Comparing panoramic radiography with Cone beam computed ...

Comparing panoramic radiography with Cone beam computed tomography (CBCT) in the detection of anatomical structures

and its effect on treatment planning in the placement of implants in the posterior region of the mandible and maxilla (a Pilot

Study)

___________________________________________________________

A Thesis

Presented to the Faculty of Tufts University School of Dental Medicine

in Partial Fulfillment of the Requirements for the Degree of

Master of Science in Dental Research

by

Salem Alaqel, BDS

December 2016

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© 2016 Salem Alaqel

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THESIS COMMITTEE

Thesis Advisor:

Nadeem Karimbux, DMD, MMSc

Tufts University School of Dental Medicine

Associate Dean for Academic Affairs

Committee Members:

Aruna Ramesh BDS, DMD, MS Diplomate AAOMR

Interim Chair and Associate Professor

Department of Diagnostic Sciences

Division of Oral and Maxillofacial Radiology


&

Matthew Finkelman, PhD

Associate professor

Director of the Division of Biostatistics and Experimental Design


&

Dr. Yong Hur, DMD, DDS, MS.

Assistant professor of Periodontology


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Abstract

Aims and hypothesis: The aims of the study were to 1) determine if the Cone beam computed tomography (CBCT) would provide more anatomical structures details than panoramic radiography that may affect the surgical treatment planning of implant placement in the maxillary sinus region and the posterior region of the mandible, 2) evaluate and compare treatment options between experienced specialists and residents, 3) evaluate and compare treatment options between specialties (periodontics, oral surgery and prosthodontics), and 4) evaluate and compare treatment options between second and third year residents in the Department of Periodontology. The primary hypothesis was that the CBCT image provides more information than a panoramic radiograph regarding anatomical structures impacting the treatment choice for implant placement (sinus proximity, IAN, bone dimension, surgical intervention prior to implant placement, e.g., sinus or ridge bone augmentation). The secondary hypothesis was that CBCT is better suited for choosing the optimal implant (length, diameter and shape) compared to a panoramic radiograph in the placement of an implant in the maxillary sinus region and posterior mandible.

Materials and Methods: Five criteria were researched: maxillary sinus proximity (bone height), maxillary bone width, mandibular bone width, IAN proximity and the FSG in the posterior region of the mandible. 10 cases were chosen (2 cases for each criterion). Each case had both a CBCT and a panoramic radiograph. 10 periodontal residents (5 2nd year and 5 3rd year residents) and 5 prosthodontics residents were recruited. Five faculty were recruited from three departments: Periodontology, Prosthodontics and Oral Surgery. The participants had two sessions to evaluate the images and answer a hard copy survey questionnaire regarding the appropriate treatment plan for implant placement regarding a specific site in the case. The participants were exposed to either panoramic radiographs or CBCT images per session with a 1-month washout period in between. The CBCT and panoramic radiographs were presented to the enrolled clinicians/residents via a high quality hard copy image of the panoramic radiograph and CBCT with the related cross sections. The participants were not aware that both sets of images/radiographs were from the same patients (blinding).

Results: All 30 participants completed both surveys. Bone width (maxilla or mandible) was the criterion with the most reduction in regards to choice of implant suitability between the two researched images. The reduction was seen in most cases when the CBCT image was used in comparison to panoramic radiograph. The departments with a surgical background had a more invasive surgical approach in regards to both site preparation and implant design. The prosthodontic department selected shorter implant lengths in comparison to the other two departments. The faculties were more reserved than residents in placing an implant when using a panoramic radiograph. 2rd year residents and 3nd had similar choices in regards to all researched criterions.

Conclusions: This study shows that the use of a panoramic radiograph alone would restrict the clinician from having a full grasp of the existing anatomical landmarks leading to a considerable change of treatment outcome. Though this study is a pilot study, it shows that the treatment approach differs noticeably between departments and the level of experience the clinician has. Future studies are needed involving a larger number of participants and cases leading to more significant results that would support our findings.

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Dedication

First and foremost, I would like to thank my wife Fajer and daughters Dalal and Aseel for their

encouragement, support, patience and prayers. Without them none of my accomplishments at Tufts

University School of Dental Medicine would have been achieved.

To my parents and the rest of my family in Kuwait and the UK for their continuous support and

prayers.

To my close friends Saqer Al-Saqer and Farraj Al-Saeedi for their unconditional support.

To the outstanding committee members and I would like to sincerely thank them for their guidance

and support throughout this study as well as during my time in the residency program. It was an

honor to work closely with each one of them and I appreciate their precious time they devoted for this

project.

In particular, I want to mention Prof. Karimbux for being a great mentor and a father figure during

my time working on this study.

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ACKNOWLEDGMENTS

Special Thanks to:

• Gerard Cedrone from the Office of Academic Affairs for not only being a great friend and

colleague, but also for all his hard work in setting up the meeting schedules and preparation

for the survey sessions.

• Dr. Britta Magnuson for her help in writing the protocol and IRB process.

• The Office of Advanced and Graduate Education, Tufts University School of Dental

Medicine.

• Amanda Gozzi in the department of research administration at Tufts University School of

Dental Medicine for all her help and hard work.

• Faculty, Residents, and Staff of the Department of Periodontology, Tufts University School

of Dental Medicine, for their help and support.

• The departments of Prosthodontics and Oral Surgery for taking the time from their busy

schedule to participate in the study.

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TABLE OF CONTENTS

DEDICATION ........................................................................................................................ 5 ACKNOWLEDGMENTS ...................................................................................................... 6

TABLE OF CONTENTS ....................................................................................................... 7 LIST OF ABBREVIATIONS ................................................................................................ 8

Introduction ........................................................................................................................... 10 Aim and Hypothesis………………………………………………………………………...22

Materials and Methods ......................................................................................................... 23 Results .................................................................................................................................... 32

Discussion .............................................................................................................................. 64 Conclusion ............................................................................................................................. 72

References .............................................................................................................................. 73 APPENDICES ....................................................................................................................... 79

Appendix A: Figures ............................................................................................................. 80 Appendix B: Surveys .......................................................................................................... 136

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LIST OF ABBREVIATIONS TUSDM – Tufts University School of Dental Medicine

IAN – Inferior Alveolar Nerve

FSG – Fossa of the submandibular gland

ESL – Eternal Sinus Lift

ISL – Internal Sinus Lift

CBCT – Cone Beam Computed Tomography

PR- Panoramic radiograph

ALARA- As Low As Reasonably Achievable

PeD – Department of Periodontology

PrD – Department of Prosthodontics

OSD – Department of Oral Surgery

PeDF – Faculty of the Department of Periodontology

PrDF – Faculty of the Department of Prosthodontics

OSDF – Faculty of the Department of Oral Surgery

PeDR – Residents of the Department of Periodontology

PeDR2 – Second year Residents of the Department of Periodontology

PeDR3 – Third year Residents of the Department of Periodontology

PrDR – Residents of the Department of Prosthodontics

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Comparing panoramic radiography (PR) with cone beam computed tomography (CBCT) in the detection of anatomical structures and its effect on treatment planning in

the placement of implants in the posterior region of the mandible and maxilla (a Pilot Study)

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INTRODUCTION

The use of dental implants to replace missing teeth has increased rapidly. It has been

reported in various studies that the functional 5-year success rate of implants is 90% or

higher [1]. According to a review analyzing the long-term results of fixed implant

restorations, 39% of all patients were affected by complications or failures during a 5-year

observation period. The 10-year survival rates reached 93% (implant-fixed dental prosthesis,

FDP) and 94% (single tooth implants) on an implant level, whilst survival of the implant

restorations varied between 87% (implant-FDP) and 90% for the ISC [2]. Due to the reported

high success rates, clinicians and patients have been moving towards the option of having a

dental implant replace a missing tooth or multiple teeth. Though the rates of implants success

are high, there are many local anatomical factors that the clinician should evaluate prior to

any dental implant placement.

Appropriate clinical and radiographic imaging assessments are required to avoid any

surgical complications. Thorough pretreatment analysis also increases the treatment’s success

rate. Clinical assessment for implant treatment planning involves a thorough clinical and

radiological examination. Both clinical and radiographic examination of the existing bone

ridge and soft tissue could be evaluated using multiple recommended classification systems

proposed in the literature. There are several published classification systems that take clinical

and radiological features into consideration [Table 1].

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Study Classification

Soft and hard tissue defects

Seibert [3] Class I: bucco-lingual loss of tissue with normal apico-coronal ridge height

Class II: apico-coronal loss of tissue with normal bucco-lingual ridge width

Class III: combination-type defects (loss of both height and width)

Allen et al [4]

A: apico-coronal loss of tissue B: bucco-lingual loss of tissue C: combination Mild: < 3 mm; medium: 3–6 mm; severe: > 6 mm

Wang and Al-Shammari [5] Horizontal (h), Vertical (v) or combination (c) of tissue or bone loss.

Subdivided into: small (s): <3mm medium (m): 4-6mm large (l): >7mm

Hard Tissue defects

Misch and Judy [6] A: abundant bone B: barely sufficient bone C: compromised bone (C-h: compromised height; C-w: compromised width) D: deficient bone

Table 1.Different published radiological and clinical classification systems for hard and soft tissue defects evaluation.

Typically a combination of clinical and radiographic examination is most accurate.

For example, if one simply did a clinical exam using calipers or palpitation only, the ridge

could be underestimated due to the presence of a thick biotype, limited accessibility or the

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patient having a sensitive gag reflex. The presence of a dehiscence or the placement of the

calipers in the wrong measurement site would provide the clinician with a measurement error

[7]. Another limitation of such an approach is the inability to accurately evaluate the vertical

height of the ridge and the inability to investigate any vital anatomical structures or

pathology at the dental implant proposed site [8].

There are several anatomical factors that must be considered when analyzing cases

for implant placement or implant site preparation.

Maxillary Areas of Concern

In the maxilla the maxillary sinus, septa, artery, and amount of existing bone are

important anatomical structures that need to be taken into consideration to reach a well-

designed treatment plan.

At present, the function of the maxillary sinus is not yet fully understood and many

theories were presented in the literature. Functions listed are resonance to the voice, olfactory

related function, to warm and humidify the inspired air. Other theories address the physical

presence of the sinus and its role in reducing the overall weight of the skull [9,10]. At

adolescence, the maxillary sinus pneumatization reaches its completion at around 12 to 15

cm3 [11,12] with adult average dimensions of 25 to 35 mm in width, 36 to 45 mm in height and

38 to 45 mm in length [13]. According to McGowan et al. 1993, the floor of the antrum is

approximately 1 cm beneath the nasal floor [12].

The anterior segment of the sinus usually extends to the canine and premolar region.

The sinus floor, which is usually convex in shape, is typically the deepest point in the first

molar area. There is, however, great anatomical variation in the size, shape and extension of

sinuses. These variations even exist within the same subject. The increase of size and shape

of the sinus continues throughout adult life, frequently involving a significant portion of the

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alveolar process, resulting occasionally in a paper-thin bone wall on the lateral and occlusal

sides. The rate of pneumatization and extent differs from one person to another. The local

anatomy of the maxillary sinus and its restrictions needs to be taken into account when

planning to place an implant or multiple implants [15].

The incidence of maxillary sinus septa is mentioned in the literature to be anywhere

between 16% and 58% [14-20]. According to the study conducted by Krennmair et al 1997, the

incidence of antral-septa in edentulous regions was significantly greater than in dentate

regions, yet the height of the septa was lower [13]. Of those septa in the edentulous regions,

the authors concluded that 70% are located more mesially. This is something that has to be

taken into account when a sinus floor elevation procedure is planned. There are many

anatomical variations in the number, size and location of the septum. The septum is more

recognizable in the younger adult population [15]. The septa may divide the sinus in recesses

(several compartments). They may even be complete, dividing the sinus in smaller accessory

sinuses [20]. It has been theorized that the septa function as a masticatory force absorber

through the dentate phase and disappears gradually after the loss of teeth [14]. The septa size

and position dictate the size, number, shape and position of the lateral window, which has an

input in the treatment planning process and outcome. Therefore, a well-planned and accurate

location of the septum is an integral part of treatment planning of the implant placement in

the region of the maxillary sinus.

The presence of an artery, the posterior superior alveolar artery (PSAA), should be

detected prior to sinus elevation to avoid and prepare for any risk of complications during the

surgery. In a study, this artery was seen in more than 60% of the cases; 68% of them were

integrated within the bone [21].

The limitation in the height or width of bone at an implant site is a common challenge

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that many clinicians face when they attempt or plan for implant placement. In the posterior

maxillary region, one of the major issues is the proximity of the maxillary sinus. This

challenge could be overcome with the use a shorter length and narrower diameter of an

implant or to perform a guided bone regeneration (GBR) graft surgery to increase the

existing height. Another more invasive procedure would be to elevate the sinus by grafting

the floor of the existing sinus by an internal or lateral sinus floor elevation [22].

If the alveolar ridge width is a limitation, lateral augmentation via GBR techniques or

a block graft is used to laterally augment the ridge. The choice of the procedure and the

multiple bone graft attempts/limitations is dictated by the surgeon’s ability and experience,

the patient’s compliance and locally on the available bone and anatomy at the site of implant

placement.

Mandibular Areas of Concern

In the mandible, the inferior alveolar nerve (IAN), fossa of the submandibular gland

(FSG), and amount of existing bone are important anatomical structures.

In the mandibular region, the IAN and FSG are two anatomical structures in the

posterior region of the mandible the clinician usually locates prior to implant placement.

Serious complications may occur in the case of an implant perforation into the FSG that may

result into both short-term complications, such as infections into the submandibular spaces,

or long-term complications, such as irritations of the surrounding structures: muscles,

mucosa or tongue [23].

IAN injury could be due to direct trauma from preparation of the implant site

(osteotomy) or the implant invading the IAN territory. The choice of implant width, length,

shape and position prior to implant preparation or placement is vital to avoiding serious

injury. Implant related injury to the IAN ranges from 0-40% [24]. Damage to the IAN could be

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reversible or non reversible, depending on the degree of damage, neurapraxia, axonotmesis,

or neurotmesis. Neurapraxia is the form that possesses the best prognosis, while neurotmesis

is the most severe and the poorest prognosis of the three categories. A safety margin of at

least 2 mm above the mandibular canal should be respected at both the implant treatment

planning stage and the surgical stage [25,26].

Several studies reported on the dimensional accuracy of different systems for both the

size and location of the IAN as well as the mandibular height and width. The challenge of

detecting the mandibular canal is due in part to the lack of the cortical outline in some

mandibles [27]. Studies have shown that the canal could be easily seen by conventional

tomography whereas in others images acquired via computed tomography resulted in better

results [28,29,30].

The presence of the lingual posterior mandibular bone depression (LPMBD), or FSG,

provides a risk for implant perforation if the correct diagnostic tools were not utilized during

implant placement. This perforation may result in serious complications [31,32]. The

perforation may result in infection post-surgically, which has the potential of spreading to the

parapharyngeal space and eventually to a more critical space, the mediastinum. [33]

If an infection was avoided a further risk would develop via the perforated implant tip

that may result in a long term frictional irritation to the local moving mucosa, muscles, and

the tongue. Though one study evaluated this risk in humans, [34] the study only discussed the

potential complication in the first molar region. Due to the nature of the mandibular anatomy

in this region, the depression would be more evident and prominent in the second molar

region increasing the risk for such perforations.

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Radiographic Options for the Assessment of Area of Concern

A clinical exam only provides limited information. Therefore a radiographic exam is

typically required. There is no defined standard given for one type of radiographic

examination for any treatment planning. Several different methods can be used depending on

the clinical situation.

Radiography is an evolving field that is a vital tool for successful diagnosis and

reaching a predictable treatment plan while avoiding unwanted incidents by invading vital

structures adjacent to the field proposed for treatment. High accuracy in reproducing vital

anatomical structures with minimal magnification and projection inaccuracies is a

prerequisite for this diagnostic tool.

Currently in dentistry, multiple imaging modalities are available and used for

measurement of distances between anatomic structures, dimensions of both anatomic or

pathologic entities and implant site evaluation. The widely used are intraoral radiographs,

panoramic, lateral cephalometric radiographs, cross sectional imaging such as conventional

tomography, computed tomography, magnetic resonance imaging (MRI) and the most

currently developed is the cone beam-computed tomography (CBCT).

Intraoral radiographs could be used in the pretreatment phase to assess an implant

site. Such radiographs provide multiple advantages such as them being inexpensive, readily

available and well tolerated by patients. The images produced provide a high-resolution

image of the implant site as well as a low radiation dose to the patient. The lack of

reproducibility of those images serves to be a major disadvantage [35]. The two dimensional

image does not provide the required buccal-lingual anatomical information needed for

implant placement [36]. Another disadvantage is the limited visualization the image provides

(e.g. a restricted view of vital structures such as the path of the inferior alveolar [37].)

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The use of a lateral cephalometric radiograph has been shown to be beneficial as a

diagnostic aid for dental implants site evaluation [38,39,40]. Advantages and challenges of

cephalometric radiography have been documented in literature [35,37].

Pantomography is a unique tomographic technique that creates a panoramic

radiograph of an arched surface. Panoramic radiograph is a curvilinear complex variant of

conventional tomography. It follows the principle of the reciprocal movement of an x ray

source and an image receptor around a central point which moves during the image

acquisition; this movement and its path of motion differs as designed by the manufacturer.

