Access cavity

( part 2 )

DR\ MOHAMMED SAAD EASA

LECTURER OF ENDODONTICS
AL-AZHER UNIVERSITY
Access related mishaps:

Treating the wrong tooth .

2. Missed canals .

3. Damage to existing restoration .

4. Over extended preparation

5. Under extended preparation

6. Access cavity perforations .

7. Crown fractures .
1- Treating the wrong tooth

 Prevented by marking the diseased tooth

2-Missed canals:
2-Missed canals:
2- Missed canals
2- Missed canals

Before After

Radix entomolaris or paramolaris

 -
3 Damage to an Existing Restoration:

 Porcelain crowns are the most susceptible to chipping and fracture.

 4- Crown Fracture:

Due to excessive force during excavation of caries or removing large

restoration .
 5- Over extended preparation

Weakens the coronal tooth structure and compromises the final restoration. This mistake results
from failure to determine correctly the position of the pulp chamber and the angulation of the
bur.
5- Over extended preparation
 6- Under extended preparation

The whitish color of the roof, the depth of the access cavity, and the lack of developmental
grooves are clues to this underextension. Root canal orifices generally are positioned at or
slightly apical to the CEJ.
6- Under extended preparation
7- Access Cavity Perforation:
 Proximal perforation

Failure to align the bur with the long axis of the tooth. This is a common error in teeth with full
crowns.
 Labial perforation

Labial perforation caused by failure to extend the preparation to the incisal before the bur
shaft entered the access cavity.
 8- Inconvenient access

This can lead to bur and file breakage, coronal discoloration because the pulp horns remain,
inadequate instrumentation and obturation, root perforation, canal ledging, and apical
transportation.
Remember :

 Prevention is better than curing .

 Do not be panic when mishap happens .

 Inform the patient before treatment about the possible

risks involved .
MODIFICATIONS OF ACCESS CAVITY DESIGNS
1- Presence of extra canals
1- Presence of extra canals
1- Presence of extra canals
2-Teeth with abrasion
2- Teeth with abrasion
3- Teeth with extensive labial caries
4- PROSTHETICALLY PREPARED TEETH
4- PROSTHETICALLY PREPARED TEETH
MODERN ACCESS CAVITY DESIGNS
 Prevalence and predisposing factors of the
fractures.
Age
changes Intra
in radicular
dentin Post
nature restoration

Endodontic Traditional
irrigants and access cavity
medicaments preparation

Kishen A. Biomechanics of fractures in endodontically treated teeth. Endod Topics. 2015; 33: 3–13.
 What happened to c hange?

 Progress in the field of imaging, materials,

instruments, and computers has transformed the
clinical practice of dentistry
1) ultra-flexible instruments,

2) visual magnification,

3) superior illumination,

4) enhanced root canal irrigation systems, and

5) 3D imaging tec hnology (CBCT).

 Bio minimalism

Bio-minimalistic approac h

Minimally invasive dentistry

 Minimally invasive endodontics

3
 Minimally invasive endodontic access cavity
Is an openings to gain access to
the root canal system, which aim
to preserve sound tooth structure.

1 Contracted access,

2 “Ninja" access( ultra conservative )

3 Truss" access

4 Caries driven access cavity

5 Restoration driven access cavity

Minimally invasive endodontic access cavity

Advantages Disadvantages

3
 "just suck the pulp out,
without cutting any tooth structure."
 In recent years, Clark and Khademi have described
a conser vative endodontic cavity (CEC) concept
designed to minimize tooth structure removal and to
improve fracture resistance of root-filled teeth.

