Implant radiography and radiology

The Role of Radiographic Imaging in the Diagnosis and Management of Periodontal and Peri-Implant Diseases

This article highlights the role of dental imaging techniques, including periapical, bitewing, panoramic, and cone-beam computed tomography images, in the diagnostic and therapeutic decision-making process for patients with periodontal and peri-implant disease. A brief overview of common radiographic findings of periodontal disease, including periodontitis, and peri-implantitis is also provided.

Prevalence and Severity of Circumferential Alveolar Bone Loss Using CBCT Images: A Retrospective Study of 20,620 Surfaces of 5155 Teeth

Periodontal disease is a site-specific disease affecting the supporting tissues of the teeth. It is useful for the clinician to have information about the prevalence and severity of alveolar bone loss (ABL) according to the site, location, and position of the teeth for a better treatment plan and expected prognosis. This study aimed to assess the prevalence and severity of ABL at mesial, distal, buccal and lingual sites of teeth in different locations, positions and sides of the dentition. The ABL of 20,620 sites of 5155 teeth in 212 patients was assessed using cone-beam computed tomography from the cemento-enamel junction to the crest of the alveolar bone. The prevalence of ABL was higher in the interproximal sites as well as anterior and mandibular teeth compared to their counterparts. Buccal sites and anterior teeth revealed higher ABL levels than the other tooth sites and posterior teeth, respectively. Furthermore, associations in the severity of ABL were observed between distal and mesial sites, buccal and lingual sites, maxillary and mandibular teeth, anterior and posterior teeth, and right and left sides. This study showed that the prevalence and severity of ABL differ from one tooth site to another and according to the tooth's location in the dentition. Higher prevalences were found in the interproximal sites, anterior teeth and mandibular teeth; higher ABL was found in buccal and distal sites, with the strongest associations between distal and mesial sites, buccal and lingual sites, and right and left sides.

Radiographic Evaluation in Implant Patients: A Review

Diagnostic imaging is crucial in assessing dental implant patients. The height, width, and shape of the bone are precisely depicted and measured by these tests, which help pinpoint the locations of significant anatomical structures adjacent to the implant placement sites. The type of implant to be utilized, the positioning of the remaining dentition, and the degree to which bone quality or quantity is in question all play a role in determining the radiologic approach that is most suited for a given patient. This review is an update on the current knowledge in the field of radiographic evaluation in implant placement. Considering the radiation exposure and the expense of each test, it is important to carefully determine whether pre-implant imaging is acceptable in each situation. Although multislice computed tomography is the gold standard from the authors' perspective, not every implant situation can justify such a test.

Evaluation of one-piece zirconia dental implants: An 8-year follow-up study

OBJECTIVES

Long-term studies of modern zirconia implants are still insufficient. This prospective 8-year follow-up study investigated one-piece zirconia implants.

MATERIALS AND METHODS

Patients who had received a one-piece zirconia dental implant (PURE ceramic implant, Institut Straumann GmbH, Basel, Switzerland) were included in this study. Next to the implant survival and success rates, the radiographic and clinical implant parameters were assessed.

RESULTS

The overall survival rate of 67 zirconia implants in 39 patients was 100%. The overall success rate was 89.6%. Around the immediate zirconia implants, the success rate was 94.7%, and around the delayed implants, 87.5%. The immediate implants showed a significantly higher bone crest compared to the delayed implants (p = 0.0120). According to the pink esthetic score, the immediate implants revealed more favorable esthetic results compared to the delayed implants after an 8-year follow-up (p = 0.0002).

CONCLUSIONS

After 8 years, the one-piece zirconia implants presented an 89.6% success rate. Regarding the timing of implantation, in individual cases, immediate implantation can have slight advantages over delayed implantation.

CLINICAL RELEVANCE

Immediate implants can also be considered for zirconia implants and should not be excluded on principle.

Automatic segmentation of inferior alveolar canal with ambiguity classification in panoramic images using deep learning

Background

Manual segmentation of the inferior alveolar canal (IAC) in panoramic images requires considerable time and labor even for dental experts having extensive experience. The objective of this study was to evaluate the performance of automatic segmentation of IAC with ambiguity classification in panoramic images using a deep learning method.

Methods

Among 1366 panoramic images, 1000 were selected as the training dataset and the remaining 336 were assigned to the testing dataset. The radiologists divided the testing dataset into four groups according to the quality of the visible segments of IAC. The segmentation time, dice similarity coefficient (DSC), precision, and recall rate were calculated to evaluate the efficiency and segmentation performance of deep learning-based automatic segmentation.

Results

Automatic segmentation achieved a DSC of 85.7% (95% confidence interval [CI] 75.4%-90.3%), precision of 84.1% (95% CI 78.4%-89.3%), and recall of 87.7% (95% CI 77.7%-93.4%). Compared with manual annotation (5.9s per image), automatic segmentation significantly increased the efficiency of IAC segmentation (33 ms per image). The DSC and precision values of group 4 (most visible) were significantly better than those of group 1 (least visible). The recall values of groups 3 and 4 were significantly better than those of group 1.

Conclusions

The deep learning-based method achieved high performance for IAC segmentation in panoramic images under different visibilities and was positively correlated with IAC image clarity.

Anatomical study of the maxillary sinus: which characteristics can influence its volume?

PURPOSE

To investigate whether there is a relationship between the volume of the maxillary sinus and individual parameters such as gender, side, posterior tooth absence, sinus membrane thickening, bony septa, vertical and sagittal skeletal patterns.

METHODS

The tomographic volume of the maxillary sinus from 211 individuals (422 sides) was evaluated using Horos DICOM Viewer Software. Bony septa and sinus membrane thickening were classified as absent or present. At the same time, loss of one or more teeth in the posterior region of the maxilla (except for the third molars) was considered. The t test was applied to analyze maxillary sinus volume according to gender, age, side, posterior tooth absence, sinus membrane thickening and bony septa. A one-way analysis of variance (ANOVA) with Tukey's post-hoc test was applied to compare sagittal and vertical patterns. Pearson's correlation coefficient was also used to verify the association between maxillary sinus volume, age and skeletal patterns.

