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Cone Beam Computed Tomography and the

Orthodontic Office of the Future
Antonio Magni
The use of technological devices has not always successfully increased the
efficiency of orthodontic practices. Often, new technology is introduced into
the practice too soon, effectively interrupting the learning process of their
older counterparts and hindering optimization. Consequently, the ultimate
goal of efficiency can easily become eclipsed by indulging into new orthodontic gadgets. Cone beam computed tomography can similarly get in the
way, if the users are not aware of such phenomena. In this article the author
relates how these can negatively affect efficiency, while explaining the role
of software interoperability for the ergonomics of the orthodontic practice.
Some suggestions on how to prepare for the future are provided. (Semin
Orthod 2009;15:29-34.) © 2009 Published by Elsevier Inc.

he advantages of computerized equipment
within the orthodontic practice has been
emphasized through many applications ranging
from patient demographics to real-time threedimensional oral surface scanning.1 Over the
past decades, the concepts of a paperless work
environment and innovative imaging technology
have pushed orthodontic practices into an era
considered by some to converge with the computer screen.2 In this transitional phase, innovators of paperless technology have been attempting a collaboration with paper charts, in what
frequently turned into an inefficient use of both
systems. In essence, no established structure exists yet that defines how to optimize the collaboration between orthodontic technologies.3,4
The task of keeping up with the latest innovations becomes more and more straining each
year, as can be observed by the constantly growing orthodontic trade shows. The sensation of
being overwhelmed by technology is known to
many in the field: one has not had the chance to
fully unleash the power of their present electronic instrument, yet one is strongly tempted to

T

From Cogent Design, Inc., Rossiglione, Italy.
Address correspondence to Dr. Antonio Magni, Cogent Design,
Inc., Cascina Ciapee, Via Valle Berlino 151, 16010 Rossiglione,
GE, Italy. E-mail: afm@antoniomagni.com
© 2009 Published by Elsevier Inc.
1073-8746/09/1501-0$30.00/0
doi:10.1053/j.sodo.2008.09.005

purchase a new one. Cone beam computed tomography (CBCT), for example, has probably
been one of the most revolutionary medical informatics innovations in the field of dentistry of
the past decade.5 Thanks to its lower costs and
lower dosage (compared with regular CT) it has
made three-dimensional (3D) imaging a tangible reality for the dental field. If widely used, it
will affect a very large area of the orthodontic
practice in the future, from visual treatment objectives (VTO) to digital casts to 3D cephalometric analysis and incidental findings.6 However,
the previous technology (2D digital x-ray imaging) has not worked out all of its problems yet.
Issues related to comparing images produced by
different devices7 (uneven magnification
and/or distortion) and interoperability still remain unanswered for most users.
As we believe simple observation of mankind’s past and present behavior to be an effective prediction method, this trend can be of
great evidence to foretell the future of orthodontic technology. Therefore, if the consumer
market is constantly fed with new gadgets, older
ones will rapidly lose their monetary value, making them affordable to an ever increasing number of users. So what will happen within the
orthodontic practice?

There will be interoperable gadgets almost
everywhere, which will optimize time management and increase patient care, making use of

