PRACTICAL GUIDE

TO PANORAMIC
AND CONE BEAM
IMAGING
PRACTICAL GUIDE TO PANORAMIC AND CONE BEAM IMAGING

The radiological iconography published in this document was created with the cone beam CS 9300 from
Carestream Health Inc. The CS 9300 is a class 2b medical device manufactured by Carestream Health Inc.,
which has been subject to a conformity assessment according to the BSI. It is intended to produce digital
radiographic images in two or three dimensions of the dento-maxillo-facial and ENT areas. Read the
instructions for use carefully.

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PRACTICAL GUIDE TO PANORAMIC AND CONE BEAM IMAGING

Summary

1. Note
• Positioning for panoramic imaging page 4-7
• Acquisition parameters page 8-9

2. CBCT acquisition
• Patient positioning page 10 - 11
page 12 - 13
3. The different types of volumes
4. The different planes
page 14 - 19
5. The protocols
page 20 - 23

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PRACTICAL GUIDE TO PANORAMIC AND CONE BEAM IMAGING

Panoramic positioning
Although it is generally considered to be one of the easiest images to capture
and can only provide a rough diagnostic examination, the panoramic image
still requires precise patient positioning.

1. Ask the patient to remove all metal accessories

• All jewelry (earrings, chains. etc.), hair accessories, eyeglasses, hearing
aids and removable dental prostheses must be removed to prevent the
projection of their image onto the plate conceiling clinically relevant
information.

2. Position the patient horizontally with a Frankfurt plane

• The Frankfurt plane is a "virtual" plane passing through the lower
edge of the orbit (in front) and the upper edge of the external auditory
canal.

Horizontal
Frankfurt plane

-- Complying with this standard allows an almost rectilinear occlusal

plane (a) to be obtained, the hard palate is at a tangent to the
direction of the beam and is therefore not divided (b), and teeth from
different sectors will be included in the panoramic cutting plane (and
will be clear and without enlargement of the apices).

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PRACTICAL GUIDE TO PANORAMIC AND CONE BEAM IMAGING

Panoramic positioning
b

a ---------------------------------------------------------------


-- If this positioning guide is not met, the occlusal plane will be
excessively curved, the hard palate will be divided in two, and
the teeth will appear too large or too small (depending on the
angle of the Frankfurt plane).

Incorrect positions: head too low

• Result:
• deformed occlusal plane (d)
• divided hard palate (e)
• teeth in sectors 1 and 2 magnified (f)

• teeth in sectors 3 and 4 minified and outside the panoramic
reference plane (blurred) (g)

d f

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PRACTICAL GUIDE TO PANORAMIC AND CONE BEAM IMAGING

Panoramic positioning
Incorrect positions: head too high
• Result:
• deformed occlusal plane (h)


• divided hard palate (i)
• teeth in sectors 3 and 4 magnified (j)
• teeth in sectors 1 and 2 minified and outside the panoramic
reference plane (blurred) (k)
• appearance of a trail of deletion caused by out-of-field
structures (l)

k
h
j

l
3. Position the median plane of the patient correctly

• To prevent any axial deformations and any asymmetry of

anatomical structures, the operator must ensure that the
patient is correctly centered in the unit and that the "pacifier"
is being bitten correctly between 11-21 and 31-41 (m)

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PRACTICAL GUIDE TO PANORAMIC AND CONE BEAM IMAGING

Panoramic positioning
-- If this positioning guide is not
met, there is asymmetry of the
ascending branches, in extreme
cases one of the arches will be
blurred, the teeth will appear
stretched and one of the TMJs
may be truncated.
m 
Median plane of the
patient

"Bite" offset to the

left

4. Ask the patient to place the tongue on the palate 

• Reason: To expel air from the mouth to reduce the buccal clarity
and so as reveal the jaw structure more clearly




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PRACTICAL GUIDE TO PANORAMIC AND CONE BEAM IMAGING

Acquisition parameters
Although panoramic and CBCT systems benefit from the latest acquisition
technologies and are configured to provide optimal image quality for the selected
exam type, it is essential that certain basic rules are observed in order to
guarantee the best results in terms of image quality while not losing sight
of the principles of radiation protection of patients.
Selecting the patient size allows the adjustment of the ellipse of the panoramic
unit or centering a 3D volume as well as to influence the "quality" of the
radiation reaching the patient.
However, in some cases, it may be necessary to change these parameters, for
example in the following cases:
• patient size does not correspond to the standard programs
• it is desired to reduce noise in the image
• the presence of artifact-generating material (3D examinations)

