Access Cavity Preparation & Working Length

Determination
INTRODUCTION
Most of the endodontic literature published, specially the text books
have a tendency to concentrate or rather emphasize on the preparation of access
cavities in teeth with ideal anatomic crowns and root canal systems. It is
however, equally important for the clinician to be well versed with the practical
world of the canal morphologies and their complexities that exist.
Right from the early work of !"" to the recent studies which
demonstrate the anatomic complexities of the root canal system, it has been
shown that a root with gracefully tapering canal and a single apical foramen is
more of an exception rather than a rule. Investigators have shown multiple
foramina, deltas, accessory canals etc. in most of the teeth.
#he success of root canal therapy, thus has been equally attributed to a
careful access cavity preparation as much as to the obturation. $s Ingle rightly
states, the apical%moisture%proof seal, which is so very essential for the success
of non % surgical endodontic therapy is not possible unless the space to be filled
is carefully prepared to receive the restoration.
If mentioned as in relation to &perative 'entistry (#he final restoration
is rarely better than the initial cavity preparation).
*
Divisions of Cavity Preparation
+or sake of descriptive convenience Ingle has divided endodontic cavity
preparation into
$. ,oronal -reparation
.. Radicular -reparation
Principes of !n"o"ontic Cavity Preparation
$ny discussion of cavity preparation must ultimately revert back to the
basic principles of cavity preparation established by 'r. /.0. 1lack.
- 1y slightly altering these principles, a list of principles of !ndodontic cavity
preparation is established. #hus as the preparation of coronal and radicular
portions was divided, similarly the principles, therefore we have 2
!n"o"ontic Corona Cavity Preparation# $ Principes
I. &utline +orm
II. ,onvenience +orm
III. Removal of Remaining ,arious 'entin 3and defective restoration4
I0. #oilet of the ,avity
I% O&tine 'orm
In order to obtain complete access for instrumentation from the cavity
margins to the apical foramen the outline form of the endodontic cavity must
be correctly shaped and positioned. Moreso, the external outline form evolves
from the internal anatomy of the tooth established by the pulp. 'ue these
.
internal external relationships endodontic preparations are through necessity
done in a reverse manner i.e. from the inside of a tooth to the outside.
#hus to achieve an optional preparation with an ideal outline form, three
factors of internal anatomy must be considered.
i. #he size of the pulp chamber
ii. "hape of the pulp chamber
iii. 5umber of individual root canals, their curvature and their
position.
i. "ize of the pulp chamber in young patients the endodontic cavity
preparation is surely more extensive than in an older patient in whom the
pulp has receded and the chamber is small in all 6 dimensions.
ii. "hape of the pulp chamber for an ideal outline form, the finished outline
form should accurately reflect the shape of the pulp chamber. !g., floor of
pulp chamber in molars is triangular.
iii. 5umber, position and curvature of root canals 2 $s far as the outline form is
concerned. In order to accommodate extra canals 3when present4 into the
prepared cavity and to instrument each canal efficiently without
interference, the cavity walls have to be extended to allow an unstrained
instrument approach to the apical foramen. #his could be regarded as a
change for convenience in preparation.#hus we could say that the
convenience form partly regulates the outline form.
6
II% Convenience 'orm#
- In operative dentistry the term convenience form was concieved by /.0.
1lack as a modification of the cavity outline form to establish greater
convenience in the placement of intra coronal restorations. In endodontic
therapy however, convenience form makes more convenient 3and accurate4
the preparation as well as filling of the root canal.
- +our important advantages 7 benefits are gained through this convenience
form 2
i. 8nobstructed access to canal orifice
ii. 'irect access to apical foramen
iii. ,avity expansion to accommodate various filling techniques
iv. ,omplete authority even enlarging instrument
#hus it must remembered that a failure to properly modified the access
cavity outline by extending the convenience form will ultimately lead to failure
by either root perforation, (ledge) or (shelf) formation within the canal,
instrument breakage or the incorrect shape of the completed canal preparation
often as (zipping) or (apical transportation).
III% Remova of Remaining Cario&s Dentin#
#his, according to Ingle must be done for 6 reasons viz.
a. #o eliminate mechanically as many bacteria as possible from the interior of
the tooth
9
b. #o eliminate discolored tooth structure with may eventually cause staining
of the crown
c. #o eliminate any possible bacteria laden saliva leaking into the prepared
cavity
- :hile performing this step if a perforation results, sealing the perforation
with a cement 7 adhesive composite from inside the cavity, preferably has
been stated.
