Transcribed by Charles Buchanan Date of the Lecture: 10/01/14

[Diagnosis and Treatment of Oral Diseases] [Lecture #43] [Introduction to Root and
Pulp Anatomy] by Dr. Fleischer
[Slide 1] [Introduction to Root and Pulp Anatomy Title Slide]
[Dr. Fleischer] Alright, hi. Today, were going to talk about a very exciting topic. Root
and pulp anatomy and how it really makes and intertwines with access cavity preparation.
But in order to really understand access cavity preparation, you have to really know the
tooth. Very, very well. And not just the coronal aspect of the tooth but what the root and
the root morphology is like.
[Slide 2] [Introduction to Root and Pulp Anatomy]
[Dr. Fleischer] Because it really affects how you even decide whether endo, crown
lengthening, how - uh - is accomplished. So of course were going to go over some basic
terms. Basic terminology and then Im going to show you some really important points.
Well be moving a little quickly, only because of the time limit on this. Do you all have
another lecture right after this? Okay. Because I was willing to stay. So basic terminology.
And I know a lot of it is going to be repeat. But I do include it in this lecture, because I
want you to all have a very full Powerpoint that you could go back to for reference. So
theres a lot more in this than you will need. Meaning, need for your exam. So I put a lot
more information in there. And a lot of students who have already graduated say that they
go back to this lecture a lot. So, of course we all know, when we talk about a clinical
crown, thats the part of the crown thats visible. Im sure all of these terms up here are
very familiar to you. Also, the sagittal section of the tooth, youre all familiar with that.
[Slide 3,4] [SKIP]
[Slide 5] [Tissue Terminology]
[Dr. Fleischer] And how we talk about a tooth in cervical, middle, apical thirds as far as
the root is concerned, and you have to realize that just as the diagram here is showing
you, that when we talk of the coronal structure were also talking not only horizontally-
breaking things up into cervical, middle and incisal or occlusal thirds - but also in respect
to distal, middle and mesial as well.
[Slide 6] [Arbitrary Division]
[Dr. Fleischer] Ok, we always talk about the long axis of the root and the anatomical
root v. the anatomical crown. And the CEJ is usually pretty coincident, but not always -
when we have recession of course.You know what is considered clinically visible is very
different at age 70 per se than at age 20.
[Slide 7] [Long axis of the root/ root axis line]
[Dr. Fleischer] skip
[Slide 8] [pulp chamber - coronal]
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Transcribed by Charles Buchanan Date of the Lecture: 10/01/14
[Dr. Fleischer] Alright, so we talk about the pulp chambers, the canals, the cementum,
the dentin, the pulp horns. Pulp horns are varying height and as we get older, the pulp
horns recede. Its not only just with age that pulp horns do recede.
[Slide 9] [floor of the chamber - the apical]
[Dr. Fleischer] They also recede if you grind your teeth. Your diet. There are also parts
of the world where they chew betel nuts and very hard substances which is traumatic to
the tooth. And it causes the pulp to lay down extra protective layers of secondary dentin.
So, the pulp has sometimes pulp stones and tend to recede. We talk about the root canal
as a root canal system. You also have to realize that the walls of the chamber- thats
where the proximal surfaces of the pulp chamber are described as mesial, buccal, distal
and lingual or palatal. The orifice which is the opening on the floor of the chamber, which
is leading to the canal and this would be the floor of the chamber.
[Slide 10] [anatomic root - has a cementum.]
[Dr. Fleischer] Ok. Root trunk. Furcation or whats called here bifurcation. And it
comes in many forms. Sometimes it bifurcates. Its all of these aspects of where the
bifurcation, how the root is either convergent or divergent will all affect how you will
approach the root canal system with your instruments.
[Slide 11] [furcation - where the]
[Dr. Fleischer] Ok. Interradicular just means between the roots. Interdental is between
two adjacent teeth.
[Slide 12] [Furcations - trifurcation]
[Dr. Fleischer] Ok. So lets talk about furcations. A trifurcation is seen in maxillary
molars and other three rooted teeth. There are actually, because we have 3 areas. 1-2-3 as
a tripod. 3 areas to come around, and with the tooth sort of standing on its head, you can
actually see these visible. Ok.
[Slide 13] [Furcations - bifurcation]
[Dr. Fleischer] A bifurcation of course means two. Now some lower molars, of course,
have three separate roots. Most of them have 2 roots where you have your mesial canals
within the one mesial root.
[Slide 14] [Naming Canals By Location]
[Dr. Fleischer] This is a really good diagram for you to have and I have even a better
one later on where it actually shows you a birds eye view and this is half the mandibular
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Transcribed by Charles Buchanan Date of the Lecture: 10/01/14
arch and half the maxillary arch because theyre sort of assuming you know that theyre
mirror images of each other. And it really shows you the the ideal access cavity
preparation. What I want you to know, and when we get to the mandibular teeth, is many
times you see in the mandibular centrals and incisors - its not uncommon for two canals
to be present. Ok? Here is where your MB2 would lie and actually, they show you here
what the topography, or the landmarks would be if you have 4 canals - it comes out like a
box v. a 3 canal lower molar. Even though they are illustrating it in a second molar, you
have to realize if a distal canal is in between the two mesial canals forming a triangular
shape, you know there is three canals. Because people say how do you know if theres
three or four canals in a lower molar Dr.Fleischer? If you uncover one that is exactly
parallel to one of your mesial canals, you better start looking for a fourth.
