RADIOGRAPHIC DETERMINANTS

OF IMPLANT PERFORMANCE
MICHAEL S. REDDY*
I-CHUNG WANG

Department of Periodontics
School of Dentistry
University of Alabama at Birmingham
UAB Station 34
1919 7th Avenue South, Room 412
Birmingham, Alabama 35294-0007, USA
* Corresponding author
Adv Dent Res 13:136-145, June, 1999

AbstractThis paper reviews and compares the strengths and

weaknesses of radiographic techniques including periapical,
occlusal, panoramic, direct digital, motion tomography, and
computed tomography. Practical considerations for each
method, including availability and accessibility, are discussed.
To date, digital subtraction radiography is the most versatile
and sensitive method for measuring boss loss. It can detect both
bone height and bone mass changes on root-form or blade-form
dental implants. Criteria for implant success have changed
substantially over the past two decades. In clinical trials of
dental implants, the outcomes require certain radiographic
analyses to address the hypothesis or clinical question
adequately. Radiographic methods best suited to the objective
assessment of implant performance and hypothesis were
reviewed.
Key words: Dental implants, radiographs, digital imaging,
implant assessment.

Presented at the 15th International Conference on Oral

Biology (ICOB), "Oral Biology and Dental Implants ", held in
Baveno, Italy, June 28-July 1, 1998, sponsored by the
International Association for Dental Research and supported
by Unilever Dental Research

136

he assessment of bone support in endosseous dental

implants is fundamental to the clinical utility of
implants for restoration of function. Radiographs are
a critical tool for the assessment of bony architecture,
and radiographs are used at each of three phases of implant
treatment, evaluation, and maintenance. The first phase is presurgical assessment of the bone at potential implant recipient
sites during the treatment planning phase of therapy. The
second common use is intrasurgical assessment of the
proximity of adjacent structures and parallelism of osteotomy
sites being prepared. The final use of radiographs is in longterm assessment of the success or failure of implant therapy.
This paper focuses on the radiographic methods to evaluate the
third phase and briefly addresses the other methods. In implant
research, the evaluation of longitudinal performance of the
implant is of primary importance in transferring new
developments to the practicing clinician.

DIAGNOSTIC METHODS READILY

AVAILABLE
The radiographic methods available are considered from the
simplest (use of intra-oral films) to the more complex
utilization (computed tomography). The radiographic methods
commonly available in longitudinal implant studies are
presented in Table 1. A vast amount of radiographic imaging
associated with dental implants is used for diagnosis of the
implant recipient site. The radiographic assessment of the
recipient site ideally indicates the quantity of bone in three
dimensions, the location of anatomical structures (such as the
mandibular canal and maxillary sinuses), and the quality of
bone available. Although an enormous body of literature (over
1000 papers since 1990) addresses the pre-surgical planning of
dental implants, no technique truly satisfies this ideal goal
(Fritz, 1996). In an attempt to achieve this ideal radiographic
assessment, clinicians often combine multiple radiographic
views or utilize several imaging techniques.
Intra-oral films are utilized in pre-surgical planning of
implant treatment, intra-operatively, and for longitudinal
assessment. Occlusal films are used as a method of assessing
the buccal to lingual width of the edentulous ridge area during
the pre-surgical planning phase. The use of occlusal films is
limited to the anterior mandible, because the superimposition of
other anatomical structures tends to obscure the ridge in the
posterior segment of the mandible. In addition, distortion of
maxillary occlusal films is common. Periapical radiographs are
used to assess limited areas or individual implant sites. The
periapical films have minimal distortion if well-angulated and
are suitable for the evaluation of bone height. A limitation of
periapicals is that the area imaged is small, and adjacent
anatomical structures may not be visible on the film (Fig. 1).

