Dentistry

Review Article

Adibi` et al., Dentistry 2012, 2:1 http://dx.doi.org/10.4172/2161-1122.1000115

Open Access

Cone Beam in Dentistry: What a Practitioners Must Know

Shawn Adibi1*, Wenjian Zhang1, Tom Servos2 and Paula ONeill3
1 2 3

Assistant Professor, Department of Diagnostic Sciences , The University of Texas, School of Dentistry at Houston, USA Associate Professor, Department of Diagnostic Sciences , The University of Texas, School of Dentistry at Houston, USA Professor and Associate Dean, Department of Diagnostic Sciences , The University of Texas, School of Dentistry at Houston, USA

Introduction
Recent advancements in cone beam computed tomography (CBCT) have identified the importance of providing outcomes related to the appropriate use of this innovative technology in dentistry. To assist in determining whether evidence exists, the authors conducted a PubMed search during last week of December 2010 using the key words cone beam in Dentistry. This search revealed 697 articles with 41 reviews recently published in national and international journals. However, Cochranes review of PubMed revealed only one article on the subject of CBCT. This result demonstrates many opinion literatures needing for studies that meet methodological standards for diagnostic efficacy of CBCT. The purpose of this article is to review the effect of this enhanced diagnostic tool and its practical application for practitioners in order to increase patient quality outcome care. Since most dental practices are focused in their own area of discipline, the initial question that needs to be answered is: what qualitative measures gained by use of cone beam for that particular discipline in dentistry. As this diagnostic tool evolve with time, more possibilities, and hopefully more evidence will become available related to the more indications for use of this extra ordinary technology inpatient care. In the past, two dimensional images have provided diagnostic evidence for dentistry and medicine. There is little doubt that these two dimensional images will continue to contribute to the diagnostic processes for many years. However; our profession has the responsibility to investigate the reality of the newly emerging three dimension (3D) technology. Does the CBCT image offer additional relevancy in clinical dentistry for diagnosis and treatment planning? To answer this question, risk quantification of CBCT versus benefit received by utilizing this technology has to be assessed. Additionally, in many disciplines in dentistry, Clinicians need back ground evidence history to base their patient care decision making on day to day basis.

dimensional images can be produced by a single scan of the fan shaped helical x-ray source, which reduces exposure time and dosage [5]. A cone-beam scanner uses a cone shaped beam and the reciprocating detector, which rotates around the patient 360 degrees and acquires projected data. Using sophisticated computer software along with a back-filtered projection, a three dimensional image is produced in an axial, coronal and sagittal planes. All CBCT units produce a three dimensional image, although each manufacturer uses slightly different parameters and viewing software. The software reconstructs the sum of the exposures via algorithms specified by the manufacturer into as many as 512 axial slice images. These images are in the Digital Imaging and Communications in Medicine (DICOM) data format. DICOM data enables the dentist to view the image in a volumetric fashion as well as in all three planes (axial, sagittal, and coronal). The dentist would also be able to take measurements in any of the three planes listed above [6]. CBCT has been around for many years, however, the recent advancements in this technology, i.e., reduced cost of production for the sophisticated x-ray source, a quality detector, the advancement in software design, and a more powerful computer system, have allowed the commercial production and practical application into todays dentistry. Dr. Hashimoto and his colleagues [7] compared the image performance between CBCT and multi-detector helical CT for dental use. The authors concluded that in the terms of image reproducibility and quality, the CBCT produced an image with much higher quality than the helical CT, with approximately 400 fold less radiation exposure in the dental radiology field. Therefore, CBCT technology was demonstrated to be useful in maxillofacial radiology. CBCT is well utilized and has several major advantages for evaluation of hard tissues, although detection and evaluation of soft tissue is not as clear as desired. One important advantage of CBCT is the ability to minimize the irradiation of tissues by limiting the specific area of interest. Accuracy is another advantage of CBCT over conventional CT. CBCT can generate a size of voxels, a three dimensional cuboid unit of images, to be as small as 0.125 mm in depth dimension, which contributes to the image resolution and quality. In a study published by Razavi and colleagues in 2010 [8], using Accuitomo at a voxel size of 0.125 produced images with better resolution and a more accurate measurement of thickness of the thin cortical bone adjacent to dental

