LD Final Priyanka
LD Final Priyanka
LD Final Priyanka
RADIOGRAPHIC EVALUATION OF
PROSTHODONTIC PATIENTS
Dr. PRIYANKA G
Post Graduate Student
2019-2022
DEPARTMENT OF PROSTHODONTICS
AND
CROWN & BRIDGE
by Dr. PRIYANKA G and was presented under our guidance and to our satisfaction
Guided by:
Chennai. Chennai.
CONTENTS
INTRODUCTION
REVIEW OF LITERATURE
DISCUSSION
o Background
o Imaging modalities
o TMJ radiographs
o Implant imaging
SUMMARY
CONCLUSION
INTRODUCTION
becomes important to have a good knowledge of all those techniques which will
determine whether disease is present: then identify its type, extent, distribution
diagnostic aids.1
esthetics and/or function of their existing dentition. They could also be missing 1
prosthodontics helps to assess the dentate as well as edentulous patients for oral
rehabilitation, but pathologies in the edentulous patient are different from those in
the dentate patient, however the problems related to routine screening are still
The publication of the American Dental Association intended for patients, Guide
to Dental Health, states that ―An x-ray examination is performed only when
necessary, not as a routine procedure, and only when the dentist believes such an
The report of the American Dental Association Council on Dental Material and
which the dentist anticipates that the information he is likely to obtain will contribute
time in the light of changing patterns of the incidence of disease and of treatment.
Changes noted by Swenson8*g between his 1944 and 1964 studies have continued,
and reflect improved access of the patient population to good dental treatment. Later
studies that appear to contradict this trend should be analyzed with respect to the
population studied. Later studies have also shown a change in the nature of the
pathosis reported. Early studies reported large numbers of root fragments, cysts, and
other residues of incomplete dental surgery. Later studies, while still reporting some
residual tooth fragments, have also reported on morphologic changes and nonspecific
in Dentistry can be categorized as: intraoral and extraoral, analogue and digital,
P.F. van der Stelt et al, 1989 studied that the reliability of subtraction
order to do so, the coordinates of the source position of one projection, relative to
the source positions of the set of projections used for fomosynthesis, has to be
accuracy of 0.513 degrees (range 0.000-1.289 degrees), which is well within the
radiography
collaboration between the restorative dentist and the surgeon to determine the
optimum placement of the implant in relation to the available bone and the
proposed prosthesis. Diagnostic and surgical guides can aid in treatment planning
and the implementation of that plan. Many different types of guides were
proposed. They vary from the very simple, which may not provide enough
information to achieve the desired results, to the extremely complex which require
a great deal of time to fabricate and are so precise as to not permit any
guide that can be constructed to aid in the diagnosis and treatment of patients
diagnosis of diseases associated with the teeth and to consider its value in routine
for large proportions of dentate and edentulous populations, while in those cases
selection criteria are reviewed. They concluded that new, high-yield selection
Mozzo et al 1997 introduced a new type of volumetric CT which uses the cone-
radiation dose absorbed by the patient are obtained using specific phantoms.
Absorbed dose is compared with that given off by spiral CT. Geometric accuracy,
measurements. Radiation dose absorbed during the scan shows different profiles
in central and peripheral axes. As regards the maximum value of the central
profile, dose from the new unit is approximately one sixth that of traditional spiral
CT. The authors concluded that the new system appears to be very promising in
dentomaxillo-facial imaging and, due to the good ratio between performance and
low cost, together with low radiation dose, very interesting in view of large-scale
image interpretation for dental implant treatment and revealed that the
when planning treatment for dental implants. Potential bone sites for implant
mucosa; however, diagnostic imaging provides the best means for indirectly
measuring bone dimensions. After healing of the Implant site, the application of
radiology is useful to verify the amount of bone adjacent to the implant and that
the transmucosal abutments fit the implant. Upon completion of the implant
application of radiology over the course of treatment which are made for various
Dula et al 2001 reported that modalities in implant dentistry are proposed based
on clinical need and biologic risk for the patient. To calculate the biologic risk,
the authors carried out dose measurements. They demonstrated that the risk from
molar region carry 5% and 13% of the risk from computed tomography of the
imparts a low dose while giving the best radiographic survey. Periapical
radiographs are used to elucidate details or to complete the findings obtained from
film tomography being preferred for smaller regions of interest and computed
tomography being justified for the complete maxilla or mandible when methods
for dose reduction are followed. During follow-up, intraoral radiography is
anterior region of the maxilla or for scientific studies. In patients requiring more
radiography. The present review outlines the indications of the most frequently
visualized with CT and cone beam CT. Cone beam CT provides high-resolution
considered to be the gold standard in imaging the soft tissue components of the
TMJ. MRI is used to evaluate the articular disc in terms of location and
morphology. Moreover, the early signs of TMD and the presence of joint effusion
and maxilla in three planes of reference: axial, panoramic, and oblique sagittal (or
cross-sectional). The clarity and identical scale between the various views permits
all three planes. Unlike previous imaging techniques, the oblique sagittal view
permits the evaluation of distinct buccal and lingual cortical bone margins, as well
alveolar canals.
