Dental Implants

3D X-rays deliver the precision mandated for safe jawbone grafts and implant placement!

Surgically-placed dental implants are now the most popular choice for tooth replacement. But do you and your dentist know about 3D X-ray technology? Without it, you could suffer nerve injuries, permanent numbness, sinus perforations, involuntary drooling, incorrect tooth angles, even a broken jawbone. Called cone beam computed tomography or CBCT, it's now the standard of care for many implant cases. For most, don't get implants without it!As general dentists, periodontists and prosthodontists move into a field that has been the exclusive territory of oral surgeons, this article helps you stay safe by making CBCT your ally. Based on actual outcomes and patient dental imagery, the article explores, educates and enlightens.

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Dental Implants Introduction

Get prepared with CBCT

Fig. 1: Titanium Implant

Science and technology to the rescue! When the reporters at KENS5-TV produced the foregoing YouTube video, they were portraying a future based on 3D X-ray dental imaging. The future has arrived. Dental implants are the proven and therefore preferred way to replace missing and damaged teeth, regain lost chewing function and rebuild confidence after a long period without teeth. For an increasing number of patients, implants are now recommended instead of dentures. And 3D X-rays are the standard of care to determine bone depth and the exact location of nerves and sinus floors so that penetration may be avoided.
Fig. 1 is a magnified representation of a tapered titanium dental implant. Typically, standard implants measure 4 - 6mm wide by 5 - 15mm long (a U.S. dime is 1.35mm thick). It's not unusual for patients to receive several implants. Under proper conditions, fully edentulous patients (no teeth) can receive a mouthful of these long lasting cylindrical tooth root replacements. Patients want stable chewing solutions, and implants rise to the occasion. For others, an implant may immediately replace a tooth that has to be pulled. In some cases, an implant is an alternative treatment for a root canal.

Although mini dental implants are similar, they are not often used to replace teeth and are therefore not the subject of this article. Mini dental implants are very narrow -- 2mm or smaller. A growing debate among dentists characterizes opinions on the use of mini implants as a solution for tooth replacement and denture support. The most experienced implantologists use them in limited situations, observing warnings like the one offered at the enriched website of Dr. S. Robert Davidoff, DMD.

Based on tooth root-shaped titanium cylinders that are machined with screw threads as shown in the photos above and to the right, standard implants are surgically placed in jawbone, below the gum after careful drilling and preparation. The titanium implant is literally screwed into the prepared hole (the osteotomy)

Fig. 2: Implant supported crown

where it bonds with jawbone over several months. The bonding is a unique property of titanium. Bonded or osseointegrated implants receive a metal abutment or post inserted in the top. It extends through and above the gum. The abutment either receives a temporary or permanent ceramic crown or firmly connects to a denture (the process called restoration). Restored implants often function better than healthy teeth (they don't get cavities). With excellent patient care, properly installed implants can last decades.

The illustration at right conceptualizes a restored single implant. The gap below its tip illustrates procedural drilling depth of the osteotomy. The implant must be carefully torqued into the osteotomy to establish ideal conditions for osseointegration. The gap ultimately fills in with new bone.
Implants are now being placed by oral surgeons, periodontists (gum specialists), prosthodontists (denture specialists) and regular restorative / cosmetic dentists. Even endodontists (root canal specialists) are beginning to recommend an implant instead of a root canal in certain cases.
Because a single implant can cost upwards of $3, 000 - $5, 000 including restoration with a custom ceramic crown, the dental profession loves the cash flow. Worldwide, dentists are rushing to offer implants. Careful advance preparation protects your dental and financial interests. Each case benefits from patient education (the mission of this Knol). The knowledge enables good questions and access to widely available three-dimensional or 3D cone beam X-rays for comprehensive diagnosis and safety, and precision computer-manufactured surgical guides that assure proper drilling. A 3D digital X-ray is the dental equivalent of a CT scan. Dentists call it CBCT, or cone beam computed tomography. CBCT fully reveals your jawbone structure, and also guides the actual surgery with precision that is far superior to 2D dental office X-rays.
Not all dentists and oral surgeons recommend or reveal CBCT to their patients. Consider the sharply drawn distinction between two modern dental practices. Pennsylvania Oral and Maxillofacial Surgery's rich website and the practice's four highly qualified dentists make no mention of the technology. Compare this with the New York (Hudson Valley) practice of Dr. Michael Tischler, whose "life changing" CBCT experience is documented on YouTube.
A new website dedicated to CBCT also has an educational mission. It is a recommend destination for patients and dental professionals alike:http://www.marcilan.com/.
Washington, D.C. board certified oral surgeon Dr. Steven A. Guttenberg, is president of the Washington Institute for Mouth, Face, and Jaw Surgery. in a recent Dentistry IQ magazine interview, Dr. Guttenberg said:

