Implant Dentistry
The Use of Cone Beam Computed Tomography (CBCT)

Thinking ahead. Focused on life.

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The Authors

Prof. Dr. med. dent. Michael BornsteinProf. Dr. med. dent. Daniel Buser

Dental degree and thesis at the University of Basel.
Board-certified oral surgeon since June 2003.
In 2004, visiting assistant professor at the Departmentof Periodontics (Prof. Dr. D. Cochran) at the Universityof Texas Health Science Center at San Antonio, USA.
Since autumn 2007 head Section of Dental Radiology
and Stomatology at the Department of Oral Surgery
and Stomatology at the University of Bern.
In October 2009, Habilitation (Privatdozent / PD) in
the field of „Oral Surgery and Stomatology“. Since
2014, Associate Professor at the University of Bern.

Dr. Daniel Buser is Professor and Chairman at the
Department of Oral Surgery at the University of Bern in
Switzerland. He served as President of various academic
associations including the European Association for
Osseointegration (EAO) in 1996/97, the Swiss Society ofOral Implantology (SSOI) in 1999-2002, the Swiss Societyof Oral Surgery and Stomatology (SSOS) in 2002-2007.
Most recently, he was President of the ITI (2009-2013),
the world’s largest association in the field of implant dentistry. He received several scientific awards by professional organizations such as the ITI, the AO, the AAP and theAAOMS. Recently, he was honored with the Brånemark
Osseointegration Award by the Osseointegration Foundation in the USA (2013).

Fields of research: cone beam computed tomography(CBCT) in clinical dental practice, stomatology/oral
medicine, GBR procedures with bioresorbable membranes and dental implants.

His main research areas are in tissue regeneration arounddental implants, surface technology and Guided BoneRegeneration. He has authored and co-authored morethan 300 publications and several text books including
two GBR books and two ITI Treatment Guides. He widely
lectures at national and international conferences.

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Content
Preface5Technical details of the 3D Accuitomo 170

6Dose optimization for CBCT imaging

8

CBCT imaging for implant treatment planningin the anterior maxilla

10

Case example: Replacement of a maxillary
central incisor following dento-alveolar trauma

12

CBCT imaging for implant treatment planningin the posterior maxilla

14

Case example: Replacement of a missing firstleft maxillary molar following tooth loss due toendodontic complications

16

Case example: Replacement of missing maxillary
premolars and molars in the posterior right maxilla(distal extension situation)

18

CBCT imaging for implant treatment planningin the posterior mandible

20

Case example: Extended edentulous space withtwo missing premolars in the posterior mandible

22

CBCT imaging for implant treatment planningin the anterior mandible

24

Case example: Replacement of missing
mandibular incisors following bone loss due
to periodontal disease

26

Examination of implant failures and complications
using CBCT

28

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1. Harris D, Horner K, Gröndahl K, Jacobs R, Helmrot E, Benic GI, Bornstein
MM, Dawood A, Quirynen M: Guidelines for the use of diagnostic imaging in implant dentistry 2011: update of the E.A.O. A consensus workshop
organized by the European Association for Osseointegration in the Medical
University of Warsaw, Poland. Clin Oral Implants Res 2012;23:1243-53.
2. Mozzo P, Procacci C, Tacconi A, Tinazzi Martini P, Bergamo Andreis IA.
A new volumetric CT machine for dental imaging based on the cone-beamtechnique: preliminary results. Eur Radiol 1998;8:1558-64.

4. Guerrero ME, Jacobs R, Loubele M, Schutyser F, Suetens P,
van Steenberghe D. State-of-the-art on cone beam CT imaging for
preoperative planning of implant placement. Clin Oral Investig 2006;10:1-7.
5. Bornstein MM, Al-Nawas B, Kuchler U, Tahmaseb A. Consensus
statements and recommended clinical procedures regarding contemporary
surgical and radiographic techniques in implant dentistry. Int J Oral Maxillofac
Implants 2013; doi: 10.11607/jomi.2013.g1. (epub ahead of print).

3. De Vos W, Casselman J, Swennen GR. Cone-beam computerized tomography (CBCT) imaging of the oral and maxillofacial region: a systematic reviewof the literature. Int J Oral Maxillofac Surg. 2009;38:609-25.

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Preface
Proper diagnosis and treatment planning in implant dentistry
is done with a clinical examination and appropriate radiographs. For many years, the information required to satisfy
these goals has been obtained from clinical examinationand most commonly two-dimensional (2D) imaging suchas intraoral periapical, lateral cephalometric and panoramic
radiography. Using these imaging modalities, implants havebeen used predictably and with high success rates in clinicalpractice for more than 30 years. The decision to proceed tothree-dimensional (3D) imaging should be based on clearly
identified needs and the clinical and surgical requirements ofthe clinicians involved. Clinical situations that might benefit
from 3D imaging prior to implant surgery are:1

Since the first description in 1998,2 cone beam computed
tomography (CBCT) has become a popular and important
technique for diagnosis and treatment planning in dental
medicine.3 It has already become an established diagnostic
tool for various indications in dental medicine including dental implant surgery.4 Today, when cross-sectional imaging is
indicated for dental implant treatment planning purposes,
CBCT is preferable over CT.5
The present brochure covers the different aspects of treatment planning for dental implants in the maxilla and mandible, presents the diagnosis of failures and complications,and discusses radiation dose protection issues with the use
CBCT imaging.

1. When the clinical examination and conventional radiography have failed to adequately demonstrate relevant
anatomical boundaries (e.g. nasopalatine fossa and canal,
nasal fossa, mental foramen, submandibular gland fossa,
inferior alveolar canal) and the absence of pathology suchas retained root tips, sinus disease or adjacent inflammatory processes.
2. When reference to such images can provide additional
information that can help to minimize the risk of damage
to important anatomical structures.
3. In clinical borderline situations where there appears to
be limited bone height and/or bone width available forsuccessful implant treatment.
4. Where implant positioning can be improved. The diagnostic information can be enhanced by use of radiographic
templates, computer assisted planning andsurgical guides.

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Technical Details of the
3D Accuitomo 170

The 3D Accuitomo 170 is the 4th generation of the
Accuitomo product line. It combines a high level of image
quality with efforts to minimize patient dosage. The device
offers different imaging modes, Fields of View (FOV) varying
from small to large (maxillo-facial) FOVs, voxel sizes from80 μm to 250 μm, zoom reconstructions to analyze areasof special interest with voxel sizes as small as 80 μm, anda DICOM 3.0 compliant imaging software (i-Dixel 3D).
Image acquisition with the 3D Accuitomo 170 is done bya rotating gantry composed of an X-ray source emitting acone-shaped beam – in contrast to a fan-shaped beamemitted by CT devices – and a detector that transmits
the digital signals to the computer. The multiple projections (basis projection images) created during the rotationof the gantry are converted into secondary reconstructed3-dimensional images that can be analyzed on a computer
monitor. Cone beam computed tomography (CBCT) images
are evaluated using the classical orthogonal planes (axial,
sagittal and coronal), multiplanar reformation (MPR) to provide panorama-like thin-slice images and stacked sequential
images orthogonal to the curved planar reformation, and 3D
volume rendering.

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Figure 1: The principle behind the
CBCT technique, as its name implies,
is a cone-shaped X-ray beam with the
X-ray source and detector rotatingaround a point of interest in the patient.
This figure shows a rotating gantry
with x-ray source (so-called emitter)and detector attached to it.
Emitter

Detector

Figure 2 (left): Orthogonal planes(axial, sagittal and coronal) in a patientreferred for implant treatment planning.
Figure 3 (right): 3D volume rendered
jaw in a patient referred for dental
implant treatment planning.

Figure 4: Multiplanar reformation(MPR) of the maxilla in a patientreferred for dental implant treatment
planning.

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Dose Optimization for CBCT Imaging

Figure 1: A small FOV (4 x 4 cm) of a single-tooth gap forevaluation and treatment planning prior to dental implant
placement in area of the first left mandibular premolar.

Figure 2: A medium FOV (8 x 4 cm) of the maxilla for evaluation of the peri-implant status of dental implants placed at
the left lateral incisor and first molar regions.

Patient risk from radiation has been a continuing concern inoral and maxillofacial imaging, due to the frequency of X-ray
examinations in dental practice. ALARA is the acronym for
As Low As Reasonably Achievable and is a fundamental
principle for diagnostic radiology.1 With the increased useof CBCT imaging in dental practice, clinicians must be
made aware that patient radiation doses associated with
CBCT imaging are higher than those of conventional radiographic techniques. Therefore, routine replacement of current radiographic techniques must be considered with greatcare – especially when treating children. Strategies which
optimize exposure, such as Field of View (FOV) reduction
to the region of interest, and reduction in exposure parameters often provide images of sufficient image quality formost diagnostic tasks associated with dental procedures.

For the 3D Accuitomo 170 the following FOVs areavailable (as classified by Bornstein et al. 2013): 2
Small FOV
< 40 cm2 / diameter x height in cm; Figure 1:
4 x 4 cm; 6 x 6 cm
6 x 4 cm (optional); 6 x 5 cm (optional)
Medium / dento-alveolar FOV
40 cm2 to < 100 cm2; Figure 2 and 3:
8 x 8 cm; 10 x 5 cm; 14 x 5 cm; 17 x 5 cm
8 x 4 cm (optional); 8 x 5 cm (optional)
Large / maxillo-facial FOV> 100 cm2; Figure 4:
10 x 10 cm; 14 x 10 cm; 17 x 12 cm

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Figure 3: A medium FOV (8 x 8 cm) in a patient referredfor diagnosis of multiple cystic lesions in the upper andlower jaw.

Figure 4: A large FOV (14 x 10 cm) has been used for theevaluation of all maxillary and mandibular third molars andthe TMJ regions.

Additionally, four imaging modes are available to selectthe appropriate scan time, while keeping patient doseto a minimum:

High fidelity mode (360˚: 30.8 seconds / 180˚: 15.8 seconds):
Used for zoom reconstructions, and indicated for adults, notchildren.

Standard mode (360˚: 17.5 seconds / 180˚: 9.0 seconds):
This is the standard setting used for most patients andFOVs. Most of the studies published using the Accuitomo
device have applied this mode.

High speed mode (360˚: 10.5 seconds / 180˚: 5.4 seconds):
Used to reduce motion artefacts, especially for children andsmall FOVs.

High resolution mode (360˚: 30.8 seconds / 180˚: 15.8
seconds): This setting is used for detailed bone or tooth
structures within small FOVs. Usually indicated for adults,
not children.
1. Farman AG: ALARA still applies Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2005;100:395-7.
2. Bornstein MM, Scarfe WC, Vaughn VM, Jacobs R: Cone beam computed
tomography in implant dentistry: a systematic review focusing on guidelines,
indications, and radiation dose risks. Int J Oral Maxillofac Implants 2014
(in press).

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CBCT Imaging for Implant Treatment
Planning in the Anterior Maxilla

Figure 1A: Coronal CBCT slice through the alveolar socketof the missing right central incisor and the neighboring
teeth. (*) Nasal openings (foramina of Stenson) of thenasopalatine canal

Figure 1B: Sagittal CBCT slice

Figure 1C: Axial CBCT slice

Figure 1D: Volume rendered data set

Figure 1: Visualization of the nasopalatine canal in a patientreferred for dental implant treatment planning in the anterior
maxilla (right central incisor). The canal consists of two parallel bony channels.
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Relevant clinical questions
Is a correct 3-dimensional (3D) implant positioning possible?
Besides reestablishing function, the esthetic result of the implantrehabilitation is of great importance in the anterior maxilla. Therefore, the clinician needs to achieve a correct oro-facial, mesio-distal, and corono-apical position of the prospective implant shoulder.
Can we achieve good primary stability of the implant in the desired position? If primary stability of an inserted dental implant is
not achievable, the clinician has to decide between site development using guided bone regeneration (GBR) or an alternative
treatment concept without dental implants.
Figure 2A: Coronal CBCT slice
When GBR is needed, can we use a simultaneous approachwith implant insertion or do we need a staged approach?
When GBR is not indicated, can we place the implant using
a flapless approach?

Anatomic structures of interest
Anatomical structures and boundaries that need to be considered,
when planning a dental implant in the anterior maxilla include:
Nasal floor
Nasopalatine canal (Figure 1) 1

Figure 2B: Sagittal CBCT image

Anterior superior alveolar canal and canalis sinuosus (Figure 2)
1. Bornstein MM, Balsiger R, Sendi P, von Arx T: Morphology of the nasopalatine canaland dental implant surgery: A radiographic analysis of 100 consecutive patients using
limited cone beam computed tomography. Clin Oral Implants Res 2011;22:295-301.

Figure 2: Patient referred for dental implant treatment planning exhibiting a visible canalis sinuosus (+) on the left in the coronal CBCT
slice. From the canalis sinuosus, an anterior maxillary canal (*) runs
to the anterior palate in the vicinity of the canine.

Figure 2C: Axial CBCT image
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Case Example
Replacement of a maxillary central incisor following dento-alveolar trauma

Figure 1: Initial clinical presentation of a 19-year old female
patient referred for dental implant treatment planning. The
patient had an avulsion of the maxillary left central incisor
with 8 years. The tooth was replanted using a titanium post.
Since a few months, the patient had noticed a buccal fistulaand growing „pinkish“ discoloration of the tooth.
Figure 2: Panoramic view of the patient exhibiting the
replanted maxillary left central incisor. A lytic, hypodense
region is visible between the crown of the respective toothand the titanium post. The root of the central incisor is notdiscernible – and seems to have been resorbed in mostparts. Additional findings include non-erupted third molars
in the maxilla and mandible.

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Figure 3A: Sagittal CBCT image

Figure 3B: Sagittal CBCT image

Figure 3C: Coronal CBCT image

Figure 3D: Coronal CBCT image

Figure 3E: Axial CBCT image

Figure 3F: Volume rendered data set

Figure 3: CBCT analysis of the site
after extraction of the left maxillary
central incisor including the titanium
post (small FOV: 4 x 4 cm): the evaluation of the images exhibits a root canalfilled left lateral incisor, a prominent
nasopalatine canal (Y-shaped), and visible excessive root canal filling material
in the bone apically to both maxillaryleft incisors.
Based on the findings of the CBCT images, a dental implant placement withsimultaneous guided bone regeneration was planned.

Figure 4: Radiographic (A) and clinical(B) presentation two years after dental
implant insertion in the region of theleft maxillary central incisor.

Figure 4A

Figure 4B
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CBCT Imaging for Implant Treatment
Planning in the Posterior Maxilla
Relevant clinical questions

Anatomic structures of interest

Is correct 3-dimensional (3D) implant positioning possible?

It has been established that panoramic views of the posterior maxilla will underestimate the amount of bone available
for implant placement. CBCT can overcome this problem
as it provides more accurate measurements of the available
bone volume. CBCT can also provide information on arterial
channels in the lateral wall of the sinus, the presence, andextent of any septae, as well as on the health of the sinus
such as absence of sinus membrane thickening, polyps or
fluid levels.1
Anatomical structures and boundaries that need to beconsidered, when planning a dental implant in the posterior
maxilla include:

Can we achieve good primary stability of the implant in thedesired position? If primary stability of an inserted dental
implant is not achievable, the clinician has to decide between site development using sinus floor elevation (SFE)procedures or an alternative treatment concept not using
dental implants.
When SFE is needed, can we use a simultaneous SFE withimplant insertion or do we need a staged approach?
When a simultaneous SFE is possible, do we use a lateralwindow or a transcrestal osteotome technique?

Maxillary sinus and related structures: this includes theextension (pneumatization) of the sinus, the status of theSchneiderian membrane (dimension and type of thickening),
presence of bony septa, opacification of the maxillary sinus(sinusitis or mucocele). The sinus mucosa exhibits various
morphological alterations: 2 healthy Schneiderian membrane(no thickening, Figure 1); flat and shallow thickening(Figure 2); semi-aspherical thickening rising in an angle of> 30° from the floor of the walls of the sinus; mucocelelike / complete opacification of the sinus (Figure 3); mixed
flat and semi-aspherical thickenings.
Posterior superior alveolar canal
Maxillary tuberosity
Pterygoid plates

1. Harris D, Horner K, Gröndahl K, Jacobs R, Helmrot E, Benic GI, Bornstein
MM, Dawood A, Quirynen M: E.A.O. Guidelines for the use of diagnostic
imaging in implant dentistry 2011. A consensus workshop organized by theEuropean Association for Osseointegration at the Medical University of Warsaw.
Clin Oral Implants Res 2012;23:1243-53.
2. Janner SFM, Caversaccio M, Dubach P, Sendi P, Buser D, Bornstein MM:
Characteristics and dimensions of the Schneiderian membrane: A radiographic
analysis using cone beam computed tomography in patients referred for dental
implant surgery in the posterior maxilla. Clin Oral Implants Res 2011;22:1446-53.

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Figure 1: Visualization of the right posterior edentulous maxilla and maxillarysinus in a patient referred for dental
implant treatment planning. The maxillary sinus is pneumatized without any
signs of a thickening of the Schneiderian membrane.

Figure 2: Patient referred for dental
implant treatment planning in theposterior maxilla exhibiting a flat, shallow thickening of the Schneiderian
membrane.

Figure 1A: Sagittal CBCT slice

Figure 1B: Coronal CBCT slice

Figure 2A: Sagittal CBCT image

Figure 2B: Axial CBCT image

Figure 3B: Coronal CBCT image

Figure 3C: Axial CBCT image

Figure 3: Patient exhibiting an almost
complete opacification of the maxillarysinus and a bony septum in the region
between the second and third molar
extending from the buccal to the palatal. The first molar exhibits an apicalradiolucency, and the alterations in the
maxillary sinus can be diagnosed as asinusitis of odontogenic origin.

Figure 3A: Sagittal CBCT image

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Case Example
Replacement of a missing first left maxillary molar
following tooth loss due to endodontic complications

Figure 1: Initial clinical presentation ofa 41-year old male patient referred for
dental implant treatment planning. The
patient had an extraction of the firstleft maxillary molar following a failed
root canal treatment one year ago.

Figure 2: Panoramic view of the patient
exhibiting the single-tooth gap in theupper left posterior maxilla.
Additional findings include agenesis ofboth lateral maxillary incisors. Otherwise, there are no pathologic findingsin the radiograph.

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Figure 3: CBCT analysis of the left
posterior maxilla including the missing first molar area (small FOV:
6 x 5 cm): the evaluation of theimages exhibits well pneumatizedmaxillary sinus without any pathologic findings, premolars and asecond molar without fillings or othersigns of decay, and a reduced verticalbone height and even missing bone
towards the maxillary sinus in theregion of the first molar.
Figure 3D: The coronal slice exhibits
an enamel pearl in the furcation areaof the second molar (*).
Based on these findings, a staged
sinus floor elevation procedure withimplant insertion was planned anddiscussed with the patient.

Figure 3A: Sagittal CBCT image

Figure 3B: Coronal CBCT image

Figure 3C: Coronal CBCT image

Figure 3D: Coronal CBCT image

Figure 3E: Axial CBCT image
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Case Example
Replacement of missing maxillary premolars and molars
in the posterior right maxilla (distal extension situation)
Figure 1: A 73-year old male patient
was referred for dental implant treatment planning in the right posterior
maxilla. Upon initial examination he did
not report any acute medical problems. He had lost the molars and thesecond premolar due to periodontal
and endodontic complications. CBCT
analysis of the right posterior maxilla
using of a radiographic template (small
FOV: 6 x 5 cm) exhibits reduced vertical bone height in the molar area, boneloss between the canine and the firstpremolar, and opacification of the rightmaxillary sinus.
The tentative diagnosis was a maxillarysinusitis of rhinogenic origin. Based onthese findings, the patient was referredto the ear, nose, throat (ENT) specialist
for further diagnosis and treatment.

Figure 1A: Sagittal CBCT image

Figure 1B: Coronal CBCT image,second premolar region

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Figure 1C: Coronal CBCT image, first molar region

Figure 1D: Coronal CBCT image,second molar region

Figure 1E: Axial CBCT image,bone loss between canine and firstpremolar is visible
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CBCT Imaging for Implant Treatment
Planning in the Posterior Mandible
Relevant clinical questions

Anatomic structures of interest

Is correct 3-dimensional (3D) implant positioning possible?
This includes the number and dimensions (length and diameter) of the implants to be inserted?

Anatomical structures and characteristics of the posterior
mandible that need to be considered, when planning dental
implant insertion are:

Can we achieve good primary stability of the implant in thedesired position? If primary stability of the implant is notachievable, the clinician has to decide between site development using guided bone regeneration (GBR) or an alternative treatment concept without dental implants.

Inferior alveolar nerve canal / mandibular canal (Figures 1
and 2): The intraosseous course of the inferior alveolar
nerve is not always straightforward. Thus the risk for a surgical injury may vary accordingly. A bifid mandibular canalhas been reported with a frequency of 1%.1

When GBR is needed, can we use a simultaneous approachwith implant insertion or do we need a staged procedure?

Mental foramina (Figure 1)
Retromolar foramen 2

When GBR is not indicated, can we place the implant using
a flapless approach?

Sublingual fossa („lingual undercut“; Figure 2): Perforationof the lingual cortical plate during implant placement in theposterior mandible can be a severe surgical complicationand the presence of a lingual undercut is considered an
important anatomical risk factor.3

1. de Oliveira-Santos C, Souza PH, de Azambuja Berti-Couto S, Stinkens L,
Moyaert K, Rubira-Bullen IR, Jacobs R: Assessment of variations of themandibular canal through cone beam computed tomography. Clin Oral Investig
2012;16:387-93.
2. von Arx T, Hänni A, Sendi P, Buser D, Bornstein MM: Radiographic study ofthe mandibular retromolar canal: an anatomic structure with clinical importance.
J Endod 2011;37:1630-35.
3. Braut V, Bornstein MM, Lauber R, Buser D: Bone dimensions in theposterior mandible – a retrospective radiographic study using cone beam
computed tomography. Part 1 - Analysis of dentate sites. Int J Perio Rest Dent
2012;32:175-84.

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Figure 1: Visualization of the course of
the mandibular canal (+) in a patientreferred for dental implant treatment
planning in the right posterior mandible (first molar region). The mental
foramen (*) can be seen apically to thesecond premolar.

Figure 1A: Sagittal CBCT slice

Figure 1B: Coronal CBCT slice

Figure 1C: Axial CBCT slice

Figure 1D: Volume rendered data set

Figure 2A: Coronal CBCT image

Figure 2B: Sagittal CBCT image

Figure 2: Patient referred for dental
implant treatment planning in the left
posterior mandible (first molar)
exhibiting a distinct lingual undercut.
+ = mandibular canal;* = lingual undercut.

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Case Example
Extended edentulous space with two missing
premolars in the posterior mandible
Figure 1A: Sagittal CBCT image withmandibular (+) and incisive canal (*)

Figure 1: CBCT analysis of a patient referred for dental implant treatment planning of an extended edentulous space in the posterior mandible with two missing
premolars. Due to the reduced vertical and horizontal dimensions of the alveolar
ridge and the location of the mental foramen, safe dental implant insertion is
only possible in the region of the first premolar. The desired future position andangulation of the implant can be evaluated in three dimensions demonstrating theneed for simultaneous guided bone regeneration procedures at the crestal region
and the distances to the mental foramen and incisive canal.

Figure 1B: Coronal CBCT image withincisive canal (*)

Figure 1C: Axial CBCT image

Figure 1D: Volume rendered data set

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Figure 2: CBCT analysis further reveals
furcation involvement of the first molar(Figures A to C) and a root remnant of
the first premolar located distally to theapex of the canine (Figures D to F).

Figure 2A: Sagittal CBCT image withmental foramen (*)

Figure 2B: Coronal CBCT image withmandibular canal (*)

Figure 2C: Axial CBCT image

Figure 2D: Sagittal CBCT image

Figure 2E: Coronal CBCT image

Figure 2F: Axial CBCT image withmental foramen (*)
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CBCT Imaging for Implant Treatment
Planning in the Anterior Mandible
Relevant clinical questions

Anatomic structures of interest

Is correct 3-dimensional (3D) implant positioning possible?
This includes the number and dimensions (length and diameter) of the implants to be inserted?

Apart from the mental nerve, the incisive nerve is thesecond terminal branch of the inferior alveolar nerve, which
has an intraosseous course in a so-called mandibular incisive
canal (Figure 1).1
This canal is located anteriorly to the mental foramen fromboth left and right sides of the mandible. Sensory disturbances, caused by direct trauma to the mandibular incisive
canal bundle have been reported after implant placement in
the interforaminal region.2
Besides neurosensory complications, the literature describes several cases with hemorrhage and potentiallylife-threatening upper airway obstruction in the floor of themouth following implant placement.3 Those hemorrhages
were mostly related to lingual perforations, long implants
or deep osteotomy preparations.

Can we achieve good primary stability of the implant in thedesired position? If primary stability of the implant is notachievable, the clinician has to decide between site development using guided bone regeneration (GBR) or an alternative treatment concept without dental implants.
When GBR is needed, can we use a simultaneous approachwith implant insertion or do we need a staged procedure?
When GBR is not indicated, can we place the implant using
a flapless approach?

Anatomical structures and characteristics of the posterior
mandible that need to be considered, when planning dental
implant insertion are:
Lingual foramen (Figure 2) 4
Incisive canal
Genial tubercles

1. Mardinger O, Chaushu G, Arensburg B, Taicher S, Kaffe I: Anatomic
and radiologic course of the mandibular incisive canal. Surg Radiol Anat
2000;22:157–61.
2. Jacobs R, Lambrichts I, Liang X, Martens W, Mraiwa N, Adriaensens P,
Gelan J: Neurovascularization of the anterior jaw bones revisited using highresolution magnetic resonance imaging. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2007;103:683-93.
3. Mardinger O, Manor Y, Mijiritsky E, Hirshberg A: Lingual perimandibular
vessels associated with life-threatening bleeding: an anatomic study.
Int J Oral Maxillofac Implants 2007;22:127-31.
4. von Arx T, Matter D, Buser D, Bornstein MM: Evaluation of location and dimensions of lingual foramina using limited cone-beam computed tomography.
J Oral Maxillofac Surg 2011;69:2777-85.

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Figure 1A: Coronal CBCT slice

Figure 1B: Sagittal CBCT slice

Figure 1C: Axial CBCT slice

Figure 2A: Sagittal CBCT image

Figure 2B: Coronal CBCT image

Figure 2C: Axial CBCT image

Figure 2D: Volume rendered data set

Figure 1: Visualization of the courseof the incisive canal (*) in a patientreferred for dental implant treatment
planning in the right anterior mandible(first premolar region). The mental
foramen (+) can be seen disto-apicallyto the second premolar.

Figure 2: Lingual foramen in the region of the symphysis (*) that entersthe mandibular body to form a bonychannel.

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Case Example
Replacement of missing mandibular incisors
following bone loss due to periodontal disease

Figure 1: Panoramic view of a 64-year
old patient exhibiting generalized boneloss due to periodontal disease including vertical defects in the left maxillary
first molar and mandibular incisor area.
The patient complained about mobile
teeth in the anterior mandible andhalitosis.

Figure 2A: Coronal CBCT image withboth canines laterally to the planned
implants

Figure 2: CBCT analysis and implant
treatment planning in the anterior
mandibular region following periodontal
therapy including extraction of the left
maxillary first molar and three mandibular incisors. The 3D images (small
FOV: 6 x 6 cm) exhibit sufficient vertical and horizontal bone height for theplacement of two dental implants with
reduced diameter.

Figure 2B: Sagittal CBCT image for
implants in the position of the rightand left lateral incisor

Figure 2C: Sagittal CBCT image for
implants in the position of the rightlateral incisor

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Figure 2D: Axial CBCT image at acoronal and apical position

Figure 2E: Axial CBCT image at acoronal position

Figure 2F: Volume rendered data set

Figure 3: Presentation two years after
dental implant insertion in the regionof the anterior mandible. The missing
teeth were restored with a fixed partial
denture of three units including pink
porcelain to cover the bone and soft
tissue loss due to initial periodontal
breakdown.

Figure 3A: Panoramic view

Figure 3B: Periapicalradiograph

Figure 3C: Clinical aspect27140311_id_final.indd 27

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Examination of Implant Failures
and Complications Using CBCT
During the surgical procedure conventional (2-dimensional,
extra- and intraoral) radiographic techniques are adequate toconfirm the position of an implant in relation to anatomicalboundaries. In the absence of symptoms, there is no indication for 3-dimensional radiographic imaging during follow-up.
However, CBCT may be helpful for the diagnosis and management of certain post-operative complications.1

Therefore, indications for CBCT imaging when assessing complications during / after dental implant treatment
comprise:

Implant failures and complications are often caused by
implant malpositions in oro-facial direction, which can resultin a missing facial bone wall and a compromised esthetic
outcome due to mucosal recession (Figures 1 and 2).

Neurovascular disturbances following most often damage
to the mandibular canal (Figure 3), but also can result form
damage to the nasopalatine canal, or perforation of the lingual bone plate in the anterior mandible and resulting severe
hemorrhages and life-threatening airway obstructions.

When studying claims for neurosensory disturbances of theinferior alveolar nerve, implant placement accounts for only
3% of all reported cases, while being responsible for 12% of
all permanent injuries. The latter implies that a high numberof neurosensory disturbances following implant placement
are found to be of permanent nature (Figure 3).2
Postoperative complications after SFE are less common andconsist mostly of acute or chronic sinus infection, bleeding,wound dehiscence, exposure of the barrier membrane, andgraft loss. Displacement of dental implants can occur during
as well as after SFE procedures (Figure 4). In the literature,
several case reports have been published with displaced
implants into the maxillary sinus. Infections of the maxillarysinus can also be caused by dental implants perforating into
the maxillary sinus (Figure 5).

Assessment of malpositioned implants (Figures 1 and 2):
Analyze the buccal / oral bone dimensions, and proximity
to neighboring roots.

Displacement of dental implants into the maxillary sinus(Figure 4), maxillary sinus infection following sinus floor
elevation procedures with or without simultaneous dental
implant placement (Figure 5) or perforation of the floor of
the nose during implant bed preparation and/or placement.
The 3D imaging with CBCT demonstrates in the sagittal
slice a deep peri-implant bone loss on the mesial and distal
aspect of the implant, which is in agreement with a recurrent peri-implant infection (Figure 1B). The axial slice shows
the implant in a facial malposition (Figure 1C). In addition,
the implant perforates into the nasopalatal canal (*). The
sagittal slice demonstrates that the implant is not osseointegrated at all on the facial and palatal aspect (Figure 1D).

1. Harris D, Horner K, Gröndahl K, Jacobs R, Helmrot E, Benic GI, Bornstein
MM, Dawood A, Quirynen M: Guidelines for the use of diagnostic imaging in implant dentistry 2011: update of the E.A.O. A consensus workshop
organized by the European Association for Osseointegration in the Medical
University of Warsaw, Poland. Clin Oral Implants Res 2012;23:1243-53.
2. Jacobs R, Quirynen M, Bornstein MM: Neurovascular disturbances after
implant surgery. Periodontol 2000 2014 (in press).

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Figure 1: Female patient referred for
3-dimensional analysis of an esthetic
complication in the left maxillary incisor
region (Figure A). The clinical status
exhibits a mucosal recession as well
as a flattening and discoloration of the
facial mucosa at the implant crown.
The patient complained about recurrent
peri-implant infections.

Figure 1A: Clinical aspect at the initial examination

Figure 1C: Axial CBCT slice

Figure 1B: Sagittal CBCT slice

Figure 1D: Sagittal CBCT slice
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Figure 2A: Clinical aspect

Figure 2: 30-year old male patientreferred for 3-dimensional analysis
and treatment of an esthetic implantfailure in the right lateral maxillary incisor region. The clinical status exhibits
a severe mucosal recession andplaque accumulation (Figure 2A). The
respective CBCT images confirm thatthe implant has been inserted in anincorrect axis (Figures 2B to 2E) andthat the inserted implant is too large
or oversized, since it almost touches
the adjacent teeth (Figures 2C to 2E).
Figure 2B: Sagittal CBCT slice

Figure 2C: Coronal CBCT slice

Figure 2D: Coronal CBCT slice

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Figure 2E: The axial CBCT slice
confirms the oversized diameter ofthe implant filling almost the entire
edentulous space

Figure 2F: Volume rendered data set

Figure 2G: Upon removal of the implant, the extreme buccal angulation of thedental implant becomes visible31

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Figure 3: Patient referred for evaluation neurosensory disturbances in
the region of the mental nerve following implant placement in the second
premolar (i35) and second molar (i37)region of the left posterior mandible.
The CBCT images show that i35 isinserted partially into the mandibular
canal and mental foramen region.
* = mandibular canal / mental foramen.

Figure 3A: Sagittal CBCT image

Figure 3B: Coronal CBCT image

Figure 3C: Coronal CBCT image

Figure 3D: Axial CBCT image

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Figure 4: Patient referred for evaluationof the whereabouts of the implant inserted at the position of the left maxillary first molar. The CBCT images showthat the implant has been displaced
into the maxillary sinus, and that the
Schneiderian membrane exhibits an
inflammatory reaction with air-bubbles(sign for an acute sinusitis).

Figure 4A: Sagittal CBCT image

Figure 4B: Coronal CBCT image at the region of the first molar with visible
perforation of the cortical bone of the maxillary sinus

Figure 4C: Coronal CBCT image at the
distal aspect of the maxillary sinus

Figure 4D: Axial CBCT image

Figure 4E: Axial CBCT image

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Figure 5: A 57-year old male patient
was referred for evaluation of acutesinusitis symptoms on the left side
following implant placement and sinus
floor elevation (SFE). The CBCT images(medium FOV: 8 x 8 cm) show that two
dental implants (first premolar, second
molar) and a SFE procedure had been
performed on the right side. On the left,
two dental implants are visible in the firstpremolar and second molar position. The
maxillary sinus on the right (Figure 5A)
is pneumatized without signs of pathology, whereas the left sinus is opacified
and the basal lateral bone wall in theregion of the second molar is missing– probably the entry site for the SFE. In
the sinus, some foreign body material
can be diagnosed, which is most likely
grafting material from the failed SFE
procedure. The distal implant perforates
into the maxillary sinus (Figure 5B).
The diagnosis was a maxillary sinusitis of odontogenic (iatrogenic) origin.
Based on these findings, the patient
was referred to the ear, nose, throat(ENT) specialist for treatment.
Figure 5A: Sagittal CBCT image of the right maxillary sinus

Figure 5B: Sagittal CBCT image of theleft maxillary sinus

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Figure 5C: Coronal CBCT image, second molar implant regions on both sides

Figure 5D: Coronal CBCT image, firstmolar region on the right, first premolar
implant region on the left

Figure 5E: Axial CBCT image

35

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Diagnostic and Imaging Equipment
Treatment Units
Handpieces and Instruments
Endodontic System
Laser Equipment
Laboratory Devices
Educational and Training Systems
Auxiliaries
Development and Manufacturing
J. MORITA MFG. CORP
680 Higashihama Minami-cho. Fushimi-ku,
Kyoto-shi, Kyoto 612-8533. Japan
T +81. (0)75. 611 2141, F +81. (0)75. 622 4595
www.jmorita-mfg.com
Morita Global Website
www.morita.com
Distribution
J. Morita Corporation
3-33-18 Tarumi-cho. Suita-shi, Osaka 564-8650. Japan
T +81. (0)6. 6380 1521, F +81. (0)6. 6380 0585
J. Morita USA, Inc.
9 Mason. lrvine CA 92618. USA
T +1. 949. 581 9600, F +1. 949. 581 8811
J. Morita Europe GmbH
Justus-von-Liebig-Strasse 27a. 63128 Dietzenbach. Germany
T +49. (0)6074. 836 0, F +49. (0)6074. 836 299
J. Morita Corporation Australia & New ZealandSuite 2.05, 247 Coward Street. Mascot NSW 2020. Australia
T +61. (0)2. 9667 3555, F +61. (0)2. 9667 3577
J. Morita Middle East
4 Tag Al Roasaa, Apartment 902. Saba Pacha 21311 Alexandria.
Egypt T +20. (0)3. 58 222 94, F +20. (0)3. 58 222 96
Siamdent Co., Ltd.
444 Olympia Thai Tower, 3rd Floor, Ratchadapisek Road. Samsennok,
Huay Kwang, Bangkok 10310. Thailand
T +66. (0)2. 512 6049, F +66. (0)2. 512 6099
www.siamdent.com
Catalog Design: f/p design, Germany

Subject to technical changes and errors.
12.16 Implant Dentistry140311_id_final.indd 36

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