Periodontology 2000, Vol.

66, 2014, 203213

Printed in Singapore. All rights reserved

2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

PERIODONTOLOGY 2000

Dental cone beam computed

tomography: justication for use
in planning oral implant
placement
REINHILDE JACOBS & MARC QUIRYNEN

More than one-quarter of all medical radiographs are

taken by dentists. The signicance of radiographs for
dental diagnosis is illustrated by the fact that hardly
ntgen reported the discov2 weeks after W. C. von Ro
ery of X-rays in 1896, a German dentist (O. Walkhoff)
had already made the rst radiographic image of
human teeth. For more than a century, this type of
dental radiograph was the principal source of diagnostic information on the maxillofacial complex. Yet,
two-dimensional projective techniques cannot fully
display complicated three-dimensional anatomic
structures and related pathologies.
In the 1980s, a rst revolution came with the introduction of digital dental (radiographic) imaging in
dentistry. A second milestone was reached in the
1990s with the introduction of typical dentomaxillofacial software applications for two- and three-dimensional diagnostics, and presurgical planning (17, 19, 53,
54). At that time there was a steep upward trend in the
use of three-dimensional information as an aid in
dentomaxillofacial diagnostics and therapy, with cone
beam computed tomography imaging becoming more
widely available in specialized clinics (6, 11, 37). Likewise, three-dimensional imaging applications for oral
implant rehabilitation, including guided surgery, experienced a simultaneously successful development (47,
48, 52, 55). It can even be stated that the three-dimensional triumph in dentistry is largely attributable to the
substantial and global growth of (guided) oral implant
surgery during the last decade, now emerging as the
prime treatment option for tooth replacement.
Although the required three-dimensional acquisition was initially achieved by conventional multislice
computed tomography, dental cone beam computed
tomography rapidly became more popular (6, 11, 22,

37). The main reasons for this success are to be found

in the fact that cone beam computed tomography
enables volumetric jaw bone imaging at reasonable
costs and low radiation doses, with the relative
advantage of having affordable and compact, and
therefore often in-house, equipment. The latter
aspect is crucial when considering the fact that the
power of a dental three-dimensional data set is not
only situated in the diagnostic eld but also in a multitude of presurgical and therapeutic applications.
The rapid progression in digital technology and computer-aided design/computer-aided manufacturing
systems indeed creates challenging opportunities for
diagnosis, surgical implant planning and delivery of
implant-supported prostheses. The ultimate integration is a full three-dimensional data registration of
radiographic, optical and potential clinical images,
creating the virtual patient, allowing simulated surgery with proper planning and transfer to the real surgical eld (1, 14, 22, 49).
Concomitantly with these evolutions, medical
awareness of the public is largely increased, resulting
in greater expectations of possible treatment options
for oral implant rehabilitation. A proper answer for
this increased demand can again be obtained from
the available three-dimensional image data sets.
Although collection of those data sets could never be
justied simply to assist the demanding patient, having a virtual jaw, and even patient model, chair-side,
could allow demonstration and further discussion of
the therapeutic options and prospects in a threedimensional environment.
The aim of the present literature study is threefold:
rst, to provide support for the use of threedimensional information in oral implant surgery;

203

Jacobs & Quirynen

second, to provide support for the hypothesis that

cone beam computed tomography should be preferred over multislice computed tomography; and,
third, to formulate some guidelines for justied and
optimized use of cone beam computed tomography
during the various implant treatment phases.

