SYSTEMATIC REVIEW

Survival and success of endocrowns: A systematic review

and meta-analysis
Raghad A. Al-Dabbagh, BDS, MClinDent Pros, MPros CRS Edin, PhD

The successful restoration of ABSTRACT

endodontically treated teeth is
Statement of problem. Endocrowns are a monoblock type of restoration that use the pulp
dependent on the type and chamber and remaining coronal tooth structure as a means of retention. However, data on their
quality of the coronal restora- long-term survival and success rates as compared with conventional crowns are lacking.
tion.1-4 Endodontically treated
Purpose. The purpose of this systematic review and meta-analysis was to collate published work on
teeth restored with crowns
endocrowns to assist clinicians in making decisions on when and whether they are an appropriate
have a 5-year survival rate restorative option with a predictable outcome for extensively damaged endodontically treated
similar to vital teeth restored teeth.
with crowns (94.2% versus
Material and methods. Databases such as PubMed (MEDLINE), Scopus, EMBASE, Cochrane library,
95%).1,5 However, in the
and Google Scholar were searched up to June 2019 for clinical and in vitro studies on endocrown
absence of cuspal coverage survival and success rates. For the meta-analysis, endocrown and conventional crown survival and
(restored with composite resin), success rates were compared, and the pooled effects were presented as relative risks and 95%
endodontically treated teeth confidence intervals using a random effects model.
have a lower success rate, with Results. Ten studies fulfilled the inclusion criteria (3 clinical and 7 in vitro) and were included in the
a 5-year survival rate of 63%.1 systematic review. The meta-analysis of the clinical studies showed an estimated overall 5-year
The improved survival of teeth survival rate of 91.4% for endocrowns and 98.3% for conventional crowns. The estimated overall
treated endodontically with 5-year success rates were 77.7% for endocrowns and 94% for conventional crowns. There were
satisfactory coronal cuspal no significant differences in overall survival or success estimates between the assessed
coverage has been attributed to restorations (P>.05).
a reduction in microleakages Conclusions. Additional well-designed clinical studies with long-term assessment are needed;
and the preservation and pro- however, endocrowns appear to be a promising conservative restorative option with acceptable
tection of the remaining tooth long-term survival for endodontically treated posterior teeth in selected patients. (J Prosthet
6,7 Dent 2021;125:415.e1-e9)
structure. Immediate place-
ment of a satisfactory coronal
restoration has been reported to reduce microleakage and conservative with advances in adhesive dentistry.8 Such
subsequently decrease the risk of endodontic treatment designs include incorporating fewer mechanical retentive
failure,6 while cuspal coverage and preservation of the features such as undercuts, grooves, or boxes,8 with
remaining coronal tooth structure have been reported to retention being mainly dependent on adhesion to the
improve fracture resistance and the outcome of the tooth structure.8
2,3,7
endodontically treated tooth. Endocrowns are conservative coronal restorations that
Preparation designs for coronal restorations of have been used to restore endodontically treated teeth
endodontically treated teeth have become more with significant loss of coronal tooth structure. They are

Assistant Professor and Consultant in Prosthodontics, Oral and Maxillofacial Rehabilitation Department, Faculty of Dentistry, King Abdulaziz University, Jeddah, Kingdom of
Saudi Arabia.

