1

Influence of Access Cavity Design on Root

Canal Detection, Instrumentation Efficacy,
and Fracture Resistance Assessed in
Maxillary Molars
Journal of endodontics · July 2017
Journal of endodontics · July 2017
INTRODUCTION
• Traditional endodontic cavities (TECs) emphasize straight-line
pathways into root canals to increase preparation efficacy and
prevent procedural errors. However, a concern related to TECs
is the amount of tooth structure removed,which may reduce
its resistance to fracture under functional loads.
• As an alternative to this traditional approach, minimally
invasive endodontic cavities or contracted endodontic cavities
(CECs) have been described, emphasizing the importance of
preserving the tooth structure, including pericervical dentin. It
was already shown that CECs improved the fracture resistance
of premolars and mandibular molars; however, this kind of
access compromised the efficacy of root canal
instrumentation in lower molars.
• Yuan et al showed, through finite element analysis, that
CECs reduced stress in the occlusal and cervical regions
when performed in mandibular molars. On the other hand,
another study showed that CECs were not able to improve
the fracture resistance of maxillary molars when compared
with TECs. Thus, the influence of CECs on the root canal
preparation outcomes and fracture resistance remains
limited and controversial.
• Moreover, no data regarding the location of root canals and debris
accumulation when performing CECs have been provided. Therefore, the
present study aimed to assess the influence of CECs on root canal
detection, instrumentation efficacy and fracture resistance assessed in
maxillary molars. TECs were used as a reference for comparison. The null
hypothesis tested was that there would be no influence of the type of
endodontic cavity on any of the investigated outcomes.
Materials and Methods
• Sample Size Estimation
– The sample size was estimated based on studies
comparing TECs and CECs , both with 10 teeth per group.
Accordingly, for analysis with a = 0.05 and 80% power, at
least 10 teeth were allocated for each of the following
groups: CEC (experimental) and TEC (control).
Sample Selection
• After ethics approval, 49 human first maxillary molars extracted
for reasons not related to this study with fully formed apices
and intact crowns were preselected using periapical
radiographs. Teeth were selected based on the following
inclusion criteria for chamber and root canal anatomy: similar
general dimensions, length and degree of canal curvature, and
pulp chamber height <2 mm. The sample was stored in a 0.9%
saline solution at 4○C and used within 6 months after extraction.
• To obtain an outline of the root canals, the specimens were
scanned in a micro–computed tomographic device using the
following parameters: 70 kV and 114 mA, isotropic resolution
of 21 mm, 360○ rotation around the vertical axis,X-rays were
filtered with a 1-mm-thick aluminum filter to reduce beam
hardening artifacts.
• Images were reconstructed with NRecon v.1.6.9 software using
30% beam hardening correction and ring artifact correction of 5,
resulting in the acquisition of 900 to 1000 transverse cross
sections per tooth. After reconstruction of the images, the root
canals were then matched to create 15 pairs based on similar
morphologic elements of the canal (number, volume, surface
area, and configuration). One tooth from each pair was randomly
assigned to the CEC or TEC group and accessed accordingly.
• Each group consisted of 12 teeth that presented the second
mesiobuccal (MB2) root canal and 3 teeth that did not present
the MB2 root canal.
TEC
• Endodontic cavities were drilled with high-speed diamond burs
and an Endo Z drill following conventional guidelines already
described in the literature. The roof of the chamber was
removed, and an straight-line access into the coronal third of
the root canal was established.
CEC
• Endodontic cavities were drilled with high-speed diamond
burs. The teeth were accessed at the central fossa and
extended only as necessary to detect canal orifices, preserving
peri- cervical dentin and part of the chamber roof .
Root Canal Detection
• In both groups, canal orifices were detected with an endodontic explorer #6
and size 6, 8, 10, or 15 K-files in 3 stages:
• Stage 1: The detection was performed without the use of magnification
• Stage 2: The detection was performed under magnification (16X ) using an
operating microscope (OM).
• Stage 3: The detection of teeth, in which not all canals (including the MB2
canal) were located with an OM, was performed under magnification as
described in the previous stage and with the aid of ultra-sonic tips . Small wear
(maximum of 2 mm) was performed on the mesial wall of the pulp chamber
following the buccal-palatine direction.
• The root canal that was not found after stage 3 was
considered ‘‘not detected.’’ A single experienced operator,
who did not know the distribution of the specimens between
the groups and did not have prior access to the micro-CT data,
performed the endodontic cavities, root canal detection,
preparation, and filling procedures.
Root Canal Preparation and Filling Procedures
• Root canals were negotiated with a size 10 K-file until its tip
was visualized on the apical foramen, and the working length
was established 1.0 mm shorter. The root canals were
prepared with Reciproc R25 (25/0.08) and R40 (40/0.06)
instruments in buccal and palatal roots, respectively. Instru-
ments were driven with the VDW Silver reciproc endo motor
according to the manufacturer’s instructions.
• Each instrument was used in 1 tooth and then discarded.
