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Endo tips    Better Endo    Endo abstracts    Endo discussions

 Searching for mb2 again
The opinions within this web page are not ours.Authors have been credited <
for the individual posts where they are. - www.rxroots.com photographs courtesy: gary l. henkel

From: "gary l. henkel"
To: "ROOTS"
Sent: Saturday, September 10, 2005 8:13 PM
Subject: [roots] Desperately searching for mb2 again

Had this patient in this a.m., tooth #15.  completed instrumentation of 3
canals without incident, but spent an hour troughing with ultrasonics and
long shank diamonds for my usual nemesis the mb2.  I thought I found it, and
spot troughed right on a small catch.  I can feel a slight catch at the
bottom of my depression with the endo explorer, but I can't get a #6c file
to stick.  I didn't feel comfortable completing the case, so I placed caoh2
primarily to come back and fight another day.  Any suggestions or comments
are most welcome.

I seem to have two types of mb2's in my office.  They either jump right out
at me withing seconds, or they are impossible. Nothing in between.  I
estimate 3mm of troughing along the line, and an additional 2-3 mm of spot
troughing where it appears there is an access opening. - Gary

searching for MB2
searching for MB2
searching for MB2
searching for MB2
searching for MB2
When I come up against this situation, I find it can sometimes help to merge those two orifices into one .... It may turn out that MB2 is a fin or fold and you can't get into it because it is almost horizontal. When you trough out the little line between them there may be nothing left to do, or conversely you may find MB2 somewhere along the line or deeper ... in a necrotic case, that little line is worth cleaning out anyway - Simon Thanks simon. I'll give that a try at the next visit. - gary Gary, I think you're looking too distal. That catch is probably a small furca perf - looks like bleeding near "Furca City" Check it with an EAL. In your photo there seems to be a faint white line just palatal to MB1. It fades into the blue curved line I drew. There also seems to be a white "dot" right at the end of my Look Here arrow. MB2s are usually mesial to where you are looking. See my drawing. - Robert Kauffman searching for MB2 Thanks rob. Ben pretty much recommended that also, and the previous case I posted both you and john wanted me more mesial. Fred has always said move the mesial wall mesially then trough the line. I guess I need to get the mesial part right. Appreciate the imput. - gary Don't trough deeper until you trough a little bit towards the mesial, .then go deeper another 2 mm deep ....if nohing...just stop and pack the other canals. Use lots of NaOCl2 in the mesial system before packing if you do not find the elusive MB2 The MB2 in Second molars is more elusive than in first molars. You are doing a good job Gary.- Benjamin Schein
searching for MB2 searching for MB2
Thanks ben. I appreciate all the help you and all the rooters have offered. The ability to take photos and share findings through the scope has been an unforeseen advantage of the scope. Maybe Iíll have this figured out by amed. - gary gary, I ran the numbers for a six month period for my office a few years ago. About two thirds of maxillary seconds had four or more canals. I'll post a few cases showing locations, and my observations of anatomy, but for "searching" 1) Vital, no AP-->Don't kill the tooth and make the patient worse. 2) Vital, AP-->look pretty good. 3) Necrotic, Virgin case-->look really good. 4) Vital (orig diagnosis--no lesion) retreatment--->if ext is the alternative, then you don't have a helluva lot to loose by perfing while looking. If symptoms not so bad that they can be tolerated, look pretty good. 5) Necrotic (original diagnosis-lesion) retreatment-->ext is really the only alternative. Find additional anatomy or perf trying. In other words, look with intent, moderated by the liklihood of the consequences of failing to address all the anatomy vs. the consequences screwing it up so badly that the subsequent clinician can't fix it or it ain't worth fixin'. Maxillary first molars are another story. I think I have had two this year with three canals. I inform the patient of the liklihood that I missed canals, and stress recall. One of them I know is fine. ps. your burs look to fat - John A Khademy I had one of these last week. I knew there was an MB2 and I troughed deep enough to feed hogs. Finally the spot where the MB2 was disappeared. I gave up and filled the tooth. Surgery might be down the road but I'm betting it went right back into the MB1. Remember, 40 years ago MB2's were very rare. :-) Guy Put your troughing tip into the mb1 orifice and drag it toward the depression you've made looking for the mb2. Create a ramp of sorts, removing the dentin between the two orifi. You will end up with a single teardrop shaped orifice, or possibly will find