CT Scans for Dental Implant Treatment

With the advent of Cone beam CT machines which can use radiation levels less than a full series of dental radiographs, why not get a CT for every implant case? The only issue is cost to the patient and cost is coming down rapidly. If one can interpret CT images or use software they will benefit from using a CT.

I JUST PURCHASED AN I-CAT CONE BEAM SCANNER AND I CAN ASSURE EVERYBODY THAT THIS IS THE WAY TO DO GOOD IMPLANT DENTISTRY. FURTHERMORE,we can complete the tratment with Nobel's surgical guide and place all our implants at the exact location planned.

i have had my ICAT for about 1 year. It is by far the best way to do implants. No more guessing with Pan's and PA's. Cost is not an issue when your patients safety is on the line. You will see things you would not have realized, cysts, polyps, size of ridges for block harvest etc. It is the standard of care.

... and also don't forget the legal issue. hard to say, but with a CT scan, you'll ever feel better in a court. just in case... I'm perhaps to much pessimist, but an accident can arrive to every one, for any patient, and without consideration of previous experience etc... ie an accident is not only a mandibular nerve problem, but also a cortical perforation, a sinusitis after or without manipulation of the sinus... to make it on the best side, I think we have to know the maximum before the surgery: it gives us the best way to do it, and in case of problem we know we have done our best, and we will be able to defend ourselve more easily.

Everyone contemplating whether to invest in a CT Scanner should read and re-read Dr. Goldmann's post. He is right on with the legal issues. In event of an incident, defense counsel will breathe a huge sigh of relief when he/she finds that a CT Scan machine was used. This is good insurance.

how can you be sure that a ct scan (dentascan)has vitually zero magnfication

I agree with everyone else. I have had my i-CAT for a year and it is an indispensible tool. I will not do implant surgery without one and cost is not an issue for the patient. It is the standard of care and should be mandatory. Zero magnification is hard to come by but the accuracy, up to .1 mm is some scans is hard to beat. I wish I would have gotten the machine years ago!!!!

I agree that the use of a CT scan is almost indispensable for anyone placing implants. I would never do a lower posterior implant without CT, it is so useful for identifying the inferior alveolar nerve, shape of the mandible including lingual undercuts, and alveolar width. Even in the maxillary anterior knowledge of cross sectional shape of the alveolus is very helpful in implant size selection and placement. I acknowledge there are isolated instances where a CT is only a luxury, such as a recently lost upper permolar, but for 95% of implants CT is a must. Even if you prefer not to have a machine in your own office, its easy to refer to a dental Radiologist.

Wow! I can't believe what I am seeing... people who say that they recommend using CT for almost every case...! Times have changed. Glad to finally witness the movement of the implant industry to a scientific manner of placing implants based on the true three dimensional picture of the bone.... this is great. CT is the best tool to teach, and learn the actual anatomy, rather than guessing with two dimension radiographs ... and we can thank the Cone Beam CT machines for being a huge catalyst - helping to give us access to the technology directly in our offices, removing yet another hurdle for the non-believers. However, we should not lose sight of the fact that it is "Not the Scan... but the PLAN" which makes this all work. So remember, we still need to convert this data to usable templates to accurately place the implants according to our PLAN... and this is where software is of utmost importance... as a planning tool, as well as the best communication tool we can have between members of the implant team.

To all those questioning the cost of a CT scan, it is at most 15% the cost of the case to replace a single tooth with an implant, and that is with lower than usual surgical and restoraive fees. Once you go to two, three or more teeth/implants, its cost becomes negligible and the information very valuable.

It is interesting that what should have been embraced more than a decade ago is yet being debated. Dr. Ganz emphasised the obvious,. It is the Plan and not the Scan.. I will add that the Scan + the Plan + the Guide (Surgical Guide) make a home-run in Dental Implant Treatment. Why in the world would someone wish to take a chance in this age and time. DenterScan Diagnostic Radiologic Services is a stand-alone dento-maxillofacial imaging service with expertise for your outsourcing resource and support you technologically decision in this decision at minimal cost (.far less than the cost of 1 single implant) Dental-CT combined with the planning software such as SimPlant, DDent, and Nobel Biocare/Procera (to mention a few) along with a CAD/CAM fabricated Surgical Guide is the paradigm shift towards a New Standard-of-Care for Dental Implant Therapy. Why? Simply, it is Image-Guided and Restorative-Driven for accuracy and optimum surgical results. “We ensure that you are sure”.

I have a good understanding of the value of the CT, and I fully understand and accept, that "it is the plan" that counts. I am unclear, however, as to how NobelGuide or Materialise or the other stent companies assure that 1 mm of implant and a 1 mm of arch form on the slice correspond 1:1 with each other.

using horizontal line pasing through the upper edge of mental nerve on panoramic x ray is working well in my hand.

i am asking pr hossam barghash,a hoizontal line on a panoramic rx? what about ,magnification,

CT scan will become the standard of care in Dental implantology. Let us look at the business case of investing in I-CAT/Simplant and NobelGuide software. You will plan all your cases upfront, you will precisely know size of implants and direction of implants. You will also know in advance when you need bone graft etc. When you know precisely what components you need, there is no inventory to keep. This is a tremendous saving for all. Today health care quality, predicability and reliability of treatment is a big issue. In Implant dentistry, we are able to provide all that with the use of CT scan and planning software. Gary Wadhwa DDS., MBA

i like using the cat scan on almost every case, but with a single implant for single tooth replacement, and when i am certain of the anatomy in the area, i have to admit i do not always use it. many of my patients come from long distances and i do not have the i-cat in my office yet(waiting for the price to come down!)

