Comparative Evaluation of the Internal

and Marginal Adaptations of CAD/CAM

Endocrowns and Crowns Fabricated from
Three Different Materials
Mahya Hassanzadeh, DDS, MS
Dental Research Center, Dentistry Research Institute and Department of Prosthodontics,
School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran.

Majid Sahebi, DDS, MS

Simindokht Zarrati, DDS, MS
Leila Payaminia, DDS, MS
Department of Prosthodontics, Faculty of Dentistry, Tehran University of Medical Sciences,
Tehran, Iran.

Marzieh Alikhasi, DDS, MS

Dental Research Center, Dental Implant Research Center, Dentistry Research Institute,
Department of Prosthodontics, Faculty of Dentistry, Tehran University of Medical Sciences, Tehran, Iran.

Purpose: To evaluate and compare the internal and marginal adaptations of chairside CAD/CAM (CEREC)
endocrowns and crowns fabricated from lithium disilicate glass-ceramic (IPS e.max CAD), zirconia-reinforced
lithium silicate glass-ceramic (VITA Suprinity), and hybrid ceramic (VITA Enamic). Materials and Methods:
Dental models of the two first maxillary molars were selected. One was prepared for an endocrown, and the
other for a standard all-ceramic crown. A total of 72 CAD/CAM restorations, including 36 endocrowns and 36
crowns made of IPS e.max CAD, VITA Suprinity, and VITA Enamic (n = 12 each), were fabricated. Discrepancies
were measured in the buccal, mesial, lingual, and distal aspects of three sites (marginal, mid-axial wall, and
occlusal/floor) using the noncontact ATOS scanner. Statistical analysis was performed using MANOVA and
between-subject effects tests (α = .05). Results: Mesial axial wall discrepancy was significantly lower in
endocrowns compared to occlusal discrepancy in crowns, while distal axial wall discrepancy was significantly
higher. Moreover, floor discrepancy was found to be significantly lower in endocrowns compared to crowns.
However, type of material had no significant effect on any kind of discrepancy. Conclusion: The marginal
and internal adaptation values were within a clinically acceptable range for both kinds of restoration and all
three materials. However, restoration type (crown vs endocrown) was significantly different in the mesial and
distal axial wall and occlusal/floor discrepancies, regardless of restoration material. Int J Prosthodont 2020
(7 pages). doi: 10.11607/ijp.6389

T
he functional and esthetic restoration of severely damaged endodontically treat-
ed teeth is still a clinical challenge.1 A typical protocol to restore these teeth is to
use posts and cores and a full-coverage crown. However, with the development
Correspondence to:
of adhesive dentistry, this goal is easily made feasible by an endocrown.2 An endo- Dr Leila Payaminia
crown is a one-piece, post-free ceramic restoration that assemble the crown and the Department of Prosthodontics,
School of Dentistry
pulpal cavity part in one component.3 In comparison to the classical post-and-core
Bushehr University of
approach, this modern alternative treatment modality offers several advantages, such Medical Sciences
as more preservation of tooth structure, less need for sufficient interocclusal space, Moallem St, Bushehr, Iran.
Fax: +987733322206
reduced risk of root fracture, and possibility of retreatment in case of endodontic
Email: leilapayaminiya@yahoo.com
failure. Moreover, both the number of appointments and the cost decrease, as there
is no need for the many technical steps for post cementation, core build up, and po- Dr Marzieh Alikhasi
Fax: +982188196809
tential crown lengthening.4,5
Email: m_alikhasi@yahoo.com;
A systematic review done by Wittneben et al6 revealed an overall survival rate malikhasi@razi.tums.ac.ir
of 91.6% after 5 years for computer-aided design/computer-assisted manufacture
Submitted February 18, 2019;
(CAD/CAM) single-tooth restorations, which is considered clinically similar to con-
accepted September 14, 2019.
ventional restorations. However, the lowest rate was found in endocrowns (82.3%). ©2020 by Quintessence
This admits the concern that endocrowns might not always represent a predictable Publishing Co Inc.

