Clinical Oral Investigations

https://doi.org/10.1007/s00784-020-03495-y

ORIGINAL ARTICLE

The fracture strength of endocrowns manufactured from different

hybrid blocks under axial and lateral forces
Duygu Hazal Acar 1 & Elif Kalyoncuoğlu 1

Received: 10 June 2020 / Accepted: 3 August 2020

# Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
Aim This in vitro study was conducted to compare the fracture strength of endocrowns manufactured from different hybrid
blocks under axial and lateral forces.
Material and methods Following root-canal treatment, 100 permanent mandibular first molars were randomly distributed among
5 groups according to restoration material. Endocrown restorations were produced from IPS e.max CAD (IPS), Vita Enamic
(VE), GC Cerasmart (GC), Shofu (SH), and Brilliant Crios (BC) using CAD/CAM technology. Specimens were cemented,
subjected to artificial aging, and further divided into 2 subgroups (n = 10) per group for fracture testing. Each specimen was
placed on a universal testing machine and subjected to axial or lateral forces applied at a crosshead speed of 1 mm/min. Fracture
data were analyzed using one-way ANOVA, Tukey, Tamhane T2, and Weibull tests.
Results Statistically significant differences in fracture-strength (FS) values under axial and lateral forces were observed among
the groups (P < 0.05). Group BC had the highest FS value under axial forces, whereas group IPS had the highest FS value under
lateral forces. According to Weibull analysis, VE exhibited the highest reliability under axial forces (7.62), whereas IPS exhibited
the highest reliability under lateral forces (4.68). No statistically significant differences were detected in the distribution of failure
types under either axial or lateral forces among the groups (P > 0.05).
Conclusion All of the hybrid blocks tested showed sufficient fracture strength for use as CAD/CAM-fabricated endocrowns.
Clinical relevance Hybrid blocks can be used as an alternative to lithium disilicate blocks in endocrown restorations.

Keywords CAD/CAM . Endocrown . Fracture strength . Hybrid block

Introduction monoblock restoration that is connected to both the inner

The clinical success of endodontic treatment has been posi-
tively correlated with the quality of post-treatment restoration
[1]. However, there is currently no consensus as to the appro-
priate treatment protocol for restoring teeth with high coronal
hard tissue loss [2]. Traditionally, teeth that have undergone
excessive material loss have been restored with a post-core
and crown following endodontic treatment [3]. However, post
failure led to the development of an alternative restoration
technique known as an “endocrown.” First described by
Pissis [4], an endocrown combines core and crown in a
* Duygu Hazal Acar
duyguhazal.guler@gmail.com
1
Department of Endodontics, Faculty of Dentistry, Ondokuz Mayis
University, Samsun, Turkey
walls of the pulp chamber and the cavity margins. This tech-
nique is designed to secure macromechanic retention from the
pulp chamber and both micromechanical and chemical reten-
tion from adhesive cementation [5]. Endocrowns represent a
conservative form of treatment whose production requires lit-
tle time and whose supragingival margins facilitate plaque
control and clinical inspection. These advantages have quick-
ly made endocrowns the preferred choice of clinicians [6].
Recent innovations in CAD/CAM (Computer Aided
Design/Computer Aided Manufacture) technology have
made it possible to produce endocrown restorations with
suitable anatomical form, dimensions, and superb marginal
fit for teeth with excessive material loss [7]. Not only do
CAD/CAM restorations reduce the amount of time re-
quired for both patient and clinician, but also they elimi-
nate the need for impressions and temporary restoration;
the risk of cross-infection is reduced in comparison to tra-
ditional post-core systems [8].

