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Imaging in Dental Implantology: A

Review
IOSR JDMS

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IOSR Journal of Dental and Medical Sciences (IOSR-JDMS)
e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 17, Issue 7 Ver. 1 (July. 2018), PP 13-23
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Imaging in Dental Implantology: A Review

Dr. Sourabh Sharma1, Dr. Vivek Sharma2, Dr. Meenakshi Khandelwal3,
Dr. Vikas Punia4, Dr. Saransh Malot5, Dr. Anand Porwal6.
1
(Department of Prosthodontics, Darshan Dental College and Hospital, Udaipur, rajasthan, India)
2
(Department of Prosthodontics, Darshan Dental College and Hospital, Udaipur, rajasthan,India)
3
(Department of Prosthodontics, Darshan Dental College and Hospital, Udaipur, rajasthan,India)
4
(Department of Prosthodontics, Darshan Dental College and Hospital, Udaipur, rajasthan,India)
5
(Department of Prosthodontics, Darshan Dental College and Hospital, Udaipur, rajasthan,India)
6
(Department of Prosthodontics, Darshan Dental College and Hospital, Udaipur, rajasthan,India)
Corresponding Author: Dr. Sourabh Sharma

Abstract: Dental radiology have completely revolutionized the field of dentistry. For successful implant
treatment, a presurgical treatment planning is most important. For this, diagnostic imaging plays a vital role.
There are various imaging modalities available to aid in placing the implant in an appropriate location with
relative ease and also get a predictable outcome. The various modalities described are intraoral radiography,
cephalometric radiography, panoramic radiography, conventional tomography, computed tomography, cone-
beam CT and magnetic resonance imaging. The choice of which imaging modality to use along with when to
image, is dependent on a number of factors including determination of quality and quantity of bone to establish
the most favorable position of implant placement, detection of anomalies or pathological lesions if present and
availability at a reasonable cost to patient. In addition, patients exposure to radiation dose as low as
possible should always be in priority during radiographic examinations. This article reviews the various
imaging modalities available currently and their clinical applications for sussesful implant placement.
Keywords: Computed Tomography, Cone Beam Computed Tomography, Digital Radiography, Lateral
Cephalometric Radiographs, Magnetic Resonance imaging, Panoramic Radiography.
----------------------------------------------------------------------------------------------------------------------------- ----------
Date of Submission: 20-06-2018 Date Of Acceptance: 04-07-2018
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I. Introduction
Dental implants provide completely and partially edentulous patients the function and esthetics they
had with natural dentition. It enables patients to regain normal masticatory function, esthetics, speech, smile and
deglutition.1
Imaging objectives are to provide the clinician with cross-sectional views of the dental arch for
accurate visualization of spatial relationship of internal structures of the maxilla and mandible. Imaging studies
should help to determine the optimum position of implant placement relative to occlusal loads.2Various
imaging techniques have been used to evaluate bone quality, quantity and anatomic structures in relation to
proposed implant sites.
Until late 1980s, conventional radiographic techniques such as intraoral, cephalometric and panoramic
views had been the accepted standard. Since then, developments in cross-sectional imaging techniques, such as
spiral tomography and reformatted computerized tomograms, have become increasingly popular in preoperative
assessment and planning of implant patients. The advent and acceptance of 3-dimensional computed
tomography (CT) and newer-generation lower-dose cone beam CT scan devices (CBCT) in combination with
interactive treatment planning software provides the clinicians with the ability to truly appreciate each patient‟s
anatomic reality.
Imaging options currently available includes intra-oral radiography, conventional extra-oral
radiography, tomography, computed tomography (CT), cone beam computed tomography (CBCT), cone beam
volumetric tomography (CBVT) and magnetic resonance imaging (MRI). 3
When planning for dental implants and especially when guided surgical applications are considered, it
is essential that the true 3-dimensional anatomic presentation is understood and that all adjacent vital structures
be accurately visualized.4This article is a compilation of various imaging modalities that are used for dental
implant assessment in different stages of implant treatment and their application as well as diagnostic
contribution to presurgical evaluation, treatment planning and post-operative assessment of dental implants.