- $nother thought expressed by Ingle is that during removal of the defective
restoration or common teeth structure if the tooth is sufficiently weakened
and access cavity exposed to salivary contamination, restoration of the
missing walls could be postponed until completion of the radicular cavity
preparation, as this would allow greater access for instrumentation. #he
cavity should however be isolated with proper radicular placement.
I(%Toiet of the Cavity#
#his pertains to the removal of all of the caries, debris and necrotic
material from the chamber before the preparation is begun.
- ,alcified or metallic debris carried into the canal may act as obstruction
during the canal enlargement. &n the other hand, soft debris carried in from
the chamber would increase bacterial population in the canal. #hus is it
imperative to removal all debris.
- Instruments used for this purpose include, a slow speed round bur, long
blade endodontic spoon excavator and of course another good method is
copious irrigation with "odium hypochlorite.
;
Access Cavity Preparation ) 'or In"ivi"&a Teeth%
+or sake of simplicity we have grouped the teeth for access opening as
follows2
a. Maxillary anterior. #eeth d. Mandibular anterior
b. Maxillary -re<molars e. Mandibular -re<molars
c. Maxillary molars f. Mandibular molars
In addition we would be dealing with access openings along with the
following subheadings viz2
*. $verage tooth length
.. -ulp chamber = Root ,anal anatomies
6. $natomic relations in situ
9. $ccess openings
;. !rrors 7 ,omplecations
Access cavity preparation for ma*iary anterior teeth#
+enera feat&res# ,for a anterior ma*iary teeth-
*. #he entrance is always made through the lingual surface in the middle *76
region.
.. Initial entrance 7 penetration is made with a round ended tapered fissure bur.
&nly enamel is penetrated. #he bur should not be forced but allowed to cut
it>s own way, because if it is forced it will act as a wedge and causes
enamel to (check) or (craze) and would therefore weaken the tooth.
?
6. $long with initial penetration, comes the convenience extension where the
same bur with it>s tip in the middle is turned incisally so that the bur
parallels the long axis of the tooth and the enamel and dentin are beveled
incisally.
9. "o the preliminary outline form which is triangular is ready with a short
incisal bevel and then the dentin (nest) which would receive the no. . or 9
round bur to penetrate into the pulp chamber.
;. "low speed, contra<angle no. . or 9 round bur then used to penetrate into
the pulp chamber.
- igh speed instruments, according to Ingle, must be avoided due to a
lack of tactile sensation with these.
?. &nce penetrated, the round bur should be worked from inside to outside to
remove the lingual and labial walls of the pulp chamber.
@. #hen a surgical length bur or a long tapering diamond point 3accessory to
Ingle4 or /ates /lidden drills 3of size 9 usually4 are used to eliminate the
lingual shoulder.
A. #he no. * or . round bur maybe used laterally and incisally to eliminate
pulpal horn debris and bacteria. #his step aids in preventing future
discoloration.
B. "o the final preparation we have is mostly a triangular shaped opening,
which funnels down to the canal orifice.
@
A short note on#
Location of cana orifices ,.essing & /tock-
"ometimes it is difficult to locate a canal orifice in the pulp chamber
floor, particularly in the posteriors. #herefore, for one, a thorough knowledge
of the number of canals likely to be present and their location is essential.
8sually, a good pre<operative radiograph or two from different angles is useful.
&ther methods used to locate canals include 2
a. a good access opening which allows a complete view of the pulp
chamber and the canal orifices.
b. 3'/ *?4 canal explorer
c. 1inocular loops % with a magnification of C.. #hese could be fitted
onto spectacles.
d. +or the posteriors, one canal maybe located but it is not possible to
decide which one. #hen an instrument is placed in the canal and
radiograph taken. Identification is made using the buccal obDect rule.
e. #ransillumination of the tooth using a fiber optic, keeping the light at
a gingival level may reveal position of the canal orifices.
f. 'yes such as iodine maybe used which show the canal orifice as a
darker area.
g. $s a last resort a bur maybe used.
A
- $ hole .mm deep is cut where the canal orifice is expected and parallel to
the long axis of the tooth. If the canal is not located then the bur should be
removed from the handpiece placed in the prepared hole and retained by
soft wax. $ pencil line is drawn on the buccal surface of the tooth and a
radiograph taken. $, .<' picture is obtained with helps to provide correct
allignment of the bur. #hen further penetration into the root maybe carried
out.