Radiology
The American Academy of Oral and Maxillofacial Radiology (AAOMR) has provided the rational for image selection for several areas of head and neck [1,2]. For many areas of dentistry, the conventional panoramic and/or the full mouth survey would be adequate, but there may come a time for the need of a multi-planar image such as computed tomography [3]. During the last couple of decades, more indications have been presented in literature that are worthy of discussion and consideration in dentistry. Conventional CT was developed by Sir Godfrey Hounsfield in 1967 and there has been a gradual evolution to what is currently in use today. To ensure that CT is being used appropriately, is important to review and discuss needed improvements in this technology for better performance and the possibility of more applications [4]. Two types of beams are commonly used in CT including fanbeam and cone-beam. In fan-beam scanners, a narrow fan-shape ray passes through the axial plan of the body contiguously. The final 3D images are produced by stacking all the two dimensional (2D) axial slices together. In a multi-detector helical CT unit, 64 slices of the two
Dentistry ISSN: 2161-1122 Dentistry, an open access journal

*Corresponding author: Shawn Adibi, Assistant Professor, Practice Leader, Department of Diagnostic and Biomedical Sciences, Director of Examination, Diagnosis, and Treatment Planning Clinic, Director of Second Year Clinic, 6516 MD, Anderson Blvd., Room 214, Houston, Texas 77030, USA, Tel: 713-500-4565; Fax: 713-500-4416; E-mail: Shawn.Adibi@uth.tmc.edu Received December 02, 2011; Accepted December 29, 2011; Published January 03, 2012 Citation: Adibi S, Zhang W, Servos T, ONeill P (2012) Cone Beam in Dentistry: What a Practitioners Must Know. Dentistry 2:115. doi:10.4172/2161-1122.1000115 Copyright: 2012 Adibi S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Citation: Adibi S, Zhang W, Servos T, ONeill P (2012) Cone Beam in Dentistry: What a Practitioners Must Know. Dentistry 2:115. doi:10.4172/21611122.1000115

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implants than what can be achieved with an i-Cat NG system at a voxel size of 0.3 mm. In all systems, scan time for CBCT is approximately a minute or less. This allows for a quick collection of data from the patient thus reduces the possibility of motion artifacts. Several published reports indicating that the average radiation effective dose of CBCT is within 36.9-50.3 microsievert, which is up to a 98% reduction when compared to fan-beam CT systems [9,10]. Another study shows that the radiation effective dose of CBCT is between 6 to 477 microsievert, depending on the parameters used [11]. Based on the data from International Commission on Radiological Protection (ICRP), the effective dose from panoramic radiography is approximately 13 microsievert, from cephalometric radiography is 1-3 microsievert, and from periapical radiography is 1-8 microsievert. J.A Roberts et al. [12] found that i-CAT CBCT delivers a higher dose to the patient than a typical panoramic radiography by a factor of 5-16. Apparently, the dose from a CBCT is low compared to a conventional CT, but is significantly higher than the traditional dental radiography techniques. Contrary to the radiation concerns raised by of many critics, CBCT units provide choices for field of view (FOV). These choices allow excellent resolution with reduced radiation to the patient while also focusing on the particular area of interest for the dentist. CBCT volumetric data is isotropic, which is an advantage in that it can be re-oriented to fit the patients anatomic features to assess real time measurements. Clinical reports and experiences revealed that CBCT is able to reduce the level of metal artifact when compared to conventional CT, especially in secondary reconstruction of viewing the maxillary and mandibular dentition [3]. Other advantages of CBCT over conventional CT are its size and practical use for the head and neck regions. This property, in addition to its affordability, has allowed this technology to be suitable for the dental office setting. Moreover, the most advantageous aspect of the introduction of CBCT to the maxillofacial area is its ability to use an obtained computer image for the creation and interpretation of data slicing in many formats that the oral care provider is already familiar with. For instance, a CBCT image can be reconstructed to a panoramic, cephalometic or bilateral multi-planar projections for evaluation of temporomandibular joint anomalies. These images, in turn, can be annotated, assessed and measured for diagnostic purposes [13,1]. Aaron Dean Molen [14] recently published a study using CBCT to measure buccal cortical bone thickness. The article advocates that when it is possible, the smallest field of view containing the region of interest should be used with long scan time, with more frame acquisition to prevent poor resolution. He also recommends a 16-bit sensor should be used, if possible, for the best gray scale. The standard of care for the use of diagnostic monitors has been set by medicine [15]. Dentistry is unique, in a sense because the practicing dentist is often reading the images without a consultation of radiologists. Gutierrez and colleagues [16] found that the usual desktop computer display being used is not adequate for accurate diagnostic radiology . Therefore, it is essential that the dentist ensures that radiologic equipment is calibrated to ensure that there is adequate contrast and sufficient brightness along with a reduced level of ambient lighting. Knowing that no technology is without a limitation,CBCTs dynamic range for contrast resolution can only reach 14-bit maximally. To accurately read the soft tissue phenomenon a 24-bit contrast resolution is needed. This would not be a problem if only hard tissue evaluation is the objective of the examination. Even though, it is not
Dentistry ISSN: 2161-1122 Dentistry, an open access journal

