Endodontics | OPEN | VERIFIABLE CPD PAPER

CLINICAL

Endodontic access cavity preparation: challenges and

recent advancements
Ahmed Elmatary,1,2 Emad Moawad,*1,2 Omid Heidarifar1,2 and Simon Stone3,4

Key points
Provides an improved understanding of Offers an insight into endodontic access cavity Increases awareness of conservative endodontic
endodontic emergency management. procedures. access cavity approaches, the challenges and
complications in endodontic access cavity
procedures, and the technological advancements
used in the endodontic access cavity.

Abstract
Odontogenic pain from various dental issues significantly impacts quality of life, necessitating effective treatment
during emergency dental care. Endodontic access cavity preparation is essential for alleviating symptoms and
preventing further infection. This procedure aims to achieve symptom relief while conserving as much tooth
structure as possible. This paper discusses the importance of proper endodontic access, emphasising the balance
between adequate disinfection and preserving tooth integrity. It also identifies challenges in endodontic access
cavity preparation. This study reviews existing literature on endodontic access, examining different approaches
to access cavity preparation and the tools and techniques used. Factors affecting access difficulty, including tooth
anatomy, patient-related challenges and operator skills, are evaluated, alongside advancements in imaging and
instrumentation. The review shows conservative techniques, like minimally invasive access cavities, which helps to
preserve tooth structure but requires advanced skills and may risk incomplete disinfection. Cone beam computed
tomography (CBCT) aids in complex cases, improving canal location accuracy. Operator skills and proper equipment
are key to success. Traditional cavities offer better access but can weaken the tooth, while conservative approaches
maintain structure but demand more expertise. Imaging tools, including CBCT, are beneficial for complex anatomy
but can be costly. To conclude, effective endodontic access cavity preparation requires a balanced approach tailored
to each case. While conservative methods offer advantages in preserving tooth structure, their success depends on
operator expertise and equipment. Incorporating imaging advancements like CBCT can enhance access success,
especially in anatomically complex cases, but careful assessment of case complexity remains crucial.

Introduction this is particularly challenging where there cements), allowing comprehensive care,
is uncertainty about the origin of pain and including restoration, in one visit.2,3,4 Perhaps
Odontogenic pain arising from pulpitis, potential for spread of infection (including more commonly, an access cavity preparation
pulpal necrosis, periradicular periodontitis sepsis), and therefore, there is a need to is created along with coronal pulpotomy or
or dental abscess can significantly and investigate, rapidly diagnose, consent and total pulpectomy and temporisation, allowing
substantially impact quality of life.1 Treatment carry out operative treatment to provide root canal therapy to be carried out at a later
at ‘unscheduled dental care’ appointments symptomatic relief. Priority should be given appointment. Where dental trauma has
varies significantly because of time constraints; to pain relief and drainage of pus in the case occurred, the relevant guidelines should be
of acute dental abscess and, where teeth are consulted and followed concerning the need
deemed restorable, plan for follow-up care. and timing of root canal treatment.5
1
School of Dentistry, Institute of Life Courses and Medical
Sciences, University of Liverpool, Liverpool, UK; 2Liverpool
These management strategies are designed The cornerstone of endodontic treatment is
University Dental Hospital NHS Foundation Trust, to address endodontic issues effectively and predictably accessing the coronal part of the
Liverpool, UK; 3School of Dental Sciences, Newcastle
enable teeth to be retained that are pain-free pulp to identify the main root canal anatomy
University, Newcastle upon Tyne, UK; 4The Newcastle upon
Tyne Hospitals NHS Foundation Trust, Newcastle upon and functional. and commence bio-mechanical disinfection of
Tyne, UK. Endodontic access cavity preparation is the root canal system. This is carried out using
*Correspondence to: Emad Moawad
Email address: [email protected] often considered the initial stage of endodontic a combination of end-cutting and non-end-
Refereed Paper.
treatment. Conservative treatment with cutting burs (Fig. 1), with end-cutting burs
Submitted 13 November 2024 removal of some or all the coronal pulp being used to cut through enamel, dentine and
Revised 20 January 2025 may be considered where there is vital but restorative materials and entering the coronal
Accepted 2 February 2025 inflamed pulp remaining (pulp cap, partial pulp chamber before switching to non-end-
https://doi.org/10.1038/s41415-025-8442-8
or full pulpotomy with calcium silicate cutting burs for pulp chamber unroofing.

