IMPLANT IMAGING TECHNIQUE

08/08/18 1
IMPLANT IMAGING
Presented by:
Dr Ripunjay kr Tripathi
Post Graduate Student
Dept of Periodontology
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The ultimate goal of dental implant therapy:
to satisfy patient’s desire to replace
one/more missing teeth in an esthetic,
secure, functional & long lasting manner.
To achieve this goal proper case selection is
of utmost importance.

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Treatment considerations for implant
patients should include an evaluation of:
1. Oral health status;
2. Medical and psychological status;
3. Patient motivation/ability to provide home
care;
4. Patient expectations of therapy outcome;
5. The various habits and conditions which
may place the patient at higher risk for
implant failure;
6. Periodontal and restorative status of the
remaining dentition.

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• When implant is not placed in proper
position-
• Restorative problems
• Esthetic problems
• Soft tissue problems Etc …

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Case selection:
1. Thorough case history
2. Evaluation of medical status
3. Examination of implant site & vicinity:
Clinical,
Radiological (imaging techniques)

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Imaging modalities:
• Standard projections:
1. Periapical radiography,
2. Panaromic radiography,
3. Occlusal radiography,
4. Cephalometric radiography,
• Three dimensional imaging :
1. Tomography- a. conventional (motion)
b. computed (CT)
c. digital volume (DVT)/CBCT
2. Magnetic resonance imaging
3. Interactive computed tomography

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Analog imaging modalities:
1. Periapical radiography,
2. Panaromic radiography,
3. Occlusal radiography,
4. Cephalometric radiography,

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When considering the use of ionizing radiation, the
following conditions should be met:
• The image projection should be in a plane
that allows accurate measurements of
anatomical features to be made;
• All relevant features such as vital
structures, anatomical boundaries and
bone structure, should be clearly visible;
• If possible, sectional information of the
implant site should be available;

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• Artifacts should be minimal and not affect
the accuracy or clarity of the area of
investigation;
• Radiation dosage should be kept to a
minimum, and
• The quality of the films should justify the
exposure.
• Maximizing the ratio of the benefit/risk
for imaging examinations is the
fundamental tenet of radiology.

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According to International Commission on
Radiation protection, ICRP 60(1991) all
radiographic examination should be
justified & optimized.
Until the mid- 198Os, plain film
radiography was used for preoperative
assessment of potential implant sites in
the edentulous jaw bone. Later, more
advanced imaging techniques were
introduced (eg, computed tomography
[CT])

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Diagnostic imaging & techniques:
Pre-prosthetic implant imaging:
all past & new radiographs taken to
assist in determining comprehensive
treatment plan.
Objectives-
1.To determine surgical & prosthetic
information to determine quantity,
quality & angulation of bone,
2.Relationship of critical structure to the
implant,
3.Presence/absence of disease at implant
site

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Surgical & interventional implant imaging:
Assists in surgical & prosthetic intervention
of the patient.
Objectives:
• To evaluate surgical site
during/immediately after surgery
• To assist in the optimal positioning &
orientation of implants,
• To evaluate healing & integration part of
implant surgery,
• To ensure abutment position & prosthesis
fabrication are correct

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• Film periapical radiographs,
• Digital periapical radiographs,
• Panoromic
A B

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Post-prosthetic implant imaging:
Commences just after prosthesis
placement & continues as long as the
implants remain in the jaws.
Objectives:
• To evaluate long term maintenance of
implant rigid fixation and function,
including the crestal bone levels around
each implant,
• To evaluate the implant complex.

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PERIAPICAL RADIOGRAPHS:
• Are images of a limited region of the
mandibular or maxillary alveolus.
• Most often used for single tooth implants
with abundant bone width.
• Useful high-yield modality for ruling out
local bone or dental disease.
• of value in determining critical structures

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• Easy to obtain, inexpensive, deliver low
radiation to the pt.
• Offer highest details & spatial resolution.
• Due to ease of acquisition, can be taken
intra-operatively.