[Slide 15] [Naming Canals By Location - Endodontic Access Openings]
[Dr. Fleischer] Ok. This is actually the teeth in cross section. We name the canals by
location. So this would be mesiobuccal, mesiolingual, distal, distobuccal, distolingual.
Ok?
[Slide 16] [Diagram- both arches]
[Dr. Fleischer] And this shows the whole mouth in total. If any of you are ever in the
urgent care clinic, youre always welcome to visit me downstairs. This is hanging up
always on the wall. I will make sure that this powerpoint gets to you all.
[Slide 17] [Canal Configurations By Type]
[Dr. Fleischer] Ok. Canals are also in different configurations. Some split up in the
middle 1/3rd. Sometimes we have 2 distinct. And then we have these which are very
challenging to do where theyre splitting in the apical 1/3rd. Because really what you are
seeing on your two dimensional view of your radiograph is not showing you what a cone
beam would show you. And then if you denature the tooth, you clear it, you fill it with an
opaque material. I may have a picture of it. It shows you that it is amazing how many root
canals really work because so much of the root canal system is never really even
addressed by our abilities. We don't have the ability to mechanically get in to really all of
the little tributaries that are there. That is why your irrigation is so important. Okay?
[Slide 18] [Root Cross-Sections]
[Dr. Fleischer] Lets talk a little bit about root shapes. I dont want to stray off topic
talking about cleaning and shaping. But, as you can see, many have a kidney bean shape.
Many are tear drop shaped. Many have a figure 8 configuration. Why is it important to
know this. Its really important to know what the root and the root morphology is like
because the dreaded word - perforation. The dreaded word- perforation.
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Transcribed by Charles Buchanan Date of the Lecture: 10/01/14
[Slide 19] [Dentin Lives!!!!]
[Dr. Fleischer] Ok. And being able to do a really more than adequate root canal.
Alright, think about dentin as a living tissue. The deeper you drill into dentin, the wider
the tubules become. Ok.
[Slide 20] [Calcific Metamorphosis]
[Dr. Fleischer] And this is what I was talking about before. When we are all very
young, the pulp chamber is quite large and as we age, or as we have more trauma or
youre a bruxer or a clencher, this is the calcific metamorphosis.
[Slide 21] [Calcific metamorphosis]
[Dr. Fleischer] It responds to insult. And you can see here. Sagittal sections. Look how
thing this is in comparison. Ok. The main purpose of the pulp is to grow the root and lay
down dentin. Alright.
[Slide 22] [The coronal aspect of this canal]
[Dr. Fleischer] Which I know is a repeat from some of your other courses. Here you
can see a microscopic view that the top of the canal, the coronal aspect, is calcifying.
And there is a bridge. This is not an induced calcification. This is just a normal pulp that
is aging, that the most apical part still stays much more vascular.
[Slide 23] [Clinical Relevance of Pulp Chamber Anatomy]
[Dr. Fleischer] What is the clinical relevance of all of this. Well here is a picture of a
hand piece with a drill. The average depth from the occlusal to the furcation is about
7mm. So what am I trying to show you here? Im trying to show you that if you, most of
the time, see that you have shallow, like in the tooth right adjacent to it, this is a much
shallower amount of pulp tissue here. And if youre just sort of getting introduced to
access cavity preparation, it would be much more advantageous to use a shorter, high
speed bur because you have no chance of perforating here. If you were afraid of missing
the access to that chamber.
[Slide 24] [Accessory/Lateral Canals]
[Dr. Fleischer] Ok. What are accessory or lateral canals. The terms are used
interchangeably. They are the same. And what it does is really show you what I was
talking about before. That all of the tissue is still disturbed all throughout the tooth. You
may not see it, but its there.
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Transcribed by Charles Buchanan Date of the Lecture: 10/01/14
[Slide 25] [Accessory/Lateral Canals (Radiograph)]
[Dr. Fleischer] Here is a case and if the lights were down you would see it more.
Sealant has filled in these accessory canals. This is it tucked against the PDL. It has
nowhere to go so it just squashes out against the PDL. And what is most important - I
wish you could see it - this was a very important thing to achieve clinically because the
radiolucency was actually along the lateral aspect of this tooth. So the accessory canals
were of significant contribution to the radiolucency that was there.
[Slide 26] [Accessory/Lateral Canals - Clinical Relevance]
[Dr. Fleischer] Ok. We talked about the clinical relevance.
