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Title: SIU-SDM HAWAIIAN CRUISE


1
SIU-SDM HAWAIIAN CRUISE
2
SIU-SDM HAWAIIAN CRUISE
CONE BEAM C T IS IT FOR THE GENERALISTS OFFICE?
3
DEBRA DIXON, DMD
  • SDM GRADUATE 1993
  • SDM AEGD 1995
  • SDM IMPLANT FELLOW 1996
  • THE UNIVERSITY OF LONDON MSc DENTAL
    RADIOLOGY 2002
  • SDM DIRECTOR OF RADIOLOGY

4
FUR
5
OUR AGENDA
  • History
  • Radiology
  • Digital Radiology
  • CT
  • Cone Beam CT
  • What it is and What it can do for me

6
HISTORY
  • Nov 8, 1895 Wilhelm RÖntgen discovers the X-Ray
  • Digital radiography is more than 25 years old
  • 11 to 30 of dentists have converted to digital
  • Financial investment
  • Complexity of computers
  • Software
  • Hardware
  • Simply reluctant to switchif everything is
    running smoothly, why change it?

Van der Stelt 2008
7
BASICS OF DIGITAL IMAGING
  • Composed of pixels (picture elements) which are
    characterized by 3 numbers
  • These numbers are stored in an image file in the
    computer
  • Image processing is possible
  • Brightness/Darkness
  • Contrast
  • Zoomlimited by the resolution of the system

8
BASICS OF DIGITAL IMAGING
  • Image Analysis
  • Measurement of root length for Endo
  • Digital subtraction radiography

9
BASICS OF DIGITAL IMAGING
  • Advantages
  • Immediate image with CCD sensor
  • Ability to manipulate the image
  • Integrated storage with software systems
  • Security of backup and off-site archiving of
    images
  • Ease of transfer by email
  • Security of the original image
  • DICOM (Digital Imaging and Communications in
    Medicine) format standards

10
BASICS OF DIGITAL IMAGING
  • Dose Reduction?
  • Once promoted as a huge advantage to digital
    imaging
  • Why the dose reduction is not as large as often
    suggested
  • Dose per exposure
  • Reduction of 0 to 50 as compared with F speed
    film
  • Increase in the number of radiographs made
  • Increase in the number of retakes due to the ease
    of exposing additional images


Van der Stelt 2008
11
SALLY
12
C TCOMPUTED TOMOGRAPHY
13
C T
  • History
  • Basics of Tomography
  • Generations of Scanners
  • 1st Generation
  • 2nd Generation
  • 3rd Generation
  • 4th Generation
  • 5th Generation
  • Conventional data gathering versus Spiral
    geometry

14
C T
  • History
  • The word Tomography can be traced to the 1920s
  • Tomography section, from the Greek tomos
  • Dr. Godfrey Hounsfield
  • Born 1919 in Nottinghamshire, England
  • The inventor of clinical computed tomography
  • First patient scanned in 1972
  • Demonstrated a suspected brain lesion
  • Dr. Allan Cormack
  • Born 1924 in Johannesburg, South Africa
  • Developed solutions for the mathematical problems
    in CT

Seeram, Computed Tomography, 2001
15
C T
  • History
  • Dr. Robert Ledley
  • 1948 Doctorate in Dental Surgery, New York
    University
  • 1949 Masters in theoretical physics, Columbia
    University
  • Developed the first whole-body CT scanner

Seeram, Computed Tomography, 2001
16
C T
  • History
  • Tomography
  • X-ray tube and film move simultaneously and in
    opposite directions
  • This keeps the object of interest in focus while
    blurring out the structures around it
  • Panoramic technique

Seeram, Computed Tomography, 2001
17
C T
  • History
  • A
  • 1st Generation
  • B
  • 2nd Generation
  • C
  • 3rd Generation
  • D
  • 4th Generation

