Auto-generated from YouTube's captions for this 2+ hour recorded lecture — unlike the shorter videos in this library, it has not been manually corrected line-by-line, so treat exact numbers, settings, and terminology as approximate rather than a verified written protocol.
i'm going to try today to give you guys some some information we like related to idixo related to your units about patient positioning scanning you know how to maximize your image quality give you guys some pointers on how to better plan your cases and then from there we can actually have a few a little bit of a debate in the end as i was talking to mr zlimming about um you know i dixo um he was mentioning to me that um our colleagues there in the middle east were we're having some questions related to how to better um use i dixo better use the the cbct units that you own and um i i wanted that i want to let you know that you can raster sure knowing that you you have um the top uh hardware in the world today when it comes to auto accident official radiology uh morita is well known worldwide for two things resolution and reliability uh as as the the former director of the largest radiology department here in north america uh somebody that has used uh pretty much every single piece of hardware out there uh i can honestly tell you that every time that i have a chance to use to work with multiple units i always navigate towards merida it is in my opinion the best system out there uh to help you uh image for uh your patients regarding surgeries regarding endo you know and and also implants so i'll show you today why why why my experience has been so positive with morita and what are the differentials that you should uh look for also i'll try to help you as much as i can to calibrate your image quality and help you with patient positioning a little tool and little tricks that can actually help you increase your resolution in your workflow even further uh it's also important to stress that morita is the company that started a revolution of convincing imaging doctor yoshinori arrives the father of obesity image in the way
we know it at least high resolution complexity change in the way we know it and uh mourinho is now celebrating over 20 years of of cbct imaging in the industry so again just a shout out to my my peeps there in japan um you know you guys been doing extremely good work for the past 20 years and i look forward to see what's ahead now um it's very safe to say that folks that are here today are pretty much using one of those three units meaning that the last two the verifox are 100 and all the units related to x800 are probably the most popular among the middle east uh market and uh if you are using those two the the r100 x800 this is where we're going to focus today okay and it's important to also to stress that there is a learning curve related to software related to hardware and and also related to engineering um we are all learning here you know i know mister's leaving now for almost 20 years that we've been you know friends and colleagues and we've been discussing things about how to improve the units and how to improve image quality and i think it's awesome when uh you know groups like this can share experiences uh share pains and uh it's important also for for for the folks in japan to to hear a little bit of uh on how to maximize image quality how what are some of the pains that you guys are suffering there as clinicians so the engineers can can can try to find solutions for some of the problems that we are talking the goal today again like i said is to help you increase your clinical knowledge regarding 3d image but most importantly regarding like dexo and regarding the piece of hardware that you have there are a lot of little things idxo related to even the hardware uh a component with with patient uh parameters sorry imaging parameters that we don't uh sometimes pay too much attention to and
that can be you know the the switch of that that can determine you know a good image versus a great image so before we start it's important that you understand that imaging any type of imaging we have to navigate through four pillars okay those four pillars are interconnected and you cannot change this sequence everything starts with acquisition acquisition is the number one pillar for the imaging workflow after acquisition we have data correction after data correction we have data navigation and only after data navigation we can get to data interpretation so in order for you to maximize your data interpretation you have to maximize your data acquisition your data correction your data navigation and to get to the interpretation if your data acquisition is not ideal your data interpretation will suffer if your data correction is not ideal your data interpretation will suffer and if your data navigation is not ideal again your data interpretation suffers and and everything starts with the first pillar right the acquisition so one of the things that i do every time that i'm looking at new systems or neocombine ct scanners i always want to know how is the acquisition workflow and and what is it different about it also i want to know what are some of the data what are the data correction tools that we have uh then the data navigation tools how do i slice and dice the volume and and most importantly also what what is the correct sequence for that then we can talk about image patterns related to that interpretation now i think the marita shines when it comes to uh the data acquisition data correction and the interpretation navigation component there are tons of excellent tools there that allows us to really uh uh differentiate ourselves as imaging centers or clinicians when we use this product the final product is going to be a high resolution scan with minimal artifacts and minimum scatter so um questions that i get all the time is bruno why is your database so good why are
all your scans you know perfect it's because i pay a lot of attention on pillar number one acquisition i acquisition to me is it's just more than just pushing the button i want the patient to be perfectly positioned i want the parameters of the unit to be perfectly adjust for what type of imaging i'm doing i want to make sure that my scout imaging is placed correctly um on on the on the piano couch and also i can stabilize the patient to the best of my ability uh sometimes you know being too friendly with the patient being being you know not adjusting for example the the temporal guides um stabilizes them slightly the temporal stabilizers hard enough it's enough for the patient to just move a little bit and then make your image a tank so i'm going to share with you my secrets how do i do it why do i get images that look like this all the time and then hopefully we can share some ideas here throughout the next few hours so the number thing uh the number one thing that your unit has the burrito unit is that it's very user-friendly okay and when i say user-friendly i'm talking about the fact that when you look at brochures from different manufacturers and you look uh you know what they all have in common the interesting thing here is what they all have in common is the fact that the patient on the brochure is always a super model with the longest neck a human being can have so those patients are very easy to position very easy to stabilize right we're looking at you know patients with beautiful smiles uh but in in reality uh it's more than just beautiful smiles sometimes we have patients with no smiles and we have to um you know somehow adjust the machine to better position patients like this so the idea here is i want i want you always to remember the saying you never adapt the patient to the unit you adapt
the unit to the patient so uh the merida scans scanners they will come with different types of chain rests uh different types of bike blocks and it's important that you know when to use them and how to use them so as we um progress with our scanning the patients are going to be better stabilized we're going to be able to better aim at the region of the interest and therefore will be able to achieve the best image quality as possible so if you are an r100 user or if you are an x800 user you will know that you have those two types of chain rests one of the bite stick and one with the chin cup every time that you have an identical station for the anterior region meaning if the patient cannot bite on that bite stick please use the disposable by block that comes with your unit okay because that is the best way to make sure that you are lining up the maxilla and the mandible uh to put to place them together in the focal trough of the unit and to also to better stabilize the patient from movement if you try to put cotton rolls here so one now what you're trying to do is you're trying to adjust the patient to the machine don't do that that those are some of the reasons why sometimes you don't get great images uh when you're trying to do that so make sure that you always adjust it now we have three types of patients that will come to your practice patients where their jawline is above their shoulders and patients where their jawline is at the level of your shoulders or below your shoulders if that is the case it's not uncommon for the c-arm regardless of the unit that you have to hit the patient on the shoulders like this so there are ways for you to bypass this problem in ways for you to also bypass the problem of height when it comes to patients and it's important to
remember particularly if you have an r100 uh um x 700 right if you have this particular unit that has the mirror that your chain rest has three different positions position one position two position three those those three different positions here we'll discuss it a little bit more in length in a second they will determine if you actually have the c-arm hitting the patient's shoulders or not also if you have the x800 you can control the height of the uh of the chin of the of the cr independently than the chin cup so the x800 it's a little bit different because when you position your patient you can control now the horizontal position for your your panoramic scouting differently than what you had to do with the uh with the x800 so you can see here a couple things that i do i always like to position my patients in such a way that they i put the tragus right perpendicular i'm sorry uh parallel to the infraorbital foramen um always trying to find it where the canine line is typically what we're trying to do here is actually find the position of the abuses of the sensory incisors making sure the patient is well positioned to acquire the scan secondly if i can't if i don't if the patient has teeth i can always do the same thing here right instead of adjusting the pipe block i can always have the patient bite the bite stick one problem that happens all the time is that patients try to bite and then the chin cup prevents the patient from biting see this is a very common mistake so do me a favor um ask your red tac to always show the patient the bite stick so you're gonna say hey listen here's the bite stick there is a group on the bottom a groove on the on the top uh in a second i'm going to ask you to bite with your front teeth within those grooves and always make sure to raise the bite block
so the patient can actually come in here and bite the bite block without having the chin cup blocking the chin so it's a much better experience for the patients i know those are simple things but always make sure uh that the patient is biting the pipelock one of those things that i just did here i always place my finger in front of the forehead of the patient like this and i ask the patient to try to touch my my finger with their forehead so basically what you're really trying to do is tell the patient to bring their chin to their chest in order to stretch the neck as much as you can possibly can and this way you avoid what's called a slump position so see how the patient went forward and this way i can stretch the neck and really tight this is as hard as you can so the patient does not bite then you go back again and you stabilize the frame for plane mid central line and the k9 line the k9 line is going to be the last line that you're going to stay you're going to um uh adjust so remember if you every time that you put a patient in there you start with mid-size or line then frankfurt plane then the k-9 line always in that sequence if you start with the k-9 line and then you go you go do the other ones your k-9 line's going to be off the k9 line is always the last thing we adjust so from here now i can go take my panel my piano scout or my phone bct scan one thing that most people don't use it's actually the t-bar so your units the x800 the r100 and also the x800 will come with the t-bar the tb the t-bar is used for tmj scans so basically every time that you have a patient that needs tmj imaging you will use the t-bar for that and what the t-bar does is allows the patient to rest the