RESULTS

Concerning the sagittal skeletal pattern, a statistically significant difference was observed between Classes II and III (p = 0.05) and it was confirmed by the Pearson's correlation coefficient (r = - 0.107/p = 0.029). No statistically significant differences were observed between the maxillary sinus volume according to gender (p = 0.06), side (p = 0.37), posterior tooth absence (p = 0.92), sinus membrane thickening (p = 0.47), bony septa (0.89) and vertical skeletal pattern (p = 0.67). No significant differences were observed with age (r = - 0.076/p = 0.109) and the vertical skeletal pattern (r = - 0.078/p = 0.108).

CONCLUSION

Maxillary sinus volume was influenced by the sagittal skeletal pattern and was higher in Class III individuals.

Efficacy of low-dose cone beam computed tomography and metal artifact reduction tool for assessment of peri-implant bone defects: an in vitro study

BACKGROUND

Early accurate radiographic assessment of peri-implant bone condition is highly important to avoid excessive loss of supporting bone and implant failure. Cone beam computed tomography (CBCT) is the radiographic technique of choice if peri-implant dehiscence and fenestration defects are suspected. The higher radiation dose and the presence of beam hardening artifacts are the main drawbacks of CBCT imaging techniques. This study aims to evaluate the influence of low-dose cone beam computed tomography (LD-CBCT) and metal artifact reduction (MAR) tool on the assessment of peri-implant dehiscence and fenestration.

METHODOLOGY

Thirty titanium implants were inserted into bovine rib blocks. Twenty had standardized bone defects (10 with dehiscence and 10 with fenestration), while the remaining 10 were used as control group with no defects. Radiographic examinations held with high-definition CBCT (HD-CBCT) and LD-CBCT with and without application of MAR tool. Images were assessed by four examiners for the presence or absence of peri-implant defects. The area under the area under the receiver operating characteristic (ROC) curve (AUC), sensitivity, specificity, and accuracy were calculated for all radiographic protocols.

RESULTS

In the absence of MAR tool, there was no difference in AUC and diagnostic values between LD-CBCT and HD-CBCT for detection of both defects. When the MAR tool was applied, the AUC values, sensitivity, and accuracy were higher in HD-CBCT than in LD-CBCT for the detection of both defects, especially for the dehiscence, while specificity remained the same.

CONCLUSION

LD-CBCT can be used in the evaluation of peri-implant dehiscence and fenestration without any decrease in diagnostic accuracy. The application of MAR tool decrease the diagnostic ability of both defects, especially for the detection of dehiscence defects.

Canal-Net for automatic and robust 3D segmentation of mandibular canals in CBCT images using a continuity-aware contextual network

The purpose of this study was to propose a continuity-aware contextual network (Canal-Net) for the automatic and robust 3D segmentation of the mandibular canal (MC) with high consistent accuracy throughout the entire MC volume in cone-beam CT (CBCT) images. The Canal-Net was designed based on a 3D U-Net with bidirectional convolutional long short-term memory (ConvLSTM) under a multi-task learning framework. Specifically, the Canal-Net learned the 3D anatomical context information of the MC by incorporating spatio-temporal features from ConvLSTM, and also the structural continuity of the overall MC volume under a multi-task learning framework using multi-planar projection losses complementally. The Canal-Net showed higher segmentation accuracies in 2D and 3D performance metrics (p < 0.05), and especially, a significant improvement in Dice similarity coefficient scores and mean curve distance (p < 0.05) throughout the entire MC volume compared to other popular deep learning networks. As a result, the Canal-Net achieved high consistent accuracy in 3D segmentations of the entire MC in spite of the areas of low visibility by the unclear and ambiguous cortical bone layer. Therefore, the Canal-Net demonstrated the automatic and robust 3D segmentation of the entire MC volume by improving structural continuity and boundary details of the MC in CBCT images.

Identifying the course of the greater palatine artery using intraoral ultrasonography: cohort study

AIMS

The greater palatine artery (GPA) is one of the most important anatomical structure for free gingival grafts or connective-tissue grafts during soft tissue surgery for dental implants. Several studies have identified the approximate location of the GPA, but it is impossible to detect its exact location during surgery due to large variability between individuals. The authors, therefore, investigated the course of the GPA using intraoral ultrasonography to determine the feasibility of using real-time nonionizing ultrasonography for implant surgery.

MATERIALS AND METHODS

This study included 40 healthy young participants. The courses of the GPA were identified using intraoral ultrasound probes from the first premolar to the second molar. The distance from the gingival margin to the GPA (GM-GPA) and the depth of the palatal gingiva from the GPA (PG-GPA) were measured by two independent examiners. Measurements were analyzed statistically, and interexaminer reliability was determined.

RESULTS

The distance of the GM-GPA and the mean depth of the PG-GPA were 14.8 ± 1.6 mm and 4.10 ± 0.51 mm (mean ± SD), respectively. GM-GPA decreased when the GPA ran from the second molar to the first molar, and GM-GPA was significantly shorter in females (P < 0.05). PG-GPA increased when the GPA ran to the posterior teeth. Interexaminer measurement agreements were excellent, with intraclass correlation coefficient values of 0.983 and 0.918 for GM-GPA and PG-GPA, respectively.

CONCLUSIONS

Using an intraoral ultrasound probe, real-time GPA tracking is possible, which is expected to help reduce the possibility of bleeding during surgery.