The parameters that can be changed are:

• kV (kilovolts):
This value represents:
-- the potential difference applied between the cathode and anode in
the X-ray tube.
-- the penetration of the radiation emitted

• mA (milliamps):
This value represents:
-- the electric current intensity applied to the cathode of the X-ray tube
-- the quantity of photons emitted

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PRACTICAL GUIDE TO PANORAMIC AND CONE BEAM IMAGING

Acquisition parameters
In practical situations, when the operator wants to:
• reduce the dose delivered to the patient:

-- it is necessary to reduce the mA and increase the kV.

• reduce the quantum noise in the image (grain):
-- it is necessary to increase the mA, without forgetting that this will
have a direct impact on the dose delivered.
• reduce the impact of artifact-generating material during the acquisition of
volumes (CBCT):

-- it is necessary to increase the kV

• adapt the beam penetration according to the morphology of the patient:
-- it is necessary to reduce the kV and mA if the patient's size is smaller
than that defined in the morphotypes offered by the user interface.
-- it is necessary to increase the kV and mA if the patient's size is larger
than that defined in the morphotypes offered by the user interface.

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PRACTICAL GUIDE TO PANORAMIC AND CONE BEAM IMAGING

Patient positioning
• CBCT technology allows volume acquisition at very high
resolutions (voxel size sometimes less than 100 μ): it is therefore
essential to prevent any patient movements.
-- A suitable restraint device must be applied systematically (using straps and
headbands).
-- Attaching this restraint device may be inconvenient but will significantly
reduce the percentage of retakes and limit the patient dose.
-- To prevent the patient's eyes from following the unit during the
examination, it is recommended to ask the patient to close their eyes. This
will reduce the risk of movement and will also reduce the radiation dose
to the ocular lens.
-- The patient should breathe calmly through the nose and swallow the
saliva before the acquisition begins.
• Although it is recognized as less susceptible to artifacts than CT
technology, it is nevertheless recommended to do the following to
reduce the perception of the repetition artifact:
-- position the occlusal plane of the patient horizontally (if possible)

Occlusal plane · · · · · · · · · ·

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PRACTICAL GUIDE TO PANORAMIC AND CONE BEAM IMAGING

Patient positioning
-- ask the patient to place the tongue on the palate (in the same way as
a dental panorama acquisition) to make the densities homogeneous
in the buccal clarity.

Heterogeneous density in the

Tongue placed on the palate,
buccal clarity, repetition artifact
repetition artifact less visible
more visible

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PRACTICAL GUIDE TO PANORAMIC AND CONE BEAM IMAGING

The different field sizes

• The size of the selected fields and therefore the spatial resolution of the
acquired volumes depends on the indication of the examination.
• All CBCT units on the market are similar in terms of the type of field sizes:
- sectoral
- single arch
- medium
- large

• In general:
- Sectoral fields (5x4, 5x5, etc.)
- w
 ith high definition (voxel size less than 100 µm) and high
quality are used in endodontic and periodontal investigations.
- w
 ith a standard resolution (less irradiating) are used in
orthodontic investigations (resorptions, inclusions, malposition)
or single implant investigations

- Single-arch fields (8x8, 10x5, etc.)

- a re used in implant, orthodontic and stomatological
examinations and in all cases requiring the irradiation of only
a single arch (dose optimization)

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PRACTICAL GUIDE TO PANORAMIC AND CONE BEAM IMAGING

The different field sizes

- Medium fields (10x10, 8x8, etc.)
are used in the following examinations:
- orthodontics (8x8 or 10x10)
- implants (10x10)
- search for sites of infection
- exploration of wisdom teeth (4 quadrants)

- Large fields (17x11, 17x13.5, 17x6, etc.)

are used in the following examinations:
- complex implants (pterygoid implants)
- orthodontics
- stomatology
- sinuses (for dental purposes)
- maxillofacial (reconstructive and orthognathic surgery)
- bilateral exploration of the TMJ

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PRACTICAL GUIDE TO PANORAMIC AND CONE BEAM IMAGING

The different planes

THE ORTHOGONAL PLANES
• The software for processing the volumes acquired by CBCT
was developed to enable optimized diagnostics of the dental
sphere and its environment.
• The so-called "orthogonal" planes allow a rapid assessment
of the quality of the acquisition as well as a "scan"-type
exploration of the sinus cavities
• The three "orthogonal" planes are therefore:

