Comparison of t w o - d i m e n s i o n a l orthoradially r e f o r m a t t e d computed t o m o g r a p h y and panoramic radiography for dental implant t r e a t m e n t planning

E r n e s t W. N . L a i n , D M D , M S c , a A x e l R u p r e c h t , D D S , M S c D , F R C D , b a n d Jie Yang, MB, MMI c

College of Dentistry and The University of Iowa Hospitals and Clinics, The University of Iowa, Iowa City, Iowa
The w i d e s p r e a d use of d e n t a l i m p l a n t s in partially and c o m p l e t e l y e d e n t u l o u s p a t i e n t s has brought about a need to p r e o p e r a t i v e l y depict and q u a n t i f y accurate bone height and contour. A n u m b e r of c o n v e n t i o n a l intraoral and e x t r a o r a l radiographic t e c h n i q u e s h a v e b e e n used, including the r e l a t i v e l y n e w m o d a l i t y of t w o - d i m e n s i o n a l orthoradially r e f o r m a t t e d c o m p u t e d t o m o g r a p h y . D e s p i t e rapid a d v a n c e s in i m a g i n g technology, m a n y clinicians continue to rely on t e c h n i q u e s such as p a n o r a m i c r a d i o g r a p h y that produce i m a g e s that distort the j a w s nonuniformly. This study c o m p a r e d bone h e i g h t m e a s u r e m e n t s of j a w s m a d e w i t h t h e s e t w o i m a g i n g modalities. N i n e t e e n sites in 10 patients w e r e i m a g e d w i t h both t e c h n i q u e s and m e a n b o n e height w a s d e t e r m i n e d for each i m a g i n g t e c h n i q u e and site. Significant differences w e r e found b e t w e e n m e a n bone heights m e a s u r e d w i t h the t w o i m a g i n g m o d a l i t i e s (p < 0.0005). Situations in w h i c h the use of d e n t a l i m p l a n t s w o u l d be p a r t i c u l a r l y a d v a n t a g e o u s d e m o n s t r a t e d the l a r g e s t discrepancies, that is, w h e n bone h e i g h t m e a s u r e m e n t s w e r e l e s s than 15 ram. (J PROSTHET DENT 1995;74:42-6.)

R a d i o g r a p h i c examinations of the jaws play an important role in the preoperative evaluation of a patient about to undergo surgery for the placement of dental implants. 1 These examinations provide information not only about the amount of bone available to accommodate the implant but also about the contour and quality of the bone. These examinations also provide information about the locations of vital anatomic structures adjacent to the sites of implant placement, for example, the maxillary sinuses and nasal fossae, and the inferior alveolar canals and mental foramina. Numerous plain film and tomographic projections have been used to evaluate the maxillae and mandible for dental implant placement. The ideal imaging technique would permit cross-sectional (buccal-lingual) views through the jaws with minimal distortion of the image from beam or film angulation or subject-to-film distance. Furthermore, the ideal imaging technique would depict the density of the cancellous bone and the thickness of the cortices. From the aFellow Associate, Departments of Oral Pathology, Radiologyand Medicine. bprofessor, Department of Radiology, University of Iowa Hospitals and Clinics, and Department of Oral Pathology and Medicine, College of Dentistry. CResident, Department of Oral Pathology, Radiology and Medicine. Copyright 9 1995 by The Editorial Council of THE JOURNALOF PROSTHETICDENTISTRY. 0022-3913/95/$3.00 + 0. 10/1/63979

surgical standpoint, the imaging technique would provide a simple means of relating the location of an image with that of other similar views, as well as with the site of implant placement, intraorally. Finally, the ideal imaging technique should be readily available at low cost to the patient. More common imaging techniques used for preoperative evaluation of the jaws include intraoral periapical 2 and occlusal radiography? panoramic radiography,4 and lateral skull cephalometric radiography. 3' 4 The disadvantages of these techniques are the inability to image the jaws in buccal-lingual cross-section and image distortion, although the severity of these problems is variable. Cephalometric radiography does permit a cross-sectional view of the jaws and is likely to be less distorted; however, the view obtained is limited to the midline of the jaws. Recently, two-dimensional (2-D) orthoradially reformatted computed tomography (CT) has been used to image the partially or fully edentulous maxillae or mandible. This technique, which has been described by several authors, 5"s uses a reconstruction software package, Dentascan (General Electric Medical Systems, Milwaukee, Wis.). Axial CT images are acquired through the jaw to be examined. The individual CT slices are then stacked on top of each other to recreate the three-dimensional imaging volume. The final step in the procedure is to reslice (reformat) the reconstructed three-dimensional imaging volume in a plane perpendicular, or orthoradial, to the arc of the mandible or maxillae. All of the studies cited have been

