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Seeing Is Believing by Dr. Kristen Andrews

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Categories: Imaging, CBCT, and Radiography;
Seeing Is Believing 

What cone beam imaging can do for your patients and practice

by Dr. Kristen Andrews

Where I practice, in rural North Dakota, it’s not uncommon for some patients to drive up to an hour for an appointment. Access to high-quality dental care is critical to their health and well-being, so our practice is equipped with the latest digital technology and equipment. While we’ve invested in everything—scanning, milling and 3D printing—cone beam computed tomography (CBCT) is the workhorse of our practice.

3D cone beam imaging has improved diagnosis and treatment planning and enhanced the patient experience through visual data for easy communication and education. Upgrading to CBCT comes with a price tag, but new and advanced technology can have an enormous impact and create a great opportunity for growth of a dental practice. I know this much is true: 3D imaging has helped transform my practice and allowed us to reach our full potential as dental care practitioners.

 CBCT in practice

When we decided to upgrade our 3D/2D imaging system, we ultimately chose the Dentsply Sirona Axeos CBCT because it enabled us to deliver a variety of services under one roof. The unit’s Sidexis 4 software integrates other digital tools, such as intraoral sensors and X-rays from my CBCT, to streamline workflows for several dental applications, including implant placement, endodontics and orthodontics.1 As a result, we can provide a wider range of services to more patients, who are happier because they don’t have to visit multiple offices to get treatment. We are also happy to limit our referrals and take care of our patients in-house.

In a single 14-second rotation, CBCT provides 3D images of the entire head, and can also detail quadrant regions. This provides a very accurate and reliable diagnosis tool. There are four fields of view that can be taken based on what you are trying to analyze: 17-by-13, 11-by-10, 8-by-8 and 5.5-by-5 cm. The smaller volumes are ideal for diagnosing single-tooth fractures or endodontic lesions, while the larger volumes are more appropriate for treating implants, TMJ and airway problems.

 Case study 1

A patient came to our office for a routine hygiene visit and cleaning. During the hygiene exam, it was discovered that there was decay present on the mesial buccal aspect of tooth #14 (Fig. 1). This tooth served as an abutment to a three-unit PFM bridge spanning from #12–14. The bridge was sectioned and the crown from #14 was removed to determine the restorability of the tooth. Significant decay was found under the bridge, extending into the buccal furcation of the tooth.

The patient was asymptomatic, but upon reviewing the CBCT, it was discovered that #14 had a significant lesion extending into the maxillary sinus (Figs. 2 and 3). It was also found that #15 was necrotic, with a lesion extending into the maxillary sinus (Fig. 4). The patient was referred to an endodontist for evaluation, who recommended extracting both teeth and restoring with implants.

Without the CBCT, a misdiagnosis likely would have occurred and created unnecessary procedures for the dentist and unnecessary expenses for the patient. The patient is now scheduled for an implant in the position of #13, and a future implant in the site of #14 after grafting and allowing the site to properly heal.
CBCT Cases
Fig. 1
CBCT Cases
Fig. 2
CBCT Cases
Fig. 3
CBCT Cases
Fig. 4


CBCT-guided implant placement

Beyond improving the core aspects of dental exams—diagnosing tooth decay, fractures and other tooth/root abnormalities—I find that CBCT is incredibly helpful in planning and placing dental implants. With just one scan, I can get a comprehensive look at the surrounding nerves and oral structures and integrate these images with a full jaw intraoral scan for accurate implant placement.

Patients gain confidence in me as a clinician because they are a part of the implant process from beginning to end. Using CBCT, I’m able to show them how precisely I plan the placement of the implant and integrate the CAD/CAM data. From there, I can design and fabricate a guide allowing for a seamless implant placement. Often, it may result in only a small punch of tissue rather than an entire flap. This allows much more rapid healing time for the patient.

Depending on the stability of the implant, I will usually wait approximately two months before restoring the implant. There are occasions where I’m able to scan the patient at the time of implant placement, thereby allowing the third appointment to be the delivery of the final crown. Occasionally, for proper tissue contouring and healing, I may scan after the implant has been fully integrated. Utilizing a well-connected CBCT like Axeos allows me to gain at least one appointment per patient per procedure. Regardless, the appointments are minimal and mostly painless for patients.

