Artifacts / / Read Article

CBCT: Guiding Clinicians to Informed Decisions with PERRY E. JONES, DDS, MAGD, IADFE

Categories:

Author(s):

Date: 09-21-2020 08:06:32 am



Q: How has CBCT changed your practice?
A: CBCT can be compared to a Swiss army knife in that it is a multipurpose tool. Using CBCT, I’m able to collect general diagnostic data, evaluate implant sites, plan implant surgeries, fabricate surgical guides, generate radiology reports, evaluate sites for endodontic treatment, diagnose TMD, evaluate and make critical measurements related to airway and sleep studies, and evaluate patients for orthodontic treatment. The accuracy, quality, and versatility of CBCT has allowed me to provide a higher level of care to my patients. To put it simply, CBCT provides me with better data. The end result is informed clinical decision-making.

Q: What is a good example of a case where CBCT saved the day?
A: I have a specific case where I was planning an implant surgery for a patient, and was in the process of designing a surgical guide using CBCT and intraoral scan data. While virtually planning the case, I found a periapical lesion at the root of an adjacent tooth. If I had placed the implant without knowledge of this lesion, the implant would have certainly failed. The ability to evaluate bone accurately using CBCT allowed me to treat the tooth in question before the implant was placed. Without CBCT, this surgery would not have been successful.

Q: Can you tell us about the study you conducted?
A: I did a study of 100 CBCT scans taken for “routine” diagnosis, and I compared them to commonly used 2D panoramic images. Out of the 100 cases, 36 presented with pathology that was not identified using conventional 2D imaging. So, we missed diagnostic data about one-third of the time! That finding has been repeated in the dental and medical literature in multiple studies. And that is because, in 2D, we see 2 dimensions: height and width. With 3D data, we see all 3 dimensions: height, width, and depth.

Q: What does having CBCT in your practice do for ROI?
A: CBCT drives income into my office daily. Every periapical lesion I find using CBCT data results in endodontic treatment followed by crown placement. CBCT is also an integral part of my implant service. I use CBCT data to plan implant placement and fabricate surgical guides. CBCT allows doctors to plan implant restorations prior to placement. This cuts down on unnecessary costs and adjustments related to improperly placed implants. CBCT has many uses that allow practices to better serve their patients.
Article 37 of 39

Online Continuing Education / Course Details

ADA Credits: 2 | AGD Credits: 2 | Cost: $29.00

2D vs 3D Imaging in Endodontics: CBCT Application in Modern Endodontic Treatment

Categories:

Author(s):

Course Type: Self-instruction journal and web based activity

Target Audience: Dental Assistants, Dental Hygienist, Dentists from novice to advanced

Educational Objectives

After completing this course, the reader should be able to:

1. Discuss the American Association of Endodontists and American Academy of Oral and Maxillofacial Radiology joint position statement on the use of CBCT in endodontics.

2. Explain how to use CBCT 3D imaging to evaluate unusual or complex anatomy of root canal systems, calci­ ed canals, and periapical pathosis.

3. Describe how to assess sinusitis of endodontic origin using CBCT imaging.

4. List other documented advantages of the routine use of CBCT in endodontics.

5. Discuss the impact of 3D imaging in decision-making in endodontics.


Download this course PDF

________________________

Abstract

The use of cone beam computed tomography (CBCT) in endodontics has expanded in recent years. 3D imaging adequately supports the interpretation of dental anatomy and surrounding areas during root canal therapy. To assist decision making in endodontic cases, experts recommend small field-of-view (FOV), high-resolution CBCT imaging for diagnostic and treatment planning as well as for intraoperative procedures and managing cases post-treatment. This article presents some examples of everyday clinical cases to illustrate how CBCT images can help diagnose, treat, and solve endodontic problems.

