CBCT in Orthodontics
CBCT in Orthodontics
BY
DR M GREESHMA HARINI
3RD YEAR POST GRADUATE
DEPT. OF ORTHODONTICS
NARAYANA DENTAL
CBCT IN ORTHODONTICS
CONTENTS:
1. Introduction
2. History
3. CBCT vs. CT
4. Classification of CBCT
5. Indications ,limitations & Errors in CBCT
6. Application of CBCT in
• Orthodontic diagnosis
• Treatment planning
• Assessing treatment progress and outcome
• Risk assessment
7. Radiation safety
8. Radiation Guidelines
9. Conclusion
10. References
3
INTRODUCTION :
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INTRODUCTION :
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INTRODUCTION :
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History :
CBCT IN ORTHODONTICS
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2.CBCT VS CT
CBCT VS CT
Presentation
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Types of CT scanners
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• Acc to Sukovic et al., 2001; A CBCT scan with a single revolution of the
radiation source is sufficient to scan the entire maxillofacial region.
• CBCT technology is based on the use of a cone-shaped X-ray beam that
is directed through the patient and the remnant beam is captured on a flat
two-dimensional (2D) detector.
• The X-ray source and detector are able to revolve about a patient’s head,
and a sequence of two-dimensional (2D) images is generated.
• These 2D images are then converted into a 3D image using computer
software.
• The rapid movement of the X-ray tube and digital detector through 180°,
or more frequently through 360°, produces essentially instantaneous and
precise 2D and 3D radiographic images of an anatomical structure.
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Advantages of CBCT over conventional CT:
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Classification of CBCT scanners :
Presentation
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Operational principles of CBCT
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FIGURE : In CBCT, a complete or partial rotation of gantry around subject
head produces the multiple sequential base images. From these base
images, volumetric dataset composed of isotopic voxels is reconstructed by
software programmes.
Presentation
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Field of view(FOV) : Area of interest to be covered during the scanning
procedure.
Presentation
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• The desired FOV is determined by the region of interest.
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The size of the FOV depends on:
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Indications of CBCT imaging in orthodontics:
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Application of CBCT in orthodontics.
Presentation title
Orthognathic Surgery 26
superimposition
Risk assessment Investigation of orthodontic-
associated paraesthesia
Assessment of orthodontics induced
root resorption
Post treatment TMD
Machado G. L. (2015). CBCT imaging - A boon to orthodontics. The Saudi dental journal, 27(1), 12–21.
Presentation title 27
• Assessment of skeletal and dental structures:
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3D evaluation of impacted teeth:
• CBCT is commonly used to assess an impacted tooth and its position .
• Research has shown that enhanced precision in the localization of
canine teeth and improved estimations of the space conditions in the
arch can be obtained with CBCT, and this can greatly affect diagnosis
and treatment planning to facilitate a more clinically- orientated approach.
• Acc to Wriedt et al., 2012 ;Small volume CBCT is also justified as a
supplement to routine panoramic X-rays in the following cases: when
canine inclination in the panoramic X-ray exceeds 30°, when root
resorption of adjacent teeth is suspected, and/or when the canine apex is
not clearly discernible in the panoramic X-ray, implying dilaceration of the
canine root
Presentation title 29
Acc to Katheria et al. (2010) ;When comparing conventional radiography
and CBCT, found that CBCT provides more information regarding the
location of pathology, the presence of root resorption, and treatment
planning.
However, the benefits of CBCT imaging must be weighed against the
radiation risk to pediatric patients and the complexity of the pathology
involved.
Presentation title 30
re-treatment images derived from CBCT of a patient with retained mandibular primary second molars and
impacted second premolars. (a) Reconstructed panoramic radiograph shows a distally impacted mandibular
right second premolar and mesially impacted mandibular left second premolar. The precise spatial positions
of the mandibular second premolars and their relationships to neighbouring structures can be determined
from axial
Presentation title (b, c), sagittal (d, e) and three-dimensional volumetric (f) reconstructions to develop a virtual 31
treatment and biomechanical plan. Reproduced from Kapila and Nervina48, Copyrightª2014, John Wiley and
Son
Growth assessment:
Joshi et al., 2012; CBCT scans can be used to reliably assess cervical
vertebrae maturity, which provides a consistent evaluation of skeletal
maturity
Pharyngeal airway analysis:
Vizzotto et al., 2012; Lateral cephalograms have been routinely used to
assess the airway .
Conventional radiography and reconstructed 2D CBCT images provide
similar assessments of the airway.
In comparison, axial cuts of 3D CBCT scans provide soft tissue points that
are derived from the projection of shaded areas, which are more clearly
visible in axial CBCT cuts compared with conventional radiographs, thereby
enhancing airway assessment.
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• Three-dimensional CBCT-assisted airway analysis also facilitates the
diagnosis and treatment planning of complex anomalies including
enlarged adenoids and obstructive sleep apnea (OSA).
• Acc to Ogawa et al.2007;
• The apnea-affected subjects showed a significant decrease in airway
volume, area, and distance, thereby highlighting the importance of CBCT
in the diagnosis of this condition.
