Basi c Pri nci pl es of

Cone Beam Computed

Tomography
Kenneth Abramovitch, DDS, MS*, Dwight D. Rice, DDS
INTRODUCTION
Imaging with cone beam technology has rapidly become a popular and frequently
used imaging modality to assist dentists and other health care professionals in a multi-
tude of diagnostic tasks to improve patient care.
Cone beam imaging technology is most commonly referred to as cone beam
computed tomography (CBCT). The terminology cone beam refers to the conical
Loma Linda University School of Dentistry, 11092 Anderson Street, Loma Linda, CA 92354, USA
* Corresponding author.
E-mail address: kabramovitch@llu.edu
KEYWORDS

Cone beam computed tomography

Flat-panel silicon detector

DICOM viewer software

Beam-hardening artifacts
KEY POINTS
The use of cone beamcomputed tomography (CBCT) imaging in the dental profession has
blossomed since its inception 15 years ago. CBCT unit design has undergone many
changes that enhance CBCT access and practical utility in dentistry. The scanners have
become smaller, scan patients in an upright position, use primarily flat panel detectors,
and readily convert projection data to DICOM file formats. Units themselves have various
scanning options that include the size of the area to be scanned (field of view [FOV]), voxel
size (spatial resolution), bit depth (contrast resolution), and scan times (frame rate).
CBCT manufacturers have incorporated various aspects of imaging technology in a cost-
effective, efficient, and practical manner. There are now numerous CBCT applications in
many software formats that are helpful in a multitude of dental disciplines including but not
limited to dentoalveolar disease and anomalies, vertical root and dentin fractures, jaw tu-
mors, prosthodontic evaluations, and advances in orthodontic/orthognathic and implant
patient evaluations. The latter also include mechanisms for surgical and prosthodontic
splint design and the capability of CBCT scan data to bridge with computer-aided
design/manufacturing image files for the fabrication of various dental restorations.
Streaking and beam hardening remain as ominous imaging artifact that compromise
CBCT utility in various case situations. However, because of the popularity of CBCT, com-
puter hardware and software developers, machine manufacturers and dental researchers
will continue to improve the applications of this imaging modality for the betterment of pa-
tient care.
Dent Clin N Am 58 (2014) 463484
http://dx.doi.org/10.1016/j.cden.2014.03.002 dental.theclinics.com
0011-8532/14/$ see front matter 2014 Elsevier Inc. All rights reserved.
shape of the beam that scans the patient in a circular path around the vertical axis of
the head, in contrast to the fan-shaped beam and more complex scanning movement
of multidetector-row computed tomography (MDCT) commonly used in medical
imaging.
First introduced at the end of the millennium,
1,2
CBCT heralded a new dental tech-
nology for the twenty-first century. Its practical applications for implant dentistry and
orthognathic/orthodontic patient care were the main applications at that time. Owing
to the dramatic and highly positive impact that CBCT had on these disciplines, addi-
tional applications for this technology became apparent. New software programs
were developed to improve the applicability and access of CBCT for the care of dental
patients.
Two factors played a big part in the rapid incorporation of CBCT technology into
dentistry, the first of which was the availability of improved, rapid, and cost-
effective computer technology. The second was the ability of software engineers to
develop multiple dental imaging applications for CBCT with broad diagnostic
capability.
CBCT VERSUS COMPUTED TOMOGRAPHY
CBCT, by virtue of the terminology, is a formof computed tomography (CT). In a single
rotation, the region of interest (ROI) is scanned by a cone-shaped x-ray beam around
the vertical axis of the patients head. Digitized information of objects in the ROI such
as shape and density is acquired from multiple angles. These imaging data are then
processed by specialty software that ultimately constructs tomographic images of
the ROI in multiple anatomic planes, namely the standard coronal, axial, and sagittal
anatomic planes (Fig. 1) and their various paraplanar derivatives, the parasagittal, par-
acoronal and para-axial planes.
The historically standard and more sophisticated form of CT, present since the
1970s, was developed in part by British engineer and Nobel Prize winner Sir Godfrey
Hounsfield. It is of interest that by the end of the decade, the technology of Houns-
fields first scanner was followed by the development of a larger body scanner by a
group of researchers in the United States headed by American dentist and physicist
Robert S. Ledley.
3
This more advanced form of CT is known as MDCT, although other
terms such as multislice CT and multirow CT are used. Because MDCT is more
commonly used in medicine, it is often referred to as medical CT. However, this
Fig. 1. Standard anatomic planes of imaging used for multiplanar reconstructions in cone
beam computed tomography (CBCT) and multidetector-row computed tomography.
(Modified from Washington CM, Leaver DT. Principles and practice of radiation therapy.
Philadelphia: Mosby; 2004.)
Abramovitch & Rice 464
term is a misnomer, as CBCT is now also being used and further modified for patient
evaluations in medicine.
4,5
A more appropriate term for MDCT might be conventional
CT. Differences between CBCT and MDCT have been widely reported.
