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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 29  |  Issue : 2  |  Page : 106-110

A comparative study of digital radiography, panoramic radiography, and computed tomography in dental implant procedures


1 Department of Oral Medicine and Radiology, St. Joseph Dental College, Eluru, Andhra Pradesh, India
2 Department of Oral Medicine and Radiology, Panineeya Mahavidyalaya Institute of Dental Sciences and Research Centre, Hyderabad, Telangana, India
3 Department of Oral Medicine and Radiology, Sri Sai College of Dental Surgery, Vikarabad, Telangana, India
4 Department of Oral Medicine and Radiology, Navodaya Dental College, Raichur, Karnataka, India
5 Department of Conservative Dentistry and Endodontics, Sri Venkata Sai Dental College, Mahaboobnagar, Telangana, India

Date of Submission07-Jan-2017
Date of Acceptance20-Oct-2017
Date of Web Publication9-Nov-2017

Correspondence Address:
Shefali Waghray
Department of Oral Medicine and Radiology, Panineeya Dental College, Road No. 5, Kamala Nagar, Dilsukhnagar, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.JIAOMR_4_17

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   Abstract 

Introduction: The science of dental implantology has evolved exponentially in the recent past but the intricacies in the selection of implant site, size and angulations has always been challenging to the clinician and it is very difficult to meet these challenges without dental imageology. Aims: To compare panoramic radiography with computed tomography (CT) and radiovisiography to analyze the relative advantages and disadvantages of these modalities. Materials and Methods: Total 27 sites in 20 patients of mandibular posterior molar edentulous areas were radiographed with four different radiographic methods. The implant sites were selected and the height of the available bone, the mean width of the available crestal bone and density were measured using all the three techniques (except density which was measured on CT alone). Comparison of all the values obtained with the three imaging modalities was done and data tabulated for statistical analysis. The one way analysis of variance (ANOVA) with post hoc analysis using least significance method (LSD) was used to test the differences between each group using the SPSS software version 16. Results: The mean value of vertical measurements using conventional OPG, panoramic CT, RVG, and paraxial CT was found to be 19.32, 18.43, 19.09, and 16.81 mm, respectively. The mean value of density of the bone using paraxial CT was found to be 631.23 HU with a standard deviation of 123.14. The mean value of width of the crestal bone below the height of the crest using paraxial CT was found to be a maximum of 14.03 mm and a minimum of 5.86 mm. Conclusion: The overall results suggested that the paraxial view of CT was better in assessing the parameters of implant site when compared to the other three modalities.

Keywords: Computed tomography, implant, pantomography, radiovisiography


How to cite this article:
Athota A, Gandhi Babu DB, Nagalaxmi V, Raghoji S, Waghray S, Reddy CR. A comparative study of digital radiography, panoramic radiography, and computed tomography in dental implant procedures. J Indian Acad Oral Med Radiol 2017;29:106-10

How to cite this URL:
Athota A, Gandhi Babu DB, Nagalaxmi V, Raghoji S, Waghray S, Reddy CR. A comparative study of digital radiography, panoramic radiography, and computed tomography in dental implant procedures. J Indian Acad Oral Med Radiol [serial online] 2017 [cited 2020 Dec 5];29:106-10. Available from: https://www.jiaomr.in/text.asp?2017/29/2/106/217915


   Introduction Top


Replacing missing teeth is one of the biggest challenge faced by the dental surgeon. The invention of implant has brought about a great change in delivering a successful fixed prosthesis to the patient but entails few anatomic, physiologic, functional, and economic challenges. Though the science of dental implantology has evolved exponentially in the recent past, the intricacy in the selection of implant site, size, and angulations is challenging to the clinician, and it is very difficult to meet these challenges without proper dental radiographs of the implant site, both prior and after the placement of implants.[1] The role of oral imageologist is very vital in giving complete information about the quality and quantity of implant recipient sites along with the available sophisticated computer software. The knowledge and experience of oral and maxillofacial imageologist will help the clinician in presurgical, surgical, and postsurgical prosthodontics and in assessing the prognosis of dental implants. Conventional and advanced imageologic techniques such as computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET) have been used in implant radiography. This study aims at comparing panoramic radiography with CT and radiovisiography (RVG) to analyze relative advantages and disadvantages based on various parameters.[2],[3]


   Materials and Methods Top


The present study was conducted in the Department of Implantology, Sri Sai College of Dental Surgery, Vikarabad, Telangana, India. The inclusion criteria included subjects free from any systemic disease, age group of 19–60 years, and subjects having at least mandibular posterior edentulous area. Totally, 27 sites in 20 patients of mandibular posterior molar edentulous areas were selected and subjected to clinical examination. Diagnostic casts were then made. The sites were then radiographed using four different radiographic methods, which included conventional panoramic radiography, RVG, panoramic view of CT, and paraxial view of CT.

