doi:10.1111/iej.

13379

Effect of access cavity design on gaps and void

formation in resin composite restorations
following root canal treatment on extracted teeth

E. J. N. L. Silva1,2 , V. B. Oliveira1, A. A. Silva1, F. G. Belladonna2 , M. Prado3 ,

H. S. Antunes1 & G. De-Deus2
1
Department of Endodontics, Grande Rio University, Duque de Caxias; 2Department of Endodontics, Fluminense Federal
University, Niterói; and 3Department of Endodontics, Veiga de Almeida University, Rio de Janeiro, Brazil

Abstract by an overlaying of regular composite. After restora-

tion procedures, a new micro-CT scan was performed
Silva EJNL, Oliveira VB, Silva AA, Belladonna FG,
to check the quality of the coronal restoration by
Prado M, Antunes HS, De-Deus G. Effect of access
analysing the percentage volume of empty spaces pre-
cavity design on gaps and void formation in resin composite
sent in the tooth-restoration interface (gaps) and
restorations following root canal treatment on extracted teeth.
inside the restoration (voids). Data were analysed sta-
International Endodontic Journal, 53, 1540–1548, 2020.
tistically using Shapiro–Wilk and Student’s t tests
Aim To evaluate the influence of ultraconservative with a significance level of 5%.
endodontic access cavities (UEC) on gaps and void for- Results All specimens had gaps and voids. There
mation in resin composite restorations in extracted were significant differences between the access cavity
two-rooted maxillary premolars after root canal treat- designs regarding the formation of voids with signifi-
ment. Traditional endodontic access cavities (TEC) cantly more voids associated with the UEC (P < 0.05).
were used as a reference for comparison. Gap formation did not differ between groups (P > 0.05).
Methodology Two-rooted maxillary premolars
Conclusion The access cavity design used during
were scanned in a micro-computed tomographic (mi-
root canal treatment interfered with the adaptation of
cro-CT) device, matched based on similar anatomical
the restorative material. The minimally invasive
features and allocated into two groups (n = 10)
access cavity design was associated with a signifi-
according to the design of the access cavity: TEC or
cantly greater number of voids within restorations.
UEC. Teeth were mounted on a mannequin head and
a single operator performed the treatment, including
Keywords: composite restoration, maxillary pre-
endodontic access cavity preparation, root canal
molars, micro-CT, ultraconservative endodontic access
detection, preparation, filling and restoration proce-
cavity.
dures, under magnification. For restorative procedure,
a bulk fill flowable layer was applied initially followed Received 21 March 2020; accepted 29 July 2020

et al. 2020) and may impact on the outcomes of root

Introduction
The design of an access cavity has a significant
impact on subsequent procedures (Rover et al. 2017,
Yahata et al. 2017, Silva et al. 2018, Mendes
canal treatment. Traditionally, conventional endodon-
tic access cavities consist of the removal of caries and
permanent restorations and preserving healthy tooth
structure when possible. Such cavities remove the

Correspondence: Emmanuel João Nogueira Leal da Silva, Department of Endodontics, Grande RIo University, Rua Herotides de
Oliveira, 61/902, Icaraı́, Niterói, RJ 24220-000, Brazil (e-mail: nogueiraemmanuel@hotmail.com).

1540 International Endodontic Journal, 53, 1540–1548, 2020 © 2020 International Endodontic Journal. Published by John Wiley & Sons Ltd

