UNIVERSIDADE ESTADUAL PAULISTA
“JÚLIO DE MESQUITA FILHO”
Instituto de Ciência e Tecnologia
Campus de São José dos Campos
LITERATURE REVIEW DOI: https://doi.org/10.4322/bds.2023.e3668
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Biomimetics and the restoration of the endodontically treated tooth
Biomimética e a restauração do dente tratado endodonticamente
Paridhi KIMBLE1 , Anne Marie CORSO1 , Maxwell BEATTIE1 , Marcia Sampaio CAMPOS1 , Bruno CAVALCANTI1
1 - University of Michigan School of Dentistry, Department of Cariology, Restorative Sciences and Endodontics, ADE Endodontics. Ann
Arbor, MI, USA.
How to cite: Kimble P, Corso AM, Beattie M, Campos MS, Cavalcanti B. Biomimetics and the restoration of the endodontically treated
tooth. Braz. Dent. Sci. 2023;26(1):e3668. https://doi.org/10.4322/bds.2023.e3668
ABSTRACT
Although much progress has been obtained in terms of the Endodontic treatment, the literature shows that true
success can be only achieved with adequate coronal seal to avoid bacterial contamination, and protect the tooth
structure from fracture. There are many options available to the clinician to restore the endodontically treated
tooth; however, there is not much evidence available on what alternative is better than another. This review
will critically present the current knowledge on restorative choices, including posts and endocrowns, showing
advantages and disadvantages of different treatment forms. With this knowledge, we will also introduce the
concept of biomimetics to endodontically treated teeth, and how the nature of their remaining tooth structure
can benet from this approach. This concept entails the use of mechanisms and biologically produced materials
to restore a tooth in a way that would mimic its natural structure, with the purpose of achieving better long-
term prognosis.
KEYWORDS
Endodontics; Dental restoration; Biomimetics; Adhesion; Tooth fracture.
RESUMO
Embora tenha se obtido progresso em relação ao tratamento endodôntico, a literatura mostra que o sucesso real
só pode ser atingido com o selamento coronal adequado, para evitar-se a contaminação bacteriana e proteger-se
a estrutura dental de fraturas. Há muitas opções disponíveis para o clínico para a restauração do dente tratado
endodonticamente; entretanto, não há muita evidência disponível sobre qual alternativa é melhor que a outra.
Esta revisão apresentará criticamente o conhecimento atual sobre opções restauradoras, incluindo retentores
intraradiculares e
endocrowns
, mostrando vantagens e desvantagens das diferentes formas de tratamento. Com esse
conhecimento, também introduziremos o conceito de biomimética, uma vez que dentes tratados endodonticamente,
devido a natureza de sua estrutura dental remanescente, podem se beneciar desta abordagem. Esse conceito
envolve o uso de mecanismos e materiais produzidos biologicamente para restaurar um dente de forma a imitar
a estrutura natural, com o objetivo de alcançar melhor prognóstico de longo-prazo.
PALAVRAS-CHAVE
Endodontia; Restauração dental; Biomimética; Adesão; Fratura dental.
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Biomimetics and the restoration of the endodontically treated tooth
Kimble P et al. Biomimetics and the restoration of the endodontically treated
tooth
INTRODUCTION
The ultimate goal of endodontic therapy
is to prevent or eliminate the development of
apical periodontitis [1], which includes the
adequate conclusion of the treatment with a proper
restoration that will prevent recontamination.
During root canal treatment, there are multiple
components that each play a role in the overall
success of the procedure. This includes the
elimination and/or reduction of bacteria from the
canal system, followed by a tight seal between the
oral cavity and periradicular tissues to prevent
recontamination [2].
Following disinfection of the root canal
system, a prompt restoration is required to avoid
microleakage that could cause an endodontic
failure or fracture of the remaining tooth structure,
with deleterious effects of coronal leakage on
the success of root canals. Bacterial products
were found at the apex of root-lled teeth after
3 months in the absence of coronal restoration [3],
and showed the deterioration of apical healing in
cases with poorly sealed coronal restorations [4].
