Ó

Operative Dentistry, 0000, 00-0, 000-000

Performance of Monolithic and

Veneered Zirconia Crowns After
Endodontic Treatment and Different
Repair Strategies
A Scioscia  A Helfers  S Soliman  G Krastl  NU Zitzmann

Clinical Relevance
Two-step repair fillings with silica coating, silanization, and bonding provide improved
fracture loads in monolithic and better marginal integrity in veneered zirconia restorations
than one-step fillings. Monolithic restorations provide higher fracture loads but require
more time for access preparation.

SUMMARY Methods and Materials: Seventy-two human

Objectives: To investigate failure loads of molars were restored with monolithic (Zr-All)
monolithic and veneered all-ceramic crowns or veneered (Zr-Ven) zirconia crowns. Molars
were assigned to six groups (n=12 per group)
after root canal treatment and to analyze
depending on restoration material, access type
marginal integrity of repair fillings.
(no access cavity [control] or endodontic treat-
ment [test]), and type of filling (one-step [1-st]
 Adriana Scioscia, DMD, Department of Reconstructive or two-step [2-st]). For type of filling, molars
Dentistry and Temporomandibular Disorders, University of were treated using a self-etch universal adhe-
Basel, Basel, Switzerland sive and cavities were either filled with lay-
 Alexandra Helfers, DMD, private practice, Luzern, Switzer- ered composite (1-st) or filled until the crown
land material was reached, which was additionally
Sebastian Soliman, DMD, Department of Operative Dentistry conditioned and then filled (2-st). Scanning
and Periodontology, University of Würzburg, Würzburg, electron microscopic analysis of the restora-
Germany tion margins was performed before and after
Gabriel Krastl, DMD, professor, Department of Operative thermomechanical loading (TML), and the per-
Dentistry and Periodontology, University of Würzburg, centage of continuous margins was assessed.
Würzburg, Germany
Crowns were then loaded to failure.
*Nicola Ursula Zitzmann, professor, Department of Recon-
structive Dentistry and Temporomandibular Disorders, Results: Preparation of the access cavity re-
University of Basel, Basel, Switzerland quired more time in monolithic (445 s) than in
*Corresponding author: Hebelstrasse 3, Basel 4056, Swit- veneered crowns (342 s). Loads to failure were
zerland; e-mail: N.zitzmann@unibas.ch higher in control groups (Zr-All: 5814 N; Zr-
 These authors contributed equally. Ven: 2133 N) and higher in monolithic test
(2985 N) than in veneered test crowns (889 N).
DOI: 10.2341/17-063-L
In monolithic crowns, 1-st had lower fracture
 Operative Dentistry

