Dentomaxillofacial Radiology (2008) 37, 477478 2008 The British Institute of Radiology http://dmfr.birjournals.

org

LETTER TO THE EDITOR

The so-called cone beam computed tomography technology (or CB3D, rather!)
Dentomaxillofacial Radiology (2008) 37, 477478. doi: 10.1259/dmfr/51832728

As probably everybody in dentistry and radiology has noticed, cone beam volumetric radiography is currently enjoying phenomenal interest and expansion in the dentomaxillofacial field. This technology and the related machines are most commonly referred to as CBCT cone beam computed tomography, a terminology which is now firmly established especially in the scientific literature. Unfortunately this name and acronym is etymologically wrong (and so are a number of other colloquial names in common use, such as dental CT or digital volumetric tomography), and may cause significant confusion among non-specialists. The reason why it is wrong is because this technology does not use tomography. Consequently, it is not CT. The word tomography comes from the ancient Greek Ein (to write). roots tomos (slice, layer), and craw According to Wikipedia, tomography is imaging by sections or sectioning.1 According to the International Electrotechnical Commission technical report number 60788 (2nd edition 2004-02, Medical electrical equipment Glossary of defined terms),2 CT is reconstructive tomography in which recording and processing is effected by a computing system; reconstructive tomography is tomography in which information obtained from the object is recorded for constructing images of layers in the object by processing; and tomography is radiography of one or more layers within an object. Contrary to classic CT, imaging is not performed by sections or layers in cone beam technology. A sequence of classic radiographic projections is performed and these two-dimensional images are churned by the reconstruction algorithm (Feldkamp, algebraic reconstruction technique (ART), or other) directly into a three-dimensional (3D) or volumetric data set, without passing through reconstructing a stack of individual sections, slices or layers. Indeed, the outcome of the scan is often presented to the observer as a sequence of axial slices or of cross-sections in other planes, but this is the result of a secondary operation by the application software, is not inherent with the cone beam technology and might be entirely avoided. In fact, various commercial 3D imaging software programs offer the option of displaying the reconstructed volumetric data set directly as a semitransparent volumetric rendering, a surface rendering, or a maximum intensity projection (MIP).

(To be really linguistically fastidious, one may also contend that a large part of cone beam machines nowadays are not even cone beam, but pyramid beam, due to the rectangular field of view of the detector. In this case the distinction is substantially irrelevant and pedantic.) I advocate that the term CBCT should be abandoned in the scientific literature and propose that it be replaced by the more sound CB3D cone beam three-dimensional imaging, which describes exactly and tersely what this technology is about. As a matter of fact, many or even most of the most important commercial manufacturers of cone beam systems do not designate their products as CBCT, but as cone beam 3D or names akin. Why bother with a matter that may appear to be of mere linguistic fastidiousness, for a term and an acronym that are already rooted? Because the use of tomography and CT in the name is a source of considerable misunderstanding among the general public, the non-specialist professionals (and even some of the specialists!), and the regulatory and legislative bodies, conveying the idea that this is just a variation of CT with all the strings attached. But it is not! Not only is the data-capturing technology different, the data themselves are somewhat different from those obtained with CT, as numerous scholars have pointed out. For instance, the consistency of CT numbers and their conversion into Hounsfield units (firmly established in CT) is still problematic38 and a matter of ongoing development in CB3D. Conversely, CB3D may usually lend to geometric accuracy and spatial resolution even higher than CT.9,10 The procedures and test objects (phantoms) for standardized assessment of performance, which were developed long ago for CT,1113 are difficult or impossible to apply to CB3D to the extent that the development of a method and standard test object for CB3D has become a necessity and is among the goals of the recently-established SEDENTEXCT project (see www.sedentexct.eu) sponsored by EURATOM, as well as by a 3D imaging working group within the German DIN (Deutsches Institut fu r Normung). Radiation dose to patient and environment with CB3D is an order of magnitude smaller than with CT,
Dentomaxillofacial Radiology

478

Letter to the Editor

as has been firmly established by all authors who investigated the matter,14-18 yet many people are still sceptical about the radiological load from CBCT because of that CT in the name and associate it with that of much larger social relevance19,20 from medical computed tomography. Last, but absolutely not least, the socioeconomic implications of CB3D are vastly different from those of CT. The much smaller purchase and maintenance cost of the former, as well as the smaller footprint (in all senses including physical space occupation, but also resources required, radiation shielding, electrical power etc.) has fostered its adoption by a different class of users than the latter, with different diagnostic goals, expectations, operational context: not the hospital/large

clinic environment for multi-purpose diagnostics, but the more capillary private practice or radiology centre, for targeted clinical uses. In conclusion, let us bestow to cone beam 3D imaging a proper name of its own, as it deserves, unfettered by computed tomography! R Molteni Chief Technical Officer, AFP Imaging & QR/NewTom Dental, 250 Clearbrook Road, Elmsford, NY 10523, USA

