ANATOMY

74% - apical third

11% - middle third
15% - cervical third.
All groups of teeth had at least one accessory
foramen.



The maxillary premolars had the most and the largest
accessory foramina (mean value, 53 m) and the most
complicated apical morphologic makeup. The
mandibular premolars had strikingly similar
characteristics, a possible reason why root canal
therapy may fail in premolar teeth.
Anatomy of the Apical Root

The space between the
major and minor
diameters has been
described as funnel
shaped or hyperbolic, or
as having the shape of a
morning glory.
According to Weine
CANAL CONFIGURATIONS
According to Vertucci
The only tooth that showed all eight possible
configurations was the maxillary second premolar.
C-SHAPED CANAL

that often occurs in
MANDIBULAR SECOND MOLAR

C-shaped mandibular molars are so named because of
the cross-sectional morphology of their fused roots and
their root canals.




Instead of having several discrete orifices, the pulp
chamber of a molar with a C-shaped root canal system is
a single, ribbon-shaped orifice with an arc of 180
degrees or more.

Melton et al. in 1991 proposed the following classification of C-
shaped canals based on their cross-sectional shape. Fan et al. in
2004 modified Meltons method
Isthmus classifications described by Kim and colleagues.

Type I is an incomplete isthmus; it is a faint communication between two
canals.
Type II is characterized by two canals with a definite connection between them
(complete isthmus).
Type III is a very short, complete isthmus between two canals.
Type IV is a complete or incomplete isthmus between three or more canals.
Type V is marked by two or three canal openings without visible connections.
Nine guidelines, or laws, of pulp chamber
anatomy to help clinicians determine the
number and location of orifices on the
chamber floor:-


Law of centrality: The floor of the pulp chamber is
always located in the center of the tooth at the level of
the CEJ.


Law of concentricity: The walls of the pulp chamber are
always concentric to the external surface of the tooth at
the level of the CEJ, that is, the external root surface
anatomy reflects the internal pulp chamber anatomy.
Law of the CEJ: The distance from the external surface
of the clinical crown to the wall of the pulp chamber is
the same throughout the circumference of the tooth at
the level of the CEJ, making the CEJ is the most
consistent repeatable landmark for locating the position
of the pulp chamber.


First law of symmetry: Except for the maxillary molars,
canal orifices are equidistant from a line drawn in a
mesiodistal direction through the center of the pulp
chamber floor.






Second law of symmetry: Except for the maxillary molars,
canal orifices lie on a line perpendicular to a line drawn in
a mesiodistal direction across the center of the pulp
chamber floor.
Law of color change: The pulp chamber floor is always darker
in color than the walls.


First law of orifice location: The orifices of the root canals are
always located at the junction of the walls and the floor.


Second law of orifice location: The orifices of the root canals
are always located at the angles in the floorwall junction.


Third law of orifice location: The orifices of the root canals are
always located at the terminus of the roots developmental
fusion lines.
Allowing sodium hypochlorite
(NaOCl) to remain in the pulp
chamber may help locate a
calcified root canal orifice. Tiny
bubbles may appear in the
solution, indicating the position of
the orifice.
INSTRUMENTS USED IN
ACCESS CAVITY
Access burs: #2
and #4 round
diamond burs.
Access burs

Safety-tip tapered
diamond bur (left);

Safety-tip tapered
carbide bur (right
Access bur: round-end
cutting tapered diamond
bur
Access burs

A, Mueller bur

B, LN bur.
Gates-Glidden burs, 1 through 6.
Access instruments
DG-16 endodontic explorer (top);

JW-17 endodontic explorer (bottom).
It is the efficient uncovering the
roof of the pulp chamber &
providing the direct access to the
apical foramina by the way of
the pulp canals.
ACCESS OPENING
According to R.E. Walton, the 3 main objectives of access
cavity preparation are :-

1. Straight line access : Helps in
a. Improved instrument control.
b. Improved obturation.
c. Decreased procedural errors.
2. Conservation of tooth structure :-
a. Minimal weakening of tooth.
b. Prevention of perforation.

3. Un roofing of chamber and exposure of pulp
horns :-
a. Maximum visibility.
b. Location of canals.

Principles of Endodontic Cavity
Preparation
Endodontic Coronal Cavity Preparation :-
I. Outline Form
II. Convenience Form
III. Removal of the remaining carious dentin and
defective restorations.
IV. Toilet of the cavity
Principle I: Outline Form
The outline form of the endodontic cavity must be
correctly shaped and positioned.