With current available evidence supporting
the need for an adequate restoration, efforts should
be directed towards rebuilding devitalized teeth
using techniques and materials that mimic the
physical and mechanical properties of the natural
tooth. This concept is known as biomimetics,
which refers to the use of a variety of mechanisms
and biologically produced materials to restore
a tooth in a way that would mimic its natural
structure [5]. Endodontic treatment entails access
to the root canal system which oftentimes involves
removal of caries and additional tooth structure
to gain access. This compromises the structural
integrity exhibited by the natural tooth. The nal
goal is to build a restorative framework that has
similar physical properties to a natural tooth [6].
This review will present the current knowledge
on the use of restorative options, while also
introducing advanced biomimetic concepts to
improve the prognosis of endodontically treated
teeth.
CURRENT KNOWLEDGE ON EVI-
DENCE-BASED OUTCOMES AND CLINI-
CAL RECOMMENDATIONS
The restoration of endodontically treated teeth
has largely been studied from both restorative and
endodontic perspectives and yet has rendered few
conclusive results. Several classical studies provide
specic evidence-based clinical recommendations
that acknowledge the loss of structural integrity
and differences in dentin following endodontically
treated cases [6-9]. Access preparations, caries, and
existing restorations compromise the structural
integrity of the tooth and thus often contribute
to tooth fracture [7]. Additionally, although
there is evidence stating that the dentin still
maintains the same resistance [8], common sense
establishes that endodontically treated teeth are
less resistant [9]. The differences in endodontically
treated teeth make the restorative process complex
and controversial. It is commonly established,
however, that prognosis of a tooth with pulpal
and periapical disease is dependent on both
proper endodontic therapy and a proper denitive
restoration after endodontic treatment [10].
In this context, there were attempts in
the literature to observe the success of root
canal treatment and its association with an
adequate restoration. Studies on the restoration
of endodontically treated teeth have rendered
that, especially when bared to substantial loading
forces, restorations that enhance structural
integrity and resistance are expected to improve
prognosis [10-12]. An assessment on if the type
of restoration associated to the tooth group has
relevance in the outcome are available, but there
are suggestions that anterior teeth with minimal
loss of tooth structure and integrity may be
restored with a bonded restoration to ll its access
opening [11]. Posts and crowns should not be
considered unless there is minimum remaining
natural tooth structure [10]. Heydecke’s study
compared the fracture strength and survival rate
of sixty-four caries free maxillary incisors with
approximal class III cavities and different core
build-ups [12]. The study found that the nal
restoration of endodontically treated anterior
teeth can be successfully performed by restoring
the endodontic access with composite while also
observing that the cementation of endodontic
posts offers no advantageous fracture resistance.
A retrospective study that include
in vitro
studies
conrm that lling the access of anterior teeth is
an appropriate treatment option [11].
In general, it is agreed that endodontically
treated posterior teeth should receive full cuspal
coverage. Pantvisai and Messer studied cuspal
deection in molars in relation to endodontic and
restorative procedures and concluded that cuspal
deection increased with increasing cavity size and
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was greatest following endodontic access [13].
