CASE�REPORT Endocrown is a conservative restorative option for extensively damaged posterior teeth. The primary objective is to attain a bonded biomimetic reconstruction, i.e., to reconstruct a tooth without any excessive preparation for post or core. The clinical procedure is less complex for both dentist and patient as compared to conventional crowns with post and core. This article highlights case report of a mutilated molar treated by composite endocrown after an adequate endodontic treatment with a follow up of 6 months' time span. ABSTRACT Key Words: Biomimetic Reconstruction, Composite, Endocrown, Endodontic Treatment, Resin Cement. and cementation will be discussed to ease its use. Case Report A 21 year old male patient visited operative department of Islamic International Dental Hospital, Pakistan with a chief complaint of pain in right mandibular molar since last one week. On examination, root canal was initiated 6 months back but was not completed due to unfortunate circumstances. Clinically there was an extensive loss of coronal structure, with a decreased interocclusal space between the maxillary and mandibular molar. Occlusogingival height of the remaining crown structure was 4mm.The radiographic findings revealed unobstructed canals and remnants of temporary restorative material in chamber along with periodical changes. (Fig. 1) Endocrown, a monoblock single piece construction, is an effective alternative for endodontically treated molars with severely broken down coronal 3 structure. It helps in maintaining the structural integrity by excluding the steps of post and core- cementation, crown lengthening and also reduces the effect of hybrid layer degradation by decreasing 4 the number of adhesive interfaces. The purpose of this article is to present clinical case of a molar restored with composite endocrown after endodontic treatment. The steps of its fabrication The propensity of a root canal treated tooth to fracture due to changes in biomechanics as a result of tissue loss is an argumentative topic for dentists. Several factors such as pathologic processes, steps of endodontic procedure and extensive restorations causes the loss of coronal and radicular structure, thus making the tooth more fragile and prone to 1 fracture. In order to prevent these deleterious effects dentists adopt a more conservative approach such as bonded overlay and endocrown instead of full coverage crowns with the aid of recent advances 2 in adhesive techniques. Introduction “Endocrown” A Novel Approach for Restoration of Endodontically Treated Teeth: A Case Report 1 2 3 4 5 Romana Yaqoob , Anum Moiz , Sohaib Siddique , Huma Zahir , Usman Ibrahim Correspondence: Dr. Romana Yaqoob Department of Dentistry Islamic International Dental Hospital Riphah International University, Islamabad E-mail: romanayaqoob.ry@gmail.com 1,2,3,4 Department of Dentistry Islamic International Dental Hospital Riphah International University, Islamabad 5 Department of Dentistry Ibrahim Dental and Implants Center, Rawalpindi Funding Source: NIL; Conflict of Interest: NIL Received: February 28, 2019; Revised: July 15, 2019 Accepted: August 14, 2019 JIIMC 2019 Vol. 14, No.4 “Endocrown” A Novel Approach Fig 1: Pre-Opera�ve Radiographic Image A conservative approach of restoring the tooth with an endocrown was decided as the treatment option after explaining and taking patients consent. Root canal treatment was done by Hi Flex rotary system using 2% NaOCl as an irrigant. Triple antibiotic paste was placed as an intracanal medicament for 5 days. Obturation was done using Hi Flex gutta percha points. 217 Appropriate shade with a shade guide was chosen. An impression was taken with a polyvinyl siloxane material and sent to the laboratory along with the shade information. An endocrown may be produced from composite or mineral ceramic and, because of the slightly lower cost and ease of repair of any potential damage, the patient chose the composite endocrown. On next visit cementation was done. The tooth was etched with 37% phosphoric acid for 15 seconds, with the application starting from the margins in enamel. Afterward preparation was washed and air dried. (Fig.5 and Fig.6). To embed the endocrown, a self-etch bonding system (ESPE Single Bond Universal Adhesive) was used, which was spread on the surface of preparation and then light-cured. (Fig.7). A dual cured composite resin cement (Rely X Ultimate ClickerAdhesive Resin Cement) was spread on the surface of the preparation. The endocrown was seated, and any excess cement was removed and the restoration was polymerized and finished after evaluating any occlusal interference Fig 8. ! Palatal and lingual cusps can be simply reduced by 2 to 3 mm with a butt-joint. The tooth was prepared to achieve a butt-joint margin.The appropriate reduction of the buccal and lingual walls was done. The lateral retentions of the pulp chamber walls and the orifices were sealed with two-step adhesive and flowable resin composite. The