Seeram, Computed Tomography, 2001
18
C T
  • History
  • 1st Generation
  • Minimum 4.5 to 5.5 minute whole body scan
  • Parallel beam, Translate Rotate
  • After 1 translation, the tube and detector rotate
    by 1 and translate again, repeated for 180
    around the patient

Seeram, Computed Tomography, 2001
19
C T
  • History
  • 2nd Generation
  • Scan time 20 sec to 3.5 minutes
  • Fan beam, Translate Rotate
  • Fan beam 30 detectors coupled to the x-ray
    tube and multiple pencil beams
  • Process is repeated for 180

Seeram, Computed Tomography, 2001
20
C T
  • History
  • 3rd Generation
  • Scan time of a few seconds
  • Fan beam geometry that rotates continuously
    around the patient for 360

Seeram, Computed Tomography, 2001
21
C T
  • History
  • 4th Generation
  • Scan time is very short, varies by manufacturer
  • A rotating fan beam within a stationary ring of
    detectors

Seeram, Computed Tomography, 2001
22
C T
  • History
  • 5th Generation
  • High-speed CT scanners
  • EBCT Electron Beam CT scanner
  • DSR
  • Dynamic Spatial Reconstructor
  • Scan time of milliseconds

Seeram, Computed Tomography, 2001
23
C T
  • History
  • A
  • Conventional Slice by Slice data acquisition
  • The x-ray tube stops between slices, the patient
    is repositioned for the next slice

Seeram, Computed Tomography, 2001
24
C T
  • History
  • B
  • Helical or spiral geometry
  • The latest development in CT data acquisition (as
    of the writing of the text in 2001)
  • Volume scanning
  • Utilizes a narrowly collimated, fan shaped x-ray
    beam, projected through a limited thickness slice
    through the body
  • Utilizes a linear array of detectors
  • Patient has to be advanced through the gantry
    while the x-ray tube and detectors rotate around
    the patient

Seeram, Computed Tomography, 2001
25
C T
  • Spiral Scanners
  • Provide improved multiplanar image
    reconstructions
  • Reduced exam time
  • 12 seconds versus 5 minutes for an incremental
    scan
  • Reduced radiation dose
  • Up to 75 of the dose delivered by an incremental
    scanner

26
C T
  • Image is recorded and displayed as matrix of
    individual blocks called voxels (volume elements)
  • Voxel length (1 to 20 mm) is determined by the
    width of the x-ray beam
  • Analogous to the tomographic layer in film
    tomography
  • For image display, each pixel is assigned a CT
    number
  • Represents density
  • Also known as a Hounsfield unit
  • Air -1000
  • Water 0
  • Dense bone 1000

27
EM
28
CONE BEAM C T
29
C B C T
  • Definition
  • Indications
  • Comparisons
  • CBCT versus Panoramic
  • CBCT versus Plain-film Tomography
  • CBCT versus Medical CT
  • Disadvantages
  • Currently available units
  • Specialized Uses
  • Orthodontic Analysis
  • Dolphin Imaging Software Program
  • Interpretation

30
C B C T
  • Developed for Dental purposes to provide 3D
    volume images of the dental and craniofacial
    complex
  • Available for craniofacial imaging
  • Since 1999 in Europe
  • Since 2001 in the U.S.
  • Ideally suited for craniofacial imaging
  • The compact size of the unit
  • Relatively low radiation dose
  • Becoming the Standard of Care for diagnosis of
    the craniofacial region
  • Allows multiplanar viewing of the anatomical
    volume and overcomes the limitations of 2D
    radiography

www.conebeam.com
31
C B C T
  • Cone Beam
  • Utilizes a cone shaped x-ray beam
  • Round or rectangular
  • Utilizes an area detector
  • Acquires a full volume of images in a single
    rotation with no need for patient movement
  • Rotates 360 around the head
  • 360 projections
  • Scan time typically lt 1 minute

