Chapter 23

Diagnostic Imaging of the Periodontal and Implant Patient

Outline:

 Introduction
 Basic principles of diagnostic imaging in dental medicine
 Modalities
 Radiation hazards and radiation dose protection
 Diagnostic imaging in periodontology
 General recommendations
 Future trends and developments
 Diagnostic imaging in oral implantology
 General recommendations for implant treatment planning purposes
 Recommendations during and after implant placement (follow-up)
 Recommendations for special indications and techniques
 Future trends and developments
 Conclusions and future outlook
Introduction

Diagnostic imaging plays a pivotal role in dental medicine, complementing clinical examinations
and facilitating various aspects of patient care, including:

 Treatment Planning: Both non-surgical and surgical procedures.

 Monitoring Treatment Outcomes: Ensures effectiveness and guides adjustments if
necessary.

Key Considerations for Practitioners:

 Understand the advantages and disadvantages of imaging modalities.

 Select imaging modalities tailored to the patient's underlying condition and specific
clinical needs.
 Weigh the benefits against potential risks, such as biological effects from ionizing
radiation exposure.

This chapter emphasizes the basic principles of diagnostic imaging in dental medicine, focusing
on:

1. Periodontal health and disease assessment.

2. Implant treatment planning and follow-up.

Basic Principles of Diagnostic Imaging in Dental Medicine

Modalities

Imaging modalities in dental medicine vary based on their physical principles of image
formation and can be broadly classified into two categories:

1. Ionizing Imaging Modalities

o Predominantly used in clinical practice for evaluating the health and pathology
of hard tissues, such as teeth and jaws.
o Common X-ray-based modalities include:
 Periapical radiographs: Ideal for localized assessments, such as dental
caries or root canal morphology.
 Bitewings: Useful for detecting interproximal caries and bone loss.
 Occlusal views: Provide a broader overview of tooth and jaw structures.
 Panoramic images: Offer a comprehensive view of the maxillofacial
region.
 Cephalometric views: Often used in orthodontics and craniofacial
assessment.
 Cone beam computed tomography (CBCT): Provides high-resolution
3D imaging, particularly valuable for implant planning and bone
evaluation.
 Multidetector computed tomography (MDCT): Reserved for complex
or selected cases requiring detailed imaging.
2. Non-Ionizing Imaging Modalities
o Techniques include ultrasound and magnetic resonance imaging (MRI):
 These are more commonly used in clinical medicine for observing soft
tissue changes.
 Their application in dental medicine is limited but growing, particularly
for:
 Soft tissue evaluations.
 Periodontal and peri-implant disease assessments.
o Advantages of non-ionizing modalities:
 Lack of ionizing radiation makes them safer for repeated use.
 Superior soft tissue contrast, which motivates researchers to adapt these
modalities for dental and periodontal purposes.

Key Takeaways

 The selection of imaging modality should align with the patient’s clinical needs and
minimize risks associated with radiation exposure.
 Ionizing techniques dominate current clinical practice due to their effectiveness in
evaluating hard tissues, but non-ionizing methods are emerging as promising
alternatives, particularly for soft tissue evaluations.
 CBCT and panoramic imaging are crucial tools for periodontal and implant
assessments due to their detailed visualization of bone structures and anatomical
landmarks.

This review underscores the necessity for dental practitioners to stay informed about advances in
imaging modalities and adapt them appropriately to improve patient care while minimizing risks.

Ionizing Modalities

Overview
  Most diagnostic imaging modalities in dental medicine involve ionizing radiation, which is
generated by X-ray machines.
 Mechanism: High-energy photons (X-rays) ionize electrons in the scanned region, producing
images on photographic film or digital receptors.
 Categories:
o Intraoral techniques (film/receptor positioned inside the mouth).
o Extraoral techniques (film/receptor positioned outside the mouth).

Intraoral Techniques

1. Periapical Radiography
o Features:
 Small X-ray film (22 × 35 mm to 30.5 × 40.5 mm) for 2D images of 2-3 teeth and
surrounding bone.
 High spatial resolution, low radiation dose.
o Uses:
 Early detection of dentoalveolar pathologies (e.g., caries, periapical lesions,
bone loss).
 Assessment of root morphology, pulpal cavities, and implant osseointegration.
 Monitoring peri-implant bone loss and determining endodontic instrument
lengths.

2. Bitewing Radiography
o Features:
 Similar size to periapical films, positioned in the lingual vestibule.
 Captures coronal portions of maxillary and mandibular posterior teeth on one
side.
o Uses:
 Early diagnosis of interproximal caries and periodontitis.
 Evaluating bone density and crestal bone levels.

3. Occlusal Radiography
o Features:
 Large X-ray film (58 × 77 mm) placed between the upper and lower teeth for 2D
images of maxillary/mandibular arches and palate.
o Uses:
 Locating supernumerary, unerupted, or impacted teeth.
 Identifying radiolucent/radiopaque lesions (e.g., cysts, sialoliths) or jaw
fractures.
o Limitations:
 Unsuitable for precise implant planning due to the inability to show alveolar
bone width (replaced by CBCT).
Extraoral Techniques

1. Panoramic Radiography
o Features:
 Uses a rotating X-ray source to generate a 2D image of teeth, jaws, and TMJs.
o Uses:
 Routine examination, evaluation of dentition, impacted teeth, bone levels, and
TMJs.
o Limitations:
 Low spatial resolution, image distortion, and superimposition of structures.

