Pulp space anatomy and access cavities

SUMMARY
Knowledge of pulp space anatomy is essential to achieving the
objectives of endodontic treatment. The advent of newer imaging
techniques including three-dimensional tomography has revealed
and confirmed the complex and divergent anatomy of the pulp space.
Classical, pre-conceptualized access cavity designs are informative
in the understanding of pulp space anatomy. However, they have
been replaced by emergent and customized access cavity designs,
prepared according to treatment requirements. Unnecessary and
excessive destruction of tooth tissue during access cavity preparation
remains unwarranted. The wider adoption of magnification and
enhanced illumination, especially the clinical use of an operating
microscope, is invaluable, greatly aiding access cavity preparation
and allowing the detailed examination of the pulp space.
INTRODUCTION
The major factors involved in the development of apical periodontitis
are loss of integrity of coronal tooth substance and the entry of
microorganisms into the dentine and pulp space. The primary aim of
root canal treatment is the removal and exclusion of these
microorganisms, their substrates and products from the pulp space
and surrounding dentine. Current practice involves the
chemomechanical cleaning, followed by the complete sealing of the
pulp space. In addition, the need for a good coronal restoration is
integral to reducing the risk of pulp space recontamination.
A clear understanding of the anatomy of human teeth is an essential
prerequisite to achieving the objectives of adequate access, thorough
cleaning, effective disinfection, and complete obturation of the pulp
space. Many of the problems encountered during endodontic
treatment occur because of the pulp response to irritation and an
inadequate understanding of the pulp space anatomy. Both students
and clinicians need to familiarize themselves with the intricacies,
complexities and aberrations that are likely to occur within the pulp
space. The importance of developing a visual picture of the expected
locations and numbers of canals in a particular tooth cannot be
overemphasized.
The internal anatomy of human teeth has been studied by many
investigators, who have provided a valuable insight into the size,
shape and form of the pulp space. Methods of study have included
replication techniques, 1,2 ground sections, 3 clearing
techniques4.5. and 6. and radiography.7.8.9.10.11. and 12. Clinical
radiographs show the forms of roots and pulp canals in two planes
only. A third plane exists in a buccolingual direction. The pulp space
volume is invariably much greater than the clinical radiograph would
suggest. Micro-computed tomography has allowed the appreciation
of pulp space anatomy in three-dimensions (Fig. 4.1). More recently,
Cone Beam Computed Tomography (CBCT) has increased our
knowledge of the pulp space13,14 and allowed the identification of
missed anatomy.
NOMENCLATURE
Anatomically, the dental pulp space is surrounded by dentine to form the pulp-
dentine complex. Dentine forms the bulk of the mineralized tissue of the tooth.
The dentinal tubules, which are interconnected, make up 20–30% of the total
volume of dentine. 15 The number of tubules per square millimetre more than
doubles and the area occupied by tubules increases three-fold from the
dentine near the amelodentinal junction, to that near the pulp. 16 These
differences have a significant clinical effect on the permeability of dentine. It is
now realized that the dentinal tubules are an important reservoir of
microorganisms when pulpal necrosis occurs. 17 A direct route of
contamination from unclean root canals into the periapical tissues may be
created by the exposure of infected tubules following root-end resection
during apical surgery. 18,19
The pulp space is divided into two parts: the pulp chamber, which is usually
described as that portion within the crown; and the pulp canal or root canal,
which lies within the confines of the root. The pulp chamber is a single cavity,
the dimensions of which vary according to the outline of the crown and the
structure of the roots. Thus if the crown has well-developed cusps the pulp
chamber projects into well-developed pulp horns. In multirooted teeth the
depth of the pulp chamber depends upon the position of the root furcation and
may extend beyond the anatomical crown. In young teeth, the outline of the
pulp chamber resembles the shape of the exterior of the dentine. With age,
the dentinal tubules and the pulp chamber become reduced in size by the
laying down of intratubular dentine, secondary dentine and tertiary dentine,
particularly in areas where there has been caries, tooth wear and exposure to
operative treatment (Fig. 4.2). The pulp chamber may then become irregular
in outline. With age, there is also a gradual decrease in pulp space volume,
the number of nerves, blood vessels and cells within, but an increase in the
fibrous and mineral components. The rate at which the pulps age varies from
one tooth to another, and from one patient to another. Calcific changes can
lead to the pulp space appearing entirely obliterated radiologically. A residual
canal, although radiologically unidentifiable, almost certainly remains within
the root as a pathway for microbes to reach the apex and cause periapical
changes.
The pulp of root canals is continuous with the pulp chamber and normally the
greatest diameter is at the pulp chamber level. Because roots tend to taper
towards their apex, the canals also have a tapering form which is constricted
at the end, the apical constriction, before emerging at the apical foramina,
near the root end; rarely do the foramina open at the exact anatomical apex of
the tooth. During root development, the pulp and periodontal tissues become
separated, maintaining neural and vascular connections through the apical
foramina.
The pulp space is complex and root canals may divide and rejoin, and
possess forms that are considerably more involved than many textbooks of
anatomy have implied. Many roots have additional canals and a variety of
canal configurations. Eight separate pulp space configurations have been
identified6 (Fig. 4.3). In the simplest form, each root has a single canal and a
single apical foramen (Type I). Commonly, however, other canal complexities
are present and exit the root as one, two or more apical canals (Types II–VIII).

