ACCESS CAVITY PREPARATION OF MAXILLARY TEETH

The access cavity preparation generally refers to the part of

the cavity from the occlusion table to the canal orifice. (according to Stephen Cohen)

OBJECTIVES
Well designed access preparation is essential for a good endodontic result. Without adequate access, instruments and material becomes difficult to handle properly in the highly complex and variable canal system. To achieve a straight or direct line access to the apical foramen. To locate all root canal orifice. To conserve sound tooth structure. Well prepared and correct access cavity allow complete irrigation, shaping ,cleaning and quality obturation. Ideal access results in a straight entry into the canal orifice, with the line angles forming a funnel that drops smoothly into the canal.
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GUIDELINES
It is essential for the completion of ideal access preparation. 1. Visualization of internal anatomy because internal anatomy dictates access shape. This require evaluation of angled peri-apical radiograph, examination of coronal and cervical tooth anatomy. 2. Evaluation of CEJ and occlusal anatomy.traditionally, access cavity is prepared in relation to the occlusal anatomy.CEJ is the most important anatomical landmark for determining the location of pulp chamber and root canal orifice. 3. Preparation of the access cavity is through lingual in anterior teeth and on the posterior teeth through occlusal surface. 4. Removal of unsupported tooth structure.This reduce the tooth's resistance to stress. 5. Creation of access cavity walls. So that sufficient tooth structure must be removed to allow instrument to be placed in a straight line and easily into canal orifice. 6. Location, flaring and exploration of all root canals orifices. A sharp endodontic explorer used to locate the canal orifice and to determine their angle of departure from the pulp chamber.

7. Magnification and illumination.These are important in root canal therapy, especially for determining the location of canal, curved and calcified canal and debriding and removing tissue from the pulp chamber.
8.Tapering of cavity walls and evaluation of space adequacy for a coronal seal. A proper access cavity has tapering walls and is widest at occlusal surface. At least 3.5 mm of temporary filling material is needed to provide an adequate coronal seal for a short period.
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MORPHOLOGY AND ACCESS CAVITY PREPARATION FOR MAXILLARY CENTRAL INCISOR

Developmental and anatomic data Average time of eruption-: 7-8 Years Average age of calcification-: 10 Years Average tooth length-: 23.5mm Average crown length-: 10.5mm Average root length-:13mm M-D of crown-: 8.5mm M-D of crown at cervix-: 7mm Labio-lingual diameter of crown-: 7mm Labio-lingual diameter at cervix-: 6mm
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Pulp chamber It is located in the centre of crown equidistant from the dentinal wall. It is broad m-d, with its broadest part incisally. It has three pulp horns that corresponds to the double mammelons in a young tooth. Root and root canal It has one root with one root canal. Root canal is broad labio-palataly, conical shape, and centrally located. In cross-section, canal is ovoid m-d in cervical third, rounded in middle and apical third.

INCIDENCE
Root
o o o o Straight : 75% Distally curved : 8% Mesially and palatally curved : 4% Labially curved: 9%

Apical foramen
o Centrally located in anatomic apex : 12% o Apical delta : 1%

Anatomic relationship in situ Labial surface of the root lies under the labial cortical plate of the maxilla and may fuse with it. It has an average of 2 degree of mesio-axial inclination and 29 degree of palato-axial angulations in its alveolus.

Access opening

Shape, size and coronal extension of pulp chamber are estimated by diagnostic radiograph. Enamel is penetrated in the centre of the lingual surface at an angle perpendicular to it, with a number 4 round bur in high speed contra-angle. After penetration of the enamel, a No 4 carbide bur in a slow speed contra-angle is directed along the long axis of the tooth until the pulp chamber is reached. A drop of the bur into the chamber may be felt if the chamber is large enough. The overhanging enamel and dentin lingual surface of the pulp chamber is removed with a No 4 round bur in a slow speed contraangle by working from inside to outside following internal anatomy. The lingual extension of the pulp chamber, with a straight line penetration to the apical root canal. Direct access can be verified by placing a straight end of the endodontic explorer in the canal orifice. The access shape is slightly triangular, with the base of the triangle to the incisal edge.
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Anatomic alteration in pulp

The usual anatomic structure of the chamber in the root canal may be altered in any tooth due to deposition of reparative or secondary dentin. This alteration in anatomy may be due to trauma, caries, restorative procedure, aging. To escape this alteration we can use No 2 round carbide bur. Enlarge the enamel portion of the access cavity to an ovoid shape, with greatest diameter incisogingivally.

