Original Research Article

In vitro evaluation of the strength of endodontically treated teeth after preservation

of soffit and pericervical dentin

Ashwini Gaikwad1,*, Varsha Pandit2

1Professor, 2Associate Professor, Dept. of Conservative Dentistry and Endodontics, Bharati Vidyapeeth Deemed University
Dental College and Hospital, Pune

*Corresponding Author:
Email: [email protected]

Abstract
Aim: To evaluate the strength of an endodontically treated tooth after preservation of peri-cervical dentin and soffit.
Methodology: 30 human molars having well developed cusps and morphology were extracted for periodontal reasons were
included in this study. They were divided in two groups. In gp. A, Clark- Khademi access was made and endodontic treatment was
carried out with 2% NiTi K-files and in gp. B, Straight line access was made and endodontic treatment was carried out with 2%
NiTi K-files. Normal endodontic treatment was carried out with 2% flexible NiTi K-files with 17% EDTA as chelating agent and
5.25% Sodium Hypochlorite solution for irrigation. Obturation was carried out using the lateral condensation technique with gutta-
percha coated with sealer. After this, the pulp chamber was cleaned thoroughly with cotton and all-in-one bonding agent was
applied and scrubbed with an applicator tip for 30 seconds. Next, Composite restoration was done as post-obturation restoration.
Specimens were then tested with a universal testing machine, set to deliver an increasing load until failure. Failure was defined as
a 25% drop in the applied load. The load was applied parallel to the long axis of the tooth. The variable of interest was the load at
failure measured in Newtons.
The data thus obtained was subjected to statistical analysis and was analysed using one way ANOVA test for significance
with Bonferroni corrections.
Result: The teeth with Clark-Khademi access preparation with 2% taper of the endodontic files were more efficient at resisting the
fracture than the teeth with straight line access preparation with 2% taper of the endodontic files.
Conclusion: The teeth after preservation of pericervical dentin and soffit were found to be structurally reinforced as compared to
the teeth with straight line access. Clark-Khademi access preparation was found to be more effective at dentin preservation and
strengthening the tooth when compared to straight line access.

Keywords: Soffit, pericervical dentin, Strength of endodontically treated teeth.

Introduction negates the traditionalist straight-line access protocol

Access cavity preparation is the first and arguably and the total deroofing of the pulp chamber.(6)
the most important phase of root canal treatment. A well- Drs. Clark and Khademi have coined the term
designed access preparation is essential for a good “soffit”, which is a small piece of dentin roof around the
endodontic result. Without adequate access, instruments entire pulp chamber, to preserve the critical region of
and materials become difficult to handle properly in the peri-cervical dentin (PCD) that is 4mm above and below
highly complex and variable root canal system.(1) the crestal bone, without compromising debridement and
A properly prepared access cavity creates a smooth, without inducing iatrogenic misadventure. This type of
straight- line path to the canal system and ultimately to more constrained, constricted and conservative access
the apex. Ideal access results in straight entry into the cavity encourages the preservation of dentin, thus
canal orifice, with the line angles forming a funnel that increasing the strength of the remaining tooth structure
drops smoothly into the canal(s).(2) and thus prevents the chances of fracture of the tooth.(3,6)
A Traditional access cavity generally has tapering The prognosis of endodontically treated teeth depends
walls with its widest dimension at the occlusal surface. not only on the success of the treatment but also on the
Stainless steel files were used which were stiffer and amount of remaining dentin. Fractures of restored
were not so efficient in negotiating the curvatures of the endodontically treated teeth are a common occurrence in
root canal. To counter this, a large wider access clinical practice, due to excessive removal of dentin.(7)
preparation was advised.(3,4,5) But, wider access So improvement in the access cavity preparation to save
preparation done traditionally, resulted in unnecessary the unnecessary removal of dentin is required.(6)
dentin removal and hence weakening of the tooth In light of these observations, we had planned to
structure. The advent of Nickel-titanium instruments evaluate the strength of an endodontically treated tooth
paved way for more conservative access preparations, as after preservation of dentin at the soffit region and at the
these files are super elastic and flexible which can pericervical area.
negotiate the canal curvatures easily. Drs. Clark and
Khademi have described a concept of conservative
endodontic access cavity preparation. This concept

Indian Journal of Conservative and Endodontics, October-December,2016;1(3):93-96 93

Ashwini Gaikwad et al. In vitro evaluation of the strength of endodontically treated teeth after……….

