How to read a Color mapping of a tooth

From: John A. Khademi, DDS MS
To: ROOTS
Sent: Sunday, March 11, 2007 5:10 AM
Subject: [roots] Color Mapping

henkel asked me a while ago to do somthing on color mapping i.e. how to read the color map of a tooth.

I had a case that I started in Nov/06 that I finished last week that had some pretty good color hints.

Image 1:
-Preop radiograph
-S/T on B.
-Initial outline form and
-closeup after initial outline form.  The small blackish dot is a perforation into the "chamber"



Image 2:
-The rough outline of the pulp chamber when the patient was young.
-You can see the changes in color, and the position and size of the original MB pulp horn.
-The arrow pointing to the smaller white dot begins to give hints as to some possible
 PON (Points of Negotiation aka canals)
-Slightly different angle



Image 3:
-Slightly different angle with arrow pointing to "persistent white dot."  Chase these dots.
-Different angle.
-The circled DB "white dot" is really a strip coronally that...
-...separates into two white dots as we chase farterh down the root.  Also note the MB white dots.



Image 4:
-The two DB PON's, and the MB PON.  Also note how much farther buccally the chamber goes towards the MB line angle.
-Different view--same as next pic that is drawn on.
-Tip:  There are two DB PON's so far, which is an indicator that the DB root is not round.
 If the DB root is not round it is essentially impossible that the MB root will be round.
 Looking at the angles of the access outline form, which is parallel to the buccal outline of the chamber,
 and compare that to the angle of the line connecting the DB1 and MB???.  Oooppsss.  That is the MB2.
 We found the MB2 before the MB.  You can see the extent of the MB horn pointed to by the arrow.
 Also note in Pic2, the upside-down horseshoe which is the buccal extent of the original DB canal system
 when the patient was young.  More on this later.
-Fluting to chase the MB and MB2



Image 5:
Lots of colors here.  The "greenish" of the chamber floor, the whitish of some tertiary dentin (arrow, pic3),
Yellowish of probably 2ndary dentin laid down over decades as the pulp receded, the white dots of the PON's.
(I don't know that these have been fully characterized in light of what we see clinically with the scope)
Last pic speaks miles (drawn on in page six).



Image 6:
-Page5:Pic4 drawn on showing the marked color change from the pulpal floor to the colors on the axial walls.
 You can follow the green all the way to the MB line angle of the access, and THERE is where the MB canal will be.
-Pic2, now, in your minds eye, draw a lines connecting the DB and MB, and you will see they are parallel to the
 access outline form, and buccal outline of the chamber (like I did Page4:Pic3).
-Closeup, orifices opened MB, DB/DB2, P.  MB2 still a dot.  Have not placed a file in the MB2 yet.
 Use BUC1, Mueller or Munce to chase down canal.
-Modified outline form.  Compare with Page1:Pic3



Image 7:
-Prepared
-Note the MB/MB2 distance is greater than the DB/DB2 distance.  If they are equal, or MB/MB2 is smaller than DB/DB2,
 suspect an MB3.
-Filled.
-Final.  Try as I might, I spent 1.5hrs at the start visit in Nov, 3 CH changes, and 1.5hrs at the completion visit,
 and never got to length on the MB2.  The S/T closed over in early December and never came back.
 Symptoms are completely gone.



Only five POE's identified here Pat.  Two DB's, Two P's (one I obviously missed) and one MB.
So no, my work is not beyond reproach, and I don't get down everything.  Nobody bats 1000.

My fellow educator "Master" endodontists surely must have cases like this if they are teaching GP's how to do endo.
I'd sure like to see their material on access and how to find canals.  I've never seen it, and I think it's pretty
important.
Really, any discussion about instrumentation pre-supposes that the canals have been found and negotiated, No?
I mean, does it really make sense that they pick at my preparation sizes on canals that they never even find?
- John A Khademy

Dear John, If this tooth has six-canals, then I am a Dallas Cowboys cheerleader.

