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Advanced Imaging Systems -- Lecture #11 Radiology by Dr. Chain

[1] [Advanced Imaging: An Overview for General Dentistry]
[Dr. Chan] Hello, sorry Im late. So Ill spend the next hour and a half with you guys,
introducing the different imaging modalities that are available to general dentists
and were talking about advanced imaging modalities so were talking about CTs and
MRIs. And this lecture is not intended to teach you how to read CTs or MRIs but just
to give you a brief introduction of what they look like, how they work, the pros and
cons and when you should consider ordering a CT or MRI or ultrasound or nuclear
medicine for your patients. So, in terms of the physics, we wont go into heavy detail.
It will be an overview and for the exam, I would expect you to know the pros and
cons and the indications because thats going to be practical for you in your practice
as well, okay? All right.

[2] [Advanced Imaging Overview]
[Dr. Chan] So heres the outline of what is advanced imaging. There are three key
advanced imaging modalities that you gusy have. And were going to talk about
some more advanced imaging modalities that are more commonly used in the
medical field or, you know, oromaxillofacial surgery. So, you know, what makes it
advanced, right?

[3] [What is advanced imaging?]
[Dr. Chan] So tomos is actually, I think, the Greek word for slice. So by
tomography we mean slicing tissue. So we take a patients head and we virtually
slice it into very thin cuts and those virtual electronic images of the patients head is
your tomos, your slice. So that is what makes it advanced. So, it actually takes
tomographic images and it represents images of slices through tissues, right? And
there are two steps that make this advanced. You acquire the image so we expose
the patient, acquire the image, and then through very complex physics and
mathematical algorithms that even I dont know about, its a physicists job to know
about those. The computer actually reconstructs the acquired data so what was
exposed and then finally after the reconstruction gives us the images that we see on
the computer screen, all right? So, what we actually see on the computer screen is a
reconstruction of raw data. All right? And advanced imaging, being all high-tech and
what not, it doesnt replace plain film imaging. You still need your bitewings and
your periapicals and your pans, okay? You only consider the possibility of advanced
imaging such as CT, cone beam CT, medical CT, or MRI after a history, after a clinical
exam and after plain film radiography, all right? Even for some of the head and neck
cancer cases that oral surgery does here, they still resort back to periapical imaging.
All right? So you still actually follow a sequence of thinking, take your history, take
your clinical, you know, collect both your subjective and your objective data first,
and then decide, is radiography beneficial for this patient? And if yes, you proceed
with plain film radiographs, bitewings for caries, okay? Recurrent decay, you cant
really see that on cone beam CT because theres a lot of artifacts on that, all right?
So, advanced imaging does not replace your history, clinical and your plain film
images, all right?
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[4] [Three Key Advanced Imaging Modalities]
[Dr. Chan] And these are the three key imaging modalities that we have. Medical
CT computed tomography, thats what CT stands for. Cone beam computer
tomography and MRI, magnetic resonance imaging, which is not ionizing radiation.
What should I say? Oh, okay, you know what? So in the olden days there was
something called a CAT scan, right? It actually stands for computer axial
tomography because the first type of CT unit actually can only take axial cuts and if
you go in the literature and find some obscure paper from the 1979 and 1980 of
monkeys getting CAT scans, youll see how pixelated and how ugly the original CAT
scans are. You just get axial cuts through the monkeys head and its you know
those video games you had in the 1980s, 1970s? maybe not. Anyway, it really
looked bad. No detail, no resolution, very minimal contrast. So, thats why, you
know, some people still call CT, CAT scans. Its just FYI, theyre no longer CAT scans
because now CT technology, you can get coronal, sagittal, multi-planar, different,
you know, panoramic reconstructions. You can get all these different kinds of cuts
from a medical CT unit. So many people just call them CT now but thats the history
of a CAT scan. I mean, its just axial images because thats the only type of image that
can be acquired and reconstructed back in the old days. But now we can do coronals
and any plane possible, all right?

[5] [Medical CT]
[Dr. Chan] Okay, so first modality and well break before we talk about MRI
because MRI is completely different. All right, medical CT uses ionizing radiation to
form the image, okay? It has a large footprint. By large footprint, I mean its big. All
right? So you only see these in the hospital setting or in large private radiology or
imaging clinics, okay? And theyre usually housed in what is called the CT suite,
okay? So the CT suite actually consists of the patient area where you have the
scanner separated by, you know, lead glass and you have your where the
technology sits, the operator, okay? So its two rooms, the patient and the
technologist. This here is called the table of the CT scanner or the CT unit. Here is
the gantry. And what happens is the patient on the table will, you know, be going
through the gantry like a tunnel and as hes doing that, as the tables moving, many
many rotations of the x-ray tube and the receptor, which is housed in this little
gantry here, are going to acquire the images theyre going to expose the patient,
acquire the images and once the images have been acquired they transfer, you
know, through electronic cables to a computer here and the computer actually
reconstructs that data into the images that we see. Heres an axial soft tissue
window of the patients head at the level of the eyes. All right? That is, in a nutshell,
what, how CT works, okay?

[6] [Inside the Gantry]
[Dr. Chan] So now we break it down to, you know, inside the gantry. So lets
simplify the gantry. Gantry is just, you know, doughnut shaped unit with a table
going through like this, okay? So medical CT it meets a fan-shaped beam. Okay?
Like the shape of a fanthis is the green thing right here. And theres an x-ray
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source and a roll of receptors called the detector array and this rotates quite quickly
actually around the patients body. And the table goes this way through the gantry
like that. And as it is doing that, its acquiring these unique data points in the
computer system and once everything has been acquired, its just transmitted to the
computer where the technologist sits in the other room and then reconstruction
occurs to give you the images that we see on the screen.