 The novel conser vative endodontic cavity (CEC)

involves preser vation of the pulp c hamber roof and
pericer vical dentin

Clark D, Khademi J. Modern molar endodontic access and directed

dentin conservation. Dent Clin Nor th Am. 2010;54:249-73.
 The concepts of conser vative endodontic
access

1.the removal of restorative materials before tooth structure,

2.the removal of enamel before dentin
3.the removal of occlusal tooth structure before cer vical
dentin. (located 4 mm above and below the crestal bone)
4.It disregards the traditional requirements of a SLA and
complete unroofing of the pulp c hamber

Clark D, Khademi JA. Case studies in modern molar endodontic access and
directed dentin conservation. Dent Clin Nor th Am. 2010;54:275-89.
Conser vative endodontic cavities model
 conservative access
Traditional access
encourages the retention of preparations were slightly
“soffits,” to minimize cuspal divergent to enable
flexure during mastication. convenience form

Drs. Clark and Khademi have described a new concept of conservative endodontic access
 Pericervical Dentin

• Pericervical Dentin is a term that was first described in 2008.

• it is an area roughly 4 mm coronal to crestal bone and 6 mm apical to crestal bone
.
• It acts as the “neck” of the tooth and is key because it transfers occlusal forces to
the root.
• the strong, PCD trumps is responsible for long-term retention of the tooth.
• It is the most common area for catastrophic root fractures and catastrophic
 Aids to preser ve dentin in
conser vative endodontic cavities
 Magnification

1) Operating microscopes and other visual Enhancers

(operating microscopes, loupes, and increased light levels,)
 Dental Radiographs
(CBCT)
aids in visualizing the precise anatomical
configurations of the tooth and supporting
structures.
 How to make a CEC ?
In the incisors, drilling was initiated 1 mm palatal to the incisal
edge and extended apically along the long axis.

In the premolars, drilling was initiated 1 mm buccal to the central

fossa and extended apically maintaining a part of the chamber
roof and lingual shelf.

In the molars, drilling was initiated at the mesial one quarter of

the central fossa and extended apically and distally while
maintaining part of the chamber roof . Canals were located while
minimizing mesial-distal, buccal-lingual and circumferential
pericer vical dentin removal.

The enamel in all teeth was beveled with a tapered diamond bur.
 Contracted Access Cavity

Krishan R, Paqué F, Ossareh A, Kishen A, Dao T, Friedman S. Impacts of conservative endodontic access cavity
on root canal instrumentation efficacy and resistance to fracture assessed in incisors, premolars, and molars. J
Endod. 2014; 40:1160-6.
Contracted Access Cavity
an incisal cavity is convenient, and as small as the instrument shank used to shape the canals.
post-op radiographs, demonstrating the preservation of the roof-wall interface
(or soffit).
Access cavities can even be diminished by maintaining the occlusal isthmus not larger than
one-third of the intercuspal distance.
 Treatment c hallenges related to minimally
invasive canal enlargement

1. The inability of antimicrobials to eliminate biofilm bacteria

in anatomical complexities and uninstrumented portions of
the root canal limited irrigant penetration,

2. Irrigating needle wedging,

3. Challenges associated with sonic/ultrasonic/apical negative

pressure irrigation.

4. Training and Tec hnical competency

Caries driven conservative access cavity prep
Caries oriented access cavity prep
Lesion guided access cavity prep
Caries driven access cavity
Caries driven access cavity
Caries driven conservative access cavity prep
Almost no tooth structure being cut
and the postoperative structural
integrity of a tooth with only a
mesial operative restoration.

No need for a full-coverage crown

Truss access simply means that cavities are created
strategically using :

CBCT information and magnification.

These accesses are placed above the root canals and the
instrumentation of the canals is done via these holes.
Traditional vs Truss Access Cavity
 ultrasonic tip [straight or bended] to clean everything. This dentin bridge gives much more
resistant to tooth. no mised anatomy, cleand and shaped using Reciproc R25 file with Hyflex
CM 30/04 file.
“X-entry” access cavity
Postoperative radiograph
of a mandibular molar
treated through an
alternative to the truss
configuration –an “X-
entry” access cavity –a
design that minimizes
removal of tooth structure
in the critical trunk of the
tooth.
 Ninja access
Ultracontracted access
Don't add more stress to your tough work by making " mouse" hole access cavity...
Smart, dynamic and conservative access is what we need...
IDEAL Conser vative Access Cavity Through PFM Crown