In vitro study investigating the mass of

tooth structure removed following

endodontic and restorative procedures
Sela K.F. Hussain, BDS, MSc,a Ailbhe McDonald, BDentSc, PhD,
MSc,b and David R. Moles, BDS, PhD, MScc
Eastman Dental Hospital and UCL Eastman Dental Institute,
London, UK
Statement of problem. There is limited scientific evidence which quantifies the amount of tissue removed during end-
odontic and restorative procedures.

Purpose. The purpose of this study was to measure and compare the mass of tissue structure removed from incisor
and canine teeth following successive preparations.

Material and methods. Twenty-two intact, disease- and restoration-free teeth (n=11/group) were collected from con-
senting patients undergoing dental extractions at Eastman Dental Hospital. The teeth were stored in 4% formaldehyde
saline and successively prepared for an access opening (AC), endodontic instrumentation (EI), porcelain laminate
veneer (PC), metal-ceramic (MC) crown, and post-and-core (PC) preparations. The baseline mass for each tooth was
measured and recorded, in grams, at baseline and after each preparation, on a digital analytical balance. A standard
protocol was applied to ensure accurate mass measurements. Repeated measures analysis of variance (ANOVA) was
used to make comparisons between the incisor and canine groups (α=.05) for actual mass of tooth in milligrams,
percentage of tooth mass remaining compared to baseline, and percentage decrease in mass compared to the preced-
ing procedure.

Results. The estimated marginal percentage mass lost was significantly greater (P<.001) in the incisor group com-
pared to the canine group, as an overall trend, with the incisors losing proportionally more mass for each procedure
(P<.001).

Conclusions. Mean percentage of removed tooth tissue increased successively from EI, AC, PC, and PV prepara-
tion, with greatest change from the previous procedure occurring for MC crown preparation. (J Prosthet Dent
2007;98:260-269)

Clinical Implications
In a sequence of preparations, metal-ceramic crown preparations
removed a greater mass of tooth structure than other prepara-
tions in endodontically treated teeth. Overall, considerable tooth
structure is removed after completion of these procedures.

Teeth receiving endodontic thera- are designed to return teeth to ac- allows healing of the periapical tissue.
py typically lose both coronal and ra- ceptable form, function, and esthet- It is intended, therefore, that restored,
dicular tooth structure. Thus, restora- ics. Restorations should also provide endodontically treated teeth should
tions for endodontically treated teeth an environment that protects and/or also prevent both tooth fracture1 and

This study was a poster presentation at the annual 83rd IADR meeting, Baltimore, Md, March 2005.

