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Presented by:-
Dr. Richa Sahai
II MDS
Guided by:
Dr. U.M. Radke Dr. N.A. Pande Dr. S Deshmukh
HOD & Guide Professor Reader
Dr. T.K. Mowade Dr. R. Banerjee Dr. A. Chandak
Reader Reader Reader
Radiographic Considerations in Implants
CONTENTS
1. Introduction
2. Imaging Objectives
3. Imaging Modalities
4. Pre-surgical Imaging
5. Imaging of vital structures
6. Intra-operative Imaging
7. Fabrication of Diagnostic template
8. Radiographic signs associated with failing endosseous implants
9. Conclusion
10. References
• In the present era when it comes to oral rehabilitation, a wide range of options are
available to restore the missing teeth using fixed or removable prosthesis.
• The advent of implants in the field of dentistry has given dental professionals a viable
option to provide the patients with early third set of dentition.
INTRODUCTION
Diagnostic Options range from
1) Standard projections (routinely available)
• Intraoral (periapical, occlusal)
• Extraoral (panoramic, lateral cephalometric) r/g’s
2) More complex imaging techniques in the dental office
• Conventional x-ray tomography
• Computed tomography (CT), and
• Cone-beam CT (CBCT)
***Diagnostic imaging techniques must always be interpreted in conjunction with a good
clinical examination.
To
PHASES OF IMAGING
Phase- II
Surgical &
intraoperative
implant
imaging
Phase- III
Post-prosthetic
imaging
Phase- I
Pre-surgical
implant
imaging
 Involves all past and new R/G examinations to determine the patient's final treatment
plan.
Objectives
1. To assess the overall status of the remaining dentition.
2. To identify and characterize the location and nature of the edentulous regions,
particularly to determine the quantity , quality and angulations of bone.
3. To determine the relationship of critical structures to the implant site.
4. To detect regional anatomic structures.
5. To determine the presence or absence of disease at the implant site.
1) Pre-surgical implant imaging
• Assists in the surgical and prosthetic intervention of the patient.
Objectives
1. To evaluate the surgical site during & immediately after surgery.
2. Assist in the optimal position and orientation of dental implants.
3. To evaluate the healing and integration phase of implant surgery.
4. To ensure that abutment position and prosthesis fabrication are correct.
2) Surgical & intra-operative implant imaging
• Commences just after the prosthesis placement and continues as long as the implant
remains.
Objectives
1. To evaluate the long-term maintenance of implant rigid fixation and function.
2. To assess the Crestal bone levels around each implant.
3) Post-prosthetic imaging
IMAGING MODALITIES
Can be:
 Analog imaging - 2-D systems  uses radiograph films or
intensifying screens
 A digital 2-D image - is an image matrix with individual picture
elements (pixels)
 A digital 3-D image - is an image matrix with individual volume
elements (voxels)
- is described not only by its width &
height but also by its depth/ thickness
Analog / Digital 2-D/ 3-D
Analog 3-D
1. Periapical Radiography
2. Panoramic Radiography
3. Occlusal Radiography
4. Cephalometric Radiography
1. Tomographic Radiography
2. Computed Tomography
3. Magnetic Resonance Imaging
4. Interactive Computed
Tomography
S no. TYPES EXAMPLES FUNCTION
1. PLANAR 2-
DIMENSIONAL
Periapical, Bite-wing, Occlusal
and Cephalometric imaging
Gives a 2-d projection of
patient's anatomy
2. QUASI-3-
DIMENSIONAL
X-ray tomography, Cross-
sectional Panoramic imaging
Gives a 3-d perspective of
patient's anatomy
3. 3-DIMENSIONAL CT and MRI Gives the dentist to view
the volume of the patient's
anatomy.
1. Direct systems: CCD (charged coupled device) & CMOS (complementary metal
oxide semi-conductor) solid-state sensors contain silicon crystals converting photons to
electrons.
2.Indirect systems: Photostimulable storage phosphor (PSP) plates resemble the thin &
small intraoral films.
 can be designed into similar formats of occlusal sizes, and therefore better tolerated
by patients.
CCD CMOS
pixel charges are transferred to a common
output source.
conversion takes place at each pixel.
IMAGE RECEPTOR
PRESURGICAL IMAGING
Recommended principle  ALARA Principle.
“As Low As Reasonably Achievable”
1. PERIAPICAL RADIOGRAPHY
• Film is placed parallel to the body of the alveolus.
• The central ray of the x-ray device - perpendicular to the alveolus at the site .
• Produces a lateral view of the alveolus, but no cross-sectional information
• Low radiation dose
• Minimal magnification (with proper alignment and positioning)
• High resolution
• Inexpensive
ADVANTAGES
• Distortion and magnification (compared with 3-D)
• Minimal site evaluation, 2-D representation
• Difficulty in film placement, BL width assesment—not possible
• Technique sensitive
LIMITATIONS
• Evaluation of a small area
• Alignment and orientation during surgery
• For recall and maintenance therapy
INDICATIONS
PARALLELING TECHNIQUE
• Less magnification when there is a
greater distance between the x-ray
source and the film with the film being
as close to the tooth as possible.
BISECTING ANGLE TECHNIQUE
• . This technique results in decreased
exposure time.
Increasing image quality -
• Use smallest focal spot possible
• Increase the distance between the x-ray source and the film.
• Place the film- as close & parallel to the object as possible (e.g. tooth).
• X-rays  perpendicular to the film.
BUCCAL OBJECT RULE:
• Used to determine the buccolingual relationship of an object in relation to a second
object i.e to determine if the object (e.g. artifact) lies buccal or lingual to the second
object (e.g tooth)
• The protocol is to take two separate images at two different angles.
• The first image is made straight on, while the second image- at an angle more toward the
mesial or distal.
• By comparing the two images, you can decipher the relationship using this simple rule:
SLOB = Same Lingual, Opposite Buccal
• If you take the second image from a more mesial angle, if the object moves more mesial as
well (or in the Same direction), then the object is buccal to the second object.
DIGITAL RADIOGRAPHY(RVG)
• The film is replaced by a sensor that collects the data.
• Data is interpreted by a specialized software and the image is formed on a computer screen.
Types of sensors:
1. Charge-coupled device (CCD)
2. Complementary metal oxide semiconductor / active pixel sensor (CMOS/APS)
3. Charge injection device (CID)
Digital
radiographic
system that
includes digital
sensor and
computer.
• Less radiation because the sensors are more sensitive (exposure times 50-
90% less).
• Immediate result
• Ability to enhance the images (which can lead to more effective diagnoses)
• Patient education is better because the dentist is able to show things easier
• You don’t need a processor, chemicals, special rooms, film, etc.
Advantages
• High initial start-up costs
• Learning curve (the staff and the doctor must be trained on how to take,
view, and manipulate the radiographs)
• Increased thickness of the sensors & position of the connecting cord
• (Positioning of sensor difficult in some sites such as those adjacent to tori or
tapered arch form in region of canines)
Disadvantages
• Maxillary occlusal view  is oblique and so distorted that they are of no
quantitative use for implant dentistry for determining the geometry or the degree of
mineralization of the implant site.
• Mandibular occlusal radiograph is an orthogonal projection, it is less
distorted projection than the maxillary occlusal r/g.
OCCLUSAL RADIOGRAPHY
Maxillary occlusal view Mandibular occlusal view
ADVANTAGE
• Evaluation for pathology
LIMITATIONS
• Does not reveal true
buccolingual width in
mandible
• The skull is oriented to the x-ray device using a cephalometer.
• Fixes the position of the skull with the projections into the external auditory canal.
• Mid-sagittal plane oriented parallel to the image receptor.
• Helps to determine The width of bone in the symphysis region and the relationship
between the buccal cortex and the roots of the anterior teeth before harvesting this bone
for ridge augmentation
CEPHALOMETRIC RADIOGRAPHY
Not useful for demonstrating bone quality and only demonstrates a cross sectional
image of the alveolus
ADVANTAGES
• Height/width in anterior region
• Low magnification
• Skeletal relationship
LIMITATIONS
• Technique sensitive
• Image information is limited to ant.
region.
INDICATIONS
• Used in combination with other techniques
for anterior implants.
• Symphysis bone graft evaluation.
PANORAMIC RADIOGRAPHY
• A curved plane tomographic technique used to depict the body of the mandible, the
maxilla, and the lower half of the maxillary sinuses in a single image.
• Image receptor: radiographic film/ digital storage phosphor plate/ digital CCD
• Equipment horizontal rotating arm which holds an X-ray source and a
moving film mechanism (carrying a film) arranged at opposed extremities.
 The patient's skull sits between the X-ray generator and the film.
 The X-ray source is collimated toward the film, to give a vertical
blade beam shaped (width of 4-7mm when arriving on the film, after crossing the
patient's skull)
• Height of that beam covers the mandible and the maxilla regions.
• The arm  rotates around an instant center which shifts on a dedicated trajectory.
