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Essential guidelines for using CBCT in implant dentistry — clinical considerations: part 3

Continuing Education (CE)

The continuing education article below is available to Implantologists and general dental practitioners who perform implants.

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Educational aims and objectives

This clinical article aims to provide clinicians with an overview of the scientific literature relating to the use of cone beam computed tomography.

Expected outcomes

Implant Practice US subscribers can answer the CE questions by taking the quiz to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can:

  • Identify when to use a CBCT and how to systematically analyze and read the data volume
    in order to maximize the diagnostic and treatment planning benefits of this technology.
  • Identify certain imaging goals to support preoperative diagnostics and treatment planning.
  • Realize how CBCT can offer information regarding quantitative bone availability and ridge morphology.
  • Observe how CBCT can help the clinician identify physiological, biological, and pathological considerations.
  • Recognize how clinicians can increase therapeutic opportunities by computer-assisted prosthetic and surgical treatment planning in conjunction with CBCT data.
  • Realize how CBCT images can aid in postoperative assessment of failures and complications.

Dr. Johan Hartshorne continues his overview of the scientific literature and exploration into CBCT for implant therapy.

Introduction

This article is the third in a series that aims to provide clinicians with an overview of the scientific literature relating to the use of cone beam computed tomography (CBCT). It will suggest clinical guidelines for selecting an appropriate radiographic imaging modality, indications for using CBCT, and how to read and analyze CBCT data volume. It will also address the clinical application and use of CBCT, and the advantages and limitations of CBCT in implant dentistry.

The knowledge gained and guidelines provided by this article aim to enhance clinicians’ understanding of when to use a CBCT, and how to systematically analyze and read the data volume to maximize the diagnostic and treatment planning benefits of this technology, while optimizing patient safety and minimizing radiation-related patient risk. Radiographic images used were obtained from a Kodak Carestream CS 9300 CBCT unit.

Application of CBCT imaging in implant dentistry

Successful and predictable implant dentistry requires accurate preoperative diagnostics and treatment planning information of the amount of bone available, bone density, and the proximity to anatomical structures. Healthcare providers are also obligated to acquire adequate information from patients to provide a basis for informed patient consent (Miles and Danforth, 2014).

Clinical complexity, regional anatomic considerations, potential risk of complications, and esthetic considerations in the location of implants are factors that determine the individual clinician’s needs for information supplemental to that already obtained from the clinical and radiographic examinations (periapical and panoramic) to formulate a diagnosis and to assist in implant therapy treatment planning (Bornstein, et al., 2014).

The introduction and widespread use of CBCT over the last decade has enabled clinicians to diagnose and evaluate the jaws in three dimensions, thus replacing CT as the standard of care for implant dentistry (Bornstein, et al., 2014). Additionally, multiplanar imaging-reformatting (MPR) of CBCT has significantly increased diagnostic accuracy and efficiency (Jacobs and Quirynen, 2014; Deeb, et al., 2017) and offers an unparalleled diagnostic approach when dealing with previously challenging unknown anatomical boundaries and/or pathological entities (Angelopoulos, 2014).

This has prompted several different organizations to develop clinical guidelines and recommendations for the appropriate use of CBCT for assessing potential dental implant sites. Examples follow:

  • American Academy of Oral and Maxillofacial Radiology (AAOMR)
  • European Academy of Osseointegration (EAO)
  • International Congress of Oral Implantologists (ICOI)
  • Academy for Osseointegration (AO)
  • International Team for Implantology (ITI)

CBCT has applications in several aspects of dentistry. To appropriately use this technology, clinicians should be able to identify those situations when CBCT is likely to provide useful information, and when this additional information translates into enhanced diagnoses, treatment plans, and treatment outcomes (Mallya, 2015).

The application or use of CBCT in implant dentistry includes preoperative diagnostics and treatment planning, computer-assisted treatment planning, and postoperative evaluation — focusing on implant failures and complications due to damage of neuro-vascular structures (Jacobs and Quirynen, 2014; Bornstein, et al., 2014).