[7] [Multidetector/Multislice CT]
[Dr. Chan] So, in the past, the earlier generation of CT units, they only have a single
roll of detectors like this. So here again, x-ray source, the patients head, the patients
nose is here lying on the table. And here is the fan-shaped beam and then the
receptors right here. But nowadays, there are like multiple detectors in this roll
called multidetector array and this multidetector array nowadays if you have a
cardiac CT, I think they go up to like 256 little microdetectors in an array like that
and what happens is that it can acquire through one single rotation, around 256 or,
you know, that number of detectors actually equals the number of slices that are
acquired in each rotation. So if I have a 64-roll detector array in one swing of the
rotation, I can get like 64 slices in one swing. Its actually a very quick process, all
right? And because of this, of the presence of this technology, multidetector,
multislice, more formally speaking, in the medical world, they call medical CT
multidector or multislice CT. So in contrast, now that we have cone beam, the
medical people call it the dental CT. Get it? Never mind. Yeah. So, what we call
medical CT in their world, in their terms, they talk about multidetector, multislice
CT and its because the detector, they have rolls and rolls of detector and then one
single swoop, you know, the same number of slices are acquired in one single
swoop, all right?

[8] [Helical Motion]
[Dr. Chan] Now, as the patient is, you know, going through lying on the table
going through the gantry, there is a motion of the x-ray tube and you know,
around the gantry like this, this motion here? This is called helical motion and that
brings us to the other term that medical radiologists call, or you know, people in
medicine call medical CThelical CT. So medical CT, more formally speaking, has
three synonyms: helical CT, multidetector CT, or multislice CT, okay? So ... and the
helical CT comes from this motion of the x-ray tube going around and round and
round like that and the patient moving along the table like that, okay?

[9] [Images in Medical Computed Tomography]
[Dr. Chan] So thats how CT works, in a nutshell. And the images acquired in
medical CT, compared to cone beam CT, is different. First of all, these are axial cuts.
This is the soft tissue window and this is the bone window. We dont have soft tissue
window in cone beam CT, so thats a difference there. Okay? So theres no soft-tissue
contrast, very very poor soft-tissue contrast in cone-beam CT. Second, sometimes,
depending on the pathology present and the indication for the medical CT, the
technologist and the radiologist will choose to inject contrast in the patient to light
up the vessels, okay? So, again, this contrast use of contrast-enhanced CT is only
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available in medical systems, not in cone beam. So already, two differences; no
contrast and no soft-tissue windows in cone beam CTs. Now, if we look at the bone
windows, nowadays, the bone beam CT scanner, the bone resolution is equal to, if
not superior, to that of the bone windows used in medical CTs. So if you want to look
at something that is affecting the bone, for instance, you can elect using cone beam
CT as opposed to medical CT, all right?

[10] [Medical Computed Tomography]
[Dr. Chan] And for the exam and for your reference, I guess, you can refer to this
chart, okay? Medical CT, also known as helical, multidetector, multislice CT. I think
these are British people, British radiologist and physicists. In 1972, it was first
developed. And, again, the shape of the bean is fan-shaped, okay? And theres a
detector array and then, you know, the patient is on the bed moving through the
gantry. The pros is: unlike panoramic imaging, which we talked about last week,
theres no anatomic sulperimposition. So what you get, you get a slice, a very clean
slice, through the head. Theres nothing to obscure the view of your mandible, of
your maxilla, of your skull. So theres no anatomic superimposition. Multiplanar
reformatted imaging is possible, meaning its no longer restricted to just axial
images so its no longer called a CAT scan, okay? Theres excellent bone detail but
nowadays cone beam CT matches that detail, if not, is superior to the medical CT.
High contrast resolution and you can use contrast to enhance vascular structures
because you know malignancies from your, you know, basic pathophysiology,
system pathology lectures, malignancies are highly vascular. As we inject contrast in
a patient you can actually view the malignancy much more clearly from the adjacent
anatomic structure and this helps the surgeons to get a map of the area and where
to resect, okay? You cant do that with cone beam, all right? Okay, now the cons. The
cons is, you know, its high dose. Head CT, approximately, you know, 2,000
microsieverts or 2 millisieverts, okay? At least twice as high as cone beam CT.
Although we do have soft tissue contrast, still if we want really good soft tissue
contrast, we resort to MRI, okay? Thats the king of soft tissue resolution. Soft tissue
imaging? Consider MRI, okay? And of course, anyone whos actually had the chance
to read a report from a medical radiologist of a medical CT of the head and neck,
theyll usually have something like this in the report: there are dental artifacts in the
CT, or you say something like dental artifacts obscure anatomic detail of the
mandible and, you know, theyll have this dental artifacts word. And what dental
artifacts is, it refers to all of the metal artifacts that are from the dental restorations,
okay? Indications, when you should think of ordering a medical CT now, patient,
for instance, comes to your office and theres a swelling, you know. Clinically, you
see a swelling of the buccal cortex and the mandibular right molar region and you
now, just by palpating the swelling alone, a periapical will not cover the entire
extent of the swelling radiographically. Okay? Thats the first line of management.
And you have a pan and you see that theres a large radiolucency, you know, on the
mandibular right molar region that extends to the midline, okay? The cortices are
intact, everythings well-defined so you think benign, right? So, in cases where you
suspect that the pathology, the bone pathology, is really definitely only in the bone,
you can consider using a cone beam. But, if, in your clinical palpation, you do notice
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areas that the cortices are breached, areas are more softer than others, that you
should suspect soft tissue extension of the lesion through the bone into the soft
tissues. So if you suspect soft tissue extension, all right? You should consider a
medical CT, okay? Because medical CT has soft tissue contrast, okay? And that will
allow the clinician, radiologist, everyone whos involved in that case to visualize the
exact extent of the lesions. For instance, you have an immunoblastoma [?] of the
jawbone, all right? And theres soft tissue extension but if we order a cone beam, we
cannot tell you where the tumor is heading. Only with a medical CT or an MRI can
we see clearly that oh dear, the tumor has involved the masseteric muscle, okay?
Because when surgeons need that in order to treat and minimize the chance of
recurrence, okay? So thats why if you suspect theres soft-tissue involvement, i.e.
something has perforated through the bone and extended in the soft tissue, think
medical CT, not cone beam, all right? And, you know, you can also, for orthognathic
treatment planning, you may consider a medical CT in some instances but
nowadays, most of the medical facial deformities do not have soft tissue
involvement because the lower dose safeings [?] you get with cone beam. Some
people prefer using cone beam over medical CT. but prior to the emergence of cone
beam CT, in dentistry, the standard of care has been for complex cases where you
know patient is syndromic, hemi-facial microsomia, craniofacial microsomia, you
know something syndormic that requires extensive orthognathic surgery, they will
actually order medical CT for those purposes. And trauma at the hospital setting,
you know, patient is in the ER, they get sent for medical CT to evaluate the fracture
planes and, you know, full of [unintelligible] and all that. Okay? But for your
purposes, just know that if theres bone pathology and it extends into the soft tissue
or you suspect it extends into the soft tissues, think medical CT, all right? Any
questions on medical CT? Okay.

