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Available online at www.sciencedirect.com

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journal homepage: www.intl.elsevierhealth.com/journals/dema

Stability of endodontically treated teeth with

differently invasive restorations: Adhesive vs.
non-adhesive cusp stabilization

Roland Frankenberger a,∗ , Inka Zeilinger a , Michael Krech a , Gernot Mörig a,b ,
Michael Naumann c , Andreas Braun a , Norbert Krämer d ,
Matthias J. Roggendorf a
a Department of Operative Dentistry and Endodontics, Medical Center for Dentistry, University Medical Center
Giessen and Marburg, Campus Marburg, Georg-Voigt-Str. 3, D-35039 Marburg, Germany
b Private Practice, Düsseldorf, Germany
c Department of Prosthetic Dentistry, University of Ulm, Albert-Einstein-Allee 11, D-89081 Ulm, Germany
d Department of Pediatric Dentistry, Medical Center for Dentistry, University Medical Center Giessen and Marburg,

Campus Giessen, Schlangenzahl 14, D-35392 Giessen, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Objectives. Aim of the present study was to evaluate fracture strength of endodontically
Received 11 March 2015 treated molars with different preparations/restorations after thermomechanical loading in
Received in revised form vitro.
11 August 2015 Methods. 264 extracted human third molars were used. Beside the control group, 256 teeth in
Accepted 17 August 2015 32 test groups (n = 8) received root canal treatment (MTwo #40/.6) and root canal obturation
Available online xxx with AH Plus and Guttapercha. After postendodontic sealing and build-up (Syntac, SDR),
specimens were additionally prepared MO or MOD. Postendodontic restorations were: Direct
Keywords: restorations (Tetric EvoCeram Bulk Fill bonded with Syntac; as filling or direct partial crown
Endodontically treated teeth (PC) after reducing the cusps 3 mm; amalgam as filling or direct pin-retained partial crown
Cuspal stabilization (PC)), vs. indirect adhesive restorations (I: Inlay vs. PC; IPS Empress I/PC; Celtra Duo I/PC;
Resin composites e.max CAD I/PC; Lava Ultimate I/PC; Enamic I/PC – all inserted with Syntac/Variolink) vs.
Resin nano ceramic cemented cast gold I/PC. After 300,000 thermocycles (5/55 ◦ C) and 1.2 Mio. 100 N load cycles,
Lithium disilicate ceramic specimens were loaded until fracture.
Leucite-reinforced glass ceramic Results. Whereas IPS Empress showed no difference between I and PC (p > 0.05), in all other
Cast gold groups PC were significantly more stable than fillings/inlays (p < 0.05), this effect was more
Amalgam pronounced after MOD preparations. Cast gold PC exhibited the highest fracture strengths
(p < 0.05), inlays the lowest (p < 0.05). IPS Empress was generally inferior to the other bonded
materials under investigation (p < 0.05) which as PC almost reached the level of control
specimens. Amalgam fillings showed the worst outcome (p < 0.05).

∗
Corresponding author. Department of Operative Dentistry and Endodontics, Medical Center for Dentistry, University Medical Center
Giessen and Marburg, Campus Marburg, Georg-Voigt-Str. 3, D-35039 Marburg, Germany. Tel.: +49 6421 5863240; fax: +49 6421 5863745.
E-mail address: frankbg@med.uni-marburg.de (R. Frankenberger).
http://dx.doi.org/10.1016/j.dental.2015.08.160
0109-5641/© 2015 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Frankenberger R, et al. Stability of endodontically treated teeth with differently invasive restorations: Adhesive
vs. non-adhesive cusp stabilization. Dent Mater (2015), http://dx.doi.org/10.1016/j.dental.2015.08.160
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Significances. Less invasive preparation designs were not beneficial for the stability of pos-
tendodontic restorations. Except for IPS Empress, PC were generally more successful in
restabilization of weakened cusps after endodontic treatment and preparation. Cast gold
PC remain the ultimate stabilization tool for ETT in terms of fracture resistance.
© 2015 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.

