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Makhija et al
Invited Review
Integrating Cone Beam Computed Tomography (CBCT) In Dentistry-Review
Authors: P.G.Makhija*, Priyanka Makhija**
Correct diagnosis is vital to proper treatment.
Although the history and clinical examination are of
prime importance when evaluating patients, the use
and evolution of non-invasive technology from 2D xray modalities to three-dimensional (3D) cone
beam CT, for imaging areas not visible to the human
eye is increasingly becoming popular1.
In the ever expanding volume of knowledge it is vital
for any clinician to remain in touch with latest
innovations in the field of one's expertise and apply
the same for the benefit of patient care and be ready
and willing to accept new trends, find time to learn
and practice the technological and diagnostic or
treatment advances in the related field. CBCT is one
such recent advancement in the field of Dentistry
which one should learn and adapt into clinical
practice.
Of the recent advances, two things have changed the
way we practice dentistry, the first one is
advancements in computer and digital applications
for dentistry and the second most wonderful area is
the advent of Dental Cone Beam Computed
Tomography is popularly known as Cone Beam CT,
CBCT, cone beam volumetric tomography (CBVT).
The word CT stands for Computed Axial
Tomography used mostly in medicine. Radiology
added new dimension to diagnosis in medical field
by allowing us to see deeper structures in two
dimensions without surgical interventions. Medical
CT and CBCT both are imaging technology using xrays with little difference in acquisition of images,
primary reconstruction algorithm, and radiation
dose and acquisition time.
Address For Corresspondence:
Dr P.G.Makhija
Professor & Head, Department of Orthodontics,
Modern Dental College &Research Centre,
Indore
Historical:
The medical CT scanner was developed in the late
1960s, and subsequently patented by Hounsfield
(1973).In 1979, Sir Godfrey Hounsfield and A.M.
Cormack were awarded the Nobel Prize in medicine
for developing CT scanner and for developing
software to read and reformat the CT data
respectively.
CT (Computed tomography) or Computed Axial
Tomography (CAT scan) has remained one of the
most important methods of radiological diagnosis
in medicine. Its use in dentistry was limited to
craniofacial imaging for trauma, syndromes,
implant dentistry etc. The use of 3D medical CT was
however limited because of its high machine cost,
high acquisition cost, and high radiation, lack of
reformatting and viewing software with dentist.
In the late 1990s Italian and Japanese groups 2, 3
working independently of each other, developed a
new tomographic scanner known as cone beam
computed tomography (CBCT) or digital volume
tomography (DVT) specifically for maxillofacial and
dental use4.
The first dental CBCT system became commercially
available for dentomaxillofacial imaging in 2001
(NewTom QR DVT 9000; Quantitative radiology,
Verona Italy).5
The popularity of dental CBCT has been growing
since then along with the controversies of its
radiation dose, usefulness of altering the treatment
outcome, onus of responsibility to diagnose and
locate incidental findings as well as limitations like
cost, uniform software, training of orthodontist,
time required to study scan, knowledge of 3D
structures, skill and knowledge of computer and
software.
Uses of CBCT in Dentistry
*Professor and Head, Department of Orthodontics, Modern Dental College &Research Centre, Indore
**PG Student, Department of Prosthodontics, Modern Dental College & Research Centre, Indore
BHAVNAGAR UNIVERSITY'S JOURNAL OF DENTISTRY
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W. De Vos, J. Casselman, G. R. J. Swennenin6 in their
study, reviewed Pubmed for CBCT in oral and
maxillofacial region. 176 clinically relevant articles
out of 375 total articles from 1998 to 2007 were
selected. 86 papers (49%) were related to clinical
applications, 65 (37%) to technical parameters, 16
(9%) to radiation dose and 26 (15%) were synopsis
papers.
Alamri HM, Sadrameli M, Alshalhoob MA, Sadrameli
M, Alshehri MA 7 in their article presented a review of
the clinical applications of cone-beam computed
tomography (CBCT) in different dental disciplines. A
literature search was conducted via PubMed for
studies on dental applications of CBCT published
between 1998 and 2010. The search revealed a total
of 540 results, of which 129 articles were clinically
relevant and were analyzed in detail and various
%uses were shown as follows :Oral and
maxillofacial surgery (OMFS) 26.3%, Endodontics
25.6%, Implant Dentistry 16.3% , Orthodontics
11.6% , General Dentistry 9.3 %, Temporoman
dibular joint (TMJ) 5.4%, Periodontics 4.65%,
Forensic Dentistry 0.80%.
