Basic Research—Technology

Impact of Access Cavity Design and Root Canal

Taper on Fracture Resistance of Endodontically
Treated Teeth: An Ex Vivo Investigation
Mohammad Sabeti, DDS, MS,* Majid Kazem, DDS, MS,†‡ Omid Dianat, DDS, MS,‡§
Nazanin Bahrololumi, DDS,k Amirreza Beglou, DDS,k Kasra Rahimipour, DDS,k
and Farshad Dehnavi, DDSk

Abstract
Introduction: The susceptibility of endodontically
treated teeth (ETT) to fracture is mainly associated
with the loss of tooth structure. This study evaluated
the effect of the access cavity design and taper
preparation of root canals on ETT fracture resistance
of maxillary molars. Methods: For tapering assessment,
30 sound distobuccal roots of maxillary molars were
T ooth fracture is 1 of the
randomly assigned to 1 of 3 groups (n = 10): a .04 taper,
a .06 taper, or a .08 taper. Endodontic canal
preparations were performed using the Twisted Files
rotary system (Kerr Co, Glendora, CA). In addition,
48 intact maxillary first and second molars were
randomly assigned to 1 of 3 groups (n = 16) for cavity
preparation approaches: intact teeth, traditional access
cavity (TAC), or conservative access cavity (CAC).
Fracture resistance was tested using a universal
testing machine. For statistical analysis, the level of
significance was P # .05. Results: The .04 taper
instrumentation had the highest fracture resistance
(259.61  52.06), and the .08 taper had the lowest
(168.43  59.63). The .04 and .06 groups did not
differ significantly (P > .05); however, these groups
differed significantly from the .08 group (P # .05).
Regarding the cavity preparation approaches, the 3
groups of intact teeth, CAC, and TAC showed fracture
resistance mean values of 2118.85  336.97,
1705.69  591.51, and 1471.11  435.34, respectively,
with no significant difference between the CAC
and TAC groups (P > .05). Conclusions: Increasing
the taper of the root canal preparation can reduce
fracture resistance. Moreover, access cavity preparation
can reduce resistance; however, CAC in comparison
with TAC had no significant impact. (J Endod 2018;-
:1–5)
Key Words
Access cavity, endodontically treated teeth, fracture resistance, maxillary molars,
minimally invasive, root taper
most undesirable phe-
nomena in endodontically
Significance
The effect of the root canal taper and the influence
of the access cavity design on tooth fracture
treated teeth (ETT) and
resistance remains limited and controversial. We
usually leads to tooth
provide information regarding the effect of the
extraction (1). Research
root canal taper and access cavity design on
has reported that the
fracture resistance of root canal–treated maxillary
susceptibility of ETT to
molars. Our results showed that increasing the
fracture is mainly associ-
root canal taper can predispose them to fracture,
ated with the loss of
but CAC designs did not show benefits compared
tooth structure because
with TACs.
of dental carries or the-
rapeutic endodontic pro-
cedures such as access cavity and root canal preparation (2, 3). Hence, the amount
of remaining structure appears to be a major factor determining the prognosis of ETT.
The endodontic access cavity is considered an important step in endodontic
treatments (4). Recently, a new concept of a conservative access cavity (CAC), inspired
by concepts of minimally invasive dentistry, has been designed and developed in order
to minimize the removal of the chamber roof and pericervical dentin (5). The rationale
of this approach is to avoid excessive dentin removal from tooth structures (6, 7). With
advances in the field of imaging, endodontic instruments, visual enhancers, and clinical
microscopes, the traditional requirements of the endodontic access cavity start to
diminish. For instance, newly developed ultraflexible canal preparation instruments
make straight-line access to the canals less important; also, the progress in visual
magnification makes it easier to find canal orifices without the need for excessive
expansion of access cavity walls (4, 8). However, this relatively new cavity design
may confine cleaning, shaping, and obturation of root canals (9). An inadequate access
cavity also increases the prevalence of iatrogenic complications during endodontic
procedures (4).