Monsour et al 2008 reported that the practitioner placing dental implants has
They also stated that the Intra-oral and extra-oral radiographs are generally low
dose but the information provided is limited as the images are not three-
variable. Computed tomography (CT) has been the gold standard for many years
dose to the patient. The latest imaging modality introduced is cone beam
volumetric tomography (CBVT) and this technology is very promising with
resonance imaging is showing some promise, but the examinations are not readily
available, generally expensive and bone is not well imaged. Magnetic resonance
imaging is excellent for demonstrating soft tissues and therefore may be of great
tooth with naturally occurring caries derived from an even newer system are
displayed. All data are consistent with the hypothesis that TACT imaging yields
Shah et al 2012 reviewed that with advances in dentistry, the need for more
From the simple intra-oral periapical X-rays, advanced imaging techniques like
imaging and ultrasound have also found place in modern dentistry. Changing
from analogue to digital radiography has not only made the process simpler and
cropping, etc.) and retrieval easier. The three-dimensional imaging has made the
complex cranio-facial structures more accessible for examination and early and
dentistry.
systems designed for imaging hard tissues of the maxillofacial region and
scans. Increasing availability of this technology provides the dental clinician with
CBCT scanners. We propose to use two dose metrics, the volume average dose
and the mid plane average dose, to quantify the dose performance in a circular
cone-beam scan. Under the condition of equal mid plane average dose, we
evaluated the image quality of a CBCT scanner and an MDCT scanner, including
low-contrast resolution to those obtained with the MDCT scanner when the doses
were matched (mid plane average dose 9.2 mGy). The CT number uniformity and
accuracy were worse on the CBCT scanner. The image artifacts caused by beam
hardening and scattering were also much more severe on the CBCT system. The
authors concluded that with a matched radiation dose, the CBCT system for sinus
relative to the MDCT scanner. Because of the more severe image artifacts on the
CBCT system due to the small field of view and the lack of accurate scatter and
beam-hardening correction, the utility of the CBCT system for diagnostic tasks
Background:
image cast from the cathode ray generator which was projected far beyond the
possible range of the cathode rays. A week after the discovery, Röntgen
discovered its medical use when he made a picture of his wife’s hand on a
rays. It clearly revealed her wedding ring and her bones. The first original dental
roentgenogram from a portion of a glass imaging plate was taken by Dr. Otto
Walkhoff in January 1896 in his own mouth for an exposure time of 25 min.
Since then, dental imaging has seen tremendous progress and its applications in
clinical signs or symptoms and are typically discovered only through use of dental
radiographs.
analogue and digital, ionizing and non-ionizing imaging, and two-dimensional (2-
reveal caries, periodontal and periapical diseases, and other osseous conditions. A
collapsing 3-D structural information onto a 2-D image, which leads to loss of
The objectives of diagnostic imaging depend upon the amount & type of
information required and the time period of treatment rendered. Imaging can be
sites & the presence or absence of disease at the proposed surgery sites.
sites during & immediately after surgery, assist in the optimal position and
are correct.
bone levels around each implant & to evaluate the implant complex.
IMAGING MODALITIES
Analog imaging modalities are two dimensional systems that use X-ray films are
intensifying screens as the image receptors. Digital images can also be produced
Peri-apical radiography
Panoramic radiography
Occlusal radiography
Cephalometric radiography
II 3-D modalities
• Computed tomography
• X-ray tomography .
important to observe certain guide lines to improve their accuracy and avoid
excessive base fog, improper exposure factors or poor processing which can
reduce the diagnostic value of a film. Secondly exposures should be made with a
collimated beam, a long target to film distance and a paralleling technique. These
1. Useful high yield modality for ruling out local bone or dental disease.
spatial relationship between the structures & the proposed implant site.
may be distorted and does not depict the third dimension of bone width.
4. Of limited value in determining bone density or mineralization because the
lateral cortical plates prevent the accurate interpretation and cannot differentiate
Occlusal Radiographs:
Occlusal films are some times used in the setup for computed tomographic
examinations in the mandible. Data from these images are used to map the areas
to be scanned and to measure the distance between teeth or the distance along the
buccolingual width of bone because they show only the widest dimension, usually
at or near the inferior border of the mandible. Occlusal films in either arch may
aid is the diagnosis of disease. They are rarely helpful or reliable in establishing
bony dimensions.
