Table of Contents  
REVIEW ARTICLE
Year : 2013  |  Volume : 5  |  Issue : 2  |  Page : 88-94

"Dental implant radiology" - Emerging concepts in planning implants


1 Department of Oral Medicine and Radiology, Sri Sai College of Dental Surgery, Vikarabad, Andhra Pradesh, India
2 Department of Oral Medicine and Radiology, Panineeya Dental Institute and Hospital, Hyderabad, Andhra Pradesh, India
3 Department of Oral Medicine and Radiology, Rangoonwala College of Dental Sciences, Pune, Maharashtra, India
4 Senior lecturer in Periodontics, Sri Sai College of Dental Surgery, Vikarabad, Andhra Pradesh, India

Date of Web Publication3-Jan-2014

Correspondence Address:
Amara Swapna Lingam
Department of Oral Medicine and Radiology, Sri Sai College of Dental Surgery, Vikarabad, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-8844.124250

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  Abstract 

Dental radiology has long played an exciting and critical diagnostic role in dentistry. This has been never truer than now with the rapidly expanding array of imaging modalities. Radiography offers the sole method of (non-surgical) analysis of bone required for implant therapy. The choice of when to image, along with which imaging modality to use, depends on a combination of factors including determination of the bone quality and quantity to establish the most favorable position of implant placement, detection of the presence or absence of pathoses and accessibility at a reasonable cost to the patient. In addition, exposing patients to radiation dose as low as reasonably achievable should always be considered when selecting radiographic examinations. This article, reviews the current concepts on implant planning using different radiographic techniques and their applicability to facilitate the clinician's work in successful implant placement.

Keywords: Computed tomography, implant radiography, interactive computed tomography, spatial relationship


How to cite this article:
Lingam AS, Reddy L, Nimma V, Pradeep K. "Dental implant radiology" - Emerging concepts in planning implants. J Orofac Sci 2013;5:88-94

How to cite this URL:
Lingam AS, Reddy L, Nimma V, Pradeep K. "Dental implant radiology" - Emerging concepts in planning implants. J Orofac Sci [serial online] 2013 [cited 2017 May 23];5:88-94. Available from: http://www.jofs.in/text.asp?2013/5/2/88/124250


  Introduction Top


The goal of modern dentistry is to restore the patient to normal contour, function, comfort, esthetics, speech and health, whether by removing caries from a tooth or replacing several teeth. What makes implant dentistry unique is the improved ability to achieve this goal, regardless of the atrophy, disease or injury of the stomatognathic system. [1]

However, the more teeth a patient is missing, the more challenging this task may become. As a result of continued research, diagnostic tools, treatment planning, implant designs, materials and techniques, predictable success is now a reality for the rehabilitation of many challenging clinical situations. [2],[3],[4] Dental implantology has experienced explosive growth during last few years. Treatment planning for implants includes a radiographic examination that provides information about the location of anatomical structures, the quality and quantity of available bone, the presence of infrabony lesions, the occlusal pattern and the number and size of implants as well as prosthesis design, all which are essential for successful implant treatment. [5],[6],[7]]

The imaging objectives are to provide the clinician with cross-sectional views of the dental arch for visualization of spatial relationship of internal structures of the maxilla and mandible. Minimal image distortion permits accurate measurement. Ideally, the images should allow evaluation of the density of trabecular bone and thickness of the cortical plates bone quality. Imaging studies should help to determine the optimum position of implant placement relative to occlusal loads. In addition, detection of the presence or absence of pathoses and which is assessable at a reasonable cost to the patient are the desirable features. [8]

The decision of when to prescribe imaging depends upon the integration of these factors and can be organized into three phases. Those are: (1) Pre-surgical implant imaging, (2) surgical and interventional implant imaging. (3) post prosthetic implant imaging. Although several image diagnostic methods are available to evaluate proposed sites for implants, currently, not a single technique is considered ideal for pre- and post-operative analyses. Therefore, few authors suggest a combination of various techniques to obtain reliable information. [9],[10] However, when weighing risk and cost against the benefit, excessive utilization of newer techniques should be avoided, especially when conventional methods are similarly efficient and adequate.


