CLINICAL RESEARCH

Accelerated fatigue resistance of

endodontically treated incisors
without ferrule restored with CAD/
CAM endocrowns

Marco Aurélio de Carvalho, DDS, MS, PhD

Professor, Department of Oral Rehabilitation, School of Dentistry, Evangelic University of
Goias, Anápolis, Brazil

Priscilla Cardoso Lazari-Carvalho, DDS, MS, PhD

Professor, Department of Oral Rehabilitation, School of Dentistry, Evangelic University of
Goias, Anápolis, Brazil

Altair A. Del Bel Cury, DDS, MS, PhD

Professor, Department of Prosthodontics and Periodontology, Piracicaba Dental School,
University of Campinas, Piracicaba, SP, Brazil

Pascal Magne, DMD, PhD

The Don & Sybil Harrington Professor of Esthetic Dentistry, Division of Restorative
Sciences, Herman Ostrow School of Dentistry, University of Southern California,
Los Angeles, CA, USA

Correspondence to: Dr Lazari-Carvalho

Universidade Evangélica de Goiás, Faculdade de Odontologia. Avenida Universitária, km 3,5, Cidade Universitária,
CEP 75083515, Anápolis, GO – Brazil; Tel: (62) 999723755; Email: [email protected]

534 | The International Journal of Esthetic Dentistry | Volume 16 | Number 4 | Winter 2021
 CARVALHO ET AL

Abstract at P = 0.05) and Life Table survival analysis for load at

failure, followed by the Wilcoxon pairwise comparison
Purpose: The present study aimed to investigate the at P = 0.05.
resistance and failure mode of broken-down en- Results: All specimens failed before 140,000 load cy-
dodontically treated incisors without ferrule restored cles. There was no statistically significant difference
with CAD/CAM endocrowns. between the endocrown materials (Eld: 53,448 mean
Materials and methods: Endodontically treated endured cycles; Erc: 52,397 mean endured cycles;
bovine incisors (N = 30) without ferrule were divided P = 0.844). Endocrowns outperformed the group with
into two groups and restored with two types of CAD/ lithium disilicate crowns on incisors without ferrule
CAM endocrowns: lithium disilicate (Eld) or resin na- and post-and-core buildup (NfPf with mean endured
noceramics (Erc). The preparations included a 4-mm– 35,025 cycles), showed no statistical difference com-
deep ‘internal ferrule’ and immediate dentin sealing. pared with the group with no-post fiber-reinforced
The samples were subjected to accelerated fatigue composite resin core buildup (NfNpFR with 45,557
testing. Cyclic isometric loading was applied to the mean endured cycles), and had a lower survival rate
incisal edge at a 30-degree angle at a frequency of compared with the group with ferrule (FNp with mean
5 Hz, beginning with a load of 100 N (5,000 cycles). A endured 73,244 cycles). Endocrowns generated a
100 N load increase was applied every 15,000 cycles. majority of non-catastrophic failures (with an advan-
Specimens were loaded until failure or to a maximum tage for Erc), while 100% of catastrophic failures were
of 140,000 cycles. Previously published data from the found in the group with a post.
same authors regarding lithium disilicate crowns over Conclusions: CAD/CAM endocrowns of nonvital in-
post-and-core buildups without ferrule (NfPf), core cisors without ferrule improved the resistance and
buildups without post without ferrule (NfNpFR), and optimized the failure mode when compared with
with a 2-mm ferrule (FNp) using the same experimen- traditional bonded crowns with adhesive post-and-
tal setup were included for comparison. Groups were core and no-post buildups.
compared using the Kaplan Meier survival analysis for
cycles (log rank pairwise post hoc test comparisons (Int J Esthet Dent 2021;16:2–19)

