CONE BEAM COMPUTED

TOMOGRAPHY
 INTRODUCTION
It is the most significant technologic advance in
maxillofacial imaging since the introduction of
panoramic radiography.

CBCT imaging was initially developed commercially

for angiography in the early 1980s.

It uses a divergent cone-shaped or pyramid

shaped source of ionizing radiation and a two-
dimensional area detector fixed on a rotating
gantry to provide multiple sequential transmission
images that are integrated directly, forming
FOUR TECHNOLOGIC DEVELOPMENTS CONVERGED TO
FACILITATE CONSTRUCTION OF AFFORDABLE CBCT
UNITS SMALL ENOUGH TO BE USED IN THE DENTAL
OFFICE FOR MAXILLOFACIAL IMAGING
Introduction of x-ray detectors capable of rapid
acquisition of multiple basis images

Development of suitably high-output x-ray generators

Evolution of suitable image acquisition and integration

algorithms

Availability of inexpensive computers powerful enough to

process the enormous amount of acquired image data
 ATHREE-DIMENSIONALCONE (THIS
EXAMPLE)ORPYRAMIDAL(IFCOLLIMATION
ISRECTANGULAR)DIVERGENTX-RAYBEAM
ISDIRECTEDTHROUGHTHEPATIENTONTO
ADETECTOR(EITHERSOLID-STATEFLAT
PANEL DETECTORORII/CHARGE-COUPLED
DEVICE).

AFTERASINGLETWO-DIMENSIONAL
PROJECTION ISACQUIREDBYTHE
DETECTOR,THEX-RAYSOURCEAND
DETECTORROTATEASMALLDISTANCE
AROUNDATRAJECTORYARC.

ATTHISSECONDANGULARPOSITION,
ANOTHERBASISPROJECTION IMAGEOR
FRAMEISCAPTURED.THISSEQUENCE
CONTINUESAROUNDTHEOBJECT

FORTHE ENTIRE360DEGREES(FULL
TRAJECTORY)CAPTURINGHUNDREDSOF
 THESE SINGLE-PROJECTION
IMAGES CONSTITUTE THE
RAW PRIMARY DATA AND ARE
INDIVIDUALLY REFERRED TO
AS BASIS, FRAME, OR RAW
IMAGES.

THERE ARE USUALLY

SEVERAL HUNDRED TWO-
DIMENSIONAL BASIS IMAGES
FROM WHICH THE IMAGE
VOLUME IS CALCULATED AND
CONSTRUCTED. THE
COMPLETE SERIES OF IMAGES
IS REFERRED TO AS THE
PROJECTION DATA.
 COMPONENTS OF CBCT IMAGING

IMAGE PRODUCTION

(2) VISUALIZATION

(3) INTERPRET
PRINCIPLES OF CONE BEAM COMPUTED
TOMOGRAPHIC IMAGE
IMAGE PRODUCTION
3 MAJOR COMPONENTS

X-ray generation

X-ray detection

Image reconstruction
 PATIENT STABILIZATION
CBCT examinations are made with the
patient sitting, standing, or supine

With all systems, immobilization of the

patients head is more important than
patient positioning because any head
movement degrades the final image.

Immobilization of the head is

accomplished by using some combination
of a chin cup, bite fork, or other head-
restraint mechanism.
 X-RAY GENERATOR
X-ray generation may be continuous or pulsed to coincide with the detector activation.

It is preferable to pulse the x-ray beam to coincide with the detector sampling; this means
that actual exposure time is up to 50% less than scanning time

The ALARA (As Low As Reasonably Achievable) principle of dose optimization necessitates
that CBCT exposure factors should be adjusted on the basis of patient size.

This adjustment can be achieved by appropriate selection of tube current (milliamperes

[mA]), tube voltage (kilovolt peak [kVp]), or both.

Both kVp and mA may be fixed on some units, they are automatically modulated in near
real time on other units by a feedback mechanism detecting the intensity of the
transmitted beam, a process known as automatic exposure control.

On other units, exposure settings are automatically determined by the initial scout
exposure.
 SCAN VOLUME
The dimensions of the field of view (FOV) or scan volume able to
be covered primarily depend on the detector size and shape,
the beam projection geometry, and the ability to collimate
the beam.

The shape of the scan volume can be either cylindrical or

spherical.

Collimating the primary x-ray beam limits x radiation exposure

to the ROI.