69
However,
owing to the specific advances and innovations of CBCT technology for the care of
dental patients, it has become and will remain a vital and significant imaging modality
in dentistry.
HISTORICAL DEVELOPMENT OF CBCT UNITS
During the early development of CBCT, the technology was being advanced primarily
for the dental office. Subsequently, many of the earlier units were modified to include
designs that more readily fit within dental offices and clinics. The integration of CBCT
imaging in dentistry has in some ways paralleled the transition of panoramic imaging
x-ray machines into dental offices. Early panoramic units were mainly sit-down,
10,11
but there was also a lay-down unit.
12
Several other sit-down machines were manufac-
tured, but eventually units were made whereby the patient could stand upright for the
panoramic exposure. Upright machines became preferable, as it is more convenient
and takes less time to transfer patients into and out of these stand-up panoramic units.
The physical size and shape of CBCT units has paralleled this panoramic pathway.
One of the very first commercially available cone beam machines, the NewTom 9000
(QR srl, Verona, Italy), was a large unit that scanned the patient lying in a supine posi-
tion. It was followed by the NewTom3G(Fig. 2A). These early NewTomunits eventually
lost favor to smaller, sit-down chair units or to stand-up units. These smaller units with
better scanner quality more readily fit into dental office space and overhead budgets
(see Fig. 2BF). Despite the previous drawbacks of the NewTom prototypes, CBCT
units that scan patients in a supine position have made a comeback; the NewTom
5G (QR srl) and the SkyView (MyRay, Imola, Italy) are currently available. These units,
with upright patient loading and supine position for patient scanning, are presented in
Fig. 2GH. NewTom is also producing standing machines such as the VGi.
EFFECT OF FIELD OF VIEW ON SCANNER TYPE
The size of the scanned object volume is called the field of view, commonly abbrevi-
ated as FOV. The FOV for units with a flat-panel detector (see later description) is a
cylindrical shape in the center of the scanner between the detector and the x-ray
source. The CBCT scanning controls are programmed to scan an FOV of sizes and
areas that are built into the scanner by the manufacturer. Other factors that affect
the FOV are the size and type of the detector and the degree of beam collimation
on the x-ray tubehead. Fig. 3A demonstrates how the dimensions of a flat-panel
detectors FOV cylinder are expressed by the height of the cylinder (H) and the diam-
eter of the base (D). The FOV is a very flexible option in contemporary scanners. The
range of commercially available FOVs for flat-panel detectors can be from3.0 cm(H)
3.0 cm (D) to 24 cm (H) 16.5 cm (D) (Table 1).
The FOV for image-intensifier detectors is shaped differently, not as a cylinder but
rather as a sphere. The dimensions are usually measured by the diameter of the circu-
lar shape in inches (eg, 6
00
, 9
00
, 12
00
).
The size of the FOV significantly affected the evolution of the CBCT scanner. Early
CBCT units were restricted to a single-size FOV that was either large or small, which
limited the usefulness of the scanner. The general rule was the larger the FOV, the
greater the cost of the scanner. The higher cost is attributed to the larger detector
size and the larger kilovoltage (kV) generator needed for imaging denser parts of the
skull for orthognathic and orthodontic evaluations. The FOV most typically included
Basic Principles of Cone Beam CT 465
the jaws, midface, and skull base. Some had options that included a more extended
part of the skull toward the vertex, that is, 40 cm(H). Because of the limited indications
and increased cost, the larger FOVs were not as popular for limited dentoalveolar ap-
plications. Smaller FOV units large enough to image 2 to 4 teeth of a jaw(either maxilla
or mandible) was another earlier scanner option. The area covered in these smaller
volumes is adequate for a thorough 3-dimensional (3D) periapical evaluation of
selected teeth, alveolar bone, and a limited amount of maxillary or mandibular basal
bone. Contemporary scanners are now capable of a range of FOVs (see Fig. 3B)
from the smaller 3.0 cm (H) 3.0 cm (D), to the midrange FOVs for coverage of one
or both jaws, to the larger FOVs that include the cervical spine, jaws, more of the para-
nasal sinuses, skull base, and parts of the cranium. Larger FOVs that include superior
areas of the skull are not usually indicated for most dental applications.
Because of these technological improvements and enhancements, CBCT is now
readily identified as part of the imaging equipment in modern dental clinics. Table 1
lists many of the currently available CBCT units with larger FOV capabilities along
with notations of some of their other options. Table 2 is a similar listing of units with
Fig. 2. (A) NewTom 3G. This supine CBCT scanner was one of the first commercially available
units in North America. It was replaced by units that scanned patients seated with the head in
an upright position. (B) The Accuitomo 170 (J. Morita USA, Irvine, CA). (C) The Scanora 3Dx
(Soredex, Milwaukee, WI). (D) The CS 9300 (CarestreamHealth, Rochester, NY). (E) The Ortho-
phos XG 3D (Sirona USA, Charlotte, NC). (F) The i-CAT FLX (Imaging Sciences International,
Hatfield, PA). (G) The NewTom 5G in patient entry (left) and patient scan (right) positions.
