The Effects of Endodontic Access Cavity Preparation Design on the

Fracture Strength of
Endodontically Treated Teeth: Traditional Versus Conservative
Preparation

Shaziya Anjum (JR 1)

DEPT OF CONSERVATIVE DENTISTRY &
ENDODONTICS
 INTRODUCTION
• The structural, esthetic , and functional rehabilitation of endodontically treated
teeth is very difficult.

• Studies showed that by critically reducing the amount of dentin, endodontic

access cavity preparation decreased the fracture strength of teeth and increased
cuspal deflection during function

• The loss of dentin and anatomic structures, such as cusps, ridges, & the pulp
chamber roof, can result in fracture of the tooth after the final restoration.
• The conservative endodontic cavity (CEC) preparation is a minimally invasive
procedure that can preserve tooth structures, such as pericervical dentin.

• Advancements in adhesive technology have enabled conservative and

esthetic post endodontic restoration.

• Conventional composites and flowable bulk-fill base composites ex SDR,

which can be bulk filled in layers up to 4 mm in thickness, are a good
alternative for the restoration of endodontically treated posterior teeth .
• SDR has an increased depth of cure because of increased translucency.
It includes a flexible polymer that does not translate the shrinkage stress to
the tooth. Thus, it is hypothesized that this will reduce the strengthening effect
of the composite on the tooth.

• New composite resin–based materials, including polyethylene and glass fibers,

are also available for use in endodontic restoration. The use of newly developed
fiber based composites means that wide cavities exposed to a high level of
stress, especially those in posterior teeth, can be more successfully restored.
• EverX Posterior ( GC Dental, Tokyo, Japan) has been introduced for
dentin replacement in large, deep, and high C-factor design cavities.

• It can be used in 4-mm increments in extensive posterior cavities to

mimic the stress absorbing properties of dentin.

• Because these composites enable 4–5 mm thick increments to be

cured in one step, they are time-saving and easy handling composites.
 The aim of the present study was to compare the fracture strengths of
mandibular molar teeth prepared using traditional & conservative methods
and restored using SDR and EverX Posterior base composite materials.

The null hypotheses of the present study were as follows:

• The access cavity preparation method would have no effect on the fracture
strength of endodontically treated mandibular molar teeth.

• The different base composite materials used in the restoration would have no
effect on fracture strengths of endodontically treated mandibular molar teeth.
 Materials and Methods
Sample Size Estimation

• Power analysis was conducted using G Power 3.1 (Heinrich Heine University,
Dusseldorf, Germany) software by selecting the analysis of variance test of the
F tests family.

• An alpha-type error of 0.05, a beta power of 0.95, and a ratio N2/N1 of 1

were also stipulated. The power calculation indicated that the sample size for
each group should be a minimum of 20 teeth.
Sample Selection

• After ethics committee approval (no. 2016/272), 100 mandibular first molar
teeth were included in the study.The teeth were collected from patients aged
between 40 and 60 years old. All the teeth had completed root development
without any cracks or defects on the surface & no restoration history.

• Soft and hard tissue residuals on the tooth surfaces were removed using an
ultrasonic scaler. The buccolingual & mesiodistal diameters of teeth were
measured using a caliper.
• Care was taken to ensure that all the teeth had similar dimensions for
standardization.

• During the study, the teeth were kept in distilled water at room temperature (25 C)
when not used.

• The maximum storage time for the teeth was 6 months.

• The teeth were randomly divided into 5 groups (n = 20/each group), and the
following procedures were implemented.
• Group 1: The teeth in this group underwent no treatment, and the teeth
served as a control group.

• Group 2: In this group, after TEC preparation root canal treatment was
performed. EverX Posterior was applied as the base material , but the
proximal cavity was not completely filled.

• The final restoration was completed using Filtek Z250 composite resin.
Figure 1. (A) TEC preparation, (B) EverX Posterior application to TEC, and (C) final restoration of TEC.
• Group 3: After CEC preparation, root canal treatment was performed.
EverX Posterior was applied as the base material, but the proximal cavity was
not completely filled. The final restoration was performed using Filtek Z250
composite resin.

• Group 4: After TEC preparation, root canal treatment was performed.

SDR was applied as the base material, and the proximal cavity was
completely
filled. The final restoration was completed using Filtek Z250 composite resin.
• Group 5: After CEC preparation & rct ,SDR was then applied as the base
material, and the proximal cavity was completely filled.The final restoration
was completed using Filtek Z250 composite resin.

Figure 2. (A) CEC preparation, (B) a proximal view of CEC, (C) SDR application to CEC, and (D) the final
restoration of CEC.
 TEC and CEC Preparation
• In TEC preparation, a class II mesio-occlusal endodontic cavity was
prepared.
Occlusal enamel and dentin tissue between the mesial and distal root canal
orifices were removed.

• Similarly, in CEC preparation, a class II mesio-occlusal cavity was prepared.