These ndings support the importance of cuspal
coverage to reduce the risk of marginal leakage
and cuspal fracture in endodontically treated
teeth [14]. Aquilino and Caplan completed a
retrospective study that looked at the association
between cuspal coverage and the survival rate of
endodontically treated molars. The study found
that endodontically treated teeth that did not
receive full cuspal coverage following endodontic
treatment were lost at a six times greater rate
than teeth crowned after obturation [15]. Most
retrospective studies have shown that, in general,
crowns are more efcient in terms of increasing
the success rates [15,16]. Other authors even
analyzed the time span between the end of the root
canal treatment and the placement of restoration
and found that success rates decrease with time,
where the authors showed that teeth not crowned
within 4 months after obturation were extracted at
a 3.0 to 6.0 times greater rate than teeth crowned
right after obturation [15,17]. This points out a
strong association between crown placement and
the survival of endodontically treated teeth which
may impact treatment planning if long-term tooth
retention is the primary goal [15]. However, it is
important to emphasize that direct restorations
can be performed, especially on anterior teeth
or teeth with a good number of well-preserved
walls. In general, crown placement has no
signicant effect on the success of anterior teeth
but signicantly improves clinical success rates
of posterior teeth [11]. These data support the
concept that crowns generally should be used
on endodontically treated posterior teeth and
on anterior teeth with substantial loss of tooth
structure [18,19].
The literature available for restoring
endodontically treated teeth comes with major
limitations. For
in vitro
studies, evidence is
highly limited in its application to clinical
recommendations due to a lack of specicity and
account for uncontrolled variables.
In vitro
data
disregard essential clinical elements to patient
specic outcomes that include but are not limited
to caries risk, parafunctional habits, and occlusion
determinants [20]. Additionally,
in vivo
data
are questionable as the impact of the elasticity
of tooth structure, the periodontal ligament,
and alveolar bone in success and prognosis are
not considered [11]. Although the evidence is
convincing for retrospective studies, the problem
with the studies cited is that they investigate
large databases but with no specics to the details
involved in the restorative process. Few details are
provided on the type of restoration and isolated
outcomes for each one of them. Clinical data
rarely provide information about the initial tooth
biomechanical status nor do they provide details
of protocol and technique during the restorative
process, and therefore fail to provide signicant
outcomes if the type of restoration associated to
the tooth group has relevance in the outcome [20].
There is a wide diversity of published
opinions in relation to restoring endodontically
treated teeth and ultimately may lead to less-
than-optimal treatment selections. With the
limitations provided above, we do not have good
quality of evidence to support one or another
type of restorative procedure for endodontically
treated teeth, besides common-sense and
careful interpretation of the results available.
The evidence for restoring endodontically treated
teeth should be improved by a more specic case
selection protocol that includes information about
specic details about pretreatment and treatment
statuses and technique.
POSTS AND ENDOCROWNS
There are a number of factors impacting
clinical performance of endodontically treated
teeth restored with posts and crowns. In general,
the literature suggests that posts should be
used only when the coronal portion cannot
be retained by another means [21]. This data
can be corroborated by other studies reporting
success in restoring endodontically treated
teeth with crowns without posts when there
are a number of remaining coronal walls and
adequate dentin height [22-24]. Nevertheless,
when posts are deemed necessary, it is better
to perform a post preparation with no delay
from the obturation [25]. In this context, when
considering teeth with remaining coronal walls,
both cast and prefabricated posts may be used.
In the absence of a ferrule, posts with high values
of elastic modulus are indicated [26], as
in vitro
observations have found that cast post and
core systems lead to more irreparable failures
compared to ber post systems regardless of the
amount of remaining root tissue [27].
Even though the literature has no good
evidence on the survival rates for cast versus
prefabricated posts [28], there is some evidence
showing that premolars benefit more from
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prefabricated adhesive posts as custom posts
increase the odds of critical failure for this group
of teeth [24]. Additionally, a randomized clinical
trial showed that self-adhesive luted prefabricated
posts achieved high long-term survival rates
irrespective of using a glass ber or a titanium
post [29]. For anterior teeth, in the absence of
ferrule, the use of berglass posts represents a
conservative choice due to homogeneous stress
distribution, compared to the stress concentration
into the root canal presented by cast post.
The length of 7 mm for cast post and cores seem
to produce high rates of root fractures [30].
Another important aspect to be considered
when restoring the endodontically treated
tooth is the presence of a ferrule (Figure 1).