Dr. Steven A. Guttenberg

My original impetus for purchasing a CBCT was to assist in the complete evaluation of a site to accept a dental implant. It allowed me not only to appreciate the true location of the inferior alveolar nerve canal and the mental foramen, but also the maxillary sinus and the true proximity to the incisive canal, adjacent teeth, and nasal floor. Plain films allow only the ability to judge the height of the alveolus, but with CBCT I was able to get complete information to a hundredth of a millimeter of not only the alveolar ridge height but also of its width. The CBCT also allows us to appreciate the morphology of that ridge. These are all extremely important factors to have in one's command prior to implant placement.
CBCT is quickly gaining evangelists among dental bone graft specialists. Osteogenics' 2010 is a professional symposium focussed on jawbone grafting in support of implants. The group's publicity includes this eye-opening statement by keynote speaker Dr. Michael Pikos, whose professional practice trains dentists to perform implantology: Comprehensive diagnosis and treatment planning is the cornerstone of all that we do in dentistry, said Dr. Pikos. While there can be more than one treatment plan for a given case, there is but one diagnosis, and cone beam CT has had a dramatic impact on this critical process, both in my private practice and with the Pikos Implant Institute. A companion directory to this article, CBCT X-ray Services Directory, provides an organic list of practitioners who behave like Doctors Tischler, Guttenberg and Pikos. The good news for patients is that the CBCT wave is coming on fast. There are now over a thousand CBCT installations around the world. If you live in a G20 nation, CBCT is probably nearby.
Many patients should not proceed without the benefits of CBCT because it prevents mistakes like drilling at wrong angles and into dental nerves or other vital structures of the jawbone. Given each implant's cost, another $300 - $500 for a CBCT is a moderately priced insurance policy. Periodontist and dental malpractice attorney Edwin J. Zinman, DDS and JD, says, "If locally available, CBCT is the standard of care for complex cases and particularly the lower posteriors if the implant approaches the inferior alveolar nerve canal."

Initial Preparation

For most cases, first and second opinions top the list of things to do before surgery. When your dentist recommends implants (or you ask for them), you'll want a full discussion and a second opinion. Seek disclosure from two restorative/cosmetic dentists even before you speak with an implantologist. The balance of this article helps gather questions. Begin by understanding the role of the implantologist (the dentist or oral surgeon who surgically installs the implants). If the dentist recommending implants also plans to do the surgery, you'll want an opinion from a clinician who does not place implants. Oral surgeons and other implantologists -- even regular dentists -- who make a living from implant surgery are biased. Plan to seek an opinion from a dentist who does not rely on implants as a way to send the kids to college or buy a vineyard. The most effective way to assure excellent dental opinions is a CBCT, which has quickly become the standard of care for many implant cases. This type of X-ray is usually offered by imaging clinics located in urban areas and at schools of dentistry. As you'll learn, it's worth every penny.

Fig. 3 Imaging Sciences i-CAT

Cone Beam Scanner

Some forward-looking dentists and implantologists are installing CBCT units in their offices. Dr. Anthony Lizano, DDS, at Diablo Valley Implant Dentistry in Danville, California, recently installed an Imaging Sciences i-CAT cone beam scanner like the unit pictured (Fig. 3). At his practice's website, Dr. Lizano says "Our practice is one of a select few dental implant centers with an in-house 3D cone beam scanner. After this non-invasive, 20 second scan we can accurately examine the bone structure of your jaws. This allows us to precisely diagnose the bone quality and density for placing dental implants. In addition we get a clear view of the inside areas of the bone to see and avoid nerves (emphasis added) and determine sinus locations." These clinicians know that 3D is becoming the standard of care. Be suspicious of a dentist who claims this isn't true (dental malpractice attorneys will affirm).

Fig. 4A: Two of three implants impinge nerve

CBCT Provides Safety

Unless your case is simple, a CBCT is most important. It enables clinicians to see inside your jawbone with an accuracy as small as 0.1mm (less than the width of a human hair), and to avoid the problem illustrated at right. This image portrays three implants. #29 and #31 have been drilled and placed into the nerve canal in the mandible or lower jaw. This nerve serves each tooth and "enervates" the lip and chin through a branch called the mental nerve. Our ability to sense touch, heat, cold and pain is this nerve's function. A patient's complaint (after anesthesia wears off) might be "my (right or left side) lip and chin are painfully numb, and I can't stop drooling because I can't feel it to control it."

