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Dentomaxillofacial Radiology (2008) 37, 309–318 ’ 2008 The British Institute of Radiology http://dmfr.birjournals.org RESEARCH Image quality vs radiation dose of four cone beam computed tomography scanners M Loubele*,1,2, R Jacobs2,3, F Maes1, K Denis4, S White5, W Coudyzer6, I Lambrichts7, D van Steenberghe2,3 and P Suetens1 1 ESAT-PSI, Katholieke Universiteit Leuven, Belgium; 2Perdiodontology, Katholieke Universiteit Leuven, Belgium; 3Oral Imaging Center, Katholieke Universiteit Leuven, Belgium; 4EMAP, Xios Hogeschool Limburg, Belgium; 5School of Dentistry, University of California at Los Angeles, USA; 6Radiology, UZ Leuven, Belgium; 7Morphology Section, Universiteit Hasselt, Belgium Objectives: To evaluate image quality by examining segmentation accuracy and assess radiation dose for cone beam CT (CBCT) scanners. Methods: A skull phantom, scanned by a laser scanner, and a contrast phantom were used to evaluate segmentation accuracy. The contrast phantom consisted of a polymethyl methacrylate (PMMA) cylinder with cylindrical inserts of air, bone and PMMA. The phantoms were scanned on the (1) Accuitomo 3D, (2) MercuRay, (3) NewTom 3G, (4) iCAT and (5) Sensation 16. The structures were segmented with an optimal threshold. Thicknesses of the bone of the mandible and the diameter of the cylinders in the contrast phantom were measured across lines at corresponding places in the CT image vs a ground truth. The accuracy was in the 95th percentile of the difference between corresponding measurements. The correlation between accuracy in skull and contrast phantom was calculated. The radiation dose was assessed by DPI100,c (dose profile integral 100,c) at the central hole of a CT dose index (CTDI) phantom. Results: The results for the DPI100,c were 107 mGy mm for (1), 1569 mGy mm for (2), 446 mGy mm for (3), 249 mGy mm for (4) and 1090 mGy mm for (5). The segmentations in the contrast phantom were submillimeter accurate in all scanners. The segmentation accuracy of the mandible was 2.9 mm for (1), 4.2 mm for (2), 3.4 mm for (3), 1.0 mm for (4) and 1.2 mm for (5). The correlation between measurements in the contrast and skull phantom was below 0.37 mm. Conclusions: The best radiation dose vs image quality was found for the i-CAT. Dentomaxillofacial Radiology (2008) 37, 309–318. doi: 10.1259/dmfr/16770531 Keywords: cone beam computed tomography; image quality; radiation dose Introduction During the last decade, there has been a trend towards using three-dimensional (3D) information to assist dentomaxillofacial diagnostics and surgical planning.1 This could first be realized by the use of conventional single and later multislice CT (MSCT).2 Nevertheless, because conventional CT protocols are generally associated with relatively high radiation dose levels,3 alternative CT protocols for bone visualization and modelling that would allow the lowering of the effective *Correspondence to: Reinhilde Jacobs, Centrum voor Orale Beeldvorming, Kapucijnvoer 7 blok a bus 7001, 3000 Leuven, Belgium; E-mail: [email protected] Received 11 June 2007; revised 7 October 2007; accepted 12 October 2007 radiation dose for the patient without significant loss of image quality are being investigated. Examples of these protocols are modified protocols on MSCT scanners4 or the use of cone beam CT (CBCT).5,6 Recently, an impressive number of CBCT scanners have been introduced in the field of dentomaxillofacial radiology. Unfortunately, hardly any research-based evidence is available for either optimal image quality or radiation dose levels. Besides the development and research of clinical evaluation protocols of these scanners,7,8 it is essential to develop a technical test protocol aiding optimization of the individual scanner parameters according to the ALARA (as low as reasonably achievable) principle.9 Such optimization Image quality and radiation dose of CBCT M Loubele et al 310 procedures can only be approached by a combined research strategy of radiation dose assessment for various image quality levels. A technical method for the evaluation of radiation dose in MSCT is the CT dose index (CTDI).10 Because of the shortcomings of these measurements,11 Mori et al12 suggested the use of the dose profile integral (DPI). The advantage of such a DPI is efficient data acquisition. The link to the effective patient dose can then be established by correlating effective dose levels with those technical measures.13 For the evaluation of the image quality, analysis on physical8,14 as well as anthropomorphic phantoms8 can be used. This paper is based on a combined research strategy reported in two of our previous studies.15,16 In the first study, a method was developed which made it possible to evaluate the bone