Basic Research—Technology
Effect of Truss Access and Artificial Truss
Restoration on the Fracture Resistance of
Endodontically Treated Mandibular First Molars
Mahmoud Y. Abou-Elnaga, DDS, MSc,* Moataz-Bellah A.M. Alkhawas, DDS, MSc, PhD,*
Hyeon-Cheol Kim, DDS, MS, PhD,† and Ashraf S. Refai, DDS, MSc, PhD*
Abstract
Introduction: This study evaluated the effects of tradi-
tional and truss access cavity preparations in addition to
artificial truss restoration on the fracture resistance of
endodontically treated mandibular molars. Methods:
A total of 66 recently extracted, intact mandibular first
molars were collected from patients between 20 and
45 years of age. After the preparation of a mesio-
occluso-distal cavity in all teeth, the teeth were
randomly grouped into the following 4 groups according
to the access cavity design: traditional access cavity,
artificial truss restoration, truss access cavity, and con-
trol groups. Endodontic access cavities were performed
in the experimental groups according to each treatment
modality followed by instrumentation, irrigation, and
obturation. After composite restoration, the teeth
were subjected to a vertical occlusal force until fracture
occurred. The data were statistically analyzed, and the
fracture patterns were evaluated. Results: First, a 1-
way analysis of variance test analysis of the fracture
resistance of the experimental groups showed nonsig-
nificant differences among groups (P > .05). Second,
the data were statistically analyzed using the Student
t test to compare the fracture resistance of each exper-
imental group with that in the control group. The control
group had statistically significantly higher mean values
for fracture resistance than the traditional access group
and the artificial truss restoration group (P < .05). No
statistically significant difference was recorded in the
fracture resistance between the control group and the
truss access cavity group (P > .05). Conclusions: The
truss access cavity preparation improved the fracture
resistance of endodontically treated teeth with mesio-
occluso-distal cavities, whereas the artificial truss resto-
ration did not improve it. (J Endod 2019;-:1–5)
From the *Department of Endodontics, Faculty of Dental Medicine, Al-Azhar University, Cairo, Egypt; and †Department of Conservative Dentistry, School of Dentistry,
Pusan National University, South Korea.
Address requests for reprints to Dr Moataz-Bellah A.M. Alkhawas, Al-Azhar University, Department of Endodontics, Faculty of Dental Medicine, Cairo 00202, Egypt.
E-mail address: malkhawas@yahoo.com
0099-2399/$ - see front matter
Copyright ª 2019 American Association of Endodontists.
https://doi.org/10.1016/j.joen.2019.02.007
JOE — Volume -, Number -, - 2019
Key Words
Artificial truss restoration, conservative access cavity, endodontic access cavity, fracture
resistance, truss access cavity
T raditional access cav-
ity preparation may
result in weakening of
Significance
This research has been directed to evaluate the ef-
fects of truss access cavity and artificial truss
the remaining tooth
restoration and to see whether they are relevant
structure added to the
in reducing tooth fracture after endodontic treat-
previously weakened
ment.
structure because of pa-
thology. This tooth weak-
ening occurs because of the loss of strategic internal tooth architecture at the
center of the tooth and/or the marginal ridges, which may manifest in the form
of cuspal deflection (1–3). To restore these teeth, various treatment modalities
may be used, ranging from a simple direct restoration with or without an
intraradicular post to more complex indirect restorations, including inlay,
onlay, and full-coverage crowns (4). Trials of more conservative access cavity de-
signs such as contracted (a small conservative cavity on the occlusal surface that
allow the clinician to access all the canal orifices), truss (a direct access from the
occlusal surface to expose the mesial and distal canal orifices and leaving the
intervening dentin intact), and ninja (ultraconservative approach) access cavity
preparation methods have been reported to improve fracture resistance of
endodontically treated teeth and reduce the dependency on complex, more expen-
sive post endodontic restorations (5–7). An alternative treatment modality was
reported for restoration of the endodontically treated teeth by a horizontal
placement of a glass fiber post within the coronal tooth structure in the
buccolingual direction (artificial truss restoration [ATR]) (8). This study evalu-
ated the fracture resistance of endodontically treated mandibular first molars
with mesio-occluso-distal (MOD) cavities using different treatment modalities,
including traditional access cavity (TAC) and truss access (TA) cavity preparations
in addition to ATR. The null hypothesis tested was that there would be no influ-
ence of the tested treatment modalities on the fracture resistance of the endodon-
tically treated mandibular first molars.
Truss Access and Artificial Truss Restoration 1
Basic Research—Technology
Materials and Methods
Sample Size Computation
The sample size was estimated based on studies comparing tradi-
tional, conservative access cavities and ATR (8–10). Accordingly, for
analysis with alpha = 0.05 and 80% power, at least 9 teeth were
allocated for each group.
