Interpretation of CBCT

Interpretation of CBCT
Resource faculties:
Dr. Jyotsna Rimal, Prof. and Head
Dr. Iccha Kumar Maharjan, Associate Prof.
Dr. Pragya Regmee, Assistant Prof.
Dr. Abhinaya Luitel, Senior Resident
Presenter :
Sagar Adhikari
JR III 1
2
Contents:
• Essential elements of a CBCT radiographic
report
• Patient information
• Scan information
• Radiologic findings
• Radiologic impression
• General principles of CBCT reporting
• Normal anatomic landmarks in Maxillofacial
CBCT Images
• Artifacts in CBCT
3
Essential Elements of a CBCT Radiographic
Report
White SC, Pharoah MJ. Oral radiology-E-Book: Principles and interpretation. Elsevier
Health Sciences; 2014 May 1.
4
Patient information
• Patient’s name
• Unique identifier code
• Date of birth
• Referring practitioner’s name
• Rationale for procedure
5
Scan information
• Succession number
• Date of procedure
• Date of reporting
• Location of facility
• Equipment used
• Scan parameters
• Images provided
6
Image quality
• Problems encountered during procedure (e.g.

patient motion)
• Artifacts that compromise diagnostic evaluation
7
Radiologic findings
• General findings (Gnathic):
Dental status including specific missing teeth
Restorative status
Root canal
Filled teeth
Peri-apical lesions
General marginal alveolar bone status
Status of edentulous region
8
• Extragnathic
TMJ
Para-nasal sinuses
Nasopharyngeal airway
Soft tissue of the neck
Intracranial calcifications
9
• Structures specific findings should provide

observations addressing rationale for procedure
• Significant incidental findings should be identified
10
Radiologic impression
• Definitive or differential diagnosis, related to
rationale for imaging examination or clinically
significant incidental findings.
• Correlation to patient presentation addressing

pertinent clinical issues.
11
Radiologic impression
• Comparison with previous imaging studies, if
available.
• Recommendations for follow-up or additional

diagnostic or clinical studies, as appropriate, to
clarify, confirm, or exclude diagnosis.
12
Task-specific applications
• Diagnosis and preoperative assessment
• Impaction
• Location of inferior alveolar nerve canal
• Implant placement
• Trauma
• Odontogenic/ non-odontogenic cyst/ neoplasm
• Maxillary sinus
• TMJ evaluation
• Airway analysis
• Ortho mini implants
• Bone structures (Dehiscence, fenestration,
periodontal defects)
13
• Endodontics
• Canal morphology
• Location of inferior alveolar nerve canal
• Root fractures
• Resorption – internal/external
• Pre-surgical evaluation
• Evaluation of healing
14
General principles
• Evaluate the imaged volume systematically in axial,

coronal and sagittal planes
• Anatomic structures must be identified
• Symmetry and the continuity of the bony outlines
must be assessed
• Images are displayed as multiplanar
reconstructions in 3 orthogonal planes; for ease of
visualization, the imaged volume may have to be
reoriented
15
• Reorient the axial planes to facilitate viewing of

specific structures
-parallel to Frankfort plane when examining the

skull base
-parallel to occlusal plane when examining the

dentoalveolar arch
16
• View the entire image volume in all three

orthogonal planes may be necessary to make
additional custom reconstructions in specific
planes
17
Basic tomographic planes
The axial plane The sagittal plane The coronal plane
Abramovitch K, Rice DD. Basic principles of cone beam computed tomography. Dental Clinics of
North America. 2014 Jul 1;58(3):463-84.
18
19
TASK SPECIFIC REPORTING

20
Implant Planning
Images provided: Cone Beam CT images in the
bone window. Axial, coronal & sagittal planes.
Voxel size: 150 µm KV: 90 mA: 14 s: 15.031
Radiographic Findings:
Missing teeth with respect
to 21
Root canal filling material
present with respect to 11, 22
21
Implant Planning
16.61
22
23
24
Radicular Cyst
25
Radicular Cyst
26
27
Two rooted maxillary incisor (11)
28
29
30
31
Impacted Tooth
32
Impacted Tooth
33
34
35
36
ANATOMIC LANDMARKS
37
Axial sections
1. Frontal sinus
2. Frontal bone
3. Anterior cranial
fossa
4. Squamous
portion of
temporal bone
Axial section of head : above the level of orbit