GENERAL RULE I live by !! CT Scans are necessary if you are UNSURE of any of the following : 1)bone volume ( width/height ) 2) bone orientation 3) exact position of anatomic vital structures. If you are UNSURE of any of these PRIOR to implant placement and you have access to a CT Scanner/ICAT, ABSOLUTELY do a scan first.

Hmmm.. I guess I have been doing it wrong all these years. I've placed well over 5000 implants since 1982, most without the benefit of a CT scan. Nearly all in perfect location, angulation, etc. Hasn't anyone ever heard of ridge mapping with a caliper for single implants? A scan (ct or cbct) is not the only method for determining bone width, height, and trajectory. That same information can be obtained via PA's, a corrected panoramic film, and bone mapping. In additon, a CT scan is no guarantee of not injuring a nerve. If it were, I would not currently be the expert witness on numerous parasthesia cases. Finally, if I keep hearing that CT or CBCT is becoming the "standard of care", I am going to enroll in law school!

Incidentally, attorneys present the law with a perspective different from the rationale and thinking of a clinical dentist. Ridge mapping may not be as convincing as CT Scan with a virtual planning software. Even if Dr. David Levitt enrolls in the law school, he may graduate not remembering his previous line of thought as a dentist relative to "the standard-of-care for dental implant treatment. Taken together, “It takes a lot of courage to release the familiar and seemingly secure, to embrace the new. But there is no real security in what is no longer meaningful. There is more security in the adventurous and exciting, for in movement there is life, and in change there is power” Allan Cohen. Unequivocally, change is inevitable and the use of 3D CT-Scan combined with Virtual Planning using software platforms such as SimPlant ® and Nobel Biocare is the New Standard-of-Care for Dental Implant Treatment.

I can't believe what I'm reading. I have no problem with using all the tools necessary, I repeat, necessary to maintain the success and health of our patients, but we all need to understand the implications of deeming something the "standard of Care". Standard of care implies that anything otherwise is possibly malpractice. We are educated professionals for the purpose of making prudent decisions regarding proper diagnosis and treatment of our patients. CT scan is certainly valuable and sometimes necessary, but not always. Just because we have a new hammer doesn't mean everything is a nail. When we label something as standard of care, we allow uneducated, uninformed parties to use this "standard" in their arsenal of accusation. Professional judgement and treatment become secondary to this new standard. Of course the supply and equipment companies would love all of their products to become the "Standard of Care". To what extent do we go? Should all endodontic tx be performed via a microscope? What about crown and bridge. Is 2.5 x magnification enough or is 3.5 x the "Standard". Should headlights and fiberoptic light be the "Standard". Do we have to have CT for all extractions? If not, which ones should? Is one particular type of impression material the most accurate? Should it be "the standard of care?" I know it sounds ridiculous but we all can make good arguments for things we believe are "absolutely necessary". If we are not careful with our labels, our own discretion as professionals will be compromised by those seeking to place blame regarding our decisions for monetary gain.

I practice in a third world country that has recently joined the developed status and I am glad that there are still drs like David Levitt and Brian Humble who I am sure not only has the experience and know how but also the means to purchase an I_CAT... As for Akintade Dare who quoted" THERE IS NO REAL SECURITY IN WHAT IS NO LONGER MENINGFULL AND MORE SECURITY IN THE ADVENTUROUS AND EXCITING" can he please tell us if he really believe that statement and be willing to live by that. I think that statement borders in the illogic, and the statement that "if you have only a hammer then every thing has to be a nail". By the way I uses a CO2 laser , an Er YAG and a diode laser in my daily routine in dentistry yet I think the HIGH SPEED AIR...ROTOR..is still the mainstay of the day. Here in my country we still enjoy our food using hands as well as fork and spoons. Keep it up David and Humble and not forgetting Prof.Hossam Barghash. KoayCL from Malaysia

Isn't it now ( in the US ) considered malpractice to place a lower posterior implant without a CT Scan ?

.....or another way to put it....if you place a lower posterior implant without a CT scan, cause iatrogenic damage and are subsequently sued, your case is INDEFENSIBLE in a US court. True ?

A bad CT scan may lead you to a incorrect implant size. Before they make it a standard care they should teach the CT operators how to do it right.

Congratulations Dr. David Levitt. You are THE LUCKY MAN...

If the phrase "standard of care" implies that 3-D radiography must be used in each and every implant case, then I agree it can't be considered a standard of care. There are many situations where CT is not at all warranted. However anyone doing implant dentistry routinely must surely agree that you can't practice without it. I'm sure the numbers will differ from one surgeon to another, but for me a CT scan is essential in about 75 % of all implant cases. In another large portion of cases I find CT to be very useful in the diagnostic and planning process as well as for the surgical implant placement appointment. "Standard of care" no, but essential tool, yes.

Do you prefer to drive to a new city using a GPS navigation, or do you prefer using a paper map? Of course, if the city is small, and the avenues N/S, and the streets E/W, you might get away without any of the above. I guess it is the same for the computerized software to navigate through a CT Scan. By the way, I have been using the SimPlant for more than 10 years, and love it. But you do not need a bomb to kill a mosquito!