This unit is currently manufactured by QR srl, Verona, Italy. (H) The SkyView CBCT scanner
(MyRay, Imola, Italy) in patient entry (left) and patient scan (right) chair positions.
Abramovitch & Rice 466
mediumto smaller FOV options. Because of the constant modifications in CBCT scan-
ner technology, manufacturers, and machine trade names, the information in these
tables is time sensitive and only current at the time of publication. For additional infor-
mation, other listings may also be referenced.
1315
FEATURES OF THE IMAGING PROCESS
Image Capture
As in any radiographic imaging system, CBCT requires x-ray production, x-ray atten-
uation by an object, signal detection, image processing, and image display. These
Fig. 2. (continued)
Basic Principles of Cone Beam CT 467
parameters are vital to all aspects of dental imaging, but they are understandably more
sophisticated for CBCT.
During a rotational scan of an object, multiple exposures are taken at fixed intervals
(angles) of the rotation. Each of these exposures is referred to as a basis image. The
images are standard radiographic images captured on the detector, and the signal of
each projection is unique for each of the different angles in the rotational arc. Instan-
taneously the image data for each basis image are sent to a data-storage area so that
the detector can be cleared to capture the next basis image at a position interval
further along the rotational arc. Once the rotation is complete and all the basis im-
ages are made, the complete set of basis images forms the projection data. The
total number of basis images taken depends on the radiographers preferences
and the scanners capability. This total ranges from 100 to 600 basis images per
scan. The greater the number of basis images, the longer the scan time, the greater
the radiation dose, and the better the quality of the constructed images. Fig. 4 dem-
onstrates a hypothetical scheme for projection-data formation with the capture of 2
basis images.
Imaging Software and Data File Management
Image reconstruction software programs, usually proprietary to each machine manu-
facturer, then manage the projection data and construct a 3D volumetric data set.
These processed data are then accessed to construct various types of images for
display. The choice of images constructed depends on the power of the imaging soft-
ware and the needs and preferences of the clinician. The image selection from3Dsoft-
ware is not limited to a single type of image display. Depending on the capability of the
software, there are multiple options of image construction fromthe 3D volumetric data
set. Most scanner programs display a primary image reconstruction of the object in
the 3 anatomic planes of imaging: the axial, sagittal, and coronal planes. These pri-
mary reconstruction displays are also referred to more typically as the multiplane or
multiplanar images. Primary multiplanar reconstructions from 2 different software pro-
grams are presented in Fig. 5. The same volumetric data set can be used to also
construct multiple kinds of secondary reconstructions. The choice of secondary
Fig. 3. (A) Cylindrical shape and measurement characteristics of the field of view (FOV)
for CBCT. (B) The different FOV option sizes from the Vatech CBCT (Vatech America,
Fort Lee, NJ). Many CBCT units now have the capability of scanning a range of FOV sizes.
Abramovitch & Rice 468
reconstruction is often task specific, and is also related to the reconstruction options
within the scanners proprietary software.
At present, a variety of independent third-party imaging software is commercially
available for image reconstruction of CBCT volumetric data sets. Third-party imaging
software is software not associated with the capture and proprietary software of the
CBCT scanner. A limited selection of third-party software is listed in Table 3.
If third-party software is being used, the file format of the volume set must be con-
verted from the proprietary file format or file language to a more universal or common
digital file format. This common format must be conformant with the Digital Imaging
and Communications in Medicine standard (DICOM 09v11dif); that is, the current
DICOM standardized file format.
16
This digital format is the International Organization
for Standardization (ISO) referenced standardized digital file format for medical im-
ages and related information, namely ISO 12052. To facilitate access to health care,
multiple imaging modalities (x-ray, visible light, ultrasound, and so forth) used in med-
icine and dentistry must be compliant with ISO12052. Digital applications in veterinary
medicine also follow this standard.
If CBCT vendors do not specifically use the DICOM file format in their proprietary
scanner software, their proprietary software should have the capability of converting
the volume data to the DICOM standard file format. In so doing, they make their vol-
ume data usable in other and often more specialized software applications.
Types of task-specific reconstruction capabilities of viewing software include, but
are not limited to, panoramic reconstructions, implant planning reconstructions with
2-dimensional and 3D windows, temporomandibular joint reconstructions, airway re-
constructions, and so forth. Examples of these latter reconstructions are presented in
Fig. 6.
X-Ray Tube and Generator Systems
Because CBCT is a radiographic imaging system, scanners have x-ray tubes with kV
and milliamperage exposure controls. Although the time of exposure is usually an
exposure control for an x-ray system, in CBCT the time of the exposure is actually
dependent on the number of basis images and the degree of spatial resolution
requested in the voxel size. The smaller the voxel size and the greater the number
of basis images, the longer the exposure. The major difference in a CBCT exposure
compared with the exposure of intraoral and panoramic imaging is that the CBCT
exposure consists of capturing the series of multiple basis images. Because of the
process of basis-image projection, the x-rays are not generated during the entire rota-
tional path. In most units, the exposure is pulsed at intervals so that there is time be-
tween basis-image acquisition for the signal to be transmitted from the detector area
to the data-storage area and the detector to rotate to the next site or angle of expo-
sure. Hence, the x-ray tube does not generate x rays for the entire rotational cycle.