Axial section head: through the 38
supra-orbital ridge
1. Frontal sinus
2. Frontal bone
5. Crista galli
6. Orbit
7. Greater wing of
sphenoid
39
Axial section head: at the level of
orbits(superior half)
8. Nasal bone
9. Anterior ethmoidal
air cells
10.Perpendicular
plate of ethmoid
bone
11.Posterior
ethmoidal air cells
12.Optic canal
13.Superior orbital
fissure
Axial section head: at the level 40
of orbits(inferior half)
8. Nasal bone
air cells
11. Posterior ethmoidal
air cells
14. Nasal process of
maxillary bone
15. Uncinate process
16. Sphenoethmoidal
recess
17. Sphenoidal sinus
18. Floor of sella
turcica
of infra-orbital margin
8. Nasal bone
air cells
11. Posterior ethmoidal
cells
14. Nasal process of
maxillary bone
17. Sphenoidal sinus
19. Nasolacrimal duct
20. Superior turbinate
21. Inferior orbital
fissure
22. Middle cranial
fossa
below the orbit (roof of the
Maxillary Sinus)
1. Nasal septum
3. Maxillary sinus
4. Nasal turbinate
5. Zygomatic process of
maxilla
6. Zygomaticomaxillary
suture
7. Zygomatic arch
8. Pterygopalatine fossa
9. Greater wing of sphenoid
10. Carotid canal
11. Petrous part of temporal
bone
12. Internal auditory canal
43
Axial section head: at the
level of the glenoid fossa
3. Maxillary sinus
4. Nasal turbinates
7. Zygomatic arch
13. Infraorbital canal
14. Lateral wall of maxillary
sinus
15. Pterygomaxillary fissure
16. Foramen ovale
17. Foramen spinosum
18. Glenoid fossa
19. Mandibular condylar
head
20. Carotid canal
44
Axial section at the level of
mandibular condyle
1. Nasal septum
3. Maxillary sinus
4. Nasal turbinate
19.Mandibular condyle
20.Carotid canal
21.Infraorbital foramen
22.Nasal cavity
23.Pterygoid plates
24.Nasopharyngeal
airway
25.Occipital bone
26.Jugular bulb
45
Axial section at the level of
maxillary sinus
3. Maxillary sinus
4. Nasal turbinates
19. Mandibular condylar
head
23. Pterygoid plates
24. Nasopharyngeal
airway
27. Medial wall of
maxillary sinus
28. Coronoid process
29. Pharyngeal wall
30. External auditory
meatus
31. Mastoid process
46
Axial section through the
hard palate
3. Maxillary sinus
14. Lateral wall of
maxillary sinus
31. Mastoid process
32. Anterior nasal spine
33. Nasopalatine canal
34. Hard palate
35. Intermaxillary suture
36. Ramus of mandible
37. Anterior arch of atlas
38. Foramen magnum
47
apices of maxillary teeth
1. Incisive foramen
2. Tongue
3. Maxillary tuberosity
4. Soft palate
5. Oropharyngeal airway
space
6. Styloid process
7. Anterior Arch of atlas
8. Odontoid process of
C2
48
Axial section through

maxillary occlusal plane
5. Oropharyngeal
airway space
6. Styloid process
9. Ramus of
mandible
10. Lingula
49
Axial section through

mandibular teeth
11. Inferior body of C2

12. Transverse
foramen
13. Lamina of C2
50
body of mandible
14. Mandibular
symphysis
15. Genial tubercle
16. Mental foramen
17. Epiglottis
51
lower border of mandible
18. Body of hyoid

19. Greater cornu of
hyoid
20. C2 – C3 neural
foramen
21. Superior articular
process of C3
22. Inferior articular
process of C2
52
The coronal sections

• Structures that have a postero-anterior orientation
are best visualized in these section
• The nasal cavity

• The para-nasal sinuses
• The temporomandibular joint space
53
Coronal section through
anterior third of nasal cavity
1. Frontal bone
2. Frontal sinus
3. Nasal bone
4. Maxillary bone
5. Nasal septum
6. Inferior nasal
turbinate
54
Coronal section through the
anterior third of nasal cavity
2. Frontal sinus
7. Ethmoid air cells
10. Maxillary sinus
11. Nasopalatine
canal
12. Incisive foramen
55
Coronal section of face: at

the level of premolar
1. Frontal bone
6. Inferior nasal
turbinate
10.Maxillary sinus
13.Orbit
14.Middle nasal
turbinate
15.Zygomatic process
of maxilla
56
the level of 1st molar
6. Inferior nasal turbinate

14. Middle nasal turbinate
17. Crista galli of ethmoid
bone
18. Fronto-zygomatic suture
19. Uncinate process
20. Infraorbital ethmoid air
cells
21. Ostium of maxillary sinus
57
the level of molar teeth

2. Superior nasal
turbinate
3. Middle nasal
turbinate
4. Zygomatic arch
5. Maxillary sinus
6. Inferior nasal
turbinate
7. Hard palate
58
Coronal section of face at
the level of maxillary
tuberosity

2. Superior nasal turbinate
8. Sphenoid bone
9. Inferior orbital fissure
10. Perpendicular plate of
ethmoid bone
11. Coronoid process of
mandible
12. Maxillary tuberosity
13. Mandibular canal
59
mandibular ramus(anterior
1/3)
8. Sphenoid bone
9. Inferior Orbital fissure
14. Sphenoid sinus
15. Pterygopalatine
fossa
16. Lateral Pterygoid
plate
17. Medial Pterygoid
plate
18. Mandibular ramus
60
mandibular ramus(middle
1/3)

14. Sphenoid sinus
19. Floor of sella
20. Anterior Clinoid
process
21. Optic canal
22. Foramen rotundum
23. Pterygoid (vidian)
canal
24. Nasopharyngeal
airway
61
mandibular ramus(posterior
1/3)
19. Floor of sella

20. Anterior Clinoid
process
25. Squamous temporal
bone
26. Zygomatic process of
temporal bone
27. Spheno-squamosal
suture
28. Foramen ovale
29. Palatine tonsils
30. Hyoid bone
62
mandibular condyle
1.Glenoid fossa
2. Mandibular
condyle
3. Foramen
spinosum
4. Basiocciput
5. Carotid canal
6. Petrooccipital
suture
7. Styloid process
63
Coronal section through
the external auditory
meatus
10. Semicircular canal

11. External auditory
meatus
12. Odontoid process of
C2
13. Ossicles of ear
14. Occipital condyles
15. Lateral mass of C1
64
cervical vertebrae
16. Mastoid air cells

18. Jugular foramen
22. Foramen
magnum
23. Mastoid process
65
Mid-sagittal section of
head
1. Frontal bone
2. Frontal sinus
3. Nasal bone
4. Sella turcica
5. Sphenoid sinus
6. Clivus
7. Anterior Nasal spine
8. Nasopalatine canal
9. Hard palate
10. Incisive foramen
11.Mandibular symphysis
66
Sagittal section of head :
through nasal cavity (lateral
1/3)
12.Nasopharyngeal airway
13. Oropharynx
14. Epiglottis
15. Hyoid bone
16. Hypopharynx
17. Anterior arch of C1
18. Odontoid process of C2
19. Posterior arch of C1
20. Spinous process of C2
21. Body of C3
22. Body of C4
67
Sagittal section of head:

through lateral nasal wall
2. Frontal sinus
5. Sphenoid sinus
9. Hard palate
13. Oropharyngeal airway
14. Epiglottis
24. Hiatus semilunaris
25. Middle turbinate
26. Inferior turbinate
27. Soft palate
28. Base of tongue
29. Vallecula
68
through the orbit and the
maxillary sinus (through
premolar)
2. Frontal sinus
19. Posterior arch of C1
30. Orbit
31. Floor of orbit
32. Maxillary sinus
33. Floor of maxillary
sinus
34.Pterygopalatine fossa
35. Occipital condyle
69
through the lateral wall of
orbit
36. Ossicles of middle

ear
37. Mastoid process
38. Artricular
eminence
39. Mandibular
condyle
70
Sagittal section of mandible
through the midline
Sagittal section of 71
mandible: through
incisor
2. Lingual foramen
72
Sagittal section of
mandible : through
premolar region
3. Mental foramen
4. Mandibular canal
73
Sagittal section of
mandible: through
molars
4. Mandibular canal
5. Submandibular fossa
6. Inferior border of mandible
74
Sagittal section of mandible:
through the ramus and
lingula
4. Mandibular canal
6. Inferior border of
mandible
7. Lingula
75
Artifacts in CBCT
• Any distortion or error in the image that is unrelated
to the subject being studied.
• Inherent artifact
• Procedure related artifact
• Introduced artifact
• Patient motion artifact
Nagarajappa AK, Dwivedi N, Tiwari R. Artifacts: The downturn of CBCT image. Journal
of International Society of Preventive & Community Dentistry. 2015 Nov;5(6):440.
76
Inherent artifact
• Arise from limitations in the physical processes
involved in the acquisition of CBCT data.
• Produced due to the beam projection geometry
of CBCT, reduced trajectory rotational arcs, and
image reconstruction methods.
• Scatter
• Partial volume averaging
• Cone beam effect
Nagarajappa AK, Dwivedi N, Tiwari R. Artifacts: The downturn of CBCT image. Journal
of International Society of Preventive & Community Dentistry. 2015 Nov;5(6):440.
77
Scatter
78
Partial volume averaging:
• Feature of both MDCT and CBCT imaging.
• Occurs when the selected voxel size of the

scan is larger than the size of the object being
imaged.
79
Aliasing artifacts :
• Divergent beam
• Results in a line
patterns commonly
diverging towards the
periphery
Nagarajappa AK, Dwivedi N, Tiwari R.

