The Radiology Decision

Robert P. Scholz
This article discusses the many issues that should be considered if an
orthodontic practice is considering changing from the film platform for
radiography to a digital format. As cone beam use increases and its technology improves, one may consider continuing to use film, moving to a
2-dimensional system, or considering a cone beam computed tomography
(CBCT) system. Decisions regarding the routine use of CBCT in the orthodontic
office are discussed here, as well questions regarding technology selections
and their advantages and disadvantages. A radiation dose chart is included as
is a desired feature list for CBCT. (Semin Orthod 2011;17:15-19.) 2011 Elsevier
Inc. All rights reserved.

he authors of a recent survey1 have reported that 36% of orthodontists in the

United States and Canada have changed from
film to one of the digital systems, leaving 64% of
orthodontic clinicians continuing to use film.
The questions facing those in the latter group
are as follows:

Should the use of film be continued?

Should one change to an indirect (phosphor
sensor) system?
Should one purchase one of the direct 2-dimensional machines?
Should the clinician go from what is presently
being used directly to cone beam images, either by outsourcing to cone beam computed
tomography (CBCT) providers or by personally purchasing a CBCT system?

In deliberating these questions, there is need to

consider how a new system will affect office efficiency, patient flow, staff job descriptions, and
economics. Factors to consider might include
maintaining the film system because it is inexpensive, it is effective, and the clinician is satisfied with showing films to the patients/parents
on a light box, or alternatively has time to scan

Adjunct Professor, Department of Orthodontics, University of

North Carolina, Chapel Hill, NC.
Address correspondence to Robert P. Scholz, 5120 Edgeview Dr,
Discovery Bay, CA 94514. E-mail: rpscholz@aol.com
2011 Elsevier Inc. All rights reserved.
1073-8746/11/1701-0$30.00/0
doi:10.1053/j.sodo.2010.08.001

the radiographs into the offices computer network. This approach will also eliminate the additional learning and training associated with
change. However, if the existing hardware is
aging, there is a risk of having to replace a part
that may be expensive and, for a very old machine, not available. However, it will be necessary to trust the system or have a backup plan in
place so that if radiographs cannot be taken for
those patients who are scheduled, a remedy will
be in place until the problem has been solved.
Possible long-term solutions include purchasing
a 2D direct system, a previously owned film machine, or the commercial Panoramic Deal,
which involves installing a new film machine at
no cost and paying a per-film fee (http://www.
pancorp.com/).
Some might consider one of the indirect
(phosphor sensor) systems, but this choice is
reasonable only if the current panoramic/cephalometric (pan/ceph) hardware is in good order
and has considerable remaining life. To have
purchased one of these systems only to have to
replace a very expensive part on an old pan/
ceph machine is inadvisable because the money
invested would be close to having purchased a
direct 2D system. This approach will substitute
sensor scanning time for film processing time,
which may save time depending on the system
chosen. It will also eliminate the darkroom and
any time previously used to scan films into the
network and the cost will be less than a direct 2D
system. Most indirect systems claim a reduction
in radiation exposure but this authors experi-

Seminars in Orthodontics, Vol 17, No 1 (March), 2011: pp 15-19

15

16

Scholz

ence has found it to be close to the exposures

required for film.
The 2D direct choice is for those who want
maximum efficiency, rapid image acquisition
time (most are at 20 s at present), and are willing
to spend some money. The darkroom is no longer required, and maximum efficiency with this
approach is obtained. Because the author has
not used all the available systems, it is not appropriate to recommend one over the other. Cost
and local product support are important as are
recommendations from colleagues using a particular system. Personal review of the system and
having a staff member assess the user-friendliness by actual use of the machine and assessing
image quality is advised.
The first CBCT system was installed at Loma
Linda University in 2001, and it has been reported that there were 1000 installations in 2007
and that number doubled by the end of 2008
(personal communication, Dr James Mah). In
2003 one could find 9 articles on cone beam in
the PubMed library; by 2008, that number had
grown to 40. Clearly, the use of 3-dimensional
radiography has had an impact on the orthodontic specialty greatly, has created many controversial issues, and will continue to affect orthodontics and how decisions are made.
Historically, an orthodontist using a filmbased system who desired to upgrade had only to
choose between keeping the existing hardware
and purchasing an indirect (phosphor sensor)
system or spending more money and selecting a
direct 2D system. Currently, the decision is more
difficult, with the addition of cone beam systems
joining the decision-making process. The decision as to whether the clinician should discontinue with film and purchase a 2D system or pass
it over and select a cone beam system becomes
pertinent. Previously, clinicians in most locations purchased their own in-office system for
patient convenience. However, because of the
cost of cone beam systems, there has been a new
approach with the creation of many digital laboratories to which an office can outsource this
task.
Several decisions need to be made. The first
decision is how many patients in the practice will
require a cone beam exposure at the beginning,
during, or after their treatment. This presents a
problem if it is currently considered that the use
of a cone beam exposure will be used on only a

few select patients, but as technology evolves and

more studies are completed it is decided to use
CBCT on all new patients. Once a decision has
been made to use CBCT on all new patients and
a CBCT laboratory is not easily accessible, the
orthodontist might be inclined to install an inoffice system.

