Hindawi Publishing Corporation

Case Reports in Dentistry

Volume 2013, Article ID 210763, 5 pages
http://dx.doi.org/10.1155/2013/210763

Case Report
Restoration of Endodontically Treated Molars Using All
Ceramic Endocrowns
Roopak Bose Carlos,1 Mohan Thomas Nainan,1 Shamina Pradhan,1 Roshni Sharma,1
Shiny Benjamin,1 and Rajani Rose2
1

Department of Conservative Dentistry and Endodontics, Vydehi Institute of Dental Sciences and Research Centre, No. 82, EPIP Area,
Whitefield, Bangalore 560066, India
2
Dental Solutions, 157, 4th Main, BEML layout, Off ITPL Road, Thubarahalli, Bangalore 560066, India
Correspondence should be addressed to Roopak Bose Carlos; [email protected]
Received 28 October 2013; Accepted 17 November 2013
Academic Editors: D. W. Boston and K. Seymour
Copyright 2013 Roopak Bose Carlos et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Clinical success of endodontically treated posterior teeth is determined by the postendodontic restoration. Several options have
been proposed to restore endodontically treated teeth. Endocrowns represent a conservative and esthetic restorative alternative to
full coverage crowns. The preparation consists of a circular equigingival butt-joint margin and central retention cavity into the entire
pulp chamber constructing both the crown and the core as a single unit. The case reports discussed here are moderately damaged
endodontically treated molars restored using all ceramic endocrowns fabricated using two different systems, namely, CAD/CAM
and pressed ceramic.

1. Introduction
Postendodontic restoration should preserve and protect the
existing tooth structure, while restoring satisfactory esthetics,
form, and function. The goal is to achieve minimally invasive
preparations with maximal tissue conservation for restoring
endodontically treated teeth. This will help to mechanically
stabilize the tooth-restoration complex and increase surfaces
available for adhesion.
A number of options are available in every clinical
situation. The choice depends on the structural integrity
of the tooth, esthetic, and protective requirements [1]. In
this perspective, endocrowns can be considered as a feasible alternative to full crowns for restoration of nonvital
posterior teeth, especially those with minimal crown height
but sufficient tissue available for stable and durable adhesive
cementation [2].
The evolution of ceramic technology especially dental
CAD/CAM systems have enhanced the options to produce
single all ceramic endocrowns with high biocompatibility and
optimal mechanical properties [3].

In the present paper two ceramic endocrowns fabricated

by different methods are presented as case reports.

2. Case 1
A 32-year-old female patient reported for the filling of her
lower 1st molar. On clinical examination tooth number
36 was root canal treated one month back (Figure 1). It
was asymptomatic and the occlusogingival height of the
remaining crown structure was approximately 4 mm. The
radiographic findings revealed well obturated canals with no
periapical changes.
A conservative approach of restoring the tooth with an
endocrown was decided as the treatment option, as more than
half the residual tooth structure was remaining and there
were no occlusal wear facets. On additional request by the
patient for an advanced and a prompt restoration, CAD/CAM
ceramic was chosen.
After removal of the provisional restoration, preparation
for endocrown was initiated. Resin modified glass ionomer
cement (Fuji II LC GC Corporation, Tokyo, Japan) was used

Case Reports in Dentistry

Figure 3: CAD/CAM image.

Figure 1: Postobturation occlusal view showing the amount of

residual tooth structure.

Figure 2: Tooth preparation for endocrown.

to achieve a flat pulpal floor and to block the undercuts.

The preparation consisted of a circular equigingival buttjoint margin and central retention cavity into the entire pulp
chamber constructing both the crown and the core as a single
unit. The appropriate reduction of the buccal and lingual
walls was done (Figure 2).
Interocclusal space was carefully evaluated and occlusal
reduction done to achieve a clearance of 2 mm. Shade-B1 was
selected (VITAPAN Zahnfabrik, Germany). Retraction cord
was placed and impressions made with polyvinyl siloxane
impression material (Aquasil LV, Putty/Light Body, Dentsply
DeTrey, Germany) using putty wash technique. Die stone
model was fabricated.
CAD/CAM Processing. The three-dimensional reconstruction
of the preparation was done using the Yenadent D40 milling
machine (Yenadent, Istanbul, Turkey) and DWOS scanner
(Dental Wings Inc., Montreal, Canada). The 3D scanning
of the individual die and the antagonist arch for occlusal
function (virtual articulation) were done. The milling was
then initiated on a monolithic solid zirconia block (Metoxit
AG, Thayngen, Switzerland) (Figures 3 and 4).