loads than 2-st fillings (2149 N vs 3821 N). to 2354 N as compared to small-grit diamond burs
Continuous margins of 66% to 71% were (126 lm, 3464 N).9 In zirconia restorations, external
achieved, which deteriorated after TML by stress from grinding induces a phase transformation
39% to 40% in Zr-All, by 34% in Zr-Ven-1-st, from tetragonal to monoclinic and is associated with
and by 24% in Zr-Ven-2-st. a 4% increase in volume. This volume increase
Conclusions: Endodontic access and adhesive results in compressive stresses and increased frac-
restorations resulted in reduced fracture load ture toughness. Crack propagation occurs only when
in monolithic and veneered zirconia crowns. these clamping constraints are surpassed and stress
Two-step fillings provided higher fracture factors exceed arresting factors.16,17 Following RCT,
loads in Zr-All and better marginal quality in an adhesive composite filling restoration should
Zr-Ven crowns. provide successful endodontic outcome, re-establish
crown stability, and ensure crown retention.13,18-21
INTRODUCTION To meet these requirements, a variety of techniques
for pretreatment of the restoration have been
The need for root canal treatment (RCT) is one of the examined, including etching or sandblasting of the
most common biological complications following surface as well as the application of special bonding
reconstructive treatment and may lead to subse- agents.20,22 While surface sandblasting with an
quent technical complications with veneering frac- aluminum oxide powder created microretention,20,22
tures after preparation of the endodontic access corundum particles coated with silicium oxide
cavity.1 Among abutment teeth initially positive for (CoJet, 3M ESPE, Rüschlikon, Switzerland) led to
sensitivity testing, approximately 11% required RCT a retentive silicated surface and, in combination
during an observation period of 10 years.2 For single- with a silane, enabled a chemical connection to the
crown abutments, the pulp survival rate reached filling material.23-25
84.4% after 10 years and 81.2% after 15 years, while
The aim of this experimental study was to
abutments in fixed dental prostheses (FDP) had a
investigate the fracture load of monolithic and
lower pulp survival rate of 70.8% after 10 years and
veneered all-ceramic crowns following RCT and
66.2% after 15 years.3 The increased risk of pulpal
access cavity filling and to analyze the marginal
necrosis following abutment preparation is related to
integrity of one- or two-step repair fillings before and
an additive effect of several noxious agents, such as
after thermomechanical loading (TML).
caries, repeated fillings, periodontal disease, and
physical or restorative trauma.4,5 Extensive reduc-
METHODS AND MATERIALS
tion of the tooth structure to facilitate a similar path
of insertion in long-span FDP or to provide sufficient Ethical approval was obtained for the use of
space for all-ceramic restorations is another poten- extracted teeth for material testing of dental resto-
tial cofactor.3,6 rations. Seventy-two extracted human mandibular
In a recent review, factors influencing damage molars that had no caries, fractures, fillings, or
around endodontic access cavities and fracture restorations were selected. Teeth were kept in 0.1%
resistance of all-ceramic crowns after access repair thymol suspension for disinfection and to prevent
were investigated.7 Although the authors were not dehydration.26 The specimens were divided into six
able to provide a ‘‘best practice’’ clinical protocol, groups (n=12 per group) and labeled according to the
decisive factors were identified, such as the crown intended crown restoration type and the filling
material and its adhesive potential, the cement procedure (group 1: Zr-All; 2: Zr-All-1-st; 3: Zr-All-
material used, damage along the access cavity, and 2-st; 4: Zr-Ven; 5: Zr-Ven-1-st; 6: Zr-Ven-2-st; Figure
the ratio between cavity and crown size. 1,8-12 1).
Further, the grit size of the diamond bur used for
access preparation9 and the filling technique to Preparation of Specimens, Crown Fabrication,
restore the access cavity13 have been documented and Cementation
to influence fracture resistance of all-ceramic To simulate the periodontal ligament, a gum resin
crowns. While glass ceramic crowns had lower (Anti-Rutsch-Lack, Wenko-Wenselaar, Hilden, Ger-
fracture resistance than zirconia restorations,14 many) was applied in a thin layer on the root surface.
veneered (bilayered) zirconia was not as resistant To fix the specimens in the loading device, the roots
as monolithic zirconia.8,15 In lithium disilicate glass were embedded in acrylic resin (Dermotec 20,
ceramics, the use of larger-grit rotary diamonds (180 Dermotec Siegfried Demel, Nidderau, Germany).
lm) reduced the failure load of bonded restorations Teeth were prepared for crown restoration by two
Scioscia & Others: Endodontic Access and Repair Strategies in Zirconia All-Ceramic Crowns

Figure 1. Schematic overview of the study design and group treatment.

operators (AS and AH) according to the guidelines for anatomic contour of a mandibular molar were
Lava All-Zirconia restoration (3M ESPE). A circular designed and computerized, ensuring a minimal
shoulder preparation of 1 mm (horizontally) was crown thickness of 1 mm. Crowns were milled from
performed along the cemento-enamel junction using ceramic blocks (Lava, 3M ESPE), and the surfaces
cylindrical burs (no. 307 [106-lm grit] and no. 4315 were finally glazed. For groups 4 to 6, 3M zirconia
[40 lm-grit]; Intensiv, Grancia, Switzerland). Foot- copings of 0.5-mm thickness were manufactured
ball-shaped diamonds were used for the preparation (Lava, 3M ESPE). A professional dental technician
of the occlusal relief (no. 4250 [40-lm grit], no. 5250 (Diethard Schwarz, Dental Laboratory, Velden/Vils,
[15-lm grit]; Intensiv). While the no. 307 bur was Germany) conducted the feldspathic porcelain ve-
used only twice, the nos. 4315, 4250, and 5250 burs neering at a minimal thickness of 0.5 mm with final
were used a maximum of four times. Standardization glazing. Before cementation, the crown thickness of
of a similar preparation was ensured using a silicon each specimen was measured in the area of the
key (Affinis putty, Coltène, Whaldent, Altstätten, endodontic access with a thickness gauge (M&W
Switzerland) made from the original crown contour, Dental, Illnau, Switzerland). The prepared abut-
which was sectioned and applied during substance ment surface was cleaned with pumice mixed with
reduction to illustrate sufficient clearance. Ringer‘s solution (Ringer Ecotrainer Plus, B. Braun,
Digital impressions of all specimens were taken Maria Enzersdorf, Austria), rinsed with water, and
with the Lava scanner (3M ESPE). In groups 1 to 3, air-dried. The restorations were degreased with
the monolithic zirconia crowns representing the trichloroethylene (Merck KGaA, Darmstadt, Ger-
 Operative Dentistry

Figure 2. (a): Sample (no. 3) of group 2 Zr-All-1-st crown after cementation. (b): Endodontic access and cavity preparation. (c): Overview with
scanning electron microscope; detail indicated by square. (d): Detail of the restoration margin with 100% continuous margin before thermomechanical
loading. (e): Same area after thermomechanical loading with proportion of continuous margin reduced to 53%.

