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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
Tufts University School of Dental Medicine
&
Matthew Finkelman, PhD
Associate professor
Director of the Division of Biostatistics and Experimental Design
Tufts University School of Dental Medicine
&
Dr. Yong Hur, DMD, DDS, MS.
Assistant professor of Periodontology
Tufts University School of Dental Medicine
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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
Sinus proximity (Bone Height - Maxilla)
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%).
Bone Width (Maxilla)
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.
Bone Width (Mandible)
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%).
IAN Proximity (Mandible)
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%).
Fossa of the Submandibular Gland (Mandible)
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
Sinus proximity (Bone Height - Maxilla)
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
Bone Width (Maxilla)
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
Bone Width (Mandible)
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
IAN Proximity (Mandible)
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
Fossa of the Submandibular Gland (Mandible)
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
Sinus proximity (Bone Height - Maxilla)
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%).
Bone Width (Maxilla)
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%).
Bone Width (Mandible)
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.
IAN Proximity (Mandible)
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
Fossa of the Submandibular Gland (Mandible)
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)
Sinus proximity (Bone Height - Maxilla)
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
Bone Width (Maxilla)
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
Bone Width (Mandible)
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
IAN Proximity (Mandible)
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
Fossa of the Submandibular Gland (Mandible)
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)
Sinus proximity (Bone Height - Maxilla)
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.
Bone Width (Maxilla)
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%).
Bone Width (Mandible)
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%).
IAN Proximity (Mandible)
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.
Fossa of the Submandibular Gland (Mandible)
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
66
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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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
SiteprepiraOonneeded
GBRbeforeimplant
placementLateral
GBRduringimplant
placementlateral
Implantdiameter3.5
mm
Implantdiameter4.0mm
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
SitepreparaOonneeded
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
SitepreparaOonneeded
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
SitepreparaOonneeded
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
SitepreparaOonneeded
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
SitepreparaOonneeded
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
ProsthodonOcDepartment 100 100 0 100 30 0 70 0
OralSurgeryDepartment 60 60 0 60 0 0 60 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
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
SitepreparaOonneeded
GBRbeforeimplant
placementlateral
GBRduringimplant
placementlateral
Implantdiameter3.5
mm
Implantdiameter4.0mm
Implantdiameter4.3
mm
