CBCT Imaging for your Practice: Is Now the Time?

By Dr. Kenneth R  Webb

As I walked the exhibit floor at the AAO Annual Session in San Diego this past April, I stopped and talked to several of the company reps displaying the latest generation of CBCT scanners. Competition is good – what struck me is how far this technology has come in such a short period of time. Effective dose, image quality, and versatility are three areas where the advances are most impressive. I have witnessed these advancements first hand in my practice where we have been using CBCT since 2012 and recently upgraded a satellite office from a 2D digital Pan / Ceph to an “Ultra Low Dose” current generation CBCT scanner. I’d like to share some of my thoughts about the 2D to 3D transition.

Effective Dose
I encourage anyone interested in CBCT technology to search for studies authored by Dr. John Ludlow and his team. Dosimetry data and image quality for many CBCT scanners (both older and current generations) have been researched in great detail. Comparative data for 2D dental radiographic imaging (both intra and extra oral) is also available. By replacing our 2D Digital Pan / Ceph with a current generation CBCT scanner we have reduced the effective dose of our diagnostic records imaging by approximately 60%. (Ludlow JB, Walker C. AJO-DO, 2013;144 (6): 802-817) This is accomplished with one, approximately 5 second, ultra-low dose CBCT scan compared to the two longer duration exposures (pan then ceph) required with 2D imaging. Certainly a win-win for our patients.

Versatility
What else can we use the 3D data for? Digital models: used to assess the inter-arch and intra-arch relationship as well as aiding the determination of arch length and arch width requirements and assessing arch symmetry. Modelling labs can produce articulated 3D study models from the CBCT data (DICOM) files.

STL files of the patient’s dentition and occlusion can be uploaded into whatever software you may be using in your office for 3D model storage and viewing. Additionally, these models can be used (with appropriate software) to produce treatment simulations by “moving” individual teeth or the arches as a whole. Imagine completing your diagnostic records with Intra / Extra Oral photos and one 5-second CBCT scan!

Viewing the Diagnostic Data
The software that comes with a CBCT scanner can easily produce the customary 2D diagnostic images that we are used to evaluating (panoramic, lateral and A-P ceph). In addition – you see everything! The data can be viewed in sagittal, axial or coronal sections (slices) or as a 3D “volume rendering” which can be rotated and sliced (“clipped”) at will. So why is this additional information gained from CBCT imaging important?

Pathology
You will see pathology in the 3D data that isn’t visible with standard 2D imaging. When pathology is visible in 2D, the 3D data can more accurately ascertain location, extent, and character of the area of concern. This is beneficial to our patients.

Developmental Anomalies
One of my first revelations when we began imaging in 3D was the prevalence and extent of “individual anatomic variation”. But how much is too much? We have made referrals to medical specialists for significant developmental anomalies in the cervical spine, nasal cavity and paranasal sinuses. Patients / parents are appreciative of the thoroughness of our diagnostic process that includes 3D imaging.

Asymmetries
They get their own paragraph! Your patient smiles at you and you notice a vertical asymmetry and occlusal plane “smile” cant. Is it caused by hemimandibular hyperplasia, condylar hyperplasia, a unilateral expansive lesion in the maxilla, a growth response to unilateral progressive condylar resorption (to name a few) or a growth response to a foreign object lodged in the nasal cavity? I’ve seen them all. Similar clinical presentations – different treatment plans.

TMJ
Condylar position in centric occlusion, condylar size and shape, glenoid fossa morphology, condylar osseous morphology, joint space, findings suggestive of degenerative joint disease – both active and stable. It is hard to argue that these are not important considerations in our diagnostic process.

Airway
The value of volumetric and cross-sectional analysis of the naso – pharyngeal airway and its relationship to orthodontic diagnosis and treatment planning has, and continues to be, studied in great detail. Is the growth and development of a patient who presents with narrow arches, an anterior open bite or anterior crossbite, tongue thrust and a strong mouth breathing pattern secondary to adenoid / tonsillar hyperplasia, a deviated nasal septum, environmental allergies or restrictive airway dimensions in general? Should your imaging modality include an assessment of these areas?