I% Access cavity preparation for ma*iary centra incisor#
1efore going in to the detail of the access opening, a short update on the
tooth anatomy and it>s relations are necessary.
$. $verage tooth length .*. Amm.
1. -ulp chamber < located in the centre of the crown
< broad mesio % distally
< broadest < incisally
< has 6 pulp horns % with correspond to the developmental
mamelons in a young tooth.
0% Root an" Root cana )
- "ingle rooted
- Root canal % broad labio<lingually
- &void in cross < section mesio % distally
- ,onical in shape
- "tatistics reveal that maDority of roots are straight 3@;E4, some curve
distally 3AE4, mesially 39E4 palatally 39E4 or labially 3BE4.
B
1% anatomic reations in sit&#
Fabially % labial cortical plate maybe fused with the root, because of this
proximity fenestration>s and dehiscence maybe present and also abscesses may
perforate the cortical plates.
- $pex of the tooth is in relation with the floor of the nasal fossa.
!% Access opening#
- Is similar as mentioned before in general features.
- #o summarize2
- Initial penetration % . schools of thought /rossman prefers a no. 9 round
bur with high speed and coolant, while Ingle suggests a round ended
tapering bur.
- !namel is penetrated the middle *76 of lingual surface
- #hen (drop) into chamber with a slow speed no. 9 carbide bur.
- Remove all debris
- Remove lingual shoulder using gates gladden drill, working inside out with
light strokes.
- Fingual shoulder is not an anatomic entity but a prominence of dentin
created when the lingual roof is removed.
- #herefore on removal of this shoulder and lingual root one gains direct
access to the apical area of the root canal.
*G
- #hus the access cavity prepared in the maxillary central has a angular
shape, with it>s apex towards the cervical zone.
II% Access cavity preparation for ma*iary atera incisor#
$. $verage tooth length % .6.*mm
1. -ulp chamber % similar to central
has only two pulp hours
,. Root and Root canal % conical in shape
has a finer diameter
lateral canals are frequent 3.?E4
- MaDority of the roots curve distally, and therefore the root tips maybe in the
centre of the cancellous bone pointing distally, thus giving an indication
why abscesses arising from the laterals usually drain palatally.
C% Access opening ) simiar to centra2 3&t is smaer an" more ovoi" in
shape%
- #echnique for entry is same except that a smaller i.e. a no. . round bur may
be used instead of no. 9 as for central.
- $ccess cavity preparation in maxillary lateral need to be modified in certain
case such as in anomalies such as dens invaginatus, peg laterals and talon
cusps.
III% Access Cavity Preparation for .a*iary canines#
$. $verage tooth length % .?mm
1. -ulp chamber % Fargest amongst single rooted teeth
**
- #riangular labiolingually
- +lame shaped % mesio % distally
- &nly one pulp horn present
,. Root canal % oval in shape, wider in labio palatal direction
'. $natomic relations in situ % the canine root often called as the (canine
pillar) is positioned in the cancellous portion of the maxilla between the
nasal cavity and maxillary sinus.
- 1ecause of it>s great size it causes the most prominent bulge in the maxilla
called alveolar or canine eminence.
- $bscesses from the maxillary canine usually perforate the labial cortical
plates below the insertion of the levator muscles of the upper lip and drains
into the buccal vestibule. 3If perforation is below this insertion the abscess
drains into the canine pace and causes cellulitis4.
!% Access Opening#
- "hape of the opening is ovoid, as dictated by the pulp chamber anatomy.
.a*iary Anterior Teeth# !rrors in Cavity Preparation
*. -erforation % usually at the labratervical level caused by failure to complete
convenience extension at the incisal.
.. /ouging % of labial and distal walls due to failure to recognize .BH lingual
and *?H mesial inclination of teeth respectively.
*.
6. -ear "haped preparation < due to failure to provide convenience extensions
% causes inadequate debridement and obturation % thus leads to failure.
9. 'iscoloration % of crown caused by a failure to remove pulpal debris
;. Fedge +ormation and -erforation % caused by a very small cavity
preparation and thus reduced access in apically curved canals.
Access Cavity Preparation for .an"i3&ar Anterior Teeth
+enera 'eat&res#
#he basic principles followed in access preparation in mandibular
anterior are similar to those of maxillary anterior teeth. #hey are as follows2
*. #he entrance 7 initial penetration is always begun at the middle *76 zone. $
common error here is to begin far too gingivally.
