ESLAM S.

ZAKZOUK

ENDOCROWN
From virtuality to reality
Endocrown
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By Eslam S. Zakzouk
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Introduction
Definition
Indications/Contraindications
Advantages/Disadvantages
Material choices
Cavity preparation
In-office CAD/CAM protocol
Try-in
Cementation
Clinical cases

Experience, continued training and our imagination is the source of success

and the only way we can achieve individual quality and true esthetics..
Douglas A. Terry
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Introduction

When a posterior tooth has extensive tissue damage associated with

endodontic treatment, it's traditionally treated through a cast-metal
post and core, metal post with build-up, or even a fiber post with
composite build-up. Whatever the material but all of this is to help
the retention and improve the stability of the indirect restoration.
The endocrown is an alternative that simplifies the protocol in
restorative endodontically treated teeth.
The concept was first introduced by Pissis in 1995.

What is endocrown?

Basically, endocrown is an overlay with an

extension into the pulp chamber. In other
words, it is a crown that extends to include
the pulp chamber in endodontically treated
teeth, a crown with its core part as a single
unit.

It is a large ceramic block that fills the pulp

chamber and is adhesively cemented to the
dental substrate, thereby achieving
macromechanical retention provided by the walls of the pulp chamber and
micromechanical retention by means of adhesive bonding. This technique
presents satisfactory long-term clinical results in molars; maybe this is due
to the sufficient surface area available to adhesion.

Indications:
● Successfully treated tooth
● Excessive coronal loss
● Limited interocclusal space
● Cavity depth at least 3mm &
cervical margin with 2 mm
width
● Short clinical crowns
● Calcified root canals.
Advantages:
● Simple, easier to perform
● No preparation for root dentin
● No post
● Conservative preparation design
● Less chairside time.
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Contraindications:
● If the pulp chamber is shallow
(less than 3mm)
● If the cervical margin is less
than 2 mm wide for most of its
circumference.
● If adhesion can not be assured.
Disadvantages:
● Risk of root fractures and
debonding
● Limitations may be restricted to
materials that provide adhesion
● Laborious upon removal or
drilling through it.
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Material choices:

Materials that can be adhesively cemented can give the best results as that
type of restorations depends mainly upon adhesion. CAD/CAM composites
and silica-based ceramics would give superior results when compared to
zirconia-based materials. From among grindable silica-based ceramic
blocks, one may choose feldspathic porcelain blocks (eg, Vita Mark II, Vita),
leucite-reinforced (eg, Empress CAD, Ivoclar Vivadent), and lithium
disilicate ceramic blocks (eg, IPS e.max CAD, Ivoclar Vivadent). As a result
of their relatively high proportion of glass, these ceramics are, in contrast
to oxide ceramics, etchable with hydrofluoric acid, and can thus be inserted
very well using adhesive systems. The currently available ceramic blocks
can be mono- or polychromatic.
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You can read more about materials by clicking the following link:
CAD/CAM materials

Implementation

Cavity preparation CAD/CAM system Cementation

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Cavity preparation:

The preparation design is extremely simple requiring only the pulp

chamber to be expulsive/divergent towards the occlusal surface, the
preparation margins exhibit sharp, well-defined termination at 90 degrees
to the outer surface, and that the interior angles are rounded.
● The depth of the cavity at least 3mm
● At least 2 mm thick cervical margin
● No internal line angles
● Flat pulpal floor whenever possible
● Supragingival finish line is preferred, although sometimes a deep
margin needs to be relocated at a more supragingival position for
better management.
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The cavity preparation consists of :

Supragingival margins Deep margin elevation

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Armamentarium:

Diamond points with different shapes and sizes and different degrees of
abrasiveness can be employed throughout the preparation phase similar to
points that are used for inlay and onlay preparations.
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1. Occlusal reduction:

A proper occlusal reduction is important to protect cusps from

occlusal stresses and it is the keypoint for a good occlusal anatomy of
the restoration as well, so 2 mm occlusal clearance is required.
Buttjoint margin or cervical sidewalk with at least 2 mm thickness is
required. A wheel-shaped bur is also helpful while reducing the
occlusal surface.
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2. Axial reduction:

The diamond points used are only positioned parallel to the long axis
of the tooth and automatically confer the ideal taper to the axial
walls of the pulp chamber and always result in rounded internal
angles. It is always of utmost importance to protect the surfaces of
the adjacent teeth during the proximal preparation by using strips of
a metallic matrix.
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Ferrule or NO ferrule ?

