Materials
Materials
Materials
Article
Post-Fatigue Fracture and Marginal Behavior of Endodontically
Treated Teeth: Partial Crown vs. Full Crown vs. Endocrown vs.
Fiber-Reinforced Resin Composite
Roland Frankenberger 1, * , Julia Winter 1 , Marie-Christine Dudek 1 , Michael Naumann 2 , Stefanie Amend 3 ,
Andreas Braun 1,4 , Norbert Krämer 3 and Matthias J. Roggendorf 1
1 Medical Center for Dentistry, Department of Operative Dentistry, Endodontics, and Pediatric Dentistry,
Campus Marburg, University Medical Center Giessen and Marburg, Georg-Voigt-Str. 3,
35039 Marburg, Germany; [email protected] (J.W.);
[email protected] (M.-C.D.); [email protected] (A.B.);
[email protected] (M.J.R.)
2 Department of Prosthodontics, Geriatric Dentistry, and Craniomandibular Disorders,
Charité-Universitätsmedizin Berlin, Aßmannshauser Str. 4-6, 14197 Berlin, Germany;
[email protected]
3 Medical Center for Dentistry, Department of Pediatric Dentistry, Campus Giessen,
University Medical Center Giessen and Marburg, Schlangenzahl 14, 35392 Giessen, Germany;
[email protected] (S.A.); [email protected] (N.K.)
4 Department of Operative Dentistry, Periodontology and Preventive Dentistry, RWTH Aachen University,
Pauwelsstraße 30, 52074 Aachen, Germany
* Correspondence: [email protected]
1. Introduction
Today there is sufficient evidence that vital teeth may be effectively restored even
when substantially decayed [1–4]; however, after root canal treatment the prognosis is
considerably worse [5–7] because both pre-existing defects and endodontic access cavities
significantly weaken the tooth complex [8–10]. Consequently, clinical trials involving
endodontically treated teeth (ETT) reported worse results than vital teeth [11–16]. As
main reasons for clinical failure 12% vertical root fractures, 15% cusp fractures, and 40%
periodontal issues have been reported [14]. Both adequate preparation and restoration
have been permanently in the focus of primarily in vitro research [17–20]. In addition,
beside the previously investigated issues, also endocrowns have been increasingly focused
on [21–25] as special treatment option.
Clinical studies are still the preferable test for dental biomaterials, but they are com-
ing with extremely high efforts and potential patient drop out, and always involve the
risk that after several years of clinical service the tested materials are not on the market
anymore [1–4]. This is the reason in vitro studies are so important, primarily when fatigue
phenomena are involved [6,7,16,19,26–29]—nevertheless, of course also in vitro studies
have limitations.
In a previous investigation, we evaluated the influence of direct vs. indirect and
intracoronal (MO/MOD) vs. coverage restorations (partial crowns) [19]. It was clearly
shown that partial crowns always gave more stability to ETT compared to inlays, and
the same was true for direct resin composite restorations [19]. Although the mentioned
publication involved already 264 teeth, there remained some questions unanswered:
1. Is there a difference between partial crowns and full crowns?
2. Have fiber-reinforced resin composites advantages compared to conventional resin
composites in terms of stability [30–33]?
3. What is the status of endocrowns in that context?
Therefore the null hypotheses of this investigation were: There would be a. no differ-
ence between partial, full, and endocrowns irrespective of the material and b. no difference
between conventional and fiber-reinforced resin composites. It is the key innovation of this
paper to combine fracture strength and marginal quality evaluation, and that it is based on
a previously published fundament.
Materials 1. Specimen
Figure 2021, after
14, x FOR PEER MOD preparation and root canal obturation with standardized oro-buccal extension4 and
REVIEW of 12
Figure 1. Specimen after MOD preparation and root canal obturation with standardized oro-buccal extension and MOD
MOD preparation.
preparation.