many) and cemented with a self-adhesive resin Intensiv) was used for each specimen in a high-
cement (RelyX Unicem, 3M ESPE).1 After initial speed hand piece (40,000 min 1) under water cooling
light curing for two seconds (Bluephase C8, Ivoclar (Figure 2a,b). The time required to penetrate the
Vivadent, Schaan, Liechtenstein), excess cement crown and complete the access cavity with all root
was removed, and final light curing was performed canal entrances was recorded in seconds. Root length
with 800-mW/cm2 light intensity from four direc- was defined based on the radiograph. Root canals
tions for 20 seconds each. Photographs and periapi- were prepared using rotary instruments (Mtwo,
cal radiographs (Insight Dental film, Kodak, Ro- VDW, Munich, Germany) up to a master apical file
chester, NY, USA) were taken, and after 10 minutes, 40/04. Between the different instrument sizes the
the specimens were stored again in the 0.1% thymol canals were flushed with 10 mL sodium hypochlorite
suspension. (1%, Caelo, Hilden, Germany). The root canals were
dried with paper points, coated with sealer (AH Plus,
Dentsply De Trey GmbH, Konstanz, Germany), and
Endodontic Access, Root Canal Treatment, and
filled with BeeFill 2 in 1 gutta-percha (BeeFill
Restoration of the Endodontic Access Cavity
Gutta-percha cartridge, VDW) by the warm vertical
The endodontic access preparation was performed by compaction technique. The gutta-percha filling was
two operators (AS and AH) applying a standardized then reduced with a round bur (0.9-1.4-mm diame-
trapezoidal access shape for mandibular molars. A ter, Komet, Lemgo, Germany) up to 1 mm under-
new cylindrical diamond (no. 307 [106-lm grit], neath the root canal orifice to increase the adhesive
Scioscia & Others: Endodontic Access and Repair Strategies in Zirconia All-Ceramic Crowns

surface for the filling material. The access cavity was samples were then loaded to fracture in a univer-
finished with cylindrical burs (no. 307 [106-lm grit] sal testing machine (Allround-Line, Zwick GmbH&
and no. 4315 [40-lm grit], Intensiv) and sandblasted Co., Ulm, Germany) and a 20-kN-load cell. Spec-
with 50 lm Al2O3 particles (Dento-Prep, Ronvig, imens were fixed in a metal holder with the long
Daugaard, Denmark) to remove any remnant of axis of the roots at an angle of 158 to the direction
sealer or gutta-percha and to increase adhesion. To of the load. A linear load (crosshead speed of 0.5
generate adhesion to both dentin and the ceramic mm/min) was applied in the direction of the
surface, a novel self-etch universal adhesive con- lingual cusp until fracture.
taining the functional monomer 10-methacryloylox-
ydecyl dihydrogen phosphate (10-MPD) and silane SEM Analysis of Marginal Quality
(Scotchbond Universal, 3M ESPE) was applied for 20 All replicas taken before and after TML were sputter
seconds, gently air-dried for five seconds, and light coated with gold (EMITECH K550 Emitech, Taunus
cured with Elipar S10 (3M ESPE) for 10 seconds. Stein, Germany) and numbered to facilitate a
The endodontic access cavities were then filled with blinded analysis by one of the authors (SS) not
a one- or two-step filling procedure, applying 2-mm involved in the restoration procedure. The restora-
layers of a universal composite (Filtek Supreme tion margins of the endodontic access cavities were
XTE, 3M ESPE). With the one-step procedure, the examined with a scanning electron microscope (DSM
cavity was filled with several layered increments. 940, Zeiss, Oberkochen, Germany) at 1003 to 10003
For the two-step procedure, composite layers were magnification and analyzed using dedicated mea-
applied until the level of the ceramic material was surement software (RaEm, programmer Peter Müll-
reached. The remaining cavity was then conditioned er, Würzburg, Germany). Prior to all measurements,
with silica coating (CoJet Sand, 3M ESPE), water a measuring grid (copper mesh, item no. S150,
sprayed and air-dried, silanated (ESPE Sil, 3M Plano, Wetzlar, Germany) was scanned, and the
ESPE), and air-dried after one minute. A light-cured measurement software was normalized at 1003
adhesive (Bonding Visio Bond, 3M ESPE) was magnification. Images of the restoration margins
applied for 20 seconds and light cured for 20 seconds, were saved and measured at 1003 magnification. To
and the filling was finished with two oblique layers. investigate the margin quality of the restorations,
For both techniques, the surface was finished with a criteria modified from the classification introduced
fine diamond bur (no. 4250 [40-lm grit], Intensiv) by Blunck and Zaslansky27 were applied to distin-
and polished with Occlubrush (Kerr, Bioggio, Swit- guish between 1) continuous margin (without any
zerland) and a one-step diamond paste (Unigloss, signs of gap formation), 2) noncontinuous margin
Intensiv). (hairline crack or gap), and 3) not judgeable margin
(due to excess composite material or fracture).27
Replica Before and After Fatigue Testing, Load Finally, the proportion of continuous margin in each
to Fracture specimen was calculated and presented as a per-
An impression of the sealed endodontic access centage of the individual judgeable margin (Figure
cavity was taken with a polyvinyl siloxane impres- 2c through e).
sion material (Affinis Regular Body). Replicas were
manufactured with epoxy resin (Stycast 1266 A & Statistical Analysis
B 2 Part clear epoxy, Emerson & Cuming, West- The prediction variable fracture load was log
erlo, Belgium). These replicas were controlled with transformed as verified by preliminary analysis,
an optical microscope (Wild M3B, Heerbrugg, including a quantile comparison plot. Descriptive
Switzerland) to ensure that the entire filling statistics included means (standard deviation) for
margins were visible. All specimens underwent metric variables and median (interquartile range)
TML in a chewing simulator (CoCoM 2, OOK, for fracture load. Linear models were performed to
Zürich, Switzerland). Stressing comprised 1.2 predict either thickness, time for access, or fracture
million occlusal loads of 49 N at 1.7 Hz and load; these models provided estimates of slope
simultaneous thermal cycling (3000 thermal cycles values (for continuous variables) or difference of
between 58C and 508C) using antagonistic natural means as well as ratios (for categorical variables).
teeth. Following TML, the specimens were visually For the percentage change of continuous margin
inspected, and the presence of any ceramic chip- (after vs before TML), linear regression models
ping or fracture was recorded. An additional set of were performed to compare crown (Zr-All vs Zr-Ven)
replicas was manufactured as described above. All and access restoration (2-st vs 1-st). The corre-
 Operative Dentistry

