MINIMAL INVASIVE

ENDODONTICS
 virtually impossible to
render root canal systems Herbert Schielder
of teeth bacteria-free

1 2 3 4

The objective of eliminating the

root canal microorganisms from
treatment is to the canal system one
eliminate should also make sure
microorganisms that there is no
and preventing extensive loss of tooth
reinfection structure in the process
 Minimally invasive endodontics treatment modalities
include two major rewards:
clinical research on vital pulp therapy now
provides options for enveloping new
biologically driven treatment protocols
During the endodontic procedures
08 diagnosis to Treatment Planning
07 01

With advancements in research pulp minimal invasive approach which

biology have developed over time, 06 02 includes correct diagnosis and
decision-making
05 03
RCT 04 Diagnosis and treatment planning

mature teeth diagnosed with irreversible

pulpitis or apical periodontitis
firstly, preservation secondly, lesser removal
and maintaining of hard tissue which
physiological and preserves the structural
defensive functions integrity of the tooth
 Irreversible pulpitis
cases have shown
biological A recent histological morphological
Thorough study -shows a good changes indicating
partially response of correlation between
knowledge the inflammation or
retained the immune clinical symptoms of
of pulp necrosis of coronal
pulp system could pulpitis and the
pulp while the
biology histological state of a
be enhanced diseased pulp radicular pulp is
. . viable..

This paves way of preserving radicular pulp thus preventing need for a pulpectomy.
This less invasive treatment approach (‘Endolight’) has the
following advantages:
1. preservation of immunological functions and retaining
structural integrity of the tooth.
2. simplifying treatment procedures and avoiding complications
associated with difficult root canal anatomy.
3. suggested procedures cause little pain (Simon et al. 2013).
4. reducing cost and inconvenience for patients and society
 MIE
The concept of Minimally invasive endodontics (MIE) involves preserving maximum healthy

coronal

cervical

radicular tooth structure

during endodontic procedures.

MIE can be incorporated in various phases of endodontic treatment, namely

ACCESS OPENING CLEANING SHAPING

According to Gianluca Plotino,

The term minimally -synonymous with anatomically

Anatomically Invasive Endodontics.

 The first articles describing how to apply the minimally invasive concept to
access cavity preparation were published by Clark and Khademi.

Amongst the several concepts introduced by the authors, the core aspect

concentrates on maintaining the pulp chamber roof – the so-called

soffit and the pericervical dentine as much as possible to ultimately

improve the tooth's survival.

Silva EJNL, De-Deus G, Souza EM, Belladonna FG, Cavalcante DM, Simões-Carvalho M,
Versiani MA. Present status and future directions - Minimal endodontic access cavities. Int
Endod J. 2022 May;55 Suppl 3:531-587.
WHEN HOW

MIE

WHY
 E N
H
W
Direct visualization of the entire floor of the pulp chamber

Ability to fully explore the anatomy of the pulp chamber

Ability to localise all of the anticipated canal orifices

Complete removal of any present calcifications on the floor

of the pulp chamber
 HOW

The conservative design of access cavities can

be applied only when the operator has adequate
experience and with the aid of modern
technologies

such as a dental operating microscope,

ultrasonic tips, modern nickel-titanium rotary
files and modern 3-D cleaning
when it is performed with experience and with

the updated technologies while respecting all of

the previously discussed parameters, iatrogenic

errors can be avoided. Not only will the tooth be

treated in a safe and healthy approach that will

preserve valuable tooth structure, but the

short- and long-term success will be
improved as well WHY
 NEED FOR MIE

WThe
hen eremaining
ndodontically
Degree of stress experienced by
structural
treated teethintegrity
fail under the tooth under load
is important factor
function, that ou
that determines tcome is
determined prim
prognosis asait rily by
relates
tw o etioloto
giethe
s post- Inherent biomechanical
endodontic properties of the remaining
survival rate of the structure responsible for resisting
tooth fracture

This makes the concept of minimal intervention highly significant in the field of
endodontics.
 Attempts made to prevent the fracture rates are by Preservation of

a)Peri Cervical
Dentin
(PCD):
Dentin near the alveolar crest which is roughly 4 mm above the crestal bone
and extending 4 mm apical to the crestal bone