From the *Endodontic Department, School of Dentistry, University of California, San Francisco, California; †Endodontic Department, School of Dentistry, Shahid
Beheshti University of Medical Sciences, Tehran, Iran; ‡Iranian Center For Endodontic Research, Research Institute of Dental Sciences, Dental School, Shahid Beheshti
University of Medical Sciences, Tehran, Iran; §Endodontic Division, School of Dentistry, University of Maryland, Baltimore, Maryland; and kResearch Institute of Dental
Sciences, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Address requests for reprints to Dr Omid Dianat, Endodontic Division, School of Dentistry, 650 West Baltimore Street, Baltimore, MD 21201. E-mail address:
omiddianat@gmail.com
0099-2399/$ - see front matter
Copyright ª 2018 American Association of Endodontists.
https://doi.org/10.1016/j.joen.2018.05.006

JOE — Volume -, Number -, - 2018 Impact of Access Cavity Design and Root Canal Taper 1
Basic Research—Technology
Rotary systems facilitate debridement of canals, and the higher
instrument tapers lead to superior canal and canal wall cleanliness
and decrease the concerns regarding microbial removal of canal walls
(1). However, there are some concerns regarding the excessive removal
of radicular dentin because of increased instrumentation taper (10).
Fundamentally, any removal of hard tissue from the canal walls
increases the chance of root fracture (3). On the contrary, some
authors claim that increased canal preparation taper allows forces to
be better distributed in the apical third of the canal; this better
distribution increases the tooth’s fracture resistance (11).
Accordingly, the aim of the present study was to evaluate and
compare the effect of access cavity preparation and 3 different root
taper preparations on ETT fracture resistance of maxillary molars.
The 2 null hypotheses tested were there would be no difference in
the fracture resistance of teeth with different access cavity designs,
and there would be no difference in the fracture resistance of roots
with different root canal tapers.
Materials and Methods
Sample Preparation
This study used a total of 78 sound maxillary first and
second molars. All of these teeth were extracted for periodontal reasons
after written informed consent was obtained. The inclusion criteria were
noncarious teeth with mature apices, absence of cracks, and free of any
defects. The study was approved by the Ethics Committee of Shahid
Beheshti University of Medical Sciences, Tehran, Iran. For infection
control, the teeth were stored in 0.5% chloramine-T trihydrate for 2
weeks before the experiment. At no stage in the procedure were the
teeth allowed to dehydrate.
After comprehensive visual and stereomicroscopic assessment of
all intact teeth, 30 maxillary first molars were similarly decoronized by a
calibrated endodontist. Three roots of each tooth were divided by burs
(ISO no. 806 104 199 544 016; NTI, Kahla, Germany) under sufficient
water cooling. The distobuccal roots were randomly assigned to 1 of 3
groups (n = 10) for tapering evaluation (ie, a .04 taper, a .06 taper, or a
.08 taper). The buccolingual and mesiodistal dimensions of the roots
were measured using a digital caliper, and roots with more than 20%
deviation were replaced.
All specimens of the tapering groups were prepared for
endodontic treatment. Canals were negotiated with size 10 K-type files
(Flexofile; Dentsply Maillefer, Ballaigues, Switzerland) to the apical
foramen, and the working length was established 0.5 mm shorter. After
the initial preparation, canals were instrumented up to an apical size of
25; instrumentation was performed with the Twisted Files rotary system
(taper .04, .06, and .08; Kerr Co, Glendora, CA) according to the
manufacturer’s instructions. Twisted Files are a progressive tapered
instrument used for shaping and finishing root canals. In our study, a
new set of instruments was used for each tooth. Intermittent irrigation
with 5 mL 2.5% sodium hypochlorite was applied with 30-G needles. In
order to omit other covariates, the specimens were not obturated.
Another 48 teeth that were free of carious lesions, previous
restorations, and any enamel or dentin defects and had a similar crown
anatomy and size with 3 separate mature roots were selected. The teeth,
which were similar in buccolingual and mesiodistal size, were
randomly assigned to 1 of 3 groups (n = 16): intact teeth, no treatment
(negative control); traditional access cavity (TAC, positive control); and
conservative access cavity (CAC, experimental).
Access cavities were prepared using coarse, flat-end diamond burs
(ISO no. 806 104 199 544 016, NTI) in a high-speed handpiece
with sufficient water cooling. For each 10-access cavity preparation,
a separate diamond bur was used.
