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Continuing Dental Education

Diagnosis and Treatment Planning

Using CBCT Technology
Curtis E. Jansen, DDS

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2 CDEWORLD.COM AUGUST 2016


Diagnosis and Treatment Planning
Using CBCT Technology
Curtis E. Jansen, DDS
ABSTRACT
Cone-beam computed tomography
(CBCT), which uses a fraction of the
radiation dose of medical CT, offers general
practitioners many advantages, some of
which they may be unaware. Its use for
diagnosis and treatment planning in tooth
removal, implant, endodontic, orthodontic,
temporomandibular joint disorder, and
obstructive airway cases is well known.
But general practitioners should know
that beyond diagnosing fractures, tooth/
root anomalies, and assessing hard tissue
before and after implant placement, this
extraoral 3-dimensional technology can be
used to perform more common diagnostic
tasks, such as panoramic x-rays and
bitewings. When used in place of intraoral
sensors, it spares patients the discomfort
of the rigid sensor. CBCT can also be used
to help clinicians create digital versions of
their conventional impressions and poured
models for digital transmission to other
dental team members. For practitioners
who place implants—as an ever-increasing
number are—CBCT provides the ability
to do “top-down treatment planning” to
offer patients restorative-based implant
placement.
LEARNING OBJECTIVES
• Discuss the primary uses of CBCT
for diagnostic purposes in a general
dental practice.
• Explain how CBCT is used for
implant treatment planning.
• Understand the advantages of CBCT
as part of the digital workflow.
• Address prospective concerns about
radiation exposure.
VOLUME 3 • NUMBER 49
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any general practitioners believe that the needs of their
practices do not justify the purchase of a cone-beam
computed tom­ography (CBCT) system. Beyond the
financial cost, they may be concerned about the risk it poses
to patients in terms of radiation exposure. This article aims to
demonstrate the significant advantages CBCT offers general
practitioners who add it to their armamentarium, including us-
ing the technology to generate and incorporate the vital patient
information contained in its digital imaging and communications
in medicine (DICOM) files, which can be merged with stereolitho-
graphic (STL) files to create multiple digital workflows.
It will especially emphasize how CBCT, for the first time, offers
the growing number of general practitioners who place implants
the ability to offer their patients restorative-based implant place-
ment. Finally, this article will put the radiation risks, which are
minimal—especially when compared to medical CT and even
everyday environmental exposure—into perspective, and explain
strategies for reducing that dosage further still with collimators,
low-dose settings, and confined exposure based on scout films.
USING CBCT DIAGNOSIS
General practitioners who associate CBCT with—and perhaps
even use it for—root canal, tooth removal, temporomandibular
joint disorder (TMJ), implant placement, obstructive airway, and
orthodontic diagnosis and treatment planning may not understand
how this technology can serve their practice needs in other ways.
Even practitioners who do not place many implants or see many
endodontic patients can use CBCT technology more readily in
their offices to perform common diagnostic tasks in place of
traditional methods. This can be advantageous for many patients.
Because, like panoramic x-rays, CBCT data is captured extra-
orally, patients may be either standing or seated while a scan is
being performed, depending on what is more comfortable. CBCT
data capture is especially popular with patients who find intraoral
sensor placement uncomfortable; this is particularly the case with
children and others who cannot tolerate having anything placed in
CDEWORLD.COM 3
 1
Fig 1. Traditional intraoral bitewing showing limited field of view (left) compared to the expanded view possible using the CBCT (right).
their mouth, whether because of anatomic limita-
tions, a sensitive gag reflex, or other reasons.
CBCT can also be used in this same way to
perform an even more common task, bitewing
images, which are clinically indicated as often as
every 18 to 24 months. Hygiene patients whose
films require updating clearly appreciate this more
“patient-friendly” approach. Given that these films,
which are usually performed intraorally, are often
taken on an hourly basis in the typical general
practice, the technology can be well utilized while
also increasing comfort and satisfaction among
patients. In addition, because of the expanded
field of view that is possible to achieve with these
extraoral CBCT images, they can often be more
diagnostically valuable than images produced with
an intraoral sensor (Figure 1).
DIGITIZING TRADITIONAL
IMPRESSIONS AND MODELS
CBCT is not for every situation. It is not intended
to supplant intraoral radiography—which may be
either traditional or digital—and should only be
used in addition to those technologies when the
2-dimensional data gathered using them dictates
the need for 3D evaluation.1 Indeed, although
CBCT scans can provide invaluable images of
the maxilla and mandible, the technology has
some limitations when it comes to assessing
4 CDEWORLD.COM
other anatomic structures, including the tooth
surface.2 While intraoral scanning is making
more and more inroads into general practices,
there are many clinicians who are reluctant, for
many reasons, to convert their practices to a
completely digital workflow. For this reason,
general practitioners who are not currently using
intraoral scanners or taking digital impressions
can benefit from CBCT ownership by using the
technology to create digital versions of tradi-
tional impressions or poured models.
Typically, a traditional impression is made and
sent to a laboratory, where it is often scanned
using 3-dimensional (3D) technology, then de-
signed and milled. Clinicians who have CBCT
technology in the office can generate digital ver-
sions of traditional impressions or poured mod-
els, which then can be electronically sent to their
laboratory or CAD/CAM system. Workflows for
restorations, surgical templates, model fabrica-
tion, model storage, and other procedures can
then be carried out. These now digital versions
can be sent to a multitude of partners for many
different types of workflows without the need
for intraoral scanning.
With CBCT, clinicians can otherwise enjoy
all the benefits of digital radiography, including
the ability to enhance images and easily share
AUGUST 2016
 2
Fig 2. Example of using digital workflow to import restoration data and plan implant treatment.
the digital files with other dental team members.
Furthermore, the DICOM files generated by
CBCT can be used with a multitude of different
software programs and merged with the com-
monly used STL files. In this way, digital images
can be “pinned” with DICOM data. These can
then be used for electronic transmission to their
laboratory or CAD/CAM system, imported into
their implant planning software, or otherwise
placed into the digital workflow for purposes
of diagnosis, treatment, electronic transmission,
and communication.
TREATMENT PLANNING
From the author’s perspective, the real beauty of
this technology is how it can completely transform
implant treatment planning from a “bottom up”
undertaking, where the clinician must restrict the
plan to existing bone, to a “top down” approach
that focuses first on ideal tooth placement—ie,
“restorative-based” implant placement.
Although workflows can differ, in many im-
plant cases, typically a CBCT scan of the area of
concern is made. Then, with an intraoral scan or
digital version of a model or impression, practi-
tioners begin working with the design software
of their particular intraoral scan or CBCT system
(Figure 2 and Figure 3). The edentulous area or
area where teeth are to be extracted can then
VOLUME 3 • NUMBER 49
be thoroughly evaluated. Ideal restorations can
then be pre-visualized or treatment planned from
both an esthetic and functional standpoint. Once
this is done, the intraoral information is pinned
or overlaid onto the CBCT. The restoration
or restorations can then be imported into the
mix, toggled on or off—ie, shown or not—and
the underlying bone evaluated.3 If the ideally
designed restorations cannot be supported by
available bone, additional surgical procedures,
such as grafting, may be indicated. Implants
can be placed in 3D in the ideal location for
esthetics and function, allowing the practitio-
ner to visualize where osseous grafting may be
needed to achieve that positioning. Or implants
can be virtually positioned based on the avail-
able anatomy, respecting anatomical structures
such as the inferior alveolar nerve, maxillary
sinus, and the buccal/lingual plates (Figure 4
and Figure 5). This restorative-driven implant
placement workflow allows general practitioners
to see what may be needed to augment bone to
support ideal restorations. This may alert them
to the need for additional surgical procedures or
to open a dialogue with surgical team members.
If the intraoral scan data is not available, once
the CBCT is acquired, some systems have soft-
ware that uses the tooth library to place the teeth
ideally in terms of function, form, and esthetics.
CDEWORLD.COM 5