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• unpredictable magnification & distortion
(long cone parelleling technique will limit
this to less than 10%).
• of limited value in determining bone
quantity due to distortion.
• Of limited value in determining the bone
density or mineralization( the lateral
cortical plats prevent accurate
interpretation & cannot differentiate
subtle trabecular bony changes).
• Burn out effects are common.

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• The x-ray beam should be angled to be
perpendicular to the crestal bone region
of the implant or the abutment to implant
connection.
• The image is optimal when the implant
body threads are clearly seen in both the
sides.
• When the right side of the implant threads
is clear , the central ray is too low.
• Opposite occurs when the cone head is too
high.
• When the implant threads are clear on
only one side, the cone correction is app.
10 degrees.

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• Planar radiographs produced by placing
the film intra-orally parallel to occlusal
plane with central x-ray perpendicular to
the film for mandibular image & oblique
(45º) to the film for maxillary image.
• Maxillary occlusal radiographs-
inherently oblique & so distorted –no
quantitative use in implant dentistry
OCCLUSAL RADIOGRAPH:

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• mandibular occlusal radiographs- taken
in orthogonal projection-less distortion,
but due to anterior flaring of the arch and
lingual inclination, some distortion
occurs.
• Bone quality, degree of mineralization,
spatial relations to adjacent structures
cannot be determined
• Hence rarely indicated.

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CEPHALOMETRIC RADIOGRAPHS:
• Oriented planar radiographs of the skull.
• Lat. Ceph.-cross sectional images of both
jaws in mid-sagittal plane can be
demonstrarted
• With slight rotation of the cephlometer
cross- sectional image in the region of
lateral incisor or canine can be obtained

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• The cross-sectional view of the alveolus
demonstrates the spatial relationship
between occlusion & esthetics with the
length, width, angulation, and geometry of
the alveolus
• More accurate in bone quantity
determination unlike the periapical or
panoromic.
• Relationship of the lingual plate to
patient's skeletal anatomy can be
obtained.

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• The bone width in symphysis region &
buccal cortex & roots of anterior teeth can
be determined- for bone harvesting.
• Help to evaluate loss of vertical
dimension, skeletal arch
interrelationship, anterior crown: implant
ratio, anterior tooth position in the
prosthesis, and resultant moment of
forces.
• Not useful in determining bone quality

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BITE WING RADIOGRAPH:
• Superior 1/3 of the implant region is the
area of interest.
• For post-prosthetic implant imaging.

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TEMPORAL DIGITAL SUBTRACTION
RADIOGRAPHY (SR):
• Enables two radiographs made at different
time of same anatomical region to be
subtracted, resulting in an image of the
difference between the two radiographs.
• Depicts changes in patient’s anatomy.
• Requires the same orientation between
the x-ray source, pt., & film during each
radiograph- use of registration templates.

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Two methods have been developed for the
computerized alignment of the follow-up
images:
• The reference point alignment method,
• The real-time subtraction alignment
method,

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• Standardization- Digitization- Registration-
Subtraction.
• Accurate for changes in bone volume,
mineralization in all mesial, Distal, buccal,
lingual.
• Modality of choice to depict temporal
changes of alveolar Bone.
• But limited in use- difficulty in obtaining
reproducible periapical radiographs.

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PANAROMIC RADIOGRAPH:
• The most widely used diagnostic modality
in implant dentistry; though not most
diagnostic
• A curved plane tomographic radiographic
technique
• Structures seen- body of the mandible,
maxilla, lower half of maxillary sinuses
• Opposing landmarks are easily identified,

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• Initial assessment of vertical height of
bone can be obtained
• Goss anatomy of jaws & related pathologic
findings can be evaluated

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• Easy, convenient, speedy
• Broad picture, less radiation
• Magnification- vertical:~10%
horizontal:~ 20%
Overall: 25% of actual size
• Posterior maxillary region: least distorted
• Maxillary anterior region: most difficult
area to evaluate because its curvature,
inclination of the bone.

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• Modification of the panoramic machine to
make cross-sectional jaw images.
• Employs limited angel linear tomography
(zonography) & a means for pt.
positioning.
• Enables the appreciation of spatial
relation between the critical structure &
implant site & quantification of the
geometry of the implant site.