Isn't the yardstick to measure "Standard of Care" influenced by what is being done in dental schools? Are there lit reviews, scientific papers analyzing data of failure vs success of implants with or without CT Scans? The bottom line is that practitioners who embrace technology that makes the procedure more successful, more efficient AND with the best net will smile broadest!

great answer Dr. Giorno.

To dokchop: I have successfully defended (as an expert witness) three such cases in the last twelve months.

Some of these cone beam CT scans ares not that accurate! I am a part time faculty at a University and we routinely use these scans. I have consented at least 2 patients for ramus grafts with the CBCT scans showing a narrow mandible and when we opened up the osteotomy site there was MORE than enough bone for implant placement without grafting!! FYI

No CT scanner (MSCT or CBCT)can give wrong distances. The only risk is to use viewing stations containing a bug and in this situation you should contact the manufacturer. I am an old CT specialist and I base my affimation on knowledge of these systems.

I have read the previous blogs and have waited to formulate an opinion on the use of 3D imaging until now. For the past year and a half, I haved used a NewTom 3G for my implant cases. While there have been some valid points on both sides, I will try to put this technology into perspective. First, volumetric imaging has been an invaluable tool for pre-treatment planning. It helps me to determine if we can place an implant in the site, place an implant and simultaneously graft, or graft prior to implant placement. It shows interarch relationships using virtual modeling. But what it does NOT do is to translate knowledge of anatomy into surgical reality. Unless you are willing to use CAD milled surgical guides or use surgical navigation (i.e. RoboDent), your placement of implants is still determined by your surgical skill. It has very little to do with survival tables or enhanced osseointegration. What IS important, in an era of having to meet the aesthetic paradigm, is exquisite implant placement so that the implant is indistinguishable from the tooth it is replacing. I don't care if someone has placed 10,000 implants without an untoward consequence. It will be the one case where you have perforated the buccal/lingual plates, have a severe bleeding episode, violate the neurovascular bundle, peroforate a sinus, touch an adjacent tooth, or MISS additional anatomy like a bifurcated mandibular canal, deinnervate the synphysis by severing the incisive canal, or miss pathology that you will find yourself in a very difficult defense. Put yourself in the patients perspective. Would you want a surgeon doing implant surgery on you using a PA, Panorex, or DVT? I plead nolo contendre. There IS a changing standard of care whether you like it or not. There is a CT on virtually every street corner and an increasing number of focused cone beam DVT machines available. It is my opinion that the use of DVT imaging will become as commonplace as the use of pans today. There is simply no logical excuse to avoid the use this technology.

How much radiation doe the CT scanner expose the Brain to? Does the brain get x-rayed with this CT scanner or just the teeth and jaw?

The xray exposure for the NewTom 3G is the lowest of all the focused cone beam machines. It is comparable to a panorex when used in the 6" field of view. The brain is not exposed in this narrow scan.

The x-ray exposure of NewTom 3G as well as of the other CT scanners (spiral or cone beam) is higher than panoramic. According to Sharon L. Brooks,(American Board of Oral and Maxillofacial Radiology), the dose is 4 times to six times higher with this scanner than with a conventional panoramic device. In my opinion, this ratio is even higher. The brain is also irradiated by scattered radiation. However, despite these values, one should take into account that this irradiation is equivalent to some background radiation days (cosmic radiation) and compared to the benefit of good planning and good surgery results, the dose issue is not significant.

The exposure for a DVT scan is dependent on the field of view. When using the NewTom in the 6" FOV, the x-ray exposure is virtually identical to a panorex and the brain is not irradiated. Do not compare the 9 and 12" FOV in making the comparison as they are used for different procedures and the voxel size is lower (less resolution). Ultimately, in the next 5-7 years, ALL of us will be using volumetric scans rather than a panorex whether you want to accept it or not, especially if you are involved with implant dentistry.

My dentist uses all digital x-rays so with taking that into account will that make the radiation from the NewTom safe? Is the NewTom as effective as the iCat in safely placing implants? Thanks!

X-ray exposure is cumulative. This is why you should be looking for devices that minimize dose. The NewTom 3G employs SmartScan, which measures the grey scale of the image every ten slices and adjusts the x-ray exposure accordingly. The I-CAT does not employ this modality, resulting in some overexposure in areas not needed.

The use of cone beam CT is not essential in the success of implants, especially if you wish to raise a flap and study the bone outlines directly. Undoubtedly, many implants were placed using these methods. However, CBCT is a reality that can make planning for minimal surgery possible; hence, CBCT perhaps should now be advocated for planning all dental implants. And I would consider the CBCT cost to be aroubnf 5% of most implant plus prosthodontic procedures. This expense is low considering the problems and time savings potential.

The cost of these scans really does matter. In the case of single implants it could be the item that will decide if the procedure is one that is affordable. Adding $1000 to the cost of treatment is a problem for many people on fixed income and families with children to support. This standard of care thing is something that could result in useless exposure to radiation, as well as needless increased costs. Education as to when this tool is needed and when it is a nice additional aid for treatment planning is what we need. Just because you can do something it does not follow that you must do it as "standard of care" implies.

can someone please help me. I am looking for information on the law that is proposed to be passed that a dr. can not own a ct etc. and refer to himself. does anyone have any information? thank you

CT scans for all implant cases? What a load of industry-driven nonsense. If the dentist is incapable of taking a decent PA and raising a flap to visualise the bone beneath perhaps the CT will make up for their lack of skill or experience, especially if he/she doesn't do many implants and consequently keeps few sizes in stock!

