ACCESS CAVITY

PREPARATION
















CONTENTS:
INTRODUCTION
RULES FOR ACCESS PREPARATION
PRINCIPLES FOR ENDODONTIC ACCESS PREPARATION
ARMAMENTARIUM FOR ACCESS CAVITY PREPARATION
ACCESS CAVITY PTREPARATION OF VARIOUS TEETH AND
ERRORS IN ACCESS PREPARATION
MODIFIED ACCESS CAVITY PREPARATION
RECENT CONCEPTS IN ACCESS CAVITY PREPARATION
CONCLUSION
REFERENCES


















INTRODUCTION:
All the treatment that follows hinges on the accuracy and correctness
of the entry
Franklin S. Weine
Access cavity is first objective procedure done on an endodontically
compromised tooth.
Endodontic treatment may be considered as a stair, each step representing a
basic phase. To reach the top i.e. to effectively salvage a compromised tooth
to its form and function in the masticatory apparatus, meticulous care is
required to be shown at each step.










The main objective of this preparation is to enable direct access to the
apical foramen by an endodontic instrument, not just exposing canal orifice.
It has been well established that a root with locally tapered root canal and a
single apical foramen is more of a desire than a reality. From earlier studies
to the recent sophisticated works it is clear that multiple foramina, extra root
canals, lateral and accessory canals, deltas loops, cul de sac etc are present
in most teeth. This notes the need for a proper access opening even more
important, since without proper access, the root canal system cannot be
properly negotiated and therefore treated.
Case selection
X-ray examination
Access opening
Cleaning & shaping
Obturation
Proper restoration



Accessory canals: found in apical III of the root and are branches of main
root canal. End in accessory foramen. More in young age as they later get
obliterated by cementum.
Accessory canals: which opens approximately at right angles to the main
pulp cavity are termed lateral canals and generally found in furcation area.

Definition of access cavity preparation:
Defined as coronal opening into pulp cavity required for effective
cleaning, shaping and filling of pulp space during root canal therapy.
- Harty Rugston dental dictionary

RULES FOR PROPER ACCESS PREPARATION
To ensure the most efficient access cavity preparation, the following
rules should be observed:
1) The objective of entry is to give direct access to the apical
foramina, not merely to the canal orifices.
Because it is the apical foramen of each canal that must be sealed,
the access cavity must allow for removal of any tooth structure that might
impede the preparation and filling of that area.






Direct access to apical foramen



2) Access Cavity preparations are different from typical operative
occlusal preparation.
The typical occlusal cavity preparations used in operative dentistry
are based on the topography of occlusal grooves, pits, and fissures, and on
the avoidance of underlying pulp. The access cavity preparations for
endodontic therapy are designed for efficiently uncovering the roof of the
pulp, chambers and providing direct access to the apical foramina by way
of the pulp canals. Because the two types of preparations must satisfy
different criteria, it is only natural that they have differing configuration.







Different from typical occlusal cavity preparation

3) The likely interior anatomy of the tooth under treatment must be
determined.
Before starting the access, radiographs taken from at least two
different angles must be studied. Operator should have proper knowledge
regarding typical length, number and configuration of roots and canals.
Thus information gained before initiation of preparation will greatly
facilitate the entry as well as further treatment.

4) When canals are difficult to find, the rubber dam should not be
placed until correct location has been confirmed.


It is often difficult to prepare access in a malposesd tooth or one
that is part of a bridge or splint. The occlusal anatomy, which ordinarily
gives excellent clues to the position of the underlying canals, may be
considerably altered. Teeth with and / or deep restoration causing heavy
dentinal sclerosis also may cause problems. Therefore, in such teeth, it is
best to make the initial poison of the access preparation before the
placement of the rubber dam so that the shape and inclination or the
adjacent teeth, the gingival tissues, and the hard structures covering the
roots help in determining the position of the canals.


Once the roof of the chamber is penetrated and the correct access is
verified, the rubber dam may be applied. Because the canals will be
enlarged considerably with heavy irrigation, the effect of any
microorganism contamination before dam placement is minimal. If for some
reason it is mandatory to use the rubber dam for every phase of treatment,
the access cavity for complex cases should be prepared with multiple tooth
rather than single tooth isolation. This will allow for visualization of
adjacent teeth while the dam is in place.

5) Endodontic entries are prepared through the occlusal or lingual
surface never through the proximal or gingival surface.
When existing proximal or gingival opening is done from existing
restoration or carious lesion, the canal enlarging instruments must be bent
at severe angles to pass through the access and still perform their function.
Inadequate canal preparation and/or broken instruments may result. When
proximal or gingival tooth destruction occurs, affected areas should be
excavated and restored, with either a temporary seal, or a permanent filling


material .Then the normal access cavity is prepared through the occlusal or
lingual surface.

6) As part of the access preparation, the unsupported cusps pf
posterior teeth must be reduced.
Endodontic therapy requires the removal of much of the central
portion of the treated tooth, greatly reducing resistance to stress. Although
this problem is solved by the placement of a proper restoration after
treatment, the tooth is severely weakened until that time. Therefore, as part
of access preparation all unsupported cusps must be reduced by trimming
with a tapered fissure carbide or diamond stone until a definite clearance
in occlusal and lateral movement is obtained. This decreases the chances
for cuspal fracture beneath the gingival or bony attachments, which is so
difficult to repair, or vertical fracture of the root which is hopeless.

PRINCIPLES OF ENDODONTIC ACCESS PREPARATION:

Endodontic preparation deal with both coronal and radicular cohorts
each prepared separately but ultimately flowing together into a single
preparation.

Coronal cavity preparation principles:

I. Outline form: outline form of the endodontic cavity must be correctly
shaped and positioned to establish complete access for instrumentation from
cavity margin to apical foramen. External Outline form is established by
mechanically projecting the internal anatomy of the pulp onto the external
surface. This may be accomplished only by drilling into the open space of
the pulp chamber and then working with the bur from the inside of the tooth


to the outside, cutting away the dentin of the pulpal root and walls
overhanging the floor of the chamber.

3 factors of internal anatomy must be considered:
1) Size of the pulp chamber: in young patients, these preparations must be
more extensive than in older patients, in whom the pulp has receded and
pulp chamber is smaller in all 3 dimensions.
2) Shape of pulp chamber: finished outline form should accurately reflect
the shape of the pulp chamber. E.g. coronal pulp of maxillary premolar is
flat mesiodistally but is elongated buccolingually. The outline form is,
therefore, an elongated oval that extends buccolingually rather than
mesiodistally, as does blacks operative cavity preparation.
3) Number, position and curvature of root canals: to prepare each canal
efficiently without interference, the cavity walls often have to be
extended to allow an unstrained instrument approach to the apical
foramen. When cavity walls are extended to improve instrumentation the
outline form is materially affected.

II. Convenience form: makes more convenient preparation and filling of
the root canal.
4 important benefits are:
a) Unobstructed access to the canal orifice: enough tooth structure must
be removed to allow instruments to be placed easily into the orifice of
each canal without interference from overhanging wall. Clinician must
be able to see each orifice and easily reach it with instrument points.
One should always search for extra canals.

