CLINICAL

Essential guidelines for using cone beam

computed tomography (CBCT) in implant
dentistry. Part 2: Clinical considerations
Johan Hartshorne1

Summary
The purpose of Part 2 of this series is to provide dentists with clinical guidelines and
recommendations pertaining to: (i) radiographic selection criteria; (ii) indications for
CBCT; (iii) how to read a data volume; (iv) application and use; and (v) the advantages
and limitations of CBCT in implant dentistry. The knowledge gained and guidelines
provided will enhance dentists understanding on when to use a CBCT, how to
systematically analyse and read the data volume in order to maximize diagnostic and
treatment planning benefits of this technology, whilst optimizing patient safety and
minimizing radiation-related patient risk. The potential benefits for accurate assessment,
diagnosis of pathologies, identification of anatomical landmarks and neurovascular
structures, as well as topographical and morphological deviations in alveolar bone, in
pre-surgical treatment planning are undisputed and has resulted in CBCT becoming the
new professional standard of care as imaging modality for diagnosis and pre-surgical
treatment planning in implant dentistry. A protocol is proposed on how to do a
structured review and read a CBCT data volume to ensure that pathosis or critical
anatomical structures are not missed that may impact on, and to enhance diagnosis,
treatment planning and treatment outcomes. Additionally, CBCT imaging and 3D
computer software has significantly increased the accuracy and efficiency of diagnostic
and treatment capabilities, thereby contributing towards more predictable treatment
outcomes and improved patient care in implant dentistry. With this technology,
adequately trained dentists can enhance their practice and best serve the interests of
their patients.

Introduction
The role of 3D CBCT imaging as a new diagnostic tool in modern day dentistry cannot
be overemphasized and has increasingly been referred to as the ‘standard of care’ for
diagnostic maxillofacial imaging.1,2,3 It serves as an essential diagnostic tool for clinical
assessment and treatment planning and has revolutionized every aspect of how dental
implant practices are performed.4,5,6
Traditionally pre-operative information for dental implant diagnostics and treatment
planning have been obtained from clinical examination, dental study model analysis,
and two-dimensional (2D) imaging such as intra-oral peri-apical, lateral cephalometric,
and panoramic radiography. These radiographic procedures, used individually or in
combination, suffer from the same inherent limitations common to all planar two-
1
Johan Hartshorne dimensional (2D) projections namely, magnification, distortion and angulation
B.Sc., B.Ch.D., M.Ch.D., M.P.A., discrepancies, superimposition, and misrepresentation of structures.7 When an implant
Ph.D., (Stell), FFPH.RCP (UK) is to be placed in proximity to a vital structure, such as a nerve, artery, or sinus cavity;
General Dental Practitioner,
Intercare Medical and Dental Centre,
or where there are bone morphology discrepancies; radiographic information from
Tyger Valley, Bellville, 7530 traditional 2D radiographic imaging is limited due to its inadequacy to properly assess
South Africa the distance in proximity to vital neuro-vascular or anatomical structures, or when implant
[email protected] placement is potentially violating critical cortical bone margins. The resulting errors from

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the reliance on the traditional imaging leads to potential of the scientific literature and provide clinical guidelines
complications, soft-tissue insufficiency, implant failure, and pertaining to: (i) selecting the appropriate radiographic
paresthesia.8,9 Complications may lead to an unsatisfactory imaging modality; (ii) indications for using CBCT; (iii) how
patient outcome, referral to other specialists, and subsequent to read and analyze a CBCT data volume; (iv) clinical
medico-legal claims.2,10 application and use; and (v) the advantages and limitations
The introduction and widespread use of CBCT imaging of CBCT in implant dentistry. The knowledge gained and
over the last decade has enabled clinicians to diagnose and guidelines provided will enhance clinicians understanding
evaluate the jaws in three dimensions, thus replacing when to use a CBCT, how to systematically analyse and
computed tomography (CT) as the standard of care in read the data volume in order to maximize diagnostic and
implant dentistry.11 Furthermore, CBCT imaging has treatment planning benefits of this technology whilst
revolutionized dento-maxillofacial radiology by overcoming optimizing patient safety and minimizing radiation-related
the major limitations of conventional 2-D intraoral, patient risk. Radiographic images used were obtained from
cephalometric and panoramic radiograph12, thereby a Kodak Carestream CS9300 CBCT unit.
facilitating accurate pre-surgical treatment planning that is
key to successful dental implant rehabilitation. Published Guidelines for selecting appropriate radiographic
studies have reported improved clinical efficacy and imaging modalities and indications for using CBCT
diagnostic accuracy of CBCT13,14, compared with standard The goal of radiographic selection criteria is to identify
radiographic techniques for the evaluation of implant sites appropriate imaging modalities that complement diagnostic
with challenging unknown anatomical boundaries and/or and treatment goals prior to and at each stage of dental
pathological entities, and for ideal positioning of dental implant therapy. The following consensus-derived clinical
implants.15,16 guidelines and recommendations allow practitioners to select
The value of CBCT imaging as a diagnostic tool has also the appropriate imaging modality (with particular relevance
been reported for various other fields of dentistry such as oral- to CBCT) at each phase of dental-implant therapy.20 The
maxillofacial surgery, dental traumatology, endodontics, American Association of Endodontists (AEE) and the
temporo-mandibular joint, periodontology, orthodontics, American Association of Oral and Maxillofacial Radiology
airway analysis and fabrication of implant surgical (AAOMR) have also jointly developed a position statement
guides.7,17 to guide clinicians on the use of CBCT in endodontics and
As in any new technology introduced to a profession, the to support decision-making when to treat or to extract.21
education lags far behind the technological advance. This Additional guidelines have also been published by the
is especially true of cone beam imaging. Dentists are quick European Society of Endodontology.22
to grasp the advantages and applications of using cone
beam technology but, once adopted, often make the Initial examination
following statements: “These images are great, but what am The purpose of the initial radiographic examination is to assess
I looking at, and where can I get more information on the overall status of the remaining dentition, to identify and
interpreting the scan?”18 An important basic requirement of characterize the location and nature of the edentulous regions,
using CBCT imaging as a diagnostic tool is that practitioners and to detect regional and site-specific anatomic structures
should have appropriate training to develop critical skills for and pathologies. The initial diagnostic imaging examination
operating CBCT equipment, managing imaging software is best achieved with panoramic radiography and may be
and acquiring a high level of competence and confidence supplemented with periapical radiography.20 The use of CBCT
in using and interpreting CBCT images. Such training should is not recommended as an initial diagnostic imaging
include a thorough review of normal maxillofacial anatomy, examination. However, CBCT may be an appropriate primary
common anatomic variants, and imaging signs of diseases imaging modality in specific circumstances, for example when
and abnormalities. This is particularly important for CT and multiple treatment needs are anticipated or when jawbone or
CBCT imaging because of the complexity of structures within sinus pathology is suspected.11
the expanded FOVs.19
Endodontic assessment decision to treat or to extract
Purpose Radiographic imaging is an indispensable component of
The purpose of Part 2 of this series is to provide an overview endodontic diagnosis and treatment planning, i.e. decision

