RESEARCH AND EDUCATION

Mechanical behavior of endocrowns fabricated with different

CAD-CAM ceramic systems
Nereu Roque Dartora, MS, DDS,a Izabela Cristina Maurício Moris, PhD, MS, DDS,b
Stephanie Francoi Poole, DDS,c Ataís Bacchi, PhD, MS, DDS,d Manoel Damião Sousa-Neto, PhD, MS, DDS,e
Yara Terezinha Silva-Sousa, PhD, MS, DDS,f and Erica Alves Gomes, PhD, MS, DDSg

An emphasis on minimally ABSTRACT

invasive principles combined
Statement of problem. The mechanical behavior of ceramic endocrowns is unclear.
with adhesive materials has
led to the development of new Purpose. The purpose of this in vitro and 3-dimensional finite element analysis (3D-FEA) study was
options for the restoration of to evaluate the mechanical behavior of endodontically treated teeth restored with ceramic
1 ,2 endocrowns made by using different computer-aided design and computer-aided manufacturing
endodontically treated teeth,
(CAD-CAM) systems.
including the single-piece
, Material and methods. Sixty mandibular human molars were endodontically treated, prepared for
endocrown.3 4 These are
fabricated with the crown and endocrowns, and divided into 4 groups (n=15) according to the following various ceramic systems:
leucite-based glass ceramic (LC group), lithium disilicate-based glass ceramic (LD group), glass
the core as a single unit
ceramic based on zirconia-reinforced lithium silicate (LSZ group), and monolithic zirconia (ZR
anchored to the internal group). After adhesive bonding, the specimens were subjected to thermomechanical loading and
portion of the pulp chamber, then to fracture resistance testing in a universal testing machine. The failure mode of the
thereby achieving macro- specimens was qualitatively evaluated. Three-dimensional FEA was performed to evaluate the
mechanical retention provided stress distribution in each group. Data were analyzed by using a 1-way ANOVA and the Tukey
by the walls of the pulp HSD test (a=.05).
chamber and micromechanical Results. Statistically significant differences among the groups were observed (P<.05). The outcomes
retention by means of adhe- of the LC, LD, and LSZ groups were similar (1178 N, 1935 N, and 1859 N) but different from those of
sive bonding.5,6 These resto- the ZR group (6333 N). The LC and LD groups had a higher ratio of restorable failures, while LSZ and
rations are particularly ZR had more nonrestorable failures. Fractographic analysis indicated a regular failure pattern in the
indicated for endodontically ZR group and irregular failure patterns in the other groups. Three-dimensional FEA revealed similar
values and stress pattern distributions among the groups.
treated posterior teeth with
extensive loss of the crown, Conclusions. The mechanical performance of monolithic zirconia was better than that of the other
weakened axial walls, limited ceramic endocrowns considered in this research; however, monolithic zirconia presented a higher
rate of catastrophic tooth structure failure. (J Prosthet Dent 2020;-:---)
interocclusal space, and/or
2 ,7 ,8
short clinical crowns.
Ceramic molar endocrowns have greater retention as compared with fiber or metal posts.6,10 In addition,
9
and stability and are less prone to fracturing because in compressive tests, molars restored with endocrowns
they lead to a decrease in dentin tensile stress levels have been reported to be more resistant to fracture

This research received support from São Paulo State Research Foundation (FAPESP) (research grant numbers 2016/25311-7).
a
Postgraduate student, School of Dentistry, University of Ribeirão Preto (UNAERP), Ribeirão Preto, Brazil.
b
Professor, School of Dentistry, University of Ribeirão Preto (UNAERP), Ribeirão Preto, Brazil.
c
Postgraduate student, School of Dentistry, University of Ribeirão Preto (UNAERP), Ribeirão Preto, Brazil.
d
Professsor, Meridional Faculty (IMED), School of Dentistry, Passo Fundo, Brazil.
e
Professor, Department of Restorative Dentistry, Dental School of Ribeirão Preto, University of São Paulo (FORP-USP), Ribeirão Preto, Brazil.
f
Professor, School of Dentistry, University of Ribeirão Preto (UNAERP), Ribeirão Preto, Brazil.
g
Professor, School of Dentistry, University of Ribeirão Preto (UNAERP), Ribeirão Preto, Brazil.

