Eur Radiol (2010) 20: 26372655

DOI 10.1007/s00330-010-1836-1 HEAD AND NECK

Bart Vandenberghe Modern dental imaging: a review

Reinhilde Jacobs
Hilde Bosmans of the current technology and clinical
applications in dental practice

Received: 12 January 2010 H. Bosmans direct receptors, while extraoral

Revised: 15 April 2010
Accepted: 29 April 2010
Published online: 11 June 2010
# European Society of Radiology 2010
B. Vandenberghe ()) : R. Jacobs
Oral Imaging Centre, Faculty of Medicine,
School of Dentistry, Oral Pathology and
Maxillofacial Surgery,
Katholieke Universiteit Leuven,
Kapucijnenvoer 7, 3000, Leuven, Belgium
e-mail: bart.vandenberghe@med.kuleuven.be
Tel.: +32-16-332410
Fax: +32-16-332410
Radiology Section, Department of Medical
Diagnostic Sciences,
Katholieke Universiteit Leuven, Leuven,
Belgium
Abstract A review of modern
imaging techniques commonly used
in dental practice and their clinical
applications is presented. The current
dental examinations consist of intrao-
ral imaging with digital indirect and
imaging is divided into traditional
tomographic/panoramic imaging and
the more recently introduced cone
beam computed tomography.
Applications, limitations and current
trends of these dental in-ofce
radiographic techniques are
discussed.
Keywords Dentistry . Dental
imaging . Intraoral radiography .
Panoramic imaging . Cone beam
computed tomography