Many materials can be used with CAD/CAM systems. The
high fracture resistance, biocompatibility, and esthetic proper-
ties of ceramics have made these materials popular for use as
endocrowns: however, ceramics also result in a high level of
wear on antagonist teeth [9] that has prompted the production
of high-filled hybrid ceramic materials with properties some-
where between those of classical particle-filled resins and ce-
ramics [7]. While IPS e.max CAD (Ivoclar Vivadent, Schaan,
Liechtenstein) is a lithium disilicate ceramic that is considered
to be one of the best restorative materials available today for
single-unit indirect restorations [10], CAD/CAM-compatible
ceramic-resin hybrids such as Vita Enamic (Vita Zahnfabrik,
Bad Sackingen, Germany), GC Cerasmart (GC America,
Alsip, IL, USA), Brilliant Crios (Coltene Whaledent,
Altstatten, Switzerland), and Shofu (Shofu Dental Mfg.CO.,
Kyoto, Japan) have also been used. Vita Enamic (VE) is a
hybrid ceramic consisting of glass ceramic (86% by weight)
and a polymerized dimethacrylate monomer to combine the
positive properties of ceramic and composite [11]. GC
Cerasmart (GC) is a nano-ceramic with a matrix containing
a homogenous distribution of 71% silica and barium glass
[12]. Shofu (SH) is a resin-ceramic hybrid containing silica
and zirconium silicate (61% by weight) [13]. Brilliant Crios
(BC) is a resin nano-ceramic hybrid with an inorganic filler
(71% by weight) containing less than 20-μm silica and less
than 1-μm barium glass [14]. Unlike traditional restorative
composites, CAD/CAM composites are polymerized at high
pressures and temperatures, which gives them superior me-
chanical properties that may make them preferable for use in
areas with high occlusal forces [15].
Considering the importance of material selection in
endocrown performance, more research is needed to help
guide dentists in selecting appropriate materials with biome-
chanical properties similar to those of natural teeth. Therefore,
the present study was conducted to compare the fracture
strengths under axial and lateral forces of endocrowns pro-
duced from different materials using CAD/CAM technology.
The null hypothesis tested was that there are no differences
between the fracture strength of the endocrowns under either
axial or lateral forces.
Materials and methods
The study was approved by the Ondokuz Mayis University
Institutional Review Board’s Human Ethics Committee
(OMU-TAEK 2017/92). A total of 100 permanent mandib-
ular first molars of similar sizes that had been extracted for
periodontal or orthodontic reasons were used in the study.
Teeth with fractures, cracks, caries, or old restorations
were excluded. Prior to preparation, teeth were stored in
distilled water at 37 °C.
Clin Oral Invest
Teeth crowns were sectioned 1 mm above the cemento-
enamel junction using a diamond bur. Root canals were pre-
pared using an X-Smart (Dentsply, Maillefer, Ballaigues,
Switzerland) endomotor and NiTi Protaper Next file system
(Dentsply, Maillefer, Ballaigues, Switzerland). Canals were
obturated with a single gutta percha cone and resin-based
root-canal sealer (AH Plus; Dentsply DeTrey, Konstanz,
Germany), and the canal opening and pulp chamber were
sealed with a flowable composite material (Tetric Flow,
Ivoclar Vivadent, Schaan, Liechtenstein).
Roots were immersed in melted wax and embedded in
silicon (Zetaplus, Zhermack, Spa, Italy). The wax was then
removed from around the roots, and polyether impression ma-
terial (Soft Monophase, 3M ESPE, Seefeld, Germany) was
injected into the vacated space to simulate the periodontal
ligament. Teeth were then fixed in acrylic resin up to 1 mm
below the cemento-enamel junction using polyvinyl chloride
(PVC) tubes. Standardized cavities with a distance of 2 mm
between the internal cavity margin and the floor of the pulp
chamber and a cervical band width of a minimum of 2.0 mm,
as measured with a graded periodontal probe, were prepared
using 8–10° angled and round-ended stainless-steel diamond
burs.
Samples were randomly distributed among five groups for
endocrown restoration with either a lithium disilicate (IPS
e.max CAD—control), a hybrid ceramic (Vita Enamic,
Shofu), a hybrid nano-ceramic (GC Cerasmart), or a hybrid
composite (Brilliant Crios). Each group was further divided
into 2 subgroups (n = 10) for axial and lateral fracture testing.
Material composition and manufacturer details for each group
are given in Table 1.
Digital impressions of the samples were obtained with a
powder-free intraoral scanner (Cerec Omnicam, Sirona
Dental Systems, Bensheim, Germany). Endocrown restora-
tions were designed and milled to conform to original tooth
anatomy stored in the database (CEREC MC XL, Sirona)
(Fig. 1a–c). Crystallization and polishing of IPS e.max CAD
restorations were performed using a porcelain oven
(Programat P310, Ivoclar Vivadent AG, Schaan,
Liechtenstein). Finishing and polishing of all other restora-
tions were performed using Al2O3-coated flexible finishing
and polishing discs in order to obtain a smooth restoration
surface and accurate occlusal morphology.
Enamel surfaces of teeth were selectively etched with 37%
phosphoric acid (Etch-37, Bisco Inc., Schaumburg, IL, USA)
for 30 s. An adhesive agent (Single Bond Universal; 3M
ESPE, St. Paul, MN, USA) was applied to the entire tooth
surface, dried for 5 s, and polymerized (Elipar FreeLight 2;
3M ESPE, St Paul, MN, USA) for 20 s.
Prior to cementation, endocrown intaglio surfaces were
treated according to the manufacturers’ instructions. IPS
e.max CAD endocrowns were etched for 20 s with 5% IPS
Ceramic Etching Gel (Ivoclar Vivadent, Liechtenstein); VE
Clin Oral Invest