I had been told from one of the sales people at i-cat that a dr. can have a patient sign a form that holds the dr. only responsible for reading the ct scan dental information and not medical, as I am finding out the hard way, this is not legal and i-cat sales person will do anything and say anything to make a sale!

Recpect to all, but some doctors remind me on topic, 20 years ago, “do we really need panoramix, as a tool for implant planning"

I am replacing an aging/faltering Pan in a perio practice. It would be the first iCat in a city of about 350K and a referral base of about 1mill persons. I've used iCat images for one implant patient, I've also been on site reviewing techniques and outputs with Oral/Max Radiologists at a major U.S. University clinic using one, and had a few discussions with Periodontists/prosthodontists/orthodontists encouraging and "resisting" the technology. Question 1. Does it replace a Pan diagnostically? Certainly it a huge leap over my failing machine, but I am curious as to how others feel. Question 2. My implant referrals are small, but growing. What experiences have users had justifying its use in non-implant cases, such as ortho exposures and TMJ cases or replacing full mouth series to inform general perio diagnostics and treatment responses?? Question 3. How do people handle "scan only" referrals?? I am told there will be considerable interest in this, but I am wondering how much of it makes sense, at what fee, and what info along with the images should be provided to the referring dentist/physician. Is this a part of my practice that I want to encourage or avoid?

Alert - Alert- Alert With his earlier communique, Dr. Miller referred to the NewTom 3G and how pleased he was with this unit. However, things have changed during the last 10 months and the NewTom now has service issues. The new agent for the US market refused to service any of the previously installed units. The owners of NewTom 9000 and 3G units are exceedingly unhappy with the new, exclusive distributor of this product. This company does not even have any software engineer to assist users with critical software issues.

While I cannot comment about other clinician's experience with the new NewTom distibutor, I will stand by my statements regarding my NewTom experience. It is an outstanding machine with more capability than the competition. I do not have ANY relationship with the company, previous or present. Time, however, does march on and technology will continue to evolve. I have been working with the new 16-bit TerraRecon system and can tell you it can image soft tissue better than anything I have seen. Each clinician must look at the application, field of view, number of axial slices, voxel size, shades of grey, exposure, report generator, time of reconstruction, and ease of use to make an educated decision as to which unit to purchase. But to make the statement that the 3G is a has been is shear fantasy on your part. RJM

I do need one good reliable dental scan what are the current prices and providers???

I wanted to jump in to comment on Robert Tonello's remarks about the change of ownership of NewTom. This poster is very misinformed of the situation regarding NewTom and support for both new and old users and his comments are not correct. Indeed, QR Verona, the manufacturer of NewTom, has been purchased by AFP Imaging of Elmsford, NY, which means that the support level for any US and Canadian customers has been enhanced by additional parts, people, and resources thanks to ownership by a larger, publicly traded imaging company. We have fully stood behind any existing machines in place, and have a staff dedicated to servicing those existing customers, including software engineers both in the US and Italy. Extended warranty plans are available for purchase by users as well. We have spent literally hundreds of hours helping existing users, and apparently our efforts as a good samaritan and new stewards of this company have gone overlooked by some. Please, if you have unresolved issues, contact me directly and I will assist you. The NewTom remains the original and best unit in this catgeory, and through continuous innovation, remains the product of choice for leading users globally. Christopher Weed Vice President, Sales and Marketing AFP Imaging/Dent-X/NewTomDental cweed@dent-x.com

Our imaging center purchased a NewTom 3G a couple of months ago. We have been extremely pleased with both the machine itself and the owner/distributor AFP Imaging Corporation. We did a lot of research on the company before our purchase, and found the company has been in business for close to thirty years, and supplies a full range of radiography products to the dental, medical, and veterinary markets. We felt confident that they would stand behind their product, and they certainly have. Upon installation, we encountered a few minor issues, but their engineers were very knowledgeable and quick to provide solutions. Our center chose the NewTom 3G for multiple reasons, including its capability of providing a large field of view, comfortable and stable supine positioning, as well as providing a much lower radiation dose to the patient compared to the ICat and others. I completely stand by Dr. Millers earlier statements and those made by Mr. Tonello are without merit. Anyone interested in purchasing the NewTom may feel free to contact me directly.

I have been using the I_CAT scanner for almost three years. As a surgical prosthodontist, I would not consider doing implants without the scan any more than I would consider doing endo without an x-ray. While I have done without CT scan with only a few complications, the ICAT has been indispensible. I had purchased a digital(schick)upgrade to my Pano machine 4 months before getting the ICAT. It immediately made the pano machine obsolete and I sold it to another doctor. I charge my patients $250 per scan. I can print the scan using a pdf printer driver and e-mail the results to doctors all over the area in minutes. $1000 would be an absurd price for a CT scan. My cost for the ICAT is about $3400 per month for five years. The maintenance contract for the scanner after one year was about 8,000 for three more years. Any other questions can be directed to me at brooksby1aol.com.

