Foundations of CBCT Imaging for Implant Planning and Surgical Guides

Transcription

1 Earn 3 CE credits This course was written for dentists, dental hygienists, and assistants. Foundations of CBCT Imaging for Implant Planning and Surgical Guides A Peer-Reviewed Publication Written by Douglas L. Chenin, DDS Abstract The use of CBCT imaging has drastically enhanced and changed the way dentists can diagnose and assess patient anatomy in preparation for implant placement. Now, with a single CBCT scan the patient s entire craniofacial complex can be visualized and viewed from every angle in 3D and any structure can be cross-sectioned into 2D slices for detailed assessments and measurements. Furthermore, virtual implant planning within the CBCT scans can be performed and converted into a physical surgical guide that can be used during surgery. These abilities give the clinician tremendous potential but also create new challenges such as: where to start, what anatomy to look at, how to cross-section the anatomy properly, and what are the protocols and steps for ordering a surgical guide? The purpose of this CE course article is to clarify some of these questions, to provide an organizational framework by which clinicians can approach scans, and to review the terminology, capabilities and protocols of surgical guides. INSTANT EXAM CODE Go Green, Go Online to take your course Publication date: Mar Expiration date: Feb Supplement to PennWell Publications Educational Objectives At the end of this self-instructional educational activity the participant will be able to: 1. Conceptualize how CBCT imaging enhances the diagnostic potential and accuracy of implant planning beyond traditional 2D images. 2. Assess and visualize patient CBCT data properly in 3D and 2D crosssections for virtual implant planning and to summarize which anatomical structures are critical to examine. 3. Discuss the terminology, capabilities, and tools needed for the various levels of control that surgical guides offer. PennWell designates this activity for 3 continuing educational credits. Dental Board of California: Provider 4527, course registration number CA# This course meets the Dental Board of California s requirements for 3 units of continuing education. The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from (11/1/2015) to (10/31/2019) Provider ID# Author Profile Douglas Chenin, DDS is a graduate of the University of the Pacific Arthur A. Dugoni School of Dentistry. Dr. Chenin worked directly with Anatomage for five years as the Director of Clinical Affairs where he helped in the development of the Invivo5 CBCT Imaging software and the Anatomage Surgical Guide system. He also worked in conjunction with BeamReaders Inc for several years directing the implant planning consultations and surgical guide facilitation services. He has earned a reputation of a CBCT technology expert with his extensive participation in study clubs, seminars, conferences, and his numerous professional publications about CBCT imaging for various dental specialities. Dr. Chenin also founded his own CBCT Consulting and education company called Clinically Correct Inc which focuses specifically on teaching CBCT imaging technology. Author Disclosure Douglas Chenin, DDS has no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course. All images created for OP300 scans with the InVivo5 software by Anatomage: This educational activity has been made possible through an unrestricted grant from KaVo. This course was written for dentists, dental hygienists and assistants, from novice to skilled. Educational Methods: This course is a self-instructional journal and web activity. Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third party has had any input into the development of course content. Requirements for Successful Completion: To obtain 3 CE credits for this educational activity you must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with products or services discussed in this educational activity. Heather can be reached at hhodges@pennwell.com Educational Disclaimer: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. Image Authenticity Statement: The images in this educational activity have not been altered. Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and represents the most current information available from evidence based dentistry. Known Benefits and Limitations of the Data: The information presented in this educational activity is derived from the data and information contained in reference section. The research data is extensive and provides direct benefit to the patient and improvements in oral health. Registration: The cost of this CE course is $59.00 for 3 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

