Diagnostic imaging plays an important role in treatment planning for dental implants. This document discusses various imaging modalities and their use at different phases of implant treatment. 2D imaging like panoramic radiographs provide an overall view but lack detail. Cross-sectional imaging like CT provides more detailed assessment of bone dimensions, quality and proximity to anatomical structures, important for accurate implant planning and placement. The selection of an appropriate imaging technique depends on the treatment phase and desired information.

1. Diagnostic Imaging for the Implant Patient
-Dr.Oinam Monica Devi

2. Contents
• Introduction
• Standard Projections
• Cross – sectional imaging
• Interactive “ Simulation” Software Programs
• Patient Evaluation
• Clinical Selection of Diagnostic Imaging
• Conclusion

3. • Diagnostic imaging techniques help to create effective and accurate treatment plans for
implant patients.
• Radiographic modalities help define region anatomic requirements for the positioning of
implants.
• The selection of an accurate and comprehensive imaging system is the first and very
basic step toward obtaining the required information along with the best dimensional
accuracy.
• Until the late 1980s, conventional radiographic techniques such as intraoral,
cephalometric and panoramic views have been the accepted standard.
• Recent advances in imaging techniques have increased the level of precision that can
be delivered at the treatment phase for dental implants.
Introduction

4. • Successful rehabilitation with implants is highly dependent on proper diagnosis and
treatment planning; this is dependent on accurate imaging as well as skillful
interpretation.
• The variety of imaging modalities available vary from simple 2-Dimensional views
such as panoramic radiographs to more complex views which allow image
visualization in multiple planes.
• In the year 2000, The American Academy of Oral and Maxillofacial Radiology
recommended that clinicians should employ cross-sectional imaging to plan implant
cases.
• The imaging techniques should ideally enable the operating dentist to assess the
quality and quantity of bone present in addition to visualizing the locations and
proximity of critical internal anatomical structures to the implant site.

5. • Imaging modalities for dental implants can be broadly classified as Analog or
Digital and 2-Dimentional or 3 – Dimensional imaging modalities.
• Analog imaging modalities include peri-apical radiographs, occlusal radiographs,
panoramic radiographs and 2-Dimensional lateral cephalometric radiographs which
use X-ray films and / or intensifying screens as the image receptors.
• Images obtained by the use of digital imaging modalities provide better information
with regard to depth, width, height and image clarity.
• These modalities include computed tomography, tuned aperture computed
tomography, cone-beam CT and magnetic resonance imaging.

6. The Goals of Imaging
• To measure bone height and width (bone dimensions)
• To assess bone quality
• To determine the long axis of alveolar bone
• To identify and localize internal anatomy
• To establish jaw boundaries
• To detect any underlying pathology
• To estimate implant position, orientation, and prognosis

7. Requirements of an Imaging Modality
Any diagnostic imaging modality should ideally satisfy the following
basic principles:
1. Adequate number and types of images should be obtainable in order to provide
required anatomical information.
2. The imaging technique selected should provide the accurate required information.
3. It should be possible to accurately relate the images available to the anatomy of the
patient.
4. The images obtained should be with minimal distortion.
5. If more than one imaging modality is feasible, the imaging information should be
governed by the ALARA (As Low As Reasonably Achieved) principle.
6. It should be affordable for most patients.

9. Imaging Modality in Three Phases of Treatment
Phase 1: Preprosthetic Implant Imaging
• Imaging in this phase determines
1. The quantity, quality, and angulation of bone
2. Relationship of critical structures to prospective implant sites
3. The presence or absence of disease at the proposed surgical sites

10. Phase 2: Surgical and Interventional Implant Imaging
• Imaging in this phase evaluates the surgical sites during and immediately after surgery.
• Assists in the optimal positioning and orientation of dental implants.
• Ascertains the healing and integration phase of implant surgery.
• It also ensures appropriate abutment positioning and prosthesis fabrication.

11. Phase 3: Post-prosthetic Implant Imaging
• This phase commences just after placement of the prosthesis and continues as long as the
implant remains in the jaw.
• Imaging in this phase evaluates the long-term change, if any, in the implant’s fixed
position and function, including the crestal bone levels around each implant, and
evaluates the status and prognosis of the dental implant.
• It also helps to routinely assess the bone adjacent to the dental implant to note any
changes in mineralization or bone volume.

12. STANDARD PROJECTIONS
1. Periapical Radiographs
2. Occlusal Radiographs
3. Panaromic Radiographs
4. Lateral Cephalometric Radiographs
5. Digital peri-apical imaging

13. Periapical Radiographs
• Used during the initial stages of clinical examination to evaluate small edentulous
spaces, status of teeth adjacent to the planned implant site and/ or regions of
single implants during surgery to determine implant alignment.
• Used post-surgery to check for the presence of any pathosis and/or prognosis
during recall appointments and placement.
• Vertical height, architecture and bone quality, bone density, amount of cortical
bone and amount of trabecular bone can also be determined to some extent with
the use of peri-apical radiographs.

14. • Periapical radiographs produce high resolution planar images.
• No information on the width of the available bone and the proximity of critical
anatomical structures is possible with the use of peri-apical radiographs.
• When periapical radiographs are used it is mandatory that exposure should be made
using the paralleling angle technique which helps limit both distortion and
magnification.

15. Radiographic techniques:-
• Two techniques for periapical radiography have been developed:
(i) Paralleling technique
1. The film packet is placed in a holder and positioned in mouth parallel to the long axis
of implant under investigation.
2. The X-ray tubehead is then aimed at right angles (vertically and horizontally) to both
the implant and the film packet.
3. By using a film holder with fixed film packet and X-ray tubehead positions, the
technique is reproducible.