2. Cephalometric Radiography
o Features:
 Captures craniofacial regions in lateral or posteroanterior projections.
o Uses:
 Primarily for orthodontics and orthognathic surgery.
 Identifying skeletal, dental, and soft tissue landmarks.
o Limited Use in Periodontology and Implantology.

3. Multidetector Computed Tomography (MDCT)

o Features:
 Uses fan-beam X-rays to capture multiple axial slices reconstructed into 3D
images.
o Uses:
 Detailed visualization of anatomical structures and soft tissue evaluation.
o Limitations:
 High radiation dose, cost, and limited availability in dental practice.

4. Cone Beam Computed Tomography (CBCT)

o Features:
 Cone-beam X-rays generate high-resolution 3D images with a lower radiation
dose compared to MDCT.
 Spatial resolution is 2-8 times higher than MDCT.
o Uses:
 Comprehensive evaluation of hard tissues (teeth and jaws), implant planning,
and pathological assessments.
o Limitations:
 Low contrast resolution limits visibility of soft tissues.
 Susceptible to artifacts from dental restorations and movement.

Key Takeaways

1. Ionizing Imaging Techniques:

o Intraoral techniques are first-line modalities for localized evaluations.
o Extraoral techniques offer a broader field of view but lower resolution.
 o CBCT is increasingly preferred for implantology and complex cases.
2. Clinical Decision-Making:
o Selection depends on the clinical need, balancing diagnostic benefits against radiation
risks.

Non-Ionizing Modalities

Overview

 Unlike X-ray-based imaging, non-ionizing modalities do not expose patients to ionizing radiation.
 The application of non-ionizing imaging in dentistry has gained attention to minimize radiation
risks and provide alternative diagnostic tools.
 While their biological effects are negligible, repeated exposure to ionizing radiation has been
linked to an increased risk of conditions such as salivary gland tumors, thyroid cancer, and
meningioma.

1. Ultrasound Imaging

Principle:

 Ultrasound imaging relies on high-frequency sound waves (1–20 MHz) emitted by a transducer.
These sound waves interact with tissues of varying acoustic impedance, and the reflected waves
are captured to generate real-time cross-sectional 2D images.

Current Applications in Dentistry:

 Ultrasound has traditionally been used in general medicine for diagnosis and image-guided
surgeries. Its applications in dental medicine include:
o Evaluation of major salivary glands (e.g., sialadenitis or tumors).
o Imaging of superficial mass lesions and cervical lymph nodes.
o Assessment of masticatory and neck muscles, maxillofacial fractures, and
temporomandibular joints (TMJ).

Potential Advancements:

 With the development of smaller intraoral transducers, ultrasound shows promise for:
o Visualizing gingiva and alveolar bone contours.
o Assessing peri-implant bone resorption, particularly since ultrasound imaging is
unaffected by metal artifacts, a common limitation of other modalities like CBCT.

2. Magnetic Resonance Imaging (MRI)

Principle:

 MRI uses static magnetic fields and radiofrequency pulses to stimulate hydrogen nuclei within
the body. These nuclei absorb and release resonance energy, which is detected and converted
into high-resolution images.

Current Applications in Dentistry:

 MRI is highly effective for soft tissue evaluation and is commonly used in the following areas:
o Temporomandibular Joint (TMJ): Diagnosing disk pathologies, joint effusion, and
functional disorders.
o Evaluation of floor of the mouth, salivary glands, tongue, and paranasal sinuses.

Advantages:

 MRI is free from ionizing radiation, making it safer for patients.

 It provides excellent contrast for soft tissues, making it ideal for visualizing pathologies that are
difficult to detect with X-ray-based modalities.

Limitations:

 Accessibility and Cost: MRI units are expensive and not widely available in general dental
practices.
 Patient Eligibility: Patients with cardiac pacemakers, insulin pumps, or claustrophobia cannot
undergo MRI.
 Metal Artifacts: MRI images are significantly affected by metal restorations, limiting its use for
dentoalveolar evaluations.

Future Potential:

 Efforts are underway to improve the use of MRI in dentistry:

o Special Coils: Designed for high-resolution dental imaging in shorter acquisition times.
o Applications for more detailed evaluations of dental and periodontal conditions.

Key Takeaways

1. Ultrasound:
o Offers a non-ionizing alternative for visualizing gingival and peri-implant structures,
unaffected by metal artifacts.
o Its use may expand with advancements in intraoral transducer technology.

2. MRI:
o Provides unparalleled soft tissue contrast, making it invaluable for TMJ and soft tissue
pathology evaluations.
 o However, cost, accessibility, and limitations with metallic artifacts restrict its widespread
use in dental practice.

Non-ionizing modalities hold significant potential to enhance diagnostic capabilities in dentistry

while minimizing radiation exposure, and ongoing advancements will likely expand their clinical
applications.

Radiation Hazards and Radiation Dose Protection

Overview

Diagnostic imaging in dental medicine primarily involves X-rays, which emit ionizing radiation.
While generally considered safe at low levels, ionizing radiation can induce cellular and
chromosomal damage, leading to potential risks such as radiation-induced cell death, mutations,
and carcinogenesis.

