pan ceph 3D Benefits of cone beam in a dental practice

Transcription

1 pan ceph 3D Clinical cases Benefits of cone beam in a dental practice

2 Clinical Cases - 3D Imaging Introduction Dear Reader, We invite you to discover in this brochure some concrete examples of the benefits of 3D imaging to a dental practice. In these various cases*, created by Dr Christophe Foresti, and by Drs Nguyen and Wach, you will see how I-Max Touch 3D has made it possible to refine the analysis, make the right diagnosis and choose the best operating technique. These various cases also demonstrate that the I-Max Touch 3D three-dimensional imaging system represents a major benefit for the apprehension and understanding of complex cases not only for implant and guided surgery, but also in dental surgery, endodontics, perioodontics and general practice. The Owandy team * Due capture modes and print modes, the quality of the pictures is not always representative of the actual quality of the images. Had it not been for them, you would not be reading about these cases As dedicated general practitioners, based in Rosheim, in the heart of Romanesque Alsace, they decided to pool their specialist know-how in order to offer their patients a multi-disciplinary, consistent and up-to-date approach. For even safer and more predictable operations, only a three-dimensional view of the bone anatomy and implant planning make it possible to guarantee our patients optimal aesthetic and functional outcomes in complex cases. 3D display and simulation create an ideal educational environment for informing them about every step of their treatment plan. Cometh the hour cometh the team Dr Christophe Foresti Dr Annie NGUYEN, Rosheim - France Dr Valérie WACH, Rosheim - France Dr Camille MULLER, Rosheim - France A big thank-you for enabling us to publish this work! 2

3 I-Max Touch 3D Clinical Cases Table of Contents Clinical Case 1 : Relationship between the mandibular wisdom tooth and the lower dental canal...4 Clinical Case 2 : The exact localisation and quantification of a dental focus under a complete bridge pillar...6 Clinical Case 3 : Chronic apical focus or presence of mesiodens on 11 and 21?... 8 Clinical Case 4 : Validation of the implant surgical technique according to bone volume...10 Clinical Case 5 : Extract or leave? Periodontology or implantology?...12 Clinical Case 6 : 2D versus 3D implant planning, the choice and number of non-standard implants...14 Clinical Case 7 : Sinus exploration before lateral window and pre-drilling guide in guided surgery...16 Clinical Case 8 : Guided surgery in the anterior zone: transmucosal drilling guide...18 Clinical Case 9 : Chirurgie guidée avec guide à appui osseux suite à greffe maxillaire bilatérale...20 Clinical Case 10 : Guided surgery with bone-supported guide after bilateral maxillary graft...22 Dr Annie NGUYEN, Rosheim - France Clinical Case 11 : Canal anatomy...24 Dr Valérie WACH, Rosheim - France 3

4 Clinical Case - 3D Imaging Clinical Case 1 : Relationship between the mandibular wisdom tooth and the lower dental canal The patient consults for an oppressive sensation behind his last right mandibular molar; it seems obvious that it is due to the eruption of 48, a panoramic radiography is done immediately and confirms this diagnosis. It is impossible to ascertain the precise anatomical relationship between the roots of the wisdom tooth and the mandibular nerve even after taking a complementary retroalveolar image with an angulator. However it is necessary to ascertain the existing relationships with certainty so as to adapt the surgical technique, and therefore a 3D exploration is mandatory. 4

5 I-Max Touch 3D Clinical Case Cone beam allows us to assert that the mesial root of 48 is on the roof of the dental canal but without effraction. The distal root is in tight contact with the mesial wall of the canal along which most of it runs. The wisdom tooth does not therefore cross the canal and the roots do not form a hook around its path, the nerve is compressed between the roots and the lingual cortical. Thanks to 3D exploration, the operation is planned with complete certainty, the operation time is reduced, the wisdom tooth will be extracted in its entirety and, most importantly, the patient is reassured on both the surgical technique used and the post-op follow-up. 3D display creates an ideal educational environment for informing the patient about every step of his treatment plan. 5

6 Clinical Case - 3D Imaging Clinical Case 2 : The exact localisation and quantification of a dental focus under a complete bridge pillar Aa complete bridge was done a few years earlier, the patient is sent to us by her practitioner as he has had a chronic fistula for a month facing 16 which has yielded neither to antibiotics nor to repeated subgingival curettages. In the panoramic examination there is in fact a small radiolucent image of the apex of the 16 but nothing that seems alarming. Aa complementary retro-alveolar image is done by interposing a radiopaque gutta cone in the fistula path. The origin of the infection seems to be the disto-vestibular root whose obturation is however correct. The treating practitioner had also made this type of image and it seemed obvious to him that the cause emanated from the palatine root. Given this uncertainty, 3D exploration of the area is offered to the patient in order to define the right therapeutic choice. 6