.. Initial penetration % of enamel only % is done with high speed tapered
fissure bur 3@G* 84 with an air water coolant. 'o not force the bur.
6. ,onvenience extension towards incisal continuous with the initial
penetration. Maintain point of bur in central cavity and rotate handpiece
towards incisal and mesio distal so that bur parallels long axis of the tooth.
!namel and dentin are beveled toward incisal.
9. #he preliminary cavity outline is thus formed with is roughly triangular in
shape with apex cervically.
;. #hen penetrate into pulp chamber with slow speed no. . round bur.
*6
?. &nce into the chamber, working from inside chamber to outside suing the
round bur remove lingual and labial walls of pulp chamber.
@. #hen use a long surgical bur or /ates /lidden drill 35o. .4 to remove the
lingual shoulder.
A. &ccasionally a no.* round bur maybe used laterally and incisally to
eliminate pulpal horn bebris and bacteria. #his also prevents future
discoloration.
B. +inal preparation shows a angular preparation which funnels down to the
orifice of the canal.
.an"i3&ar centra Incisor
*. $verage tooth length .G.A mm.
.. -ulp chamber smallest in the arch.
pulp chamber is flat mesio<distally, ovoid labio<
lingually
has 6 pulp horns when recently erupted which calcify
and disappear early because of constant masticatory stress.
6. Root and Root canal % flat % mesio < distally
wide % labio % lingually
*9
has a ribbon % shaped configuration in middle *76
where bifurcation usually occur and perforates usually
can occur here.
9. $ccess &pening % same as mentioned with greatest dimension oriented
incisogingivally.
.an"i3&ar Latera Incisor
$verage #ooth Fength % ...?
-ulp chamber same, but lateral tooth has larger dimensions
$natomic relation maybe fused to labial cortical plate
$ccess same as central
.an"i3&ar canine
$verage tooth length % .;mm
-ulp chamber more wide labiolingually
single cusp
$natomic Relation same as mandibular incisors
&pening same as maxillary cuspid with anatomy variations.
Access Cavity Preparation in .a*iary Premoars
+enera feat&res#
*. $s we know entrance to the pulp chamber in all posterior teeth always
gained to the occlusal surface for the pre<molars the initial
access7penetration is made II>l to the long axis of the tooth in exactly the
*;
centre of the central groove. +or this the @G*8 tapered fissure bur with high
speed and air<water coolant is recommended for use. #his initial penetration
must be restricted to only the enamel surface.
.. +urther penetration then into the pulp chamber is done using a slow speed
round bur until the characteristic (drop) of the bur is felt.
$s Ingle states, if the chamber happens to be calcified and the drop is
not felt then the vertical penetration is made until the contrangle rests against
the occlusal surface. #his depth is approx Bmm, the position of the floor of the
pulp chamber that lies at the cervical level.
#hen while removing the bur the orifice is widened % buccolingually to
twice the width of the bur to allow exploration of the canals orifices.
6. #he endodontic explorer can be used to locate the canal orifices.
9. +ollowing this, the no. . or 9 round bur is used at low speed, working from
inside the pulp chamber to outside, to extent the cavity bucco<lingually by
removing the roof of the pulp chamber.
;. #hen the bucco<lingual extension and final finishing of the access cavity is
accomplished using the @G*8 fissure bur at high speed.
?. #he final bucco<lingual ovoid preparation reflects the anatomy of the pulp
chamber and position of buccal and lingual orifices.
.a*iary 4
st
Pre .oar
$verage tooth length % .*.;mm
*?
-ulp chamber % narrow % mesio % distally
:ide % bucco< palatally
* pulp horn under each cusp
Roof of the pulp chamber is coronal to cervical line
+loor of pulp chamber is usually convex lies deep in
the coronal third of the root below the cervical line.
0% Roots an" Root canas )
usually has . roots
when roots are fused, a groove running in an occluso<
apical direction divides the root into buccal and palatal
portions.
- #he palatal canal is generally the larger of the two and is directly under the
palatal cusp and it>s orifice can be traced by following palatal wall of the
pulp chamber
- #he buccal canal is directly under the buccal cusp and it>s orifice can be
penetrated by following the buccal wall of the pulp chamber.
9.Anatomic reation ) the maxillary first premolar lies below the maxillary
sinus and is separated from it by a thin layer of spongy and compact bone.