segmentation accuracy based on a ground truth acquired with a laser scanner.15 In the second study, the physical image quality was compared with the radiation dose for four different CBCT scanners and one MSCT scanner.16 In the present study, the evaluation of the image quality on an anthropomorphic phantom and a physical phantom is combined with the radiation dose for four CBCT scanners and one MSCT scanner. Materials and methods Radiation dose assessment The radiation dose was measured by means of the DPI100,c, Equation (1), measured at the central hole of a dedicated CTDI-phantom. For the i-CAT (Imaging Sciences International, Hatfield, PA) and the NewTom 3G (Quantitative Radiology, Verona, Italy) the DPI100,c was measured with an electrometer and an ion chamber with an active length of 10 cm, calibrated for measurements in CT scanners (Radcal Corporation, Monrovia, CA). For the measurement of the DPI100,c on the Accuitomo 3D (Morita, Kyoto, Japan) and the MercuRay CB (Medico Technology Corporation, Kashiwa, Japan), there was no ion chamber available on site and therefore the DPI100,c was measured with strips of thermoluminescent dosemeters (TLD) of type TLD 100 (Li:Mg:Ti) (Bicron, Solon, OH) placed 1.5 cm from each other. The TLDs for the Accuitomo 3D were read out on a fully automated Harshaw 6600 reader (Bicron) in our hospital. The TLDs for the MercuRay were read out with a fully automated Harshaw 8800 Card Reader Workstation (Bicron). The DPI100,c was then calculated by approximation of the integral in (1) using the trapezium rule. Figure 1 The volume rendering of the laser model of mandible is shown based on the CTDI values as listed by ImPACT, London, UK (see ImPSCT website http://www.impactscan. org/ctditables.htm/). After appropriately adapting the listed CTDI values to the selected tube current settings of each evaluated MSCT protocol and correcting for collimation as described on the ImPACT website, the DPI was calculated by multiplying the adapted CTDI value with a length of 60 mm, which was sufficient to acquire the complete mandible. In this way the radiation dose was truncated corresponding to the approach for the dose measurements in CBCT. ð1Þ Image quality assessment For the evaluation of the image quality of CBCT and MSCT, we applied the method previously reported for observer measurements.17,18 We therefore measured the thickness of different structures in the CBCT images in an automated way. By comparing the measured thickness of the structures in the CT images with the real thickness of the structures, the accuracy of the measures can be determined. Because it is important to have an upper boundary for the accuracy measurements, the 95th percentile of the difference between the thickness measurements on the CT image and the ground truth image can be used. This procedure was applied on both a skull phantom and a physical phantom (contrast phantom) belonging to the image quality kit of the Accuitomo 3D. The skull phantom was used to mimic the diagnostic situation. The test on the contrast phantom was used to see whether information about diagnostic quality could be learned based on a physical phantom. In the sections below, the complete procedure for the evaluation of the image quality will be further elaborated. For the technical evaluation of the radiation dose on the MSCT scanner, the DPI100,c value was calculated Skull phantom For the study, the dry skull from a person who donated his body to research and which was kindly provided by l ð2 DPIl,j ~ d ðzÞdz ½mGy:mm {12 Dentomaxillofacial Radiology Image quality and radiation dose of CBCT M Loubele et al the Department of Morphology, University of Hasselt (Belgium) was used for the construction of this phantom.15 The skull was cut into four parts: the mandible, the calvarium, the left zygoma and left part of the maxilla, and the right zygoma and part of the maxilla. The four different sections were scanned with an XC50 Cross Scanner (Metris, Leuven, Belgium) with three laser planes, mounted on a Wenzel LH57 3D coordinate measurement machine. With this laser scanner it is possible to obtain surfaces in the form of a point cloud (Figure 1) with an accuracy of 15 mm. Because the skull was cut into four sections, it was possible to acquire the outer and inner bone surface in one acquisition, allowing the measurement of bone thickness along the point cloud. After acquiring the laser scan, the skull was placed in a head mould enclosure in the form of a face filled with water for softtissue simulation. For further analysis of the image quality, the segmentation accuracy of the mandible will be evaluated. a b (mm) c Figure 2 Linear measurements are used for image quality assessment. Measurement lines are defined on (a) the computer model of the phantom