Guideline reports
When seeking justication and optimization of cone
beam computed tomography use in oral implant
placement, it is important to consult four major documents (of which three were published in 2012) as
the prime sources for any further reference. The fundament to these documents is the basic principle of
radioprotection (ALARA: keep radiation dose As Low
As Reasonably Achievable), considering that no exposure to ionizing radiation can be regarded as completely free of risk (8, 46). The latter is translated in a
most useful document reporting 20 basic principles
for the correct use of cone beam computed tomography (16). These principles are listed in Table 1.
The rst 2012 contribution acquires key information for sound and scientically based clinical use of
cone beam computed tomography in dental and
maxillofacial imaging (7). Detailed (SEDENTEXCT)
guidelines were based on a systematic review of the
literature, whilst the core guidance has been from the
two Euratom key Directives: (i) the 96/29/Euratom,
laying down the basic safety standards for health protection of workers and the general public against the
dangers arising from ionizing radiation, and (ii) the
97/43/Euratom on health protection of individuals in
relation to medical exposure to ionizing radiation.
The European Association for Osseointegration (13)
used the above-mentioned guidelines (7) to stress the
need to establish guidelines for the justication and
optimization of cone beam computed tomography
use in implant dentistry. This document is based on a
European Association for Osseointegration consensus
workshop organized in 2011 and is, in fact, an update
of the 2002 European Association for Osseointegration guidelines (12). Around the same time, another
position paper was prepared by the American Academy of Oral and Maxillofacial Radiology (45), as a
revision of the 2000 American Academy of Oral and
Maxillofacial Radiology guidelines (44).
The main reason for both revisions is to be found
in the role that cone beam computed tomography
started to play, particularly in implant dentistry, over
the last decade. Whilst the American Academy of Oral
and Maxillofacial Radiology recommends cross-sec-

204

tional imaging for the assessment of all dental

implant sites, with cone beam computed tomography
being the method of choice for gaining this information (45), the European Association for Osseointegration stresses the fact that cone beam computed
tomography cannot be undertaken without: (i) proper
training of both referrers and cone beam computed
tomography practitioners and operators, (ii) thorough
justication for its use, and (iii) a mandatory optimization of the procedure and nal application (13).

Cone beam computed tomography

or multislice computed
tomography: an obvious answer?
Although two-dimensional intra-oral and panoramic
radiographs are routinely applied in dental practice,
such images often fail to answer the required questions because of anatomic superposition and panoramic distortion. Three-dimensional imaging may
then be indicated. Different tomographic modalities
have previously been used. The so-called classical
(linear and spiral) tomography has now been fully
replaced with computed tomography.
Computed tomography was invented by Hounseld in 1972, which gained him the Nobel Prize in
Medicine in 1979 because it revolutionized modern
diagnostic medicine. Since its invention, computed
tomography has been constantly rened to enhance
image quality for hard- and soft-tissue visualization,
whilst controlling the radiation dose. In modern
computed tomography imaging, a three-dimensional
image is constructed from a large number of twodimensional projections, which are acquired by rotating an X-ray tube and detector around the object.
From a geometrical point of view, computed tomography scanners using a fan-shaped beam should be
distinguished from those using a cone-shaped X-ray
beam.
The former type (including a rotating fan-shaped
X-ray beam and detector arc) is still considered as the
standard conguration of modern multislice or multidetector computed tomography units. However, in
the new generation of computed tomography
machines, the fan-shaped X-ray beam has been widened, and new detector and reconstruction technologies have been introduced, to permit the replacement
of traditional one-dimensional detector arcs with
multiple detector rows (up to 320) in a two-dimensional array (9). This advancement meant a further
revolution for computed tomography imaging, as

