doi:10.1111/iej.

13219

Does ultraconservative access affect the efficacy

of root canal treatment and the fracture resistance
of two-rooted maxillary premolars?

A. A. Silva1, F. G. Belladonna2 , G. Rover3, R. T. Lopes4, E. J. L. Moreira1, G. De-Deus2

& E. J. N. L. Silva1,2
1
Department of Endodontics, Grande Rio University, Duque de Caxias, Rio de Janeiro; 2Department of Endodontics, Fluminense
oi, Rio de Janeiro; 3Department of Dentistry, Federal University of Santa Catarina, Florian

Federal University, Niter
opolis, Santa
Catarina; and 4Nuclear Engineering Program, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil

Abstract were analysed statistically using Shapiro–Wilk and

Silva AA, Belladonna FG, Rover G, Lopes RT,
Moreira EJL, De-Deus G, Silva EJNL. Does
ultraconservative access affect the efficacy of root canal
treatment and the fracture resistance of two-rooted maxillary
premolars? International Endodontic Journal, 53, 265–275, 2020.
Aim To evaluate the influence of ultraconservative
endodontic cavities (UEC) on canal shaping and filling
ability, cleaning of the pulp chamber, time required to
perform root canal treatment and fracture resistance of 2-
rooted maxillary premolars in comparison with tradi-
tional endodontic access cavities (TEC) in extracted teeth
placed in a phantom head to simulate clinical conditions.
Methodology Twenty extracted intact 2-rooted
maxillary premolars were scanned in a micro-com-
puted tomographic device, matched based on similar
anatomical features of the canals and assigned to UEC
or TEC groups (n = 10). Then, teeth were mounted on
a mannequin head and their pulp chamber accessed.
After canal preparation, filling and cavity restoration,
the time required to perform root canal treatment was
recorded and the specimens were loaded to fracture in
a universal testing machine. The maximum load at
fracture was recorded. The sample was scanned after
root canal instrumentation, filling and restoration pro-
cedures. Untouched canal areas, accumulation of
hard-tissue debris (AHTD), voids in root fillings and
cleaning of the pulp chamber were analysed. Data
Student’s t-tests with a significance level of 5%.
Results The percentage of untouched canal area did not
differ significantly between UEC and TEC groups
(P > 0.05). However, UECs were associated with a greater
percentage of AHTD after canal preparation (P < 0.05).
No differences were observed in terms of voids in root fill-
ings between the groups (P > 0.05). Nonetheless, UEC had
a greater percentage of root filling remnants in the pulp
chamber after cleaning procedures (P < 0.05). The time
required to perform root canal treatment was significantly
longer in the UEC group (P < 0.05). There was no differ-
ence regarding the mean load at fracture between the
groups (P > 0.05). Unrestorable fractures were observed
in all specimens of both groups.
Conclusions There was no true benefit associated
with ultraconservative endodontic cavities. UEC
resulted in more AHTD remaining inside the root
canals. UEC did not influence the quality of root fillings;
however, UEC made the cleaning procedure of the pulp
chamber more difficult, thus increasing the total time
required to perform root canal treatment. Moreover,
UEC were not associated with an increase in fracture
resistance of root filled 2-rooted maxillary premolars.
Keywords: fracture resistance, maxillary premo-
lars, micro-CT, root canal treatment, ultraconserva-
tive endodontic cavity.
Received 6 June 2019; accepted 9 September 2019

Correspondence: Emmanuel Jo~ ao Nogueira Leal da Silva, Rua Herotides de Oliveira, 61/902, Icara
ı, Niter

oi, RJ 24220-000,
Brazil (e-mail: nogueiraemmanuel@hotmail.com).

© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 53, 265–275, 2020 265
 Impact of ultraconservative endodontic cavities Silva et al.
Introduction
An adequate endodontic access cavity is a key step to
achieve proper cleaning, shaping and filling of all root
canals within a tooth (Siqueira & R^oßcas 2008, Moore
et al. 2016, Rover et al. 2017). Recently inspired by
the minimally invasive dentistry concept, several
designs of endodontic access cavities have been pro-
posed to minimize tooth structure loss and thus theo-
retically increase mechanical stability and fracture
resistance of root filled teeth (Clark & Khademi 2010a,
b). First, diverging from general basic principles of tra-
ditional straight-line endodontic access cavities, conser-
vative endodontic access cavities (CEC) have been
suggested to maximize the preservation of the pulp
chamber roof (Clark & Khademi 2010a,b). Then, over-
estimating the CEC concept, there came the so-called
ultraconservative endodontic access cavities (UEC), also
popularly known as “ninja” access (Plotino et al.
2017), and truss-access or orifice-directed design cavi-
ties (Neelakantan et al. 2018). UEC consist of small
access openings achieved using small calibre burs (Plo-
tino et al. 2017), while the truss-access cavity pre-
serves a dentine truss between separate individual
cavities in multirooted teeth (Neelakantan et al. 2018).
Unquestionably, these new conservative accesses
modalities are significantly more technically, demand-
ing than their conventional access counterparts.
Moreover, they make canal detection, cleaning and
shaping procedures more challenging and, last but
not least, they increase the risks of iatrogenic compli-
cations (Rover et al. 2017, Alovisi et al. 2018, Nee-
lakantan et al. 2018, Saygili et al. 2018). Within this
context, few studies have been conducted to deter-
mine whether such conservative access approaches
impact on the outcomes of root canal treatment and
fracture resistance of root filled teeth (Krishan et al.
2014, Moore et al. 2016, Chlup et al. 2017, Ivanoff
et al. 2017, Plotino et al. 2017, Rover et al. 2017,
Corsentino et al. 2018, Marchesan et al. 2018, Nee-
lakantan et al. 2018, Ozy€ € urek et al. 2018, Sabeti
et al. 2018). However, a recently published systematic
review concluded that fracture resistance, root canal
preparation and root canal filling outcomes are lim-
ited and controversial (Silva et al. 2018). Moreover,
all previous studies used stored teeth without simula-
tion of the clinical setting (Krishan et al. 2014, Moore
et al. 2016, Chlup et al. 2017, Ivanoff et al. 2017,
Plotino et al. 2017, Rover et al. 2017, Corsentino
€ urek et al. 2018, Sabeti et al. 2018).
et al. 2018, Ozy€
266 International Endodontic Journal, 53, 265–275, 2020
Also, these studies did not investigate the impact that
UEC may have on filling ability of the root canals or
on the capacity of removing root fillings from the
pulp chamber prior to tooth restoration.
The aim of the present study was to assess the
impact of UEC during root canal treatment performed
on 2-rooted maxillary premolars on several outcome
parameters: canal shaping and filling ability, and
cleaning of the pulp chamber. In addition, the time
required to perform the treatment was recorded and
fracture resistance assessed. Traditional endodontic
cavities were used as a reference technique for com-
parison. The null hypothesis tested was that there
would be no differences between the two types of
endodontic access cavities on any of the investigated
outcomes.
Materials and methods
Sample size calculation
A Wilcoxon–Mann–Whitney test was selected from
the t-tests family in G*Power 3.1 software for Win-
dows (Heinrich Heine-Universit€ at, D€ usseldorf, Ger-
many). Based on data from a previous study (Krishan
et al. 2014), the effect size for the study was estab-
lished (=2.63). 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 12 samples (six per group) were
indicated as the ideal size required for observing signif-
icant differences. Ten samples per group were used.
Specimen selection and grouping
After the approval of a local ethics committee (proto-
col n. 1.559.163), a total of 52 extracted sound,
intact, mature human 2-rooted maxillary premolars
were included. These teeth were stored in 0.9% saline
solution at 4 °C for a maximum of 6 months. Teeth
were initially selected based on similar length and
degree of canal curvature, and pulp chamber
height < 2 mm. Then, the specimens were scanned in
a micro-CT device (Sky-Scan 1173; Bruker microCT,
Kontich, Belgium) using the following parameters:
70 kV and 114 mA, isotropic resolution of
22.08 lm, 360° rotation, rotation step of 0.5, frame
averaging of 5, camera exposure time of 250 ms and
1-mm-thick aluminium filter. Images were recon-
structed with NRecon v.1.6.9 software (Bruker
microCT) using 25% beam hardening correction and
© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd

ring artefact correction of 5, resulting in the acquisi-
tion of 900 to 1000 axial cross sections per sample.
After reconstruction procedures, the specimens
were matched to create 10 pairs of teeth having simi-
lar morphologic elements of the canal (volume, sur-
face area and three-dimensional [3D] configuration)
(Fig. 1). One tooth from each pair was randomly
assigned to UEC or TEC groups.
A single operator (A. A. S.) with 25 years of experi-
ence in Endodontics, who did not have prior access to
the micro-CT data, prepared the endodontic access
cavities, root canal detection, canal preparation, filling
and restoration procedures. Prior to the procedures,
each tooth was mounted on a mannequin in a maxil-
lary jaw to simulate clinical condition (Manequim
Odontol
ogico; Mar
ılia, S~ao Paulo, Brazil) (Fig. 2).
Then, teeth were accessed under magnification (16X)
using an operating microscope (DF Vasconcellos;
Valenca, Rio de Janeiro, Brazil) as follows:
UEC group. Endodontic access cavities were pre-
pared with a diamond bur (1012HL; KG Sorensen,
S~ao Paulo, Brazil) mounted on a high-speed
Figure 1 3D models of 2 pairs of teeth ([a] and [b] are pair as well as [c] and [d]) having similar morphologic elements of the
root canals.
© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd
Silva et al. Impact of ultraconservative endodontic cavities
handpiece with water cooling. All teeth were accessed
at the central fossa and extended only apically, main-
taining a considerable part of the pulp chamber roof
and lingual shelf (Plotino et al. 2017) (Fig. 3a).
TEC group. Endodontic access cavities were prepared
with a diamond bur (1012HL) and an Endo Z drill
(Dentsply Sirona Endodontics, Ballaigues, Switzerland)
mounted on a high-speed handpiece with water cool-
ing following conventional guidelines (Ingle 1985,
Schroeder et al. 2002). The roof of the pulp chamber
was removed, and an unimpeded (straight-line) access
into the coronal third of the root canal was estab-
lished (Fig. 3b).
Root canal procedures
In both groups, root canal orifices were detected with
an endodontic explorer n. 6 (Golgran, S~ao Caetano do
Sul, Brazil) and a size 10 K-file (Dentsply Sirona
Endodontics). When needed, ultrasonic tips (TRA12
and TRA 24D tips; Trinks, S~ ao Paulo, Brazil) were
used to aid root canal detection.
International Endodontic Journal, 53, 265–275, 2020 267
 Impact of ultraconservative endodontic cavities Silva et al.
Figure 2 Mannequin used to simulate clinical conditions.
The mannequin set-up allowed connection to an
apex locator (Root ZX; J Morita USA Inc, Irvine, CA,
USA) to enable the electronic measurement of the
working length (WL), which was established 1.0 mm
short of the apical foramen. A glide path was per-
formed with a size 15 K-file (Dentsply Sirona
Endodontics). All root canals (buccal and palatal)
were instrumented with Reciproc Blue R25 (tip 25
and 0.08v taper) instruments (VDW, Munich, Ger-
many). Briefly, the instrument was moved in the api-
cal direction using a slow in-and-out pecking motion
of about 3 mm amplitude with light apical pressure
in a reciprocating motion (‘RECIPROC ALL’) powered
by an electric motor (VDW Silver; VDW) until the WL
was reached. After 3 pecking motions, the instrument
was removed from the canal and cleaned. The WL
was reached after three waves of instrumentation for
268 International Endodontic Journal, 53, 265–275, 2020
all canals. Each instrument was used in one tooth
and discarded.
Root canal irrigation was performed with 2 mL 2.5%
sodium hypochlorite (NaOCl) with a 30-G Endo-Eze nee-
dle (Ultradent Products Inc; South Jordan, UT, USA)
inserted up to 2 mm from the WL between each instru-
ment insertion. Final irrigation was performed with
5 mL 2.5% NaOCl followed by 5 mL 17% EDTA for
1 min followed by 5 mL 2.5% NaOCl. Then, the canals
were dried with Reciproc Blue R25 paper points (VDW).
The specimens were filled with Reciproc Blue R25
gutta-percha cones (VDW) and AH Plus sealer (Dents-
ply De Trey, Konstanz, Germany) using a single-cone
technique associated with the use of a McSpadden size
3 instrument (Dentsply Sirona Endodontics). The
cleaning of the pulp chamber was performed in the
same way for both groups. For this, remnants of root
fillings were removed with the aid of a n. 6 endodon-
tic explorer followed by the use of ultrasonic tips
(TRA12 and TRA 24D tips) with 20 mL of saline
solution. Then, a cotton pellet with 70% alcohol was
used against root canal walls aiming to remove
remaining root canal sealer.
The endodontic access cavities were filled with 37%
phosphoric acid gel (Condac 37; FGM, Joinville, Brazil),
rinsed with water, air-dried, and 2 layers of bonding
agent (Adper Single Bond 2; 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, Aus-
tralia). A composite material (Filtek Z350 XT; 3M
ESPE, Sumar
e, S~ ao Paulo, Brazil) was applied in incre-
ments of at most 2 mm thick and each cured for 20 s.
The time required to perform the procedures was
recorded. This analysis was divided in two parts: first,
the time required to access and prepare the root
canals was registered; then, the time required to fill
the root canals and clean the pulp chamber was also
recorded. Each tooth was stored in a 0.9% saline
solution at 4 °C from the time of sample selection to
the fracture resistance test. The sample was scanned
and reconstructed after root canal instrumentation,
filling and restoration procedures using the aforemen-
tioned parameters.
Micro-CT assessment
Pre- and postoperative models of the canals after
preparation and filling were rendered and coregistered
with their respective preoperative data sets using an
affine algorithm of the 3D Slicer 4.10.1 software
(Fedorov et al. 2012). The outcomes evaluated were
© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd

Figure 3 Representative 3D models of access cavities performed in 2 pairs of teeth ([a] and [b] are pair as well as [c] and [d]).
UEC were performed in (a) and (c), while TEC were performed in (b) and (d).
shaping and filling quality, and also the cleaning of
the pulp chamber. The shaping ability was measured
based on the percentage of untouched canal area and
the quantification of accumulated hard-tissue debris
(AHTD). According to De-Deus et al. (2015a), the
untouched canal area was calculated based on the
number of static voxels (voxels present in the exact
same position on the canal surface before and after
instrumentation). Then, it was expressed in percent-
age following the formula:
number of static voxels  100
total number of surface voxels
AHTD was calculated as the percentage volume of
the original canal anatomy after intersecting the
stacks of sound and instrumented root canal space
(De-Deus et al. 2015b, Neves et al. 2015), where
material with density similar to dentine inside instru-
mented canal regions, which were previously occu-
pied by air, was considered debris (Paqu
e et al. 2009).
The root filling quality was evaluated based on the
quality of root fillings, which was assessed by analys-
ing the presence of voids (mm3) inside the root canal
filling (gutta-percha and sealer) and also between the
root filling and dentine. Segmentation (binarization)
of root fillings and voids were achieved based on the
grey scale range required to recognize each object
© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd
Silva et al. Impact of ultraconservative endodontic cavities
under study. Then, the percentages of voids and also
root filling remnants present in the pulp chamber
were quantified.
Load at fracture
Prior to the resistance test, simulation of the peri-
odontal ligament and alveolar bone was performed
with high fusion wax (Galileo; Talladium Inc, Valen-
cia, CA, USA) and self-curing resin (JET; Campo
Limpo Paulista, Brazil), as described previously (Rover
et al. 2017). The specimens were fixed in a 30° incli-
nation device coupled to the bottom of the universal
testing machine (EMIC DL2000; EMIC, S~ ao Jos
e dos
Pinhais, Brazil) (Rover et al. 2017), and then received
a load in the central fossa with 30° inclination in
relation to the long axis of the tooth, simulating the
occlusal contact of the dental elements. A continuous
compressive force was applied with a 4-mm spherical
crosshead at 1 mm min 1 until failure occurred. The
load at fracture was recorded in Newtons (N) (Dast-
jerdi et al. 2015).
Statistical analysis
The normal distribution of micro-CT data and the
compression test results were confirmed by the
International Endodontic Journal, 53, 265–275, 2020 269
 Impact of ultraconservative endodontic cavities Silva et al.
Figure 4 3D models of pair-matched teeth of each group after endodontic procedures. Representative images of sound canal
(a), after canal preparation (b) and filling (c) in the UEC group. Representative images of sound canal (d), after canal prepara-
tion (e) and filling (f) in the TEC group.
Shapiro–Wilk test (P > 0.05). The t-test was used to
compare the results between the groups. All statistical
procedures were performed with a cut-off for signifi-
cance at 5%.
Results
The degree of homogeneity of the groups was con-
firmed with regards to length, volume and surface
area of the sound root canals (P > 0.05) (Fig. 1).
There was no significant difference between the per-
centage of untouched canal area (P > 0.05) (Fig. 4).
However, UEC had a significantly greater percentage
of AHTD after canal preparation when compared to
TEC (P < 0.05) (Fig. 5). These results are summarized
in Table 1.
270 International Endodontic Journal, 53, 265–275, 2020
No differences were observed with regards to voids
found in root fillings between the groups (P > 0.05).
Nonetheless, UEC had a significantly greater percent-
age of root filling remnants in the pulp chamber
after cleaning procedures (P < 0.05) (Fig. 6 and
Table 1).
There were no significant differences in the time
required to access and prepare the root canals
between the two access preparations (UEC:
47  10 min; TEC: 40  13 min) (P > 0.05). How-
ever, UEC required a significantly longer time to fill
the root canals and clean the pulp chamber (UEC:
37  8 min; TEC: 30  5 min) (P < 0.05). In addi-
tion, the total time required to perform the root canal
treatment was longer in the UEC group (UEC:
84  13 min; TEC: 70  15 min) (P < 0.05).
© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd

Figure 5 Representative cross-sectional images of 2 pairs of teeth ([a] and [b] are pair as well as [c] and [d]) showing the pres-
ence of debris (white arrows) in the UEC group.
The mean load at failure values for UEC and TEC
groups were 556  154 N and 600  281 N,
respectively, which was not significantly different
(P > 0.05).
Discussion
Considering the intrinsic heterogeneity of root canal
anatomy, which is a known bias for comparative stud-
ies, several efforts were made to ensure comparability
of samples regarding root canal anatomy. For this, a
pre-screening of the specimens based on anatomical
and morphological configuration (volume, surface area
and 3D configuration) using the micro-CT technology
allowed excellent pairing of samples. As a result, the
statistical analysis revealed an adequate balance
between the pairs in terms of root canal length, vol-
ume and surface area (Fig. 1 and Table 1). This pair-
ing process increases the validity of the present study
and substantially reduces anatomical biases that could
induce erroneous results. Moreover, given the greater
accuracy and spatial resolution associated with its
nondestructive nature, micro-CT imaging technology
was used to analyse root canal preparation and filling
procedures, and the cleaning of the pulp chamber. This
technique provides insight into the details of 3D images
of root fillings at a level that is impossible to achieve
with other methods (Kierklo et al. 2015).
All operational procedures were performed under
simulated clinical conditions using a dental
© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd
Silva et al. Impact of ultraconservative endodontic cavities
mannequin in an ergonomic working position.
Besides, endodontic and restorative procedures were
also performed under rubber dam isolation using an
operating microscope, ultrasonic tips and an elec-
tronic apex locator. This is the first time that this
experimental model was used in minimally invasive
access cavities studies. Using this model, a greater
degree of difficulty was created for the execution of
the root canal treatment steps and, at the same time,
it was possible to obtain greater trustworthiness of
the clinical conditions that were being simulated.
The evaluation of untouched canal walls is an
important outcome parameter that reveals technical
deficiencies of current mechanical canal preparation.
The first result of the present study revealed that the
type of access did not influence the shaping outcome
as the percentage of untouched canal walls was simi-
lar. This result is in line with the findings of Moore
et al. (2016) and Rover et al. (2017). However, it is
important to emphasize that previous studies demon-
strated significantly more canal transportation in CEC
when compared to TEC, even when using M-Wire
(Rover et al. 2017) or controlled-memory instruments
(Alovisi et al. 2018).
In the current study, the percentage of AHTD was
significantly greater in UEC (P < 0.05). Therefore, the
null hypothesis tested was partially rejected. This
result contrasts with the findings of Rover et al.
(2017) in maxillary molars. These discrepancies
might be explained by the use of different tooth
International Endodontic Journal, 53, 265–275, 2020 271
 Impact of ultraconservative endodontic cavities Silva et al.

groups, differences in the instrumentation protocol, as

resistance (N)

Equal superscript letters in the same column represent absence of significant differences between the different types of access cavities (P > 0.05). Values presented in mean  stan-
Fracture
well as in the size of the access cavities created. It is

Table 1 Parameters of sound and prepared canals, percentages of untouched canal area and accumulated hard-tissue debris (AHTD), presence of voids after root fillings and

556  154
600  281
possible that UEC prepared in this study did not allow

volume of root filling remnants in the pulp chamber in teeth having ultraconservative endodontic access cavities (UEC) and traditional endodontic access cavities (TEC)
a proper flow of irrigants inside the root canals, thus
preventing close-to-optimal debris removal. From a

Root filling remnants in the

clinical point of view, AHTD has been considered an

pulp chamber (mm3)

undesirable side effect of canal shaping as it can pro-
tect bacterial contents from disinfection procedures
(Paqu
e et al. 2009). Moreover, it interferes with filling

0.006  0.007A
0.002  0.003B
procedures, blocking the filling materials flowing
where AHTD remains (Endal et al. 2011). Thus, the
present micro-CT results revealed that UEC cannot be
regarded as an effective strategy for anti-debris accu-
mulation.
0.002  0.002A
0.001  0.001A
The tip size used for apical preparation is a major
Filling voids

concern. Several studies have shown the benefits of

(%)

large apical preparations, which increase the chances

for the instrument to touch more of the root canal
walls, promote more effective irrigation in the apical
1.4  2.2A
3.2  3.1B
AHTD (%)

third of the canal, and thus improve infection control

(De-Deus et al. 2015b, Rodrigues et al. 2017, P
erez
et al. 2018). Clinically, large apical preparations can
improve the treatment outcome of teeth with infected
canal area (%)
Untouched

18.7  12.9A
13.2  11.2A

canals and apical periodontitis (Saini et al. 2012).