cervical margins were leveled with a tapered diamond-coated bur. The pulp chamber was prepared with the same diamond-coated tip with an internal taper of 8 to 10 degrees. The preparation margins had a width of 1.5 mm and core exceeding the height of 3mm. (Fig.3 and Fig.4) Interocclusal space was carefully evaluated and occlusal reduction done to achieve a clearance of 2mm. Guidelines for full occlusal coverage according to 1 Rocca et al: ! The ultra-conservative buccal cusp coverage (1.5 mm) On the contrary, for buccal cusps there are 3 options: ! The conventional buccal cusp coverage (2–3mm) ! The full buccal cusp coverage Fig 2: Post Obtura�on Radiograph Fig 3: Pre Op Clinical Image Fig 4: Clinical Image of Prepared Tooth Fig 5: Composite Endocrown JIIMC 2019 Vol. 14, No.4 218 “Endocrown” A Novel Approach options are decreased stress concentration as a result of lesser number of adhesive restorative interfaces, conservative preparatory design maintaining biologic width and increased surface area for bonding provided through pulp chamber which is equal or even superior to post in radicular 4 dentin. Endocrowns overall success rate is quite promising although there are some limitations such as depth of pulp chamber should not be less than 3 mm and the width of cervical margin be more than 2mm, adhesion is difficult to achieve or presence of only 11 negligible tooth structure. For ensuring longevity of the endocrowns case selection is a critical step. Further studies are required to assess its durability in the long term. 1 1. Rocca GT , Rizcalla N, Krejci I. Fiber-reinforced resin coating for endocrown preparations: a technical report. Oper Dent. 2013 May-Jun;38(3):242-8 It is proven by a systematic review that survival rate and in vitro fracture strength of endocrown is equal or better than the conventional treatments, hence it is indicated for all molars especially those with loss of coronal structure, calcified or constricted canals, and is also reliable in patients with bruxism and 10 unfavorable occlusal relationship. 2. Bitter K, Kielbassa AM. Post-endodontic restorations with adhesively luted fiber-reinforced composite post systems: a review American Journal of Dentistry 2007; 20(6) 3533-60. 3. Dogui H, Abdelmalek F, Amor A, Douki N. Endocrown: An Studies have shown that albeit endocrowns are desirable option for restoration of all the teeth in the arches, but they should be restricted to the restoration of posterior teeth especially molars, because their performance in molars against the action of masticatory forces is much better as compared to premolars. Other reasons include limited bond strength of adhesive systems because of smaller pulp chamber area and adhesive surface 5 of premolars. A long lever arm may be created because of premolar crowns configuration resulting in greater endocrown height as compared to width, increasing the risk of adhesive interface fracture and 6 displacement. However when their use is limited to restoration of molar teeth, they have shown satisfactory performance in achievement of esthetic 7,8,9 and functional recovery and bond strength. REFRENCESDISCUSSION In modern era of dentistry, endocrowns are conservative, easier and effective alternative option 1 for restoring an endodontically treated tooth. It achieves retention macro mechanically through pulp chamber and micromechanically by adhesive 2,3 cement. The benefits of endocrown over other Fig 6: Intaglio surface of Endocrown Fig 7: Lu�ng Cement Fig 8: Cemented Endocrown JIIMC 2019 Vol. 14, No.4 219 “Endocrown” A Novel Approach utilizing the monobloc technique. Pract Periodontics Aesthet Dent 1995;7:83–94. 8. Göhring TN, Peters AO. Restoration of endodontically treated teeth without posts. Am J Dent 2003;16:313–18. 9. Biacchi GR, Basting RT. Comparison of fracture strength of endocrowns and glass fiber post-retained conventional crowns. Oper Dent 2012;37:130–3. 10. Rocca G.T & Serge. B – Alternativetreatment for restoration of non-vital teeth. Revue d' Odonto Stomatology 2008; 37: 259 -272 11. Bernhart J, Brauning A, Altenburger MJ, Wrbas KT. Cerec 3D endocrowns-two-year clinical examination of CAD/CAM crowns for restoring endodontically treated molars. Int JCompt Dent 2010; 13:141-154 Alternative Approach for Restoring Endodontically Treated Molars with Large Coronal Destruction.Case Rep Dent. Aug 30; 2018:1581952. 4. Biacchi GR, Mello B, Basting RT. The endocrown: an alternative approach for restoring extensively damaged molars. J EsthetRestor Dent. 2013 Dec;25(6):383-90 5. Bindl A, Richter B, Mörmann WH. Survival of ceramic- computer-aided/manufacturing crowns bonded to preparations with reduced macro retention geometry. Int J Prosthodont 2005;18:219–24. 6. Valentina V, Aleksandar T, Dejan L, et al. Restoring endodontically treated teeth with all-ceramic endo- crowns—case report. Serbian Dent J 2008;55:54–64. 7. Pissis P. Fabrication of a metal-free ceramic restoration JIIMC 2019 Vol. 14, No.4 220 “Endocrown” A Novel Approach