Australian Dental Journal 2008; 53:(1 Suppl): S11S25 doi: 10.1111/j.1834-7819.2008.00037.

Implant radiography and radiology

PA Monsour,* R Dudhia*
*School of Dentistry, The University of Queensland, Brisbane.

ABSTRACT
The practitioner placing dental implants has many options with respect to pre-implant radiographic assessment of the jaws. The advantages and disadvantages of the imaging modalities currently available for pre-implant imaging are discussed in some detail. Intra-oral and extra-oral radiographs are generally low dose but the information provided is limited as the images are not three-dimensional. Tomography is three-dimensional, but the image quality is highly variable. Computed tomography (CT) has been the gold standard for many years as the information provided is three-dimensional and generally very accurate. However, CT examinations are expensive and deliver a relatively high radiation dose to the patient. The latest imaging modality introduced is cone beam volumetric tomography (CBVT) and this technology is very promising with regard to pre-implant imaging. CBVT generally delivers a lower dose to the patient than CT and provides reasonably sharp images with three-dimensional information. A comparison between CT and CBVT is provided. Magnetic resonance imaging is showing some promise, but the examinations are not readily available, generally expensive and bone is not well imaged. Magnetic resonance imaging is excellent for demonstrating soft tissues and therefore may be of great use in identifying the inferior dental nerve and vessels. All of the above technology is of little value if the information required is not obtained and so information is also provided on imaging of some of the vital structures. Of particular interest is the inferior dental canal, incisive canals of the mandible, genial foramina and canals, maxillary sinus and the incisive canal and foramen of the maxilla.
Key words: Radiography, radiology, implants, computed tomography, cone beam volumetric tomography. Abbreviations and acronyms: CBVT = cone beam volumetric tomography; CT = computed tomography; FOV = field of view; IC = incisive canal; IDC = inferior dental canal; MRI = magnetic resonance imaging.

INTRODUCTION It is essential to obtain appropriate information about the jaws prior to implant placement and this includes assessment of bone grafts. It is also necessary to obtain information about consolidation of implants and positioning following placement of implants in the jaws or adjacent bones. There are many imaging options currently available, including intra-oral radiography, conventional extra-oral radiography, tomography, computed tomography (CT), cone beam volumetric tomography (CBVT) and magnetic resonance imaging (MRI). The appropriateness of each of the imaging options will be discussed and information will also be provided on interpretation. In recent times we have seen the emergence of CBVT units and as with any new technology many claims have been made to convince prospective users of the benets of the new technology. This paper will examine in some depth the benets and failings of CBVT as the technology currently stands.
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Intra-oral radiography Periapical radiographs and occlusal radiographs have been used to assess the jaws pre- and post-implant placement. The use of the bisecting angle technique for taking periapical radiographs should be discouraged because of the inherent distortion of the resultant image. The bisecting angle technique relies on a geometric trick to produce the image, but only a portion of the structures being imaged are dimensionally accurate. The long cone paralleling technique for taking periapical radiographs is the technique of choice for the following reasons: reduced skin dose; less magnication; a true relationship between the bone height and adjacent teeth is demonstrated; no superimposition of the zygoma over the upper molar region. It should be remembered that to get the most from the long cone paralleling technique it should be performed with a lm-focal distance of approximately 30 cm.
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PA Monsour and R Dudhia Occlusal radiographs have minimal application in implant dentistry. Cross-sectional occlusal radiographs of the mandible give some information about the buccolingual dimension of the mandible, but this information is only accurate with regard to the inferior aspect of the body, not the width of the alveolar ridge where the implant is to be placed. The use of cross-sectional occlusal radiographs can be helpful when assessing the position of the implant within the jaw following placement; this applies to both the mandible and maxilla. Extra-oral radiography Lateral cephalometric radiographs provide accurate information about the available bone in the mid-sagittal region of the maxilla and mandible. Because of the long lm-focal distances used in cephalometric radiography the resultant image has minimal magnication. Figure 1 shows a lateral cephalometric radiograph taken with a trial lower denture in place and radio-opaque material dening the proposed implant site in the anterior mandible. The cross-sectional dimensions and morphology of the ridge are shown accurately in the midsagittal plane of the anterior maxilla and mandible. Rotational panoramic radiography (OPG) is an incredibly popular form of radiography in dentistry generally. No other imaging modality gives as much information about the jaws with such a small radiation dose. With rare earth intensifying screens the dose from a single OPG is approximately 0.007 mSv using Table 1. Radiation dose
MODALITY Background radiation (per annum) Intra-oral radiography Long-cone paralleling periapical radiograph4042 Full-mouth periapical survey8,10,42,43 Occlusal radiograph40,41 Extra-oral radiography Rotational panoramic radiograph8,10,11,15,4046 Lateral Cephalometric radiographs41,45 Tomography (4 slices)40,4245,47 Tomography (full survey)40,43,44 Cone beam volumetric tomography8,10,11,15,30,46,48 Multislice computed tomography8,30,4044,46,48 Low-dose multislice computed tomography10,40,43,45,46,48 (most data pertains to single arch scans) Magnetic resonance imaging
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1990 (mSv) 2.000 0.0010.010 0.0130.150 0.0070.008 (mx) 0.00290.026 0.0020.005 0.0060.134 0.0630.477 0.0370.847 0.1042.100 0.1000.760

