AJMAN UNIVERSITY OF

SCIENCE AND TECHNOLOGY

Faculty of Dentistry
Laboratory endodontic
manual

Guide for practical steps:-

access opening for
Anterior Teeth
ANTERIOR ANATOMY:- ACCESS OPENING
Outcomes
1. Discuss the internal anatomy of all anterior teeth.
2. Describe the access outline and process for making access
into all anterior teeth.
3. Explain the objectives of endodontic access.
4. Cite the most common error in making endodontic access.
5. Discuss procedures to avoid making errors in endodontic
access.
6. Discuss general principles in controlling the depth of
access.
7. Describe the two basic outline shapes of access and give
the reason for their shapes.
8. Demonstrate proper processing of radiographs.

ANATOMY OF ANTERIOR TEETH

Maxillary Central Incisor
The maxillary central incisor has a roughly triangular shaped crown with
its pulp chamber reflecting that same shape. The triangular shape of the
pulp chamber creates two pulp horns, mesial and distal. During endodontic
treatment, all tissue must be removed from the pulp horns.
If tissue is left behind in the pulp horn extensions, pigments from the
breakdown of the tissue can cause discoloration of the tooth.
The average length of the maxillary central is 22.5mm. Maxillary
centrals very rarely have multiple canals. They often have accessory canals,
though, which are not visible on a radiograph before endodontic treatment.
Accessory canals may be implied on the radiograph of a tooth with necrotic
pulp by the location of a radiolucency in the bone adjacent to an accessory
canal – a radiolucency is usually centered on its source.
Accessory canals can often be visualized after obturation of the root by
the presence of radiopaque sealer in the accessory canals. Approximately
45% of maxillary centrals have the foramen located away from the
anatomic terminus (apex) of the root, usually to the buccal or lingual.
 Access into the maxillary central is triangular in shape, reflecting the
triangular form of the pulp chamber. It is made by first cutting the
triangular outline into tooth structure to a depth of 2mm.

Initial penetration into the pulp chamber is made with the bur at the
cingulum area of the preparation. After penetration is made, the chamber is
unroofed with withdrawal strokes, cutting with the top of the round bur.
The preparation may be smoothed using the Endo-Z bur. There may be a
lingual overhang of dentin partially obstructing the orifice of the canal.
This is removed using a long shank #2 or #4 round bur or Gates-Glidden
drills creating straight-line access into the canal.

Maxillary Lateral Incisor

The maxillary lateral has a coronal shape similar to the central but with
smaller dimensions. The average length is 22mm, almost the same as the
central. The shape of the pulp chamber in the lateral is triangular like the
central. Due to the smaller dimensions of the lateral, though, the access is
usually oval. If the lateral incisor is larger, with a corresponding larger pulp
chamber, the outline may be triangular.
Maxillary lateral incisors very often have a moderate to severe distal
curvature in the apical 1/3 of the root with the foramen most often
corresponding to the anatomic apex. The curve may also have a palatal
aspect to it. Mishandling of the apical curvature during instrumentation can
result in failure of the endodontic treatment (the maxillary lateral incisor
has one of the highest failure rates).
Access is accomplished similarly to the maxillary central incisor. The
outline is made to be oval instead of triangular if the pulp chamber is found
to be of average size.

Maxillary Canine
The maxillary canine is the longest tooth in the dental arch with an
average length of 26.5mm.The coronal pulp is ovoid in cross-section and the
access preparation reflects this shape. The root may have mild to moderate
apical curvature and the foramen is usually close to the anatomic apex.
 Accessory canals occur less frequently than in maxillary incisors. The
root apex may have a distolabial curvature.
Access is made in a manner similar to the central and lateral, keeping
the outline oval in shape. The incisal extension is about 2/3 of the distance
to the cusp tip.

