materials

Article
The Influence of Ferrule Design and Pulpal Extensions on the
Accuracy of Fit and the Fracture Resistance of
Zirconia-Reinforced Lithium Silicate Endocrowns
Samah Saker 1 , Ahmed Yaseen Alqutaibi 2,3, * , Mohammed Ahmed Alghauli 3 , Danya Hashem 4 ,
Sary Borzangy 2 , Ahmed E. Farghal 2 , Ahmad A. Alnazzawi 2 , Sultan Ainoosah 2 and Mohammed H. AbdElaziz 2,5

1 Fixed Prosthodontics Department, Faculty of Dentistry, Mansoura University, Mansoura 35516, Egypt;
[email protected]
2 Substitutive Dental Sciences Department, College of Dentistry, Taibah University,
Al Madinah 41311, Saudi Arabia; [email protected] (S.B.); [email protected] (A.E.F.);
[email protected] (A.A.A.); [email protected] (S.A.); [email protected] (M.H.A.)
3 Prosthodontics Department, College of Dentistry, Ibb University, Ibb 70270, Yemen; [email protected]
4 Restorative Dental Sciences Department, College of Dentistry, Taibah University,
Al Madinah 41311, Saudi Arabia; [email protected]
5 Fixed Prosthodontics Department, Faculty of Dental Medicine, Al-Azhar University, Cairo 11884, Egypt
* Correspondence: [email protected]

Abstract: The study aimed to assess the marginal, axial, and internal adaptation, as well as the
fracture resistance of zirconia-reinforced lithium silicate (ZLS) endocrowns with varying pulpal inlay
extensions and marginal geometry. Sixty extracted maxillary first molar teeth were divided into six
groups (n = 10) according to pulpal inlay extension and marginal configuration. The first three groups
(J2, J3, and J4) utilized prepared teeth for endocrowns without ferrule design and 2 mm, 3 mm, and
4 mm pulpal extensions, respectively. The second three groups (F2, F3, and F4) utilized prepared teeth
Citation: Saker, S.; Alqutaibi, A.Y.; with 1 mm shoulder margins and 2 mm, 3 mm, and 4 mm pulpal extensions. The endocrowns were
Alghauli, M.A.; Hashem, D.; fabricated from ZLS blocks using CAD/CAM milling technology. After cementation, the specimens
Borzangy, S.; Farghal, A.E.; underwent thermal aging for 5000 cycles and were evaluated for marginal adaptation. Using a
Alnazzawi, A.A.; Ainoosah, S.; universal testing machine, the fracture resistance was tested under quasistatic loading (1 mm/min).
AbdElaziz, M.H. The Influence of
Two-way ANOVA and the Tukey’s post hoc test were employed for data analysis (p ≤ 0.05). The
Ferrule Design and Pulpal Extensions
results of this study revealed that endocrowns without ferrule exhibited superior fracture strength
on the Accuracy of Fit and the
than a 1 mm ferrule design p < 0.05, irrespective of the inlay depth. All designs with and without
Fracture Resistance of Zirconia-
ferrule and all inlay depths showed clinically acceptable marginal and internal fit. The conventional
Reinforced Lithium Silicate
Endocrowns. Materials 2024, 17, 1411.
endocrown design without ferrule and 2 mm inlay depth showed the lowest surface gap. The
https://doi.org/10.3390/ma17061411 pulpal surface showed the highest discrepancy among all groups compared to the other surfaces.
Endocrowns without ferrule are more conservative and have higher fracture strength than 1 mm
Academic Editors: Han-Chao Chang
ferrule designs; extending the inlay depth showed a significant increase in fracture resistance of the
and Satoshi Yamaguchi
1 mm ferrule design, but not for the conventional design without ferrule and 2 mm inlay depth. All
Received: 16 February 2024 groups exhibited a high auspicious fracture strength value for molar endocrown restorations.
Revised: 13 March 2024
Accepted: 18 March 2024 Keywords: endocrowns; zirconia-reinforced lithium silicate; fracture resistance; accuracy; marginal
Published: 20 March 2024 and internal fit

Copyright: © 2024 by the authors.

1. Introduction
Licensee MDPI, Basel, Switzerland.
This article is an open access article The severity of tooth structure loss of endodontically treated teeth (ETT) can signifi-
distributed under the terms and cantly impact the treatment’s prognosis; the second most common cause of ETT extraction
conditions of the Creative Commons is vertical root fracture, primarily associated with post-placement [1,2]. The endodontic
Attribution (CC BY) license (https:// access cavity preparation removes tooth structure, weakens the cusps, and reduces their
creativecommons.org/licenses/by/ strength [3]. The clinical considerations of successful ETT are a combination of periodon-
4.0/). tal health and endodontic restoration perfection [4,5]. Although there is no evidence of

Materials 2024, 17, 1411. https://doi.org/10.3390/ma17061411 https://www.mdpi.com/journal/materials

