Ó

Operative Dentistry, 2014, 39-6, 595-602

Laboratory Research

Influence of No-Ferrule and No-Post

Buildup Design on the Fatigue
Resistance of Endodontically

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Treated Molars Restored With Resin
Nanoceramic CAD/CAM Crowns
P Magne  AO Carvalho  G Bruzi
RE Anderson  HP Maia  M Giannini

Clinical Relevance
Endodontically treated molars with extensive loss of coronal structure and no ferrule effect
could be restored successfully with resin nanoceramic CAD/CAM crowns, with or without
underlying composite resin buildup.

SUMMARY
*Pascal Magne, PhD, University of Southern California,
Restorative Sciences, Los Angeles, CA, USA Objectives: To evaluate the influence of adhe-
Adriana Oliveira Carvalho, PhD, Piracicaba Dental School/ sive core buildup designs—4-mm buildup, 2-
State University of Campinas, Department of Restorative mm buildup, and no buildup (endocrown)—on
Dentistry, Salvador, Bahia, Brazil the fatigue resistance and failure mode of
Greciana Bruzi, MSc, Universidade Federal de Santa Cata- endodontically treated molar teeth restored
rina, Odontology, Federal University of Santa Catarina with resin nanoceramic (RNC) CAD/CAM com-
(UFSC), Department of Odontology, Santa Catarina, Brazil plete crowns placed with self-adhesive resin
Robert E Anderson, DMD, University of Southern California, cement.
Graduate Endodontics Department, Los Angeles, CA, USA
Methods and Materials: Forty-five extracted
Hamilton Pires Maia, PhD, Universidade Federal de Santa molars were decoronated at the level of the
Catarina, Operative Dentistry, Department of Odontology, cementoenamel junction, and the roots were
Santa Catarina, Brazil
endodontically treated. Specimens received
Marcelo Giannini, DDS, MS, PhD, associate professor, different Filtek Z100 adhesive core buildups
Piracicaba Dental School, University of Campinas, Depart-
(4-mm buildup, 2-mm buildup, and no buildup,
ment of Restorative Dentistry, Piracicaba, Brazil
endocrown preparation) and were restored
*Corresponding author: 3305B S. Hoover Street, Bldg. A -
with Cerec 3 CAD/CAM RNC crowns (Lava
Room A-122B, Los Angeles, CA 90089-7001, USA; e-mail:
[email protected] Ultimate). Restorations (n=15) and prepared
teeth were treated with airborne-particle
DOI: 10.2341/13-004-L
abrasion, followed by cementation with RelyX
596 Operative Dentistry

Unicem 2 Automix. Specimens were then sub- poor structural integrity, with loss of root and
jected to cyclic isometric loading at 10 Hz, coronal dentin resulting from preexisting caries
beginning with a load of 200 N (for 5000 cycles), and/or tooth preparation.1-4 There is controversy
followed by stages of 400, 600, 800, 1000, 1200, regarding which technique would be ideal for ETM
and 1400 N at a maximum of 30,000 cycles each. restoration.
Specimens were loaded until failure or to a Although earlier publications have called for
maximum of 185,000 cycles (10-mm-diameter stabilization of ETM with intracanal posts and
composite resin sphere antagonist). The fail- ferrule, other evidence has demonstrated that post
ure mode was assessed: ‘‘catastrophic’’ (tooth/ reinforcement is not beneficial.3,5 Even though posts

