Is 3D Cone Beam now the standard of care for implants?

Wow, a GREAT question. IMO, CBCT is not Standard of Care (yet), but it will be in the near future. I placed implants free handed with Pano and PA and BW using the 5mm metal sphere for calibration from 2002-2012. Since my CBCT arrival in 2012, we have been doing all surgeries Guided and with a CBCT. I think that if the results are great, and all turns out well, CBCT is not needed. However, it is when things do go well that having a CBCT will play big part in how the case is defended. It is a great way to avoid simple silly mistakes. Honestly, guided or CBCT is not needed on simple cases such as upper premolars or even molars. In the mandible, i would personally not feel comfortable doing case without a cbct unless i am certain there is no nerve or vessel or artery anywhere near the site. With that said, if one is placing implants and if one plans to continue to do implants, an investment into CBCT will be well worth it. Good luck and hope this helped.

Mark, I am glad that you asked the question and I really don't know the legal definition of "standard of care". My remarks would include that I have had a cone-beam for the last 15 years and that it has really improved my anxiety level as well as the accuracy of the implant placement. I, if anything, was too cautious in my approach and could have been a bit more aggressive with the additional info that the CT offers. I will say that I have viewed what I thought was a perfectly accurate scan and during the surgery realized that there might have been a mm or 11/2 mm of error one way or the other. Sometimes that amount is critical, and has made me not completely comfortable with only a surgical guide in the most dimensionaly restrictive areas. I know there are studies which confirm this. I was lucky to have helped with the Misch Institute for twenty five ears and Carl's last word on it, although about four years ago, was exactly what your acquaintance stated. I know mine was not a definitive answer and look forward to seeing what others may know, or feel.

CBCT is a wonderful tool but if you flap the patient and there before your eyes is the "3D" image right in front of you of the patient's bone....then standard of care I think not. I would highly recommend everyone that is able to get one though because of the other applications in endo, pedo, path and ortho. CBCT will eventually work it's way into most dental offices because of these other applications. It's not just for guided surgery.

18 years ago I bought my first CT scanner . From that moment on I wondered how I ever lived without it. I never place any implant without a CT scan. Look at it this way if you don't take one and there is a problem WATCH OUT. I can hear the lawyer now"so the technology was available and you chose not to use it?

Two years ago I asked Peter Moy the director of UCLA Implants the same question. His response was" Cone beam is not currently the standard of care. We have been doing it with pa's and panos for years. "However, the the first question a plaintiff's attorney will ask you is "Why didn't you take a ct scan, Doctor?" Bottom line is Cover your butt and get the CT. Having done quite a few implants both with and without, I find it makes my life much easier to have a ct scan.

This is a very interesting discussion..... students at this time are only l being taught about the necessity of using CBCT images .....forget a about the 2 D image...….however, as terrific as 3D images are, there is also the factor that a surgical guide must be used when placing implants when relying solely on the CBCT and nothing to do with the surgeon's dexterity, experience and / or feeling where the drill is going ,and not visualizing the procedure through an open flap, etc....….but the guide does not always sit 100% accurately, and because of this, what follows may be completely inaccurate, along with the possibility of overheating the bone during the drilling, because the coolant is blocked by the guide , and ending up with an osteotomy in the wrong place....so the end result could be a disaster.... lawyers should know about this , and not condemn a failed case because it was not done guided...…..there is no question that the information gleaned from a Cone Beam scan is terrific, but don't dismiss all the implants that were placed without a scan for so many years ……….current students should be taught to work with 2 D images as well.

If you do not mind, I will bring up another issue related to this question and it is this. What if you a sued and you did not use a CBCT. Whether it is considered the "standard of care" or not you can be sure of the following: The plaintiff's attorney with buy the soul of and "expert witness" for $750 per hour. Every action, decision and step will be dissected to show you in the worse light possible. This particular issue will be hit hard and often and multiple witness and journal articles will be presented to show how wonderful CBCT data is and why you are so behind the curve. An if behind the curve in this, in how many other ways. I agreed that CBCT is not always necessary. I placed implants for 15 years without it until 2008 when I got my first CBCT. At the same time, I never do a case without that information now. For what it's worth.....

