The Endocrown: An Alternative Approach For Restoring Extensively Damaged Molars
The Endocrown: An Alternative Approach For Restoring Extensively Damaged Molars
The Endocrown: An Alternative Approach For Restoring Extensively Damaged Molars
ABSTRACT
Endocrown-type restorations are single prostheses fabricated from reinforced ceramics that can be acid etched,
indicated for endodontically treated molar teeth that have significant loss of coronal structure. Endocrowns are formed
from a monoblock containing the coronal portion integrated into the apical projection that fills the pulp chamber
space, and possibly the root canal entrances. In this study, the proposal was to discuss the indication and use of the
endocrown to replace single crowns with intraradicular retention, and to present a clinical case report on the 3-year
follow-up of an endocrown-type restoration, fabricated from injected lithium disilicate ceramic (IPS e.Max Press/Ivoclar
Vivadent) in a mandibular first molar with extensive coronal destruction from fracture. It was found that endocrown
restorations could be made following the development of reinforced ceramics that can be acid etched, that have
aggregate strength and esthetics, that bond to the dental structure, and that have developed from broader knowledge
of the biomechanical behavior of depulped teeth restored with and without intraradicular posts. Clinical studies have
shown that the endocrown has functional longevity, and has become a promising alternative in the esthetic and
functional recovery of endodontically treated molar teeth.
CLINICAL SIGNIFICANCE
It should be borne in mind that endocrowns offer advantages for the restoration of depulped molar teeth, insofar as
they promote adequate function and offer adequate esthetics, and also maintain the biomechanical integrity of the
compromised structure of non-vital posterior teeth. By eliminating the use of a post and filling core, the number
of adhesive bond interfaces is reduced, thus making the restoration less susceptible to the adverse effects of
degradation of the hybrid layer. In this clinical case, the 3-year survival of the endocrown restoration may be
considered successful.
(J Esthet Restor Dent 25:383–391, 2013)
*PhD student, Dental School and Institute and Research Center São Leopoldo Mandic, Campinas, SP, Brazil
†
Professor, Federal University of Santa Maria, Santa Maria, RS, Brazil
‡
MS student, Dental School and Institute and Research Center São Leopoldo Mandic, Campinas, SP, Brazil
§
Professor, Department of Restorative Dentistry, Dental School and Institute and Research Center São Leopoldo Mandic, Campinas, SP, Brazil
© 2013 Wiley Periodicals, Inc. DOI 10.1111/jerd.12065 Journal of Esthetic and Restorative Dentistry Vol 25 • No 6 • 383–390 • 2013 383
ENDOCROWN FOR DAMAGED MOLARS Biacchi et al.
restoration,9,11 and that it was necessary to fabricate a ceramics have been the materials of choice for the
filling core that would offer greater stability to the fabrication of endocrowns, because they guarantee the
restoration. This was particularly true in the case of mechanical strength needed to withstand the occlusal
posterior teeth in which the direction of the main forces exerted on the tooth, as well as the bond
masticatory forces is parallel to the long axis of the strength of the restoration to the cavity walls.16,20,23,24
tooth. In this case, the filling core favors retention of
the restoration, even in cases of more extensive As an upshot of this new restorative proposal, some
restorations such as total crowns.12 Moreover, the laboratory and clinical studies have been made to
placement of posts in root canals could be limited by evaluate the effectiveness,20–22 feasibility,17,18,23 and
root anatomy, such as dilacerations or reduced root clinical performance19–22,24,25 of endocrowns as a
portions (short roots).13 restorative procedure for endodontically treated teeth.
However, the success and longevity of the endocrown
Therefore, with the advent of adhesive dentistry, it has are directly related to the correct preparation of the
become acceptable to restore teeth with extensive tooth, the selection of the most suitable ceramic
coronal destruction by performing onlays and overlays, options, and the choice of bonding material, since
without using intraradicular posts, and by using the adequate adhesive cementation is absolutely necessary
entire extension of the pulp chamber as a retentive for the success of this restorative treatment.17,18,21
resource.11,14–16 These restorative procedures were made
possible by the development of acid etchable ceramics Endocrowns are relatively new, and few professionals
(such as leucite and lithium disilicate-based ceramics), feel confident about performing these procedures.
dentinal adhesives, and resin cements. These resources Nevertheless, they are easy and quick to perform,
may be used to perform restorations of total crowns in compared with traditional single crowns with posts and
endodontically treated teeth, using the pulp chamber as cores. In this study, the proposal was to discuss the
a retentive resource, as is the case of endocrowns.17–23 indication and use of the endocrown to replace single
crowns with intraradicular retention, and present a
The first study published on endocrown restoration (or clinical case report on the 3-year clinical follow-up of
adhesive endodontic restoration) was conducted by an endocrown restoration, fabricated from injected
Pissis16 in 1995. In it, he described the ceramic lithium disilicate ceramic (IPS e.Max Press/Ivoclar
monoblock technique for teeth with extensive loss of Vivadent), performed in a mandibular first molar with
coronal structure. However, it was Bindl and extensive coronal destruction from fracture.