2 Educational Objectives At the end of this self-instructional educational activity the participant will be able to: 1. Conceptualize how CBCT imaging enhances the diagnostic potential and accuracy of implant planning beyond traditional 2D images. 2. Assess and visualize patient CBCT data properly in 3D and 2D cross-sections for virtual implant planning and to summarize which anatomical structures are critical to examine. 3. Discuss the terminology, capabilities, and tools needed for the various levels of control that surgical guides offer. Introduction / Abstract The use of CBCT imaging has drastically enhanced and changed the way dentists can diagnose and assess patient anatomy in preparation for implant placement. Now, with a single CBCT scan the patient s entire craniofacial complex can be visualized and viewed from every angle in 3D and any structure can be cross-sectioned into 2D slices for detailed assessments and measurements. Furthermore, virtual implant planning within the CBCT scans can be performed and converted into a physical surgical guide that can be used during surgery. These abilities give the clinician tremendous potential but also create new challenges such as: where to start, what anatomy to look at, how to cross-section the anatomy properly, and what are the protocols and steps for ordering a surgical guide? The purpose of this CE course article is to clarify some of these questions, to provide an organizational framework by which clinicians can approach scans, and to review the terminology, capabilities and protocols of surgical guides. (Figure 1) Figure 1. This image shows a virtual implant treatment plan with virtual restorations as well. This makes it very easy to see how the actual implants will fit into the proposed anatomical sites and if their trajectories are restoratively driven. Benefits of CBCT imaging over Traditional 2D Imaging for Implant Planning As a preface to understanding how to approach CBCT scans, the following is a brief review of the reasons why clinicians should be using 3D imaging in the first place. There are multiple limitations of traditional 2D imaging and conversely there are multiple benefits of 3D CBCT imaging for implant planning. The primary limitation of traditional 2D imaging in any form including panoramic, bitewing, or periapical X-rays is that they do not provide information on the faciolingual dimension. The thickness of the dental arches is flattened into a 2D image and anatomical aspects such as the width of the bone or lingual undercuts cannot be determined. For this reason, all 2D images have a degree of distortion. The image size of the x-ray is not an exact 1:1 ratio to the real size of the anatomy. 1,2,5,7 Also, in panoramic images there are overlapping structures that make location and boundaries difficult to visualize since the entire width of the anatomy is flattened and overlapped. Moreover, 2D imaging is also not compatible with accurate virtual implant planning software tools for the manufacture of surgical guides. (Figure 2) Figure 2. This is an image of a traditional 2D panoramic image. Notice how there are many overlapping structures and that there is no ability to visualize or measure the faciolingual dimension of anatomy. The benefits of 3D imaging essentially overcome all the limitations of 2D imaging for implant planning. Firstly, images can be acquired without distortion. Therefore, the image size to the real anatomical size is a ratio 1:1, thus, any measurements preformed will be precise. Since all three dimensions including the faciolingual are present, the clinician has the ability to measure the width of bone and to perform virtual implant planning with the actual virtual implants placed during surgery. (Figure 3) These virtual treatment plans can then be converted into physical surgical guides for the most accurate translation of the treatment plan to the patient during the surgery. 3,8 It is for this reason that CBCT images are often called the virtual patient. How to Approach CBCT Data for Implant Planning The first time a clinician approaches CBCT data can be overwhelming and disorientating because there are so many options in terms of visualizations in both 3D and 2D. With 3D imaging software, it is possible to rotate the data in 3D, visualize it from any angle, and slice it into different cross-sections at any plane. This gives the clinician unlimited visualization possibilities. (Figure 4) 2

3 Figure 3. This images shows a series of cross-sections going perpendicular through the dental arch to obtain accurate cross-sections that can be relied upon for anatomical measurements. Figure 5. This image shows the boundary of the maxillary sinus above the middle of the implant. Notice how the sinus slopes down distally so the single cross-section in the upper right hand corner does not represent the anatomy at the mesial or distal ends. That is why a series of slices is preferred as shown in image 10. Figure 4. This image shows some of the various 3D imaging visualizations possibilities that are available. In terms of the mandible, the boundary conditions are the location and full pathway of the inferior alveolar canal and the location of the mental foramen. The presence and extent of an anterior loop of the inferior alveolar canal should also be determined. The anterior loop is the full body of the canal which projects anteriorly towards the mental foramen, which is located slightly distal to the furthest anterior point of the canal in its curve towards the foramen exit. 10 The incisive branch of the inferior alveolar canal is a separate entity which is different than the anterior loop and should also be assessed. (Figure 6) Figure 6. This images shows an