Cone beam computed tomography

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Diagnostics
MeSH D054894

Cone beam computed tomography (or CBCT, also referred to as C-arm

CT, cone beam volume CT, or flat panel CT) is a medical imaging
technique consisting of X-ray computed tomography where the X-rays
are divergent, forming a cone.[1]

CBCT has become increasingly important in treatment planning and

diagnosis in implant dentistry, interventional radiology (IR), among
other things. Perhaps because of the increased access to such
technology, CBCT scanners are now finding many uses in dentistry,
such as in the fields of endodontics and orthodontics, as well.
Integrated CBCT is also an important tool for patient positioning and
verification in image-guided radiation therapy (IGRT).

During dental imaging, the CBCT scanner rotates around the patient's
head, obtaining up to nearly 600 distinct images. For Interventional
Radiology, the patient is positioned offset to the table so that the
region of interest is centered in the field of view for the cone beam. A
single 200 degree rotation over the region of interest acquires a
volumetric data set. The scanning software collects the data and
reconstructs it, producing what is termed a digital volume composed of
three-dimensional voxels of anatomical data that can then be
manipulated and visualized with specialized software.[2][3]

There are three commercially available systems of C-arm CBCT in the

US: DynaCT (Siemens Medical Solutions, Forchheim, Germany), XperCT
(Philips Medical Systems, Eindhoven, the Netherlands), and Innova CT
(GE Healthcare, Waukesha, Wisconsin). The systems differ with regard
to their rotation time, number of projections acquired, image quality,
and time required for reconstruction.[4]

Principle of CBCT.
Contents [hide]
1 History
2 CBCT use in implantology
3 CBCT use in orthodontics
4 CBCT use in Interventional Radiology
4.1 Clinical Applications
4.2 Technical Limitations
5 Risks of CBCT technology
6 Disadvantages of CBCT technology
6.1 Bone density and the Hounsfield scale
7 Literature
8 References

History[edit]

Cone beam technology was first introduced in the European market in

1996 by QR s.r.l. (NewTom 9000) and into the US market in 2001.[2]

October 25, 2013, during the "Festival della Scienza" in Genova, Italy,
the original members of the research group: Attilio Tacconi, Piero
Mozzo, Daniele Godi and Giordano Ronca received an award for the
cone-beam CT invention, a revolutionary invention that changed
world's dental radiology panorama.[5][6][7]

Axial image obtained from the first Cone-Beam 3D Scan performed on

July 1, 1994[8]

Axial image obtained from the first Cone-Beam 3D Scan performed on

July 1, 1994

Axial image obtained from the first Cone-Beam 3D Scan performed on

July 1, 1994

Original notes about the first Cone-Beam 3D Scan performed on July 1,

1994
CBCT use in implantology[edit]

A dental cone beam scan offers invaluable information when it comes

to the assessment and planning of surgical implants. The AAOMR also
suggestes cone-beam CT as the preferred method for presurgical
assessment of dental implant sites.[9]
CBCT use in orthodontics[edit]

As a 3D rendition, CBCT offers an undistorted view of the dentition that

can be used to accurately visualize both erupted and non-erupted
teeth, tooth root orientation and anomalous structures that
conventional 2D radiography cannot.[10]

Processing example using x-ray data from a tooth model:

single sampled (noisy) image

several samples overlay

joined images to panoramic

algorithmic reconstruction

in-vivo image
CBCT use in Interventional Radiology[edit]

The CBCT scanner is mounted on a C-arm in the IR suite, which offers

real time imaging with a stationary patient. This eliminates the time
needed to transfer a patient from the angiography suite to a
conventional computed tomography scanner and facilitates a broad
spectrum of applications of CBCT during IR procedures. The clinical
applications of CBCT in IR include treatment planning, device or
implant positioning and assessment, intra-procedural localization, and
assessment of procedure endpoints. CBCT is useful as a primary and
supplemental form of imaging. It is an excellent adjunct to DSA and
fluoroscopy for soft tissue and vascular visibility during complex
procedures. The use of CBCT before fluoroscopy potentially reduces
patient radiation exposure.[3]
Clinical Applications[edit]
Chemoembolization for Hepatocellular Carcinoma: CBCT with contrast
confirms that the proper artery is selected to deliver the therapy. The
contrast enhances the parenchyma supplied by the selected artery and
therefore reveals if the vasculature also supplies the tumor. Post
treatment noncontrast CBCT confirms lipiodol staining of the tumor,
which improves operator confidence of complete tumor coverage or
further treatment.[4]
Prostate artery embolization for benign prostatic hypertrophy: CBCT
provides the soft tissue detail needed to visualize prostatic
enhancement, identify duplicated prostatic arteries, and avoid
nontarget embolization. CBCT is superior to DSA for this therapy since
the enhancement patterns on DSA can be difficult to discern due to the
overlapping pelvic structures and variable arterial anatomy.[11]
Abscess drainage: CBCT confirms needle tip location after placement
under ultrasound and confirms drain placement by revealing contrast
injection into the desired location.
Adrenal Vein sampling for an adenoma: contrast enhanced CBCT shows
perfusion of the adrenal gland to confirm catheter placement for
obtaining a satisfactory sample.[12]
Stent placement: CBCT improves the visualization of intracranial and
extracranial stents compared to conventional DSA and digital
radiography by providing a better depiction of the relationship of the

stents to nearby structures (i.e. vascular walls and aneurysm lumen).

