Prognosis of Indirect Composite Resin Cuspal Coverage

on Endodontically Treated Premolars and Molars: An In Vivo

Prospective Study
Maria Carlos Real Dias, DDS, MSc,1 Jorge N.R. Martins, DDS, MSc,2 André Chen, DDS, MSc,3
Sérgio André Quaresma, DDS, Msc,4 Henrique Luı́s, PhD, MS, BS,5 & João Caramês, DDS, PhD, FICD6
1
Clinical Assistant Faculty, Occlusion and Oral Rehabilitation, Lisbon University, School of Dental Medicine, Lisbon, Portugal
2
Department of Endodontics, Implantology Institute, Lisbon, Portugal
3
Clinical Assistant Faculty, Implant Dentistry, Lisbon University, School of Dental Medicine, Lisbon, Portugal
4
Assistant Professor of the Master of Endodontics, International University of Catalunya, Barcelona, Spain
5
Professor of Statistics and Probabilities, University of Lisbon Dental School, Lisbon, Portugal
6
Full Professor and Chairman of the Implantology Department, Lisbon University, School of Dental Medicine, Lisbon, Portugal

Keywords Abstract
Composite resins; dental restoration failure;
follow-up studies; root canal therapy; dental
Purpose: This prospective clinical study evaluated the success rate of indirect com-
cavity preparation. posite resin cuspal coverage on endodontically treated molars and premolars and the
survival rate of the restored teeth.
Correspondence Materials and Methods: One hundred fifty endodontically treated teeth were restored
Jorge N.R. Martins, Instituto de Implantologia with total resin cuspal coverage and randomly selected for the study. Patients were
of Lisbon, Av. Columbano Bordalo Pinheiro, recalled after 2 to 5 years for clinical evaluation. Data were subjected to standard tests
50 – 5º e 6º, 1070-064 Lisboa, Portugal. of statistical correlations using Spearman test.
E-mail: jnr_martins@yahoo.com.br. Results: Out of the 150 teeth, 84 were molars and 66 were premolars. Of these teeth,
58.7% had mesio-occlusal-distal (MOD) cavities, 20.7% had mesio-occlusal (MO),
Jorge N.R. Martins ORCID and 20.7% had occlusal-distal (OD). A build-up procedure was performed in 51.3% of
http://orcid.org/0000-0002-6932-2038. the teeth, and buccal veneer composite resins were placed at the margins of 96.7% of
The authors deny any conflicts of interests.
the teeth. Out of the 150 teeth, 30 (20%) presented margin discoloration, 3 teeth (2%)
had restoration reparable fractures, 2 teeth (1.3%) had restoration irreparable fractures,
Accepted August 2, 2016 and 1 tooth (0.7%) exhibited secondary recurrent caries. The opposing arch that
occluded with the treated teeth presented 58% natural teeth (no restoration material),
doi: 10.1111/jopr.12545 26.7% ceramic crowns, and 15.3% implant-supported ceramic crowns. Statistically
significant differences (p = 0.018) between irreparable restoration fractures and the
type of support material present in the opposing arch were found.
Conclusions: In a period of up to 5 years, the resin cuspal coverage of endodontic
treated teeth had a success rate of 96%, while the tooth survival rate was 100%. The
type of support material on the opposing arch may influence the longevity of the
restoration of endodontically treated teeth.

The success of endodontically treated teeth depends not only leading to pulpal problems.4,5 Another issue is the failure to
on the clinician’s ability to eliminate intracanal microorgan- obtain a complete and uniform polymerization throughout the
isms and avoid new contamination, but also skill in avoiding restoration,6 potentially leading to postoperative pain, marginal
coronal and root fractures.1,2 Several techniques and materi- pigmentation, secondary recurrent caries, or fractures causing
als have been used to restore damaged teeth. Direct compos- microleakage.
ite resin restorations have become a standard for intracoro- The development of systems for indirect composite restora-
nary cavities,3 but unfortunately some limitations inherent in tion, with the material handling to be performed in an environ-
composite resin systems have not been fully overcome.4 The ment of controlled light, temperature, humidity, pressure, and
light-cured resin contraction during polymerization represents time, allows for better polymerization, which in turn results in
a significant limitation, since it may lead to a volume shrink- a well-cured restoration, minimizing shrinkage and improving
age of 2% to 4%.4,5 A large polymerization contraction can mechanical properties due to a postpolymerization cycle. In
cause excessive forces against the tooth structure, potentially addition, the extraoral handling gives the restoration improved