MORPHOLOGY AND ACCESS CAVITY PREPARATION FOR MAXILLARY LATERAL INCISOR

MAXILLARY LATERAL INCISOR Developmental and anatomic data Average time of eruption-: 8-9Years Average age of calcification-: 11Years Average tooth length-: 22mm Average crown length-: 9mm Average root length-: 13mm M-D of crown-: 6.5mm M-D of crown at cervix-: 5mm Labio-lingual diameter of crown-: 6mm Labio-lingual diameter at cervix-: 5mm
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Pulp chamber The shape of the pulp chamber is similar to the maxillary central incisor. It only has two pulp horn, corresponding to the developmental mamelons. Root and root canal Configuration of the root canal is conical but it has a finer diameter than maxillary central incisor. In cross-section, the canal is ovoid labio-palataly in the cervical third and middle third, round in apical third.

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INCIDENCE Root o Straight : 30% o Distally curved : 53% o Mesially and palatally curved : 3% o Labial curved: 4% o S-shaped or bayonet curved: 6% Apical foramen o Centrally located in anatomic apex : 22% o Apical delta : 3%

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Anatomic relationship in situ

It has an average of 16 degree of mesio-axial inclination and average of 29 degree of palato axial angulations in its alveolus.

Access opening
It is similar to that for a maxillary central incisor, but is smaller and usually more ovoid. Except a No 2 round bur may be used instead of a No 4.

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MORPHOLOGY AND ACCESS CAVITY PREPARATION FOR MAXILLARY CANINE

Developmental and anatomic data
Average time of eruption-: 10-12Years Average age of calcification-: 13-15Years Average tooth length-: 27mm Average crown length-: 10mm Average root length-: 17mm M-D of crown-: 7.5mm M-D of crown at cervix-: 5.5mm Labio-lingual diameter of crown-: 8mm Labio-lingual diameter at cervix-: 7mm
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Pulp chamber It has the largest pulp chamber than any single rooted tooth. Labio-palatally triangular in shape, apex is toward the single cusp and base toward the cervical third of crown. Mesio-distally it is narrower and may resemble like flame. In cross-section it is ovoid in shape, with greater diameter labio-palatally. Only one pulp horn is present.

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Root and root canal Single root canal of maxillary cuspid is larger than that of maxillary incisor. It is wider labio-palatally than its mesio-distal diameter, and on reaching middle third, it taper gradually to an apical constriction. In cross-section, root canal is ovoid in the cervical and middle third and generally round in the apical third

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INCIDENCE Root o Straight : 39% o Distally curved : 32% o Palatally curved : 7% o Labially curved: 13% o S-shaped or bayonet curved: 7% Apical foramen o Centrally located in anatomic apex : 14% o Apical delta : 3%

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Anatomic relationship in situ

The root of maxillary cuspid is positioned in the cancellous bone of the maxilla between the nasal cavity and the maxillary sinus, called the canine pillar. It has an average of 6 degree disto-axial inclination and an average of 21 degree palato-axial angulation in its alveolus.

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Access opening
External access outline form is oval or slot shaped because no mesial or distal pulp horn are present Mesio-distal slope is determined by the mesio-distal width of pulp chamber. Inciso-gingival diameter is determined via straight line access factor and removal of the lingual shoulder.

Incisal extension is approached with in 2-3 mm of the incisal edge to allow for straight line access. All internal walls funnel to the orifice.

