Endodontic Topics 2015, 33, 169186

All rights reserved

2015 John Wiley & Sons A/S.

Published by John Wiley & Sons Ltd
ENDODONTIC TOPICS
1601-1538

Contracted endodontic cavities:

the foundation for less invasive
alternatives in the management of
apical periodontitis

CARLOS B OVEDA
& ANIL KISHEN
Compromised structural or mechanical integrity of teeth results in different types of tooth fractures, which are
known to be one of the most common causes for tooth extraction. Minimally invasive concepts and
procedures are currently advocated as less invasive alternatives to traditional treatments. Recent advances in the
available resources and technologies have made a significant impact on endodontic treatment procedures,
allowing minimally invasive treatment procedures such as contracted endodontic cavities for preserving coronal
and radicular tooth structure. The purpose of this article is to provide a framework for understanding
the clinical reasoning for contracted endodontic cavities and their possible benefits in contemporary
endodontics.
Received 13 October 2015; accepted 16 October 2015.

Introduction
In recent years, restorative dentistry has been
undergoing a paradigm shift toward embracing
therapeutic modalities that methodically respect the
original tooth tissues (1,2). The philosophy of
minimally invasive dentistry acknowledges that
dental caries cannot be managed merely by cavity
preparations and restorations, because such
treatment procedures can weaken the remaining
tooth structure (1). Current advances in the field of
adhesive dentistry, as well as progress in the science
of cariology, have made minimally invasive dentistry
possible practically (35). Although the paradigm of
minimally invasive treatment has limited supporting
evidence, it is gradually gaining acceptance in clinical
dentistry (1,6).
The endodontic access cavity is considered the
foremost step in root canal treatment (7). In root
canal treatment, an adequately prepared access cavity
is crucial for effective instrumentation and delivery of

irrigants into the root canal system. The effective

cleaning and shaping of the root canals have been
linked with the overall goals of endodontic therapy.
It is deemed that all subsequent steps which follow
endodontic cavity preparation may be compromised
if adequate access is lacking (7). An endodontic
cavity that has been inadequately prepared will make
locating, negotiating, debriding, disinfecting, and
filling of the root canal system a challenging task
(8,9). An adequate endodontic cavity also aids in
preventing
iatrogenic
complications
during
endodontic treatment procedures. Any of the above
complications may contribute to a reduced prognosis
of endodontic therapy (8,9).

Traditional endodontic cavities

Traditional endodontic cavities are geometrically
predesigned shapes (10). The outline form in a
traditional endodontic cavity determines the occlusal
extent of the prepared cavity. The convenience form

169

Boveda & Kishen

is dictated by the degree of dentin to be removed at
specific locations so as to achieve a straight-line
access to the root canal orifices (9). The extension for
prevention in the endodontic cavity involves the
removal of dentin obstructions to extend the
straight-line access to the apical foramen or to the
primary curvature of the root canal (7,8). Employing
the concept of extension for prevention facilitates the
treatment procedures and avoids procedural errors.
Nonetheless this occurs at the expense of crucial
structural dentin, which may compromise the
biomechanical integrity of tooth (Fig. 1).
The designs of traditional endodontic cavities
have remained almost unchanged for the past
several decades (10). This is due to existing
limitations in diagnostic and imaging techniques,
which have created the need to delve into the

variations and complexities of root canal anatomy

more clinically. Thus traditional endodontic cavity
preparation usually results in the removal of dentin
in order to explore the expected pulp chamber
floor anatomy and canal openins. Additional
alterations to the tooth anatomy, such as
preflaring the coronal aspect of the root canal, are
usually recommended to facilitate cleaning,
shaping, and filling of the root canals (11).
Moreover, the taper of endodontic instruments has
moved from its traditional size of 0.02 to larger
and even variable designs, which increases the
amount of radicular dentin removed during
instrumentation (12). It is crucial to realize that
both the remaining (residual) dentin and
modification of original root canal geometry play a
crucial role in the biomechanical responses of

Fig. 1. Traditional endodontic cavity designs rely on the convenience form and extension for prevention concepts
where complete unroofing of molars is a requisite for gaining access to canals and to facilitate intracanal
procedures. No less important is the constant search for variations in the anatomy, which means an ample reduction
of hard tissue, justified by the statistics and what might be present in terms of isthmuses and extra canals. As an
example, the literature states that the mandibular first molar has a 115% chance of a negotiable middle mesial
canal on the mandibular first molar (21). Once completed, this type of approach requires a cuspal protective
restoration for long-term success. Follow-up on this case is 14 years.

