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Influence of Access Cavity Design on Root Canal Detection, Instrumentation

Efficacy, and Fracture Resistance Assessed in Maxillary Molars

Article  in  Journal of endodontics · July 2017

DOI: 10.1016/j.joen.2017.05.006

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Influence of Access Cavity Design on Root Canal
Detection, Instrumentation Efficacy, and Fracture
Resistance Assessed in Maxillary Molars
Gabriela Rover, DDS, MSc,* Felipe Gonçalves Belladonna, DDS, MSc,†
Eduardo Antunes Bortoluzzi, DDS, MSc, PhD,* Gustavo De-Deus, DDS, MSc, PhD,†
Emmanuel Jo~ ao Nogueira Leal Silva, DDS, MSc, PhD,‡§
and Cleonice Silveira Teixeira, DDS, MSc, PhD*
Abstract
Introduction: The aim of this study was to assess the
influence of contracted endodontic cavities (CECs) on
root canal detection, instrumentation efficacy, and frac-
ture resistance assessed in maxillary molars. Traditional
endodontic cavities (TECs) were used as a reference for
comparison. Methods: Thirty extracted intact maxillary
first molars were scanned with micro–computed tomo-
graphic imaging at a resolution of 21 mm, assigned to
the CEC or TEC group (n = 15/group), and accessed
accordingly. Root canal detection was performed in 3
stages: (1) no magnification, (2) under an operating
microscope (OM), and (3) under an OM and ultrasonic
troughing. After root canal preparation with Reciproc in-
struments (VDW GmbH, Munich, Germany), the speci-
T raditional endodontic
mens were scanned again. The noninstrumented canal
area, hard tissue debris accumulation, canal transporta-
tion, and centering ratio were analyzed. After root canal
filling and cavity restoration, the sample was submitted
to the fracture resistance test. Data were analyzed using
the Fisher exact, Shapiro-Wilk, and t tests (a = 0.05).
Results: It was possible to locate more root canals in
the TEC group in stages 1 and 2 (P < .05), whereas
no differences were observed after stage 3 (P > .05).
The percentage of noninstrumented canal areas did
not differ significantly between the CEC (25.8%

9.7%) and TEC (27.4%
8.5%) groups. No signifi-
cant differences were observed in the percentage of
accumulated hard tissue debris after preparation (CEC:
0.9%
0.6% and TEC: 1.3%
1.4%). Canal transpor-
tation was significantly higher for the CEC group in the
palatal canal at 7 mm from the apical end (P < .05). Ca-
nal preparation was more centralized in the palatal ca-
nal of the TEC group at 5 and 7 mm from the apical
end (P < .05) and in the distobuccal canal of the CEC
From the *Department of Dentistry, Federal University of Santa Catarina, Florianopolis, Santa Catarina; †Department of Endodontics, Fluminense Federal University,
Niteroi, Rio de Janeiro, Brazil; ‡Department of Endodontics, School of Dentistry, Grande Rio University, Duque de Caxias, Rio de Janeiro, Brazil; and §Department of
Endodontics, Rio de Janeiro State University, Rio de Janeiro, Rio de Janeiro, Brazil.
Address requests for reprints to Dr Cleonice Silveira Teixeira, Rua Haroldo Soares Glavan, 929/16, CEP 88050-005, Cacupe, Florianopolis, Santa Catarina,
Brazil. E-mail address: cleotex@uol.com.br
0099-2399/$ - see front matter
Copyright ª 2017 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2017.05.006
JOE — Volume 43, Number 10, October 2017
Basic Research—Technology
group at 5 mm from the apical end (P < .05). There was no difference regarding fracture
resistance among the CEC (996.30
490.78 N) and TEC (937.55
347.25 N) groups
(P > .05). Conclusions: 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. (J Endod 2017;43:1657–1662)
Key Words
Endodontic cavity, fracture resistance, instrumentation efficacy, micro–computed
tomography, minimally invasive intervention
cavities (TECs) empha-
size straight-line pathways
Significance
The influence of CECs on root canal preparation
outcomes and fracture resistance remains limited
into root canals to increase
and controversial. We provide new insights
preparation efficacy and
regarding root canal detection, instrumentation ef-
prevent procedural errors
ficacy (noninstrumented canal area, hard tissue
(1, 2). However, a concern
debris accumulation, canal transportation, and
related to TECs is the
amount of tooth structure centering ratio), and fracture resistance of maxillary
molars. The current results did not show benefits
removed, which may
associated with CECs compared with TECs.