Can you post a single x-ray, a single case from anytime during your
entire career, that shows six canals on the x-ray and without
requiring any written explanation? - Patrick Wahl

Wow John:  I always learn from your visually driven cases.  I will also
say that you dont get money from these posts, have nothing that you are
selling (which remind me......when do you come out with your Atlas of
endodontic anatomy!! (hint hint)

I really enjoy your cases which challenge me to be better, I am far far
far away from where your cases are but you set the bar high enough to
challenge each of us to be better ........to find more anatomy and to be
the best clinicians we can be.

From this humble but inspired GP to you.
A hearty thanks for such a wonderful teaching case.
CLAP CLAP CLAP  - Glenn

Outstanding!  - Bob

I did?  in any event, this is excellent stuff, the kind of stuff we need here on roots.
I'm archiving all of this.  beautiful access john.  that is textbook stuff.- gary

gary, Thanks.
I guess if I knew you had forgotten I wouldn't have felt so bad about taking so long to post it.  :-)))
From where I stand, I feel an obligation to teach.  It is part of being a specialist.
So when someone like you asks, I hafta try to deliver.
I don't care who does the dentistry.  I just want it done well, by someone who cares.

Anyway, That was fun...at the course...getting that pulp stone out and seeing all those PON's, No?
Who knows where they lead?  Do you still have the tooth? - John A Khademy

you know what?  i wonder where the damn thing is?  it was my intent just for kicks and giggles to instrument
and obturate the stupid thing and radiograph it 360%.  i'll have to see if i can dig it up.

you have some great stuff in that 500 gig brick you carry around.  please continue to share.

i think we ALL have an obligation to teach, or at least be willing to share information.
This stuff is not a contest.  As Kendo is fond of saying, we need to continue raising the bar.
And , beyond that, we all really need to be lifelong STUDENTS. - Gary

Don't worry, that's not the last five or six canaled maxillary molar you'll ever see.  ;-))) - John A Khademy

wow. I have already saved it..Its more or like a textbook .Even the present day books in endodontics
dont have such info..thankyou once again dr john.hoping to get such literature from you doctor
in the near future. thankyou once again.. Joseph Joy

Beautiful teaching case. In partnership,- Fred

John,You are a textbook waiting to happen.Awesome, dude.- wes

Inspiring...What do you use to do the throughing? Burs or ultrasonics - with or without cooling? - Maarten.

So here is my last case today that we started in Dec.  She has been fine since her first visit,
but due to the crack, I thought I would follow her for a few months before finishing.

Image 1:

Given how calcified the tooth was, I cut a pretty wide swath through the porcelain crown to find
this M/D crack, and the other one running around the lingual.


Image 2:
Referring to the color map above, you can see the darker pulpal floor dentin, transitioning up
the walls to the lighter axial wall dentin.  The chamber was a mess of bzillions of little stones.
Pic2 points out a couple of stones in the MB and ML "orifices."  If they are big enough,
you can pick them out with a #10/.06 Maillfer micro-opener.  The "expected" outline form for the
distal root is dotted in, and surrounds a few PTR's (pulp tissue remnants--the white dots)



Image 3:
Chasing in the expected area, and also following the PTR's you can begin to see the "ring" that
was the original canal shape when the patient was young.  The canal is filled with stones as
identified by the arrows.  Again, once your are down far enough, you can pick them out.
It is important to make sure you have the full buccal and lingual extent of the canal system
in a case like this, and you can see in pic4 that the white ring of PTR's is pretty much an oval.
It would be easy to stop at pic2, and chase the whitish crescent shaped area and presume that
you only have one distal.  In other words, from pic2, you really don't know how broad B/L
the distal system is...vs in pic4, you can see basically the entire loop of tissue remnants
that outline the system.  The same goes for maxillary teeth (next...)



Image 4:
Getting a #20 hand file to length sucked down the entire first visit.  Today we cut shape and filled.
The shortest canal was 24mm.  Please note the size and shape of the access as demonstrated by the amalgam.
Probings have remained stable at 4mm. - John A Khademy



Now that was a beautiful case.  John, do you think if this case was seen when she was forty years younger, we'll every
develop a way to simply clean that entire nexus between the MB and ML out and compact into it rather than two or three
individual holes.  I know that Ultradent's handpiece and files are supposed to do something similar, I don't think it
would do this on a molar and would probably be too dangerous.  When we find these canals that we know are connected by
a nexus of canals, do you think there will be a way to clean all of it?  Guy