[11] [Cone Beam Computed Tomograph]
[Dr. Chan] So now we talk about cone beam CT, all right? It was first actually
developed in 1982 for cardiology. So it wasnt for dentistry. It only became more
commercially available in dentistry in the early 2000s so I think the first cone beam
scanner that I know of actually, my colleague got it in 2004. One of the iCAT units.
Very basic iCAT unit, okay? And, well, first of all, just looking at the size of the cone
beam CT units, all right? The footprint is much smaller than that of a medical CT,
right? So you can put it in your office and there are two flavors. There are large-
fields. This is a large-field cone beam CT unit where you can scan, you know, the
entire head or just a segment of the quadrant. Or there are small fieldssmall to
medium fields cone beam CTs, which is not much different, just by looks, from a
panoramic unit, right? I mean, if you compare this image to the one I showed you
earlier, theres not much difference between a small field of view cone beam unit
and a panoramic unit, all right? So you can actually fit these in your office quite
nicely.

[12] [Cone-Shaped X-ray Beam]
[Dr. Chan] Now the reason why cone beam is called cone beam is because the
shape of the x-ray beam is conical in shape, okay? So what happens is, similar to a
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pan, patient stands between the C-arm. And the C-arm consists of the x-ray source
and a detector array, all right? And what happens is, in acquisition the first step in
the advanced imaging procedure, this rotates around the patients head and as it is
doing that, it is actually capturing many, many planar images of the patients head.
So all these images are kind of like the cephalometric images that we see in ortho
but except every different angle of the patients head, all right? And after the x-ray
source and detector swing around the patient in a circle, the computer actually
reconstructs these images, the sagittal, axial, coronal images here, by doing some
mathematic algorithm. This is the FELDKAMP algorithm on these basis projections
to give you these images. Okay? So thats how its acquired and reconstructed to give
you this, all right? Oh, and the other thing I want to say is but understanding this
basic sequence in cone beam CT acquisition, you can actually tweak it to make it, to
make the images look betterhaving higher resolutionby increasing the number
of basis projections. So if, on your scanner, there is a high-resolution function, this is
what its doing. Its actually acquiring more basis projections so theres more
information feeding the computer more information to reconstruct the final images
that you see on the computer screen. Or, if, for instance, you have a child who fell
down or theres a sports injury, trauma to the tooth, they cant, you know, theyre in
pain, they cant sit still for a long time, theyre crying, you can choose a truncated
scan protocol. So most cone beam studies are done using a 360-degree scan
protocol. For truncated protocols, you do a 180 scan. And the 180 scan will be
quicker and just easier for the patient because that patient cant sit still, there will be
patient-movement artifact. But if you can get them to hold still for, you know, eight
seconds, then the likelihood for a diagnostic scan would be increased. And also, if
you dont want to truncate the scan because that has a lot of guessing, the computer
has to do a lot of guessing to reconstruct these images; you can actually do a quick-
scan protocol. So instead of acquiring more basis images, you get less basis images.
So the images may not be as clear but at least youll have something to work with for
diagnosis, okay? But understanding whats ... how the images are acquired and, you
know, the basis projections right here, you can kind of understand, you know, what
it means when the high-resolution button is pressed on the scanner or when the 180
or the fast-scan protocols are applied, okay? So it all has to do with tweaking the
number of basis images the machine acquires in each scan or actually truncating the
arc to 180 instead of 360.

