Dentomaxillofacial Radiology (2011) 40, 76–83

’ 2011 The British Institute of Radiology

http://dmfr.birjournals.org

RESEARCH
Magnification rate of digital panoramic radiographs and its
effectiveness for pre-operative assessment of dental implants
Y-K Kim1, J-Y Park1, S-G Kim*,2, J-S Kim3 and J-D Kim3
1
Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, Republic of
Korea; 2Department of Oral and Maxillofacial Surgery, School of Dentistry, Chosun University, Republic of Korea; 3Department of
Oral and Maxillofacial Radiology, School of Dentistry, Chosun University, Republic of Korea

Objectives: The purpose of this study was to determine the accuracy and effectiveness of
digital panoramic radiographs for pre-operative assessment of dental implants.
Methods: We selected 86 patients (221 implants) and calculated the length of the planned
implant based on the distance between a selection of critical anatomical structures and the
alveolar crest using the scaling tools provided in the digital panoramic system. We analysed
the magnification rate and the difference between the actual inserted implant length and
planned implant length according to the location of the implant placement and the clarity of
anatomical structures seen in the panoramic radiographs.
Results: There was no significant difference between the planned implant length and actual
inserted implant length (P . 0.05). The magnification rate of the width and length of the
inserted implants, seen in the digital panoramic radiographs, was 127.28 ¡ 13.47% and
128.22 ¡ 4.17%, respectively. The magnification rate of the implant width was largest in the
mandibular anterior part and there was a significant difference in the magnification rate of
the length of implants between the maxilla and the mandible (P , 0.05). When the clarity of
anatomical structures seen in the panoramic radiographs is low, the magnification rate of the
width of the inserted implants is significantly higher (P , 0.05), but there is no significant
difference between the planned implant length and actual inserted implant length according
to the clarity of anatomical structures (P , 0.05).
Conclusions: Digital panoramic radiography can be considered a simple, readily available
and considerably accurate pre-operative assessment tool in the vertical dimension for dental
implant therapy.
Dentomaxillofacial Radiology (2011) 40, 76–83. doi: 10.1259/dmfr/20544408

Keywords: panoramic radiograph; dental implant

Introduction

Before dental implant surgery it is a prerequisite to assess tomogram may be used and recently the frequency of the
the height of residual alveolar bone in the area where application of CT for pre-implant evaluation has risen.
implants are to be placed, the location of the nasal floor CT facilitates the understanding of bone thickness of
and the maxillary sinus floor, the location of the the buccolingual side, three-dimensional (3D) maxillary
mandibular canal, detection of lesions within the jaw sinus floor as well as nasal floor, the buccolingual
bones, the interval to the adjacent dental roots and so on. position of the mandibular canal, and so on. Addi-
Panoramic radiographs have been used frequently as a tionally, in cases where important anatomical structures
radiographic method for pre-implant evaluation and the cannot be detected clearly on panoramic radiographs, it
preparation of treatment protocols. In addition, a linear may be of help while performing implant surgery.1–3
However, pre-implant CT is not required in all cases. In
previous studies it has been shown that the use of
*Correspondence to: S-G Kim, Department of Oral and Maxillofacial Surgery, panoramic radiographs is sufficient for evaluation
School of Dentistry, Chosun University, 421, SeoSukDong, DongGu,
GwangJu City, Republic of Korea; E-mail: sgckim@chosun.ac.kr
before implant surgery. In particular, it was revealed
Received 30 March 2009; revised 24 November 2009; accepted 23 December that for measuring the height of residual alveolar bone
2009 for the placement of implants in the mandibular posterior
 Digital panoramic radiographs
Y-K Kim et al 77

