Ó

Operative Dentistry, 2015, 40-2, 201-210

Fracture Resistance and

Microleakage of Endocrowns
Utilizing Three CAD-CAM Blocks
HM El-Damanhoury  RN Haj-Ali  JA Platt

Clinical Relevance
Fracture resistance and mode of failure of CAD/CAM-fabricated monoblock endocrowns
varies widely between materials. Clinicians should be cautious with material selection for
endocrown restorations.

SUMMARY nanoceramic (Lava Ultimate [LU], 3M ESPE,

This study assessed marginal leakage and St Paul, MN, USA).). Thirty extracted human
permanent maxillary molars were endodonti-
fracture resistance of computer-aided design/
cally treated. Standardized preparations were
computer-aided manufacturing (CAD/CAM)
done with 2-mm intracoronal extensions of the
fabricated ceramic crowns with intracoronal
endocrowns into the pulp chamber. Teeth were
extensions into the pulp chambers of endodon- divided into three groups (n=10); each group
tically treated teeth (endocrowns) using either was restored with standardized CAD/CAM fab-
feldspathic porcelain (CEREC Blocks [CB], ricated endocrowns using one of the three
Sirona Dental Systems GmbH, Bensheim, Ger- tested materials. After cementation with resin
many), lithium disilicate (e.max [EX], Ivoclar cement, specimens were stored in distilled
Vivadent, Schaan, Liechtenstein), or resin water at 378C for one week, subjected to
*Hatem M. El-Damanhoury, BDS, MS, PhD, assistant
thermocycling, and immersed in a 5% methy-
professor, College of Dentistry, University of Sharjah, lene-blue dye solution for 24 hours. A compres-
Sharjah, United Arab Emirates, and lecturer, Department sive load was applied at 35 degrees to long axis
of Operative Dentistry, Faculty of Dentistry, Suez Canal of the teeth using a universal testing machine
University, Ismalia, Egypt until failure. Failure load was recorded, and
Reem N. Haj-Ali, BDS, DDS, MS, associate professor, College specimens were examined under a stereomi-
of Dentistry, University of Sharjah, Sharjah, United Arab croscope for modes of failure and microleak-
Emirates, and University of Missouri-Kansas City School of age. Results were analyzed using one-way
Dentistry, Kansas City, MO, USA
analysis of variance and Bonferroni post hoc
Jeffrey A. Platt, DDS, MS, associate professor, Restorative multiple comparison tests (a=0.05). LU showed
Dentistry, Indiana University, Indianapolis, IN, USA
significantly (p,0.05) higher fracture resis-
*Corresponding author: Department of General and Spe- tance and more favorable fracture mode (ie,
cialist Dental Practice, M28-126, Sharjah 27272, United
Arab Emirates; e-mail [email protected]
fracture of the endocrown without fracture of
tooth) as well as higher dye penetration than
DOI: 10.2341/13-143-L
CB and EX. In conclusion, although using resin
202 Operative Dentistry

