Preoperative radiologic planning

of implant surgery in
compromised patients
Reinhilde Jacobs
Theosseointegrationtechniqueinsures long-termsur-
vival of endosseous implants and makes it possible to
maintaina stablemarginal bone level. Thepredictabil-
ity of this methodology canbe jeopardizedby unfavor-
able quality or quantity of the jawbone hosting the
implants. It is preferable to select locations with
enough cortical and cancellous bone to insure good
primary stability. Poor xation may lead to micro-
movements during implant healing, potentially caus-
ingbrous encapsulation. Implants inthemaxillaor in
poor quality bone (lack of corticalization, poor trabe-
cular bone mineralization and rests of pathological
processes) are associated with higher failure rates.
A thorough radiographic examination may provide
information about the height and width of the bone,
degree of corticalization, density of mineralizationand
amount of cancellous bone in the areas considered.
Such planning can become a necessity in compro-
misedpatients andmay inuence treatment planning.
It denitely helps to select the implants on the basis of
dimensions, location, orientation and the number of
implants to be placed. If bone characteristics seem
unsuitable after thorough radiographic assessment,
alternative rehabilitation, without the use of implants,
may even be favored. The availability today of elabo-
rate three-dimensional (3D) planning software, which
allows a reliable transfer to the surgical eld, increases
possibilities for a reliable transfer to the surgical eld
and helps the clinician to place implants even in such
borderline cases (72, 73).
Techniques for oral implant
planning
A variety of imaging modalities is presently avail-
able for preoperative planning purposes. Each of
these techniques has its own strengths and weak-
nesses, offering a certain amount of information at
a particular cost and radiation dose (for review, see
17, 33). Technique selection should be based on
weighing the required image quality against the
risks and costs involved (Table 1) (36). In the case
of a compromised host bone, surgery is more
demanding and the amount of information needed
is increased. The latter usually justies the choice
of more elaborate and specic imaging techniques,
balancing benets and risks. The application of
cross-sectional imaging techniques in this perspec-
tive has received a lot of attention in the literature.
Correct identication of the mandibular canal is of
vital importance (33). The potential risk of inferior
alveolar nerve injury during implant surgery is pro-
minent. Visualization of other anatomic structures,
such as the maxillary sinus or the nasal fossae, has
received less attention in the literature since violating
these structures does not result in serious side effects
(11). There is evidence that even in the anterior parts
of the upper and lower jaw, jaw morphology and
variations in anatomic structures may impinge on
implant placement (37). A typical example is the
nasopalatine canal, where insertion of implants in
the immediate vicinity is associated with higher fail-
ure rates (57). Contact of the implant surface with the
contents of the canal (fat) may prevent osseointegra-
tion or lead to sensory dysfunction. Furthermore,
nasopalatine duct cysts occur in about 1% of the
population and should be recognized and treated
prior to implant surgery (Fig. 1) (53). In the mand-
ible, the occurrence of unfavorable buccolingual
morphology or the presence of a well-dened inci-
sive canal may present other challenges (37, 56).
Cross-sectional imaging may also be required in
anterior jawbone areas.
12
Periodontology 2000, Vol. 33, 2003, 1225 Copyright
#
Blackwell Munksgaard 2003
Printed in Denmark. All rights reserved
PERIODONTOLOGY 2000
ISSN 0906-6713
Cross-sectional images may be obtained by spiral
tomography or spiral computed tomography (see
Table 1). The latter obviously gives more information
and possibilities at the expense of some increase in
radiation dose and cost. Nevertheless, whenever
dealing with compromised jawbones, selection of
three-dimensional CT-based imaging seems justied.
This allows using dedicated software for accurate
Table 1. Strategies for preoperative planning and intraoperative transfer of implant placement in the compromised
jawbone. Cross-sectional imaging is advocated in these cases. The extend of the area and complexity of the surgery
should determine the choice of the planning technique. In compromised jawbone, three-dimensional CT based
planning may often prevail. Such planning data could then be accurately transferred using computer-based
navigation or stereolithographic drill guides.
Preoperative radiologic planning of implant surgery
13
three-dimensional modeling, interactivethree-dimen-
sional based planning and simulation of implant
surgery (72, 73). Different planning tools are avail-
able, although clinical validation and assessment of
the in vivo accuracy and reliability remain poorly
documented in the literature (34, 35). Particular
planning tools have also been developed for more
complex surgical procedures (e.g. zygoma implants,
grafting procedures, distraction osteogenesis, barrier
membrane modeling) (70, 71, 62).
Intraoral radiography
Intraoral radiography allows evaluation of the jaw-
bone and the remaining dentition in two dimensions.
In patients with advanced periodontitis, this offers
key information on the prognosis of the remaining
dentition. The paralleling technique with position-
ing instruments should be used to enable a reliable
projection of the anatomic structures on plain views.
Good quality intraoral radiographs help to reveal
Fig. 1. Dental CT
1
scan images of
the edentulous maxilla of a 44-years
old male clearly visualising a large
radiolucency in the anterior maxilla
on the axial, panoramic and cross-
sectional images. (A) Uponinspection
of the axial images, the radiolucent
lesion has a paramedian location at
the region of the nasopalatine canal
(black ball). The horizontal sections
show a round monolocular shape,
with a diameter of approximately
10 mm and a smooth, well-dened
outline. Note that the right maxillary
sinus mucosa appears thickened. (B)
The panoramic view conrms the
presence of the paramedian radiolu-
cency (cross-sectional slices n8 19-
26), vertically extending from the
nasal oor to the palate. The thick-
ened mucosa of the right maxillary
sinus is also visualized. (C) Refor-
matted cross-sectional images in
this region illustrate the horizontal
and vertical extension of the lesion
at the location of the nasopalatine
canal (black arrow).
14
Jacobs
minute pathologic changes of the periodon-
tium and the teeth, which can interfere with implant
placement. For the edentulous and resorbed jaw-
bone, however, this technique can be difcult to
use because of the inability to nd adequate support
for the positioning instrument. Attaching lm
holders to the tube, while carefully positioning the
jawbone under investigation parallel to the lm,
may offer a solution. Alternatively, a positioning
device connected to the implants has been pro-
posed to guarantee parallelism between lm and
implant (49).
Even with the most stringent methodology, this
technique remains suboptimal for preoperative plan-
ning in severely resorbed jawbones. Additional cross-
sectional imaging may be justied to obtain reliable
information on buccolingual bone volume and mor-
phology and the precise location of anatomic land-
marks.
