Transcript Document 7191251

SIU-SDM
HAWAIIAN CRUISE
SIU-SDM
HAWAIIAN CRUISE
CONE BEAM C T
IS IT FOR THE
GENERALIST’S OFFICE?
DEBRA DIXON, DMD
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SDM GRADUATE 1993
SDM AEGD 1995
SDM IMPLANT FELLOW 1996
THE UNIVERSITY OF LONDON
MSc DENTAL RADIOLOGY 2002
SDM DIRECTOR OF RADIOLOGY
FUR
OUR AGENDA

History
Radiology
 Digital Radiology
 CT

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Cone Beam CT
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What it is and What it can do for me
HISTORY


Nov 8, 1895 Wilhelm RÖntgen discovers the
X-Ray
Digital radiography is more than 25 years
old
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11% to 30% of dentists have converted to digital
Financial investment
 Complexity of computers
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Software
Hardware
Simply reluctant to switch…if everything is running
smoothly, why change it?
Van der Stelt 2008
BASICS OF DIGITAL IMAGING

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Composed of pixels (picture elements)
which are characterized by 3 numbers
These numbers are stored in an image file in
the computer
Image processing is possible
Brightness/Darkness
 Contrast
 Zoom…limited by the resolution of the system
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BASICS OF DIGITAL IMAGING
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Image Analysis
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Measurement of root length for Endo
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Digital subtraction radiography
BASICS OF DIGITAL IMAGING
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Advantages
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Immediate image with CCD sensor
Ability to manipulate the image
Integrated storage with software systems
Security of backup and off-site archiving of images
Ease of transfer by email
Security of the original image
DICOM (Digital Imaging and Communications in
Medicine) format standards
BASICS OF DIGITAL IMAGING

Dose Reduction?
Once promoted as a “huge advantage” to digital
imaging
 Why the dose reduction is not as large as often
suggested
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Dose per exposure
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Reduction of 0% to 50% as compared with “F” speed film
Increase in the number of radiographs made
 Increase in the number of retakes due to the ease of
exposing additional images
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Van der Stelt 2008
SALLY
CT
COMPUTED TOMOGRAPHY
CT
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History
Basics of Tomography
 Generations of Scanners
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 1st
Generation
 2nd Generation
 3rd Generation
 4th Generation
 5th Generation
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Conventional data gathering versus Spiral
geometry
CT
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History
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The word Tomography can be traced to the 1920’s
Tomography = section, from the Greek tomos
Dr. Godfrey Hounsfield
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Born 1919 in Nottinghamshire, England
The inventor of clinical computed tomography
First patient scanned in 1972
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Demonstrated a suspected brain lesion
Dr. Allan Cormack
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Born 1924 in Johannesburg, South Africa
Developed solutions for the mathematical problems in CT
Seeram, Computed Tomography, 2001
CT
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History
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Dr. Robert Ledley
1948 Doctorate in Dental Surgery, New York
University
 1949 Master’s in theoretical physics, Columbia
University
 Developed the first whole-body CT scanner
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Seeram, Computed Tomography, 2001
CT