doi: 10.11607/ijp.6389 1
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NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 alternative treatment option, as Bindl et al7 and Otto
and Mörmann8 declared regarding premolar endo-
crowns. In contrast, there are some studies that have
reported a survival rate of > 90% for endocrowns,
showing no significant differences between premolars
and molars.4,9 However, as the endocrown concept was
introduced about two decades ago, there are not suf-
ficient long-term study results with large sample sizes
on endocrown survival and success rates.
Although endocrowns have both macro- and micro-
mechanical retention,3 their retention mainly relies on
bonding; so, it is essential to use materials that can be
bonded to tooth structure.10
CAD/CAM technology has witnessed widespread ad-
vances in materials over the past 10 years.5 Glass- and
composite-based materials are the main categories of
adhesive ceramics that can be used with CAD/CAM
technology. Glass-based materials are nonmetallic in-
organic ceramic materials that contain the glass phase.
Lithium disilicate and its derivatives, including zirconia-
reinforced lithium silicate (ZLS), are categorized into this
group. Composite-based materials are categorized into
different subgroups—polymer-infiltrated ceramic net-
work (PICN) and composite resin—according to their
chemical composition. The first is composed of a dual
network: a dominant ceramic network infiltrated by
a polymer network. The latter is comprised of mate-
rials with an organic matrix highly filled with ceramic
particles.11
IPS e.max CAD (Ivoclar Vivadent) is a lithium disilicate
available in partially crystallized block form that pro-
ceeds with crystallization at 850°C after milling with
0.2% shrinkage. VITA Suprinity (VITA Zahnfabrik) is
a ZLS ceramic enriched with highly dispersed zirconia
(10% by weight) and is available in a partially crystallized
form that contains lithium metasilicate crystals; there-
fore, it can be milled easily.12 Adding zirconia results
in a round and slightly elongated crystalline structure
with an average crystal size of 0.5 µm compared to the
needle-shaped, interlocked, randomly oriented crystals
with an average size of 1.5 µm found in lithium disili-
cate ceramic.13 VITA Enamic (VITA Zahnfabrik) is a PICN
material with 14 by weight polymer and two distinct
interpenetrating phases. This material was introduced
to overcome the high modulus elasticity, hardness, and
brittleness of glass-matrix ceramics. A more favorable
brittleness index of this material makes it a suitable op-
tion for milling units compared to lithium disilicate and
ZLS materials.14 Furthermore, these hybrid ceramics re-
quire less preparation of the tooth structure to provide
sufficient durability.15
The marginal adaptation of indirect restorations is
an important factor for clinical long-term success. The
presence of a marginal gap can lead to dissolution of
the luting agent, secondary caries, and periodontal
2 The International Journal of Prosthodontics
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NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
disease.16–18 A marginal gap of less than 120 μm is
considered clinically acceptable.19 In addition, the in-
ternal gap can also affect the clinical outcome because
internal gaps greater than 70 μm can reduce the frac-
ture resistance of dental crowns.20 However, there is
no consensus on an acceptable threshold for internal
gap.21 As a result, it is important to address two ques-
tions when restoring endodontically treated teeth:
(1) Which restoration is preferable? and (2) Which
material should be chosen to achieve highly adapted
restorations? The purpose of this study was to evalu-
ate and compare the marginal and internal adaptation
values of chairside CAD/CAM (CEREC) endocrowns
and crowns fabricated of lithium disilicate (IPS e.max
CAD), ZLS glass-ceramic (VITA Suprinity), and hybrid
ceramic (VITA Enamic). The null hypothesis was that
there would be no difference in the internal and mar-
ginal adaptations between CAD/CAM endocrowns
and crowns of these three materials.
MATERIALS AND METHODS
A sample size of 12 was calculated for each group for
80% power according to the two-sample t test power
analysis (PASS 11), assuming the reported mean and
standard deviations (SDs) reported by Shin et al22 (mean
= 100 µm, SDs = 98 µm and 60 µm). A total of 72 speci-
mens were used in this study, divided into two groups:
36 crowns and 36 endocrowns. The crown type groups
were further divided into three subgroups each based
on material: IPS e.max CAD, VITA Suprinity, and VITA
Enamic (n = 12 each).
Tooth Selection and Preparation
Dental models of the two first maxillary molars (Nissin
Dental Products) were selected. The teeth were embed-
ded with self-curing acrylic resin (Fastray, Harry J. Bos-
worth) to 2 mm below the cementoenamel junction in
an aluminum base with specified geometric features. In
order to reproduce the surface anatomy, both models
were scanned using an intraoral scanner (CEREC Omni-
cam, Dentsply Sirona). One of the teeth was prepared to
receive an endocrown restoration. Accordingly, the buc-
cal and lingual cusps received 3-mm and 5-mm occlusal
reductions, respectively, with butt-joint margin designs.
A tapered fissure diamond bur (G845KR, Edenta) was
used to create the internal taper of the pulp chamber,
which was 8 to 10 degrees in the mesial and distal, 22
degrees in the buccal, and 11 degrees in the lingual cav-
ity walls. The depth of the cavity from the lingual wall
was considered to be 3 mm. The finishing procedure
was accomplished using a bur (806314141014 fine,
Jota) with the same shape and taper, a larger diameter,
and a finer particle size to allow for smooth internal
transitions.

