Basic ResearchTechnology
Fracture Strength of Endodontically Treated
Teeth with Different Access Cavity Designs
Gianluca Plotino, DDS, PhD,* Nicola Maria Grande, DDS, PhD, Almira Isufi, DDS, PhD, MSc,*
Pietro Ioppolo, DpHS, Eugenio Pedull
a, DDS, PhD, Rossella Bedini, DSc, PhD,
Gianluca Gambarini, MD, DDS,* and Luca Testarelli, DDS, PhD*
Abstract
Introduction: The purpose of this study was to
compare in vitro the fracture strength of root-filled
and restored teeth with traditional endodontic cavity
(TEC), conservative endodontic cavity (CEC), or ultracon-
servative ninja endodontic cavity (NEC) access.
Methods: Extracted human intact maxillary and
mandibular premolars and molars were selected and as-
signed to control (intact teeth), TEC, CEC, or NEC groups
(n = 10/group/type). Teeth in the TEC group were pre-
pared following the principles of traditional endodontic
cavities. Minimal CECs and NECs were plotted on cone-
beam computed tomographic images. Then, teeth were
endodontically treated and restored. The 160 specimens
were then loaded to fracture in a mechanical material
testing machine (LR30 K; Lloyd Instruments Ltd, Fare-
ham, UK). The maximum load at fracture and fracture
pattern (restorable or unrestorable) were recorded. Frac-
ture loads were compared statistically, and the data
were examined with analysis of variance and the
Student-Newman-Keuls test for multiple comparisons.
Results: The mean load at fracture for TEC was signifi-
cantly lower than the one for the CEC, NEC, and control
groups for all types of teeth (P < .05), whereas no differ-
ence was observed among CEC, NEC, and intact teeth
(P > .05). Unrestorable fractures were significantly
more frequent in the TEC, CEC, and NEC groups than
in the control group in each tooth type (P < .05).
Conclusions: Teeth with TEC access showed lower frac-
ture strength than the ones prepared with CEC or NEC.
Ultraconservative ninja endodontic cavity access did
not increase the fracture strength of teeth compared
with the ones prepared with CEC. Intact teeth showed
more restorable fractures than all the prepared ones.
(J Endod 2017;-:16)
Key Words
Conservative access cavity, endodontic access cavity,
fracture resistance, ninja cavity, traditional endodontic
cavity
From the *Department of Endodontics, La Sapienza University of Rome, Rome, Italy; Catholic University of Sacred Heart, Rome, Italy; Technologies and Health
Department, Istituto Superiore di Sanita, Rome, Italy; and Department of General Surgery and Surgical-Medical Specialties, University of Catania, Catania, Italy.
Address requests for reprints to Dr Eugenio Pedulla, Via Cervignano, 29, 95129, Catania, Sicily, Italy. E-mail address: eugeniopedulla@gmail.com
0099-2399/$ - see front matter
Copyright 2017 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2017.01.022
JOE Volume -, Number -, - 2017
O ne of the most impor-
tant steps for success-
ful endodontic treatment is
Signicance
CEC and NEC access was proposed to reduce
fracture risk of endodontically treated teeth. Teeth
access cavity preparation.
with CEC and NEC showed similar fracture
The traditional endodon-
strength, which was higher than that of teeth with
tic cavity (TEC) design for
traditional endodontic access.
different tooth types has re-
mained unchanged for de-
cades, and only minor modifications have been done (1). However, the removal of tooth
structure needed for access cavity preparation may undermine the strength of the tooth
to fracture under functional loads (2, 3). Extraction is the most frequent consequence
of fracture of endodontically treated teeth (46). Extended preparation of endodontic
access cavities critically reduces the amount of sound dentin (710) and increases the
deformability of the tooth (8), compromising the strength to fracture of endodontically
treated teeth (7).
Recently, conservative endodontic cavity (CEC) preparation (11, 12) to minimize
tooth structure removal and preserve some of the chamber roof and pericervical
dentin was reported in the literature. This sound dentin preservation could be
achieved with the help of cone-beam computed tomographic (CBCT) imaging to
identify all the canals (13, 14). This could improve the fracture strength of
endodontically treated teeth (11).
Following this concept, an extreme conservative approach has recently been pro-
posed, which is conventionally known as ninja. This technique may improve the
fracture strength of endodontically treated teeth (15). To date, there are no studies
comparing CEC access cavity preparation with ultraconservative ninja endodontic
cavity (NEC) access. Therefore, the purpose of this study was to investigate the fracture
strength of endodontically treated teeth with a TEC, CEC, or NEC access cavity.
Materials and Methods
Specimen Selection and Preparation
After ethics approval, 160 recently extracted intact human maxillary and mandib-
ular molars and premolars from a white population with completely formed apices were
used. The exclusion criteria for the tested teeth were the presence of caries, previous
restoration, and visible fracture lines or cracks.
After a debridement with hand scaling instruments and cleansing with a rubber
cup and pumice, the teeth were stored in individually numbered containers with
0.1% thymol solution at 4 C until used and during all the time between the different
phases of the experiment in order to prevent their dehydration.
Fracture Strength of Endodontically Treated Teeth 1
Basic ResearchTechnology

