Good morning. I'm Doctor Patrick Ball from Animal Dental Care and Oral Surgery in Colorado Springs, Colorado, in the United States. And I want to thank the British Veterinary Dental Association for inviting me to do a talk for this webinar on Conebeam CT and thank you for Zoom during this time of pandemic and the ability to do these webinars.

The unfortunate thing about a recorded webinar is that we have no way of answering questions. So I want to let anyone know who attends this, this meeting. If you have any questions for me, you can see my email down below [email protected].

Feel free. To send me any of your questions. I'm actually right now, here in late September, recording this webinar in County Donegal, Ireland.

I had the pleasure of being at the IM 3 Dublin facility a few days ago for a diplomat learn and share meeting. And to take a few holidays, holiday days with one of my daughters and a colleague of mine who is at the meeting, and we're hiking here in County Donegal. So I have a beautiful view of Donegal Bay and the Atlantic Ocean, and I'm gonna go ahead and see how the technology works here as far as recording this event and we'll go from there.

So, let me Go ahead and go to full screen here. And will launch. So conebeam CT for me was something that I knew was on the horizon that I knew was becoming more and more popular, that the technology was improving.

And I kept on telling myself that it was something on the 5 to 10 year plan, and that was just kind of my way of putting off getting conebeam CT until a few years ago at the veterinary Dental Forum, where I had the pleasure of Meeting David Sarment from Zoran and got to see a vetA unit up close and personal, and got to see it in action. And then we did a trial run in my clinic in Colorado, and within a few days, I made the order to get a vetAT unit and I've been nothing but pleased with it since then, and it's just greatly changed the way I practise veterinary dentistry. So the benefits of cone beam CT over digital dental X-rays that I've realised is number one, it gives you a three dimensional image in great detail.

And if you look at the 4 images in this slide, these are the planes that we can view our patients in. You get a coronal view, an axial view, and a sagittal view. And then on the lower right.

We get a panoramic reconstruction. I don't use the panoramic function quite as much. Maybe I should do it more, but I really depend upon the other 3D views significantly, and you can scroll in and out of these different planes and, be able to pinpoint your location for each one, and I'll show you that function in just a second here.

So really, in my opinion, it's significantly better than digital dental X-rays, and you also get a 3D reconstruction. I'll show you, multiple images of 3D reconstructions. So compared to dental X-rays, Which are two dimensional shades of grey, 256 different shades of grey of superimposed objects over each other.

You truly get a 3D image with cone beam CT, and these are examples of 3D reconstructions. The image on the left, you can see that this patient had a large digerous cyst secondary to an impacted tooth, this cat on the right. Was a case of trauma where it had a pretty significant fracture to the zygoma and comminuted fracture with a pretty large piece of bone there and multiple other smaller pieces of bone.

So I'll actually talk about that case towards the end of my presentation. So again, this is the multiplanar view that we have. You have your coronal view where you can scan down through that aspect.

You have your sagittal view, which is up here. On the, let me see if I can move my screen there, sagittal view on the upper right that we can scan across back and forth, and then in the lower left, you have your axial view. There's a skin reconstruction here, and these different lines represent the different planes that you're in.

So at that point, That's the location of the sagittal section here. The green line is the axial section here. If I was to rotate that 3D reconstruction, which I can do quite easily with this unit, then it would show me the plane that I was in for the coronal view.

So really, it's, David Sarmet described the software to me as elegant software, before I purchased the unit. And I didn't quite know what that meant. Then when I got into this and I started using it, I thought, yeah, he's right.

This is quite an elegant piece of software as far as the ease of working through these images. And for me, the the learning curve was was minimal. I picked it up far more quickly than I anticipated.

So, what are some of the benefits of cone beam CT over dental X-rays as well, besides the increased detail, but, in my opinion, you decrease anaesthesia time. It takes probably about 4 to 5 minutes to perform this scan. So, in my practise, that probably saves about 10 to 15 minutes off the anaesthesia time.

Do I still do full mouth radiographs in these patients that are having a cone beam scan? And I don't. The vast majority of the time, I don't.

