ORIFICES: KEY ROLE

TO A SUCCESS RCT

BY DRG. HENNY SUTRISMAN SP KG., MDSC.

At LaDenta Dental Clinic

Medan, 8th February 2015

ROOT CANAL THERAPY

The complete removal of all vital,

necrotic
tissue
and
microorganisms from the complex root

How ???

3
2
1

OBTURATION
AND POST
ENDODONTIC
RESTORATION

SHAPING AND CLEANING

DISINFECTION

CORONAL CAVITY
PREPARATION

Pengetahuan dan pengalaman merupakan hal yang penting

- Variasi anatomi gigi dapat dijumpai pada semua gigi.

- Pemahaman morofologi saluran akar merupakan salah
satu tahap terpenting perawatan saluran akar.

CBCT

DENTA SCAN

AKSES KAVITAS

Maxillary Mandibular
Maxillary Mandibular
Incisor
Maxillar First Molar First Molar
Incisor
y
Premola
r

OBJECTIVES OF ACCESS CAVITY

PREPARATION

Straight line
access
to apical

Locate all the

canal orifices

Conservation of
sound tooth
structure

GUIDELINES OF ACCESS CAVITY PREPRATIO

Tooth
length Internal
of
Number
of
Visualization Average
of the Likely
Anatomy
tooth (mm)
canals
Maxillary central Incisor

23.3

one

Maxillary lateral incisor

22.8

one

Mandibular central/lateral
incisor

21.5

0ne- 70%
Two- 30%

Maxillary first premolar

21.8

Two- 85%
One 9%
Three- 6%

21

One- 75%
Two-24%
Three- 1%

MB- 19.9, DB- 19.4, P20.6

Three- 4045%
Four- 5560%

Mesial- 20.9, Distal 20.9

Three- 6070%
Four 30-40%

Maxillary second premolar

Maxillary first molar

Mandibular first molar

C
Inci

Lat
In

Canin
e

1st
PM

2nd
PM

1st
Mo

2nd
Mo

3rd
Mo

C
Inci

Canin
e

2nd

1st
PM

1st

2nd

Penetration phase

Enlargement phase

Finishing and flaring phase

Errors in access cavity preparation

Gouging at
labial
surface

Missed
canal

Gouging at
distal wall

Incomplete Ledge
removal of
pulp
chamber
roof

Perforation

Under
extension
Overextens
ion

Perforation

REQUIREMENT OF ACCESS CAVITY

1.

2.

3.

Permit the removal of all the chamber

contents
Permit complete, direct vision of the floor of
the pulp chamber and canal openings
Facilitate the introduction of canal
instruments into the root canal openings

4.

5.

6.

Provide access as direct as possible to the

apical one third of the canal for both
preparation instruments and canal filling
instruments
Provide a positive support for temporary
fillings
Always have four walls

Prepare the access cavity through the

palatal / lingual surface in anterior teeth
Maxillary incisor

Initial penetration in
the center of the palatal or lingual

Round-point tapered fissure directed

perpendicular to the palatal surface
(1.0mm into enamel )

Bur parallel to the long axis

of the tooth

Bevel

Funnel the access cavity incisally

using tapered fissure

Penetrate the pulp

chamber using round bur
Feel a drop-in effect

Explore the root canal orifice

using DG 16 Probe

Remove the roof of pulp chamber

completely using round bur
in reverse stroke

Smoothen the walls using

round end tapered fissured bur
or Endo Z bur

Enlarge the canal orifice

using GG drill
in brushing motion

Irrigate the access cavity

Dry the access cavity

using cotton pellet

Straight line access

Triangular shaped access cavity

AKSES GIGI ANTERIOR

MAKSILA

5.(CONT.D)
AKSES GIGI ANTERIOR
MAKSILA

Mandibular incisor

Oval shaped access cavity

Try to locate an additional canal

lingual to the main canal

AKSES GIGI ANTERIOR

MANDIBULA

Prepare the access cavity through the

occlusal surface in posterior teeth
Access cavity preparation for premolars

Bur parallel to the long axis of t

Mark two points on the occlusal

surface (Buccal and Palatal) for
the maxillary first premolar

Initial penetration is
in the exact center of the
central groove
(Round end tapered or round bur)

Perforate the roof of the pulp chamber then move Bucco-lingually

Explore the canal

using DG 16 probe

Negotiate the canal

using endodontic files

Enlarge the canal orifices

using GG drill

Complete straight line access

Access cavity shape- Oval

Access cavity preparation for Maxillary First Molar

Distobuccal
Mesiobuccal

Distal
boundary

Mesial
boundary

Mesiopalatal

Palatal

Access should always be

mesial to the oblique ridge
(Mesial 3/5th of the crown)

Access cavity shape- Quadrilateral

Draw an outline,
mesial to oblique ridge

Angle of penetration toward the

largest canal (palatal). perforate the
pulp chamber

From mesiobuccal towards

distally and slightly palatally
in search of DB canal
DB is 2-3mm distally and palatally to MB

Mesiopalatal canal
2-3 mm palatally
from MB canal

Explore the palatal canal

using DG 16 probe

Move from palatal to buccal

in search of MB canal,
MB canal is below the MB cusp tip

AKSES GIGI POSTERIOR

MAKSILA

5.(CONT.D)
AKSES GIGI POSTERIOR
MAKSILA

Access cavity preparation for Mandibular First Molar

Mesiobuccal
Distal

Mesial
boundary

Distal
boundary
Mesiolingual

(Mesial 2/3rd of the crown)

Initial penetration is made in the

exact center of the mesial pit, with
the tapering fissure bur directed
toward the distal

Round bur to open

into the pulp chamber

Explore the distal canal using DG

16 probe and negotiate the canal
using endodontic file

Move from distal to Mesiobuccal

in search of MB canal,
MB canal is below the MB cusp tip

Dentinal Map

Move from distal to mesiolingual

Presence of four canals,
in search of ML canal,
then shape becomes
ML canal is below the ML cusp tip
Rectangular
Presence of three canals , shape is Trapezoidal

Presence of MB, ML
and Distal canals

Enlarge the canal

orifice using GG drill

 Examine of the pulp chamber floor using DG 16 probe - can

reveal clues to the location of orifices and to the type of canal
system present.
If only one canal is present, it usually is located in the center of
the access preparation, (Such canals are generally oval shaped).
If only one orifice is found and it is not in the center, then
search for another orifice on the opposite side.

