  

Preparation Premolars
  
Preparation Access Opening


Before going for access cavity preparation, a study of

De nition
preoperative periapical radiograph is necessary with a
Access cavity preparation is de ned as an endodontic coronal
paralleling technique.
preparation which enables unobstructed access to the canal
ori ces, a straight line access to apical foramen, complete control
Radiographs help in knowing
over instrumentation and accommodate obturation technique.
(Fig. 15.4).
(Figs 15.5 and 15.6).
A proper coronal access forms the foundation of pyramid
of endodontic treatment (Fig. 15.1). Any improperly prepared
access cavity can impair the instrumentation, disinfection
and therefore obturation resulting in poor prognosis of the
treatment. occlusal surface.
e optimal access cavity results in the straight entry
(Fig. 15.7).
into the canal ori ces with line angles forming a funnel
which drops smoothly into the canals (Fig. 15.2). Removal
of coronal contacts on instruments reduces the adverse
unidirectional forces directed on the instruments which may
result in instrumental errors like ledging and perforation
(Figs 15.3A and B).

Fig. 15.1 Pyramid of endodontic treatment Fig. 15.2 Smooth, straight line access to root canal system
 A B
Figs 15.3A and B
bending of instrument while inserting in canal leading to instrumental
Fig. 15.6 Root canal anatomy of anterior teeth
line access to the canal without any undue bending

Fig. 15.4 Radiograph helps to know morphology of teeth

Fig. 15.7 Radiograph showing calci ed canal

An ideal access preparation should have following features:

the access cavity.

touching any portion of the access cavity.

Fig. 15.5 Anatomy of root canal of molar
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Objectives of access cavity preparation

– Improved instrument control because of minimal instrument

de ection and ease of introducing instrument in the canal
– Improved obturation

– omplete debridement of pulp chamber

– Improving visibility
– ocating canal ori ces
– Permitting straight line access
– Preventing discoloration of teeth because of remaining
pulpal tissue.
onserve sound tooth structure as much as possible so as to
avoid weakening of remaining tooth structure.
Fig. 15.9 Access opening burs

INSTRUMENTS FOR ACCESS CAVITY

PREPARATION FIG. 15.8
Access Opening Burs (Fig. 15.9) A

ey are round burs with 16 mm bur shank (3 mm longer

than standard burs).
B
Access Re ning Burs (Figs 15.10A to C)
ese are coarse grit ame shaped, tapered round and
diamonds for re ning the walls of access cavity preparation. C

Surgical Length Burs Figs 15.10A to C Access re ning burs

access and visibility.

increased because of displacement of handpiece away

from incisal or occlusal surface of tooth.

Munce Discovery MD Burs

with sti shafts that are 1 mm in diameter.

Fig. 15.11

exposing separated instruments deep within radicular

structures.

Müller Burs (Fig. 15.11)

used in low speed handpiece.

long shaft is useful for working deep in the radicular

portion.

Fig. 15.8 Instruments for access preparation

GUIDELINES FOR ACCESS CAVITY
PREPARATION FIG. 15.12

check the depth of preparation by aligning the bur and

handpiece against the radiograph. is is done so as to note
the position and depth of the pulp chamber (Fig. 15.13).

form. e bur is penetrated into the crown until the roof of

pulp chamber is penetrated (Fig. 15.14).
Round ended carbide burs are used for access opening
into cast restorations because these burs have distinct

Fig. 15.14 Gain entry to pulp chamber with round bur

Fig. 15.12 Guidelines for access cavity preparation

A.
B.
C. Re nement of the pulp chamber and removal of pulp chamber roof
using round bur from inside to outside
Fig. 15.15 Once “drop in” into pulp chamber is obtained,
D.
bur is moved inside to outside

tactile sense when “drop in” to the pulp chamber (Figs

15.15 to 15.19).
Access nishing is best carried out by using burs with safe
noncutting ends.
Advantage of using these burs is that they are less likely to
damage or perforate the pulp chamber oor.
But these burs cut in lateral direction and cannot drop into
small canal ori ces.

not apply rubber dam until correct location has been

con rmed.

tooth fracture during treatment.

removal of all the pulp tissue, calci cations, caries or any

residuals of previous restorations (Figs 15.20 and 15.21).