region, without the use of CT, panoramic radiographs 4. the height of residual bone up to the level of the inferior
were sufficient4 and there was little difference from cases alveolar canal was very insufficient.
that used linear or spiral CT.5 In addition, the width of
residual alveolar bone could be evaluated by clinical tests. The digital panoramic radiographic equipment used
The width of the alveolar ridge and the presence and was the OrthopantomographH OP100 (Instrumentarium
extent of lingual undercuts in the edentulous region can Corp., Tuusula, Finland), and the CT equipment used
be evaluated by manual examination of the superficial was the MX 8000 IDT (Philips, Eindhoven, the Nether-
bone structures. If necessary, a more meticulous assess- lands). All digital panoramic radiographs were taken by
ment could be done for an impression model.5 one technician according to the standard method pro-
In comparison with CT and other expensive precision vided by the manufacturer.
tests, panoramic radiography is rapid and inexpensive While standing, patients were asked to look at the
and its radiation dose is low. Furthermore, if metal equipment and then bite on the biting portion of the
prostheses, posts or pins are present, CT may generate radiographic equipment using the anterior teeth; this esta-
streak artefacts. It also has the disadvantage that the blished the location. As described, the Frankfort hor-
patient should not move during the relatively long CT izontal (FH) plane was placed parallel to the horizontal
imaging period.6 plane. This maintained a consistent head position.
This study was conducted to evaluate the efficacy and On digital panoramic radiographs, the distance
accuracy of cases in which pre-implant diagnosis as well as between anatomical structures as well as the length
treatment protocols were prepared through the applica- and width of placed implants were measured by the
tion of the digital panoramic radiation system without IMPAXH (Agfa, Belgium) system.
performing CT and other expensive precision tests. For each implant included in the research participants,
the following factors were measured and analysed. Before
treatment, one dentist subjectively determined the clarity
Materials and methods
of images shown on panoramic radiographs and classified
them as good, moderate or poor. ‘‘Good’’ described cases
This study was conducted on 86 patients (50 male, 36 in which the inferior alveolar canal, the mental foramen,
females). Between July 2007 and December 2007, 221 the nasal floor and the maxillary sinus floor could be
implants (124 in males, 97 in females) were consecu- observed distinctly; ‘‘poor’’ included cases in which those
tively placed at the dental clinic in the Seoul National structures could hardly be distinguished; and ‘‘moderate’’
University Bundang Hospital. All of the patients were cases approximately in the middle. Any difference in
enrolled in this study were partially edentulous or had clarity of the images of observed anatomical structures
single missing teeth. Since dental implants cannot be depending on gender or age was also examined. The
located accurately in completely edentulous patients implant length to be placed in the area was determined
without the use of a radiographic stent, these patients based on major anatomical structures.
were excluded from this study. The mean age of The concurrence rate of the planned implant length
patients was 54.7 ¡ 12.5 years (Table 1). to the implants actually placed, the magnification rate
On all patients, digital panoramic radiographs were of panoramic radiographs and so on were analysed by
taken before the treatment and after implant surgery. one dentist, who did not participate in the surgery.
For 10 of the 86 patients, CT was also performed before
surgery (4 males, 6 females). CT was performed in some
cases depending on whether the surgeon decided: Concurrence rate of the length of implants planned before
treatment to the length of actually placed implants
1. the margins between the major anatomical structures The length of the dental implants to be placed was
were obscured on panoramic radiography; determined by a single surgeon (YKK). Before treat-
2. major operations, such as bone grafting, were needed; ment, one dentist measured the vertical length to major
3. multiple dental implants were placed simultaneously on anatomical structures (location of the maxillary sinus
the left and right sides of the maxilla and mandible; or floor, the nasal floor, the inferior alveolar canal, the
mental foramen, etc.) on digital panoramic radio-
graphs. Up to the level of the inferior alveolar canal
Table 1 Age and gender distribution of participants and mental foramen of the mandible, the safe distance
Age (years) Males Females Total was set at 2 mm–5 mm. In the maxilla, where the sinus
20–29 1 (1) 3 (5) 4 (6) bone graft was performed, the safe distance was not
30–39 2 (8) 5 (7) 7 (15) significant. Dental implants . 10 mm in length were
40–49 13 (28) 2 (4) 15 (32) selected. The location of dental implants for a partial
50–59 10 (40) 12 (18) 22 (58) edentulous ridge was determined clinically, considering
60–69 21 (41) 11 (57) 32 (98)
70–79 3 (6) 3 (6) 6 (12) the adjacent and opposing teeth. Based on a magnifica-
Total 50 (124) 36 (97) 86 (221) tion rate of 30%, stated by the manufacturer, the length
Mean age (years) 55.0 ¡ 11.3 53.8 ¡ 14.1 54.7 ¡ 12.5 of the dental implants to be placed was determined. No
Numbers in parentheses 5 no. of implants objects, such as radiographic stents, were used.

