Conservative Anterior Endodontic Access
Jon Richards DDS MS
A case highlighting the benefits of a minimally invasive endodontic access in a maxillary incisor,
This patient sustained trauma to his upper front teeth while he was young, over 40 years ago. He has never experienced any pain from the region. Just two years ago, he had crown placed to improve the esthetics of teeth 6-11. About a month ago, he noticed a sinus tract had formed ginigval to tooth #8. He had an extreme dental phobia dating back to the traumatic episode.
A periapical finding was present consistent with a chronic apical abcess. Tooth #8 did not respond to cold, but neither did tooth #9. Other teeth in the sextant responded normally.
Pre-treatment concerns were expressed. The periapical radiograph was very suggestive of advanced horizontal periodontal bone loss. Tooth #8 was class III mobile (depressible). Present was an all ceramic crown, very well done from both a technical and esthetic point of view. The paitent was informed that the desired treatment of root canal therapy would not be exptected to resolve the periodontal shortcomings. Also, accessing through the crown could damage the porcelain and make necessary a new crown. The patient understood, and deeply desired to preserve his natural tooth. He elected to proceed.
Conservative incisal access was made to minimize removal of tooth structure and restorative material. One necrotic canal was located and cleaned, with an emphasis on maintaining patency. Folliowing obturation, an immediate access restoration was placed while #8 was still isolated under the rubber dam.
By directing the access from just lingual t the incisal edge and axially in a straight-line with the anatomic position of the canal, risk was minimized in several areas. Less risk to the crown. Less risk to crown retention. Less risk of instrument breakage due to true straight line access. A post could have been placed without any post space preparation. The pericervical and cingulum dentin remain just as they were prior to treatment. Commonly, and as was the case here, the mandibular incisors occlude the lingual surface of the maxillary anteriors. With this area undisturbed, force concentration is much less likely to lead to a future negative event.