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Dentomaxillofacial Radiology (2003) 32, 97-103
© 2003 British Institute of Radiology
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doi: 10.1259/dmfr/90063447 Articles by Lofthag-Hansen, S
Articles by Petersson, A
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Radiographic assessment of PubMed Citation
the marginal bone level Articles by Lofthag-Hansen, S
Articles by Petersson, A
after implant treatment:
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a comparison of
periapical and Scanora® What's this?
detailed narrow beam
radiography
S Lofthag-Hansen, C Lindh* and A Petersson
*Correspondence to: C Lindh, Department of Oral Radiology, Faculty of Odontology, Malmö University,
Carl Gustafs väg 34, SE-205 06 Malmö, Sweden; Email: Christina.Lindh@od.mah.se
Abstract
Top
Abstract
Introduction
Materials and methods
Results
Discussion
References
Objectives: To compare assessments of the marginal bone level around dental implants
in the mandible using periapical radiography and Scanora® detailed narrow beam (DNB)
radiography.
Methods: Forty patients treated with Br nemark dental implants in the lower jaw were
examined with periapical and Scanora® DNB radiography. Ten implants were selected
from each of the four dental regions (molar, incisor, canine, premolar), and no more than
one implant was selected from the same patient. Seven observers assessed the level of the
marginal bone on the mesial and distal surfaces of the implants. Three of the observers
made all the assessments twice.
Results: Agreement between the methods was 61%. The highest agreement was found in
the molar region. In DNB radiography the marginal bone level was observed to be
situated more "coronally" in 17% and more "apically" in 22% compared with periapical
radiography. The kappa value for interobserver agreement for all observers was 0.33 for
periapical radiography and 0.27 for DNB radiography. The weighted kappa value for
intraobserver agreement ranged from 0.75 to 0.99 for DNB radiography and from 0.94 to
0.98 for periapical radiography.
Conclusions: Scanora® multimodal radiography simplifies examination of implants in the
mandible, and observer variation is comparable with that in intraoral periapical
radiography.
Introduction
Top
Abstract
Introduction
Materials and methods
Results
Discussion
References
Success criteria have been defined for evaluation of oral implants and all include
radiographic measurement of marginal bone loss.1–4 Intraoral periapical radiography has
been the method of choice for such measurements. An optimal periapical image is based
on a paralleling technique, and any deviation from the correct vertical angle leads to
errors in assessment of the marginal bone height. Since marginal resorption of the
alveolar crest of the upper or lower jaw may be so severe that film placement parallel to
the implant is not only extremely difficult but is also painful for the patient, it is
sometimes difficult to use the paralleling technique.
One possible solution to the problem is to use an extraoral radiographic technique such as
panoramic radiography. This technique has been used for post-surgical evaluation of
implants but has been found to be of limited benefit owing to inferior image resolution
and the inability to modify the angle of the X-ray beam.5 In 1989 the Scanora®
multimodal radiography system was introduced onto the market.6,7 This system includes
the principle of narrow beam radiography with two imaging modes: the large area and the
detailed area projections. Detailed narrow beam (DNB) radiography allows horizontal
and vertical beam directions to be varied separately, which according to Tammisalo et al7
improves the diagnostic capacity compared with panoramic radiography. The technique
has also been evaluated in periodontal and periapical pathology and has been found to be
an acceptable alternative to periapical radiography.8,9 Svenson and Palmqvist10 used the
technique to image dental implants in severely resorbed maxillae and came to the
conclusion that DNB radiography is a viable alternative when conventional intraoral
techniques cannot be properly used. However, observer agreement was not evaluated.
The aim of this study was to compare the DNB technique with conventional intraoral
radiography in the assessment of marginal bone loss around dental implants in the
mandible and to evaluate observer agreement.
Patients
Forty-eight consecutive patients referred to the Department of Oral Radiology, Faculty of
Odontology at Malmö University, for a follow-up examination after treatment with Br
nemark dental implants in the lower jaw were examined. The follow-up examination after
implant installation varied from the time of bridge installment up to 10 years after surgery
(mean 4.2 years). In addition to conventional periapical radiography, an examination with
DNB radiography was made. Radiographs from two patients were excluded from the
study because of movement unsharpness in the DNB radiograph or because the periapical
radiographs were not optimal. In all, 183 implants had been installed in the remaining 46
patients. Forty implants (ten in each of the four dental regions incisor, canine, premolar
and molar) were selected. No more than one implant was selected from the same patient.
Implants were randomly selected if the same patient had more than one implant in the
same region. Owing to this selection, only 40 of the patients were included in the study.
The sex and mean age of the patients and the number of implants in the mandibular
regions are presented in Table 1 .