Materials 2024, 17, 1411 2 of 14

reduced sensory function and proprioception of ETT, the non-vital teeth may receive a
higher occlusal load than the vital teeth, as reported in a clinical study [6], so ETT possesses
a higher probability of damage. Hence, enhancing ETT strength after the coronal seal is
essential to guarantee clinical long-term survival [7].
Various procedures can be used to restore ETT, including direct composite restorations,
indirect composite restorations, and metal and ceramic restorations. Many clinicians prefer
indirect, full-coverage methods [8]. ETT with an extensive loss of hard tissue coronally
might require a post-and-core crown, and that might be the only option; however, the
presence of enough tooth structures and a minimum of two remaining axial walls would
omit the need for root canal posts [9,10]. Recent advancements in dental adhesive materials
and restoration fabrication technologies such as CAD/CAM, along with the development
of contemporary ceramic materials, have led to the adoption of new and more advanced
restorative approaches in dentistry. One of these evolutionary approaches is endocrown
restoration, a conservative treatment approach that mitigates the failure risk by avoiding
intracanal post-placement [11]. The endocrown is a monobloc all-ceramic restoration
comprising a circumferential flat margin and an inlay cavity in the middle fitting the dental
pulp chamber. It utilizes adhesive bonding and the available surface area in the pulp
chamber to ensure the stability and retention of the restoration. This approach adheres
to the concept of minimal invasive preparations [12]. The idea was first introduced in
1995 by Pissi and was called the Mono-block technique [13]. The idea was then modified
to suit the posterior teeth by Bindl and Mörmann [14], pioneers of the endocrown as a
terminology and concept for molar teeth. The design was further developed in a successive
study usinga uniform and wide flat occlusal margin, 1–1.2 mm shoulder extension, and a
3 mm inlay depth, for less than 3 mm stump height, reduced preparation parameters were
performed [15]. Endocrown restoration is an easy-to-perform treatment that conserves
tooth structure, reduces treatment sessions and time, and increases patient satisfaction [16].
The original and recommended preparation design includes a 90◦ butt wide occlusal
flat margin, which utilize the remaining tooth structure for restoration support and ad-
hesion, a 6◦ internal axial walls taper with a flat pulpal floor, and supragingival enamel
margins [15]. Including the ferrule feature in the preparation has enhanced the resistance
to ceramic endocrown fracture [17,18]. Several ceramic materials have been utilized for
endocrown restorations, oxide ceramics possess high strength to failure [17,19], meanwhile
higher non-repairable failure rates [20], glass ceramics are the originally used endocrown
restorations [13–15], and preferred regarding esthetic considerations, above all lithium
disilicate, it has the highest flexural strength among glass–ceramics and offers the desired
esthetic values [21]. Tetragonal zirconia fillers were incorporated into the microstructure
to enhance the material flexural strength, resulting in zirconia-reinforced lithium silicate
ceramics (ZLSs) [22]. However, another laboratory study reported higher fracture resis-
tance for lithium disilicate endocrowns than ZLSs and resin nano-ceramic endocrowns
under lateral and axial loading [23]. ZLS endocrowns reported higher fracture resistance
than lithium disilicate endocrowns when loaded at 45 degrees [24]. Meanwhile, polymer-
infiltrated ceramic, lithium disilicate, and ZLS mandibular molar endocrowns possess
fracture resistance that exceeds the physiological limit of a normal person [25]. Moreover,
polyetheretherketon endocrowns reported higher fracture resistance than lithium disilicate
and ZLS [26].
Besides the material used for endocrown fabrications, there are several factors govern-
ing the fracture resistance of dental restorations, such as the tooth anatomy and type [27],
the amount of remaining tooth structure [28], the accuracy and adaptation of the restora-
tions [29], and the restoration design and extensions [17,30]. Extending the pulpal inlay
depth to 5 mm in the pulp chamber seems to affect the scanning accuracy of the digital
workflow, increasing the pulpal extensions of endocrowns need to be accompanied by
most modern scanning devices such as Primescan for better accuracy results [31]. The
endocrowns’ accuracy and adaptation might depend on the tooth type and form; a labora-
tory study reported that mandibular endocrowns showed better adaptation than maxillary
Materials 2024, 17, 1411 3 of 14

endocrowns [32]. In terms of endocrown preparation designs, there are several labora-
tory studies executed to evaluate the effect of endocrown pulpal extensions on fracture
resistance [33,34]; others extend the preparation on the axial surface utilizing ferrule prepa-
ration [17,18,35]. The presence of the ferrule design can improve fracture resistance by
acting as a reciprocal support against laterally exerted stresses [17,18]. Moreover, increas-
ing the pulpal extension enhances the fracture resistance of endocrowns based on recent
evidence-based conclusions [29]. All these design variations have been studied indepen-
dently on mandibular endocrowns. Therefore, the present study aimed to compare the
effects of varying lengths of pulp inlays (2 mm, 3 mm, and 4 mm) and the inclusion of
ferrules in the design. The null hypotheses for this study are as follows: (1) there will be no
statistically significant difference in fracture resistance among endocrowns with different
depths of pulp inlays. (2) The presence or absence of a ferrule will not affect the fracture
strength of the endocrowns. (3) Varying depths of pulp inlays and the presence or absence
of a ferrule will not impact the marginal, axial, and pulpal discrepancies of the endocrowns.
(4) All designs, regardless of the presence of a ferrule and different pulp inlay extensions,
will exhibit the same modes of failure.

2. Materials and Methods

2.1. Specimens Preparation
Teeth Selection, Preparation, and Grouping
The research protocol received approval from the Faculty of Dentistry ethics committee
at Taibah University, with the assigned reference number 210323/TUCDREC for the year
2023. Freshly extracted, intact, and caries-free human maxillary molars were collected for
the study. The teeth were inspected for preexisting visible chippings or cracks. The teeth
were cleaned in an ultrasonic device and then transferred to a distilled water container at
4–5 ◦ C until further use. The teeth with a similar dimension range were selected for the
experiment (n = 60); the specimens’ mean dimensions were 10.47 ± 0.5 mm buccolingually
and 11.13 ± 0.5 mesiodistally.
The molar teeth were reduced horizontally to 3 mm above the most occlusal point of
the cementoenamel junction (CEJ) using a diamond disc and a milling machine (BEGO.
PARASKOP M.100-120, Bremen, Germany). Following the pulp morphology, the pulp
chamber roof was removed using a round carbide high-speed bur. All teeth received
endodontic treatment performed by the same operator (M.H) utilizing the protaper system
(Dentsply-Maillefer; Ballaigues, Switzerland) and a standardized sequence with a 2.5%
sodium hypochlorite irrigation solution. The teeth were held in wet gauze during the
preparation and kept in a saline solution in between steps to prevent dehydration.
All excess sealer and debris were removed from the access cavity. The pulp chamber
was cleaned using ethylene alcohol. All teeth were mounted in an auto-polymerizing
acrylic resin (Ivocron; Ivoclar Vivadent AG, Schaan, Liechtenstein) in a standardized
position parallel to their long axis and 3 mm apical to the CEJ. The pulp chamber cavity
varied significantly from one tooth to another. The pulpal inlay was prepared with 8–10◦
divergence of the vertical walls. The discrepancies in the pulp chamber and the pulpal floor
were restored using a two-step, self-etch adhesive (Clearfil SE; Kuraray America, Houston,
TX, USA) and a dual-cure core material (Gradia Core; GC America, Alsip, IL, USA). The
final preparation depth for the endocrown pulpal inlays was standardized at 2, 3, and 4 mm
for the three major groups (n = 20), with a parallel pulpal floor to the endocrown occlusal
table (Figures 1 and 2).
A silicone stopper was used to standardize the depth of preparation, and the drill
was equipped with a silicone stopper to measure the depth of the cavity. All-access
cavities were modified to the same width (4 ± 0.2 mm buccolingually and 6 ± 0.2 mm
mesiodistally). The teeth were further divided into two subgroups (n = 10) based on the
type of external coronal preparation. Group N received no ferrule preparation, and Group
F1 had 1 mm circumferential ferrule preparation with a shoulder finish line (Figure 1).
 Materials 2024, 17, 1411 4 of 14