www.conebeam.com
32
C B C T
  • End Result
  • 3-D visualization of the oral and maxillofacial
    complex from any plane
  • A stack of 360 images or exposures compiled into
    a volumetric dataset through a computer process
    known as primary reconstruction
  • This data volume is then converted into a
    patient-study by accompanying software
  • Can be visualized as
  • 2D trans-axial, multi-planar reformatted
  • 3D techniques such as surface reconstruction and
    volume rendering
  • A combination of 2D and 3D techniques

www.conebeam.com
33
C B C T
  • Indications
  • Evaluation of the jaw bones
  • Implant placement and evaluation
  • TMJ
  • Pathology
  • Bony Soft tissue lesions
  • Periodontal assessment
  • Endodontic assessment
  • Alveolar ridge resorption
  • Assessment of the IAN prior to extraction of
    impactions
  • Orthodontic evaluation
  • Airway assessment
  • Need for 3D reconstructions

www.conebeam.com
34
C B C T
  • Evaluation of the jaw bones
  • Implant placement and evaluation 12-13
  • a) Panoramic line and cross-section line in the
    axial image of Maxilla identified
  • b) Slices of the area in cross-section
  • c) Reconstruction in a panoramic-like layout

Araki et al. Dentomaxillofac Radiol 31 (1)51,
Figure 9
35
C B C T
  • Evaluation of the jaw bones
  • a) Slice as seen from a frontal view
  • b) Slice as seen from the side
  • c) Reconstructed maxilla and mandible

Dentomaxillofac Radiol (2004) 33, 285-290
36
C B C T
  • Evaluation of the jaw bones

www.ddsgadget.com
e-ssentialnetworks.com
37
C B C T versusPANORAMIC
  • PANORAMIC
  • Provides a distorted (unequal magnification) and
    magnified image
  • Image layer view only
  • Structures are superimposed
  • CBCT
  • Provides an undistorted image
  • Cross-sectional (bucco-lingual), axial, coronal,
    sagittal, and panoramic views
  • Structures can be separated

www.conebeam.com
38
C B C TversusPLAIN-FILM TOMOGRAPHY
  • PLAIN-FILM TOMOGRAPHY
  • Provides an undistorted image, but there is
    magnification
  • Provides direct cross-sectional, sagittal, and
    coronal views
  • Scan time may be short, but chair time can be
    lengthy
  • CBCT
  • Provides an undistorted, 11 image
  • Provides reconstructed views
  • Scan time
  • 10-40 second range, dependent on the region being
    imaged and the desired quality
  • Provides an indication of bone quality

www.conebeam.com
39
C B C TversusMedical C T
www.osseonews.com
  • Med CT
  • Conventional linear fan beam
  • Single row or a series (4, 8, 12, 32, 64) of
    solid state detectors
  • Provides a set of consecutive slices of the
    patient
  • CBCT
  • Cone beam
  • Square 2 dimensional array of detectors
  • Provides a volume of data

www.conebeam.com
40
C B C TversusMedical C T
  • Med CT
  • Greater contrast resolution
  • More discrimination between different tissue
    types (i.e. bone, teeth, and soft tissue)
  • CBCT
  • Equipment
  • Cost 3-5x less than MDCT
  • Lighter Smaller
  • No special electrical
  • No floor strengthening
  • No special cooling
  • Ease of operation
  • Dedicated to dental
  • Patient sits or stands
  • Both jaws can be imaged at the same time
  • Lower radiation burden

www.conebeam.com
41
C B C T
  • Disadvantages
  • Noise from radiation scatter
  • Streak artifacts from metal restorations
  • Algorithms and filters try to correct for noise
    artifacts
  • Image degradation from patient movement
  • Head stabilizing devices
  • Cost
  • Range from 150,000 to 300,000
  • Training
  • For maximum benefit
  • For interpretation of the volume of data images
  • Within the purview of the dentist
  • Outside the purview of the dentist

Howerton et. al.
42
C B C T
  • Currently available units
  • 3D Accuitomo FPD XYZ Slice View Tomograph
  • J. Morita USA, Irvine, CA
  • 3D X-ray CT Scanner Alphard Series
  • Asahi, Kyoto, Japan
  • Quolis Alphard Alphard-3030-Cone-Beam
  • Belmont Equipment, Somerset, NJ
  • CB MercuRay
  • Hitachi Medical Systems America, Twinsburg, Ohio
  • Galileos 3D
  • Sirona Dental Systems, Charlotte, NC
  • i-CAT
  • Imaging Sciences International, Hatfield, PA

Howerton et. al.
43
C B C T
  • Currently available units
  • Iluma Ultra Cone Beam CT Scanner
  • Carestream, Rochester, NY
  • NewTom 3G and VG
  • AFP Imaging, Elmsford, NY
  • Picasso
  • E-woo Technology, Houston
  • PreXion 3D
  • TeraRecon, San Mateo, CA
  • ProMax 3D
  • Planmeca USA, Roselle, IL
  • Scanora 3D
  • Soredex, Tuusula, Finland

Howerton et. al.
44
C B C T
i-CAT NewTom VG 3D Accuitomo
Position Seated Stand/Seated Seated
Scan time 5, 8.9, 26.9 sec 20 sec 18 sec
Scan Hgt 4,6,8,10,13 cm 9.84 inches 1.57-2.36 inches
kVp/mA 120/3-5 60-80/1-10
Rad Time 9 sec 5.4 sec Not listed
Scan thick 0.12-0.4 mm 0.1-0.5 mm .125-2.0 mm
Ceph Yes Yes No
Software Xoran Cat NewTom VG I-Dixel
Price 170,000 170,000 252,000
website imagingsciences.com newtomdental.com jmorita.com
Inside Dentistry 190-93, 2007, Dental Economics
August 2007, Dental Town August 2007
45
C B C T
  • All Cone Beam Units are not created equal!
  • Volume Size
  • Geometric resolution
  • Contrast resolution
  • Slice thickness
  • Radiation dose
  • Ease of use
  • Image Capture

46
C B C T
Effective dose (µSv) Dose in of Pans Dose in days Dose in Med CT
i-Cat 12 FOV 135 21 13 6.4
NewTom 3G 12 FOV 45 7 4 2.1
Panoramic 6 1 1 0.3
CT Maxilla Mandible 2,100 385 243 100
Farman AG, Levato CM, Scarfe WC. A primer on
cone beam CT. Inside Dentistry 190-93, 2007
47
C B C T
  • The i-CAT CT scanner
  • Low dose settings for children
  • Landscape View
  • Full resolution and detail obtained for smaller
    fields of view
  • Portrait View
  • Captures Extended Field of View data
  • Ceph data in 8.5 seconds

www.imagingsciences.com
48
C B C T
  • i-CAT
  • Typical reconstruction time
  • Less than 30 seconds

www.imagingsciences.com
49
C B C T
  • i-CAT
  • Measurement
  • Labeling
  • Hounsfield units
  • Density

www.imagingsciences.com
50
C B C T
  • NewTom VG
  • Features a single 8"x10" Field Of View,
  • Most utilized by implantologists and
    maxillo-facial surgeons.
  • Small focal spot high quality images
  • Volume of data captured kept to a minimum
  • Short reconstruction times (3 minutes)
  • Low dose
  • up to 20 - 50 times less radiation than
    conventional CT
  • Adjusts dose to size and age of patient
  • Unique pulse system
  • Activates the x-ray source only when
    neededdelivering less than 4 seconds of total
    exposure for a full scan.

www.afpimaging.com/newtom
51
C B C T
  • NewTom

www.afpimaging.com/newtom
52
C B C T
  • 3D Accuitomo
  • J. Morita Manufacturing
  • Imaging Areas 40x40 mm 60x60 mm
  • High resolution for large imaging area
  • Voxel size 0.125 mm, high resolution (2.0 line
    pair/mm)
  • Low effective dose
  • Wide dynamic range and expresive tone create
    brilliant images of both soft and hard tissue
    areas
  • Enables the most accurate diagnosis for implants,
    apical lesions, temporomandibular joints,
    impactions, etc.