Fig. 4B

Figure 4B provides a close up of implant #29 striking the mental nerve. In actuality, the drills used to prepare the osteotomy would shred or cut the nerve first. Even under deep sedation the patient might moan or cry out. Extreme pain for months would follow. Numbness may be permanent. As you prepare for implants, youll also need an appreciation for the surgeries in the treatment plan. Some implant cases require advance bone graft surgery (with ample healing time) before implants can be placed. If you're replacing an old implant, additional time is needed to allow jawbone to remodel (jawbone regrows under the right conditions). It's not unusual for complete implant prep, surgery and restoration to span a full year. A full mouth of implants can take longer.
Prudent implantologists facing a complex case will refer the patient for a CBCT as the leading diagnostic, planning and surgical prep tool. A bonus described later is the computer-aided production of a surgical guide that helps the implantologist drill with precision into your jawbone.
A note about "teeth in an hour" advertising. Very simple cases may employ technology that installs both the implant and crown in a single surgery. Patients are strongly admonished to avoid full chewing for several months in order to give the implant time to bond with the jawbone. Although "teeth in an hour" has strong appeal in our instant gratification society, very few patients qualify. A moment of forgetfulness when chewing through a sticky caramel, peanut brittle or tough piece of meat can have a bad outcome.

Question your Clinicians

Implants arrived in the dental toolkit more than 30 years ago. They have seen steady progress as the preferred way to replace missing and damaged teeth. Because titanium forms a strong bond with jawbone, even food-grinding molars can be replaced. So, don't be surprised when your dentist recommends implants. Here are key questions to pose. Schedule a consult when the dentist isn't busy. Take notes!

• What other solutions are available?
• What are the cost differences?
• What are the functional differences?
• What happens if nothing is done?
• Am I a candidate for teeth in an hour?

• How can I be sure that implants are needed? What's the basis for your diagnosis?
• Who do you recommend to do the surgery, and why?
• How much experience have you had with the recommended implantologist?
• Do you know if the implantologist has a clean malpractice history?
• Can you recommend more than one surgeon and let me decide?
• Do I have enough jawbone to achieve a crown to root ratio of 1:1 or better? What are the tradeoffs if the ratio can't be achieved? (A short implant life with risk of a cracked jaw is one tradeoff!)

• What kind of life cycle can I expect for the types of implants recommended for me?

• Are implant placement angles a problem in my case? How will you assure correct angulation?

• Does the standard of care for my case require a 3D cone beam X-ray?
• Will a CBCT 3D X-ray help guarantee the correct angulations and drilling depths?

• If the answer is no, would the diagnosis and surgery benefit from a CBCT or will I be wasting money?
• Can/will you refer me to a CBCT 3D imaging center? What are the choices and tradeoffs among different systems offered by these centers?

• Since my case is challenging, will you refer me to a regional expert at an accredited dental school, for an enriched opinion?

The X-ray shown in Figure 5A demonstrates why some of these questions are needed. An oral surgeon's 2-dimensional panoramic X-ray machine produced this image. This specific X-ray unit is known to generate images whose magnification distortion can exceed 25%. By his testimony in a malpractice lawsuit, the image did not reveal to the surgeon that two of the implants had been drilled and placed into the patient's nerve.

Fig. 5A: 2D X-ray fails to reveal nerve impingement, says surgeon

Fig. 5B Drill Strikes Nerve

Look again at the artist concept (Figs.4A and 4B, above). They are based on this 2D X-ray. On the other hand, Fig. 5B shows the missing third dimension -- jawbone depth (cheek side to tongue side depth). It illustrates how one of the drills impinged on the nerve. This view is based on the 3D CBCT X-ray image shown later (the right half of Fig. 6, below). Don't you want to ask those questions to avoid this outcome?