Materials 2024, 17, x FOR PEER REVIEW 4 of 15

All the preparation steps were completed with a parallelometer to ensure standardized
preparation for all specimens.
Materials 2024, 17, x FOR PEER REVIEW 4 of 15

Figure 1. The preparation designs inlay depth differences and the presence of ferrule, upper raw 1
Figure
Figure1.1.The
Thepreparation
preparation
mm circumferential
designs
designs
ferrule
inlay
inlay
preparation
depth
depth differences
withdifferences
a shoulderand the
finish
and the presence
presence
line, lowerofraw
of no
ferrule, ferrule,
withupper rawupper
ferrule mm raw 1
1prep-
mm circumferential
circumferential
aration. ferrule preparation with a shoulder finish line, lower raw with no ferrule preparation. prep-
ferrule preparation with a shoulder finish line, lower raw with no ferrule
aration.

Figure 2.
Figure 2. Endocrown
Endocrown preparation.
preparation.

The prepared
A silicone teeth was
stopper wereused
scanned using a TRIOS
to standardize the 3depth
intraoral scanner (3Shape,
of preparation, Copen-
and the drill
hagen,
Figure 2. Denmark).
Endocrown The endocrowns
preparation. were then designed with a 60-µm cement space
was equipped with a silicone stopper to measure the depth of the cavity. All-access cavi- using
computer-aided
ties were modified design (CAD)
to the same software
width (4 (3Shape
± 0.2 mmCAD Design software,
buccolingually and 6 ±version
0.2 mm1.7.1.4,
mesi-
3Shape) and
A silicone
odistally). were
The subsequently
stopper
teeth werewas milled
used
further frominto
ZLStwo
to standardize
divided blocks
the(VITA
depth
subgroups Suprinity, VITA Zahnfabrik,
of=preparation,
(n 10) based andtype
on the the drill
of external coronal preparation. Group N received no ferrule preparation,
was equipped with a silicone stopper to measure the depth of the cavity. All-access and Group F1 cavi-
had 1 mm circumferential ferrule preparation with a shoulder finish line
ties were modified to the same width (4 ± 0.2 mm buccolingually and 6 ± 0.2 mm mesi- (Figure 1). All
the preparation
odistally). stepswere
The teeth werefurther
completed with ainto
divided parallelometer
two subgroupsto ensure
(n =standardized
10) based on prep-
the type
aration for all specimens.
of external coronal preparation. Group N received no ferrule preparation, and Group F1
Materials 2024, 17, 1411 5 of 14

Bad Säckingen, Germany) using a CAD/CAM milling machine (Ceramill; Amann Girrbach
AG, Koblach, Austria), following the manufacturer’s recommendations. To ensure con-
sistency in the testing design, all restorations were designed with identical occlusal table
anatomy and height, thereby minimizing the incorporation of different lever action vectors.
A comprehensive list of the materials utilized in this study is provided in Table 1.

Table 1. Materials used in the study.

Trade Name Scientific Name Composition Productive Company

SiO2 56–64 wt%, Li2 O 15–21 wt%, K2 O
Zirconia-reinforced 1–4 wt%, P2 O5 3–8 wt%, Al2 O3 1–4 wt%,
Vita Suprinity VITA Zahnfabrik, Germany
lithia silicate ZrO2 8–12 wt%, CeO2 0–4 wt%, La2 O3
0–1 wt%, Pigments 0–6 wt%.
Resin; Bis-GMA, TEGDMA.
Filler: Silanated glass, silica
Dual-cured composite core
Gradia Core Filler loading: (74 wt%) 52 vol% GC America
build-up material
The particle size of 0.04 µm to 23 µm
Camphorquinone, Benzoylperoxide
Primer: MDP, HEMA, dimethacrylate
monomer, water, catalyst Kuraray America, Houston,
Clearfill SE Two-step, self-etch adhesive
Bond: MDP, HEMA, dimethacrylate TX, USA
monomer, microfiller, catalyst
Glass powder, initiator, silica, substituted
Self-adhesive resin
pyrimidine, calcium hydroxide, peroxy 3 M ESPE, Seefeld, Germany.
cement powder
compound, pigment
Rely X Unicem
Self-adhesive resin Methacrylated phosphoric ester,
cement liquid dimethacrylate, acetate, stabilizer, initiator.

