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CBCT

Edited by
Ahmed Hesham Abu Bakr
 Cone-beam computed tomography (CBCT)
Terminology:
Cone-beam computed tomography (CBCT):
 Imaging technique uses a cone-shaped x-ray beam to acquire information and present it in three
dimensions.

1. Axial plane (X)

o A horizontal plane that divides the body into superior and inferior parts; runs parallel to the ground.
o Occlusal view.
2. Coronal plane (Y):
o A vertical plane that divides the body into anterior and posterior sides; runs perpendicular to the ground.
o Divide posterior teeth bucco-lingual and anterior teeth mesio-distally
3. Sagittal plane (Z):
o A vertical plane that divides the body into right and left sides; runs perpendicular to the ground.
o A midsagittal plane describes a plane that runs through the midline of the body.
o Divide posterior teeth mesio-distally and anterior teeth bucco-lingual

DICOM data:
 The universal format for handling, storing, and transmitting three-dimensional images; the acronym
refers to Digital Imaging and Communications in Medicine.
o Can be shared among dental professionals, imaging centers, and referring physicians via CD or e-mail.
o The file found on CD in the name of (the program itself (on demand, blue sky) or image data – DICOM file)
Multiplanar reconstruction (MPR):
 The reconstruction of raw data into images when imported into viewing software to create three
anatomic planes of the body.
Contrast resolution:
 The number of gray-scale colors available for each pixel in the image.
Spatial resolution:
 A measurement of pixel size in multiplanar reconstruction (voxel)
Voxel:
 The smallest element of a three-dimensional image; also referred to as volume element or three-
dimensional pixel.
Field of view (FOV):
 The area that can be captured when performing imaging procedures.
 The larger FOV, high cost, more radiation and less resolution.

The common uses of CBCT:

 Implant placement:
o Bone available and density.
o Position, size and relation of implant to anatomical structure.
o Evaluation of biotype by measuring hard and soft tissue thickness of the alveolar process.
o Detect facial plate thickness and for identification of a dehiscence or fenestrations over root surfaces.
o Surgical guide fabrication.
 Minor surgery:
o Impaction (to determine its position especially bucco-lingually – relation to anatomical structure)
o Bone reduction surgical guide.
 Diagnosis in periodontal disease:
o CBCT is more accurate in the detection and measurement of
intrabony defects and furcation involvement (IOR
underestimate the severity of each)
o No statistical difference between measurements of horizontal
bone loss when measured by either CBCT or direct intra-
surgical measurements.
o Ability to assess root concavities of first premolars and associated pattern of bone loss.
 Endodontic assessment:
o Provide better planing to the case (number of canals, complexity of case, calcified canal, broken file,
missing canal, split or perforation).
o To restore or extract: The data suggest a tooth that has a radiolucent periapical lesion greater than 5 mm
will have a decreased long-term success rate for treatment planned definitive restorations. (CBCT varying
from 0.37 mm to 0.58 mm for linear distances, compared with the actual measurements )
 Evaluation of lesions and abnormalities.
 Airway and sinus analysis.
 Evaluation of temporomandibular joint (TMJ) disorders.
 Orthodontic evaluation.
 Trauma evaluation
 Advantages of CBCT
Advantages of CBCT over CT:
 Lower radiation dose: Studies have found the effective dose estimates for a dental CBCT scan to be comparable with
three or four full mouth series of intraoral images.
 Brief scanning time: Scan times vary between 7 and 30 seconds; shorter scan times are desirable to eliminate
artifacts created by patient movement
 Lower cost.
 Better spatial resolution.
Advantages over traditional intraoral x-ray:
 Anatomically accurate images.
o CBCT eliminates the superimposition of structures, and the magnification of measurements does not occur. Cone-beam
data provides an accurate measurement of anatomic structures with a 1:1 ratio relationship.
 Ability to save and easily transport images.
o Three-dimensional images can be saved and shared digitally in a .jpg (Joint Photographic Experts Group) or .bmp
(bitmap) format and then viewed online, placed on a compact disc, or printed on paper or lm. The images can also be
shared electronically.
Disadvantages of CBCT:
 High radiation dose compared with
traditional x-ray.