a
Specialist Registrar, Restorative Dentistry.
b
Consultant, Restorative Dentistry.
c
Senior Clinical Lecturer, Health Services Research.
The Journal of Prosthetic Dentistry Hussain et al
October 2007
endodontic failure through coronal
leakage, by means of an inadequate
restoration.2,3
It is accepted that the greater the
amount of residual dentin, the more
predictable the longevity and strength
of a tooth and its restoration.4 Pres-
ervation of tooth structure to pro-
vide strength and fracture resistance
is important, therefore, when restor-
ing endodontically treated teeth.4-6
Sedgley and Messer’s5 in vitro study
concluded that the apparent greater
susceptibility to fracture of endodon-
tically treated teeth was due to the
cumulative loss of tooth structure
during restorative and endodontic
procedures. Hansen and Asmussen6
suggested that coronal flare with ro-
tary canal preparation burs and sub-
sequent canal instrumentation may
also result in further weakening of
tooth structure. This opinion concurs
with the in vitro findings of Trabert
et al,4 who reported that the fracture
resistance of endodontically treated
teeth diminishes with a decrease in
dentin. Similarly, Mattison7 stated
that the remaining strength of a tooth
is directly related to the remaining
bulk of dentin.
Endodontically treated teeth have
been considered to have altered phys-
ical characteristics when compared
with their vital counterparts.8 This dif-
ference was initially thought to be due
to dentin dehydration causing an in-
creased brittleness in endodontically
treated teeth.8 Helfer et al8 examined
teeth from dogs after pulp extirpation
to determine the moisture content of
vital and pulpless teeth. The authors
established that nonvital teeth con-
tained 9% less moisture than their
vital counterparts. However, this was
shown not to be statistically signifi-
cant. Papa et al9 examined the mois-
ture content of matched vital and
nonvital root-treated human teeth.
The authors concluded that there
was no significant difference in mois-
ture content between extracted vital
and nonvital teeth. Thus, it appears
that the physical properties of root-
treated dentin are not dissimilar from
Hussain et al
those of vital dentin, but the clinical
effects of endodontic procedures on
these properties remain unclear.
Magne and Douglas10 concluded
from an in vitro study of extracted
mandibular incisors, that endodon-
tic procedures were responsible for a
38% reduction in flexural strength of
crowns. Similarly, Lang et al11 showed
significant reductions in rigidity fol-
lowing access cavity and post prepa-
rations. The authors concluded that
both substance loss and alteration
of canal morphology played an im-
portant role in tooth rigidity. Ho et
al12 demonstrated in an in vitro study
that conservative access preparations
restored with composite resin in end-
odontically treated mandibular inci-
sors showed no differences in fracture
resistance and modes of failure when
compared to intact teeth. Thus, it
may be concluded that endodonti-
cally treated anterior teeth (incisors
and canines) with conservative access
preparations may be restored without
the need for further tooth destruction
to accommodate a cast restoration.
Edelhoff and Sorensen13 attempt-
ed to quantify and compare the
amount of tooth structure removed
from acrylic resin typodont teeth
with preparations for porcelain lami-
nate veneers, all-ceramic crowns, and
conventional metal-ceramic crowns.
The authors reported that there were
significant differences in the amount
of tooth structure removed between
different preparations. Seow et al14
suggested that the amount of sound
tooth structure that remains follow-
ing endodontic therapy is an impor-
tant factor to consider when planning
the subsequent definitive restoration.
The authors also indicated that it is
important to preserve as much tooth
structure as possible to prevent clini-
cal fracture of a tooth, and the use
of minimal preparation techniques
should be adopted wherever pos-
sible.
Therefore, the recommendations
for restoring endodontically treated
teeth are commonly based on clinical
experience, as there is little evidence-
261
based information upon which a cli-
nician can rely in the decision-making
process.15 Thus, the aims and ob-
jectives of this in vitro study were to
measure the mass of tooth structure
removed in making an endodontic ac-
cess cavity (AC), endodontic instru-
mentation (EI), porcelain laminate
veneer preparation (PV), convention-
al metal-ceramic (MC) crown prepa-
ration, and a cast post-and-core (PC)
preparation. This study also aimed to
compare the mass of tooth structure
removed from maxillary and mandib-
ular central and lateral incisors (inci-
sor group) with maxillary and man-
dibular canine teeth (canine group). It
was considered important to measure
the difference in the amount of tooth
tissue removed for differing endodon-
tic and restorative procedures for 2
different tooth groups. A certain min-
imal amount of tooth tissue needs to
be removed for a restoration such as
a porcelain laminate veneer or metal-
ceramic crown to ensure strength and
rigidity in the definitive restoration.
However, there is a proportional dif-
ference in mass between maxillary
and mandibular central and lateral in-
cisors and maxillary and mandibular
canine teeth, which may be clinically
significant with regards to the remain-
ing tooth tissue and subsequent lon-
gevity of a tooth. The null hypothesis
was that there was no difference in
the mean percentage of tooth mass
removed between the 2 groups at
each stage of preparation.
MATERIAL AND METHODS
Prior to commencement of this
study, ethical approval was sought
by application to the Joint Research
and Ethics Committee, Eastman Den-
tal Institute, and the Research and
Development Directorate, University
College London NHS Hospital Trust.
Patients were given an explanation
of the research project by either the
author or the dentist performing the
extraction and provided with an in-
formational leaflet before providing
consent. Twenty-two intact, restora-
262 Volume 98 Issue 4

Table I. Preparation design and armamentarium used for each procedure

Procedure Preparation Design Burs Used

1. Access opening From incisal edge, midway between L767.9C

mesio-distal surfaces for each tooth. (Two Striper green stripe bur; Claudius Ash, Potters Bar,
Hertfordshire, UK)