Table 1. Results of Different Parameters in the Six Groups With Crown Thickness, Time for Trepanation, Fracture Load, and
Changes in Continuous Margin Before and After Loading, Mean (Standard Deviation), and Median (Interquartile Range)
for Fracture Load
Material Zr-All (Monolithic) Zr-Ven (Veneered) p-Value
Control Test Control Test (All Groups)

Parameter 1 Zr-All 2 Zr-All-1-st 3 Zr-All-2-st 2 and 3 4 Zr-Ven 5 Zr-Ven-1-st 6 Zr-Ven-2-st 5 and 6

Crown 1.38 1.46 1.5 1.48 1.34 1.44 1.55 1.50 0.474
thickness (0.35) (0.26) (0.33) (0.29) (0.19) (0.29) (0.23) (0.26)
(lm)
Time for — 517 374 445 — 389 295 342 0.003
trepanation (80) (73) (105) (131) (89) (120)
(s)
Fracture load 5955 1975 3265 2705 2200 923 844 844 ,0.001
(N) (5105-6603) (1480-2335)b (2718-4540)b (1983-3698)a (1855-2400) (601-1274) (568-1008) (577-1141)a
Continuous — 67 71 69 — 66 67 66 0.838
margin (13) (21) (17) (10) (12) (11)
before load
(%)
Continuous — 28 31 30 — 33 43 38 0.148
margin after (19) (22) (20) (10)c (14)c (13)
load (%)
Change in — 39 40 40 — 34 24 29 0.121
continuous (16) (29) (23)a (10)c (12)c (12)a
margin (%)
p-values derived from analysis of variance (F-test) except for the following:
a
Statistically significant differences between groups 2 3 and 5 and 6 (fracture load p,0.001; rank sum test; change in continuous margin p=0.042; t-test).
b
Statistically significant differences between groups 2 and 3 (p,0.001; linear regression predicting log transformed fracture load values).
c
Statistically significant difference between groups 5 and 6 after load (p=0.038) and changes (p=0.043; t-test).