 Size of the FOV.

o If the FOV is small, findings or pathology in other regions of the oral and maxillofacial area may be missed.
o The FOV should include not only the region of interest but also anatomic features related to the region of
interest. For example, a patient present with pain in a maxillary molar tooth. To appropriately diagnose this
condition, the FOV should include the maxillary posterior teeth, the temporomandibular joint complex, the
auditory complex, and the paranasal sinuses.
 Higher cost than intraoral X-ray.
Disadvantages compared with CT
 Lower contrast resolution so deficiency to display soft
tissue.
 Higher scatter radiation.

CBCT Software:
 It is a computer software for viewing and reformatting images created by CBCT and can be used for virtual
implant treatment planning and surgical guide fabrication.
o On demand.
o Blue sky plan: it is free (https://www.blueskyplan.com/download)
 Minimum hardware requirements:
o Operating System: Windows 10 Home/Professional 64 bit or OS X 10.13 (High Sierra) or newer
o Processor: Quad Core Intel i7 or comparable
o RAM: At least 16 GB
o Video Card: dedicated NVidia or AMD card, at least 3 GB video RAM (e.g. NVidia GeForce GTX 650,
AMD Radeon HD 7750, …)
o Monitor: 21 inch, resolution at least 1920x1080
o Hard Disk: 5 GB of free space
 CBCT implant planing:
When to use CBCT:
a- Initial assessment:
o Panorama: is the 1st choice for initial evaluation to exclude any pathological lesions, local contraindication.
o Periapical x-ray: can be used in cases of single tooth implant. (paralleling technique is preferred)
b- Preoperative assessment:
o CBCT: for evaluation of available bone (quantity & quality) – width and length of implant – position of implant –
relation to vital structure (nerve mapping) – surgical stent.
o Implant mode: voxel size 0.25 is enough (voxel size 0.08 is high resolution needed in cases of endo – but
resulted in high doses and decreasing field of view)
c- Postoperative assessment:
o Periapical x-ray: in cases of absence of signs and symptoms.
o CBCT: when implant retrieval is planned.
DICOM file:
 In case of sky blue software:
o Open the program.
o Select surgical guide module (as
implant planing is the first step in case
of surgical guide fabrication)
o Import patient CT scan (select any file
in DICOM file then the program will
begin)
o Select maximum quality or medium
according to your hardware.
o The Scout view will appear (adjust /
edit your view: make occlusal plane
parallel to floor – determine your field of view…etc.)

Arch curve:
 In case of sky blue software:
o Move axial line in panorama view to level of teeth neck (must be
on teeth and bone).
o Then draw curve in axial cut (view – draw curve: in middle of
molars and mid or just buccal in anterior)
o Ensure that all dots / squares in included within arch.
o May increase arch curve width (yellow lines) to ensure that the cut
contain all of your field.
o Note that:
 arch curve determines cuts that appear in panorama view.
 Make curve for arch that you need in your plan (if you will
manage both arches, start with maxillary)
Nerve tracing:
o It is important in case on implant placement or impaction to the determine relation to nerve.
o Note that: Canal width is 3.4 mm & nerve width is 2.2 mm.
o You can trace nerve by two methods:
1- Manual tracing (add nerve):
 By adding several points along nerve pathway in cross sectional cuts (bucco-lingulal)
 Start from the most posterior point, then move anterior.
 The mandibular nerve ends by nerve loop (5mm anterior to mental canal)
 So locate nerve anterior to canal first then add the last point in canal opening.
 Make point in middle of canal.
 You can determine color and width of nerve (2.2 mm)
 May place point in panorama then edit it in cross sectional view.
2- Detect nerve: just one point in nerve pathway (then edit your point in cross-sectional)

o Clinical significance:
 Mean distance between canal and root apices of: 2nd molar: 3.7 mm -
1st molar: 6.9 mm (the safest) - Premolar: 4.7 mm.
 The implant should be placed greater than 2 mm from the inferior alveolar canal.
 The implant should be placed greater than 2 mm above mental foramen & 5 mm anterior to it.
CBCT crop:
 It is important to make patient bite on cotton roll
or …. To separate upper and lower arch so can
isolate each arch to see it from occlusal view in
case of implant planing (imaginary implant) or
surgical guide fabrication.
 In Sky-blue panel: select (panels) then
(surfaces) then select (isolate = in case of
separated volumes) or select (cut = manual
remove excess)