2.2. Marginal and Internal Adaptation Assessment

The marginal and internal adaptation of the restorations were assessed using the
silicon replica technique. Each endocrown was loaded with a light-body impression
material (President light body green; Colten, Konstanz, Germany) and seated for 5 min
under a constant axial force of 50 N. After polymerizing the light-body material, the
restoration was removed gently, and a heavy-body silicone (President’s heavy body) was
injected into the tooth to stabilize the thin silicone film. Once polymerized, each replica
was cut into four sections using a sharp surgical blade in a mesiodistal and buccolingual
direction (no. 11; Feather Safety Razor Co., Ltd., Osaka, Japan). A 2-mm thick parallel wall
slice was then sectioned from each piece to facilitate evaluation under a digital trinocular
stereomicroscope (AmScope 3.5; Irvine, CA, USA) at ×50 magnification. Each slice was
divided into four areas of interest for better comparison: axial, cervical, marginal, and
pulpal floor.
Eight measurements were obtained on each slice: one marginal gap measurement,
M1; two cervical area measurements (C1 in the center and C2 at the cervical–axial angle);
three axial measurements (A1, A2, and A3); and two pulpal measurements (P1 on the axio-
pulpal angle and P2 at the center of the pulpal area). The M1 measurement represented
the marginal gap, while the internal adaptation of the restoration was expressed by the
average of C1, C2, A1, A2, A3, P1, and P2. A total of 1920 measurements were taken for the
6 groups (8 measurements × 4 sections × 10 endocrowns × 6 groups).

2.3. Fracture Resistance Test

The internal surfaces of the endocrowns were etched with 5% hydrofluoric acid (IPS
Ceramic Etching Gel; Ivoclar Vivadent) for 20 s, rinsed with water for 15 s, and dried with
oil-free compressed air. A thin coat universal primer (Monobond Plus; Ivoclar Vivadent)
was then applied to the etched intaglio surface using a micro brush for two 60-s intervals,
with excess agent dispersed by compressed air. The prepared teeth were cleaned with
 Ceramic Etching Gel; Ivoclar Vivadent) for 20 s, rinsed with water for 15 s, and dried with
oil-free compressed air. A thin coat universal primer (Monobond Plus; Ivoclar Vivadent)
was then applied to the etched intaglio surface using a micro brush for two 60-s intervals,
Materials 2024, 17, 1411 with excess agent dispersed by compressed air. The prepared teeth were cleaned 6 of 14
with
fluoride-free pumice paste for 15 s and rinsed with water for 15 s. The endocrowns were
then cemented with self-adhesive resin cement (Rely X Unicem, 3 M ESPE, Seefeld,
Germany) and pumice
fluoride-free held under
pastea for
constant
15 s andaxial loadwith
rinsed of 4.9 N exerted
water for 15 s.byThea specially designed
endocrowns
were for
device then5 cemented
min. After with self-adhesive
removing resin cement
the excess cement, (Rely X Unicem,
each side was3 Mlight-cured
ESPE, Seefeld,for 20 s
Germany) and held under a constant axial load of 4.9 N exerted
(Woodpecker iLED, Guilin, Guangxi, China, 2400 mW/cm ). The cemented endocrowns 2 by a specially designed
device
were for 5inmin.
stored After water
distilled removing in athe37excess cement, each
°C incubator sideh.was
for 24 Thelight-cured
specimens forwere
20 s then
(Woodpecker iLED, Guilin, Guangxi, China, 2400 mW/cm2 ). The cemented endocrowns
subjected to thermocycling at 5 °C to◦ 55 °C and 15-s dwell time for 5000 cycles before
were stored in distilled water in a 37 C incubator for 24 h. The specimens were then
undergoing
subjected to thethermocycling
quasistatic loadat 5 test.
◦ C to 55 ◦ C and 15-s dwell time for 5000 cycles before
All specimens were loaded
undergoing the quasistatic load test. vertically along their long axis in a universal testing
machine All specimens were loaded verticallyProducts,
(Model 3345; Instron Industrial along their Norwood,
long axisMA, in a USA) withtesting
universal a load cell
of machine
5 KN at (Model
a speed3345; of 1Instron
mm/min until fracture,
Industrial Products,indicated
Norwood,by MA, sudden dropa of
USA) with resistance,
load cell
of 5 KN
Figure at a fractured
3. Each speed of 1 specimen
mm/min until fracture, inspected
was visually indicated by at sudden drop of resistance,
20× magnification (Hirox KH-
Figure
7700, 3. Each
Hirox, fractured
Torrance, CA,specimen
USA) towas visually the
determine inspected 20× magnification
failureatmode, (Hirox
which was classified as
KH-7700, Hirox, Torrance, CA, USA) to determine the failure mode,
cohesive within the ceramic material, the adhesive between the ceramic and the tooth which was classified
as cohesive within the ceramic material, the adhesive between the ceramic and the tooth
structure, or fracture of the tooth material. The modes were further categorized into
structure, or fracture of the tooth material. The modes were further categorized into
favorable
favorable(repairable)
(repairable)or or unfavorable
unfavorable (not (notrepairable),
repairable), based
based on agreement
on agreement between
between two two
examiners.
examiners. If the failure occurred above the cementoenamel junction (CEJ) and the causecause
If the failure occurred above the cementoenamel junction (CEJ) and the
of of
failure was
failure wasonly onlydebonding and/or cohesive
debonding and/or cohesivefracture
fracture of of
thethe restoration,
restoration, or within
or within the the
endocrown,
endocrown, it itwas
wasconsidered
considered aa favorable
favorablefracture.
fracture. Meanwhile,
Meanwhile, the the
toothtooth fracture
fracture belowbelow
CEJ,
CEJ, includingvertical
including verticalroot
root fracture,
fracture, was
wasconsidered
considered unfavorable.
unfavorable.

Figure 3. The
Figure quasistatic
3. The quasistaticloading.
loading.