sponding 95% confidence intervals and p-values Load to fracture varied between 5814 6 1084 N for
were calculated for all regressions. Nested model Zr-All and 806 6 273 N for Zr-Ven-2-st (p,0.001).
designs were performed to separately analyze For both materials, fracture loads were significantly
selected study groups. The level of significance higher for preserved control groups than for the test
was set at a = 0.05. Adjustment of significance level groups (Table 1; Figure 3). Fracture loads were
for multiple comparisons was omitted because of the higher for Zr-All test specimens (groups 2 and 3;
descriptive nature of the study. All analyses were 2985 N) than for Zr-Ven specimens (groups 5 and 6;
performed with the statistical program R version 889 N; p,0.001). The comparison of one-step and
3.1.2 (R Core Team 2014).28 two-step filling restorations within the different
crown materials revealed significantly higher frac-
RESULTS ture loads for Zr-All-2-st than for Zr-All-1-st, while
The occlusal crown thickness in the area of the no difference existed between the two procedures in
access varied between 1.34 and 1.55 mm without the Zr-Ven groups 5 and 6 (Table 1).
significant differences among the groups (Table 1). The relative proportion of continuous margin
The time to complete the access cavity was along the endodontic access restoration varied
significantly longer for Zr-All crowns (groups 2 between 66% and 71% before TML and was reduced
and 3) with 445.3 6 104.5 seconds than for Zr-Ven to 28% to 43% after TML (Table 1; Figure 4). The
(groups 5 and 6) with 342.3 6 119.5 seconds deterioration of the marginal quality was greater in
(p=0.003). Visual inspection following chewing the Zr-All groups with 40% change compared with
simulation revealed that ceramic chippings had the Zr-Ven groups with 29% change of continuous
occurred in the Zr-Ven groups (two crowns in Zr- margin (p=0.042; Table 1). The reduction in the
Ven-1-st, four crowns in Zr-Ven-2-st), while no proportion of continuous margin was significantly
ceramic chipping or fracture was observed in greater with the one-step procedure (Zr-Ven-1-st
preserved Zr-Ven crowns (control group 4) or in 34%) than with the two-step procedure (Zr-Ven-2-st
any Zr-All specimens (groups 1 to 3). 24%; p=0.043).
Scioscia & Others: Endodontic Access and Repair Strategies in Zirconia All-Ceramic Crowns

Figure 4. Box plots of proportions of continuous margin before and

after thermomechanical loading in groups with repair fillings (groups 2,
Figure 3. Box plots of loads to fracture in groups 1 to 6. 3, 5, and 6).

DISCUSSION
clinic. The coarse-grit diamonds of 106 lm that
The aim of this in vitro experiment was to compare were used provided adequate access without weak-
monolithic and veneered zirconia crowns after access ening the ceramic integrity but may have resulted
cavity preparation, RCT, and repair fillings. It was in marginal microfractures. However, the docu-
observed that preparation of the access cavity mented preparation time of 7.25 minutes for
required more time in monolithic than in veneered monolithic zirconia crowns and 5.42 minutes for
crowns. Furthermore, loads to failure were signifi- veneered zirconia crowns would have been even
cantly higher in monolithic crowns than in veneered more prolonged with the use of smaller grit sizes. To
crowns, and the two-step filling technique had a avoid heat-induced crack initiation and propagation
positive influence on fracture resistance with mono- in the ceramic material, the use of a diamond bur
lithic crowns. While an approximately two-thirds- with sufficient water cooling has been recommend-
perfect margin of the repair filling was initially ed.11,29-31 Carbide burs were found to be ineffective
achieved with either technique, thermomechanical and associated with a higher risk of fractures and
load resulted in a deterioration of the marginal craze lines, particularly in glass-ceramic materi-
quality, particularly in the Zr-All groups, while the als.7,11,12 In an experimental study using lithium-
two-step filling procedure provided better marginal disilicate crowns (IPS e.max CAD) cemented with
integrity in veneered crowns. dual-polymerizing resin cement (Multilink Implant,
Ivoclar Vivadent), the use of a 126-lm-grit-size
In the present in vitro study, extracted human diamond rotary instrument and subsequent com-
teeth were used. Each tooth was individually posite filling restoration did not affect fracture load
prepared, and crown specimens were fabricated (3464 N) as compared to the unprepared control
with computer-assisted design and manufacturing (3316 N), while failure loads were reduced to 2915
in accordance with the manufacturers’ guidelines. A and 2354 N when using coarse-grit diamonds of 150
possible limitation of the current study protocol is and 180 lm, respectively.32 In the study by Qeblawi
that a certain variation in abutment dimensions and others,32 destructive experimental testing was
and crown thickness existed. In other experimental applied without any artificial aging, which is known
studies, standardized epoxy or composite resin dyes to have a considerable impact on the values
with similar crown specimens were used and RCT generated in load-to-fracture tests.33 In the current
was simulated.1,9,10 In the present study, RCT was experimental protocol, cyclic loading within physi-
performed in groups 2 to 5 to ideally reflect the ological limits and simultaneous thermocycling was
clinical situation. For the preparation of the selected, and the periodontal ligament was simu-
endodontic access cavity, new burs were used for lated to mimic oral cavity conditions.34 These
each specimen to ensure comparability, while factors may be responsible for the observed reduc-
repeated use of burs is common practice in the tion in fracture loads among repair restorations,
 Operative Dentistry