reduce its resistance to
fracture under functional
loads (3, 4). As an alternative to this traditional approach, minimally invasive
endodontic cavities or contracted endodontic cavities (CECs) have been described
(3,5–11), 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 (8). Yuan et al (9) 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 (10). Thus, the influence of CECs on the root canal prepa-
ration outcomes and fracture resistance remains limited and controversial. Moreover,
Contracted Endodontic Cavity in Maxillary Molars 1657
Basic Research—Technology
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 (noninstrumented ca-
nal area, hard tissue debris accumulation, canal transportation, and
centering ratio), 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 (8, 11), 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 (reference #1.559.163), 49 human first
maxillary molars extracted for reasons not related to this study with fully
formed apices and intact crowns were preselected using periapical ra-
diographs. 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 (micro-CT) device (Sky-
Scan 1173; Bruker microCT, Kontich, Belgium) using the following pa-
rameters: 70 kV and 114 mA, isotropic resolution of 21 mm, 360
rotation around the vertical axis, rotation step of 0.5 , camera exposure
time of 7000 milliseconds, and frame averaging of 5. 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
(Bruker microCT) using 30% beam hardening correction and ring arti-
fact correction of 5, resulting in the acquisition of 900 to 1000 trans-
verse 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 con-
sisted 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
(1014; KG Sorensen, S~ao Paulo, Brazil) and an Endo Z drill (Dentsply
Maillefer, Ballaigues, Switzerland) following conventional guidelines
already described in the literature (1, 12). The roof of the chamber
was removed, and an unimpeded (straight-line) access into the
coronal third of the root canal was established (Fig. 1A).
CEC
Endodontic cavities were drilled with high-speed diamond burs
(1014-3080, KG Sorensen). 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 (3, 10) (Fig. 1B).
1658 Rover et al.
Root Canal Detection
In both groups, canal orifices were detected with an endodontic
explorer #6 (Golgran, S~ao Caetano do Sul, Brazil) and size 6, 8, 10,
or 15 K-files (Dentsply Maillefer) in 3 stages:
1. Stage 1: The detection was performed without the use of magnification.
2. Stage 2: The detection was performed under magnification (16)
using an operating microscope (OM) (DF Vasconcellos; Valença,
Rio de Janeiro, Brazil).
3. Stage 3: The detection of teeth, in which not all canals (including the
MB2 canal) were located with an OM, was performed under magni-
fication as described in the previous stage and with the aid of ultra-
sonic tips (E3D e E7D; Helse Dental Technology, Santa Rosa de
Viterbo, S~ao Paulo, Brazil). 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 distri-
bution of the specimens between the groups and did not have prior ac-
cess 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 estab-
lished 1.0 mm shorter. The root canals were prepared with Reciproc
R25 (25/0.08) and R40 (40/0.06) instruments (VDW GmbH,
Munich, Germany) in buccal and palatal roots, respectively. Instru-
ments were driven with the VDW Silver motor (VDW GmbH) 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 (Ultradent Products Inc, South Jordan, UT)
inserted up to 2 mm from the apical foramen. Final irrigation was per-
formed 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 points (VDW GmbH), and
the specimens were submitted to a postoperative scan and recon-
struction applying the aforementioned parameters.