  Periapical Radiographs Top


The long cone paralleling technique for exposing periapical radiographs is the technique of choice for the following reasons: Reduced skin dose; minimal magnification; a minimally distorted relationship between the bone height and adjacent teeth is demonstrated; and minimal superimposition of the zygomatic process of the maxilla over the upper molar region. It should be remembered that to get the most from the long cone paralleling technique, it should be performed using a long collimator with a film-focal distance of approximately 30 cm. [11]

In a study, 108 implant sites in 42 patients were observed to investigate peri-implant bone resorption around dental implants 1 year after prosthetic loading using panoramic radiographs, conventional periapical and digital radiographs and concluded that conventional periapical films and digital radiographs were more accurate than panoramic radiographs in the assessment of peri-implant bone loss. [12] The use of the digital subtraction radiography technique in clinical radiographic image acquisition and subsequent subtraction analysis clearly enhanced the accuracy of alveolar crestal bone loss detection when compared to conventional film viewing. Digital radiography is a reliable and versatile technology that expands the diagnostic and image-sharing possibilities of radiography in dentistry. [13]


  Occlusal Radiographs Top


Cross-sectional occlusal radiographs of the mandible give some information about the buccolingual dimension of the mandible, but this information is only accurate with regard to the inferior aspect of the body and not the width of the alveolar ridge where the implant is to be placed. The use of cross-sectional occlusal radiographs can be helpful when assessing the position of the implant within the jaw following placement both in the mandible and maxilla. The spatial relationship between the critical structures and proposed implant site is lost with this projection and the degree of mineralization of trabecular bone cannot determined from this projection. [13]


  Cephalometric Radiographs Top


Oblique lateral cephalometric radiographs have been shown to give reproducible height measurements in the mandible, but the information is still two dimensional and care must be taken to avoid positioning errors due to angulation of the beam.

The lateral cephalometric radiograph is useful because it demonstrates the geometry of the alveolus in the anterior region and the relationship of the lingual plate to the patient's skeletal anatomy. [2]


  Panoramic Radiography Top


In a study, it was confirmed that approximately 63.8% of the dentists prescribed only panoramic radiography for dental implant assessment and 28.9% ordered panoramic radiography plus periapical radiography and/or conventional tomography and/or computed tomography (CT). Only 7.2% of the dentists ordered conventional tomography or CT as a single examination, although 10.1% ordered it in combination with other imaging modalities. The main reasons given for prescribing panoramic radiography were broad coverage and cost 86.4%. [14],[15]

The panoramic radiographs are not particularly useful for implant planning because of the magnification factor, the overlapping of the image at the premolar region and the hard tissue and soft-tissue artifacts. The magnification factor can be calculated at the given site by dividing the actual diameter of the object by the diameter measured on the radiographic image. Diagnostic templates that have 5-mm ball bearings or wires incorporated around the curvature of the dental arch and worn by the patient during the panoramic X-ray examination enable the Dentist to determine the amounts of magnification in the radiograph [Figure 1]. A technique for evaluating the panoramic radiograph for mandibular posterior implants and comparison with the clinical evaluation during surgery was developed by identifying the mental foramen and the posterior extent of the inferior alveolar canal. [16],[17],[18],[19] Measurement is performed with a ruler from the crest of the alveolar ridge to the opposing landmark, such as the planned apical position for implant placement the superior cortex of the mandibular canal or inferior border of the maxillary sinus in the posterior regions [Figure 2].
Figure 1: Orthopantogram taken with metal ball placed in wax in the edentulous area

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Figure 2: Pre-operative longitudinal and cross-sectional transtomograms. The horizontal lines are drawn with the planmeca program to improve the assessment of critical anatomic structures. The distance from the top of alveolar crest to the lingual undercut is 10 mm. The distance from the top of the alveolar crest to the superior border of the mandibular canal is 13 mm

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The evaluation of the height of alveolar bone available for implantation can then be determined by the application of the following mathematical formula. [20]



Where by ADB = Actual diameter of metal ball which is known to be 5 mm.

RDB = Diameter of metal ball on radiograph orthopantogram (OPG) or periapical.

ABH = Actual bone height available for implantation vertical distance between alveolar crest and opposing landmark.

RBH = Bone height available for implantation as measured from the radiograph.

Thus:



In a study, conducted among 50 patients undergoing implant surgery at 77 edentulous areas it was observed that the pre-operative OPG and spiral CT images with the post-operative OPG and concluded that panoramic radiograph alone suffices the requirement to formulate an appropriate treatment planning without the necessity of other sophisticated imaging modalities in standard implant cases that is the premolar and molar areas. [16]


  Tomography Top


Tomographic units produce cross-sectional slices of the jaws that can be as thin as 1 mm and are suitable for pre- and post-implant assessment. The images are produced at a constant known magnification and therefore measurements may be taken directly from the images using a special ruler provided with the appropriate scale or in the case of digital images using a measurement program after calibration. [21] Tomography is technique sensitive with superimposition of the structures outside of the plane of focus causing significant blurring of the image, making them very difficult to read. Different patterns of movement, including linear, spiral or hypocycloidal have been attempted to reduce blurring artifacts and provide a sharper and more useful image. This technique is difficult to use in cases of multiple implant sites. Anatomic variations may result in images that are difficult to interpret.