Recent pantomographic models center of rotation follows a path defined by the

manufacturer. Objects that are found outside or inside the image become distorted [41]. The

wide visualization region the panoramic radiograph provides a comprehensive view of the

maxillofacial region, images including both the mandible and maxilla in a single radiograph,

and when compared to intraoral radiographic images, it has a significantly reduced radiation

exposure to the patient [42], compared to an intraoral full mouth series. In agreement with the

ALARA (As Low As Reasonably Achievable) principle, exposing patients to radiation

should be avoided unless the benefit from the proposed exposure outweighs the risks from

the procedure [41].

Linear measurements made on pantomographs can in some instances be inaccurate

due to inconsistencies in magnifications and distortion. A key disadvantage to a panoramic

image alone is that it offers no information regarding the bone thickness (facial-buccal

distance), which could lead to significant errors in determining the bone width during the

pretreatment planning of the dental implant placement [43]. This would provide a challenge to

the clinician as well as unwanted negative outcomes during the procedure, such as

perforations leading to an unanticipated increase in treatment cost and a negative treatment

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experience for the patient. Image quality is affected negatively by the presence of

superimposed structures. For example metallic restorations, bone screws etc. result in

metallic artifacts appearing on the image.

Due to the limited information 2-Dimensional images provide, there was a need for

the 3-Dimensional imaging that can provide information that was lost or restricted due to

superimposition, magnification and blurring. The 3D imaging is also important for

visualization of anatomical structures necessary for diagnosis and treatment planning of the

surgical placement of dental implants.

Computed tomography (CT) was present in the medical field prior to its use in the

placement of dental implants. In 1967 Godfrey Hounsfield developed the first modern CT

scanner; it was initially introduced in clinics in 1971 [44]. Since then, significant technological

evolution has occurred. In the late 1980s, it required 45 to 60 minutes, compared to today

that the time has reduced to nearly 5 seconds [45].

CT scanners provide measurement via attenuation of multiple positioned and angled

x- ray beams through and around the subject. The possibility of distinguishing between soft

and hard tissue was enabled due to the determination of attenuation differences of 0.5% [44].

The details and image quality found in a CT image is developed as a result of computer

calculations that result in the weighted average of all tissues (voxel; volume elements) [46].

The advantages of CT include constant magnification; high contrast images with little

blurring, simultaneous multiple implant sites assessment in a single image rather than

multiple exposures and multi-planar images. The significant disadvantages include its high

cost, a relatively high radiation dose and artifacts due to the presence of metallic objects such

as dental restorations.

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When dimensional accuracy for CTs is evaluated, reports showed some degree of

variance in results. This variance is particularly evident regarding measurement of the

distance from the alveolar crest to the superior border of the inferior alveolar canal. A study

conducted by Lindhe in 1996 looked at conventional tomography and showed that there was

an underestimation of the distance by less than 1 mm when it was compared to a larger

inaccuracy with standard panoramic imaging [30]. Another study concluded that CT was

superior to the conventional tomography [27]. Other reports showed a significant

overestimation of the distance between the alveolar crest and the top of the canal in linear

tomography [29,30].

Although magnetic resonance imaging (MRI) does not impart a radiation dose to the

patient, it has limited value for implant planning and diagnosis. With the advantage of CT in

providing detailed and highly accurate cross sectional images, its high radiation exposure,

cost and limited availability restrict its use from being used for routine dental treatment

planning and evaluation. A new maxillofacial CT was introduced in 1997-99 called cone-

beam computed tomography (CBCT), NewTom 9000 in Italy [46,47].

The technology continued to evolve and improve by allowing the capture of 3D

images with a reduced amount of radiation when compared to the conventional CT [48].

Though CBCT primary use was for angiography, it was later introduced in radiotherapy

guidance, mammography and dentistry [49].

Other applications of CBCT imaging in detection of pathology, evaluating the

temporomandibular joint complex, any anatomic variations, orthodontic treatment and

trauma. Its detailed detection of hard tissue provided a good platform for clinicians to

thoroughly evaluate the proposed site for the placement of dental implants by assessing the

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quality and quantity of existing bone. A limitation of CBCT is its inability to cannot detect

difference between different types of soft tissue [48].

Even though CBCT has developed with many advantages, there are still

disadvantages that have yet to be corrected or reduced. The cone beam projection geometry

results in a large amount of scattered radiation due to the irradiation of a large volume of

tissue. The detector records scattered radiation, or noise, but this does not reflect the definite

attenuation of an object along the path of an x-ray beam [49]. The cone beam has an increased

divergence resulting in a pronounced ‘heel effect’ which leads to a non-uniform beam

projection producing amplified noise on images. On encountering metal restorations in the

mouth, the beam is reduced generating information voids that result in image artifacts that

obstruct the adjacent anatomy [49].

Accuracy of CBCT measurements in regards to distance is fundamental for

procedures such as surgical procedures and dental implant placement within close proximity

to vital structures such as the maxillary sinuses and the inferior alveolar canal. Studies have

shown that linear measurements are accurate when using CBCT images. Yet, these studies

have been carried out on dry skulls without the presence of soft tissue. The absence of soft

tissue may have led to these studies showing CBCT to be accurate, which leads to a

decreased scatter [50-55]. There are limited amount of studies showing the high accuracy of

CBCT using skulls with soft tissue [56].

Despite all these advances in 3D imaging, some clinicians depend on their experience

and 2D radiographs, specifically panoramic radiography, to develop a definitive treatment

plan regarding their choice of dental implant shape and size as well as any site modifications,

such as bone grafting, prior to or during the surgical placement of dental implants.

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There are no gold standards for the examination and treatment planning for surgical

placement of dental implants. Therefore, the purpose of this study was to compare and

evaluate the outcome of CBCT and panoramic radiographs in the presurgical treatment

planning of the placement of dental implants in the posterior region of both maxilla and

mandible. This study hypothesized that on CBCT, a clinician can visualize more details of

important anatomical structures that would affect the treatment planning of implant

placement that are not viewed on an panoramic radiography. The study also evaluated and

compared treatment options between experienced specialists and residents, between

specialties (periodontics, oral surgery and prosthodontics) and between second and third year

residents in the Department of Periodontology.

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AIMS AND HYPOTHESES 1. To determine if the Cone beam computed tomography (CBCT) would provide more

anatomical structural details than panoramic radiography that may affect the surgical

treatment planning of implant placement in the maxillary sinus region and the posterior

region of the mandible.

2. Evaluate and compare treatment options between experienced specialists and residents

3. Evaluate and compare treatment options dental specialists (periodontics, oral surgery and

prosthodontics)

4. Evaluate and compare treatment options between second and third year residents in the

Department of Periodontology.

Hypothesis

CBCT provides more information than panoramic radiographs regarding anatomical

structures impacting the treatment choice for implant placement (sinus proximity, IAN, bone

dimension, surgical intervention prior to implant placement, e.g., sinus or ridge bone

augmentation).

Significance

This research may provide evidence that on a CBCT a clinician can observe more details of

important anatomical structures that would affect the treatment planning of implant

placement that are not viewed on an a panoramic radiograph.

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MATERIALS AND METHODS The research protocol was sent and approved by the Institutional Review Board at TUSDM prior to conducting the study.

Part 1: Criteria being studied

There were several criteria identified for the purpose of this study. The five criteria

being researched were maxillary sinus proximity (bone height), maxillary bone width,

mandibular bone width, IAN proximity and the FSG in the posterior region of the mandible

[Figures 1a-1e].

Part 2: Selection of cases from record review

Co-Investigators, have manually searched the axium database of patients at Tufts

University School of Dental Medicine (TUSDM) for qualifying CBCT scans and evaluated

their qualifications to meet the inclusion criteria. The search was filtered to patients having a

single full arch CBCT (mandible or maxilla) and then to patients have both arches in a single

CBCT scan. Patient selection for the study was determined using the established inclusion

criteria. The CBCT scans and panoramic radiographs were stored as DICOM (Digital

Imaging and Communications in Medicine) files in the databases. Scans and records dating

from 2000 to 2016 were searched. Any patient identifiable information attached to the CBCT

scan and panoramic radiographs were removed. Images were printed on a high quality

photograph paper and labeled with a unique code without any patient identifiers.

10 cases were chosen (5 criteria being studied, 2 cases each). Each case had both a

CBCT and a panoramic radiograph (taken within a minimum of 1 month apart, with no

dental treatment conducted during that period of time).

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The cases were given to three independent dental radiologists (R1, R2 and R3) to

measure the bone width, distance to the maxillary sinus and distance to the IAN when

applicable. An average measurement was calculated for both images for each case. In cases

3,4,5 and 6, bone height was measured at two points. The first measurement was taken at a

distance of 3mm from the bone crest (ridge) and the second measurement was at 7mm. In the

maxilla, 7 mm distance was used or when reaching the floor of the sinus if the floor of the

sinus was less than 7mm away from the most coronal part of the ridge. (Table 2)

Case No. Panoramic Radiograph CBCT Average for Panoramic

Radiographs

Average for

CBCT Images

R1 R2 R3 R1 R2 R3

1 5 mm 4.5 mm 5 mm 4 mm 4.5 mm 4 mm 4.8 mm 4.2 mm

2 3 mm 9 mm 8 mm 4.5 mm 4.5 mm 4.5 mm 6.7 mm 4.5 mm

3 _ _ _ 3 mm

7 mm

2.5 mm

7 mm

2.5 mm

7 mm

_ 2.7 mm

7 mm

4 _ _ _ 3 mm

5 mm

3.5 mm

5.5 mm

3 mm

6 mm

_ 3.2 mm

5.5 mm

5 _ _ _ 3 mm

6.5 mm

3.5 mm

7 mm

4 mm

6.5 mm

_ 3.2 mm

6.7 mm

6 _ _ _ 2.5 mm

5 mm

3 mm

5 mm

3 mm

5 mm

_ 2.8 mm

5 mm

7 11 mm 11 mm 12 mm 12 mm 12 mm 12 mm 11.3 mm 12 mm

8 8 mm 8.5 mm 9 mm 10 mm 10 mm 9.5 mm 8.5 mm 9.8 mm

9 _ _ _ _ _ _ _ _

10 _ _ _ _ _ _ _ _

Table 2. Three different radiologists independently measured the sinus proximity, bone width (maxilla and mandible), IAN proximity for both panoramic radiograph and CBCT when applicable.

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Part 3: Selection of cases from record review

In addition, inclusion and exclusion criteria were developed and used to screen cases

for the study.

Inclusion criteria:

• Age: >21yr

• Needed an implant placed in the maxillary sinus region or posterior region of the mandible

• Patient had a full maxillary or mandibular arch CBCT and a panoramic radiograph prior to

any treatment rendered.

Exclusion criteria:

• CBCT/Panoramic radiographs were not taken at the same time period (>1 month)

• The number of teeth present in the patient’s maxillary/mandibular arch in CBCT differed

from the panoramic radiograph.

• Dental treatment has been conducted in the patient’s maxillary/mandibular arch that could be

seen in one radiograph but not the other (CBCT/Panoramic radiograph)

• Presence of a pathology or foreign body at the sextant concerned (e.g., cysts, abscess, peri-

implantitis, remaining root, fracture, residual amalgam particles)

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Part 4: Recruitment

10 periodontal residents (5 2nd year and 5 3rd year residents) and 5 prosthodontics

residents were recruited. There were also 5 periodontology, 5 prosthodontic and 5 oral

surgery faculty members recruited. This study was a pilot study.

Inclusion Criteria for Residents

2nd or 3rd year residents

Residents in the department of periodontology or department of prosthodontics

Residents with the surgical placement of dental implant experience of <5years.

Exclusion Criteria for Residents

Residents with no experience in the placement of dental implants

Inclusion Criteria for Faculty

Faculty from the department of periodontology, prosthodontics and oral surgery with an

experience of >5years surgical placements of dental implant or treatment planning.

Exclusion Criteria for Faculty

Faculty with <5 years of surgical implant placement or surgical implant placement treatment

planning experience.

Recruitment

The faculty and residents enrolled in the study were contacted directly by word of

mouth at the periodontal, oral surgery and prosthodontics departments at Tufts University

School of Dental Medicine.

27

Part 5: Study Design

The cases were dispersed randomly to the 6 groups of participants (1st year, 2nd year

periodontal residents, prosthodontics residents, periodontal, prosthodontics and oral surgery

faculty). Randomization was conducted via a flip of a coin to choose which group would start

with cases of CBCT or panoramic radiograph. Choosing the periodontal faculty and residents

to be in the same group was due to ease of contact and scheduling of the survey sessions. It

also provided a combination of both faculty and residents in both groups 1 and 2.

Figure 2. The study design, survey administration process and timeline

TimeA

TotalNo.OfSubjects30

CBCT(survey)

Panoramic(survey)

Panoramic(survey)

CBCT(survey)

Group2

• 10residents(perio)• 5Faculty(perio)

Group1

• 5residents(Prostho)• 5Faculty(Prostho)• 5Faculty(OS)

1monthlater

TimeB

28

Part 6: Development of the Survey

The PI and one of the Co-I reviewed the cases and developed two surveys. Each

survey was comprised of tailored questions specific to the related arch (mandible or maxilla).

There were two cases used for each criterion in the study. Cases 1 and 2 investigated the

maxillary proximity, cases 3 and 4 investigated maxillary bone width, cases 5 and 6

investigated mandibular bone width, cases 7 and 8 investigated IAN proximity and the final

two cases 9 and 10 investigated the fossa of the submandibular gland (FSG) proximity.

The participants were expected to complete the surveys as described below.

Administration of Survey

Prior to answering the survey questions, a 5-minute presentation was conducted by

one of the Co-I explaining the study goals and providing examples of the questions that

would be encountered. The treatment planning of cases that were used as examples were not

discussed; the presentation was only used as a guide of what to expect during the survey. An

information sheet describing the study was also given to the participants. There was adequate

time to read the sheet before answering the survey and any questions that did not interfere

with the outcome of the treatment plan were answered prior to or during the answering of the

surveys.

Time A

The paper-based surveys were handed out to the participants. At Time A, each group

of participants was randomly assigned to answer questions about either cases with CBCT

images or panoramic radiographs only. The participants were not aware that both sets of

images/radiographs were from the same patients (blinding). The CBCT and panoramic

radiographs were presented to the enrolled clinicians/residents via a high quality hard copy

29

image of the panoramic radiograph and CBCT with the related cross sections. In the initial

survey at Time A, brief questions were asked regarding the participant’s background and

experience. This information was used to investigate the association between demographics

and the treatment planning approach or outcome of the surgical placement of dental implants.

These background questions were not asked again at Time B. The survey was comprised of

multiple questions (see Appendix B) guiding the clinician/resident into choosing what was

needed for the placement of the dental implant. It was used to assess the need for treatments

or sight preparation prior to the surgical placement of the dental implant, e.g., sinus lift,

GBR, etc., as well as choosing the appropriate implant’s size and shape. Using the survey,

the participants were able to construct a definitive treatment plan. They were provided with

the appropriate measuring tools (calibrated rulers/implant shape and size overlays). The

participants were given an option of three types of implant shapes and designs: two tissue

level implants, shaped either tapered or straight, and one bone level tapered shaped implant.

Two cases for each criterion were used, resulting in a total of 10 cases [Figure 2].

Time B (approximately 1 month washout period after Time A):

The same cases were evaluated again with the same survey to construct the treatment

plan. If at Time A CBCT images were provided, then at Time B a set of panoramic

radiographs were provided and vice versa depending on the randomization [Figure 2].

30

Part 7: Data Analysis

Descriptive statistics (counts and percentages) were calculated. These statistics were

computed separately for the CBCT questionnaire and the panoramic questionnaire. Results

were further stratified by department and by status of clinician (e.g., second-year resident,

third-year resident, or faculty). SPSS version 22 was used in the analysis.

31

Results

The study was conducted over a period of 3 months. The total number of participants was

met. The age of participants ranged from 27 to 66 years old. 12 females and 18 males

participated in the study. 9 of the 15 faculty members in the study were board certified. The

surveys were collected and tabulated into an excel spread sheet, then transferred and

processed via SPSS software.

The results will be presented in the following order: 1) All participants, 2)

Comparison between departments, 3) Comparison between faculty members of different

departments, 4) Comparison between faculty members and residents, 5) Comparison between

faculty members and residents in the Department of Periodontology and 6) Comparison

between 2nd and 3rd year residents within the Department of Periodontology.

1. All Participants

Sinus proximity (Bone Height - Maxilla)

Case 1

In Figure 3A, more participants chose that an implant is suitable when using a CBCT

than panoramic radiograph (93.3% versus 86.7%). Though more chose an internal sinus lift

(ISL) with a panoramic compared to CBCT (76.7% versus 40%), considerably more opted to

perform an ESL (46.7%) when using a CBCT in comparison with a panoramic (6.7%).

Figure 3B is also consistent with table 3A in regards to longer implant lengths being selected

with a CBCT compared to a panoramic radiograph (11.5 mm 10%, 3.3% and 13 mm 3.3%,

0%).