Selection of the Teeth
Sixty-six recently extracted mandibular first molars were collected
from patients between 20 and 45 years of age. The selected teeth were
cleaned of calculus and soft tissue remnants using a hand curette. The
teeth were disinfected using 5.25% sodium hypochlorite (Clorox;
Clorox Inc, Oakland, CA) for 10 minutes and rinsed with distilled water.
The operators examined the teeth using a dental operating microscope
(S2300; Zumax Medical Co, Suzhou, China) at 10.4 magnification to
exclude teeth that had caries, deep cracks, attritions, fractures, or res-
torations. The buccolingual and mesiodistal dimensions were
measured at the level of the cervical margin using a digital caliper. Teeth
with buccolingual and mesiodistal widths of 10.73 mm (0.44 mm)
and 10.91 mm (0.44 mm), respectively, were included in the study.
The selected teeth were stored in normal saline solution at room tem-
perature until the time of use.
Preparation of the Samples
Preoperative cone-beam computed tomographic scans (Planmeca
ProMax 3d MID; Planmeca, Helsinki, Finland) (voxel size = 75 mm with
90 kV and 12 mA) of the selected teeth were obtained to measure the
average mesiodistal dimensions of the pulp chamber and the average
distance between the occlusal surface (central fissure) and the roof
of the pulp chamber. Only those teeth that had pulp chambers with me-
siodistal dimensions between 3.74 and 4.44 mm were included in this
study. Additionally, teeth with an average distance between the occlusal
surface and the roof of the pulp chamber of 4.19 mm (0.17) were
included (Fig. 1A).
The operators used a custom-made parallelometer device
(Fig. 1B) to create standard MOD cavities with a specific dimension
(2.5-mm wide  2.0-mm deep) and 2 proximal boxes with specific di-
mensions (2.5-mm wide  2.0-mm deep  4.0-mm high) for all
samples.
The samples were randomly grouped into 4 groups (n = 12)
according to the access cavity design as follows:
1. The TAC group (Fig. 2A)
2. The ATR group: traditional access cavity preparation and restored
with a horizontally placed glass fiber post (Fig. 2C)
3. The TA group (Fig. 2B)
Figure 1. (A) A cone-beam computed tomographic scan (coronal view)
showing mesiodistal measurements and the occlusal distance to the roof of
the pulp chamber. (B) The parallelometer device.
2 Abou-Elnaga et al.
4. The control group (without access cavity preparation)
The TAC and ATR groups were prepared as follows: the MOD cavity
was completed with dimensions of 2.5-mm wide  4-mm long. In the
TA group, the mesial and distal proximal boxes were prepared with
dimensions of 2.5-mm wide  4.0-mm deep  4.0-mm long.
Root Canal Treatment Procedures
In the TAC and ATR groups, the access cavity was prepared by com-
plete deroofing of the pulp chamber with exposure of all pulp horns and
straight-line access into the canals. In the TA group, the access cavity
was prepared by exposing the mesial and distal canals with smooth-
ening of the pulp chamber walls and leaving the intervening dentin
intact. Canal negotiation and patency were accomplished using size
#10 and #15 K-files (Mani Inc, Tochigi, Japan.). The working length
was measured, and instrumentation of the root canals was performed
using the ProTaper Universal Rotary File System (Dentsply Maillefer,
Ballaigues, Switzerland) according to the manufacturer’s protocol up
to size F2 for mesial canals and F3 for distal canals. Canals were inter-
mittently irrigated throughout instrumentation with 3 mL of 5.25% so-
dium hypochlorite between each file. The canals were dried and
obturated using gutta-percha points and resin-based root canal sealer
(Adseal; Meta Biomed Co Ltd, Chungbuk, South Korea).
Restoration of the Samples
In the ATR group, before the restoration of the samples, 2 holes
were drilled in both the buccal and lingual walls at a point 2.5 mm below
the cavosurface angles between the mesial and distal cusps. A size #7
rounded diamond bur (Diamond Bur, 001/BR-28 series, round, me-
dium; FG, Syndent, Jiangsu, China) attached to a high-speed handpiece
was used to create the holes (2 mm in diameter). The parallel part of a
size 3 fiber post (RelyX Blue; 3M ESPE, St Paul, MN) 1.9 mm in diameter
was trial fitted into the 2 holes and was then removed, cleaned with ethyl
alcohol, and dried. A self-adhesive resin cement capsule (G-CEM Cor-
poration, Tokyo, Japan) was used to cement the fiber post horizontally
within the 2 holes as follows: the surfaces of the holes were first washed
and etched with 37% phosphoric acid (Meta Etchant, Meta Biomed Co
Ltd) for 15 seconds and then rinsed and dried. The resin cement was
mixed and dispensed into the 2 holes followed by placement of the fiber
post. A tack cure for 3 seconds was performed to allow slight hardening
of the cement, and the excess cement was removed with a sharp probe.