Panoramic radiographic procedure

Planmeca Proline EC Panoramic X-ray machine was used with standard parameters for all the subjects. The radiographs were made with a stent, with metal ball of size 6.5 mm to rule out magnification factor. After obtaining the measurements the constant magnification factor of the panoramic machine that is 1.2% was deducted and the final measurements were obtained [Figure 1].
Figure 1: Panoramic radiograph showing edentulous implant site in mandible

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Radiovisiography equipment and procedure

The RVG machine used for evaluation of the edentulous area was SUNIRAY RVG system. The sensor dimension used was 39.5 × 26 mm 2 with an active area of 31.1 × 20.2 mm 2. Paralleling cone technique was used for taking radiographs, and the measurements were made on the captured images using the SUNIRAY software supplied by the manufacturer [Figure 2].
Figure 2: RVG image of edentulous implant site in mandible

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Computed tomography equipment and procedure

The CT scanner used for panoramic radiographic evaluation of mandible was a 64-slice scanner (Siemens – Somatom Sensation 64, Erlangen, Germany). The scans were acquired from the level of hyoid bone to mandibular condyles. The sections of the acquired data with 0.75 mm reconstruction with 50% overlap were imported into the dental CT software provided by the vendor, Siemens, Erlangen, Germany and four sets of data were obtained. The first image taken was the panoramic view of CT [Figure 3]. The paraxial sagittal images were obtained from right condyle to the left condyle. The paraxial sections were contiguous sections depicting the buccal and lingual aspects of the mandible [Figure 4]. Measurements were performed using these images after identifying the inferior alveolar nerve canal, height of the bone, density of the bone as well as bucco-lingual width of the bone as follows:
Figure 3: Panoramic view of CT

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Figure 4: Paraxial view of CT

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  • Height of the available bone for implant placement- From superior border of inferior alveolar canal till the crest of the alveolar ridge, using all the four techniques
  • The mean width of the available crestal bone and density were measured in CT alone.
  • Comparison of vertical height was done as obtained in the conventional orthopantomogram (OPG), RVG, panoramic view of CT, and paraxial sections in CT.


All the values thus obtained were tabulated for statistical analysis using the SPSS software version 16 (SPSS Inc., Chicago, IL, USA).

Statistical analysis

The one-way analysis of variance with post hoc analysis was used to test the intergroup differences and also pairwise variable differences.


   Results Top


The values obtained from the measurements are mentioned in the tables. Height of the available bone for implant placement from superior border of inferior alveolar canal till the crest of the alveolar ridge was measured using all the four techniques [Table 1]. The mean width of the available crestal bone and density was measured in CT alone [Table 2]. The mean value of vertical measurements using conventional OPG, panoramic CT, RVG, and paraxial CT was found to be 19.32, 18.43, 19.09, and 16.81 mm, respectively. The mean value of density of the bone using paraxial CT was found to be 631.23 HU with a standard deviation of 123.14. The mean value of width of the crestal bone below the height of the crest using paraxial CT was found to be a maximum of 14.03 mm and a minimum of 5.86 mm.
Table 1: Measurements of bone height measured with all four techniques

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Table 2: CT measurements of bone density and width of bone at implant site

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Comparison of orthopantomogram, panoramic view of computed tomography, and paraxial view of computed tomography

On comparison of the height of the bone measured with conventional OPG and panoramic CT, the mean value obtained in the conventional OPG was 19.32 mm with a standard deviation of 2.64 mm, and the mean value obtained in the panoramic CT was 18.43 mm with a standard deviation of 2.50 mm. The mean difference between the two was 0.88, with a P value of 0.19, which is a nonsignificant difference [Table 3].
Table 3: Comparison of OPG, panoramic view of CT, RVG, and paraxial view of CT by post hoc test

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On comparison of the height of the bone measured using conventional OPG and paraxial CT, the mean value obtained in conventional OPG was 19.32 mm with a standard deviation of 2.64 mm, and the mean value obtained in paraxial CT was 16.28 mm with a standard deviation of 3.90 mm. The mean difference between the two was 2.50 with a P value of 0.000, which is a significant difference [Table 3].