Seminars in Orthodontics, Vol 15, No 1 (March), 2009: pp 29-34

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and other next generation imaging modalities (chair-side oral scanning 3D in motion1) and all other gadgets still to come. because by themselves. For instance. tension between staff members.30 ● ● ● ● ● ● A. to be all that efficient? Will it really make us feel happier? What are we going to do with the extra resources?” Consequently. The orthodontic practice and their members will depend on computers to such an extent that.12 If we look closely.10. When thinking about this concept. the suggestions of Piehler14 seemed to provide the missing link between efficiency and its existential reasons. The goal is to make processes as efficient as possible and the underlying reasons are often taken for granted. Adding new services to the practice. Operating systems are already increasing reliability (Mac OS X is very stable. many of the above predictions are somehow linked with ergonomics and interoperability. after all. Technological gadgets and their promised increased efficiency lose significance. driven also by the constantly rising price of raw energy. The orthodontic practice will have the capabilities of being more efficient by making use of digital tools such as digital photography. Windows Vista seems a major improvement over its predecessors. creating a more pleasant and relaxing working environment.” The orthodontic field. in an ethically ideal world. practice activity will come to a full halt. none of these seem to address happiness directly. digital 2D and 3D radiography. The term “ergonomics” is defined to be “the study of people’s efficiency in their working environment. The conclusion was that there is something incomplete with this view of efficiency. We believe happiness is the universal need of mankind. On the other hand. which shall be discussed in further detail. as most medical fields. (Please note that absolute stability is probably utopia: It is believed to be mathematically impossible to develop a completely bug-free software.”13 where one of the definitions of “efficient” is “preventing the wasteful use of a particular resource. time and concentration spent trying to convey anger in words via email). Ergonomics of the Future In this section the importance of understanding efficiency at the deepest level. At first glance. and other resources. because of its price and stability). Thinking about today’s society though. and how a superficial understanding can actually lead the individual toward inefficiency is discussed. Increasing competitiveness. through an informal survey some possible ways to use the resources gained from increased efficiency was collected: ● ● ● ● ● Treating more patients. After all. Investing time outside of the workplace (family. if issues such as stress. and Linux is becoming extremely popular. Magni next generation technologies such as nanotechnology8 and quantum computers. Making the assumption that the ultimate goal of practicing our profession is to help us (and those around us) lead a happier life. Time and money will be better managed through an increased awareness and consciousness. He suggests investing the time gained by increased efficiency into face-to-face time with the patients. hobbies). if they fail to operate. patients and practitioners are not addressed. one treats more patients to help society by increasing patient care. so the thought process was: “Is it really necessary. A similar reasoning could be applied to most of the remaining points as well. there is something missing.9 Less time will be spent on erratic computer behavior caused by unstable systems. and more pleasurable to work with. questioning started about the ethical value of efficient systems. eagerness could cause the principal motivation to be to increase one’s income. is striving for optimized processes in its working environment in an attempt to reduce wasteful use of time. Empirical evidence shows us that it is a human trait to tend to indulge in materialistic dis- . Renovating the working environment.11) User interfaces will be easier to use. generating negativity is an expensive process that drains valuable energy (for example. Orthodontics will spread all over the world. they do not lead toward the universal goal of happiness. but are worth analyzing. The need to save power will develop from purely environmental into an economical reality. energy. they do appear to be quite “positive” goals.

3. new. with characteristics such as: ● ● ● ● ● ● Patients less hesitant to pay. Patient leaves practice happier. and patient) peaceful and happy. Less arguing between staff members.14 Therefore. Because of the impermanent characteristic of all sensations. but how will the new gadget cooperate with the existing electronic inhabitants of the orthodontic practice? The consumer might soon realize that interoperability between these devices is not well established. and most of them focus on self-awareness. and does not hesitate to feed the demand of the consumer by introducing new gadgets on the market in a very controlled fashion: when a new technology becomes available. many techniques are available to help increase self-awareness16. This awareness is what will keep the individual in the future from falling into inefficient use of technology. that is. but on our ultimate goal of happiness. more time spent toward work instead of toward negativity (such as generating long emails and letters of complaints). increased referral rate. because these can cause immediate pleasurable sensations connected with more control over the environment they are intended to work in.15 This time frame is therefore based on the arising and passing away of the above-mentioned sensations of the consumer. and to try to predict the direction we. The reader should not be discouraged by the fact that reaching these goals requires a great amount of effort: as one progresses toward selfawareness. which will allow to more quickly identify and solve the problems 31 encountered during everyday life. be it easy or extremely challenging. Today. when one works toward a goal one is fully convinced of. that is. which keeps the individual (doctor. slightly better object. that is. initial results appear immediately providing motivation for further development. are headed toward. but merely to observe it. smiling.Office of the Future tractions. it does not enter mass production until the old one has exhausted its profits. Increased communication between patient and staff. Based on this observation.4 Interoperability is the ability to exchange and to make use of exchanged information. without having to manually dupli- .15 The consumer is tempted to indulge in promising features. The most common consequence is indulgence into the purchase of a new. A wholesome service to society. often leaving an unpleasant sensation of craving behind. staff.) Piehler’s suggestions of concentrating on selfawareness. in turn. that is. something to be proud of. It takes a very balanced mind to remain equananimous to all these sensations and break out of this cycle. including those related to ergonomics. more enhanced models of microelectronic software driven tools get introduced into the market before the average consumer has had time to unleash the full power of older models. that is. Fewer complaints from staff and patients. rather than on the efficient use of the product in one’s working environment. as long as one is constantly aware that it has been set to fulfill the universal need of happiness. our vision for the orthodontic office of the future is a peaceful practice. that is. which.17: a diligent practical approach is the quickest way toward a more sensitive mind. addresses exactly the heart of the problem: the goal is not to focus on (as one may be tempted) the materialistic distractions. and establishing more human and friendly interactions with the patients and staff. it is very easy for one to feel good about oneself. they are bound to disappear. Interoperability As stated above. and the cycle continues. Besides. (We suggest that the reader keep in mind that the intention of this article is neither to condemn nor to praise this schema. reduced late fees. triggers new impermanent pleasant sensations of control and power. Every year there is an increasing number of invited speakers at medical and orthodontic conventions who deal with issues related directly to happiness (like stress). reduced premature treatment ending due to misunderstandings. increased collaboration and efficiency. Industry is well aware of this. as technology users. there is nothing inappropriate or inherently “wrong” with the above-mentioned list. The power of medical informatics lies in the ability to quickly search through large amounts of data. and to be able to manipulate those data in different ways.

