INDEX

 HISTORY

 GUIDELINES

 PRINCIPLES OF CBCT

 CLINICAL CONSIDERATIONS AND SPECIFIC APPLICATIONS IN

DENTISTRY

 ARTIFACTS

 ADVANTAGES

 LIMITATIONS

 CONCLUSION

 REFERENCES
 HISTORY

In 1972 Godfrey Hounsfield, an engineer, announced the invention of a revolutionary

imaging technique that used image reconstruction mathematics developed by Alan
Cormack in the 1950s and 1960s to produce cross-sectional images of the head.
Currently this form of imaging is called computed tomography, abbreviated as CT.
Hounsfield and Cormack shared the Nobel Prize in Physiology or Medicine in 1979
for their pioneering work.

Cone-beam computed tomography (CBCT) is a recent technology initially

developed for angiography in 1982 and subsequently applied to maxillofacial
imaging. It is only since the late 1990s that it has become possible to produce clinical
systems that are both inexpensive and small enough to be used in the dental office.

The principal feature of CBCT is that multiple planar projections are acquired
by rotational scan to produce a volumetric dataset from which interrelational images
can be generated. This technology has been given several names including

› dental volumetric tomography,

› cone-beam volumetric tomography,

› dental computed tomography, and

› cone-beam imaging

The most frequently applied and preferred term is cone-beam computed tomography

GUIDELINES

1. The decision to conduct a radiographic examination should be based on the individual

needs of the patient.

2. These needs are determined by findings from the dental history and clinical
examination and modified by patient age and general health.

3. A radiographic examination is necessary when the history and clinical examination

have not provided enough information for complete evaluation of a patient’s condition
and formulation of an appropriate treatment plan.
4. Radiographic exposures are necessary only when, in the dentist’s judgment, it is
reasonably likely that the patient will benefit by the discovery of clinically useful
information on the radiograph.

Consensus guidelines of European Academy of dental and maxillofacial

radiology (2009)

1. Cone beam computed tomography examinations must not be carried out unless a
history and clinical examination have been performed.
2. Cone beam computed tomography examinations must be justified for each patient to
demonstrate that the benefits outweigh the risks.
3. Cone beam computed tomography examinations should potentially add new
information to aid the patient’s management.
4. Cone beam computed tomography should not be repeated ‘routinely’ on a patient
without a new risk/benefit assessment have been performed.
5. When accepting referrals from other dentists for CBCT examinations, the referring
dentist must supply sufficient clinical information(results of a history and
examination) to allow the CBCT practitioner to perform the justification process.
6. Cone beam computed tomography should only be used when the question for which
imaging is required cannot be answered adequately by lower dose conventional
(traditional) radiography
7. Cone beam computed tomography images must undergo a thorough clinical
evaluation (radiological report) of the entire image dataset.
8. Where it is likely that evaluation of soft tissues will be required as part of the patient’s
radiological assessment, the appropriate imaging should be conventional medical CT
or MR, rather than CBCT.
9. Cone beam computed tomography equipment should offer a choice of volume sizes
and examinations must use the smallest that is compatible with the clinical situation if
this provides less radiation dose to the patient.
10. Where CBCT equipment offers a choice of resolution, the resolution compatible with
adequate diagnosis and the lowest achievable dose should be used.
11. A quality assurance program must be established and implemented for each CBCT
facility, including equipment, techniques and quality control procedures.
12. Aids to accurate positioning (light beam markers) must always be used.
13. All new installations of CBCT equipment should undergo a critical examination and
detailed acceptance tests before use to ensure that radiation protection for staff,
members of the public and patient are optimal.
14. Cone beam computed tomography equipment should undergo regular routine tests to
ensure that radiation protection, for both practice/facility users and patients, has not
significantly deteriorated.
15. For staff protection from CBCT equipment, the guidelines detailed in Section 6 of the
European Commission document ‘Radiation Protection 136. European Guidelines on
Radiation Protection in Dental Radiology’ should be followed.
16. All those involved with CBCT must have received adequate theoretical and practical
training for the purpose of radiological practices and relevant competence in radiation
protection.
17. Continuing education and training after qualification are required, particularly when
new CBCT equipment or techniques are adopted.
18. Dentists responsible for CBCT facilities who have not previously received ‘adequate
theoretical and practical training’ should undergo a period of additional theoretical
and practical training that has been validated by an academic institution (university or
equivalent). Where national specialist qualifications in DMFR exist, the design and
delivery of CBCT training programs should involve a DMF Radiologist.
19. For dentoalveolar CBCT images of the teeth, their supporting structures, the mandible
and the maxilla up to the floor of the nose (e.g. 8 ‘ 8 cm or smaller fields of view),
clinical evaluation (radiological report) should be made by a specially trained DMF
radiologist or, where this is impracticable, an adequately trained general dental
practitioner
20. For non-dentoalveolar small fields of view (e.g. temporal bone) and all craniofacial
CBCT images (fields of view extending beyond the teeth, their supporting structures,
the mandible, including the TMJ and the maxilla up to the floor of the nose), clinical
evaluation (radiological report) should be made by a specially trained DMF
radiologist or by a clinical radiologist (medical radiologist).