16. • An important aspect of radiologic evaluation should be a qualitative description of bone
in a given area.
• The Misch system is widely divides bone into four subdivisions (D-1 to D-4) based on
observed density.
1. D-1 bone - characterized by thick, dense cortices surrounding densely calcified spongy
bone, with little or no porosity; normally found in atrophic anterior mandibles.
2. D-2 bone - characterized by dense cortical plates; thick, coarse trabeculae; and small
areolar spaces; normally found in the anterior maxilla and mandible and in the posterior
mandible.
3. D-3 bone - thin cortical bone and poorly mineralized or thin trabeculae; found in
anterior and posterior maxilla, in posterior mandible, and after osteoplasty of D-2 bone.
4. D-4 bone - characterized by thin or absent cortical plates with a paucity of mineralized
trabeculae; often found in posterior maxilla or in post-osteoplasty D-3 bone.
• Implants placed in either D-1 or D-2 bone stand an excellent chance of undergoing
osseointegration, while implants placed in D-3 or D-4 bone either undergo fibro
integration or fail to integrate at all.

17. • This positioning has the potential to satisfy most of the ideal requirements.
• The anatomy of palate and the shape of arches mean that the implant and the film packet
cannot be both parallel and in contact.
• To prevent the magnification and distortion of the image, a large focal spot to skin
distance can be achieved, by having a long spacer cone or beam-indicating device (BID)
on the X-ray set.
• When x-ray is perpendicular to film but not to object, foreshortening will occur.

18. (ii) Bisected angle technique
1. The film packet is placed as close to object under investigation as possible without
bending the packet.
2. The angle formed between the long axis of object and long axis of the film packet is
assessed and mentally bisected.
3. The X-ray tubehead is positioned at right angles to this bisecting line with the
central ray of the X-ray beam aimed through the tooth apex.
4. Using the geometrical principle of similar triangles, the actual length of the object
in mouth will be equal to the length of the object‟s image on the film.

19. Advantages
1. Easily available
2. Greater resolution
3. Cost effective
4. Less distortion
5. Low dose
Disadvantages
1. Limited area imaging
2. Facio-lingual dimension not
recorded
3. Limited reproducibility
4. Image distortion

20. Occlusal Radiographs
• Planar radiographs
• Placed between the occlusal surfaces of the teeth with the central beam directed at 90o to
the plane of the film.
• The patients head is rotated so that the film is at right angles to the floor.
• The film intra-orally parallel to the occlusal plane with central x-ray beam perpendicular to
the film for mandibular image and oblique (usually 45°) to the film for maxillary image.

21. • The main application is to determine the bucco-lingual dimensions of the
mandibular alveolar ridge.
• Mandibular occlusal radiograph projection is an orthogonal projection, it is less
distorted than the maxillary occlusal radiograph.
• Due to anatomic constraints its application in the maxilla is limited.
• Maxillary occlusal radiographs are inherently oblique and so distorted that they are
of no quantitative use for implant dentistry for determining the geometry or the
degree of mineralization of the implant site.
• The main disadvantage is that it records only the widest portion of the mandible and
little information is available regarding the width of the crest which is actually of
chief interest to the operator.
• Its use in implant dentistry is limited.

22. Advantages
1. Easy availability
2. High image definition
3. Relatively large imaging area
4. Low cost
5. Low dose
Disadvantages
1. Image superimposition
2. Not much information on
bucco-lingual dimension
3. Less use in maxilla
4. Limited reproducibility

23. Panaromic Radiographs
• It produce a single image of size 5”x11” of the maxilla, mandible and its supporting
structures in a frontal plane.
• It provides for better visualization of the jaws and anatomical structures.
• This modality of imaging has highly variable magnification in the horizontal plane
when compared to the vertical plane.
• The main limitation of it is that the procedure cannot be performed in the dental
operatory and requires additional set up.
• Optimal patient positioning is crucial in this procedure because jaw positioning errors in
the sagittal plane can occur easily, especially in the edentulous patient.

24. • It is often the first choice method for the placement of implants because it provides
information on the overall shape of the jaws, the position of maxillary sinus floor and the
nasal cavity floor and the proximal distal as well as vertical position of mandibular canal
and the mental foramen.
• It also provides information on the presence or absence of dental caries, tooth fractures,
infections, residual dental roots or lesions in dental root apex or within the bone, the
interval between remaining teeth.
• Because the third-dimension cross-sectional view is not demonstrated, the relationship
between the vital structures and dimensional quantization of the implant site is not easily
depicted.

25. Advantages
1. Easy availability
2. Minimal cost
3. Large imaging area
4. Identifies opposing landmarks
5. Measures vertical height of
bone in the area of interest
6. Low dose
Disadvantages
1. Bucco-lingual dimension
not provided
2. Image distortion present
3. Lesser resolution than
periapical or digital
periapical radiography
4. Technique errors are
common
5. Inconsistent horizontal
magnification

26. Lateral Cephalometric Radiographs
• These provide a one-to-one image of the relationship between the maxilla, mandible and
skull base in the mid-sagittal plane.
• The projections obtained usually show a 10% magnification with a 60 inch focal object
and a 6 inch object-to-film distance.
• This technique aid in positioning the dental implant inclination of the proposed implant
of the anterior regions by adding an additional dimension to the two dimensional view
provided by an intraoral periapical view.
• The images obtained help in determining the feasibility of implant reconstruction of the
edentulous alveolus in its present position or in establishing the need for orthognathic
correction.

27. The images obtained help in
determining the feasibility of
implant reconstruction of the
edentulous alveolus in its present
position or in establishing the need
for orthognathic correction.

28. • The cross-sectional view of the alveolus demonstrates the spatial relationship between
occlusion and esthetics with the length, width, angulation and geometry of alveolus
and is more accurate for bone quantity determinations.
• It gives limited information about the symphyseal area, the inclination and
buccolingual dimensions of the anterior jawbone region can be obtained.
• These images do not provide useful information when planning placement of implants
lateral to the midsagittal plane.
• Overly optimistic bone volume assessments are created due to the presence of genial
tubercles.
• This technique is not useful for demonstrating bone quality.

29. Digital peri-apical imaging
• Digital radiographs are captured electronically, loaded into, viewed and stored in a
digital format.
• With the aid of the various digital tools present in the software, the clinician can
magnify, reduce, color, lighten, darken and record measurements required for
implant placement.
• The most significant advantage is the instantaneous speed in which images are
formed, which is highly useful during surgical placement of implants and the
prosthetic verification of component placement.

30. • It eliminates the space, equipment, time required for processing a conventional
IOPA (Intra-oral peri-apical) radiograph and reduces radiation exposure by almost
up to 90%.
• Indirect digital imaging makes use of a small photosensitive imaging plate coated
with phosphorus.
• In direct digital radiography, the x-ray is taken on a sensor and the image is directly
loaded in to the computer.

31. Advantages:
1. The resultant image can be modified
in various ways, such as grayscale,
brightness, contrast and inversion.
2. Computerised software programs
(i.e. SimImplant) allow for the
calibration of magnified images,
thus ensuring accurate
measurements.
3. 3. Images are formed
instantaneously during the surgical
phase.
Disadvantages:
1. The size and thickness of the
sensor and the position of the
connecting cord makes
positioning the sensor more
difficult in sites, such as those
adjacent to tori or the tapered
arch form in the region of the
canines.

32. CROSS – SECTIONAL IMAGING
1. Zonography
2. Conventional X- ray Tomography
3. Linear Tomography
4. Spiral Tomography
5. Transtomography or Sectional Tomography
6. Computed Tomography
7. Cone- Beam Computed Tomography
8. Cone Beam Volumetric Imaging
9. Tuned Aperture Computed Tomography (TACT)
10. Interactive CT
11. Denta-Scan Imaging
12. Magnetic Resonance Imaging (MRI)

33. Zonography
• Zonography is a modification of the panoramic X-ray machine and generates cross-
sectional image of the jaws.
• The tomographic layer is around 5 mm.
• The images obtained are cross-sectional images of the jaws. The tomographic layer
obtained is relatively thick.
• This technique allows the operator to visualize the relationship of critical structures to
the implant site in different planes.
• A major disadvantage of Zonography is that there is superimposition of the adjacent
structures over the obtained image giving it a blurred appearance and hence limiting its
usage as a diagnostic tool.
• This technique cannot determine different bone densities and diseases at the site of
implant placement.

34. Conventional X- ray Tomography
• The basic principle of tomography is that when the system is energized, the x-ray tube moves
in one direction with the film plane moving in the opposite direction and the system pivoting
about the fulcrum.
• The fulcrum remains stationary and defines the section of interest, or the tomographic layer.

35. • Mainly, two types of tomographic movements are known: linear and
multidirectional.
• Multidirectional movements comprises four motions: Circular, spiral, elliptic and
hypocyclocidal are tube motions employed in complex tomography.
• In contrast to spiral and hypocycloid tomography, which have a constant
magnification factor, linear tomography may have a non uniform magnification.
• The 3-dimensional dataset consists of 4 basic views:
(1) The axial
(2) The cross-sections
(3) The panoramic reconstructed view
(4) The 3-dimensional reconstructed volume.
• Each of these views is important, as no one view alone should determine the
ultimate desired treatment

37. • Cross-sectional views are as small as 1 mm obtained from the tomographic slicing.
• Two-dimensional tomography is a complex motion tomography where there is uniform
blurring of the patient’s anatomy adjacent to the tomographic motion.
• Hypocycloidal motion is the most accepted effective blurring motion.
• The magnification factor is constant in all directions but varies with different
manufacturers.
• The magnification may vary from between 10%-30% with higher magnification
producing higher quality images.
• It can be used either within one quadrant for single implant site or multiple implants
where bone densities or volumetric analyses are not required.
• In dental implant patients’ high quality complex motion tomography helps in
determining the quantity of bone and proximity of

38. Advantages
1. Minimal image overlap
2. Low to moderate dose
3. Provides bucco-lingual
information
4. Simulates implant
placement with use of
software
5. Moderate cost
6. Accurate measurements
Disadvantages
1. Overlapping of the
shadows of tissues
2. Less shades of gray
3. Less resolution
4. Technique sensitive
5. Limited availability
6. Less image resolution than
plain films
7. Requires trained personnels

39. Linear Tomography
• Linear tomography is the simplest form of tomography where the X-ray tube and
film move in a straight line.
• This is a one dimensional motion which produces blurring of adjacent sections in
one dimension resulting in linear streak artifacts also referred to as ‘parasite lines’
in the obtained image, making it obscure.
•
• It is a comprehensible type of tomography, but the effect is standard streak artifacts
known as “parasite line.”
• Constant magnifications in tomographic images depend on the distance from the
focus to the film to the target.