For the record, I will not engage publicly in a debate with Hans Nahme about the disposition of the customers he mentions. However, some public response is called for given the comments above. I will restrict my comments to saying that the author is now associated with a competitor, and formerly was an independent sales rep we elected not to hire when we acquired the company. We have spent considerable time making good on his unfulfilled promises and misrepresentations to many customers. Hans, I suggest you reign in your tongue before we send the lawyers after you again, and I start handing out your home phone number to the number of dissatisfied customers you and your wife have left in your wake. There are still a number of people looking for you, but it seems that your inability to return phone calls and pay your debts is quite apparent. I believe your reputation precedes you. We will not respond further in a public forum, no matter how much you wish to bait us.

To me the a NewTom scan is essential when planning implant cases for most areas of the mouth. The quality and accuracy of the images is incredible. I've practiced my speciality of periodontics for 24 years and implant surgery has been a large part of my work for over 16 years. Originally all planning was done using PAs and panographs. Frequently during implant surgery my anxiety level would rise, sweat would flow and afterwards I may have lost sleep due to uncertainty and anxiety about a particular case. For the last 3 years I have been fortunate to have access to the NewTom unit and radiologist reports. Now I'll never be convienced that surgical experience together with a pan and looking at bone profiles after the flap is raised is enough information for implant surgery. I now place my implants more quickly, more accurately and with a much higher level of confidence, comfort and safety using a NewTom scan than was ever possible using two-dimensional radiography. Its also been 3 years since I had to bale out of a case after raising the flap only to find the site unsuitable for implant dentistry. And as for the cost, my patients pay a dental radiologist around $500 which includes a detailed report together with the images. I find this an exceptional value! Like it or not, the standard of care is changing and I see it as a change for the better.

Hello: Recently {Apr 24th}, Dr Steve C states that "To me [the]a NewTom scan is essential when planning implant cases for most areas of the mouth"...He then describes his planning and "confidence and comfort"...finally, makes a comment on "Like it or not, the standard of care is changing and I see it as a change for the better". These three comments piqued my interest, and prompted a response to "thread" that actually dates back over a year. For the record, I practice in Boca Raton Fl, and have done "Guided Surgery" courses at my teaching center there and at various other teaching venues. I own an ICAT, from the original Imaging Sciences Divison, not the new entities that they are involved with {Danaher-ownership and Sullivan Schein-sales}. On service: before and after there is no adverse change and it has been and remains "excellent, knowledgeble, friendly and effective"...in that, my asistants can quickly and effectively communicate with the company and I dont even know what has taken place {no stress for me]. One time in the 2 plus years that I have the ICAT, a new part was needed, and it came in less than 48 hrs, installed and up and running. In my town, we have one NewTom unit {Dr Rbt Miller, who has commented on this thread a few times}. I know Robert well, for 20 + years, and his dedication, knowledge to this aspect of our field and his comments are accurate. The other 5 ConeBeam units in my town are all ICAT. My colleagues who have them, are equally satisfied as I am with the device, and with the company and its product and service. Some of us use the device just for planning, some for Navigation, some for creating surgical guides...but all of us are using it in a way, that , like Dr Steve C states, with "confidence and comfort". Robert Miller, by the way, had his NewTom before any of us got our ICATs. I will refrain from comments regarding my machine being better than his or vice versa, because, the shear number of devices in my little town, speaks for itself, whether its salesmanship or product advantages and product differentition. So in conclusion on that part, Miller is extremely happy with his NewTom experience, and the rest of us are thrilled with our ICAT experiences. Next: comment on the NewTom being the ..., my thoughts are simple, Cone Beam CT should have been Dr Steve C's thought, cause obviously there are other devices ,and way more popular devices, achieving excellence in this area. Next: "Standard of Care" is a slipperly slope. Clinical dentist are not attornies. Defending the "implant Miss-Adventures" that are "anatomically" based are almost indefensible today, with the "availabilty" of 3D data at medical centers, scan centers, or in office devices. So, having data,is a "state of the art issue", today, not a "standard of care" issue except when defending a miss adventure, the patient plaintiff, will certainly bring it up as the "Standard".. I am pleased that is is changing and "heading" towards that standard, but that standard brings up other issues and Turf Battles with other self interested groups like "Dental/Medical Radiologists"- ie. pathologies in the "field" that are not noted , looked at or even recognized.. So, I am in favor of commentary that is positive such as "State of the Art" vs legally based, "Standard of Care". And, who cares what I think, in order for it to "actually" be the "Standard", it is a real long way to go, before it is in "every" office or community" for every routine case. But, Im not an attorney, and see little gain for my patients if I am on the side of "Standard" vs. "State of the Art", where there is a real and specific benefit to our patients. Finally, the concept of "Restorative Driven" is a reasonable one that is jargon the last few years. So what is available from the use of these ConeBeam devices for our "Team" if we practice that way, or if you are your own team. With the single exception, you can get a printed report or a digital data disc, that can be read by the teammate, assuming that the teammate has "reading software" that can be down at their convienience, or it has to be done together. The single exception is "ICAT Vision". Here, my staff in a few minutes, can burn a CD of that patient's data with built in reading software allowing my teammates to review it at their desktop/laptop whenever they want to. They can manipulate the data and review vital anatomic structures. This is truly and "interesting advance" for our case planning incorporating a true team concept. A very interesting thread...except for the commercial name calling. Thank you for letting me ramble on...and as I taught Ganz years ago...If you hear a great quote along the way..."It's not the scan...it's the plan!", use it, so I let Scott have good time with it. The "triangle of bone" concept is clearly his [circa 1992].

