Clinical Periodontology

DIAGNOSTIC IMAGING FOR THE

IMPLANT PATIENT
A H M A D H I J A Z I | M E L H E M K A A S A M A N I | R A W A N A B U
Z E I N A B | S A M E R R A H O U L Y
 INTRODUCTION

For patients getting dental implants, a variety of radiographic

imaging choices are available for diagnosis and treatment
planning. Options include more sophisticated 3D volumetric
radiography methods as well as the traditional projections that
are frequently available in dental offices.
CRITERIA FOR
SELECTION OF
RADIOGRAPHIC
TECHNIQUE:
• Case type
• Radiation dose
• Cost
• Availability

OUTCOME OF
TREATMENT:
• Identify anatomic structures
• Performing implant placement without endangering
these structures
 STANDARD
PROJECTIONS

Standard diagnostic imaging modalities include :

•Periapical
•Panoramic
•Lateral cephalometric
•Occlusal radiographs
ADVANTAGES AND DISADVANTAGES OF THE VARIOUS
RADIOGRAPHIC PROJECTIONS
PERIAPICAL RADIOGRAPHS

It provides an overall assessment of the

First imaging modality used to
quality and quantity of edentulous alveolar
evaluate implant patient
ridge and adjacent teeth

Easy to obtain in dental office Deliver low radiation dose

Dentist is familiar to the anatomy Shows the highest detail and

and possible pathology spatial resolution
•The most significant disadvantage of
periapical radiograph is their susceptibility
to underpredicted the magnification of the
anatomic structures thus unreliable
measurements.
•Fore-shorting and elongation can be
minimized by the using of parallel technique
•Distortion is obvious in edentulous areas where missing teeth and resorption of the alveolar
bone need placement of the receptor at specific angulation in relation to the alveolar bone.
•It’s a 2D image of 3D objects (no info about buccolingual dimension).
•Structures that are separated in buccolingual dimension appear to be
overlapped.

•So, it illustrates a limited area of dentoalveolar region.

•When long span is needed to be assessed many

periapical should be taken.

•Thus, it’s impossible to imagine the entire height of

alveolar ridge.
 PANORAMIC RADIOGRAPHS

• They offer several advantages over other modalities

• Panoramic radiographs provide a broad view of both dental arches at a low radiation dose , allowing
assessment of longer edentulous spans, the angulation of existing teeth and the occlusal plane, as well as
anatomic structures important for implant planning, such as the maxillary sinus, nasal cavity, mental foramen,
and mandibular canal.

• Panoramic units are widely available and easy to operate, and dentists are familiar with the anatomy and
pathology depicted by the images

• Like intraoral projections, panoramic images are two-dimensional and thus do not offer diagnostic information
with respect to the buccal–lingual dimension of the alveolar arch.
•The existence of ghost shadows,
unpredictable horizontal and vertical
magnification, distortion of structures
outside the focal trough, projection
geometry generated by the negative vertical
angulation of the x-ray beam, and the
inclination of patient-positioning errors do
not allow consistently detailed and accurate
measurements to be generated.
 MEASUREMENT DISTORTION IS
MORE PREVALENT AND VARIES
PANORAMIC RADIOGRAPHS DO ACROSS THE RADIOGRAPHIC
NOT PROVIDE THE HIGHLY IMAGE. ON AVERAGE, OBJECTS
DETAILED IMAGES THAT ARE ON PANORAMIC RADIOGRAPHS
GENERATED BY INTRAORAL ARE 15% TO 25%
RADIOGRAPHS. MAGNIFICATIONS OF THEIR
ACTUAL SIZE.
THE ACTUAL MAGNIFICATION
MAY RANGE FROM 10% TO 30%
IN DIFFERENT AREAS WITHIN FOR THIS REASON, PRECISE
THE SAME IMAGE AND DEPENDS MEASUREMENTS ON
GREATLY ON PATIENT PANORAMIC PROJECTIONS ARE
POSITIONING DURING NOT POSSIBLE.
PANORAMIC RADIOGRAPHY.
OFFER AN OVERALL VIEW OF MORE PRECISE DIAGNOSTIC
THE MAXILLA AND MANDIBLE IMAGING SHOULD BE USED TO
THAT CAN BE USED TO MEASURE THE PROXIMITY OF
ESTIMATE BONE CRITICAL ANATOMIC
MEASUREMENTS AND STRUCTURES, SUCH AS THE
EVALUATE THE APPROXIMATE MAXILLARY SINUS OR THE
RELATIONSHIPS BETWEEN MANDIBULAR CANAL, TO
TEETH AND OTHER ANATOMIC PROPOSED IMPLANT POSITIONS.
STRUCTURES.
 PANORAMIC PROJECTIONS PROVIDE USEFUL INFORMATION FOR THE
INITIAL ASSESSMENT OF THE IMPLANT PATIENT. HOWEVER, DUE TO
MAGNIFICATION AND DISTORTION ERRORS, PANORAMIC RADIOGRAPHS
SHOULD NOT BE USED FOR PRECISE MEASUREMENTS OF PROPOSED
IMPLANT SITES.
 CROSS SECTIONAL
IMAGING