Fig 1   Digital die of crown.
The other tooth was prepared for a standard all-
ceramic crown. Preparation consisted of a 2-mm reduc-
tion of the occlusal surface and a 1-mm reduction of all
the axial walls with a deep chamfer finish line using a
round-end taper diamond bur (806314290 coarse, Jota).
The preparation was completed after the finishing pro-
cedure with a fine diamond bur (806314290 fine, Jota).
Scan and Design
Data from each of the two models were captured us-
ing an intraoral scanner (Figs 1 and 2). The endocrown
and crown were designed with CEREC premium SW
4.0 software (Dentsply Sirona) using initial scans before
preparation as master models and a biogeneric copy
design option. A 60-μm cement space was considered
in all of the groups.
Restoration Fabrication
The digital information was transferred to the milling
machine (CEREC MC XL, Dentsply Sirona). A total of 72
restorations, including 36 endocrowns and 36 crowns
made of IPS e.max CAD, VITA Suprinity, and VITA En-
amic (n = 12 in each subgroup), were fabricated.
The restorations made of IPS e.max CAD and VITA
Suprinity blocks needed an additional crystallization
step. Therefore, they were placed in a furnace (CEREC
SpeedFire, Dentsply Sirona) at 840ºC for 25 minutes.
Measurement of Marginal and Internal
Adaptations
Before measurement, in order to reach a maximum
adaptation, the proper seating of the restorations was
verified until achieving the best possible fit using a dis-
closing media (Kettenbach). Restorations were adjusted
if needed under magnification by a dental loupe. A ref-
erence point–matching scan protocol was performed
for three-dimensional (3D) fit assessment. Four scans
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NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Hassanzadeh et al
Fig 2   Digital die of endocrown.
were obtained using the industrial noncontact ATOS
scanner (ATOS III Triple Scan, GOM). First, the die and
base, which had a star-shaped configuration, were
scanned. In the second step, the restoration was placed
on the die and fixed with light-body silicone (Speedex,
Coltène). Then, the assembly of restoration, die, and
base was scanned. In the third step, a hexagon-shaped
cylindrical index was fixed on the top of the restora-
tion, and the assembly was scanned again. Finally, the
restoration was removed from the tooth with an index
in its place, and the inner and outer surfaces of the
endocrown/crown and the hexagon-shaped index were
scanned. GOM software (Inspect 7.5) was used to ana-
lyze the dataset of each specimen using the reference
model–matching technique. The superimposition of the
mesh data was done with reference points on the hexa-
gon-shaped and star-shaped indices of the base, which
were equal for all samples in each scan. After process-
ing the data, a uniform scan of the restoration seated
on the die was obtained. Each model was sectioned
mesiodistally and buccolingually across the intersecting
edge of the star in the base. Each section was measured
in the marginal, mid-axial wall, and occlusal/floor sites.
Data Analysis
Data were analyzed using statistical software (SPSS
22.0, IBM). Normality distribution was checked using
Kolmogorov-Smirnov test. Group means and SDs were
calculated for all the measurements obtained from the
mesial, distal, buccal, and lingual marginal and axial wall
discrepancies and for occlusal/floor discrepancies. In ad-
dition to the mean values at each region, the total mar-
ginal, axial, and occlusal/floor discrepancies were also
calculated using the mean of the values obtained from
all the regions for each group. Multivariate analysis of
variance (MANOVA) was performed to investigate the
following questions: (1) What are the main effects of
doi: 10.11607/ijp.6389 3
 Table 1   Interpretation of Table 2   Mean and Standard Deviation Marginal, Axial, and Occlusal/Floor
Effect Size Values Gaps (μm)
Values Interpretation IPS e.max VITA Suprinity VITA Enamic
0.01 Small effect Marginal Crown 65.93 ± 26.42 77.88 ± 36.68 56.09 ± 16.68
Endocrown 69.22 ± 23.49 77.52 ± 13.39 71.00 ± 31.76
0.06 Moderate effect Axial Crown 71.72 ± 17.17 74.13 ± 20.57 80.72 ± 19.35
Endocrown 70.18 ± 14.03 73.36 ± 19.86 77.16 ± 23.78
0.14 Large effect Occlusal/floor Crown 222.66 ± 58.67 230.50 ± 65.51 204.09 ± 36.59
Endocrown 102.62 ± 26.30 100.04 ± 14.93 93.91 ± 44.62

