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RADIOGRAPHIC DETERMINANTS OF IMPLANT PERFORMANCE

MICHAEL S. REDDY* I-CHUNG WANG

Department of Periodontics School of Dentistry University of Alabama at Birmingham UAB Station 34 1919 7th Avenue South, Room 412 Birmingham, Alabama 35294-0007, USA * Corresponding author

Adv Dent Res 13:136-145, June, 1999

Abstract—This paper reviews and compares the strengths and weaknesses of radiographic techniques including periapical, occlusal, panoramic, direct digital, motion tomography, and computed tomography. Practical considerations for each method, including availability and accessibility, are discussed. To date, digital subtraction radiography is the most versatile and sensitive method for measuring boss loss. It can detect both bone height and bone mass changes on root-form or blade-form dental implants. Criteria for implant success have changed substantially over the past two decades. In clinical trials of dental implants, the outcomes require certain radiographic analyses to address the hypothesis or clinical question adequately. Radiographic methods best suited to the objective assessment of implant performance and hypothesis were reviewed.

Key words: Dental implants, radiographs, digital imaging, implant assessment.

Presented at the 15th International Conference on Oral Biology (ICOB), "Oral Biology and Dental Implants ", held in Baveno, Italy, June 28-July 1, 1998, sponsored by the International Association for Dental Research and supported by Unilever Dental Research

T he assessment of bone support in endosseous dental

implants is fundamental to the clinical utility of

implants for restoration of function. Radiographs are

a critical tool for the assessment of bony architecture,

and radiographs are used at each of three phases of implant treatment, evaluation, and maintenance. The first phase is pre- surgical assessment of the bone at potential implant recipient sites during the treatment planning phase of therapy. The second common use is intrasurgical assessment of the proximity of adjacent structures and parallelism of osteotomy sites being prepared. The final use of radiographs is in long- term assessment of the success or failure of implant therapy. This paper focuses on the radiographic methods to evaluate the third phase and briefly addresses the other methods. In implant research, the evaluation of longitudinal performance of the implant is of primary importance in transferring new developments to the practicing clinician.

DIAGNOSTIC METHODS READILY AVAILABLE

The radiographic methods available are considered from the simplest (use of intra-oral films) to the more complex utilization (computed tomography). The radiographic methods commonly available in longitudinal implant studies are presented in Table 1. A vast amount of radiographic imaging associated with dental implants is used for diagnosis of the implant recipient site. The radiographic assessment of the recipient site ideally indicates the quantity of bone in three dimensions, the location of anatomical structures (such as the mandibular canal and maxillary sinuses), and the quality of bone available. Although an enormous body of literature (over 1000 papers since 1990) addresses the pre-surgical planning of dental implants, no technique truly satisfies this ideal goal (Fritz, 1996). In an attempt to achieve this ideal radiographic assessment, clinicians often combine multiple radiographic views or utilize several imaging techniques.

Intra-oral films are utilized in pre-surgical planning of implant treatment, intra-operatively, and for longitudinal assessment. Occlusal films are used as a method of assessing the buccal to lingual width of the edentulous ridge area during the pre-surgical planning phase. The use of occlusal films is limited to the anterior mandible, because the superimposition of other anatomical structures tends to obscure the ridge in the posterior segment of the mandible. In addition, distortion of maxillary occlusal films is common. Periapical radiographs are used to assess limited areas or individual implant sites. The periapical films have minimal distortion if well-angulated and are suitable for the evaluation of bone height. A limitation of periapicals is that the area imaged is small, and adjacent anatomical structures may not be visible on the film (Fig. 1).

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TABLE 1

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RADIOGRAPHIC METHODS COMMONLY AVAILABLE IN LONGITUDINAL STUDIES OF DENTAL IMPLANTS

Radiographic Method Application Imaging Plane

Limitations

Periapical (intra-oral film or direct digital)

(1) Pre-surgical single site (2) Intrasurgical (3) Longitudinal assessment

Buccal-lingual

Limited view of adjacent anatomy Two-dimensional view Geometry commonly non-standardized

Occlusal (intra-oral film)

(1) Pre-surgical

Occlusal-apical

Commonly distorted

Direct digital (intra-oral film)

(1) Pre-surgical single site (2) Intrasurgical (3) Longitudinal assessment

Buccal-lingual

Limited detector size Inherent distortion

Panoramic (extra-oral film)

(1) Pre-surgical multiple sites (2) Longitudinal assessment

Buccal-lingual

Geometric distortion and magnification errors. Decreased resolution

Motion tomography

(1) Pre-surgical limited sites

Mesial-distal

Limited availability

(extra-oral film)