2. Endodontic Coronal preparation: step-down technique. Gates Glidden No. 1 & 2 (Gates Glidden; Pulpdent Corp,
instrumentation Watertown, Mass). K-Flexofile size 8 (K-Flexofile; Dentsply
Ltd, Weybridge, UK), to establish patency
Apical preparation: step-back technique
with watch-winding motion. K-Flexofile sizes 10, 15, 20, 25, master apical file 30,
K-Flexofile sizes 35, 40, 45, 50

3. Porcelain- Chamfer finish line1 mm coronal to CEJ. L767.9C

laminate veneer 0.5-mm labial reduction extending interproximally. LSP767.9VF (Two Striper, yellow stripe; Claudius Ash)
2-mm incisal reduction with 1-mm incisal overlap,
with chamfer finish line.

4. Metal-ceramic Buccal shoulder margin and lingual chamfer margin L767.9C

crown 1 mm coronal to CEJ. 285.5VF (Two Striper, yellow stripe); Claudius Ash)
1.5-mm labial reduction extending interproximally
through contact point.
0.8-mm reduction palatally/lingually, LSP767.9VF
2-mm incisal reduction was maintained.

5. Cast post and 3-mm coronal height retained above and followed L722.10C (Twostriper, Premier; Claudius Ash)
core contour of CEJ.
Incisor group: 10-mm post length and yellow Yellow 1-mm ParaPost (ParaPost XT system;
parallel-sided ParaPost. Coltene/Whaledent Inc, Cuyahoga Falls, Ohio)
Canine group: 10-mm post length and black Black 1.5-mm ParaPost (ParaPost XT system;
parallel-sided ParaPost. Coltene/Whaledent Inc)