nose um right here on the tip of the uh um of the t-bar so you'll see here in a second i can select what i'm doing you know the type of programs that i'm doing for doing panels if i'm doing ct and the reason why i can do um uh i can use the t-bar is that on this position i can i can image the patient with the patient opening or closing his or her mouth so as the patient gets into the unit if the patient if need be i can actually have the patient open his or her mouth and take the scan with the patient with it with with the mouth open so this way i can see the translation of the condor hats so that's what what this little disposable i'm sorry this little t-bar does um another option for you to use the t-bar in your clinic if you see trauma patients you know particularly somebody has fell on on their chin and there's lacerations now or the patient has pain uh by placing the chin on the chin cup or on the chin rest make sure to use the t-bar this is also a good substitution for any time the patient cannot put the chin down because of trauma or because of lacerations of soft tissue lacerations on on the chin okay so i would i would do that now if you have a an accident an x700 right there on 100 unit there are a couple things you should know about the chain rest position every time that you guys gonna take a panoramic image for for for um for cone beans if the if the area of interest is demandable okay for example if you're gonna do a four by four scan on number 36 uh please place the chin rest on position one meaning that all you're going to do is drop the the chin rest there and you'll be able to now take a panoramic image here position one so the reason why you you want to
place the chin rest on position one is to allow you to acquire a smaller field of view or even a medium field of view of the mandible without the maxilla interfering but if you if you want to place um if you want to take a scan of the maxilla on position one the vast majority of times um what's going to happen is this instead of um oops let's go one more what's going to happen is as you move this guy up this is going to turn red so if you have problems with the the the box turning red for the maxilla that is because your chin rest is too high and therefore uh you really can't image this properly so every time that you do a mandibular scan i want you guys to use position one if you guys are using if you guys are going for a maxillary scan i want you to go for position two so how do i get to position two instead of dropping this straight down turn the the pipe block to the right okay turn the bike block to the right then drop it into the into this little hole here and you can see that you're gonna the the sea um the chin the chimeras is gonna drop about half an inch down and that is the clearance that a lot of times you need to clear the shoulders on larger patients but most importantly that's the clearness that you you allows you to go from here to here to maxilla and and and not have of the maxilla turn red right not have the box turn red another important component here too is that even though this patient you know had them they made a mistake they acquired panoramic image with uh uh with removable dentures the metal from that removable dentures is not interfering interfering with the quality of the of the convincing scan so the idea here is if you can avoid imaging the crowns of the lower teeth uh when you're doing um
upper teeth please do so okay so this is one of those those times that you have to keep thinking about okay what is best for me to include metal from the bottle or to avoid metal from the bottle it's always it's always important that you you change you you try to check to avoid metal any time that you're placing those smaller fields of view over around so in this way as you can see here we were able to capture the that canine perfectly without any interference from the image quality from um from the from the mandeville and and unfortunately this patient as you can see here there is an area of um that is ill-defined and perforated bone no expansion soft tissue swelling this was actually a malignant tumor that was growing behind that canine it was a case of of a minor salivary gland tumor growing in the palate and then you also have position three position three is when you drop the chin cup all the way down turn it to the left okay turn it to the and and then this will drop all the way down you will pretty much cut a little bit of the mandible but the maxilla will be there so anytime that you guys have patients with problems with the sinuses or or even challenging patients you know patients that have large hunchbacks or you know somebody that perhaps looks like her neck issues here or back issues you can actually use position three um ideally speaking this is actually the case of a girl similar to that um and we are actually interested to see what the k9 was doing but you can see here that by putting on position three i i can avoid the c arm hitting her shoulders and i have a pretty decent image of the maxilla on that particular case so if i if i needed to see anything related to the sinus you know scan any any area of the sinus that's what i would use here you know to
show that i can take a scan of that k9 and and be okay now another component too every time that you're moving the box around please think about what's going to be inside the box so for example you can see here that adjacent to that area there is a there's dental implant um one thing that i that that i will not do it's actually include the dental implant here because i know that if i if i were to remove this block a little box a little bit more distal and include a dental implant that dental implant would create artifacts on this particular scan so the idea is you not only want to move the box up and down and avoid the mandibular crowns but you can also move the box side to side and avoid areas that can actually create artifacts within the area of interest so just be mindful of that um another important thing for you to think about whenever you're you're doing your panels particularly if you have an x800 it's going to be your level so um i don't know if you guys uh are using levels or different levels for your panos i like to keep my panoramic images with the x800 with level six and level five um you know those are the best ones i think by default the unit count it's about two so um if you are um working with a you know an imaging center and you wanna have a better image quality please make sure your level is a six if you are using an x800 x 700 you know this previous unit here please make sure that on your unit your level is a four that's the maximum we'll go here so there are two different resolutions right you have the the high speed resolution and the hd resolution the differences between the high speed and and uh the the high definition is always the acquisition time so here on high speed the panoramic is going to be 7.4 seconds on the high
definition the panorama is going to be 15 seconds um if you're just using the panoramic image for scouting the the area of interest then you should use high speed if you're using the panoramic image for diagnosis meaning that's the primary reason why you're imaging the patient you should be using the high definition one uh basically um on the high definition panoramic image you're gonna acquire double the amount of bass images than the high speed one so you're gonna have a much higher resolution panel um and but the trade-off is that the reconstruction time of that panoramic image is going to be higher it's going to take longer so that's why you don't want to use the high definition for a scout imaging although you could because in in reality it's going to take much longer for the image to actually pop up and allow you now to aim at the area of interest there so just be mindful of the acquisition time here high speed 7 seconds high definition 14 seconds 15 seconds um what is different about uh the c arm of the x800 is that i don't have to change positions for the chin cup the chin cup only has one position uh so differently than this the 700 right where i can actually turn to the right for position two and turn to the left of position three on um on the x800 the c arm moves itself up so here is uh what i mean by that if you ever encounter patients doing your panoramic acquisitions where the patient has a hunchback or neck issues and now you see the crm touching their shoulders please make sure to change your your horizontal position in in my clinic my my default horizontal position is five this is what i use for everybody it's five but you can go a little bit up to ten if you want to and you can see here that now it's not touching your shoulders anymore uh but you can go see look at that it just
moved a little bit up perhaps he would crop a little bit of the inferior board of the mandible but in this case it's not really that important uh because you know it's between touching his shoulders or or no image at all i'm sorry uh it's about not touching his shoulders or no imaging at all so here this is the type of clearness that you can get with the exit x800 without um moving the patient away without having to change the byte stack all right so again my default setting here is five for horizontal position that so click here horizontal position five that's my default so um you can go horizontal position five levels uh you can adjust on your unit see what works best for us um the vast majority of of the x800 that i work with actually work with three of them they are they actually um give different images on different levels uh but there's going to be at least four um this this actually when i was imaging this patient this was a very small patient that's why it's all four but my average is it's five now one thing that i want you to i want to talk about the marita that is very different that you won't see on other systems are those um those those other um programs that they have particularly this one called the sl the sl program is called the shadow last uh program and a lot of folks don't know when to use this so let me explain to you when we use the shadow last program on your unit so one of the problems with panoramic imaging is the fact that we have ghost images associated with um metal uh sometimes earrings um you know things that are on the buccal aspect of the layer and then on the posterior side of the mouth and then therefore they create this uh ghost artifact uh ghost image on the opposite side so it always it always happens on the opposite side so when would
you use a shadow less last module every time that you have ghost images coming for example from the rhema so if you have a patient that had orthognatic surgery there's tons of hardware here and then you are now seeing ghost images on the opposite side you can use the shadow last module and as you can see here this is actually the same patient acquired with the shadow last module there is no ghost images on the opposite side absolutely no ghost images on the opposite side so here we go ghost images no ghost images that's what the shadow last module is for um and it's a fantastic tool that can help you differentiate your panoramic images from your competitors uh just because there will be no ghost images associated with that another thing that's important about panoramic imaging promorita is the fact that it has this direct acquisition module the direct acquisition module has to do with the fact that the kvma is being corrected in real time when you take a panoramic image with morita and therefore you have a very homogeneous uh density on your panels so you're gonna have you don't have burnout areas with your panoramic image so the idea is as the machine rotates around the patient's head kvnma is being corrected real time so it's not uncommon to see this type of problem on competitor systems where you know there is a lot of burnout or sometimes the image gets overexposed where on merida everything if you've done the panoramic correctly everything gets homogeneous from a density perspective so therefore when you are taking a scan and you actually compare side by side this is preferable um and you can also remember use this to understand where to scan the patient right um so if you are now using the panoramic image to aim at the area of interest right on where to scan the patient it makes a very fast workflow for for particularly your smaller fields of view there are different fields of view with different capabilities on