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The principle objective of access cavity

preparation is to remove the roof of the pulp
chamber, locate the canal orifice(s), and
establish straight-line access. This enables
subsequent steps, including coronal flaring,
creating a reproducible glide path, determining
the working length, and carrying out
biomechanical preparation and disinfection
of the root canal system. Ultimately, the
procedure aims to achieve effective obturation,
ensure the longevity of the restoration, and
preserve as much of the natural tooth structure
as possible.6 This can only be achieved through
knowledge of the underlying dental anatomy
(Fig. 2) and by selecting the most appropriate
bur or burs to use. The depth of an access cavity
preparation may vary depending on the depth
of the coronal pulp horn, which in older, worn,
heavily carious or restored teeth may have
receded and been replaced by secondary or
tertiary dentine deposition, necessitating a
careful approach to canal location.
Vision is often a limiting factor and Fig. 1 End-cutting round diamond bur, often used for endodontic access followed by a non-
magnification, particularly with an attached end-cutting tungsten carbide Endo-Z bur (Dentsply Sirona, USA), often used for deroofing
of the pulp chamber. A Meisinger bur (Hager & Meisinger, Germany) is also shown and can
light along with standard operating light, will
be used for refining the access cavity and troughing to identify canal orifices (note the long
significantly improve the ability to correctly
shank which can aid operator visibility during access). A diamond-coated ET18D ultrasonic tip
identify canal orifices and be conservative (Acteon, UK) is also shown and can be used for this purpose also
of coronal dentine. The dental operating
microscope offers unrivalled vision in this
respect regarding the clinical ability to visualise
anatomical challenges, such as sclerosed canal
entrances and variations, such as additional root
canals. A well-made access cavity will improve
the ability to disinfect and instrument the
canal system and significantly reduce the risk
of iatrogenic errors.
What is often forgotten, particularly for
patients returning following emergency
treatment, is the importance of stripping down
teeth and assessing their restorability. Both Beach
et al. (1996) and Krakow et al. (1977) identified
microleakage following initial endodontic
temporisation and it is important that teeth can
be adequately isolated to facilitate disinfection.7,8,9
Defective restorations and complete caries
removal should be undertaken as part of the
access cavity preparation to confirm restorability.
Restorability can be influenced by a multitude
of factors, including whether a successful
Fig. 2 Classical access cavity shapes for upper and lower adult dentition. These can be
coronal seal could be achieved following
modified to accommodate variations in anatomy identified on scouting of canals or from pre-
endodontic therapy, as well as the presence of operative imaging, such as periapicals or CBCT
a ferrule (1.5–2 mm of supragingival sound
tooth structure).10 It is worth remembering
that teeth scheduled for endodontic treatment have been altered significantly. Accessing perforation. The recommendation is therefore
have often been subject to a lifetime of caries, teeth through crowns is often challenging and to strip down teeth and make decisions about
restorations, trauma or tooth wear and as increases case complexity,11 increasing the risk restorability early, with thought given to what
such, the original anatomy of the crown may of iatrogenic damage and the likelihood of root the final restoration will look like.12 This involves