Occlusal radiography
Occlusal radiography is sometimes applied to
evaluate the shape and outer width of the mandi-
ble. Nevertheless, the usefulness of such images
remains limited. Vertical bone height and bone
morphology cannot be assessed, and two-dimen-
sional image formation will mask particular as-
pects of bone morphology (such as fossae and
concavities).
True cephalometric lateral skull view
Related to preoperative planning of implant place-
ment, the lateral skull view only offers information
regarding buccolingual bone morphology in the
mandibular symphyseal area. Proper collimation
is needed to reduce the radiation dose and limit
the exposure to the area of the jawbone under con-
sideration. Tangential views may offer an alterna-
tive chairside method when extraoral equipment is
not available (60). To obtain such an image, an
occlusal lm can be placed laterally in a vertical
position at the level of the symphyseal area. It is
important to note that the information gathered is
not very accurate and not always clinically relevant
because of the two-dimensional overlap in the
image. When planning placement of mandibular
implants lateral to the strict sagittal plane, one
should be aware that anatomic concavities may
reduce the locally available bone volume dramati-
cally.
Panoramic radiography
This technique has become an important diagnostic
tool in daily clinical practice. A wide choice of both
conventional and digital systems is available. For
preoperative planning purposes, panoramic radio-
graphy allows visualization of critical anatomic
structures with a broader coverage than intraoral
radiographs. Optimal patient positioning is crucial
in this respect because jaw positioning errors in the
sagittal plane can occur quite easily, especially in the
edentulous patient. It may be helpful to use a stent or
template with radio-opaque markers, which give
some idea of local positioning errors or magnica-
tions. Even with proper positioning, another aspect
should be considered. The radiographic beam is
usually directed 788 upwards, which implies that
the true relationship between anatomic structures
may be altered on such view. Additionally, it is a
two-dimensional image, lacking information on
bone width. Panoramic radiography is often consid-
ered suitable for preoperative planning of implant
placement in the mandibular interforaminal area.
This area is regarded as a safe surgical site, usually
offering enough bone volume without the danger of
damaging a neurovascular bundle. Nevertheless,
there is increasing evidence that in a number of cases
the sole choice of this technique for preoperative
planning in the mandibular interforaminal area
may not be justied. Firstly, the presence of a true
incisive canal in this jawbone has been conrmed in
more than 90% of jawbones (Fig. 2) (37). Secondly,
the morphology of the jawbone in this area may also
show important variations, some of which can render
implant placement hazardous (Fig. 3) (56). In the
compromised jawbone, this technique should be
considered insufcient. The fact that the bone is
compromised from a quality and/or quantity point
of view dictates that additional imaging in a two- and
three-dimensional environment should be per-
formed. It should be realized that a surgeon works
in a three-dimensional environment, while the radio-
graphic information relating to the anatomic struc-
tures is usually only provided in a two-dimensional
mode. When risks and doubts about treatment out-
come are raised, three-dimensional information may
become necessary.
Conventional tomography
With cross-sectional imaging it is possible to supple-
ment the two-dimensional nature of the aforemen-
tioned radiographs. Conventional tomography offers
15
Preoperative radiologic planning of implant surgery
information on the buccolingual aspect of the bone
at potential implant sites. The location of anatomic
structures, such as the mandibular canal, and the
bone width can easily be determined.
In the last two decades, conventional tomographic
machines have been introduced in oral health care.
Some extraoral X-ray equipment may also offer pos-
sibilities for cross-sectional imaging. The tomo-
graphic principle is based on sharply visualizing
structures in the focal plane, while blurring all other
structures. This is achieved by working with different
tomographic movements: linear, circular, spiral,
elliptical and hypocycloidal. Complex tomographic
movements (e.g. spiral and hypocycloidal) are the
most widely used.
As for all the aforementioned techniques, reliable
image interpretation can only be achieved with an
optimal projection geometry. Patient positioning is a
critical factor and should allow perpendicular projec-
tion of the X-ray beam through the bone at the
potential implant site. Dental splints with radiopa-
que markers aid localization in both buccolingual
and vertical dimensions, which optimizes the
esthetic and biomechanical aspects in the preopera-
tive plan. Digital tomographic images offer increased
image quality by contrast enhancement, reduction of
blurring and image manipulation. Further image
processing may yield precise information on bone
volume and (relative) bone density and help to simu-
late implant surgery by visualizing the planned
implant in relation to the anatomic structures.
For radiographic visualization of the mandibular
canal, cross-sectional imaging provides the best
information. When comparing computed to conven-
tional tomography (hypocycloidal and spiral) for
measuring distances to the canal, CT does not seem
more accurate (45). Spiral tomography performs bet-
ter than hypocycloidal tomography as the borders of
the canal are better identied with the former tech-
nique (46). The greatest inaccuracy is found when
using panoramic images (44, 46). For preoperative
implant planning, spiral tomography seems recom-
mended, because this technique offers an accurate
and reliable method to visualize the jawbone and the
related anatomic structures in the buccolingual
aspect (6, 9). It also leads to less radiation dose than
spiral computer tomography in restricted edentulous
areas (7, 8). It is worth mentioning that dose values
for spiral tomography with the Cranex Tome
1
(Sor-
edex, Helsinki, Finland) are generally 5060 % lower
than with the Scanora
1
(Soredex), reaching effective
dose levels in the rst molar region of 0.06 mSv ver-
sus 0.12 mSv in the mandible and 0.04 mSv versus
0.08 mSv in the maxilla (18).
When the jawbone to be implanted is a restricted
area being compromised with regard to bone quality,
quantity or both, spiral tomography may be the pre-
ferred planning tool keeping the ratio dose-cost/
benet balanced (see Table 2). For more extended
areas of compromised jawbone or in very complex
situations, working in a true three-dimensional
image planning environment is justied (33).
Fig. 2. The presence of a true incisive canal, as a continua-
tion of the mandibular canal in the anterior jawbone, can
be clearly seen on both panoramic (A) and spiral tomo-
graphic (B) images taken from a 66-year-old edentulous
female patient with a severely resorbed mandible.
Fig. 3. Even with sufcient bone height, the presence of a
unfavorable buccolingual bone morphology, as visualized
on spiral tomographic images, may jeopardize implant
placement.