• The posterior maxillary regions  the least distorted regions in OPG
• The tomographic section thickness of panaromic radiograph or trough of focus is thick,
approximately 20mm, in the posterior regions and thin 6mm, in the anterior regions.
All panoramic beam angles
are approximately at 8
degrees, which gives the image
inherent magnification
Because of the curvature of the
arch, panoramic machines have
changing rotational centers.
LIMITATIONS
Distortions
Errors in
patient
positioning
Does not
demonstrate
bone quality.
Misleading quantitate
because of
magnification and no
third dimension
No spatial
relationship
between
structures
ADVANTAGES
Easy
identification
of opposing
landmarks.
Initial assessment
of vertical height
of bone.
Convenience, ease,
and speed in
performance in most
dental offices.
Evaluation of gross
anatomy of the jaws
and any related
pathological findings.
FOCAL TROUGH
• Invisible area (3D curved zone) in which structures are clearly
demonstrated on a panoramic radiograph.
• Also called – plane of acceptable detail or image layer.
• Structures  within the focal trough  well defined
 outside focal trough.  blurred.
• Narrow anterior region and
• Wide posterior region.
0
PROBLEM CAUSE CORRECTION
Blurred Magnified Patient positioned too far
posterior
Make sure anterior teeth
are properly in the holder
Blurred Narrow anterior region Patient positioned too far
anterior
Make sure anterior teeth
are in holder
Flattened curve of Spee; Hard palate
superimposed
Patient chin tipped too far
upward
Correctly align ala-tragus
Radiopaque shadow over anterior
region
Patient slumped too far
forward
Straighten neck
Ramus larger on one side uneven
pattern of blurring
Patient head rotated in
machine
Patient midsagittal plane
should be perpendicular to
the floor
Large radiolucency over maxilla Patient tongue not in floor of
mouth
Patient place tongue on
roof of mouth, swallows
TOMOGRAPHY
• Greek word  Tomo (slice) and graph(picture)
• X-ray and the film are connected by a rigid bar called the fulcrum bar, which pivots on a
fulcrum point.
• When the system is energized, the x-ray tube moves in one direction with the film plane
moving in the opposite direction and the system pivoting about the fulcrum.
• The fulcrum remains stationary and defines tomographic layer.
PRINCIPLE
CONVENTIONAL TOMOGRAPHIC IMAGES
Indications-
• Single-site
evaluation
• Vital structures
evaluation
Advantages-
• Cross-sectional
views
• Constant
Magnification
Limitations-
• Availability
• Cost
• Multiple Images
• Technique
sensitive
• Blurred images
• High radiation
COMPUTED TOMOGRAPHY
• Non-invasive Digital & mathematical imaging that creates tomographic sections
• Enables differentiation of soft & hard tissues.
• Invented by Hounsfield (1972).
• Produces axial images perpendicular to long axis of body.
The x-ray source is attached to a fan-beam geometry detector
array, which rotates 360 degrees around the patient.
The image detector is gaseous or solid state, producing electronic
signals that serve as input data for a dedicated computer.
The computer processes the data using back-projection Fourier
algorithm techniques first to produce CT images.
CT images are inherently three-dimensional digital images,
typically 512X512 pixels with a thickness described by the slice
spacing of the imaging technique.
The original imaging computer can create secondary images from
almost any perspective by reprojecting or reformatting the original
3D voxel data
• The individual element of the CT image is called a voxel, which has a value, referred to in
Hounsfield units, that describes the density of the CT image.
• The density of structures within the image is absolute and quantitative and can be used to
differentiate tissues in the region and characterize bone quality.
Muscle 35–70 HU
Fibrous tissue 60–90 HU
Cartilage 80–130 HU
Bone 150–1800 HU
D1 bone >1250 HU
D2 bone 750–1250 HU
D3 bone 375–750 HU
D4 bone <375 HU
COMPUTED TOMOGRAPHY
INDICATIONS
• Interactive treatment
planning
• Determination of bone
density
• Vital structure location
• Determination of
pathology
• Preplanning for bone
augmentation
ADVANTAGES
• Negligible
magnification
• Relatively high-contrast
image
• Various views
• Three-dimensional bone
models
• Interactive treatment
planning
LIMITATIONS
• Cost
• Technique sensitive
CONE BEAM VOLUMERIC TOMOGRAPHY
CBVT
• The first CBVT scanner in dentistry NewTom QR-DVT 9000 and NewTom 3G.
(latest version)
• The x-ray tube rotates 360 degrees capture images of the maxilla and mandible in 36
seconds, requiring only 5.6 seconds for exposure.
• The images recorded are placed onto a CCD chip with a matrix of 752 x 582 pixels then
converted into axial, sagittal, and coronal slices permit reformatting to view traditional r/g
images & 3-D soft tissue/ osseous images.
CONE-BEAM COMPUTED TOMOGRAPHY
CBCT
• Introduced to dentistry in the late 1990’s.
• The difference between CBCT and CT is the shape of radiation beams and the
mode of motion.
• CT - fan-beam and CBCT- a cone-shaped x-ray beam (which images a larger area
 Thus, at the end of a single complete rotation, 180 to 500 images of the area are
generated).
• The computer uses these images to generate a digital, 3-D map of the face.
CS 3D Imaging software
INTERACTIVE COMPUTED TOMOGRAPHY
• Enables a) the radiologist to transfer the imaging study in a computer file &
b) the practitioner to view with the imaging study on a personal computer.
Interactive computer guided implantology using NobelGuide software system
The first step  impressions for study casts.
a diagnostic wax-up
Fabrication of a radiopaque template
• will allow the transfer of the ideal positioning of the
teeth.
Acrylic template along with the plaster
model.
Arrows indicate the radiopaque
markers of the proposed implant area.
• For conventional and CT the positioning of the teeth is integrated into a scanning template
by way of a radiopaque material.
• Accomplished by way of an acrylic template coated with barium sulfate, gutta percha
markers or radiopaque denture teeth.
• These radiopaque templates may then be modified into use for surgical templates
Implant placement in relation to the mandibular canal and mental foramen; all images
are cross-referenced with each other.
Three dimensional analysis for the evaluation of proximity to vital structures may be
generated from the same computed tomography images
CT-BASED SURGICAL GUIDANCE
TEMPLATES AND NAVIGATION SYSTEMS
• Advanced technology has introduced guidance systems to facilitate dental implant
placement procedures during surgery.
• These systems allow the transfer of the pre-surgical plan to the patient, thus indicating
when there is deviation from the predetermined drilling parameters.
• Therefore the depth and trajectory of the drilling sequence is made to the exact location of
the preplanned position.
MAGNETIC RESONANCE IMAGING
• Introduced by Lauterbur
• Produces images of thin slices with excellent spatial resolution
• Uses combination of magnetic fields to generate images without
the use of ionizing radiation.
• Adv.  flexibility in the positioning & angulation of image
sections
 can produce multiple slices simultaneously
• The images created by MRI are the result of signals created by hydrogen protons in water
or fat such that :
1. Cortical bone  appear black (radiolucent)/ as having no signal
2. Cancellous bone  will generate a signal & will appear white (fatty marrow)
• Metal restorations do not produce scattering  thus appear black images.
• Advantages  quantitatively accurate technique with exact tomographic sections & no
distortion
• In cases where the inferior alveolar canal cannot be differentiated by conventional or
computed tomography, MRI would be a viable alternative as the trabecular bone is
easily differentiated with the inferior alveolar canal
• In cases of nerve impairment or infection, MRI may be used because of added
advantages including differentiation of soft tissue with respect to CT
• secondary imaging technique when primary imaging techniques (such as complex
tomography or CT) fail
Uses:-
Advantages
• No radiation
• Vital structures are
easily seen
Uses
• Evaluation of vital
structures when
computed tomography
is not conclusive
• Evaluation of infection
Limitations
• Cost
• Technique sensitive
• No reformatting
technique
• Availability
• Non-signal for cortical
bone
• Not useful in
characterizing bone
mineralization or as a
high-yield technique
for identifying bone or
dental disease
ADVANTAGES AND DISADVANTAGES OF THE VARIOUS
RADIOGRAPHIC PROJECTIONS
Modality Advantages Disadvantages
Periapical and occlusal
radiography
- High resolution and detail
- easy acquisition,
- low exposure
- inexpensive.
-Unpredictable magnification
-small imaged area,
-2D representation of
anatomy
Panoramic radiography
-Easy to acquire, images
whole ridge
-low exposure,
-inexpensive.
-Unpredictable magnification
-2D representation of
anatomy, not detailed
Modality Advantages Disadvantages
Lateral cephalometric
radiography
-Easy to acquire,
-predictable magnification
-low exposure
-inexpensive.
-Limited use in area of
midline
-2D representation of
anatomy
Tomography
-3D representation,
-predictable magnification,
-sufficient detail,
-low exposure,
-images area of interest only.
