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Case Report

Mouth Rehabilitation Using Ceramic Endocrown with Deep Marginal Elevation Technique

Areej A Dirham and Ehab N Alshouibi*

Faculty of Dentistry, King AbdullAziz University, Jeddah, Saudi Arabia

Citation: Areej A Dirham and Ehab N Alshouibi. “Mouth Rehabilitation Using Ceramic Endocrown with Deep Marginal Elevation Technique”. EC Dental Science 19.3 (2020): 01-12.

*Corresponding Author: Ehab N Alshouibi, Assistant Professor in Dental Public Health, Consultant in Restorative and Esthetic Entistry, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia.

Received: January 27, 2020; Published: February 21, 2020

Background

In the clinical setting, it is common to find teeth that have lost part of their structure, affecting at least one of the proximal areas. It must be kept in mind that proximal caries with deep cervical margins are particularly complex to manage clinically. In addition to the loss of tooth structure, the sub-gingival position hinders clinical management. Therefore, reconstruction of such cavities is a challenge for the operator from endodontic, restorative, and periodontal perspectives [1]. Despite restorative sealing becoming almost unreachable in a proportion of cases, most other cases are complicated by the absence of enamel and the complexity of the isolation [2]. There are various

AbstractAim: This article presents an advanced therapeutic approach to rehabilitate the mouth and to restore the endodontically-treated teeth(ETT) based entirely on adhesive dentistry.

Background: The restoration of (ETT) has been widely and controversially discussed in the dental literature, most of which recommends cuspal coverage of ETT to protect against potential tooth fracture. The main goal of conservative dentistry in managing ETT is to achieve minimally invasive preparation with maximal cuspal coverage. The “endocrown” follows this rationale. In addition, proximal caries with deep cervical margins are particularly complex to manage clinically. Moreover, there are various clinical approaches to such challenges, such as placing a base of composite resin to coronally displace proximal margins underneath indirect bonded restorations restorations as known as deep margin elevation(DME) or coronal margin relocation.

Case Description: This study is a clinical case report of a excellent clinical result was achieved by restoring esthetics and function of the ETT using ceramic endocrowns. In combination with the clinical procedure presented here, some of the ETT with deep cervical margins were managed by applying direct composite resin restoration using the DME technique.

Conclusion and Clinical Significance: The ideal treatment of ETT has been widely and controversially discussed in the literature. Based on current evidence, endocrowns can be considered a reliable treatment option for moderately mutilated ETT. The achieved adhesive monoblock system reduces the need for macro-retentive geometry and provides an efficient outcome and better esthetics.

Furthermore, the DME technique represents another useful treatment approach for patients with financial restrictions and those with higher risk of negative outcomes involving more invasive surgical procedures. Thus, it could be used in clinical situations with deep subgingival cervical margin where isolation with a rubber dam remains possible and adequate periodontal biological width is available.

Keywords: Case Report; Endocrown; E-max Ceramic; Deep Marginal Elevation; Coronal Margin Relocation; Coronal Rehabilitation; Endodontically Treated Teeth; Adhesive Dentistry

Citation: Areej A Dirham and Ehab N Alshouibi. “Mouth Rehabilitation Using Ceramic Endocrown with Deep Marginal Elevation Technique”. EC Dental Science 19.3 (2020): 01-12.

Mouth Rehabilitation Using Ceramic Endocrown with Deep Marginal Elevation Technique

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clinical approaches to such challenges. One of these approaches was presented by Dietschi and Spreafico in 1998 [3] and again by Magne in 2012 [4], which was to place a base of composite resin to coronally displace proximal margins underneath indirect bonded restorations. This procedure, known as deep margin elevation (DME) or coronal margin relocation, is performed under rubber dam isolation following the placement of a matrix system, thereby facilitating the creation of planned and well-placed composite resin margins in this area [5].