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root fracture that would require tooth extrac- are frequently used to retain coronal buildup
tion), ‘‘possibly reparable’’ (cohesive/adhesive
materials, they do not reinforce roots and may even
failure with fragment and minor damage, chip
weaken them through loss of radicular dentin
or crack, of underlying tooth structure), or
necessitated by post space preparation.5,6 In addi-
‘‘reparable’’ fracture (cohesive or cohesive/ad-
tion, preparing a post space also involves a certain
hesive fracture of restoration only). Groups
degree of risk of accidental root perforation. The loss
were compared using the life table survival
of tooth structure during preparation affects tooth
analysis. Intact specimens were loaded to
stiffness, reduces its resistance to fracture, and
failure and compared with one-way analysis
consequently limits its prognosis. Other studies7-9
of variance.
have confirmed that ETM restored without posts
Results: All specimens survived the fatigue test have similar fracture resistances and failure modes
until the 800 N-step. The survival rates for 4- compared with those with posts, which suggest that
mm, 2-mm, and no buildup (endocrown) were posts are not necessarily required. Lima and others7
53%, 87%, and 87%, respectively, and were not confirmed that the presence of a ferrule (with a
statistically different even though crowns with composite resin buildup) is more critical than the use
2-mm buildups only started to fail at 1200 N. of a post. However, there is no consensus about the
Minor cohesive chips were detected in many optimal buildup design necessary to restore ETM in
samples despite having survived all 185,000 the absence of any ferrule. The endocrown restora-
cycles. Postfatigue load-to-failure ranged from tion is another alternative restorative treatment for
2969 N with 4-mm buildup (eight specimens), ETM.10,11 Pissis10 was a pioneer in proposing this
2794 N for 2-mm buildup (13 specimens), and ‘‘monobloc’’ porcelain technique in 1995. This type of
2606 N for endocrowns (13 specimens) and restoration preserves root tissue and limits internal
were also not statistically different. There preparation of the pulp chamber to its anatomic
were only two catastrophic failures during shape. It constructs both the crown and core build-up
the fatigue test and small subgingival delami- as a single unit. Even though the original technique
nation fractures and cracks (only with 4-mm described the use of porcelain, in vitro fatigue tests
buildup). All specimens in the load-to-failure showed that endocrowns made of more flexible
test exhibited nonrestorable catastrophic frac- composite resin or newer resin nanoceramic (RNC)
tures. materials may also have a great potential for this
Conclusions: There was no influence of the indication.11-14 Another consideration is the possible
buildup design on the performance of end- use of a core buildup to remove retention from the
odontically treated molars restored with RNC endodontic preparation, provide some kind of posi-
CAD/CAM complete crowns placed with self- tive geometry, decrease restoration thickness (allow-
adhesive cement. All restoration designs sur- ing for the use of light-polymerized luting
vived the normal range of masticatory forces. composites), and facilitate provisionalization. Yet
Failure mode tended to be more favorable with there is a lack of data about the biomechanical
the 2-mm buildup or no buildup (endocrown). behavior of different buildup designs to restore ETM.
Therefore, the aim of this study was to evaluate
INTRODUCTION the influence of a 4-mm buildup, a 2-mm buildup, or
The decision of how to rehabilitate endodontically no buildup (endocrown) on the mechanical perfor-
treated molars (ETM) with extensive loss of coronal mance and failure mode of ETM restored with RNC
structure is a challenge for restorative dentistry. CAD/CAM complete crowns placed with self-adhe-
Those teeth are considered to have a higher risk of sive cement. The null hypothesis was that there is no
fracture than vital teeth because of their inherently significant difference in the fatigue resistance and
Magne & Others: Endodontically Treated Molars Restored With CAD/CAM Crowns 597

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Figure 1. Restorative techniques. (A): Group I. (B): Group II. (C): Group III.