Introduction
The rapid technological advancement of x-ray systems for
dental practice requires a continuous update and justica-
tion of radiographic applications and guidelines. Dentists
are challenged by the increasing complexity of systems
and multitude of diagnostic tasks. The purpose of this
review article is to inform general radiologists about the
current concepts and latest radiographic imaging techni-
ques in modern dental practice.
Background
Although dental exposure only contributes a few percent to
the population's total medical exposure, it is crucial to adopt
certain measures to avoid unnecessary repeated examina-
tions, especially with the advent of three-dimensional
imaging in dentistry [1]. These general safety principles
have recently been reinforced by two facts: (1) 2 years ago,
the ICRP updated the recommendations to calculate effec-
tive doses with new or updated weighting factors like those
for salivary glands that may contribute to a signicant
change in dental risk estimation [2, 3]; (2) the multitude of
new 3D techniques with a presumably negligible dose
increases the risk of overexposure, especially if using these
new tools for (hidden) screening purposes. For each of the
techniques mentioned below and for their designated
diagnostic purpose, it is important to establish a justied
positive net balance of the x-ray examination [1, 2, 4, 5].
This can be guaranteed by applying selection criteria, using
physical methods to minimise exposure and by adequate
quality assurance programmes. Although this review will not
discuss guidelines and recommendations, it will present
many techniques available in dental practice and reveal risks
and difculties with selection criteria.
In general, following clinical examination, radiographs
are only indicated when providing additional information
about a disease [4, 5]. However, in clinical practice, this
broad concept is often subject to interpretation. On the
other hand, dental radiographs may have additional
valuable information related to generalised processes like
osteoporosis [6, 7]. Complicated, simultaneous diseases
2638
may require sophisticated imaging, but prescription may
be suboptimal if access is limited [5]. We refer to some
recent review articles describing modern imaging techni-
ques for specic dental subdisciplines, including caries
[8, 9] and periodontal disease diagnosis [10, 11],
endodontics [12, 13], orthodontics [14, 15], dental and
maxillofacial trauma [16, 17], implantology [18, 19],
temporomandibular joint (TMJ) disorders [20, 21], and
jawbone or sinus lesions [22, 23].
Intraoral dental radiography
Intraoral radiography is still the most common radiographic
technique used in dental imaging. By means of an x-ray
generator and intraoral receptor, a projection radiograph is
obtained of a small region in the dentoalveolar process. The
three congurations are periapical, bitewing and occlusal
radiographs. For the rst two, the paralleling technique is
most often used: the central beam is projected perpendicular
to the receptor, which is aligned parallel to the long axis of
the teeth. This projection geometry shows minimal distortion
and can be more or less guaranteed when using specic
aiming devices. Periapical radiographs image entire teeth
including the bone surrounding the roots. Bitewing radio-
graphs only image the teeth crowns and alveolar crest, but
from both upper and lower teeth, making them most suitable
for visualisation of interproximal areas and associated
carious lesions [5, 8]. Occlusal radiographs are obtained
with larger receptors (approximately 75 cm), positioned
between the occlusal teeth surfaces. They are useful when
periapical imaging is clinically impossible or when an
additional dimension is desired to localise certain structures
[5]. The x-ray tube can be oriented towards the chin for
mandibular views, the nose for maxillary projections or
sideways for lateral views. Occasionally, other views or
additional imaging may be required, increasing the summed
radiation dose.
Technology
X-ray exposure X-ray tube positioning is critical for
adequate image quality. In practice, aiming devices enable
such stable projection geometry [24]. Aluminium ltration,
longer cones and rectangular collimators are important tools
for radiation reduction [4, 25]. The tube potential for
intraoral radiography is usually only minimally variable,
ranging between 60 kV and 70 kV [4, 26, 27] with both AC
and DC voltages still being used. Rening exposure time is
the most important step towards optimised patient doses.
Some older generators with preset times cannot fully cope
with the low doses (or short exposure times) of new digital
detectors.
Image receptor Digitalisation in dentistry is ongoing with
both direct and indirect detectors, the rst referring to
solid-state sensors, the latter referring to storage phosphor
systems [25].
Direct systems: CCD (charged coupled device) and CMOS
(complementary metal oxide semi-conductor) solid-state
sensors contain silicon crystals converting photons to
electrons. For CCDs, pixel charges are transferred to a
common output source, while for CMOS conversion takes
place at each pixel [28]. Although CCD chips have generally
been found to produce less noise, both have proven
reliability for intraoral radiography [2931]. They can be
fabricated into intraoral formats (except occlusal sizes), but
their active areas are somewhat smaller than lm. In
addition, read-out technology and cable connection for
electrical supply make them much thicker. CMOS technol-
ogy can provide slightly larger areas and its lower power
consumption enables manufacturing of wireless devices
[32], but at the cost of a thicker sensor because of battery
integration. The signal transfer curve of solid-state detectors
depicts their higher sensitivity compared with conventional
lms, allowing lower exposure times [3336]. One consid-
erable drawback is the occurrence of blooming artefacts [28,
34, 35]. CMOS technology is said to be more resistant to
these artefacts by correcting small areas of overexposure
[28]. These limitations are gradually overcome [28, 37, 38].
Indirect systems: Photostimulable storage phosphor (PSP)
plates for dental imaging [39] strongly resemble the small
and especially thin intraoral lms. These plates can be
designed into similar formats, including occlusal sizes,
and are thus often better tolerated by patients. The major
difference with lm is the absence of saturation [30, 33
36, 3941]. PSP detectors have a much larger dynamic
range than solid-state detectors, decreasing the risk of
radiographic retakes. Still, optimised exposure levels for
PSP should carefully be established as high doses generate
adequate radiographs (Fig. 1).
Clinical applications
Intraoral radiographs provide dentists with additional
information concerning the bony contour around a tooth,
internal anatomy and associated pathology, which cannot
be derived from the clinical examination alone.
For caries diagnosis, intraoral radiographs allow visual-
isation of interproximal surfacesoften difcult to inspect
clinicallyor evaluating occlusal caries that may be
present in the deep grooves of occlusal surfaces [8, 9].
In addition, initial carious lesions may clinically seem
intact because surface demineralisation may leave an
intact outer contour of the tooth. As carious lesions are
depicted as small radiolucencies due to demineralisation
of the internal structures (Fig. 2a), contrast resolution may
be an important parameter in the diagnostic accuracy of
caries detection [42]. Although rst generation digital
sensors often performed suboptimally compared with
conventional lm, new detector technology is improving
and approaching or surpassing lm in terms of contrast
 2639

Fig. 1 PSP (left) and CCD

(right) periapical radiographs
of a human skull's mandibular
molar region at rising
exposure time (40 to 80 ms).
While radiographic contrast
for PSP remains unchanged,
CCD radiographs darken,
causing typical blooming
artefacts. The alveolar crest
distal from the rst molar
shows a defect (arrow)
expanding into the furcation
area (where the tooth root
divides into multiple root
endings, dotted arrow): this
marginal bone darkens at
rising exposure. Notice the
large periapical inammation
around the rst molar (*)