Ferrule effect is always important to improve the mechanical retention of

the restoration by preparation of a deep chamfer or a rounded shoulder
margin encircling the remnant tooth structure. The ferrule increases the
surface area available for adhesion and causes the restoration to embrace
the tooth remnant. The axial distance between the walls of the pulp
chamber and the external surfaces of the tooth should include the
necessary reduction to define a chamfer/shoulder margin without resulting
in weak and thin walls.
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Ferrule can add to the retention of the restoration but it should not be
implemented at the expense of the tooth remnant like in cases of extensive
destruction and there is a lack of sufficient tooth structure. Thus a
butt-joint margin is performed in such cases to preserve the tooth
structure to only delimit the preparation margins.

Ferrule No Ferrule
● encircling the entire tooth ● Lack of sufficient tooth
● improves the mechanical structure
retention of the restoration ● Only delimit the preparation
● improves stability and stress margins.
distribution
● additional benefit, but not at
the expense of tooth structure
● not strictly necessary for
obtaining a high quality
preparation (optional).
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3. Cavity floor preparation:

Cleaning the pulp chamber and its floor thoroughly with no abrasion
nor drilling of the dentin, but removing any remnants of endodontic
sealer and gutta percha from canals orifices. Making a filling with
adhesive and composite in the region of canals orifices - not
exceeding 2 mm for better sealing of canals - , alternatively it may be
kept as exposed gutta percha. But, it is preferable to make the filling
in order to :

● prevent contamination of the root canals through leakage in

case of dislodgement of the temporary
● block the undercuts in this area in this irregular region of the
tooth.
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4. Finishing and polishing:

It is not recommended for the preparation to present sharp angles

since they lead to the concentrations of stresses and may
compromise the mechanical properties of the restoration.
Smoothing of the interior angles is performed initially with
fine-grained diamond points, with the same shapes as the points
already used during preparation. The smoothing of the internal
angles consists of rounding off the occlusal-axial angles. Refinement
of the preparation surface both along the margins and within the
axial walls of the chamber. Then the steps are repeated with
extra-fine diamond points of equal shapes. The finishing and
polishing are completed through using specially shaped abrasive
rubbers.
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In-office CAD/CAM protocol:

The CAD/CAM systems allow the clinician to either;

1. take a digital impression, design the restoration, and mill the

restoration in the office or
2. send the digital impression to the laboratory for designing by the
technician and milling as well as for staining and glazing.

In-office CAD/CAM systems include a scanner, a designing software and a

milling device. The conventional impression is replaced by a digital optical
impression, and in most cases, the prosthetic restoration is manufactured
on the spot, which is a major time-saving advantage.

I’m going to explain my

way and how to implement
CAD/CAM restorations and
the ability to deliver them
the same visit for most
cases.
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Try-in:

Remove the temporary restoration then use a prophylactic paste to clean

the cavity from any debris or residuals of the temporary cement. The
operation field is isolated using a rubber dam thus, the margins are visible
and the dryness greatly facilitates the assessment and adjustments of the
margins.
If the first attempt of insertion was not successful and the restoration can
not be completely seated, check the proximal region for presence of
interference , detect it using articulating paper, these regions are gently
adjusted with fine and extra fine diamond points until the endocrown has
obtained proper seating to the preparation and therefore an optimal
marginal adaptation. The adjusted regions are then polished with special
rubbers to remove the cracks generated by the adjustment and give it back
its original shine and smoothness.
⛔️ At this time, the patient should not bite on the restoration as it can easily
break due to excessive biting forces.
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Cementation:

For this type of restoration a successful treatment depends on the quality of

adhesion, both to the tooth structure as the ceramic surface, because
endocrowns do not follow the classical geometric principles responsible for
retention and stability.