failure mode of ETM among the three different Warm vertical obturation of the canals was then
designs tested in this in vitro study. performed using gutta percha to the orifice level and
condensed. An additional horizontal reduction of 1.0
METHODS AND MATERIALS mm was obtained (flat preparation following the CEJ,
Once approval was obtained from both the Ethical no ferrule) with the aid of a coarse round diamond bur
Committee of the Piracicaba Dental School (Campi- (Brasseler, Savannah, GA, USA). Finally, a 1.0- to
nas State University) and the University of Southern 1.5-mm-thick glass-ionomer barrier (Ketac Molar, 3M
California Review Board, 45 freshly extracted, sound ESPE, St Paul, MN, USA) was applied to the base of
human maxillary molars stored in solution saturated the pulp chamber.
with thymol were used. Teeth were mounted in a The teeth were randomly divided into three groups
special positioning device with acrylic resin (Pala- according to the different restorative techniques
press; Heraeus Kulzer, Armonk, NY, USA) embed- (n=15):
ding the root up to 3.0 mm below the cementoenamel
junction (CEJ).  Group I: large buildup (4-mm height from CEJ at
cusp tips, 2-mm height from CEJ at central groove)
Tooth Preparation þ complete crown restorations (1.5 mm thick;
A standardized tooth preparation was applied to all Figure 1A)
specimens. The intact crowns were removed by a  Group II: short buildup (2-mm height from CEJ at
horizontal section 1 mm above the CEJ using a cusp tips, 1-mm height from CEJ at central groove)
diamond saw (Isomet, Buehler Ltd, Lake Bluff, IL, þ complete crown restorations (2.5-3.5 mm thick;
USA), under water lubrication. A standard access Figure 1B)
opening was prepared to simulate root canal treat-  Group III: endocrown restoration (ca. 5- to 5.5-mm
ment in each tooth. Teeth were accessed using slow- thickness; Figure 1C)
speed round and GK269 burs to deroof the pulp
Buildups for groups I and II were made using
chamber and smoothen the internal walls. Canals
Optibond FL adhesive system (Kerr Corp, Orange,
were located and patency achieved using #10 K-files
CA, USA) and Filtek Z100 composite resin (3M
(Dentsply Tulsa Dental, Johnson City, TN, USA).
ESPE) placed in 1.5-mm increments polymerized for
Coronal flare was created using Gates #3 (Dentsply
20 seconds each at 1000 mW/cm2.
Tulsa Dental), and canals were chemomechanically
debrided using 04 rotary files (Protaper Niti Rotary,
Dentsply Tulsa Dental) and NaOCl (5.25%) to within Design and Manufacturing of Restorations
3 mm of the apex. A final rinse with H2O was The molars were restored using the Cerec 3 CAD/
performed, and canals were dried using paper points. CAM system (Sirona Dental Systems GmbH, Ben-
598 Operative Dentistry

Table 1: Failure Mode During Fatigue Testing

Reparable Not Reparable
Cohesive Failure Cohesive Failure Adhesive Failure Cohesive Failure Catastrophic Failure
at Crown at Crown and Buildup Between Crown and at Crown
þ Adhesive Failure Buildup þ Adhesive and Buildup
at Dentin Margin Failure at Dentin Margin þ Dentin Chip
Endocrown 1 — — 1 —
2-mm Buildup 2 — — — —
4-mm Buildup 1 3 1 — 2