pulp chamber roof completely to provide direct access
to the apical foramen or at least to the initial curva-
ture of the root canal, by removing overhanging cer-
vical dentine and enlarging the root canal orifice
(Patel & Rhodes 2007).
Recently, inspired by the concept of minimally
invasive dentistry, conservative endodontic access
cavities have been designed aiming to minimize the
removal of the pulp chamber roof and pericervical
dentine (Clark & Khademi 2010). This approach was
based on the prevention of excessive removal of
healthy tooth structure, with the assumption of
increasing the resistance of tooth to fracture (Clark &
Khademi 2010). A development of the conservative
cavities concept led to the so-called ultraconservative
endodontic access cavities (UEC), popularly known as
’ninja’ access (Plotino et al. 2017), which consist of
small access openings achieved using small burs (Plo-
tino et al. 2017, Silva et al. 2020).
Resin composites are considered the first choice for
the restoration of root filled teeth, especially in mini-
mally invasive endodontic access cavities, because
they are cheaper, a more rapid option with good aes-
thetic performance and a less invasive technique
when compared to indirect restorations (Dammaschke
et al. 2013, Özyürek et al. 2018). However, perform-
ing restorative treatments in these minimal cavities is
challenging. The dimensions of the access cavity asso-
ciated with the retention of some of the pulp chamber
roof may lead difficulties during the restorative pro-
cess of an incremental build-up technique, which can
lead to adhesion failures and/or spaces at the interface
between the restorative material and cavity walls
(van Dijken & Pallesen 2014).
Advances in direct composites have promoted the
development of bulk fill resin composites that, accord-
ing to manufacturers, can be used in a single incre-
ment of 4–5 mm depth, due to modifications in their
organic matrix, initiator and filler content. The use of
this material simplifies the restorative procedure by
reducing the number of increments and the final cur-
ing time, without impairing the polymerization of the
material (Atalay et al. 2016, Veloso et al. 2018, Sam-
paio et al. 2019). Such composites are available in dif-
ferent viscosities, flowable and high. Flowable bulk fill
composites have comparable or lower volumetric
polymerization shrinkage than a conventional flow-
able resin composite (Sampaio et al. 2017). The same
behaviour has been observed for high viscosity bulk
materials (Algamaiah et al. 2017).
© 2020 International Endodontic Journal. Published by John Wiley & Sons Ltd
Silva et al. Access design and coronal restoration
Considering the advantages in the use of flowable
bulk fill composites associated with the importance of
adapting the restorative material, and the possible dif-
ficulties associated with the restoration of minimally
invasive endodontic access cavities, led to the aim of
the present study that was to evaluate the influence
of the access cavity design (traditional and ultracon-
servative) in the adaptation of the restorative mate-
rial. The null hypothesis tested was that there would
be no differences between the two types of endodontic
access cavities on the formation of gaps and voids
after resin composite restorations were placed follow-
ing root canal treatment of extracted teeth.
Materials and Methods
Sample size estimation
This study was approved by the local ethics commit-
tee (protocol n. 2.743.799). Due to the absence of
specific studies using micro-computed tomographic
(micro-CT) technology to evaluate gaps and voids in
the coronal restoration, a pilot study was performed.
The sample size estimation took into consideration
three initial test results of the two groups tested. A
Wilcoxon–Mann–Whitney test was selected from the
t-tests family in G*Power 3.1 software for Windows
(Henrick Heine-Universität, Düsseldorf, Germany).
Based on the data from the pilot study regarding per-
centage values of voids [traditional endodontic cavity
(TEC) = 6.56
1.0, ultraconservative endodontic
cavity = 2.71
2.7), the effect size for this study was
established (=1.86). An alpha-type error of 0.05,
power beta of 0.95 and allocation ratio N2/N1 of 1
were also specified. A total of 16 specimens (eight per
group) were indicated as the ideal size required for
observing significant differences. Ten teeth were allo-
cated for each group, as following: UEC (experimental
group) and TEC (control group).
Sample selection
A total of 32 extracted sound, intact, mature human
2-rooted maxillary premolars were used. Teeth were
stored in 0.1% thymol solution during all phases of
the study. Using periapical radiographs, teeth were
initially selected based on general dimensions, similar
length and degree of canal curvature, and pulp cham-
ber height of at least 2 mm and less than 4 mm
