tist

Den ry

ISSN: 2161-1122
Dentistry Al-shibri and Elguindy, Dentistry 2017, 7:12
DOI: 10.4172/2161-1122.1000464

Research OMICS International

Fracture Resistance of Endodontically Treated Teeth Restored With

Lithium Disilicate Crowns Retained With Fiber Posts Compared To
Lithium Disilicate and Cerasmart Endocrowns: In Vitro Study
Saleh Al-shibri and Jylan Elguindy*
Fixed Prosthodontics Department, Cairo University, Egypt
*Corresponding author: Jylan Elguindy, Professor of Fixed Prosthodontics, Cairo university, Giza, Cairo, Egypt, Tel:+201100115007; E-mail: [email protected]
Received date: October 26, 2017; Accepted date: November 07, 2017; Published date: November 14, 2017
Copyright: © 2017 Al-shibri S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

Purpose: The purpose of this in vitro study was to compare the effect of endocrowns and glass fiber post-
retained crowns on the fracture resistance of endodontically treated maxillary premolars made of different ceramics
materials.

Materials and Methods: Thirty sound maxillary premolars were endodontically treated. They were randomly
assigned into 3 groups (n=10), in which, teeth were prepared to receive all- ceramic restorations. GP: fiber post and
resin core and ferrule with all-ceramic (IPS E-max CAD, Ivoclar-Vivadent) conventional crown. GE: Endocrown with
butt joint finish line design made of (IPS E-max CAD, Ivoclar-Vivadent). GC: Endocrown with butt joint finish line
design made of hybrid nanoceramic (CERASMART, GC Dental, USA). The lithium disilicate (IPS E-max press,
Ivoclar-Vivadent) and hybrid nanoceramic (CERASMART, GC Dental, USA) all-ceramic restorations were made by
CAD/CAM system (CEREC MC XL SW 4.0) and adhesively cemented with dual-cure resin cement (BisCem Bisco,
Inc, USA). Specimens were mounted in a universal testing machine (Model 3345; Instron Industrial Products,
Norwood, MA, USA). Each specimen was loaded to failure at a crosshead speed of 5.0 mm / min. Mode of failure
was also examined. Data were analyzed using one way analysis of variance (ANOVA) and Tukey’s post hoc
significance difference tests. Differences were considered significant at P<0.05.

Results: One way ANOVA test showed that group (GC) recorded statistically significant (p<0.05) highest mean
value (1522.64 N) followed by group (GP) (1301.34 N) then group (GE) (725.73 N). Group (GE) recorded the lowest
statistically significant (p<0.05) mean value (725.73±137.89 N). Pair-wise Tukey’s post-hoc test showed non-
significant (P>0.05) difference between GP and GC groups.

Conclusions: Within the limitations of this study, all fracture resistance loads obtained in this study were far
beyond the maximum masticatory forces and the presence of hybrid nanoceramic increased the fracture resistance
of endodontically treated maxillary premolars restored with endocrown than those restored with lithium disilicate
endocrowns, in failure mode hybrid nanoceramic showed favorable fracture pattern than lithium disilicate.

Keywords: Endocrown; Lithium Disilicate; Hybrid Ceramic; Different from conventional approaches using intraradicular posts,
Cerasmart; CAD/CAM; Fiber Post; Fracture Resistance endocrown restorations are anchored to the internal portion of the
pulp chamber and on the cavity margins, thereby resulting in both
Introduction macro- and micro mechanical retention, provided by the pulpal walls
and adhesive cementation, respectively. In addition, endocrowns have
Rehabilitation of endodontically treated teeth with large coronal the advantage of removing lower amounts of sound tissue compared to
destruction is still a clinical challenge, especially due to the loss of other techniques, and with much lower chair time needed.
strength characteristics associated to the removal of pulp and
surrounding dentin tissues. Coronal retention of the restoration is Also, the masticatory stresses received at the tooth/restoration
usually compromised, thus intraradicular posts combined or not with interface are more properly dissipated along the overall restored tooth
core materials may be required. Despite all clinical success achieved structure when endocrowns are placed. Depending on the material
with the use of intraradicular posts, one disadvantage of this system is chosen, ceramic or resin composites, the system may become more
the additional removal of sound tissue needed for fitting the post into rigid than the dental structure (in case of ceramics) or biomechanically
the root canal; additionally, this procedure was revealed to affect the similar to the tooth (in case of resin composites) [4-6].
overall biomechanical behavior of the restored teeth. Alternatively, The type of material may also have influence on the performance of
other restorative approaches have been suggested, including but not endocrowns, with wide collection of ceramic material has been
limited to the well-known endocrown restorations [1-3]. available for CAD/CAM technology, ranging from weak feldspathic
Endocrowns assemble the intraradicular post, the core, and the ceramic and Lucite glass ceramic to high-strength lithium disilicate
crown in one component, thus representing monoblock restorations. glass ceramic and zirconium oxide. Most recently, a resin nanoceramic
has been introduced for permanent CAD/CAM fabricated

Dentistry, an open access journal Volume 7 • Issue 12 • 1000464

ISSN:2161-1122
Citation: Al-shibri S, Elguindy J (2017) Fracture Resistance of Endodontically Treated Teeth Restored With Lithium Disilicate Crowns Retained
With Fiber Posts Compared To Lithium Disilicate and Cerasmart Endocrowns: In Vitro Study. Dentistry 7: 464. doi:
10.4172/2161-1122.1000464

Page 2 of 9

restorations. Ultrastructure and mechanical properties of available maxillary premolars has not been clearly established. In this vitro
CAD/CAM material vary widely, their and, accordingly, their study, there were two-null hypothesis, the first; Endocrowns would
mechanical behavior in the tooth restoration complex is expected to have more fracture resistance than IPS e.max CAD crowns retained
vary as well. With the intent of increasing the amount of information with fiber posts and composite core, the second; Endocrowns
about the behavior of these material when used for endocrowns, I was restoration made of hybrid ceramics CERASMART material would
found worth to evaluate the fracture resistance, and the failure modes show more fracture resistance than endocrowns made of IPS e.max
of CERASMART and E.max CAD endocrowns restoration compared CAD (Figures 1 and 2).
with conventional crowns retained by glass fiber posts and core of
maxillary premolars teeth when compressive force was applied [7,8]. Materials and Methods

Teeth selection
Thirty caries free of recently extracted human maxillary premolars
were selected for the study. The teeth were inspected under high light
condition with magnifying lens (2*magnification). The anatomic
crowns were selected to be with average dimensions after measuring
the bucco-lingual (9 ± 1 mm) and mesio-distal (7 ± 0.5 mm) using a
caliper (MarCal 16 DN, Germany).

