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org on August 12, 2009

Advancements in digital imaging
What is new and on the horizon?
W. Bruce Howerton Jr., DDS, MS; Maria A. Mora, DDS, MS

ithin the last 20

W years, diagnostic
digital imaging
modalities in den-
tistry, including
periapical, bitewing, panoramic and
cephalometric imaging, have been
replacing conventional (film-based)
radiography. Drawbacks of two-
dimensional (2-D) imaging include
inherent magnification, distortion
and overlap of anatomy.1
As early as the 1920s, manufac-
turers attempted to overcome the
inherent problems of 2-D imaging
by devising movement of the
receptor and source in opposite
directions to produce tomographic
“slices” of oral and maxillofacial
anatomy; this process is termed
“linear” or “multidirectional tomog-
raphy.” In the 1990s, researchers
used software to reconstruct 2-D
images of an object from random
angles and distances into a three-
dimensional (3-D) image in a
process termed “tuned-aperture
ABSTRACT
Background and Overview. Cone beam computed tomography
(CBCT) is a diagnostic imaging technology that is changing the way
dental practitioners view the oral and maxillofacial complex. CBCT
uses radiation in a similar manner as does conventional diagnostic
imaging and reformats the raw data into Digital Imaging and Com-
munications in Medicine (DICOM) data. DICOM data are imported
into viewing software that enables the manipulation of multiplanar
reconstructed slices and three-dimensional volume renderings.
DICOM data also may be used in third-party software to aid in dental
implant placement, orthognathic surgery and orthodontic assessment.
Conclusions and Clinical Implications. The information
gained from using CBCT requires careful interpretation to achieve
optimum results for the patient and provider.
Key Words. Computed tomography; oral and maxillofacial radiog-
raphy; digital radiography; dental radiography.
JADA 2008;139(6 supplement):20S-24S.
Dr. Howerton is in private practice in oral and maxillofacial radiology, Carolina OMF Imaging, 3200
Blue Ridge Road, Suite 218, Raleigh, N.C. 27612, e-mail “bhowerton@carolinaomfimaging.com”.
Address reprint requests to Dr. Howerton.
Dr. Mora is in private practice in oral and maxillofacial radiology, Carolina OMF Imaging, Raleigh, N.C.

20S JADA, Vol. 139 http://jada.ada.org June 2008

Copyright © 2008 American Dental Association. All rights reserved.
computed tomography” (TACT) (Wake Forest
University, Winston-Salem, N.C.).1 Abreu and col-
leagues2 found that the diagnostic performance of
TACT imaging was comparable with that of
bitewing images with regard to detecting proxi-
mal caries in vitro.
Within the past decade, technology termed
“cone beam computed tomography” (CBCT) has
evolved that allows 3-D visualization of the oral
and maxillofacial complex from any plane. This
imaging modality eliminates the shortcomings of
2-D imaging, produces a smaller radiation dose
than that produced by medical CT and enables
clinicians to make more accurate treatment plan-
ning decisions, which can lead to more successful
surgical procedures.3,4 In this article, we describe
how CBCT works, describe its use in dentistry
today and envision how it will be used in the
future.
CONE BEAM COMPUTED TOMOGRAPHY
How CBCT works. Currently available CBCT
units include the following: 3D Accuitomo FPD
XYZ Slice View Tomograph (J. Morita USA,
Irvine, Calif.), 3D X-ray CT Scanner Alphard
Series (Asahi, Kyoto, Japan), Quolis Alphard
Alphard-3030-Cone-Beam (Belmont Equipment,
Somerset, N.J.), CB MercuRay (Hitachi Medical
Systems America, Twinsburg, Ohio), Galileos 3D
(Sirona Dental Systems, Charlotte, N.C.), i-CAT
(Imaging Sciences International, Hatfield, Pa.),
Iluma Ultra Cone Beam CT Scanner (Care-
stream, Rochester, N.Y.), NewTom 3G and VG
(AFP Imaging, Elmsford, N.Y.), Picasso (E-woo
Technology, Houston), PreXion 3D (TeraRecon,
San Mateo, Calif.), ProMax 3D (Planmeca USA,
Roselle, Ill.) and Scanora 3D (Soredex, Tuusula,
Finland). In addition, some digital panoramic
radiographic systems include CBCT technology.