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Airway measurement with CBCT: anatomic boundaries of the upper pharyngeal air-
way (pink) (A). Segmentation of the upper airways: nasopharynx (green), oropharynx
(red) andhypopharynx (lower yellow) (B)
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Assessment of the temporomandibular joint (TMJ) complex in three
dimensions
• Honey et al. (2007) compared CBCT imaging of the TMJ complex with
panoramic radiography and linear tomographic views, and found that the
CBCT images were more accurate and showed superior reliability in
diagnosing condylar morphology disturbances and erosion.
• For a complete bilateral TMJ exam, an average of four tomographic cuts in
both the lateral and frontal planes are needed for each TMJ.
• When validating the use of CBCT for TMJ analysis, the clinician should
deliberate whether the information acquired will affect the management of
the patient.
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• Findings such as hard tissue erosions, remodeling, or the presence
of any structural deformities may be absolutely documentary and
may have no bearing on treatment protocol.
• In general, CBCT is not the imaging of choice for TMJ disorders such
as myofacial pain dysfunction or internal disk derangements.
Presentation title 36
• 6.6. Cleft palate assessment
• CBCT for patients with cleft lip and palate is useful for both preoperative
and therapeutic evaluations.
• The real-time creation of images in several planes and parasagittal
sections through the imaging volume has broad applications in the
assessment of cleft palate cases.
• Schneiderman et al., 2009;Three-dimensional reconstructions of images in
association with 3D navigation systems allow preoperative evaluations of
the cleft palate regarding the volume of the bone defect, the location of the
bone defect, the presence of supernumerary teeth, and an appraisal of
permanent teeth and alveolar bone morphology
Presentation title 37
• In a study by Albuquerque et al. (2011), CBCT was found to be
equivalent to multi-slice CT in both the volumetric assessment of bone
defects in alveolar and palatal regions and in establishing donor area
and the volume of the bone graft to be used in the rehabilitation of cleft
patients.
Presentation title 38
Volume rendering of CBCT scans of an individual with a unilateral cleft lip
and palate (a) before and (b) after alveolar bone grafting . With CBCT
imaging, assessing the morphology, locating the position and determining the
developmental stage of the unerupted maxillary left canine (arrow)
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Applications of CBCT in treatment planning
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• Kim et al., 2007; Surgical guides that have been developed using a
method employing high resolution CBCT scans and rapid prototyping
have been shown to provide accurate placement of TADs on the buccal
aspect of the jaws
• Qiu et al., 2012; Three-dimensional CBCT image-based stereo
lithographic surgical stent guides have also been found to be more
accurate than 2D surgical guides in micro implant placement.
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(a) Cone-Beam Computed Tomography (CBCT) image with virtual mini-
implant in place. (b) Digital model A: Digital Imaging and
Communications in Medicine (DICOM) and stereolithography (.stl) files
combined. (c) Design of the surgical guide on the digital model.
(d,e) .stl model of the surgical guide.
Presentation title 46
• 7.3. Accurate estimation of the space requirement for unerupted/impacted
teeth
• CBCT scans enable the accurate localization of impacted and/or transposed
teeth, and this helps determine the best method for surgical access and bond
placement.
• It also helps delineate the ideal and most efficient path for extrusion into the
oral cavity to circumvent or decrease collateral damage.
• This information can then be used to place adjacent teeth and their roots away
from the traction path of the impacted tooth so as to avoid untoward changes
in these teeth.
• Another advantage of CBCT over conventional radiographs is its capacity to
obtain precise dimensions of an impacted tooth, which aids in estimating and
creating the necessary space to accommodate the tooth within the arch
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Fabrication of custom orthodontic appliances
• Ye et al., 2011;The fabrication of custom lingual orthodontic
appliances has been demonstrated using CBCT image data with
existing technology to virtually plan a patient’s treatment and the
manufacturing of custom appliances with 3D printing technology
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8. Application of CBCT in assessing treatment progress and outcome:
• Dentofacial orthopedics
• Cevidanes et al. (2009) previously investigated the possibility of using CBCT
scans for evaluating treatment outcomes for Class III growing patients that
were treated with maxillary protraction using Class III inter-arch elastics
attached to mini-plates.
• They found that 3D overlays of superimposed models and 3D color coded
displacement maps provided visual and quantitative assessments of growth
and treatment changes.
• CBCT scans were able to identify maxillary and mandibular positional
changes and bone remodeling relative to the anterior cranial fossa.
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8.2. Orthognathic surgery superimposition
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Application of CBCT in risk assessment:
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• Dudic et al. (2009) compared the efficacy of orthopantograms versus
high-resolution CBCT scans in evaluating and estimating apical root
resorption secondary to orthodontic treatment.
• They found that the CBCT scans were useful diagnostic tools for
making a decision whether orthodontic treatment should be continued
or modified when orthodontic-induced root resorption is detected.