Prosthetic driven implant planing:

 Ideal implant positioning:
o Mesiodistal position:
 Minimum 1.5 - 2 mm from the implant neck to adjacent tooth.
 Space between two implants should be 3mm or more.
o Faciopalatal position:
 The centre of implant is located directly below incisal edge of the final restoration or slight palatal.
 In posterior teeth: The centre of implant is located directly below central fossa of the final restoration
 Bone thickness after implant placement: Buccal bone: 2 mm - Palatal bone: 1mm
o Apicocoronal position:
 The depth position of the implant platform is 3mm (2 to 4 mm) below the facial free gingival margin / CEJ
of the adjacent. (running space)
 Steps:
1- Restoration first:
 Insert tooth crown to act as final restoration before implant placement:
 ADD tooth (select tooth and size (changeable))
 Place it in correct position regarding its neighboring and opposing teeth. (ensure the correct position in all
cuts (cross sectional – axial – panoramic view))
 Note that your restoration will be subgingival 0.5 mm.

2- Is this site can be implanted?

 Mesiodistal position:
 Measure distance between 2 teeth in axial cut (most accurate) by ruler.
 The distance must allow 1.5 mm between implant and tooth (3mm) and
implant with > 3 - 3.5 mm
 In this case MD distance = 7.78 mm (that allow placement implant 4 mm)

 Bone width (B-L) = plateau level: by ruler measure width of crest of

ridge or just below it.
 Most edentulous areas have a triangular C-section. Which if bone is not
available in width then slight osteoplasty would increase the width.
 Keep 1.5 – 2 mm from buccal and lingual (minimum 1mm)
 Implant diameter is restricted not only by Mesio distal and buccolingual
space but also emergence profile.
 Ideal implant width:
- Centrals: not more than 3.7
- Lateral: 3 -3.3
- Canine: 3.7 -4 mm
- Premolars: not more than 4.2 (restricted by M-D width)
- Molars: 5 -5.5 mm (molars area has the greatest MD width o larger implant to avoid cantilever effect)
 Bone length: By ruler measure bone height / length from bone width line to anatomical structure.
 Minimum length is 9.5 or 10 mm while the optimum is 12 mm (Longer implant doesn’t provide additional
retention of distribution of stress as force disseminated at bone at the level of 7: 10 (9) mm and not
transmitted to the apex)
 For posterior mandible estimate 2 mm at least from mandibular nerve.
 In premolar region implant length should be 5 mm away from mental foramen.
 Note: most drill systems extend 1.5 :2 mm beyond implant length.
  Bone density:
 CBCT less accurate than CT or DEXA scan (gold standard)
 From tools select (density value measures) then place button on area need to be
determined.

D1 (> 1250)
D2 (850 - 1250): the ideal bone for implant placement.
D3 (350 - 850): 2nd ideal bone.
D4 (350)

3- Insert implant below restoration:

 Steps:
 Continue to implant planing:
 Add implant you may choose implant from company system in software or customize your implant)
 Select length and width of implant (tapered implant = apical D < coronal D)
 Place implant below restoration and change its angle direction to cope with the restoration without violating
the remaining bone width.
 Avoid as possible using angled abutment especially in posterior.
 You can also insert abutment

4- Insert another implant:

