)ril)-*t

\\
Cavity Preparation
FrankI. Verrucci,
IamesE,.H addix, and LeandroR. Britto

C O M F O N ET ITCSF T H E R C IOT
C A h {AL Tapering of Cavity Wolls and Evoluqtlon
5YSTEF/l of
SpaceAdequacy for o Coranol Seal
ROOT'CAruAL AzuATCIftNY MECHAruICA!-
PHASES
CFACCESS
EAVITY
ANATOFv{Y 0F TF-{EApteAL RSOT PREPARATTOiq
OBJ EC T EVAN
E SD GU T E E L IN EFSOR Ar m anr entar ia
ACCESS C,qVITY PREPARATIO Mognificatian and llluminotion
N
Objecti.res Handpieces
Guidelines Burs
Visuslizstion of the Likety lnternal Anatomy Endadonii-cExplorer,Endodontic Spoon,
#17
Evaluation af the CementaenamelJunction Operctive Explorer
and OcclusqlAnotamies Ultrasonic llnit and Tips
f>repcratian af the Access CoviS thraugh Access Cavify preparatians
the
Lingual ond Occlusal Surtaces Anteriar 4ccess Cavit:yFreparations
Remaval a{ All DefectiveRestarations Posterior Access Cavity Freparations
and
Caries before Entry into the puip Chamber CI-IAI.LET.J
C ; NG ACEESS P R EFA P.ATIO N 5
Remavol of lJnsupparted Tooth Structure
Teeth with Mictjmal or No Cllnical
Creotian af AccessCavity Wslls That erown
Do Not Heavily Restored Teeth (!ncluding
f?estrictStraight- or Direct_Line possage o Those
with Full Veneer Cnowns)
of Instrumentsto the Apica! Foramen
or Teeth with Calclfied eanals
lnitiol Cansl Curvature
Delay of Dental Dom plocement Crowded Teeth
until
Difficult Canols ltove Been tacatid Rotated Teeth
ond
Confirmed ERRORS IT"iACCESS CAVIry
PREPARATION
Location.,Floring, and Explorotion
Conol Arifices
of All Root MgSf|ioLoGYANDAeeESseAVtTY
lnspection af the pulp Chamber
PREPARATIONS
FCRIT,J
DruIilUAL TEETFI
l]sing
Mognificotion ond Adeguate Iilumiination

148
.
Th i s d r apt er is div ide d i n to e i g h t m a j o r s c a i o n s: (t)
co rrp onent sof t he ro o t c a n a l s y s te m; (2 ) ro o t cai ral
I
3 1 3 ro i nf i ( 3) anat omy o f th e a p i c a iro o t; (4 ) o b j e c ti ves
aqd guidelines for access caviw preparation, (5)
medtanicalphasesof accesscavitypreparation;(6) cf al-
iengtng accesspreparations;(7) enors in accesscavity
preparation, and (8) n-roryhology and accesscavify
preparaLionsfor individual teeth.
The hard tissue encompassingthe dental pulp can
take a i'ariefy of configurationsand shapes.A thorough
lg'iowledgeof tooth morphology, careful inrerpretaDon
of angled radiographs, and adequate accessto and
erpioraiion of the tooth's interior are prerequisitesfor
ueatnent. Magnification and illumination are indis-
pensable aids. This chapter descnbes and illustrates
tooth morphology and expiarns the techniques crucial
Fi r:. :-' l P eri api cal
radi ographs
canreveal cl uesto roo t canal
to achier.ingunobstructed direa accessto the root canal morphol ogy. A bruptdi sappearance of the l argecanalin t he
and apical foramina. Only after correct completion of mandi bul premotars
ar usuai lsi
y gni fi es
a canalbi f' urcatro n.
this pirase of tJ'rerapycan the clinician perform thor-
o u g h sh aping and c le a n i n g a n d tJ rre e -d i m e n s i o n al (3-
D) o b tur at ion.T he opt i ma l e n d o d o n ti cre s u k i s d i ff cul t the i nci denceof canalbi furcati on i n a root.r02 W he n t he
ro achieve if the accessis not properly prepared. The fostbrenhgui del i nerryas used (i .e.,di sappearance or nar _
clinician must have an understanding of the compiex- rorvi ng of a canal i mpl i es that i t di vi des
IFi g. 7_t]) , m.
ity of the root canal systemto understandthe principles result rvas failure to diagnose one third of these divi_
and problems of shaping and cleaning to determine the si ons from a si ngl eradi ographi cvi erv.E val uari ono f r he
li-ir^
aptcar
-^i-^l llmtrs ano
^^l dlmensions
-]:-
of preparations, and to root canal system is .most accuratervhen the clinician
perform m i crosurgical procedures successfully. uses information from several radiographic views
Practitionersmust have a knowiedge of the internal together ri'ith a ttrorough clinical explorarion of the
a n a to mic r elat ions hip so f te e th a n d mu s t b e a b l e to interior and exterior of the tooth.
visualize these relationships before undertaking ffi
tlS}".l" roor canaltherapyare rhor-
gndodontic therapy.Careful evaluation of hvo or more oughshap-ine"Ui..ii"Sf
u"4 .16gg of all pulp ,pu.., and com_
periapicai radiographs,exposedar different horizontal
lJ9le_,o[r!Ig of d'r-esfspacesrvith an inert filling
angulationsof the x-ray cone, is mandatory. Theseradi_ presence
rclgT: of an untreatedcanal-h-a/5E?
ographs provide important information about root reasonlor tarlure.A canal may go untreatedbecausethe
canalmorphology. The clinician must keeo in mind that clinician fails to detect it. It is e{tremely important that
the inclination of the x-ra)/rube significantly influences cl i ni ci ansuse al l t} te armamentari aat thei r di spo salt o
the ability to detect root canal ,yr1"-, present in pre_ locate and treat the entire root canal sl,stem.The com_
molar teerh. For *lample, if the horizontal angle is plexity of rie spacestiat must be accessed,shaped,
varied by .20 or'40 degrees,tie number of root canals
ci eaned,and fi l l ed i s remarkabl e.H orvever,.r.n u nd. ,
seenin rhe maxrllaryfirst and second
Dremoiarsand the the most difficult circumstances,current root canal
m a n d i bularf ir s t pr em o l a rsc o i n c j d e,u l th tf," n u mb e r of
techniqueshave an exceptionallyhigh rate of success.
ca n a l sa ct uallypr es ent.eIn 3 th e m a n d i b u l a r s e c o n dp re_ D i agnosti cmeasuresare i mportant ai ds i n the loca-
molat only the 40-degree horizontal angle correctly
tion of root canal orifices. These measures include
identifiesthe root canal morphology. The
cr"iticalimpor- .obtai ni ng mul ti pl e preueatment radi ographs,exa m ln-
tanceof a careful reading of eachradiograph
before and ing the pulp chamber floor rvith a sharp cxplorer,
during root canal therapl, is y'ell ..cognired.
As shou,n troughing grooves with ultrasonic tips, staining the
in a casereport of fir'ecanalsin a
mandlbuiar first molar, chamberfl oorw i th 1% merhyl enebl ue dye,perform ing
t h e ra d i ogr aphic appe a ra n c es i g n i fi c a n tl y
a i d e d re cog- the.sodi umhypochl ori te" champagnebubbl e,,test ( Fig.
nrti o n o f r he c om pler c a n a l rn trp h o l o g y .a 6
T h i s s tuJy 7-2), and vi sual i zi ngcanal bl eedi ng poi nrs. S equ ent ial
co n cl u d_ed t hat " any at t e m p t to d e v e l o pi e c h n i q u e sth at appl i cati on of l Zok aqueous el h1,l sn.6l rmi ne rer r a_
re q u i refe r v err adiogr ap h sru n s th e
ri s k o f m i s s i n g i n for_ aceti caci d (E D TA )and 95% ethanol (usi ng rhe S tr opko
mation rvhich ma), be significant for
the successof i rri gator fi ued w i th a 27-gauge notched i rri g at ing
Lh e ra p v . "
needl e) has been recommended for effecti vecl ea ning
However,radiographsmay not alrr,ays
determine the and dryi ng of the pul p chamber fl oor before visual
c o rre ctm or phology ,pa rti c u l a rJ yrv h e n
o n l v a b u c c o l i n- i nspecti onof the canal system.rq6
glralviqr^,'is taken. In one
studr,,790 effa(;d mandibu_ ,{n i mportant ai d for l ocari ngroor canal si s rhe de nt al
lar i n ci so r sand pr em ol a .,
.r,.r. ra d i o g ra p h e dto a s sess operati ng mi croscope (D OM), rvhi ch rvas i nrroduced
 a -::1
')

:a: :aa

pulp cha mbe rma y ai d loc at ionof a c alc if iedr oot c analor i f i c el.i n y
bub ble smay ap pe ari n t he s olut ion,indic at ingt he pos it i o no f t h e
orifice.
l:,:. '-t' The dental operatingmicroscope(DOM) has vastty
improvedthe locationand'negotiation
of canalanatomy.

|
L d^tu
r ^t - ^ t d t L^ ^d^t ^ l td l
J o...sso
\l-

Accessoryforamina
Apicalforamen
Majo ra na t om icc om ponent sof t he r oot c an a ls y s t ? m

i r{o endodont ic sto p ro u i d . e n h a n c e dl i g h ti n g a nclvi s-. effectivefor locating MB-2 canalsin maxillary molars.'t
( F r g. 7- 3) . T h e D O M e n h a n c e srh e c l i ni ci an' s Otier investigatorsdetermined that the DOM did not
'b rilt y
ability to remove dentin with great precision, thereby significantlyenhancethe ability to locate canalsbut did
mi n im iz ing pr oc e d u ra l€ rro rs .N u me ro u s s tu d i es have improve the ability to negotiate rhem.st Nevertheless,
shown that rt also significantly in-rprovesthe practi- most cliniciansv'ould agreethat the DOM makes canals
ti o ner ' s abilif y t o l o c a te a n d n e g o ti a te c a n al s. For easi er to l ocate by magri fi Ti ng and i l l umi n at ing *r e
e xam ple, t he num b e r o f s e c o n d m e s i o b u c c a l (MB -2) groovesi n the pul pal fl oor and by di sti nguishingr he
canals identified in ma-rrllary molars increased from color differencesof the dentin of the floor and walls.27
517ou'ith the naked e;'e to 820,,0 rvith the microscope.a
In a not her s t udy ,4 1 .3 % o f MB -2 c a n a l su ' e re i d enti fi ed
when magnif ing loupes lvere used, and 93.7o/ot^tere e0ftrrPS[*EF"{TS
#F THE RSST
i d e n t if iedwhen t h e D O N 4rv a su s e d .' 3 rO th e r c l i ni ci ans EA[-{AI.SYSTEM
have noted that use of the DOM imDrovesthe detection
of MB-2 canals to more than g06tojn maxrllary first the dentin rvhere is hou
mo l ar s and 60% i n m a -ri l l a rys e c o n d mo l a rs .' 5.r,6 All . The outlineof
th e s e s t udiesdem o n s tl a teth a t rn a g n i fi c a ti o na nd i l l u- ru
ontour ol Lne
mi n at ion ar e ess e n ti a l c o mp o n e n ts o f ro o t canal
og lc apn&
therapy. ln contrast, one group of investigatorsdeter- pathosis,and occlusionall modifo irs dimensions
mi n ed t hat dent a l i o u p e s a n d rh e D O M u ' e re equal l y tJrroueh
thc oroduoionof secondarv
andterl!]qry
denrin
 -r
)