Comparison of the Efficacy of the Panoramic and Cone Beam Computed Tomography Imaging Methods in the Surgical Planning of the Maxillary All-On-4, M-4, and V-4

This study is aimed at analyzing the difference between the measurements made according to certain anatomical signs of the maxillary jaw using panoramic radiography and cone beam computed tomography (CBCT) to decide whether to use all-on-4, M-4, or V-4 configuration to prevent complications caused by incorrect measurements during the presurgical planning stage of the placement of implants in the all-on-4 technique. A retrospective study was conducted with 50 patients with upper edentulous jaws suitable for the all-on-4 technique, who underwent preoperative panoramic radiography and cone beam computed tomography evaluation for dental implant surgery. The shortest vertical distances between anatomical structures were measured. Measurements were made independently by two oral and maxillofacial surgeons, one experienced and the other inexperienced. A statistically significant difference was found between the mean values according to gender (p=0.045). When the measurements made by the experienced surgeon and the inexperienced surgeon were compared, there was no significant difference between panoramic radiography and cone beam computed tomography. In situations where bone measurements are required for deciding on all-on-4 or one of its configurations (M-4 and V-4), it was found that panoramic radiography gives significantly incorrect results compared to cone beam computed tomography (p<0.05). Cone beam computed tomography is more reliable than panoramic radiography and eliminates the margin of error in the planning of all-on-4 or its variations to be made by either an experienced or an inexperienced oral surgeon.

Panoramic radiography and patients with disability: a new simple breathing technique to reduce common airspace error

Patients with intellectual disabilities often fail to follow traditional tongue position instructions for panoramic radiographs resulting in missed pathology or unnecessary further radiation. This simple breathing technique is a new clinical instruction method for panoramic radiography developed to reduce the most common patient position error: patient failure to hold the tongue to the roof of the mouth. The technique is suitable for all patients including young patients and those with intellectual disabilities. The simple breathing technique uses 'tell-show-do' communication methods and does not mention the tongue but utilises the known tongue positions that occur during breathing and swallowing. This simple breathing technique instruction for panoramic radiography uses a demonstration of 'breathe-in, breathe-out, swallow, lips closed and hold still' to reduce the intensity of both the palatoglossal and pharyngeal airspaces on panoramic radiographs. This method, referred in this article as the simple breathing technique, can improve the diagnostic potential of panoramic radiographs and can be used with young children and patients with intellectual disabilities, and this slow breathing technique can help them further relax.

Bone Phenotyping Approaches in Human, Mice and Zebrafish - Expert Overview of the EU Cost Action GEMSTONE ("GEnomics of MusculoSkeletal traits TranslatiOnal NEtwork")

A synoptic overview of scientific methods applied in bone and associated research fields across species has yet to be published. Experts from the EU Cost Action GEMSTONE ("GEnomics of MusculoSkeletal Traits translational Network") Working Group 2 present an overview of the routine techniques as well as clinical and research approaches employed to characterize bone phenotypes in humans and selected animal models (mice and zebrafish) of health and disease. The goal is consolidation of knowledge and a map for future research. This expert paper provides a comprehensive overview of state-of-the-art technologies to investigate bone properties in humans and animals - including their strengths and weaknesses. New research methodologies are outlined and future strategies are discussed to combine phenotypic with rapidly developing -omics data in order to advance musculoskeletal research and move towards "personalised medicine".

Efecto de los daños causados por el insecto escudo verde (Palomena prasina L.) en las características cualitativas de la avellana

Este estudio se realizó en 2018 para determinar el efecto del daño del insecto escudo verde (DV) en las propiedades químicas del cultivar de avellana "Tombul". La composición proximal, proteína, lípidos totales (LT), carbohidratos, relación total de cenizas (CT), vitamina E (VE), fenólicos totales, valores de energía (E), color, composición de ácidos grasos, ácidos grasos totales, oxidación de lípidos e índice de calidad nutricional se determinaron en relación con los daños causados por el insecto. Se encontró que el nivel de LT, CT, VE, E, ácidos grasos monoinsaturados (MUFA) y ácidos grasos insaturados/saturados (UFA/SFA) fue menor en los granos de DV que en los granos buenos (GB). Aunque los granos de DV tienen niveles más altos de yodo, acidez, grasa libre y peróxidos, tienen niveles más bajos de la relación ácido oleico/linoleico y de los valores de rancimat. Además, los granos de DV tienen una relación más baja PUFA/SFA y de hipocolesterolémica/hipercolesterolémica, pero tienen valores de índice de aterogenicidad y trombogenicidad más altos.

Three-Dimensional Classification of Lower Third Molars and Their Relationship to the Mandibular Canal

PURPOSE

To develop a novel classification making full use of radiographic three-dimensional (3D) information to describe the position, geometric configuration of a mandibular third molar (M3M) and its spatial relation to neighboring structures such as the mandibular canal (MC). The classification presented in this study helps to establish a common language and serves as a framework for further studies, for example, on 3D parameters influencing prognosis of the M3M and level of difficulty associated with its removal.

MATERIAL AND METHODS

A total of 8 parameters were included in the classification including position, the cranio-caudal height, the number of roots of the M3M as well as its spatial relationship to the MC, its course, its deformation, and distance to the M3M. The classification was retrospectively applied to a sample of 483 patients and these data were statistically evaluated.

RESULTS

The most commonly observed categories were the (+) vertical position (39.8%); the cranio-caudal height A (38.7%); 2 roots (83.2%); and the spatial relationship no contact caudal (37.5%). Contact between the M3M and inferior alveolar nerve was observed in 58% of all cases. A deformation of the MC was found in 81% of cases.

CONCLUSIONS

Our novel classification aims to provide a more holistic description of parameters defining 3D M3M position, as well as its spatial relation to relevant neighboring structures. It creates a uniform terminology that can be applied in practice by surgeons and radiologists, and also serves as a foundation for further research projects, such that results from similarly designed studies could be compared.