-Requires special equipment,
-for evaluation of multiple
sites can be a lengthy
procedure because the
patient must be repositioned
for each site,
-expensive
Modality Advantages Disadvantages
Computed tomography (CT)
-3D representation,
-predictable magnification,
-sufficient detail,
-digital format,
-images whole arch.
-Requires special equipment,
-expensive,
-high-exposure dose
Cone-beam computed
tomography (CBCT)
-3D representation,
-predictable magnification,
-sufficient detail,
-digital format,
-images whole arch,
-low dose.
-Requires special equipment
-expensive
ANATOMIC STRUCTURES PERTINENT TO TREATMENT
PLANNING OF THE IMPLANT PATIENT
Maxilla
1. Maxillary sinus (floor & anterior
wall)
2. Nasal cavity (floor & lateral wall)
3. Incisive foramen
4. Canine fossa
Mandible
1. Mandibular canal
2. Mental foramen
3. Submandibular fossa
4. Lingual inclination of the
alveolar ridge
R/G IMAGING OF VITAL STRUCTURES
Mental Foramen And Mandibular Canal
• Identified to avoid trauma to the inferior alveolar nerve & mental nerve
• Because of the curvature of the mandible, care must be given to the angulation of the x-ray
beam for intraoral radiography.
• For IOPA’s & OPG- If the image is taken from orientations:-
1. Mesio-oblique foreshortened and
2. Distal-oblique elongated.
• In edentulous mandible, the risk of error increases in resorbed
alveolar crest.
 Most accurate means of identification is with conventional
& computerized tomography.
 Tilting the patient’s head approximately 5 degrees
downward in reference to the Frankfort horizontal plane
allows these anatomical structures to be seen in 91% of
radiographs.(Dharmar S)
Mandibular Lingual concavities
• Usually seen in advanced atrophy in posterior mandible.
• Overestimation of the amount of bone perforation of the lingual plate when drilling.
• Lingual bleeding problems - can be life-threatening.
• Technique of choice cross-sectional tomography
Mandibular Ramus
• popular donor site for autogenous onlay bone grafting.
• Extremely variable in the amount of bone present.
• Usually panoramic images are taken and the location of the external oblique and the
mandibular canal is noted.
• For accurate representation - use of computerized tomography.
Mandibular Symphysis
• critical anatomical area.
• A common position for implants in mandibular
edentulous patients
• donor site for autogenous grafting.
• With 2-D imaging inherent errors due to lingual
concavities.
• R/g’s  lateral cephalometric and conventional CT,
may be used.
Computed tomography images illustrate
various views of the mandibular anterior
region.
Maxillary Sinus
• CT gold standard.
• provides detailed information –
1. Prevalence and position of septa
2. Maxillary sinus anatomy
3. Detection of sinus pathology
• With digital radiography technology, instantaneous images are achieved, allowing for
multiple images to be completed in a fraction of the time.
• Additional advantages –
Manipulation of images
Calibration
Accurate positioning
Maintenance of aseptic protocol
INTRAOPERATIVE IMAGING
Initial pilot
orientation with
slight mesial
inclination
Angulation
corrected and
verified with final
depth indicator
Implant placement.
Note poor angulation of
radiograph leading to
distorted measurements.
Ideal implant placement
radiograph.
Due to the perpendicular
orientation of x-ray
beam all threads are
seen without distortion
IMMEDIATE POSTSURGICAL IMAGING
• A 2-D imaging is done to obtain a baseline image that may be used to evaluate
against future films
• Additional imaging tools may be used to evaluate a zone of safety around vital
structures.
Abutment and Prosthetic Component Imaging
 Transfer impressions with two-piece abutment component placement
radiographs should be taken to verify secure adaptation.
 When positioning is difficult for periapical radiographs, bitewing or panoramic
radiographs may be used.
Verification of
direct transfer
coping
placement
before final
impression.
Note ideal
angulation
from thread
alignment
RECALL & MAINTENANCE IMAGING
• Done for-
1. For marginal bone level evaluation.
• For investigating complications after implant placement the image of choice.
Panoramic r/g  multiple implants & Periapical r/g single implants
 Immobility and Radiographic evidence of bone adjacent to the implant are the two most
accurate diagnostic aids in evaluating success.
 Follow-up or recall radiographs  taken after 1 yr of functional loading and yearly for
the first 3 years.
 marginal bone loss and a higher rate of failure are seen - in the first 6 months.
POST-PROSTHETIC IMAGING
• R/g-- loss of integration is indicated as a radiolucent line around the implant.
1. false-negative dx- when the soft tissue surrounding an implant is not wide enough
to overcome the resolution of the radiographic modality used.
2. false-positive dx- when a “Mach band effect” results from an area of lower
radiographic density adjacent to an area of high density (implant), which results
in a more radiolucent area than is actually present.
Digital radiography has the advantage of “edge enhancement (ability to detect space
between the implant and the surrounding bone).”
EVALUATION OF ALVEOLAR BONE CHANGES
PERIAPICAL RADIOGRAPHS
• In recall IOPA’s the marginal bone level is compared with the immediate post-prosthetic
r/g.
Alveolar bone level evaluation.
A- Ideal positioning showing ideal thread orientation.
B, Improper angulation showing diffuse thread
orientation.
If the implant threads are not clearly seen in the
r/g’s
Modify the beam angle
If diffuse threads are present on the right side of
the implant
beam angle was positioned too much in the
superior direction.
If the threads are diffuse on the left side then the beam angle was from an inferior
angulation
BITEWING RADIOGRAPHS
• In cases where the x-ray source cannot be positioned perpendicular to the implant because of
oral anatomy or existing prosthesis, horizontal or vertical bitewings are taken to evaluate the
crestal bone area.
• Limitation  apical portion cannot be seen.
 2 r/g’s taken at different times superimposed on one another gives an image
that exhibits the differences in the bone level.
 ***requires same positioning and imaging technique between the two radiographs
with respect to the x-ray source, patient and film position, exposure, and
processing variables.
DIGITAL SUBTRACTION RADIOGRAPHY
PANORAMIC RADIOGRAPHS
• The images are substracted and the resultant image left
depicts the osseous changes between the r/g’s.
• More accurate  accessing bone mineralization and
volume changes
 Not used routinely for evaluation of osseous bone levels
and recall as they use intensifying screens poor
resolution.
 Technique of choice- when multiple implants need to be
evaluated.
COMPUTED TOMOGRAPHY
• D/A of 2-D r/g’s do not give buccolingual condition of alveolar bone.
• CT gives 3-D information about the osseous status around an implant.
• Adv  bone density evaluation using Hounsfield unit that helps determine bone
maturation.
• D/A Resolution and scattering overcome with cone beam technology.
• Image of choice for evaluation of sinus infection/ postsurgical sinusitis
complications
FABRICATION OF DIAGNOSTIC TEMPLATES
• The purpose  to incorporate the proposed treatment plan into the radiographic
examination.
• Steps:-mounted diagnostic casts a diagnostic wax-up template fabrication.
• The pre-prosthetic imaging enables evaluation of the proposed implant site at the ideal
position and orientation.
COMPUTED TOMOGRAPHY TEMPLATE
• Designs for diagnostic CT templates have evolved from
one produced
from a processed
acrylic
reproduction of
the diagnostic
wax-up
• The acrylic template is modified by coating the proposed restorations with a
thin film of barium sulfate and filling a hole drilled through the occlusal
surface of the restoration with gutta-percha seen as radiopaque in the CT
examination.
A - A vacuum-formed imaging stent with a metal rod to indicate desired axis of
insertion.
B - A processed stent with metal cylinders marking the implant sites. This can also be
used as a surgical stent by inserting the guide bur through the cylinders.
C - A processed stent with insertion axis markers, along with a radiopaque strip
outlining the buccal and lingual contours of the planned restoration. The stent
provides an image of the emergence profile of the restored implant and can also be used
as a surgical guide.
• Radiopaque teeth designed for the fabrication of diagnostic templates for fixed and
removable implant-supported restorations have been introduced.
• Advantages –
• The diagnostic template then can be modified into a surgical template
• Time saving
• Easily placed
• Provide high radiopacity
• Bond easily with the
template.
Dov , Almog, Romano PR. CT-Based Dental Imaging for Implant Planning and
Surgical Guidance A CASE REPORT. New York state dental journal. 2007
TOMOGRAPHY TEMPLATE
• The simplest tomography template is obtained by a vacuform of the patient’s diagnostic
cast with 3-mm ball bearings.
• A number of tomograms of the implant region are produced with the implant site
identified by the one in which the ball bearing is in sharp focus.
• It can also serve as a measure of the magnification of the imaging system.
RADIOGRAPHIC SIGNS ASSOCIATED WITH FAILING
ENDOSSEOUS IMPLANTS
Radiographic appearance Clinical implications
Thin radiolucent area that closely
follows the entire outline
Failure of implant to integrate with
adjoining bone.