Grondahl HG8 reported use of CBCT in various areas
as follows: Implantology: 40%, Oral surgery: 19%,
Orthodontics: 19%, Endodontics: 17%,
Te m p o r o m a n d i b u l a r j o i n t ( T M J ) : 1 % ,
Otorhinolaryngology: (ENT) 2%, Other
investigations 2% (Periodontology, forensic
dentistry, research).
Adibi S, Zhang W, Servos T, O'Neill PN.9 in the latest
review conducted using PubMed, Google, and
Cochrane Library searches in the spring of 2011
using the key words "cone beam computed
tomography and dentistry." resulted in over 26,900
entries in more than 700 articles including fortyone reviews recently published in national and
international journals. This article is based on
existing publications and studies and provides
readers with an overview of the advantages,
disadvantages, and indications/contraindications
of this emerging technology as well as some
thoughts on the current educational status of CBCT.
clinical uses of CBCT in various areas can be
summarised as under:
BHAVNAGAR UNIVERSITY'S JOURNAL OF DENTISTRY
Uses in Orthodontics: 10-14
The CBCT can potentially find maximum uses in
orthodontics for Understanding 3D anatomy,
patient consultation, communication, practice
management. (pictures 1 to 8)
Picture1
picture2Airway volume minimum vol Bony panormic view
picture-3
condyle irt eminence
picture-4
dilacerated teeth
treatment planning
picture - 5 dentascan
picture-6
lingual occlusion,
inclination, labial bone
Picture-7
Mixed dentition, condyles,
airway, interincisal
Picture - 8
asymmetry
measure
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Makhija et al
Orthodontic Diagnosis: qualitative and quantitative
extra oral examination of face, dimensions, facial
type, facial convexity, soft tissue analysis, facial
p ro p o r t i o n s , m i d l i n e s y m m e t r y, g ro w t h
development, anatomy, pathology, developmental
disturbances, and soft tissue thickness in various
areas.
Research: Pre treatment and post treatment
comparison, asymmetry, FEM analysis, growth and
development, Muscle volume, linear accuracy,
dosimetry, airway, 3D cephalometric measurements, biomechanics, syndromes including cleft lip
palate, alveolar bone graft planning in CLP,
Asymmetry, pre post treatment comparisons.
Complete hard tissue examination and record, type
of dentition present, Arch size, arch shape,
symmetry of arches, arches coordination, vertical,
anteroposterior and transverse maxillo mandibular
relationship, number, size of teeth, automatic Bolton
ratio, shape of teeth, fractures and cavities of teeth
present, Unerupted, impacted teeth, supernumerary teeth, impacted third molars, their relation to
mandibular nerve, relation of teeth to each other
and jaws, root completion, Root resorption, root
fracture, quality and quantity of bone, periodontal
problems, Root Torque, buccal corridor, Airway
examination, Tongue size and Posture, TMJ. CBCT
data can be used to make digital study models
Uses in Oral Medicine & Radiology15: CBCT is
wonderful tool to study various anatomy &
pathology in 3D. All syndromic cases, TMJ, Salivary
glands, muscles can be studied in detail. The CBCT
data can be used for regressing back to computer
generated 2d pictures and radiographs. If one
desires, the inbuilt tools can generate variety of xrays either in 2d or 3 D format. E.g. OPG, lateral
cephalogram, PA views, sectional views, nerve
anatomy views, submento vertex view, waters view.
Practically any x-ray view is possible without fear of
superimposition as the virtual patient and virtual
machine is with us to take and retake any number of
x-ray views without actually subjection the patient
to x-ray machine. (Pictures 2,5)
Impacted Teeth: diagnosis and treatment planning
of impacted teeth, number of un erupted impacted
teeth, their 3D position, 3D relation to adjoining
teeth, ankylosis or pathology associated with it, root
resorption caused by them to adjoining teeth, size
and shape of impacted tooth, its root size shape,
from this we can plan possible movement plan and
biomechanics for dis impaction.