[Slide 27] [The Apex]
[Dr. Fleischer] So lets talk about the apex. As you can see. Where the apical foramen is
not always coincident where your radiographic apex is. And sometimes this can be very
confusing. In this school core curriculum, we work to the radiographic apex. But I also
want you to be aware that especially lateral incisors and teeth with curves on them - you
may be fooled into thinking that you are either short or long because the root is curving
away from the plane of the film. So never hesitate that when you feel the canal is curving,
that you go and take an off angle picture to really give you better visibility. Except for-
especially for upper laterals. A lot of times, I come off angle because the canal- the root
curves distopalatally and you really want to capture that on your film. Ok so this is
important to know, the difference between an anatomical apex and a radiographic apex.
Ok, know that.
[Slide 28] [The Apex - The actual apical foramen] - SKIP
[Slide 29] [The Apex - Apical Constriction]
[Dr. Fleischer] And here is a diagrammatic representation of it. You have a few things
here. You also have whats called apical constriction- which is the narrowest part of the
canal. That is the constriction. This here is your radiographic apex. This is your
anatomical apex. Now usually there is a difference of about 0.5mm to about 0.75mm.
And that seems to stir up tremendous controversy in the world of endodontics. Do we fill
0.5mm short because really the anatomical apex isnt really where the radiographic apex
is. Personally, I always fill to the radiographic apex.
[Slide 30] [II. Maxillary Root and Pulpal Anatomy]
[Dr. Fleischer] So now [SKIP]
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Transcribed by Charles Buchanan Date of the Lecture: 10/01/14
[Slide 31] [Maxillary Central Incisor - Root]
[Dr. Fleischer] lets get into the real interesting stuff. What every root looks like. Im
sorry, Ive tried over the years to make this a very exciting lecture. What I want you to
know about the maxillary central incisor is why on the NERBs do they ask you to do this
tooth? Why? Is because they want you to know that you have pulp horns that lend itself
to the need to have a triangularly shaped access cavity. So you know ahead of time that
the NERB is picking out this tooth for one reason. Not to do a circular access, but to
realize that the - and this is, I think, is way too incisal - is to be able to know that youre
representing in your access cavity that those two pulp horns have to be cleaned out. Years
ago, when people said oh, your tooth will turn black when you have a root canal. It was
because they left so many pulp horns, especially in anterior teeth, in the coronal structure.
And the hemosiderin deposits that were in whatever was left in the vascular of the pulp
was left in the tubules.
[Slide 32] [Maxillary Central Incisor - Pulp]
[Dr. Fleischer] Ok. So tell me about the pulp. The pulp is simple in form. This is one
root, very conical in shape. Very rounded. Ok.
[Slide 33] [Maxillary Central Incisor - Pulp] - SKIP
[Slide 34] [Image- Maxillary Incisors (Labial)]
[Dr. Fleischer] And this is just to see the variation of what can be anterior centrals here.
These are laterals. But what I want you to see is that the apices lean distally in almost all
root tips. How does that apply clinically? If you feel, in your upper arch, and you feel
where your clinical crowns are, and then you go and palpate back towards the nares, you
feel that the maxilla curves back. Well, your roots are not coming straight up. Theyd be
projecting through the maxilla. They are following that shape of the maxilla palatally. So,
when you go and do your access cavity, you have to realize, and youre cleaning and
shaping, that that root is tipping palatally. Alright.
[Slide 35] [When viewed from the apex]
[Dr. Fleischer] I will never ask you this on an exam but its nice to know - when you do
a cross section of a tooth, which one it represents by the shape of a cross section. I will
never ask you this but its sort of a fun fact. If you have nothing to do on a weekend, look
in the book on cross sections of teeth and which ones they are.
[Slide 36] [a maxillary left central incisor] - SKIP
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Transcribed by Charles Buchanan Date of the Lecture: 10/01/14
[Slide 37] [Maxillary Lateral Incisor]
[Dr. Fleischer] Lets talk about our laterals. Everybody thinks lateral incisors are very
easy teeth to do, but actually, lateral incisors - maxillary - are one of the most challenging
because theyre single, straight, but they all curve. I would say mostly all curve to the
distal palate. So you have to know if youre putting a straight instrument in or trying to
do access, you have to realize that youre going to need to create ease of your instrument
going in a distal palate motion. The apex in this tooth is sharp and not rounded.
[Slide 38] [Maxillary Lateral Incisor - Root]
[Dr. Fleischer] Sorry. Alright. I would say that the most important thing to know about
this tooth - that it has - it can exhibit a lingual groove, which can cause periodontal
defects, but also tips distopalatally.
[Slide 39] [Maxillary Lateral Incisor - Pulp] - SKIP
[Slide 40] [Maxillary Lateral Incisor - IMAGE] - SKIP
[Slide 41] [Maxillary Lateral Incisor - Examples of reasoning]
[Dr. Fleischer] And this will show you that not realizing that the tooth is tipping
palatally. And this is a common mistake the first time youre out doing a root canal. You
think that youve got an easy case and then you see that youre coming from the front of
the rubber dam. Ok. Because you have to look at the angle, and I always palpate and feel
how the root structure is before I put a rubber dam on. And I always see how the crown
itself is inclined in relationship to the root and in relationship to the adjacent teeth.
Because if you have teeth that are rotated, teeth that are tipped - you know, not everyone
has perfectly aligned teeth. Once you get the rubber dam on, you really lose perspective
of where youre going.