where to scan the patient so you can go all the way from larger fields of view like this with the x800 uh to smaller fields of view another option that you can have if you don't want to take a panoramics on on on your patients is to use what's called the 2d scouting so 2d scouting is available in all marita units the x800 the the x 700 and also the equitomo and and what is that it's when you take a lateral shot and a frontal shot of the anatomy of the patient and you use those areas to aim at the area of interest so i can move this box now and through your two posterior here in the maxilla so in this case i'm doing the center incisors and here with the frontal view i can move this to the right to the left or to uh you know to the whatever to i want to center so it's a different way for you to think about where to take the scan but every single unit from rita allows you to take scans using 2d scout with two dimensional language instead of the panoramic the panoramic imaging in my view is preferred because allows us to be very precise at the area of interest right so you can see here high resolution quality panel and say this is the area that i want it's easier for your assistants to know where to aim and sometimes you can use the panoramic imaging as a screen tool particularly when the patient has multiple problems so it helps you determine what is the best field of view for that patient but the idea here is if the the panoramic image is correctly was uh uh acquired the unit is gonna is gonna make sure that whatever the region of interest is always centered within the the center of the field of view and this is the area that you have the highest resolution within the scan right so you can see here a patient that we have this
high density fine it is short just so happens to be uh peripheral center losses dysplasia right this is a stage three peripheral cerebrosis dysplasia this patient was also having problems uh from a root canal perspective there was a lingua canal that was never filled and this is actually a problem because every time that you have infection associated with the fibrozostas lesion it can lead to osteomyelitis because the tissue associated with fibrosis lesion it's not as vascular and therefore you cannot fight infection so be careful every time that you have situations like this and again correct acquire panoramic images will allow us now to aim precisely in any area we want within the jaws and make sure that whenever you aim at this area you know we will include exactly the area that we want and that will be centered within the scan and that is the most important thing we can ask for right is for those areas to be centered within the scan remember everything that's in the center of the scan that's when you're going to have the highest resolution within the scanner everything that's on the edges of the scan they don't have the same resolution of whatever it's on the center part so every time that you can try to place the center i try to put the region of interest right in the middle right in the center of the scan for those who use the r100 or also the x800 it's important to remember you also have the ability to crop panoramic images if you want to do the panoramic bitewings and that would be back here one very fast um and that would be this module here where you can go to um normal to shadow last and then you have the orthogonal projection which is the ot so the ot you would use to do uh the bitewings panoramic bitewings that that's when you do the ot and then um if you go back here to your panels you you just you know unselect the condylar heads
and the the and the center incisors when you select the ot this will be equivalent to what's called a panoramic uh a bitewing with your merida x800 so um if you actually use um the the the cropped images for scout they will also work so here's a good example of a panoramic a cropped panoramic image that we use as a scout and that actually works really well too so do not fear not not using the the the full panel if you if you just don't need it another component too is that if you if you wanted to see this canine here although it's not on the image i could actually move this line forward and scan the canine even though i don't see it right so the the the regions adjacent to the to the cropped pattern became this can also be uh used um just to be image by by using the box to aim at the area of interest here you can see that it got exactly what we wanted and the challenge that i see in lots of imaging centers and lots of uh offices they're using marita and they're using um the panoramic scout it's this situation where 50 of the scan is composed of information that can create scatter so um think about this for a second every time that you guys see this box you're talking about two centimeters to the right two centimeters to the left two centimeters to the top and two centimeters down because the volume is four by four if we were to evaluate this just just just for a you know a simple math evaluation two centimeters or half fifty percent of the scan is just crowns that can truly interfere with image quality so the idea here is as much as you can possibly can avoid taking those types of scans i would prefer for you to in this situation do something more like right to go in here and acquire uh just the maxillary grounds and avoid them in the work rounds
the problem is when we do this a lot of times the this line here will turn red this doesn't happen with the x800 but does happen with the r100 so just be careful uh place that on position two to avoid that turning red and the challenge is sometimes and this patient has a little bit of motion and a lot of artifacts related to this but why think about it 50 of the scam is just garbage it's just stuff that's creating lots and lots of artifacts i can have the same situation the same situation same tooth and then from here instead of acquiring the image with all the crowns i can put it on position three or position two on my x800 and i'm sorry x700 um i 100 and then i can image the crowns now or even crop the crowns all together and get a much cleaner image okay because those crowns are not interfering with my image quality so remember this when every time that you have a chance don't don't scan areas okay don't skin with lots of crowns like this try to avoid as much as you can anything that can create artifacts to uh to allow for better image quality of your scans now when you use this i'll show you a case now um you will have superb resolution absolutely superb resolution okay so here's a good example of a case where um i have uh we're going to go over this case in a little bit this is a fracture case okay and i'm going to show you in a bit how to actually look for this fracture but i just want to show you right now there's nothing here that is interfering with the image quality of the area of interest that happens to be the premolar the premolar it's centered within the scan exactly where i wanted it to be and now we're going to go back here in a second i'm going to show you later on when we talk about navigation how to actually
look for fractures and things like that this is what this is what came out of the unit i haven't touched anything i just opened this volume and um we're going to evaluate later on the image i'm fighting for the fracture but what is important is that none of that the mandibular crowns are interfering with image quality uh another important field of view that we have within morita is the four by eight uh the four by eight field of view uh is uh it's the tallest one of all the smaller fields of view out there and it's super helpful particularly when we're doing anterior mandibular cases or any time that the patient has deferred pain so if i have a patient with pain or number 16 but i don't know if he's number 16 or 46 i would use that so the idea here is remember to use the 4x8 scans they're very very important i also use this this particular field of view for all my trauma cases typically this is what i use if i want to evaluate the interior of the tissue during trauma and the beauty of this particular scan is the fact that i can isolate the mandible and the maxilla so i'm gonna in a bit i'm gonna show you how do i adjust the histogram how do i keep it like that but what is important for you to know now is that i can isolate a maxilla or a mandible or see one of those arches at a time i don't know if you know the streak or not but marina has what i like to call the zoom box so if you go under tools here on your idixo we should go under tools on igso this button right here that looks like a cylinder when you click this button this yellow box pops up okay and when this yellow box what's up pops up i can actually move this box using my chronos sagittal and and axial lines and every time i and if i click
on the edges i can make it smaller i can make it larger right i can kind of move it around and if i double click the edges of that of that of that box again you're going to see me double click the edge of the box i can now zoom in to the information that's inside that box so as you can see right now i only see the maxilla and i'm paying attention to the incisive canal area here where i have a size of canal cyst right i'm gonna i can measure that um and now you know do any any type of annotations that i need for for that particular region and in order to come out of that all i have to do is double click inside the and now i'm out of that box and to go to the mandible i can i'm going to create another box just moving my my axial image there and click on the box here under tools remember it's this little cylinder part there see that that's that's what we're gonna evaluate now i can zoom in and by the advantage of zooming in versus what i just did which was to drag the images around is that allows me now to see not only one plane magnified but all planes magnified so the actual corona sagittarius are magnified that was a lingual canal there uh one thing that i always want you to use is are the two annotations and i'm going to show you later why this is so important but every time that you have a finding within your combing please add some sort of annotation within your skin because that later can be so helpful for your uh for your doctors that they're receiving the scan to actually see and understand your reports and see and understand what the findings are another thing about all merida units that they are very friendly for wheelchair and larger patients so for example this is a patient of the weights over 380 kilos and as you
can see here he's on a wheelchair and we can imagine with the marina as long as you use those uh those tools that i told you about position one position two position three uh or horizontal position 5 on the x800 we can definitely scan those patients no problem one issue that i see that happens a lot with all units that the patient are are standing when you're taking the scan is the issue of height i am a very tall individual i am one meter 93 centimeters so i'm 6'4 in the us and it's not easy for assistance to position me because i'm so tall so one thing that i always recommend for all imaging centers and and in offices is to acquire images with the patient sitting down if you acquire images with the patient sitting down um you have to you have two two advantages here number one now all the patients are homogeneous it doesn't matter how tall the patient is uh your assistants are going to be able to see their faces well you're going to have better patient stabilization because you have uh the ability to sit the patient down particularly elderly patients this makes a huge difference uh and then number three is this by bringing the by sitting down the patient you bring in the center of gravity of the unit down there's less wobbling there their better harmonics on on the unit so on average you'll have better scans by having the the patient patient seated when the patient is standing the secret is what do i need to sit the patient down you need a chair with wheels and also with back support that's what that's that's the ideal chair for you to acquire an image so why is this important because by having a chair with wheels and back support allows you now to have the patient sit more towards the edge of the chair and i'm being very be very exaggerated here but the idea here is if i ever encounter a patient with a
hunchback or neck issues where the chain line or the jawline is below the shoulders i can have the patient sit at the edge of the chair and then just push the patient in and as i push the patients in and the patients lean back as i lean back what's going to happen is my shoulders now are going to drop down and i'm going to get clearance around the patient's head okay so that's why i have the back support here so i can really really lean back as you're taking the scan all right so um i would strongly recommend you doing this and um when it comes to the x800 at least in our clinic at the north louisville um all the scans that i acquired with this particular unit the patients were seated i thought it was much much easier to acquire images with the patient seated so as you can see here we have a little chair patients would sit on that chair and that would be just much easier for us to stabilize the patient one thing that i'll tell you is not to do what this lady here is doing see this patient here has her foot flat on the ground her feet flat on the this lady does not this gentleman here has it so as as much as you can make sure that their feet are flat on the ground so they have better stabilization if they don't move themselves okay another trick that i'll show you to anybody here that has an x800 is this if you can place a mirror in front of the unit okay if you place a mirror in front of that unit you will help you uh because the patients are going to able to see the lasers and you have better patient cooperation when taking the scans so um anybody that has this capability um you know if your imaging lab or your office where the unit is installed if you have a wall there i strongly encourage you putting a mirror on