• Occlusal radiograph
• CBCT
• MDCT
 OCCLUSAL RADIOGRAPH

ROLE IN IN PREOPERATIVE IMPLANT

EVALUATION IS LIMITED

MAXILLA : DISTORTION
BEAMS
SHAPE OF DENTAL
ARCH/BL DIMENSION MANDIBLE:SUPERIMPOSITION
OF ALVEOLAR RIDGE WIDEST BL
DIMENSION=FALSE
DIMENSION
CONE -BEAM COMPUTED TOMOGRAPHY

HOW IT WORKS?
 MULTIDETECTOR COMPUTED
TOMOGRAPHY
• Gives typical dental views:
⚬ Scout
⚬ Axial
⚬ Cross sectional
⚬ Panoramic
• Alveolar ridge defects
• Contrast resolution (muscles, fat, and other soft tissues)
• Advantage:
⚬ accurate cross-sectional imaging and three-dimensional visualization of anatomic structures
• Disadvantages:
⚬ High radiation dose compared to CBCT (MDCT, maxillofacial 650 uSV, Large field-of-view CBCT 120 uSV)
⚬ Specialized equipments, only found in medical centers.
⚬ Radiologists and technicians need to be knowledgeable so that optimal views will be provided.
⚬ High cost
 INTERACTIVE “SIMULATION”
SOFTWARE PROGRAMS

• Enhance treatment planning in implant patients by specialized software:

⚬ Quantity and quality of bone
⚬ Use CT (CBCT or MDCT) scan data to simulate placement of implants and restorations
⚬ Simulation of commercially available implants according to angulation, length, width, and
prosthetic position.
⚬ Quantification of needed bone augmentation.
⚬ Simulation of forces distribution.
 INTERACTIVE “SIMULATION”
SOFTWARE PROGRAMS

• Software programs specialized in implant treatment planning:

⚬ Simplant Pro (Dentsply, Sweden)
⚬ coDiagnostiX (DentalWings, Canada)
⚬ NobelClinician (Nobel Biocare, Switzerland)
⚬ Implant Studio (3Shape, Denmark)
⚬ InVivo (Anatomage, United States)
⚬ BlueSkyPlan (FREE)

Computer-generated surgical guide is produced to facilitate the surgical placement of implants in the
planned positions
PATIENT
EVALUATION
EXCLUDE
PATHOLOGY

• Healthy bone is a prerequisite for successful osseointegration and

long-term implant success.
• The first step in the radiographic evaluation of the implant site is to
establish the health of the alveolar bone and other tissues imaged
within a particular projection.
• Local and systemic diseases that affect bone homeostasis can
preclude, modify, or alter the placement of implants.
 Retained root fragments, residual
periodontal disease, cysts, and
tumors should be identified and
resolved before implant placement.
Systemic diseases, such as osteoporosis and
hyperparathyroidism, or local bone dysplasia, such as
Areas of poor bone quality should be identified and, if
fibrous dysplasia and cemento-osseous dysplasia, alter
indicated, adjustments to the treatment plan
bone structure and homeostasis and might affect
incorporated.
implant osseointegration.
Maxillary sinusitis, polyps, or other
sinus pathology should be diagnosed
and treated when implants are
considered in the posterior maxilla,
especially if sinus bone augmentation
procedures are planned.
IDENTIFY ANATOMIC
STRUCTURES