a separate mb2 down a bit deeper. - Mark Dreyer DMD Porcine references seem to come up quite a bit in endo. Rob had advised me a few weeks back to open up the mesial aspect of my access a little more but not hog the thing out. Now we are troughing to feed hogs. The obvious conclusion I draw from this is that it isní't kosher to do endo - Gary Gary that is a great photo that shows what you have accomplished so far. I like the photos. Wow , nice stuff. In addition, I wanted to say that posts by John Khademi and others are so helpful in giving you a clue as to how to progress from here. Nice thread folks....... Glenn On a more serious note, is anyone other than me having any problem in these hot humid summer months with their lenses fogging. I've got a 30000 microscope setup rendered totally blind by humidity. I'm trying something different since yesterday. Went to loewes and bought the biggest baddest dehumidifier going, set it to constant run, and let it go for 2 days. I'm anxious to see if anyone else has this problem. Particularly guys like Arturo, dan s, and even that Einstein Fred guy, since you are all subject to the same weather conditions - gary Now if you can show me at amed how to aim at and actually see a lower tooth (ok, I am the master of the incisors :)) I can start taking photos of my 5,6, 7 canal lowers. And the loch ness monster! On a more serious note, is anyone other than me having any problem in these hot humid summer months with their lenses fogging. I've got a 30000 microscope setup rendered totally blind by humidity. I'm trying something different since yesterday. Went to loewes and bought the biggest baddest dehumidifier going, set it to constant run, and let it go for 2 days. I'm anxious to see if anyone else has this problem. Particularly guys like Arturo, dan s, and even that Einstein fred guy, since you are all subject to the same weather conditions. - Gary John A. Khademi, DDS MS wrote: Skip the mask. Not a great idea if you are polishing composites all day long......... Lots of problems with that and lungs......... If all you are breathing is NaOCL, I guess its ok. - Glenn If you had an assistant's side and she managed the field correctly you would not have this problem, but I don't want to start that debate again, as the "co-observer tube" does not work for restorative dentistry. :-) I will remind the readers that I do all the restorative in my endodontic practice, including many partial and complete crown preparations, all under the dam, all with the assistant's side. I do not get the garden variety conservative CL II's or the simple CL III's. I get the bombed out, impossible to clamp, upper second molars on the squirrely patient's you hate to treat who won't open their mouths and won't stop wiggling. In other words, I get the stuff even Glenn does not want to do. I'll post one from last friday. :-)) As a further note, if you place the composites well, there is very little polishing. You're not polishing these things dry are you? Too much heat generation :-)) - John A Khademi You dont have to cut out old amalgams, cut out old resins, I guess........ I for one dont want to ruin my lungs and there is alot of "stuff" floating around in the air. I for one prefer to wear a mask . As for the coobservation tube stuff, you wont let it lie....... Tell you what John.......next year you teach the course at AMED........its all yours to teach the docs about how to use the co observation tube. - Glenn Where do you practice? In most states a specialist can only do what is defined by his state's spatiality act. In Oklahoma an endodontist can remove the tooth he was referred if wanted and place build ups and P & C. but not do prosthetics. I am not sure where endo would fit in here (Oklahoma), I have no problem with a skilled endodontist placing implants. None around here are doing so at this time - Alan Cady Alan, Colorado, but I did the same thing in CA. I don't do the crown, just put margins in, or make sure that the restorative does not have overhangs and break the contact. This is all part of the "coronal endodontics" :-)) I do what is best for the patient given my training and skill set. There is definitely overlap with essentially every other specialty except ortho, but I know guys that extrude teeth as well. I think JoeyD does this. I might also add that both JoeyD and Stropko also do all the coronal endodontics. - John A Khademi I know guys that extrude teeth as well. I think JoeyD does this. I might also add that both JoeyD and Stropko also do all the coronal endodontics. I do about 1-3 extrusions per year....it's definately NOT my most popular Tx...with implants.... it dwindles every year....10 years ago, I was doing 4-8..... And yes....I do the coronal endodontics on every case! Unlike John K......I'll leave overhangs for the refering doc to remove if I know they can prep it.....some endodontists are better at crown preps under the scope then others... Stropko does a great job....John K does a great job....Joey D...OK on a good day... so I know I'm weaker on this issue.....as a consequence...I prefer not to screw it up. As for implants....we are refering out about 4 a week now...add that up to 200 a year and you see that's a significant part of my practice ...seems to be to condem the tooth and recommend ext and replacement with an implant.