Cone beam CT for implant surgery

Table 1. European Academy of Dentomaxillofacial Radiology (EADMFR) basic principles on the use of cone beam
computed tomogrpahy (reprinted from 16)
1 CBCT examinations must not be carried out unless a history and clinical examination have been performed
2 CBCT examinations must be justied for each patient to demonstrate that the benets outweigh the risks
3 CBCT examinations should potentially add new information to aid the patients management
4 CBCT should not be repeated routinely on a patient without a new risk/benet assessment having been performed
5 When accepting referrals from other dentists for CBCT examinations, the referring dentist must supply sufcient
clinical information (results of a history and examination) to allow the CBCT Practitioner to perform the Justication
process
6 CBCT should only be used when the question for which imaging is required cannot be answered adequately by lower
dose conventional (traditional) radiography
7 CBCT images must undergo a thorough clinical evaluation (radiological report) of the entire image data set
8 Where it is likely that evaluation of soft tissues will be required as part of the patients radiological assessment, the
appropriate imaging should be conventional medical CT or MR, rather than CBCT
9 CBCT equipment should offer a choice of volume sizes and examinations must use the smallest that is compatible with
the clinical situation if this provides less radiation dose to the patient
10 Where CBCT equipment offers a choice of resolution, the resolution compatible with adequate diagnosis and the lowest
achievable dose should be used
11 A quality assurance program must be established and implemented for each CBCT facility, including equipment,
techniques and quality control procedures
12 Aids to accurate positioning (light beam markers) must always be used
13 All new installations of CBCT equipment should undergo a critical examination and detailed acceptance tests before
use to ensure that radiation protection for staff, members of the public and patient are optimal
14 CBCT equipment should undergo regular routine tests to ensure that radiation protection, for both practice/facility users
and patients, has not signicantly deteriorated
15 For staff protection from CBCT equipment, the guidelines detailed in Section 6 of the European Commission document
Radiation Protection 136. European Guidelines on Radiation Protection in Dental Radiology should be followed
16 All those involved with CBCT must have received adequate theoretical and practical training for the purpose of
radiological practices and relevant competence in radiation protection
17 Continuing education and training after qualication are required, particularly when new CBCT equipment or
techniques are adopted
18 Dentists responsible for CBCT facilities who have not previously received adequate theoretical and practical training
should undergo a period of additional theoretical and practical training that has been validated by an academic
institution (University or equivalent). Where national specialist qualications in DMFR exist, the design and delivery
of CBCT training programmes should involve a DMF Radiologist
19 For dento-alveolar CBCT images of the teeth, their supporting structures, the mandible and the maxilla up to the oor
of the nose, clinical evaluation (radiological report) should be made by a specially trained DMF Radiologist or,
where this is impracticable, an adequately trained general dental practitioner
20 For nondento-alveolar small elds of view (e.g. temporal bone) and all craniofacial CBCT images (elds of view
extending beyond the teeth, their supporting structures, the mandible, including the TMJ, and the maxilla up to the
oor of the nose), clinical evaluation (radiological report) should be made by a specially trained DMF Radiologist
or by a Clinical Radiologist (Medical Radiologist)
CBCT, cone beam computed tomography; CT, computed tomography; DMF, Dentomaxillofacial; DMFR, Dentomaxillofacial Radiology; MR, magnetic resonance;
TMJ, temporomandibular joint.

higher-resolution images could be obtained in a

shorter scanning time, reducing radiation time and
risks for movement artifact. Indeed, since the introduction of 16- and 32-slice scanners, submillimeter
scanning can be accomplished in very short scanning
times, with <1 s per rotation and imaging of multiple

slices. Nevertheless, even now, with 64-detector rows,

multiple rotations remain necessary to image the
dentomaxillofacial complex. In addition, the high
milliampere seconds (mAs) values, with increased signal at lower noise levels, still result in the exposure of
patients to high doses of X-rays (10, 49).

205

Jacobs & Quirynen

In contrast to fan-beam computed tomography,

cone beam computed tomography makes use of a
cone- or a pyramid-shaped X-ray beam, in conjunction with a two-dimensional detector array, to scan
an entire volume in one rotation (2, 6, 30, 37, 49). This
distinct difference in scanning mechanisms between
fan-beam and cone-beam computed tomography
scanning, generates the characteristic properties
associated with cone beam computed tomography
compared with multislice computed tomography.
The conical X-ray beam allows an entire volume to be
scanned in one single rotation, with a reduced X-ray
tube power, whilst using a at two-dimensional
image receptor. The lower-power conguration
reduces both costs and radiation, but is often associated with increased noise and lower contrast resolution, making cone beam computed tomography
unsuitable for soft-tissue imaging (2, 6, 30, 37, 49).
Yet, its compact size (2 m surface), the greatly
reduced purchase and maintenance costs, the low
radiation dose and the high spatial resolution for the
depiction of small bony structures have led to an
exponential growth of cone beam computed tomography systems for dentomaxillofacial applications.
Although many studies have reported that cone
beam computed tomography has a superior image
quality compared with multislice computed tomography for dentomaxillofacial applications or hard-tissue
visualization, it is important to consider the differences between cone beam computed tomography
systems as well as the differences in within-unit parameters, which may have a signicant inuence on the
outcome (24, 2629, 3436). Cone beam computed
tomography units often allow a change in exposure
parameters, such as mAs, kV, voxel-size and number
of frames; however, most dentists are still unaware of
the respective effects of these changes. The use of
specic protocols for dened indications, optimized
for individual patients, would be very helpful.
Finally, it should be noted that the wide fan-shaped
beams used in current-generation multislice computed tomography scanners start to mimic cone
beam effects, leading to a fading distinction between
multislice computed tomography and cone beam
computed tomography, based on beam shape (9).