And there is more…
Orthognathic surgical treatment planning, TAD placement guidance, precise localization of ectopic and supernumary teeth, and assessment of treatment progress – including evaluation of root torque. All are possible or enhanced with 3D imaging. And by managing scan parameters (field of view, scan time and voxel size) at an effective dose equal to or less than 2D imaging modalities.

So, if you haven’t brought this technology into your practice – is now the time?

At the 2017 AAO Winter Conference in Ft. Lauderdale, Mr. Chris Bentson reported on a survey of recent (2016) U.S. Orthodontic Residency graduates: 88% responded that they had used CBCT imaging for diagnosis and treatment planning during their residencies including 21% that used it on all patients.

For the 2013 graduates, the responses were 76% and 9% for the same questions.

Based on these statistics, are we that far away from 3D imaging being included in the “standard of care” discussion? Embracing new technology is not easy but the value added for the practitioner and our patients is significant. The orthodontic educators who expertly taught my generation faced a similar situation during their careers with a then relatively new technology: panoramic radiographic imaging. My generation faced the challenges of transitioning from analog imaging (film) to digital.

Change is not easy. The transition from 2D to 3D imaging in your practice will require a financial and educational commitment. The whole staff will be a part of this paradigm shift. A positive – 3D imaging will be a differentiator for your practice. If you are seeking an associate, partner or complete transition, 3D imaging will make your practice more attractive to the next generation of orthodontists.

3D imaging will benefit you and your patients. Is now the time?

2017 Winter Conference – Technology: Balancing Profit, Lifestyle & Patient Care

By Dr. Doug Depew

The 2017 AAO Winter Conference is quickly approaching. Our theme of this year’s meeting Technology: Balancing Profit, Lifestyle and Patient Care.  It promises to be a meeting filled with information for both newer and established practices to help make those tough decisions on what technology is important to use in our practices and when we may wish to invest in it.

The meeting will begin with keynote speaker Jack Shaw.   Mr. Shaw is a world- renowned technology futurist who will be discussing how cutting edge and disrupting technologies will change the way we do business and run our practices in the coming years.

IT guru Steve McEvoy will be answering some of those pesky questions we all have about computer hardware, effective and cost-efficient data backup, and security.   In the ever changing world of computers, what you hear at this meeting will certainly be different than what Mr. McEvoy would have talked about even a couple of years ago.

On Friday afternoon we’ll have a lively discussion by Drs. Greg Jorgensen and Neil Kravitz regarding building our practices through social media, websites, and Internet marketing. Their success in these areas has been paramount in growing their thriving practices.

Saturday morning will begin with Dr. Aaron Molen sharing his experience and thoughts on bringing emerging technology into our practices to help create more efficient and more comfortable patient care.

We’re excited to have Drs. Ed Lin and Christian Groth discussing how to integrate some of the latest technology hardware into our orthodontic practices. This includes workflows for using CBCT, Scanners and 3D Printing.

The conference will conclude with Chris Bentson and Charles Loretto with a discussion on how technology can affect the value and profitability in our practices. This should help answer the question about at what stage of practice a doctor might consider investing in advanced technology.

The location for the meeting is at the gorgeous Marriott Harbor Beach Resort and Spa in Ft. Lauderdale, Florida. The dates are February 10-11, 2017. The schedule is organized in a way to allow some time for afternoon recreation.

There will be plenty of time allotted for attendees to ask questions of the speakers to be sure all bases are covered.   To learn more and to register, visit https://www.aaoinfo.org/meetings/2017-winter-conference-technology-balancing-profit-lifestyle-patient-care

3D Printing and Orthodontics

By Dr. Christian Groth

As we move towards the 2015 AAO Annual Session in San Francisco many of us will be making check lists for items to investigate at the exhibition hall and lectures. Anybody who has attended recent meetings has seen that intraoral scanners are a hot topic. Every year new products are being released, or updates to current systems are offered. Intraoral scanning has opened the door for additional technologies within (and outside of) the orthodontic office. Dr. John White wrote a very informative blog post in February talking about the use of intraoral scanning for same day consultations (click here to read it). As more people are offering clear aligner therapy (including general dentists and the mail order aligner system that we all know about) it is time that we differentiate ourselves as orthodontic specialists. One way in which we can do this is to incorporate 3D printing into our daily practices.

