CLINICAL ARTICLE

The Endocrown: An Alternative Approach for Restoring

Extensively Damaged Molars
GISLAINE ROSA BIACCHI, DDS, MS*,†, BEATRIZ MELLO, DDS‡,
ROBERTA TARKANY BASTING, DDS, MS, SCD, PhD§

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)

INTRODUCTION technique of bonding to dentin, resulting from the

development of resin materials, the restoration of
Traditionally, the functional and esthetic recovery of endodontically treated teeth became simpler, more
endodontically treated teeth with extensive coronal loss economical, and biocompatible.7–10
has been achieved by fabricating total crowns supported
on cast metal cores.1–6 However, with the development Studies showed that the use of intraradicular posts
of intraradicular posts made of glass fiber, and of the alone did not increase the retention of the

*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
 ENDOCROWN FOR DAMAGED MOLARS Biacchi et al.

FIGURE 6. Impression made with polyvinyl siloxane material.

FIGURE 5. Schematic representation of the preparation for

the endocrown. The dotted margin represents the preparation
terminal at the vestibular margin.

of the anatomic configuration of the chamber itself with

an internal taper of 8 to 10 degrees. The chamfered
walls and margins were smoothed with a fine-grained
tapered-trunk diamond-coated tip #4138 at low FIGURE 7. Temporary restoration made with
speed. self-polymerizing acrylic resin, with smooth and perfectly
adapted cervical margins.
The preparation inside the pulp chamber promoted the
mechanical retention and stability of the endocrown. In
this clinical case, the pulp chamber was not very deep, self-polymerizing acrylic resin (Duralay, Reliance
but the presence of the whole wall on the lingual face of Dental), in shade 66, with adequately adapted gingival
the tooth made it possible to obtain stability and margins to ensure healthy gingival tissue (Figure 7). The
retention. The preparation performed for making the impression of the antagonist arch was taken with
endocrown is represented in the schematic diagram in alginate and the casts were sent to the prosthesis
Figure 5. laboratory with the bite registration made in
self-polymerizing red acrylic resin (Duralay, Reliance
Polyvinyl siloxane silicone (Hidroxtreme, Coltène/ Dental, Reliance Dental Manufacturing, Co., Worth, IL,
Whaledent, Cuyahoga Falls, OH, USA) of light and USA).
heavy consistency was used with a simultaneous
molding technique (Figure 6) to take the impression, The option was taken to fabricate the endocrown from
together with dual retractor cord 00 and 0 (Ultrapak, lithium disilicate-based ceramic (IPS e.Max Press,
Ultradent) and hemostatic gel (Vicostat, Ultradent). Ivoclar Vivadent), in shade A2 (Figure 8). The technique
The temporary restoration was performed with consists of injecting the melted ceramic pellet into a

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.

cotton rolls and a suction device were used. The

internal surface of the piece was treated in accordance
with the technique recommended for lithium
disilicate-based ceramics: application of 10%
hydrofluoric acid (Condac, FGM) on the internal
surface for 20 seconds, washing with water/air for 30
seconds, application of the silane agent (Prosil, FGM,
Joinville, Santa Catarina, Brazil) for 1 minute, and
application of a thin coat of the adhesive agent (Adper
Scotchbond Multi-Purpose, 3M Espe, Saint Paul, MN,
USA), using a disposable applicator, followed by a light
air jet and light activation for 20 seconds.
FIGURE 10. Resin cement application on the internal surface
of the endocrown restoration.
The tooth was etched with 37% phosphoric acid
(Villevie, Dentalville, Joinville, Santa Catarina, Brazil),
lining mold fired in a furnace at a temperature of for 15 seconds, with the application starting from the
850°C, in accordance with the manufacturer’s margins in enamel. Afterward, the tooth was washed
instructions. with abundant water, and an air jet was applied for 20
seconds; the preparation was dried, keeping the dentin
In the cementation session, the provisional crown was moist, and the activator, primer, and catalyzer of the
removed, and the pulp cavity and cavity margins were adhesive system (Adper Scotchbond Multi-Purpose, 3M
cleaned with pumice-water slurry, aided by a Robinson Espe) were applied, waiting 15 seconds between each
brush. The endocrown was tried-in, and small proximal application.
adjustments were made (Figure 9). The preparation at
the intrasulcular level prevented the rubber dam The chemically activated resin cement (Multilink,
isolation of the operative field from being implemented. Ivoclar Vivadent) was spatulated for 10 seconds, and the
In order to control the moisture in the gingival sulcus, a piece was washed and placed in position on the
retractor wire and a hemostatic solution, as well as preparation (Figure 10). The piece was pressed onto the

© 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.

structure. Loss of dental structure was observed at the

distal surface due to periodontal scaling and root
planing. However, the endocrown piece was well fitted
in the margins, with no sign of marginal infiltration.