Implant Planning: bone quality and quantity can
be measured, 3D implant placement can be
practiced, mini Implants can be virtually placed to
check for proximity to root surfaces and FEM
analysis
Treatment Planning: Evaluation of asymmetry
cases, cephalometric analysis, orthodontic and
surgical treatment planning, surgical splint
preparation, models for mock surgery etc
CAD CAM: Customised labial or lingual brackets can
be designed and printed or casted for lingual
orthodontics; clear aligners can be fabricated over
digital models.. Robotic wire bending. Orthodontic
appliances, Biomechanically efficient devices
BHAVNAGAR UNIVERSITY'S JOURNAL OF DENTISTRY
Picture-2
Bony panormic view
Picture - 5
dentascan
Uses in Endodontics4, 16-20
Crown morphology, pulp chamber, proximal caries,
Root morphology, number of root canals, course and
direction of canals, accessory canals, root
resorption, root fractures, Obturation , filling, under
and overfilling, sinus problems, Broken
instruments. Early detection of previously
undiagnosed Periapical lesions. CBCT is clinically
more accurate & more useful than biopsy. It is also
useful in planning peri apical endodontic surgery as
the anatomical structures such as inferior dental
canal, mental foramen, maxillary sinus can be easily
differentiated and relation to root can be quantified.
(Pictures 9-11)
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planning and in designing a surgical guides.
(Pictures 5, 15, 16)
Picture-9
Periapical pathology
picture11-root canals
Applications in Oral Maxillofacial surgery 6, 21:
Jaw pathology, pre & post surgical evaluation of
fractures, impacted teeth, super numerary teeth,
relation of third molar to nerve, cortical and
trabecular bone quantity & quality, assessment of
bone grafts, paranasal sinuses, OSA, midface &
orbital fractures, guided surgery, surgical splint
fabrication, mock surgery, pre & post surgical
comparisons. Orthognathic surgeries, 3D virtual
model, post treatment esthetic evaluation, TMJ,
condyle, salivary gland, tooth auto transplant, cleft
lip palate, craniofacial reconstruction etc.
Evaluation roots of upper posterior teeth in respect
to the maxillary sinus, sinus lift. CAD CAM,
craniofacial reconstruction. (Pictures 12-14)
Picture-12-fracture
maxilla, zygoma
mandible, nasal
Picture-14
Impacted teeth
Applications in implant dentistry &
Prosthodontics 22:
Picture - 5
dentascan
Picture15
Faulty implant planning,
periodontal loss
picture-16 Implant planning
Applications in TMJ imaging 23:
Bony views and X-ray views can be generated
without any superimposing shadow of adjoining
structures. The condyles can be viewed from all
angles and measured. Condylar axis, inter-condylar
distance, condylar symmetry, fractures, relation to
glenoid fossa, visualization of glenoid fossa, size and
shape of glenoid fossa can be seen also AP and
lateral views of Condyle and rotational views with
every few degrees e.g. 15 degrees can be generated.
Defining true position of condyle in TMJ in
dislocations, extent of translation of condyle in
fossa, measurement of roof of fossa, visualization of
soft tissue around joint, pathology of TMJ, ankylosis,
asymmetry, trauma, pain dys function, fibro osseous
ankylosis. Condylar cortical erosion & cysts, image
guided puncture technique treatment modality for
TMJ adhesion. (Pictures 3,17)
Implant site evaluation, accurate measurements,
accurate planning of implant in relation to vital
structures, surgical guide, Computerised Prosthesis
for developmental disturbances
surgical implant guides , To assess the quantity and
quality of bone in edentulous
Ridges and implant cases. To plan implants and
assess the success of osseo integration
BHAVNAGAR UNIVERSITY'S JOURNAL OF DENTISTRY
Picture-3
Condyle irt eminence
Picture17-TMJ
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Makhija et al
Periodontics 24:
Safe use and Radiation issues 5, 25, 26, 27
Detailed morphologic description of bone,
measurement of bony defects equivalent to
periodontal probe, furcation involvement, buccal &
lingual defects, dehiscence, fenestration, accurate
analysis of bone loss as well as bone healing,
periodontal cyst, regenerative periodontal therapy,
grafts. (Pictures 9, 15, 18)
An effective dose in the broad range of 13–498 µsv
has been seen, with most scans falling between 30
and 80 µsv , depending on exposure parameters and
the selected FOV size. In comparison, standard
panoramic radiography delivers 13.3 µsv and multi
detector CT with a similar FOV delivers 860 µsv .