PRINCIPLES OF CBCT

All CT scanners consist of an x-ray source and detector mounted on a rotating

gantry. During rotation of the gantry, the receptor detects x rays attenuated by the
patient. These recordings constitute “ raw data ” that is reconstructed by a computer
algorithm to generate cross sectional images. CT can be divided into two categories on
the basis of acquisition x-ray beam geometry, namely,

 fan beam and

 cone beam.

Cone beam geometry has inherent quickness in volumetric data acquisition and
therefore the potential for significant cost savings compared with CT. CBCT
produces an entire volumetric dataset from which the voxels are extracted. Voxel
dimensions are dependent on the pixel size on the area detector. Therefore CBCT
units in general provide voxel resolutions that are isotropic — equal in all three
dimensions.

IMAGE AQUISITION

The cone-beam technique involves a rotational scan exceeding 180 degrees of an x ray
source and a reciprocating area detector moving synchronously around the patient’s
head. During the rotation, many exposures are made at fixed intervals, providing
single projection images known as basis images. The complete series of basis images
is referred to as the projection data. Software programs incorporating sophisticated
algorithms are applied to these projection data. A 3D volumetric data set is generated
that can be used to provide primary reconstruction images in three orthogonal planes.
There are four components to CBCT image acquisition:

 X-ray generation

 Image detection system

 Image reconstruction

 Image display

X-RAY GENERATION

Patient Positioning

CBCT can be performed with the patient in three possible positions that is
sitting, standing or supine. Because scan times are often greater than that used with
panoramic imaging, perhaps more important than patient orientation is the head
restraint mechanism used. With all systems it is important to immobilize the patient’s
head because any movement degrades the final image.

X-ray Generator

Technically, the easiest method of exposing the patient is to use a constant

beam of radiation during the rotation and allow the x-ray detector to sample the
attenuated beam in its trajectory. However, this results in a continuous radiation
exposure to the patient, much of which does not contribute to the formation of the
image. It is preferable to pulse the x-ray beam to coincide with the detector sampling.
This means that actual exposure time is markedly less than scanning time. This
technique reduces patient radiation dose considerably. The ALARA ( As Low As
Reasonably Achievable) principle of dose optimization necessitates that CBCT
exposure factors should be adjusted on the basis of patient size. This can be achieved
by appropriate selection of either tube current (milliamperes [ mA ] ), tube voltage
(kilovolts peak [ kVp ] ), or both.

Scan Volume

The dimensions of the field of view or scan volume able to be covered are
primarily dependent on the

 detector size and shape

 beam projection geometry

 and the ability to collimate the beam

Limiting field size therefore ensures that an optimal field of view can be selected for
each patient on the basis of individual needs.

Scan Factors

The speed with which individual images are acquired is called the frame rate
and is measured in frames, projected images, per second. The maximum frame rate of
the detector and rotational speed determines the number of projections that may be
acquired. The number of projection images comprising a single scan may be fixed or
variable. With a higher frame rate, more information is available to reconstruct the
image; therefore, primary reconstruction time is increased. However, higher frame
rates increase the signal-to-noise ratio, producing images with less noise. In the
maxillofacial region, another advantage of a higher frame rate is that it reduces
metallic artifact. Note that higher frame rates are usually accomplished with a longer
scan time and hence higher patient dose.

Most CBCT imaging systems use a complete circular trajectory or a scan arc of
360 degrees to acquire projection data. This physical requirement is usually necessary
to produce adequate projection data for 3D reconstruction. However, it is theoretically
possible to reduce the completeness of the scanning trajectory to less than a full circle
and still reconstruct a volumetric data set. This approach potentially reduces the scan
time and is mechanically easier to perform.

