Talking cone beam

Dr. Reznick & Dr. Patel discuss 3D cone beam imaging in the practice and how it can help doctors work together to provide better care for their patients

Q. Tell us about yourself and your practice:

Dr Reznick (hereafter, Dr R): I went to dental school at Tufts University, trained in Oral and Maxillofacial Surgery at the University of Southern California, then went back to obtain my medical degree. I have practiced in suburban Los Angeles for 18 years. My practice is in a middle to upper-middle income area, and my patients vary from blue-collar workers, to soccer moms and their kids, to the CEOs of major corporations, to a number of well-known Hollywood celebrities.

Dr Patel (hereafter, Dr P): I graduated from Ohio State University in 2006. Most candidates are required to complete a specialty in Prosthodontics, but I was fortunate enough to be admitted into the Implant Prosthodontics Program under Professor Edwin A McGlumphy directly from dental school. I now have a private practice that focuses on General, Cosmetic and Implant Prosthodontic Dentistry. I enjoy treating complex reconstructive cases and plan to focus my practice entirely on these cases in the near future. I rely on my specialists (Oral Surgeons, Periodontists, Orthodontists, et al) for comprehensive and inter-disciplinary care.

Q. What do you look for when referring to specialists?

Dr P: Without cone beam in my office, I’ve never really had defined criteria for referring patients. It was almost like I used to pick a surgeon out of a hat. With cone beam in my office, I can clearly see everything I need in order to formulate and develop an ideal treatment plan. I have the ability to refer with confidence, knowing that I am providing my specialists with what they need to achieve optimal results. I can make decisions quickly and efficiently because with 3D imaging, what you see is what you get!

Q. What are the sources of your referrals?

Dr R: In my practice, the majority of patients referred to me are from GPs in the local area. I also see a number of patients referred from GPs and specialists throughout Southern California. Another referral source is from the Internet. I was one of the first oral surgeons to have a website for my practice. Many patients come to me after reading about the practice on my website. If you Google my name, you get at least ten pages, and I suspect many patients come to my office as a result.

Q. What types of cases do you see, and what about general practitioner referrals; do they involve a certain type of case?

Dr R: I see the full variety of situations from simple single implant cases, to multiple implant reconstruction, to complicated cases that may require multiple procedures over a one to two year period. What I’ve found in teaching oral surgery is that there are varying levels of training and expertise with GPs as well as with specialists. There are some very competent and well-trained GPs doing their own implant surgery. There are also those who have taken a couple of courses, but only do a few implant placements each year so their experience remains limited. What I’ve found is that the general dentist who is very well versed in implant dentistry is more apt to think about implants as an option when planning their patient’s treatment. I actually see more complicated cases come from those GPs who are comfortable with implant dentistry and actually place their own implants and do the restorations on simpler cases.

Q. What sort of impact does cone beam have on guided implant surgery?

Dr R: This is the prime use of cone beam imaging in dental practices. Guided Implant Surgery is the latest quantum leap. We used to use a panoramic radiograph and study models to evaluate potential implant sites. From there, clinical experience, surgical art, and guess work were used to perform implant surgery. Many factors could adversely affect implant placement. I’ve seen articles and textbook chapters where even the ‘experts’ had implants coming out off-angle or poorly-positioned. Guided Implant Surgery allows us to diagnose, treatment plan and work from 3-dimensional CT images of the bone. Because we can see all the important anatomy without distortion, and take accurate measurements, we can place implants with much more precision. Many times, smaller incisions can be made, and using custom-made surgical guides, the implant placement is more accurate. This saves significant time in surgery. As a result, I can schedule more patients in my day, increasing my daily productivity. This is one of the unexpected benefits we enjoy that I alluded to earlier.

Q. What effect does cone beam have on the communication process?

Dr P: For me, things have changed very rapidly. Prior to cone beam imaging, communication with a referral was difficult and cumbersome. Communication is something we all strive to improve upon, along with continuity of care. We need to have everyone, the GP, the specialist and the patient all on the same page. With the system we employ we can pull up the very treatment plan we work on, change it and send it back and forth for review until we come to an agreement. Communication is now less of an issue because it’s so much easier to do with cone beam and its tools. It’s a great benefit to our patients.

Dr R: Communication is absolutely essential. The general dentist is the captain of the ship when dealing with multi-disciplinary treatments. As a specialist, where I rely very heavily on referrals, it’s essential that I have good communication channels with my referring dentists, because if I don’t they will be out of the loop and feel like they would need to refer elsewhere. Having the cone beam in the office has improved the communication with the general dentist. They can see implant treatment plans before they are placed, through emails, or on interactive 3D viewer CDs. They can give their feedback to me and the final result will be the most ideal treatment plan from both the surgical and prosthetic standpoints.