Preoperative diagnostics and treatment planning

Radiographic assessment of the 3D implant position, angulation, and restorative space is essential during preoperative diagnostics and treatment planning of implant sites within the residual alveolar bone.

Positioning of single implants within the dental arch can be challenging, considering the proximity to adjacent tooth roots, vital structures, occlusal plane, and relative position within the arch (Scherer, 2014).

CBCT imaging therefore must provide information supportive of the following goals:

  1. To establish the quantitative bone availability (morphologic characteristics) of the residual alveolar ridge.
  2. To determine the orientation of the residual alveolar ridge.
  3. To identify local anatomic or pathologic boundaries within the residual alveolar ridge limiting implant placement (Bornstein, et al., 2014).

Quantitative bone availability

Effective preoperative assessment requires clinicians to interpret implant sites for many factors related to predictable and successful implant restorations, including adequate bone volumes, distance away from teeth/implants, sufficient prosthetic space for restoration, and precise implant placement. Essential preoperative assessment should include an evaluation of the saddle length (mesiodistal), vertical bone height (occlusal-apical), and horizontal width (buccolingual) bone availability of the proposed implant recipient site (Figure 1) to facilitate proper planning, correct implant selection, 3D placement of the dental implant (Figure 2), and the necessity for implant site development (Tyndall, et al., 2012; Scherer, 2014).

Most CBCT viewing and analysis software packages feature measurement tools that can be used to easily determine the height and width of bone and the proximity of the proposed implant placement site to adjacent vital structures. With this software, the clinician can accurately visualize the 3D alveolar ridge bone contour of a patient and make determinations about surgical entry, implant diameter and length, and prosthetic requirements before the surgical procedure.

CBCT also provides a qualitative assessment of the type of bone (bone quality) and local trabecular architecture (Figures 3 and 4) to assist in selecting the correct implant type to optimize implant stability. The standard practice is to visually analyze trabecular density and sparseness at the edentulous site.

Some studies have explored the feasibility of measuring CBCT gray values at the edentulous area to infer bone quality (Mah, et al., 2010; Valiyaparambil, et al., 2012).

However, there is strong evidence that the relationship between gray value and object density is markedly influenced by several factors, including exposure parameters, FOV, and anatomic location (Oliveira, et al., 2013, 2014; Parsa, et al., 2013; Pauwels, et al., 2013). Current gray value approaches to quantitatively assess bone quality are thus unreliable.

CBCT is an essential tool for identifying the extent and size of bone defects at potential implant sites that may require augmentation or site development to prepare it for simultaneous or later implant placement (Harris, et al., 2012). Examples of procedures requiring augmentation or site development follow:

  • horizontal bone volume deficiencies (Figure 5)
  • fenestration defects (marginal bone intact) (Figure 6)
  • dehiscence bone defects (denuded areas extend through the marginal bone) (Figure 7)
  • post-extraction site (Figure 8)
  • vertical bone deficiency (Figure 9)
  • combined horizontal and vertical bone deficiencies of the alveolar ridge (Figure 10)
  • sinus floor elevations (Figure 11)

The use of CBCT before bone block grafting helps define both the donor and recipient sites, allows for improved planning for surgical procedures, and reduces patient morbidities.

Ridge morphology

The buccolingual ridge pattern cannot be viewed on 2D radiographs, but CBCT provides the advantage of showing the type of alveolar ridge pattern present. Cross-sectional images (coronal view) provide the implant dentist with the appearance of ridge patterns such as irregular ridges, narrow crestal ridges, and knife-shaped ridges (Figures 12 and 13).

The loss of cortical plates and undulating concavities (Figure 14) can also be appreciated on cross-sectional images, and they cannot be seen on panoramic images. In the case of a compromised jaw bone (in terms of quality and/or quantity of bone), the panoramic technique is an inefficient imaging tool. Three-dimensional imaging is often indispensable when treatment planning to identify potential risks.