Cone Beam Computed Tomography Imaging devices have always constituted an important step in the patient’s flow of an orthodontic practice. the ability to work on the patient’s virtual body (the 3D images produced by CBCT machines) and to recreate any set of 2D images from it. Over the past decade. What is often ignored is that releasing the consumer’s data from bonds to a specific software (which is what happens when a software stores patient data in a public. and space requirements. that is. inability to exchange clinical data seamlessly is unacceptable. These issues are being currently addressed by the American Dental Association (ADA) Standards Committee for Dental Informatics (SCDI) Working Group (WG) 11.18 and it is currently being revised and approved by the DICOM committee.3. Today. The use of already developed clinical informatics standards has been limited to observation and prototyping by vendors and experimentation in academia. making use of existing standards such as digital imaging and communication in medicine (DICOM). This will not materialize until flawless patient data interchange across medical fields becomes a reality. While it has been proven to improve diagnosis and treatment outcome results for surgical procedures. A first proposal for defining digital cephalograms in a well-established medical imaging format (DICOM) has been published by Magni in 2006.3.6 and DICOM is WG 12. standardized format) means more freedom of choice and purchase.org/panio for more information) to help define the technological aspects of the orthodontic office of the future.1 through the development of a standard for the electronic orthodontic patient record. other companies collaborate and develop “bridges” (an application that creates a bridge for patient data between two different software products) that allow their software to work together. As a result. orthodontic software interoperability has found limited implementation. any change to these devices will most likely require a fundamental change in the patient’s workflow.antoniomagni.20 We expect initial standards to be ready for implementation within the next few years. Computed tomography (CT) offers 3D imaging. On that account we strongly encourage both orthodontic software developers and consumers to join the development efforts today (visit http:// www. costs. In other words. A few institutions are using a medical informatics standard called Health Level Seven (HL7). CBCT seems to have had greater impact on the dental field than other technological gadgets have. involvement with the HL7 community and the origination of a document that clearly specifies how DICOM and HL7 should be used when defining electronic orthodontic patient records.16 but mostly only an older version of it.4 Some software systems allow images to be exchanged. This explains why vendors are reluctant to implement a new informatics standard. as they produce two central tools for the diagnosis and treatment of an orthodontic case21: photographs and radiographs. The radiation dosage and the size of a conventional CT device are too high to justify its use in dentistry. rendering it an expensive task. Next steps include: the definition and approval of use case scenarios for the utilization of orthodontic digital data. If we accept the assumption that computer programs should improve patient care by making processes more efficient.3 A standard only gains commercial value once it has been widely implemented. without the need to further irradiate the patient. called cone beam CT (CBCT) has been introduced into the market. In general. including their own.32 A. mainly because the use of proprietary design maintains the vendors’ competitive position in the marketplace. the increase of efficiency in medical informatics lies in its capacity to be interoperable. For this reason. a simplified version of the CT scanner. Currently we see increasing interest in these standards owing to current US federal government initiatives in health information interoperability. not too many software products are compatible with these standards. therefore greater chances for consumers to invest in various different software products. offering considerably lower radiation dosage.22 no clinically relevant evidence has been recorded for a pure orthodontic . tops (developers of topsOrtho™ and topsCephMate™) is directly participating in this task by supporting the author in his efforts. Magni cate them.19 following a trend already present in other regions like Europe (where there is greater government involvement in health care programs).