and transferred to (b) the CT image. After proper registration between them, (c) the one-dimensional CT intensity profile along each line is extracted by interpolation and segmented by thresholding in order to measure the thickness of the structure of interest 311 Registration of point cloud to CT data To assess accuracy, bone thickness measurements on CT are compared with those of the ground truth. To achieve a reliable assessment technique, there should be absolute agreement regarding the position to be measured on CT and the laser model. An accurate registration of the point cloud to the CT data was therefore needed. For this registration, the MIRIT Software19 was used. This software calculates a sixparameter rigid transformation T (i.e. a combination of a 3D translation and a 3D rotation), mapping every location in a floating image, A, to a corresponding location in the reference image B by maximizing the statistical dependence between intensity values of corresponding voxels in both images. A point cloud exists of a set of 3D coordinates which represent a surface and not a volume. This means that a point cloud does not contain voxels. Therefore, a function was needed, indicating when a specific point was located inside or on the bone surface and when it was located outside the bone surface. This function was calculated based on the FastRBF Interpolation Toolbox (FarField Technology Limited, Christchurch, New Zealand), which computes an implicit function through the point cloud of the laser data in such a way that this function evaluates to zero on the surface, negative inside the surface and positive outside. The function was evaluated on a cubical grid in which the complete mandible was situated. This grid had a voxel size of 0.1 mm. As a result, the discretization of the grid did not influence the registration accuracy.20 Definition of quality measure For the evaluation of the CT image quality, a measure needs to be defined. In this paper, the error on the bone thickness measured on the bone model will be used as the quality measure, as was done in a previous study.15,16 To evaluate this error, measurement lines are defined along the bone surface in the laser model. These measurement lines are transferred to the CT image based on the transformation calculated in the previous section. For the definition of the measurement lines, a cylindrical grid with the vertical axis through the centre of mass of the object as z-axis was calculated. This is the central axis of a cylindrical grid defined by a vertical increment Dz and an angular increment Dh. In all elements (iDz, jDu) of the cylindrical grid where bone exists, a measurement line is defined by two points on the bone surface along a radial through this element (one point nearest to the z-axis and one point farthest to the z-axis). With this method, 3589 measurement lines were found. Across these measurement lines, 1D intensity profiles are calculated by a 3D trilinear interpolation of the image intensity at equidistant points between the beginning and the end point of each line. The sample distance was 0.1 mm. The intersections of each measurement line with the bone surface are extracted by thresholding of its 1D intensity profile by using a global bone threshold. Linear interpolation of the profile values is used to locate Dentomaxillofacial Radiology Image quality and radiation dose of CBCT M Loubele et al 312 candidate intersection points at sub-voxel precision. If more than two candidates are found, which is typically the case when the bone consists of two cortical plates surrounding an inner spongiosa, the locations that are retained are those closest to the reference bone surface derived from the laser data. cylinders with a diameter of 10 mm consisting of aluminum, PMMA, bone equivalent plastic and air (Figure 2a,b)). Based on the phantom, image-based measurements of the diameters of the cylinders at various positions were also performed in a similar way to those for the skull phantom. Because the different parts of this phantom exist as homogeneous materials, the threshold value was calculated as the average of the mean intensity of the bone/aluminium and PMMA. The evaluation procedure is briefly depicted in Figure 2. For a more elaborate explanation, refer to the previous study.16 Calculation of threshold value If a human observer measures bone thickness on a CT image, they delineate the bone in their mind by seeking the transition between soft-tissue and bone. Such delineation is performed by the computer using a segmentation algorithm. The easiest segmentation algorithm to use is the use of a global threshold value. This means that a single threshold value is used to segment the whole object everywhere in the image. Some pilot tests were performed at