Periodontology 2000, Vol. 73, 2017, 51–72 © 2016 John Wiley & Sons A/S.
& Sons A/S. Published by John Wiley & Sons Ltd
Printed in Singapore. All rights reserved
Use of cone beam computed
tomography in implant dentistry:
current concepts, indications and
limitations for clinical practice
and research
M I C H A E L M. B O R N S T E I N , K E I T H H O R N E R & R E I N H I L D E J A C O B S
Since its initial description in 1998 by Mozzo et al.
(99), three-dimensional radiographic imaging using
cone beam computed tomography has become an
established diagnostic technique in dental medicine
for various indications in the fields of orthodontics
(79, 86, 115), endodontics (including apical surgery)
(108, 128, 152), periodontology (153), oral and max-
illofacial surgery (3) and implant dentistry (17). Com-
pared with multislice computed tomography, cone
beam computed tomography imaging appears to
offer the potential of an improved diagnostic value
for a wide range of clinical applications, and usually
at lower doses of radiation. However, apart from
applications in implant dentistry, computed tomog-
raphy has few uses in dentistry, and cone beam com-
puted tomography exposes patients to higher doses
of radiation doses than encountered with the use of
conventional (two-dimensional) dental radiographic
techniques. Although cone beam computed tomogra-
phy imaging continues to gain popularity, its use cur-
rently is primarily recommended for cases in which
clinical examination supplemented with conventional
two-dimensional intra- and extraoral radiography
cannot supply satisfactory diagnostic information.
Thus, cone beam computed tomography scanning
has to be considered basically as an adjunctive diag-
nostic radiographic modality (39, 40).
In 2009, the European Academy of Dental and Max-
illofacial Radiology published basic principles on the
use of cone beam computed tomography imaging
(Table 1) (68). The set of 20 principles was formulated
PERIODONTOLOGY 2000
to act as core standards and to be adopted and to be
of value in national standard-setting procedures
within Europe (68). The first eight statements relate
principally to justification of cone beam computed
tomography examinations, while the first four of
these implicitly condemn routine three-dimensional
examinations. Statements nine to 15 deal broadly
with optimization and dose limitation. The final
statements (16–20) discuss training and competence
issues, as, in some countries of the European Union,
cone beam computed tomography equipment can be
purchased, installed and used by a dentist and there
is no specific requirement for additional training. The
European Academy of Dental and Maxillofacial Radi-
ology maintains the view that, with adequate training,
it is reasonable to expect dentists to perform clinical
evaluation of images in the familiar area of teeth and
their supporting structures, whilst advocating
specialist evaluation for other anatomic areas. This
vision is also maintained in the 2012 European evi-
dence-based guidelines on the use of cone beam
computed tomography for dental and maxillofacial
radiology (43).
This review will present current concepts for the
use of cone beam computed tomography imaging,
before and after implant placement, in daily clinical
practice and research. Guidelines for the selection of
three-dimensional imaging will be discussed and
limitations will be highlighted. Current concepts of
radiation dose optimization, including novel imaging
modalities using low-dose protocols, will be
51
Bornstein et al.

Table 1. Basic principles of the use of cone beam computed tomography imaging, as proposed by the European Acad-
emy of Dental and Maxillofacial Radiology (Horner et al. (68)
1 Cone beam computed tomography examinations must not be carried out without a medical history and clinical
examination
2 Cone beam computed tomography examinations must be justified for each patient to demonstrate that the
benefits outweigh the risks
3 Cone beam computed tomography examinations should potentially add new information to aid the patient’s
management
4 Cone beam computed tomography should not be repeated ‘routinely’ on a patient without a new risk/benefit
assessment
5 When accepting referrals from other dentists for cone beam computed tomography examinations, the referring
dentist must supply sufficient clinical information to justify the examination
6 Cone beam computed tomography should only be used when the question for which imaging is required cannot
be answered adequately by lower-dose conventional radiography
7 Cone beam computed tomography images must undergo a thorough clinical evaluation of the entire image data
set (reporting)
8 When soft-tissue evaluation is required, the appropriate imaging should be conventional medical computed
tomography or magnetic resonance, rather than cone beam computed tomography
9 Cone beam computed tomography equipment should offer a choice of volume sizes, and examinations must use
the smallest that is compatible with the clinical situation
10 Where cone beam computed tomography equipment offers a choice of resolution, the resolution compatible with
adequate diagnosis and the lowest achievable dose should be used
11 A quality assurance program must be established and implemented for each cone beam computed tomography
facility, including equipment, techniques and quality control procedures
12 Aids to accurate positioning (light beam markers) must always be used

13 All new installations of cone beam computed tomography equipment should undergo an examination and
detailed acceptance tests before use to ensure that radiation protection for staff, members of the public and
patient are optimal
14 Cone beam computed tomography equipment should undergo regular routine tests to ensure that radiation
protection has not significantly deteriorated
15 For protection of staff from cone beam computed tomography equipment, the guidelines detailed in Section 6 of
the European Commission document Radiation Protection 136. European guidelines on radiation protection in
dental radiology should be followed
16 All those involved with cone beam computed tomography must have received adequate theoretical and practical
training for the purpose of radiological practices and competence in radiation protection
17 Continuing education and training after qualification are required, particularly when new cone beam computed
tomography equipment or techniques are adopted
18 Dentists responsible for cone beam computed tomography facilities who have not previously received ‘adequate
theoretical and practical training’ should undergo a period of additional theoretical and practical training that
has been validated by an academic institution (university or equivalent). Where national specialist qualifications
in dental and maxillofacial radiology exist, the design and delivery of cone beam computed tomography training
programs should involve a dental and maxillofacial radiologist
19 For dentoalveolar cone beam computed tomography images of the teeth, their supporting structures, the
mandible and the maxilla up to the floor of the nose (e.g. 8 9 8 cm or smaller fields of view) and clinical
evaluation (radiological report) should be made by a specially trained dental and maxillofacial radiologist or,
where this is impracticable, an adequately trained general dental practitioner
20 For nondentoalveolar small fields of view (e.g. temporal bone) and all craniofacial cone beam computed
tomography images (fields of view extending beyond the teeth, their supporting structures, the mandible,
including the temporomandibular junction, and the maxilla up to the floor of the nose), clinical evaluation
(radiological report) should be made by a specially trained dental and maxillofacial radiologist or a medical
radiologist

52

presented. Finally, new imaging technologies under
investigation will be reviewed and evaluated for their
potential as future options for imaging in oral implan-
tology.
Aspects of radiation exposure when
using cone beam computed
tomography in implant dentistry
Patient risk from radiation is an ongoing concern as a
result of the high frequency of dental radiographic
examinations in developed countries (144). In the
context of dental cone beam computed tomography,
in which higher radiation doses are usually seen than
for conventional (two-dimensional) radiography, it is
important to consider the risks that are associated
with exposure to X-radiation. These risks are stochas-
tic in nature, specifically cancer induction. ‘Stochas-
tic’ means that there is a statistical probability (risk)
of an adverse event occurring as a result of the X-ray
exposure. The risk is proportional to the dose, but it is
generally accepted that there is no ‘safe’ dose of radi-
ation. The risk is age-related, with children having
higher risks than adults for the same dose of radia-
tion, a fact that has particular dental relevance.
Therefore, it is reassuring that in implant dentistry,
patients tend to be older (14, 42) and accordingly the
risk from radiation is lower. Nonetheless, in the
absence of a ‘safe’ dose of X-rays, radiation protection
of patients should not be ignored. Pauwels et al. (110)
reported that the lifetime attributable cancer risk
for cone beam computed tomography, expressed as
the probability of developing a radiation-induced
cancer, varies between 2.7 per million (for pa-
tients > 60 years of age) and 9.8 per million (for
patients ranging from 8 to 11 years of age) with an
average risk of 6.0 per million. On average, the risk
for female patients is reported to be 40% higher
than that for male patients. Overall, the estimated
radiation risk is primarily influenced by the age at
exposure and the gender, highlighting the continu-
ing need for radiation protection, particularly in
patients of younger age groups.
Principles of radiation protection
To reduce the levels of radiation-associated risk, it is
essential to adhere to radiation protection principles.
These are: justification; optimization; and limitation
of doses (72). Only the first two of these apply to
patients because there can be no dose limits in this
context. For staff working with radiation and for the
Cone beam computed tomography in implant dentistry
wider public (excluding patients), dose limitation is
the paramount principle of radiation protection,
although optimization of patient dose will sometimes
translate into exposure of the clinical staff performing
the procedure to a low dose of radiation.
Under normal circumstances, the risk from dental
radiography is very low. Nonetheless, it is essential
that every radiographic examination should show a
net benefit to the patient. The use of radiation is
accepted when it is expected to do more good than
harm (determined by weighing the total potential
diagnostic benefits gained against the detriment to
the individual that the exposure might cause [justifi-
cation]). The criteria for X-ray imaging should be
reviewed from time to time as more information
becomes available about the risks and effectiveness of
the existing procedure and as new procedures
emerge. The process of justification requires ade-
quate knowledge of the patient’s history and the
results of the clinical examination. When acting as a
referrer, the dentist should therefore ensure that ade-
quate clinical information about the patient is pro-
vided to the person taking responsibility for the
radiographic examination (62, 68).
Optimization of dose in radiological procedures is
often defined by the ALARA principle. ALARA is the
acronym for ‘As Low As Reasonably Achievable’, in
this case referring to the radiation dose (44). Imple-
menting ALARA into practice involves consideration
of many factors, including initial equipment selec-
tion, maintenance, individualized selection of X-ray
exposures and an ongoing quality assurance program,
all aimed at consistent production of adequate diag-
nostic information at the lowest possible exposure to
ionizing radiation, taking into account economic and
social factors. Regular quality-control tests are
involved, including regular equipment testing, audit
of the radiation dose received by patients and assess-
ment of image quality.
Radiation doses with cone beam
computed tomography equipment
Radiation dosimetry can be confusing to the novice,
as several different concepts and multiple units are
used. The dose metric commonly reported in the
literature is the effective dose, defined by the Interna-
tional Commission on Radiological Protection as the
weighted sum of doses absorbed by different radio-
sensitive organs (72). It is measured in sieverts (Sv) or,
more usually, in millisieverts (mSv) or even in
microsieverts (lSv). The reason for this complicated
concept is that different organs and tissues have
53
Bornstein et al.