Figure 2. Regimen for fundamental MOD preparations (a): rounded angles; (b): 90-degree transitions; (c): schematic over-
Figure 2. Regimen for fundamental MOD preparations (a): rounded angles; (b): 90-degree transitions; (c): schematic
view. These preps were further prepared to partial or full crowns or filled directly with RC and FRC.
overview. These preps were further prepared to partial or full crowns or filled directly with RC and FRC.
The involved protocols for restoration are shown in Figure 5. RC procedures: A matrix
band was applied to the cavities (MOD) which were bonded with AdheSE Universal
(Ivoclar, Figure 3), and restored with Tetric EvoCeram Bulk Fill (Ivoclar) in oblique layers
of 2–4 mm thickness. Direct FRC adhesive procedures: After application of a metal matrix,
cavities were bonded with G-Premio Bond (GC), and restored with EverX Flow (GC) as
dentin substitute being covered with 2 mm Essentia Universal (GC) in same layers as RC.
In the DPC groups, all cusps were reduced 2 mm and restorations sculpted coronally. Resin
composite layers were polymerized for 40 s each with the curing unit touching the matrix
band’s upper edge. Matrices were removed and restorations were additionally polymerized
from both sides for 20 s. Marginal overhangs were scaled (A8 S204S, Hu-Friedy, Leimen,
Germany) and restorations were polished with flexible disks (SofLex Pop-on, 3M ESPE,
St. Paul, MN, USA).
Materials 2021, 14, 7733 4 of 12
Figure 2. Regimen for fundamental MOD preparations (a): rounded angles; (b): 90-degree transitions; (c): schematic over-
view. These
Figure preps were
2. Regimen for further prepared
fundamental MOD to preparations
partial or full(a):
crowns or filled
rounded directly
angles; with RC and
(b): 90-degree FRC. (c): schematic over-
transitions;
view. These preps were further prepared to partial or full crowns or filled directly with RC and FRC.
Figure 4. (a): Typical ceramic partial crown preparation with central FRC base. (b): Classic cast gold preparation with steps
and bevels.
Figure 4. (a): Typical ceramic partial crown preparation with central FRC base. (b): Classic cast gold preparation with steps
4. (a):
Figureand Typical ceramic partial crown preparation with central FRC base. (b): Classic cast gold preparation with steps
bevels.
and bevels.
Indirect adhesive groups were treated with milled lithium disilicate ceramics (e.max
CAD PC/FC, Ivoclar Vivadent, Schaan, Principality of Liechtenstein), zirconia-reinforced
lithiumsilicate ceramics (Celtra Duo PC/FC, Dentsply Sirona, Konstanz, Germany), zirco-
nia (Cercon ht, Dentsply Sirona, Konstanz, Germany), and cast gold (Degunorm, Degudent,
Hanau, Germany). Endocrowns (PC/FC) were manufactured using e.max CAD. Etchable
ceramics were adhesively luted (AdheSE Universal/Variolink Esthetic, Ivoclar Vivadent,
Schaan, Principality of Liechtenstein), zirconia was luted with a self-adhesive resin compos-
ite cement (RelyX Unicem 2), and cast gold was luted using Ketac Cem (3M Oral Healthcare,
Seefeld, Germany). Figure 5 shows the complete methodology, compositions of involved
materials are shown in Table 1. CAD/CAM restorations were computed with Cerec 3-D
(Sirona, Bensheim, Germany), cast gold was made on traditional dies, zirconia was sintered
according to the manufacturer’s recommendations. PC preparations for indirect restora-
tions were carried out as previously described (Figures 4 and 6), cast gold preparations
were carried out with step and bevel (Figure 4).
