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CBCT Map Quest Directions to an MB2 - Courtesy ROOTS

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: Thursday, July 22, 2010 9:30 PM
Subject: [roots] CBCT Map Quest Directions to an MB2 after a Barf Bag Rest Stop

Yesterdayís Diary:

I saw this patient last week (calcific dengeneration, Cox-Crapped Molar, 
gagging patient, refused to take Xanax, and couldnít tolerate being reclined).

I started treatment on this patient, she insisted on no drugs but needed them.  
She would have been a perfect candidate for IV sedation.  I canít remember the 
last maxillary first molar where I couldnít find anything resembling a 
mesiolingual groove or an MB2 canal system but this was one.  I ended up 
deciding to treat the 3 canals I could find and treat then take a CBCT 
post-treatment.  She was having a tough time with positioning, felt hot, 
couldn'ít recline, needed to constantly swallow, and was gagging during the 
entire treatment but refused meds and the suggestion of sedation.  
Ií'm a masochist so I decided to torture myself and try to treat her anyway.
Right when I finished backpacking the palatal she puked all over my operatory 
and stained her white blouse with the blueberries, bananas , and oatmeal she 
had for breakfast right before seeing me.  The tooth had a temporary
crown which had been taken off so I had punched multiple holes clamped the 
second molar and ligated a forward anterior tooth with floss. When she Ralphed, 
it was a fire drill to stuff a big ball of Cavit into the access and simply 
rip the latex dam off without dicking around trying to remove the floss and 
deep distal clamp. Gary Carr would have been disappointed that I didnít take 
the time to ergonomically capture a photo.

After she went to the restroom, cleaned up, and changed her blouse into one 
of our assistantís scrubs, I took a CBCT which was invaluable for todayís 
appointment.

She thanked us all for being so patient but still refused the meds when I 
saw her today. She was better only in the sense she didnít barf today, but 
it was still a struggle.  The MB2 discovery was a very interesting
CBCT process that Iíve done a couple times now.  The coronal section of the 
MB root clearly demonstrated that there was a missed MB2.



The MB1 was well to the buccal and the transverse sections showed a 
dumb-bell shaped outline suggesting  a major untreated system. Only a faint
hint of a patent MB2 was suspected but it was enough to identify itís
location and triangulate coordinates that I could transfer to the mouth 
and find it.  It was still a leap of faith not seeing any pulpal floor map 
when penetrating with a bur.quite scary.  The triangulation worked by
drawing a line from the center of the palatal to the MB1 filled canals on 
a transverse section like this one:



I then simply dotted the spot where the bury treasure was supposed to be 
and lightly brushed away the dentine until I cold start to uncover darker 
root dentin giving me a better clue where the white dot of the MB2 canal
was to be. Fascinatingly it was right were it was supposed to be from the 
triangulation.  I didnít need to search and destroy and the canal finally 
revealed itself after deeper penetration than I ever would have dared
if I hadnít had the triangulated CBCT coordinates  (1.5 mm mesial to the 
line connecting the MB1 and P canals and 3.5mm palatal from the MB1)   
The attached photos show the access sequence. I repacked the palatal 
because I had rushed the previous obturation while she was puking and had 
filled slightly short.  - Terry

Protaper flaring

6 yr old Empress

Cvek pulpotomy

Middle mesial

Endo misdiagnosis

MTA retrofill

Resin core

BW importance

Bicuspid tooth

Necrotic #8 treatment

Finding MB2 / MB3

Deep in a canal

Broken file retrieval

Molar cases

Pushed over apex

MB2 and palatal canal

Long lower third

Veneer cases

CT Implant surgury

Weird Anatomy

Apical trifurcation

Canal and Ultrasonics

Cotton stuffed chamber

Pulp floor sandblasting

Silver point removal

Difficult acute curve

Marked swelling

5 canaled premolar

Sealer overextension

Complex anatomy

Secondary caries

Zygomatic arch

Confluent mesials

LL 1st molar (#19)

Shaping vs Cleaning

First bicuspid

In Vivo mesial view

Inaccesible canals

Premolar 45

Ortho and implant

Radioluscency

Lateral incisor

Obturation

Churning irrigant

Cold lateral

Tipped to lingual

Acute pulpitis images

Middle distal canal

Silver point

Crown preparation

Epiphany healing

Weird anatomy

Dual Xenon

Looking for MB2

Upper molar resorption

Acute apical abcess

Finding MB2

Gingival inflammation

Irreversible pulpitis

AG BU ortho band

TF Files

using TF files

Broken bur

Warm technique

Restorative prognosis

Tooth # 20 and #30

Apical third

3 canal premolar

Severe curvature

Interesting anatomy

Chamber floor

Zirconia crown

Dycal matrix

Cracked tooth

Tooth structure loss

Multiplanar curves