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The Effects of Endodontic Access Cavity Preparation Design on the Fracture

Strength of Endodontically Treated Teeth: Traditional Versus Conservative
Preparation

Article  in  Journal of Endodontics · March 2018

DOI: 10.1016/j.joen.2018.01.020

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Taha Özyürek Ozlem Ulker

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Basic Research—Technology
The Effects of Endodontic Access Cavity
Preparation Design on the Fracture Strength of
Endodontically Treated Teeth: Traditional Versus
Conservative Preparation
€ urek, DDS, PhD,* Ozlem
Taha Ozy€ € €
Ulker, €
DDS,† Ebru Ozsezer
Demiry€
†
and Fikret Yılmaz, DDS, PhD
Abstract
Introduction: The aim of this study was to compare the
fracture strengths of mandibular molar teeth prepared
using traditional endodontic cavity (TEC) and conserva-
tive endodontic cavity (CEC) methods and restored using
SDR (Dentsply Caulk, Milford, DE) and EverX Posterior
(GC Dental, Tokyo, Japan) base composite materials.
Methods: A hundred mandibular first molar teeth
were randomly divided into 5 groups. In group 1 (the
control group), samples were kept intact. In group 2,
TECs were prepared, and the samples were restored
with EverX Posterior and composite resin. In group 3,
CECs were prepared, and the samples were restored
with EverX Posterior and composite resin. In group 4,
TECs were prepared, and the samples were restored
with SDR and composite resin. In group 5, CECs were
prepared, and the samples were restored with SDR
and composite resin. This load was applied on the sam-
ples at 1-mm/min speed using a 6-mm round-head tip
until fracture. The forces resulting in fracture were re-
corded in newton units. The data were analyzed using
Kruskal-Wallis and Pearson correlation tests at a 5% sig-
nificance level. Results: The fracture strengths of the
samples in the control group were significantly higher
than the experimental groups (P < .05). There was no
statistically significant difference in the endodontic ac-
cess cavities prepared used the TEC and CEC methods
and restored using the same composite base material
(P > .05). Conclusions: CEC preparation did not in-
crease 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 EverX Posterior.
(J Endod 2018;44:800–805)
From the Departments of *Endodontics and †Conservative Dentistry, Faculty of Dentistry, Ondokuz Mayıs University, Samsun, Turkey.
€ €urek, Department of Endodontics, Faculty of Dentistry, Ondokuz Mayıs University, Samsun 55137, Turkey. E-mail
Address requests for reprints to Dr Taha Ozy
address: tahaozyurek@hotmail.com
0099-2399/$ - see front matter
Copyright ª 2018 American Association of Endodontists.
https://doi.org/10.1016/j.joen.2018.01.020
800 €zy€urek et al.
O JOE — Volume 44, Number 5, May 2018
urek, DDS, PhD,*
Key Words
Conservative access cavity, EverX Posterior, fracture strength, SDR, traditional access
cavity
T he structural, esthetic,
and functional rehabil-
itation of endodontically
Significance
Conservative endodontic cavity preparation was
proposed to reduce fracture risk of endodontically
treated teeth is very diffi-
treated teeth. Conservative and traditional end-
cult (1). Previous studies
odontic cavity preparation showed similar fracture
showed that by critically
strength, which was lower than the intact teeth.
reducing the amount of
dentin, endodontic access
cavity preparation decreased the fracture strength of teeth and increased cuspal deflec-
tion during function (2–4). In traditional endodontic cavity (TEC) preparation, the
controlled removal of the tooth structure is supported to prevent complications that
can occur during endodontic treatment (5, 6). The loss of dentin and anatomic
structures, such as cusps, ridges, and the pulp chamber roof, can result in fracture
of the tooth after the final restoration (7). In contrast to TEC preparation, conservative
endodontic cavity (CEC) preparation is a minimally invasive procedure that can pre-
serve tooth structures, such as pericervical dentin (7–14). There are no exact rules
to prepare the CEC; the aim is to preserve as much of the tooth structure as possible
and to locate the canal orifices. In the present study, CECs were prepared
considering a tooth with a mesial cavity.
Advancements in adhesive technology have enabled conservative and esthetic post-
endodontic restoration (15). Conventional composites and flowable bulk-fill base com-
posites, 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 (16). A well-known
example of bulk-fill base composites is SDR (Dentsply Caulk, Milford, DE). SDR has
an increased depth of cure because of increased translucency (17). SDR includes a flex-
ible polymer that does not translate the shrinkage stress to the tooth. Thus, it is hypoth-
esized 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 (18). 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 (19). EverX Posterior (GC
Dental, Tokyo, Japan) has been introduced for dentin replacement in large, deep, and