Get That CBCT and Second Opinion

If the initial opinion supported a CBCT, get it now. Your dentist will write the referral Rx and may direct that the X-ray be read by a Board-certified radiologist. However, if your dentist feels that CBCT is unnecessary, this becomes question #1 for that second opinion. Avoiding the outcome shown in Figure 4A and 4B is the purpose. Lets say you get the CBCT. Your dentist will review it and may revise the treatment plan. 3D cone beam X-rays are usually delivered both as a photographic image set and a digital CD or DVD with software that allows review on your dentists computer (as well as your own computer). If trained in the use of the software, your dentist will be able to demonstrate his concerns by displaying your images on his chairside monitor. But he may also be able to enlighten you with the excellent paper image set produced by the CBCT machine. A 3D X-ray rotates around your head as you lay prone or sit up, depending on the manufacturer. A typical scan takes under 30 seconds and captures precision digital detail of your full jawbone and teeth (and surrounding head and neck), not just the region for implants. This data has occasionally revealed hidden health concerns (like tumors) and thus helped save patient lives. Clinicians who seek training in the analysis of 3D X-rays are also being taught how to recognize problems that would otherwise go undetected until symptoms appeared. Imaging centers that offer CBCT usually employ the services of a Board-certified radiologist who will review the scan, opine on available bone depth, width and height, and any signs of trouble such as a dangerous nerve loop or unanticipated rise near the implant site; anatomical structures that must be avoided during drilling; too-soft or extra hard bone that can be discerned in a CBCT. Radiologists are fully trained to diagnose the patient with these X-rays.
If your dentist is unfamiliar with CBCT, dont be surprised if he or she expresses appreciation for the detail and clarity (the upside), and discovers issues and conditions that impact other teeth (a downside that becomes an upside via improved treatment). Companies that make in-office X-ray equipment for dentists, like Imaging Sciences and Planmeca, are beginning to offer CBCT units that are affordable for individual dental and surgical practices. Lengthy (and costly) training courses conducted by recognized experts are now front and center in the dental profession and dental schools. With or without a CBCT, get another opinion. Friends and co-workers are reliable sources of dentist recommendations, or try a University dental school. If you implicitly trust your dentist, he or she will be happy to suggest another clinician. Be sure to take your X-rays used for the initial diagnosis. And, if you've proceeded with a CBCT, take the CD/DVD, the image set and radiologist's report.
The following images, taken with a NewTom 3G CBCT AFTER a failed surgery, show an implant impinging on the nerve (red line) in both a frontal (left) and jawbone cross section view (right). If only these images had been available to both patient and implantologist before surgery! These images and others led to a settlement as a malpractice trial was getting underway.

Fig. 6: 3D CBCT shows width and height (left) and depth and height (right). Red line represents the location of nerve tissue. Implant drill's nerve impingement caused chronic pain, permanent numbness and drooling. It was one of two implants where the osteotomy drills shredded the patient's nerve because the drills are longer than the implant being placed.

ig. 7: Blow up of another CBCT image shows tip of implant impinging nerve canal. Implantologists are frequently warned in their training and surgery manuals that the drills are longer than the implant. Impingement by drill and implant was the opinion of two Board-certified radiologists.

Reach out but Beware

There's no shortage of implant information on the Internet. One reasonably scholarly source is Wikipedia: http://en.wikipedia.org/wiki/Dental_implants. You may discover important information specific to your case (for example, the relationship between intravenous treatment for certain types of cancer and many other contraindications for implant surgery are discussed in the article).

Google searches are an excellent way for patients to acquire health information. Perhaps you found this article by searching dental implants. However, information that is both bias free and deeply biased results from Internet search. Don't rely on any single information source, including this article. Consider each websites motives.

One of the top-ranked websites for dental implants is http://www.yourdentistryguide.com/dental-technologies/. Calling itself the Consumer Guide to Dentistry, it provides a sponsored Dentist Directory (the motive). Although the site delivers extensive information, oddly it provides no easy access to guidance and information on CBCT X-rays and surgical guides. Only by deep diving will you find this:

CAT Scans: A 3-D image CAT scan is used to help implantologists (dentists who provide surgical and restorative implant services) view and work on the jawbone or surrounding bone structure to produce more accurate results. CAT scan technology has become increasingly specialized for dentistry as implants, rather than dentures, have become the standard of care for tooth replacement.

This is typical for the fruits of Google-like searches on dental implants, even as CBCT and surgical guides gain broad acceptance around the globe as the standard of care for a significant fraction of implant cases. For example, a website entitled dental-implants-guide.com claims to have the "best online info" but offers no content on CBCT, even through the site's search function. Its as if the dental community does not want patients to know up-front about the technology. However, if you read the conversations at dentist-to-dentist websites, its clear that CBCT X-rays are gaining broad support (a declining number of dentists are labelling them suitable only in difficult cases). Acceptance of CBCT is also evident at the leading implant manufacturer's site, www.Nobelbiocare.com. Here, the topic receives direct menu selection under the name NobelGuide. And, a growing number of dentists are adding newly-available lower-cost CBCT units to their practice. As they become known, these are being listed in the companion CBCT Directory.

