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    October 25th October 25th Presentation Transcript

    • 2
    • One of these individuals is “not” in the dental profession 2
    • Data collection Patient objectives Medical/Dental history Critical thinking Patient compliance; Articulated models Comprehensive reasoning physical and emotional Flat field radiography Diagnosis Team approach; Cone beam tomography Treatment plan laboratory professional Periodontal probing Occlusal assessment Long term maintenance Extraction of hopeless teeth Foundational Cypher Cementation Operative phase Esthetic artistry Endodontic therapy and provisionalization Endo Porcelain/zirconia assessmentOngoing reassessment Soft and hard tissue correction/augmentationCreate stable plateaus Framework try-in Occlusal equilibration/correction Impression taking Implant Perio Orthodontics Patient OHI compliance Endo reassessment Soft and hard tissue correction/augmentation Soft and hard tissue response Extraction of questionable teeth Provisionalization Implants - surgical phase
    • What we’ve known for a hundred years
    • cbCT is a radiographic tool for a myriad of clinical applications • Anatomically accurate 3D information • Better understanding of patient (diagnosis) • Identify possibilities and limitations of treatment (Tx planning) • Powerful communication with colleagues
    • cbCT is a radiographic tool for a myriad of clinical applications • Anatomically accurate 3D information • Better understanding of patient (diagnosis) • Identify possibilities and limitations of treatment (Tx planning) • Powerful communication with colleagues
    • Small FOV cbCT
    • Small FOV cbCT
    • Small FOV cbCT
    • Small FOV cbCT
    • 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 330Comparison of the effective dose of different radiographic techniques (McCullough CH, Schueler BA. Calculation of effective dose. Med. Phys. 2000;27:828-838)
    • 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 panoramicKodak 9000 3D max ant and post Intraoral periapical 300 150 225 0 75 Time period for equivalent effective dose from natural background radiation in days
    • CT maxilla and mandible CT maxilla or mandible CBCT large FOV Denver, CO per year Rad: obsolete unit of radiation absorbed dose, equal to .01 gray FMX Rem: obsolete unit of radiation dose equivalentThe “Sievert” is the preferred term - Sievert (Sv):1uSv* = .0001rem Bitewings (4) 1 day background radiation: 6 - 7uSv Kodak 9000 3D mand posterior Yearly background radiation: @2400uSv Kodak 9000 3D mand anterior Kodak 9000 3D panoramic Kodak 9000 3D max ant and post Intraoral periapical 300 150 225 0 75 Time period for equivalent effective dose from natural background radiation in days
    • Principals of CBCT – VOXEL 50 mm✦ Voxel (VOlume piXEL), is short for ‘volumetric pixel’ and is the smallest “box-shaped” building .38 mm block of a 3-D image✦ Voxel (VOlume piXEL), is the smallest building block of a 3-D image .076mm✦ Simulated bone defects in acrylic blocks and the .076mm human mandible proved that CBCT is an .076mm Cubic Voxel 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 mmThe Kodak 9000 3D features a minimum .38 mmslice thickness of 0.076mm (76u)0.076mm images are the highest resolution .076mm .076mmin the industry today Cubic Voxel .076mm Pinsky HM, Dyda S, Pinsky RW, Misch KA, Sarment DP. Accuracy of three-dimensional measurements using CBCT. DentomaxillofacRadiol 2006:35;410-416
    • LargeWe care for 3-D patients with 3-D disease &provide 3-D treatmentShouldn’t we use 3-D technology fordiagnosis and treatment planning?
    • We care for 3-D patients with 3-D disease &provide 3-D treatmentShouldn’t we use 3-D technology fordiagnosis and treatment planning? Medium
    • 1. Focused ‘FOV’ provides substantially lower doses than medium and large FOV cbCT units. Focused
    • cbCT is the cypher, the piece of auxiliary information,called a key, a cryptovariable that has enabled a newdimension in dental diagnosis. The encrypting procedureis varied depending on the key, which changes the Axialdetailed operation of an algorithm. A key must be selectedbefore using a cipher to encrypt a message. Withoutknowledge of the key, it should be difficult, if not nearlyimpossible, to decrypt the resulting ciphertext intoreadable plaintext....without understanding the endo perioimplant algorithm, you can’t practice biologically soundfoundational dentistry. Coronal Sagittal
    • Axial Coronal Sagittal
    • Sagittal planeCoronal plane AxialOrientation test - 1-800-565-4591
    • Sagittal planeCoronal plane AxialOrientation test - 1-800-565-4591
    • Sagittal planeCoronal plane AxialOrientation test - 1-800-565-4591
    • Sagittal planeCoronal plane AxialOrientation test - 1-800-565-4591
    • Endodontic
    •   indications
    •   for
    •   cbCT
    • Endodontic
    •   indications
    •   for
    •   cbCT differentiation of pathosis from normal anatomyrelationship with important anatomical structuresmanagement of aberrant anatomy (ie: dens, c-shapes)external & Internal resorptionroot perforationsaccessory/ missed canal identificationmanagement of fractured instrumentsaiding surgical planningretreatmentstraumatic injuriesintra-operative (ie: finding canals)MSDOcalcified casesfacial pain cases to rule out odontogenic etiology
    • Panorex and Pathosis both begin with “P”
    • Panorex and Pathosis both begin with “P”
    • DIAGNOSISRadiolucency mid-root tooth #2.4
    • Missed root
    • “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 andlimited cone-beam tomography in posterior maxillary teeth referred for apical surgery.J Endod 2008;34:557–562
    • Detection/Size of Apical Periodontitis Occasionally, apical periodontitis will not penetrate the antral floor, but will displace the periosteum, which will deposit new bone (periapical osteoperiostitis or “halo”).• 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? Lesion detection
    • 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? Rootfracture
    • In Lieu of CBCT: What Are We Missing? Rootfracture
    • 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??Post-opOne year post-op
    • Retreatment Initial RCT done 5 years prior Retreatment 2 years prior Intermittent pain and swelling for the past 18 months
    • Retreatment Initial RCT done 5 years prior Retreatment 2 years prior Intermittent 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 / rg o d e. ui ag m au ltr ta den w. w The day of the impact the w coronal fragment was ://tp stabilized by splinting.ht CBCT image attached. One week later tooth is cold sensitive and percussion is painful. Help me, treat meow.........