• In contrast to the TEC preparation, occlusal enamel and dentin tissue

between the root canal orifices in the mesial and distal segments were not
removed.
• The distal cavity in the CEC preparation was determined & standardized
to the distal marginal ridge thickness. The distal marginal ridge thickness of
both cavities was 1.5 mm.

• On the mesial side, the distance between the gingival margin and the
enamel–cement line junction was prepared to be 1 mm. Care was taken to
ensure a thickness of 2 mm between the buccal and lingual walls and the
interproximal cavity walls.

Pulpal tissue in the pulpal chamber was completely removed using an

ultrasonic scaler.
Root Canal Preparation and Obturation

• After preparing the endodontic access cavity, a #15 K-type canal file
was placed into the root canals of the teeth under 2.5 magnification
until the apical foramen was reached.

• The working length was set at 1 mm shorter than this length.

• X1 and X2 files of the ProTaper Next (Dentsply Sirona) rotary

instrument system were used for shaping the mesial root canals, and
X1, X2, X3, and X4 files were used for shaping the distal root canals.
• The files were operated at 300-rpm speed and 300-g/cm torque
using the ‘‘DR’S CHOICE’’ program of the VDW Reciproc Gold (VDW,
Munich, Germany) endodontic motor in accordance with the
recommendations of the manufacturer. Each of the files was used to
shape a maximum of 4 root canals.

• While changing the files, the root canals were irrigated with 2 mL
5.25% sodium hypochlorite solution.
• To remove the smear layer, 2 mL 17 % EDTA (CanalPro) was applied for 2
minutes, & 2 mL 5.25% sodium hypochlorite was applied in the final irrigation.

• After drying with paper points, the canals were filled with AH Plus (Dentsply
DeTrey, Konstanz, Germany) & gutta-percha (Dentsply Sirona) using the
single-cone technique.

• Redundant gutta-percha was removed from the canal orifices using a hot
excavator. The access cavities were then cleaned using ethylene alcohol.
Simulating the Periodontal Ligament

• The samples were coated with molten wax to 2 mm apical from the
enamel- cement line.

• Then, using a metal mold, all the samples were embedded in a self-
curing resin to 2 mm apical of the enamel cement line.

• During this procedure ,a parallel meter was used for aligning the
long axes of the teeth perpendicularly to the ground plane.
• After visually confirming the beginning of polymerization, the teeth were
removed from the acrylic resin, and the molten wax was removed using hot
water.

• To simulate the periodontal ligament, the gap in the acrylic resin was filled
with silicon impression material (Panasil Light Body; Kettenbach GmbH & Co
KG, Eschenburg, Germany), and the teeth were replaced in the gap.
Restoration of the Samples

• Except for the control group, all the samples were etched for 15 seconds
using 37% ortho phosphoric acid (Etch-37 w/BAC; Bisco, Schaumburg, IL)
for selective enamel etch, rinsed for 15 seconds, and then gently air dried.

• After this step, a 2-stage self-etching adhesive was applied for 20

seconds,
thinned with air, and then polymerized for 10 seconds using an LED
device.
• For the samples in groups 2 and 3, 4-mm-thick EverX Posterior
(GC Dental) was applied as the base material to imitate the lost
dentin tissue and then polymerized with an LED light device for
40 seconds.

• Subsequently, 2 mm composite resin restorative material was

placed on this base & polymerized for 40 seconds using an LED
light device.
• For the samples in groups 4 and 5, as in groups 2 and 3, roughening
& adhesive procedures were implemented; 4-mm-thick SDR
(Dentsply Caulk) was used to imitate the lost dentin tissue and then
polymerized for 40 seconds using an LED light device.

• After polymerization, 2 mm composite resin restorative material was

placed on this base and then polymerized for 40 seconds using an
LED light device.
• The occlusal anatomy of the samples was processed in accordance
with that of the mandibular molar teeth occlusal anatomy.

• Surface polishing of all the restored samples was accomplished

using SofLex (3M ESPE) finishing & polishing discs.
Fracture Strength Test
• The teeth in all the groups were kept in distilled water at room temperature
(25˚C) for 24 hours before the fracture strength test.

• For fracture testing, all the samples were placed on an Instron Universal
Testing Machine, which applies a compressive load on the central fossa
in the lingual direction at a 15 angle to the longitudinal axes of the teeth.

• This load was applied on the samples at 1-mm/min speed using a 6-mm
round-head tip until fracture.
• The forces resulting in fracture were recorded in newton units, fracture
types were classified by 2 independent observers using a
stereomicroscope.

• The failures including vertical root fractures below the level of bone
simulation were defined as non restorable fractures.

• The failures including adhesive failures above the level of bone

simulation were defined as restorable fractures.
Figure 3. (A) A nonrestorable fracture in the TEC group restored with EverX Posterior.
(B) A restorable fracture in the CEC group restored with EverX Posterior.
 Statistical Analysis

• The BL and MD dimensions and BL MD diameter were subjected

to the Shapiro-Wilk statistical test to examine the normality of
continuous variables.

