Cone Beam CT Interpretation for Zest LODI Implants by Robert Chen

Cone Beam CT Interpretation for Zest LODI Implants by Robert Chen


Hello this is Robert Chan with learn LODI, a free resource for learning how
to market, treatment plan, place, and maintain LOCATOR Overdenture Implants. The purpose of today’s video is to
discuss utilizing Cone Beam CT imaging and software to optimize your treatment
planning and produced the most predictable surgical and restorative outcomes. In this video we’ll be evaluating a CT scan to place
4 Zest LODI implants in any dentureless
mandible. A little background on me I am a co-owner of Reveal Diagnostics and we run Dental Cone Beam CT imaging
centers servicing the San Francisco Bay Area. In
the years prior to this I worked with Anatomage, a leader in CT
imaging software in implants surgical guides. So from my own
experience I spent years optimizing patient scans
both at the time of capture, as well as,
manipulating it downstream with cutting-edge software. That is at
the time of capture looking at little things such as
settings, positioning, and protocols to make the
raw data itself as good as possible and then
downstream on the other side how we can take that image data and make it really work for us and give us the most
diagnostically relevant clinical information and that’s
what I’d like to share with you today. So I’ve opened up the patient’s scan and I’ll walk you through the process
planning an implant supported overdenture using the Zest LODI
Narrow Diameter Implant System. Reveal Diagnostics works very closely
with the universities, the implant companies, CT manufacturers, and
software companies all to integrate the various aspects of treatment planning in the surgical
process to generate the best plan in most predictable outcomes. So in this
video and in additional videos to follow we’ll
share with you what our teams have developed and why it
works. This first case here will be a relatively high
level introduction just to the basic tools in navigating within a CT image.
Considerations when requesting a scan. We want to take a scan from calibrated high-quality cone-beam
CT machine. Just within the machine settings there
are a number of factors that will contribute your scan quality. Higher resolution scans will give you
better visualization of the bone, margins, and density. However it’ll also increase the amount of
radiation to the patient and extend the scan time. Longer scans can be
really challenging for some patients who can’t remain still and movement can completely thorough of
the accuracy of your scan. The scanning tech will also need to scan the
patient in the optimal position within the machine’s field of view and adjust the KBMA values
depending on the patient’s bone density and the
amount of metal. An imaging center with highly-trained staff is critical to getting the best images
and our centers employ only hospital trained, certified radiology technologists for
this reason. So this here’s a scan that’s already
been taken. What you’re looking at now is what we
call the section tab or the multi-planer view. It
essentially breaks scan up into you three plane slicings. So this axial
slicing in the top left, sagittal slicing in the top right in coronal slicing here
in the bottom left. Almost every CT imaging software will give you these tools and this is the
basic package. You can use it to search through your 3D
scan volume, to check for pathology, take measurements,
and evaluate bone height within relative density. So for example evaluating the maxillary sinus we can manipulate each of these 3 views. So let’s start with this axial view
here and the level of this axial slice is
represented by this orange line and if I move this line superiorly you’ll see that the axial slice is
changing so right now we’re looking at the
maxilla and the very bottom the sinus here and I can go from there and continue to
move superiorly and we’ll look at the sinus all the way
from inferior to superior. And here at the very top and we can just
bring that orange line back down and we’ll move
from superior to inferior. So that same process can be done using this sagittal slice. So right now this sagittal slice is represented by this
green line right here and it’s about on the mid-sagittal plane
right here. So if i start and I’m move this green
line towards the patient’s right side we’ll
see as we move laterally we’ll get that same effect will see the
maxillary sinus there and we can move laterally and back medially and we can do the same thing now here
for the patients left side see the sinus is here and move laterally and medially. The same concept again applies to this
coronal slice. So we can start maybe in the anterior and follow that sinus as we go from
anterior to posterior like that and back towards the anterior. So that’s very useful in looking at
things like the sinus but there’s one big problem to this and
these views are adaptations from the medical CT scan standards in the mouth isn’t aligned well to be used in these rigid slicing planes. While it’s an excellent way to evaluate the
sinus we orient ourselves in dentistry using more functionally
