CONE BEAM COMPUTED

TOMOGRAPHY

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 CONTEN
TS
Introduction
Principles
Image Acquisition X-ray
generation
Image detection system
Image reconstruction
Image display

Clinical considerations
Imaging protocol
Comparison with CT
Artifacts
Applications in Dentistry
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 INTRODUCTI
ON
• It is also known as Dental volumetric tomography, Cone beam
volumetric tomography, dental computed tomography and cone
beam imaging.

• A recent technology initially developed for angiography in 1982.

• It is a digital analog of film tomography in a more exact way than

is traditional CT

• It uses a divergent or “cone“ shaped source of ionizing radiation

(conical or pyramidal) and a 2D area detector fixed on a
rotating
gantry to acquire multiple sequential projection images in one
complex scan around the area of interest.
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• Since the late 1990s it is become possible to
produce clinical system (inexpensive & small
enough)

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 Principles of
CBCT
Uses a cone shaped divergent beam of ionozing
•ra dia t io n lik e X - ra y s a n d a 2D
R ou n d C o ne s h a p e d X -
raayrebaedaemtector mounted on
a rotated gantry to acquiremultipalanar
sequential projection images in one single scan
around the area of
•int2e-reDst area detector
Combine with 3D x ray beam with circular
collimation – cone shaped resultant beam
•360 0 rotation around the object – both source
and Pdreotjeeccttoiornmsomunatdeedinonalal
pglaannterys at a 5
time volumetric images obtained 5
• X-ray beams attenuated by patient- detected by the receptor

• Raw data assembled by computer algorithm

• Generate cross sectional components of image called pixels

• CBCT acquires volumetric data. Each unit is called a voxel.

• Size of each voxel corresponds to size of pixel of the

detector

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 IMAGE ACQUISITION

• Rotation scan exceeding 1800 of an x ray source

and area detector.
• BASIS IMAGES – During the rotation, many
exposures made at fixed interval, providing a
single projection images.
mage
• The complete series of basis is k/a
i PROJECTION
DATA

100 – 600 images in single scan

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• Software programs – backprojection filters
are applied – to generate 3D volumetric
data- reconstruction of images in 3
planes.

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4 components for CBCT
acquisition:

•X-ray generation
•Image detection system
on
•Image reconstructi
•Image display
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 X –ray
Generation
• Single scan of the patient is made to
acquire a data set.

• Patient positioning
• X-ray generator
• Scan Volume
• Scan factors

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 Patient
1.
Positioning
Equipment required
Supine Large surface area/ physical
footprint
Not for physically disabled patients

Not able to
2. Standing adjust the height
Units
in wheelchair bounded
patients

3. Seated
Most comfortable
units Not for physically
Immobilization of patients head is disabled
necessary
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Upright patient loading and e
supin

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 X Ray
Generator
• Scan times are longer than panoramic  due to pulsed
exposure.

• So, Actual exposure time is markedly less than

scanning time

• ALARA – CBCT exposure factors should be adjusted

on the basis of patient size.( Tube current , tube
voltage or both )

• Automatic exposure control – Kvp and mA 15

automatically modulated in near real time by feedback
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• Patient exposure depends
upon :

Presence of pulsed X ray beam

Size of the image field

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 Scan
Volume

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 Scan
•
•
Volume
Also called as field of view
It is the amount of area to be exposed in a single scan.

Depends on:
• Detector size
• Geometry of beam projection
• Collimation of the beam

Shape – cylinder or Spherical

Can be selected based
on individual requirements.