different radiation sensitivities; thus, a specific X-ray Image quality and radiation dose
exposure to one part of the body, such as the abdo-
When attempting to practise ALARA, it is essential to
men, would give a very different dose and risk if
recognize the close relationship between image qual-
applied to another part of the body, such as the face.
ity and radiation dose. It would be easy to reduce
Because almost all organs and tissues for which
radiation doses to extremely low levels, but this might
dose measurements are needed to calculate effective
dose are internal, effective dose cannot be measured make images diagnostically useless. In reality, we
require diagnostically adequate images, rather than
in patients directly, so it is usually measured using an
those of the highest quality. Consequently, the ALARA
anthropomorphic phantom, representing an average
principle has been recently modified to emphasize
human (140). Effective dose provides an estimation of
the need to give equal weighting to image quality and
the stochastic risk for an average-size adult reference
patient. In practice, however, patient dose will vary dose optimization. This has resulted in the new con-
cept of ALADA (i.e. ‘As Low As Diagnostically Accept-
between individuals, with patient size and mass as
able’) (74). For cone beam computed tomography
the main influencing factors (25, 92). Although it is
equipment, a key influence on radiation dose and
possible to purchase different sizes of dosimetry
image quality is the selection of exposure factors (e.g.
phantoms, representing women and children, to
X-ray tube current exposure time product and operat-
provide more appropriate measurements of effective
ing potential) (54). Some cone beam computed
dose, multiple calculations of effective dose for differ-
tomography equipment offers high-resolution pro-
ent scenarios is very time-consuming. Dedicated
grams; these achieve their image quality by increasing
Monte Carlo computer simulations offer a valuable
the exposure. In contrast, some equipment offers low
alternative, which can model a wide variety of imag-
exposure options through reducing exposure factors.
ing systems, exposure variables and examination in
patients of different gender and ages (133, 157, 158). A few manufacturers have incorporated automatic
exposure controls into their cone beam computed
A large number of dental cone beam computed
tomography machines. Automatic exposure controls
tomography devices are currently available commer-
have the advantage of selecting exposures specific to
cially (103), and considerable variability in radiation
each patient; however, a disadvantage is that the
doses has been reported for these (17, 109). In a
choice of image quality is taken away from the clini-
recent systematic review by Bornstein et al. (17), cone
cian and the exposure could easily be set at the wrong
beam computed tomography devices were grouped
level for specific diagnostic tasks.
according to their field of view, resulting in three cat-
Several studies have considered the impact of
egories of device, namely those with small, medium
reducing exposure factors in the context of implant
and large fields of view. When analyzing the reported
dentistry (4, 37, 134, 146, 154). All show substantial
effective dose ranges for all three categories, wide
ranges of dose were found – 11–252 lSv for small, scope for reducing exposure factors, and hence
patient dose, without significant loss of image quality.
28–652 lSv for medium and 52–1,073 lSv for large
The impact of dose-reduction techniques on the
fields of view. The authors therefore concluded that a
quality of three-dimensional virtual models fabri-
single average effective-dose value is not a concept
cated using cone beam computed tomography data
that should be used for the cone beam computed
tomography technique as a whole, when comparing should, however, be considered when performing
optimization efforts (37).
it with alternative radiographic methods. As most
Low-dose protocols have been recommended to
devices exhibited an effective dose in the 50–200 lSv
assist practitioners in optimization, such as that pro-
range, it can be stated that cone beam computed
posed by Harris et al. (62). A low-dose protocol for
tomography imaging results in higher doses in
pediatric cone beam computed tomography has been
patients than do standard two-dimensional radio-
developed, which represents a reduction of as much
graphic methods used in dental practice but that the
as 50% compared with the manufacturer’s recom-
doses remain well below those reported for common
mendations for that specific piece of equipment (64).
multidetector computed tomography protocols. It is
However, in practice, dentists are likely to depend on
important to recognize that doses in children may be
the manufacturers’ instructions when deciding on
different from those in adults because of their relative
size and the different positions of the radiosensitive appropriate exposure settings, so it is encouraging
that new low-dose protocols have also been devel-
organ in the body (139). For example, the proportion-
oped by manufacturers. Such an example is the ultra-
ally higher thyroid dose in children was highlighted in
low-dose protocol proposed by Planmeca (Helsinki,
a recent meta-analysis (90).

54

Finland), which allows operators to adjust imaging
parameters individually, in particular the mA values.
These can be adjusted for patient groups by selecting
the mA value of the scan according to the size of the
patient (small/medium/large). This results in effec-
tive dose values for cone beam computed tomogra-
phy scans in the range of panoramic views. Although
there is still a need to determine for which clinical
indications the image quality provided by these low-
dose protocols is sufficient, these radiation doses (in
the range of those given by panoramic radiography)
could allow cone beam computed tomography scans
to be used as primary imaging modalities in specific
circumstances (18).
Although a dose advantage is frequently cited for
cone beam computed tomography compared with
multislice computed tomography, low-dose protocols
are possible for the latter. Depending on the model
and the setting used, radiation levels for multislice
CTs may even be lower than for cone beam com-
puted tomography scans (66, 155). This progress in
dose optimization for two-dimensional and three-
dimensional technologies in dentomaxillofacial
radiology demonstrates clearly that radiation dose–
exposure and radiation risks are a dynamic field and
need to be constantly monitored and updated by the
clinician for the respective radiographic device used
in daily practice. Only by doing so can the practi-
tioner really comply with ALADA principles and
implement radiation protection into their daily rou-
tine.
Recommendations for cone beam
computed tomography imaging for
dental implant treatment planning
(preoperative imaging)
In a recent survey in Norwegian dental clinics on the
use of cone beam computed tomography (67), the
most common indications for this imaging modality
were implant treatment planning (34% of all clinics)
and localization of impacted teeth (43% of all clinics).
As implant treatment planning is one of the most
common indications for radiographic three-dimen-
sional imaging, accepted recommendations and
guidelines for the use of cone beam computed
tomography for this purpose are clearly needed. Clin-
ical guidelines are able to provide a framework for the
use of a new technology or technique, and are
designed to assist the clinician and the patient in
making appropriate decisions for certain specific
Cone beam computed tomography in implant dentistry
clinical circumstances. There are three fundamental
approaches to guideline development: the first is to
rely on the opinion of an expert panel; the second is
to employ a consensus method; and the third is to
use an ‘evidence-based’ guideline development
methodology. Evidence-based methods are consid-
ered as being optimal to limit the influence of individ-
ual opinion and bias by using defined and objective
methods based upon a systematic review of the litera-
ture (57, 91). In a recent review, Horner et al. (69)
identified 26 publications containing guidelines on
the clinical use of cone beam computed tomography
in dental and maxillofacial radiology. The articles
selected by the authors that specifically addressed the
use of cone beam computed tomography in dental
implant treatment planning were somewhat conflict-
ing in their recommendations: three publications rec-
ommended cone beam computed tomography
imaging for planning before all dental implant place-
ments (38, 104, 142); other guidelines maintained that
a selective approach is appropriate (10, 62); while a
further group of publications gave equivocal state-
ments (2, 33, 60).
Diagnostic imaging is an essential component of
treatment planning in oral rehabilitation using
osseointegrated dental implants. Some authors have
demonstrated that clinical examination and panora-
mic radiography alone may provide sufficient imag-
ing for posterior mandibular implant placement (70,
136), especially when there is a 2 mm margin of safety
above the inferior alveolar canal (149). The European
Association for Osseointegration guidelines for the
use of diagnostic imaging in implant dentistry were
published in 2002 (61). Since the publication of these
guidelines, cone beam computed tomography has
become available, offering cross-sectional imaging
and three-dimensional reconstructions at potentially
lower radiation doses compared with medical multi-
slice computed tomography. Experts in both clinical
practice and radiology were invited for a closed work-
shop held at the Medical University of Warsaw,
Poland, in May 2011, to review and update the initial
European Association for Osseointegration guidelines
(62). Regarding the issue of what radiological infor-
mation is required by a surgeon when planning
implant placement, the authors stated that a clinician
requires information on the following: bone volume,
structure and density; topography and the relation-
ship to important anatomic structures, such as
nerves, vessels, roots, nasal floor and sinus cavities;
and any clinically relevant pathology. This informa-
tion is initially obtained from a clinical examination
and appropriate conventional (two-dimensional)
55
Bornstein et al.
radiographs. The decision to proceed to
cross-sectional three-dimensional imaging should be
based on clearly identified needs and the clinical and
surgical requirements of the clinicians involved. The
European Association for Osseointegration has made
the following specific recommendations for the use of
preoperative cross-sectional imaging (including cone
beam computed tomography): (i) when clinical exam-
ination and conventional radiography fail to ade-
quately demonstrate relevant anatomic boundaries
or the location of important anatomic structures, (ii)
when imaging is deemed appropriate in cases where
extensive bone augmentation is anticipated, (iii) for
all sinus floor elevation procedures, (iv) for all guided
implant surgery (computer-assisted planning and
placement of dental implants) cases, (v) when further
information regarding intraoral autogenous bone
donor sites is needed, and (vi) when planning the use
of special surgical techniques, such as zygomatic
implants or osteogenic distraction.
In a recent systematic review by the International
Team for Implantology from the consensus confer-
ence in Bern, in 2013 (17), the authors identified
numerous articles describing the importance of vari-
ous anatomic structures identified on cross-sectional
imaging, including the inferior alveolar (mandibular)
canal, anterior loop and mandibular incisive canal,
mental foramen, lingual canal, submandibular gland
fossa/lingual undercut, maxillary incisive/na-
sopalatine canal and maxillary sinus and their rela-
tion to implant placement. Although the placement
of dental implants is an important cause of iatrogenic
inferior alveolar nerve injuries (50, 117, 132, 137),
especially when focusing on permanent neurosensory
disturbances (87), it should be pointed out that it will
be difficult to prove a clear benefit of cone beam
computed tomography over conventional two-
dimensional imaging, such as panoramic radiogra-
phy, with respect to damage prophylaxis of the infer-
ior alveolar nerve or other vital neurovascular
structures in prospective studies. This is simply
related to the fact that the sample sizes needed for
such controlled prospective clinical trials will be diffi-
cult to achieve (119) and, furthermore, many institu-
tional review boards and ethical committees will not
approve studies comparing complex surgical inter-
ventions performed in a randomized manner using
two-dimensional imaging alone vs. a group of
patients who benefit from two-dimensional imaging
in combination with three-dimensional imaging
(cone beam computed tomography) (58). Besides
neurosensory disturbances, neurovascular complica-
tions caused by implant surgery can also result in
56
severe postoperative hemorrhage. Significant hemor-
rhage is mostly described after anterior mandibular
implant placement and after sinus floor elevation
procedures, before or with implant placement (73).
A scientifically proven beneficial effect of cone
beam computed tomography imaging over two-
dimensional radiographs alone to decrease complica-
tions caused by anatomic constraints is still missing.
Yet, there is evidence that planning dental implants
based on cone beam computed tomography scans
versus panoramic views exhibits significant devia-
tions from normal anatomy (138). In a recent study,
the efficacy of observers’ prediction for the need of
bone grafting and the presence of perioperative com-
plications was evaluated on the basis of cone beam
computed tomography and panoramic radiographic
planning compared with the surgical outcome (59).
Patients were included if both panoramic images and
cone beam computed tomography scans had been
taken with a maximum interval of 4 months and if
the presurgical planning phase was followed by
implant placement. Four observers carried out
implant planning using panoramic image data sets,
and, at least 1 month later, using cone beam com-
puted tomography scans. The findings of the study
indicate that cone beam computed tomography-
based preoperative implant planning enabled treat-
ment planning with a higher degree of prediction and
agreement compared with the surgical standard. In
panoramic-based surgery, the prediction of implant
length was poor. There have been similar studies in
recent years that at least partially confirm these find-
ings but also emphasize the importance of subjective
factors, such as observer opinion or experience (8, 34,
35, 46, 80, 114, 125).
A recent systematic review by Vogiatzi et al. (150)
stated that one of the main reasons for using maxillo-
facial cone beam computed tomography imaging in
dental medicine was for assessment of the residual
ridge and maxillary sinus before sinus floor elevation
or dental implant placement. Cross-sectional imaging
(cone beam computed tomography) has been recom-
mended, by several professional organizations, for
preoperative evaluation of the available bone in the
posterior maxilla and for assessing health or pathol-
ogy of the maxillary sinus (10, 17, 62). Vogiatzi et al.
(150) state that the most common anatomic variation
in the maxillary sinus is the thickness of the Schneide-
rian membrane, which seems to be significantly
thicker in the mid-sagittal aspect and in male sub-
jects. Furthermore, septa within the maxillary sinus
are common findings and are most frequently located
in the middle region of the sinus. Their prevalence