the wall uh it can be just a simple mirror you know a cheap one because what happens is it's this by having a mirror on the wall i'm just going to switch backs here really fast um what happens is this you have the ability now the patient has [Music] the patient now can see the lines right the the the lines in front of them and if anything happens you can ask the patient to just you know adjust the face themselves so if you if you are here and the patient is tilted or crooked all and you have a mirror in front of them all you have to do is say hey can you please line up your face with that with that line that you see there with that laser you see there and then you have you have perfect patient cooperation okay so that's why it's important that you guys um um uh add the mirror on the wall so you have the best of both worlds you have the patient facing the operator but you can also have the patient seeing themselves and that will help okay now as we position the patient on the unit now comes a very important uh a piece of information for you which is to select the appropriate field of view or fov on a patient so you have within the marina family three options you have larger fields of view you have median fields of view and you have smaller fields of view and it's important that you understand why are they there why do we use larger median and small and also what are your expectations related to uh the resolution of each one of those fields of view so basically you're going to have good resolution with larger fields of view you're going to have better resolution with medium fields of view and you're going to get to best resolution when we get to smaller fields of view the ideal scenario here is for you to think about what is more important to you
do you want quantity of information meaning do i need larger fields of view or do you want quality of information do you want smaller fields of view they are different and the expectations about them should be also different for example if i want quantity of information meaning i want to see larger fields of view it's very hard to see detail although this is not a marita image here on on the left the larger the field of view the worse detail you will have the smaller the field of view the better detail you will have so um what is more important quality or quantity of information if you want perhaps you're not going to be able to see root fractures if you want to see root fractures you're going to have to go to a smaller field of view and not have quantitative information i'm not going to be able to see all the maxillary all demanding on those patients and the reason for that it's because every time that i have a larger field of view right there's going to be some computational issues associated with the image and it starts with a voxel size so the larger the field of view which will give us good resolution i'm going to have larger voxels typically on the x800 when you're doing a larger field of view your voxel size is 0.32 microns uh which means that uh you're you're 320 microns of resolution so um so uh 0.32 millimeters i'm sorry for resolution if i go to medium fields of view and that's now when you do your 8x8 or your ruler triangle acquisition you're now dealing with voxel sizes that are uh smaller and they're about 1.6 millimeters or 160 microns in size so remember voxels are three-dimensional pixels right they're cubes but just to so you guys can visualize uh you understand the spawn set every time that i'm dealing with this type of voxel if i were a 0.32 before and now i'm at 0.16 i don't have double the resolution i
actually have eight times more resolution because where i had one voxel before now i have eight so you really from um from from a display perspective you know if i can have eight voxels displaying information where before i had one it's much better and the idea here is this is actually a ten by ten from an equitomo is that i can actually start to get very good image quality although i still have some scatter from some of the grounds the overall resolution of the scan to look for bone to look for um detail of of of the anatomy and detail of the dentition is pretty good okay but in in many ways what we're looking for here it's the the show stopper right where morita is known for the ultra high resolution that we have with the smaller fields of view and in this particular case um what we're doing here is we're we're using a very very small voxel size of 0.08 to achieve the best resolution the unit can display so the 0.08 voxel size of morita it's not by chance this actually comes from the work of doctor yoshinori arai who is the father of high resolution obesity imaging the way we know it and what he does what he determined with his studies is that 0.08 is the smallest voxel size that you can go to we doubt and this is important we doubt loss of resolution uh to be honest with you the 0.8 or 1.6 or 0.3 those are all arbitrary numbers morita determines this or any other manufacturer determines this from there on bct scans you can actually reconstruct any volume from with merida with smaller voxel sizes i dixo has that capability um you know the aquitomo actually has a module that allows you to reconstruct the volume as 0.20 um right so you can go to 20 microns with with the acquaintance does that make the image better no what it does is actually introduces a lot of noise to the to the to the volume
and actually tanks it so dr arai actually said that 0.08 is the smallest you can go without the detriment detriment of the image quality that's why marina keeps a zero zero eight so if another manufacturer tells you oh i have a smaller voxel size that i therefore have higher resolution it's nonsense uh doesn't make any sense actually does not increase resolution whatsoever actually shoots themselves on the foot and i'm going to show you this here why in a second so the idea here is this the smaller resolution right the show stopper from rita is the one that's going to give us the highest image quality we could possibly get we can we can possibly can get and give us the amount of detail that we need from bone trabeculation uh pdl spaces and of course root anatomy so from a visual perspective this is where we are today we have here good resolution better resolution and best resolution so remember when you take a larger field of view with your x800 and now you're dealing with a box of 0.32 millimeters which means 320 microns in the same area if you were to acquire an image with a smaller field of view by four you would have 64 voxels displaying the same amount of information so please understand this your your your ability to display detail is going to be related to those numbers however it's important to stress that your final resolution it's not just the voxel numbers there is a lot more to resolution than just voxel numbers themselves um i'm just trying to compare this here so you can actually have a visual understanding of the importance of of the of the ability to display detail so you can have good better best from uh from from a display perspective so what is the difference between that um good quality better quality best quality then the ability to display detail so do i need this what i need quantity of information when do i need this when i need quality of information
so there are two different things um now how about the voxel size right we keep talking about voxel size voxel size voxel size is that important not important um that's what the term resolution so we have this box of wars happening right now we probably have competitors telling uranus saying hey you know my machine is better than theirs because my box of size is smaller um and so on so this is actually not true if anybody tells you that they have a higher resolution than you because their voxel size is smaller they're flat like flat out lying to you because final resolution uh it does not only depend on voxels uh just to give you an idea this is what determines high resolution on a scan it's all those factors here so it goes all the way from the sensor quality to the focal point to the spatial resolution of the volume to the field of view how do you aim at the field of view the amount of noise artifacts the number of base images what was the kv what was the ma what is the air gap which is the distance between the sensor and the tube head you know how to stabilize the patient how about the sharpness of the skin how much i can see the the edges of the scan and this is a problem right now because a lot of manufacturers are trying to trick people to to to actually have beautiful images and they are using filters to remove sharpness and by doing so they are actually removing a lot of really important information for the scan so the ability to see sharpness is actually really important in my opinion when it comes to diagnosis you know overall what is the general projection of the scan what is the diacom output quality what is the dynamic range of the image meaning how how many shades of gray and black and white can i see you know the amount of contrast of course those you know what type of
maintenance do i see do i need calibration um and calibration during installation so those are all things that can control like i'm sorry that can can impact your image quality and therefore um without uh without paying too much attention to voxel size if any of those parameters are off your voxel size won't matter so please don't let anybody tell you just because they have a smaller box of size than you they have better image quality because it's just not true and in order just to show a point you can look at a volume here that was acquired at 76 microns right and you can see that the image is just very noisy extremely extremely noisy and um when we look at the a very similar scan acquire the merida with a box of size of 0.125 the image quality is superb in that perspective and the difference here is very very large and that has to do because it's not only about the voxel size it's about parameters so what is it that you need to do when you scan your patients in your practice uh make sure that your kv is always maxed out okay so for everybody that's listening to me right now make sure that all your acquisitions are done with kv 90 if you have the r100 and kv 100 if you have the xc this is very important and then uh typically this is what i use for my ma if i'm dealing with a child i will do ma5 if i'm dealing with interior teeth i'm doing ma6 if i'm doing three molars i'm doing an a7 if i'm doing molars i'm doing ma8 you know if i'm dealing with an area that has angle or implants i am doing ma8 okay this is very very important um in order to maximize your image quality so again child five ontario achieve six premolar seven molars eight any time that i have endo or implants on on the dentition uh uh within my field of view i'm gonna use eight
you're welcome to you know copy those settings that's what i use here uh in the us and for those that are uh using um the the the new x800 that has the new tube ahead with the 100kv this is just outstanding because um the higher the kv the last amount of artifacts you get it gets to this point where you know you can see the implant here and you you really can appreciate the fact that we can even see the buccal cortical plate with minimum artifacts associated with this okay so in this particular situation which may would i use i would i would use an a8 to really minimize all the artifacts associated with with the dental implants so here's another good example of a 8x8 scan of the maxilla therefore um you know we can zoom into the dental implant and again this is a a 90kv with a 80mm i'm sorry 100kv with ama and therefore very little amount of artifacts but starts with acquisition for average uh it's important to also stress that there are different types of dental implants out there different types of scatter and typically the higher the anatomical number of the metal that you are scanning uh the more likely you will get to have artifacts or what's called being harding artifact what are the best what is the best way to to avoid being hearty artifact is to maximize your acquisition parameters so make sure that you you're taking scans um with the longest acquisition time the 17 second scans are preferred uh over the 9.4 second scans with the x800 um and um another another thing too is that if you need the maxilla for example um you can do a separate scan for the maxilla for the mandible and i would use the maxilla i would use the 8x8 scan in high definition with the x800 in order to avoid those artifacts so if you're going straight to the reload triangle which is the 9x8 the 9x8 acquisition is actually a 9.4 acquisition seconds uh
