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Modern Anterior Endodontic Access and Directed

Dentin Conservation
Written by David Clark DDS and John Khademi DDS MS

The authors are Dr. David Clark, a general dentist and pioneer in Biomimetic Microendodontics and Minimally Traumatic Restorative Micro-
dentistry; and Dr. John Khademi, an endodontist and pioneer of Restoratively Driven Micro-Endodontics. Together they explore the Endodon-
tic-Endo-Restorative-Prosthodontic (EERP) continuum. This article focuses on the pervasive endodontic problems vexing patients, restorative
dentists and endodontists. The authors provide alternative models and thought processes to treat the tooth in a non-traditional approach -- from
cusp tip to apex. Finally they will propose immediate tools to implement these important changes.

During patient treatment, the clinician needs to con- In both of our practices, our endodontic goals and arma-
sider a multitude of factors that will affect the ultimate mentarium have been in a constant state of flux for nearly
outcome. In simple terms, these factors can be grouped a decade as we have collaborated to bring the EERP con-
into three categories: the operator needs, the restoration tinuum to maturity. The goal? To satisfy the demands
needs, and the tooth needs. The operator needs being of the afore mentioned big 5 forces for change. In so
conditions the clinician needs to treat the tooth. The doing we have come to realize that when cutting end-
restoration needs being the prep dimensions and tooth odontic access our previous needs as dentists were often
conditions for optimal strength and longeity. The tooth in conflict with the needs of the tooth.
needs being the biologic and structural limitations for a
treated tooth to remain predictably functional. In this The Hierarchy of Tooth Needs
article we want to discuss failures of endodontically This table (left) represents
Table 1
treated teeth that occur not because of chronic or acute The Hierarchy of Tooth Needs the hierarchy of needs to
apical lesions but because of structural compromises to for Anterior Teeth maintain optimal strength,
the teeth that ultimately renders the tooth useless. We Extremely High Pericingulum and fracture resistance,
want to shift the coronal focus to the cervical area of the Dentin
along with several other
Pulp in Immature
tooth and create awareness for an endo-restorative inter- Teeth characteristics needed for
face. This article will introduce a set of criteria that will High Cingulum Enamel long-term full function of
guide the clinician in treatment decisions to maintain Axial Wall DEJ
the endodontically treated
Cervical Enamel
optimal functionality of the tooth. tooth. This brief article is
Medium Peri-incisal Enamel
designed to simply intro-
Endodontic accesses are traditionally conservative to Low 2 Dentin
duce the reader to the re-
the occlusal/incisal tooth structure. However with the No Value or 3 Dentin shuffling of the values as-
Liability Inamed Pulp in
changes that occurred in restorative dentistry, this tech- Mature Teeth signed to different tooth
nique is unnecessarily restrictive for the operator and Exposed Dentin in structures and of the nu-
Incisal Area
potentially damaging to the more critical cervical area anced role of the impor-
of the tooth. tance of regional tissues. A full explanation of the new
hierarchy will be presented in future articles.
A New Model For Endodontic Access
As we deconstruct endodontic access, it is crucial to un- The brevity of this article precludes a full definition for
derstand the five catalyst forces that will change the fu- all of the terms of the glossary. However, there are four
ture of endodontic access and coronal shaping. They are: terms that will be explained below. Others will be men-
1. Implant Success Rates (The bar is raised) tioned in the context of the featured case.
2. Operating Microscopes and Micro-Endodontics
The Inverse Funnel and Blind Tunneling are demon-
3. Biomimetic Dentistry
strated by the two endodontic accesses performed on
4. Minimally Invasive Dentistry
my younger brother Tom, who occasionally bumps his
5. Esthetic demands of patients combined with
manufacturers recommendations for axial reduction teeth while on the ski slopes and soccer field (Figure 1).
for porcelain crowns A round bur was used by his general dentist as he la-
bored to discover the canal systems in these calcified in-
Table 2 Glossary of Terms for Modern Endodontic Access
and Acronyms
Note: The red text indicates a nondes irable outcome, or technique.
Glossary of Terms Acronym
The endodontic-endorestorative-prosthodontic continuum EERP
Three-Dimensional ferrule 3-D Ferrule
Peri-Cervical dentin PCD
Peri-Cingulum dentin
The inverse funnel
Blind tunneling
Figure 1
Blind funneling My younger brother Tom received trauma to both upper and lower central inci-
Partial de-roong sors and the teeth subsequently underwent dystrophic calcification. Although the
teeth are still in function, they have been badly weakened. His dentist lacked the
Soft proper tools and followed an access form that is no longer appropriate.

