The effect of mandibular buccal tilting on the accuracy of posterior mandibular spiral tomographic images: An in vitro study
Identifieur interne : 002B61 ( Pmc/Corpus ); précédent : 002B60; suivant : 002B62The effect of mandibular buccal tilting on the accuracy of posterior mandibular spiral tomographic images: An in vitro study
Auteurs : Mahnaz Sheikhi ; Vida MalekiSource :
- Dental Research Journal [ 1735-3327 ] ; 2011.
Abstract
Accurate measurement of the height and buccolingual thickness of available bone has a significant role in dental implantology. The shadow of ramus on the mandibular second molar region disturbs the sharpness of conventional tomographic images. The aim of this study was to evaluate the effect of transferring the shadow of ramus from the center of the focal plane, by changing the position of mandible, on the sharpness of the posterior mandibular region.
In this experimental study, we used 10 dry human mandibles. Three metal balls were mounted on the midline and mandibular second molar regions bilaterally. Standard panoramic and tomographic images were taken. Then, the mandible was tilted buccaly for 8° – compensating the normal lingual inclination of the mandibular ridge and teeth on this region – and tomographic images were taken again. The height and thickness of bone were measured on the images and then compared with the real amounts measured directly on mandibles. Also, the sharpness of mandibular canals was compared between the two tomographic methods. Findings were analyzed with repeated measured ANOVA test (
The height of mandibular bone, on the images of the tilted tomography technique was more accurate compared to standard (
Buccal tilting is recommended when measuring the bone height is more important, but routine standard tomography is preferred when the thickness is requested.
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PubMed: 23372586
PubMed Central: 3556287
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">The effect of mandibular buccal tilting on the accuracy of posterior mandibular spiral tomographic images: An <italic>in vitro</italic> study</title><author><name sortKey="Sheikhi, Mahnaz" sort="Sheikhi, Mahnaz" uniqKey="Sheikhi M" first="Mahnaz" last="Sheikhi">Mahnaz Sheikhi</name><affiliation><nlm:aff id="aff1">Torabinenejad Dental Research Center and Department of Oral and Maxillofacial Radiology, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran</nlm:aff></affiliation></author><author><name sortKey="Maleki, Vida" sort="Maleki, Vida" uniqKey="Maleki V" first="Vida" last="Maleki">Vida Maleki</name><affiliation><nlm:aff id="aff1">Torabinenejad Dental Research Center and Department of Oral and Maxillofacial Radiology, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">23372586</idno><idno type="pmc">3556287</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3556287</idno><idno type="RBID">PMC:3556287</idno><date when="2011">2011</date><idno type="wicri:Area/Pmc/Corpus">002B61</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">002B61</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">The effect of mandibular buccal tilting on the accuracy of posterior mandibular spiral tomographic images: An <italic>in vitro</italic> study</title><author><name sortKey="Sheikhi, Mahnaz" sort="Sheikhi, Mahnaz" uniqKey="Sheikhi M" first="Mahnaz" last="Sheikhi">Mahnaz Sheikhi</name><affiliation><nlm:aff id="aff1">Torabinenejad Dental Research Center and Department of Oral and Maxillofacial Radiology, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran</nlm:aff></affiliation></author><author><name sortKey="Maleki, Vida" sort="Maleki, Vida" uniqKey="Maleki V" first="Vida" last="Maleki">Vida Maleki</name><affiliation><nlm:aff id="aff1">Torabinenejad Dental Research Center and Department of Oral and Maxillofacial Radiology, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran</nlm:aff></affiliation></author></analytic><series><title level="j">Dental Research Journal</title><idno type="ISSN">1735-3327</idno><idno type="eISSN">2008-0255</idno><imprint><date when="2011">2011</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec id="st1"><title>Background:</title><p>Accurate measurement of the height and buccolingual thickness of available bone has a significant role in dental implantology. The shadow of ramus on the mandibular second molar region disturbs the sharpness of conventional tomographic images. The aim of this study was to evaluate the effect of transferring the shadow of ramus from the center of the focal plane, by changing the position of mandible, on the sharpness of the posterior mandibular region.