10 Top Tips: Access

cavities and canal

location
AUTHOR: TONY DRUTTMAN

You have to follow some basic rules. You have to know where to
look, otherwise a large amount of tooth tissue can be
unnecessarily destroyed and the long-term prognosis for the tooth
affected (Figure 1).

Figure 1: The floor of the pulp chamber

has been considerably damaged, including a perforation while
looking for the canals
A good quality preoperative long cone periapical radiograph gives
important information about the depth of the pulp chamber, the
mesio-distal position of the canal or canals, the canal curvature
and whether the canals divide along the way (Figure 2).

Figure 2: Important information can be

gleaned from a good quality periapical radiograph
The pulp chamber and the canals reduce in size through life as
secondary dentine is laid down, but they also react to trauma and
insult, and tertiary or reparative dentine can be laid down to
completely or partially obliterate the pulp chamber and canal,
especially in the coronal part. This was discussed in the third
article of the series on radiography.
The pulp chamber and the root canals should flow one into the
other so that instruments can be introduced into the root canals
without hitting obstructions on the way. Once entry into the pulp
chamber has been achieved, the preliminary shape of the pulp
chamber can be created using safe ended Endo-Z burs (available
from Dentsply) (Figure 3).

Figure 3: Endo-Z bur

This allows the walls to be shaped without damaging the floor of

the pulp chamber. Once the canals have been located and the
first instruments placed, a sense of the canal anatomy starts to
form and the access design may have to be modified during canal
preparation as progressively larger and stiffer rotary instruments
are used.
Canal positions
Basic canal positions can be found in any textbook on
endodontics so this is not the place to repeat the information.
However, it is worth reminding readers how to find an mb2 canal
in upper molars. Inability to find the mb2 canal is the most
common cause for failure of endodontic treatment in upper molars
(Figures 4a and 4b).

Figure 4a: Endodontic lesion above the

mb root

Figure 4b: Re-treatment including

identification and treatment of the mb2 canal
The incidence varies depending on the papers you read (and how
adept the authors are at finding them). The range seems to be
about 70-90%, so the answer is always look for the canal.
For those of you that did not see the earlier article on anatomy in
the series, I've repeated the schematic diagram to show the
relative positions of the canals in an upper molar below (Figure 5)
(See the bottom of the page for links to other articles in this
series).

Figure 5: Schematic of an upper molar

showing the relationship of the mb2 canal to the other canals
Draw a line between the palatal canal and the mb1 and then drop
a perpendicular line from the db canal to the line between the
other two canals. You will usually find the mb2 where they
intersect. There are basic rules about canal position which if
followed make canal location easier and conserve tooth tissue.

1. The floor of the pulp chamber is always located at the centre of

the tooth and at the level of the CEJ - Cementoenamel Junction
(Figure 2)
2. The walls of the pulp chamber are concentric to the external
surfaces of the the tooth at the level of the CEJ (Figure 6)
3. The CEJ is the most consistent landmark in locating the
position of the pulp chamber
4. Except for maxillary molars, the orifices of the canals are
equidistant from a line drawn in a mesio-distal direction across the
floor of the pulp chamber (Figure 6)
5. The pulp chamber floor is always darker than the walls (Figure
6)
6. The orifices of the root canals are always located at the
junction of the walls and the floor (Figure 6).

Figure 6: Position of the pulp chamber and

canals in relation to the external outline of the tooth
Difficulties
Often we experience difficulties in being able to recognise the
difference between the roof and the floor of the pulp chamber. If
the roof is not removed then canals can never be cleaned
properly and there will always be a source of bacteria to
contaminate the canal system (Figure 7a). It is therefore
necessary to examine the floor of the access cavity carefully to
determine that any tertiary dentine has been removed (Figure 7b).

Figure 7a: The floor of the pulp chamber is

covered with reparative or tertiary dentine

Figure 7b: The floor of the pulp chamber is

revealed
Small long shank burs are then used to remove pulp stones over
the canal entrances and remaining pulp stones in the canals
themselves (Figure 8) can be removed with ultrasonic files (Figure
9). It is helpful of course to do this under magnification and with
good light, but more about that in the next issue on magnification
and illumination.

Figure 8: Pulp stone in the entrances to

the canals

Figure 9: Bur selection used in

endodontics
Check radiographs
Occasionally, canals that are very clear on radiographs can be
very difficult to find, often in crowned teeth where the natural
shape of the coronal tooth tissue has been lost. In these cases it
is important to take check radiographs to ensure that a new canal
is not being created heading off towards the periodontal
membrane (Figure 10). In heavily restored, damaged or
traumatised teeth, the canal may be sclerosed and difficult to
locate. The radiograph may well not even show the presence of a
canal.

Figure 10: Even though the canal was clearly

visible from the pre-operative radiograph, the canal was difficult to
locate until a check radiograph had been taken