nanoceramic blocks for fabrication of endo- Moreover, endocrowns have the advantage of pre-
crowns may result in better fracture resistance serving tooth structure, reducing the need for
and a more favorable fracture mode than other auxiliary macroretentive features, and saving pa-
investigated ceramic blocks, more microleak- tient’s and operator’s time due to fewer clinical steps
age may be expected with this material. and absence of the laboratory procedures needed for
fabricating conventional crowns. This approach has
INTRODUCTION shown promising results and comparable short-term
Restoration of endodontically treated teeth contin- survival when compared to post, core, and crown
ues to be a challenge in reconstructive dentistry. A systems.18-22
common protocol of restoring such teeth has been to A wide collection of ceramic materials has been
build up the tooth with a post and core to aid the available for CAD/CAM technology, ranging from
retention of an overlying crown. This can be achieved relatively weak feldspathic ceramic and leucite glass
through a direct approach using a prefabricated ceramic to high-strength lithium disilicate glass
intraradicular post followed by a direct core material ceramic and zirconium oxide.23 Most recently, a
or through an indirect post and core restoration for resin nanoceramic has been introduced for perma-
teeth with more extensive loss of tooth structure. nent CAD/CAM fabricated restorations.24,25 Ultra-
However, many clinical and laboratory studies have structure, physical, and mechanical properties of
reported that placing a post will contribute to the available CAD/CAM materials vary widely, and,
retention of the core portion of the restoration but accordingly, their mechanical behavior in the tooth-
may have a weakening effect on the root.1-5 The use restoration complex is expected to vary as well.26,27
of intraradicular post and cores is complicated by the With the intent of increasing the amount of
necessity to prepare an adequate ferrule, which information about the biomechanical behavior of
reduces the risk of failure through root fracture.6 these materials when used for endocrowns, the
Failure of post and core systems may be due to present study evaluated the microleakage, fracture
different mechanical behaviors relative to tooth resistance, and failure modes of three types of CAD/
structure in response to intraoral cyclic stresses.7 CAM fabricated restorations when they were sub-
This failure can be classified as repairable failure mitted to an oblique compressive force.
(favorable fracture) or nonrepairable failure (cata-
strophic fracture) that requires extraction of the METHODS AND MATERIALS
tooth and subsequent prosthetic replacement.8,9
Tooth Collection and Preparation
With the increasing popularity of adhesive den-
tistry, a shift in treatment decisions toward more Thirty freshly extracted human permanent maxil-
conservative modalities has been observed, and the lary first and second molars with approximately
need for conventional post and cores has become less similar mesiodistal/buccolingual dimensions and
clear.10 Ceramic inlays, onlays, and endocrowns root length were collected after patients’ informed
have been introduced as alternative restorations consents were obtained under a protocol approved by
for endodontically treated molars, depending on the the institutional review board and in conformity
availability of remaining tooth structure.11-14 Initial- with the university’s guidelines for handling biolog-
ly proposed by Pissis15 in 1995, endocrowns are a ical tissues. Teeth were ultrasonically cleansed of
type of restoration consisting of the entire core and calculus and soft tissues, stored in a 1% chloramine-
crown as a single unit (ie, monoblock). Endocrowns T solution at 48C, and used within one month. Teeth
use the available surface of the pulp chamber axial were sectioned parallel to the occlusal surface at 2
walls as macroretentive resources and adhesive mm above the cementoenamel junction (CEJ) to
resin cement as a means of micromechanical reten- remove occlusal tooth structure and to deroof the
tion.16 Additionally, this type of restoration is made pulp chamber.
available through computer-aided design/computer-
aided manufacturing (CAD/CAM) technology, which Endodontic Procedures
provides the possibility for chair-side design and Removal of pulp tissues was done with an endodontic
fabrication. reamer, and determination of root canal lengths was
Endocrowns are especially indicated in cases of done radiographically with endodontic files inserted
inadequate clinical crown length, insufficient inter- in the canals. Standardized canal enlargement was
occlusal space, and extensive loss of dental tissues performed with an engine-driven rotary NiTi system
that do not allow the use of an adequate ferrule.17 (ProTaper, Dentsply Maillefer, Ballaigues, Switzer-
El-Damanhoury, Haj-Ali & Platt: Fracture Resistance and Microleakage of Endocrowns 203

Table 1: The Materials Tested in This Study

Code Material Manufacturer Batch Number Ceramic Type Fracture Toughness Modulus of Elasticity
(MPa m½)a (GPa)a
CB CEREC Blocks Sirona Dental 108290 Aluminosilicate 1.4 (0.2) 45.0 (0.5)
Systems (feldspathic) ceramic
EX e.max CAD Ivoclar Vivadent P84622 Lithium disilicate 2.6 (0.3) 81.0 (3.3)
glass ceramic
LU LAVA Ultimate 3M ESPE N333039 Resin nanoceramic 2.0 (0.2) 12.8 (1.0)
a
Values obtained from manufacturer’s data.