preparation and (2) the restoration would have no influence on

1. Introduction
Since decades, vital teeth can be safely restored and kept vital
using amalgam and more and more resin composites in order
to act minimally invasive [1–5]. During and especially after
completed endodontic treatment, the situation considerably
changes due to the weakening effect of endodontic access
preparation and the often large amount of tissue having been
lost by extensive caries excavation [6–12]. It is proven that the
biomechanical stability of posterior teeth after access cavity
and even further preparation is dramatically decreased with
a high risk of vertical root fracture [13–18]. Thus, it is logical
that clinical studies focusing on endodontically treated teeth
(ETT) reveal inferior outcomes compared to vital teeth [19–24],
although recent studies could not find less tactile sensitivity
of ETT compared to vital teeth which makes the “cherry stone”
theory questionable, i.e. that the opening reflex for ETT is be
delayed, involving heavier load input during routine mastica-
tion of hard items [25].
However, a deeper look into clinical data exhibits that
vertical root fractures accounted only for 12% of extractions
of ETT, compared to 15% cusp fractures and 40% periodon-
tal problems [20]. Nevertheless, this altogether sums up to
27% fractures as reason for ETT loss [20]. So the appropriate
preparation and/or restoration was always a matter of con-
cern in the literature, having been reflected by several studies
and reviews with a special focus on postendodontic restora-
tions [26–34]. Whereas for the restoration of vital teeth it is
generally accepted that minimally invasive preparations are
supporting clinical long-term success [1,4,35], the influence of
preparation invasiveness with ETT is still not fully understood.
For eample, the clinical outcome of direct resin compos-
ite restorations is discussed contradictorily in the literature
of the field ranging from simply catastrophic to acceptable
[14,20,36–41]. The same is true for the preclinical estimation
of innovative ceramics and hybrid materials, which have been
claimed to act as better shock absorbers during mastication
which also makes them interesting as ETT restorations [28,51].
Although prospective, randomized clinical long-term trials are
the optimum instrument to investigate clinical behavior of
different restorative procedures in vivo, these studies are time-
consuming, expensive, and permanently suffering potential
patient drop out which is finally corroborating statistical
impact [3,35]. Therefore, in vitro studies are still of concern,
especially when thermomechanical loading scenarios are
applied being close to the clinically observed circumstances
[7,8,42,43].
Aim of the present study was to evaluate the fracture
resistance and behavior of different preparation/restoration
concepts of ETT. The null hypothesis was two-fold, that (1) the
fracture strength of previously thermomechanically fatigued
ETT.
2. Methods and materials
264 intact, non-carious, unrestored human lower third molars
with similar size and fully developed roots, extracted for ther-
apeutic reasons under informed consent of the patients and
upon approval by a local ethics committee (Ref no. 143/09),
were stored in an aqueous solution of 0.5% chloramine T at
4 ◦ C for up to 30 days. The teeth were debrided of residual
plaque and calculus, and examined to ensure that they were
free of defects under a light microscope at ×20 magnifica-
tion. Beside the control group without any preparation (n = 8),
256 teeth in 32 groups (n = 8) received endodontic access cavi-
ties and root canal preparation at a working length of −1 mm
from the apical foramen using MTwo rotary instruments (VDW,
Munich, Germany) up to size .04/#40. Tooth length was estab-
lished using a C-Pilot file ISO 10 (VDW) that was inserted
into the root canal until it could be visualized at the api-
cal foramen. Working length was determined by subtracting
1 mm from this length. Root canals were filled with laterally
compacted gutta-percha (VDW) and AH Plus sealer (Dentsply
DeTrey, Konstanz, Germany), and immediately sealed (Syntac
and SDR/Dentsply).
Specimens were additionally prepared MO or MOD. The
cavities were cut using coarse diamond burs under profuse
water cooling (80 ␮m diamond, Komet, Lemgo, Germany), and
finished with a 25 ␮m finishing diamond (one pair of diamonds
per four cavities). Inner angles of the cavities were rounded
and the margins were not beveled except for direct restora-
tions where margins received a 0.5 mm bevel. Polymerizable
materials were light-cured with a Bluephase light-curing unit
(Ivoclar Vivadent, Schaan, Principality of Liechtenstein). The
intensity of the light was checked periodically with a radiome-
ter (Demetron Research Corp, Danbury, CT, USA) to ensure that
1000 mW/cm2 was always delivered during the experiments.
The different restorative procedures are displayed in
Table 1. Direct adhesive procedures: cavities (MO, MOD, par-
tial crown preparations, Figs. 1 and 2) were surrounded with a
metal matrix band, bonded with Syntac, and restored with Tet-
ric EvoCeram Bulk Fill in oblique layers of 2–4 mm thickness.
The increments were separately light-cured for 40 s each with
the light source in contact with the coronal edge of the matrix
band. After removal of the matrix band, the restorations were
light-cured from their buccal and lingual aspects for an addi-
tional 20 s on each side. Prior to the finishing process, visible
overhangs were removed using a posterior scaler (A8 S204S,

Please cite this article in press as: Frankenberger R, et al. Stability of endodontically treated teeth with differently invasive restorations: Adhesive
vs. non-adhesive cusp stabilization. Dent Mater (2015), http://dx.doi.org/10.1016/j.dental.2015.08.160
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Table 1 – Experimental set up of the study.

