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Grossmans Corner

ACCESS CAVITY PREPARATION AN ANATOMICAL AND CLINICAL PERSPECTIVE


Dr. V. Gopi Krishna, MDS, FISDR is a clinician, researcher and academician of national acclaim. He is the Co-Editor of Grossmans Endodontic
Practice - 12th Edition (Wolters Kluwer Lipincott) and Editor of Preclinical Manual of Conservative Dentistry (Elsevier). He is also the Editorin-Chief of the Journal of Conservative Dentistry (www.jcd.org.in) and is working as Professor, Dept. of Conservative Dentistry & Endodontics
at Thai Moogambigai Dental College. He runs the Root Canal Centre - an exclusive endodontic training and treatment centre at Chennai,
which mentors more than 100 dentists every year in improving their endodontic skills. For more information on microscope aided clinical
endodontic training modules with live patient demonstrations you can contact Dr. Gopi Krishna at hi_gopikrishna@hotmail.com (Ph: 919840218818) and on Facebook Root Canal Centre.

Dr. V. Gopi Krishna

You dont know how much you know until you know

commonly to the prolongation of the pulp itself directly under a

how much you dont know

cusp. The floor of the pulp chamber runs parallel to the roof and

Access is success. These three words in a nutshell convey the

consists of dentin bounding the pulp chamber near the cervix of

significance of a proper access opening on the overall quality and

the tooth, particularly dentin forming the furcation area. The canal

success of endodontic treatment. In this era of instrument driven

orifices are openings in the floor of the pulp chamber leading into

endodontics it is important that one understands that the efficacy

the root canals. The canal orifices are not separate structures, but

of cleaning and shaping is effective only if employed after a good

are continuous with both pulp chamber and root canals. The walls

access opening.

of a pulp chamber derive their names from the corresponding walls


of the tooth surface, such as the buccal wall of a pulp chamber. The

Anatomy of Pulp Cavity

angles of a pulp chamber derive their names from the walls forming

The pulp cavity is the central cavity within a tooth and is entirely

the angle, such as the mesiobuccal angle of a pulp chamber.

enclosed by dentin except at the apical foramen (Fig. 1). The pulp

(Fig. 1)

cavity may be divided into a coronal portion, the pulp chamber,


and a radicular portion, the root canal. In anterior teeth, the pulp

Anatomy of Root Canals

chamber gradually merges into the root canal, and this division

The root canal is that portion of the pulp cavity from the canal

becomes indistinct. In multi-rooted teeth, the pulp cavity consists

orifices to the apical foramen. It may be divided for convenience

of a single pulp chamber and usually three root canals, although

into three sections, namely: coronal, middle, and apical thirds.

the number of canals can vary from one to four or more. The roof

Accessory canals, or lateral canals, are lateral branching of the

of the pulp chamber consists of dentin covering the pulp chamber

main root canal generally occurring in the apical third or furcation

occlusally or incisally (Fig. 1).

area of a root (Fig. 1). A distinction sometimes made between an


accessory canal and a lateral canal is that a lateral canal is an
accessory canal that branches to the lateral surface of the root and
may be visible on a radiograph. Lateral canals occur 73.5% of the
time in the apical third, 11.4% of the time in the middle third and
6.3% of the time in the cervical third of the root. The apical foramen
is an aperture at or near the apex of a root through which the
blood vessels and nerves of the pulp enter or leave the pulp cavity.
Accessory foramina are the openings of the accessory and lateral
canals in the root surface (Fig. 1).
Although variations are the norm in root canal configurations;

Fig. 1 Various views of the root canal system:


(a) Labial view of a central incisor. (b) Apical third of a root. (c) Buccal view of a
maxillary first molar. (d) Buccal view of a mandibular first molar.

various researchers have classified them according to the number


of canals, intracanal branching & fusion and exit from the canal.

A pulp horn is an accentuation of the roof of the pulp chamber

The most widely accepted clinical classification was proposed by

directly under a cusp or developmental lobe. The term refers more

Vertucci and his classification is as follows: (Fig. 2)

FAMDENT PRACTICAL DENTISTRY HANDBOOK

Vol. 10 Issue 3 Jan. - Mar. 2010

ACCESS CAVITY PREPARATION AN ANATOMICAL

INDUSTRY WATCH

AND CLINICAL PERSPECTIVE


3. To de-roof the pulp chamber

4. To remove the coronal pulp tissue including vital pulp, necrotic


pulp and pulp stones.

