REVIEW ARTICLE

Juzer Shabbir, MDS, BDS,*

Access Cavity Preparations: Tazeen Zehra, FCPS, BDS,*
Naheed Najmi, MCPS, BDS,*
Classification and Literature Arshad Hasan, FCPS, BDS,†
Madiha Naz, BDS,*
Review of Traditional and Lucila Piasecki, DDS, PhD,‡ and
Adham A. Azim, BDS‡
Minimally Invasive Endodontic
Access Cavity Designs

ABSTRACT
SIGNIFICANCE
Introduction: Several endodontic access cavity designs have been proposed in the past
decade to access the root canal space in a minimally invasive manner. The rationale for this There is a lack of evidence that
approach was derived from the assumption that preserving more tooth structure during minimally invasive access
access preparation will improve the tooth’s resistance to fracture and its long-term surviv- cavity designs will improve the
ability. However, is this assumption valid? Also, can this approach compromise other fracture resistance of root
treatment-related aspects? Methods: We conducted a literature review using 4 online canal–treated teeth. They also
databases and classified the access cavity designs presented in each article according to our present potential risks during
proposed classification. Results: Through the literature search, we identified 49 articles that endodontic treatment.
evaluated the effect of the access cavity design on 11 different treatment parameters. The
majority of the studies failed to demonstrate clear benefits of the minimally invasive access
designs, whereas others raised concerns regarding the ability to adequately disinfect, fill, and
restore teeth with a minimally invasive access cavity design. Conclusion: Minimally invasive
access cavity designs present more risk than benefit on the outcome of endodontic treatment.
Clinicians should reconsider the application of a minimally invasive access cavity for routine
endodontics and cautiously apply it in selected cases when the proper armamentarium is
available. (J Endod 2021;47:1229–1244.)

KEY WORDS
Access cavity preparations; conservative access cavity; computer-aided access cavity;
guided access cavity; minimally invasive access cavity

An endodontic access cavity (EAC) is the first step in nonsurgical endodontic treatment. The objectives of
an access preparation have been established for several decades, which are to remove any caries, deroof From the *Department of Operative
Dentistry and Endodontics, Liaquat
the pulp chamber, locate all of the canal orifices, and establish straight-line access to the canals while also
College of Medicine and Dentistry,
conserving the remaining tooth structure.1 Currently, the use of minimally invasive treatments is adopted Karachi, Pakistan; †Department of
in the medical and dental fields given the technological advancement in applied sciences, magnification, Operative Dentistry and Endodontics,
and imaging techniques. For instance, the dental operating microscope has enhanced visibility and Dow Dental College, Dow University of
allowed the endodontic treatment to be more conservative and predictable.2 Similarly, cone-beam Health Sciences, Karachi, Pakistan; and
‡
Department of Periodontics and
computed tomographic (CBCT) imaging has increased the detection of extra canals and complex
Endodontics, School of Dental Medicine,
anatomic variations.3 The improvement in the quality and properties of endodontic files has also allowed University at Buffalo, Buffalo, New York
them to bear substantial stresses without separation or deviation from the original canal anatomy.4
Address requests for reprints to Dr Adham
Moreover, irrigation activation has enabled the debridement and disinfection of unreachable areas of the A. Azim, Advanced Specialty Program in
root canal system without the need for excessive enlargement of the root canal space.5 With all these Endodontics, School of Dental Medicine,
advancements, is it now possible to perform an effective endodontic treatment through conservative University at Buffalo, 240 Squire Hall,
endodontic access? Buffalo, NY 14214.
E-mail address: azim@buffalo.edu
Minimally invasive access cavity preparations have been proposed in endodontics with the aim of 0099-2399/$ - see front matter
preserving the pericervical dentin. Because the pericervical dentin functions as a stress distributor,
Published by Elsevier Inc. on behalf of
preserving it may potentially improve the resistance to fracture.6 This approach was proposed by Clark American Association of Endodontists.
and Khademi6 based on the assumption that the removal of dental hard tissues such as the pericervical https://doi.org/10.1016/
dentin, the oblique ridges, and thinning the marginal ridges for clinical convenience can potentially j.joen.2021.05.007

