Minimal endodontic access

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Minimal endodontic access

Postby BarryMusikant on Wed Jul 15, 2015 11:10 am

The latest fashion in endodontics appears to be centered around minimal access openings leaving the roofs of pulp chambers only partially removed in the quest for retaining increased amounts of tooth structure and leaving the tooth more resistant to vertical fracture. Along with minimal access, is the reduction in both the size of the apical preparation and the taper along the length of the canal again preserving more tooth structure.  Reasonable questions to ask are whether these techniques can be routinely applied to most teeth, what conditions may be present that don’t allow for this approach and what is the impact of lesser-tapered preparations?

I saw examples of this conservative approach on DentalTown and noted that the access was into pulp chambers filled with soft pulp tissue, the type of chambers one “fall” into.

This is not the configuration of the majority of the pulp chambers we treat in our endodontic office. Many of our patients are older with secondary calcifications obliterating the pulpal spaces completely. We are not falling into anything. As a result, finding the canal orifices requires a slow methodical removal of overlying dentin with the color of dentin along with our knowledge of canal anatomy as the prime criteria directing us where to go. Vision in these cases is essential. Leaving any dentinal bridges constituting the roof of the chamber would be impediments that compromise our ability to view the floor as we negotiate deeper in the quest for the canal orifices.

Along with the maintenance of the roof of the pulp chamber as demonstrated in the posted case on DentalTown was the final obturation of the prepared canals, shown radiographically, canals prepared with minimal taper in the mesio-distal plane and what appears to be apical preparations no greater than a 25.

I am all for minimal preparations in the mesio-distal plane because it preserves tooth structure where the roots are the thinnest reflecting the thin configuration of pulp tissue in this plane. When the radiograph clearly shows well-defined canals in the mesio-distal plane, we know that most often significant amounts of pulp tissue also reside in the buccal and lingual extensions.

If the goal is to remove minimal amounts of tooth structure, canals open to minimum tapers and apical preparations will encounter little resistance mesio-distally and particularly bucco-lingually where the canals are wider. In these situations the more conservative usage of rotary instruments leads to smaller conical shapes and tapers preserving tooth structure, but leaving more tissue remnants in the bucco-lingual planes. Using rotary instruments vigorously in the bucco-lingual plane subjects the instruments to a greater chance of separation further discouraging their use in this manner. Minimal access also implies a reduced ability to work the instruments in the bucco-lingual plane. The narrower walls of access limit the degree the instruments may be extended in this plane before they encounter the axial walls.

Minimal access as a philosophy has value in preventing the wholesale destruction of coronal dentin by eliminating lateral gouging. With the standard conservative access made into pulp chambers whether filled with pulpal or calcified tissue, the differences in the amount of dentin removed should be relatively inconsequential. Of more importance is the conservative preservation of dentin in the mesio-distal plane along with thorough debridement of the canal in the bucco-lingual plane. This criteria imo is far more important than the  the minimalist approach to coronal openings.

Regards, Barry
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Re: Minimal endodontic access

Postby ASHOK on Thu Jul 16, 2015 11:14 am

I totally agree with you Dr. Barry. Regards, Ashok.
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Re: Minimal endodontic access

Postby william on Thu Jul 16, 2015 10:50 pm

that tooth still needs an onlay even if the bridge of dentin was preserved...
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