CLINICAL REPORT

Using modied polyetheretherketone (PEEK) as an alternative

material for endocrown restorations: A short-term
clinical report
Panagiotis Zoidis, DDS, MS, Dr Dent,a Eleonora Bakiri, DDS,b and Gregory Polyzois, DDS, MScD, Dr Dentc

The conventional restoration ABSTRACT

protocol for endodontically
A modied polyetheretherketone (PEEK) framework material veneered with indirect light-
treated teeth with excessive polymerized composite resin was used as an alternative material for the fabrication of an endo-
coronal loss has been metal crown restoration for an extensively damaged molar. The elastic modulus of the poly-
post and core followed by a etheretherketone framework (4 GPa) veneered with indirect composite resin could dampen the
complete crown.1,2 The use of occlusal forces protecting tooth structures better than ceramic materials. This is important in the
glass ber posts combined restoration of extensively damaged molars with weak roots. Long-term clinical evidence is required
with the dentin bonding before recommending the application as a substitute material. (J Prosthet Dent 2016;-:---)
technique made the restora-
tion of endodontically treated teeth more straightfor- restorations over composite resins.12 Endocrowns have
3
ward, biocompatible, and economical. Initially, the post been recommended for teeth with short clinical crowns
was thought to reinforce the remaining tooth structure.4 and calcied, short, or curved root canals that make post
However, several studies have reported adequate clinical and core restorations impossible.13 They can also be used
5
post adhesion to tooth structure, whereas others have in patients with limited interocclusal space, which pre-
shown variable results with high incidences of root vents adequate thickness for both the ceramic veneer and
fracture, indicating that excessive removal of tooth the metal or ceramic framework.7
6
structure to place a post further weakens the root. The materials of choice for the fabrication of endo-
The advent of high-strength ceramic materials and crowns have been reinforced, acid etchable ceramics
the progress made in adhesive dentistry has resulted in because they provide mechanical strength adequate to
restoring posterior teeth without the use of a post and withstand occlusal tooth load and adequate bond
core.7 Teeth with excessive coronal loss can be restored strength to tooth structure.14,15 The best option seems to
with the use of the endocrown. The rst endocrown be pressed or machined computer-aided design and
report was made by Pissis8 in 1995 and is known as the computer-aided restoration (CAD-CAM) ceramics rein-
monoblock porcelain technique. In 1999, Bindl and forced with lithium disilicate.16 Lithium disilicate dem-
Mrmann used the term endocrown to describe a
9
onstrates high mechanical strength, excellent adhesion
ceramic crown which extends into the pulp chamber or properties to tooth structures,17 and excellent esthetics,
the root canal orices of an endodontically treated tooth as the thickness and quantity of the ceramic material
in order to gain retention.10 used for an endocrown is greater than that of a con-
The rst clinical endocrown report was published in ventional ceramic crown.18
11
2008 by Lander and Dietschi, and in 2009, ceramics Premolar endocrowns have been less successful than
were considered the material of choice for these molar endocrowns because of less tooth surface area

a
Lecturer, Department of Prosthodontics, National and Kapodistrian University of Athens, Greece, Dental School, Athens, Greece.
b
Endodontist, private practice, Athens, Greece.
c
Professor, Department of Prosthodontics, National and Kapodistrian University of Athens, Greece, Dental School, Athens, Greece.