CEJ = cementoenamel junction

tion-free, disease-free, single-rooted
teeth were collected from consenting
patients undergoing dental extrac-
tions as part of orthodontic, orthog-
nathic, or periodontal treatment at
the Eastman Dental Hospital. They
were divided into 2 groups (n=11),
the incisor group (maxillary and man-
dibular central and lateral incisors)
and the canine group (maxillary and
mandibular canines), and stored in
4% formaldehyde-saline (35% (w/w)
formaldehyde and 10% (w/w) metha-
nol; JM Loveridge Ltd, Southampton,
The Journal of Prosthetic Dentistry
Hampshire, UK) throughout the ex-
periment.
Initial preparation of the teeth
involved the removal of any superfi-
cial staining, calculus, and adherent
soft tissue using an ultrasonic scaler
(Piezon Master 400; EMS SA, Nyon,
Switzerland) and subsequent polish-
ing with a rotary brush (White bristle;
Stoddard Mfg Co, Letchworth Garden
City, Hertfordshire, UK) and pumice-
water mixture (Pumice powder, coarse
grit; Bracon Ltd, Etchingham, East
Sussex, UK). The teeth were examined
under a microscope at x2.5 magnifi-
cation (GX Microscope model C2D;
GT Vision Ltd, Haverhill, Suffolk, UK)
to ensure they were free from caries,
restorations, crazing, and fractures.
The buccolingual and mesiodistal
dimensions were measured at the ce-
mentoenamel junction using a thick-
ness gauge (Thickness gauge, series
547; Mitutoyo, Kawasaki, Japan) ac-
curate to 0.001 mm, to ensure that
teeth in each group were matched in
size.
The baseline mass for each tooth
Hussain et al
October 2007 263
was measured and recorded at the
start of the study. All teeth were blot-
ted for 10 minutes on absorbent paper
towels (UnoDent green hand towels;
Unodent, MarktSchwaben, Germany)
prior to weighing on a digital analyti-
cal balance (Analytic balance, Model
SI 124; BDH, London, UK), accurate
to 0.0001 grams. After the comple-
tion of each stage of tooth prepara-
tion outlined in Table I, the teeth were
rehydrated for 24 hours in the storage
medium. They were then placed on
an absorbent paper towel, with 2 size
40 paper points (Roeko Paper Points,
white; Coltene/Whaledent Inc,
Cuyahoga Falls, Ohio) within the root
canal system and dehydrated for 10
minutes. The mass was then calculat-
ed using the digital analytical balance.
This technique was proven accurate in 1 Silicone holding jig for canine specimen 1 and reduction
a pilot study, evaluating the minimum guide sectioned in mesial-distal plane prior to preparation.
time necessary to produce consistent
mass measurements. Standardized
preparations were completed for all to produce appropriate reduction of tem for each test tooth. Canals were
teeth as shown in Table I, following a both the labial and palatal surfaces of instrumented by hand, using a stan-
sequence of tooth preparation proce- teeth when preparing them for por- dardized watch-winding technique
dures as follows: access cavity prepa- celain laminate veneers. The authors (45-degree rotational movement
ration (AC), endodontic instrumenta- reported that an operator’s ability clockwise and counterclockwise, with
tion (EI), porcelain laminate veneer to distinguish comparative depths of gentle apical pressure). The coronal
preparation (PV), complete metal-ce- preparation was accurate to within and apical portions of the tooth were
ramic (MC) crown preparation, and 0.1 mm when using a silicone reduc- prepared as shown in Table I, as are
cast post-and-core (PC) preparation. tion guide. the preparation designs for the re-
Eleven teeth per group were pre- The access cavity was made slightly maining 3 procedures.
pared by a single operator. Table I lingual to the incisal edge to allow for The data were transcribed to a
shows the preparation designs, in- straight line access to the root canal, statistical software program (SPSS
cluding the armamentarium used for while preserving the labial enamel. A 12.0.1; SPSS Inc, Chicago, Ill) to en-
each procedure. Vinyl polysiloxane bur diameter of 1.5 mm and a length able statistical analysis. Repeated
putty (Lab-Putty; Coltene/Whaledent of 3 mm was used (L767.9C Two measures analysis of variance (ANO-
Inc) was used as a holding jig prior Striper green stripe bur) and held par- VA) was used to make comparisons
to tooth preparation. Two additional allel to the long axis of the tooth. The between the 2 different tooth types
polymerized silicone (Doric Flo-Light; bur was replaced after every fourth (incisor and canine group) and
Davies Schottlander and Davis Ltd, preparation. In this way, the access across each restorative procedure
Letchworth, UK) reduction guides cavity preparation was standardized. type (α=.05). Analyses were made
were fabricated for each tooth, which Following access cavity preparation separately for 3 outcome measures:
were sectioned in a mesial-distal and (procedure 1), each single canal was actual mass of tooth in milligrams,
buccal-lingual plane and used as ref- identified using a size 08 K-Flexofile, percentage of tooth mass remaining
erence guides to standardize tooth and pulpal remnants were removed compared to baseline, and percent-
reduction (Fig. 1). This was achieved using a Hedstrom size 10 and 15 file. age of decrease in mass compared
by measuring the distance between Measurement of the working length to the preceding procedure. Residual
the tooth surface and the fitting sur- to the apex was performed both vi- and predicted values were generated
face of the reduction guide. This was sually and using a periapical radio- and used for statistical model evalua-
supported by the in vitro study con- graph. Canal patency was obtained tion purposes. Model evaluation con-
ducted by Brunton et al,16 who rec- and maintained throughout the in- firmed the validity of the analytical
ommended the use of silicone indices strumentation of the root canal sys- approach.
Hussain et al
264 Volume 98 Issue 4
RESULTS