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 Scan
Factors
FRAME RATE: Speed with which the images are
acquired.
Projected images / second

frame rate images acquired for reconstruction

higher frame rate reduces metallic artifact.
frame rate scanner time Patient dose
SCAN ARC: It is the trajectory of the scan or the path
traveled in
a single scan. It is usually 360 degrees. SCAN TIME : < 30
secs.
Lesser the scan time , lesser will be the motion artifacts.20
 IMAGE N
DETECTIO
CBCT

Image intensifier
+
Flat panel
charge coupled
device
area
detectors
Fiberoptic
coupling

• Detection of X rays with an indirect detector

• Large area solid state sensor coupled with
scintill layer (cesium iodide)
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 DETECT
ORS
The detector must be able to:
–Record X ray photons
–Read off and send signal to the computer
–Be ready for the next acquisition many hundreds of times
within the single rotation

•Rotation is usually performed within times (10-30

seconds) which necessitates frame rate image
acquisition times of milliseconds

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– Flat detectors are composed of a large-area pixel array of
hydrogenated amorphous silicon thin-film transistors. X
rays are detected indirectly by means of a scintillator, such
as terbium activated gadolinium oxysulphide or thallium-
doped cesium iodide, which converts X rays into visible
light that is subsequently registered in the photo diode
array.

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 Grid distortion pattern produced by the image-intensifier detector
that affects the image construction and is noted in the image display.
When moving away from the center.
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Image receptor area receiving the signal from the flat-panel detector’s
scintillator is flat.
Therefore, even at more distant areas from the center of the grid, there
is minimal to no distortion of the grid pattern.
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Advantage of flat panel detectors;
•The configuration of such detectors is less
complicated
•Offers greater dynamic range and
•Reduced peripheral distortion

Disadvantage of flat panel detectors;

•These detectors require a slightly greater radiation
exposure.
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 VOXEL
SIZE
• Determinants of voxel
size
 Focal spot determine degree
X ray geometric
size of geo
 Matrix
configuration unsharpness
 Pixel size of solid state detector

Object to detector distance Source to object –

minimizes geometric unsharpness

Source to object – magnified projected image.

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 GRAYSC
ALE
• Ability of the panel to detect subtle contrast
differences called as bit depth of the system.

• CBCT units use detectors capable of

recording grayscale differences of 12 bits or
higher.

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 RECONSTRUC
TION
• Basis projection frames are process to create volumetric data set k/a
primary
reconstruction.
• Single cone beam rotations < 30 sec
• 100 – 600 individual projection frames

• Data acquired by one computer then transfer to processing

computer
(workstation)

• Reconstruction depends on :
Acquisition parameters (voxel size, size of image field, no of projection
Hardware
Software
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 RECONSTRUC
TION
PROCESS

Once all slices have been reconstructed they combine into single volume of
 DISPL
AY
• The volumetric data set is a compilation of all available
voxels.
• Reconstruction of images – 3 orthogonal planes

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 MULTIPLANAR
REFORMATION
Isotropic nature of volumetric data , nonaxial 2 dimension images
refers as
Multiplanar reformation. This includes :
Oblique , curved planar reformation, serial transplanar reformation.

Axial image – occlusal image

MPR oblique curve line – panoramic
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Serial cross section 1 mm thick images 3
 RAY SUM
IMAGE

An axial projection use as reference image Correspond to mid sagittal

plane
Thickness of this increase due to right and left side of volumetric data set
Thickness of the “slab” increases
Anatomic noise 3
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THREE DIMENSIONAL VOLUME RENDERING

•A TECHNIQUE which allows the visualization of 3D

data by integration of large volumes of adjacent voxels and selective
display.

INDIRECT VOLUME RENDERING

Selection of intensity or density of grayscale levels of voxels to be
displayed within an entire data set called as segmentation.
Requires software
Volumetric surface reconstruction with depth.

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DIRECT VOLUME RENDERING

•Simpler process
•Maximum Intensity Projection (MIP)
•MIP visualization – Evaluating each voxel
ry projection ray from
value along an imagina
eye within a parti observer’s
represent the hig
cular volume of interest and
h value as a display value
 CLINICAL
CONSIDERATION
• PATIENT SELECTION
CRITERIA
• PATIENT PREPARATION
• IMAGING PROTOCOL
• IMAGE OPTIMIZATION
• REPORTS
• ARCHIVING, EXPORT &
DISTRIBUTION
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 PATIENT SELECTION
CRITERIA

• CBCT is more commonly used for diagnostic

purpose.