It's essential to visit implantology websites to search for specific information. One information-rich site designed for dentists but available to all is http://osseonews.com/. Use the search tool just below the top right of the landing page to enter terms for your chief concerns. For example, enter bisphosphonates or osteoporosis if you are concerned about oral and intravenous drugs for osteoporosis or osteopenia. Enter smoking if you have the habit (being a smoker impairs healing and reduces the success rate). Or enter cone beam to learn a great deal more about 3D imaging, or diabetes if you wish to know if implants are contraindicated. The site also includes a list of popular topics in the left navigation space.
You'll discover patients asking important questions in the extensive conversations. Clinicians who both favor CBCT and have doubts about it freely discuss their opinions (the trend leans heavily in favor of 3D). Dentists warn their colleagues about drill length, a key factor favoring CBCT. And, you can ask questions in the site's topic-oriented forums.
You'll get answers from dentists, implantologists and civilians. As with any Internet-based source, caution and care must rule your use of what you learn. Since this is a website ostensibly written by clinicians -- dentists and oral surgeons for dentists and oral surgeons -- a lot of the content may be difficult to comprehend. However, the site's reputation is one of helpfulness, so don't be afraid to jump into a forum with questions, even if you think it's dumb or embarrassing. Ask for lay language answers, too. There are no dumb questions when it comes to medical and health procedures, just potentially poor outcomes when the knowable is not gained in advance. A list of other useful implant and CBCT websites is included
at the end of the article

Computer Aided Diagnosis and Manufacturing

CBCT X-rays have another key advantage: because they are digital, clinicians can use the data to create new accurate views in real time for treatment investigation, planning and the design of surgical guides.
In Fig. 8, Simplant (simulated implant) software has allowed the dentist to use the patient's CBCT data to try in different implant sizes in a conveniently reformatted view. If the chosen size won't work because it's too long or wide, or the proper angulation cannot be achieved, an alarm sounds (which is the case here). The software presents frontal and side views (width, height and depth) based on the patient's data (which is stored in an industry standard format called DICOM).
The dentist uses the computer mouse to select implants from various manufacturers and attempts to place them in the patient's jawbone image, which is a 1:1 representation of the actual jawbone with typical accuracy of 0.1mm. The data for Fig. 8 was prepared with a NewTom 3G CBCT X-ray unit. For this patient, the result was to NOT attempt to place an implant at the site shown because it would collide with a nerve. (In actuality, the drills used to prepare the site would shred the nerve).

Fig. 8: Materialise' Simplant software adds the element of safety based on the patient's

3D data. Fig. 9 shows more detail of a nerve collision

Fig. 9A: Try-in collision

In Fig. 9A, a blowup from the Simplant image set, the clinician is attempting to find an implant that will correctly fit at a specific depth and angle in the jawbone. The patient's CBCT data allows a thin "slice" of the jawbone to be selected for the Simplant try-in, and the software reformats the proper precision image. This is shown by the light to medium gray peanut shape. It's a cross section of the mandible (lower jaw) at the position of the first molar (squeeze your lower right jawbone between left thumb and forefinger to help visualize this image).

The patient's cheek is to the left, tongue to the right (neither is visible). Note the dark opening on the left, under the horizontal red line. This is the canal that carries the mental nerve that enervates the lip and chin. It rises more than usual (only a CBCT image will reveal this, according to a Board certified dental radiologist). The opening is a standard anatomical feature that all of us have on both sides of our mandible. It is named the mental foramen.

The three overlapping red circles down the middle form a zone of safety of 2mm. This area must be avoided to eliminate the possibility of nerve damage. The yellow cylinder shape (numeral 1) is the selected simulated implant. It has been positioned high, 4mm above the top of the jawbone. Nevertheless, the tip of the implant denoted by the white x fails to clear the topmost red circle. This causes an alarm to sound as a warning box pops onto the screen. As a result, the software would convince the dentist that a suitable implant could not be placed in this position.

Fig. 9B, an artist's conception based on Fig. 9a, provides a clearer view of what happened when an implant was actually drilled and placed in this exact situation (because of their shape and the surgical protocols, drills penetrate about 1mm deeper than implant placement). After the fact, both a world-renowned Board certified dental radiologist and an expert implantologist concluded that an implant should not have been placed at this location due to the rising nerve canal. Because the surgeon claimed this condition was not visible on the patient's 2D X-ray (Fig. 5A), and did not order a CBCT beforehand, the surgery caused permanent injury.

