dental

1. ACCESS CAVITY
PREPARATION
Presented by –
Dr.S.Sharmista Reddy
II MDS
1

2. CONTENTS
Introduction
Definition
Objectives of cavity preparation
Principles of access cavity preparation
Guidelines for preparation of access cavities
Mechanical phases of access cavity preparation
Anterior access cavity preparations
Posterior access cavity preparations
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3. Challenging access preparations
Errors in access cavity preparation
Newer access preparation designs
Conclusion
References
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4. INTRODUCTION
Access - first and arguably most important phase of non - surgical root canal
treatment.
Endodontic cavity preparation begins the instant the involved tooth is approached
with a cutting instrument.
4

5. DEFINITION
The access cavity preparation generally refers to the part of the cavity from the
occlusion table to the canal orifice.
(Ingle and Cohen)
5

6. OBJECTIVES OF CAVITY PREPARATION
6
To remove all coronal pulp tissue (vital or necrotic)
To locate all root canal orifices
To achieve straight- or direct-line access to the apical foramen or to the initial curvature of
the canal
To establish restorative margins to minimize marginal leakage of the restored tooth.

7. • Traditional concepts –
• One of the requirements of a traditional endodontic access cavity (TEC) is to allow for
a straight-line introduction of the endodontic instruments into the canals without
interference.
• To achieve this goal, an adequately extended access cavity by selective removal of the
tooth structure is necessary
• The survival rate of ETT can be jeopardised by their increased susceptibility to fracture
due to the loss of tooth structure.
• An excessive loss of sound tooth structure may cause a significant decrease in the
fracture resistance and increased cuspal flexure of ETT under functional load.
• Adjustments to the form and size of access cavity, canal taper, and apical preparation
size have correspondingly been proposed.
7

8. • Current developments –
• concept of MIEC underlies the development of the conservative endodontic access
cavity (CEC).
• All defective restorations and caries are removed before the preparation of CEC.
• Remaining sound tooth structures are preserved by preparing the access cavity from the
central fossa and extending only as far as needed to locate the canal orifices instead of
gaining complete straight-line access to them.
• In addition, the axial walls of CEC are often slightly convergent and occlusally bevelled
to allow for better visualisation of the pulp chamber and the canal orifices when viewed
from different angles.
8

9. • Clark and Khademi (2010a) strived to deconstruct the classical principles of access
cavity preparation: the complete unroofing of the pulp chamber and the straight-line
access to root canals.
• Instead, they proposed a new cavity design aiming to maintain as much as possible of
the pulp chamber roof and the socalled pericervical dentine, an area located 4 mm above
and below the crestal bone, which theoretically is responsible for the transmission and
balance of occlusal force to the root.
• According to their rationale, the safest way to avoid damaging this structure is through
partial preservation of the pulp chamber roof, which would reduce the flexion of the
cusps.
9

10. 10

11. PRINCIPLES OF ACCESS CAVITY PREPARATION
Endodontic Coronal Cavity Preparation
I. Outline Form
II. Convenience Form
III. Removal of the remaining carious
dentin(and defective restorations)
IV. Toilet of the cavity
Endodontic Radicular Cavity
Preparation
I and II. Outline Form and Convenience
Form (continued)
IV. Toilet of the cavity (continued)
V. Retention Form
VI. Resistance Form
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12. Outline form
The size of the pulp chamber
In young patients, these preparations must be more extensive than in older
patients, in whom the pulp has receded and the pulp chamber is smaller in all
three dimensions
 The shape of the pulp chamber,
The finished outline form should accurately reflect the shape of the pulp
chamber.
The number of individual root canals, their curvature, and their position.
To prepare each canal efficiently without interference, the cavity walls often
have to be extended to allow an unstrained instrument approach to the apical
foramen.
12

13. 13

14. Convenience Form
(1) unobstructed access to the canal orifice
(2) direct access to the apical foramen
(3) cavity expansion to accommodate filling techniques and
(4) complete authority over the enlarging instrument.
14

