• Possible errors:

– Extension too far gingivally.

– Failure to remove the lingual shoulder that mostly
causes missed lingual canal.
– Gouging due to improper bur angulation and failure
to recognize the linguoaxial or mesioaxial angulation
of tooth.
– Inadequate incisal extension causing failure
to completely remove the pulp debris causing
discoloration of tooth after treatment as shown in
Figure 13.48F.
Mandibular Lateral Incisor
• External access outline form: Triangular or oval
shaped which is longer incisogingivally and narrower
mesiodistally.
Figure 13.49B shows the access outline form of
mandibular
lateral incisor with two canals from incisal
view.
• Stepwise procedure: Same as mandibular central incisor
• Possible errors:
– Extension too far gingivally.
– Failure to remove the lingual shoulder that mostly
causes missed lingual canal.
– Gouging due to improper bur angulation and failure
to recognize the linguoaxial or mesioaxial angulation
of tooth.
– Inadequate incisal extension causing failure
to completely
remove the pulp debris causing
discoloration of tooth after treatment.
Mandibular Canine
• External access outline form: Oval or slot-shaped narrow
mesiodistally and wider buccolingually. Its incisal
extension is towards the incisal edge and gingival
extension penetrates the cingulum. Mandibular canine
has almost straight mesial edge, its distal surface is
Fig. 13.50 Access cavity outline form of mandibular canine (incisal
view) with one and two canals, (B, Buccal; D, Distal; M, Mesial;
L, Lingual)
larger and its cusp tip is inclined lingually, so the access
preparation lies more to the mesial of the midpoint
mesiodistally.
Figure 13.50 shows the access outline form of
mandibular canine (incisal view).
• Stepwise procedure: Technique is similar to Maxillary
canine. The lingual shoulder must be removed to gain
access to the lingual wall of the root canal or to the
entrance of a second canal. Buccal wall is larger and the
lingual wall is slit-like. As a result, cleaning and shaping
may be difficult.
Like the mandibular incisors, butt joint junctions are
not necessary.
• Possible errors:
– Extension too far gingivally
– Failure to remove the lingual shoulder that mostly
causes missed lingual canal
– Gouging due to improper bur angulation and failure
to recognize the linguoaxial or mesioaxial angulation
of tooth.
– Inadequate incisal extension causing failure
to completely remove the pulp debris causing
discoloration of tooth after treatment.
Mandibular Premolar Teeth
Steps of Endodontic access cavity preparation of mandibular
premolar teeth are shown in Figures 13.51A to E.
Mandibular First Premolar
• External access outline form: Oval shaped as shown in
Figure 13.52.
• Stepwise procedure: The procedure is the same as for
the maxillary premolars. But some specific points for
mandibular first premolar are:
– Usually the initial entry is made at the upper third
of lingual incline of the facial cusp with #2 round
AB
222 Short Textbook of Endodontics
carbide bur centered mesiodistally and directed
along the long axis of root. This helps to compensate
for the tilt and to prevent perforations.
– When two canals are present, they tend to be round
from the pulp chamber to their foramen. Sometimes
a single broad root canal may bifurcate into two
separate root canals.
– Direct access to buccal canal usually is possible,
whereas lingual canal may be very difficult to find
due to following reasons: The lingual canal tends
to diverge from the main canal at a sharp angle and
the crown has lingual inclination that directs files
buccally, making location of lingual canal orifice
more difficult. To counter this, lingual wall of the
access cavity needs to be extended farther lingually,
this makes lingual canal easier to locate.
– Because of lingual inclination of the crown, buccal
extension can nearly approach the tip of buccal cusp
to achieve straight-line access.
– Mesiodistally the access preparation is centered
between the cusp tips.
• Possible errors: Perforation due to improper bur
angulation or due to failure to recognize the lingual
inclination of the crown
– Inadequate extension causing further preparation
errors
– Apical perforation due to overinstrumentation or
due to failure to recognize the buccal or lingual apical
curvature.
• Important considerations: Due to lingual inclination
of the crown, the access cavity needs to be extended
lingually so that the lingual canal is easier to locate
and negotiate. Also the buccal extension should be
approaching the buccal cusp tip to achieve straight-line
access.
Mandibular Second Premolar
• External access outline form: Oval shaped as shown in
Figure 13.53.
• Stepwise procedure: Similar to mandibular first premolar,
with few specific variations:
– Crown has less lingual inclination, so less extension
up the buccal cusp incline is required for straight-line
access.