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 Imaging In Dental Implantology: A Review

II. Various Imaging Modalities

Imaging techniques provides the most accurate means by which the clinician can assess the morphologic
features of proposed fixture site and evaluate the fixture in time after implantation.Several imaging techniques
are currently available for pre-surgical and post-surgical examinations. These include both intraoral and extra-
oral plain film and digital radiography. „

2.1 Role of imaging in site assessment and treatment planning:

Imaging studies can include basic plain radiography as well as advanced studies such as computed
tomography (CT) and reformatted cross-sectional, panoramic and 3D imaging.5 The mandibular canal, mental
foramen are readily identified on panoramic and cross-sectional images, while the incisive canal is usually
identifiable on cross-sectional images distal to the level of the mental foramen.6 The mental foramen,
mylohyoid ridge and genial tubercle are identifiable on 3D images, on panoramic and cross-sectional
reformatted images and on direct axial CT sections.
Another important aspect of radiologic evaluation should be a qualitative description of bone in a
given area. Although there is no universally accepted system for classifying bone quality in maxilla and
mandible, we routinely use the Misch system in evaluating cross-sectional reformatted images. The Misch
system is widely divides bone into four subdivisions (D-1 to D-4) based on observed density.7
1. D-1 bone - characterized by thick, dense cortices surrounding densely calcified spongy bone, with little or
no porosity; normally found in atrophic anterior mandibles.
2. D-2 bone - characterized by dense cortical plates; thick, coarse trabeculae; and small areolar spaces;
normally found in the anterior maxilla and mandible and in the posterior mandible.
3. D-3 bone has thin cortical bone and poorly mineralized or thin trabeculae; found in anterior and posterior
maxilla, in posterior mandible, and after osteoplasty of D-2 bone.
4. D-4 bone is characterized by thin or absent cortical plates with a paucity of mineralized trabeculae; often
found in posterior maxilla or in post-osteoplasty D-3 bone.
Implants placed in either D-1 or D-2 bone stand an excellent chance of undergoing osseointegration, while
implants placed in D-3 or D-4 bone either undergo fibro integration or fail to integrate at all.8

2.2 2-Dimensional Imaging Modalities -

Many imaging modalities have been reported as useful for dental implant imaging. These modalities can be
described as analog or digital and two or three dimensional imaging. Most dentists are more familiar with
analog two dimensional imaging.9 Types of two dimensional imaging modalities are as follows:

2.2.1Periapical Radiography
Periapical radiography describes intraoral techniques designed to show individual teeth, implants and the tissues
around the apices. Each film usually shows two to four teeth and provides detailed information about the teeth
and surrounding alveolar bone.
Radiographic techniques:-
Two techniques for periapical radiography have been developed:
(i) Paralleling technique
1. The film packet is placed in a holder and positioned in mouth parallel to the long axis of implant under
investigation.
2. The X-ray tubehead is then aimed at right angles (vertically and horizontally) to both the implant and
the film packet.
3. By using a film holder with fixed film packet and X-ray tubehead positions, the technique is
reproducible.
This positioning has the potential to satisfy most of the ideal requirements. However, the anatomy of palate and
the shape of arches mean that the implant and the film packet cannot be both parallel and in contact. So, to
prevent the magnification and distortion of the image, a large focal spot to skin distance can be achieved, by
having a long spacer cone or beam-indicating device (BID) on the X-ray set. When x-ray is perpendicular to
film but not to object, foreshortening will occur.9
(ii) Bisected angle technique
1. The film packet is placed as close to object under investigation as possible without bending the packet.
2. The angle formed between the long axis of object and long axis of the film packet is assessed and
mentally bisected.
3. The X-ray tubehead is positioned at right angles to this bisecting line with the central ray of the X-ray
beam aimed through the tooth apex.
4. Using the geometrical principle of similar triangles, the actual length of the object in mouth will be
equal to the length of the object‟s image on the film.10

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 Imaging In Dental Implantology: A Review

In terms of the objectives of presurgical imaging, periapical radiography is:

1. A useful high yield modality for ruling out local bone disease.
2. For visualization that is limited to mesiodistal and apicocoronal directions, and does not depict the
third dimension of bone width.
3. Of limited value in determining bone density or mineralization.
4. Value in identifying critical structures but of little use in depicting spatial relationship between the
structures and the proposed implant site.

