Cone beam technology: a brief technical

overview
August 1, 2008
By Matthew R. Lark, DDS, MAGD, FICD, FACD
Who knew the Beatles provided funding for the early models of CAT scans?
For more on this topic, go to www.dentaleconomics.com and search using the following
key words: computerized axial tomography, CAT scanners, Cone Beam Computerized
Tomography, Hounsfield units, orthogonal reconstruction.
Computerized scanning technology has been in use for over 30 years. Originally, it was
called Computerized Axial Tomography or CAT. Hospital-based CAT scanners were
radiation intensive, supine gantry-style units which required large suites in radiology
centers. The computer itself would take the space of an entire room. Except for the
occasional trauma or involved pathology patient, dentists really did not utilize CAT
scan technology. Today, with advances in miniaturization and computer software and a
revolution in imaging, CAT scan technology has moved from the hospital to the private
dental office.
The goal of this article is to provide dental personnel with an overview of the science
and terminology used in Cone Beam Computerized Tomography (CBCT). The clinician
will need to become familiar with terms such as scan height, slice thickness, and scan
diameter. Many important concepts unique to CBCT — such as radiation dosage,
volume averaging, voxel size, attenuation, Hounsfield units, orthogonal reconstructions,
surface-rendering, multiplaner reconstruction, axial-corrected temporomandibular joint
sagittal and coronal tomography, DICOM format, 3-DVR, stereolithographics, and data
portability — will be discussed.
Basic radiographic studies, such as panoramic or cephalogram views, are diagnostically-
driven sectional views which can be obtained from the volume of data generated by
CBCT scans. One of the benefits of CBCT is the capability of measuring areas of
interest using specialized digital tools. When measuring structures using CBCT, the
readings are both accurate and precise; therefore, structures and pathology can be
serially calculated indicating subtle dimensional changes of lesions or structures. The
digital environment enables not only linear measurement, but also volumetric
calculation (i.e., airway volume) and tissue or bone density.
History of CAT and CBCT
CAT scan technology was developed in the 1970s by British engineer Godfrey
Hounsfield of EMI Laboratories, England, and physicist Allan Cormack of Tufts
University, Mass. For their work, they were awarded Nobel Prizes. The term "CAT
scanning" (Computerized Axial Tomography) comes from the Greek "tomos" which
means "slice" or "section" and "graphia" which means "describing." It took several
hours to acquire the raw data for a single scan or "slice" with the first CT scanner
developed by Hounsfield in his lab at EMI, and it took days to reconstruct a single
image from this raw data.
We can thank the Beatles — John, Paul, George, and Ringo — for providing funding
for the early models of CAT scanners. The success of the Beatles generated research
dollars for their recording company, EMI, which in turn developed the CAT scan. EMI
developed the technology at its research arm. Computerized tomography was originally
known as the "EMI scan." Ironically, this company is far better known for its music and
recording business than for its much more important contribution to health care.
 Hounsfield units
Hounsfield units (HU) are a quantitative measure of the radiolucency of different
materials in a CAT scan. Hounsfield units allow us to differentiate the relative densities
of various biological structures. The Hounsfield scale ranges from air at -1000 HF,
through water at 0 HF, up to +1000 HF for cortical bone, +400 for cancellous bone, and
2000-3000 for metallic structures. Each pixel in the CT image is assigned a value
between the -1000 and +1000 range. HUs are helpful when assessing the bone density
of the potential implant site. Bone density is graded from D-1 through D-4, as shown in
Figure 1. A Hounsfield reference chart can be done in any font or arrangement. But
bone hardness can vary from bone density when certain bone allografts are imaged.

e 1: Hounsfield Units and Bone Density Chart.

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The attenuated radiodensity of imaged tissues is displayed in varying hues of gray. It

also can be color-coded to match specific Hounsfield units. CBCT scanners offer
between 6 and 14 bit gray-scale capability, or over 16,384 shades of gray. This
characteristic allows selection of areas of high or low density which can be highlighted
for better visualization of tissue variants. The outline of a cystic area can be made to
stand out from its surrounding bone. Higher radiation, medical 64-head CT is more
sensitive to the subtle variations of HUs and therefore better for reading soft tissue than
an in-office CBCT.
Pixels and voxels
The term pixel is a contraction derived from the words picture and element. Pixel
represents the smallest single component of an image on a two-dimensional grid. The
intensity, hue, and value of a pixel can vary, thus displaying multiple combinations of
data elements that, when projected using an electronic display grid or printed on a
photographic medium, will form an accurate rendering or image. The image can be
viewed in color or as a black and white image using a gray scale. The attenuation of an
X-ray signal by an object or tissue will determine the value and intensity of the
individual pixels.
 A voxel is a volume pixel. The voxel adds the third dimension (3-D) to the digital image
by adding the z-axis (depth) to the x-axis (width) and the y-axis (height). Stacks of these
volumetric boxes of data allow 360 degrees of virtual manipulation of imaged objects
(see Figure 2).

e 2: Pixel and voxel diagram. Voxels are 3-D pixels.

