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CBCT Om Seminar

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At a glance
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The key takeaways are that CBCT utilizes a cone-shaped x-ray beam and a detector to capture multiple planar projection images as it rotates around the patient. These images are then used to reconstruct a 3D volumetric dataset. CBCT has various applications in dentistry due to its ability to provide high resolution 3D imaging.

The principles of CBCT imaging are that it uses a rotating gantry with an x-ray source and detector to capture divergent cone beam projection images as it rotates around the patient. This allows reconstruction of a 3D volumetric dataset.

CBCT image formation involves x-ray generation using a pulsed x-ray source, detection of the attenuated x-ray beam using a detector, and software-based reconstruction of the 3D volume from the multiple 2D projection images captured during rotation.

Group 22

Cone-Beam
Computed
Tomography
Krystell Lau 181323047 Law Phui Wai 181323048 Visvam Rathinam 181323049
Learning Objectives
1. Describe the principles of CBCT. (C2)
2. Explain image formation in CBCT. (C2)
3. List the uses of CBCT in dentistry. (C1)
4. Search the recent concepts. (LL1)

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Principles of CBCT

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● Imaging performed using a
rotating platform/gantry
○ X-ray source (divergent
cone-shaped/pyramidal)
○ Detector
● X-ray directed through region
of interest (ROI)
● Attenuated beam projected
onto detector

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● Moves 180 to 360°- multiple sequential planar projection
images
● Individual images = basis, frame or raw images
○ constitute the raw primary data
● Projection data = the complete series of images
● Software programs generate a volumetric data set
○ provide primary reconstruction images (axial, sagittal
& coronal planes)

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Image Formation in CBCT

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Components of cbct image production
● X-ray generation
● X-ray detection
● Image reconstruction

Image Reconstruction

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1. X-ray Generation
Parameters in X-ray Generation

Patient X-ray
Stabilization Generator

Scan Scan
Factors Volume

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A) Patient Stabilization

Supine Unit Standing Unit Sitting Unit

● Physically larger. ● May not be able to ● Most comfortable.


be adjusted to a
● Greater physical height low enough ● May not allow
footprint. to accommodate scanning of
wheelchair-bound physically disabled
● May not be suitable patients. or
for patients with wheelchair-bound
physical disabilities. patients.

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A) Patient Stabilization
A. Supine Unit B. Standing Unit C. Sitting Unit

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A) Patient Stabilization
● Immobilization of the patient’s head is more important than patient
positioning .
● This can be achieved by using some combination of
➔ Chin cup
➔ Bite fork
➔ Other head-restraint mechanism

Chin cup Bite fork Combination of All


B) X-ray Generator

X-ray Generator

Continuous Pulsed
- Preferable.
- Actual exposure time is up to
50% less than scanning time .
- Reduces patient radiation
dose considerably.

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B) X-ray Generator

➢ ALARA (As Low As Reasonably Achievable) Principle of Dose


Optimization:

“ CBCT exposure factors should be adjusted on the


basis of patient size and specific diagnostic task.”

● This adjustment can be achieved by appropriate selection of


tube current (mA), tube voltage (kVp), or both.

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C) Scan Volume/ Field of View (FOV)
● Dimensions of the FOV or scan volume primarily depend on
- Detector size and shape
- Beam projection geometry
- Ability to collimate the beam

● Shape of the scan volume can be either Cylindrical


- Cylindrical or
- Spherical

Spherical

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C) Scan Volume/ Field of View (FOV)

● Collimating the primary x-ray beam limits radiation exposure to the


Region of Interest (ROI).

● Field size should be:


- Limited to the smallest volume that images the ROI.
- Selected for each patient based on the individual needs.

● Reduction of FOV
- Reduces unnecessary exposure to the patient.
- Produces the best images by minimizing scattered radiation, which
degrades image quality.
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C) Scan Volume/ Field of View (FOV)
Methods enabling scanning of ROI greater than the
FOV of the detector

Method 1
- Obtaining data from two or more separate scans

- Superimposing the overlapping regions of the CBCT data


volumes using corresponding fiducial reference landmarks
(“bioimage registration” or “mosaicing”).

- Software is used to fuse adjacent image volumes


(“stitching” or “blending”) to create a larger volumetric
data set.