2.4.2.4. Statistical
Statistical Analysis
Analysis
Shapiro–Wilk’s and Levene’s tests were employed to test the assumption of normal
Shapiro–Wilk’s and Levene’s tests were employed to test the assumption of normal
distribution of the adaptation and resistance to fracture data. Given a non-significant result
distribution of the adaptation and resistance to fracture data. Given a non-significant
from the Levene test, indicating equal variances, a two-way analysis of variance (ANOVA)
result
was from the Levene
conducted test,the
to evaluate indicating equal variances,
overall statistical significance a of
two-way analysis
differences. of variance
A pair-wise
(ANOVA) was conducted to evaluate the overall statistical significance of
statistical comparison was carried out using Tukey’s post-hoc test. Moreover, a Chi-squared differences. A
pair-wise
test was statistical
conducted comparison was carried
to assess the fracture modes.outTheusing Tukey’s
statistically post-hoc
significant test.
level Moreover,
was set at a
p-value ≤0.05.
Chi-squared test was conducted to assess the fracture modes. The statistically significant
level was set at p-value ≤0.05.
3. Results
All the data had a normal distribution according to the Shapiro–Wilk’s test p > 0.05.
3. Results
The mean values and standard deviations of marginal adaptation values for the tested
All the
groups aredata had a in
presented normal
Table 2distribution
and Figure 4.according to the Shapiro–Wilk’s
The endocrowns test p a> 0.05.
with ferrule showed
Thestatistically
mean values and standard
significantly deviations
higher gap of marginal
at marginal, adaptation
cervical, and values for
internal surfaces: the tested
p = 0.002,
<0.001, and <0.001, respectively. However, it was not statistically significant at the axial
and pulpal surfaces, p = 0.323 and 0. 341, respectively. The largest gap was observed at the
pulpal floor with a depth of 4 mm and a 1 mm ferrule marginal design p < 0.001, followed
 statistically significantly higher gap at marginal, cervical, and internal surfaces: p = 0.002,
<0.001, and <0.001, respectively. However, it was not statistically significant at the axial
and pulpal surfaces, p = 0.323 and 0. 341, respectively. The largest gap was observed at the
pulpal floor with a depth of 4 mm and a 1 mm ferrule marginal design p < 0.001, followed
Materials 2024, 17, 1411 7 of 14group
by the 3 mm inlay depth of both endocrowns with and without ferrule p < 0.001. The
with a 2 mm inlay depth recorded the highest adaptation.
Regarding fracture resistance, endocrowns without ferrule groups showed higher
by the 3 mm inlay depth of both endocrowns with and without ferrule p < 0.001. The group
resistance to failure than the ferrule design p < 0.001, irrespective of the pulpal inlay depth.
with a 2 mm inlay depth recorded the highest adaptation.

Table 2. The
Table mean
2. The meanand
andstandard
standard deviation
deviation ofofthe
themarginal,
marginal, cervical,
cervical, axial,
axial, pulpal,
pulpal, and internal
and internal gaps gaps
of endocrowns with different design values are in
of endocrowns with different design values are in µm.µm.

Measurements Location
Measurements Location
Marginal
Marginal
Cervical
Cervical
Axial
Axial
Pulpal
Pulpal
Internal
Internal
Endocrown Design
Endocrown Design Mean
Mean St. Dev.
St. Dev. Mean
Mean St. Dev.
St. Dev. Mean
Mean St. Dev.
St. Dev. Mean
Mean St. Dev.
St. Dev. MeanMean St. Dev.
St. Dev.
2 mm inlay
2 mm inlay 90.700 Aa 11.3925
A
90.700 a 11.3925 85.800 A
85.800 a
Aa 8.9790
8.9790 90.290
90.290 aA Aa 4.9328
4.9328 123.000 A
123.000 b
Ab 14.7573
14.7573 99.6980
A
99.6980 a
Aa 5.64745
5.64745
Butt joint
Butt joint
3 mm inlay
3 mm inlay 105.300
105.300 B bb 13.2082
B
13.2082 88.300
88.300 A a a 9.3101
A 9.3101 94.730
94.730B
a a 5.4766
B 5.4766 138.300
138.300B
c c 10.2095
B 10.2095107.1110
107.1110
B
b
B b 4.29440
4.29440
designdesign
4 mm inlay
4 mm inlay 107.100 B
107.100 b Bb 16.3670
16.3670 94.500 B
94.500 a Ba 11.6357
11.6357 97.360B
97.360 a Ba 5.2243
5.2243 143.400 C
143.400 c C c 12.1582
12.1582 111.7540
C
111.7540 b C b 5.07847
5.07847
2 mm inlay
2 mm 102.300 bb 13.5158
inlay 102.300 B B 13.5158 94.600
94.600 a a 10.2220
B B 10.2220 90.270
90.270A
a a 2.7105
A 2.7105 126.400
126.400c c 11.4426
A A 11.4426103.7590
103.7590
B
b B b 6.82651
6.82651
FerruleFerrule
3 mm inlay
3 mm inlay 116.500
116.500 CCbb 12.7126
12.7126 109.000
109.000 C b Cb 12.8841
12.8841 95.120
95.120 B
a Ba 6.7690
6.7690 138.500
138.500 B
c Bc 10.2095
10.2095 115.4080
115.4080 C
b b 8.28399
C8.28399
designdesign CC D D C C D
4 mm inlay 119.500 b 15.8902 118.100 b 13.6092 102.590 a 13.4518 147.000 b 12.1582 122.5640 b 10.56441
4 mm inlay 119.500 b 15.8902 118.100 b 13.6092 102.590 a C 13.4518 147.000 b C 12.1582 122.5640 b D
10.56441

TheThe superscript uppercase

superscript uppercase letters represent
letters the statistically
represent significant difference
the statistically withindifference
significant a column; the small letters
within a column;
represent the statistically significant difference within rows.
the small letters represent the statistically significant difference within rows.

Figure 4. 4.The
Figure Thebar chartshows
bar chart showsthethe mean
mean and standard
and standard deviation
deviation of the cervical,
of the marginal, marginal, cervical,
axial, pulpal, axial,
pulpal, and internal
and internal gaps ofgaps of endocrowns
endocrowns with designs;
with different differentthe
designs; theinvalues
values are µm. are in µm.