Dentomaxillofacial Radiology
 Digital panoramic radiographs
78 Y-K Kim et al

Magnification rate of the length and width of placed In addition, we assessed whether there was a
implant fixture on digital panoramic radiographs difference in the magnification rate depending on the
After implant surgery, based on the length and width of clarity level of the images of anatomical structures seen
the implant fixture actually placed, the length and on panoramic radiographs. The magnified implant
width of implants shown on post-surgical digital image shown on post-surgical panoramic radiographs
panoramic radiographs were measured by one dentist is the image reflecting the placement of the implant
and the magnification rate of each placed area was inclined to the long axis of the buccolingual side, and
calculated (Figures 1 and 2). The magnification rate thus it has a different meaning from cases imaged
was calculated by the following formulae: vertically to the direction of the radiation. By assessing
the magnification rate of the width and length of
already placed implants, in each placement area the
magnification rate of digital panoramic radiographs
The magnification rate of length ð%Þ
was assessed by reflecting the placement angle of
 
The length of implant on digital radiographs implants and was more clinically relevant.
~ |100 70 implants were placed in the maxillary molar region,
The length of actually placed implant fixture
45 implants in the maxillary premolar region, 24 implants
in the maxillary anterior region, 55 implants in the
mandibular molar region, 14 implants in the mandibular
The magnification rate of width ð%Þ premolar region and 13 implants were placed in the
  mandibular anterior region. When the width and length
The width of implant on digital radiographs of placed implants were measured on digital panoramic
~ |100
The width of actually placed implant fixture radiographs, the distance corresponding to the width and

Figure 1 Measurement of implant width

Dentomaxillofacial Radiology
 Digital panoramic radiographs
Y-K Kim et al 79

Figure 2 Measurement of implant length

length of fixture suggested by the implant manufacturer structures seen on digital panoramic radiographs was
was measured. different depending on gender and age, cross-tabulation
analysis was applied.
Comparison of patients additionally imaged by CT before The magnification rate of the mean width and leng-
surgery compared with patients imaged only by th of placed implants as well as the magnification rate
panoramic radiography of the width and length of implants in each placement
Cases imaged only by digital panoramic radiography area were calculated, and ANOVA was used to exa-
before implant surgery (76 patients, 158 implants) were mine whether the magnification rate of the width and
compared with cases additionally imaged by CT (10 length of implant in each placement area was statis-
patients, 63 implants) in terms of development of post- tically significantly different. The magnification rate of
surgical dysaesthesia, the rate of replacement, maxillary the width and length of the placed implant was analysed
sinus elevation and the frequency of performing bone graft. to see if there were significant differences depending on
gender, age and clarity of the anatomical structures.
Statistical analysis
SPSS 12.0 KO for windows release 12.0.1 program
(SPSS Inc., Chicago, IL) was used at the 5% significant Results
level. To examine whether the length of implant fixture
planned before surgery was statistically different from
the length of the actually placed implant fixture, the Concurrence rate of the length of implant fixture planned
paired t-test was applied. In addition, to examine before treatment to the length of actually placed implant
whether the planned length was significantly different fixture
from the placed length depending on gender and age, The length of implant fixture planned before surgery
the t-test and ANOVA were applied. To examine was on average 11.59 ¡ 1.72 mm, and the length of the
whether the clarity of the images of anatomical actually placed fixture was shown to be an average of

