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Dentomaxillofacial Radiology (2021) 50, 20200133

© 2021 The Authors. Published by the British Institute of Radiology

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DMFR 50th Anniversary: Review Article

The way we were (and how we got here): fifty years of

technology changes in dental and maxillofacial radiology
Roberto Molteni

Localita` Lubiara 119, Caprino Veronese VR, Italy

The history of the last 50 years (1970–2020) of technological changes and progresses for
equipment and procedures in dental and maxillofacial radiology is related from the insider
perspec-tive of an industrial physicist and technologist who has been instrumental at innovating
and developing medical equipment in different parts of the world. The onset and improvement
of all major categories of dental and maxillofacial radiographic equipment is presented, from
the standpoint of their practical acceptance and impact among common dentists and
maxillofacial radiologists: X-ray sources and detectors for intraoral radiography, and panoramic
systems, both film-based and digital (including photo-stimulated phosphor plates); and cone
beam CT.
Dentomaxillofacial Radiology (2021) 50, 20200133. doi: 10.1259/dmfr.20200133

Cite this article as: Molteni R. The way we were (and how we got here): fifty years of tech-
nology changes in dental and maxillofacial radiology. Dentomaxillofac Radiol 2021; 50:
20200133.

Keywords: Radiology History; Dentistry History; Digital Imaging; Dental Radiology; With e
Beam CT

Introduction

“According to laws of aerodynamics, the bumble bee
cannot fly; its body is too heavy for its wings and that's
the simple reason why. But the bumble bee doesn't
know this fact, and so it flies anyway for all to see.” (ACE
Waldrop) I have repeatedly encountered examples of
this fake scientific aphorism (sometimes apocryphally
attributed to Albert Einstein) during my professional life,
and dental and maxillofacial radiology is a prom-inent
area to demonstrate it.
More than half a century ago, in August 1968, the
International Association of Dento-Maxillo-Facial
Radiology was founded at the conclusion of its first
congress in Santiago, Chile, hosted by Professor
Gregorio Faivovich.
Even for those who were already adults at that time
(and more so for those who were not yet born!), it is
difficult now to realize or remember how different
everyday life was back then, as far as requisite gadgets
go. We did not have Internet and electronic mail, SMS, Whatsapp
Correspondence to: Dr Roberto Molteni, E-mail: robertodocmolteni@yahoo. especially if such information was not published on
com
Received 03 April 2020; revised April 26, 2020; accepted 27 April 2020 excursus about the technology changes of dental and
and socials, word processors, “smart devices,” tablets,
cellular phones, personal computers, digital cameras,
microprocessors, solid-state digital memories (RAM),
electronic pocket calculators, fax machines, flat LCD
color screens (we had only bulky monochromatic CRT
terminals, without any graphic capability, and they were
for large centralized industrial or scientific computers,
not for personal use). Storage of digital data (for big
computers) would occur through magnetic tape,
perforated paper tape, or punched cards. Even
photocopying was a still-immature awkward business,
with ammonia-stinking paper that would fade away after
some time; reports were handwritten and handed over
to a secretary who would typewrite them in the required
number of copies using carbon paper on tissue paper sheets.
Consequently, retrieving documents and data from
the current XXI century, when a huge amount of
information in standard digital formats is available
through the Internet, or from various storage media, is
immensely less challenging than for the XX century—
easily available public media. In writing this insider
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maxillofacial radiology in the last 50 years, I had to rely

largely on my own memory (with the help of a few other
old-timers), and on a few scraps of scattered documents
in my possession that have not been dispersed with the
continuous changes and vicissitudes of the dental and
radiological industry. My tale is not focused on theoret-
ical scientific advancements as reported in professional
papers and discussed in academia (which may precede
mass adoption by many years), but rather about the
practical conditions experienced by the ordinary dentist
and maxillofacial radiologist. The year of introduction of
commercially available equipment reported here are
often approximate, because there may not be a precise
and univocal date: prototypes or pre-production units
are installed at pilot sites in advance of regular
production, and frequently companies start
commercialization of a new product only in the country
of their domestic market, before making it available to
the international market. The years indicated here refer
to when the products are generally available in the international market.
For almost four decades, I have been a manager of
R&D and innovation for several manufacturers of
radiographic and electromedical equipment, and I have
witnessed that the scenario of technologies and
procedures for dental and maxillofacial radiology has
also changed enormously (albeit perhaps not so much
as for the paraphernalia of daily life).

X-ray sources for dental intraoral radiography

After World War II, the dental profession became
accustomed to the “monoblock” (or “tubehead”) design
of dental intra oral X-ray sources (ie with X-ray tube,
high-voltage transformers, collimation, and other
necessary components all enclosed in a sealed metallic
housing: no more exposed high voltage wires, a
significant cause of fatal accident in the prior decades),
all suspended from the wall with a pantographic arm
(Figure 1). The control was an electromechanical timer.
Initially, the high-voltage was around 50 kV or even 45
kV, just adequate for proper dental imaging, especially
with alternate current (AC) anodic power supply. In the
70's and 80's, induced by changes in regulations and
standards under the pressure from professional opinion-
leading radiologists (not from the dentists themselves,
who were and are the overwhelming current clientele),
the manufacturers gradually increased the high voltage
to 65 kV and eventually 70 kV in new products. Not all
dentists were completely happy of the change, longing
for the sharper image contrast associated with
moderately low kV, as opposed to the “softer” images
associated with higher kV and favored by trained
(general) radiologists. The control became an electronic timer. [Note *: a cone (or coning device) combines in a
Various studies published in the scientific literature
over several decades have claimed and proven that any
high-voltage in the 50–90 kV range is adequate for
dental intraoral imaging. There is a broad optimum of X-
ray hardness (ie kV) at 70 kV for best image
Figure 1 The tubehead of Oralix 50 by Philips, a popular dental
intraoral X-ray of the '70s (50 kV AC, short pointed cone). AC,
alterna-nate current.
quality—depending, however, also on the detector, the
diagnostic task, and the observer preferences and habits.
In the same timeframe, in new products the “short
cone” formerly used (or “coning device” actually shaped
as a pointed cone) was being replaced with a “long
cone”—and concurrently, the older bisecting tech-nique
was generally supplanted by paralleling technique
(note*). This was made possible by the greater X-ray
beam flux (dose rate) attained with the higher kV, which
is required for retaining adequate dosage (without
increasing too much the exposure time) with the larger
source-to-detector distance that paralleling technique
implies. This also brought about the wide adoption of
film-holder and positioner devices (inconvenient with
pointed short cones and bisecting technique), especially
in USA where full-mouth surveys are common.
single device a positioning indicating device (PID) and a
collimator, also formally known as beam limiting device
(BLD).]
It should be clarified that when I say “short” and “long”
in this context, I mean typically about 10cm

