Access Cavity Preparation

Contents
• Definition
• What is an ideal access
• Principles
• Instruments used
• Guidelines for access preparation
• Laws of access cavity preparation
• Procedure
• Access cavity of maxilary and mandibular teeth
• Management of difficult cases
• Recent concept
• conclusion
 Definition

Access cavity preparation is defined as endodontic coronal preparation

which enables unobstructed access to the canal orifices, a straight line
access to the apical foramen, complete control over instrumentation and
accommodate obturation technique.
A PROPER CORONAL ACCESS FORMS THE FOUNDATION OF
PYRAMID OF ENDODONTIC TREATMENT
A PREOPERATIVE PERIAPICAL RADIOGRAPH IS A MUST ,PRIOR ACCESS
CAVITY PREPARATION

RADIOGRAPHS HELP IN KNOWING:

Morphology of tooth

Anatomy of root canal Branching of canal system

system
Position and depth of pulp
chamber
Number and length of canals

Position of apical foramen

As well, calcification,resorption present,if

any
What is an ideal access cavity?
• Improved instrument control
• Improved obturation
Straight line
access

• Ensure proper debridement

• Improve visibility
Complete • Locate canal orifices
deroofing of pulp • Prevent teeth discoloration due to pulp remnants
chamber

• Avoid weakening of remaining tooth structure

Conservation of
tooth structure
 Principles
• Regardless of the tooth, there are three
phases in the preparation of the access
cavity:
 Penetration
 Enlarging
 Finishing
 Instruments for access cavity
preparation

ACCESS OPENING
BURS

They are round burs with 16mm bur shank (3mm longer than standard burs)
• ACCESS REFINING
BURS

These are coarse grit flame shaped ,tapered round and diamonds for refining
walls of access cavity preparation
SURGICAL LENGTH
BURS
MUNCE DISCOVERY
BURS
MULLER BURS

Other burs used

Guidelines for access cavity
preparation
Laws of access cavity preparation

LAW OF CENTRALITY

LAW OF CEMENTO ENAMEL JUNCTION

LAW OF CONCENTRICITY

LAW OF COLOR CHANGE

LAW OF SYMMETRY

LAW OF ORIFICE LOCATION

 Laws of access cavity preparation
LAW OF CENTRALITY
Floor of pulp chamber is always located in the center of tooth att he level of
cementoenamel junction
LAW OF CONCENTRICITY
Walls of pup chamber are always concentric to external surface of tooth at the level
of CEJ. This indicates anatomy of external tooth surface reflects the anatomy of
pulp chamber
LAW OF COLOR CHANGE
Color of pulp chamber floor is darker than the cavity walls.
LAW OF SYMMETRY
Canal orifices are equidistant from a line drawn in mesial and distal direction through
the floor of pulp chamber.
LAW OF ORIFICE LOCATION
Canal orifices are located at the junction of floor and walls, and at the terminus of
root development fusion lines.
Access cavity
PROCEDURE Removal of caries/defects/restorations

Direct round bur perpendicular to the lingual surface

at its center and then parallel to long axis ,until a drop
in effect-i.e pulp chamber entry

Deroofing of the chamber completed by working inside

out

Locate the canal orifices using endodontic explorer

Remove the liungual shoulder using GG drills/Orifice

enlargement

Straight line access/Refining access

 Maxillary central incisors
Outline form-The inverted-triangular
shaped access cavity is cut with its
base at the cingulum to give straight
line access.

Width of base depends on distance

between mesial and distal pulp horns.

Shape may change from triangular

to slightly oval due to less prominent
pulp horns in older individuals.
 Maxillary lateral incisors

Shape of access cavity

similar to maxillary central
incisors,except that

Smaller in size

When pulp horns are

present,shape of access
cavity is rounded triangle

If pulp horns are missing,

shape is oval
 Maxillary canine

Shape of access cavity

No pulp horn
Acess cavity is oval in shape with greater
diameter labiopalatally
 Maxillary first premolar

Oval shaped acess cavity-The

two horns are situated just within
the peaks of their cusps.
The orifices of the two canals are
also slightly more within the
horns. Thus, one can generally
prepare a good access cavity
without involving the cusps.
 Maxillary second premolar

Ovoid shape of
access cavity
 Maxillary first molar
Shape of pulp chamber
–rhomboid;
Palatal canal orifice
located palatally,
mesiobuccal canal
orifice located under
mesiobuccal cusp,
distobuccal canal orifice
located slightly distal
and palatal to
mesiobuccal orifice.
A line drawn to connect
all three orifices forms a
triangle- molar triangle
LEUBKE showed there is no need of extenstion of
entire wall ,he recommended extension of only
that portion of the wall were extra canal is
present ,resulting in a clover leaf appearance in
outline form- shamrock preparation.
 Maxillary second molar
Mb2 less likely to
be present
Three canals form
a rounded triangle
with base towards
buccal side.
Mesiobuccal orifice
is located more
towards mesial and
buccal than first
molar.
 Maxillary third molar
• Alavi et al. found that 50.9%
of third maxillary molars
had three separate roots of
which 45.5% had two or
more canals in the
mesiobuccal root.
About 45.7% had fused
roots
2% had C-shaped canals
2% had four separate roots
• Modifications must be
made in accessing these
teeth compared to first and
second molars to
accommodate these
anatomical variations.
 Mandibular incisors
Access cavity of
mandibular central
and lateral incisors is
almost similar
Shape is long oval
with greater
dimensions directed
incisogingivally
 Mandibular canine
Shape of acces opening
similar to maxillary
canine-oval, but,
Smaller in size
Root canal outline
narrower in mesiodistal
dimension
Two canals may be
present
Mandibular first premolar