IPS e.max independent variables (restoration type and restoration

VITA Suprinity material)? and (2) What is the interaction between the
140 VITA Enamic independent variables (restoration type and restoration
120
Marginal discrepancy

material)? When MANOVA was significant, a univariate

100
test was run for each variable (mesial, distal, buccal, and
80 lingual) to interpret the respective effect. The results of
60 between-subject effects tests were used to answer the
40 above questions. In all analyses, the significance level
20 was set to P ≤ .05. Partial eta-squared analysis was also
0 used to estimate the effect size. The interpretations of
Endocrown Crown eta-squared values are presented in Table 1.
Restoration

Fig 3   Mean and standard deviation total marginal discrepancies of RESULTS
two restoration types and three restoration materials.
Three specimens, including one VITA Suprinity endo-
crown, one VITA Enamic crown, and one VITA Suprinity
IPS e.max crown, were excluded due to rocking after the adjust-
VITA Suprinity
140
VITA Enamic
ment. The mean values of the descriptive analyses of the
120 margin, axial, and occlusal/floor discrepancies are sum-
Axial discrepancy

100 marized in Table 2 and are also shown graphically in Figs

80 3 to 5. The results indicated that the range of marginal
60
discrepancies was 23.55 μm (buccal aspect of VITA En-
amic crown) to 110.55 μm (distal aspect of VITA Suprin-
40
ity crown), and the mean marginal gaps in all six groups
20
were less than 80 μm. The MANOVA result was not
0
Endocrown Crown significant for the margin discrepancies (P > .05), imply-
Restoration ing that the changes of the four points were highly cor-
related. However, the multivariate result was significant
Fig 4   Mean and standard deviation total axial wall discrepancies of
for axial wall discrepancy (P < .001). Therefore, the four
two restoration types and three restoration materials.
axial points were separately analyzed. The between-
subject effects tests showed that there was no signifi-
IPS e.max
cant difference in the marginal, buccal, or lingual axial
VITA Suprinity wall discrepancies between crowns and endocrowns.
350
VITA Enamic The mesial axial wall discrepancy was significantly lower
Occlusal/floor discrepancy