seems to be independent of age and gender. In a
recent study using cone beam computed tomography
images to evaluate the presence and type of septa,
the authors found that 66.5% of the patients included
had septa as did 56.5% of the sinuses, respectively
(19). In the majority of these cases, septa were
observed in the first or second molar regions of the
floor of the maxillary sinus. Furthermore, the most
common orientation of the septa was coronal
(61.8%), followed by axial (7.6%) and sagittal (3.6%),
but more than one-quarter of the septa could not be
classified as coronal, sagittal or axial, and were
grouped as ‘other’ septa. The authors also underlined
that their study did not provide evidence that the fre-
quency of maxillary sinus septa was associated with
age, gender or status of the dentition of the patients.
The presence of septa has been related to an
increased risk for perforation of the Schneiderian
membrane during sinus floor elevation. In the study
by Zijderveld et al. (159), on 100 patients scheduled
for sinus floor elevation, the authors reported 11
membrane perforations, five of which were directly
related to the presence of septa. In a recent investiga-
tion by von Arx et al. (151), the authors found a per-
centage of perforations in patients with septa of
42.9% vs. 23.8% in patients without septa. Several fac-
tors, other than sinus septa, have been reported that
can influence the chance of perforation of a Schnei-
derian membrane during sinus floor elevation, such
as the presence of a narrow sinus, previous sinus sur-
gery and absence of alveolar bone (105). Thus, before
performing sinus floor elevation, detailed knowledge
of the anatomic structures of the maxillary sinus
(which ideally is gained radiographically by the use of
cone beam computed tomography scans) seems to
be beneficial to avoid surgical complications.
According to the literature, a mucosal thickening of
> 2 mm is classified as pathological according to the
criteria defined by Cacigi et al. (24). If the width of
mucosal thickening is < 3 mm, the detection rate on
panoramic radiographs vs. cone beam computed
tomography scans has been reported to be signifi-
cantly decreased (126). To assess a potential treat-
ment need of pathological findings in the maxillary
sinus based on cone beam computed tomography
imaging, a classification for the morphology of the
Schneiderian membrane was proposed using sagittal
and coronal cone beam computed tomography scans
according to criteria adapted and modified from
Soikkonen & Ainamo (127) in several studies (Fig. 1)
(16, 75, 113, 122):
 Healthy: no thickening.
Cone beam computed tomography in implant dentistry
 Flat: shallow thickening without well-defined out-
lines.
 Semi-aspherical: thickening with well-defined out-
lines rising in an angle of > 30° from the floor of
the walls of the sinus.
 Mucocele-like: complete opacification of the sinus.
 Mixed: flat and semi-aspherical thickenings.
Regarding the high incidence of antral mucosal
thickening found in those studies using a mucosal
thickening of > 2 mm as a threshold value to distin-
guish physiologic from pathologic findings (16, 75,
113, 122), the clinical significance of this value has to
be questioned. In clinical situations when there is evi-
dence of sinus pathology or when the clinician
believes that sinus drainage is impaired and may
jeopardize the outcome of the prospective implant
procedure to be undertaken, it seems advisable to
consult an ear, nose and throat specialist (65). This is
especially true for maxillary sinuses with partial or
complete mucocele-like opacification of the antrum.
This is also supported by a case series analyzing fail-
ures of sinus floor elevation procedures in which it
was reported that of 13 patients included, preopera-
tive chronic maxillary sinusitis had been present in
four (5). The authors therefore stated that elimination
of sinusitis and other potential pathological condi-
tions is necessary before sinus floor elevation. If the
findings, such as mixed flat and semi-aspherical
thickening of the antral mucosa, are visible, and the
bony walls of the sinus are resorbed, leading to dis-
continuity of the cortical outline, and if the roots of
the maxillary teeth are resorbed, rapidly growing dis-
eases or malignancies have to be suspected (9, 15).
A still-controversial issue regarding assessment and
diagnosis of the maxillary sinus using cone beam
computed tomography imaging before sinus floor
elevation or dental implant placement is the ade-
quate field of view. Vogiatzi et al. (150) reported that
there are insufficient data to comment on the effect
of the field of view (small/medium vs. large; one max-
illary sinus vs. both maxillary sinuses visualized) of
the cone beam computed tomography scans on the
detection and prevalence of maxillary sinus pathol-
ogy. Therefore, they were not able to recommend an
optimal field-of-view scan or to state that both maxil-
lary sinuses should always be visualized when per-
forming three-dimensional imaging (Figs 2, 3 and 4).
Harris et al. (62) stated that a preoperative screening
of the maxillary sinuses using large fields of view is
not recommended for dental implant treatment plan-
ning. However, in some clinical situations, when
there is evidence of sinus pathology that may
57
Bornstein et al.

A B Fig. 1. Schematic illustrations of the classification for the

morphology of the Schneiderian membrane, as analyzed
using sagittal and coronal cone beam computed tomogra-
phy scans according to criteria adapted from Soikkonen &
Ainamo (127). (A,B) Healthy Schneiderian membrane: no
thickening (A, sagittal view; B, coronal view). (C,D) Flat
Schneiderian membrane: shallow thickening without well-
defined outlines (C, sagittal view; D, coronal view). (E,F)
Semi-aspherical Schneiderian membrane: thickening with
well-defined outlines rising in an angle of > 30° from the
floor of the walls of the sinus (E, sagittal view; F, coronal
view). (G,H) Mucocele-like Schneiderian membrane: com-
C D plete opacification of the sinus (G, sagittal view; H, coronal
view). (I,J) Mixed Schneiderian membrane: flat and semi-
aspherical thickenings (I, sagittal view; J, coronal view).

jeopardize the outcome of the planned surgical pro-

cedure, there may be justification to extend the field
of view to include the whole of the sinus, including
the ostiomeatal complex (62, 75, 122, 150). This is fur-
ther emphasized by the high radiation doses applied
to the eye lens using cross-sectional imaging (cone
E F
beam computed tomography or multislice computed
tomography) or in the area of the paranasal sinuses,
and the need to adhere to ALADA principles by always
trying to implement dose-reduction procedures. It
needs to be pointed out here that there is increasing
attention and evidence in the literature of negative
effects on the eye lens (i.e. cataract) of radiographic
imaging, even at low doses of radiation (111, 124).
Thus, a decrease of eye-lens doses of radiation through
field-of-view reduction should be borne in mind,
and clinical recommendation, such as visualization
G H
of the entire maxillary sinus, or even bilateral maxillary
sinuses, using cone beam computed tomography
scans with medium- to large field of views for preoper-
ative treatment planning of dental implants, is not
supported by the literature and thus is not justified.
In a recent study, the indications and frequency for
three-dimensional imaging for implant treatment
planning in a pool of patients referred to a specialty
clinic over a 3-year period were evaluated (19). The
results show that 40% of the patients included were
I J
radiographically assessed using two-dimensional
technology alone. This demonstrates that even in a
specialty clinic, patients are not routinely exposed to
cone beam computed tomography imaging before
implant placement. In addition, the authors reported
that a typical patient receiving additional cone beam
computed tomography scanning for dental implant
treatment planning would be over 55 years of age
with an extended or distal edentulous gap in the max-
illa with the need for bone augmentation

58
 Cone beam computed tomography in implant dentistry

A A

B B

C C

Fig. 2. Visualization of the entire right maxillary sinus
using cone beam computed tomography with a small field
of view (6 3 6 cm) for implant treatment planning in a 54-
year-old female patient. The sinus exhibits good pneuma-
tization and open ostium without enlargement of the Sch-
neiderian membrane. Sagittal (A), coronal (B) and axial (C)
views of the cone beam computed tomography scan.
(simultaneous or staged). An interesting further find-
ing of the study regarding the frequency of three-
dimensional imaging was that there was a significant
increase in the number of cone beam computed
tomography scans over the study period from 2008
Fig. 3. Visualization of the basal aspects of the right maxil-
lary sinus using cone beam computed tomography with a
small field of view (4 3 4 cm) for implant treatment plan-
ning in a 61-year-old male patient. The sinus exhibits good
pneumatization without visualization of the open ostium.
The Schneiderian membrane exhibits a flat and shallow
thickening of the mucosa. Sagittal (A), coronal (B) and axial
(C) views of the cone beam computed tomography scan.
(52.4% of all patients) to 2010 (65.9%). This is certainly
also an effect of the growing popularity of this radio-
graphic methodology and its acceptance by clini-
cians. Therefore, it seems realistic to predict that the

59
Bornstein et al.
A cases, with no clinically identified local problems,
B implant placement
C
Fig. 4. Visualization of the basal aspects of the right maxil-
lary sinus using cone beam computed tomography with a
small field of view (4 3 4 cm) for implant treatment plan-
ning in a 62-year-old male patient. The sinus exhibits radio-
graphic signs of sinusitis with honeycomb-like surface
loculations without visualization of the ostium. This finding
makes it advisable to consult an ear, nose and throat special-
ist before sinus floor elevation. Sagittal (A), coronal (B) and
axial (C) views of the cone beam computed tomography scan.
percentage of three-dimensional imaging – primarily
cone beam computed tomography scans – will
increase further over the next few years. Nevertheless,
if patients are limited to straightforward implant
60
such as a limited horizontal ridge width, cross-sec-
tional imaging makes no difference to the implants
selected based on panoramic views alone (47). The
authors state that the clinical examination provides
sufficient information for selecting implant diameter
and that the panoramic radiograph provides suffi-
cient information for selection of implant length in
standard cases.
Recommendations for cone beam
computed tomography imaging
during and/or following dental
Despite careful planning, surgical complications can
arise following implant placement. These include:
infection; intraoral hemorrhage; wound dehiscence;
postoperative pain; lack of primary implant stability;
inadvertent penetration into the maxillary sinus or
nasal fossa; neurosensory disturbances; injuries to
adjacent teeth; tissue emphysema; and aspiration or
ingestion of surgical instruments (55). The evaluation
of complications includes careful clinical examina-
tions and selected radiographic imaging. The Euro-
pean Association for Osseointegration has published
clear statements on radiographic imaging during and
following dental implant surgery (62). The authors
emphasize that during implant surgery conventional
two-dimensional radiographic techniques are ade-
quate, in most cases, to confirm the position of an
implant in relation to anatomic landmarks. Regarding
follow-up examinations, the authors state that in the
absence of symptoms, there is no indication for cross-
sectional imaging. However, three-dimensional imag-
ing might be helpful for the diagnosis and manage-
ment of specific postoperative complications (such as
nerve damage) or postoperative infections in relation
to sinus cavities close to the inserted dental implants.
Even when taking careful measures, including
appropriate clinical and radiographic assessments
before surgery, nerve injuries may occur. The litera-
ture seems to indicate that three-quarters of neural
injuries after implant placement result in permanent
injury (87, 117, 118). In general, damage to sensory
nerves can result in anesthesia, dysesthesia, pain or a
combination of these. In the event of acute nerve
injury, timely nerve and implant decompression are
essential with supportive analgetic or anticonvulsant
therapy. Indeed, early removal of implants associated
with mandibular nerve injury (less than 36 h post-
injury) may assist in minimizing, or even resolving,