• Several important anatomic

structures are found close to
desired areas of implant placement
in the maxilla and mandible.
•Familiarity with the radiographic appearance of these structures is important during
treatment planning and implant placement. Their exact localization is central to
prevent unwanted complications and unnecessary morbidity. Important anatomic
structures in the maxilla include the floor and anterior wall of the maxillary sinus,
incisive canal, floor and lateral wall of the nasal cavity, canalis sinuosus, and canine
fossa.
•Important anatomic structures in the
mandible that should be recognized
include the mandibular canal,
anterior loop of the mandibular
canal, mental foramen, anterior
extension of the canal, median
lingual canal, and submandibular
fossa.
•The existence of anatomic variants,
such as incomplete healing of an
extraction site, sinus loculation,
division of mandibular canal or
absence of a well-defined corticated
canal should also be recognized.
EVALUATE RELATION OF ALVEOLAR RIDGE WITH EXISTING
TEETH AND DESIRED IMPLANT POSITION

• Long term prognosis of the implant is related to accurate position of the restoration.
• Preimplant evaluation, position of the implant in relation to:
⚬ Occlusal plane
⚬ Adjacent teeth
⚬ Alveolar crest
• Slight variations in implant position and inclination could be accommodated by using custom or angulated abutments to a certain
extent.
• Consideration during planning for implant patient:
⚬ Prolonged tooth loss:
￭ Ridge atrophy
￭ Sinus pneumatization
⚬ Traumatic tooth extraction (buccal and lingual plate)
⚬ Anatomic variations:
￭ Narrow ridge
￭ Lingual inclination of the alveolus
EVALUATION OF THE AVAILABLE BONE RELATIVE TO THE “PROSTHETICALLY
DRIVEN” IMPLANT POSITION

Conventional planning methods(analogue)

•Wax up for the desired tooth position on

diagnostic model
•Surgical guide with radiographic markers
•Steel balls, brass tubes, gutta-percha, or
tooth-shaped, resin-based markers may be
used as markers to establish the proposed
tooth positions relative to the existing
alveolar bone.
•CBCT or CT with radiographic guide worn.
EVALUATION OF THE AVAILABLE BONE RELATIVE TO THE “PROSTHETICALLY
DRIVEN” IMPLANT POSITION

Digital workflow

•CBCT is aligned with an optical scan (STL

file) of diagnostic cast with the restoration
waxup.
•Datasets are then superimposed
•Facilitate planning of implant position in
relation to the desired tooth position
according to the available bone.
ASSESS BONE QUANTITY, QUALITY, AND VOLUME

CLINICAL EVALUATION:
DIAGNOSIS WILL NOT BE COMPLETED
WITHOUT XRAY
WHAT WE SHOULD EVALUATE ?
AVAILABLE BONE VOLUME

1.HEIGHT
2.WIDTH
3.DENSITY
WHY?
TO PREVENT COMPLICATIONS TO CRITICAL
ANATOMIC STRUCTURES
 ASSESMENT >PLAN

EXAMPLE 1: INADEQUATE BONE

VOLUME>BONE AUGMENTATION

EXAMPLE 2: PRESENCE OF THIN

CORTICAL BONE OR LARGE MARROW
SPACE >POOR IMPLANT STABILISATION
 CLINICAL SELECTION OF DIAGNOSTIC
IMAGING
When assessing an implant patient, radiography is a crucial diagnostic tool. But radiographic imaging on its
own is not enough.

Correlating diagnostic data with a comprehensive clinical assessment is crucial.

On the other hand, an occlusal plane clinical examination had to be carried out.

