CLINICAL RESEARCH

Evaluation of the marginal and internal discrepancies

of CAD/CAM endocrowns with different cavity depths:
An in vitro study
Yooseok Shin, DDS, PhD,a Sungho Park, DDS, PhD,b Jeong-Won Park, DDS, PhD,c
Kwang-Mahn Kim, DDS, PhD,d Young-Bum Park, DDS, PhD,e and Byoung-Duck Roh, DDS, PhDf
An endocrown is a 1-piece
ABSTRACT
restoration for endodontically
Statement of problem. The marginal and internal discrepancies of computer-aided design/
treated teeth that has develcomputer-aided manufacturing (CAD/CAM) endocrowns are unknown.
oped with advances in adhesive
Purpose. The purpose of this in vitro study was to evaluate the marginal and internal discrepancies
techniques.1 It consists of a
of endocrowns with different cavity depths by measuring them with microcomputed tomography
crown part and a cavity part in(mCT).
side the pulp chamber and uses
Material and methods. Endocrowns (n=48) of 2 different cavity depths (2 mm and 4 mm) were
the pulpal chamber surface to
fabricated in 2 different chairside CAD/CAM systems (CEREC AC and E4D). A mCT scan was made
achieve stability and retention
before and after cementation. For analysis of the marginal and internal discrepancies, reference
of the restoration by means of
points were selected in 2-dimensional views of 3 buccolingual cross-sections and 3 mesiodistal
adhesive cementation instead
cross-sections. To calculate the total discrepancy volume, the mCT sections were reconstructed 3of a post and core system. With
dimensional views, and changes in volume and surface area were examined. Statistical analysis
was performed using 2-way ANOVA with Bonferroni correction (a=.05).
the development of computeraided design/computer-aided
Results. An endocrown with a 4-mm cavity showed a larger marginal and internal volume than one
manufacturing
(CAD/CAM)
with a 2-mm cavity. Cementation did not show signicant differences in total discrepancy thickness.
technology, endocrowns could
Discrepancies on the pulpal oor were largest in other sites. Both chairside CAD/CAM systems
showed similar discrepancy in the endocrowns.
be made more simply.
According to research on
Conclusions. Based on the present study, marginal and internal discrepancies increased depending
CAD/CAM endocrowns, the
on cavity depth. Cementation did not increase the dimension of the discrepancy between the
restoration and the cavity wall. The discrepancy on the pulpal oor appeared to affect these
overall failure rate of an
results. (J Prosthet Dent 2016;-:---)
endocrown and a conventional
single crown is similar under
loading. However, the fracture resistance of an endoFRC post.3,4 Thus, an endocrown is suitable for restoring
crown is higher than that of the conventional single
endodontically treated teeth from restorative, esthetic,
crown in fatigue fracture testing.2 Finite element analysis
and clinical viewpoints.5
has revealed low stress values in endocrowns compared
Recently, a chairside operation using CAD/CAM
with conventional crowns; endocrowns are more resishas been demonstrated to simplify the procedure for
tant to stress than are conventional crowns with an
providing endocrowns, minimizing the chair time and
Supported by grant No. 6-2015-0104 from a faculty research grant of Yonsei University, College of Dentistry, Seoul, Republic of Korea.
a
Clinical Assistant Professor, Department of Conservative Dentistry, Oral Science Research Center, College of Dentistry, Yonsei University, Seoul, Republic of Korea.
b
Professor, Department of Conservative Dentistry, Oral Science Research Center, College of Dentistry, Yonsei University, Seoul, Republic of Korea.
c
Professor, Department of Conservative Dentistry, College of Dentistry, Gangnam Severance Hospital, Yonsei University, Seoul, Republic of Korea.
d
Professor, Department of Dental Biomaterials, College of Dentistry, Yonsei University, Seoul, Republic of Korea.
e
Professor, Department of Prosthodontics, College of Dentistry, Yonsei University, Seoul, Republic of Korea.
f
Professor, Department of Conservative Dentistry, Oral Science Research Center, College of Dentistry, Yonsei University, Seoul, Republic of Korea.

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Clinical Implications
The marginal and internal discrepancies of
computer-aided design/computer-aided
manufacturing endocrowns increased depending
on cavity depth. Dentists should be aware of
possible discrepancies on the pulpal oor in deep
endocrown restorations.

providing esthetically excellent ceramic restorations.

