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Data collectionCritical thinking
Comprehensive reasoningDiagnosis
Treatment plan
Extraction of hopeless teeth
Operative phase
Endodontic therapy and provisionalization
Soft and hard tissue correction/augmentation
Occlusal equilibration/correction
Soft and hard tissue correction/augmentation
Extraction of questionable teeth
Implants - surgical phase
Provisionalization
Patient OHI complianceEndo reassessment
Soft and hard tissue response
Impression taking
Framework try-in
Porcelain/zirconia assessment
Esthetic artistry
Cementation
Long term maintenance
Foundational Cypher
Ongoing reassessmentCreate stable plateaus
Endo
PerioImplant
Medical/Dental history Articulated models
Flat field radiographyCone beam tomography
Periodontal probingOcclusal assessment
Patient objectivesPatient compliance;
physical and emotionalTeam approach;
laboratory professional
Orthodontics
Techniques Effective Dose (µSv)Intraoral radiograph (per exposure) 1 to 8
Dental panoramic radiograph 4 to 30
Cone beam CT (small field of view) 5 to 35
Cone beam CT (large field of view) 70 to 550
Full mouth series 30 to 150
CT scan (maxilla and mandible) 75 to 100
CT scan (skull) 400 to 1000
Medical CT 1200 to 330
Comparison of the effective dose of different radiographic techniques (McCullough CH, Schueler BA. Calculation of effective dose. Med. Phys. 2000;27:828-838)
0 75 150 225 300Time period for equivalent effec:ve dose from natural background radia:on in days
CT maxilla and mandible
CT maxilla or mandible
CBCT large FOV
Denver, CO per year
FMX
Bitewings (4)
Kodak 9000 3D mand posterior
Kodak 9000 3D mand anterior
Kodak 9000 3D panoramic
Kodak 9000 3D max ant and post
Intraoral periapical
0 75 150 225 300Time period for equivalent effec:ve dose from natural background radia:on in days
CT maxilla and mandible
CT maxilla or mandible
CBCT large FOV
Denver, CO per year
FMX
Bitewings (4)
Kodak 9000 3D mand posterior
Kodak 9000 3D mand anterior
Kodak 9000 3D panoramic
Kodak 9000 3D max ant and post
Intraoral periapical
Rad: obsolete unit of radiation absorbed dose, equal to .01 gray Rem: obsolete unit of radiation dose equivalent
The “Sievert” is the preferred term - Sievert (Sv):1uSv* = .0001rem1 day background radiation: 6 - 7uSv
Yearly background radiation: @2400uSv
Principals of CBCT – VOXEL
50 mm
.38 mm
.076mm
.076mm
.076mmCubic Voxel
✦ Voxel (VOlume piXEL), is short for ‘volumetric pixel’ and is the smallest “box-shaped” building block of a 3-D image
✦ Voxel (VOlume piXEL), is the smallest building block of a 3-D image
✦ Simulated bone defects in acrylic blocks and the human mandible proved that CBCT is an accurate way to measure osseous lesion and volume
Pinsky HM, Dyda S, Pinsky RW, Misch KA, Sarment DP. Accuracy of three-dimensional measurements using CBCT. DentomaxillofacRadiol 2006:35;410-416
Principals of CBCT – VOXEL
50 mm
.38 mm
.076mm
.076mm
.076mmCubic Voxel
Pinsky HM, Dyda S, Pinsky RW, Misch KA, Sarment DP. Accuracy of three-dimensional measurements using CBCT. DentomaxillofacRadiol 2006:35;410-416
The Kodak 9000 3D features a minimum slice thickness of 0.076mm (76u)
0.076mm images are the highest resolution in the industry today
LargeWe care for 3-D patients with 3-D disease & provide 3-D treatment
Shouldn’t we use 3-D technology for diagnosis and treatment planning?
MediumWe care for 3-D patients with 3-D disease & provide 3-D treatment
Shouldn’t we use 3-D technology for diagnosis and treatment planning?