Teeth mounting
All teeth were mounted in epoxy resin block using a custom-made
round teflon shape sample holder (2 cm length, 2 cm internal
diameters) in a vertical direction using parallel meter, teeth are
embedded in the epoxy resin block up to 2 mm below the CEJ
(simulated bone level) and hold in position till complete
polymerization of the resin.
Figure 1: Schematic diagram illustration Endocrowns preparation
design. Preparation of the teeth
Decapitation of teeth: The crowns of the collected teeth were
removed 2 mm above the cemento-enamel junction from the proximal
surfaces using a diamond disc and a sufficient coolant. After crowns
separation sample teeth, were stored in 0.9% sterile saline solution to
avoid dryness.
Endodontic treatment: The access cavities of the teeth were
performed a round bur followed by an ENDO-Z bur (Dentsply,
Switzerland) using high speed hand piece under copious water coolant.
The working length of each tooth determined by using K-file size 15
with radiograph than teeth canals were treated using rotary system Ni-
Ti (Protaper, Dentsply, Switzerland) with lubricant (MD-Chelcream,
METABIOMED, Korea) till files size F3 with working length 1 mm
before apical foramen with irrigation using sodium hypochlorite 4.2%
in between files, after intermittent irrigation, the root canals were dried
with paper points.
With matched tapered single cone (Dentsply, Switzerland)
obturation technique. A size F3 master cone was tried to fit the
prepared canal and reaching the full working length with tug-back
action.
Figure 2: Schematic diagram illustration post & core the
preparation with 2mm ferrule. Gutta-percha point were coated with resin sealer (ADSEAL,
MetaBiomed, korea) and placed in root canal till to the working length.
Excess gutta-precha was removed using heated instrument (cherry red)
Endocrowns were revealed to fail more when fixed to premolars, and the coronal part was compacted with a plunger vertically.
probably due to their smaller adhesion area and greater crown height
compared to molars. In addition, premolars receive more horizontally Classification of the samples
(non-axial) directed forces than molars, which may also influence
fracture resistance [9]. Strong bonding between the indirect restoration The teeth were randomly divided in to 3 main groups (10n) in each
and tooth structure increases the durability and longevity of the group, according to the type of restoration and material used as shown
prosthesis [10]. The influence of different crown material on fracture in Table 1:
resistance of ceramic crowns placed on endodontically treated

Dentistry, an open access journal Volume 7 • Issue 12 • 1000464

ISSN:2161-1122
Citation: Al-shibri S, Elguindy J (2017) Fracture Resistance of Endodontically Treated Teeth Restored With Lithium Disilicate Crowns Retained
With Fiber Posts Compared To Lithium Disilicate and Cerasmart Endocrowns: In Vitro Study. Dentistry 7: 464. doi:
10.4172/2161-1122.1000464

Page 3 of 9

Group (GP): Endodontically treated teeth with 2mm ferrule effect straight hand-piece perpendicular to surveyor platform, Teeth were
restored with glass fiber posts retained lithium disilicate crowns. prepared with 2 mm circumferential ferrule axial wall heights, and
with 10o convergence. All axial walls had circumferential 90o shoulder
Group (GE): Endodontically treated teeth restored with Lithium
margin 1 mm wide with rounded internal line angle, the teeth were
disilicate endo-crowns with butt joint finish line.
further. The height of the prepared teeth was 6 mm from the finish line
Group (GS): Endodontically treated teeth restored with Hybrid to the buccal cusp (2 mm ferrule, 4 mm core) and 5 mm from finish
ceramic (CERASMART) endo-crowns with butt joint finish line. line to the central groove of occlusion (2 mm ferrule, 3 mm core).

Allocation concealment mechanism GE and GS (IPS e.max CAD and CERASMART,

The samples were numbered from 1-30 and written on folded paper
Endocrowns)
then placed in opaque sealed envelopes. After coronal sectioning to prepare a circular butt margin, gutta
Implementation: All steps of sample selection, randomization and percha was removed till canals entrance with no more drilling inside
preparation was assigned by the candidate under supervision. the canals, a thin layer of flowable composite material (Filtek Z350, 3M
ESPE Dental products, St. Paul, USA) was bonded to seal the canal
Blinding: Was done by assessor (technician). entrance and to enhance the bonding of the ceramics endocrowns
Randomization: All samples were numbered from 1 and ascending constructed in later stage.
to 30 and then were divided by the web site by www.randomizer.org The pulp chamber was prepared to eliminate undercuts with a 10o
into 3 equal groups. coronal divergence, with an oval shape and a depth of 4 mm from the
cavosurface margin with all internal line angles were rounded and
Preparation design smooth 11 using a special milling machine incorporated with
conventional-speed straight hand-piece perpendicular to surveyor
GP (Post and core supported crowns): The ten teeth of group GP platform. The internal line angles were rounded and smooth (Figures
received glass fiber posts size no.2 (Nordin Glassix+plus fiber post, 3, 4 and 5).
Switzerland) and a light cure resin composite filling core (Light-Core,
Bisco Inc, USA). After coronal sectioning, the gutta-percha was
removed from palatal canal using a pilot reamer of the post system to
the length of 11 mm from the preparation margins. Each glass fiber
post was reduced to length of 14 mm by cutting the coronal end with
diamond separating disc, resulting in a dowel extending 3 mm above
the coronal surface of the trimmed crown.
A post space was prepared with the corresponding calibrating drill
(size no.2) included in the post system. The canals were etched with
37% phosphoric acid (ETCH-37 w/BAC, Bisco Inc, USA) for 15
seconds. The canals were thoroughly rinsed with water, dried with
compressed air and paper points.
A light cure adhesive agent (All-Bond Universal, Bisco, Inc, USA)
was applied inside the root canal using a micro brush. The adhesive
was rubbed to canal walls for 10 seconds and the excess solvent was Figure 3: Endocrown preparation.
removed with gentle oil free compressed air for 1-3 seconds and light
cured for 20 seconds according to manufacturer instructions.
Using a microbrush, silane coupling agent (Porcelain Primer/Bis-
Silane, Bisco, Inc, USA) was applied on the post surface for one 60 sec
and then gently air dried for 5 seconds. The post was luted with dual
cure resin cement BisCem (Biscem, Bisco Inc, USA) were auto mixed
and applied along the post surface and inside the post space canal. The
post inserted, then positioned in place after up and down motion to
ovoid air bubbles formation. The post was positioned in place with a
frim finger pressure, then the excess resin cement was removed with a
microbrush, followed by light curing for 20 seconds from occlusal
surface.
Composite core construction: The core build up (Light-C, Bisco Inc,
USA) was made by injecting desired amount of Light-Core Composite
injected the around the post and into transparent celluloid crown
which then placed over the post to allow for shape standardization Figure 4: Post and core the preparation.
between samples. Light cure was for 20 seconds done for each surface.
Ferrule preparation: Using a special milling machine (PARASKOP
M MILLING UNIT USA) incorporated with conventional-speed

