Journal of Dentistry 63 (2017) 1–7

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Journal of Dentistry
journal homepage: www.elsevier.com/locate/jdent

Full Length Article

No post-no core approach to restore severely damaged posterior teeth: An up MARK

to 10-year retrospective study of documented endocrown cases
Marcia M. Belleflammea,b, Sabine O. Geertsa,b, Marie M. Louwettea,b, Charlotte F. Grenadeb,c,
⁎
Alain J. Vanheusdenb,c, Amélie K. Mainjotb,c,
a
Department of Conservative Dentistry and Endodontics, Institute of Dentistry, University of Liège Hospital (CHU), Liège, Belgium
b
Dental Biomaterials Research Unit (d-BRU), Institute of Dentistry, University of Liège, (ULg), Liège, Belgium
c
Department of Fixed Prosthodontics, Institute of Dentistry, University of Liège Hospital (CHU), Liège, Belgium

A R T I C L E I N F O A B S T R A C T

Keywords: Objectives: The objectives of the present study were to (1) retrospectively evaluate documented cases of ceramic
Endocrowns and composite endocrowns performed using immediate dentin sealing (IDS); (2) correlate failures with clinical
Fixed dental prostheses parameters such as tooth preparation characteristics and occlusal parameters.
Minimal intervention dentistry Methods: 99 documented cases of endocrowns were evaluated after a mean observation period of
Post and core
44.7 ± 34.6 months. A classification of restorations was established in function of the level of damage of
Lithium-disilicate glass-ceramic
Polymer infiltrated ceramic network
residual tooth tissues after preparation, from 1 to 3. Evaluation was performed according to FDI criteria and
endodontic outcomes were analyzed. Occlusal risk factors were examined and fractographic analysis was
performed in case of fracture.
Results: 48.4% of patients were shown to present occlusal risk factors. 75.8% of restorations were Class 3
endocrowns. 56.6% were performed on molars, 41.4% on premolars and 2.0% on canines. 84.8% were
performed in lithium-disilicate glass-ceramic and 12.1% in Polymer-Infiltrated Ceramic Network (PICN)
material. The survival and success rates of endocrowns were 99.0% and 89.9% respectively, while the 10-
year Kaplan-Meier estimated survival and success rates were 98.8% and 54.9% respectively. Ten failures were
detected: periodontal disease (n = 3), endocrown debonding (n = 2), minor chipping (n = 2), caries recurrence
(n = 2) and major fractures (n = 1). Due to the reduced amount of failures, no statistical correlation could be
established with clinical parameters.
Conclusions: Endocrowns were shown to constitute a reliable approach to restore severely damaged molars and
premolars, even in the presence of extensive coronal tissue loss or occlusal risk factors, such as bruxism or
unfavorable occlusal relationships.
Clinical significance: Practitioners should consider the endocrown instead of the post and core approach to
restore severely damaged non-vital posterior teeth. This minimally invasive solution reduces the risk of
catastrophic failures and is easily performed. The use of IDS procedure and lithium-disilicate glass-ceramic as
prosthesis material gave very good results.

1. Introduction tooth. This minimally invasive approach is easily performed, less

Nowadays, the development of adhesive dentistry has reduced the
need of posts and cores to restore endodontically non-vital posterior
teeth with extensive coronal tissue loss. Indeed, it has been more than
20 years since Pissis [1] introduced the “mono-block porcelain technic”
in which the retention of the restoration lies on the use of adhesive
cementation and macromechanical retention in canal entrance. In
1999, Bindl and Mormann [2] introduced the term “endocrown” to
describe a mono-block ceramic crown bonded to a depulped posterior
expensive and most of all could reduce failures related to post
placement [3,4]. Yet, surprisingly few in vitro [5] [5,4,6–12] and
clinical [13,2,14–16] studies have been dedicated to those restorations.
Moreover, there is no exact definition of the endocrown, particularly
regarding the amount of residual tooth tissues and the specific
characteristics of the tooth preparation. Some authors define an
endocrown as a preparation with “a circular equigingival butt margin
and a central retention cavity of the entire pulp chamber” [2], others as
“a total porcelain crown fixed to depulped posterior tooth, which is