An example of each procedure

(tooth preparation) is represented
in the illustrations for Incisor 1 from
the incisor group (Figs. 2 through 6).
The results in Table II present the esti-
mated marginal mean mass of the ca-
nine group and incisor group in milli-
grams, along with the associated 95%
confidence intervals (95% CI) at base-
line and at each procedural stage, as
derived from the repeated measures
ANOVA. The absolute mass of the in-
cisor group was less than the canine A B
group at baseline and following each 2 Incisor group specimen at baseline. A, Labial view. B, Proximal view.
procedure (P<.001). Also, by defini-
tion, the mass decreased within each
tooth group as progressively more
tooth structure was cumulatively re-
moved with each subsequent proce-
dure (P<.001).
Table III demonstrates the estimat-
ed marginal mean values for the per-
centage of the original mass remain-
ing in both tooth groups following
each procedure. This standardization
allows direct comparison between the
2 tooth groups. The mass lost in per-
centage terms is significantly greater
in the incisor group than the canine A B
group, both as an overall trend and 3 Incisor group specimen showing amount of remaining tooth structure fol-
following each sequential procedure lowing tooth preparation for access opening. A, Lingual view. B, Incisal view.
(P<.001).
Table IV presents the estimated
marginal mean mass lost at each cu-
mulative procedure, as a percentage
of the mass at the preceding proce-
dural stage for both tooth groups. The
overall trend is for the incisor group to
lose proportionally more mass (tooth
material) at each stage as compared
to the canine group (P<.003). The
notable exception to this trend is at
the final transition from the metal-
ceramic (MC) crown preparation to
the post-and-core (PC) preparation,
where the canine group lost propor- A B
tionately more material than the in- 4 Incisor group specimen showing amount of remaining tooth structure fol-
cisor group (P<.003 for interaction lowing tooth preparation for porcelain veneer preparation. A, Labial view. B,
from the repeated measures ANOVA). Proximal view.
The proportion of material sacrificed
at each stage was not constant. For
the incisor group, 3.9% (95% CI, 3.4%
to 4.4%) of tooth structure was lost,
The Journal of Prosthetic Dentistry Hussain et al
October 2007 265

A B
5 Incisor group specimen showing amount of remain-
ing tooth structure following tooth preparation for
metal-ceramic crown preparation. A, Labial view. B,
Proximal view.
A B
6 Incisor group specimen showing the amount of
remaining tooth structure following tooth preparation
for post and core preparation. A, Proximal view. B,
Incisal view.

Table II. Estimated marginal mean mass (mg) at each cumulative procedural stage
95% Confidence Interval
Group Procedure Mean (SD) Lower Upper

Incisor Baseline measurement 535.9 (98.8) 417.9 6534.0

Access opening 515.1 (95.2) 400.4 629.8

Endodontic instrumentation 504.3 (94.6) 391.7 616.9

Porcelain veneer preparation 432.8 (81.7) 330.4 535.1

MC crown preparation 329.4 (65.9) 241.5 417.3

Post preparation 313.2 (61.9) 235.1 391.2

Canine Baseline measurement 1129.3 (246.4) 1011.3 1247.4

Access opening 1103.8 (239.7) 989.1 1218.5

Endodontic instrumentation 1087.5 (234.8) 974.9 1200.1

Porcelain veneer preparation 973.0 (215.2) 870.6 1075.3

MC crown preparation 795.3 (186.4) 707.4 883.2

Post preparation 716.3 (164.2) 638.2 794.3

Hussain et al
266 Volume 98 Issue 4

Table III. Estimated marginal mean percentage of baseline mass remaining at each cumulative procedural stage
95% Confidence Interval
Group Procedure Mean % Lower Upper

Incisor Baseline measurement 100.0 100.0 100.0

Access opening 96.1 95.6 96.6

Endodontic instrumentation 94.0 93.6 94.5

Porcelain veneer preparation 80.7 79.8 81.6

MC crown preparation 61.3 59.4 63.2

Post preparation 58.3 56.2 60.4

Canine Baseline measurement 100.0 100.0 100.0

Access opening 97.8 97.3 98.2

Endodontic instrumentation 96.3 95.9 96.8

Porcelain veneer preparation 86.1 85.2 87.0

MC crown preparation 70.4 68.4 72.3

Post preparation 63.5 61.4 65.6

and 2.2% (95% CI, 1.8% to 2.7%) was
lost for the canine group when mak-
ing an access opening preparation.
Further tissue loss occurred in the
order of 2.1% (95% CI, 1.8% to 2.4%)
for the incisor group, and 1.4% (95%
CI, 1.1% to 1.8%) for the canine group,
when converting the access opening
preparation to a complete endodontic
preparation. The relative magnitude
of tooth tissue loss for the porcelain
laminate veneer increased to 14.2%
(95% CI, 13.3% to 15.1%) for the inci-
sor group and 10.6% (95% CI, 9.7%
to 11.5%) for the canine group. The
relative magnitude of tooth tissue loss
for the MC crown preparation was
24.0% (95% CI, 22.2% to 25.9%) for
the incisor group and 18.3% (95% CI,
16.4% to 20.2%) for the canine group.
The Journal of Prosthetic Dentistry
The final procedure in the sequence,
the cast post-and-core (PC) prepara-
tion, was the only one in which the
canine group sacrificed proportion-
ately more tooth tissue than the inci-
sor group, with a further 4.9% (95%
CI, 3.5% to 6.3%) tissue loss in the
incisor group compared to 9.8% (95%
CI, 8.4% to 11.1%) tissue loss in the
canine group.
DISCUSSION
The null hypothesis was rejected,
as there was a difference in the mean
percentage of tooth tissue removed
between the 2 groups at each stage
of preparation. This study showed
the mass decreased within each tooth
group as progressively more tooth
structure was cumulatively removed
with each successive preparation.
This was in agreement with the find-
ings by Magne et al,10 who reported
an increase in tooth structure removal
following each subsequent procedure
(porcelain veneer, composite resin res-
toration, and endodontic treatment).
This reduction in tooth structure re-
sulted in an increase in mandibular
incisor crown flexibility. The authors
concluded that endodontic proce-
dures were responsible for most of the
loss in crown stiffness. However, if the
estimated marginal mean percentage
of tooth structure removed for each
procedure from this study is exam-
ined, the total mean cumulative per-
centage of tooth structure removed
for performing both endodontic pro-
Hussain et al
October 2007 267

Table IV. Estimated marginal mean percentage decrease in mass compared to preceding stage
95% Confidence Interval
Group Procedure Mean % Lower Upper

Incisor Access opening 3.9 3.4 4.4

Endodontic instrumentation 2.1 1.8 2.4

Porcelain veneer preparation 14.2 13.3 15.1

MC crown preparation 24.0 22.2 25.9

Post preparation 4.9 3.5 6.3

Canine Access opening 2.2 1.8 2.7

Endodontic instrumentation 1.4 1.1 1.8

Porcelain veneer preparation 10.6 9.7 11.5

MC crown preparation 18.3 16.4 20.2

Post preparation 9.8 8.4 11.1

cedures successively (access cavity
and endodontic instrumentation) was
6.0% (95% CI, 5.2% to 6.8%) for the
incisor group and 3.6% (95% CI, 2.9%
to 4.5%) for the canine group from
the baseline mass (Table IV), respec-
tively. These values are relatively small
when compared to the mean percent-
age of tooth structure removed for
the restorative preparations, such as
the porcelain veneer and MC crown
preparation.
There was a significant difference
(P<.001) for the estimated marginal
mean total of tooth structure (mass)
removed between the incisor and ca-
nine group as calculated by the re-
peated measures analysis (ANOVA)
for both endodontic procedures AC
and EI (Table III). Therefore, propor-
tionately larger amounts of tooth tis-
sue were removed from the smaller
teeth (incisor group) when perform-
ing these procedures, although this
may be offset by the preparation of
a larger post diameter in the canine
group. The reported increase in crown
Hussain et al
flexure due to endodontic procedures
by Magne et al10 may be related to
the site of hard tissue removal from a
more critical area (near the cingulum
of the mandibular incisor teeth) and
less related to the amount removed.
Similarly, Lang et al11 evaluated the
effects on tooth rigidity of maxillary
central incisors and different end-
odontic procedures: access prepa-
rations, manual instrumentation,
and tapered and parallel-sided post
preparations. Significant reductions
in rigidity occurred after access cavity
preparations and post preparations.
The authors concluded that both sub-
stance loss and alteration of the canal
morphology had an important role in
tooth rigidity.
The porcelain laminate veneer
preparation removed a mean of
14.2% (95% CI, 13.3% to 15.1%) of
tooth tissue for the incisor group and
10.6% (95% CI, 9.7% to 11.5%) from
the canine group (Table IV). This is
comparable to results reported by
Edelhoff et al13 for anterior typodont
teeth. Edelhoff et al13 found that a
mean of 16.7% of tooth structure was
removed for a similar design of veneer
preparation. However, in the present
study, teeth underwent endodontic
treatment prior to the porcelain lami-
nate veneer preparation, compared
to only the porcelain laminate veneer
preparation in Edelhoff et al’s study. A
limitation of this study was the stan-
dardized reduction for the laminate
veneer preparation for both groups,
limiting the reduction to the specific
requirements of the material. This
may not reflect a true clinical scenar-
io, as esthetic or occlusal reasons for
removing greater or lesser amounts of
tooth tissue would normally be con-
sidered.
The results of this study demon-
strated that the porcelain laminate
veneer preparation is a relatively con-
servative option for restoring anterior
teeth, particularly for small teeth such
as maxillary and mandibular central
and lateral incisors. This is in agree-
ment with findings from Magne et
268
al10 and Ho et al,12 who advocate the
use of porcelain laminate veneers for
endodontically treated anterior teeth.
Magne et al10 concluded from an in vi-
tro study of mandibular incisors that
pulpless veneered incisors performed
similar to natural teeth. Similarly, in
an in vitro study, Ho et al12 confirmed
that mandibular endodontically
treated incisors, using conservative
access and porcelain veneer resto-
rations, were able to withstand the
same oblique loading as intact man-
dibular incisors. Thus, it seems that
the loss of tooth structure associated
with extensive restorative procedures
in endodontically treated teeth may
be important to their function, while
the effect of pulpal removal on the
remaining tooth may have a lesser
role.4,9
The MC crown preparation was
shown in the present study to remove
the greatest amount of tooth struc-
ture, 24.0% (95% CI, 22.2% to 25.9%)
for the incisor group and 18.3% (95%
CI, 16.4%to 20.2%) for the canine
group, under the current experimen-
tal design where sequential prepara-
tions were performed on the same
tooth (Table IV). The mean percent-
age of tooth structure removed from
baseline was 38.7% (95% CI, 36.8%
to 40.8%) for the incisor group and
29.6% (95% CI, 27.7% to 31.6%) for
the canine group (Table III). These val-
ues were again significant (P<.001),
showing that more tooth structure
was removed from the incisor group
than the canine group, and may re-
flect the anatomical shape of these
teeth.
However, the results obtained
from the present investigation fol-
lowing the MC crown preparation
are smaller than the values reported
by Edelhoff et al,13 who stated a mean
removal of 71.9% for an MC crown
preparation similar to that performed
in this study. The large difference
between the 2 studies in the mean
amount of tooth structure removed
may be explained by the fact that
Edelhoff et al13 used typodont teeth.
This suggests that typodont teeth may
The Journal of Prosthetic Dentistry
not be a suitable substitute for natu-
ral teeth, which differ greatly in their
anatomical shape, the presence of a
pulp chamber, intertubular dentin,
and dentinal tubules. Additionally,
the tactile feedback of human teeth
differs from typodont teeth, which
may have caused a difference in the
preparation procedure. One advan-
tage of using typodont teeth would
be the standardization in the size of
teeth. However, by conducting this
experiment on similarly sized, single-
rooted natural teeth with a single ca-
nal, as well as by a single operator, the
authors attempted to minimize both
the amount of morphological and
operator variability encountered, and,
subsequently, ensured that the results
obtained were as accurate as possible
with regards to changes in mass. This
may have resulted in conservative
preparations, which could be investi-
gated further by conducting a similar
study with differing operators.
Seow et al14 investigated the
amount of tooth structure remain-
ing following preparations for various
all-ceramic restorations and an MC
crown preparation that may be used
to restore an endodontically treated
maxillary second premolar. The au-
thors used illustrations of endodonti-
cally treated maxillary second premo-
lars in buccopalatal, mesiodistal, and
occlusal sections and superimposed
the outline of the various ideal intra-
and extracoronal preparations. They
found that approximately 1.0 mm
of tooth structure remained buccally
and 1.6-1.8 mm palatally, following
a reduction of 1.2 mm for the buccal
shoulder and a 0.8-mm palatal cham-
fer and axial reduction for the MC
crown preparation. Thus, the authors
concluded that the completed crown
would be largely supported by a foun-
dation restoration, and the fracture
resistance of the tooth may be com-
promised given the absence of re-
maining tooth tissue. The anatomical
variations that exist between the same
type of tooth, as well as alterations in
preparation design due to occlusal
and esthetic requirements, were not
Volume 98 Issue 4
considered.
This study examined the mass of
tissue removed for both the coronal
and root dentin, even though it is the
coronal dentin which provides struc-
tural integrity for the prepared tooth.
In this manner, it was dissimilar to
the study by Edelhoff et al13 in which
only the coronal dentin was weighed,
following teeth preparation. Thus, it
would have been interesting to calcu-
late the mass removed from the coro-
nal dentin only by removing the root
below the cemento-enamel junction,
and investigating the impact on the
percentage of coronal mass removed.
An unexpected finding was that
the post-and-core preparation re-
moved a further 4.9% (95% CI, 3.5%
to 6.3%) and 9.8% (95% CI, 8.4% to
11.1%) of tooth tissue for the incisor
and canine groups, respectively (Ta-
ble IV). This equated to a mean differ-
ence from baseline of 41.7% (95% CI,
39.6% to 43.8%) for the incisor group
and 36.5% (95% CI, 34.4% to 38.6%)
for the canine group (Table III). Per-
forming a post-and-core preparation
with 3 mm of coronal tissue for both
incisor and canine teeth may not be
overly destructive of tooth structure.
Post sizes used were clinically appro-
priate, but conservative, ensuring re-
moval of a minimal amount of tooth
tissue. Additionally, these teeth had
already been prepared for MC crowns
and may not have needed extensive
amounts of further reduction. Lang et
al11 reported a significant loss of tooth
rigidity as a result of post preparation.
Modification of the anatomical root
canal shape to accommodate tapered
and parallel-sided posts produced
a large reduction in rigidity. There is
general agreement in the literature
that conservation of tooth structure
is one of the critical aspects for in-
creasing the longevity of a tooth and
its subsequent restoration. Despite
the limitations of this study, the au-
thors are not aware of other research
that has attempted to quantify the
amount of tooth structure removed
with both endodontic and restorative
procedures in natural teeth. Further
Hussain et al
October 2007
investigations are needed to confirm
the relative contribution of the loss of
tooth structure for each design prepa-
ration to the structural rigidity of the
tooth.
CONCLUSIONS
Within the limitations of this in
vitro study, the following conclusions
were drawn:
1. The greatest relative amount of
tooth structure was removed for the
metal-ceramic (MC) crown prepara-
tion when sequential preparation was
performed.
2. The estimated marginal mean
mass removed following access cavity
preparation, endodontic instrumen-
tation, and laminate veneer or metal-
ceramic crown preparations, as a per-
centage, was found to be significant
(P<.001) when comparing the incisor
and canine groups. The incisor group
lost a proportionately greater amount
of tooth structure (mass).
3. The mean percentage of tooth
tissue removed following the cast
post-and-core preparation was the
only sequential procedure that result-
ed in the canine group losing propor-
269
tionately more tooth tissue than the terior crown flexure: intact versus veneered
incisors. Quintessence Int 2000;31:5-18.
incisor group. 11.Lang H, Korkmaz Y, Schneider K, Raab
WH. Impact of endodontic treatments
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Noteworthy Abstracts of the Current Literature