Bone quality is a matter of not only content, but also structure. It has been shown that the quality and quantity of bone available at the implant site are very important local patient factors in determining potential implant stability and the success of dental implants. Bone quality is categorized into four groups (Figure 4; Bone Quality Index) (Lekholm and Zarb, 1985):

  • Type 1: homogeneous cortical bone
  • Type 2: thick cortical bone with marrow cavity
  • Type 3: thin cortical bone with dense trabecular bone of good strength
  • Type 4: very thin cortical bone with low-density trabecular bone of poor strength.

In the jaws, an implant placed in poor quality bone with thin cortex and low-density trabeculae (Type 4 bone) has a higher chance of failure compared with the other types of bones. This low-density bone is often found in the posterior maxilla, and several studies report higher implant failure rates in this region (Lekholm and Zarb, 1985).

Topography and orientation of residual alveolar bone

The orientation and residual topography of the alveolar basal bone complex must be assessed to determine whether or not there are variations that could compromise the alignment of the implant fixture with the planned prosthetic restoration. This is particularly important in the mandible (for example, the submandibular gland fossa) (Figure 15) and anterior maxilla (for example, labial cortical bone concavity) (Figure 16). Information on the topography and orientation of the residual alveolar bone is important to optimize implant selection and placement.

Anatomical considerations, boundaries, and limitations

Each location in the dental alveolus has unique morphologic and topographical characteristics owing to edentulousness and specific regional anatomic features that need to be identified and assessed in the diagnostic and treatment-planning phase of dental implant therapy.

The clinician must have full knowledge of oral bone anatomy, boundaries, and limitations so that any osseous topography, bone volume excesses/deficiencies can be identified to facilitate optimal implant placement and to avoid surgical complications. A comprehensive overview of the oral and maxillofacial anatomy is provided in the literature, but for the purposes of this article, only the critical anatomical elements related to implant dentistry are presented.

Anterior maxilla

The maxillary anterior region (commonly referred to as the esthetic zone) often presents both surgical and prosthetic implant-assessment complexities (Dawson, et al., 2009; Buser, et al., 2007). Subsequent to tooth loss, decrease in the height and/or width of the alveolar process and the development of a labial concavity often necessitate bone augmentation to facilitate implant placement (Misch, 2008) (Figure 16).

The morphology and dimension of the nasopalatine (incisive canal) (Figure 17) and the location of the floor of the nasal fossae may also compromise bone availability for implant placement (Ganz, 2011; Mraiwa, et al., 2004; Romanos and Greenstein, 2009; Asaumi, et al., 2010).

Posterior maxilla

Atrophy of the edentulous posterior alveolar ridge and pneumatization of the maxillary sinus are the most common causes of lack of bone availability for implant placement in the posterior maxilla.

Additionally, the maxillary posterior region has the lowest bone density (Figure 3) and the highest implant failure rate (Gupta, et al., 2017). Sinus floor elevation surgery, along with bone grafting, is a well-accepted technique before or simultaneously with implant placement to increase support in an atrophic maxilla.

Knowledge about the sinus anatomy and residual alveolar ridge is critical before the conduction of surgical procedures. CBCT images provide an accurate 3D representation of the anatomy and are suitable for the detection of morphologic variations in the maxillary sinus to assist with preoperative assessment for sinus augmentation surgery, implant planning, and placement (Danesh-Sani, et al., 2017; Shanbhag, et al., 2014).

The available residual alveolar ridge in the posterior maxillary premolar and molar regions is limited superiorly by the floor of the maxillary sinus (Figure 11).

Anatomical variations of the maxillary sinuses — such as the presence of septa (also known as Underwood septa), number, location, and shape, particularly in the inferior sinus wall — complicate sinus floor elevation surgical procedures (Mallya, 2015).