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Prognosis of Indirect Composite Resin Cuspal Coverage Dias et al

contours, proximal contacts, occlusal anatomy, and cavosurface The primary objective of this study was to evaluate, in in
adaptation.6 vivo conditions, the influence of several factors (type of tooth,
In heavily destroyed endodontically treated teeth, it is im- type of preexisting cavity, presence of build-up, discoloring of
portant to preserve as much of the remaining dental structure the composite veneering, type of restoration fractures, loss of
as possible, especially in the cervical region, for a better me- adhesion, tooth fracture, secondary decay, and opposing arch
chanical stabilization of the restoration. The use of posts is not characteristics) in the prognosis of indirect composite resin cus-
mandatory, unless there is insufficient tooth structure to retain pal coverage, as a restorative option for endodontically treated
the core. The pulp chamber can be used as part of the retention, teeth. The secondary objective was to evaluate the survival rate
in addition to adhesion.7 of teeth with endodontic treatment after being restored with
Restoring an endodontic tooth is subject to some controversy, composite resin cusp coverage.
although it has been extensively studied. A few years ago, sev-
eral studies supported the theory that a greater risk of fracture Materials and methods
in endodontic teeth was due to dentin dehydration and loss of
collagen links.8 At present, this fragility is associated with the Tooth selection
loss of tooth structure.9 Premolars and molars with recently performed endodontic
The loss of structural integrity, associated with the access treatment, requiring restorative procedures were preselected
opening, in endodontically treated teeth has led to a greater for this study. All teeth were placed in a proper occlusion with
prevalence of fractures when compared to vital teeth.10-13 The their opposing tooth (Angle’s class I occlusion). Periodontal
coronal access results in an increased deflection during the cusp disease was absent from all cases, and the mobility was within
function, raising the possibility of cusp fracture and microfrac- physiological limits for all of them. Teeth with class I cavities
ture of the restoration margins. This is supported by the fact (due to the great amount of tooth integrity) or previously re-
that, in addition to the destruction resulting from access to the stored with posts, definitive restorations with cuspal coverage,
pulp chamber, there is an association with the loss of tooth core reconstructions, or crowns were excluded.
structure due to caries or previous restorations.12,14
There are several options to restore a tooth with endodon-
Tooth restorative procedures
tic treatment, and there is no single solution for all clinical
situations. Taking into account the best scientific knowledge, All teeth had endodontic treatment performed by two experi-
preference should be given to restorative treatments that pre- enced endodontists, according to the quality guidelines of the
serve the maximum natural structure.7,9 Restorations that in- European Society of Endodontology.17 The restorative proce-
crease the structural integrity also improve the prognosis of a dures were performed by a clinician with exclusive practice to
tooth exposed to the forces of chewing, especially in teeth with restorative dentistry (single operator) at the Instituto de Implan-
root canal treatment. Cuspal coverage is essential to strengthen tologia, Lisbon, between 2009 and 2012, having followed the
the cusps of an endodontically treated tooth,15 except for the Rocca protocol.3 According to this protocol, each tooth was
cases where a class I can be solved by a direct restoration in a covered with flow composite at the channel inlet (immediately
safe occlusal context.9 Rocca and Krejci9 give a rationale for after the root canal filling procedure performed in a previous
a proper therapeutic option in endodontic teeth, highlighting endodontic appointment), and measured for the distance be-
important aspects such as the thickness of the remaining walls, tween the floor of the pulp chamber and the remaining tooth, in
the dimension of the cavity, and above all, the occlusal surface. order not to exceed 4 mm (all measurements were performed
Schwartz and Robbins14 suggested that a cuspal coating using a periodontal probe). If the depth of the cavity exceeded
should be placed on the tooth to ensure long-term success, this value, the tooth was subjected to a composite resin build-up
since there is a greater chance of survival when compared with (Filtek Z250 micro-hybrid resin; 3M ESPE, St. Paul, MN). This
intracoronary restorations. Mondelli et al16 also researched and procedure was also applied when the remaining margin was less
evaluated the fracture resistance of highly destroyed premolars than 2 mm deep from the gingival margin, or the remaining wall
(mesio-occlusal-distal [MOD] cavity preparation with removal was less than 1.5 mm thick (Fig 1). The objective was to have
of the pulp chamber roof) restored with a packable composite margins and thickness equal or superior to those values. This
resin, with and without cuspal coating. The results showed that a procedure was performed under proper rubber dam isolation.
cuspal coating can be a safe option for restoring weakened teeth The exposed dentine was submitted to immediate dentine seal-
treated endodontically. They also stated that restoring premo- ing (all enamel margins were cleaned after this procedure to
lars with cuspal coating increased the fracture toughness, when ensure perfect enamel adhesion). Tooth preparation followed a
compared with teeth restored without cuspal coating. protocol requiring 1.5 to 2 mm wear on functional cusps and
Composite onlays may be seen as a restorative option that 1 mm wear on non-functional cusps. All corners were rounded
gives all the advantages of a cusp coverage restoration, and and the angle of divergence of the walls was about 10°. The
also the advantage of being a less expensive treatment option, peripheral limits of the restorations had a cavosurface angle of
which presents the possibility of correcting minor fractures in 90°, except in cases where esthetics were mandatory (an es-
the mouth with composite resin without requiring a new restora- thetic bevel was implemented in the buccal wall at 1 mm deep).
tion. Despite the extensively published literature on the restora- The final impression was made at the same appointment with
tion of endodontically treated teeth, the information available dual consistency addition silicone in one stage. Fermit (Ivoclar
regarding the use of composite resin cuspal coverage is very Vivadent, Amherst, MA) was used as a provisional restorative
scarce. material. The measures were confirmed in working models. All