15. • Luebke has made the important point that an entire wall need not be extended in the
event that instrument impingement occurs owing to a severely curved root or an extra
canal.
• In extending only that portion of the wall needed to free the instrument, a clover leaf
appearance may evolve as the outline form- shamrock preparation
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16. Removal of the Remaining Carious Dentin and Defective Restorations
(1) to eliminate mechanically as many bacteria as possible from the interior of the
tooth
(2) to eliminate the discolored tooth structure, that may ultimately lead to staining of
the crown
(3) to eliminate the possibility of any bacteria-laden saliva leaking into the prepared
cavity.
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17. Toilet of the access opening
All of the caries, debris, pulp tissues and necrotic materials must be removed from
the chamber before the radicular preparation is begun, otherwise
these elements my be carried into the canal, it may act as an obstruction during canal
enlargement.
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18. GUIDELINES FOR PREPARATION OF ACCESS
CAVITIES
Visualization of the likely internal anatomy
Evaluation of the cementoenamel junction and occlusal anatomies
Preparation of the access cavity through the lingual and occlusal surfaces
Removal of all defective restorations and caries before entry into the pulp
chamber
Straight- or direct-line passage of instruments o the apical foramen or initial canal
curvature
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19. Delay of dental dam placement until difficult canals have been located and
confirmed
Location, flaring, and exploration of all root canal orifices
 Inspection of the pulp chamber, using magnification and adequate illumination
Tapering of cavity walls and evaluation of space adequacy for a coronal seal
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20. 1. Visualization of the Likely Internal Anatomy
Evaluation of angled periapical radiographs and examination of tooth anatomy at the
coronal, cervical, and root levels.
 Diagnostic radiographs
Palpation along the attached gingiva
help the clinician estimate the position of the pulp chamber, the degree of chamber
calcification, the number of roots and canals, and the approximate canal length
aids the determination of root location and direction.
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21. 2. Evaluation of the Cementoenamel Junction and Occlusal Anatomies
In a study involving 500 pulp chambers, Krasner and Rankow found that the CEJ
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
30(1):5, 2004.
21

22. 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 the CEJ: The distance from the external surface of the clinical crown to the
wall of the pulp chamber is the same throughout the circumference of the tooth at
the level of the CEJ
Law of color change: The pulp chamber floor is always darker in color than the
walls.
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23. First law of symmetry: Except for the maxillary molars, canal orifices are
equidistant from a line drawn in a mesiodistal direction through the center of 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.
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24. First law of orifice location: The orifices of the root canals are always located
at the junction of the walls and the floor.
Second law of orifice location: The orifices of the root canals are always
located at the angles in the floor–wall junction.
Third law of orifice location: The orifices of the root canals are always located
at the terminus of the roots’ developmental fusion lines.
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25. 3. Preparation of the Access Cavity Through the Lingual and Occlusal
Surfaces
Access cavities on anterior teeth usually are prepared through the lingual tooth
surface, and those on posterior teeth are prepared through the occlusal surface.
25
An incisal access cavity on mandibular
anterior teeth may allow for improved
straight-line access and canal débridement.

26. 26
A, Set of Micro-Openers (Dentsply Maillefer) for canal identification and enlargement.
B, Similar tool but with changeable instruments that are placed in the EndoHandle and
can be positioned straight or at different angles.

27. 4. Removal of All Defective Restorations and Caries Before Entry Into
the Pulp Chamber
With an open preparation, canals are much easier to locate, and shaping, cleaning,
and obturation are much easier to perform.
All carious dentin must be removed during access preparation.
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28. Removal of Unsupported Tooth Structure
All unsupported tooth structure should be removed to assess restorability and to
prevent tooth fracture.
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29. 5. Straight- or Direct-line Passage of Instruments to the Apical
Foramen or Initial Canal Curvature
Sufficient tooth structure must be removed
to allow instruments to be placed easily into each canal orifice without interference
from canal walls, particularly when a canal curves severely or leaves the chamber
floor at an obtuse angle.
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30. 6. Delay of Dental Dam Placement Until Difficult Canals Have Been
Located and Confirmed
Difficulty can arise in gaining access into teeth that are crowded and rotated,
fractured to the free gingival margin, heavily restored and calcified, or part of a
fixed prosthesis.
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31. 7. Location, Flaring, and Exploration of All Root Canal Orifices
A sharp endodontic explorer is used to locate canal orifices and to determine their
angle of departure from the pulp chamber.
Next, all canal orifices and the coronal portion of the canals are flared to make
instrument placement easier.
The canals are then explored with small, precurved K- files (#6, #8, or #10).
31