and spatial resolution [30]. Furthermore, software allows
image manipulation by applying specic lters [43, 44].
Recent studies therefore nd digital imaging comparable
for detecting carious lesions [45, 46], while image
enhancement may often be benecial for accuracy and
observer variability [47, 48] (Fig. 2b). Variations in study
outcomes are due to multiple factors like enhancement
technique, detector type, display screen resolution or
ambient light settings.
For periodontal diagnosis, the high resolution of
intraoral radiography helps the visualisation of the bony
supporting tissues, including small details like periodontal
ligament space, lamina dura and bony trabecularisation.
Digital imaging allows measuring bone loss extent
[distance between the cemento-enamel junction (CEJ)
and the alveolar crest] using image analysis tools
(Fig. 2b). This measurement accuracy has been found to
lie within 1-2 mm clinically [49, 50], but is especially
dependent on the projection geometry and presence of
irregular, hard to diagnose infrabony defects (crater-like
bone loss within the alveolar ridge, see the section
Limitations). In addition, alveolar crest depiction, which
is of great importance for disease extent estimation, may
also be inuenced by blooming artefacts due to over-
exposure of solid-state sensors [34, 35] or by image
processing [51, 52]. More studies are still needed to
determine the inuence of digital parameters on periodontal
diagnosis.
A simple example of spatial resolution and image
processing inuence is illustrated in Fig. 2c. When
extensive lesions cause pulpal inammation associated
with periapical destruction (see Fig. 1), endodontic
2640

Fig. 2 (a) Periapical

radiograph of the maxillary
right molar region. The
radiolucency (arrow) is an
interproximal carious lesion,
reaching into dentin. (b)
Image processing algorithms
like contrast enhancement,
sharpening or zooming may
inuence caries detection.
Image analysis tools allow
measuring alveolar bone loss
at interproximal sites. (c)
Radiographic estimation of
endodontic canal length of a
mandibular cadaver molar
using two le sizes (0.06 mm
or 6, 0.1 mm or 10). While
smaller le size tips may be
more difcult to depict, high
spatial resolution and/or
dedicated ltering may help in
their visualization [5557]

therapy consists of pulpotomy and canal preparation for
endodontic root canal lling. This can be veried using
periapical radiographs. Often instruments as small as
0.06 mm are needed to prepare the narrow and curved root
canals. Therefore, digital sensors have previously been
reported to be suboptimal compared with conventional lm
for endodontic le length assessment [53, 54]. Recent
studies have proven the opposite using high resolution
technology and/or dedicated endodontic ltering, improving
the visibility of small le tips [5557].
One last important application of digital intraoral
radiography is the follow-up of dental lesions. Serial
radiographs with identical geometric projection and expo-
sure settings can be subtracted using digital subtraction
radiography. This allows for qualitative evaluation by
underscoring small changes like caries progression [8],
periapical lesions [58] (Fig. 3a) or even quantitative
evaluation of periodontal bone loss [11, 59] (see Fig. 3b).
Although a promising technique, the required precision
cannot be obtained routinely, which has mostly limited its
application to research. Many studies have explored image
processing algorithms to correct for geometric and/or
contrast deviations with encouraging results [59, 60], but
lack of comparability of the multiple processing tools
further hinders routine implementation.
Limitations
The major limitation of intraoral radiography is its two-
dimensional nature with overlapping anatomical struc-
tures. This often limits distinction between oral or buccal
structures like the alveolar bony plates [11, 61]. Infrabony
defects on the oral side may be supra-projected by buccal
bone, hindering interpretation and adequate treatment
planning (Fig. 4a). Consequently, this technique is also
prone to projection errors, which can create overlap of
interproximal crown surfaces (see Fig. 4b, left) and
prevent adequate caries diagnosis. However, in the
craniocaudal direction, too, projection errors may lead to
misinterpretation of the actual alveolar bone height
(Fig. 4b, right).
Extraoral dental radiography
Extraoral dental imaging generates diagnostic images of
the larger craniofacial complex and can be subdivided
into extraoral projection radiography and tomographic
imaging. While conventional projections are especially
useful for evaluating the facial skeleton or its growth,
the need for 3D information in dentistry has led to
many developments in tomographic imaging. An over-
view of the different extraoral dental techniques is
provided in Fig. 5.
Indirect and direct dental systems are based on extraoral
PSP plates or on limited dimension CCD sensors. Multi-
modal extraoral units can further reduce costs by combining
panoramic with tomographic and/or cephalometric imaging,
or even local 3D cross-sectional imaging.
 2641