7 I-Max Touch 3D Clinical Case Cone beam interpretation is unambiguous, the palatine and disto-vestibular roots are recorded in a very voluminous cystic area. Without 3D imaging what would the diagnosis have been but most importantly, what root to resect and by what approach? It is undeniably through the precise information brought by imaging that we are able to offer the patient the best treatment plan, i.e. complete resection of the palatine and disto-vestibular roots associated with the osseous filling of the curetted crypt. The patient is relieved to have and to see a rational explanation of his problem. 7

8 Clinical Case - 3D Imaging Clinical Case 3 : Chronic apical focus or presence of mesiodens on 11 and 21? The patient consults for a recurring, unsightly redness on 11 and 21; on clinical examination and on periodontal probing nothing seems able to explain this vestibular irritation away from the two zirconia crowns. The panoramic image shows a qualitative endodontic treatment, and there has also been a lack of symptoms for many years. In view of the patient s discomfort (sensation of pressure under the gum) a retro-alveolar image is taken. Despite a negative percussion test, could it be a root fracture? And if so on which tooth? 8

9 I-Max Touch 3D Clinical Case In view of the uncertainty, 3D exploration is offered to the patient. It highlights the presence of an odontoid type structure located under the apex of 11, with slight mesial displacement. There can be no doubt as to the existence of this perfectly distinct odontoid or its position in relation to the surrounding apices and to the incisive canal. Panoramic and retro-alveolar radiographies did not highlight this supernumary tooth; moreover, its exact localisation thanks to cone beam imaging will enable a more precise and safer surgical operation. For the patient, the visual display of his problem and the certainty of the diagnosis are as reassuring as possible for his follow-up treatment. 9

10 Clinical Case - 3D Imaging Clinical Case 4 : Validation of the implant surgical technique according to bone volume Aafter undergoing mandibular rehabilitation, the patient now wants to have his maxillary dealt with, on the right side at first. In the panoramic examination, it seems that the residual bone height seems sufficient for envisaging a simple implant treatment. However the presence of a large residue of canal dental paste surrounded by a radiolucent halo in the extraction site of 14 makes us recommend the prescription of a 3D exploration. The cone beam imaging obtained shows that there is no contra-indication regarding the installation of an implant in sector 14. The quality of the image obtained enables the future implant site in 14 to be identified perfectly and by the same token the technical characteristics of the future implant to be chosen. 10

11 I-Max Touch 3D Clinical Case Regarding 15, while the panoramic image seemed favourable, the planning highlights a lack of subsinus bone height; it is therefore appropriate to modify the surgical technique and the associated quotation Same comment regarding the two molars. The benefit of 3D imaging is undeniable, it enables the surgical technique to be anticipated and therefore the duration of the operation to be better forecast, the patient to be informed and reassured, and above all a quotation to be made which is in line with clinical reality. If dental panoramics remains an excellent initial evaluation method it is clear that in this precise case we have reached its limits and that a single qualitative three-dimensional examination gives us a reliable investigation. 11

12 Clinical Case - 3D Imaging Clinical Case 5 : Extract or leave? Periodontology or implantology? The patient consults in order to undertake a complete rehabilitation, in the maxillary the choice is unambiguous, however what about preserving the mandibular anterior block? Since the best implant is still the natural tooth, on seeing the panoramic, we encourage the patient to accept a periodontal treatment to save the 8 remaining mandibular anterior teeth; although preferring a more radical solution, the patient opts for the preservation of his teeth. A cone beam exploration is scheduled to establish the quotation and assess the plan s feasibility. Another undeniable benefit of the Julie Owandy cone beam lies in the size of its field, in fact the maxillary exploration will allow the patient to be shown the condition of the mandibular anterior sector and enable the type of periodontal treatment indicated in his case to be explained to him. 12

13 I-Max Touch 3D Clinical Case The absence of a vestibular table facing the incisors, the more than unfavourable clinical crown/clinical root ratio of the premolars and the weakness of the canines make us revise the treatment plan entirely. Without the 3D investigation, an extremely tedious periodontal treatment would have been undertaken whose medium-term prognosis would have been very compromised. The clinical validation and the visual display of the three-dimensional residual bone mass create an extremely favourable educational environment for obtaining an informed consent from our patient. 13

