Endodontic Access Flashcards by sophie rosen

To Gain Access
to the pulpal
space for:
(3)

Visualization
Instrumentation
Obturation

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To Maintain
Strength of the
tooth:
(3)

Preserve Incisal Edge
Conserve Marginal Ridges
Maintain correct Shape, Size & Position

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First: Know the Proper Outline Form: ANTERIORS
Maxillary central incisors

are triangular with the base of the triangle toward the incisal edge

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First: Know the Proper Outline Form: ANTERIORS
Maxillary lateral incisors

follow the same form but are narrower and less flared incisally

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First: Know the Proper Outline Form: ANTERIORS
Maxillary canines

also have the same general form but are closer to an oval

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MAXILLARY ANTERIORS
OUTLINE FORM

Triangular to Ovoid

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ANTERIORS
The red dots in the center of the access (penetration
points) are where you would generally expect to find the
pulp. Usually in the — mass of the root form.

center

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Mandibular central & lateral incisors are very narrow and have 2 canals —% of the time so
the access is very narrow M-D and extends further incisally

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Mandibular canines are — and similar to maxillary canine access

oval

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BEWARE: Mandibular Incisors are VERY

NARROW M-D

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BEWARE: Mandibular Incisors are VERY NARROW M-D
We must be AWARE of this to avoid

ruining the tooth by
tipping our access bur to the mesial or distal and drilling
out the side of the tooth

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We must VISUALIZE the angulation of the unseen root in
both

M-D and B-L directions

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MANDIBULAR ANTERIORS:

Triangular to oval

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Crucial to have a — understanding of
the tooth/pulp you are attempting to access

visual and spatial

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Don’t ever look for the canals with the —

bur

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Don’t expect to always feel a “—” into the
pulp chamber

drop

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You will find the — of the pulp chamber first

roof

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Make a mark on your entry bur at

7 mm.
Mark your ACCESS bur at 7 mm.
Use a permanent marker:

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IF you don’t know for certain where you are:
(3)

STOP & TAKE A RADIOGRAPH
*Have someone else take a look
*Don’t become DISORIENTATED

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Access: Maxillary Central Incisor

*Triangular access (base of
triangle at incisal)

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“Incisal compromise”

Total straight-line access on anteriors would involve access from the facial and create a weakening of the incisal edge and an esthetic issue.***

Base of triangle parallels
incisal edge with NO
gouging of surface to
incisal of base of ▲
Angles of triangle
are slightly
rounded.
M&D Marginal
Ridges are
not invaded
or weakened
About 3 mm. on all sides
of access 14
Pulp Horns and
chamber are free
of tissue and caries

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Access: Maxillary Lateral Incisor (use #2 round)
(3)

*Triangular/Oval Access
*Thinner root than central (narrower access M-D narrower pulp horns)
*“Incisal Compromise” on all anterior teeth

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Access: Maxillary Canine Use #2 or #4 round bur
(4)

*Oval access
*Canal narrower M-D than F-L
*One root (larger and longer
than lateral)
*USUALLY SINGLE CANAL
(most max. anteriors)

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Access: Mandibular Incisors
Oval access (use #2 round bur)
(5)

*Root wider F-L than M-D
*Very narrow M-D (easy to perforate to side
of root)
*One canal 60% Two canals 40%
*When two canals-mostly Type II (See
Weine)
*Cervical access will miss Lingual canal

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Mandibular lateral incisor --- % two root canals

Premolar Access: Planning for success *Type I: *Type II: *Type III: *Type IV:

one canal from pulp chamber to apex 2 canals from pulp chamber, join prior to apex 2 canals from pulp chamber to apex one canal from pulp chamber divides prior to apex (most difficult to treat)

Maxillary first premolars have a B. & a L. canal in at least ---% of cases.

85 M-D width of the access is no wider than a #4 round bur and the opening usually extends from near the tip of the buccal cusp lingually

Maxillary second premolars contain a second canal in at least ---% of cases and the access form is very similar to the first PM. If there is a single canal, it is

35 centrally located and wide from B to L.

All premolars are very easy to perforate to the mesial or distal! Use --- bur and align carefully with root angulation.

Access: Maxillary 1st Premolar ***Access always gained through the

occlusal approach on all posterior teeth.

Access: Maxillary 1st Premolar (4)

Thin Oval Access (width of #4) Thin M-D root Two canals most prevalent Canal orifices lie under respective cusp tips

Access: Maxillary 1st Premolar Two canals most prevalent --% two canals --% one canal --% three canals

85 9 6

Access: Maxillary 1st Premolar Most Common Error

Not totally unroofed

An Ideal Maxillary 1st Premolar Access: (3)

Use a #2 round bur remove pulpal roof finish with ENDO-Z bur

An Ideal Maxillary 1st Premolar Access: FINAL WIDTH OF ACCESS IS NO WIDER THAN #--- ROUND BUR

2nd maxillary premolar --- % two canals

Access: Maxillary Second Premolar Access: Slightly less F-L extension than 1st Most often Type 2 roots (---%) 3 roots very rarely If one canal found but not in center F-L, Beware Type IV, very hard to shape, clean and fill

Thin oval (width of #4) I 1 root 1 canal (75-85%); Type II, III & IV less frequently 15 -25 there are probably 2 canals

Access: Maxillary Second Premolar M-D width = Use #--- round bur to keep small

4 Round Bur 2

First: Know the Proper “Outline Form” PREMOLARS Mandibular PMs also have a very narrow --- width and access extends from 2 canals in mandibular PMs are somewhat rare and very difficult.