with none of them being able to restore the to zirconia restorations is challenging, and despite a
maximum load capability to the same level as was wide variety of recommended surface conditioning
recorded for the specimens without endodontic methods, to date no universally accepted protocol
access cavity. exists.37 In the present study, both repair methods
In a recent review of in vitro studies, protocols were applied for restoration of the access cavities of the
assessed with regard to fracture resistance of end- monolithic zirconia crowns showed favorable results
odontically accessed and repaired all-ceramic in terms of percentage of continuous margins.
crowns.7 In addition to the initial baseline strength However, gap formation significantly increased
under in vitro stress conditions, confirming previous
of the ceramic material, the application of adhesive
studies that revealed that artificial aging affects the
cementation techniques, the size of the access cavity
bonding effectiveness to zirconia.38,39 For the one-
in relation to the crown size, and the residual tooth
step protocol, a universal adhesive containing the
structure were discussed as potential key factors
phosphate-based functional monomer 10-MDP was
influencing fracture resistance.7 In the current study,
selected because of its proven chemical bonding
higher fracture resistance was found with monolithic
capability to zirconia. However, since 10-MDP is
compared to veneered all-ceramic crowns. Following
one among many ingredients mixed into one solu-
endodontic access and cavity restoration, veneered
tion, bond durability to zirconia is inferior compared
crowns demonstrated reduced fracture values of 955
to dedicated ceramic primers based on the same
and 806 N, which is close to the maximal bite forces of
monomer.38 These factors are possibly responsible
807 6 140 N in the molar region of 20- to 24-year-old
for the rather low marginal quality achieved in
males35 but exceeds normal chewing forces ranging
group Zr-All-1-st after TML.
from 70 to 150 N.36 Previous studies have demon-
strated favorable mechanical properties for monolith- For the veneered zirconia crowns, both repair
ic crowns compared to veneered all-ceramic restora- protocols used in the present study comprised
tion.14,15 Highest loads to fracture were documented silanization because there is consensus that appli-
for monolithic zirconia crowns (6517 N), while for the cation of a silane after mechanical conditioning of
two veneered designs with or without a cervical collar the veneering porcelain is crucial to achieve a
of zirconia, average values of 4712 and 4091 N, chemical bond to the composite resin.40 In the one-
respectively, were achieved.15 For veneered Procera step protocol, the silane is incorporated into the
crowns cemented with Rely X Luting Plus cement formulation of the utilized adhesive Scotchbond
(3M ESPE) on epoxy resin dies and provided with Universal. In this group, marginal quality was
repair fillings, the endodontic access did not influence inferior, though not statistically significant, com-
failure loads of alumina crowns (1459 N control, 1531 pared to the two-step approach. These findings are
N with access restoration), while data for zirconia comprehensible since there is recent evidence that
showed differences with 2514 N for the unprepared the silane coupling agent in universal adhesives is
control and 2246 N for the repaired crowns.1 less efficient compared to dedicated silanes.41-44

In the current study, ceramic chipping during CONCLUSIONS

TML occurred in six out of 24 veneered and prepared
crown specimens, while no chipping fractures were It can be concluded that the two-step repair filling
observed in the unprepared control group Zr-Ven with silica coating, silanization, and bonding of the
and in none of the monolithic crowns. Edge chipping marginal crown material led to improved fracture
around the endodontic access restoration was also loads in monolithic zirconia crowns and better
observed when Procera crowns were loaded to marginal integrity in veneered zirconia restorations
failure.1 In this experimental study, Procera crowns as compared to the one-step filling. While monolithic
were fabricated based on alumina and zirconia restorations provided generally higher fracture loads
copings with the veneering porcelain pressed over and no chipping fractures, more time was required
the copings.1 In alumina crowns, core fractures and for preparing the endodontic access cavity than in
veneer shear were observed, while with zirconia veneered zirconia crowns.
copings, the veneering delaminated frequently from
the core.1 Analyzing the occlusal surface following Acknowledgements
endodontic access preparation in monolithic and The authors would like to thank Günther Smailus (Intensiv,
veneered zirconia three-unit FDP also demonstrated Grancia, Switzerland) for supporting this study with diamond
burs, Diethard Schwarz (Dental Laboratory, Velden/Vils,
that more microfractures and chippings occurred in Germany) for the dedicated work with the crown veneering,
veneered restorations.8,11 Achieving durable bonding and Prof Dr Susanne Scherer (University of Geneva, Switzer-
Scioscia & Others: Endodontic Access and Repair Strategies in Zirconia All-Ceramic Crowns