    • Trauma
    • Trauma
    • Complications Perforation
    • Complications Perforation
    • Complications
    • Complications
    • 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
    • C R A C K !Root Fracture
    • C R A C K !Root Fracture
    • C R A C K !Root Fracture
    • Root Cracks/Fractures
    • Root Cracks/Fractures
    • Root Cracks/Fractures
    • Root Cracks/Fractures
    • Root Cracks/FracturesPre-op 6m follow-up
    • Root Cracks/Fractures
    • Root Cracks/Fractures
    • Intra-operative
    • Intra-operative
    • Intra-operative
    • Maxillary Sinusitis of Dental Origin (MSDO)MSDO: When a dental infection extends directly through the sinusfloor 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
    • THE ENDODONTIC (PERIODONTIC) IMPLANT ALGORITHM
    • THE ENDODONTIC (PERIODONTIC) IMPLANT ALGORITHMFoundational Dentistry
    • • Chief complaint • Dental history • Medical history • Head and neck exam • Intraoral exam • Radiographic exam - small FOV cbCT • Clinical testing • Perio probing • Differential diagnosis • Treatment plan • Patient discussion • Team discussion TOTALITY OF TREATMENT PLANNINGTHE ENDODONTIC (PERIODONTIC) IMPLANT ALGORITHM: UNTYING THE GORDIAN KNOT © T. Pannkuk, K. Serota
    • ACCESS Restorability: parameters for determination • radiographic assessment • design occlusal entry • extension - peel away pulp chamber ceiling • identify primary orifices • trough grooves • identify accessory orifices • orifice lengthening and widening • straight line glide path to apical third • no frictional file impediment along axial walls • discovery of deep anatomy • no unnecessary dentin removal • safe angulation- orientation avoids furcal aspect of root TOTALITY OF TREATMENT PLANNINGTHE ENDODONTIC (PERIODONTIC) IMPLANT ALGORITHM: UNTYING THE GORDIAN KNOT © T. Pannkuk, K. Serota
    • ROOT FRACTURE Small FOV cbCT Fracture Clinical tests Perio defect? Radiography externally visible? Exploratory access, remove crown if necessary Extraction/Implant Tipping Point 1 Ca(OH)2 interim therapy, for 1 to 2 months Tipping Point II Obturate, restore transitionally, reassess Tipping Point IIITHE ENDODONTIC (PERIODONTIC) IMPLANT ALGORITHM: UNTYING THE GORDIAN KNOT © T. Pannkuk, K. Serota
    • APICAL PERFORATION OR TEAR Small FOV cbCT Is a split Does crown need to be Perio defect? replaced? Radiography evident? Exploratory access, remove crown if necessary Tipping Point 1 Extraction/Implant Ca(OH)2 interim therapy, for 1 to 2 months Tipping Point II Obturate, restore transitionally, reassess Tipping Point III Endodontic microsurgery TOTALITY OF TREATMENT PLANNING Tipping Point IVTHE ENDODONTIC (PERIODONTIC) IMPLANT ALGORITHM: UNTYING THE GORDIAN KNOT © T. Pannkuk, K. Serota
    • SURGICAL RETREATMENT WITH POST Small FOV cbCT Is a split Does crown need to be Perio defect? replaced? Radiography evident? Exploratory access, Is the post remove crown if necessary loose? Tipping Point 1 Extraction/Implant Ca(OH)2 interim therapy, for 1 to 2 months Tipping Point II Obturate, restore transitionally, reassess Tipping Point III Endodontic microsurgery TOTALITY OF TREATMENT PLANNING Tipping Point IVTHE ENDODONTIC (PERIODONTIC) IMPLANT ALGORITHM: UNTYING THE GORDIAN KNOT © T. Pannkuk, K. Serota
    • EXTERNAL OR INTERNAL CERVICAL RESORPTION Small FOV cbCT Is the resorption What type of Perio defect? Radiography surgically accessible resorption? cbCT mapping Tipping Point 1 Access, Heithersay technique, Ca(OH)2 for 1 month Extraction/Implant Tipping Point II Obturate, restore transitionally, reassess Tipping Point III Endodontic microsurgery TOTALITY OF TREATMENT PLANNING Tipping Point IVTHE ENDODONTIC (PERIODONTIC) IMPLANT ALGORITHM: UNTYING THE GORDIAN KNOT © T. Pannkuk, K. Serota
    • ‘And in the end the love you take is equal to the love you make’