[Oradlist] Fw: Guidelines for CT/CBCT
Allan G Farman
agfarm01 at louisville.edu
Sat Jan 9 17:53:50 PST 2010
Agreed that a surgeon can screw up irrespective of the information provided, but it is more likely to happen if ignorant of the 3D anatomy when placing the implant. If there is not enough bone in 3D where biomechanics suggest an implant is needed, then appropriate augmentation by bone grafting can be planned. We should not be blindfolding the profession and failing to provide information that can help the practitioner and patient choose the best course. What can look good on a 2D image and is accepted as success by many implantologists is actually symptomatic and far from ideal in many cases when viewed in 3D. AGF
Allan G. Farman
Professor of Radiology & Imaging Science
Tel/Fax +1(502) 852.1241
>>> AndrewDawood Dawood <andrewdawood at hotmail.com> 01/09/10 10:14 AM >>>
Exactly, we do need more balance
Computer Guided Surgery is exciting and can be incredibly accurate, but this is not what you are
talking about.
Without control of the transfer to the operative field,
it is a tremendous extrapolation to say that access to 3D data
would necessarily change the outcome of surgery. This is
anecdotal, based primarily upon the views of radiologists, not
surgeons - is not evidence based.
We
can not just assume that all implants placed after 3D imaging are going
to be 'better' placed, either in respect to bone or prosthetic
considerations.
There are many excellent surgeons out there who do not always use 3D imaging routinely.
No doubt it will become a standard of care one day. It will then also
become the standard of care in endo and perio as well, because there is
always something more we can learn where morphology is complex.
MY concern, and the reason that I can not ignore this dialogue is that
it is not yet fair to label all individuals who do not routinely carry
out 3D imaging as 'defendants'. We should be carrying out the exposures
because the patient needs them, not because we are covering our backs. The exposure also needs to be optimized for the patient - not all current apparatus allow this.
One day all imaging will be in 3D; for now we need to handle that transition in a responsible fashion
Andrew Dawood
Cavendish Imaging, London
From: shdesch at aol.com
Date: Sat, 9 Jan 2010 09:26:06 -0500
To: oradlist at lists.ucla.edu
Subject: Re: [Oradlist] Fw: Guidelines for CT/CBCT
Hello All,
I read all the posts that appear on this board. Being in complex
imaging for 30 years, first panoramic and periapical, tomography and now
CBCT I've heard all the objections from clinicians. The best one is they
hold up their two fingers, as if they were measuring the thickness of bone with
them,and say" I know what I'm feeling and seeing and if there is
enough bone for an implant." Maybe so....., I've never placed one.
What I do see is that guidelines are needed for this technology. Users
tend to think that more is better. Taking a full volume for every records
patient in ortho is way too much information, especially if you want only one
slice for the ceph and one slice for the pan. What about the rest of the
volume?
Having these data sets read by you guys is the right thing to do for
the patient's sake.
Interestingly enough, when asked if the scans are sent out to be read by a
professional, the response is,,,why?
I too have kept out of the discussion mainly because I subscribe to this
list to learn and contribute in anyway possible to the profession.
One question to Axel:
May I borrow this?
Question: What do you call people who use only periapicals and
pantomographs for their implant planing?
Answer: Defendants
Steve Desch
In a message dated 1/8/2010 2:32:48 P.M. Eastern Standard Time,
axel-ruprecht at uiowa.edu writes:
Hello
Like Johan, I have kept out
of this discussion, and like him, I am concerned about overuse of CBCT. Also,
like him, I am on Allan's side of this argument. Unless you have done many
CBCTs, and CTs before that, and tomographs before that, you really do not have
much of a concept of what the cross-sections of bones in the jaws are really
shaped like. And, like Allan, I have seen implants in places where one can but
shake one's head. Usually these come from surgeons who have been asked by the
original implant placer to help rescue the case.
We have riddle around
here, mainly from me.
Question: What do you call
people who use only periapicals and pantomographs for their implant
planing?
