Comparison of the Amount of Artifacts Induced by Zirconium and Titanium Implants in Cone-Beam Computed Tomography Images

doi:10.21203/rs.3.rs-1505468/v1

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Comparison of the Amount of Artifacts Induced by Zirconium and Titanium Implants in Cone-Beam Computed Tomography Images

https://doi.org/10.21203/rs.3.rs-1505468/v1

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Background: This study aimed to compare the amount of artifacts induced by the titanium and zirconium implants on cone-beam computed tomography (CBCT) and assess the effect of different exposure settings on the image quality for both materials.

Methods: In this experimental study, zirconium and titanium implants were placed in bovine rib bone blocks. CBCT images were taken in two different fields of view (FOV: 4×6 cm² and 6×8 cm²) and at two resolutions (133 µ and 200 µ voxel size). Subsequently, two observers assessed the images and detected the amount of artifacts around the implants through gray values. Data were analyzed using SPSS 21 and the significance level was set at 0.05.

Results: The results showed that titanium implants caused lower amounts of artifacts than zirconium implants, which was statistically significant (P<0.001). By increasing the FOV, the amount of artifacts was decreased in both groups, although the results were only statistically significant in the zirconium group (P<0.001). The amount of artifacts was increased by increasing the resolution in both groups, which was only significant in the zirconium group (P<0.001).

Conclusion: Our results suggest that zirconium implants induce higher amounts of artifacts than titanium ones. We also concluded that the artifacts could be minimized by increasing the FOV and decreasing the resolution.

Artifacts

Cone-Beam Computed Tomography

Titanium

Zirconium

Cone-beam computed tomography (CBCT) has developed as a three-dimensional imaging system used in various specialties of dentistry to provide precise diagnosis and treatment plans [1, 2]. In implantology, preoperative surgery planning and postoperative evaluation are critical steps. CBCT is recommended as a preoperative examination of dental implants [3, 4]. It enables the accurate localization of anatomical structures, quantification of the remaining bone, and exact measurements of both depth and height of the implantation site [5].

Besides the numerous advantages of the CBCT technique, some problems limit its application. The most commonly encountered problem is the formation of image artifacts [6]. Artifacts are errors formed in the image through the data reconstruction process unrelated to the actual characteristics of the subject being studied [1, 7]. Factors involved in inducing the artifacts can be classified as follows: 1) artifacts caused by the physical structure of the CBCT system, such as the mathematical format used in the 3-dimensional reconstruction, 2) artifacts related to the image acquisition, such as patient movement, exposure settings including milliamperage (mA) and peak kilovoltage (kVp), and presence of high-density elements [5, 8–10].

As one of the high-density materials used in dentistry, traditional titanium implants are accounted for artifact formation in CBCT images, which may prevent proper analysis of the peri-implant area. Therefore, CBCT is not an inerrant protocol for post-implant evaluations due to the inherent limitations of the imaging process [7, 11, 12].

Metal-free implants such as zirconium have recently become a feasible alternative to titanium implants. Zirconium implants are preferable in the esthetic area due to their tooth-like color [13]. Reduced plaque accumulation and enhanced biocompatibility around zirconium implants have diminished the inflammatory and allergic reactions compared to titanium implants [14, 15]. In addition, it has been reported that the mechanical stability and success rate of zirconium and titanium implants are comparable [16–18]. Despite the mentioned advantages, zirconium is also a high-density element causing image artifacts.

Each type of dental implant material impacts the CBCT image quality differently, and exposure settings' alterations affect the image quality depending on the type of implant's material. Therefore, we aimed to compare the amounts of artifacts produced by titanium and zirconium implants on CBCT images. Additionally, we evaluated how different exposure parameters of a CBCT system, such as field of view (FOV) and resolution, impact the image quality for different materials (titanium and zirconium).

This experimental study was approved by the Ethics Committee of Hamadan University of Medical Science (IR.UMSHA.REC.1397.544). Bone blocks were prepared using freshly slaughtered cows' rib bones that appropriately resemble the human alveolar bone. The ribs were kept refrigerated to avoid dehydration. After removing the soft tissue around the ribs, we used a computer numerical controlled machine (Pooya Mechatronic, Hamadan, Iran) to cut the bones into 60 bone blocks of exactly equal dimensions, measuring 8×8×11 mm [19, 20]. Also, a plastic box with holes of the same size as the bone blocks was designed by the same manufacturer (Pooya Mechatronic, Hamadan, Iran) to tightly hold the blocks during implant insertion (Fig. 1A). Furthermore, an experienced oral and maxillofacial surgeon inserted 30 titanium implants (SIC invent AG, Basel, Switzerland) and 30 zirconium implants (which were manufactured especially for this study by Pouyan Teb Hegmataneh Industries Company, Hamadan, Iran) with 4 mm diameter and 11 mm length in bone blocks (Fig. 1B). These custom-made zirconium implants were used to eliminate confounding variables, such as length, diameter, and surface properties of the implants, and the type of material was the only variable between the two groups.