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to do endodontic treatment or to extract, partial extraction proportion of borderline cases, will show that implants can
therapies, and consideration of dental implant therapy. The be placed without recourse to sinus surgery.24, 25 Because
AAE and AAOMR21 recommend that intraoral and cross-sectional imaging offers improved diagnostic efficacy,
panoramic radiography be used for the initial evaluation of it is the preferred method for preoperative assessment for
the endodontic and dental implant patient. Both of these sinus augmentation surgery.
position statements emphasize that CBCT imaging should be
used only when the diagnostic information is inadequate by Postoperative imaging
conventional intraoral (periapical X-rays) or extraoral The purpose of postoperative imaging after dental implant
(panoramic) radiography, and when the additional placement is to confirm the location of the fixture and crestal
information from CBCT is likely to aid diagnosis and decision bone levels at implant insertion.
making for endodontic treatment or extractions, and planning Intraoral periapical radiography is recommended for this
for immediate or future dental implants therapy. A CBCT with purpose and is commonly referred to as the baseline image.
limited FOV is the preferred imaging protocol for most Intraoral periapical radiography is also recommended for
endodontic applications.23 periodic postoperative assessment of the bone-implant
Thus, CBCT imaging should be prescribed for patients interface and marginal peri-implant bone height implants.20
who present with nonspecific or poorly localized clinical Panoramic radiographs may be indicated for screening of
signs and symptoms of periapical pathology, but in whom more extensive implant therapy cases. Titanium implant
conventional radiography fails to identify such pathology. fixtures inherently produce artifacts such as beam-hardening
CBCT is particularly useful in investigating the potential cause and streak artifacts with CBCT, obscuring subtle changes in
for endodontic treatment failures. However, the clinician must marginal and peri-implant bone. In addition, the resolution
recognize that the diagnostic accuracy is influenced by the of CBCT images for the detection of these findings is inferior
presence of beam hardening artifacts from metal posts or to intraoral radiography.
gutta percha. CBCT imaging however, is indicated if the patient presents
with implant mobility or altered sensation, especially if the
Pre-surgical site-specific imaging fixture is in the posterior mandible.20,23 to facilitate
Pre-surgical site-specific imaging must provide information assessment, characterizing the existing defect, and planning
supportive of dental implant diagnostics and treatment for surgical removal and corrective procedures.
planning goals. Such information includes: (i) quantitative
bone volume availability (height and width); (ii) edentulous Indications for CBCT in implant dentistry
saddle length; (iii) orientation of the residual alveolar ridge; Harris and co-workers26 provide the following guidelines for
(iv) anatomical and pathological conditions that can restrict clinical situations where patients might potentially benefit from
implant placement; and (v) to facilitate prosthetic treatment CBCT imaging for diagnosis and treatment planning.
planning. CBCT is recommended as the imaging modality (i) When the clinical examination and conventional
of choice for pre-surgical diagnostics and treatment planning radiography have failed to adequately demonstrate relevant
of potential dental implant sites.20 CBCT imaging is also anatomical boundaries and the absence of pathology.
indicated if bone reconstruction and augmentation (ii) When reference to such images can provide additional
procedures (e.g., ridge preservation or bone grafting) are information that can help to minimize the risk of damage to
required to treat bone volume deficiencies before or with important anatomical structures and which is not obtainable
implant placement. The use of CBCT before bone grafting when using conventional radiographic techniques.
helps define both the donor and recipient sites, allows for (iii) In clinical borderline situations where there appears to
improved planning for surgical procedures, and reduces be limited bone height and/or bone width available for
patient morbidities. successful implant treatment.
Panoramic views of the posterior maxilla will underestimate (iv) Where implant positioning can be improved so that
the amount of bone available for implant placement and, if biomechanical, functional, and esthetic treatment results are
relied on, will therefore overestimate the number of clinical optimized.
situations requiring a sinus augmentation. CBCT can The diagnostic information can be enhanced by use of
overcome this problem as it provides more accurate radiographic templates, computer-assisted planning, and
measurements of the available bone volume and, in a surgical guides.26