Biological Risks of Radiation

1. Deterministic Effects:
o Occur only when radiation exposure exceeds specific threshold doses.
o Severity increases with higher doses.
o Common deterministic effects include:
 Fetal abnormalities: 0.1–0.5 Gy.
 Sterility: 2–3 Gy.
 Skin erythema and hair loss: 2–5 Gy.
 Irreversible skin damage: 20–40 Gy.
o Relevance: Threshold values are much higher than doses used in dental diagnostics,
making deterministic effects rare in dentistry.

2. Stochastic Effects:
o DNA damage caused by ionizing radiation can result in mutations, increasing the risk of
cancers such as:
 Leukemia, thyroid cancer, salivary gland tumors, brain neoplasias, and breast
cancer.
o Stochastic effects:
 Have no dose threshold (even the smallest dose may contribute).
 The risk increases proportionally with radiation dose.
o Relevance: Stochastic effects are more relevant to diagnostic imaging due to the
cumulative nature of radiation exposure.
Principles of Radiation Dose Protection

1. Justification:
o Imaging should only be performed if the benefits outweigh the risks of radiation
exposure.
o Key steps in justification:
 Conduct a thorough clinical examination and review the patient’s medical
history.
 Refer for imaging only if clinical findings are insufficient for diagnosis.
 Use intraoral radiographs (e.g., periapical or bitewing) as the first choice for
periodontal evaluations.
 CBCT imaging should be reserved for selected cases, such as furcation lesions,
and avoided as a routine diagnostic tool due to its higher radiation dose.

2. Optimization (ALARA/ALADA Concepts):

o Minimize radiation exposure by ensuring it is "As Low As Reasonably Achievable"
(ALARA) or "As Low As Diagnostically Acceptable" (ALADA).
o Implementation in dental practice includes:
 Using radiation detectors with maximum sensitivity.
 Selecting the smallest field of view (FOV) to cover only the region of interest.
 Using low-dose scanning protocols and appropriate exposure parameters.
 Shielding patients with protective devices (e.g., lead aprons, thyroid collars).
 Avoiding unnecessary high-resolution scans when diagnostically acceptable
images suffice.

3. Dose Limitation:
o Primarily aimed at protecting occupationally exposed individuals (e.g., radiographic
operators) from excessive radiation exposure.
o Guidelines for clinical staff include:
 Limiting whole-body exposure to <20 mSv annually (as per ICRP guidelines).
 Using radiation shielding and monitoring accumulated radiation doses.
o Patients: Dose limitation for medical exposure is not applicable since imaging benefits
outweigh risks, but protective measures (e.g., lead aprons) are encouraged.

4. Dose Reference Levels (DRLs):

o DRLs represent acceptable upper limits for radiation doses in diagnostic imaging.
o Example: For periapical and bitewing radiographs, the recommended DRL is 1.6 mGy
(NCRP).
o DRLs provide benchmarks to guide operators in maintaining safe exposure levels.

Radiation in Periodontology

1. Purpose of Imaging in Periodontology:

o To assess supporting bony structures of teeth affected by periodontal disease.
o To evaluate the presence, extent, and morphology of bone destruction.
 o Imaging is unnecessary for soft tissue conditions (e.g., gingivitis) without bone
involvement, as these cannot be visualized on X-ray-based modalities.

2. Imaging Modalities for Periodontal Diagnosis:

o Intraoral Radiography (Periapical/Bitewing): First-line choice for evaluating marginal
bone loss.
o CBCT: Used selectively for complex cases such as furcation defects, providing detailed
3D views.
o Panoramic Radiography: Useful for an overview of dental and supporting bone
structures but limited by low spatial resolution and superimposition of anatomical
features.

Key Takeaways

 Minimizing Risks:
o Radiation exposure should be carefully justified and optimized to balance diagnostic
benefits against potential hazards.
o Use the lowest effective dose and smallest imaging area to meet clinical needs.
 Preferred Modalities:
o Conventional intraoral radiographs remain the gold standard for periodontal
evaluations, while CBCT should be reserved for specific indications.
 Occupational Safety:
o Clinicians must adhere to dose limitation principles and ensure protective measures are
in place for both staff and patients.

General Recommendations for 2D Imaging in Periodontology

Overview

Intraoral 2D imaging remains the standard for complementing clinical findings during
periodontal evaluation. Bitewing and periapical radiographs are widely used for assessing
supporting bone conditions, while panoramic radiographs serve as a general overview tool but
with limitations.

Key 2D Imaging Modalities

1. Bitewing Radiography:
o Features:
 Superior accuracy in evaluating coronal bone loss due to an X-ray projection
perpendicular to the long axis of the teeth.
 Reduced distortion and superimposition.
o Limitations:
  Limited field of view (FOV), unable to depict moderate to severe bone defects
exceeding the middle third of the tooth root.
o Use in Periodontal Evaluation:
 Preferred for early periodontal bone loss assessment.

2. Periapical Radiography:
o Features:
 Depicts the full length of the tooth, making it suitable for evaluating the extent
of bone destruction.
o Recommendations:
 A full-mouth intraoral X-ray is ideal for patients with signs of general
periodontitis.
o Use in Periodontal Evaluation:
 More effective than bitewings for evaluating severe periodontal bone defects
and monitoring disease progression.

3. Panoramic Radiography:
o Features:
 Provides an overview of teeth and supporting bone.
o Limitations:
 Low spatial resolution, vertical magnification, and superimposition can lead to
inaccurate assessments.
o Recommendations:
 Should only be used if existing panoramic images are available to minimize
additional radiation exposure (ALARA principle).
 Supplement with periapical radiographs as needed.

