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Diagnostic Models vs. Computer-Generated Guides

posted in CT Scans for Dental Implant Treatment, Cone Beam CT Imaging, Computer-Generated Implant Placement, Surgical Guides for Implant Placement

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Dr. Shelly asks:

I have been restoring dental implants now for 5 years. I make the surgical guide stents for my surgeon from diagnostic models. I use the information from the panoramic radiograph to help plan where to place the implants, what diameter and what length.

However, I recently took a course where the lecturer said that was below the standard of care for some dental implant cases. He said what we should all be doing now is using a CT scan and a computer- generated guide stent. Am I still in the stone age with my diagnostic models? Should I really be abandoning these methods after 5 years of success? Comments?

19 Responses to “ Diagnostic Models vs. Computer-Generated Guides ”

• Scott D. Ganz, DMD November 7th, 2006

  
  

  “Am I still in the stone age with my diagnostic models? Should I really be abandoning these methods after 5 years of success? Comments?”

  Interesting statements… most dentists will stick with a proven method of success, and you have obviously found one that works for you. However, if you wish to move into an even more predictable environment for planning all aspects of the implant reconstruction, then CT imaging, and CT derived templates are the next best thing.

  As more implant companies wake up to the fact that better planning means better implant placement which leads to more implants being done correctly, the focus of the industry has turned to guided surgery. There is no question that today this is the clear direction of the industry, and if you wish to stay current, then jump on board and learn more about the various methods for achieving success.

  One place to start would be www.SIMPLANTACADEMY.com a great resource to learn more about this technology. Or other companies who offer similar solutions.

• Anonymous November 7th, 2006

  
  

  I believe I know the lecturer that stated that. It is “HIS” opinion for now and until a court of law says otherwise (Or a respected study), I would stick with what works for me. If you have had little to no failures and your method brings you to a success rate of 90%,you are within all parameters of success using all scientific data published to date. If and when a study shows that using a CT scan gives me a 99% success rate, I’m stcking with what works for me and I urge you to do the same.

• Alejandro Berg November 7th, 2006

  
  

  Dr. Shelly:
  The answer to your question is NO.
  Dont stop doing what you are doing,it is not below standards at all.
  If your results are succesfull in terms of osseointegration, function and cosmetic, you are in the zone, so why stop.
  CT derived templates are good I use them sometimes but in the end a good surgeon and a good rehabilitator as a team are better.

• Dr. Klassman November 7th, 2006

  
  

  The standard of care today for planing the majority of implant cases is the CT software. You could easily combine this approach with your models and stent fabrication. That is what we do for the majority of our casses. Having an ICAT makes it even easier. I do use simplant but with my stents and the ct images, my case flow beuatifully. Not to mention legal ramifications. Panorex have too much distortion. Your techniques sound good but could be made even more predictable as Dr. Ganz has stated.

• Anonymous November 8th, 2006

  
  

  CT is not the standard of care. I am not an attorney but the definition involves something greater than the majority of providers in your geographic area would do in a similar case. CT is not in the majority of providers or cases but is a valuble tool in some cases. I am still waiting for litigation on poor treatment planning by GP’s avoiding the use of implants and using only C&B or failing to place 2 implants in the fully edentulous mandible as the standard of care like stated in a JADA within the past year. The ADA continues to give wiggle room but this appears to be a more likely slam dunk for the attorneys

• Anonymous November 8th, 2006

  
  

  If you screw up an implant case and it goes to trial, the first question a “good” lawyer will ask is did you have a catscan. The second question they will ask is did you have a stent. The third question is did you use the stent. I don’t ever want to have to answer those questions. Would you let an orthopedic surgeon work on you without the necessary diagnostic imaging ? Being able to see bone in 3 d is vital for complex cases.

• Paul R Romano, DDS November 8th, 2006

  
  

  I have been doing implants for over 10 years and use surgical guides for all cases. These guides are made from diagnostic wax-ups and additional imaging is obtained.

