1. SIU-SDM HAWAIIAN CRUISE

2. SIU-SDM HAWAIIAN CRUISE
CONE BEAM C T
IS IT FOR THE GENERALIST’S OFFICE?

3. DEBRA DIXON, DMD SDM GRADUATE 1993 SDM AEGD 1995
SDM IMPLANT FELLOW 1996
THE UNIVERSITY OF LONDON MSc DENTAL RADIOLOGY 2002
SDM DIRECTOR OF RADIOLOGY

4. FUR

5. OUR AGENDA History Cone Beam CT Radiology Digital Radiology CT
What it is and What it can do for me

6. HISTORY Nov 8, 1895 Wilhelm RÖntgen discovers the X-Ray
Digital radiography is more than 25 years old
11% to 30% of dentists have converted to digital
Financial investment
Complexity of computers
Software
Hardware
Simply reluctant to switch…if everything is running smoothly, why change it?
Van der Stelt 2008

7. BASICS OF DIGITAL IMAGING
Composed of pixels (picture elements) which are characterized by 3 numbers
These numbers are stored in an image file in the computer
Image processing is possible
Brightness/Darkness
Contrast
Zoom…limited by the resolution of the system

8. BASICS OF DIGITAL IMAGING
Image Analysis
Measurement of root length for Endo
Digital subtraction radiography

9. BASICS OF DIGITAL IMAGING
Advantages
Immediate image with CCD sensor
Ability to manipulate the image
Integrated storage with software systems
Security of backup and off-site archiving of images
Ease of transfer by
Security of the original image
DICOM (Digital Imaging and Communications in Medicine) format standards

10. BASICS OF DIGITAL IMAGING
Dose Reduction?
Once promoted as a “huge advantage” to digital imaging
Why the dose reduction is not as large as often suggested
Dose per exposure
Reduction of 0% to 50% as compared with “F” speed film
Increase in the number of radiographs made
Increase in the number of retakes due to the ease of exposing additional images
Van der Stelt 2008

11. SALLY

12. C T COMPUTED TOMOGRAPHY

13. C T History Basics of Tomography Generations of Scanners
1st Generation
2nd Generation
3rd Generation
4th Generation
5th Generation
Conventional data gathering versus Spiral geometry

14. C T History The word Tomography can be traced to the 1920’s
Tomography = section, from the Greek tomos
Dr. Godfrey Hounsfield
Born 1919 in Nottinghamshire, England
The inventor of clinical computed tomography
First patient scanned in 1972
Demonstrated a suspected brain lesion
Dr. Allan Cormack
Born 1924 in Johannesburg, South Africa
Developed solutions for the mathematical problems in CT
Seeram, Computed Tomography, 2001

15. C T History Dr. Robert Ledley
1948 Doctorate in Dental Surgery, New York University
1949 Master’s in theoretical physics, Columbia University
Developed the first whole-body CT scanner
Seeram, Computed Tomography, 2001

16. C T
History
Tomography
X-ray tube and film move simultaneously and in opposite directions
This keeps the object of interest in focus while blurring out the structures around it
Panoramic technique
Seeram, Computed Tomography, 2001

17. C T History A B C D 1st Generation 2nd Generation 3rd Generation
4th Generation
Seeram, Computed Tomography, 2001

18. C T History 1st Generation Minimum 4.5 to 5.5 minute whole body scan
Parallel beam, Translate & Rotate
After 1 translation, the tube and detector rotate by 1° and translate again, repeated for 180° around the patient
Seeram, Computed Tomography, 2001

19. C T History 2nd Generation Scan time 20 sec to 3.5 minutes
Fan beam, Translate & Rotate
Fan beam = ~30 detectors coupled to the x-ray tube and multiple pencil beams
Process is repeated for 180°
Seeram, Computed Tomography, 2001

20. C T History 3rd Generation Scan time of a few seconds
Fan beam geometry that rotates continuously around the patient for 360°
Seeram, Computed Tomography, 2001