3
Fig 3. Example of using digital workflow to import restoration
data and plan implant treatment.
In this way, the first priority is always determin-
ing how best to place the implant according to
the restoration, not where the bone is; but it also
provides advanced notice when other procedures
are needed to achieve that ideal.
Armed with this information, the clinician
can inform the patient that the ideal restoration
may involve additional time or cost, and pos-
sibly arrive at a compromise solution—eg, in
tooth position or esthetics—because of patient
considerations such as finances or other issues.
An additional advantage is that other mem-
bers of the dental team can quickly and easily
evaluate the plan via “the cloud” or electronic
transmission of the DICOM file and, once it is
approved, the dental team may proceed using
this information to create precise surgical guides
that consider both hard tissue and optimal res-
toration location. Using both CBCT data and
intraoral scan impression or model scans, the
restorations can be pre-visualized and the im-
plants can be placed accordingly.
6 CDEWORLD.COM
RADIATION CONCERNS MEDICAL
VS DENTAL CT
Much of the concern about radiation exposure
from dental imaging, including CBCT, stems from
the much higher dosage generated by medical
CT devices, which function differently. Medical
CT devices use a beam of radiation that rotates
around a patient multiple times, depending upon
the area being scanned, thus emitting a higher
dose of radiation; they also create slices, which
are then reformatted into images In contrast,
advanced dental CBCT can achieve a complete
scan of the desired part of an individual’s jaw
with a single quick beam that creates an image,
which is then reformatted into slices.4 CBCT uses
a cone-shaped beam of radiation to acquire data in
a single 360° rotation,3 thus revealing the internal
architecture of an object.5
Compared to conventional medical CT scan-
ning, an advantage of CBCT relates to x-ray beam
limitation (collimation of the primary beam) and
significant dose reduction. The dose for a con-
ventional CT, measured in microsieverts (1 μSv
= 0.000001 Sv) ranges from 100 μSv to 300 μSv
for the maxilla and 200 μSv to 500 μSv for the
mandible, whereas CBCT ranges from 34 μSv
to 102 μSv for both the maxilla and mandible
together.5 The use of a thyroid collar and patient
positioning modifications can reduce dosages by
up to 40%. (For comparison’s sake, one recent
study found that the dosing of digital panoramic
units varied from 8.9 to 37.8 μSv depending on the
type of unit used and other factors.6) In addition,
with CBCT, rapid scan times (10 to 70 seconds)5
make this method of imaging comfortable for the
patient; in contrast, medical CT scans can take 2
minutes or more to complete.
PLACING RADIATION CONCERNS IN
PERSPECTIVE
Both dentists and their patients need to under-
stand that radiation exposure is part of daily life
apart from its medical and dental applications.
AUGUST 2016
 4 5
Fig 4. Implants and abutments placed, with the model turned off and the CBCT in view. Fig 5. Implants and abutments in place with pinned
model scan and CBCT off.
Humans are exposed to radiation from natural
materials in the earth, radon in the air, cosmic
exposure from outer space, and as a result of the
food and water they consume. The average dose
of radiation, measured in millisieverts (1 mSv =
0.001 Sv), per person, per year from all sources is
about 6.2 mSv, and international standards allow
exposure to as much as 50 mSv a year for those
who work with and around radioactive material.7
The National Council on Radiation Pro­tection
and Measurements places the effective radiation
dose equivalent from all sources in the United
States at 3.6 mSv per year, of which 3 mSv is
from natural sources. And of that remaining
0.6%—most of which is medically related—only
1% is dental.8
MINIMIZING EXPOSURE
Nevertheless, dentists should use radiographic
procedures that increase patients’ radiation dose
only when necessary for diagnosis and treatment
and should apply the ALARA principle—as low
as reasonably achievable—to reduce radiation
exposure to their patients by: “determining the
need for and type of radiographs to take; using
‘best practices’ during imaging, including the
VOLUME 3 • NUMBER 49
application of quality control procedures; and in-
terpreting the images completely and accurately.”9
They can further minimize dose reduction
by adjusting the exposure factors and limiting
the field of view to the smallest dimensions
consistent with the clinical situation.1 This can
be achieved using a scout film—ie, a prelimi-
nary film, low-dose image, taken of a region to