Figure 1. (A) TEC preparation, (B) EverX Posterior application to TEC, and (C) final restoration of TEC.
high C-factor design cavities. EverX Posterior can be used in 4-mm in-
crements 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 (20).
The aim of the present study was to compare the fracture strengths
of mandibular molar teeth prepared using traditional and conservative
methods and restored using SDR and EverX Posterior base composite
materials. The null hypotheses of the present study were as follows:
1. The access cavity preparation method would have no effect on the
fracture strength of endodontically treated mandibular molar teeth.
2. 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
Based on data from a previous study (14), a 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
Figure 2. (A) CEC preparation, (B) a proximal view of CEC, (C) SDR application to CEC, and (D) the final restoration of CEC.
JOE — Volume 44, Number 5, May 2018
Basic Research—Technology
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 sur-
face and no restoration history. Soft and hard tissue residuals on the
tooth surfaces were removed using an ultrasonic scaler. The buccolin-
gual (BL) and mesiodistal (MD) diameters of the 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:
1. Group 1: The teeth in this group underwent no treatment, and the
teeth served as a control group.
2. Group 2: In this group, after TEC preparation (Fig. 1A), root canal
treatment was performed. EverX Posterior was applied as the base
material (Fig. 1B), but the proximal cavity was not completely filled.
Endodontic Access Cavity Preparation Design 801
Basic Research—Technology
The final restoration was completed using Filtek Z250 (3M ESPE, St
Paul, MN) composite resin (Fig. 1C).
3. Group 3: After CEC preparation, root canal treatment was per-
formed. 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.
4. Group 4: After TEC preparation, root canal treatment was per-
formed. SDR was applied as the base material, and the proximal cav-
ity was completely filled. The final restoration was completed using
Filtek Z250 composite resin.
5. Group 5: After CEC preparation, root canal treatment was performed
(Fig. 2A). SDR was then applied as the base material, and the prox-
imal cavity was completely filled (Fig. 2C). The final restoration was
completed using Filtek Z250 composite resin (Fig. 2D).
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 seg-
ments were not removed (Fig. 2B). The distal cavity in the CEC prepa-
ration was determined and standardized according 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 ultra-
sonic scaler. All the aforementioned procedures were performed by
2 specialist dentists experienced in endodontics and restorative
dentistry.
Root Canal Preparation and Obturation
After preparing the endodontic access cavity, a #15 K-type canal
file (Dentsply Sirona, Ballaigues, Switzerland) was placed into the
root canals of the teeth under 2.5 magnification until the apical fora-
men 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
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.
802 €zy€urek et al.
O JOE — Volume 44, Number 5, May 2018
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 (CanalPro; Coltene/Whaledent, All-
stetten, Switzerland) solution. To remove the smear layer, 2 mL 17%
EDTA (CanalPro) was applied for 2 minutes, and 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) and gutta-percha (Dentsply Sirona) using the single-cone
technique. Redundant gutta-percha was removed from the canal ori-
fices 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 parallelometer was used for align-
ing 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% orthophosphoric 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
(Clearfil SE Bond; Kuraray Noritake Dental Inc, Tokyo, Japan) was
applied for 20 seconds, thinned with air, and then polymerized for
10 seconds using an LED device (Elipar S10, 3M ESPE).
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 (Gradia Direct
 Basic Research—Technology
TABLE 1. Cross-sectional Diameters, Buccolingual (BL)  Mesiodistal (MD) Diameters, and Fracture Loads of the Roots
Group n BL MD of BL  MB Fracture (N)
Control 20 7.07  0.45 4.95  0.43 34.94  3.18 2472.63  308.21a
TEC + EverX Posterior 20 7.05  0.66 4.97  0.66 35.04  5.84 971.03  114.28b
CEC + EverX Posterior 20 7.06  0.84 4.96  0.33 34.96  4.40 1008.25  216.83b
TEC + SDR 20 6.83  0.75 5.03  0.38 34.36  4.71 1451.92  205.39c
CEC + SDR 20 7.27  0.92 4.95  0.34 35.84  4.24 1674.07  238.36c
P value 20 >.05 >.05 >.05 <.05
CEC, conservative endodontic cavity; TEC, traditional endodontic cavity.
Different superscript letters indicate a significant difference (P < .05).