2 Sabeti et al.
In the intact group, no treatment was performed on teeth, and they
remained intact until the fracture resistance test. In the TAC group,
traditional endodontic access cavities were prepared following
conventional guidelines (12). In order to obtain straight-line access
to all canal orifices, outlines of the cavity and pericervical dentin
were removed or modified where necessary (Fig. 1A). In the CAC group,
in order to determine the outlines of the access cavity and locate the
pulp chamber and canals, we used 2 periapical radiographs made
from buccal and mesial aspects as a guide. Then, starting from the
central fossa, cavities were extended only as necessary to visualize
and locate canal orifices while taking care to preserve pericervical
dentin and the root chamber vault where possible as described
previously (Fig. 1B) (2, 13).
Using the analyzing rod of the dental surveyor, each tooth or root
was positioned vertically in a brass ring of self-cured acrylic resin, and
teeth were embedded up to 2 mm below the cementoenamel junction.
To simulate the periodontal ligament space, roots were covered before
acrylic embedment with a uniformly thin 0.2-mm layer of light body
silicone impression material.
Fracture Testing
For both experimental groups (ie, the tapering and cavity
preparation groups), a fracture resistance test was conducted at the
laboratory of the Dental Research Center at Shahid Beheshti University
of Medical Sciences. The testing device used was the Universal Testing
Machine (Model 55144; Zwick/Roell, Ulm, Germany). The testing
machine allowed an error of 0.04% for a maximal load of 10,000 kg,
0.01% for a repetitive maximal load of 10,000 kg, resolution of
displacement of 0.01 mm (10 mm), and an accurate speed of 0.01%
of full scale.
Statistical Analysis
To analyze the results, statistical software (SPSS 17; SPSS Inc,
Chicago, IL) was used. Averages and standard deviations were
established. Statistical tests of normality (the Shapiro-Wilk test) were
used to check whether data matched a particular distribution such as
the normal distribution or the exponential distribution. For all
comparisons, the level of importance was P # .05, and the Tukey
test was used as the post hoc test.
Results
Root Canal Tapers
The normality of the obtained data was confirmed using the
Shapiro-Wilk test (P > .05). The .04 taper showed the highest
(259.61  52.06) and the .08 taper showed the lowest
(168.43  59.63) fracture resistance values (Fig. 1). Comparison of
data using the 1-way analysis of variance test revealed a significant
difference between groups (Fig. 2). Pair-wise comparison of the groups
using the Tukey test showed the .04 taper and .06 taper groups did not
significantly differ (P > .05), but both groups differed significantly from
the .08 taper group (P # .05).
Effect of Access Cavity Design
Three groups of intact teeth, CAC, and TAC showed fracture
resistance mean values of 2118.85  336.97, 1705.69  591.51,
and 1471.11  435.34 N, respectively (Table 1). The 1-way analysis
of variance test showed no significant difference between the groups
(P > .05). Pair-wise comparison of the groups using the Tukey test
revealed no significant difference between CAC and TAC (P > .05),
but they both showed a significant difference with intact teeth (P # .05).
JOE — Volume -, Number -, - 2018

Figure 1. (A) Conventional access cavity design. (B) CAC design.
Discussion
ETT are prone to root fracture, which may lead to extraction and
undermine the long-term benefits of endodontic treatment (7,14–16).
A major factor endangering the survival of root-filled teeth is the loss of
dentin (17, 18). Endodontic procedures encompass various steps such
as access cavity preparation and root canal preparation, which may
result in the loss of excessive tooth structure, weakening of the tooth,
and a subsequent reduction in the tooth’s capability to resist forces
(3, 17, 19). Therefore, recently, the conventional methods in the
aforesaid procedures have given rise to some criticism because of the
possibility of excessive tooth removal, and conservative approaches
Figure 2. Fracture resistance values of roots after different root canal tapers.
JOE — Volume -, Number -, - 2018
Basic Research—Technology
have gained attention for the restoration of tooth stability (3, 20).
However, this relatively new concept has been slow to impact the
endodontists’ mainstream practice and had not been well supported
by research data. In this regard, this study sought to evaluate and
compare the fracture resistance of ETT in both conventional and
conservative approaches of access cavity preparation and canal
shaping. Because the available data on the fracture resistance of
maxillary molars are lacking (unlike respective data on mandibular
molars) and it was shown in a previous study that the impact of CAC
varied in different unrestored tooth types (5), this study assessed the
influence of different endodontic procedures on fracture resistance
in maxillary molars.