Fig. 3 Digital subtraction radiography. (a) Follow-up of a periapical and calibrated with a step wedge. A region of interest (blue) can be
lesion with failing restoration 9 months after retreatment. After (rigid) chosen to quantify small density changes of the bony defect created
geometric transformation, the images were subtracted to enhance the (courtesy of Dr. O. Nackaerts)
differences. (b) Molar region of a Beagle dog with identical projection

Fig. 4 (a) Intraoral radiograph of a maxillary molar region revealing (left) and cranio-caudal (right) projection errors can cause overlapping
extensive bone loss. Exact localisation of defects and their topography interproximal contacts (*, B1) or incorrect bone level projections (*,
is difcult because of tissue overlap on 2D images. (b) Mesio-distal B2: bone normally lies more than 1 mm from the CEJ)
2642

R Fig. 5 Extraoral dental techniques: skull projections (a), tomog-
raphy (b), pantomography (c), computed tomography (CT) (d),
cone beam CT (e). Notice the self-made collimator effect on
cephalometric exposures (*) in (A), reducing radiation exposure.
The wedge lter improves soft tissue visualisation (arrow) [75].
Also notice the bilateral tonsillar calcications as additional ndings
on the panoramic radiograph in C, projected onto the mandibular
angles (arrows). The CBCT datasets (E) can easily be processed for
cephalometric analysis on 3D surface rendered models (left, down)
or on simulated projections, like ray-sum images (left, down) or
maximum intensity projection reconstructions (right, down)
Technology
Conventional techniques
Skull projections These low-dose radiographs [3, 6264]
are used for evaluating the craniofacial skeleton or spine
and are generated using a stationary x-ray tube with a
pyramid-shaped beam and a screen-lm or digital
receptor (Fig. 5a). The most common dental projection is
the lateral cephalometric used for orthodontic growth
assessment, but other projections can be generated by
positioning the head with different angles towards the
receptor. The magnication factor depends on the distance
among source, focus and receptor. Conventional screen-lm
systems can integrate extraoral PSP plates. Direct digital
systems based on CCD technology perform linear imaging
with stepwise exposure using a fan-shaped beam [25, 65,
66]. This results in exposure times of less than a second for
the classical approach, but up to 20 s with the fan beam.
Recently, a so-called one shot CCD system has been
introduced capturing the entire head in one single shot using
optical lenses [66]. For workow aspects, CCD-based
systems provide advantageous direct read-out, but care
should be given when establishing diagnostic yields as
magnication and distortion have been found to cause
differences in linear and angular measurements on fan-
beam and optical CCD systems [66]. Despite the already
high sensitivity of screen-lm combinations, reports still
demonstrate dose savings when using both digital projection
types [62, 63]. Collimation or eld-size trimming can further
reduce radiation dose (Fig. 5a) [67] and is therefore
recommended [3, 4]. Remarkably, its incorporation into
dental cephalometric units is still lacking, even though these
projections are most often used for small children [64].
Tomography and panoramic radiography In dentistry, the
tomographic technique is still often utilised given the
relatively low cost and availability. In particular, the curvi-
linear variant, panoramic imaging, is one of the standard
dental radiographic examinations.
During tomographic acquisition, the x-ray tube and image
receptor move simultaneously in opposite directions,
leaving objects within the focal plane in a xed position,
with clear depiction as a result (Fig. 5b). Structures
outside the focal plane are blurred. The resulting sections
from unidirectional tomography have the disadvantage of
inconsistent magnication and non-uniform densities.
Advanced patterns, like spiral (multidirectional) movements,
2643
allow more consistent magnication and a sharper image
[68]. Similarly, panoramic imaging follows a curved image
layer centred at the jaw contours, but uses a narrow
collimated beam moving in the same direction as the
receptor (Fig. 5c). Just like tomography, panoramic imaging
is also highly dependent on patient positioning [6871].
Modern multi-technique units often combine panoramic
radiography with cross-sectional tomographic imaging.
Phosphor plates can replace screen lms in traditional
cassettes. Direct imaging is again limited by expenses related
to large detectors [25, 65, 69, 70]. Therefore, three to four
CCD sensors are arranged vertically to cover the panoramic
x-ray beam height, and the image can then be built up by
increments. However, the focal trough is narrower, making
positioning errors more likely [69]. A wide variety of
tomographic movements have been introduced for CCD-
based units to provide practitioners with some form of
relatively inexpensive cross-sectional imaging [72]. How-
ever, because of the rapid growth of low-dose 3D imaging
techniques and their indications, recent multi-technique
panoramic units now often allow local 3D cone beam
imaging, which will further reduce tomographic use. With
their low cost and doses as low as 10 Sv [7376], panoramic
overviews are still more useful for dental practices.
Modern techniques
Computed tomography (CT) versus cone beam CT
(CBCT) The basic principles of (third generation) CT and
CBCT are illustrated in Fig. 5d and e. Modern multidetector
(MD)CT units use a widened fan-shaped beam and a
two-dimensional array detector [33, 7779]. Sub-
millimetre imaging (as small as 0.5 mm) can now be
accomplished with sub-second rotation times. Nevertheless,
even with 64 detector rows where the wider fan-shaped
beam starts to exhibit cone beam effects [78], multiple
rotations are necessary to image the dentomaxillofacial
complex. For CBCT with a conical x-ray beam, the entire
volume is imaged in one single rotation, using a at two-
dimensional image receptor (or image intensier with CCD
sensor) [33, 8086]. Less powerful and cheaper x-ray tubes
can be used [80, 83], which greatly reduce radiation
exposure [8790]. However, this is often associated with
increased noise andtogether with the smaller dynamic
range of CBCT detectorswith a lower contrast resolution,
preventing soft-tissue imaging. Nevertheless, the most
important dentomaxillofacial diagnostic requirement is
high 3D spatial resolution for depiction of small bony
structures. In practice, near isotropic 3D voxels as small as
75 m are obtained [8084], giving higher bony resolution
than MDCT [9093].
Numerous systems have now been developed for dento-
maxillofacial use [84], even surpassing 50 when including
multi-technique units. When undergoing imaging the patient
is most often standing or seated, which makes in-ofce units
resemble compact panoramic machines. However, most
systems differ in geometrical conguration: the rotation
centre may be closer to the detector or in the middle of the
source-detector distance, while beam angles may differ for
2644
different units or within one unit. [84, 94]. This leads to a
wide range of different elds of view (FOV) with truncation
or partial volume artefacts as the entire volumes are often not
covered by the detector. In addition, data reconstruction may
be based on either modied Feldkamp or algebraic recon-
struction techniques (ART); the latter being computational is
more expensive, but may help counteract the many beam
hardening artefacts when metal objects are present [77]. For
these reasons, there is great variation in image quality and
radiation dose for different systems (Fig. 6) [90, 92, 9497].
Furthermore, exposure parameters further inuence image
quality within one system (Fig. 7) [98, 99]. Measurement
accuracywhether based on 3D model accuracy or linear
measurementshas been found to be adequate for CBCT
compared with MDCT [100103], but recent ndings seem
to indicate large differences between and within units
depending on exposure parameters [104, 105]. Thus, despite
the excellent properties and growing use of CBCT, more
research is needed to check their performance.
Clinical applications and limitations
Extraoral plain skull radiographs have lost quite a bit of
territory in the evaluation of the head and neck since the
Fig. 6 Comparison of MDCT with different CBCT units. The eld
of view differs between each CBCT unit and can often be adjusted to
smaller or larger sizes. Notice the more detailed bony depiction for
advent of low-dose 3D imaging. Just like occlusal radio-
graphs, benet must outweigh summed radiation doses and
should be compared with that of other available techniques.
For evaluating maxillofacial fractures in particular CBCT
seems to offer new potential over skull projections [16,
106], given its detailed bony depiction at relatively low
doses. Of course, when higher soft tissue contrast is needed,
CTs and/or MRIs are the methods to be considered.
Nevertheless, the most common dental projection is the
lateral cephalometric. Its major disadvantages are overlap,
magnication differences between the left and right side,
and distortion [25, 65, 66]. CBCT data on the other hand
can easily be processed to obtain similar cephalometric
views without magnication or distortion [107]. For
instance, multiplanar reformatting (MPR) of CBCT data
allows locating cephalometric landmarks in three dimen-
sions or selecting the midsagittal slice, which can be
thickened to obtain a ray-sum image of the entire facial
complex mimicking a projection image (Fig. 5e). Many
reports have demonstrated that linear measurements on
CBCT-derived cephalograms or using MPR are more
accurate than conventional ones [108112]. Furthermore,
analyses on maximum intensity projection images or on
true 3D rendered models of CBCT data (Fig. 5e) are also
accurate and reliable methods, and therefore bound to
CBCT systems, but also their differences in image quality and metal
artefacts (from left to right: Somatom Sensation 64 MDCT, Pax Uni3D
CBCT, VeraviewEpocs3D CBCT, I-CAT Next Generation CBCT)