170

Contracted endodontic cavities

tooth structures to functional forces (13,14). The
remaining dentin also serves as a foundation for
the restorative procedures that follow endodontic
therapy (1518). Thus, it is desirable to preserve
the coronal/radicular dentin structure and maintain
the geometry of the root canal anatomy so as to
conserve the mechanical integrity of endodontically
treated teeth (Fig. 2).

Contracted endodontic cavities

Recently, new designs for endodontic access
cavities
called
conservative
or
contracted

endodontic cavities have been advocated in order

to minimize tooth structure removal (19).
Contracted endodontic cavities are considered to
be an alternative to traditional endodontic cavities
in maintaining the mechanical stability and
subsequently the long-term survival and function
of endodontically treated teeth (19,20). Since no
restorative material or technique can replace the
mechanical characteristics of the lost dentin in
stress-bearing areas of the tooth, treatment steps
directed toward dentin conservation are essential as
the primary measure to reinforce root-filled teeth
(19). As well, the endodontic cavity is inevitably

Fig. 2. The accumulative removal of tooth structure undermines the resistance of the tooth to fracture, and even
teeth treated under accepted endodontic and restorative protocols, despite the fact that the endodontic disease
could be resolved, may fracture.

Fig. 3. Visual enhancers, such as loupes and clinical microscopes, increase the precision and efficacy of clinical
endodontics, providing detailed visualization of the tooth to be treated and allowing the clinician to conservatively
solve complex situations such as calcified teeth.

171

Boveda & Kishen

linked to the effectiveness of succeeding steps in
the endodontic treatment. Therefore, it is normal
for those changes to be judiciously assessed before
being accepted into routine clinical practice.
Fortunately, current advances in technology offer
new possibilities in endodontics. Progress in the
field of imaging, materials, instruments, and
computers has considerably transformed the clinical
practice of dentistry. Some of the developments in
endodontic practice that make dentin conservation
possible include ultra-flexible instruments, visual
magnification, superior illumination, enhanced root
canal irrigation systems, and three-dimensional
imaging technology [cone beam computed
tomography (CBCT)].
The emerging concept of conservative endodontic
access is a shift to transform the outline of the
endodontic cavity from a traditional operator-centric
design to a scheme that focuses more on dentin
preservation and the endodonticrestorative interface
(15,19,20). Contracted endodontic access prioritizes
the removal of (i) restorative material ahead of tooth
structure, (ii) enamel ahead of dentin, and (iii)
occlusal tooth structure ahead of cervical dentin.
It overlooks the traditional requirements of
straight-line access and complete unroofing of the
pulp chamber while emphasizing the importance of
preserving the crucial pericervical dentin (21).
Pericervical dentin is the dentin located 4 mm
above and 4 mm below the crestal bone (20).
This regional dentin is significant for the
distribution of functional stresses in teeth. It is
thus necessary to conserve pericervical dentin as
much as possible to maintain the biomechanical
response of the radicular dentin (22,23). In the
case of incisors, the conservation of cingulum
dentin (pericingulum dentin) is suggested to
improve the functional stress distribution in teeth.
These viewpoints are in direct disagreement with
the principles of traditional endodontic access (24).
A soffit is described as the underside of an
architectural feature such as the ceiling, the corner
of the ceiling, and the wall (25). A contracted
endodontic cavity preserves a portion of the roof
around the entire coronal aspect of the pulp
chamber. This dentin is known as dentin roof strut
or soffit (19). The long-term strength attributes of

172

dentin preservation in the contracted endodontic

cavity are not clearly established at this time, but it is
presumed to provide some degree of structural
bracing, which in turn would minimize cuspal
flexure during chewing.

Fig. 4. CBCT can be quite useful in understanding

and knowing in advance the exact configuration of
each tooth and root to be treated. As an example,
mandibular premolars and the distal root of
mandibular molars might show more than 14 different
configurations each, not possibly detailed on a
conventional x-ray, but easily seen on the adequate
CBCT slice, guiding the clinician on the procedure and
avoiding extensive exploratory hard structure removal.

