Ó

Operative Dentistry, 2013, 38-3, 242-248

Fiber-reinforced Resin
Coating for Endocrown
Preparations: A Technical
Report
GT Rocca  N Rizcalla  I Krejci

Clinical Relevance
The presented clinical technique using fiber-reinforced composite as a resin-coating layer
was developed for adhesive endocrown restorations. This may reduce the risk of
catastrophic fractures and thus improve the success rate of this type of restoration on
nonvital teeth.

SUMMARY conservative, faster, and less expensive dental

Coronal rehabilitation of endodontically treat- treatment. However, the absence of a metal or
high-strength ceramic substructure as in full-
ed posterior teeth is still a controversial issue.
crown restorations can expose this kind of
Although the use of classical crowns supported
restoration to a higher risk of irreversible
by radicular metal posts remains widespread
fracture in case of crack propagation. The
in dentistry, their invasiveness has been large-
aim of this case report is to present a tech-
ly criticized. New materials and therapeutic nique to reinforce the cavity of an endodonti-
options based entirely on adhesion are avail- cally treated tooth by incorporating a fiber-
able nowadays, from direct composite resins to reinforced composite (FRC) layer into the
indirect endocrowns. They allow for a more resin coating of the tooth preparation, before
*Giovanni Tommaso Rocca, Dr Méd dent, Geneva School of the final impressions of the cavity. This tech-
Dentistry, Department of Cariology and Endodontology, nique allows the use of FRCs in combination
Geneva, Switzerland with any kind of restorative material for an
Nicolas Rizcalla, Dr Méd dent, Geneva School of Dentistry, adhesive overlay/endocrown.
Department of Cariology and Endodontology, Geneva, Swit-
zerland INTRODUCTION
Ivo Krejci, Prof Dr Med Dent, Geneva School of Dentistry,
The tendency of endodontically treated teeth (ETT)
Department of Cariology and Endodontology, Geneva, Swit-
zerland
to fracture is still a highly debated issue.1 The
biomechanics of an ETT are principally altered by
*Corresponding author: Rue Barthélémy-Menn 19, Geneva,
1205 Switzerland; E-mail: Giovanni.Rocca@unige.ch
the tissue loss due to prior pathologies (caries,
fracture, cavity excavation), endodontic treatment
DOI: 10.2341/12-139-TR
(access cavity, root canal shaping), and invasive
Rocca, Rizcalla & Krejci: Fiber-Reinforced Endocrowns 243

Figure 1. Initial view of the endodontically treated first maxillary

molar after the removing of the provisional restoration. Figure 2. Isolation of the cavity.

restorative procedures (post placement, crown fabri- replacing restoration.15,17,18 Beside improving the
cation).2 All of these factors may contribute to a strength of the restoration, results of these studies
consistent elimination of coronal and radicular demonstrate that the incorporation of glass fibers
tissues, which increases the fragility and thus the into composite resin materials usually leads to more
fracture risk of an ETT.3 Recently, the restoration of favorable fracture patterns—above the CEJ—be-
ETT with adhesive techniques has been advocated cause the fiber layer acts as a stress breaker and
both in the root and in the crown to prevent further stops the crack propagation. For classic lab-made
loss of sound tissues as adhesion ensures sufficient indirect composite restorations, FRCs are commonly
material retention without the need for aggressive incorporated during the laboratory fabrication into
macroretentive preparation.4–6 In particular, the use the base of the work piece.15,19 Unfortunately, this
of bonded overlays, such as endocrowns, for the technique is not possible when the composite
coronal restoration of an ETT is becoming more restoration is milled from a CAD/CAM block or with
common than classic full-crown restorations. The any kind of ceramic material. The aim of this case
reason for this change of paradigm is to achieve a report is to present a technique that will allow the
more conservative approach, which preserves tooth reinforcement of the cavity of an ETT, as opposed to
tissues and allows reintervention in case of failure. the restoration.
Furthermore, endocrowns eliminate many technical Before taking the final impressions of the cavity,
steps during the fabrication, such as post cementa- the FRC layer is incorporated on the surface of the
tion, core buildup, temporary crown, and potential tooth preparation. This technique allows for the use
crown lengthening, which increase treatment time of FRCs in combination with any kind of restorative
and costs. Several in vitro studies and some in vivo material for an adhesive overlay/endocrown.
trials have confirmed the validity of this adhesive
approach, especially for molars.4,7–12 METHODS AND MATERIALS
However, even with conservative overlays/endo- The case reported is an endodontically treated
crowns, drastic failures—below the cementoenamel maxillary first molar in need of a restoration (Figure
junction (CEJ)—are possible, and they have been 1). A conventional indirect technique to fabricate an
reported.12–14 In case of crack propagation, the endocrown is accomplished by programming two
absence of a metal or high-strength ceramic sub- appointments. During the first appointment,20 the
structure as in full crowns can expose this type of cavity is cut under local anesthesia. Once the cavity
restoration to higher risk. To improve toughness, is properly isolated (Figure 2), an adhesive system is
leucite and lithium-disilicate reinforced ceramics applied to the entire dentin and to the mesial thin
have been proposed.15,16 As an alternative to subgingival portions of enamel margins and then
ceramics, composite resins have been suggested light cured.21 Then, an adequate amount of compos-
because of their superior stress-absorbing properties ite resin is applied on the dentin and into the mesial
and high degree of toughness.8,10 In some in vitro box and light cured. The goal is to fill the pulp
studies, fiber-reinforced composites (FRCs) have chamber eliminating the undercuts, cover all the
been also employed to reinforce this kind of cusp- dentin, and relocate the cervical margins 1 mm
244 Operative Dentistry