⁎
Correspondence to: 45 Quai G. Kurth, Liège, 4020, Belgium.
E-mail address: a.mainjot@chu.ulg.ac.be (A.K. Mainjot).

http://dx.doi.org/10.1016/j.jdent.2017.04.009
Received 18 February 2017; Received in revised form 19 April 2017; Accepted 25 April 2017
0300-5712/ © 2017 Elsevier Ltd. All rights reserved.
M.M. Belleflamme et al.
Fig. 1. Classification of endocrowns, which was established on the basis of residual tooth tissue amount after preparation. For Class 2 and 3, the presence of a buccal chamfer or an
extension in the pulp chamber were registered.
anchored to the internal portion of the pulp chamber and to the cavity
margins” [17], while for Bernhart et al. [13], a preparation with a
height reduction of only 2 mm is considered as an endocrown, if the
tooth is non vital and there is at least a 2 mm of height retention in the
pulp chamber. However, the amount of residual tooth walls, the
creation of a peripheral butt margin (which can promote a ferrule
effect) or the use of the pulp chamber cavity as macromechanical
retention are variables which could influence restoration retention and
performance.
Since endocrown retention mainly lies on bonding, it is crucial to
use prosthetic materials, which can be resin bonded to tooth tissues.
Clinical studies about endocrowns usually refer to glass-ceramic
materials, particularly feldspathic ceramic (Vita Mark II, Vita
Zahnfabrik, Bad Säckingen, Germany) manufactured with a computer-
aided design and manufacturing (CAD-CAM) process (Cerec system,
Sirona, Benscheim, Germany) [15,13,14,16], except Bindl et al. who
used In Ceram alumina or In Ceram spinell (Vita Mark II, Vita
Zahnfabrik, Bad Säckingen, Germany) [2]. Indeed glass-ceramic mate-
rials such as feldspathic ceramic are etchable ceramics, which can
effectively bond to resin cement through the application of hydrofluoric
acid and silane on their surface [18]. Currently, the range of materials
available for endocrowns also comprises lithium-disilicate reinforced
glass-ceramics, which are popular materials with an excellent short
clinical background for single unit restorations [19] and a higher
flexural strength than feldspathic ceramic [17]. Yet, there are no
clinical studies about the use of lithium-disilicate glass-ceramic for
endocrowns. On the other hand, CAD-CAM composites appeared on the
market a few years ago and are also recommended for single unit
bonded restorations. CAD-CAM composites constitute a growing family
of materials, which can be divided into two sub-classes: dispersed filler
and Polymer Infiltrated Ceramic Network (PICN) materials [20,21].
Particularly, PICNs (Vita Enamic, VITA, Vita Zahnfabrik, Bad Säckin-
gen, Germany) represent a promising class of materials composed of a
partially sintered glass-ceramic block (75% vol.) secondarily infiltrated
with dimethacrylate monomers, which are polymerized under high
temperature and high pressure [22]. Currently there are very limited
data about bonding properties and clinical behavior of current CAD-
CAM composites. Finally, immediate dentin sealing (IDS) with a
bonding agent directly after tooth preparation has been recommended
for indirect bonded restorations [23–25]. It is intended to improve bond
strength, marginal adaptation and decrease bacterial leakage [26].
Those arguments are based on in vitro studies and to author’s knowl-
edge there are no clinical data about IDS.
2
Journal of Dentistry 63 (2017) 1–7
Consequently, the objectives of the present study were to (1)
retrospectively evaluate the documented cases of lithium-disilicate
reinforced glass-ceramic, artisanal composite and CAD-CAM composite
endocrowns performed in the Department of Fixed Prosthodontics of
the University of Liège using the IDS procedure; (2) correlate failures
with clinical parameters such as residual tooth tissue amount, tooth
preparation characteristics and occlusal parameters.
2. Materials and methods
2.1. Study design
This is a retrospective record evaluation and a clinical examination
of patients treated with posterior endocrowns, using IDS in the bonding