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CLINICAL RESEARCH

Introduction the pulpal walls. Compared with traditional

crowns with posts and cores, which require
The rehabilitation of severely broken-down many steps to perform, the endocrown
endodontically treated teeth (ETT) without has many practical advantages: it is easy to
coronal tooth structure is still a challenge in perform, simpler, quicker, cheaper due to
modern dentistry and involves a variety of fewer steps involved, and has good esthet-
treatment options.1,2 Despite the fact that ic acceptance.22-24 Moreover, endocrowns
restorative treatment is critical to the long- manufactured through CAD/CAM techno-
term success of endodontic treatment, the logy are straightforward to obtain.
possible reconstruction materials and tech- Due to the recent increase in popular-
niques are still being debated, especially for ity of endocrowns, many case reports
the anterior dentition. Traditionally, anterior have been published describing the clinic-
teeth with extensive coronal loss have been al steps for their fabrication, their enhanced
restored with full crowns cemented over in vitro performance,8-10,25 and their high
cast post-and-core buildups (retention and success rate in posterior teeth.22,26-29 Ac-
resistance form) or direct post-and-core cording to short-term clinical reports, the
buildups (adhesion form). survival rate of endocrowns is 90% to 95%
It has been proven that the main role of a for posterior teeth.29-31 Recent systematic
post in the retention of the core is not as rel- reviews and meta-analyses evaluating clin-
evant for posterior teeth, where masticatory ical trials and in vitro studies on endocrowns
loads are essentially compressive vertically.1,3 suggest that they may perform similarly or
On the other hand, as maxillary incisors are better than conventional treatments using
loaded obliquely, the influence of a post intraradicular posts, direct composite resin
on the flexural behavior of a tooth should or inlay/onlay restorations.28,32,33 This tech-
be considered in order to reduce tooth nique represents a promising and conser-
fracture.1,4 Controversy exists regarding the vative alternative to full crowns for the treat-
biomechanical requirement of the macro- ment of posterior nonvital teeth that require
mechanical retention provided by posts in long-term stability.22,28,29,34 However, apart
both in vivo and in vitro investigations,5-18 with from all the research on posterior endo-
many associated complications, especially crowns, there are only a few finite element
the high stress concentration on the root, analyses35-38 and in vitro studies10,39 on endo-
leading to unfavorable root fractures.14,17,19-21 crowns used in the anterior dentition. To
Recent studies have shown that the date, no in vitro studies have been carried
placement of a post causes a large number out on incisors without ferrule restored with
of catastrophic failures, even among resto- different endocrown materials.
rations with adhesive post-and-core build- In addition, thanks to CAD/CAM techno-
ups.14,17,20 A no-post alternative to treat ETT logy, besides the traditional ceramic blocks,
involves the use of the pulp chamber and/or high-performance polymer blocks (HPP) have
coronal part of the endodontic canal as an recently been introduced. The manufacturing
adhesive surface for a bonded endocrown. of these materials under controlled industrial
This technique is a significant simplification, conditions has been shown to provide opti-
with both the crown and the core buildup mized mechanical properties of the resulting
being a single unit. Endocrowns are retained restoration compared with those prepared
mainly by micro-retention through the use under handcrafted conditions.40 Due to their
of adhesive cementation and also in part enhanced biomimetic properties (dentin-like
by macromechanical retention provided by flexibility and enamel-like wear), composite

536 | The International Journal of Esthetic Dentistry | Volume 16 | Number 4 | Winter 2021
 CARVALHO ET AL

resin materials may also have an advantage Tooth preparation

in the monolithic restoration of broken-down
endodontically treated incisors (ETIs). In all 30 roots, a standard chemomechanical
The no-post adhesive endocrown ap- endodontic protocol with ideal irrigants was
proach in combination with new, enhanced used.41,42 After the endodontic treatment,
HPPs could increase the fatigue resistance a so-called ‘internal ferrule’ was prepared
of no-ferrule ETIs and provide a more favor- using a conical-shaped bur. The internal fer-
able failure mode. The aim of the present rule was in the form of a box to simulate
study was to investigate the fatigue resis- an extensively damaged ETI and had the fol-
tance, load-at-failure, and failure mode of lowing dimensions – depth: 4 mm from the
broken-down ETIs without ferrule restored CPL; buccolingual width: 4 mm; mesiodis-
either with a lithium-disilicate ceramic tal width: 3 mm, which left a 1.5-mm–thick
endocrown or with a resin nanoceramic residual dentinal wall (Figs 1 and 2). Then, a
endocrown. glass-ionomer barrier (Vitrebond Plus; 3M
The main null hypothesis in the present ESPE) of a thickness of 1 to 1.5 mm was ap-
study was that the endocrown material plied to the base of the box. The prepared
would not lead to different fatigue resist- teeth were sandblasted with 27-μm silicated
ance of failure mode. Additional groups Al2O3 powder for cleaning purposes (CoJet;
with classic lithium disilicate crowns (in- 3M ESPE). Prior to the digital impression, im-
cluding composite resin buildups) from pre- mediate dentin sealing (IDS) was performed
vious studies with the same experimental for bonding optimization.29,43-45 The dentin
setup were included to test two additional was etched for 10  s with 35% phosphor-
hypotheses:14, 17, 21 a group with ferrule and ic acid (Ultra-Etch; Ultradent), rinsed, and
without post (FNp); a group without ferrule gently dried. A total-etch adhesive system
and with fiber post (NfPf); and a group with- was used (OptiBond FL; Kerr) with 20  s of
out ferrule and without post (NfNpFR). The primer application, followed by a bonding
first additional null hypothesis was that the layer (no air thinning). The adhesive was
presence of ferrule would not influence the polymerized at 1,000 mW/cm2 (VALO Cur-
fatigue resistance and failure mode. The ing Light; Ultradent) for 40 s, followed by a
second additional null hypothesis was that final polymerization for 10 s with a glycerin
the presence of post would not influence barrier (K-Y Jelly; Johnson & Johnson) in or-
the fatigue resistance and failure mode in der to limit the oxygen-inhibited layer. The
adhesively restored ETIs. final aspect of the preparation is presented
in Figure 2.
Materials and methods
Manufacturing of endocrowns
Thirty identical bovine incisors with similar
pulp space dimensions had the anatomical The teeth were restored using monolithic
crown sectioned 13 mm from the apex. The restorations obtained with the Cerec 3
teeth were mounted with acrylic resin (Pala- (Sirona) CAD/CAM system. Following IDS,
press vario; Hereaus Kulzer), embedding the roots were powdered for digital impres-
the root up to 2.5  mm below the cervical sion (IPS Contrast Spray Chairside; Ivoclar
preparation limit (CPL). The teeth were ran- Vivadent) with the Cerec Bluecam IOS (Siro-
domly distributed into two groups (n = 15): na). Endocrowns of standardized dimen-
lithium disilicate endocrowns (Eld) and resin sions and anatomy (incisocervical length:
nanoceramic endocrowns (Erc). 11  mm; mesiodistal width: 9  mm) were