www.jmorita-mfg.com
53
C B C TSPECIALIZED USES
ISLAND OF LANAI
54
C B C T
  • Specialized Uses
  • Orthodontic Analysis
  • Dolphin Imaging Software Program
  • Oral Surgery
  • Impactions
  • Trauma
  • Implants
  • Endodontics
  • Periodontics
  • TMJ

55
C B C T - ORTHO
Ortho Evaluation and Treatment Planning
www.dolphinimaging.com
56
C B C T - ORTHO
  • The Dolphin 3D software module
  • A powerful tool that makes processing 3D data
    extremely easy, enabling dental specialists from
    a wide variety of disciplines to accurately
    diagnose and plan treatment.
  • Dolphin 3D allows visualization and analysis of
    craniofacial anatomy from data produced by CBCT,
    MRI, medical CT and 3D facial camera systems.

www.dolphinimaging.com
57
C B C T - ORTHO
  • Dolphin Imaging Software
  • Comprehensive cross sections with Multiple Planar
    View (MPV)
  • 3D nerve marking
  • TMJ analysis
  • Create stunning, accurate cephalometric and
    panoramic radiographs
  • Import from a variety of 3D files
  • High-quality, fast 3D rendering
  • Easily detect impacted teeth
  • Analyze, visualize and measure airway
  • Precise volume orientation
  • Establish 3D/2D measurements
  • Create movies
  • Design automated image layouts
  • Images export to other applications, including
    PowerPoint, Word, etc.
  • Images easily saved into Dolphin patient file
  • Export to standard file formats and Windows
    Clipboard
  • Fully embedded in Dolphin Imagings SQL database

www.dolphinimaging.com
58
C B C T - ORTHO
  • Dolphin Imaging Software
  • Object Orientation
  • Comprehensive cross sections with Multiple Planar
    View
  • Instant Ceph/Pan
  • Ceph Tracing
  • 3D Nerve Mapping
  • TMJ analysis
  • 3D Visualization

www.dolphinimaging.com
59
C B C T - ORTHO
  • Object Orientation
  • To maximize the consistency of analysis of a 3D
    volume, it is crucial to establish a default
    orientation.
  • Dolphin 3D provides comprehensive tools for
    defining the mid-sagittal, axial and coronal
    planes. You can also adjust the objects default
    yaw, pitch and roll.
  • These operations can be performed on the CT soft
    tissue surface, CT hard tissue surface or 3D
    photo surface.

www.dolphinimaging.com
60
C B C T - ORTHO
  • Multiple Planar Views and Layouts
  • Choose a layout that is best suited to your task
  • 3D volume (just the 3D volume view)
  • Volume3 planes (3D volume and 3 cross section
    planes on the side)
  • 4-views (3D volume and the cross section planes
    in equal sized windows)
  • Individual orthogonal projected slices sagittal,
    coronal and axial planes

www.dolphinimaging.com
61
C B C T - ORTHO
  • Instant Ceph/Pan
  • Create two-dimensional radiographic images from
    3D volume dataset in the lateral, panoramic
    (OPG), frontal and SMV views.
  • 11 projection
  • no distortion
  • no magnification

www.dolphinimaging.com
62
C B C T - ORTHOCeph Tracing
www.dolphinimaging.com
63
C B C T - ORTHO Nerve Mapping
www.dolphinimaging.com
64
C B C T - ORTHO
  • TMJ View
  • Choose an area of interest set center point and
    axis direction, designed specifically for
    analyzing the temporomandibular joint
  • Choose desired slice thickness, width, number and
    direction (coronal, sagittal, or patent-pending
    circular)
  • View key cross-sections at the chosen axes

www.dolphinimaging.com
65
C B C T - ORTHO
  • 3D Visualization
  • Dolphin gives you the power to freely visualize
    the volume in 3D. In addition to switching from
    hard tissue and soft tissue views, you can also
    activate the see-thru hard tissue renderings.
    Adjust the factor of translucency and intensity
    to reveal the structure you desire.Clipping
    tools are also very useful for quickly
    visualizing hidden structures, or to simply
    eliminate portions of the contents that are not
    relevant.

