Physica Medica 31 (2015) 844–860

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Physica Medica
j o u r n a l h o m e p a g e : h t t p : / / w w w. p h y s i c a m e d i c a . c o m

Review Paper

Dental cone beam CT: A review

Timo Kiljunen a,*, Touko Kaasalainen b, Anni Suomalainen b, Mika Kortesniemi b
a Docrates Cancer Center, Saukonpaadenranta 2, 00180 Helsinki, Finland
b HUS Medical Imaging Center, Radiology, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, 00290 Helsinki, Finland

A R T I C L E I N F O A B S T R A C T

Article history: For the maxillofacial region, there are various indications that cannot be interpreted from 2D images and
Received 3 July 2015 will benefit from multiplanar viewing. Dental cone beam CT (CBCT) utilises a cone- or pyramid-shaped
Received in revised form 15 September X-ray beam using mostly flat-panel detectors for 3D image reconstruction with high spatial resolution.
2015
The vast increase in availability and amount of these CBCT devices offers many clinical benefits, and their
Accepted 19 September 2015
Available online 23 October 2015
ongoing development has potential to bring various new clinical applications for medical imaging. Ad-
ditionally, there is also a need for high quality research and education. European guidelines promote the
use of a medical physics expert for advice on radiation protection, patient dose optimisation, and equip-
Keywords:
Dental ment testing. In this review article, we perform a comparison of technical equipment based on manufacturer
CBCT data, including scanner specific X-ray spectra, and describe issues concerning CBCT image reconstruc-
Characteristics tion and image quality, and also address radiation dose issues, dosimetry, and optimisation. We also discuss
Dosimetry clinical needs and what type of education users should have in order to operate CBCT systems safely.
Image quality We will also take a look into the future and discuss the issues that still need to be solved.
Guidelines © 2015 Associazione Italiana di Fisica Medica. Published by Elsevier Ltd. All rights reserved.
Development

Introduction interpreted from 2D images and therefore will benefit from 3D

Intraoral, panoramic and cephalometric radiographs are the basic
imaging techniques in dentomaxillofacial (DMFR) radiology, allow-
ing two-dimensional (2D) imaging of oral hard tissues [1,2]. 2D
radiographic images have been used in dentistry for decades.
However, the maxillofacial region includes fairly complex 3D
anatomy where traditional dental modalities may fail to provide
optimal visualisation of adjacent overlaying structures which will
be superpositioned in any single projection. Specifically, a tradi-
tional radiograph presents the anatomy mostly in the mesiodistal
(from the surface of a tooth that is closest to the middle of the front
of the jaw to the farthest from the middle of the front of the jaw)
plane, while the structures in the labiopalatal or buccolingual di-
mension are overlaid. This compression of 3D anatomy precludes,
for example, a clear depiction of the dental roots in relation to the
surrounding anatomy and associated periapical lesions [3], as shown
in Fig. 1. Furthermore, difficulties in implementing parallel image
settings in the oral cavity by positioning the image detector per-
pendicular to the target and the focus, and magnification related
to the varying distance of the detector from the dental object, cause
inaccurate reproduction of the clinical structures in terms of ge-
ometry. There are various indications which cannot be adequately
* Corresponding author. Docrates Cancer Center, Saukonpaadenranta 2, 00180
Helsinki, Finland. Tel.: +358505001861; fax: +358107732099.
E-mail address: timo.kiljunen@docrates.com (T. Kiljunen).
imaging with multiplanar review [4].
As in many fields of radiology, technological advances have led
to the introduction of new methods also in dentomaxillofacial ra-
diology (DMFR). One of these is cone beam CT (CBCT), which is also
known as digital volumetric tomography (DVT). Dental CBCT tech-
nology first emerged in 1995 when Italian inventors Attilio Tacconi
and Piero Mozzo introduced the first maxillofacial imaging device,
the NewTom DVT 9000 [5]. This scanner was introduced commer-
cially in Europe in 1999 [6,7]. At the same time, Arai et al. also
introduced their CBCT developments [8].
Dental CBCT utilises a cone- or pyramid-shaped X-ray beam
which is directed on the pursued maxillofacial field-of-view (FOV).
Most of the modern CBCT scanners use flat panel detectors (FPD)
comprising of a pixel array of amorphous silicon thin-film transis-
tors (TFT) or complementary metal oxide semiconductors (CMOS).
For both of these, X-rays are first converted to light photons by a
scintillator material which may consist of thallium doped caesium
iodide (CsI:Tl) or terbium activated gadolinium oxysulphide
(Gd2O2S:Tb). Thereafter, the light is detected on the photodiodes and
finally read from the entire detector array to compile a projection
raw-data digital image. Flat panel detectors offer higher spatial res-
olution and greater dynamic range, and are less bulky and
complicated compared to image intensifiers (II) and charge coupled
devices (CCD) which have gradually become obsolete as CBCT de-
tectors [6,9,10].
The pre-processing steps of the acquired projection raw-data vary
between manufacturers for flat-panel detectors. Typical steps include

http://dx.doi.org/10.1016/j.ejmp.2015.09.004
1120-1797/© 2015 Associazione Italiana di Fisica Medica. Published by Elsevier Ltd. All rights reserved.
 T. Kiljunen et al./Physica Medica 31 (2015) 844–860 845

Figure 1. (a) D. 16 is endodontically treated. In the intraoral radiograph the apical regions of the buccal roots are suspicious – distobuccal root (arrow), mesiobuccal root
(broken arrow). (b) A CBCT examination carried out for treatment planning shows a large lesion in the distobuccal root, indicating apical periodontitis (arrow) with perfo-
ration of the buccal cortex (broken arrow). Sagittal view (upper left), coronal view (upper right), 3D view (lower left) and axial view (lower right). There is mucosal swelling
in the floor of the right maxillary sinus in region 16 referring reactive changes. In the mesiobuccal root there was apical periodontitis palatoapically (not shown). Note also
the beam hardening artefacts caused by the metal fillings (Courtesy: Tapio Tammisalo).

