SPECIALISED RADIOGRAPHIC

TECHNIQUES
OUTLINE

≥ Digital imaging
≥ Ultrasound
≥ Computed Tomography
≥ Cone beam Computed tomography
≥ Magnetic resonance imaging
≥ Radioisotope imaging
CONE BEAM COMPUTED
TOMOGRAPHY
 Dental volumetric tomography,
Cone-beam volumetric tomography,
Dental computed tomography, and
Cone-beam imaging.

 Cone-beam computed tomography because it is a digital analog of

film tomography in a more exact way than is traditional computed
tomography (CT), the x-ray is either conical or pyramidal.

 The principal feature of CBCT is that multiple planar projections

are acquired by rotational scan to produce a volumetric dataset from
which inter-relational images can be generated.
 Principles of Cone-Beam Computed Tomography
 Cone-beam scanners use a two-dimensional digital array providing an area
detector rather than a linear detector as in CT.

 This is combined with a three-dimensional (3D) x-ray beam with circular

collimation so that the resultant beam is in the shape of a cone, hence the
name "cone beam."

 Because the exposure incorporates the entire region of interest (ROI), only
one rotational scan of the gantry is necessary to acquire enough data for
image reconstruction.
There are four components to CBCT image acquisition:
1. X-ray generation
2. Image detection system
3. Image reconstruction
4. Image display

Voxel are isotrophic in CBCT whereas in CT they are anisotrophic

X-ray Generator
 Kvp:80-120

 Focal spot size: 0.5 to 0.8mm same as CT

 Tube current :1-20mA (much lower heat production than CT)

 Stationary anode.

 Pulsed X-ray beam that co-insides with detector activation, which

a. Reduces total scan time,
b. Low heat production and
c. Reduced patient exposure.
Field of view(FOV):
 Field of view is the term used to refer to the scan volume of a particular CBCT
unit.

 The dimensions of the field of view or scan volume able to be covered are
primarily dependent on the
a. detector size and shape,
b. beam projection geometry, and
c. the ability to collimate the beam which limits x-radiation exposure to the
Region Of Interest (ROI).

 The availability of different FOVs makes it possible to select the most

appropriate FOV for a specific application.

 Depending on different sizes of FOVs, CBCT units are classified as,

i. Small: scan either sextant, quadrant or single jaw
ii. Medium: both jaws
iii. Large volume units: entire head.
Image detection:
 All CBCT systems utilizes an area detector to capture and record images.

 Uses flat panel detectors(FPD) comprising a large area pixel array of

hydrogenated amorphous silicon thin film transistors.

 X-rays are detected indirectly by a scintillator such as thallium-doped

cesium iodide or terbium-activated gadolinium oxysulfide which covers the
FPD silicon matrix.

 This scintillator converts the x-rays to visible light, by photo-diodes that

produce an electric charge proportional to incident X-ray energy.

 For each basis image, the detector records incident X-ray photons, collects a
charge, and sends a signal to the computer.

 The speed with which a detector performs this acquisition is called ―frame
rate‖
Image reconstruction:
The reconstruction process consists of two stages:
 Acquisition stage. This stage is performed at the acquisition computer. Once
the multiple planar projection images are acquired, these images must be
corrected by for inherent pixel imperfections and uneven exposure. Image
calibration should be performed routinely to remove these defects.

 Reconstruction stage. The remaining data-processing steps are performed on

the reconstruction computer. The corrected images are converted into a special
representation called a sinogram, a composite image developed from extracting
a row of pixels from each projection image.

 The sinogram is then reconstructed with a filtered back-projection algorithm

for CBCT-acquired volumetric data called the Feldkamp algorithm.
Image Display:
 The volumetric data set is a compilation of all available pixels and, for
most CBCT devices, is presented to the clinician on screen as secondary
reconstructed images in three orthogonal planes (axial, sagittal, and
coronal), usually at a thickness defaulted to the native resolution.
Advantages of CBCT
1. Lower effective radiation dose
2. Lower cost than conventional CT.
3. Fewer space requirement
4. Easy image acquisition
5. Higher image accuracy and hard tissue definition compared to CT
6. Interactive display modes such as multi-planar reconstruction that are applicable
to maxillofacial imaging.
7. Interactive treatment planning and computer aided surgeries.