Fig. 9B: Artist's Concept of Fig. 9A

Avoiding injury is the chief safety benefit of CBCT. And here's another: assuming that the try-in succeeded, the same digital data may be used to fabricate a precision surgical drilling and angulation guide after implant size, shape, angle and drilling depth are established with the software. Through the try-in procedure, the clinician arrives at a suitable solution that includes implant selection from among many manufacturers. The treatment plan data is then sent to Simplant and a SurgiGuide is quickly produced. As its name suggests, the guide prevents drilling errors.

In addition to Simplant, other makers of implants and treatment planning software are offering this service (e.g., NobelGuide). For good reason, it's becoming a standardized treatment approach.

Experienced implantologists will be first to tell you that surgical guides are not always the answer. In actual clinical practice, with the patient under sedation and the jawbone fully exposed, the surgeon or dentist may encounter bone that is too soft at a predetermined location. It then becomes necessary to alter the location of the osteotomy -- or abandon placement. With the patient's CBCT on the chairside monitor during the procedure, the implantologist in this situation is armed with the best technology to succeed.

Other Important Considerations

CBCT X-rays usually require a prescription or referral. Whether your dentist recommends implants or you decide to ask for them, have the discussion right up front and get the referral if appropriate in your case. Ask about the need for a Board certified radiologist's report, which is highly recommended if the amount of available jawbone is questionable or if drilling near anatomical structures like nerves and the mental foramen is contemplated.
Because CBCT's can be "reformatted" for different accurate views by your dentist (using free or inexpensive software), the utility is amazing. First, the images are a one to one (1:1) full size precise representation of your jawbones, which means that they have no distortion or magnification (distortion and magnification in your dentist's 2D X-rays can make them grossly inaccurate). Second, because cone beam X-rays are extremely precise, the zone of safety can be reliably reduced to 1mm in difficult cases. Some implantologists resist the use of CBCT. This is regrettable and potentially hazardous. One implantologist testifying in a malpractice case stated he only uses single-tooth periapical X-rays even when several successive implants are being placed. This is like a carpenter choosing a hand saw when a power table saw is available nearby. If your dentist and/or implantologist fails to raise the CBCT topic, bring it up yourself, letting the clinician know that safety, not expense, tops your list. Let's say that you proceed with implant surgery without a CBCT, and then suffer chronic pain and / or numbness after surgery. You'll want to insist on CBCT for ongoing diagnosis and treatment. If your implantologist balks, go to a hospital emergency room or to a dentist who agrees to help you get a CBCT for diagnosis leading to treatment. Refusing a diagnostic tool like CBCT in this kind of situation could be motivated by a need to avoid evidence of malpractice. Don't make the mistake of trusting your clinician in this kind of dire situation. Another issue is bone grafting. If your implantologist recommends grafting in advance of implant surgery, find out how much vertical bone gain needs to be achieved. Grafting is most successful for adding horizontal width to jawbone. But vertical height is extremely difficult to achieve, so you'll want proof that it's been achieved before allowing the implantologist to drill. Proof is relatively easy to get using standard 2D X-rays (they show height and width, but not depth), available in every dental office. Have your implantologist take and show before and after views of the bone graft. If you cant see added height, demand an explanation and fresh measurements for implant length and width. An issue deserving mention is the use of bisphosphonates like Fosamax, Boniva and Actonel for osteoporosis and osteopenia. For several years prior to 2007, it appeared that dental implants should be avoided if oral and intravenous bisphosphonates were being taken, due to an unexpected condition called osteonecrosis of the jaw (jawbone death) reported by several dentists. Since the growth rate for oral bisphosphonate treatment has been accelerating, alarms went off. A contraindication would eliminate a key demographic from implant consideration the huge population of women (and some men) over 50.
However, clinical studies launched by the American Dental Association (and reported in ADA's journal, JADA) as well as by oral surgery trade associations around the world helped the implant industry heave a collective sigh when oral bisphosphonates were exonerated. Clinicians have now been advised that only intravenous administration of bisphosphonates (usually as an adjunctive treatment in certain cancer cases) is a contraindication for implants. More information on this topic is available in a Google Knol by Dr. Terry Shapiro Yet another issue is dental tourism, the temptation to seek treatment outside of your region or nation because of the budget. You may save as much as 75% in Mexico, Costa Rica, Hungary, India or South America and get a mini vacation in the process. What's the downside? Clearly, there are many reasons to NOT have implant surgery beyond your locality:

• Who delivers the critical follow up treatment, which can last for several months via regular office visits? The serious inflammatory condition called peri-implantitis can threaten your implants, necessitating aggressive treatment.
• If something goes terribly wrong after you've returned home (for example, an implant falls out or numbness develops and persists), from whom do you seek corrective treatment?
• If genuine malpractice occurred during your offshore treatment, how can you sue to win a fair recovery? It's difficult at best at home.