protocol. The study received approval from the Ethics Committee of the
University of Liège (Comité d’Ethique Hospitalo-Facultaire
Universitaire de Liège, number B7072201524093, reference 2015/
46). The patients were recruited in the Department of Fixed
Prosthodontics of the University of Liege and were treated by four
experienced practitioners or pre-graduated students. Only cases docu-
mented with photos and/or master casts highlighting the residual tooth
tissue amount and the tooth preparation characteristics were included
in this study. 94 patients (n = 137 endocrowns) were recalled. They
were informed of the purposes of the study and consent was obtained
before examinations. The endocrowns were performed during the
follow-up period from July 2004 to July 2015.
2.2. Endocrown classification (Fig. 1)
Three classes of endocrowns were established on the basis of
residual tooth tissue amount after preparation. Determination of the
endocrown class was based on the analysis of clinical pictures and/or
master casts by two independent evaluators. In case of discrepancy, an
agreement was found between evaluators. Class 1 describes a tooth
preparation where at least two cuspal walls have a height superior to
the half of their original height. Class 2 describes a tooth preparation
where maximum one cuspal wall has a height superior to the half of its
original height. Class 3 describes a tooth preparation where all cuspal
walls are reduced for more than the half of their original height (Fig. 1).
Moreover, the presence of a buccal chamfer or an extension in the pulp
chamber were registered.
M.M. Belleflamme et al.
Table 1
Distribution of restorations in function of endocrown class, localisation and material
brand.
Endocrown class
Class 1
Class 2
Class 3
Pulp chamber anchorage
Ferrule
Localisation
Molars
Premolars
Canine
Material
Lithium disilicate glass-ceramic
(IPS empress 2 or IPS e.max Press, Ivoclar Vivadent)
PICN (Enamic, Vita)
Artisanal indirect composite
2.3. Patient record registrations
Specific data were collected regarding the following parameters:
sex, age, prosthetic material brand, bonding protocol and associated
products, and antagonistic teeth characteristics.
2.4. Clinical evaluation of restorations
Two independent evaluators clinically evaluated restorations fol-
lowing criteria of the World Dental Federation (FDI) [27,28]. Three
dimensions, which represent 18 items, are described: esthetic, func-
tional and biological. The functional dimension includes the patient-
reported satisfaction. Each item is assessed on a 5-point Likert scale (1
corresponding to an excellent restoration and 5 corresponding to a
restoration that needs to be replaced). In case of discrepancy, an
agreement was found between evaluators to determine the final score.
Scores 4 and 5 were considered as failure. Additionally, periodontal
probing of the restored tooth was performed in order to detect root
fracture.
2.5. Endodontic evaluation
On the basis of pre-op and follow-up radiographs examination, the
presence of a periapical lesion before treatment and at follow-up was
detected. The realization of an endodontic retreatment before prostho-
dontic procedure was recorded. At follow-up, percussion pain of the
restored tooth was tested.
2.6. Occlusal risk factors evaluation
Occlusal relationships were characterized as favorable or unfavor-
able based on the clinical examination by the two independent
evaluators. Class III or class II.2 malocclusion, anterior or posterior
crossbite, edge to edge or open bite, were considered as unfavorable
occlusal relationships. The presence of parafunctional habits was
recorded if the patient related grinding or clenching habits, masticatory
muscle discomfort, or if abnormal wear facets were observed on teeth.
The use of an occlusal nightguard was noted. Finally, when a material
fracture was detected, the occlusal contact points and facets were
examined in order to determine whether the fracture was located on an
occlusal contact or guidance.
2.7. Replica preparation and fractographic analysis
