Patient presented with #1-3 pulp necrosis and chronic apical abscess.  Due to missing #1-2, mesially tilted tooth #1-3 had been restored as #1-3 and #1-4 splinted crowns in the place of  #1-2 and #1-3. The clinical picture shows a ceramic interdental papilla which covers the root of tooth #1-3.

The key aspects in treating such a case are as follows:

1. reviewing the risks of the procedure in detail with the patient (i.e. possible damage to the restorative work to the point of needing replacement, possible mishaps during the endodontic treatment [perforation, instrument fracture], etc.)
2. through assessment of the tooth/root under the crown using a probe and by palpating the root
3. good understanding of the root angulations in mesial-distal and buccal-lingual directions
4. planning for initial access location
5. good isolation with a stable clamp that can be placed over the root
6. constantly aligning the bur with the long access of the root while drilling in the center of it
7. and finally, Patience, Patience and more Patience!

endodontic access straight line access