land) using a crown-down technique; 1% NaOCl was Systems GmbH, Bensheim, Germany). All endo-
used as an irrigant for 10 seconds between each file. crowns were designed to have similar occlusal
Root canals were obturated with a thermoplasticized anatomy by using the biogeneric reference option
gutta-percha (Calamus Dual, Dentsply Maillefer, as well as having the same occlusogingival height.
Woodinville, WA, USA) and root canal sealer (AH Teeth were randomly distributed into three equal
26 sealer, Dentsply Maillefer) according to the groups (n=10) according to the block material:
manufacturer’s instructions, providing a standard- feldspathic block ceramic (CB), lithium-disilicate
ized filling procedure. blocks (EX) and resin nanoceramic blocks (LU).
The superior aspect of the gutta-percha material Tested materials are listed in Table 1.
was removed using a small carbide bur to 1 mm Before cementation, the marginal adaptation of
below the orifice of each canal, then flowable resin the endocrowns was checked using a Measurescope
composite (Filtek Z350XT flowable, 3M ESPE, St (UM-2, Nikon, Tokyo, Japan), and any specimen
Paul, MN, USA) was used to fill the canals up to the with a marginal gap .40 microns was rejected and
level of the pulp chamber. replaced with a new specimen. Intaglio surfaces of
each endocrown were treated according to the
Endocrown Preparation manufacturer’s instructions for the respective block
material. Etching with 5% hydrofluoric acid gel (IPS
The teeth were individually fixed in fast-cure acrylic
Ceramic Etching Gel, Ivoclar Vivadent, Schaan,
resin (Fastray, Harry J. Bosworth Co, Skokie, IL,
Liechtenstein) was done for 60 seconds for CB or
USA) using polyvinyl chloride rectangular molds. The
20 seconds for EX, then rinsed for 60 seconds with
roots were embedded in resin up to 2 mm below the
running water and dried for 30 seconds with oil-free,
CEJ (simulated bone level). Intracoronal height of the
moisture-free air. Intaglio surfaces of LU crowns
prepared walls was reduced to 2.0 mm, measured
were sandblasted with 25-lm aluminum oxide
from the internal cavity margin to the floor of the
particles (MicroEtcher CD, Danville Materials, San
pulp chamber, using a periodontal graded probe.
Ramon, CA, USA), then sand was removed with
A standardized cavity preparation was performed alcohol and dried with oil-free, moisture-free air. A
in all teeth limited to removal of undercut areas of ceramic primer containing silane coupling agent
the pulp chamber and alignment of its axial walls (Monobond Plus, Ivoclar Vivadent) was applied to
with an internal taper of 8-10 degrees using a the intaglio surfaces of all endocrowns and allowed
tapered diamond coated stainless-steel bur with a to dry for 60 seconds.
rounded end (G845KR, Edenta, Basel, Switzerland)
Prepared tooth surfaces were etched with 37%
held perpendicular to the pulpal floor. All internal
phosphoric acid–etching gel for 15 seconds, rinsed
line angles were rounded and smoothed using the
for 20 seconds, and dried with oil-free air for another
same type of bur. The axial walls were prepared from
5 seconds. Dentin primer (Syntac, Ivoclar Vivadent)
the pulpal side to provide for a standardized cavity
was applied for 15 seconds and dried thoroughly for
wall thickness of 2.0 6 0.2 mm measured with a
10 seconds, then dentin adhesive (Syntac, Ivoclar
digital caliber (Mitutoyo IP 65, Kawasaki, Japan)
Vivadent) was applied for 10 seconds and dried
having a precision of 0.001 mm.
thoroughly for another 10 seconds. Adhesive resin
(Heliobond, Ivoclar Vivadent) was applied and air
Endocrown Fabrication and Thermocycling blown to a thin layer for 15 seconds. All specimens
CAD/CAM ceramic endocrowns were fabricated with were cemented with dual cure resin cement (Vari-
a CEREC AC system by using the software package olink II, Ivoclar Vivadent) under a constant load of
provided (CEREC 3D, version 3.8, Sirona Dental 50 g for 30 seconds. Excess material was removed
204 Operative Dentistry

Figure 1. Crack of endocrown/tooth complex above margin of bone level simulation (type III, acceptable failure) characteristic for feldspathic ceramic
crowns (CB) with little penetration of the dye materials at the margin.

