Cone beam computed tomography (CBCT)

scanners have been available to dentists for

about a decade now. This imaging modality
has revolutionised the ability of dentists to
see the third dimension, to gain information
such as bucco-lingual bone width, unsuspected
extra root canals, presence or absence of root
resorption, spatial relationship between lower
molar roots and ID canal, etc., all of which have
ao |ooeoce oo t|e teateot t|at a oat|eot
oeeos, bot .||c| |ave beeo o|co|t to assess
using conventional dental X-ray equipment.
Cone Beam Technology
Cone beam technology itself has been in use
for a long time, principally in radiotherapy.
Dental use is a fairly recent development. The
shape of the X-ray beam is cone-shaped, as
the name suggests, where the apex of the cone
beam emanates from the X-ray tube while the
open end of the cone beam points towards
the patient.To generate a 3-dimensional image,
the X-ray beam revolves around the patient.
It makes a single 360 revolution in less than
a minute. After passing through the patient,
the X-rays are captured by an image receptor,
which converts the X-ray energy into digital
information that can be processed and become
a series of axial images or dataset. From these,
other images can be reconstructed, such as
coronal and panoramic-like views.
The Kodak 9000 3D is able to take small
sectional scans (5cm by 3.8cm) allowing
|o|a| e|o o v|e. aoo eooceo eect|ve
radiation for the patient. This also reduces the
e|o t|at oeeos to be eooteo.
The Dental Implant Clinic
The Dental Implant Clinic welcomes
referrals from general dental
practitioners who wish to use the
advantages of CBCT to allow
effective diagnosis and treatment
planning. The images will be
saved onto a CD and sent to
the referrer (with the report if
requested). The software needed
to view and manipulate the
images is pre-loaded on the CD to
allow viewing.
Cone beam CT
By Tim Harris and Suk Ng
Fig 1b CBCT view
of the upper right
central incisor showing
WMKRMGERX VSSX VIWSVTXMSR
(bottom right screen).
Clinical Evaluation
CBCT images, as with all dental X-ray images,
have to be clinically evaluated and a written
eoot 'eot |o t|e oat|eot's |es. T|e |atest
guidelines from the Health Protection Agency
(HPA) is that a dentist who has gained additional
appropriate training is allowed to report on
CBCT images of the dentoalveolar region.
Areas outside of the dentoalveolar region
should be reported by a dental maxillofacial
radiologist, or a medical head and neck
radiologist. Dr Suk Ng, a Consultant Radiologist,
has recently joined the team at the Dental
Implant Clinic and is able to offer fast and
ec|eot eoot|o sev|ces o ao scao ta'eo.
Fig 1a. Periapical radiograph of
suspected root resorption on upper
right central incisor.
Common dental uses of CBCT:
U Endodontics
U Implant planning
U Periodontics
U Oral surgery
Unlike many other
CBCT machines the
Kodak 9000 3D allows small
Field of view scans that
reduces the patient dose
and the area that needs
to be reported
No Impressions!
Optical scanning in the
mouth for crowns, veneers
and implants.
&].SREXLSR7GLSIPH
The ability to optically scan an
implant in the mouth can offer
several advantages: There are
inherent inaccuracies associated
with taking impressions. The potential
inaccuracies include: tray distortion, tray
at|oo, |oess|oo ate|a| o|stot|oo
and casting inaccuracies. Furthermore,
a clinician may not be able to detect that
an impression has a defect on it. The defect
may only be detected in the laboratory when
the model has been cast. Inta-oral scanning software
can tell the clinician whether a scan is useable, and if not,
additional scanning can be performed before the patient has
left the dentists surgery.
The iTero
TM
digital impression system came onto the market in 2007. The
iTero
TM
system uses parallel confocal imaging to capture the digital impression. Parallel confocal
imaging uses laser and optical scanning to digitally capture the surface and contours of the tooth,
implant scanning body and gum structure. There is no need to coat the tooth.
The electronic laboratory script is completed on-screen with the patients information, delivery
date, restoration type, material choice, shade requirements, and any other information particular
to the case. When these scans are complete, the patient is asked to close into centric occlusion
and a virtual registration is scanned. Complete upper and lower quadrant scans and virtual bite
registration can be taken in less than 3 minutes, which is less than conventional impressions and
bite registration.
