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Contents lists available at ScienceDirect

Journal of Oral Biology and Craniofacial Research

journal homepage: www.elsevier.com/locate/jobcr

Original Article

Feasibility of Dentascan in planning of implant surgery in posterior

maxilla and mandible
Siddhartha Chandela,* , Nishi Singhb , Amiya Agrawalc , Harmurti Singhd, H. Nandakumare
a
Department of Dentistry, Era’s Lucknow Medical College, UP, India
b
Department of Periodontics, Career Dental College & Hospital, UP, India
c
Department of Trauma & Emergency, KGMU, UP, India
d
Department of Maxillofacial Surgery, Career Dental College & Hospital, UP, India
e
Department of Maxillofacial surgery, KCDS, Bangalore, India

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: The present evaluate the feasibility of Computed tomography (Dentascan), in assessment of
Received 10 January 2017 the implant site in posterior maxilla & mandible.
Accepted 1 March 2017 Material and Methods: data of total 11 patients with 20 implant sites were involved in the present study.
Available online xxx
Out of the 20 implant sites selected 10 were in posterior maxilla and 10 in posterior mandible. All the
patients were routinely examined by panoramic radiography and CT. All images obtained i.e.,
Keywords: conventional panoramic radiograph, and film based Dentascan MPR- CT images were evaluated for
Implants
the detectability of mandibular canal at the mental foramen, 1 cm, 2 cm, and 3 cm posterior to mental
Panoramic radiography
Dentascan
foramen. The judgments were then compared by using the four point grading score.
Posterior maxilla and mandible Results: Both the statistical analysis and radiographic observation showed that Dentascan MPR CT gives
significantly clearer images at the mental foramen and 1 cm, 2 cm , 3 cm posterior to it. Dentascan also
provides significantly better visualization of the vital structures along with the bone density. The
panoramic and Dentascan MPR CT images did not show a significant difference in visualization of the
crest of alveolar ridge in both maxillary as well as the mandibular arch.
Conclusion: The Dentascan MPR- CT images revealed significantly clearer images as well as better
visualization of the vital structures than conventional panoramic radiography. Apart from providing
clearer images Dentascan also gives the buccopalatal/buccolingual dimension at the implant site, along
with the density of the available bone.
© 2017

1. Introduction Despite of the remarkable progress done in the field of implant

dentistry, the maxillary and the mandibular posterior regions
The modern times of dental implantology was steered in by the present unique challenging conditions in rehabilitation as
innovative work of Branemark and his coworkers. Their research compared to other regions of the jaw.4 This was shown by
demonstrated the relationship between bone and implant that longitudinal clinical studies that have reported success rate at 10
now is known as osteointegeration. They described osteointegera- years ranging from 81% to 85% for the maxilla and from 98% to 99%
tion in histologic terms as the direct contact of living bone with the for the anterior mandible. The highest failure rate has been
implant surface at microscopic level.1 Since then the use of implant reported for the posterior maxilla, which has been attributed to the
has gained immense popularity and wide acceptance.2 The fact that this area often presents specific problems for the
placement of dental implants has revolutionized our ability as placement of dental implants.5 The generally poor bone quality
oral health care practitioner to manage and restore partially frequently faced in this region in combination with inadequate
edentulous and completely edentulous state3 . Implant prosthesis bone volume, related to both the size of the maxillary sinus and
offers a more expected treatment outcome than customary resorption of the alveolar ridge have rendered long term success
restoration. rate for implants less favorable here than in the other region of the
jaws. Similarly the preoperative assessment of dental implant site
in the posterior segment of the mandible, requires accurate
* Corresponding author. localization of the mandibular canal.6
E-mail address: siddhartha.chandel@gmail.com (S. Chandel).

