A total of 100 intact human mandibular first molars extracted for periodontal reasons were used for this study. All teeth were free from caries, defects, restoration and cracks and were used in compliance with ethical guidelines of Gazi University Faculty of Dentistry Clinical Research Ethics Committee (ethical protocol no. 2021.19/6). Plaque, attached periodontal tissues and calculus deposits were removed by hand-scaling and then stored in 0.1% thymol solution until use. The bucco-lingual and mesio-distal dimensions of the teeth were measured using a digital caliper (Insize 1112 − 150, Insize, Jiangsu, China). The teeth were divided into five groups so that there was no difference in the oneway analysis of variance (ANOVA) test between buccolingual and mesio-distal widths (p > 0.05) [32, 33]. The materials used in the study and their contents are listed in Table 1. Before preparing the cavities in the teeth, the distance between the cusps was measured using the digital caliper. To prepare a conservative access cavity, digital radiography was used to determine the borders of the access cavity according to the dimensions of the teeth. Then, the canal entrances were confirmed by considering the length of the periodontal probe according to the notches of the periodontal probe on the radiograph. The gingival step of the cavity Table 1 The composition of the materials used in the study Material (CEJ). The conservative mesio-occlusal (MO) endodontic access cavity was applied to all teeth except the control group (intact teeth) using a straight fissure carbide bur (Hicare Medical Co. Ltd., Guangzhou, China) using a highspeed handpiece under water cooling and all Cavo surface margins prepared at 90° with internal line angles rounded. The bur was changed after every five cavity preparations, and cavity dimensions were measured during the preparation using a digital caliper to ensure standardization. Following the endodontic access cavity, the working length was determined using #10 K-files (Shenzhen Perfect Medical Instruments Co. Ltd., Shenzhen, China), and the root canals were instrumented using ProTaper rotary files (Endoart, İstanbul, Turkey) up to sizes F3 with the crowndown method. During instrumentation, the root canals were irrigated with 1 mL of 2.5% NaOCl before each file was introduced into the canal and finally with distilled water. The canals were dried with paper points (Diadent Group International, Almere, the Netherlands) and obturated with gutta-percha cones and an AH Plus sealer (Dentsply De Trey, Konstanz, Germany) using the single cone technique. Excess gutta-percha cones were cut 1 mm apically from the canal orifices with a gutta cutter (C-Blade, Coxo, Guangdong Province, China) and covered with resin-modified glass ionomer cement (Ketac Cem Plus, 3 M, St. Paul, MN, USA). All teeth were examined after root canal treatment using periapical radiography to ensure accurate root canal treatment.To simulate the clinical conditions, each specimen was embedded in a block of self-curing acrylic cylinders at a level of 2.0 mm below the CEJ. The periodontal ligaments were simulated using a base plate wax at a 0.3 mm (Efes Dental, Bursa, Turkey). The distal cavity was determined and standardized according to the distal marginal ridge ness and periapical radiography. On the mesial side, the distance between the gingival margin and the CEJ was prepared at 1 mm. Care was taken