 1st insert restoration.
 Determine mesio distal distance between 2 implants > 3mm
 Determine bone density, length and width.
 Insert implant (select diameter and length: in this case the bone width and length is optimum so we can
choose 10 mm implant length and 5.5 mm molar implant diameter)
 Notice the parallelism between two implants.
Advanced cases in planing:
 Deficient buccolingual width:
Case 1
o In this case there is adequate mesiodistal distance but deficient
buccolingual width (4.5 mm).
o Management:
 By bone grafting technique to increase width.
 Or bone expansion by osseodensification bur (Densah bur)
- Maximum Implant width to be used equal or slightly larger (0.7mm)
than initial ridge width.
- The ideal minimum ridge to expand is 4 mm (2 mm trabecular core +
1mm cortex on each side).
- It is D3 bone (soft bone = better expanded)

Case 2
o In this case B-L width is 2.8 mm and bone density is D2
o Osseodensification need 4mm. (can’t be done here)
o Management:
 Bone grafting is the ideal here: it is better to be
autograft cortical plate.
 Khoury technique (we found that there is sufficient
bone in retro molar area, so we will take buccal plate
to graft it in our implant site)

Case 3
o In this case B-L width is 3 mm with wide apical base 8.5 mm – and bone density of
D3.
o Management:
 Bone splitting (need wider base and bone density D2 –D3)

 Different angulation between implant and restoration:

o Use angled abutment: we can determine angle needed by measure angle
between implant and prosthesis.

 Dilacerated neighboring tooth:

o Apicoectomy.
o Short implant.
 Insufficient bone height (sinus approximation)
o Management: Sinus lifting
 If bone height 3 – 4 mm: open sinus lifting.
 If bone height 6 – 8 mm: closed sinus lifting.
o Sinus lifting by Densah bur:
 In this case height is 4mm and width is 6mm so can be done by
Densah lift protocol II (Minimum residual bone height = 4-5 mm
minimum alveolar width = 5 mm)
Surgical guide:
Types of surgical guide:
1- Bone supported:
o It is the most accurate: The template rests on the alveolar bone.
o Requiring the reflection of a full-thickness flap (extensive flap)
2- Mucosa supported:
o Most commonly used with a flapless technique.
o Used in cases of all on 4 (if no flap required)
o It depends on tissue (movable part) so to avoid this problem:
 Use well fitted denture (can be made with functional impression during jaw relation)
 Take x-ray with denture during biting.
 Patient bite on guide by the same bite.
 Fix the guide by anchor pins.
3- Teeth supported:
o It is accurate technique and most used- the template is directly placed on the natural teeth for support.
o In case of tooth tissue supported: the guide need to be fixed by pins.
Teeth supported surgical
 To prefabricate surgical guide, we need:
1- STL file: intraoral scan or model scanning.
2- CBCT:
 Registration of CBCT + model (superimposition of model on cast)
o Auto registration: by importing STL model (from “file” choose import STL model)
o Manual registration:
 Choose (points from model registration list)
 CBCT and model will appear close to each other.
 Zooming in occlusal view the place points at the same area in each model in different area.
 Choose tooth with clear scan (avoid any tooth with metal artifact, that will result in fault reading)

Adaptation of green
line (model) on each
tooth = correct
registration
Virtual wax up:
1. Make CBCT surface invisible to work on cast. (panels – surfaces – invisible)

2. Implant planing:
o Insert tooth crown (we can choose two crown
together by pressing shift button)
 Place it according to opposing, adjacent teeth
and contralateral teeth.
 Fix your virtual wax up: from tooth list – tooth
label – locking ()
 return CBCT to visible mode.

o Implant placement:
 Insert implant in middle M.D as possible – and slightly palatal esp. in anterior area.

3. Guide design:
o Guide design made on model: so we don’t need the virtual wax up (delete) or CBCT (make invisible)
o Choose advanced mode (change normal mode of blue scan program to advanced from the most RT upper are)
o From “panels” choose “implant list” then choose “guide tube”
 Guide hole diameter is larger than outer diameter of implant system sleeves by 0.1 mm to avoid
any errors in 3D printer (shrinkage)
 Height according to sleeve height.
 Offset: (9-11 mm): it is the distance between coronal part of implant to highest point of guide.
 Make guide tube visible.