land) and Stefan Keß (University of Würzburg, Germany) for 11. Sutherland JK, Teplitsky PE, & Moulding MB (1989)
their support in conducting the SEM analyses. The authors Endodontic access of all-ceramic crowns Journal of
acknowledge Urs Simmen (Simmenstat, Basel, Switzerland) Prosthetic Dentistry 61(2) 146-149.
for the statistical analyses and James Ashman, PhD (Basel,
Switzerland), for proofreading the final draft of the manu- 12. Teplitsky PE, & Sutherland JK (1985) Endodontic access
script. of Cerestore crowns. Journal of Endodontics 11(12)
558-558.
Regulatory Statement 13. Mulvay PG, & Abbott PV (1996) The effect of endodontic
access cavity preparation and subsequent restorative
This study was conducted in accordance with all the
procedures on molar crown retention Australian Dental
provisions of the local human subjects oversight committee
guidelines and policies of the Ethik beider Basel. The approval Journal 41(2) 134-139.
code for this study is EK 221/12. 14. Guazzato M, Proos K, Sara G, & Swain MV (2004)
Strength, reliability, and mode of fracture of bilayered
Conflict of Interest porcelain/core ceramics International Journal of Prostho-
dontics 17(2) 142-149.
The authors of this article certify that they have no
proprietary, financial, or other personal interest of any nature 15. Oilo M, Kvam K, & Gjerdet NR (2016) Load at fracture of
or kind in any product, service, and/or company that is monolithic and bilayered zirconia crowns with and
presented in this article. without a cervical zirconia collar Journal of Prosthetic
Dentistry 115(5) 630-636.
(Accepted 27 April 2017) 16. Guazzato M, Albakry M, Swain MV, & Ironside J (2004)
Mechanical properties of in-ceram alumina and in-ceram
REFERENCES zirconia International Journal of Prosthodontntics 15(4)
1. Wood KC, Berzins DW, Luo Q, Thompson GA, Toth JM, & 339-346.
Nagy WW (2006) Resistance to fracture of two all-ceramic 17. Lucas TJ, Lawson NC, Janowski GM, & Burgess JO
crown materials following endodontic access Journal of (2015) Phase transformation of dental zirconia following
Prosthetic Dentistry 95(1) 33-41. artificial aging Journal of Biomedical Materials Research
2. Karlsson S (1986) A clinical evaluation of fixed bridges, 10 Part B: Applied Biomaterials 103(7) 1519-1523.
years following insertion Journal of Oral Rehabilitation 18. Hachmeister KA, Dunn WJ, Murchison DF, & Larsen RB
13(5) 423-432. (2002) Fracture strength of amalgam crowns with
repaired endodontic access Operative Dentistry 27(3)
3. Cheung GS, Lai SC, & Ng RP (2005) Fate of vital pulps
254-258.
beneath a metal-ceramic crown or a bridge retainer
International Endodontic Journal 38(8) 521-530. 19. Ray HA, & Trope M (1995) Periapical status of endodon-
tically treated teeth in relation to the technical quality of
4. Ericson S, Hedegard B, & Wennström A (1966) Roent-
the root filling and the coronal restoration International
genographic study of vital abutment teeth Journal of
Endodontic Journal 28(1) 12-18.
Prosthetic Dentistry 16(5) 981-987.
20. Schwartz RS, & Fransman R (2005) Adhesive dentistry
5. Pjetursson BE, Sailer I, Zwahlen M, & Hämmerle CH and endodontics: materials, clinical strategies and proce-
(2007) A systematic review of the survival and complica- dures for restoration of access cavities: A review Journal
tion rates of all-ceramic and metal-ceramic reconstruc- of Endodontics 31(3) 151-165.
tions after an observation period of at least 3 years. Part I:
Single crowns Clinical Oral Implants Research 21. Schwartz RS, & Robbins JW (2004) Post placement and
18(Supplement 3) 73-85. restoration of endodontically treated teeth: A literature
review Journal of Endodontics 30(5) 289-301.
6. Randow K, & Glantz PO (1986) On cantilever loading of
vital and non-vital teeth: An experimental clinical study 22. Wolfart M, Lehmann F, Wolfart S, & Kern M (2007)
Acta Odontologica Scandinavica 44(5) 271-277. Durability of the resin bond strength to zirconia ceramic
after using different surface conditioning methods Dental
7. Gorman CM, Ray NJ, & Burke FM (2016) The effect of Materials 23(1) 45-50.
endodontic access on all-ceramic crowns: A systematic
review of in vitro studies Journal of Dentistry 53 22-29. 23. Oguri T, Tamaki Y, Hotta Y, & Miyazaki T (2012) Effects
of a convenient silica-coating treatment on shear bond
8. Grobecker-Karl T, Christian M, & Karl M (2016) Effect of strengths of porcelain veneers on zirconia-based ceramics
endodontic access cavity preparation on monolithic and Dental Materials Journal 31(5) 788-796.
ceramic veneered zirconia restorations Quintessence
International 47(9) 725-729. 24. Xie H, Chen C, Dai W, Chen G, & Zhang F (2013) In vitro
short-term bonding performance of zirconia treated with
9. Qeblawi D, Hill T, & Chlosta K (2011) The effect of hot acid etching and primer conditioning etching and
endodontic access preparation on the failure load of primer conditioning Dental Materials Journal 32(6)
lithium disilicate glass-ceramic restorations Journal of 928-938.
Prosthetic Dentistry 106(5) 328-336.
25. Xie H, Li Q, Zhang F, Lu Y, Tay FR, Qian M, & Chen C
10. Stokes AN, Hood JA, Casley PB, Cawley RM, & Cho GJ (2016) Comparison of resin bonding improvements to
(1988) Endodontic access cavities in porcelain jacket zirconia between one-bottle universal adhesives and
crowns—Two methods of repair compared Restorative tribochemical silica coating, which is better? Dental
Dentistry 4(3) 56-58. Materials 32(3) 403-411.
 Operative Dentistry