[Slide 42] [Maxillary Canine - Root]
[Dr. Fleischer] Ok, lets talk about the canine. This is the maxillary canine - is the
longest tooth in the mouth. Thats an important fact to know. The maxillary canine is the
longest tooth in the mouth. It is the cornerstone of the mouth really. I really do my very
best if a patient has a compromised canine, is to try to have them never lose that tooth.
Its the cornerstone of the mouth. It shapes the face. People who lose their canine, the
mouth shape changes dramatically. Im not talking about totally edentulous people. A
canine is where that mouth turns. The mouth really, thats really an important curvature of
the mouth. Alright. Theres usually one pulp horn. Ive actually seen two-rooted canines.
Its very rare.
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Transcribed by Charles Buchanan Date of the Lecture: 10/01/14
[Slide 43] [Maxillary Canine - Pulp]
[Dr. Fleischer] Ok. Im going through some of these really quickly because I really
want to cover almost all two hours.
[Slide 44] [Maxillary Canine Image] skip
[Slide 45] [Maxillary Canine Image- 41mm]
[Dr. Fleischer] Alright. This is one of the longest teeth on record. 41mm long. What
amazes me is they got that out in one piece.
[Slide 46] [Maxillary First Premolar - Roots]
[Dr. Fleischer] Ok. Now were going to talk about maxillary premolars. The first
premolar has some very important characteristics. The first and most noteworthy is its
mesial concavity. And this can be the kiss of death when youre doing your access.
Because you can perforate right out that mesial concavity. It is a very, very significant
mesial concavity. Very, very significant. Alright. Its kidney beaned in shape. All have 2
canals. Alright. And its mesial concavity - I cannot stress to you enough -
[Slide 47] [Maxillary First Premolar - Roots]
[Dr. Fleischer] Thats probably one of the most important landmark sites. Ok. And one
of the most important things to take into consideration when doing access on that tooth.
Ok.
[Slide 48] [Maxillary First Premolar - Pulp] SKIP
[Slide 49] [Maxillary First Premolar Image] SKIP
[Slide 50] [Maxillary First Premolar Image] SKIP
[Slide 51] [Maxillary Second Premolar - Pulp - One single pulp canal]
[Dr. Fleischer] The second premolar. Most of the time, the second premolar has one
canal, but always, always have a diagnostic film to make sure because the worst thing to
do is to assume that a maxillary second premolar has one canal and youre going and
doing your access in the center and you find yourself in a furcation. So it is common for
upper second molars. It is not rare. It is, I would say, about, well I dont like to quote
statistics, because, but I would say almost half of my upper - between 1/3 and 1/2 have 2
canals. Alright. So if youre not prepared with a PA and a bitewing, you really have no
ability to know where to begin your access cavity. You think youre dropping into a pulp
chamber and what youre dropping in is to the furcation.
[Slide 52] [Maxillary Second Premolar - Root]
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Transcribed by Charles Buchanan Date of the Lecture: 10/01/14
[Dr. Fleischer] Please feel free to ask questions anywhere along the way. It does have a
mesial concavity, but it is not pronounced. It is not as pronounced. So its not something
that I would - if the word mesial concavity came up, thats always an association with the
first premolar.
[Slide 53] [Maxillary Second Premolar IMAGE] SKIP
[Slide 54] [Maxillary Second Premolar - Remember how roots form]
[Dr. Fleischer] What do you not see here? But you dont see a pulp or a canal. But on
examination, microscopically, they exist. They exist, they are there, they are there. Ok?
[Slide 55] [Maxillary Second Premolar - One root is the rule]
[Dr. Fleischer] One root is the rule, two roots the exception. I disagree with this slide.
Even though I made this slide. But, I really, really believe - Ive been seeing - I dont
know, maybe its just the patient population Im seeing lately. But I see a tremendous
amount of second rooted, uh, second premolars.
[Slide 56] [Maxillary First Molar - Root]
[Dr. Fleischer] My favorite teeth. Upper first molars. Any one whos worked with me
in the clinic or they know upper first premolars are wonderful! Because the beauty of
the flow of the roots and the shape I know yes. I am weird. I am an endodontist.
But you have to realize a couple of things. This is another tooth that they ask you to do
for the NERBS. Why? Because it shows your ability to also know not to cross the
transverse ridge. It also shows your ability to know that the palatal canal lies halfway up
the incline plane of the palatal cusp. And not come in this direction - thats my famous,
when you get in your D4 year, I do a NERB review where I say please, you dont go to
Florida, you go to Texas. It means its in the middle. Right in the middle. Also you know
your distobuccal is never on the same line like an equilateral triangle. But if you look at
the occlusal profile of this tooth, it is actually following parallel to that. But looking at the
tooth you can be thrown off. So usually, I say, do your distobuccal access first and then
go halfway up the incline plane on your mesiobuccal canal -root and then come down to
your palatal. Also know that the longest distance between any two orifices is between the
mesiobuccal and the palatal - mesiobuccal and the palatal. Your MB2, which is in 66.6%
of all upper molars, lies mesial and palatal to that mesiobuccal canal. Ok so this is the
mesial aspect. So its a little mesial to it and its more towards the palatal. I have to prove
to myself that this canal doesnt exist. Because I consider it there until I can prove that it
isn't there. Because thats how many times it is there. Ok. The palatal root is of course the
largest. Its given- it has a curvature usually toward the buccal side. And why is that
important to know? So youre not digging you instrument in, trying to move it towards
the palate. Ok. You have to realize the root curves toward the buccal.