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MORPHOLOGY AND ACCESS CAVITY PREPARATION FOR MAXILLARY 1ST PREMOLAR

Developmental and anatomic data Average time of eruption-: 10-11Years Average age of calcification-: 12-13Years Average tooth length-: 22.5mm Average crown length-: 8.5mm Average root length-: 14mm M-D of crown-: 7mm M-D of crown at cervix-: 5mm Labio-lingual diameter of crown-: 9mm Labio-lingual diameter at cervix-: 8mm
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Pulp chamber It is narrow M-D, wider bucco-palatally. The buccal pulp horn is more prominent than the palatal in young tooth. The floor of the pulp chamber is convex usually with two canal orifices with one buccal and other palatal, it lies deep in the coronal third of the root. The roof of the pulp chamber is coronal to the cervical line. Root and root canal It may have one, two, or three roots and canals. It most often has two roots namely buccal and palatal. The roots are considerably shorter and thinner than the canine. The palatal orifice is slightly larger than buccal orifice. In the cross-section at the CEJ, the palatal orifice is wider bucco-lingually and kidney shaped because of the mesial concavity.
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Anatomic relationship in situ The tooth lies in the alveolar socket below the maxillary sinus and is separated from it by a thin layer of spongy and compact bone. It has an average of 10 degree of disto-axial inclination with average of 6 degree of bucco-axial angulation in its alveolus INCIDENCE Root( Single rooted) o Straight : 38.4% o Distally curved : 36.8% o Buccally curved : 14.4% o Palatally curved: 2.4% o S-shaped or bayonet curved: 8% Apical foramen o Centrally located in anatomic apex : 14% o Apical delta : 3%
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Double Rooted Teeth

Buccal Root
o o o o o Straight : 27.8% Distally curved : 14% Buccally curved : 14% Palatally curved: 36.2% S-shaped or bayonet curved: 8% Apical foramen o Centrally located in anatomic apex : 12% o Apical delta : 3.2%

Palatal Root
o o o o o Straight : 44.4% Distally curved : 14% Buccally curved : 27.8% Palatally curved: 8.3% S-shaped or bayonet curved: 5.5% Apical foramen o Centrally located in anatomic apex : 12% o Apical delta : 3.2%

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Access opening
The diagnostic radiograph is used for measuring the shape and extension of the pulp chamber mesially, distally and coronally. The access preparation is oval or slot shaped. It is also wide bucco-lingually, narrow mesio-distally and centered mesio-distally between the cusp tips. Using a No 2 round bur in a high speed contra angle one penetrates the enamel in the center of the occlusal surface and the bur is directed into the long axis of the tooth. Than a No 2 round carbide bur in a slow speed contra angle, align in the long axis of the tooth is used to penetrate through the dentin into the pulp chamber.

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 Using the radiographic measurement, one penetrate deep enough to remove the roof of the pulp chamber without cutting into the chamber floor. To remove the roof of the pulp chamber, one should place the bur along the side of walls of the chamber and cut occlusally. A tapered cylinder, self limiting diamond in slow speed contra angle is used to remove the remaining roof of the pulp chamber. The walls of the cavity are smoothened and sloped slightly to the occlusal surface. The divergence of the access cavity creates a positive seal for the temporary filling such as cavity.

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 The border of the ovoid access cavity should not exceed beyond half the lingual inclined of the facial cusp and half the facial incline of the palatal cusp. Any loose debris is removed by irrigating the access cavity with 5.2% sodiumhypochlorite solution. Excess solution is removed by suction with 2 x 2 gauge. The anatomic dark lines in the pulpal floor should be examined with an endodontic explorer. The orifice of the buccal canal lies beneath the buccal cusp and the orifices of the palatal canal lies beneath the palatal cusp.

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Schematic representation of three canal access preparation.