After that, the sample was filled using a single-cone technique
associated with vertical condensation using AH Plus sealer (Dentsply
De Trey, Konstanz, Germany) and Reciproc R25 and R40 gutta-
percha cones in buccal and palatal roots, respectively. Endodontic
cavities were filled with 37% phosphoric acid gel (Condac 37;
FGM, Joinville, Brazil), rinsed with water, and air dried, and 2 layers
of bonding agent (Adper Single Bond 2; 3M ESPE, St Paul, MN) were
applied interspersed by a light jet of air and followed by each cured
for 20 seconds (Radii-cal; SDI, Bayswater, Australia). The composite
restoration (Filtek Z350 XT; 3M ESPE, Sumare, Brazil) 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 (13). 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
JOE — Volume 43, Number 10, October 2017

Figure 1. Three-dimensional renderings of 2 maxillary first molars. An occlusal view of (A) TEC and (B) CEC. A palatal view of preoperative root canal anatomy in
(C) TEC and (D) CEC groups and postoperative root canal anatomy in (E) TEC and (F) CEC groups. The green color indicates the preoperative area, and the red
color indicates the postoperative area.
total number of voxels present on the canal surface (14) 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 (15). The volume of dentin removed after preparation
was calculated by subtracting pre- and postoperative segmented
root dentin using morphologic operations (Fiji v.1.47n; Fiji,
Madison, WI).
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 (16, 17):
Degree of canal transportation ¼ ðm1m2 Þ  ðd1d2 Þ
Canal centring ratio ¼ ðm1m2 Þ=ðd1d2 Þ or
ðd1d2 Þ=ðm1m2 Þ;
JOE — Volume 43, Number 10, October 2017
Basic Research—Technology
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 dis-
tance 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 direc-
tion. 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 indi-
cated 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
Contracted Endodontic Cavity in Maxillary Molars 1659
Basic Research—Technology
TABLE 1. Detection of the Root Canals in Maxillary Molars
TEC
Stages n (%)
Stage 1 11 (73.33)A
Stage 2 12 (80.00)A
Stage 3 13 (86.67)A
Not detected after 3 stages 2 (13.33)A
CEC, contracted endodontic cavity; TEC, traditional endodontic cavity.
Different superscript letters in the same row represent statistically significant differences between the
different types of cavities in the same stage (P < .05).
(Glue, Nova Veneza, Brazil) and a thin layer of approximately 0.3-mm-
high melting wax (Galileo; Talladium, Inc, Valencia, CA), simulating the
periodontal ligament.
The fracture resistance was determined by a universal testing ma-
chine (EMIC DL2000; EMIC, S~ao Jose dos Pinhais, Brazil). The speci-
mens 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. In both groups, all root canals classified as ‘‘not de-
tected’’ were MB2 canals. In stages 1 and 2, the TEC group allowed a
greater number of detected root canals when compared with the CEC
group (P < .05). After stage 3, no statistically significant differences
were observed in root canal detection between the TEC and CEC groups
(P > .05).
The degree of homogeneity of the groups was confirmed in rela-
tion to the length, volume, and surface area of the canals (P > .05). The
percentage of noninstrumented canal areas was 25.8%
9.7% in the
TEC group and 27.4%
8.5% in the CEC group; there was no statistical
difference (P > .05) (Fig. 1C–F). No significant differences were
observed in the comparison between the results of the percentage of
accumulated hard tissue debris after preparation (TEC, 1.3%

1.4%; CEC, 0.9%
0.6%) (P > .05) (Table 2).
Canal transportation was higher in the palatal canal at 7 mm from
the apex for the CEC group (P < .05). TECs kept the preparation of the
canals more centralized in the palatal canal at 5 and 7 mm from the apex
(P < .05). In the distobuccal canal, CECs maintained the preparation of
the root canal more centralized at 5 mm from the apex (P < .05).
TABLE 2. Parameters of the Intact Canals, Prepared, the Percentages of Debris Accumulated, and Load to Fracture after the Canal Preparation in Teeth with
Traditional Endodontic Cavity (TEC) and Contracted Endodontic Cavity (CEC)
Intact canal Prepared canal
Groups volume (mm3) volume (mm3)
TEC 6.6
2.1A 10.6
2.7A
CEC 7.0
3.2A 11.1
4.9A
CEC, contracted endodontic cavity; TEC, traditional endodontic cavity.