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(4”) and 20 cm (8”) respectively. Later, when all new
collimators become suitable for paralleling technique, a
commercial “long cone” would typically mean 30cm
(12”), a size that never become really popular. As to the
40cm (16”) cones (obtained with special modifications
of the standard ones) which are occasionally mentioned
in scientific literature, essentially they have never existed design was bulky and expensive, and images generally
outside some academic milieus. The 80's also saw the
introduction of the first rectangular-field dental colli-
mators, which slowly began to attain popularity initially
in Sweden, then in North Europe in general.
There is a particular model of dental X-ray source
that deserves a special mention for its uniqueness:
General Electric GE 1000 (later by Gendex). This device
(or its direct predecessor) was developed and launched
in the 50's and was produced virtually unchanged for 50
years, quite a record! Undoubtedly, it must have been
state-of-the-art when it was first launched, but became
a very mature and ordinary technology in the subsequent factors; The radiation hardness with a DC X-ray source
decades. However, it possessed a unique feature: like
in the bigger X-ray sources for medical radiology, the
operator had the capability of directly setting all three
technique factors—anodic current (mA), AC anodic high-
voltage (kVp), exposure time (s)—independently from
each other and over a broad range. Of course, the
control was achieved with rotary switches,
potentiometers and analog dials, given the technology
of the time. This made it precious in certain dental
schools for teaching and investigative purposes—
although not much so for the general dentist who rather
seeks ease and immediacy of use. It was also quite
sturdily built, as it was weighted twice as much as the
average dental X-ray source, with a cyclopean
suspension arm that let it be slammed against the wall
by careless students, without too much damage (to the
arm, not to the wall!). It was produced and sold until
the early 2000s in ever dwin-dling minuscule numbers,
before being discontinued to the dismay of dental old-school was
It is a mantra of the entire industry that it must be
“market-oriented”, ie it must strive to satisfy the
expectations and needs of the user, both expressed
and unaware. But the practical application of this
principle usually passes through asking the input of the salesman
Hence, “market-oriented” often becomes the needs and
expectations of the salesmen, who may be more skilled
and motivated at immediately selling products rather
than with technology and clinical applications. What
almost all salesmen want above all is the same product
as their competitors, but better performing, bigger,
faster… and less expensive; and the better performance
should be quantifiable with a scalar number. For a dental
As an example of the above, in the 80's the company
for which I worked, that had already updated its offering
for North America with a 70 kV model, was requested
by its sales force to increase the product line with a 75
kV model (AC), launched in the second half of that
decade. It was a memorable commercial failure, with
only very few hundred units sold in North America over
a span of several years. Scaling up with kV is not at all
linear with size, weight, and cost, and in fact the resulting
less contrasted (hence, less palatable) than with the
prior models.
In the 80's, the advent of DC dental intraoral X-ray
sources, that is with direct current (DC) anodic high-
voltage supply, changed this paradigm. DC X-ray
sources offer many advantages over AC (especially in
association with the fast digital detectors that would
come into use in the 90's, as we shall see, less so with
chemically processed X-ray films): lighter construction,
much more accurate exposure time and possibility to
impart very short irradiations, stability of the technical
is approximately equivalent to that from an AC X-ray
source with anodic voltage 5 kVp higher.
The first commercial DC dental intraoral X-ray
sources was the American-made Intrex by SS White in
1980,1 the second was MinRay DC by Soredex of
Finland in 1984.2
There is no basic technical reason why a DC and an
AC dental X-ray source of good quality construction
should have a significantly different cost (although a
cheap design can be achieved for AC systems, without
compromising too much the reliability, by renouncing on
features and performances). But at the beginning, DC
systems were offered at prices generally higher than
AC systems, on the ground of the additional cost for the
electronic converter board, not present in the AC
systems. So, initially salesmen needed an argument to
push the new technology into the market. However, the
argument chosen, the “scalar figure” usually flaunted,
an erroneous one: it was claimed that DC
instructors.
technology involved significantly less radiation dose for
the patient than AC.
I believe that, to some extent, this questionable belief
originated from a misunderstanding of the early studies
conducted
in theon the first DC dental intraoral X-ray sources,
field.
including studies conducted around 1985 by Erkki
Tammisalo, Ebba Helmrot and Olof Eckerdal in Sweden,
in which the radiation dose from Min-Ray DC was
measured and compared with that from the Philips
Oralix 65 AC dental X-ray source.1–4 In these studies,
it was found that the DC unit implies a slightly lower (a
decrease of 20% or less) entrance dose (skin dose) to
the (simulated) patient. Immediate comparison of input
dose readout between X-ray sources of different kinds
is problematic, since a different set of technical factors
may be optimal for the different cases. But the main
problem was that many recipients of this study didn't
understand (or choose not to understand) the difference
between entrance dose (or skin dose), and total
absorbed dose and/or equivalent dose (E). Entrance dose alone is

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an easily measured practical index that can be
associated with radiation-induced risk only in a general
way, whereas small differences are substantially
irrelevant (especially at the very-low-doses involved with
dental radiology). A higher kV (=harder) X-ray beam
deposits less energy to the skin than in the deeper
tissues, but the situation is further complicated by the
shielding action of the intraoral detector itself.
At the beginning, the adoption of DC dental intra-oral
X-ray sources was frequently fraught with reliability
problems, and the failure of the power stage of the
converter board was not infrequent. The tech-nology
for (moderate) power electronics was still relatively
immature in the 80's and early 90's, and technical
competence was not easy to find. We had to wait for the
next millennium for this technology to fully mature and
achieve complete reliability. I have observed that, oddly,
systems designed in Europe tended to fail more
frequently in America, and vice versa; I believe this
might have been caused by the different nature of the
electrical power mains in the two continents (not just
voltage and frequency, but, eg also network impedance
and protection devices).
The 70's and 80's saw a lot of activity not only with
the X-ray source, but also with the X-ray detector, ie at
that time the X-ray film. The discussion resonated in the
professional and scientific literature about whether and
when the faster intraoral X-ray E-film would eventually
supplant the prior D-film in the market (the even-faster
F-film was also considered). Proponents of the E-class
film contended and demonstrated, in many scientific
articles, that the E-film—when properly processed—
It offers essentially the same image quality, contrast,
sharpness, and noise properties, as the slower D-film,
therefore it should be universally adopted because of
the advantages in reduced radiation dose to patient
(and also less cause of movement blurring). “When
properly processed”: this was the key; many ordinary
dentists were aware that their chemical processing of
dental X-ray films frequently run short of being optimal
(spent developer, wrong temperature and time,
inadequate safelights, …). The perception was that the
slower D-film was more tolerant to mishandling, whereas
in such condition the E-film turned out grainier. This has
slowed down the general replacement of the D-film by
the E-film, especially in USA where the latter never fully
took over the former—until the rise of digital radiology
made the matter moot.
The United States was also rather dissimilar from the
rest of the world in the much more popular adoption of
automatic film processors at (small) dental clinics,
starting from the late 80's. Undoubtedly, this was caused
by the frequent habit of submitting patients to peri-odic
full-mouth intraoral radiographic surveys, a practice not
universally adopted elsewhere. This required processing
many dental intraoral X-ray films in a short period of
time, which was inconvenient and lengthy if done
manually (or semi-manually). The industry offered
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Molteni
various models of automatic processors for dental X-ray
films, which for the most part were designed essentially
as a-down of the larger models used in scaling scaling
medical radiology. One notable exception was the fairly
compact British-made Velopex by Medivance (still being
produced), which transports the X-ray films through the
processing baths via a nylon mesh.
Panoramic radiography
Notwithstanding the importance of intraoral radiography,
the device, technology, and application whose expansion
and consolidation characterized the last quarter of the
XX century was panoramic radiography.
Panoramic radiography as we know today had been
conceived and also practically developed back in the
50's, with the pioneering work of Yrjo Veli Paatero in
Finland, who had been anticipated—but with different
and more embryonic technical approaches—eg by K.
Heckmann in Germany and by Hisaji Numata in Japan
and supplemented, eg by Sydney Blackman in UK, J.
Duchamel in France, and D. Hudson and Henry Hollman
in USA.5–9
By the 70's, many commercial models were estab-
lished in the marked, notably the Orthopantomograph
by the Finnish Palomex resulting from the implementation
of the original works of Paatero by Timo Nieminen, and
co-produced and marketed by Siemens (that provided
the X-ray generation subsystem); and, eg Panoral by
Ritter X-ray; Panellipse by General Electrics; Panorex
by SS White; various models by Japanese brands, eg
Asahi Roentgen, Yoshida, Hida, and J Morita (Figure
2); the old Rotograph produced by the short-lived
Watson in UK and the subsequent homonymous long-
lived Rotograph (1975) by FIAD (later Villa Sistemi
Medicali, Italy) (Figure 3); and Cranex by Soredex. In
America, this technique was generally known as
“panoramic,” in Europe and also in Japan as
“pantomography” or “orthopantomography” (OPT,
OPTG) (a term that was claimed by Siemens as its own
trade name, but that had already been used primarily in
public scientific literature since 1958, eg by Paatero
himself). Finn, Japanese, American, Italian, German,
and lately Korean brands have dominated the world
market for this kind of devices ever since.
In the USA, initially the fortune of panoramic radiology
was greatly facilitated by its procurement by the Armed
Forces, who needed an effective method to screen
mass military personnel during and after the Korean
War and later the Vietnam War, also for the purpose
(sadly) of post-mortem identification of corpses via the dentition.
The technology of the early systems focused on
implementing the proper cinematic trajectories through
purely mechanical means, such as cams and/or
eccentric levers. All movements—that of the rotating
gantry and that of the film cassette—were synchronously
driven by a single electric motor. With this design,
essentially only one kind of trajectory and projection was possible in a
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Figure 2 Panex by J. Morita, a panoramic machine from 1971.