2005 (mSv) na 0.0050.015 na na

0.0090.022 0.003 0.012 na 0.0521.025 na 0.924

1990 guidelines for effective dose calculation do not apply an individual tissue weighting to salivary glands and brain tissue. 2005 draft guidelines apply an individual tissue weighting to salivary glands and brain tissue increasing their relative weighting in the effective dose calculation. n a: not available.

analogue technology (Table 1). Panoramic radiographs provide an excellent general overview of the dentition and the jaws. However, OPGs have their limitations when being used for pre- and post-implant assessment of the jaws. There are inherent problems with OPGs which include distortion in the horizontal plane, magnication in the vertical plane, true relationships are not demonstrated well and the image is only twodimensional. The accuracy of the image is largely operator dependent and varies greatly with patient positioning. Figure 2 shows an OPG in which the patients head is rotated to the left, resulting in horizontal magnication of the structures on the left

Fig 1. Lateral cephalometric radiograph of an edentulous patient showing the available bone in the mid sagittal plane of the maxilla and mandible (arrows) with the trial mandibular denture in place (arrowhead). (Courtesy of Dr Gary Smith.)
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Fig 2. Panoramic radiograph showing horizontal enlargement of structures on the left side due to rotation of the head to the left during taking of the radiograph.
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Fig 3. (a) Panoramic radiograph with the occlusal plane in the incorrect position (chin up). (b) Same patient with the chin down further.

and a reduction in the horizontal dimension of structures on the right. Figure 3 shows the effect on horizontal dimension of having the patient positioned with the chin up too high for an OPG. Figure 4 shows the effect on horizontal dimension of the head being too far forward and too far back in the OPG machine. The inferior dental canal is not always well shown on
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Fig 5. Cross-sectional diagram of the mandible showing that structures that are more lingual are projected higher on the lm than structures that are more buccal. (a) shows the inferior dental canal close to the buccal cortex and a relative indication of where the canal is projected onto the lm, (b) demonstrates that when the inferior dental canal is more lingual, the canal is projected higher on the lm. The inferior line drawings depict the difference in appearance of the canal when buccal or lingual, on the panoramic radiograph.

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rotational panoramic radiographs and when it is shown, its relationship to the crest of the ridge may be distorted. For example, if the inferior dental canal lies close to the lingual cortex it will be projected higher on the lm and therefore appear higher in the arch than it really is (Fig 5). Due to the mode of operation of OPG machines and the shape of the alveolar ridge, the ridge may appear to have adequate vertical dimension for an implant, but the reality is very different (Fig 6). Also, as the image on an OPG is only two-dimensional, it is difcult to assess the available bone width (Fig 7). Other problems with OPGs include superimposition of airway shadows, soft tissue shadows and ghost images, all of which can interfere with interpretation of the radiograph. As a general rule if the inferior dental canal is poorly visualized on a well-taken OPG it will be difcult to localize, but not impossible, using other imaging modalities. Tomography A number of multifunctional imaging machines are currently available that are capable of performing rotational panoramic, cephalometric and tomographic
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Fig 4. (a) Cropped panoramic radiograph with the anterior teeth inside the focal trough, resulting in horizontal enlargement and blurring of the anterior teeth. (b) Panoramic radiograph with the anterior teeth in front of the focal trough, resulting in all structures being compressed in the horizontal plane.
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Fig 6. (a) Cropped panoramic radiograph demonstrating considerable bone height in the left mandibular body. Three lines identied as 1, 2 and 3 have been drawn vertically across the left mandibular body. (b) Reformatted cross-sectional CT images corresponding to each line from (a), indicating there is far less usable bone height in the left mandibular body than the panoramic radiograph suggests.

Fig 7. (a) Cropped panoramic radiograph demonstrating excellent bone height in the lower right molar region. (b) Reformatted cross-sectional CT images showing reasonable bone height, but the ridge is narrow bucco-lingually.

examinations. Cross-sectional images obtained using specially designed panoramic radiographic units have been shown to be acceptable for dental implant planning.1 The tomography performed is usually linear, spiral or hypocycloidal. These devices are capable of producing thin (as small as 1 mm) cross-sectional slices of the jaws that are suitable for pre- and post-implant assessment. Figure 8 shows a series of cross-sectional images of the mandible obtained using hypocycloidal tomography to demonstrate the available bone and the location of the inferior dental canal. The images are produced at a constant known magnication and therefore measurements may be taken directly from the images using a special ruler provided with the appropriate scale or in the case of digital images using a measurement programme after calibration. The multifunctional units are also capable of providing images similar to intra-oral radiographs. Limitations of these types of units are that the examination times can be very long (up to 20 minutes) and the patient is required to remain still for up to 20 seconds during tomographic acquisition of each site. Additionally, image detail may not be sharp due to slight patient movement or superimposition of adjacent structures, tomographic
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examinations are not widely available and the examination can be uncomfortable for the patient due to the restraining devices and the length of the examination. Trans-tomographic examinations when performed with a radiographic reference guide during implant surgery have been shown to provide accurate information for implant placement.2 This form of navigation surgery allows the surgeon to rectify the drills orientation when needed. Trans-tomographic navigation protocols may allow apless surgical procedures to be utilized in a greater range of cases. Computed tomography (CT) For a long period of time CT has been the gold standard for pre-implant assessment of the jaws. Modern CT units have extremely fast gantry speeds and generate multiple fan-shaped x-ray beams. As a result multislice CT units have very short examination times and isotropic images can be reformatted in any plane. The scan time using a 16-slice Toshiba CT unit is approximately ve seconds for one arch. With appropriate software packages, reformatted images are generated in the panoramic plane and cross-sectional images are generated at right angles to the panoramic plane with intervals of between 1 and 2 mm. The CT pre-implant imaging software is designed to produce life-size images
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Fig 8. Cross-sectional and panoramic images of the 46 region produced using hypocycloidal tomography to demonstrate the inferior dental canal (arrows) and the available bone.