adjustments related to detector dark-current, gain and pixel defects
by applying offset and gain corrections. A possible latent image signal
from the previous projection read-out also has to be erased by af-
terglow correction, especially if higher frame-rates are applied. Other
processing methods can be utilised based on the physical proper-
ties of the acquisition system, such as X-ray beam spectral factors,
estimated scatter distribution, focus-detector distance, detector re-
sponse, among others [11].
From an economical perspective, typical dental CBCTs can be ob-
tained with significantly lower costs compared to general MSCT
scanners. One of the low cost factors of CBCT technology is the x-ray
tube which can be implemented with similar technical specifica-
tions as in panoramic scanners. The basic structure of a dental CBCT
gantry can be designed similar to panoramic system, but in the case
of CBCT, combined with more advanced digital detectors, soft-
ware and a reconstruction computer [4].
One of the main characteristics of CBCT is its ability to produce
scans with varying FOVs according to clinical indication. With user
adjustable FOV sizes and image quality settings, different image data
voxel sizes can be acquired. As the voxel size is connected to spatial
846 T. Kiljunen et al./Physica Medica 31 (2015) 844–860
Figure 2. Implant treatment planning with CBCT: Linear measurements in region 46. The patient wore a scanning appliance in the CBCT examination where the planned
location of the implant is marked. Axial image (upper left), cross sectional view (upper right), panoramic view (lower left) and 3D image (lower right).
resolution by sampling principles, it is clearly anticipated that smaller
voxel sizes can provide images with more accurate representa-
tions of fine structures than what could be achieved with larger voxel
sizes [4,12].
Furthermore, CBCT image data are typically isotropic which means
that the voxels have the same dimensional length in all three di-
rections of the volumetric image data. As such, the isotropic 3D image
data can be reviewed from any projected direction using reformat-
ted slice orientation with similar image quality – a clear asset with
regard to complex 3D anatomy (Figs. 1 and 2). Additionally, the 3D
image data set can be post-processed into visualisations similar to
traditional dental radiology representations, such as panoramic,
cross-sectional, cephalometric, or bilateral multiplanar projec-
tions of the temporomandibular joint [4]. The volumetric CBCT image
data do not have diverging geometry as in projection images, and
therefore the linear measurements can be done with high reliabil-
ity and precision (Fig. 2) [13].
CBCT has limited low contrast resolution due to various physi-
cal and technical factors which bring limitations for soft tissue
evaluation [4]. Highly scattered radiation during image acquisi-
tion will adversely affect the contrast of the projection data and the
final reconstructed images. Also, the flat panel technology can cause
artefacts. There are various solutions to the beam hardening effects
which adversely affect the clinically observed image quality, espe-
cially when imaging of patients with extensive restorations, multiple
prostheses or previous implant treatments [14]. However, the prop-
erties of CBCT are well suited for dental examinations in the
maxillofacial region where high spatial resolution of hard tissue is
typically the primary interest.
The 3D image reconstruction methods used in the currently avail-
able CBCT scanners mainly still apply an approximate Radon
inversion algorithm that was introduced originally by Feldkamp et al.
in 1984 [15]. However, due to the need of improving image quality
further, iterative methods are being developed in many fields of CT
imaging [16].
Spatial resolution is essential for dental CBCT imaging where de-
piction of fine details is crucial for reliable diagnosis, e.g. for
periodontal applications where the periodontal ligament gap is pre-
sented in the range of 0.1 mm [17,18]. Current CBCT models achieve
a spatial resolution of 0.1 mm or even less [9,17]. Spatial resolu-
tion is closely related to the detector pixel size due to sampling
principles, but there are also other important factors which affect
the image quality. Focus size, contrast range, detector motion blur
and fill factor, the number of raw-data projections (basis images),
noise level, and reconstruction technique significantly influence the
observed resolution [6]. The main exposure parameters such as tube
voltage (effect on contrast, dose and image noise), tube current and
exposure time (effect on dose, image noise and movement arte-
fact probability through scan time) also have a fundamental effect
on the general perceived image quality. Therefore, the isotropic res-
olution of CBCT which is achieved with a stationary phantom is
probably not achieved with living patients where e.g. hemody-
namic pulsation introduces movements also in the maxillofacial
region. The resulting spatial resolution of CBCT is likely to be limited
 T. Kiljunen et al./Physica Medica 31 (2015) 844–860
to around 500 μm in clinical practice [17]. This should be kept in
mind when comparing CBCT image quality with MSCT [17,19,20].
In the field of dental 3D imaging, CBCT acts not as a substitute but
rather as a complement to MSCT in maxillofacial imaging [9].
According to a recent review by Nemtoi et al. [9], a total of 47
CBCT devices by 20 companies were available for dentomaxillofacial
imaging when the focus was particularly on the European market.
The vast increase in availability and amount of these CBCT devices
and their increasing use in DMFR offer many benefits, but there is
still an obvious need for high quality research and education. Even
though there is an abundance of research connected to CBCT in
DMFR, there is an obvious lack of evidence regarding the impact
of CBCT examinations upon treatment decisions. In particular, more
research is needed to show the possible benefits of the use of CBCT
to treatment outcomes in comparison to conventional dental imaging
methods. For a CBCT examination to be justified it needs to be po-
tentially beneficial to the patient – it must have the ability to change
the treatment decision and patient outcome. For example, Larheim
et al. [21] reported that current data concerning the use of CBCT
in temporomandibular joint diagnostics are mainly limited to tech-
nical efficacy and diagnostics accuracy, i.e. the two first levels in the
six-stage framework to assess the efficacy of imaging methods –
technical, diagnostic accuracy, diagnostic thinking, therapeutic,
patient outcome and societal efficacy – by Fryback and Thornbury
[22]. However, little attention has been paid to diagnostic think-
ing efficacy and therapeutic efficacy [21].
European guidelines promote the use of a medical physics expert
for advice on radiation protection, patient dose optimisation, and
equipment testing [23]. In this review article, we are performing a
comparison of technical equipment based on manufacturer data,
and describe issues concerning CBCT image reconstruction and image
quality, and also radiation dose issues and optimisation. We also
discuss clinical needs and what type of education users should have
in order to operate CBCT systems safely. We will also take a look
into the future and discuss the issues that still need to be solved.
Technical characteristics of current dental CBCT scanners
General features
Depending on the practical necessities, it is possible to choose
from CBCT systems with different imaging features and capabili-
ties. The technical properties of the reviewed dental CBCT scanners
are summarised in Table 1 and discussed in the text. Data were col-
lected from manufacturers’ brochures available in Internet, and
furthermore, checked and completed by the representatives of each
vendor with a questionnaire (a few manufacturers did not answer
the questionnaire). CBCT systems are typically divided into three
different categories according to FOV size: (1) large FOV (>15 cm
maximum scan volume height), (2) medium FOV (from 10 cm to
15 cm field height), and (3) small FOV (≤10 cm field height) [24].
Some of the devices available are multimodality imaging systems
that also include digital 2D panoramic and cephalometric imaging
features in the same unit, and thereby enable savings in office space
and investment cost. Additionally, in some devices there are also
possibilities to perform 3D photography (e.g. Planmeca ProFace for
all Promax 3D systems, Planmeca Oy, Helsinki, Finland) to assist pre-
operative treatment planning and follow-up.
Gantry size and type
The size and geometry of the available CBCT systems vary de-
pending mostly on the technique used for patient positioning. The
weight of the systems themselves ranges from 128 kg to 600 kg.
Scanning can be performed in a standing, sitting or supine posi-
tion, depending on the scanner and the needs of a patient. The
847
standing position is the most commonly used for scanning, but it
is vulnerable to patient movements, especially when the head fix-
ation tools are insufficient. To minimise movement artefacts, standing
devices can also be used with the patient in a sitting position. The
scanners utilising a standing position typically also have a motorised
column that allows vertical translation of the x-ray tube and de-
tector system, thus providing access also to wheelchair patients. The
seated position allows patient comfort and natural orientation of
anatomy, and thereby reduces artefacts induced by patient motion.
Similar to some of the standing systems, some of the seated systems
also have a column that serves access to wheelchair patients. There
are also a few CBCT systems that utilise supine position in scan-
ning (MyRay SkyView, Cefla Dental Group, Imola, Italy; NewTom 3G
and NewTom 5G, both from Quantitative Radiology Systems, Verona,
Italy). Although the supine position minimises the patient motion
and maximises the stability of the scanning process, and there-
fore may result in excellent image quality and patient satisfaction,
the needs for room dimensions are more demanding compared to
both standing and seated systems. Device footprint is an impor-
tant practical aspect in dental practices where space is often limited
with office-like installations [9].
Field of view (FOV)
The FOVs available in dental CBCT systems vary from FOVs suit-
able for a single jaw (D × H usually 4 × 4 cm2 or 5 × 5 cm2) to full
craniofacial imaging (from approximately 15 × 15 cm 2 up to
23 × 26 cm2). The dimensions of the FOV depend on the size and
shape of the detector, the beam projection geometry and the ability
to collimate the beam [6]. The reduction of the FOV in most units
is performed by using adjustable lead shields as a primary colli-
mation at the radiation source. Moreover, most of the systems utilise
either one or a few prefixed FOVs planned for different indica-
tions, whereas in some devices one can freely adjust the FOV within
certain limits in both the vertical and the horizontal cross-sectional
volumes. Additionally, in some CBCT devices it is possible to stitch
together adjacent 3D volumes, resulting in larger FOVs. Impor-
tantly, users should remember, while scanning patients, that the FOV
is the most important scanning parameter affecting the patient ra-
diation dose and image quality, and therefore it should be selected
according to clinical questions (these are discussed more thor-
oughly in later sections).
Data collection during the scan
CBCT data reconstruction with complete information requires the
acquisition of projection images from at least a scan arc of 180° [6].
The rotation angle typically varies between 180° and 360° depend-
ing on the CBCT device. In some scanners it is possible to select a
variable angular range depending on scan protocol whereas most
of the scanners function only with a single fixed rotation angle [9,25].
The rotational movement and gantry of CBCT devices are mostly
based on existing dental panoramic gantry designs which use shorter
angular ranges. The number of projections collected during the ro-
tation depends of the detector frame rate and varies from 128 to
1024 projections, giving different bases for the image reconstruc-
tion [6,9]. The number of projections during the scan arc movement
is determined by the frame rate (number of projection images per
second), the length of the rotational trajectory, and the speed of the
rotational movement [6]. Image quality is affected to some extent
by the number of projection images, as an increased number of
samples basically result in higher image quality. The projections
(basis images) form the total raw data which are then pre-processed
and used to reconstruct the final isotropic 3D image data. The
greyscale depth of the image data varies between 8 and 16 bits,
 848
Table 1
CBCT device specifications of different systems.