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CLINICAL RESEARCH

a b c

Fig 1 Detailed tridimensional representation of the samples and dimensions: buccal (a), proximal (b), and incisal (c)
views. Root dimensions – length: 13 mm; mesiodistal width: 6 mm; buccolingual width: 7 mm. Internal ferrule
dimensions – depth: 4 mm; mesiodistal width: 3 mm; buccolingual width: 4 mm, which left a 1.5-mm–thick
dentinal wall.

a b

Fig 2 Preparation and corresponding CAD model for endocrown (tooth and CAD model): incisal (a) and proximal
(b) views.

designed in the 4.2 Cerec software (Siro- resin nanoceramic restorations were pol-
na) to fit the root preparation (Fig 3). The ished with a coarse rubber wheel to grind
restorations were milled either in lithium off the sprue, a medium rubber wheel to
disilicate ceramic (IPS e.max CAD; Ivoclar finish the sprue area, a soft brush with a pol-
Vivadent) or resin nanoceramics (Lava Ulti- ishing agent (Diamond Twist SCL; Premier
mate; 3M ESPE). Table 1 presents the me- Dental), and a muslin rag wheel to buff the
chanical properties of these materials. restoration.
After milling, the lithium disilicate restor-
ations were glazed and crystalized ac- Adhesive luting of restorations
cording to the manufacturer’s protocol
(Programat CS; Ivoclar Vivadent) using IPS The endocrowns were cemented with dual-
Object Fix Putty and IPS e.max CAD Crys- cure resin cements: Variolink Esthetic DC
tall Glaze Spray (both Ivoclar Vivadent). The (Ivoclar Vivadent) for the lithium disilicate

538 | The International Journal of Esthetic Dentistry | Volume 16 | Number 4 | Winter 2021
 CARVALHO ET AL

a b c

Fig 3 Restoration design steps in Cerec 4.2 software showing the endocrown root preparation (a), final endo-
crown restoration (b), and cross-sectional view of the endocrown and root preparation (c).

Table 1 Mechanical properties (according to manufacturers) of restoration materials used to obtain the two
endocrown types

Parameter IPS e.max CAD Lava Ultimate

Manufacturer Ivoclar Vivadent 3M ESPE

Lithium disilicate Resin nanoceramic high-

Description
glass-ceramic performance polymer

Flexural strength (MPa) 360 ± 60 204 ± 19

Fracture toughness, K1c (MPa m1/2) 2.0 – 2.5 2.02 ± 0.15

Modulus of elasticity (GPa) 95 ± 5 12.77 ± 0.99

and RelyX Ultimate (3M ESPE) for the res- 20 s, then air thinned for 5 s. For the lithium
in nanoceramic restorations. Before ce- disilicate restorations, an ultrasonic bath
mentation, each restoration was fitted on was also performed for cleaning, followed
its respective tooth to check its marginal by etching with 5% hydrofluoric acid (IPS
adaptation. The fitting surface of the resin Ceramic Etching Gel; Ivoclar Vivadent) for
nanoceramic restorations was cleaned in an 20 s, then post-etching cleaning was carried
ultrasonic bath in distilled water for 1 min, out for 1  min in distilled water, again in an
air dried, sandblasted with 27-μm silicated ultrasonic bath. Silane for lithium disilicate
Al2O3 powder, cleaned with alcohol, and (Monobond Plus; Ivoclar Vivadent) was ap-
air dried. Scotchbond Universal Adhesive plied with a microbrush and heat dried at
(3M ESPE) was applied and rubbed in for 100°C for 5 min (DI-500 oven; Coltene).

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CLINICAL RESEARCH

a b c

Fig 4 Resin nanoceramic endocrowns after milling showing the internal ferrule restoration extension/box (a) as
well as the buccal (b) and proximal (c) views of the bonded and finished endocrown ready for the fatigue test.

