RADIOGRAPHS IN PROSTHODONTICS

seminar (3)

Presented by
Dr.R.Yogananth
pg student(1 st year)
department of prosthodontics
RADIOGRAPHS IN PROSTHODONTICS
Introduction
Dental radiographs are a necessary component of comprehensive patient
care
Radiographs provide information that cannot be determined clinically, they
are an adjunct, however, and not the sole or primary source of diagnostic
information.
. The radiographic interpretation is combined with all other available findings
when making a definitive diagnosis and developing a treatment plan
RADIOGRAPHS IN PROSTHODONTICS
CONTENTS
INTRODUCTION
Types of dental radiographs
Dental radiographs in complete denture
Dental radiographs in removable partial denture
Dental radiographs in fixed partial denture
Dental radiographs in implant dentistry
Conclusion
REFERENCES
Types of dental radiographs used in prosthodontics
periapical radiography

{two dimensional imaging}

panoramic radiography {two dimensional imaging}

occlusal radiography {two dimensional imaging}
cephalometric radiography {two dimensional imaging}

computed tomography{three dimensional imaging}

Cone beam computed tomography{three dimensional imaging}
magnetic resonance imaging and {three dimensional imaging}
interactive computed tomography{three dimensional imaging}
Intraoral Periapical Radiography
Periapical radiographs are
images of a limited region of the mandibular or maxillary alveolus.
They are produced by placing the film intra-orally parallel to the body of the
alveolus with the central beam of the X-ray device perpendicular to the alveolus
at the region of interest, producing a lateral view of the alveolus.
They do not provide cross-sectional information
Periapical radiographs produce a high resolution planar image of a limited region
of the jaws. Number 2 size dental film provides a 31 by 41 mm view of the jaws
with each image.
Periapical radiographs may
suffer from both distortion
and magnification.
The long cone paralleling technique will
eliminate distortion and limit
magnification to less than 10%.
Advantages of periapical radiographs
high quality
low cost
low radiation exposure, and
availability
Disadvantages of periapical radiographs
Only a small area of the jaw is visible on each image, and
The periapical image does not provide a cross-sectional view of the alveolar
process.
Occlusal Radiography

Occlusal radiographs are planar radiographs produced by placing the film

intraorally parallel to the occlusal plane with the central x-ray perpendicular to
the film for the mandibular image and oblique (45) to the film for maxillary
image.
Occlusal radiography produces high resolution planar images of the body of the
mandible or the maxilla.
Maxillary occlusal radiographs are inherently oblique and so distorted
Additionally, critical structures such as the maxillary sinus, nasal cavity and nasal
palatine canal are demonstrated

The mandibular occlusal radiography is 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.
Occlusal radiograph
Lateral Cephalometric Radiographs
Cephalometric radiographs
are oriented planar
radiographs of the skull.
The skull is oriented with
respect to the x-ray device
and the image receptor using
a cephalometer, which physically fixes the position of the 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 focalobject and 6 inch object to film distance.
A lateral cephalometric radiograph is produced with the patients midsagittal
plane oriented parallel to the image receptor.
A cross-sectional image of the alveolus of both the mandible and the maxilla in
the midsagittal plane is demonstrated by this radiograph.

The lateral cephalometric radiograph can help to evaluate

loss of vertical dimension, skeletal arch interrelationship, anterior crownimplant ratio, anterior tooth position in the prosthesis.
cephalometric radiographs are a useful tool for the development of an implant
treatment plan, especially for the completely edentulous patient.
Disadvantage of Lateral Cephalogram
This technique is not useful for demonstrating bone quality
It only demonstrates a cross-sectional image of the alveolus where the central
rays of the x-ray device are tangent to the alveolus
The images of structures not in the midline are superimposed on the
contralateral side, complicating the evaluation of other implant sites.
Panoramic radiography
Panoramic radiography is a curved plane tomographic radiographic technique
used to depict the body of the mandible, maxilla, and the lower one half of the
maxillary sinuses in a single image.
BONY LANDMARKS IN MANDIBLE
BONY LANDMARKS IN MAXILLA
OTHER STRUCTURES
Advantages of panoramic images
Opposing landmarks are easily identified.
The vertical height of bone initially can be assessed.
The procedure is performed with convenience, ease and speed.
Gross anatomy of the jaws and any related pathologic findings can be evaluated.
Limitations of Panoramic imaging
Does not demonstrate bone quality/mineralization.
Is misleading quantitatively because of magnification and because the third
dimension, cross-sectional view is not demonstrated.
Is of some use in demonstrating critical structures but of little use in depicting
the spatial relationships between the structures and dimensional quantification
of the implant site.
COMPLETE DENTURES
Radiographic evaluation

Radiographs are important aids in the evaluation of submucosal conditions in

patients seeking prosthodontic care.
The presence of abnormalities in edentulous jaws may be unsuspected because
of absence of any clinical signs or symptoms.
. Extraoral radiographs can provide survey of the patients denture foundation
and surrounding structures.
Panoramic dental radiograph are readily available for convenient examination of
edentulous patients. Knowledge of location of the anatomic structures is an
essential prerequisite in the evaluation of the radiographs.
Other investigations tools
these include
Tomography,
Zonography,
Computed Tomography,
Magnetic Resonance,
Radionuclide Imaging and Ultrasounds.
.