relevant references than superior inferior, medial lateral, and anterior posterior. So let’s start here, just for example, if I wanted to plan my implants from view like this what I might do is move this sagittal slice down into the height and the mandible and I can move
each of these. So let’s say I’m planning an implant in about the 23 region So this right here gives me in the sagittal
view gives me a pretty good view of the boney height and the ridge width. So I’ll just blow this up so we can
see it a little bit better and let me show you what it will look
like if I took a measurement. So I can click here and click here and that would give me estimation of the
ridge width and I can do the same thing here if we’re to measure out about 12 millimeters of height and that works great. now if I wanted to move distal
and let’s say I wanted to place now implant number 20 and let’s say
we want to move that and place it just mesial to the mental foramen which we can see
right here and we might place right there. So again let’s go into the sagittal slice and do the same process. Might have about this much ridge width and we’ll measure at about 12 millimeters
again and there we have it. Now the problem with
what we just did here and the reason it doesn’t work with
number 20 but it does with number 23 is the measurement that we just took isn’t a straight measurement of ridge width. So when we’re working within these
planes we need to be very mindful of the measurements that were taking. The measurement that we’re taking is
actually the length of this green line or the width of this green line so what that means is
we just measured this right here. When in fact the measurement that we wanted was the
actual ridge width right here So 3.2 millimeters verses 5.1 millimeters is a huge difference and we need to be
very conscious of that as we move forward with our treatment
planning. So let me delete that 5.1 and this is what we want. So how do we get that? There are some better tools that are more specific to dentistry and
we would call that within this software the arch section tab, The arch section tab instead of using axial, sagittal, and coronal slices it gives us what we call cross-sectional
R slices for better treatment planning. So now we can more accurately measure
the true width of the ridge at each of our implant sites and
specifically for the Zest LODI implant system
we’ve learned we would like to place 4 implants in the anterior mandible and would like to space them out 7
millimeters from center to center so let’s do that
now. I will increase the size here for this
axial view and what I can do is start from the center and I’ll take and measurement here and go distal three-and-a-half
millimeters about and we’ll just simulate our
implant with the little circle here so three-and-a-half millimeters to the
distal. I’ll delete that mesurement and I’ll do another one so
from the center this implant we’ll take seven millimeters
distal and again make a little circle just to
simulate that implant and we’ll do the same thing here about three-and-a-half millimeters from the center and I’ll place that with an implant and then I’ll do 7 millimeters again and place a little circle to indicate an implant and that can be are finished treatment plan as we might
conventionally do it and with cone beam CT images we can have high confidence that there’s adequate bone height and width. So I can
take a look at this implant at site number 23 and I can take
my measurement tool and just measure how
much width we have and also how much height we have. So easily knowing that there’s enough
bone to place each of these implants and I
can do the same thing at each of the sites in notice that as I
drag this green line along arch it’s actually following the arch so that the slice I’m looking at is always straight perpendicular
cross-section and that’s exactly what we want for measuring the bone width. Now because we have this full CT volume we can do much better with our treatment
plan. We can see the mental foramen here and we can optimize are AP spread from that. So I’ve already mapped out the inferior alveolar nerve canal on the
patient’s left side and let me do the same thing with the
right and I’ll show you what we can do to maximize our AP spread. So in this panoview on the bottom you
can see the canal and what I’ll do is click on this button
for a new nerve and I will just click on points along
the canal starting in the posterior near the mandibular foramen and just
click on points as we go and moving towards the mesial and as we start to
loose visualization we can follow here is the mental foramen and I’ll follow
it out with my mouse pointer and you can see as
I’m following it out we can verify on this axial section we can see that nerve coming out of the metal foramen and I’ll click done and again to verify I can toggle visibility off and on and we can see the mental foramen right there and right there. So we have
mapped it properly. Now from here what I’ll do is delete each of these circles that we’ve done with our
conventional planning and now we can say knowing where the
mental foramen is let me start my implant planning there
and work towards the mesial. Let’s say if we’re looking at 5 millimeters
from the mental foramen I can take this measurement and say we’ll
place our first implant right here 5 millimeters and we’ll do the same
