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Huge pulp stone and irrational dentin - Courtesy ROOTS
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The opinions and photographs within this web page are not ours. Authors have been credited for the individual posts where they are. - www.rxroots.com |
From: Terry Pannkuk
To: ROOTS
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 photo...it's more conservative that you would think from my other angled photos. More recaps
in the MB2 with hand files...always flooding with irrigant.
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 he 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
