Radiographic Examination of the Implant Patient fi lled with new bone, digital volume tomography is a helpful tool.

This is illustrated in Fig. 28-19, where it is also apparent how well this technique is able to demonstrate the conditions anterior and inferior to the frontal border of the maxillary sinus. In some patients in whom the available bone height below the maxillary sinus is too small one can occasionally fi nd bone suitable for implant placement on the palatal side of the sinus. Tomography must be performed so that this can be determined (Fig. 28-20). In the posterior parts of the upper jaw the maxillary sinus may extend so far down into the alveolar bone that there is not enough bone available in which to insert an implant. By entering the sinus through a buccal window, bone substitutes can be placed under the mucosal lining. Digital volume tomography is an ideal method to evaluate how the bone substitute is positioned and its relation to the adjacent bone (Fig. 28-21). When implants are intended to be placed in more than one region, the use of computed tomography may be justifi ed (Buser et al. 2002) provided that lowdose protocols are applied (Rustemeyer et al. 2004). A panoramic radiograph and, when remaining teeth are not well displayed in it, complementary intraoral radiographs are nevertheless important. Figure 28-22 describes how the results of such an examination can look. From the stack of axial images a representative image is chosen in which the curvature of the jaw is drawn. A dedicated computer program then makes new tomographic images at chosen distances. These images describe layers that are perpendicular to the curve and in which measurements of bone height and width can be made. Computed tomography is mostly performed in medical radiology departments and images considered relevant for the purpose are sent to the clinician. Sometimes these are limited to the axial image describing the curvature of the jaw and the reconstructed cross-sectional images. We recommend that the referring dentist should also receive the scout image and the stack of axial images. In the scout image it is possible to see what reference plane that was used and, if needed, make the appropriate adjustment of the measurements taken in the crosssectional views. In the axial images one may be able to pick up information about the remaining teeth not displayed in the panoramic or intraoral radiographs (Huumonen et al. 2006). Fig. 28-19 Digital volume tomography in the upper fi rst premolar area. Notice the lack of complete bone fi lling of the extraction socket and the relation of the alveolar bone to the nasal and maxillary sinus cavity. Radiographic examination for implant planning purposes

lower jaw examination In the lower jaw there is a distinction between implant placement in the region anterior to the mental foramina and in regions posterior to the foramina. The height of the anterior region is usually well preserved if teeth have not been m issing for a long time. This is rarely the case in the partially dentate patient. Its width, however, may be a limiting factor. One can get an indication that the alveolar bone is thinner than normal from periapical radiographs or from panoramic images, provided that the anterior region is well reproduced. This is often the case when one can see vertically running radiolucent structures corresponding to the blood vessel canals in the inner walls of the cortex. They become visible when the bone is thin or has fewer and thinner bone trabeculae than normal. In such cases a tomographic examination may be advisable so that one can determine beforehand whether a thin upper ridge will be removed or a bone augmentation procedure applied. When implants are to be placed posterior to the mental foramina one must not only take into account the factors one had to consider in the frontal regions. One must also be able to identify the path of the mandibular canal and accurately assess the distance between the upper level of the alveolar bone, where it is suffi ciently wide, to the upper border of the canal. To do this before su rgery requires that tomography is performed, so that the jawbone anatomy can be evaluated in image layers that correspond to cross sections of the mandible. Estimating this distance in panoramic radiographs, as many seem to do (Worthington 2004), requires so many assumptions of unknown variables that mistakes can easily be made (Fig. 28-23). These can result in temporary or permanent damage to the inferior alveolar nerve. These problems are more frequent than expected (Worthington 2004). We are convinced that careful presurgical planning, including the use of tomography, will keep the incidence of nerve damage to an absolute minimum. The entire distance from where suffi cient width of the mandible is found to the upper border of the mandibular canal cannot be used for implant surgery. One reason is that the drill used for preparing the implant site will go deeper than the implant itself. Another is that one cannot always measure distances in radiographs with absolute accuracy and precision. Therefore, prudent clinicians make use of at least a 2 mm safety zone between the upper border of the mandibular canal, as seen in th e radiograph, and the planned level of the tip of the implant (Fig. 28-24). Among other factors that must be considered in the planning process is the outer shape of the mandible. Both concavities and the lingual tilt differ in extension between patients and between different parts of the jaw (Figs. 28-25 and 28-26). Accidental penetration of the lingual wall of the mandible can