When the budget is limited, a better approach is to seek treatment at an accredited school of dentistry. In the U.S., a list is maintained at http://www.dentalsite.com/dentists/densch.html. Most dental schools offer implants and some of the best clinicians are the supervising instructors. Costs are sometimes less than half the commercial rate. These schools also offer CBCT as well as accompanying Board-certified radiology reports to help diagnose and guide the surgery. Patients in Northern California, for example, have a choice of UCSF and University of the Pacific, and both schools offer CBCT X-rays and Board-certified radiologists.

Another choice during our current economic downturn is to do the unthinkable: negotiate with your dentist. A scan of professional dental websites reveals that dentists are hurting, too. Don't be afraid to attempt to strike a deal that is win-win for both patient and dentist.

Implantologists Who Support CBCT

CBCT technology continues to gain traction around the globe at the same time that an increasing number of general dentists are starting to place implants, often with minimal training. Before long, simple implants will be standard in most cosmetic dentistry practices while difficult cases continue to be the specialty of oral surgeons, periodontists and prosthodontists.

CBCT Implantologist, Lab and University Listings

As dentistry and medical schools train more professionals, the word is spreading about CBCT, helping standardize its use. If you are an implantologist who wants patients to know that you employ CBCT for the patient's benefit, please accept my invitation to list yourself in this section of the article, in a future revision. Simply use the comment tool below or click to send an e-mail. Include your contact information and location(s).
This section has developed so rapidly that I've written a growing Knol directory. It includes three categories of CBCT-supportive service providers: implantologists, Universities and private labs. Simply refer to CBCT Services Directory

Dental Malpractice

This section of the Knol will probably be the least liked by the profession. However, just as it's important to inform patients of all options, it is equally important to let them know about their rights in the rare event things go wrong in surgery. Various studies place the success rate for implant surgery above 95%, an excellent outcome. But that leaves several patients out of every hundred in the negative column. As the number of dentists placing implants grows, the success rate may fall due to what appears to be a "gold rush" mentality, accompanied by too little training. By shining our light on CBCT as the best approach in evidence-based dentistry, we also shine our light on the legal profession involved in malpractice cases. In the long run, openness is likely to increase the success rate while simultaneously decreasing malpractice insurance rates.

Sadly, some fraction of those poor outcomes will be victims of negligence or malpractice. For example, the patient involved in the nerve penetration portrayed in many of this article's examples discovered that the implantologist rushed through the surgery, including all of the following steps, in a mere 30 minutes:

• Anesthesia
• Surgical flapping of the gingiva (gum) and retraction to fully expose mandibular jawbone
• Under a written protocol of care and caution to prevent overheating of bone and warnings that the drills are longer than the implants being placed, drilling and placement of the first implant (up to six drilling steps)
• Drilling and placement of the second implant (up to six drilling steps)
• Drilling and placement of the third implant (up to six drilling steps)

• Placement of three healing caps
• Surgical suturing of the gingiva over the implants to foreclose the possibility of germ entry (often calls for placement of a special membrane)

• Cleanup

All of this in 30 minutes! Was the oral surgeon in a race? Had he made a speed bet with another surgeon? Did he have a balloon payment coming due on his vineyard? Expert testimony in the subsequent malpractice case supported safe surgical times averaging about 45 - 60 minutes per implant, not 30 minutes for all three. In my own personal experience in 2011, a single maxillary implant surgery spanned just over one hour (plus recovery time for the anesthesia).

If your outcome is not in the 95% column, you may wish to consult attorneys who specialize in dental malpractice. Some attorneys are also licensed dentists, imparting unusual expertise to their legal practice. This section of the Knol is an open invitation for malpractice attorneys to list themselves. Simply use the comment tool below or click to send an e-mail. Include contact information and location(s).
Dental Malpractice Attorney Listings
Ciulla Torralba, PLLC
3030 North Central Avenue, Suite 608
Phoenix, AZ 85012
602-495-0053

Law Office of Bohdan Neswiacheny
540 N.E. 4th Street
Fort Lauderdale, FL 33301
(954) 522-5400

Baird Law Group
505 East Jackson Street Suite 205
Tampa, FL 33602
Toll Free: 866.604.4036