Establish complete access for instrumentation, from
cavity margin to apical foramen.

External outline form = internal anatomy of pulp.

Principle II: Convenience form
(1) Unobstructed access to the canal orifice.


(2) Direct access to the apical foramen.


(3) Cavity expansion to accommodate filling
techniques.


(4) Complete authority over the enlarging
instrument.
Principle III: Removal of the Remaining Carious
Dentin and Defective Restorations
This according to Ingle, must be done for three reasons:-

(1) To eliminate mechanically as many bacteria as
possible from the interior of tooth


(2) To eliminate discoloration of tooth structure


(3) To eliminate the possibility of any bacteria- laden
saliva leaking into the prepared cavity.
Principle IV: Toilet of the Cavity
1. All of the caries, debris, and
necrotic material must be removed
before the radicular preparation is
begun.


2. 0bstruction, bacterial growth.
Pulp Canal Anatomy and Access Cavity Preparations
Endodontic Cavity Preparation Maxillary Anterior Teeth
Maxillary Central Incisor
Pulp chamber: -

Centrally located.
Broad mesio-distally.
Broadest incisally
3 pulp horns



Access opening:
Triangle in shape.
Maxillary Lateral incisor
Pulp chamber
Similar to central.
2 pulp horns


Access opening
Triangular /
ovoid
The root apex and the
apical foramen were
displaced distolingually.
Radicular developmental palatogingival groove.
A, Radiograph show lesion resulting from bacterial access along groove.
B, Extracted tooth shows extent of groove.
The incidence of radicular grooves is 3.0% in lateral incisors
Maxillary Canine
Pulp chamber
Largest among single
rooted teeth
Triangular
(labiolingually)
Flame shaped
(mesiodistally)
1 pulp horn


Access opening
Ovoid

Endodontic Cavity Preparation in Mandibular
Anterior Teeth
Mandibular Central and Lateral Incisors
Pulp chamber
Smallest in the arch.
Flat (mesiodistally)
Ovoid
(labiolingually)
3 pulp horns

Access opening
Long oval
(incisogingivally)
MANDIBULAR LATERAL INCISOR
A cross section of the root is
ovoid or hourglass in shape due
to the developmental
depressions on each side.
Mandibular Canine
Pulp chamber
More wide
(labiolingually)

Access opening
Ovoid

Anomalies
Rarely more than 1
canal and 1 root.
Endodontic Preparation of Maxillary
Premolar Teeth
Maxillary First Premolar
Pulp chamber
Narrow
(mesiodistally).
Wide
(buccolingually)
2 pulp horns (Buccal
& Palatal)
Root & root canal
2 roots (i.e. Buccal &
Palatal)
Access opening
Ovoid
(buccolingually).
The mesial root concavity is more prominent and
extends onto the cervical third of the crown.



This results in a root that is broad buccolingually and
narrow mesiodistally with a kidney shape when viewed in
cross section at the cementoenamel junction.



These anatomical features have implications in
restorative dentistry and in periodontal treatment, and
are common areas for endodontic root perforations.
Maxillary Second Premolar
Pulp chamber
Similar to 1
st
premolar
2 pulp horn.
Single canal orifice.

Root & root canal
Single rooted (90%)

Access opening
Ovoid (buccolingually)

The cross-sectional root
anatomy of the maxillary
second premolar in the
midroot area is described
as oval- or kidney-shaped
Endodontic Preparation of Mandibular
Premolar Teeth
Mandibular First Premolar
Pulp chamber
Prominent buccal pulp
horn.
30 lingual tilt of crown.

Root & root canal
Narrow (mesiodistally)
Broad (buccolingually)

Access opening
Ovoid
Upper 1/3
rd
lingual
incline of buccal cusp.
Mandibular Second Premolar
Pulp chamber
Prominent lingual
pulp horn.