It is desirable to limit the field size to the smallest volume that

images the ROI.
 CBCT UNITS ARE CLASSIFIED ACCORDING TO THE MAXIMUM FOV
INCORPORATED FROM THE SCAN OR SCANS

LARGE FOV SCAN MEDIUM FOV SCAN FOCUSED/RESTRICTED STITCHED SCA

UES TO ENABLE SCANNING OF AN ROI GREATER THAN THE FOV
R

LargerROIcanbe
acquiredbysmall
FOVCBCTunits
bystitching
adjacentlimitedarea
volumetricdatasets.

Thisprocessrequires
acquisitionof
separatescans(left),
registrationofeach
volumeby
superimpositionof
fiduciallandmarks,
UES TO ENABLE SCANNING OF AN ROI GREATER THAN THE FOV
R
Conventional geometric
arrangementwherebythe
centralrayofthex-ray
beamfromthefocalsource
isdirectedthroughthe
middleoftheobjecttothe
centeroftheFPD.
Alternativemethod
increasingimagesize
involvesshiftingthelocation
oftheflatpanelimagerand
collimatingthex-raybeam
laterallytoextendtheFOV
object.Inthisinstance,the
FPDisshiftedtothe
oppositesideofthemidline
halfway throughthe
exposure.Theresulting
imagedoublesthe
horizontalROI.
 SCAN FACTORS

The number of images constituting the projection data

throughout the scan is determined by:

DETECTOR FRAME RATE (NUMBER OF IMAGES

ACQUIRED PER SECOND)

COMPLETENESS OF THE TRAJECTORY ARC (180 TO 360

DEGREES)

ROTATION SPEED OF THE SOURCE AND DETECTOR

 X-RAY DETECTION

Current CBCT units can be divided into two groups

based on detector type:
(1)image intensifier tube/charge-coupled device
(II/CCD) combination
(2) flat panel detectors (FPDs)

FPDs employ an indirect detector based on a large-

area solid-state sensor panel coupled to an x-ray
scintillator layer.
The most common flat panel configuration consists of
a cesium iodide scintillator applied to a thin film
transistor made of amorphous silicon.
 X-RAY DETECTION

VOXEL SIZE
The spatial resolutionand therefore detail of a
CBCT imageis determined by the individual
volume elements (voxels) produced in formatting
the volumetric data set.

CBCT units in general provide voxel resolutions that

are isotropicequal in all three dimensions.

The principal determinants of nominal voxel size in

a CBCT image are the matrix and pixel size of the
detector.
NT FACTORS DETERMINING DEGREE OF GEOMETRIC SH

SMALL FOCAL SPOT SIZE

GEOMETRIC CONFIGURATION OF X-RAY SOURCE

MOTION OF THE PATIENTS HEAD DURING THE

EXPOSURE

TYPE OF SCINTILLATOR USED IN THE DETECTOR

IMAGE RECONSTRUCTION ALGORITHMS APPLIED.

 GRAYSCALE
The ability of CBCT imaging to display differences in
attenuation is related to the ability of the detector to reveal
subtle contrast differences.

This parameter is called the bit depth of the system and

determines the number of shades of gray available to
display the attenuation.

All currently available CBCT units use detectors capable of

recording grayscale differences of 12 bits or greater.

A 12-bit detector provides 212 or 4096 shades to display

contrast. A 16-bit detector provides 216 or 65,536 shades of
gray.
PREPROCESSING STAGE
RECONSTRUCTION
IMAGE ACQUISITION AND RECONSTRUCTION
 RECONSTRUCTION
To facilitate data handling, data are usually acquired by one
computer (acquisition computer) and transferred by an Ethernet
connection to a processing computer (workstation).

After the basis projection frames are acquired, it is necessary to

process these data to create a volumetric data set. This process is
called primary reconstruction.

These data are processed to create a volumetric data set

composed of cuboidal volume elements (voxels) by a sequence of
software algorithms in a process called reconstruction.
 Reconstruction times vary depending on the

ACQUISITION PARAMETERS (voxel size, size of the

image field, and number of projections)

HARDWARE (processing speed, data throughput

from acquisition to reconstruction computer)

SOFTWARE (reconstruction algorithms)

 ARCHIVING, EXPORT, AND DISTRIBUTION

The process of CBCT imaging produces two data

products:
(1) the volumetric image data from the scan
(2) the image report generated by the operator.