[13] [Various Fields-of-View (FOV)]
[Dr. Chan] All right. So advantages of cone beam CT over medical CT include: cone
beam CT, there are different fields of view, okay? Different fields of view is field of
view is volume that will be that youre actually scanning and that will appear on
your computer screen. And its good for dentistry because if youre doing a single
site implant, for instance, patient lost their #7, youre doing, you know, an implant
there, you dont need to scan the entire head, right? Thats not really following the
ALARA principleas low as reasonably achievable. You can just select the 40x40
field of view and just center this field of view, this volume here, onto the #7 site to
give you the information you need for implant treatment planning. In contrast,
medical CT, all you get is the head. If you order a medical CT of the head or of the
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face, you get the entire head and it doesnt really you cant really select the exact
site you want to ... youre doing treatment on. You have to get the rest of the head so
in terms of ALARA principle, thats not really consistent with ALARA if we do a
medical CT for a single site implant. No one does that anymore. Other things is
larger fields, for instance, ENTs, some ENTs down at Columbia use cone beam CT
technology to do FESS, functional endoscopic sinus surgery. So for ENT cases, you
may choose 100x100 or 140x100 field of view and center it on the sinonasal area, so
that they have the information they need to do their FESS surgery. And even in
neural surgery, in some hospital settings, I dont think we do it here at NYU, but
some medical settings elsewhere, they employ the 40x40 dead on the temporal bone
so if the patient has ear abnormalities, they can just expose that region of the head
and do the surgery. So its more versatile, you can actually pick the size that you
want to expose and from a radiation safety point of view, its just beneficial for the
patient, all right? Most commonly, 40x40, 60x60, 80x80 fields of view is more than
adequate for most dental-alveolar cases, in particular, endodontics. Thats very
useful if you have a very small field of view.

[14] [FOV in Dentistry]
[Dr. Chan] If you want to see if theres a periapical lesion of the maxillary left first
molar, you cannot see any change in the periodontal ligament space on a periapical
image but clinically and from the history, the symptoms and signs are classic for
inflammation, you may consider ordering a cone beam CT to find out and to localize
the periapical radiolucency, okay? So for those cases, endodontic treatment
planning, apicoectomies, single implant cases, these fields of view should be more
than adequate for most dentoalveolar needs, all right?

[15] [Voxel Sizes]
[Dr. Chan] Now, one of the reasons why with cone beam CT data we can generate a
panoramic curve very nicely and the panoramic image thats generated is very
smooth and very clear is because the volume, this cone beam CT data is made up of
little cubes called voxels. So just as one the computer screen your have jpgs,
bitmapsthose are made of pixelsin CT land, its three-dimensional so its called
voxels. The same thing as pixels, voxels is three-dimensional equivalent. And, you
know, each volume is made up of these little boxes. So thats cone beam CT and this
is the reason why if we slice and dice the data, if we cut a curve here to generate, tell
the computer that oh, we want to see a panoramic projection, the projection thats
created is still smooth and clear because of the isotropic voxeltheyre all equal in
dimension, all right? In contrast, most medical CT, especially not the super new ones
but the ones from 1990s, early 2000, their volumes are made up of anisotropic
voxels. So the C dimension, theyre like little triangular prisms. So if you slice and
dice the data, you will get very pixelated artifacts as well on the medical CT
reconstruction. So thats why medical CT, we dont really do a panoramic
reconstruction because the end result is not diagnostic, all right? Thats part of the
reason why. Okay.

[16] [Standard Orthogonal Views]
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[Dr. Chan] So, after reconstruction we get these 3 views: axial view, the birds eye
view, coronal viewthats the face-on view. Oh, and then of course the sagittal view,
all right?

[17] [Multiplanar Reconstruction]
[Dr. Chan] In addition, as I mentioned before, you can generate a panoramic curve
of the mandible or the maxilla, depending on where your site of interest is. Here is a
panoramic curve of the mandible body. And here it is. And you can see how crisp
and smooth all the outline are. You can see the details very nicely. And partly was
because of the isotropic voxels, all right? And you can see also the reconstructed
buccolingual slices here. Again, its very smooth and clear. Again, its because of the
isotropic voxels. The other benefits of cone beam CT is you can generate your own
three-dimensional reconstruction.

[19] [Advanced Imaging: An Overview for General Dentistry]
[Dr. Chan] So there are three types of three-dimensional reconstruction in cone
beam CT. theres manual segmentation. This involves ... now, in each cone beam CT
software program that comes with the unit, they have a histogram. So in Photoshop,
just as you have a histogram that you can tweak the brightness and contrast in
Photoshop, you can actually tweak similar parameters on cone beam CT just as
using that histogram on the software. And manual segmentation means you, as the
operator, are manually segmenting each slice of the patients anatomy to show just
the relevant parts. For instance, this is the case that I did for a surgeon for extraction
or localization of the maxillary left canine in relation to the its buccal, lingual,
resorbing roots. To give people a very easy reference of the canine with respect to
the erupted teeth, you can actually generate this three-dimensional model and I
spent an hour and a half teasing away the skin and the bone, the cortices, the callous
bone, just to show the teeth like this. So its very time consuming process but the
final images that you will get are really really exquisite and very clear, all right?

[20] [Maximum Intensity Projection]
[Dr. Chan] The other pseudo three-dimensional reconstruction is called maximum
intensity projection. Now, what it does is these pseudo three-dimenional models are
made up of only those voxels with highest intensity. Highest intensity meaning those
corresponding to bone and metal. Okay? And contrast. To be honest, this is a
projection that I have not seen used except in sialograms. When I was a resident, we
did silaograms, the parotid, the submandibular gland. So we inject contrast, heres
the catheter, heres the contrast material and its nice for surgeons or clinicians to
see this three-dimensional detail through the MIP projection. And there are like
structures here thats why patient was having salivary flow problems. But I have not
seen many people use this function for three-dimensional reconstruction. Most
people still use manual segmentation. They get like a dental assistants to do it so
yeah.