Dentomaxillofacial Radiology
 Digital panoramic radiographs
80 Y-K Kim et al

11.52 ¡ 1.61 mm. The result of the paired t-test was Table 3 Gender and radiographic clarity of anatomical structure
P 5 0.446, and there was no statistically significant
Clarity of anatomical structure Male Female Total
difference (Table 2).
Clearly seen 96 46 142
Similarly, according to each placement area, the Moderately seen 28 23 51
planned length and the actually placed length was shown Poorly seen 0 28 28
not to be significantly different (one-way ANOVA; Total 124 97 221
P 5 0.75; Tukey’s test; Duncan analysis method). Significance of cross-tabulation analysis for gender and radiographic
The clarity of the image of anatomical structures on clarity of anatomical structure; P 5 0.000
panoramic radiographs was classified as good, moder-
ate or poor. The planned length of the fixture and the The magnification rate of the width was divided into
concurrence rate was compared with the actually placed three groups; the mandibular anterior region was the
length, and it was found that, according to the clarity of largest, followed by the mandibular premolar area and
the image of anatomical structures, the concurrence other areas. The magnification rate of the length was
rate was not significantly different (one-way ANOVA; divided into two groups, the maxilla and the mandible,
P 5 0.241). In addition, it was examined whether there and it was slightly more enlarged in the maxilla than the
was a difference in the clarity of the image of anato- mandible.
mical structures on panoramic radiographs depending The result of the one-way ANOVA test showed
on gender or age. It was found that the clarity of ana- F 5 6.146 and P 5 0.003. Depending on the clarity
tomical structures was different depending on gender of the image of anatomical structure on panoramic
(cross-tabulation analysis; P 5 0.000). All 28 cases radiographs, the magnification level of the width of
identified as ‘‘poor’’ who did not show anatomical implant fixture was shown to be different, and in cases
structures clearly were female (Table 3). A significant showing a ‘‘poor’’ clearness level, the magnification rate
difference according to age was not detected. of width was shown to be significantly larger, while
It was examined whether the planned length was ‘‘good’’ and ‘‘moderate’’ did not show a signi-
significantly different from the placed length by t-test, ficant difference (one-way ANOVA; Duncan analysis;
and a significant difference between males and females Table 7). Nevertheless, it was found that the magnifica-
was shown (P 5 0.032) (Table 4). In males, the tion rate of the length of implant fixture was not
actually placed implant fixture was shorter than the significantly different depending on the clarity of the
length planned before surgery by an average of image of anatomical structures.
0.371 mm, and in females the placed length was longer It was shown that according to gender and age the
than the planned length by 0.139 mm. However, a magnification rate of the width and length of the
significant difference between the planned length and images on radiographs was not significantly different
the placed length according to age was not detected. (t-test; one-way ANOVA).

Magnification rate of the width and length of placed Comparison of cases additionally imaged by CT before
implant fixture on digital panoramic radiographs surgery compared with patients imaged only by
The magnification rate of the width of the placed panoramic radiography
implant fixture on the digital panoramic radiography The rate of performing maxillary sinus elevation during
system was an average of 127.28% ¡ 13.47%, and the the placement of maxillary implants in the group in
magnification rate of the length was shown to be which only panaromic radiographs were taken (Group
128.22% ¡ 4.17%. 1) was 29.41%, and in the group in which CT images
The result of the one-way ANOVA test showed that were additionally taken (Group 2) was shown to be
F 5 29.503 and P 5 0.000, the magnification rate of 37.85%. In the maxilla and the mandible, the rate of
width was significantly different depending on the area, performing bone grafts was 41.77% for Group 1, and
and the magnification rate of the length was also 31.75% for Group 2 (Table 8). The result of Pearson’s x2
significantly different (F 5 21.475 and P 5 0.000) test showed that, regarding the rate of performing
depending on the area. The groups showing a maxillary sinus elevation and bone graft, there was no
significant difference in the magnification rate of the significant difference between the group additionally
width as well as the length are shown in Tables 5 and 6. imaged by CT and the group imaged only by the
panoramic radiography (P 5 0.587, P 5 0.168).

Table 2 Mean and standard deviation of inserted implant length and Table 4 Difference between inserted implant length and planned
planned implant length implant length by gender
Inserted Planned Sig. (two- Male Female Sig. (two-tailed)
implant length implant length tailed) Mean¡SD 20.371 ¡ 1.898 0.139 ¡ 1.519 0.032*
Mean¡SD 11.523 ¡ 1.606 11.588 ¡ 1.716 0.446 SD, standard deviation; Sig, significance of t-test for difference
SD, standard deviation; Sig, significance of paired t-test between between inserted implant length and planned implant length by
inserted implant length and planned implant length gender; *P , 0.05