Reconstruction

requirements,
Manufacturer

W × D × H (m)
Tube current

Weight (kg)
Trade name

positioning
Scan mode

FOV, D × H
Focal spot

Voxel size

Greyscale
Exposure
Scanning
potential

filtration

Rotation
Detector

time (s)

Patient
display
Space
(mm)

(mm)

angle
(mA)

Total
Tube

Dose
time

time

(cm)
(bit)
(kV)

(s)

(s)

(°)
Auge SOLIO Z CSi FPD 60–100 2–12 >2.5 mmAl 0.5 0.100–0.315 8.5–17 N/A Continuous N/A 180/360 12 1.90 × 1.37 N/A Standing 5.1 × 5.5, 9.7 × 10, 170
Cefla Sc* Carestream* Carestream* Carestream* Carestream* Carestream* Asahi Roentgen Asahi Roentgen Asahi Roentgen

CM × 2.40 16.1 × 10
JAP

Alioth CM CSi FPD 60–100 2–12 >2.8 mmAl 0.5 0.100–0.226 8.5–17 8.5–17 Continuous N/A 180/360 8–14 1.90 × 1.41 N/A Standing 5.1 × 5.5, 7.9 × 8, 314
× 2.29 11.6 × 8
JAP

T. Kiljunen et al./Physica Medica 31 (2015) 844–860

Alphard-3030 FPD 60–110 2–15 >2.8 mmAl 0.6 0.100–0.390 N/A 17 N/A N/A N/A N/A 2.02 × 1.67 N/A Standing 5.1 × 5.1, 480
× 1.95 10.2 × 10.2,
15.4 × 15.4,
JAP

20 × 17.9

CS8100 CMOS FPD 60–90 2–15 >2.5 mmAl 0.6 0.075–300 7–15 N/A Pulsed 10–55 N/A 14 1.0 × 1.2 × 2.2 DAP Standing/ 4 × 4, 5 × 5, 8 × 5, 92
wheelchair 8 × 8, 8 × 9

CS 9000 3D CMOS FPD 60–90 2–15 >2.5 mmAl 0.5 0.076–0.200 22 10.8 Pulsed 10–55 360 15 1.5 × 2.0 × 2.4 DAP Standing/ 5 × 3.75, 7.5 × 3.75 160
wheelchair (extended mode)

CS 9300 aSi FPD 60–90 2–15 >2.5 mmAl 0.7 0.090–0.500 12–28 6.2–20 Continuous/ 20–90 190/360 14 1.5 × 2.0 × 2.4 DAP Standing/ 5 × 5, 8 × 8, 10 × 5, 160
pulsed wheelchair 10 × 10, 17 × 6,
17 × 11, 17 × 13.5

CS 9300 Select aSi FPD 60–90 2–15 >2.5 mmAl 0.7 0.090–0.500 12–28 6.2–20 Continuous/ 20–90 190/360 14 1.5 × 2.0 × 2.4 DAP Standing/ 5 × 5, 8 × 8, 10 × 5, 160
pulsed wheelchair 10 × 10

9500 aSi FPD 60–90 2–15 >2.5 mmAl 0.7 0.200–0.300 24 10.8 Pulsed 140 360 14 1.73 × 1.64 DAP Standing/ 9 × 15, 18.4 × 20.6 176
× 2.4 wheelchair

MyRay HR image 90 1–10 11.4 mmAl 0.5–0.6 0.16–0.33 10–30 6.9 (std) Pulsed 120–180 190/360 12 1.54 × 2.51 DAP Supine 15, 11, 7 (spherical) 360
SkyView intensifier (std 15) × 1.72
– CCD

(continued on next page)

Table 1 (continued)

Reconstruction

requirements,
Manufacturer

W × D × H (m)
Tube current

Weight (kg)
Trade name

positioning
Scan mode

FOV, D × H
Focal spot

Voxel size

Greyscale
Exposure
Scanning
potential

filtration

Rotation
Detector

time (s)

Patient
display
Space
(mm)

(mm)

angle
(mA)

Total
Tube

Dose
time

time

(cm)
(bit)
(kV)

(s)

(s)

(°)
MyRay ASi FPD 60–90 1–10 N/A 0.5 0.075–0.15 18–26 3.6–9 Pulsed >15 360 14 1.31 × 1.52 × 2.4 DAP Standing/ 5 × 5, 8 × 5, 8 × 8, 170
J. Morita J. Morita Instrumentarium* Instrumentarium* Imtec Corp. Imaging Sciences Image Works Gendex Gendex Cefla Sc*

Hyperion X9 wheelchair 11 × 5 11 × 8,
11 × 13 (stitched)

GXCB-500 HD aSi FPD 90–120 3–8 N/A 0.5 0.125–0.400 8.9–23 N/A N/A 20–90 360 14 1.22 × 1.34 × 1.8 N/A Sitting 8 × 8, 14 × 8 231

GXDP-700 S aSi 57–90 −16 N/A 0.5 0.125–0.400 10–20 2.34– Pulsed 20–90 360 14 1.4 × 2.0 × 2.4 N/A Standing/ 4 × 6, 6 × 8 200
12.5 wheelchair

Panoura 18S CdTe 58–82 2–10 2.5 mmAl 0.5 0.08–0.1 N/A 11.5–23 N/A 90–180 190 (×2 16 1.89 × 1.14 N/A Standing/ 4 × 5.7, 7.7 × 5.4 205
(XP73) CMOS sliding × 2.32 wheelchair

T. Kiljunen et al./Physica Medica 31 (2015) 844–860

Corp.

sensor
system)

iCAT aSi 90–120 3–7 N/A 0.5 0.125–0.40 5–26.9 2–7.2 Pulsed 30 360 14 1.22 × 0.94 DAP Sitting 8 × 8, 4 × 16, 6 × 16, 231
International

× 1.80 8 × 16, 10 × 16,

13 × 16

Iluma Elite aSi 120 1–3.8 N/A 0.3 0.09–0.40 20–40 20–40 Continuous 120 190/360 14 2.14 × 1.83 × N/A Sitting Up to 10.8 × 9.6 350
(360), (360), 2.44 (small), up to
7.8 7.8 21.1 × 14.2 (large)
(190) (190)

OP-300 CMOS 57–90 3.2– 3.2 mmAl 0.5 0.085–0.33 10–20 1.2– Pulsed 10–60 200 16 2.01 × 1.41 DAP Standing/ 6.1 × 4.1, 6.1 × 7.8 250
16 12.6 × 2.41 wheelchair

OP-300 Maxio CMOS 57–90 3.2– 3.2 mmAl 0.5 0.085–0.42 10–40 1.2–9 Pulsed 10–60 200 16 2.01 × 1.41 DAP Standing/ 5 × 5, 6.1 × 7.8, 250
16 × 2.41 wheelchair 7.8 × 7.8, 7.8 × 15,
13 × 15

3D Accuitomo aSi (CsI) 60–90 1–10 3.1 mmAl 0.5 0.08–0.25 <18 <18 Continuous 20–120 360 14 1.62 × 1.20 CTDI Sitting 4 × 4, 6 × 6, 8 × 8, 400
170 × 2.08 10 × 10, 17 × 12

Veraviewepocs CMOS 60–80 1–10 N/A 0.5 0.125 9.4 9.4 Continuous 60–240 180 13 2.00 × 1.33 CTDI Standing/ 4 × 4, 4 × 8, 8 × 8 258
3D (CSi) × 2.36 wheelchair

(continued on next page)

849
 850
Table 1 (continued)

Reconstruction

requirements,
Manufacturer

W × D × H (m)
Tube current

Weight (kg)
Trade name

positioning
Scan mode

FOV, D × H
Focal spot

Voxel size

Greyscale
Exposure
Scanning
potential

filtration

Rotation
Detector

time (s)

Patient
display
Space
(mm)

(mm)

angle
(mA)

Total
Tube

Dose
time

time

(cm)
(bit)
(kV)

(s)

(s)

(°)
Veraviewepocs CMOS 60–90 1–10 N/A 0.5 0.125 9.4 9.4 Continuous 30–60 180 14 2.00 × 2.30 CTDI Standing/ 4 × 4, 4 × 8, 8 × 5, 190/
J. Morita

3D R100 (CSi) × 2.36 wheelchair 8 × 8, 10 260

(equivalent) × 5, 10
(equivalent) × 8
3D exam aSi 90–120 3–8 N/A 0.5 0.125–0.4 8.5–26 2–7.2 Pulsed <60 360 14 1.22 × 1.16 DAP Sitting 8 × 8, 16 × 13 200
Owandy KaVo Dental KaVo Dental

× 1.83
GmbH

T. Kiljunen et al./Physica Medica 31 (2015) 844–860

3D exam i aSi 90–120 3–8 N/A 0.5 0.125–0.4 8.9–23 Pulsed 20–95 360 14 1.22 × 1.17 DAP Sitting 8 × 8, 14 × 8
× 1.80
GmbH

I-Max Touch aSi 60–86 6–10 2.5 mmAl 0.5 0.156 20 8 Pulsed <30 200/180 16 1.97 × 1.27 DAP Standing/ 8.3 × 9.3 140
Radiology*