Contracted endodontic cavities

Aids to preserve dentin in

contracted endodontic cavities
Operating microscopes and other visual
enhancers
It is well recognized that operating microscopes and
other aids for magnification improve clinical
performances in endodontics (26). The minuscule
dimensions of root canal orifices/lumen make it an
extremely difficult anatomy to perform precise clinical
procedures on without magnification. In recent years,
there has been wide-ranging development and
application of technologies in endodontics. Most
important are the operating microscopes, loupes, and
increased light levels, all of which result in
improvements in the precision with which endodontic
procedures are routinely practiced (Fig. 3).

Dental radiology
Radiological examination is an indispensable part of
the diagnosis and management of apical
periodontitis. Generally, radiological examinations
are limited to intraoral and panoramic radiography.
These methods are usually limited to a twodimensional representation of three-dimensional
structures. The presence of complex anatomy and
surrounding structures can make the interpretation
of such images very difficult. Most essentially,
information about the three-dimensional anatomy of
the tooth and the adjacent supporting structures is
not visible, even with the best intentions and
paralleling techniques (27).
Root canal morphology and configuration
might present the clinician with a complex
anatomy to work on during root canal treatment.

Fig. 5. CBCT as a necessary resource to run precise procedures with minimum wear of dental structures. This case
shows how a preoperative high-resolution focalized CBCT study provides detailed information on the exact
anatomy of this mandibular lateral incisor to be endodontically treated, not visible on the conventional x-ray,
allowing the practitioner to design and individualize an extremely conservative approach, understanding that an
incisal cavity is convenient, and as small as the instrument shank used to shape the canals.

173

Boveda & Kishen

Fig. 6. Another case that shows how high-resolution CBCT slices provide information for precise procedures
without an exploratory search and/or wide removal of dental structures. See how the mesial root of this second
mandibular molar splits from 1 canal to 2 at the mid-level root. The conventional x-ray and clinical view might
make the clinician presume a single canal configuration on this root, thereby missing part of the anatomy.

Fig. 7. CBCT as an aid in conventional root canal treatment provides detailed information on the horizontal
dimensions of roots and canals, allowing clinicians to make decisions in accordance with these dimensions, thereby
avoiding sub- and over-preparations. 4-year follow-up.

174

Contracted endodontic cavities

Fig. 8. Focalized high-resolution CBCT slices provide detailed information on teeth with complex morphology,
anomalies, and pathologies such as root resorptionquite useful for a precise endodontic approach and follow-up.
6-month follow-up.

To successfully localize, negotiate, disinfect, and

seal the root canal system without debilitating
the remaining tooth structure, a precise
diagnostic approach that acquires this anatomy
completely,
prior
to
endodontic
cavity
preparation, without depending upon the clinical
skills of the operator becomes mandatory. CBCT
has enabled the practitioner to assess the
endodontic anatomy and disease process in a new
way (28). CBCT aids in visualizing the precise
anatomical configurations of the tooth and
supporting structures (Fig. 4).
CBCT images appear to be a reliable, noninvasive measuring tool that can be used in all
spatial planes to explore root canal anatomy (29).
With high-resolution CBCT, we are able to obtain
a detailed identification of the root canal system,
its variations, and anomalies; the position and size

of the pulp chamber; calcifications; the number,

position, size, extent, and curvatures of the roots
and their canals; the tri-dimensional shape of each
canal: whether it is round, oval, or has any other
form at any specific level of the root; as well as
the status of the surrounding bone (30).
Preoperative cone beam volumetric tomography
(CBVT) imaging provides additional diagnostic
information when compared with preoperative
periapical radiographs, which may lead to
diagnostic and/or treatment plan modifications in
approximately 62% of cases (31) (Fig. 5). Limited
field-of-view (FOV) CBCT should be considered
the imaging modality of choice for the initial
treatment of teeth with the potential for extra
canals, suspected complex morphology (mandibular
anterior teeth, maxillary and mandibular premolars
and molars), and dental anomalies (32) (Fig. 6).

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Boveda & Kishen

Fig. 9. By knowing in advance the sizes and anatomical details of the tooth to be treated, access cavities can even be
diminished to the level where a cuspal protection is not restoratively indicated, by maintaining the occlusal isthmus
not larger than one-third of the intercuspal distance.

