Open Journal of Radiology, 2013, 3, 136-142
http://dx.doi.org/10.4236/ojrad.2013.33023 Published Online September 2013 (http://www.scirp.org/journal/ojrad)
Acrylic Customized X-Ray Positioning Stent for
Prospective Bone Level Analysis in Long-Term Clinical
Implant Studies
Ana Messias*, João Paulo Tondela, Salomão Rocha, Rita Reis, Pedro Nicolau, Fernando Guerra
Department of Dentistry, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
Received May 16, 2013; revised June 16, 2013; accepted June 23, 2013
Copyright © 2013 Ana Messias et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Objectives: This paper describes a technique to produce individualized X-ray positioning devices for intraoral digital
imaging of dental implants with long-term stability. Materials and Methods: An X-ray positioning device was built for
Gendex® Visualix® eHD sensor, using the Dentsply rinn XCP-DS® system individualized by the incorporation of the
bite piece within an acrylic stent to perform successive standardized radiographs to 16 patients. X-ray tube stabilization
was achieved with polivinylsiloxane. Series of 3 radiographs were taken to each patient in different moments. Specific
linear measurements as the implant diameter (mesio-distal width) and the height between consecutive threads (thread
pitch) were made to all radiographs to determine the reproducibility and accuracy of the procedure. Results: The intra-
class correlation coefficient for the mesio-distal width was 0.964 [(0.920 - 0.986) 95% CI] (p < 0.01) and 0.990 [(0.976
- 0.996) 95% CI] (p < 0.01) for the thread pitch. Bland-Altman plots comparing implant diameter showed mean bias of
0.01 ± 0.01975, 0.01 ± 0.02243 and 0.0006 ± 0.025 for groups 1 - 2, 1 - 3 and 2 - 3 respectively. Mean bias of 0.0024 ±
0.00552, 0.0027 ± 0.00552 and 0.0003 ± 0.0012 was found for the thread pitch analysis of groups 1 - 2, 1 - 3 and 2 - 3.
One sample t-test for trueness of mesio-distal width, thread pitch and ratio showed mean difference of 0.00156 mm for
the test value of 3.3 (p = 0.9), −0.00026 mm for 0.8 (p = 0.96) and 0.0124 for 4.125 (p = 0.72), respectively, after the
application of a magnification correction factor. Conclusion: The device produced reproducible images in different
moments and was suitable for comparative clinical examinations of marginal bone as it was convenient to perform reli-
able linear measurements.
Keywords: Dental Radiovisiography; Radiograph; Dental Implant; Outcome Measurement Errors; Reproducibility of
Results
1. Introduction
Long-term evaluation of dental implants and their sur-
rounding structures is crucial to provide more informa-
tion concerning the success or failure of these therapies
in clinical trials. The radiographic analysis, in conjunc-
tion with the clinical evaluation of the implant sites, is
the best non-invasive method for bone level determina-
tion [1-4]. Among the diverse radiographic techniques,
the periapical technique has proven to be the most accu-
rate method for the linear measurement of alveolar bone
height [5-7]. However, the diagnosis of progressive bone
loss or the identification of bone gain from one radio-
graphic examination to the next may be very difficult to
interpret due to errors in the alignment of successive im-
ages. This, together with intra and inter-examiner vari-
ability, leads to incorrect interpretations of bone height
and density changes, and limits the diagnostic value of
conventional periapical radiographs, especially in can-
cellous bone [8-11].
To overcome this problem, Updegrave [12] detailed
the paralleling extension-cone technique and introduced
the Rinn system, the first film holder to keep the film
parallel to the tooth and in a flat position, but still not
producing acceptable images for continuous reproduction.
Ever since, numerous systems have been proposed to
obtain superimposable dental radiographs but have not
proven to prevent projection errors effectively as they
fail to ensure the realignment of the initial imaging ge-
ometry [13-21]. The two main sources of differences in
the projection geometry between pairs of radiographs
*Corresponding author.