3D (TMJ) × 2.45 wheelchair

Promax 3D aSi (CsI) 50–84 1–16 2.5 mmAl 0.5 0.075–0.4 18 4.8–15 Pulsed 30–150 200 15 2.15 × 1.63 CTDI/ Standing/ 4.2 × 4.2, 5 × 5, 119
Planmeca* Planmeca*

+ 0.5 mmCu × 2.43 DAP wheelchair 4.2 × 6.8, 5 × 8,

9 × 6 × 8 (triple
scan)
Promax 3Ds aSi (CsI) 60–90 1–14 2.5 mmAl 0.5 0.075–0.4 7.5–27 2.4–15 Pulsed 2–25 200 15 2.15 × 1.63 CTDI/ Standing/ 4.2 × 4.2, 5 × 5, 119
+ 0.5 mmCu × 2.43 DAP wheelchair 4.2 × 6.8, 5 × 8,
8.5 × 9 (stitched),
10 × 11 (stitched)
ProMax 3D aSi (CsI) 60–90 1–12 2.5 mmAl 0.6 0.075–0.6 9–33 2.4–15 Pulsed 2–55 200/360 15 2.06 × 1.37 CTDI/ Standing/ 3.4 × 4.2, 4 × 5, 136
+ 0.5 mmCu × 2.39 wheelchair 3.4 × 6, 4 × 7,
Planmeca*

Plus or 60– DAP

120 6 × 4.2, 7 × 5, 6 × 6,
7 × 7, 7.5 × 4.2,
9 × 5, 7.5 × 7.5,
9 × 9, 16 × 5, 16 × 9
Promax 3D Mid aSi (CsI) 60–90 1–12 2.5 mmAl 0.6 0.075–0.6 9–33 2.4–12 Pulsed 2–55 200/360 15 2.06 × 1.37 CTDI/ Standing/ 3.4 × 4.2, 4 × 5, 136
or 60– + 0.5 mmCu × 2.39 DAP wheelchair 3.4 × 6.8, 4 × 8,
6.8 × 4.2, 8 × 5,
Planmeca*

120
6.8 × 6.8, 8 × 8,
8.5 × 5, 10 × 6,
8.5 × 8.5, 10 × 10,
20 × 6, 20 × 10,
20 × 17
(continued on next page)
Table 1 (continued)

Reconstruction

requirements,
Manufacturer

W × D × H (m)
Tube current

Weight (kg)
Trade name

positioning
Scan mode

FOV, D × H
Focal spot

Voxel size

Greyscale
Exposure
Scanning
potential

filtration

Rotation
Detector

time (s)

Patient
display
Space
(mm)

(mm)

angle
(mA)

Total
Tube

Dose
time

time

(cm)
(bit)
(kV)

(s)

(s)

(°)
Promax 3D aSi (CsI) 60–90 1–12 2.5 mmAl 0.6 0.075–0.6 9–40 23.6–15 Pulsed 2–55 210 / 15 1.16 × 1.37 CTDI/ Standing/ 4.2 × 5, 5 × 5.5, 134
Max or 60– + 0.5 mmCu 360 × 2.39 DAP wheelchair 8.5 × 5, 10 × 5.5,
120 8.5 × 7,5, 10 × 9,
11 × 5, 13 × 5.5,
Planmeca*

11 × 7.5, 13 × 9
8.5 × 11, 10 × 13,
11 × 11, 13 × 13,
11 × 13.6, 13 × 16,
18.7 × 14.5, 22 × 17,
23 × 16, 23 × 26
Prexion 3D CSi FPD 90 4 N/A 0.2 0.101–0.147 8.6– 8.6– Continuous 30 217/ 13 1.57 × 1.17 N/A Sitting 8.1 × 7.5, 5.6 × 5.2 363
Prexion

Elite 33.5 33.5 360 × 1.93

T. Kiljunen et al./Physica Medica 31 (2015) 844–860

Giano** aSi 60–90 1–10 6.2 mmAl 0.5 0.075 18–26 3.6–9 Pulsed 15–60 360 16 1.83 × 1.52 CTDI Standing/ 5 × 5, 8 × 5, 8 × 8, 190
Systems*

@85 kV × 2.41 wheelchair 11 × 5, 11 × 8,

QR

11 × 13 (stitched)

NewTom VGi aSi 110 1–32 12.0 mmAl 0.3 0.1 15–18 1.8–4.3 Pulsed <60 360 16 1.20 × 1.13 CTDI Standing/ 5 × 5, 8 × 5, 8 × 8, 260
Systems*

evo @75 kV × 2.29 wheelchair 10 × 5, 10 × 10,

QR

12 × 8, 15 × 5,
15 × 12, 16 × 16,
24 × 19
NewTom 3G Image 110 1–15 1.4 mmAl @ 0.5–1.5 0.15–0.3 36 5.4 Pulsed >60 360 12 1.90 × 2.50 CTDI Supine 10, 15, 20 480
intensifier 70 kV × 1.98 (spherical)
+ CCD (inherent) +
QR Systems*

11.4 mmAl
@ 110 kVp
(12″ & 9″
FOV) OR
2.2 mmAl @
110 kVp (6″
FOV)***
NewTom 5G aSi 110 1–20 4.4 mmAl @ 0.3 0.075 18–26 3.6–6.7 Pulsed <60 360 14 1.75 × 3.60 CTDI Supine 6 × 6, 8 × 8, 12 × 8, 600
Systems*

70 kV × 1.78 15 × 5, 15 × 12,
QR

18 × 16

WhiteFox aSi 105 6–10 9.2 mmAl 0.5 0.10–0.50 18–27 6–9 Pulsed 30 360 16 1.89 × 1.58 × 2.38 N/A Standing/ 6 × 6, 8 × 8, 12 × 8, 275
Sirona Dental Sirona Dental Saletec

wheelchair 15 × 13, 20 × 17

GALILEOS Image 85 5–7 N/A 0.5 0.15–0.30 14 2–6 Pulsed 150–270 200 12 1.60 × 1.60 N/A Standing/ 15 (spherical) 120
Systems*

Comfort intensifier × 2.25 wheelchair

+ CCD

GALILEOS Image 98 3–6 N/A 0.5 0.125–0.25 14 in 2–5 Pulsed <240 200 12 1.60 × 1.60 N/A Standing/ 15.4 (spherical) 120
Systems*

Comfort Plus intensifier HD × 2.25 wheelchair

+ CCD mode

(continued on next page)

851
 852
Table 1 (continued)

Reconstruction

requirements,
Manufacturer

W × D × H (m)
Tube current

Weight (kg)
Trade name

positioning
Scan mode

FOV, D × H
Focal spot

Voxel size

Greyscale
Exposure
Scanning
potential

filtration

Rotation
Detector

time (s)

Patient
display
Space
(mm)

(mm)

angle
(mA)

Total
Tube

Dose
time

time

(cm)
(bit)
(kV)

(s)

(s)

(°)
Orthophos XG CMOS FPD 60–90 3–16 N/A 0.5 0.1–0.16 2–14 2–5 Pulsed 270 200 12 1.41 × 1.28 N/A Standing/ 5 × 5.5, 8 × 5.5, 110
Soredex* Sirona Dental
Systems*

3D × 2.25 wheelchair 8 × 8

Scanora 3D CMOS FPD 60–90 4–12.5 6.6 mmAl 0.5 0.133–0.35 10–26 2–6 Pulsed 60–240 360 12 1.60 × 1.40 DAP Sitting 6 × 6, 7.5 × 10, 310
× 1.97 7.5 × 14.5, 13 × 14.5

T. Kiljunen et al./Physica Medica 31 (2015) 844–860

Scanora 3Dx aSi FPD 60–90 4–10 6.6 mmAl 0.5 0.10–0.50 18–34 2.4–6 Pulsed 60–240 360 14 1.60 × 1.40 DAP Sitting 5 × 5, 5 × 10, 8 × 10, 310
Soredex*

× 1.97 8 × 16.5, 14 × 10,

14 × 16.5, 18 × 16.5
(stitched),
24 × 16.5 (stitched)
Cranex 3D CMOS FPD 60–90 4–12.5 3.2 mmAl 0.5 0.133–0.35 10–26 2.3–6 Pulsed 60–240 180/360 14 1.60 × 1.40 DAP Standing/ 6 × 6, 7.5 × 10, 200
Vatech Vatech Vatech Soredex* Soredex*