32

Case 2

Figure 3B presents similar results outcome in comparison to table 3A. In Figure 3B, all

participants (100%) indicated that an implant placement is suitable when using the CBCT

compared to 90% when using the panoramic radiograph. The data presented show more than

double the percentage of participants chose to perform an external sinus lift (ESL 76.7%)

when CBCT is used compared the panoramic radiograph (36.7%). Longer lengths of

implants were planned with a CBCT (11.5mm: 3.3% and 13 mm: 3.3%) while for the

panoramic radiograph the participants chose shorter implant lengths (8 mm, 8.5 mm and 10

mm).

Bone Width (Maxilla)

Case 3

When comparing all participants (Figure 3C) in regards to the maxillary bone width,

6.7% more participants found that the site is not suitable for an implant placement when

using a CBCT. 90% of the participants chose to place and implant and all 90% chose to

perform some sort of site preparation while in panoramic radiograph analysis, 93.7% chose

to place an implant and only 53% opted for site preparation when using the panoramic

radiograph. Lateral guided bone regeneration (LGBR) prior to implant placement was the

majority of choice when using CBCT compared to panoramic radiograph, 73.3% and 23.3%

respectively. The implant diameter shifted dramatically from a wide implant towards a

narrow implant of 3.5 mm when using a CBCT (40%, versus 3.3% with panoramic).

33

Case 4

When comparing all participants (Figure 3D) in regards to the maxillary bone width

choice of treatment, more participants found that the site is suitable for an implant when

using the panoramic (93.3%, versus 76.7% with CBCT). LGBR increased from 0% for the

panoramic radiograph usage to 63.3% when using the CBCT. Similar to case 3, the implant

diameter also reduced from the majority choice of 4.3 mm (Panoramic: 56.7%) to 3.5 mm

(CBCT: 46.7%). None of the participants chose the wide implant diameter of 5.0 mm when

using the CBCT, while 20% chose 5.0 mm when using the panoramic radiograph.

Bone Width (Mandible)

Case 5

Figure 3E shows that 10% more participants opted for an implant placement when a

CBCT was evaluated compared to a panoramic radiograph. Almost double (96.7%) chose the

need for a site preparation when a CBCT was evaluated in comparison to a panoramic

radiograph (50%). LGBR substantially increased in CBCT evaluation (83.3%) in comparison

to panoramic (10%). Implant diameter of 5.0mm was mostly chosen using the panoramic and

reduced to 23.3% from 63.3% with more choosing a narrower implant diameter with CBCT.

The 3.3% of participants choosing 5.5mm implant in panoramic radiograph evaluation

reduced to none when CBCT was evaluated.

34

Case 6

In Figure 3F, all participants chose that an implant is suitable in the panoramic

radiograph evaluation and reduced by 40% when CBCT was used (60%). All participants

who chose to place an implant opted for a site preparation procedure using a CBCT (60%)

while only 33.3% of the 100% chose site preparation in the panoramic group. LGBR prior to

implant placement increased from 6.7% in panoramic to 53.3% in CBCT and LGBR during

implant placement reduced by 20% from 26.7% in panoramic radiograph analysis to 6.7% in

CBCT. More chose a narrow implant diameter of 3.5mm when using a CBCT (26.7%)

compared to panoramic radiograph (10%) and fewer chose 4.3mm from 60% in panoramic to

only 26.7% in CBCT.

IAN Proximity (Mandible)

Case 7

All participants chose implant suitability for the case using CBCT while 6.7% fewer

chose to place an implant when using the panoramic radiograph (Figure 3G). The need for

site preparation reduced from 53.3% in panoramic image analysis to 40% in CBCT. Vertical

increase using guided bone regeneration technique (VGBR) changed from 33.3% in

panoramic to none in CBCT. There was little change in regards to implant length; 6.7% more

chose a shorter implant length using CBCT in comparison to panoramic (36.7% versus 30%)

as well as an increase from 46.7% to 50% using the 10mm length implant. Implant lengths of

8.5mm and 11.5mm were the same (6.7%).

35

Case 8

In the case used for Figure 3H, the participants choosing implant suitability nearly

doubled from the panoramic radiograph to CBCT (56.7% to 93.3%). For site preparation, the

percentage more than doubled when using CBCT (36.7% to 76.6%). VGBR before implant

placement remained the same (13.3%) and reduced from 10% to 3.3% for VGBR during

implant placement. The most considerable change was the implant length of 10mm

increasing in the CBCT image analysis from 6.7% in panoramic radiographs to 46.7%.

There was a reduction in the choice of shorter implants, 7mm and 8mm, in CBCT compared

to panoramic radiographs.

Fossa of the Submandibular Gland (Mandible)

Case 9

In Figure 3I, fewer participants indicated that an implant is suitable when using the

CBCT by 10% in comparison with the use of panoramic radiograph. 20% more indicated the

need of a site preparation procedure with the pretreatment analysis of the CBCT image

comparing to the panoramic radiograph. LGBR before implant placement increased from

23.3% in panoramic to 50% in CBCT. The 10mm implant length was the most popular

choice in both panoramic (63.3%) and CBCT images (46.7%).

Case 10

Figure 3J shows a small increase from 93.3% in panoramic radiographs to 96.7% in

CBCT regarding implant suitability. There was a 10% increase when using a CBCT from

panoramic radiograph pre-treatment evaluation (13.3%) regarding LGBR during implant

placement. The 10mm implant length was most prevalent in both panoramic and CBCT

36

images but reduced in CBCT radiographs from 73.3% to 50%. The short implant length of

8mm was not chosen when panoramic radiographs were evaluated while 36.7% chose to use

it in CBCT image evaluation.

2. Comparison between Departments


Case 1

When comparing departments in Figure 4A, the oral surgery department (OSD) had

the fewest participants who stated that the site to be treated is suitable for an implant

placement (60%). Regarding site preparation, ESL and ISL had similar percentages in all

three departments. All participants from the periodontal department (PeD) and OSD who

indicated that an implant is suitable chose the same implant length of 10 mm (93% and 60%),

while the prosthodontics department (PrD) chose multiple lengths with 50% choosing the

shortest implant of 8mm.

Figure 4B shows that all members of all departments indicated an implant is suitable

when using a CBCT (100%) compared to a panoramic radiograph (Figure 4A: PeD 93.3%

and OSD 60%). Additionally, all chose to perform a site preparation technique (100%). All

OSD participants chose an ESL while the PeD and PrD chose similar percentages of ESL

(73.3% and 70%, respectively) and ISL (26.7% and 30%, respectively). PeD and PrD had the

highest percentage of participants choosing the shortest implant length of 8 mm (26.7% and

20%, respectively) while 10 mm implant was the most chosen in PeD and PrD (66.7% and

80%, respectively). 60% of the OSD chose 11.5 mm implant and 20% chose 13 mm.

37

Case 2

Figure 4C compares all three departments using a panoramic radiograph only. OSD

had the smallest percentage of participants indicating that the site is suitable for an implant

(60%), while all (100%) of the PrD stated that the site is suitable for an implant and only

86.7% of the PeD agreed. The highest percentage of implant length was 10 mm for all

departments (PeDF: 73.3%, PrDF: 70%, OSDF: 60%). PrD had the highest percentage in

choosing the shortest implants (8 mm: 30%).

Figure 4D shows that the PrD participants agreed with their initial assessment of the

panoramic radiograph when using the CBCT regarding implant suitability (100%). For PeD,

the percentage increased from 86.7% to 93.3%, and for OSD it increased by 20% (60% to

80%). All 80% of OSD participants who agreed that an implant is suitable indicated that site

preparation is needed, with 90% of the PrDF and 86.7% of the PeDF agreeing. ESL was

chosen more when using a CBCT than panoramic radiograph in all departments’ faculty

(PeD: 46.7% versus 13.3%, PrD: 30% versus 0%, OSD: 80% versus 0%). The majority of the

PeD chose 10 mm implant (73.3%), the most compared to the other departments (PrD 50%,

OSD 20%). Longer implants were used by the OSD (11.5 mm: 40% and 13 mm: 20%).


Case 3

In Figures 4E and 4F, in regards to implant suitability, the PrD was the only group

that reduced their choice from the panoramic radiograph to CBCT, 20% less. More chose to

perform site preparation in both the PeD and PrD when the CBCT was evaluated compared

to the panoramic radiograph, as opposed to the OSD where all participants chose to perform

site preparation in both. Greater choice of a narrow implant (3.5mm) was observed in all

38

departments when CBCT was evaluated compared to the panoramic radiograph (PeD: 0% to

13.3%, PrD: 10% to 80% and OSD: 0% to 40). Only the PeD chose a wide implant using the

CBCT (5.0 mm 33.4%).

Case 4

All departments’ implant suitability choice reduced from the use of panoramic

radiograph to CBCT by 20% in both PrD and OSD groups and by 13.4% in the PeD group.

All OSD and PeD who chose to place an implant chose to perform site preparation in both

panoramic and CBCT analysis. None chose to have LGBR prior to implant placement in any

department when using the panoramic and increased considerably with the CBCT (PeD:

53.3%, PrD: 70% and OSD: 80%). The choice of a narrow implant diameter was more

popular when using CBCT (PeD: 26.7%, PrD: 80% and OSD: 40%). These data can be seen

in Figures 4G and 4H.


Case 5

Regardless of the department, all participants indicated implant suitability when

assessing the CBCT (Figure 4J) while the PeD and OSD had less agreement in the panoramic

assessment in Figure 4I (PeD: 86,7% and PrD: 80%). OSD had the highest percentage of site

preparation (60%) compared to PeD (46.7%) and PrD (50%) when using the panoramic

radiograph. LGBR was the highest in OSD and PeD using CBCT (90% and 73.3%,

respectively). Narrow implant of 3.5mm was recommended in CBCT (PeD; 20%, PrD; 40%

and OSD; 20%) and none recommended in panoramic radiograph assessment.

39

Case 6

With the panoramic radiograph, all members of all departments chose to place an

implant (Figure 4K) while that reduced when using the CBCT in Figure 4L (PeD: 60%, PrD:

50% and OSD: 80%) and all of them in the CBCT chose to perform site preparation. More

participants chose site preparation when using the CBCT than panoramic radiograph

assessment (PeD: 26.7%, PrD: 30% and OSD: 60%). LGBR prior to implant placement had a

higher percentage in CBCT (PeD: 46.7%, PrD: 50% and OSD: 80%) than panoramic

radiographs (PeD: 0%, PrD: 10% and OSD: 20%). The highest percentage of the PeD chose

4.3mm in both images and PrD and OSD chose narrower implants in CBCT (PrD: 50% and

OSD: 20%).


Case 7

All departments indicated implant suitability for both panoramic radiographs and

CBCT (Figures 4M and 4N); only the PeD had less than 100% choosing so in panoramic

radiographs (86.7%). The OSD had the most reduction when choosing site preparation in

CBCT compared to panoramic radiographs (40% to 10%). All departments chose not to

perform VGBR before implant placement when using the CBCT and the PeD and OSD had

more percentage of participants choosing to perform VGBR prior to implant placement using

panoramic radiographs (40%) compared to the PrD (20%). The PrD were highest in choosing

the short 8mm implants when using the CBCT (70%) and the OSD choosing the long

11.5mm implant (40%).

40

Case 8

The OSD had the lowest percentage in indicating implant suitability in panoramic

radiograph analysis (40%; Figure 4O) and the highest in CBCT (100%; Figure 4P). All three

groups increased their indication of implant suitability when CBCT was used compared to

panoramic. A relative increase in site preparation is also seen in all departments from

panoramic radiographs to CBCT with the OSD highest (from 20% to 100% in CBCT).

VGBR reduced in the PeD group from during implant placement to before implant placement

when comparing panoramic to CBCT (Figure 4P), except the PrD that stayed at 10% and the

OSD stayed at 0%. The choice of 10mm implant length showed the highest increase in

choice when using the CBCT compared to panoramic radiograph (PeD: 13.3% to 66.7%,

PrD: 0% to 20% and OSD: 0% to 40%).


Case 9

Figures 4Q and 4R show that the PrD was the only department maintaining their

indication of implant suitability in both CBCT and panoramic radiograph evaluation (90%)

while the other two departments decreased (PeD: 73.3% and OSD: 60%). Both PeD and PrD

increased their choice of site preparation when using a CBCT (PeD: 46.7% and PrD: 80%). All

departments increased their choice of LGBR before implant placement in CBCT evaluation

except for the OSD, which stayed the same at 60%. Implant length of 10mm in panoramic was

chosen mostly by PeD (73.3%) and all of the OSD. Longer lengths of implant 11.5mm and

13mm was chosen only by OSD in CBCT (20%).

41

Case 10

Both PrD and OSD tended to indicate implant suitability in both panoramic

radiograph and CBCT analysis (Figures 4S and 4T); the PeD increased from 86.7% to 93.3%

in CBCT. Only the PeD in the panoramic radiograph evaluation chose LGBR before implant

placement (6.7%). An increase from 6.7% in panoramic to 33.3% in CBCT was seen in the

PeD while OSD reduced from 40% to 20% and the PrD maintained a percentage of 10%. The

PeD most popular choice of implant length was the 10mm in both images (panoramic: 66.7%

and CBCT: 60%). 8mm implant length was chosen more in all departments using the CBCT

compared to none in panoramic (PeD: 33.3%, PrD and OSD: 40%).

3. Comparison between Faculty members


Case 1

Comparing the faculty only, Figure 5A, all faculty of the prosthodontic department

(PrDF) decided that the case is suitable for an implant (100%) while the faculty of the

periodontal department (PeDF) 80% and only 60% of the oral surgery department faculty

(OSDF) indicated that an implant is suitable. ISL was chosen more by the PeDF and PrDF

(40%, 60%) than OSDF (20%). Two thirds of OSDF participants agreeing that an implant is

suitable chose ESL as a site preparation procedure with only 20% of both PeDF and PrDF

choosing ESL. Regarding implant length, the PrDF had the highest percentage in choosing 8

mm (60%) and the PeDF chose the highest percentage of 10 mm implants (80%). All the

OSDF agreeing to place an implant chose 10 mm length (60%).

42

All faculty members, Figure 5B, in the study agreed that an implant is suitable when

CBCT was used for evaluation (100%). 80% of both PeDF and PrDF opted for an ESL while

all OSDF chose an ESL. The choice of implant length was diverse. 60% of OSDF chose 11.5

mm, a length that none of the PrDF and only 20% of PeDF chose. The majority of PrDF

chose 10 mm implant (60%) and an equal number of PeDF chose 8 mm and 10 mm implants

(40%).

Case 2

Figure 5C shows that using only the panoramic radiograph, all PrDF found that an

implant is a suitable treatment plan. 80% of PeDF agreed in regards to implant suitability and

60% of the OSDF. None of the faculty participating chose ESL as a site preparation

procedure, but all indicated that an ISL is the option to choose. The shortest implants, 8 mm,

were chosen only by the PrDF (60%). 60% of PeDF chose 10 mm implants length, while all

OSDF agreeing to place an implant chose 10 mm length.

In Figure 5D, all PeDF and PrDF and 80% of OSDF found that the implant site

suggested is suitable for implant placement when only the CBCT was used for pre-treatment

planning. All the OSDF who opted to place an implant chose ESL for the implant to be

placed (80%), compared to 60% of the PeDF and 40% PrDF (while none of the faculty chose

the ESL procedure when evaluating the panoramic radiograph). None of the PeDF chose 8

mm implant length while the majority of PrDF chose it (60%). 80% of PeDF chose 10 mm

implant and half of the OSDF (40%) opting for an implant to be placed chose 10 mm as well.

43


Case 3

Figure 5E shows that all faculty members of the three departments found that the site

proposed is suitable for implant placement when using the panoramic radiograph. The choice

of suitability, Figure 5F, reduced by 20% when using the CBCT in two departments, PeDF

and PrDF. LGBR at time of implant placement reduced from 100% in panoramic to 20% in

CBCT within the PeDF group. All groups increased their choice of LGBR prior to implant

placement when the CBCT was evaluated compared to the panoramic radiograph. Choice of

a narrow implant diameter increased in PrD and OSD when using CBCT (3.5 mm PrD 80%

and OSD 40%) while the PeD generally chose 4.3mm and 5.0mm in both.

Case 4

In Figure 5G all faculty members agreed that an implant is suitable, yet when the

CBCT (Figure 5H) was evaluated that percentage decreased (PeDF: 60%, PrDF: 80% and

OSDF: 80%). All faculty members agreeing to place an implant agreed in both panoramic

and CBCT that site preparation is needed, except that PrDF had 20% less in panoramic

radiographs. None chose to perform LGBR prior to implant placement in the panoramic

radiograph. On the other hand, in the CBCT analysis, two thirds of the PeDF, three quarters

of the PrDF and all the OSDF who chose to place an implant chose to perform LGBR prior to

implant placement. Implant diameter has shifted from regular diameter of 4.3 mm in the

panoramic analysis to a narrower implant diameter in the CBCT in all groups (PeDF; 0% to

40%, PrDF; 40% to 80% and OSDF; 20% to 40%).

44


Case 5

Figure 5I shows that 20% fewer participants in both PeD and OSD (80%) indicated

that an implant is suitable compared to PrD (100%) when using the panoramic radiograph.

All faculty members indicated implant suitability and site preparation needed when the

CBCT was evaluated (Figure 5J). For PrD, only 20% indicated that site preparation is needed

using the panoramic radiograph. Narrower implants were chosen after the evaluation of a

CBCT compared to panoramic radiographs.