Since roots tend to be broader buccolingually than they are

mesiodistally, the pulp space is similarly oval in cross-section. The
diameter of the root canal decreases towards the apical foramen and
reaches its narrowest point 1.0–1.5 mm from the foramen. This point,
the apical constriction lies within dentine just prior to the first layers of
cementum and is the narrowest point to which the canal tapers.
During root development the apical part of the pulp is described as
being ‘open’. As the tooth matures, the funnel-shaped foramen
closes and constricts to a normal root shape with a small apical
foramen. The position of the apical foramen may also be altered,
.relative to the root apex with the deposition of secondary cementum

ACCESSORY AND LATERAL CANALS

The pulpal and periodontal tissues not only maintain connection through the
apical foramina but also through accessory and lateral canals. A lateral canal
can be found anywhere along the length of a root and tends to be at right
angles to the main root canal. Accessory canals usually branch off the main
root canal somewhere in the apical region. The presence of lateral canals in
the furcation areas of molar teeth is well documented and their incidence is
relatively high. Patent lateral canals are present in the coronal or middle third
of 59% of molars; 20 76% of molars are reported to have openings in the
furcation. 21 It has been shown, using a vascular injection technique that these
accessory canals often had a greater diameter than the apical foramina, and
the blood vessels passing through them often had a greater diameter than
those in the apical foramina. 22 The accessory and lateral canals may be
demonstrated histologically, by clearing techniques, or clinically on
radiographs (Fig. 4.4). The presence of these canals in teeth with necrotic
pulps allows microbial toxins to stimulate inflammatory responses in the
periapical tissues.

LOCATION OF APICAL FORAMINA

The majority of endodontists consider that the apical extent of canal
preparation should be determined by the position of the apical constriction in
the region of the dentine-cementum junction (Fig. 4.5). Provided that this
constriction is not destroyed, the periapical tissues are not damaged during
root canal preparation and obturation.