40. Advantages
1. Least image distortion due to
uniform magnification factor.
Disadvantages
1. Blurring of area adjacent to
implant site is seen in single
dimension
2. Metallic restorations may
distort the desired image
3. Intensifying screen is used
making it difficult to identify
the anatomical structure and
bone topography

41. Spiral Tomography
• In this technique, images are produced using spiral motion, and blurred shadows are kept
at equal distances.
• It gives better contrast in 3D and a better resolution in space.
• With a fixed projection angle, a projection of four images is created.
• Through view has a thickness of 4 mm, and all are 4 mm apart with 10–30%
magnification.
• Each fill shows 16mm thick section of maxilla or mandible.
• With more the magnification, higher is the image quality.
• This technique helps to determine the spatial relationship between specific anatomical
structures and the location of the implants.

42. Advantages
1. Higher image quality
2. For alveolus, high-quality
complex motion tomography
enables quantification of
geometry
3. For identifying critical structures,
image enhancement can be done
4. Spatial relationship between
critical structures and implants
can be identified.
Disadvantages
1. Operator sensitive
2. Superimposing structures beyond
the target field, causing image
blurring
3. Constant magnification is seen
which varies from image to image
4. Bone disease cannot be identified.

43. Transtomography or Sectional Tomography
• Welander et al. defined this technique as a combination of translational motion and
pendular beam and detector movement.
• This technique can be used for individual implant site only because the adjacent
structures that is blurred and superimposed on the image.
Advantages
1. This technique helps in obtaining immediate results suing computer program.
2. This technique can be used intraoperatively and measurements can be recorded on
screen.
3. Less distortion is obtained than conventional tomography.
4. Images can be used for the same purposes as conventional tomography.

44. Computed Tomography
• A CT scanner consists of radiographic tube that emits a finely collimated, fan-shaped x-
ray beam directed to a series of scintillation detectors or ionizing chambers.
• Depending on the scanner’s mechanical geometry, both the radiographic tube and
detectors rotate around the patient.
• The CT image is a digital image made up of matrix of individual blocks called voxels,
which has a value referred in Hounsfield units that describes the density of the image
at that point.
• Thin sections of the structures of interest can be made in several planes and viewed
under different conditions

46. • CT has several advantages over conventional film
1) Differences between tissues that differ in physical density by less than 1% can be
distinguished without super-imposition
2) Multiplanar views of data allowing rapid correlation of the different views.
3) CT can produce 3 dimensional images with high resolution with uniform magnification
4) Three-dimensional reconstruction is possible
5) CT is useful for the diagnosis of disease in the maxillofacial complex, including salivary
glands and TMJ
6) As compared to peri-apical and panoramic radiography Computed tomography provides
better information regarding position of the mandibular canal.

48. Advantages
1. Information on all sites are
available
2. No superimposition
3. Uniform magnification
4. Accurate measurements
5. Simulates implant placement
with use of software
6. Makes interpretation more
reliable and minimizes inter
operator interpretation errors
Disadvantages
1. Technique sensitive
2. Limited availability
3. Special training required
4. High cost
5. High doses
6. Limited availability of
reconstructive software

49. Multislice Helical CT
• Invented to conquer the drawbacks of conventional CT.
• It is more comfortable to the patient.
• It reduces patient motion and breath holding time during data acquisition.
• It helps in obtaining a more rapid and extended coverage.
• Distortion in image is also less than conventional CT.
• It is almost 8 times faster, and therefore, slicing can be done up to 0.5 mm.
• It also helps in providing z-axis resolution of reconstructed data.

50. Cone- Beam Computed Tomography
• Cone beam imaging technology is the latest
development in conventional tomography.
• It is characterized by true volumetric data
acquisition obtained simultaneously during one
rotation of the x-ray source.
• It produces a 3-D image volume that can be
reformatted using software for customized
visualization of the anatomy.
• CBCT provides three-dimensional, multi-planar
assessment of the maxillofacial skeleton and the
ability to reconstruct the imaged volume in virtually
any plane.
• For pre-surgical implant treatment planning, CBCT
is used to evaluate both the bone quantity and
quality.

52. • The effective dosage ranges from two to eight panoramic radiographs.
• Unlike conventional peri-apical and panoramic radiographs, CBCT images are free
of any geometric distortion or magnification.
• The master cast can be made before surgery using data stored on the software; a
temporary restoration can be fabricated and placed immediately after surgery.
• During the scanning process, radiographic markers may be inserted which indicate
the exact location of the proposed implant.
• Stents help recognize radiographic landmarks that can be used to connect proposed
implant position and angulations within the accessible alveolar bone .

53. • The clinician can precisely measure the height and width of the residual alveolar
bone, detect any anatomic variations, and determine the proximity to vital
structures, such as the maxillary sinus and neurovascular canals.
• CBCT also allows assessment of bone quality with an evaluation of cortical plate
thickness, radio-density and architecture of the trabecular bone at the potential
implant site.
• CBCT also provides a quantitative measure of bone quality at the potential implant
site - most CBCT and third-party software allow clinicians to measure the gray
values of the image voxels within a delineated region of interest (ROI).

57. • Five major benefits of cone beam CT scan (CBCT) for dental implant planning and
placement:
(i) Precision placement of implants in bone: CBCT along with 3-D software allows to
accurately measure and localize the available bone.
(ii) Proper orientation of implant with its overlying restoration: A CBCT is merged with an
optical scan of the patient‟s teeth (digital impression) to create a complete bone, teeth and
soft tissue virtual model. Then, dentist design the perfect bite and precise position of the
implants to support the planned restorations.
(iii) Prevention of nerve injury: Using CBCT, the surgeon maps out the path of the sensory
nerves in jawbone and selects the right implant length.
(iv) Prevent implant penetration into the sinus: CBCT provides an accurate picture of the
maxillary sinus and its position in relation to available bone. The surgeon can make an
accurate measurement and select the right implant length to avoid puncturing the maxillary
sinus.
(v) Selection of right size implant for optimal support: CBCT allows the surgeon to measure
the available bone and select the widest and tallest implant appropriate for the site.