Implantdiameter5.0
mm
Implantdiameter5.5
mm
PerioDepartment 93.3 53.7 13.3 40 0 0 53.3 40 0
ProsthodonOcDepartment 100 30 20 10 10 10 40 30 10
OralSurgeryDepartment 100 100 60 40 0 0 100 0 0
0%10%20%30%40%50%60%70%80%90%
100%
Percen
tage
Panoramic
ImplantSuitability
SitepreparaOonneeded
GBRbeforeimplant
placementLateral
GBRduringimplant
placementlateral
Implantdiameter3.5
mm
Implantdiameter4.0mm
Implantdiameter4.3
mm
Implantdiameter5.0
mm
PerioDepartment 93.3 93.3 73.3 13.3 13.3 6.7 40 33.4
ProsthodonOcDepartment 80 70 60 10 80 0 0 0
OralSurgeryDepartment 100 100 100 0 40 20 20 0
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
SitepreparaOonneeded
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
ProsthodonOcDepartment 100 90 0 20 20 10 50 20
OralSurgeryDepartment 100 100 0 20 0 20 60 20
0%10%20%30%40%50%60%70%80%90%100%
Percen
tage
Panoramic
ImplantSuitability
SitepreparaOonneeded
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
ProsthodonOcDepartment 80 80 70 20 80 0 0
OralSurgeryDepartment 80 80 80 0 40 0 40
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
SitepreparaOonneeded
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
ProsthodonOcDepartment 100 50 20 30 0 10 50 30 10
OralSurgeryDepartment 80 60 20 40 0 0 0 80 0
0%10%20%30%40%50%60%70%80%90%
100%
Percen
tage
Panoramic
ImplantSuitability
SitepreparaOonneeded
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
OralSurgeryDepartment 100 100 90 0 20 20 60 0
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
SitepreparaOonneeded
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
ProsthodonOcDepartment 100 30 10 20 20 10 40 30
OralSurgeryDepartment 100 60 20 40 20 20 60 0
0%10%20%30%40%50%60%70%80%90%100%
Percen
tage
Panoramic
ImplantSuitability
SitepreparaOonneeded
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
ProsthodonOcDepartment 50 50 50 10 50 0 0
OralSurgeryDepartment 80 80 80 0 20 40 20
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
SitepreparaOonneeded
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
ProsthodonOcDepartment 100 50 20 0 10 30 0 60 0
OralSurgeryDepartment 100 40 40 0 0 20 20 40 20
0%10%20%30%40%50%60%70%80%90%
100%
Percen
tage
Panoramic
ImplantSuitability
SitepreparaOonneeded
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
ProsthodonOcDepartment 100 40 0 0 70 10 20 0
OralSurgeryDepartment 100 10 0 0 20 0 40 40
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
SitepreparaOonneeded
GBRbeforeimplant
placementverOcal
GBRduringimplant
placementverOcal
Implantlength7.0mm
Implantlength8.0mm
Implantlength10mm
PerioDepartment 53.3 33.3 6.7 13.3 0 40 13.3
ProsthodonOcDepartment 70 50 20 10 20 50 0
OralSurgeryDepartment 40 20 20 0 40 0 0
0%10%20%30%40%50%60%70%80%90%
100%
Percen
tage
Panoramic
ImplantSuitability
SitepreparaOonneeded
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
ProsthodonOcDepartment 90 60 10 10 60 10 20 0
OralSurgeryDepartment 100 100 20 0 40 0 40 20
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
SitepreparaOonneeded
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
ProsthodonOcDepartment 90 30 20 10 10 40 30 10
OralSurgeryDepartment 100 60 60 0 0 0 100 0
0%10%20%30%40%50%60%70%80%90%100%
Percen
tage
Panoramic
ImplantSuitability
SitepreparaOonneeded
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
SitepreparaOonneeded
GBRbeforeimplant
placementlateral
GBRduringimplant
placementlateral
Implantlength10mm
Implantlength11.5mm
Implantlength13mm
PerioDepartment 86.7 20 6.7 6.7 66.7 20 0
ProsthodonOcDepartment 100 10 0 10 80 10 10
OralSurgeryDepartment 100 40 0 40 80 20 0
0%10%20%30%40%50%60%70%80%90%100%
Percen
tage
Panoramic
ImplantSuitability
SitepreparaOonneeded
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