Export of image data is usually in the Digital

Imaging and Communications in Medicine standard
version 3 (DICOM v3) file format.
An IMAGING
PROTOCOL is a set of
technical exposure
parameters for CBCT
imaging that depend
on the specified
purpose of the
examination

Exposure Settings
The quality and quantity of the x-ray beam depend on tube
voltage (kVp) and tube current (mA).
 SPATIAL RESOLUTION
Spatial resolution refers to the ability of an image to reveal
fine detail.

It is determined primarily by detector nominal pixel size, beam

projection geometry, patient scatter, detector motion blur, fill
factor (the fraction of a pixels area capable of collecting light),
focal spot size, number of basis images, and reconstruction
algorithm.

SCANNING TRAJECTORY
Reconstructed images from incomplete, limited, or truncated
scanning trajectories of less than 360 degrees may have
limited-angle artifacts because of missing information.

These include greater peripheral unidirectional streaking

SCAN TIME AND NUMBER OF PROJECTIONS
Adjusting the detector frame rate to increase the number
of basis image projections results in reconstructed images
with fewer artifacts and better image quality

FIELD VIEW
 IMAGE ARTIFACT
ARTIFACT IS ANY DISTORTION OR ERROR IN THE IMAGE THAT IS UNRE
THE SUBJECT BEING STUDIED.
INHERENT ARTIFACTS

Scatter results from x-ray

photons that are diffracted from
their original path after
interaction with matter.

Because CBCT uses area

detectors, they capture scattered
photons that contribute to
overall image degradation or
quantum noise
 INHERENT ARTIFACTS

PARTIAL VOLUME AVERAGING is a feature of both MDCT

and CBCT imaging.

It occurs when the selected voxel size of the scan is larger

than the size of the object being imaged.

Boundaries in the resultant image may have a step

appearance or homogeneity of pixel intensity levels.
CONE-BEAM EFFECT

Divergence of the x-ray

beam as it rotates around the
patient in a horizontal plane,
structures at the top or
bottom of the image field are
exposed only when the x-ray
source is on the opposite side
of the patient.

The result is image distortion,

streaking artifacts, and
greater peripheral noise.
 PROCEDURE ARTIFACTS

A reduced data
sample leads to
misregistration, sharp
edges, and noisier
images as a result of
aliasing, which
appear as fine
striations in the
image MOIREARTIFACT
 INTRODUCED ARTIFACT

CIRCULARORRINGARTIFACTS
PATIENT MOTION ARTIFACTS
 STRENGTHS

SIZE AND COST

FAST ACQUISITION

SUBMILLIMETER RESOLUTION

RELATIVELY LOW PATIENT RADIATION DO

INTERACTIVE ANALYS
 LIMITATIONS

POOR SOFT TISSUE CONTRAST

IMAGE NOISE
APPLICATIONS OF CBCT IN DENTISTRY

Implant Site Assessment

 A DIAGNOSTIC STENT IS MADE WITH
RADIOGRAPHIC MARKERS AND INSERTED AT THE
TIME OF THE SCAN
VIRTUAL
SIMULATIO
NFOR
IMPLANT
PLANNING

PLACEMEN
T
CBCTIMAGINGFORENDODONTICS

Identification of potential accessory canals in teeth with

suspected complex morphology
Identification of root canal system anomalies and
determination of root curvature
Diagnosis of dental periapical pathosis in patients who
present with contradictory or nonspecific clinical signs
and symptoms or conventional radiographic findings
Diagnosis of pathosis of nonendodontic origin
Intraoperative or postoperative assessment of
endodontic treatment complications
Diagnosis and management of dentoalveolar trauma
Localization and differentiation of external from internal
root resorption or invasive cervical resorption
Presurgical case planning to determine the exact
location of root apex or apices and to evaluate the
proximity of adjacent anatomic structures
MANDIBULAR THIRD MOLAR ASSESSMENT
TMJ IMAGING
TRAUMA
MAXILLOFACIAL PATHOLOGIES
 IMAGE-GUIDED SURGERY AND RAPID PROTOTYPING
Imaged-guided surgery
refers to techniques that
translate softwarederived
virtual surgical plans
developed from virtual
simulations to the surgical
environment.

Rapid prototyping is a broad

term used to describe a
group of related processes
and techniques that are
used to fabricate physical
scale models directly from
three-dimensional computer-
assisted design data.