Dentistry, an open access journal Volume 7 • Issue 12 • 1000464

ISSN:2161-1122
Citation: Al-shibri S, Elguindy J (2017) Fracture Resistance of Endodontically Treated Teeth Restored With Lithium Disilicate Crowns Retained
With Fiber Posts Compared To Lithium Disilicate and Cerasmart Endocrowns: In Vitro Study. Dentistry 7: 464. doi:
10.4172/2161-1122.1000464

Page 4 of 9

were supported by an object fix material and fired on their special

firing tray according to the manufacture’s and fired on their maximum
functional and esthetic properties. The starting temperature was 403°C
and increased at rate of 90°C/min until 890°C and hold for 2 minutes;
then firing was increased at a rate of 30°C/min until 840°C and hold
for 7 minutes.
Finishing and polishing of CERASAMRT endocrowns: As
CERASMART restorations do not need for firing as it hybrid ceramic,
the restorations were finished using GC ultimate finishing and
polishing kit (GC polishing kit America Inc USA) and Diapolisher
paste (GC DiaPolisher Paste America Inc USA), which was applied
with low hand speed. The luster quickly appeared as the restorations
were polished.

Figure 5: Tin foil was placed between the tooth and the loading
stainless steel tip.

Construction of Cerec CAD/CAM endocrowns and crowns

A CAD/CAM system (CEREC MC XL SW 4.0) was used for the
fabrication of all samples in this study. Figure 6: A column chart of fracture resistance mean values for
Scanning and designing for all groups: To obtain a three- group fiber post, E.max CAD endocrown and CERASMART
dimensional image for each prepared tooth on the computer screen of endocrowns.
the Cerec CAD/CAM (CEREC MC XL SW 4.0) software system the
prepared tooth was scanned using Omnicam scanner, then the
captured picture was saved in preparation catalogue of software. The
Bonding procedures
software calculated a virtual model from the scanned pictures and
automatic margin finder was used for preparation margin detection.
With the aid of Cerec (CEREC MC XL SW 4.0) software the scanned Surface treatment of restorations
prepared teeth was correlated to a virtual endocrowns restoration with IPS e.max CAD restorations (GP and GS): Intaglio surfaces of each
5.5 mm buccal cusp height and 5 mm lingual cusp height in order to endocrown and conventional crown were treated according to the
standardized tooth from with 80 mμ cement space, while full crowns manufacturer’s instructions for the respective block material. Etching
had 1.5 mm thickness with 4% hydrofluoric acid gel (Porcelain Etchant Gel- 4% Buffered
Milling process for all groups: To start the milling procedure, the Hydrofluoric, Bisco Inc, USA) was applied for 20 seconds then rinsed
type of the block (IPS e.max CAD or CERASMART Block) as well as for 60 seconds with running water and dried for 30 seconds with
the size were selected and confirmed with “OK” button. The selected moisture-free air. A ceramic primer containing silane coupling agent
ceramic block of the required size was inserted in spindle of the milling (Porcelain Primer/Bis-Silane™, Bisco Inc, USA) was applied to the
chamber of the Cerec MC XL milling Machin and fastened with the set intaglio surfaces of all endocrowns and allowed to dry for 60 seconds.
screw. Cerasmart restoration (GS): Intaglio surfaces of each endocrown
The milling process was fully automated without any interference were treated according to the manufacturer’s instructions. Etching with
with two diamond bures acting together simultaneously in the shaping 4% hydrofluoric acid gel was applied for 20 seconds then rinsed for 60
process with copious water cooling sprayed from both directions. After seconds with running water and dried for 30 seconds with moisture-
completion of the milling process, the crowns were separated manually free air. A ceramic primer containing silane coupling agent was applied
from the block holder with a diamond cutting instrument. All to the intaglio surfaces of all endocrowns and allowed to dry for 60
endocrowns and crowns were cheeked over there corresponding teeth seconds.
for seating. Surface treatment of the prepared natural tooth: Prepared tooth
Crystallization and glaze firing only for GP and GE (IPS e.max CAD surfaces were etched with 37% phosphoric acid–etching gel (ETCH-37
crowns and endo crowns): The Program at P300 furnace (Ivoclar w/BAC, Bisco Inc, USA) for 15 seconds, rinsed for 20 seconds, and
Vivadent, Schaan, Liechtenstein) was used for crystallization and glaze dried with oil-free air for another 5 seconds. Two separate coats of all-
firing. The IPS e.max CAD ceramic crowns appeared to be in their pre- bond (Universal ALL-BOND UNIVERSAL, Bisco Inc, USA), were
crystallized from after milling where they have the bluish-gray color. applied to the preparation with a microbrush with no light curing
Their crystallization process imparts the glass ceramic with its final between the coats. Excess solvent was then dried with oil-free air for 3
strength and esthetic properties. The IPS e.max CAD ceramic crown seconds, then light cured for 20 seconds.