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The CBCT scan (data volume) provides cross sections

through various planes allowing 3-dimensional evaluation of
hard and soft tissues. There are three orthogonal planes
(Fig.1): (i) axial or horizontal plane that provides cross
sections of the data volume from top to bottom of the FOV;
(ii) coronal or frontal or side view, that provides cross
sectional views from front to back of the FOV; (iii) sagittal
view provides cross sections from buccal to lingual, or left to
right of the FOV. Besides the three planes there is also a 3-
D rendering (Fig.1 – Upper right)
A structured or systematic approach for reading a CBCT
Figure 1: Orthogonal planes (10 x 10 FOV): Axial or horizontal
scan is recommended because there is a huge amount of
plane (top to bottom cross sections)(upper left), 3D Rendering (upper
right), Coronal or frontal plane (front to back cross sections) (lower anatomy contained within the scanned volume and unless a
left), and Saggital plane (right to left or buccal to lingual cross structured approach is used, it is likely that you will miss some
sections) (lower right) information that could impact on your diagnosis and
treatment planning.
How to do a structured review of a CBCT data volume
All CBCT volumes, regardless of clinical application, should Protocol for structured reviewing of a CBCT data
be evaluated in a structured fashion for signs of abnormalities volume
and to ensure that no available diagnostic and treatment Each section of the data volume (FOV) must be reviewed and
planning information is missed. Dental practitioners must not analyzed for possible clinically significant findings. This
be caught in the trap of only looking at the data they are requires discipline, and it may take some time and practice
interested in, such as an impacted tooth or implant site to establish a pattern so as to make it almost “second nature”
evaluation, or characterization of some pathologic entity that to follow this process. In reviewing each of the anatomical
they found in another radiograph. They must examine all the structures in the FOV, special attention is paid to the “main
data in the scan and must do so in a systematic and complaint” or the reason for the scan acquisition. The
somewhat structured fashion.18 purpose of a structured reviewing process is to prevent
Reviewing CBCT scans can be performed by an overlooking significant diagnostic findings that may have an
adequately trained dentist or specialist treating the patient, impact on the success or predictability of outcome of implant
or alternatively, a specialist maxillofacial radiologist.20 treatment and any other abnormalities that may lead to
Critical skills that dentists need for reviewing CBCT scans medico-legal actions. The following reviewing protocol is
are: (i) know what they are looking at; (ii) mastering the based on the Kodak Carestream CS9300-3D unit.
CBCT imaging software and speaking the CBCT language;
(iii) how to manipulate and work through the data volume; (i) Clinical history: Start by reviewing the clinical history, what
(iv) reading the CBCT; (v) analyzing and interpreting the is the purpose of the data acquisition, which teeth have been
data; (vi) understanding the different anatomical structures removed when, to explain areas of bone loss with healing
that can cause problems in implant placement surgery; and and/or residual alveolar bone defects. Know if previous
(vii) applying the imaging software to do virtual implant bone grafts or socket augmentations were done previously.
treatment planning. A wide range of video tutorials are
available on You Tube and the Internet on how to use CBCT (ii) Orientation: Open the patient’s data volume. The default
3D Imaging Software. scan is usually on ‘Orthogonal Slicing” (Fig.2). Select
To meet these CBCT reviewing objectives, clinicians need ‘Curved Slicing’ on the upper menu bar (Fig.3). Identify the
to acquire the necessary skills and images should have three cross-sectional planes: axial is upper left, sagittal is
appropriate diagnostic quality and not contain artifacts that upper right, 3D rendering is lower left, and coronal is lower
could compromise anatomic-structure assessments. Images right (Fig.3). Identify where is left and right and buccal a
should also extend beyond the immediate area of interest to lingual, and the horizontal (yellow) and vertical (blue and
include areas that could be affected by implant placement red) lines and cursor buttons used for scouting and orientation
or vice versa. vertically and horizontally along the planes.

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2 3

Figure 2: Opening the patients data volume defaults on orthogonal slicing. (5x5 FOV)
Figure 3: Orientation of patient’s data volume on ‘Curved Slicing’ (5 x 5 FOV) - axial plane (upper
left), sagittal plane (upper right), 3D rendering (lower left) and coronal plane (lower right)
Figure 4: Activate “Manually Create Arch” on the tools (5 x 5 FOV) 4

Scout the axial (Top to bottom) (yellow cursor line), coronal Note any morphological abnormalities, neurovascular
(front to back) (red cursor line) and sagittal (right to left) (blue structures, anatomical structures (sinus, nasal), and residual
cursor line) planes by moving the horizontal and vertical lines alveolar ridge morphology or other clinically significant
to orient yourself where you are and what you are looking at. findings that may have an impact on implant treatment
planning. Move the horizontal line of the sagittal cross
(iii) Set arch on the axial plane: Select the ‘Manually Create section (upper right) to 1mm below the crestal level. (Fig.6)
Arch’ icon on the tool menu on the left side of the image. (vii) Implant treatment planning: Software tools can now be
(Fig.4) A text box will pop up with prompt: ‘Delete Previous applied to facilitate implant treatment planning. Activate the
Arch’ Select OK. Move the blue cursor button on the ‘Measurement Mode’ icon in the ‘Tools Menu’ (Fig.7). Go to
horizontal bar below the axial cross section to get a good the axial cross section (upper left) and click buccal and then
cross sectional view of the roots on the arch (Fig.4). Click palatal to measure the bucco-palatal width. Go to sagittal
and draw an arch through the center of the root from left to cross section (upper right) and click mesial to distal of the
right side (Fig.5). implant site to measure the saddle length of the residual
alveolar ridge (Fig.7). Go to the coronal cross section (lower
(iv) Scouting the coronal cross section: Go to the sagittal right) and measure the width and length of the residual
plane (upper right cross section) (Fig.6). Move the vertical alveolar bone (Fig.7). If the implant site is in the lower
cursor (Blue) from left to right on the FOV to review the posterior mandible then measure from the crestal level to 2
coronal cross section (lower right) to identify clinically mm above the inferior alveolar nerve. The correct implant
significant pathosis and neurovascular structures (Fig.6). diameter and length can now be selected for this implant site.
Return again to the center of the area of interest with the
vertical line in the sagittal cross sectional plane. (viii) Virtual implant selection and placement: Position the
vertical line in the correct position of the osteotomy site in the
(v) Scouting the sagittal cross section: Go to the coronal cross coronal cross section (Lower right). Activate the ‘Implant
section (lower light) (Fig.6). Move the red cursor of the Placement Tool’ icon in the ‘Tool Menu’ (Fig.8). Select the
vertical line from buccal to lingual (left to right) to review the desired implant type, diameter and length according to the
upper sagittal cross section to identify any clinically abovementioned measurements. Adjust fine tuning of the
significant pathosis and neurovascular structures. Return implant in its correct three dimensional position by checking
again to the center of the area of interest with the red vertical all three planes (axial, sagittal and coronal (Fig.9). A stent
line in the coronal cross sectional plane. (Fig.6) At this stage can also be used to position the vertical line in the correct
the ’Nerve Canal Tool’ icon can be activated to plot the position where the implant must be placed. (Figure 10)
inferior alveolar nerve. (Fig.7) Check placement of the implant in all three planes to assess
whether the cortical plate, anatomical structures such as the
(vi) Review area of interest (Implant site): Lastly scout and sinus and nasal cavity, neurovascular structures and
assess the region of interest (implant site) and adjacent teeth. neighboring teeth are not violated and that the implant is