5. To locate all the root canal orifices


6. To achieve straight line access into the root canal
7. To remove the dentinal shelves between the canal orifices
Armamentarium
I would like to classify the instruments and equipments required for
access cavity preparation into two separate lists:
I. Must Have Instruments & Equipments
a. Burs

Fig. 2 Vertuccis classification.

Type I (Fig. 2a)


Single canal extends from the pulp chamber

to the apex

ii.

Tapering fissure bur with a round head

(Fig. 4)

One canal leaves the pulp chamber and

divides into two in the root; the two then merge to exit as one

canal (1-2-1)

Type IV (Fig. 2b)

Two separate, distinct canals extend from

the pulp chamber to the apex

Type V (Fig. 2b)

One canal leaves the pulp camber and

divides short of the apex into two separate, distinct canals with

separate apical foramina (1-2)

Type VI (Fig. 2b)

Two separate canals leave the pulp

chamber, merge in the body of the root, and re-divide short of

the apex to exit as two distinct canals (2-1-2)

Type VII (Fig. 2b)

divides and then rejoins in the body of the root and finally re-

divides into two distinct canals short of the apex (1-2-1-2)

Type VIII (Fig. 2c)

Fig. 3 Round bur

One canal leaves the pulp chamber,

Round burs ( #2, #4 and #6)

chamber and join short of the apex to form one canal (2-1)

Type III (Fig. 2a)

i.

Two separate canals leaving the pulp

Type II (Fig. 2a)


(Fig. 3)

iii.

Fig. 4 Tapering fissure bur with a


round head

Safe end burs e.g.: Endo Z bur

(Fig. 5)

Three separate, distinct canals extend

from the pulp chamber to the apex (3)

Thus, a clinician must be familiar with the various pathways the root

Fig. 5 Endo Z Safe end cutting bur

canals take to the apex.

iv.

Transmetal bur e.g.: Trihawk burs

(Fig. 6)

Fundamental Objectives of Access Cavity Preparation


The following are the fundamental objectives which one has to keep
in mind while preparing the pulpal access cavity after achieving
profound local anesthesia:
1. To remove all decay, leaking restorations and undermined tooth

structure

2. To conserve healthy tooth structure


Fig. 6 Trihawk bur

FAMDENT PRACTICAL DENTISTRY HANDBOOK

Vol. 10 Issue 3 Jan. - Mar. 2010

ACCESS CAVITY PREPARATION AN ANATOMICAL

INDUSTRY WATCH

AND CLINICAL PERSPECTIVE


b. DG 16 Endodontic Explorer

(Fig. 7)

c. Orifice Enlargers

Fig. 7 DG 16

(Fig. 8)

d. Orifice Enlargers
i.

X Gates

(Fig. 13)

Fig. 13 X gates

c. Endodontic Spoon excavator


i.

Gates Glidden Drills

(Fig. 9)

ii.

Rotary orifice shapers

iii.

Endodontic Micro Openers (Dentsply Maillefer)

(Fig. 14)

Fig. 14 Micro opener

d. Dental Operating Microscope for Magnification and Illumi


Fig. 8 Endodontic excavator

nation

(Fig. 15)

Fig. 9 Gates Glidden drills

e. Patency files

i.

K Files ISO sizes #06, #08 and #10

II. Nice To Have Instruments & Equipments


a. Burs
(Fig. 10)

i.

LN Bur (Dentsply Maillefer)

ii.

Munce Discovery Burs (CJM Engineering)

(Fig. 11)

Fig. 15 Dental operating microscope greatly enhances both the illumination


and magnification during access cavity preparation

The use of surgical telescopes of greater than 2.5X magnification


(ideally 4X or greater) and accompanying coaxial high-intensity
illumination or an operating microscope is highly recommended.
Fig. 10 LN bur

Fig. 11 Munce discovery burs

Access Cavity Guidelines For Permanent Teeth

b. Ultrasonic Tips

i.