you would you're not going to have the same resolution as the 8x8 field of view so one more time if you have an x800 within your practice avoid use the 9x8 whenever you have to deal with artifacts and use the 8x8 scan with the hd module at 17 seconds acquisition that will increase your resolution substantially and decrease the amount of artifacts substantially related to dental implants and crowns then um again that's when you get those beautiful scans with um with angel high kv ima all right uh for those who are thinking about upgrading your units 7x7 you know your 100 to the x800 what is the basic difference the basic difference between those two units is that because the the x800 has um a much better tube head and projection geometry you know it's the upgraded version of it uh situations like this where you have been hardening right and you compare side by side of the same patient you can see that that bean hardening is pretty much all gone and that is the reason why you should be scanning the patients with high kg ima difference between the r100 and the x800 and uh david i can take questions right now if that helps um actually it was uh some of it was on parameters there are some machines on the market as well that have 120 kv and they're wondering that uh if that machine has 120 kv would it be even better uh no we're seeing it it's very simple no no you wouldn't so um it by that logic you know 140 would be 160 would be better and so on so it doesn't quite work like that um number one remember if i go back here to that slide that talks about what is resolution right um here there is a lot to do with you you can have a lot of power coming in but it doesn't necessarily mean that uh your your sensor can actually capture all that information from that extra power that is one thing
uh the other component too is also the number of base images you know you're gonna have units out there that have a gazillion amount of base images but they are terrible on an image quality perspective uh and the interesting thing is this in one second here and i'll show you this is the tube head for rita okay so you can see here there are a few windows and that's the that's the uh the collimation for the panoramic you can see here is just a thin line right and what is the difference between morita with 100kv and all the others with 120kv is that when we actually select angel module on the merida it takes away what's called the uh the copper filter of the unit so there's a copper filter coming down up and down so when you are going uh you're changing your your acquisition one of the things that morita does is on on the endo module it actually removes the copper filter and and what it does it's actually filters the that 120 kv and and and creates a lot of noise on the on the on the volume on the other side so the fact that maria can actually remove that copper filter is one of the reasons why we can actually increase the resolution instead of decreasing the resolution the other component about maria that is very different than everybody else and people forget about it is that marina is a continuous acquisition where everybody else is actually flipping it's flicking you're like flicking flicking flicking flicking acquisition so it's a it's a pull shaded acquisition and so the quality of the x-ray being uh almorita it's extremely better uh remember one thing whenever we are talking about uh the x-ray being coming from from a tube head we are talking about what's called polychromatic beam there are different energies there you know you can reach out to 120 kv but it doesn't mean that all the photons on that particular um tube head it's coming at 120 kv particularly
when they're pulsated because they're generating new photons in you know new explosions in every single time where maria is actually continuous so the projection geometry and the um the quality of the x-ray being a merida would be much much better and any part is because of of the the lack of copper filtration and also because of the um of the continuing exposure versus pulsating exposure does that help it does actually uh we have actually experimented with pulsating exposures as well but uh our r d team is simply not satisfied with the quality of the output that's right we can very very correct one of the the most important features of of morita of the software is the zone reconstruction it's important to stress that the zone reconstruction doesn't work on all volumes if you have an x800 the maximum field of view that you can acquire the image it's an eight by eight so if you have an acrylic then it doesn't matter where it's with with all volumes but um of the x800 only up to eight by eight you have to be you you have to acquire the volume with with 17 seconds in order for the zone reconstruction to work okay so you have to acquire the volume uh with the hd uh module for the zone reconstruction to work so how does that how does that uh work the zone reconstruction so the idea here is you know i acquired a mandible and as you can see there are many interesting findings with this mandible this was for dental implant you know you already saw that there was some sort of a silent silo lift here but i'm going to be more focusing a little bit more on the anterior dentition here i'm looking at the center and size i'm going there's something weird about that center incisor so i click here on the reconstruction icon i can click now on zoom reconstruction this little icon right there it's on reconstruction and this circle pops up i can determine the size
of the circle right i can just put it over the area that i want to reconstruct and determine the diameter of that of that circle so here i don't need to do five centimeters i just need to do 30 millimeters which is three centimeters here so i select that area and now i'm going to choose the voxel size that um i am going to use so as i told you before maria has the ability to go even below 80 right so this this this could go to 20 but the vast majority of you will see 80 here so we're going to click on that case 80 microns then i typically i change my slice thickness and my slice interval to the minimum voxel size as possible which in this case will be 80 right 80 microns for one one just keep it a one to one and then all i have to do now is hit the button run so i selected the area i selected my new voxel size i selected now the the smallest interval this this the smallest thickness and i hit run what the computer is going to do it's use the base images acquired for the large field of view and reconstruct a brand new volume just for that area of interest so it takes about three minutes for this process to to work i'm just speeding up the video here so you can see it's doing its processing say yes or no up to you if you want to save this or not now it's going to open the new volume so the moment that he opens a new volume you can see now that this is a 3x3 scan and now it's just like if i were if i had acquired a smaller field of view of the anterior dentition so i can go in now and start to evaluate you know the area that i thought was happening there was a problem and i was right see you can see now that there was invasive cervical resorption
associated with that area then i can start doing all my imaging manipulation i can change my image my slice thickness you know and go from there and you can clearly see now that uh um you know i i do need to go and take another scan to highlight the fact that this tooth had invasive cervical resorption associated with it yeah so so that's how you use zone reconstruction okay there's really no uh no secret here it's very easy for you to to use um and um it's very helpful anytime that you need detail uh of an area right uh particularly after the patient left your office or left your imaging center and then you don't you know you avoid having to call the patient back and say hey come back i think i see something you know i want to take another scan or whatever so that is very helpful another thing that um it's important for me to tell you it's how to enhance your skins um i i've been using this now for years i've been lecturing this for years i use this now on pretty much every endo scan i acquire uh which is how do i improve image quality okay for endo scans so i would i would ask everybody that's hearing me here now to use this technique so instead of taking a scan where the patient um you know uh uh uh the lips or the bustline muscle collapsing against the gingival tissue this is what i want you to do i want you to now every time the division comes in for a scan for angle place a cotton roll on the buckle aspect of the tooth of interest okay so if you place a cotton roll on the buckle aspect of the tooth of interest that will push the business muscle away or or the lips away from your gingival outline and will allow you to better see the soft tissue of the patient so you can use also lip retractors if you don't if you want
to lose if you want to do larger fields of view i if you're doing smaller fields of view um the the cotton rolls are preferred they will enhance the buccal cortical plate for you and most importantly they will give you this information here for the soft tissue outline of the gingiva so anybody that's doing scans for periods you can actually start doing uh perio analysis for your doctor so basically you'll measure the distance between the cj and the alveolar crust the thickness of that of that soft tissue the thickness of the the cortical bone here and the thickness of the soft tissue as well so your periodontists are going to love you for this if you provide the service um one thing that i use a lot particularly if you're doing medium fields of view or larger fields of view it's this guy's called the free access to from rita um it has this little wing here that pinches the business muscle and opens this buccal corridor all the way back to the third molar area right to the to the tuberosity area so the way this works it's like this i place this inside the patient's mouth with the with the metal part um you know going up towards the patient's eyes this will not interfere with the image quality whatsoever so you rest assured there will be no artifacts coming from um from this and then you can now go take your scan and this will allow you now to image the patient all the way back to the tuberosity area and and it really helps you better um you know evaluate the soft tissue profile of the patient not only for maxilla but also for mandible so that's a very good trick for you there to kind of help you uh enhance your image quality and if you ever need to see the pellet for whatever reason right what you can also do is actually place a tongue depressor uh around um you know the back side and that tongue depressor here
will act as a gauge that'll prevent the uh the tongue from going up and now you have not only what's happening from a buccal side but also from a palatal side so this is how i would do uh maxillary scans for example uh for implants as that that gives a lot of extra information for doctors related to the buccal cortical outlines of the dentition another important tool related to the software it's the motion correction tool so how do i use the motion correction tool of merida it's not uncommon from time to time for us to have patience with motion so as you can see here on this particular scan you know there's double coordination see double coordination of the outline of here we're looking at the frontal bone but you can see that double coordination there that means that this patient moved you look at the dentition area everything is fuzzy that's because of that type of motion so if i go back here to um if i go back to the scan itself i can right click on it right click on that scan and i can i can select show display ct movie okay i'm gonna do the display ct movie and then you will see the acquisition movie for the um for the scan you're gonna see that that that is just loading here you will see here in a second the the the acquisition move here we go and then you observe the the acquisition and then you have to figure it out when does the patient move you know perhaps the patient swallowed the patient moved a little bit you know sometimes it is in the beginning of the scan sometimes it's in the end of the scan sometimes in the middle of the scan so the idea here is to try to figure it out when did this patient move and after you do that what's this after we do that what we're going to do now is we're going to go back to the same area that we