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5 7
Figure 5: Setting the arch on the axial plane by clicking on centre of the roots to draw an arch (red
dots and line).
Figure 6: Scouting the data volume & reviewing the area of interest.
Figure 7: Activating ‘Nerve Canal Tool’ icon to plot the inferior alveolar nerve and ‘Measurement mode’
icon for measuring the implant osteotomy site. Typical implant treatment planning measurements –are
saddle length (mesio-distal) (upper right), residual alveolar bone width (bucco-lingual) and vertical
length (occlusal-apical) (lower right).

placed in the correct 3D position in the residual alveolar formulate a diagnosis and to assist in implant therapy
bone for optimal implant stability and a successful prosthetic treatment planning.27
restoration. Go to the menu bar above the sagittal cross The introduction and widespread use of cone beam
section (upper right) and select ‘Set Integration’ and select computed tomography (CBCT) over the last decade has
15mm on the scroll down menu to activate ray sum for the enabled clinicians to diagnose and evaluate the jaws in
sagittal cross section to simulate a typical panoramic X-ray. three dimensions, thus replacing computed tomography (CT)
The magnification tool can be used to better assess the area as the standard of care for implant dentistry.11 Additionally,
of interest (Fig.11) The virtual implant planning and multiplanar imaging-reformatting (MPR) of CBCT has
placement can now be communicated visually and discussed significantly increased diagnostic accuracy and
with the patient. efficiency13,14 and offers an unparalleled diagnostic
approach when dealing with previously challenging
Application of CBCT imaging in implant dentistry unknown anatomical boundaries and/or pathological
Successful and predictable implant dentistry requires entities.15 This has prompted several different organizations
accurate pre-surgical diagnostics and treatment planning to develop clinical guidelines and recommendations for the
information of the amount of bone available, bone density appropriate use of CBCT for assessing potential dental
and the proximity to anatomical structures. Health care implant sites. These include the American Academy of Oral
providers are also obligated to acquire adequate information and Maxillo-Facial Radiology (AAOMR),20 European
from patients to provide a basis for informed patient Academy of Osseointegration (EAO),26 International
consent.18 Clinical complexity, regional anatomic Congress of Oral Implantologists (ICOI),28 the Academy for
considerations, potential risk of complications and aesthetic Osseointegration (AO)29 and the International Team for
considerations in the location of implants are factors that Implantology.”(ITI).11
determine the individual clinicians needs for information Cone beam computed tomography (CBCT) has
supplemental to that already obtained from the clinical and applications in several aspects of dentistry. To appropriately
radiographic examinations (peri-apical and panoramic) to use this technology, clinicians should be able to identify those

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Figure 8: Activate the ‘implant placement tool’ icon to select the type Figure 9: Virtual implant placement in the correct 3D position.
of implant, implant diameter and length.

Figure 10: Using a radiographic stent for virtual implant placement. Figure 11: Using the magnification tool to assess views in close-up
to check that the implant is placed in the correct 3D position.

situations where the information from CBCT is likely to the residual alveolar ridge limiting implant placement.16
provide useful information, and where this additional
information translates into enhanced diagnoses, treatment Quantitative bone availability of the residual alveolar
plans and treatment outcomes.23 The application or use of ridge (amount of bone available at the implant site
CBCT in implant dentistry includes: (i) pre-surgical Effective pre-surgical assessment requires that clinicians
diagnostics and treatment planning; (ii) computer-assisted interpret implant sites for many factors related to predictable
treatment planning; and (iii) postoperative evaluation and successful implant restorations, including adequate bone
focusing on implant failures and complications due to volumes, distance away from teeth/implants, sufficient
damage of neurovascular structures.13,16 prosthetic space for restoration, and precise implant
placement. Essential pre-surgical assessment should include
Pre-surgical diagnostics and treatment planning an evaluation of the saddle length (mesio-distal), vertical
Radiographic assessment of the 3D implant position, bone height (occlusal-apical), and horizontal width (bucco-
angulation, and restorative space is essential during pre- lingual) bone availability of the proposed implant recipient
surgical diagnostics and treatment planning of implant sites site (Fig.7) to facilitate proper planning, correct implant
within the residual alveolar bone. Positioning of single implants selection, 3D placement of the dental implant (Fig.9) and the
within the dental arch can be challenging considering the necessity for implant site development.20,30
proximity to adjacent tooth roots, vital structures, occlusal Most CBCT viewing and analyses software packages
plane, and relative position within the arch.30 CBCT imaging feature measurement tools that can be used to easily
therefore must provide information supportive of the following determine the height and width of bone and the proximity of
goals, namely (i) to establish the quantitative bone availability the proposed implant placement site to adjacent vital
(morphologic characteristics) of the residual alveolar ridge; (ii) structures. With this software the clinician can accurately
to determine the orientation of the residual alveolar ridge; and visualize the 3D alveolar ridge bone contour of a patient
to (iii) identify local anatomic or pathologic boundaries within and make determinations about surgical entry, implant