21. C T History 4th Generation
Scan time is very short, varies by manufacturer
A rotating fan beam within a stationary ring of detectors
Seeram, Computed Tomography, 2001

22. C T History 5th Generation High-speed CT scanners
EBCT Electron Beam CT scanner
DSR
Dynamic Spatial Reconstructor
Scan time of milliseconds
Seeram, Computed Tomography, 2001

23. C T History A Conventional Slice by Slice data acquisition
The x-ray tube stops between slices, the patient is repositioned for the next slice
Seeram, Computed Tomography, 2001

24. C T History B Helical or spiral geometry
The latest development in CT data acquisition (as of the writing of the text in 2001)
Volume scanning
Utilizes a narrowly collimated, fan shaped x-ray beam, projected through a limited thickness slice through the body
Utilizes a linear array of detectors
Patient has to be advanced through the gantry while the x-ray tube and detectors rotate around the patient
Seeram, Computed Tomography, 2001

25. C T Spiral Scanners Provide improved multiplanar image reconstructions
Reduced exam time
12 seconds versus 5 minutes for an incremental scan
Reduced radiation dose
Up to 75% of the dose delivered by an incremental scanner

26. C T
Image is recorded and displayed as matrix of individual blocks called voxels (volume elements)
Voxel length (1 to 20 mm) is determined by the width of the x-ray beam
Analogous to the tomographic layer in film tomography
For image display, each pixel is assigned a CT number
Represents density
Also known as a Hounsfield unit
Air
Water
Dense bone

27. EM

28. CONE BEAM C T

29. C B C T Definition Indications Comparisons Disadvantages
CBCT versus Panoramic
CBCT versus Plain-film Tomography
CBCT versus Medical CT
Disadvantages
Currently available units
Specialized Uses
Orthodontic Analysis
Dolphin Imaging Software Program
Interpretation

30. C B C T
Developed for Dental purposes to provide 3D volume images of the dental and craniofacial complex
Available for craniofacial imaging
Since 1999 in Europe
Since 2001 in the U.S.
Ideally suited for craniofacial imaging
The compact size of the unit
Relatively low radiation dose
Becoming the “Standard of Care” for diagnosis of the craniofacial region
Allows multiplanar viewing of the anatomical volume and overcomes the limitations of 2D radiography

31. C B C T Cone Beam Utilizes a cone shaped x-ray beam
Round or rectangular
Utilizes an area detector
Acquires a full volume of images in a single rotation with no need for patient movement
Rotates 360° around the head
360 projections
Scan time typically < 1 minute

32. C B C T
End Result
3-D visualization of the oral and maxillofacial complex from any plane
A stack of 360 images or exposures compiled into a volumetric dataset through a computer process known as primary reconstruction
This data volume is then converted into a patient-study by accompanying software
Can be visualized as
2D trans-axial, multi-planar reformatted
3D techniques such as surface reconstruction and volume rendering
A combination of 2D and 3D techniques

33. C B C T Indications Evaluation of the jaw bones Airway assessment
Implant placement and evaluation
TMJ
Pathology
Bony & Soft tissue lesions
Periodontal assessment
Endodontic assessment
Alveolar ridge resorption
Assessment of the IAN prior to extraction of impactions
Orthodontic evaluation
Airway assessment
Need for 3D reconstructions

34. C B C T Evaluation of the jaw bones
Implant placement and evaluation #12-13
a) Panoramic line and cross-section line in the axial image of Maxilla identified
b) Slices of the area in cross-section
c) Reconstruction in a ‘panoramic-like’ layout
Araki et al. Dentomaxillofac Radiol 31 (1):51, Figure 9

35. C B C T Evaluation of the jaw bones
a) Slice as seen from a ‘frontal’ view
b) Slice as seen from the side
c) Reconstructed maxilla and mandible
Dentomaxillofac Radiol (2004) 33,