• Cone beam exposure is higher than other

radiographs, there should be justification of
the exposure to the patient so that the total
potential diagnostic benefits are greater than
individual detriment radiation exposure.
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PATIENT PREPARATION

•Personal radiation barrier

protection-
Acc to federal legislation- Lead
torso apron Pregnant patients &
children
Highly recommended Lead thyroid
collar (when not interfere with
scan)
•Head Stabilization Chin cups to
posterior Lateral head supports

Image quality degraded by head 39

• Alignment of area of interest with x-ray beam is
critical in imaging
• Facial topographic reference planes (middle
saggital , frankfort horizontal) or internal
references (occlusal plane , palatal plane) aligned
with external laser light position.

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• Removal of metallic objects – eyeglasses, jewellery, metallic partial
dentures

• Not necessary to remove plastic completely removable p rosthesis

( unless closed TMJ view or orthodontic view )

• Separate the dentition – tongue depressor , cotton roll

This is useful in single arch scan where scatter from metallic
restorations in the opposing arch can be reduced.

• Direct the patient to remain still n breathe slowly through nose

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 IMAGING PROTOCOL

• It is a set of technical exposure

parameters

• It is developed to produce images of

optimal quality with the least amount of
radiation exposure to the patient.

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 VOXEL SIZE

• Voxel size with which projection images are acquired varies

from manufacturer to manufacturer principally on the basis
of matrix size of the detector and projection geometry.

• Image detector collects information over a series of pixels in

horizontal and vertical direction.

• voxel size spatial resolution

• But higher radiation dose required to the pixel fill factor.

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Limiting the irradiation field to fit the field of view with a reduced exposure dose
to the patient and improved image quality because of reduced scattered
radiation 4
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 IMAGE
OPTIMIZATION
• To optimize image presentation & facilitate dia gnosi
it is necessary to adjust contrast/window and s
brightness/level parameters to favor bony
structures.
• CBCT software have window/level presets
• This is adjusted for each scan
• Enhancement can pe rform sharpening ,
by application of
filtering.

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 REPORT
S

• Interpreting the resultant volumetric data

set:

Series of images formatted to display/

image report
Cognitive interpretation of the significance
of image finding/ interpretive report

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 ARCHIVING, EXPORT,&
DISTRIBUTION

CBCT imaging produces 2 data products:

• Volumetric image data from scan

• Image report generated by operator

Export of image data – DICOM( Digital Imaging and

Communications in Medicine) file format is
standard for use in specialized software.
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ADVANTAGES OF CONE-BEAM CT IN DENTISTRY

• Being considerably smaller, CBCT

equipment has a greatly reduced
physical footprint.

• Is approximately one quarter to one

fifth the cost of conventional CT.

• CBCT provides images of highly

contrasting structures and is
therefore particularly well suited for the imaging
of osseous structures of the
craniofacial area.

• Rapid Scan time 48

• Beam Limitation

• Image accuracy

• Reduced patient radiation dose

• Interactive display modes applicable to maxillofacial imaging

• Multiplanar reformation

• Three dimensional Volume Rendering

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 LIMITATIONS OF CONE-BEAM CT IN DENTISTRY

•X-ray beam artifacts

•Patient related artifacts
•Scanner-related artifacts
•Cone beam related artifacts
The beam projection geometry of the CBCT and the image
reconstruction method produce three types of cone-beam related
artifacts:
(1) partial volume averaging.
(2) undersampling
(3) cone-beam effect.
•Image noise
•Poor tissue contrast

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DIFFERENCE BETWEEN CONE BEAM CT AND
MULTISLICE CT

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CONE BEAM CT MULTISLICE CT

Image the whole area in one rotation, Image the patient in multiple slices
then reconstruct slices

Cone beam Geometry Fan beam Geometry

Radiation Dose; 45-477µSv Radiation Dose; =2000µSv

Operating voltage 80 – 120Kvp 80 – 140 Kvp

Focal Spot size 0.5- 0.8mm 0.5 – 1.2mm

1-13% Annual Background radiation =65% Annual Background radiation

Dose Dose
Lesser cost Higher Cost

Spatial resolution = 0.07-0.4 mm 5 Spatial resolution = 0.3-0.4 mm 2-3

lp/mm lp/mm

Sections are not skipped, No loss of Sections may be skipped, diagnostic

diagnostic information information may be lost if thicker
sections are taken 5
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 CONE BEAM CT MULTISLICE CT