These intervals may inherently reduce patient exposure during the time interval that
the detector is not ready to receive x rays. These intervals are also beneficial for the
x-ray duty cycle, reducing heat buildup during an exposure cycle.
In general, the longer the exposure and the more basis images produced, the longer
it takes to complete the rotational arc. This time for the acquisition of basis images is
known as the frame rate. For a shorter exposure, the rotational arc remains the same
but the frame rate is reduced. In this scenario where less basis images are taken, the
radiation exposure is less, the rotational arc takes less time, and the scanner parts
rotate faster. The clinician can actually observe the slower or longer scan times neces-
sary for longer exposures with higher frame rates.
Basic Principles of Cone Beam CT 469
Table 1
Scanners with large field of view (FOV)
Model Manufacturer
Maximum to
Minimum FOV
Height 3 Width (cm)
Minimum
Voxel (mm
3
)
Two-Dimensional
Options Bit Depth
Scan
Time (s) kV Notes
3D Accuitomo 170 J. Morita USA, Irvine,
CA, USA
12 17 to 4 4 0.08 No 14 5.430 90
3D eXam KaVo, Charlotte, NC,
USA
17 23 to 8 8 0.125
a
14 8.526 120
CS 9300 Carestream Health,
Rochester, NY, USA
13.5 17 to 5 5 0.09 Panoramic
cephalogram
14 1220 90 Previously Kodak
(dental division)
Available in 2 versions
DaVinci D3D Cefla Dental, Imola,
Italy
15 15 to 7 7 0.17
a
12
a a
Supine position for scan
Galileos Comfort
Plus
Sirona USA, Charlotte,
NC, USA
Sphere 15.4 cm (D) 0.125 No 12 14 98 Plus model is upgraded
Comfort
Uses image intensifier
detector
i-CAT FLX Imaging Sciences
International,
Hatfield, PA, USA
17 23 to 8 8 0.125 Panoramic 14 526.9 120 QuickScan1 option
allows for ultralow
dose exposures
NewTom 5G QR srl, Verona Italy 16 18 to 6 6 0.075 No 14 1826 110 Supine position for scan
NewTom VGi QR srl, Verona, Italy 15 15 to 6 6 0.075 No 14 1826 110 VGi Flex version
intended for mobile
use
A
b
r
a
m
o
v
i
t
c
h
&
R
i
c
e
4
7
0
PaX-Reve3D Plus Vatech America Inc,
Fort Lee, NJ, USA
15 19 to 5 5 0.08 Panoramic 14 1524 90
ProMax 3D Max Planmeca USA Inc,
Roselle, IL, USA
17 22 to 5.5 5 0.10 Panoramic 15 1826 96 Can obtain a stitched 26
23 cm FOV and
upgradable to
ProFace 3D Photos
ProMax 3D Mid Planmeca USA Inc,
Roselle, IL, USA
17 20 to 5 4 0.10 Panoramic
cephalogram
15 1826 90
Quolis Alphard
3030
Asahi Roentgen Ind.
Co., Ltd, Kyoto, Japan
17.9 20 to 5.1 5.1 0.10 No
a
17 110
Scanora 3D Soredex, Milwaukee,
WI, USA
13 14.5 to 6 6 0.133 Panoramic 12 1026 90
Scanora 3Dx Soredex, Milwaukee,
WI, USA
24 16.5 to 5 5 0.10 Panoramic
a
1834 90
SkyView MyRay, Imola, Italy Sphere 22.9 cm (D)
15.3 cm (D)
10.2 cm (D)
0.17 No 12 1030 90 Supine position for scan
Uses image-intensifier
detector
WhiteFox Acteon North America,
Mt. Laurel, NJ, USA
17 20 to 6 6 0.10 No 16 1827 105
a
Information was not available at press time.
B
a
s
i
c
P
r
i
n
c
i
p
l
e
s
o
f
C
o
n
e
B
e
a
m
C
T
4
7
1
Table 2
Scanners with medium and small FOV
Model Manufacturer
Maximum to
Minimum FOV
Height 3 Width (cm)
Minimum
Voxel (mm
3
)
Two-
Dimensional
Options
Bit
Depth
Scan
Time (s) kV Notes
AUGE ZIO Asahi Roentgen Ind.