A relatively low patient dose for dedicated
dentomaxillofacial scans is a potentially attractive
feature of CBCT imaging particularly when we look
at the amount of information available and possible
uses of CBCT data.
Conclusion:
Picture-9
Periapical pathology
Picture15
Faulty implant planning,
periodontal loss
Forensic Dentistry, Incidental findings, ENT,
Picture-18 periodontal bone loss
plastic surgery7
Dental age estimation, 3D face reconstruction,
matching of radiographs with computer generated
radiographs, Various incidental findings like fusion
of vertebra, bifid, trifid condyles. It is useful in
assessing ENT problems like DNS, paranasal air
sinuses, syndromes, pre & post evaluation after
plastic surgery. (Pictures 19-21)
Picture-19
Trifid condyle,
STL model
Picture-21
DNS, mucous cyst
BHAVNAGAR UNIVERSITY'S JOURNAL OF DENTISTRY
CBCT with 3D volume rendering provides all the
necessary information in a single radiologic study
and generates clinically accurate and immediately
available images to get the virtual 3D patient which
can be evaluated again and again by same operator
or different operators till diagnosis is finalized or
treatment planning is finalized. Not only that, it can
be used in future for comparing the outcome of
treatment with another CBCT. It has educational,
communicational advantages and serves as life time
record. Even the areas which were not intended for
study can be seen checked for incidental findings
which may be beneficial from patient point of view.
May be, Training in basics of CBCT and 3D anatomy
will become essential part of dental curriculum in
India in coming years.
Although presently CBCT is not prescribed in each
and every case of dental treatment, CBCT scan is
going to become essential diagnostic aid in near
future to analyze each orthodontic case from start to
finish, for digital diagnosis, planning anchorage,
orthodontic VTO, biomechanics, brackets design
and fabrication. Virtual digital articulators will be
part of each patient to study functional examination
and check mandibular movements, occlusal
interferences, distribution of forces of occlusion,
checking occlusion on digital models for success and
finishing of orthodontic treatment and at the end,
retention planning and fabrication of retainers.
REFERENCES:
1.
Steven L Thomas, Christos Angelopoulos.
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Preface. Dent Clin N Am;52 (2008) xi–xii
11.
Ponder SN, Benavides E, Kapila S, Hatch NE.
Quantification of external root resorption by
low- vs high-resolution cone-beam computed
tomography and periapical radiography: A
volumetric and linear analysis. Am J Orthod
Dentofacial Orthop. 2013;143(1):77-91
2.
Y Arai, E Tammisalo, K Iwai, K Hashimoto, K
Shinoda. Development of a compact
computed tomographic apparatus for dental
u s e . D e n t o m a x i l l o f a c i a l R a d i o l o g y.
1999;28:245 -8
3.
Mozza P, Pracaci C, Tacconi A, Martini PT,
Andreis IA. A new volumetric CT machine for
dental imaging based on the conebeam
technique: Preliminary results. Eur J Radiol
1998; 8:11558-64.
12.
Huang H, Richards M, Bedair T, Fields HW,
Palomo JM, Johnston WM, Kim DG. Effects of
orthodontic treatment on human alveolar
bone density distribution. Clin Oral Investig.
2012; December 20
4.
S Patel, A Dawood, T Pitt Ford, E. Whaites. The
potential applications of cone beam
computed tomography in the management of
e n d o d o n t i c p ro b l e m s . I n te r n a t i o n a l
Endodontic Journal.2007; 40:818–830.
13.
5.
Miracle AC, Mukherji SK. Conebeam CT of the
head and neck, part 2: clinical applications.
AJNR Am J Neuroradiol. 2009;30(7):1285-92.
Ashima Valiathan, Siddhartha Dhar, Nikhar
Verma. 3D CT Imaging in Orthodontics:
Adding a New Dimension to Diagnosis and
Treatment Planning Trends Biomater. Artif.
Organs. 2008; 21 (2):116-120 downloaded
from http://www.sbaoi.org
14.
6.
W. De Vos, J. Casselman, G. R. J. Swennen: Conebeam computerized tomography (CBCT)
imaging of the oral and maxillofacial region: A
systematic review of the literature. Int. J. Oral
Maxillofac. Surg. 2009;38:609–625.