Radiolucent area around coronal
portion
Peri-implantitis resulting from poor
plaque control, adverse loading or
both
Apical migration of alveolar bone one
side of implant
Non axial loading resulting from
improper angulation of implant
Widening of periodontal space of the
nearest natural abutment
Poor stress distribution
Fracture of fixature Unfavorable stress distribution during
function
RECENT ADVANCES
DIGITAL IMAGING
NOBEL PROCERATM
TUNED APERTURE COMPUTED TOMOGRAPHY
(TACT)
• In this technique image is produced by
passing a radiographic beam through an
object several different angles.
• Advantages :
 it can accommodate patient movement
during firing with affecting the quality of
the image produced with reduced
radiation dose.
 Localization of bone disease, anatomical
structures and abnormalities at implant
site is much easier with TACT.
• A modification of the panoramic x-ray machine for
making cross-sectional images of the jaws.
• The tomographic layer is approx. 5mm.
• For appreciation of spatial relationship between the
critical structures and the implant site.
• Limitations :
Tomographic layers are relatively thick.
Adjacent structures blurring and superimposed.
Not useful for determining the differences in bone
density or for identifying disease at implant site.
ZONOGRAPHY
• Provides programmed reformation, organization and
display of the imaging study.
• The curvature of the mandibular or maxillary arch is
selected, & the computer is programmed to generate
referenced cross-sectional and tangential/panoramic
images of the alveolus along with 3-D images of the
arch.
Axial CT view of the mandible
showing the potential
crosssectional slices that can be
reformatted by Dentascan.
Limitations:-
1. not true size images and requires compensation for magnification
2. Determination of bone quality requires workstation
3. Hard-copy only include a limited range of the diagnostic grayscale
4. Tilt of the patient’s head during the examination, which is critical because all the cross-
sectional images are perpendicular to the axial imaging plane.
DENTASCAN
SIMPLANTS
• It is an interactive dental implant software package.
• It allows dentists to view and manipulate processed CT images.
• Simplant software can be used to superimpose images of actual size
implants on the CT images for treatment planning.
• Radiographs play an important part in the successful planning and execution of
implant treatment.
• They are an important part of the patients records and as such constitute a
significant proportion of the medico-legal documentation of the patient.
• It is important to have an understanding of the different techniques available and
their appropriate application.
• It is the responsibility of the clinician to ensure that radiographs are appropriate,
readable and are retained and repeated at accepted intervals throughout treatment
and follow-up.
CONCLUSION
1. Contemporary Implant Dentistry. Carl E. Misch – 3rd Edition
2. Caranza's Clinical Periodontology - 11th Edition
3. Swati S Bhosale, P Balaji Raman and Joshua Mall. Guided implant placement in the edentulous
mandible: A novel approach. Journal of ICDRO 2010; Vol 2 (1): Page 30 – 34.
4. Lingeshwar D, Dhanasekar B, Aparna IN. Diagnostic Imaging in Implant Dentistry. International
Journal of Oral Implantology and Clinical Research, September-December 2010;1(3):147-153
5. Bart Vandenberghe Reinhilde Jacobs Hilde Bosmans, Modern dental imaging: A review of the
current technology and clinical applications in dental practice. Eur Radiol 2010 20: 2637-2655
REFERENCES
THANK-YOU !

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Radiographic Considerations in Implants

  • 1. Presented by:- Dr. Richa Sahai II MDS Guided by: Dr. U.M. Radke Dr. N.A. Pande Dr. S Deshmukh HOD & Guide Professor Reader Dr. T.K. Mowade Dr. R. Banerjee Dr. A. Chandak Reader Reader Reader Radiographic Considerations in Implants
  • 2. CONTENTS 1. Introduction 2. Imaging Objectives 3. Imaging Modalities 4. Pre-surgical Imaging 5. Imaging of vital structures 6. Intra-operative Imaging 7. Fabrication of Diagnostic template 8. Radiographic signs associated with failing endosseous implants 9. Conclusion 10. References
  • 3. • In the present era when it comes to oral rehabilitation, a wide range of options are available to restore the missing teeth using fixed or removable prosthesis. • The advent of implants in the field of dentistry has given dental professionals a viable option to provide the patients with early third set of dentition. INTRODUCTION
  • 4. Diagnostic Options range from 1) Standard projections (routinely available) • Intraoral (periapical, occlusal) • Extraoral (panoramic, lateral cephalometric) r/g’s 2) More complex imaging techniques in the dental office • Conventional x-ray tomography • Computed tomography (CT), and • Cone-beam CT (CBCT) ***Diagnostic imaging techniques must always be interpreted in conjunction with a good clinical examination. To
  • 5. PHASES OF IMAGING Phase- II Surgical & intraoperative implant imaging Phase- III Post-prosthetic imaging Phase- I Pre-surgical implant imaging
  • 6.  Involves all past and new R/G examinations to determine the patient's final treatment plan. Objectives 1. To assess the overall status of the remaining dentition. 2. To identify and characterize the location and nature of the edentulous regions, particularly to determine the quantity , quality and angulations of bone. 3. To determine the relationship of critical structures to the implant site. 4. To detect regional anatomic structures. 5. To determine the presence or absence of disease at the implant site. 1) Pre-surgical implant imaging
  • 7. • Assists in the surgical and prosthetic intervention of the patient. Objectives 1. To evaluate the surgical site during & immediately after surgery. 2. Assist in the optimal position and orientation of dental implants. 3. To evaluate the healing and integration phase of implant surgery. 4. To ensure that abutment position and prosthesis fabrication are correct. 2) Surgical & intra-operative implant imaging
  • 8. • Commences just after the prosthesis placement and continues as long as the implant remains. Objectives 1. To evaluate the long-term maintenance of implant rigid fixation and function. 2. To assess the Crestal bone levels around each implant. 3) Post-prosthetic imaging
  • 9. IMAGING MODALITIES Can be:  Analog imaging - 2-D systems  uses radiograph films or intensifying screens  A digital 2-D image - is an image matrix with individual picture elements (pixels)  A digital 3-D image - is an image matrix with individual volume elements (voxels) - is described not only by its width & height but also by its depth/ thickness Analog / Digital 2-D/ 3-D
  • 10. Analog 3-D 1. Periapical Radiography 2. Panoramic Radiography 3. Occlusal Radiography 4. Cephalometric Radiography 1. Tomographic Radiography 2. Computed Tomography 3. Magnetic Resonance Imaging 4. Interactive Computed Tomography
  • 11. S no. TYPES EXAMPLES FUNCTION 1. PLANAR 2- DIMENSIONAL Periapical, Bite-wing, Occlusal and Cephalometric imaging Gives a 2-d projection of patient's anatomy 2. QUASI-3- DIMENSIONAL X-ray tomography, Cross- sectional Panoramic imaging Gives a 3-d perspective of patient's anatomy 3. 3-DIMENSIONAL CT and MRI Gives the dentist to view the volume of the patient's anatomy.
  • 12. 1. Direct systems: CCD (charged coupled device) & CMOS (complementary metal oxide semi-conductor) solid-state sensors contain silicon crystals converting photons to electrons. 2.Indirect systems: Photostimulable storage phosphor (PSP) plates resemble the thin & small intraoral films.  can be designed into similar formats of occlusal sizes, and therefore better tolerated by patients. CCD CMOS pixel charges are transferred to a common output source. conversion takes place at each pixel. IMAGE RECEPTOR
  • 13. PRESURGICAL IMAGING Recommended principle  ALARA Principle. “As Low As Reasonably Achievable”
  • 14. 1. PERIAPICAL RADIOGRAPHY • Film is placed parallel to the body of the alveolus. • The central ray of the x-ray device - perpendicular to the alveolus at the site . • Produces a lateral view of the alveolus, but no cross-sectional information
  • 15. • Low radiation dose • Minimal magnification (with proper alignment and positioning) • High resolution • Inexpensive ADVANTAGES • Distortion and magnification (compared with 3-D) • Minimal site evaluation, 2-D representation • Difficulty in film placement, BL width assesment—not possible • Technique sensitive LIMITATIONS • Evaluation of a small area • Alignment and orientation during surgery • For recall and maintenance therapy INDICATIONS
  • 16. PARALLELING TECHNIQUE • Less magnification when there is a greater distance between the x-ray source and the film with the film being as close to the tooth as possible. BISECTING ANGLE TECHNIQUE • . This technique results in decreased exposure time.
  • 17. Increasing image quality - • Use smallest focal spot possible • Increase the distance between the x-ray source and the film. • Place the film- as close & parallel to the object as possible (e.g. tooth). • X-rays  perpendicular to the film.
  • 18. BUCCAL OBJECT RULE: • Used to determine the buccolingual relationship of an object in relation to a second object i.e to determine if the object (e.g. artifact) lies buccal or lingual to the second object (e.g tooth) • The protocol is to take two separate images at two different angles.
  • 19. • The first image is made straight on, while the second image- at an angle more toward the mesial or distal. • By comparing the two images, you can decipher the relationship using this simple rule: SLOB = Same Lingual, Opposite Buccal • If you take the second image from a more mesial angle, if the object moves more mesial as well (or in the Same direction), then the object is buccal to the second object.