inferior alveolar canal traced in the panoramic reconstruction and in the cross-section of the middle of the implant. Notice how the IA canal goes further anterior before bending back distally to exit the mental foramen. This anterior aspect is called the anterior loop. When analyzing a CBCT scan for implant planning it is important to look at both the gross anatomy and the fine details. These details are usually obtained in 2D cross-sections, and the most essential details to analyze when focusing on specific implant sites are the boundary conditions of the site in question. Boundary conditions are defined as the anatomical constraints of an implant s proposed location that will influence implant placement. A few examples of critical boundaries are: the faciolingual width of the alveolar bone; the location and size of the inferior alveolar canal; and the proximity to adjacent implants and/ or teeth. Boundary conditions vary depending upon the site; some apply specifically to the maxilla or mandible and some apply to both. 4,6,7,9 The boundary conditions that apply specifically to the maxilla are the location and size of the nasopalatine canal when the implant is close to the maxillary midline. The location and boundary of the maxillary sinus floor is crucial for any maxillary implant as many anatomical variations exist and the maxillary sinus can extend much further anteriorly than expected. Additionally, the location of the floor of the nose should also be determined. (Figure 5) Furthermore, at the lingual midline of the mandible, there can be a sizable median lingual vascular canal that can result in hemorrhagic complications if violated. Therefore, when placing implants near the mandibular midline it is important to look for a wide median lingual canal in this area. (Figure 7) The following boundary conditions apply to both the maxilla and mandible. First, is the faciolingual width of the alveolar bone at the alveolar crest and more apically within the basal bone throughout the implant site. This will be the limiting factor which determines if a specific implant diameter will fit and whether bone grafting will be required. The vertical height of 3

4 Figure 7. This images shows the median lingual vascular canal at the center of the mandibular lingual midline. In some cases, it is quite wide and can have serious complications if severed. the alveolar bone is also a foundational boundary since it will limit the length of the implant that can fit safely into the site without violating any boundary structures such as the inferior alveolar canal. The adjacent teeth and roots or implant and crown locations and their proximity are also critical factors for any implant site. In addition, the overall contour and presence of concavities or undercuts should be assessed. 4 All boundaries can be visualized and measured with standard 2D cross-sections perpendicular to the curve of the dental arches. (Figure 8) For most of the implant specific boundary conditions, 2D cross sections are ideal images to locate and measure them. Cross-sections of the dental arch and implant site can be created in the mesiodistal direction and the buccolingual dimension. The mesiodistal cross-section enables the assessment of adjacent implants and teeth, while cross-sections in the faciolingual dimension allow for the visualization and measurement of the width of alveolar bone. (see Figure 8) cross-sections that are oblique and do not directly go straight through the site in a perfect mesiodistal cut that is parallel to the arch or a faciolingual cut perpendicular to the arch. This results in visualization and measurement errors. (Figure 9) CBCT images are true representations of anatomy, being a 1:1 ratio of image to anatomy size, thus, the representations of anatomy are free from magnification and distortion errors. However, a cross-section that is created in an oblique fashion can distort the true representation of the anatomy. 6,7 Another imaging pitfall is to perform only one cross-section of the implant site at the middle of the location. However, for implant sites near the maxillary sinus the distal and mesial height of bone can be quite different since the sinus floor often slopes. (Figure 10). The same consideration applies to mandibular implants above the inferior alveolar canal. Therefore, cross-sections and measurements should be taken all along the implant site. Another imaging consideration of great importance is the corresponding references to the cross-sections on either an axial slice of the dental arch or a panoramic reconstruction. Thus, it is essential to know where each cross-section is located; whether it is at the mesial end of the site or the distal end. (see Figure 10) Figure 9. This images shows an incorrectly created cross-section of the dental arch represented by the yellow line in the upper-left hand corner. Notice how the measurement is longer on it as it cuts through more anatomy in its oblique trajectory. Figure 8. This images shows correctly created cross-sections of the dental arch. In the upper-left hand corner, the blue line shows the mesiodistal dimension and is projected in the box to the lower-left. The Yellow line in the upper left image shows the faciolingual dimension projected in the upper-right hand corner of the image. Notice how it is perfectly perpendicular to the dental arch. Figure 10. This image shows why a series of slices is important as structures like the maxillary sinus (and IA canal) often slope and thus make the distal and mesial heights of bone much different. It is critical to check completely around the implant, not just at its center slice. One of the most powerful aspects of CBCT imaging is the true-to-size and accurate measurements that can be performed on the cross-sections. However, creating cross-sections is often the step where clinicians make mistakes by creating 4