It is insisted to preserve PCD in order to prevent fracture, preserve the ferrule

a) Peri Cervical
a) 3D Ferrule
Dentin (PCD):

axial wall dentin covered by the axial wall of the crown and has been
described as the backbone of prosthetic dentistry
which has 3 components [8]:
 Vertical component - around 1.5 to 2.5 mm
 Thickness of dentin (Girth)-Absolute minimum thickness-1-2 mm
 Net Taper is the total draw of 2 opposing axial walls to receive a
fixed crown of 10 degrees in 3mm of vertical ferrule, 20 degrees [9]
in 4mm, possible in the traditional stainless steel crowns. However,
the newer porcelain crowns demand 50 degrees or more taper due to
their deep chamfer marginal zones
a) Peri Cervical Dentin
a) 3D Ferrule a) Soffit/Banking
(PCD):
The underside of a ceiling, at the corner of the roof and wall, is referred to as soffit

stepped access

The dotted line shows the typical cut made to remove the
entire pulp horn. The area between the lines is referred to as
the soffit
attempts at removing the soffit that are
far more damaging to the surrounding
PCD

The primary reason to maintain the soffit

is to avoid the collateral damage that
usually occurs, namely the gouging of
the lateral wall.
Traditional Access Cavity (TradAC):
Traditional Access Cavity (TradAC):
Traditional Access Cavity (TradAC):
• Complete unroofing of the pulp
chamber
• Exposure of all the pulp horns
• straight-line access to the root
canals
• Coronally divergent walls without
undercuts,
• Visualize the pulp chamber floor
and all the root canal orifices from
the same visual angulation
Conservative Access Cavity (ConsAC):
Conservative Access Cavity (ConsAC):
Conservative Access Cavity (ConsAC):
 Following the principles given by Clark and
partial unroofing of the pulp chamber with
Khademi,
preservation of the pulp horns, with slightly
convergent walls occlusally beveled, to
It means that clinicians can visualize the
visualize the pulp chamber floor and all the
chamber space and the floor even if not by
root canal orifices from different visual
the same angulation, but also by tilting the
angulations
mirror
Ultra-Conservative Access Cavity (UltraAC):
Ultra-Conservative Access Cavity (UltraAC):
Ultra-Conservative Access Cavity (UltraAC):
Ultra-Conservative Access Cavity (UltraAC):

ultra-conservative cavity just locating

the orifices, with an extreme

unroofing of the pulp

chamber and preservation of
all the pulp horns, extremely
convergent walls and preservation
of the occlusal enamel
Truss Access Cavity (TrussAC):
“an orifice-directed access, in
which separate cavities are
prepared to negotiate the different
roots of molars avoiding removal
of the central part of the pulp
chamber’s roof”
Caries-Driven Access Cavity (CariesAC):
Caries-Driven Access Cavity (CariesAC):
Caries-Driven Access Cavity (CariesAC):

a strategic interproximal or
buccal access aiming to
remove all the carious tissue
and the entire old fillings,
taking advantage of the loss
of tooth structure to enter
the root canal system from
the pre-existing cavity
without enlarging it with a
predefined shape.”
 Restorative-Driven Access Cavity (RestoAC):

In restored teeth with no caries, access to

In restored teeth with no caries, access to the
the pulp chamber is performed by totally
pulp chamber is performed by totally or
or partially removing existing
partially removing existing restorations and by
restorations and by preserving all
preserving all possible remaining tooth
possible
structures remaining tooth structures
 Image-Guided Endodontic Access

Instead of practicing a standard access design, a tooth-specific and

unique access design is proposed

GOAL

strategically remove and preserve dentin, and not prepare the smallest
access cavity possible
Two types of image-guided end endodontic access preparations:
(a) static and
(b) dynamic
Static-guided access utilizes a stent or guide, which is
fabricated using computer-aided design/computer-assisted
manufacture (CAD/ CAM) technology and 3D printing
technology
Dynamic guidance utilizes computer-aided surgical
navigation technology, which corresponds to the global
positioning systems
(GPS)

Dynamic guided access preparation uses CBCT

image volume to plan an access cavity

The overhead tracking cameras in the system are used to

relate the position of the jaw and the bur in a 3D space

During the therapeutic procedure, the clinician views the software interface and
obtains immediate feedback on the bur position, which is related to the position
of the planned access cavity in the tooth.
 advantages such as

it is compatible with high-speed handpiece

burs,
(3) it does not require wait time for the
fabrication of static guides, and
(4) allows treatment procedures to be changed if
required
 Blind Tunnelling

Gouging is commonly
observed with round burs
which are aggressive in nature
and cingulum access. Buccal-
lingual gouging (not easily
seen in X-rays) occurs in
nearly every traditionally-
accessed case
 Cala Lilly Enamel Preparation