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descriptive in nature and focus on the technical aspects of patient positioning, scan acquisition, and jaw anatomy. Shimura et al. 9 quantified bone height and width with reformatted CT by use of maxilla/mandible shaped pattern analysis; however, that study did not compare the measurements obtained with data acquired from other imaging modalities. This study compared bone height measurements made of the jaws with 2-D orthoradially reformatted CT images with those made with panoramic radiography in patients undergoing preoperative evaluation for dental implant placement. It was hypothesized that bone height measurements made directly from the panoramic radiographs either overestimated or underestimated bone height in comparison with measurements made with the 2-D reformatted CT image. MATERIAL AND METHODS

Nineteen sites (10 maxillary and 9 mandibular) were identified in 10 patients who were to have one or more dental implants placed. The sites of implant placement and orientation were determined by the referring clinician. Each patient had a duplicate denture made, and the sites of implant placement and orientation were identified by use of either a metal sphere or gutta-percha cylinder placed directly into the denture base. A Siemens Somatom DR CT unit (Siemens Medical Systems, Iselin, N.J.) was used to acquire a series of 2 mm thick axial images with 1 mm offset through either the mandible or maxillae. The image data were transferred by magnetic tape to a Sun Sparc 10 graphics workstation (Sun Microsystems, Mountain View, Calif.) for reconstruction with software (ToothPix, Cemax Corp., Fremont, Calif.) similar to the Denta-scan system (General Electric Medical Systems). The resulting 2-D orthoradially reformatted images represented 2 mm thick orthoradial images through the buccal and lingual cortices of the imaged jaw. Bone height measurements were made directly from the lifesized, reformatted 2-D orthoradial images in which the gutta-percha cylinders were depicted. The axis of implant placement was determined by the orientation of the guttapercha cylinder, and bone height measurements were made along this axis from the crest of the alveolar process to the cortex of the nearest vital structure (Fig. 1). In the mandible, this was the roof of the inferior alveolar canal or the inferior border of the mandible. In the maxillae, this was either the floor of the maxillary sinus or the floor of the nose. Panoramic radiography was performed with a variety of systems that could not be standardized because these radiographs were ordered locally by the referring clinicians for implant assessment. The panoramic radiographs were made with Panelipse (General Electric Medical Systems) and OP-5 and OP-10 units (Siemens Medical Systems). The position of implant placement was determined by the

Fig. 1. CTimage(2-Dorthoradiallyreformatted)through
mandible. Gutta-percha marker (white arrow) and inferior alveolar canal (black arrow) are indicated. Axis of implant orientation is shown, and bone height measurements were made between two arrowheads.

location of the depicted metal sphere implanted within the acrylic resin base of the duplicate denture. Bone height measurements were made from the crest of the alveolar process to the cortex of the nearest vital structure at this location, along an axis parallel to the midsagittal plane (Fig. 2). In all instances, an oral and maxillofacial radiologist and two oral and maxillofacial radiology residents made the bone height measurements for all sites, and for each site measurement means and standard deviations were then calculated. Student's paired t-test was used to compare the differences between mean bone height measurements made on the panoramic radiographs and 2-D orthoradially reformatted CT images. Spearman's rho test was used to determine the degree of correlation between mean bone height measurements made on the panoramic images and those made on the 2-D orthoradially reformatted CT images. These statistical tests were done with StatView SE+Graph software (Abacus Concepts, Berkeley, Calif.) and the data were graphically depicted with Cricket Graph software (Cricket Software, Malvern, Pa.). The null hypothesis was rejected at the 0.05 level of significance.

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Fig. 2. Portion of panoramic radiograph showing metal sphere and axis of implant orientation. Bone height measurements were made between two arrowheads.

40

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Ranked Bone lteight Measurement Numl)er Fig. 3. Ranked mean bone height and standard deviations from 2-D orthoradially reformatted CT images and panoramic radiography (OP).