Fig. 15.13 Preoperative radiograph can help to note the

position and depth of pulp chamber
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Fig. 15.16 Access preparation using tapered ssure burs

Fig. 15.19 Access re ning

Fig. 15.17 Access preparation Fig. 15.20 Final access preparation

Fig. 15.18 Access preparation continues Fig. 15.21

 Shape of pulp chamber is determined by:
Size of pulp chamber: In young patients, access preparation is
wider than the older ones.
Shape of pulp chamber: Final outline form should re ect
the shape of pulp chamber. It is triangular in anteriors, ovoid

molars.
Number, position and curvature of the canal It can lead to
modi ed access preparation, like Shamrock preparation in

Laws of access cavity preparation for locating canal ori ces

Law of centrality: Floor of pulp chamber is always located in the
center of tooth at the level of cementoenamel junction.
Law of cementoenamel junction:
surface of clinical crown to the wall of pulp chamber is same

Fig. 15.22 Law of concentricity: Walls of pulp chamber are always

anatomy of pulp chamber.

Law of color change:
the cavity walls.
Law of symmetry: Usually canal ori ces are equidistant from a
line drawn in mesial and distal direction through the oor of
pulp chamber.
Law of ori ce location:
of oor and walls, and at the terminus of root development
fusion lines.

ACCESS CAVITY OF ANTERIOR TEETH

to prevent contamination of pulp space and have a straight

line access into the canals.
Fig. 15.23

surface (Fig. 15.24). If it is made too small and too close to

the cingulum the instrument tends to bind the canal walls
and thus may not work optimally.
gentle funnel shape with larger diameter towards occlusal
surface (Figs 15.20 and 15.22).

or lingual surface never through proximal or gingival

surface. If access cavity is made through wrong entry, it
will cause inadequate canal instrumentation resulting in
iatrogenic errors (Fig. 15.23).

canals, curvatures, calci cations using well magni cation

and illumination.

Clinical Tips
the overpreparation. Once “drop in” into the pulp chamber is
obtained, round bur is replaced by tapered ssured bur.

access walls, causing multiple ledges. Fig. 15.24 Access opening is started at the center of lingual surface
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Fig. 15.25 Once enamel is penetrated, bur is directed Fig. 15.26

at its center to penetrate the enamel. Once enamel is

penetrated, bur is directed parallel to the long axis of the
tooth, until ‘a drop’ in e ect is felt (Fig. 15.25).

remainder of chamber roof is removed by working a round

bur from inside to outside. is is done to remove all the
obstructions of enamel and dentin overhangs that would
entrap debris, tissues and other materials.

Sharp explorer tip is used to locate the canal ori ces,

to penetrate the calci c deposits if present, and also to
evaluate the straight line access.

shoulder (Fig. 15.26) using Gates-Glidden drills or safe

tipped diamond or carbide burs.

Fig. 15.27 Improper access cavity preparation causing

be ared so that it becomes con uent with all the walls of
access cavity preparation. By this a straight line access to
the apical foramen is attained, i.e. an endodontic le can
reach up to apical foramen without bending or binding
to the root canal wall. Any de ection of le occurs should
be corrected because it can lead to instrumental errors
(Fig. 15.27).
passing a le passively into the canal, evaluate the access
cavity using magni cation and illumination.
de ection of instrument
cavity is done to allow better and précised placement of
nal composite restoration with minimal coronal leakage.
Since the outline form of access cavity re ects the internal
anatomy of the pulp space, technique of the access opening
of anterior teeth is the same, the shape may vary according to
internal anatomy of each tooth.
Maxillary Central Incisor Mandibular Incisors
Access cavity of mandibular central and lateral incisors is
is a rounded triangular shape with base facing the incisal almost similar in shape. Access cavity of mandibular incisors
aspect (Fig. 15.28). is di erent from maxillary incisors in following aspects (Fig.
15.30)
and distal pulp horns.