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TABLE 1
RADIOGRAPHIC METHODS COMMONLY AVAILABLE IN LONGITUDINAL STUDIES OF DENTAL IMPLANTS
Radiographic Method

Application

Imaging Plane

Limitations

Periapical
(intra-oral film or direct digital)

(1) Pre-surgical single site

(2) Intrasurgical
(3) Longitudinal assessment

Buccal-lingual

Limited view of adjacent anatomy

Two-dimensional view
Geometry commonly non-standardized

Occlusal (intra-oral film)

(1) Pre-surgical

Occlusal-apical

Commonly distorted

Direct digital (intra-oral film)

(1) Pre-surgical single site

(2) Intrasurgical
(3) Longitudinal assessment

Buccal-lingual

Limited detector size

Inherent distortion

Panoramic (extra-oral film)

(1) Pre-surgical multiple sites

(2) Longitudinal assessment

Buccal-lingual

Geometric distortion and magnification

errors. Decreased resolution

Motion tomography
(extra-oral film)

(1) Pre-surgical limited sites

(2) Longitudinal assessment

Mesial-distal

Limited availability
Repositioning is difficult

Computed tomography
(extra-oral digital)

(1) Pre-surgical multiple sites

Buccal-lingual,
mesial distal, axial,
three-dimensional

Relative cost
Access to CT services
Metal artifact

The periapical image in Fig. 1 has minimal geometric

distortion, as illustrated by the spherical shape of the 5-mm ball
bearings; however, the mandibular canal and the mental
foramen cannot be visualized. The use of a film such as this
does not provide adequate information for the planning of the
surgical procedure. Periapical films are particularly well-suited
for the longitudinal assessment of implants. The lack of
distortion and ability to standardize projection geometry
enables them to be used in conjunction with a variety of linear,
digital, and subtraction radiography techniques (Jeffcoat, 1992).
Direct digital periapicals utilize an intra-oral detector to
capture a radiographic image of the diagnostic area of interest
(Jeffcoat, 1992; Reddy et ai, 1992a; Welander et al, 1993).
The direct digital periapical image is used in a fashion
analogous to that of the film-based periapical for both presurgical planning and longitudinal assessment. The limitation of
the diagnostic image area may even be more pronounced with
the digital image. This is largely due to the limited size of the
intra-oral detectors which are currently available. The
resolution of the digital image is less than that available with
conventional intra-oral film but is adequate for diagnosis and
longitudinal assessment of bone loss (Wenzel, 1994). There are
at least two major categories of direct digital radiography
machines. The first uses a solid-state detector with or without a
light pipe to amplify the signal. These detectors result in a
nearly instantaneous display of the radiograph on a monitor
with no chemical processing of conventional film. Signal
amplification and detector sensitivity may result in major
reductions in ray dose compared with conventional non-screen
intra-oral film. The second type of detector is a re-usable solidstate detector that is placed in a reading device, similar in

concept to an optical scanner. Following a brief (approximately

one-minute) delay, the image appears on a monitor. The
technology of both the hardware and software associated with
direct digital imaging is rapidly evolving. Both the gray-level
resolution and the image accuracy are rapidly improving. In
addition, the thickness of the detector, which was a previous
problem with patient acceptance, has decreased, making the

Fig. IA periapical film demonstrating good geometric

projection as illustrated by the spherical appearance of the 5mm reference ball bearings. Some of the shortcomings of intraoral periapical films are also apparent. The mental foramen
and mandibular canal are not visible on the film, making presurgical planning difficult.

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positioning of the detector much more comfortable for the

patient. Direct digital radiography offers several advantages for
intra-operative use. The solid-state detector replaces film, so
there is no delay while the film is chemically processed. The
contrast and brightness of the image may be adjusted
retrospectively on the monitor so that different structures can be
visualized. Since the image is digital, it can be stored on a disk
to facilitate measurements of bone loss along the root surface.
This eliminates the step of indirectly digitizing a film through a
camera or scanner.
One current limitation of digital systems concerns the
documentation and archiving of images for medico-legal
purposes. Where film has been used as a permanent record of
pre-treatment conditions and treatment delivered, digital images
must now be archived. The more widespread use of digital
systems and the expansion of disk storage space and back-up
systems will most likely alleviate this potential shortcoming in
the near future.
Panoramic radiography is one of the most commonly
utilized radiographic techniques in dental implantology.
Panoramic images provide a global assessment for multiple
implant placement and are commonly used for initial treatment
planning or screening. Clinical studies have utilized panoramic
films either to score the presence or absence of bone loss or to
quantify the amount of bone loss (Branemark et al., 1977; Adell
etal., 1981; Naert, 1991; Quirynen etal., 1991; Mericske-Stern
et al., 1994; Spiekermann et al., 1995). However, despite its
widespread use, panoramic imaging has a number of limitations
that decrease its usefulness as a method for the longitudinal
assessment of dental implants. Because film-based panoramic
images utilize screens, they have decreased resolution when
compared with intra-oral films, resulting in a decreased ability
to detect small changes in bone support along the implants
(Backstrom et al., 1989). All panoramic films are magnified
approximately 30% when the patient is ideally positioned
(Glass, 1991). When the patient is positioned as little as 5 mm
from ideal, the magnification may range from 10 to 61%
(Reddy et al., 1994). Additionally, if the patient is rotated
slightly, the magnification may differ from one side of the jaw