Between successive steps, the canals were irrigated with 2 mL
2.5% sodium hypochlorite (NaOCl) with 30-G Endo-Eze needles
inserted up to 2 mm from the apical foramen. Final irrigation
was performed with 5 mL 2.5% NaOCl followed by 5 mL 17%
EDTA (pH = 7.7) for 1 minute followed by 5 mL 2.5% NaOCl.
• Then, the canals were dried with R25 or R40 absorbent
paper point, and the specimens were submitted to a
postoperative scan and reconstruction applying the
aforementioned parameters.
• After that, the sample was filled using a single-cone
technique associated with vertical condensation using AH
Plus sealer and Reciproc R25 and R40 gutta- percha cones in
buccal and palatal roots, respectively.
• Endodontic cavities were filled with 37% phosphoric acid gel ,
rinsed with water, and air dried, and 2 layers of bonding agent
were applied interspersed by a light jet of air and followed by
each cured for 20 seconds. The composite restoration was
applied in increments of at most 2-mm thick and each cured
for 20 seconds. Then, the teeth were stored in a 0.9% saline
solution at 4○C for all stages of this study.
Micro-CT Evaluation
• The image stacks of the specimens after root canal
instrumentation were rendered and coregistered with their
respective preoperative data sets using an affine algorithm of
the 3D Slicer 4.6.2 software .
• The noninstrumented canal area was determined by
calculating the number of static voxels (voxels present in the
same position on the canal surface before and after
instrumentation) and expressed as a percentage of the total
number of voxels present on the canal surface according to
the following formula:
number of static voxels × 100
total number of surface voxels
• The quantification of accumulated hard tissue debris was
expressed as the percentage of the total canal system volume
after preparation for each specimen and undertaken as
described elsewhere. The volume of dentin removed after
preparation was calculated by subtracting pre- and
postoperative segmented root dentin using morphologic
operations.
• Canal transportation and centering ratio were calculated
at 3 cross-sectional levels (3, 5, and 7 mm distance from
the apical end of the root) using the following equations
• Degree of canal transportation =(m1—m2)— (d1—d2)
• Canal centring ratio = (m1—m2)/(d1—d2) or
(d1—d2)/(m1—m2);
• where m1 is the shortest distance from the mesial margin of
the root to the mesial margin of the noninstrumented canal,
m2 is the shortest distance from the mesial margin of the root
to the mesial margin of the instrumented canal, d1 is the
shortest distance from the distal margin of the root to the
distal margin of the noninstrumented canal, and d2 is the
shortest distance from the distal margin of the root to the
distal margin of the instrumented canal.
• Canal transportation equal to 0 means that no transportation
occurred, a negative value means that transportation
occurred in the distal direction, and a positive value indicates
transportation in the mesial direction. The formula adopted
for the centering ability calculation depends on the value
obtained by the enumerator, which should always be lower
than the values obtained by the differences.
• Therefore, values equal to 1 indicated perfect centering ability
of the instrument, whereas values closer to 0 indicated a
reduced ability of the instrument to maintain in the central
axis of the root canal. Analysis of canal transportation and
centering ratio were performed only in the mesiobuccal,
distobuccal, and palatal canals.
Load at Fracture
• The specimens were mounted up to 2 mm apical to
the cementoe- namel junction in a customized
cylinder fabricated with polyester resin and a thin
layer of approximately 0.3-mm- high melting wax ,
simulating the periodontal ligament.
• The fracture resistance was determined by a universal testing
machine . The specimens were loaded at their central fossa at
a 30○ angle from the long axis of the tooth. A continuous
compressive force was applied with a 4-mm spherical
crosshead at 1 mm/min until failure occurred. The load at
fracture was recorded in newtons.
Statistical Analysis
• Root canal detection results were analyzed using the Fisher
exact test. The normal distribution of root canal
instrumentation data and the compression test were
confirmed by the Shapiro-Wilk test (P > .05). The t test was
used to compare the results between the groups. All sta-
tistical procedures were performed with a cutoff for
significance at 5%.
Results
• The detection of root canals in each of the operative stages is
shown in Table 1.
• The degree of homogeneity of the groups was confirmed in
relation to the length, volume, and surface area of the canals
(P > .05).
Discussion
• The root canal system of maxillary first molars, especially the
mesial root, may present several anatomic conformations.
Different studies have reported the incidence of the MB2
canal ranging from 56.8%–96% in maxillary molar.
• Similar to what has been done in previous studies ,a micro-CT
screening of the volume, surface area, and root canal anatomy of
each specimen was performed. Based on these mea- surements, 2
similar teeth were grouped and further allocated in 1 of the 2
groups. A statistical test showed the effective balance between
the groups with respect to the canal volume and surface area,
thus enhancing the internal validity of the study and potentially
eliminating significant anatomic biases that may confound the
outcomes.
• This meticulous care in teeth selection and pair matching of
samples differs from previously published studies that
evaluated CECs using conventional periapical radiographs
during sample selection and group allocation .
• CECs preserve more dental hard tissue; however, it may be
challenging to find, clean, and shape the root canals with such
an access approach. The results of canal location analysis
showed that TECs allowed the location of significantly more
root canals in steps 1 and 2 when compared with CECs.
• After the use of magnification and ultrasonic troughing (stage
3), no differences were observed between the groups (P > .
05). Even after all the stages, it was not possible to locate the
MB2 canal in 2 samples of TECs and in 3 samples of CECs.
Using a similar methodology, Das et al clinically detected the
MB2 canal using TECs in stages 1, 2, and 3 in 36%, 54%, and
72% of the cases, respectively.
• Buhrley et al clinically located the MB2 canal without any
magnification, with the aid of magnifying glasses and with the aid
of an OM in 17.2%, 62.5%, and 71.1% of the cases, respectively.
These data are in accordance with the present results, which
highlight the importance of magnification on root canal treatment.
The detection of MB2 canals without an OM is not as predictable,
which is why the OM is critically needed when treatment is
performed through CECs and very helpful when working through
TECs.
However, it is important to emphasize that only the use of
magnification (stage 2) did not increase root canal detection in
both groups. The present study also showed the importance of
ultrasonic troughing associated with an OM on root canal
detection in maxillary molars when performing CECs. To the best
of the authors’ knowledge, no other study has evaluated the
influence of CECs on root canal location.
• Root canals were prepared using Reciproc R25 and R40 instru-
ments in the buccal and palatal canals, respectively. No
instrument fracture occurred during root canal preparation.
The efficacy of instrumentation was evaluated by means of
high-resolution micro-CT imaging, similar to previous studies.
• This technology allows canal scanning before and after
instrumentation, thus verifying changes in the anatomy of the root
canal, such as the noninstrumented canal area, accumulation of
hard tissue debris and volume of dentin removed. Noninstrumented
canal areas may be colonized by biofilms and serve as a potential
cause of persistent infection, which may compromise the treatment
outcome.
• In the current study, the mean percentage of the
noninstrumented canal area in TECs and CECs was 25.8% and
27.4%, respectively. These results are in accordance with
those obtained by Moore et al, which showed that the
percentage of the noninstrumented canal area was not
affected by the endodontic access cavity design.
• According to Gambill et al , root canal transportation corre-
sponds to a deviation of the prepared canal from its natural
axis (in millimeters) after instrumentation when compared
with pretreatment measurements. Moreover, centering ability
indicates the ability of the instrument to stay centered in the
canal.
• In the present study, canal transportation and centering ability
were performed only on mesiobuccal, distobuccal, and palatal
canals. The rationale to eliminate MB2 canals in this
evaluation was because this canal was not present in all
samples. The palatal canal showed less transportation and
was more centralized in TECs when compared with CECs,
probably because of the straight-line access in the TEC group.
• In accordance with the present results, Krishan et al
observed a negative influence of CECs on the preparation of
the distal canals in lower molars. Moreover, Eaton et al also
verified the deviation of the original canal anatomy in lower
molars prepared with CECs when compared with TECs. In
contrast to the present results, Moore et al did not find
significant differences in the canal transportation and
centering ability between TECs and CECs in upper molars.
• It is important to note that in this previous study thermally
treated instruments with a smaller tip size and taper (20/.06
and 30/.06 in the vestibular and palatal canals, respectively)
were used, whereas Reciproc R25 (25/.08) and R40 (40/.06)
instruments were used herein in the vestibular and palatal
canals, respectively.
• Thermally treated instruments with a smaller tip size and taper have
greater flexibility, which may help to justify these results .Dentin
particles cut from the canal walls by endodontic instruments can be
actively packed into anatomic complexities of the root canal system,
compromising disinfection and hermetic filling and becoming a niche for
future reinfection of the root canal . In the current study, accumulation
of hard tissue debris occurred regardless of the endodontic access cavity
design. The mean volume of hard tissue debris accumulation was 1.3%
and 0.9% for TECs and CECs, respectively.
• It was previously established that the use of different root
canal instrumentation systems results in the packing of hard
tissues debris . However, this is the first study to assess the
influence of the endodontic access cavity design on the
accumulation of hard tissue debris through a nondestructive
methodology.
• Before the fracture resistance test, the root canals were filled,
and restorations of endodontic accesses with composite resin
were performed, reproducing the usual clinical procedures.
Then, the specimens were submitted to the compression test
with a load in the central fossa at a 30○ angle from the long
axis of the tooth, simulating the occlusal contact of the dental
elements.
• The present results showed no differences among the 2 tested
endodontic access cavity designs .These results corroborate
with the findings of Moore et al,which showed no differences
in the resistance to fracture of maxillary molars accessed with
TECs and CECs .
• Krishan et al found greater resistance to fracture in premolars
and lower molars with CECs when compared with teeth with
TECs; how- ever, it is important to emphasize that the
compression test was performed without restoration of the
teeth, which may have affected the obtained results, once it
did not faithfully reproduce the clinical situation.
cross references
 conclusion
The current results did not show benefits associated with CECs.
This access modality in maxillary molars resulted in less root
canal detection when no ultrasonic troughing associated to an
OM was used and did not increase fracture resistance.
Thank You