[21] [Ray Sum Image]
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[Dr. Chan] And this one ray sum function. Im sure youve heard that many
people say cone beam CT study, with just one study, you can generate all your views
you need for orthodontic treatment planning. You can get your submentovertex
view; you can get your cephalometric views. That is possible but not the standard of
care, first of all. And the second, the function used to generate these views is called
ray sum. Okay? Ray sum function. So, essentially, for instance, if you want to
generate, if you want the computer to reconstruct a lateral cephalometric image,
you take a mid-sagittal plane, dead along the middle of the patients head like this.
Okay? And you ask the computer to sum up all the voxels to the right and left of this
plane. Okay? Once you do that, you get this simulated or reconstructed lateral
cephalometric image. And basically its a full thickness ray sum because this image is
actually taking the voxels of all of the entire head from right to left and pressing it
into a two-dimensional planar image. It sounds very complicated but its just like a
little button on the software and you can choose how many voxels or how many
millimeters of tissue to use for your reconstructed image. For instance, maybe Im
just interested for these pathology cases the thickness of this lesion here. So for my
ray sum image, just so that we have a easy reference to see the extent of the lesion
and what its doing to the neighboring teeth, we can draw a panoramic curve in the
middle of the mandible like this ... like panoramic curve like this. We can tell the
computer to add up, you know, 8 millimeters of tissue to both the fronts and the
back of the curve and then well have a very nice reconstructed image of the lesion.
And this is actually a centric drying cell lesion [?] from my colleague in Iran. So ray
sum is, again, operator depending, you tell how many millimeters of tissue that you
want the image to have and you just enter it in the computer, okay?

[22] [Metal Artifacts]
[Dr. Chan] The disadvantages is, you know, metal artifacts. You get these in
medical CT as well. So these are beam-hardening artifacts. So what beam-hardening
artifacts represent is actually in metal you know from Dr. Friedmans lecture is that
they attenuate a lot of radiation, right? They make the beam stronger, right? Because
photons hitting the metal become stronger because it takes away the low energy
photons. So whats coming out of the metal is actually all high energy photons. And
high-energy photons is exposing your receptor, thats where you get these black
bands over here. So thats why its called beam-hardening artifacts. You harden the
beam because you know it went through metal and made the beam stronger,
hardening the beam and you get these from dental restorations, metal crowns, even
root canal fillings, okay? And this is one of the reason, from a practical standpoint,
you dont want to diagnose recurrent decay by cone beam CT or medical CT because
simply theres too much artifacts. Youll likely overcall or undercall the lesions. So
you always always always go back to bitewings and periapicals, all right? And
sometimes in endodontic land, there will be requests to determine if theres a
fracture in the root of an endodontically treated tooth. Unfortunately because the
root canal filling also has this kind of beam-hardening artifact, sometimes we may
not be able to tell the endodontist or the clinician if there is a fracture or not. Just
because theres this artifact, all right?

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[23] [Ring/Detector Artifact]
[Dr. Chan] And the other thing that medical CT does not have but is quite prevalent
in some bone beam CT units--its called the ring/detector artifact. The iCAT units,
from imaging sciences, there will be this ring/detector artifacts because its due to
calibration error of the detector. So if youre thinking of getting a cone beam CT unit
and there are so many out there right now, ask if you need to calibrate the receptor.
If you need to calibrate the receptor on a daily basis and if you dont do it or dont do
it correctly, the images that will be acquired during that day when you see patients,
you will get this ring/detector artifact. In contrast, some units such as the one in this
school does not require daily calibration of the receptors so we dont have this
artifact at all. So depending on whether you want to be how anal you are, you can
actually choose one of those cone beam units that require daily calibration but just
keep in mind that if you see this, that tells you, you know, there may have been some
error involved in calibration, all right?

[24] [CBCT Limitation As Compared with Medical CT]
[Dr. Chan] And finally, as we said before, cone beam CT limitations, as compared
with medical CT, theres no soft tissue inflammation in cone beam. And theres
higher image noise in cone beam CT because it has to do with the shape of the
beampartly because it has to do with the shape of the beam. Cone beam, youve
got a conical shape so naturally, as the patient is being exposed youre actually
exposing a larger area of the patient and when you do that, you get more scatter
radiation. And scatter radiation, some of it is captured on the receptor, okay? But, in
contrast, medical CT, you have a fan-shaped beam. So you dont expose as much
volume of tissue per scan. All right? So because of that, the scatter radiation
produced is much less compared to cone beam CT. so thats why medical CT, the
resolution is slightly better and theres less image noise in medical CT.

[25] [CBCT Effective Doses]
[Dr. Chan] And finally for those of you who are interested in dose, this is a chart
from the dental CT document. The dental CT document is currently the so-called
only evidence-based document on cone beam CT used in dentistry. It was compiled
by a bunch of European radiation physicists, radiation biologists, head and neck and
oromaxillofacial radiologists. They scour the literature for everything on cone beam
CT and then kind of did a systematic review on it. And from the dose perspective,
this is what they came up with. So for units that are small to medium fields, the dose
range is from 11 to 674 microsieverts. And for craniofacial or full head scans, it
ranges from 30 to 1073 microsieverts. So, although dose is less in cone beam CT
when we compare it to the 2,000 microsieverts in medical CT, it really depends on
the application. So, dont skimp on the dose if the patient has soft tissue involvement
of a jaw tumor or whatever just go ahead with the medical CT. Dont just think oh,
its lower dose, its better to use cone beam CT. But you dont have that information
you need, right? So you need to expose the patient again with medical CT. So just go
directly to medical CT in those cases. So for those cases where you know theres soft
tissue involvement, always go with medical CT, dont worry about the dose. All
right? For those cases.
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[26] [Cone Beam Computed Tomography]
[Dr. Chan] And finally cone beam CT. this is the chart again, discovery for
cardiology purposes in 1982, but in clinical dentistry only very recently. Its called
cone beam because of the conical shape. Pros are youve got a lot of fields of view to
work with. So dont expose the full head if youre just working on a single tooth,
okay? Lower dose compared to medical CT, but if the patient is indicated for medical
CT, please order medical CT. No anatomic superimposition and excellent bone detail
as we talked about earlier. Cons, no soft-tissue detail. You cannot use contrast in
cone beam CT yet and there are many artifacts and higher noise. Uses in dentistry,
for instance, you want to see how close the roots of the mandibular right third molar
are in relation to the inferior alveolar canal. Is it lingual to the roots, is it buccal to
the roots; you can order a cone beam. Select endodontic applications, we talked
about earlier. Implant and orthognathic treatment planning and, of course, jaw bone
pathology but without soft tissue involvement, all right? So, lets take a break and
then well go with MRI and with like ultrasound and all that. Okay?