JOE  Volume 47, Number 8, August 2021 Access Cavity Preparations 1229
increase the chances of tooth fracture.7
Although traditional access preparations have
consistently achieved the required goals,
concerns were raised on their effect on tooth
survivability and resistance to fracture. On the
other hand, minimally invasive access
preparations in their attempt to preserve the
tooth structure may potentially compromise 1
or more of the access preparation goals.
Clinicians should strive to minimize the amount
of tooth structure lost during access
preparation. However, it is essential to critically
evaluate the pros and cons of minimally
invasive approaches before full embracement.
In this literature overview, we describe and
classify the various access designs proposed
in the endodontic literature, compare the
findings, and present the potential limitations of
the existing published data.
CLASSIFICATION AND
DESCRIPTION OF EAC DESIGNS
There is a wide variety of minimally invasive and
novel access designs that have been recently
mentioned in the endodontic literature.8 The
objective of most of these types of cavity
designs is the preservation of the tooth
structure. However, there is a discrepancy in
their titles, definitions, and dimensions. Thus,
we find it essential to group the various access
cavity designs that have been proposed in the
literature to facilitate easier identification and
standardization for future research in this field
(Fig. 1).
The EAC in anterior teeth is usually
designed from the palatal/lingual (lingual
access cavity) side for esthetic purposes. It
also represents the shortest path to the pulp
chamber.9 The access would extend from just
coronal to the cingulum to within 2 mm of the
incisal edge to remove the entire pulp chamber
cervicoincisally and mesiodistally.10 These
types of access cavities can either be ovoid (in
canines) or triangular (in incisors) in shape.
However, it was reported that through this
design, straight-line access could only be
achieved in 10% of the maxillary central
incisors and 0.8% of the maxillary lateral
incisors and was unachievable in mandibular
incisors.11–13 This is because the long axis of
the crown and root are not parallel in anterior
teeth. The “incisal access cavity” (IAC), or
“incisally shifted access cavity,” has been
proposed as an alternative access location for
anterior teeth.13,14 It starts from the center of
the incisal edge toward the lingual/palatal
surface and extends buccolingually and
mesiodistally to include the entire pulp
chamber.15 The facial access cavity is another
access cavity design for anterior teeth in which
1230 Shabbir et al.
access is gained just occlusal to the midfacial
point and extends until the entire chamber is
deroofed.14 It is often considered when the
lingual or incisal approaches are not feasible or
when a significant amount of tooth structure is
already compromised on the facial side.14 The
lingual, facial, or incisal approaches can all be
designed conservatively without any
extensions, and thus part of the pulp chamber
roof will be preserved (Fig. 2).
In posterior teeth, traditional access
cavity (TAC) preparation includes complete
deroofing of the pulpal chamber and achieving
straight-line access to the first curvature or the
apical part of the canal.1 Other access cavity
designs have been proposed in posterior teeth
to be minimally invasive by being conservative
or ultraconservative. The conservative access
cavity (CAC) represents a contracted form of
conventional cavities. It starts from the central
fossa and extends just as necessary to detect
the canal orifices with small files. In this cavity
design, the pericervical dentin and part of the
pulp chamber roof are preserved.16 The CAC
can either be divergent or convergent based
on the orientation of the walls. It can also follow
the outlines of the orifices like a splat.16
Ultraconservative access cavities aim to
conserve as much tooth structure as possible
at the expense of visibility and convenience
and preserve a significant amount of the pulp
chamber roof and the pericervical dentin. They
generally can be divided into 2 types. For the
ninja access (NA), also known as “point
access,” access is gained through the central
fossa or deepest part of the occlusal surface
and advanced apically with a minimal increase
in dimension.17,18 Through this small hole, all
the canals should be accessed. The truss
access, or “orifice-directed access,” is another
ultraconservative cavity design in which the
access targets only the canal orifices, and the
dentinal bridge between the mesial and distal
canals (in mandibular molars) or the buccal and
palatal canals (in maxillary molars) is
preserved.19,20 This design can be modified
further to access each canal through a
separate hole. However, the truss access is
not standardized and has been presented in
the endodontic literature with different sizes.21–24
It has also been suggested that the design of
the truss access is dependent on the size of
the pulp chamber and the taper of the rotary
instruments.15,21,25 (Fig. 3).
Computer-assisted access cavity
(CAAC) preparations, as the name suggests,
include the use of software and 3-dimensional
imaging to assist in establishing a predictable
path to the root canal space while conserving
the tooth structure. This approach was
imported from implant dentistry, and it is
considered a form of minimally invasive
access. It can be classified into 2 types. The
first is the guided access cavity (GAC), which
uses intraoral scanners and CBCT imaging to
create a custom-made stent that guides the
access drill to the desired location. This type
of cavity is conservative, purpose based, and
not operator dependent (Fig. 4). A few
limitations of the GAC include longer
treatment planning, delayed treatment, the
requirement of a straight path to the apex or
until the canal is located, poor accessibility in