ADA Credits: 2 | AGD Credits: 2 | Cost: $29.00

Course 113 of 124

Online Continuing Education / Course Details

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

The Power of Chairside Milling: An Overview of Scanning, Designing and Milling for Single Visit Restorations

Categories:

Author(s):

Course Type: Self-instruction journal and web based activity

Target Audience: Dental Assistants, Dental Hygienist, Dentists from novice to advanced

View Video

Educational Objectives

After completing this webinar, participants will be able to:
-Learn the advantages of intraoral scanning how digital impression workflows differ from traditional impression-taking methods
-Examine the importance of capturing a clear and accurate digital impression that fully captures the patient’s dentition
-Review the clinical implications of digital impressions and how they can be used to facilitate single-visit restorations
-Explore the chairside milling workflow as a completely digital CAD/CAM solution
-Gain an understanding of the adhesive ceramic materials available for chairside milling
-Study the benefits of using 3D printing technology to fabricate surgical guides

Abstract

Take a deep dive into the clinical workflows of digital impressions. Explore milling, conservative ceramics, digital smile design and 3D printed surgical guides. Participants will understand the how to leverage a completely digital CAD/CAM solution for greater efficiency, increased quality control and exceptional restorative outcomes.

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

Course 100 of 124

Online Continuing Education / Course Details

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

The Power of 3D Imaging: Transitioning from 2D to 3D in Private Practice

Categories:

Author(s):

Course Type: Self-instruction journal and web based activity

Target Audience: Dental Assistants, Dental Hygienist, Dentists from novice to advanced

View Video

Educational Objectives

Learning Objectives
After completing this webinar, participants will:
»     Learn how 3D Imaging leads to faster, more accurate diagnosis.

»     Understand how 3D Imaging simultaneously expands your knowledge, increases the enthusiasm of your team, and adds to the scope of procedures you can provide. 

»     Understand how 2D/3D imaging will immediately bring new revenue into your office 

»     Recognize the multiple avenues to ROI when investing in 3D Imaging.

Abstract

Making the transition from 2D to 3D is like stepping into a whole new world. In this webinar, Dr. Daron Clark will illustrate the differences in workflow and diagnostic protocols offices experience when implementing CBCT technology. He’ll also shed light on some strategies he used to prepare himself and his staff for working with CBCT images, the training necessary to harness the full potential of CBCT and how to leverage it for practice growth.

Supported through an unrestricted educational grant from Planmeca

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

Course 97 of 124

Artifacts / / Read Article

CASE PRESENTATION: Stabilizing a Maxillary Denture With Narrow-Diameter Overdenture Implants

Categories:

Author(s):

Date: 05-13-2020 08:00:19 am


A healthy 75-year-old female presented with a loose maxillary complete denture and the desire to place implants to assist the denture to remain in place. Approximately 20 years ago, she had implants placed on her mandibular arch and an implant overdenture fabricated. She was always told, however, that her bone was insufficient in her maxillary arch for implants. She was referred to the author’s practice for evaluation for narrow-diameter implant placement.

A CBCT scan of the patient was made using cotton rolls for occlusal and soft-tissue separation in combination with a radiopaque PVS impression liner placed on the intaglio of her maxillary denture to enhance the radiographic visualization. A second CBCT scan of the denture was made and an extraoral digital impression was used with an intraoral scanner (3M True Definition Scanner, 3M). Six 2.4 mm x 12 mm Zest LOCATOR Overdenture Implants (LODI, Zest Dental Solutions) were planned in the computer software (Invivo, Anatomage). A computerized surgical guide was planned and fabricated (Anatomage Guide, Anatomage).

The patient was anesthetized, complete adaptation of the surgical guide confirmed, osteotomies prepared, and implants were placed using a minimally invasive technique. Recesses in the denture were prepared using specialized burs specifically designed for overdentures (Denture Prep & Polish Kit, Zest Dental Solutions). LOCATOR abutments (Zest Dental Solutions) were attached to the implants and connected the denture the same day using an overdenture attachment material (CHAIRSIDE, Zest Dental Solutions). The LOCATOR Black Processing Male inserts were kept inside the denture, and the patient was seen for recall 8 weeks later, when the tissues were fully healed. At the recall appointment, the inserts were changed from the processing males to the light, standard-range retentive male inserts. The patient was followed up over the course of several years and has continued to report a high degree of satisfaction.