Q. What about using cone beam images for patient education?

Dr R: That’s been really important. I’m a strong advocate of patient education. I have used models and audio-visual representations of our oral surgery procedures for many years. Nothing has had as profound or dramatic an effect as when I bring up a 3D image of the patient to demonstrate their anatomy and show them their treatment options. The patients have a greater understanding of their situation and the proposed treatment for it, and this increases case acceptance.

Dr P: As a GP, cone beam has opened my eyes to all aspects of surgical treatment. It took the majority of dentists a long time to learn to read 2D X-Ray images and we were working from those 2D images to show patients pathology and propose treatment plans. We all have to admit that some patients do not easily see what we see in a 2D X-ray film or image. How could they? With cone beam we are able to show more realistic and specific 3D images. When we show them an area in need of dental treatment, patients can see it clearly. It’s almost tactile and when a patient sees an image or a model of his or her own skull it brings it all home. When we look at a cone beam image, the patients see exactly the same thing we are seeing. It’s no longer a case of asking them if they see what we see; it’s a case of both of us seeing the same image at the same time. It provides clarity for both the dentist and the patient and it take much less time to explain the treatment proposal.

Q. Do you use cone beam with all patients, or just for the complex cases?

Dr P: For me, it’s my primary diagnostic tool.I generally scan all of my patients except for pediatric patients. I am able to diagnose the health of every single tooth in the mouth, and I can isolate problems quickly. I honestly couldn’t work without cone beam anymore. With incidental findings as high as 25%, I find myself justifying CBCT scans as a routine diagnostic procedure. If I have any questions I readily refer my scans for review by an Oral Maxillofacial Radiologist, and I follow their guidelines for limiting unnecessary radiation exposure. Dr R: I don’t know how I lived without cone beam either. Cone beam has revolutionized how we look at (and through) our patients. You can see more in 3D than you could possibly imagine in 2D. Although I don’t scan everyone, if there is any question of larger problems, then a scan is almost mandatory. Cone beam CT imaging is essential for evaluation of patients with impacted teeth to know exactly where the teeth are located.

Q. How do you justify the financial commitment to purchase the 3D imaging unit in your practice?

Dr R: I’m often asked if it’s worth spending almost $200,000 on a piece of equipment when, in the present economic climate, doctors are wondering if they will have patients in their chair next week. Looking at cone beam CT as
just another piece of equipment is not the right way to look at it. The money is more than covered by the increase in productivity and patient acceptance. Patients come to us because of the technology we incorporate, and how well we use it to provide them with better care. It has to be seen as a way of elevating the level of service you provide and setting yourself apart from the others. Having the treatment information that cone beam gives you puts you in a better situation to treat your patients.

Dr P: I’m a GP and I am like all the other GPs. We are all concerned about the financial impact of owning a cone beam scanner. I learned very quickly that the business of cone beam is not in charging for scans. It’s for the quality of service it helps me provide to my patients. With cone beam I’ve seen a direct increase in patient case acceptance. Everyone’s thinking about cone beam, they’re all questioning the cost, but that issue will become smaller and smaller as more companies improve it and the standard of care increases. There will come a day when cone beam will be readily available for all patients. It’s all about being a better dentist.

Q. Why is the uptake and integration of conebeam technology slow in some practices?

Dr P: I think it’s because they’re not educated regarding all of its potential uses. Some articles on the subject have merit and others don’t. Cone beam is so new that doctors, such as Dr Reznick and I feel that it is very important help our colleagues to understand the various uses of Cone beam imaging and how it is applied in our practices every single day. Although integrating a unit into your practice can be challenging the rewards are great, and I don’t think anyone ever looks backward to working only in 2 dimensions.

Dr R: There are a number of factors and the major one is simply a lack of understanding. There are some doctors who really embrace technology and others who shy away. Some think of it as only a tool for treatment planning implants, as opposed to a tool to aid in everything from patient education to full-scope treatment planning. The negative experience has generally come from implant planning software that utilized images from a medical CT scan. One of the things Dr Patel and I have benefited from is that the system we use has very intuitive software. It makes the whole process extremely efficient. Within 30 seconds of the scan coming up on the screen we can already begin to treatment plan and we can do this with the patient chair-side.