History

Tomography
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X-ray tube and film
move simultaneously
and in opposite
directions
This keeps the object of
interest in focus while
blurring out the
structures around it
Panoramic technique
Seeram, Computed Tomography, 2001
CT
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History
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A
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B
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2nd Generation
C
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1st Generation
3rd Generation
D
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4th Generation
Seeram, Computed Tomography, 2001
CT
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History
1st Generation
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Minimum 4.5 to 5.5
minute whole body
scan
Parallel beam, Translate
& Rotate
After 1 translation, the
tube and detector rotate
by 1° and translate
again, repeated for 180°
around the patient
Seeram, Computed Tomography, 2001
CT
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History
2nd Generation
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Scan time 20 sec to 3.5
minutes
Fan beam, Translate &
Rotate
Fan beam = ~30
detectors coupled to the
x-ray tube and multiple
pencil beams
Process is repeated for
180°
Seeram, Computed Tomography, 2001
CT
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History
3rd Generation
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Scan time of a few
seconds
Fan beam geometry
that rotates
continuously around
the patient for 360°
Seeram, Computed Tomography, 2001
CT
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History
4th Generation
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Scan time is very
short, varies by
manufacturer
A rotating fan beam
within a stationary
ring of detectors
Seeram, Computed Tomography, 2001
CT
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History
5th Generation
High-speed CT
scanners
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EBCT Electron
Beam CT scanner
DSR
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Dynamic Spatial
Reconstructor
Scan time of
milliseconds
Seeram, Computed Tomography, 2001
CT
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History
A
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Conventional Slice by Slice
data acquisition
The x-ray tube stops between
slices, the patient is
repositioned for the next slice
Seeram, Computed Tomography, 2001
CT
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History
B
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Helical or spiral geometry
The latest development in CT data
acquisition (as of the writing of the
text in 2001)
Volume scanning
Utilizes a narrowly collimated, fan
shaped x-ray beam, projected
through a limited thickness slice
through the body
Utilizes a linear array of detectors
Patient has to be advanced through
the gantry while the x-ray tube and
detectors rotate around the patient
Seeram, Computed Tomography, 2001
CT
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Spiral Scanners
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Provide improved
multiplanar image
reconstructions
Reduced exam time
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12 seconds versus 5 minutes
for an incremental scan
Reduced radiation dose
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Up to 75% of the dose
delivered by an incremental
scanner
CT
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Image is recorded and displayed as matrix of
individual blocks called voxels (volume elements)
Voxel length (1 to 20 mm) is determined by the
width of the x-ray beam
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Analogous to the tomographic layer in film tomography
For image display, each pixel is assigned a CT number
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Represents density
Also known as a Hounsfield unit
 Air
-1000
 Water
0
 Dense bone
+1000
EM
CONE BEAM C T
CBCT
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Definition
Indications
Comparisons
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CBCT versus Panoramic
CBCT versus Plain-film
Tomography
CBCT versus Medical CT
Disadvantages
Currently available units
Specialized Uses
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Orthodontic Analysis
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Dolphin Imaging Software
Program
Interpretation
CBCT
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Developed for Dental purposes to provide 3D
volume images of the dental and craniofacial
complex
Available for craniofacial imaging
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Since 1999 in Europe
Since 2001 in the U.S.
Ideally suited for craniofacial imaging
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The compact size of the unit
Relatively low radiation dose
Becoming the “Standard of Care” for diagnosis of the
craniofacial region
Allows multiplanar viewing of the anatomical volume
and overcomes the limitations of 2D radiography
www.conebeam.com
CBCT
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Cone Beam
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Utilizes a cone shaped x-ray beam
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Round or rectangular
Utilizes an area detector
Acquires a full volume of images
in a single rotation with no need
for patient movement
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Rotates 360° around the head
360 projections
Scan time typically < 1 minute
www.conebeam.com
CBCT
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End Result
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3-D visualization of the oral and maxillofacial complex
from any plane
A stack of 360 images or exposures compiled into a
volumetric dataset through a computer process known
as primary reconstruction
This data volume is then converted into a patient-study
by accompanying software
Can be visualized as
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2D trans-axial, multi-planar reformatted
3D techniques such as surface reconstruction and volume
rendering
A combination of 2D and 3D techniques
www.conebeam.com
CBCT
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Indications
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Evaluation of the jaw bones
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Implant placement and evaluation
