Welcome to Scribd, the world's digital library. Read, publish, and share books and documents. See more
Standard view
Full view
of .
Look up keyword
Like this
0 of .
Results for:
No results containing your search query
P. 1


Ratings: (0)|Views: 190|Likes:
Published by Artan

More info:

Categories:Types, School Work
Published by: Artan on Feb 15, 2011
Copyright:Attribution Non-commercial


Read on Scribd mobile: iPhone, iPad and Android.
download as PDF, TXT or read online from Scribd
See more
See less





Published for the Dental Professional Community by the
 American Association of Endodontists 
Spring 2010
 Access Opening and Canal Location
Cover artwork: Rusty Jones, MediVisuals, Inc.
he endodontic triad consisting o biomechanical preparation, microbial control and complete obturation o the canalspace remains the basis o endodontic therapy.
However, unless access to the canal orifces and the apical oraminaare done properly, achieving the goals o the triad will be difcult and time consuming. The ultimate goal o endodontictreatment is to create an environment in which the body can heal itsel. Adequate access is the key to achieving this and,thereore, the key to achieving endodontic success. The purpose o this newsletter is to help the practitioner develop anunderstanding o how to access the pulp chamber and fnd the orifces o the root canals. To do so, a systematic method oraccessing the pulp complex and locating root canal orifces is presented.
Basic Concepts
The pulp complex should be conceptualized as a continuum beginning occlusally at the pulp horns and ending at the api-cal oramina.
In order to remove pulp tissue entirely rom the pulp complex, the coronal portion o the complex must beaccessed in a manner that will permit pulp removal and acilitate the location and debridement o the root canals withoutcompromising the strength o the coronal enamel and dentin.This process o cleaning and shaping the pulp complex can be broken down into our stages—pre-access analysis, removalo the pulp chamber roo, identifcation o the pulp chamber and oor root canal orifces, and instrumentation o the rootcanals.
Pre-Access Analysis
Removal o the pulp tissue begins with an analysis o the anatomy o the tooth being treated and the anatomy o the sur-rounding tissues.In order to remove the contents o the root canal system, the coronal portion o the system, the pulp chamber and theradicular pulp must be identifed. According to Krasner and Rankow
, the pulp chamber o every tooth is in the center o the tooth at the level o the cementoenamel junction; they described this as “The Law o Centrality.The validity o this lawcan be seen in Figures 1a and 1b.The Law o Centrality can be used as a guide or the beginning o access. How-ever, it is critical that the operator understand that the law is consistently true onlyat the level o the CEJ and unrelated to the occlusal anatomy.
 Since we know that the pulp chamber is always in the center o the tooth atthe level o the CEJ, the initial penetrating bur shouldbe directed towards the center o the CEJ. Thereore, ina counterintuitive method, access should be initiated bymentally ignoring the clinical or restored crown o thetooth and looking beyond the crown to the mentally im-aged CEJ.
As can be seen in Figure 2, prosthetic crownscan mislead a clinician because the crown’s anatomy is notalways centered over the CEJ.
Step 1 
The frst step in accessing any tooth begins with the physical identifcation o the shape and position o the CEJ. Thiscan be accomplished by using a periodontal probe to explore the complete circumerence o the CEJ in order to orm amental picture o its extent as shown in Figures 3a-d.Once the CEJ is visualized,a penetration point on the oc-clusal surace can be selected.On a restorative surace thispoint may be unrelated tothe occlusal anatomy present.This can be seen in Figure 3e,on page 3, where the correctpenetration point on the oc-clusal surace is indicated by the blue circle. This point has been determined by radiograophic examination, periodontalprobing and the mental picture o the CEJ perimeter.
Fig. 1a.Cut specimens showing Law of Centrality.Fig. 1b.Fig. 2.Location of CEJ unrelatedto oversized crown.Fig. 3a.Periodontal probing to locate the CEJ.Fig. 3b.Fig. 3c.Fig. 3d.
The visualization o the ultimateoutline o the pulp chamber can beaided by utilizing another law o pulp chamber anatomy, The Law o Concentricity.
This law states that“the walls o the pulp chamber areconcentric to the external outline o the tooth at the level o the CEJ.TheLaw o Concentricity is illustrated inFigure 4.The Law o Concentricity will help the clinician to extend his access properly. I there is a bulge o the CEJ in anyparticular direction the pulp chamber also will extend in that direction. For example, i the tooth is narrow mesiodistally,then the clinician will know that the pulp chamber will be narrow mesiodistally, as shown in Figures 5a and 5b.
Step 2 
The second step is to determine the angulation o the tooth. This can be done by use o radio-graphs (Figure 6) and clinical observation. Cone beam tomography can aid in this determinationin a aciolingual direction.
Step 3 
The third step, shown in Figure 7, is to measure, on the radiograph, thedistance rom the cusp tip to the urcation. Once the cusp tip-pulp oordistance (CPFD) has been determined, a bur can be set in the handpieceshort o this length and, thereby, prevent peroration in the urcation.I the bur is directed towards the center o the CEJ, parallel to the long axis o the tooth andset short o the urcation, peroration o the chamber is unlikely.
Step 4 
Following the identifcation o the CEJ perimeter, the angulation o the long axis o the tooth and the CPFD, an initialocclusal penetration point can be selected. Thus, the entry point on the occlusal surace o the tooth is variable andwill be completely dependent on all o these actors. All recommendations about beginning at a particular point on anocclusal surace such as a pit or ossa relationship can be misleading. In some bizarre circumstances, the access startingpoint can even be on a cusp. The underlying concept or this is: the internal anatomy o the pulp chamber dictates theultimate outline orm. This outline orm may be triangular, trapezoidal or irregular.
Technique o Access
Step 1 
Beore beginning the mechanical portion o the access, all deective restorations and caries should be removed. Leavingleaky restorations or caries can permit bacterial contamination during and ollowing treatment.
Step 2 
The shape and type o bur to be used is completely up to the clinician. A #4 carbide or round diamond or #557 tapedfssure bur are commonly used. For prosthetic crowns, special metal cutting fssure burs are available. Whichever bur isselected should penetrate the occlusal surace at the point determined by the pre-access actors(CEJ perimeter, tooth angulation, CPFD). The bur should be advanced towards the center o thementally imaged CEJ until a drop is elt or the head o the handpiece touches the cusp. However,a word o caution—a drop-o will only be elt when the pulp chamber is at least 2mm deep.When evaluating a tooth or treatment or reerral, the pulp chamber roo to oor distance shouldinuence this decision. Teeth that appear to have calcifed pulp chambers, such as in Figure 8,should be considered or reerral.
Continued on p. 4
Fig. 3e.Location of initialpenetration point based on theCEJ perimeter.Fig. 4.Fig. 5a.Cut specimens showing the Law of Concentricity.Fig. 5b.Fig. 6.Determining angulationwith radiograph. Note mesialtipping of the maxillarysecond molar.Fig. 7.Measuring the occlusal-furcal distance.Fig. 8.Radiograph ofcalcified canals in a molar.

Activity (4)

You've already reviewed this. Edit your review.
Ben Ong liked this
1 hundred reads
Goran Subotić liked this
Al Per liked this

You're Reading a Free Preview

/*********** DO NOT ALTER ANYTHING BELOW THIS LINE ! ************/ var s_code=s.t();if(s_code)document.write(s_code)//-->