Dr P: I was fortunate enough to be a consultant before opening my private practice. I was hired by specialists to help them integrate Cone Beam into their practices. I have had extensive experience with many of the machines available in the USA. Of all the equipment you can buy, integrating a cone beam system into your practice is one of the most challenging, but the payoff is extremely high.

The company we purchased our CBCT unit from designed their technology with how it could be integrated clinically with maximum efficiency. What would take other CBCT units hours to achieve in diagnostic and treatment planning is done in five minutes in my practice.

Q. How does it affect your case acceptance rates?

Dr P: Across the US we have around a 50-70% treatment acceptance rate in general dentistry. In terms of my case acceptance rate, and I attribute this figure to the integration of cone beam into my practice, I went from around 60% to 90%. I think it’s because: 1) Patients see exactly what their needs are; 2) The intuitive software tools allow us to measure and increase accuracy 3) We can show patients the steps we will take and their options for treatment; and 4) Our patients value our technology and the way we use it to provide better care. Some patients seek second and third opinions, but if the other dentist doesn’t have the technology and capabilities that I do, the patient invariably comes back.

Dr R: I see a lot of patients for second and third opinions, and much of the time patients choose to go with me. Maybe not just for me, but for the technology I will employ in their treatment for their benefit. Patients are generally very sophisticated with regards to the use of the Internet, so they often go ‘doctor shopping’ because they want the best. I used to work with a partner who didn’t want to use cone beam the same way I did. From my former partner’s point of view Computer guided implant treatment was an unnecessary added expense, but to the patients it was about having the best treatment, and the technology reflected that.

Q. What would you like to see developed in the future?

Dr R: We know a little of what’s coming down the road, and it is very exciting. One day we will be able to do all our treatment planning in virtual reality and show patients their treatment options at each step along the way. Comprehensive 3D digital dentistry is coming soon and many applications are yet to be invented.

Dr P: I think as dentists we always dream to be able to comprehensively and completely treatment plan in 3D. Imagine in how a short period of time we’ll be able to scan a patient and superimpose periodontal charting, endodontic treatment, restorative treatment, (veneers, crowns, bridges, etc…) and superimpose those onto a 3D view of the patient’s skull. Imagine not having to take an impression ever again…the possibilities are endless!

Dr R: When we think about the future we get really excited. 3D Digital dentistry and the associated information is easily portable and transferable between practitioners, so real-time collaboration across town or across the world will become commonplace. Digital information can also be stored in much less space, and more easily retrieved than stone models and film radiographs. Technologies that are just in their infancy today will become the standard of care for dentistry in the future. If you want to learn more, please join us at the 3D Summit September 17-19 at the Scottsdale Center for Dentistry, and look for our future articles in Implant Practice US where we will present patient cases.

Neal S. Patel, DDS.
Dr. Patel is a General Dentist with Implant Prosthodontic Training from The Ohio State University. He maintains a private practice in Powell, Ohio. He received a degree in Molecular Genetics from OSU as well. His special clinical interests are in the areas of cosmetics, dental implantology, CAD/CAM dentistry, laser surgery, and complex reconstructions. He also has expertise in the integration of complete digital dentistry, 3-D imaging, dental materials, and CT-guided implant prosthetics.

He frequently lectures at continuing education meetings, and has published numerous clinical articles on advanced treatment techniques and procedures.He is a consultant for a number of dental manufacturers and works closely with R&D for product development and enhancement. He can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Jay B Reznick, DMD, MD
Dr. Reznick is a Diplomate of the American Board of Oral and Maxillofacial Surgery. He received his Dental degree from Tufts University, and his M.D. degree from the University of Southern California, and trained in Oral and Maxillofacial Surgery at L.A. County- USC Medical Center. His special clinical interests are in the areas of facial trauma, jaw and oral pathology, dental implantology, sleep disorders medicine, laser surgery, and jaw deformities. He also has expertise in the integration of digital photography, 3-D imaging, and CT-guided implant surgery in clinical practice.

He frequently lectures at continuing education meetings, and has published articles in JADA, Journal of the California Dental Association, Oral Surgery-Oral Medicine-Oral Pathology, Compendium of Continuing Education in Dentistry, DentalTown Magazine, CE Digest, and Gastroenterology. Dr. Reznick is one of the Founders of the website OnlineOralSurgery.com, which educates practicing dentists in basic and advanced oral surgery techniques. He is the Director of the Southern California Center for Oral and Facial Surgery (www.sccofs.com) in Tarzana, California, and a consultant for many dental and surgical manufacturers. He can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .