International Medical Journal Vol. 20, No. 3, pp.

355 - 358 , June 2013 DENTAL SCIENCES

355

Validity of Cone Beam Computed Tomography (CBCT) on Estimation of Implant Fixture Length

Liyana Izzati binti Mohamad Amin, Shaifulizan Ab Rahman, Mohammad Khursheed Alam, Firdaus Daud
ABSTRACT
Objective: To study the validity of cone beam dental image in terms of distortion by using clinically placed implant on patient. Methods: A total of 47 cone beam dental images of implants taken between the year 2010 to 2011, were examined. The implant fixtures lengths were measured using Planmeca RomexisTM Software 2.3.1.R, which is a product of Planmeca Oy, Finland. Every measurement was then repeated three times and the mean was obtained. The discrepancies between the radiographic estimated length and actual length of implant fixture were calculated. Differences in measurements were analyzed using paired t-test. The intraclass correlation was used to determine the correlation. Results: The measurement error was found to range from -1.64 mm to 0.64 mm (4.61% to 1.86%). The errors were minor and only 1 value exceeded 1 mm. The average measurement error was 0.35 mm. Paired T-test showed no significant difference (p < 0.05) between implant fixtures length measured in CBCT and the actual size of implant fixtures length. Conclusion: There is no significant difference between implant fixtures length seen in CBCT and the actual implant fixtures length. Cone beam dental image has proven to be a reliable diagnostic tool in assessment and estimation of implant fixture length.

KEY WORDS
cone beam computed tomography (CBCT), implant, fixtures length

INTRODUCTION
Conebeam CT (CBCT) is an advancement in CT imaging that has begun to emerge as a potentially low-dose crosssectional technique for visualizing bony structures in the head and neck. This advanced cross-sectional imaging techniques are used in dentomaxillofacial imaging to solve complex diagnostic and treatment-planning problems, such as those encountered in craniofacial fractures, endosseous dental-implant planning, and orthodontics, among others. With the advent of CBCT technology, cross-sectional imaging that had previously been outsourced to medical CT scanners has begun to take place in dental offices. Early dedicated CBCT scanners for dental use were characterized by Mozzo et al1) and Arai et al2) in the late 1990s. Since then, more commercial models have become available, inciting research in many fields of dentistry and oral and maxillofacial surgery. To date, multiple ex vivo studies have attempted to establish the ability of CBCT images to accurately reproduce the geometric dimensions of the maxillodental structures and the mandible3-6). Practitioners have begun using office-based CBCT scanners in preoperative imaging for implant procedures, capitalizing on availability and low dosing requirements. A review by Guerrero et al.7)
Receive d on June 8, 2012 and accepted on September 20, 2012 School of Dental Sciences, Health Campus, Universiti Sains Malaysia Correspondence to: Shaifulizan Ab Rahman (e-mail: shaifulrahman@lycos.com)

outlines the clinical and technical aspects of CBCT, which have popularized this new technique. Preliminary evidence addresses the ability of CBCT images to characterize mandibular and alveolar bone morphology, as well as to visualize the maxillary sinuses, incisive canal, mandibular canal, and mental foramina, all structures particularly important in surgical planning for dental implantation 8-10) . Several studies have described the 3D geometric accuracy of CBCT imaging in the maxillodental and mandibular regions as well3-6). It is well known that three-dimensional(3D) computed tomography (CT) scan-based pictures allow for a more reliable planning than when only 2D data are available, Jacobs et al.11). CT is a fast and convenient imaging method for obtaining data useful in implant surgery. Advances in CT software have led to the availability of programs that will yield axial, oblique, and panoramic reformations of the jaws12-14). Many authors believed that CT images were the most accurate technique for implantation site diagnosis for pre-surgical assessment15-18). The American Academy of Oral and Maxillofacial Radiology (AAOMR) 19) also recommended CT tomography for implant site assessment, including precise measurement of distances in three dimensions. However, to date, CBCT has never been validated in terms of its reliability and accuracy in assessing implant fixtures lengths. The purpose of this study was to determine the validity of CBCT in terms

C 2013 Japan International Cultural Exchange Foundation & Japan Health Sciences University

356
Table 1. Specification of CBCT used in Dental clinic, HUSM20)
Scanner Name Manufacturer Promax 3D Plenmeca Oy, Finland Detector Type Maximum detector size Voxel Size Scan Time Exposure Time Effective dose Reconstruction time kV mA Focal spot Weight FDP 8.0 x 8.0 cm 0.16 mm3 16-18 seconds 6 seconds 45 v < 3.0 minutes 84 12.0 0.5 248 Ib 47

Mohamad Amin L. I. et al.

Table 2. The mean of each measurement. Only small differences were found when comparing the CBCT measurement with the actual length
Total sample Mean (mm) Length on the CBCT, (avg) (avg) 10.1993 10.1277 0.07 Actual Length, La Mean differences (Mean Lc (avg) - mean La)

Table 3. Comparison of measurement of implant fixtures length in the CBCT with the actual length of the implant fixture
Paired Samples Test Paired Differences Mean Std. Deviation Std. Error Mean Pair 1 CBCT Actual 0.0716 0.4463 0.0651 95% Confidence Interval Lower -0.0594 Upper 0.2027 1.100 46 0.277 t df P-value

Figure 1. The CBCT image of one of the patient who had done multiple implants in his oral cavity view in Romexis 2.1.3.R software. There are 3 main planes; A: coronal, B: sagittal and C: axial which are used for assessment and measurement. The 3D image (D) is basically use to have general view of patient's oral cavity.

of distortion by using clinically placed implant on patient. The hypothesis was that there are no significant difference between the placed implant length seen in the cone beam dental image and actual inserted implant length.

MATERILAS AND METHODS

Cone beam dental images (CBCTs) of 11 patients who had 2 to 11 implants in their oral cavity were examined. The CBCTs that were used in this study are those performed between the year 2010 to 2011 which were available in the radiology department of Dental clinic of Universiti Sains Malaysia and some were from those who turned up for CBCT scan in review session. The details of CBCT scanner used

Validity of CBCT
in this study are described in the Table 1. The CBCT scans were saved into Romexis 2.3.1.R. and the implant fixture lengths were measured using Romexis software operating with computer (DX2810 Microtower PC, HP Compaq, US) and 17-inch monitor screen (LE1711 LCD monitor, HP Compaq, US)20). The measurements were done in dim light condition. Two trials (2 separate orientations) were also done for each CBCT images. The orientation of each tooth involved a 4-step process. 1. The coronal, sagittal, and axial planes were adjusted to intersect in the fixture of the implant. 2. By using axial view, the sagittal and coronal planes were moved to intersect in the center of the tooth. After establishing this axis of rotation (intersection point), the axial view was rotated so that the sagittal plane passed through the most mesial and distal aspects of the radiopacity of the implant fixture (Fig 1). 3. By using the coronal view, the sagittal and axial planes were moved and the coronal view was then rotated in order to get the clearest image of the implant fixture for the measurement. 4. The sagittal plane was adjusted until the clear image of implant fixture was visible in the sagittal view. The radiopacity of the implant fixture allowed the measurement to be done where the length of the implant fixture was taken from the collar of the implant fixture to the apical tip of the implant fixture using the ruler function available in the software. The collar of the implant fixture was connected to the abutment anatomically and both fixture and abutment were radiopaque. Thus, the junction between both fixture and abutment was used as reference point for the measurement. Three measurements were made for each implant and the result was recorded.

357

ference (p = 0.277) as shown in Table 3. The mean difference was 0.07 mm. The 95% confidence interval lies between -0.0594 and 0.2027 which includes zero, as well as the P value is greater than 0.05. This concludes that the difference is not statistically significant. Intra-class correlations (ICC) for the measurement of CBCT and the actual length were high. The Pearson correlation is impressive, r = 0.961. The Spearman rho is 0.936 and Kendall's tau is 0.828. The correlation is significant at p value = 0.01. In conclusion, the ICC of 0.961 indicates that measurement of implant fixtures length using CBCT with the actual length have a very high agreement. They are almost the same.