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the removal of poorly adapted crowns and

other restorations before access preparation.
Once restorability is confirmed, a tooth can be
re-walled efficiently, thus aiding isolation and
containment of irritants (Fig. 3).
It is often emphasised that achieving the right
balance in endodontic access is crucial. This
balance involves preserving as much healthy
tooth structure as possible while effectively
removing coronal interferences, necrotic pulp
tissue, and providing straight line access to the
canal orifices. There is nothing inherently wrong
Fig. 3 a) The 26 requiring rewalling to aid isolation and containment of irrigant. A Greater
with the traditional access cavity shapes (Fig. 2);
Curve matrix band was used in this case and the pulp chamber was blocked out by
however, advances in magnification, with many
polytetrafluoroethylene. b) The 26 was rewalled with Fill-Up! dual cure bulk fill composite
practitioners using dental loupes, microscopes (Coltene, Switzerland). Image courtesy of Dr Shakil Umerji
and improved lighting, have led to a trend
towards more conservative access cavities.
Recent social media trends have popularised
minimal access cavities and innovative designs
like ‘ninja’ and ‘truss’ cavities, which aim to
further preserve sound tooth tissue. This
paper will aim to discuss the merits and pitfalls
of these access cavities, as well as common
challenges encountered during endodontic
access, complications and errors.

Key factors in access preparation

Access cavity preparation in endodontics

presents several challenges.

Tooth factors
There is significant variation in tooth anatomy
which can complicate access cavity preparation.
Crown morphology, including the shape and
size of the crown, and the presence or absence of
direct and indirect restorations may make pulp
Fig. 4 The 21 became non-vital underneath a four-unit bridge which has removed all the normal
chamber and root canal identification more
anatomical landmarks. The access cavity had been misaligned and, in this case, resulted in
challenging. Pulp chambers and canal orifices iatrogenic perforation of the root. Note the white arrow showing the location of the perforation
can be obstructed by pulp stones, calcification,
or cutting debris from access cavity preparation,
complicating their identification. Accessing Patient factors However, effective training and investment in
through indirect restorations can result in the Patient-related factors can complicate access appropriate equipment can be costly and require
excessive removal of restorative material and cavity preparation. Physical limitations, such as significant financial resources.
dentine, impacting the integrity of the restoration an inability to recline in the chair, can restrict
and potentially causing fractures, chipping, or access and visibility. Anxiety and a strong Guidance for achieving good
dislodgement of the restoration.13 The position gag reflex, particularly in posterior teeth, can outcomes
of the tooth within the arch also plays a role; further complicate the procedure. Additionally,
posterior teeth can present difficulties in access reduced mouth opening (<25 mm) can increase A thorough pre-operative assessment is
and visibility.14 Tooth inclination and rotation treatment difficulty by limiting access and necessary to identify case difficulty and
can lead to loss of orientation and increase the visibility and increasing stress on instruments.15 potential pitfalls. Teeth requiring endodontic
risk of perforation. Some teeth, such as those in treatment can be heavily restored with either
patients with dentinogenseis imperfecta, have Operator factors intra-coronal or extra-coronal restorations,
poor-quality dentine, short clinical crowns and Limited experience and misjudgement in with dental caries and cracks also being
often obliterated root canal anatomy, making evaluating case complexity, alongside inadequate commonly present.9 In these cases, dismantling
identification of the original root canal very use of essential tools, such as magnification, can of the intra- or extra-coronal restoration is
difficult. impede successful canal location and disinfection. recommended to fully assess restorability

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and reduce the risk of unnecessary sound