thing on the other side 5 millimeters. So here is my first implant and here is my first implants these in the two terminal and implants just to delete these measurements now. So now as we looking through the arch how much
room do we have? So I’ll take the measurement tool again and let me just measure the arch length here and we have about 34 millimeters. So what I might do is if we’re spacing out
for implants let me place them 11
millimetres apart from center to center and that
will give us a pretty good estimation and about evenly spaced
implants. So take measurement tool again click on the center this implant and here is 11 millimeters 11 millimeters right here here and I’ll place that second implant and we’ll do the same thing from here right here the center of this implant and we’ll go 11 millimeters and I’ll go ahead and place that second implant. There we go, so now we can get a much better AP spread across these 4 implants and again we can go through and evaluate
the bone. So let’s check to make sure that we have adequate ridge width and height to place these implants and we can continue to do this and
take these measurements at each of the sites 26 same concept here and to 29 here and I’m just doing it very quick n easy
to give you the basic idea that yes we have enough space to plan
those implants and we can of course take our measurements much more carefully and go through that whole process as
well but in a nutshell that’s how we can accurately evaluate if there’s enough bone for implant placement and get us the maximum AP spread all from the
cone beam CT scan. So the final tool I’d like to show
you today with this video is really how we can
incorporate the advanced 3D visualization tools and what benefits that it can provide to us
in terms of evaluating the relational spacing for each of these implant fixtures and
also critical structures as we’re looking at the inferior
alveolar nerve. So this is especially important in cases like these where there are
multiple implant units and spacing is very
important, parallelism is very important, so I’ll jump into
the implant tab now and we’ll take a look at how that works. So I’ll zoom in here and this is our 3D volume and it shows the bone and it has this orange
translucent view so that we can have a little
bit of transparency through it. We can see the models that we’ve placed here so one of these being the inferior alveolar
nerve and then we’ll go ahead and throw in those
4 implants. So starting from scratch again I’m going
to click on the pano implant button and I find that placing implants in a pano
environment the easiest way for multi-unit cases. So I’ll just drop the number 20, 29 and we’ll again start those as distal
as possible so very close to the mental foramen there
and course we’ll go back and hone that spacing and we’ll also do number
23 and 26 and we’ll just space these out for
now as evenly as possible and make adjustments once we get back into the 3D environment. So let’s do that now and click on 3D implant and this shows us each of these implants planned in this mandible and so far it looks pretty good. So typically were saying we want to
keep these terminal implants about 5 millimeters from the mental foramen, in my opinion with the cannal mapped out very cleanly like this and we have full visualization of any anterior lobes we can pretty
confidently even closer than 5 millimeters. So maybe as close as 2 but we can leave it at 5 just to kind of go over that and whatever you’re most
comfortable with is going to be the best way to go. Let me turn on some
additional tools for us. First I’ll do this and I’m going to
enable collision warnings and it will look a little
bit messy at first but the benefit of this is now it’s telling
us the distance between each of these
models that we have within the software. So these terminal in implants are 1.7 and 2 millimeters from the inferior
alveolar nerve so let’s just go ahead and move it until
it says 5 millimeters. So here we go about 4.9
5.1 leaving at 4.9 here. Same thing here I’m going to move this until its says about 5 millimeters and okay we’ll 4.9. Now between each of these
implants we have the distance shown and a little difference within
the software here’s it’s not telling us the distance from center to center it’s telling us the difference from the
edge implant to the edge of the adjacent implant. So what I would need to do first is let me click on these and these are just generic implant models that the software starts with and we can choose any implant
manufacturer we like and it will throw in the actual model for
the implant itself. So were using Zest Anchors’ LODI
implants for this case and I am going to change each of these
to Zest LODI we’ll do 2.99 x 10. Same thing here will go to the Zest Anchors LODI and change each of these so that it’s the
proper implant for us. So the nice part about this is
especially when we’re looking in very tight spaces having the exact
model for the implant that you’re using can really make the difference between a
case that you’d wanna take on and maybe one that you would pass up or choose a different
treatment plant for. So now that we have each of these
implants we can see the distance in between each one. Again smaller implants so I will move these
