CLINICAL RESEARCH

A 3-year clinical evaluation of endodontically treated posterior

teeth restored with two different materials using the
CEREC AC chair-side system
Ting Lu, MS, PhD,a Ling Peng, MS,b Fu Xiong, PhD,c Xiao-Yu Lin, BS,d Ping Zhang, BS,e Zhi-Ting Lin, BS,f and
Bu-Ling Wu, DDS, PhDg

Chairside immediate ceramic res- ABSTRACT

torations make use of computer-
aided design and computer-aided
manufacturing (CAD-CAM) to
complete the restoration fabrica-
tion process in a single visit. This
technique has become popular
and led prosthetic dentistry into a
digital era.1 CEREC AC (Dentsply
Sirona) was first introduced in
2009. The CEREC AC Bluecam
uses blue wavelength light and
allows dentists to produce virtual
models of a higher resolution
than with those of the earlier
CEREC Acquisition unit system.2
The fracture rate of endodon-
tically treated teeth is higher than
that of vital teeth.3 An onlay is an
indirect restoration retained by
intracoronal boxes (vital teeth) or
extended into the pulp chamber
(nonvital teeth) that covers the
occlusal surface.4 Onlay restora-
tions not only restore the tooth
structure, but can provide optimal
Statement of problem. The introduction of polymer-infiltrated ceramic network (PICN) materials
may provide more options for dentists in restoring short clinical crowns and extensively damaged
posterior teeth, but clinical data for their performance are lacking.
Purpose. The purpose of this clinical study was to compare the 3-year performance and survival
rates of PICN material with those of conservative ceramic onlay restorations for endodontically
treated posterior teeth using the CEREC AC chair-side system.
Material and methods. A total of 101 onlay restorations of endodontically treated posterior teeth
using the CEREC AC chair-side system were provided in 93 participants. The 101 teeth were
divided into 2 groups: Vita Enamic group and Vitablocs Mark II group. Using the modified US
Public Health Service quality evaluation system, 2 calibrated evaluators examined the
performance of the onlay restorations over 3 years. The Kaplan-Meier method was adopted to
analyze the survival rate of restorations (a=.05). The log rank test was used to compare the
survival rates of the 2 groups. The Fisher exact test was performed to detect differences in
the success rates for extensively damaged teeth and short clinical crown restorations between
the 2 groups. The Silness and Löe gingival index was also recorded.
Results. The restoration survival rates in the 2 groups were 97.0% (Vita Enamic) and 90.7%
(Vitablocs Mark II) (P>.05). Five failures were recorded (4.95%). These failures were caused by
restoration debonding (60%), ceramic fractures (20%), and tooth fractures (20%). There were no
significant differences between the success rates of restoring extensively damaged teeth and short
clinical crowns between the 2 groups (P>.05). The periodontal condition of 25% of participants
was improved 3 years after the onlay restorations.
Conclusions. Onlay restorations of endodontically treated posterior teeth with Vita Enamic using
the CEREC AC chair-side system are clinically promising prosthodontic alternatives, with a survival
rate of 97.0% after 3 years. More research is needed to verify the results of this study. (J Prosthet
Dent 2018;119:363-8)

Supported by National Natural Science Foundation of China (grant 81371137). T.L. and L.P. contributed equally to this work.
a
Postdoctoral student, Graduate Endodontics, Department of Stomatology, Nanfang Hospital, College of Stomatology, Southern Medical University, Guangdong, PR China.
b
Predoctoral student, Graduate Endodontics, Department of Stomatology, Nanfang Hospital, College of Stomatology, Southern Medical University, Guangdong, PR China.
c
Assistant Professor, Deparment of Medical Genetics, School of Basic Medicine Sciences, Southern Medical University, Guangzhou, PR China.
d
Visiting Doctor, Department of Stomatology, Nanfang Hospital, Guangdong, PR China.
e
Visiting Doctor, Department of Stomatology, Nanfang Hospital, Guangdong, PR China.
f
Doctor, Department of Stomatology, Nanfang Hospital, Guangdong, PR China.
g
Professor, Department of Stomatology, Nanfang Hospital, College of Stomatology, Southern Medical University, Guangdong, PR China.