IMAGE DETECTION

Current CBCT units can be divided into two groups on the basis of detector
type that is image intensifier tube and flat panel imager.
Voxel Size:

The principal determinants of nominal voxel size in CBCT are the

 x-ray tube focal spot size,

 x-ray geometric configuration, and

 matrix and pixel size of the solid state detector.

Both the focal spot size and the geometric configuration of the x-ray source determine
the degree of geometric unsharpness, a limiting factor in spatial resolution. 0.076 mm
images are the highest resolution in industry today.

Grayscale:

The ability of CBCT to display differences in attenuation is related to the

ability of the detector to detect subtle contrast differences. This parameter is called the
bit depth of the system and determines the number of shades of gray available to
display the attenuation.

RECONSTRUCTION

Once the basis projection frames have been acquired, it is necessary to process
these data to create the volumetric data set. This process is called primary
reconstruction. Although a single cone-beam rotation may take less than 30 seconds,
it produces 100 to more than 600 individual projection frames, each with more than a
million pixels with 12 to 16 bits of data assigned to each pixel. The reconstruction of
these data is computationally complex. To facilitate data handling, data are usually
acquired by one computer (acquisition computer) and transferred by an Ethernet
connection to a processing computer (workstation). In contrast to conventional CT,
cone-beam data reconstruction is performed by personal computer – based rather than
workstation platforms.

DISPLAY

The volumetric data set is a compilation of all available voxels and, for most
CBCT devices, is presented to the clinician on screen as secondary reconstructed
images in three orthogonal planes (axial, sagittal, and coronal).
 CLINICAL CONSIDERATIONS

PATIENT SELECTION CRITERIA

Cone beam exposure provides a radiation dose to the patient higher than those
of other dental radiographic procedures. Accordingly, the ALARA principle must be
applied: there should be justification of the exposure to the patient so that the total
potential diagnostic benefits are greater than the individual detriment radiation
exposure might cause.

PATIENT PREPARATION

 Head stabilization

 Alignment of the area of interest with the x-ray beam

 Patient should be asked to remove all metallic objects form the head and neck areas

SPECIFIC APPLICATIONS IN DENTISTRY

IMPLANT SITE ASSESSMENT

Perhaps the greatest impact of CBCT has been on the planning of dental
implant placements. CBCT provides cross-sectional images of the alveolar bone
height, width, and angulation and accurately depicts vital structures such as the
inferior alveolar dental nerve canal in the mandible or the sinus in the maxilla. The
most useful series of images for implant site assessment include the axial, reformatted
panoramic, and serial transplanar images at the specific location. CBCT allows for the
clinicians to assess the bone in all three dimensions unlike conventional radiographs,
enabling them to detect any abnormalities in the bone structure, concavities or vital
structures in the vicinity. The concavity below the mylohyoid ridge in the posterior
mandible if entered by an implant can lead to haemorrhage. Thus CBCT helps plan to
reduce perforations and improve treatment outcome.

In many instances a diagnostic stent is made with radiographic markers and

inserted at the time of the scan. This provides a precise reference of the location of the
proposed implants or teeth. The data set may then be used to construct a surgical
implant guidance stent to facilitate the precise placement of implants.

LOCALIZATION OF THE INFERIOR ALVEOLAR CANAL

The relationship of the inferior alveolar canal to the roots of mandibular molars
and during placement of implants is of utmost importance. Injury to the nerve can lead
to paresthesia. The final part of the inferior alveolar nerve sometimes passes below the
lower border and the anterior wall of the mental foramen. After giving off the smaller
mandibular incisive branch, the main branch curves back to enter the foramen and
emerge to the soft tissues, as the mental nerve. The section of the nerve in front of the
mental foramen and just before its ramification to the incisive nerve can be defined as
the anterior loop of the inferior alveolar nerve.

In a study by Dimitrios Apostolakis et al. (2012) on anterior loop concluded

that

1. In 48% of the cases an anterior loop was identified.

2. The mean length (range) of the anterior loop was 0.89 mm (0–5.7).

Selective surgery in the area of the anterior mandible such as implant

installation in the interforaminal region or symphysis bone harvesting, may violate the
anterior loop resulting in neurosensory disturbances in the area of the lower lip and
chin.