CEREC AC (Sirona Dental Systems) and E4D Sky (E4D
technologies) are popular dental CAD/CAM systems.
These systems use an optical impression to capture the
prepared tooth with a short capture time. However, the
systems use different scanning methods, including light
source, contrast powder usage, scanning size, and clarity
between the margin of the prepared teeth and surrounding gingival structures.6
Ceramic materials for CAD/CAM endocrowns have to
offer appropriate strength and esthetics.7 Materials with
high rigidity such as lithium disilicate can endure occlusal
stress and are reported to be reliable material for single
crowns.8 Furthermore, the use of a single restoration
material in an endocrown can reduce the stress concentration that results from material property differences.3 Additionally, adhesive failure can be minimized
because the interface exists only between the 1-piece
restoration and the tooth material.9
Minimal marginal and internal discrepancies are
crucial for the clinical outcome of dental restorations.10
Marginal and internal discrepancies have been determined by using a variety of measuring techniques: dental
probing,1 mid-buccal sectioning of specimens with a
diamond disk after embedding in acrylic resin,11,12 direct
measurement with a light microscope,13 or a replica
technique with polyvinyl siloxane impression materials.14,15 Most discrepancy measurement methods are
indirect and invasive. Recently, mCT has been introduced
to evaluate the internal structure of teeth noninvasively.
This technique provides 3-dimensional images of small
specimens with high resolution and is used for
measuring the amount of shrinkage and marginal and
internal discrepancies in dentistry.16,17
The clinically acceptable range of a marginal
discrepancy is less than 120 mm in terms of longevity of
the restoration.18 However, the initial CAD/CAM restorations had poor adaptation, with discrepancies greater
than 270 mm.19 The ranges of marginal discrepancies
before cementation in CAD/CAM restorations were 85 to
247 mm.20 The advance of CAD/CAM technology has
made the marginal t of restoration more acceptable.16
Cavity depth can inuence the difference in retention
and stability in an endocrown. This depth can also affect

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Issue

internal cavity volume, cavity surface area, and marginal

and internal discrepancy. Shallow cavity depth can be
associated with severe attrition of the crown portion,
while a deep cavity depth can occur with less attrition on
the coronal structure.
The purpose of this study was to evaluate the marginal and internal discrepancies of CAD/CAM endocrowns with different cavity depths by comparing mCT
images.
MATERIAL AND METHODS
This study was approved by the Institutional Review of
Yonsei Dental Hospital, Board IRB number 120153(2-2012-0064). Forty-eight human mandibular rst
and second molars without any dental caries or anatomic
defects were selected and kept in normal saline. The
specimens were allocated into 2 groups for 2 chairside
dental CAD/CAM systems such that the tooth size distributions of both groups were similar.
Two different preparation designs were tested, and
each group was divided into 2-mm and 4-mm subgroups
according to cavity depth. After reduction of the coronal
portion, the occlusal margin was prepared 1.5 mm from
the cementoenamel junction. The cavity depth was
prepared as either 2 mm or 4 mm. After preparation, the
depth was measured with a digital caliper (Mitutoyo
Corp) and adjusted to within 0.1 mm. The margins were
nished with a 1.5-mm shoulder preparation, and total
occlusal convergence was set at 10 degrees with a
tapered at end diamond rotary instrument (845R 016;
Diatech Diamant AG). The path of insertion was
checked so that it was without any interference and
undercuts, and the preparations were nalized. One
trained practitioner (Y.S.) prepared the teeth manually.
Pulpal orices and undercuts in the mesial and distal
canals were protected by using a resin adhesive system
(One-Step; Bisco Inc), and cavities were covered with a
owable resin (Aeliteo; Bisco Inc). All teeth were stored
in saline. The prepared teeth were put into the position
of a mandibular rst molar on a dentiform to form an
anatomic morphology similar to the dimensions and
occlusal forms of clinical crowns. Occlusal morphologies
were intended for a similar form of clinical crown. They
were xed with utility wax so that the margins were
positioned 1mm subgingivally, and clearance was
checked on the buccolingual and mesiodistal sides of the
dentiform.
To fabricate the endocrowns, 2 chairside CAD/CAM
systems (CEREC AC, v4.2; Sirona Dental Systems, E4D
Sky, v 2.0; Planmeca/E4D Technologies) were used according to the manufacturers directions. For the CEREC
AC group preparations, a thin contrast powder (VITA
CEREC Powder) was applied on the dry surface before
the optical impression. A CEREC AC Bluecam (Sirona

Shin et al

2016

Table 1. Type of cement, tooth conditioning, ceramic conditioning, and light polymerization during cementation
Cement Type
Duo link
Dual-polymerized resin cement
(lot 1300003015)a

Tooth Conditioning

Ceramic Conditioning

Uni-Etch
Phosphoric acid
30-s application
(lot 1000011578)a
One-step
(lot 1200000313)a
20-s application
20-s dry
40-s light-polymerizedb

Porcelain Etchant Ceramics etch 9.5%

Hydrouoric acid gel
2 min
(lot 1300003017)a
Bis-silane
Silane agent
(lot 1300002786)a
60 s
All-Bond Universal, light-polymerized Adhesive
(lot 1200012015)a

Light Polymerization During Cementation

31 min
Occlusal, buccal, and lingual side

Bisco.
Light-emitting diode polymerizing unit 1000 mW/cm2 (Bisco).

