Cone beam computed tomography (CBCT)
Cone beam computed tomography (CBCT) has been developed in recent years specifically for use in the dental and maxillofacial regions and is gradually establishing itself as the imaging modality of choice in certain clinical situations. It is also referred to as digital volume tomography or cone beam volumetric imaging. As described later, the size of the volume or field of view (FOV) of the maxillofacial skeleton imaged varies; as a result CBCT scans are often described by their field of view:
As this type of equipment is gradually being installed in dental practice, as well as in dental hospitals, it is likely that dental care professionals will increasingly encounter it in the future. This chapter is therefore included to provide an introduction and overview to this new technology.
Considerable controversy exists as to the main indications for CBCT and robust clinical research justifying its use is limited. Some authorities argue that CBCT should be regarded as almost routine for all dental and maxillofacial applications, while others argue that CBCT should not be used unless the results of the examination are going to alter patient management as the technique delivers a higher dose than conventional two-dimensional imaging. In 2011 the European-wide Safety and Efficacy of a New and Emerging Dental X-ray Modality SEDENTEXCT project published guidelines based on what evidence was available at that time. These guidelines, and a more cautious approach to the justified use of CBCT, are endorsed by the authors. Hence the indications summarised below are based broadly on the SEDENTEXCT recommendations.
Multiple CBCT machines are currently available with new, upgraded models launched regularly by most manufacturers of X-ray equipment. Almost all modern machines resemble panoramic units, as shown in Fig. 13.1.
All equipment employs a cone-shaped X-ray beam and a special detector (e.g. an image intensifier linked to a charge-coupled device (CCD) or, more commonly, an amorphous silicon flat panel). The scanning/image creation process divides into three stages:
The patient is positioned with the unit (as described later). The equipment orbits around the patient in a 180°, 270° or 360° rotation, taking approximately 5–40 seconds, and in one cycle or scan, images a cylindrical or spherical volume referred to as the field of view (FOV). As all the information/data is obtained in the single scan, the patient must remain stationary throughout the exposure. As described earlier, the FOV can vary in size enabling small, medium or large volumes of a patient to be imaged. Using a large field of view (e.g. 15 cm3) most of the maxillofacial skeleton fits within the cylindrical or spherical shape and is imaged in the one scan as shown in Fig. 13.2.
Fig. 13.2 Diagram showing the basic 3-stage concept of a large CBCT scan. Stage 1 – Data acquisition: a cone-shaped X-ray beam is used which orbits around the patient obtaining information/data in a cylindrical volume. The patient’s maxillofacial skeleton is positioned within the cylinder. Stage 2 – Primary reconstruction: the computer divides the cylinder into tiny cubes or voxels. Stage 3 – Secondary or multiplanar reconstruction: the computer creates separate images in the sagittal, coronal and axial anatomical planes.
Having obtained data from the one scan, the computer then divides the volume into tiny cubes or voxels (ranging in size between 0.076 mm3 and 0.4 mm3) and calculates the X-ray absorption in each voxel. As with pixels in two-dimensional digital imaging, described in Chapter 3, each voxel is allocated a number and then allocated a colour from the grey scale from black through to white. Typically one scan contains over 100 million voxels. The overall image resolution clinically of hard tissues (teeth and bones) is generally very good in CBCT imaging, although measured spatial resolution/>