ACCESS CAVITY PREPARATION

A well designed access cavity is essential for quality endodontic result. Ideal Access: 1. The objective of entry is to give direct access to the apical foramina, not merely to the canal orifice. 2. Access cavity preparations are different from typical operative occlusal preparations. 3. The likely interior anatomy of the tooth under treatment must be determined. 4. When canals are difficult to find, the rubber dam should not be placed until correct location has been confirmed. 5. Endodontic entries are prepared through the occlusal or lingual surface never through the proximal or gingival surface. 6. As a part of access preparation, the unsupported cusps of posterior teeth must be reduced. ACCESS PREPARATION GUIDELINES: COMMON CANAL CONFIGURATION: Types of Configurations: Type 1: Single canal from the pulp chamber to the apex.

Type 2: Two separate canals leaving the chamber but merging short of the apex to form only one canal. Type 3: Two separate canals leaving the chamber and exiting the root in separate apical foramina. Type 4: One canal leaving the pulp chamber but dividing short of the apex into two separate and distinct canals with separate apical foramina. The following terms have been used to indicate the frequency of occurrence:

Most frequent - present in more than 55% of cases. Less frequent - present in less than 45%, but more than 25% of cases.

Least frequent present in less than 25% but more than 2% cases. Rare Occurring in less than 2% of cases but still present occasionally. ARMAMENTARIUM FOR ACCESS PREPARATION: 1. Front surface mirror. 2. Endodontic explorer. 3. Endodontic excavator. 4. Plastic instrument. 5. Amalgam plugger. 6. Spatula. 7. Cotton pliers. 8. Broaches.

9. Glass slab. 10. Cotton pellets. 11. Burs. 12. Rubber dam kit. GENERAL SHAPE OF WALLS IN ACCESS PREPARATIONS: Removal of obturations to the apex: Need for divergent walls. Access for badly worn or fractured anterior teeth. PREPARATION OF AREA FOR TREATMENT: 1. Certain preparation of the site of treatment must be made to reach a successful result from both the dentists and the patients viewpoint. 2. To ensure patient comfort the tooth must be correctly anaesthetized. 3. The tooth to be treated must be able to accommodate a rubber dam. 4. Need for local anesthesia during endodontic treatment. Types of anaesthetic solutions used in endodontics: Lidocaine (Xylocaine). Mepivacaine (Carbocaine). Injections needed for removal of vital pulp tissue (Table 6-8 Weine).

Special comments about mandibular block injections: Administer correct amount of solution.

Use of the short needle. Use care when giving IAM block with a short needle.

Intraligamentary anaesthesia: Application of rubber dam for severely broken down teeth: Use of bands. Access when a deep gingival decay is present. Aid for a leaky rubber dam.

ACCESS PREPARATION GUIDELINES: 1. Because internal anatomy dictates the access shape, the first step in preparing an access is the visualization of the location of the pulp space. 2. Buccolingual angulations and coronal anatomy are judged visually. 3. Cervical anatomy can be judged tactically using an explorer under the sulcus to feel the cervical shape. 4. Palpation along the attached gingiva will help determine root location and direction. 5. Diagnostic radiographs are then used to estimate pulp chamber position, degree of calcification of pulp chamber, and approximate canal length.

The clinician uses information gained from these investigations to make a decision about the long axis penetration of the initial access.

In difficult situations it is sometimes recommended that the initial access be prepared without a rubber dam in place.

Any restorative material impinging in the straight line access should be removed before the pulp chamber is accessed to prevent the lodging of debris in the canals. This is especially important in mandibular teeth. It is not necessary to remove all restorative materials, only material that will be in path of an ideal access.

Caries is removed to prevent irrigating solutions leaking from the rubber dam into the mouth and to prevent bacterial contamination of the canal system with saliva.

Occasionally it is necessary to place an interim restoration, creating an efficient seal and fascilitating rubber dam placement. A 1mm to 2mm occlusal adjustment of teeth may be done to establish a more accurate point for measuring canal length and to reduce postoperative pressure sensitivity. The roof of the pulp chamber is best perforated with a round bur. A no. 2 bur should be used in anterior and premolar teeth. No. 4 bur should be used in molar teeth.

For teeth with porcelain crowns, a water cooled round diamond instrument should be used until dentin is reached, this prevents fracture of thin porcelain.