On comparison of the height of the bone measured using conventional OPG and RVG, the mean value obtained in conventional OPG was 19.32 mm with a standard deviation of 2.64 mm, and the mean value obtained in RVG was 19.09 mm with a standard deviation of 2.30 mm. The mean difference between the two was 0.22 with a P value of 0.74, which is a nonsignificant difference [Table 3].

On comparison of the height of the bone measured using panoramic CT and RVG, the mean value obtained in panoramic CT was 18.43 mm with a standard deviation of 2.50 mm, and the mean value obtained in RVG was 19.09 mm with a standard deviation of 2.30 mm. The mean difference between the two was 0.66 with a P value of 0.33, which is a nonsignificant difference [Table 3].

On comparison of the height of the bone measured using RVG and paraxial CT, the mean value obtained in RVG was 10.09 mm with a standard deviation of 2.30 mm, and the mean value obtained in paraxial CT was 16.81 mm with a standard deviation of 2.50 mm. The mean difference between the two was 2.28 with a P value of 0.01, which is a significant difference [Table 3].

On comparison of the height of the bone measured using panoramic CT and paraxial CT, the mean value obtained in panoramic CT was 18.43 mm with a standard deviation of 2.50 mm and mean value obtained in paraxial CT was 16.81 mm with a standard deviation of 2.50 mm. The mean difference between the two was 1.61 with a P value of 0.02, which is a significant difference.


   Discussion Top


The field of implant dentistry is gaining fame in the last couple of decades through awareness of the patients and the improvement in technological and surgical procedures, making implant dentistry as one of the most preferred line of management for the edentulous patients. There are many types of implant modules which utilize both conventional and computerized imaging technologies for the best possible placement of implants in the most suitable sites in the implant recipient areas.

As the preference of imageologic technique differs from one implantologist to the other, an attempt was made to compare conventional radiology with advanced CT techniques in implant imaging. This study was intended to give a clarity on the advantages of various imaging modalities so that the implantologist can choose the required imaging technique based on the requirement of the patient.

The most important requisite for any saddle area to receive a successful implant is the height of the alveolar/crestal bone from that of inferior alveolar nerve canal.[4] It was found in our study that panoramic radiography was helpful in getting this particular data in a simplified and economic way. A similar finding was also reported by Schulz et al.,[5] who reported the precision of panoramic radiographic measurements. Although panoramic imaging has the disadvantage of magnification of image, it can be easily calculated by simple mathematic equations by deducting the magnification factor specified by the manufacturer. But the lack of feasibility in controlling the angulations between the X-ray beam, and vertical and horizontal planes of jaw bones may contribute to distortions and deviated measurements of various structural sites of jaw bones.[6]

When there is a feasibility to use advanced imageologic techniques such as CT, it should be preferred since the CT scan gives images of axial and coronal sections with minimum distortion. Once the recipient implant site is finalized, the CT scan really helps in accurate placement of implant of accurate size and in accurate axis. CT scanning not only helps in measuring the height of the bone but also helps in measurement of the bone in all three dimensions accurate to the nearest millimeter, thereby helping the implantologist in successful placement of the implant. CT also gives detailed information of various patterns of bone, various anatomical changes such as unusual bony canals, bony calcifications, and foreign bodies, which is really useful not only in the placement of implant but also in successful prediction of prognosis of the implant procedure.[7],[8] The CT also gives clear-cut information about anatomical and histological patterns of buccal and lingual cortical plates and patterns of the medullary bone. The perfect information of all these parameters makes CT scan an advantageous modality in implant planning compared to simple panoramic radiography, but the limitations in submission of patient such as inability to cooperate for a scanning procedure due to claustrophobia, economic considerations, and lack of availability of advanced CT equipment with desirable software applications in all dental centers makes CT a less acceptable modality. Though the additional radiation exposure during CT procedure is high when compared to OPG, which is a disadvantage, the additional information that is obtained from a CT scan can be of good help in implant imaging. On considering all the parameters, pros and cons of various imageological techniques, CT is ideally recommended for implant procedure, but in places where the patient is not cooperative, panoramic radiography can be used as a choice of implant-guiding imageologic technique by explaining the relative risk and benefits to the patient.[3]