posterior teeth, and overheating while
drilling.26 Moreover, the accuracy in locating
the canals can be affected by artifacts
generated while acquiring the CBCT scan.
The other computer-assisted design is
referred to as dynamic-navigated access. It is
a freehand approach that uses a dynamic
navigation interface aided by passive optical
technology, CBCT imaging, and software to
guide the drilling procedure in real time.
Although this approach may not require a
significant amount of planning compared with
the GAC, it is a costly device with multiple
intraoral attachments that are required to be in
place before initiating treatment.26 CAACs
have been recently introduced in the field of
endodontics through a few in vitro studies and
case reports as a proof of concept.27–29 They
appear to be promising, particularly in the
management of calcified structures.
Review of the Literature
Search Methodology
A MEDLINE literature search was performed
via PubMed, Scopus, Web of Science, and
ScienceDirect to identify articles published on
access cavity preparation with no date
restrictions until October 29, 2020. In PubMed,
the following combinations of key words (All
fields) were used to identify the articles: (1)
((access cavity) AND (design)) AND (types), (2)
(access cavity) AND (conservative), (3)
((Traditional) OR (Conventional)) AND (Access
cavity), (4) ((Incisor) OR (Incisal)) AND (access
cavity), and (5) (Guided) AND (access cavity).
Additionally, the following key words (All fields)
were used separately: (1) Endodontic access
cavities, (2) Truss access, (3) Contracted
access cavity, (4) Anterior teeth access cavity,
and (5) Ultraconservative access cavity. The
same key words were used to search articles
in Scopus (TITLE-ABS-KEY), Web of Science
(TOPIC), and ScienceDirect (ALL FIELDS,
Research articles). To be included in the
review, the articles had to meet the following
criteria:
1. Articles in English
2. Full text available
JOE  Volume 47, Number 8, August 2021
FIGURE 1 – A diagram showing the different types of standard and minimally invasive access cavity preparations in anterior and posterior teeth.
3. A clear definition and description of the
access cavity design
4. The presence of a description and
illustrative images for any of the CAC
designs presented
5. Experimental studies that included at least
2 types of access cavities
First, the title and abstracts of all the
articles were read independently by 3
reviewers (J.S., T.Z., and M.N.) for preliminary
exclusion of unrelated articles. The remaining
articles were then reviewed for inclusion by
reading the full-text articles. Duplicate articles
and articles not related to comparisons of
access designs were eliminated by the second
set of reviewers (A.H. and N.N.). The access
designs presented in each study were
evaluated and assigned to 1 of the access
designs mentioned in Figure 1. In case of
disagreement on inclusion or the access cavity
design appraised, a discussion was held with
an independent reviewer (A.A.A.) who made
the final decision.
After reviewing the full text of all the
relevant articles, the selected articles were then
categorized based on the following
methodologies:
1. Remaining tooth structure
2. Stress distribution
3. Resistance to fracture
4. Ability to locate the canal
JOE  Volume 47, Number 8, August 2021
5. Remaining pulp tissue and hard tissue
debris
6. Uninstrumented areas
7. Canal transportation and centering
ability
8. Operation time
9. Obturation and restoration quality
10. Retreatment
11. Internal bleaching
RESULTS OF THE REVIEW
A total of 6510 articles were identified from the
initial search. After preliminary exclusion and
manual elimination of duplicate entries, a total
of 139 articles related to EACs were included
for full-text review. Of these articles, 49 articles
met the inclusion criteria and were qualitatively
analyzed. The articles reviewed are presented
in Tables 1–4, respectively.
Remaining Tooth Structure
The amount of remaining tooth structure was
evaluated in 14 studies (Table 1). Ten studies
evaluated only the amount of tooth structure
removed from the crown portion (until the
cementoenamel junction).7,15,26,30–36 Three
studies evaluated the amount of dentin
removed from the canal during instrumentation
(root portion only).20,37,38 Only 1 study
evaluated the total amount of tooth structure
lost in the crown and root portion
simultaneously.39 There was a unanimous
agreement among the studies that more tooth
structure is lost from the crown with the TAC
compared with any of the conservative
approaches, and there was no difference
between the various EACs in regard to dentin
volume removed in the root canal space.
Stress Distribution
Seven studies evaluated the amount of stress
distribution (Table 1) through finite element
analysis (FEA). Five studies concluded that
TACs consistently showed more stresses
generated, particularly at the cervical
area.16,25,40–42 On the other hand, 2 studies
showed opposite results. Guler43 showed that
stress values were lower with the TAC
compared with the NA.7 Saber et al7 also
showed that the size of the EAC was inversely
proportional to the cervical stresses
generated, with more apical transmission of
stresses as the size of the access cavity
becomes larger.
Resistance to Fracture
A total of 24 studies compared various access
cavity designs in regard to fracture resistance
(Table 1). All studies evaluating fracture
resistance in anterior teeth (5 studies)36,37,44–46
showed no difference between the different
EAC designs and fracture resistance.
Access Cavity Preparations 1231
FIGURE 2 – A micro–computed tomographic illustration of a maxillary central incisor showing lingual, incisal, and facial access cavity preparations in standard and conservative
manner. The access is presented from the sagittal, coronal, and axial views. The green area represents the tooth structure removed during access preparation.

