How orthodontists can raise their game with CBCT and intraoral scanning

Excellent images and more data lead to better diagnoses, treatment planning, and communication

John White, DDS, MSD

Most of my colleagues have yet to embrace intraoral scanning and cone beam computed tomography (CBCT). Some find it hard to justify the investment-especially for CBCT systems. Some are concerned with the additional radiation. Or they simply feel that they already provide excellent care, their practices are thriving, and they don't see any need to change.

An "easier sell" is intraoral scanners (IOs), which are far less expensive. They are a great improvement over traditional impressions for the design and production of complex appliances, including Invisalign (Align Technology). IOs provide virtual models that can be incorporated into imaging software for viewing by patients and colleagues as well as sent to orthodontic labs.

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For those of us who have invested in these technologies, their impact has transformed our practices dramatically. With a more complete picture of what is going on in our patients' mouths, our ability to better understand and communicate "the story" can lead to higher levels of case acceptance and more efficient patient care. Most of all, we can feel confident that the treatments we recommend and provide are based on the best available tools.

Cone beam for better braces

When I purchased Galileos from Sirona Dental Systems in 2007, it was one of only four CBCT systems in the state of Ohio, including the Hitachi at Case School of Dental Medicine, where I viewed my first scans. Since then, I purchased a second Galileos and jointly have done more than 11,000 scans, radically expanding my appreciation for the value of 3-D imaging.

We live in a 3-D world, and this is especially true in our specialty. Patients' jaws, faces, and teeth are 3-D-and we treat in 3-D. When I use cone beam images to explain to patients with no technical knowledge the issues faced and their solutions, the messages they receive are especially compelling. And when I provide a second opinion, it is based on data and measurements that can't be acquired any other way.

Views from a 2-D radiograph don't provide the full picture; some areas are indistinct, distorted, or don't show up at all, which can lead to incomplete diagnoses. Using the cone beam, I can show the patient and/or parent what I see, what needs to be done, and how and why I recommend a particular approach.

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Admittedly, most cases can be handled adequately without cone beam. In fact, that is the case about 80% of the time. But you don't always know which cases will be among that other 20%. Incorporating additional information from cone beam allows you to build more customization into the treatment plan from the beginning, whether you are planning a bracket prescription, designing customized archwires as with suresmile (OraMetrix, Inc.), or setting up an Invisalign case.

Further, sometimes cone beam can be used to "make the case" with other dental team members. For example, I was able to convince an oral surgeon to redo an exposure by using a CBCT image to show her that inadequately removed bone was preventing tooth eruption.

To ensure that temporary anchorage devices (TADs) are placed in the best position possible or when exposing impacted cuspids, I have multiple views on the cone beam to delineate exactly where an attachment or TAD should be placed.

Galileos

Cone beam and the office workflow

The CBCT and intraoral scanner fit seamlessly into my workflow. Here's how we use it in my offices. A new-patient visit begins with a tour of the office and completion of necessary paperwork. The patient is introduced to the doctor and basic questions are addressed. The patient is then CBCT scanned, photographed, and scanned with the CEREC OmniCam (Sirona Dental Systems) intraoral scanner.

By the time the patient is ready to sit down with me in front of a 43-inch LED monitor, I have his or her IO photos in Dolphin Imaging, as well as virtual models from the OmniCam scan, and the basic cone beam images. I prefer the Galaxis 3-D software (Sirona Dental Systems) for reviewing the CBCT in real time. I do the diagnosis and treatment plan as the patient, parent, and I view the images together, explaining what I see and screening for issues that may impact treatment. I have a routine that takes about two to three minutes just to screen for nasal and pharyngeal airway issues, joint position and morphology, growth pattern and jaw relationship, and problematic alveolar and/or root issues. A team member takes notes that eventually become my treatment plan.

Conclusion

In my view, our specialty has always done high-level work using the tools we have available. But now, using newer tools gives us the opportunity to raise the level of our game. Having more information provides the opportunity for improved decision making and the ability to do things more elegantly and in a more customized manner. This is not to say those who don't use cone beam aren't doing good work, but if you do use it, your quality level can either be maintained with less effort or the same effort will produce a slightly better quality.

John White, DDS, MSD, a graduate of the Ohio State University College of Dentistry, received his MSD in orthodontics from Case Western Reserve University in 1982, where he is an associate professor. The first Invisalign SuperElite provider in Northern Ohio, suresmile provider, and consultant to Sirona and 3M Unitek, he lectures on CBCT imaging and intraoral 3-D scanning for orthodontics, Invisalign, and the integration of gnathologic and neuromuscular dental principles in orthodontics. He is a contributing editor for Orthodontic Practice US and has a private practice in suburban Cleveland, Ohio.