ORIGINAL ARTICLE

Impact of cone-beam computed tomography on

orthodontic diagnosis and treatment planning
Ryan J. Hodges,a Kathryn A. Atchison,b and Stuart C. Whitec
Los Angeles, Calif

Introduction: In this study, we measured the impact of cone-beam computed tomography (CBCT) on
orthodontic diagnosis and treatment planning. Methods: Participant orthodontists shown traditional orthodontic
records for 6 patients were asked to provide a diagnostic problem list, a hypothetical treatment plan, and a clinical
certainty. They then evaluated a CBCT scan for each patient and noted any changes, confirmations, or enhance-
ments to their diagnosis and treatment plan. Results: The number of diagnosis and treatment plan changes
varied widely by patient characteristics. The most frequently reported diagnosis and treatment plan changes
occurred in patients with unerupted teeth, severe root resorption, or severe skeletal discrepancies. We found
no benefit in terms of changes in treatment plan for patients when the reason for obtaining a CBCT scan was
to examine for abnormalities of the temporomandibular joint or airway, or crowding. Orthodontic participants
who own CBCT machines or use CBCT scans frequently in practice reported significantly more diagnosis
and treatment plan changes and greater confidence after viewing the CBCT scans during the study.
Conclusions: The results of this study support obtaining a CBCT scan before orthodontic diagnosis and
treatment planning when a patient has an unerupted tooth with delayed eruption or a questionable location,
severe root resorption as diagnosed with a periapical or panoramic radiograph, or a severe skeletal discrepancy.
We propose that CBCT scans should be ordered only when there is clear, specific, individual clinical justification.
(Am J Orthod Dentofacial Orthop 2013;143:665-74)