Rectangular boxes were fabricated using two layers of 2 mm red dental wax. Bone blocks containing and without implants were placed in these boxes alternatively [21] (Fig. 1C).

The CBCT images were obtained using CBCT Cranex 3D (Soredex, Tuusula, Finland) with exposure settings of 90 kVp, 10 mA, 6.1 s, two different sizes of FOVs (4×6 cm² and 6×8 cm²), and two different resolution modes (high: 133 µ voxel size and low: 200 µ voxel size).

All CBCT images were imported as DICOM files into On Demand 3D dental software (Cybermed, Seoul, Korea) to be reconstructed and analyzed. For the assessment of images, cross-sections were reconstructed so that the sections passed through the implant's center.

One way to examine the artifact is to evaluate the gray value intensity in the implant areas compared to the bone without the implant. A perpendicular axis to the implant's longitudinal axis was reconstructed for data evaluation like Benic GI et al. [22] and Sancho-Puchades M et al. [23] studies. The region of interest (ROI) with 15×5 pixels dimensions was considered for each section in a way that passed through the middle of the buccal plate from the buccolingual point of view and covered the highest amount of artifacts from the corono-apical point of view. Finally, the gray value of the selected ROI was recorded, presenting the amount of artifact (Fig. 2).

Two observers (one maxillofacial radiologist and one dentist) examined all samples' scans twice at two-week intervals. Agreement between the two observers was assessed.

Data were analyzed using SPSS software version 21. Data were reported as mean ± standard deviation and were analyzed using descriptive statistics and statistical tests such as repeated measurement, paired t-test, and independent t-test. The intra-class correlation coefficient (ICC) was used to control inter-observer and intra-observer agreements. The significance level was set at 0.05.

The calculated ICCs were 0.961 (intra-observer) and 0.945 (inter-observer), showing excellent agreement between the two observers. Therefore, we reported study results according to the measurements obtained from the first iteration of one of the observer's reports.

The results showed that the amount of artifacts induced by the zirconium implant group was significantly higher than the titanium implant group (P < 0.001). The difference between the two groups of implants was significant in both FOVs (small and large) and both resolutions (low and high) (P < 0.001, Table 1, Fig. 3).

Table 1

Comparison of the amount of artifacts induced by study groups in different FOVs and resolutions
FOV	Resolution	Group	Mean ± SD	Mean dif. ±SE	P-value
Small	High	Zirconium	1566.10 ± 0.77	1098.65 ± 41.50	< 0.001
Small	High	Titanium	167.44 ± 143.76	1098.65 ± 41.50	< 0.001
Small	Low	Zirconium	1434.46 ± 0.9	1061.18 ± 33.96	< 0.001
Small	Low	Titanium	373.28 ± 117.65	1061.18 ± 33.96	< 0.001
Large	High	Zirconium	1251.02 ± 62.74	928.86 ± 60.71	< 0.001
Large	High	Titanium	322.16 ± 200.75	928.86 ± 60.71	< 0.001
Large	Low	Zirconium	1329.05 ± 36.43	1016.52 ± 49.40	< 0.001
Large	Low	Titanium	312.53 ± 167.23	1016.52 ± 49.40	< 0.001

The amount of artifacts induced by zirconium implants was significantly decreased by the increment in the size of the FOV in both high and low resolutions (P < 0.001). In the titanium implants group, the amount of artifacts was also decreased by the increment in the size of the FOV in both resolutions, but the results were not statistically significant (high resolution: P = 0.212 and low resolution: P = 0.281) (Table 2).

Table 2

Comparison of the amount of artifacts induced by study groups in large and small FOVs
Group	Resolution	FOV	Mean ± SD	Mean dif. ± SE	P-value
Zirconium	High	Small Large	1566.10 ± 0.77 1251.02 ± 62.74	315.07 ± 18.11	< 0.001
Zirconium	Low	Small Large	1434.46 ± 0.9 1329.05 ± 36.43	105.40 ± 10.52	< 0.001
Titanium	High	Small Large	467.44 ± 143.7 322.16 ± 200.75	145.28 ± 71.28	0.212
Titanium	Low	Small Large	373.28 ± 117.65 312.53 ± 167.23	60.75 ± 59.02	0.281

The amount of artifacts increased with resolution enhancement in both study groups, which was statistically significant only in the zirconium group (P < 0.001, Table 3).

