RESEARCH AND EDUCATION

Examining the adaptation of modified endocrowns prepared

with CAD-CAM in maxillary and mandibular molars: A
microcomputed tomography study
Can Topkara, DDSa and Ali Keleş, DDS, PhDb

Endocrowns have become ABSTRACT

popular for restoring exten- Statement of problem. Endocrowns have been reported to be successful restorations for
sively damaged endodonti- endodontically treated molars. However, comparisons between maxillary and mandibular molars,
cally treated teeth.1 The with different pulp chamber configurations are lacking. Information on the influence of venting
endocrown is a monobloc on the adaptation of endocrowns is also lacking.
restoration retained by Purpose. The purpose of this in vitro study was to evaluate the adaptation of endocrowns in
extension into the pulp maxillary and mandibular molars by means of microcomputed tomography (mCT).
chamber and with a shoulder
Material and methods. Mandibular and maxillary first molars were divided into 4 groups (n=10):
margin2-5 and has been re- ManE: mandibular endocrown; ModManE: modified mandibular endocrown; MaxE: maxillary
ported to be successful for endocrown; and ModMaxE: modified maxillary endocrown. Endocrowns were produced by using
extensively damaged computer-aided design and computer-aided manufacture (CAD-CAM). Modification was carried
endodontically treated mo- out on the part of the endocrown that extended into the pulp chamber by preparing vents. The
lars.1,6 Macroretention is specimens were cemented and scanned by using mCT, the images reconstructed, and the
provided by the axial walls of internal and marginal adaptation examined. Statistical analyses were performed by using a 3-
the pulp chamber and micro- way ANOVA, 2-way ANOVA, and the independent samples t test (a=.05).
retention from adhesive Results. ManE displayed better mean ±standard deviation internal adaptation (182 ±59 mm) than
cementation, making the MaxE (215 ±55 mm) (P<.01). Regardless of the groups, the pulpal floor was the area with the poorest
restoration suitable for teeth fit (P<.001). The marginal gap of mandibular molars (91 ±20 mm) was lower than that of maxillary
molars (110 ±26 mm) (P<.05). The effect of modifying endocrowns on the marginal gap was not
with short or severely curved
found to be statistically significant (P>.05).
roots, for which an end-
odontic post cannot be used.7 Conclusions. Internal and marginal adaptation of endocrowns differ between maxillary and
Endocrowns are typically mandibular molars. (J Prosthet Dent 2021;-:---)
provided with computer-
aided design and computer-aided manufacturing decreases fracture resistance.11 Adaptation can be
(CAD-CAM) technology and provide a restoration with determined with microcomputed tomographic (mCT)
excellent esthetics. imaging,12 a noninvasive, nondestructive, high-
The adaptation of restorations, both marginal and resolution technology that allows accurate measure-
internal, plays a significant role in their clinical ments. The adaptation of the endocrown can be inves-
outcome.8-10 Poor marginal adaptation increases the tigated from various angles, both in 2D and 3D, together
decomposition of adhesive cement,8 and increased or separately. Also, quantitative and qualitative mea-
cement thickness from poor internal adaptation surements can be made by using mCT.13

Supported by Ondokuz Mayıs University Research Fund, grant #1904.17.020.

a
Research Assistant, Department of Endodontics, Faculty of Dentistry, Ondokuz Mayıs University, Samsun, Turkey.
b
Associate Professor, Department of Endodontics, Faculty of Dentistry, Ondokuz Mayıs University, Samsun, Turkey.