Cone beam computed tomography

for dentomaxillofacial diagnostics
The NewTom 9000 (QR, Verona, Italy) was the rst
cone beam computed tomography machine to be
designed for use in a dental practice (1996) with the

206

rst scientic reports dating back to 1998 (2, 30). Currently, more than 50 types of cone beam computed
tomography models are available, including multimodal types for additional panoramic and/or cephalometric imaging, and cheaper primary panoramic
machines with a small eld-of-view three-dimension
button. These machines are used for a wide array of
clinical indications, mainly in implant surgery, endodontics, orthodontics and maxillofacial surgery (6,
15, 22, 33, 3942). Unfortunately, a gap has been created between available hardware and the scientic
literature. Moreover, research ndings cannot simply
be extrapolated from one type of cone beam computed tomography unit to another.
Besides the practical advantages, one should also
be aware of the disadvantages. Different cone beam
computed tomography units indeed show important
variations in geometric congurations (2729, 3436).
The rotation center may vary from the middle of the
source or closer to the receptor, and beam angles
may differ between and within units, resulting in a
wide range of different eld-of-views with a variable
expression of truncation artifacts or partial volume
effects as the detector often does not cover the entire
volume. In addition, the reconstruction of cone beam
computed tomography data may be based on either
modied Feldkamp or algebraic reconstruction techniques; the latter is computationally more expensive
but is more effective at preventing beam-hardening
artifacts from metal llings, crowns and implants
(35). Patients are scanned most often in standing or
seated positions, which makes the in-ofce cone
beam computed tomography unit resemble compact
panoramic machines. This factor is of utmost importance, as movements made by the patient may result
in detrimental effects, certainly when occurring
together with artifacts from metal.
Considering the aforementioned differences, there
is a huge variation in image quality and radiation
dose among different scanners (Figs 1 and 2). More
research needs to be conducted to establish proper
protocols and adequately relate image quality to radiation dose.

Dosimetric aspects of dental cone

beam computed tomography
When considering radiation doses linked to medical
exposure, the values are often compared with equivalent doses of natural background radiation. The
worldwide average natural background dose of radiation for a human is about 2.4 mSv per year (10). This

Cone beam CT for implant surgery

Fig. 1. Effective radiation doses of typical dentomaxillofacial applications are relatively low when compared with the
annual background radiation. CBCT, cone beam computed tomography; CT, computed tomography.

Veraviewepocs3D

73

SkyView

87

Scanora 3D upper+lower

45

Scanora 3D lower

47

Scanora 3D upper

46

Scanora 3D extended field

ProMax 3D low dose
ProMax 3D high dose
Picasso Trio low dose
Picasso Trio high dose
Pax-Uni 3D front
NewTom VGi small field HR
NewTom VGi large field
Kodak 9500 small field
Kodak 9500 large field
Kodak 9000 lower molar
Kodak 9000 upper front
Iluma
i-CAT Next Generaon 13cm
Galileos 35 mAs
Galileos 28 mAs

68
28
122
81
123
44

265

92

194
136

40
19

83
114
84

368

0
50
100
150
200
250
300

Eec ve dose for CBCT (Sv)

350
400

Fig. 2. A large variation in effective dose levels is found when evaluating cone beam computed tomography scanners with
the typical clinical protocols for the same indication. CBCT, cone beam computed tomography.