Fig. 7 Effect of different exposure parameters on image quality and
model accuracy within one CBCT system (I-CAT Next Generation).
The cadaver jaw was imaged at 120 kV, 5 mA, 26 s with 360 frames
and 0.25 mm voxel size (a); at 100 kV (b); at 3 mA (c); and with a
replace traditional orthodontic planning [113117]. For
orthodontic follow-up, traditional records cannot directly
be compared with CBCT cephalograms or 3D analyses, but
only with similar 2D projections derived from CBCT data
(base images or scout) [107]. Still, it is of the utmost
importance to relate diagnostic benet of different examina-
tions to their respective and accumulated doses especially to
minimise risks in young children. Therefore, studies are
investigating whether for CBCT lower exposure parameters
can also be used for cephalometric assessments [115].
Panoramic radiographs provide a broad overview of the
orofacial region including jaws, teeth, sinuses and TMJ
[5]. They are especially useful in showing dental develop-
ment stages (Fig. 8a) or anomalies, or as an initial
examination for generalised disease or multiple problems.
They can reveal inammatory or traumatic bony lesions
and are comfortable for patients compared with intraoral
imaging. For heavily mutilated or edentulous patients,
panoramic radiographs are thus the preferred initial
examinations. Although panoramic screening for occult
diseases should be discouraged [5], dentists must be aware
of possible additional ndings (Fig. 5c). For instance,
despite their low sensitivity for detecting calcied athero-
mas in the bifurcation region of the carotid artery [118,
2645
reduced number of frames (180, only half of the exposure time) (d).
The histograms differ slightly in grey scale range, but this is less
apparent in the clinical image quality. Isosurfaces with similar
thresholds depict these differences
119], these ndings on available images may still help,
especially for older patients or after radiation therapy
[120122]. Similarly, mandibular cortical erosionclearly
seen on panoramic radiographsmay be a signicant
marker for osteoporosis detection [6, 7]. Panoramic
equipment is a lot less costly compared with 3D imaging
and is easily accessible for dentists, but major disadvan-
tages are the presence of magnication and distortion of
3D anatomical structures onto a 2D plane with over-
lapping of tooth surfaces or other important landmarks.
The thin image layer makes patient positioning critical to
properly visualise both dental arches. Asymmetrical
positioning will cause structures to fall out of the image
layer and cause asymmetrical distortion (Fig. 8a). Their
spatial resolution is much lower than that of intraoral
radiographs, hampering detection of minor or nascent
lesions. They are thus not recommended for diagnosis of
periapical lesions, caries or marginal bone loss without
additional intraoral radiographs [123]. Furthermore,
absence of the third dimension limits further treatment
planning (Fig. 8b).
Cone beam CT is rapidly becoming the radiographic
standard in 3D dental imaging. System software is
developed for dental clinicians containing several modules
2646
Fig. 8 (a) Panoramic
radiographs' positioning errors
limiting its diagnostic value:
overlapping interproximal
tooth contacts hindering caries
or alveolar bone loss
diagnosis; unequal horizontal
magnication (see comparison
of right and left mandibular
ramus) due to sideways tilting
of the head during acquisition;
vertical magnication (anterior
mandibular height seems
much higher). (b) Cone beam
examination of the right
impacted canine in (a) reveals
resorption of the neighbouring
incisors, not seen on the
panoramic image
in addition to the standard MPR module for orthogonal
reslicing. A panoramic simulation, an implant and a TMJ
module are most often included. The panoramic module
consists of oblique reslicing: by drawing an oblique line
following the jaw's arch, an overview of both jawbones is
created at sub-millimetre resolution (Fig. 9a). Raising the
slice thickness simulates high-resolution panoramic recon-
structions without the many artefacts caused by panoramic
imaging (Fig. 9b). This overview is useful for dental
clinicians to start evaluation during chair-time. In addition,
many platforms generate automated arch detection
(Fig. 9c). Cross-sectional imaging is often desired for
surgical interventions like dental implant rehabilitation as
information is required on bone quality and quantity, but
also on the relationship with important anatomical
structures [124]. For this, CBCT provides an excellent
alternative to CT [19, 80, 125], and implant assessment
modules generate multiple cross-sections in the desired
jawbone region. Some platforms contain integrated
implant databases useful for dynamic on-screen implant
placement simulation. Because of inadequate low contrast
detail in CBCT, removable prosthetic (acrylic) restorations
of missing teeth cannot clearly be distinguished after
imaging, but adding radiopaque markers may help in
planning implants for the axis of the restorations
(Fig. 10a). The excellent bony depiction though is
especially useful for TMJ evaluation: when soft tissue
involvement is not suspected [126], CBCT can offer great
detail on the joint's bony morphology [127129]. Some
clinical studies have conrmed its potential (compared
with other techniques) for evaluating osteoarthritic
changes [130, 131] or even for image-guided puncturing
of the TMJ space [132]. For tooth or periodontium-
associated lesions, too, small or medium eld CBCT
examinations may bring added value to current diagnostic
techniques. Periodontal diagnosis is often hindered by the
difculty to interpret three-dimensional bony breakdown
creating infrabony craters and furcation problems around
teeth (Fig. 10b). In vitro research demonstrated that CBCT
allows accurate periodontal bone loss measurements and
is superior in detecting complex periodontal defects [133
136]; nevertheless, clinical studies are still sparse despite
these encouraging results [137, 138]. This is surprising as
treatment approaches, such as osteoplasty, may vary with
bone morphology [139]. On the other hand, within
endodontic imaging, several clinical studies have been
conducted and stress that CBCT provides more adequate
diagnosis of periapical lesions [140142], root canal
obturations [143] or root fractures [144, 145], or help in
better endodontic surgery planning with accurate depiction
of maxillary sinus anatomy such as the presence of septa
[142, 146, 147] (Fig. 10c). In-ofce cone beam CT is
consequently also being explored for paranasal sinus
imaging, and preliminary studies have depicted its useful-
ness for the evaluation of chronic sinusitis or fractures [23,
80, 148]. However, literature is still scarce, but it is likely
that it will pertain to hard tissue imaging while C-arm
based cone beam technology will become increasingly
important for intra-operative evaluation [23]. Even for
caries diagnosis in vitro studies have shown much
potential for CBCT imagingmaybe not as an alternative
to intraoral imaging, but more as additional ndings on
 2647

