RADIOGRAPHIC TECHNIQUES

Standard dental radiographs

 Help to make an initial assessment of the bone levels available for implant treatment.
 Provide an assessment of osseointegration and long term maintenance
Standard dental radiographs are 2 dimensional images and they give no indication of
bone width. Tomographic examinations can give cross sectional and 3-dimensional
images. They provide information about bone quantity and also indications of the bone
quality available, notably the thickness of the cortices as well as an approximation of the
density of the cancellous bone.
Screening:
Screening radiograph gives the clinician an indication of
a) Overall status of teeth and supporting bone
b) Those sites where it is possible to place implants using a straight forward protocol
c) Those sites where it is unlikely that implants can be placed without using complex
procedures such as grafting.
d) Those sites where it is inadvisable to recommend implants
e) Anatomical anomalies or pathological lesions.
The dental panoramic tomograph (DPT) is the radiograph of choice in most cases.
Here, the image of both the upper and lower jaws is provided within a predefined focal
trough. They give a reasonable approximation of:
- Bone height
- Position of the inferior dental neurovascular bundle.
- The size and position of the maxillary antra
- Any pathological conditions present.
Hence DPT’s are:
- an ideal view for initial treatment planning
- an ideal view for providing patient information
- Dental panoramic tomographs- they are narrow beam rotational tomographs which
use 2 or more centres of rotation to produce an image of the dental arches.
- For all the areas to be imaged well, the patient should be positioned correctly in the
machine and the appropriate programme selected.
- Radiation dosage of DPT= Approximately 0.007 to 0.014 mSV. This is less than a full
mouth series of periapical radiographs where each periapical radiograph= 0.001 to 0.008
mSV
- DPT gives more information about associated anatomical structures than periapical
radiographs; but with less fine details of the teeth.
DPT’s are magnified images (1.3X); hence distortion occurs, mainly in the antero-
posterior dimension, this reduces their usefulness when planning implant spacing and
implant numbers.
- The information provided by a DPT can be supplemented by using other standard
extraoral and intraoral radiographs. Eg:- The lateral cephalogram can give more detail of
the morphology of both jaws close to the midline; this is useful when planning
overdenture treatment.
- Standard occlusal views aid in assessing the bone morphology in the lower jaws.
- Intra oral radiographs taken with a long cone paralleling technique helpful for single
tooth replacement or small bridges in individuals with little bone loss.
Factors to be considered:-
- Image quality is of utmost importance
- All relevant anatomical structures should be shown
- Allowances for distortion of image should be made.
These factors important when assessing available bone height close to important
anatomical structures like inferior canal, maxillary antrum etc.
Computerised digital radiovisiography (CDR) provides an alternative medium to
produce an image. Here, the detectors are solid state, hence the doses can be greatly
reduced. Also, manipulation of the digitally derived image can provide further
information about relative bone densities, particularly when assessing periimplant bone
density changes by subtraction radiography. Their application in implant dentistry will
become more widespread.
Evaluation and planning:
Radiographic stents
A stent mimicking the desired tooth set up is constructed. Radiographic markers usually
made of guttapercha or another radioopaque material placed within it.
If the patient has a suitable acrylic denture, radiographic makers may be placed within
occlusal or palatal cavities cut in the acrylic teeth.
The radiographic marker or rod can be placed in the position and angulation of the
planned prosthetic set-up.
The relation of the bone ridge to the proposed tooth set-up shown by painting the labial
surface of the stent with a radiopaque varnish.
Choice of radiographic marker important-
It should be visible on the radiographic image, but should not interfere with the scan.
When using CT scan, metal markers avoided as they produce scattering on the image.
Stents particularly useful in the edentulous patient as they also serve to stabilise the
position of the jaws while radiographs are being taken.
Computerised tomography ( CT Scan );
Ct scan - provide most detailed images; but high cost and high radiation dose; hence their
use limited to complex cases such as full arch maxillary reconstructions, bilateral
posterior mandible imaging or cases where extensive grafting procedures required.