again distal we can get a little bit closer to mental foramen here so about 5 so that’s
from the edge of the implant to the nearest mapped part of the nerve for us so now 5 millimeters on each
side there and then now between each in these we’re
showing 7 millimeters between these two implants 8.3 and 8.6 millimeters here. So we can move these implants distal and move this one mesial. what we’ll want to do is try to get it
somewhat similar here in terms of how much space we have. So I’m just trying to get something about, let’s see about 8, 7.9 and 8 perfect so we have 8 millimeters
from the edge of each implant to the edge of the
next adjacent implant. Now a couple of different things we can do
clicking on each of these implants now instantly gives us these cross-sectional views right here that we
were using in the previous screen also this axial view but now the axial view is a little bit more relevant for us its instead of a pure axial it’s along the axis the implant. So it’s always going
to be perpendicular to that implant. So if we have an angled implant it will follow that with this slicing and then also this will give us a mesial distal view. So from here I would check each of these implants to make sure that
we have adequate bone across each one and we may need to
adjust place it in the center bone here and now
we can also see the angle that we’ve planned these implants we’ve dropped them in and they all have
a zero degree angle so there are perfectly parallel
right now if I wanted to adjust the angle in
this implant you’ll see this measurement right here tells you
the angle of divergence. So one tool I have is I can make all these parallel so I’ll check this box
for all mandibular implants parallel and then now if I were to make that
change again you can watch in the 3D volume that all of
these implants will snap together and they’re moving in unison so again
these numbers reset to 0 degrees. So let me go ahead and check each of these implants we’ll
see is there adequate bone? do I need to make
some fine adjustments here? and change the angle and what we’ll end
up doing is in each of these cases we’ll say, how do I need to adjust the angle verses implant location within bone or do I have to compromise keeping them all
exactly parallel? Maybe I can uncheck this box for all mandibular implants parallel and then tweak one individual implant if
need be. So that’s how we can optimally plan using this 3D software and now that we’re comfortable with that
let’s discuss one additional trick we can use at the time a scan acquisition to give
us even more tools within this 3D planning environment and to me this is ultimately the best
way to be planning and for patients with
existing well-fitting dentures we’re using a scanning protocol that we
developed that will allow us the best
visualization for prosthetic planning and that comes without having to scan
the patient multiple times or spending the
time to create or modifying the special CT scanning
appliances. This is another implant overdenture case and have already done mostly the
treatment planning to get where we left off with the other case
but I wanted to use this to show you how we can utilize the denture in this scan just straight from one
patient’s scan. So we’ve taken his existing denture and you can see that right here, you can
see the contours of it and we’ve aligned it with a radio pake
material green moose and that separates the denture from the mucosa here and then we also
scan the patient with cotton rolls in the vestibule and
you can see the outline here and we keep the tongue away from the denture using cotton rolls and you can see there’s
no tongue here. So you can see the difference
between what we’ve done here in the mandible where we can very clearly see the margins of this denture in the cross-section verses what we have in the maxilla where
you do see the margins here and then it gets lost from the lip and
you can see the curve of the lip right here and it just completely blends in with the dentures. So had we scan these patient just at
rest wearing his denture everything in
here which is be filled as a gray blob and we wouldn’t see this nice differentiation here. So as we scroll
through all of this you can follow the denture as we’re
going distal and it’s a really nice tool to be able
to use for our treatment. Now just to show you a little bit more
about what this means I want to take a quick detour in use a different 3D rendering mode and this one is our soft tissue
rendering. I want to do a clipping on the mid-sagittal plane here and rotate it so that you can see what we’re working with. So again is denture here has about the same density in the scan as the soft tissue so it really shows up as the same color when we’re taking the
scan and then you can see here’s that green moose and here is the bone and kind of neat you can see definitely see the outline of that cotton roll here in the vestibule and that gives us a little bit better idea of how the patient was scanned and just as a neat thing some of these renderings can be useful in terms of looking at the bone. So if we’re to change it into a bone
rendering a lot of people use this to
determine if there’s enough bone around each of those implants my
opinion is we want to be, of course, very careful
