POINT/COUNTERPOINT

Cone-beam computed tomography is the imaging technique of choice for comprehensive orthodontic assessment
Brent E. Larson Minneapolis, Minn

t is interesting to observe the adoption of new technology in dentistry and orthodontics. Of particular interest is the use of cone-beam computed tomography (CBCT) as the imaging protocol of choice for comprehensive orthodontic treatment. A concise review of the diffusion of innovation in dentistry was published by Parashos and Messer,1 who concluded that the adoption of technology is affected by factors that “include a complex interplay of perceived benefits and advantages, and psychosocial and behavioral factors, in decision-making.” Lateral and posteroanterior cephalograms were introduced to orthodontics in the early 1930s by Broadbent; yet, adoption of this technology, which is an accepted standard today, was still being resisted when Steiner2 wrote in 1953 about the use of cephalogram films: “It has been claimed by many that it is a tool of the research laboratory and that the difficulties and expense of its use in clinical practice are not justified. Many have argued that the information gained from cephalometric films, when used with present methods of assessment, do not contribute sufficient information to change, or influence, their plans of treatment.” Steiner’s statement could easily be applied to the use of CBCT today. A recent review suggested that CBCT should be used as an adjunct imaging technique in orthodontics.3 I propose that, although we still have much to learn about how to best use CBCT imaging to improve the outcomes of orthodontic treatment, we know enough about its application to consider it the imaging of choice for comprehensive orthodontic treatment.

I

BENEFITS OF CBCT FOR ORTHODONTIC ASSESSMENT

Associate professor and director, Division of Orthodontics, University of Minnesota, Minneapolis. Reprint requests to: Brent E. Larson, Division of Orthodontics, University of Minnesota, 6-320 Moos Tower, 515 Delaware St SE, Minneapolis, MN 55455; e-mail, larso121@umn.edu. Am J Orthod Dentofacial Orthop 2012;141:402-11 0889-5406/$36.00 Copyright Ó 2012 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2012.02.009

The benefits of CBCT for orthodontic assessment include accuracy of image geometry. Clinicians have learned to deal with the inherent image magnification and distortion that is part of 2-dimensional radiography. With lateral cephalograms, structures on the left side are magnified less than the same structures on the right because of proximity to the film. With panoramic imaging, the amounts of horizontal and vertical magnification vary at different rates as objects are displaced from the focal trough. However, CBCT offers the distinct advantage of 1:1 geometry, which allows accurate measurements of objects and dimensions. The accuracy and reliability of measurements from CBCT images have been demonstrated, allowing precise assessment of unerupted tooth sizes, bony dimensions in all 3 planes of space, and even soft-tissue anthropometric measurements—things that are all important in orthodontic diagnosis and treatment planning.4-6 Additionally, to allow use of our historic growth and normative data, it has been shown that landmarks can be located reliably on cephalometric images that are generated from the CBCT volumes.7 Other benefits include the localization of ectopic teeth and the assessment of root resorption. The accurate localization of ectopic, impacted, and supernumerary teeth is vital to the development of a patient-specific treatment plan with the best chance of success. There seems to be little debate in the literature that CBCT is superior for localization compared with conventional imaging methods.8,9 One study indicated that this improved localization and space estimation does result in changes in diagnosis and treatment recommendations.10 Another study analyzed the “failed” treatment of 37 impacted canines, successfully delivering the canine in about 70% of these cases because of careful diagnosis and 3-dimensional imaging. Initially, failure occurred because of mistaken localization and directional traction in 40.5% of the patients. 11 There is also increasing evidence that assessment of