Disadvantages:
i. Higher radiation dose than 2D imaging
ii. Inability to accurately represent the internal structure of the soft tissues and their
lesions
iii. Limited correlation with HUs for standardized quantification of bone density.
iv. Various metal artifacts, which interfere with diagnostic process.
Specific Applications in Dentistry

 CBCT technology has had a substantial impact on maxillofacial imaging.

 It has been applied to diagnosis in all areas of dentistry and is now
expanding into treatment applications.

a. Implant Site Assessment

 Bone width and height
 Angulation and location of implant
b. Orthodontics And Three-dimensional Cephalometry
 CBCT imaging used
 diagnosis, assessment, and analysis of maxillofacial orthodontic and orthopedic
anomalies,
 tooth inclination and torque, root resorption, and
 available alveolar bone width for
buccolingual movement of teeth can be obtained.
c. Localization Of The Inferior Alveolar Canal
 Thus accurate assessment of the position of the canal in relation to the impacted
third molar may reduce injuries to this nerve.

d. Temporomandibular Joint
 CBCT provides multiplanar and potentially 3D images of the condyle and surrounding
structures to facilitate analysis and diagnosis of bone morphologic features, joint space and
dynamic function.

 Imaging can depict the features of degenerative joint disease, developmental anomalies of the
condyle, ankylosis, and rheumatoid arthritic disease.
e. Conditions Of The Maxillofacial Complex like any pathologies and anomalies.
f. In Endodontics, root canal morphology, periapical pathosis and pre-,intra- and post
operative assessment and root resorption evaluations can be done.

g. In Periodontics, assessment of marginal bone contours and 3D defects, especially

furcations and infrabony defects and buccal and lingual surface defects are better
visualized.
h. Cysts and tumor of jaws
MAGNETIC RESONANCE IMAGING
≥ The original name for the
medical technology is nuclear
magnetic resonance imaging
(NMRI)

≥ Domadian (1972) and Lautrbere

(1973) indicated the potential of
NMR to obtain images of the
intact human body.
Basic Physics of MRI

 Magnetic Resonance Imaging (MRI) uses

nonionizing radiation from the radiofrequency
(RF) band of the electromagnetic spectrum.
 MRI is based on the magnetic properties of an
atom.
 When an external magnetic field is applied, two
states are possible: spin-up, which parallels the
external magnetic field, and spin-down, which is
antiparallel with the field.
 The transition from one energy level to another is
called ―Resonance.‖
 The axes of spinning protons actually oscillate or
wobble with a slight tilt from a position absolutely
parallel with the flux of the external magnet. This
tilting or wobbling, called ―Precession‖
 The rate or frequency of precession is called the
resonant or Larmour frequency.
 The magnetic field strengths used for MR imaging
range from 0.1 to 4.0T.
 The energy loss is detected as a signal, which is called free induction decay (FID).

 A mathematical technique called the Fourier transform converts the signal intensity
i.e transforming the oscillating FID signal to a pulse of energy (current), which is
displayed as MR image.

 Tl-weighted images are called fat images because fat has the shortest Tl relaxation
time and the highest signal relative to other tissues and thus appears bright in the
image. Mostly used for location of anatomical areas.

 T2-weighted images are called water images because water has the longest T2
relaxation time and thus appears bright in the image. Mostly used for assessment of
pathological or inflammatory changes.

MR Contrast Media:
≥ Gadolinium complexes
Applications in Dentistry.
a. TMJ: Internal disk derangement, Septic arthritis and articular disc
perforations of TMJ.
b. Salivary gland tumors and diseases and cystic lesions.
c. Malignant tumours: diagnosis, staging and the extent of spread of
carcinomas of head and neck region.
d. Maxillary sinus: diseases and tumours of maxillary sinus and sinusitis,
e. Benign tumours like ameloblatoma, myxoma, hemangioma, lympangiomas,
neurofibrokas.
f. Immunological diseases like Systemic diseases like Multiple sclerosis (MS)
Advantages:
 Ionizing radiation is not used

 No adverse effects have yet been demonstrated.