height.
International Endodontic Journal, 53, 1540–1548, 2020 1541
 Access design and coronal restoration Silva et al.
To obtain a detailed image of the internal anatomy,
the specimens were scanned in a micro-CT device
(SkyScan 1173; Bruker-microCT, Kontich, Belgium)
using the following parameters: 70 kV and 114 mA,
pixel size of 21 µm, 360° rotation, rotation step of
0.5, frame averaging of 5, vertical exposure time of
7000 ms and 1-mm-thick aluminium filter. Then, the
acquired projections were reconstructed with NRecon
v.1.6.10 software (Bruker-microCT) using 30% beam
hardening correction, ring artefact correction of 5
and similar contrast levels, resulting in the acquisition
of 700–800 transversal images per tooth (Silva
et al. 2020).
After the initial scanning and reconstruction proce-
dures, the specimen pairing process was carried out
considering anatomical similarity such as the number
of root canals and the volume of dentine. Volume,
area and height of the pulp chamber were also used
to standardize the groups. The final sample consisted
of 10 pairs of teeth, which were allocated to two
groups (n = 10) according to the type of endodontic
access cavity performed: TEC or UEC.
Endodontic access cavities preparation
Teeth were mounted on a mannequin head (Silva
et al. 2020) and a single operator with 25 years of
experience in Endodontics performed the root canal
treatment and restoration procedures, under magnifi-
cation (16×) using an operating microscope (DF Vas-
concellos; Valença, Rio de Janeiro, Brazil).
TEC group
Endodontic access cavities were prepared with a dia-
mond bur (1012; KG Sorensen, São Paulo, Brazil)
and an Endo Z bur (Dentsply Sirona, Ballaigues,
Switzerland) mounted on a high-speed handpiece with
water cooling, following the traditional standards
established in the literature (Hargreaves et al. 2011,
Silva et al. 2020), which consist on the removal of
the entire roof of the pulp chamber and establishing
direct access to the cervical third of the root canal.
UEC group
Endodontic access cavities were prepared using a dia-
mond bur (1012; KG Sorensen) mounted on a high-
speed handpiece with water cooling. The procedure
was carried out in the central fossa until the pulp
chamber was exposed by the dimensions of the dia-
mond tip, but not extending the access in any direc-
tion (Plotino et al. 2017, Silva et al. 2020).
1542 International Endodontic Journal, 53, 1540–1548, 2020
Root canal preparation and filling procedures
Root canal preparation was similar for both groups.
The mannequin set-up allowed connection to an
apex locator (Denjoy, Hunan, China) to enable an
electronic measurement of the working length (WL),
which was established 1 mm short of the apical
foramen. A glide path was performed with Logic size
25, .01 taper instrument (Easy Equipamentos Odon-
tológicos; Belo Horizonte, Minas Gerais, Brazil). Then,
the root canals were prepared with Reciproc Blue R25
(tip 25 and .08 taper) instruments (VDW, Munich,
Germany) according to manufacturer instructions.
Root canal irrigation was performed with 2 mL 2.5%
sodium hypochlorite (NaOCl) with a 30-G Navitip
(Ultradent Inc., South Jordan, UT, USA) inserted up to
2 mm short of the WL (Perez et al. 2017) after each
instrument change. The final irrigation protocol was
performed with 5 mL 2.5% NaOCl followed by 5 mL
17% EDTA for 1 min and by 5 mL 2.5% NaOCl, being
activated with the EasyClean plastic instrument (Easy
Equipamentos Odontológicos). Then, the canals were
dried with Reciproc Blue R25 paper points (VDW).
The root canals were filled with Reciproc Blue R25
gutta-percha cones (VDW) and AH Plus sealer (Dents-
ply De Trey, Konstanz, Germany) using the single-
cone technique associated with the use of a McSpad-
den condenser (Dentsply Sirona) in the cervical and
middle thirds. The level of gutta-percha after the final
condensation was standardized at 1 mm below the
root canal orifices.
Cleaning of the pulp chamber was performed in the
same way in both groups, using a cotton pellet with
70% alcohol, n. 5 and 6 endodontic explorers, 20 mL
of saline solution and the use of ultrasonic tips (TRA
12 and TRA 24D tips; Trinks, São Paulo, Brazil)
against the cavity walls and pulp chamber roof.
Restorative procedures
After 24 h, the restorative procedures were per-
formed. The endodontic access cavities were condi-
tioned with 37% phosphoric acid (Condac 37; FGM,
Joinville, Brazil) for 15 s in dentine and 30 s in
enamel, rinsed with water for 30 s and air-dried.
Then, two layers of bonding agent (Single Bond
Universal; 3M ESPE, St Paul, MN, USA) were used
interspersed by a light jet of air and then cured for
20 s (Radii-cal; SDI, Bayswater, Australia).
Filtek bulk fill flowable composite resin (Shade A2;
3M ESPE) was used to fill the pulp chamber in a
© 2020 International Endodontic Journal. Published by John Wiley & Sons Ltd