to ensure a thickness of approximately 2 mm between the buccal and lingual walls and the interproximal cavity walls using the digital caliper. The buccolingual size of the cavity was 4 mm, and this width was measured above the cavities [34]. Clearfil S3 Bond Universal (Kuraray, Osaka, Japan) was applied using total etch mode with 35% orthophosphoric acid gel (Scotchbond Universal Etchant, 3 M ESPE, St. Paul, MN, USA). Acid gel was applied and left on enamel for 30 s and on dentin for 15 s, before being rinsed with water and gently dried with air to create a moist dentin surface. Clearfil S3 Bond Universal (Kuraray, Osaka, Japan) was applied using a micro-brush for 20 s and light-cured for 10 s with an LED light curing unit (D-Light Pro, GC, Leuven, Belgium). Upon completion of root canal treatment, the restorative steps for each group were as follows (Figs. 1 and 2): ● Group 1 (positive control group): Intact teeth without any cavity preparation were used as the positive control. ● Group 2 (negative control group): The mesial endodontic access was prepared, and coronal restoration was not applied. ● Group 3: A 4 mm glass fiber post (Cytec Blanco, Hannerkratt, Germany) was cut with a diamond fissure bur. The post was then fixed to the buccal and lingual walls of the cavity with a flowable resin composite (Filtek Ultimate Flowable, 3 M Espe, St. Paul, MN, USA). For this purpose, a flowable resin composite was applied to both ends of the post and adapted to the buccal and lingual cavity walls in the middle one-third of the cavity. The overflowing flowable resin composite was removed using a sond. Then, the flowable resin composite was polymerized at the connection points of the post with the cavity using an LED light device for 20 s. Then, bulk-fill resin composite (Filtek One Bulk Fill Restorative, FOB; 3 M ESPE, St. Paul, MN, USA) was applied in 4-mm layers for the restoration of the entire cavity and polymerized on the occlusal, buccal and lingual sides for 10 s using an LED Light Device. ● Group 4: A 4-mm thick fiber-reinforced composite (EverX Posterior, EXP; GC, Tokyo, Japan) was applied to the first half of the cavity and polymerized with an LED light device for 20 s. Then, a 4-mm thick bulk-fill resin composite (Filtek One Bulk Fill Restorative, FOB; 3 M ESPE, St. Paul, MN, USA) was applied to the upper part of EverX Posterior, and the restoration was completed by polymerizing the occlusal, buccal and lingual sides for 10 s using an LED Light Device from. ● Group 5: Coronal restoration completed with FOB using the bulk technique. The preparation and restoration of all specimens were performed by the same operator. Teeth were stored in distilled water for 24 h at 37 °C to prevent dehydration of the teeth and complete the post polymerization. They were then thermocycled at 5 °C and 55 °C for 10,000 cycles with a 30-s dwell time (MTE-101, MOD Dental, Ankara, Turkey).To determine fracture resistance, a 5 mm stainless steel spherical tip mounted on a universal testing machine (Shimadzu IG-IS, Tokyo, Japan) and a 45° oblique compressive load were applied to the central fossa of the teeth at a crosshead speed of 1 mm/min until a fracture occurred. The maximum load before fracture was recorded in Newtons (N). The fractured specimens were examined by two different operators, indicating the fracture mode as restorable (fracture above the CEJ or within 1 mm apical to the CEJ