Comparison of the retentive characteristics of cobalt-chromium and commercially pure
titanium clasps using a novel method

Tse ET, Cheng LY, Luk HW, Chu FC, Chai J, Chow TW.
Int J Prosthodont 2006;19:371–2.

This study aimed to compare the retentive forces of cast cobalt-chromium (Co-Cr) and commercially pure titanium
(cpTi) clasps. A clasp assembly comprising a pair of symmetrical clasps was made to fit the opposite halves of a hard-
ened stainless-steel sphere. This twin clasp was designed to counterbalance the tipping forces when the clasp assem-
bly was drawn from the sphere. A total of 120 clasp assemblies were fabricated in cast Co-Cr and cpTi and placed at
undercut depths of 0.25 mm, 0.50 mm, and 0.75 mm (n = 20 for each). For Co-Cr clasps, the retentive forces at these
undercuts depths were 2.34 ± 0.23 N, 4.65 ± 0.35 N, and 7.56 ± 0.50 N, respectively. The corresponding retentive
forces for cpTi clasps were 1.24 ± 0.13 N, 2.34 ± 0.23 N, and 3.70 ± 0.27 N. The retentive force of cpTi clasps was ap-
proximately half that of Co-Cr clasps for the same undercut depth.

Reprinted with permission of Quintessence Publishing.

Hussain et al