26. Preston KP, Higham SM, & Smith PW (2007) The efficacy force endurance, and facial morphology during growth: A
of techniques for the disinfection of artificial sub-surface cross-sectional study Acta Odontologica Scandinavica
dentinal caries lesions and their effect on demineraliza- 51(5) 323-331.
tion and remineralization in vitro Journal of Dentistry
36. Tortopidis D, Lyons MF, Baxendale RH, & Gilmour WH
35(6) 490-495.
(1998) The variability of bite force measurement between
27. Blunck U, & Zaslansky P (2011) Enamel margin integrity sessions, in different positions within the dental arch
of class I one-bottle all-in-one adhesives-based restora- Journal of Oral Rehabilitation 25(9) 681-686.
tions Journal of Adhesive Dentistry 13(1) 23-29.
37. Tzanakakis EG, Tzoutzas IG, & Koidis PT (2016) Is there
28. R Core Team (2014) A language and environment for a potential for durable adhesion to zirconia restorations?
statistical computing. R Foundation for Statistical Com- A systematic review Journal of Prosthetic Dentistry
puting, Vienna, Austria. http://www.R-project.org 115(1) 9-19.
29. Davis MW (1998) Providing endodontic care for teeth 38. Inokoshi M, Poitevin A, De Munck J, Minakuchi S, & Van
with ceramic crowns Journal of the American Dental Meerbeek B (2013) Bonding effectiveness to different
Association 129(12) 1746-1747. chemically pre-treated dental zirconia Clinical Oral
Investigations 18(7) 1803-1812.
30. Haselton DR, Lloyd PM, & Johnson WT (2000) A
comparison of the effects of two burs on endodontic access 39. Ozcan M, & Bernasconi M (2015) Adhesion to zirconia
in all-ceramic high lucite crowns Oral Surgery, Oral used for dental restorations: A systematic review and
Medicine, Oral Pathology, Oral Radiology and Endodon- meta-analysis Journal of Adhesive Dentistry 17(1) 7-26.
tics 89(4) 486-492.
40. Kimmich M, & Stappert CFJ (2013) Intraoral treatment
31. Zhang Y, Han Y, Chu Z, He S, Zhang J, & Feng Y (2013) of veneering porcelain chipping of fixed dental restora-
Thermally induced structural transitions from fluids to tions Journal of the American Dental Association 144(1)
hydrogels with pH-switchable anionic wormlike micelles 31-44.
Journal of Colloid and Interface Science 394 319-328.
41. Kalavacharla VK, Lawson NC, Ramp LC, & Burgess JO
32. Qeblawi D, Hill T, & Chlosta K (2011) The effect of (2015) Influence of etching protocol and silane treatment
endodontic access preparation on the failure load of with a universal adhesive on lithium disilicate bond
lithium disilicate glass-ceramic restorations Journal of strength Operative Dentistry 40(4) 372-378.
Prosthetic Dentistry 106(5) 328-336.
42. Kim RJY, Woo JS, Lee IB, Yi YA, Hwang JY, & Seo DG
33. Naumann M, Sterzenbach G, & Proschel P (2005) (2015) Performance of universal adhesives on bonding to
Evaluation of load testing of postendodontic restorations leucite-reinforced ceramic Biomaterials Research 19(1)
in vitro: Linear compressive loading, gradual cycling 11.
loading and chewing simulation Journal of Biomedical
43. Passia N, Lehmann F, Freitag-Wolf S, & Kern M (2015)
Materials Research Part B: Applied Biomaterials 74(2)
Tensile bond strength of different universal adhesive
829-834.
systems to lithium disilicate ceramic Journal of the
34. Brosh T, Porat N, Vardimon AD, & Pilo R (2011) American Dental Association 146(10) 729-734.
Appropriateness of viscoelastic soft materials as in vitro
44. Yoshihara K, Nagaoka N, Sonoda A, Maruo Y, Makita Y,
simulators of the periodontal ligament Journal of Oral
Okihara T, Irie M, Yoshida Y, & Van Meerbeek B (2016)
Rehabilitation 38(12) 929-939.
Effectiveness and stability of silane coupling agent
35. Kiliaridis S, Kjellberg H, Wenneberg B, & Engström C incorporated in ‘‘universal’’ adhesives Dental Materials
(1993) The relationship between maximal bite force, bite 32(10) 1218-1225.