to the other (Fig. 2). Furthermore, the implant bone surface may
be out of the curved plane of the tomogram being created by the
panoramic machine, resulting in an inaccurate image of the
bone-to-implant interface. Fig. 2 illustrates what appears to be a
panoramic film of good diagnostic value and consistent
magnification. The panoramic film shown was made with 5mm metal ball bearings attached to an acrylic vacuum-formed
stent made from a diagnostic cast. The resultant image, which
appeared initially to have uniform magnification, is actually
unevenly distorted from right to left. The second ball bearing
from the right appears as a sphere, whereas the left side
demonstrates geometric distortion, illustrated by the oblong
appearance of the ball bearings. The errors of magnification and
geometric distortion become important in clinical research
which seeks to quantitate, from panoramic films, the amount of
bone loss over time. Panoramic films will most likely continue
to be used to evaluate implants radiographically over time
because of their availability, ease of use, and patient
acceptance. The continued development of direct digital
panoramic images may decrease some of the limitations found
with the film-based machines. In longitudinal clinical trials,
care should be taken to use a method that corrects or controls
for geometric distortion errors.

Fig. 2A second panoramic image with four 5-mm reference

ball bearings in place. The image which initially appeared
uniform in magnification is actually distorted, with non-uniform
magnification from right to left.

Fig. 3A cross-sectional view of the mandible obtained with a

film-based motion tomography machine. The image obtained
allows for the assessment of the available bone in two
dimensions.

Film-based motion tomography has been suggested as a

cost-effective method for pre-surgical evaluation of a
prospective implant site (Miles and Van Dis, 1993). The images
obtained are cross-sectional views that are useful for the
evaluation of bone width and bone height from one image (Fig.
3). In addition, the cross-sectional images are useful for
diagnosing bony undercuts not readily apparent on other

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radiographic views (Kassebaum et al., 1990). Film-based

tomography has not been utilized in the longitudinal assessment
of dental implants over time. The lack of use is largely due to
the limited availability of the machines themselves and the
technical ability required to make images and use them to
measure bone loss accurately. Linear or multidirectional
tomography machines are readily available at most universitybased medical centers. Tomography machines are less likely to
be available in private dental practices due to the cost of the
equipment. The lack of availability of the tomographic
equipment may limit its usefulness in controlled clinical trials
as opposed to field trials. With the production of relatively lowcost tomography machines, their widespread use is likely to
increase.
Tomography machines which are intended for in-office or
imaging laboratory (hospital) use are now available. Two basic
principles should be considered in the selection of a
tomography machine that will produce the highest possible
image quality. Both slice thickness and the amount of out-ofplane blurring contribute to image "readability". The longer the
path the tomography machine traverses, the thinner the slice in
the resultant image. Out-of-plane blurring is inherent to motionbased tomography. The more complex the path of the radiation
source, the less out-of-plane blurring. Thus, linear tomography
will produce more blurring than a machine using a
hypocycloidal path. Furthermore, a machine designed to take
up little space in the office and which has a small tomographic
path will have a thick resultant image "slice thickness".
The repositioning of the patient over time to obtain a
reproducible image suitable for clinical research is technically
difficult with most standard techniques (Poon et al., 1992).
Tomography machines that use a cephalostat such as the Quint
Sectograph (Denar Corp., Anaheim, CA, USA) may be
advantageous in longitudinal studies (Miles and Van Dis,