Materials 2021, 14, 7733 5 of 12
Materials 2021, 14, x FOR PEER REVIEW 5 of 12
Figure5.5.Experimental
Figure Experimentalsetset
upup
of of
thethe
study. Abbreviations:
study. F: Filling,
Abbreviations: DPC:
F: Filling, direct
DPC: partial
direct crown,
partial PC: Partial
crown, crown,crown,
PC: Partial RC: resin
RC:
composite, FRC: Fiber-reinforced resin composite, EM: e.max CAD, CD: Celtra Duo, CG: Cast gold, ZI: Zirconia, EC: endocrown.
resin composite, FRC: Fiber-reinforced resin composite, EM: e.max CAD, CD: Celtra Duo, CG: Cast gold, ZI: Zirconia, EC:
endocrown.
Thermomechanical loading of all specimens including controls was carried out in a
chewing simulator
Indirect (CS4groups
adhesive professional line, SDwith
were treated Mechatronik, Feldkirchen,
milled lithium disilicateGermany)
ceramics under
(e.max
water. Liquids such as artificial saliva were not used in order not to falsify marginal
CAD PC/FC, Ivoclar Vivadent, Schaan, Principality of Liechtenstein), zirconia-reinforced
quality. Each restored
lithiumsilicate tooth
ceramics was mounted
(Celtra Duo PC/FC, in one simulator
Dentsply chamber
Sirona, beingGermany),
Konstanz, hit by a steatite
zirco-
antagonist (6 mm diameter, Figure 7b) obliquely chewing on cusps for
nia (Cercon ht, Dentsply Sirona, Konstanz, Germany), and cast gold (Degunorm, 1,200,000 cycles
at 100 N at a frequency of 0.5 Hz after having been thermocycled 300,000× at +5 ◦ C and
Degudent, Hanau, Germany). Endocrowns (PC/FC) were manufactured using e.max
+55 ◦ C (THE 1100, SD Mechatronik, Feldkirchen, Germany). The mechanics as well as
CAD. Etchable ceramics were adhesively luted (AdheSE Universal/Variolink Esthetic,
water temperature within the chewing chambers were periodically reassured for reliable
Ivoclar Vivadent, Schaan, Principality of Liechtenstein), zirconia was luted with a self-
thermomechanical loading (TML). Finally, each specimen was stressed using a universal
adhesive resin composite cement (RelyX Unicem 2), and cast gold was luted using Ketac
testing machine (Zwicki, Zwick, Ulm, Germany) with the same antagonist material, the
Cem (3M Oral Healthcare, Seefeld, Germany). Figure 5 shows the complete methodology,
loading cell travelled at 0.5mm/min statically until fracture. Fractured restorations were
compositions of involved materials are shown in Table 1. CAD/CAM restorations were
photographed (Figure 7).
computed with Cerec 3-D (Sirona, Bensheim, Germany), cast gold was made on tradi-
tional dies, zirconia was sintered according to the manufacturer’s recommendations. PC
Materials 2021, 14, 7733 6 of 12
Table 1. Cont.
Restorative
Classification Composition (%wt) Manufacturer
Material
Dimethacrylate, prepolymer, Barium glass, Ivoclar Vivadent,
Tetric EvoCeram Nanohybrid resin
Ytterbiumtrifluoride, mixed oxides, initiators, Schaan, Principality of
Bulk Fill composite
stabilizators Liechtenstein
(1-Methylethyliden) bis [4,1-phenyleneoxy (2-
hydroxy-3,1- propanediyl)] bismethacrylate, 2,2′-
everX flow Fiber-reinforced
Ethylenedioxydiethyldimethacrylat, Diphenyl(2,4,6-
posterior bulk-fill composite
trimethylbenzoyl) phosphinoxid, 6-T ert-butyl-2,4-
xylenol 0.2%, short glass fibers, barium glass
7,7,9(or 7,9,9)-trimethyl-4,13-dioxo-3,14-dioxa-5,12-
GC Germany, Bad
diazahexadecane-1,16-diyl bismethacrylate,
Homburg, Germany
Ytterbium trifluoride, (octahydro-4,7-methano-1H-
Essentia Fine hybrid resin indenediyl) bis (methylene) bismethacrylate,
Universal composite Esterification products of 4,4′-
isopropylidenediphenol, ethoxylated and 2-
methylprop-2-enoic acid, 2-(2H-benzotriazol-2-yl)-p-
cresol, glass fillers
Ivoclar
Figure 7. Images of fractured specimens. In every failed restoration, catastrophic fractures were recorded, Vivadent,
either vertical
Figure 7. Images ofLithium
fractureddisilicate
specimens. In every failed restoration, catastrophic fractures were recorded, either vertical (a)
e.max
(a) CAD (b).