M-D near the tip of the buccal cusp lingually.

Beware: 2nd canals can occur in

both mandibular canals (look for 4 PDLs and/or a “fast-break” or “fuzzy” canal somewhere in the mid-root

Access: Mandibular First Premolar Access: Usually one root, 1 canal (type I), --- % Type III, --- %*** Three canals less than --- %

thin oval 73.5 19.5 1

Don’t Forget: “The Law of Color Change”

The color of the pulp chamber is always darker than the surrounding walls.

law of centrality

pulp chamber in the center of the tooth

law of concentricity

walls of the pulp cahmber are always concentric to the external surface

law of concentricity

walls of the pulp cahmber are always concentric to the external surface law of the

law of concentricity

walls of the pulp chamber are always concentric to the external surface law of the

law of the CEJ

CEJ is the most consistent landmark for locating the position of the pulp chamber

--- RCT is monumentally more difficult than anteriors and PM

MOLAR

MOLAR RCT is monumentally more difficult than anteriors and PM why? (2)

Attention to detail is much more complicated and compacted into a smaller area Many new opportunities to mess up are presented

--- mm. mark on bur***

why mark 7mm?

so you dont perforate!!!!!

OUTLINE FORM: FIRST MANDIBULAR MOLAR Some texts recommend a triangular access. However,

in view of the common probability of 2 distal canals (30%), we feel the wisest plan is to use the TRAPEZOIDAL FORM with rounded angles as shown.

OUTLINE FORM: FIRST MANDIBULAR MOLAR why TRAPEZOIDAL FORM?

The wider base of the form is to the Mesial (taking care to preserve the mesial marginal ridge) and extending only as far distally as to provide clear access to the distal canals or canal.

A missed canal is

a failed RCT

OUTLINE FORM: FIRST MANDIBULAR MOLAR Historically, a --- Access (for 3 canals) and a --- Access for 4 canals

Triangular Trapezoidal

OUTLINE FORM: FIRST MANDIBULAR MOLAR Historically, a Triangular Access (for 3 canals) and a Trapezoidal Access for 4 canals - BUT (3)

You often cannot tell if there are 3 or 4 canals in the tooth until you enter the pulp You may THINK you have 3 canals but may NOT find the DL canal until you open up the access to see. If it is a singular distal canal, it will be generally in the center of the form as illustrated and it may be wide B-L.

OUTLINE FORM: FIRST MANDIBULAR MOLAR About ---% have 2 distal canals so it is worth looking for them every time. You will most likely miss the ---

30 D-Lingual

“SYMMETRY RULE”

2-8 % VARIABLE: A --- Canal between the MB and ML Or, it could be a Totally Different animal such as this “---” canal

Middle Mesial C-Shaped

The “C-Shaped Canal” tooth contains

3 or more canals associated by an irregular network of thread- like canals and areas that are variable in size, shape and complexity and are extremely difficult to find and worse to instrument. These are largely seen in 2nd molars.

Second molars in general are considerably more difficult than 1st molars which explains why

Advanced Endo does all 2nd molars.

--- are very rarely done (Bizarre anatomy, negligible strategic value and extreme access difficulty)

Third molars

Intelligent CASE SELECTION requires strong consideration for

REFERRAL on ALL complex teeth

MAXILLARY MOLARSYOUR BIGGEST CHALLENGE :

MB2 CANAL As often as 95%

As many as ---% of Maxillary Molars have 4 canals *

This fact makes Maxillary 1st Molars far more difficult in that the MB2 canal is

minute, dangerous and very time-consuming to find and to negotiate and to shape.

If you are NOT consistently finding and successfully treating this MB2 canal, you are doing the patient a disservice and should STRONGLY CONSIDER

REFERRAL before the

Malpractice Actions begin.HERE is an ACCESS completed in the mouth:

Note how the Endo-Z bur is used to define the walls as they meet the floor of the prep. With this ACCESS, it would be EASY to do a nice OBTURATION of the canals.

If you find placing 3 files in the canals at the same time for a radiograph to be difficult . . . Endodontics is a fairly simple concept;

EXECUTION is the TRUE measure of the SKILL OF THE CLINICIAN Maxillary Molars are mechanically difficult as the MB2 canal may require exceptional skill in locating and shaping. MB2 may require as much TIME as all 3 other canals in total !

BE ACUTELY AWARE OF THESE STANDARD VARIATIONS: LOOK FOR THE MOST COMPLEX VARIATION UNTIL

YOU CAN PROVE IT IS LESS COMPLEX