Abbreviations: F: filling, DPC: direct partial crown, I: inlay, PC: partial crown, RC: resin composite, IP: IPS Empess, EM: e.max CAD, CD: Celtra
Duo, LU: Lava Ultimate, EN: Enamic, CG: Cast gold, AM: Amalgam, MO: additional MO preparation, and MOD: additional MOD preparation.

Hu-Friedy, Leimen, Germany). Proximal margins were finished
with flexible disks (SofLex Pop-on, 3M ESPE, St. Paul, USA).
Direct amalgam procedures: cavities (MO, MOD, partial
crown preparations with flattened cusps) were surrounded
with a metal matrix band, and amalgam (Dispealloy,
Dentsply, Konstanz, Germany) was applied with a syringe in
consecutive layers. In partial crown situations, one para-
pulpal pin was applied on each replaced cusp (Edenta, Au,
Switzerland). Amalgam restorations were polished after 24 h.
Indirect adhesive procedures (I: Inlay vs. PC) were IPS
Empress CAD I/PC and e.max CAD I/PC (Ivoclar Vivadent),
Celtra Duo I/PC (Dentsply), Lava Ultimate I/PC (3 M Espe),

Fig. 1 – Illustration of the experimental setup with (a) Control tooth. (b) Endodontic access cavity. (c) Situation directly after
root canal filling. (d) Inlay preparation for ceramic/hybrid materials. (e) Inlay dimensions and rounded angles. (f) Cast gold
partial crown preparation with step and bevel.

Please cite this article in press as: Frankenberger R, et al. Stability of endodontically treated teeth with differently invasive restorations: Adhesive
vs. non-adhesive cusp stabilization. Dent Mater (2015), http://dx.doi.org/10.1016/j.dental.2015.08.160
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Fig. 2 – Recordings from the restorative procedures. (a) Partial crown preparation with postendodontic seal (SDR) during
further adhesive pretreatment. (b) e.max CAD inlay after finishing, polishing, and individualization. (c) Celtra Duo partial
crown during adhesive luting in vitro. (d) The inlay from (b) directly after adhesive luting.

and Enamic I/PC (Vita Zahnfabrik, Bad Säckingen, Germany),
all adhesively luted using Syntac/Variolink (Ivoclar Vivadent)
after pretreatment of the intaglio surface as recommended
by the manufacturers (HF etching or airborne particle abra-
sion). The chosen indirect conventional procedure was cast
gold I/PC (Degunorm, Degudent, Hanau, Germany), cemented
with Ketac Cem (3M Espe, Seefeld, Germany). The experimen-
tal set up is displayed in Table 1, compositions of involved
materials are shown in Table 2. CAD/CAM restorations were
made in a Cerec 3-D device (Sirona, Bensheim, Germany),
cast gold was manufactured on stone cast dies according to
the lost-wax technique. Inlay preparations for indirect adhe-
sive restorations were butt-joint, preparations for cast gold
received a 1 mm bevel. PC preparations for indirect adhesive
procedures were cut according to previously published guide-
lines for CAD/CAM restorations (Fig. 1), PC preparations for
cast gold were conventional with step and bevel (Fig. 2).
Thermo-mechanical loading of all specimens – also control
teeth – was then performed in an artificial oral environ-
ment (CS4 professional line, SD Mechatronik, Feldkirchen,
Germany). One specimen was arranged in one simulator
chamber and occluded against a steatite (a multi-component
semi-porous crystalline ceramic material) antagonist (6 mm
in diameter, Fig. 3a) obliquely hitting cusps of restored teeth
for 1,200,000 cycles at 100 N at a frequency of 0.5 Hz. The
specimens were previously subjected to 300,000 thermal
cycles between +5 ◦ C and +55 ◦ C (THE 1100, SD Mechatronik,
Feldkirchen, Germany). The mechanical action and the water
temperature within the chewing chambers were checked peri-
odically to ensure a reliable thermo-mechanical loading (TML)
effect. After completion of the thermomechanical fatigue reg-
imen, specimens were loaded in a universal testing machine
(Zwicki, Zwick, Ulm, Germany) until fracture. Failed specimens
were subjected to photographic documentation (Figs. 3 and 4).
For statistical appraisal of recorded results, the
Kolmogorov–Smirnov test proved values to be consistent
with a normal distribution curve, so parametric statistical
analyses were carried out (one-way ANOVA and post hoc
Tukey–Kramer test), considering the preparation and restora-
tion techniques as variable. The significance level was set as
5% (SPSS 15.0, SPSS Inc., Chicago, IL, USA).
3. Results
The results are displayed in Tables 3 and 4. For MOD prepa-
rations, statistically higher fracture strengths were recorded
for all groups except IPS Empress CAD (p > 0.05). The results
of partial crowns made of e.max CAD, Celtra Duo, Lava Ulti-
mate, and Enamic showed fracture strengths being almost
comparable to the control teeth without restoration and com-
parable to each other (p > 0.05). However, cast gold PCs even
outperformed control teeth (p < 0.05). Amalgam partial crowns