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diameter and length, and prosthetic requirements before the radiographs, but CBCT provides the advantage of showing
surgical procedure.30 the type of alveolar ridge pattern present. Cross-sectional
CBCT also provides a qualitative assessment of the type images (coronal view) provide the implantologist with the
of bone (bone quality) and local trabecular architecture appearance of ridge patterns, such as irregular ridge
(Fig.12a-12c and 13a-13d) to assist in selecting the correct (Fig.21a, 21b), narrow crestal ridge (Fig. 21c, 21d)), and
implant type to optimize implant stability. The standard knife shape ridge (Fig.21e and Fig.22). Also, the loss of
practice is to visually analyze trabecular density and cortical plates and undulating concavities (Fig.23) can also
sparseness at the edentulous site. Some studies have be appreciated on cross-sectional images, and they cannot
explored the feasibility of measuring CBCT gray values at be seen on panoramic images. In the case of a
the edentulous area to infer bone quality.31,32 However, there compromised jaw bone (in terms of quality and/or quantity
is strong evidence that the relationship between gray value of bone), the panoramic technique is an inefficient imaging
and object density is markedly influenced by several factors, tool. In case of potential risks in treatment plan 3D imaging
including exposure parameters, FOV and anatomic may prove indispensable.
location.33,34,35,36 Thus, current gray value approaches to Bone quality is not only a matter of mineral content, but
quantitatively assess bone quality are unreliable. also of structure. It has been shown that the quality and
CBCT is an essential tool to identify the extent and size of quantity of bone available at the implant site are very
bone defects at potential implant sites that may require important local patient factors in determining potential
augmentation or site development to prepare it for implant stability and the success of dental implants. Bone
simultaneous or later implant placement.26 quality is categorized into four groups: groups 1–4 or types
Examples where augmentation or site development 1–4 (Bone Quality Index):37
procedures are required are horizontal bone volume Type 1: homogeneous cortical bone; (Fig.13a )
deficiencies (Fig.14), fenestration defects (marginal bone Type 2: thick cortical bone with marrow cavity; (Fig.13b)
intact) (Fig.15), dehiscence bone defects (denuded areas Type 3: thin cortical bone with dense trabecular bone of
extend through the marginal bone (Fig. 16a & 16b), post good strength (Fig.12a, 13c); and
extraction site ((fig.17), vertical bone deficiency (Fig.18), Type 4: very thin cortical bone with low-density trabecular
and combined horizontal and vertical bone deficiencies of bone of poor strength. (Fig.12c)
the alveolar ridge (Fig.19), and sinus floor elevations In the jaws, an implant placed in poor-quality bone with thin
(Fig.20). cortex and low-density trabeculae (Type 4 bone) has a higher
The use of CBCT before bone block grafting helps define chance of failure compared with the other types of bones. This
both the donor and recipient sites, allows for improved low-density bone is often found in the posterior maxilla, and
planning for surgical procedures, and reduces patient several studies report higher implant failure rates in this region.37
morbidities.
Ridge morphology (Bone shape and quality) Shape and Topography and orientation of the residual alveolar bone
quality of the bone available The orientation and residual topography of the alveolar-basal
The bucco-lingual ridge pattern cannot be viewed on 2D bone complex must be assessed to determine whether or not

12a 12b 12c

Figure 12: Qualitative pre-surgical assessment of alveolar bone and trabecular architecture in the maxilla
Figure 12a: (Type 2 bone). Figure 12b: (Type 3 bone). Figure 12c: (Type 4 bone).

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13a 13b 13c 13d

Figure 13: Qualitative pre-surgical assessment of alveolar bone density and trabecular architecture in
the mandible. Figure 13a: (Type 1 bone). Figure 13b: (Type 2 bone). Figure 13c: (Type 3 bone). Figure
13d: (Type 4 bone).

there are variations that could compromise the alignment of anatomy is provided in the literature.15, 37,38,39,40,41,42 For the
the implant fixture with the planned prosthetic restoration. This purposes of this article only the critical anatomical elements
is particularly important in the mandible (e.g., submandibular related dental implantology is presented.
gland fossa) (Fig.24) and anterior maxilla (e.g., labial
cortical bone concavity).20 (Fig.25) Information on the Anterior maxilla
topography and orientation of the residual alveolar bone is The maxillary anterior region (commonly referred to as the
important to optimize implant selection and placement. esthetic zone) often presents both surgical and prosthetic
implant-assessment complexities.43,44
Anatomical considerations, boundaries and limitations Subsequent to tooth loss, decrease in the height and/or
(important anatomic landmarks width of the alveolar process and the development of a labial
Each location in the dental alveolus has unique morphologic concavity often necessitate bone augmentation to facilitate
and topographical characteristics owing to edentulousness implant placement.45 (Fig.25) The morphology and dimension
and specific regional anatomic features that need to be of the nasopalatine (incisive canal) (Fig.26a-26d)46,47,48,49
identified and assessed in the diagnostic and treatment and the location of the floor of the nasal fossae may also
planning phase of dental-implant therapy.20 The clinician compromise bone availability for implant placement.
must have full knowledge of oral-bone anatomy, boundaries
and limitations so that any osseous-topography, bone-volume Posterior maxilla
excesses/deficiencies can be identified, to facilitate optimal Atrophy of the edentulous posterior alveolar ridge and
implant placement and to avoid surgical complications.20 A pneumatization of the maxillary sinus are the most common
comprehensive overview of the Oral and Maxillofacial causes of lack of bone availability for implant placement in the

Figure 14: Horizontal bone volume deficiency requiring Figure 15: Fenestration defect (marginal bone intact) requiring
augmentation. buccal bone augmentation.

