|Year : 2014 | Volume
| Issue : 1 | Page : 23-32
Application of cone beam imaging in dentistry: A mini review
Santosh Doddamani, Sunitha N Shamnur, Jacqueline Tan Wun Lin
Department of Prosthodontics, Bapuji Dental College and Hospital, Davanagere, Karnataka, India
|Date of Web Publication||18-Feb-2015|
Department of Prosthodontics, Bapuji Dental College and Hospital, Davangere - 577 002, Karnataka
Source of Support: None, Conflict of Interest: None
Cone beam volumetric imaging has many advantages over simple panoramic film and digital images, including enabling accurate visualization of head and neck structures and reducing X-ray doses. It has been rapidly adopted and is becoming the "standard of care" for several applications, and is being preferred for others.
Keywords: Cone beam computed tomography, cone beam imaging, implants, virtual model
|How to cite this article:|
Doddamani S, Shamnur SN, Lin JT. Application of cone beam imaging in dentistry: A mini review. Int J Oral Health Sci 2014;4:23-32
| Introduction|| |
Cone beam computed tomography (CBCT) was introduced to the dental field to replace the cumbersome, expensive and high radiation-producing medical computed tomography (CT) scans around a decade ago.  The introduction of CBCT specifically dedicated to imaging the maxillofacial region heralds a true paradigm shift from a 2D to a 3D approach to data acquisition and image reconstruction.  Unlike conventional CT scanners, which are large and expensive to purchase and maintain, CBCT is suited for use in clinical dental practice where cost and dose considerations are important, space is often at a premium and scanning requirements are limited to the head. CBCT visualization for dental planning allows the clinician to evaluate the subjacent anatomy and feasibility of the proposed implant placement and make needed modifications to the plan to optimize the spatial and functional relationships between the planned prosthetic treatment and the anatomy.  This article reviews the various application of CBCT in the field of dentistry.
| Materials and Methods|| |
Clinical and scientific literature discussing the application of cone beam imaging in dentistry was reviewed. A MEDLINE (PubMed) search from 1995 to 15 th June 2014 was conducted. Application of cone beam imaging in dentistry was used as key to extend the search to all the various dental disciplines. The search revealed 312 articles, of which 211 articles were found to be not relevant for our study. Thus, the systemic review consisted of 108 clinically relevant papers that were analyzed and categorized [Table 1].
According to Tsiklakis et al., although CT is readily available, it is not very popular in dentistry, due in large part to its high cost and the high dose of radiation involved.  CBCT makes it possible to examine the joint space and the true position of the condyle within the fossa, which is instrumental in revealing possible dislocation of the joint disk. , CBCT's accuracy and lack of superimposition makes it possible to measure the roof of the glenoid fossa and visualize the location of the soft tissue around the Tempero Mandibular Joint [Figure 1], which can offer a workable diagnosis and reduce the need for magnetic resonance imaging (MRI). ,, According to Tsiklakis et al., MRI "is considered one of the most useful investigations since it provides images of both soft tissue and bony components."  MRI is recommended for TMJ soft tissue examination because CBCT does not provide soft tissue details. The advantages outlined above have made CBCT the best imaging device for cases involving trauma, fibro-osseous ankylosis, pain, dysfunction and condylar cortical erosion and cysts. ,,,,
|Figure 1: Cone beam computed tomography image of the tempero mandibular joint|
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Oral and maxillofacial surgery
3D images acquired with CBCT have been used to investigate the exact location and extent of jaw pathologies and assess impacted [Figure 2] or supernumerary teeth and the relationship of these teeth to vital structures. ,,,,,,,,,,,,,,,, CBCT images are used for pre- and post-surgical assessment of bone graft recipient sites and to evaluate osteonecrosis changes of the jaws (such as those associated with bisphosphonates) and paranasal sinus pathology [Figure 3] and/or defect. ,,,,,,,,,,,,,,,,,, CBCT technology has also been used for thorough pre-treatment evaluations of patients with obstructive sleep apnea [Figure 4] to determine an appropriate surgical approach (when necessary). ,
|Figure 2: Cone beam computed tomography image to determine the extent of jaw pathology in odontogenic keratocyst|
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As CBCT units become more widely available, dentists have increasingly used this technology to evaluate maxillofacial trauma. In addition to overcoming the structural superimpositions that can be seen in panoramic images, CBCT allows accurate measurement of surface distances. , This particular advantage has made CBCT the technique of choice for investigating and managing midfacial and orbital fractures, [Figure 5] post-fracture assessment, interoperative visualization of the maxillofacial bones and intraoperative navigation during procedures involving gunshot wounds. ,,,,,
CBCT is widely used for planning orthognathic and facial orthomorphic surgeries, where detailed visualization of the interocclusal relationship and representation of the dental surfaces to augment the 3D virtual skull model [Figure 6] is vital. Utilizing advanced software, CBCT allows for minimum visualization of soft tissue, allowing dentists to control post-treatment esthetics and evaluate the outline of the lip and bony regions of the palate in cases of cleft palate. ,,,,, The recently developed CBCT presents a higher spatial resolution with a lower radiation dose, simultaneously with excellent accuracy and without magnification of images. It can be used to obtain a precise occlusal splint in virtual 3D subapical segmental osteotomy by combining CBCT with plaster models that could guarantee the measurement accuracy of root length, interradicular distance and intertooth distance. 