C
opyright © 2013 SciRes. OJRad

A. MESSIAS ET AL. 137
arise due to the differences in the relationships between
either the object and the radiographic film/sensor, or the
object and the X-ray source [9,22]. While the first can be
solved using a film or sensor holder placed within a rigid
bite stent that facilitates consistent positioning of the film
behind a group of teeth, the second cannot be so easily
addressed [23,24]. Nevertheless, reproducible alignments
are achievable by fixing the patient’s head to the tube
head using some forms of extra-oral apparatus, as the
metallic tip of the Dentsply Rinn XCP® system (Dentsply
Rinn, Elgin, IL) that promotes the perpendicular position
of the central X-ray to the film plane. The most important
feature is to prevent changes in the projection geometry
between consecutive radiographs, as they are responsible
for irreversible distortions that may lead to different two-
dimensional images of the same clinical three-dimen-
sional situation [5,8,10].
Even though perfect parallelism between the object
and the film plane is not always achievable under clinical
conditions, consistent projection geometry has been re-
ferred as the most important feature for correct bone le-
vel assessment. Several systems have been described pre-
viously in the literature for the standardization of con-
ventional periapical radiographs [13-19,21] but lack the
needed and yearning accuracy.
Considering the widespread of radiovisiography and
the need for repeatable images prone to further digital
imaging treatment as linear measurement or DSR, the
authors firstly propose to report an improved technique
to attain standardization of serial radiographs with geo-
metric projection matching and minimization of the dis-
tortion of structures, which allows the isolation of the
area of interest, the superimposition of structures such as
teeth, implants and bone, and facilitates the quantifica-
tion of peri-implant bone level changes. Secondly, the
authors aim at the determination of the reliability and
trueness of the described device.
2. Materials and Methods
2.1. Clinical and Laboratorial Procedures
Sixteen patients enrolled for a non-interventional clinical
study with Straumann Roxolid® Bone Level implants
(Institute Straumann AG, Waldenburg/BL, Switzerland)
authorized by the Committee for Ethics in Health of the
University Hospital of Coimbra-Portugal—were selected
for the build up of an X-ray standardization appliance.
The proposed device is a modification of the Han-Shin
type positioner for the periapical technique [14,15] that
uses the Dentsply rinn XCP-DS® system adapted for the
Gendex® Visualix® eHD (Gendex Dental Systems, IL,
USA) universal size sensor (37.5 mm × 25.5 mm). The
system is composed of a plastic bite piece, a sensor
holder, a metallic arm and a plastic aiming ring for ori-
entation of the tube head cylinder. Both bite block and
the aiming ring are individualized for each patient, which
requires two appointments.
In the first appointment, impressions from the upper
and lower arch are made using alginate impressions.
The alginate impressions are filled with dental plaster
and the stone models obtained are mounted according to
jaw relation onto the semi-adjustable articulator.
A bilateral acrylic block is built over the arch with the
area of interest; for instance, if the area is on the lower
jaw, the acrylic block is built over the mandibular teeth.
The bite plastic piece, the sensor basket and a sensor rep-
lica (with the same size as the sensor) are placed over the
cured acrylic block ensuring that the sensor replica is
parallel to the area of interest and acceptable mouth
opening is checked (Figures 1 and 2). The bite piece, the
sensor holder and replica are held against the opposite
dental arch and stabilized bilaterally with acrylic (Figure
3). The result, after cure, is a bimaxillary splint that en-
sures the reproducibility of the intra-oral sensor orienta-
tion in sequential radiographs (Figures 4-6).
2.2. Series of Radiographs
Series of radiographs were taken for all the patients using
the Gendex® Visualix® eHD universal size sensor at the
Figure 1. Sensor replica and horizontal basket set with the
plastic bite piece and placed parallel to the region of inter-
est (upper view).
Figure 2. The plastic bite piece is held against the opposite
arch teeth. Mouth aperture is checked to ensure that the
patient supports the splint.

A. MESSIAS ET AL. 138
Figure 3. Bilateral bite block frontal view after cure.
Figure 4. Device try-in with sensor placed in basket. The
acrylic block is seated over the mandibular teeth. After-
wards the patient fits the maxillary teeth in the splint and
stabilizes the device.
Figure 5. After the try-in, the aiming ring is individualized
with silicone putty to keep the tube cylinder stable and
perpendicular to the sensor.