the start of the study, and the results of this test showed that the rule applied by Wiemker and Zwartkruis21 performed best, therefore this rule was used. They showed that the transition from a region to segment and their background corresponds to a local optimum in the cumulative Laplace-weighted histogram. In some cases an optimum of the surface, the mean gradient, the volume or the sphericity histogram can give more information to find the ideal threshold value. For the calculation of the histograms, a cuboid region was indicated on the 3D images of the CBCT or MSCT images. The materials present in this cuboid region were air, water and bone. To find the maximum which corresponds to the transition between bone and soft tissue on the cumulative histogram of the Laplacian, first the intensity values which correspond to soft tissue and bone needed to be selected. This intensity region was found by inspection of the histogram of the image intensities. Experiments Dose measurements and image quality assessment were performed in one MSCT and four different CBCT scanners. An overview of the protocols is given in Table 1. The MSCT scanner was the Somatom Sensation 16 (Siemens, Erlangen, Germany). The CBCT scanners were the NewTom 3G, the i-CAT, the MercuRay and the Accuitomo 3D. When we initiated this study, the different CBCT scanners were not available at many sites and hence measurements needed to be performed at different institutions. The measurements with the Somatom Sensation 16 and the Accuitomo 3D were performed at the University Hospital Leuven (Leuven, Belgium), the measurements with the NewTom 3G were performed at the UCLA School of Dentistry (Los Angeles, CA), the measurements with the MercuRay CB at were performed at SmartScan Imaging (Orange, CA) and the measurements with the i-CAT were performed at Golden State X-ray Lab (North Hollywood, CA) and Imaging Sciences International (Hatfield, PA). For all CBCT scanners except for the MercuRay, the protocols suited for the planning of oral implants were evaluated. Due to practical reasons, we could not evaluate the implant protocol on the MercuRay and therefore the protocol with the largest diameter was evaluated. A comparison between the radiation dose of the MercuRay and the other CBCT scanners would therefore not be fair. It is, however, possible to estimate the radiation dose of an MSCT scanner with a similar height as the MercuRay. Physical phantom For the evaluation of the image quality based on the physical phantom, the results acquired for the segmentation of the contrast phantom in a previous study were used.16 The contrast phantom of the Accuitomo 3D was used for the evaluation of the physical performance. This phantom is made of polymethyl methacrylate (PMMA) with an insert of four smaller Table 1 Overview of the parameters of the evaluated protocols Scanner Protocol Tube potential (kVp) Tube current (mAs) Diameter (mm) Height (mm) Rotation time (s) Exposure time (s) Voxel size (mm) Kernel NewTom 3G NewTom 3G NewTom 3G i-CAT i-CAT i-CAT i-CAT MercuRay Accuitomo 3D Sensation 16 Sensation 16 N1 N2 N3 I1 I2 I3 I4 M1 A1 S1 S2 110 110 110 120 120 120 120 120 80 120 120 22 22 22 11 11 20 40 150 72 90 90 100 100 100 160 160 160 160 193 40 90 90 100 100 100 60 60 60 60 193 30 60 193 36 36 36 10 10 20 40 10 18 – – 7.2 7.2 7.2 1.92 1.92 3.67 7.19 10 18 – – 0.1860.1861 0.1860.1860.4 0.1860.1860.4 0.360.360.3 0.460.460.4 0.460.460.4 0.260.2 0.2 0.3860.3860.38 0.1360.1360.5 0.2560.2560.4 0.2560.2560.4 Standard High Very high N/A N/A N/A N/A N/A N/A H60s H60s N/A, not applicable Dentomaxillofacial Radiology Image quality and radiation dose of CBCT M Loubele et al The results of the analysis of the segmentation accuracy can be found in Table 2. The highest accuracy for the segmentation of the mandible was found for the i-CAT (protocols I2 and I3), this accuracy was also higher than for the Somatom Sensation 16. The lowest accuracy was found for the MercuRay. The high accuracy for the i-CAT could be achieved because this image suffered less from the intensity inhomogeneity and it was therefore possible to calculate a threshold value based on the complete mandible. The MercuRay suffered most from the intensity inhomogeneity and there was therefore a lower accuracy for the bone segmentation. For the segmentation of the cylinder of bone and aluminium in the contrast phantom, for all protocols an accuracy better than 1 mm was achieved. The Pearson correlation coefficient between the accuracy achieved on the mandible and the bone equivalent plastic was 0.37 and the correlation coefficient between the accuracy achieved on the mandible and the aluminium cylinder was 0.03. This means that based on the analysis of the physical phantom, no conclusion can be drawn about the