Initially, I did for the 1st 2 to 3 weeks. Once I got comfortable to with reading these images, I, I was performing full mouth X-rays on all these patients, and then I just stopped that. And now I, I may take isolated images if I feel the need to do that, but I typically do not do full mouth X-rays.

So again, you get greater detail than two-dimensional dental X-rays. It really is the diagnostic tool of choice for the TMJ joints. It's very good.

It's excellent for imaging degenerative joint disease changes in the TMJ joint or jaw fractures, Mandibular fractures, anything involving the temporal mandibular joint, the code unit is very reliable for that. In my practise, it's become invaluable for evaluating caudalmandibular fractures or any type of oral maxillofacial fracture for that matter. This is an ongoing case that we have in our practise.

You can see this right TMJ and the severe changes that are going on there. And this is septic arthritis of the TMJ in a 3 year old golden retriever. And I apologise.

I also have slides, or images of the, tympanic bula, the middle ear, which is, is imaged very, very well with a cone beam unit. And this dog had pretty significant otitis media, and we believe that there may have been extension of the TMJ septic arthritis to the middle ear. Or vice versa.

We don't know what came first. Oddly enough, the culture for the middle ear was negative, but the dog at the time of culture was on antibiotics. But either way, this was a case that I did an arthrotomy on, clean the joint, lavas the joint, got my Culture and biopsy samples and then put the dog on an extended course of antibiotics.

And it would have been very difficult to get an image like this or to get a clear idea with skull radiographs compared to Koebe CT. What are some of the limitations of cone beam CT? So you do have a large field of view, a very large field of view.

And you can't scan down to an isolated tooth, and only scan that area, you have to scan the entire patient again. . You do not get nearly as good of soft tissue detail with cone beam CT as you do with conventional or helical CT scans, and you really do not get an added benefit of contrast agent with cone beam CT compared to conventional scan.

I have tried that a handful of times and simply have not been able. That kind of detail. So if I feel the need for more soft tissue information, perhaps in a neoplasia case, and the need for a contrast agent, then in my specialty practise, we do have conventional CT available to us to do that.

So when I'm doing something like a root canal procedure where in the slide on the right, I'm getting my working length, it's something that I'm not gonna go and scan a patient all over again to get this image. I'm simply gonna take an X-ray of that tooth. I don't have to do full mouth X-rays, of course, but I'm gonna take an X-ray of that tooth.

If I'm extracting a tooth. You know, I'm not gonna scan a patient to be sure that I extracted the entire tooth. I already have my scan in place.

I'm gonna go and I'm gonna take an isolated radiograph of that site where I did that, that extraction. I will say that cone beam CT, in my experience has been far more sensitive for detecting retained tooth roots compared to dental X-rays, and I will show you an example of that. In a moment.

Is it cost effective? I have to be careful as far as going into cost and pricing and, and all those things in a situation like this, but I can tell you my biggest reservation going into the purchase of a cone beam CT unit was, would it pay for itself? Would it be cost effective, or would it just be an expensive diagnostic toy?

And that's the farthest thing from the truth as far as being an expensive diagnostic toy. It has more than been economical in my practise for generating revenue and more than paying for itself. So what I, what I can tell you is that our clients in Colorado, accept cone Beam CT as a choice when we give them a treatment plan, I would say about 85% to 90% of the time, and we will charge, .

For a regular what we call cohab procedure in our practise, we'll charge $395 for that scan, US dollars. If it's part of a trauma case, a neoplasia case, anything else other than routine, we will charge $495 US dollars for that. And again, we, we have a very good compliance for that.

I can tell you that since March of 2020, right at the beginning of the pandemic, when we got this unit, up until just a few days before I left the United States, last week, we had done 928 total scans in our practise. I'll let you do the math on that, but it is something where it's more than paid for itself. You can see the unit on the right, they, they nicely custom painted it for me, with the colours of my alma mater, the Ohio State University, and they also were kind enough to put our clinic logo on the side of the unit.