Artifacts: The downturn of CBCT image.
Journal of International Society of Preventive
& Community Dentistry. 2015 Nov;5(6):440.
80
Procedure-Related Artifacts
• Scanner-related artifacts appear as circular or
ring streaks resulting from imperfections in
scanner detection or poor calibration
• Either of these problems results in a

consistently repetitive reading at each angular
position of the detector, resulting in a circular
artifact.
81
Introduced Artifacts
• As an x-ray beam passes through an object,
lower energy photons are absorbed in
preference to higher energy photons.
82
Introduced Artifacts
• Called beam hardening, results in two types of
artifact:
(1)distortion of metallic structures as a result of
differential absorption, known as a cupping
artifact, and
(2)Streaks and dark bands, which, when
present between two dense objects, create
extinction or missing value artifacts
83
Motion artifact
84
SUMMARY
Essential elements of a CBCT radiographic
report
85
86
87
88
MCQ
1. Which of the following is inherent artifact?

a. Scatter
b. Motion
c. Beam hardening
d. All
Answer: a
89
Which of the following anatomic landmark is

NOT visible in axial section above orbit?
a. Frontal sinus
b. Frontal bone
c. Middle cranial fossa
d. Squamous part of temporal bone
Answer: b
90
Which of the following is an essential factor to

formulate a radiographic diagnosis?
a. Age
b. Clinical information
c. Image quality/Artifacts
d. All
Answer: d
91
Conclusion :
• The successful identification of an unknown entity
lies in the ability of observer to approach it from all
perspectives
• The diagnostic efficiency is based on our sound

knowledge of anatomy and our skill to retrieve
relevant diagnostic information.
92
References:
• White SC, Pharoah MJ. Oral radiology-E-Book: Principles and interpretation. Elsevier Health Sciences;
2014 May 1.
• Angelopoulos C. Cone beam tomographic imaging anatomy of the maxillofacial region. Dent Clin North
Am 2008;52(4):731–52.
• Angelopoulos C. Anatomy of the maxillofacial region in the three planes of section. Dent Clin N Am 58
(2014) 497–521
• Abramovitch K, Rice DD. Basic principles of cone beam computed tomography. Dental Clinics of North
America. 2014 Jul 1;58(3):463-84.
• Whaites E, Drage N. Essentials of dental radiography and radiology. Elsevier Health Sciences; 2013
Jun 20.
• Horner K, Islam M, Flygare L, Tsiklakis K, Whaites E. Basic principles for use of dental cone beam
computed tomography: consensus guidelines of the European Academy of Dental and Maxillofacial
Radiology. Dentomaxillofacial Radiology. 2009 May;38(4):187-95.
• Venkatesh E, Elluru SV. Cone beam computed tomography: basics and applications in dentistry. Journal
of Istanbul University Faculty of Dentistry. 2017;51(3 Suppl 1):S102.
• Scarfe WC, Farmna AG, Sukovic P. Clinical applications of cone beam tomography in dental practice. J
Can Dent Assoc. 2006;72:75–80.
• Ludlow JB, Ivanovic M. Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and
maxillofacial radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106:106–114
• Hatcher DC (October 2010). "Operational principles for cone-beam computed tomography". Journal of
the American Dental Association (1939) 141 (Suppl 3): 3S–6S.PMID
• Carter L, Farman AG, Geist J, et al. American Academy of Oral and Maxillofacial Radiology executive
opinion statement on performing and interpreting diagnostic cone beam computed tomography. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106:561–562.
93
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Interpretation of CBCT

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Interpretation of CBCT

• Unique identifier code

• Referring practitioner’s name

• Rationale for procedure

• Problems encountered during procedure (e.g.

• Artifacts that compromise diagnostic evaluation

• Structures specific findings should provide

• Significant incidental findings should be identified

• Correlation to patient presentation addressing

• Recommendations for follow-up or additional

• Evaluate the imaged volume systematically in axial,

• Reorient the axial planes to facilitate viewing of

-parallel to Frankfort plane when examining the

-parallel to occlusal plane when examining the

• View the entire image volume in all three

TASK SPECIFIC REPORTING

Axial section of head : above the level of orbit

Axial section through

Axial section through

11. Inferior body of C2

18. Body of hyoid

The coronal sections

• The nasal cavity

Coronal section of face: at

6. Inferior nasal turbinate

1. Ethmoid air cells

1. Ethmoid air cells

13. Mandibular canal

19. Floor of sella

10. Semicircular canal

16. Mastoid air cells

Sagittal section of head:

36. Ossicles of middle

Partial volume averaging:

• Feature of both MDCT and CBCT imaging.

• Occurs when the selected voxel size of the

Nagarajappa AK, Dwivedi N, Tiwari R.

• Either of these problems results in a

1. Which of the following is inherent artifact?

Which of the following anatomic landmark is

Which of the following is an essential factor to

• The diagnostic efficiency is based on our sound

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