exposure is mostly from cosmic radiation and natural

radionuclides in the environment. This is far greater
than human-caused background radiation exposure,
which in 2000 amounted to an average of about
0.005 mSv per year, and is greater than the average
exposure from medical tests (0.041 mSv per year). In
Europe, average natural background exposure, by
country, ranges from <2 mSv annually in the UK to
>7 mSv annually in Finland (10). Some of the highest
levels of natural background radiation recorded in
the world are from areas around Ramsar (Iran),
having an effective dose up to 200 times greater than

normal background levels (23). Annual exposures of

people living in Ramsar range from 10 to 260 mSv
(compared with 1 mSv for a computed tomography
scan) (23).
Generally, the radiation risk from exposures to the
head and neck area can be considered as relatively
low compared with other areas of the human body.
The sole organ with a high radiosensitivity in the head
and neck is the thyroid gland, followed by the salivary
glands and the brain. The lowest doses of radiation are
found for intra-oral and extra-oral radiographs. For
dental multislice computed tomography exposures,

207

Jacobs & Quirynen

effective doses of up to 1 mSv are seen, as well as considerably lower doses for reduced eld-of-view (e.g.
single jaw) or low-dose (5, 28, 36, 38) protocols (Fig. 1).
The effective radiation doses for cone beam computed tomography should be far below the levels of
clinical spiral computed tomography, to be accepted
as a true benet. The dose should preferably be
equivalent to two to maximally 10 panoramic radiographs (20100 lSv) (22, 28, 36). Unfortunately, many
of those systems seem to vary enormously (Fig. 2).
Reported radiation dose levels vary from around 10 to
1000 lSv (which is equivalent to two to 200 panoramic radiographs, or 2.4240 times the average natural background radiation), according to the cone
beam computed tomography device being assessed
(Figs 1 and 2). It should also be considered that even
in the same machine, there can be a huge range of
variable options in eld-of-view, resolution and exposure parameter settings, with, as a consequence, an
effective dose range of the same order as the variability amongst the machines (22, 36, 49).

Image quality aspects of cone beam

computed tomography
A wide range in image quality has been reported for
cone beam computed tomography, similarly to (but
not solely determined by) the range in exposure (27,
28, 34) (Fig. 3). Cone beam computed tomography
images are generally considered to be of high resolution. The voxel sizes of reconstructed cone beam
computed tomography data sets, representing the
upper limit of the actual resolution, range from 0.08
to 0.4 mm, and preliminary studies have pointed out
that the sharpness of cone beam computed tomography can be superior to that of multislice computed
tomography. Cone beam computed tomography is
therefore particularly useful for cases in which small
structures (e.g. roots and periodontal tissues) need to
be visualized in three dimensions. The same holds
true for segmentation accuracy, which is crucial for
integrated virtual planning, including models of the

CBCT 1, HR volume

CBCT 1, standard

CBCT 2, HR

CBCT 2, standard

CBCT 3, HR

CBCT 3, standard

Fig. 3. The variation in cone beam

computed tomography image quality based on different machines and
different parameter settings is
shown on axial slices at the level of
the maxillary trabecular bone and
sinus. CBCT, cone beam computed
tomography; HR, high resolution.

208

Cone beam CT for implant surgery

jaw and the (scanning) prosthesis, and for a potential

secondary outcome applying stereolithographic models during and after surgery.
Depending on the cone beam computed tomography unit and the parameter settings, a level of
200 lm should be feasible, but then again, larger
inaccuracies may apply (1000 lm and above). This is
partly related to the lower contrast resolution of cone
beam computed tomography compared with multislice computed tomography. Apart from the poor
contrast resolution, cone beam computed tomography devices usually have relatively high noise levels,
making them more suitable for visualization of structures with a high inherent contrast: teeth; bony structures and canals; and air cavities. The drawback is the
lack of any diagnostically valid soft-tissue contrast on
cone beam computed tomography images, which
limits their application. Furthermore, cone beam
computed tomography images are generally hampered by a varying degree of artifact expression,
mostly deriving from patient jaw movement and from
dense dental restorative materials or, even worse,
from a combination of both. Besides, altering cone
beam computed tomography geometric congurations creates a variable expression of artifacts, including truncation, partial volume and several others. In
addition, varying reconstruction protocols greatly
impact image output and artifact expression (such as
beam hardening and metal streak artifact).
One factor that complicates the optimization of
cone beam computed tomography in practice is the
variable implementation of the basic cone-beam
principle by manufacturers. Cone beam computed
tomography devices exhibit wide ranges for essential
imaging parameters, affecting the exposure and/or
image quality. A quality assurance protocol could
offer a solution, with the greatest challenge being to
develop a protocol applicable for any type of cone
beam computed tomography scanner and relevant in
terms of clinical use and/or patient risk. This would
enable scanner optimization and follow up of an
individual scanners performance and any potential
deterioration.