Figure 6. Frontal view of the complete set up in the mouth
and with the cylinder tube fixed.
maximum image resolution of 25.6 LP/mm to assess the
reproducibility of the procedure at distinct times: base-
line, implant surgery, rehabilitation and first year (after
surgery). Figure 7 is representative of the series of ra-
diographs; image size considered was 1590 × 1024 pixels.
All patients signed an informed consent form.
2.3. Statistical Analysis
To determine the accuracy and repeatability of the digital
images obtained through the standardization method,
series of repeated measurements were obtained from the
16 clinical situations of areas with Straumann Roxolid®
Bone Level implants (Institute Straumann AG, Walden-
burg/BL, Switzerland) by a professional trained in im-
plant therapy and radiographic analysis of dental im-
plants using the ruler tool of the VixWin™ Platinum
(Gendex Dental Systems, IL, USA) imaging software.
Thus, for each clinical situation specific points were
identified in the threads of the implants of the first radio-
graph of the series and the mesio-distal length (diameter)
and the thread pitch registered in the same conditions for
all three images, as represented in Figure 8. Radiographs
were taken at the surgery (initial moment) (group 1),
rehabilitation (3rd - 4th month) (group 2) and control (1st
year) (group 3) and the results were analyzed with the
PASW® Statistics 18 (IBM). To determine agreement of
the measurements of the 3 moments, intraclass correla-
tion coefficients (ICC) were calculated based on the
two-way mixed model using an absolute agreement defi-
nition for single measures and Bland-Altman plots were
built for both the mesio-distal length and for the thread
pitch height of the implants (95% Limit of Agreement)
[25]. The first accounts for the evaluation of magnifica-
tion errors from one image to the next while the second
determines variations of the projection geometry between
successive images. Variations in the beam-object-sensor
angulations result in distortion of the implants detectable
by thread height reduction or elongation. Overall image
distortion was determined by calculating a new variable
was computed to determine the ratio between the mesio-
distal length and the thread pitch. A relationship proxi-
mal to the theoretical value for the ratio demonstrates the
same proportionality of the implant, confirming low dis-
tortion and correct angular projection. The values were
analyzed with the one sample t-test to (95% CI) to com-
pare the mean difference between each value and the
standard value for the implant diameter, for the thread
pitch and the ratio. Values are expressed in millimeters.
3. Results
The setup described guarantees even projection geometry
in sequential radiographs, regardless the head position
fthe patient. The X-ray cone-area of interest-sensor angu- o

A. MESSIAS ET AL. 139
Figure 7. Tooth 24 area: a) pre-operatory; b) surgery; c) definitive restoration; d) 1 year follow-up.
Figure 8. Representation of the method used for measure-
ments acquisition. a: Acquisition of the Mesio-Distal (MD)
length; b: Acquisition of the thread pitch. Figure 9. Bland-Altman plot of thread height measurements
for groups 1 and 2; 1 and 3; 2 and 3. Mean differences be-
tween groups of −0.0024 mm, −0.0027 mm and 0.0003 mm,
respectively.
lation is determined by the fixation of the plastic bite
with rigid acrylic and by the silicone putty individualized
aiming ring.
Table 1 summarizes the descriptive statistics for the
differences between pairs of groups for implant diameter
and thread pitch height. Reliability analysis for the im-
plant diameter revealed an ICC of 0.964 [(0.920 - 0.986)
95% CI] calculated for single measures of the three
groups using the absolute agreement definition (p < 0.01).
Intraclass correlation coefficient determined for the
thread measurements was 0.990 [(0.976 - 0.996) 95% CI]
(p < 0.01). Figure 9 represents the Bland-Altman plot for
the agreement of the paired groups 1 - 2, 1 - 3 and 2 - 3
regarding the differences in thread pitches between ra-
diographs. The values of the three groups for me-
sio-distal length, thread pitch and mesio-distal length to
thread pitch ratio were gathered into a single group with
correspondence. These three groups with 48 values each
were compared to the respective reference values. The
real implant diameter of 3.3 mm and the real thread pitch
value of 0.8 mm were obtained from the manufacturer
catalog. The determined reference ratio was 4.125 and
the results are summarized in Table 2; p values stand for
the one sample t-test results for the comparison of the
group means with the reference values provided to test
for the trueness of the standardization method. No sig-
nificant differences were found (p > 0.05). The mean
difference of the measured values and the reference val-
ues was negligible for all three groups. Single measure-
ments range from the real value (95% CI): [−0.0234,
Table 1. Descriptive statistics for bias between measure-
ments (mm). Min—minimum; Max—maximum; SD—
Standard Deviation.