Loebke stated that the entire wall need not be extended in the event
that instrument impingement occurs owing to a severely curved root or


an extra canal. In extending only that portion of the wall needed to free
the instrument, a cloverleaf appearance may evolve as the outline form
termed as SHAMROCK PREPARATION.










Shamrock preparation.

b) Direct access to the apical foramen: enough tooth structure must be
removed to allow the endodontic instrument freedom within the coronal
cavity so they can extend down the canal in an unstained position.
c) Extension to accommodate filling techniques: to make certain filling
techniques more convenient or practical. E.g. rigid vertical pluggers are
used in a vertical thrust, and then the outline form may have to be widely
extended to accommodate these heavier instruments.
d) Complete authority over the enlarging instrument: if the instrument
is impinged at the canal orifice by tooth structure that should have been,
the dentist will have lost control of the direction of the tip of the removed
instrument, and the intervening tooth structure will dictate the control of
the instrument.


If, on the other hands the tooth structure is removed around the orifice
so that the instrument stands free in this area of the canal, the instrument
will then be controlled by only 2 factors; the clinician fingers on the
handle of the instrument nothing is to intervene between these two
points.

III. Removal of the remaining carious dentin and defective restorations:
Caries and defective restorations remaining in an endodontic cavity
preparation must be removed for 3 reasons.
1) To eliminate mechanically as many bacteria as possible from the
interior of the tooth.
2) To eliminate the discolored tooth structure, that may ultimately lead
to staining of the crown.
3) To eliminate the possibility of any bacteria laden saliva leaking into
the prepared cavity.
- If carious perforation of the wall is allowing salivary leakage, the area
must be repaired with cement, preferably from inside the cavity cavit,
cavit G.
- If lateral wall is extensively destroyed, it is important that restoration be
postponed until the radicular preparation has been completed as it is easy
to complete radicular preparation through an open cavity than through a
restored crown. As long as a rubber dam can be placed on the tooth, it
need not be built up with amalgam, cement or an orthodontic band,
having to work through a hole only complicate the endodontic procedure.

IV. Toilet of the cavity
All the caries, debris and necrotic material must be removed from the
chamber before the radicular preparation is begun. If the calcified or


metallic debris is left in the chamber and carried into canal, it can cause
obstruction.
- Soft debris - increases bacterial count
- Round burs
Long blade endodontic spoon excavation
Sodium hypochlorite irrigation
Chamber may be finally wiped out with cotton, and a careful flush of
air will eliminate the remaining debris.

Radicular cavity preparation:
Objectives: 2 objectives
- Through debridement of the root canal system and the specific shaping
of the root canal preparation to receive a specific type of filling.
- Ultimate objective, however, should be to create an environment in
which the bodys immune system can produce healing of the apical
periodontal attachment apparatus.
Cleaning and debridement of the root canal:
- Skillful instrumentation + liberal irrigation will help to eliminate most
bacterial contaminants of the canal as well as the necrotic debris and
dentin.
- Intracanal medication - sterilization during intra appointment period.

Principles
I) Outline form and convenience form: must be continually evaluated by
monitoring the tension of the endodontic instruments against the margins of
the cavity. They must stand free and clear of all interference. Access must
have to be expanded if instruments start to bind.
II) Toilet of the cavity: through douching through irrigation is important
for total debridement, through certain hooks and crannies of the root canal


system are virtually impossible to reach with any device or system. But
success is possible in spite of microscopic remaining debris.
III) Retention form: Initial primary GP point fit tightly in apical 2-3mm of
the canal. These nearly parallel walls ensure the firm seating of this
principal point. Other techniques strive to achieve a continuously tapering
funnel from the apical foramen to the cavosurface margin. Retention form in
these cases is gained with custom fitted cones and warm compaction
techniques. These final 2-3mm of the cavity are the most crucial as this is
where the sealing against future leakage or percolation into the canal takes
place. This is also the region where accessory or lateral canals are most apt
be present.
IV) Resistance form: resistance to overfilling is the primary objective of
resistance form.
Maintaining the integrity of the natural constriction of the apical foramen is
a key to successful therapy.
Violating this integrity by over instrumentation leads to complication.
1) Acute inflammation of periradicular tissue from the injury by
instrument, bacteria or canal debris forced into tissue.
2) Chronic inflammation of this tissue caused by presence of a foreign
body - filling material forced there during obturation.
3) Inability to compact the root canal filling because of the loss of the
limiting apical termination of the cavity apical stop.





Cretention form
Bresistance form


ARMANENTARIUM FOR ACCESS PREPARATIONS:

Tray set up should contain following things:
- Front surface mirror - For maximum visibility
- Endodontic explorer - One end comes to a point to aid in locating
orifices, while the other has a slight hook to cheek shelves at edges of the
preparation.
- Endodontic excavator - to remove decay and pulp tags.
- Plastic instrument
- Amalgam plugger
- Spatula
- Cotton pliers
- Broaches
- Glass slab, cotton pellets
- Burs - long shank no. 701/558, No. 4, No. 2 and specially prepared no.
701 or 558 with a rounded or safe tipped end to prevent going.
- Rubber dam materials should be available i.e. sheets, punch, frame,
clamp holder and clamps
- No. 26 and 27 - wingless clamps for molars SS White
- No. 12A and 12B - winged clamps for molars Colombus Dental
- No. 209 - for bicuspids and bulky anterior teeth SS White
- No. 211 or 9 - For small anterior and broken down teeth or a similar
assortment
- Temporary filling materials and Intracanal Medicaments.

-Weine.





ACCESS CAVITY PREPARATION FOR VARIOUS TEETH:
Because internal anatomy dictates the access shape, the first step in
preparing an access is visualization of the location of the pulp spaces.
Buccolingual angulations and coronal anatomy are judged visually.
Cervical anatomy can be determined tactically using an explorer
under the sulcus to feel the cervical shape. Palpation along the
attached gingiva will help determine root location and direction.
Diagnostic radiograph in one straight and one in mesial or distal
angulation atleast. Will help to estimate pulp chamber position,
degree of calcification of pulp chamber and approximate canal length.
In difficult situations it is sometimes recommended that the initial
access be prepared without rubber dam in place.
Any restorative material impinging on straight line access should be
removed before the pulp chamber is accessed to prevent the lodging
of debris in the canal. Generally only material in the path of an ideal
access also caries.
Occasionally necessary to place an interim restoration, creating an
efficient seal and facilitating rubber dam placement.
1-2mm of occlusal adjustment of teeth may be done to establish a
more accurate point for measuring canal length and to reduce
postoperative pressure sensitivity.

Endodontic entry
Ingle Initial entrance through the enamel surface or restoration Round
end 702U carbide tissue bur / endodiamond stone.
With this instrument enamel, resin, ceramic or metal perforation is easily
accomplished and surface extension may be rapidly completed. Used always
with coolant to reduce heat.