-{3
'$'
J
F

" 't . ', ''l

A c c e s s o rcya n a l so p g i n t h r e ed i s t i n c tp a t t e r n si n th e
mandibularf irst molars.A, In Qo/o)asinglefurcalioncanale.xlends
: Ma nd iblla rfir s t m olars howinga f ur c at ionc ana l( F C
iir. -' f r o m t h e p u l p c h a m b e rt o t h e i n t r a r a d i c u l ar re g i o n .B , l n 2 3 a /aa
crrows)- Kl- Ro otca na l;P Q pulp c ham berf loor ;F, f ur c at ion . l a t e r a lc a n a le x t e n d sf r o m t h e c o r o n a lt h i r d o f a m a j o r r o ot ca n a l
.'olr,dl*-* to the furcationregion (B0o/o extendfrom the distalroot canal) C,
A b o u t l O o / oh a v eb o t h l a t e r a al n d f u r c a t i o nc a n a l s . I
and cel].enllrq lhg-raol-!3w
ttvo__plrttgll::-rhe pulP chamber, located tn th9-
'-a+aqL
th-PulP orroot t
inffind u 'h i r h l r e c o n r e q r h e n r r l n c h a m b e r f l o o r .
: : , : : : j -s \ v , v u rP u l q . | rv
l n m a nd i b u -
l ar mol arsJthcse canal soccur i n thrce d j i tj nct pa t t em s-
GZj*-t bles 7-1 and 7'2 presentthe incidenceof
furcation canals for each toot.h.
A ccordi ng to the fi ndi ngs of scanni ng eleclr on
mi croscop;' , the di ameter of furcati on opel .r ingsin
mandi br-rl armol ars vari es from 4 to 720 um."' The
number of furcati on canal srangesfrom none to m oie
than 20 per speci men. Forami na on both the pulp
chamber floor and the frircation surfacelvere found in
cl e a n ingpr oc edur esb e c a u s eth e y a re tl o t e v i d e n t on a 36% of ma-xillaryfirst n-rolars,12 o/aof nla,rillarysecond
sta n d a r df ac ial r adio g ra p h .Al i g l e d v i e w s a re n e c essary mol ars, 3)a/oo{ mandi br.tl .rrfi rst mol ars. and 2 4ah a{
to d e ter m ine t heir pr e s e n c ed, i re c ti o n , a n d s e v e d ty.A rrandibular second molars (Frg.Z -l). Mandibular teeth
l- .
-1 nvd,.rr
LUI Lu l
1rC d-I I-lc.ly' uc d" <-r. jcd l l a l c u rv e o f th e e n ti re c a nal or have a higher incidence of foramina involving both the
a sh a r p c ur y at ur ene, i t tl te a p e x .D o u b l e S s l ta p e dcanal pulp charnber floor and the furcation surface (56%)
curyatur€salso can occr-ir.In most casesthe number of than do maxillary teeth (aS%).r/No relationship was
found benveenthe incidenceof iccessoryforamina and
horverrer,an the occurrenceof pulp chamber calcificationor the dis-
tarce frorri the chamber floor to the furcarion. Radi-
osraohsl ai l ed to demonst-rate tl te D resenceof frjiat lon
and lateral canals in the coronal porlion of these roots.
l n one strrdy,Te pul p chamber fl oor of 200 permanent
molars in a Turkish population rvas stained rvith 0 5%
basi c fuschi an dy..tt P atent furcal i on canals wer e
detected i n 24ok of maxl l ary and mandrbular f ir st
mol ars,2Ookof mandi bul ar secondmol ars, and 16% of
oel maxi l l an' secondmol ars.Thesecanal smay be th e cause
cally tltey are avenues of pri mary endodonti c l esi onsi n the furcati onso f m ul-
f";1h"ffi pLl l P t o ti rooted teeth (Fi g.7 8).

n .aat r ot c , r n. t l:r n r;' ,rl s oq c c u I ifurcationor

tri fu rc at ion of r lul ti ro o te d t€
Fig.7 5). Fur
ry-0.0J=
s&H&-&sryguY
**:-:*_ --- ---
ca i i cn c an. r lsf or r n . r sr r? i l l t o T -i l rec n l i T p i n e n t o f peri Together rvith diagnosis and treatnent planning a
o d o rr t al$- es s elsdun n g rh e fi s i o n o i th e d i a p h r agm,
Canals8'
7'acTe556[
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F, i A, Electronp hot om ic r ogr aph
of t he pulp c ham be rf l o o r o f a m a n d i b u l a rf i r s t m o l a r .M u l t i p l ea c c e s s o rfyo r a m i n ac a n b e se e n ,
ran3ingfrom 20 to l4O pm (x20),B, Electronphotomicrograph of the furcationsurfaceo f a m a n d i b u l afri r s tm o l a r .M u l t i p l ea c c e s s o ry fo r a m -
ina can be se eno n th e furcationsurface(>'30)(D, distalcanal;M, mesialcanals).

A B
' : ' ,. : ' :,:. A, Preo pe rati vreadiogr aph
of a m andibularf ir s tm o l a rs h o w i n gf u r c a t i o na n d p e r i r a d i c u l ar ar d i o l u c e n c i eBs ,. O n e y e a rf o ll o w - u p
radiograph showingsignificanthealing.(CourtesyDr. RoedS. Kasem,Cleirwoter,FL.)

ca n a l g e om et r y bef or e s h a p i n g a n d c l e a n i n g h a d .r often enough to be consi derednornral . ' fhe fi rst pr e- '

greatereffecton the charrgesti.rt occurreddr.rrrngprepa- mol ar i n Fi g. 7-g, A i s a good exarnpl e of complex
ra ti o n than t he ins t r ume l tta tio n te c h n i q n e si.la 'rr6 anatomy. The extra root i s not obvi ous i n a nor m al
From the early u'ork of Hess and Zurcher60to the radi ogr,rpl r(Fi g 7 !, B ). fi g 7- i 0 sl rorvsa crossse ct ion
mo st re c enls t udies r r ' 5 5 .6 d 3e ,' m
ri o n s tra ti n sth e .l l )a tol l ti c of a si mi l ar tooth. Thi s roofi has a fi ne, ri bbon-sh aped
c o mp l e xit iesof t - her oo t c tn ,tl s 1 r5 1 q 1i tn ,h a s l o rrg b c cn canal s1' stenri nsteadof trvo di sti nct canal s.B oth t hese
esta b l i s hed t hat a r oot w i th a ta p e ri n gc a n a l a n d a s i ngl e teeth present chai l engesfor shapi .ng,cl eani ng and
foremen is the exceptionrather than r,henrle. lnvesrig;r- obtu r;rti on.
t o rs h a ve s hor v n m ult i p l e fl o ra m i n a ,a d d i ti o n rrlc a n al s, f----t
l heLl l nrcr;nIrrrrrstbe famj ]j rr rvi l h rhe vari ouspat h-
f i n s, d elt as , int er c ana l c o n n e c ti o n s , l o o p s , C s h a p ed ,.,-
r \ ,. u v ( \- .- *. - l r^ ( r r r a n < r o rl h e..-a^-o a r . rTFl r g o u l o c a n a l w ste m
o'\ J i'.^,
ca n a l s, and f ur c at ion a u d l a te ra l c a n a l s rn n tost is comple-r, - - ^.^
and canalsmarffi
' 'L

te e th .1 06' x ; ' r 3e' ' t u eq u e n tl r,,

Cons i n rre a ti n ge a c hto o th t he \\ erne ' catcgonl ed tl re root canal sysl erns l n any r oot
,:-- !r------:--1---

c l i n i ci a n m us t as s um e th a t c o n rp l e r J n a to rrrv o c curs i nto four basi cqpes. V ertuccjq ol ,' ' n usi ng cl earedt eet lr
 j€lae*iiH

,., A M andibular f ir s tpr em olarwit h t hr ee

;-^
lrom the mai n c analc r eat e separaterootstrifurcating
a c onf igur at ion at midroot.B,
t hat is very difficult ro views'
smatr
Preparea n d o b t u r a t e#*::;::Hlrthree canars
diverg-

Roo tse c t ionof a pr em olar

. u;u r ,yu .r. s howinga r ibbo n - s h a p e d

r oot c a n a l 5\'Stems
h a d b e e n s ta i n edrvi th
dy e, fo u n d ant
c o n rp l er canal
rcen tih
c an b e
orts (Fig 7_l-i
\--aIH A singieL(
canal
-- " '^ ,b ,. crrencls
1r t.lt C\Iel-
, . _ q r*_ fionr the pr-ilp
to rhe apar
- - f * ' \ (1)
r
- T-_t:?I:er
.vq e II: Trr.o '/'
L .'
- ,,, co^ lla( J n, t ls
r,,vr(lrat,
r.:;-
_. l e a i ' eth e
- - t / L, r c r r L
pulp chamber
and y oin s hon o f rf
..tcn p Px to fo rm
/(2
r r\
1) one canai
 TypeI Type ll T y p el l l

3 A On ec a n aal t a p e x
#

Type lV Type V TYPevl

&&
TypeV l l TypeVlll

u
.zJ
l w o c an alsa t a pe x C Threecanalsat apex I
J
Diag ramma t ic s n alconfi gurati ons.
of V e rtu c c ci 'a
r epr es ent at ion