Dentistry, an open access journal Volume 7 • Issue 12 • 1000464

ISSN:2161-1122
Citation: Al-shibri S, Elguindy J (2017) Fracture Resistance of Endodontically Treated Teeth Restored With Lithium Disilicate Crowns Retained
With Fiber Posts Compared To Lithium Disilicate and Cerasmart Endocrowns: In Vitro Study. Dentistry 7: 464. doi:
10.4172/2161-1122.1000464

Page 5 of 9

The dual cure resin cement BisCem cement (BisCem, Bisco Inc, compartment of testing machine traveling at cross-head speed of 0.5
USA) was applied on the prepared surface of teeth. Then each crown mm/min with two layers foil sheet in-between to achieve homogenous
and endocrown was bonded to its corresponding tooth with finger stress distribution and minimization of the transmission of local force
pressure, excess cement was removed immediately with a microbrush. peaks.The load at failure manifested by an audible crack and confirmed
A customized loading device then used to apply constant load 3 Kg by a sharp drop at load-deflection curve recorded using computer
parallel to the long axis of each restoration to prevent rebounding of software (Bluehill Lite Software Instron® Instruments). The load
the restoration during cementation, then light activated at each surface required to fracture was recorded in Newton. (Figures 4, 5 and 6) Data
for 20 seconds according to manufacturer’s instructions. recorded were collected, tabulated and statically analyzed.

Fracture resistance determination Fracture mode

A single static compressive load application was applied along the Following the fracture resistance test, fracture mode all samples
long axis of each specimen, were individually mounted on a computer were examined visually and photographically using a digital camera
controlled materials using a universal testing machine (Model 3345; (Canon D600). The specimens were inspected to determine different
Instron Industrial Products, Norwood, MA, USA) with a loadcell of 5 fracture modes whether favorable (repairable) or unfavorable
KN and data were recorded using computer software (Instron® Bluehill (irreparable) the failure was considered unfavorable if the tooth
Lite Software). Samples were secured to the lower fixed compartment fracture was below the CEJ including vertical root fracture. In other
of testing machine by tightening screws. Fracture test was done by hand, favorable fracture was defined as restorable failure above CEJ
compressive mode of load applied occlusally using a metallic rod with (Tables 1 and 2).
round tip (3.4 mm diameter) attached to the upper movable

Descriptive Statistics

Groups N Minimum Maximum Mean Std.Deviation

E.max CAD GP (Post) 10 1068.51 1611.32 1301.34 ± 177.12

GE (Endocrowns) 10 428.54 914.83 717.33 ± 198.59

CERASMART GS (Endocrowns) 10 930.62 1871.19 1522.64 ± 352.52

Table 1: Descriptive statistics of all groups.

Fracture MODE

Study Groups Repairable Irreparable

Count Row % Count Row %

Full Crown 6 60.0% 4 40.0%

E.max Endocrown 2 20.0% 8 80.0%

CERASMART Endocrown 7 70.0% 3 30.0%

Table 2: Fracture mode (%) in groups.

Results In this group the most common pattern of fracture was fracture
above the CEJ which recorded (60% repairable) (Figures 2 and 4) and
One way ANOVA showed statistically significant differences the fracture below the CEJ which recorded (40% irreparable).
between studied groups and post hock test showed significant
differences between GP (1301.34 ± 177.12) and GE (717.33 ± 198.59) The fracture patterns in group GE (IPS e.max CAD endocrown
and between GE (717.33 ± 198.59) and GS (1522.64 ± 352.52) while crown): In this group the most common pattern of fracture was below
between GP and GS there was no statistical significant difference. the CEJ which recorded the highest percentage of the fracture pattern
(80% irreparable), and the lowest percentage of the fracture pattern
The highest mean value of maximum load (Fracture resistance) was was recorded for the fracture pattern occurred above the CEJ (20%
found in GS (CERASMART) (1522.64 ± 352.52) followed by GP (Fiber repairable).
post) (1301.34 ± 177.12), the lowest mean value of maximum load
(Fracture resistance) was found in GE (E.max) (717.33 ± 198.59). The fracture patterns in group GS (CERASMART endocrown
crown): In this group the most common pattern of fracture was
Fracture mode fracture above the CEJ which recorded the highest percentage (70%
repairable), and the lowest percentage fracture pattern was recorded
The fracture patterns in group GP (IPS e.max CAD with fiber post for the fracture pattern occurred below the CEJ (30% irreparable).
and core retained crown):

Dentistry, an open access journal Volume 7 • Issue 12 • 1000464

ISSN:2161-1122
Citation: Al-shibri S, Elguindy J (2017) Fracture Resistance of Endodontically Treated Teeth Restored With Lithium Disilicate Crowns Retained
With Fiber Posts Compared To Lithium Disilicate and Cerasmart Endocrowns: In Vitro Study. Dentistry 7: 464. doi:
10.4172/2161-1122.1000464

Page 6 of 9

Discussion surface easily and their stress absorbing properties, for all this
advantages CERASMART were selected in this study on other hands
Premolar teeth with extensive loss of coronal tooth structure have the previous study didn’t evaluated the mechanical performance of the
traditionally been restored by means of a cast metal or fiberglass hybrid ceramic CERASMART endocrowns in maxillary premolars
reinforced composite post and Crown [12]. Concerns regarding such a [25].
procedure include the risk of root perforation and the need for
removal of sound tissue in the root canal to facilitate the room for the The unique composition of CERASMART allows the material to
post material, thus weakening the tooth-root complex. Moreover, the have modulus of elasticity similar to that of dentin (18 ± 2 GPa) with
benefit of a post in the root canal for the overall retention of the 220 MPa to 240 MPa flexural strength, (150) which is slightly higher
successive reconstruction in general is being questioned in recent years than feldspathic ceramics (151) Convectional ceramics in general are
[13]. exhibited more rigidity with high flexural strength and flexural
modulus, this material tend to be stronger but more brittle than hybrid
Clinical results from long-term studies up to 17 years with crowns ceramic, while hybrid ceramic exhibited high flexural strength and low
cemented on composite core build-ups have failed to demonstrate the flexural modulus to be less brittle and more flexible in order to absorb
merits of a metal post on the tooth survival in the presence of adequate high stress loading [24-26].
ferrule effect [14,15]. The introduction and application of fiber
reinforced composite posts has changed the view on the subject. The In vitro testing was used because it over comes the many limitations
use of glass fiber posts has gained acceptance, particularly on associated with clinical testing such as individual variation by creating
premolars and anterior teeth. Their modulus of elasticity is similar to a controlled environment. These tests provide a guideline about the
dentine, allowing better dissipation of masticatory loads through the load bearing capacity of the different systems on prosthetic restoration
tooth, which does not occur with cast metal posts [16]. The amount of like crowns may provide information that is closer to the clinical
remaining ferrule seems to be the predominant factor for tooth situation than testing material properties on standardized samples
survival in extensively structurally compromised non-vital teeth [17]. [27].

