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Providing imaging in 3 dimensions, computed tomog- CBCT machines have 2 major differences compared
raphy (CT) has had a profound effect on surgical and with so-called “medical” CT scanners. First, CBCT
medical practice since its introduction in 1973.1 Practi- uses a low-energy fixed anode tube, similar to that
tioners at that time certainly marveled at the new tech- used in dental panoramic x-ray machines. Second,
nology, but likely were at a loss as to how to apply it or CBCT machines rotate around the patient only once,
what exactly the images meant. It was only after years of capturing the data using a cone-shaped x-ray beam.
research, as well as the development of a whole new These changes allow for a less expensive, smaller
aspect of radiology, that we have been able to apply this machine that exposes the patient to approximately
technology for the benefit of our patients. 20% of the radiation of a helical CT, equivalent to the
In oral and maxillofacial surgery, we are accustomed exposure from a full-mouth periapical series.5-8
to using CT in patients with trauma and pathological All of the CBCT scanners currently on the market use
conditions in the hospital setting; however, in dental the same technology, with only slight differences. The
practice, practitioners depend almost entirely on 2-di- major difference is in the detector used, either an amor-
mensional plain films. The applications and advantages phous silicon flat-panel detector or a combination of an
of CT in dentistry remain largely unrealized. image intensifier and a charge-coupled device (CCD)
Cone beam CT (CBCT) was first developed for use camera. Both these technologies have been proven to
in angiography. In 1998, Mozzo et al2 reported the be accurate and reliable and to provide sufficient reso-
first CBCT unit developed specifically for dental use, lution for the needs of dental medicine (Fig 1).
the NewTom 9000 (Quantitative Radiology, Verona, Within every field, the introduction of new technol-
Italy). Other similar devices introduced at around that ogy raises several fundamental questions, including iden-
time included the Ortho-CT, which was renamed the tifying the practical applications of the new technology
3DX (J. Morita Mfg Corp, Kyoto, Japan) multi-image and determining whether it is truly superior to existing
micro-CT in 2000.3,4 In 2003, Hashimoto et al4 re- modalities. These questions are not easily answered, but
ported that the 3DX CBCT produced better image require research and comparison. This article explores
quality with a much lower radiation dose than the the possible applications of this new CBCT technology
newest multidetector row helical CT unit (1.19 mSv and the ongoing research in these areas, with the goal of
vs 458 mSv per examination). applying CBCT data in an evidence-based manner.
791
792 CONE BEAM COMPUTED TOMOGRAPHY
terms of bone height, bone width, nerve position, only for the skull base. Imaging within the dentomax-
and even objective measures of bone quality.9 illofacial regions was found to be quite reliable, dem-
With regard to a traditional panoramic radiography, onstrating no significant differences.10 The fact that
the average machine produces approximately 25% measurements from the CBCT are routinely accurate
magnification, which must be accounted for when throughout the maxilla and mandible makes this an
planning implant placement. Preliminary studies on excellent modality for planning implant placement.11
CBCT, specifically the NewTom 9000, have con- Conventional multislice CT has been used for im-
cluded that the CBCT image underestimates the actual plant planning and in fabrication of a stent used in-
distances; however, these differences were significant traoperatively for precise implant placement in pre-
determined locations. The stent can be fabricated on the gold standard for imaging the intra-articular compo-
top of a CT image without the need for patient con- nents of the TMJ, evaluation of the bony components is
tact, allowing for precise placement of implants, pre- often left to conventional panoramic radiographs. Pan-
fabrication of the prosthesis and abutments, and de- oramic radiographs can provide a general impression of
livery of the prosthesis on the same day as surgery.12 the joint in 2 dimensions but have low sensitivity in
CBCT images have similar capabilities with the bene- evaluating changes in the condyle, poor reliability, and
fit of less radiation exposure to the patient. low accuracy in evaluating the temporal components of
the joint.13 The imaging offered by current CBCT ma-
chines has been shown to provide a complete radio-
Oral and Maxillofacial Pathology
graphic evaluation of the bony components of the TMJ
Conventional CT is used routinely in the diagnosis of (Fig 4). The resulting images are of high diagnostic
maxillofacial pathology. Given the higher resolution, quality. Given the significantly reduced radiation dose
lower radiation dose, and lower cost of CBCT in imaging and cost compared with conventional CT, CBCT may
the maxillofacial region, it stands to reason that CBCT soon become the investigational tool of choice for eval-
can easily replace conventional CT in this regard. Three- uating bony changes of the TMJ.14
dimensional imaging of cysts and tumors of the maxil-
lofacial region can give the surgeon the vital information
necessary for planning surgery; with volumetric analy- Craniofacial Surgery
sis, this can help anticipate the need for and volume of a
potential graft for reconstruction (Fig 3). CBCT data also Treatment planning for patients with cleft lip and
can be useful in creating a stereolithic model of the area palate entails many unique considerations. Due to the
of interest. young age of the patients and concerns about radiation
exposure, conventional CT is not always used. Timing of
alveolar cleft repair is often determined based on pan-
Temporomandibular Joint Disorders
oramic and occlusal radiographs. Other considerations
The diagnosis and treatment planning of temporo- include palatal expansion as well as segmental align-
mandibular joint (TMJ) disorders often are quite chal- ment. CBCT should allow better evaluation of dental
lenging. Although magnetic resonance imaging remains age, arch segment positioning, and cleft size compared
794 CONE BEAM COMPUTED TOMOGRAPHY
with traditional radiography (Fig 5). Volumetric analysis ing the stability of the arch after grafting, the quality of
promises to offer better prediction in terms of the mor- the bone graft over time, and the effect on overall facial
phology of the defect, as well as the volume of graft growth; CBCT provides a means to investigate these
material necessary for repair. Questions abound regard- issues in depth.
Orthognathic Surgery bility combined with the lower radiation dose also
will help bring this technology into the mainstream.
Clinicians have long evaluated the usefulness of
The applications described herein are merely the be-
3-dimensional imaging in orthodontics and orthog-
ginning. We are now capable of obtaining signifi-
nathic surgery, with a major concern being the
cantly more data to characterize a patient’s condition.
correlation between soft tissue and hard tissue
The next step is to establish how best to use these
changes.15 For decades, lateral cephalography has
additional data in the most effective manner.
been the standard modality for diagnosing skeletal
and dental deformities, as well as for use in surgical
prediction and treatment planning. These applica-
tions are made possible by the early growth studies of References
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1973
stands to reason that before a 3-dimensional model 2. Mozzo P, Procacci C, Tacconi A, et al: A new volumetric CT
can be reliably adopted for orthodontic and orthog- machine for dental imaging based on the cone-beam technique:
nathic analysis and surgical prediction, extensive re- Preliminary results. Eur Radiol 8:1558, 1998
3. Arai Y, Tammisalo E, Iwai K, et al: Development of a compact
search is needed to characterize the landmarks and computed tomographic apparatus for dental use. Dentomaxil-
relationships that this technology allows us to mea- lofac Radiol 28:245, 1999
sure. 4. Hashimoto K, Yoshinori A, Kazui I, et al: A comparison of a
new, limited cone beam computed tomography machine for
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are greatly improved by adding the third dimension raphy (CBCT-NewTom). Dentomaxillofac Radiol 33:291, 2004
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assessment of implant sites. J Calif Dent Assoc 31:825, 2003
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CBCT finds its way into the average oral and maxillo- maxillary canines with cone-beam computed tomography.
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