Periodontal Bone Loss Assessment

1. Key Indicators:
o Initial Phase:
 Reduced density and erosion of the interradicular alveolar crest with diffuse
borders.
o Advanced Phase:
 Increased bone loss and widening of the periodontal ligament space.
 The interradicular crest is more than 2.0 mm apically to the cementoenamel
junction (CEJ) in periodontitis patients.

2. Bone Loss Classification (Radiographic Stages):

o Stage I: Bone loss <15% of root length.
o Stage II: Bone loss between 15%–33% of root length.
o Stage III: Bone loss to the middle third of the root.
o Stage IV: Bone loss beyond the middle third of the root.

3. Types of Bone Defects:

 o Horizontal Bone Loss:
 Involves multiple teeth, presenting as a parallel reduction in bone height relative
to CEJ levels.
o Vertical Bone Loss:
 Uneven, oblique bone destruction centered around one tooth more than the
adjacent teeth.

Intrabony Defects

1. Types:
o Three-Walled Defect: Surrounded by buccal and oral cortical plates and interradicular
bone.
o Two-Walled Defect: Enclosed by either buccal or oral cortical plate and interradicular
bone.
o One-Walled Defect: Loss of both buccal and oral cortical plates.

2. Imaging Recommendations:
o Two- and Three-Walled Defects:
 Often not clearly visible due to superimposition by buccal/oral plates. Use CBCT
for detailed evaluation.
o One-Walled Defects:
 Can be easily visualized on 2D images.
o Gutta-Percha Tip:
 Used during radiography to identify the bottom level of the bone defect.
o Interdental Crater:
 A specific type of two-walled defect, often requiring 3D imaging for accurate
visualization.

Furcation Defects

1. Features:
o Common in multirooted teeth due to their anatomical complexity.
o Early signs include widening of the periodontal ligament space.
o Advanced stages show radiolucency in the furcation region, often with an inverted "J"-
shaped radiolucency in maxillary molars.

2. Imaging Recommendations:
o Periapical Radiography with angled projections for better visualization.
o CBCT is ideal for assessing the extent and morphology of furcation defects.
Endo-Perio Lesions

1. Features:
o Present as radiolucent defects extending from the alveolar crest to the root apex,
reflecting periodontal and periapical inflammatory lesions.
o Larger radiolucent areas are more likely of periodontal origin but must be correlated
with clinical findings.

2. Imaging Recommendations:
o 2D images provide baseline data but should be supplemented with clinical evaluation
for accurate diagnosis.

Limitations of 2D Imaging

1. Challenges in Bone Defect Visualization:

o Superimposition by dense buccal/oral cortical plates affects the clarity of interproximal
bone defects.
o Buccal and oral bone destruction is not clearly visible.

2. Non-Standardized Follow-Ups:
o Deviations in X-ray angulation during follow-ups can mimic bone healing or loss,
resulting in diagnostic errors.

Key Takeaways

 Intraoral 2D imaging is the first choice for baseline periodontal evaluation due to its high spatial
resolution and low radiation dose.
 Periapical and bitewing radiographs are recommended for assessing marginal bone loss and
periodontal progression.
 For complex cases involving intrabony or furcation defects, CBCT is preferred for its ability to
provide 3D insights.
 Limitations of 2D imaging necessitate cautious interpretation and, in some cases, supplementary
3D imaging for accurate assessment.

Three-Dimensional Modalities

MDCT and CBCT in Periodontology

 Overview:
o MDCT (Multidetector Computed Tomography) and CBCT (Cone Beam Computed
Tomography) provide 3D cross-sectional views, allowing for detailed visualization of the
architecture of periodontal bone defects.
 o These modalities improve accuracy in evaluating the presence, severity, and
morphology of periodontal bone destruction, especially for complex defects like
intrabony and furcation defects in maxillary molars.

 Recommendations:
o Use Cases: Recommended for complex cases where 2D imaging cannot provide
sufficient diagnostic information.
o Limitations:
 Should not be used for routine preoperative imaging or follow-up examinations
due to higher radiation doses.
 Cannot assess soft tissue conditions, such as gingiva health.
 Bone loss observed on 3D images indicates prior disease but not current
activity.
o Clinical Application: The scanning protocol and Field of View (FOV) should be
customized to the specific clinical case to reduce radiation exposure and optimize
imaging accuracy.

Future Trends and Developments

Ultrasound Imaging

 Advantages:
o Non-ionizing, real-time imaging suitable for periodontal diagnosis and follow-up.
o Newly developed small, high-frequency transducers (40 MHz) allow visualization of:
 Gingival thickness and sulcus depth.
 Levels of alveolar bone crest, CEJ, and free gingival margin.
o Unaffected by metallic artifacts, making it ideal for evaluations near dental restorations
or orthodontic appliances.
o Useful in maintenance phases to monitor stability of periodontal soft and bone tissues.

 Limitations:
o Cannot visualize bone defects covered by buccal or oral plates (e.g., three-walled
intrabony or furcation defects).
o Interpretation requires skilled practitioners due to subjective image analysis.

Magnetic Resonance Imaging (MRI)

 Advantages:
o Provides detailed 3D imaging of periodontal soft tissue (e.g., gingiva and periodontal
ligament).
o Differentiates between inflamed and healthy tissues by detecting changes in water
content.
 o May aid in early diagnosis of gingivitis and monitoring healing after periodontal
treatment.