5% Access opening ) a""itiona points are to 3e note" are#
*@
a4 #he walls of the access cavity are smoothened and sloped slightly
towards the occlusal surface. #his occlusal divergence creates a positive
seat for the temp filling.
b4 #he borders of this ovoid access cavity should not extend beyond half
the lingual incline of the facial cusp and half the facial incline of the
palatal cusp.
#he access cavity preparation for endodontic treatment of a premolar
differs from 1lack>s cavity preparation for an occlusal restoration 3,lass I4. In
1lack>s preparation the ovoid shape runs mesiodistally and ecompasses all pits
and fissures whereas endodontic preparation runs ovoid in a bucco<lingual
direction and permits direct access to the root canal.
.a*iary 6
n"
premoar
$verage tooth length % .*.?mm
-ulp chamber % similar to *
st
premolar, may have single orifice, but with . pulp
horns.
Root and Root canals % 8sually single rooted 3BG.6E4
- 3/rossman4 roots maybe straight 36@.9E4, distal curve 366.BE4 buccal
curve 3*;.?E4, I"> or bayonet curve 3*6E4.
- ,anals are usually ovoid in bucco<lingual direction
$natomic Relation2 roots are closer to the max sinus.
*A
- #he sinus may dip down and surround the tip of the root or roots forming
prominences in the sinus floor.
- #he roots and sinus maybe separated by a thin layer of bone, or bone maybe
totally absent thus leaving only the periodontal membrane and the
schneiderian membrane of the sinus.
$ccess &pening % "ame as I
st
-remolar
!rrors in Cavity Preparation in .a*iary premoars ,Inge-%
*. 8nder extended preparation % exposing only pulp horns
.. &verextended preparation % undermining of enamel walls while searching
for a receded pulp.
6. -erforation % when distoaxial inclination of tooth 3*GH4 is neglected by
clinician.
9. 1roken Instruments % seen when internal cavity preparation has not
completely exposed orifices.
Access Cavity Preparation for .an"i3&ar P%.%
+enera feat&res#
*. $s in all posterior % initial penetration is performed through the occlusal
surface, more precisely at the centre of the central groove.
- #his is done using a high speed, air<water coolant assisted no. @G.8 taper
fissure bur.
*B
- $t this Duncture only the enamel is penetrated.
.. &nce the enamel thickness has been penetrated a slow speed, no. 9 round
bur is used then to open the pulp chamber. If chamber is calcified
penetration is continued till contrangle rests on the occlusal surface.
#hen while removing the bur, the occlusal opening is widened buccolingual
to twice width of the bur to allow room for exploration location of the
orifices. #he cavity should be cut more on the buccal than on the lingual
cusps.
6. 8sing the endodontic explorer locate the canal3s4.
9. Remove the roof of the chamber with the no. . or 9 round bur, working
inside out.
;. +inish the buccolingual extension and cavity walls with the @G.8 fissure
bur.
?. #he finished bucco lingual ovoid outline reflects anatomy of the pulp
chamber and position of the centrally located canal.
.an"i3&ar 4
st
Pre .oar
*. $verage #ooth Fength % .*.Bmm
.. -ulp chamber % #he mandibular first premolar is the transitional tooth
between anterior and posterior teeth, and in anatomic structure resembles
both.
.G
- It has a prominent buccal pulp horn.
- #he prominent buccal cusp and smaller lingual cusp give the crown a
6GH lingual tilt.
6. Root and Root canal % usually single rooted with a single canal which is
cone shaped and simple in outline. 5arrow mesiodstally and broad
buccolingually.
9. $natomic Relation % closely related to alveolar plates and sometimes also
to mental canal and foramen with maybe misdiagnosed for a peri apical
pathosis.
;. $ccess &pening % in addition to mentioned 2
- #o compensate for the 6GH lingual tilt and to prevent perforations the
enamel is penetrated at the upper *76 of the lingual incline of the facial
cusp.
.an"i3&ar 6
n"
Pre .oar
$verage tooth length % ...6mm
-ulp chamber % lingual horn more prominent.
Roots and Root canal % usually single rooted
greater overall girth of root canal
$natomic relation % closer to mental foramen
$ccess &pening % ovoid opening is widen mesio<distally to the
wider pulp chamber.
.*
Access cavity preparation for .a*iary .oar Teeth#
+enera 'eat&res#
*. $s in all postures, the entrance to the pulp chamber is always gained
through the occlusal surface.
- #he initial penetration is made at the exact centre of the mesial pit with the
bur directed slightly in a lingual direction .