THE JOURNAL OF PROSTHETIC DENTISTRY 415.e1

415.e2
Clinical Implications
Limited data suggest that endocrowns can be used
as a coronal restoration for endodontically treated
posterior teeth with acceptable long-term
outcomes when used selectively. Feldspathic
computer-aided design and computer-aided
manufacturing (CAD-CAM) ceramics appear to be a
suitable choice for endocrown fabrication.
monoblock coronal restorations that are retained by the
pulp chamber and by bonding to the remaining coronal
tooth structure.9 Pissis10 first described the concept in
1995, and Bindl and Mormann9 introduced the term
endocrown in 1999. However, only limited data exist on
the long-term survival and success of endocrowns as
compared with conventional crowns. Therefore, the
purpose of this systematic review and meta-analysis was
to compare the survival and success rates of endocrowns
with conventional crowns for the restoration of
endodontically treated teeth. The null hypothesis was
that there would be no difference between the 2 resto-
ration types.
MATERIAL AND METHODS
This systematic review followed the Preferred Reporting
Items for Systematic Reviews and Meta-Analysis (PRIS-
MA) statement.11 The population, intervention, control,
and outcome (PICO) for this systematic review were
defined as follows: the population was participants or
teeth undergoing root canal treatment; the intervention
was ceramic or composite resin endocrowns; the com-
parison was conventional post-and-core crowns; and the
outcome measures were survival and success rates,
fracture strengths, catastrophic failure rates, and per-
centage of marginal adaptation.
Two investigators (R.A., A.M.) undertook an elec-
tronic search of the English language literature in the
databases such as PubMed (MEDLINE), Scopus,
EMBASE, Cochrane Library, and Google Scholar up to
June 2019. The search strategy included the following
keywords: crown, endocrown, survival, survival analysis,
survival rate, failure rate, failure, compressive strength,
materials testing, follow-up studies, prosthesis failure,
fracture strength, marginal adaptation, and catastrophic
failure.
All relevant clinical and in vitro studies were included.
No randomized clinical studies published in the English-
language dental literature comparing endocrowns to
conventional crowns were identified. Clinical studies
considered suitable for this systematic review and meta-
analysis included prospective cohort studies or case se-
ries, retrospective studies, studies with a mean follow-up
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume 125 Issue 3
of at least 3 years (for the meta-analysis), and the pres-
ence of a control group (conventional or classical
crowns). The in vitro studies considered in this systematic
review were those conducted on extracted teeth and
measuring the fracture strength, survival, catastrophic
failure, and marginal adaptation as outcome parameters.
The intervention of interest included ceramic or com-
posite resin endocrowns, including monoblock-type
restorations. Metal alloy restorations were excluded.
The comparison included conventional crowns made of
ceramic or composite resin excluding crowns made of
metal alloys. Survival rate was defined as when endo-
crowns or conventional crowns were present in the oral
cavity but with biological and/or technical complications.
Success rate was defined as restorations not associated
with any of these complications. Catastrophic failure was
defined as nonrestorable or nonrepairable failures in both
of the assessed restorations.
Two investigators (R.A., A.M.) assessed the article
titles and then searched and reviewed the abstracts. Only
relevant articles fulfilling the review objectives and in-
clusion criteria were considered. Full-text articles of po-
tential papers were retrieved and then critically assessed
before inclusion in the study if they fulfilled all eligibility
criteria. The Newcastle-Ottawa Scale (NOS) was used to
assess the quality of the included clinical studies.12 Ac-
cording to the NOS, studies with 5 stars or less have an
inherent methodological risk of bias, while those with
more than 5 stars have minimal bias. Consequently, only
cohort studies with over 5 stars were included in the
present review. The risk of methodological bias in the
in vitro studies was assessed based on a modification of
parameters used elsewhere,13 which included the use of
sound teeth for testing, morphologically similar tested
teeth, sample size calculation, group randomization,
presence of a suitable control group, use of materials
according to the manufacturer’s instructions, cavity
preparation performed by the same operator (standard-
ization), and blinding of the operator to the testing ma-
chine. Studies with 1 to 3 parameters were deemed to be
having a high risk of bias; studies with 4 to 5 parameters
were of a medium risk of bias; and studies with 6 or more
parameters and including a suitable control were classi-
fied as having a low risk of bias.13 Only in vitro studies