The restoration of endodontically-treated teeth (ETT) has been widely and controversially discussed in the dental literature. Most of the dental literature recommends cuspal coverage of ETT to protect against potential tooth fracture [6]. The main goal of conservative dentistry in managing ETT is to achieve minimally invasive preparation, with maximal cuspal coverage [7,8]. The “endocrown” follows this rationale, with an indirect ceramic prosthesis fixed to the depulped posterior tooth. It is anchored to the internal portion of the pulp chamber and the cavity margins, thus obtaining macro- and micro-mechanical retention by using adhesive cementation [9-11]. The concept of using a radicular configuration for the restoration of a missing coronal structure is not new. The first study published on endocrown restoration was conducted by Pissis in 1995 [12]. However, it was Bindl and Mörmann who named this restorative procedure endocrown in 1999 [13].

This article presents an advanced therapeutic approach based entirely on adhesive dentistry. In this study, we share a clinical case report of posterior teeth rehabilitation using endocrown restoration performed on ETT with extensive coronal destruction. Together with the clinical procedure presented here, some of the ETT with deep cervical margins were managed by applying a direct composite resin restoration using the DME technique.

Case Description

A 21-year-old female visited the dental clinic at King AbdulAziz University Faculty of Dentistry (KAUFD) with defective composite restorations on all the upper and lower molars with recurrent caries. All teeth received root canal treatment. A review of her medical history revealed no medical disease and no known allergy. She was a non-smoker and took no medications or supplements.

As for the teeth, #46, 36 revealed that the distance between the cavity margins and the alveolar bone crest were between 0.5 and 1 mm (Figure 1 and 2). Due to the existence of some distance to the bone crest, this would allow the use of a circumferential matrix system, such as the Tofflemire Matrix. The Tofflemire Matrix band was modified manually at the gingival half to allow for better root adaptation and deep sulcular seating. Then the Tofflemire Matrix band was utilized to raise the margin with composite (DME) under rubber dam isolation, creating a basis for the future restorations.

Figure 1

Citation: Areej A Dirham and Ehab N Alshouibi. “Mouth Rehabilitation Using Ceramic Endocrown with Deep Marginal Elevation Technique”. EC Dental Science 19.3 (2020): 01-12.

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Figure 2

Prior to bonding, the margin was minimally adjusted using a fine diamond bur. Afterward, DME was performed using a conventional two-step adhesive system (Excite DS, Ivoclar/Vivadent) followed by placement of flowable composite resin (Tetric Evo Flow, Ivoclar/Vivadent, Liechtenstein, Germany) on the cavity margin. Then, another layer of packable composite resin was placed (Tetric Evo Ceram, Ivoclar/Vivadent) to relocate the margin by approximately 2 mm coronally. Final polymerization was done through a layer of glycerin gel. Once the modified matrix band is removed, the preparation was completed by careful elimination of excess composite around the tooth using a no. 12 blade. A bitewing radiograph was taken to confirm the adaptation of the composite resin in the gingival area before proceeding with the final preparations and impression (Figure 3 and 4).

Figure 3

Citation: Areej A Dirham and Ehab N Alshouibi. “Mouth Rehabilitation Using Ceramic Endocrown with Deep Marginal Elevation Technique”. EC Dental Science 19.3 (2020): 01-12.

Mouth Rehabilitation Using Ceramic Endocrown with Deep Marginal Elevation Technique

