LIBRARY DISSERTATION

RADIOGRAPHIC EVALUATION OF
PROSTHODONTIC PATIENTS

Dr. PRIYANKA G
Post Graduate Student
2019-2022

DEPARTMENT OF PROSTHODONTICS
AND
CROWN & BRIDGE

RAGAS DENTAL COLLEGE & HOSPITAL

2/102, East Coast Road, Uthandi, Chennai -600119

 CERTIFICATE

This is to certify that this Library Dissertation title “RADIOGRAPHIC

EVALUATION OF PROSTHODONTIC PATIENTS” is a bonafide record work done

by Dr. PRIYANKA G and was presented under our guidance and to our satisfaction

during her postgraduate study period between 2019- 2022.

Guided by:

Dr. N.S.Azhagarasan, M.D.S Dr.Vallabh Mahadevan, M.D.S

Principal, Professor and Head, Professor,

Department of Prosthodontics Department of Prosthodontics

and Crown and Bridge and Crown and Bridge

Ragas Dental College & Hospital, Ragas Dental College& Hospital,

Chennai. Chennai.
CONTENTS

 INTRODUCTION

 REVIEW OF LITERATURE

 DISCUSSION

o Background

o Imaging modalities

o Radiographs in completely edentulous patients

o Radiographs in partially edentulous patients

o Radiographs in FPD prosthesis

o Radiographs in maxillofacial prosthodontics

o TMJ radiographs

o Implant imaging

 SUMMARY

 CONCLUSION
 INTRODUCTION

Dental radiographs play a very important role in diagnosis and treatment

planning. With the everyday new emerging techniques in oral radiology it

becomes important to have a good knowledge of all those techniques which will

help us in better treatment planning of Fixed Prosthesis, Implants and

Maxillofacial defects as well.

Proper diagnosis is essential to intelligent treatment for this diagnosis should

determine whether disease is present: then identify its type, extent, distribution

and severity; and finally should amalgamate information obtained from a

thorough clinical examination along with information gained from various

diagnostic aids.1

Prosthodontics is the dental specialty pertaining to the diagnosis, treatment

planning, rehabilitation, and maintenance of the oral function and esthetics of

patients with missing or deficient teeth by using prosthetic substitutes.

Prosthodontic patients may be completely dentate and interested in improving the

esthetics and/or function of their existing dentition. They could also be missing 1

or more teeth (partially edentulous) or all of their teeth (completely edentulous)

and seeking to replace their missing dentition. Diagnostic aids used in

prosthodontics helps to assess the dentate as well as edentulous patients for oral

rehabilitation, but pathologies in the edentulous patient are different from those in
the dentate patient, however the problems related to routine screening are still

present. Diagnostic aids used in prosthodontics include diagnostic casts,

photographs and various imaging techniques.

The publication of the American Dental Association intended for patients, Guide

to Dental Health, states that ―An x-ray examination is performed only when

necessary, not as a routine procedure, and only when the dentist believes such an

examination will benefit your health.‖

The report of the American Dental Association Council on Dental Material and

Devices states that ―Diagnostic radiography should be limited to those instances in

which the dentist anticipates that the information he is likely to obtain will contribute

materially to proper diagnosis, treatment, or prevention of disease, or all of these.‖

Many well-accepted features of clinical practice should be reevaluated from time to

time in the light of changing patterns of the incidence of disease and of treatment.

Changes noted by Swenson8*g between his 1944 and 1964 studies have continued,

and reflect improved access of the patient population to good dental treatment. Later

studies that appear to contradict this trend should be analyzed with respect to the

population studied. Later studies have also shown a change in the nature of the

pathosis reported. Early studies reported large numbers of root fragments, cysts, and
other residues of incomplete dental surgery. Later studies, while still reporting some

residual tooth fragments, have also reported on morphologic changes and nonspecific

radiographic changes. The clinical significance of this type of information must be

weighed against the exposure of the patient to radiation.

Radiographs are a valuable diagnostic tool, as an adjunct to clinical

examination in the diagnosis of dental diseases. Broadly, imaging techniques used

in Dentistry can be categorized as: intraoral and extraoral, analogue and digital,

ionizing and non-ionizing imaging, and two-dimensional (2-D) and three-

dimensional (3-D) imaging.

 REVIEW OF LITERATURE

P.F. van der Stelt et al, 1989 studied that the reliability of subtraction

radiography strongly depends on the ability to obtain two identical projections. A

computer-aided radiographic imaging technique (tomosynthesis) brings the

reconstruction of arbitrary projections within reach. He said that this technique is

used to reconstruct the projection required for a proper subtraction. However, in

order to do so, the coordinates of the source position of one projection, relative to

the source positions of the set of projections used for fomosynthesis, has to be

determined. A method is described based on similarity measurements, in pairs of

images (expressed in the form of standard deviations) to achieve this. The

coordinates of the unknown source position could be determined with an average

accuracy of 0.513 degrees (range 0.000-1.289 degrees), which is well within the

range of deviations tolerable for the clinical application of subtraction

radiography

Monson et al 1994 reported that the treatment planning requires close

collaboration between the restorative dentist and the surgeon to determine the

optimum placement of the implant in relation to the available bone and the

proposed prosthesis. Diagnostic and surgical guides can aid in treatment planning

and the implementation of that plan. Many different types of guides were

proposed. They vary from the very simple, which may not provide enough
information to achieve the desired results, to the extremely complex which require

a great deal of time to fabricate and are so precise as to not permit any

intraoperative changes mandated by local anatomy. They also described a simple

guide that can be constructed to aid in the diagnosis and treatment of patients

requiring dental implants.

Rushton et al 1996 studied the clinical role of panoramic radiology in the

diagnosis of diseases associated with the teeth and to consider its value in routine

screening of patients. Their results stated that routine screening is unproductive

for large proportions of dentate and edentulous populations, while in those cases

where pathology is detected the diagnostic accuracy can be questioned.

Furthermore, the "detection' of asymptomatic anomalies may have no effect on

patient management. Attempts to develop and test panoramic radiographic

selection criteria are reviewed. They concluded that new, high-yield selection

criteria for panoramic radiography are proposed as a means of reducing

unnecessary examinations, limiting radiation doses and reducing financial costs to

patients and health service providers. However, research is indicated to develop

further and to test such selection criteria.

Mozzo et al 1997 introduced a new type of volumetric CT which uses the cone-

beam technique instead of traditional fan-beam technique. The machine is

dedicated to the dento-maxillo-facial imaging, particularly for planning in the

field of implantology. Images obtained are reported as various 2D sections of a

volume reconstruction. Also, measurements of the geometric accuracy and the

radiation dose absorbed by the patient are obtained using specific phantoms.

Absorbed dose is compared with that given off by spiral CT. Geometric accuracy,

evaluated with reference to various reconstruction modalities and different spatial

orientations, is 0.8±1 % for width measurements and 2.2 % for height

measurements. Radiation dose absorbed during the scan shows different profiles

in central and peripheral axes. As regards the maximum value of the central

profile, dose from the new unit is approximately one sixth that of traditional spiral

CT. The authors concluded that the new system appears to be very promising in

dentomaxillo-facial imaging and, due to the good ratio between performance and

low cost, together with low radiation dose, very interesting in view of large-scale

use of the CT technique in such diagnostic applications.

Wyatt et al 1998 reviewed the literature on radiographic imaging techniques and

image interpretation for dental implant treatment and revealed that the

radiographic images are indispensable in the evaluation of osseous structures

when planning treatment for dental implants. Potential bone sites for implant

placement can be assessed clinically by means of palpation or probing through the

mucosa; however, diagnostic imaging provides the best means for indirectly

measuring bone dimensions. After healing of the Implant site, the application of
radiology is useful to verify the amount of bone adjacent to the implant and that

the transmucosal abutments fit the implant. Upon completion of the implant

prosthesis, radiology may be used to monitor initial and long-term success of

implant treatment. The authors concluded with recommendations for the

application of radiology over the course of treatment which are made for various

implant cases ranging from the overdenture to the single-tooth implant.

Dula et al 2001 reported that modalities in implant dentistry are proposed based

on clinical need and biologic risk for the patient. To calculate the biologic risk,

the authors carried out dose measurements. They demonstrated that the risk from

a periapical radiograph is 20% of that from a panoramic radiograph. A panoramic

radiograph and a series of 4 conventional tomographs of a single-tooth gap in the

molar region carry 5% and 13% of the risk from computed tomography of the

maxilla, respectively. Panoramic radiography is considered the standard

radiographic examination for treatment planning of implant patients, because it

imparts a low dose while giving the best radiographic survey. Periapical

radiographs are used to elucidate details or to complete the findings obtained from

the panoramic radiograph. Other radiographic methods, such as conventional film

tomography or computed tomography, are applied only in special circumstances,

film tomography being preferred for smaller regions of interest and computed

tomography being justified for the complete maxilla or mandible when methods
for dose reduction are followed. During follow-up, intraoral radiography is

considered the standard radiographic examination, particularly for implants in the

anterior region of the maxilla or for scientific studies. In patients requiring more

than 5 periapical images, panoramic radiography is preferred.

Talmacenu et al 2018 reported that the diagnosis and management of

temporomandibular disorders (TMD) require both clinical and imaging

examinations of the temporomandibular joint (TMJ). A variety of modalities can

be used to image the TMJ, including magnetic resonance imaging (MRI),

computed tomography (CT), cone beam CT, ultrasonography, conventional

radiography. The present review outlines the indications of the most frequently

used imaging techniques in TMD diagnosis. Osseous changes are better

visualized with CT and cone beam CT. Cone beam CT provides high-resolution

multiplanar reconstruction of the TMJ, with a low radiation dose, without

superimposition of the bony structures. MRI is a noninvasive technique,

considered to be the gold standard in imaging the soft tissue components of the

TMJ. MRI is used to evaluate the articular disc in terms of location and

morphology. Moreover, the early signs of TMD and the presence of joint effusion

can be determined. High-resolution ultrasonography is a noninvasive, dynamic,

inexpensive imaging technique, which can be useful in diagnosing TMJ disc

displacements. The diagnostic value of high-resolution ultrasonography is strictly

dependent on the examiner's skills and on the equipment used.

Bhatia et al 2012 reported that DentaScan is a unique new computer software

program which provides computed tomographic (CT) imaging of the mandible

and maxilla in three planes of reference: axial, panoramic, and oblique sagittal (or

cross-sectional). The clarity and identical scale between the various views permits

uniformity of measurements and cross-referencing of anatomic structures through

all three planes. Unlike previous imaging techniques, the oblique sagittal view

permits the evaluation of distinct buccal and lingual cortical bone margins, as well

as clear visualization of internal structures, such as the incisive and inferior

alveolar canals.

Monsour et al 2008 reported that the practitioner placing dental implants has

many options with respect to pre-implant radiographic assessment of the jaws.

They also stated that the Intra-oral and extra-oral radiographs are generally low

dose but the information provided is limited as the images are not three-

dimensional. Tomography is three-dimensional, but the image quality is highly

variable. Computed tomography (CT) has been the gold standard for many years

as the information provided is three-dimensional and generally very accurate.