Evaluations should be done of the:

• mandibular maximum opening
• protrusive and lateral motions
• temporomandibular joint function
 CLINICAL EXAMINATION
ASK
Etiology of tooth loss
Duration of tooth loss
Any history of traumatic extraction

Review
patient’s file

Assess
Occlusion
Adjacent teeth
Type of mucosa
TMJ : fnction/opening/movements
 SCREENING RADIOGRAPHS

It is now time to conduct a comprehensive evaluation of the jaws' general condition.

The first assessment of a patient receiving a dental implant should be done using
panoramic radiography, with periapical radiographs added as necessary, according to
the American Academy of Oral and Maxillofacial Radiology.
(A) Cross-sectional view through the
mandibular midline shows a prominent
median lingual canal. Branches of the
sublingual artery enter the mandible via this
canal.
(B) Cross-sectional view
through the area of the left maxillary lateral
incisor depicts the canalis sinuosus
extending from near the floor of the nasal
cavity to the palatal cortex.
This canal houses nervous structures that
innervate the anterior maxilla.
3D VOLUME-RENDERING VIEW, •Panoramic slice view showing
•a well corticated mandibular canal and prominent
OPTIMIZED FOR BONE,
anterior extension (incisive
DEMONSTRATING A DOUBLE •branch of the mandibular canal) extending beneath the
MENTAL radiographic marker
foramen, which is an anatomic variation. •in the anterior mandible.
• A high-resolution picture of the alveolus and its surrounding tissues, including
nearby teeth, can be obtained using periapical radiography
• Bone height and width can be estimated for extended edentulous areas using 3D
volumetric imaging techniques and panoramic radiographs.
• Any pathology found in the surrounding tissues or in the bone at the potential
implant site should be recognized and treated appropriately.
FABRICATION OF RADIOGRAPHIC AND SURGICAL
GUIDES

• Casts should be taken (whether analog or digital)

• Number and position of implants
• Radiographic markers used on radiographic guides
• Such guide improves the diagnostic information
 CROSS-SECTIONAL IMAGING

•Cross-sectional imaging orthogonal to the site of interest should be included in any

radiographic study of a possible implant site, it goes on to say that CBCT ought to be
thought of as the preferred imaging technique for preoperative cross-sectional
imaging of possible implant locations
ACCESSORY MANDIBULAR CANAL
• Cross-sectional imaging is preferred for the vast majority of implant treatment
planning due to:
• potential morbidity of a compromised anatomic structure
• poor performance
• potential failure of an implant that is misplaced, and the relatively wide
availability of advanced imaging (CBCT or MDCT).
• It is imperative that the cross sections go parallel to the intended implant and
perpendicular to the mandibular curve.
• An overestimation of the height and width of accessible bone may result from
improper cross section orientation.
• New pictures should be requested if the surgeon feels that sections were made
at an incorrect angle.
 INTRAOPERATIVE AND
POSTOPERATIVE
RADIOGRAPHIC ASSESSMENT

• Periapical Radiographs in Intraoperative assessment

⚬ High resolution and ease of use
⚬ Evaluate proximity of anatomical structures
⚬ Depth, direction, parallelism during sequential
drilling
⚬ Appear on the screen almost instantaneously
 •Periapical and panoramic radiographs offer a fast, easy, and low-radiation
depiction of the implant and surrounding tissues.

POSTOPERATIVE •Paralleling technique should be used to assess peri implant bone height.
•Beam hardening artifacts limits the use of CBCT in monitoring peri
implant bone.
ASSESSMENT •Periapical radiographs remains the gold standard for assessing peri implant
bone.
POSTOPERATIVE
ASSESSMENT
 Three-dimensional imaging is considered
(CBCT or MDCT):
POSTOPERATIVE • Implant failure
ASSESSMENT • Poor implant placement
• Compromising vital anatomical
structures
 CONCLUSION

There are numerous radiographic projections available, each with pros and cons, to assess implant placement.
When evaluating patients, the doctor must follow a set of procedures, and radiography is a crucial diagnostic tool
for implant design and the patient's successful outcome. The patient will receive a radiation dose that is "as low
as reasonably achievable" while receiving the most diagnostic information possible, preventing unintended
consequences, and optimizing treatment results through the selection of suitable radiography modalities.
THANK YOU