Case 6

All faculty members indicated that an implant is suitable using a panoramic

radiograph (Figure 5K) but that reduced by 40% for both PeDF and PrDF while it reduced by

20% for OSDF when using the CBCT (Figure 5L). In CBCT, all participants opting to place

an implant chose to prepare the implant site via LGBR prior to implant placement. The same

percentages (PeDF: 60%, PrDF: 60% and OSDF: 80%) were also seen for LGBR prior to

implant placement when using the panoramic radiograph. In the CBCT evaluation, none

chose to have LGBR during implant placement. The PrDF had the largest increase of

choosing 3.5mm implant diameter from 20% in Figure 5K to 60% in Figure 5L. A 20%

increase from 0% in choosing 5mm diameter was seen in both PeDF and OSDF.

45


Case 7

The PeDF had the lowest percentage of indicating implant suitability in Figure 5M

(80%) compared to the rest of the departments (100%). However, when the CBCT was

viewed, all faculty members agreed in implant suitability (Figure 5N). None of the

departments chose VGBR prior to implant placement using the CBCT but some chose to do

so when using the panoramic (PeDF: 20%, PrDF: 40% and OSDF: 40%). Using the CBCT,

the PeDF was the only department to perform VGBR during implant placement (40%). 40%

of the OSDF used the 11.5mm in CBCT analysis and neither of the other departments’

faculty used it.

Case 8

The PrDF maintained their percentage of implant suitability choice of 80% in both

panoramic and CBCT images (Figures 5O and 5P) while there was an increase in the PeDF

and OSDF in the CBCT from the panoramic (PeDF: 40% to 80% and OSDF: 40% to 100%).

The same could be said about site preparation: PrDF maintained 60% and PeDF increased

from 20% to 60% and OSDF from 20% to 100%. No VGBR prior to implant placement was

chosen in the CBCT image analysis while 20% was chosen in the panoramic by the PrDF and

OSDF groups. Longer implants were chosen equally by both PeDF and OSDF groups when

using the CBCT (10mm: 40% and 11.5mm: 20%) and 0% by the PrDF group.

46


Case 9

More faculty members in the PeD (80%) and OSD (100%) found the site suitable for an

implant using the panoramic radiograph than the CBCT (60%). All the PrDF indicated that an

implant is suitable for both images (Figures 5Q and 5R). Site preparation increased to 80% from

20% when CBCT was viewed in the PrDF group while the PeDF and OSDF remained the same

(40% and 60%). LGBR before implant placement was 0% in PeDF and PrDF while the OSDF

had 60% in panoramic. This increased to 40% in the PeDF group and 60% for the PrDF group

and OSDF maintained 60% for CBCT. All participants from the PeDF choosing to place an

implant chose an implant length of 10mm in both panoramic and CBCT images. OSDF chose

longer implants when using CBCT (11.5mm 20% and 13mm 20%) while the PrDF group chose

shorter implants (7.0mm 20% and 8.0mm 60%), the same as their choice in panoramic.

Case 10

All three groups agreed that an implant is suitable for both CBCT and panoramic

radiograph except 20% of the PeDF did not agree in the panoramic radiograph analysis

(Figures 5S and 5T). None of the PrDF indicated that site preparation is needed in panoramic

evaluation, but that increased to 100% in CBCT. The PeDF maintained 40% for both and

OSDF increased from 40% to 80% in CBCT. All departments agreed that no LGBR is

needed before implant placement in the CBCT analysis. The implant length of 8mm was

chosen by all three groups when using the CBCT (PeDF: 40%, PrDF: 60% and OSDF: 40%).

47

4. Comparison between Faculty Members and Residents


Case 1

All residents found that an implant is suitable in both panoramic and CBCT

radiographs (Figures 6A and 6B). All faculty agreed that an implant is suitable except that

only 80% found an implant is suitable when a panoramic alone was evaluated. Both faculty

and residents chose site preparation when CBCT was evaluated (100%), but that reduced in

the residents groups to 86.7% when panoramic radiographs were evaluated and the faculty

group remained 100%. The choice of ESL was increased dramatically when comparing

panoramic radiographs to CBCT alone in the faculty group (26.7% to 86.7%), while the

residents had similar percentages (PAN: 53.3% CBCT: 66.7%). In the residents group, the

similarity was also seen in the 10 mm implant length (PAN: 80% CBCT: 86.7%). Some

faculty chose longer implants when the CBCT was evaluated (11.5 mm: 26.7% and 13 mm:

6.7%) that were not used in the panoramic radiograph evaluation.

Case 2

Figures 6C and 6D show no change to the percentage of residents who agree that an

implant is suitable in both panoramic and CBCT evaluation (93.3%). There was a slight

increase in the faculty participants in this category from 80% in panoramic radiographs to

93.3% in CBCT. All who agreed to place an implant indicated that a site preparation is

needed regardless of the use of a panoramic radiograph or CBCT. None of the faculty chose

ESL in the panoramic radiograph assessment, while 60% chose ESL when using CBCT. The

majority of both groups chose ISL in the panoramic radiograph assessment (faculty 80%,

48

residents 73.3%). Faculty chose longer implant lengths when using CBCT (11.5 mm: 20%

and 13 mm: 6.7%).


Case 3

Figures 6E and 6F compare the faculty members to residents. Fewer faculty members

chose to place an implant when they looked at the CBCT (86.7%) than the panoramic (100%)

while for residents there was no change (93.3%). The residents’ choice of site preparation

increased considerably when panoramic radiograph was used compared to CBCT (26.7% to

93.3%). An increase was also seen in both groups regarding LGBR before implant placement

(faculty: 33.3% to 66.7% and residents: 13.3% to 80%). Implant diameter reduced toward the

popular choice of 3.5 mm in both groups from panoramic radiograph analysis to CBCT

(faculty: 6.7% to 40% and residents: 0% to 40%).

Case 4

Faculties implant suitability reduced from 100% (Figure 6G) to 73.3% (Figure 6H)

while residents’ reduction was less (from 86.7% to 80%). The percentage indicating the need

for site preparation reduced in CBCT in comparison to panoramic. Neither of the groups

chose to perform LGBR prior to implant placement when assessing the panoramic

radiograph, yet when the CBCT was used 60% of faculty and 66.7% agreed to do so. 53.3%

of faculty chose 4.3mm diameter implant when looking at the panoramic radiograph; the

same percentage (53.3%) chose a narrower implant when using the CBCT and only 20%

chose 4.3mm. Half of the residents kept the same choice of 4.3mm in panoramic to CBCT

49

(66.7% to 33.3%) with a noticeable increase in the choice of a narrower implant of 3.5mm

(0% to 40%).


Case 5

More residents than faculty indicated implant suitability in this case (Figure 6I). All

faculty and residents indicated implant suitability when the CBCT was evaluated (Figure 6J).

Equal percentage (53.3%) of faculty and residents in panoramic radiograph analysis opted for

a site preparation procedure, while all residents chose to perform site preparation; 6.7%

fewer faculty members did when evaluating a CBCT. The majority of site preparation,

LGBR prior to implant placement, was chosen by both groups when using the CBCT

(faculty: 80% and residents: 86.7%) while only 6.7% were chosen by faculty and 13.3% by

residents when using the panoramic radiograph. 5.0mm diameter implants were more popular

with residents in both images than with faculty members.

Case 6

In both groups, Figures 6K and 6L, there was a reduction of implant suitability

between panoramic radiographs and CBCT evaluation (faculty: 100% to 66.7% and

residents: 100% to 53.3%). LGBR prior to implant placement increased from 6.7% in both

groups when using a panoramic radiograph to 66.7% for faculty and 40% for residents

(Figure 6L). Faculty’s choice of LGBR during implant placement had a major reduction from

40% in panoramic to 0% in CBCT while residents stayed the same (13.3%). More

participants chose narrower implants of 3.5mm when using the CBCT compared to the

50

panoramic. Residents using 5.0mm diameter implant were 26.7% in panoramic evaluation

compared to 0% in CBCT analysis.


Case 7

Figures 6M and 6N show both faculty and residents’ choice of implant suitability

were equal in both panoramic and CBCT images (93.3% and 100% respectively). More

residents chose site preparation in both images analysis compared to faculty, panoramic:

46.7% and 60% compared to CBCT: 33.3% and 53.3%. With CBCT, neither of the two

groups chose to perform VGBR before implant placement. Residents showed more choice of

the 10mm implant length in both panoramic radiographs and CBCT compared to faculty

members (panoramic: 73.3% and CBCT: 60%).

Case 8

Both groups increased their indication of implant suitability (Figures 6O and 6P) from

panoramic compared to CBCT images, but in both, residents have a higher percentages of

choice compared to faculty (panoramic: 53.3% compared to 60% and CBCT: 86.7%

compared to 100%). The same could be said about site preparation (panoramic: 33.3%

compared to 40% and CBCT: 73.3% compared to 80%). Shorter implants were chosen more

by faculty for both panoramic and CBCT images (8mm: 40%) and residents had a higher

percentage of choosing 10mm in both panoramic and CBCT pre-treatment image analysis

(panoramic: 13.3% and CBCT: 66.7%).

51


Case 9

Faculty implant suitability dropped from 93.3% in panoramic radiograph to 73.3% in

CBCT while the residents maintained 80% for both (Figures 6Q and 6R). Site preparation

was equal for both groups (panoramic: 40% and CBCT: 60%). Faculty had a higher

percentage in the need for LGBR before implant placement than the residents for CBCT

evaluation (53.3% compared to 46.7%) but less in panoramic (20% compared to 26.7%). In

panoramic evaluation, the faculty (66.7%) and residents’ (60%) most popular choice was

10mm. Longer implant lengths were chosen by faculty in the CBCT evaluation (11.5mm:

6.7% and 13mm: 6.7%) and none by residents.

Case 10

Figure 6S shows that 93.3% of faculty and residents indicated implant suitability in

panoramic radiograph evaluation. Residents in CBCT chose the same percentage while

faculty increased to 100% (Figure 6T). Residents for site preparation saw a notable increase

from panoramic image evaluation (13.3%) to CBCT (33.3%). 6.7% of the faculty group

chose LGBR before implant placement in the panoramic group (compared to 0% for the

CBCT), and none of the residents chose to perform LGBR prior to implant placement in

either diagnostic image. Nearly twice the percentage of faculty compared to residents chose

the 8mm implant length in the CBCT (46.7% compared to 26.7%). More residents chose

11.5mm (26.7% compared to 6.7%) and 13mm (6.7% compared to 0%) implant lengths than

faculty in the panoramic radiograph evaluation.

52

5. Comparison between Faculty Members and Residents (Department of Periodontology)


Case 1

All residents of the Department of Periodontology (PeDR) found that the site is

suitable for an implant with both the panoramic and CBCT (Figures 7A and 7B). Only 20%

of the faculty found that an implant is not suitable; this was in association with the panoramic

radiograph only. All participants agreed that a site preparation is needed when the CBCT is

analyzed. 30% fewer residents found site preparation is needed with the panoramic

radiograph (70%). In CBCT image analysis, ESL was predominantly chosen (faculties;80%,

residents;70%). All participants chose 10 mm in the panoramic analysis. 20% of the faculty

chose a longer implant when CBCT was used (11.5 mm; 20%).

Case 2

20% more faculty members indicated that the site proposed is suitable for an implant

when using a CBCT compared to a panoramic radiograph in Figures 7C and 7D (80%

compared to 100%). The residents on the other hand had 90% for both images. ESL was a

popular choice when using the CBCT (60% and 40%) compared to when using the

panoramic (0% and 20%). ISL was more often chosen with the panoramic radiograph (80%

and 60%) and went down to only 40% in both groups when using the CBCT. Implant length

of 10mm was the most popular choice in both groups for both images (panoramic; PeDF

60%, PeDR 80%, CBCT: PeDF 80%, PeDR 70%).

53


Case 3

The PeDF reduced by 20% as compared to PeDR who increased by 10% in implant

suitability between panoramic radiograph and CBCT assessment (Figures 7E and 7F). A

higher percentage of PeDR indicated that site preparation is needed in CBCT compared to

panoramic (30% to 100%) while all PeDF attempting an implant placement agreed site

preparation is needed in both. LGBR increased dramatically when using a CBCT for both

groups (PeDF: 20% to 60% and PeDR: 10% to 80%). Residents chose more narrow implants

than faculty in the CBCT (3.5mm: 0% compared to 20% and 4.0 mm: 0% compared to 10%).

Case 4

Figures 7G and 7H show that the PeDF implant suitability choice reduced in the

CBCT usage by 40% when compared to panoramic radiograph pre-treatment assessment,

while it stayed the same in the PeDR group (80%) for both images analysis. Site preparation

was increased in residents from 20% in panoramic images to 80%. LGBR before implant

placement increased from none in both groups for panoramic radiographs to 40% in the

faculty group and 60% in the residents group in CBCT. Both groups chose 4.3mm to be the

popular option in the panoramic radiograph (PeDF: 40% and PeDR: 70%). 3.5mm implant

diameter was only used when the CBCT image was evaluated (PeDF: 40% and PeDR: 20%).

54


Case 5

All PeDF and PeDR found the site suitable for an implant when using CBCT

compared to panoramic 80% and 90% respectively (Figures 7I and 7J). Site preparation

increased to 90% in CBCT within the PeDR group from 30% in panoramic while all PeDF

placing an implant in either image agreed site preparation is needed. From no LGBR prior to

implant placement in panoramic radiographs increased to 60% in PeDF and 80% in PeDR

groups. More participants chose 5.0mm in panoramic radiographs than CBCT (PeDF: 80% to

40% and PeDR: 80% to 30%).

Case 6

In Figure 7K all faculty members and residents chose the site to suitable for an

implant but in CBCT that reduced to 60% for both groups (Figure 7L). All who chose to

place an implant found the need to perform site preparation (60%) when CBCT was

evaluated with only 10% of residents choosing to perform site preparation in the panoramic

group. None chose to do LGBR before implant placement in panoramic evaluation while

60% of PeDF and 40% of PeDR did so in CBCT. In panoramic radiograph assessment

implant diameter of 4.3mm was chosen 80% (PeDF) and 70% (PeDR) of the time, which

reduced to 20% in the PeDF group and 50% in the PeDR when using the CBCT image.

55


Case 7

Figure 7M shows more PeDR indicating implant suitability than PeDF by 10% (PeDF

80% and PrDF 90%). The entire department regardless of faculty or residents found the site

suitable for an implant when CBCT was viewed (Figure 7N). More PeDF agreed that the site

requires preparation in panoramic radiograph (60%) compared to CBCT (40%). The PeDR

on the other hand increased from 30% in panoramic to 50% in CBCT. VGBR prior to

implant placement was only chosen in the panoramic radiograph analysis by both residents

(10%) and faculty (30%). During implant placement the CBCT analysis showed that 40% of

PeDF chose to do so while none of the PeDR opted for this option. 60% of PeDF chose

8.5mm implants in panoramic in comparison to 0% in CBCT. PeDR had 10mm as the most

popular choice in both images (panoramic: 60% and CBCT: 70%).

Case 8

Indication of implant suitability increased from panoramic radiograph pretreatment

analysis (Figure 7O) to CBCT (Figure 7P) by 40% in both groups, with PeDR having 20%

more indicating suitability than PeDF. Site preparation increased dramatically from

panoramic to CBCT with the PeDR having higher percentages than PeDF in both

(panoramic: 40% compared to 20% and CBCT: 90% compared to 60%). Residents chose

VGBR preparation either with implant placement or before more than the faculty, who chose

0% in both regardless of image analysis. Implant length of 10mm was the most popular

choice in the CBCT group by both residents (80%) and faculty (40%). Only the PeDF when

using the CBCT chose a longer implant length, of 11.5mm.

56


Case 9

Regarding implant suitability, PeDR had the same percentage (80%) in both

panoramic and CBCT images (Figures 7Q and 7R). The PeDF also had 80% in the

panoramic radiograph but dropped to 60% for CBCT. Similar percentages were found for site

preparation for both images (panoramic: 40% and CBCT: 40% and 50%). LGBR in both

groups changed from 0% in panoramic radiograph evaluation to 40% in CBCT. Implant

length results were the same for 8.0mm between panoramic and CBCT (PeDF: 0% and

PeDR: 10%) and similar for 10mm (panoramic: PeDF 80% and PeDR 70%, and CBCT:

PeDF 60% and PeDR 70%).

Case 10

Indication of implant suitability increased from panoramic radiograph pretreatment

analysis (Figure 7S) to CBCT (Figure 7T) by 20% in PeDF group, with PeDR having 90%

for both. Site preparation increased only in the PeDR group from panoramic to CBCT by

20% with the PeDF maintaining 40%. Residents’ choice of site preparation increased by 20%

in CBCT images compared to panoramic radiographs . The PeDF group maintained 40% for

both images. Implant length of 10mm was the most popular choice in the panoramic group

by both faculty (80%) residents faculty (60%). PeDR was the only group choosing the

11.5mm implant length. 8mm implant lengths was chosen by both groups in the CBCT image

evaluation (PeDF: 40% and PeDR: 30%) and none using the panoramic.

57

6. Comparison between 2nd Year and 3rd Year Residents (Department of Periodontology)


Case 1.