However, there were discrepancies in the showed a decreased fracture resistance with Ability to Locate the Canal
results among posterior teeth. Eleven studies TACs compared with other conservative We found 3 studies that assessed the
showed no difference between the different designs,16,18,35,36,40,42,50–52 most of which relationship of computer-guided access cavity
EAC designs,17,20–24,38,39,47–49 and 9 studies were FEA studies. approaches with canal orifice location

FIGURE 3 – A micro–computed tomographic illustration of a mandibular first molar showing traditional, conservative, and ultraconservative access cavity preparations. The access is
presented from the occlusal and buccal views. The green area represents the tooth structure removed during access preparation.

1232 Shabbir et al. JOE  Volume 47, Number 8, August 2021

FIGURE 4 – An illustration of GAC preparation performed on a maxillary central incisor and a mandibular first molar. The green area represents the tooth structure removed during
access preparation.
(Table 2). Two studies 26,32 suggested there
was no difference between the different
approaches, and 1 favored the guided
approach with simultaneous conservation of
dental hard tissue.36 When nonguided
approaches were compared, 3 studies were
identified, with only 1 showing the superiority of
TACs compared with CACs. The NA was
evaluated in only 1 study and showed more
difficulty in detecting the second mesiobuccal
canal compared with CACs and TACs.53
Microbial Reduction
Only 3 studies were found that investigated the
impact of the EAC designs on bacteria
reduction inside the root canal space. In
posterior teeth (2 studies),20,54 there appears
to be no difference between TACs and
minimally invasive access cavities in regard to
microbial reduction (Table 2). On the other
hand, in anterior teeth (1 study), the minimally
invasive access yielded more bacteria-positive
samples and a higher bacteria count
compared with the TAC.55
Remaining Pulp Tissue and Hard
Tissue Debris
Three studies17,37,49 evaluated the amount of
hard tissue debris inside the root canal space,
all of which showed no significant difference
JOE  Volume 47, Number 8, August 2021
between TACs and any of the minimally
invasive approaches (Table 2). Only 1 study
evaluated the amount of remaining pulp tissue
in the root canal space and the pulp chamber
after TACs and truss access. Their results
showed that truss access yielded more
remaining pulp tissue in the pulp chamber but
not in the root canal space or the isthmus area.
Uninstrumented Areas
Ten studies were identified that addressed the
amount of untouched/uninstrumented areas
within the root canal space (Table 3). In anterior
teeth (4 studies),10,36,37,55 only 1 study
comparing the TAC and IAC showed that the
IAC had the highest proportion of
instrumented root canal surface and the TAC
had the worst.10 However, the study used ink
to compare the touched/untouched surfaces,
and there was no standardization in terms of
canal volume before instrumentation. In
studies using micro–computed tomographic
imaging for assessment (3 studies),36,37,55 no
difference was found between the LAC and
conservative access preparations regardless
of their position (incisal or lingual). In posterior
teeth (7 studies), there was disagreement
among the studies, with 4 studies showing no
difference17,21,38,49 and the other 3 favoring
TACs in addressing more canal walls.20,36,39
Canal Transportation and Centering
Ability
Eight studies were identified that evaluated
canal transportation and centering ability
(Table 3). Only 2 studies evaluated these
parameters in anterior teeth. When the IAC-C
was compared with LAC, no differences were
found in regard to transportation and centering
ability.37 However, transportation was
significantly less in the regular IAC compared
with LAC.57 In posterior teeth (6 studies), 2
studies49,58 showed that the CAC increased
the chance of canal transportation, and 3
studies showed no difference between the
TAC and minimally invasive designs.20,38,59
One study compared the TAC and the GAC.39
Their results showed no difference when
single-rooted premolars were compared, but
in 2-rooted premolars, the deviation of the
central point after instrumentation for the TAC
was significantly smaller.
Time for Access Preparation and
Instrumentation
Overall, 8 studies evaluated the treatment time
(Table 3). When CAAC techniques were
evaluated (3 studies), all the studies were
associated with a decreased treatment time to
locate the canals compared with freehand
approaches in anterior26,32,34 and posterior
Access Cavity Preparations 1233
TABLE 1 - A Summary of In Vitro Studies Evaluating Remaining the Tooth Structure, Stress Distribution, and Fracture Resistance of Traditional and Minimally Invasive Access Cavity
Designs
Author and year
Remaining coronal tooth structure
Isufi et al, 202033 TAC vs CAC vs NA
Saber et al, 20207
Loureiro et al, 202030
Lin et al, 202031
Jain et al, 202032
Xia et al, 202039
Dianat et al, 202026
Connert et al, 201934
Makati et al, 201835
Varghese et al, 201612
Krishan et al, 201436
Dentin removed from the canal only
Barbosa et al, 202020 TAC vs CAC vs Truss
Augusto et al, 202038
Xia et al, 202039
1234 Shabbir et al.
EAC design Tooth type Position Main outcome
Maxillary and mandibular Posterior Dentinoenamel removal was
molars and premolars ,6% in the NA group, up
to 15% in the CAC group,
and .15% in the TAC
group.
TAC vs CAC vs truss Mandibular molars Posterior CAC and truss preserved a
significant amount of tooth
structure.
LAC vs GAC Mandibular incisors and Anterior and posterior Increased preservation of
TAC vs GAC maxillary molars tooth structure in GAC in
maxillary molars
No difference in tissue
removal between the
groups in incisors
TAC vs CAC vs NA Maxillary and mandibular Posterior TAC had the greatest tooth
molars substance loss at the
cervical area followed by
CAC and NA.
IAC vs DNA Maxillary and mandibular Anterior Significant conservation of
central incisors tooth structure in the DNA
group compared with IAC
TAC vs GAC Maxillary and mandibular first Posterior GAC resulted in increased
premolars (single rooted tooth structure
and 2 rooted) conservation in 2-rooted
first premolars.
LAC vs DNA Single-rooted teeth Anterior and posterior Significantly increased tooth
conservation in the DNA
group
LAC vs GAC Incisors Anterior Less substance loss in GAC
compared with LAC
TAC vs CAC Mandibular molars Posterior The remaining dentin
thickness was less in TAC
than CAC.
CAC was more conservative
at the PCD.
LAC vs IAC Mandibular anterior Anterior Significant loss of tooth
structure was observed in
the LAC group at all the
surfaces compared with
IAC in which only mesial,
lingual, and distal surfaces
had significant loss of
tooth structure.
In IAC, less loss of dentin at
peri-cervical region was
observed
LAC vs LAC-C Incisors Anterior and posterior Significantly less removal of
TAC – CAC Premolars and molars dentin was observed in
CAC compared with LAC/
TAC in incisors,
premolars, and molars.
Mandibular molars Posterior No difference in the amount
of dentin removed from
the canal
NA vs TAC Mandibular molars Posterior No difference in the amount
of dentin removed from
the canal
TAC vs GAC Maxillary and mandibular first Posterior No difference in the amount
premolars (single rooted of dentin removed from
and 2 rooted) the canal
(continued on next page )
JOE  Volume 47, Number 8, August 2021
TABLE 1 - Continued

Author and year EAC design Tooth type Position Main outcome
37
Rover et al, 2020 LAC vs IAC-C Mandibular incisors Anterior No difference in the amount
of dentin removed from
the canal
Stress distribution
Saber et al, 20207 TAC vs CAC vs truss Mandibular molars Posterior The size of the EAC was
inversely proportional to
cervical stress. As the size
increased, the stresses
were transmitted more
apically.
Wang et al, 202040 TAC vs NA Maxillary first molars Posterior NA reduced tensile stress
and failure chance of
dentin.
Guler, 202043 TAC vs NA Maxillary molars Posterior Stress values were lower in
TAC compared to NA
Zhang et al, 201916 TAC vs CAC vs NA Maxillary molar Posterior Larger stress concentration
areas were found in
cervical region in TAC and
the CAC as compared to
NA
Allen et al, 201842 TAC vs NA Mandibular molar Posterior TAC access had higher
stress values
Jiang et al, 201841 TAC vs extended TAC vs Maxillary molars Posterior Stress concentration on
CAC PCD was directly
proportional to the size of
the EACs.
No difference in the
distribution of stress on
occlusal surfaces
between the EACs
Yuan et al, 201625 TAC vs CAC Mandibular molars Posterior CAC resulted in lesser stress
at crown and cervical area
as compared to TAC
Fracture resistance
Maske et al, 202047 TAC vs NA Mandibular molars Posterior No difference in fracture
resistance
Barbosa et al, 202020 TAC vs CAC vs truss Mandibular molars Posterior No difference in fracture
resistance
Rover et al, 202037 LAC vs IAC-C Mandibular incisors Anterior No difference in fracture
resistance
Augusto et al, 202038 TAC vs NA Mandibular molars Posterior No difference in load to
fracture
Wang et al, 202040 TAC vs NA Maxillary first molars Posterior CAC reduced the failure
chances of dentin
Saberi et al, 202050 TAC vs truss Mandibular molars Posterior Minimum fracture strength
was observed in TAC
with thermocycling.
Truss had better fracture
strength under thermal
stresses.
Silva et al, 202017 TAC vs NA Maxillary premolars Posterior No difference in mean load to
induce fracture.
Xia et al, 202039 TAC vs GAC Maxillary and mandibular first Posterior No difference in mean load to
premolars (single rooted fracture.
and 2 rooted).
Marinescu et al, 202051 TAC vs CAC vs NA Maxillary and mandibular Posterior CAC and NA had increased
molars fracture resistance
compared to TAC.
Abou-Elnaga et al, 201952 TAC vs truss Mandibular molars Posterior Truss improved the fracture
resistance of teeth with
MOD cavities.
Zhang et al, 201916 TAC vs CAC vs NA Maxillary molar Posterior
(continued on next page )