tooth tissue removal or perforation caused
by a loss of anatomical landmarks associated
with the tooth.9 Figure 4 shows an iatrogenic
perforation occurring as a result of a
misaligned access through an abutment tooth
of a four‑unit bridge.
As part of the pre-operative assessment,
radiographic assessment is crucial in
determining the size and height of the pulp
chamber. Cases with a large pulp chamber
present radiographically, such as those shown
in Figure 5, will often carry less complexity,
as clinicians will likely feel a ‘drop’ when
accessing these teeth with their bur of choice,
thus reducing the risk of complications. Fig. 5 a) The 26 requiring root canal treatment, with a significantly reduced pulp chamber,
indicating higher complexity. b) The 36 with a reduced pulp chamber, also indicating additional
However, other teeth may present with
complexity. Note the gutta-percha cone showing the location that the sinus tract is originating
smaller and reduced pulp chambers, such as
from. The reduced sized pulp chambers increase the complexity of treatment due to increased
those shown in Figure 6, and these can carry risk of iatrogenic damage including perforation
higher complexity, as clinicians are unlikely to
feel a ‘drop’ when accessing these cases, and this
may be due to a reduced/invisible pulp chamber,
or due to calcifications such as pulp stones.
It is often good practice to use a measuring
tool using the radiographic viewing software
to measure the distance from the top of the
crown to the roof of the pulp chamber on
periapical radiographs, and additionally from
the top of the crown to the cemento-enamel
junction. Krasner and Rankow (2004) advise
that the cemento-enamel junction is the most
consistent repeatable landmark for locating the
positions of the pulp chamber.16 Although the
Fig. 6 a, b) Periapical radiographs showing the 36 and 46, in both cases requiring endodontic
measurement taken radiographically can be
treatment, with large, visible pulp chambers. This reduces the complexity of access cavity
influenced by foreshortening or elongation, a preparation, as the pulp chamber and canal orifices will be more easily located
bitewing radiograph can give a more accurate
reading in this regard.
Use of good lighting and magnification
will aid identification of the canal orifice(s),
developmental fusion lines and the ‘colour
change’ often mentioned when identifying the
floor of the pulp chamber.16 The choice of initial
bur when making the initial ‘pilot hole’ into
the pulp chamber is important, and it is the
opinion of the authors that a round diamond
or cylindrical bur, such as a 541 or a tapered
556, be used for this purpose. Whatever the Fig. 7 Showing different types of access cavities. (TradAC = traditional; ConsAC = conservative;
choice, the operator needs to be aware of the UltraAC = ultraconservative; TrussAC = truss; CariesAC = caries-orientated;
RestoAC = restorative). Reproduced with permission from Silva et al., ‘Current status
length of the cutting diamonds and stop and
on minimal access cavity preparations: a critical analysis and a proposal for a universal
re-assess the angle and orientation regularly, nomenclature’, International Endodontic Journal, 2020, Wiley
and most importantly, stop if the end of these
is reached. A longer crown preparation bur
(>8 mm) should be avoided due to the risk of (Dentsply Sirona, USA); diamond equivalents bur parallel to the long axis of the tooth
perforation. Once the pulp chamber has been are also available. The use of a non-end-cutting to reduce the risk of excessive tooth tissue
uncovered, the pulp chamber can be deroofed bur reduces the risk of damage to the pulp removal. Alternatively, a slow-speed, rose-
in its entirety with the use of a non-end-cutting chamber floor, reducing the risk of perforation. head, stainless steel bur can also be used to
tungsten carbide bur, such as an Endo‑Z bur It is imperative to keep the non-end-cutting deroof the pulp chamber. At various intervals,

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a ball-ended or Briault probe can be used to