Studies indicate that the apical foramen rarely coincides in position

with the anatomical apex. According to various radiological and
morphological studies of different teeth,23.24.25.26.27. and 28. the mean
distance between the apical foramen and the most apical end of the
root is between 0.2 and 2.0 mm. Furthermore, the apical constriction
tends to occur about 0.5–1 mm from the apical foramen. 24 Ideally,
the apical constriction should be used as a natural ‘stop’ or ‘end
point’ in root canal treatment, and the integrity of the constriction
should be maintained during treatment if complications are to be
avoided. This position can usually be located accurately with an apex
locator.29.30. and 31.
VARIATIONS IN PULP SPACE ANATOMY
Variations in tooth form have interested scientists and
anthropologists as well as dentists. These studies of variations have
primarily been concentrated on the systematic description of dental
crown morphology rather than root form. Variations in root form and
number are likely to have a direct influence upon the configuration of
the root canals in affected teeth. One variation, which has received
some attention, is the three-rooted mandibular first molar; surveys of
Mongoloid populations indicate a high prevalence.32.33. and 34. The
prevalence of other Mongoloid root traits has been less well studied.
In clinical practice it is not always possible to observe these
variations from radiographs.
In the condition dens invaginatus, the surface of the tooth formed with
a deep pit into the pulp space during tooth development, which
subsequently becomes a route for infection into the pulp. Depending
on the severity of the condition, endodontic treatment will be difficult
or very challenging. The most commonly affected tooth is the
maxillary lateral incisor. 35,36 In the opposite condition dens evaginatus,
the surface of the tooth formed into a very protuberant cusp during
tooth development. There is a high risk of this cusp fracturing during
function creating a route for infection of the pulp space. The
mandibular premolar is most frequently affected and is more often
found in Mongoloid people. 37 It is best managed by prophylactic
treatment. 38
The descriptions of the frequently occurring root and canal forms of
permanent teeth are based largely on studies conducted in Europe
and North America, and relate to teeth of predominantly Caucasoid
origin. The descriptions may not be wholly applicable to teeth of non-
Caucasoid origin. For example, the average lengths of teeth, around
which there is wide variation, apply to Caucasoid populations.
Practitioners who regularly treat Mongoloid populations are aware
that roots are usually shorter. Racial differences and its influence on
pulp space anatomy should always be kept in mind.
EFFECTS OF TERTIARY DENTINE ON PULP SPACE
Tertiary dentine is formed by odontoblasts in response to irritation
from caries, restorative dentistry or tooth wear. The amount formed is
dependent on the degree and duration of irritation. The function of
this dentine is to wall off the pulp from the irritants; it is generally of
great benefit to operative dentists. However, when root canal
treatment becomes indicated, the coronal pulp is then exceedingly
small and, therefore, difficult to locate. In addition, canal orifices
become narrowed by deposition of tertiary dentine making their
identification difficult.
There is no substitute for a good knowledge of pulpal anatomy;
however, the clinician should be aided by a good quality preoperative
radiograph from which the depth and direction of the root canals can
be gauged. When inside the centre of the tooth and attempting to
locate the pulp space, illumination and magnification are major
assets. Whilst this can be provided by a headlamp and loupes, it is
best achieved using an operating microscope. The increased
illumination reveals the different colours of circumpulpal and tertiary
dentine, so that the access to the root canals can be correctly
orientated.
PULP SPACE ANATOMY AND ACCESS CAVITIES
Each line drawing accompanying the description of pulp space
anatomy represents, from left to right:
• longitudinal mesiodistal section, viewed from the lingual in anterior teeth and
from the buccal in posterior teeth;
• longitudinal buccolingual section viewed from the mesial, and also the axial
angulation of the tooth relative to the horizontal occlusal plane;
• horizontal sections through the root(s): (above) 3 mm from apex; (below) at
the cervical level;
• incisal or occlusal view.

The classical outline of the access cavity is shown as a dotted line.

The size of the pulp cavity shortly after completion of root formation is
as shown in pink, and in old age in brown. Line drawings are
accompanied, where appropriate, by photographs of cleared
specimens to give an insight into the variations of canal form that
exist in the adult dentition.
Access cavity design should not be thought of as a one size fits all.
Rather they should be developed to suit the specific pulpal anatomy
of individual teeth. 39 The classical outline of access cavities is helpful
in the appreciation of pulp space anatomy. However, it must be
emphasized that rather than pre-conceptualized designs, access
cavities should be prepared according to access requirements. Whilst
unnecessary and excessive destruction of tooth tissue must be
avoided it is important to remember that all caries and the roof of the
pulp chamber must be completely removed. If and where necessary,
following caries removal, a good temporary restoration should be
placed to prevent coronal leakage.
Recently, several authors40,41 have recognized the importance of the
systematic development of the pulp space during tooth formation to
the understanding of access cavity preparation. This recognition has
led to a number of ‘laws’ being postulated, to serve as a guide to
clinicians in developing the access cavity and locating accurately root
canal orifices (Table 4.1).
Table 4.1 Laws relating to pulp chamber anatomy (Adapted from Krasner & Rankow 37 and Peters38
Law of centrality The floor of the pulp chamber is always located in the centre of the tooth at the level of the cem
Law of concentricity At the level of the CEJ the shape of the pulp chamber mimics the external anatomy of the toot
The distance from the external surface of the tooth to the wall of the pulp chamber is the same
Law of the CEJ
tooth at the level of the CEJ. The CEJ is the most reliable and consistent feature for ascertaini
First law of With the exception of the maxillary molars, the orifices of the canals are equidistant either side
symmetry the floor of the pulp chamber.
Second law of With the exception of the maxillary molars, the orifices of the canals lie on a line perpendicular
symmetry through the floor of the pulp chamber.
The law of colour The dentine of the floor of the pulp chamber is, invariably a darker colour than the roof and wa
change illumination this allows the clinician to differentiate and selectively remove tissue.
First law of orifice
The orifices of the root canals are located where the walls and the floor meet.
location
Second law of
The orifices of the root canals are located at the angles in the floor/wall junctions.
orifice location
Third law of orifice
The orifices of the root canals are located at the ends of the root developmental fusion lines.
location

Maxillary central and lateral incisors

The outlines and pulp cavities of these teeth are similar (Figs 4.6& 4.7). Central
incisors are larger with a mean length of 23 mm. Lateral incisors are smaller with a
mean length of 21–22 mm. The canal form is usually Type I, and it is extremely rare
for these teeth to have more than one root or more than one root canal. Where
abnormalities do occur they seem to affect the maxillary lateral incisor, which may
present with an extra root, second root canal, dens invaginatus, gemination or
fusion. 42,43 The pulp chamber, when viewed labiopalatally, is seen to be pointed
towards the incisal and widest at the cervical level. Mesiodistally both pulp chambers
follow the general outline of their crowns and are thus widest at their incisal levels.
The central incisors of young patients normally have three pulp horns. Lateral
incisors usually have two pulp horns, and the incisal outline of the pulp chamber
tends to be more rounded than that of central incisors.