Equal superscript letters in the same column represent absence of statistically significant differences between the different types of cavities (P > .05). Values presented in mean
standard deviation.
1660 Rover et al.
Table 3 presents the transportation and centering ratio values of both
groups.
CEC
n (%) The mean load at failure values for the TEC and CEC groups were
937.55
347.25 N and 996.30
490.78 N, respectively; this differ-
4 (26.67)B ence was not statistically significant (P < .05) (Table 2). Fracture pat-
5 (33.33)B
12 (80.00)A terns were variable.
3 (20.00)A
Discussion
The root canal system of maxillary first molars, especially the
mesial root, may present several anatomic conformations (18–20).
Different studies have reported the incidence of the MB2 canal
ranging from 56.8%–96% in maxillary molars (21–24). Despite
natural variations in the morphology of this group of teeth, attempts
were made to ensure the comparability of the groups regarding root
canal morphology. Similar to what has been done in previous studies
(25–28), 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 conven-
tional periapical radiographs during sample selection and group allo-
cation (8–10).
CECs preserve more dental hard tissue; however, it may be chal-
lenging to find, clean, and shape the root canals with such an access
approach. The results of canal location analysis showed that TECs al-
lowed the location of significantly more root canals in steps 1 and 2
when compared with CECs (P < .05). After the use of magnification
and ultrasonic troughing (stage 3), no differences were observed be-
tween 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 (29) 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 (30) 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 empha-
size 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.
Intact canal Prepared canal Noninstrumented Debris Load to
area (mm2) area (mm2) canal area (%) accumulated (%) fracture (n)
89.1
26.0A 130.0
20.2A 25.8
9.7A 1.3
1.4A 937.5
347.2A
87.0
28.2A 130.4
34.4A 27.4
8.5A 0.9
0.6A 996.3
490.7A
JOE — Volume 43, Number 10, October 2017
 Basic Research—Technology
TABLE 3. Mean
Standard Deviation of Canal Transportation (mm) and treated instruments with a smaller tip size and taper have greater flex-
Centering Ratio Values for Tested Groups ibility, which may help to justify these results (26).
Level/Canal Assessment TEC CEC Dentin particles cut from the canal walls by endodontic instru-
ments can be actively packed into anatomic complexities of the root ca-
3 mm/P Transportation 0.047
0.01 A
0.056
0.01A nal system, compromising disinfection and hermetic filling and
Centering ratio 0.440
0.14A 0.414
0.14A
3 mm/MB1 Transportation 0.097
0.01A 0.062
0.01A becoming a niche for future reinfection of the root canal (35). In the
Centering ratio 0.465
0.04A 0.559
0.11A current study, accumulation of hard tissue debris occurred regardless
3 mm/DB Transportation 0.050
0.01A 0.070
0.01A of the endodontic access cavity design. The mean volume of hard tissue
Centering ratio 0.498
0.05A 0.361
0.07A debris accumulation was 1.3% and 0.9% for TECs and CECs, respec-
5 mm/P Transportation 0.043
0.01A 0.046
0.01A
Centering ratio 0.519
0.12A 0.282
0.11B
tively. It was previously established that the use of different root canal
5 mm/MB1 Transportation 0.104
0.01A 0.085
0.01A instrumentation systems results in the packing of hard tissues debris
Centering ratio 0.500
0.07A 0.459
0.08A (15, 33, 35). However, this is the first study to assess the influence of
5 mm/DB Transportation 0.113
0.01A 0.060
0.01A the endodontic access cavity design on the accumulation of hard
Centering ratio 0.375
0.08B 0.687
0.11A tissue debris through a nondestructive methodology.
