A Comparative Study on the Cor relation between Periapical and Bitewing Radiographs

Implant Esthetics:
Form Meeting Function
Assessing Crestal Bone Levels Around Implants With Different Platfor m Designs
El Hachem, Wadih; Kharouf, Zeineb; Yoon, Wonsuk; Jalbout, Ziad; Cho, Sang-Choon; Froum, Stuart; Elian, Nicolas; Tarnow, Dennis. Ashman Department of Periodontology and Implant Dentistry, New York University
RESULTS
The total population provided a potential of 37 paired BW and PA measurements with a total of 168
sites that could be compared. A total of 29 sites were excluded from the results due to a poor radi-
ograph or disagreement between the examiners. The results showed that in 44% of the sites meas-
ured the difference between the two types of radiographs was within 0.2mm; and in 56 % of the sites
measured the difference was greater than 0.2mm. The mean value of the overall measurements
showed no difference between the two techniques. However, when the data was analyzed by arch,
in the maxilla the BW measurements were on average 0.3mm less than the PA measurements. An
opposite tendency was found in the mandible were the bitewing measurements where on average
0.1mm higher than the periapical measurements.
DISCUSSION
“ . . .in the maxilla, when dealing
The radiographic technique of choice for the assessment of crestal bone levels around implants is the
intra-oral radiograph using the paralleling technique (4-7). This assesment can be performed utiliz-
sponding bone loss measurements on two radiographs would mean larger underestimation of bone CONCLUSION
loss on the type of radiograph exhibiting the shortest CEJ-BONE distance. Therefore, studies con-
cluded that in the maxilla, the bitewing radiographs reproduce the alveolar bone level of teeth bet-
ter than periapical radiographs. ince the data in this investigation indicates that differences frequently exist between measure-
The results from the present study were unable to show a significant difference between mean cre-
S ments obtained from BW and PA radiographs, the two methods cannot be used interchange-
ably to evaluate the same site. In addition one may conclude that in the maxilla, when deal-
ing with implants, PA radiographs may be more adequate than BW to assess the crestal bone loss.
The preference of one technique over the other can be critical when using the Albrektsson and Zarb
stal bone level values from the two techniques. The results showed that in 56% of the comparisons criteria for implant success.
a difference of more than 0.2mm was measured. However, maxillary arch measurements alone
showed a higher mean value for the measurements on periapical radiographs. In average the dif-
ference between the value of PA radiographs and BW was 0.3mm. This is not in agreement with
studies made on teeth (8, 11). This discrepancy may be significant when using the Albrektsson and
Zarb (1) criteria to assess implant success. When radiographs of implants are evaluated over time, a
difference of 0.3mm between PA and BW radiographs may erroneously place a “successful” implant
into a failure category. This inaccuracy is also critical in studies designed to assess the ability of new
implant designs (platform switching) to maintain crestal bone levels.

with implants, periapical radi-

ographs may be more adequate >0.2 mm =<0.2 mm

than bitewing radiographs to 44.0%

56.0%

assess the crestal bone loss.. . . ”

ne criteria of success of osseointegrated implants is the stability of the crestal bone levels

O around the implant (1). Radiographic evaluation of each implant should reveal not more
than 1.0 mm of marginal bone loss during the first year of loading, followed by not more
than 0.2mm resorption per year (2).This was determined by a standardized radiograph using a par-
Fig 1. Crestal bone level measured on PA Fig 2. Low correlation between BW and PA Fig 5. PA film not parallel to the tooth axis in maxilla Fig 6. PA film parallel to the implant axis in the maxilla Fig 9. Angle deviation in PA : implant vs tooth Fig 10. Implant angulation in the maxillary bone

alleling technique. The type of radiograph periapical or bitewing was not specified in the criteria.
8.0
In conventional dentistry, the correct visualization of the cervical area of teeth is critical to detect
7.0
cervical decay, overhanging margins and infra-bony defects. For this purpose, many practitioners Bitewing
prefer bitewing radiographs. Bitewing x-rays are easy to take and provide a good perspective of the 6.0 Periapical
crestal area of teeth. 5.0

The implant literature shows that radiographs are an unreliable method for diagnosing peri-implant 4.0

spaces (3), however, they remain an effective method of evaluating crestal bone levels. Peri-implan- 3.0
titis, the introduction of new implant designs and new concepts like platform switching increase the
need to accurately assess the bony crest surrounding the implant. To date, no published studies 2.0

have compared the accuracy of periapical and bitewing x-rays taken of implants. 1.0