</p></sec><sec id="st2"><title>Materials and Methods:</title><p>In this experimental study, we used 10 dry human mandibles. Three metal balls were mounted on the midline and mandibular second molar regions bilaterally. Standard panoramic and tomographic images were taken. Then, the mandible was tilted buccaly for 8° – compensating the normal lingual inclination of the mandibular ridge and teeth on this region – and tomographic images were taken again. The height and thickness of bone were measured on the images and then compared with the real amounts measured directly on mandibles. Also, the sharpness of mandibular canals was compared between the two tomographic methods. Findings were analyzed with repeated measured ANOVA test (<italic>P</italic><0.05).</p></sec><sec id="st3"><title>Results:</title><p>The height of mandibular bone, on the images of the tilted tomography technique was more accurate compared to standard (<italic>P</italic><0.001), but standard tomography had more accuracy in estimating the buccolingual thickness at the half-height point. Regarding the sharpness of mandibular canals, we found no significant differences between two tomographic methods.</p></sec><sec id="st4"><title>Conclusion:</title><p>Buccal tilting is recommended when measuring the bone height is more important, but routine standard tomography is preferred when the thickness is requested.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="White, S" uniqKey="White S">S White</name></author><author><name sortKey="Pharoah, M" uniqKey="Pharoah M">M Pharoah</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Bhat, S" uniqKey="Bhat S">S Bhat</name></author><author><name sortKey="Shenoy, K" uniqKey="Shenoy K">K Shenoy</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Mupparapu, M" uniqKey="Mupparapu M">M Mupparapu</name></author><author><name sortKey="Singer, Sr" uniqKey="Singer S">SR 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Dent Res J (Isfahan)</journal-id><journal-id journal-id-type="iso-abbrev">Dent Res J (Isfahan)</journal-id><journal-id journal-id-type="publisher-id">DRJ</journal-id><journal-title-group><journal-title>Dental Research Journal</journal-title></journal-title-group><issn pub-type="ppub">1735-3327</issn><issn pub-type="epub">2008-0255</issn><publisher><publisher-name>Medknow Publications & Media Pvt Ltd</publisher-name><publisher-loc>India</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">23372586</article-id><article-id pub-id-type="pmc">3556287</article-id><article-id pub-id-type="publisher-id">DRJ-8-100</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original Article</subject></subj-group></article-categories><title-group><article-title>The effect of mandibular buccal tilting on the accuracy of posterior mandibular spiral tomographic images: An <italic>in vitro</italic> study</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Sheikhi</surname><given-names>Mahnaz</given-names></name><xref ref-type="aff" rid="aff1">1</xref></contrib><contrib contrib-type="author"><name><surname>Maleki</surname><given-names>Vida</given-names></name><xref ref-type="aff" rid="aff1">1</xref><xref ref-type="corresp" rid="cor1"></xref></contrib></contrib-group><aff id="aff1"><label>1</label>Torabinenejad Dental Research Center and Department of Oral and Maxillofacial Radiology, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran</aff><author-notes><corresp id="cor1"><bold>Address for correspondence:</bold> Dr. Vida Maleki, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran. E-mail: <email xlink:href="vida_maleki@yahoo.com">vida_maleki@yahoo.com</email></corresp></author-notes><pub-date