Root & root canal
Wider (mesiodistally)
Broad
(buccolingually)

Access opening
Ovoid
Endodontic Preparation of Maxillary Molar Teeth
Maxillary First Molar
Pulp chamber
Largest in dental
arch.
4 pulp horns.
Roof: rhomboidal

Root & root canal
3 roots and 3 canals

Access opening
Rhomboidal

Of all the canals in the maxillary first molar, the MB2 can be the
most difficult to find and negotiate in a clinical situation.
The mesiobuccal root is broad buccolingually and has
prominent depressions or flutings on its mesial and distal
surfaces.

The internal canal morphology is highly variable, but the
majority of the mesiobuccal roots contain two canals.
The distobuccal root is generally rounded or ovoid in cross
section and usually contains a single canal.
The palatal root is more broad mesiodistally than
buccolingually and ovoidal in shape but normally contains only
a single canal. Although the palatal root generally appears
straight on radiographs, there is usually a buccal curvature in
the apical third.
Maxillary Second Molar
Pulp chamber
Similar to 1
st
molar.
Narrow
(mesiodistally)
Root & root canal
3 roots & 3 canals
Access opening
Similar to 1
st
molar
with variations as
anatomy dictates.
Endodontic Preparation of Mandibular Molar
Teeth
Mandibular First Molar
Pulp chamber
4 pulp horns.
Roof: rectangular
Floor: rhomboidal

Root & root canals
Usually 2 roots & 3
canals

Access opening
Trapezoidal or
rhomboid

Mandibular Second Molar
Pulp chamber
Same as 1
st
molar.

Root & root canals
Usually 2 roots & 3
canals

Access opening
Trapezoidal or
rhomboidal.
ERRORS IN CAVITY PREPARATION :

1. Perforations : caused due to failure to recognize
inclinations; depth of pulp chamber; assuming canal is
straight.
2. Gouging , overextension : caused due to failure to
recognize inclinations; unsuccessful search for canals or
receded pulp.
3. Under extension : Entire roof of pulp chamber not
removed, lingual shoulder not removed leading to curved
access.
4. Ledge : caused due to loss of instrument control.
5. Discoloration : incomplete removal of pulp debris.
6. Missed canals : due to small access cavity.
7. Broken Instruments : occurs in curved canals due to
failure in extending outline/internal prep.
QUESTIONS

1. Two pulp canals are usually found in

A. Mesial root of permanent mandibular first molar

B. Distal root of permanent mandibular first molar

C. Palatal root of permanent maxillary first molar

D. Distal root of permanent mandibular second molar
2. Shown below in the photograph dark lines between
two canal orifice is :-

A. Dentinal Groove

B. Dentinal Map

C. Formed because of faulty
access opening

D. Dentinal shadow
3. What % of lower 1
st
molars show 2 distal canals

A. 10%

B. 30%

C. 60%

D. 75%
4. Shown below tooth 43 is the case of :-

A. External root resorption

B. Internal root resorption

C. Lateral root perforation

D. Iatrogenic root perforation
5. What should be the treatment for the above case:-

A. Extraction

B. Repair of the resorption

C. Do a follow up for 6 months

D. No treatment is required
6. Shown below in the photograph is an example of:-

A. Furcation perforation

B. Pulp stone

C. Dental pulp

D. Both A & B
7. Two canals are most often seen in the:-

A. Maxillary canine

B. Mandibular canine

C. Maxillary lateral incisors

D. Mandibular first premolar
[Ref. Grossman 11
th
Ed Pg 166]
Bifurcations and trifurcations are most common in
mandibular 1st premolar.

They present a challenge during cleaning, shaping and
obturation. Because, of this it is known as "Enigma to
endodontist".
8. The fourth root canal if present in a maxillary 1st molar
is usually present in:

A. Mesiolingual root

B. Mesiobuccal

C. Palatal root

D. Distal root

9. Cervical cross section of maxillary first premolar has:

A. A round shape

B. Elliptical shape

C. Oval shape

D. Square shape
The mesial root concavity is more prominent
and extends onto the cervical third of the crown.


This results in a root that is broad buccolingually
and narrow mesiodistally with a kidney shape
when viewed in cross section at the
cementoenamel junction.


These anatomical features have implications in
restorative dentistry and in periodontal
treatment, and are common areas for
endodontic root perforations.

10. Shown below in the photograph is?

A. Endodontic explorer

B. Spoon excavator

C. Periodontal probe

D. Gingival marginal trimmer

11. Of the following permanent teeth, which is least
likely to have two roots?

A. Maxillary canine

B. Mandibular canine

C. Maxillary first premolar

D. Mandibular first premolar
CASE

Patient report to a clinic and
complains of pain while biting
in his lower anterior teeth. He
gave history of root canal
treatment 5 years back with
his lower anterior teeth.