[Slide 57] [Maxillary First Molar - Root Palatal root is the]
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Transcribed by Charles Buchanan Date of the Lecture: 10/01/14
[Slide 58] [Maxillary First Molar - Root mesiobuccal root]
[Dr. Fleischer] Ok. The mesiobuccal root is the second largest and the longest. These
are inclined mesially and you have to also realize that they may be very close to the sinus.
Ok.
[Slide 59] [Maxillary First Molar - Root - distobuccal root]
[Dr. Fleischer] The distobuccal root is the shortest but I find that it is also usually the
first one that I go to to negotiate because its usually very straight. And distally inclined.
The palatal, of course, can be deceiving. That you think its going to be a piece of cake,
because its a very big, beefy root. But that curvature towards the buccal can sometimes
really, um, throw a kink. And I just want you to remember, not only when youre doing
your access, when youre doing your cleaning and shaping, put a curve on all of your
files. Im sure theyre teaching you that. Otherwise youre going to find that youre
sticking into the dentin of the roots where they are starting to curve. Nothing in nature is
straight.
[Slide 60] [Maxillary First Molar - Pulp one pulp horn for] - SKIP
[Slide 61] [Image]
[Dr. Fleischer] And this is what I was talking about. And you have to realize that
youre never going to get into an area like this, or like that. But if you use a lot of irrigant,
it will leech out all of that organic matter.
[Slide 62] [Maxillary First Molar]
[Dr. Fleischer] Maxillary first molar - mesiobuccal rootMany times they are one
together sometimes, they are two separately. And that goes for itseverything OK?
That goes for its exit in the orifice. Alright. And sometimes exit in the apex. And
sometimes in the orifice, youll find that they slide into each other. It can be like a slit.
[Slide 63] [Maxillary First Molar- Accessing the canals]
[Dr. Fleischer] Ok. This is a little more mesial. Hair breadth and more towards the
palate. Ok. Im not going to ask you to identify them.
[Slide 64] [Maxillary First Molar]
[Dr. Fleischer] Skip
[Slide 65] [Maxillary First Molar]
[Dr. Fleischer] Skip
[Slide 66] [Maxillary First Molar]
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Transcribed by Charles Buchanan Date of the Lecture: 10/01/14
[Dr. Fleischer] Skip
[Slide 67] [Maxillary Second Molar - Root]
[Dr. Fleischer] As the roots go back, they tip more distally and the roots become
shorter. Which makes sense because theres less room. Ok.
[Slide 68] [Maxillary Second Molar - Pulp]
[Slide 69] [Maxillary Second Molar - In general, as you]
[Slide 70] [Maxillary Third Molar - Root]
[Slide 71] [Maxillary Third Molar - Pulp]
[Slide 72] [Maxillary Third Molar - Roots are indistinct]
[Slide 73] [Maxillary Third Molar - Generally, roots are conical]
[Slide 74] [Clinical Significance of Root Divergence]
[Dr. Fleischer] When we talk about root morphology, theres a clinical reason for
knowing whether a tooth is divergent in its roots, or convergent. And thats not only for
endodontics, but for also how stable it would be in the mouth and also if you would have
to extract it. A tooth like this is a very difficult extraction as compared to a tooth that
would have very convergent roots. A tooth like this though would be tremendously more
stable in the mouth especially w/ periodontal bone loss as opposed to a tooth with very
convergent roots. But also, it tells you how you have to have straight line access to all
your canals.
[Slide 75] [Clinical Significance of Root Convergence]
[Dr. Fleischer] Ok? Root convergence.
[Slide 76] [Range Table]
[Dr. Fleischer] I will never ask you anything here but I will ask you what the average
range is. I familiarized myself with this because it gives me an idea while Im looking at
a radiograph what is relative to this chart. In other words, if you look at a series of teeth
and you know what the average lengths are, you can sort of get an idea if the patient
youre treating falls within that average range. Theres some teeth that I look on the
radiograph and I can see that they are much shorter - because you have to realize that PA
is not a true indication of what is the exact length of the root. PAs are not like bitewings.
Bitewings are reproducible because theyre taken at a 90 degree angle. A PA can be
foreshortened or elongated. Alright. So, you have to realize, a lot of people think oh its
easy. You go on a digital radiograph and you use a ruler and you measure out how long a
canal is. But that will give you a guesstimate. Yeah.
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Transcribed by Charles Buchanan Date of the Lecture: 10/01/14
[Student] - If you use cone beam, then it will be 1 to 1, right?
