In AOX surgery, treatment planning emphasis is normally placed upon the CT image. The 3-dimensional information provided is paramount to assessing and treatment planning a full-arch case. This is without a doubt the standard of care.
In addition to the CT scan, however, I also rely heavily on a traditional panorex image.
In fact, it is incredibly difficult, if not impossible, for me to accurately treatment plan a full-arch case without a high quality panorex image.
I was reminded of this recently when I started operating at a second full-arch practice location and began working with a new CT system. This particular system provides a “3D rendering” of the panorex image. In my opinion, this 3D generated image was not of the best quality and it was difficult to see the detailed anatomical nuances required for optimal treatment planning. I was informed by other doctors that most of the surgeons simply use the CT images to treatment plan their cases.
It goes without saying (but I’ll say it anyway), that I always utilize CT images as a part of my treatment planning protocol for full-arch surgery. Click here to see how I treatment plan a case in 2 minutes or less.
BUT, I also utilize and value the panorex image just as much as the CT scan for surgical planning and information. Without having access to a high-quality, high resolution panorex image – I was immediately reminded just how important the panorex is in my treatment planning process.
I use a panorex image to:
Assess a bird’s-eye view of the case at hand.
There is no better image than the panorex to give you a bird’s-eye view that will tell you within 3-5 seconds the relative perceived difficulty of the case, anticipated AP spread/cantilever, existing pathology, and whether 4 or 6 implants will be required. Of course, this is not 100% accurate and requires evaluation of the CT scan as well. However, the amount of information you can gather in 3-5 seconds is unmatched.
Receive the most accurate assessment of sinus anatomy and extension relative to planned implant sites.
Being able to evaluate sinus anatomy and anterior extension relative to posterior-tilted implant placement is actually far easier for me to accomplish on a Panorex than it is on a CT scan.
Select identification points or anatomic anomalies that might correlate to intra-operative implant locations.
The panorex image is phenomenal at allowing you to visualize and correlate freehand ID points. The CT scan struggles in this regard. Locating sockets, bone irregularities, fractured roots, and even PARL’s that can be used as ID points to guide intra-op implant placement is easy and accurate with a panorex image.
Get a rough estimate of implant lengths.
This is NOT 100% accurate and I do not rely solely on this for planning implant lengths. However, this gives me a quick (3-5 second) assessment of what the case is likely to entail. I always correlate this with a CT scan.
Quickly visualize the mental foramen position to assess if a traditional four-implant configuration anterior to the foramen will provide adequate A-P spread.
The panorex does a good job (I would say the 3-D reconstruction does a “great job”) at providing you an initial assessment of mental foramen position (key is initial assessment – not only assessment). I know that if this is located below the second bicuspid, most of the time a 4-implant configuration is achievable that will have a one-tooth cantilever or less. If the foramen is located inferior to the 1st bicuspid (or more anterior), I know that I may need to look for a short posterior implant to ensure adequate AP spread/cantilever ratios.
Without a quality panorex image, some of these tasks are much more difficult to perform. This is especially true regarding assessment of the maxillary sinus and planned position of the posterior maxillary implants.
Note that we solved the issue of panorex resolution with this particular imaging system by taking a separate panorex image and a separate CT image – and not using the 3D panorex rendered by the CT scan software.
Sure, the CBCT is the standard of care. And, it should be.
But in my opinion, the true gold standard for full-arch treatment planning should be:
A high quality panorex resolution image that allows for calibrated measurements, as well as a high quality CT image that allows for calibrated measurements. The combination of these two techniques will yield the most accurate results.
“When the vision is clear, the results will appear.”
Germany Kent
Q & A with Dr. K
“Which CT system do you like best for AOX?” |
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Obviously, I have not used all the CT systems out there. But, I have used ~6 different systems. While virtually all of the systems that I have used are clinically acceptable and provide you the tools to get the job done, in my opinion, there is not a system that comes close to the quality that the iCAT CBCT unit delivers for full-arch surgery (Note that this is not the imaging system shown in the panorex images above). As it is arguably the best – it is also very expensive, which can understandably be a deterrent for many practices. However, the iCAT CBCT provides a crystal clear panorex and CT scan (with one image), allows accurate measurements on both the pano and the CT, and is incredibly user friendly. This is hands down my favorite unit to date. |