An advanced imaging modality, called cone beam CT, is used these days as it has many advantages over CT. Although our study showed that paraxial view of CT proved more accurate for implant site radiology, cone beam CT has certain advantages over CT. The amount of radiation is relatively less as it is shot in a single-cone-shaped beam. The image can be sectioned and viewed in all three planes along with virtual implant placement options using various software. However, the image is relatively noisy and comparatively unclear when compared to CT.[9],[10]

RVG is considered a feasible and cost-effective radiographic technique for implant imaging with minimum addition of equipment and minimum discomfort to the patient along with less radiation exposure. An added advantage in using RVG for implant imaging is the ease of acquiring the required number of images on a surgical table or on a dental chair instantaneously. Advantages of RVG and digital radiography were highlighted by some authors as being advantageous for intraoperative implant imaging, thereby reducing the chances of iatrogenic injuries during implant surgeries.[11]


   Conclusion Top


The present study concludes that the paraxial view of CT is more accurate when compared to the other three modalities, such as conventional panoramic radiography, RVG, and panoramic CT. However, more radiation exposure and economic constraints are the major disadvantages of CT. Panoramic imaging and RVG were found to be equally valuable in implant imaging owing to their ease of access and cost-effectiveness. The present study found that panoramic imaging and RVG showed accurate results for measurement of length in a single plane; however, the paraxial view of CT scan showed better measurements in all three planes. Further studies with a larger number of subjects are required to establish available oral and maxillofacial imageological guidelines with available advanced imageological techniques.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

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Reddy MS, Wang IC. Radiographic determinants of implant performance. Adv Dent Res 1999;13:136-45.  Back to cited text no. 1
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Tyndall DA, Brooks SL. Selection criteria for dental implant site imaging: A position paper of the American Academy of Oral and Maxillofacial Radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:630-7.  Back to cited text no. 2
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van der Stelt PF. Filmless imaging: The uses of digital radiography in dental practice. J Am Dent Assoc 2005;136:1379-87.  Back to cited text no. 3
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Madrigal C, Ortega R, Meniz C, Lopez-Quiles J. Study of available bone for interforaminal implant treatment using cone beam computed tomography. Med Oral Patol Oral Cir Bucal 2008;13:E307-12.  Back to cited text no. 4
    
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Schulze R, Krummenauer F, Schalldach F, d'Hoedt B. Precision and accuracy of measurements in digital panoramic radiography. Dentomaxillofac Radiol 2000;29:52-6.  Back to cited text no. 5
    
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Peltola JS, Mattila M. Cross-sectional tomograms obtained with four panoramic radiographic units in the assessment of implant site measurements. Dentomaxillofac Radiol 2004;33:295-300.  Back to cited text no. 6
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Mehra A, Pai KM. Evaluation of dimensional accuracy of panoramic cross-sectional tomography, its ability to identify the inferior alveolar canal, and its impact on estimation of appropriate implant dimensions in the mandibular posterior region. Clin Implant Dent Relat Res 2012;14:100-11.  Back to cited text no. 7
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Fernandes RJ, Azarbal M, Ismail YH, Curtin HD. A cephalometric tomographic technique to visualize the buccolingual and vertical dimensions of the mandible. J Prosthet Dent 1987;58:466-70.  Back to cited text no. 8
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Parks ET. Digital radiographic imaging. Is the dental practice ready? J Am Dent Assoc 2008;139:477-81.  Back to cited text no. 9
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Angelopoulos C, Thomas SL, Hechler S, Parissis N, Hlavacek M. Comparison between digital panoramic radiography and cone-beam computed tomography for the identification of the mandibular canal as part of presurgical dental implant assessment. J Oral Maxillofac Surg 2008;66:2130-5.  Back to cited text no. 10
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van der Stelt PF. Better imaging the advantages of digital radiography. J Am Dent Assoc 2008;139:7-13.  Back to cited text no. 11
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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