58. Jacobs R et al., 2018

59. Indications for presurgical use of CBCT
1. Identification of critical anatomic boundaries
2. Prevention of neurovascular trauma
3. Specific challenges for the anterior esthetic zones
4. Borderline cases related to inadequate bone morphology, volume and quality
5. Augmentation procedures
6. Special techniques (grafting, distraction, zygoma implants)
7. Suspected trauma history of jaws and teeth
8. Doubtful prognosis of neighboring teeth
9. Presurgical planning and transfer
10. The virtual patient

60. Indications for postsurgical use of CBCT
1. Postsurgical complications (e.g. neurovascular trauma)
2. Healing follow-up of complex surgical procedures
3. Maxillofacial trauma with suspected complications at the implant level
4. Retrieval of osseointegrated implants (infectious or mechanical failure etiology)

61. Advantages
1. Better image resolution
2. Lower dose than CT
3. Lower cost than CT
4. Simulates implant placement with
use of software
5. Easy availability
6. Compact equipment
7. Images with better resolution due
to smaller individual voxels
8. Minimal distortion and
magnification
9. Increased accessibility to oral
health specialists
10. Makes interpretation more reliable
and minimizes inter operator
interpretation errors
Disadvantages
1. Does not represent the actual gray
scale value
2. Restricted field of view
3. Due to small detector size,
scanned volume is decreased
4. Gives less information about
inner soft tissue
5. Increased noise from radiation
scatter and artifacts
6. Radiation propagation
7. Limited dynamic range of the X-ray
area detectors
8. Density values without a linear
correlation to bone density
9. Bone density cannot be evaluated
because of X-ray scattering
10. Longer scanning time

62. Cone Beam Volumetric Imaging
• Since its introduction in 2001, Cone Beam Volumetric Imaging (CBVI), sometimes
called Cone Beam Volumetric Tomography (CBVT).
• Image acquisition using CBVI is much different than when a conventional medical
Computed Axial Tomography (CAT) scan is used.
• Medical CT images of a proposed implant site show low image resolution and the
clinician must use a ruler to “count” the millimeters of height and width.
• In contrast, the CBVI images show significant improvement in image resolution.

63. Advantages:
1. It minimises the cost of
radiation detectors in
conventional CT.
2. It provides a more rapid
acquisition of the data set of the
entire field of view (FOV).
3. It involves a shorterexamination
time, better image sharpness
, reduced image distortion, and
increased x-ray efficiency.
Disadvantages:
1. Image noise and low-contrast
resolution due to the detection
of scattered radiation are the
biggest disadvantages of a large
FOV.

64. Tuned Aperture Computed Tomography (TACT)
• TACT is a new 3D radiographic technique for based on optical aperture theory.
• It is an alternative to film based tomography and CT.
• This technique uses information that is obtained by passing a radiographic beam
through an object from several different angles.

65. • TACT can map the incrementally collected data into a single 3- dimensional matrix.
• It can isolate images of desired structures limited to certain depths and can
accommodate patient’s motion between exposures without affecting the final 3D image.
• It allows to adjust contrast and resolution.
• TACT can improve the clinician's ability to detect and localize disease, important
anatomical structures, and abnormalities.
• TACT imaging is efficient to identify the location of crestal defects around dental
implants and natural teeth and also can detecting subtle or recurrent decay.

66. Advantages
1. Calculation of projection
geometry after individual
exposures
2. Reduced radiation doses
3. Ability to accommodate for
patients motion
4. Cost efficient
5. Is of greater diagnostic value
6. Contrast and resolution of
image can be adjusted
Disadvantages
1. Technique sensitive
2. Limited availability
3. Special training required
4. Low quality of images

67. Interactive CT
• ICT allows the transfer of images to the clinician as a computer file.
• The main advantage of ICT is that it enables the clinician to perform “electronic surgery”.
• It helps the clinician measure the length and the width of the alveolus and also bone
quality.
• This enables 3D treatment plan that is integrated with the patient’s anatomy and can be
visualized before the implant surgery by the clinician and the patient.

68. • This technique enables the practitioner to view and interact with the imaging data
provided from the radiologist in a DICOM format on a personal computer.

69. • A software is used for implant planification and navigation.
• Through these software dentist can perform electronic surgery by selecting and placing
arbitrary sized cylinders that simulate root form implants in the images.
• Electronic implants can be placed at arbitrary positions with respect to each other, the
alveolus, critical structures and the prospective occlusion and esthetics.
• ICT enables the determination of bone quality adjacent to the prospective implant sites.