Focused
1. Focused ‘FOV’ provides substantially
lower doses than medium and large FOV cbCT units.
Small FOV cbCT
Small FOV cbCT
Small FOV cbCT
Small FOV cbCT
Axial
Coronal plane
Sagittal plane
Axial
Coronal plane
Sagittal plane
Axial
Coronal plane
Sagittal plane
Axial
Coronal plane
Sagittal plane
Endodontic����������� ������������������ indications����������� ������������������ for����������� ������������������ cbCT
Endodontic����������� ������������������ indications����������� ������������������ for����������� ������������������ cbCT differentiation of pathosis from normal anatomy relationship with important anatomical structuresmanagement of aberrant anatomy (ie: dens, c-shapes) external & Internal resorption root perforations accessory/ missed canal identification management of fractured instruments aiding surgical planningretreatmentstraumatic injuriesintra-operative (ie: finding canals)MSDOcalcified casesfacial pain cases to rule out odontogenic etiology
Sousa Melo et al, 2010
Axial tomographic cross sections at the coronal portion of the root of specimens with similar subtle experimentally induced root fractures show the fracture line (arrows) in nonfilled root (A) and presence of star-shaped streak artifacts of gutta-percha (B) and post (C).
Unfilled
Gutta-percha
Gold post
Sousa Melo et al, 2010
Diagnosis
1. Patient referred for endodontic treatment, tooth #4.62. Sensible to cold testing, tender to percussion3. 7mm probing on distal aspect
Axial view
Diagnosis
Sagittal view
Distal surface
Diagnosis
Diagnosis
DIAGNOSIS
Radiolucency mid-root tooth #2.4
Missed root
Diagnosis
“cbCT showed significantly more lesions (34%, p< 0.001) than PA’s” Low KMT, Dula K, Bürgin W, von Arx T. Comparison of periapical radiography and limited cone-beam tomography in posterior maxillary teeth referred for apical surgery. J Endod 2008;34:557–562
Diagnosis
• Occasionally, apical periodontitis will not penetrate the antral floor, but will displace the periosteum, which will deposit new bone (periapical osteoperiostitis or “halo”).
Detection/Size of Apical Periodontitis
• CBCT is significantly better at demonstrating ‘AP’ than conventional
• x-rays Estrela C et al, JOE 2009• Cotton TP et al, JOE 2007• Lofthag-Hansen S et al, OOOE 2007
In Lieu of CBCT: What Are We Missing?
Lesiondetection
In Lieu of CBCT: What Are We Missing?
Lesiondetection
In Lieu of CBCT: What Are We Missing?
Lesiondetection
In Lieu of CBCT: What Are We Missing?
In Lieu of CBCT: What Are We Missing?
Do we have a lesion?
In Lieu of CBCT: What Are We Missing?
Do we have a lesion?
In Lieu of CBCT: What Are We Missing?
Identifycomplexity
In Lieu of CBCT: What Are We Missing?
Identifycomplexity
In Lieu of CBCT: What Are We Missing?
Identifycomplexity
In Lieu of CBCT: What Are We Missing?
Identifycomplexity
In Lieu of CBCT: What Are We Missing?
Extent of lesion
In Lieu of CBCT: What Are We Missing?
Extent of lesion
In Lieu of CBCT: What Are We Missing?
Extent of lesion
In Lieu of CBCT: What Are We Missing?
Extent of lesion
Size of lesion
Mental Foramen
Healing??
One year post-op
Post-op
Retreatment
Retreatment
RetreatmentInitial RCT done 5 years priorRetreatment 2 years priorIntermittent pain and swelling for the past 18 months
RetreatmentInitial RCT done 5 years priorRetreatment 2 years priorIntermittent pain and swelling for the past 18 months
Retreatment
Post-op 4.6 1 year post-op 4.6
Retreatment
Preop 12 mos. Postop
Trauma
Help me, treat meow.........