14 Clinical Case - 3D Imaging Clinical Case 6 : 2D versus 3D implant planning, the choice and number of nonstandard implants Having decided to do some dental tourism in Hungary, a patient asks for an opinion on the continuation of his treatment: the 11 and 21 implants are not osteo-integrated and 22 is fractured. He opts for removal of the implants and extraction of the lateral incisor. After a few months consolidation, a radiological guide, a standard copy of his current prosthesis, is created; a 3D analysis is done to choose the technical characteristics of the 9 implants to install. A study has specifically shown that the implant installation reflected the planning more exactly when it was preceded by a 3D display of the anatomical structures than when it was the result of planning done based on reconstructed 2D sections (Jacobs et al., 1999). 14

15 I-Max Touch 3D Clinical Case On the 2D (a flat 3D), in view of the large quantity of residual bone, the implant choice is for 9 implants with a 4mm diameter and 12mm length. At least everything seems easy with such sites. In the 3D simulation, there is a complete mismatch between the number of the implants and their selection: the software detects the risk of collisions between all the implants at installation. 3D planning directs us to only install 8 implants out of the 9 and to choose an implant diameter of 3.5mm instead of 4 so as to respect the biological distances. One single question remains: without this simulation how would the surgical stage have gone? The advantage of implant planning is undeniable: throughout the patient s treatment, it enables the management aspect of the initial prosthetic assembly to be respected, so guaranteeing the success of the recommended therapy.ii 15

16 Clinical Case - 3D Imaging Clinical Case 7 : Sinus exploration before lateral window and pre-drilling guide in guided surgery The patient consults with a view to posterior maxillary implant restoration. The panoramic made indicates too low a residual bone volume to undertake a simple installation. The 3D examination confirms the need to make a sinus floor elevation by a lateral bi-maxillary approach. Four months after the operation, a new cone beam examination is done in order to validate the implant plan. Since the patient has already undergone a fairly long operation, he would like the installation of the implants to be the least traumatising possible; to grant his request, he is offered the creation of a pre-drilling guide for guided surgery. 16

17 I-Max Touch 3D Clinical Case Eight Anthogyr implants with a 4mm diameter and 10mm length fit naturally in the transplanted sinuses. The pre-drilling guide is set up and in an hour the eight implants are installed. The operation has gone in a perfectly predictably way and in complete calm. The combination of the Anthogyr Guiding System, the Simplant Pro software and the Owandy I Max Touch 3D imaging delivers a high-precision guided surgical technique. 17

18 Clinical Case - 3D Imaging Clinical Case 8 : Guided surgery in the anterior zone: transmucosal drilling guide This patient wants to get rid of his anterior 4-tooth maxillary removable prosthesis, the dental panoramic does not give any contraindication, on palpation the bone volume seems sufficient; a 3D examination is done to validate the implant plan. As he in constant contact with the public, our patient wants the least aggressive surgery possible and cannot let himself be seen without teeth. The bone volume, the prosthetic-implant angulation, and above all the quantity and good position of the attached gum allow us to offer the patient a transmucosal surgical technique. 18

19 I-Max Touch 3D Clinical Case The four Anthogyr implants are installed without the need for a flap procedure as are the four transgingival connectors. The patient s removable prosthesis is used as a temporary prosthesis, it will only have taken two hours in the laboratory to transform it. The post-operative check on the installation of the implants is important (length of operation: 1h30). The prosthesis is installed two hours later, the patient is delighted with the speed in which it is accomplished and the outcome obtained and knows that the post-operative follow-up will be negligible. Planning benefits: better fit between the implant site contemplated at simulation and the site implanted, better predictability regarding the choice of the size and diameter of the implants, better prosthetic-implant angulation/to volume of bone available. 19

20 Clinical Case - 3D Imaging Clinical Case 9 : Guided surgery with bone-supported guide after bilateral maxillary graft The patient wants to remove his complete maxillary prosthesis with a screw-retained implant structure; the first cone beam done shows an atrophied bone making it necessary to do a major bilateral maxillary apposition graft. Four months after it is done a new 3D exploration is done validating the incorporation of the grafts at the receiving site. When the implants are installed, all the osteosynthesis screws will have to be removed; however, on this grafted bone there are no markers for positioning the implants with certainty. To facilitate the installation and secure the prosthetic plan, it is agreed to design a bonesupported guided surgery screwed guide. 20