The introduction of new software in orthodontic assessment, such as Dolphin (Dolphin Imaging and Management Solutions) [Figure 7] and InVivo Dental (Anatomage), [Figure 8] has allowed dentists to use CBCT images for cephalometric analysis, making it the tool of choice for assessing facial growth, age, airway function and disturbances in tooth eruption. ,,,,,,,,,,,,,,,,, The displacement of mini implants used for orthodontic anchorage before and after force application can be assessed with the help of a CBCT image. 
CBCT is a reliable tool for assessing the proximity of impacted teeth to vital structures [Figure 9] that could interfere with its orthodontic movement. , When mini-implants are required as temporary anchors, CBCT offers visual guides for safe insertion thus avoiding accidental and irreparable damage to the existing roots. ,, Assessing bone density before, during and after treatment can show whether it is decreasing or remaining the same. ,
CBCT displays multiple views of the maxillofacial complex with a single scan, giving dentists access to anterior, coronal and axial images in addition to a 3D reconstruction of the bony skeleton. These images can be rotated, allowing dentists to visualize multiple planes and angles, including some that are not available with 2D radiography. , CBCT images are self-corrected for magnification, producing orthogonal images with a practical 1:1 measuring ratio; as a result, CBCT is considered a more accurate option than panoramic and traditional 2D images. 
CBCT can be used to create an integrated digital maxillodental model and to apply it in a computer-aided design (CAD) of individualized lingual brackets in order to align both crowns and roots without fenestration and dehiscence. 
According to Vandenberghe et al., 2D intraoral radiography is the most common imaging modality used for diagnosing bone morphology, such as periodontal bone defects. However, the limitations of 2D radiography could cause dentists to underestimate the amount of bone loss or available bone due to projection errors, and has led to errors in identifying reliable anatomical reference points.  These findings confirm the observation by Misch et al. that 2D radiographs are inadequate for detecting changes in bone level or determining the architecture of osseous defects.  CBCT provides accurate measurement of intrabony defects and allows clinicians to assess dehiscence, fenestration defects and periodontal cysts [Figure 10]. ,,, While CBCT and 2D radiographs are comparable in terms of revealing interproximal defects, only 3D imaging such as CBCT can visualize buccal and lingual defects. ,,
CBCT has been used to obtain detailed morphologic descriptions of bone as accurately as direct measurement with a periodontal probe. ,, CBCT can also be used to assess furcation involvement of periodontal defects and allow clinicians to evaluate post-surgical results of regenerative periodontal therapy. ,,
The increasing need for dental implants to replace missing teeth requires a technique capable of obtaining highly accurate alveolar and implant site measurements to assist with treatment planning and avoid damage to adjacent vital structures during surgery [Figure 11]. In the past, such measurements were generally obtained by utilizing 2D radiographs and (in specific cases) with the aid of conventional CT. However, CBCT is the preferred option for implant dentistry, providing greater accuracy in measuring compared with 2D imaging, while utilizing lower doses of radiation. ,, New software has reduced the possibility of malpositioned fixtures and damaged anatomical structures [Figure 12]. ,,
At present, the combined use of CBCT 3D data and CAD/computer-aided manufacturing (CAM) technology makes it possible to manufacture custom-made, root-analogue direct laser metal-forming (DLMF) implants (RAI) with sufficient precision.  The introduction of DLMF technology signals the start of a new revolutionary era for implant dentistry as its immense potential for producing highly complex macro- and microstructures is receiving vast interest in different medical fields.  Recently, new computer-aided design and manufacturing (CAD/CAM) techniques, such as stereolithographic (SLA) rapid prototyping, have been developed to fabricate surgical guides to improve the precision of implant placement according to the patient's 3D model, which was attained from the CBCT images. 
CBCT has reduced implant failures by providing information about bone density, the shape of the alveolus and the height and width of the proposed implant site for each patient. ,, CBCT does not provide accurate Hounsfield unit (HU) numbers; as a result, bone density numbers measured with this technique cannot be generalized over a group of CBCT units or patients. However, CBCT's effectiveness in quantifying and assessing the shape of the alveolus has led to improved case selection. ,, By knowing in advance the complications that can occur during a specific proposed treatment, the treatment plan can be designed to address the complications or to plan an alternate treatment. CBCT is commonly utilized in post-surgical evaluations to assess bone grafts and the implant's position in the alveolus. 