http://dx.doi.org/10.1016/j.jobcr.2017.03.001
0976-5662/© 2017

Please cite this article in press as: S. Chandel, et al., Feasibility of Dentascan in planning of implant surgery in posterior maxilla and mandible, J
Oral Biol Craniofac Res. (2017), http://dx.doi.org/10.1016/j.jobcr.2017.03.001
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So for the long term success, it is important to be able to place 2 cm, and 3 cm posterior to mental foramen. The judgments were
implants in mandible and maxilla with high degree of precision. then compared. The four point grading score was used for
The assessment of bone support in endosseous implants is assessment (1 = no display as a result of impossible demarcation
fundamental to the clinical utility of implants for restoration from the surrounding tissue 2 = localization of canal/sinus not
and function. Radiograph are critical tools for assessment of bony possible; discontinuity >3 mm; 3 = some artifacts, local bloating/
architecture and are useful for each of the three phases of implant too narrow/or discontinuation for short distance (1–3 mm);
placement i.e. evaluation, implant treatment and maintenance.7 4 = continuing smooth sharply defined contour.)
Conventional panoramic radiography is still the most com- For qualitative evaluation of the panoramic radiography with
monly used imaging modality in the treatment planning for Dentascan, the proximity of the vital structures (maxillary sinus
implant placement; however they don’t provide the precise and inferior alveolar canal) was assessed on a four point grading
determination of quantity and quality of the available bone which score utilizing the image evaluation questionnaire. The four point
is critical for the long term success of implants.8 grading was used to assess the visualization of the inferior border
Computer Assisted Tomography is the method of choice for of the maxillary sinus and the crest of the alveolar ridge at the
achieving the above mentioned goals, as it reveals cross sectional implant site. Similarly the superior border of the inferior alveolar
views of the dental arches, allows visualization of inclination of canal and the crest of mandibular alveolar crest were assessed
alveolar process, localization of mandibular canal and precise using the four point grading scale.
measurements of bone quantity and quality.9 With these Further the assessment of quantity of bone was done by
considerations a need was felt to evaluate the accuracy and measuring the height and width of bone available for implant
feasibility of the computed tomography (Dentascan) with pan- placement, by utilizing panoramic radiography and Dentascan. The
oramic radiography for rehabilitation of edentulous or partially height of the bone was calculated from crest of the alveolar ridge to
edentulous posterior maxilla and mandible with implants. the superior border of the inferior alveolar canal for mandible and
from the alveolar crest to the floor of the maxillary sinus for
2. Material and methods maxilla. Similarly the width of the bone was calculated in the
mesiodistal direction. Dentascan was utilized to obtain the
Total 11 patients involved in this study were aged 18 to 58 years buccolingual and the buccopalatal dimensions of bone in the
(average age 24 years; all of them were males). Total 20 implant mandible and the maxilla respectively. Further Dentascan software
sites were considered in the study. Out of these 10 were in was used to calculate the density of the available bone in
mandible and 10 in maxilla. All patients had been routinely Hounsfield units and Misch classification was used know the type
examined using conventional panoramic radiographic machine, EC of bone available for implant placement. Misch classified the type
PROLINE (Planmeca Of Asentajankatu – Helinski Finland). Ten of bone as D1- dense cortical bone(>1250 HU), D2- thick dense to
panoramic radiograph had been processed using standard porous bone on crest and course trabecular bone within (850–
processing conditions. 1250 HU), D3- thin porous cortical bone on crest and fine
High resolution,1.5 mm thick axial slices with 1 mm slice trabecular bone within (350–850 HU) D4- fine trabecular bone
interval,120 kVp,120 Ma, 512  512 matrix had been used as the (150–350 HU), D5- immature- non mineralized bone (<150 HU.
protocol of CT examination. The axial CT data had been transferred
to a workstation and reformatted by Dentascan to generate 3. Results
paraxial and panoramic images and printed on films (Kodak T mat).
The archived axial CT data were stored on CD- R and transferred to The distribution of grading score for visibility of mandibular
a personal computer with 15.1 in LCD monitor. Paraxial and canal according to the radiographic methods (panoramic radiog-
Panoramic images were reconstructed using Dentascan software. raphy/Dentascan) in the four regions (at the mental foramen, 1 cm,
All images obtained i.e., conventional panoramic radiograph, 2 cm, and 3 cm posterior to mental foramen) (Table 1). The
and film based Dentascan MPR- CT images were evaluated for the mandibular canal was better visualized with Dentascan MPR-CT
detectability of mandibular canal at the mental foramen, 1 cm, than panoramic radiography in all the four regions. Especially at

Table 1
Comparison of Visibility of Mandibular Canal And Mental Fo Ramen in Panoramic Radiograph and Dentascan.