with a low risk of bias were included in the present
systematic review.
Data were extracted from the included clinical studies
and tabulated in a spreadsheet (Microsoft Office Excel
2016; Microsoft Corp) with the following information:
authors, year, journal, number of participants, mean age,
sex, number of restorations, type of teeth, type of resto-
ration, restoration survival time, restoration success and
failure, type of failure, follow-up period, and NOS. When
the same data were published more than once, data were
obtained from the most complete version. When the
Al-Dabbagh
March 2021
Identification
Independent electronic search by
2 investigators yielded 2584 titles
Application of exclusion
criteria and discussion
Screening
at title and abstract
level led to exclusion of
2536 titles
Independent analysis of full text
of the 48 selected articles by the
Eligibility
Application of exclusion
criteria and critical
assessment of
methodology led to
exclusion of 38 articles
Inclusion
systematic review of which the 3
clinical articles were included in
Figure 1. Flow chart of search strategy and number of included endocrown articles.
study data were unclear, the authors were contacted for
clarification.
Review Manager (RevMan) software version 5.2 (The
Nordic Cochrane Centre, The Cochrane Collaboration)
was used for the meta-analysis. The success and survival
of endocrowns and conventional crowns were
measured. Comparisons and pooled effects were pre-
sented as relative risks (RR) and 95% confidence in-
tervals (CI) using a random effects model (a=.05).
Subgroups were analyzed to compare the effect of tooth
type (molars and premolars) on the survival and success
of endocrowns versus conventional crowns. Study het-
erogeneity was measured using the chi-squared test
(a=.05). The test of inconsistency (I2) was calculated
and interpreted as minimal, moderate, or substantial
heterogeneity at levels of <25%, 25% to 50%, and
>50%, respectively.
RESULTS
A total of 2584 potential records were initially identified.
The titles and abstracts were screened, and nonqualifying
articles and duplicates were removed to leave 48 full
articles (9 clinical and 39 in vitro). Excluded articles were
omitted because they were not endocrown articles or
they were review articles,14-18 case reports,19-39 finite
element analysis studies,40-59 alloy-based restoration
studies,60,61 or unpublished clinical research. These 48
articles were critically evaluated, and their quality of
methodology was assessed. Five more articles were
excluded because they did not fulfill the inclusion criteria
(absence of comparison with a conventional crown),4,62-
65
leaving 10 eligible articles for the systematic review
and 3 clinical studies for the meta-analysis (Fig. 1). The
38 excluded articles are summarized in Supplementary
Al-Dabbagh
415.e3
PubMed/MEDLINE 1340
Scopus 547
EMBASE 320
Cochran Library 170
Google Scholar 207
Not endocrown/
unpublished 2476
Finite element analysis 21
Case reports 22
investigators Reviews 5
Alloy based 2
Ongoing clinical trials 10
10 full-articles analyzed for the
No conventional crown
control 6
High risk for bias 22
the meta-analysis
Tables 1 and 2 (available online). The article by
Otto66 was excluded because the cohort was similar to
that of Otto and Mormann.67
Seven in vitro studies compared the fracture strengths
and catastrophic failure rates of endocrowns and con-
ventional crowns: 1 in incisors, 4 in premolars, and 2 in
molars (Table 1).68-74Additionally, 1 in vitro study
assessed marginal adaptation in premolars restored by
endocrowns.75 In central incisors, the load to fracture
strength of resin ceramic endocrowns and conventional
crowns was not significantly different (869 ±247.8 N and
580.0 ±295.4 N), with a catastrophic failure rate of 100%
for endocrowns and 0% for conventional crowns.71
Likewise, the load to fracture strength of lithium dis-
ilicate ceramic endocrowns (915.9 ±182.1 N) and con-
ventional crowns (646.8 N) was not significantly
different, with a catastrophic failure rate of 85% and 0%,
respectively.71
In premolars, the fracture strength of composite
resin endocrowns (230 N) was higher than for con-
ventional crowns (135 N), 71 while the fracture
strength of resin ceramic endocrowns (1522.64 ±352.52
N) was not significantly different from that of con-
ventional crowns (1301.34 ±177.12 N), with a cata-
strophic failure rate of 30% for endocrowns and 40%
for conventional crowns.70 The fracture strength of
lithium disilicate ceramic endocrowns (220 N or 933
±183 N) was similar to that of conventional crowns
(200 N or 925 ±186 N), with a catastrophic failure rate
of 0 or 80% for endocrowns and 0 or 40% for con-
ventional crowns (Table 1).68,73 When the effect of the
type of restorative material was assessed with respect
to the fracture strength of endocrowns resin ceramic
(1522.64 ±352.5 N), endocrowns had higher load to
fracture strengths than lithium disilicate ceramic
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415.e4 Volume 125 Issue 3

