committee report

CONE BEAM IMAGING; the essential considerations

...it remains necessary that further clinically based studies are carried out to confirm the benefits of CB imaging... These investigations are complex and involve extended time periods.
INTRODUCTION
Orofacial cone beam (CB) systems produce 3-D images of parts of the head and neck, including the jaws. All dental, oral and maxillofacial clinicians must be familiar with the role of this technique. It does not replace other imaging modalities. Instead, it complements plain 2D radiography, panoramic radiography (OPG), multislice computed tomography (MCT) and other techniques including MRI, ultrasound and nuclear medicine. Soft tissues are not sufficiently well examined with CB technique. MCT is far superior in this regard, which can be critical. It should be noted that many soft tissue lesions are best examined with MRI. Measurements made on images from MCT and CB data have been shown to be similarly accurate.

APPLICATION
There is some evidence for the use of CB imaging in many areas of dentistry, including pain diagnosis, endodontics, periodontics, implant planning, ectopic and impacted teeth, orthodontics and orofacial surgery, including image guided surgery. Caries diagnosis seems promising although further clinical studies are required. While the advantages of being able to evaluate structures in 3D and high resolution are obvious, it remains necessary that further clinically based studies are carried out to confirm the benefits of CB imaging, especially the advantages of CB over plain 2D radiography and how CB compares with MCT and MRI. These investigations are complex and involve extended time periods. This limitation of research on extremely fast evolving equipment is recognised. It is therefore essential that, when used in place of panoramic and/or intraoral 2D imaging, ultra low dose CB units should be used and appropriate low dose protocols employed. MCT is a much more powerful and flexible modality and presently remains the technique of choice over CB imaging in several instances, especially complex cases (including dentoalveolar related inflammatory disease) and in the evaluation of more serious disease, e.g., severe infection and where a tumour is suspected. Low dose MCT protocols can be employed. The use of intravenous contrast media with MCT examinations is sometimes essential for appropriate diagnosis. The value and practicality of post-contrast CB studies is not known although questionable, since soft tissues are poorly visualised.

RADIATION DOSE LEVELS

Not all CB units are low dose. CB radiation doses range widely, largely depending on the unit used. Some CB units can deliver higher radiation dose levels than MCT scans of the jaws (when appropriate low dose MCT protocols are employed). Some CB units are able to deliver lower dose levels than low dose MCT scans for the same volume (3D data scanned). Small field of view (FOV) CB units do not necessarily deliver doses that are lower than some larger FOV CB units. Some CB units are capable of delivering doses comparable to some panoramic (OPG) units and some intraoral 2D series (number of projections, technique and detector dependent). Comparing available data is difficult and the limitations in the measurement of the dose levels delivered are recognised. Like most imaging technology, CB machines continue to evolve quickly.

IMAGE QUALITY
Cone beam units produce images with higher spatial resolution than MCT although this benefit can be negated as a result of the weaknesses of CB, including scatter, beam hardening, imaging time and patient position.
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INTERPRETATION AND RESPONSIBILITIES
Persons who employ CB imaging must be familiar with all other imaging modalities, including MCT, MRI, ultrasound and nuclear medicine, which may be more appropriate. Under normal circumstances, CB imaging should not be prescribed solely on the basis of convenience, e.g., in-office CB units. Persons carrying out the technical (performing the scan) aspects of imaging must have had appropriate training. The clinician overseeing/obtaining the CB examination is responsible for appropriate radiologic interpretation of the study. The entire volume data set from a CB study must be evaluated and interpreted. To varying extents, the majority of CB scans include the paranasal sinuses, pharyngeal air spaces, skull base, cervical spine and upper neck. The minimum skill set required to interpret CB studies includes: A thorough understanding of the strengths and weaknesses of this modality. The ability to apply an appropriate algorithm for evaluating volume data. This is not the same as that used in interpreting 2D radiographs. The ability to perform morphologic analyses and plan surgical procedures is different from the skill set required to evaluate the data set for disease. Thorough knowledge of the radiologic anatomy of all structures included in the scan. This differs from clinical/surgical anatomy and that seen in plain 2D radiographic images. Knowledge of the pathoses and clinical significance of the various disorders which may affect all the structures included in the scan. Knowledge of and the ability to identify radiologic features which suggest presence of disease. Many abnormalities do not present as obvious opacities or lucencies. The ability to identify the key radiologic characteristics of a specific type of disease and the knowledge to interpret those radiologic characteristics so identified. This requires a thorough knowledge of the radiologic features of diseases affecting the orofacial structures. Radiological reports should be provided for CB scans. The radiological skill levels of clinicians involved in CB imaging as well as the associated ethical, insurance and medico-legal implications require consideration. If the practitioner is not able to comprehensively interpret CB datasets in their entirety or does not have suitable training, it seems prudent that arrangements should be made for this to be performed by radiologists with appropriate training and expertise in dental and orofacial imaging. Concerns have been raised for clinicians who issue disclaimers and those who obtain patient agreement to a waiver of liability with respect to the complete interpretation of CB studies for which the clinician is responsible. This paper does not address this issue. Legal advice is strongly recommended. Orofacial 3D cone beam (CB) imaging is an essential technique which all dental and orofacial clinicians must now be familiar with. However, rather than replacing other modalities, CB imaging complements plain 2D radiography, panoramic radiography, multislice computed tomography (MCT) and other techniques including MRI, ultrasound and nuclear medicine. This document is largely based on the recently published review paper Cone beam imaging: Is this the ultimate imaging modality? (Clin Oral Implants Res. 2010;21:1201-8). Members are encouraged to read this review. Bernard Koong Oral and Maxillofacial Radiologist On behalf of the Dental Instruments Materials and Equipment Committee

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