se co n d m olar s . : r T he d i ffe re n c e sa re m o s t l i k e l y the

re su l t of v ar iat ions of p o p u l a ti o n s i n th e n v o s tu di es.
Aro th e r gr oup s t udie d i 0 0 m a n d i b u l a r a n te ri o r te eth
a n d l o u r r d n\ 7ol] er v r o o t c a n a l fy p e s .o In
s o n e c o n fi gu-
ra ti o n , t \ v o s €par at ec a n a l s e x e n d e d fro m th e p ul p
chamber to midroot, rvhere the lingual canai divided
i n to h {o; all t } r r eec an a l s j o i n e d i n th e a p i c a l th i rd of
th e ro o t and ex it ed as o n e c a n a l (F i g . 7 -I2 ,Ie ft).l n ttre
o th e r conf igur at ion,o n e c a n a l l e ft rh e p u l p c h a mber,
di vi d e d int o t wo in t h e m i d d l e th i rd o f tl -rero o t, then
re j o i n edt o f or m one ca n a l ,rv h i c h a g a i ns p l rt a n d e -ri ted
as tiree separatecanalsrvith separateforamina (Fig. Z-
12, right). Another set of variants\\,asfirst observedin
th e ma n dibr r larnr olar so f Bu rme s es tu d y s u b j e c ts t; hi s
stu d y rev ealed s ev en a d d rtro n a l c a n a l c o n fi g u ra t i ons
(Fi g .7 -1 3) 55T hes einc l u d e rh re ec a n a l sj o i n i n g i n ro one .AB
o r two c anals ;nv o c an a l s s e p a ra ti n gi n to th re e c a nal s; t:g. ' ;" ; .;-
D i agrammatirepresentati
c on
of K artat and
l l 'o ca n alsjoining, r e d i v i d i n g i n to n v o , a r-rdte rm i nat- Y ani kogl u' s confi gurati ons.
canal
L Itg a s one c anal; f ou r c a n a l s j o i n i n g i n to n v o ; four
ca n a l s e r r ending f r om o ri fi c e to a p a x ; a n d fi r' e c a n al s
jo i n i n g int o f our at t h e tp e x . A n o th e r s tu d y e v a l u ated both gender and ethni c ori gi n shoul d be consi de r edin
ge n d e r- s pec if ic r oot c a n a l c o n fi g u ra ti o n si n 2 8 0 0 te eth the preoperativeevaluation for root canal therapy.
ii -r a Tur k is h populat i o n .,' , Of th e s e s p e c i me n s 9 9% o In addi ti on to i n vi tro studi es,a l argenumber o f case
rve rei d e nt ic alt o t hos e i n th e V e rtu c c ci l a s s i fi c a ti o nThe
. reports published over the past rwo decades have
re ma i n i ng lV o ( 36 t e e th ) re p re s e n re di 4 a d d i ti o nal described a variety of complex canal configurations.
ca n a l m or phologies ,u ' h i c h o c c u rre dtw i c e a s o fte n i n S ome of these reports are l i sted i n Tabl es 7-B l o 7- 27.
m a n d i bular t eet h.T hes ea u rh o rsc o n c l u d e dth a t g e nder S ome authors have been cri ti cal of casestudi esrepof i-
p l a ,vsa r ole in det er m i n i n g c a n a l mo rp h o l o g y a n d i_hat ing "freak" casesthought to be rare.'" Horvever,reports
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 TypeI Type ll
(3 -1
) Typelll
(3-2) TypelV
(2-3) (2,12.1)

TypeVl
(4-2)
ru
Type Vl
T y p eV t l
(4)
Dia gra m m at ic
(s 4)
r epr es ent at ion
of c ur abiv ar a n d c o w o r k e r s , s u p p r e m e n t a r
c a n a lc o n f i g u r a t i o n s .

or complex anatomy liom

>-W ry,1 dti-\ ,:\ <*-
-Ltr-
e!-Jl;sus
'to both in vitro and in vivo
invesri.qationsse€m b.eincreari"g ifri emphasizes
rJ-readr ge r lr at it i s
reature
i? r,;l#il::r;.'J::?::,
""" 'n anatomic
Specific
r)?esof canai moqphof
ogyofp.ur to occur
raci,af
]i.l:l:l
:T
I l'I;o'J$n'j:ffi qouls. Forerampte,
compared rvith

;! i:
(3 2 .8o/ o
ii:': i,:r*:ruli*,
::
v er s us 13J % ) a n d ti e n r." i l i " f
s e c o ndpre_
mo l a r ( 7. 9% v er s u s ,l g % o ;.,,, " ,l ,,
,n u a J i " ,i o p u ,i .n* of
Asian descent have dilferent
p"r.*,.S;r- of .urrul .o.,_
figurationsthan *rose ."po.t.d
in studj-esdominated
ca u cas ian and A f r ic a n p o p u l a ti o n s .r6 4 .r6 6 ,,;0 by
recognrzed elhnic va.rjant o 4 e rvel l _
is the higher incidence
si n g l e - r oot edand C_ s h a p e c t of
m a n d i b u j a r ,..o .,a mol ars
i n.Asianscomp ared
wirh ottrer f ;o;il;;,0
this.is not alrval,stlre case; Howe'e,
tie occurrena"of n"o canals
i' the
mesiobuccal
roor of *otu^ i,.
lapanese is similarro"r;ii;;;;,.it
parienrs tharJJr..lt.a for other.
ethni.cgroups.,,!Aj rhis
information ;;k"r',a clear
ti e cl inic ian is c onf r crn te d tiat
d a i l y rv i th h i g h l y c o mpl ex
a n , r,: _i. k r ^ - ^^.

,w u, c r ur auon, o t o n h c e s
rc.5 -^"'" a i td to ,h " 8 6 ._ d S g g l
:iffirl:'illt-]l::'toiG-or
-T6ffid i' p,.,.n,,it
tLusuary is
usuarryIs
in Lhecenler.r,r.. J1"". pieparation.
crifices,particularlv;2xt:::t -:^:::l:' All such

iri i,1."
t+)f
r',;il .;;.ii$#.ii,ll';,1
cr.i
if onlyoneonficeis ftund
i,'i ff.ilrl;:;i
,ra i, ir,-, in rhecenrer

,:-.: J . . . - - - - * - % ____

- E- - - - - - - - ---- _
' _
 izing this configuratiolt as a lorver case letter h. The
, b u cca l c anai, i- st ie s tra i g h t-l i n ep o rri o n o f rh e h ; * re
I Iingual canal existsabout midroot at a sharp angJefrorn
, dre'buccal .canal. @tion of the
' accessto acnreveunobstructed passag,e oflnstrumEiG
into the iingual

AN4IqI4I!F rFtEAPreArRoor
The classicconcept of apical root anatomy is based on
*rree anatomic and histologic landmarks in the apical
region of a root: the apical consulcrion (AC), the fhe CDJ is the ooint il the cq,q4.rvhere.cementum]
I
cenrentodentinal jLrncrion (CDl), and the apical
foramen (AF). Kuttler's description of the anaromy of
,tt@,*n.r.ou,ourr'... l
p=I9!g iaLl:I yg$ql T!9rocariqn .TG-e-CDf
rn"ffie(
roorcanTfv.rriAi
cofiA3rally_n-g,"JElllyi;;af ii: tLr.C

'f
t--
me aC, oiirinoiapical diametet ttre canal
T-
as it appToachesrhe af, oiffior api.-ulatunr._
J-) ::osjr
Slll^r:space bcrween the majorana minor diamerers
g|t ut.o"gl described-as
funnelshapedor hyperbolicpras
na\lng t_t-re
shapeol a moming glory.iThe fi=eEffiancr-
benveenthe major rnd minoiapic:ETam-ei€rsls-Ol
/
I
,{

funnel or crater,that differentiates

the terminationof
the cementalcanal from the axteriorsurface
of the
root."'o&g diameterof the foramenrvas502 pm
in
i4iua stffi
of rhe AF
r4/rurag_e.
i.'rJycompanson,Lhese
sizesarelargerthan the
r;-, .r cross-secti onal
di ameter of #50 and #60 endodonr ic
nnffirific
,''1|rin,t,,,#ff.' #:JH:ff"J[:"J
:f#,'j,iJ
[1^L
:1ffi
:
rt'iih
the tip to buccalwhen tryingtJ f"..t" if-l"-UJccal
fte tip is placedtowardthe"palrt.," .rf i","
canal.A ru fuoffs.to3loTil-f rhis
Lr the patatal vanation is more marke@men_
;;;A
tum apposition. Studies have shorvn
thai the ,qI
dua\ roa\ = <lvot\ oyi[r'cq-

r
I
I

DM

'-'" \
J ..:i'j
.--r4li .'. .,r:--:r..,.
,,r,,,:..i:i"
1

(- i AB
Lfp A' ln a mandibularsecondmolarwith
t n e mesic distal two canals,both orificesare in the mesiodistal
't midlin e'a s ear c hs houldbe , nua. t o, anot h! r ; . ; . | '; ; ; ; . midline.B, lf two orificesare not directly
o p p o s i t es i d e u s i n gK r a s n ear n d R a n k o w , lsa w s
o f a n a t om v.
 coi nri deq,.i rvi'tli tlr the
r api rni cal
calroot ve \/efi €xi n \7a/o
rtex | 7a/o\o 460/
46% 0ot
cases. *
The l ocati on and di ameter of the C D J dif f ei f iom
those of the AF in ma-nllaryanteilor teelh.r20 The erlen-
si on of cenrentumfrom the A F i nto the root ca naldif f er s
consi derabi y,evenw hen opP osi tecanal \val ls ar e com -
nared C pn-rpnt.mrpachesthe same l evel on all canal
walls in only 5ozir of cases.The greatester1ensiongener-
.11.,
dr/ ^--,-.
u LLur ) ^nI u t c .^,tcave
vl
+ kn L vl S i de of the C analcur vaf ule.
Thi s vari abi l i tyconfi rmsthat the C D J and th e AC gen'
eral l v are not i n the sameareaand that rhe CD] should
be consi deredj ust a vanabl ej uncti on at rvhi ch nvo his-
tologic tissuesmeet in the root canal. The diameter of
A the canal at the CDI varied considerably it rvas deter-
nri ned to be 353.2 i rm for the central i nci so r s,292. 25
pm for ti e l ateral i nci sors, and 298 )6 pLm f cr i- he
cani nes.r' These 0 measuresapproxi matet-hes ize of #30
B to #35 endodonti cfi l es.
In ma-l i l l aryanteri or teeth, the root apex and m ain
ii: :,{.;-; .. A, Mes ialv iew of a m andibularpr em olarw i t h a V e r -
The lingualc anals ePa r a t efsr o m
tucci type V can alconf igur at ion. A -Fcoi nci dedi n i 6.7 % oof exami nedcenuali n cisor sand
the main can ala t n ear lya r ight angle.B, This anat om yr e q u i r e s cani nesand i n 6.7oko{ l ateral i nci sors.t'B ot h t he r oot
w ide nin gof acce ssin a lingualdir ec t iont o ac hiev est r a i g h t - l i n e aoexand the A F of the centrali .nci sorsand caninesr ver e
accessto th e ling ua lc anal.Thiss houldbe done us ingt h e D O M .
di spl aceddi stol abi al l y,rvhereasthose of the l a t er alinci-
sors w ere di spl aceddi srol i ngurl l y.Tl re pcrpendicular
distance from the root apex to the AC and both
mesi odi staland l abi ol i ngualroot canaldi ane t er s at t l- r e
A C are show n i n Tabl e 7-5. The l abi ol i ngua l dianlet er
i n al l maxrl l aryanteri orteethi s approxi mate ly0. 05 m m
l arger rhan tl .remesi odi staldi arneter.Thi s h as def init e
i mpl i cari ons for shapi ng and cl eani ng p r o( edur es
herarrseonl v the di ameter i s evident or - t
-esi odi stal
radi ographs.
S canni ngel ecuonmi croscopyhas beenusedt o det er -
mi ne the number and si ze of mai n api cal f or ar nina,
their distancefrom the anatomic apej{,and the size of
accessory forami na.' o'In one study,more than one m ajn
foramen u'as found in all teeth exceptthe palatel root
^r irt.nrtJty
wr -^" ;rr--' -' ^r' -' rnd the di stal root of rn andibular
iiluldiJ.