Start X tips (Dentsply Maillefer)

I. Maxillary Incisors
(Fig. 12)

Steps of access cavity preparation:


Divide the tooth into nine boxes. The box in the centre is the

region for penetration of the bur. This is usually just incisal to the

cingulum,

The lingual surface is entered perpendicular to the lingual


surface,

The bur head is then oriented parallel to the long axis to the
Fig. 12 Start X ultrasonic tips

FAMDENT PRACTICAL DENTISTRY HANDBOOK

tooth,

Vol. 10 Issue 3 Jan. - Mar. 2010

ACCESS CAVITY PREPARATION AN ANATOMICAL

INDUSTRY WATCH

AND CLINICAL PERSPECTIVE


(a)

A round bur on slow speed contra-angled handpiece is used to


(b)

de-roof the pulp chamber,

Completed access preparation must have a triangular outline


with the base towards the incisal edge and apex towards the

cingulum.

Fig. 18 Maxillary canine.


(a) Ovoid funnel-shaped preparation. (b) Clinical image

Key Rules for Maxillary Anteriors:


1. Entry slightly incisal to the cingulum
2. Go palatal- Always ensure a Palatal orientation of the bur

after crossing the DEJ

3. No variations Single orifice with a single canal


II. Mandibular Anteriors

(a)

(b)

Fig. 19 Mandibular central and lateral incisor. The preparation is ovoid in


shape, which is more lingual in order to ensure the tracing of the second
lingual canal

(F) Clinical Image


Fig. 16 a f: Steps of access cavity preparation for mandibular anteriors

(a)

(b)

Fig. 20 Mandibular canine. The preparation should be ovoid, funnel-shaped.


The cavity should be extended inciso-gingivally for room to find the orifice and
enlarge the apical third without interference.
Fig. 17 Maxillary lateral incisor. It is similar to maxillary central incisor, but the
size is smaller in dimensions.

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Vol. 10 Issue 3 Jan. - Mar. 2010

ACCESS CAVITY PREPARATION AN ANATOMICAL

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III. Maxillary Premolars

Key rules for mandibular anteriors


1. Change the bur

Key Rules:

Use the smaller round diamond No. 2

1. Bucco - lingual orientation of cavity preparation

Preserves the tooth structure

2. Change the operator seating position

2. Oval shaped access

12 oclock position

3. In case of bulkier roots suspect extra canals

Better orientation

IV. Mandibular Premolars

3. Change the radiographic position (exaggerated mesial shift)


Helps in identification of extra lingual canal

Fig. 23 Mandibular premolars. The preparation is ovoid in shape which is less


extensive bucco-lingually than that of the maxillary premolar

Key rules:
1. Ovoid / Round shaped access

Fig. 21 Maxillary premolars. The ovoid coronal preparation need not be as


long bucco-lingually as the pulp chamber. Final preparation should provide
unobstructed access to canal orifices. Cavity walls should not impede complete
authority over enlarging instruments.

(a)

2. In case of bulbous roots suspect bifurcation of canals


V. Maxillary Molars

(b)

Fig. 24 Maxillary first molar. The outline is trapezoidal in shape with the broader
base towards the buccal surface. The cavity is entirely within the mesial half of
the tooth and need not invade the transverse ridge but is extensive enough,
buccal to lingual, to allow positioning of instruments

Fig. 22
(a) Incomplete de-roofing of a maxillary
premolar access cavity preparation
(b) De-roofing allows access to the
isthmus area which contains pulp tissue
(c) Completed access opening allowing
straight line access to both the buccal
and palatal canals

Maxillary molars generally have three roots and can have as many
as three mesial canals, two distal canals, and two palatal canals.
The mesiobuccal root of the maxillary first molar has generated
more research and clinical investigation than any root in the mouth.
It generally has two canals and they are called mesiobuccal (MB-1)

(c)

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and second mesiobuccal (MB-2)

Vol. 10 Issue 3 Jan. - Mar. 2010

ACCESS CAVITY PREPARATION AN ANATOMICAL

INDUSTRY WATCH

AND CLINICAL PERSPECTIVE

Key Rules for tracing the canals:

VI. Mandibular Molars

1. All canals are present in mesial 60% of tooth


2. Trace the palatal canal under the palatal cusp
3. Straight line up from palatal canal orifice towards buccal

wall

Disto buccal canal

4. Mesial line from Disto buccal canal

Mesio buccal canal

Most Common Variations:


i. If Mesio-buccal canal not present at the expected area then

trough for the canal more buccally towards buccal wall

ii. If Mesio-buccal canal is present near the buccal wall, trough for

the second canal MB2 below it. MB2 is consistently located

mesial to or directly on a line between the MB-1 and the palatal

orifices, within 3.5mm palatally and 2 mm mesially from the

MB-1 orifice.