Figure 1
Fig 2- 10
Article 20 of 39

Artifacts / / View Webinar

The Power of 3D Imaging: Transitioning from 2D to 3D in Private Practice

Categories:

Target Audience: Dental Assistants, Dental Hygienist, Dentists

Duration: 1 hour 9 minutes

Synopsis

Making the transition from 2D to 3D is like stepping into a whole new world. In this webinar, Dr. Daron Clark will illustrate the differences in workflow and diagnostic protocols offices experience when implementing CBCT technology. He’ll also shed light on some strategies he used to prepare himself and his staff for working with CBCT images, the training necessary to harness the full potential of CBCT and how to leverage it for practice growth.


 

Dr. Daron Clark received his Bachelor of Science degree in biology from Mississippi College. He went to receive his DMD from University of Mississippi Medical Center, School of Dentistry in 2007. He is a member of the American Dental Association, the Tennessee Dental Association, the American Academy of Cosmetic Dentistry, and the Academy of Laser Dentistry. His passion for continuing his education and. His continual search for more advanced dental technologies has led him to progressive training in laser dentistry and an associate fellowship with the World Clinical Laser Institute

Webinars 7 of 8

Online Continuing Education / Course Details

ADA Credits: 2 | AGD Credits: 2 | Cost: $29.00

Impacted Canines: Etiology, Diagnosis, and Management

Categories:

Author(s):

Course Type: Self-instruction journal and web based activity

Target Audience: Dental Assistants, Dental Hygienist, Dentists from novice to advanced

Educational Objectives

The overall goal of this article is to provide the reader with information on impacted canines. After completing this article, the reader will be able to:

1. Describe the radiographic investigations that may be required to assess impacted canines
2. List etiological factors for impacted canines
3. Review the rationale for interceptive orthodontics and methods used in intercepting impacted canines
4. List and describe treatment options and considerations involved in the treatment of impacted canines.

Download this course PDF
_________________________________________

Abstract

Impacted canines are frequently encountered in clinical practice and a common obstacle during routine orthodontic care. While canine impaction is multifactorial, the exact etiology is not always known. Impacted canines should be identified and diagnosed as early as possible to determine and permit the best path of treatment. In some cases, interceptive orthodontics at a young age can resolve canine impaction; for example, by extracting the primary canine and/or the primary first molar. Treatment options for impacted canines include extraction of primary canines and molars, rapid maxillary expansion, canine substitution, autotransplantation, surgical exposure, and orthodontic extrusion, and for those with a poor prognosis, extraction.

ADA Credits: 2 | AGD Credits: 2 | Cost: $29.00

Course 45 of 124

Artifacts / , / Read Article

Proper Clean-up: Removing Excess/Residual Resin-based Dental Cement

Categories: ,

Author(s):

Date: 08-03-2017 03:39:33 am

The primary functions of dental cements are to enhance resistance to displacement and to seal the interface of the restoration to the remaining tooth structure. Available options include but are not limited to composite resin cements and resin modified glass ionomers. Proper selection of dental cements is a key factor that increases the success of restorations. Several factors determine which type of dental cement, restorative material, and restoration a clinician chooses, including the ability to maintain a dry field, esthetic demands, tooth structure, the location of margins and chewing forces.

Resin cements were introduced in the 1970s as an alternative to acid-based reaction cements such as zinc phosphate. These cements vary in their setting mechanisms, which consists of polymerization either by chemical curing, dual curing, or light curing. Resin cements offer good adhesion (and therefore retention) as well as low solubility once set and good compressive strength. They are, however, technique-sensitive, require careful clean-up, and excess cement is generally difficult to remove once set.

Resin-modified glass ionomer cements contain resin filler particles consisting of polymerized functional methacrylate monomers. These monomers modify glass ionomer cements which consist of powder containing fluoroaluminosilicate with a liquid that is composed of polyacrylic acid and tartaric acid. When mixed, the polyacrylic acid reacts with particles and releases aluminum, calcium, and fluoride ions. Resin modified glass ionomers offer improved adhesion, strength, and low solubility. In addition, they are easier to manipulate than glass ionomer cement. The working time is affected by temperature: high temperatures shorten the working time while low temperatures prolong it.