 Image manipulation available.

 High-resolution images can be reconstructed in all planes (using 3D

techniques).

 Excellent differentiation between different soft tissues is possible and

between normal and abnormal tissues enabling useful differentiation
between benign and malignant disease and between recurrence and
postoperative effects.

 Useful in determining intramedullary spread and rapid localization of

intracranial pathology.

 No streaking artifacts.
Disadvantages:
≥ Bone does not give MRI signal, a signal is only obtainable from bone
marrow.

≥ Scanning time can be long.

≥ It is contraindicated in patients with certain types of surgical clips, cardiac

pacemakers, cochlear implants and in first trimester of pregnancy.

≥ Equipment tends to be claustrophobic and noisy.

≥ Metal object need to be replaced by non-ferromagnetic alternatives

≥ Very expensive and Facilities are not widely available.

RADIONUCLIDE IMAGING
Nuclear Medicine
≥ Nuclear medicine, also known as radionuclide imaging,
nuclear scintigraphy or simply ―nue med‖ or ―nm‖ is a
radiological modality.

≥ Radionuclide imaging (or functional imaging) provides the

only means of assessing physiologic changes that is a direct
result of biochemical alterations.
Working principle:
≥ This is done by injecting certain very low-level radioactive chemicals
called radionuclides, radiopharmaceuticals or radiotracers compounds
into the patient that have an affinity for particular tissues – so called
target tissues.

≥ The radioactive compounds become concentrated in the target tissue

and they emits radiation which are then detected, and imaged, usually
by using a gamma camera.

≥ Route of administration by oral, I.V and intrathecally.

Radiopharmaceuticals :
≥ Pyrophosphate and methylene disphosphonate (MDP) compounds are used
for localization in the skeleton.

≥ Sodium iodine for the thyroid gland

≥ Xenon and/or krypton gas, for pulmonary studies and

≥ Sulfur colloid for liver, spleen and bone marrow.

Several radioisotopes are used in conventional nuclear medicine, depending on

the organ or tissue under investigations.
Imaging equipment :
≥ The radiation emitted from the radionuclide inside the body is
usually detected using a gamma camera.
Detection of gamma rays by Gamma camera
Gamma rays

Picked up by the Sodium Iodide crystal Detectors

Photo multiplier tube of Gamma Camera

Fluorescence light change into electrical signal

This signal is converted into radionuclide image in the computer monitor

Recorded as scintigraphy
≥ The electronics used for planar nuclear imaging include a
photomultiplier tube, a pre-amplifier and associated computer
systems.
≥ These components facilitate the acquisition and processing of
incoming data as well as image display and image analysis.
≥ Small portable nuclear detection imaging systems are also
available for use in the oral cavity.
≥ Small probes containing a cadmium telluride crystal have been
used to image areas of the alveolar processes in laboratory and
clinical studies of periodontitis.
 Advantages:
 Target tissue function is investigated

 Detection of lesion at early stage less than 5% of

demineralization of bone is adequate.

Disadvantages:

 Poor image resolution — often only minimal information is

obtained on target tissue anatomy
 The radiation dose to the whole body can be relatively high
 Images are not usually disease-specific
 Difficult to localize exact anatomical site of source of emissions
 Some investigations take several hours
 Facilities are not widely available
Indications:
 Tumour staging — the assessment of the sites and extent of bone
metastases

 Investigation of salivary gland function and thyroid functions.

 Evaluation and viability of bone grafts

 Temporo-mandibular changes and assessment of continued growth in

condylar hyperplasia

 Osteomyelities and metabolic bone disorders.

 Brain scans and assessment of a breakdown of the blood-brain barrier

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