Please cite this article in press as: Frankenberger R, et al. Stability of endodontically treated teeth with differently invasive restorations: Adhesive
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Table 2 – Materials under investigation.

Restorative material Classification Composition (%wt) Manufacturer
Tetric EvoCeram Bulk Fill Nanohybrid resin Dimethacrylate, prepolymer, Ivoclar Vivadent, Schaan,
composite Barium glass, Ytterbium principality of
trifluoride, mixed oxides, Liechtenstein
initiators, and stabilizators
IPS Empress Leucite reinforced glass 57–80% SiO2 , 11–19% Li2 O, 0–13%
ceramic K2 O, 0–11% P2 O5 , 0–8% ZrO2 , 0–8%
ZnO, ZnO, 0–5% Al2 O3 , 0–5% MgO
e.max CAD Lithium disilicate ceramic 57–80% SiO2 , 11–19% Li2 O, 0–13%
K2 O, 0–11% P2 O5 , 0–8% ZrO2 , 0–8%
ZnO, ZnO, 0–5% Al2 O3 , 0–5% MgO
Celtra Duo Zirconia reinforced lithium Lithium silicate with ∼10% ZrO2 Dentsply DeTrey, Konstanz,
silicate ceramic Germany
Lava Ultimate Hybrid A: resin nano 80% Nanoceramic, 20% resin 3M Espe, Seefeld, Germany
ceramic matrix
Enamic Hybrid B: polymer 86% Feldspathic ceramic, 14% Vita Zahnfabrik, Bad
infiltrated ceramic network polymer Säckingen, Germany
Degunorm Cast gold 73.8% Au, 9% Pt, 9.2% Ag, 4.4% Cu, Degudent, Hanau, Germany
2% Zn, 1.5% In, 0.1% Ir
Dispersalloy Amalgam 50% Hg, 25–50% Ag, 5–15% Cu, 1% Dentsply, Konstanz,
Zn Germany
Luting material
Syntac 4-Step etch-and-rinse Etchant: 36% phosphoric acid Ivoclar Vivadent, Schaan,
adhesive Primer: maleic acid, TEGDMA principality of
(triethyleneglycol dimethacrylate), Liechtenstein
water, acetone
Adhesive (2nd primer)
Polyethyleneglycol dimethacrylate,
glutaraldehyde, water
Heliobond: Bis-GMA
(1-methylethylidene)bis[4,1-
phenyleneoxy(2-hydroxy-3,1-
propanediyl)] bismethacrylate),
TEGDMA, UDMA (urethane
di-methacrylate: 1,6-dimethacryl-
ethyl-oxy-carbonylamino-2,4,4-
trimethylhexane)
Variolink II Luting resin composite Base: Bis-GMA, UDMA, TEGDMA,
fillers, ytterbium trifluoride,
stabilizers, pigments
Catalyst: Bis-GMA, UDMA,
TEGDMA, fillers, ytterbium
trifluoride, stabilizers, pigments,
benzoyl peroxide
Ketac Cem Luting glass ionomer Powder: calcium FASG 3M Espe, Seefeld, Germany
cement Liquid: copolymer of acrylic and
maleic acid + water

Fig. 3 – Recordings from the fracture strength evaluation in the universal testing machine. (a) Cast gold partial crown during
loading. (b) Crashing of the roots because for cast gold partial crowns no restoration fracture occurred. (c) Occlusal view after
root fracture in a cast gold partial crown: a distinct plastic deformation of the gold is visible (arrows).