single increment. After pulp chamber filling using the
bulk fill composite, a capping layer with regular Filtek
Z350 XT composite resin (Shade A2, 3M ESPE) was
placed with increments of no more than 2 mm. Each
resin increment was light-cured for 20 s (Radii-cal)
followed by a final polymerization of 40 s.
Micro-CT assessment
After the restoration procedures, a new micro-CT scan
using the same parameters was performed to check
the quality of the coronal restoration by analysing
the volume of empty spaces present in the tooth-
restoration interface (gaps) and inside the restoration
(voids) (Fig. 1). After the reconstruction procedures,
pre- and post-coronal restoration images were ren-
dered and coregistered with their respective pre-opera-
tive data sets using an affine algorithm of the 3D
Slicer 4.10.2 software (Fedorov et al. 2012). Then,
the segmentation (binarization) of the crown, restora-
tive material, gaps and voids was performed using the
ImageJ software (Fiji v.1.51n; Fiji, Madison, WI, USA)
as described previously (Neves et al. 2015). After seg-
mentation, the volume (mm3) of gaps and voids were
analysed through the Object Counter plugin of the
ImageJ software. 3D images were created using the
CTVol software (Bruker-microCT).
As the specimens had different access cavities vol-
umes, the percentage volume of voids (% VoidsVol)
and gaps (% GapsVol) was calculated using the fol-
lowing formula (Iglecias et al. 2017)
Voids Vol  100
% Voids Vol ¼ and
Access cavity volume
Gaps Vol  100
% Gaps Vol ¼
Access cavity volume
Statistical analysis
The normal distribution of coronal restoration data
was confirmed by the Shapiro–Wilk test (P < 0.05).
Student’s t test was used to compare the different
parameters between TEC and UEC groups (Prism 5.0;
GraphPad Software Inc, La Jolla, CA, USA) with a sig-
nificance level of 5%.
Results
The height, initial volume and area of the pulp cham-
bers were similar in the TEC and UEC groups
(P > 0.05). However, after endodontic procedures, the
© 2020 International Endodontic Journal. Published by John Wiley & Sons Ltd
Silva et al. Access design and coronal restoration
volume and area of the pulp chamber in the TEC
group was greater than those of UEC (P < 0.05;
Table 1). The percentages of gaps and voids are
shown in Table 1. There were significant differences
between the access cavities designs regarding the for-
mation of voids, with more voids in the UEC
(P < 0.05). Gap formation did not differ between
groups (P > 0.05). Figures 2 and 3 present represen-
tative images of the two groups evaluated.
Discussion
The present study aimed to analyse the influence of
UEC on the quality of coronal restoration through
volumetric analysis of the percentage of empty spaces
present in the tooth-restoration interface (gaps) and
inside the restoration (voids). The presence of gaps
can be detrimental to the longevity of coronal restora-
tions, compromising its marginal integrity and mak-
ing it more susceptible to microleakage and recurrent
caries (Pereira et al. 2008, Soares et al. 2008). In this
study, UEC were similar to TEC regarding the forma-
tion of gaps (P > 0.05).
Resin composites suffer dimensional shrinkage and
volume loss when they are polymerized. When poly-
merization shrinkage stress exceeds the strength of
the bond to the cavity walls, it affects the marginal
integrity, leading to debonding from the surrounding
tooth structure, and gap formation. Many factors
influence the magnitude of the polymerization shrink-
age, such as the elastic modulus and flow capability
of the composite, curing method, filling technique, as
well as the cavity configuration factor and size of the
cavity (Lee et al. 2007a,b, Cho et al. 2011, Bicalho
et al. 2014, Han & Park 2017). Lee et al. (2007a,b),
comparing cavities with different widths and depths,
reported greater cuspal deflection and polymerization
shrinkage stress for the larger cavities. In the present
study, since TEC had larger dimensions, it would be
expected that the number of gaps in this group would
be greater than in minimal cavities such as the UEC.
However, this outcome was not observed in the cur-
rent study as both endodontic cavities (UEC and TEC)
had similar volumes of gap formation, confirming that
bulk fill composite resin does not eliminate the poten-
tial for gap formation (Cho et al. 2011, Han & Park
2017).
Almeida Jr et al. (2017), evaluating bulk fill com-
posites, reported that the final gap formation was
more dependent on the initial gap that was present
rather than the polymerization shrinkage. In the
International Endodontic Journal, 53, 1540–1548, 2020 1543
 Access design and coronal restoration Silva et al.

