BUJOD 2013-b final

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fracture, quality and quantity of bone, periodontal .... lateral views of Condyle and rotational views with ... periodontal cyst, regenerative periodontal therapy,.


Makhija et al

Invited Review Integrating Cone Beam Computed Tomography (CBCT) In Dentistry-Review Authors: P.G.Makhija*, Priyanka Makhija** Correct diagnosis is vital to proper treatment. Although the history and clinical examination are of prime importance when evaluating patients, the use and evolution of non-invasive technology from 2D xray modalities to three-dimensional (3D) cone beam CT, for imaging areas not visible to the human eye is increasingly becoming popular1. In the ever expanding volume of knowledge it is vital for any clinician to remain in touch with latest innovations in the field of one's expertise and apply the same for the benefit of patient care and be ready and willing to accept new trends, find time to learn and practice the technological and diagnostic or treatment advances in the related field. CBCT is one such recent advancement in the field of Dentistry which one should learn and adapt into clinical practice. Of the recent advances, two things have changed the way we practice dentistry, the first one is advancements in computer and digital applications for dentistry and the second most wonderful area is the advent of Dental Cone Beam Computed Tomography is popularly known as Cone Beam CT, CBCT, cone beam volumetric tomography (CBVT). The word CT stands for Computed Axial Tomography used mostly in medicine. Radiology added new dimension to diagnosis in medical field by allowing us to see deeper structures in two dimensions without surgical interventions. Medical CT and CBCT both are imaging technology using xrays with little difference in acquisition of images, primary reconstruction algorithm, and radiation dose and acquisition time. Address For Corresspondence: Dr P.G.Makhija Professor & Head, Department of Orthodontics, Modern Dental College &Research Centre, Indore

Historical: The medical CT scanner was developed in the late 1960s, and subsequently patented by Hounsfield (1973).In 1979, Sir Godfrey Hounsfield and A.M. Cormack were awarded the Nobel Prize in medicine for developing CT scanner and for developing software to read and reformat the CT data respectively. CT (Computed tomography) or Computed Axial Tomography (CAT scan) has remained one of the most important methods of radiological diagnosis in medicine. Its use in dentistry was limited to craniofacial imaging for trauma, syndromes, implant dentistry etc. The use of 3D medical CT was however limited because of its high machine cost, high acquisition cost, and high radiation, lack of reformatting and viewing software with dentist. In the late 1990s Italian and Japanese groups 2, 3 working independently of each other, developed a new tomographic scanner known as cone beam computed tomography (CBCT) or digital volume tomography (DVT) specifically for maxillofacial and dental use4. The first dental CBCT system became commercially available for dentomaxillofacial imaging in 2001 (NewTom QR DVT 9000; Quantitative radiology, Verona Italy).5 The popularity of dental CBCT has been growing since then along with the controversies of its radiation dose, usefulness of altering the treatment outcome, onus of responsibility to diagnose and locate incidental findings as well as limitations like cost, uniform software, training of orthodontist, time required to study scan, knowledge of 3D structures, skill and knowledge of computer and software. Uses of CBCT in Dentistry

*Professor and Head, Department of Orthodontics, Modern Dental College &Research Centre, Indore **PG Student, Department of Prosthodontics, Modern Dental College & Research Centre, Indore


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BUJOD W. De Vos, J. Casselman, G. R. J. Swennenin6 in their study, reviewed Pubmed for CBCT in oral and maxillofacial region. 176 clinically relevant articles out of 375 total articles from 1998 to 2007 were selected. 86 papers (49%) were related to clinical applications, 65 (37%) to technical parameters, 16 (9%) to radiation dose and 26 (15%) were synopsis papers. Alamri HM, Sadrameli M, Alshalhoob MA, Sadrameli M, Alshehri MA 7 in their article presented a review of the clinical applications of cone-beam computed tomography (CBCT) in different dental disciplines. A literature search was conducted via PubMed for studies on dental applications of CBCT published between 1998 and 2010. The search revealed a total of 540 results, of which 129 articles were clinically relevant and were analyzed in detail and various %uses were shown as follows :Oral and maxillofacial surgery (OMFS) 26.3%, Endodontics 25.6%, Implant Dentistry 16.3% , Orthodontics 11.6% , General Dentistry 9.3 %, Temporoman dibular joint (TMJ) 5.4%, Periodontics 4.65%, Forensic Dentistry 0.80%. Grondahl HG8 reported use of CBCT in various areas as follows: Implantology: 40%, Oral surgery: 19%, Orthodontics: 19%, Endodontics: 17%, Te m p o r o m a n d i b u l a r j o i n t ( T M J ) : 1 % , Otorhinolaryngology: (ENT) 2%, Other investigations 2% (Periodontology, forensic dentistry, research). Adibi S, Zhang W, Servos T, O'Neill PN.9 in the latest review conducted using PubMed, Google, and Cochrane Library searches in the spring of 2011 using the key words "cone beam computed tomography and dentistry." resulted in over 26,900 entries in more than 700 articles including fortyone reviews recently published in national and international journals. This article is based on existing publications and studies and provides readers with an overview of the advantages, disadvantages, and indications/contraindications of this emerging technology as well as some thoughts on the current educational status of CBCT. clinical uses of CBCT in various areas can be summarised as under:


