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MODIFICATIONS OF

ACCESS CAVITY
PREPARATION
PRESENTED BY –
DR. SANKET HANS PANDEY
CONTENTS

 Introduction
 Traditional endodontic cavity
 Need for newer modifications
 Pericervical dentin
 CT guided endodontic access cavity
 Truss access
 Limitations of Contracted Access Opening
 Conclusion
TRADITIONAL ENDODONTIC CAVITY

 Traditional endodontic cavities are geometrically predesigned shapes.

 The outline form in a traditional endodontic cavity determines the occlusal


extent of the prepared cavity.

 The convenience form is dictated by the degree of dentin to be removed at


specific locations so as to achieve a straight-line access to the root canal
orifices.
 The extension for prevention in the endodontic cavity
involves the removal of dentin obstructions to extend the
straight-line access to the apical foramen or to the
primary curvature of the root canal.

 Employing the concept of extension for prevention


facilitates the treatment procedures and avoids
procedural errors. None the less this occurs at the
expense of crucial structural dentin, which may
compromise the biomechanical integrity of tooth.
 Conservative endodontic cavity (CEC) may improve fracture
resistance of teeth but compromise the instrumentation of canals.

 CEC promotes the controlled removal of tooth structure beyond


gaining access to canal orifices to facilitate cleaning, shaping, and
filling of root canals and to prevent procedural complications

Ingle JI. Endodontic cavity preparation. In: Ingle J, Tamber J, eds. Endodontics,
3rd ed. Philadelphia: Lea & Febiger; 1985:102–67
 Consequent removal of tooth structure, coronal to the pulp chamber, along the
chamber walls, and around canal orifices, may undermine the resistance of the tooth
to fracture under functional loads.
Endod Top 2006;13:57–83.

 Fractures and possible subsequent extraction of root-filled teeth have undermined


the confidence of dentists and patients in the long-term benefits of endodontic
treatment.

Dent Clinic North Am 2010;54:249–73.


 Recent advances in the available resources and technologies (like microscopy,
cbct, endodontic access & exploration & guide burs, niti instrumentation) have
made a significant impact on endodontic treatment procedures, allowing
minimally invasive treatment procedures such as contracted endodontic
cavities for preserving coronal and radicular tooth structure.

Recently, Clark and Khademi modified the endodontic


cavity design to minimize tooth structure removal. In
departure from the completely unroofed, coronally
divergent, straight-line access to canal curvatures, the
conservative endodontic cavity (CEC) preserves some of the
chamber roof and pericervical dentin
 Contracted endodontic cavities are considered to be an alternative to
traditional endodontic cavities in maintaining the mechanical stability and
subsequently the long-term survival and function of endodontically treated teeth.

 Since no restorative material or technique can replace the mechanical


characteristics of the lost dentin in stress-bearing areas of the tooth, treatment
steps directed toward dentin conservation are essential as the primary measure
to reinforce root-filled teeth.

Bóveda & A. Kishen. Endodontic Topics 2015, 33, 169-186


Why do we need modifications

 the long-term functional survival of initial endodontically treated


permanent teeth was reported as 97.1% after 8 years in a very large
epidemiologic survey.
J Endod 2004;30:846–50.
 coronal tooth fractures continue to remain important reasons for
post endodontic tooth repairs and extractions.

Endod Dent Traumatol 1990;6:49–55.


 A 5-year follow-up survey involving 857 randomly selected teeth with
nonsurgical root canal treatment found that 18 (28.1%) of the total 64 tooth
extractions performed by the dentists were attributed to nonspecific tooth
fractures.
J Endod 2008;34:671–4.

 An in vitro investigation found that the loss of structural tooth integrity


associated with endodontic access preparation might lead to a higher
occurrence of fractures in endodontically treated teeth

J Prosthet Dent 2003;89:


368–73.
Cavity Shapes of different teeth
with TEC and CEC
 INCISORS

TEC
CEC
PREMOLARS
MOLARS
Pericervical dentin (PCD)

 PCD is the dentin near the alveolar crest.


 While the apex of the root can be amputated, and the coronal third of the clinical crown
removed and replaced prosthetically, the dentin near the alveolar crest is irreplaceable.
 This critical zone, roughly 4 mm above the Crestal bone and extending 4 mm apical to crestal
bone, is sacred for 3 reasons: (1) ferrule, (2) fracturing, and (3) dentin tubule Orifice proximity
from inside to out.
 long-term retention of the tooth and resistance to fracturing are directly related to the
amount of residual tooth structure.
 This regional dentin is significant for the distribution of functional stresses in teeth

J Endod. 2003;29:523-528
 The emerging concept of conservative endodontic access is a shift to transform the
outline of the endodontic cavity from a traditional operator-centric design to a
scheme that focuses more on peri cervical dentin preservation.

 Contracted endodontic access prioritizes the removal of:


 -restorative material ahead of tooth structure,
 -enamel ahead of dentin, and
 -occlusal tooth structure ahead of cervical dentin

 It overlooks the traditional requirements of straight-line access and complete


unroofing of the pulp chamber while emphasizing the importance of preserving the
crucial Pericervical dentin.
 In the case of incisors, the conservation of cingulum dentin
(pericingulum dentin) is suggested to improve the functional stress
distribution in teeth.