Compared to other indirect restorative alternatives that may require In this study, human teeth were used instead of bovine, metal or
root canal therapy, provision of an endocrown is a relatively easy, cost- plastic teeth because of their bonding characteristics, thermal
effective procedure that requires less chairside time, supragingival conductivity, modulus of elasticity and strength that closer to clinical
margins facilitate plaque control and clinical inspection [18]. In situation [28]. Attention was paid to the selection of teeth with
addition, endocrown allows minimal tooth reduction and thus comparable sizes, in which the teeth were selected to be of approximate
strengthens the tooth, by preserving sound dental tissue and root canal similarity in size and shape with 10% maximum deviation from the
structures [19]. determined mean to eliminate any extreme variation for the maxillary
premolars.
Endocrown restorations seemed to eliminate the need for posts and
buildups. For Several factors including the differences in Posterior premolar teeth were used on previous studies [9,21]
configuration/design, thickness, and elastic moduli, less expansive, showed non-satisfactory performance of premolar endocrowns in
time saving and more practical that endocrowns have compared to comparison to molar endocrowns in action of occlusal forces, and
conventional systems [20]. bond strength. This may be due to the smaller surface area of the pulp
chamber and using restoration material with less bonding effect to the
By avoiding the ferrule, which is typically found in conventional teeth.
crowns and can be described as a ‘bracing mechanism’ of the
restoration around the cervical tooth structure may cause the loss of Maxillary premolar teeth were chosen because the performance of
sound enamel and dentin tissues that would be important for proper premolar endocrowns with CERASMART hybrid ceramic may
bonding of the restoration. In addition its reduce the need for macro- improve the bonding to the tooth structure and improve the flexure
retentive geometry, and provide a more esthetic result being strength by the stress absorption ability as this not evaluated before in
constructed from ceramic [21]. any previous study.

Today, a large variety of CAD/CAM materials is available, from A specially designed centralizing device was used to embed the
resin composite and silica-based ceramics to high-strength ceramics teeth vertically in the center of the epoxy resin blocks to ensure the
[22]. position standardization. Teeth were embedded in epoxy resin 2 mm
below the cemento enamel junction to mimic the position if the root in
Though various machinable materials are available for all ceramic the bone. Epoxy resin was used as it modulus of elasticity (12 GPa)
restoration using CAD/CAM systems, IPS e.max CAD block was resemble that of the human bone (18 GPa) [29]. All teeth were
selected in this study due to long term clinical success, stability and less decapitated perpendicular to the long axis 2 mm coronal to the
laboratory steps, in addition the good bonding characteristic to the proximal CEJ in order to simulate the compromised condition of
tooth structure as it etchable ceramic [23]. severely damage endodontically treated teeth premolars [29,30].
Hybrid materials have recently been introduced to the dental Teeth were prepared according to clinically established preparation
market and form a new class of CAD/CAM materials. The new hybrid criteria for all ceramic endocrowns using a special milling machine to
ceramic CERASMART join the market since 2014, it’s a nanoparticle- ensure standardization of the preparation [31,32]. The development of
filled high-density composite resin, which contains 71% of filler Cerec CAD-CAM systems and software offers several advantages in
particles by weight [24]. clinical practice.
Since CERASMART has particular benefits such as less brittle and First with the change in the grinding system from discs to a stepped
more flexible compared to conventional ceramics, fewer flaws and cylindrical diamond bur and a cylindrical diamond with a tapered tip,
irregularities were observed, the possibility to modify or repair the the more flexible CAD-CAM shaping technique allows custom shaping

Dentistry, an open access journal Volume 7 • Issue 12 • 1000464

ISSN:2161-1122
Citation: Al-shibri S, Elguindy J (2017) Fracture Resistance of Endodontically Treated Teeth Restored With Lithium Disilicate Crowns Retained
With Fiber Posts Compared To Lithium Disilicate and Cerasmart Endocrowns: In Vitro Study. Dentistry 7: 464. doi:
10.4172/2161-1122.1000464