I’m not going to say that a CBCT is the standard of care. However, a CBCT yields an incredible amount and quality of diagnostic information. One can use PAs, bone sounding and palpation to muster data for placing an implant in most cases. There are times when only a CBCT will reveal anatomic pitfalls. So the long and short of it is: if your placing implants; diagnosing tooth fractures, use a CBCT. Your ahead of the curve using a CBCT. I was trained by Linkow, Roberts, Clark ann Tatum and resisted for years. So, do yourself a favor and start using CBCT technology.

CBCT Is not the standard of care PERIOD. It is a nice tool, many advantages, I have used since the 80’s even before simplant, but let’s not give The Sharks an excuse to sue and sue and sue.

I have been placing implants with CBCT guided and unguided for many years now successfully I have also used 2d placement for many cases as well With proper training one should know which cases lend themselves to safe 2d placement With 3D info it will provide an opportunity to render more conservative yet safe treatment I have just purchased my first scan unit and I find that it affords me the opportunity to treat a patient safely and immediately as there is no delay posed by outsourcing Also I can glean information from post op or intraoperative scans if need be As a GP, I never used CBCT for Endo Airway or TMJ but now am eager to expand my usage into these areas as well Prices of these units has made them more affordable Their footprint is small and quality of images better than ever

It’s simple more information or less . If you had to get surgery would you want your doctor knowing more or less information to preform his tasks

My thoughts are that every case should have a proper work up and guide. It is not just about the standard of care, but more about the duty of care. These are important differences. I think everyone would acknowledge the value of a pre-op conebeam report and analysis. In my opinion, the more you do, the more you realise the value of a good, well fitting (printed) surgical guide. So the question is not about the ease and value of these tools, but rather are they necessary. So why would you not use both? The answer is always going to come back to time and cost. Using these tools will always take more time and cost more. If they took no extra time and cost nothing I am sure we would all use them. So the next question is: Would I have a colleague use these tools on me if I needed an implant? And would I use a conebeam and accurate surgical guide if I was treating my spouse, children or grandkids? I cannot answer the questions for you, but I would want a colleague using both on me and I would definitely only place implants in my familiy’s mouths with these tools. I have seen too many cases of colleagues (who are specialists and with years of experience) making simple mistakes in the placement of implants which could have easily been avoided if a 3D and surgical guide had been used. These cases were indefensible. So do you want the best for your patients or not? It is a personal choice but I say without hesitation I want the best. And I know the experienced dentists can “huff and puff” about this, but you will not convince me that the best treatment is not to use a 3D image and surgical guide. In the regards to the legal aspect of negligence, if there is an issue to defend, I do not think there is any doubt that you would have to tell the judge that, if you had taken a 3D image and used a surgical guide, you would have known more about the likelihood of an imminent problem and probably could have: elected not to proceed, or warned the patient of the increased risk or simply avoided the issue by placing the implant differently. The question to ask yourself and answer the judge is: Would an average person have reasonably expected an average dentist to use a 3D image and surgical guide in the course of placing an implant? I think we would all understand that to place implants is more difficult than placing a standard filling. As such, the definition of “average dentist” would have a different “strength” of expectation for a dentist placing an implant. I have no doubt that legally we are obliged to take all precautions to “do no harm” – it is our duty of care. Whether those brave people who have experience decide that to take extra precaution is not required or justified is going to be an individual decision. However, in my mind it would be an error of judgement. I strongly suspect it would also be considered an error of judgement in the mind of a judge and more importantly in the mind of a patient who has a problem due to lack of your pre-op information and planning.

CONE BEAM has ALLOWED me to do cases that I would have not done CONE BEAM has STOPPED me from doing cases I would have done More information, the better the treatment........how many 1000s of teeth were taken out with out x rays over the centuries..........was that ok.