TheRegarding fracture
pulpal inlay resistance,
depth 2 mm, 3endocrowns
mm, and 4 without
mm showed ferrule groups showed higher
a non-statistically significant
resistance to failure than the ferrule design p < 0.001, irrespective of the pulpal inlay
effect on the resistance to fracture p = 0.265, 0.926, and 0.307, respectively. Table 3 presents depth.
The pulpal inlay depth 2 mm, 3 mm, and 4 mm showed a non-statistically significant
the mean and standard deviations of resistance to fracture (N) for different marginal
effect on the resistance to fracture p = 0.265, 0.926, and 0.307, respectively. Table 3 presents
designs and pulp chamber depths (mm) of the ZLS endocrowns. Regarding the effect of
the mean and standard deviations of resistance to fracture (N) for different marginal
thedesigns
pulpaland extension of the endocrowns,
pulp chamber depths (mm) of thethe
results showed thatRegarding
ZLS endocrowns. restorations with aof3 mm
the effect
pulpal
the pulpal extension of the endocrowns, the results showed that restorations with ainlay
extension exhibited higher mean fracture resistance values than 4 mm 3 mm depth,
followed by endocrowns
pulpal extension with
exhibited a 2 mean
higher mm pulpal
fractureextension.
resistance However,
values thanthis
4 mmdifference was not
inlay depth,
statistically
followed by significant
endocrownsamong
with the buttpulpal
a 2 mm joint endocrowns withoutthis
extension. However, ferrule groups
difference was(pnot
> 0.05).
statistically significant among the butt joint endocrowns without ferrule
However, endocrowns with 1 mm ferrule designs showed lower fracture resistance for 4 groups (p > 0.05).
mm However,
deep inlay endocrowns
than 3 and with
2 mm1 mm ferrule
pulpal designs
inlays, andshowed lower
all ferrule fracture
groups resistance
exhibited for
statistically
4 mm deep inlay than 3 and 2 mm pulpal inlays, and all ferrule groups exhibited statistically
significantly lower fracture resistance to the endocrowns without ferrule p < 0.001.
significantly lower fracture resistance to the endocrowns without ferrule p < 0.001.
The Chi-squared test revealed no significant difference between the modes of failure
of the tested groups. Unfavorable fracture was the most common mode of failure among
all the tested groups, Figure 5. The specimens in the group with a chamber extension depth
of 3 and 4 mm demonstrated almost universal catastrophic tooth fracture, while 70% of the
specimens with a chamber depth extension of 2 mm showed unfavorable fracture.
 Table 3. Fracture resistance of endocrowns with and without ferrule at different pulpal inlay depths,
the results are given in N.

Materials 2024, 17, 1411 Butt Joint Design Ferrule Design

Endocrown Design 8 of 14
Mean St. Dev. Mean St. Dev.
2 mm inlay 1371.0900 Aa 105.48131 1162.1600 Bb 375.71287
3 mm inlay Table1409.6600 a
3. Fracture Aresistance 49.95278 with and without
of endocrowns 1246.6100 b different pulpal
ferruleAat 104.55067
inlay depths,
4 mm inlay 1396.4833
the results A
are givena in N. 81.54658 1215.3867 b A 225.40423
The superscript uppercase letters represent the statistically significant difference within a column;
the small letters represent the statisticallyButt
Endocrown Design
Joint Design
significant Ferrule Design
difference within rows.
Mean St. Dev. Mean St. Dev.
The Chi-squared
2 mm inlay test revealed no significant
1371.0900 Aa difference between
105.48131 1162.1600theB b modes of failure
375.71287
of the tested groups. Unfavorable fractureA was the most common mode of failure among
3 mm inlay 1409.6600 a 49.95278 1246.6100 A b 104.55067
all the tested groups, Figure 5. The specimens in the group with a chamber extension
Aa 81.54658catastrophic Ab 225.40423
depth of 34 mmand inlay
4 mm demonstrated 1396.4833
almost universal 1215.3867tooth fracture, while
The superscript uppercase letters represent the statistically significant difference
70% of the specimens with a chamber depth extension of 2 mm showed unfavorable within a column; the small letters
represent the statistically significant difference within rows.
fracture.

Figure5.
Figure 5. Unfavorable
Unfavorable fractured
fractured specimen.
specimen.

4.
4. Discussion
Discussion
The
The rehabilitation
rehabilitation of
of severely
severely damaged
damaged ETTETT poses
poses aa significant
significant challenge
challenge in
in dentistry.
dentistry.
Recent advancements in restorative materials, adhesive protocols, and
Recent advancements in restorative materials, adhesive protocols, and computer-aidedcomputer-aided
design/computer-aided
design/computer-aided manufacturing
manufacturing (CAD/CAM) technology introduced
(CAD/CAM) technology introduced endocrowns
endocrowns
as a reliable and promising option for restoring ETT [15].
as a reliable and promising option for restoring ETT [15]. Numerous Numerous studies havehave
studies em-
phasized the importance of effectively restoring ETT. The coronal hermitical
emphasized the importance of effectively restoring ETT. The coronal hermitical seal with seal with
aa successful
successful coronal
coronal restoration
restoration meant
meant not
not only
only to
to restore
restore function
function and
and esthetics
esthetics but
but to
to
prevent the ingress of microorganisms to the obturated root canals [36–38].
prevent the ingress of microorganisms to the obturated root canals [36–38]. Endocrown Endocrown
restorations
restorations bonded
bonded toto coronal
coronal structure
structure offer
offer aaviable,
viable,conservative,
conservative, and
and time-efficient
time-efficient
clinical option for sealing and restoring ETT [16].
clinical option for sealing and restoring ETT [16].
In literature, most of the main bulk of data were on mandibular molar endocrowns
In literature, most of the main bulk of data were on mandibular molar endocrowns
or premolars [39]; in recent years, there have been more studies executed on maxillary
or premolars [39]; in recent years, there have been more studies executed on maxillary
molar teeth [32,40–43], all these records focused on the adaptation, marginal and internal
molar teeth [32,40–43], all these records focused on the adaptation, marginal and internal
discrepancies, as well as the retention and pullout tests. To the best of our knowledge, nearly
discrepancies, as well as the retention and pullout tests. To the best of our knowledge,
all the existing records on fracture resistance and mechanical behavior of endocrowns have
nearly all the existing records on fracture resistance and mechanical behavior of
been conducted on mandibular molars. Only two studies were carried out on maxillary
molars, and those studies used the conventional design without pulpal extensions or a
ferrule design [44,45]. Due to anatomical variations in form, size of the pulp chamber,
and location on the tooth, selecting maxillary molar teeth for this study appears highly
beneficial. This will provide new data on endocrowns and establish a reliable reference
for readers and clinicians involved in decision-making. This study investigated how pulp
Materials 2024, 17, 1411 9 of 14

