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 difcult 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,thereore, 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.
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.
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. Thereore, 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.
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 circumerence 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 surace can be selected.On a restorative surace 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 surace 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.