In first pic (offset 10) the guide tube rest on mesial soft tissue, so increase offset in second picture
o Guide fabrication: from panels choose guide fabrication.
 Choose “Use automatic brush” then choose Guide thickness (2-3 mm)
 Block undercuts: choose “Define insertion direction then Define insertion direction from view
Insertion view = occlusal view

 Draw guide: choose draw curve

 First point is distal to guide tube. (shift + LT click).
 Make guide below teeth by 2mm to be retentive.
 Create surgical guide:
 Mucosa supported surgical guide:
 We need to scanning:
o CBCT scanning to patient: Patient wear will-fitted denture with radiographic marker
(metallic insert or gutta percha)
o CBCT scanning to the denture.
 Steps:
o CBCT crop: crop the opposite arch (lower arch in this case)
o Insert denture scan: from File insert DICOM –scan appliance with marker
o Adjust threshold of each image to make markers identical in each pic.

Markers in patient scan Markers in denture

o superimposition of denture scan and patient scan: Shift + lift click to place points on contralateral marker
in each scan.

o Implant planing:
o Surgical guide tube: should be above fitting surface of denture
o Guide fabrication: panels – guide fabrication – create scan appliance guide.
o Make denture scan invisible to see guide: panels – surface – scan appliance model (invisible)
 CBCT in perio
Surgical crown lengthening:
 lip retraction: placing cotton roll or using
Without cotton roll With cotton roll
retractor in sulcus between lip and teeth, make it
We can’t differentiate
easy to see gingival tissue in CBCT.
gingival tissue from lip tissue
 It is important to maintain biological
width2mm: (1.7 mm CT + 0.97 mm attachment
epith) + 0.5 mm sulcus depth
 So maximum gingivectomy to be at CEJ or
above by 0.5 mm + remove bone to be below
CEJ by 2mm.
 Steps:
o Make the cut line in middle of each tooth
in panorama view.
o So we can see middle of tooth in cross
sectional cut.
o Measure distance between free gingival margin and crest of bone in cross sectional cut = 6.04 mm
o In DSD the amount of gingiva need to be removed is 2 -3 mm (so enough remaining gingiva to form
biological width, so only gingivectomy is required in this tooth)

Soft tissue measure

 The soft tissue measurement is accurate using CBCT with an accuracy of 0.1 mm.
 Voxel size of 0.25 mm3
1. Measuring gingival biotype:
o The clear visualization of both soft and hard periodontal structures was possible
by conducting CBCT scans with soft tissue retraction (by cotton roll or lip
retractor)

2. Measuring palatal soft tissue thickness:

o Palatal soft tissue is common donor site for connective tissue grafting
used in mucogingival surgery.
o Palatal soft tissue thickness on maxillary posterior teeth and its
relation to palatal vault angle:
 Palatal vault angle on the maxillary first molar was measured
using the junction angle between the horizontal plane at the
cementoenamel junction (CEJ) and an imaginary line from the
midpalatal suture to the CEJ.
A- Shallow group: the angle was <30 degrees / the distance = 0-5 mm
thicker palatal soft tissue
B- Moderate group: the angle between 30 and 40 degrees. / the
distance = 5-10 mm
C- Deep group: the angle was >40 degrees / the distance = > 10 mm
 Impaction:
 We need to know relation between impacted tooth and anatomical
structure.
 And to know it’s exactly position (if 8 located buccal or lingual).
 Steps for impacted lower 8:
o 1st you must include the impacted tooth in your cut, so enlarge or
modify the arch curve to contain the tooth.
o Nerve tracing.
o See the position of tooth in axial cut (the 8 is located lingually in this
case)

 Another case:
o There is approximation of lower 7 root to nerve (must close to it so separation and removal).
o Lower 8 is located lingually.

CBCT in endo:
 When you ask for CBCT in endo cases: inform the technician that you
need endo mode for better resolution.
o Endo mode: voxel size 0.08 is high resolution needed in cases of
endo – but resulted in high doses and decreasing field of view.
 We can locate canals in axial cut.
 In this case: the incomplete cleaned and obturated canal resulted in
abscess.