R
adiographs are an indispensible tool in the
evaluation of the bony structures of the head
and neck in pretreatment orthodontic diagnosis
and treatment planning.1,2 Previous research has
shown that lateral cephalograms and panoramic,
anterior periapical, and posterior bitewing radiographs
provide sufficient information for most orthodontic
patients.3 These radiographic techniques provide
2-dimensional information about the maxillomandibu-
lar relationship, the position of the dentition in relation
to basal and alveolar bones, the airway, skeletal or dental
disease, root anatomy and angulation, and a gross
visualization of the osseous anatomy of the temporo-
mandibular joint (TMJ).
From the School of Dentistry, University of California, Los Angeles, Calif.
a
Resident, Division of Orthodontics.
b
Professor, Division of Public Health and Community Dentistry.
c
Professor emeritus, Section of Oral and Maxillofacial Radiology.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts or companies described in this article.
Reprint requests to: Ryan J. Hodges, 4352 Camino De La Rosa, Newbury Park,
CA 91320; e-mail, hodges1542@gmail.com.
Submitted, June 2012; revised and accepted, December 2012.
0889-5406/$36.00
Copyright Ó 2013 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2012.12.011
With the advent of cone-beam computed tomogra-
phy (CBCT), it became possible to evaluate the hard
and soft tissues of the maxillofacial region in 3 dimen-
sions and in high spatial detail. Additionally, visualiza-
tion of the craniofacial complex in 3 dimensions is also
possible with surface reconstruction views. Such
information has the potential to improve orthodontic
diagnosis and treatment planning, including airway
analysis,4-9 TMJ evaluation,10-14 positions of impacted
teeth,15-24 orthognathic surgical planning,25-29
evaluation of skeletal asymmetries,30-34 root position
and structure,35-39 and miniscrew placement.18,40-49
However, the use of CBCT entails both financial costs
and potential risks from radiation exposure.
Some researchers have provided recommendations
for ordering CBCT scans based on specific characteris-
tics, including facial asymmetry, sleep apnea, impacted
teeth, intent to use dental mini-implants, consideration
of rapid maxillary expansion, and persistent TMJ symp-
toms.50 Others have advocated the routine used of
CBCT in standard orthodontic diagnosis and treatment
planning because of the additional diagnostic informa-
tion that is potentially available.8,48,51 The decision
to use any imaging modality before orthodontic
treatment is justified when there is a reasonable
665
666
Table I. Patient case characteristics
Patient Angle Unerupted Root
case Age Sex class tooth position/resorption
1 13 y 0 mo M II N N
2 7 y 3 mo F III Y N
3 15 y 3 mo M I N N
4 11 y 6 mo F II Y Y
5 20 y 1 mo F II Y N
6 16 y 1 mo M III N N
M, Male; F, female; N, no; Y, yes; TMD, TMJ disorder.
expectation that a radiograph will result in a clinical
benefit. This study was designed to measure the
impact of CBCT in orthodontic diagnosis and
treatment planning, and to determine the extent to
which patient characteristics might provide benefits to
clinicians in diagnosis and treatment planning.
MATERIAL AND METHODS
The records and study models of 6 patients treated in
the orthodontic clinic at the University of California at
Los Angeles were selected and duplicated. The patient
case records included, at a minimum, medical and dental
histories; stone study models trimmed to centric
relation; images of the full-mouth intraoral and extrao-
ral photographs; lateral cephalometric, panoramic, and
full-mouth series views; and the initial CBCT examina-
tion. All CBCT scans were made on a NewTom 3G
machine (QR S.r.l., Verona, Italy) with a 12-in field of
view and reconstructed with a 0.5-mm slice thickness.
The cases were selected to represent a broad range of
clinical characteristics commonly encountered in
orthodontic practices, including Class I, Class II, and
Class III molar relationships, canine impactions, anterior
open bites, anterior and posterior crossbites, dental
crowding, airway and TMJ problems, and severe skeletal
asymmetries (Table I). The cases exposed the participants
to common patient characteristics, especially problems
where CBCT has been suggested to be beneficial, but
without regard to prevalence. For example, the preva-
lence of impacted maxillary canines is 1% to 2.5%, but
in our study, impacted maxillary canines were present
in 2 of the 6 cases.52
Letters briefly describing the study and inviting
participation were sent via e-mail to 219 members of
the Pacific Coast Society of Orthodontists who resided
in the Southern California area. A letter was also sent
to the program directors of the 3 regional orthodontic
programs: University of California, Los Angeles;
University of Southern California, Los Angeles; and
Loma Linda University, Loma Linda, Calif. Those who
May 2013
Vol 143
Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Hodges, Atchison, and White
Severe
skeletal Airway Case
discrepancy TMD problem Crowding severity
N N N N Low
N N N Y Low
N N Y Y Medium
N N N Y High
Y Y Y N High
Y N Y Y Medium
responded were contacted and told that participation
would consist of 1 interview (estimated to last about
2 hours) during which the participant would be shown
orthodontic cases and asked to provide hypothetical
diagnoses and treatment plans. The participants were
assured that the accuracy of their diagnosis and treat-
ment plan was not being evaluated, but, rather, the
investigators wished to determine the information
used to formulate their diagnoses and treatment plans.
This study was approved by the institutional review
board of the University of California at Los Angeles.
A standardized interview was used. Descriptive data
were gathered about the participants (sex, orthodontic
program and year of graduation, whether they owned
a CBCT device, and for what percentage of their patients
did they order CBCT scans before treatment). The
participants were shown the case records for the 6
patients. One case, selected by the investigators as an
easy diagnostic one, was always presented first to
familiarize the participants with the process. The order
of presentation of the other 5 cases was systematically
varied to prevent changes to the outcome variables
associated with fatigue.
Each case was presented on a 15.4-in screen
(MacBook Pro; Apple, Cupertino, Calif) with software
(Dolphin Imaging, Chatsworth, Calif). The participants
were given each patient’s medical and dental histories
and shown the study models, intraoral and extraoral
photographs, and lateral cephalometric, panoramic,
and full-mouth series radiographs. The participant was
allowed to rotate and manipulate all images (except
the CBCT images) during this part of the interview.
They were asked to describe their diagnostic problem
list. They were also asked to provide their degree of
certainty with their diagnosis using a visual analog
scale ranging from 0% (complete guess) to 100%
(absolutely certain). This process was repeated for the
treatment plan.
The participants were then asked whether they
would request a CBCT scan for this patient and
their rationale. Regardless of whether they requested
Hodges, Atchison, and White
Fig 1. Participants’ self-reported use of CBCT in private practice.
a CBCT scan, the participants were asked to evaluate the
CBCT examination and note any changes, enhance-
ments, or confirmations to their diagnosis and treatment
plan, including reasons for these changes. Next, the
participants were given preconstructed images of the
TMJ, impacted teeth, and teeth with root resorption.
They were also encouraged to view the multi-planar
reconstructions and to create any other cross-sections
from the CBCT scan that would contribute to their
diagnosis and treatment plan.
After data collection, the considerations for ordering
CBCT scans and associated diagnostic and treatment
plan changes were grouped into the following 8
categories: unerupted tooth, root position or resorption
(.2 mm), severe skeletal discrepancy (2 $ ANB $ 6 ,
or asymmetry $4 mm), TMJ disorder (signs or symptoms
of clicking, popping, or pain), airway problems,
crowding (.5 mm in either arch), medico-legal reasons,
and financial costs. During the analysis, a hierarchy of
change, enhancement, and confirmation was estab-
lished, with a change having the greatest impact. For
example, if a participant reported a change and an
enhancement to a diagnosis, both were recorded but
only the change was used for analysis.
The participants then provided final percentages of
certainty for both their diagnoses and treatment plans.
At the conclusion of each case, the participants were
asked how the CBCT scan was useful in their diagnosis
and whether the information from it would have
influenced the treatment outcome for that patient.
American Journal of Orthodontics and Dentofacial Orthopedics
667
They were allowed to explain any radiographs or other
diagnostic aids that they would have ordered if the
CBCT scan were unavailable.
Statistical analysis
The P values for comparing binary outcomes
(percentages) from the same participants across patient
profiles were computed by using the Cochran Q proce-
dure, a generalization of the McNemar test for balanced
2 3 k tables, where k is the number of subjects. For com-
parisons across categories when participant-patient was
the unit of analysis, this was expanded to a repeated-
measure logistic model with a random participant effect
to take into account nonindependence.
The P values for comparing continuous confidence
score outcomes across patients from the same
participants were computed by using the nonparametric
Friedman test for repeated-measure comparisons,
a generalization of the Wilcoxon signed rank test for
paired continuous data.
RESULTS
Twenty-four participants began the interview
process, and 23 finished all 6 patient cases; 1 participant
finished 5. The participants were mostly men (n 5 21),
trained at 10 orthodontic programs, and had an
average of 24 years of experience (range, 1-44 years).
The participants reported using CBCT examinations
May 2013
Vol 143
Issue 5
668 Hodges, Atchison, and White