Sinus septa are bony projections commonly found in the inferior or lateral sinus walls separating the maxillary sinus into two or more compartments (Figure 18). Studies show approximately 45% of patients had at least one septum (Sakhdari, et al., 2016). Strong sinus membrane adhesion at the location of septa, particularly of the inferior sinus wall, may cause perioperative complications; therefore, the presence, extent, and location of septa must be accurately detected in presurgical radiographic imaging to facilitate proper selection of the surgical technique and prevention of unwanted perioperative complications and thus increase success rate of sinus surgeries (Park, et al., 2011; Sakhdari, et al., 2016). Medium-sized or long septa may necessitate a modified surgical approach. Detection of septa may also influence the decision about the location of the window in the lateral window approach during sinus floor elevation surgery.

Assessment of the anterior recess of the maxillary sinus is also important if markedly angled implants are considered for implant-supported edentulous prostheses. CBCT can also provide information on arterial channels in the lateral wall of the sinus, presence of apical pathology (Figure 19) as well as on the health of the sinus such as absence of sinus membrane thickening (Figure 20).

In some clinical situations, when there is evidence of sinus pathology, or it is the clinician’s opinion that sinus drainage is impaired and may jeopardize the outcome of the procedure to be undertaken, there may be a justification to extend the FOV to include the whole of the sinus, including the osteo-meatal complex (Ribeiro-Rotta, et al., 2011; Janner, et al., 2011; Carmeli, et al., 2011).

Anterior mandible

The anterior mandible is a relatively safe location for implant placement. However, proper diagnostics are essential to avoid intraoperative and postoperative hemorrhage, neurosensory loss, and risk of perforating the cortical plate. The locations of osseous structures (buccal and lingual cortical plates) (Figure 22) and neurovascular structures include the lingual foramen (Figure 22), the terminal branch of the inferior alveolar nerve at the mental foramen, and the anterior loop (Figures 21 and 23).

The mental foramen is a strategically important landmark during osteotomy procedures in the mandible. Its location and the possibility that an anterior loop of the mental nerve may be present mesial to the mental foramen need to be considered before implant surgery to avoid nerve injury (Greenstein and Tarnow, 2006).

Posterior mandible

In the posterior mandible, there are several anatomic structures that can compromise prosthetically driven, dental implant placement. The most important landmarks in the posterior mandible are the inferior alveolar canal and the submandibular gland fossa (Figures 24 to 26). Both these structures can present with anatomic variations that may restrict implant placement and result in complications.

Correct identification of the inferior alveolar (mandibular) canal may help the clinician to avoid damaging the nerve during surgery and, thereby, prevent the occurrence of complications, such as impaired sensory function and paresthesia of the lower lip and the neighboring soft tissues (Abarca, et al., 2006).

It is advisable to measure from the crest of the alveolar bone to the coronal aspect of the IAN and subtract 2 mm to provide a safety zone. The submandibular fossa is denoted by a lingual concavity or undercut in the posterior mandible and contains the submandibular gland.

Physiological, biological, and pathological considerations

Other local anatomic boundaries and limitations or pathologic conditions that could potentially restrict implant placement and cause complications include:

  • Inadequate distance between neighboring teeth
  • Angulation of roots
  • Apical pathology on neighboring teeth (Figures 19 and 27)
  • Impacted teeth (Figures 27 and 28)
  • Residual roots
  • Presence of foreign material (Figure 29)

Computer-assisted prosthetic and surgical treatment planning

Apart from the diagnostic capabilities, dental CBCT may also offer therapeutic capabilities through computer-assisted surgical and prosthetic treatment planning via computer-aided design/computer-aided manufacturing solutions (Jacobs and Quirynen, 2014; Harris, et al., 2012). Bornstein, et al. (2014), propose some guidelines for treatment planning. CBCT DICOM data is merged with stereolithography (STL) files from an intraoral optical scanner to produce a 3D rendering (3D conversion) model of the jaw for virtual planning.