However, CT examinations are expensive and deliver a relatively high radiation

dose to the patient. The latest imaging modality introduced is cone beam
volumetric tomography (CBVT) and this technology is very promising with

regard to pre-implant imaging. CBVT generally delivers a lower dose to the

patient than CT and provides reasonably sharp images with three-dimensional

information. A comparison between CT and CBVT is provided. Magnetic

resonance imaging is showing some promise, but the examinations are not readily

available, generally expensive and bone is not well imaged. Magnetic resonance

imaging is excellent for demonstrating soft tissues and therefore may be of great

use in identifying the inferior dental nerve and vessels.

Webber et al 1997 introduced a new method for creating three-dimensional (3-D)

radiographic displays based on optical aperture theory known as tuned-aperture

computed tomography (TACT). With a number of advantages over conventional

plain film and tomographic imaging.Current imaging strategies in dentistry and

their shortcomings in the detection of dento-alveolar disease are reviewed.

Pertinent theoretical aspects of the TACT reconstruction algorithm are described

and dental applications discussed in light of these limitations. Sample images of a

tooth with naturally occurring caries derived from an even newer system are

displayed. All data are consistent with the hypothesis that TACT imaging yields

diagnostic performance either comparable, or superior, to that obtainable from

conventional control modalities depending on the diagnostic task. Moreover, all

investigations cited demonstrated conclusively the obvious theoretical benefits

associated with the acquisition of multiple projections in three dimensions.

The authors concluded that TACT shows promise as a supplement to film-based

dental radiography and as a digital alternative to conventional tomographic

systems used in dento-alveolar applications.

Shah et al 2012 reviewed that with advances in dentistry, the need for more

precise diagnostic tools, specially imaging methods, have become mandatory.

From the simple intra-oral periapical X-rays, advanced imaging techniques like

computed tomography, cone beam computed tomography, magnetic resonance

imaging and ultrasound have also found place in modern dentistry. Changing

from analogue to digital radiography has not only made the process simpler and

faster but also made image storage, manipulation (brightness/contrast, image

cropping, etc.) and retrieval easier. The three-dimensional imaging has made the

complex cranio-facial structures more accessible for examination and early and

accurate diagnosis of deep seated lesions. This paper is to review current

advances in imaging technology and their uses in different disciplines of

dentistry.

Scarfe et al 2006 reviwed the Cone-beam computed tomography (CBCT)

systems designed for imaging hard tissues of the maxillofacial region and

reported that the CBCT is capable of providing sub-millimetre resolution in

images of high diagnostic quality, with short scanning times (10-70 seconds) and

radiation dosages reportedly up to 15 times lower than those of conventional CT

scans. Increasing availability of this technology provides the dental clinician with

an imaging modality capable of providing a 3-dimensional representation of the

maxillofacial skeleton with minimal distortion. This article provides an overview

of currently available maxillofacial CBCT systems and reviews the specific

application of various CBCT display modes to clinical dental practice.

Yu et al 2010 evaluated the dose and image quality performance of a dedicated

cone-beam CT (CBCT) scanner in comparison with an MDCT scanner. The

conventional dose metric, CT dose index (CTDI), is no longer applicable to

CBCT scanners. We propose to use two dose metrics, the volume average dose

and the mid plane average dose, to quantify the dose performance in a circular

cone-beam scan. Under the condition of equal mid plane average dose, we

evaluated the image quality of a CBCT scanner and an MDCT scanner, including

high-contrast spatial resolution, low-contrast spatial resolution, noise level, CT

number uniformity, and CT number

accuracy. CBCT system had comparable high-contrast resolution and inferior

low-contrast resolution to those obtained with the MDCT scanner when the doses

were matched (mid plane average dose 9.2 mGy). The CT number uniformity and

accuracy were worse on the CBCT scanner. The image artifacts caused by beam
hardening and scattering were also much more severe on the CBCT system. The

authors concluded that with a matched radiation dose, the CBCT system for sinus

study has comparable high-contrast resolution and inferior low-contrast resolution

relative to the MDCT scanner. Because of the more severe image artifacts on the

CBCT system due to the small field of view and the lack of accurate scatter and

beam-hardening correction, the utility of the CBCT system for diagnostic tasks

related to soft tissue should be carefully assessed.

 DISCUSSION

Background:

On 8 November, 1895 Wilhelm Conrad Röntgen accidentally discovered an

image cast from the cathode ray generator which was projected far beyond the

possible range of the cathode rays. A week after the discovery, Röntgen

discovered its medical use when he made a picture of his wife’s hand on a

photographic plate formed due to unknown radiation, which he termed as X-

rays. It clearly revealed her wedding ring and her bones. The first original dental

roentgenogram from a portion of a glass imaging plate was taken by Dr. Otto

Walkhoff in January 1896 in his own mouth for an exposure time of 25 min.

Since then, dental imaging has seen tremendous progress and its applications in

various fields of dentistry. Many dental diseases and conditions produce no

clinical signs or symptoms and are typically discovered only through use of dental

radiographs.

Various imaging techniques can be categorized as: intraoral and extraoral,

analogue and digital, ionizing and non-ionizing imaging, and two-dimensional (2-

D) and three-dimensional (3-D) imaging.

2-D Conventional radiographs provide excellent images for most dental

radiographic needs. Their primary use is to supplement the clinical examination

by providing insight into the internal structure of teeth and supporting bone to

reveal caries, periodontal and periapical diseases, and other osseous conditions. A

significant constraint of conventional radiography is the superimposition of

overlying structures, which obscures the object of interest. Eventually it results in

collapsing 3-D structural information onto a 2-D image, which leads to loss of

spatial information in the third dimension.

Uses of dental radiographs:

1. To detect lesions, disease and conditions of teeth and surrounding

structures that cannot be identified clinically.

2. To confirm and classify or foreign objects.

3. To localize lesions or foreign objects.

4. To provide information during dental procedures.

5. T o evaluate growth and development.

6. To illustrate changes secondary to caries, periodontal disease and trauma.

7. To document the condition of patient at a specific point of time.

IMAGING OBJECTIVES:

The objectives of diagnostic imaging depend upon the amount & type of

information required and the time period of treatment rendered. Imaging can be

organized into three phases.

 PHASE ONE - Preprosthetic implant imaging & involves all past

radiologic examinations along with the new ones.

The objectives of this phase of imaging include all necessary surgical

& prosthetic information to determine the quantity, quality & angulation

of bone, the relationship of critical structures to the prospective implant

sites & the presence or absence of disease at the proposed surgery sites.

 PHASE TWO - Surgical & interventional implant imaging.

The objectives of this phase of imaging are to evaluate the surgery

sites during & immediately after surgery, assist in the optimal position and

orientation of dental implants, evaluate the healing and integration phase

of implant surgery & ensure abutment position & prosthesis fabrication

are correct.

 PHASE THREE is termed post prosthetic implant imaging.

 The objectives of this phase of imaging are to evaluate the long term

maintainance of implant rigid fixation and function, including the crestal

bone levels around each implant & to evaluate the implant complex.

IMAGING MODALITIES

Classification according to planar dimensions:

A) Analog two dimensional

B) Digital three dimensional

C) Quasis three dimensional

Analog imaging modalities are two dimensional systems that use X-ray films are

intensifying screens as the image receptors. Digital images can also be produced

with each analog imaging modality.

A digital three dimensional image in described by an image matrix that has

individual image/picture elements called voxels.

A 3-D characterization of the patient is produced by contiguous images, which

produce a 3-D structure of volume elements.

Quasis-3 D - produce a number of closely spaced tomographic images and the 3-

D perspective of the patents autonomy is developed by viewing each image and

mentally filling in gaps.

I Analog modalities

 Peri-apical radiography

 Panoramic radiography

 Occlusal radiography

 Cephalometric radiography

II 3-D modalities

• Computed tomography

 Magnetic resonance imaging

 Interactive computer tomography

III. Quasis-3 D imaging

• X-ray tomography .

• Cross sectional panoramic imaging

Periapical Radiographs:

When periapical radiographs are used for assessing implant sites it is

important to observe certain guide lines to improve their accuracy and avoid

excessive base fog, improper exposure factors or poor processing which can

reduce the diagnostic value of a film. Secondly exposures should be made with a

collimated beam, a long target to film distance and a paralleling technique. These

measures help in minimizing the risk of significant geometric distortion.

1. Useful high yield modality for ruling out local bone or dental disease.

2. Of value in identifying critical structures but of little use in depicting the

spatial relationship between the structures & the proposed implant site.

3. Of limited value in determining quality because the usage is magnified,

may be distorted and does not depict the third dimension of bone width.
 4. Of limited value in determining bone density or mineralization because the

lateral cortical plates prevent the accurate interpretation and cannot differentiate

subtle trabecular bone changes.

Occlusal Radiographs:

Occlusal films are some times used in the setup for computed tomographic

examinations in the mandible. Data from these images are used to map the areas

to be scanned and to measure the distance between teeth or the distance along the

ridge. These two-dimensional images are not helpful in establishing the

buccolingual width of bone because they show only the widest dimension, usually

at or near the inferior border of the mandible. Occlusal films in either arch may

aid is the diagnosis of disease. They are rarely helpful or reliable in establishing

bony dimensions.
Lateral Cephalometric Images:

Lateral cephalometric images are obtained with the midsagittal plane of the

patient 5 feet from the target of the X ray tube. Because the film is close to the

patients face, magnification is minimized. A radioopaque molar is normally

included in the x-ray field so that corrections for small amount of magnification

are possible. A head holder ensures that a true lateral position is obtained with a

slight a rotation of the cephalometer, a cross sectional image of the alveolus of

both the mandible & the maxilla can be demonstrated in the lateral incisor or in

the canine region as well. The cross sectional view of the alveolus demonstrates

the spatial relationship between occlusion & esthetics with the length width,

angulation and geometry of the alveolus & is more accurate for bone quantity

determinations, unlike panoramic or periapical images.

 Often implants must be positioned in the anterior region adjacent to the

lingual plate. The lateral cephalometric radiograph is useful because it

demonstrates the geometry of the alveolus in the anterior region and the

relationship of the lingual plate to the patient’s skeletal anatomy. The width of the

bone in the symphysis region and the relationship between the buccal cortex and

the roots of the anterior teeth may also be determined before harvesting bone for

ridge augmentation. It also gives a spatial relationship of the implant site with the

critical structures present in that region. Additionally the lateral cephalometric

view can help evaluate loss of vertical dimension, skeletal interarch relationship,

anterior crown implant ratio, anterior tooth position in the prosthesis and resultant

moment of force.

Panoramic Radiography:

Panoramic radiographs represent image slices through the mandible and

maxilla. They are magnified by approximately 10% to 20% but the amount of

magnification is not uniform in a horizontal or vertical direction. As result, it is

difficult to measure the amount of available bone in vertical or in mesiodistal

directions with any degree of certainty. Although panoramic images may provide

a useful overview and may be used in conjuction with ridge mapping or other

diagnostic tools, they are unlikely to meet strict criteria for a primary images test

for implant planning.

 However they offer the following advantages:

1. Opposing land marks are easily identified.

2. The vertical height of bone initially can be assessed

3. The procedure is performed with convenience, ease & speed in most dental

offices.

4. Gross anatomy of the jaws and any related pathologic findings can be

evaluated.

Computed Tomography:

CT was introduced in the early1970’s, it helped to revolutionize the way

neuroscientists viewed the brain. These devices produced a pair of 1cm thick

cross sectional images in 5 minutes. Current state of the art CT equipment is

capable of producing 1.5mm thick cross sections in several seconds.

In May 1987 a special software by the name of Denta scan was introduced

which helped in the preoperative analysis of both maxilla and mandible for

osseointegrated dental implants.

Denta Scan:

The scanner has 4 main components

1. Computerized couch

2. Gantry with X-ray tube

3. Series of microprocessors for data analysis

4. A television monitor and filming device for the production of images.

Patient is placed in supine position & mouth is held open either with a

prefabricated intraoral bite plate or more commonly a tongue depressor covered

with gauze. Pt is instructed to hold absolutely still and not to speak or swallow

while the data are being gathered. The alveolar ridge should be aligned

perpendicular to the top of the table. To verify proper angulation a lateral scout

radiograph of the jaw is performed by the CT scanner.

The scanner is programmed to begin scanning the mandible at the inferior

cortical border and stop at a plane through the cusps of teeth. In maxillary
examinations, scanning begins at the cusps of any remaining natural teeth and is

carried through the lower third of maxillary sinuses.

Each CT image is 1.5mm thick. It is called an axial image because its plane is

perpendicular to the long axis of the body. The picture is usually created as a 512

x 512 matrix of data points.

To optimize visualization of the IAN canal, within a matrix of medullary

bone and fatty marrow, they have found it necessary to set the interslice distance

at 1mm when studying the mandible. The maxilla is generally scanned at 1.5mm

intervals. In order to decide whether or not implantation is possible, and if so the

optimal length, position and orientation of the implant, the surgeon must be able

to visualize the configuration of the alveolar ridge in cross section and must be

able to measure the height & buccolingual dimension at the exact positions where

implants are to be placed. It is possible to create a series of oblique cross-sectional

CT images along the curvature of the bone from the axial CT data stored in the

computer. This technique is called ―REFORMATION‖.

Using elaborate programs the computer is directed to rearrange the data &

display, all of the data points along an axis. It is possible to produce panoramic

images of the jaw corresponding to very thin slices of a conventional panoramic

radiograph. There are special dental reformatting programs that will automatically

produce a series of images of known size sequentially around the jaw, number
them, and organize them so that they can be photographed on several sheets of X-

ray films to reduce the time consumption. These films can be analyzed in the

dental office and all surgery planned from the film.

It is important that the image data should be displayed on the fewest number

of X-ray films. The images should be nearly life sized so that measurements can

be made with a ruler or calipers directly from the films. It also helps in cross

referencing any anatomic structure on all three planes.

After the scan, a technologist chooses one of the stack of the axial scans as a

reference slice.This slice should be through the roots of any remaining teeth at a

level near the crest of the ridge.

The technologist then draws a line around the curvature of the jaw by placing

a series of sequential dots from the posterior right border of the jaw to the

posterior left, the computer then generates a curve from these dots. A command is

given and the computer creates a series of lines perpendicular to the previously

drawn curve 2mm apart.

A series of thin cross sectional oblique pictures is then created corresponding

to each of the perpendicular lines. The number of images are displayed

sequentially and the buccal and lingual sides are marked. The distance between
the marks is equivalent to the spaces between the original axial scans. In most

cases that will be 1mm in the mandible and 1.5mm in the maxilla.

When this operation is completed, the program computes four additional

curves around the jaw paralleling the original curve. Two curves produced lingual

& two buccal to the original curve. Five panoramic reformations are then made

along those lines and the image sequentially labeled from buccal to lingual side.

The surgeon & prosthetic dentist decide the position for optimal fixture

implantation by measuring from known anatomic landmarks. They define these

positions the axial and panoramic views and using the corresponding oblique

cross sectional images measure the height and buccolingual dimension of the

bone where fixtures need to be placed. Thus, Denta scan can be used as an

important diagnostic tool in treatment planning and identification of several

important issues like revealing difficult to detect pathology, correct assessment of

bone trajectory to avoid iatrogenic injury and choosing appropriate implant shape

to fit residual bone.

Advantages of conventional CT Scans are:

1. One to one imaging with unsurpassed detail relative to all potential

implant sites

2. Three dimensional imaging

 3. Density of structures within the image is absolute and quantitative and

can be used to differentiate tissues in the region and characterize bone

quality

4. In combination with computer software they are capable of producing

3D and cross sectional images for arbitrary placement of implants in

the image.

The disadvantages of conventional CT scans include

1. Produce cross sections perpendicular to the alveolar ridge which are blurry

in nature.

2. Lack of adequate cross referencing with standard lateral, frontal and

panoramic radiographs. There are no intrinsic markers to absolutely identify the

precise location of each individual slice.

3. Use of stents with radio opaque markers must be fabricated prior to the

Xray film examination, and if the bone is found inadequate in any of the marked

locations it may become necessary to re-radiograph other locations.

4. Time consuming.
Subtraction Radiography:

Digital subtraction radiography was introduced to dental diagnosis by

Ruttimann et al in 1981. Woo et al. (2003) developed and validated a digital

subtraction radiography program based upon a Linux system. It can be used as a

sensitive and potential diagnostic tool for assessment of periodontal and peri

implant tissue changes. As early as 2-3 months post surgically an increase in bone

density in the defect area can be documented by means of subtraction

radiography.

Digitised images are imported into the subtraction software allowing analysis

of the alveolar bone changes. The first step in the software is to align the paired

images by selecting the same sets of two reference points. The software then

compares the coordinates of the reference points and moves the subsequent image

vertically, horizontally, and rotationally until the pairs of images are matched.

Pixel-by-pixel movement of the subsequent image can be performed manually

whenever necessary. Grey-level normalisation is performed nonparametrically

using a cumulative density function (Ruttimann et al. 1986). After normalisation,

the images are digitally subtracted. The selected sites are defined as regions of

interest on the radiographs. The computer-assisted densitometric image analysis

(CADIA) value is calculated for each region of interest according to a formula

described by Brägger (1988). CADIA value is used to quantify alveolar bone

changes and is presented as a net value between two standardised radiographic

images at different time points.

Paired radiographs are taken at the same appointment and processed together

in different patients randomly in order to determine the threshold used for the

digital subtraction radiography system (Woo et al. 2003). This threshold value is

then applied in all subsequent digital radiographic subtractions and allows for the

small degree of variability involved in using separate radiographs.

 The use of subtraction radiography is not a new concept and has been utilised

in dentistry for several decades (Webber et al. 1990, Grondahl et al. 1983,

Hausmann et al. 1985). Grondahl et al. (1987) found that there was a higher inter-

observer agreement in estimating periodontal bone changes from subtraction

radiographs compared to conventional radiographs.

Janssen et al. (1989) examined the detection thresholds of different

radiographic methods in the study of a dry human mandible. Bone cylinders at

interdental sites were removed, with a variation in the diameters of the artificially

created lesions (that sequentially increased in size by 0.1mm diameter). The

lesions were assessed using conventional radiographs, photographically

subtracted radiographs, and quantitative digital subtraction technique. The

radiographs were observed by 10 individuals who were to label each radiograph

as producing a „signal‟ (presence of a lesion) or ―no signal‖ (no lesion) and this

was repeated three times for each radiograph with a interval of one week between

viewings. The detection threshold was defined as the smallest defect in a series of

at least three consecutive increasing defect sizes which was consistently detected

at the three examinations performed at intervals of one week. It was found that the

smallest periodontal bone changes were detected with the quantitative digital

subtraction technique compared to the other methods. However, had the

experiment been in vivo, results may have varied due to the difficulty of
standardising X-ray images and changes in exposure parameters between baseline

and follow-up examinations. Other in vitro studies have examined the sensitivity

of digital subtraction radiography (Nicopoulou-Karayianni et al. 1991).

Cone beam computed tomography

The emergence of cone-beam computed tomography (CBCT) has expanded

the field of oral and maxillofacial radiology. CBCT imaging provides three-

dimensional volumetric data construction of dental and associated maxillofacial

structures with isotropic resolution and high dimensional accuracy. Cone beam

computed tomography or volumetric tomography was developed duringthe 1990s

(Arai et al. 1999) and the first machines became commercially available during

2000 (Terakado et al. 2000, Ito et al. 2001a). There are now several machines

available on the market, including the i-CAT and Newtom CB3D scanners, and

scanners are constantly being refined and upgraded.

 Similar to conventional multi-slice CT, CBCT allows three-dimensional

visualization of the oral hard tissues, though there are some fundamental

differences. Conventional CT scanners use a fan-shaped beam with the

transmitted radiation taking the form of a helix or spiral, whereas a CBCT

scanner uses a collimated x-ray source that produces a cone- or pyramid-shaped

beam of x-radiation, which makes a single full or partial circular revolution

around the patient, producing a sequence of discrete planar projection images

using a digital detector. These two-dimensional images are reconstructed into a

three-dimensional volume that can be viewed in a variety of ways, including

cross-sectional images and volume renderings of the oral anatomy.1 Volumetric

image acquisition is then achieved using an image intensifier or flat panel

detector.

Data from CT is interpolated by the scanner into a set of slices, producing a

volume. CBCT data is reconstructed using algorithms to produce three-

dimensional images at high resolution. Additionally, CT scanners require the

patient to be supine during image acquisition, whereas the majority of CBCT

scanners position the patient in a seated or standing position.

As cone-beam technology is based upon complex-motion tomography, the

radiation dose is lower than a multi-slice CT scan of the jaws (Hashimoto et al.
2003) though the reduced exposure results in a reduction in soft tissue contrast

and increased intrusion of noise (Ludlow et al. 2003, Schulze et al. 2004).

Implant dentistry fueled a desire for a 3D imaging system - had lower

radiation dose than medical CT as well as lower cost to the patient. CBCT may be

an efficient tool to evaluate bone remodeling compared to medical CT scanning

since it has a relatively low acquisition time and patient dose, and the images are

suitable for evaluation of treatment results at various post-operative periods in

longitudinal studies. DICOM (Digital Imaging and Communications in Medicine)

has become the standard format protocol for large image data sets such as CBCT-

based data sets. There is a wide range of software able to import DICOM files and

export sections or images in other formats, which can later be used for specific

measurements

CBCT units can be dedicated machines for only 1 field of view (FOV) or

may be able to image a variety of FOVs within the same unit.

Example of the various FOVs associated with corresponding diagnostic tasks

are as follows:

1. Focused or restricted FOV scans - 4 to 10 cm (2‖–400): adequate for

imaging the dentoalveolar region for a more local or endodontic purpose.

 2. Medium FOV scans - 10 to 15 cm (4‖–600): adequate for imaging the

maxillary and mandibular region for implants and dentoalveolar concerns.

3. Large FOV scans - 15 to 23 cm (6‖–900): desirable for the maxillofacial

and craniofacial regions for orthodontic and oral surgery, and evaluation of the

temporomandibular joints.