segmentation of the mandible. For the protocols used for oral implant placement, the DPI100,c was the highest on the Somatom Sensation 16. The highest radiation dose for the CBCT scanners was for the NewTom 3G and the lowest for the Accuitomo 3D. The i-CAT had the highest accuracy combined with a low radiation dose and had as a surplus a submillimeter accuracy for the segmentation of the mandible. We can therefore say that this scanner performed the best on this test. When the radiation doses of the MercuRay and the Somatom Sensation 16 are compared, one can see that the radiation dose levels are similar. Because the radiation dose of the Somatom Sensation 16 is higher than the CBCT scanners for placement of oral implants, one may therefore expect that if a protocol with a lower height is used on the MercuRay, we will also have a radiation dose for the MercuRay that is Therefore a comparison will be made between the MercuRay and the Somatom Sensation 16. Data and statistical analysis For the evaluated protocols on the different scanners, descriptive statistics were used to express the mean and standard deviation between the ground truth values measured on the laser model and the bone thickness measured on the CT images for all measurement lines. Positive values indicated an underestimation of the true thickness; negative values indicate an overestimation. Also the 95th percentile of the absolute difference between the ground truth and the measured thickness was calculated. A similar analysis was performed in the previous study for the images of the contrast phantom.16 Finally, the Pearson correlation coefficient between the accuracy achieved on the mandible and the segmentation of the cylinder in bone and aluminum were calculated. Results The setup for the experiment did not fit in the Accuitomo 3D and therefore a smaller box was used for the experiment on the Accuitomo 3D. Typical histograms, i.e. the histogram of the image intensities and the cumulative histogram of the Laplacian of the image, are shown in Figures 3–6 for the different CBCT scanners. For each image, the region of interest (ROI) is indicated with highlighted intensities. Due to the intensity of the grey values in the NewTom 3G and the MercuRay, several ROIs needed to be tested before a cumulative histogram of the Laplacian was found which was suitable for analysis. Such a histogram could be achieved when only a small region was taken into account. In the image histograms the intensities which were taken into account to find the bone threshold are indicated in a thicker line. a 313 b c Figure 3 (a) A slice of the NewTom (protocol N2) together with a highlighted rectangle representing the region of interest. (b) Represents the histogram of the image intensities and (c) represents the cumulative Laplacian histogram. The image intensities which are taken into account are shown in a thicker line Dentomaxillofacial Radiology Image quality and radiation dose of CBCT M Loubele et al 314 a b c Figure 4 (a) A slice of the Accuitomo 3D. (b) Represents the histogram of the image intensities and (c) represents the cumulative Laplacian histogram. The image intensities that are taken into account are shown in a thicker line similar to Somatom Sensation 16 and thus higher than the other CBCT scanners the X-ray beam at two opposite positions. Because of the larger distance between the source of the X-ray beam and the object, and considering the limited collimation of the X-ray beam, the irradiated area will only be small; therefore, one can expect much of the scattered radiation to be covered when an ion chamber with a length of over 10 cm is used. In Figure 7b, a similar composition is made, but this time for the iCAT scanner. The figure has been made for a protocol with a height of 13 cm. Because the scanned height is even longer than the 10 cm of the ion chamber, it is obvious that not all scattered radiation is covered by the ion chamber. If we divided the DPI by the slice thickness, for achieving the CTDI, we could obtain a completely wrong dose descriptor. In Figure 7c, we give the configuration for the Accuitomo 3D. For this scanner, a similar reflection can be made as for the i-CAT, except that the scanned height here is smaller than 10 cm. The use of longer phantoms as proposed by Mori et al12 is not feasible in CBCT scanners for dentomaxillofacial applications.11 Another problem for the CTDI measurement is the way that different CTDI measurements are combined.11 For the CTDI measurements in MSCT scanners, the Discussion In this paper, the radiation dose and image quality of different CBCT scanners was compared with the radiation dose and image quality of an MSCT scanner. The radiation dose was evaluated by a technical dose measurement, the DPI100,c measured in the