3D printing, also known as additive manufacturing, is a process by which a physical object is created from a digital file (check out a video of 3D printed models here). There are several different types of 3D printers available that range in price from a few hundred dollars to almost one hundred thousand dollars. They all have one thing in common: they build models layer-by-layer with a build platform that moves vertically. The smaller the layer thickness the better looking the model will be. The four most popular types of printers are: Fused Deposition Modeling (FDM), Stereolithography (SLA), Digital Light Projector (DLP), and Polyjet Photopolymer (PP). Without getting too technical here is how each basically works. FDM involved heating up a thin strand of plastic resin that comes off of a spool and is deposited in layers as thin as 100 microns. SLA and DLP technologies are similar in that they utilize a vat of liquid, photosensitive resin. When the light hits the resin it is cured and platform moves to enable the next layer to be cured. The different between SLA and DLP is that SLA uses a single laser point to draw an image whereas DLP uses a projected image to cure a whole layer simultaneously, which allows the printing process to move faster (think of this as the difference between drawing a picture and stamping a picture). PP printers are probably the most popular in dentistry and use inkjet technology (yes, just like your desktop printer). Liquid resin is jetted out of nozzles in an extremely accurate fashion and cured by a UV. Layer thickness of SLA, DLP, and PP printers can be as low as 16 microns (for your reference the average piece of paper is 100 microns thick).

While the technologies differ between printers what truly sets them apart is the quality of the parts. Cheap printers are made from cheap parts that can degrade over time and result in inaccurate models. It is truly a case of you get what you pay for. So if you are in the market for a 3D printer to be used in your practice, buy the best one that you can afford.

3D printed models can be used for anything in the orthodontic office.   The most practical use is for retention and relapse treatment. A major downside to stone models is that they are often destroyed during the retainer fabrication process. 3D printed models do not get ruined and can be used as many times as necessary for retainer fabrication. Imagine being able to print a model, make a clear retainer, and mail it off to a patient who is away at college. What a service you have just provided to your patient and they never stepped foot in your office! Pairing 3D printing with one of several software programs available allows us to create sequential setups/models for minor tooth movement. By controlling the process we control the overhead and thus have the ability to pass these savings on to the patient. Another great service that we can offer our patients if they have a lapse in retainer wear.

Whatever your practice is like there is a place for 3D printed models in it. While you will pay a little bit more for the physical model, the longevity, versatility, patient excitement, and ability to virtually eliminate alginate impressions from your practice will pay off in the end!

3D Printing – Is It Time to Consider It for Your Practice?

By Edward Y. Lin, DDS, MS  – www.osgb.comwww.applecreekortho.com

DrLin-Headshot-2

The combination of 3D models and 3D printing was first commercially introduced into orthodontics in 1999 by Invisalign. Companies such as OrthoCAD, E-models, and then OrthoProof soon followed with 3D digital model storage and 3D virtual treatment planning with each company possessing their own proprietary software. In the early days of 3D models, data acquisition was accomplished by either sending in an impression or a plaster/stone model with a bite registration, which would be either cone beam computed tomography (CBCT) scanned or laser scanned by a desktop scanner. Hard copies of these 3D models were also available to be 3D printed from any of these companies. However, the cost of 3D printing from a lab manufacturer until the early 2010s was quite expensive with costs in the range of ~$100 – $200/model. This high expense was due to the cost of the hardware and software that was required to acquire and produce these 3D models and truly not practical for use on an everyday basis for our patients. As a result, the thought of an orthodontic practice in the 2000s utilizing 3D acquisition and 3D printing technology was really never a possibility.

Today, as with many different types of technologies (i.e. – HDTVs, PCs, and laptops), over time with technology integration and mass production, prices have not only dropped significantly with the hardware and software but the technology has continued to improve. The cost for desktop laser scanners (~$8000 – $15,000) and 3D printers (~$30,000 – $75,000) has been significantly reduced. As a result, 3D labs can now 3D print our patient models at a fraction of the cost in the range of $12 – $30 per model. The thought of an orthodontic practice owning its own 3D printer also is truly no longer out of the realm of possibilities. In addition, the advent of cost effective, efficient, and patient friendly intra-oral scanners has truly revolutionized how we can acquire 3D data, making 3D data acquisition much easier and more comfortable for our patients.