× 1.97 wheelchair 7.5 × 14.5, 13 × 14.5

Cranex 3Dx CMOS FPD 57–90 4–16 3.2 mmAl 0.5 0.085–0.40 10–40 1–9 Pulsed 60–240 180/360 14 1.96 × 1.41 DAP Standing/ 5 × 5, 6.1 × 7.8, 200
× 2.41 wheelchair 7.8 × 7.8, 7.8 × 15,
13 × 15

Master 3Ds N/A 40–90 2–10 N/A 0.5 0.164–0.40 15–24 N/A N/A 9–51 360 14 1.02 × 1.24 N/A Standing/ 16 × 7, 16 × 10, N/A
× 2.29 sitting/ 20 × 15, 20 × 19
wheelchair
PaX-Reve 3D CMOS FPD 40–90 2–10 N/A 0.5 0.08–0.25 15–24 3–13.5 Pulsed <60 360 14 2.05 × 1.57 N/A Standing/ 5 × 5, 8 × 6, 12 × 8, 400
× 2.33 wheelchair 15 × 15, 15 × 19

PaX-Duo 3D CMOS FPD 60–90 2–10 N/A 0.5 0.08–0.20 15–24 <9 Pulsed 18–30 360 14 1.07 × 1.57 N/A Standing/ 5 × 5, 8.5 × 5, 400
× 2.35 wheelchair 8.5 × 8.5, 12 × 8.5

PaX-Zenith 3D CMOS FPD 50–120 4–10 N/A 0.5 0.08–0.30 15–24 <9 Pulsed <221 360 14 1.80 × 2.00 N/A Sitting/ 5 × 5, 8 × 8, 12 × 9, 493
Vatech

× 1.85 wheelchair 16 × 14, 24 × 19,

free FOV 5 × 5 –
24 × 19

* Specifications checked and completed by the vendor.

** All Giano’s values are referred to the CB3D mode (not 2D panoramic and cephalometric images).
*** There are various versions of NewTom 3G installed: the values expressed here are referred to NewTom 3G 12″ multiple fields, latest release.
 T. Kiljunen et al./Physica Medica 31 (2015) 844–860
Figure 3. Mean photon energies for different dental CBCT scanners with 90 kVp tube voltage available were determined from the simulations using a 10° anode angle. The
highest mean energy, and thus the greatest total filtration, was observed to be in Planmeca’s CBCT systems that are using additional copper filtration in addition to alu-
minium filtration.
where the majority of modern CBCT models currently operate with
14 bits [9].
Voxel size
Currently, dental CBCT systems typically offer the possibility to
choose the used voxel size according to the specific task. The small-
est voxel size available nowadays is 75 μm and the highest possible
selection is 600 μm. The voxel size is related to spatial resolution,
and the smaller it is, the higher the spatial resolution can theoret-
ically be. Thus, voxel size can influence diagnostic performance with
special tasks, such as the assessment of dental trauma, which re-
quires a high level of detail [26,27]. However, smaller pixels capture
less X-ray photons, resulting in more image noise, and therefore the
radiation dose may have to be increased. In addition to voxel size,
the focal spot size also affects the spatial resolution. In most of the
CBCT systems the focal spot size is 0.5 mm, although the full range
is from 0.2 mm to 1.5 mm. Although the theoretical spatial resolu-
tion of CBCT systems may be high due to small voxel and focal spot
sizes, it is also affected by beam projection geometry, scatter and
patient movement, detector motion blur and fill factor, the number
of projections, and the reconstruction algorithm. As CBCT scan-
ning may take up to 40 s, the scanning is vulnerable to patient
motion. It has been discussed that the heartbeat alone induces a
slight but relevant movement of the patient’s head [17]. This move-
ment has been shown to be approximately 80 μm per heartbeat [28].
Exposure settings
Some of the dental CBCT devices still use a continuous radia-
tion exposure whereas most of the scanners are now utilising a
pulsed x-ray beam exposure. The generators operating in the pulsed
mode typically result in lower radiation doses to patients as the ra-
diation is turned off intermittently during the image acquisition
process.
In some CBCT scanners the tube potential and tube current are
fixed for 3D imaging, whereas in others they can be changed within
certain limits, allowing better possibilities for scan optimisation in
terms of radiation dose and image quality. Available tube currents
vary between 1 and 32 mA. Tube voltages range from 40 to 120 kVp
853
with typical values between 60 and 90 kVp (see Table 1), resulting
in mean photon energies of 34–57 keV (based on SpekCalc [29] sim-
ulation, see also Fig. 3). Further kV optimisation could be possible
in CBCT, where a medical physicist should be involved with possi-
ble voltage adjustments, if they become more available in the new
CBCT models, and extending clinical indications [9]. The total fil-
tration of the systems, affecting the X-ray spectra (Fig. 4), varies
remarkably (from 2.5 mmAl at minimum up to 12 mmAl (NewTom
VGi evo, QR Systems srl, Verona, Italy)). Additionally, some scan-
ners utilise additional copper filtration (Planmeca CBCT systems,
Planmeca Oy, Helsinki, Finland) which hardens the photon beam
remarkably.
Scan time
The scanning times in CBCT vary from approximately 5 seconds
up to 40 seconds, depending among other things on the number
of acquired projection images. However, the exposure times are
usually less than this due to pulsing the x-ray beam, ranging from
circa 1 second up to 40 seconds. Additionally, the reconstruction
times differ between scanners from a few seconds up to several
minutes depending on the acquisition parameters (FOV, voxel size,
number of projections), hardware (processing speed, data transfer
from acquisition to reconstruction computer) and software (recon-
struction algorithms) used [6].
Image reconstruction
Image reconstruction in CBCT (and for CT in general) is a math-
ematical process where the measured projection raw-data are related
to the image data which describe the patient object attenuation (i.e.
reduction of beam intensity caused by photon interactions) with
the used X-ray spectrum and beam geometry. The attenuation dis-
tribution of the patient is presented in the 3D CBCT image data by
the greyscale value of each voxel. The image reconstruction is an
inverse problem where traditional reconstruction methods do not
offer a direct solution. The reconstruction technique mostly used
in CBCT utilises 3D filtered back projection (FBP) via the Feldkamp–
Davis–Kress (FDK) algorithm [11] due to its simplicity and fast
reconstruction times. Applied filtering in FBP can be adjusted to
854 T. Kiljunen et al./Physica Medica 31 (2015) 844–860
Figure 4. X-Ray spectra for different dental CBCT scanners with 90 kVp tube voltage available were determined from the simulations using a 10° anode angle. As total fil-
tration was increased, the beam was hardened, which can be seen as a higher mean energy of the beam.
control the level of sharpness of the resulting image data. However,
the sharper image also accentuates noise. Balance between the level
of edge detection and noise must be set by the selection of an ap-
propriate filter for each specific protocol or diagnostic task. Cone
beam CT with a limited amount of projections, shorter angular range
in data acquisition, and truncated data could benefit considerably
from more advanced iterative reconstruction techniques which are
discussed in the later chapter (future aspects).
Typical clinical presentation of the dental CBCT image data in-
cludes axial, coronal and sagittal planes, in addition to a volume
rendered 3D visualisation (Fig. 1). Image data can be navigated
through mouse-driven cursor lines with rotating and tilting func-
tions as needed. Various specially designed visualisations may be
used for dentomaxillofacial applications, including e.g. virtual pan-
oramic display computed as a curved multi-planar reformat of the
3D image data (Fig. 2).
Stitching volumes
In some cases, the single FOV does not have enough coverage
for the clinical volume of interest. Thus, separate scans producing
FOVs adjacent to and partly overlapping each other may be stitched
together to provide a larger effective field of view. This stitching may
be used to combine horizontal or vertical image volumes to compile
a larger image volume. The stitching process itself may utilise exact
information on patient positions between the separate original
scans or automatic matching of the images using image registra-
tion [6,11].
Beam hardening and artefacts
An X-ray tube produces a beam with a continuous spectrum of
energies (Fig. 4). When the polyenergetic beam is attenuated and
scattered in the patient, the mean energy of the remaining primary
photons becomes higher. Therefore, the beam is hardened. Basic re-
construction algorithms such as FBP assume a monoenergetic beam.
For the actual polyenergetic beam, the attenuation values of struc-
tures that cause beam hardening are thus falsely considered lower
than their true attenuation values [16,30]. Beam hardening changes
the calculated attenuation values in the reconstructed image data
and causes artefacts related to highly attenuating materials in the
patient, such as metal implants. Beam hardening also causes a
cupping effect when the X-rays which pass through a thicker centre
part of a cylindrical object are filtered to higher photon energies
compared to the X-rays which pass through the edges of an object,
and thus are filtered less by the object thickness. The spectrum of
the X-ray beam can be narrowed by increasing the added filtra-
tion of the beam to decrease the basis for beam hardening, but this
will increase the power requirements of the X-ray source and/or
cause longer exposure times in order to acquire a sufficient amount
of quanta for the image signal collection. However, if added filtra-
tion can be applied, it is also beneficial due to the decreased radiation
exposure of the patient, as the softer X-rays are more optimally
removed from the primary beam.
Scatter and beam hardening give rise to characteristic image ar-
tefacts in CBCT where dark shading and bright streaks are typically
shown especially around highly attenuating metallic objects within
the image volume (Fig. 1) [11,31]. Scatter removal may include phys-
ical grids with a related increase in dose level, computational scatter
correction methods, including simple (polynomial) background signal
estimations, or more elaborate Monte Carlo simulation based
methods applied to each raw-data projection. Metal artefact cor-
rections are more application-specific and may take advantage of
an iterative reconstruction approach and prior information of the
metallic material in the scan volume [11]. Artefacts in the maxil-
lofacial region are commonly produced by metal objects – metal
fillings and crowns, fixed orthodontic appliances, etc. – causing prob-
lems, for example, in caries diagnostics (Fig. 1).
Greyscale values and HU calibration
The intrinsic greyscale values in MSCT image data are cali-
brated to the Hounsfield unit (HU) scale which describes the relative
X-ray attenuation in a voxel in relation to the attenuation of air
(−1000 in HU range) and water (zero in HU range). The applicabil-
ity of the HU scale in CBCT image data is limited due to several
physical factors including, most of all, X-ray scatter due to the cone
beam geometry, and projection data truncation, which bring un-
certainty and inconsistency to the claimed HU values and ultimately
limit low-contrast (soft-tissue) resolution. Therefore, the exact
 T. Kiljunen et al./Physica Medica 31 (2015) 844–860 855