[13]
Lung nodule percutaneous transthoracic needle biopsy: CBCT guides
needle placement and demonstrated a diagnostic accuracy, sensitivity,
and specificity of 98.2%, 96.8%, and 100%, respectively. Diagnostic
accuracy was unaffected by technically challenging conditions.[14]
Vascular Anomalies: After correction of arterio-venous malformations
with coiling, CBCT sensitively detects small infarcts in tissue that has
been "sacrificed" during the procedure to prevent further shunting. The
infarcted tissue appears as a small area of contrast retention.
Peripheral Vascular Interventions
Biliary Interventions
Spine Interventions
Enterostomy Interventions
Technical Limitations[edit]

While the practicality of CBCT fosters its increasing application in IR,

technical limitations hinder its integration into the field. The two most
significant factors that affect successful integration are image quality
and time (for set up, image acquisition, and image reconstruction).
Compared to MDCT, the wider collimation in CBCT leads to increased
scatter radiation and degradation of image quality as demonstrated by
artifacts and decreased contrast-to-noise ratio. The temporal resolution
of cesium iodide detectors in CBCT slows data acquisition time to
approximately 5 to 20 seconds, which increases motion artifact. The
time required for image reconstruction takes longer for CBCT (1
minute) compared to MDCT (real time) due to the computationally
demanding cone beam reconstruction algorithms.[3][4]
Risks of CBCT technology[edit]

Total radiation doses from dental CBCT exams are generally lower than
other CT exams (which cover a wider area), but dental CBCT exams
typically deliver more radiation than conventional dental X-ray exams.
[15] Properly shielded CBCT scans expose patients to many times the
radiation of 2d digital dental x-rays.[16][17][18] Doses are sometimes
inaccurately compared to what you would receive in on a very long
airplane flight. One of many problems with this comparison is that in

the CBCT the dose is being applied to a very narrow section of the
body.

CBCT use is only lightly regulated in the U.S. The recommended

standard of care is to use the smallest possible FOV, the smallest voxel
size, the lowest mA setting and the shortest exposure time in
conjunction with a pulsed exposure mode of acquisition.[19] It is up to
the patient to keep a record of their lifetime radiation exposure and
weigh the risks versus benefits.

The risks are highest for children and teens, who have a longer lifetime
for cells to develop cancers or errors due to exposure. Children have
higher estimates of the lifetime risk for cancer incidence and mortality
per unit dose of ionizing radiation.[20] It is recommended that children
or adolescents have no more exposure than medically necessary.[15]
Disadvantages of CBCT technology[edit]

There are a number of drawbacks of CBCT technology over that of

medical-grade CT scans, such as increased susceptibility to movement
artifacts (in first generation machines) and to the lack of appropriate
bone density determination.[21]
Bone density and the Hounsfield scale[edit]

The Hounsfield scale is used to measure radiodensity and, in reference

to medical-grade CT scans, can provide an accurate absolute density
for the type of tissue depicted. The radiodensity, measured in
Hounsfield Units (HU, also known as CT number) is inaccurate in CBCT
scans because different areas in the scan appear with different
greyscale values depending on their relative positions in the organ
being scanned, despite possessing identical densities, because the
image value of a voxel of an organ depends on the position in the
image volume.[22] HU measured from the same anatomical area with
both CBCT and medical-grade CT scanners are not identical[23] and
are thus unreliable for determination of site-specific, radiographicallyidentified bone density for purposes such as the placement of dental
implants, as there is "no good data to relate the CBCT HU values to
bone quality."[24]

Although some authors have supported the use of CBCT technology to

evaluate bone density by measuring HU,[25][26] such support is
provided erroneously because scanned regions of the same density in
the skull can have a different grayscale value in the reconstructed
CBCT dataset.[27]
X-ray attenuation of CBCT acquisition systems currently produces
different HU values for similar bony and soft tissue structures in
different areas of the scanned volume (e.g. dense bone has a specific
image value at the level of the menton, but the same bone has a
significantly different image value at the level of the cranial base).[21]

Dental CBCT systems do not employ a standardized system for scaling

the grey levels that represent the reconstructed density values and, as
such, they are arbitrary and do not allow for assessment of bone
quality.[28] In the absence of such a standardization, it is difficult to
interpret the grey levels or impossible to compare the values resulting
from different machines. While there is a general acknowledgment that
this deficiency exists with CBCT systems (in that they do not correctly
display HU), there has been little research conducted to attempt to
correct this deficiency.[29]

With time, further advancements in CBCT reconstruction algorithms will

allow for improved area detectors,[30] and this, together with
enhanced postprocessing, will likely solve or reduce this problem.[22] A
method for establishing attenuation coefficients with which actual HU
values can be derived from CBCT HU values was published in 2010 and
further research is currently underway to perfect this method in vivo.
[29]
Literature[edit]
Jonathan Fleiner, Nils Weyer, Andres Stricker: CBCT-Diagnostics, Cone
Beam Computed Tomography, The most important cases in clinical
daily routine, Systematic Radiographic Investigation, Diagnostics,
Treatment Approach Verlag 2einhalb, ISBN 978-3-9815787-0-6.
www.cbct-3d.com.
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http://en.wikipedia.org/wiki/Cone_beam_computed_tomography