Although all CBCT units provide 3-D informa-
tion, each manufacturer uses slightly different
scanning parameters and viewing software. For
example, patients may sit, stand or be supine,
depending on the CBCT unit. The radiation beam
is 3-D in shape and similar in photon energy to
that used in conventional and digital radiog-
raphy. The receptor captures 2-D images and is
solid-state (digital) or an image intensifier. Solid-
state receptors absorb photons that are converted
to an electric charge, which is measured by the
computer. One advantage of solid-state receptors
is improved photon utilization; one disadvantage
is the high cost of production. Image intensifiers
Copyright © 2008 American Dental Association. All rights reserved.
capture photons and convert them to electrons
that contact a fluorescent screen that emits light
captured by a charge-coupled device camera.
As the source and receptor rotate once around
the patient, many exposures are made, ranging in
duration between 8.9 and 40 seconds. The soft-
ware “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) (National Electrical Manufac-
turers Association, Rosslyn, Va.) data format.5
DICOM is a standard for handling, storing,
printing and transmitting information in medical
imaging. During a single rotation of the source
and receptor, the receptor captures the entire
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volume of anatomy within the field of view.
Medical CT differs in that it uses a fan-shaped
beam and captures portions or slices of anatomy
as the source and receptor move along the long
axis of the section of anatomy being examined.
The clinician imports the DICOM data into
viewing software, enabling him or her to see
axial, coronal and sagittal multiplanar recon-
structed images of the volume, as well as 3-D
volume renderings. One advantage of using a
DICOM data format is that the dentist can make
precise measurements in any plane within the
viewing software. DICOM viewers are available
readily and can be downloaded from the Internet
free of charge or purchased from third-party
retailers. Figure 1 shows examples of images pro-
duced with a third-party DICOM viewer.
Another important advantage of CBCT over
medical CT is that the amount of radiation
received by the patient is markedly less than the
dose received with medical CT units. Ludlow and
colleagues6 reported that the effective dose equiv-
alent measured after an exposure using indirect
digital panoramic imaging was 6 to 7 microSiev-
erts. (The effective dose equivalent is the amount
of radiation received after taking into account the
tissue’s sensitivity to radiation.7 It is calculated
by multiplying the dose received by the organs by
a weighting factor that represents the organs’
sensitivity. One sums up the various doses to
ABBREVIATION KEY. CBCT: Cone beam computed
tomography. CT: Computed tomography. DICOM:
Digital Imaging and Communications in Medicine.
TACT: Tuned-aperture computed tomography.
3-D: Three-dimensional. 2-D: Two-dimensional.
JADA, Vol. 139 http://jada.ada.org June 2008 21S
A B
Figure 1. OnDemand3DApp software (CyberMed, Seoul, South Korea). A. Hard-tissue evaluation for dental implant planning. B. Three-
dimensional (3-D) volume rendering of the anatomy captured within the field of view. C. Sculpting of the 3-D volume rendering with soft-
tissue overlay (in this case, the airway space).
obtain the effect on the body.) The effective dose
equivalent measured using CBCT is between 30
and 400 µSv,6 depending on the manufacturer
and technical factors involved. This compares
with an effective dose equivalent of 2,100 µSv
from a conventional medical CT scan of the max-
illa and mandible.6
Uses in dentistry. Dentists can use the infor-
mation obtained from the data to evaluate hard
tissues for possible dental implant placement
and/or grafting, orthodontic treatment planning,
temporomandibular joint complex evaluation,
pathosis evaluation, demonstration of anatomic
variations and evaluation of patients who have
experienced trauma. CBCT can aid in presurgical
planning for dental implant placement by local-
izing the anatomy to be avoided during surgery,
measuring bone volume precisely and assessing
the quality of hard tissue.