Methodology Next, Composite was added in small increments

Thirty human molars having well developed cusps (gently tapped with the applicator tip) to adapt properly
and morphology were extracted for periodontal reasons in the pulp chamber and light cured after every
were included in this study. The teeth were without increment. Composite instruments were used to gently
caries, anomalies and fractures. This study was carve the occlusal anatomy of the tooth.
conducted in the Department of Conservative Dentistry Specimens were then tested with a universal testing
and Endodontics, Bharati Vidyapeeth Deemed machine, set to deliver an increasing load until failure.
University Dental College and Hospital, Pune. Failure was defined as a 25% drop in the applied load.
The crosshead speed was 1 mm per minute, and the load
The teeth were randomly divided into two groups as was applied parallel to the long axis of the tooth. The
follows: variable of interest was the load at failure measured in
Groups Sample Procedure Newtons.
size The data thus obtained was subjected to statistical
Clark- Khademi access analysis and was analysed using one way ANOVA test
Group 15 design was made and for significance with Bonferroni corrections.
A endodontic treatment was
carried out with 2% NiTi K- Group A Group B
files.
Straight line access was
Group 15 made and endodontic
B treatment was carried out
with 2% NiTi K-files.

 Group A (n=15): A Large Round bur was used to

create the initial access. The central pit of the teeth
was selected as the reference point for guiding the
bur into the pulp chamber. The position of the bur
was held parallel to the long axis of the tooth as all Pre-operative X-ray Pre-operative X-ray
times. After the initial drop into the pulp chamber, a
DG-16 probe is used to locate the canals by tactile
sensation.
The back end of the explorer or probe is used to
check for “soffit,” which is the dentin roof around the
entire coronal portion of the pulp chamber. A X-ray was
made at this stage of the access preparation to check for
the soffit radiographically.
 Group B (n=15): A Large round bur was used to
create the initial access. After the initial drop into
the pulp chamber, a endo-access preparation bur Access cavity Access cavity
was used to widen the access preparation till the bur preparation x-ray preparation x-ray
reaches the walls of the pulp chamber, so that a
straight-line access was made. A X-ray was made at
this stage to check for the straight line access
radiographically.
For Groups A & B - After confirming the X-ray’s
respectively, normal endodontic treatment was carried
out with 2% flexible NiTi K-files with 17% EDTA as
chelating agent and 5.25% Sodium Hypochlorite
solution for irrigation. Obturation was carried out using
the lateral condensation technique with gutta-percha
coated with sealer. Post obturation x-ray Post obturation x-ray
After Obturation was carried out for all the groups, and por with and por with
the pulp chamber was cleaned thoroughly with cotton Composite resin Composite resin
and all-in-one bonding agent was applied and scrubbed
Statistical analysis
with an applicator tip for 30 seconds. After this, another
drop of bonding agent was applied and scrubbed again The compressive strength of the samples prepared in
for 30 seconds and then light cured. each group was expressed as means and standard
deviations (mean ± SD). The between group comparison
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Ashwini Gaikwad et al. In vitro evaluation of the strength of endodontically treated teeth after……….