The called “ferrule effect” can be dened as a
circumferential dentin collar of 2 mm or more in
height [29,30,31]. Overall, a ferrule represents
a determining factor in the strain, fracture
resistance, and fracture pattern [30] that will
increase tooth strength due to the remaining
coronal dentin, and untimely, improve the long-
term prognosis [24, 32]. Evidence from
in vitro
and
in vivo
studies shows that the presence
of ferrule has a positive effect on the fracture
resistance of endodontically treated teeth [24,33].
Thus, in order to provide a ferrule, strategies such
as crown lengthening or orthodontic extrusion
should be considered, or even obtaining an
incomplete ferrule is better than a complete lack
of ferrule [34]. Interestingly, another study found
that when adequate ferrule is provided, type of
post, nal restoration, and luting agents, have
less impact on the performance of endodontically
treated teeth [34]. Finite element analyses have
shown greater values of stress, including the
cervical region, associated with the absence of
ferrule suggesting that ferrule could enhance
stress distribution [35].
Following the advent of CAD/CAM and
adhesive methods, intracoronal restorations
called “endocrowns” emerged as a possibility to
reconstruct damaged posterior teeth [36]. Their
advantages include good resistance and quick
restoration, little preparation compared with
posts and cores, no interference in the root with
retention based on macromechanical fixation
in the pulp chamber [37], similar or better
longevity compared to traditional post/core
systems [38,39], potential to increase fracture
resistance of restorations [40,41], and stabilization
of weakened tooth structures [42]. The literature
has shown that teeth restored by endocrowns
are potentially more resistant to failure than
those with ber posts. Under physiological loads,
ceramic endocrowns cemented in molars are
more resistant to damage or debonding [41].
Disadvantages of endo crowns include difcult
removal, possibility to expose root canals to
external environment, and need for at least 2 mm
of pulp chamber depth to be effective, although
they may present a conservative approach
depending on the clinical conditions [43].
ROLE OF BIOMIMETICS IN IMPROV-
ING THE ENDODONTIC PROGNOSIS
Endodontically treated teeth often present
a restorative challenge as these teeth are
structurally compromised with deep caries,
cracks, several missing walls, and extensive
previous restorations. The marked reduction
in cuspal stiffness and strength of the teeth is
attributed more to the missing coronal structure
than to additional dentin removal during
conventional endodontic treatment. It was
proven that endodontic procedures reduced the
relative cuspal stiffness of premolar teeth by only
Figure 1 - Schematics showing the dentin collar, responsible for the
ferrule effect. The higher the height and longer the circumference
[30,31,33], the best the prognosis will be on the survival of posts.
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5%, in contrast to an occlusal cavity preparation
(20%) and a mesio-occluso-distal (MOD)
cavity preparation (63%). For these reasons,
preservation of tooth structure is important for its
protection against fracture under occlusal loads
and for its survival [7]. As stated above, there is
no consensus regarding the choice of the nal
restoration for endodontically treated teeth. Most
restorative decisions are driven by factors such
as missing proximal walls, remaining dentin, and
nature of the root canal structure. Historically,
devitalized teeth were restored with cast post and
core which involved extensive preparations and
removal of dentin. Advances in adhesive dentistry
have allowed more tooth conservation.
Teeth are naturally multiphasic, with enamel
that acts as a compression dome, transforming
and transferring loads to the dentino-enamel
complex (DEC) into primarily compressive loads
in the dentin [44]. The DEC is a stress bearing
interface that prevents the underlying dentin from
damaging tensile forces that it is not designed to
handle. The primary load bearers of the tooth are
the peripheral rim of enamel, the sub-occlusal
transverse ridges and the biorim: the area of
the tooth that lies below the maximum point of
convexity. These structures act as a rebar that
buttress the tooth from top to bottom and side to
side, resisting fracture. Any restorative procedure,
be it direct or indirect, that invades these natural
load bearing structures lead to signicant loss in
the fracture resistance of the tooth. To effectively
mimic the physical and mechanical properties
of the tooth, efforts should be directed towards
minimally invasive techniques that preserve these
load bearing structures while using materials
and techniques that would reconstruct the
multiphasic layer of the tooth.