Edwin J. Zinman, DDS, JD
220 Bush Street Suite 1600
San Francisco, CA 94104
(415)391-5353
zinman@toothattorney.com

Dane Levy, JD
444 West Ocean Boulevard, Suite 800
Long Beach, CA 90802
(562) 951-5996

Steigerwalt Associates
Kerry Steigerwalt, JD
San Diego, CA
888-775-3779

Toothlaw
Attorney Alan Kelman
6439 NW 43rd Terrace
Boca Raton, Florida 33496
561.703.2768

Berman & Simmons
85 Exchange Street
Portland, Maine 04101
(207) 774-5277

Paulson Coletti Trial Attorneys
1000 SW Broadway, Suite 1660
Portland, Oregon 97205
503.226.6361

Gerald M. Oginski, LLC
25 Great Neck Road , Suite 4
Great Neck, New York 11021
(516) 487-8207

Greshin Ziegler & Amicizia, LLP
199 East Main Street
Smithtown, New York
631.265.2550

Jason B. Kessler
111 Church Street
White Plains, NY 10601
Local number: 914-220-1088

Boyd W. Shepherd, DDS, JD
Houston, TX
(281) 304-1000

Farber Law Group
1700 Seventh Avenue, Suite 2100
Seattle, WA 98101
1-800-244-9087

Further Viewing, Further Reading

Informative Web Links

• NY Times article (22 November 2010), video on CBCT radiation (preceded by a commercial but worth watching)

• 3D Orthodontist.com advances the use of CBCT for precision orthodontics

• Wikipedia http://en.wikipedia.org/wiki/Dental_implants (note: the content has recently been edited to reduce CBCT applicability and importance, which is opposite of the trend. This may be vandalism to protect an at-risk implantologist)
• OsseoNews http://osseonews.com/
• American Dental Associationhttp://ada.org/
• 3D Cone Beam X-rays http://www.conebeam.com/?q=cbct-clinician/verDental

• Implant Patient Animated Movie http://www.bicon.com/patient/video.html
• Nobel Biocare website http://www.nobelsmile.us/en_us/
• Planmeca Office 3D website http://www.planmeca.com/index.php?page=00301&lng=1
• Materialise Simplant website http://materialise.com/materialise/view/en/84113-Dental+homepage.html

YouTube Videos on Dental Implants

Another CBCT Endorsement

Introduction to CBCT (San Antonio, TX news report)

Austin Cone Beam Imaging/Dr. Brian Smith
Medical Breakthrough/Dr. Joe Kravitz
Iluma Cone Beam CT/Dr. Steven Sullivan
Mobile CT - NewTom VG Flex (silent)
i-CAT CBCT/Dr. Bryon Scott
Evolution's Iluma
Galileos Sirona Cone Beam (animated video)

Simpson Dental pitches the practice

Useful 3D cone beam X-ray websites

• PowerPoint presentation of available CBCT Scanners, with a link to each: http://www.box.net/shared/xb0tuzskc2
  

• American Society of Radiologic Technologists https://www.asrt.org/content/News/IndustryNewsBriefs/CT/CTDentalSy050222.aspx
• Straumann video on measurement and analysis procedure for treatment planning http://www.straumann.us/us_index/pc_us_products/pc_us_archive.htm/pc_us_archive?func=movie&type=9864
• Imaging Sciences iCAT http://www.imagingsciences.com/pro_iCAT_design.htm

• PreXion http://www.prexion3d.com/dental_index.html
• Planmeca http://www.planmecausa.com/index.php?page=00343

• NewTom 3G http://www.afpimaging.com/newtom
• Accu-i-Tomo http://www.jmorita-mfg.com/en/en_products_diagnostics_general_3d_accuitomo.htm
• Comprehensive 2001 implant article: http://radiology.rsnajnls.org/cgi/content/full/219/2/334
• Nobel Biocare NobelGuide http://www.nobelbiocare.com/global/en/ClinicalProcedures/NobelGuide/default.htm?flash=falseC-Dental X-ray Laboratory http://www.cdental.com/index.php?action=tech

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About the Author

Murry Shohat Deeply experienced, widely published. Reporter, editor, strategic and tactical PR, outbound and inbound marketing, articles, research, positioning, press releases, white papers, case studies, SEO, newsletters, desktop publishing design templates. My work spans conceptual, analytical, interpretive, journalistic, and persuasive projects. Experience in high technology, real estate, dentistry and health care, aerospace, law, general business, B-B and B-C. Located in California's vino-licious wine country, my education includes a degree in Journalism and post-grad work in Business.
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