CT uses X-rays to produce sectional images as in conventional tomography.
High resolution images achieved by initially scanning in an axial plane keeping the
sections thin and by making the scans overlap.
The large number of sections in a high resolution scan of a jaw approximates to a
radiation dose of 3 mSV.
The new generation HELICAL CT scanners are faster and have significantly lower
radiation dose.
The scan should be limited to the area of interest and avoid radiosensitive tissues such as
the eyes.
In place of conventional film, radiation is detected by highly sensitive crystal or gas
detectors which are then converted to digital data. This data stored and manipulated by
computer software to produce a grey-scale image. The software then allows multiplane
sections to be reconstituted, the quality of which are dependant on the original scan
selection thickness and the integers between successive sections.
Images produced as:
 Standard radiographic negative images on large sheets.
 Positive images on photographic paper.
 Images for viewing on a computer monitor.
The patients head is aligned in the scanner with light markers, and a scout view is
obtained which gives an image similar to a lateral skull film.
Radiations dose of thin scout view is low; can be repeated if alignment incorrect.
Generally, mandible scanned with slices parallel to the occlusal plane; maxilla using the
same plane or parallel to the floor of the nose.
If there is a deviation from this alignment, the cross sectional slices will not be in the
same direction as the proposed implant placement.
Heavy metals will produce a scatter-like interference pattern if present in the slice, and
the interference will appear in all the generated sectional images.
Extensive interferences renders a CT scan unreadable.
Interferences can be produced by large posts in root canals or heavily restored teeth.
The various scan images can be measured for selection of implant length and diameter.
The nominal magnification of the images is 1:1; but some machines and cameras produce
images where the magnification may vary. In such cases, a scale is usually incorporated
alongside the various group of images and the real magnification determined. A
correction factor can then be applied to measurements taken directly from the films.
Simplant is a computer based image software programme where it is possible to produce
images of implants and their restorative components which can then be placed within the
‘CT scan’. Hence the relationship between the proposed implant and ridge morhology,
anatomic features and the adjacent teeth can be evaluated.
SCAN ORA:-
Scan ora is a new generation sophisticated tomographic device similar to conventional
DPT machines, but with facilities to generate high quality sectional images.
In CT scanning, the sectional images are software generated; but the scan ora produces a
tomographic image directly onto film.
Scan ora uses complex broad beam spiral tomography and is able to scan in multiple
planes.
The scans are computer controlled with automatic execution; but they still rely heavily on
good patient positioning and experience in using the machine.
The patients head is carefully aligned within the device and this position recorded with
skin markers and light beams. A DPT image is produced from which the sites which
require sectional tomographic data determined.
The patient is repositioned in exactly the same alignment and the appropriate
tomographic programme selected for the chosen region of the jaw.
Scan ora magnification- 1.3 X or 1.7 X for routine DPT; but 1.7 for all sectional images.
Tomographic sections = normally 2mm or 4mm thickness; scan sections are thicker and
fewer; hence overall patient dose much less than a CT scan.
Transparent overlays depicting implants of various lengths and diameters at the
corresponding magnifications can be superimposed directly on the radiograph which
provides a simple method of assessing implant sites and implant placement at different
angulations.
PERIOPERATIVE AND FOLLOW UP RADIOGRAPHS:-
Intraoral radiographs useful at time of implant placement which allows visualisation of
drills or direction indicators and their relation to adjacent teeth or anatomical structures.
Radiovisiography also useful as it produces an instant image at a lower radiation dose.
During second stage surgery, radiography may be required to ensure full seating of
abutments.
During prosthetic phase, it is essential to ensure full seating of components and
frameworks, and radiographs provide the only method of checking fit.
Radiographs taken at 900 to the long axis of the implant and it are therefore recommended
to use long cone parallel radiographs.
Problems which arise during treatment or once the prosthesis is in function like burnt
bone syndrome, bone loss, component loosening, screw breakage, implant fracture,
adjacent endodontic lesions or loss of integration can be readily diagnosed using standard
intraoral views.