The IDS layer of the prepared teeth was flat surface provides a realistic simulation
sandblasted with 27-μm silicated Al2O3 pow- of tooth contact through a wear facet, al-
der. The cement was applied to the inner lowing the distribution of the load with-
walls of the concave internal ferrule in the out reaching the compressive limit of the
root, and then the endocrown was seated restorative materials.
on the tooth. Cement excesses were re- The force was applied at a palatal angle
moved, followed by light polymerization of 30 degrees with the flat surface con-
three times for 20  s each on each surface tacting 3/4 of the incisal edge. The load
(buccal and lingual) with a LED light (120 s chamber was filled with distilled water to
in total). Air-blocking barrier was used to submerge the sample during testing. Cyclic
cover all the margins, and additional poly- loading was applied at a frequency of 5 Hz,
merization was carried out for 10 s per sur- starting with 100  N (warm-up of 5000 cy-
face. The margins were finished with hand cles), followed by a 100  N increase every
instruments (scalpel and scaler). The final 15,000 cycles up to 1000 N. Samples were
restoration aspect is presented in Figure 4. loaded until fracture or to a maximum of
The samples were stored in distilled water at 140,000 cycles.
room temperature (24°C) for a minimum of
24  h following adhesive restoration place- Analysis
ment and then subjected to accelerated
fatigue testing. Table 2 presents the mate- To identify any premature failure, all fatigue
rials used in the present study. tests were monitored using transillumination
(IL-88-FOI Microscope Light Source; Scien-
Accelerated fatigue procedure scope) and a macro video camera (Canon
Vixia HF S100; Canon) to film the entire test.
Masticatory forces were simulated using The number of endured cycles, load-at-
a closed-loop artificial mouth electro- failure, and failure mode of each specimen
dynamic machine (Acumen III; MTS Sys- was recorded. After the test, each sample
tems). The chewing cycle was simulated was evaluated by transillumination (Micro-
by an isometric contraction (load control) lux; AdDent) and optical microscope (Leica
applied through a flat composite resin an- MZ 125; Leica Microsystems) at 10:1 magni-
tagonist (Z100; 3M ESPE). The low stiffness fication. Considering the reparability of the
and toothlike wear of the composite resin tooth, a visual distinction was made among

540 | The International Journal of Esthetic Dentistry | Volume 16 | Number 4 | Winter 2021
 CARVALHO ET AL

Table 2 Material application, brand name, composition, and manufacturers of the materials used in the present study

Application Brand name Composition Manufacturer

Hereaus Kulzer,
Acrylic resin for tooth Powder: methyl methacrylate copolymer;
Palapress Vario Wehrheim,
mounting Liquid: methyl methacrylate, dimethacrylate
Germany

Liquid: resin modified polyalkenoic acid,

HEMA (2-hydroxyethymethacrylate), water,
3M ESPE,
and initiators (including camphorquinone);
Glass-ionomer barrier Vitrebond Plus Seefeld,
Paste: HEMA, BIS-GMA, water, initiators and
Germany
a radiopaque fluoroaluminosilicate glass (FAS
glass)

3M ESPE,
Air abrasion/ High-purity 30-μm aluminum oxide, modified
Rocatec Soft Seefeld,
silicatization with silica (SiO2)
Germany

Primer: 2-hydroxyethyl methacrylate ethanol;

2-[2-(methacryloyloxy)
ethoxycarbonyl] benzoic acid, glycerol
Kerr,
Total-etch adhesive phosphate dimethacrylate;
OptiBond FL Orange,
system for IDS Adhesive: 2-hydroxyethyl methacrylate,
USA
3-trimethoxysilylpropyl methacrylate,
2-hydroxy-1,3-propanediyl bismethacrylate,
alkali fluorosilicates (Na)

Alcohol solution of silane methacrylate,

Silane/MDP for Ivoclar Vivadent,
Monobond Plus phosphoric acid methacrylate, and sulphide
lithium disilicate Schaan, Liechtenstein
methacrylate

Phosphoric acid methacrylate, methacrylated

carboxylic acid polymer, hydrophilic mono- Ivoclar Vivadent,
Adhesive system for
Adhese Universal functional methacrylate, hydrophilic/hydro- Schaan,
lithium disilicate
phobic crosslinking dimethacrylate, hydro- Liechtenstein
phobic crosslinking dimethacrylate

Monomer matrix: urethane dimethacrylate,

Resin cement for Variolink Esthetic inorganic fillers (ytterbium trifluoride and Ivoclar Vivadent,
lithium disilicate Dual Cure spheroid mixed oxide), initiators, stabilizers, Schaan, Liechtenstein
and pigments

Ivoclar Vivadent,
Etching for lithium IPS Ceramic Etching
5% hydrofluoric acid Schaan,
disilicate Gel
Liechtenstein

Ivoclar Vivadent,
Lithium disilicate SiO2, Li2O, K2O, P2O5, ZrO2, ZnO, Al2O3, MgO,
IPS e.max CAD Schaan,
block for endocrown coloring oxides
Liechtenstein

Universal adhesive MDP phosphate monomer, dimethacrylate 3M ESPE,

Scotchbond Universal
system for resin resins, HEMA, filler, ethanol, water, initiators, Seefeld,
Adhesive
nanoceramic silane Germany

3M ESPE,
Resin cement for Methacrylate monomers, radiopaque silanated
RelyX Ultimate Seefeld,
resin nanoceramics fillers, initiators, stabilizers, and pigments
Germany