[28] [Magnetic Resonance Imaging]
[Dr. Chan] So for MRI, the setup is similar. You also have the MRI suite and because
of the large footprint of the unit, here weve got the patient on the table and the
gantry the gantry actually is much larger than that of a CT scanner so thats first
difference. But the main difference is MRI were no longer dealing with ionizing
radiation. So theres no x-ray involved. Were all talking about Magnetisms. Okay?
Magnets and dipole movements. All right? So no x-rays whatsoever. Its completely
different way of producing images. Okay? And it really is interesting. So I tried to
simplify it as much as I can but it still needs a bit of imagination on your part, all
right? And again, once the patient goes through the gantry, the signals are acquired;
signals are passed through wires to the computer, which, again, through different
algorithms will reconstruct these images that we see on the computer screen. And
the other difference is that the walls of the MRI suite are usually thicker because
they need different materials to shield out extraneous radiofrequencies. So the
radiofrequencies from the microwave, radio needs to be shield out. Otherwise, they
interfere somehow with the magnetisms of the MRI scanner.

[29] [Inside the Tunnel]
[Dr. Chan] So inside the gantry you have a large magnet. Okay? Thats your large,
large, big magnetthe main magnetic coil. And the magnetic coil, basically, when
the patient is inside the tunnel, it aligns all our magnetic moments. So all the tissues
in the body have different molecules and the most numerous is the hydrogen atoms.
So the hydrogen atom has just one proton , okay? And so we call it one proton. And
the proton actually has a spin and a wobble. So they alignthe large, main magnetic
coil align all the protons in our body in one direction. Because at rest, theyre all
kind of randomly going everywhere. So once, were in the magnet, the main
magnetic coil aligns these protons. If were doing MRI of the head, the patient will
another coil, a transmitter and receiver on the head. So usually for the head its like
a bird cage. So youre actually wearing a birdcage on the table. Its kind of funny. For
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other areas, you get like surface magnets on the abdomen or on the knee or on the
shoulder, youve got one on the thyroid, youve got other different coils, other
magnets on them. And this will also help in tweaking the proton movement of our
tissues to generate the image that we see on the computer screen. And in addition to
the main magnetic coil, there are three other magnetsthe X, Y, and Z magnetic
coils. And theyre involved in producing different sequences of the MRI study as well
as determining slice thickness. So it determines how thick the slices are in the MRI
study. Okay? So in a nutshell, the patient is on a table, and they go through a tunnel.
The protons are aligned in a certain direction. The technologist actually sends a
radiofrequency, an RF pulse, a radiofrequency pulse, to the patient and it tweaksit
actually bring the protons in a different state. And as these protons are more
energized, the RF pulse is released, allowing the protons that were more energized
to relax. And as the protons relax, energy is released and it actually induces a signal
through the receiver. And its this signal that gets transmitted to give you the images
that we see as the MRI study of the head. So thats MRI physics in a nutshell. And you
know that by in our body, weve got fat, muscle, bone, salivary glands, blood
vessels. So all these different tissues, soft and hard tissues of our body have different
distribution, different density of protons. So through different RF pulse sequences
and through different relaxation times, so depending how fast we actually give the
patient a pulse, we can tweak these magnetic moments in our body to give us
different sequences that we see on the MRI study. So you want your T1 sequence,
your T2 sequence and there are like flare sequences and all the other sequences
echo, EP, EPI sequences. So through these different tweaking of pulse and different
relaxation times, you can get these images. And this is one reason why, for MRI, the
soft tissue contrast is much better, far more superior than medical CT. Okay?

[30] [Magnetic Dipoles and Protons]
[Dr. Chan] So well take it step by step. So again, protonsmost prevalent, most
common atom in our body, protons. And the proton, really hydrogen atom proton,
and they have spin. Okay? They spin in one direction and they go round like this.
Okay. They spin.

[31] [Randomly Oriented Magnetic Dipoles]
[Dr. Chan] And as they spin, they also have a wobble. So theyre wobbling as they
spin. Okay? And the wobblingthe physics term is called procession. Okay?
Procession means wobbling. And theres always a procession frequency. Okay?
Outside the main magnetic coil, outside any influence of magnetic field, right now, in
resting state, all our protons are kind of randomly cancelling each other out. So we
dont have a net magnetic moment, okay? Its just randomly cancellationtheyre
like wobbling and spinning in all sorts of different directions like this, okay?

[32] [Magnetic Dipoles Aligning in Parallel with the External Magnetic Field]
[Dr. Chan] But under the influence of magnetic field, so once the patient is in that
large, main magnet, the protons aligns. And there are two ways that they align. One
is parallel to the external magnetic field, meaning they go in the same direction as
the magnetic field and thats the low energy state. Because it doesnt take much
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energy to go with the flow, so to speak. But some protons are kind of rebels. They go
the other way. They, actually, invert themselves and, you know, align themselves
anti-parallel to the main magnetic field. And these protons are high-energy state. So
you can remember this as it takes more energy to stand with your hands than with
your legs, right? You need to do a like a head I dont know what theyre called
but it takes more energy to stand with your hands than with your legs, right? So
thats kind of like what its doing here as well. In reality, remember what I said,
protons sort of wobble. Well, even though theyre aligned parallel and anti-parallel
to the field, they still kind of wobble. All right? So theyre kind of not precisely
parallel, theyre kind of wobbling as theyre aligned to the field like that. So they
kind of angle here is kind of like theyre wobbling. They wobble with a tilt.