Mean ± SD Mean
difference p
MD width (3.3) 3.3016 ± 0.08611 0.00156 0.9
Thread pitch (0.8) 0.7997 ± 0.03385 −0.00026 0.96
MD/Thread ratio (4.125)4.1374 ± 0.23446 0.0124 0.72
Table 2. Mean ± SD for MD width, thread pitch and
MD/Pitch ratio error and one sample sample t-test (α =
0.05). Bracket values represent the reference values for the
t-test. SD—standard deviation.
Min Max Mean ± SD
Group 1 and 2 0.00 0.06 0.0100 ± 0.01975
Group 1 and 3 −0.02 0.06 0.0100 ± 0.02243
Implant
Diameter
Group 2 and 3 −0.06 0.06 0.0006 ± 0.02542
Group 1 and 2 0.00 0.02 0.0024 ± 0.00552
Group 1 and 3 0.00 0.02 0.0027 ± 0.00552
Thread
Pitch
Height
Group 2 and 3 0.00 0.00 0.0003 ± 0.00120
0.0266 mm] for the MD width, [−0.0101, 0.0096] for the
thread height and [−0.0557, 0.0805] for the ratio.

A. MESSIAS ET AL. 140
4. Discussion
Presently in clinical practice, alveolar bone loss is as-
sessed either by measuring the linear crestal bone height
from sequential radiographs or by density methods as
DSR [3,19,26]. These methods are easily influenced by
changes on the projection geometry of successive peri-
apical radiographies as it affects the image of anatomical
structures superimposed and constrains variations of the
trabecular pattern of the cancellous bone. Moreover, the
artifacts created by the high radiographic opacity of the
dental implants, together intra and interexaminer vari-
ability, limit the diagnostic value of conventional radio-
graphs with uncontrolled angular variations [27-29].
Differences in the projection angles between consecu-
tively obtained radiographs has a distorting effect that
leads to misinterpretations of bone levels [10,23,24,30].
Hence, X-ray standardization and the degree to which all
details can be superimposed is critical for the correct
evaluation of bone levels and density changes between
consecutive images, which is particularly true at the al-
veolar crest [3,15,31]. Despite being the most recom-
mended system to attain X-ray standardization, the XCP
system does not permit reproducible film placement or
image density normalization by itself [6,16,20]. Consis-
tent film or sensor to area of interest alignment can only
be achieved through the cross-arch stabilization design of
the described splint that incorporates the XCP bite block
and establishes the exact position of the film or sensor
for each follow-up examination, eliminating this source
of misalignments. Unilateral bite registrations with
non-rigid materials allow small horizontal and vertical
planar rotations of the detector relative to the object, de-
teriorate over time and are a source of distortion. Some
authors even refer no improvement in the measurements
of bone levels using silicone-based bite blocks [13,32].