1993). Without replicate cross-sectional images at the same

plane on the implant, quantitative assessment of the bone
support over time is likely to be highly inaccurate. An
additional inherent limitation of film-based tomography is the
limited experience that most clinical researchers have with the
interpretation of tomograms. This may be overcome if the
resulting images are digitized and electronically enhanced to
improve the contrast (Fig. 4). The use of tomograms in
longitudinal studies allows for the assessment of facial and
lingual bone support that is not evaluated by intra-oral and
panoramic radiographic techniques (Geurs, 1995). An
additional limitation of tomograms occurs when multiple
implants are close to each other: The implants tend to become
superimposed, rendering interpretation nearly impossible.
For pre-surgical assessment, the most accurate technique for
surgical site diagnosis is computed tomography (CT)
(Petrikowski et al, 1989; Miller et al., 1990; Kassebaum et al,
1992; Reddy et al., 1994). The CT images obtained have
minimal geometric distortion and are available in twodimensional panoramic and cross-sectional formats as well as
three-dimensional images (Figs. 5, 6). Slice thickness in CT
imaging is a function of the scanning protocol. When
overlapping slice protocols are utilized, at the expense of
additional radiation doses, thinner slices with greater spacial
resolution result. For longitudinal analysis of implant bone
support, the virtue of CT imaging is greatly limited, due to a
streaking artifact that occurs when metal is encountered during
the CT imaging (Fig. 7). This artifact is due to the high density
of gold and silver alloys compared with that of the adjacent
bone (Curry et al., 1990). In one study of 138 CT images for
dental implant treatment planning, 34% of the images had
distortion due to metal restoration of the teeth (MayfieldDonahoo et al, 1994). When dental implants are scanned after

Fig. 4The application of image enhancement to aid in the

interpretation of cross-sectional images.

Fig. 5Panoramic and axial cross-sectional images obtained

from computed tomography.

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Fig. 7A streaking artifact on a three-dimensional CT image

due to the presence of high-density metal restoration of the teeth.

Fig. 6A three-dimensional image of the mandible reconstructed

from a computed tomography image.
restoration, the high density of titanium and superstructure
metal renders the resulting images of little value in the
assessment of longitudinal performance. Therefore, CT
imaging is not a practical technique for use in routine follow-up
clinical research of dental implants.

HISTORICAL RADIOGRAPHIC CRITERIA

FOR IMPLANT PERFORMANCE
Complications in dental implantology tend to occur due to
failures in the prosthetic superstructure or a loss of supporting
bone integration on the implant body itself. The assessment of

implant performance generally relies on the detection of

mobility, the clinical signs of gingival inflammation,
periodontal attachment loss and pocket formation, and
radiographic bone loss. Radiographs are important tools in the
evaluation and early diagnosis of implant-associated pathology.
The use of radiographs allows for a quantitative assessment of
bone loss along the implant surface.
Historically, different criteria have been utilized to assess
the success of implants based on radiographic appearance or
measurements (Table 2). The recommendations of the 1978
Harvard Consensus Conference on Dental Implants utilized the
following categorical radiographic criteria: (1) no radiolucency
and (2) bone loss not greater than 1/3 of the implant length
(Schnitman and Shulman, 1979). This was an initial attempt at
objective assessment of implant success or failure based on
radiographs. Later, a publication from the Branemark group
established a success criterion of 0.2 mm of bone loss annually
after the first year of service (Albrektsson et al., 1986; Smith
and Zarb, 1989). The problem with the 0.2-mm criterion is that
it was not an annual measurement but a retrospective
calculation such as 2-mm loss over a ten-year period. The
authors did not utilize a method that could actually measure
0.2 mm or less. Further, when the observed bone loss is
divided over 10 years, it is assumed that it is a continuous
linear process. The American Dental Association (ADA)
established a radiographic criterion of 2 mm of vertical bone
loss at 5 years, measured by a technique with a resolution and
validity that exceed the threshold for clinical success (ADA,
1996). The ADA guidelines do not specifically exclude bone
loss that occurs in the first year of service, but rather
incorporate all bone loss over a five-year period.