chamber extension depth and marginal design influence the accuracy of fit and resistance
to fracture of mandibular molar endocrowns made from ZLS (VITA Suprinity) ceramics.
The findings provided evidence to reject the null hypotheses, indicating that both variables,
pulp chamber extension depths, and marginal design, significantly impact the accuracy of
fit and resistance to fracture.
The findings showed that the resistance to fracture of ZLS endocrowns directly corre-
lates to pulpal extension depth. Increasing depth shall increase the adhesion surface area
enhance the distribution of stresses upon loading, and increasing the resistance to fracture.
These findings were supported by previous studies by Dartora et al. 2018 [34] showing
improved mechanical behavior with an increased pulpal extension of the endocrowns;
the fracture resistance values were 2008.61 N, 1795.41 N, and 1268.12 N for 5 mm, 3 mm,
and 1 mm inlay depth respectively. The fracture resistance of the current non-ferrule
designs encountered 1371.1 N, 1409.6 N, and 1396.5 N for 2 mm, 3 mm, and 4 mm pulpal
extensions, respectively.
On the other hand, Kuijper et al. 2020 [46] compared no extension overlay restoration
to 2 mm and 4 mm pulpal extension endocrowns; the authors stated that there were no
statistically significant differences between the fracture resistance of the three groups.
However, the results of 2 mm and 4 mm groups were comparable and obviously higher
than the overlay group, 812 ± 235 for the 0 extension, 1071 ± 408 N for 2 mm, and
1036 ± 278 N for the 4 mm extension [46]. The study tested the specimens after excessive
fatigue loading, and the direction of the applied load was exerted at a 45◦ angle, simulating
the parafunctional dynamic occlusion, unlike the current study, which tested the specimens
without aging and directed the load in a vertical pattern simulating the centric occlusal
contact, reflected upon the differences in the fracture resistance values of the two studies.
Moreover, a study by Hayes et al. 2017 [47] found that mandibular molars restored
with endocrown restorations featuring 2- and 4-mm pulp chamber extensions had a higher
resistance to fracture compared to endocrowns with a 3-mm pulp chamber extension, the
fracture resistance mean values were 843.4 N, 943.5 N, and 762.8 N for the three extensions
respectively. This difference can be attributed to the different base and endocrown ceramic
materials utilized in Hayes et al. [47] and the current study, and primarily the direction of the
load to failure, that the study exerted the load on the functional cusp with a 45◦ angle to the
long axis of the tooth, encountering comparable outcomes as Kuijper et al.’s 2020 study [46].
Furthermore, compared to the study by Hayes et al. [47], the current investigation outcomes
indicate that the base material used could affect the fracture resistance of ZLS endocrowns.
The composite base material improves fracture resistance compared to resin-modified
glass ionomer cement (RMGIC) [48,49], regardless of the extent of pulpal extension in the
restoration, bringing about more support and less flexion and plastic deformation of the
overlying restoration.
When comparing the fracture resistance of teeth with 4 mm extension inlay depths
to those with 3 mm depths, it was observed that the former had a lower average fracture
resistance. Although this difference was not statistically significant, it is reasonable to
attribute the reduced fracture resistance associated with deeper inlay preparations to the
increased weakening of the tooth structure. The need to remove more tooth material to
accommodate a 4 mm extension inherently compromises the tooth’s structural integrity.
Moreover, previous studies have reported that increasing inlay extension leads to an
increased endocrown discrepancy [31,50]. As a result, the tooth becomes more susceptible
to fractures under stress. Notably, all observed fractures occurred within the tooth structure
itself, reinforcing that the depth of the inlay preparation is directly related to the tooth’s
ability to withstand force. Preserving as much natural tooth substance as possible is a
fundamental principle in restorative dentistry for maintaining the strength and durability
of the tooth, and the findings of this comparison support this principle.
Although the pulpal extension depth exhibited a direct correlation to the fracture re-
sistance, utilizing a 1 mm axial ferrule reduced the resistance to fracture of the endocrowns;
this could be attributed to the fact that the ferrule design reduced tooth structure and
Materials 2024, 17, 1411 10 of 14