Breaking new ground in mineralized tissue: Assessing tissue quality in clinical and laboratory studies

Mineralized tissues, such as bone and teeth, have extraordinary mechanical properties of both strength and toughness. This mechanical behavior originates from deformation and fracture resistance mechanisms in their multi-scale structure. The term quality describes the matrix composition, multi-scale structure, remodeling dynamics, water content, and micro-damage accumulation in the tissue. Aging and disease result in changes in the tissue quality that may reduce strength and toughness and lead to elevated fracture risk. Therefore, the capability to measure the quality of mineralized tissues provides critical information on disease progression and mechanical integrity. Here, we provide an overview of clinical and laboratory-based techniques to assess the quality of mineralized tissues in health and disease. Current techniques used in clinical settings include radiography-based (radiographs, dual energy x-ray absorptiometry, EOS) and x-ray tomography-based methods (high resolution peripheral quantitative computed tomography, cone beam computed tomography). In the laboratory, tissue quality can be investigated in ex vivo samples with x-ray imaging (micro and nano-computed tomography, x-ray microscopy), electron microscopy (scanning/transmission electron imaging (SEM/STEM), backscattered scanning electron microscopy, Focused Ion Beam-SEM), light microscopy, spectroscopy (Raman spectroscopy and Fourier transform infrared spectroscopy) and assessment of mechanical behavior (mechanical testing, fracture mechanics and reference point indentation). It is important for clinicians and basic science researchers to be aware of the techniques available in different types of research. While x-ray imaging techniques translated to the clinic have provided exceptional advancements in patient care, the future challenge will be to incorporate high-resolution laboratory-based bone quality measurements into clinical settings to broaden the depth of information available to clinicians during diagnostics, treatment and management of mineralized tissue pathologies.

Estimating bone mineral density using MRI in medicine and dentistry: a literature review

OBJECTIVES

Studies performed in the medical area have shown that an indirect diagnosis of bone mineral density (BMD) is feasible by assessing the amount of bone marrow fat with non-ionizing magnetic resonance imaging (MRI). In dentistry, radiographic methods are still the most used for alveolar bone diagnosis. The present literature review aimed at addressing the role of MRI in assessing BMD in medicine and dentistry.

METHODS

MEDLINE and EMBASE databases were searched for articles published up to 2019.

RESULTS

A total of 428 potentially eligible papers were screened. Of these, 397 were excluded after title, abstract and keyword assessment, yielding 31 papers that potentially met the inclusion criteria. Eleven studies were then excluded because their full texts did not discuss the role of MRI in the indirect diagnosis of BMD. As a result, a total of 20 studies were finally identified as eligible for inclusion in this literature review. Most studies found satisfactory accuracy of MRI for indirectly assessing BMD by quantifying bone mineral fat (BMF). However, only one of these studies was on dentistry.

CONCLUSION

Within the limitations of this study, the present findings suggest that MRI is accurate to indirectly estimate bone density by assessing BMF, and could be clinically relevant during dental treatment planning.

Radiographic Evaluation in the Diagnosis of Alveolar Bone Quality in Implant Rehabilitation

This study evaluated the optical bone density of the maxilla and mandible and correlate with the classification of bone quality of the Lekholm and Zarb (L & Z). Sixty edentulous areas were evaluated. Panoramic and periapical radiographs were performed with an aluminum scale to evaluate the optical bone density. L & Z classification was also applied. By using periapical radiographs, a statistically significant difference was observed in the optical bone density of the posterior maxilla (2.38 ± 1.06) and the posterior mandible (3.84 ± 0.68), when compared to the other regions (P ≤ 0.015). However, with panoramic radiographs, no differences were observed in the optical bone density (P = 0.6322). A negative correlation was observed between the L & Z classification and the optical bone density obtained by the periapical radiographs (rho = -0.463; P < 0.001), that is, the worse the bone quality, the lower the bone density. However, there was no significant correlation with the bone density obtained by panoramic radiographs (rho = -0.009; P = 0.948). As for gender, a correlation between aging and the presence of medullary bone was observed in females, assessed by the L & Z classification (rho = 0.398; P = 0.006). However, there was a correlation between aging and a denser and less medullary presence in males, both assessed by the L & Z classification (rho = -650; P = 0.016), as well as the optical density assessed by periapical (rho = 0.621; P = 0.023) and panoramic (rho = 0.588; P = 0.035) radiographs. These results suggest that gender and age interfere with the bone quality and periapical radiographs are an acceptable method for evaluating bone density. However, a panoramic radiograph was not found to be a reliable method.

A CBCT Based Three-Dimensional Assessment of Mandibular Posterior Region for Evaluating the Possibility of Bypassing the Inferior Alveolar Nerve While Placing Dental Implants

A high rate of nerve injury and related consequences are seen during implant placement in the posterior mandibular arch. An approach has been proposed to avoid nerve injury by dodging the inferior alveolar nerve (IAN) while placing an implant. A prospective study with a total of 240 CBCT (cone beam computed tomography) images of patients with three dentate statuses, namely, edentulous (group I), partially edentulous (group II) and dentate (group III) were included in the study. The nerve path tracing was done on CBCT images with On-demand 3D software. The three dimensions, i.e., the linear distance from the outer buccal cortical plate to the inferior alveolar nerve (BCPN), linear distance from the outer lingual cortical plate to the inferior alveolar nerve (LCPN) and linear distance from the midpoint of the alveolar crest to the inferior alveolar nerve (ACN) were assessed. The data were presented and analyzed between variables using one-way ANOVA and independent t-test in SPSS version 21.LCPN of the right 1st premolar region (p < 0.05) was significantly different among the groups with edentulous subjects recorded with the minimum value (6.50 ± 1.20 mm). Females were found to have significantly (p < 0.05) less available bone (6.03 ± 1.46 mm) on the right side of the mandibular jaw compared to males in edentulous group of patients. On comparing age groups for partially edentulous subjects, LCPN of the right 1st premolar region had significantly (p < 0.05) less available bone (6.03 ± 0.38 mm) in subjects with age ≥54 years. The IAN follows a lingual course in the molar region and later flips to the buccal side in the premolar region. The LCPN dimension in the 1st and 2nd premolar region was found to be more than 6 mm irrespective of age, gender and side of the jaw. Thus, it can be considered as a suitable site for placing implants while bypassing the IAN with CBCT assessment remaining as the mainstay in the pre-surgical phase.