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Dias et al Prognosis of Indirect Composite Resin Cuspal Coverage

Figure 1 Composite resin build-up decision making.

Figure 2 Clinical procedures for overlay placement on the second premolar: (A) initial; (B) composite resin build–up; (C) cuspal reduction; (D) overlay
laboratory work; (E) standard measurements; (F) prepared for cementation; (G) premolar overlay; (H) matching measurements; (I) cementation; (J)
final esthetic result of the second premolar treatment.

Figure 3 Buccal veneering composite placement for esthetic reasons in the maxillary first premolar (before and after).

indirect restorations were performed with the Adoro System occlusion of all restorations was checked with shimstock paper.
(Ivoclar Vivadent, Schaan, Liechtenstein), following manufac- The paper was folded to be 16 mm thick. For esthetic reasons,
turer’s recommendations. Cementation with RelyX Unicem-Tr if there was a visible transition between tooth and resin restora-
(3M ESPE, Seefeld, Germany) was performed 15 days after tion, an additional layer of microhybrid composite veneering
the initial treatment under rubber dam isolation (Fig 2). The was implemented to opacify the final result (Fig 3).

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Prognosis of Indirect Composite Resin Cuspal Coverage Dias et al

Final sample selection and recalls Table 1 Type of cavity and tooth type

From the preselected larger sample, a smaller sample was ran- Sample (n) Percent
domly selected to be included in the study and subjected to
Tooth type Molar 84 56.0
posterior clinical evaluation. The randomization method con-
Premolar 66 44.0
sisted of picking papers with a patient chart and tooth number
Total 150 100.0
from a bag. The picked cases were to be included in the study.
Cavity MO 31 20.7
A total of 150 teeth were admitted in this in vivo study. All pa- OD 31 20.7
tients were scheduled for a 2-year recall, and those who failed MOD 88 58.7
this appointment would be contacted by phone or e-mail to Total 150 100.0
try to bring them back to a proper recall, although no recall
should exceed 5 years. This study was approved by the Ethics
Commission of the Instituto de Implantologia.
Table 2 Opposing arch
Statistical analysis
Sample (n) Percent
The primary outcome (restoration success) was defined as a
Natural teeth 87 58.0
failure if the tooth required a new restoration, tooth repair, or
Ceramic crowns-tooth 40 26.7
extraction during the follow-up period. Teeth lost due to en- Ceramic crowns-implants 23 15.3
dodontic and periodontal reasons were to be excluded (from Total 150 100.0
the restoration success rate) due to the independence of the
restoration. The exception would be tooth loss due to en-
dodontic reasons caused by restorative microleakage. The sec-
ondary outcome (tooth survival) was considered successful if Table 3 Reparable fractures versus type of cavity
the tooth was functional, or in the case of the presence of
fracture (of the restoration or of the tooth) still possible to be Reparable fracture∗
restored. No Yes Total
The independent variables analysed were: type of tooth (pre-
∗
molar or molar), type of preexisting cavity (mesio-occlusal Type of cavity MO 31 0 31
[MO], occlusal-distal [OD], MOD), presence of build-up, dis- OD 30 1 31
coloration of the composite veneering, type of restoration frac- MOD 86 2 88
tures (reparable [possible to be repaired in mouth] or irreparable Total 147 3 150
[impossible to be repaired in mouth and requiring a new restora-
tive procedure]), loss of adhesion, tooth fracture, secondary
*
No correlation between the type of cavity and the reparable fracture (ρ = 0.042,
decay, and opposing arch (intact tooth with enamel occlusal p = 0.612).
contact point, tooth-supported ceramic crowns and implant-
supported ceramic crowns). Data were collected in SPSS and and 2 irreparable (1.3%) (1 male, 1 female patient) restoration