2.2.2 Digital radiography

Digital radiology is an imaging process wherein the film is replaced by a sensor that collects the data.
The analog information received is then interpreted by specialized software and an image is formulated on a
computer monitor (Fig. 1). The resultant image can be modified in various ways, such as gray scale, brightness,
contrast, and inversion. Computerized software programs (i.e., Dexis Implant) are now available that allow for
calibration of magnified images.
The most current digital systems have significantly less radiation with superior resolution. The most
significant advantage of digital radiography is the instantaneous speed in which images are formed, which is
highly useful during surgical placement of implants and the prosthetic verification of component
placement.These images can be manipulated, enhanced, stored and exchanged for referral and other
purposes.11The only disadvantage is size and thickness of sensor that makes positioning of sensor difficult in
some sites.

Fig. 1- Digital radiographic system includes digital sensor and computer.

1.2.3 Occlusal Radiography

Occlusal radiographs are planar radiographs produced by placing the film intra-orally parallel to the
occlusal plane with central x-ray beam perpendicular to the film for mandibular image and oblique (usually 45°)
to the film for maxillary image. Occlusal radiography produces high-resolution planar images of jaw bones.12
Maxillary occlusal radiographs are inherently 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. In addition,
critical structures such as the maxillary sinus, nasal cavity, and nasal palatine canal are demonstrated, but the
spatial relationship to the implant site generally is lost with this projection.

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 Imaging In Dental Implantology: A Review

Fig. 2- (A) Occlusal radiographs showing the width of bone in the anterior region. (B) Occlusal radiographs
actually showing the widest buccolingual distance (red arrows) not in the same plane. Actual width of
bone (green arrow).

As the mandibular occlusal radiograph is an orthogonal projection, it is a less distorted projection than
the maxillary occlusal radiograph. However, the mandibular alveolus generally flares anteriorly and
demonstrates a lingual inclination posteriorly, producing an oblique and distorted image of the mandibular
alveolus, which is of little use in implant dentistry. In addition, the mandibular occlusal radiograph shows the
widest width of bone (i.e., the symphysis) versus the width at the crest, which is where diagnostic information is
needed most (Fig. 2).13 The degree of mineralization of trabecular bone is not determined from this projection,
and the spatial relationship between critical structures, such as the mandibular canal and the mental foramen,
and the proposed implant site is lost with this projection. Therefore, occlusal radiographs rarely are indicated for
diagnostic presurgical phases in implant dentistry.12

2.2.4Cephalometric Radiography
The skull is oriented to the x-ray device and the image receptor using a cephalometer, which physically
fixes the position of skull with projections into the external auditory canal. The geometry of cephalometric
imaging devices results in a 10% magnification of the image with a 60-inch focal object and a 6-inch object-to-
film distance.11
A lateral cephalometric radiograph is produced with the patient‟s midsagittal plane oriented parallel to
the image receptor. The cross-sectional view of the alveolus demonstrates the spatial relationship between
occlusion and esthetics with the length, width, angulation and geometry of alveolus and is more accurate for
bone quantity determinations. The width of bone in the symphysis region and the relationship between the
buccal cortex and the roots of anterior teeth also may be determined before this bone is harvested for ridge
augmentation (Fig. 3).14 The lateral cephalometric view also can help evaluate a loss of vertical dimension,
skeletal arch relationship, anterior crown-to-implant ratio, soft tissue profile, anterior tooth position in the
prosthesis, and resultant moment of forces. However, this technique is not useful for demonstrating bone
quality.

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 Imaging In Dental Implantology: A Review

Fig. 3-A limited projection of mandibular symphysis region is useful for preoperative evaluation of the width of
the bone in the midsymphysis.