Fig. 27 Quadrilateral outline form reflects the anatomy of the pulp chamber.
Both mesial and distal walls slope mesially. The cavity is primarily within
the mesial half of the tooth but is extensive enough to allow positioning of
instruments. Further exploration should determine whether a fourth canal can
be found in the distal. In that case, an orifice will be positioned at each angle
of the rhomboid.

Key Rules:
1. Quadrilateral / Trapezoidal shape access
2. Suspect for the fourth canal
Fig. 25 The two most common locations of the MB2 canal

Common variations:
1. Possibility of a 2nd distal canal which can be in the following

configuration

C shaped canals

2 canals with orifices very close together

2 distinct orifices

Fig. 26 Clinical image of a maxillary first molar with four canals

iii. If Disto-buccal canal is not present at the expected area, always


trace it towards the mesial direction, towards a line joining

Mesio-buccal canal and palatal canal.

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Fig. 28 Single distal canal oval


shaped

Fig. 29 Single Distal canal - C


shaped

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ACCESS CAVITY PREPARATION AN ANATOMICAL

INDUSTRY WATCH

AND CLINICAL PERSPECTIVE


STEP # 4

De-roofing of pulp chamber

Most important

rule of access opening


STEP # 5

Observe the color change

Color is the

language of endodontics
STEP # 6

Remove dentinal shelves

Establish straight

line access
Locating the Canal Orifices

STEP # 7

Eureka

Moment!!!
Fig. 30 Two distal canals Orifices next Fig. 31 Two distal canals Distinctly
to each other
separate orifices

STEP # 1

Relieve the tooth out of occlusion

Reduce

2. Possibility of 2nd mesial canal (Between the 2 mesial canals)

Post operative Discomfort

3. Possibility of an extra root having a canal which is referred to as

This is the first step of access cavity preparation in relation to

premolars and molars. This crucial step is recommended for the

Radix entomolaris / Radix paramolaris

4. Teeth having two canals in a straight line do not have any third

following reasons:

or extra canals and this configuration is seen in the second and

i. Establishes stable occlusal reference points for working length

the third molars.

determination

ii. Reduces post operative discomfort by minimizing trauma to the


apical periodontium from occlusal loads

iii. Improves convenience form for the operator

Fig. 33 Relieving the occlusion with a


Tapering Fissure diamond

STEP # 2

Use caries as a guide

Fig. 34 Occlusal view after


completion of relieving the
occlusion

Chase the caries

The thumb-rule to follow while doing access opening in a cariously


involved tooth is to start removing the dental decay immaterial of
the location of the decay. Invariably the dental decay would lead
into the pulp chamber. Hence in cases of a tooth with distal decay
the access opening commences from the distal side towards the

Fig. 32 Single mesial canal which is in line with the distal canal in a
mandibular second molar.

mesial pulp chamber.

Steps of Access Opening


We can divide the complete process of access cavity preparation

STEP # 3

into seven distinct steps :

Geography

STEP # 1

Relieve the tooth out of occlusion

Reduce

STEP # 3

Use caries as a guide

Know your

The biggest fear an operator has while preparing an access cavity

Post operative Discomfort


STEP # 2

Laws of Access Opening

is the Fear of Perforation. This fear stems from the fact that many
Chase the caries

Laws of Access Opening

operators are not clear of the internal map / geography of the pulp

Know your

chamber. One of the key landmarks, which help the operator in

Geography

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avoiding procedural errors and helps in determining the location of

Vol. 10 Issue 3 Jan. - Mar. 2010

ACCESS CAVITY PREPARATION AN ANATOMICAL


AND CLINICAL PERSPECTIVE

INDUSTRY WATCH

the pulp chamber and root canal orifices, is the Cemento-enamel


Junction. (Fig. 35)

Fig. 35 Cemento-enamel junction is the key anatomical landmark during


access cavity preparation

Krasner and Rankow proposed guidelines or laws that are of


immense help to a clinician during access cavity preparation. The
laws are:
Fig. 36 Starting the access cavity preparation with a tapering fissure bur with
a round head

i. Law of Centrality: The floor of the pulp chamber is always


located in the center of the tooth at the level of the CEJ

ii. 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, that is, the external root surface anatomy reflects the

internal root canal anatomy.

iii. Law of the CEJ: The distance from the external surface of the

clinical crown to the wall of the pulp chamber is the same

throughout the circumference of the tooth at the level of the

CEJ, making the CEJ the most consistent repeatable landmark

for locating the position of the pulp chamber.