Stepped access
Figure 2
Secondary dentin 2 Dentin A new model for lower incisor
access is depicted, along with
Tertiary dentin 3 Dentin the new EndoGuide Bur 1A
which was used to create ideal
Biomimetic endodontic shaping BES access. Note that the access
has been moved away from the
Arbitrary round shaping ARS cingulum and towards the inci-
The dentinal map sal edge. The diminutive size
of the tip, along with the conical
The Dentino-enamel junction DEJ shape of the cutting surface are
helpful to both visual (dentists
The junction of primary and secondary dentin DJ using microscopes) and tactile
(little or no magnification) end-
The junction of primary and tertiary dentin DJ odontics.
Pulp tissue remnant PTR
Points of negotiation PON

cisors. Note that as the access goes deeper into the tooth,
it becomes wider internally, hence the term inverse fun-
nel. In the new approach advocated by Clark/Khademi,
the access and EndoGuideTM Bur (SS White Burs, Inc.
Lakewood, NJ) selection should allow the formation of
a true funnel; wherein the narrow portion of the funnel
is in the pericervical dentin zone, and the cavosurface
Figure 3a, b, c, d, e
has a 45 angle with an infinity edge margin which be- Blind Tunneling: Gouging that is common with round burs and cingulum access.
comes a generous mouth or top of the funnel. Mod- BuccalLingual gouging which is not easily seen in x-rays, occurs in nearly every
traditionally accessed case. Fig 3b, 3c, 3d, 3e; The Inverse Funnel. As the size
els contrasting the C/K funnel created with EndoGuide of the access cavitation is enlarged internally, an inverse funnel results. Vital
peri-cervical dentin is removed each time the bur enters the tooth.
Burs, the inverse funnel and the blind tunnel are shown
in Figures 2 and 3. The stark difference between the tip
size of the patented EndoGuide Bur designed for use long term retention of the tooth and resistance to frac-
for endodontic access & exploration and a comparable turing are directly relational to the amount of residual
round bur is shown in Figure 4. tooth structure.1, 2 The more dentin we keep, the longer
we keep the tooth.
Peri-Cervical Dentin or PCD is the dentin near the al-
veolar crest. While the apex of the root can be amputat- Peri-Cingulum Dentin: In the instance of incisor ac-
ed, and the coronal third of the clinical crown removed cess, the research done by Pascal Magne 3 and others in
and replaced prosthetically, the dentin near the alveolar regards to the importance of the cingulum directly con-
crest is irreplaceable. This critical zone, roughly 4 mil- flicts with traditional cingulum positioned endodontic
limeters above the crestal bone and extending 4 milli- access that is currently taught. There are severe tensile
meters apical to crestal bone, is sacred for 3 reasons: 1) forces that are concentrated at the cingulum when the
ferrule, 2)fracturing, and 3)dentin tubule orifice prox- maxillary anterior teeth are functionally loaded. These
imity from inside to out. The research is unequivocal; forces can lead to structural breakdown when the peri-
Figure 4
This illustration compares the En-
doGuide Bur to a corresponding
round bur. The tip size of the En-
doGuide Bur is less than half the
width as the corresponding round
bur. The EndoGuide Bur (right)
is shown in contrast to the cor-
responding surgical length round
bur (left). The EndoGuide Bur,
designed by Dr. Clark and Dr. Kha-
demi, were introduced in February
2011.

Figure 5
Lingual view of the C/K model of lower anterior ac-
cess. This extremely calcific tooth shows the ideal
cavity outline to satisfy operator, restorative, and
tooth needs. Collage of Gouged Access
(Mural is described in the text) Note: Blue arrows indicate gouges. Red arrows
indicate perforations. JK indicates that case was done by Dr. John Khademi
with adherence to the modem model of directed dentin conservation.

sial and distal gouges nearly eliminating ferrule qual-


ity resulted from using square ended carbides as shown
in the second case. Round burs which are used both
cervically and deeper in the root system have severely
Figure 6 compromised the PCD. This eventually results in per-
Facial view of the access and the
tiny lingual notch. In a case with sig-
foration (in red) of the root system in the fourth case.
nificant wear and significant exposed Note that the access gets wider (inverse cone) as it pro-
dentin, the access will go directly
through the incisal. The facial exten- gresses apically in this lateral incisor. Keep in mind that
sion of the exposed DEJ becomes
the facial margin of the access. the gouging is usually more severe in the bucco-lingual
plane. Correct incisally placed access maximally pre-
serves the irreplaceable PCD.