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category Radiographic
appearance
incidence
continuous Foramen in
continuity with canal
21%
separated Foramen distinctly
separated from canal
43%
diffuse Foramen has
indistinct border
24%
unidentified Foramen
unidentified
12%
Yosue & Brooks (1989)

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• To improve visualization of mandibular
canal –the patient’s head should be tilted
5º downwards with reference to FH
reference bar of OPG machine -Dharmar
(1997)

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• During taking an OPG a 5mm ball bearing
inserted in wax can be used to calculate
the radiographic error.
if the ball bearing is 5mm on radiograph,
then bone height can be measured directly
on the film, otherwise- rs/5=rm/rx
rs- size of radiographic sphere
rm-radiographic measurement of
bone
rx-corrected bone measurement

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DIGITAL RADIOGRAPHY:
• Fast
• Calibration
• Low radiation
• Magnification
• Excellent quality
• Keeps aseptic setting
• Pt. stays in surgical setting
• Measures depth, density, & neighboring
structures.

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TOMOGRAPHY:
• tomo= slice, graph= picture
• Principle:- x-ray tube & film are connected
by a fulcrum bar, which pivots on a point
‘fulcrum’. When the system is energized,
the x-ray tube & film plane move in
direction opposite of each other & the
system pivoting around fulcrum. The
fulcrum remains stationary & defines the
tomographic layer. Different tomographic
sections are produced by adjusting the
position of fulcrum or the pt. relative to
fulcrum in fixed geometric systems.
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tomography
LINEAR-simplest form
X-ray tube & film move
in straight line.
One dimensional
HIGH QUALIY-
Complex, two dimensional
motion
Circular, spiral, hypocycloidal

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Diagnostic quality depends on-
Section thickness,
Degree of magnification,
Tomographic motion- hypocycloidal :most
effective blurring motion.

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• Tomographic techniques used for peri-
implant assessment- a. Conventional
(motion)
b. Computed (CT)
c. Digital volume
(DVT)/CBCT

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CONVENTIONAL TOMOGRAPHY:
• Scanora, Cranex Tome
• It is done with small unit that can also be
used with other radiographic
examinations
• Similar working principle as that of
panromic radiography

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COMPUTED TOMOGRAPHY (CT):
• Invented by Sir Hounsfield in 1972.but
had its origin in mathematics(1917) &
astrophysics(1956)
• It is a digital & mathematical imaging
technique that creates tomographic
sections where the tomographic layer is
not contaminated by blurred structures
from adjacent anatomy.
• Enables differentiation & quantification of
both soft & hard tissues.

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• Produces axial images i.e. perpendicular
to the long axis of the body.
• CT images are inherently 3-dimensional
digital images typically 512 by 512 pixels
• The individual element of the CT image is
called voxel (hounsfield unit), describes
the density of the CT image at that point.
• Each voxel contais 12 bits of data ranging
from -1000 to +3000 hounsfield unit.
• CT scanners are standerdized at a
Hounsfield value of 0.
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Also known as…….
“computerized axial tomography”,
“computerized tomographic scanning”,
“axial tomography”, and
“computerized transaxial tomography”.

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• Resolution,
• Spatial discrimination, and
• Three-dimensional imaging capability
• The images can be adjusted and printed
without magnification- direct
measurements
• The digital format - image enhancement
tools, rapid communication between the
radiologist and the surgeon, and
generation of multiple copies of the
images.

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• The precision of CT enables use of a
complex and precise diagnostic template-
vacuform reproduction
processed acrylic reproduction
radio-opaque teeth
• The diagnostic template then can be
modified into a surgical template

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Basic components:
• Gantry- detector array, the x-ray source
or tube, and the patient support couch.
• Computer- high speed.
• Operating console
• Presently, CT scan imaging is
performed with multislice CT imaging
(MSCT), where several slices of the jaw
bone are acquired at each turn of a
spiral movement of radiation sources
and detectors

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Detector array
contains numerous discrete detectors or
cells. These convert the incident X-rays of
varying intensity to electric signals. These
analog signals are amplified by
downstream electronic components and
converted to digital pulses.
X-Ray Source
currently available CT scanners consists
of an x-ray generator and an x-ray tube.
The x-ray generator is designed to
produce a high-milliampere (400mA)
beam at a nearly continuous rate.
power rating of 20–60 kW, voltages of 80-
140 kV.

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Patient Support Couch
The patient support couch provides a way
to stabilize the position of a patient during
a CT scan.

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Control Console
allows the operator to dictate the
parameters of the CT scan,
to view the images as they are being
generated,
and to determine the output format.

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• Typical dental views obtained from a CT scan
include-
AXIAL PANORAMIC
SAGITTAL 3-D RECONSTRUCTION
59

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Orientation of axial tomographic slice

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Quality Bone
(Lekholm &
Zarb)
Density range
(HU) (Norton &
Gamble 2001)
Region of
interest
Quality 1 >+850 Ant. mandible
2/3 +500 to +850 Post. Mandible/
ant. maxilla
4 0 to +500 Post. maxilla
4*
failure zone < 0 Tuberosity

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• High radiation dose.
Doses have been reduced by 15 to 50% & 40
to 60% by lowering the mAs, whereas
reducing the number of slices enables a
similar level of dose or mortality risk
reduction(60%) without compromising the
diagnostic image quality
• Height of the examined volume to be kept
as small as possible.

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• Metallic restorations can cause ring
artifacts –impair diagnostic quality.
• Higher cost.

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• Conventional pre-surgical planning of
implant placement is typically facilitated
by secondary reformatting using
dedicated software.
• Specific software applications have been
developed which can directly import
Digital Imaging and Communication in
Medicine (DICOM) data into a diagnostic
& interactive treatment planning tool.
• Current software applications allow the
user to locate an implant receptor site and
simulate the placement of the implant in
various views reconstructed from the CT
scan data.
65

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• Utilize data from CT/CBCT scans & allow
the simulation of implant placement &
restoration on the computer.
• The length, width, angulation, & position
of implants can be simulated in the
desired positions.
• In cases of augmentation, the additional
bone volume needed can be evaluated &
quantified.
• the distribution of mechanical forces onto
the implant & adjacent bone can be
predicted.

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• Examples of software programs are:
1.Artma Virtual ImplantTM
(VISIT)
2. coDiagnostiX
3. Easy Guide
4. Implant LogicsTM
5. ImplantMasterTM
6. Med 3D
7. NaviGuide System
8. Procera Software
9. Simplant, SurgiCase

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Dentascan
• computerized reformatting program
• developed to obtain true cross-sections of
the mandible and maxilla from the easily
obtained CT scans for patients being
considered for dental implant surgery in
either the mandibular or maxillary
arches.

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• CT with the dentascan program eliminates
the need to make strategic decisions after
surgery has been initiated.
• It enables the dental surgeon to visualize
the bony structures pre-operatively; the
surgeon does not have to make decisions
at the time of surgery when the
mucoperiosteal flap is already elevated to
visualize the bony structures directly.
• Dentascan CT provides the surgeons an
operation with information of the internal
structures that cannot even be gained by
direct intra-operative visualization.

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SimPlant
• SimPlant is a precise preoperative
planning software to accurately plan the
placement of dental implants.
• The software allows treatment planning
for the ideal position of the implants in
both 2D and 3D, while taking into account
clinical and aesthetical considerations.

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The SimPlant software exists on 3 different
levels:
• SimPlant Planner software,
the standard full licensed implant planning
software, dependent on a conversion
service to create a SimPlant planning
environment.
• SimPlant Pro software,
a package with all the necessary software to
import CT data independently from a
service provider and to process and edit
these data.

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• SimPlant Master software,
processing software that facilitates servicing
to SimPlant users. With SimPlant Master,
scan data can be imported, edited and
converted into a SimPlant study.

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Simplant overview showing the
lower jaw from the front, top, and
in cross-section slices.
A 3-D view is also shown
With Simplant, the height and width
of the bone can be measured, and
anatomical structures visualized.
Here the mandibular nerve is
identified and highlighted in red,
and implant simulations are inserted
to preview implant placement.