2.2.5 Panoramic Radiography

Panoramic radiography is often the first choice method for the placement of implants because it
provides information on the overall shape of the jaws, the position of maxillary sinus floor and the nasal cavity
floor and the proximal distal as well as vertical position of mandibular canal and the mental foramen. It also
provides information on the presence or absence of dental caries, tooth fractures, infections, residual dental
roots or lesions in dental root apex or within the bone, the interval between remaining teeth, etc.15Moreover,
situations of bone resorption as well as radicular cysts, tumors, inflammation, post-accident fractures, temporo-
mandibular joint disorders, and sinusitis can be identified. In addition, the patient is exposed to a low dose of
radiation.
Panoramic radiography does not demonstrate bone quality or mineralization and is misleading
quantitatively because of magnification. Because the third-dimension cross-sectional view is not demonstrated,
the relationship between the vital structures and dimensional quantization of the implant site is not easily
depicted.16

2.3 3-DIMENSIONAL IMAGING MODALITIES

Three dimensional imaging techniques are quantitatively accurate and three dimensional models of the patient‟s
anatomy can be derived from the image data and used to produce stereotactic guides and prosthetic frameworks.
3D imaging techniques include:

2.3.1 Conventional Tomography

The basic principle of tomography is that 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 the section of interest, or the tomographic layer. 17
Mainly, two types of tomographic movements are known: linear and multidirectional. The latter
comprises four motions: Circular, spiral, elliptic and hypocyclocidal are tube motions employed in complex
tomography.18 In contrast to spiral and hypocycloid tomography, which have a constant magnification factor,
linear tomography may have a non uniform magnification. Generally, the 3-dimensional dataset consists of 4
basic views: (1) the axial, (2) the cross-sections, (3) the panoramic reconstructed view and the 3-dimensional
reconstructed volume. Each of these views is important, as no one view alone should determine the ultimate
desired treatment.19
The cross-sectional view is important to help determine the quality of bone, the thickness of cortical
plates, sinus pathology, periapical pathology, the trajectory of tooth within the alveolus and can aid clinicians in
determining the topography of alveolus, root morphology and extent of any facial/buccal concavities (Fig. 4-
A).20

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 Imaging In Dental Implantology: A Review

Fig. 4- (A) The cross-sectional image can aid clinicians in determining the topography of the alveolus, root
morphology, and the extent of any facial/buccal concavities (red arrow).(B) In the posterior maxilla, the facial-
palatal dimensions of the maxillary sinus can be fully appreciated as well as any sinus pathology or thickening
of the Schneiderian membrane (red arrow) and the presence of intraosseous vessels (yellow arrow).

The posterior maxillary arch is another region in which cross-sectional imaging can provide anatomic
details not visualized by any other means. The facial-palatal dimensions of the maxillary sinus can be fully
appreciated as well (Fig. 4-B).Conventional tomography has certain limitations like overlapping of the shadows
of tissues, less shades of gray and less resolution.

2.3.2 Computed Tomography

CT was invented by Housefield and the first CT scanners appeared in medical imaging departments
during the mid 1970s and replaced complex tomography by the early 1980s. 21CT is a digital medical technique,
which can generate 3D images allowing the clinicians to visualize the bony architecture, nerves, joints, sinuses
and other structures much more completely than traditional flat radiographs. 22 The newer generation of CT
scans provides images of a combination of soft-tissues, bone and blood vessels.23
In dental implantology, computer programs are used to rearrange the data and reformat the series of
axial images into oblique images along the curvature of bone of the alveolar ridges.24 Used in critical anatomic
situations and for placing the implant in an ideal position in bone, CT scanning software eliminates possible
manual placement errors and matches planning to prosthetic requirements. 25The CAD/CAM techniques can be
used for single tooth edentulous spaces, single tooth immediate extraction cases, partially edentulous spaces,
fully edentulous maxillary and mandibular overdenture cases or fully edentulous maxillary or mandibular full
arch permanent restorations.26Dentascan is a computed tomography (CT) software program introduced in mid-
1980s that allows imaging in three planes: axial, panoramic and cross-sectional.27It has been widely used pre-
operatively for implant surgery as it provides a comprehensive assessment of bone morphology and
measurement of dental implant (Fig. 5-A,B).