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sheim, Germany). The specimens were fitted with a bristle brush) with diamond paste (Diamord Twist
crown or endocrown of standardized thickness and SCL, Premier), and buffed with a muslin rag wheel.
occlusal anatomy (third maxillary molar, Lee Culp
Youth database). Using the Crown Master Mode and Testing
the Design Tools of the Cerec software (v. 3.6, Sirona
Fatigue Testing—Each specimen was stored in
Dental Systems), the occlusal surface was moved and
distilled water at room temperature for at least 24
rotated to make parallel the cusp tips and the
hours following adhesive restoration placement.
preparation surface as well as to align the central
Masticatory forces were then simulated with an
groove. All restorations were milled in RNC (Lava
artificial mouth using closed-loop servo hydraulics
Ultimate blocks, 3M ESPE) using the Endo mode
(Mini Bionix II; MTS Systems, Eden Prairie, MN,
with the sprue located at the lingual surface, then
USA). Each specimen was placed into the load
polished mechanically with a diamond ceramic
chamber and situated with a positioning device
polisher (CeramiPro Dialite W16DM; Brasseler),
(sliding table). The chewing cycle was simulated by
polishing brush (soft bristle brush) with diamond
an isometric contraction (load control) applied
paste (Diamond Twist SCL, Premier, EC Represen- through a composite resin sphere (Filtek Z100, 3M
tative: MDSS GmbH * Schiffgraben, Hannover,
ESPE) with a diameter of 10.0 mm. Because of the
Germany), and buffed with a muslin rag wheel. standardized occlusal anatomy, all specimens could
be adjusted (through the positioning device) in the
Crown Placement same reproducible position with the sphere contact-
All crowns were cemented with a dual-cure self- ing the mesiobuccal, distobuccal, and palatal cusps
adhesive resin cement (RelyX Unicem 2 Automix, (tripod contact). The load chamber was filled with
3M ESPE). Before cementation, each crown was distilled water to submerge the sample during
fitted on its respective tooth to check its marginal testing. Cyclic load was applied at a frequency of
adaptation and steam cleaned. The inner surface of 10 Hz, starting with a load of 200 N for 5000 cycles
LU crowns were sandblasted with 50 lm aluminum (preconditioning phase to guarantee predictable
oxide (Danville, San Ramon, CA, USA), rinsed, and positioning of the sphere with the specimen),
cleaned in an ultrasonic bath in distilled water for followed by stages of 400, 600, 800, 1000, 1200, and
one minute. The prepared teeth were sandblasted 1400 N at a maximum of 30,000 cycles each. Samples
with 27 lm aluminum oxide, rinsed, and dried. The were loaded until fracture or to a maximum of
cement was applied to the inner surface of the 185,000 cycles. The number of endured cycles and
crowns, which were then seated on the tooth with an failure mode were recorded. Following a two-exam-
approximate pressure of 70 N. Cement excesses were iner agreement using optical microscopy, a distinc-
removed after a brief light exposure (approximately tion was made between ‘‘catastrophic’’ failure (crown/
two seconds) with an LED light (VALO Curing root fracture that would require tooth extraction) or
Light, Ultradent Products Inc, South Jordan, UT, ‘‘reparable’’ failure (cohesive or cohesive/adhesive
USA) and followed by light polymerization for 20 failure with or without fragment and minor damage,
seconds on each surface. Air-blocking barrier (KY chip or crack, of underlying tooth structure; Table 1).
Jelly; Johnson & Johnson Inc, Montreal, QC, Load-to-Failure Testing of Intact Postfatigue Speci-
Canada) was used to cover all margins, and mens (in Case of Major Percentage of Specimen
additional polymerization was carried out for 20 Surviving Fatigue)—After the fatigue test, intact
seconds per surface. The margins were finished and specimens were axially loaded until failure or to a
polished with a diamond ceramic polisher (Cerami- maximum load of 4500 N with a 10-mm composite
Pro Dialite W16DM; Brasseler), polishing brush (soft resin sphere. The sphere had the same three-point
Magne & Others: Endodontically Treated Molars Restored With CAD/CAM Crowns 599

RESULTS
The survival rates after the fatigue test for ETM
with 4-mm buildups, 2-mm buildups, and endo-
crowns were 53% (eight samples), 87% (13 samples),
and 87% (13 samples), respectively, and no statisti-
cally significant differences were found among them
(p.0.05; Figure 2). In groups with large buildups
and endocrowns, all specimens survived until the
800 N-step, while for specimens with short buildups,