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Clinical Implications
Endocrowns display better internal and marginal
adaptation in mandibular molars. Modification of
vents to the retentive part of endocrowns does not
improve internal and marginal adaptation in
mandibular and maxillary molars.
The marginal and internal adaptation of the endo-
crown is influenced by the cavity design and depth and
the restorative material.12,14-19 The cross-sectional shape
of the pulp chamber varies between maxillary and
mandibular molars, being typically trapezoidal in
mandibular molars and triangular in maxillary molars.20
However, a detailed examination of the cross-sectional
differences of the pulp chamber of the mandibular and
maxillary molar in the adaptation of the endocrown is
lacking.
Venting can improve the seating of restorations21,22
by assuring a uniform distribution of the luting cement
and relieving intracoronal pressure. To the authors’
knowledge, information on the influence of venting on
the adaptation of the endocrown is lacking. Thus, the aim
of this in vitro study was to describe the influence of the
cross-sectional shape of the pulp chamber and of venting
on the internal and the marginal adaptation of the
endocrown by using mCT. The null hypotheses were that
no differences would be found in internal and marginal
discrepancy between mandibular and maxillary molar
endocrowns, with or without venting.
MATERIAL AND METHODS
After approval of the research protocol by the local ethics
board of Ondokuz Mayıs University (KAEK-
B.30.2.ODM.0.20.08/789), 20 maxillary and 20 mandib-
ular first molars were selected. The inclusion criteria were
a developed root structure, no caries or visible fracture
lines, and similar buccolingual and mesiodistal di-
mensions (maximum difference of 10%), measured with
digital calipers (47252; Cen-tech). The ages of the donor
patients were unknown. After removal of the soft tissue
residuals on the teeth with an ultrasonic scaler, the teeth
were kept in distilled water at room temperature.
Endodontic access cavities were prepared in accor-
dance with the morphologies of the pulp chambers of all
teeth, and, for standardization, all procedures were per-
formed by a single operator (C.T.). Rotary files (Protaper
Next; Dentsply Sirona) were used for root canal prepa-
ration irrigated with 5 mL 5.25% NaOCl. A resin sealer
(AH Plus; Dentsply Sirona) and gutta percha cones
(Protaper Next; Dentsply Sirona) were used to seal the
prepared root canals. Then, a thin layer of a flowable
composite resin (Filtek Ultimate Flowable Restorative;
THE JOURNAL OF PROSTHETIC DENTISTRY
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3M ESPE) was applied to the canal orifices. The crowns
were removed by cutting 1 mm above the enamel-
cement junction with a linear precision saw (IsoMet
5000; Buehler) under water cooling.
The internal edge angles of the pulpal chamber were
prepared to create a butt margin. The intaglio walls of the
cavity were smoothed with a tapered fissure diamond
rotary instrument (845KR-026; SS White), avoiding sharp
edges, corners, or undercuts on the intaglio surface.
The specimens were scanned by using an intraoral
scanner (CEREC Omnicam; Dentsply Sirona), and the
cavity depth (distance between the butt margin and pulp
chamber floor) of specimens was measured by using a
dental CAD software program (CEREC SW 4.4.4;
Dentsply Sirona). Four homogeneous groups (n=10) in
terms of cavity depth were established: ManE: mandib-
ular endocrown; ModManE: modified mandibular
endocrown; MaxE: maxillary endocrown; and ModMaxE:
modified maxillary endocrown.
The dimensions of each specimen were measured by
using an intraoral scanner (CEREC Omnicam; Dentsply
Sirona). The endocrowns were automatically designed by
the software program (CEREC AC SW 4.4.4; Dentsply
Sirona) by using the Biogeneric Individual tool. The
cement gap was set to 120 mm and the margin thickness
to +50 mm in accordance with the manufacturer’s in-
structions. The Bio Jaw tool (CEREC AC SW 4.4.4;
Dentsply Sirona) was used for restoration positioning
and standardization. The restorations were milled from
14-size ceramic blocks (CEREC Blocs; Dentsply Sirona)