DISCUSSION
A vast amount of radiographic imaging21) associated with dental implants is used for diagnosis of the recipient site. Ideally, this will allow assessment in terms of quality and amount of bone, location of anatomical structures, and longitudinal morphological change through bone loss along the implant surface as well as the anatomy of implant itself including the abutment and fixtures length. Cone Beam CT was first introduced in the imaging of the dental and maxillofacial region in 1997. CBCT is a useful tool for imaging the craniofacial area that produces more realistic images that facilitate interpretation. All the previous conventional and digital intraoral and extraoral procedures, as they were two dimensional (2D) projections, suffer from several limitations. These limitations were magnification, distortion, superimposition and misrepresentation of structures. CBCT has achieved a transition of dental imaging from 2D to 3D images. Moreover, the application of sophisticated software, contribute to the reestablishment of imaging sciences role. Now dentomaxillofacial radiology has been expanding from the diagnosis field to image guidance of operative and surgical procedures. As a consequence the treatment outcome is enhanced22-26). Our goal in this study was to determine the validity of CBCT by determining the distortion in the images of clinically placed implant on patient. The actual length of implant fixture was used as the gold standard for comparison. The distortion of CBCT images is still unavoidable. The absolute differences between the CBCT measurements and the actual length of implant fixtures length was 0.07 mm. The measurements differed from the actual measurements by less than 0.1 mm; this was determined to be clinically insignificant in most situations. In terms of measurement error, 0.35 mm is found to be the average error in this study. The error is acceptable in clinical setting because previous study stated that the measurement error should be less than 1 mm on images for implant treatment. Thus, CBCT appears to be a more accurate tool for distance measurement with regards to implant planning 27). However, data analysis showed a tendency for the CBCT measurements to slightly underestimate the gold standard. These findings were similar to those of Lascala et al.28) who showed that CBCT measurements for internal and external cranial anatomic sites tend to be slightly smaller than the same measurements made with calipers directly on the skulls29) found no statistical difference between the measurements from the CBCT images and the anatomic truth. Unfortunately, 64% of the measurements tend to magnify the gold standard. This result may unreliable since various previous studies showed almost no magnification of images occurred in CBCT images 30,31). The magnification distortion may misinterpret by the error in measurement. Errors can be made during orientation, image acquisition, and landmark identification. Since the method of measurement using several orientations and angulations, the errors are likely to happen when the measurement is made in angulation position. The measurement will tend to lengthen rather than shorten. The landmark identification is also subjective. Implant fixture is connected with the abutment of implant anatomically and both implant fixture and the abutment are radiopaque in the image. Thus, the junction between both is use as reference point; but still there is no fix point to use during the measurement to make sure that the measurement is perfectly accurate. In order to overcome these random errors, the mean or average of the measurements should be obtained. Individual measurements can have fairly large errors, but the mean of many such measurements will tend to fall close to the true value. The more measurements taken, the closer the mean will be to the true value.

STATISTICAL ANALYSIS
These analyses were carried out with the statistical package (PASW Statistics 18), with a probability level of 0.05 considered statistically significant. All the data from the sample were checked using the Kolmogorov-Smirnoz Test to see whether they followed a normal distribution. The significant for each variable analyzed being then obtained. The data obtained showed that the variables followed a normal distribution with significant value of 0.243. The correlation between variables was determined using Pearson's correlation coefficient. In order to consider that both measuring methods are comparable, the correlation coefficients must be high. This ensures that there are no systematic differences in the measurements and that an increase in the size of the object measured would represent the same increase in the measuring methods. The discrepancy was calculated as the differences between the mean values of the CBCT measurement compared to the mean value of the actual measurement. To discover the intra-observer error of the measurements taken by CBCT, all the measurement were repeated three times by the same observer. To assess measurement accuracy, systematic differences within and between trials were assessed. Measurements were averaged for all the trials. Systematic differences between actual and CBCT measurements were also evaluated. The mean differences and standard deviations of the differences were described; differences were statistically tested with paired t tests. Statistically significance was set at P < 0.05.

RESULTS
The measurement error was found to range from -1.64 mm to 0.64 mm (4.61% to 1.86%) compared with actual measurement. 64% of the images tends to be magnified the implant fixture length whereas 36% of the images tend to underestimate the length. The measurement errors were not large and only 1 value exceeded 1 mm. The average measurement error was 0.35 mm. When comparing the measurement of implant fixtures length in the CBCT with the actual length of the implant fixture placed in patient's oral cavity using paired T-test, it showed no significant dif-

358

Mohamad Amin L. I. et al.