4. Stitched scans from multiple focused FOV scans provide larger regions of

interest to be imaged from superimposition of multiple scans

The dimensions of the field of view (FOV) or scan volume that are to be

covered primarily depend on the detector size and shape, the beam projection

geometry, and the ability to collimate the beam. The shape of the scan volume can

be either cylindric or spherical (eg, NewTom 3G). Collimation of the primary x-

ray beam limits x-radiation exposure to the region of interest. Field size limitation

therefore ensures that an optimal FOV can be selected for each patient, based on

disease presentation and the region designated to be imaged.

 Extended FOV scanning incorporating the craniofacial region is difficult to

incorporate into cone-beam design because of the high cost of large-area

detectors. Two approaches have been introduced to enable scanning of an ROI

greater than the FOV of the detector. One method involves obtaining data from

two or more separate scans and super imposing the overlapping regions of the

CBCT data volumes using corresponding fiducial reference landmarks (referred to

as either ―bio image registration‖ or ―mosaicing‖). Software is used to fuse

adjacent image volumes (―stitching‖ or ―blending‖) to create a larger volumetric

data set either in the horizontal or in the vertical dimension

 The disadvantage of stitching overlapped regions is that such overlapped

regions are imaged twice, resulting in double the radiation dose to such

regions. A second method to increase the height or width of the FOV using a

small area detector is to offset the position of the detector, collimate the beam

asymmetrically, and scan only half the patient’s ROI in each of the two offset

scans.

Methods of obtaining an widespread FOV by the use of a flat panel detector:

A: Shows arrangement where the central ray of the x-ray beam from the focal source is
directed through the centre of the object to the middle of the flat panel detector.
B: Shows an Alternate technique of shifting the place of the flat panel imager and
Accuracy
collimating theof cone
x-ray beam
beam computed
laterally so as totomography
extend the FOV object.

The accuracy of cone beam computed tomography in dentistry has been

widely examined in the past years, spurred by the increase in usage of this

radiographic method. Sherrard et al. (2010) assessed the accuracy and reliability

of an i-CAT machine at evaluating tooth and root lengths in porcine heads.

Different voxel sizes were used and the measurements were compared to
periapical radiographs. While the periapical radiographs could overestimate or

underestimate root and tooth lengths by up to a mean of 2.58mm, the CBCT could

reproducibly and accurately measure with a mean error of less than 0.3mm.

Using an in vitro geometric model, Marmulla et al. (2005) found that the

mean variation in measurement was 0.13mm with a maximum deviation of

0.3mm, when using the NewTom 9000 scanner (NewTom AG, Marburg,

Germany). Using the same CBCT scanner, Lascala et al. (2004) compared direct

large measurements of eight dry skulls with linear measurements obtained in

CBCT images. It was found that the CBCT tended to underestimate the

measurement but the difference was only significant when measuring the skull

base. Additionally, measurement of anatomical structures on CBCT scans may be

affected by operator influence and subjectivity.

Using CBCT to evaluate the accuracy of three-dimensional measurements,

Pinsky et al. (2006) assessed in vitro simulated bone defects in an acrylic block

and a human mandible. Volume measurements showed that manual measurements

of CBCT scans had a mean inaccuracy of -6.9mm3 compared to direct volumetric

measurements. Other studies have found similar accuracies (Ballrick et al. 2008,

Stratemann et al. 2008, Damstra et al. 2010, Liu et al. 2010).

The growing inclination for the selection of dental implants as a viable

alternative to replace missing teeth has necessitated a reliable technique capable

of obtaining highly accurate measurements to avoid likely damage to vital

structures during implant surgery. Anatomic structures such as the inferior

alveolar nerve, maxillary sinus, mental foramen, and adjacent roots are easily

viewed using CBCT. Further, these specific CBCT images permit precise

measurement of distance, area, and volume. In traditional panoramic radiography,

the average machine produces approximately a 1:1.2 ratio magnification,

depending on the center of rotation it takes for the particular structure. This must

be accounted for when planning implants. Preliminary studies on CBCT have

concluded that the CBCT image underestimates the actual distance. However,

these differences were significant only for the skull base. The detail of a CBCT

image is determined by the individual volume elements (voxels) produced in

formatting the volumetric data set. CBCT units in general provide voxel

resolutions that are isotropic—equal in all three dimensions. Imaging of the dental

and maxillofacial regions were found to be quite accurate as the voxels exhibit a

sense of ―isotropism‖ that is, uniformity in all dimensions, demonstrating no

significant differences. The fact that measurements from the CBCT are routinely

accurate throughout the maxilla and mandible makes this an excellent imaging

modality for planning implant placement.[3] Using these features, an

implantologist can gain confidence in treatment planning for complex surgical

procedures such as sinus lift and ridge augmentation, apart from gaining a secure

sense during intricate extraction procedures and implant placement – with or

without a surgical guide. The surgical guide can be fabricated with a CBCT

image, in the complete absence of the patient (thereby reducing the number of

patient appointments), thus, allowing precise placement of implants,

prefabrication of the abutments and prosthesis, and ―same day‖ delivery of the

prosthesis. Computed tomography (CT) images also have similar capabilities, but

the benefit of CBCT is less radiation exposure to the patient and greater image

accuracy.

CONE BEAM CT VS COMPUTED TOMOGRAPGHY

 Cost of equipment is approximately 3–5 times less than traditional

Medical CT

 The equipment is substantially lighter and smaller

 CBCTs have better spatial resolution (i.e., smaller pixels)

 No special electrical requirements are needed

  No floor strengthening required as most CBCTs are wall mounted

 Very easy to operate and to maintain; little technician training is required

 Some cone beam manufacturers and vendors are dedicated to the dental

market. This makes for a greater appreciation of the dentist’s needs

 In the majority of CBCTs, the patient is seated, as compared with lying

down in a medical CT unit. This, together with the open design of the CBCTs

virtually eliminates claustrophobia and greatly enhances patient comfort and

acceptance.

 The upright position is also thought by many to provide a more realistic

picture of condylar positions during a TMJ examination, thereby opening

possibilities of real-time imaging

 The lower cost of the machine may be passed on to the patient in the form

of lower fees

 Both jaws can be imaged at the same time

 Radiation dose is considerably less than with a medical CT

 Protocol selection (e.g., slice thickness) selection is at times difficult with

CT in comparison to CBCT
  Metal artifacts or metal spraying is much lesser in the CBCT when

compared to the CT. Therefore, use of localization markers for precision marking

is possible

 The primary use of CBCT in the facial region is for implant planning, and

CBCT scores much higher in all aspects when compared to the CT

 Disadvantage- CT gives precise Hounsfield units in comparison to the

CBCT which due to the nature of volumetric imaging renders it inaccurate and the

reading got is an average of the entire volume in the section

 CBCT beats the CT in the facial skeleton imaging (due to the complex

nature of the anatomy and the machine design) while in all other regions CT may

have the edge.

Dental radiography and radiation dosage

The primary aim of any modality of dental radiography is to provide

adequate, useful, and adjunctive information in order to aid diagnosis and

treatment planning. With regard to implants, information regarding bony

morphology, bone quality, and location of anatomical structures are provided

almost entirely by radiographs alone and hence they are considered essential for

planning and monitoring. CBCT is currently advocated for the assessment of the

jaws prior to implant placement (Guerrero et al. 2006). Overlying all

considerations, however, is the requirement to minimise the exposure of the

patient to ionising radiation in adherence with the ALARA principle (as low as

reasonably achievable).

The International Commission on Radiological Protection (ICRP) is an

advisory body providing recommendations and guidance on radiation protection.

The recommendations of radiological protection aim ―to provide an appropriate

standard of protection for man without unduly limiting the beneficial actions

giving rise to radiation exposure‖. The latest guidelines (Wrixon 2008) establish

thresholds on the maximum individual dose (from specified sources) for safe

radiation doses to patients and also quantify tissue weighting for effective dose

calculations. For situations that have a societal benefit but no individual benefit,

in a single year, the 2007 ICRP guidelines recommend a Maximum Effective

Dose of 1mSv or 1000μSv.

Effective dose is used to compare the stochastic risk, such as carcinogenesis

and hereditary effects, of a non-uniform exposure of ionising radiation with the

risk caused by a uniform exposure of the whole body. As different body tissues

have different susceptibilities to radiation, the effective dose is calculated using

the equivalent dose to different body tissues and the weighting factors designed to

reflect the different radiosensitivities of the tissues. Additionally, the 2005 and

2007 Recommendations apply individual tissue weighting to the salivary glands

and brain tissue, which were not included in the 1990 Recommendations. Hence,

for dental radiography, which has a high possibility of including susceptible body

tissues, the effective dose of different modalities increased due to increased tissue

weightings.

The effective doses of different modalities of dental radiography vary

depending upon the settings of the X-ray unit, including the kilovolt potential

(kVp) and tube current (milliamps). Additionally, effective doses have been

reduced due to the use of collimation, intensifying screens and digital

enhancement of images. Ngan et al. (2003) compared the radiation doses of facial

CT scans with the radiation doses when taking a lateral cephalometric radiograph,

a panoramic radiograph (OPG), an occlusal film, and an intra-oral periapical

radiograph. Doses were as follows (based upon 1990 ICRP guidelines):

 Long-cone paralleling periapical radiograph 5 μSv

 Panoramic radiograph (OPG) 10 μSv

 Mandibular CT scan 1320 μSv

 Maxillary CT scan 1400 μSv

 Maxillo-mandibular CT scan 2100 μSv

The effective dose of CBCT scans has been shown to be greater than

conventional dental radiographs and panoramic radiographs but lower than

conventional CT scans (Arai et al. 1999). A review of multiple CBCT machines

has found that the effective dose of a CBCT scan ranges from 52 μSv to 1025μSv

(Monsour & Dudhia 2008) and of four machines assessed, the i-CAT CBCT

machine had the best image quality for the radiation dose (Loubele et al. 2008).

Studies evaluating the effective dose of the i- CAT CBCT machine vary

depending upon the tissue weighting. Using the 2007 Recommendations (which

were the same as the 2005 draft recommendations), the effective dose of an i-

CAT full field of view scan (of the maxillae; and mandible) is approximately

101.5 μSv (Brooks 2005), up to 193 μSv (Ludlow et al. 2006).

Recently, Roberts et al. (2009) found that the effective dose of a high

resolution scan of the mandible is 188.5 μSv and a high resolution scan of the

maxilla is 93.3 μSv. Standard resolution scans and full 13cm scans (compared

with combined single scans) produced much lower effective doses of radiation.

Thus, based upon radiation exposure to patients, the i-CAT CBCT scanner could

be safely used to longitudinally assess implant osseointegration should the need

be warranted.
 RADIOGRAPHY IN PROSTHODONTICS

Prosthodontics is the dental specialty pertaining to the diagnosis,

treatment planning, rehabilitation, and maintenance of the oral function and

esthetics of patients with missing or deficient teeth by using prosthetic substitutes.