Table 1. Summary of included in vitro studies

Type of Catastrophic Marginal
No of Specimen Failure Rates (%, Adaptation In Vitro
Objectives of Type of Specimens/ Restoration Preparation and Load to Fracture Out of Total (Mn ±SD) Quality
Reference Study Tooth Group Material Testing Strength (Mn ±SD, N) Failures) (%) Scale
Abdel- Compare the Mandibular 5 Lithium disilicate Universal load Endocrown and Endocrown and - 6
Aziz and fracture strength of premolars ceramic (IPS e.max) testing, inspection conventional crown: 933 conventional crown:
Abo- endocrown and with digital ±183=925 ±186$ 0, 0
Elmagd68 conventional crown microscope
in the presence or
absence of ferrule
Hamdy69 Assess various Maxillary 10 Lithium disilicate Thermocycling, Endocrown and Endocrown and - 6
restoration designs first molars ceramic (IPS e.max universal load conventional crown: 989 conventional crown:
fracture strength Press) testing (axial ±109.1=1076 ±132 20, 10
loading)
Al-shibri Assess fracture Maxillary 10 Resin ceramic Universal load Resin ceramic, lithium Resin ceramic, - 7
and resistance of premolars (Ceramsmart), testing, Visual and disilicate ceramic lithium disilicate
70
Elguindy endocrown and lithium disilicate photographic endocrowns, and ceramic
conventional crown (IPS e.max CAD)$ inspection lithium disilicate endocrowns, and
in 2 different conventional crowns: lithium disilicate
materials 1522.64 ±352.52>717.33 conventional
±198.59<1301.34 crowns: 30, 80, 40
±177.12
Güngör Assess fracture Maxillary 10 Resin ceramic (Lava Universal load Resin ceramic Resin ceramic - 6
et al71 strength of EC and central Ultimate), lithium testing (oblique endocrowns and endocrowns and
CC and 2 types of incisors disilicate (IPS e.max loading) conventional crowns: conventional
posts CAD) 869 ±247.8=580.02 crowns: 100, 0%
±295.4 Lithium disilicate Lithium disilicate
endocrowns and endocrowns and
conventional conventional
crowns: 915.91 crowns: 85, 0
±182.1=646.78

Catastrophic
No of Specimen Load to Fracture Survival Time/ Failure Rates Marginal In Vitro
Objectives of Type of Specimens/ Restoration Preparation and Strength (Mn ±SD, Cycles Median (%, out of Total Adaptation Quality
Reference Study Tooth Group Material Testing N) (95% CI) Failures) (Mn, %) Scale
Lise et al73 Study effect of Single 8 Composite Fatigue aged, Composite resin - - - 6
endocrown rooted resin and mastication short and long
cavity design and premolars lithium simulator endocrowns, and
material on disilicate machine, long conventional
fracture strength ceramic universal load crown: 230>140 and
CEREC AC testing (oblique 135 Lithium disilicate
CAD-CAM load), short and long
stereomicroscope endocrowns, and
long conventional
crown: 125=220=200
Rocca Study effect of Maxillary 12 Lithium Thermocycling, - Short and long Short and long Short and 6
et al74 endocrown premolars disilicate SEM, closed loop endocrowns, endocrowns, long
length on ceramic (IP servo hydraulics, and and endocrowns,
marginal e.max CAD) stereomicroscope conventional conventional and
adaptation and crown: 93 318 crown: 50, 41.7, conventional
fatigue strength (90 572; 99 176) 66.7 crown: 73.5,
=90 834 72.5<82
(90 010; 90 834)
=85 374
(71 552; 86 552)
El Ghoul Compare fracture Mandibular 10 Resin ceramic Thermocycling, Resin ceramic, - - - 6
et al65 resistance of molars (Cerasmart), Dynamic lithium disilicate
endocrown lithium mechanical ceramic and zirconia
made of different disilicate (IPS loading, SEM reinforced lithium
materials to e.max CAD), disilicate ceramic
conventional Zirconia endocrowns, and
crown reinforced lithium disilicate
lithium conventional crowns:
disilicate 2752 ±242=2914
ceramic (Vita ±205>2279
Suprinity) ±290>1347 ±185