So, anyways, that was just a nice touch, but you can see that it is very portable, and I'll show you some images here. These are two other Conebeam CT units that are on the market. I have not used the Atlantic Veterinary Imaging Unit or Planmeca.

I'm not familiar with them as far as the quality of their images, so I, you know, I can't comment on that. What I can tell you is that they simply do not have the portability that we have with the VETAT unit. And in my practise, that's been one of the biggest advantages of the VETAT unit over the other ones, and I'll, I'll put a disclaimer out there.

I am not paid by Zoran. I am not an employee of Zoran. I am paid by Buckeye Veterinary Dentistry, my corporation, and, that is all.

So, I am not, . On anyone's payroll other than my own for this lecture. And so I just want to emphasise that, but I will tell you that my experience has been one of the greatest advantages again, is the portability.

It takes up the size of about a grocery cart. On our, in our floor space and we're able to roll this to different tables and take our scans. We do not have to bring the patient to the VETAT unit.

The vet cat unit goes to that patient under anaesthesia. We don't have to roll it around on a, on a table, the patient on a table with monitoring devices to the conebeam CT unit. And I think that that's just one of the amazing innovative aspects of the Zoran VETAT unit.

So, the slide on the right is from the movie Princess Bride, and I put that in there because sometimes dental X-rays simply do not tell the truth as far as the big picture, as far as what is going on. And so, in, in my experience, does conebeam CT change my treatment plan? And often enough, it.

Because I would venture to guess that that probably at least 20 to 25% of the time, at least that often, it changes my treatment plan. And again, sometimes dental X-rays simply do not tell the full picture because they're two dimensional shades of grey of objects that are superimposed over each other. So we know that dental X-rays have become the minimum standard of care in our dental patients.

Full mouth dental X-rays, in my opinion, should be taken on all dental patients who are under anaesthesia. We know that if we don't do that, we're going to miss a lot of pathology in our patients. My experience has been that if you do cone beam CT scans on all of your dental patients, you're gonna diagnose far more pathology than you will with digital dental X-rays.

So let's talk about some cases. Let me show you some cases as far as what my experience has been. Some of them are gonna show the difference between cone beam and dental X-rays and the way it impacted my treatment plan, and some are just gonna simply show the diagnostic value of cone beam CT.

So Bailey was a 13 year old female spay min pin that came into us, very advanced periodontal disease. She required numerous extractions, but the owner was very adamant about saving as many teeth as we possibly could, and then, performing regular dental cleanings after that, as frequently as even every 6 months in this patient. And so on my oral exam, I found a 5 millimetre pocket on the distal aspect of the distal root of 309, the left mandibular first molar.

And typically in a case like that, I'm gonna treat a pocket like that. Usually in a small dog, I'll go to open root planing to start and perform a procedure called guided tissue regeneration. Some people may perform closed route planning plus or minus the placement of a parasitic product like doxyobbe, which is doxycycline.

So either way, if you, if you look at this dental X-ray, it's a little bit overexposed. You can see an infra bony pocket right here. What you can appreciate from the dental X-ray is that there was a wall of bone right here that was, you know, it's a very thin layer of bone that was burned through on that x-ray.

So the pocket was actually bigger than what you're visualising here. Here's the story though. When you look at the images from the cone beam CT, these are a little bit fuzzy, and it's not because of the cone beam.

They just turned out fuzzy when I took these images as JPEGs and zoomed in on them. I lost some of the detail when I put this in this presentation, but you can still see that pocket was far worse, far more involved than what I was seeing on that dental X-ray. The dental X-ray and my periodontal probe underdiagnosed the extent of this pocket, and you can see this large, And for bony pocket right here that extended all the way down to the apex of that route, and it was basically claws with clogged with debris.

It was what I call what we call a peroendotooth because perontal disease had extended down to the apex and was now involving the endoonic system. If you look, and this is the sagittal view, if you look at the coronal view. You can see that that pocket lower down actually wrapped around the buckle aspect of that route.