Zirconia-silica nanocluster particles: 20-nm 3M ESPE,

Resin nanoceramic
Lava Ultimate diameter silica nanomers, 4 to 11 nm zirconia Seefeld,
block for endocrown
nanomers, silane coupling agent Germany

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CLINICAL RESEARCH

three fracture modes: 1) ‘reparable’ – cohe- composite resin (everX Posterior; GC)
sive or adhesive failure of restoration only (n = 15). A schematic representation of the
(failure above CPL); 2) ‘possibly reparable’ groups is shown in Figure 6. The detailed
– cohesive/adhesive failure with fragment procedures are described elsewhere.14,17,21
and minor damage, chip or crack of under- The present study was a subset of a com-
lying tooth structure (between acrylic resin prehensive experiment that shared the con-
base level and CPL); or 3) ‘catastrophic’ – trol groups.
root fracture that would require tooth ex-
traction (fracture below acrylic resin base Results
level) (Fig 5).
The fatigue resistance of the groups was None of the 30 samples survived to the
compared using the Kaplan Meier survival 140,000 cycles, thus the mean cycles to fail-
analysis (for the number of cycles endured). ure (Kaplan Meier analysis) and median load
The log rank post hoc test was used to ana- to failure (Life Table analysis) could be ob-
lyze the influence of the endocrown mater- tained. The endured cycles to failure of the
ial on the fracture resistance of the ETI at a lithium disilicate endocrowns ranged from
significance level of 0.05. 29,724 to 86,390 (Eld mean: 53,448 ± 3,666
The fracture load step at which the SE cycles), and those of the resin nano-
specimen failed was compared using Life ceramic endocrowns ranged from 32,487
Table analysis followed by the Wilcoxon to 82,985 (Erc mean: 52,397  ±  4,396 SE
test at a significance level of 0.05. At each cycles). No statistical difference could be
time interval (defined by each load step), the observed among the endocrown groups
number of specimens that started the inter- regarding the number of endured cycles at
val intact and the number of specimens that failure (P = 0.844). The applied load at fail-
fractured during the interval were counted, ure is also an important factor to be evalu-
allowing the calculation of survival probabil- ated. It ranged from 400 to 700 N for both
ity at each interval. For all statistical analyses, endocrown groups, with mean values of
the level of significance was set at 95%. The 541  N and 512  N for Eld and Erc, respect-
data were analyzed with SPSS 23 statistical ively. No statistical difference could be ob-
software. served among the endocrown groups re-
Supplementary data from previous stud- garding the load step at failure (P = 0.652).
ies performed concomitantly by the same The two endocrown groups (Eld and
authors under strictly identical experimental Erc) were also compared with additional
conditions were combined with the pres- data from previous studies using lithium dis-
ent data for additional computation and ilicate crowns and various buildups: groups
comparison. The previous studies includ- (n = 15) with ferrule and without post (FNp),
ed CAD/CAM-fabricated lithium disilicate without ferrule and with post (NfPf), and
crowns bonded over: 1) FNp, a 2mm-ferrule short-fiber-reinforced without ferrule and
ETI restored with a nanohybrid composite without post (NfNpFR) approaches. None
resin (Miris2; Coltene) core buildup with- of those additional 45 samples survived
out post (n = 15); 2) NfPf, a no-ferrule post- to all 140,000 cycles; the mean cycles to
and-core buildup with fiber-reinforced post failure (Fig 7) and median load at failure
(ParaPost Fiber Lux; Coltene) and nano- (Fig 8) could be obtained for all 75 samples
hybrid composite resin (Miris2) (n = 15); and (5 groups; n = 15). The Kaplan Meier (cycles)
3) NfNpFR, a no-ferrule and no-post core and Life Table (load) survival curves are pre-
buildup made of short-fiber–reinforced sented in Figures 9 and 10, respectively. The

542 | The International Journal of Esthetic Dentistry | Volume 16 | Number 4 | Winter 2021
 CARVALHO ET AL

Reparable Possibly reparable Catastrophic

a b c

Fig 5 All specimens were analyzed and classified into one of three failure modes: ‘reparable’ (fracture occurred in
the green area, above the cervical preparation limit (CPL) – cohesive or cohesive/adhesive fracture of restoration
only; a); ‘possibly reparable’ (fracture occurred in the yellow area, between the resin acrylic base level and the CPL –
cohesive/adhesive failure with fragment and minor damage, chip or crack of underlying tooth structure; b);
‘catastrophic’ (fracture occurred in the red area, below the acrylic resin base level – root fracture that would require
tooth extraction; c).

Eld Erc FNp NfNpFR NfPf

a b c d e

Fig 6 Schematic representation of the endocrown groups Eld and Erc (a and b), and supplementary groups from
previous studies (c to e) FNp: with 2-mm ferrule and nanohybrid composite resin core buildup without post;
NfNpFR: a core buildup made of short-fiber–reinforced composite resin without ferrule and without post; NfPf:
a post-and-core buildup with fiber-reinforced post and nanohybrid composite resin without ferrule.