 The bur is best directed toward largest part of pulp chamber. In calcified, multirooted teeth, it is better to divert the access toward the largest canal. This will increase the likelihood of locating the canal and avoiding perforation. Once the pulp chamber is located (with light upward pressure), the round bur is used to remove the roof of the pulp chamber from underneath; the belly of the bur should be used to cut on the outstroke. This should establish on initial outline form. The pulp chamber should be frequently flushed with sodium hypochlorite solution to remove debris and bacteria. A sharp DG 16 double ended explorer is used to locate canal orifices and to determine their angle of departure from the main chamber. In heavily calcified teeth the uses of enhanced vision, transillumination, and the careful examination of internal dentin color aids in canal location. A fiber-optic light can be applied to the cervical aspect of the crown, which often reveals subtle landmarks that are otherwise invisible. Once the canals are located, a no. 10 or no. 15 type of file is introduced into the canal to determine patency.

If the canal is narrow, the upper portion needs to be instrumented with ktype or Hedstroem files to provide space for the use of Gates-Glidden drills.

 Hedstroem files may be used with lateral pressure away from the furcation to move the canal laterally to avoid perforation. Tooth length may be determined at this point, but it can also be delayed until later. Care must be taken to keep the files within the canal system until the length is accurately determined. A lubrication agent, such as RC-Prep, which is water based preparation that will not congeal vital pulp tissue, may be introduced. Congealed pulp tissue can potentially form a collagen plug at the apex that could block the apex from cleaning and shaping. The next step is to initiate radicular access. There are two ways to accomplish this. The traditional and most popular method is to use a Gates-Glidden drill in a step-back fashion.

This technique involves forming a tapered shape by introducing the smallest Gates-Glidden drill to light resistance, followed by larger drills at progressively less depth.

The clinician should produce it into the canal until resistance is felt. It is important not to force the drill apically. The no. 1, no. 2 and no. 3 Gates-Glidden drills are used for radicular step back. The no. 4, no. 5 and no. 6 are used coronal to canal orifice to create a funnel shape to facilitate the ease of file introduction.

 This procedure will establish a convenience form that creates a more straight line access into the canal. Convenience form is established by using the Gates-Glidden drill in a sweeping, upward motion, with lateral pressure away from the furcation. An alternative method is to use an 0.08 to 0.12 tapered engine driven nickel and titanium file to establish the upper canal shape; then to flare the canal with a no. 5 or no. 6 Gates-Glidden drill. Final outline form is established with a round tip, tapered, diamond bur after the canals have been located and the initial opening has been completed. This important outline form is dictated by the internal anatomy and modified to improve visibility, establish convenience form and conserve critical tooth structure. Use pathfinder for locating orifices.

ACCESS THROUGH FULL VENEER CROWNS: Properly made crowns are constructed with the occlusal relationship of the opposing tooth as a primary consideration. A cast crown can be made in any shape and diameter, height or angle; this cast crown alteration can destroy the visual relationship to the true long axis. Careful study of the preoperative radiograph identifies most of these situations.

 Achieving access through crowns should be done with coolants, even when the rubber dam is used. Friction generated heat can damage adjacent soft tissue, including the periodontal ligament; with an anaesthetized or non-vital tooth, the patient is not aware of the pain. Once penetration of metal is accomplished, the clinician can change to a sharp, round bur and move to the central pulp chamber. Metal filling and debris from the access cavity should be removed frequently because small slivers can cause large obstructions in the fine canal system. When sufficient access has been gained, the clinician should search margins and internal spaces for caries and leaks. The clinician should also search the pulpal floor for signs of fracture or perforation. Occasionally caries can be removed through the occlusal access cavity, and the tooth can be properly restored.

The interior of a crown can be a surprise package, containing every thing from extensive caries to intact dentin (as seen in periodontally induced pulpal necrosis).

METHODS OF LOCATING CALCIFIED CANALS: 1. Preoperative Radiograph. 2. all canals exist and must be cleaned, shaped and filled to the canal terminus. Canals become less calcified as they approach the root apex.