Mandibular Central and Lateral Incisor

Mandibular incisors have their greatest cross-sectional dimension in the
facial-lingual direction and are very narrow mesio-distally. The pulp space is,
therefore, ribbon shaped reflecting the same dimensional proportions as the
exterior root surface. Average length of mandibular incisors is 20.7mm. Two
canals or a dumbbell shaped canal occur in 40% of mandibular incisors,
However, two separate foramina occur less than 5% of the time. The
second canal (or second lobe of the dumbbell shaped canal) is usually located
toward the lingual after initial access is made. It is very often obscured
from view by an overhang of dentin that must be removed to make complete
access. The oval shaped access preparation is made very carefully and is not
expanded at all mesio-distally beyond the width of the #557 or #4 round
bur. A #2 round bur may be used to make the access preparation to prevent
overextension.
Access extends from the cingulum 2/3 the distance to the incisal edge
or, sometimes, even to the incisal edge. Severely rotated mandibular incisors
or those with lingually tipped crowns may require access on the labial
surface. This access is easily restored with bonded composite.
Instrumentation is done in mandibular incisors at the expense of the
facial and lingual surfaces of the canal, sparing the mesial and distal
surfaces. After obturation, the clinical radiographic view may not reveal
much taper in the shape of the canal, but if a view were taken from the
proximal, a significant taper would be seen. A mandibular incisor should
usually be treated as if it has 2 canals.

Mandibular Canine
The mandibular canine has an average length of 25.6mm. It is a fairly
straightforward tooth with minimal complications, similar to the maxillary
canine. The mandibular canine, though, may on occasion have two canals or
two roots evidenced on the radiograph by an apparent termination of the
visible canal somewhere at mid-root level. Where two canals are present,
it is usually easier to gain access into one than the other. Nonetheless, both
must be located and treated. Frequently the foramen exits to the buccal or
mesial (35%-50%).
The access preparation is oval as in the maxillary canine.

SUMMARY:
The most common error made in accessing anterior teeth is perforation
of the facial crown or root surface. If the canal is not easily encountered
within the confines of the crown of the tooth, an instructor must be
consulted. Remember to estimate the location of the pulp chamber and if you
do not find it there take a radiograph and ask for help
In order to minimize perforations you must evaluate the radiographs and
estimate where the pulp chamber will be found and determine if you are
comfortable with this search. If so, then go to this predetermined location.
If you do not find the pulp chamber at this point, take at least 2 radiographs
(at different angles) to help guide you along with faculty consultation.
Always have an objective when you cut on a tooth. When in doubt, ASK FOR
HELP!!
MAXILLARY CENTRAL INCISOR
MAXILLARY LATERAL INCISOR
MAXILLARY CANINE
MANDIBULAR CENTRAL AND LATERAL INCISOR
MANDIBULAR CANINE
 ANTERIOR ACCESS
1. Use a #2 F.G. round bur for mandibular incisors
or a #4 F.G. round bur for all other anterior teeth.
A fissure bur such as the 557 may also be used
for access. Hold the bur perpendicular to the
lingual surface and make an outline of the access
preparation 2 mm into tooth structure.
The preparation extends from the cingulum
to 2/3 of the cusp height. Mandibular incisors
may extend all the way to the incisal edge.

2. Change the angle of the bur so it is parallel

to the long axis of the tooth and place the tip
of the bur in the most cervical part of the
access outline (cingulum area). Make initial
penetration into the pulp chamber. Do not
penetrate more than 4 mm from the lingual
surface - there is a risk of perforating the
buccal surface. Get help if you have not
found the pulp chamber at this point.
Do not remove tooth structure from the walls
or floor of the pulp chamber unless specifically
instructed to do so by an instructor.

3. Locate the opening into the chamber with

the DG16 endodontic explorer.

4. Enter the pulp chamber with a round,

then with the bur parallel to the long
axis of the tooth; sweep it incisally,
unroofing the rest of the pulp chamber.
5. Probe for the orifice(s) with a sharp
endodontic explorer.

6. If the canal is large, remove

the lingual overhang with
Gates-Glidden drills,

7. Explore any remaining pulp horns with a DG16-explorer.