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The voxel becomes the smallest element in the 3-D environment. When viewed as a
digital image, the pixel size controls the resolution. The smaller pixel size yields a
higher resolution image, and conversely, the larger the pixel size, the lower the
resolution or quality of the image.
In CBCT, pixel size can vary from .12 mm to .4 mm. The lower pixel-size image takes
more exposure time (20 to 40 seconds) and more radiation. It is very susceptible to
movement distortion. Thus, even though small pixel-size images lend more definition to
smaller object areas, the risk of movement distortion makes it impractical for most
applications. Therefore, imaging subtle pathology such as caries, root fractures, or
periodontal bone loss is not practical due to movement-related distortion.
CBCT acquisition
Obtaining a CBCT scan is a relatively simple procedure. The scan parameters of image
size and pixel size are determined according to the goals of the desired study. A
cephalometric study requires a full-head image 22 cm vertical, but an implant study may
only require a 6-10 cm vertical, enough height to image the mandible and maxilla.
Larger height, wider diameter, and higher resolution studies produce more radiation
exposure and usually take more exposure time. The patient must be restrained from all
inadvertent movement.
The CBCT scanner
The cone beam scan acquires the image using a radiation source opposing a target
sensor on a rotating mechanism. The X-ray is focused (collimated) at its source and then
diverges into a fan shape by the time it reaches the detectors, hence the name cone
beam. This fan beam collimation is the major difference between the medical CT
scanners and cone beam scanners. CBCT sensors collect the data directly onto
amorphous silicone plates or indirectly using image-intensifier detectors. CBCT allows
the X-ray signal to be pulsed rather than continuous, thus decreasing the overall
 exposure to the patient. A 20-second scan may only contain 3.5 seconds of radiation
exposure. Figure 3 shows the cone beam in motion.

e 3: Illustration of cone beam in motion during scan.

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Radiation dosage
Effective radiation dosages for CBCT scans are approximately 68 µSv. (micro-Severts).
This is less than half the level of exposure from a full-mouth series of radiographs at
150 µSv. Normal daily background exposure is about 8 µSv or about 3 mSv (milli-
Severts) per year. A typical panoramic radiograph is 26 µSv, but a medical CT can
expose as much as 1,200 to 3,300 µSv per scan. The amount of radiation used in CBCT
examinations is small, and the benefits outweigh the risk of harm.
Scatter occurs when the X-ray beam hits a dense object such as metal from a crown or
filling. Scatter signal does not affect the resolution of the high-contrast anatomy.
Therefore, the image degradation from scatter is minimal in dental CBCT (except in
areas of extensive restoration). Even in this situation, though, sophisticated
reconstruction algorithms can correct for the scatter.
Data compilation
The CBCT scanner acquires hundreds of slices per rotation (see Figure 4). Once
obtained, the computer processes these slices by assembling them into a full cylinder-
shaped volume analogous to a stack of compact discs. The various proprietary software
applications compress and compile the data into the DICOM format for use in the
various applications.
e 4: Axial slices from a cone beam scan. Hundreds of reformatted axial slices comprise the volume of the scan.
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DICOM (Digital Imaging Communication in Medicine) is a format of medical imaging

data standardized by the ACR/NEMA (American College of Radiology/National
Electrical Manufacturers Association) to allow the digital transfer of data between
various diagnostic-imaging equipment and software. The rapid adoption of the current
standard, DICOM-3, has opened new opportunities for health-care organizations to
increase the quality and cost-effectiveness of patient care.
Patient file sizes from various CBCT scanners can range from 5 megabytes (I-CAT®)
to 700 megabytes for other systems. Larger file formats demand considerable storage
capacity. Such large files may be difficult to share over the Internet with third-party
users. However, as compression technology improves, these data storage and transport
issues will probably be resolved.
Multiplaner reconstruction
CBCT scanner software sorts the data into a multiplaner reconstruction which has three
interactive views: the coronal (x-y axes), the sagittal (z-y axes), and the axial (x-z axes).
Plane locator lines can be moved within each section, allowing scanning through the
entire volume of information in the three planes. The scanning function allows for a
rapid means of inspecting for gross anatomical variants and locating areas of interest
useful in designing follow-up studies for more precise viewing.
Orthogonal studies
When viewing the axial views, a specialized study can be constructed using a
perpendicular line in either a straight or curvilinear form. These are called orthogonal
studies to highlight various cross-sectional regions. The depth or length of the cross-
sectional zone can be varied to include a greater or lesser volume of the image area. The
acuity of the view increases as the image size decreases. Volume averaging will make
areas of interest less distinct as the attenuated data is averaged throughout the thickness
of the viewing area. Thick sections may display more information about shape and
 contour such as airway, facial asymmetry, or gross bone defects, but thin sections are
more useful for subtle anatomic deviations such as cysts, caries, or fractures.