or oblique SiO2, Li2O, K2O, P2O5, ZrO2, ZnO, ZnO, Al2O3, MgO Schaan, Principality of
or oblique (b). ceramic
Liechtenstein
Zirconia-reinforced
Dentsply Sirona,
Celtra Duo lithium silicate Lithium silicate with 10% ZrO2
Konstanz, Germany
ceramic
zirconium oxide, yttrium oxide, hafnium oxide, Dentsply Sirona,
Cercon ht Zirconia
Materials 2021, 14, 7733 8 of 12
Both Initially and after completed TML, impressions of the specimens were taken
(Provil Novo, Heraeus Kulzer, Hanau, Germany) and replicas (Alpha Die, Schütz Dental,
Rosbach, Germany) manufactured. The completed replicas were mounted on aluminum
stubs, sputter-coated with gold and examined under a SEM (Phenom, FEI, Amsterdam,
The Netherlands) at ×200 magnification. SEM examination was performed by one operator
with experience with quantitative margin analysis having been blinded to the restorative
procedures. Marginal quality of interfaces (enamel-resin composite, dentin-resin composite,
enamel-luting material, dentin-luting material) was expressed as a percentage of the
individual margin length in enamel and dentin. Marginal integrity was scored according
to the criteria “gap-free margin”, “gap/irregularity” and “not judgeable/artifact” where
applicable, i.e., in full crown specimens, no enamel was available (Figure 8). Afterwards the
percentage “gap-free margin” in relation to the individual judgeable margin was calculated as
Figure 7. Images of fractured specimens.
marginal qualityIn [19,26],
every failed restoration,
i.e., all catastrophic
visible changes fractures were as
were characterized recorded, either vertical
“non-gap-free margins”.
(a) or oblique (b).
Figure 8. SEM image of marginal gap between dentin (D) and resin composite (RC), 200× magnifi-
Figure 8. SEM image of marginal gap between dentin (D) and resin composite (RC), 200× magnification.
cation.
To compute statistics, Kolmogorov–Smirnov test was used to show normal distribution
To compute
of values, statistics,
so parametric Kolmogorov–Smirnov
statistical test was
analyses were taken used toANOVA
(One-way show normal distribu-
and post hoc
tion of values, so parametric statistical analyses were taken (One-way ANOVA
Tukey–Kramer test), considering the preparation and restoration techniques as variable.and post
hoc Tukey–Kramer test), considering the preparation and restoration
The significance level was set as 5% (SPSS 15.0, SPSS Inc., Chicago, IL, USA).techniques as vari-
able. The significance level was set as 5% (SPSS 15.0, SPSS Inc., Chicago, IL, USA).
3. Results
3. Results
The results are displayed in Table 2. In the direct groups, there was no difference
between TheRCresults
and FRCare in
displayed in Table(p2.>In
fracture strength the however,
0.05); direct groups, there was significantly
DPC performed no difference
between
better RC andto
compared FRCMOD in fracture
fillingsstrength (p >Regarding
(p < 0.05). 0.05); however, DPC performed
marginal significantly
quality in enamel, in-
better compared
tracoronal to MOD fillings
FRC restorations (p <a0.05).
exhibited higher Regarding
portion ofmarginal
gap-freequality
margins in compared
enamel, intra-
to
coronal FRC restorations exhibited a higher portion of gap-free margins
RC restorations (p < 0.05). In all other groups, no technique was superior in giving good compared to RC
restorations
marginal (p < 0.05).