Lateral Cephalometric Images:
Lateral cephalometric images are obtained with the midsagittal plane of the
patient 5 feet from the target of the X ray tube. Because the film is close to the
included in the x-ray field so that corrections for small amount of magnification
are possible. A head holder ensures that a true lateral position is obtained with a
both the mandible & the maxilla can be demonstrated in the lateral incisor or in
the canine region as well. The cross sectional view of the alveolus demonstrates
the spatial relationship between occlusion & esthetics with the length width,
angulation and geometry of the alveolus & is more accurate for bone quantity
demonstrates the geometry of the alveolus in the anterior region and the
relationship of the lingual plate to the patient’s 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 bone for
ridge augmentation. It also gives a spatial relationship of the implant site with the
view can help evaluate loss of vertical dimension, skeletal interarch relationship,
anterior crown implant ratio, anterior tooth position in the prosthesis and resultant
moment of force.
Panoramic Radiography:
maxilla. They are magnified by approximately 10% to 20% but the amount of
directions with any degree of certainty. Although panoramic images may provide
a useful overview and may be used in conjuction with ridge mapping or other
diagnostic tools, they are unlikely to meet strict criteria for a primary images test
3. The procedure is performed with convenience, ease & speed in most dental
offices.
4. Gross anatomy of the jaws and any related pathologic findings can be
evaluated.
Computed Tomography:
neuroscientists viewed the brain. These devices produced a pair of 1cm thick
In May 1987 a special software by the name of Denta scan was introduced
which helped in the preoperative analysis of both maxilla and mandible for
1. Computerized couch
Patient is placed in supine position & mouth is held open either with a
with gauze. Pt is instructed to hold absolutely still and not to speak or swallow
while the data are being gathered. The alveolar ridge should be aligned
perpendicular to the top of the table. To verify proper angulation a lateral scout
cortical border and stop at a plane through the cusps of teeth. In maxillary
examinations, scanning begins at the cusps of any remaining natural teeth and is
Each CT image is 1.5mm thick. It is called an axial image because its plane is
perpendicular to the long axis of the body. The picture is usually created as a 512
bone and fatty marrow, they have found it necessary to set the interslice distance
at 1mm when studying the mandible. The maxilla is generally scanned at 1.5mm
optimal length, position and orientation of the implant, the surgeon must be able
to visualize the configuration of the alveolar ridge in cross section and must be
able to measure the height & buccolingual dimension at the exact positions where
CT images along the curvature of the bone from the axial CT data stored in the
Using elaborate programs the computer is directed to rearrange the data &
display, all of the data points along an axis. It is possible to produce panoramic
radiograph. There are special dental reformatting programs that will automatically
produce a series of images of known size sequentially around the jaw, number
them, and organize them so that they can be photographed on several sheets of X-
ray films to reduce the time consumption. These films can be analyzed in the
It is important that the image data should be displayed on the fewest number
of X-ray films. The images should be nearly life sized so that measurements can
be made with a ruler or calipers directly from the films. It also helps in cross
After the scan, a technologist chooses one of the stack of the axial scans as a
reference slice.This slice should be through the roots of any remaining teeth at a
The technologist then draws a line around the curvature of the jaw by placing
a series of sequential dots from the posterior right border of the jaw to the
posterior left, the computer then generates a curve from these dots. A command is
given and the computer creates a series of lines perpendicular to the previously
sequentially and the buccal and lingual sides are marked. The distance between
the marks is equivalent to the spaces between the original axial scans. In most
cases that will be 1mm in the mandible and 1.5mm in the maxilla.
curves around the jaw paralleling the original curve. Two curves produced lingual
& two buccal to the original curve. Five panoramic reformations are then made
along those lines and the image sequentially labeled from buccal to lingual side.
The surgeon & prosthetic dentist decide the position for optimal fixture
positions the axial and panoramic views and using the corresponding oblique
cross sectional images measure the height and buccolingual dimension of the
bone where fixtures need to be placed. Thus, Denta scan can be used as an
bone trajectory to avoid iatrogenic injury and choosing appropriate implant shape
implant sites
quality
the image.
1. Produce cross sections perpendicular to the alveolar ridge which are blurry
in nature.
3. Use of stents with radio opaque markers must be fabricated prior to the
Xray film examination, and if the bone is found inadequate in any of the marked
4. Time consuming.
Subtraction Radiography:
sensitive and potential diagnostic tool for assessment of periodontal and peri
implant tissue changes. As early as 2-3 months post surgically an increase in bone
radiography.
