Small fov cb ct

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Small fov cb ct

  1. 1. 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
  2. 2. 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)
  3. 3. 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  effec:ve  dose   from  natural  background  radia:on  in  days
  4. 4. 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  effec:ve  dose   from  natural  background  radia:on  in  days
  5. 5. 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
  6. 6. 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
  7. 7. LargeWe care for 3-D patients with 3-D disease &provide 3-D treatmentShouldn’t we use 3-D technology fordiagnosis and treatment planning?
  8. 8. 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
  9. 9. 1. Focused ‘FOV’ provides substantially lower doses than medium and large FOV cbCT units. Focused
  10. 10. Small FOV cbCT
  11. 11. Small FOV cbCT
  12. 12. Small FOV cbCT
  13. 13. Small FOV cbCT
  14. 14. Sagittal planeCoronal plane Axial
  15. 15. Sagittal planeCoronal plane Axial
  16. 16. Sagittal planeCoronal plane Axial
  17. 17. Sagittal planeCoronal plane Axial
  18. 18. Endodontic
  19. 19.  indications
  20. 20.  for
  21. 21.  cbCT
  22. 22. Endodontic
  23. 23.  indications
  24. 24.  for
  25. 25.  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
  26. 26. Sousa Melo et al, 2010Axial tomographic crosssections at the coronalportion of the root ofspecimens with similarsubtle experimentallyinduced root fracturesshow the fracture line(arrows) in nonfilled root(A) and presence of star-shaped streak artifacts ofgutta-percha (B) and post(C).
  27. 27. Sousa Melo et al, 2010UnfilledGutta-perchaGold post
  28. 28. Diagnosis1. Patient referred for endodontic treatment, tooth #4.62. Sensible to cold testing, tender to percussion3. 7mm probing on distal aspect
  29. 29. DiagnosisAxial view Sagittal view
  30. 30. Diagnosis Distal surface
  31. 31. Diagnosis
  32. 32. DIAGNOSISRadiolucency mid-root tooth #2.4
  33. 33. Missed root Diagnosis
  34. 34. 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 andlimited cone-beam tomography in posterior maxillary teeth referred for apical surgery.J Endod 2008;34:557–562
  35. 35. 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
  36. 36. In Lieu of CBCT: What Are We Missing? Lesiondetection
  37. 37. In Lieu of CBCT: What Are We Missing? Lesiondetection
  38. 38. In Lieu of CBCT: What Are We Missing? Lesion detection
  39. 39. In Lieu of CBCT: What Are We Missing?
  40. 40. In Lieu of CBCT: What Are We Missing?Do we have a lesion?
  41. 41. In Lieu of CBCT: What Are We Missing?Do we have a lesion?
  42. 42. In Lieu of CBCT: What Are We Missing? Identifycomplexity
  43. 43. In Lieu of CBCT: What Are We Missing? Identifycomplexity
  44. 44. In Lieu of CBCT: What Are We Missing? Identifycomplexity
  45. 45. In Lieu of CBCT: What Are We Missing? Identifycomplexity
  46. 46. In Lieu of CBCT: What Are We Missing?Extent of lesion
  47. 47. In Lieu of CBCT: What Are We Missing?Extent of lesion
  48. 48. In Lieu of CBCT: What Are We Missing?Extent of lesion
  49. 49. In Lieu of CBCT: What Are We Missing?Extent of lesion
  50. 50. Size of lesion
  51. 51. Mental Foramen
  52. 52. Healing??Post-opOne year post-op
  53. 53. Retreatment
  54. 54. Retreatment
  55. 55. Retreatment Initial RCT done 5 years prior Retreatment 2 years prior Intermittent pain and swelling for the past 18 months
  56. 56. Retreatment Initial RCT done 5 years prior Retreatment 2 years prior Intermittent pain and swelling for the past 18 months
  57. 57. Retreatment
  58. 58. Post-op 4.6 1 year post-op 4.6
  59. 59. Retreatment Preop 12 mos. Postop
  60. 60. Trauma / o rg e. uid ag m au ltr ta en d w. w The day of the impact the w :// coronal fragment was stabilized tpht by splinting. CBCT image aached. One week later tooth is cold sensitive and percussion is painful. Help me, treat meow.........