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After removal of defective restoration and excavation of recurrent caries, the clinical evaluation revealed an adequate remaining tooth structure, where at least 50% of the remaining tooth structure was present with a minimum axial wall thickness of 2 mm. Therefore, endocrown was considered as a feasible, effective, and conservative treatment approach. The preparation was adapted from the technique recommended by Bindl., et al [13]. With 2 mm occlusal reduction to create enough occlusal clearance for lithium-disilicate based ceramic. The orifices of the root canals were sealed with a flowable resin composite (Tetric Flow, Ivoclar/Vivadent, Liechtenstein, Germany). The axial cavity walls were reinforced with micro hybrid resin composite (Tetric Ceram, Ivoclar/Vivadent) to fill undercuts and to ensure the correct design of the preparations. Finally, the chamfered margins and axial walls were smoothened with a tapered diamond bur. The preparation inside the pulp chamber promoted the mechanical retention and stability of the endocrown,as the pulp chamber was 2 - 3 mm in depth with the presence of circumferential wall height of at least 4 mm (Figure 5). Gingival displacement and hemostatic control were done with double retraction cord of 00 and 0 sizes (Ultrapak, Ultradent) impregnated in the hemostatic gel (Vicostat, Ultradent). Next, a polyvinyl siloxane silicone impression (Elite HD, Zhermack GmbH) of light and heavy consistency was taken with a simultaneous molding technique (Figure 6). The temporary restoration was performed with self-polymerizing acrylic resin (Protemp 3M ESPE, Deutschland GmbH), shade A2, with adequate gingival margins adaptation to ensure healthy gingival tissue.The impression of the antagonist arch was taken with the same technique (Figure 7) and both impressions were sent to the prosthesis laboratory with bite registration.The endocrowns were fabricated from pressed lithium disilicate-based ceramic (IPS e. Max Press, Ivoclar Vivadent), shade A2 (Figure 8-12).

Figure 4

Figure 5

Citation: Areej A Dirham and Ehab N Alshouibi. “Mouth Rehabilitation Using Ceramic Endocrown with Deep Marginal Elevation Technique”. EC Dental Science 19.3 (2020): 01-12.

Mouth Rehabilitation Using Ceramic Endocrown with Deep Marginal Elevation Technique

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Figure 6

Figure 7

Figure 8

Citation: Areej A Dirham and Ehab N Alshouibi. “Mouth Rehabilitation Using Ceramic Endocrown with Deep Marginal Elevation Technique”. EC Dental Science 19.3 (2020): 01-12.

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Figure 9

Figure 10

Figure 11

Citation: Areej A Dirham and Ehab N Alshouibi. “Mouth Rehabilitation Using Ceramic Endocrown with Deep Marginal Elevation Technique”. EC Dental Science 19.3 (2020): 01-12.

Mouth Rehabilitation Using Ceramic Endocrown with Deep Marginal Elevation Technique

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In the cementation session, the provisional crowns were removed, and the preparation margins were cleaned with Proxyt pink polishing paste (Ivoclar/Vivadent, Schaan, Liechtenstein). The endocrown was tried-in, then the bonding surface of prosthetic restorations was cleaned using Ivoclean (Ivoclar/Vivadent, Schaan, Liechtenstein). The fitting surface of the endocrown ceramic was etched and salinated using hydrofluoric acid (IPS Ceramic Etching Gel, Ivoclar/Vivadent, Schaan, Liechtenstein) and Monobond Plus (Ivoclar/Vivadent, Schaan, Liechtenstein) respectively. All indirect restorations were adhesively cemented using a dual-polymerizing resin cement (Variolink Esthetic DC, Ivoclar/ Vivadent AG). Each endocrown was seated with adequate pressure onto the preparation, excess cement was removed, and light activation was performed. Occlusion was checked, and no major occlusal adjustments were necessary after cementation (Figure 13-16).

Figure 12

Figure 13

Citation: Areej A Dirham and Ehab N Alshouibi. “Mouth Rehabilitation Using Ceramic Endocrown with Deep Marginal Elevation Technique”. EC Dental Science 19.3 (2020): 01-12.

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Figure 14

Figure 15

Citation: Areej A Dirham and Ehab N Alshouibi. “Mouth Rehabilitation Using Ceramic Endocrown with Deep Marginal Elevation Technique”. EC Dental Science 19.3 (2020): 01-12.

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Figure 16

Discussion

Endocrown appears to be a valuable and effective treatment option for ETT with moderate to extensive loss of coronal tooth structure. Endocrown has been recommended for teeth with short clinical crown and calcified, short, or curved root canals that make post and core restorations impossible [14]. Endocrown can also be used in patients with limited interocclusal space, which prevents adequate thickness for both the ceramic veneer over metal or ceramic framework [15].

