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Huge pulp stone and irrational dentin - Courtesy ROOTS
The opinions and photographs within this web page are not ours.
Authors have been credited
for the individual posts where they are. -

From: Terry Pannkuk
Sent: Friday, March 27, 2009 12:43 AM
Subject: [roots] Access Demo Sequel

Here's a case I started this morning that will highlight with 
much better photography, the points I was trying to make yesterday.  
This case had a huge pulp stone. I never refer to tertiary dentin
as "reparative dentin" , "irritational dentin" is a much better 
way to refer to it.. this dentin is diseased.   Screwing around 
with ultrasonics just wastes time, jackhammers ledges and distorts 
your perspective by making "chunky dentin"....bad idea.  Get in 
there and grossly bur the crap out. I like a tapered diamond with 
water spray blasting debris away,  At the end I'll use a football
diamond to start creating the developing corners of he access 
outline making the "bowls" as mentioned yesterday.  The MB2 is 
largely ignored at this point, you can worry about it later after
you've created the ideal extension of the "Big Three".

I plowed through the stone, not worrying terribly that I might 
horrify Khademi with an occasionaly micron deep ditch anywhere in 
the pulp chamber floor which I smoothed out later.  Once all
irritational coxcrapped dentin is removed I immediately noted a 
mesial marginal ridge fracture heading toward the MB2 like 
someone said is classic (it is).  Now is the time to start carefully
troughing out the ML groove which leads to discovery of the MB2 
orifice.  I use the smallest Discovery bur only directed on the 
mesial aspect of the groove,not toward the furcation
(shown in photo).

I then used a cone composite finishing bur to poke conservatively 
right where the groove ends palatally and right at the terminus of 
the crack line.("X" marks the spot like a treasure map...
the MB2 loot is buried there).   I rarely use a straight file,
I know the orifice is there and I don't want to stick a straight 
file into the MB2 and create a ledge right off the bat...bad idea.
I, instead, "slip,slide" an 8 file which goes passively to 
whereever it goes, who cares as long as it's passive and you 
aren't poking any dentin creating a ledge.    I believe you 
shouldn't worry about the MB2 much until you've opened up the 
MB1; It makes things much simpler. Now that I know where the MB2 
is and my access extensions are near completion, I go through 
some passive recapitulations on the MB1, DB, and P, eventually 
use light rotaries just to open up the orifices a bit after numerous 
hand file recaps, flood the chamber with RC prep, and do the passive 
Gates as described yesterday.  Gates not done on the MB2...remember 
it's only been located not opened.

The pulp chamber is again flooded with NaOCl, dried and sucked..
then 17% EDTA, some more recaps in the "Big 3", now back to the MB2.  
The MB1 is cleared, coronally flared so the MB2 should be ready
to go.  I "slip/slide" an 8 file down passively much deeper than 
before (facilitated by extended access and MB1 clearing).  I then 
start to copiously irrigate and recapitulate a few series.
Patency is established quite easily.  I even feel ok about very 
prudent rotary flaring with the S1-S2.....just a bit.  It's now 
ready for the Gates...flood with RC-Prep, 1-4 Gates down only
passively and the 4 really doesn't even go into the orifice or 
do anything.  "Passivity" is the theme.

I now note that the MB2 extension is inadequate for final apical 
third shaping(to be performed next visit in a month) so I bowl out 
toward the mesial marginal ridge with the egg shaped composite
finishing bur a bit. This pulls out the midwall.  My final 
cavosurface outline is shown in the final's more 
conservative that you would think from my other angled photos.  
More recaps in the MB2 with hand files...always flooding with 

I now note a prominent fin/groove connecting the MB1-MB2.......
I have no desire to use ultrasonics on this knowing the 
jackhammering creates irregular dentin, ledges and starts 
to obscure negotiable entry points..... I instead use a very 
narrow flame tip composiste bur (I don't always do this if
I dont' have good access and the alternative is to spend more
time brushing back and forth with an S1 rotary.  I only use 
the bur on the mesial wall and do not remove dentin on the 
furcation side. This is very safe but you don't want to go 
deep.... going deep with an ultrasonic is even more
dangerous and the jackhammering is less controlled and more 
likely to perf into an unexpected concavity, going peripherally 
with the control and the efficiency of a composite finishing 
bur is much safer.

One caveate is that you can't have ham fists.  If you think 
you can go in clumsily with a composite finishing bur and rip 
dentin out, you migh be better off leaving these fins alone. :)

I tend to use the thin flame very lightly not hitting anything 
with the tip.I brush 4 x from the MB2 to the MB1, then 4 from 
the MB1 to the MB2, then repeat 3x each way, 2x each way, then 
finally 1x each way to make sure the prep is ideally symetric 
and not over flared on any one side.Executing a systematic 
strategy for a controlled safe access gives you the most pristine 
complete view of all coronal anatomy.  It also helps you identify 
the full extent of fractures.

I used to employ ultrasonics more in the past but around 2002-2003 
but I found this technique to yield a much better result.  Once in 
a while, especially with compromised access, you have to use
an ultrasonic to trough grooves because they are much easier to 
enter in difficult access situations.....but the take home message 
is that with a properly extended access you can routinely
use composite finishing burs and get a much better result - - Terry

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