THE JOURNAL OF PROSTHETIC DENTISTRY 1

2 Volume
Figure 1. Preoperative radiograph showing perforation and apical
resorption.
availability for adhesion and their increased crown
height. Endocrowns should be limited to posterior
teeth.19
Compared with conventional crowns restored with a
cast post and core or a ber post and resin core, endo-
crowns have been proven more resistant to fracture.20,21
Endocrowns are also straightforward and require less
clinical time. The advantages of endocrowns are short
preparation time, minimal chair time, low cost, ease of
application, and excellent esthetic properties.3
A high-performance polymer, polyetheretherketone
(PEEK) has recently been introduced in dentistry. It has
been used for the fabrication of implant xtures, xed
and removable dental prosthesis frameworks,22 and for
implant frameworks and restorative implant parts.
A modied PEEK material containing 20% ceramic
llers (BioHPP; Bredent GmbH) has good mechanical
properties and excellent biocompatibility.23-25 It can be
used for the fabrication of prostheses either by injection
molding or CAD-CAM procedures. The advantages of
using this material are the elimination of allergic re-
actions, good wear resistance, good polishing properties,
and low plaque afnity.26,27
The major advantage of this modied PEEK material
is a 4-GPa modulus of elasticity, making it as elastic as
bone and allowing it to act as a stress breaker and reduce
the forces transferred to the restoration and the tooth
root accordingly.28 This, in combination with good
adhesion properties to tooth structures when cemented
with resin cements, could make the use of PEEK a viable
alternative for the restoration of endodontically treated
teeth through the use of endocrowns.29-32 Studies eval-
uating the properties of this material are limited.33-36
Existing reports on this material have generally been
in vitro.
Indirect composite resins present a low modulus of
elasticity (8 to 10 GPa) and have been proven to act as
stress breakers and reduce the occlusal forces.37,38
THE JOURNAL OF PROSTHETIC DENTISTRY
- Issue -
Figure 2. Occlusal reduction for polyetheretherketone endocrown.
Although restorations fabricated from these materials
demonstrate good mechanical properties, t, and es-
thetics,39 microleakage seems to be a major disadvan-
tage.40 This report describes the use of a modied PEEK
(BioHPP) framework material veneered with indirect
light-polymerized composite resin for the fabrication of
an endocrown restoration.
CLINICAL REPORT
A 35-year-old man presented for the restoration of his
maxillary right second molar. The tooth had undergone
multiple root canal treatments which resulted in perfo-
ration of the middle third of the mesial buccal canal and
evidence of apical resorption patterns. The tooth had
remained asymptomatic since the last root canal treat-
ment over 6 months previously, and a denitive resto-
ration was needed (Fig. 1).
The treatment plan consisted of a modied PEEK
endocrown framework material veneered with indirect
light-polymerized composite resin to reduce occlusal
forces and to protect the damaged endodontically treated
tooth. Because of the excessive preparation of the canals,
perforation, absorption patterns, and thin remaining axial
walls, a radicular post was contraindicated. An endo-
crown made of a modied PEEK material was preferred
as it would diminish and equally distribute stress under
oral function.
The tooth was prepared to provide 2 mm of occlusal
reduction and a butt joint with a ferrule (Fig. 2). The axial
walls were prepared with a chamfer nish line. Un-
dercuts were eliminated from the pulpal walls, and the
base of the pulp chamber was attened (Fig. 3). An
interim acrylic resin restoration (Jet; Lang Dental
Manufacturing Co) was fabricated with a at occlusal
surface to reduce lateral forces.
A denitive impression was made with polyvinyl
siloxane impression material (Elite HD; Zhermack
GmbH), and the denitive cast was poured with Type IV
Zoidis et al
- 2016 3

Figure 3. Flat base of pulp chamber showing elimination of undercuts Figure 4. Denitive cast showing preparation design.
and chamfer nish line.