  Often the supplemental imaging is not sufficient to accurately locate important anamtomical structures and assess the available bone volume. In these cases, we refer the patient for cross-sectional analysis with Cone Beam 3D imaging.

  There are no studies or position papers (of which I am aware) that indicate that computer generated surgical guides are the standard of care. IMO, while they may prove useful or desired in certain cases, computer generated guides may significantly increase the cost of implant care.

  Of course, the initial cost must be balanced with potential costs down the road, if improper placement or morbidity become factors. However, no such study has been done indicating that computer generated surgical guides are superior to other surgical guides in this respect.

• Andrej Meniga, PhD November 8th, 2006

  
  

  As a Nobelguide user with 19 years of experience in implant dentistry I must say that instant function (with precise prosthetic and 3D computer planning) is unmachable at the moment - only the price is an issue!

• Robert J. Miller November 28th, 2006

  
  

  Most clinicians are mistaken as to what the standard of care really means. It is NOT necessarily what the majority of clinicans in a community do in a procedure. It is rather what a PRUDENT clinican would do in a case. We are over a decade into the use of 3-D scanning. There is a CT scanner (or equivalent CBCT) on virtually every corner. If you attend any implant conference in a year, you will hear a clinicain talk about the use of non-distorted 3-D treatment planning. Because we do not practice in a vacuum, and in a compromised case if a CT scan could have avoided a complication, you may be judged as practicing below the standard of care. It would be rather difficult to use as your defense “most clinicians in my area don’t use this option and therefore I should be excused for this complication”. There simply is no excuse for not using this technology in a potentially risky procedure.

• Diana February 13th, 2007

  
  

  At our imaging center, we provide iCat scans for Dentists in the area. Some of the dentists who have been hesitant to take the 3D imaging to the next level using computer generated guides, have decided to have some scans completed while the patient wears a lab fabricated surgical stent with guttta perch placed in the holes to evaluate the accuracy of the guide. The majority of the time the slice images show that the holes are NOT in the correct position.
  This suggests that stone models are not the most effective way to determine available bone. How is it even possible to accurately compare a stone model to a panorex???
  3D imaging along with computer generated guides are the best option available today, for planning implant position. So, why not use it?
  I would not want anything less, as a patient. And, I am sure most patients would feel the same, once they are educated.
  A few extra bucks spent for more predictable results is well worth it.

• Dr. M April 11th, 2007

  
  

  Several months ago I did my first “computer fabricated stent case.” For 16 implants, both maxillary and mandibular, there were six stents corresponding to the various drill sizes I anticipated using. The stents were provided by a board certified prosthodontist. The scan was obtained using an I-Cat. My first sign of trouble was when I noticed several of the drill rings on the small drill stent actually touched each other. When I tried to use the stents in surgery, the drills missed the bone entirely. Suffice to say, I had to eyeball the entire case; and what should have taken two hours, took six. Thank goodness for intubated GA and the training to do it properly. It’s the same old story. No matter how many hundreds of thousands one spends on new technology, garbage in, garbage out.

• Dr. Ollerton April 11th, 2007

  
  

  I have been placing and restoring dental implants since 1992. I have had simplant software for many years and reserved it for fully edentulous cases until the last year or so. In this last year I have used 3-D radiographic data on most cases and it is made a world of difference.

  It has made such a difference that I will not take on a case now if the patient is unwilling to have the 3-D study done when I know that the information would be helpful. There are cases where I do not feel that I need 3-D studies, but they are becoming fewer.