RESULTS Fig. 3 illustrates the mean 2-D orthoradially reformatted CT-derived bone height data and standard deviations ranked by height from smallest to largest. Standard deviations for these data were less than approximately 20 % of the mean bone height measurement. Also depicted on this graph is the accompanying mean bone height measurement derived from the panoramic radiographs. The standard deviations for these measurements were, in most cases, larger than those measured from the 2-D orthoradially reformatted CT images. In all cases except three, the mean bone height measurements derived from the panoramic radiographs were greater than those obtained with the 2D orthoradially reformatted CT images. Student's t-test revealed significant differences (p < 0.0005) between the mean bone height measurements made by panoramic radiography and 2-D orthoradially reformatted CT.
44

Fig. 4 is a scatterplot of the mean bone height measurements made from the panoramic radiographs (y-axis) and 2-D orthoradially reformatted CT (x-axis). The dotted line is a graphic representation of the situation in which the two bone height measurements are equal (namely the null hypothesis). The solid line was the extrapolated regression line through the scatterplot, which indicated a high degree of correlation as calculated with Spearman's rho test. The correlation coefficient for the regression line was 0.89 (p < 0.0005). DISCUSSION There is inherent distortion of anatomic structures in the vertical and horizontal planes in panoramic radiography. The amount of distortion depends on the distance between the x-ray source and film, the distance between the x-ray source and the central plane of the focal trough, the effecVOLUME 74 NUMBER 1

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Fig. 4. Scatterplot and regression line (solid line) of mean bone height measurement from panoramic radiograph (OP) versus 2-D orthoradiatly reformatted CT image (r = 0.89, p < 0.0005). Dotted line represents situation in which mean bone height data derived from panoramic radiograph and from 2-D orthoradially reformatted CT are equal.

tive projection radius, the relative speed of the radiographic source and film, and beam angulation in the vertical and horizontal planes. 1 Furthermore, as the x-ray beam sweeps around the jaws, it may not remain strictly perpendicular to the surface of the mandible or maxillae. In the horizontal plane, there may be as much as a 30-degree variation in angulation between the incident beam and the bone, and in the vertical plane this variation may be as high as 15 degrees. Although the operator has no control over many of these factors, patient positioning within the unit can be controlled to some extent. All these factors contribute to magnification of the actual structure in an image; perhaps equally important is that changes in vertical angulation of the relative beam may artificially position structures either superior or inferior to other structures on the image. This most certainly has a detrimental effect when quantitating distances between structures on these sorts of images was attempted. The standard deviations of the bone height measurements made on the panoramic radiographs were greater than those of their 2-D orthoradially reformatted CTderived counterparts. In most instances, this was a result of the interpretation of the location of vital structures. In one instance, the standard deviation represented approximately 30 % of the mean bone height measurement. It may be argued that clinicians who are less familiar with interpreting these types of images may have more difficulty in identifying, for example, the crest of the alveolar process, the superior border of the inferior alveolar canal (which is often difficult to identify even by the most skilled clinician), and the floor of the maxillary sinus or nose. In such a situation, the height of bone available to accept a dental implant may be overestimated or underestimated. In conJ U L Y I995

trast, less variation was found in measurements of bone height made from the 2-D orthoradially reformatted CT images. Although panoramic radiographs were made on different units from different practitioners, in almost all cases measurements made from the panoramic radiographs were greater than those measured from the reformatted CT images. This was a consistent finding throughout the study; therefore it was believed that the use of different panoramic units did not compromise the study or have any significant bearing on the outcome. The purpose of this study was not to evaluate a particular brand of panoramic unit but to compare panoramic units in general with the CT technique. Interestingly, a regression line drawn through the scatterplot (Fig. 4) illustrated that in areas where there is a large amount of bone, the regression line converges with the line that represents the null hypothesis; that is, in the bone heights measured from both techniques were equal. In the region of the graph where bone height measurements were the least (less than 15 mm), bone height measurements made from the panoramic radiographs were greater than those made from the reformatted CT images. Indeed, for placement of dental implants into the jaws, it is at these important shorter bone heights that dental implants would be most advantageous. Unfortunately, there was no gold standard to which these radiographic techniques could be compared, and the 2-D orthoradially reformatted CT images may be underestimating the amount of bone present to accept an implant. It may, however, be safer to underestimate than overestimate the bone levels. Unlike panoramic radiography, 2-D orthoradiaity reformatted CT images offer the clinician the advantage of be45