ProsthodonOcDepartment 100 10 0 10 40 20 40 0
OralSurgeryDepartment 100 20 0 20 40 0 40 20
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
ProsthodonOcFaculty 100 100 0 100 60 40 0
OralSurgeryFaculty 60 60 0 60 0 60 0
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
ProsthodonOcFaculty 100 80 40 40 60 40 0 0
OralSurgeryFaculty 80 80 80 0 20 40 20 20
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
SitepreparaOonneeded
GBRbeforeimplant
placementLateral
GBRduringimplant
placementlateral
Implantdiameter3.5
mm
Implantdiameter4.0mm
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
SiteprepiraOonneeded
GBRbeforeimplant
placementLateral
GBRduringimplant
placementlateral
Implantdiameter3.5
mm
Implantdiameter4.0mm
Implantdiameter4.3
mm
Implantdiameter5.0
mm
PerioFaculty 80 80 60 20 0 0 40 40
ProsthodonOcFaculty 80 80 40 0 80 0 0 0
OralSurgeryFaculty 100 100 100 0 40 20 40 0
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
SitepreparaOonneeded
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
ProsthodonOcFaculty 100 80 0 20 40 0 40 20
OralSurgeryFaculty 100 100 0 20 0 20 60 20
0%10%20%30%40%50%60%70%80%90%100%
Percen
tage
Panoramic
ImplantSuitability
SitepreparaOonneeded
GBRbeforeimplant
placementlateral
GBRduringimplant
placementlateral
Implantdiameter3.5
mm
Implantdiameter4.0
mm
Implantdiameter4.3
mm
PerioFaculty 60 60 40 20 40 0 20
ProsthodonOcFaculty 80 80 60 20 80 0 0
OralSurgeryFaculty 80 80 80 0 40 0 40
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
SitepreparaOonneeded
GBRbeforeimplant
placementlateral
GBRduringimplant
placementlateral
Implantdiameter4.3
mm
Implantdiameter5.0
mm
Implantdiameter5.5
mm
PerioFaculty 80 80 0 60 0 80 0
ProsthodonOcFaculty 100 20 0 20 60 20 20
OralSurgeryFaculty 80 60 20 40 0 80 0
0%10%20%30%40%50%60%70%80%90%100%
Percen
tage
Panoramic
ImplantSuiObality
SitepreparaOonneeded
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
ProsthodonOcFaculty 100 100 80 20 40 0 40 20
OralSurgeryFaculty 100 100 80 0 20 20 60 0
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
SitepreparaOonneeded
GBRbeforeimplant
placementlateral
GBRduringimplant
placementlateral
Implantdiameter3.5
mm
Implantdiameter4.0
Implantdiameter4.3
mm
Implantdiameter5.0
mm
PerioFaculty 100 60 60 60 0 20 80 0
ProsthodonOcFaculty 100 20 60 20 20 0 60 20
OralSurgeryFaculty 100 60 80 40 20 20 60 0
0%10%20%30%40%50%60%70%80%90%100%
Percen
tage
Panoramic
ImplantSuitability
SitepreparaOonneeded
GBRbeforeimplant
placementlateral
GBRduringimplant
placementlateral
Implantdiameter3.5
mm
Implantdiameter4.3
mm
Implantdiameter5.0
mm
PerioFaculty 60 60 60 0 20 20 20
ProsthodonOcFaculty 60 60 60 0 60 0 0
OralSurgeryFaculty 80 80 80 0 20 0 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
SitepreparaOonneeded
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
ProsthodonOcFaculty 100 40 20 0 20 80 0 20 0
OralSurgeryFaculty 100 40 40 0 0 20 20 40 20
0%10%20%30%40%50%60%70%80%90%100%
Percen
tage
Panoramic
ImplantSuitability
SitepreparaOonneeded
GBRbeforeimplant
placementverOcal
GBRduringimplant
placementverOcal
Implantlength8.0
mm
Implantlength8.5
mm
Implantlength10
mm
Implantlength11.5
mm
PerioFaculty 100 40 0 40 20 0 60 0
ProsthodonOcFaculty 100 60 0 0 80 20 0 0
OralSurgeryFaculty 100 20 0 0 20 0 40 40
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
SitepreparaOonneeded
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
SitepreparaOonneeded
GBRbeforeimplant
placementverOcal
GBRduringimplant
placementverOcal
Implantlength8.0
mm
Implantlength8.5
Implantlength10
mm
Implantlength11.5
mm
PerioFaculty 80 60 0 0 20 0 40 20
ProsthodonOcFaculty 80 60 20 0 60 20 0 0
OralSurgeryFaculty 100 100 20 0 40 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