adaptation In all
after other groups,(p
fatigue-loading no>technique
0.05) withwas
onesuperior
exceptionin (zirconia
giving good mar-
partial
ginal adaptation
crowns aftersignificantly
in enamel with fatigue-loading
lower > 0.05)p with
(pscores; oneAlthough
< 0.05). exceptionmarginal
(zirconia partial
quality
significantly droppedwith
crowns in enamel aftersignificantly
TML (p < 0.05), it remained
lower scores; p stable at Although
< 0.05). a very highmarginal
level (Table 1).
quality
In the indirect groups, there was no significant difference between partial and full
crowns in any of the adhesively luted ceramic groups e.max and Celtra Duo regarding
post-fatigue fracture resistance (p > 0.05). Fully adhesive ceramic restorations gave similar
post-fatigue fracture strengths as direct partial crowns of RC and FRC (p > 0.05). Groups
with cuspal coverage in general performed better than intracoronal restorations (p < 0.05), being
in different significance levels though, but at a generally high level throughout the groups.
Materials 2021, 14, 7733 9 of 12
Table 2. Results [N] ± SD for fracture strength and results [%] (SD) for marginal quality as percentage of “gap-free margins”.
Fracture Strength Gap-Free Margins Gap-Free Margins Gap-Free Margins Gap-Free Margins
Group after TML Enamel Initial Enamel after TML Dentin Initial Dentin after TML
in N ± SD in %(SD) in %(SD) in %(SD) in %(SD)
Control 806 ± 190 B n/a n/a 100 n/a
RC-F 382 ± 83 D 100 82 (13) B 100 n/a
RC-DPC 688 ± 186 C 100 88 (9) A 100 n/a
FRC-F 402 ± 110 D 100 89 (10) A 100 n/a
FRC-DPC 699 ± 178 C 100 93 (9) A 100 n/a
EM-PC 723 ± 188 C 100 95 (7) A 100 n/a
EM-FC 736 ± 160 C n/a n/a 100 95 (5) A
CD-PC 702 ± 167 C 100 93 (9) A 100 n/a
CD-FC 733 ± 152 C n/a n/a 100 96 (4) A
ZI-PC 702 ± 143 C 100 76 (23) C * 100 n/a
ZI-FC 921 ± 102 A n/a n/a 100 94 (8) A
CG-PC 934 ± 172 A 100 90 (5) A 100 n/a
CG-FC 956 ± 200 A n/a n/a 100 93 (5) A
EC-PC 689 ± 175 C 100 88 (12) A 100 n/a
EC-FC 734 ± 197 C n/a n/a 100 94 (5) A
*: compared to the other groups under investigation, in this group marginal irregularities were predominantly recorded between enamel
and luting composite. Superscript letters: Same letters mean p > 0.05 within columns. Before and after TML, a significant decrease in
marginal quality was recorded in all groups (p < 0.05).
Zirconia FC as well as cast gold PC/FC yielded the highest post-fatigue fracture
resistance being even superior to sound teeth of the control group (p < 0.05).
4. Discussion
As mentioned in the introduction, clinical trials remain the ultimate instrument in
restorative dentistry [2,4,11,14]. Main disadvantage of these trials is that some interesting
experimental groups may not be accepted by IRBs due to their explorative and less data-
supported character. Therefore, it still makes sense in biomaterials research to simulate
clinical circumstances to predict clinical behavior [12,16,20,25,27,29]. Additionally, when
this is performed meticulously, it remains an in vitro study with several limitations such as
standardized loading, lack of sliding bruxism, and more or less rigid fixation during TML.