Everybody gets a cone beam in our practice. It's amazing what pathology you will find in terms of failed endo, root fractures, sinus polyps, airway problems, etc. that you would have missed with a 2D image. I take a 2D panoramic image as a screening tool for the initial consultation. Then when we get serious about surgery we get a 3D image and avoid the pitfalls. Standard of care is "The procedure any prudent dentist would do in the same or similar circumstances." Does that include Cone Beam? If you are doing very many implants at all, I believe you will agree that a Cone Beam gives you information you can not get any other way. So, if your treatment does not work out well, having an initial cone beam can help you figure out what went wrong and revise it quickly. It will also eliminate a series of questions by the plaintiff's attorney at deposition. A good expert witness will include Cone Beam as a line item in the complaint against you if you did not get one. It will play into, "Poor Case Planning." Now, do you get the picture?

Much respect to the original gangsters placing implants without CBCT since the 1980s. Can’t really argue with you, In my view, you guys and gals get a pass just for being the first ones. Forget about the whole lawsuit nonsense. Put your heart into every case, give your patients the time and respect they deserve... that’s the standard of care. I don’t think the issue is CBCT as much as it is proper case selection, staging and treatment planning. CBCT is 100% icing on the cake, though.

I am luckn Having 30 years of practice on implants so without 3D I worked for18 years and now 12 years with So for discussing or explaining to the patient or other colleagues it is a real plus point For medico legal purpose it is mandatory For evolution of yourself and the clinic you absolutely need one The first one I have bought 100000€ Nowdays you get the same for half the price

I believe if you intend on doing lots of implants, with or without bone grafts and occasional sinus augmentations then Definitely Buy one. If you only do occasional implants with lots of bone then use pans and PAs, but still consider one. I personally bought one 4 years ago and believed I was doing it to comply with “standard of care” I must say I’ve never looked back and I use it on every implant. Don’t get all worked up about lawyers. Do it because you want to have the extra knowledge of bone volume and precision of landmarks. And ability to make a guide on more complicated cases.

I will go out on a limb and say "Yes", a CBCt is the standard of care. I started using tomograms and medical CT's in the late 90's. I have placed well over 5000 implants, few without some kind of 3D imaging. I've owned a tomograph 7 years and CBCT for 12 years. Roughly 2-3 years into CBCT use I started noticing I wanted them on ALL cases and noticed things that were not apparent otherwise: Calcified carotid arteries, unexpected IAN 2nd divisions, locations of the lingual arteries associated with mandibular anterior and upper lingual cuspid, mandibular incisive arteries, wide incisive canals, narrow airways, , higher mental foramens than expected, LOTs and Lots of undiagnosed endodontically involved teeth, much more narrow ridges than I expected and to my horror undercuts that I hadn't expected....even with that full visualization with a BIG FLAP. Worst of all most recently, I've been taking them post surgery and I find implant positions that I hadn't wanted. Neither a guide, a PA, a PANO, ball bearings, nor direct visualization will give all the information one needs to perform an elective, highly discretionary service, invasive procedure. All radiographic images have distortion. Happily CBCT's have the least. If I was a GP NOT placing implants, I would have one just for all the endo I find alone!!! An endo/ crown pays for the machine pretty quickly and more importantly is a better service. Certainly since the technology is readily available and reasonably priced, I wonder why wouldn't you have one? Forget litigation: our job is to do what is best for the patient.

Attention Doug Kammeyer…. with your experience and knowledge, I am saking you to suggestwhat type of CBCT scanner to purchase, and what size images do we need in out field

On my last 3 malpractice renewal applications I needed to check a box next to the phrase: Do you take cone beam studies for every implant placed? I don't want to find out what would happen if I checked "no", so I checked "yes" and take one for every implant I place. It also will become the standard of care as no one in the PG program where I teach can place an implant without one. It also has saved me from many untenable situations where the bucco-lingual dimension is not always what it appears to be clinically or on the 2D X-rays. And fair or not, we all are judged by what the most experienced, expert practitioners are doing.