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Received: 24 November 2019    Revised: 4 February 2020    Accepted: 4 March 2020

DOI: 10.1111/clr.13596

ORIGINAL RESEARCH

Cone beam computed tomography artefacts around dental

implants with different materials influencing the detection of
peri-implant bone defects

Martina Schriber1,2 | Andy Wai Kan Yeung2  | Valerie G.A. Suter1 | Daniel Buser1 |

Yiu Yan Leung3 | Michael M. Bornstein2,4

1
Department of Oral Surgery and
Stomatology, School of Dental Medicine,
University of Bern, Bern, Switzerland
2
Applied Oral Sciences and Community
Dental Care, Faculty of Dentistry, The
University of Hong Kong, Hong Kong, China
3
Oral and Maxillofacial Surgery, Faculty of
Dentistry, The University of Hong Kong,
Hong Kong, China
4
Department of Oral Health & Medicine,
University Center for Dental Medicine Basel
UZB, University of Basel, Basel, Switzerland
Correspondence
Michael M. Bornstein, Department of Oral
Health & Medicine, University Center
of Dental Medicine Basel UZB, Basel,
Switzerland.
Email: michael.bornstein@unibas.ch
Abstract
Objectives: To investigate the diagnostic accuracy of cone beam computed tomogra-
phy (CBCT) for the diagnosis of peri-implant bone defects of titanium (Ti), zirconium
dioxide (ZrO2) or titanium–zirconium (Ti–Zr) alloy implants.
Materials and Methods: Ti, Ti–Zr or ZrO2 implants with two diameters (3.3  mm,
4.1 mm) and one length (10 mm) were inserted in the angle of the mandible of six
fresh defrosted pig jaws. Out of the 12 implants inserted, 6 served in the test group
with standardized buccal peri-implant bone defects, whereas 6 served as control
without bone defects. CBCTs were performed with three acquisition protocols
(standard, high and low dose) using two devices. Four observers analysed CBCTs as
follows: (a) presence of a peri-implant defect; (b) presence of peri-implant artefacts
and impact on defect diagnosis; and (c) linear measurements of buccal peri-implant
defect including height and width (in mm).
Results: CBCT device, CBCT settings, implant material, implant diameter and ob-
server background did not significantly influence diagnostic accuracy. The sensitivity
and specificity values were high for defect detection. ZrO2 led to a lower than aver-
age diagnostic accuracy (0.781). The linear measurements of peri-implant defect were
underestimated by <1 mm on average. The subjective impact of artefacts on defect
diagnosis was significantly affected by implant material and observer background.
Conclusions: CBCT showed high diagnostic accuracy for peri-implant bone defect
detection regardless of the device, imaging setting or implant material used. If CBCT
is indicated to assess peri-implant bone disease, low dose protocols could be a prom-
ising imaging modality.

KEYWORDS

clinical assessment, CT imaging, diagnosis, imaging, radiology

© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Clin Oral Impl Res. 2020;31:595–606.  |