View this
table:
[in this Table 1 Number of patients according to sex, mean age and number of
window] implants inserted in the different mandibular regions. The mesial and
[in a new distal surfaces of each implant were assessed
window]
Radiographic techniques
The periapical radiographs were taken with the paralleling technique using a Heliodent
EC (60 kVp) or a Heliodent 70 (70 kVp) dental X-ray unit (Siemens, Bensheim,
Germany). The units operated at 7 mA and had a total equivalent filtration of 2.7 mm and
2.0 mm Al, respectively. Rectangular collimation (3 cmx4 cm) with a focus–aperture
distance of 21 cm was used. E-speed dental film (Ektaspeed Plus; Eastman Kodak Co.,
Rochester, NY) was exposed between 0.25 s and 0.64 s. The films were processed in an
automatic processor (XR 24 Nova; Dürr Dental, Bietigheim-Bissingen, Germany) with a
6-min cycle at 27°C. The periapical radiographs were re-taken until the threads were
clearly visible on the mesial and distal surfaces of the implant and the density made it
possible to assess the marginal bone level.
The DNB radiographs were taken with a Scanora® multimodal radiography system
(Soredex; Orion Corp., Helsinki, Finland) operating with voltage settings ranging from 66
kVp to 70 kVp and 20 mA. Total filtration was 2.7 mm Al-equivalent. Selective narrow
beam imaging involved taking a set of four 70 mmx70 mm images using different pre-
programmed horizontal and vertical projections (Figure 1 ). Programs 107, 109, 111,
113, 115 and 117 were used, and the exposure time ranged from 13–55 s. Lanex medium
or fine screens and T-MAT G film (Eastman Kodak Co., Rochester, NY) were used. The
DNB radiographs were processed in an automatic processor (Curix 242S; Agfa Gevaert,
Mortsel, Antwerp, Belgium) with a 90-s cycle at 32°C. The DNB technique with the
Scanora® multimodal radiography system is described in detail by Tammisalo et al.7
Evaluation of radiographs
Seven observers (six oral radiologists and one general dental practitioner) were asked to
assess all radiographs. The observers had long experience of implant radiography, but
their experience of the DNB technique varied. The observers were asked to assess the
marginal bone level by counting the number of threads between the implant–abutment
connection and the level of the marginal bone on the mesial and distal surfaces of the
implant. The first thread completely imaged was designated thread number 1 (Figure 2 ).
In cases of a double marginal bone contour, assessments were made at the most apical
level. In the DNB radiographs, all four projections of the implant surface to be estimated
were available. One of the authors marked the implant that was to be assessed in one of
the projections, which ensured that the same implant surfaces were assessed by all
observers. The observers assessed all radiographs with an interval of at least 1 week
between evaluations of the periapical and DNB radiographs. Three of the observers
assessed all radiographs twice with at least a 1-week interval between the different
observations. All radiographs were evaluated with the aid of a magnifying viewer (X-
produkter, Malmö, Sweden) and a light box with constant light intensity. It was also
possible to use a light box with variable light intensity (Densoscope; Philips, Stockholm,
Sweden).
Informed consent was obtained from all patients and the investigation was approved by
the local Ethics Committee of Lund University.
Statistical methods
The 2 test was used to analyse frequencies. A P-value of <0.05 was considered
significant. Kappa and weighted kappa statistics were used to determine interobserver and
intraobserver variation.11 Statistical analysis was performed with the StatXact (Cytel
Software Corp., Cambridge, MA) statistical program.
Results
Top
Abstract
Introduction
Materials and methods
Results
Discussion
References
View this
table:
Table 2 Number of assessments that were considered impossible to
[in this
perform by the seven observers in the periapical and detailed narrowbeam
window]
(DNB) radiographs, related to mandibular region and implant surface. In
[in a new
all, 560 observations were possible for each method
window]
In 303 (61%) of the 495 assessments there was agreement between the methods based on
observations from each of the seven observers (Table 3 ). In DNB radiography the
marginal bone level was observed to be situated more "coronally" in 17% and more
"apically" in 22% of the assessments compared with periapical radiography. A
comparison between methods related to mandibular region and implant surface is given in
Table 3 and Figure 3 . Agreement varied between 44% and 66%, with the lowest
agreement in the premolar region at mesial surfaces and the highest agreement in the
molar region at mesial surfaces. A 2 test revealed no systematic difference between the
observers’ registrations with regard to surface (mesial or distal) or radiographic method.
The agreement within one thread between the two techniques for each observer is shown
in Figure 4 . Five of the seven observers agreed with themselves, within one thread, in
the assessments of periapical and DNB radiographs in more than 80% of the observations.