Table II. Number of CBCT scans ordered for each Table IV. Changes and enhancements to the diagno-
patient ses and treatment plans
CBCT scans ordered Diagnosis changes Treatment plan changes

Patient case n % SE Differences Patient case n % SE n % SE

1 2* 8 66 2, 3, 4, 5, 6 1 1 4 64 2 8 66
2 6 25 69 1, 4, 5 2 2 8 66 2 8 66
3 7 29 610 1, 4, 5 3 1 4 64 1 4 64
4 22y 92 66 1, 2, 3, 6 4 9* 38 610 8* 33 610
5 19y 79 69 1, 2, 3, 6 5 9* 38 610 11y 46 610
6 8 35 610 1, 4, 5 6 4 17 68 4 17 68
Total 64 45 62.8 Total 26 18 28 20

*Significantly fewer than all other cases (P \0.05); ysignificantly *Significantly different from cases 1, 2, and 3 (P \0.05);
y
more than cases 1-3 and 6 (P \0.05). significantly different from cases 1, 2, 3, and 6 (P \0.05).

the characteristic was present. An unerupted tooth was

Table III. CBCT scans ordered by participants
CBCT scans requested (n) Participants (n)
0 2
1 3
2 8
3 4
4 4
5 1
6 2
for 0% to 100% of their patients in their practices
(mean, 12.1%; median, 5%) (Fig 1).
There were 64 CBCT scans ordered (45% of opportu-
nities) during the interview process (Table II). The
number of CBCT requests for each case ranged from
2 to 22, and 64% of the CBCT scans requested were
for cases 4 and 5. For case 1, only 2 CBCT scans were
requested. Two participants never requested a CBCT
during their review of the 6 cases, 16 participants
ordered 2 to 4 CBCT scans, and 2 participants requested
a CBCT scan for all 6 cases (Table III).
There were 26 changes to the participants’ diagnoses
after viewing the CBCT scans (18% of opportunities) and
28 changes to the treatment plans (20% of opportuni-
ties) (Table IV). The number of changes varied widely
by patient case, ranging from 1 to 11, with cases
4 and 5 together comprising over 67% of the changes
to the diagnoses (18 of 26 changes) and treatment plans
(19 of 28 changes).
The number of CBCT scans ordered and the number
of resulting changes to the diagnoses and treatment
plans varied by patient characteristics (Table V). Multiple
characteristics were present in each case; thus,
participants gave multiple reasons for ordering a CBCT
scan and for a change to a diagnosis or treatment plan.
For 5 of the 6 patient characteristics, participants
ordered CBCT scans more frequently (P \0.05) when
the most frequently cited reason for ordering
a CBCT scan (64% of orders), followed by root resorption
(33% of orders). Of the 72 observations on patients with
unerupted teeth, a CBCT scan was ordered 39 times
when the characteristic was present (54%) and only
twice when the characteristic was not present. Root
resorption was cited as the rationale for ordering
the CBCT scan 13 times when the characteristic was
present (54%) and 8 times (7%) when the characteristic
was not present. Severe skeletal discrepancy, TMJ
disorders, and airway problems were cited less
frequently, yet still significantly more frequently when
the characteristic was present. Crowding was offered
as a reason for ordering a scan but was not statistically
significant.
For 3 of the 6 patient characteristics—unerupted
tooth, root resorption, and severe skeletal discrep-
ancy—the participants reported changes to the diagnosis
and treatment plan significantly more frequently when
the characteristic was present. An unerupted tooth was
the most frequently cited reason for changes to the
diagnosis (15 instances, or 21% of the cases with the
characteristic present) and treatment plan (16 instances,
or 22%). It was never mentioned in cases without the
characteristic present. Root position or resorption was
present in fewer cases, and CBCT scans were ordered
for diagnostic reasons both when the characteristic
was present (3 times) and when it was not (2 times).
In proportion, it was the most common reason for
treatment plan changes (6 times, or 25%). Severe skeletal
discrepancy was reported as a reason for a change to
the diagnosis 5 times (11%). For the treatment plan,
6 changes occurred when there was a severe skeletal
discrepancy and once when it was not present. There
was no significant difference in the reasons cited for
ordering by the presence or absence of the characteristics
for TMJ disorder, airway problem, and crowding.