[Dr. Fleischer] You wouldn't use cone beam for cleaning and shaping. Thats an
excessive, excessive amount of radiation to just get measurement control. I understand
what your question is saying, but its not clinically a reasonable thing to do. You have to
sort of justify what youre doing for the outcome.
[Slide 77] [III. Mandibular Root and Pulp Anatomy] - SKIP
[Slide 78] [Mandibular Central Incisor - Root]
[Dr. Fleischer] Ok Mandibular. Central incisor. You have to realize that these are very
small teeth and youre going to be tempted to use a #2 bur. Please dont. You have to
realize that as much as youre saying to yourself a #4 is going to be too big, youre going
to need an access as big as a #4 or else youll never be able to obturate it. Also, the
smaller the bur is, you will never feel the drop. It will cut so fast through, you will not
feel the change as youre going through enamel, to dentin, to pulp. Many times you
wont. Ok?
[Slide 79] [Mandibular Central Incisor - Pulp] - SKIP
[Slide 80] [Mandibular Central Incisor - Roughly 75%] - SKIP
[Slide 81] [Mandibular Central Incisor]
[Dr. Fleischer] Here is an example of a two canaland these, the crowns are always
tipped more buccally. And if you feel again, your lower jaw is moving more lingual. Ok?
[Slide 80] [Roughly 75%]
[Dr. Fleischer] Part of what I want to show you is the incisal edge should not be
impinged upon when you do your access cavity. Because it would be a very fragile break
off. You have to realize you have a very small tooth, and now youre going to have a very
small tooth with a hole inside. And that goes,really, for all of the teeth that you have
access on. You have to realize the teeth become dehydrated and a little more brittle. And
the teeth will have to be taken out of occlusion. When you say taken out of occlusion, its
really best, especially with posterior teeth. Anteriors, you want to check protrusive to
check that the patient isnt knocking into the tooth. But you should really not be too
aggressive to have it look like a tabletop with a squared end. That is a much more fragile
reduction than a bull nosed type of effect on the other teeth. Is everybody understanding
that? You want to round off the structure of the tooth that youre doing an access cavity
with rather than just going right across with a 1556 bur. I like to make believe that Im
just reproducing all the anatomy - not make believe but I really reproduce all the
anatomy about a millimeter less, for the posterior teeth, than they really do exist. I do all
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Transcribed by Charles Buchanan Date of the Lecture: 10/01/14
my occlusal reductions before I do the accesswhy? And Ill tell you because once you
establish your working lengths, if you do your occlusal reduction after youve temporized
a tooth, all the numbers youve then notated are all invalid because your reference point
has been changed. Ok? You have to realize also, when you go into this lower interior, that
youre coming in on 45 degree angle. You really want to avoid coming straight down. It
would really jeopardize that incisal edge and only leave just enamel shelf. So youre
going to come in at a 45 degree angle and then actually reduce the overhangs with a slow
speed bur.
[Slide 81] [Mandibular Central Incisor -Angle of entry]
[Dr. Fleischer] And this is an example. And this is an example why I use a round bur.
Because the cutting edge on a bur like this is up and down the entire shaft of the bur,
whereas you have a smooth area with just a cutting edge on a round bur. You have to
realize that with a bur thats very aggressive, it will be end cutting, and youre working in
- even I take the greatest amount of time with my access cavity. I dont speed through.
Actually, access, when youre given your boards, theyre going to say what is the most
important part? Theyre going to ask obturation, theyre going to say cleaning and
shaping or access cavity. The answer is access cavity. Because it sets the stage for your
cleaning and shaping and your obturation. Without a good access, you are going to
transport your apices. By transporting the apices, youll never get the proper obturation.
Ok? You have to also realize that this area here, if you come in too incisal, youre going
to really subject this tooth to fracture. This is the right angle to come in but you should
have stopped right here. And then you just lift up this little area here with a round bur. A
lot of times, this tooth fails in endo because people tend to miss that second canal. And
the second canal is usually very lingual. So if you are going in and youre feeling that
your canal is catching way buccal, please re-introduce your endo explorer and see if you
can feel. Or take a little off-angle film or go and re-examine the film. Ok?
[Slide 82] [Mandibular Lateral Incisor]
[Dr. Fleischer] Ok. Mandibular lateral. Single root usually and straight. This is what
not to do. It is way too incisal, way too oval. This is more. I would never have come in
and impinged over these marginal sort of ridge areas. I stay inside the valley of that
lingual surface. Ok.
[Slide 83] [Mandibular Lateral Incisor - Pulp] - SKIP
[Slide 84] [Mandibular Lateral Incisor - Image] - SKIP
[Slide 85] [Mandibular Canine - Root]
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Transcribed by Charles Buchanan Date of the Lecture: 10/01/14
[Dr. Fleischer] The important thing to remember about a mandibular canine is that it
has a slight mesial inclination. This is the longest tooth in the mandible, but not the
longest tooth in the head. Ok?
[Slide 86] [Mandibular Canine - Pulp] -SKIP
[Slide 87] [Mandibular Canine - If one canal is]
[Dr. Fleischer] I have seen and treated many 2 rooted mandibular canines. It is not
something that is that rare.