Proper use and clean-up of dental cement

Proper use and clean-up of dental cements ensures the success of restorations and aids in preventing postoperative complications associated with residual cement. Effective removal of excess cement is important in the prevention of gingival bleeding, soft-tissue inflammation, crestal bone loss, and peri-implant disease. The presence of dental cement is a direct result of poor clean-up and use, as well as lack of assessment of residue after cementation. Residual cement can be extremely difficult to remove from subgingival areas, making proper handling at the time of cementation crucial. To reduce the possibility of problems caused by the use of dental cements, several aspects need to be considered.

Appropriate amount of cement and placement

Proper preparation and resistance form help avoid overuse of cement. A thin layer of cement, which for crowns amounts to about 3% of the volume of the crown, should be all that is required (Fig. 1). Application of the cement near but not on restoration margins helps prevent excess cement from building up. When the crown is seated, the cement will flow toward the occlusal table of the preparation and then move to the preparation margins where the excess cement is then readily extruded. Another approach is the placement of a cement vent that helps to minimize hydraulic pressure that could otherwise push the cement subgingivally. Retraction cord also can aid in easy clean-up of excess cement.

1

Using silicone as a “cementation device” also has been described in the literature. Silicone is first injected into the crown to create an analog. Cement is then placed in the restoration, first seated over the analog to displace most of the excess, and then removed and seated over the preparation. Care must be taken if using this technique to work quickly to avoid the onset of initial setting before the restoration is fully seated over the preparation.

Working and setting times

Working times and setting (or curing) times are important to understand when handling a cement:

  • The working time is the time available for the manipulation of unset cement
  • The setting time refers to the time that is required for the cement to set or harden from its plastic or fluid stage to a rigid one.

The working and setting times are different for each cement manufacturer, it critical to read the instructions. Long-term success is heavily dependent not only on appropriate selection but also on proper handling and use of dental cements. It is extremely important that all excess cement be removed. This requires a careful technique and an understanding of when during the setting reaction excess cement may be initially removed. Various approaches can be taken to remove excess cement and minimize the risk of residual cement.

Excess cement removal at the restorative margins

Clean-up of resin-modified glass ionomer and glass ionomer cements is easy, as the excess cement can be removed with a plastic instrument or scaler while in the waxy stage. With a dual cure composite resin–based cement, in the case of ceramic restorations that transmit light, using a curing light for 1 to 2 seconds tack cures the cement, making it possible to peel away the excess with an anterior or posterior scaler while the cement is still waxy/ rubber (Fig. 2), and then following this up by using an explorer.

2

For cementation of opaque metal and zirconia based restorations, however, there is a risk with removing excess dual-cured cement using the tack curing method as the excess cement at the margin will be cured, but not the cement under the restoration since light cannot penetrate through the opaque restoration. Mechanical forces involved during cleanup can weaken or cause failure of the bond if the cement is not sufficiently cured. Therefore, it is recommended for these restorations that the cement be self-cured to reach the gel phase at which point excess can then be conveniently and safely removed.

Timing is important - if cleanup begins before cement reaches a gel state then premature failure of the restoration can occur, and conversely if cleanup is late the cement will already have set making removal of excess cement difficult without rotary instrumentation. For optimal cleanup results, it is important to check the excess cement closely to determine when it reaches the gel phase during which excess cement can be safely and efficiently removed. It is also important to follow the directions for use which should indicate when the gel phase will commence.

Floss also can be used at this stage to remove excess cement, as well as afterwards to remove loose excess in the gingival sulcus, help remove adhered excess, and to check that no residual cement remains. Methods for removing residual cement, beyond the use of floss and scalers for hard set cement, include cleaning with a water and pumice paste and prophylaxis cup, and using an intraoral sand blaster. Of all three, the sand blaster has been the most effective and manual removal the least effective. All surfaces of the tooth should be cleaned, especially the margins.