Visibility of mandibular canal and Mental foramen Poor Severe limitation Slightly limited Excellent Mean  SD P value
(1) (2) (3) (4)

At mental foramen Panoramic radiograph 1 0 5 4 3.20  0.92 0.589

(10.0%) (50.0%) (40.0%)
Dentascan 1 0 3 6 3.40  0.97
(10.0% (30.0%) (60.0%)

At 1 cm from mental foramen Panoramic radiograph 1 3 5 1 2.60  0.84 0.009**

(10.0%) (30.0%) (50.0%) (10.0%)
Dentascan 0 0 3 7 3.70  0.48
(30.0%) (70.0%)

At 2 cm from mental foramen Panoramic radiograph 0 2 5 3 3.10  0.74 0.034*

(20.0%) (50.0%) (30.0%)
Dentascan 0 0 3 7 3.70  0.48
(30.0%) (70.0%)

At 3 cm from mental foramen Panoramic radiograph 0 2 4 4 3.20  0.79 0.038*

(20.0%) (40.0%) (40.0%)
Dentascan 0 0 1 9 3.90  0.32
(10.0%) (90.0%)

Please cite this article in press as: S. Chandel, et al., Feasibility of Dentascan in planning of implant surgery in posterior maxilla and mandible, J
Oral Biol Craniofac Res. (2017), http://dx.doi.org/10.1016/j.jobcr.2017.03.001
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Table 2
Comparison of Vital Structures at Implant Site in Panoramic Radiograph and Dentascan for Maxilla.

Vital structures in maxilla Poor Severe limitation Slightly limited Excellent Mean  SD P value
(1) (2) (3) (4)

Visualization of the inferior border of maxillary sinus Panoramic radiograph 0 5 4 1 2.60  0.69 0.006**
(50.0%) (40.0%) (10.0%)
Dentascan 0 0 2 8 3.80  0.42
(20.0%) (80.0%)

Visualization of the crest of the alveolar ridge Panoramic radiograph 0 1 7 2 3.10  0.57 0.157
(10.0%) (70.0%) (20.0%)
Dentascan 0 0 7 3 3.30  0.48
(70.0%) (30.0%)

the region 1 cm posterior to mental foramen conventional provides density of the available bone at implant site which cannot
radiograph showed markedly lower percentage of excellent be assessed by panoramic radiography.
mandibular canal image than the other images.
The Dentascan MPR CT images gave significantly clearer (P 4. Discussion
value .006) images of the inferior border of the maxillary sinus as
compared to the images obtained by panoramic radiography Oral implants have become a common method of treatment for
(Table 2). Excellent images of the inferior border of the maxillary both completely and partially edentulous patients. The successful
sinus could be obtained in only 10% of the panoramic radiographs placement of implants requires careful pre-operative radiographic
as compared to the 80% of excellent images obtained in dentascan. examination as an adjunct to clinical examination. Thus, it is
Similarly the Dentascan offered significantly clearer images of the necessary to use imaging techniques that accurately determine the
superior border of the inferior alveolar canal as compared images size and location of structures such as mandibular and incisive
obtained by panoramic radiography (P value .003) Figs 1 and 2. canals, maxillary sinus, nasal fossa, density of alveolar ridges and
Excellent images of the superior border of the inferior alveolar cortical plates at the proposed site for implant placement.10 In the
canal could be obtained in only 10% of cases as compared to the 90% posterior part of mandible it is necessary to determine the amount
of excellent images obtained in dentascan. The dentascan offered of bone superior to mandibular canal. The length of implants in the
clearer visualization of the crest of alveolar ridge in maxilla as well posterior region of mandible is chosen according to the amount of
as the mandible (P value .002). bone available superior to inferior alveolar canal, to avoid trauma
Further the quantity of bone in mandible was assessed by to inferior alveolar nerve.11,12 Trauma to inferior alveolar nerve may
measuring the height of the bone from crest of the alveolar ridge to lead to severe hemorrhage and neurosensory deficits over the
the superior border of the inferior alveolar canal and also the mesio distribution of inferior alveolar nerve13 .
distal bone available at the implant site, by panoramic radiography Conventional panoramic radiography is still, the most com-
and dentascan respectively. The dentascan offers significantly monly used imaging modality to localize the mental foramen and
better estimation of the quantity of bone as compared to the the mandibular canal for the preimplant treatment planning in the
panoramic radiograph as shown in Table 3, (P <.001). Apart from posterior mandible, but the mandibular canal is often difficult to
better quantitative estimation of the available bone dentascan also locate in these regions with this technique. On panoramic

Fig. 1. Distribution of the grading score for visibility of vital structures in the maxilla.