Soft tissue imaging is not as good Better contrast; soft tissues are imaged
better

Voxel dimension depends on pixel size on Depends on slice thickness

area detector

Voxel resolution – Isotropic Anisotropic

Poor contrast resolution Good contrast resolution

Not meant for imaging malignancy Ideal for malignancy as contrast radiology
is very well imaged ; invasion into soft
tissues is well detected

Reduced artifacts from dental restorations Increased contrast; streaking artifacts are
more marked

Ideal for implant imaging Not suited for implant imaging

The machine has a smaller size Larger machines
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 IMAGE
ARTIFACTS

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 Patient related

Scanner
Acquisition Artifacts related

Cone beam
related
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 ACQUISITION
ARTIFACTS
1. Beam hardening- As an x-ray beam passes
through an object lower energy photons
are absorbed in preference to higher
energy photons.

CUPPING STREAKS & DARK

ARTIFACT BANDS

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In clinical practice it is advisable to reduce field size , modify patient
position , separate dental arches to avoid beam hardening

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 PATIENT RELATED
ARTIFACTS

• Patient motion – unsharpness in image

reconstruction
Minimize by restraining head

• Remove metallic objects – to avoid

beam hardening

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Motion blur, double cortices 6
0
• Motion artifact from
swallowing
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ALAISING ARTIFACT / MOIRE PATTERN

•Alaising artifacts appear as slightly wavy lines

that diverge outwards toward the periphery of a
cone beam image.
•Cause – By undersampling of structures.
•Related to the size of the dexels within the
detector. f the incident x-
•Dexels - measure the energy o ray or light
photons

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 IMAGE NOISE

•Random variation in the

number of x-ray photons in the
beam as it exits an object and
strikes the image detector
produces a grainy or mottle
appearance
• Inc voxel size reduces within
grainy app the image.
but spatial
solution and detection of small object reduce d
re

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 SCANNER RELATED ARTIFACTS

•Circular / ring steaks

•Result from imperfections in

scanner detection
ause – repetitive read
osition of•C
detector.
ing at each angular p

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 CONE BEAM RELATED
ARTIFACTS

Beam projection geometry and image reconstruction

causes these artifacts:

1. PARTIAL VOLUME AVERAGING

– when selected voxel size of the scan is larger than the size of object
being imaged.

Eg. A voxel of 1mm in size on a side may contain both bone and soft
tissue. Displayed pixel have different brightness value
Boundaries of image – “step” appearance “Selection of smallest
acquisition voxel “

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• 2. UNDERSAMPLING-
Undersampling of the object can occur when too few
basic projections are provided for image reconstruction.
Reduced data sample leads to sharp edges, noisier
images
Fine striations
Importan
in the image .
ce of this artifact is in diagnosis.

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3. CONE BEAM EFFECT

•Potential source of artifacts

•Seen in peripheral portions of scan
volume Because of divergence of
x ray beam as it rotates
around theatient)
patient in horizontal
plane, structures at top
and bottom of the image field only be
exposed ( x ray beam is in opposite
side of p

Peripheral area – less denser More

image noise.
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• Results – image distortion, streaking artifacts ,
greater peripheral noise .

 To minimize – Positioning the ROI in horizontal

plane of the x ray beam.

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APPLICATIONS IN
DENTISTRY

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• CBCT had a substantial impact on
maxillofacial imaging.