OPG IS PERFORMED TO,

Rule out amount of bone loss and pattern of bone loss in the edentulous space
and around the remaining teeth
rule out foreign bodies,
retained root tips,
unerupted teeth /impacted third molar and canine)
various pathoses of developmental, inflammatory ,metabolic
or neoplastic origin
The panoromic is an aid in documenting the amount of ridge resorption. A very
useful system of classifying the amount of ridge resorption was described by
WICAL & SWOOPE
WICAL & SWOOPE .They found that the lower edge of mental foramena divides
the mandible into thirds in normal dentulous panaromic radiograph. If the
distance is measured from inferior border of mandible to inferior margin of

mental foramina and then multiplied by 3 , the resultant product is a reliable

estimate of original alveolar ridge crest height.
Amount of ridge resorption can be calculated an classified as Class I (MILD
RESORPTION)Loss upto 1/3 of original vertical height
Class II (MODERATE RESORPTION) Loss upto 1/3 to 2/3 of vertical height.
Class III (SEVERE RESOPTION) Loss of 2/3 or more of vertical height.
To SUMMARIZE..
periapical radiographic survey of edentulous jaws are acceptable
but Panaromic radiographs are faster
and reduce patient exposure to radiation and image the entire maxilla and
mandible
REMOVABLE PARTIAL DENTURES
Planning a panoramic radiograph is of great diagnostic value and should be
made wherever possible.
Periapical radiographs of the remaining teeth may also be required in order to
supplement the OPG.

In case OPG not there, then a full mouth of IOPAS have to be taken.
. The diagnostic factors or criteria judged are.
(i) Carious lesion
Initial carious lesions.
Recurrent caries adjacent to existing restorations.
Deep lesions or extensive restorations on potential abutment teeth. Obvious
indications for endodontic therapy cast restorations are to be noted.
(ii) Root Length, Size & Form
Large, longer roots are more favorable abutment teeth.
Form of root the is also equally important -- tapered or conical roots are
unfavorable because ever a small loss of bone height can greatly diminish the
attachment area.
Multirooted teeth with divergent and curved roots are better than single
rooted or Multirooted with fused roots
. Position of roots of adjacent tooth is also important,

in case the roots are close with little interproximal bone separating them
even a moderate irritation of force may be destructive.
Lamina dura or periodontal space
The width of the periodontal ligament space is of significance in
evaluating the stability of the teeth.
A thin uniform ligament space and an uninterrupted Lamina dura is a
more favorable sign compared to a more widened or irregular space
.
A thickening of the lamina dura may occur if the tooth is mobile, has
occlusal trauma or is under heavy functions occlusal trauma can cause partial or
total loss of the lamina dura.
; Destruction forces or the disease processes causing changes in the lamina dura
must be correlated ( the abutment tooth will have a poor prognosis.)
Bone quality & quantity
Bones which has small closely grouped trabecular and small inter
trabecular spaces is considered well mineralized; hence strong & healthy. This is
portrayed in the radiograph as relatively radiopaque, although a certain amount
of variation is size of the trabeculae is normal and to be expected.
Bone height of quantity
In this evaluation care must be taken to avoid any interpretation
errors resulting from angulations factors with is normally used in the short cone
or Bisecting angle technique.
(i) Abutment teeth of an FPD or RPD.
(ii) Teeth involved in occlusal interferences.
(iii) Teeth receiving greater occlusal stress due to loss of adjacent teeth.
(iv) Tipped teeth with occlusal contact.
Radioluscent or radioopaque lesions.
The presence of cysts, accesses, embedded teeth or roots or foreign bodies must
be noted.
A surgical diagnosis and treatment must be planned so that a conditions
does not flare up later on jeopardizing the prognosis of the prosthesis.
Buried root tips or impacted teeth that show no signs or any pathosis and are
encapsulated by normal appearing bone
need not be surgically removed though it must be noted in the diagnosis
. It should be checked for any impacted 3 r d molars.

. Abutment teeth adjacent to distal extension bases are subjected not only to
vertical and horizontal forces but to torque as well.
that haveto be evaluated periodically.
FIXED PARTIAL DENTURES

A well defined, complete mouth radiographic series is essential.

TMJ radiographs may be indicated for patients with joint dysfunction and
a panoramic radiograph can also be helpful.
. Radiographs used in FPD are
1. Full mouth intra-oral periapical radiographs 2. Panoramic radiographs.
3. TMJ radiographs.
. Full mouth intra oral radiographs An intra oral radiographic examination
reveals.

1. Root number and morphology (short, long, slender, broad, bifurcated, fused
dilacerated etc) and root proximity.
Molar with divergent roots provide better support than a molar with little
or no inter radicular bone. .
2.
Remaining bone support After horizontal bone loss from periodontal
disease the PDL supported root surface area can be dramatically reduced. When
one third of the root length has been exposed half the supporting area is lost.
3. Quality of supporting bone trabacular patterns and reaction to functional
charges.
4. Width of the periodontal ligament spaces and evidence of traum from
occlusion.
5. Areas of vertical and horizontal osseous resorption and furcation invasions.
6. Axial inclination of teeth (degree of non parallelism if present). A well aligned
tooth will provide better support than a tilted one.
7. Continuity and integrity of the lamina dura.
8. Pulpal morphology and previous endodontic treatment with or without post
and cores.
.9. Presence of apical diseases, root resorption or root fractures.