SitepreparaOonneeded
GBRbeforeimplant
placementlateral
GBRduringimplant
placementlateral
Implantlength7.0mm
Implantlength8.0mm
Implantlength10mm
PerioFaculty 80 40 0 40 0 0 80
ProsthodonOcFaculty 100 20 0 20 20 60 20
OralSurgeryFaculty 100 60 60 0 0 0 100
0%10%20%30%40%50%60%70%80%90%100%
Percen
tage
Panoramic
ImplantSuitability
SitepreparaOonneeded
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
ProsthodonOcFaculty 100 80 60 20 20 60 20 0 0
OralSurgeryFaculty 60 60 60 0 0 0 20 20 20
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
SitepreparaOonneeded
GBRbeforeimplant
placementlateral
GBRduringimplant
placementlateral
Implantlength10mm
Implantlength11.5mm
PerioFaculty 80 40 20 20 80 0
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
SitepreparaOonneeded
GBRbeforeimplant
placementlateral
GBRduringimplant
placementlateral
Implantlength8mm
ImplantLength8.5
mm
Implantlength10
mm
Implantlength11.5
mm
PerioFaculty 100 40 0 40 40 0 60 0
ProsthodonOcFaculty 100 100 0 0 60 20 20 0
OralSurgeryFaculty 100 80 0 20 40 0 40 20
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
SitepreparaOonneeded
GBRbeforeimplant
placementLateral
GBRduringimplant
placementlateral
Implantdiameter3.5
mm
Implantdiameter4.0mm
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
SitepreparaOonneeded
GBRbeforeimplant
placementLateral
GBRduringimplant
placementlateral
Implantdiameter3.5
mm
Implantdiameter4.0mm
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
SitepreparaOonneeded
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
SitepreparaOonneeded
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
SitepreparaOonneeded
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
SitepreparaOonneeded
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
SitepreparaOonneeded
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
SitepreparaOonneeded
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
SitepreparaOonneeded
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
SitepreparaOonneeded
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
SitepreparaOonneeded
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
SitepreparaOonneeded
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
SitepreparaOonneeded
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
SitepreparaOonneeded
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
SitepreparaOonneeded
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
SitepreparaOonneeded
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
PerioResidents 90 80 40 40 20 70 0
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
SitepreparaOonneeded
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
SitepreparaOonneeded
GBRbeforeimplant
placementLateral
GBRduringimplant
placementlateral
Implantdiameter3.5mm
Implantdiameter4.0mm
Implantdiameter4.3mm
Implantdiameter5.0mm
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
SitepreparaOonneeded
GBRbeforeimplant
placementLateral
GBRduringimplant
placementlateral
Implantdiameter4.0
mm
Implantdiameter4.3
mm
Implantdiameter5.0
mm
PerioFaculty 100 100 0 40 20 40 40
PerioResidents 80 20 0 0 0 70 10
0%10%20%30%40%50%60%70%80%90%100%
Percen
tage
Panoramic
ImplantSuitability
SitepreparaOonneeded
GBRbeforeimplant
placementlateral
GBRduringimplant
placementlateral
Implantdiameter3.5
mm
Implantdiameter4.0
mm
Implantdiameter4.3
mm
PerioFaculty 60 60 40 20 40 0 20
PerioResidents 80 80 60 0 20 20 40
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
SitepreparaOonneeded
GBRbeforeimplant
placementLateral
GBRduringimplant
placementlateral
Implantdiameter4.3
mm
Implantdiameter5.0
mm
PerioFaculty 80 80 0 60 0 80
PerioResidents 90 30 0 20 10 80
0%10%20%30%40%50%60%70%80%90%100%