Page 7 of 9

and more precise milling of ceramic crowns. Furthermore, the As regards to fracture resistance, the physiologic maximal occlusal
adaptation of the inner surface of a restoration and the replication of force may vary up to (500 N) depending on facial morphology and age
the occlusal morphology are better [33]. [45] study results of serval studies reported that mean loading force
ranged between 222 to 445 N (average, 322.5 N) in the premolar región
Second endocrowns can be produced and seated in one
[46,47]. In this study, the mean fracture loads for different tested
appointment. Despite these advantages, there are clinical problems
groups were beyond the mean reported maximum masticatory forces.
with the depth of the optical impression to record the crown, pulp
Therefore, it can be assumed that all the tested specimens could with
chamber, and sometimes part of the canal [33].
stand the maximum intraoral posterior masticatory forces. The highest
The limited optical depth of Feld might result in a blurred image of mean value of maximum load (Fracture resistance) was found in
the central retention cavity of the endodontic preparation if adjacent (CERASMART) (1522.64 ± 352.52) followed by (Fiber post) (1301.34
teeth limit the position of the camera head. With improvements in the ± 177.12), the lowest mean value of maximum load (Fracture
intra-oral three-dimensional Omnicam camera CEREC 3D unit resistance) was found in GE (E.max) (717.33 ± 198.59).
without need to use reflective medium making the capture images
Regarding to the design, the result obtained in this study showed
easier and faster, while the depth scale is extended to about 20 mm
that post and core with 2mm ferrule effect supported IPS exam cad
through “double triangulation”, thereby, overcoming this limitation
crown recorded a statistically significant higher mean value fracture
[34]. CEREC MC XL milling machine was used for all the restoration
load (1301.34 ± 177.12) than endocrowns made of IPS e.max (717.33 ±
to insure standardization of the restorations.
198.59), this probably due to smaller adhesion area of IPS e.max
A strict adherence to the bonding protocols for each material was endocrown compared to post and core. On other hands, Schmidlin et
followed according to the manufacture recommendations in order to al. [48] indicated the presence of ferrule effect witch distribute the
eliminate variables during the bonding procedures. stresses of the endodontically treated tooth.
The endocrowns were cemented using BisCem (Bisco Inc., Ma et al. [49] reported the value of ferrule which increases fracture
Schaumburg, IL, USA) dual-cure adhesive resin cement as most of strength and minimizes loss of bond of conventional all ceramic
study [35-37] suggested that the resin cement provide chemical and restorations.
micromechanical bonding to the tooth structure. The luting
This result were agreement with Lin et al. [50] and another study 9
procedures followed the clinical total etch protocol to ensure a close
who reported that the stress values on the enamel, dentin and luting
simulation of clinically relevant conditions.
cement for ceramic endocrown restorations were the lowest relative to
Combination between total etch combination between total etch conventional crown restorations supported with fiber posts and
and self-adhesive cement reported to increase the bond strength and composite cores while smaller surface area of premolars for adhesion
provide high retention [38,39] in addition it acts as an inherent and the greater crown height, which compromises the mechanical
buffering layer that is able to absorb stresses during load application properties of the endocrown.
leading to increasing the fracture resistance values of the restoration
This was opposed by Biacchi et al. [51] who reported that with the
[40].
adhesive technique creating a sufficient ferrule might cause loss of
Surface treatment of CERASMART all currently available in vitro tooth structure and result in compromised bonding strength, because
studies found HF acid etching in combination with silane to be a enamel is preferred to dentine bonding, this contradictory finding
superior pretreatment [41]. The application of HF acid partially might be related to the difference in the material and methodology
dissolves the glass phase and provides undercuts in the micrometer between studies. Where Biacchi et al. used Rely X cement to perform
scale for better micromechanical interlocking with a composite their study rather than Biscem.
cement. However, the recently published working instruction of the
Regarding to the materials used for the fabrication of endocrowns
International Academy for Adhesive Dentistry (IAAD) confirms the
with butt joint design, the result obtained in this study showed that
finding of the other laboratory studies and recommends pretreatment
endocrowns made of CERASMART recorded a statistically significant
via HF acid etching and application of a silane [41,42] The silica-based
higher mean value fracture load (1522.64 ± 352.52) than endocrowns
ceramic part of the hybrid ceramic seems to determine the best choice
made of IPS e.max CAD (717.33 ± 198.59). This may be attributed to
of surface pretreatment [43].
the boding strength of CERASMART to the tooth structure and stress
The samples testing was done by applying compressive load using a absorption nature of hybrid ceramic composition with breaking energy
universal testing machine along the long axis of the endocrown using a (2.2 MPa) while the IPS e.max CAD has breaking energy (0.6 MPa).
load applicator in the form of stain less-steel round tip with a 3.4 mm Moreover, due to the low Flexural Modulus of CERASMART (7.9 GPa)
diameter centered in occlusal surface between the buccal and lingual and high Flexural Modulus of e.max CAD (32.3 GPa) [24].
cusp with tin foil sheet in-between to achieve homogenous stress
This results were in agreement with El-Damanhoury et al. [7] who
distribution and minimization of the transmission of local force peaks,
reported significantly higher fracture resistance of hybrid ceramic
at crosshead speed of 0.5mm/min until failure [29].
endocrowns than IPS e.max CAD endocrowns.
Compressive lading until fracture represented a worst-case scenario.
This was opposed by Stona et al. [52] who reported that IPS
It does not replicate what take place in the clinical oral environment, in
Empress CAD and IPS e.max CAD showed higher fracture resistance
which teeth are subjected to masticatory forces over a long period of
compared with CEREC VITABLOCS Mark II. finding might be related
time which may cause fatigue resulting in tooth fracture. However, this
to the difference in the material used in their study.
test would at least detect differences between different treatment
modalities regarding their strength. This method of testing has been Regarding to the materials and design, the result obtained in this
widely used in previous studies [44]. study recorded a non-statistically significant mean value fracture load
between endocrowns with butt joint design made of hybrid ceramic

Dentistry, an open access journal Volume 7 • Issue 12 • 1000464

ISSN:2161-1122
Citation: Al-shibri S, Elguindy J (2017) Fracture Resistance of Endodontically Treated Teeth Restored With Lithium Disilicate Crowns Retained
With Fiber Posts Compared To Lithium Disilicate and Cerasmart Endocrowns: In Vitro Study. Dentistry 7: 464. doi:
10.4172/2161-1122.1000464