Table 2
The range and mean effective doses (μSv) for dental CBCT with different FOVs [24,41].

FOV* Range Mean Range Mean

Adult Ludlow et al. Bornstein et al.

L 46–1073 212 52–1073 238
M 9–560 177 28–674 158
S 5–652 84 11–252 59
Child
L&M 13–769 175 28–282 120
S 7–521 103 16–28 22

* Ludlow: L = large (>15 cm), M = medium (10–15 cm), S = small (<10 cm), Bornstein:
L = large (>100 cm2), M = medium (40–100 cm2), S = small (<40 cm2).

ensuring adequate image quality. The tube voltage settings should

Figure 5. The lifetime attributable radiation induced cancer risk from dental CBCT
imaging derived from estimated absorbed organ doses [32].
quantitative greyscale values (or pseudo HU-scale) should be used
with caution in clinical CBCT applications [6,11,30].
Patient dose
Pauwels et al. [32] estimated the radiation risk for dental CBCT
imaging and concluded the need for justification and optimisation
of CBCT exposure with a specific focus on children. The presented
lifetime attributable radiation induced cancer risk was between 2.7
and 9.8 per million examinations (Fig. 5). For the same exposure pa-
rameters, the organ doses for children are higher compared to adults
due to the decreased attenuation and relatively larger tissue volumes
in the primary beam [33,34]. Furthermore, radiogenic tumour in-
cidence in children is more variable than in adults and depends on
the tumour type, age and gender. For about 25% of cancer types,
including leukaemia and thyroid, skin, breast and brain cancer, chil-
dren are more radiosensitive than adults [35].
However, risk analyses for small patient exposures are not done
in the spirit of international guidelines stating that below 100–
250 mSv there is no evidence for radiation-induced cancer [36,37].
While the linear-no-threshold method for small exposures remains
questioned [38], one has to rely on his/her own ability to justify the
profits and detriments of medical radiation procedures. Even though
the dose and the cancer risk from dental CBCT are almost negligi-
ble for an individual patient, broad use of radiation covering large
populations should not be accepted without proper justification. The
person responsible for CBCT should take into account the medical
history of the patient and decide whether the application of CBCT
is really justified or whether alternative dose sparing methods (pan-
oramic imaging, radiography, MRI, ultrasound) could be used. The
justification step is often the most effective step for patient dose
reduction.
After a thorough justification of the imaging procedure, the CBCT
imaging parameters have to be optimised to minimise the dose while
be adopted according to the patient’s size, although adjustment of
the tube voltage is often limited with dental CBCTs. As with tradi-
tional CT imaging, the dose is proportional to the used kVp according
to the power spectrum law (D ∝ U2.5). For dental imaging, the adult
size variation is rather small, but kVp should always be minimised
for paediatric imaging. The same applies for used mA or mAs, which
are directly proportional to patient dose. Decreasing the mAs has
more influence on dose than on image quality according to the dose-
noise inverse square law (D ∝ 1/σ2); halving the dose only increases
the image noise by 31%. The filtration usually cannot be modified
by the user, although it might have a remarkable impact on dose,
indicating that the manufacturers’ role is essential. Adding a new
0.5 mm copper filter and modulating the tube current on the Promax
3D CBCT scanner (Planmeca, Helsinki, Finland) decreased the ef-
fective dose from 674 μSv to 153 μSv between older and newer
models [39,40].
One of the key factors in CBCT optimisation is the selection of
an appropriate FOV according to clinical indication. Unfortunately
current CBCT devices seldom provide continuous adjustment of the
exposure area. Ludlow et al. [24] published a systematic review in-
cluding 20 dental CBCT articles and new data for 9 units while
Bornstein et al. [41] included 22 articles in their review. Both reviews
classified the doses according to the used FOV. The reviews re-
ported >20 fold difference on the effective doses for the same FOV
category and 10 fold differences between the devices. The mean
effective doses reported by Ludlow et al. were 212 μSv (range
46–1073 μSv) for large (>15 cm) FOVs, 177 μSv (9–560 μSv) for
medium (10–15 cm) FOVs and 84 μSv (5–652 μSv) for small (<10 cm)
FOVs. Effective doses to a child from any protocol were 175 μSv
(13–769 μSv) for large or medium FOVs and 103 μSv (7–521 μSv)
for small FOVs. The doses reviewed by Bornstein et al. were of same
magnitude (Table 2). Ludlow et al. also included mean organ doses
in their review, which are compiled in Table 3. The lens doses do
not contribute to the stochastic radiation risk, but those have been
repeatedly presented due to the radiation induced risk of cata-
racts. The range for lens doses has been reported between 30 and
2300 μSv [32,40,42,43]. However, as the threshold dose for the risk
of developing cataracts is circa 500 mSv [44–46], the lens doses of
dental CBCT imaging are not a significant concern.

Table 3
The mean equivalent doses (μSv) for critical organs with different FOVs and standard imaging settings [24].

FOV* Bone marrow Bone surface Skin Oesophagus Brain Thyroid Salivary glands Remainder

Adult
L 359 1457 189 122 2182 1130 3484 475
M 233 844 163 75 1211 762 3675 442
S 94 299 62 43 211 413 2259 316
Child
L&M 130 448 142 79 962 1621 2918 404
S 60 213 65 34 171 843 2388 336

* L = large (>15 cm), M = medium (10–15 cm), S = small (<10 cm).