If a fracture of the prosthetic material was detected, a double-mix
impression of the endocrown surface was performed with a high- and a
Journal of Dentistry 63 (2017) 1–7
low-viscous A-silicone impression material. The fractured surface was
first cleaned with a cotton pellet and alcohol and was then rinsed and
thoroughly air-dried [29]. The replicas were produced using a quad-
% (n) rafunctional hydrophilic siloxane impression material (Aquasil ULV,
Dentsply De Trey, Konstanz, Germany), the low viscosity material being
syringed onto the fractured surface and over the occlusal surface of the
16.2 (16)
endocrown. The impressions were cast with filled polyurethane (Alpha
8.1 (8)
75.8 (76) Die MF, Schütz, Rosbach, Germany). After setting, the model was
92.0 (69) sectioned to isolate the restoration replica to be analyzed, which was
54.5 (54) gold-coated for scanning electron microscopy (SEM). The fractographic
analysis was performed using an Environmental Scanning Electron
56.6 (56) Microscope with a Field Emission Gun (ESEM-FEG XL-30, FEI, Hills-
41.4 (41) boro, Oregon USA) used in high vacuum mode. The interpretation of
2.0 (2)
fracture patterns was based on the descriptions by Scherrer et al. [29],
particularly to determine the origin and direction of the crack
84.8 (84)
propagation.
12.1 (12)
3.0 (3) 2.8. Statistical analysis
Results are presented as means and standard deviations (SD) or as
medians and quartiles (Q1 and Q3) for continuous variables and as
frequency tables for categorical variables. Survival of dental crowns
was represented by Kaplan-Meier curve. Results were considered
significant at the 5% critical level (P < 0.05). Statistical calculations
always used the maximum number of data available and were carried
out with the SAS (SAS Institute, Cary, NC, version 9.4) package and R
(version 3.2.3).
3. Results
3.1. Clinical data about patients, procedures and endocrowns
Among the 94 patients (n = 137 endocrowns) recalled, 64 (n = 99
endocrowns) agreed to participate in the study. Among them, 38 were
women. The mean age was 55.2 ± 12.6 years with a range from 29 to
84 years at the time of examination. 8.1% of endocrowns were
performed by pre-graduated students. Data about distribution of
restorations in function of endocrown class, localisation and material
brand are summarized in Table 1. Immediate dentin sealing (IDS)
procedure was performed in all cases with Optibond FL (Kerr, Bioggio,
Swiss), a 3-step etch-and-rinse bonding agent, which was polymerized
on dentin directly after preparation. All restorations were bonded with
Variolink 2 (Ivoclar, Schaan, Liechtenstein) following manufacturer
recommendations and after air abrasion treatment of the IDS with Cojet
(3 M, Saint-Paul, USA) followed by the application of Excite DSC
(Ivoclar, Schaan, Liechtenstein), a 2-step etch-and-rinse and dual cure
bonding agent. Glass-ceramic restoration intaglio was chair-side pre-
treated as follows: etched with 9.0% hydrofluoric acid (Ultradent,
Cologne, Germany) for 20 s, rinsed with water, etched with phosphoric
acid (Ultra-Etch, Ultradent, Cologne, Germany) for one minute as an
additional surface cleaning procedure, rinsed with water, cleaned in an
ultrasonic bath with 90° ethanol for 5 min, dried with an air spray and
recovered by a silane layer (Monobond S, Ivoclar, Schaan, Liechten-
stein) following manufacturer recommendations. PICN restorations
were etched with hydrofluoric acid for 60 s, rinsed with water, cleaned
in an ultrasonic bath with 90° ethanol for 5 min, dried with an air spray
and recovered by a Monobond S layer, as recommended by manufac-
turer. Artisanal composite restorations (brand was unknown) were
sandblasted with Cojet, rinsed with water, cleaned in an ultrasonic bath
with 90° ethanol for 5 min, dried with an air spray and recovered by a
Monobond S layer.
3.2. Restoration evaluation
After a mean observation period of 44.7 ± 34.6 months, the
survival rate of endocrowns (n = 99) was 99.0% and the success rate
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M.M. Belleflamme et al. Journal of Dentistry 63 (2017) 1–7