neuropathy (81). The correct diagnosis of postsurgical
complications based on the presenting clinical symp-
toms (anesthesia, dysesthesia, pain or a combination
of those), using three-dimensional imaging, is recom-
mended to assess the extent of damage to neural
structures (41). In this case series of inferior alveolar
nerve injuries, the authors were able to evaluate the
trauma using cone beam computed tomography
imaging and they distinguished implant impinge-
ment, penetration and even complete obliteration of
the canal (Fig. 5). Similarly, neuropathic pain follow-
ing implant placement in the interforaminal region of
the mandible (85, 120) and the nasopalatine canal in
the anterior maxilla (Fig. 6) (145) have been described.
When suspecting such a complication, cone beam
computed tomography scans can indicate the correct
location of the implant. Thus, perforation of the inci-
sive canal and nerve during implant insertion should
be considered as a complication of implant surgery in
the mandibular anterior area (85, 100).
Accidental displacement of endosseous implants
into the maxillary sinus and potential migration
throughout the upper paranasal sinuses and adjacent
structures is an unusual complication in implant
patients. Peri-operative displacement of implants
into the sinus is the obvious consequence of incorrect
surgical planning, such as placement of implants in
A C
B D
Cone beam computed tomography in implant dentistry
sites with inadequate bone height and volume, surgi-
cal inexperience with the anatomic landmarks of the
maxillary sinus or poor surgical performance (such as
overpreparation of the recipient site, application of
heavy force during implant insertion or perforation of
the sinus membrane during the drilling sequence)
(27, 49). Implant migration into the maxillary sinus
may also be the more remote consequence of loss of
osseointegration as a result of peri-implantitis or, in
the case of loaded implants, inaccurate distribution
of occlusal forces. In a review of the literature pub-
lished on accidental displacement and migration of
dental implants into the upper jaw, the authors iden-
tified a total of 24 articles, the majority related to acci-
dental displacement and migration of dental implants
to the maxillary sinus, but there were also case reports
on migration into other craniofacial structures, such as
the ethmoid sinuses, sphenoid sinuses, orbit and cra-
nial fossae (52). Invasion of the maxillary sinus or
related structures with dental implants might not be
detected during implant placement. However, these
complications might cause problems in the long run,
and might not be adequately diagnosed using two-
dimensional imaging (such as panoramic or periapical
radiographs) alone (156).
The diagnosis of peri-implantitis is based on clinical
parameters and radiological findings (121). The
Fig. 5. Cone beam computed tomog-
raphy scan (small field of view:
6 3 5 cm) of the right mandible of a
73-year-old male patient after refer-
ral by his treating dentist following
insertion of two dental implants in
regions 45 and 47. The patient
reported complete anesthesia of the
lower right lip. (A) Sagittal view
showing proximity of the dental
implant in region 45 to the mental
foramen located distally to the tooth
44. (B) Coronal view of implant pen-
etration in region 45 into the
mandibular canal and the region of
the mental foramen. (C) Coronal
view of the implant in region 47
exhibiting its relation to the
mandibular canal. (D) Axial view
visualizing penetration of the
implant in region 45 into the mental
foramen.
61
Bornstein et al.
A radiographic diagnosis of peri-implant lesions is based
B puted tomography scanning, cone beam computed
C puted tomography should be performed rather as
Fig. 6. Cone beam computed tomography scan (small field
of view: 4 3 4 cm) of the anterior maxilla of a 66-year-old
female patient after referral by her treating dentist 1 year
following insertion of a dental implant in region 21. The
patient reported persisting neuropathic pain in the ante-
rior mandible toward the nose. (A) Sagittal view showing
penetration of the dental implant in region 21 into the
nasopalatine canal. (B) Coronal view of the restored
implant in region 21. Slight osteolysis is visible at the api-
cal region of tooth 11. (C) Axial view of the implant in
region 21 exhibiting penetration into the nasopalatine
canal.
62
on periapical radiographs (two dimensional) as a result
of their wide accessibility in dental practice. However,
use of this methodology has resulted in significant
variance in inter- and intraobserver reproducibility of
the acquired measurements (56) and in underestima-
tion of bone loss (26). Thus, cone beam computed
tomography scans have been proposed for diagnosis
of peri-implant bone defects, with the added benefit of
visualizing the buccal and lingual aspects of the dental
implant, and have shown an acceptable correlation
with histological measurements (51). In an in vitro
study comparing periapical radiographs, panoramic
views, cone beam computed tomography and com-
tomography showed the best image quality and was
able to pinpoint peri-implant bone defects in all three
planes, true to scale, and without distortion (95). In a
similarly designed, more recent, in vitro study, the best
performance in detecting peri-implant bone defects
and correctly confirming their absence was found for
periapical radiographs, while computed tomography
scans demonstrated the lowest performance in detect-
ing peri-implant bone defects (84). Therefore, the
authors conclude that periapical radiographs should
still be recommended as a favorable method for evalu-
ating bone loss around dental implants, and that
three-dimensional imaging using cone beam com-
adjunctive imaging for specific indications, for which
clinical and two-dimensional radiographs have not
provided sufficient information.
The superiority of intraoral radiographs compared
with three-dimensional imaging using cone beam
computed tomography to detect bone defects was
also reported in a study assessing implants placed in
fresh bovine ribs in osteotomy sites with varying peri-
implant spaces (36). One important issue that limits
cone beam computed tomography imaging for the
diagnosis of peri-implant bone defects is its associa-
tion with beam-hardening artefacts around metal
(Fig. 7) (123). It has been shown that artefacts in cone
beam computed tomography were always present in
the proximity of implants made from titanium,
irrespective of the implant position in the jaw (12).
Additionally, patient movement during scanning –
especially when occurring several times and for an
extended time period – results in motion artefacts,
and may even result in a need for re-exposure of the
patient (130, 131). Therefore, it is questionable
whether cone beam computed tomography imaging

A C
B D
Fig. 7. Cone beam computed tomography scan (medium
field of view: 8 3 5 cm) of the mandible of a 79-year-old
female patient referred for analysis of peri-implant bone
defects around implants in the symphysis and left first-pre-
molar area. A dental implant in the right canine region had
been lost a couple of weeks previously. The beam harden-
ing artefacts around the metal make it difficult to assess the
structures in direct or close vicinity to the dental implants.
(A) Axial view showing the two implants (symphysis and left
represents an adequate technique for the assessment
of structures in direct or close proximity to dental
implants. It should be further emphasized that cone
beam computed tomography machines perform dif-
ferently, and that only a couple of cone beam com-
puted tomography devices commercially available are
delivering images that are almost free of visible arte-
facts in the peri-implant vicinity. Yet, the resulting
image quality will still depend on the local situation
and on the number and relative density of the metals
in the field of view and/or the entire orofacial area.
Cone beam computed tomography
imaging for clinical research
purposes
Research involving human subjects is critical for
advancing clinical medicine, and this is also true in
the field of radiology in general. To advance our
Cone beam computed tomography in implant dentistry
first-premolar region) and a bone defect resulting from
implant loss in the right canine area. (B) Sagittal view
showing the two implants in the symphysis and the left
first-premolar region. (C) Sagittal view showing the implant
in the symphysis with almost no visible bone on the buccal
and lingual aspects. (D) Coronal view showing the implants
in the left first-premolar region with evident bone loss on
the buccal and lingual aspects.
clinical understanding and practice in an appropri-
ate manner, we must always be mindful of the
requirements of ethics when conducting research
with humans. Although a wide variety of ethical
issues are expected to emerge when conducting radi-
ology research, one ethical challenge that may be
particularly likely to occur in this context is distin-
guishing pure research endeavors, without evident
and immediate benefit for the patients included,
from innovative treatment concepts or standard
practice (21). Standard clinical practice involves
interventions that are intended solely for the benefit
of patients and that have a reasonable expectation
of success. Innovative therapy (also termed ‘off-label
use’) can be defined as an activity that lacks a formal
evidence base. Regarding the use of cone beam com-
puted tomography imaging in the context of implant
dentistry, there is often no clear benefit for a patient
of three-dimensional imaging, especially postopera-
tively. Therefore, justification of each additional
63
Bornstein et al.
cone beam computed tomography scan is ethically
important, regarding both the interval and the total
number of exposures. From a purely scientific per-
spective, long-term data are always of greater value
than short-term outcomes. One should consider that
there is no grey-level calibration, making the com-
parison of density values of cone beam computed
tomography scans unreliable over time (112).
Furthermore, it takes at least 6 months of bone
remodeling, with its de- and remineralization pro-
cesses, before the original mineralization level is
achieved, which renders cone beam computed
tomography imaging at short-term intervals (to
assess the effect and durability of bone-grafting pro-
cedures) somewhat unrealistic. Therefore, if possible,
cone beam computed tomography scans should be
be taken with longer intervening intervals as
opposed to planning multiple exposures during the
initial postsurgical follow-up period.
In a recent review, Benic et al. (13) stated that in
ethically approved clinical research, three-dimen-
sional imaging (computed tomography or cone beam
computed tomography) can be used pre- and postop-
eratively to evaluate bone and soft tissues, as well as
the implant position, with reference to the anatomic
structures. Cone beam computed tomography imag-
ing is increasingly being used for three-dimensional
assessment of bone following ridge preservation (1, 7,
94), sinus floor elevation (53, 93, 106, 143) and
implant placement with simultaneous bone augmen-
tation (23, 31, 77, 83) or staged procedures following
block grafts (97, 98, 129). Besides visualization of bony
structures, cone beam computed tomography is also
used to assess the contour and dimension of the peri-
implant mucosa (11, 78). This is accomplished by
applying radio-opaque contrast materials, such as
thin foils, on the surface of the mucosa, or by displac-
ing the lips and the cheeks from the alveolar process
by means of lip retractors or cotton rolls (13, 28, 29).
However, it is important to differentiate uses of
cross-sectional imaging that are intended to gather
further basic knowledge from those that actually ben-
efit the patient. Research using cone beam computed
tomography scanning should not automatically be
seen as valid selection criteria for its clinical applica-
tion. Before any imaging technique is put into clinical
use for a specific purpose, one should ideally have
evidence of patient benefit and cost-effectiveness
(48). Although evidence of a change in treatment plan
and/or management through use of an imaging tech-
nique is sometimes used to support its acceptibility,
such evidence is weak. This is because a change in
the treatment plan of a patient may lead to the same,
64
or even poorer, clinical outcomes, and may not
always improve results.
Interesting data have been gathered from
orthodontic research, in which a study on cadaver
heads investigated the accuracy and reliability of buc-
cal alveolar bone height and thickness measurements
derived from cone beam computed tomography
images (141). The authors found that buccal bone
height and buccal bone thickness were quantitatively
assessed with high precision and accuracy, but that
the buccal bone height had greater reliability and
agreement with direct measurements than did buccal
bone-thickness measurements. These findings were
corroborated by another group, which stated that a
thin buccal alveolar bone covering is not depicted
reliably by cone beam computed tomography scans
and that there is a risk of overestimating fenestrations
and dehiscence type defects on teeth (107). Regarding
the assessment of bone dimensions around implants,
a study using dry mandibles evaluated the minimum
labial bone thickness surrounding dental implants
that is detectable using cone beam computed tomog-
raphy images (102). The authors reported that only
when the buccal bone on the dental implant was
0.6 mm might it be visually detectable. Thus, when
the buccal bone thickness was < 6 mm, the bone
plate was either underestimated or not detectable.
Nevertheless, these measurements also seem to
depend on the cone beam computed tomography
device used for the study (116).
Bone density has been suggested to be an impor-
tant factor influencing the success of dental implants.
Areas of reduced bone density have exhibited higher
failure rates and reduced primary stability values (96).
A factor complicating the use of cone beam com-
puted tomography for clinical bone density assess-
ment and follow-up of bone density changes is the
lack of standardized grey value distribution. Houns-
field units have been designed for medical computed
tomography but are not applicable for cone beam
computed tomography (88, 89). Compared with
Hounsfield units for medical computed tomography,
cone beam computed tomography-based assessment
of jaw bone density has been found to be unreliable
over time and with significant variations influenced
by cone beam computed tomography devices, imag-
ing parameters and positioning (101). This lack of
standardization is a major problem for most cone
beam computed tomography devices, yet considering
the fact that nowadays a healthy vascularized bone
structure may be more beneficial for implant place-
ment than a sclerotic, poorly vascularized bone, the
Hounsfield unit limits for implant treatment may be

easily overcome. What one might need instead is a
structural bone analysis, like that available in dedi-
cated micro-computed tomography software. Such
structural analysis has already been validated for use
in cone beam computed tomography imaging (71,
147) and thus might even have clinical potential for
presurgical assessment of bone quality.
Recommendations for
communication in a digital
environment
Digital Imaging and Communication in Medicine was
originally developed by the National Electrical Manu-
facturers Association and the American College of
Radiology to create a worldwide norm for digital
image acquisition, storage and display in medicine,
and also to have a standardized method for the trans-
mission of medical images and their associated infor-
mation. ‘Digitization’ is increasingly widespread in
dental medicine in terms of radiographic image
acquisition (two-dimensional and three-dimen-
sional), optical surface scanning (intra- and extraoral),
computer-aided design/computer-aided manufactur-
ing systems and the electronic charting of patient
records. Unfortunately, the Digital Imaging and Com-
munication in Medicine standard is currently not
really fully implemented in dental medicine, with pri-
marily hospital and dental school settings complying
with the standard (22). Picture archiving and commu-
nication systems software act to integrate image
acquisition, storage, retrieval and viewing based on
the Digital Imaging and Communication in Medicine
standard. In dentistry, the use of picture archiving
and communication systems software is primarily
limited to academic centers and dental clinics in hos-
pital facilities where there is need for transmission of
data between departments (30). Newer standard den-
tal digital imaging devices, including intraoral digital
radiographic systems, panoramic views and cone
beam computed tomography scanners, are largely
Digital Imaging and Communication in Medicine
compliant. Nevertheless, standards for Digital Imag-
ing and Communication in Medicine compliance for
some devices, including cone beam computed tomog-
raphy and computer-aided design/computer-aided
manufacturing systems, and their interoperability
with respect to picture archiving and communication
systems software, have not yet been fully established.
This problem was pointed out by an expert panel of
the International Team for Implantology during the
Cone beam computed tomography in implant dentistry
consensus conference in Bern, in 2013 (18). These
experts state that to improve image data transfer, clin-
icians should request radiographic devices and third-
party dental implant software applications that offer
fully compliant Digital Imaging and Communication
in Medicine data export.
For most cone beam computed tomography sys-
tems there is loss of diagnostic data upon transfer to
Digital Imaging and Communication in Medicine/
picture archiving and communication systems soft-
ware and/or third party software. In addition, most
third party software has some additional filtering (e.g.
smoothing) at the import phase, which may result in
additional information loss. It is therefore recom-
mended to perform presurgical diagnostics using the
dedicated cone beam computed tomography soft-
ware of the imaging device, before export for presur-
gical planning purposes. Furthermore, when
performing presurgical planning, cone beam com-
puted tomography images should be made using the
recommended protocol, which is not necessarily the
highest-resolution protocol, as the latter evidently
creates more noise. Vandenberghe et al. (146)
demonstrated that for three-dimensional segmenta-
tion and anatomic model making, a voxel size of
200 lm (0.2 mm) is probably sufficiently low.
Other challenges in the digital data flow include the
fact that there is a growing availability of non-Digital
Imaging and Communication in Medicine three-
dimensional imaging data formats for use in an inte-
grated virtual patient data set (63, 76). Examples
include stereolithography and object file formats,
which are used, respectively, for digital intraoral
impressions and printing, and for facial scanning.
Transferring those data sets to picture archiving and
communication systems software is actually not pos-
sible, with the result that the power of the integrated
virtual patient information is lost at this level.
Another point for note is the lack of standardized
grey-level calibration or Hounsfield scoring, making
the comparative follow up of bone healing, grafting
and implant placement rather difficult and quite
unreliable (112).
Conclusions and outlook on novel
developments in dento-
maxillofacial imaging
It can be concluded that not only is cone beam com-
puted tomography imaging an established radio-
graphic modality in treatment planning for dental
65
Bornstein et al.
implants, but its use is also becoming increasingly
popular and widespread among clinicians worldwide.
This is partly because of a new understanding of ana-
tomic landmarks and structures, such as neurovascu-
lar canals and bundles, being at risk during implant
placement. Nevertheless, that cone beam computed
tomography imaging results in fewer intraoperative
complications, such as nerve damage or bleeding
incidents, or that implants inserted using preopera-
tive cone beam computed tomography data sets for
planning purposes will exhibit higher survival or suc-
cess rates, has not yet been demonstrated in the liter-
ature. It even seems doubtful that, for esthetic
reasons, it will be possible to demonstrate these fac-
tors in a prospective and controlled trial setting. Per-
haps more soft factors, such as the time of surgery,
the confidence of the surgeon or even patient mor-
bidity, need to be evaluated in future clinical studies
to demonstrate the potential benefits of three-dimen-
sional imaging over two-dimensional imaging modal-
ities alone before dental implant placement. Another
reason for the growing use of cone beam computed
tomography scanning is the increasing popularity of
computer-guided surgery that relies on digital plan-
ning based on high-quality cone beam computed
tomography images (135) but may also include the
superimposition of intraoral scans and extraoral face
scans to create a three-dimensional virtual dental
patient (76). The virtual patient concept is actually
demonstrating again the need for a uniform data
standard in digital imaging in dental medicine, as cre-
ating a craniofacial virtual reality model needs image
fusion of Digital Imaging and Communication in
Medicine, stereolithography and object files.
The use of cone beam computed tomography imag-
ing following insertion of dental implants should be
restricted to specific postoperative complications
(such as damage to neurovascular structures) or post-
operative infections in relation to the maxillary sinus.
To confirm the position of an implant in relation to
anatomic landmarks after insertion, and also for evalu-
ation of peri-implant bone conditions during follow-
up visits, conventional (two-dimensional) radiographic
techniques, such as periapical or panoramic views, are
sufficient. Regarding peri-implantitis, the diagnosis
and severity of the disease should be evaluated
primarily based on clinical parameters and on radio-
logical findings based on periapical radiographs (two-
dimensional). To date, the literature suggests that
three-dimensional imaging using cone beam com-
puted tomography should be rather performed as
adjunctive imaging with a clear benefit for the patient
in terms of diagnosis or treatment strategy chosen.
66
Other than for daily practice, the use of cone beam
computed tomography scans in clinicial research
might not yield any evident beneficial effect for the
patient included. Cone beam computed tomography
imaging is used in research to evaluate, pre- and
postoperatively, bone and soft tissues as well as the
implant position with reference to the anatomic
structures. The effect on peri-implant hard and soft
tissues of surgical techniques, such as ridge preserva-
tion, sinus floor elevation and implant placement
with simultaneous bone augmentation, or following
staged procedures using block grafts, is evaluated in a
short- and long-term perspective with quite variable
frequencies between the actual cone beam computed
tomography scans. As many of the cone beam com-
puted tomography scans performed for research have
no direct therapeutic consequence, dose optimiza-
tion measures should be implemented by using
appropriate exposure parameters and reducing the
field of view to the actual region of interest. To mini-
mize dose–exposure risks and the effects of cumula-
tive effective doses over time, if possible, cone beam
computed tomography scans should be taken with
longer intervening intervals as opposed to multiple
exposures following surgery and in the initial follow-
up period.
In radiation protection, ALARA is a fundamental
principle for diagnostic radiology in medicine and
dentistry. This concept has been recently adapted to
the ‘ALADA’ principle for selection and justification of
the optimal imaging modality. When cross-sectional
imaging is indicated, cone beam computed tomogra-
phy has been recommended over to be preferable
over computed tomography (18); however, imaging
modalities with the ability to perform visualization of
craniofacial hard and soft tissues without radiation
exposure would be desirable. Currently, there are two
modalities that show some clinical potential in this
regard: magnetic resonance imaging; and ultrasound
(6). Magnetic resonance imaging as a nonionizing
diagnostic tool in the dento-maxillofacial region has
been limited mostly because of compromised visual-
ization of hard tissues and feasibility concerns such
as availibility of equipment and high costs (82). In a
recent study on a human jaw ex vivo and in vivo, a
novel protocol for magnetic resonance imaging was
applied using an intraoral coil that creates an
increased signal within a defined field of view to
obtain high-resolution images within an acquisition
time applicable for clinical routine three-dimensional
radiography (45). The authors reported that com-
pared with cone beam computed tomography and
histological sections, magnetic resonance images