that can be used to assess the available bone, the location of vital structures and to present the images in an easy-to-read format. Figure 9 shows pre-implant images generated using Toshibas pre-implant imaging package. The pre-implant imaging packages can be used to assess the bone in both jaws for implants, the available bone in the various bone donor sites prior to harvesting for ridge augmentation procedures and to assess the available bone in the malar bones prior to implant placement. The limitations of CT include a relatively high radiation dose compared to other imaging modalities (Table 1), the appropriate software is not always available, the cost of the examination is relatively high and not always rebateable from Medicare, the inferior dental canal is not always shown well and beam hardening artefact or scatter from metal restorations can obscure the regions of interest. Lowdensity structures such as osteoid are generally beyond the resolution of CT units. CT is also of value in assessing the quantity and subjective quality of bone prior to harvesting for a bone graft or ridge augmentation procedure. As implants are not only placed in the jaws, CT is of value in assessing other implant sites such as the malar bones prior to surgery. It will be necessary to liaise closely with medical radiology practices when requesting CT images for pre-implant assessment. It should be made clear to the CT radiographer in the practice exactly what information is required and this is especially true when the data is to be imported for further manipulation using pre-implant planning soft 2008 Australian Dental Association

ware. CT radiographers should be encouraged to scan the patient in a way that optimizes the information obtained and that means orientating the patient to minimize artefact from metal restorations and avoiding gantry tilt wherever possible. The presence of a post in the tooth next to the region of interest or close by may result in too much beam hardening artefact or scatter to make the scan worthwhile. Computed tomography will not be of value in assessing integration of implants as a radiolucent band is usually present around the implant on CT images (Fig 10), but the location of the implant can be assessed in three dimensions using CT. Cone beam volumetric tomography (CBVT) Cone beam volumetric tomography was pioneered at the Nihon University School of Dentistry during the 1990s, and the rst machines became commercially available during 2000.3,4 Since then, numerous machines have been marketed and much research assessing the usefulness of the technology in dentistry has been performed. As with any emergent technology, it can sometimes be difcult to separate fact from ction. Cone-beam technology is progressing rapidly and scanners are constantly being rened and upgraded. Keeping abreast with the latest technologies and upgrades presents a signicant challenge. A reasonable number of scanners have already been installed in dental practices and radiology practices, and this number is sure to grow in the future.
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Fig 9. (a) Scout axial CT image of the mandible identifying the location of each reformatted panoramic and cross-sectional image using pre-implant software. (b) Three of the usual ve life size reformatted panoramic images demonstrating the ROI in the right mandibular body. (c) Consecutive reformatted life size cross-sectional images showing part of the ROI. The location of each cross-section is identied on the panoramic provided with each series of cross-sectional images.