Table 3
Distribution of failures in function of endocrown class, localisation and the presence of
occlusal risk factors.

Debonding (n) Fracture (n) Recurrence Periodontitis (n)

of caries (n)

Failures 2 3 2 3

Endocrown class
Class 1 0 0 1 1
Class 2 0 1 0 1
Class 3 2 2 1 1
Pulp chamber 2 2 1 1
anchorage
Ferrule 0 1 0 2

Localisation
Molars 2 2 2 3
Premolars 0 1 0 0
Canines 0 0 0 0

Occlusal risk factors

Parafunctionnal 1 2 1 1
habits
Fig. 2. Kaplan-Meier success curve of endocrowns with 95% confidence limits. With occlusal 1 1 0 1
nightguard
was 89.9%. The estimated Kaplan–Meier survival rate was 98.8% at Without occlusal 0 1 1 0
nightguard
10 years and the estimated success rate was 54.9% at 10 years (Fig. 2).
Unfavorable 0 0 0 0
FDI rating of endocrowns is presented in Table 2. Ten failures were occlusal
detected: they included periodontal disease (n = 3), endocrown de- relation-
bonding (n = 2), minor chipping (n = 2), caries recurrence (n = 2) ships
and major fractures (n = 1). Details about encountered failures are With occlusal 0 0 0 0
nightguard
presented in Table 3. Periodontal failures occurred in patients with Without occlusal 0 0 0 0
general periodontitis. Among debonded restorations, one was lost by nightguard
the patient. The other one was located on an upper molar with one
missing root, which served as a support for a provisional removable
prosthesis. It was cleaned and bonded again using the protocol 3.3. Endodontic evaluation
described previously. Due to the reduced amount of each type of
failure, statistical correlation with clinical parameters, such as tooth Pre-op radiographs and data about endodontic retreatment proce-
preparation characteristics and occlusal risk factors, was not possible. dure were available for 80 teeth. The presence a periapical lesion on
Finally, 95.9% of restorations were scored as clinically good or pre-op radiographs was detected for 40.0% of those teeth and the
excellent by the patients (Table 2). healing rate on follow up radiographs was of 42.1%. The realization of
an endodontic retreatment procedure was shown to induce a 60.0%
healing rate of periapical lesions observed on teeth, which were already

Table 2
FDI rating of endocrowns.

Clinically Clinically Clinically Clinically Clinically poor Acceptable% Unacceptable

Excellent% (n) Good Sufficient% (n) Unsatisfactory% (n) % (n) %
% (n)

A. Esthetic properties 100 0

Surface luster 67.3 (66) 26.5 (26) 6.1 (6)
Staining 61.2 (60) 37.8 (37) 1.0 (1)
a. surface
b. margin 52.0 (51) 42.9 (42) 5.1 (5)
Color match and translucency 55.1 (54) 28.6 (28) 16.3 (16)
Esthetic anatomical form 65.3 (64) 30.6 (30) 4.1 (4)

B. Functional properties 87.7 12.3

Fracture of material and retention 95.9 (94) 1.0 (1) 1.0 (1) 2.0 (2)
Marginal adaptation 86.7 (85) 12.2 (12) 1.0 (1)
Approximal anatomical form 74.5 (73) 16.3 (16) 6.1 (6) 3.1 (3)
a. contact point
b. contour 77.6 (76) 17.3 (17) 2.0 (2) 3.1 (3)
Radiographic examination 84.9 (79) 12.9 (12) 2.2 (2)
Patient’s view 93.9 (92) 2.0 (2) 4.1 (4)

C. Biological properties 95 5
Postoperative sensitivity and tooth vitality 90.8 (89) 8.2 (8) 1.0 (1)
Recurrence of caries, erosion, abfraction 91.8 (90) 5.1 (5) 1.0 (1) 1.0 (1) 1.0 (1)
Tooth integrity 98.0 (96) 1.0 (1) 1.0 (1)
Periodontal response 28.6 (28) 64.2 (63) 4.0 (4) 3.0 (3)
Adjacent mucosa 79.6 (78) 20.4 (20)
Oral and general health 86.7 (85) 13.3 (13)