Digitised images are imported into the subtraction software allowing analysis
of the alveolar bone changes. The first step in the software is to align the paired
images by selecting the same sets of two reference points. The software then
compares the coordinates of the reference points and moves the subsequent image
vertically, horizontally, and rotationally until the pairs of images are matched.
the images are digitally subtracted. The selected sites are defined as regions of
Paired radiographs are taken at the same appointment and processed together
in different patients randomly in order to determine the threshold used for the
digital subtraction radiography system (Woo et al. 2003). This threshold value is
then applied in all subsequent digital radiographic subtractions and allows for the
in dentistry for several decades (Webber et al. 1990, Grondahl et al. 1983,
Hausmann et al. 1985). Grondahl et al. (1987) found that there was a higher inter-
interdental sites were removed, with a variation in the diameters of the artificially
as producing a „signal‟ (presence of a lesion) or ―no signal‖ (no lesion) and this
was repeated three times for each radiograph with a interval of one week between
viewings. The detection threshold was defined as the smallest defect in a series of
at least three consecutive increasing defect sizes which was consistently detected
at the three examinations performed at intervals of one week. It was found that the
smallest periodontal bone changes were detected with the quantitative digital
experiment been in vivo, results may have varied due to the difficulty of
standardising X-ray images and changes in exposure parameters between baseline
and follow-up examinations. Other in vitro studies have examined the sensitivity
the field of oral and maxillofacial radiology. CBCT imaging provides three-
structures with isotropic resolution and high dimensional accuracy. Cone beam
(Arai et al. 1999) and the first machines became commercially available during
2000 (Terakado et al. 2000, Ito et al. 2001a). There are now several machines
available on the market, including the i-CAT and Newtom CB3D scanners, and
visualization of the oral hard tissues, though there are some fundamental
detector.
radiation dose is lower than a multi-slice CT scan of the jaws (Hashimoto et al.
2003) though the reduced exposure results in a reduction in soft tissue contrast
and increased intrusion of noise (Ludlow et al. 2003, Schulze et al. 2004).
radiation dose than medical CT as well as lower cost to the patient. CBCT may be
since it has a relatively low acquisition time and patient dose, and the images are
has become the standard format protocol for large image data sets such as CBCT-
based data sets. There is a wide range of software able to import DICOM files and
export sections or images in other formats, which can later be used for specific
measurements
CBCT units can be dedicated machines for only 1 field of view (FOV) or
are as follows:
and craniofacial regions for orthodontic and oral surgery, and evaluation of the
temporomandibular joints.
4. Stitched scans from multiple focused FOV scans provide larger regions of
The dimensions of the field of view (FOV) or scan volume that are to be
covered primarily depend on the detector size and shape, the beam projection
geometry, and the ability to collimate the beam. The shape of the scan volume can
ray beam limits x-radiation exposure to the region of interest. Field size limitation
therefore ensures that an optimal FOV can be selected for each patient, based on
greater than the FOV of the detector. One method involves obtaining data from
two or more separate scans and super imposing the overlapping regions of the
regions are imaged twice, resulting in double the radiation dose to such
regions. A second method to increase the height or width of the FOV using a
small area detector is to offset the position of the detector, collimate the beam
asymmetrically, and scan only half the patient’s ROI in each of the two offset
scans.
widely examined in the past years, spurred by the increase in usage of this
radiographic method. Sherrard et al. (2010) assessed the accuracy and reliability
Different voxel sizes were used and the measurements were compared to
periapical radiographs. While the periapical radiographs could overestimate or
underestimate root and tooth lengths by up to a mean of 2.58mm, the CBCT could
reproducibly and accurately measure with a mean error of less than 0.3mm.
Using an in vitro geometric model, Marmulla et al. (2005) found that the
0.3mm, when using the NewTom 9000 scanner (NewTom AG, Marburg,
Germany). Using the same CBCT scanner, Lascala et al. (2004) compared direct
CBCT images. It was found that the CBCT tended to underestimate the
measurement but the difference was only significant when measuring the skull
Pinsky et al. (2006) assessed in vitro simulated bone defects in an acrylic block
measurements. Other studies have found similar accuracies (Ballrick et al. 2008,
alveolar nerve, maxillary sinus, mental foramen, and adjacent roots are easily
viewed using CBCT. Further, these specific CBCT images permit precise
depending on the center of rotation it takes for the particular structure. This must
concluded that the CBCT image underestimates the actual distance. However,
these differences were significant only for the skull base. The detail of a CBCT
formatting the volumetric data set. CBCT units in general provide voxel
resolutions that are isotropic—equal in all three dimensions. Imaging of the dental
and maxillofacial regions were found to be quite accurate as the voxels exhibit a
significant differences. The fact that measurements from the CBCT are routinely
accurate throughout the maxilla and mandible makes this an excellent imaging
procedures such as sinus lift and ridge augmentation, apart from gaining a secure
image, in the complete absence of the patient (thereby reducing the number of
prefabrication of the abutments and prosthesis, and ―same day‖ delivery of the
prosthesis. Computed tomography (CT) images also have similar capabilities, but
the benefit of CBCT is less radiation exposure to the patient and greater image
accuracy.
Medical CT
Some cone beam manufacturers and vendors are dedicated to the dental
down in a medical CT unit. This, together with the open design of the CBCTs
acceptance.