exhibited dimensional accuracy, and the course of
the mandibular canal was accurately displayed.
Regarding the use of ultrasound in dento-maxillofa-
cial radiology and diagnosis, recent publications have
reported its capability for imaging representative fea-
tures for implant treatment planning in a porcine
model, such as implants placed in edentulous ridges,
implants with simulated dehiscences or mental
foramina (32). Further research for the application of
ultrasound is directed toward the sensitivity and
changes of the ultrasonic response during the healing
period of dental implants that could potentially pre-
dict the amount and level of osseointegration and
also be helpful in diagnosing peri-implant bone
changes (148). Regarding only these two recent devel-
opments in the field of dento-maxillofacial radiology,
it can be considered that this field is very dynamic
and constantly changing. Thus, although cone beam
computed tomography is currently growing rapidly in
popularity for imaging in the field of implant den-
tistry, and might even be considered as a primary
imaging modality in selected cases, future break-
throughs in research will probably bring new tech-
nologies that will again change the way in which we
visualize hard and soft tissues for pre- and postopera-
tive evaluation of dental implants.
References
1. Abdelhamid A, Omran M, Bakhshalian N, Tarnow D,
Zadeh HH. An open randomized controlled clinical trial to
evaluate ridge preservation and repair using SocketKAPTM
and SocketKAGETM: part 2 - three-dimensional alveolar
bone volumetric analysis of CBCT imaging. Clin Oral
Implants Res 2015: 27: 631–639.
2. Academy of Osseointegration. 2010 Guidelines of the
Academy of Osseointegration for the provision of dental
implants and associated patient care. Int J Oral Maxillofac
Implants 2010: 25: 620–627.
3. Ahmad M, Jenny J, Downie M. Application of cone beam
computed tomography in oral and maxillofacial surgery.
Aust Dent J 2012: 57 (Suppl 1): 82–94.
4. Al-Ekrish AA. Effect of exposure time on the accuracy and
reliability of cone beam computed tomography in the
assessment of dental implant site dimensions in dry skulls.
Saudi Dent J 2012: 24: 127–134.
5. Anavi Y, Allon DM, Avishai G, Calderon S. Complications
of maxillary sinus augmentations in a selective series of
patients. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2008: 106: 34–38.
6. Arimoto S, Hasegawa T, Okamoto N, Shioyasono A,
Tateishi C, Akashi M, Suzuki H, Furudoi S, Komori T.
Determining the location of the internal maxillary artery
on ultrasonography and unenhanced magnetic resonance
imaging before orthognathic surgery. Int J Oral Maxillofac
Surg 2015: 44: 977–983.
Cone beam computed tomography in implant dentistry
7. Avila-Ortiz G, Rodriguez JC, Rudek I, Benavides E, Rios H,
Wang HL. Effectiveness of three different alveolar ridge
preservation techniques: a pilot randomized controlled
trial. Int J Periodontics Restorative Dent 2014: 34: 509–521.
8. Baciut M, Hedesiu M, Bran S, Jacobs R, Nackaerts O,
Baciut G. Pre- and postoperative assessment of sinus
grafting procedures using cone-beam computed tomogra-
phy compared with panoramic radiographs. Clin Oral
Implants Res 2013: 24: 512–516.
9. Bell GE, Joshi BB, Mcleaod RI. Maxillary sinus disease:
diagnosis and treatment. Br Dent J 2011: 12: 113–118.
10. Benavides E, Rios HF, Ganz SD, An CH, Resnik R, Reardon
GT, Feldman SJ, Mah JK, Hatcher D, Kim MJ, Sohn DS,
Palti A, Perel ML, Judy KW, Misch CE, Wang HL. Use of
cone beam computed tomography in implant dentistry:
the International Congress of Oral Implantologists consen-
sus report. Implant Dent 2012: 21: 78–86.
11. Benic GI, Mokti M, Chen CJ, Weber HP, Ha €mmerle CH,
Gallucci GO. Dimensions of buccal bone and mucosa at
immediately placed implants after 7 years: a clinical and
cone beam computed tomography study. Clin Oral
Implants Res 2012: 23: 560–566.
12. Benic GI, Sancho-Puchades MS, Jung RE, Deyhle H,
Ha€mmerle CHF. In vitro assessment of artifacts induced
by titanium dental implants in cone beam computed
tomography. Clin Oral Implants Res 2013: 24: 378–383.
13. Benic GI, Elmasry M, Ha €mmerle CH. Novel digital imaging
techniques to assess the outcome in oral rehabilitation
with dental implants: a narrative review. Clin Oral
Implants Res 2015: 26 (Suppl 11): 86–96.
14. Bornstein MM, Halbritter S, Harnisch H, Weber HP, Buser
D. A retrospective analyis of patients referred for implant
placement to a specialty clinic: indications, surgical proce-
dures, and early failures. Int J Oral Maxillofac Implants
2008: 23: 1109–1116.
15. Bornstein MM, von Arx T, Altermatt HJ. Loss of pulp sensi-
tivity and pain as the first symptoms of an Ewing’s sar-
coma in the right maxillary sinus and alveolar process:
Report of a case. J Endod 2008: 34: 1549–1553.
16. Bornstein MM, Wasmer J, Sendi P, Janner SFM, Buser D,
von Arx T. Characteristics and dimensions of the Schnei-
derian membrane and apical bone in maxillary molars
referred for apical surgery: a comparative radiographic
analysis using limited cone-beam computed tomography.
J Endod 2012: 38: 51–57.
17. Bornstein MM, Scarfe WC, Vaughn VM, Jacobs R. Cone
beam computed tomography in implant dentistry: a sys-
tematic review focusing on guidelines, indications, and
radiation dose risks. Int J Oral Maxillofac Implants 2014:
29 (Suppl): 55–77.
18. Bornstein MM, Al-Nawas B, Kuchler U, Tahmaseb A. Con-
sensus statements and recommended clinical procedures
regarding contemporary surgical and radiographic tech-
niques in implant dentistry. Int J Oral Maxillofac Implants
2014: 29 (Suppl): 78–82.
19. Bornstein MM, Engel Bru € gger O, Janner SFM, Kuchler U,
Chappuis V, Jacobs R, Buser D. Indications and frequency
for the use of cone beam computed tomography for
implant treatment planning in a specialty clinic. Int J Oral
Maxillofac Implants 2015: 30: 1076–1083.
20. Bornstein MM, Seiffert C, Maestre-Ferrin L, Fodich I,
Jacobs R, Buser D, von Arx T. An analysis of frequency,
67
Bornstein et al.
morphology and location of maxillary sinus septa using
cone beam computed tomography. Int J Oral Maxillofac
Implants 2016: 31: 280–287.
21. Burger I, Kass N. Ethical conduct of radiology research
with human participants. J Am Coll Radiol 2006: 3: 932–
939.
22. Burgess J. Digital DICOM in dentistry. Open Dent J 2015: 9:
330–336.
23. Buser D, Chappuis V, Kuchler U, Bornstein MM, Wit-
tneben JG, Buser R, Cavusoglu Y, Belser UC. Long-term
stability of early implant placement with contour augmen-
tation. J Dent Res 2013: 92 (Suppl 12): 176S–182S.
24. Cagici CA, Yilmazer C, Hurcan C, Ozer C, Ozer F. Appropri-
ate interslice gap for screening coronal paranasal sinus
tomography for mucosal thickening. Eur Arch Otorhino-
laryngol 2009: 266: 519–525.
25. Cassola VF, Milian FM, Kramer R, de Oliveira Lira CA,
Khoury HJ. Standing adult human phantoms based on
10th, 50th and 90th mass and height percentiles of male
and female Caucasian populations. Phys Med Biol 2011:
56: 3749–3772.
26. Caulier H, Naert I, Kalk W, Jansen JA. The relationship of
some histologic parameters, radiographic evaluations, and
Periotest measurements of oral implants: an experimental
animal study. Int J Oral Maxillofac Implants 1997: 12: 380–
386.
27. Chappuis V, Suter VGA, Bornstein MM. Displacement of a
dental implant into the maxillary sinus. Report of an unu-
sual complication when performing staged sinus floor ele-
vation (SFE) procedures. Int J Periodontics Restorative
Dent 2009: 29: 81–87.
28. Chappuis V, Engel O, Reyes M, Shahim K, Nolte LP, Buser
D. Ridge alterations post-extraction in the esthetic zone: a
3D analysis with CBCT. J Dent Res 2013: 92 (Suppl 12):
195S–201S.
29. Chappuis V, Engel O, Shahim K, Reyes M, Katsaros C,
Buser D. Soft tissue alterations in esthetic postextraction
sites: A 3-dimensional analysis. J Dent Res 2015: 94 (Suppl
9): 187S–193S.
30. Chen SK. Integration of the digital imaging and communi-
cations in medicine standard into an oral and maxillofacial
image management and communication system. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 2001: 91:
235–238.
31. Chen ST, Buser D. Esthetic outcomes following immediate
and early implant placement in the anterior maxilla–a sys-
tematic review. Int J Oral Maxillofac Implants 2014: 29
(Suppl): 186–215.
32. Choi M, Culjat MO, Singh RS, White SN. Ultrasound ima-
gery for dental implant diagnosis and treatment planning
in a porcine model. J Prosthet Dent 2012: 108: 344–353.
33. Cooper LF, Pin-Harry OC. “Rules of six” - diagnostic and
therapeutic guidelines for single-tooth implant success.
Compend Contin Educ Dent 2013: 34: 94–98, 100–101.
34. Correa LR, Spin-Neto R, Stavropoulos A, Schropp L, da Sil-
veira HE, Wenzel A. Planning of dental implant size with
digital panoramic radiographs, CBCT-generated panora-
mic images, and CBCT cross-sectional images. Clin Oral
Implants Res 2014: 25: 690–695.
35. Dagassan-Berndt DC, Zitzmann NU, Walter C, Schulze RK.
Implant treatment planning regarding augmentation pro-
cedures: panoramic radiographs vs. cone beam computed
68
tomography images. Clin Oral Implants Res 2016: 27:
1010–1016.
36. Dave M, Davies J, Wilson R, Palmer R. A comparison of
cone beam computed tomography and conventional peri-
apical radiography at detecting peri-implant bone defects.
Clin Oral Implants Res 2013: 24: 671–678.
37. Dawood A, Brown J, Sauret-Jackson V, Purkayashta S.
Optimization of cone beam CT exposure for pre-surgical
evaluation of the implant site. Dentomaxillofac Radiol
2012: 41: 70–74.
38. Drago C, Carpentieri J. Treatment of maxillary jaws with
dental implants: guidelines for treatment. J Prosthodont
2011: 20: 336–437.
39. Dula K, Bornstein MM, Buser D, Dagassan-Berndt D, Ettlin
DA, Filippi A, Gabioud F, Katsaros C, Krastl G, Lambrecht
JT, Lauber R, Luebbers H-T, Pazera P, Tu € rp JC. SADMFR
guidelines for the use of cone-beam computed tomogra-
phy/digital volume tomography. Oral and maxillofacial
surgery, temporomandibular joint disorders and
orthodontics. A consensus workshop organized by the
Swiss Association of Dentomaxillofacial Radiology. Swiss
Dent J 2014: 124: 1170–1183.
40. Dula K, Benic G, Bornstein MM, Dagassan-Berndt D,
Filippi A, Hicklin S, Kissling-Jeger F, Luebbers H-T, Scu-
lean T, Sequeira-Byron P, Walter C, Zehnder M. SADMFR
guidelines for the use of cone-beam computed tomogra-
phy/digital volume tomography. Endodontics, Periodon-
tology, Reconstructive Dentistry, Pediatric Dentistry. A
consensus workshop organized by the Swiss Association of
Dentomaxillofacial Radiology. Swiss Dent J 2015: 125: 945–
953.
41. Du Toit J, Gluckman H, Gamil R, Renton T. Implant injury
case series and review of the literature Part 1: inferior alve-
olar nerve injury. J Oral Implantol 2015: 41: e144–e151.
42. Engel Bru € gger O, Bornstein MM, Kuchler U, Janner SFM,
Chappuis V, Buser D. Implant therapy in a surgical spe-
cialty clinic: an analysis of patients, indications, surgical
procedures, risk factors and early failures. Int J Oral Max-
illofac Implants 2015: 30: 151–160.
43. European Commission. Protection Radiation No 172. Cone
beam CT for dental and maxillofacial radiology (Evidence-
based guidelines). 2012. Available at, http://www.seden-
texct.eu/files/radiation_protection_172.pdf; accessed
March 5th, 2016.
44. Farman AG. ALARA still applies. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2005: 100: 395–397.
45. Flu€ gge T, Ho€ vener JB, Ludwig U, Eisenbeiss AK, Spittau B,
Hennig J, Schmelzeisen R, Nelson K. Magnetic resonance
imaging of intraoral hard and soft tissues using an intrao-
ral coil and FLASH sequences. Eur Radiol 2016: 26: 4616–
4623.
46. Fortin T, Camby E, Alik M, Isidori M, Bouchet H. Panora-
mic images versus three-dimensional planning software
for oral implant planning in atrophied posterior maxillary:
a clinical radiological study. Clin Implant Dent Relat Res
2013: 15: 198–204.
47. Frei C, Buser D, Dula K. Study on the necessity for cross-
section imaging of the posterior mandible for treatment
planning of standard cases in implant dentistry. Clin Oral
Implants Res 2004: 15: 490–497.
48. Fryback DG, Thornbury JR. The efficacy of diagnostic
imaging. Med Decis Making 1991: 11: 88–94.