21 I-Max Touch 3D Clinical Case Implant planning and positioning of the scored fixing screws. Pre-drilling then drilling through the guide once the access flap is lifted. Installation of the cicatrisation screws at the end of the operation. Installation of eight Anthogyr implants with a diameter of 3.4mm and a length of 10mm, postoperative radiographic check. For even safer and more predictable operations, only a three-dimensional view of the bone anatomy and implant planning make it possible to guarantee our patients optimal aesthetic and functional outcomes in complex cases. 21

22 Clinical Case - 3D Imaging Clinical Case 10 : Limitations of periodontal therapy Dr Annie NGUYEN, Rosheim - France A complete maxillary bridge was done a few years ago; the patient is sent to us by his practitioner for periodontal care. He complains of some gingival irritation on 26. On clinical examination, we observe a generalised gingival inflammation and deep ( 5 mm) periodontal pockets, notably in the posterior maxillary sectors. The panoramic image confirms to us the diagnosis of a moderate to severe generalised chronic periodontal disease and infected foci in the maxillary molar sectors. Aa complementary retro-alveolar image, performed on 26, reveals a mesial intraosseous lesion. Following the persistence of the deep ( 8 mm) periodontal pockets on the maxillary molars despite the initial etiological therapy, a cone beam exploration is planned in order to see these intraosseous lesions precisely and to determine the relevance of periodontal surgery. 22

23 I-Max Touch 3D Clinical Case The 3D examination highlights a severe osseous lysis with buccal-sinus communication (26) and also enables us to detect a voluminous cyst facing 17. and also enables us to detect a voluminous cyst facing 17. The 2D images did not reflect the severity of these infectious foci. The 3D investigation enables us to envisage the non-preservation of the maxillary molars. In this way, we have been able to set up with the patient an adequate treatment plan, aimed at an osteomucosal preparation/repair and an implant therapy. 23

24 Clinical Case - 3D Imaging Clinical Case 11 : Canal anatomy Dr Valérie WACH, Rosheim - France The patient is referred by his practitioner for persistent, sharp pains in 17 and its surroundings. The endodontic treatment of 17 and the avulsion of 16 were done several weeks ago. The 2D examination shows an endodontic treatment with overfillings. The cone beam reveals the presence of a second mesio-vestibular canal in 17 (present in 50% of second maxillary molars) not ascertained in the initial treatment. The oblong shape of the MV root with a non-centred, filled canal are evidence of an additional canal. The cone beam also objectivises the difficulty of the extraction site in healing. 24

25 I-Max Touch 3D Clinical Case Benefits of cone beam in endodontics: Three-dimensional examination enables us to understand the anatomy, to display intracanal obstacles, to objectivise inflammatory lesions that are invisible in conventional imaging, their anatomical relationships and their dimensions in order to develop the right therapeutic strategy. This formidable aid to diagnosis completes the arsenal of the demanding general practitioner admirably. Every endodontist has dreamed of one day examining canal anatomy. The advent of 3D imaging brings us closer to this dream. The custom of seeing our endodontic treatments in two dimensions on retro-alveolar or panoramic images prejudices our endodontist s understanding of volume. Thanks to cone beam, we access a third dimension in order to perform our treatments better and satisfy our patients. 25

26 Clinical Case - 3D Imaging TRADUCTION? notes 26

27 I-Max Touch 3D Clinical Case

28 Owandy is an international organisation that is renowned for manufacturing dental imaging solutions and developing imaging and office management software. Its software is used by around half of the dental practitioners in France today and its range of digital imaging solutions is available to dentists in more than 50 countries on all the continents throughout the world. In addition to the range of products and services, Owandy strives to contribute to the improvement of the orodental health and the well being of patients. A committed and innovative organisation, Owandy has been a hallmark partner for dentists for over 20 years. This work created in association with: Le Dr Christophe Foresti Le Dr Annie Nguyen Le Dr Valérie Wach Le Dr Camille Muller Materialise Dental Owandy equipment used for the creation of these cases: Visteo Sensor, Owandy intra-oral generator, I-Max Touch 3D. RCS Meaux / Clinical Cases 3D - EN TRADUCTION? Cachet revendeur Owandy 2, rue des Vieilles Vignes CS Croissy-Beaubourg Marne-la-Vallée Cedex 2 FRANCE Tel : +33 (0) Fax : +33 (0) info@owandy.com SOFTWARE DIGITAL SENSORS 2D 3DPANORAMIC INTRAORAL RADIOLOGY CAMERAS