www.dolphinimaging.com
66
C B C T
  • Interpretation of the Volume of Images
  • Data collected within the Region of Interest
    (ROI)
  • Within the purview of general dentists and
    specialists
  • Data collected outside of the Region of Interest
  • A large volume of information exists that is
    outside of a dentists purview
  • Comprehensive Care of the Patient
  • Documented interpretation of all the data in the
    volume
  • 2007 Chairman of the AAOMS advised that all
    volumes be read by a radiologist

67
C B C T
  • Interpretation of the Volume of Images
  • AAO Council on Scientific Affairs
  • Survey of Radiologists
  • All scans should be read by a qualified person.
  • Panoramic can be read by the diagnostician
    (dentist)
  • Cone Beam volume by an Oral Maxillofacial
    Radiologist or an MD Radiologist
  • The interpretation fee can be either included in
    the scan fee, or be billed separately
  • The entire volume of data requires
    interpretation. The patient cannot deny
    interpretation of non-dental data
  • As in medicine, a written report is the standard

Am J Orthod Dentofacial Orthop 2007131697
68
TIGGER
69
CONE BEAM C T IS IT FOR THE GENERALISTS OFFICE?
70
  • THE BOTTOM LINE
  • Is it worth your time and effort?
  • Physical Space in your office
  • Training
  • Computer memory to work with images
  • Storage of images

71
  • THE BOTTOM LINE
  • Is it worth your time and effort?
  • Physical Space in your office
  • Training
  • Computer memory to work with images
  • Storage of images
  • Will it be profitable?
  • Costof the equipment
  • Time involved
  • Number of patient scans x 250-600/scan
  • Types of images available Pan, Ceph, Bitewings,
    Periapicals

72
MAHALO
73
CONE BEAM C T
  • References
  • Araki et al. Dentomaxillofac Radiol 31 (1)51,
    Figure 9
  • Am J Orthod Dentofacial Orthop 2007131697
  • Turpin D., Editor-in-Chief. Befriend your oral
    and maxillofacial radiologist
  • Danforth RA, Miles D. Cone Beam Computed
    Tomography for Dentistry (Journal unknown)
  • Dental Economics August 2007
  • Feuerstein P. Cone Beam Technology.
  • Guttenberg S, Emery R. Profit in 3 dimensions
  • R Baba, K Ueda and M Okabe. Using a flat-panel
    detector in high resolution cone beam CT for
    dental imaging. Dentomaxillofacial Radiology
    2004 33, 285-290
  • DentalTown August 2007
  • Giacobbi T. 3D Images for 21st Century Dentistry

74
CONE BEAM C T
  • References
  • Inside Dentistry 190-93, 2007
  • Farman AG, Levato CM, Scarfe WC. A primer on
    cone beam CT.
  • JADA supplement June 2008, Vol. 139, Digital
    Imaging
  • A. Ruprecht. Oral and Maxillofacial Radiology
    Then and Now
  • P.F. van der Stelt. Better Imaging The
    Advantages of Digital Radiography
  • A.G. Farman, et al. In Practice how Going
    Digital Will Affect the Dental Office
  • W.B. Howerton Jr, M.A. Mora. Advancements in
    Digital Imaging What Is New and on the Horizon?
  • Seeram, Euclid. Computed tomography physical
    principles, clinical applications, and quality
    control, 2nd edition, 2001, Saunders.

75
CONE BEAM C T
  • References
  • www.afpimaging.com
  • www.conebeam.com
  • www.cile.co.nr
  • www.ddsgadget.com
  • www.dolphinimaging.com
  • www.e-ssentialnetworks.com
  • www.imagingsciences.com
  • www.jmorita-mfg.com
  • www.osseonews.com
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