Dental Systems) was used for the optical impression.

After obtaining the images, an endocrown was designed
with computer software. For the E4D Sky group, optical
impressions from underneath all the prepared surfaces
were made under dry conditions. The luting space and
adhesive gap were set at 30 mm. After designing each
crown, the information was sent to the milling unit (E4D
milling unit), which used 2-step and cylinder pointed
diamond rotary instruments. The endocrowns were
fabricated using lithium disilicate ceramics (IPS e.max
CAD; Ivoclar Vivadent AG).
The fabricated endocrowns were placed on each
prepared tooth, the t was evaluated, and the crowns
were xed with a exible plastic (Paralm M; Bemis). A
desktop mCT scanner (SkyScan 1172; SkyScan) was used
in this study. The x-ray beam was exposed for 474 ms per
frame with a 0.5 mm aluminum lter. The electric source
was at 65 kVp voltage and 153 mA current. Specimens
were rotated 180 degrees with a 0.7-degree step during
x-ray irradiation. The image pixel size was 15.91 mm. mCT
scanning was performed twice, before and after cementation. A reconstruction software program (NRecon;
SkyScan) was used to convert the raw data into bitmap
(bmp) les.
After the optical impression, each tooth was etched
with 37% phosphoric acid. Next, an adhesive system
was applied and light-polymerized according to the
manufacturers instructions. For the restoration, the
endocrowns were treated with 9.5% hydrouoric acid, a
silane agent, and an adhesive agent. Descriptions of the
cementation procedure and commercial brand are given
in Table 1. This process was followed by light polymerizing for a total of 3 minutes (1 minute per surface).
After applying the adhesive system, dual-polymerized
resin cement was used at room temperature with
nger pressure on the occlusal surface of the endocrown. Cementation was performed by a single clinician
(Y.S.), and excess cement was removed from the marginal areas with an explorer and a clean brush. Specimens were kept in saline before and after making the
mCT.
The area of the marginal and internal discrepancies
between the endocrown and tooth was analyzed with
Shin et al

Figure 1. Eleven reference points on 2D section. They were measured at

(a,k) cavosurface, (b, j) line angle, (c, i) cavity wall, and (d, e, f, g, h) pulpal
oor.

software (Dataviewer; SkyScan). Discrepancy thickness

was measured on 6 cross-sections according to the
Seo study.16 From the cross-sections through the center
of the tooth (x, y axis), additional cross-sections were
obtained bilaterally at 1-mm intervals for a total of
6 sections: 3 buccolingual sections and 3 mesiodistal
sections. Eleven reference points were selected on crosssections on the mesiodistal and buccolingual sides. In
this study, reference points were divided into 4 sites: the
cavosurface, the line angle, the cavity wall, and the pulpal
oor (Fig. 1). The total discrepancy volume of the
endocrown was calculated using software (rapidform2006; INUS). This program can reconstruct 3dimensional images and measure changes in the cavity
volume and cavity surface area according to the cavity
depth.
Statistical analysis of the results was performed using
2-way ANOVA to identify signicant differences in the
discrepancy thickness (mm) according to each cavity
depth and 2 chairside dental CAD/CAM systems after
stratied samplings. Two-way ANOVA was applied using discrepancy volume (mm3) in each cavity depth and 2
chairside dental CAD/CAM systems. Bonferroni tests
were used in the post hoc comparisons (a=.05). All statistical analyses were carried out using software (IBM
SPSS Statistics for Windows v20; SPSS Inc).
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Table 2. Discrepancy measurements according to cementation and site in 2D analysis

CEREC AC (mm), mean SD
Site Depth (mm)

Issue

E4D (mm), mean SD

Before

After

Average Discrepancy

Before

After

Average Discrepancy

98.93 (66.1)

144.02 (76.06)

121.48A (74.61)

107.82 (82.18)

138.06 (95.33)

122.94A (90.1)

135.94A (84.33)