e 5: Panoramic orthogonal plane. This image depicts the panoramic orthogonal reconstruction.
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A common orthogonal cut is the panoramic planing. (see Figure 5). The panoramic
plane can be formulated widely enough to include mandibular-maxillary complex, or
either arch can be selected by a thinner cut which shows a more accurate virtual
representation.
The temporomandibular joints can be highlighted with an axially-corrected slice, thus
displaying measurable joint spaces, cortical outlines, and marrow spaces.
Maximum intensity projections
Maximum intensity projections (MIPs) are images which show the compilation of the
entire volume of data and projects in the visualization plane (the voxels) with maximum
intensity. The MIP (see Figure 6) gives the illusion of a 3-D image and is the basis for
3-D software (3-DVR) applications. This software renders the volume of data in a
format which can be manipulated as a single object and then rotated 360 degrees.
Virtual cropping allows visualization of component parts of the object, such as an
impacted tooth, without the superimposition of visual obstruction from overlaying or
underlying structures. This property of CBCT allows studies of juxtaposition of
 adjacent structures and precise measurements of the volumetric and linear size of
selected objects.

e 6: MIP image. The MIP image showing three planes and the 3-D reconstruction (3-DVR).
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3-D volumetrics can be combined with 3-D photography that melds the surface
rendering of the cone beam scan with the dentofacial soft tissue information of the
photograph. Bony and soft tissue landmarks can be recorded and studied in a 3-D
environment. The traditional cephalometric analyses are based on a two-dimensional
system. The advent of new software applications (such as Dolphin 3-D®) will
revolutionize the evaluation of dentofacial and skeletal growth and development, and
change the future of orthodontic and orthognathic treatment-planning (see Figure 7).
Surface rendering treats the object as if it has a surface of a uniform color. In surface
rendering, shading is used to show the location of a light source. Some regions are
illuminated, while other regions are darker due to shadows. When surface rendering is
combined with volume rendering, it becomes possible to highlight and colorize distinct
regions of hard and soft tissues, thus providing a more accurate visualization of borders
of pathology to vital structures. Virtual dissection further fine-tunes and pinpoints exact
anatomical position.
e 7: Dentofacial cephalometrics in 3-D. Selective colorization shows skeleton with soft-tissue superimposition in pre- and po
gnatic surgery views.
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CBCT technology is perhaps the most significant advance in dentistry since the high-
speed handpiece. CBCT has already revolutionized dental diagnosis and treatment-
planning, and as the scanner technology advances and new software applications are
developed, the gap that exists between dental and medical radiology will close. CBCT
will play a defining role in the study of growth and development and of aging. It will
fundamentally alter the diagnosis of dental pathology and surgical treatment-planning.

e 8a: SimPlant® reconstruction of ossifying fibroma.

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Stereolithography
Stereolithography is also known in the industrial world as rapid prototyping. Dental
CBCT scans processed using Sim Plant® software can be digitally transformed for
creating stereolithographic models. Rapid prototyping allows the fabrication of physical
replicas of 3-D computer-generated models in a layered approach. After the 3-D
rendition is generated, software slices the file from top to bottom and then the slice data
is sent to a machine that fabricates the part slice by slice. In dentistry, the fabrication of
biomodels gives the oral surgeon a full-volume plastic template to plan surgical
procedures, fabricate custom-engineered joint- and bone-replacement prostheses, and
model facial-plastic reconstructive procedures (see Figures 8a and 8b).
e 8b: Stereolithographic model of same lesion used for surgical treatment-planning.
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Research
Dental scientific research will be enhanced by CBCT as evidence-based concepts can be
more accurately measured and improved. Portability of data will expand databases
available for wider-based, multicenter epidemiologic studies. Future software
applications can be applied to new and archived databases, giving the scientist the
ability to chronologically measure structural change over time.
A new world of diagnostic capabilities
CBCT is the new hallmark of dental imaging. While it can look very challenging
technically for the neophyte, the dental software has user-friendly interfaces which
simplify the technical experience so that dentists can readily apply their skill and
knowledge. The low radiation CBCT scan offers safety and a wide variety of clinical
applications for dentistry and medicine.
Certainly the technology associated with CBCT can be daunting to the dentist at first
glance. There are many teaching centers for those interested in further education on
CBCT. Many are listed on the Web site http://cone beam.com, where information from
many manufacturers can also be found. CBCT has opened up a new world of diagnostic
capabilities for dentistry, and these exciting changes are helping dentists provide safer,
more predictable, and better diagnostic radiological protocols than ever before.
Matthew R. Lark, DDS, MAGD, FICD, FACD, has practiced general dentistry in
Toledo, Ohio, for the past 26 years. He is the current president of the American
Academy of Orofacial Pain. He is also an assistant clinical professor at the University
of Toledo Medical Center, Department of Dentistry. He became a Diplomate of the
American Board of Orofacial Pain in 1995, is a Fellow of the International Congress of
Oral Implantologists, and a clinical instructor at the Kois Center. Currently, Dr. Lark is
conducting clinical research using cone beam radiology as a diagnostic aid for
implantology, orofacial pain, head and neck pathology, and sleep disorders. You may
contact Dr. Lark by e-mail at Abiento@aol.com.