32. DENTINAL MAPPING
Embryologic fusion lines exist between canal and orifices and may appear as
white lines.
These lines usually end in canal orifices and a sudden disappearance of a line
would suggest presence of a canal orifice.
Stewart probe - instrument to use when tracing the map
32

33. 8. Inspection of the Pulp Chamber, Using Magnification and Adequate
Illumination
Magnification and illumination are particularly important in root canal therapy,
especially for
determining the location of canals; negotiating constricted, curved, and calcified
canals; and débriding and removing tissue and calcifications from the pulp chamber.
33

34. 9. Tapering of Cavity Walls and Evaluation of Space Adequacy for a
Coronal Seal
A proper access cavity generally has tapering walls with its widest dimension at the
occlusal surface.
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35. MECHANICAL PHASES OF ACCESS CAVITY
PREPARATION
• Magnification and illumination
• Handpieces
• Burs
• Endodontic explorers
• Endodontic spoon
• Ultrasonic unit and tips
35

36. 36
Access burs: #2, #4, and
#6 round carbide burs.
Access bur: #57 fissure
carbide bur.
Access bur: Round-end
cutting tapered diamond
bur.

37. 37
Access burs: Safety-tip
tapered diamond bur ;
safety-tip
tapered carbide bur
Access burs: #2
and #4 round
diamond burs. Access burs. A, Mueller
bur. B, LN bur or Extendo
Bur.
Access bur:
Transmetal bur.

38. Removal of the pulp
horn is evaluated with
a #17 operative
explorer.
A, Access instruments: DG-16 endodontic explorer. B,
JW-17 endodontic explorer.
Access instrument: Endodontic spoon

39. 39
A, Endo ultrasonic unit (MiniEndo II). B, ProUltra Piezo Ultrasonic

40. ANTERIOR ACCESS CAVITY PREPARATIONS
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41. External outline form:
Once caries and restorations have been removed
an initial external outline opening is cut on the lingual surface of the anterior
tooth.
• Intact tooth-cutting commences at the center of the lingual surface of the
anatomic crown
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42.  A #2 or #4 round bur or a tapered fissure bur
Bur orientation-
An outline form is created, similar in geometry to an ideal access shape
42

43. Penetration of the pulp chamber roof:
The angle of the bur is rotated from perpendicular to the lingual surface to
parallel to the long axis of the root.
Penetration is continued until the roof of the pulp chamber is penetrated,
frequently a drop-in effect is felt when this occurs.
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44. Removal of chamber roof:
Once the pulp chamber has been penetrated, the remaining roof is removed
by catching the end of a round bur under the lip of the dentin roof and cutting
on the bur’s withdrawal stroke
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45. In irreversible pulpitis, pulp tissue hemorrhage can impair the vision
removal of roof
amputation of coronal pulp at the orifice level-endodontic spoon or round bur
irrigation with sodium hypochlorite
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46. If the hemorrhage continues, a tentative canal length can be established
A small broach coated with a chelating agent can be introduced into the canal
and rotated.
Complete roof removal is confirmed with a #17 operative explorer if no catches
are discovered as the explorer tip is withdrawn from the pulp chamber along
the mesial, distal, and facial walls.
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47. Removal of the lingual shoulder and orifice and coronal flaring:
Once the orifice/s has been identified and confirmed, the lingual shoulder is
removed.
It is the lingual shelf of dentin that extends from the cingulum to a point approx. 2
mm apical to the orifice
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48. The lingual shoulder can be removed with a tapered safety-tip diamond or
carbide bur or with Gates-Glidden burs.
Care must be taken while using this bur to avoid placing a bevel on the incisal
edge of the access preparation
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Incisal bevel

49. When GG’s are used, the largest that can passively be placed 2 mm apical to the
orifice is used first.
During rotation, the bur is leaned against the lingual shoulder and withdrawn.
The size of these burs is increased sequentially, and repeated until the lingual
shoulder of dentin is eliminated.
49

50. To prevent iatrogenic mishaps on thin walls facing a root concavity, these burs are
placed passively into the canal and rotated
Other approach to flaring- the use of rotary nickel–titanium orifice openers at slow
speed and low torque
50

51. Straight-line access determination:
Ideally, an endodontic file can approach the apical foramen or the first point of
canal curvature undeflected.
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52. 52
Separation of a rotary endodontic instrument as a
result of underextended access preparation rather than
canal binding.