Virtual planning software is used to construct a virtual wax-up and to place the implant fixture in its correct three-dimensional position on the virtual 3D model. Information to be gathered from the combination of high-quality CBCT images and STL files should include locations of vital structures, desired implant positions and dimensions, the need for augmentation therapy, and the planned prostheses. Once the design is completed, it is submitted to a milling machine or a digital printer for fabrication of a surgical guide. The guide can be bone, tooth, or mucosal supported.

The actual surgical guide is milled or printed, all with round cylinders, allowing dedicated instrumentation (drill bits) to be precisely guided, creating osteotomies and guiding the implant in its correct or ideal 3D position during placement. Implants placed using computer-guided surgery with a follow-up period of at least 12 months demonstrate a mean survival rate of 97.3% (n = 1,941), which is comparable to implants placed following conventional procedures (Bornstein, et al., 2014).

To improve image data transfer, clinicians should request radiographic devices and third-party dental implant software applications that offer fully compliant DICOM data export.

It is important to realize errors can occur when transferring information from a cross-sectional computer image to the surgical situation. The surgeon should be aware of these and be careful to allow an adequate safety margin in all cases (Harris, et al., 2012). The use of guided surgery for implant placement is increasing because of a number of clinical advantages, including increased practitioner confidence and reduced operating time.

Postoperative assessment of failures and complications

Altered sensation and possible damage to neurovascular structures

CBCT may offer surgical guidance and therapeutic possibilities and cases of altered sensation and possible damage to neuro-vascular structures. Current evidence (Juodzbalys, et al., 2013) supports the protocol that a CBCT be used following the neurosensory assessment to pinpoint lesion location as well as confirmation of IAN injury. Proper preoperative planning, timely diagnosis, and treatment are key factors in avoiding and managing neurovascular complications and damage after implant placement (Figure 29).

Infection or postoperative integration failure

CBCT is indicated for implant failure cases, infection, or postoperative integration failure, owing to either biological or mechanical causes. A CBCT can provide therapeutic assistance with characterizing the existing defect, plan for surgical removal and corrective procedures, such as ridge preservation or bone augmentation, and assess what the implications of surgical intervention is on adjacent structures.

Cross-sectional imaging, optimally CBCT, should also be considered if implant retrieval is anticipated (Tyndall, et al., 2012).

Implant displacement

The use of CBCT scans are helpful in postoperative evaluation of implant displacement into the sinus or nasal cavity (Figure 30) (Chappuis, et al., 2009).

Perforations

The major potential risks of encountering a lingual plate perforation (Figure 31) are massive hemorrhage of the submental and sublingual arteries (anterior mandible) (Kalpidis and Setayesh, 2004) and airway obstruction (Givol, et al., 2000). Perforation of the lingual concavity above the mylohyoid ridge might injure the lingual nerve (Chan, et al., 2010). If the extruded implant is left unattended, the infection might spread to the parapharyngeal and retropharyngeal space, leading to more severe complications, such as mediastinitis, mycotic aneurysm formation with possible subsequent rupture of the internal carotid artery, and internal jugular vein thrombosis with septic pulmonary embolism or upper airway obstruction (Greenstein, et al., 2008).

Advantages of CBCT in implant dentistry

Here are several major benefits of CBCT scans for dental implant planning and placement (Klokkevold, 2015).

Precision placement of implants in the bone

CBCT allows the surgeon to accurately measure and localize the available bone and accurately place the implant in a correct 3D position. This is verified by virtual implant placement.

Proper orientation of the implant with its overlying restoration

A CBCT can be merged with an optical scan of the patient’s teeth (widely referred to as a digital impression) to create a complete digital model of the patient’s bone, teeth, and soft tissues. This will facilitate precise positioning of implants to support planned restorations. This prevents misaligned implants, which may be difficult or impossible to restore, and avoids poor esthetics and function.