•Oval acess cavity,wider

mesiodistally
•Presence of 30 degree
lingual inclination of
crown to root,hence
starting point of bur
should be half way up the
lingual incline of buccal
cusp.
Mandibular second premolar

•Similar to mandibular first

premolar
•Enamel penetration initiated
in central groove dueto small
lingual tilt
•Ovoid acess opening is
wider mesiodistally
 Mandibular first molar

This tooth most frequently

requires endodontic
treatment.
The access cavity, which
should not be triangular,
rather trapezoidal or
quadrangular with rounded
corners.
The classical triangular
shape would hamper the
identification of the second
distal canal .
 Mandibular second molar

The access cavity of this tooth is

started from the central fossa, and it
is created according to the same rules
used for the first molar.

 Because of the slight distal

angulation of its roots, the access
cavity can, however, be less extensive
in this case.

The shape of the access cavity

depends on whether there is one, two,
three, or four canals; it may be round
to oval, triangular, or quadrangular
 C shaped canal
The incidence of C-shaped
canals is reported to be
highestin the mandibular
second molar.THE MAIN
ANATOMIC FEATURE OF C
- SHAPED CANALS IS THE
PRESENCE OF A FIN OR
WEB- connecting the
individual root canals.

The ‘‘C-shaped canal’’ by

Cooke and Cox in 1979. This
3

canal shape results from

the fusion of the mesial and
distal roots on either the
buccal or the lingual root
surface.
 Mandibular third molar
•The lower third molar may
require endodontic therapy for the
same reasons as the upper third
molar.

When it is the last distal abutment,

this tooth acquires great
importance.

The most varied and bizarre root

morphology can correspond to an
almost normal coronal
appearance .

Nonetheless, this tooth can also

be treated successfully by
endodontic means .

The same rules that apply to the

other lower molars also hold for its
access cavity.
 Radix entomolaris and radix
paramolaris
• Supernumery roots in mandibular molars
• Radix entomolaris:Presence of an
additional disto lingual root in mandibular
molars;extra root on the lingual side.
• Radix paramolaris:presence of additional
disto buccalroot in mandibular molars;
extra root on buccal side.First reported by
De Moor et al in 2004
 Clinical management of difficult
cases
For treatment of teeth with abnormal pulpal anatomy
following are required:

GOOD QUALITY RADIOGRAPHS

MAGNIFICATION

KNOWLEDGE OF CLINICAL ANATOMY

COLOR OF PULPAL FLOOR

EXTENSION OF ACCESS CAVITY

 Cases with extensive restorations

 If extensive  In case of an
restorations are access cavity
marginally intact,then cut through
access cavity can be restorations
cut through them following can
• Porcelein occur
restorations- • Coronal
Diamond burs leakage
• Metal crowns-Fine
• Poor
cross cut metal carbide visibility and
bur accessibility
 If possible ,complete
• Canal
removal of extensive blockage
restoration allows
• Misdirection
most favourable
of bur
access penetration
Tilted and angulated crowns

• Preperative radiographs
should be thoroughly
assessed
• If not taken care
followin may occur
• Failure to locate canals
• Gouging of tooth
structure
• Procedural accidents
such as
 Instrumrent
seperation
 Perforation
 Improper debridement
of pulp space
 Calcified canals
• Calcifications in the pulp space
are very common
• Obliteration of pulp space may
be partial or complete by pulp
stones

• Special ultrasonic tips used

• Avoid overcutting of dentin to prevent weakening
of tooth structure
• At first indication of canal,Introduce the smallest
instrument first gently (with passive motion
rotational and apical)
• Use of chelating agents is also helpful(overuse
may result in perforation)
 SCLEROSED CANALS

• Dyes can be used to locate

sclerosed canals
• Precise dentin removal
using ultrasonic tips advised
• Long shank low speed no2
round burs also used
Teeth with no or minimal crown

• Evaluate preoperative radiograph to assess root angulation and depth of

penetration
• Rebuild tooth structure prior endodontic procedures,if required
 RECENT ADVANCES IN CONCEPT
OF ACCESS OPENING
Many times straight line access leads to severe loss of stategic tooth structure
which may be required for the strength of crown
Atleast 2mm of of dentin thickness should be present between external tooth
surface and the endodontic access at the finish line
The dentin near the alveolar crest is irreplaceable

An area of 4mm above and below crestal bone is important for ferrule,strength
of tooth in cervical area,so it should be always conserved maximally
GG drills are non end cutting and self centering ,so care must be taken to avoid
strip perforation or overcutting at furcation area

Pulp chamber should not be completely deroofed ;some of the roof is preserved
all around the periphery of the tooth which is also called soffit to avoid damage
to the lateral walls
 conclusion

An error in access cavity preparation would compromise all

subsequent work.
This preliminary step permits localization, cleaning, shaping,
disinfection, and three-dimensional obturation of the root
canal system.
Thus the success of the endodontic treatment depends
entirely on precise, proper execution of this step.
 Reference sited

• Text book of endodontics-Nisha Garg.Amit Garg(3 rd

edition)
• Pathways of pulp-stephen cohen(9 edition)
th

• British Dental Journal  197, 379 - 383 (2004)

• Sch. J. App. Med. Sci., 2014; 2(5B):1613-1617

• Access Cavity and Endodontic Anatomy,by Arnaldo

castellucci, m.d., d.d.s.

• Grossman endodontic practice-eleventh edition

Thank you for your
attention!!