sufficient for soft tissue evaluation, there are applications for soft tissue analysis and evaluations such as soft tissue air way constrictions and obstructions for patient suffering from sleep apnea, as well as orthodontic treatments [15,17]. There are also noted risks for using CBCT with patients. For example, although risk to the patient is expressed as effective dose, it is challenging to compare existing modalities of CT, CBCT, traditional film base and digital radiography used in dental practice settings. There are difficulties in making a reliable comparison when the axis of rotation is not in the center of the patients body and a small radiation field size is used [18]. In a study of the effective radiation dose of the ProMax 3D CBCT scanner using different dental protocols, Xing-min Qu et al. [19], have concluded that choice of patient size, field of view selection, region of interest, and resolution may affect patient dose by an order of magnitude. The authors also determined that careful selection of all of the above mentioned parameters are needed to optimize the diagnostic information and reduce the patient dose at the same time. According to ICRP reports in 2009, the risk of adult patient fatal malignancy related to CBCT is between 1/100,000 and 1/350,000. In addition, when utilizing the technology for children, the risk could be twice as much. Potential benefits of using CBCT in dentistry to assess, diagnose pathologies and pre-surgical planning are undisputed. However, due to the additional radiation exposure necessary to achieve the desired results, justification will be needed [12]. Other disadvantages of CBCT are important to mention along with the need for improvement, even though profound advantages of CBCT have already been established in the literature. For instance, scattered radiation or noise that is seen as a streaking artifact when metal objects such as non-precious restorations and alloys exists. Additionally, motion artifacts are seen due to patient movement during the scanning period. Manufacturers have developed their own specific filters to resolve these problems [6]. However, it is unclear if the reconstruction of images will reduce the image quality or quantity. There is obvious profound logical evidence that the advantages of using CBCT exceed the disadvantages. Therefore, practitioners will have to weigh in risks against benefits gained by using this technology on a case by case basis.

Implantology
Dental imaging is an important tool for accurate treatment planning of a dental implant. Traditional two dimension radiography will provide adequate information about purposed implant sites in many clinical circumstances; however, limited size, image distortion, uneven magnification and a two dimensional view restrict their use in many other cases [20]. The ability of CBCT to produce cross sectional images is invaluable in coordination with a multi-discipline implant planning team [21]. Challenging circumstances do arise while planning an implant, i.e. placement of an implant in proximity of the nasopalatine canal of a young patient, which is close to vital nerves and vasculature along with an unknown quality and quantity of bone [22,23]. Traditional CT has been used in the past for pre-surgical planning of a dental implant. However, overlaid ghost artifacts, high doses of radiation, and the high cost of operation have been many of the relevant disadvantages. The ability of CBCT to characterize mandibular and alveolar bone morphology, visualize the maxillary sinuses, incisive canal, mandibular canals, mental foramina and all structures important to implant treatment planning is a big advantage for this imaging modality [1].