Removal of residual dental cement around implants

Floss is also used around implant restorations to detect and help remove residual cement. After inserting the floss on both sides of the implant, it is wrapped in a circle and crisscrossed and then moved in a shoeshine motion in the peri-implant crevice. Great care should be taken during removal of residual cement to minimize trauma to the peri-implant tissues, and to avoid roughening the neck of the implant (if exposed) and implant complex– restorative interface (Figs. 3, 4). Titanium implant scalers can be used to debride the area and dislodge excess cement. These are preferred over graphite and plastic scalers that may leave traces of graphite or plastic embedded in the rough surfaces of implants, which may increase the risk of peri-implantitis. Titanium implant scalers are strong enough to remove hard cements, yet have a low Rockwell hardness to avoid scratching implant surfaces.

34

Clinical and radiographic visualization

Good visualization and moisture control is essential when placing indirect restorations. Good visualization also aids with removal of excess cement. Proper visualization can only be achieved through the use of magnification. Loupes are invaluable in providing this for dentists, dental hygienists, and assistants. Using a dental mirror defogging solution also helps, and systems such as the Isolite system allow for improved visualization with an intraoral light incorporated into the device, in addition to providing for isolation.

There are various method for identifying excess cement. A common method is to use dental tape floss; if the floss is roughened or frayed after being used around the indirect restoration, this can be indicative of residual cement. (Note, however, that adjacent overhangs and calculus also can result in frayed or roughened floss.) It is important to use a radiograph to check for residual cement. It is therefore important to select a cement with radiopaque properties so that it can be detected radiographically. In some cases, the removal of excess cement may require use of a local or topical anesthetic so that the cement can be effectively removed.

Surgical removal of old residual cement is only recommended if nonsurgical removal is unsuccessful. This involves flap surgery to help identify, access and remove residual cement that is located 3 mm to 5 mm subgingivally. While it may be successful, it is invasive and traumatic and represents a failure at the time of treatment planning and restoration.

Conclusion

The risk of residual cement can be avoided and minimized by understanding the properties of different cements, through proper selection and handling. Practitioners should be aware of the point at which excess cement may easily be removed for a given cement, and a thorough check should be made to identify any residual cement and remove it before the patient leaves the office. By using modern technology and tools available in dentistry, it is possible to eliminate the threat posed by residual cement.

References

Bonsor SJ, Pearson GJ. A clinical guide to applied dental materials. 2013. Amsterdam: Elsevier/Churchill Livingstone.

Carson J. The pros and cons of bonding or cement restoration. Available at: http://www.speareducation.com/ spear-review/tag/cementation/ Accessed 15 October, 2014.

Chun Z, White S. Mechanical properties of dental luting cements. Journal of Prosthetic Dentistry. 1999;81(5): 597–609.

Farah J Powers J. Resin Cements. The Dental Advisor. 2003.

Leevailoj C, Platt JA, Cochran MA, Moore BK. In vitro study of fracture incidence and compressive fracture load of all-ceramic crowns cemented with resin-modified glass ionomer and other luting agents. Journal of Prosthetic Dentistry. 1998;80(6):699-707.

Lohbauer U. Dental Glass Ionomer Cements as Permanent Filling Materials: Properties, Limitations and Future Trends. Materials. 2012;3:76-96.

Lowe R.A. Dental cements: an Overview. International Dentistry. 2011;2(2):6-17.

Pameijer CH. A Review of Luting Agents. International Journal of Dentistry. 2012;10:1-7.

Ramaraju SD, Krishna SA, Ramaraju VA, Raju M. A Review of Conventional and Contemporary Luting Agents Used in Dentistry. American Journal of Materials Science and Engineering. 2014; 2(3):28-35.

Wingrove S. Peri-implant therapy for the dental hygienist: Clinical guide to maintenance and disease complications. 2013. Ames, Iowa: Wiley-Blackwell.

Yu H, Zheng M, Cheng H. Proper selection of contemporary dental cements. Oral Health Dental Management. 2014;13(1):54-49. 

Article 2 of 39