The root canal differs greatly in outline when viewed mesiodistally and labiopalatally.
The former view generally shows a fine straight canal that is seen on a radiograph.
Labiopalatally the canal is very much wider and often shows a constriction just apical
to the cervix; this view is rarely seen on radiographs and it is important to remember,
during treatment, that all canals have this third dimension. The canal is tapered with
an oval or irregular cross-section cervically that becomes round only very near the
apex. There is generally very little apical curvature in central incisors. The apex of
lateral incisors is often curved in a distal/palatal direction. Sometimes the plane in
which it lies means the apex is not easily discernible during radiographic canal length
determination.

As the teeth age, the anatomy of the pulp space alters with the deposition of
secondary dentine. The roof of the pulp chamber recedes, in some cases to the
cervical level, and the canal appears very narrow mesiodistally on a radiograph. It is
often possible to negotiate a canal that appears very fine or non-existent on a
preoperative radiograph. When some incisors are traumatized, their pulps may
mineralize, that is, the pulp canal becomes obliterated; subsequent root canal
treatment is extremely difficult as mineralization frequently occurs throughout the
length of the pulp space.

Access cavities to maxillary incisors

Access cavities in anterior teeth will vary in size and shape according
to the dimension of the pulp. They should be designed so that a
straight line approach is possible to the apical third of the root without
the instruments bending, or binding against the walls of the access
cavity or root canal. An access cavity that is too small and close to
the cingulum leads to severe stresses in the instrument with binding
against the access cavity walls and risks ledge formation apically (Fig.
4.8). The access cavity should extend far enough incisally to allow the
instrument to reach the apical part of the canal. Sometimes the
incisal edge must be involved if access is to be adequate.

As the pulp is broader incisally than it is cervically, the outline should

be triangular and must extend far enough mesially and distally to
include the pulp horns. Once adequate access has been made into
the pulp chamber, the cervical constriction should be removed to
facilitate instrumentation of the apical part. The accuracy of initial
access is particularly important in the older patient because the pulp
space is more difficult to find. It is wise to begin the access cavity
close to the incisal edge so that the pulp space can be approached in
a straight line.
Maxillary canine
This is the longest tooth, mean length 26.5 mm, and therefore, longer
root canal files are often required. It seldom has more than one root
canal; the pulp chamber is quite narrow, and as there is only one
pulp horn; the pulp is pointed incisally. The general shape of the pulp
space is similar to the incisors (Fig. 4.9). The Type I root canal is oval
and does not begin to become circular in cross-section until the
apical third. The canal is usually straight but may show a distal apical
curvature; the curvature depends on the movement of the tooth
during eruption.

Maxillary first premolar

This tooth generally has two roots with two canals. The frequency of single-rooted
maxillary first premolars ranges from 31–39% in Caucasians. 1,44 In people of
Mongoloid origin, the frequency of maxillary first premolars with one root is in excess
of 60%.45.46. and 47. Three roots have been reported in 6% of cases. 1 A typical
Caucasoid specimen has two well-developed fully formed roots that normally begin in
the middle third of the roots (Fig. 4.10). The single-rooted condition prevalent in
Mongoloid people represents a fusion of two separate roots.

Irrespective of origin, this tooth normally has two canals, and in the
case of single-rooted specimens these canals may open through a
common apical foramen. Many types of canal configuration are to be
found in this tooth (Fig. 4.11) and the presence of lateral canals,
particularly in the apical region can be as high as 49%. 44 The three-
rooted form tends to have three canals, two located buccally and one
palatally. Careful study of a preoperative radiograph should help
reveal the root canal morphology. However, this morphology may be
difficult to visualize radiologically, particularly when the apex is very
.fine

The mean length of first premolars is 21 mm. The pulp chamber is

wide buccopalatally with two distinct pulp horns, but is narrow
mesiodistally. The floor is rounded with the highest point in the centre
and generally just apical to the level of the cervix. The orifices into
the root canals are funnel-shaped and lie buccally and palatally under
the cusp tip/>

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