71. • At present, there are numerous third-party implant planning software programs such as
1. Simplant (Materialise Dental Inc, Glen Burnie, MD, USA)
2. Invivo5 (Anatomage, San Jose, CA, USA)
3. NobelClinician (Nobel Biocare, Goteborg, Sweden)
4. OnDemand3D (Cybermed Inc, Seoul, Korea)
5. Virtual Implant Placement software (BioHorizons, Inc, Birmingham, AL, USA)
6. coDiagnostiX (Dental Wings Inc, Montreal, CA, USA)
7. Blue Sky Plan (BlueSkyBio, LLC, Grayslake, IL, USA)

72. • There are also a few companies that provide treatment planning in the proprietary
software of the CBCT units such as
1. Galileos system (Sirona Dental Systems, Inc, Charlotte, NC, USA),
2. TxSTUDIO software (i-CAT, Imaging Sciences International LLC, Hatfield, PA)
3. NewTom implant planning software (NewTom, Verona, Italy).
• After the CBCT data are acquired, the images are exported into DICOM (Digital
Imaging and Communications in Medicine) files, a standard for the distribution and
viewing of medical images regardless of their origin.
• This format is compatible with all the third-party software packages listed above;
however, an additional file conversion step may be required in some software packages.

73. Denta-Scan Imaging
• Denta-Scan is a unique new computer software program which provides computed
tomographic (CT) imaging of the mandible 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 uniformity of measurements
and cross-referencing of anatomic structures through all three planes.

76. Advantages
1. Bone height and width is
obtained
2. 3D images help in the
preparation of pre-surgical
treatments
3. Identification of soft and hard
tissue pathology
4. Anatomical structures can be
located
5. Measuring vital qualitative
dimensions necessary for
implant placement.
Disadvantages
1. Radiation exposure
2. Expensive
3. Magnification of image
because the images produced
is of not true size

77. Magnetic Resonance Imaging (MRI)
• It was first described in the year 1946, is based on the phenomenon of nuclear magnetic
resonance imaging (NMRI).
• Its application in the field of implantology is of recent origin.
• It is used in cases where soft tissue imaging is indicated, as a secondary imaging technique
when primary imaging modalities fail, to visualize the fat in trabecular bone & to differentiate
the inferior alveolar canal and neurovascular bundle from the adjacent trabecular bone.
• The main concern in using MRI as an imaging modality following implant placement is the
possibility of artifacts.
• Large artifacts are seen in cases where the implant components are ferromagnetic in nature.
• Subjecting the dental implant patient to MRI may result in implant heating and translational
attraction.

78. • For pre-implant assessment, the use of T1- weighted sequences is indicated.
• In T1-weighted images, the external cortical plate appears black, unlike the normal
radio-opacity due to increased bone density seen on radiographs.
• In contrast, the more organic cancellous bone appears very bright in T1-weighted
images.
• For pre-implant imaging, Gray CF et al. (1996) suggested an initial triplanar
pilotscan in sagittal, coronal and axial planes, with a low-resolution gradient echo
sequence.

79. • The sagittal pilot is used to set up a series of high resolution, fast spin echo axial slices.
• From these slices, an appropriate slice showing the markers is selected and set up for a
series of cross-sectional high resolution images at right angles to the region of interest
may be made.

80. Advantages
1. It helps in differentiating cortical and
cancellous bone
2. Helps in obtaining information about
implant length, angulation, and
stability
3. Vital structures are easily seen
4. It is useful in soft-tissue imaging
5. Flexible plane of acquisition is
obtained with MRI without the
requirement of reformatting.
Disadvantages
1. It may show artifacts along with
geometric distortion
2. Area of signal loss may be seen
from ferromagnetic material (e.g.,
dental amalgam)
3. Artifacts are more common in
post-prosthetic phase as implant
produce extensive magnetic field
distortion
4. Strong static magnetic fields – As
a result of ferromagnetic
interactions, an object or device
may be moved, rotated,
dislodged, or accelerated toward
the magnet.

83. Recent Advances
• Using the platform of the SCANORA (Soredex Orion Corporation, Helsinki, Finland), a
limited-volume CBCT system 3DX Accuitomo was developed.
• PSR9000N is also a limited-volume CBCT system, which is an inherited technology
from another dentomaxillary multimodal tomographic system, the AZ3000.
• Cross-sectional images of a small, defined
area in the jaws and dental arches are
produced by these dental tomographic platforms.
• Minimization of the radiation dose is a remarkable
advantage of limited-volume CBCT.

84. • The main disadvantage of low-dose CBCT is the difficulty in the acquisition of reliable
CT values, which leads to poor soft tissue resolution.
• But this helps to reduce metal and beam hardening artifacts, which are inherent in CT
imaging.
• In limited-volume CBCT imaging, the size of FOV is small compared to the head and the
intensity of transparent X-radiation fluctuates during the 360° scan.
• Metals producing artifacts are usually detectable.
• It is difficult to detect the appearance of halation artifacts in CBCT because their cause is
outside the imaged area.

86. Jacobs R et al, 2018

89. Interactive “ Simulation” Software Programs
• Using these software programs, near-original 3D images can be obtained along with the
construction of surgical templates to transfer necessary information to the patient’s mouth.
1. SIMPLANT software
• In 1993 SIM/Plant™ 3D dental software program for windows was developed allowing
clinicians to utilize their own computers to interactively plan an implant case.
•
• The CT is taken at any standard Tomography site which is then translated to the SIM/Plant™
program allowing interactive analysis and planning.
• When ready, the data is sent to Implant/Logic systems for fabrication of a surgical guide stent
that aids the surgical and restorative dentist in accurate placement of the implant as planned.
• The benefits of the SIM/Plant program include
1. Ability to measure bone density
2. Identify and measure the proximity of the implant to vital structures
3. Estimate the volume needed for a sinus graft
4. Allowing verification of parallelism
5. Reduce offset loading of implants

91. 2. Sidexis (Sirona Galileos)
• Galileos Implant software due to to color visualization of the nerve canal and the depiction of the bones
in all dimensions, helps evenbeginners through the implant planning process efficiently.
• The implant can be ideally adapted to fit the patient’s anatomy and thus, stress is minimized through
precise planning and implementation.