Table 1 The brands, types, chemical compositions, and manufacturers of the CAD/CAM materials used for the experiments

Brand Type Chemical composition Manufacturer

Vita Enamic Hybrid ceramic Organic part: UDMA, TEGDMA Vita Zahnfabrik, Bad Sackingen, Germany
Inorganic part: glass ceramic (SiO2, Al2O3,
Na2O, K2O, B2O3, ZrO2, CaO) sintered
network (86 wt%)
GC Cerasmart Rezin nano ceramic, Organic part: UDMA, DMA, Bis-MEPP GC Corp., Tokyo, Japan
Nano hybrid Inorganic part: 71 wt% barium glass
(300 nm), SiO2 (20 nm)
Shofu Hybrid ceramic Organic part: UDMA, TEGDMA Dental Mfg.CO., Kyoto, Japan
Inorganic part: 61 wt% silica powder, micro
fumed silica, zirconium silicate
Brilliant Crios Hybrid composite Organic part: cross-linked methacrylates Coltene Whaledent, Altstatten,
Inorganic part: overall 71 wt%, barium glass Switzerland
with particle size < 1 μm and amorphous
silica SiO2 with particle size ,<20 nm
IPS e.max CAD Lithium disilicate 97% SiO2, Al2O3, P2O5, K2O, Na2O, CaO, Ivoclar Vivadent Schaan, Liechtenstein
Glass Ceramic F, 3% TiO2, and pigments, water, alcohol,
chloride

endocrowns were etched for 60 s with 60% hydrofluoric acid
gel (Ultradent Products Inc., UT, USA); and GC, SH and BC
endocrowns were sandblasted with 25–50 μm Al2O3 powder
(0.15 MPa/1.5 bar pressure). A silane coupling agent (3M
ESPE Dental Products, St. Paul, MN, USA) was applied to
the endocrown intaglio surfaces and allowed to dry for 60 s,
after which an adhesive agent was applied for 20 s and air-
dried.
All specimens were cemented with a dual-cure adhesive
resin cement (RelyX U200, 3M ESPE Dental Products St.
Paul, USA). Restorations were seated on the corresponding
teeth, and excess material was removed with the help of a
probe. The resin cement was light-activated for 20 s at each
of the crown surfaces to complete the polymerization.
Samples were stored in distilled water at 37 °C.
1500, Tokyo, Japan), and failure types were classified under
four headings (Fig. 3), as follows:
Type I: Cohesive failure within the endocrown material
1 Adhesive failure between endocrown and dentin
2 Cohesive failure within enamel or dentin
3 Fracture extending to the root surface
Fractures above the cementoenamel junction can be
reparable, and fractures below the cemento-enamel junc-
tion and extending up to the root were considered to be
irreparable [6].
Statistical analysis