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samples started to fail only at the 1200 N-step. At
the end of the fatigue test, minor surface chips were
detected (two specimens with large buildups and
Figure 2. Life table survival distributions by materials at each load
nine specimens with short buildups or endocrowns).
step (n=15). All specimens demonstrated less wear at the resin
sphere antagonist than the restoration itself (Figure
3).
occlusal contacts as in the fatigue test. The cross-
head speed was 0.5 mm/min. The maximum post- Postfatigue load-to-failure averaged 2969 N with
fatigue load before failure was recorded in Newtons, 4-mm buildups (eight specimens), 2794 N for 2-mm
and mean values were calculated per group. After buildups (13 specimens), and 2606 N for endocrowns
(13 specimens). One-way ANOVA revealed that
load tests, the specimens were analyzed for one of
there were no statistically significant differences
the three failure modes as in the fatigue test.
among all three restorative techniques. Failure
Statistical Analysis—The fatigue resistance of the mode analysis showed that there were only two
three groups was compared using the life table evident catastrophic failures during the fatigue test.
survival analysis. At each time interval (defined by All failure modes found at the fatigue test are given
each load step), the number of specimens starting in Table 1. All of the specimens after the load-to-
the interval intact and the number of specimens failure test exhibited nonrestorable catastrophic
fracturing during the interval were counted, allow- fractures.
ing the calculation of survival probability (%) at
each interval. The influence of the restorative DISCUSSION
material on the fracture strength (load step at Based on the results of this study, the null
which failure occurred) was analyzed by using the hypothesis was accepted for the fatigue resistance
log-rank test at a significance level of 0.05. The but rejected for failure mode analysis of ETM. The
postfatigue load-to-failure resistance of the sur- failure modes slightly varied, with less favorable
vived specimens was compared using one-way outcomes when using a large core buildup.
analysis of variance (ANOVA; data tested normal). In an effort to standardize and approximate the
For all statistical analyses, the level of significance clinical situation as much as possible, natural teeth
was set at 95%. The data were analyzed with of similar dimensions were selected, the anatomy of
statistical software (MedCalc, V. 11.0.1; MedCalc the occlusal surface and the thickness of those
Software, Mariakerke, Belgium). restorations were standardized by the Cerec ma-

Figure 3. Photographs of crown and antagonist (resin sphere) wear.

600 Operative Dentistry

chine, and the consistent load configuration of all fracture strength than the conventional crowns
samples was applied. As previously suggested,13,15 supported on posts and filling cores.
the use of a composite resin sphere antagonist was Another specific element in this study was the use
preferred rather than a stainless-steel one. A more of self-adhesive resin cement. It allows for a
realistic simulation of tooth contacts is enabled by convenient, fast, and efficient delivery of complete
the lower stiffness and higher wear of the composite crowns. This is especially significant when consider-
resin.16 No failure of the spheres was noted during ing excess cement removal in the case of subgingival
the test. Because of the simulated natural tooth margins (a common situation when replacing exist-
anatomy of the restorations, a standardized three- ing complete crowns), for which adhesive luting

