New Products | Product Spotlight | Tried & True | CLINICAL PRACTICE
Case Presentation
Eugene L. Antenucci, DDS, FAGD
Disruption! At first glance, it is not a welcoming term. But disruption in any profession signifies the potential for momentous, positive change with room for growth, innovation, and progress. Disruption has been described as an “advance that creates new market value in the process of disrupting and replacing an existing market.” Disruptors can be new technologies or a combination of technologies and processes, such as digital playback in the music industry or Uber in the taxicab business.
We’ve seen numerous disruptive technologies in dentistry. One that stands out in my practice is low dose CBCT imaging, and specifically, Planmeca Ultra Low Dose (ULD) technology. While 3D imaging is a mature technology with well-known diagnostic benefits, it has historically been associated with high patient doses and not widely accepted for routine dentistry. However, Planmeca ULD technology incorporates unique algorithms that allow for 3D cone beam images to be taken at radiation levels equal to or less than conventional 2D imaging, with no statistical reduction of image quality, as shown in a study by Ludlow at the University of North Carolina Chapel Hill School of Dentistry. This breakthrough in technology has forever altered the diagnostic workflow by placing cone beam imaging alongside all other available radiographic modalities in clinical dentistry.
The use of Planmeca ULD technology has transformed my practice. Its effectiveness is evident in a recent case when I was able to provide an accurate diagnosis and effective treatment plan while keeping patient radiation dose within the range of 2D radiology, eliminating any hesitation to order the CBCT images necessary for proper diagnosis and treatment planning. For example, I can capture an ø8 × 8 cm volume on a low resolution setting using ULD for only 9 µSv.
A patient presented to my office after suffering a fall while walking her dog. She was severely swollen, presenting with facial abrasions, superficial lip fracture, loosening of tooth No. 9, and fractures on Nos. 7 and 8. A 3D image taken with the Planmeca ProMax 3D Classic with ULD settings revealed a complete fracture of the coronal aspect of No. 9, which was horizontally fractured below the gingiva and below the crest of bone. No other root fractures were evident. No. 9 was non-restorable and required extraction, with plans for osseous grafting and a dental implant. The image showed no evidence of alveolar bone fracture. There was no damage to teeth other than Nos. 7, 8, and 9, with No. 7 having minimal incisal edge fracture, and No. 8 having an incisal edge fracture along with extensive deep crazing and stress fracture lines.
The soft-tissue wounds were fully cleansed and the coronal portion of No. 9 was removed. She reported no nerve pain from the damaged teeth. The decision was made to wait for swelling to subside before extracting No. 9. Antibiotics and analgesics were prescribed, and she returned in a week for evaluation, extraction, and grafting.
Traditional protocol would be to take a PA or a panographic image. However, much more information is obtained with a 3D image—at a similar radiation dose. The fracture was fully evaluated in all dimensions, and the surrounding areas were fully assessed. An accurate assessment was made regarding tooth extraction after the image showed that the mid to apical portion of the root was
thin and in intimate contact with the buccal plate of bone, and an osseous graft was anticipated. The cone beam image also allowed for implant planning to restore No. 9.
The extraction was accomplished with microtomes and elevators. The facial-coronal aspect of the bone lost approximately 1.5 mm of height due to the fracture. The socket and buccal plate was grafted with MinerOss cortical-cancellous particulate bone (BioHorizons) and Mem-Lok collagen membrane (BioHorizons). A provisional was fabricated with composite resin and bonded in place out of occlusion to Nos. 8 and 10. The patient’s 1-week and 2-week postoperative visits were unremarkable, and she was told to return in 4 months.
At 4 months, the bonded provisional was removed, and a second CBCT was taken using ULD settings. The graft was apparent in the image and all areas appeared to have healed properly. Teeth Nos. 7 and 8 remained asymptomatic. There was a 1-mm discrepancy in gingival height of No. 8 in relation to the crest of the alveolus in the No. 9 area.
An intraoral scan of the upper arch was taken using the Planmeca Emerald intraoral scanner. The scan is acquired within the Planmeca Romexis software platform, where it will reside in the patient’s chart along with all related patient data. The 3D data and intraoral scan were correlated and matched to give an accurate and comprehensive view of the anatomy for surgical implant planning and surgical guide fabrication.
With the virtual view of the fitted model over the scan, an implant was selected and placed using the Planmeca Romexis implant module and the extensive implant library. A Legacy 3 4.2 mmD x 11.5 mmL internal hex implant (Implant Direct) was selected. With the implant virtually placed, the software was used to create a surgical guide. The .stl file generated in Planmeca Romexis was sent to a MoonRay 3D printer (SprintRay), which printed the guide.
Implant surgery was performed using the printed guide to place the implant. A flapless surgical technique using a softtissue punch was used, and no sutures were required. A transmucosal healing abutment was used, and a provisional was fabricated using composite resin bonded to Nos. 8 and 10. The patient was prescribed 500 mg Amoxil q8h for 10 days, chlorhexidine rinse to be used daily, and 600 mg Motrin q6h for 2 days. A follow-up appointment was scheduled for 2 weeks.
As this case progresses, the Planmeca Emerald scanner will be used to capture the implant site for a final restoration using a scan body matched to the implant system, along with the veneer preparation for No. 8.
Acquiring this data by scanning is ideal, especially in a case where impression materials would be uncomfortable for a patient who has experienced trauma to her teeth. That scan will be electronically sent to a laboratory, which will return a custom abutment. We have the option at that point to ask the lab to a) fabricate a crown and veneer along with the abutment; b) fabricate the custom abutment and send an .stl file of the designed crown and veneer for our office to mill; or c) fabricate the custom abutment and design a crown to be milled after scanning with the abutment in place.
The use of the Planmeca ProMax 3D Classic in this case illustrates a marked departure in imaging capability and utility. Not only has the use of CBCT imaging disrupted traditional imaging protocols, but the integration of imaging technologies represents an extreme departure that changes many long-accepted workflows. Diagnosis, surgical planning and delivery, and prosthetic planning, imaging, design, and manufacture can all be done in a single location or facilitated with a laboratory at a much lower cost—with higher predictability and enhanced patient comfort and convenience.
This workflow fulfills the definition of disruption as momentous, positive change with room for growth, innovation, and progress.
Go-to Product Used in This Case: Planmeca ProMax 3D Classic CBCT
The Planmeca ProMax 3D Classic CBCT imaging unit is designed to handle a wide range of general practice requirements. Equipped with a sensor that covers the whole dentition, this unit provides a clear view of the mandible and maxilla. The system offers Planmeca’s true extraoral bitewings, pan segmentation, and AutoFocus technology for exceptional diagnostics. True versatility is achieved with volume sizes from 5 × 5 cm through 11 × 8 cm.