But PFM : Tungsten carbide bur chatter severely, vibration results in
patient discomfort and tends to loosen the crown from luting cement so
diamond points are preferred.
After preparation of enamel / restorative penetration slow speed 3000
to 8000 contrangle handpeice is used.

Three round burs, 2, 4 and 6 - two lengths: regular 9mm, surgical 14mm.
It is used along long access for drop and also for removal of root of
the pulp chamber.
No. 2 Mandibular anterior, maximum premolars
No. 4 Maxillary anterior, mandibular premolars, adult molars.
No. 6 Molars with large pulp chambers.
After removal of roof again high speed fissure bur is used to finish
and slope side walls.
High speed burs should not be used to penetrate into / enlarge pulp
chamber unless operator is skilled in endodontic preparation as it reduces
tactile sense.

Weine - access cavity preparation begun by using tapered fissure bur
tungsten carbide 701 or 558. Once entered the pulp chamber then safe tip
tissue bur is used to enlarge the access.

Cohen (VII Edition) - Initial round bur for entry i.e. bur drop then switch on
to tapered tissue bur for preparation of side walls.







a) Endodontic preparation for maxillary anterior teeth.
Entrance is always gained through the exact center in the lingual
surface of anterior teeth.
Initial entrance prepared with round point tapering tissue bur
accelerated speed contrangle handpeice operated at right angle to the
long axis of the tooth. Only enamel is penetrated at this time.
Convenience extension towards the incisal continues the initial
penetrating cavity preparation. Maintain the point of the bur in the
central cavity and rotate the handpeice towards the incisal so that bur
parallels the long axis of the tooth. Enamel and dentin are beveled
toward the incisal.
Preliminary cavity outline is funneled and fanned incisally with a
fissure bur. Enamel has a short bevel towards the incisal, and a nest
is prepared in the dentin to receive the round bur to be used for
penetration.
Surgical length No.2 or 4 round bur in a slow speed contrangle
handpeice is used to penetrate the pulp chamber bur is operated
nearly parallel to the long axis of the tooth.
Then round bur is used inside the chamber to outside to remove the
lingual and labial walls of the pulp chamber. The resulting cavity is
smooth, continuous and flowing from cavity margin to canal orifice.
Then lingual shoulder is removed with round or long, tapering
diamond point.
Occasionally No. 1 or 2 round bur must be used laterally and incisally
to eliminate pulp horn debris and bacteria preventing future
discoloration.
Final preparation relates to internal anatomy of the chamber.


In young tooth with large pulp large triangular internal anatomy
(Same type access which allows through cleansing as well as passage
of large instrument).
In adult teeth chamber ovoid in shape due to secondary dentin
deposition.
Further the pulp has receded; the more difficult it is to reach to this depth
with a round bur. Therefore, when the radiograph reveals advanced pulpal
recession, convenience extension must be advanced further incisally to
allow the bur shaft and instruments to operate in central axis.
Final preparation with the reamer in place. The instrument shaft clears
the incisal cavity margin and reduces lingual shoulder allowing an
unrestrained approach to the apical third of the canal.















Endodontic preparation for maxillary anterior teeth


Maxillary Central incisor:
Pulp anatomy and coronal preparation: Pulp chamber of the maxillary
central incisor is located in the center of the crown equidistant from
the dentinal walls; it is broad mesiodistally, with its broadest part
incisally.
3 pulp horns that correspond to the developmental mamelons in
young tooth.
Chamber is ovoid mesiodistally.
Labio-lingual radiograph.
- 2
0
mesial-axial inclination of the tooth
- Apical distal curvature 8% of the time.
Distal view
- Presence of lingual shoulder where chamber and canal join.
- 29
0
lingual-axial angulation of the tooth.
Cross section at 3 levels Root canal is broad labiopalatally, large and
simple in outline, conical in shape and centrally located.
1) Cervical
Ovoid Mesiodistally
2) Midroot ovoid
3) Apical third round
Large triangular tunnel-shaped coronal preparation is necessary to
adequately debride the chamber of all pulp remnants.
Adult incisor: Pulp recession.
Narrow labio-lingual width of pulp.
Operator should recognize:
- Small orifice difficult to find.
- Careful alignment of bur to prevent gouging



Cross-section
Cervical - slightly ovoid. Becomes progressively more round.
Midroot slightly ovoid to round.
Apical III round.
Adult cavity preparation is narrow in M-D width but almost as
extensive in the incisogingival direction as preparation in a young
tooth.
Kasahara et al studied 510 maxillary central incisors to determine
thickness and curvature of the root canal and locations of the canals.
Data revealed that over 60% of the specimens showed accessory
canals and apical foramen was located apart from the apex in 45% of
the teeth.














Access cavity - maxillary central incisor


Maxillary Lateral incisor:
Pulp chamber: Shape is similar to maxillary central incisor but smaller.
Only 2 pulp horns corresponding to developmental mamelons.
Labiolingual radiograph:
- Apical distal curvature 53% of time..
- 16
0
mesial axial inclination of the tooth
Distal view
- Lingual shoulder.
- 29
0
lingual axial angulation of tooth.
Root and root canal: configuration of root canal is conical, it has a finer
diameter than maxillary central incisor and occasionally, may have a fine
constriction in its course towards the apex.
Cross sections:
Cervical - Ovoid labiopalataly.
Mid root ovoid
Apical III round
Large triangular funnel shaped coronal preparation is necessary to
adequately debride the chamber of all pulpal remnants.

Adult incisor pulp recession.
Marrow labiolingual width of the pulp

Operator should recognize:
Small orifice difficult to find
Axial inclination of root careful orientation and alignment. A Cork
Screw curve to the distal and lingual complicates preparation of the
apical III of the canal.



Cross section: Ovoid, Ovoid to round, and round
Ovoid funnel shaped coronal preparation should be only slightly
skewed toward the mesial to present better access to the apical distal.
Good to have extensive bevel toward the incisal to carry preparation
nearer central axis, allowing better access to the apical III.
Apical foramen is centrally located in the anatomic apex 22% of case
and apical delta 3% of cases.

Developmental anomalies:
Dens invaginatus
Peg lateral
Talons Cusp.














Access cavity -- maxillary lateral incisor
Require modifications in the
access openings


Maxillary cuspid:

Pulp chamber is largest of any single rooted teeth labiopalatally. The
chamber is triangular in shape, with the apex toward the single cusp and a
broad base in the cervical III of the crown. Mesiodistally it is narrow,
sometimes resembling a flame.
Only one pulp horn.
Chamber ovoid in cross section with greatest diameter labiopalatally
Division between pulp chamber and root canal indistinct.


Lingual view:
- Apical distal curvature 32%.
- 6
0
distal axial inclination of teeth.

Distal view:
Labial shoulder just below the cervical
Marrow canal in apical III
21
0
lingual axial angulation of tooth.

Root: larger than maxillary incisor. Wider labiopalatally than mesiodistally.
Cervical ovoid
Midroot ovoid
Apical round

Preparation Extensive ovoid, funnel shaped coronal preparation is
necessary to adequately debride the chamber of all pulpal remnants.
Long beveled extension towards the incisal.