CI, confidence interval; Mn, mean; SD, standard deviation; N, Newton; SEM, scanning electron microscope.

endocrowns (717.33 ±198.6 N), with a catastrophic endocrowns and conventional crowns was assessed in
failure rate of 30% for resin ceramic endocrowns and 1 in vitro study, which showed that the marginal
80% for lithium disilicate ceramic endocrowns.70 adaptation of endocrowns (73%) was less than that of
Marginal adaptation of lithium disilicate ceramic conventional crowns (82%) (Table 1).74

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March 2021 415.e5

Table 2. Summary of included clinical studies

Survival Rate Success Rate Failure Rate,
Age (Mn Mean (%) (%) (Specific
(Range)), Follow- Method of (Endocrown, (Endocrown, Failure
Type of Sex (M:F No. of Up Period Dropout Type of Restoration Restoration Conventional Conventional From Total
Reference Study Ratio) Specimens (Mo) Rate Tooth Material Evaluation Crown) Crown) Failures) NOS
Bindl and Prospective Age: - 136 patients 55 ±15 0 Endocrowns: Feldspathic Clinical, Premolars: Premolars: Endocrowns: 8
Mormann75 Sex: 1:1.4 86 11 porcelain USPHS 87.5=96.7% 68.8<93.9 Premolars:
endocrowns, premolars, CAD-CAM Molars: Molars: 80=73 Loss of
70 70 molars (CEREC2) 87.1=94.6 retention;
conventional Conventional 100%
crowns, 52 crowns: Molars:
reduced 33 Periodontitis,
crowns premolars, vertical root
37 molars fracture
each; 14.3%,
Loss of
retention;
64.3%
Conventional
crown:
Premolars:
Crown
fracture,
vertical root
fracture
each; 50%
Molar: crown
fracture,
vertical root
fracture
each; 20%,
irreversible
pulpitis; 50%
Roggendorf Prospective Age: 52 35 patients 84 ±6 24.4 Molars Feldspathic Clinical, 80, 100% 72.7<100 Endocrowns: 7
et al76 observational (21-80) 12 porcelain USPHS Vertical root
longitudinal Sex: 2.1:1 endocrowns, CAD-CAM fracture:
21 (CEREC2) 66.7%
conventional Caries: 33.3%
crowns, 44
other
restorations
Otto and Prospective Age: 53 55 patients, 116 5.5 Endocrowns; Feldspathic Clinical, Premolars and Premolars: Endocrowns: 7
Mormann72 observational (25-79) 25 5 premolars, porcelain modified Molars: 80, 100 Premolars
longitudinal Sex: 1:1.4 endocrowns, 20 molars CAD-CAM USPHS 100=100% Molars: loss of
8 Conventional (CEREC 3) 90,100 retention;
conventional crowns: 100%
crowns, 32 4 premolars, Molars: loss
reduced 4 molars of retention;
crowns 50%, crown
fracture; 50%

Mn, Mean; NOS, Newcastle-Ottawa scale; USPHS, United States Public Health Service.