ments made with software on cone-beam computed tomography images. Am J Orthod Dentofacial Orthop 2008; 134: 112-16. Kumar V, Ludlow JB, Mol A, et al. Comparison of conventional and cone beam CT synthesized cephalograms. Dentomaxillofac Radiol 2007; 36: 263-69. Guerrero ME, Jacobs R, Loubele M, et al. State-of-the-art on cone beam CT imaging for pre-operative planning of implant placement. Clin Oral Investig 2006; 10: 1-7. Lothag-Hansen S, Grndahl K, Ekestubbe A. Cone-beam CT for preoperative implant planning in the posterior mandible: visibility of anatomic landmarks. Clin Implant Dent Relat Res 2008. Ito K, Gomi Y, Sato S, et al. Clinical application of a new compact CT system to assess 3-D images for the preoperative treatment planning of implants in the posterior mandible: a case report. Clin Oral Implants Res 2001; 12: 539-42. Sato S, Arai Y, Shinoda K, et al. Clinical application of a new cone-beam computerized tomography system to assess multiple two-dimensional images for the preoperative treatment planning of maxillary implants: case reports. Quintessence Int 2004; 35: 525-28. Jacobs R, Adriansens A, Verstreken K, Suetens P, van Steenberghe D. Predictability of a three-dimensional planning system for oral implant surgery. Dentomaxillofac Radiol 1999; 28: 105-111. Schwarz MS, Rothman SL, Rhodes ML, Chaftez N. Computed tomography: part I. Preoperative assessment of the mandible for the endosseous implant surgery. Int J Oral Maxillofac Implants 1987; 2: 137-42 Schwarz MS, Rothman SL, Rhodes ML, Chaftez N. Computed tomography: part II. Preoperative assessment of the maxilla for the endosseous implant surgery. Int J Oral Maxillofac Implants 1987; 2: 143-8. Rothman SLG, Chaftez N, Rhodes ML, Schwartz MS. CT in the preoperative assessment of the mandible and maxilla for endosseous implant surgery. Radiology 1988; 168: 171-5. Hanazawa T, Sano T, Seki K, Okano T. Radiologic measurements of the mandible: a comparison between CT-reformatted and conventional tomographic images. Clin Oral Impl Res 2004; 15: 226-232. Miller C, Nummikoski PV, Barnett D. Cross-sectional tomography. Oral Surg Oral Med Oral Pathol 1990; 70: 791-797. Petrikowski C, Phoroah M, Schmitt A. Presurgical radiographic assessment for Implants. J Prosthet Dent 1989; 61: 59-64. Reddy MS, Mayfield-Donahoo T, Vanderven FJJ, Jeffcoat MK. A comparison of the diagnostic advantages of panoramic radiography and computed tomography scanning for placement of root form dental implants. Clin Oral Impl Res 1994; 5: 229-238. 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: 630-637. Rahman SA, Yue CP, Alam MK. The measurement of effective dose absorption by thyroid tissue during cone beam computed tomography (CBCT). International Medical Journal, 2013; 20(2): 172-175. Purmal K, Alam MK, Nambiar P. Patients' perception on dental radiographs. International Medical Journal. 2013; 20(2): 235-238. Calhoun PS, Kuszyk BS, David G. Heath DG, et al. Three-dimensional volume rendering of spiral CT data: theory and method. Radiographics 1999; 19: 745-764. Scarfe WC, Farman AG, Sukovic P. Clinical applications of cone-beam computed tomography in dental practice. J Can Dent Assoc 2006; 72(1): 75-80. Scarfe WC, Farman AG. Voxel vision using maxillofacial CBCT: clinical applications of the maximum intensity projection http://www.aadmrt.com/currents/scarfe_ farman_summer_07_print.htm (Retrieved August 2009). Scarfe W.C, Farman AG. Cone beam computed tomography: a paradigm shift for clinical dentistry. Aust Dent Pract July/August 2007: 102-110. Boeddinghaus R, Whyte A. Current concepts in maxillofacial imaging. Eur J Radiol 2008; 66: 396-418. Al-Ekrish AA, Ekram M. A comparative study of the accuracy and reliability of multidetector computed tomography and cone beam computed tomography in the assessment of dental implant site dimension. Dentomaxillofac Radiol 2011; 40: 67-75. Lascala CA, Panella J, Marques MM. Analysis of the accuracy of linear measurements obtained by cone beam computed tomography (CBCT-NewTom). Dentomaxillofac Radiol 2004; 33: 291-4. Hilgers ML, Scarfe WC, Scheetz JP, Farman AG. Accuracy of linear temporomandibular joint measurements with cone beam computed tomography and digital cephalometric radiography. Am J Orthod Dentofacial Orthop 2005; 128: 803-11. Serman NJ. Pitfalls of panoramic radiology in implant surgery. Ann Dent 1989; 48: 13-16. Yim JH, Ryu DM, Lee BS, Kwon YD. Analysis of digitalized panorama and cone beam computed tomographic image distortion for the diagnosis of dental implant surgery. J Craniofac Surg 2011; 22(2): 669-73. Taptagaporn, Saito. Visual comfort in vdt operation: physiology resting states of the eye. Ind Health 1993; 31(1): 13-28. Sebastian BJ, Martin P, Leena P, Mark G. Hans. Reliability and accuracy of the conebeam computed tomography dental measurements Am J Orthod Dentofacial Orthop 2009; 136: 19-2. Manuel AO, Lagravre JC, Roger WT, Paul WM. Three-dimensional accuracy of measurements made with software on cone-beam computed tomography images. Am J Orthod Dentofacial Orthop 2008; 134: 112-16.