THE JOURNAL OF PROSTHETIC DENTISTRY 363

364
Clinical Implications
Polymer-infiltrated ceramic network materials
combine the merits of ceramic and composite resin,
exhibiting physical properties that are often
superior to conventional composite resins.
Restoring endodontically treated posterior teeth
with Vita Enamic onlay restorations appears
to be a promising option.
occlusion. The restoration retained within the pulp
chamber is suitable for extensively damaged posterior
teeth that have received endodontic therapy, especially for
those with short clinical crowns. In addition, onlays can
preserve more dental tissue than complete coverage
crowns.5
Vitablocs Mark II (VITA Zahnfabrik H. Rauter GmbH)
is a fine-particle (4 mm) feldspathic porcelain produced
for the milling process.6 It has a flexural strength of
137.83 ±12.4 MPa, an elastic modulus of 57.2 ±3.6 GPa,
and a fracture toughness of 1.25 MPa$m½.7 It is the most
popular CAD-CAM machinable ceramic.8 In 2013, Vita
Enamic (VITA Zahnfabrik H. Rauter GmbH) was intro-
duced for CAD-CAM restorations. Vita Enamic is a
polymer-infiltrated ceramic network material (PICN)
which contains dominant porous feldspathic ceramic
network (86 wt%) and is infiltrated with a copolymer (14
wt%).9 Coldea et al7 found that PICN materials are more
damage tolerant than commonly used dental ceramics.
The flexural strength and elastic modulus of PICN ma-
terials are higher than those of Vitablocs Mark II. The
fracture toughness is comparable. In addition, Vita
Enamic shows improved machinability than ceramic-
based materials and is capable of providing smoother
margins.10 El et al11 reported that CAD-CAM restora-
tions fabricated from processed composite resin blocks
have greater bond strength to resin cements. PICN ma-
terials combine the beneficial characteristics of ceramic
and composite resin, have a flexural strength and elastic
modulus similar to tooth structure, and reduced hardness
compared with ceramics, making them potentially
effective restorative materials.12
Long-term follow-up studies have indicated that
ceramic inlays and onlays have relatively high clinical
success rates.13-16 However, the authors are unaware of
reports about the clinical evaluation of onlay restorations
with PICN material for endodontically treated posterior
teeth using the CEREC AC chair-side system. Therefore,
the purpose of this study was to assess the clinical per-
formance of onlay restorations with the Vita Enamic
PICN material for endodontically treated posterior teeth
over 3 years, and to compare with ceramic Vitablocs
Mark II restorations. Additionally, the products were
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume 119 Issue 3
compared for restoring short clinical crowns and exten-
sively damaged teeth. The research hypothesis was that
onlay restorations fabricated with the Vita Enamic can
provide satisfactory fit, retention, and realistic appear-
ance, as well as high survival rate.
MATERIAL AND METHODS
This research was approved by the Ethical Committee of
Nanfang Hospital of Southern Medical University.
Ninety-three participants (101 teeth) were enrolled in the
study after receiving onlay restorations using the CEREC
AC chair-side immediate ceramic restoration system
(Dentsply Sirona) at the Stomatology Department,
Nanfang Hospital of Southern Medical University, from
June 2013 to August 2013. Among the participants, 36
were male, and 57 were female, and the average mean
±SD age was 37.66 (SD ±13.26; age range, 18-71 years).
Inclusion criteria were (1) Teeth must receive endodontic
therapy before restoration; (2) teeth with periodontal
disease must receive periodontal treatment before
restoration; (3) no complaint of discomfort in the teeth to
be restored; (4) radiograph revealing alveolar bone
resorption less than a third and lack of shadow around
the periapical tissues; (5) cooperative participants who
provided written informed consent; and (6) the depth of
pulpal chamber of short clinical crowns and extensively
damaged teeth was more than 2 mm. Any teeth with
cracks or fracture lines were excluded. After tooth
reduction, any clinical crowns with axial wall height less
than 2 mm were regarded as short clinical crowns.
Extensively damaged teeth were the teeth that had de-
fects in more than half of the dental tissues or tooth
defects involving 3 or more tooth surfaces. The Löe-
Silness gingival index17,18 was used to register the degree
of gingival inflammation.
For tooth preparation, 3 operators (X-Y.L., P.Z., and
Z-T.L.) performed onlay restorations for endodontically