with the help of a microbrush. Restoration margins 4.08, MTS, Eden Prairie, MN, USA) with a 2.5-kg
were covered with a glycerine gel (Liquid Strip, load cell. Force was applied through a stainless-steel
Ivoclar Vivadent) to prevent oxygen inhibition of ball (2.5 mm in diameter) representing the antagonist
polymerization. The resin cement was light activated tooth. Load was applied to the incline of the palatal
at each surface for 20 seconds using a light-emitting cusp at a crosshead speed of 0.5 mm/min. The fracture
diode curing unit (Demetron A.1, Kerr/Sybron, load needed to cause failure of the specimen, which
Orange, CA, USA) with a 12-mm-diameter curing- was signaled as a peak in the load-displacement
light tip in standard mode with irradiance output of tracing, was recorded in newtons (N). Mode of
1000 6 50 mW/cm2 held at a surface-tip distance of fracture was examined for each specimen and
0.5 mm. Output intensity was monitored after every categorized according to the following descriptions:
fifth specimen using a handheld radiometer (Kerr/ Type I: complete or partial debonding of the
Model 100, Demetron Research, Orange, CA, USA). endocrown without fracture (favorable failure)
Margins of the restorations were finished with
Type II: fracture of the endocrown without
sandpaper polishing discs (Sof-Lex, 3M ESPE).
fracture of the tooth (favorable failure)
Specimens were stored in double-distilled water at
Type III: fracture of the endocrown/tooth complex
378C for one week to allow for bonded interface
maturation. Specimens were subjected to 5000 ther- above the height of bone level simulation (acceptable
mal cycles between two water baths of 58C and 558C failure)
with a dwell time of 30 seconds at each temperature Type IV: fracture of the endocrown/tooth complex
(Thermocycler, Willytec, Munich, Germany). After below the height of bone level simulation (cata-
thermocycling, the entire surface of each specimen strophic failure)
was covered with two coats of varnish up to 1 mm from
the crown margins. Teeth were soaked in an aqueous Microleakage Testing
solution of 5% methylene blue dye for 24 hours at
The fractured coronal portion of the specimens were
378C. Following dye exposure, the teeth were rinsed
reassembled and embedded in fast-cure resin (Fas-
thoroughly with a water syringe for 30 seconds.
tray, Harry J. Bosworth Co). Resin blocks were
allowed to polymerize for 24 hours. Each specimen
Fracture Resistance Testing was sectioned buccolingually with a slow-speed
Each mounted tooth was placed in a two-dimensional diamond precision saw (Isomet 1000, Buehler, Lake
precision vice (FT-USV80, Firstec Inc, Osaka, Japan), Bluff, IL, USA) under water cooling, producing five
positioned at an angle of 35 degrees between the long sections from each tooth. The two outermost sections
axis of the tooth and the loading jig in a universal were discarded, and the middle three tooth sections
testing machine (Sintech Renew 1123, TestWorks were used for dye penetration evaluation.
El-Damanhoury, Haj-Ali & Platt: Fracture Resistance and Microleakage of Endocrowns 205

Figure 2. Crack of endocrown/tooth complex below margin of bone level simulation (type IV, catastrophic failure) characteristic for lithium disilicate
(EX) crowns with little penetration of the dye materials at the margin.

A digital multiaxis dimensional measurement Bonferroni post hoc multiple comparison tests
device (Quadra-Chek 200, Metronics Inc, Bedford, (a=0.05).
NH, USA) connected to a Measurescope (UM-2,
Nikon) was used to measure the depth of dye RESULTS
penetration with the help of a built-in digital camera The means, standard deviations, and 95% confidence
(Digital Microscope Camera, Model DMC 1, Polaroid, interval levels for both fracture resistance and dye
PLR Ecommerce, LLC, Minneapolis, MN, USA) and penetration for the three investigated CAD-CAM
fiber-optic light at a magnification of 903. Dye blocks are presented in Table 2. ANOVA revealed
penetration at the tooth/luting agent interface at that there was a statistically significant difference
both the buccal and the lingual margins of each between the groups (p,0.05) for both fracture
section was measured in millimeters, and dye resistance and dye penetration. The Bonferroni test
penetration for each tooth was calculated from the (Table 3) indicated that there was a significantly
average of all the readings of the three sections higher (p,0.05) mean fracture resistance value for
(Figures 1 through 3). LU (1583.28 6 170.55 N) when compared to both CB
and EX (1340.92 6 97.80 and 1368.76 6 237.34 N,
respectively). There was no significant difference
Statistical Analysis
between mean fracture resistance of EX and CB.
Results were analyzed with statistical software Additionally, the mean dye penetration values of LU
(SPSS version 20.0, SPSS Inc, Chicago IL, USA) (2.80 6 0.19 mm) were found to be significantly
using a one-way analysis of variance (ANOVA) and higher (p,0.05) than those of CB and EX (1.111 6