Please cite this article in press as: Frankenberger R, et al. Stability of endodontically treated teeth with differently invasive restorations: Adhesive
vs. non-adhesive cusp stabilization. Dent Mater (2015), http://dx.doi.org/10.1016/j.dental.2015.08.160
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Fig. 4 – Recordings from the fracture strength evaluation in the universal testing machine. (a) Lava Ultimate inlay during
loading exhibiting a cusp fracture. (b) Failure mode in direct resin composite restoration: the resin-composite interface as
well as the cusp tip show distinct fracture lines.

were in the range of natural teeth without cavity or root canal
treatment (p > 0.05).
For MO restorations, I/PC groups showed less difference in
fracture resistance than in MOD restorations, but still with
advantages for PCs (p < 0.05). Also here, cast gold PC exhib-
ited significantly higher fracture strengths than the other
restorations and even the control group (p < 0.05). Regarding
restorative materials, it was clearly evident that IPS Empress
showed a generally lower performance than the other mate-
rials, irrespectively of the mode of preparation and its
invasiveness. Also fracture modes in these groups exhibited
that the limitation in that particular case was not preparation
design or durability of adhesion but the intrinsic weakness of
the glass ceramic itself.
The most pronounced difference was seen among cast gold
and amalgam restorations. Whereas PC restorations revealed
the best outcome throughout the complete investigation, cast
gold inlays and amalgam fillings showed the lowest values
for fracture strength for both preparations, however, also here
the stabilizing effect of the unprepared distal lateral ridge in
MO cavities lead to a significantly better outcome compared
to MOD inlays made of cast gold or MOD amalgam fillings
(p < 0.05).
Photographic recordings of fracture mode showed cata-
strophic vertical fractures in the vast majority of specimens.
Between the materials under investigation, no single group
could achieve less catastrophic fracture patterns than others
(p > 0.05).

Table 3 – Results (N) for MOD preparations.