May 2013
Vol 143
Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Hodges, Atchison, and White 669

Table V. Summary of changes to diagnosis and treatment plan by patient characteristic

CBCT scan ordered Diagnosis change Treatment plan change
Characteristic
Patient characteristic n present n % SE (%) n % SE (%) n % SE (%)
Unerupted tooth 71 N 2 3 2 0 0 0 0 0 0
72 Y 39* 54 6 15* 21 5 16* 22 5
Root position/resorption 119 N 8 7 2 2 2 1 0 0 0
24 Y 13* 54 10 3* 13 7 6* 25 9
Severe skeletal discrepancy 96 N 3 3 2 0 0 0 1 1 1
47 Y 6* 13 5 5* 11 5 6* 13 5
TMD 119 N 9 8 2 6 5 2 1 1 1
24 Y 4* 17 8 3 13 7 2 8 6
Airway problem 72 N 3 4 2 3 4 2 3 4 2
71 Y 11* 15 4 3 4 2 3 4 2
Crowding 48 N 2 4 3 1 2 2 0 0 0
95 Y 8 8 3 2 2 1 4 4 2
N, No; Y, yes; TMD, TMJ disorder.
*Values significantly different (P \0.05).

Table VI. Treatment plan changes and effect on expected treatment outcome
Treatment plan change
Patient characteristic Treatment plan changes and outcome affected Proportion (%) SE (%)
Unerupted tooth 16 7 44 12
Root position/resorption 6 5 83 15
Severe skeletal discrepancy 7 7 100 0
TMD 3 2 67 27
Airway problem 6 5 83 15
Crowding 4 4 100 0
Total 42 30 71

TMD, Temporomandibular joint disorder.

Treatment outcome was defined as the expected
result of treatment as reported by the participants. We
evaluated the association between treatment plan
changes and expected effect on treatment outcome as
reported by the participants (Table VI). The presence of
unerupted teeth resulted in 16 treatment changes, and
the participants expected that 7 (44%) of these
would affect patient outcome. For the other patient
characteristics, the participants reported that the
changes would affect patient outcome for between
67% and 100% of the treatment plans.
The participants’ initial confidence ranged from
75% to 97% for diagnoses, and from 83% to 95% for
treatment plans (Fig 2). Patient cases 4 and 5 had the
lowest mean initial diagnosis confidence values; case 1
had the highest value. Significant increases in the
mean percentages of confidence in the diagnoses and
treatment plans were demonstrated for patient cases 2
to 6 after the participants viewed the CBCT scans (Fig 3).
We evaluated whether sex, practice experience, CBCT
use in private practice, or ownership of a CBCT machine
influenced the outcome variables (Table VII). Sex was
not significantly associated with any outcome variable.
Orthodontists in practice for a decade or less ordered
significantly fewer CBCT examinations than did more ex-
perienced orthodontists. Two orthodontists who reported
ordering CBCT scans for 90% to 100% of their patients in
private practice ordered significantly more CBCT exami-
nations than did the other orthodontists (100% vs
40%). These orthodontists also reported significantly
more changes to their diagnoses (75% vs 13%) and treat-
ment plans (83% vs 14%), and greater gains in confidence
than the 22 who ordered CBCT examinations for 0% to
15% of their private practice patients. Similarly, the 4 or-
thodontists who owned a CBCT machine ordered more
CBCT examinations (79% vs 38%) and reported more
changes to their diagnoses (63% vs 9%) and treatment
plans (67% vs 12%) and greater gains in confidence
than did the 20 who did not own a CBCT machine.
DISCUSSION
This study was designed to (1) investigate patients’
clinical characteristics associated with a decision by or-
thodontists to order CBCT examinations and (2) measure
the utility of these examinations in terms of their

American Journal of Orthodontics and Dentofacial Orthopedics May 2013
Vol 143
Issue 5
670 Hodges, Atchison, and White

Fig 2. Mean confidence intervals in the initial diagnoses and treatment plans. Error bars represent
standard deviations.

Fig 3. Mean changes in diagnoses and treatment plans. Error bars represent standard deviations.
*Significant change (P \0.05).

influence on diagnoses and treatment plans. Fryback
and Thornbury53 described a hierarchical model for
efficacy of studies in diagnostic imaging. These range
from radiographic studies assessing the technical
efficacy of the imaging system (level 1) to studies
measuring the societal benefit of imaging (level 6). Our
study measured diagnostic thinking and therapeutic
efficacy, whether the CBCT examination influences the
treatment plan (level 4) and, to some extent, patient
outcome efficacy, and whether the findings from the
examination are likely to change the patient’s outcome
(level 5).
The number of CBCT examinations requested varied
widely by participant, ranging from 2 participants who
never requested a scan to another 2 participants who
always ordered a scan, with most participants ordering
few CBCT scans. This pattern mirrored their stated
ordering practices in their private practices. These

May 2013
Vol 143
Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Hodges, Atchison, and White 671

Table VII. CBCT scan ordering patterns, number of changes to diagnosis and treatment plan, and mean change in
participant’s percentage of confidence
Number (%) of changes Mean confidence change (%)

Number (%) of CBCT Treatment

Participant characteristic n scans ordered Diagnosis Treatment plan Diagnosis plan
Sex
M (n 5 21) 125 56 (45) 25 (20) 27 (22) 10 9
F (n 5 3) 18 8 (44) 1 (6) 1 (6) 3 3
Years in practice
1-10 (n 5 6) 36 8 (22)* 4 (11) 5 (14) 10 11
11-29 (n 5 7) 42 22 (52) 7 (17) 9 (21) 10 9
301 (n 5 11) 65 34 (52) 15 (23) 14 (22) 7 6
% of patients having CBCT scan
0-15 (n 5 22) 131 52 (40) 17 (13) 18 (14) 6 6
90-100 (n 5 2) 12 12 (100)* 9 (75)* 10 (83)* 35* 33*
Own CBCT
N (n 5 20) 119 45 (38) 11 (9) 14 (12) 5 5
Y (n 5 4) 24 19 (79)* 15 (63)* 16 (67)* 26* 25*

M, Male; F, female; N, no; Y, yes.