In molars, the load to fracture strength of resin
ceramic endocrowns (2752 ±242 N) was higher than that
of conventional crowns (1347 ±185 N).72 The fracture
strength of lithium disilicate ceramic endocrowns (989
±109.1 N or 2914 ±205 N) was consistently either similar
to or higher than conventional crowns (1076 ±132 N or
1347 ±185 N), with a catastrophic failure rate of 20% and
10%, respectively.69,72 Comparisons of the fracture
resistance of endocrowns made of various materials
showed that resin ceramic endocrowns (2752 ±242 N)
had a fracture strength that was not significantly different
from that of lithium disilicate ceramic endocrowns (2914
±205 N) and a higher fracture strength than that of
zirconia-reinforced ceramic endocrowns (2279 ±290 N).72
Taken together, from in vitro studies, the fracture
strength of endocrowns restoring posterior teeth was
either similar to or higher than that of conventional
crowns, yet the overall rate of catastrophic failures of
endocrowns and conventional crowns restoring molars
was less than for the same restorations restoring anterior
teeth or premolars (Table 1).
Clinical studies included in the systematic review
and meta-analysis were prospective studies with a
population average age of 53 years (range: 21-80), a
male-to-female ratio of 1:1, and an average follow-up
period of 85 ±10 months (Table 2).67,75,76 The esti-
mated overall 5-year survival rates were 93.8% for
endocrowns and 98.4% for conventional crowns
restoring premolars, and the 5-year survival rates were
89.1% for endocrowns and 98.2% for conventional
crowns when restoring molars. The estimated overall 5-
year success rates of endocrowns and conventional
crowns restoring premolars were 74.4% and 97%,
respectively, and the 5-year success rates in tests and