[Slide 88] [Mandibular Canine - A bifurcated root]
[Dr. Fleischer] Here it is again.
[Slide 86] [Mandibular Canine - Viewed from the mesial] -SKIP
[Slide 90] [Mandibular First Premolar - Root]
[Dr. Fleischer] And first premolar. Mandibular first premolar. You have to know that
this has a very high pulp horn. This is not a tooth that I would say you want to do on a
practical or for the boards. The pulp horn is very high on this tooth. It is very easy to,
what we say, pulp out on this tooth. And it is really the transition between a canine and
a bicuspid and probably the reason the maxillary first premolar is so susceptible to
fracture is because it is a two rooted tooth and there isnt enough transition going from
the canine to the second premolar. When I trained, they used to call that tooth natures
mistake - that the first premolar in the maxilla should have also been, pretty much, a
single cusped tooth with a very small lingual cusp. I know I have fractured both of mine
and most people end up usually fracturing because of lateral excursions. You have to
realize that occlusion is dynamic. Its going to change as you chew, as you grind, as you
stress and so your interferences, whether it be protrusive or balancing or working, always
are changing. And you have to be aware of that, not only on yourself but also for your
patients. Ok.
[Slide 91] [Mandibular First Premolar - Pulp] - SKIP
[Slide 92] [Mandibular First Premolar - A pronounce lingual] - SKIP
[Slide 93] [Mandibular First Premolar - Mid-root Cross Section]
[Dr. Fleischer] This can be a cross section of a tooth. What I think happened here is
nature was trying to make a double rooted tooth and it never actually happened.
[Slide 94] [Mandibular Second Premolar - Root]
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Transcribed by Charles Buchanan Date of the Lecture: 10/01/14
[Dr. Fleischer] Mandibular second premolars. This is a nice, I would say if you could
get one of these for your first endo - thats a nice tooth to do. Its very straight. Its usually
straight forward. The hardest part of this is getting your block. Thats a nice tooth. So do
it.
[Slide 95] [Mandibular Second Premolar - Pulp] -SKIP
[Slide 96] [[Mandibular Second Premolar - Image] - SKIP
[Slide 97] [Mandibular First Molar - Root]
[Dr. Fleischer] Lower molars are very difficult in access. You have to realize that what
youre seeing coronally looks very flat and straight. And your first inclination is to go in
straight and do your access. If you do that without realizing that the roots are tipped
buccally and that all of your pulp is more buccal, you will actually come out lingual on
this tooth. This is a very tough access to do. So when you go in straight, youre going to
end up lingual. So you have to realize the inclination of your bur is going to actually be
towards the buccal. And youre going to be surprised when you do your first lower molar
that your distal canal is really not distal at all. It really lies pretty much under the central
fossa. And your mesiobuccal canal will lie very much buccal. Ok?
[Slide 98] [Mandibular First Molar - Root] - SKIP
[Slide 99] [Mandibular First Molar - Pulp] - SKIP
[Slide 100] [Mandibular First Molar - Pulp - Usually only one]
[Dr. Fleischer] Im going to make sure that all of this is put online for you. This is what
I was talking about when you have a 3 canal lower molar. The distal canal actually lies
distally but between the two in a triangle.
[Slide 101] [Mandibular First Molar - Image] - SKIP
[Slide 102] [Intercanal Webbing]
[Dr. Fleischer] Theres always all the canal webbing which is impossible to get.
[Slide 103] [Mandibular Second Molar]
[Dr. Fleischer] Second molars they will not let you do here whether its maxillary or
mandibular because, first of all, in the maxilla, the canals are closer together and actually
sometimes line up almost in a straight line where you really dont see that triangular
effect. Here, theyre much tighter and closer together and its a very tricky access. If
youre ever in urgent care, of course I will do one with you there at least the access - at
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Transcribed by Charles Buchanan Date of the Lecture: 10/01/14
least youll get the experience- but you will be in urgent care when youre D4s. And we
dont send all our pulpotomies upstairs so hopefully youll get that experience. Ok.
[Slide 104] [Mandibular Second Molar - Pulp] - SKIP
[Slide 105] [Mandibular Second Molar - Image] - SKIP
[Slide 106] [Mandibular Third Molar - Pulp] - SKIP
[Slide 107] [Mandibular Third Molar - Image] - SKIP
[Slide 108] [Mandibular Third Molar - Image] - SKIP
[Slide 109] [Access cavity]
[Dr. Fleischer] Access. This was my second lecture.
[Slide 110] [Proper Access]
[Dr. Fleischer] You have a need to visualize the location. And I know I stressed that at
the beginning.
[Slide 111] [Visualization]
[Dr. Fleischer] You have to have a current PA and bitewing. Why? A patient will come
in and say my dentist sent this to me, with me, for you, and it can be an x-ray that they
took as their pre-op film and then they went in and attempted the access, and you go in
and you see its perfed (perforated). So the film theyre sending you, this actually
happens as an endodontist, really doesnt reflect what the patient is walking in with. Also
know that for your patients here. Really, always take a film of how the present is
presenting in a current film. All posterior teeth need a PA and a bitewing. Please.