 Limitations:
o Incompatibility with metallic restorations or appliances (due to metal artifacts).
o Unsuitable for patients with pacemakers, insulin pumps, or claustrophobia.
o Costly and less accessible compared to X-ray-based modalities.

 Future Potential:
o MRI units tailored for dental applications may become essential for visualizing soft
tissue pathologies without radiation exposure.

Artificial Intelligence (AI) in Periodontology

 Applications:
o AI algorithms analyze digitally coded images to identify lesions, classify bone defects,
and predict treatment outcomes.
o Current models primarily utilize 2D images to:
 Measure bone loss.
 Automatically classify teeth as "hopeful" or "hopeless."

 Future Trends:
o Integrating AI with 3D imaging modalities (CBCT, MDCT, MRI) could enable:
 Automated volumetric calculations of bone loss.
 Enhanced defect classification.
 Customized treatment recommendations.

General Recommendations for Diagnostic Imaging in Oral Implantology

Preoperative Phase

 Use CBCT for detailed assessment of bone quality, quantity, and proximity to vital structures.
 Avoid excessive imaging or wide FOVs to minimize radiation exposure.

Intraoperative Phase

 Employ image-guided implant surgery for precise implant placement, particularly in

anatomically complex areas.

Postoperative and Follow-Up Phase

  Use intraoral 2D imaging (e.g., periapical radiographs) to monitor osseointegration and detect
any peri-implant bone loss.
 Avoid routine use of CBCT unless complications arise.

Special Considerations

 For advanced procedures such as block grafting or zygoma implants, CBCT offers a reliable
option for treatment planning and postoperative evaluation.

Key Takeaways

 MDCT and CBCT enhance diagnostic precision for complex bone defects but should be used
selectively to minimize radiation exposure.
 Ultrasound and MRI represent promising non-ionizing alternatives, particularly for soft tissue
evaluation, though their clinical applications remain limited by certain technical and logistical
challenges.
 AI advancements may revolutionize periodontal diagnosis and treatment planning, particularly
when integrated with 3D imaging modalities.

General Recommendations for Implant Treatment Planning

Overview

Preoperative imaging is essential for evaluating the bone condition and anatomical structures at
the proposed implant site, which cannot be assessed through clinical examination alone. Proper
imaging selection ensures optimal treatment outcomes and minimizes intra-/postoperative
complications.

Two-Dimensional Modalities

Periapical Radiography

 Advantages:
o Suitable for single or two adjacent edentulous sites.
o High spatial resolution allows for detailed visualization of:
 Bone structure at edentulous sites.
 Healing of extraction sockets, retained roots, and periapical lesions.
 Prognosis of traumatized anterior teeth.
 Limitations:
o Cannot provide cross-sectional views or bucco-oral dimensions of the alveolar ridge.
o Limited accuracy for linear measurements due to distortion and magnification.
o Should be interpreted cautiously and always combined with clinical findings.
Panoramic Radiography

 Advantages:
o Ideal for patients with multiple missing teeth or completely edentulous jaws.
o Provides a broad field of view (FOV) for assessing:
 Vertical bone dimensions.
 Critical anatomical landmarks (e.g., nasal cavity, maxillary sinus, mandibular
canal, mental foramen).
o Valuable for initial treatment planning of multiple implants.
 Limitations:
o Cannot provide accurate linear measurements or 3D evaluations.
o Superimposition artifacts (e.g., spinal cord) may affect assessments of anterior
edentulous sites.
o Using standardized metallic balls during imaging can help calculate magnification
factors.

Three-Dimensional Modalities

Cone Beam Computed Tomography (CBCT)

 Preferred Modality:
o CBCT is more cost-effective, has lower radiation exposure, and is more accessible than
MDCT.
o Provides accurate cross-sectional views for evaluating anatomical structures and
pathological changes.
 Applications:
o Assess Residual Bone Height (RBH) and Residual Bone Width (RBW):
 RBH: Distance between the alveolar crest and the floor of anatomical structures
(e.g., nasal cavity, maxillary sinus).
 RBW: Bucco-oral dimension of the alveolar ridge, which is often insufficient in
anterior and posterior regions due to natural resorption.
o Analyze critical anatomical landmarks:
 Nasopalatine Canal in the anterior maxilla.
 Maxillary Sinus and its pathologies in the posterior maxilla.
 Mandibular Canal and Mental Foramen in the posterior mandible.
 Sublingual and Submental Arteries in the anterior mandible to avoid life-
threatening hemorrhages.
o Identify sinus pathologies, such as:
 Mucosal thickening, cysts, or obstruction of the primary maxillary ostium, which
can lead to sinusitis and postoperative complications.
o Evaluate the morphology of alveolar ridges to prevent surgical complications.
o Use merged intraoral scans to plan guided implant surgery effectively.

Multidetector Computed Tomography (MDCT)

  Use Cases:
o Rarely used in implant dentistry today but recommended for:
 Evaluating bone density using Hounsfield Units (HU), especially for comparing
tissue calcification levels.
 Advanced treatment cases requiring precise bone density measurements.
 Limitations:
o Higher radiation dose compared to CBCT.
o Less accessibility and cost-effectiveness.

Special Considerations

Anterior Maxilla

 Challenges:
o Insufficient RBW due to natural buccal concavity and post-extraction bone resorption.
o Large nasopalatine canals may occupy the space required for implants, necessitating
complex grafting procedures.
 Recommendations:
o Use CBCT to evaluate the level of the alveolar crest, implant shoulder position, and
proximity to adjacent teeth.
o Ensure aesthetic gingival contours are achieved.