5 Restorative Considerations The restorative considerations of an implant site are other key factors to assess when conducting CBCT based implant planning. Some restorative considerations can be assessed more easily in 3D as opposed to 2D. Furthermore, they can be enhanced with virtual implants placed into the implant site in the CBCT software. Virtual implant planning and 3D visualizations make it much easier to assess the trajectory of implants towards the opposing occlusions or implant-supported removable or fixed prosthesis. 3 This is essential as excessive implant to crown angulations can cause unfavorable force distributions that lead to failure or fracture of implants, abutments and restorations. The trajectory of implant supported prosthesis cases can be visualized to determine if the implant is within the body of the denture and if it is properly positioned for optimal balance of occlusal forces. The trajectory of the implant through a virtual crown can also help determine if the case is to be performed with a screw-retained or a cementable restoration. (Figure 11) Figure 11. This image shows an virtual implant plan with the trajectory going through the virtual restoration in order to help plan for a screwretained crown. 3D implant and restoration planning capabilities make it simple to address the height and width of space between dental arches and adjacent teeth. This analysis is essential in order to determine if the final restoration will fit properly into the proposed area. 3,7 Also, teeth which have super-erupted into the implant site can limit or even precluded restorative options. Implant sites with very narrow mesiodistal lengths may also limit or prohibit implant placement and/or restoration of the implant itself. (Figure 12) Translating 3D Virtual Planning to the Operatory with Surgical Guides The creation of surgical guides can help improve the accuracy of implant placement based upon the virtual plan. There are many types of surgical guides and they offer a myriad of capabilities. A very important concept when approaching surgical guides is the concept of the Level of Control that surgical guides can offer. The level of control of a surgical guide is the degree to which a surgical guide will facilitate the various steps of an Figure 12. This images shows a case in which vertical collapse has greatly limited the ability to restore any implants placed in the area. This virtual implant and restoration planning make this visualization easy to see, measure, and show the patient as well. implant surgery. 3 This is crucial because these detailed control options must be planned ahead of time and some require using specific surgical guide tools. A large percentage of frustration and complications arise from poor planning, or a lack of the appropriate tools. Several common control options are drill sequence control and drill stop/depth control. The most common levels of control are outlined below. Drill sequence control is one of the most common levels of control requested in comparison to surgical guides that are called pilot guides that only guide the first or pilot drill of the drilling sequence. This is done by embedding a sleeve within the surgical guide whose inner diameter matches the outer diameter of the pilot drill so that it can slide through to the exact location and angulation of the planned osteotomy site. The rest of the drilling sequence is done free hand. However, a surgical guide can also be ordered to have a drill sequence control where every drill in the sequence will go through the surgical guide. This is accomplished with a large master sleeve that is embedded into the surgical guide and then special tools called insert keys, spoons or handles are selectively inserted into the sleeve whose diameter matches the drills of the specific osteotomy sequence. (Figure 13) For example, if the sequence is a 2mm drill, followed by a 2.8mm drill, followed by a 3.2mm drill, then the insert keys will match that sequence. These insert tools can be implant brand specific or can be surgical guide company-specific. Most major surgical guide companies offer universal kits that can be used with many systems and some implant companies offer these tools specifically for their implants to be used with various surgical guides. This is one of the most desired levels of control for surgical guides and it must be ordered ahead of time as the guide will be made specifically with the appropriate insert tools. Thus, if this level of control is desired, the clinician must choose which company s tools the guide should be set-up for and make sure that those tools are available for the surgery. 5