Co., Ltd, Kyoto,
Japan
8 10 to 5.5 5 0.1 Panoramic
cephalogram
12 8.517 95
Cranex 3D Soredex, Milwaukee,
WI, USA
6 8 to 6 4 0.085 Panoramic
cephalogram
a
1117 85
CS 9000 3D Carestream Health,
Rochester, NY, USA
3.75 5
Stitched
7.5 3.75
0.076
Stitched 0.2
Panoramic
cephalogram
14 10.8 90 Will stitch 3 scans
together
Finecube XP62 Yoshida, Tokyo, Japan 7.5 8.1 0.1 No 14 8.634 90 Marketed as PreXion
3D by PreXion Inc in
the USA
GXCB-500 Gendex, Hatfield, PA,
USA
8 14 to 8 8 0.125 No 14 8.923 120 Powered by i-CAT
GXCB-500 HD Gendex, Hatfield, PA,
USA
8 14 to 2 8 0.125 Panoramic 14
a
120 Powered by i-CAT
GXDP-700 Gendex, Hatfield, PA,
USA
6 8 to 6 4 0.2 Panoramic
cephalogram
a
1020 90
i-CAT Precise Imaging Sciences
International,
Hatfield, PA, USA
8 14 to 2 8 0.125 Panoramic 14 423 120
I-Max Touch 3D Owandy, Croissy-
Beaubourg, France
8.3 9.3 0.156 Panoramic
cephalogram
816 20 86
A
b
r
a
m
o
v
i
t
c
h
&
R
i
c
e
4
7
2
Orthopantomograph
OP300
Instrumentarium,
Milwaukee, WI,
USA
6 8 to 6 4 0.085 Panoramic
cephalogram
14 1020 90
Orthophos XG-3D Sirona USA, Charlotte,
NC, USA
8 8 to 5 5 0.1 Panoramic
cephalogram
12 14 90
PaX-i3D Green Vatech America, Fort
Lee, NJ, USA
10 16 to 5 5 0.12 Panoramic
cephalogram
14 5.9
a
100
PreXion 3D Eclipse PreXion, Inc, San
Mateo, CA, USA
8 11 to 8 7.5 0.15 Panoramic
cephalogram
14 8.7
17.4
90
PreXion3D Elite PreXion, Inc., San
Mateo, CA, USA
8 7.5 to 5.6 5.2 0.11 Panoramic 13 8.6
33.5
90
Promax 3D Classic Planmeca USA Inc,
Roselle, IL, USA
8 8 to 8 4 0.1 Panoramic
cephalogram
15 18 90
Promax 3D Plus Planmeca USA Inc,
Roselle, IL, USA
9 14 to 5 4 0.1 Panoramic
cephalogram
15 18 90
Promax 3D s Planmeca USA Inc,
Roselle, IL, USA
8 5 to 5 5 0.1 Panoramic
cephalogram
15 18 90
Suni3D Suni Medical Imaging,
San Jose, CA, USA
5 5 to 5 8 0.08 Panoramic
cephalogram
16 1524 90
Veraviewepocs J. Morita USA, Irvine,
CA, USA
8 10 to 4 4 0.125 Panoramic
cephalogram
13 9.4 90 Various
configurations
available
a
Information was not available at the time of writing.
B
a
s
i
c
P
r
i
n
c
i
p
l
e
s
o
f
C
o
n
e
B
e
a
m
C
T
4
7
3
A data set with fewer basis images may be undersampled. Undersampled data sets
have a lower signal-to-noise ratio, and thus lack the range of image contrast capable
with a more complete volumetric data set. However, depending on the diagnostic
task, the degree of image degradation from these smaller data sets with shorter expo-
sures may still be adequate for certain diagnostic tasks. This shorter feature reduces
patient exposure and is particularly helpful in reducing motion artifact in scans of
younger patients, geriatric patients, or those with disabilities, during which motion arti-
fact is more difficult for the patient to control. These smaller data sets also have less
computational and construction time. With fewer data, they require less storage
space. An example of undersampling is illustrated in Fig. 7.
Exposure factors for a CBCT scan can be preset from an exposure selection guide,
or can be determined by automated features in the image-acquisition software from a
scout exposure. Some units may have a direct automated exposure feedback feature
in the detector that determines the exposure factor for more optimal signal detection.
The automated exposure control predates CBCT technology and has been available
since the introduction of charge-coupled device sensors for digital panoramic radiog-
raphy. CBCT units that scan larger object areas (larger FOV) generally need higher kV
potentials. The higher kV is necessary for adequate penetration of denser and larger
anatomic structures in the maxilla, midface, and skull base. Consequently, higher
kV is often necessary for adequate diagnostic quality of the larger FOV data sets.
Fig. 4. Basis-image capture for a hypothetical CBCT rotational scan of the cervical spine. Two
basis-image capture sequences are depicted in this diagram as the machine rotates counter-
clockwise from Position 1 to Position 2. An arrow depicts the counter-clockwise rotation.
CBCT scans routinely capture in the range of 100 to 600 basis images per rotational scan.
(Modified from Zhen X, Yan H, Zhou L, et al. Deformable image registration of CT and trun-
cated cone beam CT for adaptive radiation therapy. Phys Med Biol 2013;58(22):797993.)
Abramovitch & Rice 474
Fig. 5. Examples of multiplanar reconstructions. The upper example (A) is constructed by
One Volume viewer software (J. Morita USA). The lower (B) reconstruction is by CS 3D Im-
aging Software (Carestream Health, New York).