So this is not a case for open root planning and guided tissue regeneration. The procedure would have failed, it would not have been effective. In a dog that has extensive periodontal disease, and we could be somewhat heroic and cross section that tooth, remove this root to a root canal on that mesial root, but I have to ask, why are we doing that otherwise in a periodontally unsound patient with period disease that extended all the way down to that distal root.

So I extracted this tooth. And if I had depended strictly on dental X-rays and my periodontal probe, I would have attempted a periodontal procedure in this individual patient. But he was a poodle mix, middle aged poodle mix who came into us for routine cohab procedure and evaluation of a fractured left upper 4th premolar.

So in this case, this was very early on in our cone beam CT time. This was about a week after we had started doing cone beam CT and so I had dental X-rays on this patient. And we diagnosed impacted mandibular first molars, bilateral on each side.

And you can look at these X-rays, and on the right side, you can definitely see what looks like the beginnings of a digous cyst. So dental X-rays did show this, a little bit less distinct and a little bit displaced from the crown of that tooth, on the left side, on this particular image. Maybe that could have been missed, but, but either way, you're not gonna miss that, you will never miss.

A denigous cyst, on conebeam CT. If it is present, it's gonna show these areas of lucency, and I'll show you a much larger example of a cyst in a little bit, but you can see on that axial view zoomed in, very obvious. Areas of lucency surrounding those impacted mandibular first molars very consistent with a digerous cyst, which is gonna take place about 26% of the time in dogs with impacted teeth.

These are just a couple other images. It's the zoomed in. Coronal view, and you can see the extent of those cysts on each side.

And then but he did come into us for evaluation of a fractured upper 4th premolar on the left side, and you can see very obviously a peripcal lucency consistent with an abscess when you compare that to the other side. What you can see here is the extent of bone loss on the buckle aspect of that meal buckle root. Compared to the bone that's present in the unfractured right, I'm sorry, maxillary 4th premolar.

So conine CT is extremely sensitive for picking up peripal abnormalities like this abscess that we're seeing here, and you can also see the close proximity of the infraorbital canal tracing through that area. That proximity to the upper 4th premolar. Dexter, is a six year old Labrador who came into us.

He is an avid Frisbee player. Loved to play Frisbee, loved to play fetch, but he was wearing down his teeth as a result of that. So he came into us for a cohab procedure and evaluation of worn teeth, and the oral exam revealed that he had extensive wear on 304 and 404, both mandibular.

Canine teeth to the point of pulp exposure. He also had a pretty significant wear on the left maxillary canine tooth, but it was not to the point of pulp exposure. It wasn't discoloured.

Other than the wear, it wasn't fractured. There was no pulp exposure on that tooth. If you look at the dental X-ray for Dexter, you can see this loosen area that's pretty consistent with what we call a chevron sign.

When I see something like that, I don't look at that and think, oh, that's a perillucency, that's an abscess in this patient. It's a very typical Chevron sign. So I would not suspect that Dexter was dealing with an abscess, but when you look at the conebeam CT, you definitely see this large lucency.

It's irregular. It extends out away in a halo. Kind of fashion from the apex, very consistent, especially if you compare it to the other side, very consistent with the peripcallucency which in this case was an abscess.

So rather than doing two root canal procedures, I was doing 3 root canal procedures to save Dexter's canine teeth, and we definitely modified his frisbee play and switched him over to a soft cloth frisbee. And just another view of the peripal area with the end of that route. And again, you look at that X-ray and maybe if I stare at that long enough, I could convince myself that that's a peripcal lucency, but I really don't think so.

Not based on that X-ray alone, but certainly based on the cone beam CT. Gabe is an 11 year old male neutered Labrador, came into us for also routine cohab procedure and evaluation of worn teeth. What we noticed right away on our oral exam was that his right Excuse me, right?

Mandibular second incisor, was very mobile, and it turned out that he had a root fracture, root resorption, and, it looked like on the dental X-ray that we could not see any. Anything below this area of lucency, we couldn't see any type of retained tooth root in this area based off of that X-ray, but this obvious abnormality. And typically off this X-ray, what I would have done was extracted this, this fractured crown and root segment and cleaned out this area and called it good.