Table 3

Comparison of the amount of artifacts induced by study groups in high and low resolutions
Group	Resolution	Mean ± SD	Mean dif. ± SE	P-value
Zirconium	High Low	1408.56 ± 166.67 1381.76 ± 59.44	26.80 ± 36.12	< 0.001
Titanium	High Low	394.80 ± 186.18 342.90 ± 144.77	51.89 ± 48.14	0.573

Implant placement aims to restore acceptable esthetic and function without affecting the surrounding soft and hard tissues. Rocharles C et al. [7] stated that high-density structures with great atomic numbers, such as dental implants, induce the beam hardening phenomenon in CBCT scans, affecting image quality and diagnosis. High-density materials act as filters that attenuate lower energy photons, leading to only higher energy photons left to contribute to the beam. Hence, the mean beam energy increases, resulting in data reconstruction error. This error leads to a deterioration in the image quality adjacent to these objects, demonstrated as linear structures, bands, or shadows. In addition to beam hardening, scattering also affects the image quality causing views such as cups, streaks, and dark bands between dense objects or at sharp edges. Due to the beam hardening and scattering, artifacts appear nearby high-density objects such as dental implants and thus severely reduce the diagnostic value of the images [3].

Studying the amount of artifacts induced by different implants helps decide the type of implant in clinical applications and can benefit the complication diagnosis and patient follow-up [24]. However, Chagas M et al. [25] found no significant difference regarding diagnostic accuracy between CBCT images of peri-implant bone defects around titanium implants and zirconium dioxide implants.

Numerous literature has studied the effect of various parameters, such as FOV, kVp, mA, system type, exposure time, type of material, and surrounding bone, on artifacts by the dental implant in the CBCT images [3, 26, 27]. Though, how we should change the exposure parameters depending on the specific CBCT system or type of implant being used is still a controversial matter. Hence, this study was conducted to investigate the effect of different exposure parameters and implant materials on the amount of artifacts based on the CBCT system and exposure settings used routinely in our office. Exposure parameters, including FOV and resolution, were studied in the Cranex 3D CBCT system.

Our results showed that the amount of artifacts around zirconium implants was higher than in titanium implants. This outcome confirmed the effect of implant material on the image quality. According to the Mendeleev table, titanium atoms have an atomic number of 22 and a density of 4.506 g.cm^− 3, and zirconium atoms have an atomic number of 40 and a density of 6.511 g.cm⁻³. This difference in atomic numbers and densities of the two implants materials may justify the higher amount of artifacts in zirconium implants.

Shokri A et al. [28] examined the effect of different exposure settings in a CBCT system on reducing the metal artifact around dental implants at different bone densities. The results showed that implants induce different amounts of artifacts in CBCT images by altering conditions such as FOV, bone density, time, amperage, and voltage. Notably, the effect of voltage on the amount of artifacts was more than other factors. Therefore, in order to equalize the conditions and eliminate the mediating factors, we set the same setting (90 kVp and 10 mA) and bone density in all images and conducted the study in two FOVs (4×6 cm² and 6×8 cm²) as well as two resolutions (high and low) [29].

Sancho-Puchades M et al. [23] compared the artifacts generated by titanium, titanium-zirconium, and zirconium implants in vitro. They inserted implants in 20 bone models of human mandibles and investigated the amount of artifacts in CBCT images (KaVo Dental GmbH, Biberach, Germany). Similar to our observations, they concluded that the amount of artifacts produced by zirconium implants was more considerable than others. It should be mentioned that they used different exposure settings of 120 kVp, 5 mA, and 26 s radiation time.

Fontenele RC et al. [3] also investigated the amount of artifacts induced by implants inserted in the human mandible at distances of 1.5 cm, 2.5 cm, and 3.5 cm with angles of 65°, 90°, 115°, and 140° by three various CBCT systems (Picasso Trio, ProMax 3D, and 3D Accuitomo 80). Using 80 kVp and 5 mA exposure settings, they concluded that zirconium implants produce the most significant artifacts. This outcome was in line with our study. Observations showed that titanium implants created the same amount of artifacts regardless of the CBCT system type used for imaging, while zirconium implants showed different amounts of artifacts depending on the CBCT system.

In 2017, Smeets R et al. [24] examined artifacts caused by zirconium, titanium, and titanium-zirconium implants in magnetic resonance imaging (MRI), conventional tomography (CT), and CBCT images using almost identical exposure conditions as ours (90 kVp, 8 mA, 13.6 s). In MRI images, the amount of artifacts from the zirconium implants was the least, while in the CT and CBCT images, the titanium implants had produced the minimum amount of artifacts. As a result, they suggested MRI as the excellent choice of imaging for patients with zirconium implants and CT or CBCT for patients with titanium and titanium-zirconium implants. It is mentionable that the advantage of this study was to explore the amount of artifacts in different imaging modalities; nevertheless, it confirmed the results of the present study.