2
Cavosurface
Line angle

112.72 (75.77)

127.98 (73.04)

120.35 (74.66)

134.08 (78.33)

137.8 (90.22)

Cavity wall

118.16 (70.69)

187.26 (97.66)

152.71B (91.85)

185.27 (87.99)

197.87 (92.77)

191.57B (90.44)

Pulpal oor

228.79 (85.69)

273.04 (94.21)

250.91C (92.66)

278.19 (69.06)

244.66 (93.26)

261.42C (83.68)

163.96a (98)

207.61b (108.04)

204.12a (105.04)

197.34a (104.48)

Average discrepancy
4
Cavosurface

120.15 (64.29)

128.64 (81.25)

124.4A (73.23)

90.18 (58.26)

127.45 (77.37)

109.79A (71.32)

Line angle

123.37 (71.1)

117.77 (71.69)

120.57A (71.3)

115.67 (69.4)

125.46 (58.76)

120.82AB (64.07)

Cavity wall

151.72 (91.72)

176.92 (117.77)

164.32B (106.08)

136.74 (63.02)

127.58 (56.84)

131.92B (59.89)

250.23 (105.44)

327.7 (78.73)

279.41 (90.84)

302.28C (88.6)

Pulpal oor
Average discrepancy

243.05 (88.93)
a

182.34 (99.76)

246.64 (97.52)

190.71 (113.96)

211.25 (128.56)

196.18 (108.69)

Within row, same lowercase superscript letters show mean values with no statistically signicant difference (P>05). Within column, same uppercase superscript letters show mean values
with no statistically signicant difference (P>.05).

RESULTS
In 2-dimensional analysis before cementation, discrepancy thickness increased more in the 4-mm cavity depth
than in the 2-mm cavity depth (Table 2). Signicant
differences in discrepancy thickness were found between
the site and cavity depth (P<.05). The post hoc test
revealed that the discrepancy thickness at the pulpal
oor was larger than at other sites (P<.05). The discrepancy volume is summarized in Table 3. No differences
were found in the discrepancy volume between the
CEREC AC and E4D systems (P>.05); a signicant
difference was found in discrepancy volume according
to cavity depth (P<.05).
Cementation did not show signicant differences
in total discrepancy thickness before and after cementation (P>.05). Discrepancy thickness of the pulpal oor
site signicantly decreased in value before and after
cementation. The representative dimensional images on
2 chairside dental CAD/CAM systems are shown in
Figures 2, 3.
In the analysis after cementation, discrepancy thickness increased according to cavity depths (P<.05), but no
differences between CAD/CAM systems were observed.
Discrepancy thickness at different sites showed that the
length-order was as follows: pulpal oor (P<.05)>cavity
wall>cavosurface>line angle.
DISCUSSION
With the development of CAD/CAM technology, complex restorative procedures have become simpler and less
time-consuming. In this study, endocrowns were fabricated for extracted teeth using CAD/CAM systems.
Changes in the marginal and internal discrepancy of
endocrowns were analyzed for differences due to cavity
depth, cementation, and use of the CAD/CAM system.
Marginal and internal discrepancies are a main
concern of CAD/CAM restorations. However, to date, no
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Table 3. Discrepancy volume in 3D analysis

System Cavity Depth (mm)

Discrepancy Volume (mm3), mean SD

CEREC AC
2

22.57 5.47a

29.77 4.29b

E4D
2

24.56 4.80a

28.42 4.80b

Same superscript letters indicate mean values with no statistically signicant

differences (P>.05).

method has been demonstrated to measure the

discrepancy with absolute accuracy. In this study,
noninvasive mCT was used to determine the discrepancy
volume and thickness in endocrown models before and
after resin cementation. Ultrahigh-resolution mCT has
become a popular instrument for analyzing internal
adaptation on polymerization shrinkage,21 CAD/CAM
crowns,22 and CEREC 3 partial ceramic crowns.23
Most studies have used mCT to analyze the marginal
and internal discrepancies before cementation because
the difference in radiographic contrast is not large between the dentin and the cement.16,17 However, in this
study, mCT was also used to detect the marginal and
internal discrepancies after cementation. Cement spaces
were detectable with the naked eye. Measuring the
cement space after cementation was difcult, and 3dimensional analysis of the discrepancy volume was
impossible because the computer software could not
automatically distinguish between the cement space and
the restoration. In this study, the analysis was performed
manually, and the discrepancies after cementation
should reect the clinical situation more closely. In terms
of experimental method, because each endocrown
specimen was analyzed in 3 vertical planes and 3 horizontal planes, many measurements for each specimen
were obtained and a generalized analysis of marginal and
internal discrepancies was possible. For more detailed
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2016

Figure 2. Representative dimensional images before cementation. (A) E4D, 2 mm and (B) CEREC, 4 mm. Each image was selected at axial, buccolingual,
and mesiodistal section.