49. Galindo-Moreno P, Padial-Molina M, Avila G, Rios HF,
Herna ndez-Corte s P, Wang H-L. Complications associated
with implant migration into the maxillary sinus cavity. Clin
Oral Implants Res 2012: 23: 1152–1160.
50. Galli M, Barausse C, Masi I, Falisi G, Baffone M, Tuci L,
Felice P. Inferior alveolar nerve laceration after implant
site preparation: a case report. Eur J Oral Implantol 2015:
8: 293–296.
51. Golubovic V, Mihatovic I, Becker J, Schwarz F. Accuracy of
cone-beam computed tomography to assess the configu-
ration and extent of ligature-induced peri-implantitis
defects. A pilot study. Oral Maxillofac Surg 2012: 16: 349–
354.
52. Gonza lez-Garcıa A, Gonza lez-Garcıa J, Diniz-Freitas M,
Garcıa-Garcıa A, Bullo n P. Accidental displacement and
migration of endosseous implants into adjacent craniofa-
cial structures: a review and update. Med Oral Patol Oral
Cir Bucal 2012: 17: e769–e774.
53. Gorla LF, Spin-Neto R, Boos FB, Pereira Rdos S, Garcia-
Junior IR, Hochuli-Vieira E. Use of autogenous bone and
beta-tricalcium phosphate in maxillary sinus lifting: a
prospective, randomized, volumetric computed tomogra-
phy study. Int J Oral Maxillofac Surg 2015: 44: 1486–1491.
54. Goulston R, Davies J, Horner K, Murphy F. Dose optimiza-
tion by altering the operating potential and tube current
exposure time product in dental cone beam CT: a system-
atic review. Dentomaxillofac Radiol 2016: 45: doi: 10.1259/
dmfr.20150254.
55. Greenstein G, Cavallaro J, Romanos G, Tarnow D. Clinical
recommendations for avoiding and managing surgical
complications associated with implant dentistry: a review.
J Periodontol 2008: 79: 1317–1329.
56. Gro€ ndahl K, Sunden S, Gro € ndahl HG. Inter- and intraob-
server variability in radiographic bone level assessment at
Branemark fixtures. Clin Oral Implants Res 1998: 9: 243–
250.
57. Grol R, Grimshaw J. From best evidence to best practice:
effective implementation of change in patients’ care. Lan-
cet 2003: 362: 1225–1230.
58. Guerrero ME, Botetano R, Beltran J, Horner K, Jacobs R.
Can imaging help to predict postoperative outcome after
wisdom tooth removal? A randomized controlled trial
using panoramic radiography versus cone-beam CT. Clin
Oral Investig 2014: 18: 335–342.
59. Guerrero ME, Noriega J, Jacobs R. Preoperative implant
planning considering alveolar bone grafting needs and
complication prediction using panoramic versus CBCT
images. Imaging Sci Dent 2014: 44: 213–220.
60. Handelsman M. Surgical guidelines for dental implant
placement. Br Dent J 2006: 201: 139–152.
61. Harris D, Buser D, Dula K, Gro € ndahl K, Harris D, Jacobs R,
Lekholm U, Nakielny R, van Steenberghe D, van der Stelt
P; EAO. Guidelines for the use of Diagnostic Imaging in
Implant Dentistry. Clin Oral Implants Res 2002: 13: 566–
570.
62. Harris D, Horner K, Gro € ndahl K, Jacobs R, Helmrot E,
Benic GI, Bornstein MM, Dawood A, Quirynen M. Guideli-
nes for the use of diagnostic imaging in implant dentistry
2011: update of the E.A.O. A consensus workshop orga-
nized by the European Association for Osseointegration in
the Medical University of Warsaw, Poland. Clin Oral
Implants Res 2012: 23: 1243–1253.
Cone beam computed tomography in implant dentistry
63. Hassan B, Gime nez Gonzalez B, Tahmaseb A, Jacobs R,
Bornstein MM. Three-dimensional facial scanning tech-
nology: applications and future trends. Forum Implantol
2014: 10: 6–15.
64. Hidalgo Rivas JA, Horner K, Thiruvenkatachari B, Davies J,
Theodorakou C. Development of a low-dose protocol for
cone beam CT examinations of the anterior maxilla in chil-
dren. Br J Radiol 2015: 88: 20150559.
65. Hodez C, Griffaton-Taillandier C, Bensimon I. Cone-beam
imaging: applications in ENT. Eur Ann Otorhinolaryngol
Head Neck Dis 2011: 128: 65–78.
66. Hofmann E, Schmid M, Lell M, Hirschfelder U. Cone beam
computed tomography and low-dose multislice computed
tomography in orthodontics and dentistry: a comparative
evaluation on image quality and radiation exposure. J Oro-
fac Orthop 2014: 75: 384–398.
67. Hol C, Helle n-Halme K, Torgersen G, Nilsson M, Møys-
tad A. How do dentists use CBCT in dental clinics? A
Norwegian nationwide survey. Acta Odontol Scand 2015:
73: 195–201.
68. Horner K, Islam M, Flygare L, Tsiklakis K, Whaites E. Basic
principles for use of dental cone beam computed tomog-
raphy: consensus guidelines of the European Academy of
Dental and Maxillofacial Radiology. Dentomaxillofac
Radiol 2009: 38: 187–195.
69. Horner K, O’Malley L, Taylor K, Glenny AM. Guidelines for
clinical use of CBCT: a review. Dentomaxillofac Radiol
2015: 44: doi: 10.1259/dmfr.20140225.
70. Hu KS, Choi DY, Lee WJ, Kim HJ, Jung UW, Kim S. Reliabil-
ity of two different presurgical preparation methods for
implant dentistry based on panoramic radiography and
cone-beam computed tomography in cadavers. J Peri-
odontal Implant Sci 2012: 42: 39–44.
71. Huang Y, Van Dessel J, Liang X, Depypere M, Zhong W, Ma
G, Lambrichts I, Maes F, Jacobs R. Effects of immediate
and delayed loading on peri-implant trabecular structures:
a cone beam CT evaluation. Clin Implant Dent Relat Res
2014: 16: 873–883.
72. International Commission on Radiological Protection. The
2007 Recommendations of the International Commission
on Radiological Protection. ICRP publication 103. Ann
ICRP 2007: 37: 1–332.
73. Jacobs R, Quirynen M, Bornstein MM. Neurovascular dis-
turbances after implant surgery. Periodontol 2000 2014: 66:
188–202.
74. Jaju PP, Jaju SP. Cone-beam computed tomography: Time
to move from ALARA to ALADA. Imaging Sci Dent 2015: 45:
263–265.
75. Janner SFM, Caversaccio M, Dubach P, Sendi P, Buser D,
Bornstein MM. Characteristics and dimensions of the Sch-
neiderian membrane: a radiographic analysis using cone
beam computed tomography in patients referred for den-
tal implant surgery in the posterior maxilla. Clin Oral
Implants Res 2011: 22: 1446–1453.
76. Joda T, Gallucci GO. The virtual patient in dental medi-
cine. Clin Oral Implants Res 2015: 26: 725–726.
77. Jung RE, Benic GI, Scherrer D, Ha €mmerle CH. Cone beam
computed tomography evaluation of regenerated buccal
bone 5 years after simultaneous implant placement and
guided bone regeneration procedures - a randomized,
controlled clinical trial. Clin Oral Implants Res 2015: 26:
28–34.
69
Bornstein et al.
78. Kaminaka A, Nakano T, Ono S, Kato T, Yatani H. Cone-
Beam Computed Tomography Evaluation of Horizontal
and Vertical Dimensional Changes in Buccal Peri-Implant
Alveolar Bone and Soft Tissue: A 1-Year Prospective Clini-
cal Study. Clin Implant Dent Relat Res 2015: 17 (Suppl 2):
e576–e585.
79. Kapila SD, Nervina JM. CBCT in orthodontics: assessment
of treatment outcomes and indications for its use. Den-
tomaxillofac Radiol 2015: 44: 20140282.
80. Khan M, Elathamna EN, Lin WS, Harris BT, Farman AG,
Scheetz JP, Morton D, Scarfe WC. Comparison of virtual
dental implant planning using the full cross-sectional and
transaxial capabilities of cone beam computed tomogra-
phy vs reformatted panoramic imaging and 3D modeling.
Int J Oral Maxillofac Implants 2015: 30: 814–819.
81. Khawaja N, Renton T. Case studies on implant removal
influencing the resolution of inferior alveolar nerve injury.
Br Dent J 2009: 206: 365–370.
82. Korn P, Elschner C, Schulz MC, Range U, Mai R, Scheler U.
MRI and dental implantology: two which do not exclude
each other. Biomaterials 2015: 53: 634–645.
83. Kuchler U, Chappuis V, Gruber R, Lang NP, Salvi GE.
Immediate implant placement with simultaneous guided
bone regeneration in the esthetic zone: 10-year clinical
and radiographic outcomes. Clin Oral Implants Res 2016:
27: 253–257.
84. Ku€ hl S, Zu€ rcher S, Zitzmann NU, Filippi A, Payer M,
Dagassan-Berndt D. Detection of peri-implant bone
defects with different radiographic techniques - a human
cadaver study. Clin Oral Implants Res 2016: 27: 529–534.
85. Ku€ tu
€ k N, Demirbasß AE, Go
€ nen ZB, Topan C, Kilicß E, Eto
€z
OA, Alkan A. Anterior mandibular zone safe for implants. J
Craniofac Surg 2013: 24: e405–e408.
86. Lai CS, Bornstein MM, Mock L, Heuberger BM, Dietrich T,
Katsaros C. Impacted maxillary canines and root resorp-
tions of neighbouring teeth: a radiographic analysis using
cone-beam computed tomography (CBCT). Eur J Orthod
2013: 35: 529–538.
87. Libersa P, Savignat M, Tonnel A. Neurosensory distur-
bances of the inferior alveolar nerve: a retrospective study
of complaints in a 10-year period. J Oral Maxillofac Surg
2007: 65: 1486–1489.
88. Loubele M, Maes F, Schutyser F, Marchal G, Jacobs R, Sue-
tens P. Assessment of bone segmentation quality of cone-
beam CT versus multislice spiral CT: a pilot study. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 2006: 102:
225–234.
89. Loubele M, Guerrero ME, Jacobs R, Suetens P, van Steen-
berghe D. A comparison of jaw dimensional and quality
assessments of bone characteristics with cone-beam CT,
spiral tomography, and multi-slice spiral CT. Int J Oral
Maxillofac Implants 2007: 22: 446–454.
90. Ludlow JB, Timothy R, Walker C, Hunter R, Benavides E,
Samuelson DB, Scheske MJ. Effective dose of dental CBCT
- a meta analysis of published data and additional data for
nine CBCT units. Dentomaxillofac Radiol 2015: 44: doi:
10.1259/dmfr.20140197.
91. Manchikanti L, Falco FJ, Benyamin RM, Kaye AD, Boswell
MV, Hirsch JA. A modified approach to grading of evi-
dence. Pain Physician 2014: 17: E319–E325.
92. Marine PM, Stabin MG, Fernald MJ, Brill AB. Changes in
radiation dose with variations in human anatomy: larger
70
and smaller normal-stature adults. J Nucl Med 2010: 51:
806–811.
93. Markovic A, Misic T, Calvo-Guirado JL, Delgado-Ruız RA,
Janjic B, Abboud M. Two-center prospective, random-
ized, clinical, and radiographic study comparing osteo-
tome sinus floor elevation with or without bone graft
and simultaneous implant placement. Clin Implant Dent
Relat Res 2016: 18: 873–882.
94. Meloni SM, Tallarico M, Lolli FM, Deledda A, Pisano M,
Jovanovic SA. Postextraction socket preservation using
epithelial connective tissue graft vs porcine collagen
matrix. 1-year results of a randomised controlled trial. Eur
J Oral Implantol 2015: 8: 39–48.
95. Mengel R, Kruse B, Flores-de-Jacoby L. Digital volume
tomography in the diagnosis of peri-implant defects: an
in vitro study on native pig mandibles. J Periodontol 2006:
77: 1234–1241.
96. Merheb J, Van Assche N, Coucke W, Jacobs R, Naert I, Quiry-
nen M. Relationship between cortical bone thickness or
computerized tomography-derived bone density values and
implant stability. Clin Oral Implants Res 2010: 21: 612–617.
97. Misch CM, Jensen OT, Pikos MA, Malmquist JP. Vertical
bone augmentation using recombinant bone
morphogenetic protein, mineralized bone allograft, and
titanium mesh: a retrospective cone beam computed
tomography study. Int J Oral Maxillofac Implants 2015: 30:
202–207.
98. Monje A, Monje F, Herna ndez-Alfaro F, Gonzalez-Garcıa
R, Sua rez-Lo
 pez del Amo F, Galindo-Moreno P, Mon-
tanero-Ferna ndez J, Wang HL. Horizontal bone augmenta-
tion using autogenous block grafts and particulate
xenograft in the severe atrophic maxillary anterior ridges:
a cone-beam computerized tomography case series. J Oral
Implantol 2015: 41: 366–371.
99. Mozzo P, Procacci C, Tacconi A, Tinazzi Martini P, Berg-
amo Andreis IA. A new volumetric CT machine for dental
imaging based on the cone-beam technique: preliminary
results. Eur Radiol 1998: 8: 1558–1564.
100. Mraiwa N, Jacobs R, van Steenberghe D, Quirynen M.
Clinical assessment and surgical implications of anatomic
challenges in the anterior mandible. Clin Implant Dent
Relat Res 2003: 5: 219–225.
101. Nackaerts O, Maes F, Yan H, Couto Souza P, Pauwels R,
Jacobs R. Analysis of intensity variability in multislice and
cone beam computed tomography. Clin Oral Implants Res
2011: 22: 873–879.
102. Naitoh M, Hayashi H, Tsukamoto N, Ariji E. Labial bone
assessment surrounding dental implant using cone-beam
computed tomography: an in vitro study. Clin Oral
Implants Res 2012: 23: 970–974.
103. Nemtoi A, Czink C, Haba D, Gahleitner A. Cone beam CT:
a current overview of devices. Dentomaxillofac Radiol
2013: 42: doi: 10.1259/dmfr.20120443.
104. Noffke CE, Farman AG, Nel S, Nzima N. Guidelines for the
safe use of dental and maxillofacial CBCT: a review with
recommendations for South Africa. SADJ 2011: 66: 262,
264–266.
105. Oh E, Kraut RA. Effect of sinus membrane perforation on
dental implant integration: a retrospective study on 128
patients. Implant Dent 2011: 20: 13–19.
106. Ohe JY, Kim GT, Lee JW, Al Nawas B, Jung J, Kwon YD. Vol-
ume stability of hydroxyapatite and b-tricalcium