300
in the endocrowns compared to the crowns (P < .001,
250 partial eta squared = .301), while the distal axial wall
200 discrepancy was significantly higher (P < .001, partial
150 eta squared = .198). Furthermore, floor discrepancy was
100 found to be significantly lower in endocrowns com-
50 pared to the occlusal discrepancy in the crowns (P <
0 .001, partial eta squared = .664). In the marginal, axial,
Endocrown Crown and occlusal/floor discrepancy analyses, no significant
Restoration
differences were observed among the three materials.
Fig 5   Means and standard deviation total occlusal/floor discrepan- Moreover, the interaction between restoration type and
cies of two restoration types and three restoration materials. restoration material was not always significant.

4 The International Journal of Prosthodontics

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DISCUSSION
In the scenario of restoring severely damaged endodon-
tically treated teeth, the challenging decision that deter-
mines the long-term success of the treatment is what
type of restoration and material best meet the esthetic,
biologic, and functional requirements. In addition to
the many other factors that contribute to the answer to
this question, the marginal and internal adaptations are
decisive factors. It has been demonstrated that different
factors, such as type of scanner, type of milling machine,
cement space, design of preparation, type of material,
and measuring method, could influence the marginal
and internal discrepancies.23–25 In this study, the effect
of restoration type (crowns and endocrowns) and mate-
rial (IPS e.max CAD, VITA Suprinity, and VITA Enamic)
were investigated by considering all other factors equal
in all samples. The null hypothesis was partially rejected.
While neither type of restoration nor material affected
the marginal gap, the internal gap was affected by the
type of restoration regardless of the type of material.
The results indicated that the endocrowns had statisti-
cally higher occlusal/floor adaptation in comparison to
the occlusal adaptation of the crowns and that the me-
sial axial wall discrepancy was higher in the crowns than
in the endocrowns, while the results were vice versa
for distal axial wall discrepancy. It should be noted that
partial eta-squared analysis showed that the effect sizes
were large (> 0.14) in these three dependent variables.
The marginal and internal adaptations of CAD/CAM
restorations depend on how accurately the scanner can
capture the data and how precisely the milling machine
can grind the blocks. The geometry of the preparation
could affect data capture. Crowns and endocrowns are
completely different in preparation, since a prepared die
for a crown is a projected object with approximately
parallel walls, while endocrowns have a cavity and the
accuracy of the scan depends on the cavity depth. The
other point is the access direction of the scanner, as
digital impressions are imperfect on the distal side at
a specific angle. The access direction creates a shadow
distal to the illuminated object, which is called the dis-
tal shadow phenomenon. However, the tooth structure
is placed in reverse in endocrowns. This theoretically
might cause a shadow on the mesial cavity surface.26
Machinability of blocks can be defined as the ease with
which a given material is cut, which depends on the
brittleness index, which can be derived from the hard-
ness and fracture toughness, chipping factor, and mi-
crostructure of the material.27,28 It was found that the
penetration rate of a cutting bur was higher in polymer-
containing ceramics than IPS e.max and ZLS ceramics29
and that low hardness and modulus of elasticity were
associated with greater amounts of material being re-
moved during grinding.30 In addition, the other factor is
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Hassanzadeh et al
resistance to crack propagation during grinding, which
is correlated with flexural resistance.31
The results showed that neither type of restora-
tion nor restoration material significantly affected the
marginal discrepancy. The mean marginal gaps in all
six groups were less than 80 μm. This result could be
mainly due to the fact that the distal shadow phenom-
enon was limited by using a single tooth mounted in
an aluminum base and/or that measurements were
done after the adjustment. To the authors’ knowledge,
there is no previous study that compares crowns and
endocrowns fabricated of different materials consider-
ing the marginal and internal adaptations. As a result,