Presentation title 54
9.3. Post treatment TMD
• By providing concurrent visualization of TMJs and maxillomandibular spatial
relationships and occlusion, CBCT images provide clinicians with the
opportunity to visualize and measure the local and regional effects associated
with TMJ abnormalities.
• Ferreira et al., 2009; cases involving centric occlusion versus centric relation
(CO/CR) discrepancies, unilateral Class II malocclusions, or a retrognathic
mandible may involve displacement of the TMJ in CO versus CR, and
additional diagnostic information derived from CBCT scans would be
beneficial in these cases
Presentation title 56
The mandible was rotated 6 degrees counterclockwise in the frontal plane
and 5 degrees clockwise in the axial plane.
After the virtual correction of yaw and roll of the mandible, the teal model
is the mirror model using the mid-sagittal plane.
Note the overlays between the purple/grey and teal/grey models to help
plan surgical displacements. Images courtesy Dr. Lucia H.S. Cevidanes
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ASSESSMENT OF TREATMENT OUTCOMES:
Maxillary expansion
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van Bunningen 2022; conducted a study to analyze differences in variation of
orthodontic diagnostic measurements on lateral cephalograms reconstructed
from ultra low dose-low dose (ULD-LD) cone beam computed tomography
(CBCT) scans (RLC) as compared to variation of measurements on standard
lateral cephalograms (SLC), and to determine if it is justifiable to replace a
traditional orthodontic image set for an ULD-LD CBCT with a reconstructed
lateral cephalogram
Result: Based on the lower radiation dose and the small differences in variation
in cephalometric measurements on reconstructed LC compared to standard
dose LC, ULD-LD CBCT with reconstructed LC should be considered for ortho-
dontic diagnostic purposes.
van Bunningen, R.H., Dijkstra, P.U., Dieters, A. et al. Precision of orthodontic cephalometric
measurements on ultra low dose-low dose CBCT reconstructed cephalograms. Clin Oral Invest 26,
1543–1550 (2022). https://doi.org/10.1007/s00784-021-04127-9
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• Assessment of treatment outcomes CBCT is now considered as a tool for
determining treatment outcomes in patients undergoing maxillary expansion;
patients after alveolar bone graft placement and treated cleft lip/palate patients;
and those who underwent orthopaedic corrections and orthognathic surgery.
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RADIATION SAFETY :
CBCT Published reports indicate that the effective dose varies for
various full FOV CBCT devices, ranging from 36.5 to 182.1 µSv,
depending on the type and model of CBCT equipment and FOV
selected.
Comparing these doses with multiples of a single panoramic dose or
background equivalent radiation dose, CBCT provides an equivalent
patient radiation dose of 5–7.4 times that of a single film-based
panoramic X-ray, or 3–48 days of background radiation.
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Acc to Govt. of India, Atomic board of energy.
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LIMITATIONS OF CBCT:
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LIMITATIONS OF CBCT:
• The evaluation of soft tissue is not excellent using CBCT imaging due to
poor soft tissue resolution.
• Presentation of CBCT images through volume rendering or Maximum
Intensity Projection (MIP) may increase the likelihood of false findings.
• These illustrations are created based on sophisticated software
algorithms, and therefore they may not always be accurate.
• Therefore, evaluation of the volume through axial, sagittal, and coronal
views is required.
• These limitations inherent to CBCT should be considered because they
can affect the image quality.
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IMAGE ARTEFACTS:
• FIGURE : (A) Beam hardening artefact (due to the presence of metal with low
atomic number the lower energy radiations are absorbed leaving the higher energy
photons (harder)). This can be seen as hypodense streaks.
• (B) Proton starvation artefact (alternated hypo/hyperdense streaks, arousing from
Presentation title 66
metal with high atomic number due to complete absorption of photons).
RADIATION GUIDELINES :
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Clinicians should strictly adhere to the ALARA (as low as reasonably
achievable) principle while prescribing CBCT to a patient.
The Image Gently Campaign suggested six-step plan to minimize
radiation exposure to children. It strongly advises the use of CBCT
imaging on an individual basis with clinical justification and only when
the conventional low dose radiographs are unable to provide sufficient
information (Fig. 29.16).
International guidelines such as SEDENTEXCT , American guidelines
are available and should be followed for the use of CBCT imaging in
orthodontics
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• The Swiss Association of Dentomaxillofacial Radiology recommends
that CBCT in orthodontics be used only if it brings additional
information compared to conventional two-dimensional imaging .
• The DIMITRA (Dentomaxillofacial paediatric imaging: an investigation
towards low-dose radiation induced risks),
• A European multicenter and a multidisciplinary project, released a
position statement encouraging practitioners to follow the principle of
ALADAIP—keeping radiation As Low as Diagnostically Acceptable
being Indication-oriented and Patient-specific.
• The clinically relevant ALADAIP directive is especially relevant for
young orthodontic patients.
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CONCLUSION:
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REFERENCES:
• Om P Karbandha;Textbook of Diagnosis and Management of Malocclusion
and Dentofacial Deformities in Orthodontics,3rd edition,
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• REFERENCES:
• 73
Thank you
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