c
  

  

      
 as the use of

prosthetic implants to restore orofacial form and function. Implant

technology has enabled the practitioner to help affected patients regain the

ability to chew normally and function without embarrassment. With long-

term success rates approaching 95% and higher, implant systems are rapidly

entering the mainstream of dental practice. These implants typically function

as part of a system combining metal fixtures integrated with bone, abutments

fastened to fixtures, and a variety of dental appliances attached to the

abutments. Because successful implantation depends on close integration of

the fixture and the supporting bone, radiographic imaging is an important

element of implant therapy. The burgeoning acceptance of these devices has

been attributed in part to the increasingly sophisticated imaging techniques

used in all phases of implant treatment, including preoperative treatment

planning, intraoperative assessment (integration), and postoperative

assessment (function).

Dentists must be knowledgeable about contemporary implant imaging

techniques and familiar with the radiographic appearance of various fixtures

(Figs. 30-2 and 30-3). Implants encountered on routine dental radiographs

may range from fracture fixation devices to alloplastic materials used for

augmentation. However, most of these devices are dental implants used to

restore lost masticatory function by replacing missing teeth. Although

subperiosteal and transosteal implant systems are still used occasionally,

nearly all dental implants used today are root-form devices placed within

bone (endosteal implants). Therefore this chapter focuses on the radiographic

aspects of endosteal dental implants.

Radiographic Assessment of Dental Implants

Although useful and cost-effective, the conventional methods of

implant imaging generally are considered inadequate for comprehensive

implant evaluation. Newer techniques that permit cross-sectional

visualization and interactive image analysis may be considered the standard

of care, especially for complex reconstructions. The choice of radiographic

techniques often is a function of the various phases of the surgical and

restorative procedures (Table 30-1). In every instance the imaging strategy

most appropriate for a particular phase of the implant therapy should always
be a collective decision of the implant team-the restorative dentist, surgeon,

and radiologist.

Preoperative Planning

Radiographic visualization of potential implant sites is an important

extension of clinical examination and assessment. Radiographs help the

clinician visualize the alveolar ridges and adjacent structures in all three

dimensions and guide the choice of site, number, size, and axial orientation of

the implants. Site selection includes consideration of adjacent anatomic

structures such as the incisive and mental foramina, inferior alveolar canal,

existing teeth, nasal fossae, and maxillary sinuses. Pathologic conditions,

such as retained root fragments, impacted teeth, and osteomyelitis that could

compromise the outcome must be identified and located relative to the site of

the proposed implant. The variety of radiographic techniques available to

assist the clinician includes intraoral radiography (film and digital),

cephalometric radiography, panoramic radiography, conventional

tomography, computed tomography (CT), and stereoscopic (paired) x-ray

imaging.
 In evaluating a potential implant site, particular attention should be

given both to the quality and quantity of bone required for placement of the

fixture. The bone must have the necessary dimensions and quality to provide

support for the implant fixture. Cortical bone typically is best suited to

withstand the functional loading forces of dental implants. The thicker the

cortical bone, the greater the likelihood of osseous integration and subsequent

success. Bone quantity is assessed by documenting the height and width of

available alveolar bone, as well as the morphology of the ridge. The chances

of successful implantation increase as more bone is available for anchorage.

A cross-sectional image to document the facial-lingual width and height of

the ridge, along with, the inclination of the bone contours, is especially useful

in the preoperative planning phase. Ridge width measurements aid in

maximal engagement of cortical bone, and ridge height measurements aid in

the selection of the longest appropriate fixture to maximize anchorage and

distribution of masticatory forces. Frequently, morphologic features such as

osseous undercuts and ridge concavities that is not immediately apparent on

clinical examination become evident with cross-sectional imaging. This

information may dictate the choice of implant and its axis of orientation.
 Accurate bone measurements are essential for determining the optimal

size and length of the proposed implants. The clinician should be aware that

the magnification factor of radiographic images may vary with the imaging

technique used. Except for reformatted CT, all radiographic images are

magnified because the object is never in the same plane as the film. The

clinician must consider this magnification factor when calculating the

dimensions of the bone at the implant site. To obtain the actual dimensions of

the available bone, the measurements obtained from the radiographs (usually

in millimeters) are divided by the magnification factor (usually 1.0 to 1.8) for

the particular imaging technique being used. The magnification factor of

some techniques may be variable (periapical, panoramic) or fixed

(conventional tomography). Reformatted CT images can be corrected to life

size. If the magnification factor is constant, clear plastic overlays with 1 mm

grids or diagrams of available implant sizes can be produced with the same

magnification factor as the image.