Table 2: Means, Standard Deviations,95% Confidence Intervals (in Parentheses) of the Dye Penetration and Fracture
Resistance of Different CAD/CAM Blocks
Material Mean Standard Deviation 95% Confidence Interval for Mean Minimum Maximum
Lower Bound Upper Bound
Dye penetration (mm) CB 1.11 0.19 0.98 1.24 0.92 1.37
EX 1.91 0.14 1.81 2.01 1.70 2.06
LU 2.80 0.18 2.67 2.93 2.51 2.94
Fracture resistance (N) CB 1340.92 97.80 1270.96 1410.88 1240.05 1494.48
EX 1368.77 237.34 1198.99 1538.55 811.36 1746.28
LU 1583.28 170.55 1461.27 1705.28 1316.89 1746.28
206 Operative Dentistry

Table 3: Results of Bonferroni Post Hoc Test From Multiple Comparison of Dye Penetration and Fracture Resistance of Different
CAD/CAM Blocks
Dependent Variable (I) Block Type (J) Block Type Mean Difference (I J) Standard Error Significance
Dye penetration CB LU 1.690* 0.076 0.000
EX 0.802* 0.076 0.000
EX CB 0.802* 0.076 0.000
LU 0.888* 0.076 0.000
LU CB 1.690* 0.076 0.000
EX 0.888* 0.076 0.000
Fracture resistance CB LU 242.358* 79.574 0.015
EX 27.848 79.574 1.000
EX CB 27.848 79.574 1.000
LU 214.510* 79.574 0.036
LU CB 242.358* 79.574 0.015
EX 214.510* 79.574 0.036
* The mean difference is significant at the 0.05 level.

0.185 and 1.91 6 0.14 mm, respectively), which were longer a prerequisite. The utilization of the available
also found to be significantly different. space inside the pulp chamber adds to the stability
Modes of failure of the three tested CAD/CAM and retention of the restoration and reduces the
blocks are presented in Table 4. The results showed operational errors possible during post-space prepa-
ration.20 It has been assumed that through estab-
that 50% of the CB specimens exhibited acceptable
lishing adhesion, the occlusal stresses that occur
fracture type (Figure 1) and 30% catastrophic
during function are transmitted to the walls of the
fracture. High prevalence of catastrophic fracture
pulp chamber. The deeper the pulp cavity and
(70% type IV) was demonstrated by EX, as shown in
resulting intracoronal extension, the greater the
Figure 2. Meanwhile, LU exhibited a higher occur-
surface area that can be utilized for adhesive
rence of favorable fracture modes (20% type I and
retention and transmission of masticatory forces.16
60% type II), as demonstrated in Figure 3.
In an attempt to exclude the effect of variances in
DISCUSSION the intracoronal extensions of the endocrowns, a
standardized cavity design following guidelines by
This in vitro study simulates the compromised Pissis15 was used. The preparations were done to
situation of extensive loss of tooth structure, which allow for an intracoronal extension of 2 mm. This
does not readily allow for the use of the ferrule effect minimal extension allowed for testing endocrown/
in crown preparation. Under such circumstances, tooth systems with minimal remaining tooth struc-
endocrowns take advantage of recent developments ture, in other words, the ability of the remaining
in adhesives, ceramics, and CAD/CAM technologies tooth structure to retain the restoration and the
in an approach that is based mainly on a decay- ability of the adhesive restoration to reinforce the
oriented design concept.28 This concept is built on a remaining weakened tooth structure. A previous
minimally invasive preparation that preserves max- study had reported clinical evaluation of endocrowns
imum amounts of tooth surface for bonding and with intracoronal extensions varying from 1 to 4
where extensive macroretention designs are no mm, corresponding to variances in pulp chamber
depth.17 Yet no studies report the effect of the
Table 4: Modes of Failure (%) of Feldspathic Porcelain dimension of the intracoronal extension on fracture
(CB), Lithium Disilicate (EX), and Resin resistance and modes of failure. One study reported
Nanoceramic (LU) that the possible failure of the endocrown was
Material Mode of Failure %
associated with the height of the endocrown itself
(position of the finish line) and the height level of the
Type I Type II Type III Type IV
applied force on the crown (contact with opposing
CB 10 10 50 30
teeth) rather than the concept of the endocrown
EX 0 0 30 70
itself.29 Therefore , in the present study, variability
LU 20 60 20 0
in endocrown dimensions was controlled using the
El-Damanhoury, Haj-Ali & Platt: Fracture Resistance and Microleakage of Endocrowns 207

Figure 3. Crack of endocrown without fracture of tooth (type II, favorable failure) characteristic for nanocomposite (LU) crowns with deep penetration
of the dye material.