(Picture courtesy of Yoshito Sugihara, J.Morita Mfg. Corporation)

given machine. Compared to today, the early systems

were massive, weighing several hundred of kg and
requiring shipment in separate parts and partial assembly
on site; sometimes, the walls had to be reinforced in
order to bear the weight of the machine. However, these
machines usually offered the advantage of being very
durable.
The SS White Panorex displaced the position of the
rotational center for the right and left side for better
projection geometry and to avoid casting the shadow of
the spine onto the anterior teeth. Initially, this was Figure 3 Rotograph (first series) by FIAD, a panoramic machine of
achieved by shifting (by a predetermined distance) the the late 70's. (Picture courtesy of Fabio Curti, Villa Sistemi Medicali)
patient himself (ie, the chair onto which the patient was
seated), in a later design by shifting the mechanical
center of rotation in the machine. The general consensus rotational centers (for the right, central, and left parts of
was that the image quality was quite good geometry- the jaws).
wise, but the overall image was made of two contiguous Cranex by Soredex, Finland, was the first model
pieces, separated by a white (radiolucent) band at the featuring a DC power generator for the X-ray source, in
middle. This made counting the (partially overlapping) 1977. The company was established as a start-up by a
teeth in the dentition less immediate, which was deemed group of technical managers who defected from Palomex
by many to be inconvenient. The Panellipse by General when the top management at Siemens stated that DC
Electrics owed its name to the elliptical trajectory of the power generators would have no market in dental
center of rotation. The European machines stemming radiology.
from Paatero work soon implemented projection geom- It was in the 80's and early 90's that panoramic
etries based upon the uninterrupted shift between three systems became a common staple of private dentists (at least in

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Europe, North America, and Japan). That period also

saw substantial advances in the detailed understanding
of the theoretical basis of rotational panoramic
radiography, through many studies by the late Ulf
Welander (then at the University of Umeå, Sweden,
and Editor-in-Chief of DentomaxilloFacial Radiology)
and of his allied team at the UTHCSA led by William
Doss McDavid.10–13 Additionally providing for a
comprehensive mathematical framework for rotational
panoramic radio-ography, they also pioneered (with a
working prototype) the foundations of digital panoramic radiology.14,15
They used a linear array of sensors (stripe arrays as
customary today were not yet available). No “tomo-
graphic” effects are possible with a strictly linear array,
and their practical results showed (surprisingly to many)
that the tomographic effect is not essential to produce
panoramic images similar to those we are accustomed
to seeing. Among the very many other contributions to
the theory of panoramic radiography, the work by EH
Tammisalo, by Jan Van Aken, by Gerard Sanderink, by
Masaru Shiojima, and by William Scarfe should not be
forgotten.16
I run myself into an instance of the bumblebee myth
in the mid-80's, when I set forth to lead the development
of a new panoramic system (Philips Orthoralix SD),
where the complex movements required to implement
the panoramic projections would be driven, robotwise ,
by a set of independently operated stepping motors
under the control of a microprocessor (“software-
driven,” rather than by mechanical cams, levers, and Figure 4 Planmeca PM 2002 CC (late 80's), one of the first pano-
chains), one of the first of this kind to become ramic machines to be microprocessor-controlled (with SCARA
commercially available.17 Some senior expert at the robotic technology), and the first to feature patient standing at 90°
from the wall, thus facilitating its accurate positioning by the operator.
headquar-ters' Research & Development facilities (Picture courtesy of Timo Muller, Planmeca)
declared that this approach could not work, because
the intrinsically discrete movement originated by
stepping motors would result into intolerable striping somewhat superseeded by the advent of CBCT. Sore-
artifacts. Like the bumblebee, I went forth on my way, dex's Scanora (1988) (Figure 5) and later Cranex Tome
and of course, no striping was even detected by (1996) were panoramic systems that included a small-
anybody (the mechanical inertia of the system damps field spiral tomography function for the maxillofacial
out completely the discrete-ness). The same technology region, primarily for transverse tomographic cuts of the
was soon gradually adopted also by all other jaws for implant planning purpose.
manufacturers; in 1986 also Planmeca had launched a The new-generation panoramic systems produced
panoramic machine (PM 2002 CC) with microprocessor- and marketed since the late 80's were also superior in
controlled operation, and—for the first time—patient- that all used DC X-ray generators, and generally had a
oriented sideway (instead of facing the wall) which leaner and lighter construction than their predecessors.
facilitated positioning (Figure 4) . This new technology From this time, almost all commercial panoramic
made possible by selecting different types of radiographic machines had the option—or a version—of an additional
projections in the same system, tuned to the specific arm with cephalostat (sometime nabbed a
diagnostic task, such as, for instance, special projections “teleradiograph”) for cephalometric radiography, for
for the TMJ and for the frontal sinuses. This was (and orthodontic plan-ning purposes. The geometric
still is) a feature greatly advertised to demon-strate and arrangement of such arm and cephalostat with respect
promote the high class of a panoramic system (although to the X-ray source is supposed to implement the same
I think that only a tiny fraction of all users actually take projection geometry (with Source–Object Distance of
much advantage of it). One of the features most sought 150 cm = 60 in.) according to the criteria in the
by several manufacturers, and most difficult to fundamental Broadbent-Bolton “Roentgenographic
satisfactorily implement, was the transversal Cephalometer” described by Wingate Todd in 1931,
scannographic cuts (aka transtomography) of the jaw (a which is generally considered a basis for cephalometric
sequence of linear pseudo tomographies) for the purpose of tracing
implantandplanning, whichtreatment.18,19
orthodontic was subsequently I will not enter into the specific

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Figure 6 Zonarc by Siemens (early 80's), a panoramic machine for

supine patient with multiple choice of image layer shapes.

conjunction with the spread of digital imaging. For

Figure 5 Scanora by Soredex, a panoramic system that included
spiral-tomographic capabilities for cross-sectional views of the jaws different selectable modes of projection (Figure 6); and
and the TMJs (early 90's).
but I observe that a seemingly simple device as a
ceph-alometric arm has been the object, over the
years, of a surprisingly vast and complex assortment
of insights and controversies, about humble items
such as, for instance, the wedge filter and the ear
plugs – much of which is now superseded by the
advent of digital and three-dimensional (3D) technologies. calcium tungstate (CaWO4 ) intensifying screen, dating
The 80's also saw the demise of a technology that
had previously enjoyed some popularity with a niche
of users: intraoral panoramic radiography—offered by
Siemens (Status-X), Philips (StatOralix), and Koch &
Sterzel (Panoramix). These systems used a tiny
“pencil-like” X-ray source to be positioned inside the
oral cavity, with the detector (the film with intensifying
screen) wrapped externally around the jaws. The
resulting image was quite sharp, but of course the
geometrical accuracy was completely lacking. Also,
having a high-voltage X-ray tube placed inside the
mouth was not well accepted by the patient, and the
skin dose to the oral mucosa and the effective dose to
the other radiosensitive organs in the region was
dismayingly high by today's standards, So with the
growing awareness about radiation risk reduction, this technique was dismissed.
Other uncommon devices and technological
applications saw their culmination in the 80's and—for
the most part—their demise in the subsequent years, in
instance: Zonarc by Palomex/Siemens, a remarkable
variation of rotational panoramic radiography for supine
patients (instead of standing or seated) featuring
the Axial-Tom, Com-Cat by ISI, Quint Sectograph,
dedicated linear or spiral tomographs for the head
(especially for the TMJ).
As in the case of intraoral imaging, the 70's and
80's witnessed significant progress also with the
detectors for panoramic and cephalometric radiography,
which then consisted of cassettes with film and
intensifying screen combinations. The antiquated
back to the early times of radiology, was replaced by
new materials based upon rare-earths compounds,
where the wavelength of the emitted fluorescent light
was specifically tuned to the spectral sensitivity of the correspondi
There was a small number of important manufacturers,
notably Kodak, Fujifilm, 3M-Ferrania, DuPont, and
Agfa/CaWo. The battle raged in the market and in the
scientific and professional publications as to whether
the “blue” or the “green” combination was superior,
until the introduction of digital imaging rendered the
issue moot. A topic of note was that the new rare-earth-
based screens—with the possible exception of the
DuPont make—generally provided more contrast
(perhaps too much contrast for the panoramic
application) with respect to the older CaWO4 screens .
Digital intraoral radiography
The first approaches to electronic imaging pertinent to
dental and maxillofacial radiology was xerography,