Impact of Access Cavity Design and Root Canal Taper 3
Basic Research—Technology
TABLE 1. Fracture Resistance Values of Teeth with Different Access Cavity
Designs
Access cavity type Break force (N)
Conservative access cavity 1705.691250 (591.51)a
Traditional access cavity 1471.113125 (435.34)a
Intact teeth 2118.851250 (336.92)b
Values are expressed in newtons (N). Values in the parenthesis represent standard deviation.
Mean values with the same superscript letters are not significantly different (P > .05).
In this study, periapical radiographs of teeth from 2 different
planes were used for planning conservative access outlines (13). In
addition, the method of root embedment may affect the fracture resis-
tance significantly. Thus, in the present study, simulation of the peri-
odontal ligament around the tooth was done with polyvinyl siloxane,
an elastomeric material that is able to prevent concentration of
stresses in the cervical region of the tooth because of imitating the
accommodation of the tooth in the alveolus (21). Also, an Instron
(Norwood, MA) Universal Testing machine was used to measure tooth
fracture resistance because the use of this machine is the simplest and
most frequently used method to evaluate tooth strength (17, 19).
However, this in vitro test provides a static load until failure occurs,
whereas in the oral cavity loads are dynamic and, thus, it may not
simulate in vivo conditions (22). Furthermore, to avoid confounding
by covariates, we assessed the net impacts of access cavity and root
tapering preparations by not restoring access cavities and obturating
root canals.
In the conventional approach, access cavity designs are
determined according to some main principles. According to
straight-line access, convenience form, and extension for prevention,
the outline of the access cavity must be extended beyond gaining access
to the canal orifices in order to enable thorough debridement of the
canals and prevent procedural complications such as instrument
fracture (9, 13). As shown in a study by Krishan et al (13), minimal
access cavities were associated with compromised canal instrumenta-
tion in the distal canals of mandibular molars. Moreover, the lack of
straight-line access because of inadequate tooth tissue removal may
compromise the delivery of irrigants to the apical portion of the roots
because it avoids the needle reaching further into the canal (23).
However, some researchers believe that the superfluous sound tooth
structure is sacrificed in this way, which is unnecessary and can
decrease resistance to tooth fracture (6, 7, 14). According to Clark
and Khademi (6), in TAC preparation, the dentist’s needs for facile
access to the canal systems are placed above the tooth needs, whereas
in CAC preparation the emphasis is on banking of pericervical dentin by
maintaining soffit dentin, skewing the access toward fillings/carries, and
altering the traditional reference points. Taken together, it seems that
the benefits of thorough canal instrumentation and diminished
complications must be weighed against the risk of the tooth’s resistance
to fracture being reduced.
The results of the present study showed no significant difference
between conservative and conventional endodontic cavity preparations,
whereas both showed significant differences compared with intact teeth.
In agreement with our results, Moore et al (5) reported that the fracture
strength in maxillary molars with CACs and TACs was remarkably lower
than that of intact molars. Also, although the CAC’s fracture strength was
23% greater than that of TAC, this difference was not statistically
significant; this finding suggests that, in comparison with TAC
preparation, CAC preparation provides insignificant advantages with
regard to fracture strength. In our study, the removal of the pulp
chamber roof as the reinforcing structure (24) and the disruption of
tooth integrity (25) may have been responsible for the substantial
4 Sabeti et al.
reduction in fracture resistance of the ETT of both groups in
comparison with the intact teeth, which is supported by the findings
of many other studies (3, 26–28). In agreement with our study,
Rover et al (29) showed no significant difference in the means of the
fracture resistance test between conservative and traditional endodontic
cavities in maxillary first molars. Their study suggested a reduced pos-
sibility of canal orifice detection in the CAC group in comparison with
the TAC group. They also observed an increased possibility of canal
transportation associated with CACs. Considering the drawbacks of
CACs, their study did not support the notion of CAC preparation in
maxillary first molars. On the contrary, Plotino et al (30) observed a
significant difference in the fracture resistance amounts of CACs and
TACs in maxillary and mandibular premolars and molars, whereas
CACs did not differ significantly from intact teeth.