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Citation: Adibi S, Zhang W, Servos T, ONeill P (2012) Cone Beam in Dentistry: What a Practitioners Must Know. Dentistry 2:115. doi:10.4172/21611122.1000115

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In a study published by Georgescu and colleagues [11] in 2010, CBCT was evaluated as a method of quantitative and qualitative analysis of the alveolar crest in the anterior mandibular area. It was concluded that CBCT permits the clinician to have all necessary information when planning dental implants. Additionally, in a study published by Parnia et al. [24] in 2010, it was established that the depth of the submandibular fossa was more than 2 mm in 80% of patients. Therefore, it can be concluded that this could be a contributory factor to an increased risk of an inadvertent perforation of the lingual cortical plate or the possibility of injuries to the terminal branch of the sublingual artery during implant fixture placement if a cross sectional image is not obtain pre-surgically [24]. In another study published by Stuart Froum and colleagues [25] in 2010, for immediate implant placement in the posterior mandible, it was concluded that it is advisable to take a CT scan prior to extraction in order to evaluate all treatment options available, as well as being able to anticipate and avoid potential complications while fully informing the patient of the risks of each option. In a study published by Philip Worthington and colleagues [21] in 2010, a chart consisting of a comparison of the implant imaging modalities commonly used to evaluate implant sites was presented. CBCT exceeded all imaging modalities, with only the category of bone quality was inferior to conventional CT. It was concluded that CBCT provides the anatomical data that can generate a collaborative treatment plan and achieve an optimal outcome for the restorative dentist, radiologist, surgeon and patient, leading to an increase in the precise implant treatment plan and a decrease of the associated risks. Even though the documentation is limited, CBCT provides the implant dentist with controlled surgical plan. This improved surgical plan increases the precision of the implant placement as well as reduces the possibility of surgical mishap. Therefore, the general clinical outcome will improve.

Many unusual and rare calcifying lesions such as calcifying cystic odontogenic tumor (CCOT) can be examined in 3D images produced by CBCT for their particular variations, which was not possible with previous conventional radiographical images. In particular, CBCT is very useful for evaluation of intra-osseous lesions that are in proximity with vital organs and vasculature in the head and neck region [30]. A preliminary study published by Dr. Hendrikx et al. [31] in 2010 revealed that CBCT cannot be used to predict invasion or erosion of oral squamous cell carcinoma (OSCC) to the mandible. The authors provided insight as the possibility of using dynamic contrast enhanced (DCE)-magnetic resonance image (MRI) combined with CBCT for the assessment of OSCC. This will lead us to a fewer number of segmental defects, composite flap surgeries, and reconstructive surgeries, even though reliability of CBCT to detect invasion of OSCC is still under evaluation [31]. It would be safe to say that the application of CBCT for craniofacial pathology and surgery is in its infancy stage. Many more results from evidenced-based studies are to come in the near future to expand the role of CBCT in oral and maxillofacial pathology and surgery.