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pursued with various experimental studies during the
70's and 80's.20–23 However, it never got much traction
in industry and the clinical arena. Digital imaging, the
great technological revolution in dentomaxillofacial
radiology, began its practical maturation in the 80's.
When talking about digital imaging in radiology, it is
customary to divide between computed radiography
(CR) and digital radiography (DR). The former technology
(CR) (which is also referred to as photo-stimulated
phosphors plates or PSP, and also as storage phosphors)
is regarded by some as an incomplete form of digital
imaging (because of the analogy with the conduct in
chemically processed film -based “analog” radiography),
transitional toward the latter (DR) which would be the
only ultimate and full form of digital imaging. I disagree
with this perception, and see both CR and DR as two
valid technologies that complement each other for
different applications in oral radiology. I am comforted in
this view by the observation that PSP has retained its
diffusion and popularity in dental and maxillofacial
radiology a quarter of a century after its appearance
(although not drawing much attention anymore in
scientific literature: perhaps all has been written already!).
But the first foray into digital or electronic imaging for
dental radiology came with DR technologies, at the
beginning of the 80's. My own first exposure to such
innovative technology took place in May 1984, at a busi-
ness product meeting in Stresa, Italy, where I met a
young Paul Van de Stelt, then freshly appointed professor
at the recently established ACTA in Amsterdam, NL. He
presented the prototype of a novel fluoroscopic intra-
oral system at which he had been working in co-
operation with the Philips corporation. The imaging part
of the system consisted of a hook-shaped fiber-optics,
with a scintillator screen glued to the front face, that
conveyed the image forming on the scintillator screen to
a video camera at the opposite end, all of which was
rigidly connected to the X-ray source supported by an
articulated arm. Interestingly, the video chain was not
perceived as the only important part of the system; the
ergonomics and the geometric arrangement of the X-ray
source also was. A lot of thinking had gone into how to
maneuver the source & detector gantry while retaining
isocentric projection for the object being fluoroscoped.
All this was evidently inspired by C-arm interventional
fluoroscopy, which then constituted the kind of electronic
imaging already popular in general radiology.
It is difficult to understand, from today's perspective,
that at that time the main, or only, scope conceived for
electronic radiography in dentistry was to check in real
time (ie live) the progression of an endodontic file down
the root during a canal treatment , to prevent drilling
beyond the apex into the bone. Hence, interventional
fluoroscopic C-arms was the reference application.
In addition to Van de Stelt's team in Amsterdam, also
another team of Philips LEP in Paris was co-operating
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with Jean Pierre Camus of Reims, France, in a project
very similar in scope and technical approach to the
former (aside from the fiber-optics not being curved).
A live demonstration with a prototype of canal treatment
on a volunteer, in front of a public audience of hundreds
of French dentists, was organized as part of the 1988
meeting of SITAD (Salon des Industries et Techniques
des Equipements pour l'Art Dentaire) in Paris. The
outcome was an embarrassing fiasco. The equipment
stopped to work after a fraction of a minute, midway
through the treatment, during which only vague shadows
of something that could have been constructed as an
endodontic file and the outline of a tooth were discernible
on the large screen above the surgical theater.
This outcome should not be surprising. Handling
microchips and other miniaturized and delicate parts
necessary for the video chain is a risky and complicated
busi-ness even for well-equipped laboratories and
technically competent research team, and the reliability
of early prototypes is finicky, until a robust manufacturing
know-how. how is established, which may take years.
Taking into account the modest X-ray flux from a dental
radio-graphic source, the inherent inefficiencies and
losses in the optical chain, and the approximately 20 ms
time window for each frame, it was to be expected that
the image signal-noise- ratio would be awfully poor,
which was in fact the case. Furthermore, it become clear
that the radiation cumulative load to the operator (the
dentist, even more than to the patient) would be
inacceptable. It became also evident that a real-time live
fluoroscopy in endodontics would be very impractical, or
impossible, because the dentist could not simultaneously
keep the detector in position and drill the tooth; and
unnecessary, because the progress of the file could be
checked with a discrete sequence of images as well.
At that time, I was in charge of supervising the business
and technical feasibility of those projects, and after that
event I immediately recommended to the company that
they be stopped and the focus be moved away from
fluo-roscopic to single-shot techniques.
Small-area CCD image sensors were already well
established for optical video cameras, in combina-tion
with optical components. But for intraoral oral radiology
one needs a sensor with an active area suffi-ciently
large for direct coverage of at least one tooth (which was
considered to be about 20 × 30mm), because X-rays
cannot practically be refracted and focused like optical
light can (except in several-meter-long orbiting space X-
ray telescopes). The problem was that such large-area
sensors didn't exist yet; the feasibility of manufacturing
them with sufficient reliability, production yield, and not-
too-astronomical cost was questioned and doubted by
many; and the mere investment cost necessary for
production even of one prototype was in the order of half
a million dollars, money that companies were not willing
to venture for a yet unproven business. The closest thing
existing (ie, the largest sensor commercially available)
was the 7883 CCD from
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Thompson Semiconductor that measured 9 × 13mm
(and was meant for video cameras, not radiography).
Already in the early 80's Francis Mouyen, a French
dentist from Toulouse, had embarked on a path that
would start the industrial and practical application of
electronic imaging in dental radiology. Mouyen was not
a trained engineer or a physicist, in those fields he was
rather a passionate amateur, but he understood well
the practical needs and expectations of his profession,
and had vision and ebullient enthusiasm. Having filed
for patents since 1983, he persuaded Trophy, then a
small dental X-ray equipment company active
predominantly in their French domestic market, to fund
him with a very modest grant to build, demonstrate, and
validate the prototype of a dental intraoral electronic
radiography system. It worked. He had the brilliant idea
to resize the visible-light image radiographically forming
on a 17 × 26mm intensifying screen down to the 9 ×
13mm of the CCD sensor, through a carefully fabricated
short tapering fiber optics, shaped like a squat truncated
pyramid. The whole detector, 14mm thick, could thus
be accommodated inside the oral cavity.
Francis Mouyen was the bumblebee that, not with-
standing the lack of sound technological background,
the paucity of funds, the absence of a prior references,
dared to fly high and went where no man had gone before.
He should forever be remembered and commended for
that accomplishment.
That led to production and commercialization of
Trophy RVG 25000 in 1987 (RVG staying for Radio
Visio Graphy) (Figure 7).24–27 To today's standards,
the performances of these early RVG systems were
rather questionable. Image quality was far below the
current standards; the bulky detector was uncomfortable
for the patient and difficult to position, not standing in
an active area so modest to border usability; and the
price was quite high compared to what we are accused
of now. In spite of these shortcomings it was an instant
success, at the beginning in France then in the
Figure 7 A young Francis Mouyen and a young patient being
radiographically examined with Trophy RVG 25000 (late 80's), the
first dental electronic imaging system. (Picture courtesy of Bruno
Ehrmann, CS Dental)
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Molteni 9 of 19
rest of Europe and elsewhere, so great was the need
and demand for electronic imaging. The commercial
success in France was also helped by the fact that the
French pertinent authority later established a
reimbursement rate for dental X-rays made with this
new technology, at a level fivefold higher than with the
chemical-processed X-ray film. This ranged a loud bell
for all other manufacturers of dental radiographic
equipment, who then real-ized that investing in electronic
imaging was not only possible and desirable, but even
a necessity in order to retain prominence in the market.
The shrewd reader may have noticed that I have
carefully refrained from using the term “digital imaging”
in the last few sections, and used “electronic imaging”
instead. This is because the technology implemented
in the early RVG systems, and their prototypal
predecessors, although “electronic” was not “digital”.
Images were not captured and exposed as digital files
(in some standard format like, eg the now common
JPEG or TIFF). Instead, they were transmitted to the
analog CRT display as a continuous video signal. When
another radiograph was taken (or if the equipment was
switched off) the prior image was lost forever. The only
way to retain a record of the radiograph was to print it
with a (optional) thermal paper printer. Of course, this