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Close up of side view of the lower jaw,
with the mandibular nerve highlighted in red.
Implant length and width simulation
can determine final size needed.
The cross-section view allows
for determination of the implant
width and length, and placement
angle. Here, the proposed
abutment is also shown.
The density of the bone can be seen,
to evaluate if implants are feasible.

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DVT/CBCT
• Generates a cone-shaped x-ray beam,
which images a larger area. Images are
generated in 1-degree increments. Thus, at
the end of a single complete rotation, 360
images of the area are generated.
• The computer uses these images to
generate a digital, three-dimensional map
of the face. Once this map is generated,
multiplanar reconstructions as well as
axial, coronal, sagittal, or oblique sections
of various thicknesses can be
reconstructed from the data.

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• CT scan offers a greater contrast
resolution
• reduced amount of radiation dose.
(approximately equal to a full-mouth x-ray
series); 50 to 100 times less than a typical
CT scan.
• Comparable cost.
• Ideal method to evaluate how the bone
substitute is positioned & its relation to
adjacent bone

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INTERACTIVE CT (ICT)
• Most accurate implant imaging technique
• Developed to bridge the gap in the
information transfer between the radiologist
& the clinician.
• Enables the radiologist to transfer the
imaging study to the clinician as a computer
file.
• Electronic surgery (EC) can be performed-
placing arbitrary size cylinders that simulate
root form implant in the image.

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• ES+ ICT= 3-D treatment plan.
• Refinement & exact relative orientation of
the implant position is difficult.
• Parallelism is difficult to appreciate.

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TUNED APERTURE COMUTED
TOMOGRAPHY (TACT):
• Method based on optical aperture theory.
• Uses information collected by passing a
radiograph beam through an object from
several different angles.
• Projection geometry can be calculated
after individual exposure- problems of pt.
movement are less significant.

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• Low radiation dose.
• Adjustable contrast & resolution.
• Examination of limited field:-using intra-
oral digital sensors.

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MAGNETIC RESONANCE IMAGING (MRI):
• Does not use ionising radiation.
• Instead, the patient is placed in a strong
magnetic field and subjected to short
pulses of radio-waves.
• MRI is based on the phenomenon of
nuclear magnetic resonance (NMR) which
was first described independently by two
groups of workers in the USA.

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• MRI uses signals from hydrogen nuclei
(protons) in water and fat to form cross-
sectional images of the body.
A 1.5tesla conventional mid-field magnetic resonance imaging scanner.

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A 0.2tesla ‘open’ magnetic resonance imaging scanner

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Contraindications:
• Do not scan in the first trimester of
pregnancy;
• Do not scan a patient who has a cardiac
pacemaker;
• Do not scan a patient who has shrapnel
wounds, especially around the orbit;
• Do not scan a patient with retained
ferromagnetic surgical clips in situ

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MR images are often described as being either
T1- or T2-weighted. T1 and T2 refer to the
longitudinal and transverse proton relaxation
times, respectively
T1-weighted images: normal anatomy, peri-
implant
site
T2-weighted images: infection, haemorrhage
and tumours.

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• The external cortical plate appears black-
very low signal owing to the absence of
water or lipid protons.
• Organic cancellous bone appears very
bright-signal from protons in the fatty
bone marrow.
• Neurovascular channels such as the
inferior dental canal and the naso-
palatine foramen are identified as discrete
dark structures within the bright
cancellous bone.

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• Clear delineation of the external interface
between cortical bone & mucosa/
mucoperiosteum-Using this margin as the
exterior limit of bone, measure the
available height, width and angulation to
avoid vital structures and maximise
implant size.
• maxilla more difficult to assess,
better in young patients.

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A: cortical bone. B: cancellous bone. C: mandibular
nerve and vessels. D: mental nerve and vessels.

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• Direct imaging with MRI allows flexible
plane of acquisition, with no need to
reformat.
• Multiple site acquisitions may be made, as
long as the intersection of the slices is not
at a region of interest.
• On compatible machines, CT software has
been used for reformatting MRI, but this
may invoke similar errors to those
postulated for reformatted CT.