Prevention of injury to nerves

Using the CBCT, the surgeon should map out the path of the sensory nerves in the jawbone and selects an implant of the correct length. Conventional X-rays are flat and distorted and are poor diagnostic images for predicting the position of the nerves. Nerve damage from dental implant placement results in partial or complete numbness of the lip and chin area, which can be potentially permanent. CBCT is a mandatory imaging technique to prevent this serious complication.

Prevent implant penetration into the sinus

CBCT provides an accurate picture of the maxillary sinus and its position in relation to the available bone. The surgeon can make an accurate measurement and select the right implant length to avoid puncturing the maxillary sinus. Penetration of the maxillary sinus can lead to sinusitis or other inflammatory conditions. The surgeon can also plan for necessary bone grafting if there is insufficient bone to support the implant. Conventional X-rays are highly inaccurate for these purposes and do not provide the information necessary for the safe placement of dental implants in the posterior maxilla.

Selection of the right size implant for optimal support

The longevity and success of dental implants require maximal integration and stability in the bone. CBCT allows the surgeon to measure the available bone and to select the widest and longest implant appropriate for the site. This, in turn, helps support the high bite (occlusal) forces and avoid potential failure from overload. Implant size selection should not be guesswork. Implant selection is made based on precise measurements, biological requirements, bite scheme, and individual patient needs.

Improved clinical outcomes and reduced risk of complications

CBCT offers a more accurate, predictable outcome and safer means to dental implant placement. CBCT should be mandatory diagnostic imaging for every implant treatment. Not using CBCT for planning is unwise for the surgeon and creates unnecessary risk for the patient and clinician.

Communication of data volume

CBCT allows the ability to communicate DICOM data imaging information for prosthetic restorative planning, and design and manufacturing of surgical guides.

Limitations of CBCT

There are a number of limitations with CBCT clinicians should be aware of:

  • Requires training and has a learning curve
  • Requires expertise and specialized equipment
  • Poor soft tissue contrast
  • Not an ideal tool for assessing bone density
  • Imaging artifacts
  • Radiation dose

Conclusion

CBCT imaging technology computer software has significantly increased the accuracy and efficiency of diagnostic and treatment capabilities, thereby offering an unparalleled diagnostic approach when dealing with previously challenging unknown anatomical and/or pathological entities in implant dentistry.

The potential benefits for accurate assessment, diagnosis of pathologies, identification of anatomical landmarks and neurovascular structures, as well as topographical and morphological deviations in alveolar bone, in preoperative treatment planning are undisputed.

CBCT has become the new professional standard of care as imaging modality for diagnosis and preoperative treatment planning in implant dentistry. The decision to prescribe a CBCT scan must be based on the patient’s history and clinical examination — justified on an individual basis due to consideration of diagnostic and preoperative treatment planning needs and benefits, radiation risk, and cost.

Effective assessment of proposed implant sites requires that clinicians interpret implant sites for many factors related to successful implant restorations, including adequate bone volumes, distance away from teeth/implants, sufficient prosthetic space for restoration, and precise implant placement.

This article proposes a protocol for performing a structured review and reading CBCT data volume to ensure pathology or critical anatomical structures are not missed that may impact on or enhance diagnosis, treatment planning and treatment outcomes. CBCT is increasingly being accepted as the new professional standard of care in implant dentistry. With this technology, adequately trained clinicians can enhance their practice and best serve the interests of their patients. However, with growing technological and software development and increasing use of this indispensable technology, it is important that the dental profession develops evidence-based guidelines and recommendations for its proper and effective use.

Did you miss part 2 of Dr. Hartshorne’s series on CBCT for implant therapy? Catch up on your reading here: https://implantpracticeus.com/ce-articles/essential-guidelines-for-using-cbct-in-implant-dentistry-clinical-considerations-part-2/

Author Info

Johan Hartshorne, BSc, BChD, MChD, MPA, PhD(Stell), FFPH RCP(UK), is a general dental practitioner at Intercare Medical and Dental Centre, Tyger Valley, South Africa.

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