3. Serious errors can occur when overzealous or inappropriate attempts are made to locate canals (Root wall or canal perforations). Immediate attention must be given to repair communication within the ligament space and surrounding bone. 4. There is no rapid technique for dealing with calcified cases. Painstaking removal of small amounts of dentin has proven to be the safest approach. ACHIEVING ACCESS THROUGH COMPLEX RESTORATIONS: Most teeth in need of endodontics have or have had extensive caries. Extensive coronal tooth loss requires many types of restoration. Subgingival caries requires complex restorative procedures, which often results in recession of coronal and radicular canals. Achieving access in these teeth requires major excavation of filling materials, caries and calcified tooth structure. Coronal access most often is made through multiple layers of materials placed over long periods of time. Straight line access can be difficult, particularly in teeth with calcified canals or malpositioned teeth. In cases of inclined teeth that have been crowned. Ideal access can only be achieved by removal of all restorative material.

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 In case of gold-crowns and porcelain fused to metal crowns, financial constraints may influence the choice for gaining access. Under these circumstances the clinician is well advised to inform the patient of all the potential risks (e.g. perforation and fracture). If the patient accepts these risks, the clinician should make one careful attempt at access through the existing restoration, with the understanding that if the access opening is unsatisfactory, the restoration will have to be completely removed and a new restoration be prepared after endodontic treatment. PERIODONTAL AND ENDODONTIC SITUATIONS: Complications of aging make locating of canal orifice difficult. The problems of bone loss, chronic inflammation of the periodontal ligament, mobility, and leakage into the root canal system are a combined periodontal and endodontic situation.

The gradual closure of internal spaces may be observed as the attachment apparatus demineralizes away from the root surfaces.

The height of the pulp space now moves apically making occlusal access difficult.

Perforations of root walls and furcations are real risks as the clinician reaches deeper with long shank burs.

One means of locating the position of the bur tip and proper angle of approach is to stop, remove the bur from the handpiece, replace it in the

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cavity, pack the cavity around the bur with cotton to stabilize it and expose a periapical film. Periodontal patients may have caries on exposed root sufaces and thus require extension class V restorations. These restorations and the calcifications often accompanying them can make gaining occlusal access to some canals impossible. In unusual cases it may become necessary to remove the restorative material and then locate, clean, and shape the canals from the buccal aspect. PRINCIPLES OF ENDODONTIC CAVITY PREPARATION: Blacks Principles of endodontic cavity preparation are as follows: Endodontic coronal cavity preparation: I. II. III. Outline form. Convenience form. Removal of remaining carious dentin (and defective restorations). IV. Toilet of the cavity.

Endodontic radicular cavity preparation: I and II outline form and convenience form (contd..) IV Toilet of the cavity (contd) V Retention form. VI Resistance form.

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Principle I outline form: The outline form of the endodontic cavity must be correctly shaped and positioned to establish complete access for instrumentation, from cavity margin to apical foramen. External outline form evolves from the internal anatomy of the tooth established by the pulp. Because of this internal external relationship, endodontic preparations must of necessity be done in a reverse manner, from the inside of the tooth to the outside. External outline form is established by mechanically projecting the internal anatomy of the pulp onto the external surface. This may be done by drilling into open. Space of the pulp chamber and then working with the bur from the inside of the tooth to the outside, cutting away dentin of the pulpal roof and walls overhanging the floor of the chamber. This intracoronal preparation is contrasted to the extracoronal preparation of operative dentistry in which outline form is always related to the external anatomy of the tooth. The tendency to establish endodontic outline form in the conventional operative manner and shape must be resisted. To achieve optimal preparation 3 factors of internal anatomy must be considered. the size of the pulp chamber.

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 the shape of the pulp chamber. number of individual root canals, their curvature and their position. The size of the pulp chamber:

The outline form of endodontic access cavities is materially affected by size of the pulp chamber.

In young patients these preparations must be more extensive than in older patient in whom the pulp has receeded and the pulp chamber is smaller in all three dimensions. This becomes quite apparent in preparing the anterior teeth of youngsters, whose age root canals require larger instruments and filling materials.

Shape of pulp chamber: The finished outline form should accurately reflect the shape of the pulp chamber. The floor of the pulp chamber in a molar tooth is usually triangular in shape, owing to the triangular position of the orifices of the canals. The triangular shape is extended up the walls of the cavity and out onto the occlusal surfaces, hence the final occlusal cavity outline form is generally triangular. Number, position and curvature of the root canals:

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 In order to instrument each canal efficiently without interference, the cavity walls often have to be extended to allow an unstrained instrument approach to the apical foramina. Outline form:

Standard R/G in buccolingual projection, provides only two dimensional view of what is actually three dimensional problem. If mesiodistal x-ray projection could be made one would find pulp of maxillary 2nd premolar to be flat tapering ribbon rather than round thread visualized on initial radiograph.