Fig. 9 (a) Drawing of an

oblique curve following the
mandible's contour on the
axial slice generates an
oblique reslicing at
submillimetre thickness.
(b) Augmenting the slice
thickness widens the oblique
reformat (resembling a
panoramic image layer),
simulating a panoramic
overview. (c) Medium FOV
(TMJs not included)
automatically generated
high-resolution panoramic
reconstruction (courtesy of
Marc Hermans)

acquired 3D examinations [149151]. However, despite
the excess of studies demonstrating the added value of
CBCT over other imaging techniques within almost all areas
of dentistry, research is inconsistent in technology, exposure
parameters or settings [152]. Therefore, evidence-based
guidelines are being established dealing with the justica-
tion, optimisation and referral criteria of CBCT for clinical
practice [153155].
Advanced 3D imaging
Diagnostics
In addition to justication of 3D examinations, adequate
training is required to ensure responsible use and adequate
diagnosis of possible additional ndings [153155]. Up to
25% of incidental ndings on CBCT examinations have
been reported, most of them airway-related, including
sinusitis and retention cysts, followed by TMJ ndings,
such as degenerative joint changes [156]. Although life-
threatening cases are rare [157], it is also crucial to select
the proper imaging technique. CBCT should be considered
a worthy alternative to MDCT for multiple odontogenic
and non-odontogenic lesions encountered in radiological
practice, including cysts (Fig. 11a) or infections [156,
158160], but also neoplasms like ameloblastoma [161],
odontoma [162, 163], odontogenic myxoma [164] or even
carcinoma [165]. A retrospective study [166] on patients
diagnosed with cancer and on bisphosphonate therapy
even suggested that CBCT allowed accurate visualisation
of pre-clinical necrotic bodies within osteonecrotic
jawbone lesions and allowed accurate assessment of
disease status. However, outside the jawbone region, too,
dental CBCT diagnosis is continuously being explored
for new applications like cervical vertebrae examination
[167] or post-operative assessment of cochlear implantation
[168]. Furthermore, recent studies have been conducted
focusing on overcoming the inherent drawbacks of CBCT
technology by modifying imaging protocols [169] or fusion
2648
Fig. 10 (a) CBCT cross-sections of a patient wearing a temporary
prosthetic restoration during acquisition with inserted radiopaque
markers. The latter can help verify implant angulation towards the
prosthetic rehabilitation during implant planning. (b) Clinical (after
soft tissue apping), intraoral and CBCT images of periodontal
bone loss around cadaver molars. Intraoral radiographs are limited
by supra-projection of buccal and lingual bone, while CBCT cross-
sections can reveal the exact topography of surrounding bone
of CBCT volumes with optical datasets [170]. For instance,
by wearing a lip retractor during CBCT acquisition, the
covering cheeks and lips are separated from the gingival
tissues (Fig. 11b), which allowed preliminary measurements
of soft and hard tissue relations, including measurements of
the bony crest to the gingival margin, or of the palatal
masticatory mucosa thickness needed for soft tissue grafting
[169]. To overcome the drawback of artefacts caused by
metallic dental restorations on CBCT data, fusion with
optical 3D images has been found to enhance image quality
[170].
Planning/follow-up
A large amount of third party software has become
available to aid in accurate surgical planning, to create
computer-manufactured simulation models and surgical
(dotted line = healthy bone levels, arrows = local irregular defects).
(c) Left: CBCT coronal view of an endodontically treated maxillary
rst molar: a periapical lesion around the distobuccal and palatal
root and a clear connection with the maxillary sinus can be noticed
with associated sinusitis. Right: Panoramic radiograph revealing a
large periapical lesion at the right mandibular rst molar. CBCT
examination revealed apical root resorption not visible on the
panoramic image
guides, and for advanced dentomaxillofacial image analy-
sis. However, additional costs and training often prevent
their widespread use. The largest computer-aided applica-
tion using cross-sectional imaging within dentistry is
without a doubt the surgical planning of dental implants.
Virtual, interactive 3D environments have allowed more
adequate implant planning compared with 2D approaches
by avoiding complications like nerve damage or sinus
perforation [171, 172], making them especially useful for
complex cases. Furthermore, by imaging patients with a
radiographic guide (acrylic guide with radiopaque
markers), followed by separate imaging of the guide alone,
registration of both datasets allows implant planning for the
prosthetic restoration (aesthetic outcome). Computer-aided
manufacturing of stereolithographic surgical guides based
on the virtually created environment can then help with
precise implant insertion [173177]. Many different
systems are currently available, and even though