(2) Longitudinal assessment

Repositioning is difficult

Computed tomography (extra-oral digital)

(1) Pre-surgical multiple sites

Buccal-lingual, mesial distal, axial, three-dimensional

Relative cost Access to CT services Metal artifact

The periapical image in Fig. 1 has minimal geometric distortion, as illustrated by the spherical shape of the 5-mm ball bearings; however, the mandibular canal and the mental foramen cannot be visualized. The use of a film such as this does not provide adequate information for the planning of the surgical procedure. Periapical films are particularly well-suited for the longitudinal assessment of implants. The lack of distortion and ability to standardize projection geometry

enables them to be used in conjunction with a variety of linear, digital, and subtraction radiography techniques (Jeffcoat, 1992). Direct digital periapicals utilize an intra-oral detector to capture a radiographic image of the diagnostic area of interest

(Jeffcoat, 1992; Reddy et ai, 1992a; Welander

et al, 1993).

The direct digital periapical image is used in a fashion analogous to that of the film-based periapical for both pre- surgical planning and longitudinal assessment. The limitation of the diagnostic image area may even be more pronounced with the digital image. This is largely due to the limited size of the intra-oral detectors which are currently available. The resolution of the digital image is less than that available with conventional intra-oral film but is adequate for diagnosis and longitudinal assessment of bone loss (Wenzel, 1994). There are at least two major categories of direct digital radiography machines. The first uses a solid-state detector with or without a light pipe to amplify the signal. These detectors result in a nearly instantaneous display of the radiograph on a monitor with no chemical processing of conventional film. Signal amplification and detector sensitivity may result in major reductions in ray dose compared with conventional non-screen intra-oral film. The second type of detector is a re-usable solid- state detector that is placed in a reading device, similar in

concept to an optical scanner. Following a brief (approximately one-minute) delay, the image appears on a monitor. The technology of both the hardware and software associated with direct digital imaging is rapidly evolving. Both the gray-level resolution and the image accuracy are rapidly improving. In addition, the thickness of the detector, which was a previous problem with patient acceptance, has decreased, making the

Fig. I—A periapical film demonstrating good geometric

projection as illustrated by the spherical appearance of the 5-

  • mm reference ball bearings. Some of the

shortcomings of intra-

oral periapical films are also apparent. The mental foramen and mandibular canal are not visible on the film, making pre- surgical planning difficult.

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positioning of the detector much more comfortable for the patient. Direct digital radiography offers several advantages for intra-operative use. The solid-state detector replaces film, so there is no delay while the film is chemically processed. The contrast and brightness of the image may be adjusted retrospectively on the monitor so that different structures can be visualized. Since the image is digital, it can be stored on a disk to facilitate measurements of bone loss along the root surface. This eliminates the step of indirectly digitizing a film through a camera or scanner.

One current limitation of digital systems concerns the documentation and archiving of images for medico-legal purposes. Where film has been used as a permanent record of pre-treatment conditions and treatment delivered, digital images must now be archived. The more widespread use of digital systems and the expansion of disk storage space and back-up systems will most likely alleviate this potential shortcoming in the near future.

Panoramic radiography is one of the most commonly utilized radiographic techniques in dental implantology. Panoramic images provide a global assessment for multiple implant placement and are commonly used for initial treatment planning or screening. Clinical studies have utilized panoramic films either to score the presence or absence of bone loss or to quantify the amount of bone loss (Branemark et al., 1977; Adell etal., 1981; Naert, 1991; Quirynen etal., 1991; Mericske-Stern et al., 1994; Spiekermann et al., 1995). However, despite its widespread use, panoramic imaging has a number of limitations that decrease its usefulness as a method for the longitudinal assessment of dental implants. Because film-based panoramic images utilize screens, they have decreased resolution when compared with intra-oral films, resulting in a decreased ability to detect small changes in bone support along the implants (Backstrom et al., 1989). All panoramic films are magnified approximately 30% when the patient is ideally positioned (Glass, 1991). When the patient is positioned as little as 5 mm from ideal, the magnification may range from 10 to 61% (Reddy et al., 1994). Additionally, if the patient is rotated slightly, the magnification may differ from one side of the jaw