bears the imprint of the fluoroscopic interventional C-
arms of that age, where the “digital memory” was an
extra option. This was to change very soon, and already
the second version, RVG32000 launched in 1990, had
the option for producing TIFF digital image files, through
a frame-grabber and the associated software program
mini-Julie.28,29
In partnership with the Trophy company, Francis
Mouyen applied for a number of patents with broad
claims for products that they would manufacture. In
essence, they tried to secure the priority for any kind of
electronic imaging application in dentistry. In fact, when
the first direct competitors appeared, initially Trophy
attempted to aggressively use its patent to shut the
others off the market. At the 1992 exhibition of the ADF
in Paris, a Trophy representative surveyed the booths
of competitors accompanied by a uniformed policeman
(a “flic”), threatening them of immediate coerced closure
and harsh criminal consequences for patent infringement.
In fact, the French patent application that was ultimately
granted by the patent authorities described a very
specific invention encompassing a combination of
various features that had all to be present. The
extension to dentistry of technologies that were already
established for general radiography was not considered
to be a significant invention. So, the claims in his
patents had to be strictly restricted to certain specific
technical aspects of the product, resulting into Mouyen's
second patent related to the X-ray detector, filed in
1992 and published in 1995. Maybe, the legal strictures
of the patenting process have hampered Francis
Mouyen from taking full credit and full advantage from
his innovative impetus.
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For those who are not familiar with how the patenting
process works, I need to clarify that granting a patent does
not imply that the Patent Office validates and certifies that
the invention actually works, or that it is based upon solid
scientific grounds. The essential duties of a Patent Office
are just to verify that: (i) the patent application and description
is formally structured in the prescribed manner; (ii) the “prior
art” is described and referenced; (iii) the invention and a
“preferred embodiment” is fully described (it is supposed
that a prototype has been manufactured); (iv) the “claims”
are fully and clearly stated; (v) the same invention or parts
thereof, leading to the claims, has not been previously
publicly “disclosed” (in the country for which the patent is
applied for), for instance by publication in the press and
media, or at conferences, or by any other openly accessible
manner; and of course that (vi) all fees and taxes have duly
been paid. That the invention really works the way it is
alleged or makes scientific sense is not a concern of the
Patent Office. I think that was also the case for some
aspects of the patents that Mouyen got granted. In fiber
optics, a small fraction of the fibers may be made of opaque
extramural absorbent (EMA) fibers, interspersed among the
mass of other optically transparent fibers, whose purpose is
actually to suppress the light scattered out of the optical
fibers, which would otherwise fog the image. One essential
feature of the Mouyen patents was that the fiber optics
should incorporate “metallic particles” translucent to visible
light but blocking X-rays (sic!?) (presumably EMAs made
of high-atomic-number material) to shield rays from directly
hitting the underlying semi-conductor chip, and damaging it.
A simple physical analysis reveals that this assumption is
unjustified. 12mm of glass of the fiber optics interposed
between the entry face and the semi-conductor chip already
absorb some 90% of the X-ray traversing the scintillator
screen, and the presence a small percent of fully X-ray-
absorbing EMA would not significantly change it.
I believe Mouyen may have been frustrated by the
failures and malfunctions that he must have encountered
with the very early prototypes (for the reasons to which I
have already alluded), and convinced himself that the cause
was radiation damage. This led to an amusing episode that
I will report later. It has also had one long-lasting
repercussion: scintillator-coated fiber-optics faceplates
(typically 3mm thin) for intraoral detectors are still advertised
as advisable in order to provide radiation protection for the
underlaying semi-conductor sensor. But semi-conductor
sensors specific for X-ray imaging are designed to withstand,
without degradation, cumulative loads of radiation dose
which are orders of magnitude greater than what they can
reasonably undergo in a lifetime of service in dentistry. I am
not aware of any commercial detector ever returned from
the field with failures or symptoms of degradation that could
be attributed to radiation damage; not even
one.
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In the immediately following years, ie the early 90's, a
real avalanche of innovations hit the dental radiology milieu,
with several intraoral digital imaging systems becoming
commercially available, that used a full-area sensor without
the inconvenience of image-resizing fiber optics.
The first one was Visualix by Philips Dental Systems
(soon to morph into Gendex Dental Systems) launched in
October 1991 at the Expodental trade show in Milan, in
conjunction with the annual FDI meeting. It was a truly digital
system with a flat intraoral detector using a purposely
developed (and radiation hardened) CCD sensor 18 ×
24mm, 288 × 386 isometric pixels 63µm, 8-bit grayscale,
directly coupled with a Gd2 O2 S (gadox) scintillator ( after
an initial stint with direct X-ray conversion in the silicon
sensor). It operated as a peripheral of a standard personal
computer (DOS-based, Windows wasn't out yet), and saved
images in standard file format (TIFF, JPEG, BMP) that were
stored in the computer memory and could be exported
( Figure 8).30,31
That was followed almost immediately by Sens-A-Ray
of Regam Medical Systems, with very similar characteristics,
developed in Sundsvall, Sweden, by Per Nelvig (a dental
radiologist) with the help of his brother Lars Nelvig (an
electronic engineer), in cooperation with EEV, a large
English electronic components manufacturer, and with
some (modest) financial support by the Swedish
government.32 The Nelvig brothers had worked at the
development of their invention for some years, and a
functional prototype was already built in 1985, but the
paucity of financial resources caused the project to progress
at relatively slow pace and delayed industrialization.
Many other companies followed suit in Europe and
elsewhere (Siemens, J Morita, …) and by the mid-90's the
users could choose from a diverse range of products. The
Flashdent by Villa Sistemi Medicali, released in 1991, used
a design for the detector also based upon resizing (focusing)
the scintillating image onto a smaller sensor via optical
media; This approach was fraught with some inherent
physical difficulties, and ultimately did not enjoy much
success. Trophy also abandoned the design with the
truncated-pyramid fiber optics, which must have been the
most expensive component of their system and a was cause
of positioning difficulties and discomfort for the patient, and
adopted a full-area sensor with RVG-S in 1993 .
The spread of general awareness and knowledge about
dental digital radiography was greatly promoted by a series
of five symposia—“Digital Imaging in Dental Radiology”—
organized by Paul Van de Stelt and Gerard Sanderink of
ACTA, between 1990 and 1998 in the Netherlands (this bi-
annual meeting was later succeeded by the computerized
maxillofacial imaging (CMI) congress founded and convened
by Allan G. Farman).
The second symposium held in Amsterdam in June 1992
was especially memorable. Various manufacturers
introduced their newly developed digital dental radiographic
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Figure 8 The author at the EADMFR congress in Turin, Italy, in July
1993, holding an early version of the Gendex Visualix dental intraoral
X-ray digital detector, with holder/positioner), next to a Gendex
Oralix DC, one of the first direct-voltage dental X-ray sources, with
rectangular collimator/PID. (Picture courtesy of Yoshi-hiko
Hayakawa, Kitami Technical College). PID, positioning indicating
device
systems. Among those, Ulf Welander presented Sens-
A-Ray, on behalf of Regam Medical Systems, showing
intraoral images obtained with a new full-area CCD
sensor that directly converted X-rays into charges in the
silicon substrate. At the conclusion of the presentation,
Francis Mouyen, who was in the public, contended from
the floor that those images could not possibly have been
taken with a detector like the one described, because
the unshielded direct exposure to X-radiation would
promptly deteriorate the sensor and cause the
appearance of severe permanent artifacts. Undeterred,
Ulf Welander calmly turned around to watch at the X-ray
images being displayed, and just commented: “Well, if
these are artifacts, they are artifacts that look pretty
much like teeth.” That settled the matter.
At the same meeting another momentous event took
place: from Louisville, Kentucky, Allan G. Farman
demonstrated the transmission in quasi-real-time of a
digital dental radiograph freshly taken with a Trophy
50 years of technology changes in dental and maxillo-facial radiology
Molteni 11 of 19
RVG, as an attachment to an e-mail. In the associated
abstract, he concluded that “Pilot investigations using
electronic mail networks … have proven successful for
the transmission of 32 kByte images with intercontinental
relay in as little as 20 s. However, the rate of transmission
does vary with traffic in the system and image
reconstruction on receipt can take several minutes. …”.
The audience stared in amazement.
This far, digital dental radiographic systems had