Prosthodontic patients may be completely dentate and interested in improving the

esthetics and/or function of their existing dentition. They could also be missing or

more teeth (partially edentulous) or all of their teeth (completely edentulous) and

seeking to replace their missing dentition. The prosthetic substitutes that

prosthodontists use to restore and/or replace the deficient tissues may be divided

into 4 categories depending on the type of support that is used:

1. Fixed prostheses supported on remaining teeth, which cannot be

removed by the patient, such as veneers, onlays, inlays, full-coverage

crowns, and fixed dental prostheses (FDPs).

2. Removable prostheses supported mainly on soft tissues, which can be

removed by the patient, such as complete or partial dental prostheses

(dentures) and overdentures.

3. Fixed or removable prostheses that are supported mainly by dental

implants.

4. Maxillofacial prostheses, intraoral or extraoral, and are supported on

hard and/or soft tissues and/or dental implants

 RADIOGRAPHS IN EDENTULOUS PROSTHODONTIC PATIENTS:

Radiographs are important aids in the evaluation of submucosal conditions in

patients seeking prosthodontic care. The presence of abnormalities in edentulous

jaws may be unsuspected because of absence of any clinical signs or symptoms

they show the relative thickness of alveolar ridge and the mucoperiosteum, the

quality of the bone.

Extraoral radiographs can provide survey of the patient’s denture foundation

and surrounding structures. Panoramic dental radiograph are readily available for

convenient examination of edentulous patients. Knowledge of location of the

anatomic structures is an essential pre-requisite in the evaluation of the

radiographs.

Panoramic radiography was developed as a rapid, simple method to record on a

single film the patient’s general dental condition, treatment requirements, and

information for identification.’ Panoramic radiography is commonly used in large

institutional practices as the sole method of screening edentulous patients.’ In

conjunction with the periapical radiograph, it is a valuable adjunct in dental

therapy. Panoramic radiography provides a rapid and effective method of

screening edentulous patients; suspect areas may then be examined in detail on a

periapical radiograph.’
 Intraoral radiographs have limited role in edentulous patients. They can used

in locating any localized abnormality or the examination of tuberosities.

The transition from emulsion based film radiography to photostimuable

phosphor based films CCD (charge couple devices) and CMOS (complementary

metal oxide semiconductor) are well under way. This is limiting the exposure of

patients to radiations.

Radiographs in complete dentures should rule out foreign bodies, retained root

tips, unerupted teeth or various pathoses of developmental, inflammatory or

neoplastic origin. Cephalometric and temporomandibular joint radiography are

performed to rule out relevant abnormalities for complete denture prosthesis

functioning and maintenance.

Radiographs are usually taken to find out the presence of hidden abnormalities, to

note the structure of cortical bone and trabeculae, sharp projections, thickness of

soft tissue etc., Retained roots with no apparent pathology can often be left alone

provided the patient is informed of their presence and X-rayed periodically.

The panoromic is also an aid in documenting the amount of ridge resorption. A

very useful system of classifying the amount of ridge resorption was described by

WICAL & SWOOPE. They found that the lower edge of mental foramena

divides the mandible into thirds in normal dentulous panaromic radiograph. If the

distance is measured from inferior border of mandible to inferior margin of

mental foramina and then multiplied by 3, the resultant product is a reliable

estimate of original alveolar ridge crest height.

Amount of ridge resorption can be calculated an classified as

Class I (MILD RESORPTION)-Loss upto 1/3 of original vertical height

Class II (MODERATE RESORPTION) -Loss upto 1/3 to 2/3 of vertical height.

Class III (SEVERE RESOPTION) - Loss of 2/3 or more of vertical height.

To conclude, periapical survey of edentulous jaws are acceptable but Panaromic

radiographs are faster reduce patient exposure to radiation and image the entire

maxilla and mandible.

RADIOGRAPHS IN PARTIALLY EDENTULOUS PATIENTS - FIXED

PROSTHODONTICS

Most of dental patients prefer reconstruction with fixed partial dentures (FPD)

rather than removable ones because of comfort, psychological and social

advantages of FPDs. However, a FPD which does not implement required

standards and rules of FPDs may cause different dental problems. Successful

treatment of fixed partial dentures depends on the appropriate selection of the

abutment teeth and the number of missing teeth. Radiographs are used to evaluate

the number of missing teeth, bone quality and quantity, pulpal health, any

endodontic treatment, caries, periodontal diseases, crown root ratio and various

tooth morphologies. The success of fpd is further enhanced by maintaining oral

hygiene.

Planning

A panoramic radiograph is of great diagnostic value and should be made

wherever possible. Periapical radiographs of the remaining teeth may also be

required is order to supplement the OPG.

 Teeth with questionable prognosis

 Requiring surgical & Endodontic restoration

The diagnostic factors or criteria judged are.

(i) Carious lesion

 initial carious lesions

 Recurrent caries adjacent to existing restorations

  Deep lesions or extensive restorations on potential abutment teeth.

 Obvious indications for endodontic therapy cast restorations are noted.

(ii) Root Length, Size & Form

 Large, longer roots are more favorable abutment teeth.

 Form of the root is equally important tapered or conical roots are

unfavorable because ever a small loss of bone height can greatly diminish

the attachment area.

 Multirooted teeth with divergent and curved roots are better than single

rooted or Multirooted with fused roots.

 Position of roots of adjacent tooth is also important, in case the roots are

close with little interproximal bone separating them even a moderate

irritation of force may be destructive.

Crown root ratio

 The relationship of the length of the clinical area and the amount of root

embedded is bone is a very critical factor. If the crown root ratio is greater than

1:1 then the tooth has a poor prognosis as an abutment. It is also poor when there

is furcation involvement of a multi rooted teeth is present.

Lamina dura or periodontal space

 The width of the periodontal ligament space is of significance in

evaluating the stability of the teeth. A thin uniform ligament space and an

uninterrupted Lamina dura is a more favorable sign compared to a more

widened or irregular space.

 A thickening of the lamina dura may occur if the tooth is mobile, has

occlusal trauma or is under heavy functions occlusal trauma can cause

partial or total loss of the lamina dura.

 Partial or total absence of the lamina dura may be found in systemic

disorders such as Hyperparathyroid and Paget’s disease.

 Systemic disease must be considered whenever this condition is noted;

Destruction forces or the disease processes causing changes in the lamina dura

must be correlated or the abutment tooth will have a poor prognosis.

Bone quality & quantity

Bones which has small closely grouped trabecular and small inter

trabecular spaces is considered well mineralized; hence strong & healthy.

This is portrayed in the radiograph as relatively radiopaque, although a

certain amount of variation is size of the trabeculae is normal and to be expected.

Bone height of quantity

In this evaluation care must be taken to avoid any interpretation errors

resulting from angulations factors with is normally used in the short cone or

Bisecting angle technique.

As a result of the central ray using shot at an angle results in the buccal

bone to be projected higher on the crown than the lingual or palatal bone.

Therefore when interpreting bone height it is imperative to follow the line

of the lamina dura from the apex towards the crown of the tooth until the opacity

of the lamina materially decreases.

 At this point of opacity charge, a less dense bone extends further towards

the tooth crown.

This additional amount of bone represents false bone height. Thus the true

height of the bone is ordinarily where the lamina shines a mark decrease in

opacity.

At this point the trabecular pattern of the bone superimposed on the tooth

root is lost. And the portion of the root b/w the CEJ and the true bone height has

the appearance being base as devoid of covering.

BONE INDEX AREAS

Index areas are those areas of alveolar support that disclose the reaction of

bone to additional stress.

There might be a positive Bone factor or a Negative Bone factor

depending on the response of the alveolar bone to additional loading.

A position or a favorable response

 A decrease in the trabecular pattern (bone condensation))

 A heavy cortical layer.

 Dense lamina dura

 Normal bone height

 Normal periodontal ligament space.

Retrograde or negative response

 loss of lamina dura

 decrease bone height

 widening of periodontal ligament space

 apical and furcation radioluscency

Teeth that have been subjected to greater than normal stress and provide good

index information are:-

o Abutment teeth of an FPD or RPD.

o Teeth involved in occlusal interferences.

o Teeth receiving greater occlusal stress due to loss of adjacent teeth.

o Tipped teeth with occlusal contact.

Radioluscent or radioopaque lesions.

 The presence of cysts, accesses, embedded teeth or roots or foreign bodies

must be noted.

 A surgical diagnosis and treatment must be planned so that a conditions

does not flare up later on jeopardizing the prognosis of the prosthesis.

 Buried root tips or impacted teeth that show no signs of any pathosis and

are encapsulated by normal appearing bone need not be surgically

removed though it must be noted in the diagnosis.

 It should be checked for any imparted 3rd molars.

Roentgenographic interpretation

Radiographic interpretation most pertinent to partial denture construction

are those relative to prognosis of remaining teeth that may be used as abutments.
 The quality of the alveolar support of an abutment tooth is of prime

importance because the tooth will have to withstand greater stress loads when

supporting a dental prosthesis, especially greater horizontal forces. Abutment

teeth adjacent to distal extension bases are subjected not only to vertical and

horizon The objectives of a radiographic examination are

(a) to locate areas of infection and other pathosis that may be present;

(b) to reveal the presence of root fragments, foreign objects, bone spicules, and

irregular ridge formations;

(c) to display the presence and extent of caries and the relation of carious lesions

to the pulp and periodontal attachment;

(d) to permit evaluation of existing restorations for evidence of recurrent caries,

marginal leakage, and overhanging gingival margins;

(e) to reveal the presence of root canal fillings and to permit their evaluation as to

future prognosis (the design of the removable partial denture may hinge on the

decision to retain or extract an endodontically treated tooth);

(f) to permit an evaluation of periodontal conditions present and to establish the

need and possibilities for treatment;

(g) to evaluate the alveolar support of abutment teeth, their number, the

supporting length and morphology of their roots, the relative amount of alveolar

bone loss suffered through pathogenic processes, and the amount of alveolar

support remaining. tal forces but to torque as well.

A critical evaluation of the following factors should be made:

(1) type, location, and severity of bone loss;

(2) location, severity, and distribution of furcation involvements;

(3) alterations of the periodontal ligament space;

(4) alterations of the lamina dura;

(5) presence of calcified deposits;

(6) location and conformity of restorative margins;

(7) evaluation of crown and root morphologies;

 (8) root proximity;

(9) caries;

(10) evaluation of other associated anatomic features, such as the

mandibular canal or sinus proximity. This information serves to substantiate

the impression gained from the clinical examination.

RADIOGRAPHS FOR MAXILLOFACIAL PROSTHODONTICS

Radiographs play major role in maxillofacial rehabilitation of intra and

extra oral facial structures which have been congenitally malformed or lost

due to trauma.

Main Indications for Maxillofacial radiographing are

1. Fracture of maxillofacial skeleton

2. Embroyonic abnormalities of maxillofacial region

 3. fracture of skull

4. investigations of antra

5. diseases effecting skull base and vault

6. TMJ disorders

The extent of damage to tissues needed to be rehabilitated and extent of

underneath supporting tissues vital for receiving maxillofacial prosthesis to

be analysed by various radiographic views of maxillofacial prosthesis and

treatment plan is executed.