10. Retained root fragments, radiolucent areas, calcification, foreign bodies, or

impacted teeth. 11. Presence of carious lesions and restorations to the pulp and
alveolar crest.
12. Calculus deposits.
13. Oral roentgenographic manifestation of systemic disease
. 14. Edentulous areas Presence of retained root tips or other pathosis in the
edentulous area should be noted.
In many radiographs it is possible to trace the outline of the soft tissue in
edentulous areas so that the thickness of the soft tissue overlying ridge can be
determined.
15
Crown root ratio. (Antes Law) This ratio is a measure of the length of
tooth occlusal to the alveolar crest of bone compared with the length of root
embedded in the bone. As the level of the alveolar bone moves apically, the level
arm of that portion out of the bone increases and the chance for harmful lateral
forces is increased
The optimum crown root ratio for a tooth to be used as a fixed partial denture
abutment is 2:3.
A ratio of 1:1 is the minimum ratio that is acceptable for a prospective
abutment under normal circumstances.
Size and position of the pulp
This is one of the most important factors to be assessed before preparing a
tooth and may well determine the correct choice of retainer. Where the pulp is
large particularly in the young patient, it may be impossible to obtain sufficient
reduction of tooth tissue for adequate retainers without devitalization.
. In the posterior region a bitewing X-ray is the best method of assessing the
correct position of the pulp.
With anterior teeth an X-ray taken with the ray at right angles to the crown of
the tooth is to be preferred to the usual apical view.
. Panoramic radiographs Panoramic films provide useful information as to the
presence or absence of teeth.
They give an overall view about the dentition. However they do not provide
detailed view for assessing bone support, root morphology, or caries.
Special radiographs
There are needed for the assessment of TMJ disorders. A transcranial exposure with the help of a positioning device , will reveal the lateral third
of the mandibular condyle and can be used to detect structural and positional
changes.

However interpretation may be difficult, more information can be obtained from

serial tomography, arthrography, CT scanning or magnetic resonance imaging of
the joints.
Radiographs for Dental Implants

Imaging modalities
Preprosthetic periapical radiography
occlusal radiography
cephalometric radiography
panoramic radiography
computed tomography
cbct

Preprosthetic contddentascan imaging

magnetic resonance
imaging

Surgical and interventional imaging

digital radiography(rvg)
Postprosthetic implant imagingperiapical radiography
bite-wing radiographs
temporal digital subtraction
radiography
computed tomography
cone beam computed

tomography

The widespread use of dental implants in partially and completely edentulous

patients has brought about a need to preoperatively assess the bone quantity
and quality of bone by radiographic examination.

These examinations also provide information about the locations of vital

anatomic structures, adjacent to the sites of implant placement.
For example, the maxillary sinuses and nasal fossae, and the inferior alveolar
canals and mental foramina.
The choice of radiologic technique appropriate for a given patient depends on a
number of factors, including
the type of implant to be used,
the position of the remaining dentition, and
the extent to which bone quality or quantity is in question.
Imaging Objectives
The objectives of diagnostic imaging depends on a number of factors, including
the amount and type of information required and the time period of the
treatment rendered. The decision of when to image along with which imaging
modality to use depends on the integration of these factors and can be organized
into three phases.
Phase I:

Preprosthetic imaging

Phase II: Surgical and interventional implant imaging

Phase III: Postprosthetic implant imaging
Phase I: Preprosthetic Implant Imaging
This phase involves
all past radiologic examinations along with
new radiologic examinations
chosen to assist the implant team in determining the patients final and
comprehensive treatment plan.
Objectives of this phase 1 include
To obtain

all necessary surgical and prosthetic information to determine the quality and
quantity and angulation of bone;
the relationship of critical structures to the prospective implant sites; and
the presence or absence of disease at the proposed surgery sites.
Phase II: Surgical and Interventional Implant Imaging
This phase is focused on assisting in the surgical and prosthetic intervention of
the patient.
The objectives of this phase of imaging are
to evaluate the surgery sites during and immediately after surgery,
assist in the optimal positioning and orientation of dental implants,
evaluate the healing and integration phase of implant surgery, and
to ensure if the abutment position and prosthesis fabrication are correct.
Phase III: Postprosthetic Implant Imaging
It commences just after the prosthesis placement and continues as long as the
implants remain in the jaws.
The objectives of this phase of imaging are:
to evaluate the long-term maintenance of implant rigid fixation and function,
including the crestal bone levels around each implant and
to evaluate the implant complex.
Imaging Modalities
The decision to image the patient is based on patients clinical needs.
Once a decision to image the patient has been made, the diagnostic modality is
employed that yields the necessary diagnostic information related to the
patients clinical needs and results in the least radiologic risk.
There are many imaging modalities that have been employed for implant
imaging, including devices recently developed specifically for dental implant
imaging.
The imaging modalities can be described as either analog or digital and
two dimensional or three dimensional.
Analog Imaging:
Analog imaging modalities are two-dimensional systems that employ x-ray film
and/or intensifying screens as image receptors.
Eg. Periapical radiography

panoramic radiography
occlusal radiography
cephalometric radiography
Digital two-dimensional imaging
A digital two-dimensional image is described by an image matrix that has
individual picture elements called pixels.
A digital image is described by its width and height and pixels. Digital images are
numeric and discrete in two ways:
(1) in terms of spatial distribution of picture elements
(2) in terms of different shades of gray of each of the pixels.
Spatial resolution is the capacity for distinguishing closely spaced objects .
Contrast resolution is the ability to distinguish different densities in the
radiographic image.
Each pixel has a discrete digital value that describes the image intensity at that
particular point.
The value of a pixel element is described by a scale, which may be as low as 8
bits (256 values) or as high as 12 bits (4096 values) for black and white imaging
systems or 36 bits (65 billion values) for color imaging systems.
Digital three-dimensional imaging
A digital three-dimensional image is described by an image matrix that has
individual image/picture elements called voxels.
A digital three-dimensional image is described not only by its width and height
and pixels but additionally, by its depth/thickness.
Eg.