Posterior, GC Dental) was placed on this base and polymerized for
40 seconds using an LED light device.
For the samples in groups 4 and 5, as in groups 2 and 3, rough-
ening and 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 polymeri-
zation, 2 mm composite resin restorative material (Gradia Direct Pos-
terior) was placed on this base and then polymerized for 40 seconds
using an LED light device. The occlusal anatomy of the samples was pro-
cessed in accordance with that of the mandibular molar teeth occlusal
anatomy. Surface polishing of all the restored samples was accom-
plished using SofLex (3M ESPE) finishing and polishing discs.
Fracture Strength Test
The teeth in all the groups were kept in distilled water at room tem-
perature (25 C) for 24 hours before the fracture strength test. For
fracture testing, all the samples were placed on an Instron Universal
Testing Machine (Instron, Buckinghamshire, UK), 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,
and the 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 nonrestorable fractures
(Fig. 3A). The failures including adhesive failures above the level of
bone simulation were defined as restorable fractures (Fig. 3B).
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 be-
tween the BL and MD dimensions and BL  MD diameter of the speci-
mens. 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 fracture loads of the roots and other variables in the 5 groups
are shown in Table 1. The statistical analysis confirmed the standardi-
zation 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 correlations of the fracture resistance of the teeth with the BL,
MD, and BL  MD diameter are presented in Table 2. The fracture
resistance of the teeth increased as the BL, MD, and BL  MD dimension
increased.
The percentage, frequency, and mode of failure are shown in
Table 3. 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
Conservative and minimally invasive approaches are increasingly
used in dentistry today. In the present study, TEC and CEC preparation
methods were compared. The aim of the study was to compare these 2
types of cavity preparation (TEC and CEC) and examine the effects of
different base materials on the fracture strengths of samples in the
TEC and CEC groups. In contrast to previous studies using occlusal cav-
ities (21, 22), the present study aimed to imitate clinical cases of
endodontic treatment because of interproximal caries that did not
affect the entire occlusal segment of the tooth (class II). Such cases
have been frequently reported in the literature (23, 24).
In the present study, mandibular molar teeth were selected
because vertical fractures are most frequently observed in mandibular
molar teeth among endodontically treated posterior teeth (25, 26). In
endodontic treatment of posterior teeth, the main problem with cavities
prepared using the TEC method is that the pulpal chamber floor also
constitutes the cavity floor (27). Among mandibular molar teeth,
occlusal enamel and dentin located at the center of a tooth are subject
to high chewing pressure (28). By preserving the pulpal chamber roof
using CEC preparation, the aim is to distribute the occlusal forces before
they reach the pulpal chamber floor (29). An additional aim is to pre-
serve cervical dentin, which is very important for the lifetime and
optimal function of teeth (30, 31). The results of the present study
showed that the teeth having a CEC design had more restorable
fractures than the teeth having a TEC design. The more restorable
fracture pattern in the CEC design could be attributed to the
TABLE 2. Correlation between Fracture, Buccolingual (BL) and Mesiodistal
(MD) Dimensions, and BL  MD Dimension
Fracture P value
BL dimension +0.33 .743
MD dimension +0.24 .813
BL  MD dimension +0.38 .705

JOE — Volume 44, Number 5, May 2018 Endodontic Access Cavity Preparation Design 803
Basic Research—Technology
TABLE 3. Percentage (Frequency) of Mode Failure for All Groups (n = 20 Each Group)
Group Restorable
Control 80% (n = 16)ax
TEC + EverX Posterior 40% (n = 8)cx
CEC + EverX Posterior 60% (n = 12)abx
TEC + SDR 35% (n = 7)cx
CEC + SDR 55% (n = 11)abx
P value <.05
CEC, conservative endodontic cavity; TEC, traditional endodontic cavity.
Different superscript letters indicate a significant difference (P < .05) (a, b, and c for columns and x and y for rows).
preservation of the pulpal chamber roof. In the present study, as a direct
result of using the CEC design, all the canals could be accessed via a
straight line, in contrast to previous studies that used ninja
endodontic access (21, 22). 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 statis-
tically significant difference in the fracture strengths of the samples pre-
pared with the traditional (TEC) and conservative (CEC) methods when
restored with the same base material (P > .05). Thus, the first null hy-
pothesis of the present study was accepted. In common with the findings
of the present study, Moore et al (12) and Rover et al (22) 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 asso-
ciated with significantly higher fracture resistance than the TEC method
(7). Similarly, Plotino et al (21) found 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 (21). The discor-
dant results may be caused by differences in the methodologies used in
these studies.
The maximum decrease in the fracture strength of teeth occurs
because of the loss of marginal ridge integrity. A previous study reported
a 46% decrease in the strength of teeth because of the loss of marginal
ridge integrity (2). 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 (P < .05). Thus, the second null hypothesis of the pre-
sent study was rejected. A previous study showed that the choice of
restoration material had significant effects on the fracture strength of
teeth after root canal treatment (32). In the present study, in contrast
to previous studies, the fracture strength of teeth restored with EverX
Posterior was lower than that of teeth restored using SDR (33, 34).
In a study of the fracture strengths of EverX Posterior and traditional
composites, Frater et al (35) reported that the best strength was
804 € zy€urek et al.
O JOE — Volume 44, Number 5, May 2018
Nonrestorable P value
20% (n = 4)ay <.05
60% (n = 12)by <.05
40% (n = 8)cy <.05
65% (n = 13)by <.05
45% (n = 9)cx <.05
<.05
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.
In the present study, 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 (36). A nonrestorable fracture in the tooth structure results in
extraction of the tooth (37). According to the results of the present
study, 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
and pH changes, were not simulated (37).
Conclusion
Within the limitations of this study, it can be concluded that 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 EverX Posterior regardless of access type.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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JOE — Volume 44, Number 5, May 2018
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Basic Research—Technology
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Endodontic Access Cavity Preparation Design 805