can do the zoom reconstruction and instead of doing the zoom reconstruction right now we're going to click on what's called detail next door to it and we're going to do now 180 degrees reconstruction i'm going to select 180 degrees reconstruction i'm going to select the angle and i'm going to tell the computer listen i want to i want you to scan the patient from this this this point forward because the patient moved in the beginning and in the end so i'm just going to use those base images now to reconstruct the volume and i'm going to say run i'm going to do a second reconstruction now and i'm going to eliminate the base images where the patient had the movement so it's doing his reconstruction now and try here here we go here comes the the next uh the next skin here we go so now we have the next scan we can adjust the histogram the same and all that motion is gone now the images are sharper again so any volume okay that is a see look at that beautiful there's no more double coordination anywhere within this cancel every overall the sharpness it's it's great so anytime that you guys have motion okay motion artifact it's possible to remove it um uh mr zliman um we i can process i i actually wrote a paper with dr bernstein from hong kong um related to this um which was probably your suggestion we had this talk a long time ago about this module absolutely we publish this and we can actually send to everybody uh the paper right talking about about about this and how to implement this yeah we can certainly put it together um some of the some images from that uh show up on one of the brochures as well um this was a accidental discovery bought by dr bornstein he had no idea the machine could do this and uh he sent us a an image that he thought was unrecoverable and just wanted our opinion on it and
we just asked him to do exactly what you did and uh he was actually astonished that that was a that was a thing so yeah from that the paper was uh was produced yeah so it was a collaboration which was between us here in the us and him in hong kong and beautiful paper so i can't send it you guys uh and this is a huge advantage for marina and you can see here but before and after you can see how fuzzy the image is and how sharp the images are particularly on on the the frontal bone now um there were some questions that were sent to me by some of you asking about uh convincit reconstruction okay the cbct reconstruction um filters that comes with the unit basically i would ask you not to change that there are you can go here to your reconstruction you can see there there's several defaults one of the things that i want to make sure is that the unit that you guys are using are using this particular uh one here the g003 h plus h2o5 okay if you're interested in house field units if you want to measure house fuel units with your own bct scan that age has to be there you have to be using an a plus age filter if you don't have the plus h filter you cannot measure household units with your uh with your with without dixon okay but if it has that please please use it so ideally speaking you don't want to change this this much there are different filters they're medical filters we use those more uh with the acuitomo but if you are with their 7x800 which is the r100 and the x800 please just keep yours at g003 plus h205 okay do not change that the other thing that i was going to tell you is um and and this is something that i had i had a discussion with mrs limited i want to say about six seven months ago we've been working with
this uh together is that um your capture box okay your driver box within idxo particularly for those who work with larger fields of view the x800 we can we can actually change the resolution of your reconstruction so the negative reconstruction right now for the larger field of view of of the x800 it's it's 0.32 millimeters right so 320 microns um right now we have the capability to change the the voxel size from zero three two to zero point twenty five um this is something that i was discussing this with mr slimming before this meeting so you would have to contact your engineer your marital dealer and they will log in remotely and perhaps maximize that image quality for you on your scans is that correct mr slimming yeah essentially i mean the default resolution can be changed as a as a setting of the driver so in the user manual you'll see how to get access to the driver settings and uh like dr azevedo said we don't normally recommend changing the resolution i'm sorry the reconstruction filters but in that same area you do have the ability to change the default resolution now of course there's limits to that we go down to 0.25 on this larger volume you can't really go much lower that goes back to the previous discussion that uh was made earlier in this presentation um you're looking for you know quality over quantity and your computer eventually just hits its limit you know we're not able to reconstruct a you know 0.08 at a volume size that's you know 150 millimeters in diameter uh you just don't have enough memory for this kind of thing so there will be limits and 0.25 is one of those sweet spots it works there's enough memory to do it and you can see the results on screen here yeah you you may see uh you know other manufacturers advertising this saying oh yeah we can you know we have a volume of 10 by 10 and it's a it's a zero point
you know 0.075 micron the challenge with that is what do you do with that data because that data will be about five to six gigabytes for one convexity scan and uh it becomes almost impossible for you to export and actually load into third-party softwares to actually look you know to look at the volume it becomes super super heavy and kind of clunky for you to do that even if you have very powerful computers uh to run it so uh just like mr slimming was saying if you if you uh change the computational issue here you're just making really really large files that are going to be exponentially larger than your normal ones okay but there is one more thing i want to talk to you about uh the software uh that is important and though and this is for those who export dicom uh third party softwares for example or nobel guide or things like that to to create surgical guides and this is something that i discover with mr mr sleeman this year as well so i have we had some conversations about the same time we were talking about this reconstruction component here and um mrs lehman actually developed a little tool called read a config where again you you call your dealer and they will be able to use this with you if that's what you're interested in and what we discover is that every time that you export the icom from idixo idixo adds a little bit of median filter to the volume and this medium filter actually removes a little bit of the sharpness of the edges of of the scan and and and that's why sometimes when you are looking at a scan that was exported from from rita and you're looking at a third-party software and then you look at the image on like dixo that image will look different right so you look at it on idx and it looks fine you look on the third party software the reason why it looks different is because of
this filter here this minion filter so i would ask everybody that's having problems with the dycom export uh from rita to contact your dealer so they can actually go in there and turn it off okay this is what they're gonna do they're gonna all they need to do is unclick this box that says use medium filter when slicing and then now every time you export your dicom you will have the exactly same resolution and exactly the same sharpness as the image that you guys see within idxo is that okay so that is a little a little thing that we discover very if not not too long time ago um but i feel would be important for your market perhaps because you guys export a lot of daikon or third-party software is there any question there for me um i don't think there's any question at the moment we're just discussing recordings here but actually i do want to make one additional note based on this with this particular tool as well and again your dealers and our local affiliates can help you out with this you may find that some software has some compatibility issues with dicom as well we tend to export just the basic raw data but there are occasionally some additional headers that some software expects so if you do have some issues with importing morita dicom images into your software we do have that ability to simply turn on those headers so that they're recognized properly so it's not a problem with your dicom files it's not a problem with your software it's just a setting that needs to be changed and uh our dealers can certainly help you out with that excellent thanks steve no trouble so now let's let's dive into some cases there is a couple things that i wanted to talk to you about it comes to merida and that has to do here i'm going to show you a couple things that can speed up your process when reading a case so if you guys go
into your idxo okay one thing that i want you to do is go to your settings within my dixon go to display and make sure that under display this this area right here that says 3d viewer a histogram display mode just make sure that apply default preset value is selected okay this guy right here because this will allow you now to create your own uh a histogram template but what do i mean by that so let me open a case here could be anything when the last patient was looking at okay this guy so let's take a look at this this this this patient you know sometimes they're going to open they're going to be like this i can hit auto here they'll have something that looks like this too bright 3d rendering is not as good right so what i can do here is um next time you you you open a case you can adjust your histogram typically um if you guys if you guys want to know a little bit more about how to adjust the histogram and the science behind it there's a whole video on my website convenientguy.com just explaining what i'm doing right now and just for the sake of time i'm just going to do it normally i can go here now to my color presets and uh make sure that my 3d rendering is great okay so this is something that i always do and what i go now what i do now you know if i'm happy with the image quality i'm happy with my 3d rendering preset uh of rendering i go to presets and i can create a brand new preset for me all i got to do is right click on it and say new and type you know whatever i want and hit okay and now this preset it's saved here all right and um and then from there what i what i do here is i right click on that preset and i say set as default so from this point
on every single time that i acquire a scan or open a scan within my dixo the histogram is going to follow the densities that i like the brightness the contrast that i like and the 3d rendering is also going to follow the um you know the the kind of a segmentation that i like here so this can save you a lot of time because if you're having to adjust histogram over and over again it's it's very annoying other things too is that if i messed up the histogram here you know messed up everything all i have to do is to right click on the image go here to contrast color presets and i have several colors in presets here see so this is the one that i just created marina i'm going to click on it and you go back to exactly to that i want to change for example this preset here to another preset that i created i can just right click on it so those are all things that i created in the past and i can just keep going here right so to to keep going back and forth so this idea of having to adjust histogram over and over and over again is very clunky and maria has this ability for you to save your preset so you don't have to do this ever again you know keep keep moving things over and over again just again find the densities that you like save it as a preset right click later on on it and then here it is you get everything there that you want so this this can save you a lot a lot of time okay so that is one one thing that i will tell you um another important thing that you can do this was a question that i think we got from um from folks that were watching us so let me put another scan here this is actually running out of one volume viewer let's just see here okay so if i were