16
Jacobs
Computed tomography
Nowadays computed tomography is generally per-
formed by spiral CT. This technique could be distin-
guished from incremental (conventional) CT, consisting
of successive scanning of single axial slices. Spiral
(helical) CT is a more recent technology, in which
the patient undergoes translation simultaneously with
rotation of the X-ray source, allowing a continuous
information stream during volume scanning. Spiral
CT offers reduced scanning time, improved accuracy,
superior lesion detection and optimized three-dimen-
sional reconstructions. Axial scanning of the jawbone
requires further reformatting to enable visualization
of reliable cross-sectional images. Dedicated soft-
ware has been developed for oral and maxillofacial
applications (e.g. Dental CT
1
, Siemens Erlangen
Germany; Denta Scan
1
, ISG Technologies, Missisau-
gua, Ontario, Canada), to avoid problems related to
orofacial imaging and create more standardized
images of the jawbone. More recently, CT hardware
has also been developed for particular applications in
dentomaxillofacial imaging. Such techniques are
aimed to offer the advantages of three-dimensional
imaging on one hand at a reasonably lower cost and
dose than spiral CT. These techniques require further
clinical validation to demonstrate their usefulness,
strengths and weaknesses (1, 51). No matter what
kind of software or hardware is applied, the use of
scanning templates with radio-opaque markers is
denitely recommended during the scanning proce-
dure, to enable better orientation of the potential
implant site and axis.
Three-dimensional CT-based planning
CT scan data contain information from three dimen-
sions, enabling visualization of the surgical site in
a three-dimensional environment; fabrication of
stereolithographic three-dimensional models may
be worthwhile (70, 71, 72, 73). Especially with the
introduction of spiral CT, possibilities for three-
dimensional modeling have increased dramatically.
The latter is certainly important when dealing with
highly resorbed jawbones or unfavorable bone mor-
phology. Precise planning expands the indications
for oral implant based treatments. Different software
for preoperative planning purposes is usually avail-
able to enable simulating implant surgery in a two-
dimensional or a combined two/three-dimensional
environment. The latter evidently prevails and allows
for a better transfer to the surgical eld, especially
when integrating the optimal prosthetic model in the
three-dimensional images (35, 73). The jaws can be
seen virtually from any viewpoint on a computer
screen and the implant placement can be done inter-
actively (Fig. 4). In cases when the prosthesis is
scanned, it can be visualized together with the jaw-
bone. This allows aesthetic and biomechanical
adjustments to be made. It also eliminates the need
for further discussions on the anatomic and prosthe-
tic demands because the program looks for a com-
promise preoperative planning. It has many
indications, especially in oral implant placement or
maxillofacial surgery.
When working with such three-dimensional plan-
ning software, bone anatomy and quality assessment
might beperformedontwo-dimensional images, while
aesthetic and biomechanical adjustments might be
preferred on three-dimensional views. It is essential
that corrections in two-dimensional images automa-
tically lead to visualization of these adaptations in
three-dimensional images and vice versa (35, 73).
Incorporation of the ideal prosthetic design at this
stage is preferred to allow full integration of ana-
tomic, biomechanical and aesthetic factors.
Table 2. Dose levels of CT and spiral tomography expressed relative to the average level of background radiation or
the average dose of 1 intraoral radiograph
Region to inspect Technique
Conventional spiral tomography Spiral Computed tomography
Proposed no.
of tomographic
cuts
Equivalent
no. of
intraoral
radiographs
Equivalent
background
dose level
Jaw
scan
Equivalent no.
of intraoral
radiographs
Equivalent
background
dose level
Single 12 1040 14 days Jaw scan 300400 3040 days
Partial dentate 46 40160 416 days Jaw scan 300400 3040 days
Edentulous 28 20200 220 days Jaw scan 300400 3040 days
Extrapolated from Bou Serhal et al. (7, 8), Gijbels et al. (28) and Jacobs and Gijbels (28).
17
Preoperative radiologic planning of implant surgery
Evidently, selection of three-dimensional CT and
computer-based transfer to surgery is justied for
rehabilitation of the compromised jawbone.
Although the total radiation dose of CT scans is
higher than for conventional tomography, an
increase in the required amount of information
may be balanced against rising costs and dose
level.
More information is required whenever the risk of
damaging vital anatomic structures is increased or
whenever the chance for a successful treatment out-
come is dramatically decreased. Obviously, complex
surgical procedures such as zygomatic implant pla-
cement or grafting procedures in the highly atro-
phied jawbone may also benet from such
planning software (see Table 1) (59, 69, 70).
Extreme maxillary bone resorption may lead to a
treatment option involving the placement of
implants in the zygoma. In such cases, three-dimen-
sional CT-based planning may not only depict the
complex anatomic topography to be considered in
such cases, but also help to follow the critical bone
structures along the implant trajectory (70). For com-
plex grafting procedures, the surgical approach can
be simulated preoperatively, with accurate determi-
nation of the required graft shape and volume (69).
Three-dimensional computer-based
transfer to surgery
Once interactive implant planning has been per-
formed, another crucial issue remains transfer to
Fig. 4. With three-dimensional plann-
ing software, the jaws can be seen
virtually from any viewpoint on a
computer screen and implant place-
ment can be done interactively. (A)
Implant placement on reformatted
cross-sectional images allows check-
ing the implant on all slices. (B)
Further tuning can be performed
on three-dimensional images of the
anatomic structures. The presence
of a three-dimensional prosthetic
model enables integration of esthe-
tic, biomechanical and anatomic
factors into the preoperative plan-
ning of implant placement.
18
Jacobs
surgery. Many clinicians still opt for either mental
navigation based on the visualized implant planning
or a surgical template based on a mental transfer
from planning data. Clearly, such mental actions give
the surgeon a lot of freedom, but they inherently
increase the variability and decrease the predictabil-
ity of planning towards per-operative implant place-
ment. Especially when dealing with borderline cases
or more complex surgical procedures, it could be
recommended to avoid such variability and opt for
a computer-based transfer. Various reports have
dealt with fabrication of prosthetic and/or surgical
templates allowing transfer of the preferred location
and direction of the implants to be installed (4, 12,
50, 52). The transfer of planning data via conven-
tional template fabrication remains, however, a
source of variability and uncertainty. Predictability
of treatment outcome remains limited (34, 35).
Three-dimensional computer-assisted interactive
implant planning has opened the gate for a true
computer-based transfer to the operation eld.