  • 20. DIGITAL RADIOGRAPHY(RVG) • The film is replaced by a sensor that collects the data. • Data is interpreted by a specialized software and the image is formed on a computer screen. Types of sensors: 1. Charge-coupled device (CCD) 2. Complementary metal oxide semiconductor / active pixel sensor (CMOS/APS) 3. Charge injection device (CID) Digital radiographic system that includes digital sensor and computer.
  • 21. • Less radiation because the sensors are more sensitive (exposure times 50- 90% less). • Immediate result • Ability to enhance the images (which can lead to more effective diagnoses) • Patient education is better because the dentist is able to show things easier • You don’t need a processor, chemicals, special rooms, film, etc. Advantages • High initial start-up costs • Learning curve (the staff and the doctor must be trained on how to take, view, and manipulate the radiographs) • Increased thickness of the sensors & position of the connecting cord • (Positioning of sensor difficult in some sites such as those adjacent to tori or tapered arch form in region of canines) Disadvantages
  • 22. • Maxillary occlusal view  is oblique and so distorted that they are of no quantitative use for implant dentistry for determining the geometry or the degree of mineralization of the implant site. • Mandibular occlusal radiograph is an orthogonal projection, it is less distorted projection than the maxillary occlusal r/g. OCCLUSAL RADIOGRAPHY
  • 23. Maxillary occlusal view Mandibular occlusal view ADVANTAGE • Evaluation for pathology LIMITATIONS • Does not reveal true buccolingual width in mandible
  • 24. • The skull is oriented to the x-ray device using a cephalometer. • Fixes the position of the skull with the projections into the external auditory canal. • Mid-sagittal plane oriented parallel to the image receptor. • Helps to determine The width of bone in the symphysis region and the relationship between the buccal cortex and the roots of the anterior teeth before harvesting this bone for ridge augmentation CEPHALOMETRIC RADIOGRAPHY Not useful for demonstrating bone quality and only demonstrates a cross sectional image of the alveolus
  • 25. ADVANTAGES • Height/width in anterior region • Low magnification • Skeletal relationship LIMITATIONS • Technique sensitive • Image information is limited to ant. region. INDICATIONS • Used in combination with other techniques for anterior implants. • Symphysis bone graft evaluation.
  • 26. PANORAMIC RADIOGRAPHY • A curved plane tomographic technique used to depict the body of the mandible, the maxilla, and the lower half of the maxillary sinuses in a single image. • Image receptor: radiographic film/ digital storage phosphor plate/ digital CCD • Equipment horizontal rotating arm which holds an X-ray source and a moving film mechanism (carrying a film) arranged at opposed extremities.  The patient's skull sits between the X-ray generator and the film.  The X-ray source is collimated toward the film, to give a vertical blade beam shaped (width of 4-7mm when arriving on the film, after crossing the patient's skull)
  • 27. • Height of that beam covers the mandible and the maxilla regions. • The arm  rotates around an instant center which shifts on a dedicated trajectory. • The posterior maxillary regions  the least distorted regions in OPG • The tomographic section thickness of panaromic radiograph or trough of focus is thick, approximately 20mm, in the posterior regions and thin 6mm, in the anterior regions. All panoramic beam angles are approximately at 8 degrees, which gives the image inherent magnification Because of the curvature of the arch, panoramic machines have changing rotational centers.
  • 28. LIMITATIONS Distortions Errors in patient positioning Does not demonstrate bone quality. Misleading quantitate because of magnification and no third dimension No spatial relationship between structures ADVANTAGES Easy identification of opposing landmarks. Initial assessment of vertical height of bone. Convenience, ease, and speed in performance in most dental offices. Evaluation of gross anatomy of the jaws and any related pathological findings.
  • 29. FOCAL TROUGH • Invisible area (3D curved zone) in which structures are clearly demonstrated on a panoramic radiograph. • Also called – plane of acceptable detail or image layer. • Structures  within the focal trough  well defined  outside focal trough.  blurred. • Narrow anterior region and • Wide posterior region.
  • 30. 0
  • 31. PROBLEM CAUSE CORRECTION Blurred Magnified Patient positioned too far posterior Make sure anterior teeth are properly in the holder Blurred Narrow anterior region Patient positioned too far anterior Make sure anterior teeth are in holder Flattened curve of Spee; Hard palate superimposed Patient chin tipped too far upward Correctly align ala-tragus Radiopaque shadow over anterior region Patient slumped too far forward Straighten neck Ramus larger on one side uneven pattern of blurring Patient head rotated in machine Patient midsagittal plane should be perpendicular to the floor Large radiolucency over maxilla Patient tongue not in floor of mouth Patient place tongue on roof of mouth, swallows
  • 32. TOMOGRAPHY • Greek word  Tomo (slice) and graph(picture) • X-ray and the film are connected by a rigid bar called the fulcrum bar, which pivots on a fulcrum point. • When the system is energized, the x-ray tube moves in one direction with the film plane moving in the opposite direction and the system pivoting about the fulcrum. • The fulcrum remains stationary and defines tomographic layer. PRINCIPLE
  • 33. CONVENTIONAL TOMOGRAPHIC IMAGES Indications- • Single-site evaluation • Vital structures evaluation Advantages- • Cross-sectional views • Constant Magnification Limitations- • Availability • Cost • Multiple Images • Technique sensitive • Blurred images • High radiation
  • 34. COMPUTED TOMOGRAPHY • Non-invasive Digital & mathematical imaging that creates tomographic sections • Enables differentiation of soft & hard tissues. • Invented by Hounsfield (1972). • Produces axial images perpendicular to long axis of body.
  • 35. The x-ray source is attached to a fan-beam geometry detector array, which rotates 360 degrees around the patient. The image detector is gaseous or solid state, producing electronic signals that serve as input data for a dedicated computer. The computer processes the data using back-projection Fourier algorithm techniques first to produce CT images. CT images are inherently three-dimensional digital images, typically 512X512 pixels with a thickness described by the slice spacing of the imaging technique. The original imaging computer can create secondary images from almost any perspective by reprojecting or reformatting the original 3D voxel data
  • 36. • The individual element of the CT image is called a voxel, which has a value, referred to in Hounsfield units, that describes the density of the CT image. • The density of structures within the image is absolute and quantitative and can be used to differentiate tissues in the region and characterize bone quality. Muscle 35–70 HU Fibrous tissue 60–90 HU Cartilage 80–130 HU Bone 150–1800 HU D1 bone >1250 HU D2 bone 750–1250 HU D3 bone 375–750 HU D4 bone <375 HU
  • 37. COMPUTED TOMOGRAPHY INDICATIONS • Interactive treatment planning • Determination of bone density • Vital structure location • Determination of pathology • Preplanning for bone augmentation ADVANTAGES • Negligible magnification • Relatively high-contrast image • Various views • Three-dimensional bone models • Interactive treatment planning LIMITATIONS • Cost • Technique sensitive
  • 38. CONE BEAM VOLUMERIC TOMOGRAPHY CBVT • The first CBVT scanner in dentistry NewTom QR-DVT 9000 and NewTom 3G. (latest version) • The x-ray tube rotates 360 degrees capture images of the maxilla and mandible in 36 seconds, requiring only 5.6 seconds for exposure. • The images recorded are placed onto a CCD chip with a matrix of 752 x 582 pixels then converted into axial, sagittal, and coronal slices permit reformatting to view traditional r/g images & 3-D soft tissue/ osseous images.
  • 39. CONE-BEAM COMPUTED TOMOGRAPHY CBCT • Introduced to dentistry in the late 1990’s. • The difference between CBCT and CT is the shape of radiation beams and the mode of motion. • CT - fan-beam and CBCT- a cone-shaped x-ray beam (which images a larger area  Thus, at the end of a single complete rotation, 180 to 500 images of the area are generated). • The computer uses these images to generate a digital, 3-D map of the face.
  • 40.
  • 41. CS 3D Imaging software
  • 42.
  • 43. INTERACTIVE COMPUTED TOMOGRAPHY • Enables a) the radiologist to transfer the imaging study in a computer file & b) the practitioner to view with the imaging study on a personal computer. Interactive computer guided implantology using NobelGuide software system
  • 44. The first step  impressions for study casts. a diagnostic wax-up Fabrication of a radiopaque template • will allow the transfer of the ideal positioning of the teeth. Acrylic template along with the plaster model. Arrows indicate the radiopaque markers of the proposed implant area.