Cerec technology, which allowed the fabrication of critical areas that might cause catastrophic fail-
standardized restoration size, shape, and cuspal ures.33,34 Failure modes reported in this study
inclines and hence standardizing the point of load support such an explanation, as none of the LU
application during testing. specimens showed catastrophic failure modes, while
In complex multilayered restorations, such as 80% had favorable modes of failure. On the other
cemented ceramic restorations, several factors con- hand, 70% of the EX specimens had catastrophic
tribute to the mechanical behavior of the restora- failure modes.
tion/tooth system. The intrinsic strength of each Moreover, weak bond strength between restora-
component of the system (ie, tooth, adhesive tions and resin cements could lead to a nonhomoge-
system, luting cement layer, and restoration), the neous distribution of forces that could result in
thickness of the restorative material, the ratios of cohesive failure of the resin cement. Multiple
elastic moduli between the restoration material, the authors have evaluated the bond strength of feld-
luting cement and dentin, and finally the quality of spathic and lithium disilicate–based glass ceramic to
the adhesive interface between these layers in composite resin or resin cements using tensile,
terms of bond strength and presence of micro- or microtensile, shear, and microshear mechanical
nanoleakage are all factors that play a role in the tests23,35-37 and concluded that lithium-disilicate
behavior of such restorations.31 Results of the glass ceramic exhibits significantly higher bond
present study showed a significantly higher mean strengths than feldspathic ceramics independent of
fracture resistance value for LU when compared to surface conditioning, which is attributed mainly to
EX and CB. These results were in agreement with its unique crystalline microstructure. Another study
another study by Heo and others,30 who reported reported higher bond strength to resin cement and
significantly higher impact fracture resistance and more favorable modes of failure of LU when
fewer cases of complete fracture of LU when compared to feldspathic porcelain monoblocks.38
compared to lithium disilicate. These findings can provide understanding for the
The unique composition of LU allows the material results of the current study, as the bond strength of
to have a modulus of elasticity (12.8 GPa) similar to LU to composite resin is expected to be better than
that of dentin (5.5-19.3 GPa).32 The modulus of that found with ceramics.39,40 The presence of resin
elasticity influences the susceptibility to fracture of a matrix in LU blocks should facilitate bonding to
cemented ceramic restoration since materials with resin composite luting materials, resulting in more
more compatible elastic moduli tend to bend under uniform stress distribution when compared to feld-
load and distribute stresses more evenly, while rigid spathic and reinforced ceramics and therefore better
materials with different elastic moduli, such as fracture resistance. It is worth mentioning that
lithium disilicate, produce stress concentrations at although the application of a single monotonic load
208 Operative Dentistry

to cause failure does not represent the clinical use for endocrown restoration of endodontically
situation, in which repetitive cyclic fatigue loading treated teeth with extensive loss of tooth structure.
is characteristic, the setting of this study provided a However, higher amounts of microleakage may
controlled environment that allows comparing the jeopardize the long-term performance of this material.
behavior of materials under the applied circum-
stances. Acknowledgements
Thermocycling and application of mechanical load- 3M ESPE and Ivoclar Vivadent are gratefully acknowledged
ing are widely accepted methods when testing for in for the generous donation of materials used for this study.
vitro microleakage and fracture resistance to simulate
Note
aging and stress at the adhesive interface.41 Exposure
of the hybrid layer to hot water during thermocycling This research work was presented at The 91st General
Session and Exhibition of the International Association for
can affect the adhesive layer by accelerating the Dental Research, Seattle, WA, USA, March 2013.
hydrolysis of unprotected collagen and extracting
poorly polymerized resin. Additionally, stresses are Conflict of Interest
generated at the adhesive interface during thermo- The authors of this manuscript certify that they have no
cycling due to the difference in the coefficient of proprietary, financial, or other personal interest of any nature
thermal expansion between the restorative materials or kind in any product, service, and/or company that is
presented in this article.
and the tooth structure. The linear coefficient of
thermal expansion has been suggested as an impor- (Accepted 3 September 2013)
tant factor that influences microleakage.42,43 This
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