Please cite this article in press as: Frankenberger R, et al. Stability of endodontically treated teeth with differently invasive restorations: Adhesive
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Table 4 – Results (N) for MO preparations.
4. Discussion
Daily all over the world, laboratory scientists try to simu-
late clinical conditions in order to predict clinical behavior of
dental biomaterials [7,8,17,18,42]. Although it is well-known
that prospective clinical trials remain the ultimate tool for
the evaluatin of novel restoratives [35], it was described in
the introduction that this is simply not routinely possible.
Moreover, when it comes to more experimental setups, it is
ethically not acceptable to burden patients with possibly inap-
propriate restorative approaches such as cast gold inlays in the
present study. Especially in questions of more scientific nature
like in the present investigation, preclinical evaluation is the
only favorable way to do so. Whereas in restorations of vial
teeth marginal integrity, wear, biocompatibility and biologi-
cal issues like biodegradation and absence of postoperative
hypersensitivities are of primary concern [4,43,44], ultimate
fracture strength was repeatedly investigated in ETT due to
the fact that 27% of clinical failures are attributed to fractures
[45–47].
Fatigue loading has considerably gained importance in
materials science not only regarding to adhesion but also
concerning fracture resistance over time [7,8,48–51]. Intraoral
measurements revealed that average masticatory forces are
20 MPa, however, also with much higher peak impacts [18,26].
It was empirically assumed that in ETT, after access cavity
preparation and root canal treatment, a lower threshold level
for tactile sensitivity would result. Although recent reports
were not able to confirm this, it is still widely accepted that ETT
are still more prone to fracture than vital teeth [15,25,26,28].
Therefore it can be concluded that the reason for increased
fracture risk of ETT is based on the often dramatical loss of
Please cite this article in press as: Frankenberger R, et al. Stability of endodontically treated teeth with differently invasive restorations: Adhesive
vs. non-adhesive cusp stabilization. Dent Mater (2015), http://dx.doi.org/10.1016/j.dental.2015.08.160
7
sound tooth hard tissue during preparation of the endodon-
tic access cavity, the root canal, and often additionally of a
post space [19,20,30,52]. This is the reason why – in contrast
to restorative aspects of vital teeth – crown preparations are
often recommended for ETT, and to be honest, clinical find-
ings are really encouraging, especially when being compared
to reports about direct restorations of ETT with inacceptably
high annual failure rates [23,37,41,53–56].
The chosen in vitro setup of the present study already
proved to give reliable results in several studies with an array
of different classes of materials intended for intraoral use,
also with a certain correlation to in vivo findings at least for
the case of marginal quality of etch-and-rinse adhesives vs.
self-etch adhesives [8,43,42]. It simply is closer to intraoral
conditions to thoroughly fatigue different kinds of restora-
tives before ultimate loading until fracture is performed in due
course [8]. Compared to previous studies on non-ETT, a higher
fatigue load and a higher number of thermomechanical load
cycles was chosen as shown before on zirconia crowns [57].
The chosen materials for restoration of ETT were an array
of traditional vs. innovative biomaterials, and even cast gold
was included due to the reason that fractures never occur
here. Among the newer indirect materials also hybrid mate-
rials such as Enamic and Lava Ultimate were chosen, which
were recently shown to provide good adhesion in vitro [58].
However, it was shown that cast gold inlays and amalgam
fillings provide the worst stabilizing effect for ETT due to miss-
ing cusp coverage and also missing adhesive stabilization.
On the other hand, cast gold PCs provided the highest frac-
ture strengths all over the study with not a single fracture.
The forces in the cast gold PC group were so high that finally
the roots crashed (Fig. 3b). Another extreme finding was the
behavior of the leucite-reinforced glass ceramic IPS Empress.
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Although proven to reliably restore even heavily decayed vital
teeth [44], the applied loads in the chosen in vitro setup have
been obviously too high for this material to withstand frac-
tures after intensive fatigue loading. It was surprising that for
IPS Empress, PC preparation did not result in higher fracture
strengths compared to I preparations, however, the fracture
modes here clearly showed that it was not a matter of prepa-
ration or adhesive stabilization but a matter of insufficient
flexural strength of the ceramic to durably prevent fractures.
One of the most important and clinically relevant findings of
the present investigation is therefore that IPS Empress should
not be taken into consideration anymore when ETT have to be
restored.
All other materials showed a quite similar behavior. Celtra
Duo, e.max CAD, Lava Ultimate, and also the direct procedures
were on the same high level when PC preparations were cho-
sen. This effect was more pronounced in MOD preparations
than in MO preparations, however, also in MO preparations
when fillings or inlays were chosen, many fractures origi-
nated from the unprepared distal lateral ridge. So the second
clinically relevant finding of the present paper is that an
endodontic access cavity may be always safely restored with
a direct adhesive restorations made of resin composite, how-
ever, from MO and larger – which is far more often occurring in
clinical life than access cavities alone – PC preparations should
be taken into consideration. Only when the unprepared lateral
ridge is really massive, a less invasive intracoronal restora-
tion would have an acceptable prognosis. This also means
that less invasive preparations and restorations do not auto-
matically results in better outcome of ETT restorations. The
opposite is true – in doubt the more invasive PC prepara-
tion may be a better basis for clinical success, irrespectively
of successful adhesion, a fact which could be clearly shown
for IPS Empress where adhesion itself did not fail during the
experiments. Finally it has to be stated that cast gold PC still
represent the ultimate tool for safely restoring ETT, however,
it can be assumed that the measured forces for e.max, Cel-
tra, Lava Ultimate, Enamic and resin composite should be
high enough to withstand intraorally observed forces in daily
life.
It is found as statement in the literature of the field
that some primarily resin-based materials may cause less
catastrophic fracture behavior when used to restore ETT
[50,51]. This theory could not be confirmed in the present
investigation, because also for the resin-based or resin-
reinforced hybrid materials catastrophic fractures were
regularly observed (Fig. 4a). So finally both null hypotheses
had to be rejected because both preparation and restora-
tion had a considerable impact on in vitro survival of ETT
restorations.
5. Conclusions
Within the limits of this in vitro approach it can be concluded
that cuspal coverage is generally desirable for the restora-
tion of ETT beyond a certain cavity extension. Newer polymer
and ceramic materials as partial crowns outperformed older
ceramics such as IPS Empress.
Please cite this article in press as: Frankenberger R, et al. Stability of endodontically treated teeth with differently invasive restorations: Adhesive
vs. non-adhesive cusp stabilization. Dent Mater (2015), http://dx.doi.org/10.1016/j.dental.2015.08.160
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