spread mostly in Europe, but by 1992 David Schick of
New York filed for a US patent for a dental intraoral
radiographic detector, and later began production.33 In
1997, he filed for another patent about using a so-called
active pixel sensor (APS) CMOS; this is a technology
that was already well-known and established at that time,
but he could have the patent granted by restricting the
scope to X-ray detectors for dental radiography, a
limitation that the US patent office deemed sufficient for
the requirement of “ innovation” (whether or not that
could stand have a rigorous legal challenge, is left to be
seen).34 Anyway, Schick had the merit of toppling the
cliché that the (less-expensive) CMOS technology was
not suitable for X-ray imaging , and inferior to CCD, and
rapidly obtained a vast commercial success in the USA.
In the years to come, the debate resounded in the
professional press about the presumed superiority of the
image quality with CCD-based detectors over CMOS-
based ones, or vice-versa, arguably incited by the
commercial interests of companies relying on one or the
other technology. Certain articles in the scientific press
compared apples to oranges, ie compared and rated the
performances of specific detectors as if being CCD or
CMOS was the only determinant, neglecting a multi-
tude of other unrelated factors. Time has demonstrated
that the argument was irrelevant, and the image quality
achievable with a CMOS sensor is at least as good as
with CCD sensors, plus CMOS offers other benefits such
as the greatly reduced power consumption (which in turn
brings along various advantages) and lower
manufacturing costs. In fact, almost all manufactures
have gradually converted to CMOS, including the
successors of Trophy (at the beginning a resolved
supporter of CCD) with a product that still stands among the best ava
By the early 2000s, a real plethora of digital intraoral
detectors from a multitude of vendors was commercially
available.35 In their case, the quantifiable scalar number
claimed to support their worth was, and still is, the
“geometrical (or theoretical) maximum spatial reso-
lution,” in line-pairs/mm, although, being a theoretical
maximum, that is just one of the several factors affecting
the actual practical spatial resolving power or acuity, and
the latter being just one of the factors (together with
signal-to-noise ratio and grayscale latitude) that determine
the overall imaging diagnostic value.
Alongside with the hardware (ie the detector and the
associated electronics) also the related imaging software
moved forth in great strides during the 90's. There were
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(and still are) two distinct lines of conceptual archi-
tecture: those of imaging software basically programs
developed by the equipment vendors, and those orig-
inated by software houses already active in the dental
environment with practice management software, that
is programs to organize the patients and materials
workflow in the (private) dental practice and the related
administration. The former focus on processing and
analysis of the X-ray images themselves, the latter on
database arrangement of images and patient
information. Interestingly, in certain countries (notably
France and USA) a lot of traction to the diffusion of
intra-oral digital imaging systems came from the practice medium-to-long terms, while in the short-term they
management software, that had already introduced the
required computers, and familiarity with the same, to a
vast network of private dental practices. The software
houses perceive the dental imaging system as an
optional adjunct to their practice management software,
and the interconnection between practice/patient
management and imaging is often achieved through a
“bridge” between two unrelated (and often poorly
harmonized) pieces of software programs.
This has brought along the still-debated and not well-
resolved issue of intraoperability and accessibility of
image and patient databases between equipment from
different vendors. Starting from the late 90's, a lot of
efforts have been put into addressing this through the
DICOM standard (Digital Imaging and Communication
in Medicine), especially with the work of the DICOM
Working Group for Dentistry, devotedly led and
animated for several years by Allan G. Farman and
composed of representatives from many of the major
dental industries and from academia. DICOM has
become, for many years now, an indispensable and
undisputed requirement for medical diagnostic systems
in hospital environments. However, the situation with
private dental practices is quite different. Most dentists
do not feel the urge to share their images and records
with other users outside their practice (and may not
even know what DICOM is). One might wonder why
DICOM hasn't promptly become the standard universally Systems must have realized that they also needed to
adopted by the manufacturers. The problem is that: (i)
at least initially, it did not comprise provisions
specifically suited to dentistry; and (ii) it is (or is
perceived as being) extremely complex, to the point
that very special competences are required to properly
implement it—competences that the large medical
equipment corporations necessarily have, but the
medium-to-small size dental company often don't.
Consequently, implementation of DICOM functionalities
by dental companies was often achieved through
standard software libraries licensed from specialized
independent software houses, at not-negligible cost per
individual license. Such cost is relatively minor in
relation to that of large medical radiographic equipment,
but not so for the less expensive dental radiographic
equipment, hence it is usually offered as a separate pay-for has
Only a fraction of dentists have proven willing to pay for
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such option. Over the years, the DICOM standard and
its knowledge has evolved for better, and its diffusion
in dentistry has increased with the appearance of the
more complex CBCT systems, but the situation is still
in progress.
In 1997, the economist Clayton M. Christensen
(recently passed away) authored a best-selling book by
the title “The innovator's dilemma.”36 The central thesis
expounded in the book is that large, mature, market-
dominating corporations are structurally incapable of
disrupting innovation (a term that he coined), because
new technologies would become profitable only in the
would compete against those established products that
make their immediate profit (that short term profit
against which the management is gauged and rewarded
or penalized by the company's proprietors and/or the
stock market analysts). The only way for such
corporations to innovate would be to spin-off or acquire
smaller autonomous entities. I think one of the best
examples of this construct was Kodak in the 90's. At
the beginning of that decade, Kodak dominated the film
market and the X-ray film market as well, with over 90%
market share in America and similar leading positions
in many other parts of the world. As the ascent of digital
radiology in dentistry become apparent, in 1990–1991
Kodak Medical Systems reacted by setting up a
scientific advisory panel, staffed with several among
the most illustrious dental and maxillofacial radiologists
in the world, with the purpose ( more or less explicit) of
… finding arguments to support the superiority of the X-
ray film and slow down the adoption of dental digital
radiography! The fear was that their highly profitable
market of X-ray film (and chemicals, and screens)
would be compromised (as in fact the case was in a few years).
In retrospect that was like trying to stop a waterfall with
bare hands. The paradox was that, at the same time
span, the photographic film and camera division of
Kodak was resolutely trying to migrate to digital
photography in earnest. In a few years Kodak Medical
jump on the bandwagon right away, and caught the lost
time by acquiring Trophy in France, Practiceworks (a
major software house for practice management software
in USA), and in 2005 Orex (an Israeli manufacturer of
dental panoramic CR scanners).
The practical availability of X-ray digital detectors
has made possible the development and application to
dental intraoral imaging, since the very early 90's, of
tuned aperture CT (TACT), a kind of tomosynthesis
that provides stereoscopic or pseudo-3D imaging from
a small number of conventional radiographic projections
taken with different geometry (ie from different
angulations). Its application to dentistry was developed
largely thanks to the researches of Richard Webber
and coworkers at the University of North Carolina, and
option.
seen practical implementation in commercial
equipment, notably by Instrumentarium of Finland that
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enabled it in panoramic machines since 1997. TACT is
said to provide superior diagnostic performances,
respect to conventional two-dimensional radiography,
eg in the detection of caries and cracks, and in the
analysis of periodontal bone. However, it has not spread
to general adoption and, so far, remains mostly a tool
for a minority of specialists and hobbyists.
Digital panoramic radiography
The 90's saw the adoption of CR also for dental and
maxillofacial applications. The production of photo-
stimulated phosphor plates and of the related scanners
for medical radiography, and the relevant patents, was
(and still is) essentially monopolized by three great
medical device manufacturers: Fuji Film in Japan, Agfa
in Europe (via the controlled CaWo in Germany), Kodak
in North America.
Already in 1985 Isamu Kashima from Kanagawa,
Japan, had shown that photo-stimulated phosphor
plates could be advantageously used for panoramic
radiography.37 A distinct practical advantage of PSP
and CR in panoramic radiography was that the user
already owning (or having access to) a film-based X-ray