Computed tomography,
Magnetic resonance imaging and
Interactive computed tomography

An imaging volume or three-dimensional characterization of the patient is

produced by contiguous images, which produces a three-dimensional structure of
volume elements.
Each volume element has a value that describes its intensity level. Typically,
three-dimensional modalities have an intensity scale of 12 bits or 4096 value.
Intraoral Periapical Radiography
Periapical radiographs are

images of a limited region of the mandibular or maxillary alveolus.

They are produced by placing the film intra-orally parallel to the body of the
alveolus with the central beam of the X-ray device perpendicular to the alveolus
at the region of interest, producing a lateral view of the alveolus.
They do not provide cross-sectional information
Periapical radiographs produce a high resolution planar image of a limited region
of the jaws. Number 2 size dental film provides a 31 by 41 mm view of the jaws
with each image.
Periapical radiographs may
suffer from both distortion
and magnification. The long
cone paralleling technique will
eliminate distortion and limit
magnification to less than 10%.
Advantages of periapical radiographs
high quality
low cost
low radiation exposure, and
Availability
Readily availabie in the dental office at the time of surgery
In addition, linear measurements in vertical and horizontal directions are
accurate if paralleling techniques are used to prevent image distortion.
Disadvantages of periapical radiographs
Only a small area of the jaw is visible on each image, and
The periapical image does not provide a cross-sectional view of the alveolar
process.
In terms of the objectives of preprosthetic imaging, periapical radiography is:
A useful high-yield modality for ruling out local bone or dental disease.
Of limited value in determining quantity because the image is magnified, may be
distorted, and does not depict the third dimension of bone width.

Of limited value in determining bone density or mineralization (the lateral

cortical plates prevent accurate interpretation and cannot differentiate subtle
changes in trabecular bone).

Of value in identifying critical structures, but of limited value in depicting the

spatial relationship between the structures and the proposed implant site.
Occlusal Radiography
Occlusal radiographs are planar radiographs produced by placing the film
intraorally parallel to the occlusal plane with the central x-ray perpendicular to
the film for the mandibular image and oblique (45) to the film for maxillary
image.
Occlusal radiography produces high resolution planar images of the body of the
mandible or the maxilla.
Maxillary occlusal radiographs are inherently oblique and so distorted that they
are of no quantitative use for implant dentistry, for either determining the
geometry or the degree of mineralization of the implant site.
Additionally, critical structures such as the maxillary sinus, nasal cavity and nasal
palatine canal are demonstrated, but the spatial relationship to the implant site
is generally lost with this projection.
The mandibular occlusal radiography is an orthogonal projection, thus it is 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, it shows the widest width of bone (i.e. the symphysis) versus the
width at the crest, which is where diagnostic information is needed most.
Occlusal radiograph
The degree of mineralization of trabecular bone is not determined from this
projection, and the spatial relationship between the critical structures such as
the mandibular canal and the mental foramen, and the proposed implant site is
lost with this projection.
As a result, occlusal radiographs are rarely indicated for diagnostic preprosthetic
phases in implant dentistry.
Lateral Cephalometric Radiographs
Cephalometric radiographs
are oriented planar

radiographs of the skull.

The skull is oriented with
respect to the x-ray device
and the image receptor using
a cephalometer, which physically fixes the position of the 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 focalobject and 6 inch object to film distance.
A lateral cephalometric radiograph is produced with the patients midsagittal
plane oriented parallel to the image receptor.
A cross-sectional image of the alveolus of both the mandible and the maxilla in
the midsagittal plane is demonstrated by this radiograph.
With a slight rotation of the cephalometer, a cross sectional image of the
mandible or maxilla can be demonstrated in the lateral incisor or in the canine
regions as well.
The cross-sectional view of the alveolus demonstrates the spatial relationship
between occlusion and esthetics with the length, width, angulation, and
geometry of the alveolus and is more accurate for bone quantity determination,
unlike panoramic or periapical images.
Often implants must be positioned in the anterior regions adjacent to the lingual
plate. The lateral cephalometric radiograph is useful because it demonstrates the
geometry of the alveolus in the anterior region and the relationship of the lingual
plate to the patients skeletal anatomy.
The width of the bone in the symphysis region and the relationship between the
buccal cortex and the roots of the anterior teeth may also be determined before
harvesting this bone for ridge augmentation.
Together with the regional periapical radiographs, quantitative spatial
information is available to demonstrate the geometry of the implant site and the
spatial relationship between the implant site and the critical structures such as
the floor of the nasal cavity, the anterior recess of the maxillary sinus and the
nasal palatine canal.
Additionally, the lateral cephalometric radiographic can help evaluate a loss of
vertical dimension, skeletal arch interrelationship, anterior crown-implant ratio,
anterior tooth position in the prosthesis and resultant moment of forces.
As a result, cephalometric radiographs are a useful tool for the development of
an implant treatment plan, especially for the completely edentulous patient.
Disadvantage of Lateral Cephalogram