Final ovoid occlusal cavity preparation will mirror internal anatomy rather than buccolingual x-ray image. Coronal preparation of maxillary first molar illustrating major principle of endodontic cavity outline form, internal anatomy of tooth (pulp) dictates external outline form. This is accomplished by extending preparation from inside of tooth to outside surface, that is working from inside to outside. Endodontic cavity preparation, mandibular first molar, superimposed upon inlay restoring proximal-occlusal surfaces. Blacks outline form of inlay is related to external anatomy and environment of tooth, that is, extent of carious lesions, groves and fissures, and position of approximating premolar. Triangular or rhomboidal outline form of endodontic preparation on the other hand is related to internal anatomy of the pulp.

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Size and shape of endodontic coronal preparations in mandibular incisors related to size and shape of pulp and chamber contrast in outline form between young incisor with large pulp and adult incisor is apparent.

Large triangular preparation in youngster reflects pulp horn extension and size of pulp chamber, whereas ovoid preparation in adult relates to grossly receeded pulp. Extension toward incisal allows central-axis access for instruments. Large size and shape of coronal preparation in recently calcified incisor relates to huge pulp housing. To remove all pulp remnants and to accommodate large endodontic instruments and filling materials, coronal preparation must be extensive, triangular, funnel shaped opening. Actually, no more than lingual wall of pulp chamber has been removed. In lower incisors, outline form may well be extended into incisal edge. This preparation allows absolutely direct access to apex. Outline form of endodontic coronal cavity in maxillary first premolar is narrow, elongated oval in buccolingual projection which reflects size and shape of broad, flat pulp chamber of this tooth. Buccal view of inadequate coronal preparation in maxillary molar with defalcated mesiobuccal root. There has been no compensation in cavity preparation for severe curvature of mesial canal or for obtuse direction by which canal leaves the pulp chamber. Operator can no longer maintain control of instrument, and ledge has been produced. Extension of outline form and internal preparation to mesial would have obviated this failure.

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 Shamrock preparation: modified outline form to accommodate unstrained in severely curved mesial canal. Principle II Convenience form: Convenience form was conceived by Black as a modification of the cavity outline form, to establish greater convenience in placement of intracoronal restoration. In endodontic therapy, however, convenience form makes more convenient the preparation as well as filling of the root canal. Four important benefits are gained through convenience form modifications: 1. Unobstructed access to the canal orifice. 2. Direct access to the apical foramen. 3. Cavity expansion to accommodate filling techniques. 4. Complete authority over the enlarging instrument. 1. Unobstructed access to the canal orifice: In endodontic cavity preparations of all teeth, enough tooth structure must be removed to allow instruments to be placed easily into the orifice of each canal without interference from overhanging walls. The clinician must be able to see each orifice and easily reach it with instrument points. Failure to observe this principle not only endangers the successful outcome of the case, but also adds materially to the duration of treatment. In certain teeth, extraprecautions must be taken to search for additional canals. High incidence of a second separate canal in the mesiobuccal root

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of maxillary molars. A second canal often is found in the distal root of mandibular molars. The premolars both maxillary and mandibular, can also be counted on to have extra canals. During preparation the operation mindful of these variations, from the norm, searches. Conscientiously for additional canals. In many cases, the outline form has to be modified to facilitate this search and the ultimate cleaning, shaping and filling of the extracanals. Luebke has made an important point that an entire wall need not be extended in the event that instrument impingement occurs due to an severely curved root or extracanal. In extending only that portion of the wall, needed to free the instrument, a cloves leaf appearance may evolve as the outline form. Hence Luebke has termed this Shamrock preparation. It is most important that as much crown structure be maintained as possible. MOD cavity preparations reduce tooth stiffness by more than 60%, and the loss of marginal ridge integrity was the greatest contribution to loss of tooth strength. 2. Direct Access to the apical foramen: To provide direct access to the apical foramen, enough tooth structure must be removed to allow the endodontic instruments freedom within the

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coronal cavity so that they can extend down the canal in an unstrained position. This is especially true when the canal is severely curved or leaves the chamber at an obtuse angle. Occasionally total decuspation is necessary.