6 Figure 13. This images shows a surgical guide with the insert tool inserted into the master sleeve, which is facilitating a specific drill in the sequence through the guide. Figure 15. This image shows a surgical guide with three anchor pins planned and the CBCT based virtual treatment plan for the cases as well. Depth stop control is another level of control that is often requested. This is accomplished by embedding the sleeves of the surgical guide in such a vertical position as to control the apical depth to which a preselected drill can reach. The surgical guide company must be informed about which drill will be used so that they can set-up the guide in the proper fashion. (Figure 14) Some implant companies have drills with stoppers and surgical guide companies generally have universal drills with physical depth stops and specific lengths. This also needs to be ordered ahead of time as the guide itself will be created with these specific details. Figure 14. This image shows a drill with a depth stopper that is physically hitting the top of the insert thus preventing it from drilling deeper than planned. Lastly, implant guidance control is the ability to place the actual implant through the surgical guide. Currently, the majority of surgical guides and/or implant systems do not allow for this level of control. Most surgical guides facilitate drills through the guide for the osteotomy site preparation, but then the actual implant is placed after removing the surgical guide. Usually, it is necessary to obtain a surgical guide kit that is designed by and for a specific implant company for this capability. When ordering surgical guides, specific scanning protocols are required by the company making the surgical guide. The scanning protocols for each company will vary but the starting point for all of them is to first identify what tissue the guide will be borne upon. For example, will the guide be a tooth borne guide, a mucosa borne guide, a bone borne guide or a combination? The tissue borne option that will be used is the first step which will dictate the rest of the CBCT scanning protocols and imaging requirements. (Figure 16) Following the proper Figure 16. This images shows a sagittal cross-section of a patient wearing a radiopaque duplicate denture during their CBCT scan. This case will be a mucosa borne guide and the radiopaque duplicate denture was part of the scanning protocol. Stability control can be achieved with anchor pins that fasten the guide to the underlying bone and these pins can be planned in 3D ahead of time. The surgical guide will be created to be used with specific anchor pins, either with an implant company s specific pins or with the surgical guide company s pins. These are generally recommended for bone and mucosa borne cases where retention on the arch can be limited. (Figure 15) 6

7 protocol is essential to obtain a surgical guide that is accurate and will fit properly. After determining which tissue borne option is going to be used, the next steps are to decide which level of control is desired and to obtain the necessary surgical guide related tools. Determining the tissue borne option and the level of control that is desired ahead of time will enable clinicians to approach surgical guide case in a systematic fashion and achieve predictable results. Conclusion CBCT imaging provides an amazing level of diagnostic potential, imaging options and surgical guide creation capabilities. These 3D imaging and manufacturing capabilities dramatically increase the ability to diagnose and treat patients effectively. CBCT imaging allows for the implementation of a systematic treatment planning and diagnostic process that incorporates the overall restoration plan and takes the detailed boundary conditions into consideration. If a surgical guide will be created knowing what tissue borne option is needed, what level of control is desired and what tools are necessary achieve desired results, the clinician will be set on the correct path to creating a surgical guide that successfully and predictably preforms. CBCT imaging and 3D implant planning may seem daunting at first when contemplating all the variables, but when broken down into the aforementioned steps and considerations, a foundational approach can be implemented in order to achieve amazing results with CBCT imaging for implant planning. References 1. Hatcher DC et al: Cone beam CT for pre-surgical assessment of implant sites. J Calif Dent Assoc. 31(11):825-33, Benavides E et al: Use of cone beam computed tomography in implant dentistry: the International Congress of Oral Implantologists consensus report. Implant Dent. 21(2):78-86, Friedland B et al: Virtual technologies in dentoalveolar evaluation and surgery. Atlas Oral Maxillofac Surg Clin North Am. 20(1):37-52, Kourtis S et al: Presurgical planning in implant restorations: correct interpretation of cone-beam computed tomography for improved imaging. J Esthet Restor Dent. 24(5):321-32, Tyndall DA et al: Position statement of the American Academy of Oral and Maxillofacial Radiology on selection criteria for the use of radiology in dental implantology with emphasis on cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol. 113(6):817-26, Ganz SD: Cone beam computed tomography-assisted treatment planning concepts. Dent Clin North Am. 55(3):515-36, viii, Hatcher DC: Operational principles for cone-beam computed tomography. J Am Dent Assoc. 141 Suppl 3:3S-6S, Worthington P et al: The role of cone-beam computed tomography in the planning and placement of implants. J Am Dent Assoc. 141 Suppl 3:19S-24S, Curley A et al: Cone beam CT--anatomic assessment and legal issues: the new standards of care. J Calif Dent Assoc. 37(9):653-62, Rosa MB et al: Retrospective study of the anterior loop of the inferior alveolar nerve and the incisive canal using cone beam computed tomography. Int J Oral Maxillofac Implants. 28(2):388-92, 2013 Author Profile Douglas Chenin, DDS is a graduate of the University of the Pacific Arthur A. Dugoni School of Dentistry. Dr. Chenin worked directly with Anatomage for five years as the Director of Clinical Affairs where he helped in the development of the Invivo5 CBCT Imaging software and the Anatomage Surgical Guide system. He also worked in conjunction with BeamReaders Inc for several years directing the implant planning consultations and surgical guide facilitation services. He has earned a reputation of a CBCT technology expert with his extensive participation in study clubs, seminars, conferences, and his numerous professional publications about CBCT imaging for various dental specialities. Dr. Chenin also founded his own CBCT Consulting and education company called Clinically Correct Inc which focuses specifically on teaching CBCT imaging technology. Author Disclosure Douglas Chenin, DDS has no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course. Notes 7

8 INSTANT EXAM CODE Online Completion Use this page to review the questions and answers. Return to and sign in. If you have not previously purchased the program select it from the Online Courses listing and complete the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the Take Exam link, complete all the program questions and submit your answers. An immediate grade report will be provided and upon receiving a passing grade your Verification Form will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page. Questions 1. What is the primary diagnostic limitation of traditional 2D images such as panoramic, bitewing, or periapical x-rays? a. The amount of time it takes to develop the film is too long. b. They do not provide information on the faciolingual dimension of anatomy. c. Traditional 2D images are not always digital. d. Traditional 2D images do not allow for enhanced colorizations like CBCT images. 2. All of the following statements are limitations of traditional 2D images except which statement? a. In panoramic images, there are overlapping structures that make location and boundaries difficult to visualize. b. Depending upon the angle of the x-ray and the position of the patient, distortions and magnifications can occur. c. The image size of the x-ray is not an exact 1:1 ratio to the real size of the anatomy. d. Bitewing images have a high resolution compared to most other dental x-rays. 3. All of the following statements are true regarding CBCT imaging, except which one? a. CBCT images can be acquired without distortion or magnification. b. All three dimensions including the faciolingual are present in CBCT images and this gives clinicians the ability to measure the width of bone. c. CBCT imaging allows for virtual implant planning capabilities. d. Virtual implant plans within CBCT scans cannot be converted into surgical guides. 4. Which of the following xray modalities has an image size to real size ration of 1:1: a. Bitewing b. Panoramic c. CBCT d. Periapical 5. The fine details of anatomy within CBCT scans are best assessed and measured in which view: a. 3D volume renderings. b. 2D cross-sections. c. Panoramic reconstructions. d. None of the above. 6. What is the main reason why it can be hard to see the boundaries of anatomy in panoramic images? a. They are an older imaging modality. b. Panoramic images have overlapping structures c. Panoramic images are inexpensive. d. Panoramic images have a high resolution. 7. Boundary conditions are defined as : a. The anatomical constraints of an implant s proposed location that will influence implant placement. b. How difficult the surgery will be based on the patient s anatomy. c. How difficult the surgery will be based on the patient s attitude. d. All the non-anatomical details about an implant case. 8. Boundary conditions that apply to the maxilla would be all of the following except: a. The location and boundary of the maxillary sinus floor. b. The location of the floor of the nose. c. the location and size of the nasopalatine canal. d. The median lingual canal. 9. Which of the following is a boundary conditions of the maxilla: a. The location and boundary of the maxillary sinus floor b. The median lingual canal. c. The inferior alveolar nerve canal. d. The mental foramen. 10. Boundary conditions that apply to the mandible would be all of the following except: a. the location and full pathway of the inferior alveolar canal and the location of the mental foramen. b. The presence and extent of an anterior loop of the inferior alveolar canal. c. The nasopalatine canal. d. The presence median lingual vascular canal. 