Figure 5. The customized transparent silicon key.

Figure 3. The composite resin coating.
transparent, Zhermack SpA, Badia Polesine, Italy)
supragingivally. For that purpose, a low shrinking is made to replicate the molar cavity and the occlusal
nano-hybrid composite is applied (Tetric EvoCeram, part of adjacent teeth (Figure 5). A layer of about 0.5
Ivoclar-Vivadent AG, Schaan, Liechtenstein). Con- mm of flowable composite (Tetric EvoFlow, Ivoclar-
sidering the thickness of the future restoration, at Vivadent AG), just enough to accommodate the
least 1.5 mm is recommended.9, Although adhesive FRCs, is spread into the cavity and left uncured.
luting does not require any particular taper of the The fiber network is then inserted into the cavity
cavity or a macro-retentive geometry, the fabrication
over the flowable composite film, and its mesh is
of a concavity in the middle of the pulpal chamber
slightly opened (Figure 6). Thereafter, the FRC is
will help with the positioning of the restoration
completely adapted to the cavity with the customized
during insertion (Figure 3). The next step is the
silicon key and light cured (Figure 7). A second layer
insertion of the frame of resin preimpregnated
of flowable composite is applied over the FRC and
bidirectional glass fibers (Dentapreg UFM, ADM
A.S., Brno, Czech Republic) on top of the cavity light cured to cover all the exposed fibers (Figure 8).
preparation. The suitable mesiodistal length of the The enamel margins are finished with fine diamond
fiber network can be measured in the oral cavity burs (Composhape, Intensiv SA, Grancia, Switzer-
with a periodontal probe (Figure 4). Fibers are then land) to obtain well-defined and sharp margins
cut and left under light protection outside the before the impression of the cavity (Figure 9). The
mouth. Then, a transparent silicon key (Elite

Figure 4. The suitable length of the fiber-reinforced composite sheet Figure 6. The fiber frame embedded in a flowable resin is inserted
is measured in the mouth with a periodontal probe. into the cavity.
Rocca, Rizcalla & Krejci: Fiber-Reinforced Endocrowns 245

Figure 7. The fiber-reinforced composite layer is polymerized Figure 9. Enamel is refurbished before the impressions.
through the transparent key with a powerful LED lamp.

based on adhesion are available nowadays.3,23–25 In

indirect restoration is then fabricated. In the case the case of small to medium cavities, direct compos-
mentioned, the endocrown was milled from a CAD/ ite resins and indirect inlay/onlay restorations have
CAM composite resin block (LAVA Ultimate, 3M almost replaced metallic restorations.26–29 In the
ESPE AG, Seefeld, Germany; Figure 10). During the case of large cavities, or whenever a cuspal coverage
following appointment, the intaglio surface of the is needed, bonded endocrowns made of ceramic or
restoration and the cavity are adhesively treated, composite currently represent a valid alternative to
and the restoration is luted with a conventional classical full crowns to restore the esthetics and
light-cured micro-hybrid resin composite.22 function of ETT.4,8,10–12,15