This technique is not useful for demonstrating bone quality

It only demonstrates a cross-sectional image of the alveolus where the central
rays of the x-ray device are tangent to the alveolus
The images of structures not in the midline are superimposed on the
contralateral side, complicating the evaluation of other implant sites.
Panoramic radiography
Panoramic radiography is a curved plane tomographic radiographic technique
used to depict the body of the mandible, maxilla, and the lower one half of the
maxillary sinuses in a single image.
This modality is probably the most utilized diagnostic modality in implant
dentistry.
However, for quantitative preprosthetic implant imaging, it is not the most
diagnostic.
This radiographic technique produces an image of a section of the jaws of
variable thickness and magnification.
The image receptor has traditionally been x-ray film but may be digital storage
phosphor plate or a digital CCD receptor.
Advantages of panoramic images
Opposing landmarks are easily identified.
The vertical height of bone initially can be assessed.
The procedure is performed with convenience, ease and speed.
Gross anatomy of the jaws and any related pathologic findings can be evaluated.
Limitations of Panoramic imaging
Does not demonstrate bone quality/mineralization.
Is misleading quantitatively because of magnification and because the third
dimension, cross-sectional view is not demonstrated.
Is of some use in demonstrating critical structures but of little use in depicting
the spatial relationships between the structures and dimensional quantification
of the implant site.
Panoramic Magnification
Panoramic radiography is characterized by an image of the jaws that
demonstrates both vertical and horizontal magnification, along with a
tomographic section, thickness that varies according to the anatomic position.

Panaromic radiograph produces a relatively constant vertical magnification of a

approximately 10%. The horizontal magnification is approximately 20% and
variable depending on the anatomical location, the position of the patient and
the focus-object distance, and the relative location of the rotation centre of the xray system.
Magnification can be calculated by the use of templates with incorporated
metal spheres of known diameter in situ when the radiograph is taken can
effectively eliminate the distortion problems.
If the true diameter of the sphere (D-real) is 5 mm, and its diameter on the
radiograph (D-PR) is 6 mm.
The distance between the alveolar crest and the mandibular canal is measured
on the film as 18mm (A-PR). To determine the real distance between the alveolar
crest and the mandibular canal (A-real), simply solve the following equation.
A-real / A-PR = D-real / D-PR
A-real = (5 / 6) x 18
A-real = 15 mm
Zonography
Recently, a modification of the panoramic x-ray machine has been developed
that has the capability of making a cross-sectional image of the jaws.
These devices employ limited angle (less than 10) linear tomography
(zonography) and a means for positioning the patient. The tomographic layer is
approximately 5 mm.
This technique enables the appreciation of spatial relationship between the
critical structures and the implant site.
It is particularly useful when subject contrast is low due to little difference in
physical density between adjacent structures.
The tomographic layers are relatively thick and have adjacent structures that are
blurred and superimposed on the image, limiting the usefulness of this technique
for individual sites, especially in the anterior regions where the geometry of the
alveolus changes rapidly.
This technique is not useful for determining the differences in most bone
densities or identifying disease at the implant site.
Tomography
Tomography is a generic term formed by the Greek words Tomo (slice) and
Graph (picture), that was adopted in 1962 by the International Commission on
Radiologic Units and Measurements (ICRU) to describe all forms of body section
radiography.

It is designed to image more clearly objects lying within a plane of interest.

It is accomplished by blurring the images of structures lying superficial and deep
to the plane of interest through the process of motion unsharpness.
The basic principle of tomography is that the x-ray tube and film are connected
by a rigid bar called the fulcrum bar which pivots on a point called the fulcrum.
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.
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.
Factors that affect tomographic quality are the amplitude and direction of tube
travel. The greater the amplitude of tube travel, the thinner the tomographic
section.
Linear tomography is the simplest form of tomography where the x-ray tube and
film move in a straight line. This tomographic motion is one dimensional and
produces blurring of adjacent sections in one dimension resulting in linear steak
artifacts in the resulting image, which may obfuscate the section of interest.
Complex motion, high quality tomography is described by two-dimensional
motion of the tube and film and results in relatively uniform blurring of the
regions of the patients anatomy adjacent to the tomographic motion.
Circular, spiral and hypocyclocidal are tube motions employed in complex
tomography.
The diagnostic quality of the resulting tomographic image is determined by the
type of tomographic motion, the section thickness, and the degree of
magnification. The type of tomographic motion is probably the most important
factor in tomographic quality.
Hypocycloidal motion is generally accepted as the most effective blurring
motion.
Large amplitude tube travel and 1 mm sections are preferred for high contrast
anatomic objects whose geometry changes in a relatively short distance, such as
the alveolus of the jaws.
Magnification varies from approximately 10% to 30% with higher magnification
generally producing higher quality images.