*Significantly different (P \0.05).

findings suggest no wide agreement, at least among
these orthodontists with far-ranging experience and
educational backgrounds, regarding the appropriate
indications for making CBCT examinations.
Our participants requested a CBCT scan during
diagnosis and treatment planning substantially more
often than they reported using CBCT scans for patients
in their private practices (45% vs 12%). This discrepancy
might be attributable to the higher prevalence of patient
problems we selected for our test cases than in private
practice. For example, 33% of the patients in this study
had an impacted canine, whereas the prevalence of
impacted maxillary canines is 1% to 2.5%.52 Also, it might
have simply been easier to order a CBCT scan as a part of
this study when there was no financial or radiation cost
associated with it. Three participants stated that they re-
quested a CBCT scan “only if cost is not a factor.”
The number of CBCT scans ordered was associated
with case severity. Patient cases 4 and 5 were rated as
the most difficult by the investigators and an orthodon-
tic faculty member at the University of California at Los
Angeles, and those cases had the most CBCT scans
ordered by the participants (22 and 19, respectively).
Cases 1 and 2 were categorized as having a low degree
of difficulty, and they had 2 and 6 CBCT scans,
respectively, requested by the participants. This suggests
that most participants thought that traditional radio-
graphs were sufficient to diagnose and plan these cases.
Of the 6 patient characteristics cited as reasons for
a change to the diagnosis or treatment plan, unerupted
tooth, root resorption, and severe skeletal discrepancy
were the most frequent. For these characteristics, there
were significantly more changes to the diagnoses and
treatment plans when the case had the characteristic
when compared with cases without the characteristic.
This suggests that a benefit is gained from CBCT scans
when a patient has an unerupted tooth, root resorption
as diagnosed on a periapical or panoramic view, or
a severe skeletal discrepancy diagnosed on a lateral
cephalometric view. These patient characteristics were
also reported by Kapila et al29 as those most likely to
benefit from a CBCT examination. TMJ disorders, airway
difficulties, and crowding, however, were not associated
with significant changes in the diagnosis or treatment
plan. Because of our small sample size and the selection
of patient cases, the possibility of a benefit from a CBCT
scan for some patients with these characteristics cannot
be ruled out.
We considered the possibility that valuable informa-
tion might be discovered serendipitously: ie, findings on
the images ordered for reasons not related to the patient
characteristic prompting an examination. Indeed, 19 of
the 60 reasons reported for a change to the diagnosis
or treatment plan occurred when a CBCT scan was
ordered for an unrelated reason. However, among the
79 instances when a CBCT scan was not ordered, no
changes were reported in the subsequent evaluations
of these examinations. These findings suggest that there
is little utility to an examination made without a clinical
indication. Furthermore, a recent study associated an
increase in ionizing radiation exposure in children to
leukemia and brain cancer, emphasizing the importance
of the benefit of ionizing radiation outweighing the
risk.54 Because the likelihood of finding a significant