Even though other articles refer that alignment software
overcomes these kind of planar errors after image capture
by mathematical correction of the image with basis on
the implant size, it is still advisable that, as discussed
previously, all sources of object-detector angulations are
eliminated [24,33]. Thus, considering the use of a rigid
splint to position the sensor, the orientation of the X-ray
beam is responsible for the largest source of distortion
and irreversible misalignment. In fact, the angulation
difference between the central beam and the detector
holder is more important for the interpretation of radio-
graphic changes than the angulations between the detec-
tor and the area of interest [11,34]. To reduce irreversible
alignment errors, several methods with beam aiming de-
vices have been proposed, including the use of cepha-
lostats with increased source-object distance, opto-elec-
tronic positioning devices and some sort of “film holder
to radiation source” connections. Whereas the two first
require difficult procedures that demand for special
equipment, the other connections are lighter and simpler
to use, as the XCP Rinn metallic arm and aiming ring
used in this work [3,10,13,14,17-19,35]. The rigidity of
the X-ray coupling to the film holder has been issue of
debate. Some authors argue that a rigid connection may
cause tilting between the splint and the teeth that is dif-
ficult to control [10,26,36]. However, non-rigid coupling
to the X-ray cone seems to be the largest source of align-
ment error [9,22,30,34]. The individualization of the aim-
ing ring with silicone putty presented in this paper is, in
fact, an improvement to the technique described by Cou-
ture, Dixon [15] that gives rigidity to the connection,
assures unchallenging stability of the projection and pre-
vents magnification errors between successive radio-
graphs. The ICC of 0.990 [(0.976 - 0.996) 95% CI] for
the thread width measurements for the three moments
clearly estimates a strong correlation between measure-
ments, therefore stating the high reproducibility of the
method with regard to changes in the vertical angulations.
The mean bias of 0.0024 mm [(−0.0084,0.0132) 95% CI]
for the same measurements of groups 1 and 2, 0.0027
mm [(−0.0081,0.0135) 95% CI] for groups 1 and 3 and
0.0003 mm [(−0.0020,0.0026) 95% CI] for groups 2 and
3, is perfectly acceptable considering the implant manu-
facturing tolerance of 0.01 to 0.001 inches (0.0254 to
0.254 mm). Bland-Altman plots represented in Figure 9
present small discrepancy between thread pitch meas-
urements, 0 bias for the majority of pairs of measure-
ments and very few values per graphic out of the 95%
limit of agreement, revealing negligible discrepancy be-
tween pairs of images. Accordingly, the ICC of 0.964
[(0.920 - 0.986) 95% CI] tested for the reliability of im-
plant diameter measurements shows that magnification
variations between pairs of radiographs are virtually
eliminated through the presented method, which is in line
with the results of previous studies using the XCP Rinn
system [16]. More, the method has proven to be accurate
as no significant differences were found among the mean
mesio-distal linear measurements and the real implant
diameter (3.3 mm) (p = 0.9), and the mean thread height
and the real thread pitch (0.8 mm) (p = 0.96), both with
negligible differences between each value and the refer-
ence value.
The MD/pitch ratio calculated for each radiograph and
its comparison to the reference value of 4.125 aimed at
the determination of the mean distortion of the image
caused by violation of the principles of the parallelism
technique. Seeing that the sensor holder and the metallic
tip provide the required perpendicularity between the
cone and the sensor, the referred distortion is triggered
by non-perpendicular alignment of the X-ray source and
the region of interest containing the implant. In spite of
the slightly higher mean difference of the measurements
to the value of the real ratio (0.0124 mm), all measure-

A. MESSIAS ET AL. 141
ments demonstrated to be precise, denoting no misrepre-
sented images of the implants. This, in conjunction with
the MD width and thread pitch analysis, reinforces the
validity of the method to carry out linear measurements
for bone level assessment over implant radiographs.
5. Conclusion
Highly standardized radiographs allow for accurate linear
evaluation of crestal bone regardless the observer and are
of greatest importance for the diagnostic value of densi-
tometry and subtraction techniques as the projection
geometry is controlled and a reproducible alignment is
achieved for long term follow-up. The template here de-
scribed for X-ray standardization is adapted from a com-
mercially available system meant for radiovisiography. It
consists of a rigid sensor holder-object-X-ray source type
of device with a custom-made acrylic bite-block attached
to the sensor holder and connected to the tube through an
individualized aiming ring. This X-ray alignment device
minimizes variations in X-ray imaging geometry caused
by different angulations between the central beam and
the region of interest and prevents angular distortion and
alignment errors between two consecutive radiographs,
thus making matching images that are superimposable,
which allows a quantitative analysis of longitudinal ra-
diographic crestal bone changes.
6. Acknowledgements
The authors would like to express their gratitude to Ana-
bela Pedroso, Laboratory Technician of the Department
of Dentistry, Faculty of Medicine, University of Coimbra,
for her continuous and valuable work on the elaboration
of the acrylic stents.
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