- +or this step, according to Ingle a high speed contrangle the @G. 8 tapering
fissure bur with a rounded end is ideal for penetrating enamel uptil the
dentin or even perforating cast gold restorations.
- $malgam restorations maybe penetrated with a no. 9 or ? round bur.
.. &nce the enamel is penetrated, the no. 9 round bur is used to open up the
pulp chamber important to remember here is that the bur should be directed
towards the orifice of the palatal or mesiobuccal canal orifice, where the
greatest space in the chamber exists.
- #he chamber (drop) is felt when a proper chamber exists or else if calcified
penetrate till c. angle restoration occlusal surface.
6. #hen work the round bur inside out to remove roof of the pulp chamber and
allow location of orifices with endodontic explorer.
..
#he canals usually are 6 viz2 mesiobuccal, distobuccal and palatal.
&ccassionally a fourth canal i.e. a second mesiobuccal canal maybe present in
the maxillary *
st
molars.
9. &nce canals are well located, use the round bur working inside out again to
remove remaining roof 3if any4
- #he amount of extension required in the access cavity can be guessed
by the tension of the endodontic explorer against the walls of the
endodontic cavity prepared.
;. #he final finish and funneling of the cavity is then completed using the @G.
8 fissure bur or tapered diamond points at accelerated speed.
?. #he final outline form is angular in shape with the base of the angle directed
buccally.
.a*iary 4
st
.oar#
$verage #ooth Fength2 .*.6mm
-ulp chamber < largest in the dental arch
- 9 pulp horns % mesiobuccal, distobuccal mesiopalatal,
distopalatal.
- #herefore pulpal roof has a rhomboidal appearance
- owever floor is angular in shape with apex at the
palatal orifice.
- $natomic dark lines, mentioned in &rbans as the
('entinal Map) connect the orifices.
.6
- #he palatal orifice is the longest, round or oval and
easily accessible.
M1 < Mesiobuccal < #he M1 orifice lies below the M1 cusp, is long bucco<
palatally and may have a depression at the palatal end
where 9
th
orifice i.e. second M1 orifice maybe present.
- #he distobuccal orifice is located slightly distal and
palatal to the M1 orifice.
Root an" Root Canas
- 6 roots % 6 canals % mesiobuccal mesiolingual -alatal
.esio3&cca root < is broad in a bucco<lingual direction
- usually M1 roots have a distal curve but may also be
straight or I"> 3bayonet4 shaped.
- Fateral canals 3*E4 or two separate canals 3*9E4
maybe present.
Disto3&cca root < "mall and more less round in shape
- 8sually straight 3;9E4 but maybe distally curved or "
% shaped.
- "ingle canal, lateral canals are occasionally present
36?E4 i.e. more than M1 root.
Paata Root < Fargest diameter
- Fongest of the 6
.9
- May sometimes curve buccally in the apical zone %
important to pre<curve instruction or else would lead to
perforation.
Fateral canals are present not only in roots 39;E4 but may also be in the
trifurcation areas 3*AE4.
Anatomic Reations of ma*iary 4
st
moar
- Fies under the maxillary sinus
- "o the alveolar socket may protrude into the sinus thus a bony prominence
maybe produced in the sinus.
- #he roots maybe separated from the sinus by a periodontal ligament and
mucopenosteal lining of the sinus.
- #his close relation thus produces soreness in maxillary posteriors due to
sinusitis or infection of sinus due to pulpitis.
The "ivergence of the roots may #
*. -ermit sinus to drop into trifurcation
.. -lace root surfaces in close proximity to conrtical plates and palatal
root close to lateral area of the nasal floor.
Access Opening#
.;
- #he access opening as I>ve mentioned is angular with the round corners
extending towards, but not including the mesiobuccal cusp tip, marginal
ridge and oblique ridge.
- #he angular permits direct access to the root canal orifices.
- Foose debris during the mentioned preparation can be removed with ;..;E
5a&,l.
.a*iary /econ" .oar#
*. $verage #ooth Fength % .*.@mm
.. -ulp ,hamber < similar to first molar but
a. 5arrower mesiodistally
b. Roof is more rhomboidal in appearance
c. +loor is obtuse F>ed angle
d. M1 = '1 canal orifices are very close and may appear
to have a common opening.
6. Root and Root ,anals ) 6 roots % closely grouped, maybe fused to form a
single conical root 39?E4
9. $natomic relations < More close to maxillary sinus than *
st
molar
;. $ccess opening < "ame as for maxillary first molar with variations
as anatomy dictates.