In 2002, Deliperi and Bardwell introduced
what became known as “Stress reduced direct
composite” [45]. This protocol involves restoration
of enamel and dentin as two different substrates
using selective composite placement in 1mm
increments, and light curing techniques to
minimize polymerization stress, thus allowing for
a better stress distribution throughout the entire
tooth [14,46]. It is known that human enamel
comprises of 95% hydroxyapatite. It is hard but
brittle, yet it survives the deleterious effects of
occlusal loads without cracking. Its compressive
strength is 384 mPA, so it is built to withstand
compression, but it is weak under tension with a
tensile strength of 10-40 mPA. As we get closer
to the DEJ, the inorganic content is reduced to
85%, with 25% organic matter compromising
primarily of collagen [47]. Collagen reinforces
the underside of the enamel much like rebar
reinforces a concrete beam. With a tensile strength
of 44-105 mPA, dentin is a more resilient and
tougher than enamel. Its higher organic content
makes it more compliant to withstand higher
tensile stresses than enamel [48]. With this
understanding of the natural structure of a
tooth, one could attempt to truly restore a tooth
using materials that mimic this composition and
stress bearing capabilities. In the case of enamel
replacement, ceramics such as feldspathics or
lithium disilicates are most appropriate. Their
tensile strengths are 25-40 mPA which is close
to the tensile strength of enamel. For dentin
replacement, there are a subset of composite
materials which approach a tensile strength
of 40-60mPA which is similar to dentin [49].
Identifying and utilizing these materials is a core
concept of the biomimetic approach to restorations.
In 2017, Deliperi et al. introduced the use of
ultra-high molecular weight woven polyethylene
bers as part of the “Wallpapering technique” for
restoration of devitalized teeth [50]. The strategic
adaptation of polyethylene ber to the residual
cavity walls was aimed towards a shock absorbing
and crack shielding mechanism similar to the DEC.
It required no additional tooth preparation and
therefore was considered a more conservative
approach to restoring endodontically treated teeth
(Figure 2). Another approach would be the use of
dental fragments which, although not extensively
studied, has shown good results in a clinical case
report [51].
Often with structurally compromised teeth
that are endodontically treated, there comes
a point in the restorative continuum that the
bonded direct restoration reaches their limitation.
This includes scenarios where the functional
and nonfunctional cusps are compromised.
The biomechanical integrity of these teeth can
be restored with indirect restoration, specically
onlay and non-retentive overlays that are
minimally invasive and present as a biomimetic
and a more fracture resistant alternative to
traditional crown preparation [52]. It eliminates
the need for complex geometrical design such as
steep walls and sudden transitions that would
otherwise concentrate stress and lead to reduced
fracture resistance and unfavorable outcomes.
In addition, onlay and overlays mitigate stress
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by providing a highly compressible ceramic
framework over the height of contour which
mimics the natural enamel compression dome,
while preserving the healthy tooth structure below
the height of contour, or biorim (Figure 3) [53].
Both the direct and the indirect approach rely
heavily on the strength of the underlying adhesives.
This is crucial for retention of direct restoration,
sealing against microleakage and to increase the
fracture resistance of indirect restorations. Several
bond-maximizing techniques can be incorporated
starting with establishing complete caries and
crack removal during endodontic treatment.
Adjunct methods include air abrasion of the tooth
structure for better bond strengths, beveling
enamel across the enamel rods, and employing
gold standard bonding systems, specically third
or sixth generation bonding system that can
achieve a bond strength of 35 mPA to enamel
and 60 mPA on dentin [54,55]. In addition,
immediate dentin sealing and resin coating for
better bond strengths. For this, bonding agents
are applied at the time of tooth preparations or
Figure 2 - Example of a clinical case of “wallpapering technique” in an endodontically treated tooth. The patient had financial concerns and
could not afford a crown coverage. To improve the probability of success, a polyethylene fiber was adapted within all walls of the cavity and
the tooth was restored with composite. Courtesy of Dr. Kimble.