4
M.M. Belleflamme et al.
Table 4
Distribution of occlusal risk factors.
depulped. Among all evaluated teeth, only one tooth was symptomatic,
i.e. slightly painful with percussion.
3.4. Occlusal risk factors
Data about the distribution of occlusal risk factors are detailed in
Table 4, which shows that 48.4% of patients presented occlusal risk
factors, 42.2% exhibiting parafunctional habits and 12.5% showing
unfavorable occlusal relationships.
3.5. Fractographic analysis
The fractographic analysis was performed for 3 ceramic endo-
crowns. All fractures originated from occlusal roughness corresponding
to occlusal contact point.
4. Discussion
The analysis of tooth preparations through photos and/or master
casts examination allowed for the definition of three classes of
endocrowns on the basis of residual tooth tissue amount (Fig. 3). This
parameter, as well as the type of preparation regarding the presence of
an extension in the pulp chamber (92.0% of cases) or a ferrule effect
(54.5% of cases), were taken into account in results analysis. Yet, due to
the reduced amount of failures, no statistical correlation could be
established with neither those factors, nor with occlusal risk. Indeed the
restorations demonstrated an excellent survival rate, which was shown
to be 99.0% after a mean observation period of 44.7 ± 34.6 months
while the 10-year Kaplan-Meier estimated survival rate was 98.8%.
These very good findings confirm results of previous studies about
endocrowns, which are related to smaller sample size and/or observa-
tion time [2,15,14,13,16]. They are also in line with the reported 5-year
survival rates of all ceramic and metal-ceramic single crowns [30] and,
most of all, superior to the 5-year survival rates of post and core based
single crowns, which were reported to be limited to 50% with titanium
and 71.8% with fiber-reinforced posts [3]. Consequently, the present
work supports the use of endocrowns to restore endodontically treated
posterior teeth, even in the presence of extensive coronal tissue loss
(75.8% of sample was composed of Class 3 restorations) and occlusal
risk factors (48.4% of sample). This high survival rate was associated
with a high satisfaction rate of patients regarding esthetics and function
(95.9% of restorations were scored as clinically good or excellent). The
success rate was 89.9% and the 10-year Kaplan-Meier estimated success
rate was 54.9%, which is also comparable to other studies
[2,15,14,13,16]. Encountered failures slightly differ from previous
findings. Indeed biological failures were more frequently observed in
the present work while fractures and debonding were less present than
5
Journal of Dentistry 63 (2017) 1–7
in other studies [2,14,13,16].
Surprisingly, although the endocrown concept was introduced more
than twenty years ago, many practitioners still use posts and cores to
restore endodontically treated posterior teeth with extensive coronal
loss. The post and core approach is intended to improve restoration
retention but it has been shown that this treatment option weakens
tooth structure by removing a significant amount of healthy coronal
and radicular tooth tissues [31,32] and that titanium posts are
associated to catastrophic failures and root fractures [3], more often
than reconstructions without posts [33,34]. Those root fractures can
lead to bone tissue loss and jeopardize implant placement. Moreover,
post placement induces a risk of root perforation [4,3], contamination
of the endodontic system and failure related to the amount of adhesive
interfaces to create. Inconvenience of this classical approach also
includes the need of sufficient interocclusal space and several appoint-
ments, in addition to the increased cost. In the present study, no root
fracture was detected, while Bindl et al. [14] reported a 2.3% root
fracture rate after a mean observation time of 55 ± 15 months.
Despite the absence of post and the presence of occlusal risk factors,
endocrowns only showed 2.0% (n = 2) of debonding. Those failures
were related to Class 3 endocrowns and one was in a particularly at risk
situation, i.e. located on an upper molar with one missing root, which
served as a support for a provisional removable prosthesis. This failure
was treated repeating the bonding procedure and the endocrown
survived, which is an important advantage in comparison with post-
based restorations, which induce catastrophic failures. It must be noted
that no debonding was observed on premolars (41.4% of endocrowns),
while those teeth can be submitted to non-axial occlusal loading during
function, which can stress the adhesive interface and could lead to more
failures than molars, as observed by Bindl et al. in 2005 [14] (Fig. 4).
The present data support the use of the IDS procedure [24] to improve
adhesion, which could contribute to the higher success rate than
previous studies in terms of debonding [14]. To author’s knowledge,
they also constitute the first available clinical data related to this
procedure. Regarding the restorative material, lithium-disilicate glass-
ceramic (IPS empress 2 and IPS e.max press, Ivoclar Vivadent, Schaan,
Lichtenstein) was shown to be a good material for endocrown realiza-
tion, exhibiting a fracture rate, which was shown to be inferior to
feldspathic ceramic in the same indication [13,16], despite the presence
of occlusal risk factors. All fractures originated from occlusal contact
points and minor chipping could be polished, while only one major
facture was observed in a patient suffering from bruxism. Data
regarding PICNs are promising but need to be further investigated with
respect to the small sample size and short background.
If debonding was not shown to be an issue with endocrowns, this
was not the case either regarding endodontic failures, since only one
tooth (1.0%) was found to be slightly painful with percussion and the
M.M. Belleflamme et al. Journal of Dentistry 63 (2017) 1–7