Imaging Techniques
 The ideal imaging technique for dental implant radiography should

have several essential characteristics, including the ability to visualize the

implant site in the mesial-distal, facial-lingual, and superior-inferior

dimensions; the ability to allow reliable, accurate measurements; a capacity

to evaluate the density of trabecular bone and cortical thickness; a capacity to

correlate the imaged site with the clinical site; reasonable access and cost to

the patient; and minimal radiation risk. Usually a combination of radiographs

is used. The following is a review of the imaging techniques applicable to

dental implant case management.

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Intraoral images may be acquired on film or as direct digital images.

Periapical and occlusal radiographic films provide images with superior

resolution and sharpness. Maxillary and mandibular periapical radiographs

commonly are used to evaluate the status of adjoining teeth and remaining

alveolar bone in the mesial-distal dimension. They also have been used for

determining vertical height, architecture, and bone quality (bone density,

amount of cortical bone, and amount of trabecular bone). Although readily

available and relatively inexpensive, periapical radiography has geometric

and anatomic limitations. Periapical radiographs, made on a dentate arch,

typically are made with the paralleling technique, creating an image with

minimal foreshortening and elongation. Because an edentulous alveolar ridge

may not have the same "long axis" as a tooth, positioning the film in a

consistent and repeatable fashion is difficult, and the image may be

foreshortened or elongated. Also, it frequently is difficult to place the film

either superior or inferior enough to evaluate the entire maxillary or

mandibular ridge all the way to the inferior cortical margin. One study

reported that 25% of mandibular periapical radiographs did not demonstrate

the mandibular canal. In cases when the canal was identifiable, only 53% of

measurements from the alveolar crest to the superior wall of the mandibular

canal were accurate within 1 mm.

Because periapical radiographs are unable to provide any cross-

sectional information, occlusal radiographs sometimes are used to determine

the facial-lingual dimensions of the mandibular alveolar ridge. Although

somewhat useful, the occlusal image records only the widest portion of the

mandible, which typically is located inferior to the alveolar ridge. This may
give the clinician the impression that more bone is available in the cross-

sectional (facial lingual) dimension than actually exists. The occlusal

technique is not useful in imaging the maxillary arch because of anatomic

limitations.


 
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Lateral cephalometric radiography provides an image of known

magnification (usually 7% to 12%) that documents axial tooth inclinations

and the dentoalveolar ridge relationships in the midline of the jaws. The soft

tissue profile also is apparent on this film and can be used to evaluate profile

alterations after prosthodontic rehabilitation. Although this projection

provides a cross-sectional evaluation of the ridges, this dimension is seen

only at the midline. The images of structures not in the midline are

superimposed on the contralateral side, complicating the evaluation of other

implant sites. Occasionally, lateral-oblique cephalometric radiography is used

with one side of the body of the mandible positioned parallel to the film

cassette. Image magnification on these views is not predictable, because the

body of the mandible is not the same distance from the cassette as is the

rotation center of the cephalostat. Thus measurements made from these films

are not reliable. In general, cephalometric radiographs are of limited use in

the selection of implant sites.

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Although the resolution and sharpness of panoramic radiographs are

less than those of intraoral films, panoramic projections provide a broader

visualization of the jaws and adjoining anatomic structures. Panoramic

radiography units are widely available, making this imaging technique very

popular as a screening and assessment instrument. Panoramic radiographs are

useful in making preliminary estimations of crestal alveolar bone and cortical

boundaries of the mandibular canal, maxillary sinus, and nasal fossa (Fig. 30-

8). Information acquired from panoramic radiographs must be applied

judiciously because this technique has significant limitations as a definitive

presurgical planning tool. Angular measurements on panoramic radiographs

tend to be accurate, but linear measurements are not. Image size distortion

(magnification) varies significantly between films from different panoramic

units and even within different areas of the same film. Vertical measurements

are unreliable because of foreshortening and elongation of the anatomic

structures, since the x-ray beam is perpendicular neither to the long axis of

the anatomic structures nor to the film plane. The negative vertical angulation

of the x-ray beam also may cause lingually positioned objects such as

mandibular tori to be projected superiorly on the film, which may result in an

overestimation of vertical bone height. Furthermore, the anatomic vertical

axis varies within the film image, particularly in nonmidline areas. Panoramic

radiographs provide a two-dimensional image with no cross-sectional

information.

Similarly, dimensional accuracy in the horizontal plane of panoramic

radiographs is highly dependent on the position of the structures of interest

relative to the central plane of the image layer. The horizontal dimension of

images of structures located facial or lingual to the central plane but still

within the image layer tends to be minimized or magnified. The degree of

horizontal size distortion is difficult to ascertain on panoramic radiographs

because the shape of the image layer is configured to a population average.

However, the anatomic morphology of few individuals conforms totally to

that image layer. In summary, horizontal image magnification with

panoramic radiographs varies from 0.70 to 2.2 times actual size, although

some manufacturers still claim a 1.25 average magnification (at the central

plane of the image layer). Errors in patient positioning can compound further

the measurement limitation in the horizontal dimension. Compared with

contact radiographs of dissected anatomic specimens, only 17% of panoramic

measurements between the alveolar crest and superior wall of the mandibular

canal were found to be accurate within 1 mm.

 
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Conventional tomography provides reliable dimensional measurements

at proposed implant sites, including the cross-sectional (facial-lingual)

dimension. It also is reasonably widely available. Used as an adjunct to

screening films, cross-sectional tomograms enhance visualization of the

available bone. This technique produces a cross-sectional, flat-plane image

layer that is perpendicular to the x-ray beam. Images of anatomic structures

of interest are relatively sharp, and images of structures outside the image

layer are blurred beyond recognition by the motion of the x-ray tube and film.
The thickness, orientation, and anatomic location of the image layer can be

predetermined and manipulated. It is imperative that the image layer be a true

cross-section of the dental arch, rather than oblique. Scout films (usually a

submentovertex or panoramic projection) or wax bite registrations commonly

are used to determine the appropriate cross-sectional angulation. The

complex (multidirectional) tube motion of current conventional tomography

units minimizes image superimposition and provides fixed, uniform image

magnification, allowing for accurate measurements. Complex tube motion

also permits use of a thicker image layer while retaining diagnostic quality. A

thicker image layer is desirable to maximize image contrast, making the

identification of structures such as the mandibular canal more predictable.

The dimensional accuracy of cross-sectional tomograms is particularly

useful in measuring the distance between the alveolar crest and adjacent

structures, such as the floor of the nasal fossa, maxillary sinus floor,

mandibular canal, mental canal, and inferior mandibular cortex. The

appropriate axis of insertion of the implant may also be predicted.

Measurements are directly acquired from the films and subsequently

corrected by the magnification factor used. As an alternative, acetate overlays

with appropriately magnified 1 mm grids may be used.

The clinical utility of conventional tomograms can be enhanced by the

use of an imaging stent. The stent facilitates correlation of the tomograms to

the scout film and provides a practical method of relating the radiographic

information to the surgical site. The intended implant sites are identified by

radiopaque spheres or rods (metal, composite resin, or gutta-percha) retained

within an acrylic stent. The imaging stent subsequently may be used as a

surgical guide. For optimal visualization, the width of the markers should be

less than the thickness of the tomographic image layer.

Diagnostic dentures coated with barium paste also may be used during

imaging. The site markers are visualized in a mesial-distal direction on the

scout films and in the facial-lingual dimension on the cross-sectional

conventional tomograms. Typically, two to three cross-sectional tomographic

slices are required to image each intended implant site adequately.

Conventional tomography is especially convenient in the planning of single

site implants or those within a quadrant.

COMPUTED TOMOGRAPHY

Patients who are edentulous or who are being considered for multiple

implants and augmentation procedures may be best imaged with CT. CT

studies are planned on a lateral scout image of the selected jaw with

alignment corrections made as needed. Direct axial images are then acquired

as thin, overlapping axial scans with approximately 30 axial sections per jaw.

These images usually are acquired perpendicular to the occlusal plane. The

sequential axial images subsequently are manipulated to produce multiple

two-dimensional images in various planes, using a computer-based process

called multiplanar reformatting (MPR). In general, three basic images are

reformatted: axial images with a superimposed curve, cross-sectional images,

and panoramic-like curved linear images. An axial scan including the full

contour of the mandible (or maxilla) at a level corresponding to the dental

roots is selected as a reference for the reformatting process. The computer

places a series of sequential dots on the selected scan and connects them to

develop a customized arch or curve unique for each jaw. The computer

program then generates a series of lines perpendicular to the curve. These

lines are made at constant intervals (usually 1 to 2 mm) and numbered

sequentially on the axial image to indicate the position at which each cross-

sectional slice will be reconstructed. Cross-sectional reconstructions are made

perpendicular to the curve, and panoramic (curved linear) reconstructions are

made parallel with the curve. Three-dimensional representations may also be

constructed in various orientations.