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whereas the images patients. can postural adaptations to airway problems can cause unbest be done with CBCT. or images mandibular joint has not consider it the imaging of choice for taken from a CBCT volume. Although these provided meaningful insight for Orthodontics’ requirement to include a formal peria diagnosis. since much resorption occurs desirable growth changes. we know useful for clinicians. internal or extercant enough for further follow-up or referral.13 We recently conducted a study Although we still have much to learn ramic image supplemented about how to best use CBCT using CBCT to objectively aswith bitewing and anterior sess asymmetry and found imaging to improve the outcomes of periapical radiographs.18 A similar result for incidental temporomandibular joint nal root resorption. The orthodontist can screen for bony changes derived images offer advantages for periodontal assessand get an indication of condylar position from this rement. however.21 Although as a specialty we still struggle to understand result. and our view of the sinuses has been limited to anomaly since it did not correspond with my clinical the tomographic slice on the panoramic image. nonorthodontic population. and Imaging suggestions for this has been judged to be supeevaluation include a panorior to previous methods.404 Point root resorption. lending additional support to the the sinuses are clearly visible and measurable. With experience.12 dental findings in orthodontic patients. fore orthodontic treatment has always been important study models. or retained root tips. The view of the confrom the CBCT are recondyle and the fossa on a panostructed as needed from the acquired volume with no ramic film has been used as a screening tool with additional exposure required. 3-dimensional views of the airway and ent population. of the most difficult problems to diagnose and treat. This is another item that was in a slanted direction that is not readily imaged without frequently noted by the radiologist in our study of incithe use of a tomographic technique. Misch et al23 reported subsequent specific imaging ordered for the temporothat CBCT imaging provides a significant advantage mandibular joint if bony changes are noted.25 view. ranging from relatively minor sinusitis or polyps to Before CBCT. an asymmetric malocclusion is one patient population had sinus or airway findings noted. 18 The need to assess the periodontal bone levels bethe problem were assessed from clinical examinations. 20.14 graphs including periapicals enough about its application to Imaging of the temporoand bitewings.18 These are important items to assess before final orthodontic findings was reported by researchers in North Carolina planning—items that could dramatically alter the treatin an older. I was convinced that this high degree of has been limited in its ability to assess airway dimenendodontic involvement was most likely a statistical sions. The over conventional radiographs for periodontal assessCBCT volume used for orthodontic assessment will ment because it allows for the measurement of buccal generally include the right and left temporomandibular and lingual defects as well as interproximal defects. the CBCT volume allows direct measureodontal evaluation for all patients over the age of 18 ment of the transverse dimensions and the relative poyears or for those with signs of periodontal disease.22 The first 2 are supplemental been common practice for comprehensive orthodontic images that require additional asymptomatic orthodontic treatment. the skeletal and dental contributions to complete opacification of the maxillary sinuses.19 Traditional 2-dimensional cephalometric imaging ment plan. and perhaps a posteroanterior cephaloand has been emphasized with the American Board of gram. the impact of the airway on the growth and developRecent reports have suggested that certain regions ment of our patients. we all understand that breathing are more desirable as placement sites for temporary April 2012  Vol 141  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics .15-17 A recent review of nearly 200 consecutive orA truly unexpected result from our study of CBCT thodontic patients at the University of Minnesota incidental findings in orthodontic patients was the showed that 18% had incidental temporomandibular 10% frequency of significant endodontic findings: apijoint findings noted by a radiologist that were significal periodontitis. or that this method is potentially a full-mouth series of radioorthodontic treatment. apical radiolucency. both from ectopically erupting teeth has primary biologic importance and that significant and as a side effect of orthodontic treatment. joints. and therefore they are available for routine reOther investigators have also found that CBCTview.24. sitions of the teeth within the skeletal components. Price et al19 recently reported a similar prevalence of endodontic findings in a differCBCT imaging. exposure. Nearly half our In orthodontics.