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ing able to examine the buccal-lingual contour of the bone. I n patients in this study, the alveolar process of the mandible or maxillae had resorbed more from the buccal or lingual aspect, or uniformly on both sides, leaving a "knifeedge" contour to the remaining bone. Without alveolar process augmentation on either the buccal or lingual aspect of the bone before placement of the implants, such a situation would prove unworkable for the surgeon. Unfortunately, such a situation cannot be adequately predicted with a panoramic radiograph. There are, however, inherent problems with 2-D orthoradially reformatted CT. For instance, patient movement during image acquisition presents an unfortunate problem in the reconstruction of image data. If there is patient movement in one or more slice acquisitions, entire sections of the jaw may be artifactually displaced from other regions, with the result being a step seen in the constructed image. However, patient movement represents more of a problem in the mandible than in the maxillae. To circumvent this, we devised a system whereby a patient undergoing imaging of the mandible is strapped to the headrest of the CT u n i t with tape encircling the forehead, midface beneath the nose, and chin. Furthermore, a fourth circumferential strip of tape is placed under the chin that runs along the side of the head to near the skull apex. Although this restraining process seems unpleasant and excessive, it has been our experience that patients restrained in this m a n n e r are less susceptible to movement during the 20- to 25-minute imaging process and tolerate the procedure well if it is explained beforehand in detail. Another disadvantage of this technique to the patient is the cumulative radiation dose to structures within the head and neck such as the brain, salivary glands, bone marrow, and pharynx. Recent unpublished data (Lurie, personal communication) suggest that the effective radiation dose from a CT study for dental implants is significantly greater t h a n that from other techniques, such as occlusal radiography and conventional cross-sectional tomography. Those workers report effective doses in the 5 mGy and 6 mGy range in the maxillae and mandible, respectively. In comparison, occlusal radiography imparts cumulative effective doses of less t h a n 0.2 mGy in either the mandible or maxillae. SUMMARY Panoramic radiography and 2-D orthoradially reformatted CT images were used to measure bone height in the

mandible and maxillae of patients undergoing preoperative assessments for dental i m p l a n t placement. Bone height measurements were made at 19 sites in 10 patients. Mean bone height measurements were determined for each imaging technique and site. Significant differences were found with a paired t-test between mean bone height measurements that were recorded from the two techniques (p < 0.0005). The greatest differences between the two techniques occurred in instances in which the use of dental implants would be particularly advantageous, that is, in regions with less than 15 m m of remaining bone. We thank Dr. Kirk Baumgardner for assistance with statistical management of the data.
REFERENCES

1. WelanderU, TronjeG, McDavidWD. Theoryof rotationalpanoramic radiography. In: LanglandOE, LanglaisRP, McDavidWD, DelBalso AM,eds. Panoramicradiology.Philadelphia:Lea and Febiger,1989:3875. 2. SewerinI. Identificationof dental implantson radiographs. Quintessence Int 1992;23:611-8. 3. McGivneyGP, Haughton V, Stradt JA, Eichholz JE, Lubar DM. A comparisonof computer-assistedtomographyand data-gatheringmodalities in prosthodontics.Int J OralMaxillofacImplants1986;1:55-68. 4. Gratt BM, Shetty V. Implant radiology.In: GoazPW, White SC, eds. Oral radiology, principlesand interpretation. St. Louis: CV Mosby, 1994:703-15. 5. SchwarzM, RothmanSLG,Rhodes ML, ChafetzN. Computedtomography: part I--preoperativeassessmentof the mandiblefor endosseous implant surgery. Int J Oral MaxillofacImplants 1987;2:137-41. 6. SchwarzMS, RothmanSL, Rhodes ML, Chafetz N. Computedtomography: part II--preoperativeassessmentof the maxillafor endosseous implant surgery. Int J Oral MaxillofacImplants 1987;2:143-8. 7. SchwarzMS, RothmanSL, Chafetz N, RhodesM. Computedtomography in dental implant surgery. Dent Clin North Am 1989;33:555-97. 8. WeinbergLA. CT scan as a radiologicdata base for optimumimplant orientation.J PROSTHET DENT1993;69:381-5. 9. ShimuraM, BabbushCA, MajimaH, YanagisawaS, SairenjiE. Presurgicalevaluationfor dentalimplantsusinga reformattingprogramof computed tomography: maxilla/mandible shape pattern analysis (MSPA). Int J Oral MaxillofacImplants 1990;5:175-81.
Reprint requests to:
DR. ERNEST W. N. LAM DEPARTMENT OF ORAL PATHOLOGY,RADIOLOGYAND MEDICINE COLLEGE OF DENTISTRY UNIVERSITY OF IOWA IOWA CITY, IA 52242

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