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Endodontie (cap 11 - access cavity and endodontic anatomy) - Arnaldo Castellucci

Endodontie (cap 11 - access cavity and endodontic anatomy) - Arnaldo Castellucci

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Endodontia de Arnaldo Castellucci
Endodontia de Arnaldo Castellucci

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Published by: Ciprian-Florin Barsan on Oct 25, 2009
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05/12/2013

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244
Endodontics
It is well-recognized and universally accepted that asuccessful outcome in endodontic treatment essential-ly depends on three factors:1) cleaning and shaping2) disinfection3) three-dimensional obturation of the root canal sy-stem. Although it is impossible to determine which of thethree factors is the most important, it is obvious thatgreater importance should be given to the rst; anold axiom in endodontics states that what you remo- ve from the root canal is more important that what you place inside.
77
Proper cleaning and shaping esta-blish the necessary conditions for the success of thenext two factors. It would be mistaken to try to disin-fect and three-dimensionally obturate a root canal thathad not been previously cleaned and shaped.However, there is one other step that precedes the-se three. It affects all three and therefore should ab-solutely not be undervalued or neglected. An errorin this preliminary step would compromise all subse-quent work.This preliminary step is the preparation of the accesscavity, the opening in the dental crown that permitslocalization, cleaning, shaping, disinfection, and three-dimensional obturation of the root canal system.The success of the endodontic treatment depends en-tirely on precise, proper execution of this step. Anaccess cavity that has been prepared improperly interms of position, depth, or extent will hamper theachievement of optimal results.
92
REQUIREMENTS OF THE ACCESS CAVITY 
The access cavity must make the succeeding steps ea-sier and safer. It must therefore meet the following re-quirements:
60,76
1) Permit the removal of all the chamber contents 
 As stated above, one of the rst steps for a favorableoutcome in Endodontics is proper cleaning of the en-dodontic space, which comprises not only the rootcanal, but also the pulp chamber and its pulp horns.Cleaning should be as thorough as possible.Good endodontic cleaning, therefore, begins with theremoval of the endodontic contents from the pulpchamber and its horns.To accomplish this, it is necessary to completely re-move the chamber roof. This allows the removal of allthe pulp tissue, any calcications, and all residue ortraces of old lling material.If the chamber roof is not completely removed, it willnot be possible to perform proper cleaning of thepulp horns. There are two consequences: – contamination or infection of the endodontic spacethat the dentist is trying to clean. – discoloration of the endodontically-treated tooth(especially the front teeth).To ensure adequate removal of the roof above thepulp horns, one can use a small, curve probe, suchas a # 17 (Fig. 11.1A), as Lasfargues et al.
58
suggest.It is used to probe the walls of the access cavity forthe presence of overhangings. Ardines’ probes
3
(Fig.11.1B) are also useful for this purpose.
2) Permit complete, direct vision of the oor of the  pulp chamber and canal openings 
The entire extent of the oor must be visualized, as itslandmarks help in identifying the canal openings. Thisapplies particularly to the posterior teeth: the oor fre-quently has natural grooves, at the end of which thecanal orices are located (Fig. 11.2).To meet this second requirement, the access cavi-
11
 Access Cavity and Endodontic Anatomy 
 A
RNALDO
C
 ASTELLUCCI
, M.D., D.D.S.
 
11 - Access Cavity and Endodontic Anatomy 
245
ty must sometimes be slightly modied to give it theso-called “convenient shape”. Following complete re-moval of the roof, it is necessary to orient the cavity slightly toward the dentist, particularly when dealing with the molars and patients with limited mouth ope-ning. This gives the walls a slight anterior inclinationthat facilitates inspection of the oor and thus locali-zation of the canal openings
60
(Fig. 11.3).Inspection and localization are facilitated by the use of the endodontic probe (Fig. 11.4), which is to the en-dodontist what the periodontal probe is to the perio-dontist.
17
By reaching, feeling, and frequently movingthe hard tissue, this probe functions as an extensionof the dentist’s ngers.The natural anatomy of the oor frequently indica-tes the site of the orices. Sometimes, however, re-storations, dentinal neoformations, or dystrophic cal-cications may alter the original conguration and hi-de the root canal orices. Using the endodontic probeto explore the chamber oor, one can enter the ca-nal openings and sometimes displace calcic depositsthat obstruct them.
AB
Fig. 11.4.
A
.
 
Hu-Friedy DG-16 endodontic probes.
B
. The new endodontic pro-bes JW-17 (C K Dental Specialties) designed by John West are very sharp.Fig. 11.3. Convenient access cavity shape. The aperture has been enlarged atthe expense of the mesial wall.Fig. 11.2. Access cavity of an upper right second molar. Note the grooves inthe oor of the pulp chamber, which are excellent natural guides to the ca-nal openings.
BA
Fig. 11.1.
A
. With a small, angled probe, such as a # 17, it is easy toconrm complete removal of the pulp chamber roof.
B
. Detail of Ardines’ probe, which may be used for the same purpose.
 
246
Endodontics
Lastly, the endodontic probe can be used to determi-ne the angle between the root canals and the oor of the pulp chamber.
 3) Facilitate the introduction of canal instruments into the root canal openings 
 As stated above, the pulp chamber oor of the poste-rior teeth frequently has grooves that serve as guides,not only to nd the orices of the root canals, but alsoto the introduction of endodontic instruments withinthem.The oor is also frequently convex and forms an acu-te angle with the chamber walls. It seems as thoughNature had considered the work that the endodon-tist would have to do. Thus, if the access cavity hasbeen well made and, especially, if the chamber oorhas not been affected by the cutting action of the bur,the instruments will enter the canals easily without en-countering any obstacles. It sufces to slide the canalinstrument along the wall at the point where the canalopening is located. The walls prepared by the endo-dontist and the oor created by Nature will guide theinstrument toward the apex (Fig. 11.5).If the anatomy of the oor has been modied, resul-ting in attening or irregularities, each introduction of an instrument must be checked with a mirror with thepulp chamber free of any irrigating solution, to allow visualization of the canal orice.
4) Provide access as direct as possible to the apical one third of the canal for both preparationinstruments and canal lling instruments 
Endodontic instruments should not be deected by any obstruction in the crown. When working in thecanal, they should move freely, particularly in the api-cal one third (Fig. 11.6).For a variety of reasons, the endodontic instrumentsshould never touch the walls of the pulp chamber: – They must be able to work on the entire circumfe-rence of the canal. An access cavity that is too nar-row will force the dentist to work on only one wallof the canal, while the other remains completely untouched (Fig. 11.7). Deformations of the apicalforamen may result.
39,50,60
 – The friction of the instrument’s shaft against the co-ronal obstructions will have to be overcome. Theforce required to do so impairs the endodontist’sability to sense how much the working portion of 
Fig. 11.5. Access cavity in a lower rst molar. The con-vexity of the pulp chamber oor guides the endo-dontic instruments into the canal openings.Fig. 11.6. The instrument descends freely into theroot canal without encountering any coronal in-terference.Fig. 11.7. The limited access cavity and incompleteremoval of the chamber roof limits the instrumentto working on the mesial wall of the distal canal. Theopposite wall cannot be cleansed.

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