Adult-tooth and view Pulp recession.
Narrow labiolingual width.

Operator recognize
Small canal orifice
Apical labial curvature
Distolingual inclination of the root calls for careful orientation and
alignment of the bur to prevent gouging
.
Cross sections at 3 levels:
1) Cervical slightly ovoid
2) Middle canal smaller but ovoid
3) Apical round

Preparation Ovoid funnel shaped preparation must be nearly as large as
for a young tooth.
The apical foramen is centrally located in the anatomic apex in 14% of cases
and apical delta present in 3% of times.
Fenestration is occasional finding. Accurate length determination is critical.
Another ramification of this fenestration is a slight, permanent apical
pressure sensitivity that occasionally occurs after endodontic therapy.
























Access cavity -- maxillary canine



Maxillary anterior teeth:
Errors:
a) Perforation at the labiocervical caused by failure to complete
convenience extension toward the incisal, prior to the entrance
of the shaft of the bur.
b) Gouging of the labial wall failure to recognize 29
0
lingual
axial angulation of the tooth or distal wall failure to recognize
16
0
mesial-axial inclination of the tooth.


c) Pear shaped preparation of the apical canal caused by failure to
complete convenience extension. The shaft of the instrument
rides on the cavity Margin and lingual shoulder.
d) Discoloration of the crown : Failure to remove pulp debris
access with no incisal extension
e) Ledge formation at apical distal curve caused by using an
uncurved instrument too large for the canal. The cavity is
adequate.
f) Perforation at the apical distal curve using box large an
instrument through an inadequate preparation placed too far
gingivally
g) Ledge, formation at the apical labial curve caused by failure to
complete the convenience extension. The shaft of the
instrument rides on the cavity margin and shoulder.

















b) Endodontic preparation of mandibular anterior teeth:
Lingual surface at center
Similar to upper anterior and initial entrance is by 701U tapering
fissure bur.
Pulp chamber penetrated by No.2 round bur surgical length inside to
outside and shift of bur should be parallel to long axis of the tooth
Lingual shoulder is removed with fine tapered diamond point
No.1 round bur to eliminate pulp horn debris.
Final preparation
Young tooth - triangular
In adult tooth pulp receded. So, convenience extension must be advanced
further incisally to allow bur shaft to operate in the central axis.
Final preparation should have unstrained approach to the apical III of
canal.











Access cavity preparation for mandibular anterior teeth


Mandibular central and lateral incisor:
Pulp anatomy and coronal preparation:
Central pulp chamber, small and flat mesiodistally, 3 distinct pulp horns
present in a recently erupted tooth but disappear early in life because of
constant masticatory stimulus.

Labiolingually
Wide and ovoid in cross section.
Lateral - similar to central but larger dimensions.
Lingual view
Slight apical distal curvature of the canal 23% of time.
Mesial axial inclination of tooth Central incisor -2
0
Lateral incisor -17
0

Distal view Lingual shoulder
20
0
lingual axial angulation of the tooth

Root canal: Central incisor- Root which is flat and narrow mesiodistally
but wide labiolingual.
Lateral incisor- Root configuration same but larger than CI.

Cross sections:
cervical - ovoid
Midroot ovoid
Apically - round

Preparation- young, large triangular, funnel shaped necessary to debride
the chamber of all the pulp remnants.



Adult- pulp recession, reduced size of lingual shoulder and unsuspected
presence of bifurcation of pulp into the labial and lingual canals nearly 30%
of the time.

Operator recognize- smaller canal orifice difficult to find, axial inclination
requires careful exploration.

Cross sections
Cervical III- ovoid
Midroot 2 canal, round
Apical - round.
Important that all mandibular anterior teeth be explored to both labial and
lingual for possibility of two canals

Adult -
Preparation is ovoid funnel shaped marrow in the M-D width but is
extensive in the incisogingival direction. Incisal edge may be invaded, will
allow better access to both canals and curved apical III.
Mandibular incisor roots and canal extensively studied by Rankine-Wilson
and Henry.
60% - type I They further stated that
35% - type II short squatty crowns and blunted
5% - type III roots, usually has divided or split canal.
Development depressions are found on both mesial and distal surfaces
of the root. Decrease the M-D dimension so preparation should be
extremely precise.
In terms of difficultly these teeth come right behind the molars and
the multicanaled mandibular bicuspid 40% time 2 canal


Because of their proximity, it is vertically impossible to radiograph
these teeth from a sufficient angle to know in advance that 2 canals
are present. It tooth is decoronized then the two canals can be
discovered.

Mandibular Central incisor has
Lateral canals - 20%
Apical delta - 5%
Apical foramen situated centrally in root - 25%.

Mandibular Lateral incisor has
Lateral canal - 18%,
Apical delta - 6%
Apical foramen in center of radiographic apex - 20%.













Access cavity for mandibular incisors


Mandibular cuspid:
Pulp chamber resembles maxillary cuspid but smaller in dimension.
Chamber is narrow mesiodistally. When viewed buccolingually, the
chamber tapers to a point in the incisal third of the crown, but it is wide in
the cervical area.
One pulp horn
Cross section of chamber is ovoid

Lingual view:
- Narrow M-D width of the pulp
- Apical distal curvature - 20%
- Mesial axial inclination of tooth - 13
0

Distal view:
- Narrow canal in apical III
- Apical labial curvature - 7%
- Lingual axial angulation of the tooth - 15
0


Root and root canals: generally has single root but may have two

Cross section
Cervical ovoid
Middle ovoid
Apical round

Preparation Extensive ovoid tunnel shaped canal preparation necessary
to adequately debride the chamber of all the pulp remnants.
Bevelled extension and towards incisal


Adult
Lingual - pulp recession.

Operator should recognize:
- Small canal orifice.
- Lingual axial in elevation gouging

Cross section - ovoid, ovoid and round.

Preparation - extensive ovoid funnel shaped and as young tooth. An apical
labial curve would call for extension incisally.
2 Canals - wider access
Lateral canal - 30%
Apical delta - 8%
Apical foramen located centrally - 30%.