Figure 7 Bottom row Mandibular Incisors: The sequence of


Invisible Restoration of the C/K ac-
cess and tooth at 3 year recall. The
lower incisors show the same types of errors, starting with
margins were heavily beveled before mild occult gouging and over-enlargement of the pro
restoration (not pictured). This is
the Bob Margeas or Infinity Edge cervically placed access and ending with a perforation in
Margin. The access was closed with
Filtek Supreme Plus. Our SEM evalu- the fourth case. As the earlier drawings show, these teeth
ation of this technique combined
with the unique properties of such are invariably gouged to the buccal as well. The paradox
microfills shows ideal wear and mi-
croleakage resistance.
of these case types is perhaps best illustrated by the third
case with the traditional cingulum style access and the ex-
cingulum dentin is compromised during traditional tensive cervical gouging: the more calcified the case, the
access near the cingulum. The situation is further ex- more incisal the access must be placed. In the fourth case,
acerbated by deep axial reduction when a crown prepa- the access was extended completely to the incisal edge, re-
ration is performed and the deep margin is also cut in oriented and the canal was located. The perforation was
the palatal area. For that reason, Clark/Khademi ac- repaired with MTA, and Ca (OH)2 was also placed. The
cesses which utilize EndoGuide Bur 1A have moved to- canals were obturated at a subsequent visit. The Mon-
ward the incisal edge. In the instance of the worn tooth day morning test is that the correct access is invariably
with exposed dentin, the access includes this landmark farther incisal than traditionally described, and in the cal-
as the incisal-facial border of the access (Figures 5-7). cified case, may go straight through the incisal edge (as
shown in the earlier drawings.)
Gouged Access Collage:
Top row Maxillary Anteriors: These anteriors repre- Why are round burs so destructive?
sent a spectrum of gouging typically seen in anterior In reality, it is truly impossible to cut flat walls in three
teeth. The first case shows very common occult mild dimensions with a round instrument. In reality, with
cervical gouging stemming from an access placed too the use of a round bur the chamber is unroofed in some
far cervically with round bur use. Stress focusing me- areas leaving pulpal and necrotic debris, and the walls
are overextended and gouged in other areas. Further, Figures 10, 11
Feature Case: Following the
the internal radius of curvature at many of the pulpal new hierarchy of tooth needs,
line angles is simply too small for all but the smallest of the preservation of peri-cervi-
cal dentin dictates that incisal
round burs. composite be sacrificed, an
easy compromise.

In the final analysis, round burs end cut, or point cut, in


an endodontic access application, when instead what is
needed is planing. What is needed is a new set of mental
models based on vision, and a new set of instruments
reflective of the task at hand and the desired shaping
outcomes. The new vision based mental model is Look,
Groom, Follow. The new instruments are the EndoGuide
Burs.

FEATURED CASE
The Calcified Incisor (Clark)
The maxillary left central incisor (#9) in a 21 year old Figure 12
EndoGuide Bur 1A is shown.
female was undergoing dystrophic calcification (Figures This bur is appropriate for
larger incisors. The diminu-
8-9). For such teeth, a cingulum positioned round or fis- tive size of the tip is actually
sure bur driven access runs a high risk of gouging. When more delicate than a #2 round
bur and creates the ideal cone
the access is moved toward the incisal edge utilizing En- shaped access.