7 mm/P Transportation 0.031
0.01A 0.059
0.01B
Centering ratio 0.589
0.07A 0.182
0.47B Before the fracture resistance test, the root canals were filled, and
7 mm/MB1 Transportation 0.146
0.01A 0.212
0.01A restorations of endodontic accesses with composite resin were per-
Centering ratio 0.477
0.04A 0.370
0.03A formed, reproducing the usual clinical procedures. Then, the speci-
7 mm/DB Transportation 0.145
0.01A 0.238
0.01A mens were submitted to the compression test with a load in the
Centering ratio 0.402
0.08A 0.288
0.03A
central fossa at a 30 angle from the long axis of the tooth, simulating
DB, distobuccal; MB1, mesiobuccal; P, palatal. the occlusal contact of the dental elements (8, 10). The present results
Different letters in the same row represent statistically significant differences between the different showed no differences among the 2 tested endodontic access cavity
types of cavities (P < .05). designs (TEC: 937.55
347.25 N and CEC: 996.30
490.78 N).
These results corroborate with the findings of Moore et al (10), which
showed no differences in the resistance to fracture of maxillary molars
Root canals were prepared using Reciproc R25 and R40 instru- accessed with TECs (1384
377 N) and CECs (1703
558 N).
ments in the buccal and palatal canals, respectively. No instrument frac- Krishan et al (8) found greater resistance to fracture in premolars
ture occurred during root canal preparation. The efficacy of and lower molars with CECs when compared with teeth with TECs; how-
instrumentation was evaluated by means of high-resolution micro-CT im- ever, it is important to emphasize that the compression test was per-
aging, similar to previous studies (26, 31, 32). This technology allows formed without restoration of the teeth, which may have affected the
canal scanning before and after instrumentation, thus verifying changes obtained results, once it did not faithfully reproduce the clinical situa-
in the anatomy of the root canal, such as the noninstrumented canal tion. The differences among the studies could be related to differences
area (14, 27), accumulation of hard tissue debris (15,33–35), and in the methodological design including the type of teeth considered, the
volume of dentin removed. Noninstrumented canal areas may be use of restoration, the type of material used for restorative procedures,
colonized by biofilms and serve as a potential cause of persistent and methodological issues related to the design of the fracture test and
infection, which may compromise the treatment outcome (33, 35). In cyclic fatigue. For example, in the present study, cyclic fatigue was not
the current study, the mean percentage of the noninstrumented canal tested. Moreover, the loading of teeth with a 4.0-mm diameter cylinder
area in TECs and CECs was 25.8% and 27.4%, respectively. These resulted in lower mean load values compared with the results of previ-
results are in accordance with those obtained by Moore et al (10), which ous studies that used cylinders with higher diameters (8, 10). As
showed that the percentage of the noninstrumented canal area was not highlighted in the other study (8), smaller cylinders had been associ-
affected by the endodontic access cavity design. ated with a lower force needed to generate the critical pressure required
According to Gambill et al (16), root canal transportation corre- to fracture the tooth.
sponds to a deviation of the prepared canal from its natural axis (in mil- The current results did not show benefits associated with CECs.
limeters) after instrumentation when compared with pretreatment This access modality in maxillary molars resulted in less root canal
measurements. Moreover, centering ability indicates the ability of the detection when no ultrasonic troughing associated with an OM was
instrument to stay centered in the canal. In the present study, canal used and did not increase the fracture resistance of teeth compared
transportation and centering ability were performed only on mesiobuc- with the ones prepared with TECs. There is still no clear evidence in
cal, distobuccal, and palatal canals. The rationale to eliminate MB2 ca- the literature that supports CECs, and further studies are needed to
nals in this evaluation was because this canal was not present in all assess how this form of access can affect the long-term clinical success.