Basic Principles of Cone Beam CT 475
Table 3
Third-party software available for imaging CBCT data sets
Software Manufacturer Uses
CS 3D Carestream Dental, Rochester, NY, USA Multiple applications
Dolphin 3D Dolphin Imaging and Management
Solutions, Chatsworth, CA, USA
Multiple applications
EasyGuide Keystone Dental, Burlington, MA, USA Implant planning
InVivoDental Anatomage Inc, San Jose, CA, USA Multiple applications
OnDemand3D Cybermed Inc, Irvine, CA, USA Multiple applications
OsiriX Pixmeo SARL, Bernex, Switzerland Multiple applications
Procera Software Nobel Biocare USA, LL, Yorba Linda, CA, USA Implant planning
Ultra-Fast CBCT
Reconstruction
Software
Bronnikov Algorithms, The Netherlands Multiple applications
Fig. 6. Examples of secondary reconstructions from various CBCT software programs. (A)
Two-dimensional (2D) panoramic reconstruction. Although a CBCT scan is not indicated
solely for panoramic imaging, many imaging software packages can reconstruct panoramic
images from the storage data. (B) Implant planning with 2D reconstructions and a tracing of
the mandibular nerve. (C) Implant planning with 2D/3-dimensional (3D) reconstructions. (D)
Bilateral reconstructions of the temporomandibular joints in coronal and sagittal sections.
(E) Sagittal reconstruction without (top) and with (bottom) Airway Measurement tool
from InVivo 5.2 imaging software (Anatomage, San Jose, CA). When the airway is traced
in the airway measurement window, the program wizard computes the volume of the
airway space. Threshold values for compromised airway volumes have not yet been deter-
mined for this software.
Abramovitch & Rice 476
Image Sensor Systems
Two types of image detectors are used as the sensors in contemporary CBCT units. A
scanner will have either (1) a charge-coupled device with a fiber-optic image intensi-
fier, or (2) an amorphous silicon flat-panel detector. Examples are presented in Fig. 8.
During the initial introduction of CBCT, most units were constructed with the large,
bulky image-intensifier detectors. In the latter half of the first decade of commercial
CBCT development, CBCT scanners have nearly all transitioned to the smaller, flat-
panel linear array detectors. However, as noted in Tables 1 and 2 that list represen-
tative CBCT imaging systems, Sirona and MyRay still manufacture scanner units
with this type of detector.
Fig. 6. (continued)
Basic Principles of Cone Beam CT 477
Fig. 6. (continued)
Fig. 7. (A) Sagittal temporomandibular joint reconstruction from projection data processed
from a full quota of basis images in the projection data set. (B) Sagittal temporomandibular
joint reconstruction from a shorter exposure scan that has fewer basis images in the projec-
tion data and resulting volumetric data set. There is less detail and contrast resolution in the
resulting image display than with projection data from a full quota of basis images used for
construction of the volumetric data set.
478
The image-intensifier detectors are larger and make the scanners overall dimen-
sions larger, which may be critical for certain office designs. In addition to being
more sensitive and susceptible to distortion from magnetic fields, image displays
from these detectors also demonstrate greater distortion of the grid dimensions
when moving away from the center of the detector (Fig. 9A), which ultimately reduces
measurement accuracy of the reconstructed images.
17
Because of their sensitivity to
magnetic fields, the image-intensifier detectors require more frequent calibration. In
addition, the phosphors in image intensifiers lose their sensitivity over time and use,
and the entire image-intensification unit may need to be replaced to maintain image
quality. This process is very expensive.
18
Despite the drawbacks, in certain cases
the data sets from these detectors are more compatible with bridging to some of
the data sets used in computer-aided design and manufacturing (CAD/CAM) technol-
ogy, and thus remain useful.
The flat-panel detectors are thin, amorphous silicon transistor panels with a cesium
iodide scintillator. The scintillator is the part of the detector used to amplify the elec-
trical signal from the x-ray attenuation. Besides being smaller and less bulky, the flat
Fig. 8. Two CBCT scanners from Sirona USA. The Galileos (top) has a charge-coupled image-
intensifier detector. The Orthophos XG 3D unit (bottom) has the smaller flat-panel detector.
The detectors are demarcated with dotted outlines. Differences between the two are
described in the text.
Basic Principles of Cone Beam CT 479
panels have minimal distortion of the image dimensions at the periphery of an image
display (see Fig. 9B); hence, these units are considered to generate better data sets.
Because these detectors are smaller than their image-intensifier predecessors, CBCT
units with the flat-panel detectors have smaller footprints. This feature alone had made
the flat-panel detector more popular. Differences in image quality between these de-
tectors are shown in Fig. 10.
Another property of the image detector is the bit depth, an exponential binary prop-
erty expressing the total number of gray shades the detector is able to discriminate. A
14-bit detector (ie, 2
14
) can display 16,384 shades of gray. The range of bit depth of
commercial CBCT units ranges between 12 and 16 bits (see Tables 1 and 2), indi-
cating the wide range of contrast discrimination capability. Although the detector is
capable of this degree of gray-scale discrimination, limiting features to the contrast
resolution include the lower bit depth of the imaging software and the monitor display,
Fig. 9. Distortion patterns produced by image detectors. (A) Grid type X is the type of grid-
distortion pattern produced by the image-intensifier detector that affects the image con-
struction and is subsequently noted in the image display. There is distortion of the image
grid when moving away from the center. (B) With flat-panel detectors (ie, grid type Y)
the image receptor area receiving the signal from the flat-panel detectors scintillator is
flat. Therefore, even at more distant areas from the center of the grid, there is minimal
to no distortion of the grid pattern.