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CLINICAL RESEARCH

90,000

80,000 A

70,000

60,000 C C
C
50,000
Cycles

40,000 B

30,000

20,000

10,000

0
FNp NfPf NfNpFR Eld ErD

Fig 7 Mean survived cycles and standard errors: Kaplan Meier and log rank post hoc tests (P < 0.05) with different
letters indicating significant differences. FNp: ferrule without post; NfPf: no ferrule with fiber post; NfNpFR: no
ferrule, no post, and short-fiber-reinforced composite core buildup.

800

700

600

500
Load (N)

400

300

200

100

0
FNpN fPfN fNpFR Eld Erc

Fig 8 Box and whisker diagram of fracture loads presenting the median (bold black horizontal line), the minimum
and maximum values (vertical ‘t’ lines, or whiskers), the total number of samples (N = 75), and the interquartile range
(blue box). FNp: ferrule without post; NfPf: no ferrule with fiber post; NfNpFR: no ferrule, no post, and short-fiber-
reinforced composite core buildup.

544 | The International Journal of Esthetic Dentistry | Volume 16 | Number 4 | Winter 2021
 CARVALHO ET AL

100% Group
FNp
NfPf
NfNpFR
80%
Eld
Erc

60%
Cumulative survival

40%

20%

0%

0 20,000 40,000 60,000 80,000 100,000

Cycles to failure

Fig 9 Kaplan Meier survival curves for all five groups (for better understanding of the effect of ferrule and the effect
of post and overall comparison, FNp, NfPf, and NfNpFR groups from previous studies were included).

100% Group
FNp
NfPf
NfNpFR
80%
Eld
Erc
Cumulative survival

60%

40%

20%

0%

0 200 400 600 800 1000

Load (N) to failure

Fig 10 Life Table survival curves for all groups. At each time interval (defined by each load step), the number of
specimens intact at the start of the time interval as well as the number of specimens that fractured during the
interval were counted, allowing the calculation of survival probability at each interval.

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CLINICAL RESEARCH

mean cycles to failure ranged from the low- rejected too, since the use of a fiber post
est value of 35,025 ± 2687 SE to the highest (including adhesive buildup and lithium dis-
value of 73,244 ± 4207 SE for NfPf and FNp, ilicate crown) negatively affected the fatigue
respectively. The presence of ferrule signifi- resistance and failure mode. Additionally,
cantly increased the performance of the the use of a postless short-fiber–reinforced
ETIs tested in this study. Regarding cycles core buildup increased the fatigue resist-
and load, the group with ferrule (FNp) out- ance when compared with the classic ap-
performed the endocrown groups without proach with a fiber post.
ferrule (Eld and Erc). The endocrown groups The stepped-load protocol (accel-
outperformed the group with post (NfPf) for erated fatigue test) using a closed-loop
both criteria. The short-fiber-reinforced no- electromechanic system represents a
post core buildup group (NfNpFR) outper- balanced test between the conventional
formed the group with a post (NfPf). There load-to-failure protocol and the time-con-
was no difference for either cycles or load suming low-load high-cycle fatigue test,
between either endocrown groups and the allowing a physiologic representation of
NfNpFR group. The P values for cycles and mastication.46,47 This test strategy seems
loads for all group-by-group comparisons to provide a better simulation of the clin-
are presented in Table 3. ical conditions than static high-load tests.
Considering the failure mode, the Erc Therefore, the presented protocol ap-
group presented more favorable failures pears to be the best compromise between
compared with the Eld group (80% and 73% available in vitro fatigue testing methods
non-catastrophic failures, respectively). The and clinical reality. To further challenge the
use of a post for retention generated 100% restoration, the previously described load
of catastrophic failures in the NfPf group, protocol with increasing loads from 100 to
compared with 33% and 53% in the NfNpFR 1000 N and a frequency of 5 Hz was com-
and FNp groups, respectively. The percent- bined with an angle of force of 30 degrees
ages of failure types for each group are pre- concentrated at the incisal edge of the res-
sented in Figure 11. torations to represent an extreme load con-
figuration (worst-case scenario). No arti-
Discussion ficial periodontium was placed around the
roots, as elastic films normally used for this
The present study evaluated the perfor- purpose show degradation during fatigue
mance of lithium disilicate and resin nano- testing.
ceramic endocrowns for the restoration of One of the findings of previous studies
severely broken-down no-ferrule ETIs. The was the occurrence of initial failure when
main null hypothesis was accepted, as no restoring ETT with posts.14,17 This pheno-
statistically significant differences could be menon is described as a wide gap opening
found between the two endocrown mater- at the margin between the crown and the
ials. Since the results were compared with root that propagates over time until com-
previously published data, two more hypo- plete catastrophic fracture. This indicates
theses could be tested. The first additional an adhesive failure at the crown–tooth lin-
hypothesis was rejected, since the pres- gual interface, possibly due to the bending
ence of a ferrule improved the fatigue re- forces during oblique loading in the test.
sistance compared with all other no-ferrule Such initial failures did not occur when no-
groups, regardless of material or technique. post approaches were tested. As described
The second additional null hypothesis was by Kishen,48 the initial failure is considered