to adjust this image quality just very fast here so we can kind of play with it let's go to the 3d rendering so the 3d rendering okay there are a couple of things that i want to show it to you that that is sort of annoying okay um um to me and it's very easy for you to fix so a lot of times you you see this blue line or purple line basically what this is actually showing you it's where is the coronal plane so see if i move the corona play more interior this is where the the this is where it is so if you sit sideways here it's going to move side to side or back to back right so that's that's the whole point is just to show you where is the blue line that's why it's purple so you can turn that off pretty easily here just turn click on the first button here turn that off secondly now the scan is actually uh you know every time that i rotate my axial image here you can see that the 3d rendering is also rotating it's optional for a second so if you if you want the 3d rendering to rotate by itself and click it right so just unlock them so now i can move this guy here and it's not a problem if you want to lock them again you can now synchronize so the volume will synchronize to the slices so perfect but what is annoying about the default setting of this software for me uh that's very easy for you to change is this please pay attention to the to the to the 3d rendering here every time that i rotate the volume see how the 3d rendering becomes pixelated and then i release then now the sharpening comes up so again one more time when i'm rotate everything here is pixelated and then i release and now the the 3d rendering is on focus so if you guys go on your settings okay on your idexl
settings you will see here that the dragging resolution for default on reader is always closer to low i want you guys to change that to high okay always change that to high uh and the reason for that is because the moment that you change is too high now i can rotate the volume and see how there is no more pixelation of the 3d rendering i can move this around with no pixelation okay the other thing too if you want to increase the resolution of your 3d rendering is go here where it says resolution and change that to 10 24 okay so those are the two things that i have on my ig so resolution 1024 dragging high so if i go back here you will see that that's already my default setting there see um and high resolution 10 24. so the moment that i do this what do i do now is i go here to this button and say set as i click settle as default this has the current settings has been shared i say okay now from this point on every time that i open a scan every time that i move my 3d rendering there is no more pixelation whatsoever so uh this is how you start to enhance your 3d rendering okay this guy goes here these guys go all the way back there now there are other things related to the 3d rendering that we can do so i'm going to go back here to that viewer that we were looking at and that was this guy are some of the things that i can do to enhance my 3d rendering um so the 3d area is the color presets right here okay so typically this is what i like to do i like to come in here click on my color and you can kind of uh kind of clean out the voice of the soft issue can you leave see how i'm leaving i'm leaving um all the teeth behind just by moving my line here
you can kind of play with this okay what i notice for most merida users is that they use one size fits all for um for this type of uh of scan so for example i can come in here and play not only from do i add more or or do i you know if i play with this horizontal here i'm adding more noise every time i got to the left i'm adding soft tissue at the time i'm going to the right heart tissue okay and then the horizontal line here this makes it transparent so i can make it very transparent i want to so something like this transparent okay i can you can see here of my you know the frontal sinus of this patient and so on you can see bruno i don't understand why you're doing this um well the thing about idxo um and volume rendering is that you can add different colors and different textures to this so if i go here right now and i say give me a new caller okay just press the plus button here saying you so i got a blue collar here and i can choose that color that i want i came back back you know come a little bit forward let's let's um let's move this line you know it's too much uh my crucial surface look blue right so it's it's interesting because you start now to control densities that you want to add and you keep adding and adding and adding and you can create your own template for this and then the moment that you like what you did i'm going to add another color here just for the fun of it let's add a change this color to let's say red and actually while you're doing this as well uh i'll just make a note that uh since you are doing this i can imagine on a notebook computer um yeah yeah it's rendering changes it's a bit hard for me to manipulate this but i just want to
show the idea you're right yep it's a little rough on your microphone so the sound cuts out when you're actively manipulating the volume rendering yeah so i just wanted to make sure because this is one of the questions that i get the most what can you do with this you can do a lot with your volume rendering as long as you are you know moving in in different capacities here so you can try again it's kind of hard for me to control it what i'm doing so now the roots are blue you know the frowns are red you know bone is transparent um it just kind of gives you an idea on what is possible you have to go and play with it and kind of figure it out what is that work for you and for your market and what you want to try to say and when you find what you want all you have to do is go here to presets right click it and then you save this as your preset for 3d rendering that will be there next time you need to use it does that make sense so um so that that's why this is important all right so as we are here a couple of things that i want to show you is that um if we need to zoom in in any area of the scan as you know you can drag it this okay or drag it that way that is one component but the best way that i find for you to zoom into any area within idxo is to go under tools and select the the hide your fov region which is that box and if you click on the and drag the out of the box component okay you can kind of a going out and zoom into the area you can double click this now and i can see just that area right there and um you know and pay attention to whatever was going on where we had this extraction or
pay attention to this supernumerary third molar here so now i can navigate this very easy in focus if i want to get out of here double click and you're there so if you want to zoom into the images that that was one of the questions that we had um somebody that's the best way to do so use the zoom box which is this guy here under tools all right um okay next question that i had um that i'm going to address here was a question related to how do i mark the canal what are the best ways to mark the mandibular canal within idxo so i'm going to show you guys the same thing okay we we have here see how how it pixelates because i'm using one volume viewer maximize maximize so now i can move this guy around not a problem how do i mark the canal so for those that are marking the canal the best way that that that i found to use the the mark the candle tool is to use the sagittal view for it so how do i go about that so let's start with the left canal here um i'm going to start moving around my axio and i'm going to use my now axial plane okay axial view here to start finding where the canal is i typically what i do is i go um right there where you see the canal use my axial view to kind of a trace it so now i know the canal is right here see on this line so i try to place it parallel to the to that line and here it is super simple so here's my canal so i'm gonna use my toolbox see how how i can see the canal really well it is so every time that you're marking the canal the important thing is for you to always pay close attention to this to the top part of the canal i'm not i don't know i'm too concerned about the inferior border of
it but i'm very concerned about the superior part of it because that's what your doctors are going to be paying most attention to so if we go here to the all i did now is i click the mark the canal tool okay so when i click the mark the canal tool as you can see i have now a circle okay a circle uh that is going to be where i'm going to mark my my my the canal the thing about the circle is this sometimes the circle is the size of the canal sometimes the circle is larger or smaller than the canal so what you can do is if you hold your right button down and you use the uh your your mouse wheel you can make that guy larger or smaller okay so it's a i'm controlling this i'm just holding the right button down and controlling the size of the canal or the diameter of the canal with my mouse the mouse wheel so after i find where i want to place my first dot the idea here is line up the upper part of the circle with the the superior cortical outline of the canal so i'm going to put my first dot there so i'm just going to release now my right button and here is my first dot this is a this is a point and this is where i started to mark my canal so i can go and move a little bit i typically just about one the same diameter of the canal here and i add another click so right click on it and another one click and another one click and another one there click and another one click if you feel that the canal is moving in direction i can always scroll to kind of a change change positions here so you know i'm if this guy here is i can always move this guy back and go back to you know if i feel the canal is getting tighter i can make it smaller
go there go there no more points all the way to where the mental foramen is and now i'm going to move my my lines a little bit more buckle with my with my wheel double click it i'm done so you guys can see here that i marked the canal really well so the other thing that i did was i marked the canal with a lot of points why is that i i marked the canal with a lot of points because the more points i add the easier it is for me now to perhaps edit the position of the canal okay so um as i was marking the canal i was as you guys saw here i added tons of points okay with the canal and each one of those points i can actually click on it and make and then pull them out or bring them down or bring that up so each one of those points within the the canal i can add i can add the position of the canal with them so that's why i add lots and lots of points there so one interesting thing is this is that um if you are now if you need to adjust an area within the canal that you drew and you don't have a point that you can grab so for example if i wanted to adjust this area right here i can right click the canal and i can see here insert a control point there so now i have a control point that i can kind of uh play with it okay and um what else uh you can make the canal transparent you can change the color of the canal uh that you want if you want to make it red instead of purple you know you can do any anything you want here and basically that is the best way that i found that i found to draw the mandibular canal uh some people like to use the corona i just prefer to use this azure i think it's
much faster much more predictable to do this so that this is how i do the mandibular canal component okay [Music] then if you wanted to perhaps you know plant dental implants for somebody there are different ways to do that um if you want to plan implants and i'm going to go back here to my ipixel software let's go find a case here with um with an adventurous area by this patient so i have my own presets right so i can reader or i can go here you know some of my other other presets that i've used but just to keep an idea on that okay um now if i want to draw and make implants or make a case here it's important that you understand this every time that you use the curve reconstruction and that is for you to create a panoramic arch around this patient if you are actually doing a maxilla and mandibular planning you're going to have to draw two curved npr's one for the maxilla and one for the mandible so how does that work on on average what i like to do is i go here to my you can click directly on curve npr or you can go here to tools and click on the draw npr and uh you start from where the fondular head would be and you try to follow the center part of the dentition you can double click that and that will create our panoramic arch okay so you can see here that i drew a panoramic arch focus on the maxilla not too much focus on the mandible and the other thing that i can do now is to change the slice thickness of this cut on average this should be an eight let's see here thickness see it's an eight actually this is 15 but i can make a little bit thicker let's go 30 and now i'll see this a little bit better and the reason why i don't see the mandible okay and that's the reason why a lot