by using a milling unit (CEREC MC XL; Dentsply Sirona).
The entire process, except for preparing the vents, was
applied to all the specimens as a standard protocol.
Following endocrown fabrication, the specimens of
ModManE and ModMaxE were modified by establishing
vents on the retentive part of the endocrown sitting on
the central cavity. Vents were prepared as grooves 0.8
mm wide and 0.4 mm deep (Fig. 1).
All retention surfaces of the restorations were
roughened by using 9.5% hydrofluoric acid (Porcelain
Etchant 9.5; Bisco) for 120 seconds. Then, the restora-
tions were irrigated with water for 60 seconds and air-
dried. Silane (Silane; Ultradent Products, Inc) was
applied with a brush to the retention surfaces of the
restorations for 60 seconds and then air-dried.
The enamel surfaces of all the teeth were selectively
roughened by using 37% phosphoric acid for 30 seconds.
An adhesive agent (Single Bond Universal; 3M ESPE)
was applied to all the cavity surfaces of the teeth with a
bond brush and then thinned with air. Resin cement
(Maxcem Elite; Kerr Corp) was applied inside the cavity
and to the intaglio surface of the restoration. The resto-
rations were seated in the cavity by applying finger
pressure on the occlusal surface. Extruded cement was
polymerized with light (Elipar S10; 3M ESPE) for 2
Topkara and Keleş
- 2021
Figure 1. Schematic view of endocrowns in groups. A, Mandibular endocrown. B, Modified mandibular endocrown. C, Maxillary endocrown. D,
Modified maxillary endocrown.
seconds and then removed. In accordance with the
manufacturer’s instructions, the polymerization was
completed by applying light treatment for 20 seconds to
each surface of the crown.
The mCT scanner (SkyScan 1172; SkyScan) scanning
parameters were as follows: accelerating voltage of 80 kV;
current of 124 mA; exposure time of 2500 ms per frame;
Al +Cu filter, and rotation step at 0.6 degrees for a 180-
degree rotation; the image pixel size was 11.9 mm.
Approximately 1200 cross-sections were made from each
specimen. The images obtained were reconstructed by
using a software program (NRecon v.1.6.4; Bruker). Three
symmetrical sections were selected from the core region of
each specimen in the mesiodistal (MD) and buccolingual
(BL) directions (Fig. 2). To analyze the internal adaptation,
9 points (N1−N9) were selected on each of the MD and BL
sections (Fig. 3). N1, N2, N8, and N9 were measured as
cervical seat, N3 and N7 were measured as axial walls, and
N4, N5, and N6 were measured as pulpal floor. In total, 54
points were selected to measure the internal adaptation of
each specimen. The gap between the restoration and tooth
dentin at the selected points was measured manually in
micrometers and recorded.
Topkara and Keleş
3
To examine marginal adaptation, the same sections
used in internal adaptation were used. Moreover, 2 cross-
sections joining endocrown corners were selected (Fig. 2).
In marginal adaptation measurements, 16 points, 3
points on each of the 4 sides; buccal (B1, B2, B3), lingual
(L1, L2, L3), mesial (M1, M2, M3), and distal (D1, D2,
D3) and 1 point in each of the 4 corners (C1, C2, C3, C4),
were selected for each specimen. The C1 was the buccal
corner, and a clockwise direction was followed in each
specimen (Fig. 2B). The gap between the restoration and
dentin of the tooth at selected marginal points was
measured manually in micrometers and recorded.
The data were analyzed by using a statistical software
program (IBM SPSS Statistics, v23; IBM Corp). Normality
assumption of data and homogeneity of variances were
checked with the Shapiro-Wilk and Levene tests,
respectively. A comparison of gap values at the internal
adaptation points in terms of cross-section, modification,
and teeth was performed by using 3-way ANOVA. For
each cross-section, the values obtained from the points
were compared by using 2-way ANOVA by modification
status and tooth. The independent samples t test was
used to compare marginal gap values according to tooth
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Figure 2. A, Selected sections in mesiobuccal and buccolingual directions for internal adaptation. B, Additional sections (C1-C3 and C2-C4) for marginal
adaptation.