Radiographs of maxillofacial region are

1. Intraoral radiographs – IOPA, bitewing etc

2. Extraoral radiographs – most commonly used maxillofacial imaging.

Ex. P-A Projection (Granger projection )

Inclined P-A (Caldwell projection)

Most maxillofacial rehabilitations in Prosthodontics include closure of

developmental defects like clefts and eye , ear, nose and cranial prosthesis

lost due to trauma which go best with radiographic evidence.

For best visualization of clefts most preffered radiographs are

1. Occlusal radiographs.

2. Lateral Cephalogram

3. CT scan

4. Ultrasound

Radiographs in maxillofacial sinuses

1. Standard occipeto mental projection( 0 degress)

2. Modified method (30 degrees mental projection)

3. P-A Waters view

4. Bregma menton view

Radiographs of mandible

1. P-A mandible

2. Rotated P-A mandible

3. Lateral oblique

a. Anterior body of mandible

b. Posterior body of mandible

 c. Ramus of mandible

4. CT/ CBCT

Radiographs of Zygomatic arches

1. Jughandle view

Radiographs of base of skull

1. Submentovertex projection

Radiographs of skull

1. Lateral cephalogram

2. True lateral cephalogram

3. P-A cephalogram

4. P-A skull

5. TOWNES projection

Cone beam computed tomography has now replaced the standard CT in

imaging and planning craniofacial defect reconstruction. Three-dimensional

augmented virtual models of the patient’s face, bony structures, and dentition can

be created out of CBCT DICOM data by software volume rendering for treatment

planning. DICOM or digital compatibility is the universally accepted data transfer

protocol developed for rapid, mass data transfer with minimal or nil distortion and

non-alterable primary image that helps prevent malpractice. DICOM enables the

viewer to work on any workstation. The shape of the graft can be virtually

planned and can also be positioned in the defect creating a virtual reconstruction

of the defect prior to the actual surgery. In addition, implant placement onto the

graft can also be planned. Obturators for cleft closures can be precisely milled in

larger CAD/CAM units, thereby eliminating the entire cumbersome clinical

process of obturator construction.

TEMPORAMANDIBULAR JOINT RADIOGRPHS

Radiographs of TMJ imaging

1. Panoromic radiography

2. Transcranial projection

3. Tomography

4. Arthromography

5. Arthromography with videofloroscopy

6. MRI

7. Computed tomography
 Special imaging techniques are needed to study the complex anatomy and

pathology of the TMJ. It is very common to take an image of the joint when there

is locking, pain and articular sounds. The clinician should properly decide which

patients would need special imaging techniques depending on the clinical

examination and individual selection criteria. One important thing to consider

when imaging the TMJ is the interpretation of the joint function, which can be

accomplished by comparing the condyle in the closed and opened mouth position.

Panoramic radiography

It shows the jaws and the associated structures, being a helpful tool for the

clinician in identifying any periodontal or odontogenic causes for orofacial pain.

Panoramic radiography does not appear in the list of imaging techniques provided

by RDC/TMD. Only the lateral part of the condyle can be assessed with this

technique, being limited due to the superimposition of the zygomatic arch and the

base of the skull. Panoramic radiography can help evaluate the following:
 • degenerative bone changes (only in late stages; it is inadequate for the

early detection of osseous modifications);

• asymmetries of the condyles ;

• hyperplasia, hypoplasia;

• trauma;

• tumors.

DISADVANTAGES- does not reveal the functional status of the joint and

has a relatively low specificity and sensitivity when compared with CT.

Epstein et al consider the clinical findings of greater relevance than panoramic

images for patients with TMD. Nevertheless, some authors have suggested

panoramic radiography as a good imaging modality for TMJ visualization.

Although morphological abnormalities of the condyle can be assessed with

panoramic radiography, they do not necessarily represent a sign of TMD.

Variations of condylar shape are present among individuals. Moreover, changes in

head position could affect the image of TMJ, simulating different bone

abnormalities (flattening, osteophytes, asymmetries) . Dahlstrom et al. concluded

that panoramic radiography is useful in detecting bony changes of the condyle,

but when these changes are suspected, and the radiography is normal, CT should

be performed.
 Plain radiography- Consists of transcranial projection of TMJ with different

angulations: lateral oblique transcranial projections, anterior-posterior projections,

submental-vertex projection, transpharyngeal view

Advantages-

o degenerative joint disease found in advanced stages.

o The condyle position could be assessed

Some studies have shown that the position of the condyle in the fossa is of

little clinical significance. Other studies suggest that the posterior position of the

mandibular condyle in regard to the fossa, could represent an indirect sign of an

anterior disc displacement. The position of the head during the examination could

influence the joint space, which could influence the interpretation of the

radiographs. The use of flat plane films for TMJ pathology is not sufficient,

because this joint requires three dimensional imaging views. CT has been reported

to be more suitable in identifying TMJ changes than conventional radiography

 Computed tomography (CT)

CT is considered to be the best method for assessing osseous pathologic

conditions of TMJ. It allows a multi planar reconstruction (sagittal, axial, coronal)

of TMJ structures, obtaining 3D images in closed and opened-mouth positions.

Degenerative changes in the joint, like surface erosions, osteophytes, remodeling,

subcortical sclerosis, articular surface flattening can be evaluated using CT.

Some studies have reported that radiographic changes in the joint are not

always related to pain. Therefore, some patients with osseous abnormalities may

experience pain, others may be pain free. Changes in the shape and location of the

loading zone can also be seen on CT. CT is the main radiological investigation for

tumors, growth development anomalies and fractures. Basically, any CT

examination of the TMJ should focus on the following: intactness of the cortex,

normal size and shape of the condyles and their centered position in the fossa, the

adequate joint spaces, centric relation loading zone.

Wesetesson et al. found a sensitivity of 75 % and a specificity of 100% for the

diagnosis of condylar bony changes. Regarding the visualization of the soft

tissues of TMJ (disc, synovial membrane, ligaments, lateral pterygoid muscle),

CT is not used as a primary diagnostic method. The disc could be visualized on

CT scans only with injection of contrast media in the joint (arthrography).

Arthrography is a dynamic investigation, but was never widely used, due to its

invasiveness, pain and allergic reaction. TMJ disc pathology and lateral pterygoid

muscle pathology is better assessed with MRI.

CONE BEAM CT - provides high-resolution multiplanar reconstruction of TMJ.

ADVANTAGES-

o lower radiation dose to the patient.

o The spatial resolution of cone beam CT is higher than that of conventional

CT. Hintze et al. found no significant differences between conventional

 tomography and cone beam CT in the detection of morphological TMJ

changes.

o depict early bony changes of TMJ.

Silvia Caruso et al pointed out the main contributions of cone beam CT in the

field of TMJ:

• allows the calculation of volume and surface of the condyle;

• improves qualitative analyses of condylar surface and allows detecting the

mandibular condyle shape;

• improves the accuracy of linear measurements of mandibular condyle;

• clarifies that, in case of facial asymmetry, the condyles are often symmetric,

while joint space can change between the two sides;

• clarifies the position of the condyle in the fossa.

MAGNETIC RESONANCE IMAGING (MRI)

Imaging the soft tissue structures of the TMJ (articular disc, synovial

membrane, lateral pterygoid muscle). It is the best imaging modality in

diagnosing disc displacements. MRI could also detect the early signs of TMJ

dysfunction, like thickening of anterior or posterior band, rupture of retrodiscal

tissue, changes in shape of the disc, joint effusion. Images can be obtained in all

planes (sagittal, axial coronal). In most scanning sequences, T1 weighted, T2

weighted and proton-density (PD) images are obtained. The PD images serve to

visualize the disc-condyle relationship, while T2-weighted images are used in

diagnosing inflammation in the joint. The slice thickness is important for image

quality. The most frequent used section thickness is 3 mm. Reducing the slice

thickness improves the quality of the images, but requires longer scanning time.

An axial localizing image is used to direct the long axis of the condyle in the

closed-mouth position. Sagittal images are obtained perpendicular to the long axis

of the condyle, and coronal images are obtained parallel to the long axis.

Pathological condition is considered to be present relative to the intermediate

zone of the meniscus (as a point of reference) and its interposition between the

condyle and the temporal bone .

Normal disc position, evaluated in the sagittal plane, is with the junction of

posterior band aligned approximately at 12 o’clock, position relative to the

condyle. Disc displacement is diagnosed when the posterior band sits in an

anterior, posterior, medial or lateral position with regard to the condylar surface.

In the closed-mouth position, teeth should be in contact, whereas in the opened-

mouth position, the jaw should be at the widest comfortable opening.

Being a synovial joint, synovitis is a common situation and it is characterized

by swelling due to hypertrophy of the synovia and overproduction of synovial

fluid. Synovitis can be clearly visualized on MRI images. Synovial inflammation

could lead to joint effusion, defined as an increase in the volume of intra-articular

fluid. Some studies have investigated the relationship between the articular

eminence morphology and disc patterns in patients with disc displacements. The

results showed that changes in the morphology of articular eminence (flattened)

and disc could contribute to the appearance of disc displacement without

reduction on that side. Other studies also found changes in disc shape and

dimension in cases of TMJ disc displacement.

Disadvantages of MRI investigation:

• costly and time consuming;

• restricted use in patients with claustrophobia;

• possibility of missing the portion of condyle having a pseudo cyst

• may miss different bone conditions and soft tissue calcifications with

inflammatory diseases or tumors; in these cases, CT is the preferable imaging

modality .

RADIOGRAPHS IN IMPLANTOLOGY

The American Academy of Oral and Maxillofacial Radiology (AAOMR)

recommends cross-sectional imaging for dental implant treatment planning and

that CBCT is the preferred imaging method for obtaining the pretreatment images.

In addition, a panoramic radiograph with supplemented intraoral images should

be taken for the initial pretreatment evaluation to determine whether the patient is

a candidate for implants before taking a CBCT scan. The anatomy surrounding

the potential implant site should be thoroughly evaluated.

Before focusing on the height and width of the residual alveolar bone to measure

the dimensions for implant placement, the entire volume should be reviewed to

rule out pathologic entities.

 BONE

Bone has an internal structure described in terms of quality or density that reflects

the strength of the bone.

The density of the available bone in an edentulous site is a determining factor in

treatment planning, implant design, surgical approach, healing issue and initial

progressive bone loading during prosthetic reconstruction",

Classification

(Linkow and Churcheve, 1970)

• Class I - ideal bone type, since it consists of evenly spaced trabeculae with small

cancellated spaces. Provides very satisfactory foundation for implants

• Class II – has slightly larger cancellated spaces with less uniformity of the

osseous pattern. Satisfactory for implants.

• Class III- large marrow filled spaces exist b/w bony trabeculae. Results in loose

fitting implant.

Significance-

• Class I bone – very satisfactory for implant prosthesis.

• Class II bone – satisfactory for implant prosthesis.

• Class III bone – results in loose fitting implants.

Lekholm and Zarb classification (1985)

Listed four basic qualities found in the anterior regions of the jaw

Bone quality

Class 1 Compact cortical bone

Class 2 Thick cortical bone Surrounding highly Trabecular bone

Class 3 Thin cortical bone Surrounding highly Trabecular bone.

Class 4 Thin cortical bone and Spongy core

Four different bone qualities in the regions of the jaw

Classification by Misch(1988)
Bone Density and Tactile Sense.