While CBVT permits three-dimensional visualization of the dental hard tissues in a similar manner to multislice CT,5 there are some fundamental differences.
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With the majority of cone-beam machines, the patient is seated or standing rather than being supine. Cone beam volumetric tomography utilizes a cone-shaped
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Implant radiography and radiology typically lower than a multislice CT scan of the jaws.3,4,6,14 Exposure parameters, selected FOV and acquisition times differ markedly from one model to another, and as such radiation dose is highly specic to each individual machine and varies widely. A consequence of the low exposure parameters is that softtissue contrast is markedly decreased compared with the higher-dose multislice CT examination.1518 Furthermore, image noise is more intrusive in CBVT images compared with multislice CT.15,17,19 Numerous authors have written that the lack of soft tissue contrast with CBVT is acceptable as these units are designed for hard tissue imaging,4,6,20,21 but the inability to change the exposure parameters has implications when imaging larger patients. The theoretical resolution of CBVT scanners is very high; numerous manufacturers report a minimum voxel size of between 0.1 and 0.2 mm3.9,19,22 All scans are isotropic, with typical voxel sizes ranging between 0.2 and 0.4 mm3.7,19 Smaller voxel sizes necessitate longer scan times and increased radiation dose to the patient. Isotropic multislice CT data acquired with a 16-slice unit typically produces voxel sizes of 0.5 mm3, although 0.35 mm3 is achievable with modern machines.5,7 As multislice spiral-CT acquisition is signicantly faster than CBVT, movement artefact is less of a problem, and this ensures higher image sharpness. Generally, CBVT scans performed with larger voxel sizes result in subjectively better image quality due to decreased noise. Numerous authors have reported that CBVT offers higher resolution and better image quality compared with CT, but these studies all utilized either radiographic test-phantoms with soft-tissue simulation or cadavers.14,17,21 There was no assessment of how patient movement may affect resolution, sharpness and image quality. At present no studies compare the quality of patient images obtained from CBVT with high-quality, low-dose multislice CT using either a 16- or 64-slice CT unit.17 The geometric accuracy of multislice CT scans is widely accepted,22 and recent research indicates that CBVT images are also of sufcient accuracy to use for pre-implant assessments.11,12,2327 It was found that the error in measurements obtained from CBVT scans was less than 0.5 mm.26 Volume rendered images obtained from CT data were found to be superior to those from CBVT, but the difference was minimal and the CBVT images were still of acceptable quality.28 One study has suggested that soft-tissues may decrease the accuracy of CBVT scans, but the authors did not feel that this was signicant.12 Cone beam volumetric tomography still suffers the same volume-averaging effect as CT, and this most likely accounts for the slight errors in measurements.27 Theoretically, higher resolution scans permit improved accuracy of measurements, but
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Fig 10. Axial CT image of the maxilla showing implants (arrows) in the 14 and 24 regions with the typical CT radiolucent halo artefact.

x-ray beam and either an image intensier or at panel detector for volumetric image acquisition.6,7 During a single rotation around the patients head, multiple basis images are acquired at specic intervals. These are subsequently reconstructed by a personal computer running proprietary software supplied by the machines manufacturer, and this enables the clinician to arbitrarily reformat the data in any plane.8 Standard axial, coronal and sagittal views are available, as are panoramic reformats, cross-sectional cuts of varying thickness and 3D volume rendered images.6,8,9 Image reformatting is identical to that available with multislice CT. This enables the clinician to easily assess an implant site in all three planes and perform accurate measurements using in-built measuring tools. The volumetric data can also be exported in DICOM 3 format and viewed with numerous third-party programmes including some that are freely available from the internet. Image acquisition times vary and are specic to particular models, but typically range between 10 to 70 seconds.68,1012 Acquisition time is also dependent on the selected eld of view (FOV) and voxel size, which relates to the image resolution.11 Smaller voxel sizes theoretically equate to increased resolution. Faster scan times typically result in reduced resolution (larger voxel sizes) and increased noise, but with a lower radiation dose and decreased likelihood of motion artefact.8,13 This is achieved by decreasing the number of basis images acquired prior to volume reconstruction. Longer scan times utilizing an increased number of basis images permit increased resolution or a decrease in image noise but with a signicantly higher radiation dose and an increased risk of patient movement.8 There are currently no clear guidelines for what scan parameters produce acceptable image quality with the lowest radiation dose to the patient. As cone-beam technology was built on the platform of complex-motion tomography, the radiation dose is
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PA Monsour and R Dudhia increased noise and patient movement12 may negate any potential gains. Cone beam verses multislice CT Given that CBVT and multislice CT have similar capabilities it is prudent to examine the differences between the two modalities. Acquisition time with a 16-slice CT scanner is shorter than the fastest CBVT scan, and newer 64-slice CT units reduce the scan time even further. This effectively minimizes the risk of patient movement. The theoretical resolution of CBVT is higher than CT,20 but the difference may not be as signicant as once thought due to the impact of patient movement resulting from the increased scan times. Image quality has been the subject of much debate, and there is no clear answer at present. Cadaver studies demonstrate the capabilities of cone-beam technology,14,21,29 but patient images have been less impressive.30 The low exposure parameters of CBVT result in poor soft-tissue contrast compared with CT,8,31 and the inability to alter the exposure parameters in most machines means that image quality suffers in larger patients. Furthermore, CBVT suffers from the same beam-hardening artefact that CT does; limiting the usefulness of the exam in patients with metallic restorations, posts or surgical plates.17 It has recently been reported that dental implants produce a similar artefact on CBVT images.32 Sample cross-sectional images from CT, CBVT and hypocycloidal tomography are shown in Fig 11 highlighting comparative image quality. While it is recognized that multislice CT is a higherdose examination than CBVT, reports indicate that low-dose CT protocols result in signicantly less exposure than previously thought, without compromising image quality signicantly.33 A consequence of the lesser dose of the CBVT scan is reduced contrast and therefore image quality. Image noise is also signicant, especially with larger patients or higher resolution scans. It is important to note that while the radiation dose from a CBVT scan may be less than from low-dose CT, the dose is still signicantly higher than other forms of dental radiographic examination.8 Magnetic resonance imaging (MRI) MRI has become accepted as a powerful imaging tool in medicine. Using the magnetic properties of the hydrogen atom, MRI units are capable of producing images of the human body. As the technology is dependent upon the presence of hydrogen atoms MRI is particularly suited to imaging of soft tissues. Using various radiofrequency pulse sequences and relaxation times, images may be produced to better demonstrate anatomy or pathology in the body. As MRI relies on the use of a strong magnetic eld, MRI examinations are contraindicated in patients with metal foreign bodies in the eyes, ferromagnetic intracranial aneurysm clips, cardiac pacemakers, cochlear implants and patients in