In addition to the implant's material, the present study showed that FOV is one of the factors influencing image quality. FOV size varies based on the system used for imaging, and it should be carefully set so that the resulting image can provide valuable information for the patient's diagnosis and treatment plan. Selecting the appropriate FOV size reduces the patient radiation exposure and enhances the image quality [30]. As the radiation field enlarges, the pixel size rises, which increases the fill factor and the radiation-sensitive surface, thus reducing the amount of noise. Expansion of the radiation field results in more beam scattering, which increases the amount of artifacts and noises. However, the pixel size has a more definite effect on image quality, diminishing the beam scattering influence [31].

In the present study, the amount of artifacts around the implants decreased by the FOV expansion. Previous studies have also found FOV as one of the main factors affecting image quality. In agreement with our results, Pauwels R et al. [32] suggested that the large FOV performed better than the small one using the 3D Accuitomo 170 system (90 kVp, 5 mA) for imaging.

Shokri A et al. [33] studied the effect of FOV size on gray values in CBCT images. They implanted 4 acrylic cylinders in acrylic phantoms, each containing various materials used in maxillary grafts, including Nanobone, Cenobone, Cerabone, and water (as a control group). CBCT images were taken using 90 kVp, 5 mA, and two different FOVs (4×6 cm² and 6×8 cm²). The results showed that FOV significantly affects the quality of images. The smaller FOV resulted in more variability in gray values and thus increased amounts of artifacts, which was consistent with the current study.

Whether an increase in FOV reduces or increases the amount of artifacts depends on many factors such as the CBCT system, exposure conditions (voltage and amperage), test performance, the bone or material used for implant insertion, the amount of beam scattering, and the amount of generated noise during the FOV changes.

In 2013, Parsa A et al. [30] examined the CBCT parameters (FOV, spatial resolution, number of projections, exposure time, and dose selection) on the gray value measurement in the implant area. This study included two CBCT systems (Accuitomo 170 and NewTom 5G) and Multislice CT (MSCT) for imaging. In both CBCT systems, selective spatial resolution and FOV significantly affected gray value measurements. The results presented more significant artifacts with FOV increment by Accuitomo 170 (90 kVp and 5 mA), which was not in line with the present study. This conflict might have resulted from image reconstruction and post-processing differences between the two studies. However, the results obtained from the NewTom 5G (110 kVp and 0.57 mA) showed that the amount of artifacts decreased with FOV increment, which is consistent with our study.

Regarding the effects of resolution alterations on imaging quality, we observed more artifacts with high resolutions in both study groups, but the results were only statistically significant for the zirconium implants group. Therefore, reducing the resolution seems to benefit the quality improvement of CBCT images from zirconium implants.

Resolution is the ability to detect small details on images, and it depends on the voxel size of the digital systems. According to Shokri A et al. [34], smaller voxel sizes can increase the resolution. Voxel size is a critical factor that affects the quality and duration of CBCT images reconstruction [35]. Theoretically, as the voxel size decreases, the detector's radiation-sensitive surface decreases, resulting in higher noise levels in the images. Consequently, there is a need to increase voltage, amperage, or radiation time to improve image accuracy. Thus, reducing the voxel size increases the image's resolution at the cost of additional image noise and patient exposure [31].

A study by Parsa A et al. [30] showed that higher resolutions lead to higher amounts of artifacts. This inconsistent result with ours might be due to the differences in the systems' spatial resolution used for imaging.

In conclusion, the amount of artifacts induced by dental implants is an inevitable factor affecting the quality of CBCT images. Although, it could be diminished by enhanced precision in interpreting images, improved accuracy in choosing the type of implant, and more attention to imaging settings such as FOV and resolution. Within the limitations of this study, using CBCT Cranex 3D with exposure settings of 90 kVp, 10 mA, and 6.1 s, increasing the FOV and decreasing the resolution minimize the artifacts. Furthermore, zirconium implants induce higher amounts of artifacts than titanium ones.

Ethics approval and consent to participate

This experimental study was approved by the Ethics Committee of Hamadan University of Medical Science (IR.UMSHA.REC.1397.544).

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no known competing financial interests

or personal relationships that could have appeared to influence the work

reported in this paper.

Funding

This work has been financially supported by Hamadan University of Medical Sciences (Grant number: 9709135423).

Authors’ contributions

AS: conception and design of the study; interpretation of data; manuscript revision; personal accountability. FV: conception and design of the study; interpretation of data; manuscript revision; personal accountability. LH: conception and design of the study; data acquisition and analysis; interpretation of data; manuscript revision; personal accountability. SS: conception and design of the study; interpretation of data; manuscript draft and revision; personal accountability. MF: conception and design of the study; interpretation of data; manuscript revision; personal accountability. MJ: conception and design of the study; interpretation of data; manuscript revision; personal accountability. All authors read and approved the final manuscript.

Acknowledgments

Not applicable.

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Comparison of the Amount of Artifacts Induced by Zirconium and Titanium Implants in Cone-Beam Computed Tomography Images

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