Access cavity for mandibular canine


Mandibular anterior teeth - Errors in cavity preparation:
a) Gouging at the labiocervical caused by failure to complete
convenience extension toward incisal prior to entrance of the shaft of
the bur
b) Gouging of the labial wall - failure to recognize 20
0
lingual axial
angulation of tooth
c) Gouging of the distal wall - failure to recognize 17
0
mesial-axial
angulation of tooth.
d) Failure to explore, debride or fill the second canal caused by
inadequate incisogingival extension of the access cavity.
e) Discoloration - failure to remove pulp debris
f) Ledge formation caused by complete loss of control of the instrument.



















c) Endodontic preparation of Maxillary premolar teeth:
Entrance always through occlusal surface of all posterior teeth. Initial
preparation is made parallel to the long axis of the tooth in the exact
center of the central groove. 701U tapering fissure bur in an
accelerated speed contra angle hand piece gold casting/virgin
enamel surface.
Regular length No.2 or No 4 round burs - used to open into pulp
chamber but will be felt to drop when the pulp chamber is reached. If
chamber is well calcified drop is not felt. Vertical penetration is made
until the contra angle handpeice rests against the occlusal surface.
Thus depth is approximately 9mm, the position of the floor of the
pulp chamber that lies at the cervical level. In removing the bur, the
orifice is widened buccolingually to twice the width of the bur to
allow room for exploration of canal orifices.
Working from inside to outside with round bur used at low speed to
extend the cavity buccolingually by removing the roof of the pulp
chamber.
Buccolingual extension and finish of the cavity walls completed with
701 U fissure bur at high speed.
Final preparation should provide unobstructed access to canal
orifices. Cavity walls should not impede complete authority over
enlarging instruments.
Outline form of final preparation: Buccolingual ovoid, reflecting the
anatomy of the pulp chamber and position of buccal and lingual canal
orifice. Further exploration at this time is imperative.






















Access cavity preparation for maxillary premolar









Maxillary I premolar:
Pulp anatomy and canal preparation:
Pulp chamber is narrow mesiodistally 2 pulp horns under each cusp. Wide
buccopalatally and buccal pulp horn more prominent than the palatal in
young teeth. Roof of the pulp chamber is coronal to the cervical line. Floor
of pulp chamber is convex. Cross section of pulp chamber is wide and ovoid
in a buccolingual direction.

Buccal view:
- Presence of 2 pulp canals - generally straight
- 10
0
buccal axial inclination of the tooth.

Mesial view:
6
0
buccal axial angulation of the tooth.
Broad buccolingual dimension of the pulp.

Root and root canal:
Have 2 roots in 54.6% of cases. In 21.9% of the double rooted cases the
roots are separated, when s in 32.7% the roots are partially fused.


When 2 root canals are present:
The cervical III are ovoid, mid root almost round and apical III round
and small
Vertucci has stated when 2 canals are present in one root, the distance
between the orifices is a strong indicator of their ultimate relation
with each other. In order words, if the orifices are closer to each
other, the canals will merge short of the apex and if they are far apart,


will remain separate and distinct. This is more correct with
mandibular molar mesial root.
Many of these teeth have a concavity on the mesial, which make the
area below the pulp chamber laterally thin. This must be taken into
account when locating canals, opening the orifice of the canals and
during post build op procedures
Ovoid preparation and buccal and lingual walls smoothly flow into
orifices.

Adult:
- Pulp recession.
- Buccolingual width revealing the pulp to be ribbon shaped rather than
thread like



Operator recognize:
- Small orifices are found well to the buccal and lingual and are difficult to
locate
- Virtually always there will be 2 and occasionally 3 canals.

Cross section: narrow ovoid, round, round
- Ovoid preparation must be more extensive in the buccolingual
direction because of the parallel canals.



















Access cavity preparation for maxillary I premolar


Maxillary II premolar:
Pulp anatomy and canal preparation:
Pulp chamber narrow mesiodistally wider buccopalatally than maxillary I
premolar with 2 pulp horns.
Root of the pulp chamber is similar to I premolar but floor is deeper if 2
canals are present.
In cross section pulp chamber is narrow, ovoid-shape.

Buccal view:
- Apical distal curvature - 34% of time
- 19
0
distal axial inclination of the tooth.



Mesial view:
- Broad B-L width revealing the pulp to be ribbon shaped.
- 9
0
lingual axial inclination of the tooth.

Root and root canals
Have only a single root 90.3% of patients. Only 2% have 2 well developed
roots where as 77% have 2 roots that are partially fused.
Weine 10% of time type IV canals.

Cross section-
- Cervical - very wide in B-L direction. Canal orifice is directly in the centre
of the tooth.
- Midroot - ovoid
- Apical - round. Preparation is ovoid. Allows Debridement of the entire
pulp chamber and tunnels down to the ovoid midcanal.

Adult view:
- Pulp recession thread like appearance.
- B-L width revealing canal pulp - ribbon shaped.
Operator recognize: small canal orifice deeply placed in the root and will
be difficult to locate
Cross section: Narrow ovoid, round, round
If Bayonet curve is present then preparation mesial of the occlusal
surface with a depth of penetration skewed toward the bayonet
curvature. Skewing the cavity allows an unstrained approach to the
first curve.
Apical foramen is centrally located in 12% of the cases and an apical
delta is present only in 3.2% of cases.


Errors in cavity preparation:
a) Underextended - exposing only pulp horns white color of the roof of
the chamber is a clue of the shallow cavity.
b) Over extended preparation.
c) Perforation mesiocervical indentation. Failure to observe distal axial
inclination and mesial groove.
d) Faulty alignment of the access cavity through full veneer restoration
placed to straighten the crown of a rotated tooth.
e) Broken instrument twisted off in a cross over canal. This frequent
occurrence may be obviated by extending the internal preparation to
straighten the canals.
f) Failure to explore, debride and obturate II or III canals.














Access cavity preparation for maxillary II premolar


d) endodontic preparation of Mandibular premolar teeth:
Initial preparation is made in the exact center of the central groove
with bur directed parallel to the long axis of the tooth. 702U tapered
fissure in an accelerated speed is used to the depth of the dentin.
A regular length No.4 for drop rest similar to upper premolar
Final ovoid preparation is a tapered funnel from the occlusal to the
canal, providing unobstructed access to the canal.
Buccolingual outline form reflects the anatomy of the pulp chamber
and position of the centrally located canal.
Outline form of the final preparation will be identical for both newly
erupted and adult teeth.
















Access cavity preparation for mandibular premolars


Mandibular I premolar:
Pulp anatomy and coronal preparation:
Pulp chamber:
M-D width of the pulp chamber is narrow buccolingually; the pulp
chamber is wide with a prominent buccal pulp horn that extends
under a well developed buccal cusp.
In young tooth small lingual pulp horn that may disappear with age
and give the pulp chamber an appearance smaller to that of the
mandibular cuspid
Crown of mandibular I premolar about 30
0
lingual tilt.
Cross section- chamber is ovoid with greater diameter buccolingually.

Buccal view:
Narrow M-D width of the pulp
14
0
distal axial inclination of the root
Relatively straight canal

Mesial view:
Broad buccolingual extent of the pulp
Apical buccal curvature 2%
10
0
lingual axial inclination of the root.
Type IV canal system is present in significant number of cases
ranging from 15-25%
Roots are only slightly larger in circumference and generally shorter
than the root of the adjacent cuspid

Cross section:
Cervical - pulp enormous and wide in B-L dimension- ovoid.


Midroot - ovoid
Apical - round
Preparation - ovoid to allow Debridement of entire pulp chamber and large
enough B-L.