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point/facet contact could be created and a progres- becomes more technique sensitive. RelyX Unicem 2
sive load protocol generated (from 200 N to 1400 N, was chosen also because of its self-polymerization
maximum 185,000 cycles). Loaded restorations and component, which was desirable for the thick
teeth should show wear facets and not point endocrowns. The same cement was used to deliver
contacts.15 Such wear facets both at the restorations the other crowns on the different buildups in order
and resin sphere antagonists were observed. As was not to introduce a new variable.
the case in previously published data,17 the RNC The results of this study demonstrated that the
material demonstrated more material wear than the presence of a buildup does not necessarily enhance
antagonistic wear (resin sphere). This can be the fracture resistance of ETM with extensive loss of
explained by the fact that the RNC material has coronal structure when using RNC crowns. Howev-
80% filler content by weight (20% resin matrix) er, the mean fracture loads for the 4-mm buildup
compared with 85%/15% for Filtek Z100 composite (1171 N), 2-mm buildup (1300 N), and endocrown
resin (antagonist sphere). (1000 N) failed fatigued restorations far exceeded
The present protocol seems to be the best compro- regular masticatory forces. The latter, during nor-
mise between available in vitro fatigue testing mal function, range from 50 N to 250 N and from 500
methods and clinical reality and can be called N to 800 N in bruxism behavior.22,23 The 4-mm
accelerated fatigue. Even though it is not possible buildup and endocrown restorations started to fail at
to make a direct clinical correlation about the 800 N, while all short buildups did not show fracture
significance of the load range used in this study, before 1200 N. Those results suggest that it may be
this test lies in between load-to-failure (very high possible to use all three types of RNC restorations
with self-adhesive cementation for ETM with exten-
single load until failure, not clinically relevant
sive loss of coronal structure even under high load
unless during trauma) and fatigue tests (time-
requirements. It is noteworthy to compare the
consuming low load/high cycles). A true fatigue
performance of those restored nonvital teeth with
correlation for one year of clinical service is
that of crowned vital molars from another study by
250,000 cycles at only 13.6 N.18 Therefore, given
the same author in strictly identical conditions: 1.5-
the extended range of load in the present study, the
mm RNC crowns with self-adhesive cementation.17
accelerated life cycle of the restored tooth may have
Simulated fatigue survival of the crowned vital teeth
been simulated. was 80% (53%-87% in the present study), and the
A higher frequency (10 Hz) in the cyclic loading average load-to-failure of intact postfatigue speci-
test, which was suggested by Kelly and others,19 was mens was 3122 N (2606-2969 N in the present
used in this study. It decreases the time of the study). This indicates that the restorative modalities
experiment, allowing testing of three specimens per proposed for ETM in the present study may allow
day. One may wonder whether such high frequency approaching the performance of vital teeth despite
might lead to more heat generation compared with 1 the absence of a ferrule effect.
to 2 Hz and possibly exclude time for stress There is evidence that the use of posts does not
relaxation.20 Another limitation of this study is that influence the performance of restored ETM.3,5,21 In
the load was applied only axially, limiting the addition, the placement of a post is always associated
clinical implication to a vertical loading situation. with a risk of perforation and cracking of the root.
Biacchi and Basting21 used an oblique compression Therefore, no posts were used in the present study.
force to compare the fracture strength of endocrown No-post endocrown restorations allow for maximum
and complete crowns retained by glass fiber posts. tooth structure preservation, reduce the require-
However, as in the present study, the endocrown ment for macro retentive geometry, provide an
restorations performed well, even presenting greater efficient and esthetic outcome, and seem clinically
Magne & Others: Endodontically Treated Molars Restored With CAD/CAM Crowns 601

viable.24-26 From a clinical perspective, the endo- design on the performance of ETM restored with
crown design seems to have practical advantages RNC CAD/CAM full crowns placed with self-adhe-
over restorations with a core buildup: it is cheaper, it sive resin cement. All restoration designs survived
takes less time to complete, and there is no the normal range of masticatory forces. Failure mode
composite resin shrinkage associated with this tended to be more favorable with the 2-mm buildup
technique. The endocrown is also a useful option or no buildup (endocrown). The endocrown has many
when there is simply no occlusal clearance (extra- practical advantages (simpler, quicker, more eco-
short clinical crowns). On the other hand, there are nomic), while the use of a small composite resin
advantages of using an adhesive composite resin buildup may be useful to provide enhanced geome-

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core buildup when possible. The buildup is preceded try, remove undercuts from the endodontic prepara-
by the use of a dentin adhesive system that safely tion, and facilitate provisionalization when
seals the dentin. It reduces the thickness of the necessary.
overlaying restoration, allowing for a more efficient
light polymerization during cementation. It is known
Acknowledgements
that even for dual-polymerization cements, the light-
This study was supported by CNPq 20092/2011-6, CAPES
polymerization component is a determinant in 3110/2010, and CAPES 4979/11-7. The authors thank 3M
obtaining an acceptable degree of conversion.27-29 ESPE (St Paul, MN, USA) for providing Lava Ultimate blocks,
In view of the present results, small composite resin Rely X Unicem 2 Automix, Filtek Z100.
buildups should be preferred. They also induce less
polymerization shrinkage than large ones, and they Conflict of Interest
are useful for providing enhanced geometry, remov- The authors of this article certify that they have no
ing undercuts from the endodontic preparation, and proprietary, financial, or other personal interest of any nature
or kind in any product, service, and/or company that is
facilitating provisionalization (by stabilization) when presented in this article.
necessary.
Failure modes tended to be more favorable with (Accepted 15 July 2013)
the 2-mm buildup or no buildup (just cohesive
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