  Rand

• Dr. Mehdi Jafari April 13th, 2007

  
  

  Imaging information from panoramic, cephalometric, and intraoral films alone is inadequate to evaluate the bony architecture of any implant site completely. The American Academy of Oral and Maxillofacial Radiology (AAOMR) recommends that evaluation of any potential implant site include cross-sectional imaging orthogonal to the site of interest. This information is best acquired with tomography, either conventional or CT. Conventional film tomographic views are most useful (free of streaking artifacts) when complex motions are used, such as spiral or hypocycloidal patterns, instead of linear movement. CT is most appropriate for patients who are being considered for many implants (8-10 or more) or when grafts or reconstructive surgery have been done or are being considered. The threshold for the number of sites that may need CT imaging depends on the type of conventional tomography system available. The AAOMR recommends panoramic and orthogonal cross-sectional imaging for all implant site evaluations and endorses conventional tomography as the most cost effective and lowest radiation risk modality available today for the majority of patients.

• hersheydmd April 29th, 2007

  
  

  Computer guided surgery is definitely the standard of care in any complex case. The difficulty is in deciding whether a case is simple or complex. I have an i-CAT and have taken over 300 scans for dentists in my area - excellent, dedicated, caring professionals. Many of the patients had implants placed 5, 10, 15 years ago, before scanning technology, and now are having additional implants placed in other area. I am amazed at the number of times I find previously placed implants that are not fully in bone. In the mandible, perforations are common in the lingual concavity, in the maxilla they are common in the buccal concavity. It points to the fact that not every case of cortical perforation is detected at the time of surgery, and not every case fails because of it. But some do. Wouldn’t it be nice to avoid it in the first place.
  Without a scan and an accurate computer guided appliance, the only way to know for sure is to lay a large flap and visualize the bone. Weigh that against a minimal flap or no flap, which translates to less pain and swelling and less trauma to the tissue. I know which I would rather have.

• Marvick Muradin, MD DMD June 13th, 2007

  
  

  To Hersheydmd:

  Do you perform flapless surgery with soft-tissue bourne surgi-guides?

  I am very sceptical about the soft-tissue bourne surgi-guides: As correctly stated by you, the risk of apical fenestration with flapless surgery is there! With transgingival implant-surgery the risk of placing the implants completely out of the labial alveolar bone is greater than with the bone-bourne/dental-bourne surgi-guides. Therefore I think the recent campaign by Nobel to “teach” any dentist with flapless surgery might be dangerous for the patient!

• Joe June 23rd, 2007

  
  

  As an “amature” placing implants (only 4 up to that time), I borrowed one companies software for a six implant upper edentulous case. Needless to say with the technology and a stent with changable rings for the diameters and depth limiting drills, I successfully placed the implants.

  I did this so I can write an article showing that minimally invasive dentistry can be practiced using technology. The case is now ready for restoration.

  Would I ever try a case like this without a computer generated stent-NO WAY. Standard of care or not, the accuracy and time saved was totally worth it. I see no reason in taking chances with cases that benefit from the knowledge garnerd with a CT scan and good software. Single implants in easy locations I am doing without CT scans, but bigger multiples-using the technology.

• HersheyDMD July 27th, 2007

  
  

  Marvick,
  Life is a compromise.
  Soft tissue borne guides are not perfect and the accuracy can be suspect.
  Bone borne guides have the disadvantage of requiring extensive flaps, which increases post-op pain and swelling.
  Ideally, whenever there are teeth present the guide should be tooth borne.

• Chan Joon Yee July 14th, 2008

  
  

  “Ideally, whenever there are teeth present the guide should be tooth borne.”

  Ideally, those teeth should not be mobile.

• Dr. Gonzalez July 14th, 2008

  
  

  I have been doing implants for over 20 years and using surgical guides for all cases, 5 years ago. These guides are made from diagnostic wax-ups and additional imaging is obtained. 3D imaging along with computer generated guides are the best option available today, for planning implant position. Computer guided surgery is definitely the standard of care in any complex case.
  I have seen some of my collegues having different issues because of this technology. Most of the problems I have gotten were because of my technique(planning, understanding the software, getting information about the software I used).
  Have you heard about EasyGuide of Keystone dental? it has been for me easier to use, cheaper to afford and knowledgeable and ready EasyGuide team to clear our doubts. Excellent knowledgeable representation.

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