molars. No main foramen r,vasseeuitt 24o/oof ma-l1lary

nremol ars tnd .--.-
r.-....
)6a/ouLr *llldnlildly
. :rl --' ;' ' ^:.^-. The m esial
lllti)ulJ

pre-
rootsof mandibularmolars(50%),the ma-xrllary
Minorapical
diameter molars (48.3%),and the mesial roots of marilary
mnl rrq (A l 7o/"\ hed rhp hi pl rpc.r nprr.pnt,i pp oF mrrl ti nl e
"'"]l'r'' "'
ir^i^-
tvt4)vt d^ -Ptvo
i^ ^ l l mai n forarni na.Thi s fi ndi ng i s consi stentrvit h obsen'a-
diam et e r
ti ons that bl unted roots usuai l y have more lhan one
root canal . The mean val ues for the si ze of t he m ain
lri'. r - I 1 Mo rph ology of t he r oot apex .Fr omit s or if i c et h e c a n a l foramen are l i sted i n Tabl e 7-6. S i zesranged f r om 210
or m inor apic aldiam e t e r w
tape rsto th e a picalc ons t r ic t ion, , hich Fm foi fi e maxi l l arypremol arsro 392;rm for t he dist al
gen era llyis co nside r ed
t he nar r or r v es
par
t i of t he c ana l .F r o mt h i s
roots of the n-randi bul armol ars.
pointthe ca na lwide nsas it ex it st he r oot at t he apic alfo r a m e n o ,r
ma jor a picald iame t er The
. s pac ebet weent he m inor a n d m a j o r
A l..'t*
...D 1 ,i srnr rnq of tpeth l east one accessor y
apica ld iame tersis funnels haped. foramen. The maxilla ad tl'remost and the
l :roect ecrFti i iJFanvalue,5J.a pm-l-irid
rrruJL LUrUPllLdtcu -.--l:^^,-r - ^ , : a l morphol ogi c m akeup.The
dyl(

-l r l^d l^tu rl u;r l - , , r r l d l . - ^Pt!tl

- .l u-l d i J . t ^ - l h a d stri krngl ysi mi l ar char act €r -

i R eferences
19,53, 54, I l Z 156,and l 6l
ETH MM
T4ESIODISTAL N,lN4
LABIOI-INCUAL \,TR]-ICAL MI4
']traI l n clsor 037 4.428 0 E63
erali ncisor 4307 0 369 a 825
-:^^
llt lc 0 J t5 0.375 r0l

Mb;ani T. Ohno N, l.lakamura

H: Anatomical anteriorteeth,J Endodon)8(1):344'41,)992
siudyof the rootapexin the maxillary

ETH I1EANVALUES(U)
rn ci so r s
x i llary 289.4
ndibul airt'rcis or s 2 6 2 .5
p re mo l ar s
x i llary 210
n dibul apr re molar s 268.25
mo l a rs
x i llary
)alatal 298
,4esiobuccal 235.05
)istobuccal 2 3 2 .2
ndibu l amo r l ar s t ,:.. I F i n et u b u l e sa n d m i c r o b r a n c h ecsa n b e s e e n i n t h e
/ e sial 251.5
apicalpartof the root.(FronMjorlA,Nardohl/ ArchOralBtol4l:4A1,
lrslal 392
t ee6.)
\4orfisA, Sylaras5N, Ceorgopoulou M, Kemani i..4,Prountzos F: Study of the
of human permanent teeth with the use of a s.;nning electron microscope,
urg arol Med Orol Palhol Oral Radiol Endodon 77(2):172-6, 1994.
\ras presenl l ess than hrl f the ti nte, parti cu)arl yw hcn
api cal root resorpti on rnd peri radi cul arpar,hosi rvere s
The
factors.3' ' 16' ' 16' api cal root canal often i s taperedor
r74
). / 4, P
t -^ < . i h l p
v)),urL
ra d
rL rc^n
)u tr r^rh
r'i l y ', l'^U^r
Ut (.^- "1
dlldl lh^..-
UlLldPy. tttdy f"i1
- ' ,'
tdtL w al l s are paral l el to each other or the canal has mul ti -
r em o l a r te e t h.
he m o rp h o l ogy of t he api c a l fo o t v a ri e s tre m e n -
- r,, . .L:fL tir--I,,,r
)ly lLluucJ rl u rrr(l u u J d LL( ) ) uly -^ -^
Ldr r dr1 o re a so F
Jr-..l
,--l -^^ ^:.^ ^r +^- L^- r
r- P
, i^rlurl
- dilu rcP d r(uJ -^-^-,:^- . l,
r()u l P rl ur dLr dLr l( u, (:m bgd-

a nd f,re ep u l p s t ones ;and v a ry i n ga m o u n ts o f i n e g -

. . -. t^-- t^^ .:.. .S .r, n -:-^-- r - ...:- - t .,- t,llgS
) c LUlr -u d l y u (l ttl l l . f l i l l l d ly u( lr Lr r r dl iuur afg

Ld less often than in the coronal dentin and are S..u.,r.-ibciirig tlre Ae;ird ,tr is difficult clinicallr',
e or l e ss i rregular in dir ecri o n a n d d e n s i ry .S o m e some reseJrcl rcrs contend that the radi ographi caper
i , +reco n rn let elv dev oid o f tu b u i e s . F i n e tu b u l a r i s a more rei i abl e referencepoi nt.rsTThese authors
c hes( 1 0 0 to 700 rm : ^ Uldll
r r "r m lll
r i--l ( L ( l J -+ --\ + 1 -^I-,^
+ 45_ recommendthat root canal procedurestermi nateat or
uldL ul, 'a t a

ee an p l e to r he m ain t ubu l e s a n d m i c ro b ra n c h e s 3 mm frorn the r.rdi ographi capex, dependi ng on the

10 2 0 0 mm in diam et er ) th a t ru n a t a 9 O -d e g re e pul pal di agnosi s.For vi tal cases,cl i i -ri caland bi ol ogrc
e t o th e ma i n t ubules ar e o fte n p re s e n t(F i g . 7 -1 8 ). evi dencei ndi catesthi ; fauorabi e-poi ntto ternri nate
variablestructurein the apical region pres€ntschal- rfre* py i l 7 to i mtn short of tl re ri ai ogrl pfi -.rper.ar"
ff__-___ :_1'----__.--
r s f o r ro o l c anal t her apy.O b tu ra ti o n te c h n i q u e s lnls leavesan aplcal pulp stun-rp,rvhich pr-eve-nts-Exru.
r elv o n th e npnpt r ; r t ionof a d h e s i v e si n to d e n ti n a l .i nn nf i..^......".o,...,..o.
ni rrti no fi l i i no m:tpri .rl q i ntn l l rp' --:-^ r:-"1 -
- P(lll(r(uLul.ll
lo c
t c) llld)
- -',
,.nt
llu t
n rn r-i rl o ." crp
PI U\ I UC
<c6 rl
) u\ . cpr lino in 1lp
uri
.^i."1
dPlldl ti ssues.W i th pul p necrosi s,bacteri aand thei r byprod-
rn. Therefore the formation of a hybrid layer may ucts may be present i n the api cal root canal , rvhi ch
l lrc drl
;-,^^ #- - , - , r Wnfr du
rrrlPUjtd ljL aldl L Jh/ \ Le s j reJs) JvL ( q
l t l Jl p msu s e d
jn coul d j eopardi zeheal i ng. S tudi es have sho* ' n that, i n
PdlL

rpica lro o t canai. *rese cases,a better sllccess rate is achieved rvhei'r
rns i d e r.rb l ec ont r ov er q'exi s tso re r th e e ra c t te rm i - therapy ends at or i vi tl ' ri n 2 nl m of the radi ographi c
rn po i n t fo r r oot c anal t lr e ra p y C . l i n i c a l d e te rm rn a - ?pgq.;o:" \trhen tJrerapy ended sl rort o[ the 2 nrm poi ni
-. -ar
^l .t;r € - .,t, L :St. T h g
^ f-^;-
\rr . -l
dpr\dl \dlr -^.-l-^t^-,:"
irrulpllutuS)/ l) ullllLUtt -,
dL ul or exendcd past the radi ographi capal the success rate
r nc e o f a n A C m ay be m o re c o n c e p tu a lth a n re a l . dedi ned by 20o/o.For retreatmei l tcases,therap,vshoul d
al s tu d i e shav er epor t ed t ha t a tra d i ti o n a ls i n g l eAC exend to or pref€rabl y 1 to 2 i l i m short of the radi -
 vs'i,l ,, i c ; n' ^ x l o nte VCItl cr \' .r e \le liSio n o f ittctr utrcnt$ i l l ary fi i st mol ars rvi ti tl ' reD 0 di arneterof endodont ic
^ nrtr f
:iAFII.rg-m aterials i ir to th e peli rad i ctrI ar tissues. i nstrunrerrts.os E val uati on of the root canal diam et er
*@
evilhatedapicaland peri- shot'ed that a circular shape (the trvo diameters rvere
ra dic ulart is s uesaf te rro o t c a n a lth c ra p )'c o n c l u dedthat equal ) predomi natedi n the pal atal and MB -2 canals;a
-
L h em os t f av or ab l ep ro g n o s i stv a so b ta i n e d rv h gn pro- fl at shape (tl i e l argerdi ametere.rceeded the smaJlerby
ceduresrvereterminated at the AC, and the rvorst prog- more than the radi us) occurredmost often i n t he m ain
rros isr v aspr oduc e db y trPd tn re l rt th a t c rre n d e dbel ond mesi obuccal(N 4B -1'canal ) ; and both ci rcul ar and f l. r t
30'r?t Proceduresterminated more than 2 nm shapesrvere found i n the di stobuccalcanal . Flat and
tl.reAC.;7
from the AC had the second rrorst prognosis. Tl'rese ribbon-shaped canals persistednear the apex even in
findings occurred rrrth vital and necrotic tissue and elderly patients and rnainly in tl're lr4B-1 canal. Tl-ris
rvhen bacteria were present beyond the AF. Sealer or fi ndi ng w as bel i evedto ari sefrom concentri cnar r oiving
gutta-percha (or both) in the periradicular tissues, of nbbon-shaped canai s,pri ri ari l y al ong the sm aller
lateral canals,and apical ramificationsalrvayscauseda di ameter Oval canal snsserved nrai nl y al ong the lar ger
severeinflammaton' reaclioru Horvever ttre authors of diameter and tended to become more circular. The
th e s t udic sac k now l e d g e rl red i ffl c u l ryo f i o c a ti n gfi e A C authors of thi s study concl udedthat the maxllar y f ir st
d i nic ally . S om e r e s e a rc h e rs re c o mi n e n dth a t c l i ni ci ans mol ar has ,r verv (ompl i cated cal al shapeat t ie apical
l e rm inat eall t her a p ya t o r b e ;' o n dth e ra d i o g ra p hi capox l i mi t and rhar rhi s.i nai orny makes shapi ng cleaning,
.-r llllG ll dlt. ' l dPr
dllu
. ^:ldr
. . 1 r,"
dl
n j fi c a ti o n s a rrd l a te ra lc a n al S .' :0 and obturati on di l fi cui t, parl i cr-rl arl iyn the MB- 1 and
The apic al lim it o f i n s tru me n ta ti o na n d o b turati on di stobuccalcanal s.B ecauseof thrsvari abi l i ry g uidelines
continuesto be the subjectof major controverq' in root for i nstrurnenrcal i berstl rat rvoul d guaranteeadcquat e
, canaltlierapy.However,modern electronicapexIocators canal preparati onare vi rtual l y i mpossi bl eto est ablish.
/ a re r eliable ins t m me n ts th a t c a n l -re l pth e d i nrci an One cornpreherrsi ve study revi ew ed the ap ical r oot
root canal. canal di ameters and rapers of eacl r tooth gr oup and
I" determine the rvorking iength of the
Two hallm ar k so f th e a p i c a l re g i o n a re i ts v a ri abi l i ty demonstratedthat root canal s often are l ong oval or
and unpredictability.The uen-rendous variation in canal ri bbon shapedi n the api cal5 mm (Tabl e7-7) "'A long
.henec rn rl d i rn rp l p r- - ^*..r :- - . .^ (^l^- ^:' - ^
lcdlllllS ^^ I -L^^l
dllu )l l dPl^^
llS oval canal rvasdefi ned as havi ng a l ong-to-s hor tcanal
"5 LUillPilLdl( 5
p roc edur es in al i d i m e n s i o n s . S u c c e s s fu l fi eatment ,.li"--r^.
urdrll(Lf r1r;^
I ldtlu E.l(dt(t
-^.t^r
thrn
uldrl ?
z. Thic
lrlrJ trmp
r/pc nf
wr ra."l
!arrdl llivlPrl-
-nmh