Unfavorable C factor and poor

enamel rod engagement are
typically present when
removing old amalgam or
composite restorations or with
traditional endodontic access
900 degrees to the occlusal table
• EQUIPMENT FOR
MINIMALLY INVASIVE
ACCESS PREPARATION
 size #10–12 bur
lower incisors,
upper lateral incisor,
lower canine, or
calcified pulp chambers,
size #12 and #14
BURS molars,
bicus pids,
upper central incisors, or
“young teeth” with large pulp
chambers.
Tip size less than half as wide as round bur available from SS White
Burs
 MIRRORS

Rhodium surface mirrors give the best

visibility and light transmission, especially

through small access cavities, and avoid

double image and refraction
 ENDODONTIC
EXPLORER

Location and determination of the

direction of the root canals
(DG-16 and JW-17)
 Flexible NITI

heat- treated high- flexible NiTi instruments

severe curvatures

minimal access cavities

Endo EZE TiLOS
 Self-Adjusting File (SAF) system

SAF produces minimal stress

concentrations in the apical root dentin
during shaping of the curved canal, which leads
to an increase in the chance of
preservation of root dentin integrity with
a reduced chance of dentinal defects
and apical root cracking
preparation size seems to matter with regard to the root canal treatment prognosis

For these reasons, the authors have developed a clinical concept called
“visual gauging

In this technique, the most important aspect to be evaluated from a

clinical point of view to decide the final apical size of enlargement is
the type of dentin debris cut that remains on the tip of the instrument

As a consequence, some different clinical conditions may happen

depending on the characteristics of the dentin debris cut by
mechanical files:
Presence of pulp remnants debris or that the correct working length has been

“pink/ red” dentin debris on the tip of the chosen, the diameter of apical
instrument used (in vital) preparation is still insufficient and
residual pulp is probably still present

. Very little dentin debris present inside the diameter of apical preparation is still
the flutes of the apical 3–4 mm of the insufficient to cut dentinal walls in the
instrument used apical third

Presence of “yellow/brown” dentin probably the instrument is circumferentially

debris on the tip of the instrument used (in cutting dentinal walls in the apical third, this
is still contaminated dentin that requires
necrotic cases)
further apical enlargement
Presence of white clean dentin inside the the instrument is cutting sound dentin in the
apical third but probably not
flutes of the apical 1–2 mm of the
circumferentially
instrument used

Presence of white clean dentin inside the presumably the instrument is cutting sound
dentin circumferentially in the apical third
flutes of the apical 3–4 mm of the
and this may be the correct size of apical
instrument used
preparation
Results from a microbiological analysis of the
different types of dentin that remained on the
tip of the instrument described above seem to
confirm that fewer bacteria were present in this
last type of dentin cut concerning the “brown-
yellow” type described above (Plotino and
Grande unpublished results)
 MINIMALLY INVASIVE
CANAL PREPARATION

Optimized irrigation protocols

minimal access cavities

preservation of the pulp chamber roof reduces the

available space for the influx of the irrigant solution

which may impair the intracanal disinfection process

OBTURATION IN MINIMALLY INVASIVE PREPARATION

Bio-minimalism in canal space preparation

filling material that replicates the internal anatomy of the root canal space

adheres to interfacial dentin and creates an impervious, irreversible seal at all

portals of exit

hydraulic cementation techniques.

Hydraulic endodontic procedures advocated in minimally invasive procedures due

tohighly hydrophilic and thus the natural moisture in the canal and tubules
Hydraulic endodontic cements for root canal filling
are:
1. BioRoot RCS (root canal sealer)- Septodont,
SaintMaur-desFosses Cedex, France
2. Endosequence BC (bioceramic) sealer Brasseler,
Savannah, GA, USA
3. TotallFill (bioceramic sealer)- FKG Dentaire, La-
Chaux-De-Fonds, Switzerland
4. iRoot SP (sealer)- Innovative BioCeramix Inc.,
Vancouver, Canada
5. Tech biosealer Endo-Isasan, Como, Italy
6. EndoSeal MTA-Maruchi, Wonju, Korea
7. MTA Fillapex-Angelus Industria de Produtos
Odontologicos S/A, Londrina, Brazil
8. TheraCal LC (light cured)- Bisco Inc.,
Schaumburg, IL, USA
INFLUENCE OF MINIMALLY INVASIVE
ACCESS CAVITY ON ENDODONTIC
PROCEDURES: LABORATORY
EVIDENCE
 Demonstrated a greater MB2
detection rate in teeth
Saygili et al, 2018 prepared with TradAC
(60%) and ConsAC (53.3%)
than UltraAC (31.6%).