Data analysis was performed using the statistical soft-

Thermocycling and fracture test
S pec i m e ns w e r e ther m oc yc l ed (S D M ec ha t r on i c
Thermocycler, Germany) between 5 and 55 °C (5000 cycles,
30-s dwell time) and then subjected to fracture testing using a
Universal Testing Machine (Schimadzu, IG-IS Kyoto, Japan).
Half of the samples were subjected to an axial load applied
with a 5-mm dia. round stainless steel head directed at the
central fissure perpendicular to the occlusal plane (axial
load—Fig. 2a), and the other half was subjected to a lateral
load applied with a V-shaped stainless steel head directed at
the tooth-endocrown interface (lateral load–Fig. 2b).
Specimens were placed on the base of the machine, and a load
was applied at a cross-head speed of 1 mm/min. Maximum
force at fracture was recorded in Newton.
Following fracture testing, CAD/CAM restoration speci-
mens were examined under a stereomicroscope (Nikon SMZ
ware IBM SPSS V23 (SPSS Inc., Chicago, IL, USA).
Distribution of data was checked with a Shapiro-Wilk
test. Normality of data distribution between groups was
compared with one-way ANOVA. Homogeneity of group
variances was checked with a Levene’s test. Tukey’s test
was used to evaluate homogeneously distributed data
(lateral forces), and the Tamhane T2 test was used to
evaluate non-homogeneous data (axial forces) (Minitab
Software V.17, State College, PA, USA). A level of P
< 0.05 was considered statistically significant. Fracture-
strength (FS) data was subsequently subjected to Weibull
reliability analysis for the calculation of probability of
survival with Weibull modulus as described previously.
Weibull modulus and coefficients of determination (R2)
were calculated to determine the fitness of the regression
line and generated predicted maximum FS values for
99% probability of survival.
 Clin Oral Invest

Fig. 1 a Design of endocrown

using the Cerec database to be
able to restore the teeth to their
original anatomy after
preparation. b Intaglio view of
endocrown after milling. c
Occlusal view of endocrown after
milling

Results
Significant differences were found between the fracture
strengths of the tested materials under both axial and lateral
loading. Under axial loading, group BC had the highest frac-
ture strength (2072.77 ± 454.65 N), followed by group IPS
(1913.84 ± 501.18), and group SH had the lowest fracture
strength (1068.36 ± 214.91 N). Under lateral loading, group
IPS had the highest fracture strength (670.79 ± 129.68 N), and
group GC had the lowest fracture strength (391.00 ± 86.35 N)
(Table 2).
Predicted fracture-strength (FS) values at 99% reliability,
Weibull modulus, and R2 values are given in Fig. 4 a and b.
According to Weibull analysis, group VE exhibited the
highest reliability (7.62) under axial forces, whereas group
IPS exhibited the highest reliability (4.68) under lateral forces.
Evaluation of failures indicated type 1 failure to be the most
prevalent under both axial and lateral loading, with no statis-
tically significant differences between the groups (Fig. 5).

Discussion

This in vitro study compared the fracture strength of

Fig. 2 Application of fracture strength test a axial loading b lateral
loading
endocrowns produced from different materials using CAD/
CAM technology to treat teeth with excessive loss of tooth
structure. Both material and loading had statistically signifi-
cant effects on fracture strength; thus, the study’s null hypoth-
eses were rejected.
Clin Oral Invest

Fig. 3 Representative failure

types of endocrowns. a Type I:
cohesive failure within the
endocrown material. b Type II:
adhesive failure between
endocrown and dentin. c Type III:
cohesive failure within enamel or
dentin. d Type IV: fracture
extending to the root surface

Teeth with severe coronal hard tissue loss due to extensive
caries or root-canal treatment have typically been restored
using a full-coverage crown with a post-and-core retainer
[6]. Endocrown restorations have been developed as an alter-
native to post-core systems in order to avoid compromising
the integrity of remaining tooth tissue. A systematic review
and meta-analysis of fracture strengths indicated endocrowns
perform better than post-core systems and other traditional
treatment options such as direct composite resin restorations,
inlays and onlays [3]. Not only do endocrowns conserve tooth
structure, they also offer enhanced bonding capacity and bet-
ter hygiene control because their supragingival margins rest
on peripheral enamel that has not been subjected to root-canal
preparation [16].
Endocrowns have been recommended for use in the reha-
bilitation of endodontically treated incisors [17, 18], premo-
lars [19, 20], and molars [21, 22] with severe crown damage.
However, a clinical study by Bindl et al. [23] recommended
against the use of endocrown restorations for premolar teeth
because their relatively smaller adhesion surface area and
greater restoration height as compared with molar teeth com-
promised the endocrown’s mechanical properties. Therefore,
the present study was conducted using mandibular molars.
The depth of the pulp-chamber extension required by
endocrown restorations has not been precisely defined. Bindl
and Mörmann [5] stated that while cavity depth could not be
standardized exactly, it should range between 1 and 4 mm.
However, Hayes et al. [24] reported that molar teeth with a