Is cross-sectional imaging justied

for oral implant rehabilitation?
Although various imaging options are available for a
multitude of dentomaxillofacial indications, crosssectional imaging seems to be preferred for surgical
planning (4, 18, 19) (Table 2), the most common

being the preoperative planning of implant placement, primarily to avoid neurovascular trauma, but
also to enable integration of anatomic, functional,
biomechanic and esthetic factors (19, 22).
Although panoramic and intra-oral views are the
rst choice radiographs to assess teeth and periodontal status, an obvious limitation is that these
do not provide information on the bucco-lingual
dimensions, jaw-bone morphology and irregularities
within the alveolar bone (see Table 2). Intra-oral
periapical images offer a high spatial resolution,
making them valuable for a detailed diagnosis of
tooth-related pathologies (17, 49). These radiographs
might also provide a general idea of the trabecular
bone structure, yet the anatomic structure overlap
prevents the detection of trabecular bone lesions.
Furthermore, intra-oral radiographs lack the potential to visualize bone morphology (17). Finally, these
images are limited in size, therefore depicting less
anatomic information than is sometimes required,
whilst also preventing comparison of a local problem with the environment or the contralateral side
(17). This can be the case in the posterior mandible,
in which localization of the mandibular canal and
the mental foramen is essential. Similarly, the maxillary sinus region may not always be sufciently
visualized. Usually, the detection of odontogenic
sinusitis is much lower on intra-oral radiographs
than on cone beam computed tomography, with
more than two-thirds of the lesions missed on
intra-oral radiographs (3, 22, 39) (Fig. 4). The latter
also applies for panoramic radiographs, for which
Shahbazian et al. (39) could only identify apical
lesions on the maxillary molars in 16% of cases,
meaning that ve out of six problems remain undetected. Panoramic radiographs typically provide
information on the maxillary anatomy of the jaws
and related anatomic structures, allowing a global
treatment plan to be made. The two-dimensional
nature and substantial anatomic structure overlap,
the inherent distortion and enlargement, the tomographic effect and the limited resolution, make
these images less well suited for assessing details in
teeth and bone (4, 17, 22) (see Table 2).
These drawbacks have a serious impact on evaluating
the relationship between anatomic structures, thereby
hampering detailed diagnosis and presurgical planning. This certainly also applies for sinus grafting procedures (3, 43). The shortcomings of two-dimensional
imaging make such procedures particularly less
suitable when the aim is the accurate assessment
of neurovascular structures. They thus present a

209

Jacobs & Quirynen

Table 2. When to use two-dimensional vs. cross-sectional imaging during various implant treatment phases
Treatment phase

Clinical information needed

Level of adequacy of two-dimensional vs. threedimensional radiographs in delivering the required

clinical information
Intra-oral Panoramic Cross-sectional imaging
radiographs imaging
low-dose cone beam computed
tomography

Preimplant diagnostics

Prognosis neighboring or
doubtful teeth

++

Remodeling extraction site(s)

+/

+/

++

++

+/

++

+/

++

Presence of jaw-bone lesions,

sinus, bone, and/or tooth pathology
Preoperative planning of Determination of anatomic boundaries
implant placement
Reliable visualization of jaw-bone
neurovascularization
Information on bone volume and
planning grafting

/+

/+

++

Information on bone morphology

Information on bone quality and
trabecular structure
Transfer to surgery

Peri-implant follow up

++

Integration of anatomic, functional,

biomechanic and esthetic factors

++

Decision for computer-assisted

surgical transfer

++

Diagnosis of postoperative
complications

Follow up of managing complications

Levels of adequacy: ++, excellent; +, good; +/ , poor;

/+, very poor;

, not suitable.

