF2 and 5 specimens in IF2,
and partial decementation of the core-crown in 7 speci-
mens in IF6. Fracture of the composite resin foundation-
coronal dentin and dislodgement of the crowns at the
lingual margin were observed in 7 IF6 specimens. The
trajectory and location of the root fracture varied, with
oblique, cervical third fractures and horizontal, middle
third fractures occurring most frequently. Subosseous
crack propagation occurred in almost all specimens with
post-and-cores and crowns. Failures deemed to be pre-
venting future predictable restorations were recorded for
most of the specimens with post-and-cores, except for 4
NF specimens and 1 CF2 specimen. Seven failures in the
IF6 group were considered restorable (Table 2). Failures
(favorable) were considered restorable if enough dentin
remained to restore the tooth after modifying the
preparation.
DISCUSSION
The first null hypothesis that the fracture resistance
would not be affected when a ferrule of 2 mm in coronal
height in 3 walls was present was rejected. The fracture
resistance of IF2 was negatively affected compared with
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Volume 119 Issue 3
Table 2. Failure modes
Mean ±SD Experimental Group
494 ±110a Failure Mode NF CF2 IF2 IF3 IF4 IF6
1 e Complete decementation of post-and-core 1
and crown
844 ±143a 2 e Partial decementation of post-and-core 8 1 5 7
and/or crown
853 ±115a
3 e Fracture composite resin foundation- 7
coronal dentin
896 ±210a
4 e Dislodgement of lingual cervical margin 4 6 3 7
crown
5 e Oblique fracture 1 5 7 6 3 1
6 e Horizontal fracture 1 4 3 4 7 2
7 e Propagation fracture subosseous 4 9 10 10 10
8 e Propagation fracture supra-osseous 1 3 6 6 4 3
Failure favorable/unfavorable total 4/6 1/9 0/10 0/10 0/10 7/3
Based on Fokkinga et al, 2004.33
specimens with a 2-mm-circumferential ferrule (CF2).
The higher values of fracture resistance in CF2 (932 N)
compared with IF2 (697 N) specimens showed that the
resistance of the tooth was directly related to the amount
of remaining dentin, which corroborates the findings of
other studies.10,13 A 2-mm height with parallel walls and
a 360-degree circumference is better than a 0-mm
ferrule19,20 and partial ferrule designs with 2-mm
height in the remaining walls.28-30 This indicates that
the amount of residual dentin after endodontic treatment
seems to be a crucial factor for the tooth’s prognosis.9,19
The statistically significant difference between the CF2
and IF2 groups suggests that the lack of 1 interproximal
wall increases the displacement of the crown in a lingual
direction, reducing the antirotational capacity of the
ferrule.15 The clinical implication of the results in IF2
specimens must be interpreted with caution, because the
forces that caused failures in this study were much higher
than those exerted on a natural maxillary central incisor
of individuals in maximum occlusion force (between 140
and 200 N).34
The second null hypothesis, that an increase in height
of the remaining walls to 3 to 4 mm does not compensate
for the lack of 1 proximal wall in increasing the resistance
of the tooth, was also rejected. The fracture resistance IF3
(844 N) and IF4 (853 N) specimens rendered failure loads
close to the resistance values of CF2 specimens (932 N).
The results of the present study show that the fracture
resistance in the 3-wall ferrule design of 3 to 4 mm of
coronal height is higher than that of the 3-wall ferrule
design of 2 mm in height. This suggests that a partial
ferrule can be more effective if 3 to 4 mm in height of the
remaining dentin walls can be preserved.15
In both the IF3 and IF4 groups, the height of the
lingual wall was 3 mm, but with different heights in the
buccal and interproximal remaining walls (3 mm in IF3
and 4 mm in IF4). Statistical similarity in load to failure
for the incomplete ferrule of groups IF3 and IF4 appears
to confirm results from other studies,13,30 and indicates
Santos Pantaleón et al
March 2018
that the lingual wall performs an important role in
resistance to fracture in endodontically treated teeth.
That effectiveness is logical, because the lingual wall acts
as the main counterforce to the occlusal load. A finite
element analysis study suggested that when the height of
the ferrule is higher, it becomes more efficient in
reducing the axial arm of the rotation force.15 This re-
duces the potential decementation of the post/core/
crown complex. This, therefore, could explain the partial
decementation observed in 5 specimens from the IF2
group, while in the IF3 and IF4 groups no decementation
was observed. No significant statistical differences were
detected between the fracture resistance in groups CF2,
IF3, and IF4 compared with IF6. This result possibly ex-
plains why the indication of a post for the retention and
support of a complete crown restoration is not necessary
when sufficient dentin remains. This study’s data agree
with the observations of other studies.3
Assessment of the failure mode revealed that, in
most specimens with post-and-cores, catastrophic fail-
ure resulted in root fracture, except in 4 NF specimens
and 1 CF2 specimen in which the failure was repairable.
Microscopic evaluation of sections of selected speci-
mens allowed precise detection of the type of failure.
Partial decementation of the post-and-core and/or
crown occurred in 8 NF specimens and 5 IF2 specimens.
These findings are also in agreement with other
studies.12 In all IF2, IF3, and IF4 specimens and 9 CF2
specimens, crack propagation was observed below the
simulated bone level. This can be attributed to the high
modulus of elasticity of the Ni-Cr16 alloy that concen-
trates elevated stress through the post-and-core in the
cervical third, middle, and apical canal walls and is
responsible for catastrophic radicular oblique and hori-
zontal fractures.12
However, in 7 specimens without a post (IF6), the
fracture occurred in the composite resin foundation-
coronal dentin region, making it a repairable failure.
These findings are in accordance with those of Pierris-
nard et al.17 Furthermore, crown displacement in the
lingual area was observed in 7 IF6 specimens, corrobo-
rating a finite element analysis study showing that when
an incisor is subjected to a masticatory load, the
maximum concentration of tensional stress is concen-
trated on the lingual surface.18 In a retrospective clinical
study on maxillary central incisors restored with fiber
posts and ceramic crowns, while considering the influ-
ence of residual coronal dentin, the survival was longer
for teeth that had 3 or 4 coronal walls.4 The data reported
here corroborated these findings.
A limitation of this study is that only a static, rather
than a clinically more relevant dynamic load, was
applied. However, as with any laboratory study that
involves numerous steps to produce test specimens,
unavoidable variations will always occur.
Santos Pantaleón et al
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395
CONCLUSIONS
Within the limitations of this in vitro study, the following
conclusions were drawn:
1. Restored endodontically treated maxillary central
incisors with a 2-mm-high complete ferrule were
more resistant to fracture than were teeth with a 2-
mm-high incomplete ferrule missing 1 proximal
axial wall (P<.05).
2. Increasing the wall height to 3 and 4 mm was
associated with significant increases in fracture
resistance and can compensate for the missing 1
proximal wall.
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Corresponding author:
Dr Domingo Santos Pantaleón
Calle Elipse 7, Apto 1A, Urbanización Fernández
Santo Domingo
DOMINICAN REPUBLIC
Email: dsantospantaleon@gmail.com
Acknowledgments
The authors thank predoctoral students Julio Santos Olivares and Kenny Tejada
Serrano, School of Dentistry, Autonomous University of Santo Domingo, for their
assistance in the preparation of specimens; and Dr Hira Iftikhar, Bioscience
Research Center, College of Dentistry, University of Tennessee Health Science
Center, Memphis, Tenn, for her support.
Copyright © 2017 by the Editorial Council for The Journal of Prosthetic Dentistry.
Santos Pantaleón et al