Table 2 Fracture strength results (mean ± standard deviation) (Newton) of experimental groups after axial and lateral loading and minimum-maximum
values

Groups Axial loading Lateral loading

Mean ± standard deviation Minimum- Mean ± standard deviation Minimum-

maximum maximum

IPS 1913.84ab ± 501.18 1267.61–2791.02 670.79c ± 129.68 518.3–944.18

VE 1369.5bc ± 212.97 934.9–1624.69 496.59ab ± 111.27 336.37–725.15
GC 1406.56bc ± 369.49 900.41–2077.98 391a ± 86.35 272.93–539.87
SH 1068.36c ± 214.91 818.97–1539.94 543.43abc ± 133.89 366.29–768.93
BC 2072.77a ± 454.65 1499.35–2835.59 615.61bc ± 191.97 334.59–968.42
P < 0.001

P < 0.05
Different lower-case letters in each column indicate statistically significant differences
 Clin Oral Invest

Fig. 4 Probability plot for the

tested materials calculated using
Weibull distribution function for
all groups after a axial loading b
lateral loading. Vertical axis is
survival probability, and
horizontal axis is fracture strength

pulp chamber of 2 mm in depth showed a higher fracture deeper cavities tended to result in more irreparable fractures.
resistance than teeth with deeper cavities, and the authors rec- Therefore, this study used a standardized pulp-chamber depth
ommended that extension cavities not exceed 2 mm because of 2 mm.