d e pendson t he a n ..Ito m yo f l h e ro o t c a n a l s y s tem,Lhe ology rvas for-rndto occur ir-r25o/oof the cross sections
'd i m ens ions of t he c a n a l rv a l l s , a n d th e fi n a l si ze of studi ed. In these roots the buccal /l i ngualdi am et er is
e n lar qinp ir s t n r m e n ts . l argerthan the mesi al /di staldi ameter.Thi s fi nding held
Sometimes tl-reinitial file choscn for erplorir-rgthe 1rue l or al l tanal s e\cept tJrepal al el carralof m aullar y
^ lldl
Ld --^r dlldt
' ^^'
Vllly^- ' , - ^A {t w^l - h
dllu u 'l riLrrrl
ir i rrqi n th e c a n a l i s u sed as.r mol ars. These canal rreasurerrenl ssug,gcst that apical
measure of the diameter of the apical ro'ot can.al. _. preparati onsshoul d be taken to l argersi zesthan pr evi-
Horvever,this technique does not accuratelygauge-the ousl y recommended.
size of oval-shapedapicalroot canals.In one study, file - The authors of another study concluded that
binding occurred in 750/oof such casesrvhen the file " becauseof l ong oval ranal s,l arger canal tap er s in t he
co nt ac t c donly on e s i d e o f L h ea p i c a l c a n a l w a i l, and i t buccal -hngual di recti on, r' vi der ranges i n the apr cal
^ ^-. - ^. r .\\'luluut
uLLUllcu
. . i. k ^. . r^dlly-.. dPttdt
^ ' .:..r .,..r\YdlL !vttld\f
;^ .h e r emaj n_
ltt I di amete.rsof car-ral s, and the l ack of technology t o
i n g 25o/ o.I n 90% o f th e c a n a l s ,th e d i a m e te r of the measurethesedi arneters, i t i s rery di ffi cul t i f not im pos-
i n i tial ins t r um entw a s s ma l l e rth a n th e s h o rt d i ameter si bl e to adequatei ydebri de al l canal s by i nst r um ent a-
o f the c anal. ' t oCo n s e q u e n tl yu, s i n g th e fi rs t frl e to bi nd ti on al one.' r6 Thi s fact w as fi .rrti reremph asized by
fnr o rl o i n o rh
u/ ! e /i
ur a
orme1-
rrLL(l .
rl l h^ .- ;..1 .nd :s or i d- researchthat showed that neither the balanced force
rvr
b( lu5r r r < ^fl
U lc dPl\dl Ldlldl
- ' - .1 d.^-
-- o - .-

a n c ef or apic alen l a rg e m€ n it s n o t re l i a b l e .M o re recent instntmentation mettrod nor rotary NiTi files alloived
stu dieshav es ugge s te th d a t ti i s p ro b l e m c o u l d be reme- control l ed preparati onof the buccal and l i ngual er t en-
d i ed by r enov ing th e i n te rfe re n c e isn th e c o ro nai and si ons of oval canal s.r?6 rs6The i nstruments cr eat ed a
mi ddle t hiids of th e c a n a l .t" ' F o r e x a mp l e ,ra di cul ar round bul ge i rr tJre canal , l eavi ng the e - x. t ensions
flaring before canal exploration removes interferences unprepared and fi l l ed rvi th sntear l a1' erand debr is.
a n d inc r er s c sr t r e i n i ti a i fi l e s i z eth a t i s s n u g l t t-heapex Arother seriesof studies evaluatedthe effeaivenessof
r/.r-^ "t
\dlllluJL
r,..^
L\\u
4l^
lirc
ni-^o
)lz()
nrnrror\
5l(dl(l/.
- tr,.1,'
LJll/ n..i-q
ll4llllJ pjq,pq
o-
1l1p fi ve ni ckel -ti tani umrotary i nstrumentati on syst em son
cl i n ic ian a bet t er s e n s eo f th e s i z e o f th e a p i c al canal , canal debri dernent and found that al l te chniques
a l l o r v ing bet t er d e c i s i o n s a b o u t th e fi n a l di anreter Ieft 35o/o or more of the canal surface area
n e ededf or r nic al rl r.rn i n prn d c'-"'"''b
l e ,rn i n pT',,"h i s i s anothcr unchanged."" ' u
a d v ant age of tfre c ro rv n -d o rv n i n s tru m e ntati on The resui rsof al l tJresestudi esare fai rl l ' prediolble,
te c hnique. consi deri ngthe hi ghl y vari abl eand i rregul arm or phol-
The c onelat ion sb e n v e e nm a n i mu rn c a n a l d iameters ogy of root canalsystemsand the endodonti c int r acanal
a n d ins t r um entdia m e te rsr,a ri e dc o n s rd e ra b l yi n a study i nstrumentscuuentl y i n use,rvhrch cannot c ont act all
th at c om par edt he s i -ra poef th e a p i c a lro o t c a n a lof max- the recc' scspresent al ong crnal rr' al l s.The se inst r u-
 Mesi al D i stal

5 MN4 2MM
1 MM 2MM
TOOTHI CA"\AL POSTI1ON
0.3 0.36 0.54
Maxillary 0.41 0.16
0.34 0.33 033 o.41
Cenffalincisor 0 .6 0.11
0.45 o.29 0.44 0.5
L a te rai nc
l is or 0 .58 063
0.31
Ca n i n e
o.26 0.41 0.38
Pre molar 0.63 1.13
c anal
0.37 o.23 0.31 0.31
Si n g l e 0.4 0.35
0.3 0.17 0.26 0.33
Bu ccl o.37 a.42
0.23
Pa l a tal
o.22 0.32 o.29
lv lUlo I 0.46 096
q i n cl em es iobuc c al U.4J
0.r3 0.21 o.32
o.37 0.46
0 .1 9
0.16 0.r6 0.16
FirstmestoDuccat 0 .31 038
0 .1 9
0.r7 025 o.3l
Se co n dm es iobuc c al 0 .33 049
022
o.33 0.4 o.74
Distobuccal o.4 0.55
o .2 9
Pa l a ta l
r o.75 o.25 o.79
\4 an d i b ula o.52 0.B l
a31
0.36 0.36 0.57
lncisor 0.45 0.14
047
Ca n tne
o.2B o.32 0.49
Pre molar 0.4 0.16
0 .3 5
o.23 0.29 0.41
Single 0.34 0.36
a.2 0.'lB 0.21 0.17
B UCCA I 032 a31
0 .1 3
P alalal
0.22 0.3 0.29
Mo l a r 0.8 2.1l
0 .4 5
0.21 0.26 o.32
Si n g l eM o.42 0.64
0.4
0.28 0.24 0.35
Mesiobuccal 0.44 0 61
0 .3 8
0.35 0.34 0.59
Me si olingual 0.5 107
0 .4 6
Distal 89(6):739-
O.t ,"a Orol PotholOrolRodiolEndodon
ov'
P: Prevalenceand exteft ot lon8
Wesselink
FromWu lr4( R'OrisA' BarkisD'
41, 2000.

computer-
A recent study has used high-resolution
th e c a n a l b u t a p o or of the
m e n rs d o a good 1ob o f s h a p i n g ized tomogaphy to createa detailed'
3-D model
u..o-lplithing total canal debridement' "tystem.t't precise meas-
i"J ."t.f This method permits
"f to clea-nand disinfect The
Attempting to nnd better rvays -ol of .u,t"l volume, area' and dimensions'
determined that
root canals,one group of investiSators "r"*"t, .unul diametersin the apical 0 5
1ry
of maxillary
recommended canal (l 88 i 5 pm)'
.;i;rg;;g canals-above the trad-itional moiars \\'eremeasutedfor the MB-1
-"un
lray.to remove culturable bac-
.;i."i rii.s *us rhe only ,l " ai rroU u.cal canal (I74t12P i m)' anddrepal atal
The larger.apical sizes
i.riu fro* the canal effectit'ely'" goesa i ong r vay
and facilitated canal (318 t 23 pm). S uch i nformati on
optimized irrigatron and diiinfeaion instrumentation sizes
A similar study ior"uri the establishmentof final
,ri-ft^ti..f elirination of microbes
size of canal instru- for cl eani ngand shaP i ng
concluded that an increasein the the apical anatomy also indicate that the root
i n c re a sei n 'tt'tditt
me n ta t ion at r v or k ing l e n g th p ro d u c e d .a n during surgical pro-
ape,xshould be resected2 to 3 mm
ca n a i c leat r lines s ' t 5l rri g a n tv o l u m e ' l h e n u m D e ror cedures;thi sremovesmostofrheunpreparedan d
instrument changes, tftt deptle of penetration of a potential reser-
^"i important factorst""tjlr!.::tl? unfiIled accessorycanals,eliminaring
irriganr needlesrvereless researchersused a
a d v e rs ee tl e ct oI ;;i; tap;;og.,.,s.o"o' ln one stud;"
to i a ,ral debr ider ne n t' A p o te n ti a l bevei perpendicular to the long
axis of.the root' and
b e a n i u c re ased
.n l u .g i ng t he apic alc a n a l d i a m e te rma y apical ramifications and accesJory
canals increasingly
ri sk o f pr oc edur al e rro rs o r ro o t. fra c tu re s o r b oth' root resectio
rvere eliminated by 1 mm of
re q u l re o ' " t2:": 1:\
Fr.rrth er r es ear c hin t h i s a re al s 400/o,respecti vel y),2mmofrootresectl onl /o" /odr r u
a c o ustl c
As a s upplem en t to th e s e p ro c e d u re s ' 40% ),and 3 mm oi too' resecti on
(98% and 9 3o/ o) ''2
a p p e arsto
stre a mingby s onic an d u l u a s o n i c i rri g a ti o n (ss3 This shorvedlhat root-end resections
of 3 mm are most
(F i g 7 -1 9)
e n h a n c e r he c leanlin t" o i o u u l c a n a l s rhese strLlctures'
to d e te r mtne effeclivefor eliminating most of
Ii o w e v er , f t lr t her r es e a rc hmu s t b e d o n e In root_end resectio"nsa bevel perpendicular to th'e
v a ri a b l eroot
rh e b e s t t r eat m entt ec h n i q u e sfo r a h i g h l y number oI m lf f o'
l ong axs of a root expos€sa smal l
ca n a l sv s t €m .