mature tooth because of less prominence of mesial and incisogingivally.

distal pulp horns.
Mandibular Canine
Maxillary Lateral Incisor
e shape of access opening of mandibular canine is similar
Shape of access cavity is almost similar to that of maxillary

rounded triangle.
ACCESS CAVITY PREPARATION
FOR PREMOLARS
Maxillary Canine
Shape of access cavity of canine has following di erences premolars, it is in center of the occlusal surface between
buccal and the lingual cusp tips (Figs 15.31A and B).
Slight variations exist between mandibular and maxillary
premolars because of the lingual tilt of mandibular
labiopalatally (Fig. 15.29). premolars.

contra-angle handpiece. e bur should be directed

Fig. 15.28

Fig. 15.30 Outline of access cavity of mandibular incisor

A B
Fig. 15.29 Figs 15.31A and B Outline of access cavity of premolars
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A B
Figs 15.33A and B
Fig. 15.32 Oval-shaped access cavity of premolars

parallel to the long axis of tooth and perpendicular to

the occlusal table. Generally the external outline form
for premolars is oval in shape with greater dimensions
buccolingual side (Fig. 15.32). presence of 30° lingual inclination of the crown
to the root, hence the starting point of bur penetration
penetrate deep enough to remove the roof of pulp chamber should be halfway up the lingual incline of the buccal cusp
without cutting the oor of pulp chamber. To remove the on a line connecting the cusp tips.
roof of pulp chamber place a bur (round, tapered ssure or oval which is wider mesiodistally,
safety tip) alongside the walls of pulp chamber and work when compared to its maxillary counterpart.
from inside to outside.
Mandibular Second Premolar
ori ces with the help of sharp endodontic explorer.
e access cavity preparation is similar to mandibular rst
using safety tip burs or Gates-Glidden drills and obtain a
straight line access to the canals.
because its crown has smaller lingual tilt.
slightly towards the occlusal surface. e divergence of
access cavity walls creates a positive seat for temporary dary of access opening extends halfway up to the lingual
restorations. cusp incline, i.e. pulp chamber is wider buccolingually.

Clinical Tips
“mouse hole
e ect” (Figs 15.33A and B). ACCESS CAVITY PREPARATION
FOR MAXILLARY MOLARS
further cause procedural errors.

boundaries of pulp chamber mesially and distally and

of curvature without any de ection.
coronally on the radiograph.

is determined by mesial and distal boundary. Mesial

Maxillary First Premolar boundary is a line joining the mesial cusps and the distal
Shape of access cavity is ovoid in rst premolar in which boundary is the oblique ridge. e starting point of bur
boundaries should not exceed beyond half the lingual incline penetration is on the central groove midway between
of buccal cusp and half the buccal incline of lingual cusp. mesial and distal boundaries (Fig. 15.34).

Maxillary Second Premolar central groove directed palatally and prepare an external
outline form.
It is similar to that of maxillary rst premolar and varies only
by anatomic structure of the pulp chamber.
complete roof of pulp chamber using tapered ssure,
Mandibular First Premolar round bur, safety tip diamond or the carbide bur working

anatomy of pulp chamber guides the cutting.

Fig. 15.34

point of bur penetration is on the central groove midway between

mesial and distal boundaries
A B C
Figs 15.36A to C

and palatal) forms a triangle, termed as molar triangle

(Figs 15.36A to C).

present in rst maxillary molars, which is located palatal

and mesial to the MB1. ough its position can vary
sometimes it can lie a line between MB1 and palatal
ori ces.

a rhomboid shape with corners corresponding to all the

Luebke
showed that an entire wall is not extended to search and
facilitate cleaning, shaping and obturation of extracanal.
He recommended extension of only that portion of the
wall where extracanal is present, and this may result in
Fig. 15.35 “cloverleaf appearance” in the outline form. Luebke
referred this to as a shamrock preparation.