12. What is the etiology for not healing of this lesion:-

A. Incomplete preparation & obturation

B. Missed canal

C. Lateral perforation

D. No reason

13. Accessory canals are most frequently found in:

A. The cervical one third of the root

B. The middle one third of the root

C. The apical one third of the root

D. With equal frequency in all the above mentioned
74% - apical third
11% - middle third
15% - cervical third.

14. There are sharp demarcations between pulpal
chambers and pulp canals in which of the following
teeth ?

A. Mandibular second premolars

B. Maxillary first premolars

C. Maxillary Lateral incisors

D. Mandibular canines
Ans. 'B' [Ref. Grossman 11
th
Ed Pg 156]

The division between root canal and pulp chamber is
indistinct in single rooted teeth whereas in posterior teeth
this demarcation is sharp.
15. In the mandibular arch, the greatest lingual
inclination of the crown from its root is seen in the
permanent:

A. Canine

B. Third molar

C. First premolar

D. Central incisor
Ans. C [Ref. Grossman 11
th
Ed Pg
167]
Mandibular 1st premolar contains
prominent buccal cusp and smaller
lingual cusp that give the crown a
lingual tilt of 30.

To compensate for the tilt and to
prevent perforations, the enamel is
penetrated at the upper 3rd of
lingual incline of facial cusp and
directed along long axis of root.
16. Shown below in the photograph is :-

A. Periodontal ligament

B. Iatrogenic perforation

C. Extruded gutta-percha

D. B & C
17. The mesiolingual root canal of the mandibular 1st
molar is found under the:

A. Mesio lingual cusp

B. Mesio buccal cusp

C. Central groove

D. Mesio lingual ridge.
Ans. C [Ref. Grossman 11
th
Ed Pg 170]

The mesiobuccal orifice is under the mesiobuccal cusp and is
usually difficult to find if enough tooth structure is not removed.

The mesiolingual orifice is present below the central groove.

The distal orifice has an elliptical shape and is usually present in
the centre of tooth buccolingually.
18. A divided pulp canal is most likely to occur in the:

A. Root of a maxillary canine

B. Root of mandibular canine

C. Root of a maxillary central incisor

D. Lingual root of a maxillary first molar
Ans. B]
19. If the pulp of the single rooted canal is triangular in
cross-section with the base of the triangle located
facially and apex located lingually with the mesial arm
longer than the distal, the tooth is most likely:

A. Maxillary central incisor

B. Maxillary lateral incisor

C. Mandibular second premolar

D. Mandibular central incisor
The occlusal cross-section view of maxillary central
incisor is triangular in shape; while the apex located
lingually and base of the triangle located facially.
Grossman/ll
th
ed/p-151
20. Considering the morphology of root and pulp canals, a
root canal instrument should be placed in what
direction to gain access to the Mesiofacial root of
permanent maxillary first molar:

A. From the mesiobuccal

B. From the distobuccal

C. From the mesiolingual

D. From the distolingual
Ans. D

In case of MAXILLARY FIRST MOLAR
The orifice of mesiobuccal canal is gained access from distopalatal
direction.
The distobuccal root canal is gained access from mesiolingual
direction.
The palatal root is gained access from buccal direction.


For MANDIBULAR 1
st
MOLAR:
The mesiobuccal orifice is present under mesiobuccal cusp and is
explored from mesiobucco apical direction.
The mesiolingual orifice is present below the central groove and is
explored from disto buccal direction.
The distal orifice is explored from a mesial direction.
21. Mandibular 1st molar has:

A. 2 roots and 2 canals

B. 2 roots and 3 canals

C. 3 roots and 3 canals

D. 3 roots and 4- canals
Ans. B [Ref. Grossman 11
th
Ed Pg 170]
22. In which single rooted tooth are bifurcated roots
present:

A. Mandibular lateral incisor

B. Maxillary canine

C. Mandibular central incisor

D. Mandibular premolar

23. Sown below is access opening of premolar. What iss
the error inaccess opening?

A. Outline form is incomplete

B. De-roofing is not done

C. Access cavity should be
mesio-distally wide

D. Both B and C

24. Which root canal is most difficult to prepare in
maxillary molar?

A. Mesiobuccal

B. Distobuccal

C. Palatal

D. Both A and B
Ans. A [Ref. Grossman 11
th
Ed Pg 161]

Mesio buccal root has greatest distal curvature and is
narrowest of all the three canals.