wileyonlinelibrary.com/journal/clr     595
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1 |  I NTRO D U C TI O N
Cone beam computed tomography (CBCT) has become an im-
portant radiographic tool for diagnosis and treatment planning
in the field of oral surgery and especially for oral implantology
over the last two decades (Bornstein, Scarfe, Vaughn & Jacobs,
2014;  Bornstein, Horner, & Jacobs, 2017; Carter, Stone, Clark,
& Mercer, 2016). Efficient preoperative diagnostics and surgical
treatment planning are necessary to perform successful dental
implant insertion and prosthodontic restoration. Additionally,
CBCT is also considered as an ideal diagnostic tool after implant
placement when neurovascular complications are suspected
(Jacobs, Salmon, Codari, Hassan, & Bornstein, 2018). In case of
peri-implant disease with marginal bone loss, a radiographic as-
sessment of marginal bone is required (Pelekos, Acharya, Tonetti,
& Bornstein, 2018). As current guidelines recommend, the first
choice of diagnostic imaging is intraoral radiographs (IR) (Lang &
Berglundh, 2011; Lindhe & Meyle, 2008; Sanz & Chapple, 2012).
Nevertheless, conventional two-dimensional (2D) intraoral radio-
graphs cannot depict buccal and lingual/palatal bone (Rees, Biggs,
& Collings, 1971). Therefore, CBCT is an option when visualization
of peri-implant bone in all three dimensions is required and may
enable an assessment of the peri-implant bone defect morphology
(Bender, Salvi, Buser, Sculean, & Bornstein, 2017). Nevertheless,
there is still insufficient evidence to recommend CBCT as a stan-
dard diagnostic imaging modality for evaluation of peri-implant
bone loss (Pelekos et al., 2018).
The CBCT device, the field of view (FOV), voxel sizes and
image reconstruction parameters do all influence the diagnostic
image quality of CBCT scans (Miracle & Mukherji, 2009). In addi-
tion, image quality can be negatively influenced by patient related
factors such as motion artefacts (Yeung, de Azevedo, Scarfe, &
Bornstein, 2020). Furthermore, high-density materials like metals
can cause various artefacts including beam hardening, extinction
and exponential edge gradient effects (Kuusisto, Vallittu, Lassila, &
Huumonen, 2015). Metal artefacts around dental implants present
as streaking, beam hardening or scatter (Benic, Sancho-Puchades,
Jung, Deyhle, & Hämmerle, 2013), which may impact linear mea-
surements on CBCT images (Schulze et al., 2011) and decrease the
diagnostic image quality significantly (Jacobs et al., 2018). Pauwels
and co-workers documented that metal artefacts can produce
bright radiating streaks affecting image quality and lead to dark
areas near these objects or even to a complete loss of visual infor-
mation between neighbouring dense objects (Pauwels et al., 2013,
Pauwels, Araki, Siewerdsen, & Thongvigitmanee, 2015). Especially
patients with non-removable rehabilitations using metal or zirconia
materials exhibit a major impact on the visibility of teeth in CBCT,
which can also negatively influence the accuracy of guided implant
surgery planning (Flügge et al., 2017; Jacobs et al., 2018; Tahmaseb,
Wismeijer, Coucke, & Derksen, 2014).
The aim of this in vitro study was to investigate the influence
of titanium (Ti), zirconium dioxide (ZrO2) or titanium–zirconium (Ti–
Zr) alloy dental implants on the diagnostic accuracy of peri-implant
bone defects using CBCT imaging. Secondary outcomes included
an evaluation of the impact of artefacts on linear measurements
(defect height and width), subjective image quality and an analysis
of potential influencing factors including CBCT device and setting
(standard, low dose and high resolution), implant dimensions and
observer background. The hypothesis of the present study is that
different dental implant materials and CBCT image settings do not
significantly influence the diagnostic accuracy of peri-implant bone
defect detection.
2 | M ATE R I A L S A N D M E TH O DS
2.1 | Study design
The present in vitro study was performed using three dental im-
plant material types: titanium (Ti; RN Soft Tissue Level Standard
Implant, Straumann Holding AG), titanium–zirconium alloy (Ti–Zr;
RN Soft Tissue Level Standard Implant, Roxolid, Straumann Holding
AG, Basel, Switzerland) and zirconium dioxide (ZrO2; Pure Ceramic
Implant, Straumann Holding AG). These three different dental im-
plant types were divided into three groups with two different den-
tal implant diameters (3.3  mm and 4.1  mm) and one single length
(10 mm).
Mucoperiosteal flaps were performed at the angle of the mandi-
ble of six native fresh defrosted pig jaws to accommodate one dental
implant on each side using standard implant placement protocols ac-
cording to the manufacturer (Straumann Holding AG). After random
side allocation by the flip of a coin, standardized buccal bone defects
were created on the implant site on one side (test group; Figures 1
and 2), and the implant site on the other mandibular angle was left
intact as a control (control group). The buccal peri-implant bone de-
fect was created as a dehiscence-type defect measuring 3  mm in
width (mesial to distal bone distance), 5 mm in height (crestal bone
to the bottom of the defect) and 1–2 mm in depth (vestibular implant
surface to outer oral bone edge) with two parallel walls and one flat
horizontal bottom as the most apical point (Figure 1). A water-cooled
drilling device and round diamond burs were used for defect cre-
ation. The bony walls were smoothened to produce plain surfaces.
After insertion of the dental implant, a healing abutment (RN Healing
Caps, Ø 5.5 mm, height 3 mm, Ti, Straumann Holding AG) was placed
on the Ti and Ti–Zr alloy implants. This did not apply for the ZrO2
implants as they were one-piece implants. The soft tissues around
the dental implants were adapted to the shoulder of each implant
using interrupted sutures.
2.2 | Radiographic imaging (CBCT) settings
CBCT images were performed from all six native fresh frozen
pig mandibles using two devices: (a) 3D Veraview X800 (Morita
Corp.) and (b) Planmeca ProMax 3D Mid (Planmeca). For each of
these two devices, three machine-specific acquisition protocols
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(a) (b) (c) (d)

F I G U R E 1   Schematic drawings (a, c: coronal planes, b, d: axial planes) of a dental implant with healing abutment placed in a native fresh
frozen pig mandible with a buccal peri-implant, dehiscence-type bone defect measuring 3 mm in width (mesial to distal bone distance), 5 mm
in height (crestal bone to the caudal bottom of the defect) and 1–2 mm in depth (vestibular implant surface to outer oral bone edge)

F I G U R E 2   Clinical view (a: sagittal (a) (b)

plane, b: axial plane) of an zirconium
dioxide implant (ZrO2; Pure Ceramic
Implant, Straumann Holding AG) with a
buccal peri-implant, dehiscence-type bone
defect measuring 3 mm in width (mesial
to distal bone distance), 5 mm in height
(crestal bone to the caudal bottom of the
defect) and 1–2 mm in depth (vestibular
implant surface to outer oral bone edge)