The completed digital impression is sent digitally to the iTero
TM
facility and the dental laboratory.
|ooo ev|e. b t|e |aboato, t|e o||ta| |e |s ootoot to a ooe| b |Teo
TM
. The model is milled
from a proprietary blended resin and is pinned, trimmed, and articulated based on the digital
impression created by the clinician.
\e |ave coo|eteo 20 coosecot|ve co.o scaoo|os aoo |o eve case t|e t aoo occ|os|oo |as
been excellent!
\|ote 20++
Meet our team
Our dedicated implant team are here to
help you receive the best possible service.
The milled model produced digitally Completed crown on model... And in the mouth - no adjustments!
Here
you can see
an example of a
digital impression
taken for an
implant.
.SREXLSR7GLSIPH
BDS DPDS MFGDP UK
Chris Lambert-Rose
BSc BDS DPDS MFGDP UK
8SR]-VIPERH
PhD MSc BDS FDS D Orth MOrth
RCS (Eng) Specialist Orthodontist
Timothy Harris
BDS MFDS RCS (Eng)
Chong Lim
BDS MSc Specialist Periodontist
Training at
The Dental
Implant Clinic
The Dental Implant Clinic offers
teaching to other dentists on many
aspects of dental implantology.
The Clinic houses a custom-built
lecture theatre with live video and
audio links to the operating theatre.
In addition to many other courses for
dental professionals, we offer a Live
Skills course, in which dentists get
to place an implant in a pre-selected
patient provided by the The Dental
Implant Clinic under the supervision of
a full-time implantologist.
The Dental Implant Clinic has
also recently been selected as the
practical teaching centre for the
new Bristol University MSc in Dental
Implantology. All of the dentists on
the MSc will receive their practical
training at The Dental Implant Clinic
o | ooat|oo Sc|oe|o aoo t|e
team. See the University website
for more information on the MSc
(www.bristol.ac.uk/dental) and how
to register.
We also host the meetings of SWATS,
the South West Hygienists and
Therapists Society. See the SWATS
website for more information
(www.swhats.com).
/ o|| 20+2 ooae .||| be
announced soon - contact The
Dental Implant Clinic for more details.
Te|eo|ooe. 0+22S ++8+00 o ea||
info@thedentalimplantclinic.com
Dr Suk Ng
PhD BDS BSc FDSRCS (Eng)
DDRRCR Specialist in Oral
and Maxillofacial Radiology
(V2MGO],IRHIVWSR
BDS MSc FDSRCS MOrth
Specialist Orthodontist
The Dental Implant Clinic
2+ |e.b|oe |oao
Bath
3/+ 3Z
Te|eo|ooe. 0+22S ++8+00
www.thedentalimplantclinic.com
info@thedentalimplantclinic.com
Fig 2 CBCT image with
barium teeth on a
diagnostic wax denture
in place to allow implant
planning with restorative
driven implant
positioning.
A warm welcome to Esther
Nenzou, who joins the team as
our new Implant Co-ordinator
When more tenting effect is desired, the use of
an autogenous bone block, e.g. chin or ramus graft,
is ideal. However the need for a second surgical
site (to harvest the bone block) can sometimes
be avoided by using a non-resorbable and stiff
ebaoe. |ao|e + s|o.s a |ae cst|c osseoos
defect before and after the use of Cytoplast, an
e-PTFE membrane and BoneCeramic.
The CBCT below illustrates the increased bulbosity
on the buccal aspect of an implant that received
simultaneous GBR.
Regeneration revisted
S|oce t|e st c||o|ca| oeoostat|oo o se|ect|ve
tissue regeneration using a partially permeable
membrane, Guided Tissue Regeneration (GTR)
around teeth, and Guided Bone Regeneration
(GBR) have been widely studied and applied in
periodontal and implant dentistry.
However, the high rate of complications associated
with synthetic non-resorbable membranes has led to
the increased use of resorbable collagen membranes.
Co st c||o|ca| case s|o.s soccesso| CT| aoo
cooves|oo o a oes|steot |oaeo oe|oooota|
ooc'et oo t|e o|sta| o #3 o ` to +.