I
 :j:; @trtsffitr
inrhereces_ses
*"t;T;'."*l'ft-:,T.]'1,:H;::'l:;1"r";'n*'X:1'lt"f,'P^:.:l:li: orrootcanarwars
intheapicar
,'Jil.',fi'"';i':,i#
ff.i"J:il
fj;Iffit'J:,?:j[ g:::iri:::iT"i:s:f [',iff'J"',ilr
ffil*j;1i;;ffifrjJ*,T*:?*l'ltliill'?ruT.i:'?qi^:!"J';T r mm
watrs r tr*[j;'Jll;i'y;mr*:[i:i:
intheapicar
mmafter
preparation,i,;*,u,"i.'.y itlrJfft];:ft?fl,ii"?'ii;],"?.fl
"i;i;,rfiil;;l;in: il;if,yril:::'?:n::::rJ::LHffHT[f;
l;;UgX

of the root canal sl,stem and the persistence

l i:
of peri-
i :;;'
":
I' 4 :,*
i
I i,-:i
i:i
.r l nbbon-shapedc om m unica-
i';:tr':* i;::
' .:
tion
i i. .-'{
i ;l
r '..':l!
'.
r-.J .:.
: . ': .i; . t .:,

I i."J 1,
.::..j :,'...
'1i..1 :
the preseni-'6fii
1.-'4 WTherefore
;i '''l' lsthmr.rs
shouldbe suspected
rvhenever
multiplecanals
ss; are seen on a resectedroot surface.
In one study, the
\'. ;:.' \
-. r^L\
authors recommendedthat ntethylene
blue dye be used
.;ai r'- to aid visualization of the oudine
of the resectedroot
surfaceand thus detectionof an isthmus.22
AB in onestudy,isthmiin the mesiobuccal
t .:i1.'-;- root of ma-r-
- Le ak aget hr oughdent inart ubur esor igin a t i n g iiiary first molars were found most
beveledroot surfacelA.Reveise at the often 3 t o5m m
tillingJoesnoi .i.ia .oronuttyto from the root apex.rsoA completeor partia.listimus rvas
the heightof the bevel.Arrowsindicate
a possiblepathwayfor fluid found ar the 4 mm leveltod% of this
penetration. ti-". f,,,another
b_.";i B, Reverse
;i";k;;;;i;; ; #iilfffai#jT,lIJ:,,i:,
(FromVeftucci
filli
i:f:l$# study,partiaiisthmirverefound more
often than com-
FJ,3eottyRC.J Enjodoniz,,isi, tgiZ) pl ete i sthmi .r!s
Identifi cation and treatment of isthmi
arevital to rhe
successof surgical procedures.
" Kim et ali2 identified
hve t'?es of isrhmi that can be found
on a beveledroot
surface(Fi g. z-21).
tubules.es.ee Horveveq,a root reseclionwith a 45_degree
bevel exposesa significanrlygreater Isthmi are found in I5Vo of anterior
teeth; in maxil_
of tubules, lary premolar teeth, they are found
rnc r eas ing t he c ha n c eo f l e a k a g ei n to"u_J". in l6okat the I mm
a n d o u t o f the root resectionlevel and in 52o/oat the
ca nal. ' t t' t s T o pr e v e n t.th i sro
, J t e n d a u u i a yp .a p uratrons 6 mm r€sectionlevel.
should e\1end coronally to rhe the preval enceof i stl rmi i ncreases
heighioiin'e u"u"l i n the mesiobuccal
7 -20). 1rig. root of rhe ma_xl l aryfi rsr mol ar
from 30% to 50%0as
tne root is resecredFrom the
T he r oot aper c o n ta i n s a v a ri e ty 2 b 4 mm level. Eighw
o f a n a to mi c struc- percent of the mesi al roots
tu res and t is s ue re mn a n ts . of mandi bul ar fir st m olar s
In te rc a n a lc o n n e c t i ons can have isthmi at *ie 3 to 4 mm
b ec om e er pos ed , a n d a s i n g l e resection level, rvhereas
fo r.;;;' ;o y become I5oh of di stal roots have i sthmi
n u lt iple f or ant in a . T at the 3 m m level.
urte."
d.".,o;,;i;,;ilHil ; fi i::r1':J".";':Jii: t\l i crosurgi calendodonti ctechni ques
ni ci ans to vi sual i zethe resected
have enabled cli_
rated.one studvevaluated"rhe.ooi root surfaceand iden_
,fo olt.eth *,lth tit'y the isrhmus, prepareit ri,ith
refractory.apical
periodontiris ultrasonic trps, and fill
tr,rr aij,"i respondro rne root,end preparati ont i th
root canalrherap,,,
and found that 7Oo/o acceptabl emate r ials.The
hud ,lgnifi.ul,t recogni ti on and mj croendodonti i
apicalramificarions.r6r
Thisinciden.. treatment of canal
a closerelationship suggests isthmi have significanrly reduced
behveen "r"rgfy
the anatomic-complexiw the failure rare of
endodontic surg€ry.I27. I 2s-
 -
'6. ,hl, ;'=;'-;1,

,_,',. ,:,:'l ;j
: t:j ) '

Tvna I T y p el l T y p el l l

,-t;;r-r-. _ :. 1r'r.:
-:-:
l'r@-i; ;i ,€r"

Type lV TypeV
Sch ema ticrep r es ent at ion
of is t hm usc las s if ic at i o ndse s c r i b e db y K i m e t a l . T y p el i s a n i n c o m p l e t ei s t h m u s ;i t i s a f a i n rco m -
m unicationbe twee nh ,voca nalsTy . pell is c har ac t er iz ed
by t wo c a n a l sw i t h a d e f i n i t ec o n n e c t i o nb e t w e e nt h e m ( c o m p l e t ei s t h m u s )Typ . e
l ll is a ver ysh ort,comp letei s t hm usbet weent wo c anals . _Ty p l Vei s a c o m p l e t eo r i n c o m p l e t ei s t h m u sb e t w e e nt h r e eo r m o r e c a n a ls.Typ e
V is marke db y tuvoo r th reec analopeningswit hout v is iblec on n e c t i o n s .

* f f iJ HC T I V HASN D GU E D E L !N EF5C IR
AC€H55EAVITYPREPRATION
0bjectives
Accessis the first and arguablymost important phase of
nonsurgicalroot canal treatment.A well-desigr-red access
pre p a ra t ionis es s ent ia lfo r a g o o d e n d o d o n ti c re s ul t.
Without adequate access,instruments and materials
become difficrlt to handle properly in the highly
complar and variable root canal system.The objgctives
of access
cavityprepararion
are(r) 1g"a3hlcye$mID
cr d i re o -line ac c es st o th e a e
a l l ro o t c a n al
ori fi ccs;and ( 3) r o c onse
A properiy prepared accesscavity createsa smooth,
straight-linepath ro the canal system and ultimately td
tie apex (Fig. Z-22). When preparedcorrectlyrhe access
cavityallorr,scomplete irrigation, shaping and cleaning
and qualin' obturation. Ideal accessresults in strai"ght
;a5girrto ire canal orirrce,with the line anglestffi-n-g
a.tu n n e l d' r atdr ops s m o o th l y i ru o th e c a n a l (s ).p ro j ec-
t t on o f th e c analc ent erli n e to th e o c c l u s a ls u rfa c eo f the
: ':
t o o ti r i n d ic at est he loc ati o n o f th e l i n e a n g l e s .C o n n e c_ " ', - ? 7 - S t r a i g h t - l i naec c e s st o a c a n a l T . h e i n s t r u m e nst h o u l d
t ion o f th e line anglesc r e Are srh e o u rl i n e i o n n . M o d i fi - n o t b e d e f l e c t e du n t i l i t r e a c h e st h e i n i t i a lc a n a lc u r v a t u r el n
. so m e
casescoronaltooth structuremust be sacrificedto obtain direct
t a tto n s o f t he out line f o rm ma y b e n e e d e dto fa c i l i tate
accessto the pulp chamber.
loca ti o no f c ai' r als and t o c re a tea c o n v e n i e n c efo rm. T he
cl tn i ci a nr nus t f ind a bala n c eb e n v e e nc re a ti n ga d e q u ate
Visualizotion of the Likely Internal Anatomy
acce ss a n d r em ov ingt oo m u c h d e n ti n ,i v h i c h c o u l d c o m _ Because intemal anatomydioatesaccess shape,the first
pro l l l rseth e f inal r es t or a ti o no r p ro mo te c ro rv n
fra c tu re.

;,,
Gu i c { e lln e s Evaluati
n Ltron_el!_!hq
lqron al and cervicaltoo
I-he guidelinesclescr ibed
rn.he fo l l o w i n g s e c ti ons Ag!!! radiographshelp rhe clinician istimate thE
afe essentialto the completiono f a n rd e a l a c c e ss 'n.lilr
p"r;,;"r .t r-U
pr€pafation. "f the number roors
calcification, of and caniG,Jn-d-the-
rktii,ffiti *e,{'ffitffifr#t#,bi#J'#i*sJ*
iiilFF*S$ .

a ppr ox im alcc an a l 1 e n 5 h I' a l p a ri o rr.tl o rrgrh e attached l aw of ottJl crl i a,ati oi r-Ihe ori fi ccsoI r he r oot
t,r,{y:,
ers-T; d.-tctffirtron of tor, joi.io;--u'i'j
=ingl%-a .u'orsarealu,a),s
rocated
(rLrrrL/uriLLiulr
.r'tirf"jffimon of the
direcrion.
Theclinicianusestl.ieinformarionfrom these
, rvallsand the noo.l""'"
assessmenrsro choosethe directionof iniual bur
! rrPnPlr lt i^n
Arrr";1;;"rir',',irii)ration:Theorificesoftheroor
, are alwayslocated at the anglesin the
tanals
p.,Evatuotionor the Cementoenomet
runctionand
'Occlusol AX;',:::;,1,i;tir:r,,rr: rhe orifices
of *re root
Anatomies
rraditiona1l1'I,
accesscaviries
havebeenprepared of the
in rera- :il1':ff"':;ffi|ff[,:,::t:::""'"us
tion to the occlusal anatorrry. However,
complete
relianceon th. o.1]trru]unutgmy is dangerouslbfiilG More than 95% of the teeth lfuasner and Rankow
d1)c
examined
eva--inJ
conformed
-^-r^-
r , .;-
to theselarvs.To
SlightJyfewerthan
@s@
50k of mandibular second and rhird ilroi"^
f33;as--e e did not
liQ319sb.- Co-p conform because of the occurrerce of C-shaped
anatomy may erplain Lhe occurrenceof some proce_ anatomy.

