CONE BEAM COMPUTED

TOMOGRAPHY

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 CONTENTS

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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 INTRODUCTION

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

radiation
Round like
ConeX-rays and a X-ray
shaped 2D area detector mounted
beam
on a rotated gantry to acquire multipalanar
sequential projection images in one single scan
around the area
2- D area of interest
detector
Combine with 3D x ray beam with circular
collimation cone shaped resultant beam
360 0 rotation around the object both
Projections
source made in
and detector all planes
mounted on at a
a gantry
time volumetric images obtained

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 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.
The complete series of basis image is k/a
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
Image reconstruction
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 Positioning
1. Supine
Equipment required
Large surface area/ physical footprint
Not for physically disabled patients

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

3. Seated units
Most comfortable
Not for physically disabled
Immobilization of patients head is necessary

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Upright patient loading and supine

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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 automatically

modulated in near real time by feedback mechanism.
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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.
(limiting factor in voxel resolution) 20
 IMAGE DETECTION

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 scintilla
layer (cesium iodide)
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 DETECTORS
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 detectors
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 size determine degree of

X ray geometric configuration geo unsharpness
Matrix
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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 GRAYSCALE
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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 RECONSTRUCTION

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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 RECONSTRUCTION
PROCESS

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Once all slices have been reconstructed they combine into single volume of visualization
 DISPLAY

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 33
Serial cross section 1 mm thick images
 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 34
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 value
along an imaginary projection ray from observers
eye within a particular volume of interest and
represent the high value as a display value

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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 movement .

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 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 prosthesis

( 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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 SCAN TIME & NO OF PROJECTIONS

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 44
 IMAGE OPTIMIZATION

To optimize image presentation & facilitate diagnosis

it is necessary to adjust contrast/window and
brightness/level parameters to favor bony structures.
CBCT software have window/level presets
This is adjusted for each scan
Enhancement can perform by application of sharpening
,
filtering.

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 REPORTS

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

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 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, then Image the patient in multiple slices
reconstruct slices

Cone beam Geometry Fan beam Geometry

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

Operating voltage 80 120Kvp 80 140 Kvp

Focal Spot size 0.5- 0.8mm 0.5 1.2mm

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

Lesser cost Higher Cost

Spatial resolution = 0.07-0.4 mm Spatial resolution = 0.3-0.4 mm

5 lp/mm 2-3 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 52
 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 ARTIFACT STREAKS & DARK 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 60
 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.
Dexels - measure the energy of the incident x-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
within the image.

Inc voxel size reduces grainy app but spatial

resolution and detection of small object reduced

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 SCANNER RELATED ARTIFACTS

Circular / ring steaks

Result from imperfections in scanner detection

Cause repetitive reading at each angular position

of detector.

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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 in the image .
Importance 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 the patient in horizontal plane, structures at top
and bottom of the image field only be exposed ( x ray
beam is in opposite side of patient)

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
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 IMPLANT SITE ASSESSMENT

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
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 inclination, torque, root resorption, alveolar
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, lateral, submentovertex,
posteroanterior cephalometric images) 77
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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 JOINT

Diagnosis of bone morphologic features, joint

space and dynamic functions.
Degenerative joint disease
Developmental anomaly of condyle
Ankylosis
Rheumatoid arthritis

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 MAXILLOFACIAL COMPLEX

Impacted canine , supernumerary teeth, fractured

or split teeth, periapical lesions , periodontal
disease,

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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 involvement 85
 IN ENDODONTICS

2D image True extent of lesion

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 IN PERIODONTICS

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Extent of the lesion in facio-lingual and axial view
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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

anatomic 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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 References
Oral Radiology : Principles and Interpretation. 5th ed. Stuart C.
White & Michael J. Pharoah.

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

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

Christensens 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.
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 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;523543.

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

Images.2014; Dent Clin N Am 58;485495

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

Tomography.2014; Dent Clin N Am 58 ;463484

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 ;485495
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THANK YOU

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