Radiology course –summary of Dr Ahmed Abd Al Samad lectures

Who May Own & Operate A CBCT Machine?

 As far as the taking of images is concerned, especially extra-oral films, the practice of
oral and maxillofacial radiology varies across the world.
 In some countries, most of the exposures are performed in individual dental offices, while
in others dentists refer patients to dental radiology centers.
 When CBCT first appeared on the market in the United States, almost all of the machines
were purchased by radiology centers or dental schools.
 There is an increasing trend, however, for individual offices to purchase CBCT machines.
 This is in part because manufacturers are making ‘‘mini’’ machines, which are both
smaller and cheaper than earlier CBCT machines, and marketing them to individual dentists.
 This raises the question of who may own and operate a CBCT machine
 It is not allowed for a dentist to own or operate a CBCT machine without special training.
 The law may require that CBCT machines be operated only by a
radiologist.

How large should the field of view be?

 According to accepted radiologic principles, the indications for and the extent of imaging
should be based on clinical indications
 One can also collimate too narrowly and there by exclude anatomy that ought to be
covered to avoid including anatomic structures that they are uncomfortable interpreting.
 As the increase of the trend for CBCT machines to be bought by dentists who are not oral
and maxillofacial radiologists.
 In doing this, however, there is a risk of missing relevant information

Who should interpret the CBCT scans?

 The dentist is responsible not only for reading the scan in the area of reason for which the
image was taken, but also for reading all of the anatomy in the entire volume
 Dentists who take their own CBCT scans are not required to read the scan themselves but
can refer the patient to an oral and maxillofacial radiologist.
X-ray effects
 When patients undergo X-ray examinations, millions of photons pass through their
bodies.
 These can damage any molecule by ionization, but damage to the DNA in the
chromosomes is of particular importance.
 Most DNA damage is repaired immediately, but rarely a portion of a chromosome may
be permanently altered (a mutation). This may lead ultimately to the formation of a tumor.
 The latent period between exposure to X-rays and the clinical diagnosis of a tumor may
be many years.
 The effects described above are believed to have no threshold radiation dose below which
they will not occur.
 They can be considered as “chance” (stochastic) effects, where the magnitude of the
risk, though not the severity of the effect, is proportional to the radiation dose.

Principles Of Radiation Protection

1- Justification:
 Doing more good than harm to the patient
 Justification is the responsibility of the dental personnel.
 ALARA principle (As Low As Reasonably Achievable)
 An optimized medical exposure is not always the one with the lowest dose but the one
which carefully balances the harm from the exposure and the resources available for the
protection of individuals to get the required information
Examples of optimization of exposure in diagnostic radiology are:
 Improvement of radiation detectors.
 Selection of appropriate exposure parameters
 Use of shielding devices.
 Selection of a radiographic projection in which radiosensitive organs receive the
minimum dose.
 Another aspect of optimization is the establishment and
use of diagnostic
 DRLs, based upon surveys of dose-area product or other easily measured quantities, may
be set as standards against which X-ray equipment and their operation by clinicians can be
assessed as part of quality assurance

CBCT Equipment Factors in the Reduction of Radiation Risk to Patients:

 The X-ray tube voltage, the tube current and the exposure time:
 Field of View & Collimation:
 Examinations must use the smallest that is compatible with the clinical situation if this
provides less radiation dose to the patient.
 In endodontic applications, it is likely that only small volume examinations would be
required
 FPDs (flat panel detectors) have greater sensitivity to X-rays than IIs (image intensifiers)
Therefore have the potential to reduce patient dose.
 They have higher spatial and contrast resolution and fewer artefacts than IIs but, in
general, IIs are cheaper than FPDs
 Examinations should use the largest voxel size (lowest dose) consistent with acceptable
diagnostic accuracy
 In endodontic applications, it is likely that only high resolution, small volume,
examinations would be required
 There is no evidence for the routine use of abdominal shielding (“lead aprons”) during
dental CBCT examinations. Shielding devices could be used to reduce doses to the thyroid gland
where it lies close to the primary beam

Which Radiographic Technique used?

Intra-oral Periapical Radiographs are still most commonly exposed during
endodontic procedures.
 Optimum Viewing Conditions:
1. A standard viewing box
2. Masking light outside the radiograph
3. Magnification of the area of interest.
Information gained from either conventional and digital periapical radiographs is limited
by:
1- (2D) image for 3D anatomy ------- superimposition
2- Geometric distortion Even with paralleling technique:
 Anatomy of the oral cavity (as a shallow palatal vault) may prevent ideal positioning of
the intra-oral image receptor even when using a beam-aiming device.
 The ideal positioning of solid-state digital sensors may be even more
challenging as a result of their Rigidity and Bulk compared with conventional X-ray
films and phosphor plate digital sensors
 when a ‘textbook’ paralleling technique radiograph can be exposed, the operator must
anticipate a small degree (approximately 5%) of magnification in the final image (caused
by). the object and the image receptor being slightly separated and the X-ray beam being
slightly divergent
 The use of a long cone may limit, but will not eliminate this magnification
3-Anatomical noise
 Anatomical structures may obscure the area of interest, resulting in difficulty in
interpreting radiographic images.
 These anatomical features may be Radiopaque (zygomatic process of maxilla) or
Radiolucent (maxillary sinus). Zygomatic process of maxilla obscuring the apical anatomy of the
maxillary molar teeth