Dense structures such as teeth, exostosis, thick cortical plates, dental

materials/restorations and so on are difficult to blur effectively when they are
much more dense than the structures depicted in the tomographic section.
Dense structures may persist in the tomographic image even though they are 3
or 4 times the tomographic layer thickness distant from the tomographic section
and will serve to obfuscate the structures of interest in the tomographic section.
For dental implant patients, high-quality complex motion tomography
demonstrates the alveolus, and taking magnification into consideration enables
quantification of the geometry of the alveolus.
This technique also enables determination of spatial relationship between the
critical structures and the implant site.
Ideally, tomographic sections spaced every 1 or 2 mm enable evaluation of the
implant site region, and with mental integration, enable appreciation of the
three-dimensional appearance of the alveolus.
The quantity of alveolar bone available for implant placement can be determined
by compensating for magnification.
Postimaging digitization of tomographic implant images enables use of a digital
ruler to aid in the determination of alveolar bone for implant placement.
Image enhancement can aid in identifying critical structures such as the inferior
alveolar canal.
Complex tomography is not particularly useful in determining bone quality or
identifying bone and dental disease.
Computed Tomography
Computed tomography (CT) is a digital and mathematical imaging technique that
creates tomographic sections where the tomographic layer is not contaminated
by blurred structures from adjacent anatomy.
Additionally, and probably most important, computed tomography enables
differentiation and
quantification of both soft and hard tissues.
Computed Tomography was invented by Sir Hounsfield 1972, but it had its origins
in mathematics (1917) and in astrophysics (1956).
The first CT scanners appeared in medical imaging departments during the mid
1970s and were so successful that they largely replaced complex tomography by
the early 1980s.
CT produces axial images of a patients anatomy. Axial images are produced
perpendicular to the long axis of the body. CT is a prospectively digital imaging

technique. The x-ray source is attached rigidly to a fan beam geometry detector
array, which rotates 360 around the patient and collects data.
For implant imaging applications, the axial slices should be oriented
parallel to the inferior border of the mandible for mandibular
imaging and
parallel to the hard palate for maxillary imaging.
The image detector is either a gaseous or solid state producing electronic signals
that serve as input data for a dedicated computer.

CT images are inherently three-dimensional digital images typically 512 by 512

pixels with a thickness described by the slice spacing of the imaging technique.
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 at that
point.
Each voxel contains 12 bits of data and ranges from -1000 (air) to +3000
(enamel/dental materials) Hounsfield units.
CT scanners are standardized at a Hounsfield value of 0 for water. The CT density
scale is quantitative and meaningful in identifying and differentiating structures
and tissues.
With current generation CT scanners, reformatted images are characterized by a
section thickness of 1 pixel (0.25 mm) and an in-plane resolution of 1 pixel by the
scan spacing (0.5 to 1.5 mm) producing a geometric resolution similar to that of
planar imaging.
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.
Bone quality
Tissue Characterization
CT enables the evaluation of proposed implant sites and provides diagnostic
information that other imaging or combinations of imaging techniques could not.
Advantages of Computed Tomography
CT enables identification of
disease,
determination of bone quantity,
identification of critical structures at the

proposed regions, and

determination of the position and

orientation of the dental

implants.
Thus CT is capable of determining all five of the radiologic objectives of preprosthetic implant imaging.
Disadvantages of CT
It is an expensive modality
It requires an expert radiologist to interpret the image
Radiation dosage high when compared to conventional radiographic technique
Patients head must be constant during the entire imaging process (15 to 20 min)
Dentascan imaging
The advantages of CT imaging were evident and the limitations of delivery clear,
which spawned the development of a number of techniques, referred to
generically as Dentascan Imaging
Dentascan imaging provides programmed reformation, organization, and display
of the imaging study. The radiologist or technologist simply indicates the
curvature of the mandibular or maxillary arch and the computer is programmed
to generate referenced cross-sectional and tangential/panoramic images of the
alveolus along with three-dimensional images of the arch. The cross-sectional
and panoramic images are spaced 1 mm apart and enable accurate
preprosthetic treatment planning.
Limitations of Dentascan imaging
Images may not be true size and require compensation for magnification;
Determination of bone quality requires use of the imaging computer or
workstation;
Hard copy Dentascan images only include a limited range of the diagnostic gray
scale of study; and
The tilt of the patients head during the examination is critical because all the
cross-sectional images are perpendicular to the axial imaging plane.
Interactive Computed Tomography
This technique enables the radiologist to transfer the imaging study to the
clinician as a computer file and enables the clinician to view and interact on their
own computer.
With the imaging study the clinicians computer becomes a diagnostic radiologic
work station with tools to measure the length and width of the alveolus, measure
bone quality, and change the window and level of the gray scale of the study to
enhance the perception of critical structures.

Axial, cross-sectional and panoramic images are displayed and referenced so

that the clinician can appreciate the same position or region within the patients
anatomy in each of the images.
Regions of the patients anatomy can be selected for display normally, with
magnification, or with a number of gray scale depictions facilitating the
appreciation of anatomical structures or disease.
An important feature of ICT is that the clinician and radiologist can perform
electronic surgery (ES) by selecting and placing arbitrary size cylinders that
simulate root form implants in the images.
With an appropriately designed diagnostic template, ES can be performed to
electronically develop the patients treatment plan in three dimensions
ES and ICT enable the development of a three-dimensional treatment plan that is
integrated with the patients anatomy and can be visualized before implant
surgery by the members of the implant team and the patient for approval or
modification.
ICT enables the determination of bone quality adjacent to the prospective
implant sites. With the number and size of implants accurately, determined,
along with the density of bone at the proposed implant sites, characteristics of
the implants can be accurately determined before surgery.
1. Panoramic view from Sim/plantTM Software
Limitations of ICT
Though it is the most accurate imaging technique, it suffers a few
limitations.
ES enables placement of electronic implants in the imaging study but the
refinement and exact relative orientation of the implant positions is difficult and
cumbersome.
The precision and accuracy of the treatment plan developed using ICT and ES for
the implant position, size, orientation, relative spacing, and spatial relationship to
the critical structures and proposed esthetics, and occlusion becomes a major
challenge at the time of surgery.

