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Minimally Invasive When? How? Why?: Access Cavity Preparation in Endodontics
Minimally Invasive When? How? Why?: Access Cavity Preparation in Endodontics
When?
roots
12 1 2018
trends & applications |
Figs. 3a–c: Cleaning the isthmus with an ultrasonic tip for endodontic surgery. The tip was used to remove calcification and shape the isthmus, with mesial
access to preserve the occlusal surface. Figs. 4a–c: Cleaning the isthmus with an ultrasonic tip for endodontic surgery. The tip was used to remove calcifi-
cation and shape the isthmus, with mesial access to preserve the occlusal surface. Fig. 5: Pre-op periapical radiograph of tooth #16, which presented with
mesial caries. Fig. 6: Cleaning the pulp horns with an ultrasonic tip. Fig. 7: Post-op periapical radiograph, in which the preserved tooth structure can be seen.
Fig. 8: Post-op periapical radiograph, in which the preserved tooth structure can be seen.
– access allows exploration and cleaning of the pulp with irreversible pulpitis or necrosis due to proximal car-
chamber without removing the pulp horns and with ies that does not extend to the occlusal surface. In these
minimal removal of the roof. cases, after eliminating the entire carious lesion, it is
possible to extend the preparation a little bit occlusally
According to these points, we consequently discuss in to perform the endodontic treatment through a mesial
which clinical situations preparing a conservative access or distal cavity.
cavity is recommended.
Teeth with irreversible necrosis or necrosis caused by
Teeth with irreversible pulpitis or necrosis due to preparation below crowns and bridges
Class V cavities In such cases, if the pulpal pathology is due to the
After removal of the caries, a sound occlusal surface preparation of the teeth and provided that no carious le-
can be obtained. Therefore, in this case, it is advised to sion exists and the crown or a bridge has definitive mar-
prepare a conservative access cavity in order to pre- gins, it is ideal to prepare a conservative access cavity for
serve the tooth structure. This applies likewise to teeth structural and aesthetic reasons.
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| trends & applications
Fig. 11a
Fig. 9a Fig. 9b
Fig. 11b
Figs. 9a & b: Pre-op periapical radiograph of tooth #26, which had irreversible pulpitis, for which a conservative access cavity was prepared under the crown
restoration. Figs. 10a & b: Under magnification, it is possible to see and remove calcification and expose the mesiobuccal (MB) canal. Figs. 11a–c: Under
magnification and using an ultrasonic tip, the isthmus was prepared and the second mesiobuccal (MB2) canal was found.
Teeth with irreversible pulpitis or necrosis caused by inate any debris. Afterwards, using a K-type file of small
periodontic-endodontic lesions with no or minimal diameter (0.08 mm), the root canals are probed and ex-
occlusal caries plored. Subsequently, any calcifications are visualised
Severe periodontal disease can lead to pulpal pathol- under magnification, then removed with ultrasonic tips.
ogy, while the tooth structure can be intact and sound. In If some of the root canals cannot be found at this point,
such cases, a small conservative access cavity can aid they can be located using ultrasonic tips while cutting into
in maintaining the integrity of the affected teeth. This ap- the floor of the chamber.
plies similarly to cases of teeth with irreversible pulpitis or
necrosis due to trauma or hazardous occlusal stresses. One of the important points in the conventional ex-
tended access opening cavity is the complete removal of
How? the pulp chamber roof (which is important to avoid bacte-
rial contamination from pulp residue). However, with the
The conservative design of access cavities can be ap- modern method of conservative access cavity prepara-
plied only when the operator has adequate experience tion, this excessive removal of dentine can be avoided by
and with the aid of modern technologies, such as a dental completely cleaning all of the roof of the pulp chamber
operating microscope, ultrasonic tips, modern nickel-ti- without leaving any pulp residue. This can be accom-
tanium rotary files and modern 3-D cleaning. Only under plished using ultrasonic tips designed for endodontics.
high magnification and with an efficient light is it possible In this case, it is advised to use a small ultrasonic tip with
to visualise, through the small access cavity, the entire a small round diamond end or an ultrasonic tip designed
floor of the pulp chamber, all of the root canal orifices, for periapical surgery. Such special ultrasonic tips are
the main canals, the accessory canals and any obstruc- able to clean the pulp horns and the remaining roof with-
tions, such as calcifications. Therefore, the use of the op- out removing any valuable tooth structure (Figs. 1 & 2).
erating microscope in preparing such small access cav-
ities is crucial. An additional point, which was very important in the
past, is that the insertion of the files into the root canals
Preparing a conservative access cavity is done under must be done in a perpendicular direction to the occlusal
the operating microscope and drilling with long shank surface of the tooth. In order to achieve such an entrance
burs of small diameter (0.8–1.0 mm), for better visibility, to the canals, sound tooth structure is sacrificed. With
to penetrate the pulp chamber. Once in the chamber, ir- the conservative access cavity, we can enter the canals
rigation with sodium hypochlorite is done in order to elim- at an angulation that is perpendicular to the coronal one-
roots
14 1 2018
trends & applications |
Figs. 12a–d: The four canals after obturation. P = palatal; MB2 = second mesiobuccal; MB = mesiobuccal; DB = distobuccal. Fig. 13: Post-op radiograph.
third of the canal as illustrated in Figure 1b. Moreover, obtain short- and long-term success. Above all, valuable
with the aid of pre-bent modern rotary files, which have sound tooth structure will be preserved in comparison
super-elastic alloys even in their martensitic phase (rest with the conventional access design.
phase), it is possible to enter root canals with difficult ac-
cess without sustaining fractures. Certainly, in order to prepare these conservative ac-
cess cavities, it is necessary for the operator to have
Only after we have visualised the actual anatomy of the enough clinical experience. Equally important is the use
pulp chamber is it possible to precede with root canal of modern technologies, in particular the dental operating
shaping, followed by the phases of 3-D cleaning and 3-D microscope, ultrasonic tips, modern rotary files and up-
obturation. With modern protocols of irrigant activation, to-date protocols of 3-D cleaning. In conclusion, these
it is possible to guarantee a more accurate and thorough modern technologies and this conservative access de-
cleaning. Among these protocols are ultrasonic activa- sign should be implemented by more endodontists in or-
tion, sonic activation, internal heating, laser and negative der to achieve higher rates of success and longevity of
apical pressure. root canal therapies.
Conclusion
Dr Dina Abdel Latif
If through the conservative access cavity, it is possi- is an endodontist, clinical and pre-clin-
ble to eliminate the entire carious lesion, to visualise the ical instructor (Department of Conser-
whole floor of the pulp chamber, to explore all of the ca- vative Dentistry) at Alexandria University
nal orifices, to prepare and to clean the isthmuses, and in Egypt. She can be contacted at
to remove any calcifications present, then it is possible to dinaabdellatif81@gmail.com.
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