CBCT Map Quest Directions to an MB2 - Courtesy ROOTS
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From: Terry Pannkuk
Sent: Thursday, July 22, 2010 9:30 PM
Subject: [roots] CBCT Map Quest Directions to an MB2 after a Barf Bag Rest Stop
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
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