Posterior Maxilla

 Challenges:
o Frequent RBH insufficiency due to alveolar crest resorption.
o Critical proximity to the maxillary sinus and its anatomical variations (e.g., septa or thick
lateral walls).
 Recommendations:
o Use CBCT for planning Sinus Floor Elevation (SFE) procedures.
o Assess sinus floor morphology, pathologies, and the Superior Alveolar Artery's course
to avoid hemorrhages.

Anterior Mandible

 Challenges:
o Risk of damaging sublingual and submental arteries during surgical drilling.
o Potential life-threatening complications, such as airway obstruction.
 Recommendations:
o CBCT scans must include the entire vertical height of the mandible and the region of
both mental foramina.
o Avoid penetration of the lingual cortex.

Posterior Mandible
  Challenges:
o RBH insufficiency due to proximity to the mandibular canal.
o Mental foramen often located close to the alveolar crest in atrophic mandibles.
 Recommendations:
o CBCT for accurate visualization of the mandibular canal and mental foramen to prevent
nerve injuries.
o Assess sublingual fossa morphology to avoid cortical perforations.

Preoperative Field of View (FOV) Guidelines

 For CBCT scans:

o Cover all potential implant sites, adjacent alveolar bone, and critical anatomical
landmarks.
o Avoid unnecessarily large FOVs to reduce radiation exposure.

Key Takeaways

1. Imaging Modality Selection:

o Use 2D imaging (periapical and panoramic radiographs) for preliminary evaluations.
o Reserve CBCT for complex cases or when 2D imaging fails to provide sufficient diagnostic
information.
2. Specific Anatomical Assessments:
o Carefully evaluate critical structures such as the nasopalatine canal, maxillary sinus,
mandibular canal, and sublingual fossa to prevent complications.
3. Advanced Techniques:
o CBCT integrated with intraoral scans improves implant planning accuracy.
o MDCT remains a specialized tool for bone density assessments.
4. Radiation Safety:
o Follow ALARA principles by limiting FOVs and unnecessary imaging to minimize patient
exposure

Recommendations During and After Implant Placement (Follow-Up)

During Implant Placement

1. Purpose of Intraoperative Imaging:

o Evaluate the position of the drill and correct alignment issues.
o Address intraoperative complications, such as improper drill angulation or trajectory.

2. Two-Dimensional (2D) Modalities:

 o Periapical Radiography:
 Recommended for novice surgeons to confirm the correct position of the pilot
drill.
 Useful for ensuring precise placement during osteotomy steps.
o Segmented Panoramic Radiography:
 Can help assess drill position in multiple sites when numerous implants are
placed.
o Special Considerations:
 If small instruments (e.g., screwdriver or abutment cover) are swallowed or
aspirated, a chest X-ray is required to identify the location of the object.

After Implant Placement

1. Purpose of Postoperative Imaging:

o Serve as a baseline record of the implant's position and bone integration.
o Evaluate peri-implant bone conditions and detect any complications.

2. Two-Dimensional (2D) Modalities:

o Periapical Radiography:
 Optimal for assessing:
 The level of the alveolar crest around the implant.
 Bone-implant interface.
 Recommended for follow-ups and comparisons over time.
o Panoramic Radiography:
 Preferred for documenting multiple implants in one image.
 Useful for minimizing radiation exposure when more than five intraoral
radiographs would otherwise be required.
 Limitations:
 Lower spatial resolution and susceptibility to distortion, magnification,
and overlapping phenomena.
o During Prosthetic Phase:
 Periapical and bitewing radiographs are used to:
 Assess osseointegration.
 Verify proper seating of prosthetic abutments, frames, or crowns.
 After prosthesis placement, a periapical radiograph is recommended as a
baseline for future comparisons.

3. Maintenance Phase:
o Annual radiographic evaluations of marginal bone loss are recommended, especially for
patients with:
 Risk factors like tobacco use, poor oral hygiene, or a history of periodontitis.
o Justification for follow-up imaging should be based on clinical indicators like probing
depth and inflammatory scores.
Three-Dimensional (3D) Modalities

1. CBCT/MDCT Recommendations:
o Not Recommended for routine follow-up due to:
 High radiation dose.
 Costs.
 Implant-related artifacts that make it difficult to assess bone between adjacent
implants.

2. Indications for 3D Imaging:

o Reserved for complications such as:
 Implant displacement (e.g., into the maxillary sinus).
 Damage to critical structures (e.g., mandibular canal).
 Implant fractures.
 Cases of ailing/failing implants.
 Severe peri-implantitis.
o CBCT is preferred over MDCT for 3D imaging in these scenarios due to its lower
radiation dose and cost-effectiveness.

3. Limitations of 3D Imaging:
o Implant-Related Artifacts:
 Severity increases with closer spacing between implants.
 Makes assessing the bone area between implants challenging.

Key Takeaways

 Intraoperative Imaging:
o Use periapical or segmented panoramic radiography for real-time evaluation during
implant placement, particularly for novice surgeons.
o In case of swallowed/aspirated objects, use a chest X-ray.

 Postoperative Imaging:
o Periapical radiographs are optimal for documenting implant position and peri-implant
bone conditions.
o Panoramic radiography is ideal for cases with multiple implants to minimize radiation
exposure.
o Avoid routine imaging unless clinical symptoms or complications warrant it.