Figure 1. (AD) Sketches with an (AC) occlusal view and a (D) sagittal view of access cavity designs of a first mandibular molar. (AD) A traditional access cavity
(black line dashed), (A, C, and D) conservative access cavity (green), and (BD) ultraconservative ninja access cavity (red). Comparison of the 3 access cavity
designs in the (C) occlusal and (D) sagittal view, respectively. The sagittal view shown as a conservative access cavity maintains a robust amount of pericervical
dentin. B, buccal; D, distal; L, lingual; M, mesial.

Forty maxillary first molars with 3 separate roots, 40 mandibular
first molars with 2 separate roots, 40 maxillary first premolars with 2
separate roots, and 40 mandibular first single-rooted premolars were
selected based on similar dimensions. The anatomic crown height
was measured from the occlusal surface to the cementoenamel junction
on all 4 sides of the teeth; buccolingual and mesiodistal (MD) dimen-
sions were measured at the occlusal surface. Tooth measurements were
taken with a digital caliper (Digimatic 500; Mitutoyo, Kanagawa, Japan).
Specimens were subsequently assigned to 4 groups (n = 10) for each
tooth type. Therefore, the following homogenous groups were created
based on the averages of tooth dimensions in order to minimize the
influence of size and shape variations on the results:
1. Group A: the control group, which included teeth that were left intact
2. Group B: the TEC group
3. Group C: the CEC group
4. Group D: the NEC group
TEC, CEC, and NEC cavity accesses of all teeth were drilled with size
856 diamond burs (Komet Italia srl, Milan, Italy) mounted on a high-
speed handpiece with water cooling (16). Teeth in the TEC, CEC, and
NEC groups were mounted in a custom-made device (17) and imaged
with a CBCT scanner (Kodak 9000 3D; Carestream Health, Inc, Marne-
la-Vallee, France) with a spatial resolution of 200 mm; the scans were
used to plan TEC, CEC, and NEC outlines. Teeth in the TEC group

Figure 2. (AF) CBCT 3-dimensional reconstructions and segmentations of lower molars prepared with different access cavity designs in (AC) the sagittal view
and (DF) the axial view at the occlusal surface. (A and D) A traditional access cavity (purple), (B and E) conservative access cavity (green), and (C and F)
ultraconservative ninja access cavity (red) are segmented on CBCT reconstructions.