 A contracted endodontic cavity preserves a portion of the roof


around the entire coronal aspect of the pulp chamber. This dentin is
known as dentin roof strut or soffit.
•Great White® Z Diamonds remove restorative
material including zirconia substructures
•Piranha® Diamonds to gain entrance to the pulp chamber
•Piranha® Diamonds to refine and flatten axial walls with
proper taper and finish
NINJA ACCESS OPENING ON 11
Aids to preserve dentin in
contracted endodontic cavities

Visual enhancers, such as loupes and clinical microscopes, increase the precision and efficacy of clinical
endodontics, providing detailed visualization of the tooth to be treated and allowing the clinician to conservatively
solve complex situation such as calcified teeth.
 By knowing in advance the sizes and anatomical details of the tooth
to be treated, access cavities can even be diminished to the level
where a cuspal protection is not restoratively indicated, by
maintaining the occlusal isthmus not larger than one-third of the
intercuspal distance.
 The endodontic cavity should be as small as possible while still
achieving the biological objectives of the root canal treatment and
as wide as the anatomy permits in a particular case.
 • Generally, a contracted cavity is suggested to be slightly wider
than the coronal extension of the root canal. This permits the
maintenance of some of the roof (dentin soffit) around the entire
coronal portion of the pulp chamber.
ANGLES OF ENTRY TO VARIOUS CANALS
IN ABSENCE OF STRAIGHT LINE ACCESS
CT GUIDED ENDODONTIC ACCESS
OPENING
In these cases, preparing an adequate access and identifying the
canal orifice can be challenging and may create a massive loss of
tooth structure that Is associated with a higher risk of fracture
Et al. 2006) and a high failure rate (cvek et al.
Therefore, preoperative planning is highly recommended and 3D
imaging may be a useful tool.

Templates can be produced by 3D-printing devices, based on


matched 3D surface scans with CBCT data (Kuhl et al. 2015).
Technique for CT-GEA

 Preoperative cbct images are stored as dicom files.


 3d surface scans are performed using intraoral 3d
 surface scanner(eg. iTero, Align Technology Inc.and data stored as
stl(surface tessellation language) files.
 CBCT data were uploaded into a planning software
(coDiagnosticX).

 The software allowed the creation of a virtual image of a


commercially available bur.

 In addition, a virtual sleeve for guidance is created for planning


purposes.
 The virtual bur was superimposed on each tooth with the aim of creating a
direct access to the apical third of the root canal.

 the surface scans were uploaded to the implant planning software

 Scans were matched with CBCT data by aligning the crowns of the teeth.
 Finally, a virtual template was designed by applying a tool of the software.
Information on sleeve‘s position was considered in the planning.

 Exported stl-files allowed a 3D printer to produce the templates.


 Templates were attached to the models, and their correct and reproducible fitting
was checked. Marks were set through the template sleeves to indicate the region
of access cavity.

 Enamel should be removed in the area using a diamond bur until dentine is
exposed. Then, the specific bur is used to gain access to the root canal.

 The final position was reached when the bur hit the mechanical stop of the sleeve.
Disadvantages of CT-GEA

 High price
 More time required for access cavity preparation.
 More exposure to radiation because of use full mouth CBCT and
optical surface scan.
TRUSS ACCESS

 The aim of this phase is to approach the pulp chamber through discontinuities
in the crown (caries, restorations, etc.)

Lesion-driven approach intended to take advantage of the already absent hard structures due to caries
in order to modify the approach as possible through this area and by limiting the restorative needs of
the treated tooth.
 It is important to recognize the limiting factors in this approach, which may be beyond
the operator’s control. For instance tooth position, inclination, mouth-opening
capabilities of the patient, anatomical complexity, degree of calcification, and other
patient-related factors, all of which would result in increased time required for the
endodontic treatment.
 This phase warrants considerable training and technical competency.

 By limiting the removal of hard structures at the pericervical, radicular, and apical
zones of those teeth, long-term success should improve.
IRRIGATION ON A TOOTH WITH TRUSS ACCESS
FRACTURE RESISTANCE OF TEETH
PREPARED WITH TEC AND CEC

For incisors, the mean load at fracture did not differ significantly among the 3 groups

In premolars and molars, the mean load at fracture for CEC was significantly higher than for TEC and did not
differ significantly from intact teeth.

in the TEC group, the load at fracture in premolars and molars was significantly lower (P < .05) than in
intact controls
UNTOUCHED CANAL WALL
DUE TO CONTRACTED ENDODONTIC ACCESS
VOLUME OF DENTIN REMOVED

It was statistically significantly smaller in the CEC group than in the


TEC group for all tooth types.
 Canal instrumentation efficacy was compromised in the distal
canals of molars with CEC, suggested by the larger proportion of
UCW specifically in the apical third.

 Small differences were observed between the CEC and TEC groups
in the mesial canals of molars and premolars; in incisors, the
difference was more substantial but not statistically significant.
CONCLUSION

The basis for the need of newer modification techniques for access opening derives from the
fact that an artificial restoration is of less biological and functional significance when
compared to the original healthy dentin tissue.

•Conservative endodontic cavities seem to satisfy the principles of minimally invasive


endodontics by preserving natural dentin, but newer endodontic irrigation strategies are
required before minimally invasive root canal enlargement is routinely practiced.

•Although technological advances such as CBCT imaging, operating microscopes,


and nickel-titanium instruments enable this progress, clinicians have to adapt their skills to
meet the challenge of working effectively in confined spaces.
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