Dentomaxillofacial Radiology
 Digital panoramic radiographs
Y-K Kim et al 81

Table 5 Radiographic magnification rate of implant diameter by Table 7 Radiographic magnification rate of implant diameter and
location clarity of anatomical structure
Implant fixture diameter (%) Implant fixture diameter (%)
Location n mean SD Clarity of anatomical structure n mean SD
Maxillary anterior 24 129.63 12.10 Clearly seen 142 126.05 11.95
Maxillary premolar 45 124.48 7.17 Moderately seen 51 126.22 12.75
Maxillary molar 70 123.38 7.44 Poorly seen 28 135.44 18.92
Mandibular anterior 13 159.07 25.03 Total 221 127.28 13.47
Maxillary premolar 14 135.63 14.35 Sig. 0.003*
Mandibular molar 55 123.85 7.43 Homogeneous subsetsa AB , C
Total 221 127.28 13.47 n, number of implants inserted; mean, mean magnification rate; SD,
Sig. 0.000* standard deviation; sig, significance of one-way ANOVA of radiographic
Homogeneous subsetsa ABCF , E , D magnification rate of implants diameter and clarity of anatomical
n, number of implants inserted; mean, mean magnification rate; SD, structure aSubsets are symbolized as follows: A, clearly seen; B, mode-
standard deviation; sig, significance of one-way ANOVA of radio- rately seen; C, poorly seen
graphic magnification rate of implants diameter by locations *P , 0.05
a
Subsets are symbolized as follows: A, maxillary anterior; B,
maxillary premolar; C, maxillary molar; D, mandibular anterior; E,
mandibular premolar; F, mandibular molar Discussion
*P , 0.05
Panoramic radiography is often the first choice method
Concerning the number of implants placed per for the placement of implants because it provides
individual, Group 1 had an average of 2.08 ¡ 1.55 information on the overall shape of the jaws, the
implants, and Group 2 had an average of 6.3 ¡ 4.2 position of the maxillary sinus floor and the nasal cavity
implants. Post-surgical dysaesthesia was not shown in floor, and the proximal distal as well as vertical position
Group 1, but was developed in one patient in Group 2. of the mandibular canal and the mental foramen. In
The rate of replacement was the result obtained at the addition, it provides information on the presence or
time points, average 10 months after placement and absence of residual dental roots or asymptomatic lesions
average 5 months after the completion of the prosthesis. in the dental root apex, lesions within the bone, the
In Group 1, the replacement was performed in 2 cases interval between remaining teeth, etc. CT may also be
(1.27%), and in the Group 2, 4 cases of the replacement necessary to assess the buccolingual position of anato-
(6.34%) were performed (Table 8). mical structures or for simulation. By using digital
In the group imaged only by panoramic radiography panoramic radiography before implant surgery we were
and the group additionally imaged by CT, the able to explain to the patient, on the radiograph, the
distribution according to the clarity level of the image position, method and length of the implant to be placed,
of anatomical structure on panoramic radiographs is using the drawing tools. Additionally, before surgery,
shown in Table 9. In the ‘‘poor’’ cases that did not the volume of residual alveolar bones was measured
show anatomical structures clearly on panoramic using the tools provided by the digital panoramic
radiographs, the rate was highest in those additionally radiography system and a treatment protocol, such as
imaged by CT — 61% (cross-tabulation analysis; the length of implant to be placed, could be established.
P 5 0.000). Digital panoramic radiographs have many advan-
tages, such as minimal storage in comparison with film
radiographs, explanation can be given to the patient in
Table 6 Radiographic magnification rate of implant length by front of the monitor, the radiograph appears on the
location monitor immediately after imaging, the data can be
Implant fixture diameter (%)
copied readily, it can be easily measured and magnified
using various tools, contrast can be controlled readily
Location n mean SD
and the effective radiation dose is smaller in compar-
Maxillary anterior 24 129.69 1.97
Maxillary premolar 45 130.55 2.38
ison with film panoramic radiography.7–9
Maxillary molar 70 129.83 2.59 If images are taken properly, by adjusting the
Mandibular anterior 13 124.28 6.49 position of patients, panoramic radiographs are suffi-
Mandibular premolar 14 125.73 4.66 ciently accurate for the measurement of vertical
Mandibular molar 55 125.17 4.03
Total 221 128.22 4.17
dimensions,5,7 and the results obtained by repeated
Sig. 0.000* vertical measurement of the jaws did not differ
Homogeneous subsetsa DEF , ABC greatly.10 In a study using a metal ball, the vertical
n, number of implants inserted; mean, mean magnification rate; SD, magnification rate on panoramic radiographs was
standard deviation; sig, significance of one-way ANOVA of radio- shown to be a constant level of 127 ¡ 1%.5 In this
graphic magnification rate of implants length by locations study, the vertical enlargement ratio of placed implant
aSubsets are symbolized as follows: A, maxillary anterior; B,

maxillary premolar; C, maxillary molar; D, mandibular anterior; E,

fixtures was shown to be 128.22 ¡ 4.17%. These
mandibular premolar; F, mandibular molar measurements were close to the magnification rate of
*P , 0.05 130% given by the manufacturer. In some cases there

Dentomaxillofacial Radiology
 Digital panoramic radiographs
82 Y-K Kim et al

Table 8 Comparison between pre-operative panoramic only group and CT group

Panoramic radiographs only Pre-operative CT group Sig.
*
Sinus elevation (%) 29.41 37.85 0.587
{
Bone graft (%) 41.77 31.75 0.168
Inserted implants number per patient(m¡SD) 2.08 ¡ 1.56 6.30 ¡ 4.42 0.015 **
{
Post-operative paraesthesia (case) 0 1 0.116
1
Reimplantation rate (%) 1.27 6.34 0.057
*Significance x2
of Pearson’s test between panoramic only group and additional CT group for sinus elevation per cent, {significance of Pearson’s
x2 test between panoramic radiograph only group and the additional CT group for bone graft per cent, **significance of t-test between panoramic
radiograph only group and the additional CT group for inserted implant number per patient, {significance of Fisher’s exact test between
panoramic radiograph only group and the additional CT group for post-operative paraesthesia, 1significance of Fisher’s exact test between
panoramic radiograph only group and the additional CT group for reimplantation rate; *P , 0.05

was a discrepancy between the estimated and actual horizontal enlargement ratio was between 1.12 and 1.44.
implants; this may pose problems in a clinical setting. In particular, the enlargement ratio for width was shown
In cases where the actual length of the implants to be high in the mandibular anterior area of the coronal
exceeded the estimated length, maxillary autogenous end of the implants.14
bone grafting was performed simultaneously with Occasionally, the mandibular canal may not be
dental implant placement in the maxillary molar region. shown distinctly on panoramic radiographs. This is
When there was insufficient residual bone at the level of because the inferior alveolar neurovascular bundle is
the mental foramen or inferior alveolar canal, the not surrounded by the compact cortical lining in all
procedure was performed intra-operatively in a defen- patients.13 The mandibular canal may also not be
sive manner. Accurate analysis based on a 3D imaging detected in diseases such as Gaucher’s disease. Older
modality, such as CT, would reduce these errors people may show a thinning of the cortical bone wall in
further. the mandibular canal because bone density is lower in
The effective radiation dose of panoramic radiogra- older people than in younger people, which can be due
phy was 9 mSv; of linear cross-sectional tomography is to the menopause.15 It can also be affected by gender,
9 mSv; of conventional spiral cross-sectional tomogra- as resorption of the superior border of the mandibular
phy was 44–117 mSv; and of CT is 314–3324 mSv.9,11,12 canal is detected more often in females (32.6%) than in
Based on the effective radiation dose of standard digital males (9.8%).13 Similarly, in this study, depending on
panoramic radiography and the effective dose of CT, the whether anatomical structures such as the superior and
hypothetical mortality risk was obtained. The result inferior border of the inferior alveolar nerve canal, the
showed that the mortality risk of standard digital maxillary sinus floor and nasal cavity floor were shown
panoramic radiography was 1.05 6 1026, while the clearly on panoramic radiographs, they were classified
mortality risk of CT in maxillary cases was 28.20 6 as good, moderate or poor. There were 28 poor cases
1026 and in mandibular cases was 18.20 6 1026; this was and all these were female. In this study, we found no
substantially higher than standard radiography.9 significant difference depending on age in the clarity of
Panoramic radiography can measure the vertical anatomical structures. In cases where the mandibular
dimension of the jaws relatively accurately using a lower canal could not be detected clearly by panoramic
effective dose. However, horizontal (mesiodistal) images radiography, by application of conventional tomogra-
can become distorted on panoramic radiographs.13 Such phy or by CT meant that the vertical position or the
distortion can be seen abundantly in the anterior tooth buccolingual position of the mandibular canal could be
area because the curvature level of the jaw is different in assessed. CT scans also provided information on bone
each individual and can be influenced by patient position volume and bone contour such as vestibular concavity,
during imaging.13 In this study, the diameter of the lingual undercuts and cortical defaults.
placed implant was enlarged mostly in the mandibular In cases that used linear tomography, it has been
anterior area; however, this was not significantly reported that the distance to the mandibular canal
different from other areas. According to the results from could be overevaluated by up to 219.1%.15 However,
a study examining the enlargement ratio of implants in other studies have reported it to be underevaluated and
each area using panoramic tomography, the vertical thus it is still controversial. At present, CT scans are not
enlargement ratio was between 1.21 and 1.29, and the the only way to obtain accurate information on 3D
examination. Cone beam CT (CBCT) is a relatively new
Table 9 Radiographic clarity of anatomical structure technique that imparts lower radiation to oral tissues,
but has higher spatial resolution than conventional CT
Clarity of anatomic Panoramic radiographs Pre-operative CT-
structure only group (%) group (%) and provides a better quality image. Although it may be
Clearly seen 79 21
limited in its discrimination of soft tissue because of its
Moderately seen 69 31 low contrast resolution, it can provide detailed infor-
Poorly seen 39 61 mation about cortical thickness and contour. The
Significance of cross-tabulation analysis for the additional CT group advantages of CBCT have been established; however,
and radiographic clarity of anatomical structure; P 5 0.000 at our medical institution, where this study was