Furthermore, Cobankara et al (19) showed that none of the tested
restoration techniques in their study was able to utterly restore the
fracture resistance lost from access cavity preparation. In agreement
with our study, it was shown in another study that if at least 1 marginal
ridge could be preserved, with any thickness more than 0.5 mm, its
thickness did not affect the fracture resistance of the teeth (31). In
contrast, mesial, occlusal, and distal cavity preparations weakened
the teeth severely (14, 24). Thus, the null hypothesis regarding
access cavity design has been approved. The findings of this study do
not support the use of minimally invasive access cavity preparation
because this approach still has drawbacks (6, 7), and, regarding
fracture resistance, the CAC approach was not more advantageous
than the TAC approach. Considering that maxillary molars have
challenging root canal systems in mesiobuccal roots, where
secondary canals are difficult to locate and instrument, the
application of CACs in these teeth necessitates careful consideration.
The primary aim of endodontic treatment is to eliminate
microorganisms (32). Research has established that bacteria can
penetrate into and colonize almost half the length of dentinal tubules
(23, 33). Accordingly, inadequate removal of infected dentin within
the canals can decrease the prognosis and lead to posttreatment
failures (23). On the other hand, the thickness of the dentin has a
stabilizing influence on the root. Consequently, any dentin removal in
the canal can decrease the stability of the root (3, 34). For root
canal shaping, the current study showed no significant reduction of
the fracture resistance of the root by .06 taper instrumentation
compared with .04, whereas preparation with the .08 taper showed a
significant decrease in fracture resistance. In agreement with our
results, a previous study has shown that during instrumentation,
maintaining the natural geometry of the root canals is a paramount
stabilizing factor for the tooth, and, therefore, if the root canal
outline is not substantially altered, tooth fracture resistance is
relatively unaffected (3). Conceivably, in our study, the decrease in
fracture resistance that followed .08 taper instrumentation might have
been the result of geometric alterations of the root canals because
.08 taper files are more rigid and less adaptable. Another factor could
be the typically small diameter of distobuccal roots because root
preparation with a thicker file leads to a further weakening of it (35).
Root fracture occurs as a result of propagation of microcracks
created in the root canal shaping process with occlusal forces (36).
Thus, we suggest that the increased risk of fracture with the .08 taper
in this study might be associated with the greater number of craze lines
and the greater degree of imposed stress in root dentin. Moreover, our
findings corroborated the results of a previous study that reported that
preparation with larger taper instruments significantly weakened the
roots. Also, Zandbiglari et al. (35) suggested that this result was
probably caused by the greater amount of dentin removed with larger
tapering instruments compared with common taper hand files.
JOE — Volume -, Number -, - 2018

Therefore, the null hypothesis regarding root taper has been partially
rejected because the increase in tapering from .06 to .08 influenced
tooth resistance significantly. Given our finding that in molar teeth the
.08 taper adversely affected tooth resistance, our results did not support
the use of the .08 taper in these teeth.
Notably, 1 limitation of the present study is that the variability of the
tested teeth may have confounded our results. In addition, preparing the
conventional and conservative access cavities with the same degree of
accuracy in all teeth is difficult. Given these limitations, we suggest
that in order to achieve experimental conditions that are more similar
to clinical conditions, subsequent studies should use finite element
analysis. Moreover, it should be mentioned that until now no standard
method for preparing conservative access cavities has been established.
Therefore, conservative access cavities are difficult to standardize, and,
thus, this type of research is hard to reproduce.
The data achieved in this ex vivo study provide insight into the
fracture resistance of different access designs and root canal tapers
in the clinical setting. However, for more certain results, clinical trials
with long-term follow-ups are required. In conclusion, within the
limitations of this study, for endodontic treatment of teeth, the following
can be concluded:
1. Increasing the tapering of root canal preparation can detrimentally
affect tooth fracture resistance
2. Conservative endodontic access in maxillary molars was not shown
to significantly increase fracture resistance over traditional access
Acknowledgments
The authors deny any conflicts of interest related to this study.
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Impact of Access Cavity Design and Root Canal Taper 5