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3. Expansion to accommodate filling technique: It is often necessary to expand the outline form to make certain filling techniques more convenient or practical. If a softened gutta-percha technique is used for filling, where in rather rigid pluggers are used in a vertical thrust, then the outline form may have to be widely extended to accommodate these heavier instruments.
4. Complete authority over the enlarging instrument:

It is imperative that clinician maintain complete control over the root canal instrument. If the instrument is impinged at the canal orifice by tooth structure that should have been removed, the dentist will have lost control of the direction of the tip of the instrument and the intervening tooth structure will dictate the control of the instrument. If on the other hand if the tooth structure is removed around the orifice so that the instrument stands free in this area of the canal, the instrument will then be controlled by only two factors. 1. The clinicians finger on the handle of the instrument and, 2. The walls of the canal at the tip of the instrument. Nothing is to intervene between these two points.

Failure to properly modify access cavity outline by extending the convenience form will ultimately lead to failure by either root perforation, ledge or shelf formation within the canal, instrument

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breakage or incorrect shape of the completed canal preparation often termed zipping or apical transportation. Principle III Removal of the remaining carious dentin and defective restorations.

Caries and defective restorations remaining in an endodontic cavity preparation must be removed for three reasons:

To eliminate mechanically as many bacteria as possible from the interior of the tooth. To eliminate the discolored tooth structure, that may ultimately lead to staining the crown. To eliminate the possibility of any bacteria laden saliva leaking into the prepared cavity. The last point is especially true of buccal or proximal caries that extend into the prepared cavity. After the caries are removed, if the carious perforation of the wall is allowing salivary leakage, the area must be repaired with cement, preferably from inside the cavity. A small piece of premixed temporary cement, cavit or cavit G may be forced through the perforation and applied to the dry walls of the cavity, while care is taken to avoid forcing the cement into a canal orifice. A cotton pellet, moistened with any sterile acqueous solution such as saline or a local anaesthetic will cause the cavit to set.

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 Coronal perforations may also be repaired with adhesive composite resins placed by the acid etch technique in a perfectly dry milieu. If the caries is so extensive that the lateral walls are destroyed, or if a defective restoration is in place that is loose and leaking, then the entire wall or restoration should be removed and later restored. It is important that restoration be postponed until radicular preparation has been completed. It is much easy to complete the radicular preparation through an open cavity than through an restored crown. As a matter of fact the move of the crown that is missing, the easier the radicular preparation becomes. The ultimate care is in operation of a molar tooth broken off at the gingival level. As long as an rubber dam can be placed on the tooth it need not be built up with amalgam, cement, or a copper band; having to work through a hole only complicates the endodontic procedures. In addition, if the band comes off the tooth measurements are invalidated and must be reestablished. An adequate temporary fillings can always be placed in the remaining pulp chamber. If a band must be placed, a well adapted orthodontic band is preferable.

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If enough tooth does not remain above the gingiva to place a rubber dam clamp and seal against saliva, and it is imperative that the tooth be retained, a simple gingivoplasty will establish the required crown length.

In any case this procedure is usually necessary before the tooth can be restored. In this case the occlusal cavity may be sealed and the incised gingiva protected with the placement of a putty-like periodontal dressing over the entire stump and gingiva, cotton and then a thin layer of cavity, should first cover the canal orifices. Principle IV Toilet of the cavity: All of the caries debris and necrotic material must be removed from the chamber before the radicular preparation is begun. If the calcified or metallic debris is left in the chamber and carried to the canal, it may act as an obstruction during canal enlargement. Soft debris carried from the chamber might increase the bacterial population in the canal. Coronal debris may also stain the crown, particularly in anterior teeth. Round burs are most helpful in cavity toilet. The long-blade endodontic spoon excavator is ideal for debris removal. Irrigation with NaOCl is also an excellent measure for cleansing the chamber and canals of persistent debris.

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 The chamber may finally be wiped out with cotton and a careful flush of air will eliminate the remaining debris. Air must never be aimed down the canals. Emphysema of the oral tissues has been produced by a blast of air escaping out of the apex. As previously stated toilet of the cavity makes up a significant portion of the radicular preparation. A. Radiographic apex. B. Resistance form apical stop. C. Retention form retain primary filling point. D. Convenience form. E. Outline form. Maxillary Central Incisor Average length 23.3mm Lateral canal 23% Distal curve 8% 2 mesial axial inclination. 29 lingual axial angulation. Large, angular, funnel shaped coronal preparation. Carry the preparation labially and thus nearer the central axis.