546 | The International Journal of Esthetic Dentistry | Volume 16 | Number 4 | Winter 2021
 CARVALHO ET AL

Table 3 P values for pairwise post hoc comparisons

FNp NfPf NfNpFR Eld Erc

FNp – 0.000* 0.000* 0.003* 0.003*
NfPf 0.000* – 0.031* 0.000* 0.004*
NfNpFR 0.000* 0.049* – 0.223 0.340
Eld 0.003* 0.004* 0.249 – 0.844
Erc 0.003* 0.023* 0.589 0.652 –
F: ferrule; Nf: no ferrule; Pf: fiber post; Np: no post; FR: short-fiber-reinforced; E: endocrown; ld: lithium disilicate;
rc: resin nanoceramic
Dark shaded cells: P values for post hoc tests for cycles (Kaplan Meier followed by the log rank post hoc test). Light
shaded cells: P values for post hoc tests for load (Life Table followed by Wilcoxon-Gehan test)
* Statistical difference between groups (P < 0.05)

%]
0% 20%
20% 40%
40% 60%
60% 80%
80% 100%
100%

FNp 7% 40% 53%

NfPf 100%

NfNpFR 13% 53% 33%

Eld 73% 27%

Erc 13% 67% 20%

Reparable Possibly reparable Catastrophic

Fig 11 Percentage of samples per group for each type of failure mode.

an important factor that has several me- initial failure phenomenon (associated with
chanical and microbiologic implications. post-and-core buildups) is often undiag-
Thus, for NfPf, the initial failure was used for nosed and ends up with catastrophic con-
comparison. sequences (infiltration, caries, root fracture,
The instant complete failure of no-post bone loss etc.).
restorations is a preferable scenario be- The results of the present study demon-
cause the patient is more likely to consult strated that using CAD/CAM compos-
immediately for repair. On the other hand, ite resin blocks instead of lithium dis-
the slow-propagating crack inherent to the ilicate ceramic was not detrimental to

The International Journal of Esthetic Dentistry | Volume 16 | Number 4 | Winter 2021 | 547
CLINICAL RESEARCH

fatigue resistance, even though the flexural study, endocrowns outperformed conven-
strength of resin nanoceramics are substan- tional crowns. The accelerated fatigue test
tially inferior to those of lithium disilicate performed under oblique loading in the
(see Table  1). Composite resin CAD/CAM present study challenged the weakened an-
restorations have been associated with ac- terior root cyclically, differently to axial static
ceptable and reliable performance when loading that usually provides a greater range
compared with ceramics.49-51 Despite the of fracture resistance values and therefore
relatively recent popularity of composite greater standard deviations and P values.
resin CAD/CAM blocks and endocrowns Also, the IDS for adhesion optimization for
themselves, few studies have combined the the indirect restorations used in the present
two. Gresnigt et al34 evaluated IPS e.max study might have played an important role
CAD and Lava Ultimate materials for the in the better micromechanical retention of
endocrown restoration of endodontically the endocrowns. The adhesion enhance-
treated molars and reported no statistically ment of IDS has already been proven in
significant differences in axial static loading other in vitro and clinical studies.29,43-45
fracture resistance compared with conven- The lower percentage of catastrophic
tional crown and core buildup approaches. failures found in composite resin endo-
Different results were found in the study by crowns may be due to better stress distri-
El Ghoul et al,8 wherein lithium disilicate had bution, as its lower elastic modulus may
better fracture resistance than resin nano- concentrate less stress on the root than
ceramics for static loading of molar endo- the ceramic endocrown.37,52 The more
crowns, and endocrowns presented higher biomimetic behavior of composite resin
fracture strength than conventional crowns. includes its capability of causing less op-
A study by Hassouneh et al9 comparing the posing enamel wear than glass-ceramics.53
fracture resistance of no-ferrule premolar Some concerns arise about the esthetics
endocrowns made from different CAD/ of the composite resin material used for
CAM materials showed a better mechani- endocrown fabrication because blocks are
cal performance of composite over lithium monochromatic and an esthetic modifi-
disilicate endocrowns. Differently from the cation of the raw workpiece after milling
present study, the group of zirconia crowns may be necessary, depending on the es-
luted over a post and buildup had better frac- thetic needs of the patient.52 Thus, future
ture resistance than endocrowns, but 90% research should focus on novel clinical ap-
of the failures were catastrophic compared proaches to use CAD/CAM materials as a
with 60% for endocrowns. Considering the core buildup for veneers (veneered endo-
anterior dentition, a study by Silva-Sousa et crowns) or other esthetic enhancements.54
al10 evaluated the effect of ferrule and resto- In the present study, endocrown restor-
ration design (lithium disilicate endocrown ations performed well, even presenting
versus conventional crown) on the fracture better failure modes and higher values in
resistance of human canines. In contrast to both endured cycles and load than con-
the findings of the present study, the pres- ventional crowns bonded to adhesive
ence of ferrule did not influence the resist- post-and-core buildups. When comparing
ance when using a fiber post and regular the endocrowns with the additional data
crown, although it did positively influence from the no-ferrule and no-post approach
it when using an endocrown. In that study, (NfNpFR), no statistically significant differ-
conventional crown groups outperformed ences were found regarding the fatigue
endocrown groups, whereas in the present resistance. The similar results between