Al-Dabbagh THE JOURNAL OF PROSTHETIC DENTISTRY

415.e6
Subgroup Weight M-H, Random, 95% CI
Premolars
Bindl et al, 2005 21.2%
Otto and Mormann, 2015 5.6%
Subtotal (95% CI) 26.8%
Heterogeneity: τ2=0.00; χ2=0.22, df=1 (P=.64); I2=0%
Test for overall effect: Z=0.92 (P=.36)
Molars
Bindl et al, 2005 57.3%
Otto and Mormann, 2015 9.0%
Roggendorf et al, 2012 6.9%
Subtotal (95% CI) 73.2%
Heterogeneity: τ2=0.00; χ2=0.54, df=2 (P=.76); I2=0%
Test for overall effect: Z=1.50 (P=.13)
Overall (95% CI) 100.0%
Heterogeneity: τ2=0.00; χ2=0.77, df=4 (P=.94); I2=0%
Test for overall effect: Z=1.76 (P=.08)
Test of subgroup differences: χ2=0.00, df=1 (P=.99); I2=0%
Figure 2. Forest plot of survival rates of endocrowns compared with conventional crowns in molars and premolars
controls restoring molars were 80.9% and 91%,
respectively. However, the overall survival (RR=0.92;
95% CI: 0.84, 1.01) and success rates (RR=0.91; 95% CI:
0.77, 1.08) of endocrowns and conventional crowns
were not significantly different (Figs. 2, 3). Moreover,
subgroup analysis revealed that the survival rates of
endocrowns and conventional crowns were similar
when restoring molars (RR=0.92; 95% CI: 0.83, 1.02)
and premolars (RR= 0.92; 95% CI: 0.78, 1.10). However,
this analysis demonstrated an improved but nonsignif-
icant success outcome favoring conventional crowns
when restoring premolars (RR= 0.76; 95% CI: 0.57, 1.01)
(Figs. 2, 3). Heterogeneity was minimal for both
assessed outcomes (I2= 0 and 22%).
DISCUSSION
The main objective of this review was to assess the sur-
vival and success rates of endocrowns. The analysis
showed that the fracture strength of endocrowns
restoring posterior teeth was either similar to or higher
than conventional crowns. However, there was a higher
catastrophic failure rate of lithium disilicate ceramic en-
docrowns compared with conventional crowns. Consis-
tently, clinical survival and success rates of endocrowns
and conventional crowns were similar when used to
restore endodontically treated molars and premolars,
supporting acceptance of the null hypothesis.
The analysis revealed several deficiencies in the
current literature, including a lack of randomized
controlled studies, clinical studies with sufficient
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume 125 Issue 3
Risk Ratio Risk Ratio
M-H, Random, 95% CI
0.90 [0.74, 1.10]
1.00 [0.68, 1.46]
0.92 [0.78, 1.10]
0.92 [0.82, 1.04]
1.00 [0.74, 1.35]
0.84 [0.60, 1.19]
0.92 [0.83, 1.02]
0.92 [0.84, 1.01]
0.05 0.2 1 5 20
Conventional crowns Endocrowns
Survival Rate
numbers of test and control restorations, and clinical
studies with long-term survival analysis over 3 years.
Most of the studies included in this review were,
accordingly, in vitro studies.
Most of the articles published to date were on
endocrowns used to restore endodontically treated mo-
lars and premolars.68,70,72-76 However, endocrowns were
shown to perform better when placed in posterior
teeth.76 This is possibly because of the larger pulp
chamber in premolars and molars and their axial loading
under function. In clinical studies, endocrowns were
mainly used in teeth with minimal remaining coronal
tooth structure, where establishing a ferrule would be
difficult, yet margins were mainly equigingival.68,75 In
these teeth, crown lengthening could be avoided because
it may further compromise the tooth, rendering it
nonrestorable.
Endodontically treated teeth are susceptible to
biomechanical failure and should be restored with a
coronal restoration to protect them from fracture and
failure.1-3Ideally, an endocrown should be fabricated
from a material with a low modulus of elasticity
(similar to that of the tooth structure), high mechanical
strength, and sufficient bond strength to the underly-
ing tooth structure.53 A modulus of elasticity compa-
rable with dentin helps to distribute occlusal forces
along the bonded surface and possibly improves frac-
ture resistance,53 while high mechanical strength helps
in withstanding occlusal load and resisting material
fracture.53
Al-Dabbagh
March 2021
Subgroup Weight M-H, Random, 95% CI
Premolars
Bindl et al, 2005 20.0%
Otto and Mormann, 2015 9.0%
Subtotal (95% CI) 29.0%
Heterogeneity: τ2=0.00; χ2=0.16, df=1 (P=.69); I2=0%
Test for overall effect: Z=1.87 (P=.06)
Molars
Bindl et al, 2005 34.9%
Otto and Mormann, 2015 20.9%
Roggendorf et al, 2012 15.2%
Subtotal (95% CI) 71.0%
Heterogeneity: τ2=0.01; χ2=2.56, df=2 (P=.28); I2=22%
Test for overall effect: Z=0.18 (P=.85)
Overall (95% CI) 100.0%
Heterogeneity: τ2=0.00; χ2=5.14 , df=4 (P=.27); I2=22%
Test for overall effect: Z=1.06 (P=.29)
Test of subgroup differences: χ2=2.05, df=1 (P=.15); I2=51.2%
Figure 3. Forest plot of success rates of endocrowns compared with conventional crowns in molars and premolars
