Currently Available Maxillofacial CBCT Equipment

Currently available maxillofacial CBCT equipment
CBCT systems can be described according to the orientation of the patient during image
cquisition,scan volume acquisition, maximum FOV available and whether additional
unctionality is available. CBCT units are constructed such that scanning is performed
standing, sitting or in the supine position with equipment footprint increasing respectively.
Despite patient orientation, all units provide a head stabilizing mechanism to minimize
motion artefact as scan times are often similar to panoramic imaging. Scan volumes may be
generated either from a single scan or as a composite of multiple adjacent limited field
volumes by digital stitching methods (Fig. 2).Initially, CBCT units were produced with
limited ability to adjust the FOV and were either full maxillofacial units (e.g. NewTom 3G)
or small FOV (e.g.early versions of the Morita Accuitimo). The CBCT equipment market has
matured such that available units can be grouped into one of three categories based on
maximum vertical FOV with most providing a selection of various FOVs: (1) maxillofacial –
covers most of the craniofacial skeleton, at least from below the soft tissue of the chin to
nasion. Usually greater than 13 cm maximum scan height; (2) dentoalveolar – single
or inter-arch ranging from 5 cm to 10 cm incorporating the maxilla and ⁄ or mandible; and (3)
limited – approximately 5 cm or less vertical height covering localized regions such as a
segment of the dental arch or temporomandibular joints. Selection of FOV is important for
restricting the FOV to the ROI to minimize patient radiation exposure. Selection of
equipment, and in particular maximum FOV size, should be directed towards the intended
diagnostic task. Some CBCT units are capable of high resolution imaging (manufacturer
specified 0.076 mm – 0.125 mm voxel resolution) and such high resolution attainment is
essential for tasks requiring discernment of fine detail structures and disease processes such
as the periodontal space, root resorption and root fracture. CBCT systems can also be divided
into stand-alone or hybrid multi-modal systems that combine digital panoramic radiography
with small-to-medium FOV CBCT systems. These units provide substantial cost savings as
existing robotic panoramic platforms can be re-engineered and smaller, less expensive
detectors can be used. Image generation and image detection specifications of currently
available CBCT systems reflect proprietary variations in image acquisition, detector and
image reconstruction (Table 1).
Task specific image display.
As CBCT image-capture is inherently digital, image visualization should be by digital

display. In addition, unlike other dental radiographic procedures, CBCT acquisition is
volumetric in nature and captures 3-D
information. Therefore, to enable visualization of increasing digital information contained
within the imaging volume, the interpretation should move from static hard copy (printed) to
software-assisted volumetric review. This demands that image display for interpretation be
dynamic and facilitated by the use of appropriate application of software and task specific
protocol formatting. The default presentation of the dataset by most visualization software is
usually as a series of 2-D contiguous interrelational images at a thickness defaulted to the
native resolution in three orthogonal planes (axial, sagittal and coronal). In principle, CBCT
data should be considered as a volume to be explored from which other images are extracted.
Mechanically, this involves the application of a protocol or series of logical sequential steps
to optimize image presentation. We have developed a technique involving three stages, which
in our experience, provides an efficient and consistent systematic methodological approach to
CBCT image display prior to image interpretation.
(1) Correct the data. Because econstruction of CBCT data is performed natively using a
personal computer, initial adjustment should comprise data reorientation such that the
patient’s anatomic features are realigned. This should be task specific. For example, in
craniofacial analysis the volumetric dataset should be adjusted such that Frankfort horizontal
(FH, i.e. nasion-orbital) is parallel to the floor and the midsagittal plane is perpendicular to
FH. Next, the dataset should be optimized for display by the adjustment of greyscale
brightness levels, establishment of a contrast range and the application of specific filters (e.g.
interpolation, sharpen noise), all directed towards favouring cortical and trabecular bone.
After these adjustments then secondary algorithms (e.g. annotation, measurement and
magnification) can be applied with confidence.
(2) View the data. Because of the large number of component orthogonal images in each
plane it is necessary to review each series dynamically by scrolling through the orthogonal
image stack. This is referred to as a ‘cine’ or ‘paging’ mode. It is recommended that scrolling
should be performed cranio-caudally (i.e. from ‘head-to-toe’) and then in reverse, slowing
down in areas of greater complexity (e.g. temporomandibular joint articulations). This
scrolling process should then be repeated both in the coronal and sagittal planes. Detection of
soft tissue calcifications can be improved by finally repeating this process using an
proximately 10 mm slab thickness combined with a maximum intensity profile (MIP) setting
(see later).
(3) Display the data. CBCT software provides an almost infinite and perhaps bewildering
number of visualization options, each directed towards highlighting specific components of
the volumetric dataset. Protocols incorporating FOV scan exposure parameters and display
modes (Fig. 8) should be applied selectively to highlight anatomic features or functional
characteristics within a specific diagnostic task. It is beyond the purpose of this article to
describe specific display protocols, however selection should be based on applying thin
sections for detail and thicker sections to demonstrate relationships. Because of the isotropic
nature of acquisition, the volumetric dataset can be sectioned non-orthogonally to provide
non-axial 2-D planar images referred to as multiplanar reformations (MPR). In addition, the
thickness of such planar images can be increased. MPR modes include oblique, curved
planar reformation providing ‘simulated’ distortion-free panoramic images and serial
transplanar reformation (providing cross-sections), all of which can be used to highlight
specific anatomic regions and facilitate diagnostic tasks. This is important given the complex
structure of the maxillofacial region. Because of the large number of component orthogonal
images in each plane and the difficulty in relating adjacent structures, two methods have been
developed to visualize adjacent voxels (Fig. 9).
(a) Ray sum or ray casting. An MPR image can be increased in thickness by increasing the
number of adjacent voxels. This creates an image ‘slab’ that represents a specific narrow
volume of the patient, referred to as a ray sum. Full thickness ray sum images can be used to
generate simulated projections such as lateral cephalometric images. Unlike conventional
radiographs, these ray sum images are without magnification and are undistorted. However,
this technique uses the entire volumetric dataset and interpretation suffers ‘anatomic noise’,
superimposition of multiple structures, also inherent in simple transmission radiographs.
(b) Volume rendering. Volume rendering refers to techniques which allow the visualization
of volumetric data by selective display of voxels within a dataset. Two specific techniques
are commonly used.
Indirect volume rendering (IVR) is a complex process, requiring selection and graphic
representation of a range of the intensity greyscale levels of the voxels (called segmentation).
Such a process provides a volumetric surface reconstruction with depth. Direct volume
rendering (DVR) is the selection of an arbitrary threshold of voxel intensities, below or above
which all grey values are eliminated. The most common DVR technique is MIP. MIP
visualizations are achieved by evaluating each voxel value along an imaginary projection ray
from the observer’s eyes within a particular volume of interest and then representing only the
highest value as the display value. Voxel intensities that are below an arbitrary threshold are
eliminated.
Interpretation of CBCT images