Adult:
- pulp resection and thread like
- Ribbon shaped coronal pulp.
Operator recognize: small orifices are difficult to locate and presence of a
bifurcated canal is determined only by exploration with a fine curved file.
Cross section: narrow ovoid, round, round.
Lateral canals are present 64.3% of cases.
Apical deltas are found 5.7%.
Apical foramen is centrally located in only 15% of the teeth.
Anomalies: Bifurcation and trifurcation of roots.












Access cavity preparation for mandibular I premolar


Mandibular II premolar:
Pulp chamber: Similar to I premolar except the lingual horn is more
prominent under a well developed lingual cusp.
Buccal view:
Apical distal curvature 40% of time
10
0
distal axial inclination of the root
Mesial view: 34
0
buccal axial inclination of the root
Root and root canals: Root has greater girth and is wider buccolingually
than that of the mandibular I premolar.

Cross section:
Cervical: B-L wide, ovoid; ovoid; root.
Preparation- ovoid, coronal funnel shaped preparation down to ovoid mid
canal.

Adult - pulp recession and buccolingual ribbon shaped pulp
Section - Narrow ovoid, less ovoid and round
Lateral canals are present 48.3% of time,
Apical delta 3.4%.
Apical foramen is centrally located in only 16.1% of these teeth.

Errors in cavity preparation:
a) Perforation at distogingival caused by failure to recognize that
premolar has a tilt towards distal.
b) Bifurcation of a canal completely missed. Caused by failure to
adequately explore the canal with curved instrument.
c) Perforation of apical curvature caused by failure to recognize by
exploration of buccal curvature.



















Access cavity preparation for mandibular II premolar











e) Endodontic preparation of maxillary molar teeth:
Entrance through occlusal surface. Initial penetration is made in the
exact center of the mesial pit, with the bur directed toward the lingual.
The 702U tapering fissure bur in speed - for virgin enamel and gold
casting. Amalgam filling 4 - 6 round burs.
As per size of chamber No. 4 to open into pulp chamber. The bur
should be directed toward the orifice of the palatal canal or toward the
M-B canal orifice where the greatest space in the chamber exists.
Drop will be felt if pulp chamber is reached. (Contra angle rest -
9mm).
Work inside out, back toward the buccal, the bur removes enough
root of the pulp chamber for the exploration.
An endodontic explorer is used to locate orifices of the palatal, MB
and DB canals. Tension of the explorer against the walls of
preparation will indicate the amount and direction of extension
necessary. Orifices of canal form the perimeter of preparation. Special
care should be taken to explore II canal in MB root.
Work inside out to remove roof of the pulp chamber. Final finishing
and funneling with 702U fissure or tapered diamond points at
increased speed.
Further preparation can be eased for access by leaving the entire
preparation toward the buccal for; all instruments are introduced from
the buccal.
Preparation extends almost to the height of the buccal cusps. The
walls are perfectly smooth and orifices are located at the exact pulp
axial angles of the cavity floor.
Outline form reflects anatomy of pulp chamber with base towards
buccal, apex to lingual and cavity is entirely with in mesial half of the


tooth and need not invade the transverse ridge but is extensive enough
buccal to lingual, to allow positioning of instrument and filling
material.

















Access cavity preparation for maxillary molars







Maxillary I molar:
Pulp chamber:
Largest in dental arch with 4 pulp horns MB, DB, MP and DP.
The arrangement of 4 pulp horn gives the pulpal root a rhomboidal
shape in cross section.
The four walls forming the roof converge toward the floor where the
lingual wall almost disappears; the floor of the pulp chamber thus has
a triangular form in cross section.
The orifices of the root canals are located in the 3 angles of the floor.
Anatomic dark lines in the floor of pulp chamber connect the orifices.
Palatal orifice is largest and is round / oval in shape.
MB orifice is under MB cusp, long buccopalatally and may have
depression at palatal end in which the orifice of a fourth canal may be
present.
DB orifice: Is located slightly distal and palatal to the MB orifice.
Floor of the pulp chamber is in cervical III and roof in the cervical III of the
crown.

Buccal view: 2 canals in MB root

Mesial view: Apical buccal curvature of palatal root 55% of time.
Has 3 roots.
MB root:
Broad in B-P direction canal narrowest of 3, flattered in a M-D
direction in the orifice but round in the apical III.
Lateral canal 1% of cases,
Apical delta 8%.
Apical foramen located centrally in only 14% of cases.


DB root:
Small and more or less round in shape, canal is narrow tapering canal
ending in a small round canal in apical III.
Lateral canals - 36%,
Apical delta 2%.
Apical foramen centrally located 19%.
Palatal root:
Largest diameter and largest root
Canal is ovoid mesiodistally and tapers towards apex when it
becomes a small, round canal.
Lateral canals present in 40%,
Deltas - 4%,
Apical foramen centrally located in only 18%.
Lateral canals in trifurcation - 18%
Triangular outline form with base toward the buccal and apex toward
the lingual with the orifice positioned at each angle of the triangle.
Both buccal and lingual walls slope buccally, mesial and distal walls
funnel slightly outward. The cavity is entirely within the mesial half
of the tooth. The orifice to an extra middle mesial canal may be found
in the groove near the MB canal.

Adult:
Pulp recession and thread like pulp.
A chamber constricted from secondary dentin formation.
Since the buccal roots diverge as they leave the crown, the canals
form a V shape and approach each other near the floor of the
chamber. As reparative dentin fills in the chamber and canal


diameter, the orifices are found further up their respective roots and
thus are further apart.
Weine Quadrilateral access with rounded comer to get adequate
debridement of palatal canal.
To uncover 4
th
canal safe tipped bur is moved form MB orifice
toward the palatal canal a distance of 2-5 mm.
Root:
MB - greatest difficult.
When viewed from buccal - MB canal curves first to mesial as it
leaves the floor of the chamber and then to the distal and also curves
initially towards buccal and then to the palatal.
Distobuccal and Mesiobuccal give cow horn appearance.
Good to give distal angulation.

Maxillary II molar:
Pulp chamber: similar to maxillary I molar except narrower mesiodistally.
Because of narrow dimension, roof of the pulp chamber is more rhomboidal
in cross section. Floor of Pulp chamber is obtuse in cross section. MB and
DB canals are close together and may appear to have a common opening.
Sometimes all 3 canal orifice may almost be in straight line.

View: similar to I molar

Root and root canal:
3 roots closely grouped. Because of this close grouping, the buccal
roots may fuse and occasionally all 3 roots fuse to form a single
conical root - 46%.
16% of roots are foramina centrally located.


3% apical delta.

Outline form: triangular form is flattened. DB orifice is nearer to the
center of the cavity floor. The entire preparation sharply slopes to the buccal
and is extensive enough to allow positioning of instruments.
Adult: pulp recessed and thread like. Ovoid outline form
Two rooted maxillary molar - 10% of cases.

Maxillary III molar:
Resemble II molar
Pulp chamber: Can be similar to that of maxillary II molar with 3 canal
orifices, but it may also have an odd-shaped chamber with 4 or 5 root canal
orifices or a conical chamber with only one root canal.
Root and root canals:
Variations
- 3 well developed roots
- Fused roots
- One conical root
- 4/5 independent root.
- Root canals vary from 4/5 in number

Access opening similar to II molar:
Careful examination of root morphology is recommended before
initiating treatment. Radicular anatomy is completely unpredictable and is
advisable to explore the root canal morphology before promising success.