Two methods for a computer-based transfer can be
used: navigation and drilling guides. Surgical naviga-
tion is applied in maxillofacial and oral implant sur-
gery (5, 7577) and has even been described for
zygoma implant placement (59). The technique
may minimize the surgical eld and increase the
accuracy of the transfer from planning to placement
of implants in the jawbone.
Alternatively, a computer-based transfer could be
performed with stereolithographic drill guides. Even
with such a computer-based approach, the transfer
from planning to surgery remains very critical. When
dealing with a three-dimensional computer-based
transfer via drill guides, a higher transfer precision
(1.18 rotation and 0.2 mm translation) could be
obtained (25) than with a conventional transfer from
two-dimensional CT images (4, 52). Bou Serhal et al.
(10) found transfer errors of below 2 mm between
three-dimensional CT-based planning and actual
implant placement by means of stereolithographic
templates in a severely resorbed mandible (Fig. 5).
In a recent study on three-dimensional CT-based
transfer with stereolithographic drill guides, van
Cleynenbreugel et al. (71) found angular deviation
usually below 38 and linear deviations mainly below
2.5 mm for zygomatic implants. Considering the
aforementioned data on navigation or drill guide
transfer, transfer errors usually remain within accep-
table clinical limits. Nevertheless, in the compro-
mised jawbone, deviations from planning during
actual implant placement may carry potential risks
of damaging vital structures.
Radiation doses and technique
selection
Whether the goal is to scan a single implant site or a
complete edentulous maxilla, CT necessitates irradia-
tion of the whole jawbone. Thus, any dose level com-
parison between CT and tomography should include
radiation dose levels for CT of the whole jawbone
(Table 1). When doses delivered from a CT scan of
the maxilla are compared to doses delivered during
multiple tomographic cuts of the entire maxillary
arch, the dose from the CT scan is relatively smaller
(7, 8, 18, 22). In limited edentulous regions, the use of
tomography with its low radiation dose is preferable
(16, 36). Attempts have been made to reduce doses.
Lowering mA settings during CT examination may
reduce doses signicantly (7, 15, 18, 23). Dose reduc-
tion by lowering mA settings may also be valid for
spiral tomography when switching from conven-
tional to digital tomographic examinations (27, 28).
Planning implant placement in the
compromised jawbone
Jawbone can be compromised by alteration in jaw-
bone quantity or quality. In the former category,
the inuence of both reduced bone volume and
unfavorable bone morphology should be consid-
ered. In the latter case, trabecular bone pattern,
cortical thickness and actual bone density should
be taken into account. Alteration to bone quality
or quantity aspects can be local or systemic and
should be considered during the preoperative plan-
ning phase.
Severely atrophic mandible
The preferred imaging modality for preoperative
implant planning in the complete edentulous mand-
ible is panoramic imaging in conjunction with a few
spiral tomographic cuts in the interforaminal region.
The latter allows not only the planning of implant
placement on two-dimensional images, but also
inspection of bone morphology, buccolingual width
and the location of the incisive canal, if present. This
canal might contain a neurovascular bundle, carry-
ing potential risks for surgical damage (29). On a few
occasions, implant placement is combined with very
complex surgical approaches, involving more than
the interforaminal region alone (e.g. grafting, orthog-
19
Preoperative radiologic planning of implant surgery
nathic surgery). At this point, the balance between
benets and risks might favor CT scanning (36).
Severely atrophic maxilla
The preferred imaging modality for the complete
edentulous maxilla is the spiral CT scan. This allows
planning of implant placement on two- and three-
dimensional images. It also enables a further transfer
of the data to dedicated software for simulation of
implant placement in a three-dimensional space.
Whenever the available bone volume is limited or
insufcient, three-dimensional planning software
may allow the planned treatment to be achieved or
other surgical procedures such as grafting to be
simulated. The required dimensions and shape of
the graft may be cautiously assessed during the pre-
operative planning procedure. Furthermore, the
principle of preoperative planning and transfer also
allows for the use of individualized titanium mem-
branes for bone augmentation rather than grafting
(62). A particular planning tool has also been devel-
oped for preoperative planning of zygoma implants
(70). A meticulous preoperative planning of zygoma
implants is essential because this type of surgery is
more complex and difcult than conventional oral
implant planning. Not only are the implants three to
four times longer than oral implants, but the implant
trajectory through the bone is more delicate. Intrao-
Fig. 5. Stereolithographic drill guides may allow a computer-
based transfer from the three-dimensional planning soft-
ware to the surgical eld. (A) Three-dimensional based
planning of implant placement in an edentulous upper
jaw, showing the position of the implants in relation to
the anatomic demands and the prosthetic requirements.
(B) Stereolithographic drill guides with metal cylinders to
guide drills with various diameters during the surgical
procedure. (C) Surgical use of the drill guides for a com-
puter-based transfer of the preoperative planning.
20
Jacobs
perative visibility remains very limited, usually
demanding the preparation of a lateral sinus wall slot
to control the direction of the implant axis relative to
the surrounding anatomic structures (63, 68). When
aided by three-dimensional planning and transfer to
implant surgery by stereolithographic drill guides
(70, 71), such sinus wall slot may no longer be
required and the predictability of the technique
may also be improved.
Compromised bone quality
Recent evidence has demonstrated a signicant rela-
tionship between systemic disease and implant fail-
ure (24, 61). All systemic factors associated with
increased implant failure should be taken into
account during preoperative treatment planning.
Poor quality bone could be the causal factor linked
to such disease. As long as teeth are present, local
factors may predominantly inuence jawbone, but in
the edentulous jawbone, systemic factors may
become more important (74).
A number of systemic diseases may carry risk fac-
tors for osteoporosis. A few examples are rheumatoid
arthritis, gastrointestinal problems (malabsorption
or chronic liver disease), hematologic problems
(e.g. multiple myeloma, leukemia, lymphoma),
endocrine diseases (e.g. hyperparathyroidism) or
drug therapy (corticoid treatment) (20). Other risk
factors for osteoporosis are gender- and age-related
factors, genetic predisposition and lifestyle (smoking,
alcohol abuse, physical inactivity) (68). Above the age
of 65, about one-third of the Western female popula-
tion suffers from osteoporosis (21). Osteoporosis is
characterized by alterations in the bone microarch-
itecture and a decrease in bone mass, resulting in an
enlarged bone fragility and increased fracture risk.
