Maxillary molar access - Courtesy ROOTS
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From: Terry Pannkuk
Sent: Wednesday, March 25, 2009 10:43 AM
Subject: [roots] Access Demo from Today
I decided to take sequence pics of a maxillary molar access today
in order to dispell all the bad advice floating around that is likely
to cause you to miss canals, inadequately clean systems, poorly
obturate, and increase the chance of separating an instrument.
I'm sure an argument storm is about to ensue.....so be it.
1. I rarely use ultrasonics on an access. Composite finishing burs
are much more efficient and plane walls smoother.
2. Initial penetration is basically palatal to buccal toward the
mesial and parallel to the mesial wall of the crown.
3. You can usually find the mesial pulp horn first because it is
typically the most coronal, penetrate it and peel off
the ceiling toward the palatal pulp horn, then to the DB which
is in a less predictable orientation.
4. Pull the main three corners out and flare for a direct line to
the MB1, DB and P orifices. This is the complete access outline
for those favoring the dangerous "ship-in-a-bottle" philosophy.
5. Next use a football diamond to lightly "bowl" each of the three
orifices out to the MB, DB, and ML-P line angles... not deep..
the idea is just to efficiently bowl out the mid-mass of dentin
that otherwise would take forever to eventually remove by other means.
6. Next use a cone composite finishing bur to "peel" away the orifice
dentin overhang that restricts direct line entry from the "diamond bowl"
to the orfice...this is usually a thin overhanging slice of
7. At this point the MB2 on an uncomplicated case is very easy to
identify. Don't even think of putting a file in any of the canals
yet. It's not time and you risk ledging!
8. Bowl out the clearly identified MB2 orifice with the football
diamond toward the mesial marginal ridge in the same way you did
the MB1, DB, and P. You want to be fairly aggressive bowling it
out wide but not particularly deep. You will rarely over "bowl"
although it is possible. The error is usually on the wimpy side.
9. Peel the overhanging lip off MB2 ceiling dentin to smooth it
evening from the orifice to the "bowl" ledge on the
periphery just like you did on the other three canals.
10.It is now safe to use hand files.........MB2 last! (if the MB1-MB2
are confluent, extirpating the pulp from the MB1 first is better
and simplifies things)
***** Remember that you should always copiously irrigate with NaOCl.
through out this process. Highspeed handpiece use should always have
waterspray blowing away debris. Up until you use the first hand files
rinse with EDTA after use of the high speed to clear away dentin debris
and visualize orifices and grooves.
11.Recapitulate several times with precurved hand files series in each
canal system not worrying about length but knowing you're short of
the estimated lengths.
12.Peel the orifices peripherally with the cone shaped composite
finishng bur, or the flame tip if access is adequate and the canal
is opened up enough not to hit walls with the tip which will ledge.
I tend to limit the use of the flame tip to the larger palatal canals,
rarely the DB, MB1, or MB2. The egg shaped composite finishing bur
can be used to bowl out orifices peripherally where the tooth is
smaller, an exterior concavity exists, and you are worried
that the football diamond is too large and inappropriate for the
presented root morphology.
13. Recapitulate with precurved hand files again. This centrically
moves the orifices peripherally away from the
furcation and establishes a much safer angle for file entry.
14. At this point, you might consider use of rotary files if the
recapitulations with hand files seemed to suggest
simply anatomy and a system form that allows the files to slide
safely down the root without catching fins or accessory canals.
Many times I won't use rotaries until late in the cleaning and
15. At this point it is safe to flare the coronal 1/3 with Gates.
I use 1 through 4 but only passively. The one slides down passively
never pushed into the dentin so that it contacts the walls
circumferentally. The idea is just to make an oval canal system
a bit more circular in cross-section which facilitates better
cleaning and convenience form to the mid-root and apical third.
Just let the Gates go lightly where they go lightly and use
RC-Prep flooded in the pulp chamber which is a nice viscous
irrigant that keeps debris in suspension. Sometimes the Gates
barely go into the MB2 oriice at all....don't worry about it.
The coronal flare can be developed a bit more later.
16. Take EAL (if necessary) and wire films for length measurement.
At this point you may find out the MB2 joins the MB1 at a coronal
level and you can be very conservative with the shaping.
If it doesn't and it's long, bowl out the mesial wall a little
more aggressively for safety, perform some more hand file
recapitulations and perrform the passive Gates again and begin
the cleaning and shaping sequence.
Completion of final access design has been performed. You can see
that the final access outline form has been strategically and
systematically developed which is why it should be considered a
"SEE" access. A "Strategically Extended Endodontic " access is also
a "Systematically Extended Endodontic" Access... also a "Smart
(not Stupidly) Extended Endodontic" access, and above all a
"Safely Extended Endodontic" access.
There are multiple ways to See a "SEE" access. :) - Terry
Nice presentation Terry, you are a great teacher, thanks a lot - Jose
Nice, Terry. More please - Guy
Nah. Simply unecessary, and untrue. Learn to use the mirror and
place your rotary instruments visually. Here is a patient I saw the
same day Terry posted his pics. The angles of entry call for access
extensions kinda...well...oppositve of what Pannkuk is showing
- John A Khademy
John, a couple of questions:
1. Considering the case you showed - the reason for endo was?
Root caries, crack or resoprtion? -. can't clearly seen from x-ray
... just curious.
2. In the access like that, where are your reference points for
measuring length? Let's say both MBs are measured from where the
probe hits palatal cusp incline as in your pic? and similarily to this:
DB is measured from mesial incline? and P from MB cusp tip?
3. How do you sequence preparation of the canals: do you shape one
canal to final shape and get to the next one or do you do prep them
simultaneously (first one instrument to all canals, then next instrument
and so on till final shape)? - Dmitri
Shaping isn't necessarily cleaning unless the shaping facilitates the
cleaning. Without access convenience form to facilitate flushing of irrigant
and evacuation of debris.....you just have nice looking rads hiding
the caca. - Terry
Címon John. Letís get real OK? Maybe YOU can do this with a Xenon
illuminated access and an Endodontistís experience.
Anyone else without the equipment and skills that YOU have.and you
get missed canals, missed anatomy and busted files.
If you can do it.fine. But donít for one second think that schools
can teach it (I DO teach at schools) or that it will result in raising
the bar for the average RD. It will result in exactly the opposite.
You can'ít treat what you canít see.
John, you and I are buddies, but I will say publicly that if you come
to town and try and teach that kind of crap to my referrals , I will
be all over you like Chris Brown on Rihanna.
Learn to use the mirror and place your rotary instruments visually.
You know, I distinctly remember Herb Schilder talking about finding
MB2 at a convention lecture. One guy stood up and said he couldnít
even find the MB root, never mind the MB2 canal. He might have meant
MB1 but the look on Herbís face was priceless. - Rob K
This is about radiographic esthetics and not really cleaning the case.
If you don't have the access convenience form, the system isn't clean.
Debris churns and rolls but isn't flushed out. Constricted access
also resricts file entry taking out the bend of a precruved file before
it can efficiently contact apical third walls and fins. You can tell
this by the lack of irregular Hess anatomy filled apically.
You can shape or you can clean but if you haven't shaped to facilitate
cleaning it doesn't matter how symetric, and nice it is on the
radiograph.....it's still crap-filled.
It's quite interesting how the same people that have argued for years
against the "LOOK" when it really meant something are the ones now
showing off the "LOOK" that doesn't. :):):) - Terry