- Disadvantage: Resulting in double the radiation dose to


such regions. 18
C) Scan Volume/ Field of View (FOV)
Methods enabling scanning of ROI greater than the
FOV of the detector

Method 2

- Offset the position of the


detector, collimate the beam
asymmetrically, and scan only
half the patient's ROI in each of
the two offset scans.

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D) Scan Factors

❖ The number of images that constitute the projection data from


the scan is determined by:

Detector frame rate


(number of images acquired per second)

Completeness of the trajectory arc


(180 to 360 degrees)

Rotation speed of the source and detector

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2. Image Detectors
Image Detector

Image intensifier tube/ Flat panel detectors (FPDs)


charge- coupled device
(II/CCD) combination ● Smaller and less bulky

● Larger and bulkier ● Rectangular basis image area


(Cylindrical volumes)
● Circular basis image area
(Spherical volumes) ● Minimal distortion of the image
dimensions at the periphery of an image
● Greater distortion of the grid
dimensions when moving away ● Employ an indirect detector based on a
from the center of the detector large-area solid-state detector panel
coupled to an x-ray scintillator layer
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➢ Voxel Size

● Voxels (volume elements) form the volumetric 3D data set.

● CBCT units provide voxel resolutions that are isotropic (equal in all 3
dimension).

● The principal determinant of nominal voxel size in the CBCT image are the
matrix and pixel size of the detector.

● Detectors with smaller pixels capture fewer x- ray photons per voxel and
result in more image noise.
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➢ Spatial Resolution
● The spatial resolution (detail of a CBCT image) is determined by the
dimensions of individual voxels.

● Both the focal spot size and the geometric configuration of the x-ray source
are important to determine the degree of geometric unsharpness, a limiting
factor in spatial resolution.

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➢ Spatial Resolution

● Reducing the object-to-detector distance and increasing source-to-object


distance also minimizes geometric unsharpness.

● Reducing source-to-object distance produces a magnified projected image on


the detector, increasing potential spatial resolution.

● Additional factors influencing image resolution include


- motion of the patient's head during the exposure
- type of scintillator used in the detector
- image reconstruction algorithms applied.

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➢ Gray Scale

● The ability of CBCT imaging to display differences in photon attenuation.

● This parameter is called the bit depth of the system and determines the
number of shades of gray available to display attenuation.

● All current CBCT units have 12-bit detectors that provides 4096 shades of
gray.

● A 16-bit detector can provide 65,536 shades of grey but with increased file
sizes and image processing time.
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3. Image Reconstruction
Image Reconstruction

Preprocessing Reconstruction
Stage Stage

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Preprocessing Stage

● Performed at the acquisition computer.

● Multiple planar projection images are must be corrected for inherent pixel
imperfections, variations in sensitivity across the detector and uneven
exposure.
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Reconstruction Stage

● Performed on the reconstruction computer.

● Corrected images are converted into sinogram, composite image developed from multiple
projection images (Radon transformation).

● Final image is reconstructed from the sinogram with a filtered back- projection algorithm
(Feldkamp algorithm) for volumetric data acquired by CBCT imaging.
(Inverse Radon transformation)

● When all slices have been reconstructed, they are combined into a single volume for visualization.
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➢ Reconstruction Time

➔ Reconstruction times vary depending on:

◆ Acquisition parameters (voxel size, size of image field, and number


of projections
◆ Hardware (processing speed, data throughout from acquisition to
reconstruction computer)
◆ Software (reconstruction algorithms)

➔ Reconstruction should be accomplished in an acceptable time (<5


minutes) to facilitate clinical workflow.

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Radiation Dose in CBCT

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Depends on:
● The exposure factors (kV, mA and
time of exposure)
● The volume size – field of view
● The type of equipment used
● The part of the jaw/maxillofacial
skeleton being imaged.

