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Endo tips    Better Endo    Endo abstracts    Endo discussions

Maxillary molar access - Courtesy ROOTS
The opinions and photographs within this web page are not ours.
Authors have been credited
for the individual posts where they are. - www.rxroots.com

From: Terry Pannkuk
To: ROOTS
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 
   restrictive dentin.

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 
	shaping process.

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

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