(standard, high resolution and low dose) and imaging parameters
were applied:
1. 3D Veraview X800 (Morita Corp.): FOV: 4  ×  4  cm, voxel size:
125  μm.
a. Standard: 100 kV, 5 mA, 360-degree scan (17.9 s);
b. High dose: 100 kV, 7 mA, 360-degree scan (17.9 s);
c. Low dose: 100 kV, 3 mA, 180-degree scan (9.4 s).
2. Planmeca ProMax 3D Mid: FOV: 4 × 5 cm, voxel size: 150 μm.
a. Standard: 90 kV, 5 mA, 200-degree scan (15.1 s);
b. High dose: 90 kV, 7.1 mA, 200-degree scan (15.1 s);
c. Low dose: 90 kV, 3.2 mA, 200-degree scan (15.1 s).
2.3 | Data analysis
The data were analysed using slices at an interval of 0.5  mm with
a basic voxel size of 125 and 150  μm. All 12 dental implants were
analysed in axial, sagittal and coronal planes using the corresponding
software (i-Dixel, Morita Corp.; Romexis, Planmeca). The 12 CBCT
images were all assessed on a Barco MDCC-6130 LCD diagnostic
display with 6  megapixel and a resolution of 3,280  ×  2,048  pixels
(Barco NV).
The presence/ absence of peri-implant bone dehiscences and ar-
tefacts was analysed using a digital magnifying tool if needed, and
for the linear measurements, a software-based scaling device was
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598       SCHRIBER et al.
used. A visual analogue scale (VAS 0–100) was applied as a measure-
ment instrument for subjective artefact assessment. The maximal
extent of the dehiscence was measured in a craniocaudal (height)
and mesiodistal (width) dimensions (Figures 1 and 2). All CBCT im-
ages (total of 72) were analysed by two observers with a dentomax-
illofacial radiology (DMFR) and two with an oral and maxillofacial
surgery (OMFS) background (Master or PhD students). Prior to data
collection, the observers were calibrated individually by the senior
author (MB).
The following analyses of the defects were done for all im-
plants on the CBCT images by all four observers: (a) presence of a
peri-implant defect: yes/ no; (b) presence of peri-implant artefacts
and impact on defect diagnosis: yes (VAS: 0–100)/ no; (c) linear
measurements of peri-implant defect on the buccal aspect includ-
ing maximal height (in mm) in the coronal and maximal width (in
mm) in the axial plane (Figures 1 and 2). The primary outcomes of
the present study were the sensitivity, specificity and diagnostic
accuracy to detect peri-implant bone defects using CBCT scans.
Secondary outcomes included the impact of artefacts on linear
measurements (defect height and width in mm), subjective image
quality (VAS 0–100) and an assessment of potential influencing
factors including CBCT device and setting (standard, low dose and
high resolution), implant diameter (3.3  mm and 4.1  mm) and ob-
server background.
2.4 | Statistical analysis
Descriptive statistics were initially computed for all data. To as-
sess the inter-observer reproducibility, Fleiss's Kappa values were
calculated for the detection of peri-implant defects, whereas in-
tra-class correlation (ICC) values were calculated for the impact
of artefacts on diagnostics, and the measured height and width of
the peri-implant defect. The sensitivity, specificity and diagnostic
accuracy for the detection of peri-implant defect were assessed
in consideration of CBCT device, CBCT settings, implant material,
implant diameter and observer background. The potential influ-
ence of CBCT device, CBCT settings, implant material, implant
diameter and observer background on the impact of artefacts on
measurements, and the measured height and width of peri-implant
defect were evaluated with one-way ANOVA or t test. The poten-
tial influence of CBCT device, CBCT settings, implant material,
implant diameter and observer background on the diagnostic ac-
curacy of detection of peri-implant defect were evaluated with
Friedman's test, Mann–Whitney U test or Wilcoxon signed-ranks
test. Furthermore, multiple ANOVA was performed including the
significant factors from the univariate analysis. Receiver operating
characteristic (ROC) curves were plotted, and area under the curve
(AUC) graphs with the corresponding asymptotic 95% confidence
interval were calculated.
The significance level chosen for all statistical tests was p < .05.
All analyses were performed in SPSS (Version 25.0, IBM Corp.).
3 | R E S U LT S
3.1 | Inter-observer reproducibility
The inter-observer reproducibility values were high for the de-
tection of a peri-implant defect (0.639–1.000), indicating a good
consistency in detecting the presence or absence of a defect
(Table 1). Meanwhile, the reproducibility values were lower for the
assessment of the impact of artefacts on diagnosis (0.005–0.364),
implying that the observers felt quite differently affected by the
artefacts. The reproducibility values for the height of peri-im-
plant defect were generally larger than the values for the width,
signifying that the observers measured the height with a higher
consistency.
3.2 | Sensitivity, specificity and diagnostic accuracy
The sensitivity values to detect a peri-implant defect were high,
with a minimum of 0.855, for all implant types (Table 2). The speci-
ficity values were also high, but with a minimum of 0.696 in cases
with ZrO2 implants. It also led to a lower than average diagnostic
accuracy for cases with ZrO2 implants (0.781), meaning that the
absence of a peri-implant defect was occasionally not identified as
absent by the observers in this group of implants. Respective ROC
curves for the detection of peri-implant defects (yes/no) are pre-
sented in Figure 3.
3.3 | Impact of artefacts on the assessment of peri-
implant defects and linear measurements
The impact of artefacts on subjective image quality for defect diag-
nosis in both CBCT devices was not evaluated as severe (mean VAS
values for X800: 32.3; ProMax 3D: 29.4; Table 3). The linear meas-
urements of the height and width of peri-implant defects were un-
derestimated by <1 mm on average. Similarly, CBCT settings seemed
to minimally affect the impact of artefacts and linear measurements.
In terms of implant material, however, ZrO2 had more severe impact
with regard to the generated artefacts on defect diagnosis (mean
VAS of 37.4) than Ti (29.5) and Ti–Zr (25.6). ZrO2 also resulted in a
larger underestimation of the width of peri-implant defects (mean
error of −1.28 mm) than Ti (−0.32) and Ti–Zr (−0.50). On the other
hand, the height of peri-implant artefacts was generally underesti-
mated for cases with an implant diameter of 4.1 mm (mean error of
−0.11 mm), but overestimated for cases with an implant diameter of
3.3 mm (0.04 mm). Interestingly, observers with a dentomaxillofacial
radiology (DMFR) background rated a more severe impact of arte-
facts on defect diagnosis (mean VAS of 43.5) than observers from
oral and maxillofacial surgery (18.1) background. Besides, the latter
had a larger underestimation of width of peri-implant defect (mean
error of −0.87 mm) than the former (−0.35).
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TA B L E 1   Inter-observer reliability of the detection of peri-implant defect, impact of artefacts on defect diagnosis and linear
measurements of peri-implant defects

Reliability value

Detection of peri-implant Impact of artefacts on Height of peri-implant Width of peri-

  defect* diagnostics** defect** implant defect**

CBCT device
X800 0.881 0.292 0.703 −0.008
ProMax 3D Mid 0.759 0.173 0.534 0.152
CBCT settings
High dose 0.846 0.209 0.667 0.139
Standard 0.776 0.260 0.575 0.156
Low dose 0.846 0.215 0.665 0.044
Implant material
Titanium (Ti) 0.759 0.201 0.605 0.031
Titanium–zirconium (Ti–Zr) 1.000 0.005 0.630 0.041
Zirconium dioxide (TiO2) 0.639 0.364 −0.176 −0.016
Implant diameter
3.3 mm 0.832 0.230 0.170 0.089
4.1 mm 0.813 0.222 0.759 0.126
Observer background
Radiology 0.832 0.121 0.652 0.602
Oral and maxillofacial 0.719 0.340 0.584 −0.021
surgery

*Fleiss's Kappa.
**Intra-class correlation.