But as you start to work through your images on codeine, you can see the abscess right here. But then as we scan down through that coronal area, you can see a large retained tooth root. It lit up like a Christmas tree ball, and you can see it here on this image.

So again, this is the axial, this is farther down in the coronal plane and very, very obvious, and that led to extracting the other teeth were had significant peridontal . Pockets as well. And to get at that root tip, we had to extract the neighbouring incisors and so we ended up extracting all of those mandibular incisors in that patient and we're able to get that root segment out.

Arnie is a case that we just saw recently is a six year old male neutered domestic short hair. He presented for routine cohab procedure. He had a history of previous tooth resorption, and conebeam CT revealed very obvious type one tooth resorption on the left mandibular molar, that we simply could not see on dental X-rays.

If you look at, and I'll, I'll tell you right now, there were resortive changes in this area that we could not probe into. The tooth was still periodontally sound. I couldn't probe into these areas of resorption below the gingival margin, and yet they were very much present.

When you look at the the mandibular molar on the sagittal section, you can see a large resorptive area right there. When you look at it on the axial section, especially compared to the right side, you can see obvious tooth resorption. Not visible on dental X-rays.

So in my experience, I do diagnose tooth resorptive lesions, primarily in cats, much more frequently with cone being CT than what I'm seeing on dental X-rays. Milo, is a 13 year old now, probably about 14 year old, male neutered Labradoodle, mixed but I don't know if you have those in Europe, but we certainly have them in the states, a breeding between a Labrador and a standard poodle. And he was referred to for referred to us for a chronic right-sided facial swelling that was getting larger, and the referring veterinarian was very concerned about neoplasia and rightly so with the history that Milo had.

If you look at his dental X-ray, you can certainly see some abnormal bone here. When I get a loss of detail like this, I start to lose that normal kind of trabecular pattern of bone that we will see on the dental X-ray. And when I start to see these punctate areas of lucency, I get very concerned about either neoplasia or quite often, osteomyelitis.

Perhaps osteonecrosis. And so we did a cone beam scan on that area and you can see that not only was the upper 4th premolar involved, but this is the mandibular first molar, and you can see pretty extensive resorption of that mel buckle root. With a periapical lucency right there, that you really, in my opinion, could not appreciate on that dental X-ray on that mel buckle root.

So not only did I extract the upper premolar, but I also took, because of bone changes that I could visualise both maxillary molars. I certainly did histopathology. On this area and it came back as a, a pretty intense supative osteomyelitis.

There's no evidence of neoplasia. Fortunately, there is no evidence of osteonecrosis, which complicates osteomyelitis greatly. And this is just a surgery site, and that was that route that I just showed you.

You can see the resorption, and you can see a granuloma right there that came out with the root segment. Lulu, it's a 9 year old dachshund that we saw. Had chronic left-sided nasal discharge, the referring veterinarian had attempted multiple different courses of antibiotic therapy and Many different antibiotics were tried with some of them being responsive, partially responsive, some of them not.

Either way, once the antibiotics were discontinued, the upper respiratory signs on the left side always recurred. And so with cone beam CT, it ended up revealing a large oral nasal fistula on the Maxillary canine on the left side, and then pretty significant periodical lucencies over the upper fourth premolar on the left side. So here you can see a large area of bone loss, large infra bony pocket that had actually, as we scanned through that area, had penetrated through to the nasal passages.

And when you scan in, there is just this very tiny break in the bone right there that was causing these changes of rhinitis, these fluid-filled soft tissue inflammatory changes that we are seeing because of that oral nasal fistula, which otherwise would have been very underdiagnosed on dental X-rays, and I could not probe into that area. Sometimes oral nasal fistula cases will come into us and we can put a probe in there under anaesthesia and it drops right down into the nasal passages, not so, with this case. So you can see the abscess that had formed around the palatal root of the left maxillary 4th premolar, it had eroded into the infraorbital canal.

It had gone into the nasal passages and was causing changes very consistent with rhinitis that are associated with that abscess root. We know from a study that Doctor Kevin The panic did a number of years ago that on patients with signs of chronic rhinitis, that have been biopsied and had histopathology that revealed lymphoplasma cytic rhinitis. No neoplasia was present.

