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Lou Graham DDS University Dental Professionals
Founder of The Catapult [email protected]
Incorporating 3D CBCT into the Dental Practice“You don’t know what you don’t know’!
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To Bring on Change is to Challenge you and your team and Yes…this will
be a wonderful challenge
Live training for the team MUST be 3-4 hours, we found the full morning was plenty…But there is a but!! You must have follow up on-line training one week later and then more training based on your team’s needs. One person in charge!!
YOU must be committed to scans that first week….it’s all about repetition for the team feeling comfortable….that’s the easy part!
Have your trainer come on-line and review your images…they will often find ways to tweak your images and trust me this will enhance your learning curve! Learn your mistakes early
Find a Lisa….when you need larger scans read
Training for your team
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Diagnostics Today Can be CustomizedTo Each Office
To Each Office’s FocusSpecific to Each Patient
All to the Betterment of our Patients
My fundamental philosophy or as Cynthia would say…My WHY
Getting teeth to their 85th birthday and then beyond!
Fluoresence for enhanced Caries Detection for fissures and smooth surfaces and redefining new protocols, following lesions from recall visits
Transillumination an essential tool in my office for interproximal caries in the contact zone, craze line and crack line illumination, redefining new protocols, documentation for insurance, following lesions from recall visits
Cone Beams/Digital Pans expanding new directions in protocols and maximizing information never seen before in our practices
Digital X-rays: far more options for enhanced imaging and communication
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Dexis Imaging with CariVu/Spectra/Polaris Imaging
12 months later, My hygienist utilizes Spectra
and captures the change
Michel#18 with pain upon chewing
Positive to Tooth Sleuth, 42 on pulp testing
30 year old alloy
Clinical exam reveals Distal-lingual crack
Positive response upon release when biting down
Long history of cracked teeth
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The Box
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Implant
Implant
Implant
Implant
PATH
PATH
ENDO
BWINGS BWINGS
BWINGS
BWINGS
BWINGS
BWINGS
FMXCariVUSpectra
FMXCariVUSpectra
FMXCariVUSpectra
CariVUSpectra
CariVUSpectra
CariVUSpectra
CariVUSpectra
CariVUSpectra
Periapical
Periapical
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Yes, the more we learn, the more we realize how important
this technology truly is
Today, I will relate how Cost, Efficiency and Quality of Care all
Relate to Cone Beams
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CC at a recall visit “I had pain last month in my upper left area,
I was swollen and it went away after I took an antibiotic that I had”
In the PAST, I would have waited if nothing was clear
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But with my limitation of 2D images…I have learned to scan such patients with similar histories that same day with 3D
Cost Savings…$150 in our practice (UDP -15%)Diagnosis within 10 minutes versus referral out
Treatment Plan and Appointment Booked
By the time we would refer out for a consult and get the information…this case is completed and restored….efficiency for today’s patients
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David #3 on a routine recall visit and his specific FMX
RCT 20 years old
Hx of on and off tenderness
Yet no history of swelling and acute pain
Periapical radiolucency evident
That same visit….a 5X5 FOV scan is taken at High Resolution
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Given the lesion, and NO Mb2 canal for a first molar noted…The lesion is worth retreating
3 D beyond the Diagnostics…In Volume Render an easy to follow
Patient Communication Tool
Cost Savings…$150 in our practice (UDP -15%)Diagnosis within 10 minutes versus referral out
Treatment completed within 2 weeks
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Do you retreat
On and Off History of Discomfort
Crown placed years ago
Root Canal years ago
“never felt right”
9mm probings on the distal lingual
2 mobility
Purulence on probing
The patient asks “Can we save”
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I told her doubtful…but let’s scan and take a look
3 D///not MUCH
sagittal
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Axial of palatal
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C
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Ceramir
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Confirmation of Diagnosis: Guidance to Long Term strategy, Sinus and Buccal Bone Anatomy
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Anita
Great patient…Hx of ortho, restorative, on 4 month hygiene recall
4910’s with laser decontamination therapies every 4 months
Perio-Protect for the Upper Arch because of isolated area of 5mm pocketing and history of BOP
My new hygienist calls me in for an exam, she wants to place Arestin 2/3 area because continuing BOP and the pocket is probing 7-9’s today and last visit they lasered and placed Arestin and it’s getting WORSE
Her Perio charting prior to her visit todayIsolated 5’s and bleeding in the 2/3 area
XXX
XXX
Pocketing
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Thinking in the box…Why would a pocket change from a 5-9?