serve as a baseline before a definitive imaging
study—before using full-volume CBCT, which
emits a higher amount of radiation by volume
during implant placement. Therefore, when the
area is, for example, restricted to the upper left
quadrant, the practitioner can use the collimator
or dial down the volume.
WORTH THE INVESTMENT?
It is this author’s contention that, in terms of mak-
ing an investment in new technology, general
practitioners who purchase a system designed
to meet unique practice needs and maximize
its utilization can easily recoup the investment
through appropriate frequent use for panoramic
and bitewing images while expanding their scope
of practice and increasing patient satisfaction. They
may even become a resource for dental practices
in their area. In addition, practitioners who have
CDEWORLD.COM 7
 CBCT technology in their offices may not need
to purchase intraoral scanners, as they can use the
CBCT to scan impressions or models and send
them to the laboratory for restoration fabrication.
As noted above, implant placement can be
immeasurably improved using CBCT, enabling
the practitioner to produce overlays of the miss-
ing teeth where the bone is and then, using the
captured information about the edentulous area,
they can use the software that comes with the
CBCT, the DICOM data, and imported STL
files and use the tooth library to virtually place
the implants and generate surgical guides.
Practitioners considering purchasing the tech-
nology should keep their own needs in mind at
all times. CBCT is available in a wide variety
of investment levels.
Finally, from a medical–legal standpoint,
practitioners are responsible for evaluating the
entire scanned area, even though much of it may
lie outside the area treated in the dental practice.
There are liability issues that have been raised
in the courts holding dentists responsible for
tumors and other abnormal findings that were
not identified following a CBCT scan. With that
in mind, some of the companies offering CBCT
units have developed limited scan units that tar-
get the area typically treated in dentistry. These
may limit the potential liability of the practi-
tioner if something is present on a scan that is
not identified and reported to the patient. It is
advised that practitioners review entire scans;
if something does appear that looks abnormal,
the patient should be referred to the appropriate
medical practitioner for further evaluation.
CONCLUSION
Given the theoretical risks of any technology that
could harm patients, dentists should be aware of
when CBCT is justified despite the radiation ex-
posure. They should also know about the many
ways CBCT aids diagnosis and treatment when
not used directly on patients, such as when used to
digitize traditional impressions or poured models.
8 CDEWORLD.COM
In short, they should not deny their patients
or their dental team the significant benefits pro-
vided by investing in CBCT without first fully
understanding what this technology has to offer
in terms of diagnosis, treatment, convenience,
and patient satisfaction.
REFERENCES
1. Bornstein MM, Scarfe WC, Vaughn VM, Jacobs R. Cone
beam computed tomography in implant dentistry: a systematic
review focusing on guidelines, indications, and radiation dose
risks. Int J Oral Maxillofac Implants. 2014;29 Suppl:55-77.
2. Ganz SD. The next evolution in CBCT: combining digital
technologies. Inside Dentistry. 2013;9(2):116-118.
3. Zheng QH, Wang Y, Zhou XD, et al. A cone-beam com-
puted tomography study of maxillary first permanent molar
root and canal morphology in a Chinese population. J Endod.
2010;36(9):1480-1484.
4. Gutierrez N. Discovering a new dimension in dental care.
UT Health Sciences Center website. http://uthscsa.edu/mis-
sion/article.asp?id=259. August 2004. Accessed June 24, 2014.
5. Shenoi RP, Ghule HM. CBVT analysis of canal con-
figuration of the mesio-buccal root of maxillary first per-
manent molar teeth: An in vitro study. Contemp Clin Dent.
2012;3(3):277-281.
6. Lee G, Kim J, Seo Y, Kim J. Effective dose from direct
and indirect digital panoramic units. Imaging Sci Dent.
2013;43(2):77-84.
7. Radiation dose chart. American Nuclear Society website.
www.new.ans.org/pi/resources/dosechart/msv.php. Accessed
June 4, 2014.
8. Meyer E. Living in a radioactive world. Inside Dental
Assisting. 2013;9(2). www.dentalaegis.com/ida/2013/04/
living-in-a-radioactive-world. Accessed June 24, 2014.
9. Dental x-ray talking points. American Dental Association
website. www.ada.org/EPUBS/assets/ememo/NYT-Cone-
Beam-Talking-Points.pdf. Nov. 23, 2010. Accessed June 24,
2014.
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Diagnosis and Treatment Planning Using CBCT Technology