 Follow-Up and Maintenance:

o Annual periapical radiographs are recommended, especially for high-risk patients.
o CBCT is reserved for specific complications like implant displacement, fractures, or
severe peri-implantitis.

Peri-Implant Disease
Overview

Peri-implant diseases are categorized into two main conditions:

1. Peri-implant mucositis:
o Inflammation in the mucosa around dental implants without any supporting bone loss.
2. Peri-implantitis:
o Progression from peri-implant mucositis.
o Characterized by inflammation in the peri-implant mucosa and subsequent progressive
loss of supporting bone tissue.

Management:

 Peri-implantitis may require:

o Resective treatments.
o Regenerative therapies.
o Explantation and replacement of the implant in severe cases.

Diagnostic Imaging for Peri-Implant Disease

Commonly Used Modalities

1. Periapical Radiography:
o High spatial resolution.
o More sensitive for detecting small peri-implant bone defects (e.g., mesial/distal
defects).
o Cannot evaluate bone defects comprehensively (e.g., buccal/lingual bone loss).

2. Cone Beam Computed Tomography (CBCT):

o Offers a 3D evaluation of peri-implant bone defects, including buccal, lingual, mesial,
and distal sites.
o Useful for assessing the type and extent of bone defects.
o Can detect complex bone defects but may be affected by:
 Metal artifacts: Bright streaks and dark areas that distort osseointegration
evaluation.
o Voxel size adjustments can enhance image quality for detecting smaller defects but
increase radiation exposure.

Diagnostic Accuracy

 Both periapical radiography and CBCT have clinically acceptable sensitivity and specificity
(59%–67%) for peri-implant bone defects.
  Factors influencing diagnostic accuracy:
o Size and type of peri-implant bone defects.
o Spatial resolution of the imaging modality.

Imaging Recommendations

1. Periapical Radiography:
o Considered the first-line imaging modality due to its high resolution and lower radiation
dose.
o Ideal for detecting small peri-implant defects at mesial and distal sites.
o Provides clear visualization of:
 Uniform radiolucent lining around failing implants.
 Marginal bone levels for monitoring peri-implant conditions.

2. CBCT:
o Recommended when:
 2D imaging does not provide sufficient diagnostic information.
 Additional imaging data is essential for treatment planning.
o Use the ALARA/ALADA principles to minimize radiation exposure.
o Suitable for:
 Complex cases with extensive bone defects.
 Patients presenting with clinical signs and symptoms of peri-implant disease.

Key Considerations for Imaging in Peri-Implant Disease

 Preferred Modality:
o Use periapical radiography whenever possible due to its effectiveness in detecting small
defects and its lower radiation dose.
 When to Use CBCT:
o For comprehensive 3D assessment of complex or non-mesial/distal defects.
o In cases where clinical symptoms demand additional diagnostic information.
 Limitations of CBCT:
o Metal artifacts can reduce accuracy for assessing bone-implant interfaces and
osseointegration.
o Increased voxel size for better resolution leads to higher radiation exposure.
 Radiation Protection:
o Carefully evaluate the necessity of CBCT scans based on the ALARA/ALADA principles to
avoid unnecessary patient exposure to ionizing radiation.

Conclusion
For most cases of peri-implant disease, periapical radiographs provide sufficient diagnostic
accuracy with minimal radiation exposure. CBCT should be reserved for more complex cases
where 2D imaging is inadequate, ensuring radiation protection protocols are strictly followed.

Recommendations for Special Indications and Techniques

Guided Implant Surgery

Overview

Guided implant surgery ensures accurate implant placement, minimizing complications and
optimizing treatment outcomes. Advances in digital workflows, CAD/CAM technologies, and
real-time navigation techniques have significantly enhanced the precision and reliability of
guided implant surgery.

Types of Guided Implant Surgery

1. Static Guided Surgery

 Definition:
o Uses CAD/CAM surgical templates to guide implant placement based on preoperative
planning.
 Procedure:
o Requires 3D image datasets from CBCT scans, intraoral scans, and/or stone model
images.
o The images are merged in implant planning software, enabling:
 Visualization of soft tissue and bony structures.
 Virtual setup of missing teeth and dentition.
 Precise implant positioning based on prosthetic-driven planning.
 Special Techniques:
o Double CBCT Scan for Edentulous Patients:
 First scan: Patient wears a complete denture embedded with radiopaque
markers.
 Second scan: Denture scanned separately.
 Merging these scans provides a comprehensive 3D evaluation of artificial teeth,
bone, and soft tissue contours.
 Slice Thickness Requirements:
o CAD/CAM software typically requires slice thickness <1 mm.
o CBCT Imaging:
 Slice thickness: 0.1–0.4 mm, ideal for implant planning.
o MDCT Imaging:
  Slice thickness: 0.625–2.5 mm. Thinner slices increase radiation dose, making
CBCT the preferred modality.

2. Dynamic Guided Surgery

 Definition:
o Uses real-time navigation systems to track the position of surgical instruments and align
them with planned trajectories on CT/CBCT images.
 Procedure:
o Requires a preoperative CT/CBCT scan of the patient wearing invasive/non-invasive
registration markers.
o During surgery:
 An infrared camera tracks the position of the patient and surgical instruments
using reflective markers.
 The system registers the patient’s anatomy with the CT/CBCT data, enabling
real-time 3D visualization of:
 Implant trajectory.
 Surgical instrument position.
 Adjacent anatomical structures.
o This technique provides dynamic feedback, ensuring precision in drilling and implant
placement.
 Advantages:
o Eliminates the need for surgical templates.
o Allows real-time adjustments during surgery.
 Limitations:
o Requires advanced equipment and expertise.
o Higher cost compared to static guided surgery.