RADIOGRAPHIC ANALYSIS OF IMPLANT

BONE LOSS IN CLINICAL TRIALS
One of the major problems of using radiographic analysis to
quantitate bone loss from radiographs is geometric distortion
due to misangulation of the film or misangulation of the x-ray
beam. The first misangulation error may occur when the film
angulation is changed at different radiographic exams while

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the x-ray source is held constant. The distortion produced by

this error may be retrospectively corrected with the aid of a
computer matrix transformation algorithm (Jeffcoat et aL,
1984; Webber et ai, 1984). The second misangulation error,
an x-ray direction error, occurs when the radiographic source
is moved and the implant and film are held in consistent
geometry. The first and second types of misangulation errors
occur together in most conventional clinical radiographs made
to assess dental implants.
The errors of film position and x-ray direction as sources of
geometric distortion may be minimized by the use of
standardized radiographs in a clinical trial. Standardized films
are made by controlling the projection geometry of the image
created. An occlusal index or stent is commonly used to register
the implant or prosthesis position. The stent also incorporates a
film holder and is attached or electronically coupled to the
radiographic cone (Hausmann etaL, 1985,1992). Alternatively,
a cephalostat or video feedback system may be utilized to
reposition the patient's head in combination with a long film-toobject distance (Jeffcoat et ai, 1987; Reddy et a/., 1991).
Minor errors that occur in angulation may be corrected with
the application of a matrix transformation algorithm. Errors
due to the tilt of film or detector may be retrospectively
corrected by "warping" the second image onto the first. The
radiographic assessment of implants is ideally suited to the
application of warping algorithms, because the implants are of
pre-defined dimension and known anatomy. The identification
of clear landmarks on implant images is easily accomplished
because of the known dimension. Landmarks are identified on
both images before the transformation to be applied. This
method allows for corrections in geometry without the strict
requirement of standardization of the radiographs. The
limitation of these techniques is that they allow for warping
projection in only two dimensions. Therefore, as the film is
bent in the patient's mouth in one or both radiographic

TABLE 2
RADIOGRAPHIC CRITERIA FOR IMPLANT SUCCESS
Radiographic Criteria

Criteria Established

1/3 implant length

NIH Consensus Conference

0.2 mm annually
after first year

Branemark retrospective studies

1.4 mm over 3 years

2.0 mm over 5 years

ADA Council on Dental Materials

examinations to be compared, the image will be distorted in

three dimensions. A full three-dimensional distortion
correction has been achieved with tomosynthesis (Horton et
al., 1996), and the use of software application on invariant
structures has also been reported (Ostuni et aL, 1993). To date,
we are not aware of the application of either of these
techniques to large-scale clinical implant trials. The utilization
of direct digital techniques may have an advantage in this
regard. Since the image detector is rigid and cannot bend,
distortions of the implant should be limited to two dimensions.
Approaches to evaluating dental implants in clinical studies
are outlined in Table 3. One method for assessing implant
performance by high-quality radiographs is bone height
analysis of the amount of bone loss relative to the implant
length (Fig. 8). There is a major difference in using this
approach in studies of dental implants compared with studies
measuring bone height around teeth. The length of the natural
tooth root is unknown, whereas the length of the implant is
known. If the bone height on the implant is expressed as a
percentage of the implant length, it may be easily converted
into a millimeter measurement of the bone loss present. In this

TABLE 3
APPROACHES TO RADIOGRAPHIC EVALUATION OF DENTAL IMPLANTS IN CLINICAL STUDIES

Method

Requirements for Input Radiograph

Ability to
Detect Change

(1) Measurement of %,
mm, bone loss

High-quality clinical radiographs

Moderate

Uses implant as reference scale,

ideally should be digitized and
measured under software control

(2) Measurement of bone

loss by counting threads

High-quality clinical radiographs

Low

Low tech.
Very easy

(3) Grid overlay to detect

mesial-distal and apicalcoronal bone loss

High-quality clinical radiographs

Requires
specialized
software

Time-consuming,
requires specialized software

(4) Digital subtraction

radiography

Standardized image

High, can detect changes

too small to see

Requires specialized software

Comments

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Fig. 8The application of bone height analysis on an implant

as a proportion of overall implant length. The implant has a
length of 10 mm, and the bone loss from the top of the implant
is 4.4 mm.