Curtis E. Jansen, DDS

1.  Like panoramic x-rays, cone-beam computed tomography 6. CBCT radiation dose for the maxilla and mandible
(CBCT) data is captured: together ranges from:
A. in stereolithographic (STL) files. A. 34 μSv to 102 μSv.
B. intraorally. B. 54 μSv to 72 μSv.
C. extraorally. C. 102 μSv to 304 μSv.
D. while the patient is lying down. D. 204 μSv to 502 μSv.
2. According to this article, bitewing images are clinically 7. The use of a thyroid collar and patient positioning
indicated: modifications can reduce dosages by up to:
A. every 6 to 12 months. B. every 18 to 24 months. A. 20%. B. 40%.
C. every 24 to 36 months. D. very rarely. C. 60%. D. 80%.
3. Extraoral CBCT images can often be more diagnostically 8. Humans are exposed to radiation from:
valuable than images produced with an intraoral sensor A. natural materials in the earth.
because of the: B. radon in the air.
A. patient-friendly approach. C. food and water they consume.
B. expanded field of view. D. All of the above
C. ability to digitalize.
D. availability of a tooth library. 9. A preliminary film, low-dose image, taken of a region
to serve as a baseline before a definitive imaging
4. CBCT is: study is a:
A. ideal for every oral healthcare situation. A. vector film. B. STL film.
B. superior for assessing tooth surfaces. C. scout film. D. “pinned” film.
C. not appropriate for assessing temporomandibular disorder.
D. not intended to supplant intraoral radiography. 10. CBCT units with limited scan units that target the
area typically treated in dentistry may:
5. CBCT uses a cone-shaped beam of radiation to: A. be more comfortable for the patient.
A. acquire data in a single 360° rotation. B. facilitate electronic transmission.
B. reveal the external architecture of an object. C. limit the potential liability of the practitioner.
C. rotate around the patient multiple times. D. improve pre-visualization.
D. All of the above

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