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Table 1. Details of ceramic materials used

Clinical Implications Group Material Composition Manufacturer
LC Leucite-reinforced Components: SiO2 Ivoclar Vivadent AG
Lithium-reinforced and leucite-reinforced glass vitreous ceramic (IPS Additional content:
ceramics are suitable materials for endocrowns. Empress CAD) Al2O3, K2O, Na2O, and
other oxides.
Dentists should also consider monolithic zirconia as LD Lithium disilicate- Components: SiO2 Ivoclar Vivadent AG
a promising material. reinforced vitreous Additional content: Li2O,
ceramic (IPS and K2O, MgO, Al2O3, P2O5,
max CAD) and other oxides.
LSZ Vitreous ceramic ZrO2: 8%-12% VITA Zahnfabrik H.
than conventional crowns with intraradicular reinforced with lithium SiO2: 56%-64% Rauter GmbH & Co
silicate and zirconium Li2O: 15%-21% KG
retainers.3 oxide (VITA Suprinity PC) La2O3: 0.1%
Monolithic endocrowns have been fabricated with Pigments: <10%
Other oxides: >10%
different systems,11-16 including computer-aided design ZR Monolithic zirconia ZrO2: 94.39% Qinhuangdao
and computer-aided manufacturing (CAD-CAM).17 (ZirkOM SI) Y2O3: 5.30% Aidite High-
Other oxides: 0.31% Technical Ceramics
Leucite-reinforced glass ceramic has satisfactory opti- Co Ltd
cal properties and higher flexural strength than feld-
spathic ceramics.18,19 Lithium disilicate is a good option
for endocrown fabrication, allowing for adhesive or autopolymerized acrylic resin (Jet; Artigos Odontológi-
conventional cementation,20 with optical properties cos Clássico Ltda).
similar to those of natural teeth20 and appropriate Each specimen was mounted in a high-speed milling
flexural strength.21 Lithium silicate with zirconium di- machine (Dentsply Sirona) and prepared by using a
oxide has been reported to provide increased flexural diamond rotary instrument (2136; KG Sorensen) under
strength when compared with lithium disilicate.19,22,23 water cooling. A shoulder with a width between 2.2 mm
Yttria-stabilized tetragonal zirconia polycrystal (Y-TZP) and 2.7 mm was prepared. Internally, the preparation
offers adequate biocompatibility, satisfactory was approximately 5 mm in depth, 4 mm in the bucco-
esthetics, and high fracture toughness and flexural lingual direction, and 6 mm in the mesiodistal direction.
strength.24-28 However, information about the behavior The axial walls showed an internal taper of 8 to 10 de-
of Y-TPZ when used in the fabrication of endocrowns is grees. A barrier of glass ionomer cement (Ketac Molar;
lacking. 3M ESPE) was applied to the pulp chamber.9 The spec-
The purpose of this in vitro and 3-dimensional finite imens were divided into 4 groups (n=15) according to the
element analysis (3D-FEA) study was to evaluate the different CAD-CAM systems (Table 1).
mechanical behavior of endodontically treated teeth The endocrowns were fabricated by using a CAD-
restored with ceramic endocrowns made by using CAM system (Cerec 3; Dentsply Sirona) and were mil-
different CAD-CAM systems. The null hypothesis was led (CEREC InLab MC XL System; Dentsply Sirona). For
that the different ceramic materials used in the fabrica- bonding, the internal surface was etched with 5% hy-
tion of endocrowns would not affect the mechanical drofluoric acid (IPS Ceramic Etching Gel; Ivoclar Viva-
strength, fracture pattern, stress values, or distribution dent AG) for 60 seconds for the LC group and 20 seconds
schemes in endodontically treated teeth. for the LD and LSZ groups, while, for the ZR group,
endocrowns were airborne-particle abraded (Rocatec
MATERIAL AND METHODS
system; 3M ESPE). A silane coupling agent (RelyX
After approval by the appropriate research ethics Ceramic Primer; 3M ESPE) was applied and dried. The
committee (C.A.A.E.: 55753216.3.0000.5319), 60 surfaces of the dental preparations were treated with
mandibular human molars extracted because of peri- 37% phosphoric acid (FGM Produtos Odontológicos), 2
odontal disease or for orthodontic reasons and with consecutive layers of adhesive system (Adper Single
similar root lengths and mesiodistal and buccolingual Bond Plus; 3M ESPE) were applied and light polymerized
dimensions stored in 0.1% thymol solution at 4  C were at 650 mW/cm2 power density (Radii Plus; SDI), and they
selected for this study. The teeth were sectioned parallel were cemented with dual-polymerizing resin cement
to the occlusal surface by using a diamond disk (15LC; (RelyX Ultimate; 3M ESPE).
Buehler) at a low speed with a sectioning machine The specimens were stored in relative humidity at
(Isomet 1000; Buehler) 2 mm above the cementoenamel 37  C for 7 days; subjected to thermomechanical
junction (CEJ). The endodontic treatment was per- loading testing in a pneumatic mastication simulator
formed as previously described.9 After 7 days of storage (Biopdi) at a frequency of 5 Hz, starting with a load of
at 37  C and 100% humidity, the roots were embedded 80 N, followed by stages of 120, 160, 200, 240, 280, and
1 mm from the CEJ in a plastic cylinder (25 mm 320 N, with a maximum of 20 000 cycles each9; and,
diameter, 20 mm height) in the long axis, with simultaneously, thermocycled in a water bath at 5  C

