CBCT Third Eye in Dental Implant

CBCT Third eye in
Dental Implant
Presented By: Stephanie Chahrouk
Introduction
"Imaging is a critically important aspect of diagnostics and

treatment planning when placing dental implants."
"High-quality, accurate images collected at the presurgical stage can

yield dividends both in implant outcomes and patient satisfaction."
Does Traditionaland CT Radiographic Methods Ideal?
"Traditional radiographic methods are not ideal for planning

implant placement "
"because you are visualizing a three dimensional (3D) object in two

dimensions and missing important information along the way"
"The development of computed tomography (CT) allowed clinicians to take

radiographic cross-sections, paving the way for 3D reconstructions of
maxillofacial features, though this improvement came at the cost of higher
radiation exposure"
Advantages of CBCT
 CBCT technology overcomes limitations.
 It is possible to view all aspects of the insertion site on the computer screen, virtually,
noninvasively, as though you are dissecting your actual patient.
 Modern software packages generally provide various perspectives that usually are
customizable and adjustable based on the clinician’s preference.
 It is possible to view a 3D model (volumetric view) of the entire scanned object or only parts
of it or to create tomographic slices in all three planes of space and navigate through the
volume in increments of designated thicknesses, which also are customizable (Kau et al.,
2005).
 CBCT technology allows an exact visual identification of the location, shape, and divergence
of the mesial and distal dental roots, the floor of the maxillary sinus, and the buccal and
lingual wall of the alveolar process.
 Qualitative assessments, therefore, can be made with much greater accuracy than on a
regular 2D radiograph.
 CBCT data can be quantified using the appropriate software packages.
 Thus distances between two points such as interradicular distance or buccal bone thickness
can be measured with considerable accuracy (Timock et al., 2011);
 angulation between three points can be calculated (e.g., to determine root divergence);
 The density of objects including bone can be assessed (Marquezan et al., 2012).
 More detailed approach to planning and placing of the miniscrew implants.
Disadvantages
 the only major disadvantage is that a large amount of information provided by the CBCT
can lead to
o confusion or, even worse, may provide a false sense of security and override the
clinical chairside assessment for inexperienced clinicians.
 The transfer of the information obtained on the virtual model to the real patient also can be
difficult.
“Principle of Action Of CBCT”
“The principle of CBCT is based on a:”
• “fixed x-ray source and detector with a rotating gantry.”

“The x-ray source emits a cone-shaped beam of ionizing radiation that passes through the centre of the
scan region of interest (ROI) in the patient’s head to the x-ray detector on the other side.”
“The gantry bearing the x-ray source and detector rotates around the patient’s head in 360 degree arcs.”
A: Difference between Cone –Beam and Fan-Beam Geometry
B: Procedure of Image acquisition in CBCT

 “While rotating, the x-ray source emits radiation in a continuous or pulsed
mode allowing projection radiographs or “basis images”.”
 “These are similar to lateral cephalometric radiographic images, each slightly
offset from one another.”
 “This series of basis projection images is referred to as the projection data.”
 “Software programs incorporating sophisticated algorithms including back-
filtered projection are applied to these image data to generate a 3D volumetric
data set, which can be used to provide primary reconstruction images in 3
orthogonal planes (axial, sagittal and coronal).”
"A multiplanar display panel of

CBCT showing axial, coronal,
sagittal and 3D –reconstructed
images"
"Recent Ideal Method In Radiographic Imaging Diagnosis?"
• "*CBCT is an advancement of the CT technology that uses a
cone-shaped X-ray beam and a two-dimensional image receptor"
• "*to generate high-quality 3D reconstructions with significantly
lower radiation exposure"
"Diagnostic treatment Imaging Of Implant Dentistry Requires:"

• "1) Imaging for preoperative implant treatment planning."
• "2) Imaging for postoperative implant care."
I-IMAGING FOR PREOPERATIVE IMPLANT TREATMENT PLANNING
"A-A comprehensive evaluation of the oral cavity begins with"

"A detailed medical and dentalhistory"
"Dentalhard and soft tissue clinical examination"
"Followed by conventional imaging such as two dimensional imaging

(intraoral periapical and panoramic radiography)"
"Followed by cross-sectionalimaging using MDCT or CBCT"

"Preoperative radiographs should reveal:"
" 1. Position and size of relevant normal anatomic structures, including the:"
• "a. Inferior alveolar canals"
• "b. Mental foramina"
• "c. Incisive or nasopalatine foramen and canal"
• "d. Nasal floor"
" 2. Shape and size of the antra, including the position of the antral floor
and its relation to adjacent teeth"
"3. Presence of any underlying disease that could compromise the

outcome of treatment e.g. osteoscleorosis"
"4. Presence of any buried teeth or retained roots"
"5. Quantity of alveolar crest/basal bone, allowing direct measuremtns of the height,
width and shape"
"6. Quality (density) of bone"
"Characteristics of Ideal Imaging Techniques in Implants:"
"1. Ability to visualize the site of implant site in the mesiodistal,

faciolingual, and superoinferior dimensions"
"2. ability to determine axial orientation of implants"
"3. ability to allow reliable, accurate measurements"
"4. capacity to evaluate trabecular bone density and cortical thickness"
"5. capacity to correlate the imaged site with the clinical site"
"6. reasonable access and cost to the patient"
"7. minimal radiation risk Preoperative Radiographic Assessment"

Right and left volumetric views with full course of inferior
alveolar nerve illustrated (green line)
Prominent nasopalatine canal.