Uses in Orthodontics: 10-14 The CBCT can potentially find maximum uses in orthodontics for Understanding 3D anatomy, patient consultation, communication, practice management. (pictures 1 to 8)

Picture1 picture2Airway volume minimum vol Bony panormic view

picture-3 condyle irt eminence

picture-4 dilacerated teeth treatment planning

picture - 5 dentascan

picture-6 lingual occlusion, inclination, labial bone

Picture-7 Mixed dentition, condyles, airway, interincisal

Picture - 8 asymmetry measure

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Makhija et al

Orthodontic Diagnosis: qualitative and quantitative extra oral examination of face, dimensions, facial type, facial convexity, soft tissue analysis, facial p ro p o r t i o n s , m i d l i n e s y m m e t r y, g ro w t h development, anatomy, pathology, developmental disturbances, and soft tissue thickness in various areas.

Research: Pre treatment and post treatment comparison, asymmetry, FEM analysis, growth and development, Muscle volume, linear accuracy, dosimetry, airway, 3D cephalometric measurements, biomechanics, syndromes including cleft lip palate, alveolar bone graft planning in CLP, Asymmetry, pre post treatment comparisons.

Complete hard tissue examination and record, type of dentition present, Arch size, arch shape, symmetry of arches, arches coordination, vertical, anteroposterior and transverse maxillo mandibular relationship, number, size of teeth, automatic Bolton ratio, shape of teeth, fractures and cavities of teeth present, Unerupted, impacted teeth, supernumerary teeth, impacted third molars, their relation to mandibular nerve, relation of teeth to each other and jaws, root completion, Root resorption, root fracture, quality and quantity of bone, periodontal problems, Root Torque, buccal corridor, Airway examination, Tongue size and Posture, TMJ. CBCT data can be used to make digital study models

Uses in Oral Medicine & Radiology15: CBCT is wonderful tool to study various anatomy & pathology in 3D. All syndromic cases, TMJ, Salivary glands, muscles can be studied in detail. The CBCT data can be used for regressing back to computer generated 2d pictures and radiographs. If one desires, the inbuilt tools can generate variety of xrays either in 2d or 3 D format. E.g. OPG, lateral cephalogram, PA views, sectional views, nerve anatomy views, submento vertex view, waters view. Practically any x-ray view is possible without fear of superimposition as the virtual patient and virtual machine is with us to take and retake any number of x-ray views without actually subjection the patient to x-ray machine. (Pictures 2,5)

Impacted Teeth: diagnosis and treatment planning of impacted teeth, number of un erupted impacted teeth, their 3D position, 3D relation to adjoining teeth, ankylosis or pathology associated with it, root resorption caused by them to adjoining teeth, size and shape of impacted tooth, its root size shape, from this we can plan possible movement plan and biomechanics for dis impaction. Implant Planning: bone quality and quantity can be measured, 3D implant placement can be practiced, mini Implants can be virtually placed to check for proximity to root surfaces and FEM analysis Treatment Planning: Evaluation of asymmetry cases, cephalometric analysis, orthodontic and surgical treatment planning, surgical splint preparation, models for mock surgery etc CAD CAM: Customised labial or lingual brackets can be designed and printed or casted for lingual orthodontics; clear aligners can be fabricated over digital models.. Robotic wire bending. Orthodontic appliances, Biomechanically efficient devices


Picture-2 Bony panormic view

Picture - 5 dentascan

Uses in Endodontics4, 16-20 Crown morphology, pulp chamber, proximal caries, Root morphology, number of root canals, course and direction of canals, accessory canals, root resorption, root fractures, Obturation , filling, under and overfilling, sinus problems, Broken instruments. Early detection of previously undiagnosed Periapical lesions. CBCT is clinically more accurate & more useful than biopsy. It is also useful in planning peri apical endodontic surgery as the anatomical structures such as inferior dental canal, mental foramen, maxillary sinus can be easily differentiated and relation to root can be quantified. (Pictures 9-11)

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BUJOD planning and in designing a surgical guides. (Pictures 5, 15, 16)