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Fig 11. Comparison between cross-sectional images of the mandible obtained using hypocycloidal tomography (a), multislice CT (b) and CBVT (c).
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Inferior dental canal The inferior dental canal (IDC) carries the neurovascular components that supply and innervate the teeth and bone of the mandible. In 1992, Gowgiel49 studied the position and arrangement of the IDC. He found that the neurovascular bundle remained intact from the mandibular foramen to the mental foramen. Approaching the mental foramen the IDC turned sharply from the lingual plate buccally toward the mental foramen. Anterior to the mental foramen the neurovascular bundle was smaller and close to the labial cortical plate. In 1997, Wadu et al.50 showed that in all cases they examined the inferior alveolar nerve divided into its incisive and mental branches in the molar region, well before the mental foramen was reached. They also demonstrated that before dividing into incisive and mental branches the inferior alveolar nerve gives off a branch to supply the molars and in two cases they found separate branches to the second premolar. As a general rule if the IDC is well demonstrated on the OPG, it will usually be well demonstrated on other imaging modalities. Conversely, if the IDC is poorly demonstrated on the OPG and the OPG is of reasonable quality, the canal will be difcult to localize using other modalities. The IDC is identiable on radiographs as a narrow radiolucent ribbon bordered by radio-opaque lines. Wadu et al.50 found that in a reasonable number of cases the radio-opaque border was disrupted in certain areas and in some cases absent radiographically. The superior border was more prone to disruption than the inferior border. There are a number of software programmes currently available that can be used to help locate the IDC. Figure 13 shows a cropped OPG where the IDC is difcult to localize and a reformatted CT image in the sagittal plane of the same mandible, showing the location of the canal. If the mandible is osteoporotic or the cancellous bone has few or very thin trabeculae, sometimes the only clue to the location of the canal is scalloping of the cortical plate on the endosteal surface. When in close relation to the lingual cortical plate in particular, the IDC may lie in a groove in the endosteal aspect of the cortical bone (Fig 14a). On some occasions the IDC will not appear as a circumscribed area of reduced density, but as a circumscribed area of increased density (Fig 14b). Mental foramen Typically the mental foramen is located in the buccal cortex of the mandible in the premolar region. The inferior dental canal usually rises quite sharply to the foramen. In cases where the patient has been edentulous
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Fig 12. Magnetic resonance imaging demonstrating the left inferior dental canal as a low signal line (arrow heads) surrounded by high signal cancellous bone in the ramus (a) and as a small black void (arrow) in a cross-section of the left mandibular angle (b).

the rst trimester of pregnancy. The presence of certain metals such as amalgam and non-precious alloys will result in considerable artefact on the images and often render the examination useless.34,35 Pure titanium implants show no artefact with MRI, but if there are any impurities in the titanium there will be artefact. Other considerations include the signicant cost to the patient for MRI examinations and claustrophobia is a real concern as the examinations are generally performed with the patient in a very conning tunnel. Most studies using MRI for pre-implant imaging have focused on the ability of MRI units to locate the inferior dental canal.3638 With MRI the inferior dental canal appears as a black void within the high-signal cancellous bone (Fig 12). If the inferior dental canal is surrounded by sclerotic bone, visualization of the canal is more difcult with MRI as the presence of sclerotic bone results in a low bone marrow signal. The reverse is true for CT, as the presence of sclerotic bone in the mandibular body makes the inferior dental canal more obvious. Magnetic resonance imaging has potential for pre-implant imaging due to the lack of ionizing radiation, but acquisition times can be as long as 30 minutes and there is limited bone information available. Radiographic interpretation The primary role of any pre-implant imaging system is to provide adequate information regarding bony morphology and the location of structures that should be avoided when placing implants in the jaws. To a lesser extent pre-implant imaging may also give some meaningful information on the quality of the bone. Superimposed over the above considerations is the need to keep exposure of the patient to ionizing radiation as low as possible in adherence with the ALARA principle (as low as reasonably achievable).
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Fig 15. Reformatted panoramic (a) and cross-sectional (b) CT images of an edentulous and atrophic mandible showing the inferior dental canal very close to the crest of the ridge (arrows) and the mental foramen at the crest (arrow head).