TMJ
Pathology
 Bony & Soft tissue lesions
 Periodontal assessment
 Endodontic assessment
Alveolar ridge resorption
Assessment of the IAN prior to extraction of impactions
Orthodontic evaluation
Airway assessment
Need for 3D reconstructions
www.conebeam.com
CBCT
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Evaluation of the jaw bones
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Implant placement and evaluation #12-13
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a) Panoramic line and cross-section line
in the axial image of Maxilla identified
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b) Slices of the area in cross-section
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c) Reconstruction in a ‘panoramic-like’
layout
Araki et al. Dentomaxillofac Radiol 31 (1):51, Figure 9
CBCT
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Evaluation of the jaw
bones
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a) Slice as seen from a
‘frontal’ view
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b) Slice as seen from the
side
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c) Reconstructed maxilla
and mandible
Dentomaxillofac Radiol (2004) 33, 285-290
CBCT
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Evaluation of the jaw bones
www.ddsgadget.com
e-ssentialnetworks.com
CBCT
versus
PANORAMIC
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PANORAMIC
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Provides a distorted
(unequal magnification)
and magnified image
Image layer view only
Structures are
superimposed
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CBCT
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Provides an undistorted
image
Cross-sectional (buccolingual), axial, coronal,
sagittal, and panoramic
views
Structures can be
separated
www.conebeam.com
CBCT
versus
PLAIN-FILM TOMOGRAPHY
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PLAIN-FILM
TOMOGRAPHY
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Provides an undistorted
image, but there is
magnification
Provides direct crosssectional, sagittal, and
coronal views
Scan time may be short,
but chair time can be
lengthy
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CBCT
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Provides an
undistorted, 1:1 image
Provides reconstructed
views
Scan time
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10-40 second range,
dependent on the region
being imaged and the
desired quality
Provides an indication
of bone quality
www.conebeam.com
CBCT
versus
Medical C T
www.osseonews.com
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Med CT
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Conventional linear fan beam
Single row or a series (4, 8, 12,
32, 64) of solid state detectors
Provides a set of consecutive
slices of the patient
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CBCT
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Cone beam
Square 2 dimensional array of
detectors
Provides a volume of data
www.conebeam.com
CBCT
versus
Medical C T
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Med CT
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Greater contrast resolution
 More discrimination
between different tissue
types (i.e. bone, teeth,
and soft tissue)
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CBCT
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Equipment
 Cost 3-5x less than MDCT
 Lighter & Smaller
 No special electrical
 No floor strengthening
 No special cooling
Ease of operation
Dedicated to dental
Patient sits or stands
Both jaws can be imaged at the
same time
Lower radiation burden
www.conebeam.com
CBCT
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Disadvantages
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Noise from radiation scatter
Streak artifacts from metal restorations
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Image degradation from patient movement
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Head stabilizing devices
Cost
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Algorithms and filters try to correct for noise & artifacts
Range from $150,000 to 300,000
Training
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For maximum benefit
For interpretation of the volume of data & images
 Within the purview of the dentist
 Outside the purview of the dentist
Howerton et. al.
CBCT
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Currently available units
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3D Accuitomo FPD XYZ Slice View Tomograph
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3D X-ray CT Scanner Alphard Series
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Hitachi Medical Systems America, Twinsburg, Ohio
Galileos 3D
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Belmont Equipment, Somerset, NJ
CB MercuRay
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Asahi, Kyoto, Japan
Quolis Alphard Alphard-3030-Cone-Beam
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J. Morita USA, Irvine, CA
Sirona Dental Systems, Charlotte, NC
i-CAT
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Imaging Sciences International, Hatfield, PA
Howerton et. al.
CBCT
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Currently available units
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Iluma Ultra Cone Beam CT Scanner
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NewTom 3G and VG
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TeraRecon, San Mateo, CA
ProMax 3D
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E-woo Technology, Houston
PreXion 3D
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AFP Imaging, Elmsford, NY
Picasso
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Carestream, Rochester, NY
Planmeca USA, Roselle, IL
Scanora 3D
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Soredex, Tuusula, Finland
Howerton et. al.
CBCT
i-CAT
NewTom VG
3D Accuitomo
Position
Seated
Stand/Seated
Seated
Scan time
Scan Hgt
kVp/mA
Rad Time
5, 8.9, 26.9 sec 20 sec
18 sec
4,6,8,10,13 cm
1.57-2.36 inches
9 sec
5.4 sec
Not listed
Scan thick
Ceph
Software
0.12-0.4 mm
0.1-0.5 mm
.125-2.0 mm
Yes
Yes
No
Xoran Cat
NewTom VG
I-Dixel
Price
website
$170,000
$170,000
$252,000
imagingscien
ces.com
newtomdental.com
jmorita.com
9.84 inches
120/3-5
60-80/1-10
Inside Dentistry 1:90-93, 2007, Dental Economics August 2007, Dental Town August 2007
CBCT