36. C B C T Evaluation of the jaw bones www.ddsgadget.com
e-ssentialnetworks.com

37. C B C T versus PANORAMIC PANORAMIC CBCT
Provides a distorted (unequal magnification) and magnified image
Image layer view only
Structures are superimposed
CBCT
Provides an undistorted image
Cross-sectional (bucco-lingual), axial, coronal, sagittal, and panoramic views
Structures can be separated

38. C B C T versus PLAIN-FILM TOMOGRAPHY
Provides an undistorted image, but there is magnification
Provides direct cross-sectional, sagittal, and coronal views
Scan time may be short, but chair time can be lengthy
CBCT
Provides an undistorted, 1:1 image
Provides reconstructed views
Scan time
10-40 second range, dependent on the region being imaged and the desired quality
Provides an indication of bone quality

39. C B C T versus Medical C T Med CT CBCT Conventional linear fan beam
Med CT
Conventional linear fan beam
Single row or a series (4, 8, 12, 32, 64) of solid state detectors
Provides a set of consecutive slices of the patient
CBCT
Cone beam
Square 2 dimensional array of detectors
Provides a volume of data

40. C B C T versus Medical C T Med CT CBCT Greater contrast resolution
More discrimination between different tissue types (i.e. bone, teeth, and soft tissue)
CBCT
Equipment
Cost 3-5x less than MDCT
Lighter & Smaller
No special electrical
No floor strengthening
No special cooling
Ease of operation
Dedicated to dental
Patient sits or stands
Both jaws can be imaged at the same time
Lower radiation burden

41. C B C T Disadvantages Noise from radiation scatter
Streak artifacts from metal restorations
Algorithms and filters try to correct for noise & artifacts
Image degradation from patient movement
Head stabilizing devices
Cost
Range from $150,000 to 300,000
Training
For maximum benefit
For interpretation of the volume of data & images
Within the purview of the dentist
Outside the purview of the dentist
Howerton et. al.

42. C B C T Currently available units
3D Accuitomo FPD XYZ Slice View Tomograph
J. Morita USA, Irvine, CA
3D X-ray CT Scanner Alphard Series
Asahi, Kyoto, Japan
Quolis Alphard Alphard-3030-Cone-Beam
Belmont Equipment, Somerset, NJ
CB MercuRay
Hitachi Medical Systems America, Twinsburg, Ohio
Galileos 3D
Sirona Dental Systems, Charlotte, NC
i-CAT
Imaging Sciences International, Hatfield, PA
Howerton et. al.

43. C B C T Currently available units Iluma Ultra Cone Beam CT Scanner
Carestream, Rochester, NY
NewTom 3G and VG
AFP Imaging, Elmsford, NY
Picasso
E-woo Technology, Houston
PreXion 3D
TeraRecon, San Mateo, CA
ProMax 3D
Planmeca USA, Roselle, IL
Scanora 3D
Soredex, Tuusula, Finland
Howerton et. al.

44. C B C T i-CAT NewTom VG 3D Accuitomo Position Scan time Scan Hgt
Seated
Stand/Seated
Scan time
5, 8.9, 26.9 sec
20 sec
18 sec
Scan Hgt
4,6,8,10,13 cm
9.84 inches
inches
kVp/mA
120/3-5
60-80/1-10
Rad Time
9 sec
5.4 sec
Not listed
Scan thick mm mm mm
Ceph
Yes No
Software
Xoran Cat
I-Dixel
Price
$170,000
$252,000
website
imagingsciences.com
newtomdental.com
jmorita.com
Inside Dentistry 1:90-93, 2007, Dental Economics August 2007, Dental Town August 2007

45. C B C T All Cone Beam Units are not created equal! Volume Size
Geometric resolution
Contrast resolution
Slice thickness
Radiation dose
Ease of use
Image Capture

46. C B C T Effective dose (µSv) Dose in # of Pans Dose in days
Dose in % Med CT
i-Cat
12” FOV
135 21 13
6.4
NewTom 3G ” FOV 45 7 4
2.1
Panoramic 6 1
0.3
CT Maxilla & Mandible
2,100
385
243
100
Farman AG, Levato CM, Scarfe WC. A primer on cone beam CT. Inside Dentistry 1:90-93, 2007