92. 3. Planmeca Romexis
• Planmeca Romexis helps in planning treatment and evaluation of implant placement using realistic
implant, abutment and crown models.
• This software thus allows to import and superimpose a soft-tissue scan and crown design with
CBCT data for implant planning.

93. 4. Anatomage invivo 5 (Gendex)
• Cone Beam 3D scans acquired with Gendex 3D imaging system assist in the treatment
planning process by providing clinical information.
• The Invivo 5 software enhances the data and provides control to design crowns,
abutments and implants from Cone Beam 3D scan.
• It provides the tools for a restorative driven implant planning
• The open interface of the software allows to import STL files making it possible to bring
in digital impressions generated by intraoral scanner.
• The obtained digital impressions can be combined with CBCT data and while including
the original bite registration from the intraoral scan, images can be paired together in the
correct position.

95. 5. Veraviewepocs 3D (J. Morita 3D Accuitomo)
• Veraviewepocs 3D R100 is useful for planning implant treatment with full arch
imaging, clarity and low dose to the patient.
• It creates cross sectional images of the dental arch and highlights the mandibular
canal for measuring the distance to the implant, easier viewing and determining its
buccal and lingual position.
• A high resolution volume image of the entire jaw can be obtained which offers an
easy explaination of the implant treatment process to the patient.

96. 6. CS9300 3D (Carestream Kodak)
• CS9300 3D (Carestream Kodak) provides greater flexibility and the ability to collimate
the field of view to adjust according to patients diagnostic need.
• The recommended fields of view for implantology of CS 9300 are 10 cm x 5 cm, 10 cm x
8 cm and 10 cm x 10 cm.
• The computer guided implant planning helps in visualising the anatomical structures in
three spatial planes.
• The various other programs, such as Implametric®, SimPlant®, Nobel Guide®,
med3D®, etc., surgical templates can be made for selective implant placement.
• Surgical navigation systems such as RoboDent®, DenX IGI®, VISIT®, CADImplant®,
LITORIM®, Virtual Implant®, Vector Vision®, etc are currently able to offer greater
security of critical structures to obtain improved results.

97. • The computer guided implant surgery employing surgical template has the following
advantages:
1. It precisely guide the osteotomy drills
2. Directs the surgeon in the exact location and angulation to place the implant based on
virtual treatment plan
3. It allows flapless surgery, which entails less bleeding, less swelling, decreased healing
time and postoperative pain
4. Aids in the preservation of hard and soft tissue and maintains blood circulation to the
surgical site
5. Considerably increased accuracy of implant placement
6. Avoidance of vital structures
7. Shorter period required for surgery

98. Patient Evaluation
Exclude Pathology
• The first step in the radiographic evaluation of the implant site is to establish the health of the
alveolar bone and other tissues imaged within a particular projection.
• Local and systemic diseases that affect bone homeostasis can preclude, modify, or alter placement of
implants.
• Retained root fragments, residual periodontal disease, cysts, and tumors should be identified and
resolved before implant placement.
• Systemic diseases, such as osteoporosis and hyperparathyroidism, alter bone metabolism and might
affect implant osseointegration.
• Areas of poor bone quality should be identified and if indicated, adjustments to the treatment plan
incorporated.
• Maxillary sinusitis, polyps, or other sinus pathology should be diagnosed and treated when implants
are considered in the posterior maxilla, especially if sinus bone augmentation procedures are
planned.

99. Identify Anatomic Structures
• Familiarity with the radiographic appearance of these structures is important during treatment
planning and implant placement.
• Their exact localization is central to prevent unwanted complication and unnecessary morbidity.
• The existence of anatomic variants, such as incomplete healing of an extraction site, sinus
loculation, division of mandibular canal, or absence of a well-defined corticated canal, should also
be recognized.

100. Assess Bone Quantity, Quality, and Volume
• The primary goal of diagnostic imaging for potential implant patients is to evaluate the
available bone volume for implant placement in desired anatomic locations.
• The clinician wants to estimate and verify exact adequate height, width, and density to the
recipient bone while avoiding damage to critical anatomic structures.
• Failure to assess accurately the location of important anatomic structures can lead to
unnecessary complications.
• For example, inadvertent penetration and damage to the inferior alveolar nerve can result in
serious immediate-term (profuse bleeding), short-term, and long term (nerve
paresthesia/anesthesia) complications.

101. • Depending on the technique, diagnostic imaging can estimate or measure the coronal–
apical height, the buccal–lingual width, and the mesial–distal spacing available for
implants that will be placed in proximity to teeth or relative to other planned implants.
• In cases with moderate-severe bone resorption, alveolar defects, or recent extraction
sites, obtaining a clear and accurate diagnostic image can be more challenging.
• The diagnostic imaging may reveal inadequate bone volume for the proposed implant(s)
and indicate a need for bone augmentation or depending on the severity of the
deficiency, preclude the patient from the possibility of implant therapy.
• When ridge augmentation is deemed necessary, radiographic evaluation prior and
postsurgery informs treatment planning and ensures grafting integrity and quality.

102. • A uniform, continuous cortical outline and a lacy, well-defined trabecular core
reflect the normal bone homeostasis necessary for appropriate bone response
around the implant.
• Thin or discontinuous cortex, sparse trabeculation, large marrow spaces, and altered
trabecular architecture should be noted because they might predict poor implant
stabilization and less desirable response of the bone.
• Poor bone quality may necessitate modifications of the treatment planning, such as
waiting longer for healing (osseointegration) to maximize bone-to-implant contact
before loading.