Errors in cavity preparation:
a) Under extended : Only pulp horns are Nicked


b) Over extended : Badly gouged
c) Perforation: Using surgical length but failing to realize narrow pulp
chamber has been passed.
d) Inadequate vertical preparation: related to failure to recognize severe
buccal inclination of tooth.
e) Disoriented occlusal outline: A faulty cavity has been prepared in full
crown, which was placed to straighten a rotated molar. Palpating for
MB root prominence would reveal the severity of the rotation.
f) Ledge: Large straight instrument in curved canals.
g) Perforation: palatal root as buccal curve is present in apical III.





















f) Endodontic preparation of mandibular molar teeth:
Initial preparation is made in the exact center of the mesial pit, with
the bur directed towards the distal.
The 702U tapering fissure bur in an accelerated speed for gold casting
/ virgin enamel upto depth of dentin
No 4 round bur for amalgam
As per size of pulp chamber, No. 4 / No. 6 round bur to open into
pulp chamber. The bur is directed towards the orifice of MB or distal
canal, when the greatest space in the chamber exists
Drop is felt when pulp chamber is reached.
Well calcified: Contra angle handpeice rest.
9 mm usual position of the floor of pulp chamber.
Working inside out, back toward the mesial, the bur removes enough
roof of the pulp chamber for exploration
Endodontic explorer to explore orifice and special care must be
taken to explore for an additional canal in the distal root. The distal
canal should form a triangle with 2 mesial canals. If it is asymmetric,
always look for fourth canal (29% of the time).
Final finishing and funneling of cavity walls is completed with 702U
fissure bur or diamond point at speed.
Improve ease of access by leaning the entire preparation toward the
mesial, for all instrument is introduced from mesial. Notice that
cavity outline extends to height of the mesial cusps. Walls are
perfectly smooth and the orifice located at the exact pulpal axial angle
of the cavity floor.
Square outline form. Both mesial and distal walls slope mesially.
Cavity is primarily with in the mesial root of the tooth. Further
exploration should determine if a fourth canal can be found in the


distal. If so the outline is extended in that direction and an orifice will
be positioned at each angle of the square.













Access cavity preparation for mandibular molars

Mandibular I molar:
Pulp anatomy and coronal preparation:
Pulp chamber:
Roof rectangular in shape. Mesial wall straight, distal wall round
and buccal and lingual walls converge to meet the mesial and distal
walls and to form a rhomboidal floor.
4 pulp horns
Root located in cervical III of crown just above canine and floor
located in cervical III of root.




3 distinct orifices:
MB orifice under MB cusp, ML orifice is located in a depression
formed by the mesial and lingual wells.
Distal orifice oval/kidney shaped with widest diameter
buccolingually.
If 2 canals are present then they are eccentrically placed. Further if
file No. 25 cannot penetrate distal canal, then 2 canals should be
suspected

Buccal View: curvature of mesial root 86% of time and distal axial
inclination of the tooth

Mesial View: 58
0
buccal angulation of the roots.

Roots and root canals:
Usual Roots
Mesial and distal both roots are wide and flat buccolingually with a
depression in the middle of the root buccolingually
Accentuated in mesial root.
Third root 5.3%.
MB canal curves first curves towards the mesial and then it gradually
turns towards distal.
MB canal first curves to the buccal and then to lingual. Coronal
portion of the ML canal is straighter and then in the middle III begins
a more gradual buccal curve therefore from this view canals diverge
coronally but then converge apically.
Cross section



Cervical: ovoid and enormous pulp
Midroot: Canals are ovoid and severe indentation on the distal surface of
the mesial root brings the canal within 1.5 mm of the external surface, an
area generally susceptible to strip perforation.
Apical III: round tapered preparation
General outline is trapezoidal with rounded comers. The shortest side
is to the distal aspect, and the mesial side is slightly longer. Buccal
and lingual walls are approximately of same length and taper toward
each other distally.
Some have suggested triangular shaped entry. However, the distal
canal is kidney shaped in most cases, with the greatest width
buccolingually. Also, two canals exiting the floor of the chamber are
found in distal root approx 30% of time. Attempting to enlarge the
single large canal or to locate the possibly present second canal
requires such wider access than that afforded at the apex of a triangle.

Adult: pulp recession, thread like
Cross section: oral, round, round


Mandibular II molar:
Pulp chamber is smaller than mandibular I molar and root canal orifices are
smaller and closer together.

Buccal view: mesial curvature of distal root 10%
Mesial View: 52
0
buccal axial inclination of the roots.



Roots and root canals:
Only one mesial canal does occur in II molar. This bicanalled tooth
access is trapezoid narrowed to the mesial to be move rectangular
27%
Teeth with
2 roots 71%
1 root 27%
3 root 2%
May have C shaped canal first described by Cooke and Cox, 1979 - 8%
[predominantly in mandibular II molar].

From occlusal surface it appears that the orifices of the canal are not
individually distinct but that there is a C shaped trough on the floor of pulp
chamber. C shaped configuration refers to a continuous slit between all the
canals so that the horizontal section through the root yields a space in the
shape of letter C.
Closed area of C may be towards buccal or lingual.
- If buccal Then canal is continuous from the MB to be ML around the
lingual to the DL to the DB.
- If lingual ML to the MB along the buccal to the DB to the DL and is
difficult to treatment.

Cross section: Ovoid, round, wound
- Strip perforation

Adult: Pulp recession, thread like
Access similar to mandibular I molar
Lateral Canals in mesial root - 49%. AD - 6%
Distal root 34%. AD - 7%


Lateral canals in furcation 11%
When a single apical foramen is present, it is centrally located in 19% of
cases in mesial root, 21% of cases in distal root.

Mandibular III Molar:
Pulp chamber: Anatomically resembles the pulp chamber of the
mandibular first and second molars. It is large and possesses many
anomalous configurations such as C shaped root canal orifices.
Judgment should be made as to the benefit derived from treatment of a third
molar balanced against its prognosis. In many cases the benefit is so
marginal that extraction is the best choice.

Root and root canals: Usually have two roots and 2 canals but occasionally
one root and one canal or 3 root and 3 canals. The roots are generally large
and short.

Access opening: Similar to mandibular I and II molars, with the variations
that anatomic structure dictates.
Anatomic relation in situ- root may project onto lingual plate of mandible
and apex of the root is in close proximity to the mandibular canal.


Access cavity preparation and enlargement of orifice:
Er : YAG laser ablate enamel and dentin.






MODIFIED ACCESS CAVITY PREPARATION:
Buccal access in case of lower incisor especially in the case of
crowding or for structural reasons and it may have less compromise of the
straight line principle.
If worn incisor: Access cavity positioned directly along the long axis
of the tooth Decision should be based on ease of access and conservation
of as much tooth structure as possible.