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• Artifacts –
• Patient motion: short acquisition time
(TA) of the sequence, signal averaging
may be used to minimize artifact.
• Inhomogeneities in the magnetic field
caused by magnetic susceptibility effects.
• Due to metals- lead to areas of signal
blackout.
• Machine .

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SINUS LIFT ASSESSMENT:
• An understanding of the 3-D shape of the
sinus is desirable before surgery in terms of
both anatomical form and volume.
• Conventional radiographs give very limited
pre-surgical information.
• sectional imaging: estimate the volume of
graft necessary to successfully gain the
appropriate bone height for implant
placement.

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• For dimensional assessment of the graft,
T1-weighted sequences are appropriate &
the delineation of the sinus and oral
mucosa (i.e. the boundaries of the
available bone) may be enhanced by the
use of intravenous Magnevist.
• As non- ionising radiation is used, MRI
used to give sequential images showing
the healing and maturation processes of
bone grafting.

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MAXILLARY EVALUATION:
• The whole of the bone height in the upper
jaw can be used during implant
placement.
• Anchoring the implant in the cortical bone
of the maxillary sinus or the nasal fossae.
• Panoramic radiography-extension of the
maxillary sinus and its relation to
adjacent structures.
• This technique show the floor of the sinus
as a sharp line, its localization is not
reliable because of the oblique beam
projection.

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• Frontal region- the appearance of a sharp
projection of the nasal floor may be
affected by positioning errors.
• Conventional tomography has proved its
ability to localize the maxillary sinus floor
as well as displaced bodies in the sinus.

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• Whilst ionising radiation dose may be
significantly reduced with careful use of CT
and other X-ray tomograms,
• the total absence of radiation is a
significant advantage of MRI.
• This, coupled with the flexibility of plane of
acquisition, good soft tissue detail, and the
low level of imaging artefacts, mean that
MRI should be considered as a first choice
for preimplant imaging assessment.

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MANDIBULAR EXAMINATION:
1. Mandibular Canal-
• High risks of nerve damage associated
with injuries to the inferior alveolar
nerve running into it.
• Even placing implants in close vicinity to
the mandibular canal- compression of
the nerve- permanent altered sensation.
• Presence of a cortical lining forming the
wall of the mandibular canal may be a
factor for its visualization on
radiograph- but not always….

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• CT permits an accurate demonstration of
the mandibular canal, not only in relation
to the alveolar crest but also in a
buccolingual direction.
• superior to intraoral or panoramic
radiography to measure the available
mandibular bone height.
• Conventional tomography= CT
• Spiral tomography > hypocycloid
tomography because the borders of the
canal are better identified with the former
technique.

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2. Incisive Canal
The ability to interpret the canal from
intraoral and panoramic radiographs
seems limited. Therefore, use of
conventional tomography or CT for
better imaging of the interforaminal
area.

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COMMON FACTORS:
1. Soft tissue
2. Visibility
3. Safety margin
4. Over/ underestimation
5. Observer agreement
6. Layer thickness
7. Technical errors

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CONCLUSION:
• Endosseous dental implant therapy- efficient
& predicatble. BUT can NOT be performed in
all patients.
• The clinician must evaluate each candidate &
site comprehensively.
• The evaluation includes:
Exclusion of pathology,
Identification of anatomic structure,
Evaluation of available bone.
• Failure to evaluate accurately: complications,
including inability to place an implant.

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References:
• Contemporary implant dentistry, Carl Misch.
Second edition
• Clinical periodontology & implant dentistry,
Lang & Lindhe. Fifth edition
• Clinical periodontology, Carranza. Tenth
edition.
• Advanced imaging: Magnetic resonance
imaging in implant dentistry A review; Gray et
al. Clin. Oral Impl. Res, 14, 2003; 18–27

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• Imaging Technique Selection for the Preoperative
Planning of Oral Implants: A Review of the
Literature; BouSerhal et al. Clinical Implant
Dentistry and Related Research, Volume
4,2002: 156.

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