TA B L E 2   Sensitivity, specificity, diagnostic accuracy and area under the ROC curve data for the detection of peri-implant defects
(yes/no)

Area under the (ROC) curve

  Sensitivity Specificity Diagnostic accuracy (asymptotic 95% confidence interval)

CBCT device
X800 1.000 0.800 0.875 0.875 (0.812, 0.938)
ProMax 3D Mid 0.895 0.941 0.917 0.917 (0.864, 0.969)
CBCT setting
High dose 0.953 0.868 0.906 0.906 (0.839, 0.974)
Standard 0.909 0.846 0.917 0.875 (0.798, 0.952)
Low dose 0.953 0.868 0.906 0.906 (0.839, 0.974)
Implant material
Titanium 0.855 0.976 0.906 0.906 (0.839, 0.974)
Titanium–zirconium 1.000 1.000 1.000 1.000 (1.000, 1.000)
Zirconium dioxide 1.000 0.696 0.781 0.781 (0.685, 0.877)
Implant diameter
3.3 mm 0.985 0.910 0.944 0.944 (0.901, 0.988)
4.1 mm 0.891 0.813 0.847 0.847 (0.779, 0.915)
Observer background
Radiology 0.955 0.885 0.917 0.917 (0.864, 0.969)
Oral and maxillofacial 0.922 0.838 0.875 0.875 (0.812, 0.938)
surgery
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600       SCHRIBER et al.

F I G U R E 3   Receiver operating characteristic (ROC) curves for the detection of peri-implant defect (yes/no) grouped according to (a)
CBCT device; (b) CBCT settings; (c) implant material; (d) implant diameter; and (e) observer background
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TA B L E 3   Analysis of potential influencing factors on the impact of artefacts on linear measurements and assessment of peri-implant
defects

Impact of artefacts on diagnostics Height of peri-implant defect (mm, Width of peri-implant defect
  (mean VAS ± SD, 0–100) mean ± SD)* (mm, mean ± SD)**

CBCT device
X800 32.3 ± 23.9 −0.00 ± 0.42 −0.40 ± 0.78
ProMax 3D Mid 29.4 ± 25.0 −0.05 ± 0.35 −0.76 ± 0.67
T test p = .312 p = .554 p = .007
Multiple ANOVA NA NA p = .059
CBCT settings
High dose 32.9 ± 26.1 −0.03 ± 0.38 −0.62 ± 0.78
Standard 27.5 ± 23.1 −0.01 ± 0.37 −0.61 ± 0.74
Low dose 32.1 ± 24.0 −0.04 ± 0.42 −0.58 ± 0.73
One-way ANOVA p = .257 p = .934 p = .963
Implant material
Titanium 29.5 ± 24.5 0.10 ± 0.33 −0.32 ± 0.73
Titanium–zirconium 25.6 ± 21.8 −0.17 ± 0.44 −0.50 ± 0.57
Zirconium dioxide 37.4 ± 25.6 0.00 ± 0.28 −1.28 ± 0.62
One-way ANOVA p = .003 p = .002 p < .001
Multiple ANOVA p < .001 p = .002 p < .001
Implant diameter
3.3 mm 29.1 ± 23.1 0.04 ± 0.28 −0.58 ± 0.69
4.1 mm 32.6 ± 25.7 −0.11 ± 0.47 −0.63 ± 0.81
T test p = .220 p = .040 p = .696
Multiple ANOVA NA p = .027 NA
Observer background
Radiology 43.5 ± 22.3 −0.04 ± 0.35 −0.35 ± 0.61
Oral and maxillofacial surgery 18.1 ± 19.4 −0.01 ± 0.42 −0.87 ± 0.78
T test p < .001 p = .610 p < .001
Multiple ANOVA p < .001 NA p < .001

Note: Multiple ANOVA including the significant factors (p < .05) from the univariate analysis.
Abbreviation: NA, Not applicable.
*Mean difference to control (height of defect = 5 mm) ± standard deviation.
**Mean difference to control (width of defect = 3 mm) ± standard deviation.
p value < .05 in bold.

3.4 | Potential influencing factors on the
diagnostic accuracy, impact of artefacts and linear
measurements
Results indicated that CBCT device, CBCT settings, implant material,
implant diameter and observer background did not significantly af-
fect the diagnostic accuracy of the detection of peri-implant defects
(Table 4; Figures 4 and 5). However, it was found that the impact of
artefacts on defect diagnosis was significantly affected by implant
material and observer background (Table  3). In particular, ZrO2 was
assessed as having a significantly more severe impact due to artefacts
than Ti and Ti–Zr (Figures 4 and 5). Overall, observers with a DMFR
background rated the impact of artefacts more severely as compared
to observers from an oral and maxillofacial surgery background.
In terms of height of the peri-implant defects, implant material
was also a significant influencing factor as Ti exhibited a significant
increase in the measured height compared to Ti–Zr. Furthermore, an
implant diameter of 3.3 mm had a significant increase of the values
measured in comparison with the defect height measurements of
4.1 mm diameter implants.
With regard to width of the peri-implant defects, the X800
CBCT device resulted in significantly more accurate measurements
than the ProMax 3D Mid device. This difference was not statisti-
cally significant any more after adjustment using multiple ANOVA.
Meanwhile, ZrO2 implant had a significantly larger underestimation
of the width of peri-implant defects as compared to Ti and Ti–Zr
implants. Observers from oral and maxillofacial surgery background
also had a significantly larger underestimation of the width.
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TA B L E 4   Analysis of potential influencing factors on the diagnostic accuracy of the detection of peri-implant defect (yes/ no)