(a) (b)

Figure 1 Shadow images obtained after the scanning procedure showing the coronal restoration in a representative specimen
of (a) TEC and (b) UEC groups.

Table 1 Parameters of sound and prepared pulp chamber area, percentage values of voids and gaps found after cavity restora-
tion with traditional endodontic access cavities (TEC) and ultraconservative endodontic access cavities (UEC)

Sound pulp Prepared pulp Sound pulp Prepared pulp

Height of pulp chamber area chamber area chamber volume chamber volume
Group chamber (mm) (mm2) (mm2) (mm3) (mm3) Void (%) Gap (%)

TEC 3.19
0.29A 38.9
9.1A 163.3
29.6A 5.6
1.3A 43.1
10.1A 1.8
2.5A 2.6
1.2A
UEC 3.23
0.31A 39.2
7.9A 130.5
20.7B 6.2
2.0A 19.8
4.3B 6.1
2.1B 3.2
1.1A

Different letters represent a significant difference between the various groups (P < 0.05).

present study, the similarities in the results between
UEC and TEC can be related to the low viscosity of
the composite associated with the cavity dimensions.
As Pressure = Force/Area, and Area in UEC is
reduced, with the similar force (same operator), the
greater pressure in UEC may have favoured the flow
of the composite and its initial adaptation.
According to Cho et al. (2011), the height of the
cavity could affect the shrinkage of bulk fill compos-
ites. The authors reported a detrimental effect of
shrinkage mainly in the deepest interface, the cavity
floor, due to the accumulation of shrinkage effects in
this area. However, in the present study total gap for-
mation in the material was assessed and not sepa-
rately at different levels (coronal or cervical).
The second result of the present study demonstrated
that UEC had a greater number of voids compared to
TEC (P < 0.05). Thus, the null hypothesis was rejected.
This result may be related to the difficulties in properly
inserting the restorative material into minimal access
cavities and its manipulation in order to better adapt to
UEC. The difficulties during manipulation of bulk fill
flowable composite were confirmed in a recent study,
which concluded that the flowable group had a greater
number of gaps and voids (Sampaio et al. 2019). No
previous studies have evaluated the capacity of com-
posite materials to restore different designs of endodon-
tic access cavities using 3D analysis.
In the current study, the pulp chambers were filled
with bulk fill flowable resin. After being filled, an

1544 International Endodontic Journal, 53, 1540–1548, 2020 © 2020 International Endodontic Journal. Published by John Wiley & Sons Ltd
 Silva et al. Access design and coronal restoration

(a)

(b)

Figure 2 Coronal cross-sections from the occlusal to the cervical third showing the presence of gaps (yellow arrows) and voids
(red arrows) in a representative specimen of (a) TEC and (b) UEC groups.

(a) (b)

Figure 3 Representative 3D images showing the presence of voids (in black) in both (a) TEC and (b) UEC groups.

additional occlusal layer was placed using a regular
resin composite, as previously indicated (Ilie
et al. 2013, van Dijken & Pallesen 2017). The possi-
bility of using bulk fill composite in 4-mm increments
is due to the reduction of the shrinkage tension with
the incorporation of monomers that act as modulators
of the polymerization reaction, achieving low poly-
merization shrinkage and greater curing depth. The
superior translucency of bulk fill composites allows
better light dissipation through the material (Furness
et al. 2014, Veloso et al. 2018). Though bulk fill com-
posite has low polymerization shrinkage, Ersen
et al. (2020) observed that cavity depth affects poly-
merization shrinkage. In the present study, the pulp
chambers were standardized between groups. All pulp
chambers had height values less than 4 mm and