Percen
tage
Panoramic
ImplantSuitability
SitepreparaOonneeded
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
SitepreparaOonneeded
GBRbeforeimplant
placementLateral
GBRduringimplant
placementlateral
Implantdiameter4.0
mm
Implantdiameter4.3
mm
Implantdiameter5.0
mm
PerioFaculty 100 60 0 60 20 80 0
PerioResidents 100 10 0 10 10 70 20
0%10%20%30%40%50%60%70%80%90%100%
Percen
tage
Panoramic
ImplantSuitability
SitepreparaOonneeded
GBRbeforeimplant
placementlateral
GBRduringimplant
placementlateral
Implantdiameter3.5
mm
Implantdiameter4.3
mm
Implantdiameter5.0
mm
PerioFaculty 60 60 60 0 20 20 20
PerioResidents 60 60 40 0 10 50 0
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
SitepreparaOonneeded
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
SitepreparaOonneeded
GBRbeforeimplant
placementverOcal
GBRduringimplant
placementverOcal
Implantlength8.0
mm
Implantlength8.5
mm
Implantlength10mm
PerioFaculty 100 40 0 40 20 0 60
PerioResidents 100 50 0 0 20 10 70
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
SitepreparaOonneeded
GBRbeforeimplant
placementverOcal
GBRduringimplant
placementverOcal
Implantlength8.0mm
Implantlength10mm
PerioFaculty 40 20 0 0 40 0
PerioResidents 60 40 10 20 40 20
0%10%20%30%40%50%60%70%80%90%100%
Percen
tage
Panoramic
ImplantSuiObility
SitepreparaOonneeded
GBRbeforeimplant
placementverOcal
GBRduringimplant
placementverOcal
Implantlength8.0
mm
Implantlength10mm
Implantlength11.5
mm
PerioFaculty 80 60 0 0 20 40 20
PerioResidents 100 90 20 0 20 80 0
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
SitepreparaOonneeded
GBRbeforeimplant
placementlateral
GBRduringimplant
placementlateral
Implantlength8.0mm
Implantlength10mm
PerioFaculty 80 40 0 40 0 80
PerioResidents 80 40 0 20 10 70
0%10%20%30%40%50%60%70%80%90%100%
Percen
tage
Panoramic
ImplantSuitability
SitepreparaOonneeded
GBRbeforeimplant
placementlateral
GBRduringimplant
placementlateral
Implantlength8.0mm
Implantlength10mm
PerioFaculty 60 40 40 0 0 60
PerioResidents 80 50 40 10 10 70
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
SitepreparaOonneeded
GBRbeforeimplant
placementlateral
GBRduringimplant
placementlateral
Implantlength10mm
Implantlength11.5mm
PerioFaculty 80 40 20 20 80 0
PerioResidents 90 20 0 0 60 30
0%10%20%30%40%50%60%70%80%90%100%
Percen
tage
Panoramic
ImplantSuiObility
SitepreparaOonneeded
GBRbeforeimplant
placementlateral
GBRduringimplant
placementlateral
Implantlength8mm
Implantlength10mm
PerioFaculty 100 40 0 40 40 60
PerioResidents 90 40 0 30 30 60
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
Perio2ndyearResidents 100 100 20 80 20 80
Perio3rdyearResidents 80 80 20 40 0 80
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
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
SitepreparaOonneeded
GBRbeforeimplant
placementlateral
GBRduringimplant
placementlateral
Implantdiameter4.3
mm
Implantdiameter5.0
mm
Perio2ndyearResidents 80 80 0 0 40 40
Perio3rdyearResdients 100 40 20 20 60 40
0%10%20%30%40%50%60%70%80%90%100%
Percen
tage
Panoramic
ImplantSuitability
SitepreparaOonneeded
GBRbeforeimplant
placementlateral
GBRduringimplant
placementlateral
Implantdiameter3.5mm
Implantdiameter4.0mm
Implantdiameter4.3mm
Implantdiameter5.0mm
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
SitepreparaOonneeded
GBRbeforeimplant
placementlateral
GBRduringimplant
placementlateral
Implantdiameter4.3
mm
Implantdiameter5.0
mm
Perio2ndyearResidents 80 80 0 0 60 20
Perio3rdyearResdients 80 60 0 0 80 0
0%10%20%30%40%50%60%70%80%90%100%
Percen
tage
Panoramic
ImplantSuitability
SitepreparaOonneeded
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
SitepreparaOonneeded
GBRbeforeimplant
placementlateral
GBRduringimplant
placementlateral