Dentomaxillofacial Radiology
 Digital panoramic radiographs
Y-K Kim et al 83

conducted, CBCT is not available16,17 and therefore the valuable in determining the diagnostic limitations and
use of conventional CT was unavoidable. clinical usefulness of panoramic radiography, which
In this study, cases with poor levels of clarity of can be performed easily in dental practice.
anatomical structures on radiographs were also imaged In conclusion, the digital panoramic radiography
by CT more frequently than cases which were good or system is an effective method that is simple and
moderate. In cases imaged only by panoramic radio- inexpensive for pre-implant diagnosis and establishing
graphy, post-surgical dysaesthesia was not developed, treatment protocol, and it uses a relatively low
and temporary dysaesthesia was developed in only one radiation exposure. The vertical assessment can provide
patient additionally imaged by CT. In the group imaged useful, accurate information, however, cross-sectional
only by panoramic radiography, replacement was information cannot be obtained.
performed in two cases (1.27%) and in four cases in the For cases that do not show major anatomical
group imaged by CT additionally (6.34%). It is structures distinctly on panoramic radiographs, CT
speculated that the group imaged additionally by CT can also be used. Cases that did not show anatomical
did not have a sufficient volume of residual alveolar bone structures distinctly on panoramic radiographs were
to major anatomical structures, and invasive surgery such seen more frequently in females.
as bone graft in a wide area was performed frequently, On panoramic radiographs, the vertical enlargement
and thus more complications such as nerve injury and the ratio of placed implants was shown to be constant in
failure of implants were developed. most cases. It had a tendency to be enlarged slightly
This study examined the clinical usefulness of digital more in the maxilla than the mandible, and in the
panoramic radiography, which allows general practi- horizontal enlargement ratio it showed a tendency to be
tioners to diagnose and plan the treatment for dental enlarged more in the mandibular anterior area than in
implants easily. Accordingly, the advantages of CT may other areas.
be underestimated; for example, CT can make a 3D
assessment and can also be used to establish a guided,
non-invasive surgical protocol. Obviously, CBCT has Acknowledgements
the advantage over conventional CT, resulting in less This research was supported by the National Research
radiation exposure; however, the use of CT is not Foundation of Korea (NRF), funded by the Ministry of
recommended in all implant cases. It may also be Education, Science and Technology (R13-2008-010-00000-0).