Figure 4: Tissue surface depicting the core and crown fabricated as

a single unit.

The finished endocrown was checked for shade, fit, and

occlusion in the patients mouth and then cemented using
dual cure resin luting agent (Variolink, Ivoclar/Vivadent,
Schaan/Liechtenstein).
Clinical and radiographic evaluation was done and follow
up after 28 months showed no secondary caries, fracture, discoloration or loosening/decementation of the crown (Figures
5 and 6).

3. Case 2
A 26-year-old female patient reported with a chief complaint of pain since 2 days. On radiographic examination
radiolucency involving pulp of tooth 36 was seen. Based
on the clinical and radiographic examination tooth 36
was diagnosed with acute irreversible pulpitis. Root canal
treatment was performed. Based on the remaining tooth
structure, that is, approximately 4-5 mm, occlusal evaluation,
and patients esthetic demands, IPS E.max Press endocrown
was decided as the treatment option. The endocrown
preparation and the impression technique were performed
as described in the previous case. IPS E.max Press HO

Case Reports in Dentistry

Figure 5: Occlusal view following final cementation.

Figure 6: Buccal view of tooth 36 depicting the occlusion and

imperceptible margins.

Lithium-disilicate glass ceramic ingots (Ivoclar/Vivadent,

Schaan/Liechtenstein) were used for the press technology.
The restoration was fabricated according to the lost wax
technique of investing and wax pattern burnout followed by
pressing of the ceramic ingot in the pressable furnace at a
press temperature of 915920 C. It was then finished and
polished with Proxyt pink polishing paste (Ivoclar/Vivadent,
Schaan/Liechtenstein). The endocrown was cemented using
a dual cure resin luting agent (Variolink, Ivoclar/Vivadent,
Schaan/Liechtenstein). Clinical and radiographic evaluation
was done and a 28-month followup showed no secondary
caries, fracture, discoloration or loosening/decementation of
the crown (Figures 7, 8, 9, 10, 11, and 12).

in one appointment. Inaccuracies are minimal and crosscontamination due to impression making and laboratory procedures is reduced. The net result is better patient compliance
and satisfaction [6, 7].
On the other hand, pressable ceramic systems yield good
functionality, retention, esthetics, and durability [2]. The
main advantage of endocrown fabricated using the pressing
method is the greater depth of the root extension and the
option of using an articulator [3].
The 28-month followup of both types of endocrowns
showed no esthetic and functional degradation. These results
are in agreement with the previous studies [2, 8, 9].
Bindl and Mormann demonstrated similar results in a
clinical study of Cerec endocrowns cemented adhesively. 19
endocrowns were checked (4 premolars and 15 molars) in 13
patients over 28 months. Only one molar endocrown failed
because of recurrent caries [9].
Similar results were reported by Lander and Dietschi
where a three-year followup of two Empress II endocrowns
showed satisfactory behavior in terms of esthetics, restoration
stability, and tissue preservation [2].
Endocrowns have several advantages over conventional
crowns like reduced number of interfaces in the restorative
system. Stress concentration is less because of the reduction
in the nonhomogenous material present [10, 11]. The preparation design is conservative compared to the traditional
crown [5]. Involvement of the biological width is minimal
[12]. In comparison to the post and core restorations, bonding
surface offered by the pulpal chamber of the endocrown
is often equal or even superior to that obtained from the
bonding of a radicular post of 8 mm depth. The application
and polymerization of resins is also better controlled [13].
As presented in the case reports, instead of modifying
the existing tooth structure to suit the restorative needs,
resin modified glass ionomer cement was used to block the
undercuts, thereby further conserving sound tooth structure.
The endocrown is luted with resin cement. The adhesive
monoblock system achieved reduces the need for macroretentive geometry and provides more efficient outcome and
better esthetics [7].

4. Discussion
A successful endodontic treatment has to be complemented
with an appropriate postendodontic restoration to integrate
the pulpless tooth with the masticatory apparatus [4]. When
up to one half of the coronal tooth structure is missing,
complete occlusal coverage is achieved conservatively using
endocrown [5].
The concept of a conservative protective restoration for
posterior endodontically treated teeth is not new. Amalcore,
inlays, and onlays are based on this principle. The amalcore
harnessed, the large and retentive contours of the root canal
orifices, and the pulp chamber to provide a monoblock
foundation. Inlays and onlays promoted the concept of a
supragingival finish line and conservative preparations. The
endocrown is an esthetic and conservative addition to this
continuum.
All ceramic systems have gained popularity in recent
times as they offer both esthetics and function [6]. The
development of CAD/CAM systems and software offers
several advantages in clinical practice. Custom shaping and
precise milling of ceramic restorations is now a reality;
furthermore, the adaptation of the inner surface of the
restoration and the replication of the occlusal morphology
are better. Restorations can be produced chairside and seated

Case Reports in Dentistry

Figure 7: Occlusal view showing the amount of residual tooth

structure postobturation.

Figure 10: Occlusal view following final cementation.

Figure 8: Tooth preparation for pressable ceramic endocrown.

Figure 11: Buccal view of tooth 36 highlighting the excellent shade

match and finish.

Figure 9: Tissue surface of pressed endocrown.

Figure 12: Radiographic view, postcementation. The supragingival

finish line is clearly visible.

Endocrowns have their own disadvantages like, debonding and risk of root fracture because of the difference in the
modulus of elasticity between the harder ceramic and softer
dentin [3]. Hence case selection is critical for ensuring clinical
success with endocrowns [14]. Endocrowns are indicated in

cases where there are minimal functional and lateral stresses.

When there is evidence of increased functional and lateral
stresses as evident with steep occlusal anatomy, wear facets
or parafunction, full coverage crown with or without post is
the treatment of choice [12].

Case Reports in Dentistry

Based on current evidence, endocrowns fabricated using
CAD/CAM and pressable ceramic technology can be considered as a reliable option for the restoration of moderately
mutilated endodontically treated posterior teeth. However,
long-term followup and longitudinal clinical studies are
needed to ensure their overall success.