Please cite this article in press as: S. Chandel, et al., Feasibility of Dentascan in planning of implant surgery in posterior maxilla and mandible, J
Oral Biol Craniofac Res. (2017), http://dx.doi.org/10.1016/j.jobcr.2017.03.001
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Fig. 2. Distribution of the grading score for visibility of vital structures in the Mandible.

radiographs the mandibular canal is visualized in the ramus and in WI, U.S.A.) was used to assess the quantity and quality of the bone.
the molar regions. In our study the conventional panoramic The Dentascan is a software program that allows the mandible and
radiography showed markedly lower percentage of excellent the maxilla to be imaged in three planes: axial, panoramic, and
image at the region 1 cm posterior to the mental foramen than cross sectional. It has been widely used pre- operatively for
other regions.4 implant surgery as it provides a comprehensive assessment of the
The high number of not visible canals recorded for conventional morphology and measurement of the dental implant site14 . The
radiographic method is probably related to the fact that the inferior software also provides the valuable information regarding the
alveolar nerve bundle is not always surrounded by an ossified density of bone available at implant site, as the accurate
canal. The bony sheath looks to disappear anteriorly towards the information on bone density will help the surgeon identify
mental foramen7. However the present study showed that suitable implant sites, and to predict the primary stability before
computed tomography gave a better degree of visualization of the implant insertion, thereby improving the surgical planning
the vital structures (maxillary sinus/inferior alveolarcanal) than and, eventually, the success rate of the procedures15,16.
panoramic radiography. Apart from the better visualization of the Any comparison of the radiation risk from CT with that from
vital structures the CT have the advantage over panoramic conventional panoramic radiography is problematic, but it would
radiography in that it does demonstrate the buccolingual location appear from the literature that clinician has to balance these risks
of the inferior canal, in addition to the vertical distance from the against the benefit in planning dental implants. It is suggested that
crest. In one of the patient placement of implant was deferred due for routine cases where implants of satisfactory length can be
to inadequate width of the buccolingual bone available, though the inserted safely, panoramic radiographs are adequately accurate.
patient had adequate vertical bone height for implant placement But in cases where measured vertical height is inadequate and the
as depicted by the panoramic radiograph. In addition, the images of option of interpolating the implant lateral to inferior canal is
the trabecular pattern, cortical plates and bone margins were all contemplated, CT scanning (Dentascan) serves the surgical team as
clear in the CT. comprehensive examination to achieve optimum results. The same
In the present study Dentascan (Computer tomography considerations apply to implants located beneath the maxillary
software program developed by General Electricals, Milwaukee, sinus.

Table 3
Comparison of Vital Structures at Implant Site in Panoramic Radiograph and Dentascan for Mandible

Vital structures Poor Severe limitation Slightly limited Excellent Mean  SD P value
(1) (2) (3) (4)

Visualization of the superior border of inferior alveolar canal Panoramic radiograph 0 1 8 1 3.00  0.47 0.003**
(10.0%) (80.0%) (10.0%)
Dentascan 0 0 1 9 3.90  0.32
(10.0%) 90.0%)

Visualization of the crest of the alveolar ridge Panoramic radiograph 0 0 2 8 2.80  0.42 0.002*
(20.0%) (80.0%)
Dentascan 0 0 1 9 3.90  0.32
(10.0%) (90.0%)

Please cite this article in press as: S. Chandel, et al., Feasibility of Dentascan in planning of implant surgery in posterior maxilla and mandible, J
Oral Biol Craniofac Res. (2017), http://dx.doi.org/10.1016/j.jobcr.2017.03.001
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Please cite this article in press as: S. Chandel, et al., Feasibility of Dentascan in planning of implant surgery in posterior maxilla and mandible, J
Oral Biol Craniofac Res. (2017), http://dx.doi.org/10.1016/j.jobcr.2017.03.001