[33] [Magnetic Dipoles Precessing in Parallel with the External Magnetic Field]
[Dr. Chan] And as they wobble, each proton have a different frequency of
wobbling. Some like to wobble faster than others, some like to wobble slower than
others. And this wobbling is called precession. And I mentioned that before. And
theres a precession frequency, okay? And all the protons, they precess at different
rates, okay? And by wobbling the precession frequency is also known as Larmor
frequency, for those of you who are interested in physics. So theyre synonymous
with each other. And it really depends on the strength of the magnetic field and the
type of tissue that the proton is in. So if youre in tissue A, the proton may not
wobble as fast as in tissue B so it really depends on what tissue youre in and the
strength of the magnetic field.

[34] [Larmor Frequency]
[Dr. Chan] Okay so now the patient is in the magnet and then some of the protons
are aligned parallel and antiparallel to the field and they also wobble at a certain
frequency. So now lets look at this figure A here. This is your main magnetic
moment. This vector here is the sum of all of your protons that are wobbling parallel
to the field. Okay? So as the technologist or the tech sends an RF pulse to this, this
goes down. Its because the RF pulse actually gives energy to some of the protons to
go antiparallel. So it puts the patient in a higher energy state. Okay, actually flips the
protons that were going in parallel to the field upside down to go antiparallel. So
thats why this is going down, okay? So thats the first thing that happens when the
RF pulse hits the patient.

[35] [Longitudinal Magnetic Vector]
[Dr. Chan] Now, independently, and at the same time independently yet
simultaneously, because the protons are wobbling, they also wobble once the RF
pulse is sent to the patientto create a transverse magnetic vector like this. Okay?
So once the RF pulse actually hits those protons, these protons are now wobbling at
the same frequency as the pulse. Okay?

[36] [Transverse Magnetic Vector]
[Dr. Chan] So you get a transverse magnetic vector like this, okay? And once the
pulse is released, energy some of the protons go back to their low energy phase
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and these protons actually also lose their start wobbling at different frequencies.
So once the RF pulse is released, two things happen: the protons start wobbling back
to their different frequencies. So they no longer have, you no longer have this
transverse magnetic vector and the other thing that happens at the same time but
independently is some of them go back to the resting parallel phase. And as theyre
doing that, theyre actually emitting energy to the lattice. This is the lattice. So, the
body tissues, okay? So the energy is released and it signals the receiver coil and
induces a current in the receiver coil, as the energy is released, to give you another
signal and that signal is actually used to make the MRI images. And because, again,
you have different distribution density and types of arrangement of protons in bone
as compared to fat as compared to glands as compared to fluids, and you can also
and the technologist can also apply different pulse sequences through this very
complex orchestration of excitation and relaxation, this is how you get your
different MRI sequences and different soft tissue contrast on your MRI image.

[37] [Basic Pulse Sequence]
[Dr. Chan] And this is the basic pulse sequence I talk about. So TR is basically the
time between different RF pulses. TE is kind of like spin spin. So how do I explain
this? TE is kind of like we call it echo time. But lets see how I can explain this to
you guys its basically the time between the time at the start of the RF pulse and
theres time when the tissues relax and induce the signal to the coil to give you that
image, okay? So you can TE, echo time, you can yeah, I guess you can look at it like
that.

[38] [Magnetic Resonance Imaging]
[Dr. Chan] And finally youve got your MR image. For most MR studies of the head,
of the face, dealing with the maxillofacial complex, you have your T1 sequence, your
T2 sequence, and your T1 post gadolinium sequence. The gadolinium is the type of
contrast we use in MRI. How do we know its T1? Because the subcutaneous fat is
bright, okay? How do we know its T2? Because the cerebral spinal fluid or any fluid
filled thing is bright, okay? If you see white fluid thing, T2. If you see white fat thing,
T1. And gadolinium, you know its gadolinium because all the vessels are bright, all
right? And I think this is some tumor, some squamous cell, I dont know. All right.

[39] [Magnetic Resonance Imaging]
[Dr. Chan] Okay so MRI, 1973. I think hes also a Brit. And then they applied it for
clinical use later on in the 1980s. Remember, were not dealing with ionizing
radiation. Were dealing with magnetic moments of protons. So essentially MRI
study is a map of the proton distribution in the body. No ionizing radiation involved.
This is the king of soft tissue contrast. If, for instance, you suspect a parotid swelling
clinically, and you want to see what it is, dont think contrast enhanced CT. Thats no
good. Think MRI. So if you want soft tissue pathology, palatal tumor yeah, I mean,
soft tissue. The disc in TMJ, if you want to see if the disc has been displaced or
dislocated anteriorly, go with MRI, a panoramic image. And a CT wont show the
disc, okay? Because its not soft tissue. I mean, its not a soft tissue imaging modality.
Neck nodes, patient has lymphoma, HIV, or a metastatic disease, those are really
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good on MRI. So MRI, soft tissue pathology, all right? The cons is, if you think about
it, you need to wait for the tissue to relax and the technologist needs to apply
different pulse sequences each time. The main con of MRI study is really time
consuming. Because all this waiting time to wait for tissue to relax and all this time
to apply pulse so its, you know, one study like a TMJ study can take 45 minutes.
Patients lying on the bed for 45 minutes as the technologist playing with your
protons using the [unintelligible]. Its a long time. Some dentists have asked me in
the past if the patient has titanium hardware from ortho or, you know, maybe
restorations involving nickel or cobalt, is it safe? Right? And the answer is yes, its
safe but there will be artifacts. Not as severe as dental artifacts in CT but there will
be artifacts. Its actually only if the patient has had implants in their eyes that those
are contraindicated for MRI study because the magnetic field, the magnets in the
MRI unit can actually PEW! give a projectile, missile effect and then the patient
can lose their eye because the little metal in patients eye get sucked out by the
magnet. Yeah. It happens in the past so for those cases there are contraindications to
MRI. For dental restorations its called missile effect. PEW! Yeah. I mean, I think,
the physicist that taught us in school showed us a large chair stuck to the MRI unit
and they had to shut the unit down for a week to get the chair out. It was yeah.
Yeah, so it happens. But for dental restorations for dental wires, orthodontic
brackets, those are safe. But I know in some instances, the patient still will like to
have their brackets and wires removed before the MRI study. So we do see that but
not very often, okay?