From my personal experience. a panoramic radiograph. the confidence gained in treatment decisions and the greater ability for patients to visualize problems dramatically improves my practice. a new low-dose scan protocol has been added to the CBCT machine that provides the needed orthodontic diagnostic information for an estimated 35 to 40 mSv (based on our data adjusted for reduced milliampere-second exposure). In addition.30 Recently. an investment must be made in the equipment. Obviously.29 Although 1 limitation of CBCT is that bone density in Hounsfield units is not as standardized as medical computed tomography. and promise efficient and effective treatment that is specific for each patient. they do not provide patientspecific information. identify endodontic problems.26-28 These recommendations are based on average cortical bone thickness and bone depth determined from CBCT images of skulls or patients. Tex) has been using CBCT technology for the last several years to provide the data necessary for planning and executing technology-assisted treatment through its SureSmile system. view condylar positions and temporomandibular joint bony structures. In addition to the items listed above. CONCLUSIONS The assessment of available information. 33 If fullmouth intraoral radiographs are taken to assess the periodontal status of adults. the fabrication of custom lingual orthodontic appliances has been demonstrated by using CBCT image data with existing technology to virtually plan a patient’s treatment and manufacture the custom appliances with 3-dimensional printing technology. and any supplemental films that are required. identify and quantify asymmetry. areas that might be considered as placement sites for temporary skeletal anchorage devices can be individually assessed for bone quality without the cost or the inconvenience of additional imaging. and this raised effective dose calculations from 32% to 422%. Orametrix (Richardson. the International Commission on Radiological Protection released updated guidelines in 2007 that added salivary glands. in my opinion.33 Subsequent to our testing. Most current recommendations are that CBCT should be used as an adjunct imaging technique when conventional 2-dimensional imaging proves to be inadequate. comparisons of various imaging protocols and machines should be done by using those guidelines and not the previous 1990 guidelines. To answer this question specifically for our facilities at the University of Minnesota. and many practitioners have difficulty justifying the return on this investment. However.406 Point skeletal anchorage devices. and plan placement sites for temporary April 2012  Vol 141  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics . improve localization. and airway tissues to the dose equation. The ability to measure accurately. as well as my clinical experience. we conducted dosimetry testing of our CBCT machine and our conventional 2-dimensional digital radiography equipment. oral mucosa. assess periodontal structures. The bone density measured on CT imaging has been correlated with the risk of neurosensory disturbance after sagittal split mandibular advancement. with only slightly more than conventional orthodontic imaging without any supplemental radiographs. The question of primary importance is the radiation burden of a CBCT image relative to a conventional lateral cephalogram. Although these general recommendations are helpful. visualize airway abnormalities. the transition to CBCT imaging for orthodontic assessment did not add to the patient cost of treatment in our university clinic or our private practice.31 Such advances appear to be rapid. We found that the CBCT imaging normally used for comprehensive orthodontic patients was about 65 mSv compared with about 26 mSv for a lateral cephalogram and a panoramic image taken on our digital machine. Comparison of effective radiation dose levels is difficult because of the many CBCT machines now available and the fact that new scanning protocols for the machines are constantly being implemented based on software modifications. These rapid advances in CBCT technology have resulted in 3-dimensional images that have about 2% or less of annual background radiation. CBCT imaging typically reduces the patient dose. When patients have CBCT imaging as part of their initial record set. There is little published information regarding the financial cost of CBCT technology used for orthodontics. since efficiency and income are not directly affected. has led me to believe that CBCT imaging for comprehensive orthodontic patients has substantial advantages. COSTS OF CBCT FOR ORTHODONTIC ASSESSMENT The general argument against using CBCT as a standard imaging protocol for comprehensive orthodontic treatment centers on the radiation burden to patients.32 Therefore. the use of fractal dimension analysis of CBCT images has recently been described as a promising tool for detecting bone changes caused by bisphosphonates. there are reports that suggest future benefits of CBCT imaging related to risk management.