Figure 3. Representative images after cementation. (A) CEREC, 2 mm and (B) E4D, 4 mm. Each image was selected at axial, buccolingual, and
mesiodistal section.

analysis, discrepancy thicknesses at margin sites and

internal sites were measured.
One of the limitations of this study was that during
mCT scanning, an alignment device was not used for
horizontal and vertical xation. If a device had been used,
images before and after cementation could have been
superimposed, thus enabling the evaluation of changes
Shin et al

in discrepancy thickness and volume. However, without

a device, the images could not be exactly superimposed,
and this analysis was not possible.
Cavity depth inuenced both failure resistance and
failure mode. The changes in cavity volume, cavity surface area, and marginal and internal discrepancy were
analyzed according to the changes in cavity depth.
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The volume and surface area increased in the 4-mm

cavity compared with the 2-mm cavity. These changes
inuenced the margins and internal discrepancy and led
to a signicant increase in the discrepancy thickness and
total volume.
In this study, the range of marginal discrepancies
before cementation was 99 to 278 mm, regardless of the
CAD/CAM system used. Vertical marginal discrepancies in various types of cavosurfaces should be
measured between the outermost part of the crown
margin and the outside shoulder corner according to
Nakamura et al.15 These results were similar to those
of previous studies. Similar trends were observed in
the study by Kim et al,23 which used the same method,
and, in other studies, the internal discrepancy, especially at the pulpal oor site, was similar, ranging from
200 to 300 mm.23 This was most likely because of the
differences in the marginal discrepancy measuring
methods.
A discrepancy generally increases after cementation.
Vertical marginal discrepancies of ceramic crowns almost
doubled before and after cementation.24 In this study, the
discrepancy decreased or did not change.
The discrepancy thickness at the pulpal oor
site signicantly decreased after cementation in all systems; this decrease was clinically signicant. This effect
may be observed because horizontal sites were affected
by the stress placed on the crown by polymerization
shrinkage during resin cementation. This nding was
consistent with the study of Kakaboura et al,25 who reported that composite resin shrinkage affected internal
discrepancies. Also, this might be because loading was
not applied before cementation. Lastly, the minute
distortion of the restoration itself may have reduced the
marginal discrepancy. The discrepancy on the pulpal
oor seemed to affect the results of this study.
Digital impressions have been reported to be as
accurate as those made in the conventional way.26
Optical impressions are limited on the distal side at a
specic angle because of the access direction of the
scanner; the distal shadow phenomenon creates a
shadow distal to the scanned object.20 This shadow on
the tooth preparation increases when the clinical crown
length of the prepared tooth is increased. However, in an
endocrown, the tooth structure is positioned in reverse,
and this shadow only appears on the mesial cavity
surface. Theoretically, this may cause a mesial shadow
phenomenon. However, in this study, the mesial
discrepancy was similar to the distal discrepancy, without
statistical differences and regardless of the use of the
CEREC AC or the E4D system. This suggested that this
phenomenon did not affect the margin even with a
4-mm cavity depth. Between the 2 CAD/CAM systems, a
signicant difference was found in discrepancy volume
according to cavity depth. This discrepancy volume was
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Issue

calculated by computer software and could be used only

when there was a large radiographic contrast. As a result,
it could be applied only before cementation. The same
method was tried after cementation but could not
distinguish exactly between cement and restoration.
Using the same method, the cement void after cementation was measured, and the void that formed when
loading was applied during cementation could be
obtained.
In this study using natural teeth, the marginal and
internal discrepancies before and after cementation
of endocrowns fabricated with CAD/CAM systems
were analyzed. However, whether these marginal discrepancies and internal discrepancies are clinically
acceptable remains unknown.
CONCLUSIONS
Based on the present in vitro study, marginal and internal
discrepancies increased depending on cavity depth.
Cementation did not increase the dimension of the
discrepancy between the restoration and the cavity
wall. Discrepancies on the pulpal oor appeared to affect
these results. Both chairside CAD/CAM systems exhibited similar endocrown discrepancies.
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Corresponding author:
Dr Byoung-Duck Roh
Yonsei University
College of Dentistry
50-1 Yonsei-ro, Seodaemun-gu
SEOUL, KOREA
Email: operatys16@yuhs.ac
Copyright 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.

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