central hole of a CTDI phantom. Recently, a lot of discussion for and against the use of the CTDI or another technical dose measurement has been performed.11,12,22,23 We will explain two of the shortcomings of the use of the CTDI. The main difference between the CTDI and the DPI is that the CTDI is the DPI divided by the slice thickness. One of the most important shortcomings of the CTDI is that it is measured over a length of 10 cm, which is too short to include all the scattered radiation dose in the protocol of a CBCT scanner. We show this in Figure 7. Figure 7a represents the configuration of the Somatom Sensation 16. The contour of the CTDI phantom is presented on an axial slice, together with a b c Figure 5 (a) A slice of the MercuRay together with a highlighted rectangle representing the region of interest. (b) Represents the histogram of the image intensities and (c) represents the cumulative Laplacian histogram. The image intensities which are taken into account are shown in a thicker line Dentomaxillofacial Radiology Image quality and radiation dose of CBCT M Loubele et al a b 315 c Figure 6 (a) A slice of the i-CAT (protocol N2) together with a highlighted rectangle representing the region of interest. (b) Represents the histogram of the image intensities and (c) represents the cumulative Laplacian histogram. The image intensities which are taken into account are shown in a thicker line weighted sum of the CTDI at the central position and the average of four peripheral measurements with weights of one-third and two-thirds, respectively, is used as global dose estimation. For the dose measurement in this study, only a measurement at the central hole was performed and not at the peripheral positions because there currently exists no similar rule to combine these into one dose estimate. This is intuitively explained in Figure 7. For the Somatom Sensation 16 (Figure 7a), the cross-section of the X-ray beam with the phantom is almost rectangular. For the i-CAT (Figure 7b) and the Accuitomo 3D (Figure 7c), this cross-section has a conical shape, which depends on the geometry of the scanner and the protocol which was used. It is obvious that the contribution of the dosimetry at the central and peripheral holes in the phantom does not make the same contribution to the radiation dose as for the traditional formula of the CTDI. Unfortunately, when we performed a study on the technical dose that was reported in the manuals of the evaluated CBCT scanners, we noticed that they were aware of the problem with the CTDI and had therefore adapted the definition of the CTDI based on their own opinion. However, we propose that besides the CTDI the measurement of the DPI100 should be given because this measurement can be obtained with the same measurement procedure. The aim of future research in technical dosimetry will consist of striving for a correlation between the DPI or a new technical recording method and the effective radiation dose that a patient receives. Also, correction factors will be calculated and tabulated to compensate for scattered radiation, which was not measured by the ion chamber of 10 cm, and similar correction factors will be tabulated to compensate for the geometry of the scanner. We assessed the segmentation accuracy of bone models segmented from CBCT and MSCT images by comparing them with a model acquired from a laser scanner. Our method relies on a correct geometric alignment or registration of the CT images with a volumetric model with a voxel size of 0.1 mm acquired from the laser scanner. The voxel size of this model was defined as smaller than the voxel sizes of the CT images and the registration accuracy was therefore not determined by the laser model but by the CT images.20 The availability of an accurate ground truth made it possible to evaluate some rules for the finding of a threshold value for bone. It was found that, certainly Table 2 Results of the analysis of the image quality and the radiation dose Skull phantom Contrast phantom Mandible Bone equivalent plastic Aluminium Protocol Prct 95 Mean ¡ Prct 95 Mean ¡ SD Prct 95 Mean ¡ SD CTDI phantom DPI100,c N1 N2 N3 I1 I2 I3 I4 M1 A1 S1 S2 3.5 3.5 3.4 1.4 1.0 1.0 1.1 4.2 2.9 1.2 1.2 20.7¡1.5 20.72¡1.5 20.7¡1.5 0.03¡0.7 20.03¡0.6 20.08¡0.5 20.01¡0.6 20.1¡2.0 0.5¡1.1 0.14¡0.6 0.14¡0.6 0.73 0.59 0.42 0.34 0.6 0.45 0.25 0.42 0.3 0.24 0.24 20.06¡0.17 20.02¡0.13 20.07¡0.16 0.03¡0.2 20.1¡0.19 20.04¡0.24 20.1¡0.08 20.04¡0.38 20.17¡0.09 20.07¡0.06 20.07¡0.06 0.37 0.37 0.4 0.26 1.03 1.07 0.25 1.01 0.3 0.22 0.22 20.06¡0.17 20.02¡0.13 20.07¡0.16 0.05¡0.10 0.08¡0.32 0.12¡0.29 20.19¡0.06 20.04¡0.38 20.48¡0.57 20.07¡0.06 20.07¡0.06 446 446 446 71 71 124 249 1569 107 1090 1677 CTDI, CT dose index; Prct, percentile, SD, standard deviation Dentomaxillofacial