Figures 8A and 8B show that all residents (both 2nd and 3rd year) found the site

suitable for an implant regardless of the image used. All second year residents of the

periodontology department (PeDR2) agreed that there is a need for site preparation in CBCT

and panoramic radiograph analysis, while 40% fewer third year residents (PeDR3) indicated

the need for site preparation using panoramic (60%). More PeDR2 chose ESL in CBCT

(80%) compared to PeDR3 (60%), and an equal percentage of residents chose ESL in

panoramic radiograph (40%). All residents chose 10mm implant length for panoramic

radiograph pre-treatment evaluation, and equally 20% chose 8.0mm and 80% chose 10mm

for the CBCT image.

Case 2.

All residents regardless of year of residency in the Department of Periodontology

indicated implant suitability when CBCT was evaluated (Figure 8D). The same held true for

PeRD2 when they evaluated the panoramic, but 20% fewer of the PeDR3 agreed when the

panoramic was viewed (Figure 8C). All residents who chose to place an implant also chose to

perform site preparation using either of the diagnostic images. There was a lower percentage

of ESL (20% for both groups) in panoramic compared to CBCT usage (PeDR2: 80%,

PeDR3: 60%). 80% of PeDR2 chose ISL using panoramic radiograph dropping to 20% in

CBCT while the PeDR3 stayed at 40% for both. 80% of both PeDR2 and PeDR3 selected

10mm implant for both images, with only 20% for PeDR2 selecting 8mm for both images,

58

and 20% of the PeDR3 used the 8mm in the CBCT and none in the panoramic radiograph

pre-treatment evaluation.


Case 3.

Figures 8E and 8F show that all residents regardless of year indicated implant

suitability when using CBCT with a 20% reduction in the PeDR2 group (80%) when

panoramic was evaluated and no reduction for the PeDR3. A smaller percentage of PeRD3

proposed the need for site preparation (40%) compared to double the percentage in the

PeDR2 group (80%) when using a panoramic radiograph. Both groups had an increase from

panoramic to CBCT regarding LGBR prior to implant placement (PeDR2: 0% to 80%, and

PeDR3: 20% to 80%). Both groups of residents opted to use a lesser diameter of implant

when CBCT was evaluated (3.5mm). The PeDR3 maintained their 40% choice of 5.0mm

implant diameter for both images.

Case 4.

An equal number of residents indicated implant suitability when using the panoramic

radiograph (80%; Figure 8G. That reduced to 60% in the PeDR2 group and increased to

100% in the PeDR3 group when the CBCT image was evaluated (Figure 8H). None chose

LGBR in the panoramic evaluation stage, 20% of PeDR2 proposed LGBR in CBCT and

PeDR3 all chose LGBR in CBCT. None chose 3.5mm in the panoramic radiograph analysis,

which rose to 20% in both groups for CBCT. Only the PeDR2 group chose the wide implant

diameter of 5.0mm (20%) and that was observed when using a panoramic radiograph only.

59

The most popular choice for both groups was 4.3mm in both images (PeDR2: 60% and 40%,

PeDR3: 80% and 40%).


Case 5.

All residents, except for 20% of PeDR2 in the panoramic analysis group, agreed that

an implant is suitable for this case. Site preparation increased dramatically from panoramic

image evaluation to CBCT, with the PeDR3 having the highest increase from 20% to 100%.

None of the residents chose to perform a LGBR procedure prior to implant placement when

looking at the panoramic radiograph but increased to 80% in CBCT for both groups. A wide

implant diameter of 5.0mm was the popular choice in both groups using the panoramic

radiograph (PeDR2: 60%, PeDR3: 100%). That reduced to 0% for the PeDR2 group and 60%

in the PeDR3 group for CBCT. PeDR2 when using the CBCT was the only group to choose

narrow implants of 3.5mm. (Figures 8I and 8J)

Case 6.

Figure 8K shows that when using panoramic radiograph, all residents indicated that

an implant is a suitable option. The highest reduction in suitability was seen in PeDR2 to

40% when the CBCT was evaluated, while the PeDR3 reduced to 80% (Figure 8l). The need

for site preparation increased for both groups form panoramic to CBCT with PeDR3 having a

higher increase (PeDR2: 20% to 40% and PeDR3: 0% to 80%). Neither of the groups chose

LGBR before implant placement during the panoramic image evaluation. In the CBCT image

evaluation, both groups chose to perform LGBR prior to implant placement with the PeDR3

60

having 40% more (PeDR2: 20% and PeDR3: 60%). The most popular choice of implant

diameter in panoramic was the 4.3mm diameter (PeDR2: 60% and PeDR3: 80%). That

reduced to 40% and 60% respectively in the CBCT image analysis. Only the PeDR3 chose a

narrow implant diameter in the CBCT group (3.5mm 20%).


Case 7.

All residents indicated implant suitability except for 20% of the PeDR2 group who

chose not to place an implant when evaluating the panoramic radiograph (Figures 8m and

8n). 60% of both groups proposed site preparation in the panoramic, which reduced to 40%

in the PeDR3 group when CBCT was looked at while PeDR2 stayed at 60%. VGBR before

implant placement was chosen by the groups analyzing the panoramic radiograph (PeDR2:

60% and PeDR3: 40%) but none chose to do so when CBCT was analyzed. The implant

length of 10mm was the most often chosen by both groups in both images (PeDR2: 40% and

60% and PeDR3: 80%). The short implant length of 8.mm was chosen by 40% of the PeDR2

only when using the CBCT.

Case 8.

Implant suitability percentages were equal between both groups of residents, 60% in

panoramic and 100% in CBCT (Figures 8O and 8P). The need for a site preparation

procedure was equal in both groups in the panoramic evaluation (40%), and that increased to

80% in the PeDR2 group and 100% in the PeDR3 when the CBCT was analyzed. Only the

PeDR2 chose to perform VGBR prior to implant placement in the panoramic group (20%)

61

and only the PeDR3 group chose to do so in the CBCT group (40%). Implant lengths were

equally chosen in both images, 8.0 mm: 40% and 10 mm: 20% in panoramic radiograph

analysis and 8.0 mm: 20% and 10 mm: 80% in the CBCT analysis.


Case 9.

In this case, Figures 8Q and 8R show that an equal percentage of residents indicated

implant suitability for both panoramic and CBCT radiographs (80%). Site preparation

increased in the PeDR2 group from 20% in panoramic to 60% for CBCT, while PeRD3

decreased from 60% to 40%. The only change in site preparation was a decrease in GBRV

prior to implant placement by 20% was observed in the CBCT image evaluation. An implant

length of 10mm was the most popular choice for both groups when using either image in this

case (PeDR2: 80% for panoramic and 60% for CBCT, and PeDR3: 60% for panoramic and

80% for CBCT).

Case 10.

Figures 8s and 8t show that implant suitability did not change from panoramic

radiograph to CBCT in either group. Site preparation, on the other hand, decreased in both

groups of residents (PeDR2: 100% to 60% and PeDR3: 80% to 20%). In site preparation,

GBRV was seen in the CBCT during implant placement for both groups (20%). Implant

length was shortened for both groups with PeRD2 being the only group using a shorter

implant of 8mm in the CBCT image analysis only (60%).

62

Discussion

This study supported the hypothesis that the CBCT provides more information than a

panoramic radiograph regarding anatomical structures impacting the treatment of choice

(sinus proximity, IAN, bone dimension, surgical intervention prior to implant placement,

e.g., sinus or ridge bone augmentation).. Furthermore, the comparison of different

departments, residents and faculty members, and residents in different years provides

intriguing information that reflects on how the participant’s background and their status in

their department relates to their approach to each criterion.

Sinus proximity (bone height in the maxilla):

Cases 1 and 2 looked at the evaluation of the available bone height in the maxilla and

the sinus proximity. More participants, regardless of experience and department, found that

an implant is a suitable treatment option when evaluating the proposed implant site when

using the CBCT image compared to the panoramic radiograph (Figures 3A and 3B). Even

though there was a high percentage of the participants agreeing that site preparation is

required for both images, the type of surgical preparation prior to or during implant

placement changed considerably between the CBCT and panoramic radiograph for both

questions. More participants chose to perform site preparation when using the CBCT over the

panoramic radiograph image analysis (Case 1: 36.7% to 76.7% and Case 2: 6.7% to 46.7%).

This shows how much of a difference a cross sectional image would change the outcome in

regards to evaluating the sinus proximity and anticipating anatomical difficulties. The use of

63

CBCT or an imaging tool considerably changed the approach to treatment and the kind of

surgical intervention.

Participants with a surgical background (PeD and OSD) tended to opt for an ESL, as

their experience and confidence in a more invasive approach to treatment translates to their

choice of treatment when compared to the PrD. The PrD compared to the rest of the

departments tended to choose ISL. When the type of site preparation was compared in the

CBCT analysis, ESL was a popular choice for the faculty compared to the resident group

with the residents choosing an ISL more. This could be due to the faculty having additional

surgical experience and being more comfortable in approaching the treatment with a more

invasive surgical procedure in comparison to the residents. Studies have shown that the

success rates of ESL and ISL are the same; with ESL the clinician would be able to gain

more bone height with a limited amount of existing bone of <5mm [57].

The image used also had an effect on the approach that could be seen in the shift of

choice from ISL to ESL as well as implants length. The familiarity and experience could also

be seen in the choice implant length. The residents’ longest implant and most popular choice

was the 10mm implant length. The faculty on the other hand was more comfortable in

choosing an 11.5mm length implant in both cases presented regardless of the use of a CBCT

or a panoramic radiograph. This could be attributed to the faculty having more confidence in

their abilities due to their experience and familiarity in the use of a longer implant.

Diversity in implant lengths could also be seen when the CBCT was evaluated,

having a wider range of longer as well as shorter implant lengths. In the panoramic

radiograph analysis, the average implant length, 10mm, was a popular choice as the clinician

would not want to take a higher risk using the 11.5mm or 13mm. With the clinician having

64

more information regarding the three dimensional anatomy of the ridge, this increases the

options available for the clinician in choosing a suitable implant that he/she feels more

comfortable with. The PrD had the highest percentage between the departments in choosing

the short 8mm and 8.5mm implant lengths in all images. This could be attributed to their

restorative background in regards to the success of short implants in comparison to the longer

implants. It could also be due to their conservative approach to implant placement and

staying away from the local anatomy in comparison to the more surgically experienced OSD

and PeD groups. A clear 3D image assessing the proximity of the sinus is important in

appreciating the existing anatomy and the risk in sinus perforation.

Bone Width (Maxilla and Mandible):

This criterion was evaluated in cases 3, 4, 5 and 6. In general, when the CBCT image

was used, there was a reduction in the percentage from the panoramic radiograph analysis of

participants choosing the surgical placement of a dental implant as a suitable choice for

treatment in the sites in question. This shows that a cross sectional image of the proposed

treated site is required to fully appreciate the existing ridge width. Not only did the need for

site preparation increase, but also the need for LGBR prior to implant placement increase

substantially (e.g. case 5 from 10% in panoramic to 83.3% in CBCT). This would alter the

path of a treatment plan significantly for both the patient (cost, recovery, time etc.) and the

clinician (degree of difficulty, time, cost effectiveness etc.). The decrease in all questions

regarding LGBR during implant placement shows that prior LGBR to implant placement is

critical, as the existing bone width might not achieve implant stability or a successful

treatment outcome with LGBR during implant placement alone. This also would give the

65

surgeon/clinician multiple attempts in preparing the ridge and achieving the suitable bone

width for an implant to be placed. The PrD department had the least percentage in regards to

performing a site preparation procedure. This could translate to participants with a surgical

background having a better understanding of the need of having a minimum of 2mm of bone

on the buccal or lingual aspect of the implant. This has been documented in previous studies

[58].

Implant diameter was also reduced drastically from regular and wide implant

diameters (4, 4.3 and 5mm) when using the panoramic radiograph to narrow implant

diameters (3mm and 3.5mm) when using the CBCT to analyze the case. The choice of the

incorrect implant diameter might disrupt the surgical preparation for the clinician and the

need of having a diverse implant inventory at the time of surgery. Not having good

knowledge of the existing bone width may result in the sudden change of implant diameter,

choosing an unfavorable implant diameter or consequently postponing the surgery due to the

lack of inventory of the narrow implant diameter. The planned treatment could also be

canceled due to the lack of existing bone. This would produce a negative experience for the

patient towards the clinician’s treatment, damaging the image and professionalism of the

clinic and clinician significantly [59].

IAN proximity:

The irreversible damage to the IAN would be detrimental for both the clinician and

the patient. The average distance from the ridge crest to the IAN for cases 7 and 8 has been

calculated (Case 7 panoramic: 11.3mm, CBCT: 12 mm and Case 8 panoramic: 8.5mm,

CBCT: 9.8mm). In general, the percentage of participants indicating implant suitability

increased in the CBCT group in comparison to the panoramic radiograph group. 7 out of the

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13 who declined to place an implant in case 8 explained their reason not to place an implant

to be due to the IAN proximity when evaluating the panoramic radiograph. The rest of the

reasons in both questions were due to restorative reasons, angulation or the suspicion of the

presence of pathology. None used the reason of IAN proximity for either case to be the

reason of not placing an implant when using the CBCT image. This could be due to the

clearer visualization of the nerve when using the panoramic radiograph [30].

The choice of a shorter dental implant length was slightly more when using the

panoramic radiograph. The fact that the PrD chose the 8mm (highest compared to the other

two departments) could be attributed to their restorative background in regards to there being

no difference in success rates between an 8mm implant and a longer choice of implant as

well as their reluctance to invade “unneeded” surrounding bone [60,61]. Using the safe distance

of 2 mm proposed in previous studies [62,63], a 10mm implant would cause a risk of damage

and was chosen 46.7% of the time in panoramic radiograph analysis and 50% in CBCT.

The choice of VGBR either before or during implant placement (36.9% in panoramic

and only 3.3% in CBCT) may reduce the risk of damage yet there are still participants who

proposed to place an implant without VGBR either before or during implant placement

(56.7% in panoramic radiograph and 36.7% in CBCT image evaluation). There does not

seem to be a detectable trend or difference between the departments in regard to VGBR,

except for the PrD having the least VGBR on average regardless of the diagnostic image

used in comparison to the other two departments. This could be attributed to the lesser

surgical background and experience in comparison to the other two departments.

67

FSG:

This was examined in cases 9 and 10. There was a decrease by 10% of participants

who agreed an implant is a suitable treatment option in case 9 and an increase by 3.4% in

case 10 from panoramic radiograph group to the CBCT group. Using the panoramic

radiograph alone in both questions, a total of six participants opted not to place an implant

due to multiple reasons but none was due to the concavity of the FSG. This supports the

notion that concavity is only detectable using the CBCT and has been used as a reason not to

place an implant for five participants in case 9 and one participant in case 10. The need to

place an implant in this area might require the surgeon to angle the implant more lingually

negatively affecting the restorability of the implant. That was explained in five of the six

answers that declined to place an implant. More faculty members than residents explained

their decision not to perform the implant placement due to the implant angulation. This may

reflect on the experience of the faculty resulting in their having a broader vision in taking

into account all aspects of the treatment proposed (restorability, pathology etc.). It is

interesting to note that none of the participants from the PrD declined to place the implant

due to the angulation of the implant.

Implant length was also very similar in all groups with slightly more faculty placing

shorter implants than residents when the CBCT image was evaluated. This might be an

attempt by the faculty members to avoid perforating the lingual plate as well as maintaining

favorable restorable angulation of the implant [64].

Limitations of the study

There were several limitations in the study. The design of the study could have been

improved if the images were presented using computer software that each participant would

68

be able to navigate and control the contrast of the images reflecting a more accurate

representation of the treatment planning process. More cases could be added to each criterion

studied as well as including more participants beyond TUSDM. Having only five faculty

members from each department would not provide a true representation of the department as

a whole. This is also true in regard to the number of residents and their exposure to specific

treatment modalities within their limited time in the residency. Some residents would have

more exposure to a more invasive surgical treatment modality than others due to the

uncontrolled cases distribution within the departments. Having residents with the same

number and type of surgeries and the number of implants placed in the posterior region of the

mandible or maxilla would provide more homogeneous participants.

Future research

To our knowledge there is no previous study comparing CBCT to panoramic

radiographs in the treatment planning outcomes of implants placed in the posterior region of

both the maxilla and mandible. Our study is a pilot study, with limited deduced information,

yet it has provided a good base for future research. The comparison between multiple

departments is an approach that could be used to detect and manage weaknesses integrated in

the ideology of each department in regards to their approach to treatment planning. Finding

the weaknesses and working on eliminating them would produce a more understanding-

working environment that would not only improve the treatment quality but also deliver an

outcome with the fewest unwanted side effects.

This study design could also be replicated in the anterior region of either the maxilla

or mandible, as these sextants have not been researched within our study.

69

There are data collected that were not analyzed in the study, such as time of implant

restorability and age of participants, that we did not find relevant in this current study but

may be used in future studies.

70

Conclusion The outcomes of this study provides important data and information that could be used for

future research in regards to the importance of having a CBCT during the pretreatment phase

of placing a dental implant in the posterior region of either the maxilla or mandible. This

study shows that the use of a panoramic radiograph alone would restrict the clinician from

having a full grasp of the existing anatomical landmarks leading to a considerable change of

treatment outcome. Though this study is a pilot study, it shows that the treatment approach

differs noticeably between departments and the level of experience the clinician has. Future

studies are needed involving a larger number of participants and cases leading to more

significant results that would support our findings.