American Journal of Orthodontics and Dentofacial Orthopedics May 2013
Vol 143
Issue 5
672
abnormality is small, and most likely magnified due to
the relatively high number of problems in our cases,
we do not advise ordering a CBCT scan for patients not
otherwise indicated solely because of a chance of finding
something that will provide valuable information.
Diagnosis and treatment plan changes can range from
mild to major. To assess the clinical significance of
a change, the participants indicated whether they
thought that the information obtained from the CBCT
scan would influence the patient’s treatment outcome.
The presence of unerupted teeth resulted in the most
changes, yet had the least likelihood of affecting the
expected treatment outcome. Many treatment changes
from unerupted teeth had to do with the position of
the unerupted tooth in relation to the roots of adjacent
teeth and the mechanics that would be applied to bring
it into occlusion. Although this change is significant,
many participants believed that this would not substan-
tively change the eventual outcome of the treatment. On
the other hand, changes associated with skeletal
discrepancies and dental crowding affected the expected
treatment outcome 100% of the time. The treatment
changes to skeletal problems usually resulted in a decision
whether to have orthognathic surgery, which would have
a pronounced impact on the outcome of the treatment.
Although treatment plan changes for crowding were
relatively few, the change was usually from a decision
whether to extract teeth; this can influence the eventual
positions of teeth and the length of treatment.
The availability of a CBCT examination significantly
increased the confidence of orthodontists in their
diagnostic and treatment plans. The greatest increases
in confidence were found in the 2 participants who
reported making examinations of 90% to 100% of their
private patients or the 4 who own a CBCT machine.
Atchison et al3 found that the average confidence values
in the diagnosis and treatment plan after analyzing
study models, photographs, patient history, and
2-dimensional radiographs were 87% and 84%,
respectively. Our study began with analysis of all records
plus 2-dimensional radiographs; despite different
patient cases and different participants, we found
comparable initial confidence values in the diagnoses
and treatment plans (87% and 78%, respectively). The
increases in the confidence percentages after examining
the CBCT images was statistically significant for cases 2
through 6, suggesting that our participant orthodontists
received benefits for 5 of the 6 cases.
Those who own a CBCT machine or reported using
CBCT for more that 90% of their patients in private
practice ordered more CBCT examinations and reported
higher percentages of changes to the diagnosis and
treatment plan, and greater changes in their confidence
May 2013
Vol 143
Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Hodges, Atchison, and White
after viewing the CBCT images. This study was designed
to allow participants the freedom to manipulate the
CBCT data; thus, participants with more knowledge
and experience with CBCT should be better at extracting
information from the CBCT data. Those who had less
than 10 years of experience in practice (5 of the 6 had
less than 3 years of practice experience) had received
extensive instruction on the use of CBCT in residency
programs. Despite their familiarity with CBCT examina-
tions however, these recent graduates were not
significantly different when compared with those who
graduated before CBCT training was available in
residency programs with respect to changes in diagnoses
or treatment plans. They ordered these examinations
significantly less frequently than did their colleagues
who had been in practice longer. In this study, we
allowed for subjective responses on whether the
diagnosis and treatment plan changed, and the amount
of confidence that was gained. It might be that the
greater number of CBCT examinations ordered by those
who own a CBCT machine or use CBCT for more that
90% of their private patients, and their higher rates of
changes to diagnoses and treatment plans, and higher
levels of change in confidence, all primarily reflect
a personal preference of orthodontic records.
There were several limitation to this study. First, it
relied on self-selected participants; thus, the sample
could be biased from nonprobability sampling. This
sample size was sufficient to identify clear differences
among patient cases and 3 patient characteristics with
regard to the impact of CBCT on the diagnostic and
treatment planning process. However, with more cases,
we might have found significant differences for other
patient characteristics. A larger sample of cases would
also allow for a broader range of severity of the patient
characteristics to be evaluated, providing further
information as to when a CBCT scan should be ordered.
For example, we found that a CBCT scan is beneficial for
patients with severe root resorption, but CBCT might
contribute to cases with less severe root resorption if
those cases were available to show participants.
Although we demonstrated that CBCT scans contribute
to the diagnosis and treatment planning process in
some cases, we did not attempt to evaluate the accuracy
of the diagnoses and treatment plans provided.
CONCLUSIONS
The results of this study support obtaining a CBCT
scan before orthodontic diagnosis and treatment
planning when a patient has an unerupted tooth with
delayed eruption or a questionable location, severe
root resorption as diagnosed with a periapical or