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Table 2. Mechanical properties of investigated materials Table 3. Fracture resistance values (N)
Material E (GPa) n Reference Groups Mean Standard Deviation
30
Leucite-reinforced vitreous ceramic 65.3 0.20 LC 1178 A 273
30
Lithium disilicate 102.5 0.21 LD 1935 A 530
30
Zirconium oxideereinforced lithium silicate 102.9 0.19 LSZ 1859 A 588
30
Monolithic zirconia 206.3 0.24 ZR 6333 B 2391
31
Bone marrow 1.37 0.30 Different letters indicate statistical differences (P<.05).
32
Dentin 18.6 0.31
33
Periodontal ligament 0.05 0.45
Gutta percha 1.4×10 −1
0.45 34 100

Percentage (%) of Failure

and 55  C. A 6-mm diameter metal sphere was used as 75
the antagonist. Then, the specimens were loaded to
fracture in a universal testing machine (Biopdi) until
permanent deformation or failure. The crosshead 50
speed was 0.5 mm/min, and a compressive load was
axially applied with a load cell of 4.9 kN. The
maximum load was recorded in Newtons. 25
The failure mode of the specimens was qualitatively
evaluated by using a stereomicroscope (Leica DFC295
connected to a Leica S8 APO; Leica Microsystems) at ×40 0
LC LD LSZ ZR
magnification and classified as Type I, endocrown frac-
ture; Type II, restorable remaining tooth structure, frac- Groups
ture above the bone crest level (BCL); or Type III, Type III Type II Type I
nonrestorable remaining tooth structure, fracture below
Figure 1. Percentage (%) of failure type in groups studied. LC, leucite-
the BCL. Subsequently, the fractured specimens were
based glass ceramic; LD, lithium disilicate-based glass ceramic; LSZ, glass
ultrasonically cleaned in isopropyl alcohol for 10 minutes ceramic based on zirconia-reinforced lithium silicate; ZR, monolithic
and then in distilled water for 10 minutes, dried, and zirconia.
examined under a scanning electron microscope (SEM)
(EVO 50H Electron Microscope; Carl Zeiss AG, Zeiss) to
load of 200 N was applied at 3 points of centric occlusion
determine the mode of failure based on the origin of the
on the occlusal surface of the endocrown. As a boundary
fracture and the principles of fractography.29
condition, the nodes of the base and side face of the
The Shapiro-Wilk statistical test for normality and the
cylindrical block were fixed, assuming x=y=z=0. All
Levene test for homogeneity revealed normal distribu-
structures of the models were considered perfectly joined,
tions for the data. The fracture resistance data were
without adhesion failures or interpositioning. The von
subjected to 1-way ANOVA and the Tukey HSD test
Mises stress criterion was used to evaluate the stress
(a=.05). Analyses were performed by using a statistical
values and distribution patterns.
software program (IBM SPSS Statistics, v20.0; IBM Corp).
The 3D geometry of the endodontically treated molars
RESULTS
was obtained by computed microtomography (SkyScan
1174v2; Bruker-microCT) and imported into a CAD One-way ANOVA revealed a statistically significant dif-
software program (Rhinoceros 5.0 Educational, NURBS ference among the groups (F[3,56]=54 528; P<.05). The
Modeling for Windows; McNeel North America) for Tukey HSD test revealed that the ZR group had the
modeling the endocrown, radicular dentin, gutta percha, highest fracture resistance values, statistically different
periodontal ligament (0.2-mm thick), and cylindrical from the other groups (P<.05) (Table 3). The analysis of
block (25 mm in diameter and 20 mm in height). The FE failure revealed a higher percentage of restorable frac-
mesh was obtained (SimLab 2017.2.1; Altair/Hyper- tures in the LC and LD groups (Fig. 1) and unrestorable
Works) with linear elements Type Tet10, with a total of fractures in the LSZ and ZR groups (Fig. 2).
504 659 nodes and 304 632 elements. The mechanical The SEM revealed that the fracture surface originated
properties of the materials (Young modulus E and Pois- in the occlusal surface, particularly at the point of loading,
son ratio v) were obtained from published data (Table 2). in all groups. In the occlusal surface, the presence of
Four models reproducing the different CAD-CAM ce- porosities in the LC and LD groups and cracks in the LC
ramics used to fabricate the endocrowns in the in vitro group were noted, but no porosities in the LSZ and ZR
analysis were obtained. All materials were considered groups. For the fracture features, the LC group had
linearly elastic, isotropic, and homogeneous. A static axial irregular fractures typical of vitreous ceramics in several