1) Access through full veneer crowns:
Crowns are constructed with the occlusal relationship of the opposing
tooth as a primary consideration. A cast crown may be made in any shape,
diameter, height or angle; this cast crown alteration can destroy the visual
relation to the true long axis. Careful study of preoperative radiograph
identifies most of these situations.
Should be done with use of coolants as friction generated heat can
damage adjacent soft tissues including the PDL.
Frequent irrigation to remove small slivers can cause large
obstruction in the fine canal system.
Access without rubber dam in place this allow correct angulation of
the bur, as the operator is not distracted by the angulation of the crown.
Access when anatomic crown is missing Better to palpate for root
anatomy to determine root angulation for correct bur angulation.








2) Achieving access through complex restorations:
Ideal access can only be achieved by total removal of all restorative
material. In the case of gold crowns and porcelain fused to metal crowns,
financial constraints may influence the choice for gaining access. Under
such condition patient should be informed of all risk.


3) Methods of locating calcified canals:
Pulp stone and irritation dentin may make the location of root canal
orifices difficult. Special tips of ultrasonic Handpeices are invaluable in this
situation as they allow the precise removal of dentine from the pulp floor
with minimal risk of perforation. In absence pointed ultrasonic sealer tip.
A solution of 17% EDTA is excellent for cleaning floor of the
chamber and let it stand for 1-2 min. Dentin chips and other debris can then
be washed away with a syringe of NaOCl.


4) Sclerosed canals:
Illumination and magnification are vital. There is no rapid technique
in dealing with calcified cases. Painstaking removal of small amounts of
dentin has proven to be safest approach.
Loupes, microscope and thorough knowledge
Chelating agents like EDTA should not be used as it softens dentin
indiscriminately and may lead to formation of false canal or
perforation.
Dentin removed with ultrasonic tips CT4 design or long shank low
speed no. 2 round bur. Take frequent radiograph with ultrasonic tip /
drill in place to see its relation with root canal.


Endodontic explore DG 16. Examining instrument and chipping tool
often used to flake away calcified dentin. A slight tugback in the area
of canal orifice often signals the presence of a canal.
At first indication of space, the smallest instrument No. 6 or No. 8 file
should be introduced. Gently passive both apical and rotational,
further access to canal orifice widened by G.G bur.
If pulp chamber filled with irrigates, bubbles can occasionally be seen
appearing from the canal orifice or dyes and Iodine in Potassium
iodide or methylene blue for location of canal orifices.


5) Location of extra canals:
MB

2 in maxillary molars 60%
Location of the orifice can be made by visualizing a point at the intersection
between a line running from the MB to the palatal canal and a perpendicular
from DB canal. There is often an isthmus between the main MB canal and
the second MB this can be traced until the orifice is located.
Four canals in mandibular molar 38%
If distal canal is not in middle of the tooth than a second distal canal should
be suspected and canals are often equidistant from midline.
Two canals in mandibular incisor 41%
To gain proper access to both canals - access has to be extended very near to
the incisal edge.
Two canals in mandibular premolar 11%
There are rarely two orifices. The lingual canal normally projects from the
hall of the main buccal canal at an acute angle. It can usually be located by
running a file with a sharp bend in the tip along the long wall of the canal.




6) C shaped mandibular molar:
2 types
1) Those with single, ribbon like C shaped canal from orifice to apex and
2) Those with 3 or more distinct canals below the usual C shaped orifice.
Fortunately C shaped molars with a single swath of canal are the
exception rather than the rule.
Increases common in Asians than in Caucasians
China 31.5% incidence Hadad, Mehma and Ovnsi found a 19.1% in
Lebanese subjects.






















ANATOMY OF PULP CHAMBER FLOOR:

A study has been done by Paul Krasner and Henry J Rankow where they
used 500 extracted maxillary and mandibular anterior premolar and molars.
400 teeth were cut off horizontally at level of CEJ, 50 teeth sectioned
buccolingually through crown and roots, 50 teeth sectioned mesiodistally
through crown and roots.

Following observations were noted:
1) Pulp chamber has always in the center of the tooth at the level
of CEJ
2) Walls of the pulp chamber were always concentric to the
external surface of the crown at the level of the CEJ.
3) The distance from the external surface of the clinical crown to
the wall of the pulp chamber was the same through out the
circumference of tooth at the level of the CEJ.

These observations were consistent enough that several laws could be
formulated.
Law of centrality: The floor of the pulp chamber is always located in the
center of the tooth at the level of CEJ.
Law of concentricity: The walls of the pulp chamber are always concentric
to the external surface of the tooth at the level of the CEJ.
Law of CEJ: CEJ is most consistent, repeatable landmark for locating the
position of the pulp chamber.





Following observations were noted relative to all the teeth except maxillary
molars.
1) If a line is drawn in a mesial-distal direction across the center
of the floor of the pulp chamber, the orifices of the canals on
either side of the line are equidistant.
2) If a line is drawn in mesial distal direction across the center of
the floor of the pulp chamber, the orifices of the canals on
either side are perpendicular to it.


Several laws regarding pulp chamber floor that can be proposed.
Law of symmetry 1: Except for maxillary molars, the orifices of the canals
are equidistant from a line drawn in a mesial distal direction through the
pulp chamber floor.
Law of symmetry 2: Except for the maxillary molars, the orifices of the
canals lie on a line perpendicular to a line drawn in mesial distal direction
across the center of the floor of the pulp chamber.

Relationship on the pulp chamber floor:
1) Floor of pulp chamber is always a darker color than the
surrounding dentinal walls.
2) This color difference creates a distinct junction where the walls
and the floor of the pulp chamber meets.
3) The orifices of the root canals are always located at the junction
of the walls and floor.
4) The orifices of the root canals are located at the angles in the
floor wall junction.
5) The orifice lay at the terminus of developmental root fusion lines
(DRFL)


6) DRFL are darker than the floor color
7) Reparative dentin or calcification are lighter than pulp chamber
floor and often obscure it and the orifices


Law of color change: Color of the pulp chamber floor is always darker than
the walls.
Law of orifice location 1: The orifices of the root canals are always located
at the junction of the walls and floor.
Law of orifice location 2: The orifices of the root canals are always located
at the angles formed at the junction of the walls and the floor
Law of orifice location 3: The orifice of the root canals are located at the
termination of developmental root fusion line.


















CONCLUSION
Thus the hard tissue repository of the human dental pulp takes on many
configurations that must be understood before the treatment can begin.
Detailed knowledge of anatomy of the teeth, armamentarium and
knowledge regarding access cavity preparation are critical for the success of
root canal therapy.

























REFERENCES

1) Endodontics.Ingle,Bakland V edition.
2) Endodontic theraphy.Weine VI edition
3) Pathways of pulp.Cohen VIII edition.
4) Endodntics. Stalk Walker & Gulabivala III edition.
5) Advanced endodontics for clinicians.Jacob Daniel
6) Endodontics problems solving in clinical practice Pittford.