doGuide Bur 1A, there are many benefits. Additionally,


with the use of the EndoGuide Burs, the conical shape
encourages the bur to follow a more true course. Because
this tooth contained a failing composite restoration on
the incisal edge, I had the luxury of moving the access diamonds share the same problems associated with ultra-
through the incisal edge and with a generous cone (Fig- sonic tips. EndoGuide Burs are carbide burs and have an
ures 10-11). The patented shape of EndoGuide Bur 1A advantage as they are superior in end cutting and milling
(Figure 12) is ideal for large incisors. The conical shape and they leave a polished dentinal surface which allows
produced by the EndoGuide Burs has many advantages for optimal visual navigation.
over other modalities. For example, ultrasonic tips al-
low good visualization, but do not end cut well, and do Slight binding of the file is seen, even after the access is
not leave a polished dentinal surface. The rough surface placed through the incisal edge (Figures 13-15). Upon
left by the diamond is much harder to read than a pol- re-entry, EndoGuide Bur 2 identifies without deviation,
ished surface that is produced by the EndoGuide Burs and eliminates a tiny thread of residual pulp tissue, al-
when studying the nuanced differences in color, opacity lowing for the file to re-enter the tooth without binding
and texture of dentin. Access routes created by tapered (Figures 16-18). When the non-vital tertiary dentin is en-
gaged and removed at the incisal position and carefully
followed into the cervical zone, the perfect orientation of
a long trajectory creates a safe guide and pathway, similar
to how a surgical stint can guide the drill and placement
of an endosseous implant. Incisal access is superior to
cingulum access in the same way that a rifle is more accu-
rate than a pistol; the barrel is much longer and therefore
the trajectory is much easier to control. When combined
with the operating microscope, the properly equipped
Figures 8,9 clinician can confidently access the canal system early
Feature Case: This patent 21 year old female pa-
tient was engaged to be married and had requested on from the incisal-apical direction.
comprehensive esthetic treatment. The first treat-
ment planned for the left central incisor was elec-
tive/proactive removal of the degenerating pulp, Clark Sequence for Large Incisor Access
then internal bleaching, and then finally a porcelain
laminate. 1. Begin with the EndoGuide Bur 1A, and start with the
Figure 16 Figure 17 Figure 18
Figures 13, 14, 15 Feature Case: Feature Case: Feature Case:
Feature Case Number Two Con- Mid treatment radio- Mid treatment radiograph Final radiograph with
tinued: These images demon- graph demonstrates with file to length. adequate shape and ob-
strate although the access was that the file has encoun- turation for a non-lesion
positioned through the incisal tered the pulp chamber case.
edge, the file is actually binding dead on and early.
slightly against the incisal por-
tion of the access. The series of radiographs depicts the dead on discovery of
an extremely calcified pulp. No unnecessary removal of the vital peri-cervical or
peri-cingulum, occurred.

cavosurface design. Create a beveled margin as region of the tooth will resist future staining and wear.
you begin the access, instead of later in the process. You Thus you bless the tooth as you create endodontic ac-
will get better lighting to enhance vision and the cess, as opposed to cursing the tooth with traditional
smaller internal shape will be compensated by a burs and techniques. In vital (non-lesion) cases you can
better funnel shape externally as we insert instru- confidently make very small endodontic shapes, more
ments and gutta percha into the tooth. In the words consistent with lateral condensation techniques. These
of the great John Stropko, Dont fight the case. techniques are best accomplished with the use of a mi-
croscope and proper instrument selection.
2. In a calcific canal case, switch to the EndoGuide Bur 1
or EndoGuide Bur 6, as you move deeper into the
tooth. Constant visualization of the DJ offers guid-
ance for the orientation of the bur, which allows you to
stay centered in the bullseye of the dentinal map.

Clark Sequence for Small Incisor Access


For small incisors (typically the lower incisor) you should
begin with an ovoid shape, utilizing the more delicate References
EndoGuide Bur 3 or EndoGuide Bur 4. 1) Lirtchirakarn V. Patterns of vertical root fractures: factors
affecting stress distribution in the root canal. J Endod
Final Recommendations 2003;29:523-8
It may seem odd at first, but put away your round burs 2) Tamse A., Fuss Z., Lustig J., et.al. An evaluation of endodonti-
and Gates Glidden Burs, and your square end #556 fis- cally treated vertically fractured teeth. J Endod
1999;25:506-8
sure burs. Move your anterior accesses away from the
cingulum and as close to the incisal edge as possible. 3) Magne P., Belser U., Bonded porcelain restorations in the
anterior dentition: a biomimetic approach. Chicago Ill:
For worn anteriors, go right through the incisal edge Quintessence Publishing, 2002, 2003
with your access and then take the EndoGuide Bur 1A
along the incisal edge to remove a millimeter thickness
of dentin. Generate a long bevel on enamel. Then as you Disclosure: Dr. Clark and Dr. Khademi receive a royalty from the sales
close the access with a good microfilled composite you of EndoGuide Burs by SS White. For further information regarding
the EndoGuide Burs, contact SS White Burs at www.sswhiteburs.com
will cover all of the ugly and porous exposed dentin with
at least a millimeter thickness of composite. The color The authors would like to thank Dr. Jihyon Kim and Dr. Eric Herbran-
of the tooth will immediately improve and the incisal son for their contributions.