Fig. 11 (a) Intraoral radiograph of the maxillary central incisors
showing advanced root resorption on the left incisor and a
radiolucency with corticated border at the level of the palatine
opening of the nasopalatine canal. CBCT cross-sections revealed
additional branches of the nasopalatine canal and a nasopalatine
duct cyst palatal from the right incisor. The volume-rendered
image (top view) of the cropped region clearly depicts multiple
computer-assisted implant surgery has been proven to
be a precise and reliable method, more research is being
conducted concerning further accuracy improvement
using modied guided techniques or image fusion with
optical data [178180]. Similar imaging modications
are being explored for other maxillofacial-guided
Fig. 12 (a) Sagittal CBCT section through the maxillary central
incisor before and after extraction with bone grafting (Bio-Col site
preservation technique). (b) Registering or aligning of the pre- and
2649
nasal and palatal openings. (b) Standard CBCT patient imaging
protocol (left): the arrows show no distinction between lips or
tongue and gingival soft tissues around the alveolar crest. Same
patient imaged while wearing a lip retractor (right): the arrows
depict the retractor and created air gaps, which allow vestibular
gingival tissue visualisation and palatal mucosa thickness
estimation
surgery applications like orthognatic surgery planning
[181, 182], but this is beyond the scope of this review.
It must be noted that although CBCT has been found to
be as reliable as MDCT for image-guided surgery
[183], differences in model accuracy [104, 105] may
also play a role in the accurate tting of surgical
post-surgical dataset. (c) The post-volume (blue) revealed only small
local bone loss (buccal maxillary plate of the central incisor region)
compared with the pre-volume (yellow)
2650

guides. Finally, as bony changes over time are part of a Conclusion

dynamic 3D remodelling process, and given the
limitation of 2D techniques, CBCT datasets have also
been explored to visualise bony resorption after bone
grafting (Fig. 12) [184, 185] or healing of extraction
sockets [186]. These volumetric assessments were
found to be very useful, but exact quantication of
bone remodelling requires precise segmentation techni-
ques and further investigations are needed to determine
their clinical accuracy [187].
This review presented the latest intra- and extra-oral
radiographic techniques used in dental practices. Because
of the increasing complexity of diagnostic tasks and
imaging techniques, interaction among dentists, oral
radiologists, head and neck specialists but also general
radiologists is becoming more important not only for
adequate diagnosis, but also for selection of the proper
imaging technique by any of the those disciplines.

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