CBCT provides detailed information about

anatomical
characteristics
and
dimensions
undetectable
by
conventional
radiography.
Historically, there has been a lack of studies that
define the original horizontal width of root canals
and the optimum horizontal dimensions for
prepared root canals. This limitation forces
clinicians take make decisions on canal widening
without any scientific literature support (Figs. 7
and 8) (33). By taking into account these
dimensions, clinicians can minimize the removal of
root dentin while maintaining the dentin thickness
as much as possible, especially in the proximal
areas or in the thin part of root dentin.
Maintaining dentin aids in minimizing the

additional bending response and stress distribution

in these locations (34) (Fig. 9).

Guidelines for contracted

endodontic cavities
Step 1: three-dimensional imaging

The goal of the three-dimensional image

assessment is to preclude clinically exploring the

anatomy by removing dentin structure while
focusing on the actual anatomy and practicing a
precise approach for dentin conservation.
Three-dimensional imaging is used to provide a
detailed assessment of the root canal and root

"
Fig. 10. Even anterior teeth with no complex anatomy, variations, or unusual pathologies can benefit from preoperative
CBCT, by certainty of its configuration, with no need for further exploratory structure removal, and by exact
determination of the convenience point of approachgenerally more incisal and round than traditionally described.
This central maxillary incisor with a metal-free crown is a clear example. Conventional x-ray does not show the apical
periodontitis present, nor can it be used to guide the approach through the reduced ceramic. 5-year follow-up.

176

Endodontic Topics 2015, 33, 169186

All rights reserved

2015 John Wiley & Sons A/S.

Published by John Wiley & Sons Ltd
ENDODONTIC TOPICS
1601-1538

Contracted endodontic cavities:

the foundation for less invasive
alternatives in the management of
apical periodontitis

CARLOS B OVEDA
& ANIL KISHEN
Compromised structural or mechanical integrity of teeth results in different types of tooth fractures, which are
known to be one of the most common causes for tooth extraction. Minimally invasive concepts and
procedures are currently advocated as less invasive alternatives to traditional treatments. Recent advances in the
available resources and technologies have made a significant impact on endodontic treatment procedures,
allowing minimally invasive treatment procedures such as contracted endodontic cavities for preserving coronal
and radicular tooth structure. The purpose of this article is to provide a framework for understanding
the clinical reasoning for contracted endodontic cavities and their possible benefits in contemporary
endodontics.
Received 13 October 2015; accepted 16 October 2015.

Introduction
In recent years, restorative dentistry has been
undergoing a paradigm shift toward embracing
therapeutic modalities that methodically respect the
original tooth tissues (1,2). The philosophy of
minimally invasive dentistry acknowledges that
dental caries cannot be managed merely by cavity
preparations and restorations, because such
treatment procedures can weaken the remaining
tooth structure (1). Current advances in the field of
adhesive dentistry, as well as progress in the science
of cariology, have made minimally invasive dentistry
possible practically (35). Although the paradigm of
minimally invasive treatment has limited supporting
evidence, it is gradually gaining acceptance in clinical
dentistry (1,6).
The endodontic access cavity is considered the
foremost step in root canal treatment (7). In root
canal treatment, an adequately prepared access cavity
is crucial for effective instrumentation and delivery of

irrigants into the root canal system. The effective

cleaning and shaping of the root canals have been
linked with the overall goals of endodontic therapy.
It is deemed that all subsequent steps which follow
endodontic cavity preparation may be compromised
if adequate access is lacking (7). An endodontic
cavity that has been inadequately prepared will make
locating, negotiating, debriding, disinfecting, and
filling of the root canal system a challenging task
(8,9). An adequate endodontic cavity also aids in
preventing
iatrogenic
complications
during
endodontic treatment procedures. Any of the above
complications may contribute to a reduced prognosis
of endodontic therapy (8,9).

Traditional endodontic cavities

Traditional endodontic cavities are geometrically
predesigned shapes (10). The outline form in a
traditional endodontic cavity determines the occlusal
extent of the prepared cavity. The convenience form

169

Boveda & Kishen

A

Fig. 11. An endodontically treated mandibular molar through constricted access and limited shaping, highlighting
its guidelines by area: (A) coronal, (B) pericervical, (C) radicular body, and (D) apical.

anatomy via a high-definition localized CBCT

scan.
It is used to determine the number of roots,
canals, sizes, curvatures, and characteristics in
order to establish a customized strategy with
which to approach the canal anatomy in the most
conservative way.

