Dental Tribune Asia Pacific Edition No.5, 2017

trends & applications Fig. 9 Fig. 10 Fig. 12 Fig. 13 Fig. 11 Fig. 14 Fig. 15 Fig. 16 Dental) in order to fabricate a clear acrylic radiographic guide (Figs. 1 & 2). A 3-D scan was obtained using the X-Mind trium CBCT scanner to be utilised in the treatment plan- ning of the case, and we found it to be an invaluable resource. Through the scan, the type and position of the implants in relation to the den- sity of the surrounding bone were checked. The ACTEON Imaging Suite software that comes with the device includes a library of the most current implants on the mar- ket, allowing placement of the right implant with the right angulation, plus abutments and crowns, in or- der to maximise the predictability of positioning the implants, thus improving the treatment success. For clinicians who use more than one implant system, in order to change the implant model that was inserted from the library, one sim- ply clicks in the middle of the im- plant and the implant library is opened again, allowing the selec- tion of another implant model. The software will retain the same inser- tion point and direction of the pre- vious one. In addition, the software evalu- ates the bone density around the implant. The aim is to show, both through colour maps and numeri- cally (Figs. 3 & 4), the values before commencing surgery (green if the with an implant-supported crown. In planning the case, a CBCT scan was obtained to serve many pur- poses in assessing the positions, in- cluding the anatomy and bone sur- rounding these teeth. After this im- age was taken, both teeth were ex- tracted and the socket was grafted fully to prepare the site for a later implant placement (Figs. 7 & 8). Day 4 Case 1 A mandibular molar case was in the planning stage, and the posi- tion of the mandibular canal was located. At this stage, different im- plant sizes were tested to check for best fit and the prognosis for maxi- mum integration in the future. The ACTEON Imaging Suite indicated that the first implant considered was too long and there was a risk of nerve damage (Fig. 9); thus, an- other implant size was chosen to al- low sufficient clearance above the nerve, and the density of the bone was checked at the same time, indi- cating good values in green, which the patient too could understand (Fig. 10). These tools, as mentioned above, can be quite a revelation for patients, and their use can affect the outcome positively. Case 2 A broken and loose bridge was planned to be removed. The man- ning, and it clearly showed that this may have proved difficult. In addition, on the 3-D image, we noted that the tip of the implant on the left side may have been collid- ing with the root of the adjacent tooth, with long-term uncertainty as a result (Fig. 15). In a scanning slice (Fig. 16), we also noted the challenge ahead for grafting this implant successfully, indicating that a great deal of consideration would have to be given and careful planning employed in order to ob- tain a successful outcome for this case. However, and despite the out- come at that point with these two implants, the patient appreciated the high quality of the 3-D technol- ogy and being able to see the prob- lem clearly and from different per- spectives, eliminating any guess- work that might have affected the final outcome and guiding the treatment in the right direction. Conclusion These cases and many more ev- ery week pass through any dental clinic, with patients hoping for the best available treatment under the circumstances (clinical, timescale, financial, etc.). We know that 3-D imaging is here to stay, and in order to make treatments safer and more predictable for our patients, we have to engage these technologies and involve patients more in show- “We know that 3-D imaging is here to stay.” values are acceptable or high and red if the values are low; Fig. 5), al- lowing the clinician to make the right decision. This can also be a very good educational tool to show the patient the bone density around any potential implant. In our expe- rience, patients like this feature once shown what it means. Day 2 An implant was planned to re- place a missing mandibular molar, and the position of the mandibular canal was not very clear on a 2-D image; even on the 3-D image, the position was still a little confusing. For this case, we decided to use the ACTEON Imaging Suite’s FlyMode option, which is like a virtual endo- scope that follows the mandibular canal tract from within and clari- fies the path to confirm that our nerve tracking is correct (Fig. 6). This is one of the unique features of the software. Day 3 Obtaining the correct position and trajectory of a retained maxil- lary canine has conventionally been dealt with by taking 2-D im- ages (periapical radiographs) at dif- ferent angles and possibly an occlu- sal film to determine the correct po- sition in the buccopalatal aspect, together with some guesswork. 3-D imaging can be an invaluable tool for this indication. The patient re- fused orthodontic extrusion of the maxillary left canine and wanted both the primary and permanent canines extracted and replaced dibular left second molar, which served as the most posterior bridge abutment tooth, was beyond saving (visual inspection and probing). 3-D imaging helped with planning the case, including tracking the posi- tion of the mandibular canal in re- lation to the proposed positioning of the implants (Figs. 11 & 12). In addition, the density of the bone was checked (Fig. 13), and the re- sults indicated that a wider implant would possibly be a better choice to improve integration, rather than the one chosen from the implant li- brary. This would also allow us to decide on perhaps performing an under-preparation of the osteotomy site in order for the implant to en- gage the bone better. This obviously depends on the type of implant used and other factors with which the expert clinician will be famil- iar. Day 5 This case was performed by an- other clinician, who was hoping to achieve good integration after plac- ing two anterior implants with grafting material. According to the clinician, primary stability was good at the time of placement and the implants were placed in bone with some buccal fenestrations, hence the grafting. It thus ap- peared that success was indicated. After the patient complained about some threads showing through the soft tissue, the clinician suggested further grafting to secure the im- plants. A CBCT scan was obtained (Fig. 14) as part of the case plan- ing them their clinical conditions and perhaps the limitations (ana- tomical, structural, etc.), together with other factors that may affect treatment planning and outcome, hopefully for the better. We hope to be able to use our CBCT scanner for more indications, especially in endo dontics, as we have seen amaz- ingly positive results from using a CBCT scan in some difficult end- odontic cases since we acquired this 3-D technology. It is the way forward, and we wish we had had the X-Mind trium sooner. 7 Editorial note: A list of references is available from the publisher. Dr Diyari Abdah is a cosmetic and implant ex- pert and runs a private dental practice in Cambridge in the UK. Passionate about research and in- novations, especially in the ﬁelds of implantology and 3-D imaging, he deals with all aspects of implan- tology and grafting techniques and has been actively promoting and teaching implantology to general dental practitioners worldwide for over 15 years through lectures, workshops, articles and mentoring programmes. He can be reached at drabdah@hotmail.com. Australian Dental Congress 2017 7

Dental Tribune Asia Pacific Edition No.5, 2017

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