In orthodontics, CBCT can improve clinicians’
evaluation of impacted canines and delayed tooth
eruptions in relationship to adjacent teeth. In fact,
a recent study8 demonstrated that, as a result of
using CBCT, clinicians altered more than one-half
of treatment plans involving canine-related diag-
noses. Also, dentists can view the temporo-
mandibular joint complex without interference
from surrounding dense temporal bone to demon-
strate erosion, osteophytic formation of the
condyle or both. In endodontics, it is difficult at
times for clinicians to evaluate the extent of infe-
rior cortical border erosion of the maxillary sinus
or of associated mucosal thickening extending to
the periapical region of the roots of maxillary
teeth using 2-D periapical imaging owing to super-
imposition of structures. At spatial resolutions of
300 micrometers (0.3 millimeters) and less,
images produced with CBCT show the position of
the apexes of roots of maxillary teeth extending to
22S JADA, Vol. 139 http://jada.ada.org June 2008
Copyright © 2008 American Dental Association. All rights reserved.
C
the nasal cavity and maxillary sinus, as well as
cortical border erosion of these structures
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resulting from apical rarefying osteitis.9
DICOM format. Clinicians also can import
the DICOM data format into third-party software
that serves as an adjunct in treatment planning.
For example, SimPlant (Materialise Dental NV,
Leuven, Belgium) dental implant computer-
guided software converts DICOM data into a file
that provides information for presurgical plan-
ning. The software incorporates computer-aided
design/computer-aided manufacturing replicas of
dental implants for the clinician to place into the
region of interest. The clinician sends the file to a
manufacturing facility, which creates a surgical
guide through a process termed “stereolithog-
raphy.” The guide includes metal cylinders that
direct osteotomy drills into precise locations in
the maxilla and/or mandible, as planned by the
software.
Another computer-guided software that uses
CBCT data (Procera Software 2.0, Nobel Biocare
USA, Yorba Linda, Calif.) allows the dentist to
place dental implants by using a surgical guide
(NobelGuide, Nobel Biocare USA) and a fixed
prosthesis during a single dental visit. Other
examples of third-party computer-guided DICOM-
compliant software are EasyGuide (Keystone
Dental, Burlington, Mass.), ImplantMaster
(iDent, Ft. Lauderdale, Fla.) and VIP Virtual
Implant Placement Software (Implant Logic Sys-
tems, Cedarhurst, N.Y.). Because different practi-
tioners often are responsible for the placement
and restoration of dental implants, this tech-
nology enhances communication between practi-
tioners, as well as patients’ understanding and
education. DICOM-compliant software also aids
in orthognathic surgery and 3-D cephalometric
analysis.
Figure 2. Images created with Dolphin 3D software (Dolphin Imaging & Management Solutions, Chatsworth, Calif.). With this software,
three-dimensional objects can be prepared by using preset intensity levels of soft and hard tissue. Once this is accomplished, the clinician can
view the object’s skeletal or soft-tissue surfaces by themselves or together. (Reprinted with permission of Dolphin Imaging & Management
Solutions, Chatsworth, Calif.).
Disadvantages of CBCT. Because radiation
from the source is transmitted through tissues in
the body, the receptor receives nonuniform infor-
mation from radiation scattered in many direc-
tions; this is termed “noise.” In addition, radiation
is attenuated when passing through dense objects
(such as nonprecious alloys in metal restorations,
crowns and titanium materials). Sometimes, radi-
ation is attenuated completely and does not reach
the receptor. When this “radiation-less” informa-
tion is reconstructed, streak artifacts in images
are formed that can obstruct the surrounding
anatomy. Manufacturers attempt to remove noise
and streak artifacts during reconstruction of the
raw data by using their own specific algorithms
and filters.10 Another form of image degradation
is motion artifact, which occurs when a patient
moves during the scanning process. Practitioners
can reduce patient movement by using head-
stabilizing devices and by providing oral instruc-
tions to the patient to remain still during the
scanning process.