Fig. 3. Typical endocrown clinical case on tooth #36, documented with photos and master casts highlighting the residual tooth tissue amount and the tooth preparation characteristics.
The restoration is a Class 3 endocrown, without a buccal chamfer and without an extension of the preparation in the pulp chamber to act as macromechanical retention (a–c). The day of
tooth tissue preparation, immediate dentin sealing was performed and the pulp chamber was filled with direct composite. The endocrown was performed in IPS empress 2 (Ivoclar-
Vivadent). From d) to f): clinical views the day of restoration placement. From g) to i): clinical pictures and radiograph at 9-yr follow-up. Photo courtesy of A. Mainjot.

Fig. 4. Class 2 endocrown clinical case on tooth #14, with a buccal chamfer and without an extension of the preparation in the pulp chamber. The day of tooth tissue preparation,
immediate dentin sealing was performed and part of the pulp chamber was filled with direct composite. The endocrown was performed in IPS e.max Press (Ivoclar-Vivadent). Tooth #15
is vital and was also restored with a lithium-disilicate glass-ceramic bonded restoration. From a) to c): clinical views the day of restoration placement. d) and e): clinical views at 1-year
follow-up. The endocrown approach is particularly advantageous for premolars, since post placement is risky with respect to root anatomy. Photo courtesy of A. Mainjot.

6
M.M. Belleflamme et al.
radiological healing rate of periapical lesions at follow up and after
endodontic retreatment was of 42.1%.
Finally, most encountered failures, i.e. restorative material fracture
from occlusal contact point, caries recurrence and periodontal diseases
can not be specifically attributed to the endocrown approach. The
higher failure rate than previous studies in terms of periodontal disease
and caries recurrence [14,2] can be attributed to the inclusion of
patients with periodontal disease and high carious risk, as the absence
of specific oral hygiene control protocol [16,2,13].
5. Conclusions
Endocrowns were shown to constitute a reliable approach to restore
severely damaged molars and premolars, even in the presence of
extensive coronal tissue loss (Class 3 endocrowns) or occlusal risk
factors, such as bruxism and unfavorable occlusal relationships. The
excellent survival rate (99.0% after 44.7 ± 34.6 months) and 10-year
Kaplan-Meier estimated survival rate (98.8%) were shown to be super-
ior to existing data about post and core based single crowns and were
associated with a high satisfaction rate of patients. Due to the reduced
amount of failures, no statistical correlation could be established with
clinical parameters, such as endocrown class, type of preparation
(presence of an extension in the pulp chamber or a buccal chamfer)
and occlusal risk factors. If debonding was not shown to be an issue, this
was not the case either regarding endodontic diseases while most
encountered failures, i.e. restorative material fracture, caries recurrence
and periodontal diseases were not attributed to the specific endocrown
approach.
This minimally invasive treatment strategy presents several advan-
tages in comparison with the classical post and core approach: (1) tooth
tissue preservation; (2) reduced risk of catastrophic failures such as root
fractures, root perforation and contamination of the endodontic system
and failures related to the amount of adhesive interfaces to create; (3)
no need of sufficient interocclusal space and several appointments, and
decreased cost.
The present data support the use of the IDS procedure, which could
contribute to the high success rate in terms of debonding. Lithium-
disilicate glass-ceramic was shown to be a reliable material for
endocrown realization while data regarding PICNs are promising but
need to be further investigated.
Finally, this work introduces a definition and classification of
endocrowns with respect to the residual tooth tissue amount after
preparation and the retention potential offered by an extension in the
pulp chamber or a ferrule effect presence, which could influence
restoration behavior. These parameters should be taken into account
in future studies.
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