BioGuide, a porcine collagen membrane and
BoneCeramic, a Tricalcium Phosphate/Hydroxyapatite
synthetic bonegraft material was used.
1. Pre op
|o|o |o|aot o|aceeot, |ac' o soc|eot booe
width can often be corrected by the simultaneous
aoo||cat|oo o C3| o|oc|o|es. \|ee soc|eot
support, example 2, is available for the tenting
effect of a membrane and bone graft material e.g.
BioGuide/BioOss, successful regeneration is possible.
When sinus augmentation via a lateral approach is
needed, the use of a resorbable membrane to line the
displaced sinus lining may protect against iatrogenic
membrane tears. A greater level of bone regeneration
has also been reported with this approach.
Effective use of BioOss, rather than large amounts
of autogenous bone in such procedures, also
eooces oat|eot ob|o|t. T||s |s cooeo b
numerous clinical trials and consensus reports.
A histological sample from a typical case carried
out at the DIC illustrates the formation of new
vital bone, with proliferation of new bone cells,
extracellular matrix and nutrient blood vessels.
An additional tenting screw was used with the
Cytoblast and BoneCeramic combination, in
example 5, which shows a buccal defect with
successful bone regeneration, after arduous
debridement of the amalgam contaminated
osseous bed.
In the atrophic upper posterior maxillae,
|osoc|eot vet|ca| booe o t|e o|aceeot o
dental implants is commonly found.The internal
crestal elevation of the Schnederian membrane,
the so called Summers Lift, is an established
technique for vertical bone augmentation.
Example 6 shows a staged approach and in
example 7, a simultaneous approach. Both
cases utilise the synthetic bonegraft material
BoneCeramic.
Occasionally, clinical situations can also arise where
sinus bone grafting and GBR procedures are
required simultaneously.
We are fortunate that a wide range of materials
and surgical techniques have been demonstrated
to be effective and are available for regenerative
procedures. The appropriate choice and
application of such materials is often affected by
the integrity of the overlying soft tissues. We look
forward to covering this topic in our next newsletter.
For fellow colleagues who are interested in the
practical aspects of implant and regenerative
surgery, we would like to welcome you to our
hands-on training courses.
6 months later
Example 2
4. Pre op 4. Post op
5. Pre op 5. Post op
6. Pre op 6. Post op
7. Pre op 7. Post op
Example 7
By Dr Chong Lim
Step 1
You refer a patient
D
Post removal in practice By Chris Lambert-Rose
The use of post systems to retain and support
restorations is widely used in dental practice.
Post systems can be divided into two basic
groups; passive posts or threaded posts.
Whilst posts of all forms are a useful tool, by
their nature they can weaken teeth and are
associated with a high number of restorative
failures. Failure of a post retained restoration
can also be associated with endodontic failures.
/o eoooooot|c |es|oo oooe a oost |s o|co|t to
access, o coos|oeeo to be o|co|t to access,
and often extraction or apicectomy is seen as
the only option for treatment.
Because of the long term survival rates and
oece|veo o|co|t |o teat|o teet| .|t| actoeo
posts, many such teeth are readily condemned. At
the Dental Implant Clinic we receive a number of
such referrals for extraction and replacement with
an implant supported restoration.
However, with the right equipment and technique,
many of these condemned teeth can be saved.
Whilst they may not last a lifetime, an extension
to the useful life of a tooth can be achieved. This
may be a favourable alternative for patients for
whom implant treatment is an expensive option,
or where extraction of the tooth creates issues
with the gingival aesthetics, particularly in patients
with a high lip line.
Therefore, before condemning teeth with
fractured or failing post supported restorations,
consideration should be given as to whether
it is possible and appropriate to attempt
to remove the post. If necessary, refer to a
colleague experienced in endodontics and post
removal for a second opinion. Retaining the
tooth, rather than extracting it, may keep the
tooth in function, preserve bone until it is more
appropriate to place an implant, and avoid
potential complications with gingival aesthetics.
Restore your own implants...
Step 2
We diagnose, plan and place the implants
D
Step 3
We teach you how to restore and lend you the tools
D
Step 4
You restore the implant
Watch live
surgery...
If you refer a patient to us you
are always welcome to come and
observe their treatment.