2 Plotino et al. JOE Volume -, Number -, - 2017


Figure 3. (AD) Representative pictures of fractured molars for different groups. (A) Intact teeth had more restorable fractures than teeth prepared with (B) TEC,
(C) CEC, and (D) ultraconservative NEC, which had unrestorable fractures often.
were prepared following the principles of TECs as previously reported
(1, 18). In the CEC group, premolars were accessed 1 mm buccal to
the central fossa, and cavities extended apically, maintaining part of
the chamber roof and lingual shelf. Molars were accessed at the
mesial quarter of the central fossa, and cavities extended apically and
distally while maintaining part of the chamber roof. Mesiodistal,
buccolingual, and circumferential pericervical dentin removal was
minimized to ensure the maintenance of the part of the chamber roof
compatible with the localization of all root canal orifices from the
same visual angulation (11, 12, 19). This was caused by the shape of
preparation; the occlusal enamel was only beveled at 45 (12). The
extension was not balanced equally between the buccal and palatal
orifices but rather slightly favored the buccal orifice (11). In the NEC
group, premolar and molar teeth were accessed in the same way as
the teeth in the CEC group, but the chamber roof was maintained as
much as possible. The access ninja outline was derived from the
oblique projection toward the central fossa of the root canal orifices
on the occlusal plane. By doing this, localization of all the root canal
orifices was possible even from different visual angulations because
the endodontic access was parallel with the enamel cut at 90 or
more to the occlusal table (12, 15) (Fig. 1AD). The extension was
equally balanced between the buccal and lingual/palatal orifices.
Then, teeth in the TEC, CEC, and NEC groups were scanned again
using CBCT imaging as described earlier. Digital Imaging and
JOE Volume -, Number -, - 2017
Basic ResearchTechnology
Communications in Medicine data were moved to the MeVisLab image
processing and visualization platform (MeVis Research, Bremen,
Germany) to perform 3-dimensional surface rendering of the teeth
and segmentation of the TEC, CEC, or NEC access (Fig. 2AF). The per-
centage of volume of coronal enamel and dentin removed by TEC, CEC,
and NEC access cavities and the total enamel and dentin crown volume
for each type of tooth were calculated.
Endodontic Treatment
Root canals were negotiated with size 10 K-type files (Flexofile;
Dentsply Maillefer, Ballaigues, Switzerland) to the major apical
foramen, and canals were instrumented to length with Mtwo nickel-
titanium rotary instruments (Sweden & Martina, Padova, Italy), with a
16-mm working part, up to the #25 tip size and 0.06 taper file. During
endodontic treatment, 5.25% sodium hypochlorite (Niclor 5; Ogna,
Muggio, Italy) for irrigation was intermittently deposited using ProRinse
side-vented 30-G needles (Dentsply Tulsa Dental Specialties, Tulsa,
OK), and after instrumentation, the root canals were irrigated with
17% EDTA solution. The canals were dried with paper points and filled
with gutta-percha (single-cone size 25, 0.06 taper) and a resin-based
endodontic sealer (AH Plus; Dentsply De Trey, Konstanz, Germany).
Afterward, the teeth were subjected to postoperative radiographs and
CBCT imaging to evaluate the endodontic treatment.
Fracture Strength of Endodontically Treated Teeth 3
 Basic ResearchTechnology
Teeth Restoration

crown height
The enamel and dentin of the access cavity were cleaned and

Anatomic

5.3 (0.3)b
4.7 (0.5)b
5.3 (0.3)b
5.7 (0.6)b
TABLE 1. Mean and (Standard Deviation) of the Mesiodistal (MD) and Buccolingual (BL) Dimensions and the Anatomic Crown Height (Measured at the 4 Sides of the Tooth) of the Tested Teeth in Each Group
etched with 37% phosphoric acid for 30 and 15 seconds, respectively;
rinsed for 30 seconds with a water/air spray; and gently air dried to
avoid desiccation. A light-polymerizing primer bond adhesive (XP
Bond; Dentsply International, York, PA) was applied, gently air thinned,

8.2a (0.9)
7.8a (0.9)
9.5a (1.0)
10.1a (0.8)
and exposed to light-emitting diode polymerization for 30 seconds. At

NEC
Occlusal surface
BL
the end, the access cavities were restored with direct composite
restorations (CeramX mono, Dentsply International).