Bitewing/IOPA > Panoramic > Lat. Ceph >


Occlusal > Skull > CBCT > CT

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Artefacts in CBCT

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A) INHERENT ARTEFACTS
● Scatter
Cone-beam related
● Partial volume effect artefacts
● Cone-beam effect

IMAGE
ARTEFACTS B) PROCEDURE-RELATED ARTEFACTS
● Aliasing artefact
● Circular or ring artefact
● Double contour artefact

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C) INTRODUCED ARTEFACTS
-Beam hardening phenomenon:
● Cupping artefact
● Extinction / Missing value artefacts

IMAGE
ARTEFACTS D) PATIENT MOTION ARTEFACTS
● Double contour artefact

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A) Inherent Artefacts

● Scatter - results from x-ray photons that are diffracted


from their original path after interaction with matter
● “Quantum noise”
● Streak artefacts
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A) INHERENT ARTEFACTS

● Partial volume effect


● Selected voxel size > size of the
object being imaged
● Boundaries of image may have a
“step” appearance or
homogeneity of pixel intensity
levels.
● Occur in regions where surfaces
are rapidly changing in the Z
direction, e.g the temporal bone

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A) INHERENT ARTEFACTS - Partial volume effect continued…

● In the top row, the 3 × 5 pixels in size object “projected” just on the reconstructed pixels, so the real gray
scale values of the object are displayed on the reconstructed image. On the bottom row, the object is also
3 × 5 pixels in size but is not “projected” on the reconstructed pixels, so not the actual grayscale values are
displayed on the reconstructed image.

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A) INHERENT ARTEFACTS

● Cone-Beam artefact
● Peripheral “V” artefact of increased noise and reduced contrast
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B) PROCEDURE-RELATED ARTEFACTS

● Aliasing artefact - Moiré patterns


● Caused by undersampling due to:
○ Too few basis projections
○ Incomplete rotational trajectory arcs
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B) PROCEDURE-RELATED ARTEFACTS

● Circular ring artefact


● Due to
○ imperfect scanner detection
○ poor calibration
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B) PROCEDURE-RELATED ARTEFACTS

● Double contour artefact


● Caused by :
○ Misalignment of X-ray source to detector
○ Patient motion
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C) INTRODUCED ARTEFACTS

● Cupping artefact - distortion of metallic structures


● Extinction / Missing value artefacts - a “black” area with missing
diagnostic information between high density objects e.g implants
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D) PATIENT MOTION ARTEFACTS

● Double contour artefact

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Uses in dentistry

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Orthodontics

Complete Number,Shape and


hard tissue Anterior-posterior size
examination and transverse
of teeth
relationship of jaw
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Implantology & prosthodontics

To assess ● Implant site Evaluation of upper


the quality evaluation accurate maxillary posterior
and quantity measurement , teeth in relation to
of bone accurate planning the maxillary sinus
● Computerised
prosthesis
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Useful in planning
Useful during
periapical
obturation, under
endodontic surgery
and over filling
e.g : inferior dental
and sinus
Endodontics canal mental
problem
foramen

Diagnosis of Crown Morphology or root


apical lesion morphology,pulp and root canals
chambers and
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Periodontics

Diagnosis of detailed Measuring of bony


morphologic defects , furcation
description of the involvement ,
bone buccal and lingual
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defects
Oral and maxillofacial surgery
● Orthognatic
surgery
Assessment of ● Assessment of bone ● Post-treatment
impacted teeth , graft evaluation
supernumerary teeth ● Assessing and analysing ● Mid-face fracture o
and relation to their paranasal air sinuses facial bone
vital structure ● Craniofacial
reconstruction
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Recent updates
On cbct
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Recent updates

The CBCT-MCI guide was proven


to be an excellent and simple
tool to diagnose the severity of
MCI and predict the best method
of intervention.

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Recent updates

CBCT imaging technology has


a significant clinical
application effect on the
restoration of the upper
anterior tooth area in the
elderly

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Recent updates

Incorporation of AI system in
CBCT has significantly improved
the diagnostic capabilities of
dentists.

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TYPES OF CBCT SCANNERS
AVAILABLE IN
MALAYSIA

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CBCT Special feature Price

Planmeca Promax 3Ds Has SCARA3 construction $140,892-$200,000


which allows exact location
of image volume and thus
the adjustment of volume
size

Planmeca Viso G5/G7 Live Virtual FOV Positioning $259,000

Vatech Pax-i3D Green Low dose , protect user and $48,000


patient

Vatech Pax-i3D Smart 1 scan gives 2 images $38,000

Largev Smart 3D-X AI integrated Scanner Unavailable

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Planmeca Viso G7

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Largev
Smart3D-x

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Take home messages
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● All computed tomographic (CT) scanner consist of an X-ray source and detector mounted
on a rotating gantry, including CBCT imaging.