subject to standard tests of statistical correlations using the fractures. The 3 reparable fractures occurred at 2.5 years (twice)
Spearman test. Statistical significance was declared when the and 4 years, while the 2 irreparable fractures happened at 3
average failure was >0.027 for an alpha of 0.05 and power of and 4.5 years. There were no cases of failed adhesion or frac-
0.90. tures to the underlying tooth, nor were there endodontic or
periodontic problems. In the same period, only a single tooth
Results (0.7%) exhibited secondary recurrent decay. The arch oppos-
ing restored teeth had different characteristics: 58% had natural
The 150 teeth admitted to this study belonged to 150 patients teeth (no restoration material) with an enamel occlusal contact
(79 males, 71 females). It was possible to bring back all patients point, 26.7% of the opposing arch had tooth-supported ceramic
over the recall period of 2 to 5 years, representing a 100% recall crowns, and 15.3% had implant-supported ceramic crowns
rate with 0% dropouts. (Table 2).
Out of the 150 teeth, 84 were molars (56.0%) and 66 were Spearman correlation test, with a significance level of 5%
premolars (44.0%). Preexisting MOD cavities were noted in showed no correlation between the type of cavity and the repara-
58.7% of the cases, 20.7% of the teeth had a MO cavity, and ble fracture (Table 3) or irreparable fracture (Table 4). Also,
20.7% had an OD cavity (Table 1); 51.3% of the studied teeth there was no correlation between type of teeth and reparable
had a build-up procedure done, and 48.7% did not need this fractures (ρ = 0.031, p = 0.709) or irreparable fractures (ρ =
kind of pre-restoration. In 96.7% of the cases, it was necessary 0.103, p = 0.210).
to place veneer composite on the margin. There was no correlation between the type of opposing arch
Over the follow-up period (2 to 5 years), there were 30 teeth and reparable fracture (Table 5); however, when it comes to
(20%) with margin discoloration defined as margin pigmen- irreparable fractures, all the events occurred when the op-
tation, and 120 teeth (80%) esthetically acceptable (still with posing arch had implant-supported ceramic crowns, repre-
invisible margin between tooth and restoration). In the same senting a statistical significance (ρ = 0.193, p = 0.018)
period, there were 3 reparable (2%) (2 male, 1 female patient) (Table 6). There were no correlations between the existence

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Dias et al Prognosis of Indirect Composite Resin Cuspal Coverage

Table 4 Irreparable fractures vs type of cavity investigation. The difficulty in performing a proper follow-up
and standardizing the study are cited as possible reasons for
Irreparable fracture∗
the lack of literature on this topic. According to Nagasiri and
No Yes Total Chitmongkolsuk,20 the survival rates of endodontically treated
molars without crowns were 96%, 88%, and 36% at 1, 2,
Type of cavity∗ MO 30 1 31 and 5 years, respectively. With greater amounts of coronal tooth
OD 31 0 31 structure remaining, the survival probability increased.
MOD 87 1 88 Regarding the different types of full-coverage restorative pro-
Total 148 2 150 cedures, the outcomes are also relatively high. According to a
Cochrane review by Sequeira-Byron et al22 the full-coverage
*
No correlation between the type of cavity and irreparable fracture (ρ = 0.043,
metallic-ceramic crown may reach a success of 98.1% at 3
p = 0.599).
years. A systematic review by Morimoto et al23 concluded
Table 5 Reparable fractures versus opposing arch
that ceramic onlays may reach a survival rate of 95% at 5
years. Donovan et al’s24 retrospective evaluation states that
Reparable fracture∗ full-coverage cast gold restorations may be successful in 97%
of cases in a period between 1 and 9 years.
No Yes Total