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Figure 16a: 3D rendering of a dehiscence defect Figure 16b: 3D rendering of a dehiscence defect
(denuded areas extend through marginal bone) (denuded areas extend through marginal bone)
requiring horizontal buccal bone augmentation. requiring horizontal buccal bone augmentation.

posterior maxilla. Additionally, the maxillary posterior region has location of the window in the lateral window approach
the lowest bone density (Fig. 12c) and the highest implant failure during sinus floor elevation surgery.
rate.50 Sinus floor elevation surgery along with bone grafting is Assessment of the anterior recess of the maxillary sinus is
a well-accepted technique before, or simultaneously with also important if markedly angled implants are considered
implant placement to increase support in an atrophic maxilla. for implant-supported edentulous prostheses.)
Knowledge about the sinus anatomy and residual alveolar CBCT can also provide information on arterial channels in
ridge is critical before the conduction of surgical procedures. the lateral wall of the sinus, presence of apical pathosis
CBCT images provide an accurate 3-dimensional (3D) (Fig.28) as well as on the health of the sinus such as absence
representation of the anatomy and are suitable for the of sinus membrane thickening(Fig.29). In some clinical
detection of morphologic variations in the maxillary sinus to situations, when there is evidence of sinus pathology, or it is
assist with presurgical assessment for sinus augmentation the clinicians opinion that sinus drainage is impaired and may
surgery, implant planning and placement.40,42 jeopardize the outcome of the procedure to be undertaken,
The available residual alveolar ridge in the posterior there may be a justification to extend the FOV to include the
maxillary premolar and molar regions are limited superiorly whole of the sinus including the osteo-meatal complex.52,53,54
by the floor of the maxillary sinus. (Fig.20 )
Anatomical variations of the maxillary sinuses such as the Anterior mandibula
presence of septa (also known as Underwood septa), The anterior mandible is a relatively safe location for implant
number, location and shape, particularly in the inferior sinus placement. However, proper diagnostics are essential to
wall, complicate sinus floor elevation surgical procedures.23 avoid intraoperative and postoperative hemorrhage,
Sinus septa are bony projection commonly found in the neurosensory loss, and risk of perforating the cortical plate.
inferior or lateral sinus walls separating the maxillary sinus The locations of osseous structures (buccal and lingual
into 2 or more compartments (Fig.27). Studies show that cortical plates) (Fig.30) and neurovascular structures include
approximately 45 per cent of patients had at least one the lingual foramen (Fig.30), the terminal branch of the
septum.51 Strong sinus membrane adhesion at the location inferior alveolar nerve at the mental foramen and the anterior
of septa, particularly of the inferior sinus wall, may cause loop (Fig.31, 32). The mental foramen is a strategically
perioperative complications, therefore the presence, extent important landmark during osteotomy procedures in the
and location of septa must be accurately detected in mandible. Its location and the possibility that an anterior loop
presurgical radiographic imaging to facilitate proper of the mental nerve may be present mesial to the mental
selection of the surgical technique and prevention of foramen needs to be considered before implant surgery to
unwanted peri-operative complications and thus increase avoid nerve injury.55
success rate of sinus surgeries.41,51 Medium-sized or long
septa may necessitate a modified surgical approach. Posterior mandibula
Detection of septa may also influence the decision about the In the posterior mandible, there are several anatomic

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17 18

19 20

Figure 17: Axial view of a post extraction site at 8 weeks (5x5 FOV).
Figure 18: Vertical bone deficiency in the posterior maxilla.
Figure 19: Combined horizontal and vertical alveolar ridge bone discrepancy in the posterior maxilla.
Figure 20: Vertical alveolar bone deficiencies in the posterior maxilla requiring sinus floor elevation (5
x 10 FOV).

structures that can compromise prosthetically driven, dental- placement and cause complications include: (i) inadequate
implant placement. The most important landmarks in the distance between neighbouring teeth; (ii) angulation of roots;
posterior mandibular are the inferior alveolar canal and the (iii) apical pathology on neighbouring teeth (Fig.28,36); (iv)
submandibular gland fossa (Fig.33, 34, 35). Both these impacted teeth (Fig. 36, 37) (iv) residual roots; and (v)
structure can present with anatomic variations that may restrict presence of foreign material (Fig.38).
implant placement and result in complications.
Correct identification of the inferior alveolar (mandibular) Computer assisted prosthetic and surgical treatment
canal may assist the clinician to avoid damaging the nerve planning
during surgery and thereby preventing the occurrence of Apart from the diagnostic capabilities, dental CBCT may also
complications such as impaired sensory function and offer therapeutic capabilities through computer assisted
paresthesia of the lower lip and the neighbouring soft surgical and prosthetic treatment planning via computer-aided
tissues,56 It is advisable to measure from the crest of the design/computer-aided manufacturing solutions.13,26
alveolar bone to the coronal aspect of the IAN and subtract CBCT DICOM data is merged with stereolithography (STL)
2 mm to provide a safety zone. files from an Intra-Oral optical scanner to produce a 3D
The submandibular fossa is denoted by a lingual concavity rendering (3-D Conversion) model of the jaw for virtual
or undercut in the posterior mandible and contains the planning.30 Virtual planning software is used to construct a
submandibular gland. (Fig.33,34,35) virtual wax-up and to place the implant fixture its correct 3D-
position on the virtual 3-D model. Information to be gathered
Physiological, biological and pathological considerations from the combination of high-quality CBCT images and STL-
Other local anatomic boundaries and limitations or files should include locations of vital structures, desired implant
pathologic conditions that could potentially restrict implant positions and dimensions, the need for augmentation therapy,

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21a 21b 21c 21d 21e

Figure 21a: Coronal view of an irregular alveolar ridge in the maxilla.