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Incisal extension allows better access for larger instruments and filling materials used in the apical third canal.

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Maxillary lateral incisor: Average length 22.8mm Lateral canal 10% Distal curve 53% 16 mesial axial inclination. 29 lingual axial angulation. Large, triangular, funnel shaped coronal preparation. Beveled extension toward incisal which carry preparation labially and nearer to central axis which allows better access to apical third of canal. Adult ovoid funnel shaped coronal preparation should be slightly skewed toward mesial to present better access to apical-distal extensive incisal bevel necessary to carry preparation in cases to central axis allowing better access to apical third. Mandibular central incisor and lateral: Average length 21.5mm. Lateral canals 2 canals, foramen 23.4% Distal curve 23% 2 mesial axial inclination 7 20 lingual axial angulation 20

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Large triangular funnel shaped preparation. Beveled extension towards incisal will carry preparation labially and reaches to central axis. Better access for instruments and filling materials to apical third of the canal.

Adult ovoid funnel shaped preparation. Beveled incisal extension lingual extension will often lead to discovery of second canal.

Maxillary canine: Average length 26.0mm. Lateral canals 24% Distal curve 32%; Labial curve 13% 6 distal axial inclination. 21 lingual axial angulation. Extensive, ovoid, funnel shaped coronal preparation long, beveled, incisal extension. Adult Extensive, ovoid, funnel shaped prep, nearly as large as for young tooth. Beveled incisal extension. Discovery by exploration of an apical labial curve calls for even greater incisal extension. Mandibular canine: Average length 25.2mm Lateral canals 9.5% Distal curve 20% 13 mesial axial inclination

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15 lingual axial angulation. Extensive, ovoid, funnel shaped coronal preparation. Beveled incisal extension.

Adult extensive, ovoid, funnel shaped prep as large as prep for young tooth. Beveled incisal extension. An apical labial curve would call for an increased extension incisally.

Maxillary first premolar: Average length 21.8mm. 2 canals 2 foramina 72%. Distal curve 37%. 10 distal axial inclination. 6 buccal axial inclination. Ovoid coronal prep need not be as long B-L as the pulp chamber. However, the outline form must be large enough to provide two filling points at the same time. Buccal and lingual walls smoothly flow to orifices. Adult ovoid coronal prep must be more extensive in B-L direction because of parallel canals. More extensive preparation allows instrumentation without interference. Maxillary second premolars:
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Average length 21mm.

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1 canal, 1 foramina 75%; 2 canal, 2 foramina 24%. Distal curve 27% Bayonet curve 20.6% 19 distal axial inclination of tooth. 9 lingual axial inclination. Ovoid preparation funnels down to ovoid mid canal. Adult ovoid preparation is prepared well to the mesial of occlusal surface, with a depth of penetration skewed towards the bayonet curvature. Skewing the cavity allows an unrestrained approach to the first curve.
Mandibular first premolar 2nd premolar 21.4mm 1 canal 1 foramin 85.5% ` 2 canals, 2 foramin 11.5% 40% 10 34

Average length 22.1mm. 1 canal, 1 foramine 73.5% 2 canals, 2 foramin 19.5%

Distal curve 35% 14 distal axial inclination of root 10 lingual axial angulation

Ovoid coronal preparation funnels down to ovoid is large enough B-L to allow passage of instruments midcanal used to enlarge and fill canal space.

Adult ovoid funnel shaped prep must be large enough B-L to allow enlarging instruments and for filling canals.

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2nd premolar adult ovoid funnel shaped coronal cavity is modest in size and skewed slightly to the mesial, allowing adequate room to fill the curved apical third.

Maxillary first molars: MB Average length Three canals 46.1% 4 canals 56.5% Five canals 2.4% Buccal curve Mesial curve Distal curve 55% 75% 17% 19.9 DB 19.4 Palatal 20.6 1 canal, 1 foramin 41.1% 2 canal 1 foramin 40$ 2 canal 2 foramin 18.9% Canals in MB root

Triangular outline form with base towards the buccal and apex toward the lingual, reflects anatomy of the pulp chamber with orifice positioned at each angle of the triangle. Both buccal and lingual walls. Slope buccally. Mesial and distal walls funnel slightly outward. The cavity is entirely within mesial half of the tooth and should be extensive enough to allow positioning of instruments and filling material, needed to enlarge and fill the canals. The orifice to an extra middle mesial canal may be found in the groove near MB canal.