548 | The International Journal of Esthetic Dentistry | Volume 16 | Number 4 | Winter 2021
 CARVALHO ET AL

core buildup and endocrowns could be though the endocrowns outperformed

due to the enhanced mechanical be- the post-and-core buildup group in a no-
havior of short-fiber–reinforced composite ferrule condition, the ferrule effect signif-
resin core buildup compared with regular icantly increased the fatigue resistance of
composite resin. Mechanical enhancement the ETIs, as has been confirmed by other
of fiber-reinforced composite has already studies.62,63 The 4-mm–deep internal fer-
been shown by other studies.55-58 Garoushi rule proposed in the present study did not
et al59 compared incisors without ferrule fully compensate the absence of ferrule,
restored with full direct crowns made of although the failure modes among endo-
regular particulate filler composite resin, crowns were more favorable compared
with and without fiber posts, and short- with the ferrule group. The large internal
fiber–reinforced composite resin. The ferrule preparation was performed to sim-
fiber-reinforced composite resin outper- ulate a worst-case scenario, with reduced
formed all the other groups in static load. dentinal wall thickness, as well to provide
Moreover, the endocrowns presented enough material volume to withstand the
the advantage of reducing the number of loading condition and more area for the
interfaces of restorative materials. They adhesive luting of endocrowns or bonding
also prevented polymerization shrinkage. of core buildups.
The volumetric shrinkage on the indirect The limitations of this in vitro study in-
restoration was limited to the cementa- clude the lack of correlation between the
tion gap instead of the entire buildup. Even in vitro simulation and the in vivo aging as
though it has been claimed that bulk-fill well as the lack of additional challenges of
approaches can be used to limit polymer- thermocycling and bacterial activity, be-
ization shrinkage stress, recent studies yond the mechanical challenge of masti-
demonstrate that bulk-fill shrinkage could cation. Thus, randomized clinical trials with
still interfere with the integrity of the adhe- no-post approaches should be carried out
sive interface.60 so as to better understand the real clinical
Despite the different attempts to restore potential of the techniques and materials
ETIs, vertical root fractures are still encoun- that were observed in the present study.
tered in daily clinical practice.19 There was Different preparation designs and dimen-
a significant difference when comparing sions of endocrowns should also be stud-
the endocrown failure modes with those ied to cover the multiple clinical aspects of
of the post-and-core group (NfPf). Among severely broken-down ETIs.
the endocrowns, at least 73% of the fail-
ures were non-catastrophic, whereas 100% Conclusion
unreparable root fractures were found in
NfPf. Similar findings exist in other studies Within the limitations of the present study,
on the posterior dentition.61 it is possible to conclude that, when restor-
It has already been proven that, in the ing a broken-down ETI:
presence of ferrule, fatigue resistance is 1. Endocrowns, while not fully compen-
not influenced by the presence of a post sating for the absence of ferrule (as
in ETIs.17 In fact, the use of a post was the ferrule effect outperformed all no-
detrimental to the failure mode. For that ferrule approaches), provided a super-
reason, a no-post approach with ferrule ior performance compared with the
(FNp) was selected for comparison with use of a fiber post with composite resin
the results of the present study. Thus, even buildup.

The International Journal of Esthetic Dentistry | Volume 16 | Number 4 | Winter 2021 | 549
CLINICAL RESEARCH

2. The post-and-core approach not only Acknowledgments

failed to increase the fatigue resistance,
but also always resulted in catastrophic The authors wish to express their gratitude
root fractures preceded by a clinically un- to 3M  ESPE (St Paul, MN; Kerr, Orange,
diagnosable initial failure phenomenon. CA); Ultradent (South Jordan, UT); Heraeus
3. Indirect CAD/CAM endocrowns made Kulzer (Armonk, NY); Coltène-Whaledent
from resin nanoceramics may enhance (Altstätten, Switzerland); GC Corporation
the failure mode without jeopardizing (Tokyo, Japan); Ivoclar Vivadent (Schaan,
the fatigue resistance compared with Liechtenstein); Sirona Dental Systems
lithium disilicate endocrowns. (Bensheim, Germany); Axis/Sybron Endo
(Kavo Kerr Group); Burbank Dental Lab (Emil
Funding Sahakian); University of Southern California
Endodontic Graduate Program (Dr Taoheed
The present investigation was sup- Jonhson).
ported by CAPES Foundation Brazil (PDSE
99999.009624/2014-07).

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