comparing the present results to existing studies was
done separately for each restoration type.
Yildirim et al25 measured the vertical marginal dis-
crepancy (absolute marginal discrepancy [AMD]), the
horizontal marginal discrepancy (MD), and the axial and
occlusal discrepancies of crowns made of different ma-
terials. They found that the AMD values for the IPS e.max
(155.5 μm), VITA Enamic (102 μm), and VITA Suprinity
(132 μm) crowns were higher than the present values of
the IPS e.max (65.93 μm), VITA Enamic (56.09 μm), and
VITA Suprinity (77.88 μm) crowns. However, the range
of axial (70.18 to 80.72 μm) discrepancies and the mean
occlusal (219 μm) discrepancy in the present study fell
outside the range of 41.5 to 51.7 μm and outside the
mean value of 191.5 μm in Yildirim et al.25 These results
are contrary to the Yildirim et al findings, which sug-
gest that the discrepancy values of the IPS e.max CAD
crowns were significantly higher than those made of
VITA Suprinity and that the discrepancy values of Lava
Ultimate and VITA Enamic blocks were significantly low-
er than those of others.25 These conflicting results are
due to whether the restorations were adjusted and the
amount of spacer, which was set at 40 microns in their
study. As a result, a lower cement space led to a higher
marginal gap and a lower axial discrepancy.
Shin et al22 measured the marginal and cavity wall
discrepancies of IPS e.max CAD endocrowns accord-
ing to the cavity depth. The range of the marginal gap
(99 to 120 μm), the axial discrepancy (118 to 152 μm),
and the pulpal floor discrepancy (229 to 243 μm), were
all slightly higher than the marginal (69.22 μm), axial
(70.18 μm), and floor (102.62 μm) discrepancies of the
IPS endocrowns in the present study. This could be at-
tributed to a difference in the internal taper of the cav-
ity walls, which was higher in the present study.
Moreover, the floor discrepancy in the present study
was found to be significantly lower in the endocrowns
compared to the occlusal discrepancy in the crowns. This
result is probably due to the flat surface of the pulpal
floor in endocrowns, while occlusal reduction of crowns
follows anatomical planes, and these details in the oc-
clusal surface lead to overmilling of the restoration.
doi: 10.11607/ijp.6389 5
 It was found that the measurement technique can
affect the marginal and internal values.23 A novel tech-
nique was used in this study in order to improve the
previous version of digital measurement techniques. A
hexagon-shaped occlusal index and star-shaped basal in-
dex were used as reference points to correlate the mesh
data more accurately. In a triple-scan protocol, scans are
correlated according to surface point matching, which is
not as accurate as reference point matching.
One of the limitations of the present study was that
all discrepancies were measured without luting cement.
It has been revealed that marginal discrepancy mostly
increases after cementation. The vertical marginal dis-
crepancies of all-ceramic crowns nearly doubled once
cemented.32 However, in Shin et al’s22 study, the dis-
crepancy was reduced or did not change. Even with
the additional gap caused by cementation, the present
results seem to be still in a clinically acceptable range.
Since cements have a certain thickness, evaluations
should also be accomplished after cementation. Anoth-
er limitation was that only the vertical marginal discrep-
ancies were assessed; however, it is better to assess the
vertical and horizontal discrepancies differently because
they have different clinical implications.
Currently, the “replica technique” is the only 3D tech-
nique for evaluation of restoration adaptation in clinical
studies. The noncontact scanning technique used in this
study, although more accurate, could only be used in
vitro. It is important to consider that due to the inher-
ent limitations of in vitro studies, the results could not
be simply generalized to a clinical situation, and further
clinical studies are recommended.
CONCLUSIONS
Based on the present in vitro study, neither type of resto-
ration nor material affected the marginal gap. However,
the internal gap was affected by the type of restoration.
As a result, the endocrowns had higher floor and me-
sial adaptation and less distal adaptation in comparison
with the crowns. Both kinds of restoration made of all
three materials exhibited a clinically acceptable range
for the marginal and internal adaptation values.
ACKNOWLEDGMENTS
The authors report no conflicts of interest.
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