more easily occur under those conditions than when they are not present. Severing of arteries in the underlying soft tissues can cause severe, even fatal, bleeding (Darriba & Mendonca-Caridad 1977; Niamtu 2001). Sometimes the mandibular canal, before it ends at the mental foramen, continues a little bit in an anterior direction before going upwards and distally toward the foramen making a so-called anterior loop (Arzouman et al. 1993). Therefore it is recommended not to place an implant immediately anterior to the foramen. In other cases there can be a relatively wide anterior continuation of the canal, as indicated by Fig. 28-27. It is then recommended that a radiographic evaluation is performed t o determine its position relative to potential implant positions. This is not the place to discuss factors related to general health that may have an infl uence on bone structure and architecture. In can be noted however, that in tomographic images, given that their resolution is suffi ciently high, the cancellous bone pattern in intended implant sites can be studied and the thickness of the cortical bone evaluated. Local factors can contribute to local variations in bone density. In Fig. 28-28 large differences in bone density can be seen in tomographic images less than 1 cm apart. The higher density in the more distal region is most likely a reaction to the infl ammatory conditions seen at an adjacent tooth. Fig. 28-20 From the panoramic image (left) it is not possible to determine bone for implant placement is available on the palatal side of the maxillary sinus, as is clearly seen in the tomographic (right). Notice the soft tissue swelling in the sinus. Fig. 28-21 A coronal and a sagittal tomographic layer of the lower part of axillary sinus in which a bone substitute has been placed. Fig. 28-22 Computed tomography of the upper jaw where implants are planned installed on both sides. To the lower right are cross-sectional views from one side to the other, perpendicular to the seen in the axial view to the left. Fig. 28-23 In this case implant treatment planning was based on a panoramic radiograph only. One of the implants was placed with its tip into the mandibular canal as seen in a subsequent CT image. The positioning of the implant into the canal may have been caused by a misinterpretation of the panoramic radiograph. It is the lingual part of the upper alveolar bone that gives rise to the upper contour in the panoramic image. Fig. 28-24 How measurements can be made in tomographic images to ensure that the tip of the implant will not enter the mandibular canal. (a) Measure the entire height from the upper border of the canal to the marginal bone crest. (This value can be used as a reference during surgery.) (b) Assess where the bone is wide enough for the implant. (c) Measure from this level to the canal. (d) Subtract 2 mm from the latter value. From Grndahl et al. (2003). Fig. 28-25 Lingual concavity and a that image the m to be curve

small bucco-lingual width just distal to the mental foramen and a different shape and width in a more distal position. Fig. 28-26 The shape and angulation of the mandibular jawbone can be very differ ent just a short distance apart. The dotted lines in the sagittal tomograms indicate the positions of the cross-sectional to mographic layers. This information can only be obtained pre-operatively by means of tomography. Fig. 28-27 An anterior continuation of the mandibular canal from the mental fora men as seen in tomographic images (same patient as in Fig. 28-26) and as it may appear in a panoramic view (different pa tient). Fig. 28-28 Large local differences in bone density and architecture. The much de nser bone in the most distal tomographic layer most probably is due to the infl ammatory conditions at the adjacent molar. Fig. 28-29 A scanogram (upper left image) indicates an infl ammatory reaction around the most distal and the most mesial implant and that the tip of the latter may interfere with the anterior loop of the mandibular canal. This is confi rmed by the tomographic examination (upper right images) and after removal of the two implants, the symptoms disappeared Fig. 28-30 Soon after implant insertion the patient presented with slight pain. A radiograph (left image) was interpreted as showing normal conditions. Two weeks later the pain had increased in intensity and a radiolucency could now be seen around the tip of the most mesial implant (middle image). The right image, taken some months later shows completely normal conditions. Fig. 28-31 A so-called scanogram by which even deeply seated implants can be displayed in their entirety. Radiographic monitoring of implant treatment Meticulous planning of the implant treatment together with gentle surgical technique for the insertion of the implants make immediate post-operative radiographic examination superfl uous unless something unexpected occurs during surgery. Under normal conditions, however, there is simply nothing, apart from the expected, to be found. Should the patient experience symptoms before the fi rst postoperative radiographic examination is scheduled, one should of course not hesitate in taking radiographs if information from them is considered essential for a proper diagnosis. The radiographs in Fig. 28-29 are from a patient who presented with severe pain very soon after implants were inserted. The images show unevenly demarcated radiolucent areas around the implants, especially the most distally and the most mesially placed. This is a strong indication of bone infection. In addition, the most mesially placed implant appears to have its tip in close proximity to the anterior loop of the mandibular canal. This is confi rmed by a tomographic examination. The affected implants

were removed and the symptoms soon subsided. When implants are inserted in dense bone heat necrosis can occur around the apical part of the implants, particularly when the implants are long and effective cooling during their insertion has not been applied. Usually this is accompanied by pain. In the radiograph one can see a radiolucent area surrounding the apical part of the implant. A radiolucent area just beneath the apical part and caused by the drill should not be confused with the radiolucency that is a result of heat necrosis. Heat necrosis is most commonly seen in the lower jaw (Fig. 28-30). Often it is not possible to take radiographs of implants using standard intraoral techniques. One either has to take radiographs more from below or use panoramic radiography or, better yet, so-called scanograms (Fig. 28-31). Implants that have not been correctly placed in the bone may cause symptoms as well. Should an intraoral examination fail to show the cause of the problem a tomographic examination may be needed (Fig. 28-32). It should preferably be performed with digital volume tomography, as it is less prone to cause artifacts from the implants than computed tomography. Depending upon the implant system used there may or may not be a need for a radiographic examination when abutments are placed