  • 45. • For conventional and CT the positioning of the teeth is integrated into a scanning template by way of a radiopaque material. • Accomplished by way of an acrylic template coated with barium sulfate, gutta percha markers or radiopaque denture teeth. • These radiopaque templates may then be modified into use for surgical templates
  • 46. Implant placement in relation to the mandibular canal and mental foramen; all images are cross-referenced with each other. Three dimensional analysis for the evaluation of proximity to vital structures may be generated from the same computed tomography images
  • 47. CT-BASED SURGICAL GUIDANCE TEMPLATES AND NAVIGATION SYSTEMS • Advanced technology has introduced guidance systems to facilitate dental implant placement procedures during surgery. • These systems allow the transfer of the pre-surgical plan to the patient, thus indicating when there is deviation from the predetermined drilling parameters. • Therefore the depth and trajectory of the drilling sequence is made to the exact location of the preplanned position.
  • 48. MAGNETIC RESONANCE IMAGING • Introduced by Lauterbur • Produces images of thin slices with excellent spatial resolution • Uses combination of magnetic fields to generate images without the use of ionizing radiation. • Adv.  flexibility in the positioning & angulation of image sections  can produce multiple slices simultaneously
  • 49. • The images created by MRI are the result of signals created by hydrogen protons in water or fat such that : 1. Cortical bone  appear black (radiolucent)/ as having no signal 2. Cancellous bone  will generate a signal & will appear white (fatty marrow) • Metal restorations do not produce scattering  thus appear black images. • Advantages  quantitatively accurate technique with exact tomographic sections & no distortion
  • 50. • In cases where the inferior alveolar canal cannot be differentiated by conventional or computed tomography, MRI would be a viable alternative as the trabecular bone is easily differentiated with the inferior alveolar canal • In cases of nerve impairment or infection, MRI may be used because of added advantages including differentiation of soft tissue with respect to CT • secondary imaging technique when primary imaging techniques (such as complex tomography or CT) fail Uses:-
  • 51. Advantages • No radiation • Vital structures are easily seen Uses • Evaluation of vital structures when computed tomography is not conclusive • Evaluation of infection Limitations • Cost • Technique sensitive • No reformatting technique • Availability • Non-signal for cortical bone • Not useful in characterizing bone mineralization or as a high-yield technique for identifying bone or dental disease
  • 52. ADVANTAGES AND DISADVANTAGES OF THE VARIOUS RADIOGRAPHIC PROJECTIONS Modality Advantages Disadvantages Periapical and occlusal radiography - High resolution and detail - easy acquisition, - low exposure - inexpensive. -Unpredictable magnification -small imaged area, -2D representation of anatomy Panoramic radiography -Easy to acquire, images whole ridge -low exposure, -inexpensive. -Unpredictable magnification -2D representation of anatomy, not detailed
  • 53. Modality Advantages Disadvantages Lateral cephalometric radiography -Easy to acquire, -predictable magnification -low exposure -inexpensive. -Limited use in area of midline -2D representation of anatomy Tomography -3D representation, -predictable magnification, -sufficient detail, -low exposure, -images area of interest only. -Requires special equipment, -for evaluation of multiple sites can be a lengthy procedure because the patient must be repositioned for each site, -expensive
  • 54. Modality Advantages Disadvantages Computed tomography (CT) -3D representation, -predictable magnification, -sufficient detail, -digital format, -images whole arch. -Requires special equipment, -expensive, -high-exposure dose Cone-beam computed tomography (CBCT) -3D representation, -predictable magnification, -sufficient detail, -digital format, -images whole arch, -low dose. -Requires special equipment -expensive
  • 55. ANATOMIC STRUCTURES PERTINENT TO TREATMENT PLANNING OF THE IMPLANT PATIENT Maxilla 1. Maxillary sinus (floor & anterior wall) 2. Nasal cavity (floor & lateral wall) 3. Incisive foramen 4. Canine fossa Mandible 1. Mandibular canal 2. Mental foramen 3. Submandibular fossa 4. Lingual inclination of the alveolar ridge
  • 56. R/G IMAGING OF VITAL STRUCTURES Mental Foramen And Mandibular Canal • Identified to avoid trauma to the inferior alveolar nerve & mental nerve • Because of the curvature of the mandible, care must be given to the angulation of the x-ray beam for intraoral radiography.
  • 57. • For IOPA’s & OPG- If the image is taken from orientations:- 1. Mesio-oblique foreshortened and 2. Distal-oblique elongated. • In edentulous mandible, the risk of error increases in resorbed alveolar crest.  Most accurate means of identification is with conventional & computerized tomography.  Tilting the patient’s head approximately 5 degrees downward in reference to the Frankfort horizontal plane allows these anatomical structures to be seen in 91% of radiographs.(Dharmar S)
  • 58. Mandibular Lingual concavities • Usually seen in advanced atrophy in posterior mandible. • Overestimation of the amount of bone perforation of the lingual plate when drilling. • Lingual bleeding problems - can be life-threatening. • Technique of choice cross-sectional tomography
  • 59. Mandibular Ramus • popular donor site for autogenous onlay bone grafting. • Extremely variable in the amount of bone present. • Usually panoramic images are taken and the location of the external oblique and the mandibular canal is noted. • For accurate representation - use of computerized tomography.
  • 60. Mandibular Symphysis • critical anatomical area. • A common position for implants in mandibular edentulous patients • donor site for autogenous grafting. • With 2-D imaging inherent errors due to lingual concavities. • R/g’s  lateral cephalometric and conventional CT, may be used. Computed tomography images illustrate various views of the mandibular anterior region.
  • 61. Maxillary Sinus • CT gold standard. • provides detailed information – 1. Prevalence and position of septa 2. Maxillary sinus anatomy 3. Detection of sinus pathology
  • 62. • With digital radiography technology, instantaneous images are achieved, allowing for multiple images to be completed in a fraction of the time. • Additional advantages – Manipulation of images Calibration Accurate positioning Maintenance of aseptic protocol INTRAOPERATIVE IMAGING
  • 63. Initial pilot orientation with slight mesial inclination Angulation corrected and verified with final depth indicator Implant placement. Note poor angulation of radiograph leading to distorted measurements. Ideal implant placement radiograph. Due to the perpendicular orientation of x-ray beam all threads are seen without distortion
  • 64. IMMEDIATE POSTSURGICAL IMAGING • A 2-D imaging is done to obtain a baseline image that may be used to evaluate against future films • Additional imaging tools may be used to evaluate a zone of safety around vital structures. Abutment and Prosthetic Component Imaging  Transfer impressions with two-piece abutment component placement radiographs should be taken to verify secure adaptation.  When positioning is difficult for periapical radiographs, bitewing or panoramic radiographs may be used. Verification of direct transfer coping placement before final impression. Note ideal angulation from thread alignment
  • 65. RECALL & MAINTENANCE IMAGING • Done for- 1. For marginal bone level evaluation. • For investigating complications after implant placement the image of choice. Panoramic r/g  multiple implants & Periapical r/g single implants  Immobility and Radiographic evidence of bone adjacent to the implant are the two most accurate diagnostic aids in evaluating success.  Follow-up or recall radiographs  taken after 1 yr of functional loading and yearly for the first 3 years.  marginal bone loss and a higher rate of failure are seen - in the first 6 months. POST-PROSTHETIC IMAGING
  • 66. • R/g-- loss of integration is indicated as a radiolucent line around the implant. 1. false-negative dx- when the soft tissue surrounding an implant is not wide enough to overcome the resolution of the radiographic modality used. 2. false-positive dx- when a “Mach band effect” results from an area of lower radiographic density adjacent to an area of high density (implant), which results in a more radiolucent area than is actually present. Digital radiography has the advantage of “edge enhancement (ability to detect space between the implant and the surrounding bone).” EVALUATION OF ALVEOLAR BONE CHANGES
  • 67. PERIAPICAL RADIOGRAPHS • In recall IOPA’s the marginal bone level is compared with the immediate post-prosthetic r/g. Alveolar bone level evaluation. A- Ideal positioning showing ideal thread orientation. B, Improper angulation showing diffuse thread orientation. If the implant threads are not clearly seen in the r/g’s Modify the beam angle If diffuse threads are present on the right side of the implant beam angle was positioned too much in the superior direction. If the threads are diffuse on the left side then the beam angle was from an inferior angulation
  • 68. BITEWING RADIOGRAPHS • In cases where the x-ray source cannot be positioned perpendicular to the implant because of oral anatomy or existing prosthesis, horizontal or vertical bitewings are taken to evaluate the crestal bone area. • Limitation  apical portion cannot be seen.  2 r/g’s taken at different times superimposed on one another gives an image that exhibits the differences in the bone level.  ***requires same positioning and imaging technique between the two radiographs with respect to the x-ray source, patient and film position, exposure, and processing variables. DIGITAL SUBTRACTION RADIOGRAPHY
  • 69. PANORAMIC RADIOGRAPHS • The images are substracted and the resultant image left depicts the osseous changes between the r/g’s. • More accurate  accessing bone mineralization and volume changes  Not used routinely for evaluation of osseous bone levels and recall as they use intensifying screens poor resolution.  Technique of choice- when multiple implants need to be evaluated.