pub-type="ppub"><month>12</month><year>2011</year></pub-date><volume>8</volume><issue>Suppl1</issue><fpage>S100</fpage><lpage>S104</lpage><history><date date-type="received"><month>8</month><year>2011</year></date><date date-type="accepted"><month>10</month><year>2011</year></date></history><permissions><copyright-statement>Copyright: © Dental Research Journal</copyright-statement><copyright-year>2011</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-sa/3.0"><license-p>This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p></license></permissions><abstract><sec id="st1"><title>Background:</title><p>Accurate measurement of the height and buccolingual thickness of available bone has a significant role in dental implantology. The shadow of ramus on the mandibular second molar region disturbs the sharpness of conventional tomographic images. The aim of this study was to evaluate the effect of transferring the shadow of ramus from the center of the focal plane, by changing the position of mandible, on the sharpness of the posterior mandibular region.</p></sec><sec id="st2"><title>Materials and Methods:</title><p>In this experimental study, we used 10 dry human mandibles. Three metal balls were mounted on the midline and mandibular second molar regions bilaterally. Standard panoramic and tomographic images were taken. Then, the mandible was tilted buccaly for 8° – compensating the normal lingual inclination of the mandibular ridge and teeth on this region – and tomographic images were taken again. The height and thickness of bone were measured on the images and then compared with the real amounts measured directly on mandibles. Also, the sharpness of mandibular canals was compared between the two tomographic methods. Findings were analyzed with repeated measured ANOVA test (<italic>P</italic><0.05).</p></sec><sec id="st3"><title>Results:</title><p>The height of mandibular bone, on the images of the tilted tomography technique was more accurate compared to standard (<italic>P</italic><0.001), but standard tomography had more accuracy in estimating the buccolingual thickness at the half-height point. Regarding the sharpness of mandibular canals, we found no significant differences between two tomographic methods.</p></sec><sec id="st4"><title>Conclusion:</title><p>Buccal tilting is recommended when measuring the bone height is more important, but routine standard tomography is preferred when the thickness is requested.</p></sec></abstract><kwd-group><kwd>Buccal tilt</kwd><kwd>mandible</kwd><kwd>positioning</kwd><kwd>spiral tomography</kwd></kwd-group></article-meta></front><body><sec id="sec1-1"><title>INTRODUCTION</title><p>Radiography has the most important role in dental implantology.[<xref ref-type="bibr" rid="ref1">1</xref>–<xref ref-type="bibr" rid="ref4">4</xref>] Conventional tomography, cone-beam computed tomography (CBCT), and spiral computed tomography (CT) can provide convenient cross-sectional images to recognize the vital anatomical structures and dimensions of the mandible.[<xref ref-type="bibr" rid="ref4">4</xref>] Accurate dimensions, not overlapping, and evaluation of feasible bucco-lingual dimension are considered as their advantages.[<xref ref-type="bibr" rid="ref5">5</xref><xref ref-type="bibr" rid="ref6">6</xref>] However, high cost and dosage of X-ray exposure are disadvantages of CT.[<xref ref-type="bibr" rid="ref2">2</xref><xref ref-type="bibr" rid="ref7">7</xref><xref ref-type="bibr" rid="ref8">8</xref>] In comparison with periapical radiography with rectangular collimation and F-speed film, the X-ray exposure of conventional tomography is 0.2–0.6 per each slice times less, whereas of CBCT and spiral CT are 4–42 and 25–800 times more respectively.[<xref ref-type="bibr" rid="ref1">1</xref>] Therefore, it was aimed to find an alternative technique with maximum advantages of CT but with less cost and X-ray exposure.</p><p>When a few number of implants are needed and the anatomical variation is minimal, conventional tomography is the technique of choice.