Observer performance
Of the radiographs obtained with both techniques, the seven observers agreed on the
marginal bone level at only 12 of the 80 implant surfaces (see Figure 5 ). Of these 12
cases, 10 were periapical radiographs and 2 were DNB radiographs. In these 12 cases, the
marginal bone level was assessed superior to thread 1 (value "0", see Figure 2 ). At most,
a range of eight threads between the assessments of two observers was found at two
implant surfaces in periapical radiographs and at one implant surface in a DNB
radiograph (see Figure 6 ). The interobserver agreement, expressed as the kappa value for
seven observers, was 0.33 for periapical radiography and 0.27 for DNB radiography. The
kappa value for all observers’ assessments of value 0 was 0.5; all other kappa values for
several observers’ assessments at specific levels were less than 0.5.
The intraobserver agreement expressed as weighted kappa values ranged from 0.75 to
0.99 for DNB radiography and from 0.94 to 0.98 for periapical radiography (Table 4 ).
The two techniques were evaluated by comparing the agreement of seven observers’
assessments of the marginal bone level in clinical radiographs of patients who had been
treated with implants. When observer agreement is assessed, the truth is not considered
and the diagnostic outcome expressed as sensitivity, specificity and predictive values
cannot be determined. Observer performance is the sum of multiple errors in the system,
of which observer interpretation error can be a major component. To ensure credible
generalizations of the study results, the inclusion of several observers is mandatory. Very
little is added to the analysis by more than seven observers,19 thus seven observers were
used in this study. All observers had experience in interpreting intraoral radiographs of
implants, but their experience in evaluating DNB radiographs varied, and one of the
observers had little experience of this technique. The different levels of experience of the
observers may have influenced the results. We used the weighted kappa statistic to
calculate intraobserver agreement. Because 12 categories of assessment were used, we
wanted to take into account the degree of disagreement between different categories, and
weighted kappa statistic has been proposed to adjust for the seriousness of different levels
of disagreement.11
The number of surfaces that were considered impossible to evaluate by the observers was
higher with DNB radiography than with intraoral periapical radiography. This may be
because the intraoral radiographs were optimized and re-taken until the highest quality
was obtained whereas the DNB radiographs were taken only once because we wanted to
limit the radiation dose given to the patient as much as possible. Furthermore, intraoral
radiography provides very detailed images, with a resolution of approximately 10 line
pairs per mm.20 This may be compared with DNB radiography, which in the plane of
maximum sharpness has a resolution of 4.2 line pairs per mm.6 This difference may also
have influenced the results.
The agreement between the methods in the assessment of the marginal bone level was
61%, with a variation between regions of 44–66%. Svenson and Palmqvist10 found a
higher agreement between techniques when comparing the marginal bone level in
periapical and DNB radiographs of implants in the maxilla. In their study, only one
observer assessed the radiographs, which makes it difficult to compare the results.
However, in agreement with our study, the marginal bone level was overestimated as
often as it was underestimated in DNB radiography compared with periapical
radiography. There seems to be a random distribution of more apically and more
coronally assessed bone levels, which means that DNB radiography does not overestimate
or underestimate the marginal bone level in comparison with periapical radiography.
Agreement between the techniques in the assessment of the marginal bone level within
one implant thread was 80%. The variation of one thread between the observers’
assessments may be because of difficulties in defining the first thread. Another possibility
would have been to measure the distance in mm from the implant–abutment connection,
but this was not done because we use the thread number in our clinic when we write our
report to the clinician about the marginal bone level and we wished to simulate the
everyday work situation. The magnification factor in the two radiographic methods
differed, and it can also vary in different regions of DNB radiographs. The thread number
was therefore considered to be the most accurate unit to use in our study, which was also
recommended by Ahlqvist et al.22
At only 12 of 80 implant surfaces did all observers make the same assessment in
radiographs obtained with either technique, and these 12 assessments were made above
thread one, i.e. no marginal bone loss. The distance above thread 1 is greater than between
two threads and therefore easier for observers to agree on. The greatest discrepancy was
between two observers whose assessments differed by eight threads. This occurred with
two intraoral images and with one DNB image and might be because a bony pocket was
situated along the implant surface and not obvious to all observers.
In conclusion, the interobserver and intraobserver agreement was the same for periapical
and DNB radiography, and the agreement between the techniques of within one thread
must be considered to be very high. Scanora® multimodal radiography simplifies the
examination of implants in the mandible, and the technique can therefore be
recommended when it is difficult to obtain intraoral radiographs.
References
Top
Abstract
Introduction
Materials and methods
Results
Discussion
References
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