© 2020 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 53, 1540–1548, 2020 1545
 Access design and coronal restoration Silva et al.
were statistically similar to allow effective composite
polymerization and thus similar polymerization
shrinkage (Furness et al. 2014, Veloso et al. 2018,
Ersen et al. 2020).
All stages of root canal treatment and coronal
restoration were performed on a dental mannequin,
simulating clinical treatment, in order to mimic clini-
cal conditions. It is believed that an ergonomic work-
ing position can have a direct influence on the results
of operative procedures (Silva et al. 2020). In addi-
tion, tools such as tooth isolation, operative micro-
scopy, ultrasound and electronic apex locator were
used, allowing clinical similarity.
Due to the intrinsic heterogeneity of teeth, espe-
cially the root canal system and pulp chamber mor-
phology, which is a well-known bias for comparative
studies, several efforts were made to ensure the com-
parability of the specimens. For this, pre-screening of
the specimens based on anatomical and morphological
configuration (length, volume and surface area) using
periapical X-rays and micro-CT images allowed the
sample to be properly matched. As a result, statistical
analysis demonstrated an adequate balance between
pairs in relation to the initial volume of the pulp
chamber and its surface area (Table 1). It is well
established that the pairing process substantially
reduces anatomical bias that could lead to erroneous
results, therefore increasing the validity of the present
study (Silva et al. 2020). The results of the final vol-
ume of the pulp chamber revealed differences in the
two experimental groups. These results were expected
as minimal access cavities aim to decrease the amount
of tooth tissue removal based on the assumption that
the preservation of these structures might increase the
fracture resistance of root filled teeth. However, sev-
eral studies concluded that the size of the access cavity
does not increase the fracture resistance of root filled
teeth (Rover et al. 2017, Özyürek et al. 2018, Silva
et al. 2018, 2020, Augusto et al. 2020). In theory,
traditional access cavities that have larger restorations
(Table 1) than minimal cavities should be related to a
greater number of restorative deficiencies. However,
this was not observed in the present study, which
demonstrates that minimal access cavities are more
difficult to restore from a technical point of view.
Micro-CT technology has been used as an impor-
tant methodology in several areas of endodontics (Bel-
ladonna et al. 2018, Silva et al. 2018). This imaging
technique has also been used in restorative dentistry
to verify the adaptation of restorative materials (Car-
rera et al. 2015, Almeida Jr et al. 2017), the
1546 International Endodontic Journal, 53, 1540–1548, 2020
polymerization shrinkage, and the formation of gaps
and voids, as proposed in this study. Micro-CT is a
precise, reproducible and nondestructive technology,
allowing reconstructions of 3D models, and qualita-
tive and quantitative assessments (Carrera
et al. 2015, Belladonna et al. 2018, Silva et al. 2018).
The present laboratory study revealed that access
design can interfere in the adaptation of composite,
when bulk fill resin is used to fill the pulp chamber
along with regular resin composite for restoring the
occlusion. However, this study used a single restora-
tive material and masticatory forces and ageing of the
restoration were not evaluated. New studies evaluat-
ing other bulk fill composites with different viscosities,
the longevity of the restoration and also clinical stud-
ies are needed to define the best restorative technique
for different access cavity designs.
Conclusion
The design of access cavity used during root canal
treatment of extracted teeth in a laboratory setting
interfered with the adaptation of composite restora-
tions, with minimal access cavities being associated
with a significantly greater number of voids within
the restoration.
Acknowledgements
This study was partially funded by CNPq and
FAPERJ.
Conflict of interest
The authors have stated explicitly that there are no
conflicts of interest in connection with this article.
References
Algamaiah H, Sampaio CS, Rigo LC et al. (2017) Microcom-
puted tomography evaluation of volumetric shrinkage of
bulk-fill composites in class II cavities. Journal of Esthetic
and Restorative Dentistry 29, 118–27.
Almeida Junior LJS, Penha KJS, Souza AF et al. (2017) Is
there correlation between polymerization shrinkage, gap
formation, and void in bulk fill composites? A μCT study.
Brazilian Oral Research 31, e100.
Atalay C, Yazici A, Horuztepe A, Nagas E, Ertan A, Ozgunal-
tay G (2016) Fracture resistance of endodontically treated
teeth restored with bulk fill, bulk fill flowable, fiber-rein-
forced, and conventional resin composite. Operative Den-
tistry 41, E131–40.
© 2020 International Endodontic Journal. Published by John Wiley & Sons Ltd

