Dr.

Nora Saif

Role of Radiography
in Dental Implantology
Dr. Nora Saif
Dr. Nora Saif. FUE. Implantology
“Success of the dental implants depends on meticulous treatment planning which depends
on precision and accuracy of diagnostic information of the patient's anatomy at the
proposed implant site”
Role of Imaging Modalities in Dental Implantology.International Journal of Contemporary Medical Research.2016
Dr. Nora Saif. FUE. Implantology
 Planning of Dental Implants includes:

1. Medical and Dental History

2. Clinical examination
3. Radiographic examination

Dr. Nora Saif. FUE. Implantology

 Radiographic Assessment of Dental
Implants

1. Pre-operative
2. Intra-operative
3. Post-operative

Dr. Nora Saif. FUE. Implantology

 For ALL diagnostic imaging examinations,
The choice of the imaging technique The proposed imaging technique
must be guided by a thorough clinical must maximize diagnostic benefit
examination while minimizing radiation risk
and cost.

To aid in this decision-making process, clinicians must be

familiar with the indications, advantages, and limitations of
imaging techniques used in oral implantology
Dr. Nora Saif. FUE. Implantology
 Commonly Used
Imaging
Techniques for
Implant
Placement
Dr. Nora Saif. FUE. Implantology
 Periapical Imaging
Disadvantages
Advantages
● Restricted
● Readily available
anatomic coverage
● High resolution
● X buccolingual
● Minimal distortion
dimension
● Lowest financial
● Subject to
cost
elongation/foresho
● Lowest radiation
rtening
exposure
● Anatomic
superimposition
● Difficult to
Recommendation reproduce
● Initial assessment of single edentulous space or short
edentulous span
● Intraoperative imaging during implant placement
● Initial postoperative radiograph and recall imaging
Dr. Nora Saif. FUE. Implantology
 Panoramic Imaging
Disadvantages
Advantages
● Image distortion
● Readily available
● Anatomic
● Broad anatomic
superimposition
coverage
+ghost images
● Low financial cost
● Lower resolution
● Low radiation
● X buccolingual
exposure
dimension
● Technique
sensitive

Recommendation
● Initial examination of multiple edentulous spaces
● Radiographic follow-up of multiple implants

Dr. Nora Saif. FUE. Implantology

 CBCT Imaging
Disadvantages
Advantages
● Moderate financial
● Variable field of
cost & radiation
view
exposure
● 3D tomographic
● Beam hardening
imaging:
artifacts
● X superimposition
● Special training for
● Dimensionally
interpretation
accurate
● Simulate implant
surgery with
specialized
software
Recommendation
● Following initial examination, CBCT is recommended for thorough radiologic
assessment

Dr. Nora Saif. FUE. Implantology

 First: Panoramic radiography should be used as the
imaging modality of choice in the initial evaluation of the
dental implant patient.
 Second: Use intraoral periapical radiography to
supplement the preliminary information from panoramic
radiography.
Third: Do not use cross-sectional imaging, including cone
beam computed tomography (CBCT), as an initial
diagnostic imaging examination.
Fourth: CBCT should be considered as the imaging
modality of choice for preoperative cross-sectional
imaging of potential implant sites.
 Fifth: CBCT should be considered when clinical
conditions indicate a need for augmentation procedures or
site development before placement of dental implants
(sinus augmentation, bone grafting, impacted teeth,
traumatic injury.
flat panel
detector
e am
i c alb
con

Cone Beam Volumetric Imaging

CBVI
 FOV
Beam Limitation = Optimum FOV
(field of view)

5x3.8 cm
23x26 cm
Small FOV
Large FOV
FFOV
The volume is acquired then slices are reconstructed from the
volume
Coronal Sagittal

3D
Axial reconstruction
 Voxel
A volumetric pixel

‣ Represents a specific degree

of x-ray absorption
‣ Dimensions = 3D image
resolution
‣ ISOTROPIC
‣Submillimeter resolution
‣(0.4 - 0.076 mm)
 Voxel
Isotropic voxel

perfect
cube

‣0.076 - 0.4 mm
‣Higher spatial resolution
‣Accurate measurements in all dimensions
 MPR
Multiplanar reformatting: creating cuts through a
volumetric data set
 Preoperative
Assessment and
Treatment Planning