[<xref ref-type="bibr" rid="ref6">6</xref><xref ref-type="bibr" rid="ref8">8</xref>–<xref ref-type="bibr" rid="ref11">11</xref>] Conventional tomography provides an image with an error less than 1 mm, and two or three cross-sectional tomographic slices are enough for each implant position.[<xref ref-type="bibr" rid="ref1">1</xref>] In several studies the mean value of differences in measurement of the bone height has been reported in a range of ±1 mm;[<xref ref-type="bibr" rid="ref8">8</xref><xref ref-type="bibr" rid="ref11">11</xref>–<xref ref-type="bibr" rid="ref14">14</xref>] however, it was also reported to be 2.5 mm in another study using linear tomography.[<xref ref-type="bibr" rid="ref15">15</xref>]</p><p>In images of the posterior mandibular region, the shadow of ramus usually disturbs the sharpness. By changing the position of mandible, we tried to transfer the shadow of ramus from the center of the tomographic focal plane to let the measurements be more realistic.[<xref ref-type="bibr" rid="ref16">16</xref>] The mandibular and alveolar bone and also teeth of the posterior mandibular region have a lingual inclination for 16°;[<xref ref-type="bibr" rid="ref17">17</xref><xref ref-type="bibr" rid="ref18">18</xref>] we tilted the mandible buccally for 8°, to omit the ramus shadow, taking true cross-sectional images. In previous studies the effect of rotating, but not tilting, the mandible was examined.[<xref ref-type="bibr" rid="ref19">19</xref><xref ref-type="bibr" rid="ref20">20</xref>]</p></sec><sec sec-type="materials|methods" id="sec1-2"><title>MATERIALS AND METHODS</title><p>In this experimental study, we used 10 dry human edentulous mandibles without any turous, exostosis, or defect. Metallic balls (1 mm in diameter) were fixed by sculpture paste on a point 20 mm distal to mental foramen of both sides of each mandible, and also, a metal ball was fixed on mandibular midline (to facilitate correct mandibular positioning).</p><p>While the lower borders of mandibles were parallel to the horizontal plane and midlines were in the direction of device's guide, panoramic images with a magnification of 1.5 and tomographic images with the same magnification in four sections with 4 mm of thickness were taken.</p><p>To compensate the lingual inclination of posterior mandibular bone[<xref ref-type="bibr" rid="ref17">17</xref>] – and fixtures – toward the alveolar ridge, the mandibles were tilted buccally for 8° and tomographic images were taken again with the same manner.</p><p>Among the images of each sample, the sharpest[<xref ref-type="bibr" rid="ref8">8</xref>] with better view of metallic ball (mostly in a complete circle shape) was chosen. The height of bone on Images, considering the magnification of 1.5, and also on dry mandible was measured twice with a 2-week interval by a radiologist.</p><p>The thickness of bone at the half-height point and the distance between buccal and lingual cortical plates were measured on the images of both tomography techniques and on dry mandible. All the measurements on images and dry mandible were done with a 0.1 precision caliper. The sharpness of the contour of mandibular canal, were graded as 0, 1, and 2, for nondetectable, detectable, and sharp respectively.</p><p>Panoramic radiographs (with regular cassette) and tomographic images (with medium cassette) were taken by Cranex tome (SORDEX OY, Tuusula, Finland). Panoramics and tomograms were taken at minimum X-ray factors (respectively [19 s, 10 mA, 57 kvp] and [46 s, 1 mA, 57 kvp]). Radiographs were processed using an automatic processor (OPTIMAX2010, Germany), with processing solutions (Champion, IRAN) at 33°C, 1.5 minutes.</p><p>Data were analyzed with repeated measured ANOVA test.</p></sec><sec sec-type="results" id="sec1-3"><title>RESULTS</title><p>Based on interclass coefficient correlation, the reliability of the two of measurement was more than 93%.</p><p>Measurements of height of the bone showed a mean value of 17.32±3.1 mm for standard tomography, 17.61±3.27 mm for tilted tomography, and 18.27±3.33 mm for dry mandible.