DISCUSSION

Endocrowns appear to be a valuable option for

endodontically treated posterior teeth with extensive
loss of coronal structure. Studies have shown that
although they are desirable for all the teeth in the
arches, endocrowns should be restricted to the
functional and esthetic recovery of posterior teeth,
especially molars, since their performance in premolars
FIGURE 13. Radiographic aspect of the final case after 3 against the action of masticatory forces has not been
years. Note the loss of dental structure at the distal surface the same as that achieved in molars. It is believed that
due to periodontal scaling and root planing. However, the the smaller dental structure area of the pulp chamber
endocrown restoration was well fitted in the margins, with no
and, consequently, of the adhesive surface of premolars,
sign of marginal infiltration.
limits the bond strength of adhesive systems and resin
cements.21 The configuration of premolar crowns in
preparation, excess cement was removed, and light which the height of the piece is greater than the width
activation was performed with a light activation may create a long lever arm, increasing the risk of
appliance (Radii, Southern Dental Industries, Vic., adhesive rupture and displacement.21,24 However, when
Australia), for 60 seconds on the lingual, vestibular and restricted to the posterior molar teeth, endocrowns
occlusal faces. No occlusal adjustments were necessary have shown satisfactory performance in relation to the
after cementation. Figure 11 shows the endocrown action of occlusal forces, esthetic recovery, and bond
immediately after cementation. Figures 12 and 13 show strength.16,18–23
the restoration after 3 years of clinical follow-up. Note
the whole ceramic piece with preserved margins, The clinical procedure that involves the fabrication of
healthy periodontium, and stability of the bond to tooth these restorations, compared with the fabrication of

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
provided by the endodontic filling material, an REFERENCES
endocrown allows minimal tooth wear, and thus
strengthens the tooth, since it helps preserve sound 1. Ree M, Schwartz R. The endo-restorative interface:
dental tissue and root canal structures.9–11 In 2012, current concepts. Dent Clin North Am 2010;54:345–74.
Biacchi and Basting23 observed greater resistance to 2. Hirschfeld Z, Stern N. Post and core: the biomechanical
aspect. Aust Dent J 1972;17:467–8.
compression forces of endocrown restorations,
3. Stern N, Hirschfeld Z. Principles of preparing teeth with
compared with traditional crowns supported on fiber endodontic treatment for dowel and core restoration.
posts, when these restorations were made with lithium J Prosthet Dent 1973;30:162–5.
disilicate ceramic. 4. Guzy GE, Nicholls JI. In vitro comparison of intact
endodontically treated teeth with and without
The limitation for performing this procedure may be endo-post reinforcement. J Prosthet Dent 1979;42:
39–44.
restricted to the ceramic material, which must be an
5. Ross IF. Fracture susceptibility of endodontically treated
acid etchable ceramic in order to obtain the bond to teeth. J Endod 1980;6:560–5.
tooth preparation by means of an adhesive cementation 6. Assif D, Gorfil C. Biomechanical considerations in
system, and, consequently, ensure stability of the piece restoring endodontically treated teeth. J Prosthet Dent
in the preparation. Pressed or machined ceramics, 1984;71:565–7.
especially those reinforced with lithium disilicate, 7. Heydecke G, Butz F, Strub JR. Fracture strength and
survival rate of endodontically treated maxillary incisors
appear to be the best option.15 The lithium disilicate
with approximal cavities after restoration with different
ceramic used to make the restorations has high post and core systems: an in vitro study. J Dent Res
mechanical strength and provides restorations with an 2001;29:427–33.
esthetic appearance very similar to that of tooth 8. Soares CJ, Santana F, Silva NR, et al. Influence of the
enamel.16 endodontic treatment on mechanical properties of root
dentin. J Endod 2007;33:603–6.
9. Asmussen E, Peutzfeldt A, Sahafi A. Finite element
In this clinical case, the endocrown did not meet the
analysis of stresses in endodontically treated,
indications set for the technique, especially because of dowel-restored teeth. J Prosthet Dent 2005;94:321–9.
the lack of all preparation margins in enamel17,18 and the 10. Dietschi D, Duc O, Kreji I, et al. Biomechanical
need for rubber dam isolation during cementation.25 considerations for the restoration of endodontically
Nevertheless, it was decided that the procedure would treated teeth: a systematic review of the literature, part II
be performed for the following reasons: (1) the presence (evaluation of fatigue behavior, interfaces, and in vivo
studies). Quintessence Int 2008;39:117–26.
of the whole wall on the lingual face of the tooth, which
11. Zarow M, Devoto W, Saracinelli M. Reconstruction of
made it possible to obtain stability and retention and endodontically treated posterior teeth—with or without
(2) adhesive cementation procedures conducted in an post? Guidelines for the dental practitioner. Eur J Esthet
adequate manner (controlling the moisture in the Dent 2009;4:312–27.