treated posterior teeth with same methods and princi-
ples. The method of Homsy et al19 was used. To start (1)
a 2- to 3-mm glass ionomer cement (GIC; Fuji IX GP; GC
Corp) layer was used to cover the pulp chamber. (2) An
inverted conical diamond rotary instrument (845R-025-4
ML; Diatech; Coltène) was used to prepare the flat cavity
floor and remove undercuts. (3) A taper of approximately
8 to 10 degrees was prepared without beveling the
margins. All preparations were completed along the
longitudinal axis of the teeth. (4) The functional cusps
and nonfunctional cusps were reduced according to the
different ceramic blocks selected. For Vita Enamic, the
minimal reduction was 1 to 1.2 mm and for Vitablocs
Mark II the minimal reduction was 2 mm.20 (5) The
pulpal floor depths were prepared to 2 to 2.5 mm. (6) For
class II cavities, the width of the gingival floor prepara-
tion was 1 mm. Proximal boxes of the preparations were
Lu et al
March 2018
Figure 1. Mandibular left first premolar (short clinical crown and
extensively damaged tooth). A, Tooth preparation. B, Restored by CEREC
AC chair-side immediate ceramic restorations system using Vita Enamic.
extended to the intercuspal distance. (7) Internal line
angles were rounded.
The prepared teeth were isolated with cotton rolls and
saliva ejectors, and rubber dam was used if possible. A
cord (Ultrapak; Ultradent Products, Inc) was used for
gingival displacement. Powder (Optispray; Dentsply
Sirona) was evenly sprayed to the scanning area, with a
thickness of 40 to 60 mm. For the scanning, the holder of
the Bluecam camera was stabilized by gently contacting it
to the tooth surfaces. The overlapping area between the
successive pictures was no less than 40%, and the dis-
tance moved each time was less than 8 mm. The
maxillary, mandibular, buccal, lingual, and occlusal sur-
faces were scanned to obtain 3-dimensional images.
The design and fabrication of the restorations was as
follows. (1) The shade was selected with the Vita
Toothguide 3D-Master (VITA Zahnfabrik H. Rauter
GmbH). (2) Software (Cerec SW4.3; Dentsply Sirona)
was used to design the margin, path of withdrawal, and
contour of the restoration. The restoration (Vita Enamic
or Vitablocs Mark II) was milled (Cerec MC XL; Dentsply
Sirona). (3) The restoration was inserted, evaluated, and
primary occlusal adjustment was performed. (4) The
restoration was glazed (Vita Akzent; VITA Zahnfabrik H.
Rauter GmbH) according to the manufacturer’s in-
structions and occlusal adjustments were carried out.
The intaglio of the restorations was etched for 5 mi-
nutes with 9.6% hydrofluoric acid (Pulpdent Corp),
rinsed, and silanated (Monobond S; Kerr Corp).
Concurrently, the tooth was etched with 35% phosphoric
acid (Gluma; Heraeus Holding GmbH) for 30 seconds,
rinsed, air-dried, and coated with an adhesive resin
(Optibond S; Kerr Corp). This was air-thinned light-
polymerized (light-emitting diode with 800 mW/cm2
output; Satelec; Midmark Corp) for 10 seconds. The resin
cement (NEXUS; Kerr Corp) was dispensed into the
cavity preparation, and the restorations were seated.
Excess resin cement was removed with dental floss, and
Lu et al
365
Figure 2. Mandibular right first molar. A, Tooth preparation. B, Restored
by CEREC AC chair-side immediate ceramic restorations system using
Vitablocs Mark II.
the restorations were light-polymerized for 3 seconds.
After removing excess cement, the restorations were
light-polymerized for 30 seconds on each side. Finally,
the occlusion was adjusted, and the occlusal surfaces
were polished (Figs. 1, 2).
Follow-up examinations for all participants took place
at 6, 12, 18, 24, and 36 months. Modified U.S. Public
Health Service (USPHS) criteria21 were used to evaluate
the restorations (Supplemental Table 1) and gingival
condition was recorded according to the Silness and Löe
gingival index (Supplemental Table 2). Two examiners
(T.L., L.P.) performed the examinations of each partici-
pant. The Cohen kappa values between examiners
ranged from 0.8 to 0.9, depending on the variables
collected. Discrepancies were resolved by consensus and
a third examiner (B-L.W.) was consulted. Participants’
satisfaction was assessed with a visual analog scale.
All statistical analyses were performed with software
(IBM SPSS Statistics v19.0; IBM Corp). The Kaplan-
Meier method was used to analyze restoration survival
rates. The total survival rate with 95% confidence in-
terval (CI) was acquired with the assumption that the
survival rate had an approximately normal distribution.
THE JOURNAL OF PROSTHETIC DENTISTRY
366 Volume 119 Issue 3