856 T. Kiljunen et al./Physica Medica 31 (2015) 844–860
For interventional CBCT procedures the lens doses may be sig-
nificant. However, by proper adjustment of the primary FOV, the
FOV height in particular, and using leaded glasses, the lens doses
can be reduced as much as 90% [43]. In the same study, leaded
glasses did not have a deleterious effect on image quality. More im-
portant for dental CBCT is to adjust the FOV properly to exclude the
thyroid from the primary beam. Using the mean organ doses pre-
sented in Table 3 and the ICRP 103 weighing factors, the contribution
of the thyroid to the effective dose varies between 17–20% for adults
and 30–37% for children, being the highest for large FOV CBCT [36].
Both Koivisto et al. [40] and Morant et al. [42] evaluated the con-
sequences of positioning errors to the thyroid dose and noticed a
2–3 fold increase in thyroid dose for a 3 cm caudal misalignment.
For paediatric patients with shorter distances between the organs
the effect is even more prominent. By using thyroid shields, the
thyroid dose can be reduced 17–42% on children [47] and 20–49%
on adults [48,49]. However, as the thyroid gland should not nor-
mally be in the primary beam during dental CBCT examinations,
thyroid shielding is not mandatory in the EU [23]. Instead, when
large FOV scanners are in clinical use, a decision on the possible value
of thyroid shielding should be made locally with the input of the
medical physics expert, depending on the likelihood of the thyroid
lying in, or close to, the primary beam.
Some devices let the user set the needed resolution by choos-
ing an appropriate voxel size, typically 0.1–0.4 mm [25]. Scan
protocols with the smallest voxel size are associated with the best
spatial resolution but with a higher radiation dose to the patient.
Thus a low resolution option should be preferred where the nature
of the diagnostic task permits it, as proposed by the SEDENTEXT
project.
Dosimetry
The entrance surface dose (ESD), which is routinely used in con-
ventional radiology, is not a valid patient dose quantity due to the
dimensional behaviour of CBCT. The product of the point dose mul-
tiplied by the area of the beam has been a dose index routinely used
in panoramic and cephalometric radiography, thus the dose area
product (DAP) has begun to be the most regular dose quantity pro-
vided by the vendors [50–52]. DAP can readily be measured using
either a calibrated ionisation chamber that integrates the dose across
the primary beam (DAP metre), by measuring the dose and the beam
size at a fixed point, or by using machine output data. Combining
DAP measurements from 41 CBCT units, Holroyd and Walker [53]
proposed a DAP level of 250 mGycm2 for the placement of an implant
in the upper molar region of an adult patient. This level was also
adapted by the European guidelines and proposed to be used as an
achievable dose rather than a diagnostic reference level (DRL) [23].
However, it is only valid for small FOVs, as only 3 out of 21 dental
offices fell below this level in the larger FOV study by Endo et al.
[54].
The use of DAP as a patient dose index is, however, misleading,
as it does not take into account any of the specific geometric ex-
posure issues in dental CBCT. For different CBCT exposure protocols
it is possible to have the exact same DAP value, despite having con-
siderable differences for all exposure factors. For example, Ludlow
[55] presented a three-fold change in effective dose between various
locations of the small FOV with no change in DAP. Pauwels et al.
[56] concluded that it is not possible at this moment to link DAP
values to patient effective doses in general terms, as all of the imaging
factors (e.g. FOV size and positioning, beam spectrum) determine
the actual distribution of dose throughout the patient.
The computed dose index (CTDI) is the international dose as-
sessment metric [57] that is used to quantify the radiation output
of CT scanners, and it has been adopted as an option for determin-
ing the patient dose in CBCT, too. However, the same problems
Figure 6. The measurement for CBCT dose index 1. Index 1 requires point dose mea-
surements along a diameter of the phantom and is calculated as the mean of the
readings. On-axis and off-axis exposures, and full and partial dose distributions are
measured by rotating the phantom in such a way that the isocentre of the X-ray beam
lies on the measuring diameter [23].
present in DAP are of concern for CTDI, while the present measure-
ment methodology with a 10 cm pencil chamber for the cone shaped
beam is also not adequate [58]. As stated by Pauwels et al. [56], dental
CBCT requires a definition of a specific dose index that copes with
different exposure geometries, meaning it should be sensitive to dif-
ferences in FOV diameter, positioning and non-full rotations. The
SEDENTEXCT project recommended the use of two different CBCT
specific dose indexes obtained from measurements using a small
volume dosemeter in a 16 cm Perspex phantom [23]. Index 1 allows
the measurement of an index for on-axis and off-axis exposures,
and full and partial dose distributions simply by rotating the phantom
in such a way that the isocentre of the X-ray beam lies on the mea-
suring diameter, as shown in Fig. 6. Index 2 is only suitable for
symmetrical dose distributions and as such has an analogy to
CTDIvol.
As discussed earlier, the individual effective and organ doses vary
depending on the FOV size, positioning, and the exposure param-
eters. The effective dose from a dental CBCT exposure is mainly
defined by the absorbed dose of the thyroid, remainder tissues (es-
pecially oral mucosa and extra thoracic airways), salivary glands,
and bone marrow [24]. Therefore, from the dosimetric point-of-
view, dental CBCT produces variable radiation exposures to the same
main anatomical region and organs with relatively non-varying at-
tenuation geometry (in the maxillofacial region compared to the
trunk region). Dosimetry in radiology is evolving from modality-
based dose quantities to patient specific organ dose values. In
addition to mammography, where organ doses are already imple-
mented by mean glandular dose readings provided by modern digital
mammography equipment [59–61], dental CBCT could be another
modality driver of automatic organ dosimetry, as the X-ray beam
in dental CBCT is applied to a relatively constant maxillofacial
anatomy with a more certain delineation of exposed organ cover-
age. Morant et al. [62] and Koivisto et al. [40] have already proved
the accuracy of Monte Carlo simulations for the dental organ dose
evaluations. The MC code adapted to dental CBCT could provide an
effective automatic tool for assessing patient specific organ doses
in the future. Figure 7 presents a typical dental CBCT dose distri-
bution (with an 8 × 8 cm2 scan FOV) which was calculated with a
voxel-based 3D Monte Carlo simulation (ImpactMC [63], CT Imaging
GmbH, Erlangen, Germany) applied to a female adult anthropo-
morphic phantom (CIRS ATOM 702-D, Norfolk, USA).
Clinical aspects and guidelines
Basic principles for the use of dental CBCT were published ten
years after these devices were introduced in dentomaxillofacial
imaging by both the American Academy of Oral and Maxillofacial
Radiology and the European Academy of Dental and Maxillofacial
 T. Kiljunen et al./Physica Medica 31 (2015) 844–860
Figure 7. Sagittal (a) and volume rendered (b) 3D dose distributions of a typical dental
CBCT scan (Planmeca Promax 3D Mid with 8 × 8 cm2 scan field of view, 90 kV tube
voltage, 2.5 mm-Al + 0.5 mm-Cu filtration) applied on the female adult anthropo-
morphic phantom (CIRS ATOM 702-D). Dose distribution was calculated with voxel-
based Monte Carlo simulation (ImpactMC) on the phantom CT data.
Radiology (EADMFR) [64,65]. Soon after that evidence-based guide-
lines for the use of CBCT in dental and maxillofacial radiology were
prepared by the SEDENTEXCT Project. This SEDENTEXCT guideline
is officially published as European Guideline: Radiation Protection
No. 172 [23]. The aim of the SEDENTEXCT guideline was to develop
comprehensive, evidence-based guidelines on the use of CBCT in
dentistry, including referral criteria, quality assurance guidelines and
optimisation strategies. These guidelines are directed towards dif-
ferent professional groups involved with CBCT in dental and
maxillofacial imaging, including dental and maxillofacial radiolo-
gists, dentists working in primary care and their assistants,
radiographers or imaging technicians, medical physicists, and equip-
ment manufacturers and suppliers. However, many of the
recommendations made are “Best Practice” rather than carrying any
formal evidence grade. They are based upon the informed judge-
ment of the Guideline Development Panel and it is important that
these Guidelines are reviewed.
From guidelines to clinical use
Although the high spatial resolution and linear accuracy related
to CBCT has been demonstrated in various studies, the actual effect
857
of voxel size on the diagnostic outcome in dental CBCT applica-
tions has not been systematically shown. Validation studies and
recommendations for general protocols in different diagnostic tasks
are needed to develop proper clinical guidelines for CBCT [66]. Horner
et al. [67] recently identified the guidelines on the clinical use of
CBCT in DMFR. In their review article 26 publications were iden-
tified. Less than half of them, i.e. 11, were specifically intended to
provide guidelines on the clinical use of CBCT and contained sec-
tions on selection criteria. They found that reporting on guideline
development is often poorly presented – mainly expert opinions –
and they suggested that guideline development panels should aim
to perform and report their work using the AGREE II [68] instru-
ment as a template to raise standards and avoid the risk of suspicions
of bias [67].
In the SEDENTEXCT guidelines the use of CBCT with develop-
ing dentition, restoring of dentition and surgical applications are
presented [23]. The benefits of the CBCT technique in comparison
to the panoramic technique and the basics as well as common errors
and pitfalls of these techniques have been discussed in a recent
review including the clinical indications for the use of CBCT [2]. As
mentioned previously, in addition to the SEDENTEXCT guidelines,
there are other guidelines available, most of which are from USA,
UK, and European institutions or organisations [67]. Obviously the
continuously increasing research evidence will allow the indica-
tions and benefits of CBCT to be set more precisely in the future
and the guidelines have to be updated.
In addition to the acceptable indication and well performed CBCT
examination, it is also important to notice that high quality eval-
uation of the examination is most important. For non-dento-
alveolar small fields of view (e.g. temporal bone) and all craniofacial
CBCT images (FOV extending beyond the teeth, their supporting
structures, the mandible, including the TMJ, and the maxilla up to