Fig. 4. Intra-oral radiographs often fail to show existing

sinus pathology. On the left side an intra-oral radiograph
is visualizing an endodontic treatment on a 16 overlapping
with the sinus and the zygomatic process. On the right

peroperative risk for neurovascular trauma (20, 21, 25,

31). To overcome these drawbacks, cross-sectional
imaging may be advocated if the radiation burden can
be kept at low levels. Currently, the most obvious
choice to achieve this is through the use of a dedicated
dental cone beam computed tomography device with
low-dose features (cone beam computed tomography;
see Table 2).

210

++

side, a panoramic reslice of the same area shows an odontogenic sinusitis related to an oroantral perforation caused
by an apical infection related to accessory untreated canals
(e.g. in the mesiovestibular root).

Dental cone beam computed

tomography use beyond
radiodiagnostics
Apart from the radiodiagnostic possibilities, dental
cone beam computed tomography may offer a vast
therapeutic potential, including opportunities for

Cone beam CT for implant surgery

surgical guidance and further prosthetic rehabilitation

via computer-aided design/computer-aided manufacturing solutions. Current studies are typically focused
on overcoming inherent drawbacks of the technology
by exploring modied scanning protocols or by fusion
of cone beam computed tomography image data sets
with optical data sets to overcome the drawback of artefacts caused by metallic dental restorations (1, 14, 32,
35, 50, 51). These optical data sets are derived from
recently introduced three-dimensional optical cameras, having the potential to turn conventional dentistry
completely upside down. Such optical camera systems
may indeed offer the opportunity to bypass analog
impression-taking, eliminating not only the necessity
for impression materials to be placed in the mouth, but
also reducing time and handling errors associated with
such impressions. The intra-oral three-dimensional
scanners available may have the potential to offer excellent accuracy (10 times better than cone beam computed tomography), whilst being more comfortable for
the patient and far more efcient for the ofce workow. Fusions with basic cone beam computed tomography data would thus allow a digital cast with an
accurate surface to be used or transferred for therapeutic applications via computer-aided design/computeraided manufacturing procedures. Such procedures are
used in dental practice, dental laboratories or elaborate
production centers. As a result of continuous developments, this may lead to further simplication and more
automation, with less chair-time and potential visits for
the patient, but more computer time for the practitioner, resulting in virtual customization of the oral
implant rehabilitation for the individual patient.
Meanwhile, it should also be mentioned that integrated facial scanning has become available in several
cone beam computed tomography units. This requires
a concomitant three-dimensional laser acquisition of
the soft tissues of the face, during the cone beam computed tomography rotation, allowing fully integrated
planning with the three-dimensional facial tissue scan
on top of the bony skull image. The availability of fully
integrated and accurate three-dimensional information of both face and bone allows more effective planning and predication of the treatment outcome. It not
only enhances the transfer to the surgical eld, but
also increases the possibilities of radiation-free followup of such surgical cases.

Conclusions
Cross-sectional imaging offers numerous opportunities in both diagnostic and dental therapeutic elds,

both of which are necessary for integrated presurgical

planning and transfer to oral implant placement. Evidence indicates that when cross-sectional imaging is
justied, cone beam computed tomography is preferred over multislice computed tomography. Yet, it is
obvious that cone beam computed tomography
should not be carried out without proper optimization
strategies in order to maintain the correct balance
between cost and radiation dose, on the one hand,
and information required, on the other hand. Therefore, the scanned area should not exceed the area of
interest. This would substantially limit the dose of radiation, whilst justifying the use of cone beam computed
tomography in preparing for implant surgery.
Although cone beam computed tomography has
evolved considerably in the last decade, there is still
room for optimization. Various radiation dose-reduction techniques could be implemented at different
levels of the imaging chain. In addition, hardware and
software development may lead to improvement in
image quality. Development of procedures for surgical template and computer-aided design/computeraided manufacturing procedures, as well as surgical
navigation, go hand-in-hand with procedures for
cone beam computed tomography scanning. These
concomitant developments will probably alter the
treatment strategies in oral health care and, more
specically, in implant dentistry.

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