Table 1. Descriptive analysis of failures

Patient Restored Teeth Sex Age (y) Group Time to Failure (mo) Details of Failures Reasons for Needing RCT
1 Mandibular right first premolar Male 62 Vita Enamic 12 Debonding Chronic pulpitis
2 Maxillary right second molar Female 58 Vitablocs Mark II 24 Debonding Chronic pulpitis
3 Maxillary right first molar Male 45 Vitablocs Mark II 24 Debonding Chronic pulpitis
4 Maxillary right first molar Male 38 Vitablocs Mark II 18 Ceramic fracture Chronic pulpitis
5 Maxillary right first premolar Female 55 Vita Enamic 12 Abutment fracture Chronic periapical periodontitis

Table 2. USPHS rating of 101 onlay restoration after 0.5 year Table 3. USPHS rating of 94 onlay restoration after 3 years
USPHS Score Group (N) USPHS Score Group (N)
Category Acceptable Unacceptable Vita Enamic Vitablocs Mark II Category Acceptable Unacceptable Vita Enamic Vitablocs Mark II
Anatomic form 0 67 (100%) 33 (97.1%) Anatomic form 0 59 (89.2%) 26 (89.7%)
1 0 1 (2.9%) 1 6 (10.8%) 3 (10.3%)
2 0 0 2 0 0
Marginal 0 64 (95.5%) 32 (94.1%) Marginal 0 60 (92.3%) 27 (93.1%)
adaptation adaptation
1 3 (4.5%) 2 (5.9%) 1 5 (7.7%) 2 (6.9%)
2 0 0 2 0 0
3 0 0 3 0 0
Color match 0 58 (86.6%) 27 (79.4%) Color match 0 55 (84.6%) 21 (72.4%)
1 9 (13.4%) 7 (20.6%) 1 7 (10.7%) 7 (24.1%)
2 0 0 2 3 (4.6%) 1 (3.4%)
3 0 0 3 0 0
Marginal 0 58 (86.6%) 29 (85.3%) Marginal 0 55 (84.6%) 24 (82.8%)
discoloration discoloration
1 7 (10.4%) 5 (14.7%) 1 7 (10.8%) 5 (17.2%)
2 2 (3.0%) 0 2 3 (4.6%) 0
3 0 0 3 0 0
Caries 0 67 (100%) 34 (100%) Caries 0 65 (100%) 29 (100%)
1 0 0 1 0 0

USPHS, U.S. Public Health Service. USPHS, U.S. Public Health Service.

The log rank test was used to compare the survival rates
between the Vita Enamic and Vitablocs Mark II groups
(a=.05). The Fisher exact test was used to detect the
differences between the success rates of extensively
damaged teeth and short clinical crown restorations
within the 2 groups.
RESULTS
A total of 101 ceramic onlays, including 21 premolars and
80 molars, were placed in 93 participants. These resto-
rations included 67 Vita Enamic (in 61 participants) and
34 Vitablocs Mark II (in 32 participants). Seven partici-
pants received more than 1 restoration. Two participants
did not take part in the follow-up examinations (contact
with 1 patient was lost at 12 months and 18 months with
another patient). Five restorations failed (2 Vita Enamic
and 3 Vitablocs Mark II) due to debonding (n=3), ceramic
fracture (n=1), or tooth fracture (n=1) during the follow-
up period (Table 1).
According to the modified USPHS, evaluation of
clinical indexes for the onlays was calibrated by 2 ex-
aminers (T.L., L.P.) at different times after restoration
(Tables 2, 3). The results showed that 3 years after the
restoration Vita Enamic group manifested favorable
anatomic form, favorable marginal adaptation, and good
color match. Most of the patients were satisfied with the
onlays. The average score of overall satisfaction was
8.78 ±0.912.
Kaplan-Meier analysis revealed that the total survival
rate was 95.0% (95% CI, 92.8%-97.2%). The restoration
survival rate after 3 years with Vita Enamic was 97.0%
(95% CI, 94.9%-99.1%) and 90.7% (95% CI, 85.6%-
95.8%) with Vitablocs Mark II (Fig. 3). The log rank test
indicated that there were no statistical differences be-
tween the 2 groups (chi-square=1.645; P=.20).
In regard to the soft tissue conditions of restored
teeth, results showed that 25% of participants who had
gingival inflammation (GI1) before the restoration
showed improvements in their periodontal condition
(Fig. 4). The Fisher exact test analysis revealed that there
were no statistical differences (P>.05) in the restoration
success rate of extensively damaged teeth and short
clinical crowns between the 2 groups (Table 4).
DISCUSSION
Onlay restorations with Vita Enamic using the CEREC AC
chair-side system are clinically promising. Previously,
most of the studies of clinical evaluation of restorations