This classification compares material of various densities. Drilling and placing

implants into D1 bone is similar to drilling into oak or maple wood, D2 is similar

to drilling into white pine or spruce. D3 is similar to drilling into balsa wood and

D4 into Styrofoam.
Bone Density Location.

D1 bone is almost never observed in the maxilla. In the mandible it is observed

about 8%. It is observed twice as often in anterior mandible compared with the

posterior mandible.

D2 is the most common bone density observed in the mandible.

The anterior mandible consists of D2 bone 2/3 of times. D2 is more likely in the

partially edentulous anterior and pre molar region rather than completely

edentulous posterior molar areas

D3 is common in the maxilla.

More than one 12 of the patients have D3 in maxilla.

Anterior maxilla has D3 about 65% of time.

Where as about 25% of the anterior edentulous mandibles have D3 bone.

D4 bone.

Is the softest bone.

Most often found in posterior maxilla(40%)

RADIOGRAPHIC BONE DENSITY.

Periapical and panoramic radiographs are not beneficial to determine bone density

because the lateral cortical plate often obscures the trabecular bone density. One

may determine bone density more precisely by tomographic radiographs

especially CT. CT produces axial images of the patient's anatomy, perpendicular

to long axis of the body. Each CT axial image has 260000 pixels, and each pixel

has a CT number (Hounsfield unit). In general higher the CT number denser the

tissue.

Mish bone density classification may be evaluated on the CT image by correlation

to a range of HF units.
AVAILABLE BONE

Long term success in implant dentistry requires the evaluation of more than 50

dental criteria. However, the amount and density of the available bone in the

edentulous site of the patients are arguably the primary determining factors in

predicting individual patient success.

Definition- Available bone describes the amount of bone in the edentulous area

considered for implantation.

The bone is measured in width, height, length, angulation and crown height/

implant body ratio.

As a general guideline, 2mm of surgical errors is maintained between the implant

and any adjacent land mark.

This margin of error is especially critical when the opposing landmark is the

mandibular inferior alveolar nerve.

The implant length corresponds to the height of alveolar bone.

The diameter of a root form implant is related to the width and mesiodistal length

of available bone
Classification Mish and Judy (1985)
AVAILABLE BONE HEIGHT

The height of the available bone is measured from the crest of the edentulous

ridge to the opposing landmark. The anterior regions are limited by the maxillary

nares, or the inferior border of the mandible.

The anterior regions of the jaws have the greatest bone height because

themaxillary sinus and inferior alveolar nerve limit this dimension in the posterior

regions. Maxillary canine eminence region often offers greater height of available

bone height than other maxillary anterior sites. Usually greater bone height is

available in the maxillary 1" pre molar than in the 2nd premolar which has greater

height than the molar sites because of the concave morphology of the maxillary

sinus floor. The mandibular 15 premolar region is usually anterior to the mental

foramen and provides the most vertical column of bone in the mandible.

However, on occasion, this site may present a reduced height compared with the

anterior region because of the anterior loop of the mandibular canal as it passes

below the foramen and proceeds superiorly then distally, before its exit through

the mental foramen.

The bone height is also influenced by skeletal anatomy;

 Angle class II patients have shorter mandibular height.

 Angle class III patient's exhibits the greatest height.

 The suggested minimum bone height for predictable long term endosteal

implant survival is 9mm.

AVAILABLE BONE WIDTH

The width of the Available bone is measured between the facial and lingual plates

at the crest of the potential implant sites. In most areas, because of this triangular

cross section an osteoplasty provides greater width of the bone, although of

reduced height. However, the anterior maxilla does not follow this rule because

most edentulous ridges exhibit a labial concavity in the incisor region, which is

responsible for hourglass configuration. Once adequate height is available for

implant the next most significant criteria affecting long term survival of implants

is width of available bone. Root form implants of 4mm crestal diameter usually
require more than 5mm of bone width to ensure sufficient bone thickness and

blood supply around the implant

AVAILABLE BONE LENGTH

The mesio distal length of the available bone in an edentulous area is often limited

by adjacent teeth or implants.

As a general rule the implant should be at least 1.5mm from an adjacent tooth this

dimension not only allows surgical errors but also compensate for the width of an

implant or tooth defect.

Ex: a 5mm diameter implant should have at least 8mm of mesiodistal bone a so

that 1.5mm is present on either side of the implant.

AVAILABLE BONE ANGULATION

The Available bone angulation represents the root trajectory in relation to the

occlusal plane. In anterior edentulous maxillary arch, labial undercuts and orption

after tooth loss often mandate greater angulation of the implants or correction of
the site before insertion. In the posterior mandible, the submandibular fossa

mandates implant placement with increased angulation as it progresses distally.

 Hence in anterior maxilla - 12

 2nd premolar - 10.

 1st molar - 15.

 2nd molar - 20-25.

 Wider root form implants allow up to 25 of divergence.

BONE AUGMENTATION PROCEDURES

Sinus augmentation procedure recommendations using the residual alveolar

bone height classification is used as a reference for predictable implant treatment

planning.
TREATMENT PLANNING BASED ON ANATOMICAL STRUCTURES:

Maxillary localized anatomy should be evaluated in the pretreatment assessment

of the CBCT:

1. Maxillary tuberosity

2. Maxillary sinuses

a. Thickness and angle of the lateral cortical borders

b. Topography of the sinus floor and bony septations

c. The height and width of the maxillary sinus

d. Location of the maxillary sinus ostium to ensure that sinus

augmentation will not result in blockage of the sinus drainage pathway

e. Vascularization along the floor of the maxillary sinus: posterior superior

alveolar artery, infraorbital artery, and the anastomosis between the 2

arteries known as the alveolar antral artery

f. Posterior superior alveolar nerve canal

 g. Common incidental findings that may complicate sinus augmentation,

such as mucosal thickenings/sinus disease, mucus retention pseudocysts,

and antroliths

3. Nasopalatine canal

4. Anterior superior alveolar nerve canal

5. Pathologic findings such as tumor or cysts

Mandible

1. Submandibular fossa and mylohyoid ridge

2. Mandibular foramen and lingula

 3. Mandibular canal location as well as potential bifurcation and anterior

loop

4. Mental foramen location as well as potential accessory foramina

5. Lingual canal location and anatomic variants

6. Genial tubercles

7. Pathologic findings such as tumors or cysts

In general, a minimum of 1 mm of circumferential bone is required to allow

sufficient volume to stabilize an implant. A 2-mm margin of safety is

recommended next to allpertinent anatomic structures. The presurgical

radiographic evaluation also determines the need for additional surgical

procedures before or at the time of implant placement to ensure appropriate

distance from adjacent anatomy and adequate surrounding bone volume for

implant stability, such as indirect or direct sinus augmentation, inferior alveolar

nerve repositioning, and bone graft.

Radiographic measurements of the partially edentulous site

1. Mesial-distal (MD) dimension: between an implant and a tooth at least 1.5 mm

and between 2 implants at least 3 mm are required to preserve adequate blood

supply and maintain healthy hard and soft tissues.

2. Buccal-palatal/lingual (BP/L) dimension: at least 1.5 mm from the buccal bone

is recommended to maintain tissue architecture after tooth extraction and implant

placement. To facilitate that, the implant should be placed 2 mm palatal/lingual

to the planned gingival zenith.

3. Incisal-apical (IA) dimension: the bone crest to the interproximal contact point

should be less than 6 mm to support papilla formation. The implant-abutment

interface should be approximately 3 mm apical to the adjacent tooth cement-

enamel junction

Radiographic measurements of the completely edentulous arch

For a complete arch rehabilitation, the number of implants required to

support the desired prosthesis should be taken into consideration during the

radiographic evaluation of the residual alveolar bone. Adequate anterior-posterior

(A-P) spread for fixed and removable prostheses may sometimes be offset by the

above mentioned anatomic structures. Therefore, in order to avoid extensive

grafting procedures, nowadays, fewer implants are recommended to restore a full-

arch. At least 4 implants are recommended for maxillary and mandibular full-arch
fixed or maxillary removable prosthesis. For mandibular complete removable

prosthesis, at least 2 implants are advocated.

RADIOGRAPHIC MEASUREMENT OF RESTORATIVE SPACE

Restorative space is calculated from the implant platform to the occlusal surface

of the planned restoration, and it depends on the type of prosthesis planned. This

measurement is necessary to ensure adequate space for optimum physical and

mechanical properties of all components/materials required in the prosthesis. Each

prosthesis requires different restorative space, which is why the selection of the

final prosthesis should be determined before implant surgery. Adjunctive

treatments may be required before or during implant placement, such as

alveoloplasty or alveolectomy, to ensure that the prosthetic components/materials

will have adequate space/thickness for long-lasting results (Fig. 11). If residual

alveolar bone volume is limited and alveoloplasty cannot be performed, increase

in occlusal vertical dimension may be considered in order to achieve the

recommended vertical restorative space or alternative restoration/materials should

be planned. Therefore, a template of the final prosthesis at the correct restorative

dimensions is required during CBCT imaging.

Minimum vertical restorative space for different implant-supported prostheses is:

o Fixed screw-retained prosthesis (crown or FDP) (implant level): 4 to 5 mm

o Fixed screw-retained prosthesis (crown or FDP) (abutment level): 7.5 mm

o Fixed cement-retained prosthesis (crown or FDP): 7 to 8 mm

o Unsplinted implant overdenture: 7 to 17 mm

o Splinted (bar-supported) implant overdenture: 13 to 14 mm

o Screw-retained fixed complete denture (abutment level): > 15 mm

IMPORTANCE OF RADIOGRAPHIC GUIDES FOR PLANNING OF

PROSTHODONTIC PATIENTS
 In prosthodontically driven implant imaging, the definitive prosthesis

position is represented by an appropriately designed and fabricated radiographic

guide/Stent. In an effort to correlate the most favourable position and inclination

of the fixtures as dictated by the prosthetic teeth, stents are sometimes used during

the scanning procedure. It is well known that because of the resorptive patterns of

the alveolar ridges, the prosthetic teeth may be set off the ridges in order to satisfy

the patient’s requirements for esthetics, phonetics and lip support. In reading that

CT scan, it is helpful to know the location of the teeth in order to determine

whether the axial inclination of the fixture can be or should be tipped toward the

position of the teeth. Radiographic templates containing radiopaque materials

and/or fiducial markers transfer both the proposed prosthesis design and desired

implant location for appropriate CBCT scan. There are several approaches

available to conventionally or digitally fabricate radiographic stents, which

include the use of:

1. An existing prosthesis with ideal teeth position with added

radiopaque fiduciary markers.

2. A thermoplastic stent with incorporated radiopaque markers and/or made out of

radiopaque acrylic material such as barium sulfate. This stent is made using a

duplicate cast of the diagnostic wax-up.

3. Radiopaque teeth at the position of the planned restoration in a mucosa-

supported or tooth-supported stent.

4. Digital design software is used to determine ideal prosthesis/teeth position via

virtual wax-up. Based on that design, a diagnostic model, a radiographic template

or even a surgical guide may be fabricated.