Figure 21b: Coronal view of an irregular alveolar ridge in the mandibula.
Figure 21c: Coronal view of a narrow crestal alveolar ridge in the mandibula.
Figure 21d: Coronal view of a narrow crestal alveolar ridge in the maxilla.
Figure 21e: Coronal view of a knife–shape crestal alveolar ridge in the mandibular.

and the planned prostheses.11 Once the design is completed surgical situation. The surgeon should be aware of these and
it is submitted to a milling machine or a digital printer for be careful to allow an adequate “safety margin” in all
fabrication of a surgical guide. The guide can be bone, tooth cases.26 The use of guided surgery for implant placement is
or mucosal supported. The actual surgical guide is milled or increasing because of a number of clinical advantages,
printed, all with round cylinders, allowing dedicated including increased practitioner confidence and reduced
instrumentation (drill bits) to be precisely guided, creating operating time.
osteotomies and guiding the implant in its correct or ideal 3D-
position during placement.11 Implants placed utilizing Post-operative radiographic assessment of implant
computer-guided surgery with a follow-up period of at least failures and complications
12 months demonstrate a mean survival rate of 97.3% (n = (i) Altered sensation and possible damage to
1,941), which is comparable to implants placed following neurovascular structures
conventional procedures.11 CBCT may offer surgical guidance and therapeutic
To improve image data transfer, clinicians should request possibilities and cases of altered sensation and possible
radiographic devices and third-party dental implant software damage to neurovascular structures. Current evidence
applications that offer fully compliant DICOM data export.11 supports the protocol that a CBCT be used following the
It is important to realize that errors can occur when transferring neurosensory assessment to pinpoint lesion location as well
information from a cross-sectional computer image to the as confirmation of IAN injury.57 Proper pre-surgical planning,

Figure 22: Knife–shape crestal alveolar ridge in the posterior Figure 23: Serial axial images of the maxilla showing
maxilla. undulating buccal bone concavities due to missing anterior teeth
(5 x 10 FOV).

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timely diagnosis, and treatment are key factors in avoiding restorations. This prevents misaligned implants, which may
and managing neurovascular complications and damage be difficult or impossible to restore, and avoids poor
after implant placement (Fig.38).57 aesthetics and function.

(ii) Infection or post-operative integration failure Prevention of injury to nerves: Using the CBCT, the surgeon
CBCT is indicated for implant failure cases, infection or post- maps out the path of the sensory nerves in the jawbone and
operative integration failure, owing to either biological or selects the right implant length. Conventional X-rays are flat
mechanical causes. A CBCT can provide therapeutic and distorted and are poor diagnostic images for predicting
assistance with characterizing the existing defect, plan for the position of the nerves. Nerve damage from dental
surgical removal and corrective procedures, such as ridge implant placement results in partial or complete numbness of
preservation or bone augmentation, and assess what the the lip and chin area, which can be potentially permanent.
implications of surgical intervention is on adjacent structures. CBCT is a mandatory imaging technique to prevent this
Cross-sectional imaging, optimally CBCT, should also be serious complication.
considered if implant retrieval is anticipated.20
Prevent implant penetration into the sinus: CBCT provides
(iii) Implant displacement an accurate picture of the maxillary sinus and its position in
The use of CBCT scans are helpful in post-operative relation to the available bone. The surgeon can make an
evaluation of implant displacement into the sinus or nasal accurate measurement and select the right implant length to
cavity (Fig.39).58 avoid puncturing the maxillary sinus. Penetration of the
maxillary sinus can lead to sinusitis or other inflammatory
(iv) Perforations conditions. The surgeon can also plan for necessary bone
The major potential risks of encountering a lingual plate grafting if there is insufficient bone to support the implant.
perforation (Fig.40) are massive haemorrhage of the Conventional X-rays are highly inaccurate for these purposes
submental and sublingual arteries (anterior mandible)59 and and do not provide the information necessary for the safe
airway obstruction60 Perforation of the lingual concavity above placement of dental implants in the posterior maxilla.
the mylohyoid ridge might injure the lingual nerve.61 If the
extruded implant is left unattended, the infection might spread Selection of the right size implant for optimal support: The
to the parapharyngeal and retropharyngeal space, leading longevity and success of dental implants require maximal
to more severe complications, such as mediastinitis, mycotic integration and stability in the bone. CBCT allows the
aneurysm formation with possible subsequent rupture of the surgeon to measure the available bone and select the widest
internal carotid artery, and internal jugular vein thrombosis with and longest implant appropriate for the site. This, in turn,
septic pulmonary embolism or upper airway obstruction.62 helps to support the high bite (occlusal) forces and avoid
potential failure from overload. Implant size selection should
Advantages and limitations of CBCT in implant
dentistry
There are six major benefits of cone beam CT scan (CBCT)
for dental implant planning and placement:63

Precision placement of implants in the bone: CBCT allows

the surgeon to accurately measure and localize the available
bone and accurately place the implant in a correct 3D
position. This is verified by virtual implant placement.

Proper orientation of the implant with its overlying

restoration: A CBCT can be merged with an optical scan
of the patient’s teeth (digital impression) to create a complete
24 25
bone, teeth, and soft tissue digital model. This will facilitate Figure 24: Coronal view of the topography and orientation of the
precise postioning of implants to support planned residual alveolar bone in the submandibular gland fossa area.