Conservative and endodontics
a. Operative dentistry
Based on the literature, CBCT cannot be justified for detecting occlusal caries. Not only does CBCT deliver higher doses of radiation than conventional 2D radiographs, it provides lower resolution than intraoral radiographs.  [Table 2] summarizes typical radiation scatters from various dental radiological procedures. 
|Table 2: Objects causing "scattering effects"/scatters and noise in CBCT |
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CBCT imaging is a useful tool for diagnosing periapical lesions [Figure 13]. ,, While controversial, several studies have suggested that contrast-enhanced CBCT images can be used to differentiate between apical granulomas and apical cysts by measuring the lesion's density. ,, Others have described the use of CBCT as a tool to categorize the origin of the lesion as endodontic or non-endodontic, which might suggest an alternate course of treatment.  The validity of these topics is currently under debate; however, they do underline the need for (as well as the popularity of) non-invasive techniques to diagnose lesions that traditionally had been diagnosed through invasive procedures. Several clinical case reports have focused on using high-resolution CBCT images to detect vertical root fractures. ,, CBCT is considered to be superior to periapical radiographs for detecting vertical root fractures, measuring the depth of dentin fracture and detecting horizontal root fractures [Figure 14]. ,,, CBCT imaging also allows for early detection of inflammatory root resorption, a diagnosis that is rarely possible when using conventional 2D radiographs. ,, Not only can CBCT detect root resorption (external or internal) and cervical resorption, it can also identify the extent of a lesion. ,, CBCT can be used to determine the number and morphology of roots and associated canals (both main and accessory), establish working lengths and determine the type and degree of root angulation. ,, CBCT offers a far more accurate evaluation of existing root canal obturations than 2D imaging. ,, CBCT is also used to detect pulpal extensions in talon cusps and the position and location of fractured instruments. , Because of its reliability and accuracy, CBCT has also been used to evaluate canal preparation with different instrumentation techniques. , CBCT is a reliable pre-surgical tool for assessing a tooth's proximity to adjacent vital structures, allowing for accurate measurement of the size and extent of a lesion and the anatomy of the area. ,, In post-trauma emergency cases where tooth assessment is required, CBCT imaging can help dentists to determine the most suitable treatment approach. ,,
|Figure 13: Cone beam computed tomography image of the periapical lesions|
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|Figure 14: Cone beam computed tomography image to detect vertical root fracture|
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| Discussion|| |
CBCT technology dates back to the development of X-ray CT in the 1967 by Sir Godfrey N. Hounsfield for which he won the Nobel Prize in 1972. CT was available for 3D dental imaging in the 1980s, but due to the high cost, limited access and radiation exposure, utilization was limited to management of craniofacial anomalies, complex surgeries and other unique dental situations. CBCT was initially developed for angiography,  but more recent medical applications have included radiotherapy guidance  and mammography. In 1988, CBCT was introduced to dentistry. This technology offered 3D visualization and more complex and more accurate imaging compared with analog and digital radiographs.
It is crucial that the ALARA principle (As Low As Reasonably Achievable) is the primary consideration as far as radiation dose of CBCT imaging is concerned. Dentists should ask themselves whether these imaging modalities actually add to the diagnostic knowledge and raise the standard of dental care.
The advantages of CBCT include X-ray beam limitation, image accuracy, rapid scan time, dose reduction, display modes unique to maxillofacial imaging, reduced image artefact, oblique planar reformation, curved planar reformation, serial transplanar reformation and multiplanar volume reformations.  Dose measurements of multi-slice CT (MSCT), dental CBCT (small and largefi elds of view (FOV)) and a dental panoramic system was studied. The CT dose index protocol was also performed on the MSCT to compare both methods. The dose for the large FOV dental CBCT (11.4 mGy/100 mAs) is two times lower than that of MSCT ,[ 107] but, MSCT gives better details of soft tissue.  The effective radiation doses of CBCTs in the current market fall into a considerably wide range that is from 19 μSv to 1073 μSv. 
| Conclusions|| |
The development and rapid commercialization of CBCT technology dedicated to imaging the maxillofacial region will undoubtedly increase dental practitioner access to 3D radiographic assessments in clinical dental practice. CBCT imaging provides clinicians with sub-millimeter spatial resolution images of high diagnostic quality with relatively short scanning times (10-70 s) and a reported radiation dose equivalent to that needed for four to 15 panoramic radiographs.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]
[Table 1], [Table 2]