- Joey D what is the "coronal endodontics", Joey? - Marcos it means putting the buildup or restoring the access...what ever it takes to place a restoration in the coronal aspect that's NOT a temporary.......so if the tooth is gonna get a crown...then we do build up in preparation for the crown...if the tooth has a crown which is being maintained, we are gonna restore the endodontic access. Joey D, "That's my definition of coronal endodontics" I have tried the mask trick with little success. Maybe I'll try your brand. But I think the humidity level in our office contributed a good deal. Since I put in a dehumidifier on Thursday, we've had to empty the thing 3 times. We were in on Saturday after two days of running, and the fogging issue was much reduced. - gary Gary, I had some fogging problem a while back, and found these "no fog cloth" helped. I used to use them for ski goggleswhen I used to ski. : ) http://www.smithsport.com/products/accessories/lenscare_nofogcloth.html Also, having a mask that does not allow breath to escape over the top is important as Glenn said. I havent tried removing the eyecups, but I bet that is the fastest and most surefire way to prevent fogging. Good luck, Jeff. Now if you want to view the mesial canals you either have to remove the mesial marginal ridge or tip the patient back a bit and use the mirror distal to the tooth to see. In fact to get a good photo of the mesial canals I will actually tip the microscope AWAY from me and lean slightly over the patient at times to accurately photograph the lower molars mesial canals. Hopefully that gets you started. Here is one I just cropped down to show you what is possible.- Glenn searching for MB2 Hi Gary........For a lower tooth you must do two things to visualize the tooth. One to get a direct view of the distal canal you can often 1. Raise the patient to a semi seated position (20-40 degrees off the horizontal ) 2. Tip the binocs of the scope towards you 15-30 degrees. 3. Direct you microscope almost over the cheek of the patient on the same side as the tooth you are looking at Effectively this gets you away from looking at the facial surfaces of the lower incisors to the occlusal surfaces of the molars. Now if you want to view the mesial canals you either have to remove the mesial marginal ridge or tip the patient back a bit and use the mirror distal to the tooth to see. In fact to get a good photo of the mesial canals I will actually tip the microscope AWAY from me and lean slightly over the patient at times to accurately photograph the lower molars mesial canals. Hopefully that gets you started. Here is one I just cropped down to show you what is possible.- Glenn Are you saying that generally you cannot view both mesial and distal simultaneously and directly??????????????????????? Thatís been my issue, and I felt I was doing something wrong. I could view one or the other, but usually have difficulty doing both. And because of that Iíve been reluctant to do operative and/or c and b through the scope in these regions for fear I might hair lip someone. Will we have the opportunity to cut up some typodont or other teeth under the scope, or will we be limited to scope viewing. Keep in mind you are stuck with me all day Thursday.- gary Yes Gary you can view both canal systems at the same time but only at the lower mags. I prefer to work at 8X and above mag so I can only see one system at a time. If you keep one hand in the operating field you can always find your way there. Cover the instrument and touch your fingers or thumbs together. I try to keep my left hand ALWAYS in the operating field to provide stereotactic fulcrum for the hand I pass instruments in. Gary Carr likes to only move his right hand a tiny amount with instrument passes forcing the assistant to come to him. He actually keeps the pinkie finger of his right hand touching the left hand and rolls the right hand open for instrument passes. This keeps the two hands in contact at all times reducing the risk of injury. I often move my right hand more than Gary does. Most times I am ok because the motion is so repetitive that I know by instinct where I am going. We can practice that on Thursday. - Glenn I had this problem also frequently...at least I think my problem was the same if I understand your post. The problem is related to you using those rubber cups on the oculars. Your breath forces out from under your mask and foggs things up. You have two solutions: either don't wear a mask (probably a bad idea), or learn to use the scope without those