explore the walls of the current access cavity
to identify any undercuts indicating remaining
pulp chamber roof.
Krasner and Rankow’s laws also provide
guidance on identifying the floor of the pulp
chamber and canal orifices. The floor of the
pulp chamber is normally a darker colour
than the surrounding dentine walls, and
the canal orifices are always located at the
junction between the walls and floor of the
pulp chamber.16 Darker developmental root
fusion lines exist which can map out the pulp
chamber floor, and the canal orifices are at the
end of these fusion lines. Pulp stones can also Fig. 8 a) Pre-operative periapical radiograph of the 21, with an attempted access cavity by
affect identification of the pulp chamber floor the patient’s general dental practitioner. b) Sagittal CBCT slice showing a clear and evident
and canal orifices and these can be identified canal emanating from the palatal aspect of the current access cavity. c) Periapical radiograph
pre-operatively on the radiograph through showing completed root canal treatment for the 21, with the gutta-percha sealed with resin-
modified glass ionomer cement, and the 21 now ready for internal/external bleaching. The
calcifications/radiopacities seen within the
canal was located using high magnification and the CBCT
pulp chamber. Clinically, pulp stones often
appear to carry a more ‘glassy’ appearance as
compared to the surrounding dentine. of root canal anatomy and its variations have occlusal surface to expose the canal orifices
Piezoelectric ultrasonics are very effective at developed significantly and have gone hand- while preserving the middle dentine
removing pulp stones, while standard tips are in-hand with the wider acceptance and use • Caries-driven access cavity – access to the
often adequate. Thinner tips, such as diamond- of 3D-imaging modalities, along with in vitro pulp chamber is achieved by removing
coated Acteon ET-18D (Acteon, UK) or E15D micro-computed tomography studies of caries while preserving all remaining
(NSK, Japan) or grooved profile Start-X series extracted human teeth.19 While these studies sound dentine
(Dentsply Sirona, USA) are often the instrument have confirmed what was already known about • Restorative-driven access cavity – access to
of choice for clearing pulp stones. In cases such the gross anatomy of the pulp chamber, with the pulp chamber is achieved by partially
as those seen in Figure 6, due to the lack of a CBCT, there is the ability to visualise canal or fully removing the restorations while
‘drop’ felt when accessing these teeth, care must orifices, complex branching and anastomoses, preserving as much of the remaining tooth
be exercised and it is important that slow-speed and the presence or absence of ‘additional’ structure.
burs, such as a Muller pulp or Gooseneck bur, canals before access preparation.20
be used, along with ultrasonics and plenty of MIAC involves a thorough pre-operative Preserving more sound tooth structure
irrigation and patience, in order to locate the radiographic identification of the root when preparing MIAC is thought to reduce
canal orifices. A DG-16 endodontic explorer canal system, including its variations, and the risk of tooth fracture.21 However, MIAC
can then be used to identify the canal orifices, the presence of calcifications. With this comes with risks and challenges and requires
followed by scouting of the canal(s). information, the access cavity is meticulously a high level of operator skill and specialised
designed. The access cavity is then guided with equipment, such as magnification and
Minimally invasive access cavity precision using dental magnification, along ultrasonic instruments. A major limitation is
The minimally invasive access cavity (MIAC) with small instruments with long shanks, such the difficulty in adequately mapping the pulp
preparation aims to preserve tooth integrity as ultrasonic or Muller pulp bur instruments. floor to identify canal orifices, particularly in
by removing only necessary tooth structure There are several techniques to achieve an multirooted teeth. This approach needs direct
required for instrumentation and disinfection. MIAC, as outlined below and shown in Figure 7: visual control, making the use of high-speed
This method differs from traditional access • Traditional access cavity burs impractical, since the handpiece head
cavity preparation, which involves the removal • Conservative access cavity – note the often obstructs the view during procedures.
of a larger volume of tooth structure beyond that convergent access with partial removal of In this scenario, ultrasonic tips with longer
of the pulp chamber. Advances in technology, pulp chamber roof shanks (Fig. 1) have become a basic technical
including the use of flexible instruments, • Conser vative access cavity with requirement for performing such methods.22
magnification, and 3D-imaging techniques, such divergent walls As a result, it can be more time-consuming
as cone beam computed tomography (CBCT), • Ultra-conservative access cavity (ninja and lead to increased fatigue for both patients
have made dentine conservation a feasible goal.17 access) – this approach is similar to and clinicians.23,24,25 As these are relatively
This is particularly important in the peri-cervical the conservative access cavity but with new techniques, there are currently no robust,
region of the tooth, where the pulp chamber no additional extensions beyond the long-term, tooth survival outcome studies to
meets root canal, in the distribution of occlusal initial opening suggest that MIAC root canal-treated teeth
stress and the prevention of cracked teeth.18 • Truss access cavity – this technique involves have a better survival outcome than those with
Over the last 20 years, our understanding creating separate access cavities on the traditional access cavity preparation.26

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Such minimal accesses can lead to risks

such as:
• Missed canals and incomplete cleaning of
the entire pulp chamber and root canals
• Postoperative pain and sensitivity due to
incomplete removal of infected tissue
• Instrument fracture within the canal due to
increased stress on files
• The remaining tooth structure can still
be prone to postoperative fracture if not
adequately supported by appropriate
restorative materials.