 Case study 2

A patient required emergency dental treatment for spontaneous pain on the lower left posterior mandible. Upon a clinician examination, the gingival tissue around #18 appeared to be within normal limits. The tooth was highly sensitive when I placed a tooth sleuth on the distal lingual cusp, indicating a potential fracture. A periapical radiograph was taken of teeth #18 and 19. Nothing significant was noted on the image, but the patient was insistent that the pain was coming from #18. I decided to take an 8-by-8 cm CBCT and immediately detected a lesion at the medial and distal apex of #18 (Figs. 5, 8 and 9).

The patient had previously been through a similar experience on the contralateral side and was insistent that I extract the tooth instead of performing endodontic treatment. Indeed, I identified a vertical fracture on the mesial root, causing the tooth to be unrestorable once I extracted and inspected it. I grafted the area with freeze-dried particulate bone and waited four months for healing (Fig. 7).

Using my CBCT and Primescan, I was able to plan and properly position the implant. In addition, I used Dentsply Sirona’s Azento system to obtain adequate tissue contouring for my final restoration. A 4.8-by-9 mm Astra EV implant was placed in the site and will be restored at a later date (Fig. 6). The patient was pleased that in only two appointments, the tooth was extracted and an implant was placed.

As dentists, we expect our patients to trust what we have to offer, and 3D diagnostic images help build this trust. By observing visual evidence for why a given procedure is necessary, patients are more engaged with their care and more likely to accept our treatment recommendations. Most patients will readily accept treatment based on the visual evidence. Essentially, the image sells the necessary treatment.
CBCT Cases
Fig. 5
CBCT Cases
Fig.6
CBCT Cases
Fig. 7
CBCT Cases
Fig. 8
CBCT Cases
Fig. 9


Case study 3

A patient came to our office for a hygiene visit. Routine bitewing X-rays were taken and nothing significant was noted in the area of #2. Clinically, there appeared to be a slight fracture on the distal marginal ridge, and it was recommended to restore the tooth with a crown. The patient had a fairly large occlusal amalgam restoration existing on the tooth. A full-volume 17-by-13 cm scan was also taken during the patient’s visit. Upon reading the full-volume CBCT, a through-and-through fracture was discovered on #2 and the tooth was unrestorable (Figs. 10 and 11).

Oddly, the patient was asymptomatic. Treating the tooth with a crown would have shortly turned into a RCT that would have eventually led to an extraction of the tooth. With innovative 3D technology, we were able to come up with the most accurate diagnosis from the start (Figs. 12 and 13).

While function is the most important aspect of CBCT, appearance plays a role in case acceptance, too. The Axeos is positioned in our office so every patient sees the unit as they walk back to the operatories and/or the hygiene rooms. It fits perfectly in its own little nook, which shows off ambient light, creating a pleasant, calming atmosphere for patients and making it easier to implement in our practice.
CBCT Cases
Fig. 10
CBCT Cases
Fig.11
CBCT Cases
Fig. 12
CBCT Cases
Fig. 13


Seeing strong ROI and focusing on the future

My practice is equipped with the latest digital technologies, like 3D cone beam imaging, so we can provide the best dental care and patient experience possible. CBCT allows us to streamline planning, simplify procedures and reduce chair time and the amount of visits, lessening patients’ travel burden.

CBCT has helped expand our services as well. We are more confident planning and placing implants and designing OSA appliances for patients with airway issues. There’s also flexibility to use panoramic X-rays for orthodontic alignment cases. Of utmost importance, the technology allows us to offer a whole-person clinical approach to patients. In fact, I have used data from 3D scans to detect possible carotid artery disease and jaw tumors and sinus issues.

Some dentists are apprehensive about investing in CBCT because of the expense. But the true cost of innovative technology goes beyond the price tag. It’s important to also consider the value of the purchase—for your practice, your productivity and, most importantly, your patients.

Reference
1. Pauwels R, Araki K, Siewerdsen JH, et al. Technical aspects of dental CBCT: State of the art. Dentomaxillofac Radiol. 2015; 44:20140224

Author Bio
Kirsten_Andrews After Dr. Kirsten Andrews graduated from the University of Minnesota School of Dentistry in 2007, she returned to her hometown of Devils Lake, North Dakota, where she owns and practices at Johnson Family Dentistry.

Andrews, a Cerec user since 2012, is a visiting faculty member for CDOCS, mentoring dentists who attend courses in Arizona and North Carolina. Through Patterson Dental, she also has taught dentists in her home state. She is passionate about delivering the best care to her patients and believes that offering same-day crowns is part of that. She is a member of the American Dental Association, the North Dakota Dental Association and Spear Practice Solutions.

 

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