11. Which of the following is a boundary condition of the mandible: a. The maxillary sinus. b. The nasopalatine canal. c. The median lingual canal. d. The nasal floor. 12. Boundary conditions that apply to both the maxilla and mandible would be all of the following except: a. The faciolingual width of the alveolar bone. b. The location and size of the inferior alveolar canal. c. The proximity to adjacent implants and/ or teeth. d. The vertical height of bone at the implant site. 13. Boundary conditions can also be: a. The location of opposing occlusion to the implant site in question b. The location of adjacent roots to the implant site in question c. The location of adjacent implants to the implant site in question d. All of the above can be boundary conditions of an implant site in question 14. Cross-sections in the faciolingual dimension of the dental arches are the only cross-sections that allow for the visualization and measurement of: a. The width of alveolar bone. b. The height of the alveolar bone. c. The overall appearance of the alveolar bone. d. Adjacent teeth and/or implants to the proposed implant site. 15. Cross-sections can be created incorrectly resulting in measurement errors when: a. The cross-section is created through the site in a mesiodistal cut parallel to the arch. b. The cross-section is created through the site in a faciolingual cut perpendicular to the arch. c. The cross-section is created in an oblique fashion. d. When the cross-section is zoomed in. 16. An oblique cross-section is created when: a. The cross-section is created through the site in a mesiodistal cut parallel to the arch. b. The cross-section is created through the site in a faciolingual cut perpendicular to the arch. c. The cross-section is created through the site in a faciolingual cut that is not perpendicular to the arch. d. When the cross-section is created with only a single slice instead of a series of them. 17. Why is it considered an imaging pitfall to only perform one crosssection of the implant site at the middle of the location? a. For implant sites near the maxillary sinus, the distal and mesial height of bone can be quite different since the sinus floor often slopes. b. For implant sites above the inferior alveolar canal, the distal and mesial height of bone can be different since the IA canal often slopes. c. There can be a bony defect that is present at the distal or mesial end of bone that the crosssection in the middle does not show. d. All the above statements are correct. 18. Virtual implant planning and 3D visualizations make it much easier to assess: a. The trajectory of implants towards the opposing occlusion. b. The trajectory of implants within the body of the denture. c. The trajectory of the implant through a virtual crown can also help determine if the case is possible to perform with a screw-retrained restoration or if traditional cement is required. d. All the above statements are correct. 8

9 Questions 19. A virtual crown added to the 3D implant plan can help to: a. Determine if the case is possible to restore with a screw-retained restoration b. Determine if the restoration needs traditional cement c. Determine if there is enough height and width for a crown to fit in the proposed restorative site d. All of the above 20. The level of control concept is defined as: a. The degree to which a surgical guide will facilitate the various steps of an implant surgery. b. The degree to which a CBCT scan will facilitate the various steps of an implant surgery. c. The degree to which a CBCT imaging outperforms 2D imaging. d. The degree to which a clinician can control their patients. 21. Frustration and complications arise with surgical guides commonly from: a. Not ordering a guide with the desired level of control or not having the appropriate tools to do so. b. Not having dental team members that can do the virtual planning. c. Not having enough time to treatment plan cases. d. Not having a patient who would appreciate a surgical guide for their surgery. 22. Several of the most common level of control options are a. Drill sequence control b. Drill stop/depth control. c. Stability control with anchor pins. d. All of the above. 23. What surgical guide tools are needed to have drill sequence control? a. Special tools called insert keys, spoons or handles. b. Anchor pins. c. Specific drills with specific depth stoppers or markers on them. d. No extra tools are needed. 24. What surgical guide tools are needed to have depth/stop control? a. Special tools called insert keys, spoons or handles. b. Anchor pins. c. Specific drills with specific depth stoppers or markers on them. d. No extra tools are needed. 25. What surgical guide tools are needed to have extra stability as a level of control? a. Special tools called insert keys, spoons or handles. b. Anchor pins. c. Drills with specific depth stoppers on them. d. No extra tools are needed. 