to the other (Fig. 2). Furthermore, the implant bone surface may be out of the curved plane of the tomogram being created by the panoramic machine, resulting in an inaccurate image of the bone-to-implant interface. Fig. 2 illustrates what appears to be a panoramic film of good diagnostic value and consistent magnification. The panoramic film shown was made with 5- mm metal ball bearings attached to an acrylic vacuum-formed stent made from a diagnostic cast. The resultant image, which appeared initially to have uniform magnification, is actually unevenly distorted from right to left. The second ball bearing from the right appears as a sphere, whereas the left side demonstrates geometric distortion, illustrated by the oblong appearance of the ball bearings. The errors of magnification and geometric distortion become important in clinical research which seeks to quantitate, from panoramic films, the amount of bone loss over time. Panoramic films will most likely continue to be used to evaluate implants radiographically over time because of their availability, ease of use, and patient acceptance. The continued development of direct digital panoramic images may decrease some of the limitations found with the film-based machines. In longitudinal clinical trials, care should be taken to use a method that corrects or controls for geometric distortion errors.

Film-based motion tomography has been suggested as a cost-effective method for pre-surgical evaluation of a prospective implant site (Miles and Van Dis, 1993). The images obtained are cross-sectional views that are useful for the evaluation of bone width and bone height from one image (Fig. 3). In addition, the cross-sectional images are useful for diagnosing bony undercuts not readily apparent on other

Fig. 2A second panoramic image with four 5-mm reference ball bearings in place. The image which initially appeared uniform in magnification is actually distorted, with non-uniform magnification from right to left.

Fig. 3A cross-sectional view of the mandible obtained with a film-based motion tomography machine. The image obtained allows for the assessment of the available bone in two dimensions.

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radiographic views (Kassebaum et al., 1990). Film-based tomography has not been utilized in the longitudinal assessment of dental implants over time. The lack of use is largely due to the limited availability of the machines themselves and the technical ability required to make images and use them to measure bone loss accurately. Linear or multidirectional tomography machines are readily available at most university- based medical centers. Tomography machines are less likely to be available in private dental practices due to the cost of the equipment. The lack of availability of the tomographic equipment may limit its usefulness in controlled clinical trials as opposed to field trials. With the production of relatively low- cost tomography machines, their widespread use is likely to increase. Tomography machines which are intended for in-office or imaging laboratory (hospital) use are now available. Two basic principles should be considered in the selection of a tomography machine that will produce the highest possible image quality. Both slice thickness and the amount of out-of- plane blurring contribute to image "readability". The longer the path the tomography machine traverses, the thinner the slice in the resultant image. Out-of-plane blurring is inherent to motion- based tomography. The more complex the path of the radiation source, the less out-of-plane blurring. Thus, linear tomography will produce more blurring than a machine using a hypocycloidal path. Furthermore, a machine designed to take up little space in the office and which has a small tomographic path will have a thick resultant image "slice thickness". The repositioning of the patient over time to obtain a reproducible image suitable for clinical research is technically difficult with most standard techniques (Poon et al., 1992). Tomography machines that use a cephalostat such as the Quint Sectograph (Denar Corp., Anaheim, CA, USA) may be advantageous in longitudinal studies (Miles and Van Dis,

1993). Without replicate cross-sectional images at the same plane on the implant, quantitative assessment of the bone support over time is likely to be highly inaccurate. An additional inherent limitation of film-based tomography is the limited experience that most clinical researchers have with the interpretation of tomograms. This may be overcome if the resulting images are digitized and electronically enhanced to improve the contrast (Fig. 4). The use of tomograms in longitudinal studies allows for the assessment of facial and lingual bone support that is not evaluated by intra-oral and panoramic radiographic techniques (Geurs, 1995). An additional limitation of tomograms occurs when multiple implants are close to each other: The implants tend to become superimposed, rendering interpretation nearly impossible.

For pre-surgical assessment, the most accurate technique for surgical site diagnosis is computed tomography (CT) (Petrikowski et al, 1989; Miller et al., 1990; Kassebaum et al, 1992; Reddy et al., 1994). The CT images obtained have minimal geometric distortion and are available in two- dimensional panoramic and cross-sectional formats as well as three-dimensional images (Figs. 5, 6). Slice thickness in CT imaging is a function of the scanning protocol. When overlapping slice protocols are utilized, at the expense of additional radiation doses, thinner slices with greater spacial

resolution result. For longitudinal analysis of implant bone support, the virtue of CT imaging is greatly limited, due to a streaking artifact that occurs when metal is encountered during the CT imaging (Fig. 7). This artifact is due to the high density of gold and silver alloys compared with that of the adjacent

bone (Curry et al., 1990). In one study of

138 CT images for

dental implant treatment planning, 34% of the images had distortion due to metal restoration of the teeth (Mayfield- Donahoo et al, 1994). When dental implants are scanned after

Fig. 4The application of image enhancement to aid in the interpretation of cross-sectional images.

Fig. 5Panoramic and axial cross-sectional images obtained from computed tomography.

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Fig. 7—A streaking artifact on a three-dimensional CT image due to the presence of high-density metal restoration of the teeth.

Fig. 6A three-dimensional image of the mandible reconstructed from a computed tomography image.

restoration, the high density of titanium and superstructure metal renders the resulting images of little value in the assessment of longitudinal performance. Therefore, CT imaging is not a practical technique for use in routine follow-up clinical research of dental implants.

HISTORICAL RADIOGRAPHIC CRITERIA FOR IMPLANT PERFORMANCE

Complications in dental implantology tend to occur due to failures in the prosthetic superstructure or a loss of supporting bone integration on the implant body itself. The assessment of

implant performance generally relies on the detection of mobility, the clinical signs of gingival inflammation, periodontal attachment loss and pocket formation, and radiographic bone loss. Radiographs are important tools in the evaluation and early diagnosis of implant-associated pathology. The use of radiographs allows for a quantitative assessment of bone loss along the implant surface.

Historically, different criteria have been utilized to assess the success of implants based on radiographic appearance or measurements (Table 2). The recommendations of the 1978 Harvard Consensus Conference on Dental Implants utilized the following categorical radiographic criteria: (1) no radiolucency and (2) bone loss not greater than 1/3 of the implant length (Schnitman and Shulman, 1979). This was an initial attempt at objective assessment of implant success or failure based on radiographs. Later, a publication from the Branemark group established a success criterion of 0.2 mm of bone loss annually after the first year of service (Albrektsson et al., 1986; Smith and Zarb, 1989). The problem with the 0.2-mm criterion is that it was not an annual measurement but a retrospective calculation such as 2-mm loss over a ten-year period. The authors did not utilize a method that could actually measure 0.2 mm or less. Further, when the observed bone loss is divided over 10 years, it is assumed that it is a continuous linear process. The American Dental Association (ADA) established a radiographic criterion of 2 mm of vertical bone loss at 5 years, measured by a technique with a resolution and validity that exceed the threshold for clinical success (ADA, 1996). The ADA guidelines do not specifically exclude bone loss that occurs in the first year of service, but rather incorporate all bone loss over a five-year period.

RADIOGRAPHIC ANALYSIS OF IMPLANT BONE LOSS IN CLINICAL TRIALS

One of the major problems of using radiographic analysis to quantitate bone loss from radiographs is geometric distortion due to misangulation of the film or misangulation of the x-ray beam. The first misangulation error may occur when the film angulation is changed at different radiographic exams while

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the x-ray source is held constant. The distortion produced by this error may be retrospectively corrected with the aid of a computer matrix transformation algorithm (Jeffcoat et aL, 1984; Webber et ai, 1984). The second misangulation error, an x-ray direction error, occurs when the radiographic source is moved and the implant and film are held in consistent geometry. The first and second types of misangulation errors occur together in most conventional clinical radiographs made to assess dental implants. The errors of film position and x-ray direction as sources of geometric distortion may be minimized by the use of standardized radiographs in a clinical trial. Standardized films are made by controlling the projection geometry of the image created. An occlusal index or stent is commonly used to register the implant or prosthesis position. The stent also incorporates a film holder and is attached or electronically coupled to the radiographic cone (Hausmann etaL, 1985,1992). Alternatively, a cephalostat or video feedback system may be utilized to reposition the patient's head in combination with a long film-to- object distance (Jeffcoat et ai, 1987; Reddy et a/., 1991). Minor errors that occur in angulation may be corrected with the application of a matrix transformation algorithm. Errors due to the tilt of film or detector may be retrospectively corrected by "warping" the second image onto the first. The radiographic assessment of implants is ideally suited to the application of warping algorithms, because the implants are of pre-defined dimension and known anatomy. The identification of clear landmarks on implant images is easily accomplished because of the known dimension. Landmarks are identified on both images before the transformation to be applied. This method allows for corrections in geometry without the strict requirement of standardization of the radiographs. The limitation of these techniques is that they allow for warping projection in only two dimensions. Therefore, as the film is bent in the patient's mouth in one or both radiographic

TABLE 2

RADIOGRAPHIC CRITERIA FOR IMPLANT SUCCESS

Radiographic Criteria

1/3 implant length

0.2

mm annually

after first year

1.4 mm over 3 years

2.0

mm over 5 years

Criteria Established

NIH Consensus Conference

Branemark retrospective studies

ADA Council on Dental Materials

examinations to be compared, the image will be distorted in three dimensions. A full three-dimensional distortion

correction has been achieved with tomosynthesis (Horton et al., 1996), and the use of software application on invariant structures has also been reported (Ostuni et aL, 1993). To date, we are not aware of the application of either of these techniques to large-scale clinical implant trials. The utilization of direct digital techniques may have an advantage in this regard. Since the image detector is rigid and cannot bend, distortions of the implant should be limited to two dimensions. Approaches to evaluating dental implants in clinical studies are outlined in Table 3. One method for assessing implant performance by high-quality radiographs is bone height analysis of the amount of bone loss relative to the implant

length (Fig. 8). There

is a major difference in using this

approach in studies of dental implants compared with studies measuring bone height around teeth. The length of the natural tooth root is unknown, whereas the length of the implant is known. If the bone height on the implant is expressed as a percentage of the implant length, it may be easily converted into a millimeter measurement of the bone loss present. In this

TABLE 3

APPROACHES TO RADIOGRAPHIC EVALUATION OF DENTAL IMPLANTS IN CLINICAL STUDIES

 

Ability to

Method

Requirements for Input Radiograph

Detect Change

Comments

(1) Measurement of %, mm, bone loss

High-quality

clinical radiographs

Moderate

Uses implant as reference scale, ideally should be digitized and measured under software control

(2) Measurement of bone

High-quality clinical radiographs

Low

Low tech.

loss by counting threads

Very easy

(3) Grid overlay to detect

High-quality clinical radiographs

Requires

Time-consuming,

mesial-distal and apical-

specialized

requires specialized software

coronal bone loss

software

(4) Digital subtraction radiography

Standardized image

High, can detect changes too small to see

Requires specialized software

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Fig. 8The application of bone height analysis on an implant as a proportion of overall implant length. The implant has a length of 10 mm, and the bone loss from the top of the implant is 4.4 mm.

way, the implant acts as its own ruler to compensate partially for geometric foreshortening or elongation distortion of the radiographic image during the measurement. The use of bone height measurements has an advantage in that it is very simple and does not require standardized radiographs. The image of the implant in Fig. 8 indicates the linear loss of bone along the implant. The resulting data obtained may be expressed as a percentage of overall implant length or in mm of bone loss if one knows the length of the implant. The use of bone height measurements is a linear, one-dimensional measure that is limited to the analysis of bone loss that can be visualized on the radiograph. Subtle changes may be overlooked due to a lack of

Fig. 9A digital subtraction radiography image illustrating bone loss around a failing image. The initial radiograph is subtracted from the subsequent image, and the resultant image is neutral gray, where no change has taken place. Areas of bone loss appear as a darker gray image.

contrast between gray levels. The contrast of slight areas of bone loss may be enhanced by the application of digital imaging techniques. A low-technology approach utilized in longitudinal studies has been simply to count the number of threads exposed by bone loss. The thread-counting approach is limited in resolution to the spacing of the threads. For example, if the threads are spaced at 0.6 mm, and measurement error is estimated at twice the resolution of the technique, only a 1.2-mm change in bone loss can be detected. In addition, the comparison of cylindrical implants and threaded implants with non-threaded collars represents additional complications and precludes the simple

TABLE 4

RADIOGRAPHIC METHODS FOR DIFFERENT IMPLANT STUDY DESIGNS

Type of Study/ Clinical Question

Design

Requirements to Detect Change

Method

Comments

Following an implant

Single arm,

(1) Measurement of mm

Most frequently used

over time, natural history

no blinding

Dependent on hypothesis or criteria to be satisfied

(4) Digital subtraction (2) Thread counting

High resolution Insufficient resolution to satisfy

Comparing two implant types, superiority

Parallel arms

Requires high sensitivity because most implants are successful

(1) Measurement of mm (4) Digital subtraction

Equivalency of two systems or types of implants

Parallel arms

Requires high sensitivity, and a large (n) number of implants to have sufficient power

(4) Digital subtraction, (1) Measurement of mm

"No significant difference" is not the same as "equivalent"

Comparison of implant types

Block design

Requires high sensitivity

(4) Digital subtraction

within the same patient

within subjects

(1) Measurement of mm

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Fig. 10A threshold has been applied

to the binary image to

obtain area of change and added back to the original radiograph.

use of this methodology. A variation of bone height analysis is the use of a grid to assess bone loss in two dimensions (Reddy et al., 1992b). The grid analysis is primarily useful for analyzing blade implants in which wide saucer-like bone loss tends to occur. A grid overlay is superimposed on the digital image of the blade and is based on the known dimensions of the blade. Multiple measurements are made along the grid lines from the radiolucency to the implant surface. The shortcomings of the grid method are that it is very time-consuming and, as with bone height measurements, measures only visual change.

One of the most versatile methods for measuring radiographic bone loss on both root-form and blade implants is the use of digital subtraction radiography. Subtraction radiography was introduced to dentistry in the 1980s (Webber et al., 1982; Grondahl et al., 1983; Hausmann et al., 1985; Jeffcoat et al., 1987). Subtraction radiography is used to compare two standardized radiographs taken at sequential examination visits. All structures that have not changed between examinations, such as the implant, are subtracted. The resultant computer image shows areas of bone change against a neutral gray background (Fig. 9). Areas of bone loss are conventionally shown in dark shades of gray, whereas areas of

bone gain are shown in light shades of gray. Alternatively, areas of bone loss or gain may be displayed in contrasting colors (Reddy et al., 1991). From the subtraction image, changes in bone height may be measured or two-dimensional areas of bone change may be calculated. In order to obtain an estimate of bone loss in three dimensions, investigators have carried out a quantitative analysis of the gray scale changes (Ruttimann and Webber, 1987; Bragger, 1988). The use of an area measurement from the subtraction image and the gray scale difference at the bone change has been applied to implant performance analysis (Jeffcoat, 1992). In brief, a reference wedge is used to convert the gray scale levels and area calculation to a bone loss or bone gain mass. The reference wedge is incorporated into the first radiograph and not the second, so that the resultant subtraction image has a negative image of the wedge along with an image of the bone loss. The image of the wedge is used to determine the thickness of the wedge that corresponds to the same gray level change as the bone loss. The mass of the lesion is then calculated by multiplying area x thickness x aluminum density x aluminum- to-bone-density conversion factor.

As

a final

step, the software

is used to improve

the

visualization of the area of change (Fig. 10). A threshold has been applied to the black-and-white (binary) image to obtain an area of change and added back to the original radiograph. This method has been validated by multicenter clinical trials through the calculation of the mass of cortical bone chips in skulls (Jeffcoat et al., 1992, 1996). The correlation between the calculated mass of the bone chips and the actual mass was found to be excellent (r 2 > 0.90).

Clinical studies in dental implants have been designed to answer different questions related to the performance of the

implants over time (Table 4). The design of the study requires that different radiographic analyses be utilized to address the hypothesis or clinical question adequately. A common study

design is to follow a specific

type of implant over time. In a

study of the natural history of the implant, several of the radiographic methods described in Table 3 may be used. The most frequently used method is to measure millimeters of bone loss along the implant surface over an interval of years. This technique uses digital measurement of the bone height and the length of the implant to help compensate for elongation and foreshortening (Verdonschot et al., 1991). Digital subtraction radiography could also be used to follow an implant longitudinally. Since subtraction techniques require carefully standardized radiographs, the decision to use digital subtraction radiography would have to be made prospectively (Bragger, 1988). Historically, investigators have simply counted the threads on implants of known geometry to assess bone loss in this type of longitudinal study (Albrektsson et al., 1986). However, counting threads may provide insufficient resolution to address the question of implant performance in a contemporary clinical study.

If the study design is to compare two implant types in an attempt to test for superiority, a high-resolution method needs to be utilized (Listgarten, 1992). The high-resolution radiographic techniques become necessary in this instance, because bone loss around dental implants tends to be small for

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the most part (Imrey, 1992). The fact that most implants are successful makes determining the differences between implants even more difficult. The methods useful for superiority comparisons would be digital measurement of mm of bone loss or digital subtraction radiography. A study to assess eqivalency of two implants may be even more challenging than superiority testing. The equivalency study needs the highest resolution that can be achieved, and, in addition, a sufficient number of subjects must be utilized (Imrey and Chilton, 1992). If an insufficient number of implants is used or the resolution of the radiographic method is too low, no significant difference between two implants will be observed, even if a difference actually exists. Comparing implants of different types, surface coatings, or design within the same subject presents an additional indication that the highest-possible resolution should be used (McKinney et aL, 1988). Again, since the bone loss at any modern implant is not likely to be great, a high-resolution technique and a subject population with sufficient power will be necessary. The position of the implants within the arch will also need to be determined with a random block design to ensure that the same implant does not always get the most favorable position in the arch.

CONCLUSION

Radiographic methods are essential for assessing bony support in endosseous dental implants. However, each technique has its own advantages and drawbacks. Different criteria have been utilized to determine the success or failure of implant performance based on radiographic appearance or measurements. In the design of clinical trials for dental implants, standardized radiographs should be utilized and the highest-resolution technique available must be considered. At present, digital subtraction radiography is an accurate and legitimate technique for the detection of minor bony change around dental implants.

REFERENCES

Adell R, Lekholm U, Rockier B, Branemark P-I (1981). A 15- year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 10:387-416. Albrektsson T, Zarb G, Worthington P, Eriksson B (1986). Long-term efficacy of currently used dental implants: a review and proposed criteria of success. Int J Oral Maxillofac Implants 1:11-25. American Dental Association (1996). Dental endosseous implants; an update. ADA Council on Scientific Affairs. /

AmDentAssoc

127:1238-1239.

Backstrom A, Welander U, McDavid WD, Tronje G, Sanderink GC (1989). The effect of system parameters on resolution in rotational panoramic radiography. A mathematical analysis. Dento-Maxillofac Radiol 18:169-176. Bragger U (1988). Digital imaging in periodontal radiography. A review. J Clin Periodontol 15:551-557. Branemark P-I, Hansson B, Adell R, Breine U, Lindstrom J, Hallen O, et al. (1977). Osseointegrated implants in the

treatment of edentulous jaw: experience from a 10-year period. Scand JPlast Reconstr Surg ll(Suppl 16): 1-132. Curry TS, Dowdey JE, Murry RC, editors (1990). Christensen's physics of diagnostic radiology. 4th ed. Philadelphia: Lea and Febiger, pp. 319-320. Fritz ME (1996). Implant therapy H Ann Periodontol 1:796-815. Geurs NC (1995). Quantitative analysis in dental radiography for implant dentistry (thesis). Birmingham, AL: The University of Alabama at Birmingham School of Dentistry. Glass BJ (1991). Successful panoramic radiography. Publ. No. N-406. Rochester, NY: Eastman Kodak Co. Grondahl H-G, Grondahl K, Webber RL (1983). A digital subtraction technique for dental radiography. Oral Surg

1:96-102.

Hausmann E, Christersson L, Dunford R, Wikesjo U, Phylo J, Genco RJ (1985). Usefulness of subtraction radiography in the evaluation of periodontal therapy. / Periodontol

56(Suppl):4-7.

Hausmann E, Allen K, Carpio L, Christersson LA, Clerehugh V (1992). Computerized methodology for detection of alveolar crestal bone loss from serial intraoral radiographs. J Periodontol 63:657-662. Horton RA, Ludlow JB, Webber RL, Gates W, Nason RH Jr (1996). Detection of peri-implant bone changes with axial tomosynthesis. Oral Surg Oral Med Oral Pathol Oral Radiol 81:124-129. Imrey PB (1992). Logical and analytic issues in dental/oral product comparison research. J Periodont Res 27:328-341. Imrey PB, Chilton NW (1992). Design and analytic concepts for periodontal clinical trials. / Periodontol. 63:1124-1140. Jeffcoat MK (1992). Digital radiography for implant treatment planning and evaluation. Dento-Maxillofac Radiol 21:203-207. Jeffcoat MK, Jeffcoat RL, Williams RC (1984). A new method for the comparison of bone loss measurements on non- standardized radiographs. J Periodont Res 19:434-440. Jeffcoat MK, Reddy MS, Webber RL, Williams RC, Ruttimann UE (1987). Extraoral control of geometry for digital subtraction radiography. J Periodont Res 22:396-402. Jeffcoat MK, Reddy MS, van den Berg HR, Bertens E (1992). Quantitative digital subtraction radiography for the assessment of peri-implant bone change. Clin Oral Impl Res 3:22-27. Jeffcoat MK, Reddy MS, Magnusson I, Johnson B, Meredith MP, Cavanaugh PF, et al. (1996). Efficacy of quantitative digital subtraction radiography using radiographs exposed in a multicenter trial. / Periodont Res 31:157-160. Kassebaum DK, Nummikoski PV, Triplett RG, Langlais RP (1990). Cross-sectional radiography for implant site assessment. Oral Surg 10:61 A. Kassebaum D, Stoller N, McDavid W, Goshorn B (1992). Absorbed dose determination for tomographic implant assessment techniques. Oral Surg Oral Med Oral Pathol

73:502-509.

Listgarten MA (1992). General issues in efficacy, equivalency, and superiority trials: clinical considerations. J Periodont

7^27:314-319.

Mayfield-Donahoo TL, Reddy MS, Jeffcoat MK, Berland L

V0L.1S

RADIOGRAPHIC IMPIANT PERFORMANCE

145

(1994). Reduction of tooth restoration artifacts in three- dimensional computed tomography imaging. IEEE/EMBS

16:518-519.

McKinney RV Jr, Steflik DE, Koth DL, Singh BB (1988). The scientific basis for dental implant therapy. J Dent Educ

52:969-705.

Mericske-Stern R, Schaffner TS, Marti P, Geering AH (1994). Peri-implant mucosal aspects of ITI implants supporting overdentures: a five-year longitudinal study. Clin Oral Impl Res 5:9-18. Miles D, Van Dis M (1993). Implant radiology. Dent Clin North Am 37:645-668. Miller C, Nummikoski PV, Barnett D (1990). Cross-sectional tomography. Oral Surg Oral Med Oral Pathol 70:791-797. Naert I, Quirynen M, Theuniers G, van Steenberghe D (1991). Prosthetic aspects of osseointegrated fixtures supporting overdentures. A 4-year report. J Prosthet Dent 65:671-680. Ostuni J, Fisher E, van der Stelt P, Dunn S (1993). Registration of dental radiographs using projective geometry. Dento- Maxillo-Fac Radiol 22:199-203. Petrikowski C, Pharoah M, Schmitt A (1989). Presurgical radiographic assessment for implants. J Prosthet Dent

61:59-64.

Poon CK, Barss TK, Murdoch-Kinch CA, Bricker SL, Miles DA, Van Dis ML (1992). Presurgical tomographic assessment for dental implants: Part 1. A modified imaging technique. Int J Oral Maxillofac Implants 7:246-250. Quirynen M, Naert I, van Steenberghe D, Dekeyser C, Theuniers G (1991). Periodontal aspects of osseointegrated fixtures supporting an overdenture. A 4-year retrospective study. J Clin Periodontol 18:719-728. Reddy MS, Bruch JM, Jeffcoat MK, Williams RC (1991). Contrast enhancement as an aid to interpretation in digital subtraction radiography. Oral Surg Oral Med Oral Radiol

71:763-769.

Reddy MS, Duckett AR, Geurs NC, Jeffcoat MK (1992a). Direct digital radiography for measurement of alveolar bone loss (abstract). J Dent Res 71(Spec Issue): 114.

Reddy MS, Mayfield-Donahoo TL, Jeffcoat MK (1992b). A semi-automated computer-assisted method for measuring bone loss adjacent to dental implants. Clin Oral Impl Res

3:28-31.

Reddy MS, Mayfield-Donahoo T, Vanderven FJJ, Jeffcoat MK (1994). A comparison of the diagnostic advantages of panoramic radiography and computed tomography scanning for placement of root form dental implants. Clin Oral Impl /tes 5:229-238. Ruttimann UE, Webber R (1987). Volumetry of localized bone lesions by subtraction radiography. J Periodont Res

22:215-216.

Schnitman PA, Shulman LB (1979). Recommendations of the consensus development conference on dental implants. JAm DentAssoc 98:373-377. Smith DE, Zarb GA (1989). Criteria for success of osseointegrated dental implants. J Prosthet Dent 62:67-72. Spiekermann H, Jansen V, Richter E-J (1995). A 10-year follow-up study of IMZ and TPS implants in the edentulous mandible using bar-retained overdentures. Int J Oral Maxillofac Implants 10:231-243. Verdonschoi: EH, Sanders AJ, Plasschaert AJ (1991). Applicability of an image analysis system in alveolar bone loss measurement. J Clin Periodontol 18:30-36. Webber RL, Ruttimann UE, Grondahl H-G (1982). X-ray image subtraction as a basis for assessment of periodontal changes. J Periodont Res 17:509-511. Webber RL, Ruttimann UE, Groenhuis RA (1984). Computer correction of projective distortions in dental radiography. J Dent Res 63:1032-1036. Welander U, Nelvig P, Tronje G, McDavid WD, Dove SB, Marner AC, et ah (1993). Basic technical properties of a system for direct acquisition of digital intra-oral radiographs. Oral Surg Oral Med Oral Pathol 75:506-516. Wenzel A (1994). Sensor noise in direct digital imaging (the Radio-Visiography, Sensa-Ray, and Visualix/Vixa systems) evaluated by subtraction radiography. Oral Surg Oral Med Oral Pathol 77:70-74.