Maxillary Second Molar

All the canal ori ces should be positioned entirely on the Basic technique is similar to that of rst molar but with
pulp oor and should not extend to the axial walls. following di erences:

cervical bulges, ledges or obstruction if present. a single root.

is less likely to be present in second molar.
them con uent within the walls of pulp chamber and
slightly divergent towards the occlusal surface. buccal side.

buccal than in rst molar.

Maxillary First Molar
ACCESS CAVITY PREPARATION
mesiobuccal angle, obtuse distobuccal angle and palatal
FOR MANDIBULAR MOLARS
right angles (Fig. 15.35).

canal ori ce is located slightly distal and palatal to the central fossa midway between the mesial and distal
mesiobuccal ori ce. boundaries. e mesial boundary is a line joining the
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Fig. 15.37

Fig. 15.38 Access opening of mandibular rst molar with four canals
line joining the mesial cusp tips and the distal boundary is the line Courtesy: Sachin Passi
joining buccal and the lingual grooves

mesial cusp tips and the distal boundary is the line joining
buccal and the lingual grooves (Fig. 15.37).

the distal root. Once the “drop” into pulp chamber is

felt, remove roof of pulp chamber working from inside to
outside with the help of round bur, tapered ssure, safety
tip diamond or the carbide bur.

and nally nish and smoothen the cavity with slight

divergence towards the occlusal surface.

buccal and lingual though the number, type, shape and

form of canals may vary.
Fig. 15.39 Outline of access cavity of mandibular molars is rhomboidal
rhomboid but when two canals are present, access cavity
is oval in shape with wider dimensions buccolingually.
S
Mandibular Second Molar
Access opening of mandibular second molar is similar to that
Mandibular First Molar (Fig. 15.38)

Mesiolingual ori ce is located in a depression formed by

mesial and the lingual walls. e distal ori ce is oval in
shape with largest diameter buccolingually, located distal
to the buccal groove.
two-thirds of the crown.
located closer.
almost similar to mandibular rst molar, but it is more
triangular and less of rhomboid shape.

i.e. middle mesial canal (1–15%) lying in the developmental gular, wider mesiodistally and narrower buccolingually.
groove between mesiobuccal and mesiolingual canals.
necessary to reduce a large portion of the mesiobuccal
i.e. distobuccal, distolingual and middle distal. ese cusp to gain convenience form for mesiobuccal canal.
ori ces are usually joined by the developmental grooves.
CLINICAL MANAGING DIFFICULT CASES
irrespective of number of canals present (Fig. 15.39).
FOR ACCESS OPENING FIG. 15.40
buccal and lingual walls converge to meet the mesial and
distal walls.
 Fig. 15.40
Fig. 15.41 Endo-microscope
Good Quality Radiographs
Good quality radiographs with angled views, good contrast
are preferred for better assessment of root canals anatomy.
If canal disappears midway from ori ce to roof apex, one
should always suspect bifurcation. If there is an asymmetry,
one should suspect abnormal anatomy of pulp space.
Magni cation
Use of surgical operating microscope is recommended for
endodontic treatment (Figs 15.41 and 15.42).
Knowledge of Clinical Anatomy
One should evaluate gingival contour for abnormal anatomy
premolar may suggest a broad buccal root and thus two root
Fig. 15.42 Surgical operating microscope
canals. Teeth with extra cusp may indicate aberrant pulp
chamber.
Color of Pulpal Floor
In general pulpal oor is dark gray in color, where as axial
dentin is light in color. is color di erence helps the clinician
to be very accurate in removing axial dentin so as to expose
pulpal oor.
Extension of Access Cavity
e initial access shape is determined by shape of the pulpal
oor but later it is extended to gain straight line access to
the canals. Sometimes modi ed access cavity is prepared
maxillary premolars.
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Management of Cases with