Influencing factor   Statistical test p Value

CBCT device (1) X800 Wilcoxon signed-ranks test .194

(2) ProMax 3D Mid
CBCT settings (1) High dose Friedman's test .135
(2) Standard
(3) Low dose
Implant material (1) Titanium (Ti) Friedman's test .317
(2) Titanium–zirconium (Ti–Zr)
(3) Zirconium dioxide (ZiO2)
Implant diameter (1) 3.3 mm Wilcoxon signed-ranks test .059
(2) 4.1 mm
Observer background (1) Radiology Mann–Whitney U test .667
(2) Oral and maxillofacial surgery

(a) (d)

(b) (e)

F I G U R E 4   Representative CBCT
images of dental implants (3D Veraview
X800; Morita Corp.). Control sites
(c) (f) exposed with a standard dose and the
three implant materials used: (a) titanium,
Ti (RN Soft Tissue Level Standard
Implant, Straumann Holding AG, Basel,
Switzerland); (b) titanium–zirconium
alloy, Ti–Zr (RN Soft Tissue Level
Standard Implant, Roxolid, Straumann
Holding AG, Basel, Switzerland); and (c)
zirconium dioxide, ZrO2 (Pure Ceramic
Implant, Straumann Holding AG, Basel,
Switzerland). Defect sites with Ti implants
captured with three CBCT settings: (d)
high dose; (e) standard; and (f) low dose
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F I G U R E 5   Representative CBCT
images of dental implants (Planmeca
(a) (d)
ProMax 3D Mid; Planmeca). Control
sites captured with a standard dose and
the three implant materials: (a) titanium,
Ti (RN Soft Tissue Level Standard
Implant, Straumann Holding AG, Basel,
Switzerland); (b) titanium–zirconium
alloy, Ti–Zr (RN Soft Tissue Level
Standard Implant, Roxolid, Straumann
Holding AG, Basel, Switzerland); and (c)
zirconium dioxide, ZrO2 (Pure Ceramic
Implant, Straumann Holding AG, Basel,
Switzerland). Images of defect sites with
Ti implants after exposure with three
CBCT settings: (d) high dose; (e) standard;
(b) (e)
and (f) low dose

(c) (f)

4 | D I S CU S S I O N high values for sensitivity (minimum of 0.855), specificity (minimum