of compressive strength of samples in Group A and B cleaning and shaping. The authors also noted that the
was done using One- way ANOVA test. Within group decrease in the strength of endodontically treated teeth is
comparison was done using Bonferroni correction test. the result of alteration of coronal tooth structure, which
In the tests, p value of ≤0.05 was considered as ultimately causes the loss of strength of the tooth.(11)
statistically significant. Christine Sedley, Harold Messer (1992) reported that
endodontically treated teeth had 35% lesser stiffness
Results values when compared to the vital teeth.(9)
Drs. Clark and Khademi have described the concept
Table 1: Comparison of compressive strengths of the of conservative endodontic access preparations by
samples in Group A (soffit 2%) and Group B (2% preserving the peri-cervical dentin and ‘soffit’, thereby
straight line access) negating the traditional straight line access and the
Compressive Group Group P value totality of de-roofing the pulp chamber. Soffit is a small
strength, A B (One piece of roof of the dentin around the entire pulp
Newton way chamber, and the peri-cervical dentin, that is 4 mm of
ANOVA) dentin above and below the level of crestal bone.(3,4,5)
Mean 1149.70 1031.73 Papa et al emphasized the importance of conserving
Standard 111.35 71.36 the bulk of dentine to maintain the structural integrity of
deviation 0.001* post-endodontically restored teeth.(19) Asudi et al have
*p<0.05 is statistically significant emphasized that the loss of tooth structure is the key
reason for the increase in fracture predilection of
endodontically treated teeth.(7)
In light of these observations, the present study was
conducted to evaluate and compare the effect of
conserving dentin at the region of peri-cervical dentin
and soffit, on the strength of the tooth, with two different
types of access preparations.
For this study, molar teeth were collected. As the
molars absorbs a more vertical force and, thus the higher
net compressive force.(4) Teeth were divided into two
groups. Group A consists of Clark- Khademi style access
preparation and endodontic treatment was carried out
with 2% NiTi K-files. As 2% Taper files are less
Discussion aggressive in dentin removal, and thus help in
preservation of soffit and pericervical dentin. Group B
Endodontically treated teeth are proved to be weaker
consisted of Straight-line access preparation and
than vital teeth and are known to present a higher risk of
fracture failure when compared to the vital teeth. Hence endodontic treatment was carried out with 2% NiTi K-
attention should be paid to unnecessary dentin removal files. Group B also uses 2% taper files but with straight
during endodontic treatment, in order to maintain the line access. This group represents the conventional
endodontic technique, which is still in use by majority of
strength of the teeth.(18) Access cavity preparation is the
first and arguably most important phase of root canal the clinicians.(6)
treatment. A well-designed access preparation is During the complete bio-mechanical preparation,
essential for a good endodontic result. Without adequate 5.25% Sodium Hypochlorite solution was used as an
access, instruments and materials become difficult to irrigating solution along with 17% EDTA as a chelator.
handle properly in the highly complex and variable root NaOCl possesses a broad spectrum antimicrobial
canal system.(1) The objectives of access cavity property, dissolvent of organic tissue and also lubricates
preparation is not only to create a smooth, straight-linethe canal for efficient instrumentation. EDTA chelates a
path, debridement of the entire canal system, to reduce stable calcium complex with dentin mud which helps in
the risk of file breakage but also to conserve the sound removing of canal obstructions and thus further aids in
instrumentation.
tooth structure, especially at the peri-cervical area of the
tooth.(2) Traditional endodontic design adheres to Gutta-percha was used as an obturating material in
straight line access, de-roofing of the pulp chamber and both the groups as it is the universally accepted core
pre-flaring the coronal one-third of the root canal to material used for obturation. Sealapex (Sybron-Endo)
facilitate the shaping of the entire root canal system inwas used as the sealer in all the groups. Sealapex is a
Calcium hydroxide based sealer which exhibits
order to negotiate the apical terminus. In order to achieve
these objectives, a large amount of tooth structure was antimicrobial activity.
compromised.(1) For the post obturation restoration, Composite
material, with all-in-one bonding system was chosen for
Gutmann JL et al (1992) noted in his study that there
is an excessive removal of radicular dentin during canal all the 3 groups. In a study by Trope et al, he concluded
Indian Journal of Conservative and Endodontics, October-December,2016;1(3):93-96 95
Ashwini Gaikwad et al. In vitro evaluation of the strength of endodontically treated teeth after……….