The lower cost of the machine may be passed on to the patient in the form
of lower fees
CT in comparison to CBCT
Metal artifacts or metal spraying is much lesser in the CBCT when
compared to the CT. Therefore, use of localization markers for precision marking
is possible
The primary use of CBCT in the facial region is for implant planning, and
CBCT which due to the nature of volumetric imaging renders it inaccurate and the
CBCT beats the CT in the facial skeleton imaging (due to the complex
nature of the anatomy and the machine design) while in all other regions CT may
almost entirely by radiographs alone and hence they are considered essential for
planning and monitoring. CBCT is currently advocated for the assessment of the
patient to ionising radiation in adherence with the ALARA principle (as low as
reasonably achievable).
standard of protection for man without unduly limiting the beneficial actions
giving rise to radiation exposure‖. The latest guidelines (Wrixon 2008) establish
thresholds on the maximum individual dose (from specified sources) for safe
radiation doses to patients and also quantify tissue weighting for effective dose
calculations. For situations that have a societal benefit but no individual benefit,
risk caused by a uniform exposure of the whole body. As different body tissues
the equivalent dose to different body tissues and the weighting factors designed to
reflect the different radiosensitivities of the tissues. Additionally, the 2005 and
for dental radiography, which has a high possibility of including susceptible body
tissues, the effective dose of different modalities increased due to increased tissue
weightings.
depending upon the settings of the X-ray unit, including the kilovolt potential
(kVp) and tube current (milliamps). Additionally, effective doses have been
enhancement of images. Ngan et al. (2003) compared the radiation doses of facial
CT scans with the radiation doses when taking a lateral cephalometric radiograph,
The effective dose of CBCT scans has been shown to be greater than
has found that the effective dose of a CBCT scan ranges from 52 μSv to 1025μSv
(Monsour & Dudhia 2008) and of four machines assessed, the i-CAT CBCT
machine had the best image quality for the radiation dose (Loubele et al. 2008).
Studies evaluating the effective dose of the i- CAT CBCT machine vary
depending upon the tissue weighting. Using the 2007 Recommendations (which
were the same as the 2005 draft recommendations), the effective dose of an i-
CAT full field of view scan (of the maxillae; and mandible) is approximately
Recently, Roberts et al. (2009) found that the effective dose of a high
resolution scan of the mandible is 188.5 μSv and a high resolution scan of the
maxilla is 93.3 μSv. Standard resolution scans and full 13cm scans (compared
with combined single scans) produced much lower effective doses of radiation.
Thus, based upon radiation exposure to patients, the i-CAT CBCT scanner could
be warranted.
RADIOGRAPHY IN PROSTHODONTICS
esthetics and/or function of their existing dentition. They could also be missing or
more teeth (partially edentulous) or all of their teeth (completely edentulous) and
prosthodontists use to restore and/or replace the deficient tissues may be divided
implants.
they show the relative thickness of alveolar ridge and the mucoperiosteum, the
and surrounding structures. Panoramic dental radiograph are readily available for
radiographs.
single film the patient’s general dental condition, treatment requirements, and
periapical radiograph.’
Intraoral radiographs have limited role in edentulous patients. They can used
phosphor based films CCD (charge couple devices) and CMOS (complementary
metal oxide semiconductor) are well under way. This is limiting the exposure of
patients to radiations.
Radiographs in complete dentures should rule out foreign bodies, retained root
Radiographs are usually taken to find out the presence of hidden abnormalities, to
note the structure of cortical bone and trabeculae, sharp projections, thickness of
soft tissue etc., Retained roots with no apparent pathology can often be left alone
very useful system of classifying the amount of ridge resorption was described by
WICAL & SWOOPE. They found that the lower edge of mental foramena
divides the mandible into thirds in normal dentulous panaromic radiograph. If the
radiographs are faster reduce patient exposure to radiation and image the entire
PROSTHODONTICS
Most of dental patients prefer reconstruction with fixed partial dentures (FPD)
standards and rules of FPDs may cause different dental problems. Successful
abutment teeth and the number of missing teeth. Radiographs are used to evaluate
the number of missing teeth, bone quality and quantity, pulpal health, any
endodontic treatment, caries, periodontal diseases, crown root ratio and various
hygiene.
Planning
unfavorable because ever a small loss of bone height can greatly diminish
Multirooted teeth with divergent and curved roots are better than single
Position of roots of adjacent tooth is also important, in case the roots are
embedded is bone is a very critical factor. If the crown root ratio is greater than
1:1 then the tooth has a poor prognosis as an abutment. It is also poor when there
evaluating the stability of the teeth. A thin uniform ligament space and an
A thickening of the lamina dura may occur if the tooth is mobile, has
Destruction forces or the disease processes causing changes in the lamina dura
Bones which has small closely grouped trabecular and small inter
resulting from angulations factors with is normally used in the short cone or
As a result of the central ray using shot at an angle results in the buccal
bone to be projected higher on the crown than the lingual or palatal bone.
of the lamina dura from the apex towards the crown of the tooth until the opacity
This additional amount of bone represents false bone height. Thus the true
height of the bone is ordinarily where the lamina shines a mark decrease in
opacity.