PERIODONTAL IMPLICATIONS

Radiographs are especially helpful in the evaluation of the following features:

› Amount of bone present

› Condition of the alveolar crests

› Bone loss in the furcation areas

› Width of the periodontal ligament space

› Local irritating factors that increase the risk of periodontal disease

 Calculus

 Poorly contoured or overextended restorations

› Root length and morphology and the crown-to-root ratio

› Open interproximal contacts, which may be sites for food impaction

› Anatomic considerations

 Position of the maxillary sinus in relation to a periodontal

deformity

 Missing, supernumerary, impacted, and tipped teeth

› Pathologic considerations
  Caries

 Periapical lesions

 Root resorption

To view the periodontal structures, intra- and extraoral imaging modalities are
available. The more commonly used method is the intraoral radiographs which
provide a two-dimensional view. The extra-oral panoramic radiographs are also used,
especially to view larger areas. The major disadvantage of this method is the distortion
of the images and the blurring of anatomical structures. Also, three-dimensional
information is represented in a two-dimensional plane, thus losing essential diagnostic
details. Because the radiographic image fails to reveal the three-dimensional structure,
bony defects overlapped by higher bony walls may be hidden. Also, because of
overlapping tooth structure, only the interproximal bone is seen clearly. When
compared to periodontal probing and 2D intraoral radiography, 3D CBCT scanning
was found to be more effective in assessing periodontal structures.

CBCT had better potential of detecting periodontal bone defects in all

directions compared with periapical radiographs and were as reliable as radiographs
for interproximal areas. Misch et al. (2006) reported that CBCT is as accurate as direct
measurements using a periodontal probe and as reliable as intraoral radiographs for
interproximal areas. Also, since buccal and lingual defects could not be diagnosed
with intraoral radiography, CBCT could be considered a superior technique.

Considering the various benefits, CBCT is currently being considered as a superior

diagnostic tool for applications in periodontology.

Study

In a study conducted by Sirikarn Phothikhun et al. (2012) to assess the

association between periodontal bone loss and mucosal thickening of the maxillary
sinus higher prevalence of mucosal thickening was detected than previous studies due
to the use of advanced imaging technique i.e. CBCT aiding the clinician during sinus
lift procedures to avoid sinus obstruction.

Study

In a study conducted by Qiao J et al. (2014) concluded that CBCT and intra-
surgical assessments of maxillary molar furcation involvement were found to be in
strong agreement. CBCT enables the accurate estimation and classification of
furcation involvement as well as a visualization of the root morphologies. These
measures are essential for a reliable diagnosis and prognosis of the maxillary molars
and for adequate treatment planning.
 Earlier studies have shown that computed tomography (CT) assessment of
periodontal bone height and intrabony defects is reasonably accurate and precise.
However, the higher radiation exposure could not always be adequately justified.
Vandenberghe et al. (2008) reported that CBCT images demonstrated more potential
in the morphological description of periodontal bone defects, while the digital
radiography provided more bone details

Study

In a study by Masatoshi Takane et al. (2010) on the clinical application of cone

beam computed tomography for ideal absorbable membrane placement in
interproximal bone defects, it was found that using the template prepared from the
axial view on cbct, the membrane can be easily trimmed and adapted to the root
surface in either the maxillary or mandibular arch. In contrast, without the use of cbct,
the membrane had a larger interproximal area, and was smaller at the mesial buccal
site. Furthermore, the membrane trimming time was shown to be shortened using cbct.

A break in the continuity of lamina dura and a wedgeshaped radiolucent area at

the mesial or distal aspect of the periodontal ligament space are one of the earliest
signs of periodontal disease. Only a sensitive imaging technique would be able to
detect the earliest changes in the periodontal ligament space. In terms of image
quality, the CBCT scans were found to be superior to the CT scans with particular
reference to the periodontal ligament space. (R. Mengel 2005). However Ozmeric et
al. (2008) concluded that the CBCT was inferior to conventional radiographs in terms
of the clarity of the periodontal ligament space.

In a study by Koichi et al. (2001) it was concluded that CBCT is also an

efficient aid in evaluating the outcome of regenerative therapy. Apical periodontitis is
one of the most common endodontic diseases and a study by L. M. Paes (2013) used
CBCT images from a database to determine the prevalence of apical periodontitis.
Another recent study evaluated bone resorption at the extraction sites of a group of
patients under orthodontic treatment using CBCT to evaluate the periodontal and bone
support loss after tooth extraction. (L. Lombardo et al. 2013)

ENDODONTIC CONSIDERATIONS

CBCT is used to detect periapical lesions, caries, root fractures, the number of
canals, broken instruments in the canal and resorption.