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 Acknowledgments
results, Krishan et al (8) observed a negative influence of CECs on the Supported in part by the Coordination of Training of Higher Ed-
preparation of the distal canals in lower molars. Moreover, Eaton et al ucation Graduates (CAPES), the Research Support Foundation of the
(11) also verified the deviation of the original canal anatomy in lower State of Rio de Janeiro (FAPERJ), and the Research Support Founda-
molars prepared with CECs when compared with TECs. In contrast to tion of the State of Santa Catrina (FAPESC, no. TO 10027/2012-7).
the present results, Moore et al (10) did not find significant differences The authors deny any conflicts of interest related to this study.
in the canal transportation and centering ability between TECs and CECs
in upper molars. It is important to note that in this previous study ther-
mally treated instruments with a smaller tip size and taper (20/.06 and
References
1. Patel S, Rhodes J. A practical guide to endodontic access cavity preparation in molar
30/.06 in the vestibular and palatal canals, respectively) were used, teeth. Br Dent J 2007;203:133–40.
whereas Reciproc R25 (25/.08) and R40 (40/.06) instruments were 2. Schroeder KP, Walton RE, Rivera EM. Straight line access and coronal flaring: effect
used herein in the vestibular and palatal canals, respectively. Thermally on canal length. J Endod 2002;28:474–6.

JOE — Volume 43, Number 10, October 2017 Contracted Endodontic Cavity in Maxillary Molars 1661
Basic Research—Technology
3. Clark D, Khademi J. Modern molar endodontic access and directed dentin conser-
vation. Dent Clin North Am 2010;54:249–73.
4. Tang W, Wu Y, Smales RJ. Identifying and reducing risks for potential fractures in
endodontically treated teeth. J Endod 2010;36:609–17.
5. Gluskin AH, Peters CI, Peters OA. Minimally invasive endodontics: challenging pre-
vailing paradigms. Br Dent J 2014;216:347–53.
6. Ahmed HM, Gutmann JL. Education for prevention: a viable pathway for minimal
endodontic treatment intervention. Endod Pract Today 2015;9:283–5.
7. B€urklein S, Sh€afer E. Minimally invasive endodontics. Quintessence Int 2015;46:
119–24.
8. Krishan R, Paque F, Ossareh A, et al. Impacts of conservative endodontic cavity on
root canal instrumentation efficacy and resistance to fracture assessed in incisors,
premolars, and molars. J Endod 2014;40:1160–6.
9. Yuan K, Niu C, Xie Q, et al. Comparative evaluation of the impact of minimally inva-
sive preparation vs. conventional straight-line preparation on tooth biomechanics: a
finite element analysis. Eur J Oral Sci 2016;124:591–6.
10. Moore B, Verdelis K, Kishen A, et al. Impacts of contracted endodontic cavities on
instrumentation efficacy and biomechanical responses in maxillary molars. J Endod
2016;42:1779–83.
11. Eaton JA, Clement DJ, Lloyd A, Marchesan MA. Micro-computed tomographic eval-
uation of the influence of root canal system landmarks on access outline forms and
canal curvatures in mandibular molars. J Endod 2015;41:1888–91.
12. Goerig AC, Michelich RJ, Schultz HH. Instrumentation of root canals in molar using
the step-down technique. J Endod 1982;8:550–4.
13. Fedorov A, Beichel R, Kalpathy-Cramer J, et al. 3D Slicer as an image computing
platform for the Quantitative Imaging Network. Magn Reson Imaging 2012;30:
1323–41.
14. De-Deus G, Belladonna FG, Silva EJ, et al. Micro-ct evaluation of non- instrumented
canal areas with different enlargements performed by niti systems. Braz Dent J 2015;
26:624–9.
15. De-Deus G, Marins J, Silva EJ, et al. Accumulated hard tissue debris produced during
reciprocating and rotary nickel-titanium canal preparation. J Endod 2015;41:
676–81.
16. Gambill JM, Alder M, del Rio CE. Comparison of nickel-titanium and stainless steel
hand-file instrumentation using computed tomography. J Endod 1996;22:369–75.
17. Silva EJ, Pacheco PT, Pires F, et al. Microcomputed tomographic evaluation of canal
transportation and centring ability of ProTaper Next and Twisted File Adaptive sys-
tems. Int Endod J 2017;50:694–9.