While reading through the above discussions, some thoughts came to mind. Having the information from a CT or CBCT scan in front of you is only part of the acquisition and diagnostic process - knowing what you are looking at is the other part. Many of those with CBCT/DVT machines are not looking at the full volume of data acquired, and/or do not recognize the anatomy (and possible pathology) they are looking at in three dimensions. Fortunately, there are many Oral Maxillofacial Radiologists out there who can read and interpret the data, and even assist with the planning for the more difficult cases for a relatively small fee (compared to the price of a lawsuit!). If you are ever in doubt, consult with a OMFR for added security and liability control. There was also a question of whether the brain was being subject to radiation from CBCT/DVT scans. Check your scout views and especially your base frame projections: if you can see inside the brain case from ANY angle, including a front or rear projection, then the brain is being exposed, even though it may not appear in the actual reconstructed volume. Often the reconstructed volume is noticeably smaller than the height and width you see in the scout and base projection frames. More than likely, the only CBCT/DVT scan which would not irradiate the brain to any large degree would be a highly collimated scan focused on the mandible - especially if the x-ray beam projection angle is downward.

During 2004, I purchased one of the first Newtom’s 3G from Hans and Sabine Nahme. I have nothing but praise for the way in which I was treated and supported by them and I still in contact with them. They have been a tremendous informational source for me. I am very familiar with their responsibilities and thus know that Hans and Sabine where only responsibly for the sales aspects of Aperio Services, LLC, the previous and long time distributor of the Newtom. All service related matters such as installation and maintenance where the exclusive responsibility of Aperio and I was always very pleased with the service I received from that company. Last September, AFP informed all Newtom customers that they would hence provide all service and support of the Newtom units; they had been appointed as exclusive distributor for the Newtom. Circumstances required that I had to move my Newtom to a different location. I called AFP for service and the technician came out to calibrate my NewTom. He was unable to solve the problems. Since that time I am trying to have my NewTom repaired and serviced. I have requested service from AFP since December last year, but none has been forthcoming. Repeated messages left with AFP went unanswered. I’m still waiting. I know of several other unhappy Newtom users who bought the Newton on my recommendation. They did not receive any service either.

I am interested in Newtom and I-Cat and it is a tremendous cost to purchase one for the office. But I am concerned more that there is bickering amongst the distributors on this site. Especially the comment about getting a lawyer. My suggestion is for those people to get off of this site and leave it for those interested in the clinical relevance and the acumen of other doctors.  Lets keep these threads clinical and respectable. JMHO.

Does anyone have experience with the Stark law and how it applies to dental specialists having a financial interest in a CBCT imaging center? Specifially, for example, if an oral surgeon owns a CBCT scanning center complete with a technician and staff in a separate office space and he/she refers a medicare/caid patient to his/her imaging center and charges cash to that patient and the patient then submits that charge with the approprate medical insurance billing codes on the receipt to Medicaid/care, is this considered a Stark violation? I know this is a legal-related question so I'm not expecting a legal response but I just wanted to know if anyone has had experience with this issue.

I´m in doubt about aquiring un I-Cat or a Newtom 3G. The I-Cat is a lot more expensive than the Newtom, for customers in Brazil. Is there any web site that makes clear the negative and positive points? Christopher Weed, I´d like to receive some information about the purchase of the Newtom. It might be shipped to Rio de Janeiro, Brazil. My e-mail is at the botton. If there´s anyone here who represents I-Cat, I´d like also to get some more informations by mail, if possible. Which image software do you recommend? There are a lot of them in the trade... My e-mail is the following: glauciapedro@inbox.lv Thank You

In response to a few of the recent comments about the NewTom 3G, please find below the text of a letter recently sent to all owners. To All NewTom 3G and Model 9000 Owners: AFP Imaging is pleased to advise all NewTom 3G and 9000 users that AFP has completed the acquisition of Quantitative Radiology srl, (“QR”), of Verona, Italy. This became effective on April 19, 2007. We will now assume the full responsibility for QR’s factory and their world-wide sales and marketing efforts. For 28 years, AFP has been an innovative supplier of dental, medical and veterinary imaging products. QR and its Cone Beam Technology is our latest, state of the art product line expansion. As previously stated to many owners, by telephone or letter, AFP will continue to provide full technical support or site service for all NewTom units in North America. While a distributor for QR, we have made significant progress to correct almost all of the problems in the field that we inherited. Statements to the contrary, on an open website, by a former sales agent and now a current competitor are false and misleading. Upon the ownership of the QR factory, we are in a position to guarantee all NewTom owners, the supply of appropriate spare parts and applicable software updates as they become available, plus full factory support should it be necessary. AFP continues to maintain a warm and cordial relationship with Dr. Carl Gugino (the former distributor), as an advisor, as well as Catherine Rodriquez-Ospina who is an excellent NewTom, CBCT software applications trainer. The primary question I am often asked is about our future service policy. AFP has and will continue to honor all prior QR and Aperio’s NewTom Model 3G factory warranty obligations. This coverage will be for the one year period from the date of installation providing it was purchased from AFP or Aperio and is not a resale or refurbished unit. If you have purchased a three year prepaid “extended warranty”, directly from AFP or Aperio, we will honor these agreements as well until their expiration date, as per the signed warranty contract records. AFP will support and service all NewTom 3G and Model 9000’s on a per diem fee for service and parts basis where the factory and extended warranties have expired. AFP is available to provide relocation and recalibration services for any NewTom 3G or 9000 unit, as the need may arise. We trust that this positive approach to NewTom service will be in your best interest, for the future. If you have any questions regarding servicing your unit please contact me. In order to assure a complete and timely flow of software updates and technical support we once again ask you to please supply us with your most current contact information. You may email to Ms. J. Aluisio, jaluisio@afpimaging.com, fax to 914-592-6769 or respond by regular mail with the details. Please feel free to add any comments you wish to make us aware of. As a key component in our acquisition discussions with QR we encouraged them to design and develop another new product, the NewTom VG, “Vertical Generation” for smaller North American dental operatories. Using QR’s basic CBCT technology with its proprietary software, they succeeded and we displayed the Model VG at the February 2007 Chicago Mid-Winter dental meeting, the International Dental Show in Cologne, Germany in March and now this past week at the California CDA exposition. We are preparing final brochures for distribution with unit pricing. Shipments will begin shortly, pending FDA clearance. AFP will continue to invest in additional QR product refinements and applications. We welcome all of your comments and suggestions to improve our CBCT product line and make it more productive for you. Sincerely, AFP Imaging Corp. David Vozick Chairman Vozick@bestweb.net