Implantdiameter4.3
mm
Implantdiameter5.0
mm
Perio2ndyearResidents 80 40 0 20 20 60
Perio3rdyearResdients 100 20 0 20 0 100
0%10%20%30%40%50%60%70%80%90%100%
Percen
tage
Panoramic
ImplantSuitability
SitepreparaOonneeded
GBRbeforeimplant
placementlateral
GBRduringimplant
placementlateral
Implantdiameter3.5mm
Implantdiameter4.0mm
Implantdiameter4.3mm
Implantdiameter5.0mm
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
SitepreparaOonneeded
GBRbeforeimplant
placementlateral
GBRduringimplant
placementlateral
Implantdiameter4.0
mm
Implantdiameter4.3
mm
Implantdiameter5.0
mm
Perio2ndyearResidents 100 20 0 20 20 60 20
Perio3rdyearResdients 100 0 0 0 0 80 20
0%10%20%30%40%50%60%70%80%90%100%
Percen
tage
Panoramic
ImplantSuitability
SitepreparaOonneeded
GBRbeforeimplant
placementlateral
GBRduringimplant
placementlateral
Implantdiameter3.5
mm
Implantdiameter4.3
mm
Perio2ndyearResidents 40 40 20 0 0 40
Perio3rdyearResdients 80 80 60 20 20 60
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
SitepreparaOonneeded
GBRbeforeimplant
placementverOcal
GBRduringimplant
placementverOcal
Implantlength8.0
mm
Implantlength8.5
mm
Implantlength10
mm
Perio2ndyearResidents 80 60 60 0 20 20 40
Perio3rdyearResdients 100 60 40 20 20 0 80
0%10%20%30%40%50%60%70%80%90%100%
Percen
tage
Panoramic
ImplantSuitability
SitepreparaOonneeded
GBRbeforeimplant
placementverOcal
GBRduringimplant
placementverOcal
Implantlength8.0
mm
Implantlength8.5
mm
Implantlength10
mm
Perio2ndyearResidents 100 60 0 0 40 0 60
Perio3rdyearResdients 100 40 0 0 0 20 80
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
SitepreparaOonneeded
GBRbeforeimplant
placementverOcal
GBRduringimplant
placementverOcal
Implantlength8.0mm
Implantlength10mm
Perio2ndyearResidents 60 40 20 20 40 20
Perio3rdyearResdients 60 40 0 20 40 20
0%10%20%30%40%50%60%70%80%90%100%
Percen
tage
Panoramic
ImplantSuitability
SitepreparaOonneeded
GBRbeforeimplant
placementverOcal
GBRduringimplant
placementverOcal
Implantlength8.0mm
Implantlength10mm
Perio2ndyearResidents 100 80 0 0 20 80
Perio3rdyearResdients 100 100 40 0 20 80
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
SitepreparaOonneeded
GBRbeforeimplant
placementverOcal
GBRduringimplant
placementverOcal
Implantlength8.0mm
Implantlength10mm
Perio2ndyearResidents 80 20 0 20 0 80
Perio3rdyearResdients 80 60 40 0 20 60
0%10%20%30%40%50%60%70%80%90%100%
Percen
tage
Panoramic
ImplantSuitability
SitepreparaOonneeded
GBRbeforeimplant
placementverOcal
GBRduringimplant
placementverOcal
Implantlength8.0mm
Implantlength10mm
Perio2ndyearResidents 80 60 0 20 20 60
Perio3rdyearResdients 80 40 20 0 0 80
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
SitepreparaOonneeded
GBRbeforeimplant
placementverOcal
GBRduringimplant
placementverOcal
Implantlength10mm
Implantlength11.5mm
Perio2ndyearResidents 100 100 0 0 60 40
Perio3rdyearResdients 80 80 0 0 60 20
0%10%20%30%40%50%60%70%80%90%100%
Percen
tage
Panoramic
ImplantSuitability
SitepreparaOonneeded
GBRbeforeimplant
placementverOcal
GBRduringimplant
placementverOcal
Implantlength8.0mm
Implantlength10mm
Perio2ndyearResidents 100 60 0 20 60 40
Perio3rdyearResdients 80 20 0 20 0 80
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.
☐ Vertical ☐ Lateral ☐ BothVertical/lateral
139
c)GBRatthetimeofimplantplacement:☐ Y☐ N
Ifyes,pleasechoosewhatdimensionwouldyouaimtoincrease.
☐ Vertical ☐ Lateral ☐ BothVertical/lateral
Q3)Whichtype/diameter/lengthofimplantwouldyouuseatthetimeofimplantplacement?
Type:☐1 ☐2 ☐3
Diameter:______________________
Length:_________________________
--------------------------------------------------------------------------Q4)Whenaftertheimplantplacementwouldyourestoretheimplant:☐simultaneously ☐4wks☐6wks ☐8wks☐10wks☐12wks☐14wks ☐16wks