Hodges, Atchison, and White
panoramic radiograph, or a severe skeletal discrepancy.
Obtaining a CBCT scan to examine for abnormalities
of the TMJ, airway, or crowding did not result in
significant changes in the diagnosis or the treatment
plan. We propose that CBCT scans should only be
ordered when there is a clear, specific, and clinical
justification for the patient. Our findings do not support
a CBCT examination of every patient.
We thank the 24 orthodontists who gave generously
of their time for this project, Kang Ting for his guidance,
and Jeffrey Gornbein for his statistical support.
REFERENCES
1. Graber TM, Vanarsdall RL, Vig KWL. Orthodontics: current
principles and techniques. 4th ed. St Louis: Elsevier Mosby; 2005.
2. Proffit WR, Fields HW, Sarver DM. Contemporary orthodontics. 4th
ed. St Louis: Mosby Elsevier; 2007.
3. Atchison KA, Luke LS, White SC. Contribution of pretreatment
radiographs to orthodontists’ decision making. Oral Surg Oral
Med Oral Pathol 1991;71:238-45.
4. Tso HH, Lee JS, Huang JC, Maki K, Hatcher D, Miller AJ. Evaluation
of the human airway using cone-beam computerized tomography.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:
768-76.
5. El H, Palomo JM. Measuring the airway in 3 dimensions:
a reliability and accuracy study. Am J Orthod Dentofacial Orthop
2010;137(Supp):S50.e1-9; discussion S50-2.
6. Osorio F, Perilla M, Doyle DJ, Palomo JM. Cone beam computed
tomography: an innovative tool for airway assessment. Anesth
Analg 2008;106:1803-7.
7. Schendel SA, Hatcher D. Automated 3-dimensional airway analysis
from cone-beam computed tomography data. J Oral Maxillofac
Surg 2010;68:696-701.
8. Mah JK, Huang JC, Choo H. Practical applications of cone-beam
computed tomography in orthodontics. J Am Dent Assoc 2010;
141(Supp 3):7S-13S.
9. van Vlijmen OJ, Kuijpers MA, Berge SJ, Schols JG, Maal TJ,
Breuning H, et al. Evidence supporting the use of cone-beam
computed tomography in orthodontics. J Am Dent Assoc 2012;
143:241-52.
10. Librizzi ZT, Tadinada AS, Valiyaparambil JV, Lurie AG, Mallya SM.
Cone-beam computed tomography to detect erosions of the
temporomandibular joint: effect of field of view and voxel size
on diagnostic efficacy and effective dose. Am J Orthod Dentofacial
Orthop 2011;140:e25-30.
11. Roza MR, Silva LA, Januario AL, Fioravanti MC, Barriviera M.
Cone beam computed tomography in the diagnosis of tempo-
romandibular joint alterations in cats. J Feline Med Surg 2011;
13:393-8.
12. Alexiou K, Stamatakis H, Tsiklakis K. Evaluation of the severity of
temporomandibular joint osteoarthritic changes related to age
using cone beam computed tomography. Dentomaxillofac Radiol
2009;38:141-7.
13. Honey OB, Scarfe WC, Hilgers MJ, Klueber K, Silveira AM,
Haskell BS, et al. Accuracy of cone-beam computed tomography
imaging of the temporomandibular joint: comparisons with
panoramic radiology and linear tomography. Am J Orthod
Dentofacial Orthop 2007;132:429-38.
14. Hilgers ML, Scarfe WC, Scheetz JP, Farman AG. Accuracy of linear
temporomandibular joint measurements with cone beam
American Journal of Orthodontics and Dentofacial Orthopedics
673
computed tomography and digital cephalometric radiography.
Am J Orthod Dentofacial Orthop 2005;128:803-11.
15. Guerrero ME, Shahbazian M, Elsiena Bekkering G, Nackaerts O,
Jacobs R, Horner K. The diagnostic efficacy of cone beam CT for
impacted teeth and associated features: a systematic review.
J Oral Rehabil 2011;38:208-16.
16. Bjerklin K, Ericson S. How a computerized tomography examina-
tion changed the treatment plans of 80 children with retained
and ectopically positioned maxillary canines. Angle Orthod
2006;76:43-51.
17. Katheria BC, Kau CH, Tate R, Chen JW, English J, Bouquot J.
Effectiveness of impacted and supernumerary tooth diagnosis
from traditional radiography versus cone beam computed
tomography. Pediatr Dent 2010;32:304-9.
18. Maverna R, Gracco A. Different diagnostic tools for the localization
of impacted maxillary canines: clinical considerations. Prog Orthod
2007;8:28-44.
19. Botticelli S, Verna C, Cattaneo PM, Heidmann J, Melsen B. Two-
versus three-dimensional imaging in subjects with unerupted
maxillary canines. Eur J Orthod 2011;33:344-9.
20. Haney E, Gansky SA, Lee JS, Johnson E, Maki K, Miller AJ, et al.
Comparative analysis of traditional radiographs and cone-beam
computed tomography volumetric images in the diagnosis and
treatment planning of maxillary impacted canines. Am J Orthod
Dentofacial Orthop 2010;137:590-7.
21. Nguyen E, Boychuk D, Orellana M. Accuracy of cone-beam
computed tomography in predicting the diameter of unerupted
teeth. Am J Orthod Dentofacial Orthop 2011;140:e59-66.
22. Becker A, Chaushu S, Casap-Caspi N. Cone-beam computed
tomography and the orthosurgical management of impacted
teeth. J Am Dent Assoc 2010;141(Supp 3):14S-8S.
23. Liu DG, Zhang WL, Zhang ZY, Wu YT, Ma XC. Localization of
impacted maxillary canines and observation of adjacent incisor
resorption with cone-beam computed tomography. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 2008;105:91-8.
24. Oberoi S, Knueppel S. Three-dimensional assessment of impacted
canines and root resorption using cone beam computed tomogra-
phy. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;113:260-7.
25. Swennen GR, Mollemans W, De Clercq C, Abeloos J, Lamoral P,
Lippens F, et al. A cone-beam computed tomography triple scan
procedure to obtain a three-dimensional augmented virtual skull
model appropriate for orthognathic surgery planning. J Craniofac
Surg 2009;20:297-307.
26. da Motta AT, de Assis Ribeiro Carvalho F, Oliveira AE,
Cevidanes LH, de Oliveira Almeida MA. Superimposition of 3D