The purpose of this study is to determine if there is a correlation between periapical and bitewing
x-rays in determining the crestal bone levels surrounding implants.
MATERIALS & METHODS
Clinical data in this study was obtained from an Implant Dentistry Database (IDD) established in
the Department of Periodontology and Implant Dentistry at New York University College of
Dentistry (NYUCD). This data set was extracted as de-identified information from the routine treat-
ment of patients at the department. The IDD was certified by the Office of Quality Assurance at
NYUCD to be in compliance with the Health Insurance Portability and Accountability Act (HIPAA)
requirements.
0.0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
Fig 3. Crestal bone level measured on BW Fig 4. Shortened BW measurements in the maxilla
ing a BW or a PA radiograph. While each of these techniques produces an accurate image of the
inter-proximal area, the radiographic methods differ. Consequently, it is conceivable that a difference
may exist in the radiographic measurement of the bone level of the same inter-proximal area
between the periapical and bitewing radiographs (8). With BW, the film and beam relationship is
improved, providing better accuracy. The BW technique is not usually subject to the same anatom-
ical limitations as a PA radiograph, therefore resulting in a smaller probability of deviation from par-
allelism between the film and the long axis of the clinical crown (9). Periapical radiographs with a
strict projection protocol can assess mesial and distal peri-implant bone levels almost as accurately
Fig 7. BW film parallel to the tooth axis in the maxilla Fig 8. BW film not parallel to the implant axis
Sewerin and al (12) showed that the accuracy of bone height measurements is compromised even
at very small deviations of strict parallelism between fixture axis and film plane. The influence of dif-
ferences in alveolar bone width is also demonstrated. It was calculated in vitro that a deviation of
1degree between exposures may result in a displacement of the projection of the buccal or the lin-
gual bone margins of 0.09mm to 0.25mm, depending on the width of the bone ridge. It is known
that in the maxilla the anatomical configuration may preclude strict adherence to the paralleling con-
cept (13). [In addition, in edentulous patients the maxilla and mandible resorb in opposite direction
(14, 15) resulting in a larger distance between the two bony crests.] Therefore the implants in the
Fig 11. Angle deviation in BW : implant vs tooth
REFERENCES
1. Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-term efficacy of
currently used dental implants: A review and proposed criteria of success. Int J
Oral Maxillofac Implants 1986; 1:11-25.
2. Roos J, Sennerby L, Lekholm U, Jemt T, Grondahl K, Albrektsson T. A
Qualitative and Quantitative Method for Evaluating Implant Success: A 5-Year
Retrospective Analysis of the Branemark Implant. Int J Oral Maxillofac Implants
1997;12:504-514.
3. Sewerin IP, Gotfredsen K, Stoltze K. Accuracy of radiographic diagnosis of peri-
implant radiolucencies: an in vitro experiment. Clin Oral Implants Res
1997;8:299-304.
4. Goaz P, White P. Projection Geometry, Mosby Company. Oral Radiology-
Principles and Interpretation 2002;2:83-90.
5. Flemming I. Clinical probing and radiographic assessment in relation to the his-
tologic bone level at oral implants in monkeys. Clin Oral Implants Res
1997;8:255-264.
Fig 12. Tooth angulation in the maxillary bone
DL. Crestal Bone Changes Around Titanium Implants: A Methodologic Study
Comparing Linear Radiographic with Histometric Measurements. Int J Oral
Maxillofac Implants 2001;16:475-485.
11. Albandar JM, Abbas DK, Waerhaug M, Gjermo P. Comparison between stan-
dardized periapical and bitewing radiographs in assessing alveolar bone loss.
Comm Dent Oral Epidemiol 1985;13:222-225.
12. Sewerin IP. Errors in radiographic assessment of marginal bone height around
osseointegrated implants. Scan J Dent Res 1990;98:428-433.
13. Barr JH, Gron P. Palate contour as a limiting factor in intraoral x-ray technique.
Oral Surg Oral Med Oral Pathol 1959;4:459-472.
14. Atwood DA. Reduction of residual ridges: A major oral disease entity. J Prosthet
Dent 1971;26:266-279.
15. Atwood DA, Coy W. Clinical, cephalometric, and densitometric study of reduc-
tion of residual ridges. J Prosthet Dent 1971;26:280-295.
1. Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-term efficacy of
currently used dental implants: A review and proposed criteria of success. Int J
Oral Maxillofac Implants 1986; 1:11-25.
6. Payne AGT, Solomons YF, Lownie JF. Standardization of radiographs for
Mandibular implant-supported overdentures: review and innovation. Clin Oral
Implants Res 1999;10:307-319.
7. Strid KG. Radiographic results and radiographic procedures, Osseointegration
in Clinical Dentistry. Chicago, Quintessence Publ Co. Tissue Integrated
Prosthesis 1985;1:317-327.
8. Reed BE, Polson AM. Relationship Between Bitewing and Periapical
Radiographs in Assessing Crestal Alveolar Bone Levels. J Periodontol
1984;55:22-27.
9. Jeffcoat MK. Radiographic Methods for the Detection of Progressive Alveolar
Bone Loss. J Periodontol 1992;63:367-372.
10. Hermann JS, Schoolfield JD, Nummikoski PV, Buser D, Schenk RK, Cochran
DL. Crestal Bone Changes Around Titanium Implants: A Methodologic Study
Comparing Linear Radiographic with Histometric Measurements. Int J Oral
Maxillofac Implants 2001;16:475-485.
11. Albandar JM, Abbas DK, Waerhaug M, Gjermo P. Comparison between stan-
dardized periapical and bitewing radiographs in assessing alveolar bone loss.