  Transtomography or Sectional Tomography Top


In a study, conducted to illustrate the use of transtomography for the placement of implants using a radiopaque radiographic guide and to evaluate the accuracy of the technique, it was concluded that transtomographic examination performed with a radiographic reference guide during implant surgery can provide the necessary and accurate information for implant placement.

Modern tomograms can give good accuracy, but care has to be taken in interpretation of the images. [22] Blurring has been noted in the posterior maxilla, due to overlying bony structures and posterior mandible. [22],[23],[24] This technique enables the appreciation of spatial relationship between the critical structures and the implant site and quantification of the geometry of the implant site. The tomographic layers are thick and have adjacent structures that are blurred and superimposed on the image, limiting the usefulness of this technique for individual sites, especially in the anterior regions where the geometry of the alveolus changes rapidly. This technique is not useful for determining the differences in most bone densities or identifying disease at the implant site. [8],[25],[26]


  Ct Top


CT provides essential three-dimensional (3D) information on dental and craniofacial anatomy for the diagnosis and treatment planning of clinical procedures such as craniofacial reconstruction and the placement of dental implants. With current-generation CT scanners, reformatted images are characterized by a section thickness of 0.25 mm pixel size and an in-plane resolution of 1 pixel by the scan spacing 0.5-1.5 mm, producing a geometric resolution similar to that of planar imaging. The density of structures within the image is absolute and quantitative and can be used to differentiate tissues in the region and characterize bone quality. This X-ray modality allows sectional imaging of the jaws and either the whole mandible and maxilla or a restricted region of interest may be imaged. [27] The latest modalities of CT are multislice CT, dual source CT, 256 slice CT, inverse geometry CT, etc. CT imaging protocols that associate axial with multiplanar reconstructed images in multidetector CT (MDCT) demonstrated the highest accuracy, with 93% sensitivity and 100% specificity. [28]

DentaScan imaging provides programmed reformation, organization and display of the imaging study. [28],[29],[30] The radiologist or technologist simply indicates the curvature of the mandibular or maxillary arch and the computer is programmed to generate referenced cross-sectional and tangential/panoramic images of the alveolus along with 3D images of the arch. The cross-sectional and panoramic images are spaced 1 mm apart and enable accurate presurgical treatment planning [Figure 3]. Limitations of DentaScan imaging include images that may not be true to size and require compensation for magnification; determination of bone quality that requires the use of the imaging computer or workstation; hard-copy DentaScan images that only include a limited range of the diagnostic grayscale of the study; and the tilt of the patient's head during the examination, which is critical because all the cross-sectional images are perpendicular to the axial imaging plane. Usually, a diagnostic template is necessary to take full advantage of the technique. The diagnostic template enables the dentist to incorporate the 3D treatment plan of the final prosthetic result into the imaging examination. The template also allows the dentist to evaluate the patient's anatomy relative to the proposed implant sites, esthetics and occlusion; and to record and transfer these findings to the patient at the time of surgery. MDCT enables identification of disease, determination of bone quantity and bone quality, identification of critical structures at the proposed regions and determination of the position and orientation of the dental implants. [8]
Figure 3: Cross-sectional images of maxillary alveolar ridge taken using dentascan software to calculate the ridge height and desired angle of inclination at the planned implant site

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Although the use of MDCT as a diagnostic tool has been used in medicine for many years, its application in dentistry is limited, mainly because of the high cost of equipment, the large space required for its operation and the high dose of radiation involved. Cone beam CT (CBCT) was introduced as an alternative to MDCT and is considered appropriate for a wide range of craniofacial indications. CBCT is a relatively recent technology. Imaging is accomplished by using a rotating gantry to which an X-ray source and detector are fixed. A divergent pyramidal - or cone-shaped source of ionizing radiation is directed through the middle of the area of interest onto an area X-ray detector on the opposite side. The X-ray source and detector rotate around a rotation fulcrum fixed within the center of the region of interest. During the rotation, multiple (from 150 to more than 600) sequential planar projection images of the field of view (FOV) are acquired in a complete or partial arc. This procedure varies from a MDCT, which uses a fan-shaped X-ray beam in a helical progression to acquire individual image slices of the FOV and then stacks the slices to obtain a 3D representation. Each slice requires a separate scan and separate 2D reconstruction. Because CBCT exposure incorporates the entire FOV, only one rotational sequence of the gantry is necessary to acquire enough data for image reconstruction. [31]

Single-photon emission computed tomography (SPECT), is a nuclear medicine tomographic imaging technique that uses gamma rays. It is very similar to conventional nuclear medicine planar imaging in that it also uses a gamma camera. However, it is able to provide true 3D information. This information is typically presented as cross-sectional slices of the patient and can be also be freely reformatted or manipulated as required. Few authors demonstrated the ability of SPECT to assess normal edentate jaw bone before and after titanium dental implants. [32] The value and objectivity of this method was demonstrated by its ability to provide the accurate serial quantification of osteoblastic activity. [32]