Mörmann17 who named this restorative procedure
“endocrown” in 1999. The endocrown is a total
porcelain crown fixed to a depulped posterior tooth,
which is anchored to the internal portion of the pulp CLINICAL CASE
chamber and to the cavity margins, thus obtaining
macromechanical retention (provided by the pulpal A 52-year-old man attended the Dental Prosthesis
walls), and microretention (by using adhesive Clinic at the São Leopoldo Mandic School of Dentistry
cementation).22–24 and Research Center with a recent fracture on the
vestibular face of the left mandibular first molar, with
Endocrowns are especially indicated in cases of molars extensive loss of coronal tissue. The tooth had adequate
with short, obliterated, dilacerated, or fragile roots. interocclusal space for the fabrication of a single crown
They may also be used in situations of excessive loss of (Figure 1). The periapical radiographic exam revealed
coronal dental tissue and limited interocclusal space, in endodontically treated root canals (Figure 2). The pulp
which it is not possible to attain adequate thickness of chamber was wide but not deep enough. Gingival tissue
the ceramic covering on the metal or ceramic was inflamed only in the region of the fracture, but
substructures.24 Reinforced, acid etchable dental there was preserved biologic space (Figure 3).
384 Vol 25 • No 6 • 383–390 • 2013 Journal of Esthetic and Restorative Dentistry DOI 10.1111/jerd.12065 © 2013 Wiley Periodicals, Inc.
ENDOCROWN FOR DAMAGED MOLARS Biacchi et al.
FIGURE 1. Initial aspect of the left mandibular first molar. FIGURE 2. Radiographic aspect of the initial case. Note the
Note the fracture of the vestibular face in an endodontically filled root canals.
treated tooth. There was adequate interocclusal space.
FIGURE 3. Note the preservation of the biologic space and FIGURE 4. Initial cervical margin preparation using a
the fracture line. tapered-trunk diamond-coated tip.
Although the coronal dental structure did not make it throughout the entire extension of the crown and root
possible for a preparation to be made with all the remainders, maintaining the lingual face terminal in
margins in enamel, the possibilities of adhesive enamel, with the intention of providing greater bond
restorative materials (whole dentinal tissue), the quality and greater retention. It was necessary to
quantity of dental structure present, and the partial perform a gingivectomy in the disto-vestibular region of
preservation of the lingual face—thus, making it the tooth to make it easier to prepare the terminal. The
possible to provide stability to lateral masticatory entrance of the root canals was sealed with a
forces—were considered in indicating an endocrown conventional two-step adhesive system (Excite DS,
restoration. The preparation was adapted from the Ivoclar Vivadent) and flowable resin composite (Tetric
technique recommended by Bindl et al.21 The cervical Flow, Ivoclar Vivadent, Liechtenstein, Germany). The
margins were leveled in the shape of a chamfer lateral retentions of the pulp chamber walls were filled
(Figure 4) with a tapered-trunk diamond-coated with microhybrid resin composite (Tetric Ceram,
rounded tip #4138 (KG Sorensen, Barueri, São Paulo, Ivoclar Vivadent). The pulp chamber was again
Brazil), at high speed and under constant cooling, prepared with the same diamond-coated tip to the limit
© 2013 Wiley Periodicals, Inc. DOI 10.1111/jerd.12065 Journal of Esthetic and Restorative Dentistry Vol 25 • No 6 • 383–390 • 2013 385
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386 Vol 25 • No 6 • 383–390 • 2013 Journal of Esthetic and Restorative Dentistry DOI 10.1111/jerd.12065 © 2013 Wiley Periodicals, Inc.
ENDOCROWN FOR DAMAGED MOLARS Biacchi et al.
FIGURE 8. Ceramic restoration of the endocrown after FIGURE 9. Try-in of the piece and adaptation of the
conclusion of the work in the prosthesis laboratory. restoration to determine whether adjustments are required
on the proximal faces.
© 2013 Wiley Periodicals, Inc. DOI 10.1111/jerd.12065 Journal of Esthetic and Restorative Dentistry Vol 25 • No 6 • 383–390 • 2013 387
ENDOCROWN FOR DAMAGED MOLARS Biacchi et al.
FIGURE 11. Final aspect of the cemented piece right after FIGURE 12. View of the endocrown 3 years after
removing the retractor wire. cementation.
DISCUSSION
388 Vol 25 • No 6 • 383–390 • 2013 Journal of Esthetic and Restorative Dentistry DOI 10.1111/jerd.12065 © 2013 Wiley Periodicals, Inc.
ENDOCROWN FOR DAMAGED MOLARS Biacchi et al.
crowns with cores or posts, may be considered less operating field and manipulating the cementation
complex, more practical, and easier to perform. The agents in accordance with the manufacturer’s
protocol establishes a preparation with expulsive instructions).
leveling of the pulp chamber walls, followed by sealing
of the root canal entrances and cervical margins in a
chamfer design.21,23 Sometimes it is necessary to fill DISCLOSURE AND ACKNOWLEDGEMENT
irregularities in the pulp chamber walls with resin
composite in order to remove retentive areas that The authors do not have any financial interest in the
prevent sliding and adjustment of the piece. The companies whose materials are included in this article.
internal portion of the endocrown, projected toward The authors thank Dr Sidney Kina for his clinical
the inside of the pulp chamber, is responsible for the guidance and encouragement.
mechanical microretention.17,18 By dispensing with the
use of an intraradicular post and maintaining the seal
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