The endodontic cavity should be as small as

Step 2A: preparation of the contracted

access cavity

The goal is to prepare a contracted endodontic

access cavity.

The contracted endodontic access cavity is

suggested in order to minimize changes in cuspal

deformation and decrease cuspal bending by
maintaining the bulk dentin structure without
significant restorative requirements.
In anterior teeth, it is recommended to shift the
approach as incisal as possible. In posterior teeth,
an attempt should be made to create a small
cavity centered in between the roots and existing
root canals (Fig. 10).

possible while still achieving the biological

objectives of the root canal treatment and as
wide as the anatomy permits in a particular
case.
Generally, a contracted cavity is suggested to
be slightly wider than the coronal extension of
the root canal. This permits the maintenance of
some of the roof (dentin soffit) around the
entire coronal portion of the pulp chamber
(Fig. 11A).

Step 2B: preparation of contracted access

cavity using a lesion-guided approach

The aim of this phase is to approach the pulp

chamber through discontinuities in the crown

(caries, restorations, etc.) (Figs. 12 and 13).
It is important to recognize the limiting factors
in this approach, which may be beyond the
operators control. For instance tooth position,
inclination, mouth-opening capabilities of the
patient, anatomical complexity, degree of

"
Fig. 12. Individual approach and conservative procedure due to CBCT information. This left central maxillary
incisor previously restored with a veneer suffered trauma and, when root canal treatment was needed, CBCT slices
showed the viability and opportunity to be less invasive by a vestibular approach. 1-year follow-up.

178

Contracted endodontic cavities

179

Boveda & Kishen

Fig. 13. Lesion-driven approach intended to take advantage of the already absent hard structures due to caries in
order to modify the approach as possible through this area and by limiting the restorative needs of the treated
tooth. Restorative dentistry by Dr. Melissa Jurado, Caracas, Venezuela.

calcification, and other patient-related factors, all

of which would result in increased time required
for the endodontic treatment (Fig. 14).
This phase warrants considerable training and
technical competency.

Step 3: cervical procedures

The goal is to respect and conserve the

pericervical dentin.

This step is suggested in order to allow

better transfer of occlusal forces to the
radicular portion of the tooth. In young

180

patients, this goal can be achieved by

maintaining the natural funnel shape of the
canals. In calcified teeth, attempts to
mechanically recreate this cone shape in a
meticulous manner by staying away from the
furcal area (Fig. 11B) are required.
To establish the original horizontal dimensions
of the root canal at the pericervical area such
that the final preparation size can be established
by removing no more than approximately 10%
of the dentin at this level. Thus a proposed
taper for shaping procedures can be achieved
(Fig. 15).

Contracted endodontic cavities

Fig. 14. Cases where coronal hard structures have been affected to the level where a constricted access does not offer the
advantage of avoiding a cuspal protective restoration, where the postoperative structural bracing of the coronal remains do
not seem significant, or those cases where the individual limitations of the patient do not allow a reduced access cavity can be
treated through a conventionally deroofed one. However, by limiting the removal of hard structures at the pericervical,
radicular, and apical zones of those teeth, long-term success should improve. An example is this c-shaped second mandibular
molar with a deep and wide restoration that results in symptomatic apical periodontitis. Even though the access and the
restoration may be considered conventional, the conservative shape retains most of the structural behavior of the original
tooth at this level. 6-year follow-up. Restorative dentistry by Dr. Tomas Seif, Caracas, Venezuela.

Step 4: instrumentation through a

contracted access cavity
Radicular body procedures
The goal of this step is to avoid any weakening
of the root and/or iatrogenic perforations
(Fig. 11C).

In this phase, it is necessary to adjust the

instruments and their taper to the limits and

dimensions of the horizontal configuration of
each root/root canal (Fig. 16).
Apical procedures
The goal of this step is to produce the minimum
tooth structural changes possible while still

181

Boveda & Kishen

Fig. 15. Individual shaping taper determination based on pericervical horizontal measurements of each root and
canal on axial CBCT slices. Preoperative CBCT slices can be used to determine the preoperative horizontal
dimensions of each root and canal in the pericervical area, measurements not possible to obtain confidently from a
conventional x-ray due to superimposition of the structures and magnification due to the nature of the projected
image. By knowing the initial size, a maximum point of structure removal can be proposed and then reached by
determining the taper of the instruments needed to reach this size.