Fig 13. (a) Cropped panoramic radiograph with poor visualization of the left inferior dental canal. (b) Reformatted, corrected sagittal CT image demonstrating the inferior dental canal (arrow heads) not seen on the panoramic radiograph shown at (a).

for a considerable period of time and the ridge has atrophied, the inferior dental canal may run very close to the crest of the ridge and the mental foramen may open onto the crest (Fig 15). The IDC may extend anteriorly past the mental foramen and then loop back to the foramen. The extent of this looping of the IDC is very variable and not always visible on conventional radiographs.51,52 Incisive branch of the inferior dental canal The anterior region of the mandible is generally considered to be a relatively safe area for implant surgery due to little chance of signicant damage to neurovascular structures. Previous studies however, have reported life-threatening complications caused by profuse bleeding after implant placement between the mental foramina.5355 A number of other complications have been reported following placement of implants in the inter-mental region and some of these have been attributed to damage of the incisive canal (IC).56,57 Kohavi and Bar-Ziv56 describe a case where an implant was placed through a large lumen IC resulting in pain. The incisive branch of the IDC extends anteriorly from the mental foramen to supply the lower anterior teeth. The incisive branch is usually poorly demonstrated on conventional radiographs.51,52 Generally, the IC extends anteriorly and inferiorly from the mental foramen. The IC has been shown to be located on average 9.7 mm (SD 1.8 mm) from the lower border of the mandible and continues toward the incisor region in a slightly downward direction with a mean distance to the lower border of 7.2 mm (SD 2.1 mm).58 The diameter of the IC has been found to range from 0.48 mm to 2.90 mm.52 As the incisive canal is an anterior extension of the IDC, it should be considered to contain the same neurovascular elements.58
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Fig 14. (a) Reformatted cross-sectional CT images demonstrating grooving of the endosteal surface of the lingual cortical plate (arrows) as a guide to the location of the inferior dental canal. (b) The inferior dental canal may appear as a small circular opacity on reformatted cross-sectional images of the mandible (arrow heads).
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much more common (72 to 28 per cent). The canals had a mean length of 6.5 mm (SD 2.4 mm). In most cases the canal has a downward course toward the labial plate, but in a reasonable number of cases the canal was directed upwards toward the labial side. The genial foramina and canals are not always shown on reformatted cross-sectional CT images.60 The superior and inferior genial foramina have been shown to contain neurovascular elements and this has obvious implications for pre-operative planning of surgical procedures in the anterior mandible.59,60 Submandibular depression Below the mylohyoid ridge on the lingual aspect of the mandibular body is a concavity known as the submandibular fossa or depression. There is considerable variation in length, height and depth of the submandibular fossae. The submandibular fossae are well demonstrated using tomography, CT and CBVT. Incisive foramen and canal The size and morphology of the incisive canal and the incisive foramen is extremely variable (Fig 17).61 The incisive foramen has been described as a funnel-shaped hole between the two halves of the maxilla palatal to the upper central incisors.62 The incisive canal contains the nasopalatine nerve and the descending palatine artery. It has been shown that the descending palatine

Fig 16. Reformatted cross-sectional CT images demonstrating the superior (a) and inferior (b) genial foramina (arrows) and canals (arrow heads).

Genial foramina The anatomical structures worthy of note between the mental foramina of the mandible include the midline foramina. These foramina may be denoted as the superior and inferior genial foramina with their associated canals. The typical appearance of the genial foramina on reformatted CT images is shown in Fig 16. Liang et al.59 found that 98 per cent of the 50 mandibles assessed had at least one genial foramen. Only one mandible lacked a genial foramen and in one mandible there were three foramina. In those cases with only one foramen, the superior genial foramen was

Fig 17. Cropped axial CT images demonstrating some of the variations found in the morphology of the incisive canals of the maxilla (arrows) in cross-section.
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Fig 18. (a) Reformatted CT image showing mucosal thickening on the oor of the right maxillary sinus. (b) Reformatted CBVT image showing considerable mucous in the right maxillary sinus (coronal plane). (c) Reformatted CT image showing circumferential mucosal thickening in both maxillary sinuses (axial plane). (d) Reformatted CT image showing uid on the oor of the right maxillary sinus.

artery lies in an anterior canal and there are branches sprouting from the left and right sides of the canal that contain connective tissue and blood vessels.62 Maxillary sinuses The maxillary sinuses are the rst of the paranasal sinuses to form and they usually develop symmetrically with only minor variations. Unilateral hypoplasia of the maxillary sinuses has been reported to occur in 1.7 per cent of people and bilateral hypoplasia in 7.2 per cent of people.63 The posterior superior alveolar nerve enters the maxillary sinus through the posterior wall, then runs forward and downwards in a small canal to supply the molars. Usually the maxillary sinuses do not extend anteriorly beyond the apex of the upper canine, but the maxillary sinus may on occasion extend almost to the midline of the maxilla. The maxillary sinus is visualized as an air-lled space, as the healthy mucosal lining is not visible on radiographs. The most common pathology noted in the maxillary sinus is thickening of the mucosal lining of the sinus. This mucosal thickening may sometimes take the form of polypoidal thickening or circumferential mucosal thickening. Often sinus changes on the oor of the maxillary
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Fig 19. Reformatted cross-sectional images of the mandibular body showing marked resorption of the alveolar ridge resulting in a thin plate of bone (arrows) on the lingual aspect of the ridge.
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the gold standard, this type of examination cannot be justied for every implant case. Cone beam volumetric tomography has great potential with regard to preimplant imaging. In deciding on what imaging is appropriate, the clinician should not be swayed entirely by the dose of radiation the patient will receive. There is very little to be gained by opting for pre-implant imaging where the dose is very low, if the end result is compromised because of a lack of reliable information. The risk-to-benet ratio should be determined on an individual basis so as to maximize success. REFERENCES