47. C B C T The i-CAT CT scanner Low dose settings for children
Landscape View
Full resolution and detail obtained for smaller fields of view
Portrait View
Captures Extended Field of View data
Ceph data in 8.5 seconds

48. C B C T i-CAT Typical reconstruction time Less than 30 seconds

49. C B C T i-CAT Measurement Labeling Hounsfield units Density

50. C B C T NewTom VG Features a single 8"x10" Field Of View,
Most utilized by implantologists and maxillo-facial surgeons.
Small focal spot = high quality images
Volume of data captured kept to a minimum
Short reconstruction times (3 minutes)
Low dose
up to times less radiation than conventional CT
Adjusts dose to size and age of patient
Unique “pulse” system
Activates the x-ray source only when needed—delivering less than 4 seconds of total exposure for a full scan.

51. C B C T NewTom Standard 0.5mm Ultra-high resolution 0.2mm

52. C B C T 3D Accuitomo J. Morita Manufacturing
Imaging Areas 40x40 mm & 60x60 mm
High resolution for large imaging area
Voxel size mm, high resolution (2.0 line pair/mm)
Low effective dose
Wide dynamic range and expresive tone create brilliant images of both soft and hard tissue areas
Enables the most accurate diagnosis for implants, apical lesions, temporomandibular joints, impactions, etc.

53. C B C T SPECIALIZED USES
ISLAND OF LANAI

54. C B C T Specialized Uses Orthodontic Analysis Oral Surgery Implants
Dolphin Imaging Software Program
Oral Surgery
Impactions
Trauma
Implants
Endodontics
Periodontics
TMJ

55. C B C T ORTHO
Ortho Evaluation and Treatment Planning

56. C B C T - ORTHO The Dolphin 3D software module
A powerful tool that makes processing 3D data extremely easy, enabling dental specialists from a wide variety of disciplines to accurately diagnose and plan treatment.
Dolphin 3D allows visualization and analysis of craniofacial anatomy from data produced by CBCT, MRI, medical CT and 3D facial camera systems.

57. C B C T - ORTHO Dolphin Imaging Software
Comprehensive cross sections with Multiple Planar View (MPV)
3D nerve marking
TMJ analysis
Create stunning, accurate cephalometric and panoramic radiographs
Import from a variety of 3D files
High-quality, fast 3D rendering
Easily detect impacted teeth
Analyze, visualize and measure airway
Precise volume orientation
Establish 3D/2D measurements
Create movies
Design automated image layouts
Images export to other applications, including PowerPoint, Word, etc.
Images easily saved into Dolphin patient file
Export to standard file formats and Windows Clipboard
Fully embedded in Dolphin Imaging’s SQL database

58. C B C T - ORTHO Dolphin Imaging Software Object Orientation
Comprehensive cross sections with Multiple Planar View
Instant Ceph/Pan
Ceph Tracing
3D Nerve Mapping
TMJ analysis
3D Visualization

59. C B C T - ORTHO Object Orientation
To maximize the consistency of analysis of a 3D volume, it is crucial to establish a default orientation.
Dolphin 3D provides comprehensive tools for defining the mid-sagittal, axial and coronal planes. You can also adjust the object’s default yaw, pitch and roll.
These operations can be performed on the CT soft tissue surface, CT hard tissue surface or 3D photo surface.