Extensive Restorations
If extensive restorations or full veneer crowns are marginally vibrations while access preparation.
intact with no caries, then they can be retained with access
cavity being cut through them (Fig. 15.43)
porcelain restorations diamond burs are e ective and for struck into the canal system.
cutting through metal crowns, a ne cross-cut tungsten
carbide bur is very e ective. Restorative materials often alter restorations are placed to change the crown to root
the anatomic landmarks making the access cavity preparation angulations so as to correct occlusal discrepancies).
(Fig. 15.44). If possible, complete removal of
extensive restoration allows the most favorable access to the Tilted and Angulated Crowns (Fig. 15.45)
If tooth is severely tilted, access cavity should be prepared with

of great help in evaluating the relationship of crown to the

root. Sometimes it becomes necessary to open up the pulp
chamber without applying the rubber dam so that bur can be
placed at the correct angulation.
If not taken care, the access cavity preparation in tilted

– Instrument separation

– Improper debridement of pulp space.

Calci ed Canals (Figs 15.46A to D)

Fig. 15.43 When full veneer crown is marginally intact with no caries,
access can be made through the crown

B
Figs 15.45A and B
preparation should be according to the angle of tilted crown. (A)
Fig. 15.44 Perforation caused during access cavity preparation while Proper angulation of bur according to tilted crown; (B) Perforation if
gaining entry through already placed crown bur is misdirected
A B C
B D
Figs 15.46A to D

Courtesy:

Fig. 15.47 Ultrasonic tips for use in endodontic treatment

Fig. 15.48 Use of ultrasonic tip to remove dentin

locating and further treatment of the calci ed canals. while locating calci ed canals

treating such cases. ey allow the précised removal of

dentin from the pulp oor while locating calci ed canals
(Figs 15.47 and 15.48).
sclerotic canals.
scaler tip can be used for removal of calci cations from the
pulp space. be removed with the help of ultrasonic tips to avoid over
cutting.
locate the canals, this will further result in loss of landmarks
and the tooth weakening. used (Fig. 15.50).

smallest instrument with gentle passive motion both because it softens the dentin indiscriminately, resulting in
rotational and apical to negotiate the canal (Fig. 15.49). procedural errors such as perforations.

negotiating the calci ed canals. But overuse of chelating Teeth with No or Minimal Crown
agent should be avoided to prevent perforation.
ough it seems to be quite simple to prepare access cavity
in such teeth but some precautions are needed while dealing
Sclerosed Canals
Sometimes sclerosed canals are found in teeth which make
the endodontic treatment a challenge. angulation.
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the walls before initiating endodontic treatment. In other

words, it is necessary to restore the natural form of a crown

– Return the tooth to its normal form and function.

– Allow use of rubber dam clamps.

endodontic procedure.

POINTS TO REMEMBER
Recent advances in concept of access opening

tooth structure which may be required for strength of the tooth.

possible should be conserved.

Fig. 15.49 Introduce the smallest instrument into the canal at

rst indication of canal ori ce nish line.

clinical crown can be removed and replaced prosthetically,but

the dentin near the alveolar crest is irreplaceable.

crestal bone is important for ferrule, strength of the tooth in

area and also may cause strip perforaton.

roof is preserved all around the periphery of the tooth which is

also called so t to avoid damage to the lateral walls.

QUESTIONS

cavity preparation?

Fig. 15.50 Use of long shanked round bur to negotiate

the sclerosed canal

BIBLIOGRAPHY
radiograph.

there are chances of occurrence of iatrogenic errors like

perforations due to misdirection of the bur.

the tooth previous to endodontic treatment.