(b)

1. Peltola JS, Mattila M. Cross-sectional tomograms obtained with four panoramic radiographic units in the assessment of implant site measurements. Dentomaxillofac Radiol 2004;33:295300. 2. Bousquet F, Bousquet P, Vazquez L. Transtomography for implant placement guidance in non-invasive surgical procedures. Dentomaxillofac Radiol 2007;36:229233. 3. Terakado M, Hashimoto K, Arai Y, Honda M, Sekiwa T, Sato H. Diagnostic imaging with newly developed ortho cubic super-high resolution computed tomography (Ortho-CT). Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:509 518. 4. Ito K, Gomi Y, Sato S, Arai Y, Shinoda K. Clinical application of a new compact CT system to assess 3-D images for the preoperative treatment planning of implants in the posterior mandible. A case report. Clin Oral Implants Res 2001;12:539542. 5. Vannier MW. Craniofacial computed tomography scanning: technology, applications and future trends. Orthod Craniofac Res 2003;1:2330; discussion 179-182. 6. Arai Y, Tammisalo E, Iwai K, Hashimoto K, Shinoda K. Development of a compact computed tomographic apparatus for dental use. Dentomaxillofac Radiol 1999;28:245248. 7. Jabero M, Sarment DP. Advanced surgical guidance technology: a review. Implant Dent 2006;15:135142. 8. Scarfe WC, Farman AG, Sukovic P. Clinical applications of conebeam computed tomography in dental practice. J Can Dent Assoc 2006;72:7580. 9. Scarfe WC. Imaging of maxillofacial trauma: evolutions and emerging revolutions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100(2 Suppl):S75S96. 10. Mah JK, Danforth RA, Bumann A, Hatcher D. Radiation absorbed in maxillofacial imaging with a new dental computed tomography device. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96:508513. 11. Ludlow JB, Davies-Ludlow LE, Brooks SL, Howerton WB. Dosimetry of 3 CBCT devices for oral and maxillofacial radiology: CB Mercuray, NewTom 3G and i-CAT. Dentomaxillofac Radiol 2006;35:219226. 12. Pinsky HM, Dyda S, Pinsky RW, Misch KA, Sarment DP. Accuracy of three-dimensional measurements using cone-beam CT. Dentomaxillofac Radiol 2006;35:410416. 13. van Daatselaar AN, van der Stelt PF, Weenen J. Effect of number of projections on image quality of local CT. Dentomaxillofac Radiol 2004;33:361369. 14. Hashimoto K, Arai Y, Iwai K, Araki M, Kawashima S, Terakado M. A comparison of a new limited cone beam computed tomography machine for dental use with a multidetector row helical CT machine. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:371377. 15. Ludlow JB, Davies-Ludlow LE, Brooks SL. Dosimetry of two extraoral direct digital imaging devices: NewTom cone beam CT
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Fig 20. (a) Cropped panoramic radiograph showing double radioopaque lines at the crest of the ridge in the lower left molar region. (b) Reformatted cross-sectional CT images of the mandible above showing a concavity at the crest of the ridge.

