CASE PRESENTATION: Virtual Implant Planning Using CBCT

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Date: 01-18-2021 10:45:25 am

  A 62-year-old male patient with poor oral hygiene habits presented with pain in all 4 molars. Additionally, he was dissatisfied with his chipped, discolored front teeth and “gap tooth smile” (Figure 1). His pain prevented him from eating the foods he liked and getting out and being social, and he feared that dentures were his only option. The patient also had severe anxiety about dental visits. A perio exam revealed a Type II classification, and all molars were found to be nonrestorable due to deep decay and multiple areas of abscess.
 

Treatment Plan

 

After discussing all options, a phased treatment plan was developed to allow the patient to budget:

1. Removal of pain and infection through perio therapy, extracting hopeless teeth, and bone grafting of extraction sites
2. Decay removal
3. Cosmetic treatment to include wax-up of anterior teeth, whitening, and placement of anterior crowns
4. Replacement of missing teeth using CBCT, virtual surgery, surgical guides, and implants

  Due to his treatment anxiety, the patient expressed interest in trying sedation for his initial treatment and was prepped following the Dental Organization for Conscious Sedation protocols. Periodontal therapy was completed using the NV Microlaser (DenMat), and molar teeth were extracted atraumatically using Physics Forceps (GoldenDent) (Figure 2). Socket preservation was completed using freeze-dried bone product (OsteoLife Biomedical). After this initial treatment, the patient said he felt as though he slept through the entire appointment was ready to continue treatment to replace his missing teeth and increase the esthetics of his smile.

  Six months later, a diagnostic wax-up was completed for his 4 front teeth (Glidewell Laboratories) (Figure 3), providing a blueprint to help simplify crown placement. The front teeth were prepped for BruxZir Anterior crowns (Glidewell Laboratories) using an ELECTROtorque handpiece (KaVo Kerr), and 2 weeks later, the crowns were cemented using RelyX luting cement (3M). The patient wanted his post-treatment smile to be whiter, so in-office whitening was also performed with Zoom QuickPro (Philips).
 

Image-Guided Implant Surgery

  A cone beam image was taken with the OP 3D Pro (KaVo Kerr) (Figure 4). Cone beam images—in addition to allowing me to actually see what I need to effectively and confidently come up with a plan and offer more predictable, safer, and efficient treatment—play a key role in implant surgery. Here, the high-quality cone beam image was used in the fabrication of surgical guides (Anatomage Labs) using Invivo software (Figures 5a and 5b), and I was able to virtually plan for implant placement. Virtual surgery allows me to perform prosthetically driven dentistry and increases patient safety by identifying and avoiding vital structures. Implants (OCO Biomedical) were placed using the surgical guides in the location of teeth Nos. 3, 14, 19, and 30 (Figure 6a and 6b).

  At his postoperative appointment, the patient reported only very minimal discomfort from his implant surgery. He was delighted with his temporary crowns, and he was even more thrilled when he saw the final crowns (Figure 7). The patient has his self-confidence back and advised that he is ready to get out there again and start dating.

Disclosure: The opinions expressed and procedures described are those of Dr. Ghaboussi. KaVo Kerr is a medical device manufacturer and does not dispense medical advice. Clinicians should use their own judgment in treating their patients.

GO-TO PRODUCT USED IN THIS CASE

OP 3RD PRO

  The ORTHOPANTOMOGRAPH OP 3D Pro, formerly the OP300, is a comprehensive 3-in-1 platform indicated to treat the entire maxillofacial region. Using the latest in 2D and 3D technologies, it offers a versatile selection of volumes and resolutions, intuitive patient positioning, and automatic dose control technology. A large, easy-to-use 10-inch user interface ensures easy capturing of high-quality images. The unit is designed as an expandable and upgradeable platform with a cephalometric option available.

CBCT: Guiding Clinicians to Informed Decisions with PERRY E. JONES, DDS, MAGD, IADFE

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Date: 09-21-2020 08:06:32 am

Q: How has CBCT changed your practice?
A: CBCT can be compared to a Swiss army knife in that it is a multipurpose tool. Using CBCT, I’m able to collect general diagnostic data, evaluate implant sites, plan implant surgeries, fabricate surgical guides, generate radiology reports, evaluate sites for endodontic treatment, diagnose TMD, evaluate and make critical measurements related to airway and sleep studies, and evaluate patients for orthodontic treatment. The accuracy, quality, and versatility of CBCT has allowed me to provide a higher level of care to my patients. To put it simply, CBCT provides me with better data. The end result is informed clinical decision-making.

Q: What is a good example of a case where CBCT saved the day?
A: I have a specific case where I was planning an implant surgery for a patient, and was in the process of designing a surgical guide using CBCT and intraoral scan data. While virtually planning the case, I found a periapical lesion at the root of an adjacent tooth. If I had placed the implant without knowledge of this lesion, the implant would have certainly failed. The ability to evaluate bone accurately using CBCT allowed me to treat the tooth in question before the implant was placed. Without CBCT, this surgery would not have been successful.

Q: Can you tell us about the study you conducted?
A: I did a study of 100 CBCT scans taken for “routine” diagnosis, and I compared them to commonly used 2D panoramic images. Out of the 100 cases, 36 presented with pathology that was not identified using conventional 2D imaging. So, we missed diagnostic data about one-third of the time! That finding has been repeated in the dental and medical literature in multiple studies. And that is because, in 2D, we see 2 dimensions: height and width. With 3D data, we see all 3 dimensions: height, width, and depth.

Q: What does having CBCT in your practice do for ROI?
A: CBCT drives income into my office daily. Every periapical lesion I find using CBCT data results in endodontic treatment followed by crown placement. CBCT is also an integral part of my implant service. I use CBCT data to plan implant placement and fabricate surgical guides. CBCT allows doctors to plan implant restorations prior to placement. This cuts down on unnecessary costs and adjustments related to improperly placed implants. CBCT has many uses that allow practices to better serve their patients.