Page 8 of 9

CERASMART (1522.64 ± 352.52) and post and core with 2mm ferrule Recommendations
effect supported IPS exam cad crown (1301.34 ± 177.12). This may be
attributed to the bonding strength of CERASMART to the tooth In-vivo studies should be conducted to help the clinician predict the
structure and stress absorption nature of hybrid ceramic composition clinical performance of CERASMART endocrowns.
with breaking energy (2.2 MPa) while the IPS e.max CAD has breaking
energy (0.6 MPa) [24]. Acknowledgements
CERASMART endocrowns cemented with All- Bond (Bisco) No acknowledgements
resulted in higher fracture resistance than the controls. It must be
considered that the adhesion of the restoration is dependent on the Conflict of Interest
type of cement used moreover, it can be expected that the greater the
adhesion of the restoration, the better the stress distribution within the No conflict of interest
system, thus resulting in higher fracture resistance. Not less important,
premolars and molars may receive similar forces during oral function, References
contributing for the similar results when considering only posterior
teeth [53]. Forberger et al. [54] endocrowns resulted in similar fracture 1. Zhu Z, Dong XY, He S, Pan X, Tang L (2015) Effect of Post Placement on
the Restoration of Endodontically Treated Teeth: A Systematic Review.
strength when compared to groups restored with posts based on
Int J Prosthodont 28: 475-483.
ceramic (zirconia), gold or glass fiber.
2. Lazari PC, Oliveira RCN de, Anchieta RB (2015) Stress distribution on
This result was opposed with by Lin et al. [46] observed the dentin-cement-post interface varying root canal and glass fiber post
favorable performance of endocrown restorations in premolars over diameters. A three-dimensional finite element analysis based on micro-
CT data. J Appl Oral Sci 21: 511-517.
conventional crown by using the finite element method. These results
were in agreement with Lin et al. [11], and Chang et al. [50] they found 3. Roscoe MG, Noritomi Y, Novais R, Soares J, Information RA (2013)
Influence of alveolar bone loss, post type, and ferrule presence on the
that the endocrown and conventional crown with post and core
biomechanical behavior of endodontically treated maxillary canines :
restorations for endodontically treated premolars did not significantly Strain measurement and stress distribution.
differ from each other. They explained that the endocrown restorations
4. Otto T (2004) Computer-aided direct all-ceramic crowns: preliminary 1-
recorded comparable stress values because endocrown include both year results of a prospective clinical study. Int J Periodontics Restorative
the crown and core as a single unit which decrease the effect of Dent 24: 446-455.
multiple interfaces that found in conventional crown. As well, 5. Sagsen B, Aslan B (2006) Effect of bonded restorations on the fracture
thickening of the ceramic occlusal portion compared to the resistance of root filled teeth. Int Endod J 39: 900-904.
conventional crown. 6. Tay FR, Pashley DH (2007) Monoblocks in root canals: a hypothetical or
a tangible goal. J Endod 33: 391-398.
This finding is clinically relevant because it shows that endocrowns
7. Rn HME, Platt HJA (2005) Fracture Resistance and Microleakage of
may work similar to restorations made with intraradicular posts, at Endocrowns Utilizing Three CAD-CAM Blocks. Oper Dent : 1-10.
least concerning fracture resistance of posterior teeth. According to the
8. Decerle N, Bessadet M, Eschevins C, Veyrune J, Nicolas E (2014)
previous discussion and result the first null hypothesis was rejected, Evaluation of Cerec Endocrowns : A Preliminary Cohort Study 22: 1-7.
since IPS e.max CAD endocrowns reveled low fracture resistance than 9. Bindl A, Mormann WH (1999) Clinical evaluation of adhesively placed
IPS e.max CAD crowns retained with fiber posts and the composite Cerec endo-crowns after 2 years--preliminary results. J Adhes Dent 1:
core, while CERASMART endocrowns reveled higher but not 255-265.
statistically significant. While second null hypothesis was accepted, 10. Goncalves LA d A, Vansan LP, Paulino SM, Sousa Neto MD (2006)
since endocrowns made of hybrid ceramics CERASMART material Fracture resistance of weakened roots restored with a transilluminating
reveled more fracture resistance than IPS e.max CAD endocrowns. post and adhesive restorative materials. J Prosthet Dent 96: 339-344.
11. Lin CL, Chang YH, Pai CA (2011) Evaluation of failure risks in ceramic
restorations for endodontically treated premolar with MOD preparation.
Conclusion Dent Mater 27: 431-438.
Within the limitation of this study, the following conclusions were 12. Hayashi M, Takahashi Y, Imazato S, Ebisu S (2006) Fracture resistance of
drawn: pulpless teeth restored with post-cores and crowns. Dent Mater 22:
477-485.
• CERASMART endocrowns provide promising fracture resistance 13. Magne P, Carvalho AO, Bruzi G, Anderson RE, Maia HP (2014) Influence
than IPS e.max CAD endocrowns as a treatment modality of of no-ferrule and no-post buildup design on the fatigue resistance of
endodontically treated maxillary premolars. endodontically treated molars restored with resin nanoceramic
• CERASMART Endocrowns are as promising as fiber post and core CAD/CAM crowns. Oper Dent 39: 595-602.
supported IPS e.max CAD crowns interims of fracture resistance. 14. da Silva GR, Santos-Filho PC de F, Simamoto-Jnior PC, Martins LRM, da
Mota AS (2011) Effect of post type and restorative techniques on the
• Endocrowns made of IPS e.max CAD show lower fracture strain and fracture resistance of flared incisor roots. Braz Dent J 22:
resistance than fiber post and core supported IPS e.max CAD 230-237.
crowns with irreparable. 15. D’Arcangelo C, De Angelis F, Vadini M, D’Amario M, Caputi S (2010)
• All fracture resistance loads obtained were far beyond the Fracture Resistance and Deflection of Pulpless Anterior Teeth Restored
maximum masticatory forces, which can with stand the maximum with Composite or Porcelain Veneers. J Endod. 36: 153-156.
intraoral masticatory forces in the maxillary premolar region. 16. Zhou L, Wang Q (2013) Comparison of Fracture Resistance between Cast
Posts and Fiber Posts : A Meta-analysis of Literature. J Endod 39: 11-15.
17. Creugers NHJ, Mentink AGM, Fokkinga WA, Kreulen CM (2005) 5-year
follow-up of a prospective clinical study on various types of core
restorations. Int J Prosthodont 18: 1.

Dentistry, an open access journal Volume 7 • Issue 12 • 1000464

ISSN:2161-1122
Citation: Al-shibri S, Elguindy J (2017) Fracture Resistance of Endodontically Treated Teeth Restored With Lithium Disilicate Crowns Retained
With Fiber Posts Compared To Lithium Disilicate and Cerasmart Endocrowns: In Vitro Study. Dentistry 7: 464. doi:
10.4172/2161-1122.1000464