</p><p>The analysis of data revealed no significant difference between the mean values of height of bone on the two different tomographic images (<italic>P</italic>=0.158), but significant differences between dry bone and both images were seen (<italic>P</italic><0.001). In both methods, underestimating was more than overestimating (0.8 mm to –2.7) [<xref ref-type="fig" rid="F1">Figure 1</xref>].</p><fig id="F1" position="float"><label>Figure 1</label><caption><p>The heights of bone (crest-to-lower border of mandibule) in two tomographic methods and in dry mandible, H: height of crest-to-mandibular lower border/TA: standard tomography/TB: tilted tomography/M: dry mandible, HTA-HM: Subtraction of HTA and HM/HTB-HM: Subtraction of HTB and HM</p></caption><graphic xlink:href="DRJ-8-100-g001"></graphic></fig><p>The mean values of buccolingual thicknesses of bone at the half-height point on standard and tilted tomographs, and dry mandible were 9.27±1.32 mm, 8.91±1.40 mm, and 9.58±1.58 mm, respectively. Data analysis showed a significant difference in the thickness of bone between three measurements (<italic>P</italic><0.001) [<xref ref-type="fig" rid="F2">Figure 2</xref>]. This difference was mainly between tilted tomography and both standard tomography and dry mandible (<italic>P</italic><0.001), while there was no significant difference in measurements between standard tomography and dry mandible (<italic>P</italic>=0.11).</p><fig id="F2" position="float"><label>Figure 2</label><caption><p>The alveolar ridge's buccolingual thicknesses in half-height of alveolar crest-to-mandibular lower border in two tomographic methods and in dry mandible, W: thickness in half-height of alveolar crest-to-mandibular lower border/TA: standard tomography/TB: tilted tomography/M: dry mandible WTA-WM: Subtraction of WTA and WM/WTB-WM: Subtraction of WTB and WM</p></caption><graphic xlink:href="DRJ-8-100-g002"></graphic></fig><p>The sharpness of the image of mandibular canal was not significantly different between two tomographic methods (<italic>P</italic>=0.166) [Figures <xref ref-type="fig" rid="F3">3</xref> and <xref ref-type="fig" rid="F4">4</xref>]; however, in 60% of tilted (12 cases), but in 35% of standard tomographic images (7 cases) the contour of canal was completely sharp.</p><fig id="F3" position="float"><label>Figure 3</label><caption><p>Canal counters’ sharpness in standard tomography, Non-detectable canal counters (0)/detectable canal counters (1)/sharp canal counters (2)</p></caption><graphic xlink:href="DRJ-8-100-g003"></graphic></fig><fig id="F4" position="float"><label>Figure 4</label><caption><p>Canal counters’ sharpness in tomography with tilt, Nondetectable canal counters (0)/detectable canal counters (1)/sharp canal counters (2)</p></caption><graphic xlink:href="DRJ-8-100-g004"></graphic></fig></sec><sec sec-type="discussion" id="sec1-4"><title>DISCUSSION</title><p>Numerous studies have shown different accuracy of panoramic, periapical, and spiral tomographic images in implantology.[<xref ref-type="bibr" rid="ref8">8</xref><xref ref-type="bibr" rid="ref16">16</xref><xref ref-type="bibr" rid="ref21">21</xref>–<xref ref-type="bibr" rid="ref25">25</xref>] Many studies have expressed that the CT is better than conventional tomography in determining the position of mandibular canal, height, and thickness of bone;[<xref ref-type="bibr" rid="ref26">26</xref><xref ref-type="bibr" rid="ref27">27</xref>] however, conventional tomography, with lower cost and less exposure of radiation, is more acceptable.[<xref ref-type="bibr" rid="ref12">12</xref>] Main reasons of controversies between different studies are based on patients’ positioning, proper exposure factors to achieve better contrast, spiral or hypocycloidal movements,[<xref ref-type="bibr" rid="ref21">21</xref>] image layer thickness,[<xref ref-type="bibr" rid="ref9">9</xref>] mandibular positioning, and observers’ experiences.[<xref ref-type="bibr" rid="ref13">13</xref>]</p><p>In several studies, different amounts of overestimating (0–3 mm) and underestimating (0–3.7 mm) have been reported.