rubber cups. It took me a day or two to get used to having those cups off, but now I'm fine, and no more fogging! - Mark Dreyer DMD Hey Mark , another option is to pinch the mask tight on the bridge of the nose and bend the bottom away from the chin to allow airflow down and out. Whenever I do this, blow the eyepieces with the air from the 3 way syringe it is fine. I use the laser masks that are from MAGIC ARCH. They have metal on both the bottom and the top. The key is to pinch the bridge of the nose metal very tight and to open up the lower part of the mask to create airflow down and out of the binoculars. I like to embed my eyes in the rubber cups (I actually prefer the old rubber cups on the Protege Plus compared to the newer ones on the G6 ) as I can mover the scope around slightly with my nose if I do this. Hope this helps....... Neat stuff - Glenn I remember you recommending this to me a few years ago. I tried them and it didn't work. I was to the point where I was wearing the mask during drilling to protect against aerosols, and then taking the mask off for the rest of the procedure. For me, taking the eyecups off has solved the problem for me. Thanks, - Mark Dreyer DMD I have tried the mask trick with little success. Maybe I'll try your brand. But I think the humidity level in our office contributed a good deal. Since I put in a dehumidifier on Thursday, we've had to empty the thing 3 times. We were in on Saturday after two days of running, and the fogging issue was much reduced. - gary Hi Mark........maybe it is the difference in the humidity between Vancouver and Florida. I can tell you that this works for me with ZERO problems. I pinch tight on the top end, and bring the bottom part of the mask up a little and open up the sides so that airflow will go out there. One huge problem for a GP who is moving the scope with his nose subtlely ALOT during the whole process is that this becomes incredibly difficult without the eyecups on the old Protege Plus, now try it on the new scopes. Its almost impossible with the sharp lip there on the oculars. I had one of the eyecups fall off on the G6 on the initial design (it has been redesigned) and it cut me when I started moving the scope around on the bridge of my nose. This is not a possibility in my mind for the GP. In endo in my practice the scope is much more stationary than in cutting 4 teeth in an arch or during a crown prep........I know that this conversation can quickly deteriorate into the endo scope movements vs the GP scope movements but the reality of the situation is that there is a difference there as well. Hope that adds some more information to this discussion.- Glenn Iíll try taking the rubber cups off and see what effect that has. I do have the same problem occurring when I put on my 2.5 and 3.5 loupes also. Today was day one of scope use after installation of the dehumidifier, and I had much less problem. And its humid as hell here today, remnants of hurriciane Ophelia or whatever the latest scurge is. And I donít know if weíve gotten all the moisture out of here with two days running. Thanks for the tip mark. This has been driving me nuts. - gary Yes, I've had it for two years, and am able to play it from the recording dvd in the operatory. I also have a head manikin there to practice what glenn is preaching. But, for instance, I had a lower 1st molar retreat today which was an absolute pia. There were 5, count them, 5 silver points in the ribbon shaped distal canal. After 2 hours, 2 visits, three capillary tubes, ultrasonics, and (boy do I hate to admit this) a handful of ss in an m4, I finally got the distal canal clear. I filled it with caoh2 and quit. Why? Because I couldn't see the mesial canals at all and they have never been entered! I was working through an old crown, am now planning to cut the crown off for the sole purpose of visualizing the mesial canals. I have glenn's dvd, nick forster (local global rep's dvd), global america's dvd, some other one I can't remember where I got it from, and glenn's handouts. But believe me, there's no substitute for an experienced clinician who can probably see something, most likely very minor and easily fixed, that will eliminate the problems I'm having.- gary
K 3 lightspeed

Crown replacement

Root reinforcement

Vertical root fracture

Periodontal pocket

Cox crapification

Cold sensitivity

Buccal sinus

Nikon 995

Distal canals

Second mesial canal

Narrow escape

Membrane

Severe curvatures

Unusual resorption

Huge pulpstone

Molar access

Perforation repair

Maxillary molars

Protaper shaping

Pulsing pain

Apical periodontitis

Mesial middle

Isthmus protocol

Fragment beyond apex

Apical trifurcation

Jammed K file

Mesial canals

Irreversible pulpitis

Bicuspid abscess

Sideways molar

Red Dye allergy

Small mirrors

Calcified molar

Extraction and implants

Calcificated central

Internal resorption

Bone lucency

Porcelain inlay

Bone allograft