type and the aspect of modification. The analysis results

were expressed as mean ±standard deviation (a=.05).

RESULTS
Three-way ANOVA showed that the internal discrep-
ancy values were significantly affected by modification
(P=.043) and tooth type (P<.001). Significant interactions
were found among the selected sections, modification,
and tooth type (P=.009) (Table 1). The mean ±standard
deviation internal discrepancy values of ManE (182 ±59
mm) were lower than those of MaxE (215 ±55 mm)
(P<.01). Moreover, the internal gap was found to be 167
±23 mm in ModManE and 206 ±40 mm in ModMaxE
(P<.01). No statistically significant difference was found Figure 3. Locations determined for internal adaptation.
between ManE and ModManE or between MaxE and
ModMaxE in terms of the internal gap values (P>.05).
The mean and standard deviations of the internal dis- (P<.001). In the MaxE and ModMaxE groups, this order was
crepancies in the measured areas for all groups are listed in as follows: pulpal floor>cervical seat>axial wall (P<.001).
Table 2. Two-way ANOVA showed statistically significant The effect of tooth type and modification on the
difference among tooth types and modification at some points where marginal discrepancies were measured is
sites. In the ManE and ModManE groups, the internal presented in Table 3. The independent samples t test
discrepancy gap at different sites showed that the length showed statistically significant difference between tooth
order was as follows: pulpal floor>cervical seat=axial wall types at some points (P<.05).

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Table 1. Results of 3-way ANOVA Table 2. Mean ±standard deviations of cavity depth (mm) and internal
Sum of Mean gaps (mm)
Source Squares df Square F P Cavity Pulpal Floor Cervical Seat Axial Walls
Selected sections 0.013 5 0.003 1.299 .265 Groups Depth (N4,N5,N6) (N1,N2,N8,N9) (N3,N7)
Modification 0.008 1 0.008 4.136 .043 Mandibular 2.44 ±0.37a 248 ±71DH 146 ±34CF 130 ±45CEF
Tooth type 0.077 1 0.077 37.867 <.001 endocrown
Modified 2.39 ±0.43a 234 ±51H 139 ±24FG 123 ±32EG
Sections×modification 0.008 5 0.002 0.796 .554
mandibular
Sections×tooth type 0.009 5 0.002 0.887 .491 endocrown
Modification×tooth type 0.001 1 0.001 0.258 .612 Maxillary 2.86 ±0.43a 294 ±53B 178 ±43A 159 ±45CEF
Sections×modification×tooth 0.032 5 0.006 3.175 .009 endocrown
type Modified maxillary 2.72 ±0.56a 281 ±59BD 173 ±35A 136 ±77CE
endocrown
Significant association (P<.05) indicated in bold.
Total d 264 ±63a 159±36b 137±54c

In each column and row, different superscript uppercase letters indicate statistically
significant difference between groups (P<.001). Different lowercase superscript letters in
same column and row depict statistically significant difference (P<.001).

Table 3. Marginal adaptation values (mean ±standard deviation) of measured points (mm) in mandibular and maxillary molars
Buccal Lingual Mesial Distal Corners
Tooth
Types B1 B2 B3 P1 P2 P3 M1 M2 M3 D1 D2 D3 C1 C2 C3 C4 Total
Mandibular 107 ±53 84 ±24 98 ±56 91 ±30 103 ±42 98 ±36 94 ±49 88 ±42 75 ±21 90 ±43 95 ±49 95 ±39 76 ±24 81 ±51 91 ±51 81 ±38 91 ±20
molar
Maxillary 107 ±62 103 ±47 116 ±57 116 ±57 115 ±49 122 ±55 92 ±35 85 ±38 83 ±47 119 ±72 126 ±59 113 ±53 112 ±59 121 ±61 101 ±45 130 ±58 110 ±26
molar
P .988 .130 .327 .094 .401 .113 .829 .817 .477 .141 .077 .230 .020 .030 .528 .003 .016

Significant differences (P<.05) indicated in bold.