References

1. de Oliveira RC, Leles CR, Normanha LM, Lindh C, Ribeiro- 10. Larheim TA, Svanaes DB. Reproducibility of rotational panora-
Rotta RF. Assessments of trabecular bone density at implant sites mic radiography: mandibular linear dimensions and angles.
on CT images. Oral Surg Oral Med Oral Pathol Oral Radiol Am J Orthod Dentofacial Orthop 1986; 90: 45–51.
Endod 2008; 105: 231–238. 11. Dula K, Mini R, van der Stelt PF, Sanderink GC, Schneeberger
2. Terakado M, Hashimoto K, Arai Y, Honda M, Sekiwa T, Sato P, Buser D. Comparative dose measurements by spiral tomo-
H. Diagnostic imaging with newly developed ortho cubic super- graphy for preimplant diagnosis: the Scanora machine versus the
high resolution computed tomography (Ortho-CT). Oral Surg Cranex Tome radiography unit. Oral Surg Oral Med Oral Pathol
Oral Med Oral Pathol Oral Radiol Endod 2000; 89: 509–518. Oral Radiol Endod 2001; 91: 735–742.
3. Bianchi J, Goggins W, Rudolph M. In vivo, thyroid and lens 12. Scaf G, Lurie AG, Mosier KM, Kantor ML, Ramsby GR,
surface exposure with spiral and conventional computed tomo- Freedman ML. Dosimetry and cost of imaging osseointegrated
graphy in dental implant radiography. Oral Surg Oral Med Oral implants with film-based and computed tomography. Oral Surg
Pathol Oral Radiol Endod 2000; 90: 249–253. Oral Med Oral Pathol Oral Radiol Endod 1997; 83: 41–48.
4. Vazquez L, Saulacic N, Belser U, Bernard JP. Efficacy of 13. BouSerhal C, Jacobs R, Quirynen M, van Steenberghe D.
panoramic radiographs in the pre-operative planning of posterior Imaging technique selection for the pre-operative planning of
mandibular implants: a prospective clinical study of 1527 consecu- oral implants: a review of the literature. Clin Implant Dent Relat
tively treated patients. Clin Oral Implants Res 2008; 19: 81–85. Res 2002; 4: 156–172.
5. Frei C, Buser D, Dula K. Study on the necessity for cross-section 14. Gomez-Roman G, Lukas D, Beniashvili R, Schulte W. Area-
imaging of the posterior mandible for treatment planning of dependent enlargement ratios of panoramic tomography on
standard cases in implant dentistry. Clin Oral Implants Res 2004; orthograde patient positioning and its significance for implant
15: 490–497. dentistry. Int J Oral Maxillofac Implants 1999; 14: 248–257.
6. Cho YS. Diagnostic value of dental CT (DentaScan) in dental 15. Butterfield KJ, Dagenais M, Clokie C. Linear tomography’s
implant. Chungbuk Med J 1998; 8: 11–19. clinical accuracy and validity for presurgical dental implant
7. Tal H, Moses O. A comparison of panoramic radiography with analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
computed tomography in the planning of implant surgery. 1997; 84: 203–209.
Dentomaxillofac Radiol 1991; 20: 40–42. 16. Schulze D, Blessman M, Pohlenz P, Wagner KW, Heiland M.
8. Lecomber AR, Yoneyama Y, Lovelock DJ, Hosoi T, Adams AM. Diagnostic criteria for the detection of mandibular osteomyelitis
Comparison of patient dose from imaging protocols for dental using cone-beam computed tomography. Dentomaxillofac Radiol
implant planning using conventional radiography and computed 2006; 35: 232–235.
tomography. Dentomaxillofac Radiol 2001; 30: 255–259. 17. Guerrero M, Jacobs R, Loubele M, Schutyser F, Suetens P, van
9. Dula K, Mini R, van der Stelt PF, Buser D. The radiographic Steenberghe D. State-of-art on cone beam CT imaging for pre-
assessment of implant patients: decision-making criteria. Int J Oral operative planning of implant placement. Clin Oral Investig 2006;
Maxillofac Implants 2001; 16: 80–89. 10: 1–7.

Dentomaxillofacial Radiology