Fig. 5 Frequencies of failure

modes in percentages under axial
and lateral loading
Clin Oral Invest
Soares et al. [25] reported that the periodontal ligament
alters restoration fracture resistance and fracture mode by act-
ing as a stress absorber. Although some studies in the literature
have simulated a periodontal ligament [18, 26], challenges
have been reported in terms of thickness standardization and
stability [27, 28]. An in vitro study by Marchionatti et al. [29]
found that simulation of a periodontal ligament did not affect
the fracture resistance of roots treated with fiber posts.
However, in order to better mimic actual tooth behavior
against masticatory forces, samples in this study included a
simulated periodontal ligament.
According to Bindl et al. [23], given that adhesive failure is
the main type of endocrown failure, studies examining
endocrown durability should examine performance under
both compressive and shear forces. In this study, static loading
was evaluated by applying an axial force at a 90-degree angle
along the long axis, because lateral forces are always accom-
panied with axial forces during chewing function [30].
Under axial loading, the highest mean fracture value
was found in the Brilliant Crios group (2072.77 ± 454.65
N), followed by the IPS e.max CAD (1913.84 ± 501.18 N),
GC Cerasmart (1406.56 ± 369.49 N), Vita Enamic (1369.5
± 212.97 N), and Shofu (1068.36 ± 214.91 N) groups.
Because Brilliant Crios has a relatively low elastic modu-
lus (10 GPa) that is close to that of dentin (11–19 GPa),
both the restoration and underlying dentin undergo a sim-
ilar degree of plastic deformation, which results in an ap-
plied load being transmitted to the underlying dentin rather
than accumulating in the restoration. Moreover, the simi-
larity in the chemical composition of the reinforced com-
posite block, resin cement, and adhesive bonding agent
ensures a high bond capacity among these materials.
According to the manufacturer of Single Bond Universal,
the adhesive exhibits higher bonding to composite (30
MPa) than to glass-ceramic (8 MPa) (3 M ESPE, 2016)
because the bonding agent’s monomers penetrate the com-
posite’s polymerized resin matrix to provide a combination
of chemical and mechanical bonding between the restora-
tion and the bonding agent, as the chemical chains formed
within the resin matrix of the composite lead, ideally, to
“interlooped” mechanical bonding. The superior fracture
strength of Brilliant Crios observed in the present study
could be attributed to this high level of bonding [31].
Interestingly, despite the fact that GC Cerasmart also
has an elastic modulus close to that of dentin and contains
the same inorganic filler ratio as Briallant Crios, the pres-
ent study found GC Cerasmart had lower fracture-strength
values (1406.56 ± 369.49 N) than Brilliant Crios (2072.77
± 454.65 N) (P < .05). Silane materials vary in terms of
adhesive strength, with the strongest adhesion occurring
with silica, glass and quartz, which condense on the sub-
strate to form strong siloxane (-S-O-Si-) linkages with sur-
face hydroxyl groups [32]. While Brilliant Crios and
Cerasmart both contains barium glass and SiO2, the parti-
cle size of the barium glass found in Brilliant Crios (<
1.0 μm barium glass) is smaller than that found in
Cerasmart (300 nm). This may explain the differences in
fracture strength observed between the two materials, con-
sidering the potential increase in fracture strength achieved
by decreasing the size of nanofiller particles in CAD/CAM
blocks previously reported by Yamaguchi et al. [33].
In a study by Kanat Ertürk et al. [18] comparing the fracture
strength of endocrown restorations of maxillary central inci-
sors fabricated from different CAD/CAM ceramics and with
different preparation depths (3 mm and 6 mm), IPS e.max
CAD endocrowns were found to have mean fracture strength
values higher than those of Vita Enamic at both depths of
preparation (IPS e.max: 6 mm, 225.08 ± 125.36 N; 3 mm,
244.11 ± 119.77 N; Vita Enamic: 6 mm, 182.38 ± 106.52
N; 3 mm, 172.12 ± 135.64 N). El Ghoul et al. [34] evaluated
the fracture strength of endocrowns fabricated from three
CAD/CAM materials (IPS e.max CAD, Cerasmart and Vita
Suprinity) under axial and lateral loading. They found that of
the three, IPS e.max CAD had the highest fracture resistance;
however, the differences between the fracture loads of IPS
e.max CAD (axial, 2914 ± 205 N; lateral, 1516 ± 202 N)
and Cerasmart (axial, 2752 ± 242 N; lateral, 1210 ± 97 N)
were not statistically significant. The findings of these previ-
ous studies are in line with those of the present study.
Weibull analysis of fracture strength may be used to plot
fracture estimates of dental material in order to predict
material survival [35], with a higher Weibull modulus in-
dicating greater material reliability. Accordingly, the pres-
ent study found group VE to have the highest and group
GC to have the lowest predicted fracture strength under
axial forces, whereas group IPS was found to have the
highest and group GC the lowest predicted fracture
strength under lateral forces.
Stereomicroscopic analysis of failure modes showed the
majority of failures to be type I (cohesive) failures under
both axial and lateral loading. Under appropriate condi-
tions, type I restoration failures can be repaired using resin
composites, and type II (adhesive) failures can be repaired
using resin cements following surface reconditioning.
Although the clinical longevity of recemented restorations
is unknown, it is likely that they are more susceptible to
torque forces than restorations that have undergone mate-
rial repair [6].
This study had a number of limitations. First, although
thermocycling was performed to simulate conditions in
the oral environment, it was limited to 5000 cycles.
Additional studies should simulate long-term oral usage
in order to determine the durability of the material.
Second, the study did not use artificial saliva or dynamic
force to simulate chewing cycles. Further studies should
address these limitations.

Conclusions
Within the limitations of this study, it may be stated that:
& All the hybrid blocks tested were found to have acceptable
fracture strength, and may thus be preferable to IPS e.max
for endocrown restorations because their lower hardness
values may help protect natural tooth antagonists from
occlusal wear.
& Under axial forces, Brilliant Crios has the highest fracture
strength and Shofu has the lowest fracture strength.
& Under lateral forces, IPS e.max CAD group has the
highest fracture strength and GC Cerasmart has the lowest
fracture strength.
& Fractures upon axial and lateral loading are mainly type I
failures that are repairable.
Acknowledgments The authors wish to thank GC Group, Shofu Dental,
and Coltene Group for their experimental support.
Funding information This study was funded by the Scientific Research
Projects Support Commission of Ondokuz Mayis University (grant No.
PYO. DIS.1904.18.005).
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethics committee approval The study was approved by the Ondokuz
Mayis University Institutional Review Board’s Human Ethics Committee
(OMU-TAEK 2017/92).
Informed consent Informed consent was obtained from the participants
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