ffi*.'."""i:il"1:lit;il?'il:, il3 :.'#""?'.T*'i ]. preparotion or theAccess eavity throuqh the

j unc rion(C E ] ) * u , . t h e m o s t i m p o r ta n ta n a to m icla n d - ,i? ::' :.xi&:.# ffi u,uurryu,.o
nTl,:1..ff5Tiil:f ;i:,mT';L::iJli.ffl*:: and ',ho.pq.on pos,.
, t. , .;@ , . n ..,or ur p..in. ona.fnriste,n,.noro.y
i:tT*"i+;lH.uffi-su,race,
a rep re p a rerh
d ro u g hrh e io i. lu s asiu r f a c e .
s o . ,p ,oo o ffi/r ne3e,approachesaretlre
oi;. ;b; ;e J t me
V \a" lo
n s' toer.ent ]al . i. J n g

i:ryi#";:.ff
,#"*ilffli:.,#Gt
. { . @Fa ;,\,.r y./-l1).-w-J-***,.rradition a la n t e rio ra c c e s s f o rf f id ' -1 . ! * u -. |g j! g i]
ooove movedfrom the lingualsurfaceto tl-r.i"iirut
*@of s1'mnte,y:
Lrceptfor the maxilra, $
i;;.ii;;; b,euericcessto rtrelinguarcanai
molars,canalorifices t!;;;"';
aregq-uidrsrant
fiom a line proves canal
debridement (Fig.7 24).
''i '
drawnrn a mesiodisral \n
direniontlrough rhe ,. Remaval
pulp chamberfloor. of All Defective Restorotionsond Caries
. ,- \,'
17/ Secondlatuof s1,m1ngrr1,:
F;rceprfor the.ma-rillary Entry into the Pulp Chamber
!9fore
*p9]3{!.canajorificeslieonalineperpendicular@ealldefecriVeIeStoraLion!-
toa]inedrawninamesiodistaldirectionacross.beforee''teringthe
of the pulp chamberfloor. preparation,canals u." ro locate, and
,,,the_center
colorg!g1,8e:TheHb_c\gJ!!-g#floor shaping deaning and -u.h "ilEf
obturation
*,zLaw.of is are muci easierro
alwavsFgi@;n.otot thilffi"*iir. perform. ,.rrorution, ulro u
.}ljfg_[ryggh

D
i ' i, Dia gra m m at ic
^ , _ r epr es ent at ionof Kr as n e r a n d
Rankow's first and iecond lan,s.i'rvrrrr.i.y"r"d
larr,,s iirst throughthird A n i n c i s aal c c e s sc a v i t yo n m a n d i b u l a r
of orificelocation. a n t e r i o rte e th
m a y a l l o wf o r i m p r o v e ds t r a i g hrf i n ea c c e s s
a n d . u n l r o . u ,i d ",.n .n t.
3_-__

e a s i l yi o d g e d i n the
----

carious dentin and its baderia frorn enterine the root

\anal s.':tem. ll a chdmber wall iq lpiTFT;lEtf-irfiFg
remova l of ca riou s dent in, allowing lealage of s a l i v a

m*qru*wru*L
n a ti o rr' ' \ c r own leng th e n i n gp ro c e d u res h o u l d b e per-
formed to correc{ t}ris situation before the root canaN
I
t set of Mi cro-openers
enlargement.
-.
for canali denti fi ca t ion
and

is begun.
procedure
mationcanbe usedas an indicatorof the directionof
t-Removol of UnsupportedToothStructure
-*L^''-.--.:'_-fanaccesscaviryrcsuI|sinfiel.-,,s;-.;:.ll;".
,lnP
' '' nrPnfrf,Ttnn
r-
n1

r ^f *^*
r<u l u v< uur
-^-^--^l pdr r ur
^r,l ut e
c e n tra lp o rti o n o f th e to o th ; fi i sf i nstruments " for l ocati ng canal ori fi cesw hen a dent al
\
f reduces
re d u cesrhe
t he tooth's
t oot h' s resistance
r esi s ta n c to
e stress.
to s tre s sAfter
. e r comol:"i;r(
Afl c o mp l e ti ng( ;r; Ihas not
dam been placed
not been pl aced.TheseTheseflexrble'
fl exi bl e.stainless
srai nl es ssteel
st eel
rhe
uiL nrenarari.,.
P rrPdrd Lru it, rh?ffin
LrrcL r lnlc lan sshourd
hould r.-*.tlill:11,::l
r em ov e dr r ur r r u p - :i3"tt
, r 4 r r u i n s t r u m c n t s h a v e # . 0 4 a n d +. 0 6 l a p e r e d t i p s . Th e y
I
ported tooth structureto assessrestorabiliw
'' and to \t al.so
- " " have
'' offsetl-randles
rhat provide.r'nl"..a'"irr.f i"
n r p \ / p , l r lLn vvur
ylLvcrrL n rh frra r,'-
rrd LL urc. Unnec es s ar y r em ov al of s ou n d zarion of the pulp chamber.
' t- - - "- ":"- ,:^- ::.:: )I
tooth structureshould be ar.'oided. Jhe denral da
:r.e canals
rr.otlonof AccessCavity Wa!trsThat Do Not
Resfricf Straight- or Direct-Line passage of
f nstruments to the Apicol Foramen or
lnitial Conol Curvsture
Co mp l et e c linic ianc on tro l o v e ra l l e n l a rg i n ga n d fi i l i ng A sharp endodonti cexpl oreri s used to l ocate cana l or i
instruments is vital. Sufficienttooth structure must be fi cesand to detenni nerhei eparture rrom the
removed to allotv instruments to be placed easily into
each canal orifice rvitiout interferencefrom canal walls,
pa n i cu lr r ly n, henac an a l c u rv e s Se l e r9 Iy -!r]e a v e s t}tel el l ,pre-
chamberfloor,atan.oblu.sg:gg$. Thervallsof the root cGaa-mi;s (#6, #8, or #10).'lheclinicianmusrrake
c*nal. I
, rarhqrthan the rvallsof the access
prep4l$-fffi,I careto keep'these
insrruments
rvithinthe confinesof the
must guide the passageof instrumentsdorvn the canal. canals)'stemr-rr-rtil
the rvorking length hasbeen accuratel;,
Failureto follorv this guidelineresultsin rreatmentI determined.A lubricating
agent(e.g.,RC-prepIpremier
I I
enors, i:relud'tng.root
perforation,misdirectionof an DentalProducrs, pAl),; water,based
Norristo-rvri,
I prepa-
th-emain.canal (ledge,fonnation),
il-'Jfu.m"*oL'-fiorn rationthatrvillnotcongealvitalpulprissue,
maybeused
/
lililruI0entsep,a63tion,
of cre.alipn.Of
41.jngo_r1ectcpldI on instrumentsand introducedinto the canal.Con-
sh a p e (rpic al t r ans por ta ti o n ).F o l l o rv i n gti i s g ..r;a .ti ' ' r" geal eclru,i
nrrl n ri ' srrer,ro;
mrv rwforn
I ,,JJu! rrr) a col i agen pl ug th;rt bl oc k s
mi n i mi z es t he oc c urre n c eo f p ro c ed u ra l e rro rs and I an. ape\, preventi ngcompl eteshapi ngand cl eani n g
I
ma-ximizesthe effectivenessof shaping cleaning, and l'
ob tu ra tion ins t m m ents . pulp Chomber Llsing
Qlnspection af the
' Mognificotian snd Adequote lfluminstian
,De!ay af Dental Dam Flocement until Difficult ,ttagnification
and illumination areparricularlyirnpor

;;.;;,;;;;;;;;,";;
and rotated, ro rhe- "gum line,"ly/ calcifredcanals,ana dlbriciinsanclremovinprissrreand
::.^tlj.d restored .fractured
and caicrfi.ed, or part of a flxed p.or- ' calcificationsfrom rhe pulp chamber.Enhancedvision
lf^t]lltt, f
thesesituations the clinrcian's bestcourseoff allorvsihe cliniciani"ri.l'",.rnal dentincolorchanges
l:tl: 'Il
a cro n nr d) be. t o pr ep a reth e j rri ti ;l p a rt
o f th e a c c essf and subtl e l rrrdmarks rl i at may not be vi si bl e ,o ih.
ca \'l i v h P f nr e nl" i' - t h e d e n ta l d a m s o th a t
} - , . 1, , , 5 th e i n cl i unai cl edeye.S urgi cail oupes, endodonti c endoscopes, i
n a ti o n of r oot eninenc e s c a n b e v i s u a l i z e d ;
h^ +:^ J
tn i s i n fog/ and the D O.\a are ,o-. of rhe commerci al l yavailable
 i n s t r um ent st hat c a n h e l p th e c l i n i c i a na c c o rn pJi shrhcse
pr ac llt ro n e r
tra rn e d tn m l c ro s c o p rcte chnrques
-g oals-.4
Eis i i, . . t t . , c han c eo f l o c a ti n ga r.rdr.i e g o ti a ti ng
i ntri care
foot c anal s v s t e trs .

lQ.Tapering of Covity and Evaluotion of

Adequocy for a Cgdnol Seql : i : : : : -: :

t'l'fii:-.1
A propcr.rcccg.<6viry
hastapering
al r,l'ieoc9u<51surfacc.In such a prS:dataion ocdusal
lorcesd6nor push the remporafiestorationinto d'r
crlrfu arrddLsruprthe seal.AtJdasr3.5 mm of ten{o-
ra 5' f illing m at e ri a l (e ,g it I PremrerDent4zlrod-
u ct s ] ) is neededto p ro u p d a n a d e q u rtec o ro 6 [ seal[or
a shorttinre'r RecenSX,
ori-6ce
plugsof co.lzlposire
gJass
i n n n me r f\{T A tsply-TulsaDen$, Tulsa,OKI)
h a v es hown p; 6n i s e i n e n h a n c i n gti ;y ' c o ro n a lseal(i .e
rcducin g thd ri sk of b acreriaI conlat'ni n atio n )