3D data acquisition and 3D printing technologies in the 21st century orthodontic practice are now a reality. We have been utilizing 3D printing in our practices since 2012. I have been asked to lecture on 3D printing at our upcoming AAO annual session on April 26th in New Orleans. If 3D printing is something that interests you and have been evaluating for your practice, I look forward to being able to share our experiences with you and factors to consider for implementation and purchase into your practice.

Digital Retainers- Part II / Impression-Less Orthodontics

By Anthony M. Puntillo D.D.S., M.S.D.My last article received so many comments that I felt it warranted an extension of the discussion.  In the last twenty years of practicing orthodontics, our profession has gone paper-less, film-less, brace-less, wire-less, and coming soon….IMPRESSION –LESS.  Several companies now produce intraoral scanners and by all accounts they are selling them like hot cakes.  I want to reiterate that I have no financial interest in the sale of any of these machines.  However, if you have not bought one yet, my guess is most of you within the next five years will.  We would all love to eliminate our post-lunch gaggers.  But there are more tangible reasons why this trend is gaining momentum.

First and foremost the majority of our patients simply dislike having impressions taken.  Second, intraoral scans produce more accurate models for the fabrication of better fitting appliances. Third, intraoral scans eliminate the expense and wasted time associated with impression retakes and inaccurate model pours.  Fourth, intraoral scans allow for the elimination of alginate, PVS, and plaster expenses.  Finally, the move to digital patient records has been driven largely by the improved efficiency in handling, manipulating and transferring files, photos, and radiographs.  The same benefits also can be said for models.

Digital models have been around for several years.  I believe the recent mainstreaming of intraoral scanners and 3D printers has now pushed us to a “tipping point.”  Most orthodontists today using intraoral scanning, still digitally transfer their .stl files to the lab of their choice for fabrication of models or an appliance.  But what if you could simply hit “print” and create a bubble free model in your own lab?  The model could then be used to create an in-house retainer or indirect setup just as you would with a plaster model.   In fact, this is now possible.  Some may say that the costs of 3D model printers are too expensive.  Depending upon the size of their practice, you may currently be correct.  I say currently because most of us can remember the costs of color printers when they were first released.  Now they are very affordable and ubiquitous.  Why?  Because corporations such as Hewlett Packard discovered that they could sell the machines at a loss and make their profit on the sale of ink.  I submit to you it will not be long before the same dynamic occurs with 3D model printing.  And when this happens, we will all have one in our office and alginate and plaster will go the way of film-based photography.

Digital Retainers? Now at a Lab Near You

By Anthony M. Puntillo D.D.S., M.S.D.

It’s the middle of September and a patient you just debanded last month is enjoying her first year of college… and her new smile. After 24 months in orthodontic appliances, however, you are now both relying on her retainers to make sure her smile remains perfect. Unfortunately, her roommate has just accidentally stepped on that very same retainer and with campus 6 hours away from home she has no way of returning until Thanksgiving. Her parents assume that the impressions you took last month can be used to make a new retainer. Not wanting their orthodontic investment to be for naught, mom is calling your office requesting a new retainer with plans to ship it to her daughter. You are now in the unenviable position of delivering the bad news: the original model was damaged during the fabrication of the retainer and her daughter will need to return home for a new impression or attempt to schedule an appointment with an unfamiliar orthodontist closer to campus.

If you have been practicing orthodontics for any length of time, I have no doubt that the circumstances of this story sound familiar. The good news is that technology can now offer both you and your patients a better option. The increased movement toward digital models and intraoral scanners has not only improved our ability to store and manage our patients’ records, but it has also led several well-known commercial laboratories to add capabilities for processing these 3D digital files (STL- stereolithographic). Labs that have made the investment in the technology and equipment can now accept files over the internet and then use the digital data to create any number of well-fitting orthodontic appliances. Using STL files in this manner will save you the material, staff costs, and schedule constraints associated with taking a replacement impression. Furthermore, it saves the patient and parent the inconvenience of an additional trip to the office. So the next time a frantic parent calls requesting a replacement retainer ASAP, if you’re using digital models you can let them know you’ve got it handled. Simply forward the final records STL file to your favorite commercial lab and the replacement appliance will be on its way!