These reformatted images provide the clinician with two-dimensional

diagnostic information in all three dimensions. Typical studies provide

information on the continuity of the cortical bone plates, residual bone in the

mandible and maxilla, the relative location of adjoining vital structures, and

the contour of soft tissues covering the osseous structures. Studies have

reported that 94% of CT measurements between the alveolar crest and wall of

the mandibular canal were accurate within 1 mm. Three-dimensional

reformations are particularly useful in the planning of augmentation

procedures such as a sinus lift. Unlike conventional tomograms, reformatted

CT images provide the radiographic density values of cortical plates and

trabecular bone, which may be useful in managing the case. Reformatted CT

images also may be used with interactive software to simulate implant

orientation and placement on a computer screen before surgery.

Reformatted CT studies provide diagnostic information on all available

implant sites with a dental arch. The reformatted images typically are

presented life-size on photographic prints or radiographic film. The

panoramic (curved linear) images are helpful in identifying mesial-distal

relationships and noncorticated mandibular canals. However, the quality of

the reformatted CT study depends on the ability of the patient to remain still

during image acquisition, because movement may result in subsequent

geometric image distortion. Metallic restorations can cause streak image

artifacts. However, the streaking is only within the axial plane and does not

affect axial slices superior or inferior to it. As with conventional tomography,

it is desirable to localize anticipated implant sites with imaging stents

incorporating nonmetallic radiopaque markers (gutta-percha, composite

resin). Barium-coated diagnostic dentures may also be used to establish the

spatial relationships between the anticipated prosthesis and fixtures.

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Intraoral and panoramic radiographs usually are adequate for both

intraoperative and postoperative assessments. If threaded root-form fixtures

have been placed, the optimal radiographic image must separate the threads

for best visualization. This may not always be a predictable procedure

because the exact angulation of the implant is not known. The angulation of

the x-ray beam must be within 9 degrees of the long axis of the fixture to

open the threads on the image on most threaded fixtures. Angular deviations

of 13 degrees or more result in complete overlap of the threads. In general,

periapical radiographs are appropriate for longitudinal assessments. Mesial

and distal marginal bone height is measured using known interthread

measurements and comparing that with the bone level in previous periapical

radiographs. The presence of relatively constant and distinct bone margins

suggests successful osseous integration. Resorptive changes, if present, are

evidenced by apical migration of the alveolar bone or indistinct osseous

margins. These adverse changes are progressive and should be differentiated

from the initial circumscribed resorptive osseous changes around the cervical

area of the fixture induced by the surgical procedure itself. Studies suggest

that the rate of marginal bone loss after successful implantation is

approximately 1.2 mm in the first year, subsequently tapering off to about 0.1

mm in succeeding years. Occasionally areas of marginal bone gain also may

be noted.

A clinically stable fixture is invariably associated with the radiographic

appearance of normal osseous tissue in intimate contact with the implant

surface. The development of a thin radiolucent area that closely follows the

outline of the implant usually correlates to clinically detectable implant

mobility and is an important indicator of failed osseointegration. Changes in

the periodontal ligament space of associated teeth (natural abutment) also are

useful in monitoring the functional competence of the prosthesis implant

system. Any widening of the periodontal ligament space compared with

preoperative radiographs indicates

poor stress distribution and forecasts implant failure. After successful

implantation, radiographs may be made at regular intervals to assess the

success or failure of the implant fixture. Advanced imaging studies may be

necessary for adequate assessment in some cases.

 Subtle areas of bone resorption adjacent to the fixture may be made

evident with intraoral digital images by evaluating a density profile graph of

radiographic density values, a feature available on most digital imaging units.

If intraoral digital images are acquired at the time of surgery, they may be

compared with subsequent digital images either by subjective visualization or

digital subtraction. Digital subtraction is a computerized process that may

reveal areas of bone resorption not apparent visually. Occasionally,

stereoscopic plain films or scanograms, which provide the appearance of

three dimensions, may be helpful in assessing multiple implant fixtures

within a segment of the alveolar ridge. However, measurements may not be

reliable on stereoscopic projections.

In summary, imaging is an integral part of dental implant therapy, and a

variety of imaging techniques are used for implant assessment. Cross-

sectional imaging is increasingly considered integral to optimal implant

placement, especially in the case of complex reconstructions. An initial

assessment of the feasibility of implant placement may appropriately be made

with panoramic radiography. If required, an intraoral radiograph can provide

the higher resolution required to evaluate suspected areas of pathosis. Should

the initial assessment be favorable and a decision made to proceed with the

placement of implants, a cross-sectional image is indicated. Conventional

tomography is appropriate for single-implant sites, whereas reformatted CT is

preferred for multiple sites or for an edentulous ridge in which all possible

implant sites are to be considered. Assessment of implanted fixtures typically

is performed with periapical and panoramic radiography. However, specific

cases may require more advanced imaging studies, depending on the nature

of the clinical concern.