Patient Selection for CBCT

The main argument for not using CBCT on all
new patients is the additional radiation compared with film exposures and the lack of additional findings one might see with 3D imaging.
An editorial by Turpin,2 former Editor of the
American Journal of Orthodontics and Dentofacial
Orthopedics, describes a recent British report suggesting that we should not cone beam all our
starts.2 Most clinicians will want a cone beam
exposure for a case involving impactions, missing teeth, or supernumeraries. However, the list
for whom cone beam should be used is growing
mainly as the result of claims that the additional
information rendered with a cone beam exposure has diagnostic value. Cha et al3 state that
there may be incidental findings of diagnostic
value in 26% of new patients if the cone beam is
used. In addition, the author can name at least
12 orthodontic programs that use CBCT on all
their new starting patients and, having visited
many orthodontic programs, can anecdotally
state that many resident research projects are
focused on cone beam issues. The author also
knows several orthodontic colleagues who own a
cone beam system and are using it on every
patient they start. With this volume of cone
beams being taken, research will continue to be
forthcoming. As more is learned, it is likely that
increasing numbers of orthodontists will be led
to use 3D imaging.

Radiation Dosage
Orthodontists should be aware that there is a
perceived concern from patients and referring
colleagues regarding the additional radiation
compared with film exposures. This has been a
controversial issue for some time because it
has been difficult to make appropriate comparisons. First it must be known how much
radiation patients are receiving from the cone
beam system (and different systems emit vari-

17

The Radiology Decision

ous levels of radiation) before it can be compared with a film exposure. Some comparisons
are listed in Table 1.3
Thus, when comparing cone beam radiation
levels to an orthodontic protocol that takes a
panoramic, cephalometric, occlusal, and full
mouth series on most or all patients, depending
on the cone beam system, the radiation level
could be greater. For some the radiation concern
is a nonissue, whereas for others it remains an
issue; therefore, remains an area of controversy for
the present time. The author believes that as technology evolves and the cone beam systems are
improved it will soon become a nonissue.

Standard of CareRecommendations
Another concern is the standard of care. Many
of the experts on implantology agree that the
use of cone beam exposures before placing an
implant is recommended. In addition the author considers that the use or nonuse of CBCT
in the same neighborhood on impacted cuspid
teeth may perhaps become a liability issue if
untoward treatment outcomes occurred where
the CBCT was not used.

Reading CBCT Files

Another important consideration is the personal
reading of CBCT files or their outsourcing. There
are now many services available (e.g., http://
www.dimensionsimaging.com/) that enable one to
read a DICOM file via the Internet, that offer images
that will satisfy the clinicians diagnostic needs, and
that allow one to obtain a radiology report. If the
clinician outsources to a laboratory, the laboratory
will likely have this service available.

By contrast, according to the author, it is

claimed that some graduating residents are
cone beam fluent, which means they can read
their own files and send only those they suspect
out for a radiology report. It is claimed that in
learning these skills, the orthodontist will become a much better diagnostician.

Risk and Responsibility

A further issue concerns risk and responsibility
meaning what if an orthodontists patient is referred for a cone beam exposure and pathology
evident in the DICOM file is missed? This was a
controversial topic for awhile, but in the opinion
of most experts, the referring doctor is responsible for the contents of the scan, so a report by
a radiologist is in order. According to a notice
published by the AAO Liability Insurance Company in June 2009, this is no longer a controversial issue.4 They state that Recent technological
advances have made it even more important to
recognize when it is necessary to involve other
fields. CBCT scans are a principal example.
These scans may reveal information beyond that
which we, as orthodontists, are trained to interpret. However, legally you may be presumed to
know all that is shown. Referral to a qualified
radiologist relative to the reading of CBCT scans
is therefore advisable. The author would certainly follow these steps to be sure that he was
covered in any circumstance.

Resolution Variation
A further issue involves resolution variation between the different brands of cone beam machines. There are variations and recent improve-

Table 1. Interpretation of relative dosages

Examination

Effective Radiation Dose, Sv

Equivalent Natural Background Radiation for:

Panoramic
Cephalogram
Occlusal film
Bitewing
Full mouth series
Temporomandibular joint series
CBCT examination
Medical examinations
Chest X-ray
Mamography
Medical computed tomography

3-11
5-7
5
1-4
30-170
20-30
40-135

Half- to one day

Half- to one day
Half-day
Half-day
4-21 d
3-4 d
4-17 d

100
700
8000

10-12 d
88 d
1000 d

CBCT, cone beam computed tomography.