All Cone Beam Units are not created equal!
Volume Size
 Geometric resolution
 Contrast resolution
 Slice thickness
 Radiation dose
 Ease of use
 Image Capture

CBCT
Effective Dose in # of
dose (µSv) Pans
i-Cat
12” FOV
135
21
Dose
in
days
13
NewTom 3G
12” FOV
45
7
4
2.1
Panoramic
6
1
1
0.3
385
243
100
CT Maxilla & 2,100
Mandible
Dose in %
Med CT
6.4
Farman AG, Levato CM, Scarfe WC. A primer on cone beam CT. Inside Dentistry 1:90-93, 2007
CBCT
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The i-CAT CT
scanner
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Low dose settings for
children
Landscape View
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Full resolution and
detail obtained for
smaller fields of view
Portrait View
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Captures Extended
Field of View data
Ceph data in 8.5
seconds
www.imagingsciences.com
CBCT
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i-CAT
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Typical reconstruction time
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Less than 30 seconds
www.imagingsciences.com
CBCT
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i-CAT
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Measurement
Labeling
Hounsfield
units

Density
www.imagingsciences.com
CBCT
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NewTom VG
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Features a single 8"x10" Field Of View,
 Most utilized by implantologists and
maxillo-facial surgeons.
Small focal spot = high quality images
Volume of data captured kept to a minimum
 Short reconstruction times (3 minutes)
Low dose
 up to 20 - 50 times less radiation than
conventional CT
 Adjusts dose to size and age of patient
Unique “pulse” system
 Activates the x-ray source only when
needed—delivering less than 4 seconds of
total exposure for a full scan.
www.afpimaging.com/newtom
CBCT

NewTom
Standard 0.5mm
Ultra-high resolution 0.2mm
www.afpimaging.com/newtom
CBCT

3D Accuitomo

J. Morita Manufacturing

Imaging Areas 40x40 mm & 60x60 mm

High resolution for large imaging area

Voxel size 0.125 mm, high resolution (2.0 line
pair/mm)

Low effective dose

Wide dynamic range and expresive tone
create brilliant images of both soft and hard
tissue areas

Enables the most accurate diagnosis for
implants, apical lesions, temporomandibular
joints, impactions, etc.
www.jmorita-mfg.com
CBCT
SPECIALIZED USES
ISLAND OF LANAI
CBCT
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Specialized Uses
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Orthodontic Analysis

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Dolphin Imaging Software Program
Oral Surgery
Impactions
 Trauma

Implants
 Endodontics
 Periodontics
 TMJ

C B C T - ORTHO
Ortho Evaluation and Treatment Planning
www.dolphinimaging.com
C B C T - ORTHO

The Dolphin 3D software module
A powerful tool that makes processing 3D data
extremely easy, enabling dental specialists from
a wide variety of disciplines to accurately
diagnose and plan treatment.
 Dolphin 3D allows visualization and analysis of
craniofacial anatomy from data produced by
CBCT, MRI, medical CT and 3D facial camera
systems.

www.dolphinimaging.com
C B C T - ORTHO

Dolphin Imaging Software
 Comprehensive cross sections with Multiple Planar View (MPV)
 3D nerve marking
 TMJ analysis
 Create stunning, accurate cephalometric and panoramic radiographs
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Import from a variety of 3D files
High-quality, fast 3D rendering
Easily detect impacted teeth
Analyze, visualize and measure airway
Precise volume orientation
Establish 3D/2D measurements
Create movies
Design automated image layouts
Images export to other applications, including PowerPoint, Word, etc.
Images easily saved into Dolphin patient file
Export to standard file formats and Windows Clipboard
Fully embedded in Dolphin Imaging’s SQL database
www.dolphinimaging.com
C B C T - ORTHO

Dolphin Imaging Software
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Object Orientation
Comprehensive cross sections with Multiple Planar View
Instant Ceph/Pan
Ceph Tracing
3D Nerve Mapping
TMJ analysis
3D Visualization
www.dolphinimaging.com
C B C T - ORTHO

Object Orientation

To maximize the consistency of analysis
of a 3D volume, it is crucial to establish a
default orientation.
Dolphin 3D provides comprehensive
tools for defining the mid-sagittal, axial
and coronal planes. You can also adjust
the object’s default yaw, pitch and roll.
These operations can be performed on
the CT soft tissue surface, CT hard tissue
surface or 3D photo surface.


www.dolphinimaging.com
C B C T - ORTHO

Multiple Planar Views
and Layouts

Choose a layout that is
best suited to your task:
3D volume (just the 3D
volume view)
Volume+3 planes (3D
volume and 3 cross section
planes on the side)
4-views (3D volume and
the cross section planes in
equal sized windows)
Individual orthogonal
projected slices: sagittal,
coronal and axial planes

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www.dolphinimaging.com
C B C T - ORTHO

Instant Ceph/Pan

Create two-dimensional
radiographic images from 3D
volume dataset in the lateral,
panoramic (OPG), frontal
and SMV views.