However, root canal preparation should not remove
dentine excessively as it might endanger root integrity
and potentially increase the risk of fracture (Kishen
2006). In the present study, Reciproc Blue R25
Prepared canal
area (mm2)

instruments were used, according to the manufactur-

112  10A
115  13A

ers’ instructions. In fact, commercial kits with pre-

established apical size of preparation might not take
into account the individual variability in tooth anat-
omy. Therefore, future studies should be performed
Sound canal
area (mm2)

evaluating the influence of large apical preparations

95.5  18.8A
93.6  15.2A

in teeth prepared with different access cavities.

When comparing the percentages of voids observed
after root canal filling, no significant difference was
observed between the groups (P > 0.05). Despite tech-
Prepared canal
volume (mm3)

nical difficulties, UEC did not jeopardize the filling pro-

cedure. However, it is important to point out that 2-
20.4  3.5A
24.5  6.2A

rooted maxillary premolars usually have a circular

canal shape (Ahmad & Alenezi 2016), thereby facili-
tating filling procedures. Future studies should be per-
formed using oval-shaped canals to confirm if the
volume (mm3)
Sound canal

overall root filling quality is not compromised by UEC.

14.8  5.5A
14.6  5.1A

One important finding of this study was that teeth

treated with UEC had a greater amount of root filling
dard deviation.