machine would not need to scrap and replace his
(expensive) panoramic machine in order to “go digital.”
He would just need to replace the intensifying-screen
cassette with one with a PSP plate, and add a CR/PSP
scanner; in a large radiological clinical environment, the
latter might have already been available for general
medical radiology.
But the early experimental field applications of this
technology encountered a bizarre obstacle, whose
explanation requires a short excursus about how electro-
medical companies set the specifications of their
products. Generally speaking, they are specified to
conform at least with the minimum essential provisions
of accepted international standards. Conversely, the
standards are written to encompass and describe what
the largest and leading manufacturers have produced
and successfully distributed to the market. For X-ray
films—and, by extension, intensifying screens, and, by
further extension, PSP plates—the applicable standard
is published by ISO (International Standards
Organization), and substantially describes the sizes
offered by Kodak over a long period of time. However,
the cassette hosting film and screen is considered to be
a part or accessory of a medical electrical equipment,
and as such is of relevance to another standardization
body, IEC (International Electrotechnical Commission).
One may think that the sets of sizes foreseen in both
standards coincide (since standard cassettes are made
to accommodate standard films and screens and plates)
and in fact that is the case … with one exception:
panoramic size (15 × 30 cm and the now obsolete 5 ×
12 in.). Initially, most medical CR scanners already
available in hospitals had not been designed to accept
cassettes in the 15 × 30 cm panoramic size, although
PSP plates of that size could be easily made ( eg cutting
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Molteni 13 of 19
down to larger format). Probably, most of the people
from large and leading manufacturers that manned the
working groups of IEC at that time were not involved
with panoramic machines (and possibly barely knew
about them), and were not aware of the need to include
that size in the standard , and in the capability of the
CR scanners.
In the early 90's I had worked at projects to
circumvent this obstacle, like eg a modified panoramic
machine that would carry a 24 × 30cm cassette with a
PSP plate where only the lower part would be exposed
to the X-ray beam and produce an image for the
customary 15 cm height when scanned, and to other
like contrasts. But it was clear that dental-specific CR
scanners would be eventually needed for panoramic
(and ceph-allometric) and for intraoral radiography as
well, also because the ordinary dentist customer could
not afford the large cost of a regular medical CR scanner.
However, the first commercial dental PSP scanner
was for intraoral plates only, the Digora by Soredex
launched in 1994. Basically, its design was a scaling
down of the architecture used for large-area medical
CR scanners, based upon a linear progressing laser
scanning beam , and it would do one intraoral plate at the time.
Since a cassette cannot be used intraorally, dental
intra-oral PSP plates must be complemented with
disposable opaque plastic covers or pouches (or
“barriers”), having the double purpose of preventing
cross-infection among patients, and avoiding the
ambient light to partially erase the latent image on the
plate after the radiographic exposure and before the scanning.
That was followed in 1997 by DenOptix from Gendex,
developed in California, the first dental PSP scanner to
accommodate both panoramic/cephalometric size
imaging plates and intraoral plates. At about the same
time, also Orex, an Israeli start-up, also presented a
scanner for panoramic and cephalometric PSP plates
(but not intraoral); this was the only company to use
Kodak PSP outside Kodak itself, in fact it was later
acquired by Kodak. After a few years also Dÿrr Dental
of Germany (Air Technique in USA) launched a dental
panoramic and intra oral PSP scanner (Scan-X), and
other companies followed later. All the above-mentioned
systems adopted different kinds of design than the
original Digora and the medical CR systems, eg based
upon a rotating drum.
While the immediate yearning for digital panoramic
had been quenched by PSP imaging plates and
scanners (using existing panoramic machines), that for
direct and immediate panoramic imaging, with a digital
sensor, persisted.38 Already in 1995 a kit (DXIS) for
conversion of panoramic systems to “fully digital” was
available from SIGNET of Catalin Stoichita, a start-up in Paris.
The problem with such kind of add-on kits was that they
required an invasive adaptation into the hosting
panoramic machine, which—among else—would
invalidate the warranty and technical support from the
manu-facturer of the same.
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Digital panoramic radiography is usually achieved by
the so-called time deferred integration (TDI), where the
signal accumulating in the short (but not infinitesimal)
width of the detector integrates in a manner similar to
what physically happens with an analog detector (film or
plate). Such mechanism is inherent with the operation of
CCD stripe sensors, and is electronically emulated in
case of CMOS stripe sensors.
By late 90's, the time was ripe for fully integrated digital
panoramic systems to be originally designed by various
major manufacturers. In 1997 it was DigiPan by Trophy,
which was distributed in OEM as an upgrade for panoramic
machines of other manufac-tures like the OP100 by
Instrumentarium, Panoura by Yoshida, Orthoralix DPI by
Gendex, etc. In the same general timeframe also other
vendors launched machines with their own digital detector:
Dimax by Planmeca (Finland); Orthophos DS by Siemens
(later Sirona–Germany); and by J Morita. Almost all other
manufactures followed suite soon.
The need to complement direct digital panoramic also
with (optional) direct digital cephalometrics was soon
apparent. The latter was (and is) more costly than the
former, given the need for a longer scanning detector to
cover the full height of the head (typically 24cm). Also,
the cephalometric scanning time would be a few seconds,
which is not well received by some ortho-dontists who
wish instant imaging to preclude the (very hypothetical)
problem of geometrical distortions caused by patient
movements. The work is still in progress to speed-up the
scanning or to achieve single-shot cephalo-metrics with
a large area flat panel detector.
By the 2000's, a new technology became available to
enhance the diagnostic value of panoramic radiography:
laminographic tomosynthesis reconstruction.39,40 This
technology was introduced and then patented by AJAT of
Helsinki, Finland, a start-up founded in 2001 and led by
Konstantinos Spartiotis and partially financed by the
Finnish government.41 This line of development was also
investigated in Japan at about the same time.
AJAT implemented an add-on kit that combined a new
type of high-speed, high-resolution and high-efficiency
digital imaging detector made of a combination of single-
crystal Cadmium Telluride (CdTe) detecting material with
an underlying CMOS array sensor, and an image
tomosynthetic reconstruction method consisting of the
collection of a large number of raw images that are then
processed by a reconstruction algorithm into a panoramic
image after the acquisition. Actually, the CdTe-based
detector and the reconstruction method are two separate
and distinct aspects that complement each other
advantageously but not necessarily. In fact, the
laminographic tomosynthesis reconstruction has since
been adopted in a number of commercial machines
without being associated with a CdTe detector, eg by
Instrumentarium, Vatech, and Sirona, offering the
advantage that the position and shape of the position
layer can be determined after the panoramic irradiation
Dentomaxillofac Radiol , 50, 20200133
Molteni
(conceptually, even automatically), thus relieving from the
need of accurate patient positioning. In spite of early
experiments, eg by Asahi Roentgen in Japan, the
widespread adoption of CdTe-based detector has so far
been slow, probably because of cost, production capacity,
and patent infringement issues.
Cone beam CT
At the end of the 90's, the other great revolution in
maxillofacial radiology began: volumetric radiography (3D)
via cone beam CT (CBCT). The theoretical and
mathematical basis of CBCT have been well-known
among mathematicians for many years.21 In 1978, a sole
CBCT system was built and installed at the Mayo Clinic
in Rochester, Minnesota, for cardiac and pulmonary
diagnostic applications.42 It It was 5.6 × 6.3 m large,
weighted about 17 tons, used 14 separate X-ray sources
and image-intensifier X-ray detectors, and required two
large shielded rooms to operate; it cost a fortune in yearly
maintenance; and cardiology and pulmonary do not seem
to be the best elective applications for CBCT, which
requires a stationary radiographic object. None-the-less,
it was mightily popular and appreciated at Mayo Clinic,
and was reluctantly decommissioned more than 20 years
later, when the obsolescence of the main components
made maintenance impractical or impossible.
Already since 1994 QR, a small start-up in Verona,
Italy, then virtually unknown in the dental milieu, technically
led by Pierluigi Mozzo and Attilio Tacconi, physicists,
undertook to develop and patent a maxillofacial-specific
CBCT, named NewTom 9000, using a 9” image intensifier
detector (Figure 9). At the very beginning of 1997, the
first three units were sold and permanently installed at the
private radiology practices of Giovanni Polizzi in Verona,
Italy, Paolo Sart-orato in Noale, Venice, Italy, and of
Silvio Diego Bianchi in Turin, Italy. The new machine was
also presented at the 1998 ECR in Vienna, and a paper
was published in the November 1998 issue of EJR, which