Radiology Image quality and radiation dose of CBCT M Loubele et al 316 for the i-CAT scanner and the MSCT scanner, the use of the rule indicated by Wiemker et al21 gave satisfying results. Unfortunately, this rule gave no accurate results when the images suffered more from intensity inhomogeneity. In a second experiment, the image quality was evaluated based on a physical phantom. Only a small correlation between the results of the segmentation accuracy on the mandible and the segmentation of the cylinders in the contrast phantom was found. Several reasons can be found for this small correlation. The contrast phantom is a small phantom, only 5 cm in diameter and 5 cm in height. This means that except for the Accuitomo 3D the phantom is positioned completely in the field of view and therefore does not suffer from the truncated view artefact. Secondly, because the object is so small, there is less scattered radiation which can influence the image quality. The influence of the scanner depends on the geometry of the scanner and the spectrum of the X-ray tube.24 How the scatter finally will influence the image quality can be determined by the reconstruction algorithm which is developed by the a b c Figure 7 The configuration of the X-ray beam is presented for three different scanners: (a) Somatom Sensation 16, (b) i-CAT and (c) Accuitomo 3D. Each figure shows two positions of the X-ray beam in the opposite position, together with the contours of a CT dose index (CTDI) phantom. The dashed-dotted line together with the dotted lines indicates the central and the two peripheral holes of the CTDI phantom Dentomaxillofacial Radiology Image quality and radiation dose of CBCT M Loubele et al CBCT manufacturer.24 Because these different factors are dependent on each scanner, one cannot predict the image quality of bone segmentation based on the segmentation of bone equivalent plastic in the contrast phantom. This does not mean that physical phantoms are useless for the evaluation of image quality of CBCT scanners. These phantoms are very useful for continuous quality control of CBCT scanners. A difference, for example, in contrast and therefore a deterioration of segmentation accuracy over time can indicate that there might be a problem with the CBCT scanner. Also, different parameters such as, for example, the Hounsfield units without influence of scattered radiation dose can be calculated. The benefits of this work over the work of previous studies17,18 in which the accuracy of linear measurements of CBCT was derived is that the measurements are performed automatically without much user interaction. Therefore, this method does not suffer from observer and intraobserver variability. In the current study, water was used to simulate soft tissue. Water for the use of soft tissues is not very practical and a solid water simulating or soft tissue simulating material should therefore be used for the generation of a skull phantom. However, the use of solid material instead of water belongs to a future study. Also in future studies, different parts of the skull phantom should be incorporated for the evaluation of the image quality. Besides this, a better definition of the measurement lines will also be researched. The Somatom Sensation 16, the MSCT scanner, had the highest radiation dose together with the MercuRay. Similar results for the MercuRay were found by Ludlow et al.25 The NewTom 3G had a higher radiation dose than the other CBCT scanners, but a 317 larger region was scanned, so this also should be taken into account. The lowest radiation dose was achieved for the Accuitomo 3D, but here the smallest region was scanned. If, for example, a complete mandible needs to be imaged, this would require at least three scans. As a result, the Accuitomo 3D would require the highest radiation dose. If with the i-CAT a region with a similar height would be scanned with the parameters of protocol I4, a similar dose to the NewTom 3G would be achieved. One can therefore state that the radiation dose of the i-CAT and the NewTom 3G are similar. However, the i-CAT has better segmentation accuracy for a similar radiation dose and therefore the i-CAT performed best in this study. Conclusion A framework for the evaluation of image quality and radiation dose was presented. The image quality was evaluated by measuring the segmentation accuracy of the mandible in a skull phantom and the segmentation of cylinders in a contrast phantom. The results of the image quality assessment were accumulated in the 95th percentile of the absolute difference between the measured thickness on the CT scanners and the ground truth thickness. The radiation dose was evaluated by a technical measure, the dose profile integral. 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