[40] [Additional Advanced Imaging Modalities]
[Dr. Chan] Additional imaging modalities. Nuclear medicine/radionuclide imaging,
ultrasound. Nuclear medicine is no longer anatomic imaging. So, so far with CT and
MRI, we get a very clear map of the anatomy in the human body. We can see parotid
glands, we can see arteries, we can see bone, we can see muscles. But nuclear
imagingnuclear medicine, when I was in training we used to call this unclear
medicine so instead of NUclear its called UNclear and the reason is because all you
get is blur. Its actually functional imaging. The reason why is blur is because
functional imaging, it highlights metabolic activity in particular parts of the patients
body. So the patient has a tumor and you want to see if there are nodes involved or
metastasis in nodes, you can order nuclear scan and then the nodes are positive,
theyll light up theyll become a very black blur on the nuclear medicine scan.
Ultrasound in North American is rarely used in dentistry. In the UK, they use it for
in Greece and in the UK I know, these two countries, they use the ultrasound a lot for
salivary gland imaging and even carotid scans like that.

[41] [Nuclear Medicine/Radionuclide Imaging]
[Dr. Chan] So here this is what nuclear medicine looks like. Again, patient is on a
table and these are gamma cameras. The technologist injects some radionuclide into
the patient. Again, its a time-consuming process. It can take 45 minutes to 2 hours
because the radionuclide, once its in the patients body, needs time to distribute to
other tissues of the body. And after this wait time, patient is like glowing with
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radiation. Patient is in the scanner and the gamma camera actually takes a picture
and then

[42] [Gamma-Emitting Radionuclide Imaging]
[Dr. Chan] Finally you see pictures like this. Its a blur. A blur like that. Okay?
This is just regular gamma camera. This is something called SPECT so its another
type of tomography. Therefore you get just a slice through the mandibular condyle
here. And this patient actually had condylar hyperplasia. So you know the condyle is
still growing, okay? So dont do surgery on it because itll keep growing afterwards.
So yeah, so radionuclide imaging, nuclear medicine is a blur.

[43] [Positron Emission Tomography Fused to Computed Tomography]
[Dr. Chan] But recently there is advancement in fusing CT images heres the axial
soft tissue window with contrast, and then here youve got a tumor right here. You
can see the tumor right here and then you have your PET scan, again, functional
imaging. So if you fuse the functional image and the anatomic imaging right there-
you get something like this so you can both localize the area. Oh, its in the base of
tongue, right side. So its very useful for surgical treatment planning and the more
exciting news is there is something called MRI PET fusion which I think NYU
Langone has the fourth one in the entire country. So its still a work in progress.
Theyre doing research on whether it has benefits in determining nodal metastasis
in head and neck cancer patients. So its an ongoing study right now. So the newest
thing right now is PET-MR. Thats pretty cool.

[44] [Ultrasound]
[Dr. Chan] And ultrasound some of you may have had this before already so
you lay on a table and the technologist squirts like a gel on the patients skin and the
transducer acts as the transducer and receiver. So they transduce sound waves.
Again, were not dealing with radiation anymore, its sound waves. And different
tissues interact with sound waves at different frequencies and rates. And after
interaction, the sound waves bounce back to the transducer, which also serves as
the receiver and it goes to the computer and it reconstructs these images.

[45] [Ultrasound]
[Dr. Chan] I was never trained in ultrasound. In fact, I dont think any of my
colleagues in North America in radiology are trained in ultrasound. This is I think a
thyroid I dont yeah, thyroid isthmus. Yeah. To me, its just a blur. But for
people who use it especially in third-world countries, if you look in the literature,
in South Africa, for instance, they do a lot of MRI and salivary stone diagnosis. And
theyre really good at it. So if you do it enough, youll be good at it. But no one in
North American really uses ultrasound for head and neck. But in the UK, in Greece,
and in some third-world countries, they use it quite often. I mean I remember going
over literature article in second year in radiology from South Africa and they were
using ultrasound to diagnose whether, you know, this tumor in the submandibular
gland was benign or malignant. And they were actually very good at it and so
everyone was impressed. So, yeah.
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[1] [Advanced Imaging: An Overview for General Dentistry]
[Dr. Chan] Okay so for the exam and for your practices, know the pros and cons
and indications for each type of advanced imaging modality. And remember nuclear
medicine gives us a blur, its functional but when you fuse to anatomic imaging like
CT or MR, its a very powerful tool for head and neck cancer management. And
ultrasound, again, rarely used. Okay, all right. Thank you.