remnants in the pulp chamber after cleaning proce-

dures (P < 0.05). This result is related to the well-
Groups

known difficulty of cleaning the pulp chamber

UEC
TEC

through a small coronal access. The presence of root

272 International Endodontic Journal, 53, 265–275, 2020 © 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd

Figure 6 3D models highlighting the presence of root filling remnants in the pulp chamber after cleaning procedures in UEC
(a and c) and TEC (b and d) groups.
fillings in the pulp chamber may lead to a chromatic
alteration of the crown, creating an undesirable aes-
thetic side effect (Lenherr et al. 2012). However, it is
worthwhile mentioning that root filling remnants
were observed even in TEC, which emphasizes the
need for better pulp chamber cleaning strategies.
The operative time required for root canal access
and instrumentation procedures was not different
between the two access cavities (P > 0.05). However,
the UEC were associated with a significantly longer
time to perform root canal filling and cleaning of the
pulp chamber (P < 0.05), which directly contributed
to differences in the total time required to perform the
treatment (P < 0.05). This difference in operative time
can be explained by difficulties that UEC have in dif-
ferent stages of root canal treatment, especially during
filling procedures, which have to be performed indi-
vidually for each root canal, and cleaning of the pulp
© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd
Silva et al. Impact of ultraconservative endodontic cavities
chamber. Total treatment time should be taken into
account when choosing an access modality, since a
long operative time may result in fatigue and stress
on both patient and dentist. In addition, quality of life
studies and patient satisfaction ratings revealed that
they prefer shorter than long-term care, assuming
that they are equally well performed (Dugas et al.
2002, Hamasha & Hatiwsh 2013).
CEC were initially proposed based on the premise of
increasing fracture resistance of root filled teeth (Clark
& Khademi 2010a,b). In fact, the first published study
comparing CEC and TEC concluded that the mean
load to fracture premolars and molars was signifi-
cantly higher with CEC (Krishan et al. 2014). This
result might have encouraged a widespread dissemi-
nation of such access cavities. However, in this first
publication (Krishan et al. 2014), a coronal restora-
tion was not placed, which may be considered a flaw,
International Endodontic Journal, 53, 265–275, 2020 273
 Impact of ultraconservative endodontic cavities Silva et al.
as restoration of endodontic access cavities, when well
performed, is able to rebalance the fracture resistance
(Xie et al. 2012). The fracture resistance results of
this study failed to identify significant differences
between the groups (P > 0.05), which is in agree-
ment with almost all published studies on this topic
(Moore et al. 2016, Chlup et al. 2017, Ivanoff et al.
2017, Rover et al. 2017, Corsentino et al. 2018,
€ urek et al. 2018, Sabeti et al. 2018). This outcome
Ozy€
might be explained by an interplay of two factors: (i)
the restoration of endodontic access cavities, which
reestablishes the fracture resistance of root filled teeth
(Xie et al. 2012); and (ii) the absence of marginal
ridge involvement, which does not reduce fracture
resistance of root filled teeth (Soares et al. 2008a,b).
However, even in studies that the marginal ridge was
involved, no differences in fracture resistance of the
specimens were observed regardless of the access type
€ urek et al. 2018). Also, a
(Corsentino et al. 2018, Ozy€
recent systematic review demonstrated that there is
no evidence that supports the use of CEC over TEC to
increase fracture resistance in human teeth (Silva
et al. 2018). Therefore, considering the available liter-
ature, it seems that reduced conservative access cav-
ity are unable to increase the fracture resistance of
root filled teeth, yet have negative impacts on root
canal treatment.
Conclusions
There was no benefit associated with ultraconserva-
tive endodontic access. This access cavity resulted in
more accumulated hard-tissue debris inside the root
canals. UEC did not influence the filling quality.
However, ultraconservative endodontic access made
the cleaning procedure of the pulp chamber more
difficult, thus increasing the total time required to
perform root canal treatment. Moreover, ultraconser-
vative endodontic access did not increase the frac-
ture resistance of root filled 2-rooted maxillary
premolars.
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.
274 International Endodontic Journal, 53, 265–275, 2020
References
Ahmad I, Alenezi MA (2016) Root and root canal morphol-
ogy of maxillary first premolars: a literature review and
clinical considerations. Journal of Endodontics 42, 861–72.
Alovisi M, Pasqualini D, Musso E et al. (2018) Influence of
contracted endodontic access on root canal geometry: an
in vitro study. Journal of Endodontics 44, 614–20.
 zka R, Kania J, Pribyl M (2017) Fracture beha-
Chlup Z, Zi
viour of teeth with conventional and mini-invasive access
cavity designs. Journal of the European Ceramic Society 37,
4423–9.
Clark D, Khademi JA (2010a) Case studies in modern molar
endodontic access and directed dentin conservation. Dental
Clinics North America 54, 275–89.
Clark D, Khademi J (2010b) Modern molar endodontic
access and directed dentin conservation. Dental Clinics
North America 54, 249–73.
Corsentino G, Pedull a E, Castelli L et al. (2018) Influence of
access cavity preparation and remaining tooth substance
on fracture strength of endodontically treated teeth. Jour-
nal of Endodontics 44, 1416–21.
Dastjerdi MR, Chaijan KA, Tavanafar S (2015) Fracture
resistance of upper central incisors restored with different
posts and cores. Restorative Dentistry & Endodontics 40,
229–35.
De-Deus G, Belladonna FG, Silva EJ et al. (2015a) Micro-ct
evaluation of non-instrumented canal areas with different
enlargements performed by niti systems. Brazilian Dental
Journal 26, 624–9.
De-Deus G, Marins J, Silva EJ et al. (2015b) Accumulated
hard tissue debris produced during reciprocating and
rotary nickel-titanium canal preparation. Journal of
Endodontics 41, 676–81.
Dugas NN, Lawrence HP, Teplitsky P, Friedman S (2002)
Quality of life and satisfaction outcomes of endodontic
treatment. Journal of Endodontics 28, 819–27.
Endal U, Shen Y, Knut A, Gao Y, Haapasalo M (2011) A
high-resolution computed tomographic study of changes
in root canal isthmus area by instrumentation and root
filling. Journal of Endodontics 37, 223–7.
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.
Hamasha AA, Hatiwsh A (2013) Quality of life and satisfac-
tion of patients after nonsurgical primary root canal treat-
ment provided by undergraduate students, graduate
students and endodontic specialists. International Endodon-
tic Journal 46, 1131–9.
Ingle JI (1985) Endodontic cavity preparation. In: Ingle J,
Tamber J, eds. Endodontics, 3rd edn. Philadelphia, PA: Lea
& Febiger, pp. 102–67.
Ivanoff CS, Marchesan MA, Andonov B et al. (2017) Frac-
ture resistance of mandibular premolars with contracted
© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd

or traditional endodontic access cavities and class II tem-
porary composite restorations. Endodontic Practice Today
11, 7–14.
Kierklo A, Tabor Z, Pawi
nska M, Jaworskaa M (2015) A
microcomputed tomography-based comparison of root
canal filling quality following different instrumentation
and obturation techniques. Medical Principles and Practice
24, 84–91.
Kishen A (2006) Mechanisms and risk factors for fracture
predilection in endodontically treated teeth. Endodontic
Topics 13, 57–83.
Krishan R, Paqu
e F, Ossareh A, Kishen A, Dao T, Friedman
S (2014) Impacts of conservative endodontic cavity on
root canal instrumentation efficacy and resistance to frac-
ture assessed in incisors, premolars, and molars. Journal of
Endodontics 40, 1160–6.
Lenherr P, Allgayer N, Weiger R, Filippi A, Attin T, Krastl G
(2012) Tooth discoloration induced by endodontic materi-
als: a laboratory study. International Endodontic Journal 45,
942–9.
Marchesan MA, James CM, Lloyd A, Morrow BR, Garc
ıa-
Godoy F (2018) Effect of access design on intracoronal
bleaching of endodontically treated teeth: An ex vivo study.
Journal of Esthetic and Restorative Dentistry 30, E61–E67.
Moore B, Verdelis K, Kishen A, Dao T, Friedman S (2016)
Impacts of contracted endodontic cavities oninstrumenta-
tion efficacy and biomechanical responses in maxillary
molars. Journal of Endodontics 42, 1779–83.
Neelakantan P, Khan K, Hei Ng GP, Yip CY, Zhang C, Pan
Cheung GS (2018) Does the orifice-directed dentin conser-
vation access design debride pulp chamber and mesial root
canal systems of mandibular molars similar to a tradi-
tional access design. Journal of Endodontics 44, 274–9.
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.
€ urek T, Ulker
Ozy€ € € Demiry€
O, urek EO,€ 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.
Paqu
e F, Laib A, Gautschi H, Zehnder M (2009) Hard-tissue
debris accumulation analysis by high-resolution computed
tomography scans. Journal of Endodontics 35, 1044–7.
P
erez AR, Alves FRF, Marceliano-Alves MF et al. (2018)
Effects of increased apical enlargement on the amount of
unprepared a
reas and coronal dentine removal: a micro-
computed tomography study. International Endodontic Jour-
nal 51, 684–90.
© 2019 International Endodontic Journal. Published by John Wiley & Sons Ltd
Silva et al. Impact of ultraconservative endodontic cavities
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.
Rodrigues RCV, Zandi H, Kristoffersen AK et al. (2017) Influ-
ence of the Apical Preparation Size and the Irrigant Type
on Bacterial Reduction in Root Canal-treated Teeth with
Apical Periodontitis. Journal of Endodontics 43, 1058–63.
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 43, 1657–62.
Sabeti M, Kazem M, Dianat O et al. (2018) Impact of Access
Cavity Design and Root Canal Taper on Fracture Resis-
tance of Endodontically Treated Teeth: An Ex Vivo Investi-
gation. Journal of Endodontics 44, 1402–6.
Saini HR, Tewari S, Sangwan P, Duhan J, Gupta A (2012)
Effect of different apical preparation sizes on outcome of
primary endodontic treatment: a randomized controlled
trial. Journal of Endodontics 38, 1309–15.
Saygili G, Uysal B, Omar B, Ertas ET, Ertas H (2018) Evalua-
tion of relationship between endodontic access cavity types
and secondary mesiobuccal canal detection. BMC Oral
Health 18, 121.
Schroeder KP, Walton RE, Rivera EM (2002) Straight line
access and coronal flaring: effect on canal length. Journal
of Endodontics 28, 474–6.
Silva EJNL, Rover G, Belladonna FG, De-Deus G, Teixeira CS,
Fidalgo TKS (2018) Impact of contracted endodontic cavi-
ties on fracture resistance of endodontically treated teeth:
a systematic review of in vitro studies. Clinical Oral Investi-
gation 22, 109–18.
Siqueira JF Jr, R^oßcas IN (2008) Clinical implications and
microbiology of bacterial persistence after treatment proce-
dures. Journal of Endodontics 34, 1291–1301.
Soares PV, Santos-Filho PC, Gomide HA, Araujo CA, Martins
LR, Soares CJ (2008a) Influence of restorative technique
on the biomechanical behavior of endodontically treated
maxillary premolars. Part II: strain measurement and
stress distribution. The journal of Prosthetic Dentistry 99,
114–22.
Soares PV, Santos-Filho PCF, Queiroz EC et al. (2008b) Frac-
ture resistance and stress distribution in endodontically
treated maxillary premolars restored with composite resin.
Journal of Prosthodontics 17, 114–9.
Xie KX, Wang XY, Gao XJ, Yuan CY, Li JX, Chu CH (2012)
Fracture resistance of root filled premolar teeth restored
with direct composite resin with or without cusp coverage.
International Endodontic Journal 45, 524–9.
International Endodontic Journal, 53, 265–275, 2020 275