182

Contracted endodontic cavities

Fig. 16. Mandibular first molar with symptomatic apical periodontitis certainly diagnosed with the use of CBCT. A
restricted access cavity limits the global visualization of all canals at the same time; however, it is enough to
individually approach each root canal. No restorative indication of cuspal protection. 4-year follow-up.

achieving the biological objectives of root canal

treatment (Fig. 11D).
This final step focuses on keeping the apical
foramen as small as possible (Fig. 17).

Treatment challenges related to

minimally invasive canal
enlargement
A topical antimicrobial such as sodium hypochlorite
is commonly used in root canal treatment to combat
microbial biofilms (35). The inability of
antimicrobials to eliminate biofilm bacteria in
anatomical
complexities
and
uninstrumented
portions of the root canal compromises their efficacy
in root canal treatment. Root canal irrigation is an
essential phase of canal debridement and
disinfection. Irrigant exchange in the various parts of
the root canal system is a crucial requirement in
order to ensure adequate chemical effect because

irrigants are rapidly inactivated when they come into

contact with tissue remnants or dentin (36,37).
From a clinical standpoint, steps to prevent the
extrusion of irrigant should precede the requirement
for sufficient irrigant refreshment and canal
debridement. It is apparent that irrigant replacement
extends approximately 1 mm apically to the tip in a
root canal enlarged to at least size #30 (0.06 taper)
(38,39).
Complementing
the
syringe/needle-based
irrigation with additional irrigant activating/
agitation systems will aid in enhancing the
effectiveness of root canal debridement and
disinfection (40). However, irrigating teeth with
minimally enlarged canals may pose additional
disadvantages such as limited irrigant penetration,
needle wedging, vapor lock effect, and challenges
associated with sonic/ultrasonic/apical negativepressure irrigation. Unfortunately, the current
literature does not support any additional advantage

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Boveda & Kishen

Fig. 17. In teeth already crowned, constricted access and limited shaping provides structural advantages by
maintaining key dentin, particularly in the pericervical and radicular body area, provided that the anatomy has been
previously determined by the analysis of preoperative CBCT slices.

to using other irrigation-enhancement strategies in

endodontics (41). Thus, the current limitations in
endodontic irrigation necessitate canal enlargement
to a minimum instrumentation size. Further research
is required in this area before more conservative root
canal enlargement may be considered in root canal
treatment.
A recent study characterized the canal
instrumentation performed through a contracted
endodontic cavity and traditional endodontic cavity
with respect to (i) the proportion of untouched
canal wall surface, (ii) the volume of dentin
removed, and (iii) the load-at-fracture under static
loading conditions. It was concluded that the
coronal dentin was conserved in incisors, premolars,
and molars when accessed through a conservative
endodontic cavity. The dentin conservation allowed
an increased resistance to fracture in the mandibular
molars and premolars, but it also compromised the
efficacy of canal instrumentation in the distal canals

184

of the molars (42). These results appear to support

the rationale for a revision to the guidelines of
endodontic cavity design in premolars and molars
focused on the conservation of coronal dentin.
Nevertheless, it is imperative to note that
complexities in the root canal systems are key
challenges for effective disinfection in endodontics.

Concluding remarks
The basis for minimally invasive dentistry evolves
from the fact that an artificial restoration is of less
biological and functional significance when
compared to the original healthy dentin tissue.
Minimally
invasive
endodontics
encompasses
systematic steps to conserve natural tissue in order
to benefit the patients. This concept critically hinges
on the advances in science and emerging
technologies. The skill and knowledge of clinicians
remain the most important elements in this

Contracted endodontic cavities

paradigm shift. Conservative endodontic cavities
seem to satisfy the principles of minimally invasive
endodontics by preserving natural dentin, but newer
endodontic irrigation strategies are required before
minimally invasive root canal enlargement is
routinely practiced. Clinical research to evaluate the
influence of this paradigm shift on the long-term
prognosis of endodontically treated teeth is also
warranted.

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