because depending on where we have the brightness settings
if you turn it down it may appear that there is less bone
then there really is and if you turn it up the opposite can happen some of that soft tissue starts getting I’m counted in the threshold here for the bone rendering. So
as a rule of thumb we typically say always use the 2D sections and that’s
the best indicator of bone density but getting back to this
right here what is the benefit of having the denture in this scan. Let me turn this back to our translucent teeth view let me show you what we’re working with here. Now we would like to take a look and prosthetic space, how much height do
we have? and also the occlusal forces across
these implants how that lines up? So first let’s take a measurement
here say do we have enough prosthetic space
with Zest LODI implant system we’re looking for somewhere in the range of 9 to 11 millimetrers right here we have about 7.3. Some of the things we can do here and treatment options we can move this implant towards the buckle. So say we
place it right here is that enough space? We can take another measurement and we’re looking at just below 9. We can explore the option of rotating this implant a little bit so
let me put it back little bit better in the center bone. We can
rotate this implant and angle it a little bit more
towards the buckle. So now again how much space do we have? Looks like we have adequate, an adequate amount space now. Some other options are we can reduce the
ridge. So say we didn’t want to angle the
implant that way, we’re gonna move it back and keep this angulation. We can place these implants subcrestally with the intention of reducing the ridge at the
time of surgery. If that’s an option we can place it like that. Now before we make that
determination we’re going to want to evaluate each of these implant
sites make sure that works. We can plan these to about the same height as we’re looking at it in 3D. Do we have enough prosthetic space for each of these implants? Excellent. So now we have the ability to you use the denture as we’re planning each of these implants. We can see the prosthetic
space and take the measurements and ensure that we’ll have that 9 to 11
millimetres required for the attachments and we’ve explored some different
options moving the implant, tilting the implant,
and reducing the ridge to gain some
additional space for the attachments. From here this can be our final implant
plan and we can take this knowledge and place are implant surgically. The other
option from here is we can send this information, this
planned cone-beam CT file, we can save it and send it to Anatomage and we would also send them a stone
model of the edentulous mandible and they would fabricate a surgical guide
for us and there’s no additional work
required it’s very elegant process we’ll cover some more
that in the next videos to follow. So today we’ve looked at a few
different ways we can utilize software to maximize our CBCT images we started with clumsily taking
measurements in and medical derived multi-planer
view and we then upgraded to this curved arch sectional slicing which
let’s us take more accurate measurements of ridge width and more easily space out our implants and then we moved into the 3D treatment
planning tools it gives us more custom views that incorporate implant spacing, relative
angles, the ability to map critical structures, and show the actual implant models in our plan and finally we adjusted are scanning protocols to include the denture to further hone our
treatment plan and ensure adequate prosthetic space and line up forces over the implants. And that’s this last one right here. So I want to thank Zest and Dr. Michael Scherer for their
assistance and continuing to innovate and improve the
way we incorporate CT into implant dentistry and our mission at
Reveal Diagnostics is to make CT imaging more accessible to
every clinician and educational videos such as these are
really making a big difference and I would encourage each of you to
explore your options and partner with a good imaging lab and an
implant rep who has the knowledge and is driven to help you grow your
practice because we owe it to our patients and nobody wins when an implant fails. So the technology exists to know
exactly what to expect before surgery and have a plan that we can execute
predictably and just use the technology that’s available and use it to its
fullest. Our next video will continue on this
theme and we’ll discuss the process and benefits of guided surgery and in the meantime if
you have any questions or comments you can contact us at Reveal Diagnostics I have our 888 phone number here in this 973-8325 you can visit our website at revealdiagnostics.com or just an easy way if you want to send us an email it’s [email protected]ldiagnostics.com Thank you again for your time I
appreciate your attention and I look forward to working with you on
the next video.

Author: Kevin Mason

4 thoughts on “Cone Beam CT Interpretation for Zest LODI Implants by Robert Chen

  1. nice video ..BUT…. you dont have enough bone width where you planned those implants… minimum width for implant placement is 6 mm …for a 4 mm implant… so ….you DO NOT have bone

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