In fact.25 One should not underestimate the importance of it. it is not advised to make use of CBCT imaging. DICOM. With a positive and patiently insisting attitude. It is common for a product to be a great invention. In addition. any goal can be reached. awareness. In such cases. Yet the desire to break loose from the old 2D technology and its related problems (mainly magnification and distortion7) seems to exist. and is used every single time the machine needs to be operated. Time should be taken to evaluate how technological gadgets are being used in our practices. one of the major advantages of CT technology over regular radiography is the possibility to account for distortion caused by radiographic magnification. many of them lying outside the dental field altogether. helpful self-awareness programs are becoming more popular every day. . Research is currently being done5 to try to establish if CBCT can indeed provide improved diagnosis and treatment for orthodontic cases. but the imaging software should at the very minimum be able to import 33 and export DICOM images. Summarizing. the author advises learning more about standards through the ADA SCDI. perception. and HL7 communities and Web sites and by constantly asking about standards when communicating with software vendors. it is advised to pay particular attention to the user interface when considering the purchase of new technology. To do so. which requires orthodontic and dental related software to also be able to understand DICOM. Efficiency can similarly become an obstacle. Increasing one’s own concentration and perception skills are considered to be the most effective path toward a successful and productive practice. while an increased perception can help spot a problem or a distraction before it actually arises. It requires interoperability with many other devices. Not only do they make 3D imaging affordable. Are they helpful. or postero-anterior view. The knowledge of standards could be divulged among colleagues by actually using them whenever possible15: this would also prepare the user for standards. but to ship with a very poor user interface. be it a panoramic. as this would not follow the “as low as reasonably achievable” (ALARA)23 principles: CBCT exposes the patient to considerably more (about 4-5 times24) dosage than a regular 2D radiograph. which comes with all the promising features and temptations discussed above.Office of the Future treatment. Conclusions: Orthodontic Office of the Future The author believes that technology will bring great power to the future orthodontic office. and patience are available from various sources involving simple universally available techniques16. Developing these skills on one’s own can be a tedious task (it may involve considerable change in our behavior). For this reason. Specifically. It is advisable to experiment with a few and choose one that is most compatible with the individual. but they also provide an incentive for the divulgence of software standards. for when they will become mandatory (for certain tasks). lateral. The reader will not find a complete implemented orthodontic electronic record standard yet.17 as well as more specific methods based on rituals or physical activities. One should be prepared to make wise use of these upcoming tools. Therefore. one will be prepared for any developments in the future. it is hoped for CBCT to cast a brighter light on less predictable treatment outcomes. or are they actually obstacles? Are they being used properly? How much time is being saved? Is this extra time put to good productive use? What can be done to make the work environment more peaceful and harmonious? It is believed that if one is able to keep focused on these issues. most CBCT devices save their images in an already existing medical digital imaging format (DICOM standard). High concentration can reduce susceptibility to distraction. CBCT scanners do have an important role in the dental field. if not taken seriously. otherwise they can easily transform into obstacles. CBCT is a large and expensive electronic device. as it provides the primary communication between the human being and the machine. while interoperability will make it much more efficient. Courses and programs that teach how to increase individual skills such as concentration.

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