sinus develop in response to adjacent pathology such as periodontal disease or pulpal pathology. The radiographs of choice for plain lm evaluation of the maxillary sinuses are the Waters view, Caldwell view and lateral sinus view. Sinus pathology is best demonstrated on CT images and some examples are shown in Fig 18. Ridge form Information obtained from intra-oral radiographs and rotational panoramic radiographs typically give very little information about the available bone width as they are two-dimensional. The anterior alveolar ridge may have excellent bone height but be extremely thin in the labio-lingual dimension. Another common nding in the edentulous arch is marked attening of the ridge in the lower premolar molar region and the formation of a thin plate of bone on the lingual aspect (Fig 19). It is also not uncommon to nd a concavity at the crest of the ridge in the lower molar regions that can be predicted from an OPG, but is best demonstrated with three-dimensional imaging (Fig 20). CONCLUSIONS The decision on what pre-implant imaging is appropriate for each case must be considered carefully due to the radiation involved and the cost of each examination. Although in the opinion of the authors, multislice CT is
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and Orthophos Plus DS panoramic unit. Dentomaxillofac Radiol 2003;32:229234. 16. Schulze D, Heiland M, Thurmann H, Adam G. Radiation exposure during midfacial imaging using 4- and 16-slice computed tomography, cone beam computed tomography systems and conventional radiography. Dentomaxillofac Radiol 2004;33:8386. 17. Guerrero ME, Jacobs R, Loubele M, Schutyser F, Suetens P, van Steenberghe D. State-of-the-art on cone beam CT imaging for preoperative planning of implant placement. Clin Oral Investig 2006;10:17. 18. Katsumata A, Hirukawa A, Okumura S, et al. Effects of image artefacts on gray-value density in limited-volume cone-beam computerized tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:829836. 19. Araki K, Maki K, Seki K, et al. Characteristics of a newly developed dentomaxillofacial X-ray cone beam CT scanner (CB MercuRay): system conguration and physical properties. Dentomaxillofac Radiol 2004;33:5159. 20. Sato S, Arai Y, Shinoda K, Ito K. Clinical application of a new cone-beam computerized tomography system to assess multiple two-dimensional images for the preoperative treatment planning of maxillary implants: case reports. Quintessence Int 2004; 35:525528. 21. Hashimoto K, Kawashima S, Araki M, Iwai K, Sawada K, Akiyama Y. Comparison of image performance between conebeam computed tomography for dental use and four-row multidetector helical CT. J Oral Sci 2006;48:2734. 22. Hamada Y, Kondoh T, Noguchi K, et al. Application of limited cone beam computed tomography to clinical assessment of alveolar bone grafting: a preliminary report. Cleft Palate Craniofac J 2005;42:128137. 23. Yamamoto K, Ueno K, Seo K, Shinohara D. Development of dento-maxillofacial cone beam X-ray computed tomography system. Orthod Craniofac Res 2003;6 Suppl 1:160162. 24. Lascala CA, Panella J, Marques MM. Analysis of the accuracy of linear measurements obtained by cone beam computed tomography (CBCT-NewTom). Dentomaxillofac Radiol 2004;33: 291294. 25. Kobayashi K, Shimoda S, Nakagawa Y, Yamamoto A. Accuracy in measurement of distance using limited cone-beam computerized tomography. Int J Oral Maxillofac Implants 2004;19:228 231. 26. Marmulla R, Wortche R, Muhling J, Hassfeld S. Geometric accuracy of the NewTom 9000 Cone Beam CT. Dentomaxillofac Radiol 2005;34:2831. 27. Ludlow JB, Laster WS, See M, Bailey LJ, Hershey HG. Accuracy of measurements of mandibular anatomy in cone beam computed tomography images. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:534542. 28. Naitoh M, Katsumata A, Kubota Y, Ariji E. Assessment of threedimensional X-ray images: reconstruction from conventional tomograms, compact computerized tomography images, and multislice helical computerized tomography images. J Oral Implantol 2005;31:234241. 29. Mengel R, Kruse B, Flores-de-Jacoby L. Digital volume tomography in the diagnosis of peri-implant defects: an in vitro study on native pig mandibles. J Periodontol 2006;77:12341241. 30. Wortche R, Hassfeld S, Lux CJ, et al. Clinical application of cone beam digital volume tomography in children with cleft lip and palate. Dentomaxillofac Radiol 2006;35:8894. 31. Katsumata A, Hirukawa A, Noujeim M, et al. Image artefact in dental cone-beam CT. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:652657. 32. Draenert FG, Coppenrath E, Herzog P, Muller S, Mueller-Lisse UG. Beam hardening artefacts occur in dental implant scans with the NewTom cone beam CT but not with the dental 4-row multidetector CT. Dentomaxillofac Radiol 2007;36:198203.
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53. Givol N, Chaushu G, Halamish-Shani T, Taicher S. Emergency tracheostomy following life-threatening hemorrhage in the oor of the mouth during immediate implant placement in the mandibular canine region. J Periodontol 2000;71:18931895. 54. Laboda G. Life-threatening hemorrhage after placement of an endosseous implant: report of case. J Am Dent Assoc 1990; 121:599600. 55. Mason ME, Triplett RG, Alfonso WF. Life-threatening hemorrhage from placement of a dental implant. J Oral Maxillofac Surg 1990;48:201204. 56. Kohavi D, Bar-Ziv J. Atypical incisive nerve: clinical report. Implant Dent 1996;5:281283. 57. Wismeijer D, van Waas MA, Vermeeren JI, Kalk W. Patients perception of sensory disturbances of the mental nerve before and after implant surgery: a prospective study of 110 patients. Br J Oral Maxillofac Surg 1997;35:254259. 58. Mraiwa N, Jacobs R, Moerman P, Lambrichts I, van Steenberghe D, Quirynen M. Presence and course of the incisive canal in the human mandibular interforaminal region: two-dimensional imaging versus anatomical observations. Surg Radiol Anat 2003;25:416423. 59. Liang X, Jacobs R, Lambrichts I, Vandewalle G. Lingual foramina on the mandibular midline revisited: a macroanatomical study. Clin Anat 2007;20:246251. 60. Liang X, Jacobs R, Lambrichts I. An assessment on spiral CT scan of the superior and inferior genial spinal foramina and canals. Surg Radiol Anat 2006;28:98104. 61. Mraiwa N, Jacobs R, Van Cleynenbreugel J, et al. The nasopalatine canal revisited using 2D and 3D CT imaging. Dentomaxillofac Radiol 2004;33:396402. 62. Jacobs R, Lambrichts I, Liang X, et al. Neurovascularization of the anterior jaw bones revisited using high-resolution magnetic resonance imaging. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:683693. 63. Karmody CS, Carter B, Vincent ME. Developmental anomalies of the maxillary sinus. Trans Sect Otolaryngol Am Acad Ophthalmol Otolaryngol 1977;84:ORL-723728.

Address for correspondence: Dr P Monsour X-Ray Department School of Dentistry The University of Queensland 200 Turbot Street Brisbane, Queensland 4000 Email: pajmonsour@optusnet.com.au

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