the floor of the nose), clinical evaluation including radiological re-
porting should be made by a specially trained DMF radiologist or
by a medical radiologist [65]. The reviewer of the CBCT examina-
tion – the dental practitioner or radiologist – is obligated to analyse
the entire volume and not just the region of interest, which is time
consuming [64,65]. Also, the cost-effectiveness aspect has been raised
by some researches [69].
Training aspects
EADMFR has prepared a position paper on basic training re-
quirements for the use of dental CBCT by dentists [70]. The aim of
this position paper was to recommend a minimum level and core
content of training for dentists involved in CBCT imaging in dental
practice in Europe. DMFR is a registered specialty in only five Eu-
ropean countries – Finland, Norway, UK, Sweden and Turkey – and
there is obvious need for CBCT training for dentists [70]. However,
these guidelines are suggestions made by an expert group and they
are not legally binding, nor do they replace national regulations. Adibi
et al. [4] have also paid attention to the need for dental educators
to incorporate the most updated information on CBCT technology
into their curricula. They also pointed out the need to conduct studies
meeting methodological standards to demonstrate the diagnostic
efficacy of CBCT in dentistry.
The indications for the use of CBCT imaging in DMFR have been
presented in the SEDENTEXCT guidelines [23]. The ALARA princi-
ple has to be followed, and no routine use of CBCT or other
radiological method is allowed. The referring dentist must supply
sufficient clinical information, including results of earlier exami-
nations to allow the CBCT practitioner to perform the justification
process [65]. Also, the previous images have to be available before
CBCT imaging takes place. Having all this information available, the
use of CBCT can be considered justified if 2D radiographs do not
858 T. Kiljunen et al./Physica Medica 31 (2015) 844–860
or are not expected to answer the diagnostic question and it is ex-
pected that CBCT will add new relevant information.
Quality assurance
Quality assurance (QA) is an important part of the clinical use
of any radiological modality, including CBCT, meant to assure that
the technical specifications and performance level of the scanner
are maintained during its life cycle. The manufacturer typically per-
forms quality assurance procedures during the original installation.
However, the user organisation should also pay attention to the per-
formance of regular QA tests, related to further constancy and
maintenance testing, and ensure that QA phantoms and guide-
lines are in place and implemented during the clinical use of the
device. This approach was also an essential part of the SEDENTEXCT
project, including the formulation of a quality assurance pro-
gramme. From the practical point of view, it should be emphasised
that the staff performing dental imaging must have competence in
dental imaging quality assurance issues [71].
Future aspects
Evolving detectors
Current image detectors in X-ray modalities are energy-
integrating. Thus, for each detector element, they accumulate all the
energy deposited by the x-ray quanta during the acquisition time
period to produce the detected signal charge. No information is ac-
quired on the single detected X-ray quantum energy. This may
change in the future as photon counting detectors (PCD) are de-
veloped further for general radiological use. In a photon counting
detector, information on the detected quantum energy deposi-
tions can be utilised to improve image quality, especially related
to soft-tissue low-contrast resolution and scatter correction, which
are prevailing challenges in dental CBCT imaging. PCDs are also likely
to allow reduced radiation exposures where (detector related) noise
performance is otherwise a limiting factor in the low-dose range
[16].
Iterative reconstruction
As an alternative to traditional FBP methods, iterative recon-
struction methods approach the pursued image data solution in
steps. An iteration step includes comparing the true measured raw-
data projections with forward-projected simulated projections based
on the current image data estimate during the iteration process. The
aim of the iterative method is to reduce the difference between the
simulated raw-data and the real measured raw-data until a certain
level of convergence has been achieved in the image estimate. Thus,
the resulting image estimate corresponds to the final recon-
structed image. Actually, the first CT images back in the 70s were
calculated based on the simple algebraic reconstruction tech-
nique (ART) [30,72]. However, ART is much more computationally
expensive than FBP and therefore the latter became the dominant
method for decades. Recently, iterative methods have raised pop-
ularity since their strengths in improving image quality, especially
related to noise and artefacts, have been proven in the field of MSCT
[73]. Modern iterative methods can model the acquisition chain more
faithfully with respect to noise statistics and systems optics. Al-
though the computational burden remains and even increases (with
more elaborate system and noise statistics modelling), current com-
puter systems have processing power which enables the use of
iterative methods also in routine MSCT clinical settings with rea-
sonable calculation times [16,73]. Iterative methods are likely to
appear soon also in CBCT imaging, where the basic image quality
limitations due to a lower number of projections, X-ray scatter,
detector noise, beam hardening, and truncation could be resolved
by more realistic system and physics modelling in the course of the
reconstruction process.
Image reconstruction and post-processing techniques are im-
portant prerequisites for the overall image quality improvements
in dental CBCT imaging, and for evolving computed tomography tech-
nology in general. Challenges in image reconstruction are typically
related to low photon counts and incomplete projection data with
respect to acquisition angular range, the number of projections, or
truncation. Truncation effects are generated in traditional recon-
struction techniques when the acquired projection data do not cover
the entire cross-section of the attenuating patient object. Thus, the
attenuation measured in certain projections includes signal from
outside the field-of-view, which causes higher calculated voxel values
near the lateral aspects of the reconstructed image volume. Itera-
tive methods may provide a sound solution to the truncation problem
in a form of interior tomography where the limitations of FBP data
consistency requirements can be surpassed [16,74–76].
The radiation exposure to patients can be decreased and spatial
resolution improved by pulsing the X-ray exposure during the gantry
rotation in image acquisition. The evolving iterative image recon-
struction techniques might also require fewer projections as
compressed sensing methods are coming into use. In those tech-
niques, the number of projections might be possible to reduce even
to only a few dozen, with a corresponding reduction in radiation
exposure to the patient [16,77]. This type of X-ray exposure could
be readily implemented with modern dental CBCTs which increas-
ingly utilise pulsed exposures. Overall, iterative reconstruction
methods with more advanced modelling may bring significant im-
provement particularly in the field of CBCT imaging with sparse and
truncated data, high local attenuation from metals and preferably
low photon counts for reduced radiation exposure.
Beam shaping filters
Unlike CBCT systems, the MSCT scanners include pre-patient
beam shaping filters to compensate for patient attenuation at the
detector signal level by spatially shaping the X-ray field intensity
within the scan field of view [78]. The function of a beam shaping
(or bowtie) filter is to allow maximum X-ray intensity to the thick-
est part of a patient, which also attenuates the most x-rays, and to
reduce X-ray intensity in peripheral areas with less attenuation,
thereby reducing X-ray scatter, cupping effects, and the radiation
dose of surface tissues [79]. Such filters could also be beneficial in
CBCT imaging as the larger field-of-views cover a more variable and
cylindrical attenuation geometry, and taking into account that the
prior reduction in the beam intensity also reduces scatter contri-
bution in image reconstruction and total radiation dose to the patient.
Although the reduced scatter and cupping effects could bring ben-
efits, the use of beam shaping filters may also reduce detector
efficiency and low-contrast detectability as the effective mean photon
energy in the attenuated beam is somewhat higher [80]. At the
moment, beam shaping filters are not utilised in the commercial-
ly available dental CBCT scanners.
Tube current modulation
In MSCT, automatic tube current modulation is also used to
optimise the scan exposure, taking into account the patient atten-
uation in different parts of the longitudinal scan range and in different
rotational angles. The purpose of mA-modulation is similar to beam
shaping filters: to equalise the detector signal by pre-patient mod-
ulation of the exposure. Therefore, a higher tube current is used in
angulations where patient attenuation is higher (lateral directions
during the rotation) and a lower tube current where the patient is
thinner (ap/pa direction). A similar approach could also be used in
 T. Kiljunen et al./Physica Medica 31 (2015) 844–860
CBCT to optimise the scan settings. However, this would require tech-
nical developments to add real-time mA-modulation features to the
X-ray generators in CBCT scanners [11].
General future aspects
Collaboration between medical physicists, radiologists and cli-
nicians, radiographers, and engineers is essential for an efficient
optimisation process in modern radiology, also covering the use of
CBCT [81,82]. If and when the image quality can be improved by
various developments in image acquisition technology, image post-
processing, and reconstruction methods, CBCT technology is likely
to gain ever increasing popularity in dental applications, but also
in other fields of medical imaging, e.g. in interventional and intra-
operative imaging [82]. CT imaging has undergone huge
developments from the first scanners in the 1970s to this day when
CBCT is an essential and growing technological branch in the overall
field of computed tomography. In the future, this rapid and ongoing
development is likely to bring various new clinical applications which
may revolutionise the entire field of medical imaging once
again.
Acknowledgements
The authors would like to thank the Radiation and Nuclear Safety
Authority of Finland (STUK) and Alexey Sofiev (HUS Medical Imaging
Center) for the simulation facilities and assistance in the MC cal-
culations. The authors also would like to thank Alexander Meaney
(HUS Medical Imaging Center) for the proofreading of the
manuscript.
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