Fig. 5- (A) Panoramic section in dentascan locating position of inferior alveolar canal. (B) Panoramic view in
dentascan demonstrating maxillary sinus.

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 Imaging In Dental Implantology: A Review

Types of CT scanners
A. Cone Beam Computed Tomography
The Cone Beam CT Scan (CBCT) was introduced in 1998. CBCT provides 3-dimensional images of jawbones,
teeth and surrounding vital structures that are important in planning the placement of dental implants. There are
five major benefits of cone beam CT scan (CBCT) for dental implant planning and placement:
(i) Precision placement of implants in bone: CBCT along with 3-D software allows to accurately measure
and localize the available bone. (Fig. 6).28

Fig. 6- Precision placement of implants in the bone using CBCT.

(ii) Proper orientation of implant with its overlying restoration: A CBCT is merged with an optical scan of
the patient‟s teeth (digital impression) to create a complete bone, teeth and soft tissue virtual model. Then,
dentist design the perfect bite and precise position of the implants to support the planned restorations.
(iii) Prevention of nerve injury: Using CBCT, the surgeon maps out the path of the sensory nerves in
jawbone and selects the right implant length.29
(iv) Prevent implant penetration into the sinus: CBCT provides an accurate picture of the maxillary sinus
and its position in relation to available bone. The surgeon can make an accurate measurement and select the
right implant length to avoid puncturing the maxillary sinus.
(v) Selection of right size implant for optimal support: CBCT allows the surgeon to measure the available
bone and select the widest and tallest implant appropriate for the site. This, in turn, helps in implant selection
based on precise measurements, biological requirements, bite scheme and individual patient needs. 30
B. Cone Beam Volumetric Imaging
Since its introduction in 2001, Cone Beam Volumetric Imaging (CBVI), sometimes called Cone Beam
Volumetric Tomography (CBVT), has rapidly been adopted by dentists and dental radiology laboratory owners.
Image acquisition using CBVI is much different than when a conventional medical Computed Axial
Tomography (CAT) scan is used.31 Medical CT images of a proposed implant site show low image resolution
and the clinician must use a ruler to “count” the millimeters of height and width (Fig 7). In contrast, the CBVI
images show significant improvement in image resolution (Figures 8).

Fig. 7- Medical CT images of a proposed implant site.

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 Imaging In Dental Implantology: A Review

Fig. 8- CBVI images of a proposed implant site.

2.3.3 Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) doesn‟t use ionising radiation. Instead, the patient is placed in a
strong magnetic field and subjected to short pulses of radiowaves. MRI is based on the phenomenon of nuclear
magnetic resonance (NMR).32
For pre-implant assessment, the use of T1- weighted sequences is indicated. In T1-weighted images,
the external cortical plate appears black, unlike the normal radio-opacity due to increased bone density seen on
radiographs. In contrast, the more organic cancellous bone appears very bright in T1-weighted images.33
For pre-implant imaging, Gray CF et al. (1996) suggested an initial triplanar pilotscan in sagittal,
coronal and axial planes, with a low-resolution gradient echo sequence. The sagittal pilot is used to set up a
series of high resolution, fast spin echo axial slices (Fig.9). From these slices, an appropriate slice showing the
markers is selected and set up for a series of cross-sectional high resolution images at right angles to the region
of interest may be made.2

Fig.9- A low resolution gradient echo sagittal pilot scan used to set up the plane for the acquisition of high
resolution axial slices.