Answer: Defendants.
I shall also sign off here from snowy
Iowa, where the snow is between 1 foot and 6 feet, (30 cm and 180 cm) and the
temperature is warmer today, around 0'F (~-15'C). Schools are closed. Many
highways impassable, and the sun is shining brightly, waiting for the next
storm to arrive.
Rgds
Axel
Axel Ruprecht D.D.S., M.Sc.D.,
F.R.C.D.(C)
Diplomate of the American Board of Oral and Maxillofacial
Radiology
Gilbert E. Lilly Professor of Diagnostic Sciences
Professor
and Director of Oral and Maxillofacial Radiology
Director of Advanced Education in Oral and Maxillofacial
Radiology
Professor of Radiology
Professor of Anatomy and Cell
Biology
http://ruprecht.radiology.uiowa.edu
319-335-7341
-----Original
Message-----
From: oradlist-bounces at lists.ucla.edu
[mailto:oradlist-bounces at lists.ucla.edu] On Behalf Of Johan Aps
Sent:
Friday, January 08, 2010 12:44 PM
To: Oral Radiology Discussion
Group
Subject: Re: [Oradlist] Fw: Guidelines for CT/CBCT
Dear
Friends,
I kept quiet for some time around this discussion, but I can't
anymore...
;-)
I agree 100% with Allan's arguments (for those who
know me...that's rare as
I usually have some comments on how some of us
overuse CBCT - sorry if my
self-sarcasm doesn't suit you-)
At our
university, the implantologist in charge hardly ever asks for a 3D
image.
He also claims implants can be easily placed in many cases. He
"relies" on
his experience.
His assistants, younger and maybe more keen on new
technology and perhaps
also more afraid of making mistakes as they have
far more less experience
than the 'guru', do ask more often for 3D
imaging.
I have seen several cases so far, in which on a 2D image there
seemed to be
enough bone, but where the patient came back complaining
about pain,
discomfort and so on. Implants perforating the lingual or
buccal cortex,
implants in or too close to the inferior alveolar canal
-also in the incisor
area-,...
I recognize the situation Ann Wenzel
described, where experienced
implantologists think they can "see" enough
on a 2D image. And also here in
Ghent, our 'guru' is encouraging
undergraduate and postgraduate students to
do the same.
Luckily for the
patients, the students (who are also taught by me) do not
always agree and
ask for 3D imaging right away.
So, Allan does not have to fear that the
Europeans will not accept
"change"....on the contrary.
But I also
understand, that if one has no access to CBCT or Dentascan or
other ways
of getting cross sectional images, one has to rely on the 2D
information
alone, with all disadvantages and risks involved. But this
should not be
an argument not to believe one does not really need 3D
information...
I wish you all a nice weekend (7.40 PM - I am going
home now....)
Greetings from a snow covered and cold
Belgium!
Johan
______________________________________________________________________
Prof.
Dr. Johan K.M. Aps
(DDS, MSc Paed. Dent. & Special Care, MSc DMFR
(King's College London, UK),
PhD)
Head of Dental & Maxillofacial
Radiology
Coordinator Postgraduate Teaching in Dentistry Ghent University
(accreditation system Belgium)
Senior Clinical Consultant Ghent
University Hospital, Dental School
UZG, P8, Dental School, De Pintelaan
185, 9000 Gent, Belgium
tel; + 32 9 332 5102
fax; +32 9 332
3851
secretary; +32 9 332 3857
----- Original Message -----
From: "Allan G Farman" <agfarm01 at louisville.edu>
To: "Oral
Radiology Discussion Group" <oradlist at lists.ucla.edu>
Sent: Friday,
January 08, 2010 6:52 PM
Subject: Re: [Oradlist] Fw: Guidelines for
CT/CBCT
>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:
>
>
>
>
>
_______________________________________________
> Oradlist mailing
list
> Oradlist at lists.ucla.edu
>
http://lists.ucla.edu/cgi-bin/mailman/listinfo/oradlist
>
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