103. Evaluate Relation of Alveolar Ridge with Existing Teeth and Desired Implant Position
• Accurate placement (spatial position and angulation relative to adjacent teeth and
occlusal plane) will greatly affect the restorative success and long-term prognosis of the
implant.
• A significant variable during the preimplant evaluation is the relation of the desired
implant position relative to the existing teeth, alveolar crest, and occlusal plane.
• Angled or custom abutments can accommodate slight variations in implant position and
implant inclination.

104. • Prolonged tooth loss is usually associated with atrophy of the alveolar ridge and in
the case of the maxilla, with pneumatization of the sinus floor toward the alveolar
crest.
• Traumatic extractions can compromise the buccal or lingual cortex and alter the
shape and buccolingual ridge dimension.
• Anatomic variants, such as lingual inclination of the alveolus or narrow ridges,
should be considered during treatment planning of the implant patient.

105. • An important part of diagnostic imaging must include an evaluation of the available
bone relative to the “prosthetically driven” implant position.
• This aspect of the patient evaluation is best accomplished with diagnostic models,
wax-up of planned tooth replacement, and radiographic markers in the desired tooth
positions during imaging.
• Steel balls, brass tubes, and gutta-percha have all been used to establish the
proposed tooth positions relative to the existing alveolar bone.

106. • The use of these nonanatomic markers is helpful for evaluating bone height and width
in specific anatomic location.
• Nonanatomic markers do not accurately represent the tooth contours and do not allow
the clinician to estimate variations in implant position and angulation relative to the
position and emergence of the planned tooth replacement.
• It is more desirable and beneficial to use radiopaque “tooth-shaped” markers so that the
existing alveolar bone can be evaluated relative to the entire tooth position/contours.
• Patients should always be imaged with radiographic guides (markers).

107. Clinical Selection of Diagnostic Imaging
Clinical Examination
• Before taking any radiographs, a complete clinical examination of the implant
patient is required.
• This should include the etiology and duration of tooth loss, any history of traumatic
extraction, and a review of records and radiographs, if available.
• Clinical assessment of the edentulous area, covering mucosa, adjacent and opposing
teeth, and occlusal plane should be performed.
• Temporomandibular function, mandibular maximal opening, and protrusive and
lateral movements should be evaluated.

108. Screening Radiographs
• At this point, an overall assessment of the health of the jaws should be performed.
• Periapical radiographs provide a high-resolution image of the alveolus and the
surrounding structures, including adjacent teeth.
• For extended edentulous areas, panoramic, lateral cephalometric, and occlusal
radiographs can be used to estimate bone height and width.
• Any pathology of the bone at the prospective implant site, as well as of the
surrounding structures, should be identified and treated as indicated.

109. Fabrication of Radiographic and Surgical Guides
• Once the health of the soft and hard tissues is established, casts should be taken and
detailed analysis performed.
• The clinician should decide on the number of implants and their desired location.
• Next, a radiographic guide should be fabricated, usually with clear acrylic.
• The position of the desired implants is indicated by the use of radiopaque objects such as
metallic balls, cylinders, or rods; gutta-percha; or composite resin.
• If CT imaging might be performed, the use of metallic markers should be avoided.
• The design of such a guide greatly enhances the diagnostic information provided by the
radiographs because it correlates the radiographic anatomy with the exact position of the
proposed implant location.

110. Cross-Sectional Tomography
• The potential morbidity of a compromised anatomic structure and the poor
performance and potential failure of a misplaced implant, combined with the wide
availability of tomographic facilities, favor the use of crosssectional imaging in
most cases of implant treatment planning.
• It is crucial that the cross sections are perpendicular to the curvature of the
mandible and parallel to the planned implant.
• Improper patient positioning can lead to an overestimation of the height and
width of the available bone.

111. Intraoperative and Postoperative Radiographic Assessment
• Because of the ease of acquisition and high resolution, periapical radiographs are most
commonly used.
• Intraoperative radiographs can be taken during surgery to evaluate proximity to
important anatomic structures.
• Sequential periapical radiographs guide the clinician to visualize changes in direction
and depth of the drilling procedure and parallelism to adjacent teeth and other implants .
• Implant osseointegration, and the level of periimplant alveolar bone are major
determinants of implant prognosis.

112. • Panoramic and periapical radiographs offer a fast, easy, and low-radiation depiction
of the implant and surrounding tissues and aid in assessment of implant success.
• To obtain an accurate assessment of periimplant bone height, the x-ray beam should
be directed perpendicular to the implant.
• In the case of threaded implants, the implant threads should be distinguishable and
not overlapping.
• In select cases, when poor implant placement or compromise of vital anatomic
structures are suspected, advanced imaging (CBCT, CT, or conventional
tomography) provides a three-dimensional evaluation of the oral structures in
relation to the implants.

113. Conclusion
• There are various imaging options available in the present day scenario; however, the
choice of modality should be based on individual requirements of a particular case.
• The skill, knowledge and ability of the clinician to interpret obtained data also play a
crucial role in selection of the imaging modality.
• The cost of the procedure and radiation dose should also be weighed to the benefit of
anticipated information.
• Selection of the type of modality should be made keeping in mind the type and number of
implants, location and surrounding anatomy.
• CBCT is the latest and safest technology used for dental implant imaging because it
offers fast data collection with no exposure to radiation.
• CBCT has many other advantages over other techniques making it the most ideal choice
for implant imaging.

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117. THANK YOU