Custom Focal Trough in Cone-Beam Computed Tomography Reformatted Panoramic Versus Digital Panoramic for Mental Foramen Position to Aid Implant Planning

Objectives:

To compare the linear measurements from digital panoramic (DP) radiographs and cone-beam computed tomography (CBCT) volumes for the localization of the mental foramen (MF).

Material and Methods:

Thirty-one patients with panoramic and CBCT radiographs depicted on the same machine were analyzed. The vertical and horizontal positions of the MF were compared by the differences in distances measured from reference points to the boundaries (tangents) of the MF in digital panoramic (DP) and CBCT reformatted panoramic (CRP) views. The vertical position of MF was also analyzed on CBCT oblique coronal views (CORO) and compared with its corresponding distances on DP and CRP views.

Results:

Statistically significant differences (P < 0.05) were found in all compared measurements between CRP and DP views. In addition, the vertical distance (Y1) compared between DP, CRP, and CORO views also showed a statistically significant measurement discrepancy in the mean distance (P < 0.000) with the highest mean difference of 1.59 mm (P < 0.05) was attained from Y1 (DP-CORO). Inter- and intra-examiner analysis indicated a high level of agreement for all measurements.

Conclusion:

The mean values of discrepancies in measurements between DP and CRP views for horizontal and vertical linear measurements were clinically tolerable. Nevertheless, significant differences in the vertical MF position were detected between the panoramic views (DP, CRP) and the coronal views (CORO). This implies that the use of coronal view measurements during implant planning might reduce the risk of neurovascular injuries.

Comparing the precision of panoramic radiography and cone-beam computed tomography in avoiding anatomical structures critical to dental implant surgery: A retrospective study

Purpose

The aim of this study was to evaluate the correlations between measurements made using panoramic radiography and cone-beam computed tomography (CBCT) based on certain anatomical landmarks of the jaws, with the goal of preventing complications due to inaccurate measurements in the pre-surgical planning phase of dental implant placement.

Materials and Methods

A total of 56 individuals who underwent panoramic radiography and a CBCT evaluation before dental implant surgery were enrolled in the study. Measurements were performed to identify the shortest vertical distance between the alveolar crest and neighboring anatomical structures, including the maxillary sinus, nasal floor, mandibular canal, and foramen mentale. The differences between the measurements on panoramic radiography and CBCT images were statistically analyzed.

Results

Statistically significant differences were observed between the measurements on panoramic radiography and CBCT for all anatomical structures (P<.05). The correlation coefficients (r) between the paired samples obtained from panoramic radiography and CBCT were closely correlated (P<.05), with r values varying from 0.921 and 0.979 for different anatomical regions.

Conclusion

The results of this study support the idea that panoramic radiography might provide sufficient information on bone height for preoperative implant planning in routine cases or when CBCT is unavailable. However, an additional CBCT evaluation might be helpful in cases where a safety margin cannot be respected due to insufficient bone height.

Influence of 2D vs 3D imaging and professional experience on dental implant treatment planning

OBJECTIVES

This study investigated whether professional experience and type of image examination (panoramic radiography (PAN) or cone beam computed tomography (CBCT)) could influence the pre-surgical planning for dental implant treatment.

MATERIALS AND METHODS

Six dentists, from two different levels of experience (senior (Sr) and junior (Jr)) performed simulated pre-surgical planning by using PANs and after 1 month, by using CBCTs, considering implant length (IL), implant width (IW), need for bone graft (BG), and other surgical procedures (OP). Bland-Altman test and Kappa coefficient were used to identify agreements.

RESULTS

Bland-Altman test showed good agreement in the plans for inter-professional (i.e., Sr vs Jr) comparisons. Bland-Altman plots displayed intra-observer agreement (i.e., differences between PAN and CBCT), showing discrepancy between imaging modalities for IL and a tendency towards selecting larger dental implant options when using PAN and smaller options with CBCT. Kappa showed almost perfect (0.81-1.0) agreement between Jr and Sr for OP (PAN and CBCT). For BG, agreement was substantial (0.61-0.80) when planning was done with PAN and CBCT. Descriptive statistics showed evidence that when Jrs used CBCT, they no longer indicated the BG they had planned when they used PAN.

CONCLUSION

There were differences in the pre-surgical planning for treatment with dental implants depending on the professional experience and the type of imaging examination used.

CLINICAL RELEVANCE

Variation in dental implant planning can affect treatment time, cost, and morbidity in patients.

Advances in Multiscale Characterization Techniques of Bone and Biomaterials Interfaces

The success of osseointegrated biomaterials often depends on the functional interface between the implant and mineralized bone tissue. Several parallels between natural and synthetic interfaces exist on various length scales from the microscale toward the cellular and the atomic scale structure. Interest lies in the development of more sophisticated methods to probe these hierarchical levels in tissues at both biomaterials interfaces and natural tissue interphases. This review will highlight new and emerging perspectives toward understanding mineralized tissues, particularly bone tissue, and interfaces between bone and engineered biomaterials at multilength scales and with multidimensionality. Emphasis will be placed on highlighting novel and correlative X-ray, ion, and electron beam imaging approaches, such as electron tomography, atom probe tomography, and in situ microscopies, as well as spectroscopic and mechanical characterizations. These less conventional approaches to imaging biomaterials are contributing to the evolution of the understanding of the structure and organization in bone and bone integrating materials.

Accuracy of densitometry of two cone beam computed tomography equipment in comparison with computed tomography

BACKGROUND

The use of oral implants has been growing, and cone beam computerized tomography (CBCT) has become the method of choice for oral and maxillofacial radiology.

OBJECTIVE

To assess the accuracy of bone densitometry in two different CBCT devices in comparison with MDCT (multi-detector CT).