26. Implant guidance control is defined as: a. The ability to place the actual implant through the surgical guide. b. The ability to control the everything but the implant angulation. c. The ability to have the drill stop at the correct depth. d. There is no such thing as implant guidance control. Notes 27. Who should be consulted with to make sure that the tools you have will work for the surgical guide that you are ordering? a. The surgical guide company. b. The implant company. c. A dental laboratory. d. The CBCT machine company. 28. What is the most important element about a surgical guide that will dictate the CBCT scanning protocols for the case? a. What level of control that is desired. b. Which tissue the guide will be borne upon. c. How much the guide costs. d. How soon the guide is needed for surgery. 29. All of the following are tissue borne options that surgical guides can be borne upon: a. Teeth b. Mucosa c. Bone d. All of the above 30. To obtain a surgical guide that is accurate and will fit properly, it is essential to: a. Following the proper protocols from the surgical guide company. b. Make sure to bill the patient for the cost of the surgical guide. c. Make sure to order the surgical guide with enough time for production and delivery. d. Have dental team members plan the case for you. 9

10 INSTANT EXAM CODE ANSWER SHEET Foundations of CBCT Imaging for Implant Planning and Surgical Guides Name: Title: Specialty: Address: City: State: ZIP: Country: Telephone: Home ( ) Office ( ) Lic. Renewal Date: AGD Member ID: Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 3 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call Educational Objectives 1. Conceptualize how CBCT imaging enhances the diagnostic potential and accuracy of implant planning beyond traditional 2D images. 2. Assess and visualize patient CBCT data properly in 3D and 2D cross-sections for virtual implant planning and to summarize which anatomical structures are critical to examine. 3. Discuss the terminology, capabilities, and tools needed for the various levels of control that surgical guides offer. Course Evaluation 1. Were the individual course objectives met? Objective #1: Yes No Objective #2: Yes No Objective #3: Yes No Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = To what extent were the course objectives accomplished overall? Please rate your personal mastery of the course objectives How would you rate the objectives and educational methods? How do you rate the author s grasp of the topic? Please rate the instructor s effectiveness Was the overall administration of the course effective? Please rate the usefulness and clinical applicability of this course Please rate the usefulness of the supplemental webliography Do you feel that the references were adequate? Yes No 11. Would you participate in a similar program on a different topic? Yes No 12. If any of the continuing education questions were unclear or ambiguous, please list them. 13. Was there any subject matter you found confusing? Please describe. 14. How long did it take you to complete this course? 15. What additional continuing dental education topics would you like to see? COURSE EVALUATION and PARTICIPANT FEEDBACK We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included with the course. Please all questions to: hhodges@pennwell.com. INSTRUCTIONS All questions should have only one answer. Grading of this examination is done manually. Participants will receive confirmation of passing by receipt of a verification form. Verification of Participation forms will be mailed within two weeks after taking an examination. COURSE CREDITS/COST All participants scoring at least 70% on the examination will receive a verification form verifying 3 CE credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/ Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. PennWell is a California Provider. The California Provider number is The cost for courses ranges from $20.00 to $ Customer Service PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS. PROVIDER INFORMATION PennWell is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, not does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE Provider may be directed to the provider or to ADA CERP ar org/cotocerp/ The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from (11/1/2015) to (10/31/2019) Provider ID# If not taking online, mail completed answer sheet to PennWell Corp. Attn: Dental Division, 1421 S. Sheridan Rd., Tulsa, OK, or fax to: For IMMEDIATE results, go to to take tests online. INSTANT EXAM CODE Answer sheets can be faxed with credit card payment to Payment of $59.00 is enclosed. (Checks and credit cards are accepted.) If paying by credit card, please complete the following: MC Visa AmEx Discover Acct. Number: Exp. Date: Charges on your statement will show up as PennWell AGD Code 731 RECORD KEEPING PennWell maintains records of your successful completion of any exam for a minimum of six years. Please contact our offices for a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within five business days of receipt. Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. CANCELLATION/REFUND POLICY Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. IMAGE AUTHENTICITY The images provided and included in this course have not been altered by the Academy of Dental Therapeutics and Stomatology, a division of PennWell CBCT0317DIG