Figure 5. Polyetheretherketone framework evaluation. Figure 6. Polyetheretherketone core veneered with Gradia light-
polymerized indirect composite resin.
dental stone (Prima-rock; Whip Mix Corp) (Fig. 4). The
endocrown core framework was fabricated from PEEK,
Endocrowns have been a promising treatment alter-
with the conventional lost wax technique, using a vac-
native for the endodontically treated molars with short
uum press device (2 press; Bredent GmbH) designed for
clinical crowns, short roots, and thin axial walls. In vitro
this material. The core was evaluated intraorally and t
studies have demonstrated signicantly higher fracture
was veried (Fig. 5).
strength for endocrowns than conventional crowns
The PEEK core was coated with a composite resin
restored with a cast post and core20 or with a ber post
primer (Visio.link; Bredent GmbH) and an indirect
and a resin core.21 Moreover, for superior adhesion, high
composite resin light-polymerizing veneering material
strength, and esthetic properties, these restorations
(Gradia; GC Europe N.V.) was applied in layers (Fig. 6).
should be made only with reinforced ceramics.
The endocrown was adjusted intraorally and polished.
In contrast, ceramics are considered high stiffness
The restoration was airborne-particle abraded with 110
materials with a high modulus of elasticity (210 GPa).
mm aluminum oxide and was denitively cemented with
High stiffness materials such as alumina could result in
a dual-polymerizing resin cement (Variolink Esthetic DC;
excessive loading because occlusal force transmission
Ivoclar Vivadent AG) (Fig. 7).
may have a negative impact on the biomechanical
properties of the restoration and the abutment teeth.
DISCUSSION
Materials with a lower modulus of elasticity such as PEEK
The restoration of a molar compromised by multiple and composite resins have been proved to reduce
endodontic treatments was performed using an endo- occlusal stress by acting as stress breakers.36,37 PEEK
crown framework fabricated from a modied PEEK (Bio- exhibits a modulus of elasticity of 4 GPa, which could
HPP) material veneered with a light-polymerized dampen force transmission, thereby preventing the tooth
composite resin (Gradia). and subsequently the root from overloading and

Zoidis et al THE JOURNAL OF PROSTHETIC DENTISTRY

4 Volume - Issue -

Figure 7. Polyetheretherketone endocrown denitive cementation. Figure 8. Postoperative radiograph. PEEK is radiolucent.

breakage. In addition, PEEK as a core material further

reduces the elasticity of the composite resin veneering
material from 8 to 10 GPa to 4 GPa.28
A composite resin foundation restored with an indi-
rect composite resin complete crown would be another
possible solution. This type of restoration would be a
straightforward, fast, and economic option, offering the
stress breaking effect with the same esthetic results. By
using PEEK as a framework material that extends into the
pulp chamber, the restoration not only gains retention
but further reduces the modulus to 4 GPa, protecting the
weak root and tooth structures.
The bond strength of PEEK with the veneering
composite resin material and the tooth structures has
been demonstrated to be adequate (25 MPa),30-32 Figure 9. Polyetheretherketone endocrown after 22 months of clinical
although it does require a bonding agent before the service.
composite resin veneer application29 and the use of resin
cement. However, how PEEK frameworks behave under
cautiously because this material cannot be polished
fatigue loading is not clear.
easily intraorally after denitive cementation and a dull
The fracture resistance of resin nanoceramic endo-
occlusal surface may result.
crowns is better than that of feldspathic porcelain or
Wear and staining resistance of the indirect light-
lithium disilicate under compressive load, but these
polymerized composite resin veneering material is
endocrowns seemed to demonstrate more micro-
another matter of concern. Studies have shown that
leakage.40 With the present treatment, this anticipated
these properties are the same or slightly inferior to those
microleakage was addressed by the chamfer nish line,
of ceramic materials.28 This wear or staining tendency
which extended peripherally to the butt joint preparation
may extend further to tooth survival rate.
in order to reduce cement thickness.13,18 Additionally,
PEEK is radiolucent (Fig. 8), which may facilitate
indirect composite resin restorations ensure excellent
recurrent caries detection. The endocrown restoration
marginal t, ideal proximal contacts, high wear resis-
was clinically evaluated after 22 months and showed
tance, reduced polymerization shrinkage, and optimal
good retention and appearance with no sign of micro-
esthetics.39
leakage (Fig. 9).
This combination of PEEK core veneered with
indirect composite resin resulted in an uncomplicated
SUMMARY
clinical evaluation and occlusal adjustment before
cementation, without the fear of fracturing the PEEK could be considered an alternative framework
veneering material. The esthetic appearance can be material for endocrown restorations. Further long-term
equal to that of ceramics since the indirect light- clinical evidence is required to demonstrate the use of
polymerized composite materials can be layered like a this material as a substitute for conventional ceramic or
porcelain material. Occlusal adjustments must be done metal ceramic crowns for endodontically treated teeth.

THE JOURNAL OF PROSTHETIC DENTISTRY Zoidis et al

- 2016 5

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org/10.1111/jopr.12325. Copyright 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.

Zoidis et al THE JOURNAL OF PROSTHETIC DENTISTRY