JOE  Volume 47, Number 8, August 2021 Access Cavity Preparations 1235
TABLE 1 - Continued

Author and year
D’amico et al, 201944
Allen et al, 201842
Sabeti et al, 201848
Corsentino et al, 201823
Makati et al, 201835
€ u
Ozy €rek et al, 201822
Rover et al, 201749
Plotino et al, 201718
Chlup et al, 201724
Moore et al, 201621
€
Ozkurt-Kayahan and
Kayahan, 201645
Krishan et al, 201436
Nissan et al, 200746
EAC design Tooth type Position Main outcome
The NA increased the
ultimate loads that
caused crack initiation of
dentin compared with
TAC and CAC.
LAC vs FAC vs LAC-C Mandibular incisors Anterior No difference in fracture
strength between the
groups
TAC vs NA Mandibular molar Posterior TAC access had greater
chances of tooth fracture.
TAC vs CAC Maxillary molars Posterior No significant difference in
fracture resistance
TAC vs CAC vs truss Mandibular molars Posterior No significant difference in
fracture strength
TAC vs CAC Mandibular molars Posterior Significantly less load was
required to induce fracture
in TAC compared with
CAC.
TAC vs Truss Mandibular molars Posterior No significant difference in
fracture strength between
the groups with class II
cavities
TAC vs CAC Maxillary molars Posterior No difference in fracture
resistance
TAC vs CAC vs NA Maxillary and mandibular Posterior The mean load required for
premolars and molars fracture was significantly
higher in the CAC and NA
groups compared with
TAC in all types of teeth
tested.
No difference in fracture
strength between CAC
and NA
TAC vs NA Maxillary and mandibular Posterior No difference in fracture load
premolars
TAC vs NA Maxillary molars Posterior No difference in the mean
load to fracture between
the groups
LAC vs FAC Maxillary incisors Anterior No difference in fracture
resistance between the
groups
LAC vs LAC-C Incisors Anterior and posterior CAC increased the fracture
TAC vs CAC Premolars and molars resistance in mandibular
molars and premolars but
not in anteriors.
LAC vs FAC Maxillary central and lateral Anterior No difference in failure load
incisors values

CAC, conservative access cavity; DNA, dynamic-navigated access; EAC, endodontic access cavity; FAC, facial access cavity; LAC, lingual access cavity; LAC-C, lingual access cavity-
contracted; MOD, mesial occlusal distal; NA, ninja access; PCD, per-cervical dentin; TAC, traditional access cavity.

teeth.26 All the other studies (5 studies)17,38,59–61
consistently showed that minimally invasive
approaches took a longer time to perform the
root canal in initial treatments or retreatments.
Obturation and Restoration Quality
Overall, 5 studies assessed the impact of
different EACs on the presence of voids in the
root canal filling (4 studies)17,20,37,39 and the
coronal restoration (1 study)2 (Table 4). In
posterior teeth, the size of the access did not
appear to affect the presence of voids in the
root canal filling (3 studies)17,20,39 In anterior
teeth (1 study),37 more voids were noted when
the minimally invasive access was used. As far
as coronal restoration is concerned, 1 study
directly evaluated the voids in the
postendodontic composite restoration and
found more voids associated with the NA
compared with the TAC. Two other studies
showed more remaining gutta-percha in the
pulp chamber with minimally invasive
approaches, which can indirectly affect the
quality of the coronal restoration.
Retreatment
Two studies evaluated the effect of the EAC
design on retreatment procedures60,61
(Table 4). The results showed more gutta-
percha remaining with minimally invasive
approaches and a longer time to remove
gutta-percha from the canal. One study
suggested that the type of rotary files used with

1236 Shabbir et al. JOE  Volume 47, Number 8, August 2021

TABLE 2 - A Summary of In Vitro Studies Evaluating the Ability to Locate Canals, Reduce the Microbial Load, and Remove the Remaining Pulp Tissue and Hard Tissue Debris When
Accessing the Tooth Using Traditional and Minimally Invasive Cavity Designs

Access
cavities
Author and year designs Teeth type Position Outcome
Canal location
Mendes et al, 202056 TAC vs NA Mandibular first molar Posterior No significant difference in the detection of
the middle mesial canal between the
groups
Jain et al, 202032 IAC vs DNA Maxillary and mandibular Anterior Increased (but insignificant) precision in the
central incisors DNA group for locating calcified canals
Dianat et al, 202026 LAC/TAC vs DNA Single-rooted teeth Anterior and No significant difference in the number of
posterior unsuccessful attempts to locate calcified
canals
Connert et al, 201934 LAC vs GAC Incisors Anterior Increased canal location in GAC compared
with LAC
Success was not dependent on the
operator’s experience
Saygili et al, 201853 TAC vs CAC vs NA Maxillary first molars Posterior CAC and TAC had significantly more MB2
detection compared with NA
Rover et al, 201749 TAC vs CAC Maxillary Molars Posterior Increased canal detection in the TAC
group with and without magnification
No difference between the groups in canal
detection under microscope when
ultrasonic troughing was used
Microbial reduction
Barbosa et al, 202020 TAC vs CAC vs truss Mandibular molars Posterior No difference between the different access
cavity designs
€fenkçi, 202054
Tu TAC vs CAC Mandibular First molars Posterior No difference between the different access
cavity designs
Vieira et al, 202055 LAC vs IAC-C Mandibular incisors Anterior Higher bacteria-positive culture was found
in IAC-C compared with LAC after root
canal preparation.
Higher reduction of bacterial count in the
LAC group compared with IAC-C
Remaining pulp tissue and hard tissue debris
Silva et al, 202017 TAC vs NA Maxillary premolars Posterior NA had significantly more hard tissue
debris accumulation compared with
TAC.
Rover et al, 202037 LAC vs IAC-C Mandibular incisors Anterior No difference in accumulated hard tissue
debris
Neelakantan et al, 201819 TAC vs truss Mandibular Molars Posterior The remaining pulpal tissue in the pulp
chamber was significantly more in truss
compared with TAC.
No significant difference in residual pulpal
tissue in root canals and in the
isthmuses
Rover et al, 201749 TAC vs CAC Maxillary molars Posterior No significant difference in the accumulated
hard tissue debris