is still one of the most highly cited articles in our
specialty.43,44 At the start, many experts expressed
doubts that a system like that could work or have any
diagnostic value, but the bumblebee kept flying.
However, at the very beginning the dental profession
for the most part failed to notice this disrupting innovation,
because the inventors and the company were not rooted
in the dental milieu, and the journals and exhibitions
where it was first presented were medical rather than
dental and maxillofacial.
In July 1999, at the fifth CMI (computed maxillofa-cial
imaging) section of the CARS (computer-assisted
radiology and surgery) congress in Paris, the convenor
Allan G. Farman announced that one of the planned
featured lectures on the last day of the congress would
be replaced by a different conference, to present an
innovation of great importance. This was unheard off! I
had never ever witnessed, at a major international congress
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Figure 9 The prototype of NewTom 9000 by QR (1996), the first
commercial dentomaxillofacial CBCT machine. (Picture courtesy of
Attilio Tacconi). CBCT cone beam CT.
prepared long in advance, that a planned lecture would
be substituted at the last moment, except for force
majeure. The next day Pierluigi Mozzo explained the
operation of CBCT to the audience and showed clinical
images, with an image quality that he himself admitted
was just adequate, but—he said—could be expected to
Figure 10 An early NewTom 9000 installed at the radiology department of the Sundsvall Hospital, Sweden, with Per Nelvig and staff. (Picture
courtesy of Claudiano Tagliareni)
50 years of technology changes in dental and maxillo-facial radiology
Molteni 15 of 19
improve in the future. This time the audience of
international maxillofacial radiologists definitively took
notice (although his presentation never made into the
proceedings of the congress, which had already been
edited in advance), and the CBCT revolution took off in
earnest (Figure 10 ) . NewTom began sales in North
America in 2000, promoted by renowned orthodontist
Carl Guggino.
Simultaneously, also in Japan practical work had
independently begun to develop commercial CBCT
machines, animated primarily by the indefatigable
Yoshinori Araki, and by others.45,46 J Morita introduced
the first Accuitomo small-field CBCT machine after
2000. Shortly later, following the researches of Rika
Baba and others, Hitachi also launched Mercuray, a
sophisticated and powerful CBCT machine with a large
field detector.47,48 Baba and Ueda also investigated
appli-cations of CBCT in chest and orthopedic imaging,
and the adoption of large-area flat panels detectors,
which however did not result into commercial products.49–52
But Hitachi was (and is) a purely medical company with
no application experience and commercial footprint in
dentistry, so their product was overdesigned (and over-
priced) for dentomaxillofacial applications and achieved
limited penetration outside Japan.
Initially, all available CBCT models utilized image
intensifiers, bulky and heavy, as image detector, which
constrained size, weight, and image quality. In the late
90's, Predrag Sukovic, a post-graduate student of
Biomedical Engineering at the University of Michigan
at Ann Harbor, and his mentor Neal Clinthorne at the
Department of Radiology of the Medical School,
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50 years of technology changes in dental and maxillo-facial radiology
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Figure 11 A young Predrag Sukovic sitting in the first pre-production
unit of DentoCat/iCat (that he was instrumental in developing), at
the Dental School of the University of Michigan in 2003. (Picture
cour-tesy of Neil Clinthorne, University of Michigan)
investigated at the application of the TFT flat panel as
image detector for 3D radiography. It was already evident
that the flat panel offers many advantages over the image
intensifier, in image quality and else, and its cost was in
the process of decreasing to a level compatible with
industrial deployment. With the fundamental help by
Sharon L Brooks at the Dental School (later Editor-in-
Chief of DMFR), by 2002 they had prototyped a
maxillofacial CBCT, based upon the mechanical
structure of an existing panoramic machine (by Panoramic
Corporation) and featuring a large-area TFT flat panel as
image detector.53,54 In 2003 Sukovic and Clinthorne
started up a company called Xoran (which would later
manufacture CBCT machines for ENT applications,
initially with the name MiniCat), and licensed the design
for dentomaxillofacial applications to ISI (Imaging
Sciences International) of Hatfield, Pennsylvania, which
re-adapted it on the mechanical structure of an old and
discontinued panoramic machine of theirs, and since
2004 produced it with the name iCat (Figure 11) .
The first unit (“DentoCat”) was delivered and installed
Dentomaxillofac Radiol , 50, 20200133
Molteni
at the Dental School of the University of Michigan in
February 2004. iCat enjoyed vast popularity in North
America during the 2000s, thus fostering a veritable rush
to implement this 3D technology by all other vendors in
maxillofacial radiology (like it had been for digital
radiography one (decay earlier).
At the 2005 IDS in Cologne, Planmeca presented a
prototype of small-field CBCT, with a 12 × 12cm flat
panel, that was built as a modification of their panoramic
machine, hence more compact and leaner than the other
system then available. The machine began being
commercialized 2 years later, in 2007. By the early
2010s, some 40 or 50 models from different vendors
were commercially available.
The following decade, the 2010s, is recent history,
and witnessed the continuous success, evolution, and
expansion of CBCT. Among else, a vast variety of hybrid
CBCT & panoramic (and cephalometric) machines have
become available and popular (outnumbering the purely
CBCT systems), with separate detectors for CBCT and
Panoramic or, more recently, a single detector for both
modalities. More and more machines have adopted the
offset detector technique, which makes it possible to
increase—up to a factor 2—the radius of the
reconstructed volume for a given width of the detector's
active area. This, however, requires that a scan over a
complete 360° full rotation, or more, is performed, which
may not be possible in machines whose original
mechanical design was just for panoramic, where usually
the rotation is only about 270°.
In the vast majority (or the totality) of maxillofacial
CBCT machines, the 3D reconstruction is based upon
the well-known and well-proven FDK (Feldkamp–
Davis–Kress) filtered back projection algorithm (it is
virtually impossible to have an accurate and compre-
hensive information on this, since all manufacturers
jealously guard it as a secret). Various scientific studies
have advocated the transition to other more advanced
and accurate 3D reconstruction methods (ART, itera-
tive, etc.), which require more computing power and
substantial software and mathematical development,
but the challenge generally has not yet been taken up ;
evidently, in maxillofacial imaging the approximate FDK
algorithm is good enough for the task (for now).
A technique that has its roots many years earlier with
classic CT scanning has also received great impetus,
that is the use of 3D radiographic data from CBCT
scanning, and their integration and merging with visible-
light surface data from facial photography and endoscopic
intraoral optical scanner or camera, plus the associated
3D printing of surgical models, templates and masks, for
the purpose of dental implant planning and computer-
guided surgery.
Handheld dental X-ray sources
This historical excursion would not be complete without
mentioning an innovative type of product that has not
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stirred very much attention in the scientific literature, but is
proving a game-changer of its kind in the field: hand-held
dental X-ray sources (distinct from X-ray sources that are
just portable). Probably, the first of this type of products
was Nomad, designed and initially manufactured by
Aribex of Orem, Utah, founded in 2003 and led by Clark
Turner, a physicist. Nomad was initially intended for
forensics and for special applications in the field, and was
being presented at a forensic meeting in Bangkok,
Thailand, when the terrible tsunami of 2004 hit the Far
East coast. The few units that were present at the meeting,
and others promptly shipped from the factory, were
immediately transported to the disaster area to help in the
rescue operations (identification of corpses, etc.). This
brought the product, and the very concept of handheld
dental X-ray sources, into the spotlight. From that moment,
its adoption spread quickly among dentists in the USA,
where nowadays it is among the most popular dental X-ray
sources. Almost simultaneously with Nomad, also several
companies in South Korea entered the market with a
variety of models. In Far East, the devices produced by
Korean manufacturers (Vatech, Genoray, Dexcowin,
Rexstar, …) have enjoyed a large, growing popularity. In
continental Europe, the penetration is still marginal, mostly
due to regulatory restrictions and radiation safety concerns,
that many studies in the USA have refuted as unfounded
or excessive.55–60
Conclusion
What else?
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There is no conclusion.
The technological progress does not stop, does not
come to an end or conclusion. We may expect to be sure
that the existing technologies and products will continue to
enjoy evolutionary improvements in the years to come.
There isn't a crystal ball to predict what will be the next
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•More effective X-ray image detectors, with dual energy
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