Fig. 9A digital subtraction radiography image illustrating

bone loss around a failing image. The initial radiograph is
subtracted from the subsequent image, and the resultant
image is neutral gray, where no change has taken place.
Areas of bone loss appear as a darker gray image.

way, the implant acts as its own ruler to compensate partially

for geometric foreshortening or elongation distortion of the
radiographic image during the measurement. The use of bone
height measurements has an advantage in that it is very simple
and does not require standardized radiographs. The image of
the implant in Fig. 8 indicates the linear loss of bone along the
implant. The resulting data obtained may be expressed as a
percentage of overall implant length or in mm of bone loss if
one knows the length of the implant. The use of bone height
measurements is a linear, one-dimensional measure that is
limited to the analysis of bone loss that can be visualized on the
radiograph. Subtle changes may be overlooked due to a lack of

contrast between gray levels. The contrast of slight areas of

bone loss may be enhanced by the application of digital
imaging techniques.
A low-technology approach utilized in longitudinal studies
has been simply to count the number of threads exposed by
bone loss. The thread-counting approach is limited in resolution
to the spacing of the threads. For example, if the threads are
spaced at 0.6 mm, and measurement error is estimated at twice
the resolution of the technique, only a 1.2-mm change in bone
loss can be detected. In addition, the comparison of cylindrical
implants and threaded implants with non-threaded collars
represents additional complications and precludes the simple

TABLE 4
RADIOGRAPHIC METHODS FOR DIFFERENT IMPLANT STUDY DESIGNS
Type of Study/
Clinical Question

Design

Requirements
to Detect Change

Following an implant
over time, natural history

Single arm,
no blinding

Dependent on hypothesis
or criteria to be satisfied

(1) Measurement of mm
(4) Digital subtraction
(2) Thread counting

Comparing two implant

types, superiority

Parallel arms

Requires high sensitivity

because most implants
are successful

(1) Measurement of mm
(4) Digital subtraction

Equivalency of two systems

or types of implants

Parallel arms

Requires high sensitivity, and (4) Digital subtraction,

a large (n) number of implants (1) Measurement of mm
to have sufficient power

Comparison of implant types Block design

Requires high sensitivity
within the same patient
within subjects

Method

(4) Digital subtraction

(1) Measurement of mm

Comments
Most frequently used
High resolution
Insufficient resolution
to satisfy

"No significant
difference" is not the
same as "equivalent"

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bone gain are shown in light shades of gray. Alternatively,

areas of bone loss or gain may be displayed in contrasting
colors (Reddy et al., 1991). From the subtraction image,
changes in bone height may be measured or two-dimensional
areas of bone change may be calculated. In order to obtain an
estimate of bone loss in three dimensions, investigators have
carried out a quantitative analysis of the gray scale changes
(Ruttimann and Webber, 1987; Bragger, 1988). The use of an
area measurement from the subtraction image and the gray
scale difference at the bone change has been applied to implant
performance analysis (Jeffcoat, 1992). In brief, a reference
wedge is used to convert the gray scale levels and area
calculation to a bone loss or bone gain mass. The reference
wedge is incorporated into the first radiograph and not the
second, so that the resultant subtraction image has a negative
image of the wedge along with an image of the bone loss. The
image of the wedge is used to determine the thickness of the
wedge that corresponds to the same gray level change as the
bone loss. The mass of the lesion is then calculated by
multiplying area x thickness x aluminum density x aluminumto-bone-density conversion factor.