The study analyzed the difference in measurements of the crestal bone level around implants using
as histometric measurements of peri-implant bone height in specimens of the implants (10). This is
maxilla will be more angulated buccally than the previous existing teeth (Fig 1). The implant crown
6. Payne AGT, Solomons YF, Lownie JF. Standardization of radiographs for
Mandibular implant-supported overdentures: review and innovation. Clin Oral
2. Roos J, Sennerby L, Lekholm U, Jemt T, Grondahl K, Albrektsson T. A
Qualitative and Quantitative Method for Evaluating Implant Success: A 5-Year
Comm Dent Oral Epidemiol 1985;13:222-225.
12. Sewerin IP. Errors in radiographic assessment of marginal bone height around

bitewing (BW) and periapical (PA) radiographs. The measured distance was between the implant
platform and first bone to implant contact. The study compared PA and BW radiographs, taken on
the same day. Periapical and BW radiographs selected were taken using a paralleling technique
(XCP, Rhin, Dentsply International). The exposure time was the same for all bitewings, the same for
all PA’s. The radiographs were developed using an automatic processor, they were coded and
only true with a strict study protocol and has not been proven in clinical cases. In this study the radi-
ographs were mounted on a laboratory fabricated custom bite-blocks, which were firmly attached
intra-orally on the dog mandible. The ring of the beam-aiming device was customized for a better
alignment of the long x-ray cone.
axis will be often angulated in relation to implant body axis. In these particular cases the PA x-ray
will be more parallel to the long axis of the implant than the BW radiograph. This may explain the
greater values of bone loss as seen on PA x-rays taken of implants in the maxilla within the limita-
tions of this study. These limitations may be attributed to the following factors: sample size, opera-
tor consistency, and multiple measurements made on the same radiograph. Additionally, future sim-
Implants Res 1999;10:307-319.
7. Strid KG. Radiographic results and radiographic procedures, Osseointegration
in Clinical Dentistry. Chicago, Quintessence Publ Co. Tissue Integrated
Prosthesis 1985;1:317-327.
8. Reed BE, Polson AM. Relationship Between Bitewing and Periapical
Radiographs in Assessing Crestal Alveolar Bone Levels. J Periodontol
1984;55:22-27.
9. Jeffcoat MK. Radiographic Methods for the Detection of Progressive Alveolar
Bone Loss. J Periodontol 1992;63:367-372.
10. Hermann JS, Schoolfield JD, Nummikoski PV, Buser D, Schenk RK, Cochran
Retrospective Analysis of the Branemark Implant. Int J Oral Maxillofac Implants
1997;12:504-514.
osseointegrated implants. Scan J Dent Res 1990;98:428-433.
13. Barr JH, Gron P. Palate contour as a limiting factor in intraoral x-ray technique.
3. Sewerin IP, Gotfredsen K, Stoltze K. Accuracy of radiographic diagnosis of peri- Oral Surg Oral Med Oral Pathol 1959;4:459-472.
implant radiolucencies: an in vitro experiment. Clin Oral Implants Res 14. Atwood DA. Reduction of residual ridges: A major oral disease entity. J Prosthet
1997;8:299-304. Dent 1971;26:266-279.
4. Goaz P, White P. Projection Geometry, Mosby Company. Oral Radiology- 15. Atwood DA, Coy W. Clinical, cephalometric, and densitometric study of reduc-
Principles and Interpretation 2002;2:83-90. tion of residual ridges. J Prosthet Dent 1971;26:280-295.
5. Flemming I. Clinical probing and radiographic assessment in relation to the his-
tologic bone level at oral implants in monkeys. Clin Oral Implants Res
1997;8:255-264.

mounted on frames. They were projected on a screen and measured. Two independent measure-
ments were taken by two examiners. When measurements disagreed, examiners met to resolve the
inconsistency.
ilar studies should consider differentiating measurements by site and noting the degree of angula-
tions between the implants and the clinical prosthesis.
In studies made on teeth a comparison between standardized PA and BW radiographs showed that
in the maxilla, a significant higher proportion of sites exhibited larger bone loss measurements in BW This Presentation was Sponsored by New York University Department of Implant Dentistry
than in PA films. Mandibular sites showed the opposite trend (8, 11). A difference between corre- Alumni Association (NYUDIDAA) and the Office for International Program