18

Scholz

ments have reduced the voxel size to 0.125 mm,

which is close to clinicians being able to fabricate appliances. The Kodak 9000 3D (http://
www.dentalcompare.com/newproducts.asp?id
632) advertises a voxel size of 0.076 mm. As
voxel size decreases, standard orthodontic
procedures such as impressions and intraoral
scanning will begin to disappear, and will have
a major impact on the current systems used for
customized brackets, indirect bonding, and Invisalign (http://www.invisalign.com/Pages/
Home.aspx).

low the orthodontist or laboratory to easily manipulate the DICOM file and obtain the necessary
information. There are several companies working
on these applications, including Dolphin 3D
(http://www.dolphinimaging.com/home.html)
Anatomages InVivoDental (http://www.anatomage.
com/ and 3dMDs), and Vultus (http://www.3dmd.
com/). All 3 share common features and each
have their own unique features as well and are
discussed in the paper by Grauer et al.5

Conclusions
Field of View and Multifunctionality
Cone beam machines can be grouped by 2 categories, the field of view and their multifunctionality. Field of view can be small for just the
dental area, medium to image the joints, and
enough data for a panorex or large to obtain a
cephalometric image (ceph). Recent advances
have started to permit multifunctional systems
that allow a full cone beam exposure or a 2D
panorex or ceph. At the time of this writing,
there are now 40 cone beam systems available, so
careful feature shopping is mandatory for one
contemplating a purchase. An excellent resource for cone beam information is Dr Aaron
Molens web site (http://3dorthodontist.com/).

Reading the DICOM File

An interesting area concerns the reading of the
DICOM file. An individual decision is necessary
and involves learning the process or outsourcing
to someone who can do it better and more
efficiently. There are many Internet sources
available for reading DICOM files and dealing
with the pathology, whereas there are only a few
programs that the author is aware of that can
teach these skills.
The motivation for orthodontists to consider
buying an in-office cone beam system will include the occurrence of 3 issues that will cause
orthodontists to begin using CBCT on more
patients. The first 2 have already been mentioned; first, when radiation levels, both perceived and real, reach an acceptable level; second, when resolution is increased to a point in
which appliances can be fabricated so that taking
impressions will no longer be necessary. The third
will be the evolution of third-party software to al-

A little prognostication on the future of cone

beam technology and how it will impact the
practice of orthodontics is provided, with no
idea when or if all of this will become reality, but
the sense in following cone beam evolution for
the past several years suggests:

cone beam radiation level concerns, both perceived and real, will disappear;
resolution will be improved to allow the fabrication of appliances so clinicians will no longer take impressions;
more research will be completed, causing clinicians to use cone beam for more patient
starting treatment to provide better diagnostic
information;
the 45-minute records appointment to collect
impressions, a centric registration, panoramic,
cephalometric, facial and intraoral photos will
be replaced by a 5-minute appointment to
obtain a centric registration with the condyles
seated and the teeth apart and this will be
worn during the cone beam exposure to gain
better occlusal DICOM data;
software will have a virtual articulator feature
to allow for better identification of occlusal
disharmonies and perhaps equilibrate them
on screen; and
clinicians will continue to charge for this new
records protocol so there will be revenue available to pay for the cone beam machine

This is the authors feature list of what he would

like to see in a third-party application; many of
these features are available today, although it is
not known when the others will all be available:

one-click cephalometric image;

one-click panoramic image;

The Radiology Decision

onscreen models with segmented teeth;

visual treatment objective capability;
onscreen articulator;
ability to superimpose DICOM files;
auto-cuts (eg, click on impacted maxillary canine and see diagnostic cuts which can be
fine-tuned);
pathology cuts;
affordability;
ability to measure the teeth;
Bolton analysis;
virtual extraction;
ability to move the teeth;
idealized setup; and
fabricate appliances!

19

The road to full use of this new cone beam

technology promises to be an adventurous
one!

References
1. Keim RG, Gottlieb EL, Nelson AH, Vogels DS III. 2008
JCO Study of Orthodontic Diagnosis and Treatment Procedures. Part 1: Results and Trends.
2. Turpin DL, British Orthodontic Society: Revises guidelines for clinical radiography. Am J Orthod Dentofac
Orthop 134:597-598, 2008
3. Cha JY, Mah J, Sinclair P: Incidental findings in the maxillofacial area with 3-dimensional cone-beam imaging.
Am J Orthod Dentofac Orthop 132:7-14, 2007
4. Risk Notice: Cone Beam Computer Tomography. AAO
Insurance Company eBulletin. June 9, 2009
5. Grauer D, Lucia SH, Cevidanes WR, et al: Working with
DICOM craniofacial images. Am J Orthod Dentofac Orthop 136:460-470, 2009