METHODS

Different concentrations of urografin, including 2.5%, 5%, 7.5%, 10%, 12.5%, were prepared, and the Hounsfield unit of these solution was measured by two CBCT devices (SORDEX CRANEX 3D and NEWTOM 5G) and one spiral CT device (SOMATOM SENSATION). Difference of output Hounsfield units in each concentration was compared in three devices. Correlation of devices with increase of urografin dose also was evaluated. Statistical analyses of the data were performed using SPSS18 and Kruskal-Wallis and Mann-Whitney U tests, along with Spearman's correlation coefficient.

RESULTS

The range of gray density for NEWTOM 5G CBCT, SORDEX 3D CBCT, and SOMATOM CT imaging systems was from 781 to 2311, 427 to 1464, and 222 to 994, respectively. There was significant difference between devices in the Hounsfield unit in all urografin concentrations (p<0.001). Also there was a significant correlation between three devices with increasing the urografin dose (p<0.05; r>0.95).

CONCLUSION

Our findings indicated a high correlation and linear relationship between different studied imaging systems. Although utilizing CBCT in the assessment of bone density is useful according to its lower emitted dose and less cost, clinicians should be aware of the issue that the voxel value in CBCT is not as perfect as CT.

Evaluation of keratocystic odontogenic tumors using cone beam computed tomography

Purpose:

The aim of this retrospective study is to determine the radiological features of keratocystic odontogenic tumors (KCOT) using cone-beam computed tomography (CBCT).

Materials and Methods:

CBCT images of 28 patients who had histopathologically-confirmed KCOT were retrospectively reviewed from the archives of the Department of Dentomaxillofacial Radiology, Gazi University Faculty of Dentistry. The location and size of KCOT, cortical expansion, cortical perforation, relation with the impacted teeth, and the impact on the mandibular canal were evaluated.

Results:

The mean age of patients at initial diagnosis was 34.5 years. Patients with an impacted tooth were significantly younger than those without an impacted tooth (p<0.05). Among KCOTs, 21% were localized in the maxilla whereas 79% were found in the mandible. The lesions localized in the mandible were mostly found in the retromolar-ramus region. Of these patients, 93% had cortical expansion and 75% had bone perforation. Of the 22 mandibular lesions, 20 were in close proximity of the mandibular canal and 18 (90%) of these lesions had caused destruction in the mandibular canal.

Conclusion:

KCOTs exhibit their aggressive nature in the jaw bone. CBCT is a useful radiological imaging method to examine the radiologic characteristics of KCOTs such as bone destruction and their spatial relations with the neighboring anatomic structures.

Reliability of panoramic radiography in determination of neurosensory disturbances related to dental implant placement in posterior mandible

INTRODUCTION

During implantology procedures, one of the most serious complications is the damage of the inferior alveolar nerve, which may result in neurosensory disturbances (NSD). Panoramic radiographs have been considered for a primary evaluation to determine the bone height and implant-mandibular canal distance.

MATERIALS AND METHODS

One thousand five hundred ninety-seven panoramic radiographs of patients, who were treated with 3608 dental implants in Erciyes University, Oral and Maxillofacial Hospital between 2007 and 2012, were examined. Forty-eight implants were determined to be near the mandibular canal using a 2-dimensional software program.

RESULTS

A total of 48 implants were closer than 2 mm to the mandibular canal. A range of 0 to 1.9 mm distance was detected between the mandibular canal and these implants. Fourteen implants (29.16%) placed in a distance less than 1 mm to the mandibular canal, and 34 (70.83%) between 1 and 2 mm. One patient had NSD.

CONCLUSION

Determination of the dental implant length using panoramic radiography is a reliable technique to prevent neurosensory complications. However computed tomography or cone-beam computed tomography based planning of dental implants may be required for borderline cases.

Characterization of Scattered X-Ray Photons in Dental Cone-Beam Computed Tomography

Purpose

Scatter is a very important artifact causing factor in dental cone-beam CT (CBCT), which has a major influence on the detectability of details within images. This work aimed to improve the image quality of dental CBCT through scatter correction.

Methods

Scatter was estimated in the projection domain from the low frequency component of the difference between the raw CBCT projection and the projection obtained by extrapolating the model fitted to the raw projections acquired with 2 different sizes of axial field-of-view (FOV). The function for curve fitting was optimized by using Monte Carlo simulation. To validate the proposed method, an anthropomorphic phantom and a water-filled cylindrical phantom with rod inserts simulating different tissue materials were scanned using 120 kVp, 5 mA and 9-second scanning time covering an axial FOV of 4 cm and 13 cm. The detectability of the CT image was evaluated by calculating the contrast-to-noise ratio (CNR).

Results

Beam hardening and cupping artifacts were observed in CBCT images without scatter correction, especially in those acquired with 13 cm FOV. These artifacts were reduced in CBCT images corrected by the proposed method, demonstrating its efficacy on scatter correction. After scatter correction, the image quality of CBCT was improved in terms of target detectability which was quantified as the CNR for rod inserts in the cylindrical phantom.

Conclusions

Hopefully the calculations performed in this work can provide a route to reach a high level of diagnostic image quality for CBCT imaging used in oral and maxillofacial structures whilst ensuring patient dose as low as reasonably achievable, which may ultimately make CBCT scan a reliable and safe tool in clinical practice.

Diagnostic Accuracy of Cone-Beam Computed Tomography and Periapical Radiography in Internal Root Resorption

INTRODUCTION

The aim of this study was to compare the diagnostic value of cone-beam computed tomography (CBCT) and periapical (PA) radiography in detecting internal root resorption.

METHODS AND MATERIALS

Eighty single rooted human teeth with visible pulps in PA radiography were split mesiodistally along the coronal plane. Internal resorption like lesions were created in three areas (cervical, middle and apical) in labial wall of the canals in different diameters. PA radiography and CBCT images were taken from each tooth. Two observers examined the radiographs and CBCT images to evaluate the presence of resorption cavities. The data were statistically analyzed and degree of agreement was calculated using Cohen's kappa (k) values.