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Figure 2. Occlusal view of failure mode for each studied group. A, LCdfailure Type I. B, LDdfailure Type I. C, LSZdfailure Type III. D, ZRdfailure Type III.
LC, Leucite-based glass ceramic; LD, Lithium disilicate-based glass ceramic; LSZ, Glass ceramic based on zirconia-reinforced lithium silicate;
ZR, Monolithic zirconia.

ceramic fragments (Fig. 3); the LD group had irregular was accepted because the von Mises stress values and
fractures with fewer steps than the LC and LSZ groups, distribution patterns were similar among the groups.
presenting as a vitreous ceramic (Fig. 4); the LSZ group The vitreous ceramics used in this study (LC, LD, and
had cracks, fractures with more steps but in only 1 plane, LSZ) were similar in terms of mechanical strength.
with several ceramic fragments, as in the LC group Considering the mean fracture resistance of the groups
(Fig. 5); and the ZR group had fewer steps in the surface studied and correlating it with occlusal force in healthy
of the ceramic material, while the fracture of the molars (which varies from 441 N to 981 N in individuals
tooth was characterized as a regular fracture but with a with normal occlusion and parafunctional habits),35 these
rougher surface, which is a characteristic of crystalline materials may be indicated for the fabrication of
ceramics (Fig. 6). endocrowns.
A higher level of stress was observed in the loading However, the LC group had a mean resistance
application point and the region of the angle between strength value close to that of the parafunctional occlusal
the pulp and axial walls of the endocrown and root force, suggesting that preference be given to the other
dentin among the groups (Fig. 7). Quantitatively, the von materials for restoration in patients with bruxism.36 LD
Mises stress values were similar among the groups (LC: had a mean value similar to that found in previous
636 MPa; LD: 631 MPa; LSZ: 631 MPa; and ZR: 626 studies.9 Meanwhile, LSZ had maximum resistance
MPa). values similar to those values obtained for molar crowns
produced with CAD-CAM and a thickness of 1.5 mm.17
DISCUSSION
According to the manufacturer, 8% to 10% by weight
The first null hypothesis was rejected because the of zirconium oxide should be added to provide greater
different ceramic materials affected both the fracture mechanical resistance to the material19,22,23; however,
mechanical strength and the fracture pattern of the this was not observed in the present study. The ther-
endodontically treated teeth. The second null hypothesis momechanical loading performed before the fracture

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Figure 3. Scanning electron microscope images of fracture surface testing for leucite-based glass ceramic. A, B, Fractography showed that fracture
originated in occlusal surface at point of loading. C, D, Features of fractographic analysis. (A, C, D, original magnification ×40; B, original
magnification ×100).