STEP # 4

De-roofing of pulp chamber

Fig. 37 Initial access cavity outline.


Note the color change as we enter
into the dentin

Fig. 38 Note the grayish color change as


we gradually near the roof of the pulp
chamber.

Most important

rule of access opening


Any permanent tooth not worn down occlusally/incisally has a pulp
chamber that is situated approximately 7 mm from a cusp tip or an
incisal edge. To slowly gain depth by small degrees leading up to
7 mm is needlessly inefficient, but to go beyond 7 mm in one fell

39 (a)

swoop is needlessly dangerous. You have a landmark: 7 mm. By

39 (b)

sticking to it, you will gain access in a predictable way without the
concern of perforating the floor of the chamber.
Once we enter into the roof of the pulp chamber then the operator
has to change to a lateral cutting motion instead of proceeding
in an apical direction. Care must be taken to slowly completely
remove the roof over the pulp chamber.

39 (c)

39 (d)

Fig. 39 A, B, C & D: Sequential de-roofing the pulp chamber using a lateral


cutting motion

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ACCESS CAVITY PREPARATION AN ANATOMICAL


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STEP # 5

Observe the color change

INDUSTRY WATCH

explorer. Once through the secondary dentin and pulp stones, the

Color is the

canals of a calcified canal may still not be readily apparent.

language of endodontics
Table 1: Color chart of endodontic access cavity preparation
Enamel

White

STEP # 6

Dentin

Yellow

line access

Floor of the pulp chamber

Gray

Root Canal Orifice

Dark gray or black

Pulp stone

Pearly white / Dark Yellow

Fig. 40 Pearly white color of the pulp


stone

Remove dentinal shelves

Establish straight

Fig. 41 Pulp stone, which is more


yellowish than the surrounding
dentinal walls.

Fig. 43 The probe pointing into the distal canal while straight line access is
not present for the mesial canals

Fig. 44 The DG 16 endodontic


explorer is pointing towards the
Dentinal Shelves protruding from
the respective walls

Fig. 42 Note the dome shaped floor having a distinct gray color after the
partial removal of pulp stones

Law of color change: The color of the pulp chamber floor is always

Fig. 45 Refining the access preparation


with the help of Start X ultrasonic tips
to remove the dentinal shelves and in
planing of the walls. These tips can also
be used to trace extra canals and to
dislodge calcified pulp stones.

darker than the walls.


Pulp stones take on a yellow / pearly white color and while in

STEP # 7

intimate mechanical relationship with the floor of the pulp chamber,

Moment!!!

Locating the Canal Orifices

Eureka

they do not fuse with the floor like secondary dentin does. For this
reason, they can often be picked away from the floor with a sharp

FAMDENT PRACTICAL DENTISTRY HANDBOOK

Vol. 10 Issue 3 Jan. - Mar. 2010

ACCESS CAVITY PREPARATION AN ANATOMICAL


AND CLINICAL PERSPECTIVE

INDUSTRY WATCH

Fig. 49 Representation of first and second laws of symmetry and first, second
and third laws of orifice location

Fig. 46 Access cavity preparation completed

Conclusion:
Cleaning and shaping constitutes the most important phase of
endodontics. However, it is the access cavity preparation that lays
the foundation for successful cleaning and shaping. In my opinion,
mastering the art of access cavity preparation is the single most
important operator variable that ultimately determines both the
prognosis and quality of the endodontic therapy

Fig. 47 Under higher magnification Fig. 48 Mesial canal orifices

The following laws will help the clinician in locating the canal
orifices:
Law of symmetry 1: Except for maxillary molars, the orifices of the
canals are equidistant from a line drawn in a mesio-distal direction
through the pulp chamber floor.
Law of symmetry 2: Except for maxillary molars, the orifices of the
canals lie on a line perpendicular to a line drawn in a mesio-distal
direction across the center of the floor of the pulp chamber.
Law of orifices location 1: The orifices of the root canals are
always located at the junction of the walls and the floor.
Law of orifices location 2: The orifices of the root canals are
located at the angles in the floor-wall junction.
Law of orifices location 3: The orifices of the root canals are
located at the terminus of the root developmental fusion lines.
The above laws were found to occur in 95% of the teeth examined.
Five percent of mandibular second and third molars did not
conform to these laws because of the presence of C-shaped canal
anatomy.

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