cone-beam CT models in orthognathic surgery. Dent Press J
Orthod 2010;15:39-41.
27. Almeida RC, Cevidanes LH, Carvalho FA, Motta AT, Almeida MA,
Styner M, et al. Soft tissue response to mandibular advancement
using 3D CBCT scanning. Int J Oral Maxillofac Surg 2011;40:
353-9.
28. Cevidanes LH, Tucker S, Styner M, Kim H, Chapuis J, Reyes M, et al.
Three-dimensional surgical simulation. Am J Orthod Dentofacial
Orthop 2010;138:361-71.
29. Kapila S, Conley RS, Harrell WE Jr. The current status of cone beam
computed tomography imaging in orthodontics. Dentomaxillofac
Radiol 2011;40:24-34.
30. AlHadidi A, Cevidanes LH, Mol A, Ludlow J, Styner M. Comparison
of two methods for quantitative assessment of mandibular
asymmetry using cone beam computed tomography image
volumes. Dentomaxillofac Radiol 2011;40:351-7.
31. Cevidanes LH, Alhadidi A, Paniagua B, Styner M, Ludlow J, Mol A,
et al. Three-dimensional quantification of mandibular asymmetry
May 2013
Vol 143
Issue 5
674
through cone-beam computerized tomography. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2011;111:757-70.
32. Damstra J, Fourie Z, Ren Y. Evaluation and comparison of
postero-anterior cephalograms and cone-beam computed
tomography images for the detection of mandibular asymmetry.
Eur J Orthod 2013;35:45-50.
33. de Moraes ME, Hollender LG, Chen CS, Moraes LC, Balducci I.
Evaluating craniofacial asymmetry with digital cephalometric
images and cone-beam computed tomography. Am J Orthod
Dentofacial Orthop 2011;139:e523-31.
34. Kook YA, Kim Y. Evaluation of facial asymmetry with three-
dimensional cone-beam computed tomography. J Clin Orthod
2011;45:112-5.
35. Lund H, Grondahl K, Grondahl HG. Cone beam computed
tomography for assessment of root length and marginal bone level
during orthodontic treatment. Angle Orthod 2010;80:466-73.
36. Makedonas D, Lund H, Grondahl K, Hansen K. Root resorption
diagnosed with cone beam computed tomography after 6 months
of orthodontic treatment with fixed appliance and the relation to
risk factors. Angle Orthod 2012;82:196-201.
37. Peck JL, Sameshima GT, Miller A, Worth P, Hatcher DC. Mesiodistal
root angulation using panoramic and cone beam CT. Angle Orthod
2007;77:206-13.
38. Dudic A, Giannopoulou C, Leuzinger M, Kiliaridis S. Detection of
apical root resorption after orthodontic treatment by using
panoramic radiography and cone-beam computed tomography
of super-high resolution. Am J Orthod Dentofacial Orthop 2009;
135:434-7.
39. Sherrard JF, Rossouw PE, Benson BW, Carrillo R, Buschang PH.
Accuracy and reliability of tooth and root lengths measured on
cone-beam computed tomographs. Am J Orthod Dentofacial
Orthop 2010;137(Supp):S100-8.
40. Fayed MM, Pazera P, Katsaros C. Optimal sites for orthodontic
mini-implant placement assessed by cone beam computed
tomography. Angle Orthod 2010;80:939-51.
41. Morea C, Hayek JE, Oleskovicz C, Dominguez GC, Chilvarquer I.
Precise insertion of orthodontic miniscrews with a stereolitho-
graphic surgical guide based on cone beam computed tomogra-
phy data: a pilot study. Int J Oral Maxillofac Implants 2011;26:
860-5.
42. Qiu L, Haruyama N, Suzuki S, Yamada D, Obayashi N,
Kurabayashi T, et al. Accuracy of orthodontic miniscrew implanta-
May 2013
Vol 143
Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Hodges, Atchison, and White
tion guided by stereolithographic surgical stent based on
cone-beam CT-derived 3D images. Angle Orthod 2012;82:284-93.
43. Gracco A, Lombardo L, Cozzani M, Siciliani G. Quantitative
cone-beam computed tomography evaluation of palatal bone
thickness for orthodontic miniscrew placement. Am J Orthod Den-
tofacial Orthop 2008;134:361-9.
44. Kim SH, Choi YS, Hwang EH, Chung KR, Kook YA, Nelson G. Surgical
positioning of orthodontic mini-implants with guides fabricated on
models replicated with cone-beam computed tomography. Am J Or-
thod Dentofacial Orthop 2007;131(Supp):S82-9.
45. Kim GT, Kim SH, Choi YS, Park YJ, Chung KR, Suk KE, et al. Cone-
beam computed tomography evaluation of orthodontic miniplate
anchoring screws in the posterior maxilla. Am J Orthod Dentofacial
Orthop 2009;136:628.e1-10; discussion 28-9.
46. Kim SH, Yoon HG, Choi YS, Hwang EH, Kook YA, Nelson G.
Evaluation of interdental space of the maxillary posterior area
for orthodontic mini-implants with cone-beam computed
tomography. Am J Orthod Dentofacial Orthop 2009;135:635-41.
47. Merrett SJ, Drage NA, Durning P. Cone beam computed
tomography: a useful tool in orthodontic diagnosis and treatment
planning. J Orthod 2009;36:202-10.
48. Hechler SL. Cone-beam CT: applications in orthodontics. Dent Clin
North Am 2008;52:809-23, vii.
49. De Vos W, Casselman J, Swennen GR. Cone-beam computerized
tomography (CBCT) imaging of the oral and maxillofacial region:
a systematic review of the literature. Int J Oral Maxillofac Surg
2009;38:609-25.
50. White SC, Pae EK. Patient image selection criteria for cone
beam computed tomography imaging. Semin Orthod 2009;15:
19-28.
51. Silva MA, Wolf U, Heinicke F, Bumann A, Visser H, Hirsch E. Cone-
beam computed tomography for routine orthodontic treatment
planning: a radiation dose evaluation. Am J Orthod Dentofacial
Orthop 2008;133:640.e1-5.
52. Cooke J, Wang HL. Canine impactions: incidence and manage-
ment. Int J Periodontics Restorative Dent 2006;26:483-91.
53. Fryback DG, Thornbury JR. The efficacy of diagnostic imaging.
Med Decis Making 1991;11:88-94.
54. Pearce MS, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, et al.
Radiation exposure from CT scans in childhood and subsequent
risk of leukaemia and brain tumours: a retrospective cohort study.
Lancet 2012;380:499-505.