25. The most easily perforated tooth with a slight mesial
or distal angulation of bur after a mandibular central
incisor is:

A. Maxillary premolar

B. Maxillary molar

C. Mandibular premolar

D. Maxillary canine
The mesial root concavity is more prominent and
extends onto the cervical third of the crown.





These anatomical features have implications in
restorative dentistry and in periodontal treatment,
and are common areas for endodontic root
perforations.
26. A cross-section of the cervical third of the pulp canal
of a maxillary second premolar resembles in shape:

A. A circle

B. A square

C. A triangle

D. An ellipse.
The cross-sectional root
anatomy of the maxillary
second premolar in the
midroot area is described
as oval- or kidney-shaped

27. The root canals most likely to share a common apical
opening are:

A. Mesial and distal roots of mandibular premolars

B. Mesiobuccal and mesiolingual roots of mandibular first
molars

C. Both "A & B

D. None of above
Ans. C [Ref. Grossman 11
th
Ed Pg 167, 170]
The mesiobuccal and mesiolingual roots of mandibular
first molars are the root canals most likely to share a
common apical opening..

28. Branching of pulpal canals is least likely seen in:

A. Maxillary central incisor

B. Upper 1st premolar

C. Mand central incisor

D. Mand lateral incisor.
Ans. A [Ref. Grossman 11
th
Ed Pg 151]

29. The anterior tooth most likely to display two canals is:

A. Maxillary central

B. Maxillary lateral

C. Mandibular central

D. Mandibular lateral
30. The tooth which usually has the largest pulp chamber
in the mouth is the:

A. Maxillary central

B. Maxillary canine

C. Maxillary 1st molar

D. Mandibular 1st molar
Ans. C [Ref. Grossman 11
th
Ed Pg 160]

The pulp chamber of maxillary 1st molar is the
largest in the dental arch.

The pulp chamber of the maxillary canine
(Option 'B') is the largest of any single rooted
teeth.
31. Incidence of 3
rd
root in upper first premolar:

A. 6%

B. 10%

C. 12%

D. 1%
DIAGNOSIS
16. What is your diagnosis of this case?

A. Drug induced discoloration

B. Amelogenesis imperfecta

C. Non-vital tooth

D. Staining due to systemic disease
17. What should be treatment of choice for this
tooth?

A. Microabrasion

B. Night guard bleaching

C. Home applied technique

D. Walking bleach technique
BLEACHING

Themocatalytic or in-office
technique
(35% H2O2)
Nonvital Teeth

Walking bleach (Superoxol)


Power Bleach or in-office
technique
(35% H2O2 & Heat or light)

Vital teeth
Night Guard Bleach
(10-15% Carbamide peroxide)
18. What are the choice of agent in this bleaching
technique?

A. Superoxol + sodium perborate

B. Carbamide peroxide

C. 18% hydrochloric acid

D. Superoxol
Superoxol is heated directly within the pulp
chamber in the thermocatalytic bleach or mixed with
sodium perborate and sealed in the pulp chamber to
form the walking bleach.
19. What is the most important
complication that can occur due to
use of this agent?

A. Teeth become hypersensitive

B. External cervical resorption

C. Irritation of gingival papilla

D. Thinning of enamel

Studies found the incidence of cervical root
resorption after bleaching ranged from 0 to 6.9 percent.
it could occur in as many as one of every 12 teeth
bleached.



Therefore, it appears that the age of the patient at the
time the tooth became pulpless and the presence of a
barrier may be as important as the type of bleaching
agent and the use of heat during bleaching.
Upon successful bleaching of the tooth, rinse the
chamber and fill it to within 2 mm of the cavosurface
margin with a paste consisting of calcium hydroxide
powder in sterile saline.



Reseal the access opening with a temporary
restorative material in a manner previously described
and allow the calcium hydroxide material to remain
in the pulp chamber for 2 weeks.
20. What are the treatment modalities for repair of
resorption?