Abramovitch & Rice 480
and the visual perception of the viewing clinician. Even though bit depth is important
for contrast resolution, the American College of Radiology has concluded that there is
no added benefit to diagnostic interpretations by the use of higher than 8-bit depth in
the workstations operating system.
19
Scatter and Beam-Hardening Artifact
Scatter and beam-hardening artifact occurs in CT imaging where image reconstruc-
tions of a data set are necessary for reviewof the data volume. Dense metal structures
frequently in the FOV for dental applications present metal artifact on CBCT recon-
structions. Silver amalgam, precious and semiprecious metal alloys used in coronal
restorations, dental implants, silver-point endodontic fillings, and, to a lesser extent,
gutta percha endodontic fillings, all create these artifacts in image reconstructions.
The artifact presents as light or dark streaks, or as a dark periphery adjacent to
metallic borders. Scatter artifact is seen as radiopaque lines and patterns of metallic
density that scatter on image reconstructions. The main types of beam hardening
are the dark streaks or dark bands that show up in the image reconstructions. The
latter often simulate disease such as recurrent caries or fractures in endodontically
treated teeth. The light streaks often superimpose regular anatomy, and may also
significantly degrade image quality.
These artifacts are prominent problems for dental applications with CBCT, as
metallic restorations are often within the FOV of most CBCT scans of dental patients.
The metallic restorations then cause the resultant beam hardening and streak artifact,
which then compromises the image quality with the various areas of dark and light arti-
fact. Fig. 11 illustrates examples of how these artifacts degrade image quality and
make image assessments difficult.
Recent attempts via software correction algorithms have been reported that have
the potential to control these visible artifacts on image reconstruction.
20,21
However,
the application of software correction modes to reduce these artifacts have been infe-
rior to noncorrected software viewing programs when evaluating peri-implant and
Fig. 10. Comparative reconstructions of two different scans of the same posterior left maxil-
lary quadrant from a scanner with a flat-panel detector (left) and one from a charge-
coupled device image intensifier (right). The improved image quality and the higher
signal-to-noise ratio are noted in the left image. (Courtesy of Dr Bruno Azevedo, Western
University, Pomona, CA.)
Basic Principles of Cone Beam CT 481
Fig. 11. Beam hardening and streak artifact in CBCT image reconstructions. (A) Axial section
with dental implant in #18 region highlighted by black arrow. (B) Beam-hardening artifact is
indicated by red arrows. The green arrows depict streak artifact. (C) The locations of cross-
sectional and parasagittal reconstructions are shown. (D) The effect of beam hardening
simulating peri-implantitis and alveolar bone defects in the cross-sectional and parasagittal
reconstructions. (E) The effect of streak artifact creating the outline of a ghost implant
(as well as other radiopaque streak outlines) in the cross-sectional reconstruction. The streak
artifact makes it more difficult to discern the validity of the cortical bone outlines. (Courtesy
of Dr. Gerald Marlin, Washington, DC.)
482
periodontal disease
22
as well as root fractures.
23
Consequently, there are no immedi-
ate methods to correct or minimize these prominent artifacts. The best way to avoid
streaking and beam hardening is to try to keep the FOV as small as possible in an
attempt to minimize or keep these metals outside the FOV. In so doing, one may be
able to minimize their impact on image reconstructions.
SUMMARY
CBCT is now a well-accepted diagnostic tool for the care of dental patients. Design
changes in the evolution of contemporary CBCT scanners include making the units
smaller, and making changes whereby instead of needing to be scanned in a supine
position, the patient either sits or stands upright during the scan. Along with these
design changes, better stabilization devices for the patients head and chin were pro-
duced. Mechanical changes included the switch to smaller, flat-panel silicon detectors
with better image quality compared with the bulkier, cumbersome, and eventually
more costly image-intensifier detectors.
Variable kV and multiple options for voxel size, FOV dimensions, scan times, and so
forth, then followed, alongside more powerful software applications for the care of
dental patients. The ability of CBCT manufacturers to use various aspects of imaging
technology in a cost-effective, efficient, and practical manner means that there are
now numerous CBCT applications that are helpful in a multitude of dental disciplines.
These applications include, but are not limited to, dentoalveolar abnormality, vertical
root fractures, jaw tumors, prosthodontic evaluations, and advances in orthodontic/
orthognathic and implant patient evaluations. The latter also include mechanisms
for surgical and prosthodontic splint design and the capability of CBCT scan data
to bridge with CAD/CAM image files for fabrication of various dental restorations.