Fig. 10A threshold has been applied to the binary image to

obtain area of change and added back to the original radiograph.
use of this methodology.
A variation of bone height analysis is the use of a grid to
assess bone loss in two dimensions (Reddy et al., 1992b). The
grid analysis is primarily useful for analyzing blade implants in
which wide saucer-like bone loss tends to occur. A grid overlay
is superimposed on the digital image of the blade and is based
on the known dimensions of the blade. Multiple measurements
are made along the grid lines from the radiolucency to the
implant surface. The shortcomings of the grid method are that it
is very time-consuming and, as with bone height
measurements, measures only visual change.
One of the most versatile methods for measuring
radiographic bone loss on both root-form and blade implants is
the use of digital subtraction radiography. Subtraction
radiography was introduced to dentistry in the 1980s (Webber
et al., 1982; Grondahl et al., 1983; Hausmann et al., 1985;
Jeffcoat et al., 1987). Subtraction radiography is used to
compare two standardized radiographs taken at sequential
examination visits. All structures that have not changed
between examinations, such as the implant, are subtracted. The
resultant computer image shows areas of bone change against a
neutral gray background (Fig. 9). Areas of bone loss are
conventionally shown in dark shades of gray, whereas areas of

As a final step, the software is used to improve the

visualization of the area of change (Fig. 10). A threshold has
been applied to the black-and-white (binary) image to obtain an
area of change and added back to the original radiograph. This
method has been validated by multicenter clinical trials through
the calculation of the mass of cortical bone chips in skulls
(Jeffcoat et al., 1992, 1996). The correlation between the
calculated mass of the bone chips and the actual mass was
found to be excellent (r2 > 0.90).
Clinical studies in dental implants have been designed to
answer different questions related to the performance of the
implants over time (Table 4). The design of the study requires
that different radiographic analyses be utilized to address the
hypothesis or clinical question adequately. A common study
design is to follow a specific type of implant over time. In a
study of the natural history of the implant, several of the
radiographic methods described in Table 3 may be used. The
most frequently used method is to measure millimeters of bone
loss along the implant surface over an interval of years. This
technique uses digital measurement of the bone height and the
length of the implant to help compensate for elongation and
foreshortening (Verdonschot et al., 1991). Digital subtraction
radiography could also be used to follow an implant
longitudinally. Since subtraction techniques require carefully
standardized radiographs, the decision to use digital
subtraction radiography would have to be made prospectively
(Bragger, 1988). Historically, investigators have simply
counted the threads on implants of known geometry to assess
bone loss in this type of longitudinal study (Albrektsson et al.,
1986). However, counting threads may provide insufficient
resolution to address the question of implant performance in a
contemporary clinical study.
If the study design is to compare two implant types in an
attempt to test for superiority, a high-resolution method needs
to be utilized (Listgarten, 1992). The high-resolution
radiographic techniques become necessary in this instance,
because bone loss around dental implants tends to be small for

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the most part (Imrey, 1992). The fact that most implants are
successful makes determining the differences between implants
even more difficult. The methods useful for superiority
comparisons would be digital measurement of mm of bone loss
or digital subtraction radiography. A study to assess eqivalency
of two implants may be even more challenging than superiority
testing. The equivalency study needs the highest resolution that
can be achieved, and, in addition, a sufficient number of
subjects must be utilized (Imrey and Chilton, 1992). If an
insufficient number of implants is used or the resolution of the
radiographic method is too low, no significant difference
between two implants will be observed, even if a difference
actually exists.
Comparing implants of different types, surface coatings, or
design within the same subject presents an additional indication
that the highest-possible resolution should be used (McKinney
et aL, 1988). Again, since the bone loss at any modern implant
is not likely to be great, a high-resolution technique and a
subject population with sufficient power will be necessary. The
position of the implants within the arch will also need to be
determined with a random block design to ensure that the same
implant does not always get the most favorable position in the
arch.

CONCLUSION
Radiographic methods are essential for assessing bony support
in endosseous dental implants. However, each technique has its
own advantages and drawbacks. Different criteria have been
utilized to determine the success or failure of implant
performance based on radiographic appearance or
measurements. In the design of clinical trials for dental
implants, standardized radiographs should be utilized and the
highest-resolution technique available must be considered. At
present, digital subtraction radiography is an accurate and
legitimate technique for the detection of minor bony change
around dental implants.

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