● Advantages of CBCT in dentistry include providing a high-quality image with minimal


distortion as a decreased cost and lower radiation exposure when compared to MRI and CT
will definitely be a significant tool in diagnosis,treatment planning and prognosis.

● Practitioners and operators using CBCT must have a thorough understanding of the
operational parameters and the effects of these parameters on image quality and
radiation safety.

● There should be justification of the exposure to the patient so that the total potential
diagnostic benefits are greater than the individual detriment radiation exposure might
cause.
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Quiz!

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1. CBCT is an imaging technique consisting of a
rotating gantry with an X-ray source and
detector.
True or False?

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1. CBCT is an imaging technique consisting of a
rotating gantry with an X-ray source and
detector.
True or False

65

2. Raw primary data in CBCT imaging consist of
frame images.

True or False?

66

2. Raw primary data in CBCT imaging consist of
frame images.

True or False

67

3. CBCT has a slower examination speed than CT
scan

True or False?

68

3. CBCT has a slower examination speed than CT
scan

True or False

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4. Dimension of FOV depends on ……..

A. Detector size and shape


B. Beam projection geometry
C. Ability to collimate the beam
D. All of the above

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4. Dimension of FOV depends on ……..

A. Detector size and shape


B. Beam projection geometry
C. Ability to collimate the beam
D. All of the above

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5. Which of the following factor(s) can influence
reconstruction time ?

A. Voxel size
B. Processing speed
C. Reconstruction algorithms
D. All of the above
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5. Which of the following factor(s) can influence
reconstruction time ?

A. Voxel size
B. Processing speed
C. Reconstruction algorithms
D. All of the above
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6. Moiré patterns are seen in
introduced artefacts.

True or False?

74

6. Moiré patterns are seen in
introduced artefacts.

True or False

75

5.

7. The artefact shown above can be due to misalignment of X-ray source


to detector or patient motion
True or False?
76

5.

7. The artefact shown above can be due to misalignment of X-ray source


to detector or patient motion
True or False
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thanks!
Any questions?

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References
● White, S.C. & Pharoah, M.J. (2009). Oral Radiology Principles and Interpretation (8th ed.). Mosby, St. Louis:
Elsevier
● Alhummayani, F. M., & Mustafa, Z. A. (2021). A new guide using CBCT to identify the severity of maxillary
canine impaction and predict the best method of intervention. Journal of orthodontic science, 10, 3.
https://doi.org/10.4103/jos.JOS_41_20
● Ezhov, M., Gusarev, M., Golitsyna, M., Yates, J. M., Kushnerev, E., Tamimi, D., Aksoy, S., Shumilov, E., Sanders, A., &
Orhan, K. (2021). Clinically applicable artificial intelligence system for dental diagnosis with CBCT. Scientific
reports, 11(1), 15006. https://doi.org/10.1038/s41598-021-94093
● Liu, S., Wang, S., Du, Y., Zhang, W., Cui, X., Xing, J., & Zang, Y. (2021). The clinical study of CBCT imaging
technology in the restoration of upper anterior teeth of the elderly. American journal of translational
research, 13(6), 7022–7028.
● Walsh, T., Macey, R., Riley, P., Glenny, A. M., Schwendicke, F., Worthington, H. V., Clarkson, J. E., Ricketts, D., Su, T. L.,
& Sengupta, A. (2021). Imaging modalities to inform the detection and diagnosis of early caries. The
Cochrane database of systematic reviews, 3(3), CD014545. https://doi.org/10.1002/14651858.CD014545
● Tamás Szabó, B., Dobai, A., & Dobo-Nagy, C. (2020). Cone-Beam Computed Tomography in Dentomaxillofacial
Radiology. Novel Imaging and Spectroscopy. https://doi.org/10.5772/intechopen.90932
● Guides/2014-planmeca-pricing_retail_0911814_low.pdf
● https://frontiermedicalstore.com/products/Planmeca-Viso-G7.html
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