that acid etching and restoration with a composite resin

strengthened the endodontically treated teeth.(17) Conclusion
The teeth were embedded in auto-polymerising Within the limitations of this in vitro study following
acrylic resin blocks upto the cemento-enamel junction. conclusions were made:
The dimensions of the acrylic block were 15mm X 1. The teeth after preservation of peri-cervical dentin
15mm X 20 mm. This dimension was chosen so that all and soffit were found to be structurally reinforced as
of the root surface area was adequately covered by the compared to the teeth with straight line access.
resin and also a sufficient margin of resin was left from 2. Clark-Khademi access preparation was found to be
the tooth surface, so that the sample does not undergo more effective at dentin preservation and
pre-cracking while testing under load. strengthening the tooth when compared to straight
Universal Testing Machine was used to evaluate the line access.
fracture strength of the specimens which was set to
deliver an increasing load until failure. Failure was References
defined as a 25% drop in the applied load. The crosshead 1. Frank Vertucci, James Haddix, Chap 7, Tooth Morphology
speed was 1 mm per minute, and the load was applied to and Access preparation, Pathways of the pulp Cohen
the central pit of the tooth, parallel to the long axis of the 10th Edition.
2. Monnan G, Smallwood ER, Gulabivala K: Effects of
tooth. The method of testing was fatigue loading so as to access cavity location and design on degree and
simulate the dynamic forces that act onto the tooth distribution of instrumented root canal surface in maxillary
during mastication and swallowing.(4,5) The results were anterior teeth. Int Endod J 34:176, 2001.
obtained and statistically analyzed. 3. Clark D, Khademi J. Modern molar endodontic access and
Table 1 showed that both the groups could more or directed dentin conservation. Dent Clin North Am
2010;54:249-73.
less resist the compressive loads; with Group A showing
4. Clark D, Khademi J, Herbranson E. Fracture resistant
the most statistically significant difference when endodontic and restorative preparations. Dent Today
compared to Group B, that is the Clark-Khademi access 2013;32:118,120-3.
preparation with 2% taper of the endodontic files was the 5. Clark D, Khademi J, Herbranson E. The new science of
most efficient at resisting the fracture than Group B strong endo teeth. Dent Today 2013;32:112,114,116-7.
which has straight line access. The reason for this would 6. Martin Trope. Bio-minimalism: Trends and transitions in
endodontics. Dental Town, April 2016.
be the banking of tooth structure; that is dentin preserved 7. Anil Kishen. Mechanisms and risk factors for fracture
at both pericervical region and the soffit. Gutmann JL et predilection in endodontically treated teeth. Endodontic
al also showed that the mechanical integrity provided by topics 2006,13,57-83.
even a small part of the roof of the pulp chamber allows 8. Akkayan B, Gulmez T. Resistance to fracture of
for greater flexure of the tooth during function.(11) endodontically treated teeth restored with different post
Dentin is primarily a collagen-rich organic matrix systems. J Prosthet Dent 2002;87:431.
9. Sedgley CM, Messer HH. Are endodontically treated teeth
reinforced by calcium phosphate mineral particles. The more brittle? J Endodon 1992;18:332–5.
constituents of dentin material are efficiently optimized 10. Papa J, Cain C, Messer HH. Moisture content of vital
to different mechanical demands in the mouth. Often, vsendodontically treated teeth. Endod Dent
endodontically treated teeth experience tissue loss due to Traumatol1994:10:91–93.
prior pathology or treatment procedures. The loss of 11. Gutmann JL. The dentin–root complex: anatomic and
dentine tissue will compromise the mechanical integrity biologic considerations in restoring endodontically treated
teeth. J Prosthet Dent 1992:67:458–467.
of the remaining tooth structure.(7)
The approach of banking of tooth structure in How to cite this article:
restorative dentistry dictates that whenever possible,
more tooth structure should be preserved. It may involve Gaikwad A, Pandit V. In vitro evaluation of the strength of
a less expedient, but more conservative, approach. This endodontically treated teeth after preservation of soffit and
pericervical dentin. Ind J Conserv Endod, 2016;1(3):93-96.
banked tooth structure may serve as a valuable future
asset in the advent of unforeseen future trauma or
disease, coupled with the reality that a tooth will need to
last for decades and potentially be restored and then
rerestored in the patient’s lifetime. The primary reason
to maintain the soffit is to avoid the collateral damage
that usually occurs, by the gouging of the lateral
walls.(4,5)
‘Soffit’ is totally a new concept in access cavity
preparation and further research is required to be done
on more number of samples to check the strength of the
tooth. Research will certainly need to be done to validate
other parameters like complete debridement, cleanliness,
disinfection etc. with soffit preparation.(4,5,6)
Indian Journal of Conservative and Endodontics, October-December,2016;1(3):93-96 96