[<xref ref-type="bibr" rid="ref10">10</xref><xref ref-type="bibr" rid="ref14">14</xref><xref ref-type="bibr" rid="ref28">28</xref><xref ref-type="bibr" rid="ref29">29</xref>] Lindh mentioned that sometimes artifacts or bone marrow space are considered as the canal and this leads to overestimation.[<xref ref-type="bibr" rid="ref28">28</xref>] Mahdizade and Dalili believed another cause of overestimation that was referred to the radiologists’ experience in interpreting the tomographic images.[<xref ref-type="bibr" rid="ref14">14</xref><xref ref-type="bibr" rid="ref29">29</xref>] In our study, underestimation was found more than overestimation in both tomographic methods. It might be related to the avoidance of overestimating to minimize the risks during surgery. Serhal presented the curve of Spee as the cause of overestimating.[<xref ref-type="bibr" rid="ref11">11</xref>]</p><p>In spiral tomography, the mean value of differences (MD) in measurements of the bone height has been reported in a range of ±1 mm[<xref ref-type="bibr" rid="ref8">8</xref><xref ref-type="bibr" rid="ref11">11</xref>–<xref ref-type="bibr" rid="ref14">14</xref>] and ±2.5 mm.[<xref ref-type="bibr" rid="ref15">15</xref>] Estimating the height of bone we found the results of standard tomography (MD: 0.9 mm) less accurate than those of tomography with tilted mandible (MD: 0.6 mm). Perhaps tilting the mandible eliminates the shadow of ramus from the image of the crest which makes it sharper and lets it be measured more accurately; this is the probable reason of the difference between two methods.</p><p>To improve the quality of images and views of mandibular canal, Dalili suggested to have the lower border of mandibule horizontal.[<xref ref-type="bibr" rid="ref29">29</xref>] Naitoh studied the effect of the angle of the objective plane on the quality of image of linear tomography and suggested a range of 4.2° (2.5 to -1.7). This small range of angle mentioned the importance of the correct positioning.[<xref ref-type="bibr" rid="ref19">19</xref>] Dabbaghi <italic>et al</italic>., who had studied the role of mandibular rotation for ±10° on the quality of images of spiral tomography, suggested the zero angle (factory suggested position) and because of significant differences, the researcher rejected the negative angles.[<xref ref-type="bibr" rid="ref20">20</xref>]</p><p>Estimating the buccolingual thicknesses of bone at the half-height point we found the standard tomography (MD: 0.3 mm) more accurate than tomography with tilted mandible (MD: 0.67 mm). Apparently, transferring the shadow of ramus to the mandibular external border by tilting the mandible and consequently reduced sharpness of this region makes it difficult to estimate the thickness of bone.</p><p>In the case of the sharpness of the mandibular canal images Serhal believes that the cross-sectional images of the second and third molar regions can be distorted and be more oval rather than circular because of the patient's bad position.[<xref ref-type="bibr" rid="ref10">10</xref>]</p><p>We found no significant difference between the sharpness of canal in two tomographic methods, although in 60% of tilted and 35% of standard tomographic images, the contour of canals were completely sharp, which is also explicable with the hypothesis of eliminating the shadow of ramus from the region. Therefore further studies with more samples are suggested.</p></sec><sec sec-type="conclusion" id="sec1-5"><title>CONCLUSION</title><p>Finally, it can be concluded that 8° buccal tilt of mandible, seemingly by eliminating the shadow of ramus, improves the estimation of the bone height and sharpness of the image of mandibular canal, but it is not helpful in estimating the bone thickness. In other words, buccal tilt is recommended when accurate bone height estimating is more important but routine standard tomography is preferred when the bone thickness is requested.</p></sec></body><back><fn-group><fn fn-type="supported-by"><p><bold>Source of Support:</bold> This report is based on a thesis which was submitted to the School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran, in partial fulfillment of the requirements for the MSc degree (#389214). 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