At this point the trabecular pattern of the bone superimposed on the tooth
root is lost. And the portion of the root b/w the CEJ and the true bone height has
Index areas are those areas of alveolar support that disclose the reaction of
Teeth that have been subjected to greater than normal stress and provide good
must be noted.
Buried root tips or impacted teeth that show no signs of any pathosis and
Roentgenographic interpretation
are those relative to prognosis of remaining teeth that may be used as abutments.
The quality of the alveolar support of an abutment tooth is of prime
importance because the tooth will have to withstand greater stress loads when
teeth adjacent to distal extension bases are subjected not only to vertical and
(a) to locate areas of infection and other pathosis that may be present;
(b) to reveal the presence of root fragments, foreign objects, bone spicules, and
(c) to display the presence and extent of caries and the relation of carious lesions
(e) to reveal the presence of root canal fillings and to permit their evaluation as to
future prognosis (the design of the removable partial denture may hinge on the
supporting length and morphology of their roots, the relative amount of alveolar
bone loss suffered through pathogenic processes, and the amount of alveolar
(9) caries;
extra oral facial structures which have been congenitally malformed or lost
due to trauma.
4. investigations of antra
6. TMJ disorders
developmental defects like clefts and eye , ear, nose and cranial prosthesis
2. Lateral Cephalogram
3. CT scan
4. Ultrasound
Radiographs of mandible
1. P-A mandible
3. Lateral oblique
4. CT/ CBCT
1. Jughandle view
1. Submentovertex projection
Radiographs of skull
1. Lateral cephalogram
3. P-A cephalogram
4. P-A skull
5. TOWNES projection
augmented virtual models of the patient’s face, bony structures, and dentition can
be created out of CBCT DICOM data by software volume rendering for treatment
non-alterable primary image that helps prevent malpractice. DICOM enables the
viewer to work on any workstation. The shape of the graft can be virtually
planned and can also be positioned in the defect creating a virtual reconstruction
of the defect prior to the actual surgery. In addition, implant placement onto the
graft can also be planned. Obturators for cleft closures can be precisely milled in
1. Panoromic radiography
2. Transcranial projection
3. Tomography
4. Arthromography
6. MRI
7. Computed tomography
Special imaging techniques are needed to study the complex anatomy and
pathology of the TMJ. It is very common to take an image of the joint when there
is locking, pain and articular sounds. The clinician should properly decide which
when imaging the TMJ is the interpretation of the joint function, which can be
accomplished by comparing the condyle in the closed and opened mouth position.
Panoramic radiography
It shows the jaws and the associated structures, being a helpful tool for the
Panoramic radiography does not appear in the list of imaging techniques provided
by RDC/TMD. Only the lateral part of the condyle can be assessed with this
technique, being limited due to the superimposition of the zygomatic arch and the
base of the skull. Panoramic radiography can help evaluate the following:
• degenerative bone changes (only in late stages; it is inadequate for the
• hyperplasia, hypoplasia;
• trauma;
• tumors.
DISADVANTAGES- does not reveal the functional status of the joint and
has a relatively low specificity and sensitivity when compared with CT.
images for patients with TMD. Nevertheless, some authors have suggested
head position could affect the image of TMJ, simulating different bone
but when these changes are suspected, and the radiography is normal, CT should
be performed.
Plain radiography- Consists of transcranial projection of TMJ with different
Advantages-
Some studies have shown that the position of the condyle in the fossa is of
little clinical significance. Other studies suggest that the posterior position of the
anterior disc displacement. The position of the head during the examination could
influence the joint space, which could influence the interpretation of the
radiographs. The use of flat plane films for TMJ pathology is not sufficient,
because this joint requires three dimensional imaging views. CT has been reported
Some studies have reported that radiographic changes in the joint are not
always related to pain. Therefore, some patients with osseous abnormalities may
experience pain, others may be pain free. Changes in the shape and location of the
loading zone can also be seen on CT. CT is the main radiological investigation for
examination of the TMJ should focus on the following: intactness of the cortex,
normal size and shape of the condyles and their centered position in the fossa, the
Arthrography is a dynamic investigation, but was never widely used, due to its
invasiveness, pain and allergic reaction. TMJ disc pathology and lateral pterygoid
ADVANTAGES-
changes.
Silvia Caruso et al pointed out the main contributions of cone beam CT in the
field of TMJ:
• clarifies that, in case of facial asymmetry, the condyles are often symmetric,
Imaging the soft tissue structures of the TMJ (articular disc, synovial
tissue, changes in shape of the disc, joint effusion. Images can be obtained in all
weighted and proton-density (PD) images are obtained. The PD images serve to
diagnosing inflammation in the joint. The slice thickness is important for image
quality. The most frequent used section thickness is 3 mm. Reducing the slice
thickness improves the quality of the images, but requires longer scanning time.