53. Deflected instruments function under more stress and are more susceptible to
separation during the shaping and cleaning process.
Attempts to shape and clean without straight-line access often lead to
procedural errors such as ledging, transportation, and zipping
53

54. Inadequate removal of the lingual shoulder causes the
file to deflect in a facial direction.
If the lingual shoulder has been adequately removed
and the file still binds on the incisal edge, the access
cavity should be extended farther incisally until the file is
not deflected.
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55. The final position of the incisal wall of the access cavity is determined by
two factors:
complete removal of the pulp horns
straight-line access.
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56. Visual inspection of the access cavity:
The axial walls at their junction with the orifice must be inspected for grooves that
might indicate an additional canal.
The orifice and coronal canal must be evaluated for a bifurcation.
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57. Refinement And Smoothing Of Restorative Margins
The final step in the preparation of an access cavity is to refine and smooth the
cavosurface margins.
Butt joint margins are indicated rather than beveled margins, which produce thin
composite edges that can fracture under excursive functional loads and ultimately
result in coronal leakage.
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58. Posterior Access Cavity Preparations
Removal of caries and permanent restorations:
Posterior teeth requiring root canal therapy typically have been heavily
restored or the carious process is extensive.
Such conditions, along with the complex pulp anatomy of posterior teeth, can
make the access process challenging.
58

59. Initial external outline form:
The removal of caries and existing restorations often
accomplishes the creation of an initial external outline form.
An access starting location must be determined for an intact tooth.
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60. Crowns of mandibular premolars are tilted lingually relative to their roots and
the starting location must be adjusted to compensate for this tilt
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61. In mandibular first premolars the starting location is halfway up the lingual
incline of the buccal cusp on a line connecting the cusp tips.
Mandibular second premolars require less of an adjustment because they have less
lingual inclination.
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62. Molars
To determine the starting location for molar access cavity preparations, the
clinician must establish the mesial and distal boundary limitations.
Evaluation of bite-wing radiographs is an accurate method of assessing the
mesiodistal extensions of the pulp chamber.
62

63. For molars the correct starting location is on the central groove halfway between the
mesial and distal boundaries.
Maxillary Molars
The mesial boundary : a line connecting
the mesial cusp tips.
Distal boundary: the oblique ridge
Mandibular Molars
The mesial boundary : a line connecting
the mesial cusp tips
Distal boundary: line connecting the
buccal and lingual grooves.
63

64. Penetration of the pulp chamber roof:
Continuing with the same bur, the angle of penetration should be changed from
perpendicular to the occlusal table to an angle appropriate for penetration
through the roof of the pulp chamber.
In premolars the angle is parallel to the long axis of the root(s) both in the mesiodistal
and buccolingual directions.
In molars the penetration angle should be toward the largest canal, because the
pulp chamber space usually is largest just occlusal to the orifice of this canal.
64

65. Maxillary molars the penetration angle is toward the palatal orifice
Mandibular molars it is toward the distal orifice.
Aggressive probing with an endodontic explorer often can help locate the
pulp chamber.
65

66. Complete roof removal
A round bur, a tapered fissure bur, or a safety-tip diamond or carbide bur is used
to remove the roof of the pulp chamber completely, including all pulp horns.
66

67. The goal is to funnel the corners of the access cavity directly into the orifices
using safety tip diamond or carbide bur
67

68. Identification of all canal orifices:
Ideally, the orifices are located at the corners of the final
preparation to facilitate the shaping and cleaning process.
Internally, the access cavity should have all orifices
positioned entirely on the pulp floor and should not
extend into an axial wall.
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69. Extension of an orifice into the axial wall creates a MOUSE HOLE
EFFECT which indicates internal under extension and impedes straight-line
access.
In such cases the orifice must be repositioned onto the pulp floor without
interference from axial walls.
69