CAC, conservative access cavity; DNA, dynamic-navigated access; EAC, endodontic access cavity; GAC, guided access cavity; IAC, incisal access cavity; LAC, lingual access cavity;
LAC-C, lingual access cavity-contracted; MOD, mesial occlusal distal; MB2, second mesiobuccal canal; NA, ninja access; PCD, per-cervical dentin; TAC, traditional access cavity.

minimally invasive designs can play a role in
reducing the amount of remaining gutta-
percha in the canal.61
Internal Bleaching
Only 1 study evaluated the effect of the EAC on
internal bleaching and showed that lightness
values were only reestablished with bleaching
in the TAC group compared with the CAC
groups 62 (Table 4).
DISCUSSION
Recently, a few authors attempted to
summarize and analyze the various access
preparations used in endodontic treatment.8,63
However, a few access designs were not
mentioned, and many of those proposed
categorically belong to the same design. To
enable clinicians to understand the core
differences between the various designs,
herein we presented a concise classification to
standardize the endodontic access
preparation terms and definitions presented in
the endodontic literature. In this literature
review, we presented the outcome of 49
studies evaluating 11 different parameters in
regard to the access preparation size and
location. We also reviewed every access
described and assigned it 1 of the designs
proposed in our classification. It was noted
that different terms were used for the same
access designs, which can be challenging to

JOE  Volume 47, Number 8, August 2021 Access Cavity Preparations 1237
TABLE 3 - A Summary of In Vitro Studies Evaluating the Uninstrumented Canal Areas, Transportation and Centering Ability of Instruments, and the Time for Access Preparation and
Instrumentation When Traditional and Minimally Invasive Cavity Designs Were Implemented
Author and year
Uninstrumented/untouched areas
Rover et al, 202037 LAC vs IAC-C
Vieira et al, 202055
Augusto et al, 202038
Silva et al, 202017
Barbosa et al, 202020
Xia et al, 202039
Rover et al, 201749
Moore et al, 201621
Krishan et al, 201436
Mannan et al, 200110
Transportation and canal centering ability
Barbosa et al, 202020 TAC vs CAC vs truss
Rover et al, 202037
Augusto et al, 202038
Xia et al, 202039
Marchesan et al, 201859
Alovisi et al, 201858
Yahata et al, 201757
1238 Shabbir et al.
Access cavities designs Teeth type Position Outcome
Mandibular incisors Anterior No significant difference
between the 2 EACs
LAC vs IAC-C Mandibular incisors Anterior No significant difference
between the 2 EACs
TAC vs NA Mandibular molars Posterior No significant difference
between the 2 EACs
TAC vs NA Maxillary premolars Posterior No significant difference
between the 2 EACs
TAC vs CAC vs truss Mandibular molars Posterior Significantly decreased the
percentage of unprepared
root canal surface in TAC
compared with CAC and
truss
TAC vs GAC Maxillary and mandibular Posterior The untouched canal wall
first premolars (single- was significantly lower in
and 2-rooted premolars) the TAC in single-rooted
premolars.
TAC vs CAC Maxillary molars Posterior No significant difference
TAC vs CAC Maxillary molars Posterior No significant difference
between the 2 EACs
LAC vs LAC-C Incisors Anterior and posterior No significant difference
TAC vs CAC Premolars and molars between the different EAC
in anterior teeth
More untouched canal
surface in the distal
canals of molars with
CAC
LAC vs LAC-modified vs IAC Maxillary incisors and Anterior IAC had the highest
canines proportion of
instrumented root canal
surface and LAC had the
worst
Mandibular molars Posterior No significant difference in
transportation or canal
centering ability
LAC vs IAC-C Mandibular incisors Anterior No significant difference in
transportation or canal
centering ability
TAC vs NA Mandibular molars Posterior No significant difference in
transportation or canal
centering ability
TAC vs GAC Maxillary and mandibular Posterior GAC resulted in significantly
first premolars (single- increased transportation
and 2-rooted premolars) in 2-rooted first premolars
and no difference in
single-rooted first
premolars.
TAC vs NA Mandibular molars Posterior No significant difference in
changes within the
primary canal curvature
parameters between the
EACs
TAC vs CAC Mandibular molars Posterior Better preservation of
original canal anatomy
(centering ability) and less
apical transportation in
TAC compared with CAC
LAC vs IAC Maxillary central incisors Anterior Transportation was
significantly less in IAC
compared with LAC.
(continued on next page )
JOE  Volume 47, Number 8, August 2021
TABLE 3 - Continued