Figs 13.51A to E Access cavity preparation of mandibular premolars: (A) Initial entry through occlusal surface in the central groove of
mandibular premolar; (B) Round bur used to penetrate into the pulp chamber; (C) Endodontic explorer used to locate canal orifice; (D)
After
deroofing of pulp chamber, tapered fissure bur used for buccolingual extension and finishing of cavity walls; (E) Final preparation
should
allow straight line access of Endodontic instrument to the apex
ABCDE
Fig. 13.52 Access cavity outline form of mandibular first premolar
with one and two canals respectively (occlusal view), (B, Buccal;
D, Distal; M, Mesial; L, Lingual)
Endodontic Access Cavity Preparation 223
Fig. 13.53 Access cavity outline form of mandibular second
premolar (occlusal view), (B, Buccal; D, Distal; M, Mesial; L, Lingual)
• Possible errors:
– Perforation due to improper bur angulation or due
to failure to recognize the tilt of premolar
– Inadequate extension causing further preparation
errors
– Apical perforation due to overinstrumentation or
due to failure to recognize the buccal or lingual apical
curvature.
Mandibular Molar Teeth
Steps of Endodontic access cavity preparation of mandibular
– Lingual half of the tooth is more fully developed, so molar teeth are shown in Figures 13.54A to G.
lingually access preparation may extend halfway up
the lingual cusp incline.
Figs 13.54A to G Access cavity preparation of mandibular molars. (A) Buccal view of mandibular molar in which access is to be
prepared;
(B) Proximal view of same tooth; (C) Initial entry made using round bur through the occlusal surface in the exact center of the mesial pit;
(D) Endodontic explorer is used to locate the canal orifices; (E) Round bur is used from inside to outside of the pulp chamber for
deroofing
of the pulp chamber; (F) Final finishing and funnelling of access cavity walls; (G) Final access preparation should allow unobstructed
access
to the canal orifices
ABCD
EFG
224 Short Textbook of Endodontics
Mandibular First Molar
• External access outline form: Trapezoid or triangular
shaped with rounded corners and rectangular if two
distal canals are present.
Figure 13.55 shows the external access outline form
of mandibular first molar with three, four and five canals
respectively (occlusal view).
Mesially the access preparation should not invade
the marginal ridge. Distally it should be extended so
as to have adequate access to the distal canals. Buccal
and lingual wall are formed by the lines connecting the
respective two orifices
• Stepwise procedure:
Step 1: Removal of caries and old restorations and establishing
initial outline form: Remove caries and restoration
to achieve initial outline form. Initial entry is made
using #4 round carbide bur to penetrate the enamel
in the central fossa perpendicularly. The starting
location for molar access cavity preparation is
determined by establishing mesial and distal
boundary limits.
Step 2: Penetration of pulp chamber roof: Using the same bur,
angle of penetration is changed from perpendicular
to occlusal table towards the largest canal (distal)
because the pulp chamber space usually is largest
just occlusal to the orifice of this canal. A “drop”
effect will be felt.
Step 3: Complete roof removal: Complete roof removal
including the pulp horns using a round bur, tapered
fissure bur, or a safety tip diamond or carbide bur.
Step 4: Axial wall extension: Tapered fissure carbide or
diamond bur with rounded end or safe-ended
diamond or carbide burs are used to funnel the
corners of the access cavity directly into the orifices
and to plane the axial walls and slightly flare them
towards the occlusal to remove all the obstructions
in the smooth, straight line access to the canals.
Step 5: Identification of all canal orifices: The anatomic dark
lines in the pulpal floor (Dentinal map) should be
examined with an Endodontic explorer to identify
the orifices. Usually all canal orifices are located in
the mesial two-thirds of crown. Mesial canal orifices
are connected by developmental groove and are
well-separated within pulp chamber. Mesiobuccal
orifice is under the mesiobuccal cusp. Sometimes
the mesiobuccal cusp tip has to be encroached on
to achieve straight-line access. Mesiolingual orifice
is found just lingual to the central groove. In case of
single distal canal, the orifice is oval buccolingually
and the opening generally is located distal to the
buccal groove that can be explored from mesial side.
Step 6 and 7: Removal of cervical dentin bulge and orifice
and coronal flaring and removal of internal triangles
of dentin.
Step 8: Determination of straight-line access.
Step 9 and 10: Final evaluation of access preparation and
refinement and smoothing of restorative margins.
Figure 13.56 shows the clinical photograph of
completed access cavity preparation in mandibular
molar seen under magnification.
• Variations: In between mesiobuccal and
mesiolingual canals, a middle mesial canal may
be present as seen in Figure 13.57.
• Possible errors:
– Gouging in an attempt to search for orifices
in a tooth with receded pulp chamber
– Furcal perforation due to failure to recognize
the depth of pulp chamber
– Lateral perforation due to improper bur
angulation
– Missed second distal canal
– Ledge formation due to underextended
access preparation
– Failure to recognize the curvature in the canal
causing further procedural errors such as
ledging or perforation.
• Important considerations: The mesial and the
lingual inclination of the crown should be
considered during access preparation on this
tooth to prevent unnecessary gouging.
A concavity is present on distal surface of
mesial root and on mesial surface of distal root.
So careful instrumentation should be done to
avoid strip perforation.
Mandibular Second Molar
• External access outline form: When three canals are
present, triangular form or slightly rhomboid shaped.