Imaging Recommendations for Guided Implant Surgery

Preoperative Planning:

 CBCT is the preferred imaging modality due to its:

o High spatial resolution.
o Ability to produce thin slices (0.1–0.4 mm), ideal for CAD/CAM surgical templates.
o Lower radiation dose compared to MDCT.

Special Considerations:

 For edentulous patients:

o Use the double CBCT scan technique to ensure accurate visualization of denture
position, bony structures, and soft tissue contours.
 Ensure all 3D datasets meet the slice thickness requirements of the implant planning software to
maximize accuracy.
Key Takeaways

1. Static Guided Surgery:

o Relies on CAD/CAM templates for precise, prosthetic-driven implant planning.
o Recommended for most cases due to its reliability and ease of use.
o CBCT is the optimal imaging modality for generating accurate templates.

2. Dynamic Guided Surgery:

o Offers real-time visualization and guidance during surgery.
o Suitable for complex cases requiring dynamic adjustments.
o Requires advanced equipment and expertise.

3. Imaging Modality:
o CBCT is the standard for guided implant surgery, ensuring precise preoperative planning
while minimizing radiation exposure.

Recommendations for Special Techniques in Implantology

Block Grafting Procedures

1. Overview:
o Autogenous block grafting is the gold standard for reconstructing severely deficient
alveolar ridges in bucco-oral and vertical dimensions.
o Common intraoral donor sites:
 Maxillary tuberosity.
 Mandibular symphysis.
 Retromolar area.
 Mandibular ramus.

2. Preoperative Assessment:
o Evaluate the size of the recipient site deficiency to guide bone block harvesting.
o Use 3D imaging (MDCT/CBCT) to:
 Assess the donor and recipient sites.
 Identify critical anatomical structures to avoid complications (e.g., bleeding,
paresthesia).

3. Postoperative Assessment:
o Perform a second MDCT/CBCT scan 6 months post-surgery to evaluate graft integration
before implant placement.
Zygoma Implants

1. Overview:
o Alternative for patients with severely atrophic maxillae where conventional implants
and extensive bone augmentation are not feasible.
o Implant trajectory involves the alveolar ridge, maxillary sinus, and zygomatic bone.

2. Imaging Recommendations:
o Use implant planning software with MDCT/CBCT datasets to:
 Visualize the implant's trajectory.
 Assess the bone-implant contact area to optimize stability.
o Utilize a 360-degree view along the implant axis to avoid complications (e.g.,
penetrating the infratemporal fossa or lateral orbit wall).

3. Special Considerations:
o Evaluate the zygomatic nerves on MDCT/CBCT to prevent postoperative paresthesia.
o Assess the maxillary sinus health for:
 Intrasinus, through-sinus, or extrasinus implant positioning.
o For patients with reduced alveolar ridge width, consider:
 Flattening the ridge.
 Horizontal bone augmentation.
 More palatal implant placement.

Future Trends and Developments

Ultrasound Imaging

1. Emerging Applications:
o Preoperative:
 Evaluate soft tissue phenotypes (e.g., gingival thickness).
 Screen the bucco-oral dimensions and surface morphology of alveolar ridges.
o Intraoperative:
 Identify critical structures like the greater palatine foramen, mental foramen,
and lingual foramina.
o Postoperative:
 Monitor marginal bone loss and detect early signs of peri-implantitis without
ionizing radiation.

2. Advantages:
o Non-ionizing and suitable for chairside use.
o Not affected by metal artifacts, making it useful near restorations and implants.

3. Limitations:
o Cannot assess subsurface bone defects (e.g., three-walled intrabony defects).
 o Requires further research and device improvements for routine clinical application.

Magnetic Resonance Imaging (MRI)

1. Current Applications:
o Detect and evaluate the mandibular canal and neurovascular bundle when unclear on
panoramic, CBCT, or MDCT scans.

2. Recent Developments:
o Reduced imaging time (<10 minutes) and improved spatial resolution make MRI a
potential alternative to CBCT.
o Promising for:
 Assessing bone and soft tissue quality at edentulous sites.
 Evaluating anatomical landmarks (e.g., CEJ).
 Producing CAD/CAM surgical templates with accuracy comparable to CBCT-
based templates.

3. Advantages:
o Non-ionizing, making it safer for patients.
o Comparable diagnostic accuracy to CBCT for detecting peri-implant bone defects.

4. Limitations:
o High cost and device footprint.
o Requires specialized expertise for operation.
o Susceptible to severe metal artifacts from oral restorations.

Key Takeaways

1. Block Grafting:
o Use MDCT/CBCT to evaluate donor and recipient sites preoperatively and assess graft
integration postoperatively.

2. Zygoma Implants:
o Employ 360-degree implant planning to minimize complications and optimize implant
stability.
o Assess maxillary sinus health and zygomatic nerve location with MDCT/CBCT.

3. Future Imaging Trends:

o Ultrasound:
 Promising for preoperative soft tissue evaluation and early peri-implant disease
detection.
o MRI:
 Emerging as a non-ionizing alternative for comprehensive bone and soft tissue
assessments in implantology.