phosphate biphasic bone graft material in maxillary sinus
floor elevation: a radiographic study using 3D cone beam
computed tomography. Clin Oral Implants Res 2016: 27:
348–353.
107. Patcas R, Mu € ller L, Ullrich O, Peltoma€ki T. Accuracy of
cone-beam computed tomography at different resolu-
tions assessed on the bony covering of the mandibular
anterior teeth. Am J Orthod Dentofacial Orthop 2012:
141: 41–50.
108. Patel S, Durack C, Abella F, Shemesh H, Roig M, Lemberg
K. Cone beam computed tomography in Endodontics - a
review. Int Endod J 2015: 48: 3–15.
109. Pauwels R, Beinsberger J, Collaert B, Theodorakou C,
Rogers J, Walker A, Cockmartin L, Bosmans H, Jacobs R,
Bogaerts R, Horner K; SEDENTEXCT Project Consortium.
Effective dose range for dental cone beam computed
tomography scanners. Eur J Radiol 2012: 81: 267–271.
110. Pauwels R, Cockmartin L, Ivanauskaite  D, Urboniene A,
Gavala S, Donta C, Tsiklakis K, Jacobs R, Bosmans H,
Bogaerts R, Horner K; SEDENTEXCT Project Consortium.
Estimating cancer risk from dental cone-beam CT expo-
sures based on skin dosimetry. Phys Med Biol 2014: 59:
3877–3891.
111. Pauwels R, Zhang G, Theodorakou C, Walker A, Bosmans
H, Jacobs R, Bogaerts R, Horner K; SEDENTEXCT Project
Consortium. Effective radiation dose and eye lens dose in
dental cone beam CT: effect of field of view and angle of
rotation. Br J Radiol 2014: 87: doi: 10.1259/bjr.20130654.
112. Pauwels R, Jacobs R, Singer SR, Mupparapu M. CBCT-
based bone quality assessment: are Hounsfield units
applicable? Dentomaxillofac Radiol 2015: 44: doi: 10.1259/
dmfr.20140238.
113. Pazera P, Bornstein MM, Pazera A, Sendi P, Katsaros C.
Incidental maxillary sinus findings in orthodontic patients:
a radiographic study using cone-beam computed tomora-
phy (CBCT). Orthod Craniofac Res 2011: 14: 17–24.
114. Pertl L, Gashi-Cenkoglu B, Reichmann J, Jakse N, Pertl C.
Preoperative assessment of the mandibular canal in
implant surgery: comparison of rotational panoramic
radiography (OPG), computed tomography (CT) and cone
beam computed tomography (CBCT) for preoperative
assessment in implant surgery. Eur J Oral Implantol 2013:
6: 73–80.
115. Pittayapat P, Bornstein MM, Nozu Imada TS, Coucke W,
Lambrichts I, Jacobs R. Accuracy of linear measurements
using three imaging modalities: two lateral cephalograms
and one 3D model from CBCT data. Eur J Orthod 2015: 37:
202–208.
116. Razavi T, Palmer RM, Davies J, Wilson R, Palmer PJ. Accu-
racy of measuring the cortical bone thickness adjacent to
dental implants using cone beam computed tomography.
Clin Oral Implants Res 2010: 21: 718–725.
117. Renton T, Yilmaz Z. Profiling of patients presenting with
posttraumatic neuropathy of the trigeminal nerve. J Orofac
Pain 2011: 25: 333–344.
118. Renton T, Dawood A, Shah A, Searson L, Yilmaz Z. Post-
implant neuropathy of the trigeminal nerve. A case series.
Br Dent J 2012: 212: E17.
119. Roeder F, Wachtlin D, Schulze R. Necessity of 3D visualiza-
tion for the removal of lower wisdom teeth: required sam-
ple size to prove non-inferiority of panoramic radiography
compared to CBCT. Clin Oral Investig 2012: 16: 699–706.
Cone beam computed tomography in implant dentistry
120. Romanos GE, Greenstein G. The incisive canal. Considera-
tions during implant placement: case report and literature
review. Int J Oral Maxillofac Implants 2009: 24: 740–745.
121. Salvi GE, Lang NP. Diagnostic parameters for monitoring
peri-implant conditions. Int J Oral Maxillofac Implants
2004: 19 (Suppl): 116–127.
122. Schneider AC, Bra €gger U, Sendi P, Caversaccio MD, Buser
D, Bornstein MM. Characteristics and dimensions of the
Schneiderian membrane in patients referred for dental
implant surgery in single-tooth gaps of the posterior max-
illa: a radiographic analysis using cone beam computed
tomography. Int J Oral Maxillofac Implants 2013: 28: 587–
596.
123. Schulze RK, Berndt D, d’Hoedt B. On cone-beam com-
puted tomography artifacts induced by titanium implants.
Clin Oral Implants Res 2010: 21: 100–107.
124. Seals KF, Lee EW, Cagnon CH, Al-Hakim RA, Kee ST. Radi-
ation-induced cataractogenesis: a critical literature review
for the interventional radiologist. Cardiovasc Intervent
Radiol 2016: 39: 151–160.
125. Shelley AM, Ferrero A, Brunton P, Goodwin M, Horner K.
The impact of CBCT imaging when placing dental
implants in the anterior edentulous mandible: a before-
after study. Dentomaxillofac Radiol 2015: 44: doi: 10.1259/
dmfr.20140316.
126. Shiki K, Tanaka T, Kito S, Wakasugi-Sato N, Matsumoto-
Takeda S, Oda M, Nishimura S, Morimoto Y. The signifi-
cance of cone beam computed tomography for the visual-
ization of anatomical variations and lesions in the
maxillary sinus for patients hoping to have dental
implant-supported maxillary restorations in a private den-
tal office in Japan. Head Face Med 2014: 10: doi: 10.1186/
1746-160X-10-20.
127. Soikkonnen K, Ainamo A. Radiographic maxillary sinus
findings in the elderly. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 1995: 80: 487–491.
128. Special committee to revise the joint AAE/AAOMR posi-
tion statement on use of CBCT in Endodontics. AAE and
AAOMR joint position statement: use of cone beam com-
puted tomography in endodontics 2015 update. Oral Surg
Oral Med Oral Pathol Oral Radiol 2015: 120: 508–512.
129. Spin-Neto R, Stavropoulos A, Coletti FL, Pereira LA, Mar-
cantonio E Jr, Wenzel A. Remodeling of cortical and cortic-
ocancellous fresh-frozen allogeneic block bone grafts - a
radiographic and histomorphometric comparison to
autologous bone grafts. Clin Oral Implants Res 2015a: 26:
747–752.
130. Spin-Neto R, Matzen LH, Schropp L, Gotfredsen E, Wen-
zel A. Factors affecting patient movement and re-expo-
sure in cone beam computed tomography examination.
Oral Surg Oral Med Oral Pathol Oral Radiol 2015b: 119:
572–578.
131. Spin-Neto R, Matzen LH, Schropp L, Gotfredsen E, Wenzel
A. Movement characteristics in young patients and the
impact on CBCT image quality. Dentomaxillofac Radiol
2016: 45: 20150426.
132. Steinberg MJ, Kelly PD. Implant-related nerve injuries.
Dent Clin North Am 2015: 59: 357–373.
133. Stratis A, Zhang G, Lopez-Rendon X, Jacobs R, Bogaerts R,
Bosmans H. Customisation of a Monte Carlo dosimetry
tool for dental cone-beam CT sytems. Radiat Prot Dosime-
try 2016: 169: 378–385.
71
Bornstein et al.
134. Sur J, Seki K, Koizumi H, Nakajima K, Okano T. Effects of
tube current on cone-beam computerized tomography
image quality for presurgical implant planning in vitro.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010:
110: e29–e33.
135. Tahmaseb A, Wismeijer D, Coucke W, Derksen W. Com-
puter technology applications in surgical implant den-
tistry: a systematic review. Int J Oral Maxillofac Implants
2014: 29 (Suppl): 25–42.
136. Tal H, Moses O. A comparison of panoramic radiography
with computed tomography in the planning of implant
surgery. Dentomaxillofac Radiol 1991: 20: 40–42.
137. Tay AB, Zuniga JR. Clinical characteristics of trigeminal
nerve injury referrals to a university centre. Int J Oral Max-
illofac Surg 2007: 36: 922–927.
138. Temmerman A, Hertele  S, Teughels W, Dekeyser C, Jacobs
R, Quirynen M. Are panoramic images reliable in planning
sinus augmentation procedures? Clin Oral Implants Res
2011: 22: 189–194.
139. Theodorakou C, Walker A, Horner K, Pauwels R, Bogaerts
R, Jacobs R; SEDENTEXCT Project Consortium. Estimation
of paediatric organ and effective doses from dental cone
beam CT using anthropomorphic phantoms. Br J Radiol
2012: 85: 153–160.
140. Thilander-Klang A, Helmrot E. Methods of determining
the effective dose in dental radiology. Radiat Prot Dosime-
try 2010: 139: 306–309.
141. Timock AM, Cook V, McDonald T, Leo MC, Crowe J, Ben-
ninger BL, Covell DA Jr. Accuracy and reliability of buccal
bone height and thickness measurements from cone-
beam computed tomography imaging. Am J Orthod
Dentofacial Orthop 2011: 140: 734–744.
142. Tyndall DA, Price JB, Tetradis S, Ganz SD, Hildebolt C,
Scarfe WC; American Academy of Oral and Maxillofacial
Radiology. Position statement of the American Academy
of Oral and Maxillofacial Radiology on selection criteria
for the use of radiology in dental implantology with
emphasis on cone beam computed tomography. Oral Surg
Oral Med Oral Pathol Oral Radiol 2012: 113: 817–826.
143. Umanjec-Korac S, Wu G, Hassan B, Liu Y, Wismeijer D. A
retrospective analysis of the resorption rate of depro-
teinized bovine bone as maxillary sinus graft material on
cone beam computed tomography. Clin Oral Implants Res
2014: 25: 781–785.
144. United Nations. Sources and effects of ionizing radiation.
UNSCEAR 2000 report to the general assembly, with scien-
tific annexes. Volume 1: Sources. Annex D: Medical radia-
tion exposures. New York, NY: UN, 2000.
145. Urban I, Jovanovic SA, Buser D, Bornstein MM. Partial lat-
eralization of the nasopalatine nerve at the incisive fora-
men for ridge augmentation in the anterior maxilla prior
to placement of dental implants: a retrospective case ser-
ies evaluating self-reported data and neurosensory testing.
Int J Periodontics Restorative Dent 2015: 35: 169–177.
146. Vandenberghe B, Luchsinger S, Hostens J, Dhoore E,
Jacobs R; SEDENTEXCT Project Consortium. The influ-
ence of exposure parameters on jawbone model accuracy
using cone beam CT and multislice CT. Dentomaxillofac
Radiol 2012: 41: 466–474.
72
147. Van Dessel J, Huang Y, Depypere M, Rubira-Bullen I, Maes
F, Jacobs R. A comparative evaluation of cone beam CT
and micro-CT on trabecular bone structures in the human
mandible. Dentomaxillofac Radiol 2013: 42: doi: 10.1259/
dmfr.20130145.
148. Vayron R, Soffer E, Anagnostou F, Ha€ıat G. Ultrasonic eval-
uation of dental implant osseointegration. J Biomech 2014:
47: 3562–3568.
149. Vazquez L, Saulacic N, Belser U, Bernard JP. Efficacy of
panoramic radiographs in the planning of posterior
mandibular implants: a prospective clinical study of 1527
consecutively treated patients. Clin Oral Implants Res
2008: 19: 81–85.
150. Vogiatzi T, Kloukos D, Scarfe WC, Bornstein MM. Inci-
dence of anatomical variations and disease of the maxil-
lary sinuses as identified by cone beam computed
tomography within the field of dental medicine. A system-
atic review. Int J Oral Maxillofac Implants 2014: 29: 1301–
1314.
151. von Arx T, Fodich I, Bornstein MM, Jensen SS. Perforation
of the sinus membrane during sinus floor elevation: a ret-
rospective study of frequency and possible risk factors. Int
J Oral Maxillofac Implants 2014: 29: 718–726.
152. von Arx T, Janner SFM, Ha €nni S, Bornstein MM. Evalua-
tion of new cone-beam computed tomographic criteria for
radiographic healing evaluation after apical surgery:
assessment of repeatability and reproducibility. J Endod
2016: 42: 236–242.
153. Walter C, Schmidt JC, Dula K, Sculean A. Cone beam com-
puted tomography (CBCT) for diagnosis and treatment
planning in periodontology: A systematic review. Quintes-
sence Int 2016: 47: 25–37.
154. Waltrick KB, De Abreu MJN Jr, Correa M, Zastrow MD,
Dutra VD. Accuracy of linear measurements and visibility
of the mandibular canal of cone-beam computed tomog-
raphy images with different voxel sizes: An in vitro study.
J Periodontol 2013: 84: 68–77.
155. Widmann G, Bischel A, Stratis A, Kakar A, Bosmans H,
Jacobs R, Gassner EM, Puelacher W, Pauwels R. Ultralow
dose dentomaxillofacial CT imaging and iterative recon-
struction techniques: variability of Hounsfield units and
contrast-to-noise ratio. Br J Radiol 2016: 89: 20151055.
156. Yilmaz B, Ozcelik BT, Sarantopoulos DM, McGlumphy E.
Importance of CT scans in diagnosing symptoms from
misplaced implants. Implant Dent 2012: 21: 108–111.
157. Zhang G, Pauwels R, Marshall N, Shaheen E, Nuyts J,
Jacobs R, Bosmans H. Development and validation of a
hybrid simulation technique for cone beam CT: applica-
tion to an oral imaging system. Phys Med Biol 2011: 56:
5823–5843.
158. Zhang G, Marshall N, Bogaerts R, Jacobs R, Bosmans H.
Monte Carlo modeling for dose assessment in cone beam
CT for oral and maxillofacial applications. Med Phys 2013:
40: 072103.
159. Zijderveld SA, van den Bergh JP, Schulten EA, ten
Bruggenkate CM. Anatomical and surgical findings and
complications in 100 consecutive maxillary sinus floor
elevation procedures. J Oral Maxillofac Surg 2008: 66:
1426–1438.