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MORPHOLOGY AND ACCESS CAVITY PREPARATION FOR MAXILLARY 2ND PREMOLAR Developmental and anatomic data
Average time of eruption-: 10-12Years Average age of calcification-: 12-14Years Average tooth length-: 22.5mm Average crown length-: 8.5mm Average root length-: 14mm M-D of crown-: 7mm M-D of crown at cervix-: 5mm Labio-lingual diameter of crown-: 9mm Labio-lingual diameter at cervix-: 8mm
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Pulp chamber It is like maxillary 1st premolar It is wider bucco-lingually than the maxillary 1st pre molar and shows two pulp horn in this projection, a buccal and a palatal. In cross-section, the pulp chamber has a narrow ovoid shape. Root and root canal Single rooted tooth but may be two or three root and canal . The majority of canal may be curved. They may be curved distally, buccally, palatally or bucco-palatally.

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INCIDENCE
Root (single root 90.3%) o Straight : 37.4% o Distally curved : 33.9% o Buccally curved : 15.7% o Palatally curved: 2.4% o S-shaped or bayonet curved: 13% Apical foramen o Centrally located in anatomic apex : 12% o Apical delta : 3.2% Only 2% have two well developed root.

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Access cavity preparation

Nearly identical to 1st maxillary premolar. If three canals are present, the external access outline form are triangular in shape.

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MORPHOLOGY AND ACCESS CAVITY PREPARATION FOR MAXILLARY 1ST MOLAR

Developmental and anatomic data
Average time of eruption-: 6-7Years Average age of calcification-: 9-10Years Average tooth length-: 20.8mm Average crown length-: 7.5mm Average root length-: 12mm(b) 13mm(p) M-D of crown-: 10mm M-D of crown at cervix-: 8mm Labio-lingual diameter of crown-: 11mm
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Labio-lingual diameter at cervix-: 10mm

Pulp chamber It has four pulp horns m-b, d-b, m-p, d-p, the arrangement of the four pulp horn gives the pulpal roof of a rhomboidal shape in cross-section. The four walls forming the roof converge towards the floor where the lingual wall almost disappear. The floor of the pulp chamber thus has a triangular form in crosssection. The orifices of the root canal are located in the three angles of the floor.

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 Palatal orifice is the largest, round or oval in shape and easily accessible for exploration. The mesio-buccal orifice is under the mesio-buccal is long buccopalatally. The mesio-buccal orifice is located by insinuating the tip of long shank explorer. The disto-buccal orifice is located slightly distal and palatal to the mesio-buccal orifice and is accessible from the mesial for exploration. The floor of the pulp chamber in the cervical third of the root and the roof is in cervical third of crown.

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Root and root canal It has three root with usually 3 canal situated mesio-buccally, disto-buccally, palatally. Mesio-buccal root
It is broad in the bucco-palatal direction. Majority of the m-b roots have a distal curve and some are s shaped or bayonet shaped. It has one root and one canal, it is narrowest of the 3 canals, flattened in a m-d direction in the orifice, but round in the apical third.

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 Disto-buccal root
It is small and is more or less round in shape. It may be straight (54%), distally curved mesial curve or s shaped. It is a narrow, tapering canal sometimes flattened in a mesio distal direction , but generally cone shaped.

Palatal root
It has larger diameter and is the longest root of the maxillary 1st molar. It may be straight, curved buccally, mesially or distally. Root may curve in the apical third toward buccal side. The palatal canal is ovoid m-d and tapers toward apex.

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INCIDENCE
Mesio-buccal Root
o Straight : 21% o Distally curved : 78% o Buccally curved : 14% o S-shaped or bayonet curved: 1% Apical foramen o Centrally located in anatomic apex : 14%

Disto-buccal Root
o o o o Straight : 54% Distally curved : 17% Mesial curved : 20% S-shaped or bayonet curved: 10% Apical foramen o Centrally located in anatomic apex : 19% o Apical delta : 2%

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Palatal Root
o Straight : 40% o Distally curved : 1% o Mesial curved : 4% o Buccally curved: 55% Apical foramen o Centrally located in anatomic apex : 18%

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Access opening
Radiograph is used to determine the shape and size as well as the extension of the pulp chamber mesially, distally and coronally. The enamel is penetrated with No 4 round carbide bur in a high speed contra angle by positioning the instrument in the central fossa and angling it toward palatal root. After penetration of the enamel No 4 round carbide bur in slow speed is used in a slow speed contra angle to penetrate dentin. The bur is angled toward the palatal root until the pulp chamber is reached.