18. Corbella S, Fabbro MD, Tsesis I, Taschieri S. Computerized tomography technique
for the investigation of the maxillary first molar mesiobuccal root. Int J Dent 2013;
2013:614898.
19. Domark JD, Hatton JF, Benison RP, Hildebolt CF. An ex vivo comparison of digital
radiography and cone-beam and micro computed tomography in the detection of
the number of canals in the mesiobuccal roots of maxillary molars. J Endod
2013;39:901–5.
1662 Rover et al.
View publication stats
20. Brise~no-Marroquın B, Paque F, Maier K, et al. Root canal morphology and config-
uration of 179 maxillary first molars by means of micro-computed tomography: an
ex vivo study. J Endod 2015;41:2008–13.
21. Betancourt P, Navarro P, Mu~noz G, Fuentes R. Prevalence and location of the sec-
ondary mesiobuccal canal in 1,100 maxillary molars using cone beam computed
tomography. BMC Med Imaging 2016;16:1–8.
22. Martins JN, Marques D, Mata A, Caram^es J. Root and root canal morphology of the
permanent dentition in a Caucasian population: a CBCT study. Int Endod J 2016
Nov 24; http://dx.doi.org/10.1111/iej.12724 [Epub ahead of print].
23. Stropko JJ. Canal morphology of maxillary molars: clinical observations of canal
configurations. J Endod 1999;25:446–50.
24. G€orduysus MO, G€orduysus M, Friedman S. Operating microscope improves
negotiation of second mesiobuccal canals in maxillary molars. J Endod
2001;27:683–6.
25. Capar ID, Ertas H, Ok E, et al. Comparative study of different novel nickel-titanium
rotary systems for root canal preparation in severely curved root canals. J Endod
2014;40:852–6.
26. Zhao D, Shen Y, Peng B, Haapasalo M. Root canal preparation of mandibular molars
with 3 nickel-titanium rotary instruments: a micro-computed tomographic study.
J Endod 2014;40:1860–4.
27. Amoroso-Silva P, Alcalde MP, Hungaro Duarte MA, et al. Effect of finishing instru-
mentation using NiTi hand files on volume, surface area and uninstrumented sur-
faces in C-shaped root canal systems. Int Endod J 2017;50:604–11.
28. Yang Y, Shen Y, Ma J, et al. Micro-computed tomographic assessment of the influ-
ence of operator’s experience on the quality of waveone instrumentation. J Endod
2016;42:1258–62.
29. Das S, Warhadpande MM, Redij SA, et al. Frequency of second mesiobuccal canal in
permanent maxillary first molars using the operating microscope and selective
dentin removal: a clinical study. Contemp Clin Dent 2015;6:74–8.
30. Buhrley LJ, Barrows MJ, BeGole EA, Wenckus CS. Effect of magnification on locating
the MB2 canal in maxillary molars. J Endod 2002;28:324–7.
31. Alovisi M, Cemenasco A, Mancini L, et al. Micro-ct evaluation of several glide path
techniques and ProTaper Next shaping outcomes in maxillary first molar curved ca-
nals. Int Endod J 2017;50:387–97.
32. Saberi N, Patel S, Mannocci F. Comparison of centring ability and transportation be-
tween four nickel titanium instrumentation techniques by micro-computed tomog-
raphy. Int Endod J 2017;50:595–603.
33. Leoni GB, Versiani MA, Silva-Sousa YT, et al. Ex vivo evaluation of four final irriga-
tion protocols on the removal of hard-tissue debris from the mesial root canal sys-
tem of mandibular first molars. Int Endod J 2017;50:398–406.
34. Perez R, Neves AA, Belladonna FG, et al. Impact of needle insertion depth on the
removal of hard-tissue debris. Int Endod J 2017;50:560–8.
35. Versiani MA, Alves FR, Andrade-Junior CV, et al. Micro-CT evaluation of the efficacy
of hard-tissue removal from the root canal and isthmus area by positive and negative
pressure irrigation systems. Int Endod J 2016;49:1079–87.
JOE — Volume 43, Number 10, October 2017