THE JOURNAL OF PROSTHETIC DENTISTRY Lu et al

March 2018 367

1.0 80
Before restoration
70 71
After 3 years
0.8

Number of Participants
Cumulative Survival

60

0.6

40
0.4
Vita Enamic
Vitablocs Mark II
0.2 20 14
Vita Enamic-censored 11 12
9
Vitablocs Mark II-censored
0.0 1 0
0
0 10 20 30 40 0 1 2 3
Follow-up Time (mo) Gingival Indexes
Figure 3. Kaplan-Meier survival rate of 3 years for restorations with Figure 4. Gingival index scores of 94 onlays before restoration and
Vita Enamic and Vitablocs Mark II. 3 years after restoration.

were concentrated on the traditional restoration materials, Table 4. Restoration of extensively damaged teeth and short clinical
such as ZrO2-based restorations, lithium disilicate, and crowns restored with two ceramics
leucite-reinforced glass-ceramics.14,22,23 PICN materials, a Types of Restored Type of Successful Failure
Teeth Ceramic (N) (N) Total P*
kind of hybrid ceramic, because it has flexural strength Extensively damaged Vita Enamic 30 0 30 .094
and elastic modulus similar to that of a tooth as well as teeth (n=56)
having less hardness than ceramics make it an option to Vitablocs Mark II 23 3 26
consider as a restorative material.12 More than 90% of the Short clinical crown Vita Enamic 17 1 18 .486
(n=37)
Vita Enamic restorations in the present study were well
Vitablocs Mark II 19 0 19
matched in color and had high marginal adaptation. Even
*Fisher exact test.
though Vita Enamic does not manifest remarkable supe-
riority compared with Vitablocs Mark II, onlay restora-
Results of the present study showed that 25% of the
tions with Vita Enamic can meet the restoration
participants’ periodontal conditions were improved at 3
requirements for posterior teeth with high marginal
years after restoration. The reason for this improvement
adaptation, realistic appearance, and good survival rate.
might have been due to the fact that the diseased teeth
In this 3-year follow-up study, there was 1 tooth
might have been affected by periodontal-endodontic le-
restored by Vitablocs Mark II that failed due to the
sions, food impaction, and occlusal trauma before
fracture and not a fracture of Vita Enamic. Fracture of
restoration. However, thorough endodontic therapies
ceramic blocks is a common problem in ceramic resto-
and periodontal treatments, the inflammation sources
ration.24 The reasons of fracture may include low flexural
were eliminated, and the normal occlusal function was
strength of the material, subsurface flaws of CAD-CAM
recovered by onlay restorations to help recover the
ceramics produced during machining, insufficient pol-
periodontium to support the diseased teeth. In addition,
ishing of the occlusal surfaces after adjustment, and
instructions on oral health and regular periodontal
parafunctional habits. One Vita Enamic and 2 Vitablocs
cleaning are therefore also necessary.
Mark II restorations failed due to the restoration
Vita Enamic was first introduced in 2013, therefore
debonding. The types of ceramic could affect the bond
the follow-up time was limited. In this study, there were
strength. Because of the mechanical differences between
no statistical differences between Vita Enamic and Vita-
composite resins and ceramics, CAD-CAM restorations
blocs Mark II in relation to the survival and success rates
made by processed composite resins may have higher
of extensively damaged teeth and short clinical crown
bond strength than ceramic blocks.11 Although no sig-
restorations over a 3-year follow up. Further observations
nificant differences were found in fracture and
and more samples are still needed.
debonding rates between the two groups, the authors
inferred that higher flexural strength and greater
CONCLUSIONS
machinability would make Vita Enamic more advanta-
geous in restoring endodontically treated posterior teeth Based on the findings of this 3-year follow-up study, the
in the long run. following conclusions were drawn:

Lu et al THE JOURNAL OF PROSTHETIC DENTISTRY

368
1. Onlay restorations of nonvital posterior teeth with
Vita Enamic using the CEREC AC chair-side system
are clinically promising prosthodontic alternatives,
with a survival rate of 97.0% after 3 years.
2. No significant differences were found in the survival
rates of onlay restorations between the use of Vita
Enamic and Vitablocs Mark II over the 3-year
follow-up period.
3. No statistical differences were found between the
success rates of Vita Enamic and those of Vitablocs
Mark II in the restoration of extensively damaged
teeth and short clinical crowns over 3 years.
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Corresponding author:
Dr Bu-Ling Wu
Department of Stomatology
Nanfang Hospital
College of Stomatology
Southern Medical University
No.1838 Guangzhou Avenue North
Guangzhou
PR CHINA
Email: bulingwu@smu.edu.cn
Copyright © 2017 by the Editorial Council for The Journal of Prosthetic Dentistry.
Lu et al