Cost. The high cost of CBCT technology pro-
hibits its use in most dental offices. CBCT
machines can range in cost from $150,000 to
$300,000. Thus, purchasers of this technology
typically work in a multidentist practice or an
imaging center servicing a dental community.
Training. Many practitioners who incorporate
this technology into their practices have not had
the training required to interpret anatomy
beyond the maxilla and mandible using 2-D mul-
tiplanar images reconstructed into three dimen-
sions. They need to recognize calcifications within
the cerebral hemispheres, paranasal sinuses and
oropharyngeal regions, as well as soft-tissue
asymmetries. Clinicians must exercise care and
draw precise image layer curves, resulting in
orthogonal slices that allow correct measurement
of anatomical relationships. Also, time and skill
Copyright © 2008 American Dental Association. All rights reserved.
are required to create 3-D volume images that
confirm 2-D relationships. To ensure the correct
and safe use of this technology, educational insti-
Downloaded from jada.ada.org on August 12, 2009
tutions are incorporating CBCT into their cur-
ricula, and continuing education courses are
being offered to help dental practitioners use and
interpret DICOM data.
In 1999, the American Dental Association rec-
ognized the specialty of oral and maxillofacial
radiology.11 Presently, two-year certificate and
three-year master’s-level graduate dental spe-
cialty programs are offered.12 Oral and maxillofa-
cial radiologists are trained to interpret hard-
tissue changes within the oral and maxillofacial
complex, and they may distinguish themselves by
becoming diplomates of the American Board of
Oral and Maxillofacial Radiology. The American
Academy of Oral and Maxillofacial Radiology has
stated that CT and implant imaging should be
performed only by a board-certified oral and max-
illofacial radiologist or a dentist with adequate
training or experience.13
THE FUTURE OF DIAGNOSTIC IMAGING
The future of diagnostic imaging using DICOM
data is bright. For example, DICOM-compliant
software known as “volumetric imaging software”
is being used in orthodontics to merge photo-
graphic images with radiographic images so that
clinicians can assess true soft- and hard-tissue
relationships, as shown in Figure 2. Companies
providing this technology include Anatomage
(San Jose, Calif.), Dolphin Imaging & Manage-
ment Solutions (Chatsworth, Calif.) and
Materialise Dental NV.
For example, consider a patient with a congen-
ital deformity in the oral and maxillofacial region,
malocclusion and missing teeth. Using DICOM-
compliant software, the oral surgeon, orthodon-
tist, implantologist and restorative dentist can
JADA, Vol. 139 http://jada.ada.org June 2008 23S
link their communication such that pretreatment
expectations equal posttreatment results.
Finally, dental imaging centers staffed with
board-certified oral and maxillofacial radiologists
will become more commonplace, providing patient
care that includes acquisition, interpretation and
conversion of DICOM data. In addition, oral and
maxillofacial radiologists will be charged with
educating the private practice dental community
about the advantages of using DICOM data for
better patient care.
CONCLUSION
Two-dimensional diagnostic imaging has served
dentistry well and will continue to do so for the
foreseeable future. However, the advent of CBCT
allows complete visualization of the oral and max-
illofacial complex. Through education regarding
the correct interpretation of data and training in
the scanning process, better treatment planning
and surgical treatment will result. The future of
this technology lies within an increased number
of imaging centers staffed with oral and maxillo-
facial radiologists who understand the needs of
dentists, as well as the benefits of using DICOM-
compliant software. 
Disclosure. Drs. Howerton and Mora did not report any disclosures.
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