7.9a (0.9)
7.5a (1.4)
9.8a (0.7)
10.5a (0.9)
Fracture Test

MD
The 120 teeth in the TEC, CEC, and NEC groups and the 40 teeth
(n = 10/type) kept intact were mounted on brass rings with the roots
embedded in self-curing resin (SR Ivolen; Ivoclar Vivadent, Schaan,

crown height
Lichtenstein) up to 2 mm apical to the cementoenamel junction as re-

Anatomic

5.0 (0.8)b
5.1 (0.4)b
5.6 (0.5)b
5.6 (0.4)b
ported in a previous study (19). The 160 tooth specimens were placed
in a custom-made water bath and mounted in a mechanical material
testing machine (LR30 K; Lloyd Instruments Ltd, Fareham, UK)
(19). The teeth were loaded at their central fossa at a 30 angle
from the long axis of the tooth. The continuous compressive force at

8.0a (0.5)
7.9a (0.8)
9.5a (0.9)
10.2a (0.5)
CEC
a crosshead speed of 0.5 mm/min was applied using a 6-mm-diameter

Occlusal surface
BL
ball-ended steel compressive head. The loads at which the teeth were
fractured, indicated by the software of the load testing machine, were
recorded in newtons. The fractured specimens were examined under a

7.9a (0.3)
7.3a (0.5)
9.9a (0.3)
10.7a (1.0)
stereomicroscope (SZR- 10; Optika, Bergamo, Italy) to determine the

MD
fracture levels. Fracture patterns were classified as restorable when
the failures were above the level of bone simulation (site of fracture
above the acrylic resin) and unrestorable when the failures were

crown height
extending below the level of bone simulation (site of fracture below

Anatomic

5.3 (0.7)b
4.9 (0.3)b
5.3 (0.2)b
5.7 (0.5)b
[F3] the acrylic resin) (20) (Fig. 3AD).

Statistical Analysis
The data were first verified with the Kolmogorov-Smirnov test for
8.1a (0.7)
7.8a (0.9)
9.6a (0.9)
10.2a (0.9)
normal distribution and the Levene test for homogeneity of variances.
TEC
Occlusal surface
BL

Thus, they were statistically evaluated using analysis of variance and the
Student-Newman-Keuls test for multiple comparisons (Prism 5.0;
GraphPad Software Inc, La Jolla, CA), with the significance level estab-
8.0a (0.8)
7.2a (1.3)
9.7a (0.5)
10.6a (1.3)
lished at 5% (P < .05).
MD

CEC, conservative endodontic cavity; NEC, ninja endodontic cavity; TEC, traditional endodontic cavity.

Results
Similar lowercase letters in the same row indicate no statistically significant differences (P > .05).

The mean of the buccolingual and mesiodistal dimensions at the

crown height

occlusal surface and the anatomic crown height of the tested teeth are
Anatomic

5.2 (0.7)b
4.5 (0.4)b
5.4 (0.1)b
5.8 (0.4)b

presented in Table 1. No significant differences were found when

comparing all teeth dimensions in the control and test groups for
each type of tooth (P > .05). Table 2 shows the mean volume percent-
ages of the coronal enamel and dentin removed by different access
Control

cavity designs in each tooth type.

7.8a (1.6)
7.6a (0.9)
9.4a (0.7)
10.3a (0.6)

The mean load at fracture for teeth in the TEC group was signif-
Occlusal surface
BL

icantly lower than the intact, CEC, and NEC groups (P < .05), whereas
no difference was observed among the control, CEC, and NEC groups
(P > .05) in all types of teeth (Table 3). Intact premolars had mostly
8.1a (1.0)
7.4a (1.2)
9.7a (0.6)
10.7a (1.2)

cuspal chipping, whereas those with TEC, CEC, and NEC consistently
MD

had wall fractures extending below the cementoenamel junction.