removed a substantial part of the outer circumferential conventional occlusal table of the
endocrowns, leading to reduction in the resistance against the compressive loads exerted
perpendicular to the occlusal table and parallel to the long axis of the tooth. The ferrule
design advantages are well known in the literature to improve the fracture resistance com-
pared with the non-ferrule design, particularly against the obliquely or laterally directed
loads; however, the ferrule obviously act in providing more retention and resistance to
dislodgement [51], or as a reciprocal part against the laterally exerted stresses as in the case
of dynamic occlusal load and lateral excursive occlusal contacts [17,18].
The accuracy of fit of the endocrown restorations is dependent on the design used:
the pulpal inlay depth and the presence of the ferrule design, the smallest overall gap
encountered by endocrowns without ferrule and with 2 mm pulpal inlay, and the worst gap
escorted the endocrowns with 1 mm ferrule design and 4 mm pulpal inlay depth, the lowest
gap values were the cervical, axial, and marginal, followed by the internal, and the worst
discrepancies were registered at the pulpal floor; detailed values and statistical comparison
are shown in Table 2. The discrepancies at the intaglio surfaces (99.6980–122.5640 µm) and
the pulpal floor (123–147 µm) were higher than expected. However, all the measured gaps
were within the clinically acceptable threshold, according to a common clinical consensus
in the past five decades that gap <120 µm is considered acceptable clinically [52–54]. The
discrepancy of the current study increased with the increase in pulpal depth and design
complexity in the endocrown with ferrule groups. The gap values were not directly
affected by the prepared designs but by the digital workflow’s limitations and scanning
technologies. They faced challenges in capturing and scanning deep inlay walls and
floors rather than shallow ones and complex geometrical preparations compared to simple
non-ferrule designs. A previous study by Gaintantzopoulou et al. 2016 [55] showed
increasing the discrepancy with increasing the pulpal inlay depth of the endocrowns
and the complexity of the pulpal floor geometry; these discrepancies were only but a
reflection of the scanning inaccuracies and bypassing of complex walls by CNC milling
technology [31,55,56]. In the Gaintantzopoulou et al. 2016 study, executed more than
7 years ago, the pulpal floor complex preparations of the canal orifices were bypassed by
the digital CNC milling, resulting in even more inaccurate restorations [55].
Nevertheless, a more recent study by Soliman et al. in 2022 [56] reported less than
30 µm mean endocrown gaps for premolar preparations, and the fabricated restorations
were able to fit the prepared walls, in particular, the pulpal floor precisely, even with
the presence of two small extended studs in the canal orifices. Likewise, another recent
study by Gurpinar et al. 2022 [31] reported mean endocrown discrepancies of 2 mm,
3.5 mm, and 5 mm depth to be less than 35 µm. The discrepancy increased with the pulpal
inlay depth, depending on the scanning device used [31]. Living in the era of modern
dentistry, 120 µm might not be acceptable as an efference for an acceptable, marginal fit
in the coming days. The evidence-based conclusions found that no matter the fabrication
technique applied, variable dimensions of the marginal gap will always exist. The interface
between dentin and luting resin is more susceptible to degradation with a marginal gap
of 50–300 microns [57]. Furthermore, irrespective of the risk level, recurrent caries could
originate even with 30-micron gaps [58]. Perhaps the time will come to reconsider the
upper limit of the clinically acceptable gap threshold, especially with the development
and introduction of more advanced scanning devices [31,56] and high-tech production
technologies such as 5-axis milling and 3D printing [31,59,60].
The endocrown marginal, axial, and internal fit and gap are governed by many general
factors, including predefined cement space value, cement material and professionalism of
application, marginal configuration [61], preparation and finish accuracy [62], tooth form
and type [63], and inadequate or inappropriate preparation [63,64]. While the fitness of
CAD-CAM fabricated endocrowns might be affected by the different software programs
and different versions used [65], the type and sophistication of the milling machine (the
5-axis milling over 4- and 3-axis milling machines and the dry milling over wet milling of
zirconia) [66,67], and ceramic material type [66]; however, the endocrowns’ accuracy might
Materials 2024, 17, 1411 11 of 14

not be affected by the material when fabricated by 5-axis milling [60]; and thickness of
restoration, as thin margins are more prone to chipping [68]. Several ways exist to evaluate
the internal gap and marginal fit of crowns and restorations. The current study adopted the
silicone replica technique (SRT), while some other studies utilized the triple scan method
(TSM) [31], micro-computed tomography (MCT) [55], or digital microscopy [56]. The
differences in the accuracy measurement method could explain the different outcomes of
these previous studies to the current research, and foremost, the predefined cement space,
which in the current study was 60 µm, compared to some studies that might not assigned
predefined cement space [31,56].
The fracture resistance values of all the tested groups were high for single restora-
tion, exceeding the upper limit of physiological biting force by far [69]. The conventional
endocrown design with a 2–3 mm pulpal inlay might be recommended as a more conserva-
tive option. Increasing the endocrown inlay depth might be indicated in situations with
high occlusal risk factors, and the ferrule design is beneficial to resist the lateral excursion
movement and to withstand the dynamic occlusal cycles [17,18].
The current study has some limitations. Firstly, the applied load was only axial,
not considering real-life situations where teeth are subjected to off-axis forces. Secondly,
only one type of ceramic material was evaluated. Moreover, the study did not apply
thermal aging or cyclic fatigue loading before conducting the fracture resistance test. A
post-fatigue fracture resistance test enables the comparison of the residual resistance to a
static load on a material subjected to cyclic functional stress [70,71]. To better simulate oral
conditions, it would be beneficial to subject the specimens to thermocycling with water,
drinks, or artificial saliva. Consequently, further research is needed to examine the failure
mechanisms associated with different ceramic materials, teeth, and test conditions under
more severe conditions.

5. Conclusions
Considering the limitations of the current study, it has been shown that the depth of
cavities (intracoronal extensions) significantly impacts the susceptibility of ZLS endocrown
restorations to fractures. The findings indicate a clear correlation between greater depth and
enhanced fracture resistance. A ferrule design appeared to decrease the resistance of the
teeth to fractures when exposed to a vertical load parallel to their long axis. Increasing the
depth of the pulpal inlay and incorporating the ferrule design led to decreased accuracy of
the restorations’ fit. However, all designs exhibited clinically acceptable marginal, cervical,
and axial gaps.

Author Contributions: Conceptualization, S.S., A.Y.A., M.A.A. and M.H.A.; methodology, S.S., A.Y.A.
and M.H.A.; validation, A.A.A., D.H., S.B., A.E.F. and S.A.; formal analysis, S.S., A.Y.A. and M.A.A.;
investigation, D.H., S.B., A.E.F., S.A., A.A.A. and M.A.A.; resources, S.S.; data curation, S.S., A.Y.A.
and M.A.A.; writing—original draft preparation, S.S., A.Y.A., M.A.A., D.H., S.B., A.E.F., S.A. and
M.A.A.; writing—review and editing, S.S., A.Y.A., M.A.A. and M.A.A.; visualization, S.B., A.E.F.,
A.A.A. and S.A.; supervision, S.S.; project administration, M.H.A. and A.A.A. All authors have read
and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The research protocol was approved by the ethics committee
of the College of Dentistry at Taibah University, with the assigned reference number 210323/TUC-
DREC. All methodologies utilized in this study were strictly aligned with the applicable standards
and laws.
Informed Consent Statement: Not applicable.
Data Availability Statement: Data are contained within the article.
Conflicts of Interest: The authors declare no conflicts of interest.
Materials 2024, 17, 1411 12 of 14

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