CBCT has become a widely accepted radiographic tool for diagnosis
and treatment planning in oral implantology and is also used to as-
sess peri-implant disease (Carter et al., 2016) and the stability of aug-
mented bone in long-term studies (Chappuis et al., 2018). This is of
relevance, as intraoral radiographs (IR) cannot depict buccal and oral
bone loss due to the inherent limitations of 2D imaging (Rees et al.,
1971). CBCT allows visualizing peri-implant bone morphology with-
out overlap (Schwindling et al., 2019). As a relevant limitation, highly
X-ray absorbing objects like metallic objects deteriorate image qual-
ity and impair assessment of peri-implant bone conditions due to
metal artefacts such as streaking, beam hardening or scatter (Benic
et al., 2013; Sancho-Puchades, Hämmerle, & Benic, 2015; Schulze
et al., 2011). The present in vitro findings demonstrate that peri-im-
plant defects were often correctly detected, which is underlined by
of 0.696) and overall diagnostic accuracy 0.781. Nevertheless, zir-
conium dioxide implants with no peri-implant bone defect showed a
higher false-positive rate (0.304) than implants with the other two
materials tested. Overall, CBCT device, imaging setting, implant
material, implant diameter and observer background did not sig-
nificantly affect the diagnostic accuracy for the detection of peri-
implant defects.
Several studies analysing CBCT scans of Ti implants demon-
strated that beam hardening artefacts resulted in a less accurate vi-
sual spatial resolution and were complicating the detection of bone
in direct vicinity to the implant surface (Fienitz et al., 2012; Schulze
et al., 2011). In an in vitro study (Schulze, Berndt, & d'Hoedt, 2010),
CBCT artefacts were evaluated for two different CBCT devices
using a plaster phantom containing two Ti implants. Here, a reduc-
tion of approximately 50% for GV in interproximal implant regions
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604       SCHRIBER et al.
was found. The authors stated that CBCT is unreliable for the evalu-
ation of interproximal regions of dental implants.
There are only few reports comparing ZrO2 to Ti implants re-
garding the impact of the material on image quality and diagnostic
accuracy using CBCT scans. In an in vitro study on mandibles of
type IV dental stone, Sancho-Puchades et al. (2015) assessed the
intensity of artefacts around Ti, Ti–Zr and ZrO2 implants by CBCT.
The results showed that ZrO2 implants produced significantly
more artefacts as compared to Ti and Ti–Zr implants. Similarly, the
ZrO2 induced artefacts might explain the higher false-positive rate
(0.304) of identified buccal defects for ZrO2 implants at control
sites compared to the other two implant materials tested in the
present study. A relevant difference between the two studies was
that Sancho-Puchades et al. (2015) used a computer software to
identify grey values and artefacts, and in the present study, it was
performed by human observers with different backgrounds (VAS
0–100).
Hilgenfeld and co-workers (Hilgenfeld et al., 2018) evaluated in
an in vitro study the diagnostic value of CBCT, IR, and dental mag-
netic resonance imaging (dMRI) for detection and classification of
standardized one- to four-wall peri-implant bone defects around
zirconia dental implants inserted in bovine ribs. High sensitivity and
specificity values for bone defect detection, and a high intra- and
inter-rater reliability score were observed for all three imaging mo-
dalities. The sensitivity for correct defect classification was signifi-
cantly lower for IR than for CBCT or dMRI (Hilgenfeld et al., 2018).
In another in vitro study by Schwindling et al. (2019), the diagnos-
tic accuracy of low dose CBCT (LD-CBCT) for the detection, clas-
sification and measurement of peri-implant bone lesions around Ti
implants with all-ceramic single crowns placed in bovine bone was
evaluated. The results showed that LD-CBCT provides additional
information regarding the geometry of defects compared with IR,
and HD-CBCT only insignificantly increased the diagnostic accu-
racy (Schwindling et al., 2019). This is in line with the results of the
present study demonstrating that low and high dose protocols did
not significantly affect the diagnostic accuracy for the detection of
peri-implant defects.
The impact of artefacts on subjective image quality assessment
was not severe for both CBCT devices (mean VAS values for X800:
32.3; ProMax 3D: 29.4) in the present study. Interestingly, observers
with a DMFR background reported a more severe impact of arte-
facts on subjective image quality (mean VAS of 43.5) than OMFS
observers (18.1). It is known from the literature that repeated mea-
surements ("learning bias") might influence outcomes (Hilgenfeld
et al., 2018) and also that data from inexperienced observers tend
to be less accurate (Schwindling et al., 2019). These results underline
the importance of experience and expertise of observers in analys-
ing peri-implant bone in CBCTs.
On average, linear measurements for height and width of peri-im-
plant defects were underestimated by <1 mm in the present study.
Comparing histological and linear measurements in CBCTs around
Ti implants, several studies reported underestimation (Corpas Ldos
et al., 2011; Ritter et al., 2014), but also overestimation (Fienitz et al.,
2012; Steiger-Ronay et al., 2018). Generally, overestimation was re-
ported more frequently (Pelekos et al., 2018). In an animal study by
Corpas Ldos et al. evaluating 80 Ti implants placed in 10 minipigs,
results showed significant correlations between bone defect depth
in CBCT and histology (r = +0.61, p < .01). The mean underestimation
for bone defect depth was 1.2 mm in the CBCT images, showing a
similar result as in the present study (Corpas Ldos et al., 2011). In
another animal study by Ritter et al., 26 Ti implants were placed in
canine mandibles simulating chronic type vestibular defects. Here,
the measurements in CBCTs correlated well with histomorphometry
of the vestibular bone levels, which were generally slightly under-
estimated in the CBCT scans due to metallic artefacts (Ritter et al.,
2014). Similarly, Vanderstuyft et al. reported that the accuracy of
buccal peri-implant bone thickness in two CBCT devices was under-
estimated by 0.3 mm due to artefacts (blooming) leading to an arti-
ficial increase in the implant diameters (Vanderstuyft et al., 2019).
The different CBCT settings tested (low, standard or high dose)
seemed to only minimally affect the impact of artefacts on linear
measurements. ZrO2 resulted in a larger underestimation of the
width (mean error of −1.28 mm) than Ti (mean error −0.32) or Ti–Zr
implants (mean error −0.50). In line with the present study, artefacts
in CBCT scans resulted in a general impairment of the measurement
