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ePaper created 2016-11-22, 09:52:12 | version 1.38.0
| technique access cavities 22 roots 4 2016 Cutting endodontic access cavities— for long-term outcomes Author: Dr L. Stephen Buchanan, USA Errors accumulate during procedures. That’s the rea- son botching the access at the start of an RCT is so muchmoredevastatingthansay,problemsthatcome frommisfittingagutta-perchaconejustbeforefinish- ing the case. Miss a canal and the case is going down, regardlessofhowbrillianttheremainingprocedureis carried out. Perforate the tooth, and suddenly tita- nium starts looking better. Cut huge access cavities, andexpecttoseerelativelyhugenumbersofroot-frac- tured teeth within five years of treatment. Simply cheat the access procedure by beginning the instru- mentationofcanalsbeforeastraight,perfectlysmooth path has been cut to each canal orifice, and be pun- ishedeverytimeafile,anirrigatingneedle,anexplorer, a gutta-percha point, a paper point or a plugger is taken into each of the canals scores of times. This is not a critique so much as an admission of the ways that teeth and their root canal systems have taught me, usually the hard way, to spend whatever time is needed to create perfect entry paths into canals, before I attempt to work in them. So why do I have to have a talk with myself before beginningeveryaccesscavity—evenafterdoingthis for 35 years—to be certain to hit the mark I know must be met before it is safe to venture further? Zen and the art of endo access Robert Persig, in his book “Zen and the Art of Motorcycle Maintenance,”1 described being deeply frustratedwhenaboltstrippedashewasattempting toremovethesidecoverstotheengineofhismotor- cycle,beforerebuildingit.Therebuildcouldnotcon- tinue until he was able to circumvent this problem. He had expected to spend several days completing the mission, yet he was amazed at the fury he expe- rienced when faced with this conundrum. The more he thought about it, the more mystified he became about his instinctual response, until he realized that he was tweaked because he had grossly undervalued this part of the long rebuild procedure, thinkingmostlyaboutthemoredramaticroutinesto follow,suchascrackingthecylindercase,honingthe cylinder, replacing the piston and putting it all back together afterward. When he realized that nothing was going to progress until he had successfully re- moved the side cover, he made removing that side cover a separate and important mission, an accom- plishment that would deliver satisfaction in and of itself,ifitcouldbecompletedduringthenextseveral hours spent. Fig.1: Maxillary central incisor with slot-like access cavity that is cut short of the incisal edge,adequately under the cingulum,and has been kept narrow in its mesial-to-distal dimension.(Photos:Provided by Dr L.Stephen Buchanan, unless otherwise noted) Fig.2: Mandibular premolar with slot-like access cavity for a single canal root.Note how the access cavity is skewed toward the working buccal cusp tip and shy of the idling lingual cusp,yet is centered above the root structure,as evidenced by the rubber dam clamp jaws engaged at the CEJ. Fig.3: Sagitally dissected maxillary molar with mesially inclined access cavity,parallel to the mesial surface of the tooth and shy of the distal half of the tooth. Fig.1 Fig.2 Fig.3 42016