Adult If an additional canal is found in MB roots, its orifice will usually be in the groove leading to palatal canal.

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Maxillary Second molars: MB Average length Three canals 54% Fused 46% Buccal curve Mesial curve Distal curve 20.2 DB 19.4 Palatal 20.8 Canals in MB root 1C, 1F 63% 2C 1F 13% 37% 54% 17% 17% 2C 2F 24%

Triangular outline form is flattened or it reflects the internal anatomy of the chamber. The DB canal orifice is nearer the center of cavity floor.

The entire preparation sharply sloper to buccal and is extensive enough to allow positioning of instruments and filling materials needed to enlarge and fill canals.

Adult- ovoid outline form reflects the internal anatomy of the pulp chamber and elongated parallelogram shape of the occlusal surface. The entire preparation slopes sharply to buccal.

Mandibular first molars:

average length 20.9 mesial and distal. Two roots 97.8% Three roots 2.2% 3 canals 64% Mesial 2C, 1F 40% 2C, 2F 59.5% Distal 1C 71.1%, 2C 28.9% 2C, 1F 61.5% 2C, 2F 38.5%

Distal curve 84% mesial, 21% distal.

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Triangular outline forms reflects anatomy of the pulp chamber. Both mesial and distal walls slope mesially. The cavity is primarily within mesial half of the tooth but is extensive enough to allow positioning of instruments and filling materials. Further exploration should determine whether a fourth canal can be found in the distal. In that case an orifice will be positioned at each angle of the rhomboid. Mandibular second molar:
Average length Mesial & distal 20.9mm Canals Mesial & 1C,1F 13%; Curvature Distal curve Bayonet Mesial Single 26% 19% M 61% 7% D 18% 6% 10% 2C,2F 38% 3% 2C,1F 49% Distal 92% 5%

Mesial curvature of distal root 10% Bayonet curve of mesial root 7% S-curve of M-L canal - 52 buccal axial inclination of roots. Triangular outline form reflects the anatomy of the pulp chamber. Both mesial and distal wall slope mesially. The cavity is primarily within the

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mesial half of the tooth but is extensive enough to allow positioning of instruments and filing materials. Further exploration should determine whether a fourth canal can be found in the distal. In that case an orifice will be found at each angle of rhomboid. C-Shaped Molar: The C-shaped molar is so named because of its cross-sectional morphology of the root and root canal. Instead of having several discrete orifices, the pulp chamber of a C-shaped molar is a single-ribbon shaped orifice with 180 degree are (or more), starting at the ML line angle and sweeping around the buccal to end at the distal aspect of the pulp chamber. Anatomic variations of C-shaped molar can be classified into 2 basic groups: 1. Those with a single ribbon like, C-shaped canal from orifice to apex. 2. Those with 3 or more distinct canals below the usual C-shape orifice. Fortunately C-shaped molar with a single swath of canal are the exception rather than the rule C-shaped canal can vary in number and shape along the length of the root with the result that debridement, obturation and restoration in this group may be unusually difficult. More common is the second type of C-shaped canal, with its discrete canals having an unusual form. The ML canal is separate and distinct from the apex, although it may be significantly shorter than MB and distal canals.

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These canals can be easily overinstrumented in C-shaped molar with single apex. MB canal can swing back and merge with distal canal sometimes to exist in single foramen or have separate portals of exit. Increased visibility with surgical operating microscope has made treatment more successful. Variations in incidence. Common in Asians and Caucasians. Japan and China 31.5% Lebanese subjects 19.1%.

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CONCLUSION: Access opening is an important step in root canal treatment and should not be neglected, as neglecting this step would lead to failure of the root canal treatment itself. Thus proper access opening will lay foundation for proper cleaning and shaping and obturation to be carried out successfully.

BIBLIOGRAPHY: 1. Endodontics Weine. 2. Endodontics Walton. 3. Endodontics Ingle. 4. Endodontics Cohen and Burns. 5. Endodontics Grossman.
6. Endodontics Stock

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