References
1. Wikipedia.org [homepage on the internet]. [Updated 2008 September 6; cited 2008 September 14]. Available from: http:// en.wikipedia.org/wiki/Tomography. 2. International Electrotechnical Commission. IEC Technical Report 60788. Medical electrical equipment a glossary of defined terms (2nd edn). Geneva: IEC Central Office, 2004. 3. Hashimoto K, Kawashima S, Araki M, Iwai K, Sawada K, Akiyama Y. Comparison of image performance between conebeam computed tomography for dental use and four-row multidetector helical CT. J Oral Sci 2006; 48: 2734. 4. Loubele M, Maes F, Schutyser F, Marchal G, Jacobs R, Suetens P. Assessment of bone segmentation quality of cone-beam CT versus multislice spiral CT: a pilot study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006; 102: 225234. 5. Lagrave ` re MO, Fang Y, Carey J, Toogood RW, Packota GV, Major PW. Density conversion factor determined using a conebeam computed tomography unit NewTom QR-DVT 9000. Dentomaxillofac Radiol 2006; 35: 407409. 6. Katsumata A, Hirukawa A, Okumura S, Naitoh M, Fujishita M, Ariji E, et al. Effects of image artifacts on gray-value density in limited-volume cone-beam computerized tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 104: 829836. 7. Heiland M, Pohlenz P, Blessmann M, Habermann CR, Oesterhelweg L, Begemann PC, et al. Cervical soft tissue imaging using a mobile CBCT scanner with a flat panel detector in comparison with corresponding CT and MRI data sets. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 104: 814820. 8. Yamashina A, Tanimoto K, Sutthiprapaporn P, Hayakawa Y. The reliability of computed tomography (CT) values and dimensional measurements of the oropharyngeal region using cone beam CT: comparison with multidetector CT. Dentomaxillofac Radiol 2008; 37: 245251. 9. Pinsky HM, Dyda S, Pinsky RW, Misch KA, Sarment DP. Accuracy of three-dimensional measurements using cone-beam CT. Dentomaxillofac Radiol 2006; 35: 410416. 10. Cevidanes LHS, Bailley LTJ, Tucker SFD, Styner MA, Mol A, Phillips CL, et al. Three-dimensional cone-beam computed tomography for assessment of mandibular changes after othognathic surgery. Am J Orthod Dentofacial Orthop 2007; 131: 4450. Diagnostic Radiology Committee Task Force on CT Scanner Phantoms: Judy PF, Balter S, Bassano D, McCullough EC, Payne JT, Rothenburg L. Phantoms for performance evaluation and quality assurance of CT scanners. Chicago, IL: American Association of Physicists in Medicine, Report No. 1, 1977. Available from: http://www.aapm.org/pubs/reports/rpt_01.pdf. IEC. Medical electrical equipment Part 2-44: Particular requirements for the safety of X-ray equipment for computed tomography. IEC publication 60601-2-44. Geneva: International Electrotechnical Commission Central Office, 2002. Lofthag-Hansen S, Thilander-Klang A, Ekestubbe A, Helmrot E, Grondahl K. Calculating effective dose on a cone beam computed tomography device: 3D Accuitomo and 3D Accuitomo FPD. Dentomaxillofac Radiol 2008; 37: 7279. Mah JK, Danforth RA, Bumann A, Hatcher D. Radiation absorbed in maxillofacial imaging with a new dental computed tomography device. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003; 96: 508513. Schulze D, Heiland M, Thurman H, Adam G. Radiation exposure during midfacial imaging using 4- and 16-slice computed tomography, cone beam computed tomography systems and conventional radiography. Dentomaxillofac Radiol 2004; 33: 8386. Tsikakis K, Donta C, Gavala S, Karayianni K, Kamenopoulou V, Hourdakis CJ. Dose reduction in maxillofacial imaging using low dose cone beam CT. Eur J Radiol 2005; 56: 413417. Ludlow JB, Brooks SL, Davies-Ludlow LE, Howerton B. Dosimetry of 3 CBCT units for oral and maxillofacial radiology. Dentomaxillofac Radiol 2006; 35: 219226. 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: 106114. Brenner DJ, Hall EJ. Computed tomographyan increasing source of radiation exposure. N Engl J Med 2007; 357: 22772278. Hall EJ, Brenner DJ. Cancer risks from diagnostic radiology. Br J Radiol 2008; 81: 362378.

11.

12.

13.

14.

15.

16. 17. 18.

19. 20.

Dentomaxillofacial Radiology