However, transfer of the plan to the patient at the time of surgery can be
accomplished by simple visualization and comprehension by a skilled and
experienced surgeon, using positions and orientations obtained from ICT and ES
to convert the diagnostic template into a surgical template, or the production of
a computer generated three-dimensional stereotactic surgical template from the
digital ICT an ES data.
Contents

Introduction
Imaging objectives
Imaging modalities
Preprosthetic periapical radiography
occlusal radiography
cephalometric radiography
panoramic radiography
zonography
tomography

Preprosthetic contd-

computed tomography
dentascan imaging
interactive computed
tomography
CBCT
magnetic resonance
imaging
diagnostic templates

Surgical and interventional imaging

Postprosthetic implant imagingperiapical radiography
bite-wing radiographs
temporal digital subtraction
radiography
computed tomography
Conclusion
References

Cone beam Computed Tomography

It is a relatively newer modality.
CBCT scanners are based on
volumetric tomography, using a 2D
extended digital array providing an
area detector. This is combined with
a 3D x-ray beam.
It uses a conical beam and
reconstructs the image in any
direction using a special software.
It gives all the information of a CT
but at 1/8th its cost
Advantages of cone beam computed tomography
Rapid scan time- Because CBCT acquires all basis
images in a single rotation, scan time is rapid (1070 seconds), and hence
motion artifacts due to subject movement are reduced.
Dose reduction- Published reports indicate that the
effective dose of radiation is significantly reduced by up to 98% compared
with conventional fan-beam CT systems.
Display modes unique to maxillofacial imaging- Reconstruction of CBCT data is
performed natively by a personal computer. In addition, software can be made
available to the user, either via direct purchase or innovative per use licence
from various vendors (e.g., Imaging Sciences International). This provides the
clinician with the opportunity to use chair-side image display, real-time analysis
and MPR modes that are task specific.
Reduced image artifact- With manufacturers artifact suppression algorithms and
increasing number of projections, it has been shown that CBCT images can result
in a low level of metal artifact, particularly in secondary reconstructions designed
for viewing the teeth and jaws.
Difference between ct and cbct

Magnetic Resonance Imaging

MR is an imaging technique used to image the protons of the body by employing
magnetic fields, radio frequencies, electromagnetic detectors, and computers.
The technique was first announced by Lauterbur in 1972.
MR is used in implant imaging as a secondary imaging technique where primary
imaging techniques such as complex tomography, CT or ICT fail.
Complex tomography fails to differentiate the inferior alveolar canal in 60% of
implant cases and CT fails to differentiate the inferior alveolar canal in 2% of
implant cases.
Failure to differentiate the inferior alveolar canal may be caused by osteoporotic
trabecular bone and poorly corticated inferior alveolar canal.
MR visualizes the protons in fat in the trabecular bone and differentiates the
inferior alveolar canal and neurovascular bundle from the adjacent trabecular
bone.
Double scout MR imaging protocols with volume and oriented cross-sectional
imaging of the mandible produce orthogonal quantitative contiguous images of
the proposed implant sites.
Oriented MR imaging of the posterior mandible is dimensionally quantitative and
enables spatial differentiation between critical structures and the proposed
implant site.
MR is not useful in characterizing bone mineralization or a high-yield technique
for identifying bone or dental disease
Diagnostic Templates
The purpose of diagnostic radiographic templates is to incorporate the patients
proposed treatment plan into the radiographic examination.

The pre-prosthetic imaging procedure enables evaluation of the proposed

implant site at the ideal position and orientation identified by radiographic
markers incorporated into the template.
There are two diagnostic templates, one produced from the vacuform
reproduction, and one produced from a processed acrylic reproduction of the
diagnostic wax-up.
The processed acrylic template is modified by coating the proposed restoration
with a thin film of barium sulfate and filling a hole drilled through the occlusal
surface of the restoration with gutta percha.

The surfaces of the proposed restoration then become radiopaque in the CT

examination and the position and orientation of the proposed implant is
identified by the radiopaque plug of gutta percha within the proposed
restoration.
The vacuform template has a number of variations.
One design involves coating the proposed restorations with a thin film of barium
sulfate.

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.

Lead circumferential strip

Guttapercha guide
Diagnostic templates for tomography examinations are generally less precise
than those required in CT examinations.
The simplest tomography template is produced by obtaining a vacuform of the
patients diagnostic cast with 3-mm ball bearing placed at the proposed implant
positions.
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. The ball bearing
can additionally serve as a measure of the magnification of the imaging system.