It is the professional duty of a practitioner who operates a CBCT unit or requests a specific
CBCT study to provide information on the imaging findings based on examination of the
entire image dataset. In some jurisdictions this is also legally mandatory, either for
reimbursement from third-party health insurance payers or to maintain professional medical
liability protection. An opinion expressed by some has been that the user is not responsible
for the radiologic findings beyond those needed for a specific task (e.g. implant treatment
planning). Professional bodies in both the United States18 and Europe33 vigorously oppose
this position.
Radiologic interpretation is predicated on a thorough knowledge of CT anatomy for the

entire acquired image volume, anatomic variations and observation of abnormalities. It is
imperative that all image data be systematically reviewed for disease. Competency in
interpretation of both anatomic and pathologic findings on CBCT images varies depending
principally on practitioner experience and the FOV of the scan. Qualified specialist oral and
maxillofacial radiologists may be able to assist diagnostically when practitioners are
unwilling to accept the responsibility to review the whole exposed tissue volume.
It is important to recognize that CBCT imaging comprises two components: the generation of
task specific images and an interpretation report. Often patient diagnosis may be complex and
management may involve numerous practitioners. Therefore, an interpretation report serves
as the optimal method of communication of interpretation findings for CBCT.
Currently, there is no consensus on the specific requirements for CBCT reporting. However,
guidelines for comparable reporting of MSCT images are available and should be
consulted.34,35 Within this framework, and based on dedicated CBCT imaging experience
dating to 2004, the authors suggest that the following outline form the basis for CBCT
reporting:
(1) Patient information. This section should include pertinent information to identify the
patient and provide possible relevant demographic data. This would include the patient name
or other identifier, gender, date of birth or age.
(2) Scan information. This section provides the when, where, why, and how for the CBCT
procedure. This would include succession number, date the scan was performed, date the
report was generated, the location of the facility, the equipment used, scan parameters, the
referring practitioner’s name, rationale for the procedure and images provided. In addition,
information should be provided on any problems encountered during the procedure (e.g.
patient motion)
(3) Radiologic findings. This section should be subdivided into general imaging findings,
specific radiologic findings pertinent to the imaging rationale and incidental findings. General
imaging findings should include reference to the dental status including specific missing
teeth, restorative status, root canal filled teeth, periapical lesions, general alveolar bone
status and status of edentulous regions. Specific findings should use precise anatomic,
pathologic and radiologic terminology to accurately describe gnathic or temporomandibular
joint features regarding the region of interest. In the maxilla, the paranasal sinuses should be
examined with particular reference to the characteristics of any opacification, if present.
Finally, depending on the FOV of the dataset, the dataset should then be reported ‘head-to-
toe’, reflecting the approach previously described. Incidental findings should comment on
significant conditions observed in non-gnathic structures including the cranial cavity (e.g.
physiologic and pathologic calcifications), the base of the skull including the auditory
apparatus, the nasoand oropharyngeal airway spaces, the cervical spine and the soft tissues of
the neck.
(4) Radiologic impression. Either a definitive or a differential diagnosis should be provided,
whichever is appropriate. In this section the radiologic findings should be correlated to
patient presentation and address or answer any pertinent clinical issues raised in the request
for the imaging examination. If available, findings should be compared to previous
examinations or reports. Finally, recommendations for follow-up or additional diagnostic or
clinical studies should be suggested, as appropriate, to clarify, confirm or exclude
the diagnosis.
CONCLUSIONS
The application of CBCT theory to produce equipment dedicated for use in dentistry has
reached maturity since its commercial introduction more than a decade ago. Numerous
manufacturers produce a large selection of CBCT units all capable of providing accurate,
submillimetre resolution images in formats enabling volumetric visualization of the osseous
structures of the maxillofacial region. Further applications and increasing availability of this
technology will extend maxillofacial CBCT imaging from diagnosis to image guidance
of operative and surgical procedures. CBCT will undoubtedly affect the expected standards
of care, and this has implications for increased practitioner responsibility both in the
performance, optimal visualization and interpretation of volumetric datasets.

Currently Available Maxillofacial CBCT Equipment

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Currently Available Maxillofacial CBCT Equipment

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Currently available maxillofacial CBCT equipment

Task specific image display.

As CBCT image-capture is inherently digital, image visualization should be by digital

Interpretation of CBCT images

Radiologic interpretation is predicated on a thorough knowledge of CT anatomy for the

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