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fracture resistance endodontically treated molars fiber reinforced composite glass fiber post bulk fill MOD cavity

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This is actually the methodology section of PMID 38750289 - the paper by Nezir M, Dinçtürk BA, Sarı C, Alp CK, and Altınışık H (2024), published in Clinical Oral Investigations. Here is a thorough breakdown and critical analysis of the methodology:

Study Overview

This is an in vitro fracture resistance study on 100 intact mandibular first molars, comparing how different fiber-reinforced and conventional direct restorative materials perform after conservative (mesio-occlusal) endodontic access cavity preparation and root canal treatment. The Gazi University ethics approval (2021.19/6) is cited.

Study Design Summary

GroupnDescription
G1 - Positive control20Intact teeth, no cavity, no treatment
G2 - Negative control20Conservative MO cavity + RCT, no restoration
G320MO cavity + RCT + glass fiber post (4 mm) bonded buccal/lingual + Filtek One Bulk Fill
G420MO cavity + RCT + EverX Posterior (FRC, 4 mm) + Filtek One Bulk Fill on top
G520MO cavity + RCT + Filtek One Bulk Fill only (bulk technique)

Methodological Strengths

1. Sample standardization
  • One-way ANOVA used to confirm no significant difference (p > 0.05) in bucco-lingual and mesio-distal dimensions before group allocation - a strong method to ensure dimensional homogeneity across groups.
  • Digital caliper (Insize 1112-150) used consistently for measurements.
2. Conservative cavity design
  • The mesio-occlusal (MO) access cavity (rather than the classic triangular access) is a clinically relevant choice. This is a contemporary, minimally invasive approach. Simulating only MO cavity rather than full MOD is a deliberate choice to reflect conservative endodontics.
3. Standardized root canal treatment
  • ProTaper F3 preparation with crown-down technique, NaOCl irrigation, AH Plus sealer (considered gold standard), single cone obturation - all well-standardized.
4. Periodontal ligament simulation
  • 0.3 mm base plate wax simulating PDL is widely used in fracture resistance studies and improves physiologic relevance of the load test.
5. Thermocycling
  • 10,000 cycles at 5-55°C simulates approximately 1 year of oral aging and is a standard protocol for in vitro mechanical testing.
6. Single operator
  • All specimens prepared by one operator, removing inter-operator variability.
7. Fracture mode classification
  • Classified by two independent operators as restorable (fracture at or within 1 mm apical to CEJ) vs. non-restorable - clinically meaningful distinction.
8. Load application
  • 45° oblique compressive force to the central fossa via a 5 mm stainless steel sphere at 1 mm/min is standard for simulating masticatory loads.

Methodological Considerations / Limitations

1. In vitro design
  • No saliva, enzymatic degradation, fatigue cycling, or true oral environment - inherent to all in vitro studies. Clinical longevity outcomes are not predictable from fracture resistance data alone.
2. Cavity design discrepancy
  • The text alternates between calling the cavity "MO" (mesio-occlusal) and referencing a "distal cavity" and "mesial side." A MO conservative access should not involve distal cavity preparation - this may reflect either a typographic inconsistency in the text you provided, or an actual methodological inconsistency that would need clarification from the original paper.
3. Single cone obturation
  • Used for all groups, which is acceptable for standardization but may not reflect best obturation practice for all canal morphologies in first molars.
4. Post placement method (Group 3)
  • The 4 mm glass fiber post bonded with flowable composite to buccal/lingual walls (not a conventional intraradicular post) is an unconventional anchorage technique. The mechanical rationale is to provide cross-arch structural reinforcement, but this technique's bond reliability over time is less established than intraradicular posts.
5. Cement base over gutta-percha
  • Using RMGIC (Ketac Cem Plus) over the canal orifices before coronal restoration is appropriate to seal the canals, though it differs across some prior studies.
6. Access cavity dimensions defined but confirmed visually
  • Cavity dimensions confirmed with digital caliper and radiography is robust, but the exact depth standardization of the access is not described with geometric precision in this excerpt.

Key Materials at a Glance

MaterialRoleNotes
Filtek One Bulk Fill (FOB, 3M)Bulk-fill composite cap (Groups 3, 4, 5)4 mm bulk placement
EverX Posterior (GC)Short fiber-reinforced composite base (Group 4)Acts as a structural substructure
Glass fiber post - Cytec Blanco 4 mm (Group 3)Horizontal reinforcement between wallsNon-intraradicular anchorage
AH Plus (Dentsply)Root canal sealerEpoxy-amine based, gold standard
Clearfil S3 Bond UniversalAdhesiveTotal etch mode used
Ketac Cem Plus (3M)Canal orifice sealRMGIC

What the Results Show (from PMID 38750289 abstract)

  • All restored groups had lower fracture strength than intact teeth (G1), confirming cavity preparation compromises structural integrity regardless of material.
  • Fiber-reinforced groups (G3, G4) showed significantly higher fracture strength than bulk-fill composite alone (G5).
  • Restorable fracture patterns were more prevalent in fiber-reinforced groups - clinically favorable.
  • The conclusion is that fiber-reinforced composites (especially combined with bulk-fill) are recommended over bulk-fill alone for this access cavity design.

Clinical Relevance

This study directly addresses a growing clinical question: with the shift toward conservative/contracted endodontic access cavities, how best to restore the resulting cavity? The data supports using EverX Posterior or a fiber post as a substructure beneath bulk-fill composite, rather than bulk-fill alone. This aligns with the broader principle that fiber reinforcement arrests crack propagation and redistributes occlusal stress.

If you need help with a specific section - such as statistical analysis critique, writing a discussion, comparing with other studies, or preparing a summary table - just let me know what you need.

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