!rrors in Access Preparation for ma*iary moars%
.?
*. 8nder extension % &nly pulp horns are exposed
.. &ver extension % gouging and weakening of tooth
6. -erforation % in function % by failing to realise depth of pulp chamber had
been reached.
9. Inadequate preparation % by not understanding the inclination of the tooth
3specially unopposed teeth4
Access Cavity preparation for .an"i3&ar .oars%
"ame as for maxillary molars.
;. :hen penetrating into pulp chamber with a no. 9 or ? round bur, bur should
be directed towards orifice of mandibular or distal canal.
?. +inal cavity is triangular or trapezoidal or rectangular in shape with base
directed mesially.
.an"i3&ar 4
st
.oar#
$verage #ooth Fength 2 .*.Bmm
-ulp chamber 2 as 9 pulp horns % mesiobuccal, mesiolingual,
distobuccal, distolingual.
2 Roof is often rectangular in shape
2 +loor is rhomboidal
2 6 orifices % M1. MF. 'istal
.7 orifice % Is under the mesiobuccal cusp tip
.@
- 3/rossman advocates use of "tarlite '<** explorer to locate
M1 orifice.
.L orifice < Focated in a depression formed by the mesial and lingual walls
Dista orifice < :idest buccolingually, oval in shape
< additional distal orifices maybe present
Anatomic Reation in sit&
- Mesial root is in close proximity to buccal cortical plate while distal is
centrally located.
- $pex of roots maybe close to mandibular canal depending on length of
roots and height and body of mandible.
Access opening for man"i3&ar 4
st
moar#
- In additional to the mentioned features, the access opening should extend
towards the mesiobuccal cusp to expose the M1 orifice, lingually slightly
beyond the centrol groove and distally slightly beyond the buccal groove.
.an"i3&ar 6
n"
.oar
$verage #ooth Fength % ...9mm
-ulp chamber % ,ame as first molar but smaller in size and root canal orifices
are smaller and closer.
Relation in sites % same as *
st
molar except that mesial root is centrally located
and distal root is close to lingual cortical plate.
.A
- May be more closer to mandibular canal.
$ccess &pening % same as mandibular first molar but smaller, greater amount
of M1 cusp may have to be removed because of bucco<axial inclination of
tooth and thus access to M1 canal.
Working Length Determination
"uccessful root canal treatment has been stated to be the performance of
a meticulous art.
If clinicians are to provide endodontic therapeutic procedures with a
high degree of success they must possess a complete understanding of the basic
principles of endodontics which include
*. Jnowledge of internal anatomy of teeth and
.. Mechanisms of determining the tooth length and working length of root
canals.
#he important of correct working length determination lies in the facts
that, an inaccurately determined root canal length may either lead to
I. $pical perforation and overfilling of the root canal with increased
incidence of post operative pain.
II. Incomplete instrumentation and under filling with subsequent
problems, among which notable would be persistent pain and
discomfort from inflamed shreds of retained pulp tissues.
.B
- #hus to determine the precise working lengths many methods have been
proposed over the years.
- 1ut lets first take a look at the requirements of these methods as stated by
Ingle 2 #hese are 2
*. Method must be accurate
.. "hould be easily and readily performed and
6. !asily confused.
.etho"s )
Many methods have been proposed to determine the working length of
root canals and also the length of teeth.
I% +rossman8s .etho"
- $n instrument is placed into the canal extending to the apical construction
3as act by tactile sensation4 and then a radiograph is taken
- $ stopper is also placed at the incisal 7 occlusal margin to help know the
actual instruction length.
- #he radiographic lengths of both the tooth and instrument are then
measured and also is the actual length of the instruments
- #he actual length of the tooth is then measured using the mathematical
formula
$ctual Fength K $ctual length Radiographic length
&f tooth of instrument of tooth
6G
Radiographic length of instrment
II% Inge8s .etho"
*. Measure the tooth on the pre<operative radiograph.
.. "ubstract at least *.Gmm for (safety allowance) such as for image distortion
or magnification.
6. "et the endo scale at this tentative :.F. and adDust the stop on the
instrument at that level.
9. #hen place the instrument in the canal until the stop reaches point of
reference.
;. !xpose and develop the radiograph.
?. &n the radiograph measure the difference between end of the instrument
and end of the root 3add or substract4 this amount to the original measured
length.
@. +inally from this adDusted length subtract *.Gmm (safety factor) to confirm
the apical termination of the root canal at the ,.'.L.