⛔️ Holding the restoration with an adhesive device will help you get through
the procedures very easily, eg. Optrastick “ Ivoclar Vivadent “.
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⛔️ An interesting tip :
Use two wooden wedges, one on each proximal surface, before the
cementation itself. The point is the inversion of the wedges in order not to
hinder the insertion of the restoration. In this position, the wedges will
prevent excess cement from flowing towards the interproximal spaces,
facilitating the finishing procedures and the removal of the marginal
excesses.

The cementation phase consists of;

1. Surface treatment of the restoration
2. Surface treatment of the tooth.
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Surface treatment of the restoration:

● The internal surface of the restoration is etched with hydrofluoric acid for
the time recommended by the manufacturer of the ceramic system then
rinse and dry.

● Apply several layers of a silane agent to the etched surface. “ almost for 60
seconds “.

● A thin layer of the adhesive should also be applied to the ceramic

surface previously silanized (optional).
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Surface treatment of the substrate:

● The preparation surface is etched with phosphoric acid for
approximately 15 seconds after protecting the neighboring teeth with
celluloid bands. Then rinse and remove the excess moisture.

● Multiple layers of a light-cured adhesive system are applied to the

tooth preparation surface.
Be careful to remove excesses that tend to accumulate in the internal
angles of the preparation. Then the adhesive is light-cured.
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● Dual-cured resin cement is then applied to the internal surface of the

restoration, which is placed into position and seated with gentle finger
pressure.

● After being fully seated, a spatula for composites is used to maintain

slight pressure on the restoration while the adhesive device is pulled
and removed.

● The gross excess cement along the entire margins is removed with
disposable brushes, spatulas, or with an explorer while gentle
pressure on the restoration is still maintained.
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● Tack curing is performed for about 5 seconds to keep the restoration

in position allowing for the thorough removal of the excess cement
and adhesive. The wedges are removed and all excesses are then
removed using dental floss and abrasive strips.

● The final light curing is applied to the whole surfaces, 60 seconds per
surface is recommended after applying water-soluble glycerin on all
the margins to prevent the oxygen inhibiting layer and that will ensure
complete polymerization without resulting in unsightly stained areas.
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● Remove the rubber dam, check the occlusal contacts and adjust any
premature contacts using fine and extra-fine diamond points until
obtaining an acceptable occlusal standard. All sites adjusted with
diamond points should be polished with special abrasive rubbers for
the intraoral polishing of ceramics.
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Clinical cases:

Case 1:

A badly-destructed molar limited interocclusal space

The pulp polyp was excised and root canal treatment was initiated.
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Obturated canals

Sealing canals using flowable composite

Preparation design Butt-joint margin

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For a detailed explanation about this case, click the following link:
Endocrown,, case presentation
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Case 2:

Preoperative Preparation design

Optic impression

Virtual design
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Milling Finishing & polishing

Finished & polished restoration

Glazing Surface characterization

The restoration is then inserted into the furnace ..

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Final restoration

Fitting surface

Absolute isolation
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Immediately after cementation Lingual view

Buccal view Two weeks recall

For more details about this case and the full protocol of chairside
endocrown, check this video:

In-Office CeltraDuo Endocrown

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Case 3:

Preoperative occlusal view Lingual view

Root canal treatment is initiated Finished RCT

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Virtual design

Milled restoration Final restoration

Ready to be cemented
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Rubber dam isolation

Buccal view with margin integration Postoperative lingual view

Interproximal excess cement Well-adapted & clean margins

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Preparation design Vs Preoperative situation

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A life-like restoration
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Case 4:
This is the recall photos after 18 months. An endocrown was done to the
lower first molar of a 14-years old female who came to my clinic with a
badly-decayed root canal treated tooth.

Ferrule preparation

Digital impression Proposal design

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Delivered .. 18 months recall

18 months recall X-ray reveals good margin adaptation

Finally, the endocrown reveals a simple and fast alternative treatment since
it leads to considerable clinical time saving and can be used without
damage to the quality of the final result.
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References and suggested readings:

● Restoring the intraradicular space: Esthetic post systems, Douglas A.

Terry.
● Routes for excellence in restorative dentistry, mastery for beginners
and experts.
● Comprehensive esthetic dentistry, Florin Lazarescu, editor.

Documentations are communication tools that can be used as demonstrations,

lectures, speeches, reports, and more. It is mostly presented before an audience.
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