Regarding the restoration of vital teeth, overall sealing properties, abrasion char-
acteristics, and biological issues such as biodegradation and absence of postoperative
hypersensitivities are of primary interest [1,4,26]. With ETT, fracture behavior was reg-
ularly investigated because 27% of clinical failures have been linked to any kind of frac-
ture [14,15,27,28]. In this context, fatigue-loading has significantly gained importance for
both evaluation of long-term adhesion and fracture resistance [19,26,29]. Clinical record-
ings showed average masticatory forces around 20 MPa with dramatically higher peak
load [5,10,15,29]. At least empirically, a lower threshold level for tactile sensitivity was re-
ported for ETT. Although this was not completely confirmed in the literature, it is common
sense that ETT exhibit a significantly higher fracture risk compared to vital teeth [15,28,29].
The main reason for increased fracture risk of ETT is their intentional hard tissue reduction
during endodontic access cavity and root canal preparation [6,7,10]. This may be the reason
for the observation that full crown preparations are recommended for ETT, also when
focusing on clinical outcome of direct restorations of ETT [10–13].
The methodology of this in vitro study obviously gave reproducible results with
different materials, also matching several clinical observations, and having been success-
fully established since >25 years [19,26]. Long-term thermomechanical fatigue-loading
is estimated to be closer to intraoral conditions compared to ultimate loading until frac-
ture [26]. Compared to previous investigations on “vital” teeth, both higher fatigue load
and increased number of thermomechanical load cycles was chosen as shown before [19].
Materials 2021, 14, 7733 10 of 12
The chosen restorative materials were traditional vs. recent biomaterials. The first null
hypothesis was that conventional resin composites and fiber-reinforced composites would
behave similar, although reports about short-fiber-reinforced composite were favorable [30].
The similarity in in vitro performance, however, correlated well with biomechanical prop-
erties of the investigated materials. It could be again shown that partial coverage was more
effective in both marginal and fracture behavior in the direct groups (p < 0.05). Between
the groups RC and FRC, no statistically different results occured in post-fatigue fracture
resistance; however, there was a significantly higher portion of gap-free margins in enamel
when the fiber-reinforced dentin substitute everX posterior was used as in intracoronal
restorations (p < 0.05). In all other criteria, there was no beneficial effect of short-fiber-
reinforced composite (p > 0.05). As in the previous investigation, it could not be confirmed
that resin-based materials give less catastrophic failures compared to e.g., ceramics. Alto-
gether the opposite seems to be true, the advantage of direct restorations to be less invasive
did not result in superior post-fatigue resistance, because indirect approaches were more
effective in general during the present in vitro investigation.
So finally, both null hypotheses had to be accepted because the type of direct material
had no impact on fracture strength, and there was no considerable difference between
partial crown and full crown preparation in most of the test groups, so the less invasive
partial crown can also be recommended for restoration of ETT. Altogether, previous findings
could be confirmed that cuspal coverage as well as full crowns perform best with a clear
advantage for cast gold restorations as partial or full crown.
5. Conclusions
Within the limits of this in vitro investigation, it can be concluded that any kind of
indirect restoration with cuspal coverage is suitable for the restoration of ETT when a
certain cavity extension is exceeded. All indirect restorations, i.e., endocrowns, partial
crowns, and full crowns showed a promising performance after in vitro fatigue-loading.
Author Contributions: Conceptualization, R.F. and M.N.; Data curation, M.N. and S.A.; Investiga-
tion, M.-C.D. and J.W.; Methodology, R.F. and M.J.R.; Project administration, J.W.; Supervision, N.K.;
Writing—original draft, R.F.; Writing—review & editing, A.B. All authors have read and agreed to
the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted according to the guidelines of the
Declaration of Helsinki, and approved by the Ethics Committee of JLU Giessen (143/09).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: The data presented in this study are available on request from the
corresponding author.
Conflicts of Interest: R.F. received research grants and lecture honorarium from Dentsply Sirona,
Ivoclar, GC, and 3M. N.K. received research grants and lecture honorarium from Dentsply Sirona,
GC, and 3M. All other authors declare that they have no conflict of interest.
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