After planning, the radiographic guide may be converted to a pilot surgical

stent by modification. This stent must be sterilized and then at the time of surgery,

the surgeon simply aligns his or her burs relative to the markers and relative to the

crest of ridge in the same relationship to these two known reference points that he

did with his straight edge on the CT images. It has been shown that the combined

use of a prosthodontic stent and 3D imaging is an effective technique in achieving

an ideal position of dental implants.

DIGITAL TECHNOLOGY AND IMPLANT PLANNING:

Prosthetically driven implant planning enables and ensures esthetic,

functional, and long-lasting prosthodontic outcomes. CBCT data combined with

data from intraoral scanners like the Cerec Omnicam® or Cerec Bluecam®

(Sirona, Germany) is used to interface with other interactive machinery like

CAD/CAM or three-dimensional printers for precision milling/additive

manufacturing resulting in immediate delivery of chair side fixed prostheses and

surgical guides. Prosthetically driven implant planning with digital technology

workflow is as follows:

1. Computed tomography (CBCT) scan of the patient- image used to identify

anatomical obstacles and evaluate bone structure

2. Create a digital model in two ways:

I. the clinician can use an intraoral scanner to create a digital

impression

II. clinician can take a traditional impression and then scan the

impression using a lab scanner.

3. Then, using interactive software for treatment support, the DICOM data from

the CBCT scan and data from digital impression as the standard tessellation

language or standard triangulation language (.stl) file are merged together .

4. Plan the implant and abutment

5. The interactive implant planning software provides multiple views, enabling

the clinician to evaluate potential implant receptor sites with greater accuracy.

6. Through the software, bone can be ―removed‖ or displayed with transparency,

which helps in determining the precise placement of implants, abutments and

translucent virtual teeth in proximity to the natural tooth root structure.

7. A virtual crown is used to guide the placement of the virtual implant for

optimal aesthetics and function, crown-to-implant ratio; implant diameter and

length; and the design of the restoration in terms of screw or cement retention
 For partially edentulous patients- the DICOM file from the CBCT and the .stl

file from the digital wax-up. Then, the surgical guide is milled for pilot or fully

guided surgery.

Dual-scan technique- In completely edentulous patients the first scan is

made of the patient with the radiographic guide in place and the second scan is

made of the radiographic guide separately. Both scans are merged in the planning

software using the fiducial markers in order to plan and fabricate a surgical guide.
 In the ―prosthetically driven implant‖ technique, a radiopaque marker

(barium coated teeth) can be utilized to demarcate the final tooth position. This

data, when aligned on CBCT, can be utilized to create a surgical guide for precise

implant placement, which ensures final prosthesis to implant alignment.

Cone beam computed tomography can be extremely helpful in identifying

areas of inadequate bone to support dental implants. This information would

allow in determining the volume of graft needed prior to surgery and the type of

graft material to select. Heiland et al. described the intra-operative use of CBCT
in two cases to guide the insertion of the implant after microsurgical bone

transfer. Post-graft imaging would reveal the amount of bone formed and will also

provide information on bone density. Cone beam computed tomography provides

valuable information about the thickening and perforations involving the sinus

membrane, patency of the osteomeatal complex and also aids in more informed

planning with respect to surgical access into the sinus. This confirms that the

range of anatomical detail gained through a CBCT provides the implantologist

ample amount of information to improve the success rate of grafting of the

maxillary sinus and sinus implants.

Thus, CBCT scans are reliable and accurate in dental treatment with a rapidly

expanding repertoire of applications. There is no evidence supporting the use of

CBCT in the post-placement monitoring of implants, despite the increasing usage

of CBCT for implant assessment. However, it is still the most accurate and

reliable method of assessing 3D bone level changes around an osseointegrating

implant, especially in the buccal and lingual/palatal areas.

 SUMMARY

The selection of the proper radiological technique for the patient must be

carefully made by the practitioner, in correlation with the clinical signs and

symptoms. The purpose of the chosen radiological investigation must improve the

diagnosis and the treatment outcome according to each imaging examination’s

specific indications and varying degrees of sensitivity and specificity. From the

simple intra-oral periapical X-rays, advanced imaging techniques like computed

tomography, cone beam computed tomography, magnetic resonance imaging and

ultrasound have also found place in prosthodontic evaluation. Changing from

analogue to digital radiography has not only made the process simpler and faster

but also made image storage, manipulation (brightness/contrast, image

cropping, etc.) and retrieval easier. The three-dimensional imaging has made the

complex cranio-facial structures more accessible for examination and early and

accurate diagnosis and treatment planning with desirable prosthetic rehabilitation.

Radiographic images are indispensable in the evaluation of osseous structures

when planning treatment for dental implants. Proper dental implant placement for

single crowns, multiple fixed partial dentures, implant-retained overdentures, or

fixed implant–supported restorations relies on adequate pretreatment visualization

of the proposed bone recipient site, evaluation of bone density, and assessment of

restorative goals. Radiographic visualization of facial and cervical tooth positions,

bound restorative space, and bone configuration is a necessary step in the

treatment sequence and planning of implant restorations. The ultimate success of

the dental implant relies on this radiographic assessment in combination with

proper restorative evaluation to ensure that the final outcome is compatible with

expected outcomes
 CONCLUSION

Radiographs as an adjunct to diagnostic aid of prosthodontic patients has

revolutionized treatment planning in the digital era. Recent advances in imaging

technologies has reorganized dental diagnostics and treatment planning. Correct

use of appropriate imaging technology and their correct interpretation, following

the ALARA (As low as reasonably achievable) principles and cost-effectiveness,

newer radiographic techniques can help in proper diagnosis and treatment

planning in prosthodontic evaluation leading to predictable prosthetic, esthetic,

and functional results.

Good understanding and sound knowledge of various radiographic modalities

and their specificity help to eliminate unnecessary radiation hazards and control

expense of treatment. Radiographs form final aspect of diagnostic procedure and

helps the prosthodontist correlate all the facts that have been collected listening to

the patient , examining the mouth and evaluating the diagnostic cast. Proper

modality of radiographic interpretation, good technical skill in taking radiograph,

thorough radiographic study, proper interpretation help to reach a perfect

diagnosis and optimum treatment. Arriving at definite diagnosis and treatment

plan is challenging task in Prosthodontics which is made easy by radiographic

interpretation.
 REFERENCES

1. The use of cone-beam computed tomography in dentistry. (2012). The

Journal of the American Dental Association, 143(8), 899–

902. doi:10.14219/jada.archive.2012.0295 10.14219/jada.archive.2012.0

2. Kapshe, Nikita & Pujar, Madhu & Jaiswal, Satyam. (2020). Cone beam

computed tomography: A review. International Journal of Oral Health

Dentistry. 6. 71-77. 10.18231/j.ijohd.2020.017.

3. Pipko DJ. Radiographic measurements for dental implants. Quintessence

International 1989; 20: 687-688

4. Dula K, Mini R, Stelt PF, Buser D. The radiographic assessment of

implant patients: decision making criteria. Int J Oral Maxillofac Implants

2001;16:80-89

5. Monsour PA, Dudhia R. Implant radiography and radiology. Australian

Dental Journal 2008; 53(1 Suppl): S11-S25

6. Bhatia HP, Goel S, Srivastava B. Denta Scan. J oral Health Comm Dent

2012; 6(1): 25-27

7. Nicopoulou-Karayianni K, Bragger U, Lang NP. Subtraction radiography

in oral implantology. Int J Perio Restor Dent 1997; 17: 221-231

 8. Talmaceanu, D., Lenghel, L. M., Bolog, N., Hedesiu, M., Buduru, S.,

Rotar, H., Baciut, G. (2018). Imaging modalities for temporomandibular

joint disorders: an update. Clujul Medical, 0(0). doi:10.15386/cjmed-970

9. Worthington P, Rubenstein J, Hatcher DC. The role of cone‑beam

computed tomography in the planning and placement of implants. J Am

Dent Assoc 2010;141 Suppl 3:19S‑24.

10.Gulsahi A. Bone Quality Assessment for Dental Implants, Implant

Dentistry- The most promising discipline of dentistry. In: Prof. Ilser

Turkyilmaz editor, ISBN: 978‑953‑307‑ 481‑ 8, InTech, 2011.

11. John GP, Joy TE, Mathew J, Kumar VR. Applications of cone beam

computed tomography for a prosthodontist. J Indian Prosthodont Soc

2016;16:3‑ 7.

12. Scherer MD. Presurgical implant-site assessment and restoratively driven

digital planning. Dent Clin North Am. 2014;58(3):561-595.

doi:10.1016/j.cden.2014.04.002

13. Webber RL, Horton RA. Tuned-Aperture Computed Tomography:

Theory and Application in Dental Radiology. In: Advances in Maxillofacial

Imaging. Farman AG, Ruprecht A, Gibbs SJ, Scarfe WC, eds. Amsterdam:

Elsevier Science BV, 1997:359–366.

14. Hounsfield GN. Nobel Lecture. 8 December 1979. Computed medical

imaging. J Radiol 1980;61:459–468

15.Schmitt SM (2009) Dental digital diagnosis and treatment: new tools for

predictable. http://smile.uthscsa.edu/fallSchmittjan/html. Accessed 20 July 2012

16. Misch CE. Contemporary implant dentistry. 2th edn. St. Louis: Mosby;

1997:3.

17. Shah N, Bansal N, Logani A. Recent advances in imaging technologies in

dentistry. World J Radiol 2014; 6(10): 794-807

18. Monson ML. Diagnostic and surgical guides for placement of dental

implants. J Maxillofac Surg. 1994;52:642

19. Caplanis N, Kan JYK, Lozada JL. Osseointegration: contemporary

concepts and treatment planning. J Calif Dent Assoc. 1997;12:843–851

20. Pollack BR. Legal risks associated with implant dentistry. In'. Hardin JF,

editor. Clark's clinical dentistry. Vol 5. Philadelphia: JB Lippincott; 1992. p. 1.

 21. Rushton VE and Horner K. The use of panoramic radiology in dental

practice. J. Dent 1996; 24:185-201.

22. Berger D. A brief history of medical diagnosis and the birth of the clinical

laboratory (1999) www.mlo-online.com

23. Lamster IB. A Model for Dental Practice in the 21st Century. Am J

Public Health. 2011;101: 1825–1830

24. Scarfe WC, Farman AG, Sukovic P. Clinical Applications of Cone-Beam

Computed Tomography in Dental Practice, J Can Dent Assoc 2006; 72(1):75–80

25. Basic Implant Surgery, R.Palmer, P.Palmer, Floyd, Vol 187,No 8,OCT

23,1999,BDJ

26. Stelt, P.F. & Ruttimann, U & Webber, R. (1989). Determination of

projections for subtraction radiography based on image similarity measurements.

Dento maxillo facial radiology. 18. 113-7. 10.1259/dmfr.18.3.2700350.

27. Wyatt CC, Pharoah MJ. Imaging techniques and image interpretation for

dental implant treatment. Int J Prosthodont. 1998;11(5):442-452.

28. Anadioti E, Kohltfarber H. Radiographic Evaluation of Prosthodontic

Patients. Dent Clin North Am. 2021;65(3):605-621.

doi:10.1016/j.cden.2021.02.007