CBCT-informed and guided access

In teeth with reduced pulp chambers and
calcified canals, CBCT can be an invaluable tool
for canal location in various planes. A modern,
‘small field of view’ CBCT carries a low radiation
dose, meaning the benefits will outweigh the risks
in many cases.27 Figure 8 shows the 21 which
had been referred by the patient’s general dental
practitioner, who had been unable to locate
the canal. The 21 had undergone pulp canal
obliteration because of a previous traumatic
injury. The pre-operative periapical radiograph
shows an attempted access cavity with an
indistinct/invisible canal evident.
A CBCT was taken to assess canal location
and this revealed a clear, distinct canal which
was unclear on the 2D radiograph (Fig. 8a).
As the location of the canal in relation to the Fig. 9 a) Periapical radiograph of the 21 with evidence of apical pathology and an invisible
existing access cavity could now be easily canal. b) Sagittal CBCT slide showing evidence of a patent canal with associated apical pathology
determined, the canal was easily located around the 21. c) Postoperative periapical radiograph following root canal treatment of the 21.
within minutes using high magnification and Note the voids in the access cavity restored with resin composite, owing to the very conservative
nature of the access cavity. d) 3D-printed stent seating fully on model. Note the viewing windows
the CBCT, with a minimal loss of additional
designed to check for full seating of the guide. e) Full seating of the stent, verified through the
tooth structure. This illustrates the value that
viewing windows added. f) Access cavity created by the Steco titanium drill
CBCT has, especially when used following
an attempted access, as the access cavity can
then be re-oriented in the correct direction. Virtual planning of the angulation and An intra-oral scan was then taken and
Additionally, CBCT can reveal a distinct canal orientation of the model can take place so coDiagnostiX was used to design a stent
when one is not visible in conventional 2D that the tip of the bur corresponds with both (Fig. 9c), where the tip of the titanium drill
radiography, and a measuring tool on the the start of the visible canal on the CBCT (Fig. 9d) was virtually simulated to access
CBCT viewing software can dictate the depth while remaining within the long axis of the the canal orifice parallel with the long axis of
of the access cavity with complete accuracy. tooth. From this, a stent can then be designed the tooth. Once the stent was finalised, and
In conjunction with the above, ‘guided’ and 3D-printed, which seats on the tooth of following appropriate anaesthesia and dental
endodontics can also be an invaluable tool for interest and neighbouring teeth with minimal dam isolation, the stent was fully seated and
locating calcified canals. The use of a static offset. A metal sleeve with a diameter of a Steco titanium 1 mm diameter drill (Steco-
guide is reported below to aid canal location; 1 mm is then placed into the stent, which the System-Yechnik, Germany) was used in a slow
although, dynamic navigation has also been titanium drill can be placed through. handpiece at 10,000 RPM through the sleeve in
discussed in case reports in the literature.28 The following case demonstrates the short pumping motions, until the canal could
The construction of a guide for access of a successful use of a guide to aid canal location. be scouted with a small hand file.
calcified canal begins with a CBCT and A male patient in their fifties was referred Guided access using a static guide does have
intra-oral scan/digitised impression of the regarding the 21, which had evidence of pulp limitations. It can only be used in roots with
arch. These are then transferred into implant canal obliteration with an associated area of no/minor curvatures and can lead to incisal/
planning software, such as coDiagnostiX apical pathology (Fig. 9a).29 A CBCT was slightly labially placed access cavities, which
(coDiagnostiX, Germany), where both the taken which revealed evidence of canal space can have aesthetic implications. It can also be
CBCT scan and intra-oral scan are overlayed. from the coronal third of the root (Fig. 9b). difficult to use this technique when the tooth in

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question or adjacent teeth are heavily restored, Author contributions 14. American Association of Endodontists. AAE
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