RESULTS

The mean±SD of agreement coefficient of kappa between the two observers of the CBCT images was calculated to be 0.681±0.047. The coefficients for the direct, mesial and distal PA radiography were 0.405±0.059, 0.421±0.060 and 0.432±0.056, respectively (P=0.001). The differences in the diagnostic accuracy of resorption of different sizes were statistically significant (P<0.05); however, the PA radiography and CBCT, had no statistically significant differences in detection of internal resorption lesions in the cervical, middle and apical regions.

CONCLUSION

Though, CBCT has a higher sensitivity, specificity, positive predictive value and negative predictive value in comparison with conventional radiography, this difference was not significant.

Validation of cone beam computed tomography-based tooth printing using different three-dimensional printing technologies

OBJECTIVE

Our aim was to determine the accuracy of 3-dimensional reconstructed models of teeth compared with the natural teeth by using 4 different 3-dimensional printers.

STUDY DESIGN

This in vitro study was carried out using 2 intact, dry adult human mandibles, which were scanned with cone beam computed tomography. Premolars were selected for this study. Dimensional differences between natural teeth and the printed models were evaluated directly by using volumetric differences and indirectly through optical scanning. Analysis of variance, Pearson correlation, and Bland Altman plots were applied for statistical analysis.

RESULTS

Volumetric measurements from natural teeth and fabricated models, either by the direct method (the Archimedes principle) or by the indirect method (optical scanning), showed no statistical differences. The mean volume difference ranged between 3.1 mm(3) (0.7%) and 4.4 mm(3) (1.9%) for the direct measurement, and between -1.3 mm(3) (-0.6%) and 11.9 mm(3) (+5.9%) for the optical scan. A surface part comparison analysis showed that 90% of the values revealed a distance deviation within the interval 0 to 0.25 mm.

CONCLUSIONS

Current results showed a high accuracy of all printed models of teeth compared with natural teeth. This outcome opens perspectives for clinical use of cost-effective 3-dimensional printed teeth for surgical procedures, such as tooth autotransplantation.

Radiographic evaluation of the course and visibility of the mandibular canal

Purpose

This study was performed to investigate the course of the mandibular canal on panoramic radiography and the visibility of this canal on both panoramic radiography and cone-beam computed tomography (CBCT).

Materials and Methods

The study consisted of panoramic radiographs and CBCT images from 262 patients. The course of the mandibular canal, as seen in panoramic radiographs, was classified into four types: linear, elliptical, spoon-shaped, and turning curves. The visibility of this canal from the first to the third molar region was evaluated by visually determining whether the mandibular canal was clearly visible, probably visible, or invisible. The visibihlity of the canal on panoramic radiographs was compared with that on CBCT images.

Results

Elliptical curves were most frequently observed along the course of the mandibular canal. The percentage of clearly visible mandibular canals was the highest among the spoon-shaped curves and the lowest among the linear curves. On panoramic radiographs, invisible mandibular canals were found in 22.7% of the examined sites in the first molar region, 11.8% in the second molar region, and 1.3% in the third molar region. On CBCT cross-sectional images, the mandibular canal was invisible in 8.2% of the examined sites in the first molar region, 5.7% in the second molar region, and 0.2% in the third molar region.

Conclusion

The visibility of this canal was lower in the first molar region than in the third molar region. The mandibular canal presented better visibility on CBCT images than on panoramic radiographs.

Assessment of the mandibular incisive canal by panoramic radiograph and cone-beam computed tomography

Objectives. The region between mental foramens is considered as a zone of choice for implants. However, complications may arise due to an extension anterior to the mental foramen that forms the mandible incisive canal [MIC]. Our goal is to evaluate identification of MIC by both panoramic radiograph [PAN] and cone-beam computed tomography [CBCT]. Methods. 150 cases with bilateral MIC were analyzed. Images of a radiolucent canal, within the trabecular bone, surrounded by a radiopaque cortical bone representing the canal walls, and extending to the anterior portion beyond the mental foramen, were considered by two independent radiologists as being images of MIC. PAN and CBCT of these cases were evaluated by 2 other radiologists at different times. Agreement between results of examination methods was assessed by the Kappa coefficient. The interexaminer and intramethod rates for detection of MIC were analyzed by the McNemar test. Gender, mandible side, examiner, and type of method were analyzed by the generalized estimating equations [GEE] model. Results. significant difference between examiners [PAN: P = 0.146; CBCT: P = 0.749] was not observed. Analysis by GEE model showed no significant difference between genders [P = 0.411] and examiners [P = 0.183]. However, significant difference was observed for identification in both mandible right side [P = 0.001], where the identification frequency was higher, and CBCT method [P < 0.001]. Conclusions. PAN was not shown to be a safe examination to identify MIC. CBCT should always be used in preoperative planning and to reduce the number of complications in implant surgeries.

Cone beam CT evaluation of the presence of anatomic accessory canals in the jaws

OBJECTIVES

To assess the prevalence, location and anatomical course of accessory canals of the jaws using cone beam CT.

METHODS

A retrospective analysis of 4200 successive cone beam CT scans, for patients of both genders and ages ranging from 7 to 88 years, was performed. They were exposed at the School of Dentistry, University of Michigan, Ann Arbor, MI. After applying the exclusion criteria (the presence of severe ridge resorption, pre-existing implants, a previously reported history of craniofacial malformations or syndromes, a previous history of trauma or surgery, inadequate image quality and subsequent scans from the same individuals), 4051 scans were ultimately included in this study.

RESULTS

Of the 4051 scans (2306 females and 1745 males) that qualified for inclusion in this study, accessory canals were identified in 1737 cases (42.9%; 1004 females and 733 males). 532 scans were in the maxilla (13.1%; 296 females and 236 males) and 1205 in the mandible (29.8%; 708 females and 497 males).