Augusto CM, Barbosa AFA, Lima CO et al. (2020) A labora-
tory study on the impact of ultraconservative access cavities
and minimal root canal tapers on the ability to shape canals
in extracted mandibular molars and their fracture resis-
tance. International Endodontic Journal. https://doi.org/10.
1111/iej.13369
Belladonna FG, Carvalho MS, Cavalcante DM et al. (2018)
Micro-computed tomography shaping ability assessment of
the new blue thermal treated reciproc instrument. Journal
of Endodontics 44, 1146–50.
Bicalho AA, Pereira RD, Zanatta RF et al. (2014) Incremen-
tal filling technique and composite material—Part I: cuspal
deformation, bond strength, and physical properties. Oper-
ative Dentistry 39, e71–82.
Carrera CA, Lan C, Escobar-Sanabria D et al. (2015) The use
of micro-CT with image segmentation to quantify leakage
in dental restorations. Dental Materials 31, 382–90.
Cho E, Sadr A, Inai N, Tagami J (2011) Evaluation of resin
composite polymerization by three dimensional micro-CT
imaging and nanoindentation. Dental Materials 27, 1070–8.
Clark D, Khademi J (2010) Modern molar endodontic access
and directed dentin conservation. Dental Clinics of North
America 54, 249–73.
Dammaschke T, Nykiel K, Sagheri D, Schäfer E (2013) Influ-
ence of coronal restorations on the fracture resistance of
root canal-treated premolar and molar teeth: a retrospec-
tive study. Australian Endodontic Journal 39, 48–56.
Ersen KA, Gürbüz Ö, Özcan M (2020) Evaluation of polymer-
ization shrinkage of bulk-fill resin composites using micro-
computed tomography. Clinical Oral Investigation 24,
1687–93.
Fedorov A, Beichel R, Kalpathy-Cramer J et al. (2012) 3D
Slicer as an image computing platform for the Quantita-
tive Imaging Network. Magnetic Resonance Imaging 30,
1323–41.
Furness A, Tadros MY, Looney SW, Rueggeberg FA (2014)
Effect of bulk/incremental fill on internal gap formation of
bulk-fill composites. Journal of Dentistry 42, 439–49.
Hargreaves KM, Berman LH, Cohen S (2011) Pathways of
the pulp, 10th edn. Mosby: St. Louis.
Ilie N, Bucuta S, Draenert M (2013) Bulk-fill resin-based
composites: an in vitro assessment of their mechanical
performance. Operative Dentistry 38, 618–25.
Han SH, Park SH (2017) Comparison of internal adaptation
in class II bulk-fill composite restorations using micro-CT.
Operative Dentistry 42, 203–14.
Iglecias EF, Freire LG, de Miranda Candeiro GT, Dos Santos
M, Antoniazzi JH, Gavini G (2017) Presence of voids after
continuous wave of condensation and single-cone obtura-
tion in mandibular molars: a micro-computed tomography
analysis. Journal of Endodontics 43, 638–42.
Lee MR, Cho BH, Son HH, Um CM, Lee IB (2007a) Influence
of cavity dimension and restoration methods on the cusp
deflection of premolars in composite restoration. Dental
Materials 23, 288–95.
© 2020 International Endodontic Journal. Published by John Wiley & Sons Ltd
Silva et al. Access design and coronal restoration
Lee SH, Chang J, Ferracane J, Lee IB (2007b) Influence of
instrument compliance and specimen thickness on the
polymerization shrinkage stress measurement of light-
cured composites. Dental Materials 23, 1093–100.
Mendes EB, Soares AJ, Martins JNR, Silva EJNL, Frozoni MR
(2020) Influence of access cavity design and use of operat-
ing microscope and ultrasonic troughing to detect middle
mesial canals in extracted mandibular first molars. Interna-
tional Endodontic Journal 53, 1430–37.
Neves AA, Silva EJ, Roter JM et al. (2015) Exploiting the
potential of free software to evaluate root canal biome-