Fig. 13.55 Access cavity outline form of mandibular first molar with
three, four and five canals respectively (occlusal view). (B, Buccal;
D, Distal; M, Mesial; L, Lingual)
Endodontic Access Cavity Preparation 225
When two canals are present, rectangular shaped
opening which is wider mesiodistally.
When only one canal is present, oval shaped in the
center of occlusal surface.
• Stepwise procedure: Similar to mandibular first molar
with the variations due to smaller size. Due to buccoaxial
inclination of the tooth, sometimes large portion of
mesiobuccal cusp may have to be reduced to clean and
shape the mesiobuccal canal. The two mesial orifices
are located closer together.
• Variations: Mandibular second molars have roots and
canals usually close together and may have single or
fused roots. One to six canals are possible. Sometimes
a file placed in mesiobuccal canal may appear to be in
the distal canal when these two canals are connected
by a semicircular slit in case of a C-shaped canal (Fig.
13.58).
Figures 13.59A to D show the outline form of
mandibular second molar with 3, 4, 2 canals respectively
and C-shaped canal (occlusal view).
C-shaped canals have been described in detail in
Chapter 3: Morphology and Internal Anatomy of the
Root Canal System.
• Possible errors:
– Gouging in an attempt to search for orifices in a tooth
with receded pulp chamber
– Furcal perforation due to failure to recognize the
depth of pulp chamber
– Lateral perforation due to improper bur angulation
– Missed second distal canal
Fig. 13.57 Clinical photograph of access opening in mandibular first
molar with three canals (Additional middle mesial canal) (Courtesy
of Dr Shivani Bhatt)
Fig. 13.56 Clinical photograph of access cavity preparation in
mandibular molar with four canals seen under microscope (Courtesy
of Dr Roheet Khatavkar)
Fig. 13.58 Clinical photograph of access opening done in
mandibular second molar with C-shaped canal (Courtesy of Dr
Roheet Khatavkar)
– Ledge formation due to underextended access
preparation
– Failure to recognize the curvature in the canal
causing further procedural errors such as ledging
or perforation
• Important considerations: Distal aspect of mesial
root and mesial aspect of distal root have concavities.
So careful instrumentation should be done to avoid
strip perforation. The roots have close proximity
to the mandibular canal. So appropriate working
226 Short Textbook of Endodontics
length determination should be done to avoid
overinstrumentation.
Mandibular Third Molar
It may have unpredictable anatomy. Lot of variations
are possible. May have severely curved roots. Access
preparation varies according to the number of roots and root
canals and other anatomic variations. Figure 13.60 shows
the access cavity preparation in a mandibular third molar
tooth with three canals.
WHICH ARE THE CHALLENGING ACCESS CAVITY
PREPARATIONS AND HOW TO DEAL WITH
THEM?
Teeth with Calcifications in Pulp Chamber
and Root Canals
• Challenge: Identification of calcified root canal orifices
and then negotiation of calcified canals is a challenge.
• Possible errors:
– Improper attempt to locate canals can lead to
perforations of root wall or of the furcation.
– Overzealous attempt to locate canals can cause
excavation of large amount of sound dentin resulting
in weakening of tooth structure (Figs 13.61A to C)
• Safe approach to face the challenge:
– Knowing beforehand that calcification exists, to be
prepared to deal with it, is important. Careful reading
of preoperative radiograph will reveal calcification
of pulp chamber and radicular canal spaces.
– One must know that calcification progresses from
the coronal part to the apex of the root. There may be
severe coronal calcifications but the canals become
less calcified as they approach the apex. So, complete
cleaning, shaping and obturation of these canals
upto the apical terminus needs to be achieved.
– Use of adequate illumination (For example,
transillumination with fiber-optic light) and
magnification (For example, dental operating
microscope or loupes) is very helpful diagnostic aids
in such cases.
– Careful examination of color differences can help
in searching the calcified orifices. Floor of pulp
chamber is darker in color than the walls of the
pulp chamber. Developmental grooves connecting
orifices are lighter in color than the floor of pulp
chamber.
– Exact knowledge of the anatomic location of root
canal orifices and possible variations and knowing
the fact that canal orifices are located at the end
points of developmental grooves and at the angles
formed by the pulp chamber walls and floor.
– Other diagnostic aids for location of calcified root
canal orifices:
- Use of sharp Endodontic explorer
- Use of ultrasonic tips
- Sodium hypochlorite champagne bubble test
- Sequential application of 17% EDTA and 95%
ethanol
– Patency of the canal can be determined using smaller
Endodontic files such as #6, #8 K-files coated with
chelating agent such as EDTA
Fig. 13.60 Access cavity preparation in mandibular third molar
with three canals, (B, Buccal; D, Distal; M, Mesial; L, Lingual)
Figs 13.59A to D Mandibular second molar with (A) 3 canals;
(B) 4 canals; (C) 2 canals; (D) C-shaped canal, (B, Buccal; D, Distal;
M, Mesial; L, Lingual)
A
C
B
D
Endodontic