The published prospective and retrospective clinical
studies on the clinical performance and survival of
endocrowns used feldspathic computer-aided design and
computer-aided manufacturing (CAD-CAM) ceramic
endocrowns.67,75,76 However, most of the in vitro studies
used either resin ceramic or lithium disilicate ceramics to
fabricate endocrowns.68-74 In these in vitro studies,
endocrowns made of resin ceramic restoring premolars
had higher fracture strengths and lower catastrophic
failure rates than those of endocrowns made of lithium
disilicate ceramics. A possible explanation for this is that
the modulus of elasticity of the resin ceramic is compa-
rable with dentin and thus may better distribute occlusal
forces along the bonded surface of premolars, thereby
improving fracture resistance and reducing catastrophic
failure rates.53
For feasibility and to improve the mechanical prop-
erties, most studies used CAD-CAM blocks (resin
ceramic, feldspathic, and lithium disilicate) to fabricate
endocrowns.66,70,71,73,74 The results of most in vitro
studies on endocrown CAD-CAM restorations were
positive.69,74
Clinical studies on the long-term serviceability of
endocrowns are scarce. Although there were no signifi-
cant differences in the overall survival rates of endo-
crowns compared with conventional crowns in this
meta-analysis, there was a trend toward better survival
with conventional crowns, a trend that was more pro-
nounced in premolars. This failure to detect a significant
difference was possibly attributable to the small number
Al-Dabbagh
415.e7
Risk Ratio Risk Ratio
M-H, Random, 95% CI
0.73 [0.52, 1.03]
0.83 [0.48, 1.44]
0.76 [0.57, 1.01]
1.10 [0.87, 1.38]
0.98 [0.70, 1.36]
0.76 [0.50, 1.13]
0.98 [0.80, 1.20]
0.91 [0.77, 1.08]
0.05 0.2 1 5 20
Conventional Crowns Endocrowns
Survival Rate
of assessed restorations. In their prospective study, Bindl
et al75 reported that the cumulative survival rates of
endocrowns (feldspathic CAD-CAM CEREC2) in molars
were similar to those of conventionally prepared and
minimally prepared crowns (87.9%, 94.6%, and 92.1%,
respectively). This study included 208 crowns in 136
participants, of which 109 were endocrowns (70 molars,
39 premolars). Among the endocrown restorations, 19
failed, mainly from adhesive failure (14 restorations) after
5 to 6 years of service.75 In another prospective study, the
same group showed that the 12-year survival rates of the
same type of endocrowns and crowns (with post-and-
core crowns or in vital teeth with deficient preparation)
were similar (85.7%, 90.3%, and 94.4%, respectively).
The difficulty in detecting a significant difference in
survival between test (25 endocrowns) and control (40
crowns) could be because of the small sample size.
However, in general, the failure rates were low, which
may also reflect participant selection and the standard-
ized procedure or that endocrowns could be a promising
restorative option.67
In summary, clinical evidence on the longevity of
endocrown restorations is still lacking. Most existing
in vivo and in vitro studies focused on CAD-CAM
endocrowns made of resin ceramics and feldspathic or
lithium disilicate ceramics and demonstrated the possi-
bility of using endocrowns in specific clinical scenarios
such as endodontically treated molars with minimal
remaining coronal tooth structure. When endocrowns
failed in molars, this was usually a restoration failure or
THE JOURNAL OF PROSTHETIC DENTISTRY
415.e8
repairable failure. However, regular maintenance visits
should be recommended to assess the susceptibility of
marginal leakage and debonding for immediate
intervention.
CONCLUSIONS
Based on the findings of this systematic review and
meta-analysis, the following conclusions were drawn:
1. There remains a need for large, well designed,
clinically controlled studies with long-term
assessment.
2. However, endocrowns appear to be a promising,
conservative, and inexpensive restorative option
with acceptable long-term survival for endodonti-
cally treated posterior teeth in selected patients
using standardized clinical procedures.
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Corresponding author:
Dr Raghad A. Al-Dabbagh,
Oral and Maxillofacial Rehabilitation Department
Faculty of Dentistry
King Abdulaziz University
Al Fayha’a District
Jeddah 22252-3646
KINGDOM OF SAUDI ARABIA
Email: raaldabbagh@kau.edu.sa
Acknowledgments
The author thanks Dr Mona Al-Dabbagh for her guidance and support in the
methodology of this systematic review and meta-analysis and Dr Alaa Manna for
being the second investigator in this review. She as well thanks editorial assis-
tance from Nextgenediting (www.nextgenediting.com).
Copyright © 2020 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2020.01.011
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