70. Removal of the cervical dentin bulges and orifice and coronal flaring:
Posterior teeth - internal impediments are the cervical dentin bulges and the
natural coronal canal constriction.
These bulges can be removed with safety-tip diamond or carbide burs or
Gates-Glidden burs.
The instruments should be placed at the orifice level and leaned toward the
dentin bulge to remove the overhanging shelf
70

71. As the orifice is enlarged, it should be tapered and blended into the axial wall
71

72. Visual inspection of the pulp chamber floor:
• Same as Anterior Access Cavity Preparations
Refinement and smoothing of the restorative margins:
• In both temporary and interim permanent restorations, the restorative margins
should be refined and smoothed to minimize the potential for coronal
leakage.
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73. 73
C, Penetration ofthe pulp roof.
D, Removal of the pulp roof/pulp horns with
a round carbide bur.
E, Location of the orifice with a Mueller or
LN bur.
F, Exploration of the canal with a small K-
file.
G to I, Flaring of the orifice/coronal third of
the mesial canal with Gates-Glidden burs. J,
Flaring of the orifice/coronal third of the
distal canal with a #.12 taper nickel-titanium
rotary file. K, Flaring of the orifice/coronal
third of the distal canal with a Gates-
Glidden bur.
L, Funneling of the mesial axial wall from
the cavosurface margin to the mesial orifice.
M, Funneling of the distal axial wall from
the cavosurface margin to the distal orifice.
N, Completed access preparation. O,
Verification of straight-line access.

74. CHALLENGING ACCESS PREPARATIONS
Teeth with Minimal or No Clinical Crown
74
Mandibular molar with significant
calcification of the pulp
chamber and canal spaces

75. • Access cavity preparation when the
anatomic crown is missing. A,
Mandibular first premolar with the
crown missing. B, An endodontic
explorer fails to penetrate the calcified
pulp chamber. C, A long-shank round
bur is directed in the assumed long axis
of the root. D, Perforation of the root
wall (arrow), resulting from failure to
consider root angulation. E, Palpation of
the buccal root anatomy without a dental
dam in place to determine root
angulation. F, Correct bur angulation
after repair of the perforation with
mineral trioxide aggregate (MTA). The
dental dam is placed as soon as the canal
has been identified.
75

76. Heavily Restored Teeth (Including Those with Full Coronal Coverage)
76
Access cavity error resulting from alteration of the original tooth contours by a full veneer
crown.
A, Original crown contour of the tooth.
B, A full veneer crown is used to change the original crown contour for esthetic
purposes.
C, Access perforation resulting from reliance on the full veneer crown contour rather than
the long axis of the root.

77. 77
A, In a heavily restored maxillary
second molar that requires root canal therapy,
the clinician may attempt access to the canals

78. 78
A, Radiograph showing apical lesions on both
roots and recurrent caries under the mesial
margin of the crown.
B, Clinical photograph of the crown and
tissues that appear normal. C, Cutting of the
crown from the tooth. D, Crown has been
removed, and decay is evident around the
core restoration. E, Removal of the old
restoration shows significant decay. F, Final
excavation, which allows for evaluation of the
tooth structure and facilitates direct access to
the pulp chamber.

79. 79
A, Extensive class V restoration necessitated by root caries
and periodontal disease that led to canal calcification
B, Access to the canal is occluded by calcification. Removal of
the facial restoration may be required to obtain access from
the buccal surface

80. Access in Teeth with Calcified Canals
80
Access cavity preparation through a metalloceramic crown. A, A round diamond bur is used to
penetrate the porcelain. B, Following the access outline with the round diamond bur, a transmetal
bur is used to cut through the metal. C, Prepared access cavity allowing direct approach to the
canals. D, Files are placed on the access cavity walls without impingement

81. 81
Mandibular molar with what appears to be
almost complete calcification of the pulp
chamber and root canals.
However, pathosis is present, which indicates
the presence of bacteria and some necrotic
tissue in the apical portion of the roots.

82. 82
Mandibular first molar with a class I restoration, calcified canals,
and periradicular radiolucencies

83. Crowded or Rotated Teeth
83
A, Access cavity on crowded mandibular anterior teeth. The access
preparation is cut through the buccal surface on the canine. The
lateral incisor has also been accessed through the buccal surface;
root canal procedures were performed, and the access cavity was
permanently restored with composite. B, Obturation.