ORTHODONTIC CONSIDERATIONS

CBCT imaging is being used in the diagnosis, assessment, and analysis of

maxillofacial orthodontic and orthopaedic anomalies. CBCT provides display of the
position of impacted and supernumerary teeth and their relationship to adjacent roots
 or other anatomic structures. This facilitates surgical exposure and planning of
subsequent movement. Also, information regarding palatal morphologic features and
dimensions, tooth inclination and torque, root resorption, and available alveolar bone
width for buccolingual movement of teeth can be obtained. CBCT also provides
adequate visualization of the TMJ, the pharyngeal airway space, and soft tissue
relationships.

ARTIFACTS

The fundamental factor that impairs CBCT image quality is image artifact. An artifact
is any distortion or error in the image that is unrelated to the subject being studied.
Artifacts can be classified according to their etiology.

ACQUISITION ARTIFACTS

As an x-ray beam passes through an object, lower energy photons are absorbed
in preference to higher energy photons. This phenomenon, called beam hardening.

PATIENT-RELATED ARTIFACTS

Patient motion can cause misregistration of data, which appear as unsharpness

in the reconstructed image. This can be minimized by restraining the head and using
as short a scan time as possible. It is also important to remove metallic objects such as
jewellery before scanning because of the beam-hardening artifacts described
previously.

SCANNER-RELATED ARTIFACTS

Typically scanner-related artifacts present as circular or ring streaks resulting

from imperfections in scanner detection or poor calibration.

CONE BEAM – RELATED ARTIFACTS

The beam projection geometry of CBCT and image reconstruction method

produce three types of cone-beam – related artifacts:

› Partial volume averaging:

 It occurs when the selected voxel size of the scan is larger than the size of the object
being imaged

› Undersampling:
 Occurs when too few basis projections are provided for image reconstruction

› Cone-beam effect:

 Especially in the peripheral portions of the scan volume

ADVANTAGES

Size and Cost

CBCT equipment has a greatly reduced size and physical footprint compared
with conventional CT and it is approximately one fourth to one fifth the cost.

High-Speed Scanning

Compared with conventional CT, the time for the CBCT scanning is
substantially reduced and, for most equipment, is less than 30 seconds.

Submillimeter Resolution

The size of the voxels determines the resolution of the image. CBCT produces
images with submillimeter voxel resolution ranging from 0.4 mm to as low as 0.125
mm.

Low Patient Radiation Dose

As compared to CT.

Patient education

LIMITATIONS

Image Noise

The additional recorded x-ray attenuation, due to the scatter radiation is called
noise.

Poor Soft Tissue Contrast

Due to:

1. Sensitivity of different regions of the panel to radiation (pixel-to-pixel gain

variation) may not be uniform over the entire region
2. Scatter radiation
3. Bad pixels (pixels that do not react to exposure)
 CONCLUSION

CBCT imaging systems have been recently been introduced for imaging hard
tissues of the maxillofacial region. CBCT is capable of providing accurate,
submillimeter resolution images at shorter scan times, lower dose, and lower costs
compared with medical fan-beam CT. It is now considered a “standard of care”.
Despite cost and exposure constraint, it is an indespensible tool in research.

REFERENCES

 Oral radiology : Principles and Interpretation White and Pharoah 6th edition

 Shobha J Rodrigues, Mahesh Mundathaje, Minu Raju, Sabaa Qureshi Three-

dimensional Imaging in Implant Assessment for the Prosthodontist: Utilization of the
Cone Beam Computed Tomography IJOPRD 2014 4(1) 23-33

 Yousef A. AlJehani Diagnostic Applications of Cone-Beam CT for Periodontal

Diseases International Journal of Dentistry Volume 2014

 Dimitrios Apostolakis Jackie E. Brown The anterior loop of the inferior alveolar
nerve: prevalence, measurement of its length and a recommendation for interforaminal
implant installation based on cone beam CT imaging Clin. Oral Impl. Res. 23, 2012,
1022–1030

 Masatoshi Takane, Shuichi Sato, et al. Clinical application of cone beam computed
tomography for ideal absorbable membrane placement in interproximal bone defects
Journal of Oral Science, Vol. 52, No. 1, 63-69, 2010

 Sirikarn Phothikhun, Supreda Suphanantachat, Vannaporn Chuenchompoonut, and

Kanokwan Nisapakultorn Cone-Beam Computed Tomographic Evidence of the
Association Between Periodontal Bone Loss and Mucosal Thickening of the
Maxillary Sinus Journal of Periodontology May 2012

 Qiao J, Wang S, Duan J, Zhang Y, Qiu Y, Sun C, Liu D. The accuracy of conebeam
computed tomography in assessing maxillary molar furcation involvement. J Clin
Periodontol 2014; 41: 269–274.

 Kau’s CBCT of head and neck