A c c e s sb u r s :# 2 , # 4 . a n d# 6 r o u n dc a r bi d eb u r s
M E C F { AN f i C A
P !.
F {A s8 5C IFA C C E S S
€AVETYPREPARATEOFd
A r m a m e n tar ia
unabri dged l i st of these burs w oul d be di ff icult , and
The preparation of an accesscavity requires the follorv- most cl i ni ci ans have thei r ow n set of prefer r edaccess
i n g equipm ent : burs. In realitl', creatingan accesscaviry drat me€ls the
\
. , \ 4agnif ic ar ioann d i l l u m i n a ri o n previ ousl y stated gui del i nes i s more i nrpo r t anr t han
. Handpiec es worr;,ing about which burs are r-rsedin the process.This
. Burs di scussi onthereforeco\/erssome of the more com m on
a E ndodont icax p l o re r(D G-l 6 , D E-17 ) accessburs.
E ndodor ric t op e ra ti v es p o o n R ound carbi deburs (si zes#2, #4, and #6) ( Fig.Z 26)
#17 E x plor er are used crtensivelyin the preparation of accesscar.ities.
a
Ult r as onicuni t a n d ti p s They are used to renove cariesand to createthe initial
extemal outline shape.They also are useful for pene-
Mog n ificoti o n o nd lllu m i natio n trating through rhe roof of the pulp Camber and for
The access cavity cannot be prepared adequately removing the roof. Some clinicians.preferto use a fissure
f
wiilr our r he us e o I m a g n i fi c a ti o na n d a n a p p ropri al e carbi de bur (Fi g. 7-27) or a di amond bu r u. jt h a
)
l i ghr s our c e.. { t t l re l e a s t rh c c l i n i c i a n n e e d s surgi cal rounded cutting end (Fig. 7-28) to perform rhese pro,
1{
l o L r pesr v it h an a u rl i a ry l i g h t s o u rc e (s e e C h apter 6). cedures. fhe advantageof the fi ssure ca r bide and
f
I th e DO M is t he p re fe n e dme a n s o f m a g n i fi c ati onand di amond round-end burs i s that rhey al so ca n be used
\ i l l um inat ion. for some of the axialwall exensions of the accesscar.,ity
preparation.Horvever,rvhen tlese burs are used for ttris
Hondpieces purpose by inerperiencedclinicians, tleir cutting ends
ffut experiencedclinician rvith good tactile awarenessis n gouge the pui p fl oor and axi al w al l s (seeFig. 7- 75,
likelv to perform most phasesof accesspreparation \^/ith A)
i
a
\ high- s peedhand p i e c eA . fte r p e n e tra ti o no f th e denti n, Fi ssurecarbi de and di amond br_rrs rvi th saf en' r ips
a less erperienced clinician may benefit from the (i .e.,they cl o not havea cal ni ngend) (Fi g.7-29 ) ar esaf ei
,,f
V/,( inct"^sed tacttle awarenessoffered by a slC,w-speed choices for a-rralrvall extensions.They can be used to
h andpiec e.F or c h a l l e n g i n ga c c e s sc a v i ry p re p arari ons, exend and favorably orient the a-rialrvalls of the pulp
I
e sp ec iat lyt hos e i n v o l v i n g c a l c i fi e d a n d re c e ded pul p chamber.B ecause thel ' h31' sno cutti ng end, the bur s can
I
l ch a m bet s , ev en e x p e ri e n c e dc i i n i c i a n s rn a y sacri fi ce e al.lou'edto extend to the pulp floor, and the entire
cu t t ing s peed and e ffi c re n ryi n fa v o r o f th e i ncreased axralrval l can be moved and ori ented al l i n one plane
I
cu tt ing c ont r ol of th e s l o rr,-s p e ehda n d p i e c eo r an ul tra_ from the enamel surfaceto the pulp floor. Suc]r a tech-
I
I so n ic r ip us ed r v ith th e D OM. nique produces a-rialrvalls free of gouges as rhe hnal
access erl ensi ons are created. Fi ssure carbide ar - r d
Burs di amond burs al socan be used to l eveloffcusp t ips and
N um er ous bur s ha v eb e e n d e v e l o p e dto a s s i s tr he cl i ni
rnci saledges,rvhi ch are used as referencepoi n r s f or t he
ci an r v it h ac c escsa v i typ' re p a ra ti o n p
. i o v i d i n g a d etai l ed, rvorking iength.
 ,;r Accessburs: Safety-tiptapereddiamond bur (left)
= -2 7 tapered carbidebur (right).
Acce ssb ur:#5 7 lis s ur ec ar bidebur .

A c c e s sb u r s :# 2 a n d # 4 r o u n d d i a m o n db u r s .

R ound di amond br_rrs (si zes#2 and + a) (Fi g 7 30)

are needed rvhen endodonti c accessmust
D e nt ade
through porcel ai n or cerarront€tal restorarions.
D i amond burs are l ess traumati c to porcel ai n
th an
carbi deburs and are more l i kel y to penetraterhe por ce,
l ai n w i thout cracki ng or fracturi ng i t. .l .hey sho uld
Accessb ur: rou nd- endc uf t ingt aper eddiam ond
bu r . al w aysbe usedrvi th rvatersprayto controi heai bui l dup
i n porcel ai nrestorati ons. A fter penetrati ngtl -reporce lain
the cl i ni ci an shoul d srvi tchto a carbi debur for netal
or
derrti n penetrati on becl rr-rse of rhi s bur,sgreatercutt ing
efficienry.
 Fig. -i"5 i Acce.sbur:Transmetal
bur.

Many teerh requinng accesscavity preparationshave

m et al r es t ora ti o n s th a t mu s t b e p e n e tated. These
rpqlArrlinnq marr
-,,.l rra rg d i l rs , a l r-mc
ho r-"1-.-. .ll
-.r.1 ra l cast
.. resl ora-
t ions , or m eta l c o p i n g s o f p o rc e l a i n fu s e d to metal
crowns.A transmetalbur (Fig. 7-3i) is excellentfor this
purpose becauseof its exceptionalcutting ef6ciency.To
penetrate a metal restoration, tl-re clinician should
always use a ne\v transmetal bur with water spray for
\j------^--^- -*----o -^
ItLf -4 'LVUUI
^^'l- r^ ^ ^ -lc\(u(u
e cp l,p d n r r in r(trdtltuct
hrmhpr
I
udJ d putp and caj ci fi ed
orifices, the dinician often must cut into the root to
locate and identif,, t}te canal orifices. Lrtended-shank
Fi g. 7-52 A ccess bur . B , LNb ur .
burs.A , Muel l er
r) round burs, such as the lvluellerbur (Brasseler,Savan-
nah, CA) (Fig. 7-32, A) and the LN bur (Caulk/
Dentsply,Milford, DE) (Fig. 7 -32, B), are very useful for
this purpose.The artra-long shank of these burs moves (tlZ operativecrplorer is useful for detectingany re-
t he head of t he h a n d p i e c ea i ta y fro m rh e ro o rh, i mprov- g{,'mainingpulp chamberroof, particularlyin the areaof
ing the clinician'svisibility during this delicate proce- pulp hom (Fig.7-37).
la
dure. As an alternative, ultrasonic units offer good
v is ibilit y r v it h p re c i s ec u u i n g a re a s . Ultrasonic lJnit ond Tips
r
Once the orifices have been located, they should be
\A n ul trasoni c uni t (Fi g. 7 38 ) a.nd ti p s' speci6cally
flared or eniarged and blended into the axial walls of ( desi- - - o-sned
--- for endodnnti c nroredrrrpscan be v. r luable
I
the accesscavity. This process permits the intracanal /l ai dsi n the preparati onof accesscavi ti es.Ult i- asonict ips
instruments used during shaping and cleaning to enter V - 1,..
/ (Fi g 7-39) can be used 1o trougl r and dee pen develop-
the canal(s) easily and effortlessly.Gates-Cliddenburs I mental groovesto remove tissueand erplore for canals.
|
can be used for rhis purpose, starting with smaller ' 'r -
I U l trasoni cs)' s(ems provi de axcel l entri si bi lir y com par ed
s iz es r nd pr o g re s s i n gto ti e l a rg e r s i z e s (Fi g. 7-33). w i th conven(i onal handpi ece heads, rvh ich qpically
I
M or e r ec ent l y , # .I2 ra p e re d ro ta ry e n d odonti c fi l es obstruct vi si on.. Fi ne ul trasoni c ti ps are sm aller t han
J
( F ig. 7- 3a) ha v eb e e n u s e d fo r th e fl a ri n g a n d bl endi ng conventi onal round burs, and thei r abra sii'ecoat ings
II r r
pr oc edur e.
{ Ial l otv cl i ni ci .l rrsto sand arval ' derrri rrand calcif icat ions
\ conservati i ,plrvl
r.' rencrnl ori np for ca..rl or if ices.
\;" " " -' ' -" ' ' ' )
Endodontic Explorer, Endodontic Spoon, #17
Operative Explorer
Various hand instrurnentsareusefi_rl Access Cavity Preparations Fc'r r{-ac{rq,$
( for preparingaccess
v
c av it iesT. he D G-1 6 e n d o d o n ti c e rp l o re r (Fi g. 7-35) i s AnterisrAccess Covlly-Elgpglgtions
,rr/\
t"
J used to identifiTcanal orifices ar.rdto determine canal Manyol the saniestcpsrre uscdirr simjlartoorhqpes
angulat ion.T h e C K-1 2 e n d o d o n tj c e rp l o re r (Fi g. Z-35) lnruss-ron
( C- K Dent al, S a n D i e g o , C A ) s e rv e sth e s a m e purpose, ar-rd man dibuiar ant e-
@ l ary
but its tf iinner, sriffer tip can be useful for identifoing ri or teeth.Tooth speci fi caccessconc€ms a r e r llust r at ed
c alc if iedc ana l s .T h e e n d o d o n ri c s p o o n (F i g . 7-36) can and di srussedi n S ecti onN l orphol ogvand AccessCavit y
be us ed t o r em o v e c o ro n a l n r-rl oa n d c a ri o usdenti n. A P reparati onsfor l ndi vi dual Teeth l ater i n t he cnapr er .
 ti7=.7-33 burs, I through6. B, 6ates-Cliddenburs,short shank regularshank.
Accessburs.A" Gates-Glidden

Fig.7-35 Access DC-16endodontic

instruments: (top),
explorer
CK-17 endodontic
explorer (botton).

after the endodontic appointment. Rernovaiof defeoive

pem-)al l entrestorati onsal sopermi ts straight-l in e access
and prevents restorati ve fragments from " " " ^ becom
" --" ' in
Fi g . I 3 a A c c esbur m{ i c o
s :.1 2ta p e rn i c k e l -ti ta n iouri e p e ner. ' ,1"jroot
i ' = ,," = = !' ,=the :' i t" r=carral
.-^t
^," " " " ' ' " ' "
s)' stem(see Fi g. 7-74' D) . I
T" a-g" A -f
rerurrcnt decayi s detE a?dor suspected,the perm anent
' {JR e mov al of Car ie s a n d Pe rma n e n t R e s to ra ti ons. restorati onmustberemo\Iedenti rel ytopreventc or onal
f C a ri e s t y pic ally is re mo v e d e a rl l l b e fo re tJ re pul p contami nati on of the pul p chamber.
(, The management of i nt]ct permanel l t resto r alions
-, /) chj naamb er is ent er ed. T h i s mi n i mi z e s rh e ri s k o Ic o n ta m-
ti o n
of f he pulp c h a n rb e r o r ro o t c a n a l (s ) w i th ,r,,J' rvhenrecurrenlcari esi s not presentrequi ressom e judg-
b a o e ria. Def ec t iv e p e rm a n e n r re s ro ra ti o n s ,w h ether' rypically
I \ ment. A mal gam and composi te resl oraLi ons
a ma l g am s , c om pos i te re s i n s , o r c ro w n s , mu s t be i mprove vi si bi l i ry for the sear ch
I \ are remo,redenti rel yto
te mo v edent ir ely t o p re v e l i rc o ro n rl l e a k l g e fro m con- the cl i ni ci an may want
I l for root canal ori fi ces.H orvever,
ta mi n a t ingt hepulp c h a m b e r,rh e ro o r c a n a l (s ),o r both Ii restor at ion
f 'w I to ret.ri nthe proxi mal porti on of a C l ass

j4._