Dr. Nora Saif. FUE. Implantology

 CBCT Imaging

CBCT is the imaging modality of choice for the presurgical

assessment of an implant site.
CBCT is also the modality of choice for:

● Preoperative evaluation of the maxillary sinuses prior to sinus floor

elevation
● Assessment of both donor and recipient sites for autogenous bone
grafting procedures

Dr. Nora Saif. FUE. Implantology

 CBCT Imaging

CBCT is the imaging modality of choice for the presurgical

assessment of an implant site.
CBCT is also used in the design and fabrication of surgical guides using
computer aided design and computer-aided manufacturing (CADCAM)
technology.

Dr. Nora Saif. FUE. Implantology

 As with all ionizing radiation imaging
modalities, the use of CBCT should follow
responsible image acquisition protocols.

● Anatomic field of view should be limited to the region of interest.

● The field of view may be extended beyond the edentulous sites to
include relevant adjacent anatomy, such as the maxillary sinus
prior to sinus lifting, the external oblique ridges for bone harvesting,
or the opposing dental crowns for prosthetic planning and surgical
guide fabrication.

Dr. Nora Saif. FUE. Implantology

 Image Reconstruction Techniques
The imaged volume must be reconstructed in specific planes to extract the necessary
information for implant planning.

Due the curvature of the dental arch, the

orthogonal anatomic planes (axial, coronal,
and sagittal) are not optimal for assessing the
mesiodistal and buccolingual dimensions of
available bone.

Therefore curved planar reformatting

is applied.

Dr. Nora Saif. FUE. Implantology

 Image Reconstruction Techniques

First: Selecting a reference axial slice of

the maxillary or mandibular arch, at the
midroot level of its teeth.

Dedicated software tools are used to

define the curve of the dental arch,
tailored to the patient's anatomy

Dr. Nora Saif. FUE. Implantology

 Image Reconstruction Techniques

Second, the software generates

a series of cross-sectional
images oriented perpendicular
to this arch at equally spaced
intervals (typically 1 to 2 mm).

Dr. Nora Saif. FUE. Implantology

Dr. Nora Saif. FUE. Implantology
 Image Reconstruction Techniques

Software tools are used to make

measurements of the vertical
height and buccolingual width of
the edentulous site.

Three-dimensional surface and

volumetric renderings of the
edentulous jaw can be generated to
aid in visualizing the overall shape
and contour of the edentulous jaw

Dr. Nora Saif. FUE. Implantology

 Digital/ Virtual
Implant Planning

Dr. Nora Saif. FUE. Implantology

 Radiologic Assessment of Bone
Quantity

The implant should be

placed at least

- 1.5 mm from the

adjacent teeth
- 3 mm from an
adjacent implant
- 2 mm from vital
anatomic
structures (such as
the inferior alveolar
canal)

Dr. Nora Saif. FUE. Implantology

 Radiologic Assessment of Bone
Quantity

Anterior maxilla:
- Vertical limitation: floor of the
nasal fossa.
- Vertical dimension of available
bone is often limited by residual
ridge atrophy (may lead to a
buccal concavity)

Dr. Nora Saif. FUE. Implantology

 Radiologic Assessment of Bone
Quantity
Anterior maxilla:
Proximity to the nasopalatine canal must be assessed.

There are large morphologic differences in the dimensions and configuration of

the nasopalatine canal; even within the same patient, the diameter of the canal can
vary widely across its length.

Dr. Nora Saif. FUE. Implantology

 Radiologic Assessment of Bone
Quantity

Posterior maxilla:
Vertical limitation: floor of the maxillary sinus

The pneumatization of the alveolar process is a

normal physiologic process that is often
accelerated by tooth loss.

The pattern of pneumatization may be variable

in the transverse dimension, and the exact
position of the sinus floor can be fully
appreciated only with three-dimensional
imaging

Dr. Nora Saif. FUE. Implantology

 Radiologic Assessment of Bone
Quantity
Anterior mandible
(interforaminal region)
Limitation: a narrow buccolingual bone width
secondary to residual ridge atrophy. CBCT can
provide a precise assessment.