Then, the cement was left to sit for 5 minutes, and the extremities of the
post were cut near the buccal and lingual surfaces using a tapered stone
(Diamond Bur, #F850/016, round end tapered, FG).
The samples from the TAC, ATR, and TA groups were restored as
follows: a universal Tofflemire matrix band (Original Tofflemire #1;
WaterPik, Fort Collins, CO) was placed around the teeth. The enamel
and dentin surfaces were etched with 37% phosphoric acid for 15 sec-
onds. The etched surfaces were rinsed for 20 seconds and dried using
an air/water syringe. A bonding agent (Solobond M; Voco, Cuxhaven,
Germany) was applied to the prepared surfaces with a microbrush
and then light cured for 20 seconds. Flowable composite (X-tra base
bulk fill flowable composite, VOCO) was placed in one 4-mm increment
onto the floor of the pulp chamber and the proximal boxes to a level of 1
mm below the dentino-enamel junction and then light cured for 40 sec-
onds. The rest of the cavity was filled with composite resin (Polofil Nht,
VOCO) to the level of the occlusal surface with the preservation of the
occlusal anatomy.
In the control group, the prepared surfaces were etched and
bonded followed by application of the flowable composite onto the
proximal boxes to a level of 1 mm below the dentino-enamel junction,
which were then light cured for 40 seconds. The rest of the cavity was
JOE — Volume -, Number -, - 2019
 Basic Research—Technology

Figure 2. Photographs showing (A) TAC preparation, (B) TA cavity preparation, and (C) ATR.

filled with composite resin to the level of the occlusal surface with pres- group. Then, 1-way analysis of variance followed by pair-wise Tukey
ervation of the occlusal anatomy. post hoc tests was performed to assess the significance of differences
between groups. Statistical analyses were performed using Asistat 7.6
Evaluation of the Samples software (Personal PC, Brazil). P values #.05 were considered to be
The samples were individually mounted in a computer-controlled statistically significant in all tests.
material testing machine (Model 3345; Instron Industrial Products,
Norwood, MA), and data were recorded using computer software Results
(Bluehill Lite Software, Instron Industrial Products). A long stainless
Comparing the fracture resistance of the experimental groups, the
steel rod with a rounded tip (5.6 mm in diameter  10 mm in length)
highest fracture resistance mean values in newtons were recorded for
was positioned on the center of the occlusal surface of the samples
the TA group (1977.09  316.2) followed by the TAC group
touching the inclined surfaces of both the buccal and lingual cusps.
(1723.84  453.9), whereas the ATR group had the lowest fracture
The samples were subjected to a vertical compressive force loaded at
resistance mean values (1696.25  358.4) with a nonsignificant differ-
a crosshead speed of 1 mm/min parallel to the long axis of the tooth
ence between the groups (P > .05, F = 1.4).
until fracture occurred. After mechanical testing, all the samples were
Moreover, the fracture resistance of each experimental group was
visually inspected using a dental operating microscope (17.0 magni-
compared with that of the control group, and the data were statistically
fication) to determine the fracture patterns, which were classified as
analyzed using the Student t test. The control group had statistically
either favorable fracture or unfavorable fracture. The favorable fracture
significantly higher fracture resistance mean values (in newtons)
was considered when the level of fracture dissipated to not more than 1
(2260.93  540.2) than the TAC group (P < .05) and the ATR group
mm below the cervical margin of the sample provided that the level of
(P < .05). The fracture resistance mean values recorded for the control
the fracture was above the pulp chamber floor. The unfavorable fracture
group were statistically nonsignificantly higher than those of the TA
was considered when the level of fracture dissipated to more than 1 mm
group (P > .05). When comparing the fracture patterns among the
below the cervical margin of the sample. In addition, the unfavourable
experimental groups, the difference in fracture patterns were statisti-
fracture was considered when the level of fracture dissipated to not
cally nonsignificant (P > .05, F = 0.531; Fig. 3A–C).
more than 1 mm below the cervical margin of the sample or when
the fracture was below the pulp chamber floor whether it occurred
in the buccolingual or mesiodistal directions. Discussion
The conservation of tooth structure is 1 of the most important fac-
Statistical Analysis tors that affects the survival of endodontically treated teeth. The benefits
The data were collected, tabulated, and statistically analyzed in (9–14) and possible drawbacks of the conservative endodontic access
several steps. First, the descriptive statistics were collected for each cavity concept have not been well supported by research data (15).

Figure 3. Photographs showing the fracture patterns of (A) the TAC group, (B) the TA cavity group, and (C) the ATR group.