• Applied to diagnosis in all areas of dentistry &

now into treatment application.
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INDICATIONS

•Implant site assessment

•Extension of pathologies
•Bone quality
•Maxillary sinus
•TMJ
•Incisive foramen
•Mandibular canal
•Diagnostic requirements in
endodontics, orthodontics,
periodontics, maxillofacial
surgery 72
Cross sectional images of alveolar bone height, width and angulation
Accurately depicts vital structures
Useful series of image – axial , reformatted panoramic & serial
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transplaner images 3
PREOPERATIVE IMPLANT
PLANNING

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A diagnostic stent is made with radiographic markers and inserted at the time of scan
DICOM data imported to third party software application Assess and plan surgical &
prosthetic components

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 ORTHODONTICS & 3D
CEPHALOMETRY

• In diagnosis, assessment & analysis of

maxillofacial orthodontic & orthopedic anomalies.
• Palatal morphological features & dimensions
• Tooth inclina tion,
sorption, alveolar
torque, root re bone width

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TMJ and pharangeal airway space visualization
Ray sum technique – provide both conventional two & three
dimension cephalometric image (simulated panoramic,
posteroanterior
lateral,
cephalometric
submentovertex,
images) 7
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 3D cephalometry :
Dentaloskeletal relationships
Facial esthetics
Potential for growth &
development

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 LOCALIZATION OF
INFERIOR ALVEOLAR
CANAL

Accurate assessment of the position of canal reduce injury to the nerve while 3
molar surgeries .
Panoramic imaging is adequate but in case of superimposition 3D imaging is
advisable
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 TEMPOROMANDIBULAR JOIN T

•Diagnosis of bone
morphologic features,
joint space and dynamic
functions.
•Degenerative joint
disease
d
•Developmental anomaly
arthritis
of condyle
•Ankylosis
•Rheumatoi 81
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 MAXILLOFACIAL
COMPLEX

• Impacted canine , supernumerary teeth,

fractured or split teeth, periapical lesions ,
periodontal
diseas
e,

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Fracture , widening of PDL space – suggestive of tooth subluxation
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Benign calcifications (tonsiloliths , lymphnodes, salivary gland stones)
Phlebolith
Useful for trauma
Osteomyelitis – extent & degree of 8
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 IN ENDODONTICS

2D image True extent of lesion

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 IN PERIODONTICS

Extent of the lesion in facio-lingual and axial view 8

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 RAPID PROTOTYPING

• A group of related processes and technique that are

used to fabricate physical scale models directly
from 3D computer assisted design data.

• It creates life size, dimensionally accurate model of

anat omic structures k/a biomodels.

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• DICOM data imported to proprietary software can
be used to compute 3D images generated by voxel
values which are segmented from the background.

• Models produced used for presurgical planning for

the cases caused by trauma, tumor resection,
distraction osteogenesis, dental implants

• Reduces surgical and anesthetic time.

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 Referenc
•
Pharoah.
es
Oral Radiology : Principles and Interpretation. 5 ed. Stuart C. White & Michael J.
th

• Dental Applications of Computerized Tomography. Stephen L . G. Rothman

• Fundamentals of Special Radiographic Procedures.5th ed. Albert M. Snopek.

• Christensen’s physics of Diagnostic Radiology.4 th edition. Thomas S. Curry, III ,

James E.Dowdey, Robert C.Murry, JR.

• Dental Radiography, Principles and Techniques.2 nd edition.Joen Iannucci Haring,

Laura Jansen.

• The efficiency of a computerized caries detector in Intraoral Digital Radiography

JADA 133 (7) 183-90 July 2002.
92
• Dental Radiography- Haring Jansen.

• Does digital Radiography increases the number of intraoral radiographs. 2003. Dento
Maxillofacial Radiology ;32 (2); 124-7.

• Randolph Todd, Cone Beam Computed Tomography Updated Technology for

Endodontic Diagnosis. 2014;Dent Clin N Am 58;523–543.

• Scott R. Makins,Artifacts Interfering with Interpretation of Cone Beam Computed

Tomography Images.2014; Dent Clin N Am 58;485–495

• Kenneth Abramovitch,Dwight D. Rice;Basic Principles of Cone Beam Computed

Tomography.2014; Dent Clin N Am 58 ;463–484

• M. Loubelea et al , Comparison between effective radiation dose of CBCT and MSCT

scanners
for dentomaxillofacial application.2008; European Journal of Radiology.

• Scott R. Makins, Artifacts Interfering with Interpretation of Cone Beam Computed

Tomography Images. 2014;Dent Clin N Am 58 ;485–495 93
THANK
YOU

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