Vital structures:

- Lingual vessels (anterior loop of

neurovascular bundle)
- The mandibular incisive canal (the anterior
continuation of the inferior alveolar canal
beyond the mental foramen)
Dr. Nora Saif. FUE. Implantology
 Radiologic Assessment of Bone
Quantity
Posterior mandible
Vertical limitation: inferior alveolar canal

The mandibular cross-sectional morphology usually follows a sigmoid shape in the

buccolingual plane. A concavity is present along the lingual surface of the
mandible (i.e., the submandibular fossa).

CBCT has been shown to be superior to

panoramic images in identifying the
inferior alveolar canal.

Dr. Nora Saif. FUE. Implantology

 Intra-Operative
Imaging

Dr. Nora Saif. FUE. Implantology

 Limited to quick, in-office modalities, including digital-based periapical and
panoramic radiography. These radiographs confirm appropriate pilot drill
position and allow early errors to be identified

Occasionally, surgical accidents may require advanced radiologic imaging in

the intraoperative phase—for example, when an implant is displaced into the
maxillary sinus or placed through the inferior alveolar canal. In such situations,
CBCT imaging will accurately locate the implant.

Dr. Nora Saif. FUE. Implantology

Dr. Nora Saif. FUE. Implantology
Cross-sectional imaging, optimally CBCT, should
be considered if implant retrieval is anticipated.
 Use cross-sectional imaging (particularly CBCT)
immediately postoperatively only if the patient presents
with implant mobility or altered sensation, especially if the
fixture is in the posterior mandible
 Image-Guided
Applications

Dr. Nora Saif. FUE. Implantology

 Several implant planning software programs use CBCT
datasets to determine the optimal three-dimensional
position of a proposed implant.

However, the ultimate success of the procedure depends

on the successful transfer of the virtual plan to the
surgical suite.

Dr. Nora Saif. FUE. Implantology

 guided surgery
Virtual Implant techniques
Surgical Implant
Planning Site

3D Printing
(Prototyping)

Surgical Stent

Dr. Nora Saif. FUE. Implantology

 Surgical Stent

● The surgical stent guides the dentist to the exact

implant placement during actual surgery according to
the virtual planning.
● The surgical stent design is changed to a 3D model by
rapid prototyping machines (3D printing)

Dr. Nora Saif. FUE. Implantology

Dr. Nora Saif. FUE. Implantology
Dr. Nora Saif. FUE. Implantology
 Post-Operative
Imaging &
Monitoring

Dr. Nora Saif. FUE. Implantology

 Post-Operative Implant Assessment

● Immediately following implant placement, a periapical image

should be acquired to serve as a baseline image for future
comparisons.
● If multiple implants have been placed, a panoramic image
may be appropriate.

Dr. Nora Saif. FUE. Implantology

 Maintenance Phase

Annual recall imaging through the first 4 years of follow-up has been
recommended for asymptomatic patients.

The most reliable indicators of implant success are clinical stability and
radiographic evidence of bone adjacent to the implant body.

Because of its superior resolution and ready accessibility, periapical imaging is

recommended as the first-line modality to monitor implant osseointegration.

(The angulation of the x-ray beam must be within 9o of the long axis of the
fixture)

Dr. Nora Saif. FUE. Implantology

 In the absence of clinical signs or symptoms, use
intraoral periapical radiography for the postoperative
assessment of implants. Panoramic radiographs may be
indicated for cases requiring more extensive implant
therapy.
Do not use CBCT imaging for periodic review of
clinically asymptomatic implants.
 image courtesy of White & Pharoah’s Oral Radiology Principles & Interpretation
Dr. Nora Saif. FUE. Implantology
 image courtesy of White & Pharoah’s Oral Radiology Principles & Interpretation
Dr. Nora Saif. FUE. Implantology
 If the patient becomes symptomatic

● CBCT examination may be prescribed to detect the extent of

bone loss, particularly in the buccolingual dimension, and to
assess the integrity of the adjacent cortices.
● These findings may be helpful in planning corrective bone
augmentation procedures or the complete removal and
replacement of an implant.

Dr. Nora Saif. FUE. Implantology

 Thank You

nora.taha@fue.edu.eg

Dr. Nora Saif. FUE. Implantology