Orifice TradAC and ConsAC detection of canal orifices

location performed by an
experienced endodontist
 was not influenced by
In contrast,
TradAC or ConsACthewhen
using an operative using
Mendes et al, 2020 microscope and thin UltraAC has
magnification/illumination
ultrasonic tips had no and thin ultrasonic tips.
influence in the detection of
impaired the
middle mesial canals in
mandibular molars
detection of extra
canals;
 mandibular molars with because the remnants of the
TrussAC prepared using pulp chamber roof interfered
rotary instruments had with the flow of the irrigant
Root canal Neelakantan et al. (2018),
greater amount of pulp tissue solution delivered using
cleaning
retained in the pulp chamber conventional syringe
than TradAC irrigation

additional irrigant activating/agitation systems have been recommended in teeth

prepared with minimally invasive access cavities
 concluded that warm
compared the quality of lateral compaction was the
canal filling in mandibular best option for filling canals
premolars with oval- in teeth with minimally
(Niemi et al., 2016 shaped canals prepared invasive access preparations
Root canal filling
with ConsAC or TradAC because their small size
through radiographic hindered adaptation of the
analysis gutta- percha in the single-
cone technique.
 Draw backs of various studies

• No fixed dimensions for different access designs

The same authors are trying to standardize the dimensions of the different
access cavities from a research point of view The authors showed a
significantly different percentage of the volume of dentin and enamel removed
in molars and premolars measured by CBCT among the groups analyzed,
being teeth with NEC < CEC <TEC
 TEC->15%

CEC-15%

NEC<6%

Superimposition of TEC (purple), CEC (green), and NEC (red) access cavity in a three-dimensional
simula tion that clearly underline the differences from an occlusal (a) and a lateral (b) visualization

new classification of access cavity preparation has been proposed according to percentage of
volume of dentin and enamel removed: NEC less than 6%, CEC up to 15%, and TEC more than
 Conservative Access Cavity Drawbacks

• disinfection of the pulp chamber(pulp horns left)

• Increase the risk of missed canals
• Increase the untouched canal walls
• Increase the stress on the mechanical files
• Compromise irrigant penetration, needle wedging, vapor lock,
and dampening of ultrasonic energy
• Complicate root canal obturation and coronal restoration
• Increase the period of the treatment to an unacceptable level
 CONCLUSION

Minimally invasive endodontics is in the interest of preserving tooth

structure requires
optical magnification
ultrasonic-assisted preparation techniques
modern file systems,
in-depth knowledge of the tooth and root canal anatomy
 Focusing on too much of minimal technique my lead to a higher rate of
procedural errors and benefit may be outweighed by poor clinical outcome.

Hence, the clinician should strike the right balance between minimal
preparation and traditional endodontic preparation with their own pros and
cons, thus achieving the objectives of endodontic treatment.
 REFERENCES

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Minimally invasive endodontics: a new diagnostic system for assessing pulpitis and subsequent treatment needs. Int
Endod J. 2017 Sep;50(9):825-829.

Silva EJNL, De-Deus G, Souza EM, Belladonna FG, Cavalcante DM, Simões-Carvalho M, Versiani MA. Present
status and future directions - Minimal endodontic access cavities. Int Endod J. 2022 May;55 Suppl 3:531-587

Dimri, Dr & Srivastava, Nikhil & Rana, Dr & Kaushik, Noopur. (2021). Minimally invasive endodontics: A Review.
International Journal of Applied Dental Sciences. 7. 33-35

Clark D, Khademi J. Modern molar endodontic access and directed dentin conservation. Dent Clin North Am. 2010
Apr;54(2):249-73

Plotino G, Özyürek T, Grande NM, Gündoğar M. Influence of size and taper of basic root canal preparation on root
canal cleanliness: a scanning electron microscopy study. Int Endod J. 2019 Mar;52(3):343-351..

Kuriakose, Ann & Joy, Basil & Mathew, Joy & Hari, Krishnan & Joy, Joseph & Kuriakose, Feby. (2018). Modern Concepts in
Endodontic Access Preparation: A Review. International Journal of Science and Research (IJSR). 10.21275/SR20924144034.