Picture-9 Periapical pathology

picture11-root canals

Applications in Oral Maxillofacial surgery 6, 21: Jaw pathology, pre & post surgical evaluation of fractures, impacted teeth, super numerary teeth, relation of third molar to nerve, cortical and trabecular bone quantity & quality, assessment of bone grafts, paranasal sinuses, OSA, midface & orbital fractures, guided surgery, surgical splint fabrication, mock surgery, pre & post surgical comparisons. Orthognathic surgeries, 3D virtual model, post treatment esthetic evaluation, TMJ, condyle, salivary gland, tooth auto transplant, cleft lip palate, craniofacial reconstruction etc. Evaluation roots of upper posterior teeth in respect to the maxillary sinus, sinus lift. CAD CAM, craniofacial reconstruction. (Pictures 12-14)

Picture-12-fracture maxilla, zygoma mandible, nasal

Picture-14 Impacted teeth

Applications in implant dentistry & Prosthodontics 22:

Picture - 5 dentascan

Picture15 Faulty implant planning, periodontal loss

picture-16 Implant planning Applications in TMJ imaging 23: Bony views and X-ray views can be generated without any superimposing shadow of adjoining structures. The condyles can be viewed from all angles and measured. Condylar axis, inter-condylar distance, condylar symmetry, fractures, relation to glenoid fossa, visualization of glenoid fossa, size and shape of glenoid fossa can be seen also AP and lateral views of Condyle and rotational views with every few degrees e.g. 15 degrees can be generated. Defining true position of condyle in TMJ in dislocations, extent of translation of condyle in fossa, measurement of roof of fossa, visualization of soft tissue around joint, pathology of TMJ, ankylosis, asymmetry, trauma, pain dys function, fibro osseous ankylosis. Condylar cortical erosion & cysts, image guided puncture technique treatment modality for TMJ adhesion. (Pictures 3,17)

Implant site evaluation, accurate measurements, accurate planning of implant in relation to vital structures, surgical guide, Computerised Prosthesis for developmental disturbances surgical implant guides , To assess the quantity and quality of bone in edentulous Ridges and implant cases. To plan implants and assess the success of osseo integration


Picture-3 Condyle irt eminence


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Makhija et al

Periodontics 24:

Safe use and Radiation issues 5, 25, 26, 27

Detailed morphologic description of bone, measurement of bony defects equivalent to periodontal probe, furcation involvement, buccal & lingual defects, dehiscence, fenestration, accurate analysis of bone loss as well as bone healing, periodontal cyst, regenerative periodontal therapy, grafts. (Pictures 9, 15, 18)

An effective dose in the broad range of 13–498 µsv has been seen, with most scans falling between 30 and 80 µsv , depending on exposure parameters and the selected FOV size. In comparison, standard panoramic radiography delivers 13.3 µsv and multi detector CT with a similar FOV delivers 860 µsv . A relatively low patient dose for dedicated dentomaxillofacial scans is a potentially attractive feature of CBCT imaging particularly when we look at the amount of information available and possible uses of CBCT data. Conclusion:

Picture-9 Periapical pathology

Picture15 Faulty implant planning, periodontal loss

Forensic Dentistry, Incidental findings, ENT,

Picture-18 periodontal bone loss plastic surgery7 Dental age estimation, 3D face reconstruction, matching of radiographs with computer generated radiographs, Various incidental findings like fusion of vertebra, bifid, trifid condyles. It is useful in assessing ENT problems like DNS, paranasal air sinuses, syndromes, pre & post evaluation after plastic surgery. (Pictures 19-21)

Picture-19 Trifid condyle, STL model

Picture-21 DNS, mucous cyst


CBCT with 3D volume rendering provides all the necessary information in a single radiologic study and generates clinically accurate and immediately available images to get the virtual 3D patient which can be evaluated again and again by same operator or different operators till diagnosis is finalized or treatment planning is finalized. Not only that, it can be used in future for comparing the outcome of treatment with another CBCT. It has educational, communicational advantages and serves as life time record. Even the areas which were not intended for study can be seen checked for incidental findings which may be beneficial from patient point of view. May be, Training in basics of CBCT and 3D anatomy will become essential part of dental curriculum in India in coming years. Although presently CBCT is not prescribed in each and every case of dental treatment, CBCT scan is going to become essential diagnostic aid in near future to analyze each orthodontic case from start to finish, for digital diagnosis, planning anchorage, orthodontic VTO, biomechanics, brackets design and fabrication. Virtual digital articulators will be part of each patient to study functional examination and check mandibular movements, occlusal interferences, distribution of forces of occlusion, checking occlusion on digital models for success and finishing of orthodontic treatment and at the end, retention planning and fabrication of retainers. REFERENCES: 1.

Steven L Thomas, Christos Angelopoulos.

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BUJOD computerized tomography system for use in endodontic surgery. International Journal of Oral and Maxillofacial Surgery 2007;40:22432. 20.




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