The day of the impact the coronal fragment was stabilized by splinting.
CBCT image aached. One week later tooth is cold sensitive and percussion is painful.
http://www.dentaltraumaguide.org/
Trauma
Trauma
Trauma
Trauma
Tooth #1.1 PA Tooth #1.1 cbCT
Trauma
Tooth #2.1 PA Tooth #2.1 cbCT
Trauma
Tooth #2.2 PA Tooth #2.2 cbCT
Avulsion & Replantation, teeth #‘s1.1 & #2.1
Trauma
Trauma
Alveolar fracture
#1.2 #1.1
Undiagnosed lateral luxa:on
Alveolar fracture
Trauma
Trauma
Trauma
Trauma
Complications Perforation
Complications Perforation
Complications
Complications
#2.1: avulsed & replanted
Detection of Luxations
Detection of Luxations
Tooth #1.1 - note alveolar fracture Tooth #2.1 - note change in angulation as compared to tooth #1.1
Detection of Luxations
Detection of Luxations
Tooth #2.4 PA
Detection of Luxations
Tooth #2.4 cbCT
Detection of Perforations
Detection of Perforations
Detection of Perforations
Perforations
• Resorption was detected in 69% of radiographs and 100% of CBCT scans• Estrela C et al JOE 2009
In Lieu of CBCT: What Are We Missing?
Resorption
• Resorption was detected in 69% of radiographs and 100% of CBCT scans• Estrela C et al JOE 2009
In Lieu of CBCT: What Are We Missing?
Resorption
Resorption was detected in 69% of radiographs and 100% of CBCT scans
Estrela C et al JOE 2009
Detection of Resorption
Detection of Resorption
Detection of Resorption
Detection of Resorption
?
?
Detection of Resorption
Detection of Resorption
Detection of Resorption
Detection of Resorption
Root Resorption
Root Resorption
External Cervical Invasive Resorption
CBCT- perfectly positioned for endodontics:Focused FOVMinimal radiationHighest resolutionReal-time analysis
Begin with the end in mind
Detection of Root Fractures
CBCT showed higher accuracy than PA’s for the detection of VRF.Confirmed by Hassan B et al, JOE 2009 and Edlund M et al, JOE 2011Nyquist theorem: VRF must be at least 2x voxel size to be visible
C R A C K !
Root Fracture
C R A C K !
Root Fracture
Root Fracture
C R A C K !
Root Cracks/Fractures
Root Cracks/Fractures
Root Cracks/Fractures
Root Cracks/Fractures
Root Cracks/Fractures
6m follow-up
Root Cracks/Fractures
Pre-op
Root Cracks/Fractures
Root Cracks/Fractures
Root Cracks/Fractures
1.Patient referred for evaluation2.Discomfort to biting/chewing3.Isolated 6mm probing on distal
Root Cracks/Fractures
Root Cracks/FracturesRoot Cracks/Fractures
Detection of Root Fractures
Detection of Root Fractures
Detection of Root Fractures
Detection of Root Fractures
Detection of Root Fractures
Detection of Root Fractures
Sinus tract tracing 7mm
Detection of Root Fractures
Vertical Root Fracture
Vertical Root Fracture
No apparent bone loss
Vertical Root Fracture
Intra-operative
Intra-operative
Intra-operative
Intra-operative
Intra-operative
Intra-operative
Intra-operative
Intra-operative
Intra-operative
Intra-operative
Intra-operative
Intra-operative
It appears that there are 2 canals that merge into 1
Initial accessInitial access
Coronal part of tooth
Apical part of tooth
Canals first appear to be visible
Appears to be 1 canal
Intra-operative
Maxillary Sinusitis of Dental Origin (MSDO)
MSDO: When a dental infection extends directly through the sinus floor causing a secondary maxillary sinus inflammation
Abrahams et al found maxillary sinus pathosis in 60% of cases Matilla found mucosal hyperplasia in 80% of cases
‘And in the end the love you take is equal to the love you make’