The advantages of CT images are numerous, with the magnification being almost 0% with no superimposition or overlapping of images and minimal distortion. The density of bone may also be assessed using MDCT, with all densities being measurable as Hounsfield units. When comparing CT with other types of radiographic modalities, CT has been shown to be superior in identification of vital structures and calculation of distance measurements. [33]

In a study, it was found that in more than two-thirds of mandibular CT scans, good visualization of the mandibular canal, mental foramen and lingual foramen could be accomplished. This confirms the applicability of cross-sectional CT images for visualization of critical structures prior to surgery. [33],[34],[35] The CBCT technique presents an innovation of tomographic imaging systems and subsequent volumetric image reconstruction for dentistry [Figure 4]. When compared with other methods of tomographic imaging, CBCT is characterized by rapid volumetric image acquisition from a single low radiation dose scan of the patient. This technique is particularly useful for surgical and prosthetic implant planning in the field of dentistry. [33],[34]
Figure 4: Cone beam images NewTom 9000. (a) Three-dimensional (3D) soft-tissue. (b) Lateral cephalometric. (c) 3D osseous image. (d) Coronal. (e) Lateral osseous image. (f) Panoramic

Click here to view



  Interactive Computed Tomography (ICT) Top


One of the most significant advances in CT is interactive (ICT), which addresses many of the limitations of CT. [31],[35],[36] This technique was developed to bridge the gap in information transfer between the radiologist and the practitioner. This technique enables the radiologist to transfer the imaging study to the practitioner as a computer file and enables the practitioner to view and interact with the imaging study on a personal computer. The dentist's computer becomes a diagnostic radiologic workstation, with tools to measure the length and the width of the alveolus, measure bone quality and change the window and level of the grayscale of the study to enhance the perception of critical structures. [37]

An important feature of ICT [Figure 5] is that the dentist and radiologist can perform electronic surgery (ES) by selecting and placing arbitrary-sized cylinders that simulate root form implants in the images. With an appropriately designed diagnostic template, ES can be performed to develop the patient's treatment plan electronically in 3D. Superimnosed on the CBCT image, electronic implants can be virtually previewed at arbitrary positions and orientations with respect to each other, the alveolus, critical structures and the prospective occlusion and esthetics. ES and ICT enable the development of a 3D treatment plan that is integrated with the patient's anatomy and can be visualized before surgery. [34],[38],[39],[40]
Figure 5: Reformatted computed tomography scan showing the interactive placement of implants in relation to the diagnostic wax-up fabricated radiopaque template. Note that each position is crossreferenced according to the tick marks

Click here to view



  Magnetic Resonance Imaging (MRI) Top


MRI may be applicable in implant planning when soft-tissue imaging is indicated. Studies have shown that the geometric accuracy of the mandibular nerve with MRI is comparable with CT and is an accurate imaging method for dental implant treatment planning. MRI may be used in implant imaging as a secondary imaging technique when primary imaging techniques such as complex tomography, CT or ICT fall short to provide the details of the adequate bone height and width of the area for implant site assessment. Complex tomography fails to differentiate the inferior alveolar canal in 60% of implant cases and CT fails to differentiate the inferior alveolar canal in about 2% of implant cases. Failure to differentiate the inferior alveolar canal may be caused by osteoporotic trabecular bone and poorly corticated inferior alveolar canal. [41] MRI visualizes the fat in trabecular bone and differentiates the inferior alveolar canal and neurovascular bundle from the adjacent trabecular bone. Double-scout MRI protocols with volume and oriented cross-sectional imaging of the mandible produce orthogonal quantitative contiguous images of the proposed implant sites. Oriented MRI of the posterior mandible is dimensionally quantitative and enables spatial differentiation between critical structures and the proposed implant site. However, there exist numerous disadvantages for the use of MRI for implant dentistry. MRI is not useful in characterizing bone mineralization or as a high-yield technique for identifying bone or dental disease. [2]


  Conclusion Top


Although many modalities are available for imaging the implant site, the correct and required technique should be adopted depending on the case and the clinician's judgment to interpret the image acquired. The choice of pre-implant imaging must be considered carefully due to the radiation dose, the cost of each examination and the anticipated information that may be provided by the imaging study. The risk-to-benefit ratio should be determined on an individual basis so as to maximize success.

 
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Abstract
Introduction
Periapical Radio...
Occlusal Radiographs
Cephalometric Ra...
Panoramic Radiog...
Tomography
Transtomography ...
Ct
Interactive Comp...
Magnetic Resonan...
Conclusion
References
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