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Figure 26a: Axial view of morphology of the Figure 26b: Coronal view of morphology of the nasopalatine canal
nasopalatine canal (incisive canal) in the anterior (incisive canal) in the anterior maxilla (5 x 10 FOV).
maxilla (5 x 10 FOV).

Figure 26c: Serial axial views of the nasopalatine canal. Figure 26d: Serial coronal views of implant placement
planning in relation to the nasopalatine canal in the anterior
maxilla.

Figure 27: Sinus septa in the inferior sinus wall. Figure 27: Apical pathosis in the posterior maxilla.

not be guesswork! Implant selection is made based on a mandatory diagnostic imaging for every implant treatment.
precise measurements, biological requirements, bite scheme, Not using CBCT for planning is unwise for the surgeon and
and individual patient needs. creates unnecessary risk for the patient and clinician.

Improved clinical outcomes and reduced risk of Communitation of data volume

complications CBCT allows the ability to communicate DICOM data
CBCT offer a more accurate, predicatable outcome and imaging information for prosthetic restorative planning, and
safer means to dental implant placement. CBCT should be design and manufacturing of surgical guides.

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Figure 29: Implant planning in the posterior maxilla Figure 30: Buccal and lingual cortical plates in the
and sinus membrane thickening. anterior mandibula and lingual foramen.

Figure 31: Mental foramen and anterior loop and Figure 32: Serial coronal cross sections of mental
terminal branch of the inferior alveolar nerve. foramen in the anterior mandibula.

Limitations of CBCT Imaging artifacts

Requires training and has a learning curve Streaking and motion artefacts, although limited, cannot be
It requires new competencies from the clinician and the value avoided. These artifacts contribute to image quality
of information obtained is interpretation sensitive. This degradation and can lead to inaccurate or false
requires training and new knowledge from the clinician.64 diagnosis.64,68

Large FOV may requires expertise and specialized Bone density and grayscale
monitoring equipment CBCT is commonly used for the assessment of bone quality
Referral to an Oral Maxillofacial Radiologist may be primarily for pre-implant treatment planning. Traditionally
indicated for need of expertise and because a proper bone quality has been based on bone density, estimated
monitor, ambiente lighting, and equipment settings may be through the use of Hounsfield units derived from multidetector
available only in a specialist radiologist environment64, CT (MDCT) data sets. However, due to crucial differences
especially where larger FOV are required for advanced and between MDCT and CBCT, which complicate the use of
full dental reconstructions. quantitative gray scale values (GV) for assessment of bone
density with CBCT.66 Experimental and clinical research
Poor soft tissue contrast suggest that the qualitative use of GV in CBCT to assess
One major disadvantage of CBCT is that it can only bone density should be avoided at this stage.66 Current
demonstrate limited contrast resolution. If the objective of the scientific literature suggests a paradigm shift of bone quality
examination is hard tissue only, then CBCT would not be a assessment from a density-based analysis to structural
problem. However, CBCT is not sufficient for soft tissue evaluation.66
evaluation.7,65 It provides limited resolution to deeper (inner)
soft tissues and MRI and CT are better for soft tissue Radiation dose
imaging.64 The radiation dose from CBCT is lower than conventional

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Figure 33: Inferior alveolar canal and submandibular Figure 34: Inferior alveolar canal and mental foramen
gland fossa in the posterior mandibula. showing the anterior loop of the mental nerve.

Figure 35: Implant planning in the posterior mandibular Figure 36: Apical pathosis en impacted premolars.
showing implants in relation to the inferior alveolar
canal and the submandibular glad fossa.

Figure 37: Axial view of impacted premolars in Figure 38: Foreign body located in the osteotomy site.
relation to the osteotomy sites.

CT, but is significantly higher than traditional radiographic significantly increased the accuracy and efficiency of
modalities (peri-apical, Panoramic).64 diagnostic and treatment capabilities, thereby offering an
unparalleled diagnostic approach when dealing with
Conclusions previously challenging unknown anatomical and/or
CBCT imaging technology computer software has pathological entities in implant dentistry. The potential

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Figure 38: Using CBCT for neurosensory assessment and confirmation of inferior alveolar nerve injury.
(With permission from Dr Howard Gluckman).

Figure 39: Using CBCT for post-operative Figure 40: Implant perforating the lingual cortical plate (With permission from
assessment of complications such as implant Dr Howard Gluckman).
placement into the nasal cavity (With permission
from Dr Howard Gluckman).

benefits for accurate assessment, diagnosis of pathologies, ensure that pathosis or critical anatomical structures are not
identification of anatomical landmarks and neurovascular missed that may impact on, or enhance diagnosis, treatment
structures, as well as topographical and morphological planning and treatment outcomes.
deviations in alveolar bone, in pre-surgical treatment CBCT is increasingly being accepted as the new
planning are undisputed. CBCT has thus become the new professional standard of care
professional standard of care as imaging modality for in implant dentistry. With this
diagnosis and pre-surgical treatment planning in implant technology, adequately trained
dentistry. clinicians can enhance their
The decision to prescribe a CBCT scan must be based on practice and best serve the
the patient’s history and clinical examination and justified on interests of their patients.
an individual basis taking due consideration of diagnostic However, with growing
and pre-surgical treatment planning needs and benefits, technological and software
radiation risk and cost. Effective assessment of proposed development and increasing
implant sites requires that clinicians interpret implant sites for utilization of this indispensible
many factors related to successful implant restorations, technology, it is important that
including adequate bone volumes, distance away from the dental profession develop
teeth/implants, sufficient prosthetic space for restoration, and evidence-based guidelines and
Figure 41: Streaking artefact
precise implant placement. A protocol is proposed on how recommendations for its proper from dental implant.
to do a structured review and read a CBCT data volume to and effective use.

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