• The Kruskal-Wallis test was used to evaluate differences between

the BL & MD dimensions and BL MD diameter of the specimens.
• The fracture load data were analyzed using the Kruskal-Wallis
test.
Correlations of the fracture data with the BL and MD dimensions
and BL MD diameter were assessed using the Pearson correlation
test.

• All tests were performed at 95% confidence (P < .05).

 RESULTS
• The statistical analysis confirmed the standardization of roots among the
groups in terms of the BL, MD, and BL MD diameter (P > .05).

• The fracture strengths of the samples in the control group were significantly
higher than those in the experimental groups (P < .05). There was no
statistically significant difference in the endodontic access cavities prepared
used the TEC and CEC methods and restored using the same composite base
material (P > .05).
• Regardless of the type of method used to prepare the endodontic
access cavity, among the experimental groups, the highest fracture
strength was observed in group 4 (TEC + SDR) and group 5 (CEC +
SDR) restored using the SDR composite base material.

• The fracture resistance of the teeth increased as the BL ,MD ,and

BL MD dimension increased.
• There was more restorable fracture in the control group and group 3 (CEC +
EverX Posterior) than the other groups (P < .05).

• In contrast, there were more nonrestorable fractures in group 2 (TEC + EverX

Posterior) and group 4 (TEC + SDR) (P < .05).

• There was no significant difference between restorable and nonrestorable

fractures in group 5 (CEC + SDR) (P > .05).
 DISCUSSION
• The main drawbacks of CEC preparation are the limitation in the
examination
of the pulp chamber and the difficulties in the debridement of the area under
the pulp roof that does not get exposed.

• According to the findings of the present study, there was no statistically

significant difference in the fracture strengths of the samples prepared with
the traditional (TEC) and conservative (CEC) methods when restored with the
same base material (P > .05). Thus, the first null hypothesis of the present
study was accepted.
• In common with the findings of the present study, Moore et al and Rover et al
found no significant difference between the TEC and CEC preparation methods
in terms of fracture strength.

• On the other hand, a study of the fracture strengths of mandibular molar and
premolar teeth after preparation with the TEC and CEC methods reported that
the CEC method was associated with significantly higher fracture resistance
than the TEC method
• Similarly, Plotino et al that the fracture strength of teeth prepared with
the TEC method was significantly lower than that of teeth prepared
with the CEC method and the ultra-CEC method.

• The same study reported a significant difference between the fracture

strengths of teeth prepared with the CEC and ultra-CEC methods.

• The maximum decrease in fracture strength of teeth occurs because of

the loss of marginal ridge integrity. A study reported a 46% decrease
in the strength of teeth because of the loss of marginal ridge integrity
• In the present study, we attribute the absence of a significant difference in
the fracture strengths of the TEC and CEC groups restored with the same
base material to the type of endodontic access cavity (ie, class II) prepared.

• In addition, the manipulation of base materials during restorative

procedures in cavities prepared using the CEC method is more difficult than
in those prepared using the TEC method. Thus, the base materials might have
not been adequately placed into the cavity during CEC preparation.
• Furthermore, we aimed to preserve as much dentin as possible, and spaces
under the occlusal enamel and dentin might have created areas of stress
and decreased the fracture strength of the teeth.

• According to the results of the present study, regardless of the type of

prepared endodontic cavity, the fracture strength of the samples restored
with SDR was higher than that of the samples restored using EverX Posterior.

• Thus, the second null hypothesis of the present study was rejected.
• In the present study, the fracture strength of teeth restored with
EverX Posterior was lower than that of teeth restored using SDR. In
a study of the fracture strengths of EverX Posterior & traditional
composites, Frater et al reported that the best strength was
obtained when the former was applied in oblique layers.

• In the present study, the fracture strength of EverX Posterior may

have been decreased because of the application method (ie, bulk
filled).
• Moreover, during the restoration of teeth with CEC preparation, the higher
viscosity of EverX Posterior compared with that of SDR might have resulted
in less adaptation to the cavity walls.

• The teeth in the control group and the CEC group had significantly more
restorable fractures than teeth in the TEC group (P < .05). In addition to
examining the fracture strengths of endodontically treated teeth, it is
important to examine the fracture type. A nonrestorable fracture in the tooth
structure results in extraction of the tooth.
• Although there was no significant difference in the fracture strengths of teeth
prepared using the TEC and CEC methods, the types of fractures were less
serious with CEC preparation.

• The limitations of the present study are that a static rather than a dynamic
force was applied to the samples, and intraoral factors, such as temperature
& pH changes, were not simulated
 CONCLUSION

• CEC preparation did not increase the fracture strength of teeth

with class II cavities compared with TEC preparation . The fracture
strength of teeth restored with the SDR bulk-fill composite was
higher than that of teeth restored with Ever X Posterior regardless
of access type.
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