1:1 projection


no distortion
no magnification
www.dolphinimaging.com
C B C T - ORTHO
Ceph Tracing
www.dolphinimaging.com
C B C T - ORTHO
Nerve Mapping
www.dolphinimaging.com
C B C T - ORTHO

TMJ View

Choose an area of interest;
set center point and axis
direction, designed
specifically for analyzing the
temporomandibular joint
Choose desired slice
thickness, width, number
and direction (coronal,
sagittal, or patent-pending
circular)
View key cross-sections at
the chosen axes


www.dolphinimaging.com
C B C T - ORTHO

3D Visualization

Dolphin gives you the power to
freely visualize the volume in 3D.
In addition to switching from hard
tissue and soft tissue views, you can
also activate the see-thru hard
tissue renderings. Adjust the factor
of translucency and intensity to
reveal the structure you desire.
Clipping tools are also very useful
for quickly visualizing hidden
structures, or to simply eliminate
portions of the contents that are
not relevant.
www.dolphinimaging.com
CBCT

Interpretation of the Volume of Images

Data collected within the Region of Interest (ROI)


Data collected outside of the Region of Interest


Within the purview of general dentists and specialists
A large volume of information exists that is outside of a
dentists purview
Comprehensive Care of the Patient


Documented interpretation of all the data in the volume
2007 Chairman of the AAOMS advised that all volumes be read
by a radiologist
CBCT

Interpretation of the Volume of Images

AAO Council on Scientific Affairs
 Survey of Radiologists




All scans should be read by a qualified person.
 Panoramic can be read by the diagnostician (dentist)
 Cone Beam volume by an Oral & Maxillofacial
Radiologist or an MD Radiologist
The interpretation fee can be either included in the scan fee,
or be billed separately
The entire volume of data requires interpretation. The
patient cannot deny interpretation of ‘non-dental’ data
As in medicine, a written report is the standard
Am J Orthod Dentofacial Orthop 2007;131:697
TIGGER
CONE BEAM C T
IS IT FOR THE
GENERALIST’S OFFICE?

THE BOTTOM LINE

Is it worth your time and effort?
Physical Space in your office
 Training
 Computer memory to work with images
 Storage of images


THE BOTTOM LINE

Is it worth your time and effort?
Physical Space in your office
 Training
 Computer memory to work with images
 Storage of images


Will it be profitable?
Cost…of the equipment
 Time involved
 Number of patient scans x $250-$600/scan
 Types of images available: Pan, Ceph, Bitewings,
Periapicals

MAHALO
CONE BEAM C T

References

Araki et al. Dentomaxillofac Radiol 31 (1):51, Figure 9

Am J Orthod Dentofacial Orthop 2007;131:697


Turpin D., Editor-in-Chief. Befriend your oral and maxillofacial
radiologist
Danforth RA, Miles D. Cone Beam Computed Tomography for
Dentistry (Journal unknown)

Dental Economics August 2007

Feuerstein P. Cone Beam Technology.
 Guttenberg S, Emery R. Profit in 3 dimensions
R Baba, K Ueda and M Okabe. Using a flat-panel detector in high
resolution cone beam CT for dental imaging. Dentomaxillofacial
Radiology 2004: 33, 285-290

DentalTown August 2007


Giacobbi T. 3D Images for 21st Century Dentistry
CONE BEAM C T

References

Inside Dentistry 1:90-93, 2007


JADA supplement June 2008, Vol. 139, “Digital
Imaging”





Farman AG, Levato CM, Scarfe WC. A primer on cone beam
CT.
A. Ruprecht. Oral and Maxillofacial Radiology: Then and Now
P.F. van der Stelt. Better Imaging: The Advantages of Digital
Radiography
A.G. Farman, et al. In Practice: how Going Digital Will Affect
the Dental Office
W.B. Howerton Jr, M.A. Mora. Advancements in Digital
Imaging: What Is New and on the Horizon?
Seeram, Euclid. Computed tomography: physical
principles, clinical applications, and quality control, 2nd
edition, 2001, Saunders.
CONE BEAM C T
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References
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www.afpimaging.com
www.conebeam.com
www.cile.co.nr
www.ddsgadget.com
www.dolphinimaging.com
www.e-ssentialnetworks.com
www.imagingsciences.com
www.jmorita-mfg.com
www.osseonews.com