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The Endodontist went on-line to review and said…
Take out the tooth and Save #2
“She has a “J” lesionand this maybe a vertical root
fracture”
After Socket Grafting and a 3 month wait, Implant Placement was done
In this case…the CBCT was our diagnostic tool to see why the area was worsening despite our treatments. Without it, we would
have probably referred out in the past to an endodontist and waited, or treated the tooth endodontically without knowing
what it’s true prognosis was
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So what do you do with one of your patients who on recall comes in with this?Asymptomatic but you know the post and
crown are loose 13 is loose and it’s not the
root! Periapical Pathology?
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Axial
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In this case…the CBCT was our diagnostic tool to determine whether we should spend the time to
remove the crown and retreat with a new post and crown.
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Albert….#12 blows out with swelling and requires an extraction/graft/membrane
2 Unit Temporary Bridge with fractured Pontic
Graft
It’s now 8 months later, he is temped and the question…
Do you crown 13 or extract/graft and make a temp from 12-14 with ultimately another
implant placement?
Sagittal View of Lesion #13Decision Time
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Albert’s axial view clearly showing the distal lesion surrounding the apical
areaDid I really need such a large FOV?
Albert and decision making
He opted for an extraction because we both felt 13 was not a worthwhile investment
to save.
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Pre-existing 3 Unit TempCantilever off 13 and 14
Implant Healing Cap in Place
#12 based on the fact that he was a GRINDER, I prepared an Impression Post
for a “Screw Down Temporary”
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CBCT showed me I had buccal bone and where to debride the lesion
Placement of Allograft/Collaplug and Figure 8 suture
The implant impression post (aka temp abutment) had Teflon Tape placed and then the bridge was
cemented to this implant abutment
I then removed the teflon tape via the access, unscrewed the bridge and relined the emergence off the implant
Margins finals outside of the mouth
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The posterior unit was then cemented and then the implant abutment was screwed down and sealed. I thus avoided excess cement issues
around the temporary abutment
2 weeks later the temporary is removed
After removal, the pontic is micro-etched bonding agent and then a flowable is
placed, light cured
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Cemented into place and Torqued/Sealed
Try-In or Delivery Day
To remove the bridge: remove the seal, then unscrew the abutment and remove withhemostats
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Ceramir cementation of tooth #14after cleansing of tooth with 2% Chlorhexidine
12 and 13 were screw retained
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Compare margin sealing:
Rely X LutingRely X UnicemFuji GI
CeramirProRoot MTA
Compare Margin Sealing
CeramirProRoot MTA
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CeramirAlkaline in final setting
formulation: resists long term acid attacks
Low film thickness
Easy clean-up
Radio-opaque
Calcium releasing cement* potential to close gaps at the marginal interface
Nano-particle integration into dentin
Zero shrinkageBiocompatible
which is key for implants
Hydrophilic…likes a moist tooth
Easy clean-upWhite Opaque in
colorGood Retention*
Final with a Class 4 on #10
In this case…the CBCT was our diagnostic tool to determine the course of direction by extracting #13 which ultimately saves the patient $$ from potential
long term failures
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Peter, 59 years old, trauma years ago to his upper anterior teeth
Peri-apicals taken every 3 years on Peter in our practice
New changes 8D and 9?