These problems may be overcome using Cone-Beam Volumetric Tomography Imaging

Technique
 CBCT was initially developed for angiography in 1982 then it started to have other
medical applications. In 1998, the first CBCT system specially designed for maxillofacial
application was invented

CBCT machines can scan patients in three possible positions:

 Supine
 Standing
 Seated
Source of X-ray
Detector Array
How is the Image produced?
Single partial or full rotational scan from cone-shaped x-ray
beam and detector array rotates around a fixed fulcrum within the
patient’s head.
Projection Data
Reconstruction
3D volumetric data.
Isotropic voxel (equal in the three dimensions)
 Then 3D volumetric set are secondarily reconstructed to provide orthogonal planar
images.

Field of View (FOV):

 It is the scan volume able to be covered.
Collimation of the primary x-ray beam limits x-ray exposure to the region of
interest so an optimal FOV could be selected for each patient
based on the region designated to be imaged

FOV can be:

1- Localized region: approximately 5 cm or less in height (dentoalveolar,TMJ)
2- Single arch: (maxilla or mandible)
3- Inter-arch: (mandible and superiorly to include the inferior concha)
4- Maxillofacial: (mandible and extending to Nasion)
0.4mm 0.16 mm voxel size
For most endodontic applications, limited FOV CBCT is preferred to medium or large FOV
CBCT because there is less radiation dose to the patient, higher spatial resolution and shorter
volumes to be interpreted.
How to Write CBCT Request ? (FOV- Resolution)
 The selection of the FOV depends on:
o Diagnostic task
o Spatial resolution requirements
o Clinician’s confidence interpreting the acquired data volume
For most endodontic applications, limited volume CBCT is preferred over large volume
CBCT:
1. Increased spatial resolution to improve the accuracy of endodontic-specific tasks such as
the visualization of small features including accessory canals, root fractures, apical deltas,
calcifications.
2. Decreased radiation exposure to the patient.

1- Diagnostic Task:
o  Single tooth or multiple teeth?
o  Unilateral or Bilateral?
o  In the same or different arches?
o  Facial Structures?

2- Spatial Resolution Requirements

 If I need high resolution requirement (as in case of endodontics), I need to use the
smallest FOV

3- Clinician’s Confidence Interpreting the Acquired Data Volume

 Small volume data sets reduces the diagnostic responsibility for hidden pathology outside
the region of interest (ROI) as large- FOV machines will capture structures like the paranasal
sinuses, airway, and vertebral column, so the clinician has an ethical and legal responsibility to
examine these structures for potential pathoses.
 Clinicians have the option to perform the radiographic evaluation themselves or refer the
data volume to a qualified specialist such as an oral and maxillofacial radiologist or medical
radiologist.

B- The selection of the Resolution:

 All endodontic imaging procedures require high spatial resolution.
 Canal morphology, Root morphology can be visualized with slice thickness as little as
0.1 mm while for other applications 0.2 mm is sufficient.
 File #10 for a tip size of 0.1 mm to #100 for a tip size of 1.0 mm

Not every small FOV → small voxel (electronic collimation)

Advantages of Cone-beam CT
1. CBCT equipment are smaller than conventional CT scanner
2. Short Scan Time: Because CBCT acquires all projection images in a single rotation so
reduced possibility of motion artifact.
3. Higher Image Accuracy ….CBCT Conventional CT
4. Reduced Patient Radiation Dose: CBCT provides dose reductions of about 76% to 98%
compared to conventional CT scanners.
5. Beam Limitation:
6. Interactive Display Modes:
 Reconstruction of CBCT data can be performed by the dentist through using a personal
computer to generate images in any plane.

 Basic enhancements as:

1. Zooming
2. window/level
3. cursor-driven measurements

Multiplanar Reformation
Multiplanar reformation allows reformatting the volumetric data in any non- orthogonal plane
thanks to the sub- millimeter isotropic nature of the volumetric data, subsequently any
reformatted image will have high spatial resolution

Linear Oblique Planar Reformation

Curved Planar Reformation

 An axial image that includes the full contour of the mandible (or maxilla) at a level
corresponding to the dental roots is typically selected as a reference for the reformatting process.

Ray sum
Simulated Antro-posterior Image Free from Magnification and Distortion.
3D Volume Rendering could be display from various orientations will help in relating the
findings in the 2D images

Limitations of cone-beam CT
1. Higher Image Noise:
because of the large amount of scattered radiation resulting from the large volume being
irradiated.
2. Poor Soft Tissue Contrast
The scatter and beam hardening caused by high density neighboring structures.