  • 70. COMPUTED TOMOGRAPHY • D/A of 2-D r/g’s do not give buccolingual condition of alveolar bone. • CT gives 3-D information about the osseous status around an implant. • Adv  bone density evaluation using Hounsfield unit that helps determine bone maturation. • D/A Resolution and scattering overcome with cone beam technology. • Image of choice for evaluation of sinus infection/ postsurgical sinusitis complications
  • 71. FABRICATION OF DIAGNOSTIC TEMPLATES • The purpose  to incorporate the proposed treatment plan into the radiographic examination. • Steps:-mounted diagnostic casts a diagnostic wax-up template fabrication. • The pre-prosthetic imaging enables evaluation of the proposed implant site at the ideal position and orientation.
  • 72. COMPUTED TOMOGRAPHY TEMPLATE • Designs for diagnostic CT templates have evolved from one produced from a processed acrylic reproduction of the diagnostic wax-up
  • 73. • The acrylic template is modified by coating the proposed restorations with a thin film of barium sulfate and filling a hole drilled through the occlusal surface of the restoration with gutta-percha seen as radiopaque in the CT examination. A - A vacuum-formed imaging stent with a metal rod to indicate desired axis of insertion. B - A processed stent with metal cylinders marking the implant sites. This can also be used as a surgical stent by inserting the guide bur through the cylinders. C - A processed stent with insertion axis markers, along with a radiopaque strip outlining the buccal and lingual contours of the planned restoration. The stent provides an image of the emergence profile of the restored implant and can also be used as a surgical guide.
  • 74. • Radiopaque teeth designed for the fabrication of diagnostic templates for fixed and removable implant-supported restorations have been introduced. • Advantages – • The diagnostic template then can be modified into a surgical template • Time saving • Easily placed • Provide high radiopacity • Bond easily with the template. Dov , Almog, Romano PR. CT-Based Dental Imaging for Implant Planning and Surgical Guidance A CASE REPORT. New York state dental journal. 2007
  • 75. TOMOGRAPHY TEMPLATE • The simplest tomography template is obtained by a vacuform of the patient’s diagnostic cast with 3-mm ball bearings. • A number of tomograms of the implant region are produced with the implant site identified by the one in which the ball bearing is in sharp focus. • It can also serve as a measure of the magnification of the imaging system.
  • 76. RADIOGRAPHIC SIGNS ASSOCIATED WITH FAILING ENDOSSEOUS IMPLANTS Radiographic appearance Clinical implications Thin radiolucent area that closely follows the entire outline Failure of implant to integrate with adjoining bone. Radiolucent area around coronal portion Peri-implantitis resulting from poor plaque control, adverse loading or both Apical migration of alveolar bone one side of implant Non axial loading resulting from improper angulation of implant Widening of periodontal space of the nearest natural abutment Poor stress distribution Fracture of fixature Unfavorable stress distribution during function
  • 79. TUNED APERTURE COMPUTED TOMOGRAPHY (TACT) • In this technique image is produced by passing a radiographic beam through an object several different angles. • Advantages :  it can accommodate patient movement during firing with affecting the quality of the image produced with reduced radiation dose.  Localization of bone disease, anatomical structures and abnormalities at implant site is much easier with TACT.
  • 80. • A modification of the panoramic x-ray machine for making cross-sectional images of the jaws. • The tomographic layer is approx. 5mm. • For appreciation of spatial relationship between the critical structures and the implant site. • Limitations : Tomographic layers are relatively thick. Adjacent structures blurring and superimposed. Not useful for determining the differences in bone density or for identifying disease at implant site. ZONOGRAPHY
  • 81.
  • 82. • Provides programmed reformation, organization and display of the imaging study. • The curvature of the mandibular or maxillary arch is selected, & the computer is programmed to generate referenced cross-sectional and tangential/panoramic images of the alveolus along with 3-D images of the arch. Axial CT view of the mandible showing the potential crosssectional slices that can be reformatted by Dentascan. Limitations:- 1. not true size images and requires compensation for magnification 2. Determination of bone quality requires workstation 3. Hard-copy only include a limited range of the diagnostic grayscale 4. Tilt of the patient’s head during the examination, which is critical because all the cross- sectional images are perpendicular to the axial imaging plane. DENTASCAN
  • 83. SIMPLANTS • It is an interactive dental implant software package. • It allows dentists to view and manipulate processed CT images. • Simplant software can be used to superimpose images of actual size implants on the CT images for treatment planning.
  • 84. • Radiographs play an important part in the successful planning and execution of implant treatment. • They are an important part of the patients records and as such constitute a significant proportion of the medico-legal documentation of the patient. • It is important to have an understanding of the different techniques available and their appropriate application. • It is the responsibility of the clinician to ensure that radiographs are appropriate, readable and are retained and repeated at accepted intervals throughout treatment and follow-up. CONCLUSION
  • 85. 1. Contemporary Implant Dentistry. Carl E. Misch – 3rd Edition 2. Caranza's Clinical Periodontology - 11th Edition 3. Swati S Bhosale, P Balaji Raman and Joshua Mall. Guided implant placement in the edentulous mandible: A novel approach. Journal of ICDRO 2010; Vol 2 (1): Page 30 – 34. 4. Lingeshwar D, Dhanasekar B, Aparna IN. Diagnostic Imaging in Implant Dentistry. International Journal of Oral Implantology and Clinical Research, September-December 2010;1(3):147-153 5. Bart Vandenberghe Reinhilde Jacobs Hilde Bosmans, Modern dental imaging: A review of the current technology and clinical applications in dental practice. Eur Radiol 2010 20: 2637-2655 REFERENCES

Editor's Notes

  1. GOALS OF DIAGNOSTIC IMAGING – MAXIMISE DIAGNOSTIC EFFICIENY and MINIMISE RADIATION RISK D1 – DENSE CORTICAL D2 – POROUS CORTICAL AND COARSE TRABECULAR D3 – POROUS CORTICAL AND FINE TRABECULAR D4- FINE TRABECULAR End -- Only the technical skill don’t suffice , Radiologists – lab technicians - implantologists
  2. Often, combinations of various modalities are used because no single modality can provide all information for evaluation of the implant patient Multiple factors influence the selection of radiographic technique(s) for a particular case, including cost, availability, radiation exposure and case type The decision is a balance between these factors and the desire to minimize risk of complications to the patient
  3. After the decision to obtain images has been made, the imaging modality is used that yields the necessary diagnostic information related to the patients clinical needs and results in the least radiological risk
  4. Planar – lying in a plane Quasi 3D: produce number of closely spaced tomographic images & 3D perspective of patients anatomy is developed by viewing each image and mentally filling in the gaps 3d: quantitatively accurate, 3d models of the patients anatomy can be derived from the image data and used to produce stereotactic surgical guides and prosthetic frameworks
  5. Image quality is characterize by : Analog imaging: Resolution/ modulation transfer function, contrast/H and curve, noise/Weiner spectrum and sensitivity. Digital imaging : width and height of its pixels. Digital 3-D imaging: width, height depth & thickness of pixels. 3D modality: intensity scale of 12 bits or 4096 values
  6. ALARA is a safety principle designed to minimize radiation doses and releases of radioactive materials. 1. TIME—Minimize the time of exposure. 2. DISTANCE—Double the distance between your body and the radiation source; this reduces the radiation exposure by a factor of 4. 3. SHIELDING—Use absorber materials such as Plexiglas® for beta particles and lead for X-rays and gamma rays. Pregnant workers should avoid exposure exceeding ~ 55 millirem during any one month, and large doses between the 8th and 15th weeks of pregnancy
  7. By placing the film intraorally parallel to the body of the maxillary or mandibular alveolus. The central ray of the x-ray device - perpendicular to the alveolus at the site . Produces a lateral view of the alveolus, no cross-sectional information May suffer from distortion & magnification Are two-dimensional representations of three-dimensional objects and do not provide any information of the buccal-lingual dimension of the alveolar ridge Images of alimited region of the mandibular or maxillary alveolus Most accurate: paralleling technique
  8. Prichards criteria : established 4 criteria to determine the adequate angulation of periapical rg. The radiograph should show tips of molar cusps with little or none of occlusal surface showing Enamel caps and pulp chambers should be distinct Interproximal spaces should be open Proximal contacts should not overlap unless teeth are out of line anatomicallu
  9. Start : Paralleing - The film, long axis of tooth, and x-ray source are all parallel, with the path the x-rays being perpendicular to all three. Bisecting - An imaginary line is visualized that splits the distance between the film and the long-axis of the tooth. The x-ray head is then moved to be parallel to this imaginary line
  10. 1st - (a smaller focal spot increases the sharpness of the image) this is controlled by the manufacturer. Don’t say – To reduce radiation Stand at least 6 feet away from the unit and/or stand behind a lead shield Stand at 90-135 degrees from the path of the x-rays Controlling image quality – kilovolatage kVp is increased only to accomodate a denser object to pass through, such as a thick mandible. kVp range for dentistry is 65-100 kVp. Milliamperes Affects the intensity of the x-ray. mA range for dentistry is 7-15 mA. Exposure time - refers to how long x-rays are produced or how long the patient is exposed to them. Exposure is often controlled by impulses, with there being 60 impulses in 1 sec.
