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Lou Graham DDS University Dental Professionals

Founder of The Catapult GroupLou@catapult-group.com

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