A: Axial CBCT section reveals an enlarged nasopalatine canal that measures
approximately 6 mm in diameter (arrow). Correlation with the clinical exam will
help determine the need for biopsy in this borderline case.
B: Coronal CBCT section of the same patient displaying the enlarged
nasopalatine canal (arrow)
Implant planning using cross-sectional imaging.

"Diagnosis depends on:"
• "the amount of residual alveolar ridge atrophy"
• "*the bone quality"
• "*bone quantity"
• "*remaining bone height"
• "*bone width"
• "*available bone volume"
Highly atrophied mandible and visualisation of the mandibular canal running
over the alveolar ridge with prominant cortical cone overall.the mental spines
can be seen above the level of the alveolar ridge, particularly in the 3D rendering
Pronounced atrophy in region 45 to 46. As the bone structure is markedly

reduced horizontally and there are hardly any cancellous structures
between the cortical lamellea, lateral bone augmentation in indicated.
Remarques!!
• "*The residual alveolar ridge topography needs to be understood and addressed rather carefully, as
the positioning of an implant is crucial for prosthetic treatment planning."
• "*The identification of vital anatomic landmarks and their relation or vicinity to the future implant
site/s is a crucial factor."
• "*Potential implant sites need to be safely identified"
CBCT is Ideal to detect the important landmarks in the

maxillofacial region:
In the maxilla:
• "Nasal floor",
• "naso-palatine canal",
• "anterior superior alveolar canal",
• "maxillary sinus and related structures,"
• "posterior superior alveolar canal,"
• "maxillary tuberosity, pterygoid plates."
In the mandible:
• "Lingual foramen",
• "incisive canal",
• "genial tubercles",
• "inferior alveolar nerve canal,"
• "mental foramina,"
• "retromolar foramen,"
• "sublingual fossa (lingual undercut),"
• "mylohyoid undercut,"
• "lingula of ascending ramus."
In the zygomatic region:

• "Orbital floor,"
• "infraorbital foramen,"
• "zygomatic bone."
"The decision for use of CBCT must be based on:"
"Patient history"
"Examination "
"Individualized need"
"The benefit must outweigh the potential risk."

"It is recommended that CBCT be used as an imaging alternative for computer-aided
implant planning."
The planning may include:
"Implant placement
in an esthetic zone"
"Pre- and post-
grafting/augmentat
ion procedures"
"Post-implant
complications"
"History or suspected trauma

to the jaw"
Planing augmentation in the case of multiple agenesis. As well as the vertical bone
defect, pronounced retraction of the alveolar process and an absence of cancellous
bone in the crestal part of the alveolar ridge can be seen.
Planing Of Implant insertion in the maxilla in a case of agenesis of tooth

25.the Bone structure in the region 25 shows a pronounced, thin cortical
layer vestibularly, eith slightly mineralized fine-mesh cancellous tissue. As
an incidental finding, teeth 18, 38, and 48 appear impacted, and round
mucosal proliferation is seen in the maxillary sinus.
"Planning and surgery of primary reconstruction immediately after tumor
ablative surgery"
"Reconstruction of large maxillofacial defects with free vascularized grafts
directly after tumor ablation has become a standard treatment modality and is
widely accepted and used (Taylor et al., 1975)."
"Direct reconstruction provides jaw stability and tissue support for favorable
esthetic reconstruction of the face and adequate filling of the defect."
"The resection of a bone tumor or bone invading tumor can be planned

virtually from CBCT data."
"The shape of the graft can also be planned virtually."
"Virtual shaping of the graft at the donor site helps to adequately fill the
defect created by tumor resection."
Planing Of implant insertion in the maxilla. To avoid a sinus floor
elevation procedure, an angulated implant position is chosen.
3D virtual planning of the bone graft and the implants
• "*Once the setup of the missing dentition is determined, the planning continues with
the selection of the type of donor graft."
The choice of the graft usually has several aspects.
• "*First, the graft has to anatomically fill the defect and provide sufficient support to
the implant-supported dental structure."
• "*Next, the blood supply of the graft has to be sufficient, with sufficient vessel length
for recirculation attachment."
• "*The distance of the graft to the acceptor vessels of the neck can be large, especially
when the reconstruction concerns a defect in the maxilla."
Preparation of the recipient jaw area
•"*In most large maxillofacial defects the bone needs to be shaped to fit the graft properly
without compromising the blood supply of the graft."
•"*This includes the shaping of the bony borders of the defect and the local soft tissue."
There are generally two ways to prepare the defect.

•"*One possibility is to design a cutting guide, either bone or dentition supported,"
•"*to perform the shaping of the defect."
•"*The planned graft will fit into the planned resection."
•"*Another possibility is to print the 3D planned suprastructure and the connected bone graft
in a 3D stereolithographic model."
•"*This 3D model resembles the transplant exactly and can be used intraorally in the defect to
prepare the defect"
Once the model fits the defect, the transplant will fit as well
Axial tomographic slice of Safety distance around Bone depth assessment on a
maxillary arch demonstrating miniscrew outlined using sagittal tomographic slice.
anticipated miniscrew Dolphin 3D (Dolphin
position relative to incisive Imaging software).
canal.
II-IMAGING FOR POSTOPERATIVE IMPLANT TREATMENT PLANNING
Evaluation of the surgery CBCT scans provides the possibility of

postoperative analysis for evaluation of the outcome of the surgery.
The CBCT scan shows all dimensions of the reconstruction outcome
The DICOM files from the scan can be imported into ProPlan; these
can then be superimposed on the original reconstruction plan
Postoperative CBCT scans can also be used to evaluate
consolidation of the graft bone segments to the defect edges
Reasons for a post-op insertion outcome evaluation
The misinterpretation of the images can be attributed to scatter radiation and alteration of
the screw dimensions on the scan.
This is a useful example of how findings from diagnostic imaging should be placed in the
perspective of clinical observations.
Clinician self-assessment.
The orthodontist placing miniscrews should evaluate if the implemented clinical protocol led
to the desired outcome or at least be aware of how close the final result came to the planned
“ideal insertion.”
This self-assessment is the primary and important approach to improve future TAD
insertions.
While a review of the final miniscrew position can be interesting, it is more meaningful if
compared with the virtually placed implant (Figure 18.12).
Figure 18.12 3D superimposition of pre-treatment

Treatment planning for the miniscrew and post-expansion time points using
the Hybrid-Hyrax advancer. Tan, pre-
A: Coronal view of virtual insertion expansion; blue, post-expansion.
B: Axial view of virtual insertion.
References:
 Cone beam computed tomography - oral and maxillofacial diagnosis and
applications
 Cone Beam Computed Tomography in Orthodontics Indications, Insights, and
Innovations, 1ed (2014)

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CBCT Third eye in

"Imaging is a critically important aspect of diagnostics and

"High-quality, accurate images collected at the presurgical stage can

Does Traditionaland CT Radiographic Methods Ideal?

"Traditional radiographic methods are not ideal for planning

"because you are visualizing a three dimensional (3D) object in two

"The development of computed tomography (CT) allowed clinicians to take

“The principle of CBCT is based on a:”

• “fixed x-ray source and detector with a rotating gantry.”

A: Difference between Cone –Beam and Fan-Beam Geometry

B: Procedure of Image acquisition in CBCT

"A multiplanar display panel of

"Diagnostic treatment Imaging Of Implant Dentistry Requires:"

I-IMAGING FOR PREOPERATIVE IMPLANT TREATMENT PLANNING

"A-A comprehensive evaluation of the oral cavity begins with"

"Dentalhard and soft tissue clinical examination"

"Followed by conventional imaging such as two dimensional imaging

"Followed by cross-sectionalimaging using MDCT or CBCT"

"3. Presence of any underlying disease that could compromise the

"4. Presence of any buried teeth or retained roots"

"6. Quality (density) of bone"

"Characteristics of Ideal Imaging Techniques in Implants:"

"1. Ability to visualize the site of implant site in the mesiodistal,

"2. ability to determine axial orientation of implants"

"3. ability to allow reliable, accurate measurements"

"4. capacity to evaluate trabecular bone density and cortical thickness"

"6. reasonable access and cost to the patient"

"7. minimal radiation risk Preoperative Radiographic Assessment"

Prominent nasopalatine canal.

Implant planning using cross-sectional imaging.

Pronounced atrophy in region 45 to 46. As the bone structure is markedly

CBCT is Ideal to detect the important landmarks in the

In the zygomatic region:

"The benefit must outweigh the potential risk."

The planning may include:

"History or suspected trauma

Planing Of Implant insertion in the maxilla in a case of agenesis of tooth

"The resection of a bone tumor or bone invading tumor can be planned

"The shape of the graft can also be planned virtually."

There are generally two ways to prepare the defect.

Evaluation of the surgery CBCT scans provides the possibility of

The CBCT scan shows all dimensions of the reconstruction outcome

Figure 18.12 3D superimposition of pre-treatment

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