of times i draw two arches it's because here it's enhanced for maxilla let me make this a little bit thinner go back to 15. um and then if i bring this line down here to the mandible okay look at that the maxilla the shape of the maxilla doesn't match the shape of the manual so that's why it's it's important that you always draw one panoramic reconstruction for maxilla and one panoramic reconstruction for the mandible if you just want to draw a panoramic reconstruction really fast i'm going to show you what i like to call the dirty dirty trick the dirty panoramic reconstruction uh sorry let's go down here and delete this i'm going to say i don't want to save this guy how do i do this very fast it only takes three clicks so you go one tmj needle line other tmj double click and now it gives you kind of a this arch that uh gives you like a like this dirty little panel like very fast see so um it's i call it the three click three click panel so i'm gonna show you another case here that doesn't have a lot of uh issues so if you put here in the middle you go curved look you go back forward back there is the pan okay so that's a very kind of a it's a simplistic way to do things but um uh your works all you want all you want to do is like a little thing but if you really want to be precise you're going to have to go one for demand mandible one for the maxilla so let's do the mandible here this guy oops you same yeah let's delete this guy and go one two three see write it always in the follow the middle of the dentition and you will see that we'll have the mandible now enhanced and the maxilla not enhanced so it's important that you do that okay from here um we're going to go in and start you know looking at
that area where we're going to place the implant so in this case we're going to go back to the mandible we can try to find what what the path of the insertion of a dental implant is so one of the things that i would ask you is that if you were planning implants for photosurgeons periodontists or helping them find the implants have them do a radiographic guide for you that would be very helpful if you can do that because that will kind of give you the idea on where they want the implants to be placed and so on i don't think it falls on your responsibility to know this it will be more on the responsibility of the clinician sending the patient for scanning and perhaps giving you a radiographic guide for that but if that is the case you want to place an implant in this area one more time i can put the uh i can i can do the the guy there right um if you feel that this patient oh it's twisted just turn it okay so now it's correct and the idea here is okay let's let's go plan an implant here for for this right side so we can go to your own implants tools so here under tools you got your you should have a robust implant library there here you can see i have all those implants on my library i can go to a very famous implant to go strongman you know i want to go a standard with this guy see this guy's discontinued so let's go soft tissue level one and i can choose what implant i want to use i want to say i want to use a letter 10. am i using this lower jaw upper jaw so you can do lower jaw here now and uh i can just say create and the moment that i create that implant now i can move it around how do i move this implant around is um i can just click on it right
and you can see here that i can move the implant around in any direction i want so i can place it right where i think it needs to be and the dental implant now is showing on this particular uh on the 3d rendering a cool thing that the morita software has for you know the position of the dental implant i'm just going to screw up everything here is that you can after you place an implant within idxo you can go here this button that says align the volume with the implant so you click on this button now it's upside down but got here so now everything is aligned and i can go around with with my volume 360 degrees here and you you kind of check to see if the implant is there so that's why you would do this it just aligns the the scan with the implant so you can rotate and just make sure it's there the reason why i keep telling you to add the annotations is that if you know what type of implant system the doctor uses you can actually drop this here and this will be the implant that will be sent on your report right so we planned this with a by three by by three by three uh uh three point three i'm sorry by ten so add that there um and you can capture the same and just print those images but if you send them just the the viewer okay you send them the viewer like this um it's important that every time that you send doctors viewers you guys add as many annotations as you can so for example there is a little i don't know idiopathic osteosclerosis here on the other side let's do that i just put an arrow here and just say idiopathic loss of sclerosis right so there is the arrow so the arrow here is very big so i can right click on it and say decrease size and crease size and one more time decrease size so
here is that uh here's the same area there so i'm going to do the same thing i'm going to add another arrow this position [Music] let's say right click on click on it the crew size and resize i can also go in and say what this is so uh roses okay so right there why why is this important because when you send this to your doctor right you send you send this viewer to the doctor one volume viewer and you add all the annotations here all your doctor has to do is click on those annotations so i can come in here and double click that and see it takes me straight to that finding i want to see the dental implant double click that it takes me straight to that finding so every time that you guys are reading scans and making measurements and doing annotations make sure that those annotations are here and then when you export the diaco okay when you export the diagram you guys are going to click on this button right here that says export images and do current state okay current state and as you do your current state you say yes and okay and um you know you can put this on anywhere you want on any folder you want and next time the doctor opens the one volume viewer on on their uh on their computer all you have to do all they have to do is click on the things that you added there and will take you straight to that position so it's much faster for the doctor to navigate with the annotations all right and and with that my friends my my time is coming up here baby i have about you know 10 more minutes with everybody i totally understand i mean i really really thank you for for cutting this so close today um so yes if there are any last-minute questions for dr azevedo this would be a good time to ask if there are any other questions on operation or
maybe just minor technical things i can also stick around personally for a little bit longer yeah if you guys are interested you guys can go here you go to this website here this is my personal website thecombingguy.com you go to courses and go to mastering i did so there is another one-hour webinar here for free with all kinds of tricks about idx on you know histogram and things like that so you guys can watch this at any time okay qual bean guy slash mastering idxo um and then you you just watch the webinar yeah that's excellent thank you very much at the moment uh yeah it's looking fairly quiet so i think we can also ask ahab and hideshi who are two of our representatives for the region they can also gather some of these questions after the fact and pass them along to us so we'll be very happy to answer any of the additional questions that you may have sure yeah um so one last thing here david if you don't mind one of the questions that i had i forgot to answer this is it's when do i use duo npr right so the dual mpr it was actually meant for the tmj area so anytime that you have larger fields of view that's when you actually do your your your um your dual npr analysis so you're going to draw you know the lines here for the tmj right side and then left side and that's why you have uh you have the you have the tmj so this just move the white line so now it's like that this is you know move the sagittal line away so here we go this is how this is was meant to be this was meant to be used for um for the tmj region okay and and you know so now you can see the cross sections and so on you can do tmj analysis with the dual npr however again i didn't have time to to go through a lot of
the stuff that i thought i was going to have time to um let's say let me get this case here you can also use the dual mpr on endo scans so you can go here and say dual npr and um use this guy from here to here where you can now look at cross sections right and then you can look at this guy from here so now you can look at coronal views oh sorry sagittarius and the idea here is when you are in this module you can right click it and you can change your slice interval so right now it's two millimeters but let's do uh 0.5 and you can see now that every time that i move this line it moves 0.5 millimeters in this case you can even see to start seeing the vertical root fracture right there so for those who want to see vertical loot fractures i know you're tempted just to look at the axial view but what i what i'd look for is this find where the vertical bone loss is find the large diameter for the lesion okay and then line up that large diameter with the lesion here with your uh this area and then move your in this case your sagittal view all the way to that region and look at that suddenly that that um the fracture becomes alive and then you can right click you can change your slice thickness make and make it a little bit thinner and even add sharpening to it and if that is the case and it becomes too thin [Music] becomes too noisy although i can see the fracture really well there maria has one last tool that i wanted to show you uh which david created but it's it's uh and it's really really cool so mr slimming is the father of this thing here so you can go to i and you can change now the filter type from me to medium and remove all this noise from the from the scan so you can
apply changes yes and the software is doing a reconstruction and applying the medium filter to it and every time that you have a noisy and noisier skin you can do this trick and you will you will pretty much clean every single uh dot that you saw there from noise and improve your image quality this is something that rita has i haven't seen it in many other softwares uh but he works beautifully with mourinho and i'd actually like to share with you as well since we've got a moment or two while it's uh doing its thing um we've recently released our autumn release of the software and uh for the x800 in particular comes along with a couple of new filters and in general as dr azevedo said we don't usually modify the reconstruction filters but we added a couple here that may be of interest to specialists and these ones are geared towards the reduction in noise so it sacrifices a little bit on the on the mtf or your spatial resolution but what it does is is tends to blend the noise a little bit better um there's a couple different levels that you can apply um so for dr azveto in particular maybe of interest to have a look at so see this is now the same image we're looking at exactly the same image we'll look at the fracture right there okay and you can see here we are thickness zero and we are using sharpening and now the fracture it's very well seen there on the on the on the sides of your see that just because i remove the noise so it's um it's a really really important kind of cool kind of a finding and i'm going to show you now the difference between the original one and this one so you guys can actually appreciate it so this is the original scan and this is what we did we went here to thickness zero and we apply sharpen so this is where it was okay this is where
it was and this is with the media reconstruction night and day so uh yeah i'm excited to see that thing but i haven't seen those those new presets yet yeah i'll send you i'll send you a note about that later it's uh it's a very very new release so um it's a good chance to have a look uh at this but um yeah this would be the point where there'd be you know some applause and stuff like that it's very very nice yeah so with this time man um i think i got to get going here because i got to check out of this hotel but uh um everybody uh that's on the middle east uh i wanted to say thank you for you know spending uh your evening here with us i appreciate it a lot i hope you guys learned something new today and um always a pleasure to to see you all and i hope you guys can stay safe your loved ones can stay safe uh from you know those pandemic times that we're living in the world and uh you know god bless you all and uh i'll see you guys soon thank you