CONCLUSIONS

A network of accessory canals bringing into communication the inner and outer cortical plates of the jaws was identified. In light of these findings, clinicians should carefully assess for the presence of accessory canals prior to any surgical intervention to decrease the risk for complications.

Location of the mandibular canal and thickness of the occlusal cortical bone at dental implant sites in the lower second premolar and first molar

The objective of this study was to evaluate the location of the mandibular canal and the thickness of the occlusal cortical bone at dental implant sites in the lower second premolar and lower first molar by using dental cone-beam computed tomography (CBCT). Seventy-nine sites (47 second premolar and 32 first molar sites) were identified in the dental CBCT examinations of 47 patients. In this study, 4 parameters were measured: (1) MC—the distance from the mandibular canal to the upper border of the mandible; (2) CD—the distance from the mandibular canal to the buccal border of the mandible; (3) MD—the distance from the mandibular canal to the lingual border of the mandible; (4) TC—the thickness of the cortical bone at the occlusal side. A statistical analysis was employed to compare the size and differences between these 4 parameters at the lower second premolar and lower first molar. Regarding the MC and MD, the experimental results showed no statistical difference between the first molar and second premolar. However, the TC for the second premolar was greater than that of the first molar. Thus, careful consideration is necessary in choosing the size of and operation type for dental implants.

A comparative study of accuracy of linear measurements using cone beam and multi-slice computed tomographies for evaluation of mandibular canal location in dry mandibles

Background:

Cross- sectional tomograms have been used for optimal pre-operative planning of dental implant placement. The aim of the present study was to assess the accuracy of Cone Beam Computed Tomography (CBCT) measurements of specific distances around the mandibular canal by comparing them to those obtained from Multi-Slice Computed Tomography (MSCT) images.

Materials and Methods:

Ten hemi-mandible specimens were examined using CBCT and MSCT. Before imaging, wires were placed at 7 locations between the anterior margin of the third molar and the anterior margin of the second premolar as reference points. Following distances were measured by two observers on each cross-sectional CBCT and MSCT image: Mandibular Width (W), Length (L), Upper Distance (UD), Lower Distance (LD), Buccal Distance (BD), and Lingual Distance (LID). The obtained data were evaluated using SPSS software, applying paired t-test and intra-class correlation coefficient (ICC).

Results:

There was a significant difference between the values obtained by MSCT and CBCT measurement for all areas such as H, W, UD, LD, BD, and LID, (P < 0.001), with a difference less than 1 mm. The ICC for all distances by both techniques, measured by a single observer with a one week interval and between 2 observers was 99% and 98%, respectively. Comparing the obtained data of both techniques indicates that the difference between two techniques is 2.17% relative to MSCT.

Conclusion:

The results of this study showed that there is significant difference between measurements obtained by CBCT and MSCT. However, the difference is not clinically significant.

Three-dimensional linear and volumetric analysis of maxillary sinus pneumatization

Considering the anatomical variability related to the maxillary sinus, its intimate relation to the maxillary posterior teeth and because of all the implications that pneumatization may possess, three-dimensional assessment of maxillary sinus pneumatization is of most usefulness. The aim of this study is to analyze the maxillary sinus dimensions both linearly and volumetrically using cone beam computed tomography (CBCT) to assess the maxillary sinus pneumatization. Retrospective analysis of 30 maxillary sinuses belonging to 15 patients’ CBCT scans was performed. Linear and volumetric measurements were conducted and statistically analyzed. The maximum craniocaudal extension of the maxillary sinus was located around the 2nd molar in 93% of the sinuses, while the maximum mediolateral and antroposterior extensions of the maxillary sinus were located at the level of root of zygomatic complex in 90% of sinuses. There was a high correlation between the linear measurements of the right and left sides, where the antroposterior extension of the sinus at level of the nasal floor had the largest correlation (0.89). There was also a high correlation between the Simplant and geometric derived maxillary sinus volumes for both right and left sides (0.98 and 0.96, respectively). The relations of the sinus floor can be accurately assessed on the different orthogonal images obtained through 3D CBCT scan. The geometric method offered a much cheaper, easier, and less sophisticated substitute; therefore, with the availability of software, 3D volumetric measurements are more facilitated.

Variability of dental cone beam CT grey values for density estimations

OBJECTIVE

The aim of this study was to investigate the use of dental cone beam CT (CBCT) grey values for density estimations by calculating the correlation with multislice CT (MSCT) values and the grey value error after recalibration.

METHODS

A polymethyl methacrylate (PMMA) phantom was developed containing inserts of different density: air, PMMA, hydroxyapatite (HA) 50 mg cm(-3), HA 100, HA 200 and aluminium. The phantom was scanned on 13 CBCT devices and 1 MSCT device. Correlation between CBCT grey values and CT numbers was calculated, and the average error of the CBCT values was estimated in the medium-density range after recalibration.

RESULTS

Pearson correlation coefficients ranged between 0.7014 and 0.9996 in the full-density range and between 0.5620 and 0.9991 in the medium-density range. The average error of CBCT voxel values in the medium-density range was between 35 and 1562.

CONCLUSION

Even though most CBCT devices showed a good overall correlation with CT numbers, large errors can be seen when using the grey values in a quantitative way. Although it could be possible to obtain pseudo-Hounsfield units from certain CBCTs, alternative methods of assessing bone tissue should be further investigated.

ADVANCES IN KNOWLEDGE

The suitability of dental CBCT for density estimations was assessed, involving a large number of devices and protocols. The possibility for grey value calibration was thoroughly investigated.

Using an existing denture to design a radiographic template for a two-implant mandibular overdenture

This article describes a technique for modifying an existing mandibular complete denture for use as a radiographic template with a radiopaque light-activated calcium hydroxide (Ca(OH)(2)) preparation. This allows prosthetically driven treatment planning and the surgical placement of 2 implants to support the existing mandibular denture.