The axial plane

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PRACTICAL GUIDE TO PANORAMIC AND CONE BEAM IMAGING

The different planes

The coronal plane

The sagittal plane

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PRACTICAL GUIDE TO PANORAMIC AND CONE BEAM IMAGING

The different planes

THE CURVILINEAR AND CORONAL-OBLIQUE PLANES
• The exploration of the dental sphere requires the generation of specific
planes; the very shape of the dental sphere and the structures composing
it does not permit exploration via orthogonal planes.
• One of the first obvious actions is therefore to create a curvilinear (or
pseudo-panoramic) plane to obtain a reference plane tangential to the
mandible and/or maxilla.

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PRACTICAL GUIDE TO PANORAMIC AND CONE BEAM IMAGING

The different planes

THE CURVILINEAR AND CORONAL-OBLIQUE PLANES
• Based on the curvilinear reference plane, the essential views for any dental
exploration will be generated.

The coronal oblique planes

(or: cross-section; transaxial, Dentascan*)

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PRACTICAL GUIDE TO PANORAMIC AND CONE BEAM IMAGING

The different planes

THE OBLIQUE PLANES
• The dental sphere consists of structures that are oriented in 3 spatial axes
(e.g. teeth, mandibular canals, TMJs). It is therefore essential to be able to
generate so-called "oblique" planes:
they can identify the presence of diseases, fractures, etc., by making them
visible on multiple planes, and they can also create planes tangential to
the anatomical structures explored
• The oblique planes may be oriented with double angulation depending on
the other reference planes.

The axial oblique plane

The axial
oblique
plane
Vs
Axial
plane

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PRACTICAL GUIDE TO PANORAMIC AND CONE BEAM IMAGING

The different planes

Coronal oblique plane

Coronal oblique plane

Vs
Coronal plane

Sagittal oblique plane

Sagittal
oblique plane
Vs
Sagittal plane

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PRACTICAL GUIDE TO PANORAMIC AND CONE BEAM IMAGING

Protocols
• The protocols for conducting dental examinations may differ depending
on the specialties.
• The parameters to be taken into account in conducting CBCT
examinations are:
1. the types of occlusions
2. the spatial resolution and field size
3. the types of cuts and views generated
- orientation of the axial plane
- types of cuts
- outline of the mandibular canals

1. The types of occlusions

a. Incomplete occlusion (mouth half open)
- Indications: orthodontics, endodontics and all cases where analysis of
the entire tooth is required

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PRACTICAL GUIDE TO PANORAMIC AND CONE BEAM IMAGING

Protocols
b. MIP occlusion
(Maximum Intercuspation Occlusal position)
- Indication: implantology
- Value:
» visualization of antagonistic effects
» guiding of prosthetic axes

- Patients with a removable dental prosthesis

» Keep it in the mouth if it is a resin prosthesis
» Remove it if it includes a metal frame
» Implant guide  Keep it in the mouth

Note: The goal is to visualize any antagonistic effects as clearly as

possible.
c. CR occlusion (Centered Relationship)
- Indication: orthodontics
- Value:
» Analysis of osseous maxillo-mandibular relationships

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PRACTICAL GUIDE TO PANORAMIC AND CONE BEAM IMAGING

Protocols
2. Spatial resolution and field size
see pages 12 & 13 of this booklet

3. Types of cuts and views generated

a. Orientation of the axial plane (via reformatting of the volume)

1. Parallel to the occlusal plane

2. Parallel to the basilar edge of the mandible

(mandibular implant examination)

3. Parallel to the hard palate

(maxillary implant examination)

b. Types of cuts

Types of cuts Implantology Endodontics Orthodontics

Axial 
Pseudo-Pano   
Coronal Oblique  
Oblique (3 axes)  

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PRACTICAL GUIDE TO PANORAMIC AND CONE BEAM IMAGING

Protocols
Implantology Endodontics Orthodontics
Thickness 1 mm < 100 µ 100 µ to 1 mm
Spacing 1 mm < 100 µ 100 µ to 1 mm

c. Outline of the mandibular canals

- P rincipally for examinations in implantology, malposition and apical
and periapical lesions
- T he purpose of the outline is to best image the root of the mandibular
nerve, but must not hide the canal walls




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© Carestream Health, November 2013.