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Considerations of Buying Cone Beam Imaging

Early adopters can be rewarded by increased productivity, better predictability of outcomes.
03/01/2018
If there was ever any doubt that dentistry would pursue a digital path as the so called pervasive technologies of digital communication, mobile phones and tablets have invaded our everyday lives, we are well past that dilemma. Digital dentistry is not merely a different way of doing the same thing. It acts as an enabler. It enables clinicians to carry out more complex tasks more predictably than they could previously. I like to characterize it as being to dentistry what Uber is to the taxi industry.

Digital dentistry has proven itself to be an invaluable contributor to many aspects of dentistry, most prominently expressed in implantology, prosthodontics, and orthodontics, but also penetrating into, endodontics, surgery, radiology, and even entering into the more routine provinces of restorative and prophylactic dentistry.

Dentistry is equipment centric. The nature and extent of the equipment present in a dental practice dictates the opportunities and limitations to the type of dentistry that can be performed and consequently the income that can be generated in that practice.

Two pieces of equipment have emerged as the principal portals of entry for dentists into digital dentistry. They are conebeam CT scanners and 3D intra oral scanners. In today’s environment, a dentist has to not only be a good clinician, but also be business aware.

Early adopters can be rewarded by increased productivity, better predictability of outcomes, and an entré into more advanced aspects of dental treatment. However, the transition is not without its pitfalls. All clinicians have equipment graveyards where seemingly good ideas are gathering dust in a corner. When moving into new technologies, one must make a concerted effort to understand the differences in the offerings and choose wisely. Talking to colleagues who have previously made the commitment to the type of technology that you are looking at can also be beneficial. Buying dental equipment is not like buying a car with a badge to park out front. It is both a clinical and a business decision. One needs to ensure that a brave leap into the future can deliver the promise that we were looking for and also a return on the not insignificant investment associated with it rather than joining the instrument graveyard in the corner because the equipment is too ungainly to use and the company who derived the sales hype didn’t have an understanding of how the technology should be applied. Or it could be that technology has already passed it by and it has been superseded by a better way to do things but there was a good deal on the runout model.

The introduction of the conebeam CT has provided us in dentistry with the ability to asses a volume of bone in our area of interest in three dimensions. It doesn’t replace the OPG but gives us a different capability. The OPG is still a valuable tool providing a perspective view of the mouth while incurring a relatively low dose of radiation for the patient. A CT provides us with the ability to review a three dimensional volume from any perspective and to be able to measure areas of interest very accurately without a magnification factor. It also provides us with a relative measure of bone quality in a region of interest. This enables us to more accurately assess pathology and plan for surgery.

When choosing a CT scanner, consider how you are going to use it in your practice. CT-scanners come in varying shapes and sizes, the main differentiators being the size of the volume that they can capture in a single cycle, and the dose of radiation that they deliver for a given task. Available volume size for dental application starts from a single tooth and progresses up to the entire head and neck region. If your main area of interest is endodontics, then most likely you would be more inclined towards a smaller volume size. If you are interested in implantology or maxillofacial surgery, then perhaps a larger volume size would be more appropriate.

There are a number of factors to consider when choosing the most appropriate target volume for a particular application but I believe we can find the correct answer by asking the following questions:

1. What information am I looking for?

2. What view will give me all of the information I am looking for?

The answers to the above questions are not always apparent without some consideration. For example, if you are considering placing an implant in an upper central incisor position, a clinician may consider at face value that he requires a CT scan of just that region. However, there is much more information that could be gleaned from a larger field of view. A view of the entire upper arch would enable the construction of a surgical guide to facilitate more accurate positioning of an implant. Looking forward, a view of both arches including the retro-molar area would provide enough information to determine if there is enough available bone in the retro-molar region to provide donor bone should block grafting be required to facilitate implant placement. In such a case, the clinician would have the benefit of more diagnostic information about the entire mouth and ultimately would have reduced the dose of radiation to the patient by mitigating the need for a second CT in pursuit of a source of donor bone for block grafting. Intuitive analysis of the clinical situation in required for the clinician to make a judgement call on appropriate field size but having the capability of a larger field size provides the opportunity for that choice.

The question is then when would a conebeam CT be used in general practice?

Implantology is the most obvious application.

Implantology is the fastest growing area of modern dentistry. With good treatment planning and good clinical practice, the prognosis for implants is extremely high. An essential part of that is starting planning with a CT scan. I believe that a CT scan is the starting point for treatment planning. It gives an accurate assessment of existing pathology, an insight into how much bone will be available after removable of deteriorating teeth, and is a tool that a clinician can use to plan treatment and show the patient the present situation and project possible future treatment. This ability to diagnose, treatment plan and demonstrate to the patient at a single visit is a significant contributor to case acceptance.

In specialist endodontics, a conebeam CT has become mandatory. In general practice, it is a hard to argue against its application because a CT removes the guesswork in looking for canals and reduces the possibility of leaving untreated canals.

In simple surgery it is also provides significant help. With a three-dimensional view of a tooth, a clinician can determine the path of removal of a tooth or root fragment which enables a strategic approach to tooth removal (as opposed to the overwhelming force approach). Identifying the risks associated with third molars is an obvious starting point but removal of any tooth should be a strategic process. Identifying and accurately locating supernumerary teeth, odontomes and other pathology are prime applications for conebeam CT’s.

In conclusion, when choosing your CBCT, don’t buy on price alone. Open your mind and consider how you might apply the machine in your practice. Although cost is an important consideration, it is not the only consideration. Buying a less capable machine still involves a considerable outlay which may appear to be a good deal initially but may not look so good with the benefit of hindsight if it does not live up to its potential.

Harry Schlen is a practising dentist of over 30 years’ experience and is a partner in SV Radiology which is a provider of Dental Radiology services located on the campus of at St Vincent’s Hospital Melbourne. He is also a consultant to St Vincent’s Hospital Melbourne and the Royal Victorian Eye and Ear Hospital.

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