An axial localizing image is used to direct the long axis of the condyle in the
closed-mouth position. Sagittal images are obtained perpendicular to the long axis
of the condyle, and coronal images are obtained parallel to the long axis.
zone of the meniscus (as a point of reference) and its interposition between the
anterior, posterior, medial or lateral position with regard to the condylar surface.
fluid. Some studies have investigated the relationship between the articular
eminence morphology and disc patterns in patients with disc displacements. The
• may miss different bone conditions and soft tissue calcifications with
modality .
RADIOGRAPHS IN IMPLANTOLOGY
that CBCT is the preferred imaging method for obtaining the pretreatment images.
be taken for the initial pretreatment evaluation to determine whether the patient is
a candidate for implants before taking a CBCT scan. The anatomy surrounding
Before focusing on the height and width of the residual alveolar bone to measure
the dimensions for implant placement, the entire volume should be reviewed to
Bone has an internal structure described in terms of quality or density that reflects
treatment planning, implant design, surgical approach, healing issue and initial
Classification
• Class I - ideal bone type, since it consists of evenly spaced trabeculae with small
• Class II – has slightly larger cancellated spaces with less uniformity of the
• Class III- large marrow filled spaces exist b/w bony trabeculae. Results in loose
fitting implant.
Significance-
Listed four basic qualities found in the anterior regions of the jaw
Bone quality
Classification by Misch(1988)
Bone Density and Tactile Sense.
implants into D1 bone is similar to drilling into oak or maple wood, D2 is similar
to drilling into white pine or spruce. D3 is similar to drilling into balsa wood and
D4 into Styrofoam.
Bone Density Location.
about 8%. It is observed twice as often in anterior mandible compared with the
posterior mandible.
The anterior mandible consists of D2 bone 2/3 of times. D2 is more likely in the
partially edentulous anterior and pre molar region rather than completely
D4 bone.
Periapical and panoramic radiographs are not beneficial to determine bone density
because the lateral cortical plate often obscures the trabecular bone density. One
to long axis of the body. Each CT axial image has 260000 pixels, and each pixel
has a CT number (Hounsfield unit). In general higher the CT number denser the
tissue.
to a range of HF units.
AVAILABLE BONE
Long term success in implant dentistry requires the evaluation of more than 50
dental criteria. However, the amount and density of the available bone in the
edentulous site of the patients are arguably the primary determining factors in
Definition- Available bone describes the amount of bone in the edentulous area
This margin of error is especially critical when the opposing landmark is the
The diameter of a root form implant is related to the width and mesiodistal length
of available bone
Classification Mish and Judy (1985)
AVAILABLE BONE HEIGHT
The height of the available bone is measured from the crest of the edentulous
ridge to the opposing landmark. The anterior regions are limited by the maxillary
The anterior regions of the jaws have the greatest bone height because
themaxillary sinus and inferior alveolar nerve limit this dimension in the posterior
regions. Maxillary canine eminence region often offers greater height of available
bone height than other maxillary anterior sites. Usually greater bone height is
available in the maxillary 1" pre molar than in the 2nd premolar which has greater
height than the molar sites because of the concave morphology of the maxillary
sinus floor. The mandibular 15 premolar region is usually anterior to the mental
foramen and provides the most vertical column of bone in the mandible.
However, on occasion, this site may present a reduced height compared with the
anterior region because of the anterior loop of the mandibular canal as it passes
below the foramen and proceeds superiorly then distally, before its exit through
The suggested minimum bone height for predictable long term endosteal
The width of the Available bone is measured between the facial and lingual plates
at the crest of the potential implant sites. In most areas, because of this triangular
reduced height. However, the anterior maxilla does not follow this rule because
most edentulous ridges exhibit a labial concavity in the incisor region, which is
implant the next most significant criteria affecting long term survival of implants
is width of available bone. Root form implants of 4mm crestal diameter usually
require more than 5mm of bone width to ensure sufficient bone thickness and
The mesio distal length of the available bone in an edentulous area is often limited
As a general rule the implant should be at least 1.5mm from an adjacent tooth this
dimension not only allows surgical errors but also compensate for the width of an
Ex: a 5mm diameter implant should have at least 8mm of mesiodistal bone a so
The Available bone angulation represents the root trajectory in relation to the
occlusal plane. In anterior edentulous maxillary arch, labial undercuts and orption
after tooth loss often mandate greater angulation of the implants or correction of
the site before insertion. In the posterior mandible, the submandibular fossa
planning.
TREATMENT PLANNING BASED ON ANATOMICAL STRUCTURES:
of the CBCT:
1. Maxillary tuberosity
2. Maxillary sinuses
and antroliths
3. Nasopalatine canal
Mandible
loop
6. Genial tubercles
distance from adjacent anatomy and adequate surrounding bone volume for
3. Incisal-apical (IA) dimension: the bone crest to the interproximal contact point
enamel junction
support the desired prosthesis should be taken into consideration during the
(A-P) spread for fixed and removable prostheses may sometimes be offset by the
arch. At least 4 implants are recommended for maxillary and mandibular full-arch
fixed or maxillary removable prosthesis. For mandibular complete removable
Restorative space is calculated from the implant platform to the occlusal surface
of the planned restoration, and it depends on the type of prosthesis planned. This
prosthesis requires different restorative space, which is why the selection of the
will have adequate space/thickness for long-lasting results (Fig. 11). If residual
PROSTHODONTIC PATIENTS
In prosthodontically driven implant imaging, the definitive prosthesis
of the fixtures as dictated by the prosthetic teeth, stents are sometimes used during
the scanning procedure. It is well known that because of the resorptive patterns of
the alveolar ridges, the prosthetic teeth may be set off the ridges in order to satisfy
the patient’s requirements for esthetics, phonetics and lip support. In reading that
whether the axial inclination of the fixture can be or should be tipped toward the
and/or fiducial markers transfer both the proposed prosthesis design and desired
implant location for appropriate CBCT scan. There are several approaches
radiopaque acrylic material such as barium sulfate. This stent is made using a
stent by modification. This stent must be sterilized and then at the time of surgery,
the surgeon simply aligns his or her burs relative to the markers and relative to the
crest of ridge in the same relationship to these two known reference points that he
did with his straight edge on the CT images. It has been shown that the combined
data from intraoral scanners like the Cerec Omnicam® or Cerec Bluecam®
workflow is as follows:
impression
II. clinician can take a traditional impression and then scan the
the CBCT scan and data from digital impression as the standard tessellation
the clinician to evaluate potential implant receptor sites with greater accuracy.
7. A virtual crown is used to guide the placement of the virtual implant for
length; and the design of the restoration in terms of screw or cement retention
For partially edentulous patients- the DICOM file from the CBCT and the .stl
file from the digital wax-up. Then, the surgical guide is milled for pilot or fully
guided surgery.
made of the patient with the radiographic guide in place and the second scan is
made of the radiographic guide separately. Both scans are merged in the planning
software using the fiducial markers in order to plan and fabricate a surgical guide.
In the ―prosthetically driven implant‖ technique, a radiopaque marker
(barium coated teeth) can be utilized to demarcate the final tooth position. This
data, when aligned on CBCT, can be utilized to create a surgical guide for precise
allow in determining the volume of graft needed prior to surgery and the type of
graft material to select. Heiland et al. described the intra-operative use of CBCT
in two cases to guide the insertion of the implant after microsurgical bone
transfer. Post-graft imaging would reveal the amount of bone formed and will also
valuable information about the thickening and perforations involving the sinus
membrane, patency of the osteomeatal complex and also aids in more informed
planning with respect to surgical access into the sinus. This confirms that the
Thus, CBCT scans are reliable and accurate in dental treatment with a rapidly
of CBCT for implant assessment. However, it is still the most accurate and
The selection of the proper radiological technique for the patient must be
carefully made by the practitioner, in correlation with the clinical signs and
symptoms. The purpose of the chosen radiological investigation must improve the
specific indications and varying degrees of sensitivity and specificity. From the
analogue to digital radiography has not only made the process simpler and faster
cropping, etc.) and retrieval easier. The three-dimensional imaging has made the
complex cranio-facial structures more accessible for examination and early and
when planning treatment for dental implants. Proper dental implant placement for
of the proposed bone recipient site, evaluation of bone density, and assessment of
proper restorative evaluation to ensure that the final outcome is compatible with
expected outcomes
CONCLUSION
and their specificity help to eliminate unnecessary radiation hazards and control
helps the prosthodontist correlate all the facts that have been collected listening to
the patient , examining the mouth and evaluating the diagnostic cast. Proper
interpretation.
REFERENCES
2. Kapshe, Nikita & Pujar, Madhu & Jaiswal, Satyam. (2020). Cone beam
2001;16:80-89
6. Bhatia HP, Goel S, Srivastava B. Denta Scan. J oral Health Comm Dent
11. John GP, Joy TE, Mathew J, Kumar VR. Applications of cone beam
2016;16:3‑ 7.
doi:10.1016/j.cden.2014.04.002
15.Schmitt SM (2009) Dental digital diagnosis and treatment: new tools for
16. Misch CE. Contemporary implant dentistry. 2th edn. St. Louis: Mosby;
1997:3.
18. Monson ML. Diagnostic and surgical guides for placement of dental
20. Pollack BR. Legal risks associated with implant dentistry. In'. Hardin JF,
22. Berger D. A brief history of medical diagnosis and the birth of the clinical
23. Lamster IB. A Model for Dental Practice in the 21st Century. Am J
25. Basic Implant Surgery, R.Palmer, P.Palmer, Floyd, Vol 187,No 8,OCT
23,1999,BDJ
27. Wyatt CC, Pharoah MJ. Imaging techniques and image interpretation for
doi:10.1016/j.cden.2021.02.007