2.4 HOW 3D SCAN CAN BECOME A HELP TO SURGERY –

Interactive Computed Tomography
One of the most significant advances in CT is Interactive Computed Tomogrphy (ICT), which
addresses many of the limitations of CT. This technique was developed to bridge the gap in information transfer
between the radiologist and the practitioner. This technique enables the practitioner to view and interact with
the imaging data provided from the radiologist in a DICOM format on a personal computer (Fig. 10).34
A software is used for implant planification and navigation. Through these software dentist can
perform electronic surgery by selecting and placing arbitrary sized cylinders that simulate root form implants in
the images. Electronic implants can be placed at arbitrary positions with respect to each other, the alveolus,
critical structures and the prospective occlusion and esthetics. ICT enables the determination of bone quality
adjacent to the prospective implant sites (Fig. 11,12).35

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 Imaging In Dental Implantology: A Review

Fig. 10- Reformatted computed tomography scan showing the interactive placement of implants in relation to
the diagnostic wax up fabricated radio opaque template.

Figure 11 (A, B) - In areas where there is insufficient available bone such as the maxillary sinus, the amount of
bone grafting needed may be determined. (C) Implant placement in relation to the mandibular canal and mental
foramen; all images are cross referenced with each other. 3D analysis for the evaluation of proximity to vital
structures may be generated from the same computed tomography images.

Fig. 12- (A) Valuable prosthetic information may be obtained from the positioning of the implants on the
interactive computed tomography. (B) Determination of bone density values is calculated inside and outside of
the implant and can be correlated to various densities of bone.

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 Imaging In Dental Implantology: A Review

At present, there are numerous third-party implant planning software programs such as Simplant
(Materialise Dental Inc, Glen Burnie, MD, USA), Invivo5 (Anatomage, San Jose, CA, USA), NobelClinician
(Nobel Biocare, Goteborg, Sweden), OnDemand3D (Cybermed Inc, Seoul, Korea), Virtual Implant Placement
software (BioHorizons, Inc, Birmingham, AL, USA), coDiagnostiX (Dental Wings Inc, Montreal, CA, USA),
and Blue Sky Plan (BlueSkyBio, LLC, Grayslake, IL, USA) among others. 36 There are also a few companies
that provide treatment planning in the proprietary software of the CBCT units such as Galileos system (Sirona
Dental Systems, Inc, Charlotte, NC, USA), TxSTUDIO software (i-CAT, Imaging Sciences International LLC,
Hatfield, PA) and NewTom implant planning software (NewTom, Verona, Italy). After the CBCT data are
acquired, the images are exported into DICOM (Digital Imaging and Communications in Medicine) files, a
standard for the distribution and viewing of medical images regardless of their origin. This format is compatible
with all the third-party software packages listed above; however, an additional file conversion step may be
required in some software packages.
All these dental implant computer guided softwares are similar with minor differences and convert
DICOM data into a file that provides information for pre surgical planning. Meticulous protocol is needed to
computered implant planning which ever software is chosen.

III. Summary & Conclusion

The use of endosteal implants in rehabilitation of dental patients represents one of the most
technologically advanced forms of dentistry available today. For the successful implant placement, accurate and
valid diagnosis is mandatory using various imaging techniques. The two-dimensional modalities are readily
available, cost effective with least radiation exposure, but have limitations of magnifications and
superimpositions and it is not possible for the clinician to develop a 3-dimensional perspective of patient's
anatomy with a single image.
Treatment planning of implant placement often requires accurate cross sectional information that may
be obtained by computerized tomography (CT). Dental imaging have noticeable precision and reliability in pre-
implant planification and surgical help. These technologies supply very accurate and repeatable data in user
friendly and intuitive environment. It enables instant prosthesis loading. These tools are essential in diagnostic
stage as well as surgical act.
Today clinician has wide array of diagnostic tools at his disposal. The clinician has to carefully weight
the pros and cons of each modality and choose particular technique accordingly. The excellent imaging
modalities that exist today can enhance the success of and satisfaction with implant placement. Selection of
projections should be made with consideration to the type and number of implants, location and surrounding
anatomy.

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Dr. Sourabh Sharma "Imaging in Dental Implantology: A Review. "IOSR Journal of Dental
and Medical Sciences (IOSR-JDMS), vol. 17, no. 7, 2018, pp 13-23.

DOI: 10.9790/0853-1707011323 www.iosrjournals.org 23 | Page