84. ERRORS IN ACCESS CAVITY PREPARATION
84
Errors can occur in the preparation of an access cavity. Mostly – failure to follow the
access guidelines (or) a lack of understanding of the internal and external tooth
morphology.

85. 85
E-Inadequate extension of the distal access cavity -
distobuccal canal orifice unexposed.
All developmental grooves must be traced to their
termination and must not be allowed to disappear into an
axial wall.
E-Gross overextension of the access cavity weakens the
coronal tooth structure and compromises the final
restoration.
failure to determine correctly the position of the pulp
chamber and the angulation of the bur.

86. 86
Allowing debris to fall into canal orifices
Complete removal of the restoration and copious
irrigation help prevent this problem
Failure to remove the roof of the pulp chamber
Bite-wing radiographs are excellent aids in determining
vertical depth.

87. 87
Inadequate access
opening Labial perforation Furcation perforation failure to align the bur
with the long axis of the
tooth

88. 88
entering the wrong tooth because of incorrect dental
dam placement. When the crowns of teeth appear
identical, mark the tooth with a felt-tip marker before
the dental dam is placed.
Broken instrument . A broken instrument may lock into
the canal walls, requiring excessive removal of tooth
structure to retrieve it.

89. PRESERVATION OF TOOTH STRUCTURE
• Pericervical dentin
• Banking of the tooth structure ( Soffit ) - Acc to clark and kadami - A small part of
roof of pulp chamber is retained around the pulp chamber to preserve pericervical
dentin, which is known as the soffit.
• 3- Dimensional Ferrule - Ferrule is the axial wall of dentin covered by the axial
wall of the crown and has been described as the backbone of prosthetic dentistry.
89

90. 90
SOFFIT
3D FERRULE

91. NEWER ACCESS PREPARATION DESIGNS
• Truss access
• Ninja Endodontic Access Cavity
• Caries leveraged access
• Cala Lilly Enamel Preparation
• Guided endodontic access
• Dynamic Guided access
91

92. Truss access
92
Preservation of dentin by leaving a truss of dentin
between the two cavities thus prepared.
Orifice- directed dentin conservation access cavity

93. Ninja Endodontic Access Cavity
93
To obtain outline for “ninja” access
the oblique projection during access preparation
is made in an occlusal plane towards the central
fossa of the root orifices
Ultra conservative access cavity

94. Caries leveraged access
94
Clark and Khademi
low or zero value tooth or restorative structures
i.e., existing restorative materials, decay and
less strategic tooth structure are removed for
access preparation.

95. Cala Lilly Enamel Preparation
A bevel (45 degree) is given on the enamel portion of access cavity to remove
undermined enamel which resembles a calalilly flower
improving the overall resistance and strength of the access preparation.
95

96. 96

97. Guided endodontic access
• Utilizes 3D printed templates to gain minimal invasive access to root canals.
Intraoral scanning is done followed by CBCT scanning.
97

98. • VIRTUAL Drill path is then planned on the computer screen which AND
VIRTUAL SLEEVE PREPARED FOR GUIDING THE BUR.
• TEMPLATES are prepared based on this and their fitting is checked. Marks then
set through the template sleeves to indicate the region of access cavity. Access is
then prepared in this area using specific bur to gain access to the root canal.
98

99. Dynamically guided access cavity
Uses an overhead three dimensional camera system (X-NAV System)
which helps to relate the position of the handpiece and the jaw of
the patient during the clinical procedure.
99

100. 100

101. 101

102. CONCLUSION
Successful access cavity preparation relies on a sound knowledge
of the internal and external anatomy of teeth.
The importance of gaining straight line endodontic access cannot
be over emphasised. Ultimately poor access cavity design could
lead to inadequate cleaning, shaping and obturation com-
promising successful outcome.
102

103. REFERENCES
Cohen – pathways of pulp – 11th edition
Ingles endodontics – 5th edition
Grossman’s endodontic practice,12th edition
Modern Concepts in Endodontic Access Preparation: A Review Ann
Kuriakose, Basil Joy, Joy Mathew, Krishnan Hari, Joseph Joy, Feby
Kuriakose
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