AKSES GIGI POSTERIOR

MANDIBULA

The cementoenamel junction (CEJ) is the

most important anatomic landmark for
determining the location of pulp chambers
and root canal orifices.
Krasner P, Rankow HJ. Anatomy of the pulp
chamber floor. J Endod 2004;30(1):5.

Ceiling of the pulp chamber

At the level of the cementoenamel
junction in 97 percent to 98 percent of the
maxillary and mandibular molars
Deutsch AS, Musikant BL. Morphological
measurements of anatomic landmarks in human
maxillary and mandibular molar pulp chambers. J
Endod 2004;30:38890.

First law of symmetry: Except for the maxillary molars, canal orifices are

ORIFICE
LOCATION
equidistant from a line drawn in a mesiodistal direction through the pulp
chamber floor.

Second law of symmetry: Except for the maxillary molars, canal orifices lie
on a line perpendicular to a line drawn in a mesiodistal direction across the
center of the pulp chamber floor.

Krasner P, Rankow HJ: Anatomy of the pulp chamber floor. J Endod 2004;

Law of color change: The pulp chamber floor is always darker in color than
the walls.

Law of orifice location 1: The orifices of the root canals are always located
at the junction of the walls and the floor.

Law of orifice location 2: The Orifices of the root canals are located at the
angles of the floor wall junction.

Law of orifice location 3: The orifices of the root canals are always located
at the terminus of the roots developmental fusion lines.

Canal orifice

Developme
ntal fusion
lines
(Dentinal
Krasner P, Rankow Map)
HJ: Anatomy of the pulp chamber floor. J Endod 2004; 30(1

LAW OF CENTRALITY
the floor of the pulp chamber is always located in the center of the tooth at the level of the CEJ
Law of concentricity
the walls of the pulp chamber are always concentric to the external surface of the tooth at the level of the CEJ
Law of CEJ
the CEJ is the most consistent, repeatable landmark for locating the position of the pulp chamber.
Krasner P, Rankow HJ: Anatomy of the pulp chamber floor. J Endod 2004; 30(1):5.

CORONAL CAVITY PREPARATION

Factors to be considered
Assessment of tooth restorability
Presence of caries/ old restorative
material
Removal of the Remaining Carious Dentin and
Defective Restorations

1.To mechanically eliminate as many bacteria as possible

2.To eliminate the discoloured tooth structure that may
ultimately lead to staining of the crown
3.To reduce the risk of bacterial contamination and blocking
of the root canal space

50% of all molars (maxillary and

mandibular) have a fourth canal,
more than 30% of all premolars have a
third canal, and close to 25% of all
anterior
teeth
have
two
canals.
S. Kim,
S. Baek
/ Dent
Clin
N Am 2004 ;
48 :1118

Exploration of
hidden canals
at
high
magnification
MICROOPENER
ULTRASONIC

4 Saluran akar pada gigi

M1 maksila

5 Saluran akar pada gigi M1

mandibula

6 Saluran akar pada gigi

M1 mandibula
7 Saluran akar pada gigi
M1 maksila

7 Saluran akar pada gigi

M1 maksila

3 Saluran akar pada gigi P2

maksila

Molar 1 Mandibula dengan

8 orifisi

CLASSIFICATION OF ROOT CANAL SYSTEM

Weines canal configuration

ROOT CANAL CONFIGURATION

Type I (1:1)
A single canal extends from the pulp chamber to the apex
Type II (2:1)
Two separate canals leave the pulp chamber and join short of the apex to for
Type III (2:2)
Two separate, distinct canals extend from the pulp chamber to the apex
Type IV (1:2)
One canal leaves the pulp chamber and divides short of the apex into two sep
canals with separate apical foramina

Vertuccis canal Configurations (Vertucci

et al, 2005)

Gulabivala et al.s supplemental canal configurations to

those of Vertucci.

Melton et al in 1991 proposed the following classification of C-shaped canals

based on their cross-sectional shape
As in Meltons classification, there has been no clear description of the
difference between category II and III, Fan et al in 2004 modified Meltons
method into following categories.
Category I: the shape is an uninterrupted C with no separation. (C1)
Category II: the canal shape resembles a semicolon resulting from a
discontinuation of the C outline, but either angle or should be no less
than 60. (C2)
Category III: two or three separate canals are present and both angles or
, are less than 60. (C3)
Category IV: only one round or oval canal is found. (C4)
Category V: no canal lumen can be observed, usually seen near the apex.
(C5)

CLASSIFICATION OF C-SHAPED CANAL

Angles for the C2 canal,

either angle or s more than 60.
Classification of C-shaped canal configuration

Angles for the C3 canal,

both angles or , are less than 60

Type IV

C- shape Radiographic Configuration

according to Fan

Type
1

Type
2

Type
3

Thank You