Molars in all the groups had mesiodistal fractures with a varying apical
extent.
Upper Premolars
Lower Premolars

The restorable fractures were significantly higher than the

Tooth type

Upper molars
Lower molars
(n = 10)

unrestorable ones in the intact teeth (P < .05), whereas the number
Groups

of unrestorable fractures was higher than the restorable ones in the

TEC, CEC, and NEC groups in every type of tooth (P < .05). No difference
in the number of restorable or unrestorable fractures was observed for
the TEC, CEC, and NEC groups in every type of tooth (P > .05).

4 Plotino et al. JOE Volume -, Number -, - 2017


TABLE 2. The Volume Percentage (Mean and Standard Deviation) of the
Coronal Enamel and Dentin Removed in Teeth with Different Access Cavity
Designs Including Traditional, Conservative, and Ninja Access
Coronal dentin and enamel volume
removed (% of total crown volume)
Tooth type (n = 10) TEC CEC
Upper premolars 22.15 (3.71)a 13.43 (3.12)b
Lower premolars 23.89 (3.04)a 15.17 (3.67)b
Upper molars 19.27 (3.82)a 11.03 (2.81)b
Lower molars 16.48 (3.47)a 7.31 (3.33)b
CEC, conservative endodontic cavity; NEC, ninja endodontic cavity; TEC, traditional endodontic cavity.
Similar lowercase letters in the same row indicate no statistically significant differences (P > .05).
Discussion
One of the most important causes of fractures in root-filled teeth is
the loss of tooth structure. The preparation of the endodontic access
cavity following the TEC principals was reported as the second largest
cause of loss of tooth structure (20). Thus, a proper and reduced
endodontic access design could improve the prognosis for an
endodontically treated tooth (21).
Recently, CEC and NEC were proposed to reduce the fracture risk
in endodontically treated teeth (15, 19). However, clinically, these
approaches can mainly be performed on intact teeth that are going to
be treated endodontically. This clinical scenario does not seem to
occur frequently, representing only 8% of the cases treated by the
authors in the last 5 years (G. Plotino et al, unpublished data, 2016).
Until now, in the literature, the fracture strength of teeth with CEC
and NEC access was investigated in a few studies (19, 22) and no
studies, respectively. For this reason, the fracture strength of
endodontically treated teeth with TEC, CEC, or NEC access cavity was
tested in the present study. The use of mature, intact maxillary and
mandibular molars and premolars was a priority to avoid the effects
of different amounts of tooth structure loss (22).
Anterior teeth were not tested in this investigation because no dif-
ferences between TEC and CEC fracture strength in these teeth were re-
ported (19). Although premolars and molars are subjected to a
different occlusal force in the clinical situation (23), in this study the
same loading force was applied to standardize the procedure (19).
Fracture resistance was assessed with a mechanical testing machine
as in other studies (19, 2426). A 30 inclination angle was used
because teeth are most vulnerable to fracture when eccentric forces
are applied (27), reaching the failure point at lower loads when
compared with the axial fracture loads of other studies (28, 29).
However, loading to fracture methodology used for in vitro ana-
lyses does not accurately reflect intraoral conditions in which failures
occur primarily because of fatigue. In the same way, axial cyclically
Basic ResearchTechnology
fatigued tests may not reflect complete root strain patterns for the
complex chewing process (22). Access cavities were restored with
bonded resin composite to simulate clinical procedures and facilitate
loading tests (22). Restoration of endodontic access cavities may restore
the fracture strength of teeth up to 72% of that of intact teeth (22, 30).
The same expert operator performed all specimen preparation
NEC
procedures in order to avoid different results caused by different oper-
5.13 (0.76)c ator skills. In this study, the TEC group presented lower fracture
6.07 (0.54)c
5.92 (0.75)c
strength than the control, CEC, and NEC groups. These results are in
4.81 (0.82)c agreement with a previous study in which the teeth were tested without
any restoration, which is different from clinical practice (19).
The results of the present study are in agreement and corroborate
reports that showed improved fracture strength of teeth because of
dentin preservation obtained by cavity size reduction (9, 31, 32). In
addition, no difference in the fracture strength was observed among
the CEC, NEC, or control groups in all tested teeth. These results,
relative to CEC, are in agreement with a previous study (19).
Despite the fact that our results related to NEC cannot be directly
compared with previous reports, it is not surprising that teeth in the NEC
group showed no difference in fracture strength compared with the
control and CEC groups because of the minimally invasive access cavity
designs of NEC.
However, in a recent study, the CEC cavity did not increase the frac-
ture strength of restored maxillary molars in comparison with ones pre-
pared with TEC, suggesting no apparent benefit of CEC in this regard
(22). This contrasting finding is probably because of the differences
in the methodology of that study including the type of teeth considered
(only maxillary molars were reported to be subjected to fracture more
than mandibular ones [33]); the techniques and materials used for
endodontic and restoring procedures; and the method used to assess
the fracture strength (teeth were cyclically fatigued and subsequently
loaded to failure [22]).
Although CEC improved fracture strength more than TEC, it could
increase the risks of inefficient canal instrumentation and the occur-
rence of procedural errors as previously reported (19). However, a
recent study showed that CECs in maxillary molars did not appear to
impact instrumentation efficacy (22). No studies have investigated the
quality of endodontic procedures using NEC.
In addition, the ideal access cavity would allow complete removal
of pulp tissue, debris, and necrotic materials. However, the smaller the
access cavity, the higher the risk of bacterial contaminations and the
possibility of missing some root canal orifices (22, 34).
The results of the present study showed a higher number of restor-
able fracture patterns in intact teeth than in the ones prepared with TEC,
CEC, or NEC. These findings are in agreement with a previous report
(35). Furthermore, the majority of the teeth prepared with TEC, CEC,
or NEC showed unrestorable fracture patterns with no significant
difference among the different access cavity designs.