Image-guided surgery, also known as surgical navigation guidance, has recently been introduced to implant dentistry. This technology also requires a CT scan during which a specialized acrylic splint is required to assist in the registration (3-D matching) of the patient’s position. During implant surgery, the patient must wear this acrylic template. The splint and dental handpiece are equipped with strategically positioned infrared emitters enabling camera detectors, located in the room, to track movement during surgery .Therefore, the matching of jaw position and handpiece with the patient’s CT scan and planning are performed instantaneously.

I am in the process of buying the ct scanner. However, I think that as long as we are using the technology as the tool to achieve perfection in the case planning, not as a tool to advertise or commercialize the practice, then we are on the right path. I have placed thousands of implant over ten years without ct scan, but I think it would not hurt patient if I have the technology. I plan to charge them only 50.00 for the scan so it should not be a problem. And by the way, I really admire Dr. Levitt and Dr. Brian Humble. Back to the topic of "standard of care", as long as we don't have the technology with the intent to "make the patient pay for our toy", we are ethically correct. I will use the scanner in almost every case, but "I will pay for my own toy and love it every minute because I love what I am doing."

I am considering employment in the dental equipment industry. This has been a very interesting read. I thank you all for your comments. My question to the group is: How does the CT effect the experience of the patient? 1) From a surgical planning and execution standpoint? 2) From a trust / reassurance perspective? Any insight is welcome. Ron K

I thought I might point out that SS and Imaging Sciences are not the only ones out there that sell an iCAT. There is a company out of Atlanta, Georgia called Imaging Systems that also sells the iCAT. I have heard nothing but good things about them. They know just as much about the clinical side as they they do about the CT.

wondering whether ct scan would (have)reveal(ed) the above-mentioned (see sinus lift problems) "double" cortical plate w/marrow between and exposed (and bleeding but good!) found when beginning sinus lift.....

ps- i'd like to hear from the "guided surgery" folks: actual computer guided....i've viewed a scan using the imaging sciences software, and it's pretty clear one would have to be one sharp computer geek as well as a decent surgeon

Bottom line: Cone beam CT is not standard of care. I don't care how vehemently you want to "shout it" across message boards, it is not in the Parameters of Care as standard of care in AAOMS. Oh, by the way, Parameters of Care applies to Oral & Maxillofacial Surgeons. If you are doing oral surgery, then the Parameters of Care will apply to you whether you are an OMFSornot. Check with your lawyer on that. If you do endo, then whether you arean endodontist or not, principles of endodontics per text/dental school faculty expert witness etc applies. You generalists who buy these machines and charge patients for imaging every little thing trying to pay these machines off are unethical. The machines, when properly utilized, should be in a hospital type setting so there is no incentive for ordering tests to pay for the enormous costs of purchase. There are instances of need for cone beam imaging; I am not disagreeing with this. Those who espouse use in every case are full of it. If I socket graft a case and have a pano, it is almost always more than enough information than I need to place an implant. Do you measure the tooth or root on extraction? A wealth of knowledge of measurements can be had from that. Education of the public will eventually prevail and I aim to be one of those advocates in 2008.

Why only talk about I-Cat? there are other excellent machines with LESS radiation, better images and nearly $25,000 less expensive (better warranty packagfe also). The NewTom VG for example...and it is much smaller - just a bit larger than your pan. I think the VG produces the highest quality volumetric data I have ever seen

I strongly recommend reading Andy Kessler's Book "The end of Medicine: How Silicon Valley (and naked mice) will Reboot your Doctor," reading this book made me insist that my dentist refer me for a CT Scan (it was a NewTom3G). Not only did it reveal the older implant had to be removed but it also showed a root canal several teeth over needed a retreatment.

I have purchased a CBCT. Believe me it is NOT a money maker, actually it has hurt the implant part of my business, patients want the ct scan for free... although you may do 26 implants per month not all of the patients need a CT scan. I do not want to have the patients pay for a scan that is not nexceeary to make my payment, and that is what seems to happen to other doctors. States are looking into this. I was just discussing with my wife, if scanning you own patients is the way to go lets look at what was done before: in an ob/gyn office why do they not own their own mammo machine? reimbursement by insurance, necessary every so many years... could it be the liability and referring to the ob/gyn practice.... any of this sound familiar? We are looking into having a seperate facility but we do know that other doctors will not refer to me since they are actually competitors. We are also looking into selling the CBCT.