Author and year
Rover et al, 201749
Time for access preparation and instrumentation
Augusto et al, 202038 TAC vs NA
Dianat et al, 202026
Jain et al, 202032
Silva et al, 202017
Connert et al, 201934
Marchesan et al, 201859
Fatima et al, 201860
Niemi et al, 201661
Access cavities designs Teeth type Position Outcome
IAC is beneficial in
maintaining apical
configuration.
TAC vs CAC Maxillary molars Posterior Canal transportation was
significantly higher in the
CAC group in the palatal
canal.
Canal preparation was more
centralized in the TAC
group in the palatal and
distobuccal canal in the
CAC group.
Mandibular molars Posterior Time required to prepare
root canals was
significantly lower in TAC
compared with NA.
LAC/TAC vs DNA Single-rooted teeth Anterior and posterior The mean time required for
locating calcified canals
was significantly less in the
DNA group.
IAC vs DNA Maxillary and mandibular Anterior DNA was significantly less
central incisors time-consuming in
preparing the endodontic
access cavity.
TAC vs NA Maxillary premolars posterior No difference in time
required to access and
prepare the root canals.
However, NA required
more time for filling and
cleaning the chamber.
TAC vs GAC Incisors Anterior Lesser treatment time
required for GAC
TAC vs NA Mandibular molars Posterior Treatment time was
significantly longer for NA
compared with TAC.
TAC vs CAC Mandibular premolars Posterior TAC required less time for
the removal of obturating
material compared with
CAC.
TAC vs NA First and second mandibular Posterior Significantly more time was
premolars required for retreatment in
the NA group.

CAC, conservative access cavity; DNA, dynamic-navigated access; EAC, endodontic access cavity; GAC, guided access cavity; IAC, incisal access cavity; IAC-C, incisal access cavity-
contracted; LAC, lingual access cavity; LAC-C, lingual access cavity-contracted; NA, ninja access; TAC, traditional access cavity.

follow by clinicians. In this review, we also (1) the variation in the definition and regarding the TAC designs. For example, the
excluded any study that did not present clear extension of the various access cavity illustrations of TACs in mandibular molars
images and definitions to their access designs designs, presented by Plotino et al18 and Allen et al42
to avoid misunderstanding of the proposed (2) the lack of proper sample distribution appear to be larger than those by Corsentino
design and its extensions. Although the and standardization between the et al.23 This may explain why the formers
primary purpose of minimally invasive different access groups, showed a reduced load to fracture based on
preparations is to improve the fracture (3) the type of study (in vitro vs FEA), and the access cavity design, whereas the latter
resistance, this hypothesis was not accepted (4) the presence/absence of coronal did not. Generally, access designs using
in any of the studies evaluating anterior teeth restoration before conducting the freehand approaches, whether traditional or
despite preserving more tooth structure. fracture tests. minimally invasive, cannot be standardized
However, in posterior teeth, there were because of anatomic variations between teeth
There was inconsistency noted in the
discrepancies in the results between the as well as variation among operators. To
cavity design illustrations and images
different studies. The differences may stem provide proper comparison between the
presented in some of the reviewed articles
from the following: different access groups, teeth should be

JOE  Volume 47, Number 8, August 2021 Access Cavity Preparations 1239
TABLE 4 - A Summary of In Vitro Studies Evaluating Voids in the Obturation and Restoration Material as Well as the Ability to Retreat and Bleach Teeth Through Traditional and
Minimally Invasive Cavity Designs

Author and year EAC Tooth type Tooth position Outcome

Voids in obturation and coronal restoration
Barbosa et al, 202020 TAC vs CAC vs truss
Rover et al, 202037
Silva et al, 202017
Silva et al, 20202
Xia et al, 202039
Retreatment
Fatima et al, 201860
Niemi et al, 201661
Internal bleaching
Marchesan et al, 201862
Mandibular molars
LAC vs IAC-C Mandibular incisors
TAC vs NA Maxillary premolars
TAC vs NA Maxillary premolars
TAC vs GAC Maxillary and mandibular
first premolars (single
rooted and 2 rooted)
TAC vs CAC Mandibular premolars
TAC vs NA First and second
mandibular premolars
LAC vs IAC-C Maxillary incisors
Posterior No difference in presence of voids in root
filling
Decreased volume of remaining
endodontic filling material within the
access cavity in TAC groups compared
with CAC and truss
Anterior IAC-C had more voids in root canal fillings.
No difference in remaining remnants of
filling material between the EACs
Posterior No difference in terms of voids in the root
fillings
NA had more remaining root filling material
in the pulp chamber compared with
TAC
Posterior Significantly more voids were found in the
postendodontic composite restoration in
the NA group compared with TAC.
Posterior No difference in terms of voids in root fillings
Posterior More remaining obturating material in
canals in CAC
Posterior NA with combination of instrumentation
with Vortex Blue (DentsplySirona, York-
Pennsylvania) had significantly higher
remaining obturating material in root
canals compared with other groups.
NA with combination of instrumentation
with TRUShape (DentsplySirona, York-
Pennsylvania) had the highest efficacy in
removing obturating material from
single-rooted oval canals as compared
with other groups.
Anterior Statistically similar bleaching in both groups
Lightness values were only reestablished
with bleaching in the LAC group.
The acceptable threshold for bleaching was
affected when done through IAC-C
compared with LAC.

CAC, conservative access cavity; EAC, endodontic access cavity; GAC, guided access cavity; IAC-C, incisal access cavity-contracted; LAC, lingual access cavity; NA, ninja access; TAC,
traditional access cavity.

matched regarding tooth size and dentin
volume using micro–computed tomographic
imaging. This methodology has been
implemented in most of the studies
investigating canal geometry.4,64 However, it
was not implemented in any of the studies that
showed improved resistance to fracture with
minimally invasive designs18,35,50–52 These
studies used either CBCT imaging or occlusal
measurements to standardize their samples,
which may not be as accurate. Although FEA
studies are able to overcome this limitation,
those studies still showed contradicting
results. This may stem from the parameters
provided in the FEA models. For example,
Allen et al42 did not have periodontal ligament
and bone modeled in their FEA, which would
affect the results. The other studies supporting
increased stresses at the per-cervical dentin
showed minimal differences between the load
to failure among the various EAC designs.
These differences were as low as 3.6 N in
enamel and 140 N in dentin,16 which questions
how much these differences may be of clinical
relevance.
Finally, the absence of a coronal
restoration can skew the results of fracture
resistance tests. Krishan et al36 were among
the first to show that the mean load to fracture
was significantly higher in conservative
compared with traditional access in anteriors,
premolars, and molars. However, there was no
coronal restoration in place when the fracture
resistance tests were conducted, which does
not resemble a realistic clinical scenario. When
the same research group later repeated the
work on maxillary molars after the placement of
a composite restoration in the access cavity,
no significant difference was noted in the
resistance to fracture between the CAC and
TAC.21 The fracture resistance of posterior
teeth appears to be primarily affected by the
presence or absence of the marginal ridge. In a
well-designed in vitro study, Corsentino et al23
showed that losing 1 or more of the marginal

1240 Shabbir et al. JOE  Volume 47, Number 8, August 2021

ridges was the only factor affecting the fracture
resistance of mandibular molars regardless of
the size of the access cavity (TAC, CAC, or TA).
Interestingly, similar findings were concluded
by Reeh et al65 almost 30 years earlier
regarding the significant reduction in tooth
stiffness of teeth after losing 1 or 2 marginal
ridges. As far as the impact of the access
cavity design on the fracture resistance, the
available evidence does not appear to support
the assumption that minimally invasive designs
will improve the fracture resistance of anterior
or posterior teeth. It should be noted that there
is an inherent limitation in most fracture
resistance studies because the load applied is
static, single load to failure. This constitutes a
test with less external validity compared with
cyclic loading that is more representative of
masticatory forces.66
The healing of apical periodontitis relies
primarily on adequate chemomechanical
disinfection of the root canal space, which is
entirely performed through the access cavity.
Failing to adequately disinfect or remove the
remaining pulp tissue may have negative
consequences on the treatment outcome.67
Although only a few studies evaluated these
parameters, there appear to be some
concerns about the irrigation efficacy, canal
debridement, and remaining pulp tissue
material in the pulp chambers of teeth with
minimally invasive designs. Minimally invasive
access cavities usually provide a curved path
for the endodontic instruments to enter the
canal and reach the apical area rather than the
straight-line access achieved with traditional
approaches. Thus, it can potentially give rise to
more canal transportation and iatrogenic
errors.19,36,58 However, this was only
observed in a few studies, possibly due to the
improved metallurgy and heat treatment of the
recent endodontic file system, which increased
their flexibility and centering abilities.4,68
Treatment time is another important factor that
has an effect on the operator and the patient as
well. Freehand minimally invasive designs
required consistently longer preparation and/
or treatment time. This can be expected
because the visibility and accessibility have
been compromised. When CAAC preparations
were used, opposite results were achieved. It
provided a high level of accuracy, precision,
and faster canal location. However, all studies
using computer-assisted designs were
primarily focused on narrow/calcified canals.
These results may be different when assessing
these designs in noncalcified canals or
nonobstructed pulp chambers.
The quality of endodontic treatment and
the quality of the coronal restoration both play
an important role in the success of endodontic
treatment.69 The presence of voids in either
may jeopardize the coronal seal and affect the
long-term success.70,71 In posterior teeth, the
size of the access did not appear to affect the
presence of voids in the root canal filling.17,20
However, in anterior teeth, more voids were
noted when the minimally invasive access was
used. This can be attributed to the anatomy
and obturation techniques used in these
studies. All studies evaluating the quality of
obturation in posterior teeth used a single-
cone obturation technique, which can be
performed through minimally invasive
designs.8,20 Also, posterior teeth generally
have a smaller canal space compared with
anterior teeth, and thus the single-cone
technique can be an appropriate obturation
approach. On the other hand, anterior teeth
have larger canal anatomy and may require
more than 1 cone to adequately fill the root
canal space. The use of the warm vertical
technique will require the insertion of pluggers
and proper visibility to pack the gutta-percha
apically, which may not be feasible through the
minimally invasive access. As far as voids in the
coronal restoration, only 1 study was identified
showing significantly more voids in the
composite restoration when the NA was
used.2 Posterior teeth were also associated
with more root canal filling in the pulp chamber,
which can potentially affect the coronal seal.20
As far as obturation and restoration, minimally
invasive designs may limit adequate root canal
obturation when certain techniques are used. It
can also potentially compromise the quality of
the coronal restoration. Remanent pulpal
tissue as well as root canal filling material within
the pulp chamber roof need to be removed to
avoid tooth discoloration.72 Accordingly, for an
internal bleaching procedure to be effective,
complete deroofing of the pulp chamber is
essential. This cannot be achieved with a
minimally invasive access design in anterior
teeth. Marchesan et al62 found that minimally
invasive cavities may affect the lightness values
achieved with internal bleaching, and the best
results were observed with the traditional
lingual access. Therefore, in the esthetic zone,
when internal bleaching is desired, the LAC
should be considered.
Based on this review and the limitation
of the published data, we can conclude that
minimal benefits have been demonstrated with
a minimally invasive approach that is primarily
focused on preserving more tooth structure
from the crown portion and potentially
minimizing stresses at the per-cervical dentin.
However, this did not translate to consistently
improving the resistance to fracture of root
canal–treated teeth. There are also concerns
associated with minimally invasive techniques
in regard to disinfection, procedural errors,
tooth discoloration, and extended operation
time. Studies that defend minimally invasive
access cavity designs as a resource to
minimize dental fractures must be reanalyzed
under other methodological parameters that
mimic masticatory forces to provide external
validity to this approach. On the other hand,
the CAAC appears to be of value when
attempting to manage calcified canals without
compromising the tooth structure. However,
more studies are needed to evaluate the
remaining pulp tissue and the level of bacteria
reduction that can be achieved with the CAAC.
ACKNOWLEDGMENTS
The authors deny any conflicts of interest
related to this study.

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