Nakamura S. Ren Y. Lai E. .14:17-24.” If you substitute CBCT for cephalometer and cephalometrics in Steiner’s comment. Chen YJ. Kurabayashi T. Sendi P. it would summarize my feelings on the adoption of this technology in orthodontics.408 Point skeletal anchorage devices adds to the practitioner’s knowledge base at the time of orthodontic diagnosis. he challenged orthodontists with the following words: “The cephalometer is here to stay. Sievers MM. Eur J Orthod 2011.111:634-40. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010. Berco M. American Board of Orthodontics. Price JB. CBCT has replaced conventional lateral cephalograms and panoramic images as the most commonly ordered imaging for comprehensive orthodontic patients. Northwest Dent 2011. Looking forward. and full-mouth set of radiographs with round collimation). 14. Willems G. Pazera A. Miner RM. A protocol for evaluating condylar position in symptomatic TMD patients. Larson BE. Botticelli S. 3. Major PW.136:17. 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Hu FC. Evaluation and comparison of postero-anterior cephalograms and cone-beam computed tomography images for the detection of mandibular asymmetry. visualizing root proximity and resorption. Lutz J.141(Suppl 3):14-8S. Pazera P. 21. Chang ZC. Dreiseidler T. 16. Parashos P. 8. accept the added burden it imposes. Incidental maxillary sinus findings in orthodontic patients: a radiographic analysis using cone-beam computed tomography (CBCT). Willems G.39:343-8. Am J Orthod Dentofacial Orthop 2011. Clin Oral Implants Res 2011 Sep 30 [Epub ahead of print]. All of these advantages are currently available with little increase in radiation dose relative to a modern digital panoramic and single cephalometric film. Fieuws S. Am J Orthod Dentofacial Orthop 2010. Paniagua B. Alkhader M. Chaushu G. Scheer M. Padilla RJ. Damstra J. Cone-beam computed tomography and the orthosurgical management of impacted teeth. Comparison of two cone beam computed tomographic systems versus panoramic imaging for localization of impacted maxillary canines and detection of root resorption. Jacobs R. Bornstein MM. Conley RS. Zinser MJ. J Am Dent Assoc 2010. Toogood RW. 20.39: 729-55. Yao CC. Gaillard PR.40:24-34. Palconet G. 5. Eur J Orthod 2011.americanboardortho. Lagravere MO. Harrell WE Jr.com/professionals/clinicalexam/ April 2012  Vol 141  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics . Although better scientific evidence of improved outcomes is desired. Analysis of failure in the treatment of impacted maxillary canines. Kuribayashi A. Rigali PH Jr. Steiner C. 12. Cevidanes LH. The diffusion of innovation in dentistry: a review using rotary nickel-titanium technology as an example. 4.e1-9: discussion. Alqerban A. Thaw KL. Katsaros C. REFERENCES 1. Melsen B.33:93-102. 7. In fact. Cattaneo PM. Available at: http://www. Kapila S. Pliska B. 22. et al. Incidence of significant findings on CBCT scans of an orthodontic patient population. DeLuca S. Am J Orthod Dentofacial Orthop 2011.90:12-6. Becker A.140:e129-39. 15. J Clin Orthod 2011. Quantification of condylar resorption in temporomandibular joint osteoarthritis. Am J Orthod Dentofacial Orthop 2009. Wey A.137:743-54. Cephalometrics for you and me. Ritter L. the radiation burden of a single CBCT image represents more than an 80% reduction in dose—a remarkable technologic achievement! According to the writings of Steiner2 in 1953. Dentomaxillofac Radiol 2011. Nackaerts O. compared with the standard record set I used 15 years ago (lateral and posteroanterior cephalograms. Neugebauer J.33:344-9. Incidental findings from cone beam computed tomography of the maxillofacial region: a descriptive retrospective study. 11. CBCT might help us with risk assessment by assessing bone density. Cleft Palate Craniofac J 2011. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006. Orthod Craniofac Res 2011. Am J Orthod Dentofacial Orthop 2008. Ohbayashi N. Gerrits PO. Alqerban A. Anderson NK. Twoversus three-dimensional imaging in subjects with unerupted maxillary canines. Three-dimensional accuracy of measurements made with software on conebeam computed tomography images.134:112-6. Ren Y.110:110-7. With the understanding that each patient is assessed before imaging and that patient-specific imaging decisions are made. Will LA. SEDENTEXCT Project Consortium. Tyndall DA. Case preparation. Ludlow JB. panoramic film. Eur J Orthod 2011 Mar 31 [Epub ahead of print]. 18. 2. Angle Orthod 2011 Oct 6 [Epub ahead of print]. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011. Accuracy and reliability of linear cephalometric measurements from cone-beam computed tomography scans of a dry human skull. Dentomaxillofac Radiol 2010. Chaushu S. Messer HH. 13. Verna C. and even providing the imaging data to support treatment simulation and technology-aided treatment. 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