The mean ±standard deviation marginal gap values of narrower angles than those of the mandibular molar.20
MaxE (110 ±26 mm) were found to be higher than those To examine the influence of morphological differences
of ManE (91 ±20 mm), and the difference was statistically on the adaptation, groups as similar as possible were
significant (P<.05). No statistically significant difference established. Even though the cavity depth can influence
was found between modified (95 ±22 mm) and unmod- the retention and stability of the endocrown by affecting
ified endocrowns (106 ±27 mm) in terms of the marginal internal cavity volume and surface area, a consensus on
gap values (P>.05). the influence of cavity depth on the adaptation of
endocrowns is lacking. Gaintantzopoulou and El-Dam-
anhoury15 reported that the cavity depth affected internal
DISCUSSION
adaptation. However, cavity depth has been reported to
The null hypothesis was partially accepted because, while have no significant effect on internal adaptation.12,14 In
mandibular endocrown showed better internal and the present study, except for the cross-sectional
marginal discrepancy than maxillary molar endocrowns, morphology of the pulp chamber and the modification
no difference was found between restorations with or performed on the restorations, possible factors that may
without vents. Endocrowns are becoming popular for the have influenced adaptation were eliminated.
restoration of severely damaged endodontically treated The present study compared the internal discrepancy
teeth.6 Marginal and internal adaptation are both between mandibular and maxillary molars, with
important parameters that may affect the success of these mandibular molars displaying smaller internal gaps than
restorations.8 A consensus or a standard for measuring maxillary molars (P<.01). This may be explained by
the adaptation of endocrowns is lacking, and the adap- the narrower and more complex pulpal chamber of
tation of endocrowns has been examined by using maxillary molars, leading to worse internal adaptation.
several methods, including replica,16 scanning,16,18 ste- However, although the 3-way ANOVA indicated that the
reomicroscope,4 scanning electron microscopy,5,19 and internal adaptation values were significantly affected by
mCT techniques.12,15 mCT has emerged as the most vent modification (P=.043), this limited effect did not lead
promising because it provides accurate, high-resolution to a significant difference between the modified and
images of the adaptation of the restoration without de- unmodified groups in mandibular and maxillary molars.
stroying the specimen. Consistent with the present study, the internal gap on
The morphological characteristics of the pulp chamber the pulpal floor has been reported to be greater than at
are different in mandibular and maxillary molars, with other sites.12,15,18 The present study found that the pulpal
the pulp chamber corners of the maxillary molar having floor of maxillary molars displayed bigger gaps than those

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in mandibular molars, possibly because scanning the pulp
chamber floor of a maxillary molar is challenging because
of the narrower and more complex structure of the pulpal
chamber, its depth, and shadows during scanning. Addi-
tionally, the flat pulpal floor of the endocrown may be
overmilled because of the size of the milling instruments.18
Groten et al23 stated that measurements should be
performed on a minimum of 10 randomly selected points,
and Gassino et al24 reported that measurements should be
performed all around the crown. In the present study,
measurements were performed at 16 points around the
endocrown. The results of this study showed that
mandibular molars displayed smaller marginal gaps than
maxillary molars (P<.05). Moreover, the performing vents
did not yield a statistically significant difference in either
mandibular or maxillary molars. Although it has been re-
ported that a marginal gap of less than 120 mm is clinically
acceptable in terms of longevity of the restoration,25
different luting cements have different dissolution and
microleakage behaviors for varying marginal fit values.10
According to the results of this study, marginal gap
values more than 120 mm were observed mostly in
maxillary molars. Minimizing the marginal gap is impor-
tant because an increase in the marginal gap results in an
increase in the amount of cement exposed to oral fluids,
thus increasing the cement dissolution and microleakage.
Limitations of the study included the use of a single
CAD-CAM system, restorative material, and luting
cement. Other systems or materials might result in
different outcomes. Additionally, the horizontal marginal
discrepancies were not assessed. Further studies are
suggested to investigate the vertical and horizontal
marginal and internal adaptation of endocrowns manu-
factured with different systems and materials.
CONCLUSIONS
Based on the findings of this in vitro study, the following
conclusions were drawn:
1. Variations in the cross-sectional morphology of the
pulpal chambers of maxillary and mandibular mo-
lars affected the adaptation of endocrowns prepared
by using CAD-CAM.
2. Modifications to the retentive parts of endocrowns
do not affect the adaptation of the restoration.
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Corresponding author:
Dr Ali Keleş
Department of Endodontics
Faculty of Dentistry, Ondokuz Mayıs University
Samsun 55400
TURKEY
Email: alikeles29@yahoo.com
Copyright © 2020 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2020.12.003
Topkara and Keleş