  11. Diag— The initial radiograph (left) indicated that a metal foreign object was embedded somewhere in or near the teeth, but upon clinical examination, it could not be found anywhere in the gum tissue. Upon taking another radiograph (right) exposed at a very severe distal angulation, however, the metal fragment appeared to move a great deal to superimpose on the facial aspect of the premolar, indicating that the fragment was way more buccal than initially suspected. With the use of this second film, it was determined that the metal fragment was indeed embedded in the cheek.
  12. Start – Digital radiology is an imaging process wherein the film is replaced by a sensor that collects the data Makes positionig of sensor difficult near tori or tapered arch. (commonly used)- CCD
  13. 2nd point -- Critical structures such as the maxillary sinus, nasal cavity, and nasal palatine canal are demonstrated, but the spatial relationship to the implant site is lost.
  14. Start - Oriented planar r/g’s of the skull.
  15. Start -- This is probably the most used diagnostic modality in implant dentistry For quantitative presurgical implant imaging panoramic radiography is not the most diagnostic
  16. The dimensions of inclined structures in panoramic radiographs are not reliable. Studies on panoramic x-ray units have demonstrated that objects in front of and behind the focal trough are blurred, magnified, reduced in size, or distorted to the extent of being unrecognizable.
  17. If say – More magnified if.  object-film distance increases and  object x-ray source distance decreases.
  18. Check out this table..??
  19. After Greek word --  Adopted in 1962 by the International Commission on Radiological Units and Measurements. End- Different tomographic sections are produced by adjusting the position of the fulcrum or the position of the patient relative to the fulcrum in fixed geometry systems Structures that are in the plane (focal area) of rotation are depicted in sharp focus, while structures outside the plane of rotation are blurred.
  20. Start - Is a digital and mathematical imaging technique that creates tomographic sections where the tomographic layer is not contaminated by blurred structures from adjacent anatomy. 2nd – Can view hard and soft tissues on an image without performing an invasive procedure on a patient such as injection of contrast media
  21. Anounced to imaging world in 1972
  22. CT:_ It enables the evaluation of proposed implant sites and provides diagnostic information that other imaging or combinations of imaging techniques cannot provide. Access to this diagnostic information required a radiologist to communicate with the referring doctors in detail about prospective surgery and then to sit at the imaging computer or a workstation for a considerable length of time to reformat the study, interpret the resulting images. The advantages of this type of imaging were evident and the limitations of delivery clear, which spawned the development of a number of techniques referred to generically as DentaScan imaging.
  23. The positioning of patients is similar to medical scans. The advantages of CT images are numerous, with the magnifi cation being almost 0% with no superimposition or overlapping of images and minimal distortion. The density of bone may also be assessed with all images being displayed as Hounsfi eld units. When comparing CT with other types of radiographic modalities, CT has been shown to be superior in identifi cation of vital structures and calculation of distance measurements76
  24. The image information of these sequential axial images can be postprocessed to produce multi twodimensional images in various planes, using a computerbasedprocesscalledmultiplanarreformatting(MPR)
  25. Orthogonal slicing – view from all different planes 1. Upper left – axial orientation (viewing from bottom to top , top to bottom) 2.Lower left – coronal orientation ( viewing back to front and front to back) 3.Lower right – saiggital view (allows us to move right to left and left to right) 4.Upper right – 3D rendering (rotated in any direction)
  26. 2. Curved slicing tool option. Helps to visualize at any point of the panoramic curve . Lower right – trans axial cross sectional view. 3. To do linear measurements . Click and move to the slice where we would like to take the measurements . BOTH LENGTH AND WIDTH CAN BE MEASURED. AS MANY MEASUREMENTS ASS POSSIBLE Oblique slicing tab – allows to tilt and rotate slice planes , isolate and examine 360 degrees around a region of intrest. Helps to evaluate the placement of implant in the bone, lesion examinations, root canals,
  27. Metal restorations will not produce scattering and thus will appear as black images. Therefore MRI has been shown to be less prone to artifacts from dental restorations, prostheses, and dental implants than CT scans.
  28. Failure to differentiate the inferior alveolar canal may be caused by osteoporotic trabecular bone and poorly corticated inferior alveolar canal. MRI visualizes the fat in trabec ular bone and differentiates the inferior alveolar canal and neurovascular bundle from the adjacent trabecular bone
  29. Maxillary sinus (floor and anterior wall) Nasal cavity (floor and lateral wall) Incisive foramen Canine fossa
  30. Periapical and panoramic images are still used routinely as the sole determinate of osseous measurements with respect to these vital structures. Inferior alveolar canal and mental foramina Studies have shown that tilting the patient’s head approximately 5 degrees downward in reference to the Frankfort horizontal plane allows these anatomical structures to be seen in 91% of radiographs.(Dharmar S)
  31. Overestimation of the amount of bone may lead to perforation of the lingual plate when drilling the osteotomy. In a 2d radiograph it may show as adequate bone and this will be misleading Study by Quirynen showed a 2.4% prevalence of concavities with average depth of 6mm(±2.6mm) 3D view showing significant sublingual undercut---diag
  32. The more prominent the external oblique ridge, the better candidate for the ramus as a donor site
  33. CT gold standard for viewing the osseous structures and evaluating pathology in the sinuses.
  34. With digital radiography technology, instantaneous images are achieved, allowing for multiple images to be completed in a fraction of the time
  35. There exists no conclusive scientifi c evidence that lowlevel ionizing radiation has a detrimental effect on bone metabolism and healing.
  36. After 2 points : Mach band effect can be reduced with digital image processing. Mach Bands is an optical illusion. It exaggerates the contrast between the edges of the slightly differing shades of gray, as soon as they contact one another Proper positioning along with documentation of kVp and mA settings should be documented for future reference.
  37. Therefore radiographs similar in geometry, density, and contrast are paramount. To ensure accuracy, standardized periapical radiographs are essential. However, reproducing positioning is very difficult. Numerous film- holding devices have been documented that attach to the implant, abutment, or prosthesis to standardize image geometry.109 Computer-assisted measurements, rulers, calipers, and suprabony thread evaluation have been shown to have highly reproducible results in digital radiography
  38. The only limitation of bitewing radiographs is that the apical portion cannot be seen. Conventional radiographs are of limited value if minimal alveolar bone changes occur; therefore techniques have been developed to standardize the projection geometry of radiographs for evaluation.
  39. CT can be of great benefit in the evaluation of sinus augmentation graft prognosis. . Also,
  40. The pre-prosthetic imaging enables evaluation of the proposed implant site at the ideal position and orientation (identified by the radiographic markers into the template)
  41. Although CT can identify the available bone height and width accurately for a dental implant at a proposed implant site, the exact position and orientation of the implant, which many times determine the actual length and diameter of the implant, often are dictated by the prosthesis. As such, a diagnostic template used during imaging is most benefi cial. The surfaces of the proposed restorations and the exact position and orientation of each dental implant should be incorporated into the diagnostic CT template.
  42. The vacuform template has a number of variations. Another design involves coating the proposed restorations with a thin film of barium sulfate. Although the proposed restoration becomes evident in the CT examination, the ideal position and orientation of the proposed implant is not identified by this design. Another design involves filling the proposed restoration sites in the vacuform of the diagnostic wax-up with a blend of 10% barium sulfate and 90% cold-cure acrylic. This results in a radiopaque tooth appearance of the proposed restorations in the CT examination, which matches the density of enamel and dentin of natural teeth but does not identify the exact position and orientation of the proposed implant sites. The next design modifies the previous design by drilling a 2-mm hole through the occlusal surface of the proposed restoration at the ideal position and orientation of the proposed implant site with a twist drill. This procedure results in a natural toothlike appearance to the proposed restoration in the CT examination in which all the surfaces of the restoration are evident along with a 2mm radiolucent channel through the restoration, which precisely identifies the position and orientation of the proposed implant.
  43. The diagnostic template used in CT examinations, which is produced from a vacuform of the patient’s diagnostic cast with barium coating of the proposed restoration and orthodontic wires to indicate the position and orientation of the proposed implant, also can be used for tomography and provides the most diagnostic information of the templates described.
  44. stereolithography
  45. Start -- Dentascan is a specialized CT scan of the mandible or maxilla often done before placement of dental implant. Dentascan helps the dental surgeon to evaluate the dimensions of the jaw bone and assess the quality of the jaw bone for optimal results of placement of dental implant. not true size images and requires compensation for magnification Determination of bone quality requires use of the imaging computer or workstation Hard-copy only include a limited range of the diagnostic grayscale of the study Tilt of the patient’s head during the examination, which is critical because all the cross-sectional images are perpendicular to the axial imaging plane.
  46. The rad is a deprecated unit of absorbed radiation dose, defined as 1 rad = 0.01 Gy = 0.01 J/kg.[