James K. Mah, John C. Huang and HyeRan
Choo. Practical Applications of Cone-Beam
Computed Tomography in Orthodontics J Am
Dent Assoc. 2010;141:7S-13S
15.
Alamri HM, Sadrameli M, Alshalhoob MA,
Sadrameli M, Alshehri MA. Applications of
CBCT in dental practice: a review of the
literature. Gen Dent. 2012;60(5):390-400
Jadu F, Lam E. A comparative study of the
diagnostic capabilities of 2D plain radiograph
and 3D cone beam CT sialography.
Dentomaxillofac Radiol. 2013
Jan;42(1):20110319
16.
Abella F, Patel S, Duran-Sindreu F, Mercadé M,
Bueno R, Roig M. Evaluating the periapical
status of teeth with irreversible pulpitis by
using cone-beam computed tomography
scanning and periapical radiographs. J Endod.
2012 Dec;38(12):1588-91
17.
Patel S, Horner K. The use of cone-beam
computed tomography in endodontics.
International Endodontic Journal
2009;42:755-6.
18.
Sogur E, Baksi BG, Gröndahl HG. Imaging of
root canal fillings: A comparison of subjective
image quality between limited conebeam CT,
storage phosphor and film radiography.
International Endodontic Journal
2007;40:179-85.
19.
Tsurumachi T, Honda K. A new cone-beam
7.
8.
9.
Grondahl HG. Quoted by S Manoj Kumar, PE
Chandra Mouli, S Kailasam, PH Raghuram, S
Sateesh, Karpagavalli. Applications of ConeBeam Computed Tomography in Dentistry.
Journal of Indian Academy of Oral Medicine
and Radiology, 2011;23(4):593-7
Adibi S, Zhang W, Servos T, O'Neill PN. Cone
beam computed tomography in dentistry:
what dental educators and learners should
know. J Dent Educ. 2012 Nov;76(11):14374210.
C. H. Kau and S. Richmond J. M.
Palomo and M. G. Hans Three-dimensional
cone beam computerized tomography in
orthodontics. Journal of Orthodontics,
2005;32:282–293
BHAVNAGAR UNIVERSITY'S JOURNAL OF DENTISTRY
Vol. 3 Issue-1 Jan. 2013
54
BUJOD
computerized tomography system for use in
endodontic surgery. International Journal of
Oral and Maxillofacial Surgery 2007;40:22432.
20.
21.
22.
23.
Bertrand Khayat, Jean-Charles Michonneau.
Cone-beam in endodontics. Endo Practice
2009;44-48.
Cevidanes LH, Bailey LJ, Tucker SF, Styner MA,
Mol A, Phillips CL, et al. Three-dimensional
CBCT for assessment of mandibular changes
after orthognathic surgery. American Journal
of Orthodontics and Dentofacial Orthopedics
2007;131:44-50.
Anssari Moin D, Hassan B, Parsa A, Mercelis P,
Wismeijer D. Accuracy of preemptively
constructed, Cone Beam CT-, and CAD/CAM
technology-based, individual Root Analogue
Implant technique: An in vitro pilot
investigation. Clin Oral Implants Res. 2012
Dec 21.
Tsiklaklis K, Syriopouluos K, Stamatakis HC.
Radiographic examination of TMJ using coneb e a m c o m p u t e d t o m o g r a p h y.
Dentomaxillofacial Radiology 2004;33:196201.
BHAVNAGAR UNIVERSITY'S JOURNAL OF DENTISTRY
Makhija et al
24.
Park CH, Abramson ZR, Taba M Jr, Jin Q, Chang
J, Kreider JM, et al. Three-dimensional microcomputed tomographic imaging of alveolar
bone in experimental bone loss or repair.
Journal of Periodontology 2007;78:273-81.
25.
The use of cone beam computed tomography
in dentistry. An advisory statement from The
American Dental Association Council on
Scientific Affairs.
JADA 143(8)
http://jada.ada.org JADA 2012;143(8):899902
26.
Guidance on the safe use of Dental Cone Beam
C T. h t t p : / / w w w. h p a . o r g . u k /
webc/HPAwebFile/HPAweb_C/1287143862
981.
27.
h t t p : / / w w w. s e d e n t e x c t . e u / f i l e s /
guidelines_final.pdf
Source of Support :
NIL
Conflict of Interest :
NOT DECLARED
Date of Submission :
24-09-2012
Review Completed :
25-12-2012
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