TABLE 3. Load at Fracture (Mean  Standard Deviation) and Type of Fracture, Restorable (R) or Unrestorable (U), for Intact Teeth (Control) or Traditional,
Conservative, or Ninja Access Assessed after the Static Test Using a Mechanical Material Testing Machine
Load at fracture (N) Type of fracture
Control TEC CEC NEC
Tooth type (n = 10) Control TEC CEC NEC R U R U R U R U
a b a a a b b a b a b
Upper premolars 913 (188) 498 (250) 821 (324) 805 (204) 7 3 2 8 3 7 3 7a
Lower premolars 1006 (313)a 704 (310)b 929 (384)a 945 (267)a 7a 3b 3b 7a 2b 8a 3b 7a
Upper molars 1172 (598)a 810 (425)b 1143 (506)a 1170 (432)a 8a 2b 3b 7a 3b 7a 3b 7a
Lower molars 1572 (639)a 923 (393)b 1401 (495)a 1459 (278)a 7a 3b 2b 8a 2b 8a 3b 7a
CEC, conservative endodontic cavity; NEC, ninja endodontic cavity; TEC, traditional endodontic cavity.
Similar lowercase letters in the same row indicate no statistically significant differences (P > .05).

JOE Volume -, Number -, - 2017 Fracture Strength of Endodontically Treated Teeth 5

Basic ResearchTechnology
Within the limitations of this study, it can be concluded that
conservative endodontic access cavities such as CEC and NEC
increased the fracture strength of teeth compared with those with
TEC. The ultraconservative NEC access did not improve the fracture
strength of teeth with CEC access. Moreover, restored CEC and NEC
did not reduce the fracture strength, but they did influence the frac-
ture pattern of intact teeth.
Further clinical studies are necessary to determine the efficacy of
instrumentation, difficulties during endodontic procedures and long-
term prognosis of endodontically treated maxillary and mandibular
molars and premolars with CEC or NEC.
Acknowledgments
The authors thank Giusy La Rosa from the University of
Catania for the support in the sketches of teeth with CEC and
NEC accesses.
The authors deny any conflict of interests related to this study.
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