Page 9 of 9

18. Biacchi GR, Mello B, Basting RT (2013) The Endocrown: An Alternative with Er; Cr: YSGG laser and hydrofluoric acid: an in vitro study. Br J Med
Approach for Restoring Extensively Damaged Molars. J Esthet Restor Med Res 7: 550-560.
Dent 25: 383-390. 38. Spitznagel FA, Horvath SD, Guess PC, Blatz MB (2014) Resin bond to
19. Gresnigt MMM, Ozcan M, van den Houten MLA, Schipper L, Cune MS indirect composite and new ceramic/polymer materials: a review of the
(2016) Fracture strength, failure type and Weibull characteristics of literature. J Esthet Restor Dent. 26: 382-393.
lithium disilicate and multiphase resin composite endocrowns under axial 39. Ozer F, Blatz MB (2013) Self-etch and etch-and-rinse adhesive systems in
and lateral forces. Dent Mater 32: 607-614. clinical dentistry. Compend Contin Educ Dent 34: 12-14.
20. Jotkowitz A, Samet N (2010) Rethinking ferrule–a new approach to an 40. El Guindy J, El Sherif R, Aboul-Ezz AA (2016) Evaluation Of Marginal
old dilemma. Br Dent J. 209: 25-33. Discrepancy And Microleakage Of Lava Ultimate (Resin Nano Ceramic)
21. Skupien JA, Luz MS, Pereira-Cenci T (2016) Ferrule Effect A Meta- Versus Lithium Disilicate (Ips E. Max Cad) Endocrowns. In Vitro Study.
analysis. JDR Clin Transl Res. Indian J Sci Res 7: 27.
22. Blatz MB (2002) Long-term clinical success of all-ceramic posterior 41. Lise DP, Van Ende A, De Munck J, Vieira L, Baratieri LN (2015)
restorations. Quintessence Int (Berl) 33: 6. Microtensile Bond Strength of Composite Cement to Novel CAD/CAM
23. Guess PC, Schultheis S, Bonfante EA, Coelho PG, Ferencz JL (2011) All- Materials as a Function of Surface Treatment and Aging. Oper Dent 42:
ceramic systems: laboratory and clinical performance. Dent Clin North 73-81.
Am. 55: 333-352. 42. Cekic-Nagas I, Ergun G, Egilmez F, Vallittu PK, Lassila LVJ (2016) Micro-
24. Awada A, Nathanson D (2014) Mechanical properties of resin-ceramic shear bond strength of different resin cements to ceramic/glass-polymer
CAD / CAM restorative materials. J Prosthet Dent. 2014: 1-7. CAD-CAM block materials. J Prosthodont Res 60: 265-273.
25. Alzayer AA (2016) Microleakage of lithium disilicate ceramic crowns and 43. Güngör MB, Nemli SK, Bal BT, Ünver S, Doğan A (2016) Effect of surface
nano ceramic crowns: A comparative study. treatments on shear bond strength of resin composite bonded to
26. Bhat V, Shenoy K, Dandekeri S, Reddy H (2016) CAD-CAM CAD/CAM resin-ceramic hybrid materials. J Adv Prosthodont 8:
CERAMICS-A Litrature review. 259-266.
27. Heydecke G, Peters MC (2002) The restoration of endodontically treated, 44. Azarbal A (2015) Marginal Fit Comparison Of Cad/Cam Crowns Milled
single-rooted teeth with cast or direct posts and cores: a systematic From Two Different Materials.
review. J Prosthet Dent 87: 380-386. 45. Lin CL, Chang YH, Chang WJ, Cheng MH (2006) Evaluation of a
28. Potocnik B (2015) Automated landmark points detection by using a reinforced slot design for CEREC system to restore extensively
mixture of approaches: the vole-teeth case. Signal, Image Video Process 9: compromised premolars. J Dent 34: 221-229.
93-104. 46. Lin CL, Chang YH, Pa CA (2009) Estimation of the Risk of Failure for an
29. Hamdy A (2015) Effect of Full Coverage, Endocrowns, Onlays, Inlays Endodontically Treated Maxillary Premolar With MODP Preparation and
Restorations on Fracture Resistance of Endodontically Treated Molars 1: CAD/CAM Ceramic Restorations. J Endod 35: 1391-1395.
1-5. 47. Komiyama O, Obara R, Iida T (2015) Comparison of direct and indirect
30. Bassir MM, Labibzadeh A, Mollaverdi F (2013) The effect of amount of occlusal contact examinations with different clenching intensities. J Oral
lost tooth structure and restorative technique on fracture resistance of Rehabil 42: 185-191.
endodontically treated premolars. J Conserv Dent 16: 413. 48. Schmidlin PR, Stawarczy B, DeAbreu D, Bindl A, Ender A (2015)
31. Coniglio I, Garcia-Godoy F, Magni E, Carvalho CA, Ferrari M (2009) Fracture resistance of endodontically treated teeth without ferrule using a
Resin cement thickness in oval-shaped canals: oval vs. Circular fiber posts novel H-shaped short post. Quintessence Int (Berl) 46: 2.
in combination with different tips/drills for post space preparation. Am J 49. Ma PS, Nicholls JI, Junge T, Phillips KM (2009) Load fatigue of teeth with
Dent 22: 290-294. different ferrule lengths, restored with fiber posts, composite resin cores,
32. Carvalho AO, Bruzi G, Anderson RE, Maia HP, Giannini M, Magne P and all-ceramic crowns. J Prosthet Dent 102: 229-234.
(2016) Influence of adhesive core buildup designs on the resistance of 50. Lin CL, Chang YH, Hsieh SK, Chang WJ (2013) Estimation of the failure
endodontically treated molars restored with lithium disilicate CAD/CAM risk of a maxillary premolar with different crack depths with endodontic
crowns. Oper Dent. 41: 76-82. treatment by computer-aided design/computer-aided manufacturing
33. Guo J, Wang Z, Li X, Sun C, Gao E (2016) A comparison of the fracture ceramic restorations. J Endod 39: 375-379.
resistances of endodontically treated mandibular premolars restored with 51. Biacchi G, Basting R (2012) Comparison of Fracture Strength of
endocrowns and glass fiber post-core retained conventional crowns. J Adv Endocrowns and Glass Fiber Post-Retained Conventional Crowns. Oper
Prosthodont 8: 489. Dent 37: 130-136.
34. Lee CYS, Wong N, Ganz SD, Mursic J, Suzuki JB (2015) Use of an 52. Stona D, Burnett LH, Mota EG, Spohr AM (2015) Fracture resistance of
intraoral laser scanner during the prosthetic phase of implant dentistry: a computer-aided design and computer-aided manufacturing ceramic
pilot study. J Oral Implantol. 41: e126-e132. crowns cemented on solid abutments. J Am Dent Assoc 146: 501-507.
35. Tian T, Tsoi JK-H, Matinlinna JP, Burrow MF (2014) Aspects of bonding 53. De Souza G, Braga RR, Cesar PF, Lopes GC (2015) Correlation between
between resin luting cements and glass ceramic materials. Dent Mater 30: clinical performance and degree of conversion of resin cements: a
e147-e162. literature review. J Appl Oral Sci 23: 358-368.
36. Pereira JR, Lins A, Shiratori K (2015) The effect of post material on the 54. Forberger N, Göhring TN, Lang H (2008) Influence of the type of post
characteristic strength of fatigued endodontically treated teeth. J Prosthet and core on in vitro marginal continuity, fracture resistance, and fracture
Dent. mode of lithia disilicate-based all-ceramic crowns. J Prosthet Dent 100:
37. Paul P, Duvvuri SNR, Alla RK, Rajasigamani K (2015) Evaluation of shear 264-273.
bond strength of stainless steel brackets bonded to ceramic crowns etched

Dentistry, an open access journal Volume 7 • Issue 12 • 1000464

ISSN:2161-1122