Another possible source of distortion of digital images is the viewing condition and operator factors. Any scarcity in viewing condition can leads to misinterpretation of the landmark identification. This indirectly leads to operator associated distortion when using software to measure digital images. The best way to perform diagnosis of a digital image on screen is in a darkened glare-free environment, with a downward gaze, an appropriate image blackening and contrast, and a viewing distance between 50 and 70 cm32). It should be noted that the efficacy of the operator to adjust the blackening and contrast of the images will determine the degree of distortion. This is the limitation of this study as only one operator was involved in the experiment. But, attempt was done to improve intrapersonal reliability by repeating the measurements for 3 times with interval of 3 days in between each measurement. However, in practice, CBCT is still the best radiographic method in measuring and as diagnostic tool in implantology. Dental measurements from CBCT volumes can be used for quantitative analysis. As in this study, it was proven that almost no different between the measurement in the CBCT images and the actual size of implant fixture length. However, with the CBCT images, a small systematic error were found, which became statistically significant only when it is used to combine several measurements. An adjustment for this error allows for improved accuracy33). CBCT is also able to produce 1-to-1 image-to-reality ratio. The verification of this 1-to-1 ratio to reality has greater opportunities for qualitative analysis of craniofacial structures as well as diagnostic purposes34). In addition, 3D image of CBCT provides most informative image in terms of anatomical structure on a patient's mouth, face and jaws areas, leading to enhanced treatment planning and predictable treatment outcomes. This includes the estimation of implant fixture length that will be placed clinically. It is very difficult for two-dimensional intra-oral and extra-oral images to precisely replicate the anatomy captured on their receptors. Two-dimensional images inherently exhibit magnification, distortion, and overlap of anatomy. Therefore, measuring or determining anatomical relationships will not be accurate. CBCT captures a volume of data and through a reconstruction process, delivers images that do not contain magnification, distortion, and overlap of anatomy. Measurements and anatomical relationships are therefore precise and provide practitioners a clear insight into patient hard tissue relationships. Therefore, the implant fixture length can be estimate accurately. In terms of error that was found in this study, it can be ignored since it was less than 1 mm because in practice, the applicable measurement used was 1 mm. Plus, the sizes of implant fixture available provided by the manufacturer are different by either 1 or 2 mm and it is fixed. Thus, the anatomical length that measured in CBCT images can be use as guidance in estimating the best and suitable implant fixture size that will be placed in the treatment.

6) 7) 8)

9)

10)

11)

12)

13)

14)

15)

16) 17) 18)

19)

20)

21) 22) 23) 24)

CONCLUSIONS
25)

This study found that, there is no significant difference between implant fixtures length seen in CBCT and the actual implant fixtures length. Therefore, cone beam dental image has proven to be a reliable diagnostic tool in assessment and estimation of implant fixture length since the error was found to be less then 1 mm which is clinically acceptable.

26) 27)

28)

REFERENCES
1) Mozzo P, Procacci C, Tacconi A, et al . A new volumetric CT machine for dental imagine based on the cone-beam technique: preliminary results. Eur Radiol 1998; 8: 1558-64. 2) Arai Y, Tammisalo E, Iwai K, et al. Development of a compact computed tomographic apparatus for dental use. Dentomaxillofac Radiol 1999; 28: 245-48. 3) Lascala CA, Panella J, Marques MM. Analysis of the accuracy of linear measurements obtained by cone beam computed tomography (CBCT-NewTom). Dentomaxillofac Radiol 2004; 33: 291-94. 4) Mischkowski RA, Pulsfort R, Ritter L, et al. Geometric accuracy of a newly developed cone-beam device for maxillofacial imaging. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 104: 551-59. 5) Lagrave`re MO, Carey J, Toogood RW, et al. Three-dimensional accuracy of measure-

29)

30) 31)

32) 33)

34)