DISCUSSION In the clinical case presented, the large amount of

tissue lost due to pathology and to the endodontic
In the past 30 years, the optimal performances treatment supports the use of a minimally invasive
achieved by modern adhesive systems and the adhesive endocrown restoration instead of a full
growing emphasis on minimal invasive principles crown. This technique allows for the conservation of
in all fields of dentistry have finally promoted sound dentin and, above all, peripheral enamel,
adhesive strategies for ETT. Although metallic maintaining the possibility of bonding margins of
restorations and classic PFM crowns supported by the future restorations to it, which is known to have a
radicular metal posts remain widespread, their beneficial effect on marginal stability.30 The adhesive
invasiveness in the root as well as in the crown has procedure also eliminates the need for the use of a
been largely criticized, and new therapeutic options post and a core, which would be otherwise necessary

Figure 8. A further thin layer of flowable resin is applied on fibers to Figure 10. The CAD/CAM composite restoration one month after the
isolate and protect them. luting.
246 Operative Dentistry

in a typical crown preparation. Moreover, the adhe- layer under cusp-replacing composite restorations
sive cavity configuration keeps all margins of the also led to an improvement of fracture strength for
restoration away from the periodontium, which is endodontically treated molars.
beneficial for hygiene and periodontal health.1,31 In the specific case presented, the fiber layer is
Once the tooth is isolated by a rubber dam, a micro- applied to the cavity before an impression is taken.
hybrid composite resin is applied to the cavity. The incorporation of the fiber layer is accomplished
Regardless of its composition, resin coating aids with the help of a layer of flowable composite. The
elevating cavity margins in slightly subgingival areas same highly filled micro-hybrid composite used to
as well as eliminating cavity undercuts, thus saving seal the cavity may be the best choice from different
sound tooth structure. Besides these structural points of view, as flowable composites exhibit high
functions, the placement of this composite layer on contraction stress during polymerization and may
dentin immediately after cavity preparation provides not be sufficiently resistant to deformation under
optimal cavity sealing and protection of the endodon- load.39,40 On the other hand, highly filled micro-
tic treatment during the temporization period.32–34 hybrid composites are quite difficult to spread in a
Potential exposure to oral fluids and consequent thin layer because of their high viscosity. The low
water sorption of bonding resin are minimized as viscosity of the flowable composite guarantees the
well.35 In addition, a composite base leads to the diffusion of this resin into the preimpregnated fiber
fabrication of thinner inlays and onlays. This implies network and decreases the risk of void incorporation.
a better light penetration through the definitive The use of a customized transparent silicon key to
restoration during light polymerization, introducing push the fiber layer in place during polymerization
the use of light-cured luting composites above improves the adaptation of the FRC sheet to the
chemical or dual-cured resins for cementation. Fur- geometry of the cavity and limits the thickness of
thermore, and especially for ETT, this composite base this intermediate layer. This aspect is of prime
reinforces cavity walls during the temporary phase.12 importance when a thin restoration is indicated.,41
Thereafter, a frame of resin preimpregnated Moreover, the customized key simplifies the appli-
bidirectional glass fibers is applied to the cavity cation and the polymerization of the FRC layer
(Dentapreg UFM, ADM A.S.). FRCs have been compared with the use of specific metallic instru-
largely tested as materials above all in fixed partial ments as suggested by the manufacturer (Dentapreg
dentures, and they have proved to have superior Fork, ADM A.S.). Once the FRC layer is cured,
mechanical properties compared with conventional further application of flowable composite over the
restorative particulate filler composite resins.18,36,37 fibers protects them from an accidental exposure
Their use is growing in cusp-replacing single-tooth during the temporary phase.22,37
restoration to overcome limitations in terms of The incorporation of the FRC layer into the tooth
fracture toughness of conventional composite restor- cavity before the impression gives the operator the
ative materials in high–load-bearing posterior are- choice between different restorative options. Several
as.15,17–19,38 The FRC layer is positioned between the materials can be used to fabricate endocrowns, such
tooth cavity and the restoration, in a more tensile as feldsphatic porcelain or reinforced glass-ceramic,
zone.37 In case of a classical indirect technique, this hybrid composite, or CAD/CAM ceramic and com-
configuration is achieved by incorporating the fibers posite blocks. The scientific literature is still not
at the base of the composite overlay during the in-lab clear about which material is best indicated for this
fabrication. During function, in case of a vertical kind of restoration. The authors prefer hybrid
crack inside the restoration, the FRC layer has the composite resins, citing their stress-absorbing prop-
ability to slow or stop the crack propagation through erties and their practical benefits such as the
underlying tissues, thus avoiding irreversible frac- possibility to modify and repair the surface easily.42
tures. Considering the fibers’ orientation, the choice In particular, CAD/CAM resin blocks (LAVA Ulti-
of bidirectional or woven fibers seems more appro- mate, 3M ESPE AG) may be used instead of classical
priate than unidirectional ones, as in the mouth the lab-made restorations in order to avoid defects
restoration is submitted to multidirectional chewing inherent in a free-hand laboratory technique and
loads.15,18 Although some authors consider that in thus improving mechanical properties. The in-lab
single-tooth restorations, the ability of fibers to yield insertion of an FRC layer at the base of a milled
better failure modes is the most beneficial effect of CAD/CAM composite restoration, even if theoreti-
FRC incorporation,17 Dere and others15 have recent- cally possible, would mean cutting the restoration,
ly found that the presence of a multidirectional FRC thus compromising its homogeneity.
Rocca, Rizcalla & Krejci: Fiber-Reinforced Endocrowns 247