quality, especially for ZrO2 implants and to a lesser extent also for Ti
implants (Steiger-Ronay et al., 2018). On the other hand, Ti implants
showed a significant overestimation (mean error of 0.10) for height
measurements compared with Ti–Zr in the present study.
For the present study, fresh frozen pig mandibles were chosen
to simulate peri-implant bone defects. Other studies used dental or
mandibular plaster models or well-established bovine bone models
without soft tissue mimicking surrounding gingiva (Kühl et al., 2016;
Schulze et al., 2010; Schwindling et al., 2019; Steiger-Ronay et al.,
2018). It is known that soft tissues, osseous and dental structures all
affect the signal-to-noise ratio and beam hardening, thus also influ-
encing the resulting image quality in CBCT scans (Schwindling et al.,
2019). It should be noted that the reconstruction algorithm of the
CBCT software is designed and optimized for reducing artefacts in
live patient's scans. Thus, artefacts observed from the pig model in
the present study might be different from what one would observe
in real patients.
As a limitation of the present study, only one implant was placed
on each side of the mandibular angle to avoid superimposition of
artefacts around neighbouring implants. Other studies tested more
than one implant inserted side-by-side, and scanned implants in one
image potentially causing further artefacts influencing diagnostics
and accuracy (Kühl et al., 2016; Steiger-Ronay et al., 2018). One
other important limitation, which is relevant for all in vitro stud-
ies assessing accuracy and image quality of CBCT scans, is the lack
of motion artefacts seen in patients that might negatively impair
image quality (Yeung et al., 2020). Besides, only 2 CBCT devices
with selected imaging protocols were tested, which do not reflect
the wide selection of scanners available on the market. Besides,
implant material density and implant design such as its shape may
also affect the extent of the artefact (Codari, de Faria Vasconcelos,
SCHRIBER et al.
Ferreira Pinheiro Nicolielo, Haiter Neto, & Jacobs, 2017). It is also
relevant to mention that in clinical practice, peri-implant defects
might appear more subtle and can easily be overlooked on CBCT
scans. The detection of smaller sized peri-implant defects can then
be even more difficult due to artefacts. Therefore, the findings of
the present study demonstrate ideal rather than routine findings in
daily clinical practice.
5 | CO N C LU S I O N S
The hypothesis of the present study was that different dental
implant materials and CBCT image settings do not significantly
influence the diagnostic accuracy of peri-implant bone defect
detection. Based on the 2 CBCT devices included using selected
imaging protocols, this study showed that (a) CBCT device, CBCT
settings, implant material, implant diameter and observer back-
ground did not significantly affect the diagnostic accuracy for the
detection of peri-implant bone defects. Although sensitivity and
specificity values were generally high, the specificity to detect
peri-implant defects was lowest for zirconium dioxide implants. (b)
CBCT settings seemed to minimally affect the impact of artefacts.
(c) The precision of linear measurements can be impaired due to
diameter, CBCT device and more importantly due to implant mate-
rial and observer background resulting mostly in an underestima-
tion of the defect dimensions. Based on the findings in the present
study, CBCT imaging can be used with high diagnostic accuracy for
the detection of buccal peri-implant defects. If CBCT is indicated
to assess peri-implant bone disease, protocols to lower the default
dose used by the device might be considered, especially for Ti and
Ti–Zr implants.
AC K N OW L E D G E M E N T S
The authors thank Bernadette Rawyler, medical illustrator, and Ines
Badertscher, media designer, School of Dental Medicine, University
of Bern, Bern, Switzerland, for the illustrations. The authors thank
Mr David Sleeman, Morita Corp., Kyoto, Japan, and Mr Mikko
Heinonen, Planmeca, Helsinki, Finland, for their technical support
and advice during preparation of the study and subsequent analysis
of the data. The authors thank Ms Samantha Kar Yan Li, Faculty of
Dentistry, The University of Hong Kong, Hong Kong, China, for her
statistical assistance. The authors want to thank also the Straumann
Holding AG (Basel, Switzerland) for providing all implant materials
used in the present study.
C O N FL I C T O F I N T E R E S T
Authors declare no conflict of interest.
AU T H O R C O N T R I B U T I O N S
M.B. conceived the idea for the study; M.S., V.S., D.B. and M.B.
drafted the protocol; M.S., A.Y. and Y.L. performed the experimental
study part; M.S., A.Y. and Y.L. collected and analysed the data; and
M.S., A.Y., V.S. and D.B. led the manuscript writing.
|
      605
ORCID
Andy Wai Kan Yeung  https://orcid.org/0000-0003-3672-357X
Michael M. Bornstein  https://orcid.org/0000-0002-7773-8957
REFERENCES
Bender, P., Salvi, G. E., Buser, D., Sculean, A., & Bornstein, M. M. (2017).
Correlation of three-dimensional radiologic data with subsequent
treatment approach in patients with peri-implantitis: A retrospec-
tive analysis. The International Journal of Periodontics & Restorative
Dentistry, 37, 481–489. https://doi.org/10.11607​/prd.2844
Benic, G. I., Sancho-Puchades, M., Jung, R. E., Deyhle, H., & Hämmerle,
C. H. (2013). In-vitro assessment of artefacts induced by titanium
dental implants in CBCT. Clinical Oral Implants Research, 24, 378–383.
https://doi.org/10.1111/clr.12048
Bornstein, M. M., Horner, K., & Jacobs, R. (2017). Use of CBCT in implant
dentistry: Current concepts, indications and limitations for clinical
practice and research. Periodontology, 2000(73), 51–72. https://doi.
org/10.1111/prd.12161
Bornstein, M. M., Scarfe, W. C., Vaughn, V. M., & Jacobs, R. (2014). CBCT
in implant dentistry: A systematic review focusing on guidelines, in-
dications, and radiation dose risks. The International Journal of Oral
& Maxillofacial Implants, 29(Suppl), 55–77. https://doi.org/10.11607​/
jomi.2014s​uppl.g1.4.
Carter, J. B., Stone, J. D., Clark, R. S., & Mercer, J. E. (2016). Applications
of CBCT in oral and maxillofacial surgery: An overview of pub-
lished indications and clinical usage in United States academic
centres and oral and maxillofacial surgery practices. Journal of Oral
and Maxillofacial Surgery, 74, 668–679. https://doi.org/10.1016/j.
joms.2015.10.018
Chappuis, V., Rahman, L., Buser, R., Janner, S. F. M., Belser, U. C., & Buser,
D. (2018). Effectiveness of contour augmentation with guided bone
regeneration: 10-year results. Journal of Dental Research, 97, 266–
274. https://doi.org/10.1177/00220​3 4517​737755
Codari, M., de Faria Vasconcelos, K., Ferreira Pinheiro Nicolielo, L., Haiter
Neto, F., & Jacobs, R. (2017). Quantitative evaluation of metal arti-