Diagnostic methods to assess poor
bone quality
Skeletal bone quality diagnosis
Assessment of the Bone Mineral Content (BMC) and
the Bone Mineral Density (BMD) seems to be essen-
tial to predict poor bone quality, osteoporosis and
potential fracture risk (21, 38), not only for diagnostic
purposes but also for monitoring osteoporotic indi-
viduals and their response to treatment. Dual photon
absorptiometry (DPA) and dual X-ray energy absorp-
tiometry (DXA) are nowadays mostly used, with a
coefcient of variation of in vivo measurements
not exceeding 3% for precision and 7% for accuracy
(74). DXAis preferredbecause it is faster, more precise,
more accurate and cheaper than the other methods.
The obtained bone density data are expressed as
units/cm
2
, length/cm
2
(DPA) or g/cm
2
(DXA) (19).
Quantitative computed tomography measures
volumetric density and results are given in g/cm
2
(2). Peripheral QCT (pQCT) permits assessment of
cancellous and cortical bone density, cancellous
microtexture and cortical width (42). Compared to
DXA, it has a good precision (13%) but a lower
accuracy (14%) (42). QCT has also been used in for
jawbone density assessment (47). The in vivo exam-
ination of bone microarchitecture by means of high
resolution computed tomography (3D-QCT) may
open new possibilities for differentiating various
types of bone loss (67).
Quantitative ultrasound (QUS) presents an alter-
native method for predicting jawbone quality (55). It
is a radiation-free, simple and cheap technique that
may provide information on bone quality. Usually,
broadband ultrasound attenuation (BUA) and speed
of sound (SOS) are measured. QUS seems to be as
good a predictor of osteoporotic fractures as BMD,
and has also been found useful in the follow-up of
patients.
Jawbone quality diagnosis
General factors may also be expressed in the dentate
jawbone, but local factors may have a predominant
inuence as long as periodontal ligaments and teeth
are present. When dealing with an edentulous jaw-
bone, systemic effects on bone quality may play a
major role (74). A correlation between skeletal and
mandibular bone mineral density in particular has
been established (for review, see 74, 78). Neverthe-
less, the correlation may not be strong enough (32,
64) to rely on skeletal bone density assessment for
predicting jawbone density (74).
Therefore, specic tools for jawbone density
assessment should be considered. A clear distinction
has to be made between simple clinical tools for
bone density screening and more complex but very
precise methods for bone density and morphometry
determination.
Common oral imaging modalities certainly offer
possibilities for simple chairside screening and clas-
sication of mandibular bone quality. Subjective rat-
ing scales of the jawbone quality are often used
during the preoperative planning procedure. The
most traditional method applied during preoperative
21
Preoperative radiologic planning of implant surgery
implant assessment is the one of Lekholm & Zarb
(43), in which the actual radiographic bone quality
status is categorized into four groups according to
the degree of corticalization and the trabecular bone
morphology. The basic idea behind this quality grad-
ing is that bone quality is increased by thicker cor-
tical density (grades 1 and 2), while a thinner cortical
bone (grade 3) combined with larger trabecular
spaces and thinning of the cancellous bone (grade
4) offer less suitable conditions for implant support.
It is clear that making a distinction between extreme
good (grade 1) and poor (grade 4) bone quality does
usually not create any problems for the observer.
More difculty and observer variation exist when
trying to distinguish between grades 2 and 3.
Some classication methods are based on grading
the trabecular bone pattern (47). Still other subjective
evaluation scores concentrate on the cortex only,
providing a classication for lower border cortical
porosity, structure and/or lower cortical width (3, 40).
Whenever CT material is available, one could also
consider further analyzing the Hounseld units (HU).
When calculating HU values in a particular area of
interest, relative information on local bone density
aspects canbe provided. The applicationof interactive
software for preoperative planning of implant plann-
ing can aid the clinician in such evaluations. Absolute
guidelines on these HUvalues cannot yet be provided,
as the density observations will be scanner-depen-
dent and vary according to the particular exposure
settings and window level applied. The measure-
ments do make it possible to quantify the bone into
one of the quality gradings of Lekholm & Zarb (43,
54). It is obvious that HU variations observed in the
same jaw scan reect local bone density variations
with lower HU values for poor bone quality (e.g.
tuberosity region). Another approach using cali-
brated information on bone mineral density (BMD)
exists in superimposing color-coded information on
local bone mineralization on axial and reformatted
CT images (30). A standardized calibration wedge
and a set of normative jawbone density values are
required to perform objective diagnostic measure-
ments on good or poor bone quality.
When an estimation of the overall jawbone quality
is required, analysis focuses on the basal part of the
mandible behind the mental foramen because varia-
tions in morphometric structure, shape and volume
are usually less pronounced in this area (65). Quan-
titative measuring methods include bone density
measurements using intraoral lm, with an Al or
bone calibrating wedge (32, 41). DXA scanners have
been used for jawbone density assessment (13, 31).
The same applies to total body QCT scanners (40,
64), with the disadvantage of delivering high radia-
tion doses and uncomfortable patient positioning.
Peripheral QCT scanners would avoid the drawbacks
of other methods, but an adapted p-QCT scanning
for jawbone scanning in vivo is not available.
Alternatively, the structure of trabecular bone can
also be analyzed by means of fractal analysis or other
morphological measures (14, 26). The aforementioned
variables are usually correlated with osteoporosis.
Nevertheless, osteoporotic and normal populations
Fig. 6. Bone scintigraphy by means of technetium-99m-
methylene diphosphonate is a functional imaging techni-
que allowing to visualize increased metabolic activity in
different structures of the skeleton.
22
Jacobs
show a considerable overlap, and normative studies
for jawbone density assessment are rare. Because of
this, these methods can not determine the ultimate
clinical threshold distinguishing sound and patholo-
gic jawbone.
Monitoring jawbone quality changes
For monitoring bone density changes over time,
comparison of gray scale proles and digital subtrac-
tion of subsequent standardized intraoral radio-
graphs may offer potential for clinical evaluation
(32). Quantitative ultrasound (QUS) is a non-invasive
and non-ionizing technique that also has the poten-
tial to monitor bone changes over time (55).
In a restricted number of cases, evaluation of bone
changes may be very critical, demanding the use of
elaborate but also more dose-demanding techni-
ques. Bone scintigraphy by means of techne-
tium-
99
m-methylene diphosphonate or preferably
single photon emission tomography (SPECT) is
known to be a useful and reliable method for mea-
suring increased metabolic activity of bony tissues
(Fig. 6). It could thus be applied to monitor post-
operative jawbone healing or peri-implant bone
remodeling (39, 48, 58). The latter becomes useful
in extremely complex surgical approaches of com-
promised jawbone, where evaluation of bone remo-
deling and osseintegration are most critical.
Conclusions
For oral implant surgery in the compromised patient,
preoperative radiologic planning should include
both a quantitative and qualitative evaluation of
the jawbone. These are of utmost importance for a
successful treatment outcome. In selecting the most
appropriate radiographic technique, the radiation
dose must be weighed against the required and
acquired information. Considering the radiation
doses involved and the information obtained,
cross-sectional imaging is considered the examina-
tion of choice in the compromised jawbone. Conven-
tional tomography and two-dimensional imaging
remain indicated for limited areas, while for
extended areas or complex surgical procedures
three-dimensional CT-based planning is preferred.
A further critical issue is an accurate transfer of this
planning to the surgical eld. A computer-based
transfer avoids variability related to mental interpre-
tation and transfer. Especially in limit cases, a minor
deviation may have important clinical implications.
Besides bone volumetric and morphologic measure-
ments, it is crucial to clinically establish bone quality
or density. The latter may be linked to a lower
implant success rate. Unfortunately, simple clinical
tools for accurate and reliable identication of jaw-
bone quality are still not available. More elaborate
quantitative methods are often too demanding,
whereas quality grading systems are subject to a sig-
nicant observer variation.
References
1. Arai Y, Tammissalo E, Iwai K, Hashimoto K, Shinoda K.
Development of a compact computed tomographic appara-
tus for dental use. Dentomaxillofac Radiol 1999: 28: 245248.
2. Augat P, Fuerst T, Genant HK. Quantitative bone mineral
assessment at the forearm: a review. Osteopos Int 1998: 8:
299310.
3. Benson BW, Prihoda TJ, Glass BJ. Variations in adult cortical
bone mass as measured by a panoramic mandibular index.
Oral Surg Oral Med Oral Pathol 1991: 1: 349356.
4. Besimo CE, Lambrecht JT, Guindy JS. Accuracy of implant
treatment planning utilizing template-guided reformatted
computed tomography. Dentomaxillofac Radiol 2000: 29:
4651.
5. Birkfellner W, Solnar P, Gahleitner A, Huber K, Kainberger F,
Kettenbach J, Homolka P, Diemly M, Watzek G, Bergmann
H. In vitro assessment of a registration protocol for image
guided implant dentistry. Clin Oral Implants Res 2001: 12:
6978.
6. Bou Serhal C, Jacobs R, Persoons M, Hermans R, van
Steenberghe D. The accuracy of spiral tomography to assess
bone quantity for the preoperative planning of implants
in the posterior maxilla. Clin Oral Implants Res 2000: 11:
242247.
7. Bou Serhal C, Jacobs R, Bosmans H, Hermans R, Quirynen
M, van Steenberghe D. Absorbed doses from conventional
and computed spiral tomography: a phantom vs. cadaver
study. Clin Oral Implants Res 2001: 12: 473478.
8. Bou Serhal C, van Steenberghe D, Bosmans H, Sanderink
GCH, Quirynen M, Jacobs R. Organ radiation dose assess-
ment for conventional spiral tomography: a human cadaver
study. Clin Oral Implants Res 2001: 12: 8590.
9. Bou Serhal C, van Steenberghe D, Quirynen M, Jacobs R.
Localization of the mandibular canal using conventional
spiral tomography: a human cadaver study. Clin Oral Im-
plants Res 2001: 12: 230236.
10. Bou Serhal C, Jacobs R, Van Cleynenbreugel J, van Steen-
berghe D. Validation of a 3-D-CT based stereolithographic
template for implant placement in an ex vivo atrophic
mandible. Clin Oral Implants Res 2002: abstract 11th
EAO, Brussels.
11. Cavalcanti MG, Yang J, Ruprecht A, Vannier MW. Accurate
linear measurements in the anterior maxilla using orthora-
dially reformated spiral computed tomography. Dentomax-
illofac Radiol 1999: 28: 137140.
12. Cehreli MC, Sahin S. Fabrication of a dual-purpose surgical
template for correct labiopalatal positioning of dental im-
plants. Int J Oral and Maxillofac Implants 2000: 15: 278282.
23
Preoperative radiologic planning of implant surgery
13. Corten FGA, van `t Hof MA, Buijs WCAM, Hoppenbrouwers
P, Kalk W, Corstens FHM. Measurements of mandibular
bone density ex vivo and in vivo by dual-energy x-ray ab-
sorptiometry. Arch Oral Biol 1993: 38: 22152219.
14. Devlin CV, Horner K, Devlin H Variability in measurement
of radiomorphometric indices by general dental practi-
tioners. Dentomaxillofac Radiol 2001: 30: 120125.
15. Dula K, Mini R, Van der Stelt PF, Lambrecht JT, Schneeber-
ger P, Buser D. Hypothetical mortality risk associated with
spiral computed tomography of the maxilla and mandible.
Eur J Oral Sci 1996: 104: 503510.
16. Dula K, Mini R, Lambrecht JT, Van Der Stelt PF, Schnee-
berger P, Clemens G, Sanderink GCH, Buser D. Hypotheti-
cal mortality risk associated with spiral tomography of the
maxilla and mandible prior to endosseous implant treat-
ment. Eur J Oral Sci 1997: 105: 123129.
17. Dula K, Mini R, Van der Stelt PF, Buser D. The radiographic
assessment of implant patients: decision-making criteria.
Int J Oral Maxillofacl Impl 2001: 16: 8089.
18. Dula K, Mini R, Van der Stelt PF, Sanderink GC, Schneeber-
ger P, Buser D. Comparative dose measurements by spiral
tomography for preimplant diagnosis: the Scanora machine
versus the Cranex Tome radiography unit. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2001: 91: 735742.
19. Eastell R. Assessment of bone density and bone loss. Osteo-
porosis Int 1996: 2 (Suppl): S3S5.
20. Eastell R. Treatment of postmenopausal osteoporosis. N
Engl J Med 1998: 338: 736746.
21. Eddy DM, Johnston CC, Cummings SR, Dawson-Hughes B,
Lindsay R, Melton LJ, Slemenda CW. Osteoporosis: review
of the evidence for prevention, diagnosis and treatment and
cost-effectiveness analysis. Status report. Osteoporos Int
1998: 4 (Suppl): 180.
22. Ekestubbe A, Thilander A, Grondahl K, Grondahl H-G. Ab-
sorbed doses from computed tomography for dental im-
plant surgery: comparison with conventional tomography.
Dentomaxillofac Radiol 1993: 22: 1317.
23. Ekestubbe A, Grondahl K, Ekholm S, Johansson PE, Gron-
dahl H-G. Low-dose tomographic techniques for dental
implant planning. Int J Oral Maxillofac Implants 1996: 11:
650659.
24. Esposito M, Hirsch JM, Lekholm U, Thomsen P. Biological
factors contributing to failures of osseointegrated oral im-
plants. II. Etiopathogenesis. Eur J Oral Sci 1998: 106: 721
764.
25. Fortin T, Champleboux G, Lormee J, Coudert JL. Precise
dental implant placement in bone using surgical guides
in conjunction with medical imaging techniques. J Oral
Implantol 2000: 24: 300303.
26. Geraets WG, van der Stelt PF. Fractal properties of bone.
Dentomaxillofac Radiol 2000: 29: 144153.
27. Gijbels F. Dosimetric evaluation of digital imaging. In: Ja-
cobs R, Gijbels F, eds. Oral Imaging 2000. Leuven: Catholic
University Leuven, 2000: 5965.
28. Gijbels F, Jacobs R, Sanderink G, De Smet E, Nowak B, Van
Dam J, van Steenberghe D. A comparison of the effective
dose from scanography with periapical radiography. Den-
tomaxillofac Radiol 2002: 31: 159163.
29. Hofschneider U, Tepper G, Gahleitner A, UlmC. Assessment
of the blood supply to the mental region for reduction of
bleeding complications during implant surgery in the inter-
foraminal region. Int J Oral Maxillofac Implants 1999: 14:
379383.
30. Homolka P, Beer A, Birkfellner W, Gahleitner A, Nowotny R,
Bergmann H. Local calibrated bone mineral density in the
mandible presented using a color coding scheme. Med Eng
Phys 2001: 23: 673677.
31. Horner K, Devlin H, Alsop CW, Hodgkinson IM, Adams JE.
Mandibular bone mineral density as a predictor of skeletal
osteopororis. Br J Radiol 1996: 69: 10191025.
32. Jacobs R, Ghyselen J, Koninckx P, van Steenberghe D. Long-
term bone mass evaluation of mandible and lumbar spine
in a group of women receiving hormone replacement ther-
apy. Eur J Oral Sci 1996: 104: 1016.
33. Jacobs R, van Steenberghe D. Radiographic planning and
assessment of endosseous oral implants, 1
st
edn. Berlin:
Springer-Verlag, 1998.
34. Jacobs R, Adriansens A, Naert I, Quirynen M, Hermans R,
van Steenberghe D. Predictability of reformatted computed
tomography for preoperative planning of endosseous im-
plants. Dentomaxillofac Radiol 1999: 28: 3741.
35. Jacobs R, Adriansens A, Verstreken K, Suetens P, van Steen-
berghe D. Predictability of a three-dimensional planning
system for oral implant surgery. Dentomaxillofac Radiol
1999: 28: 105111.
36. Jacobs R, Gijbels F. Oral Imaging 2000, 1
st
edn. Leuven:
Edmin, Department of Periodontology, KULeuven, 2000.
37. Jacobs R, Mraiwa N, van Steenberghe D, Gijbels F,
Quirynen M. Appearance, location, course, and morpho-
logy of the mandibular incisive canal: an assessment
on spiral CT scan. Dentomaxillofac Radiol 2002: 31:
322327.
38. Kanis JA, Devogelaer J-P, Gennari C. Practical for the use of
bone mineral measurements in the assessment of treat-
ment of osteoporsis: a position paper of the European foun-
dation for osteoporosis and bone disease. Osteoporos Int
1996: 6: 256261.
39. Khan O, Archibald A, Thomson E, Maharaj P. The role of
quantitative single photon emission computerised tomo-
graphy (SPECT) in the osseous integration process of dental
implants. Oral Surg Oral Med Oral Pathol Oral Radiol En-
dod 2000: 90: 228232.
40. Klemetti E. Edentulous jaws and skeletal mineral status
(Thesis). Kuopio: Kuopio University Publications B, Dental
Sciences 1993: 3: 1100.
41. Kribbs PJ, Smith DE, Chesnut CH. Oral findings in osteo-
porosis. Part I: Measurement of mandibular bone density. J
Prosthet Dent 1983: 50: 576579.
42. Lang T, Augat P, Majumdar S, Ouyang X, Genant HK. Non-
invasive assessment of bone density and structure using
computed tomography and magnetic resonance. Bone
1998: 22 (Suppl): 149S153S.
43. Lekholm U, Zarb G. Patient selection and preparation. In:
Branemark P-I, Zarb GA, Albrektsson T, eds. Tissue-inte-
grated prostheses: osseointegration in clinical dentistry. Chi-
cago: Quintessence Publ Co Inc, 1985: 199209.
44. Lindh C, Petersson A. Radiologic examination for location of
the mandibular canal: a comparison between panoramic
radiography and conventional tomography. Int J Oral Max-
illofac Implants 1989: 4: 249253.
45. Lindh C, Petersson A, Klinge B. Visualization of the man-
dibular canal by different radiographic techniques. Clin
Oral Implants Res 1992: 3: 9097.
46. Lindh C, Petersson A, Klinge B. Measurements of distances
related to the mandibular canal in radiographs. Clin Oral
Implants Res 1995: 6: 96103.
24
Jacobs
47. Lindh C, Nilsson M, Klinge B, Petersson A. Quantitative
computed tomography of trabecular bone in the mandible.
Dentomaxillofac Radiol 1996: 25: 146150.
48. Meidan Z, Weisman S, Baron J, Binderman I. Technetium
99-m-MDP scintigraphy of patients undergoing implant
prosthestic procedures: a follow-up study. J Periodontol
1994: 65: 330335.
49. Meijer HJ, Steen WH, Bosman F. Standardized radiographs
of the alveolar crest around implants in the mandible. J
Prosthet Dent 1992: 68: 318321.
50. Minoretti R, Merz BR, Triaca A. Predetermined implant
positioning by means of a novel guide template technique.
Clin Oral Implants Res 2000: 11: 266272.
51. Mozzo P, Procacci C, Tacconi A, Martini PT, Andreis IA. A
new volumetric CT machine for dental imaging based on
the cone beam technique: preliminary results. Eur Radiol
1998: 8: 15581564.
52. Naitoh M, Ariji E, Okumura S, Ohsaki C, Kurita K, Ishigami
T. Can implants be correctly angulated based on surgical
templates used for osseointegrated dental implants? Clin
Oral Implants Res 2000: 11: 409-414.
53. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and
maxillofacial pathology, 1
st
edn. Philadelphia: WB Saunders
Company, 1995.
54. Norton MR, Gamble C. Bone classification: an objective
scale of bone density using the computerised tomography
scan. Clin Oral Implants Res 2001: 12: 7984.
55. Prins SH, Jorgensen HL, Jorgensen LV, Hassager C. The role
of quantitative ultrasound in the assessment of bone: a
review. Clin Physiol. 1998: 18: 317.
56. Quirynen M, Mraiwa N, van Steenberghe D, Jacobs R. Mor-
phology and dimensions of the mandibular jawbone in the
interforaminal region in patients requiring implants in the
distal areas. Clin Oral Implants Res. 2003: 14: 280285.
57. Scher EL. Use of the incisive canal as a recipient site for root
form implants: preliminary clinical reports. Implant Dent
1994: 3: 3841.
58. Schliephake H, Berding G, Neukam FW, Bothe KJ, Gratz KF,
Hundeshagen H. Use of sequential bone scintigraphy for
monitoring only grafts to grossly atrophic jaws. Dentomax-
illofac Radiol 1997: 26: 117124.
59. Schramm A, Gellrich NC, Schimmig R, Schmelzeisen R.
Rechnerhestutzte Insertion von Zygomatikumimplantaten
(Branemark system) nach ablativer Tumorchirurgie. Mund
Kiefer Gesichtschir 2000: 4: 292295.
60. Sewerin I. Tangential projection for depiction of the anterior
regions of the jaws performed with the dental X-ray set.
Tandlgebladet 1991: 95: 473476.
61. van Steenberghe D, Jacobs R, Desnyder M, Maffei G, Quir-
ynen M. The relative impact of local and endogenous pa-
tient-related factors on implant failure up to the abutment
stage. Clin Oral Implants Res 2002: 13: 617622.
62. van Steenberghe D, Johansson C, Quirynen M, Molly L,
Albrektsson T, Naert I. Bone augmentation by means of
stiff occlusive titanium barrier: a study in rabbits and in
man. Clin Oral Implants Res 2003: 14: 6371.
63. Stella JP, Warner MR. Sinus slot technique for simplification
and improved orientation of zygomaticus dental implants:
a technical note. Int J Oral Maxillofac Implants 2000: 15:
889893.
64. Taguchi A, Tanimoto K, Suei Y, Ohama K, Wada T. Relation-
ship between the mandibular and lumbar vertebral bone
mineral density at different postmenopausal stages. Dento-
maxillofac Radiol 1996: 25: 130135.
65. Tallgren A. The continuing reduction of the residual alveolar
ridges in complete denture wearers: a mixed-longitudinal
study covering 25 years. J Prosthet Dent 1972: 27: 120132.
66. Tamura H, Sasaki K, Watahiki R. Primary insertion of im-
plants in the zygomatic bone following subtotal maxillect-
omy? Bull Tokyo Dent Coll 2000: 41: 2124.
67. Theodorou DJ, Theodorou SJ, Andre MP, Kubota D, Weigert
JM, Sartoris DJ. Quantitative computed tomography of
spine: comparison of three-dimensional and two-dimen-
sional imaging approaches in clinical practice. J Clin Den-
sitom 2001: 4: 5762.
68. Thomsen K, Gotfredsen A, Christiansen C. Is post-meno-
pausal bone loss an age-related phenomenon? Calcif Tissue
Int 1986: 39: 123127.
69. Uchida Y, Goto M, Katsuki T, Soejima Y. Measurement of
maxillary sinus volume using computerised tomographic
images. Int J Oral Maxillofac Implants 1998: 13: 811818.
70. Van Cleynenbreugel J, Schutyser P, Suetens P, Marchal G,
van Steenberghe D, Malevez C. A planning system for zygo-
matic fixtures based on 3-D CT images. Goteborg: Table
Clinics Nobel Biocare International Team Days, 2000.
71. Van Cleynenbreugel J, Schutyser F, Malevez C, Dhoore E,
Bou Serhal C, Jacobs R, Suetens P, van Steenberghe D.
Intra-operative transfer of planned zygomatic fixtures by
personalised templates: a cadaver validation study. Lecture
Notes in Computer Science 2208. MICCAI 2001, Utrecht.
Springer-Verlag: Berlin, 2001: 11471148.
72. Verstreken K, Van Cleynenbreugel J, Marchal G, Suetens P,
Naert I, van Steenberghe D. Computer assisted planning of
oral implant surgery: a three-dimensional approach. Int J
Oral Maxillofac Implants 1996: 11: 806810.
73. Verstreken K, Van Cleynenbreugel J, Martens K, Marchal G,
van Steenberghe D, Suetens P. An image-guided planning
system for endosseous oral implants. IEEE Trans Med Ima-
ging 1998: 17: 842852.
74. von Wowern N. General and oral aspects of osteoporosis: a
review. Clin Oral Investig 2001: 5: 7182.
75. Wagner A, Ploder O, Enislidis G, Truppe M, Ewers R. Virtual
image guided navigation in tumor surgery technical in-
novation. J Craniomaxillofac Surg 1995: 23: 217223.
76. Wanschitz F, Birkfellner W, Watzinger F, Schopper C, Pa-
truta S, Kainberger F, Figl M, Kettenbach J, Bergmann H,
Ewers R. Evaluation of accuracy of computer-aided intrao-
perative positining of oral endosseous implants in the eden-
tulous mandible. Clin Oral Implants Res 2002: 13: 5964.
77. Watzinger F, Birkfellner W, Wanschitz F, Millesi W, Schop-
per C, Sinko K, Huber K, Bergmann H, Ewers R. Positioning
of dental implants using computer-aided navigation and an
optical tracking system: case report and presentation of a
new method. J Craniofac Surg 1999: 27: 7781.
78. White SC. Oral radiographic predictors of osteoporosis.
Dentomaxillofac Radiol 2002: 31: 8492.
25
Preoperative radiologic planning of implant surgery