  61. 61. Trauma
  62. 62. Trauma
  63. 63. Trauma
  64. 64. TraumaTooth #1.1 PA Tooth #1.1 cbCT
  65. 65. TraumaTooth #2.1 PA Tooth #2.1 cbCT
  66. 66. TraumaTooth #2.2 PA Tooth #2.2 cbCT
  67. 67. TraumaAvulsion Replantation, teeth #‘s1.1 #2.1
  68. 68. TraumaAlveolar  fracture
  69. 69. Trauma Undiagnosed   Alveolar  fracturelateral  luxa:on            #1.2                                                                                                                                                                                                                                                          #1.1
  70. 70. Trauma
  71. 71. Trauma
  72. 72. Trauma
  73. 73. Complications Perforation
  74. 74. Complications Perforation
  75. 75. Complications
  76. 76. Complications
  77. 77. Detection of Luxations#2.1: avulsed replanted
  78. 78. Detection of LuxationsTooth #1.1 - note alveolar fracture Tooth #2.1 - note change in angulation as compared to tooth #1.1
  79. 79. Detection of Luxations
  80. 80. Detection of LuxationsTooth #2.4 PA Tooth #2.4 cbCT
  81. 81. Detection of Perforations
  82. 82. Detection of Perforations
  83. 83. Detection of Perforations
  84. 84. Perforations
  85. 85. 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
  86. 86. 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
  87. 87. Detection of ResorptionResorption was detected in 69% of radiographs and 100% of CBCTscans Estrela C et al JOE 2009
  88. 88. Detection of Resorption
  89. 89. Detection of Resorption
  90. 90. Detection of Resorption ?
  91. 91. Detection of Resorption ?
  92. 92. Detection of Resorption
  93. 93. Detection of Resorption
  94. 94. Detection of Resorption
  95. 95. Root Resorption
  96. 96. Root Resorption
  97. 97. External Cervical Invasive Resorption
  98. 98. Begin with the end in mind CBCT- perfectly positioned for endodontics: Focused FOV Minimal radiation Highest resolution Real-time analysis
  99. 99. Detection of Root FracturesCBCT showed higher accuracy than PA’s for the detectionof VRF.Confirmed by Hassan B et al, JOE 2009 and Edlund M etal, JOE 2011Nyquist theorem: VRF must be at least2x voxel size to be visible
  100. 100. C R A C K !Root Fracture
  101. 101. C R A C K !Root Fracture
  102. 102. C R A C K !Root Fracture
  103. 103. Root Cracks/Fractures
  104. 104. Root Cracks/Fractures
  105. 105. Root Cracks/Fractures
  106. 106. Root Cracks/Fractures
  107. 107. Root Cracks/Fractures
  108. 108. Root Cracks/FracturesPre-op 6m follow-up
  109. 109. Root Cracks/Fractures
  110. 110. Root Cracks/Fractures
  111. 111. Root Cracks/Fractures
  112. 112. Root Cracks/Fractures 1.Patient referred for evaluation 2.Discomfort to biting/chewing 3.Isolated 6mm probing on distal
  113. 113. Root Cracks/Fractures
  114. 114. Detection of Root Fractures
  115. 115. Detection of Root Fractures
  116. 116. Detection of Root Fractures
  117. 117. Detection of Root Fractures
  118. 118. Detection of Root Fractures
  119. 119. Detection of Root Fractures Sinus tract tracing 7mm
  120. 120. Detection of Root Fractures
  121. 121. Vertical Root Fracture
  122. 122. Vertical Root FractureNo apparent bone loss
  123. 123. Vertical Root Fracture
  124. 124. Intra-operative
  125. 125. Intra-operative
  126. 126. Intra-operative
  127. 127. Intra-operative
  128. 128. Intra-operative
  129. 129. Intra-operative
  130. 130. Intra-operative
  131. 131. Intra-operative
  132. 132. Intra-operative
  133. 133. Intra-operative
  134. 134. Intra-operative
  135. 135. Intra-operative It  appears  that  there  are  2   canals  that  merge  into  1 Initial access Initial access
  136. 136. Intra-operativeCoronal  part  of  tooth Canals  first  appear  to  be   visible Appears  to  be  1  canal Apical  part  of  tooth
  137. 137. 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
  138. 138. ‘And in the end the love you take is equal to the love you make’

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