CONCLUSIONS lar with MOD preparation. Dental Materials 27(5)

431-438.
Adhesive overlays, often called endocrowns, are
8. Magne P, & Knezevic A (2009) Simulated fatigue
increasingly used as a restorative alternative to full
resistance of composite resin versus porcelain CAD/
crowns for nonvital teeth. Their advantages are CAM overlay restorations on endodontically treated
minimal invasiveness, simpler preparation, and molars Quintessence International 40(2) 125-133.
optimal coronal seal. The risk associated with these 9. Magne P, & Knezevic A (2009) Thickness of CAD-CAM
restorations is rare but may result in a catastrophic composite resin overlays influences fatigue resistance of
vertical fracture of the tooth-restoration complex, endodontically treated premolars Dental Materials 25(10)
often leading to the extraction of the tooth. The 1264-1268.
presented clinical technique with FRC reinforcement 10. Lin C, Chang Y, & Pa C (2009) Estimation of the risk of
of the resin-coating layer was developed for use with failure for an endodontically treated maxillary premolar
CAD/CAM composite or ceramic restorations. It may with MODP preparation and CAD/CAM ceramic restora-
reduce this risk of extensive fractures and thus tions Journal of Endodontics 35(10) 1391-1395.
improve the success rate of this type of restoration 11. Bindl A, & Mörmann WH (1999) Clinical evaluation of
on nonvital teeth. adhesively placed Cerec endo-crowns after 2 years—
preliminary results Journal of Adhesive Dentistry 1(3)
255-265.
Acknowledgements
12. Bindl A, Richter B, & Mörmann WH (2005) Survival of
The authors would like to thank Dominique Vinci for the
ceramic computer-aided design/manufacturing crowns
laboratory work and Izabella Nerushay for the English
revision. bonded to preparations with reduced macroretention
geometry International Journal of Prosthodontics 18(3)
Conflict of Interest 219-224.

The authors certify that they have no proprietary, financial, or 13. Bernhart J, Bräuning A, Altenburger MJ, & Wrbas KT
other personal interest of any nature or kind in any product, (2010) Pubmeted molars International Journal of Com-
service, and/or company that is presented in this article. puterized Dentistry 13(2) 141-154.
14. Fennis WMM, Kuijs RH, Kreulen CM, Roeters FJM,
(Accepted 29 June 2012) Creugers NHJ, & Burgersdijk RCW (2002) A survey of
cusp fractures in a population of general dental practices.
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