JOE — Volume -, Number -, - 2019 Truss Access and Artificial Truss Restoration 3
Basic Research—Technology
Mandibular first molars were used in this study because these teeth
are more susceptible to fracture (with wider occlusal tables, which in-
crease the occlusal stresses) (16). These teeth are also the most
commonly endodontically treated posterior teeth and often require cus-
pal protection (15). The teeth were collected from patients between 20
and 45 years of age to minimize variation in the dentin nature (17) as a
result of secondary and sclerotic dentin deposition (18, 19). The
external and internal anatomy of the molars were standardized to
limit the variation of the occlusal table and dentin thickness (20).
MOD cavities were prepared to create a standardized starting point
for all the samples to eliminate the effect on the fracture resistance of
intervening tooth structure between the buccal and lingual cusps.
The TA cavity was prepared by creating bilateral proximal boxes,
leaving approximately 2 mm of intervening dentin intact to allow for
adequate root canal preparation and obturation. Furthermore, ATR
was prepared by creating 2 holes at a point 2.5 mm below the buccal
and lingual cavosurface angles of the cavities. The position of the ATR
was chosen such that the position would correspond to that of the truss
dentin bridge in the other group. The drilled holes were approximately
2 mm in diameter. These holes sizes were found to be compatible with
the parallel part of glass fiber posts (1.9 mm in diameter) and allowed
space for resin cement. The glass fiber posts were selected because of
their low elastic modulus, which is similar to that of dentin, unlike other
posts materials (21, 22). The parallel part of the post was used to create
a uniform thickness of the ATR.
The fracture resistance was tested using static compressive loading
in a universal testing machine because of its ease of availability and low
costs. The diameter of the sphere head was selected to be 5.6 mm to
allow adequate contact with the cuspal inclines during testing. Addition-
ally, these conditions are similar to those of other studies on molars that
tested fracture resistance (23).
In the present study, the control group had significantly higher
fracture resistance values than those observed for the TAC and ATR
groups. This can be explained by the fact that the access cavity prepa-
ration itself reduces the fracture resistance of the teeth as a result of
the removal of strategic internal architecture at the center of the tooth
(complete deroofing of the pulp chamber) (2, 4). Furthermore,
another reason for the poor performance of the TAC group may have
been that the TAC group was restored using bonded composite
restorations, and the maximum bond strength between composite
material and dentin is no more than 46.2  7.9 MPa (24, 25),
whereas the fracture strength of dentin is 212.9  41.9 MPa (26, 27).
ATR resulted in the lowest fracture resistance value; this result may
have many explanations. First, the point of contact (surface area) be-
tween the glass fiber post and the tooth structure in the periphery of
the buccal and lingual holes is minimal; hence, it does not provide
an adequate area for bonding. Second, the fiber post was cemented
in place using resin cement; it has been established that the bond
strength between a glass fiber post and resin cement ranges between
11.27 and 32.4 MPa (28, 29), which is weaker than the bond
strength between the composite restoration and dentin. Third, the
process of creating buccal and lingual holes might have affected the
fracture resistance of the teeth as a result of further removal of tooth
structure and microcrazing within the tooth structure during
preparation (30, 31).
There was no significant difference between the fracture resistance
of the control group and that of the TA cavity group. This result may be
explained by the fact that in the TA cavity group the dentin bridge re-
mained and connected the buccal and lingual surfaces of the tooth,
thus improving the fracture resistance compared with that of the TAC
and ATR groups. The present results contrast with the research done
by Corsentino et al (32) in 2018 in which they found no significant dif-
4 Abou-Elnaga et al.
ference between the different access cavities used in their study
including TA. The disagreement is attributed to the difference in meth-
odology because in the Corsentino study the truss was not standardized
to a specific size and the pulp chamber anatomy of each tooth dictated
the size of the truss. Furthermore, the testing parameters in the study
were different with regard to the size of the testing rod and crosshead
speed.
After the completion of this study, an analysis of the fracture pat-
terns was performed to determine whether any of the treatment modal-
ities altered the fracture pattern to a more favorable fracture. Based on
the statistical analysis, no significant difference between the experi-
mental groups regarding differences in the fracture patterns was found
that accept the null hypothesis of the research.
The literature in this field showed contradicting results that could
be caused by multiple reasons including the number of samples, the
tooth type, the inclusion criteria during the selection of teeth, teeth
with/without MOD cavity preparation, and the difference of the testing
parameters (7–12, 14).
Conclusion
Within the limitations of this study, it can be concluded that the TA
cavity preparation improved the fracture resistance of endodontically
treated teeth with MOD cavities, whereas ATR did not improve the frac-
ture resistance of endodontically treated teeth with MOD cavities. The
authors highly recommend preoperative cone-beam computed tomo-
graphic scanning before TA cavity preparation.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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Truss Access and Artificial Truss Restoration 5