Opposing arch∗ Natural 86 1 87 Cavity and tooth type

teeth The choice of a restorative method is frequently based on
Ceramic 40 0 40 cavity configuration and on residual number of cavity walls;
crowns-
however, the residual wall thickness could be a valuable clin-
tooth
ical parameter when choosing a restoration for endodontically
Ceramic 21 2 23
treated teeth.9,25 Cuspal deflection and strain increase signifi-
crowns-
cantly when axial dentine is removed as part of the endodontic
implants
Total 147 3 150
access.26 It is often necessary to build and strengthen the re-
maining tooth with composite, to increase margins, or round
*
No correlation between the type of opposing arch and reparable fracture (ρ = the internal angles.27 When the residual wall thickness is less
0.119, p = 0.148). than 2 mm, only cuspal coverage, with or without a fiber post,
provides satisfactory fracture resistance.25 The thickness of the
Table 6 Irreparable fracture vs opposing arch walls, measured in the mouth and in models, was one of the
criteria for standardization of the teeth selected for this study.
Irreparable fracture In this study, the presence of a build-up did not affect the
type of fracture (reparable or irreparable), which is consis-
No Yes Total
tent with the literature suggesting that the remaining tooth
Opposing arch Natural 87 0 87 must be at least 1.5 to 2 mm thick so that fracture tough-
teeth ness could be the greatest. This study followed the literature,3
Ceramic 40 0 40 implementing resin composite microhybrid as a build-up
crowns- material.
tooth According to the literature,15,16 the type of previous cavity
Ceramic 21 2∗ 23 (MO, MOD, and OD) is not related to the type of restoration
crowns- fracture (reparable or irreparable), if cuspal coverage is per-
implants formed. This data is confirmed in the present study, in which
Total 148 2 150
the type of cavity (MO, OD, or MOD) did not statistically affect
the type of fracture.
*
Statistical significance (p = 0.018).
The anatomy and tooth type (molars or premolars) can be
an important issue.9 The axial forces in molars and the more
of build-up and reparable fracture (ρ = 0.147, p = 0.073) or complex set of forces in premolars increase the potential of frac-
irreparable fracture (ρ = 0.119, p = 0.146). The success rate tures, especially with reduced healthy tissues.12 In this study,
of the restorative procedure was 96% after this follow-up pe- there was no relationship between the type of tooth and the type
riod. No endodontically treated teeth were lost over the same of restoration fractures (reparable or irreparable).
period.
Margin discolorations
Discussion
Evidence shows that margin discolorations, defined as margin
The best scientific evidence shows that prognosis of an en- pigmentation, are frequent after 5 years.21 The present study
dodontically treated tooth not only depends on endodontic showed 20% margin discolorations. This data is consistent with
variables, but also on correct tooth rehabilitation.18,19 To the the literature.21 This may be explained by natural pigmentation
best of the authors’ knowledge, there are only two in vivo of the composite over time. In some cases, a simple polish of
studies20,21 on a critical issue such as the one explored in this the margin was enough to restore the original color.

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Prognosis of Indirect Composite Resin Cuspal Coverage Dias et al