© 2013 Wiley Periodicals, Inc. DOI 10.1111/jerd.12065 Journal of Esthetic and Restorative Dentistry Vol 25 • No 6 • 383–390 • 2013 389
 ENDOCROWN FOR DAMAGED MOLARS Biacchi et al.

12. Ma OS, Nicholls JI, Junge T, et al. Load fatigue of teeth 20. Otto T. Computer-aided direct all-ceramic crowns:
with different ferrule lengths, restored with fiber posts, preliminary 1-year results of a prospective clinical study.
composite resin cores, and all-ceramic crowns. J Prosthet Int J Periodontics Restorative Dent 2004;24:446–55.
Dent 2009;102:229–34. 21. Bindl A, Richter B, Mörmann WH. Survival of
13. Raymond C, Payant L. In vitro fracture strength ceramic-computer-aided/manufacturing crowns bonded
evaluation of ceramic endo-crowns with an In-Ceram to preparations with reduced macroretention geometry.
core [text on the internet]. 2004. Available at: Int J Prosthodont 2005;18:219–24.
http://www.yasni.info/ext.php?url=http%3A%2F%2Fwww 22. Lander E, Dietschi D. Endocrown: a clinical report.
.fmd.ulaval.ca%2Fckfinder%2Fuserfiles%2Ffiles%2F2004- Quintessence Int 2008;39:99–106.
11.pdf&name=Claude+Raymond&showads=1&lc=en-ca 23. Biacchi GR, Basting RT. Comparison of fracture strength
&lg=en&rg=ca&rip=ca.fmd.ulaval.ca/documents/journees_ of endocrowns and glass fiber post-retained conventional
2004/11pdf (accessed October 11, 2013) crowns. Oper Dent 2012;37:130–3.
14. Leirskar J, Nordbù H, Thoresen NR, et al. A four to six 24. Valentina V, Aleksandar T, Dejan L, et al. Restoring
year follow-up of indirect resin composite inlays/onlays. endodontically treated teeth with all-ceramic
Acta Odontol Scand 2003;61:247–51. endo-crowns—case report. Serbian Dent J 2008;55:54–64.
15. Tysowsky GW. The science behind lithium disilicate: a 25. Chaio C, Kuo J, Lin Y, et al. Fracture resistance and
metal-free alternative. Dent Today 2009;28:112–13. failure modes of CEREC endo-crowns and conventional
16. Pissis P. Fabrication of a metal-free ceramic restoration post and core-supported CEREC crowns. J Dent Scie
utilizing the monobloc technique. Pract Periodontics 2009;4:110–1727.
Aesthet Dent 1995;7:83–94.
17. Bindl A, Mörmann WH. Clinical evaluation of adhesively
placed Cerec endocrowns after 2 years—preliminary Reprint requests: Roberta Tarkany Basting, DDS, MsC, PhD, Faculdade de
results. J Adhes Dent 1999;1:255–65. Odontologia e Instituto e Centro de Pesquisas São Leopoldo Mandic,
18. Göhring TN, Peters AO. Restoration of endodontically Departamento de Odontologia Restauradora—Dentística, Rua José
treated teeth without posts. Am J Dent 2003;16:313–18. Rocha Junqueira, 13 Bairro Swift, Campinas, SP CEP: 13045-755, Brazil;
19. Bernhart J, Bräuning A, Altenburger MJ, et al. Cerec3D Tel./Fax: +55-19-3211-3600; email: rbasting@yahoo.com
endocrowns—two-year clinical examination of
CAD/CAM crowns for restoring endodontically treated
molars. Int J Comput Dent 2010;13:141–54.

390 Vol 25 • No 6 • 383–390 • 2013 Journal of Esthetic and Restorative Dentistry DOI 10.1111/jerd.12065 © 2013 Wiley Periodicals, Inc.