facts using different CBCT devices, high-density materials and field
of views. Clinical Oral Implants Research, 28(12), 1509–1514. https://
doi.org/10.1111/clr.13019
Corpas Ldos, S., Jacobs, R., Quirynen, M., Huang, Y., Naert, I., & Duyck,
J. (2011). Peri-implant bone tissue assessment by comparing the out-
come of intra-oral radiograph and CBCT analyses to the histological
standard. Clinical Oral Implants Research, 22, 492–499. https://doi.
org/10.1111/j.1600-0501.2010.02029.x
Fienitz, T., Schwarz, F., Ritter, L., Dreiseidler, T., Becker, J., &
Rothamel, D. (2012). Accuracy of CBCT in assessing peri-im-
plant bone defect regeneration: A histologically controlled study
in dogs. Clinical Oral Implants Research, 23, 882–887. https://doi.
org/10.1111/j.1600-0501.2011.02232.x
Flügge, T., Derksen, W., Te Poel, J., Hassan, B., Nelson, K., & Wismeijer,
D. (2017). Registration of CBCT data and intraoral surface scans -
a prerequisite for guided implant surgery with CAD/CAM drilling
guides. Clinical Oral Implants Research, 28, 1113–1118. https://doi.
org/10.1111/clr.12925
Hilgenfeld, T., Juerchott, A., Deisenhofer, U. K., Krisam, J., Rammelsberg,
P., Heiland, S., … Schwindling, F. S. (2018). Accuracy of CBCT, dental
magnetic resonance imaging, and intraoral radiography for detect-
ing peri-implant bone defects at single zirconia implants - an in-vi-
tro study. Clinical Oral Implants Research, 29, 922–930. https://doi.
org/10.1111/clr.13348
Jacobs, R., Salmon, B., Codari, M., Hassan, B., & Bornstein, M. M. (2018).
CBCT in implant dentistry: Recommendations for clinical use. BMC
Oral Health, 18, 88. https://doi.org/10.1186/s1290​3-018-0523-5
Kühl, S., Zürcher, S., Zitzmann, N. U., Filippi, A., Payer, M., & Dagassan-
Berndt, D. (2016). Detection of peri-implant bone defects with
 |
606       SCHRIBER et al.
different radiographic techniques - a human cadaver study. Clinical
Oral Implants Research, 27, 529–534. https://doi.org/10.1111/
clr.12619
Kuusisto, N., Vallittu, P. K., Lassila, L. V., & Huumonen, S. (2015).
Evaluation of intensity of artefacts in CBCT by radio-opacity of
composite simulation models of implants in-vitro. DentoMaxilloFacial
Radiology, 44, 20140157. https://doi.org/10.1259/dmfr.20140157
Lang, N. P., & Berglundh, T. (2011). Peri-implant diseases: Where are
we now? - Consensus of the seventh European workshop on peri-
odontology. Journal of Clinical Periodontology, 38(Suppl 11), 178–181.
https://doi.org/10.1111/j.1600-051X.2010.01674.x
Lindhe, J., & Meyle, J. (2008). Peri-implant diseases: Consensus
report of the sixth European workshop on periodontology.
Journal of Clinical Periodontology, 35, 282–285. https://doi.
org/10.1111/j.1600-051X.2008.01283.x
Miracle, A. C., & Mukherji, S. K. (2009). CBCT of the head and neck, part
1: Physical principles. American Journal of Neuroradiology, 30, 1088–
1095. https://doi.org/10.3174/ajnr.A1653
Pauwels, R., Araki, K., Siewerdsen, J. H., & Thongvigitmanee, S. S. (2015).
Technical aspects of dental CBCT: State of the art. DentoMaxilloFacial
Radiology, 44, 20140224. https://doi.org/10.1259/dmfr.20140224
Pauwels, R., Stamatakis, H., Bosmans, H., Bogaerts, R., Jacobs, R.,
Horner, K., & Tsiklakis, K. (2013). SEDENTEXCT project con-
sortium. Quantification of metal artefacts on CBCT images.
Clinical Oral Implants Research, 24, Suppl, A, 94–99. https://doi.
org/10.1111/j.1600-0501.2011.02382.x
Pelekos, G., Acharya, A., Tonetti, M. S., & Bornstein, M. M. (2018).
Diagnostic performance of CBCT in assessing peri-implant bone loss:
A systematic review. Clinical Oral Implants Research, 29, 443–464.
https://doi.org/10.1111/clr.13143
Rees, T. D., Biggs, N. L., & Collings, C. K. (1971). Radiographic interpreta-
tion of periodontal osseous lesions. Oral Surgery, Oral Medicine, and
Oral Pathology, and Oral Radiology, 32, 141–153.
Ritter, L., Elger, M. C., Rothamel, D., Fienitz, T., Zinser, M., Schwarz, F., &
Zöller, J. E. (2014). Accuracy of peri-implant bone evaluation using
CBCT, digital intra-oral radiographs and histology. DentoMaxilloFacial
Radiology, 43, 20130088. https://doi.org/10.1259/dmfr.20130088
Sancho-Puchades, M., Hämmerle, C. H., & Benic, G. I. (2015). In-vitro
assessment of artefacts induced by titanium, titanium-zirconium and
zirconium dioxide implants in CBCT. Clinical Oral Implants Research,
26, 1222–1228. https://doi.org/10.1111/clr.12438
Sanz, M., & Chapple, I. L. (2012). Clinical research on peri-im-
plant diseases: Consensus report of Working Group 4. Journal
of Clinical Periodontology, 39(Suppl 12), 202–206. https://doi.
org/10.1111/j.1600-051X.2011.01837.x
Schulze, R. K., Berndt, D., & d'Hoedt, B. (2010). On CBCT artefacts in-
duced by titanium implants. Clinical Oral Implants Research, 21, 100–
107. https://doi.org/10.1111/j.1600-0501.2009.01817.x
Schulze, R., Heil, U., Gross, D., Bruellmann, D. D., Dranischnikow, E.,
Schwanecke, U., & Schoemer, E. (2011). Artefacts in CBCT: A review.
DentoMaxilloFacial Radiology, 40, 265–273. https://doi.org/10.1259/
dmfr/30642039
Schwindling, F. S., Hilgenfeld, T., Weber, D., Kosinski, M. A., Rammelsberg,
P., & Tasaka, A. (2019). In vitro diagnostic accuracy of low-dose CBCT
for evaluation of peri-implant bone lesions. Clinical Oral Implants
Research, 30(12), 1200–1208. https://doi.org/10.1111/clr.13533.
Steiger-Ronay, V., Krcmaric, Z., Schmidlin, P. R., Sahrmann, P., Wiedemeier,
D. B., & Benic, G. I. (2018). Assessment of peri-implant defects at
titanium and zirconium dioxide implants by means of periapical ra-
diographs and CBCT: An in-vitro examination. Clinical Oral Implants
Research, 29, 1195–1201. https://doi.org/10.1111/clr.13383
Tahmaseb, A., Wismeijer, D., Coucke, W., & Derksen, W. (2014).
Computer technology applications in surgical implant dentistry: A
systematic review. The International Journal of Oral & Maxillofacial
Implants, 29(Suppl), 25–42. https://doi.org/10.11607​/jomi.2014s​
uppl.g1.2
Vanderstuyft, T., Tarce, M., Sanaan, B., Jacobs, R., de Faria Vasconcelos,
K., & Quirynen, M. (2019). Inaccuracy of buccal bone thickness esti-
mation on CBCT due to implant blooming: An ex-vivo study. Journal
of Clinical Periodontology, 46, 1134–1143. https://doi.org/10.1111/
jcpe.13183
Yeung, A. W. K., de Azevedo, B. C., Scarfe, W. C., & Bornstein, M. M.
(2020). Patient motion image artefacts can be minimized and re-ex-
posure avoided by selective removal of a sequence of basis images
from CBCT datasets – A case series. Oral Surgery, Oral Medicine,
Oral Pathology and Oral Radiology, 129(2), e212–e223. https://doi.
org/10.1016/j.oooo.2019.07.003
How to cite this article: Schriber M, Yeung AWK, Suter VGA,
Buser D, Leung YY, Bornstein MM. Cone beam computed
tomography artefacts around dental implants with different
materials influencing the detection of peri-implant bone
defects. Clin Oral Impl Res. 2020;31:595–606. https://doi.
org/10.1111/clr.13596