Applications of CBCT
o Limited FOV CBCT should be considered the imaging modality of choice for initial
treatment of teeth with the potential for extra canals and suspected complex morphology,
such as mandibular anterior teeth, and maxillary and mandibular premolars and molars,
and dental anomalies.
o AAE and AAOMR 2015/2016 Update
o Limited volume, high resolution CBCT may be indicated, for selected cases where
conventional intraoral radiographs provide information on root canal anatomy which is
equivocal or inadequate for planning treatment, most probably in multi-rooted teeth
(European Commission 2012)
o CBCT must not be used routinely for endodontic diagnosis or for screening purposes in
the absence of clinical signs and symptoms (European Commission 2012) 1.
o Patients have poorly localized symptoms associated with an untreated or previously
treated tooth and clinical and periapical radiographic examination show no evidence of
disease, CBCT may reveal the presence of previously undiagnosed pathosis.

Detection of Apical Periodontitis

 Cone beam computed tomography enables radiolucent endodontic lesions to be detected
before they would be apparent on conventional radiographs because of absence of adjacent
anatomical noise and the higher geometric accuracy.
A patient has been complaining of an intermittent dull ache. Clinical and special investigations
are unremarkable
2- Assessment of Dental Trauma
 The exact nature and severity of alveolar and luxation injuries can be assessed from just
one scan from which multiplanar views can be selected and assessed with no geometric
distortion or anatomical noise.
 The same fracture may have needed multiple periapical radiographs taken at several
different angles to be detected and even then may not have been visualized.
Patient can be informed of a hopeless prognosis, and valuable treatment time, expenses, and
patient and clinician frustration can be avoided (Hargreaves & Cohen 2011)
Limited volume, high resolution CBCT is indicated in the assessment of dental trauma
(suspected root fracture) in selected cases, where conventional intraoral radiographs provide
inadequate information for treatment planning
 It was found that the presence of a root filling significantly reduced the specificity of root
filled teeth with incomplete and complete fractures compared with perfect specificity with sound
teeth.
 This was due to imaging artefacts (e.g. beam hardening) affecting the quality of the
images produced. This is also the reason why metal (i.e. radiodense) posts have a negative
impact on the diagnostic accuracy of CBCT reconstructed images (Scarfe & Farman 2008).
 The accuracy of CBCT for the detection of VRF also appears to be dependent on the
CBCT device used. This may be due to several factors including differences in different
exposure parameters, detector sensitivity, voxel settings and reconstruction algorithms of the
CBCT scanners assessed.
 It does appear that CBCT accuracy is associated with voxel size, the smaller the voxel
size the more reliable the interpretation

MARS (Metal Artifact- Reduction Software)

 It is an algorithm that automatically detects problematic metal artifacts and eliminates
their shadowing and streaks as much as possible.
3- Assessment of Root Canal Anatom
o Cone beam computed tomography reconstructed scans are important for assessing
teeth with unusual anatomy, such as teeth with an unusual number of roots,
dilacerated teeth and dens in dente.
o Evaluation of missed canals routinely visualized in axial slices
o Calcified Canal identification
4- External & Internal Root Resorption
 Localization and differentiation of and the determination of appropriate
treatment and prognosis.
Limited volume, high resolution CBCT may be indicated in selected cases of suspected, or
established, inflammatory root resorption or internal resorption, where three-dimensional
information is likely to alter the management or prognosis of the tooth
 Location and extent of Internal and external root resorption
Limited FOV CBCT should be the imaging modality of choice for nonsurgical retreatment to
assess endodontic treatment complications, such as overextended root canal obturation material,
separated endodontic instruments, and localization of perforations.
6- Pre-surgical Assessment
Limited volume, high resolution CBCT may be indicated for selected cases when planning
surgical endodontic procedures. The decision should be based upon potential complicating
factors, such as the proximity of important anatomical structuresPeriapical radiograph
Reformatted sagittal image

In Pre-surgical anatomic assessment:

o  The distance between the cortical plate and the root
apex could be measured using CBVT
o  The presence of vital structures related to the roots could be assessed
o  The thickness of the cortical plate, cancellous bone pattern
and fenestrations
Recent Advancements: SICAT ENDOGUIDE retrograde Guided access cavity preparation
using cone-beam computed tomography and optical surface scans

When to use CBCT ?

 Despite Reduced patient radiation dose delivered by CBCT, it is still higher than those of
the other imaging procedure in dentistry.
 So according to “ALARA” principle, CBCT can be used when the data gained is of
diagnostic benefits and can not be obtained from any other modality to justify the higher dose
delivered to the patient.
CBCT should not be selected unless a history and clinical examination have been performed.
“Routine” or “screening” imaging is unacceptable practice (European Commission 2012)