71

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76

APPENDICES

Appendix A: Figures

Appendix B: Surveys

Finkelman, Matthew� 12/19/2016 9:08 AMComment [1]: Inallfiguresshowingdata,indicatethesamplesize(ofeachgroup,whencomparinggroups).Youcandothisinthefiguretitles(inparentheses),ifyou’dlike.

77

Appendix A: Figures

Fig. 1a Fig. 1b

Fig. 1c Fig. 1d

Fig. 1e

Figure 1 (a, b, c, d and e). Different anatomical criteria. 1a: sinus proximity (maxillary bone height). 1b: maxillary bone width. 1c: mandibular bone width. 1d: IAN proximity (mandibular bone height). 1e: FSG.

78

All participants:

Case 1

Figure 3A. Bar chart and table comparing all participants’ panoramic radiograph and CBCT choices in regards to maxillary sinus proximity for case 1.

Case 2

Figure 3B. Bar chart and table comparing all participants’ panoramic radiograph and CBCT choices in regards to maxillary sinus proximity for case 2.

ImplantSuitability

SitePreparaOon

ExternalSinusLiS

InternalSinusLiS

Implantlength8mm

Implantlength8.5mm

Implantlength10mm

Implantlength11.5mm

Implantlength13mm

Panoramic 86.7 86.7 6.7 76.7 13.3 0 70 3.3 0

CBCT 93.3 86.7 46.7 40 20 3.3 56.6 10 3.3

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Percen

tage

ImplantSuitability

SitePreparaOon

ExternalSinusLiS

InternalSinusLiS

Implantlength8mm

Implantlength8.5mm

Implantlength10mm

Implantlength11.5mm

Implantlength13mm

Panoramic 90 83.3 36.7 36.7 16.7 6.7 66.7 0 0

CBCT 100 100 76.7 23.3 20 0 63.3 13.3 3.3

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Percen

tage

79

Case 3

Figure 3C. Bar chart and table comparing all participants’ panoramic radiograph and CBCT choices in regards to maxillary bone width for case 3.

Case 4

Figure 3D. Bar chart and table comparing all participants’ panoramic radiograph and CBCT choices in regards to maxillary bone width for case 4.

ImplantSuiObility

SiteprepiraOonneeded

GBRbeforeimplant

placementLateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm

Implantdiameter4.0mm

Implantdiameter4.3

mm

Implantdiameter5.0

mm

Implantdiameter5.5

mm

Panoramic 96.7 53.3 23.3 30 3.3 3.3 56.7 30 3.3

CBCT 90 90 73.3 10 40 6.7 26.7 16.7 0

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Percen

tage

ImplantSuiObility


GBRbeforeimplant

placementLateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm


Implantdiameter4.3

mm

Implantdiameter5.0

mm

Panoramic 93.3 90 0 16.7 6.7 10 56.7 20

CBCT 76.7 76.7 63.3 10 46.7 6.7 23.3 0

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Percen

tage

Ramesh, Aruna� 12/13/2016 10:00 AMComment [2]: SitePreparation-spelling

80

Case 5

Figure 3E. Bar chart and table comparing all participants’ panoramic radiograph and CBCT choices in regards to mandibular bone width for case 5.

Case 6

Figure 3F. Bar chart and table comparing all participants’ panoramic radiograph and CBCT choices in regards to mandibular bone width for case 6.

ImplantSuitability

SitepreparaOonneeded

GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm

Implantdiameter4.0

mm

Implantdiameter4.3

mm

Implantdiameter5.0

mm

Implantdiameter5.5

mm

Panoramic 90 50 10 33.4 0 3.3 20 63.3 3.3

CBCT 100 96.7 83.3 16.7 26.7 13.3 36.7 23.3 0

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Percen

tage

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm

Implantdiemeter4.0

mm

Implantdiameter4.3

mm

Implantdiameter5.0

mm

Panoramic 100 33.3 6.7 26.7 10 13.3 60 16.7

CBCT 60 60 53.3 6.7 26.7 0 26.7 6.7

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Percen

tage

81

Case 7

Figure 3G. Bar chart and table comparing all participants’ panoramic radiograph and CBCT choices in regards to IAN proximity for case 7.

Case 8

Figure 3H. Bar chart and table comparing all participants’ panoramic radiograph and CBCT choices in regards to IAN proximity for case 8.

ImplantSuitability


GBRbeforeimplant

placementverOcal

GBRduringimplant

placementverOcal

Implantlength7.0mm

Implantlength8.0mm

Implantlength8.5mm

Implantlength10mm

Implantlength11.5mm

Panoramic 93.3 53.3 33.3 3.3 3.3 30 6.7 46.7 6.7

CBCT 100 40 0 3.3 0 36.7 6.7 50 6.7

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Percen

tage

ImplantSuitability


GBRbeforeimplant

placementverOcal

GBRduringimplant

placementverOcal

Implantlength7.0mm

Implantlength8.0mm

Implantlength8.5mm

Implantlength10mm

Implantlength11.5mm

Panoramic 56.7 36.7 13.3 10 6.7 43.3 0 6.7 0

CBCT 93.3 76.7 13.3 3.3 0 36.7 3.3 46.7 6.7

0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

ChartTitle

82

Case 9

Figure 3I. Bar chart and table comparing all participants’ panoramic radiograph and CBCT choices in regards to FSG for case 9 only.

Case 10

Figure 3J. Bar chart and table comparing all participants’ panoramic radiograph and CBCT choices in regards to FSG for case 10 only.

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantlength7.0mm

Implantlength8.0mm

Implantlength8.5mm

Implantlength10mm

Implantlength11.5mm

Implantlength13mm

Panoramic 86.7 40 23.3 16.7 3.3 16.7 0 63.3 3.3 0

CBCT 76.7 60 50 10 3.3 16.7 3.3 46.7 3.3 3.3

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Percen

tage

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantlength8mm

Implantlength8.5mm

Implantlength10mm

Implantlength11.5mm

Implantlength13mm

Panoramic 93.3 20 3.3 13.3 0 0 73.3 16.7 3.3

CBCT 96.7 26.7 0 23.3 36.7 6.7 50 3.3 0

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Percen

tage

83

2. Comparison between Departments

Case 1

Figure 4A. Bar chart and table comparing departments’ choices when using a panoramic radiograph only in regards to maxillary sinus proximity for case 1.

Figure 4B. Bar chart and table comparing departments’ choices when using a CBCT image only in regards to maxillary sinus proximity for case 1.

ImplantSuitability

SitePreparaOon

ExternalSinusLiS

InternalSinusLiS

Implantlength8.0mm

Implantlength8.5mm

Implantlength10mm

PerioDepartment 93.3 80 33.3 33.3 0 0 93.3

ProsthodonOcDepartment 100 90 40 50 50 20 30

OralSurgeryDepartment 60 60 40 20 0 0 60

0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability

SitePreparaOon

ExternalSinusLiS

InternalSinusLiS

Implantlength8.0

mm

Implantlength10

mm

Implantlength11.5

mm

Implantlength13

mm

PerioDepartment 100 100 73.3 26.7 26.7 66.7 6.7 0

ProsthodonOcDepartment 100 100 70 30 20 80 0 0

OralSurgeryDepartment 100 100 100 0 0 20 60 20

0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

84

Case 2

Figure 4C. Bar chart and table comparing departments’ choices when using a panoramic radiograph only in regards to maxillary sinus proximity for case 2.

Figure 4D. Bar chart and table comparing departments’ choices when using a CBCT image only in regards to maxillary sinus proximity for case 2.

ImplantSuitability

SitePreparaOon

ExternalSinusLiS

InternalSinusLiS

ImplantLength8mm

ImplantLength8.5

mm

ImplantLength10

mm

ImplantLength11.5

mm

PerioDepartment 86.7 86.7 13.3 66.7 6.7 0 73.3 6.7



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability

SitePreparaOon

ExternalSinusLiS

InternalSinusLiS

ImplantLength8mm

ImplantLength8.5

mm

ImplantLength10

mm

ImplantLength11.5

mm

ImplantLength13

mm

PerioDepartment 93.3 86.7 46.7 40 13.3 0 73.3 6.7 0

ProsthodonOcDepartment 100 90 30 60 40 10 50 0 0

OralSurgeryDepartment 80 80 80 0 0 0 20 40 20

0%10%20%30%40%50%60%70%80%90%

100%

Percen

tage

CBCT

85

Case 3

Figure 4E. Bar chart and table comparing departments’ choices when using a panoramic radiograph only in regards to maxillary bone width for case 3.

Figure 4F. Bar chart and table comparing departments’ choices when using a CBCT image only in regards to maxillary bone width for case 3.

ImplantSuiObality


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm


Implantdiameter4.3

mm

Implantdiameter5.0

mm

Implantdiameter5.5

mm

PerioDepartment 93.3 53.7 13.3 40 0 0 53.3 40 0



0%10%20%30%40%50%60%70%80%90%

100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementLateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm


Implantdiameter4.3

mm

Implantdiameter5.0

mm

PerioDepartment 93.3 93.3 73.3 13.3 13.3 6.7 40 33.4



0%10%20%30%40%50%60%70%80%90%

100%

Percen

tage

CBCT

86

Case 4

Figure 4G. Bar chart and table comparing departments’ choices when using a panoramic radiograph only in regards to maxillary bone width for case 4.

Figure 4H. Bar chart and table comparing departments’ choices when using a CBCT image only in regards to maxillary bone width for case 4.

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm

Implantdiameter4.0

mm

Implantdiameter4.3

mm

Implantdiameter5.0

mm

PerioDepartment 86.7 86.7 0 11.3 0 6.7 60 20



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm

Implantdiameter4.0

mm

Implantdiameter4.3

mm

PerioDepartment 73.3 73.3 53.3 6.7 26.7 12.4 33.3



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

87

Case 5

Figure 4I. Bar chart and table comparing departments’ choices when using a panoramic radiograph only in regards to mandibular bone width for case 5.

Figure 4J. Bar chart and table comparing departments’ choices when using a CBCT image only in regards to mandibular bone width for case 5.

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm

Implantdiameter4.0

mm

Implantdiameter4.3

mm

Implantdiameter5.0

mm

Implantdiameter5.5

mm

PerioDepartment 86.7 46.7 0 33.4 0 0 6.7 80 0



0%10%20%30%40%50%60%70%80%90%

100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm

Implantdiameter4.0

mm

Implantdiameter4.3

mm

Implantdiameter5.0

mm

PerioDepartment 100 93.3 73.3 20 20 6.7 40 33.4

ProsthodonOcDepartment 100 100 26.7 20 40 20 20 20


0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

88

Case 6

Figure 4K. Bar chart and table comparing departments’ choices when using a panoramic radiograph only in regards to mandibular bone width for case 6.

Figure 4L. Bar chart and table comparing departments’ choices when using a CBCT image only in regards to mandibular bone width for case 6.

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm

Implantdiameter4.0

mm

Implantdiameter4.3

mm

Implantdiameter5.0

mm

PerioDepartment 100 26.7 0 26.7 0 13.3 73.3 13.3



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm

Implantdiameter4.3

mm

Implantdiameter5.0

mm

PerioDepartment 60 60 46.7 6.7 13.3 40 6.7



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

89

Case 7

Figure 4M. Bar chart and table comparing departments’ choices when using a panoramic radiograph only in regards to IAN proximity for case 7.

Figure 4N. Bar chart and table comparing departments’ choices when using a CBCT image only in regards to IAN proximity for case 7.

ImplantSuitability


GBRbeforeimplant

placementverOcal

GBRduringimplant

placementverOcal

Implantlength7.0

mm

Implantlength8.0

mm

Implantlength8.5

mm

Implantlength10

mm

Implantlength11.5

mm

PerioDepartment 86.7 60 40 6.7 0 33.3 6.7 40 6.7



0%10%20%30%40%50%60%70%80%90%

100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementverOcal

GBRduringimplant

placementverOcal

Implantlength8.0

mm

Implantlength8.5

mm

Implantlength10

mm

Implantlength11.5

mm

PerioDepartment 100 46.7 0 6.7 20 6.7 66.7 0



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

90

Case 8

Figure 4O. Bar chart and table comparing departments’ choices when using a panoramic radiograph only in regards to IAN proximity for case 8.

Figure 4P. Bar chart and table comparing departments’ choices when using a CBCT image only in regards to IAN proximity for case 8.

ImplantSuitability


GBRbeforeimplant

placementverOcal

GBRduringimplant

placementverOcal

Implantlength7.0mm

Implantlength8.0mm

Implantlength10mm

PerioDepartment 53.3 33.3 6.7 13.3 0 40 13.3



0%10%20%30%40%50%60%70%80%90%

100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementverOcal

GBRduringimplant

placementverOcal

Implantlength8.0

mm

Implantlength8.5

mm

Implantlength10

mm

Implantlength11.5

mm

PerioDepartment 93.3 80 13.3 0 20 0 66.7 6.7



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

91

Case 9

Figure 4Q. Bar chart and table comparing departments’ choices when using a panoramic radiograph only in regards to FSG for case 9.

Figure 4R. Bar chart and table comparing departments’ choices when using a CBCT image only in regards to FSG for case 9.

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantlength7.0

mm

Implantlength8.0

mm

Implantlength10.0

mm

Implantlength11.5

mm

PerioDepartment 80 40 13.3 26.7 0 6.7 73.3 0



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantlength7.0

mm

Implantlength8.0

mm

Implantlength8.5

mm

Implantlength10.0

mm

Implantlength11.5

mm

Implantlength13

mm

PerioDepartment 73.3 46.7 40 6.7 0 6.7 0 66.7 0 0

ProsthodonOcDepartment 90 80 60 20 10 40 10 30 0 0

OralSurgeryDepartment 60 60 60 0 0 0 0 20 20 20

0%10%20%30%40%50%60%70%80%90%

100%

Percen

tage

CBCT

92

Case 10

Figure 4S. Bar chart and table comparing departments’ choices when using a panoramic radiograph only in regards to FSG for case 10.

Figure 4T. Bar chart and table comparing departments’ choices when using a CBCT image only in regards to FSG for case 10.

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantlength10mm

Implantlength11.5mm

Implantlength13mm

PerioDepartment 86.7 20 6.7 6.7 66.7 20 0



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantlength8.0

mm

Implantlength8.5

mm

Implantlength10.0

mm

Implantlength11.5

mm

PerioDepartment 93.3 40 0 33.3 33.3 0 60 0



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

93

3. Comparison between Faculty members

Case 1

Figure 5A. Bar chart and table comparing departments’ faculty choices when using a panoramic radiograph only in regards to maxillary sinus proximity for case 1.

Figure 5B. Bar chart and table comparing departments’ faculty choices when using a CBCT image only in regards to maxillary sinus proximity for case 1.

ImplantSuitability

SitePreparaOon

ExternalSinusLiS

InternalSinusLiS

Implantlength8mm

ImplantLength8.5mm

Implantlength10mm

PerioFaculty 80 80 20 40 0 0 80

ProsthodonOcFaculty 100 80 20 60 60 20 20

OralSurgeryFaculty 60 60 40 20 0 0 60

0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability

SitePreparaOon

ExternalSinusLiS

InternalSinusLiS

Implantlength8mm

Implantlength10mm

Implantlength11.5mm

Implantlength13

mm

PerioFaculty 100 100 80 20 40 40 20 0

ProsthodonOcFaculty 100 100 80 20 40 60 0 0

OralSurgeryFaculty 100 100 100 0 0 20 60 20

0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

94

Case 2

Figure 5C. Bar chart and table comparing departments’ faculty choices when using a panoramic radiograph only in regards to maxillary sinus proximity for case 2.

Figure 5D. Bar chart and table comparing departments’ faculty choices when using a CBCT image only in regards to maxillary sinus proximity for case 2.

ImplantSuitability

SitePreparaOon

ExternalSinusLiS

InternalSinusLiS

ImplantLength8mm

ImplantLength10mm

ImplantLength11.5mm

PerioFaculty 80 80 0 80 0 60 20



0%10%20%30%40%50%60%70%80%90%

100%

Percen

tage

Panoramic

ImplantSuitability

SitePreparaOon

ExternalSinusLiS

InternalSinusLiS

ImplantLength8mm

ImplantLength10

mm

ImplantLength11.5

mm

ImplantLength13

mm

PerioFaculty 100 100 60 40 0 80 20 0



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

95

Case 3

Figure 5E. Bar chart and table comparing departments’ faculty choices when using a panoramic radiograph only in regards to maxillary bone width for case 3.

Figure 5F. Bar chart and table comparing departments’ faculty choices when using a CBCT image only in regards to maxillary bone width for case 3.

ImplantSuitability


GBRbeforeimplant

placementLateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm


Implantdiameter4.3

mm

Implantdiameter5.0

mm

Implantdiameter5.5

PerioFaculty 100 100 20 100 0 0 60 40 0

ProsthodonOcFaculty 100 40 20 20 20 0 40 20 20

OralSurgeryFaculty 100 100 60 40 0 0 100 0 0

0%10%20%30%40%50%60%70%80%90%

100%

Percen

tage

Panoramic

ImplantSuiObility


GBRbeforeimplant

placementLateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm


Implantdiameter4.3

mm

Implantdiameter5.0

mm

PerioFaculty 80 80 60 20 0 0 40 40



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

96

Case 4

Figure 5G. Bar chart and table comparing departments’ faculty choices when using a panoramic radiograph only in regards to maxillary bone width for case 4.

Figure 5H. Bar chart and table comparing departments’ faculty choices when using a CBCT images only in regards to maxillary bone width for case 4.

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm

Implantdiameter4.0

mm

Implantdiameter4.3

mm

Implantdiameter5.0

mm

PerioFaculty 100 100 0 40 0 20 40 40



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm

Implantdiameter4.0

mm

Implantdiameter4.3

mm

PerioFaculty 60 60 40 20 40 0 20



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

97

Case 5

Figure 5I. Bar chart and table comparing departments’ faculty choices when using a panoramic radiograph only in regards to mandibular bone width for case 5.

Figure 5J. Bar chart and table comparing departments’ faculty choices when using a CBCT image only in regards to mandibular bone width for case 5.

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter4.3

mm

Implantdiameter5.0

mm

Implantdiameter5.5

mm

PerioFaculty 80 80 0 60 0 80 0



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuiObality


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm

Implantdiameter4.0

mm

Implantdiameter4.3

mm

Implantdiameter5.0

mm

PerioFaculty 100 100 60 40 20 0 40 40



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

98

Case 6

Figure 5K. Bar chart and table comparing departments’ faculty choices when using a panoramic radiograph only in regards to mandibular bone width for case 6.

Figure 5L. Bar chart and table comparing departments’ faculty choices when using a CBCT image only in regards to mandibular bone width for case 6.

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm

Implantdiameter4.0

Implantdiameter4.3

mm

Implantdiameter5.0

mm

PerioFaculty 100 60 60 60 0 20 80 0



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm

Implantdiameter4.3

mm

Implantdiameter5.0

mm

PerioFaculty 60 60 60 0 20 20 20



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

99

Case 7

Figure 5M. Bar chart and table comparing departments’ faculty choices when using a panoramic radiograph only in regards to IAN proximity for case 7.

Figure 5N. Bar chart and table comparing departments’ faculty choices when using a CBCT image only in regards to IAN proximity for case 7.

ImplantSuitability


GBRbeforeimplant

placementverOcal

GBRduringimplant

placementverOcal

ImplantLength7.0

mm

Implantlength8.0

mm

Implantlength8.5

mm

Implantlength10

mm

Implantlength11.5

mm

PerioFaculty 80 60 20 0 0 60 0 0 20



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementverOcal

GBRduringimplant

placementverOcal

Implantlength8.0

mm

Implantlength8.5

mm

Implantlength10

mm

Implantlength11.5

mm

PerioFaculty 100 40 0 40 20 0 60 0



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

100

Case 8

Figure 5O. Bar chart and table comparing departments’ faculty choices when using a panoramic radiograph only in regards to IAN proximity for case 8.

Figure 5P. Bar chart and table comparing departments’ faculty choices when using a CBCT image only in regards to IAN proximity for case 8.

ImplantSuitability


GBRbeforeimplant

placementverOcal

GBRduringimplant

placementverOcal

Implantlength7.0mm

Implantlength8.0mm

PerioFaculty 40 20 0 0 0 40

ProsthodonOcFaculty 80 60 20 0 40 60

OralSurgeryFaculty 40 20 20 0 0 40

0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementverOcal

GBRduringimplant

placementverOcal

Implantlength8.0

mm

Implantlength8.5

Implantlength10

mm

Implantlength11.5

mm

PerioFaculty 80 60 0 0 20 0 40 20



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

101

Case 9

Figure 5Q. Bar chart and table comparing departments’ faculty choices when using a panoramic radiograph only in regards to FSG for case 9.

Figure 5R. Bar chart and table comparing departments’ faculty choices when using a CBCT image only in regards to FSG for case 9.

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantlength7.0mm

Implantlength8.0mm

Implantlength10mm

PerioFaculty 80 40 0 40 0 0 80



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantlength7.0

mm

Implantlength8.0

mm

Implantlength10

mm

Implantlength11.5

mm

Implantlength13

mm

PerioFaculty 60 40 40 0 0 0 60 0 0



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

102

Case 10

Figure 5S. Bar chart and table comparing departments’ faculty choices when using a panoramic radiograph only in regards to FSG for case 10.

Figure 5T. Bar chart and table comparing departments’ faculty choices when using a CBCT image only in regards to FSG for case 10.

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantlength10mm

Implantlength11.5mm


ProsthodonOcFaculty 100 0 0 0 100 0

OralSurgeryFaculty 100 40 0 40 80 20

0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantlength8mm

ImplantLength8.5

mm

Implantlength10

mm

Implantlength11.5

mm

PerioFaculty 100 40 0 40 40 0 60 0



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

103

4. Comparison between Faculties and Residents

Case 1

Figure 6A. Bar chart and table comparing faculty to residents’ choices when using a panoramic radiograph only in regards to maxillary sinus proximity for case 1.

Figure 6B. Bar chart and table comparing faculty to residents’ choices when using a CBCT image only in regards to maxillary sinus proximity for case 1.

ImplantSuitability

SitePreparaOon

ExternalSinusLiS

InternalSinusLiS

Implantlength8mm

Implantlength8.5mm

Implantlength10mm

Faculty 80 80 26.7 40 20 6.7 53.3

Residents 100 86.7 53.3 33.3 13.3 6.7 80

0%10%20%30%40%50%60%70%80%90%

100%

Percen

tage

Panoramic

ImplantSuitability

SitePreparaOon

ExternalSinusLiS

InternalSinusLiS

Implantlength8mm

Implantlength10

mm

Implantlength11.5

mm

Implantlength13

mmFaculty 100 100 86.7 13.3 26.7 40 26.7 6.7

Residents 100 100 66.7 33.3 13.3 86.7 0 0

0%10%20%30%40%50%60%70%80%90%

100%

Percen

tage

CBCT

104

Case 2

Figure 6C. Bar chart and table comparing faculty to residents’ choices when using a panoramic radiograph only in regards to maxillary sinus proximity for case 2.

Figure 6D. Bar chart and table comparing faculty to residents’ choices when using a CBCT image only in regards to maxillary sinus proximity for case 2.

ImplantSuitability

SitePreparaOon

ExternalSinusLiS

InternalSinusLiS

ImplantLength8mm

ImplantLength10mm

ImplantLength11.5mm

Faculty 80 80 0 80 20 53.3 6.7

Residents 93.3 93.3 13.3 73.3 6.7 86.7 0

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Percen

tage

Panoramic

ImplantSuitability

SitePreparaOon

ExternalSinusLiS

InternalSinusLiS

ImplantLength8mm

ImplantLength8.5

mm

ImplantLength10

mm

ImplantLength11.5

mm

ImplantLength13

mm

Faculty 93.3 86.7 60 26.7 20 0 46.7 20 6.7

Residents 93.3 86.7 33.3 53.3 20 6.7 66.7 0 0

0%10%20%30%40%50%60%70%80%90%

100%

Percen

tage

CBCT

105

Case 3

Figure 6E. Bar chart and table comparing faculty to residents’ choices when using a panoramic radiograph only in regards to maxillary bone width for case 3.

Figure 6F. Bar chart and table comparing faculty to residents’ choices when using a CBCT image only in regards to maxillary bone width for case 3.

ImplantSuitability


GBRbeforeimplant

placementLateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm


Implantdiameter4.3

mm

Implantdiameter5.0

mm

Implantdiameter5.5

mm

Faculty 100 80 33.3 53.3 6.7 0 66.7 20 6.7

Residents 93.3 26.7 13.3 6.7 0 6.7 46.7 40 0

0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementLateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm


Implantdiameter4.3

mm

Implantdiameter5.0

mm

Faculty 86.7 86.7 66.7 6.7 40 6.7 26.7 13.3

Residents 93.3 93.3 80 13.3 40 6.7 26.7 20

0%10%20%30%40%50%60%70%80%90%

100%

Percen

tage

CBCT

106

Case 4

Figure 6G. Bar chart and table comparing faculty to residents’ choices when using a panoramic radiograph only in regards to maxillary bone width for case 4.

Figure 6H. Bar chart and table comparing faculty to residents’ choices when using a CBCT image only in regards to maxillary bone width for case 4.

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm

Implantdiameter4.0

mm

Implantdiameter4.3

mm

Implantdiamter5.0

mm

Faculty 100 93.3 0 26.7 13.3 13.3 53.3 20

Residents 86.7 86.7 0 6.7 0 6.7 66.7 13.3

0%10%20%30%40%50%60%70%80%90%

100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm

Implantdiameter4.0

mm

Implantdiameter4.3

mm

Faculty 73.3 73.3 60 13.3 53.3 0 20

Residents 80 80 66.7 6.7 40 6.7 33.3

0%10%20%30%40%50%60%70%80%90%

100%

Percen

tage

CBCT

107

Case 5

Figure 6I. Bar chart and table comparing faculty to residents’ choices when using a panoramic radiograph only in regards to mandibular bone width for case 5.

Figure 6J. Bar chart and table comparing faculty to residents’ choices when using a CBCT image only in regards to mandibular bone width for case 5.

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter4.0

mm

Implantdiameter4.3

mm

Implantdiameter5.0

mm

Implantdiameter5.5

mm

Faculty 86.7 53.3 6.7 40 0 20 50 6.7

Residents 93.3 53.3 13.3 26.7 6.7 20 66.7 0

0%10%20%30%40%50%60%70%80%90%

100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm

Implantdiameter4.0

mm

Implantdiameter4.3

mm

Implantdiameter5.0

mm

Faculty 100 100 80 20 26.7 6.7 46.7 20

Residents 100 93.3 86.7 13.3 26.7 20 26.7 26.7

0%10%20%30%40%50%60%70%80%90%

100%

Percen

tage

CBCT

108

Case 6

Figure 6K. Bar chart and table comparing faculty to residents’ choices when using a panoramic radiograph only in regards to mandibular bone width for case 6.

Figure 6L. Bar chart and table comparing faculty to residents’ choices when using a CBCT image only in regards to mandibular bone width for case 6.

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm

Implantdiemeter4.0

mm

Implantdiameter4.3

mm

Implantdiameter5.0

mm

Faculty 100 53.3 6.7 40 13.3 13.3 66.7 6.7

Residents 100 20 6.7 13.3 6.7 13.3 53.3 26.7

0%10%20%30%40%50%60%70%80%90%

100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm

Implantdiameter4.3

mm

Implantdiameter5.0

mm

Faculty 66.7 60 66.7 0 33.3 20 13.3

Residents 53.3 53.3 40 13.3 20 33.3 0

0%10%20%30%40%50%60%70%80%90%

100%

Percen

tage

CBCT

109

Case 7

Figure 6M. Bar chart and table comparing faculty to residents’ choices when using a panoramic radiograph only in regards to IAN proximity for case 7.

Figure 6N. Bar chart and table comparing faculty to residents’ choices when using a CBCT image only in regards to IAN proximity for case 7.

ImplantSuitability


GBRbeforeimplant

placementverOcal

GBRduringimplant

placementverOcal

Implantlength7.0

mm

Implantlength8.0

mm

Implantlength8.5

mm

Implantlength10

mm

Implantlength11.5

mm

Faculty 93.3 46.7 26.7 0 6.7 46.7 6.7 20 13.3

Residents 93.3 60 33.3 6.7 0 13.3 6.7 73.3 0

0%10%20%30%40%50%60%70%80%90%

100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementverOcal

GBRduringimplant

placementverOcal

Implantlength8.0

mm

Implantlength8.5

mm

Implantlength10

mm

Implantlength11.5

mm

Faculty 100 33.3 0 6.7 40 6.7 40 13.3

Residents 100 53.3 0 0 33.3 6.7 60 0

0%10%20%30%40%50%60%70%80%90%

100%

Percen

tage

CBCT

110

Case 8

Figure 6O. Bar chart and table comparing faculty to residents’ choices when using a panoramic radiograph only in regards to FSG for case 8.

Figure 6P. Bar chart and table comparing faculty to residents’ choices when using a CBCT image only in regards to FSG for case 8.

ImplantSuitability


GBRbeforeimplant

placementverOcal

GBRduringimplant

placementverOcal

Implantlength7.0mm

Implantlength8.0mm

Implantlength10mm

Faculty 53.3 33.3 13.3 0 13.3 40 0

Residents 60 40 13.3 20 0 46.7 13.3

0%10%20%30%40%50%60%70%80%90%

100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementverOcal

GBRduringimplant

placementverOcal

Implantlength8.0

mm

Implantlength8.5

mm

Implantlength10

mm

Implantlength11.5

mm

Faculty 86.7 73.3 13.3 0 40 6.7 26.7 13.3

Residents 100 80 13.3 6.7 33.3 0 66.7 0

0%10%20%30%40%50%60%70%80%90%

100%

Percen

tage

CBCT

111

Case 9

Figure 6Q. Bar chart and table comparing faculty to residents’ choices when using a panoramic radiograph only in regards to FSG for case 9.

Figure 6R. Bar chart and table comparing faculty to residents’ choices when using a CBCT image only in regards to FSG for case 9.

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantlength7.0

mm

Implantlength8.0

mm

Implantlength10

mm

Implantlength11.5

mm

Faculty 93.3 40 20 20 6.7 20 66.7 0

Residents 80 40 26.7 13.3 0 13.3 60 6.7

0%10%20%30%40%50%60%70%80%90%

100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantlength7.0

mm

Implantlength8.0

mm

Implantlength8.5

mm

Implantlength10

mm

Implantlength11.5

mm

Implantlength13

mm

Faculty 73.3 60 53.3 6.7 6.7 20 0 33.3 6.7 6.7

Residents 80 60 46.7 13.3 10 13.3 6.7 60 0 0

0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

112

Case 10

Figure 6S. Bar chart and table comparing faculty to residents’ choices when using a panoramic radiograph only in regards to FSG for case 10.

Figure 6T. Bar chart and table comparing faculty to residents’ choices when using a CBCT only in regards to FSG for case 10.

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantlength10mm

Implantlength11.5mm

Implantlength13mm

Faculty 93.3 26.7 6.7 20 86.7 6.7 0

Residents 93.3 13.3 0 5.7 60 26.7 6.7

0%10%20%30%40%50%60%70%80%90%

100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantlength8mm

Implantlength8.5

mm

Implantlength10

mm

Implantlength11.5

mm

Faculty 100 20 0 20 46.7 6.7 40 6.7

Residents 93.3 33.3 0 26.7 26.7 6.7 60 0

0%10%20%30%40%50%60%70%80%90%

100%

Percen

tage

CBCT

113

5. Comparison between Faculties and Residents (Department of Periodontology)

Case 1

Figure 7A. Bar chart and table comparing the department of periodontology’s faculty to residents’ choices when using a panoramic radiograph only in regards to maxillary sinus proximity for case 1.

Figure 7B. Bar chart and table comparing the department of periodontology’s faculty to residents’ choices when using a CBCT image only in regards to maxillary sinus proximity for case 1.

ImplantSuitability SitePreparaOon ExternalSinusLiS InternalSinusLiS ImplantLength10mm

PerioFaculty 80 80 20 40 80

PerioResidents 100 70 40 30 100

0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability

SitePreparaOon

ExternalSinusLiS

InternalSinusLiS

Implantlength8mm

Implantlength10mm

Implantlength11.5mm

PerioFaculty 100 100 80 20 40 40 20

PerioResidents 100 100 70 30 20 80 0

0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

114

Case 2

Figure 7C. Bar chart and table comparing the department of periodontology’s faculty to residents’ choices when using a panoramic radiograph only in regards to maxillary sinus proximity for case 2.

Figure 7D. Bar chart and table comparing the department of periodontology’s faculty to residents’ choices when using a CBCT image only in regards to maxillary sinus proximity for case 2.

ImplantSuitability

SitePreparaOon

ExternalSinusLiS

InternalSinusLiS

ImplantLength8mm

ImplantLength10

mm

ImplantLength11.5

mmPerioFaculty 80 80 0 80 0 60 20

PerioResidents 90 90 20 60 10 80 0

0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability

SitePreparaOon

ExternalSinusLiS

InternalSinusLiS

ImplantLength8mm

ImplantLength10

mm

ImplantLength11.5

mmPerioFaculty 100 100 60 40 0 80 20


0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

115

Case 3

Figure 7E. Bar chart and table comparing the department of periodontology’s faculty to residents’ choices when using a panoramic radiograph only in regards to maxillary bone width for case 3.

Figure 7F. Bar chart and table comparing the department of periodontology’s faculty to residents’ choices when using a CBCT image only in regards to maxillary bone width for case 3.

ImplantSuitability


GBRbeforeimplant

placementLateral

GBRduringimplant

placementlateral

Implantdiameter4.3

mm

Implantdiameter5.0

mm

PerioFaculty 100 100 20 100 60 40

PerioResidents 90 30 10 10 50 40

0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementLateral

GBRduringimplant

placementlateral





PerioFaculty 80 80 60 20 0 0 40 40

PerioResidents 100 100 80 10 20 10 40 30

0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

116

Case 4

Figure 7G. Bar chart and table comparing the department of periodontology’s faculty to residents’ choices when using a panoramic radiograph only in regards to maxillary bone width for case 4.

Figure 7H. Bar chart and table comparing the department of periodontology’s faculty to residents’ choices when using a CBCT image only in regards to maxillary bone width for case 4.

ImplantSuitability


GBRbeforeimplant

placementLateral

GBRduringimplant

placementlateral

Implantdiameter4.0

mm

Implantdiameter4.3

mm

Implantdiameter5.0

mm

PerioFaculty 100 100 0 40 20 40 40


0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm

Implantdiameter4.0

mm

Implantdiameter4.3

mm

PerioFaculty 60 60 40 20 40 0 20


0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

117

Case 5

Figure 7I. Bar chart and table comparing the department of periodontology’s faculty to residents’ choices when using a panoramic radiograph only in regards to mandibular bone width for case 5.

Figure 7J. Bar chart and table comparing the department of periodontology’s faculty to residents’ choices when using a CBCT image only in regards to mandibular bone width for case 5.

ImplantSuitability


GBRbeforeimplant

placementLateral

GBRduringimplant

placementlateral

Implantdiameter4.3

mm

Implantdiameter5.0

mm



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm

Implantdiameter4.0

mm

Implantdiameter4.3

mm

Implantdiameter5.0

mm

PerioFaculty 100 100 60 40 20 0 40 40

PerioResidents 100 90 80 10 20 10 40 30

0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

118

Case 6

Figure 7K. Bar chart and table comparing the department of periodontology’s faculty to residents’ choices when using a panoramic radiograph only in regards to mandibular bone width for case 6.

Figure 7L. Bar chart and table comparing the department of periodontology’s faculty to residents’ choices when using a CBCT image only in regards to mandibular bone width for case 6.

ImplantSuitability


GBRbeforeimplant

placementLateral

GBRduringimplant

placementlateral

Implantdiameter4.0

mm

Implantdiameter4.3

mm

Implantdiameter5.0

mm

PerioFaculty 100 60 0 60 20 80 0


0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm

Implantdiameter4.3

mm

Implantdiameter5.0

mm

PerioFaculty 60 60 60 0 20 20 20


0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

119

Case 7

Figure 7M. Bar chart and table comparing the department of periodontology’s faculty to residents’ choices when using a panoramic radiograph only in regards to IAN proximity for case 7.

Figure 7N. Bar chart and table comparing the department of periodontology’s faculty to residents’ choices when using a CBCT image only in regards to IAN proximity for case 7.

ImplantSuitability


GBRbeforeimplant

placementverOcal

GBRduringimplant

placementverOcal

Implantlength8.0

mm

Implantlength8.5

mm

Implantlength10mm

Implantlength11.5

mm

PerioFaculty 80 60 10 0 20 60 0 20

PerioResidents 90 30 30 10 20 10 60 0

0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementverOcal

GBRduringimplant

placementverOcal

Implantlength8.0

mm

Implantlength8.5

mm

Implantlength10mm

PerioFaculty 100 40 0 40 20 0 60


0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

120

Case 8

Figure 7O. Bar chart and table comparing the department of periodontology’s faculty to residents’ choices when using a panoramic radiograph only in regards to IAN proximity for case 8.

Figure 7P. Bar chart and table comparing the department of periodontology’s faculty to residents’ choices when using a CBCT image only in regards to IAN proximity for case 8.

ImplantSuitability


GBRbeforeimplant

placementverOcal

GBRduringimplant

placementverOcal

Implantlength8.0mm

Implantlength10mm



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuiObility


GBRbeforeimplant

placementverOcal

GBRduringimplant

placementverOcal

Implantlength8.0

mm

Implantlength10mm

Implantlength11.5

mm

PerioFaculty 80 60 0 0 20 40 20


0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

121

Case 9

Figure 7Q. Bar chart and table comparing the department of periodontology’s faculty to residents’ choices when using a panoramic radiograph only in regards to FSG for case 9.

Figure 7R. Bar chart and table comparing the department of periodontology’s faculty to residents’ choices when using a CBCT image only in regards to FSG for case 9.

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantlength8.0mm

Implantlength10mm



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantlength8.0mm

Implantlength10mm



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

122

Case 10

Figure 7S. Bar chart and table comparing the department of periodontology’s faculty to residents’ choices when using a panoramic radiograph only in regards to FSG for case 10.

Figure 7T. Bar chart and table comparing the department of periodontology’s faculty to residents’ choices when using a CBCT image only in regards to FSG for case 10.

ImplantSuiObility


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantlength10mm

Implantlength11.5mm



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuiObility


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantlength8mm

Implantlength10mm



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

Finkelman, Matth…, 12/20/2016 11:43 PMComment [3]: Fixtypo:“preparation”ratherthan“prepiration"

123

6. Comparison between 2nd Year and 3rd Year Residents (Department of Periodontology)

Case 1

Figure 8A. Bar chart and table comparing the department of periodontology’s 2nd and 3rd year residents’ choices when using a panoramic radiograph only in regards to maxillary sinus proximity for case 1.

Figure 8B. Bar chart and table comparing the department of periodontology’s 2nd and 3rd year residents’ choices when using a CBCT image only in regards to maxillary sinus proximity for case 1.

ImplantSuitability SitePreparaOon ExternalSinusLiS InternalSinusLiS Implantlength10mm

Perio2ndyearResidents 100 100 40 40 100

Perio3rdyearResidents 100 60 40 20 100

0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability

SitePreparaOon

ExternalSinusLiS

InternalSinusLiS

ImplantLength8.0mm

Implantlength10mm

Perio2ndyearResidents 100 100 80 20 20 80

Perio3rdyearResidents 100 100 60 40 20 80

0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

124

Case 2

Figure 8C. Bar chart and table comparing the department of periodontology’s 2nd and 3rd year residents’ choices when using a panoramic radiograph only in regards to maxillary sinus proximity for case 2.

Figure 8D. Bar chart and table comparing the department of periodontology’s 2nd and 3rd year residents’ choices when using a CBCT image only in regards to maxillary sinus proximity for case 2.

ImplantSuitability

SitePreparaOon

ExternalSinusLiS

InternalSinusLiS

ImplantLength8.0mm

Implantlength10mm



0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Percen

tage

Panoramic

ImplantSuitability

SitePreparaOon

ExternalSinusLiS

InternalSinusLiS

ImplantLength8.0mm

Implantlength10mm



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

125

Case 3

Figure 8E. Bar chart and table comparing the department of periodontology’s 2nd and 3rd year residents’ choices when using a panoramic radiograph only in regards to maxillary bone width for case 3.

Figure 8F. Bar chart and table comparing the department of periodontology’s 2nd and 3rd year residents’ choices when using a CBCT image only in regards to maxillary bone width for case 3.

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter4.3

mm

Implantdiameter5.0

mm


Perio3rdyearResdients 100 40 20 20 60 40

0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral





Perio2ndyearResidents 100 100 80 20 20 20 40 20

Perio3rdyearResdients 100 100 80 0 20 0 40 40

0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

126

Case 4

Figure 8G. Bar chart and table comparing the department of periodontology’s 2nd and 3rd year residents’ choices when using a panoramic radiograph only in regards to maxillary bone width for case 4.

Figure 8H. Bar chart and table comparing the department of periodontology’s 2nd and 3rd year residents’ choices when using a CBCT image only in regards to maxillary bone width for case 4.

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter4.3

mm

Implantdiameter5.0

mm



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm

Implantdiameter4.0

mm

Implantdiameter4.3

mm

Perio2ndyearResidents 60 60 20 0 20 0 40

Perio3rdyearResdients 100 100 100 0 20 40 40

0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

127

Case 5

Figure 8I. Bar chart and table comparing the department of periodontology’s 2nd and 3rd year residents’ choices when using a panoramic radiograph only in regards to mandibular bone width for case 5.

Figure 8J. Bar chart and table comparing the department of periodontology’s 2nd and 3rd year residents’ choices when using a CBCT image only in regards to mandibular bone width for case 5.

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter4.3

mm

Implantdiameter5.0

mm



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral





Perio2ndyearResidents 100 80 80 0 40 20 40 0

Perio3rdyearResdients 100 100 80 0 0 0 40 60

0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

128

Case 6

Figure 8K. Bar chart and table comparing the department of periodontology’s 2nd and 3rd year residents’ choices when using a panoramic radiograph only in regards to mandibular bone width for case 6.

Figure 8L. Bar chart and table comparing the department of periodontology’s 2nd and 3rd year residents’ choices when using a CBCT image only in regards to mandibular bone width for case 6.

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter4.0

mm

Implantdiameter4.3

mm

Implantdiameter5.0

mm



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementlateral

GBRduringimplant

placementlateral

Implantdiameter3.5

mm

Implantdiameter4.3

mm



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

129

Case 7

Figure 8M. Bar chart and table comparing the department of periodontology’s 2nd and 3rd year residents’ choices when using a panoramic radiograph only in regards to IAN proximity for case 7.

Figure 8N. Bar chart and table comparing the department of periodontology’s 2nd and 3rd year residents’ choices when using a CBCT image only in regards to IAN proximity for case 7.

ImplantSuitability


GBRbeforeimplant

placementverOcal

GBRduringimplant

placementverOcal

Implantlength8.0

mm

Implantlength8.5

mm

Implantlength10

mm



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementverOcal

GBRduringimplant

placementverOcal

Implantlength8.0

mm

Implantlength8.5

mm

Implantlength10

mm



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

130

Case 8

Figure 8O. Bar chart and table comparing the department of periodontology’s 2nd and 3rd year residents’ choices when using a panoramic radiograph only in regards to IAN proximity for case 8.

Figure 8P. Bar chart and table comparing the department of periodontology’s 2nd and 3rd year residents’ choices when using a CBCT image only in regards to IAN proximity for case 8.

ImplantSuitability


GBRbeforeimplant

placementverOcal

GBRduringimplant

placementverOcal

Implantlength8.0mm

Implantlength10mm



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementverOcal

GBRduringimplant

placementverOcal

Implantlength8.0mm

Implantlength10mm



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

131

Case 9

Figure 8Q. Bar chart and table comparing the department of periodontology’s 2nd and 3rd year residents’ choices when using a panoramic radiograph only in regards to FSG for case 9.

Figure 8R. Bar chart and table comparing the department of periodontology’s 2nd and 3rd year residents’ choices when using a CBCT image only in regards to FSG for case 9.

ImplantSuitability


GBRbeforeimplant

placementverOcal

GBRduringimplant

placementverOcal

Implantlength8.0mm

Implantlength10mm



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementverOcal

GBRduringimplant

placementverOcal

Implantlength8.0mm

Implantlength10mm



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

132

Case 10

Figure 8S. Bar chart and table comparing the department of periodontology’s 2nd and 3rd year residents’ choices when using a panoramic radiograph only in regards to FSG for case 10.

Figure 8T. Bar chart and table comparing the department of periodontology’s 2nd and 3rd year residents’ choices when using a CBCT image only in regards to FSG for case 10.

ImplantSuitability


GBRbeforeimplant

placementverOcal

GBRduringimplant

placementverOcal

Implantlength10mm

Implantlength11.5mm



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

Panoramic

ImplantSuitability


GBRbeforeimplant

placementverOcal

GBRduringimplant

placementverOcal

Implantlength8.0mm

Implantlength10mm



0%10%20%30%40%50%60%70%80%90%100%

Percen

tage

CBCT

133

Appendix B: Surveys

134

AssignedNumber:___________

DOB:______________Sex: ☐M☐F

Department:☐ OralSurgery ☐Periodontology ☐Prosthodontics

Roleindepartment:☐Faculty ☐Resident2ndyear ☐Resident3rdyear

Experience:

SurgicalExperience

Thefollowingquestionsdealswithyoursurgicalexperienceintheplacementofdentalimplants:

a) Doyousurgicallyplaceimplants?☐Y☐N

ifno,pleasemovetoprostheticexperiencesection.Ifyespleaseanswerb,c,dande.

b) Howmanyyearsofexperiencedoyouhaveinsurgicallyplacingimplants:

☐<3 ☐3-5 ☐>5

c) Doyoutreatmentplanthesurgicalplacementofimplants?☐Y☐N

d) Inthesurgicaldentalimplantplacement,doyouconsideryourselfcompetentinplacing:

☐ singleimplantsonly

☐ multipleimplants

e) Ifyouplaceimplants,whattypeofcaredoyoutypicallyprovide(pleaseusetableasaguide):

☐Straightforward ☐Advanced ☐Complex

Straightforward Advanced Complex

Bone Sufficient,noneedforboneaugmentation

Horizontalboneaugmentationneededattimeofimplantplacement

BothVerticaland/orHorizontalboneaugmentationneededpriortoimplantplacement

SoftTissueGraft Notneeded Singleprocedure Multipleprocedures

135

SinusLift Notneeded Internalsinuslift ExternalSinusLift

PatientExpectation Low Medium High

Access Adequate Restricted SeverelyRestricted

Edentulousarea Singletooth Shortgap(2-3teeth) Extendedgap(>3teeth)

ProstheticExperience

Thefollowingquestionsdealswithyourprostheticexperienceintherestorationofdentalimplants:

a) Doyourestoredentalimplants?☐Y☐NifnopleasemovetoQ3,ifyespleaseanswerbandc.

b) Howmanyyearsofexperiencedoyouhaveintheprostheticrestorationofdentalimplants:☐<3 ☐3-5 ☐>5

c) Thedegreeofcomplexityofthecasesyourestore:☐ singleimplants☐ 2-3implants☐ >3implants☐ Fullarchimplantrestoration

Q3.

Boardcertified:☐Y☐N

Ifyes,pleasecirclecertification(s):-Periodontology prosthodontics Surgery

Othercertificates/degreesrelatedtoimplantplacement/restoration:____________________________________________________________________________________________________________________

136

Maxilla Survey:

Casenumber:X

Clinicalscenario(pleaseuseoverlayprovidedasyourguide).Thepatientwouldliketoplaceadentalimplantatsite#X(orindicatedbyaredarrow)

--------------------------------------------------------------------------Basedonlyontheradiographicinformationprovided,pleasechooseyouranswer.Q1)Doyouthinkanimplantisthesuitabletreatmentoption?☐Y☐NIfyes,pleasemovetoQ2,ifnopleaseansweraandb:a)Pleasestatethereason:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

b)Whatwouldyourecommendedtobethealternativetreatment:

☐ FPD ☐ RPD

☐ Other:

__________________________________________________________________________________

Pleaseskipquestions2,3and4andmovetothefollowingcase.

--------------------------------------------------------------------------Q2)Whichsitepreparation/modificationdoyoubelieveismostsuitableinthiscase,pleasechooseone:(ifnositepreparation/modificationneededpleasemovetoQ3)a)Externalsinuslift:☐ Y☐ NIfyes,willthesinusliftbeconducted:☐ Priortoimplantplacement ☐ simultaneousb)Internalsinuslift:☐ Y☐ Nc)GuidedBoneRegeneration(GBR)priortoimplantplacement:☐ Y☐ NIfyes,pleasechoosewhatdimensionwouldyouaimtoincrease

☐ Vertical ☐ Lateral ☐ BothVertical/lateral

d)GBRatthetimeofimplantplacement:☐ Y☐ N☐ Vertical ☐ Lateral ☐ BothVertical/lateral

137

Q3)Whichtype/diameter/lengthofimplantwouldyouuseatthetimeofimplantplacement?

Type:☐1 ☐2 ☐3

Diameter:______________________

Length:_________________________

--------------------------------------------------------------------------Q4)Whenaftertheimplantplacementwouldyourestoretheimplant:☐simultaneously☐4wks☐6wks☐8wks☐10wks☐12wks☐14wks☐16wks

138

Mandible Survey

Clinicalscenario(pleaseuseoverlayprovidedasyourguide)

Thepatientwouldliketoplacemultipledentalimplants.Animplantistobeplacedatsite#Xorthesiteindicatedbytheredarrow

--------------------------------------------------------------------------Basedonlyontheradiographicinformationprovided,pleasechooseyouranswer.

Q1)Doyouthinkanimplantisthesuitabletreatmentoption?☐Y☐N

Ifyes,pleasemovetoQ2,ifnopleaseansweraandb:

a)Pleasestatethereason:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

b)Whatwouldyourecommendedtobethealternativetreatment:

☐ FPD ☐ RPD

☐ Other:

__________________________________________________________________________________

Pleaseskipquestions2,3and4andmovetothefollowingcase.

--------------------------------------------------------------------------Q2)Whichsitepreparation/modificationdoyoubelieveismostsuitableinthiscase,pleasechooseone:a)Nositepreparation/modificationneededpriororattimeofimplantplacement☐

b)GuidedBoneRegeneration(GBR)priortoimplantplacement:☐ Y☐ N

Ifyes,pleasechoosewhatdimensionwouldyouaimtoincrease.


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c)GBRatthetimeofimplantplacement:☐ Y☐ N

Ifyes,pleasechoosewhatdimensionwouldyouaimtoincrease.


Q3)Whichtype/diameter/lengthofimplantwouldyouuseatthetimeofimplantplacement?

Type:☐1 ☐2 ☐3

Diameter:______________________

Length:_________________________

--------------------------------------------------------------------------Q4)Whenaftertheimplantplacementwouldyourestoretheimplant:☐simultaneously ☐4wks☐6wks ☐8wks☐10wks☐12wks☐14wks ☐16wks

Comparing panoramic radiography with Cone beam computed ...

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