Those cases, what we found is that 60% of the time, it is due to some type of maxillary dental issue. About 60% of those cases are endedonic, and the remainder are either periodontology cases or retained tooth roots or some combination of all of those, but you can see again the peripallucency that's very obvious here, on that, distal root of the upper fourth premolar. So, we extracted the left maxillary canine, upper 4th premolar, and first molar on the left side, .

And lo and behold, those chronic left-sided nasal issues resolved completely without further antibiotic treatment, and the underlying cause was dental disease. The take home point is when you have these chronic upper respiratory cases, always, always look at the maxillary dentition as a potential cause. Gracie was a seven year old female spayed, what we call American Staffordshire terrier, also known as a pit bull, an incredibly sweet dog.

She had no previous dental procedures, professional dental procedures. She did have once a year for 5 years, what we call in the states anesthesia-free dentals. I'm reluctant to even call them a dental procedure because in my opinion, you cannot provide quality veterinary dentistry.

In fact, many of these procedures are being performed by non-veterinarians, in grooming facilities, boarding facilities, or they are sadly being performed by veterinarians, and unfortunately, they're never gonna be able to diagnose pathology in these patients that we're able to with the patient under anaesthesia and still the most Valuable diagnostic tool, the periodontal probe. You can't do any imaging in these patients without anaesthesia, so you certainly cannot do dental X-rays or a cone beam CT. So Gracie had 5 of these procedures, once a year for 5 years before she presented to me.

And my referring veterinarian had diagnosed a left mandibular, rostral mandibular swelling, and it turned out that she had an impacted pre-molar that led to this, a large digerous cyst that was involved to the point of resorbing the meal root of the second premolar and the roots of the 3 premolar as well. And you certainly will not underdiagnose a denigerous cyst. And this is a common thing.

We see this very frequently in our dental patients, you know, when they have impacted teeth. And it's something that conebeam CT is gonna fully diagnose the extent of these large cystic lesions in multiple different planes, and you can see how much bone had been basically resorbed by this slowly expansile cystic lesion. Over, who knows that, you know, I don't know if this happened over the previous year.

It quite likely had been taking place with a large cyst like that over many years, and the moral of the story is that if we had seen Gracie earlier, And she didn't have these anesthesia-free dental procedures, this cyst would have been diagnosed much earlier with much less bone loss, and you can see this is the coronal view here, and this is a 3D reconstruction that I had shown you earlier, just with this large cystic lesion that had actually ruptured out through the bone and was weakening her mandible, perhaps setting her up for a future fracture. This is my own dog. We called her Maddie Mae and just a wonderful dog that I rescued from a shelter up in Denver, and she was just the the best dog that we ever had.

And she had, she was due for her yearly cleaning. And she had a history of very mild upper respiratory signs on the right side. She just had a very unilateral kind of serious discharge.

Every now and then it would be slightly purulent. So I thought that it'd be good to have a dental procedure done and to certainly do a cone beam scan on her and . See what I could see in the nasal passages.

And the, the cone beam, even though it's not gonna necessarily differentiate between the soft tissue fluid densities between that and a definite soft tissue mass like a tumour, it, it is gonna show any type of bone destruction, very clearly, but with Maddie, what we found was she did have this soft tissue fluid area density here, and then she had multiple little radio opacities that were showing up in her images. So this is the axial view, the sagittal view, we could see another one, and there are multiple, multiple ones present, in that area just on the right side. So I didn't know if this was some type of foreign body.

I simply could not tell. She spends a lot of time out in the trails with there did spend a lot of time. Out on the trails with us.

She loved to hike, and we have in Colorado, in our part of the state, what we call Pikes Peak granite. It's very granular, it can get up, into a dog's nasal passages. It's all over your boots when you're done with the day.

So what I, and this is just another view of one of those densities. What I did with Gracie. Maddie, I'm sorry, Gracie was a German short hair pointer before her.