,oming now to a chronological order of how generally methods to this
day were developed or determination of the wave length 2
6*
*. *B;G % 1regmen used .;mm length feat probes with steel blades fixed with
acrylic resins as a stop leaving a free *Gmm for placement into the canal.
#his probe is placed into the tooth until the metabolic end touches the
reference plane. #he radiograph is then taken and following measured 2
,$' < $pparent tooth length 3as seen in the radiograph4
,RI < Real instrument length.
,$I < $pparent instrument length.
,R' < Real tooth length is measured using the formula.
,R' K ,RI C ,$'
,$I
.. *B?G % 1est % determined the tooth length by fixing a steel pin % *Gmm
long to the labial surface of a tooth with utility wax keeping the pin parallel
to the long axis of the tooth and a radiograph is obtained.
- #his radiographs is then carried to a 31:4 gauge which would indicate the
tooth length.
- &rtho wires also used
6. *B?6 % !verett and +inot % designed a diagnostic C<ray grid system for
determine tooth length.
- #his diagnostic x<ray grid system consists of lines *mm apart running
lengthwise and crosswise.
- !very ;
th
mm has a heavier line for easier reading.
6.
- $ctually, enamelled copper<wires were placed in a plexiglass and fixed to
the regular p.a. film. #he grid has been of use to accurately determined
tooth length.
Coming ne*t to recent a"vances #
4% 9erora"iography #
#he new<radiography technique has potential use in endodontics.
#he word Ceros is from a greek word meaning dry which differentiates
% Ceroradiography from the conventional photochem system in that it does not
need wet chemical processing or a dark room.
- Ceroradiography uses a rigid aluminium photoreception plate. #his plate is
electrically charged, placed in a light proof plastic cassette positioned in the
mouth and exposed to x<rays.
- :hen exposed to x<rays, the charge on the photoreceptor is dissipated
according to the tissue density and a latent electrostatic image is formed.
- #his latent image is transformed to a visible image by the deposition of
specially pigmented particles attracted to the photoreceptor plate.
- #his Ceroradiography may be viewed by either reflected or transilluminated
light.
- It has a property of edge enhancement and endodontic studies concluded
that Ceroradiography provided better visualization of metallic instruments
tips and root apices allowing a more accurate length measurement.
66
- #he radiation levels for Ceroradiography are also much lesser.
- #herefore it is valuable addition to the endodontists armamentarium.
+urther developments in working length measurements led to develop of
some non<radiographic methods.
*BA.<5egm % Introduced a novel non<radiographic method
- #he new instrument 3$pex finder4 is used to locate the apex as well as
measure the root length.
- #he method is based on the insertion of a plastic fine tapered barb shaft
through a bevelled tube into the root canal.
- :hen resistance to withdrawal is felt with indicates that some barbs have
engaged the apical margin.
!ectrica Root Length Determination#
- :as begun as early as *B?. when it was first demonstrated by "unada.
- "unada has found the resistance to passage of an electric current, when an
instrument introduced into the root canal, reaches the apical foramen to be
9G M.$.
- In this one electrode is attached to the patients cheek and the other gently
introduced into the root canal until the micro<ammeter indicates 9GM$.
#his length corresponds to the tooth length.
69
"unada>s ideal was the followed by Inove and "aito and then these
systems were marketed 2
!g 2 +&RM$#R&5 I0 % +ormatron % -arkell 8"$.
- "&5&<!xplorer
- 'entometer
- !vident etc.
$lso we have !ndometer 7 $udiometer which indicate reaching apex by
needle deflection 7 beep ;6<A6E success.
8shDama 3*BA64 #he modern apex locations mark by sending a mild $.,. into
the canals and then monitoring the p gradient along the canal with needle type
electrodes.
- #he density of the constant current will be highest at the narrowest point
and the electric field will change at the apical foramen.
- "ome of the early apex locations used ', which had to be used in canals
without vital pulp tissues, blood, tissue fluids or pus, electrocytes and
5a&cl, saline, !'#$ or metallic restorations.
owever todays $, locators only electrocytes and metal restorations
may show false readings.
- owever of late "$I#& has redesigned these $,<!$F which work even in
the presence of 5a&cl % !g2 !ndex 8nit, !ndo ygiene ,ater
6;
Conc&sion #
#hus to conclude these electronic units, the new generation electronic
apex locators have characterized notably improved clinical accuracy and ease
of operation which thus promise their acceptance for the future in endodontic
practice.
6?