Type of material fractures, two irreparable fractures, and one secondary recur-
rent decay. No tooth was lost, which represents a 100% survival
The mode of failure is a criterion for success, since a reparable
rate of endodontically treated teeth for the period evaluated.
fracture allows repair in the mouth. It is classified as irrepara-
In our study, the fact that the same operator restored and
ble if the fracture is found below the cemento-enamel junction
evaluated all cases may mean a potential bias to influence data.
(CEJ), or if it is so extensive that it does not allow the frac-
This may be mitigated by the fact that the success criteria were
tured overlay to be repaired (it leads to extraction, full-crown
objective and minimally dependent on the operator’s opinion.
coverage, or a new overlay). The type of cement may influence
The presence of bruxism and the comparison between maxillary
cuspal deflection stability and tooth fracture resistance.28 In this
and mandibular teeth were not addressed in this study, and those
study, this variable was minimized by using the same cement,
might be good subjects for future research.
under the same conditions of absolute isolation in all cases.
It should also be noted that, according to Magne and
Knezevic’s29 in vitro study, the rate of fracture below the CEJ is Conclusion
between 30% and 40% for ceramic overlays and 20% for com-
posite overlays (with a 3 mm cuspal reduction and immediate Under the conditions of this research, it is possible to conclude
dentin sealing). For this reason, and also because it is possible to that cusp coverage of endodontically treated premolars or mo-
repair them in the mouth, all overlays in this investigation were lars showed an excellent clinical performance in a period that
performed in composite. All three cases of reparable fractures may reach 5 years. The success rate of restorations was 96%,
that occurred in the current study have been successfully solved and the tooth survival rate was 100%. The types of teeth and
with an additive composite technique in the mouth. The indi- cavity had no influence on the type of fractures that occurred
rect process of executing the restorations has been associated in the follow-up period.
with minimum material shrinkage and improved mechanical
properties due to post-polymerization cycles. In this study, all References
restorations were performed through the indirect process us-
ing the Adoro system as the only restorative material, to avoid 1. Ng YL, Mann V, Rahbaran S, et al: Outcome of primary root
variability in materials. canal treatment: systematic review of the literature—Part 2.
Influence of clinical factors. Int Endod J 2008;41:6-31
2. Ng YL, Mann V, Gulabivala K: Tooth survival following
Opposing arch non-surgical root canal treatment: a systematic review of the
A key factor that the literature does not address as a factor literature. Int Endod J 2010;43:171-189
that may influence the success rate is the type of material in 3. Rocca GT, Krejci I: Bonded indirect restorations for posterior
teeth: from cavity preparation to provisonalization.
the opposing arch. The choice of cases is critical to long-term
Quintenssence Int 2007;38:371-379
success. In this study, the type of material in the opposing arch 4. Ruyter EI: Types of resin-based inlay materials and their
significantly affected the type of fracture. More than half of the properties. Int Dent J 1992;42:139-144
opposing teeth were natural teeth with enamel contact points 5. Duquia Rde C, Osinaga PW, Demarco FF, et al: Cervical
(58.0%), the remaining were tooth-supported ceramic crowns microleakage in MOD restorations: in vitro comparison of
(26.7%) and implant-supported ceramic crowns (15.3%). The indirect and direct composite. Oper Dent 2006;31:682-687
opposing arch did not influence the reparable fractures. On the 6. Baratieri LN: Restaurações indirectas com resina composta
other hand, the irreparable fractures were influenced by the sup- (inlay/onlay). In Baratieri LN, Monteiro Jr S (eds): Odontologı́a
port material present in the opposing arch. All irreparable frac- Restauradora Fundamentos e Possibilidades (ed 2). São Paulo,
tures occurred when the opposing arch had implant-supported Livraria Santos Editora, 2015, pp. 521-541
7. Dietschi D, Duc O, Krejci I, et al: Biomechanical considerations
ceramic crowns (p = 0.018). No data regarding bruxism or
for the restoration of endodontically treated teeth: a systematic
nightguard protection was investigated, so it was not possible review of the literature, Part I (Composition and micro- and
to understand, in this study, the influence of these parameters. macroestruture alterations). Quintessence Int 2007;38:733-743
The lack of proprioception may be a possible reason for this 8. Rivera EM, Yamauchi M: Site comparisons of dentine collagen
finding. Careful conclusions should be taken regarding the inci- crosslinks from extracted human teeth. Arch Oral Biol
dence of irreparable fractures against implant ceramic crowns. 1993;38:541-546
Since this event occurred only twice, it would be important to 9. Rocca G, Krejci I: Crown and post–free adhesive restorations for
have a larger sample size or an extended follow-up period to be endodontically treated posterior teeth: from direct composite to
able to draw reasonable conclusions regarding a possible risk endocrowns. Eur J Esthet Dent 2013;8:156-179
factor. None of the irreparable fractures led to tooth loss, since 10. Gutmann JL: The dentin-root complex: anatomic and biologic
considerations in restoring endodontically treated teeth. J
both fractures were restricted to the overlays. Both teeth could
Prosthet Dent 1992;67:458-467
be restored again, one with a full crown and the other with a 11. Panitvisai P, Messer HH: Cuspal deflection in molars in relation
new overlay. to endodontic and restorative procedures. J Endod 1995;21:57-61
12. Dietschi D, Duc O, Krejci I, et al: Biomechanical considerations
Final primary and secondary outcome for the restoration of endodntically treated teeth: a systematic
review of the literature, Part II (Evaluation of fatigue behaviour,
Over the follow-up period of 2 to 5 years, the indirect compos- interfaces and in vivo studies). Quintessence Int 2008;39:117-129
ite resin cuspal coverage had a success rate of 96%. The six 13. Reeh ES: Reduction in tooth stiffness as a result of endodontic
failures, out of the initial 150 teeth, were from three reparable restorative procedures. J Endod 1989;15:512-516