CBCT seems like a nice thing to have in ones office! However, lets look at the economics and yes, the hype behind all of this. I place 350 to 400 root forms per year and refer out 4 to 6 patients per year for a CBCT, to an orthodontist down the road. I use PA's and Panos with 5mm. ball bearings most of the time and this works quite well. I believe this is overkill for all cases and drives up the already high price of implant dentistry. To say that this is the standard of care is stretching it quite a bit. I say use the technology, but only when necessary. R. Hughes, D.D.S., FAAID, FAAIP, Dipl. ABOI/ID

Dr. Hughes Good thinking! I agree with sending out scans, I wish I did this in the beginning rather than jumping on board with the i-CAT. You are doing what I should have done. Dan

I refer out for CBCT scans, but I still wish I could afford my own because it is very useful for immediate follow-up after placement. Since I do mostly mini implants without flaps, it is much easier to confirm proper placement and anatomical features with the CBCT on the spot, and I can make changes immediatelly if needed while the patient is still anesthetized. I have done a few cases with my oral surgeon using this method and it is very useful.

To say that one has to have a cbct and if not is malpractice is B.S. One has to examine those that are on the lecture tour and see what is in it for them. I had a Kodak rep in my office trying to sell one and they were going to put on lectures in my behalf etc. You have to consider how many implants were placed in the past without any problems. If the posterion mand is not ok for a root form then consider ramus boades, regular blades and yes unilateral subperiosteals. We are beating our brains out trying to place root forms in people, and doing all kinds of dances to make this work. There are outer ways to skin the cat. I will be glad to teach these modalities to any doc with an OPEN MIND. Hell, even disk work. We have way too much tunnel vision.

The first obligation we have to ourselves is to think. We also owe this to our family and patients. We are educated and trained, most as scientist. There is too much of a herd mentality in implant dentistry. If one embraced a multimodal method they would find: they save the patient time and money, more predectable results, get through cases quicker etc. First start thinking and questioning results and motives of the hired experts!

We have an I-Cat and at Month 13, 2 weeks after the warranty expired a major part went dead the X-ray Tube itself. Cost of Replacement $4,000. Extended Warranty $9,000/year. Must be paid up front to company or else. I wonder if the competition is the same.

watch out Nobel reps are selling the i-CAT scanner! what else is next!

The reality is that conventional Xrays are STILL the standard of care. When evaluating the anatomy of the oral cavity , bone, teeth , and related dental pathology, including the nerve pathways. Additional type of radiographs; cone beam, CTScan, ... are adjunctive to the Xray film where it is needed. The statement that "Patient at risk", because the state of the art imaging is not being applied routinely "All that is non sense" . Comes from a non experienced individuals I respect reduced radiation. No imaging to replace the surgical mind and clinical ability of the professionals. It is still a surgical procedure. FIND IT HIPPOCRATIC TO SUBSTITUTE THE ROLE OF A SPECIALIST WITH A MODERN MACHINE. UNETHICAL TO DO THE LATTER This is not a statement based on excellency of a surgeon vs another. Simply The humble truth . All resident and doctors should and hope they have enough expertise to understand the Dicom softwear technology and the ability to discuss it. Until then heroic statement is being said. MULTIDISCIPLINARY APPROACH IS THE SAFETY AND THE GOLDEN RULE TO OUR PATIENTS . IT HAS BEEN AND WE HOPE THAT CONTINUES TO LEAD EXCELLENCY IN DENTISTRY TODAY. PATIENT ARE SUFFERING DUE TO ADVANCED MACHINERY MAKE BELIEVE IT IS EASY AND SIMPLE FOR ALL MANKIND INCLUDING JACK OF ALL TRADE

BCCT will not be the standard of care while the price per machine is as high as they are presently. Who determines the standard of care-----the manufacturer, I don't think so! It's us the doctors. Common sense must dominate, not a heard mentality.

Ct scan before dental implant should be the standard of care. To say that implants can not be done without a CT would not be accurate. They could and they have been doing them all along, however a variation in anatomy that is not visible in a 2 D image could result in a catastrophic result to the Pt. that we as health care professionals can not afford. Therefore, I can’t imagine going any implant these days without the use of a CT especially then these machines are in such an abundance.

As far as the cost of the hardware, you really don’t need to buy a machine. Just send you Pt. to the image center just like 99% of the orthodontics do. No one will ever hold you against it.

I have read most of the discussions with regard to using ct scans for patients needing Implant dentistry, I place a good number of implants per year as a general practitioner, single and few implants can be done with periapicals and when in doubt take an x ray with a guide pin to see if u have enough length. in my opinion ct is of great value only in full edentulous arches where there is severe resorbtion and to evaluate sinus before grafting .

3d technology is an advancement in the ability to more accurately diagnose our patients. All treatment should stem from diagnosis and there are several articles which prove 2d imaging does not provide sufficient clarity to visualize anywhere from 30-50% of existing asymptomatic chronic apical periodontitis conditions. These can and often are very toxic and detrimental to general health. See enzyme denaturing science by Dr Boyd Haley. Love your pts!