This approach facilitates implant and prosthodontic rehabilitation by synchronously
planning and subsequently milling coronal restorations for teeth and rootform im-
plants. As the demand for CBCT technology continues to increase, so will the number
of new applications for improved diagnostic techniques.
REFERENCES
1. Mozzo P, Procacci C, Tacconi A, et al. A new volumetric CT machine for dental
imaging based on the cone-beam technique: preliminary results. Eur Radiol
1998;8(9):155864.
2. Arai Y, Tammisalo E, Arai Y, et al. Development of a compact computed tomo-
graphic apparatus for dental use. Dentomaxillofac Radiol 1999;28(4):2458.
3. Sittig DF, Ash JS, Ledley RS. The story behind the development of the first whole-
body computerized tomography scanner as told by Robert S Ledley. J Am Med
Inform Assoc 2006;13(5):4659.
4. Miracle AC, Mukherji SK. Conebeam CT of the head and neck, part 1: physical
principles. AJNR Am J Neuroradiol 2009;30(6):108895. http://dx.doi.org/10.
3174/ajnr.A1653.
5. Miracle AC, Mukherji SK. Conebeam CTof the head and neck, part 2: clinical ap-
plications. AJNR Am J Neuroradiol 2009;30(7):128592. http://dx.doi.org/10.
3174/ajnr.A1654.
6. Miles DA. Color atlas of cone beam volumetric imaging for dental applications.
Chicago: Quintessence Publishing; 2007. p. 914.
7. MacDonald-Jankowski DS, Orpe EC. Computed tomography for oral and maxil-
lofacial surgeons. Part 2: cone-beam computed tomography. Asian J Oral Max-
illofac Surg 2006;18:8592.
Basic Principles of Cone Beam CT 483
8. Scarfe WC, Farman AG. Cone-beam computed tomography. In: White SC,
Pharoah MJ, editors. Oral radiology principles and interpretation. St Louis
(MO): Mosby-Elsevier; 2009. p. 22543.
9. Drage N, Rout J. Diagnostic imaging. In: Kau CH, Richmond S, editors. Three-
dimensional imaging for orthodontics and oral surgery. Chichester, West Sussex
(United Kingdom): Wiley-Blackwell; 2010. p. 3854.
10. Jacobson AF, Ferguson JP. Evaluation of an S.S. White Panorex x-ray machine.
Oral Surg Oral Med Oral Pathol 1973;36(3):42642.
11. Lund TM, Manson-Hing LR. Relations between tooth positions and focal troughs
of panoramic machines. Oral Surg Oral Med Oral Pathol 1975;40(2):28593.
12. Shinozima M, Kohirazawa H, Kubota K, et al. Tomorex (curved rotational tomog-
raphy apparatus) in experimental and clinical practice. Oral Surg Oral Med Oral
Pathol 1982;53(1):94110.
13. Nemtoi A, Czink C, Haba D, et al. Cone beam CT: a current overview of devices.
Dentomaxillofac Radiol 2013;42(8):20120443.
14. Available at: http://www.3dorthodontist.com/CBCT_Machines.html. Accessed
February 5, 2014.
15. Available at: http://www.conebeam.com/pdf/CBCT_chart_12242012.pdf. Ac-
cessed February 5, 2014.
16. National Electrical Manufacturers Association. Digital Imaging and Communica-
tions in Medicine (DICOM), PS 3 2011. Rosslyn (VA): National Electrical Manufac-
turers Association (NEMA); 2011. Available at: http://medical.nema.org/standard.
html. Accessed March 13, 2014.
17. Scarfe WC, Farman AG. What is cone-beam CT and how does it work? Dent Clin
North Am 2008;52(4):70730.
18. Miles DA. CBCT: facilitating comprehensive, high-tech diagnostics. Compend
Contin Educ Dent 2011;32(4):145. Available at: http://www.dentalaegis.com/
specialissues/2011/12/cbct#sthash.PWm57wLG.dpuf.
19. Andriole KP, Ruckdeschel TG, Flynn MJ, et al. ACR-AAPM-SIIM practice guide-
line for digital radiography. J Digit Imaging 2013;26(1):2637.
20. Bechara B, McMahan CA, Geha H, et al. Evaluation of a cone beam CT artefact
reduction algorithm. Dentomaxillofac Radiol 2012;41(5):4228. http://dx.doi.org/
10.1259/dmfr/43691321.
21. Bechara B, Moore WS, McMahan CA, et al. Metal artefact reduction with cone
beam CT: an in vitro study. Dentomaxillofac Radiol 2012;41(3):24853. http://
dx.doi.org/10.1259/dmfr/80899839.
22. Kamburoglu K, Kolsuz E, Murat S, et al. Assessment of buccal marginal alveolar
peri-implant and periodontal defects using a cone beam CT system with and
without the application of metal artefact reduction mode. Dentomaxillofac Radiol
2013;42(8):20130176.
23. Bechara B, McMahan CA, Moore WS, et al. Cone beam CT scans with and
without artefact reduction in root fracture detection of endodontically treated
teeth. Dentomaxillofac Radiol 2013;42(5):20120245.
Abramovitch & Rice 484