Asymptomatic, normal probings
2D changes noted on 9 and maybe 8D
Peter Pre-op: Yes it’s easier to do a 3 unit bridge but not as
conservative…
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4 views on our CBCT
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My Team
Due to the thin buccal bone, careful elevation was essential to role out the
central. The resorption was on the lingual
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Surgical Placement: We will wait 6 months before finalization
Implant placement Graft/membrane
Showing the extent of External resorption and Internal Absorption after cleansing
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After customizing the length, a full cleansing and micro-etching was done
followed by etching and bonding
15 seconds of etching
20 seconds of Universal Bonding Agent(scrubbing not required)
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After Confirming the fit: we first secured via the buccal and then bonded on a
braided wire on the lingual
Spot Etching, Bonding and G Aenial Flowable placed
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Happy Patient45 minutes later
X-ray showing our
morning
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In this case…the CBCT was our diagnostic tool to determine that extraction was the best treatment of choice along with a group plan on extraction/implant
and temporization
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On a routine hygiene visit: An asymptomatic lesion with a Class 5 “stick”
History #23 turned yellow and then endo was done on non vital tooth years ago
History #22, No history on this tooth beyond orthodontics in high school 42 years ago
No probing
Stick on the coronal aspect
Under Volume Render
Note the Location of Resorption
Coronal View showing proximity
to the nerveThis view is the “money view”
in this case because we knew that endodontics was involved. We then pulp tested
and it was negative
Looking from the Front
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In this case…the CBCT was our diagnostic tool to determine the extent, and develop a sequential plan to treat this resorption
After creating the access and instrumenting (non vital) the canal, the incision was made to expose the defect
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The extent of the defect is noted along with the file in place to allow the next step 1:50,000 epi in gauze
to inhibit bleeding around the defect
Biodentine: “Dentine in a Capsule” The Ingredients: Powder and Liquid
Tri-Calcium Silicate Main Core Material
Di-Calcium Silicate Secondary Core Material
Calcium Carbonate and Oxide Filler
Iron Oxide Shade
Zirconia Oxide Radiopacifier
Calcium Chloride Accelerator
Hydrosoluble Polymer Water Reducing Agent
Open the Capsule: Create a Wedge of the powder6 drops into the center of the power, reseal and shake
Triturate for 15-20 seconds
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Options to Restore: The Key question are you isolated?
Polish as is. Use an ultra fine finishing diamond bur (white stripe) at high speed
Remove Biodentineexternally and place a cosmetic composite
Remove the coronal ½ of the Biodentine and place a composite
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3 weeks later…
All of these diagnostics relate to expanded information and creating a path of communication too involve the patient and guide them into wanting their treatment
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Tell me, and I will forget.
Show me, and I will remember.
Involve me, and I will understand.
Showing and Involving
Question: What % of treatment planned casework
Is NOT begun in year 1 in Dental Offices?
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78%
A Profession in TransitionKey Forces redefining the
landscape…ADA Report 2013
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Dentists are going to have to run their business’s far more efficiently
both clinically and non clinically
They are going to have to create “value” and communicate far
better in the future
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Our UDP plan…..Developed in our team meetings
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It allows patients an affordable plan without any premium for overall care but builds our hygiene system!
There are NO ‘special” discounts…just one plan
No patient financing with this plan except Comprehensive Finance
Cash in your account upfront
Far easier to maintain patients on recall with Solution Reach and far less calls trying to fill hygiene appointments because the patient has paid for their hygiene care upfront!
Easy to follow your growth with Dental Intel and this guides your vision, your recall, your team, your huddles and so much more
Lastly, and my favorite…no insurance companies getting in my way of what’s best for the patient
like a denial for a Cone Beam!
Our Billing $$$$$$$$$$$$$
FMX $150 (when appropriate)
Panorex with Bite-Wings $150Cone beam $150They are included with our Implant Placement FeesCone beam during treatment N/C
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My First Year
Year 2
Everything we create for our patients is done in
3 Dimensions. Why are we looking at them
radiographically in 2 Dimensions?
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Begin to look at your patients the way you treat them:
In 3D
Thanks for Your Time today