However, this treatment approach should be restricted to the functional and esthetic reconstruction of molars rather than premolars.This is because the clinical performance of endocrown in premolars against the action of masticatory forces has not been as effective as that achieved in molars [16,17]. It is suggested that the smaller dental structure area of the pulp chamber, the offset angulation of the premolars crown, and the smaller adhesive surface of the premolars might limit the bond strength of adhesive systems and resin cements [18]. The dental literature suggests that endocrowns have shown satisfactory performance in relation to the action of occlusal forces, esthetic reconstruction, and bond strength when restricted to the posterior molar teeth [19-21].

Endocrowns have several advantages over conventional crowns, such as a reduced number of interfaces in the restorative system. Stress concentration is less because of the reduction in the non-homogenous material present [22,23]. The preparation design is conservative compared to the traditional crown [7]. In comparison to the post and core restorations, the bonding surface offered by the pulpal chamber of the endocrown is often equal or even superior to that obtained from the bonding of a radicular post of 8 mm depth. The application and polymerization of resins are also better controlled [24]. In 2012, Biacchi and Basting [14] observed greater resistance to compression forces of endocrown restorations, compared with traditional crowns supported on fiber posts, when these restorations were made with lithium disilicate ceramic. The DME technique should not be used as an alternative to surgery. Instead, this technique should be reserved to cases where surgical crown lengthening might be precluded by furcation, root concavity, a patient’s medical history, patient’s age, and/

Citation: Areej A Dirham and Ehab N Alshouibi. “Mouth Rehabilitation Using Ceramic Endocrown with Deep Marginal Elevation Technique”. EC Dental Science 19.3 (2020): 01-12.

Mouth Rehabilitation Using Ceramic Endocrown with Deep Marginal Elevation Technique

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Bibliography

or patient’s finances [25]. Martins., et al. showed that the presence of a deep subgingival adhesive margin might not affect the periodontal status of the restored tooth [26]. It actually showed a binding capacity of the fibers of epithelial tissue to the surface of resin restorations, provided that the adaptation, polishing and hygiene conditions are optimal [27].

The limitation of these two techniques are associated with the materials used. For the endocrown, it must be an acid-etchable ceramic to obtain a superior bond to tooth preparation using an adhesive cementation system, and, consequently, ensure the stability of the prosthetic piece in the preparation [28]. The type of restoration, marginal quality, and proximity to biological width are determining factors for successful clinical performance of DME.

Clinical significance

As presented in this case report, instead of modifying the existing tooth structure to suit the restorative needs of indirect crown restoration, composite resin restoration was used to block all pulpal and coronal undercuts, thereby further conserving sound tooth structure, facilitating the path of insertion, and enhancing retention form and resistance form [29]. The endocrown is luted with resin cement. The adhesive monoblock system achieved reduces the need for macro-retentive geometry and provides a more efficient outcome and better esthetics [30,31].

The DME technique could be used in clinical situations with deep subgingival cervical margin in which isolation with a rubber dam remains possible and adequate periodontal biological width is available, to facilitate isolation for bonding and impression maneuvers respectively [32,33].

Conclusion

The ideal treatment of ETT has been widely and controversially discussed in the literature. Based on current evidence, endocrowns can be considered as a reliable treatment option for moderately mutilated ETT. The DME technique represents another useful treatment approach for patients with financial restrictions and those who are at higher risk of negative outcomes with more invasive surgical procedures. DME and endocrown conform to the main goal of restorative dentistry; the conservation of tooth structure. However, long-term follow-up and longitudinal clinical studies are needed to ensure their overall success.

Conflict of Interest

The authors of this manuscript certify that they have no proprietary, financial, or other personal interest of any nature or kind in any product, service, and/or company that is presented in this article.

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Citation: Areej A Dirham and Ehab N Alshouibi. “Mouth Rehabilitation Using Ceramic Endocrown with Deep Marginal Elevation Technique”. EC Dental Science 19.3 (2020): 01-12.

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Citation: Areej A Dirham and Ehab N Alshouibi. “Mouth Rehabilitation Using Ceramic Endocrown with Deep Marginal Elevation Technique”. EC Dental Science 19.3 (2020): 01-12.

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Volume 19 Issue 3 March 2020©All rights reserved by Areej A Dirham and Ehab N Alshouibi.

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