We did nasal retropulsion with saline, warm saline. And we flushed her nasal passages with packing in the back of her oral cavity, and we collected tissue samples that way, and that treatment's actually been found to not only be diagnostic, but therapeutic as well. And so, with Maddie, we flushed that area.

I, put her on a course of antibiotics afterwards. We repeated the scan and those little densities were still present, . But the biopsy samples came back as mild to moderate lymphoplasma cytic rhinitis, and lo and behold, the clinical signs went away after the nasal retropulsion and the course of antibiotics.

I don't know which one worked for her, perhaps both. But either way, the clinical signs resolved for Maddie and she was back on the trail with us within a couple of weeks. So, yeah, .

Just an interesting extraoral finding, and that's the other point. If you're doing cone beam CT scans on your patients, you can, You're gonna you're gonna diagnose more extraoral findings. You're gonna diagnose more nasal issues, middle and inner ear issues.

You can actually see inflammatory changes in the external ear canals, certainly signs of trauma, degenerative joint disease. TMJ all sorts of different extraoral findings. This is PISA, a seven year old Russian Blue with a history of hypertrophic cardiomyopathy.

We're doing a routine cohab procedure on her with an anaesthetist, performing her anaesthesia. And lo and behold, we found this large density which our dermatologists referred to as a seruminoli. So I'm quite spoiled.

We had our dermatologist come over and perform an otoscopic exam on PISA and flush out her ear, and we all regret not taking a picture of this huge solidification of ear wax, that had gone into the middle ear. And the head tilt did not resolve, but PISA was worked up quite successfully for allergies and her other signs of allergic skin disease improved with dietary therapy. And so the diagnosis, basically the ball started rolling with that with conebeam CT.

Just a couple more cases. I know I'm running short on time. We wanted to keep this to 40 minutes.

Julian, is a 15 year old indoor outdoor cat that was FIV positive. Unfortunately, we don't like to see those cats going outside at all. But he was, and had some type of unknown trauma and came home with a pretty significant left-sided facial swelling.

He had a large zygoma fracture. And you can see this large combinated fracture that was very displaced. There's no fixing that.

There's no pin, plate, wire that is gonna reduce that fracture in any meaningful way. So I just made a surgical incision over that area, and I started removing the bones that were protruding. And because of that 3D reconstruction, I was able to count the number of bone fragments.

And you can see the post scan, which we'll do in trauma cases very frequently, but you can see the post scan showing that area cleaned up. He did lose that portion of his zygoma but did quite well and still had plenty of support in that area. Zoe was again another zygoma fracture case, what we call a big dog little dog attack.

And, what we realised is you could see this large fracture, but it had involved the mel buckle root of The mandibular first molar on that side and something that was not visible on dental X-rays of that fracture. There is also a coincidental finding of a periodical lucency on the maxillary canine tooth. I'm sorry, the maxillary canine tooth on the left side.

And then this is just a 3D reconstruction of that zygoma fraction. You can see the pre-surgical imaging, it's comminuted. Again, there is a large deficit right here.

There's no fixing something like that. So we went ahead and we removed that segment of the zygoma and so it came back. A few weeks later for a root canal procedure on that left maxillary canine tooth.

Just quickly, trauma cases, these are from a colleague of mine in New Mexico, Doctor Chris Bannon, that show, You know, a small bone chip there in the TMJ this large mandibular caudal mandibular fracture. This is another case that Doctor Bannon, sent images to me, and you can see there's a symphoteal fracture, there's a caudal fracture of the body of the mandible with a fracture at the TMJ or just below the TMJ. So it's not going to underdiagnose fractures like that at all.

That's my daughter, Elizabeth and Maddie out on an afternoon walk during our stay at home order. We were allowed to walk our dogs in the states during that time for us during the COVID shutdown and So, that was Maddie absolutely loved the the COVID stay at home order because she got to be with her human friends even more and got to go out for even more walks. So that's the two of them on an afternoon walk with us.

Again, if you have questions, please feel free to email me at Doctor ball atwepets.com. I'd be more than happy to answer any questions that you may have regarding this presentation.