A. Extraction

B. Calcium hydroxide

C. Forced orthodontic extrusion

D. All of the above
There are treatment options for repair of resorption:-

1. Calcium hydroxide therapy.

2. Forced orthodontic extrusion.

3. Surgery.

4. Extraction.

Forced orthodontic extrusion


By extruding the root, the resorptive defect can be
elevated coronal to crestal bone.


Here it is accessible and can be included in a crown
preparation or repaired.


Specific orthodontic criteria must be met for success.
The crown/root ratio must be 1:1 and the root should
be non-tapering.
SURGERY

The most common approach to repair cervical defects is
surgery.

The resorption usually starts proximally and often wraps
around toward the palatal.

Both a labial and palatal flap are necessary for access.
The lesion is cleaned, bony contouring accomplished, and
the defect repaired.

Esthetic concerns may arise due to bone loss and tissue
changes. The tooth is more susceptible to fracturing.
Case 5

A 24 years old female patient complains of severe
throbbing pain from last few days with respect to lower
right back region.

Pain increases on lying down and is relieved with
analgesics.

Also pain is spontaneous in nature.

On oral examination, mandibular right first
permanent molar is found to be carious. The tooth is
sensitive to percussion.
21. What is diagnosis of this case?

A. Reversible pulpitis

B. Irreversible pulpitis

C. Symptomatic irreversible pulpitis

D. Hyperplastic pulpitis
Signs and Symptoms Pulpal Diagnosis Periapical
diagnosis
Sharp pain from exposed dentin on application of
thermal or osmotic stimuli. No dental abnormality.
Normal
( dentin
hypersensitivity)
Normal
Sharp pain from exposed dentin on application of
thermal or osmotic stimuli or both. Evidence of
dental caries, fractured restoration, cracked cusps
etc.
Reversible pulpitis Normal
Spontaneous, throbbing pain, sharp pain on
application of thermal stimuli that persists
following removal of stimulus.
Irreversible pulpitis Normal
Spontaneous, throbbing pain, sharp pain on
application of thermal stimuli that persists
following removal of stimulus.
Tender to bite or percussion or both. R/g widening
of PDL likely.
Irreversible pulpitis Acute apical
periodontitis
Spontaneous, throbbing pain. No response to
thermal stimuli. Tender to bite or percussion or
both. Localized or diffuse swelling may be there.
R/g may be inconclusive or lesion
Necrosis Acute
periradicular
abscess
22. Identify the area marked by circle X on radiograph?

A. Pulp stone

B. Radiolucency due to carious involvement of tooth

C. Nomal pulp canal

D. Normal pulp chamber


Increase the difficulty of negotiating the root canals.



The incidence of calcifications in the chamber or in the
canal may increase with periodontal disease, extensive
restorations, or aging.
23. What should be treatment in rendered in this
case?

A. Restoration with amalgam

B. Endodontic therapy

C. Direct pulp capping

D. indirect pulp capping
Direct pulp capping
Indirect pulp capping
24. A tooth tested nonvital in vitality tests showing
periapical radiolucency shows the presence of
a sinus tract clinically. What should be the
treatment for the sinus tract?

A no treatment

B curettage of the sinus tract

C Cauterization

D Irrigation with sodium hypochlorite
To trace the sinus tract, a size #25 gutta-percha cone is
threaded into the opening of the sinus tract.
25. In root fracture of the apical one - third of permanent
anterior teeth, the teeth usually:
A. Discolor rapidly
B. Remain in function and are vital
C. Undergo pulpal necroses and become ankylosed
D. Are indicated for extraction and prosthetic replacement

Apical 3
rd
Fracture

Fracture with no mobility no displacement of the coronal
segment and no symptoms- do not require any immediate
treatment.
Long term observation with periodic evaluation of pulp status.


If Considerable mobility- only splinting and periodic evaluation.



Healing is uneventful

Middle 3
rd
fractures

Most common site of occurrence.

Presents with considerable amount of mobility and
/or dislocation of the coronal segment.

The treatment is aimed towards preserving the
vitality and favor repair of the fracture.
Correct repositioning ( Reduction)
Splinting (Retention)

Coronal 3
rd
fractures

If reattachment of the fractured segments is
not possible the coronal segment must be
extracted and the choice of whether to retain
the apical fragment becomes major
predicament.

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