60. C B C T - ORTHO Multiple Planar Views and Layouts
Choose a layout that is best suited to your task:
3D volume (just the 3D volume view)
Volume+3 planes (3D volume and 3 cross section planes on the side)
4-views (3D volume and the cross section planes in equal sized windows)
Individual orthogonal projected slices: sagittal, coronal and axial planes

61. C B C T - ORTHO Instant Ceph/Pan 1:1 projection
Create two-dimensional radiographic images from 3D volume dataset in the lateral, panoramic (OPG), frontal and SMV views.
1:1 projection
no distortion
no magnification

62. C B C T - ORTHO Ceph Tracing

63. C B C T - ORTHO Nerve Mapping

64. C B C T ORTHO
TMJ View
Choose an area of interest; set center point and axis direction, designed specifically for analyzing the temporomandibular joint
Choose desired slice thickness, width, number and direction (coronal, sagittal, or patent-pending circular)
View key cross-sections at the chosen axes

65. C B C T - ORTHO 3D Visualization
Dolphin gives you the power to freely visualize the volume in 3D. In addition to switching from hard tissue and soft tissue views, you can also activate the see-thru hard tissue renderings. Adjust the factor of translucency and intensity to reveal the structure you desire. Clipping tools are also very useful for quickly visualizing hidden structures, or to simply eliminate portions of the contents that are not relevant.

66. C B C T Interpretation of the Volume of Images
Data collected within the Region of Interest (ROI)
Within the purview of general dentists and specialists
Data collected outside of the Region of Interest
A large volume of information exists that is outside of a dentists purview
Comprehensive Care of the Patient
Documented interpretation of all the data in the volume
2007 Chairman of the AAOMS advised that all volumes be read by a radiologist

67. C B C T Interpretation of the Volume of Images
AAO Council on Scientific Affairs
Survey of Radiologists
All scans should be read by a qualified person.
Panoramic can be read by the diagnostician (dentist)
Cone Beam volume by an Oral & Maxillofacial Radiologist or an MD Radiologist
The interpretation fee can be either included in the scan fee, or be billed separately
The entire volume of data requires interpretation. The patient cannot deny interpretation of ‘non-dental’ data
As in medicine, a written report is the standard
Am J Orthod Dentofacial Orthop 2007;131:697

68. TIGGER

69. IS IT FOR THE GENERALIST’S OFFICE?
CONE BEAM C T
IS IT FOR THE GENERALIST’S OFFICE?

70. THE BOTTOM LINE Is it worth your time and effort?
Physical Space in your office
Training
Computer memory to work with images
Storage of images

71. THE BOTTOM LINE Is it worth your time and effort?
Physical Space in your office
Training
Computer memory to work with images
Storage of images
Will it be profitable?
Cost…of the equipment
Time involved
Number of patient scans x $250-$600/scan
Types of images available: Pan, Ceph, Bitewings, Periapicals

72. MAHALO

73. CONE BEAM C T References Am J Orthod Dentofacial Orthop 2007;131:697
Araki et al. Dentomaxillofac Radiol 31 (1):51, Figure 9
Am J Orthod Dentofacial Orthop 2007;131:697
Turpin D., Editor-in-Chief. Befriend your oral and maxillofacial radiologist
Danforth RA, Miles D. Cone Beam Computed Tomography for Dentistry (Journal unknown)
Dental Economics August 2007
Feuerstein P. Cone Beam Technology.
Guttenberg S, Emery R. Profit in 3 dimensions
R Baba, K Ueda and M Okabe. Using a flat-panel detector in high resolution cone beam CT for dental imaging. Dentomaxillofacial Radiology 2004: 33,
DentalTown August 2007
Giacobbi T. 3D Images for 21st Century Dentistry

74. CONE BEAM C T References Inside Dentistry 1:90-93, 2007
Farman AG, Levato CM, Scarfe WC. A primer on cone beam CT.
JADA supplement June 2008, Vol. 139, “Digital Imaging”
A. Ruprecht. Oral and Maxillofacial Radiology: Then and Now
P.F. van der Stelt. Better Imaging: The Advantages of Digital Radiography
A.G. Farman, et al. In Practice: how Going Digital Will Affect the Dental Office
W.B. Howerton Jr, M.A. Mora. Advancements in Digital Imaging: What Is New and on the Horizon?
Seeram, Euclid. Computed tomography: physical principles, clinical applications, and quality control, 2nd edition, 2001, Saunders.

75. CONE BEAM C T References www.afpimaging.com www.conebeam.com