chanical preparation outcomes through micro-CT images.
International Endodontic Journal 48, 1033–42.
Özyürek T, Ülker Ö, Demiryürek EÖ, Yılmaz F (2018) The
effects of endodontic access cavity preparation design on
the fracture strength of endodontically treated teeth: tradi-
tional versus conservative preparation. Journal of Endodon-
tics 44, 800–5.
Patel S, Rhodes J (2007) A practical guide to endodontic
access cavity preparation in molar teeth. Brazilian Dental
Journal 203, 133–40.
Pereira RA, Araujo PA, Castaneda-Espinosa JC, Mondelli RFL
(2008) Comparative analysis of the shrinkage stress of
composite resins. Journal of Applied Oral Science 16, 30–4.
Perez R, Neves AA, Belladonna FG et al. (2017) Impact of
needle insertion depth on the removal of hard-tissue deb-
ris. International Endodontic Journal 50, 560–8.
Plotino G, Grande NM, Isufi A et al. (2017) Fracture strength
of endodontically treated teeth with different access cavity
designs. Journal of Endodontics 43, 995–1000.
Rover G, Belladonna FG, Bortoluzzi EA, De-Deus G, Silva
EJNL, Teixeira CS (2017) Influence of access cavity design
on root canal detection, instrumentation efficacy, and frac-
ture resistance assessed in maxillary molars. Journal of
Endodontics 44, 1146–50.
Sampaio CS, Arias JF, Atria PJ et al. (2019) Volumetric poly-
merization shrinkage and its comparison to internal adap-
tation in bulk fill and conventional composites: A μCT and
OCT in vitro analysis. Dental Materials 35, 1568–75.
Sampaio CS, Chiu KJ, Farrokhmanesh E et al. (2017) Micro-
computed tomography evaluation of polymerization
shrinkage of class I flowable resin composite restorations.
Operative Dentistry 42, E16–23.
Silva AA, Belladonna FG, Rover G et al. (2020) Does ultra-
conservative access affect the efficacy of root canal treat-
ment and the fracture resistance of two-rooted maxillary
premolars? International Endodontic Journal 53, 265–75.
Silva EJN, Rover G, Belladonna FG et al. (2018) Impact of
contracted endodontic cavities on fracture resistance of
endodontically treated teeth: a systematic review of
in vitro studies. Clinical Oral Investigations 22, 109–18.
Soares PV, Santos-Filho PC, Gomide HA, Araujo CA, Martins
LR, Soares CJ (2008) Influence of restorative technique on
the biomechanical behavior of endodontically treated max-
illary premolars. Part II: strain measurement and stress
International Endodontic Journal, 53, 1540–1548, 2020 1547
 Access design and coronal restoration Silva et al.
distribution. The Journal of Prosthetic Dentistry 99,
114–22.
van Dijken JWV, Pallesen U (2017) Bulk-filled posterior resin
restorations based on stress-decreasing resin technology: a
randomized, controlled 6-year evaluation. European Journal
of Oral Sciences 125, 303–9.
van Dijken JWV, Pallesen U (2014) A randomized controlled
three year evaluation of “bulk-filled” posterior resin
restorations based on stress decreasing resin technology.
Dental Materials 30, e245–51.
1548 International Endodontic Journal, 53, 1540–1548, 2020
Veloso SRM, Lemos CAA, de Moraes SLD, do Egito Vascon-
celos BC, Pellizzer EP, de Melo Monteiro GQ (2018) Clini-
cal performance of bulk-fill and conventional resin
composite restorations in posterior teeth: a systematic
review and meta-analysis. Clinical Oral Investigations 23,
221–33.
Yahata Y, Masuda Y, Komabayashi T (2017) Comparison of
apical centring ability between incisal-shifted access and
traditional lingual access for maxillary anterior teeth. Aus-
tralian Endodontic Journal 43, 123–8.
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