Templates that incorporate metal cylinder or tubes at the proposed implant sites
also enable evaluation of tomograms for the orientation along with the position
of the proposed implant.
Surgical and Interventional Imaging
Surgical and interventional imaging involves imaging the patient during and
immediately after surgery and during the placement of the prosthesis.
The purpose of surgical imaging is to evaluate the
depth of implant placement,
the position and orientation of
to evaluate donor or graft sites.

implants/osteotomies, and

Periapical radiographs have regained popularity because of the development of

user-friendly digital radiography.
The patient can be generally imaged at chairs side with periapical radiography to
determine implant/osteotomy depth, position, and orientation .
The disadvantage of periapical radiography is that a darkroom and
approximately 5 minutes per radiograph for film processing is generally required.
Digital periapical image receptors enable virtually instantaneous image
acquisition, produce image quality similar to that of dental film, and enable the
surgical procedure to proceed without undue delay.
Additional features of
digital imaging include
image enhancement and
the use of digital
measuring techniques,
which help the surgeon in
establishing the optimum depth and orientation of the implants.
For extensive implant procedures that may involve the entire jaw, both jaws,
large donor graft sites, or sinus graft augmentation, panoramic radiography will
provide a more global view of the patient's anatomy.
However, the disadvantage of panoramic radiography is that the patient must
generally leave the surgical suite and stand or sit still for the panoramic
procedure.

Additionally, panoramic radiography has less resolution than periapical or digital

periapical radiography and suffers from magnification and distortion.
Periapical or digital periapical radiography are useful modalities to determine if
the implant components and prosthesis are seated or fitted appropriately.
A radiographic examination is also performed to determine whether the metal
framework of final restoration is seated completely and whether the margins are
acceptable around the implants and teeth.
Postprosthetic Imaging
The purpose of post prosthetic implant imaging is to evaluate the status and
prognosis of the dental implant.

Objective of this phase of imaging is to evaluate the long term maintenance of

implant rigid fixtures and function including crestal bone levels around each
implant and to evaluate implant complex i.e. status and the prognosis of dental
implant.
The modalities for postprosthetic implant imaging are:
Periapical radiography
Digital periapical radiography
Bite-wing radiographs
Temporal digital subtraction radiography
Computed tomography
Periapical Radiography
The implant bone interface is depicted only at the mesial, or distal, inferior, and
crestal aspects or, where the central ray the x-ray source is tangent to the
implant surface. Other regions of the implant interface are simply not depicted
well by this modality.
Digital periapical radiography
Digital radiographs can be subjected to image processing with which the images
can be altered to achieve task specific image characteristics.
For example, density and contrast can be lowered for evaluations of the marginal
bone and increased for evaluations of the implant components.
The possibilities of pseudo-coloring, that is, to assign different colors to different
gray-level values, have been suggested to be of value in evaluating the bone
surrounding the implant. So has the possibility to graphically display the
variations in gray-level values over a distance, e.g. one that covers the implantbone interface.
Bite-Wing Radiographs
The short and long-term evaluation of crestal bone loss around implants is best
evaluated with intraoral radiographs.
Quality bite-wing radiographs placed parallel to the implant body with the central
ray of source oriented perpendicular to the film enable sequential radiographs
for crestal and periimplant bone loss .
Radiographs produced in this manner should result in an undistorted image of
the implant body, implant abutment connection, and threads.
Temporal Digital Subtraction Radiography

Temporal digital subtraction radiography (SR) is a radiographic technique that

enables two radiographs made at different points of time of the same anatomic
region to be subtracted resulting in an image of the difference between the two
original radiographs.
The resulting subtraction image depicts changes in the patients anatomy such
as alveolar mineralization or volume changes during the time between which the
two radiographs were made.
SR has had limited utilization in clinical practice because of the difficulty in
obtaining reproducible periapical radiographs.
Computed Tomography
Although CT cannot match the resolution of SR or periapical radiography, the
quantitative gray scale and three-dimensional characteristics of CT enable
evaluation of the bone implant interface in all orientations.

Failing implants characterized by trabecular and crestal demineralization;

resorption of the bone implant interface; cortical plate fenestration; and
perforation of the inferior alveolar canal cortical plates, and nasal cavity or
maxillary sinus floor can be identified with CT.
Conclusion
Today's clinician has a wide array of diagnostic tools at his disposal. The CT gives
the best information of the available modalities. More commonly though a
combination of intraoral periapical radiograph and panoramic radiograph is
used.

To date no modality has been deemed perfect. So, the clinician has to carefully
weigh the pros and cons of each modality. The future for further development of
imaging techniques specific for application in implantology is bright. We can
definitely expect much more accurate, faster and safer modalities at lower cost
to come into the field soon.
References
Contemporary implant dentistry. Carl E Misch. Second edition
Oral radiology principles and interpretation .White and Pharoah.Fifth edition
Clinical periodontology and implant dentistry. Jan Lindhe10. Modica, et al.
Radiologic prosthetic planning of the surgical phase of the treatment of
edentulism by osseointegrated implants. An invitro study. J Prosthet Dent
1991:65:541-546

Kopp KC, Koslow AH, Abdo OS. Predictable implant placement with a
diagnostic/surgical template and advanced radiographic imaging.) J Prosthet
Dent. 2003 Jun;89(6):611-5.
Michael J Pharoh. Imaging Technique and their clinical significance, Int J
Prosthodont 1993 ;6 :176-9.
Michael Tischler, Interactive Computerized Tomography For Dental Implants:
Treatment Planning FromThe Prosthetic End Result Dentistry Today 3/04.