6 Journal of Prosthodontics 00 (2016) 1–7 

C 2016 by the American College of Prosthodontists
Dias et al Prognosis of Indirect Composite Resin Cuspal Coverage

14. Schwartz RS, Robbins JW: Post placement and restoration of 22. Sequeira-Byron P, Fedorowicz Z, Carter B, et al: Single crowns
endodontically treated teeth: a literature review. J Endod versus conventional fillings for the restoration of root-filled teeth.
2004;30:289-301 Cochrane Database Syst Rev 2015 Sep 25;9:CD009109
15. Magne P: Composite resins and bonded porcelain: the 23. Morimoto S, Rebello de Sampaio F, Braga M, et al: Survival rate
postamalgam era? J Calif Dent Assoc 2006;34:135-147 of resin and ceramic inlays, onlays, and overlays: a systematic
16. Mondelli RF, Ishikiriama SK, De Oliveira Filho O, et al: Fracture review and meta-analysis. J Dent Res 2016;95:985-994
resistance of weakened teeth restored with condensable resin 24. Donovan T, Simonsen R, Guertin G, et al: Restrospective clinical
with and without cusp coverage. J Appl Oral Sci 2009;17:161- evaluation of 1,314 cast gold restorations in service from 1 to 52
175 years. J Esthet Rest Dent 2004;16:194-204
17. European Society of Endodontology: Quality guidelines for 25. Scotti N, Rota R, Scansetti M, et al: Influence of adhesive
endodontic treatment: consensus report of the European Society techniques on fracture resistance of endodontically treated
of Endodontology. Int Endod J 2006;39:921-930 premolars with various residual wall thicknesses. J Prosthet Dent
18. Lazarski MP, Walker WA, Flores CM, et al: Epidemiological 2013;110:376-382
evaluation of the outcomes of nonsurgical root canal treatment in 26. Taha NA, Palamara JE, Messer HH: Cuspal deflection, strain and
a large cohort of insured dental patients. J Endod microleakage of endodontically treated premolar teeth restored
2001;27:791-796 with direct resin composites. J Dent 2009;37:724-730
19. Imura N, Pinheiro ET, Gomes BP, et al: The outcome of 27. Swift EJ, Stundervant JR, Boushell LW: Indirect tooth colored
endodontic treatment: a retrospective study of 2000 cases restorations. In Heymann HO, Swift EJ, Ritter AV (eds):
performed by a specialist. J Endod 2007;33:1278-1282 Sturdevant’s Art and Science of Operative Dentistry (ed 6). St.
20. Nagasiri R, Chitmongkolsuk S: Long-term survival of Louis, MO, Mosby Elsevier, 2013, pp. 280-294
endodontically treated molars without crown coverage: a 28. Salaverry A, Borges GA, Mota EG, et al: Effect of resin cements
retrospective cohort study. J Prosthet Dent 2005;93:164- and aging on cuspal deflection and fracture resistance of teeth
170 restored with composite resin inlays. J Adhes Dent
21. Shafiei F, Memarpour M, Doozandeh M: Three-year clinical 2013;15:561-568
evaluation of cuspal coverage with combined 29. Magne P, Knezevic A: Influence of overlay restorative materials
composite-amalgam in endodontically-treated maxillary and load cusps on the fatigue resistance of endodontically treated
premolars. Oper Dent 2010;35:599-604 molars. Quintessence Int 2009;40:729-737

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