[Slide 112] [High Speed Initial Entry]
[Dr. Fleischer] You will run into problems unless you have that bitewing. And the PA
should be diagnostic so you know how many roots there are. Why do we use high speed
for initial entry? Minimal vibration. Minimum vibration and also it would take you
forever, but you also get that feeling of dropping through. I like the 4FGI never use a
surgical length. Personally, when I go to drop through, because I never want to be fooled
how much of that bur is being used. You know that when youre sinking a bur in, if its a
surgical length bur, you really can be fooled how deep you have gone. I like the 4RASL.
You can always take away more tooth structure. You cant put it in. So what that does is
help you get under, after you make that initial drop, and lift up. Lift up the roof, because
thats really how you get a beautiful access cavity. By lifting up the roof of the chamber,
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Transcribed by Charles Buchanan Date of the Lecture: 10/01/14
never touching the floor of the chamber, gives you the shape right there. Its all laying
right there for you. Ok?
[Slide 113] [Proper Access]
[Dr. Fleischer] Proper access leads to proper cleaning, proper shaping, proper
obturation.
[Slide 114] [3 Major Objectives]
[Dr. Fleischer] What are the three objectives. You want straight line access. You want
to conserve tooth structure. You wan to take away as much that is needed but no more.
And you want to unroof the chamber to expose the orifices. You do not want to leave
remnants of that roof sitting there. Ok.
[Slide 115] [Straight Line Access]
[Dr. Fleischer] Straight line access. It gives you better instrument control. You wont
transport the apex. You wont ledge. A popular term is zipping of the apex. You want to
be able to get good obturation. You want to be able to get your spreader or pluggers in to
get the better seal. Otherwise, youre not going to achieve that. And you want less
procedural errors. How do you strip a furcation? You strip a furcation by leaning your
instrument with improper access because you cant - youre pulling the instrument along
that furcation line. Thats one of the biggest areas of mistake in lower molars.
[Slide 116] [Tooth Structure Removed]
[Dr. Fleischer] Alright, you want to reduce that lingual shelf, you dont want to leave
that. And you want to remove any unsupported enamel. The enamel triangle, is what I
was telling you about the anterior teeth and the cusp tips on posterior teeth.
[Slide 117] [Conservation of Tooth Structure]
[Dr. Fleischer] You dont want to weaken that tooth anymore. You really- the marginal
ridge should be left alone. You want to - I remove an unsupported cusp. An unsupported
cusp, youll get a fracture of the tooth where you will have to extract the tooth.
Alright. Occlusal reduction. Of course there are times you cannot do that. If you are
going through a crown, you dont want to reduce the occlusion. Youre ruining the crown
but you have to let the patient know that it will be uncomfortable.
[Slide 118] [Extend Access to Include Pulp Horns]
[Dr. Fleischer] Pulp horns contain debris. You want the aesthetic consideration. Not all
posterior teeth should be crowned after endo. Anterior teeth, depending on the occlusion -
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Transcribed by Charles Buchanan Date of the Lecture: 10/01/14
it will depend. So if youre conservative with your access, the patient isnt necessarily
wedded to get -wedded like married- to the idea of getting a crown. No crown will ever
look as good as natures worst tooth. Natures tooth, if you can save that tooth is always
the best thing for the patient.
[Slide 119] [Fig. 5-12]
[Dr. Fleischer] These diagrams Im going to go over quickly but I have these up in the
Urgent Care. And I think that these are the best access cavity diagrams that exist. They
are from the first edition of Pathways from the Pulp which was made in 1977. If you
could ever get a hold of that edition, it is the best. Im going to go through them quickly
but Im going to make sure that you all get them. This is the triangular shape Im talking
about - Im sorry Im keeping you a few minutes late. Even a sort of triangular shape for
the lateral. The canine is an oval - canine is the oval.
[Slide 120] [Helpful Hint for Lower Anterior Teeth]
[Dr. Fleischer] Helpful hint for lower anteriors. They all look the same when youre
coming over with your rubber dam. Take a Thompson's stick and mark the tooth. Because
most of you put a rubber dam on like youre flying onto the tooth - with the clamp in the
rubber dam. Its very easy to clamp the wrong tooth. I put a - Im telling you- mark your
lower anterior teeth. Alright?
[Slide 121] [Fig 5-17]
[Dr. Fleischer] Two canals. Maxillary first premolar. Second premolar. But a lot of
times, that canal is a figure 8 shape.
[Slide 122] [Fig 5-19]
[Dr. Fleischer] Alright these are the other considerations
[Slide 123] [Fig 5-22]
[Dr. Fleischer] I will get these to you, I promise. Alright. This is when you dont have
an MB2. But what I want you to see- this is almost a much narrower triangle. A lot of
times, the distobuccal is right up here. It almost like its right here, like a little semi-colon
of a line. Where as here, its a much broader triangle. Ok.
[Slide 107] [Fig 5-24]
[Dr. Fleischer] Oh Im sorry. Alright. No. Alright. Im sorry. You should have told me.
~She got shooed off stage by the next professor~
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