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11/09/2013

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Colleagues
 for 
 
 Excellence
Published for the Dental Professional Community by the
 American Association of Endodontists 
Spring 2010
 Access Opening and Canal Location
Endodontics
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.
1
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.
1
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
2
, 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.
2
 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.
2
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.
Endodontics:
 
Colleagues
 for 
 
 Excellence
T
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.
2
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.
3
 
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.
Endodontics:
 
Colleagues
 for 
 
 Excellence
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.

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