resistance testing may have caused instability in the of unrestorable fractures.15 The addition of zirconium
phases of the lithium silicate reinforced with zirconium oxide particles provided to the LSZ a fracture pattern
oxide This resulted in an increase in local residual stresses similar to that of ZR. However, ZR had higher maximum
that were relieved during cooling by means of micro- fracture resistance than LSZ.
cracks, leading to statistically similar mechanical strength The high fracture resistance of a material is not the
resistance values between LC and LD.19 single determining factor in the observation of high
The ZR group had the highest fracture strength rates of catastrophic failures. In this study, the LSZ
resistance value (6333 N), which was better than the group had an 85% catastrophic failure rate and a frac-
fracture resistance of a healthy molar (3901 N).36 This ture resistance level of approximately 30% of that of the
finding is related to its high fracture toughness and ZR group. Even though the ZR group had a high per-
flexural strength, obtained from a composition mainly centage of catastrophic failures, they generally occurred
containing crystalline particles and suggesting its under a load that not even patients with bruxism could
appropriateness in extensive restorations.19,24,25 achieve. The better mechanical results suggest that the
Analyzing the fracture pattern and determining the fabrication of ZR endocrowns can improve success
nature of the stress distribution are as important as rates.
considering the fracture load, as, in clinical practice, after In the analysis of von Mises stress, the FE models had
the failure occurs, the tooth is assessed to determine similar stress distribution patterns among the groups,14
whether the remaining structure is repairable or not.15 with higher stress observed between the pulp base of
With regard to the patterns of endocrown failures, the the endocrown and the radicular dentin.9 FEA is a
LC and LD groups had higher percentages of Type I and complementary numerical tool because it allows the user
Type II failures, which are considered restorable fractures. to identify the regions with the highest stress concen-
However, the LSZ and ZR groups had a high percentage tration, as well as those most prone to failure. However,

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Figure 4. SEM images of fracture surface testing for lithium disilicate-based glass ceramic. A, B, Fractography showed that fracture originated in
occlusal surface at point of loading. C, D, Features of fractographic analysis. (A, C, D, original magnification ×40; B, original magnification ×100).

Figure 5. SEM images of fracture surface testing for glass ceramic based on zirconia-reinforced lithium silicate. A, B, Fractography showed that fracture
originated in occlusal surface at point of loading. C, D, Features of fractographic analysis. (A, B, C, D, original magnification ×40).

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Figure 6. SEM images of fracture surface testing for monolithic zirconia. A, B, Fractography showed that fracture originated in occlusal surface at point
of loading. C, D, Features of fractographic analysis. (A, C, D, original magnification ×40; B, original magnification ×100).

it cannot predict fracture patterns nor their progression materials containing zirconium oxide warrant further
among the materials. examination with regard to the reliability of their use.
Simulations are used to provide estimates of the Additionally, the results of the present study could be
survival rate and to predict catastrophic failures in used as a basis for future research and might be relevant
monolithic ceramic restoration.26 In this study, the eventually in clinical practice in the reconstruction of
cyclic isometric loading protocol associated with ther- dental crowns with endocrowns.
mal cycling promoted a gradual increase of the load on
the restored tooth to accommodate the restoration CONCLUSIONS
material to the dental substrate until it reached a more
Based on the findings of this in vitro and FEA study, the
critical occlusal load level that could lead to failure of
following conclusions were drawn:
the assembly. The SEM images showed high rates of
porosity and cracks in the surface of the endocrowns 1. Vitreous ceramics reinforced with leucite and
in the LC, LD, and LSZ groups, which, probably, lithium disilicate had similar levels of mechanical
was influenced by the thermomechanical loading resistance and a higher percentage of restorable
process. failures.
Laboratory studies like the present investigation have 2. Although vitreous ceramics reinforced with lithium
inherent limitations, and the results should be inter- silicate and zirconium oxide had a level of me-
preted with caution. However, a correlation was estab- chanical resistance statistically similar to that of ce-
lished between the results obtained in the mechanical ramics containing leucite and lithium disilicate, a
tests and finite element method; endocrowns made of higher rate of catastrophic dental failures was noted.
lithium-reinforced and leucite-reinforced glass ceramics 3. In relation to the fracture resistance, the mechanical
may be considered the most suitable materials for the performance of monolithic zirconia was better than
rehabilitation of endodontically treated teeth, while that of the other ceramic materials evaluated.

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Figure 7. von Mises stress distribution of each model (sagittal view). A, Leucite-based glass ceramic (LC); B, Lithium disilicate-based glass ceramic
(LD); C, Glass ceramic based on zirconia-reinforced lithium silicate (LSZ); D, Monolithic zirconia (ZR). Highest stress values in gray; lowest stress
values in blue.

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