References
[1] K. Gulabivala, Restoration of the root treated tooth, in
Endodontics, C. J. R. Stock, K. Gulabivala, and R. Walker, Eds.,
pp. 279305, Elsevier, 3rd edition, 2004.
[2] E. Lander and D. Dietschi, Endocrowns: a clinical report,
Quintessence International, vol. 39, no. 2, pp. 99106, 2008.
[3] V. Veselinovic, A. Todorovic, D. Lisjak, and V. Lazic, Restoring
endodontically treated teeth with all ceramic endo-crowns case
report, Stomatoloski Glasnik Srbije, vol. 55, pp. 5464, 2008.
[4] B. Suresh Chandra and V. Gopi Krishna, Grossmans Endodontic
Practice, Wolters Kluwer, New Delhi, India, 12th edition, 2010.
[5] D. Dietschi, O. Duc, I. Krejci, and A. Sadan, Biomechanical
considerations for the restoration of endodontically treated
teeth: a systematic review of the literaturepart 2 (Evaluation of
fatigue behavior, interfaces, and in vivo studies), Quintessence
International, vol. 39, no. 2, pp. 117129, 2008.
[6] T. S. Vinothkumar, D. Kandaswamy, and P. Chanana,
CAD/CAM fabricated single unit all ceramic post core
crown restoration, Journal of Conservative Dentistry, vol. 14,
no. 1, pp. 8689, 2011.
[7] C.-Y. Chang, J.-S. Kuo, Y.-S. Lin, and Y.-H. Chang, Fracture
resistance and failure modes of CEREC endo-crowns and
conventional post and core-supported CEREC crowns, Journal
of Dental Sciences, vol. 4, no. 3, pp. 110117, 2009.
[8] J. Bernhart, A. Brauning, M. J. Altenburger, and K.-T.
Wrbas, Cerec3D endocrownstwo-year clinical examination
of CAD/CAM crowns for restoring endodontically treated
molars, International Journal of Computerized Dentistry, vol. 13,
no. 2, pp. 141154, 2010.
[9] A. Bindl and W. H. Mormann, Clinical evaluation of adhesively
placed cerec endo-crowns after 2 yearspreliminary results,
Journal of Adhesive Dentistry, vol. 1, no. 3, pp. 255265, 1999.
[10] F. Zarone, R. Sorrentino, D. Apicella et al., Evaluation of the
biomechanical behavior of maxillary central incisors restored
by means of endocrowns compared to a natural tooth: a 3D
static linear finite elements analysis, Dental Materials, vol. 22,
no. 11, pp. 10351044, 2006.
[11] C.-L. Lin, Y.-H. Chang, and C.-A. Pai, Evaluation of failure
risks in ceramic restorations for endodontically treated premolar with MOD preparation, Dental Materials, vol. 27, no. 5, pp.
431438, 2011.
[12] D. Dietschi, S. Bouillaguet, and A. Sadan, Restoration of the
endodontically treated tooth, in Cohens Pathways of the Pulp,
K. M. Hargreaves and S. Cohen, Eds., pp. 777807, Elsevier
Mosby, 10th edition, 2011.
[13] G. T. Rocca and B. Serge, Alternative treatments for the restoration of non vital teeth, Revue dOdonto Stomatologie, vol. 37, pp.
259272, 2008.
[14] G. T. Rocca and I. Krejci, Crown and post- free adhesive
restorations for endodontically treated posterior teeth: from
direct composite to endocrowns, European Journal of Esthetic
Dentistry, vol. 8, pp. 156179, 2013.

Advances in

Preventive Medicine

The Scientific
World Journal
Hindawi Publishing Corporation
http://www.hindawi.com

Volume 2014

Case Reports in
Dentistry

International Journal of

Dentistry
Hindawi Publishing Corporation
http://www.hindawi.com

Volume 2014

Hindawi Publishing Corporation

http://www.hindawi.com

Scientifica
Volume 2014

Hindawi Publishing Corporation

http://www.hindawi.com

Volume 2014

Volume 2014

Pain
Research and Treatment

International Journal of

Biomaterials
Hindawi Publishing Corporation
http://www.hindawi.com

Hindawi Publishing Corporation

http://www.hindawi.com

Hindawi Publishing Corporation

http://www.hindawi.com

Volume 2014

Volume 2014

Journal of

Environmental and
Public Health

Submit your manuscripts at

http://www.hindawi.com
Journal of

Oral Implants
Hindawi Publishing Corporation
http://www.hindawi.com

Computational and
Mathematical Methods
in Medicine
Hindawi Publishing Corporation
http://www.hindawi.com

Hindawi Publishing Corporation

http://www.hindawi.com

Volume 2014

Volume 2014

Journal of

Advances in

Oral Oncology
Hindawi Publishing Corporation
http://www.hindawi.com

Volume 2014

Hindawi Publishing Corporation

http://www.hindawi.com

Anesthesiology
Research and Practice

Journal of

Orthopedics

Drug Delivery
Volume 2014

Hindawi Publishing Corporation

http://www.hindawi.com

Volume 2014

Volume 2014

Hindawi Publishing Corporation

http://www.hindawi.com

Volume 2014

Journal of

Dental Surgery

Journal of
Hindawi Publishing Corporation
http://www.hindawi.com

BioMed
Research International

International Journal of

Oral Diseases

Endocrinology
Volume 2014

Hindawi Publishing Corporation

http://www.hindawi.com

Volume 2014

Hindawi Publishing Corporation

http://www.hindawi.com

Volume 2014

Hindawi Publishing Corporation

http://www.hindawi.com

Volume 2014

Radiology
Research and Practice
Hindawi Publishing Corporation
http://www.hindawi.com

Volume 2014