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before capturing an impression for an indirect
restoration. This is followed by resin coating, where
a 0.5 mm layer of owable resin is applied on to
the developing adhesive/hybrid layer. This ensures
that the adhesive is fully polymerized, limiting
gap formation and ensuring a secure bond [5].
Immediate dentin sealing and resin coating
addresses the fundamental problem in adhesive
dentistry where the polymerization shrinkage
stress exceeds the early dentin bond strengths
leading to delamination of the adhesive and the
composite, setting the stage for microleakage [56].
To address this concern, the newly bonded dentin
surface must have time to “mature” before being
loaded by the shrinkage stresses of the incoming
composite resin restorative material. Maturation
entails a wait time of 5-30 mins. When allowed to
mature, dentin bonding can reach a bond strength
of 55-60 mPA, this equates or even exceed the
strength of the DEJ. In addition, immediate dentin
sealing increases the bond strength of indirect
restoration by 400% [57].
Leveraging these advanced adhesive concepts
for direct and indirect restoration that replicate
the stress bearing capabilities of a natural tooth
are crucial to improving the survivability of
endodontically treated teeth.
FINAL CONSIDERATIONS
It is clear that the adequate restoration of an
endodontically treated tooth remains a challenge,
particularly because there is a lack of evidence
from high quality clinical trials showing that one
treatment is superior to another. Most of the
information available comes from retrospective
clinical studies and/or from
in vitro
data, which
although necessary to point to some variables of
importance, lack the prospective aspect and the
level of condence to direct clinical decisions.
Even current systematic reviews conclude that
fact [58,59], and this can be a call for more well-
designed clinical studies to help clinicians in their
treatment planning.
Even with these limitations, it is clear
that endodontically treated teeth can benefit
from a biomimetics approach. This fact is even
more evident when it is well known that cracks
can reduce the long-term prognosis and this
approach can help to contain or, at least, to
mitigate the effect of the crack’s distribution on
the tooth structure. Our understanding of stress
distribution on teeth that have gone through
significant endodontic procedures are due to
benet from our understanding of appropriate
restorative techniques.
Author’s Contributions
PK, MS, BC: Conceptualization. AMC,
MSC,PK, MB: Methodology, Validation, Formal
Analysis, Investigation, Writing – Original Draft
Preparation. PK, BC: Visualization. MB, BC:
Writing – Review & Editing.
Conict of Interest
The authors have no proprietary, nancial,
or other personal interest of any nature or kind
in any product, service, and/or company that is
presented in this article.
Funding
This research did not receive any specic
grant from funding agencies in the public,
commercial, or not-forprot sectors.
Figure 3 - Schematics of the tension/compression effects on the
tooth cusps. The cusp suffering tension is more likely to develop a
crack or fracture when compared to the cusp suffering compression.
This can guide the treatment decision to cover, at least the cusp
under tension.
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tooth
Regulatory Statement
As a literature review, this manuscript does
not qualify as a study on human subjects, thus
being exempt of regulatory statement.
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9
Braz Dent Sci 2023 Jan/Mar;26 (1): e3668
Biomimetics and the restoration of the endodontically treated
tooth
Kimble P et al.
Biomimetics and the restoration of the endodontically treated tooth
Kimble P et al. Biomimetics and the restoration of the endodontically treated
tooth
Date submitted: 2022 Oct 22
Accept submission: 2022 Dec 13
Bruno Cavalcanti
(Corresponding address)
University of Michigan School of Dentistry, Department of Cariology, Restorative Sciences and
Endodontics, Ann Arbor, MI, USA.
Email: brunocav@umich.edu
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