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 A drop of the bur into the pulp chamber may be felt if the chamber becomes large. The internal anatomy of the pulp chamber guides the occlusal cutting. A tapered cylinder self limiting diamond in a slow speed contra angle is used to remove the remaining roof of the pulp chamber. The walls of the access cavity should be in good confluence with the walls of pulp chamber and should be slightly divergent to the occlusal surface. The access opening should be triangular for permitting direct access to the root canal orifice.

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 Any loose debris is removed by irrigating the access cavity with 5.2% sodiumhypochlorite solution. Excess solution is removed by suction with 2 x 2 gauge. The anatomic dark lines in the pulpal floor should be examined with an endodontic explorer.

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MORPHOLOGY AND ACCESS CAVITY PREPARATION FOR MAXILLARY 2ND MOLAR

Developmental and anatomic data Average time of eruption-: 11-13Years Average age of calcification-: 14-16Years Average tooth length-: 19mm Average crown length-: 7mm Average root length-: 11mm(b) 12mm(p) M-D of crown-: 9mm M-D of crown at cervix-: 7mm Labio-lingual diameter of crown-: 11mm
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Labio-lingual diameter at cervix-: 10mm

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Pulp chamber Similar to maxillary 1st molar, except it is narrower m-d. It is rhomboidal in shape. The roof of the pulp chamber is more rhomboidal in crosssection, The floor of the pulp chamber is an obtuse triangle in crosssection. The mesio-buccal and disto-buccal root canal are closer together and appear to have a common opening.

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Root and root canal It has usually one canal in each root however , it may have two or three mesio-buccal canal, one or two disto-buccal canal, or two palatal canal. The three main orifice ( M-B, D-B, P) usually form a flat triangle and sometimes a straight line. The mesio-buccal canal orifice is located to the buccal and mesial than 1st molar. Disto-buccal orifice approaches the mid point between the m-b and palatal orifice Palatal orifice usually located at the most palatal aspect of the root.
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 Floor of the pulp chamber is convex which gives the canal orifice a slight funnel shape. When four canal are present, access cavity preparation has a rhomboid shape, if three canal are present, it is a rounded triangle with the base placed buccally. If two canal are present the access outline form is oval and widest bucco-lingually.

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INCIDENCE
Mesio-buccal Root
o Straight : 22% o Distally curved : usually Apical foramen o Centrally located in anatomic apex : 16% o Apical delta : 3%

Palatal Root
o Straight : usually o Buccally curved : 37% Apical foramen o Centrally located in anatomic apex : 16% o Apical delta : 3%

Distal Root
o Straight : usually o Mesially curved : 17% Apical foramen o Centrally located in anatomic apex : 16% o Apical delta : 3%
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Access cavity preparation Same as 1st molar.

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MORPHOLOGY AND ACCESS CAVITY PREPARATION FOR MAXILLARY 3RD MOLAR

Developmental and anatomic data Average time of eruption-: 17-22Years Average age of calcification-: 18-25Years Average tooth length-: 17mm Average crown length-: 6.5mm Average root length-: 11mm M-D of crown-: 8.5mm M-D of crown at cervix-: 6.5mm Labio-lingual diameter of crown-: 10mm
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Labio-lingual diameter at cervix-: 9.5mm

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It is considered as a strategic abutment after loss of maxillary 1st and 2nd molars. Pulp chamber Anatomic resemblance to maxillary 2nd molar. It may also have an odd shaped pulp chamber with four or five root canal orifice. Conical chamber with only one root canal. Roots and root canal Three well developed roots, fused root, one conical root or four or more independent roots. Root may be straight, curved or dilacerated. One may find a C shaped pulp chamber with a C shaped root canal. 53

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