Orthodontics
Inexpensive office-based CBCT imaging has recently been explored and advocated for applications in orthodontics, such as assessment of palatal bone thickness, skeletal growth pattern, upper airway evaluation for possible obstructions, and evaluation of severity of impacted teeth. These are just some of the many indications for CBCT in orthodontics. The ability to produce 3D images with low radiation dose puts CBCT in favor over conventional multi-section CT [32,1]. The use of a CBCT appears to be a favorite as a diagnostic and communication tool for cases of impacted teeth in the mixed dentition that are candidates for orthodontic therapy [33]. It has been recognized for its ability to produce 3D cephalometric images and as being the new norm in orthodontics [34]. In a study published by Dr. Evangelista [35] to compare the presence of alveolar defects among class I and class II mal-occlusion patients, it was noted that CBCT was especially useful for treatment planning of orthodontic cases which need buccal tooth movement and arch expansion. Simulation of virtual patient with CBCT 3D hard and soft tissue segmentation along with superimposition photographs will enable orthodontics and all other related specialists to interact with the disease model and improve the diagnostic and therapeutic outcomes [36]. Vandana Kumar conducted an in vivo comparison study on conventional vs. CBCT synthesized cephalograms. The author concluded that synthesized cephalometic images from CBCT may be used to delineate ambiguous visual landmarks such as porion, to avoid measurement inaccuracy occurred on conventional cephalogram. In many cases, cephalometric reconstruction can be recommended as an alternative to conventional cephalograms when a CBCT volume is already available. This reduces the need for additional radiation exposure and examination expenses [37]. Traditionally, orthodontists will order panoramic and cephlametric radiographs as the baseline standard for diagnostic and treatment planning purposes. These images are not without their shortcomings. In many cases, orthodontist will have to order additional images to verify clinical and/or radiological findings. Since CBCT images are much more accurate than the other two, it looks like CBCT should be ordered in the first place for many orthodontic cases.

Oral and maxillofacial pathology and surgery

A combination of low radiation dose, high quality bony definition, and compact design requiring minimum space has made CBCT desirable as an in-office imaging system for examination of the pathology in the head and neck, extra-cranial, paranasal, and temporal bone region. Examination of fractured teeth and bone seem to be a logical application for CBCT. Evaluation of post-surgical complications such as losing screws or mandibular fracture fixation can be achieved with CBCT due to the low level metal artifact [1]. CBCT is recommended when there is a need for diagnosis of a cyst, tumor or infections in alveolar process and jaw bone [30]. In many situations, a CBCT study enables the surgeon to produce a more conservative treatment plan and approach. For instance, in a case report published by Marcelo c. Bortoluzzi [26] in 2010, it demonstrated that a CBCT examination provided an intraoral approach that was more conservative and less traumatic to the patient. In another study published by Dr. Szucs et al. [27] in 2010, the authors advocate a CBCT examination for complicated third molar extractions. This alternative approach to extractions would reduce the possibility of iatrogenic fractures of the mandible. Researchers have made many strides to translate computer-assisted virtual treatment planning to actual clinical practices for orthognathic surgery for oral and maxillofacial deformities. Once being more cost effective, CBCT and the 3D virtual software will become an excellent clinical tool for treatment planning of these types of lesions [28,29].
Dentistry ISSN: 2161-1122 Dentistry, an open access journal

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Citation: Adibi S, Zhang W, Servos T, ONeill P (2012) Cone Beam in Dentistry: What a Practitioners Must Know. Dentistry 2:115. doi:10.4172/21611122.1000115

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Temporomandibular Joint
The advancement of CBCT technology has inspired many researches in TMJ imaging. Changes in TMJ can be evaluated using magnetic resonance imaging (MRI), CT, and conventional 2D radiographs. Studies are underway to evaluate the reliability of CBCT on clinical assessment of TMJ [1,38]. In a study published by Huntjens et al. [39] in 2008, it was demonstrated that condylar volume and shape can be measured accurately using CBCT-based method, knowing that there are several distortion factors and errors in conventional radiography. Balasundaram and colleagues [40] demonstrate that CBCT is a new imaging technology that is able to diagnose maxillofacial anomalies such as synovial chondromatosis of the TMJ, with a radiation dose as low as reasonably achievable. CBCT images are not perfect for soft and cartilage tissues, or joint diagnosis. However, when examining the hard tissues of the TMJ, such as articular eminence and head of the condyles, CBCT can provide invaluable information for diagnosis and treatment planning of many types of TMJ diseases.

utilization for dental offices. Depending on the manufacturer and model, a CBCT can range from $90,000 to $300,000. It appears that at this time only the multi-provider offices can afford this technology for patient care. However, this will change in near future. More than 3,000 CBCT units have been purchased in the U.S.A. and 800 units in Germany. Will this allow the practitioners to achieve a return on investment? Will it cause unethical over-prescription of procedures? [6,45]. The belief that financial incentives have undermined the clinical decision-making process in an unethical way has triggered legislation on limiting Medicare payments for self-referral services. Many states mandate a regulatory certificate of need (CONs) documenting sufficient demand before a technology can be certified to operate in a facility [1]. CBCT allows the clinician to have an accurate three dimensional images of the position of the teeth and areas of interest that aids both orthodontist and oral surgeon. However, although CBCT is a useful tool in the clinicians armamentarium, it is essential that they are used when conventional means of radiography is unlikely to provide the needed information [46]. Ethical and legal considerations on emerging CBCT instruments do not differ from other technological trends such as laser and robotic surgeries. Only after all ethical pitfalls concerning CBCT are sufficiently addressed, will the dental profession be able to uphold higher standards than before. Therefore, they should document well and refer when faced with a condition outside of their training and practice comfort zone. Additionally, oral health professionals must embark on extensive training to meet the challenge of the emerging todays digital technology in dentistry.

Endodontics
Periapical pathology due to failed root canal therapy, dentoalveolar trauma, and pre-surgical planning has been a few reasons for CBCT examination. In many retrospective studies, CBCT has been suggested as superior to periapical radiographs when the radiolucent lesion is in close proximity to the maxillary sinus and/or the sinus membrane is involved, or when the lesion is in close proximity to the mandibular canal [1]. In another study published by Brito-junior and colleagues in 2010, it was concluded that the use of accurate imaging such as CBCT could be important in early diagnosis of a perforated defect due to internal root resorption which need nonsurgical endodontic management and long term follow up [41]. In a review article published by Dr. Scarfe and colleagues [42] in 2009, after a comparison of conventional two dimensional imaging and current available CBCT, the authors commented that conventional intraoral radiography will provide clinicians with cost effective and high resolution imaging; however, CBCT imaging can no longer be disputed and has a valuable and an important role in todays endodontic evaluation. In a clinical study carried in Turkey, CBCT was determined to be a precise imaging modality to measure the length and width of root canal, prevent iatrogenic exposure of the apex, and improves prognosis of root canal therapy [43]. When order CBCT to evaluate a suspicious periapical lesion, or already failed root canal therapy, it is important to select the right parameters, such as a voxel size of 0.125 mm, to achieve a diagnostic quality image.

Conclusion
Although many studies have favored the application of CBCT in dentistry, there are no multi-center double blind clinical trials for CBCT, which is known as the gold standard for evidence-based studies. CBCT appears to have a promising future, and its utility in dentistry will depend on the results of studies that are currently underway. The amount of existing literature for the past decade has been very encouraging for this imaging modality. However, there is a need for more training along with more protection of the profession and the public. Authors of this article have acknowledged that by the time this article is published, many more findings and indications for application of CBCT in dentistry will come out, and hopefully they will be proven by evidenced-based clinical trials eventually. Review of many recent publications reveals that CBCT is here to stay and play an integral role in treatment planning. Additionally, at this point, we conclude that if used judicially, its benefits would outweigh the inherent risks. Finally, we should advocate more professional education and training on this emerging imaging technology. Meanwhile, nothing should keep clinicians from continuing sound practices and practical clinical applications of this extra ordinary emerging technology.
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Periodontics
CBCT has been used to pre-cut and prepare absorbable membrane for placement in interproximal bony defects. It helps to select the optimal shaped membrane and shorten the time for the guided tissue regeneration, which contribute to excellent clinical outcomes [44]. CBCT has been used in the evaluation of intrabony defects and furcation involvements. Studies on the evaluation of the periodontal ligament and lamina dura using CBCT, conventional CT, and conventional radiographs have had mixed results [1].

Ethical and Legal

High cost of CBCT is another factor to be considered on its
Dentistry ISSN: 2161-1122 Dentistry, an open access journal

Volume 2 Issue 1 1000115

Citation: Adibi S, Zhang W, Servos T, ONeill P (2012) Cone Beam in Dentistry: What a Practitioners Must Know. Dentistry 2:115. doi:10.4172/21611122.1000115

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