[Oradlist] Fw: Guidelines for CT/CBCT

[Allan G Farman]

I continue to disagree with these assertions. A panoramic radiograph or
periapical is totally unacceptable as it merely provides a 2-D view. I
will concur that there might be some instances where no radiographs are
needed whatsoever.  The cross-sectional anatomy is needed and we have
the ability to create this with comparatively low dose in folk who are
usually those least affected by radiation - namely the elderly. Yes,
implants were placed prior to 3D imaging availability... but even then
linear tomography was possible. Viewing where implants that were
apparently acceptable on panoramic or periapical radiographs are
actually placed shows that many are marginal at best in 3D. I have seen
too many cases of fractured jaw, penetrated nerve canals, sectioning
roots of of an adjacent tooth, and even implants resting on or
penetrating the inferior conchae, or severasl mm past the lingual or
buccal plate of the mandible to accept that we should stick to imaging
procedures that are now outmoded for the purpose of implant placement
planning. The anterior mandible can be much narrower facio-lingually
than would ever be GUESSED on 2D images. I have also seen maxillary
sinus complications from membranes being raised above the sinus ostea.

It has been my experience that clinicians who place a good number of
dental implants and previously used 2D imaging start slowly with CBCT
for implants, but soon find that there are no "simple" cases and that
what they had previously felt satisfactory was far from optimal. Such
clinicians usually quickly transfer the rest of their implant cases from
2D to 3D. There are few Luddites against change, except Perhaps (?) the
European OM Radiology Community.

AGF

Allan G. Farman, BDS, PhD, MBA, DSc, Diplomate ABOMR

Prof. Radiology & Imaging Science
Univ. Louisville School of Dentistry: SUHD
501 South Preston Street,
Louisville, Kentucky 40292, USA 

Tel: +1(502) 852.1241
Fax: +1(502)852.1626


>>> Leif Kullman <leikul at yahoo.com> 01/08/2010 12:04 PM >>>
Dear Oradlisters
I also believe there are implant cases without need for tomography, not
at least in the anterior area of the upper and lower jaw. Intraoral and
panoramic radiographs can be enough.
We can use different other tools in such cases, at least in the
clinically simple cases: Like *poor man*s tomography* using our
fingers to get knowledge about the buccal-lingual dimension and
reducting estimated soft tissue thickness or we can use an
*osteometer* see my attachment!
A useful tool for measuring is also a metallic grid (1mm between each
line), put in close relationship to the film/sensor during exposure, see
my other attachments.
Best regardsLeif

Leif Kullman DDS, PhD
Assoc. Professor
Oral and Maxillofacial Radiology
Faculty of Dentistry
Kuwait University

--- On Fri, 1/8/10, Ann Wenzel <awenzel at odont.au.dk> wrote:


From: Ann Wenzel <awenzel at odont.au.dk>
Subject: [Oradlist] Fw: Guidelines for CT/CBCT
To: "Oral Radiology Discussion Group" <oradlist at lists.ucla.edu>
Date: Friday, January 8, 2010, 5:37 AM





 
----- Original Message ----- 
From: Ann Wenzel 
To: SDGIMPLANT at aol.com 
Sent: Friday, January 08, 2010 11:10 AM
Subject: Re: [Oradlist] Guidelines for CT/CBCT


hello all
It would be really interesting if surgeons would take part in this
discussion.
What about all of you in the Oradlist who are also surgeons? Ralf
Schulze and others?
 
One of the surgeons here is now  60, and during approximately 30 years,
he has inserted 20700 implants.
He is one of the few who has kept a very detailed record on all events
before, during and after the operation.
He has had to give up on five patients in whom no implant could be
installed after he had opened and displayed the bone. These five could
have been avoided if CBCT was used. Some of the patients had a more
comprehensive operation than expected with additional surgical
procedures.These could have been warned of an increased operation time
a
nd the surgeon would have been more prepared if CBCT had been
performed. All patients are however told before the operation that
additional procedures may be needed.

When balancing the weight, it is not only dose, but surely also all
types of resources used for CBCT that should be considered.We are trying
to analyze the data from that study, but even though the data are
sampled in a standardized way, the study is stll retrospective. 
We are to do prospective, randomized trials to provide the evidence
needed. And not only in one country. I am sure we agree on this. So why
do we see so few RCTs in our literature?
 
We will start a RCT on 3. molars; panoramic vs. CBCT. Maybe you will
find this "alarming" or even unethical. In my opinion it is unethical
not to do such studies - and the 3 surgeons involved have no problems in
this since they have until now removed thousands of 3. molars based on
panoramic images alone.  
We hope soon to be able to start a RCT on implants in the same way. 

And try to read the literature in e.g. Clin Oral Implant Res - in the
RCTs on immediate implant placement, CBCT is never used, merely
periapical radiography. To me this is both logical and ethical.
 
The implants inserted by students in supervision of surgeons at my
place are of course in very selected patients. No evidence can be
deducted from this.
 
 
all the best
Ann 
 
 
 
 
----- Original Message ----- 

From: SDGIMPLANT at aol.com 
To: awenzel at odont.au.dk 
Cc: oradlist at lists.ucla.edu 
Sent: Thursday, January 07, 2010 11:55 PM
Subject: Re: [Oradlist] Guidelines for CT/CBCT


Hello Ann -
 
Thank you for your thoughts.  While I certainly understand your
suggestion, I agree with Allan when he suggests that CBCT is important
as a diagnostic tool for dental implant placement - due to the
incredible variation in bone and root anatomy and clinical presentation.
 
 
That stated, you are correct that the person placing the implant should
have good training, and experience.  As it is important to handle all
situations which may arise, with a proper clinical / surgical skill set,
wouldn't you agree that it is better to have an understanding of the
anatomy prior to the scalpel ever touching the patient?  In this way, we
can plan ahead, and have everything ready, without the guesswork, and
full knowledge and disclosure to the patient of what will be done.  In
my opinion, CT and CBCT imaging helps clinicians to appreciate these
anatomical variations, as each patient is unique, allowing us to have a
sound basis for our decision-making process.
 
I, and perhaps many on this list, can cite a myriad of what appeared to
be simple, single tooth cases - immediate extractions even, where the
bone topography was completely different that what appeared on clinical
exam, panoramic or periapical radiograph.  In fact sometimes the single
tooth application presents the most challenge - especially in the
esthetic zone with convergent roots, or facial concavities.
 
Perhaps discussions like this help us to understand what type of
guidelines should be recommended - based upon sound clinical judgement
which relates to the treatment at hand.  The end result should be a more
favorable outcome for the patient, the surgeon, and the restorative
dentist.
 
Best regards to Denmark!  
 
Scott
________________________________________________________
Scott D. Ganz, DMD
Prosthodontics, Maxillofacial Prosthetics & Implant Dentistry
President Computer Aided Implantology Academy: CAI Academy 

158 Linwood Plaza - Suite 204 Fort Lee, NJ 07024
TEL: