3D Accuitomo FPD XYZ Slice View Tomography Clinical Report

Thinking ahead. Focused to life.

3D Accuitomo FPD XYZ Slice View Tomography Clinical Report

3D Accuitomo system - a new imaging method for accurate multidirectional slicing and graphic three-dimensional presentation of dentomaxillary structures

Background and clinical evaluation Erkki Tammisalo Emeritus Professor of Oral Radiology Tomodent, Private Laboratory of Oral Diagnostic Imaging Turku, Finland Due to continuing developments of treatment methods and operative techniques, radiologists are today required to provide their dental and surgical colleagues with accurate and threedimensional imaging of oral anatomy and pathology, allowing more precise diagnostics and more detailed preoperative treatment and surgical planning. Intraoral radiography does permit viewing internal dental anatomy without the superimposition of surrounding structures and as well as panoramic radiography it provides only a two-dimensional representation of the oral bony structures in a single buccallingual perspective. These methods are therefore for limited value when analyzing complex anatomy or when detecting and quantifying pathological changes. Since the introduction of CT, digital three-dimensional imaging has been more and more used in medical radiology. With the traditional CT methods, there is, however, a lack of spatial resolution for demonstrating the subtle dental structures or for detecting small apical and alveolar lesions. Also the dose level is high in conventional CT imaging. There has been no validated practical method available for detailed 3D Accuitomo study of the dentition and the surrounding structures in spite of the fact that

the dental profession has badly needed more sophisticated and effective imaging techniques to solve existing and new coming diagnostic tasks and problems. The recent, tremendous advances in the capability of personal computers to process data and advances in detector technologies have made it possible to use new technical solutions for creating computed tomographic scans. By applying new technology, J.Morita Mfg. Corp., has developed a CT scanner based on the use of a personal computer and a cone-shaped X-ray beam. Now, with the advent of this advanced CT scanner - called 3D Accuitomo dentistry has for the fist time been exposed to the CT technology specially designed for imaging of the dento-maxillo-facial complex. Spatial resolution of the 3D Accuitomo images is high enough to accurately demonstrate all the finest hard tissue structures, the x-ray dosage is low, it is easy to use and comfortable for the patient.

3D Accuitomo FPD XYZ Slice View Tomography Clinical Report

We have been able to use the 3D Accuitomo imaging system three years and since early 2005 the second generation of the 3D Accuitomo scanner which has been furnished with a flat panel detector. The range of contrast resolution of the FP detector is significantly larger than that of image intensifier based detector when the spatial resolution of both detectors is equally high. The FP detector is equipped with a collimation system that allows use of two different field sizes. So, when the FP detector is used, the field size and the dosage level can be selected according to the diagnostic task. Through 3D Accuitomo's software system, it is possible to generate two-dimensional reconstruction images at any plane and in any direction. Slice reconstructions in three dimensions provide a display of the structures that is morphologically exact and free of superimposition. Multidimensional, fullperspective images can also be constructed that permits appreciation of the anatomy and pathological changes in an integrated and comprehensive format. The 3D Accuitomo imaging system has shown to be particularly useful in detection of subtle pathological conditions that have been missed with other imaging modalities and in studying root canal morphology, in evaluating presurgical tooth impactions, implant sites, mandibular canal and maxillary sinus location. 3D Accuitomo is the first method of choice when analyzing complex anatomical conditions or defining the extent of cysts and tumors, and their relationship to adjacent normal structures. It permits precise planning of the surgical approach and reduces intraoperative time and improves postoperative outcome. In establishing a primary diagnosis of dental lesions conventional imaging methods remain the gold standard. With these methods, there is an acknowledged lack of sensitivity for detecting and quantifying small changes in

the hard tissues. 3D Accuitomo is therefore, the modality of choice when conventional oral radiography is inadequate in detecting existing subtle pathology. During the time we have used the 3D Accuitomo imaging system, we have been able to help a large number of patients who had been suffering from diagnostic problems which had remained undetected in conventional radiographs. In summary, three years of clinical experience in working with the 3D Accuitomo high resolution and low dose 3D Accuitomo system has established that this new imaging method has revolutionized oral radiology and opened a new dimension for displaying complex structures and establishing a diagnosis. Finally, I would like to send my warmest regards to all Japanese colleagues and oral radiologists.

3D Accuitomo FPD XYZ Slice View Tomography Clinical Report

Case 1 Large multilocular cyst in the left side of the lower jaw. Cross-sectional slice through the retained third molar shows the lingual position of the mandibular canal and the sagittal slice demonstrates the anteroposterior extent of the cyst.

Case 2 The frontal alveolar process of the lower jaw has been strengthend by a bone graft for implant surgery. The axial,coronal and sagittal slices show the outcome of the operation. Bony 3D reconstruction image demonstrates the bone graft and the place from which bone has been taken for the graft.

A short curriculum vitae of Emeritus Professor Erkki Tammisalo: Dental degree, Helsinki University, 1957 . Assistant teacher in oral radiology, Helsinki University, 1958 1960. Associate Professor of Oral Radiology, Helsinki University, Finland, 1961-1963. Doctorate degree in oral diagnostic radiology, Helsinki University, 1963. Professor and Chairman of Oral Radiology, Turku University, Finland, 1964 1998. Approximately 100 scientific and review articles on radiographic imaging physics, rotational panoramic radiography, diagnostic accuracy of oral imaging techniques and oral X-ray pathology. Written two Finnish textbooks on oral X-ray pathology and diagnostics. Honorary degree of Doctor of Dentistry, Medical Faculty, Gteborg University, Sweden, 1997 . Special interest: improving panoramic imaging technique and developing new imaging technologies and methods. Cranex, Minray, Digora FMX, Digora PCT, Scanora multimodal system,Cranex Tome and 3D Accuitomo. Five worldwide patents on the area of imaging methods and technology. Case 3 Views in axial, tangential and cross-sectional directions of the impacted multirooted third molar reveal that the mandibular canal is running lingually to the mesial root and between the two distal roots. The tips of the distal roots are bending distally and embraced by cortical bone.

3D Accuitomo FPD XYZ Slice View Tomography Clinical Report

3D Accuitomo FPD XYZ Slice View Tomography Clinical Report

Clinical Applications of 3D Accuitomo Cone Beam CT

Hans-Gran Grndahl Professor and head Department of Oral and Maxillofacial Radiology, Institute of Odontology, The Sahlgrenska Academy Gothenburg University, Gothenburg, Sweden. In most clinical areas of dentistry, radiography plays a pivotal role. The rather complex anatomical conditions have required x-rays be taken from different angulations to permit a thorough analysis of teeth and jaws. Nevertheless, there has been a lack of a technique allowing the 3D anatomy of teeth and jaws to be imaged in a simple, affordable, dose-saving and yet high qualitative way until the advent of a cone beam CT technique designed for volumes of limited size. In the Department and Clinic of Oral and Maxillofacial Radiology at the Sahlgrenska Academy in Gothenburg, Sweden, we have used 3D Accuitomo (J. Morita MFG. Corp., Kyoto, Japan) for about 4 years. We first used the unit equipped with an image intensifier and a CCD for image capture and then switched to a CMOS flat panel detector. This represented a significant step forward, not only because we could now use two different volume sizes, but also because we found the image quality to be better. The 3D Accuitomo unit is more and more frequently used as our clinical colleagues begin to appreciate the value of 3D Accuitomo i n f o r m a t i o n . Ve r y e a r l y o n , i t s v a l u e i n endodontics and implant practice became apparent and diagnostic issues related to those two fields still belong to those most commonly a p p r o a ch e d by m e a n s o f 3 D Ac c u i t o m o examinations. A pie chart (Fig. 1) describes the distribution of patient categories among the first 500 patients examined at our clinic. By and large, the distribution is still approximately the same although larger cystic lesions and tumors as well as dento-alveolar trauma are now more often examined with our 3D Accuitomo unit.

3D Accuitomo FPD XYZ Slice View Tomography Clinical Report

TMJ:5%

Ears:3%

Trauma:1%

Impacted teeth:11% Implants: 38% Orthodontics: 20% Endodontics: 22%

Fig. 1. Distribution of patients among the first 500 examined with 3D Accuitomo.

It is no exaggeration to say that the advent of this technique and this particular unit represents a major breakthrough and a paradigm shift in dental diagnostics over the entire range of dental problems. Some examples may serve to illustrate the versatility of the 3D Accuitomo unit while, at the same time, demonstrating the shortcomings of our commonly used x-ray techniques. Some examinations were made with the imageintensifier/CCD-version, others with the flat panel detector.

In endodontics, lesions at the root apices can be difficult to see in conventional radiographs either because they are hidden behind dense anatomical structures such as the roots of multirooted teeth or because they are confined to the cancellous bone only and therefore cause little loss of bone mass. Conventional images in Fig. 2. are from a patient with severe pain in the upper molar region. Although several radiographs were taken from different directions only small lesions were found at the apices of the upper right first molar.

Fig. 2. Conventional radiographs in the upper first quadrant of this patient in severe pain only demonstrated small lesions around the apices of the first molar.

3D Accuitomo FPD XYZ Slice View Tomography Clinical Report

Examination with the 3D Accuitomo unit demonstrated a large lesion encompassing both buccal roots. It expands the buccal bone and into the lower part of the maxillary sinus where its border is irregular and dense.

Fig. 3. A very different picture of the lesion at the first upper molar from that seen in the intraoral radiographs.

3D Accuitomo FPD XYZ Slice View Tomography Clinical Report

In cases of suspected fractures of teeth and alveolar bone the use of 3D Accuitomo is particularly useful because of the large number of directions from which the teeth and jawbone can be viewed from just one exposure with no

need to access the oral cavity. In Fig.4. several conventional intraoral radiographs are presented, but only one of them clearly shows the presence of a root fracture.

Fig. 4. In several intraoral radiographs, taken from different directions, only one clearly demonstrates the presence of a root fracture.

Fig. 5. In the 3D Accuitomo images, one can clearly see the horizontal, oblique root fracture, visible in one of the intraoral radiographs. In addition, the 3D Accuitomo image set demonstrates a vertical oblique root fracture not displayed in any of the intraoral radiographs.

3D Accuitomo FPD XYZ Slice View Tomography Clinical Report

When many teeth have been involved in a trauma that also includes the alveolar bone, it may be of value to do a volume rendering to better

appreciate the degree of dislocation of teeth and bone. Fig. 6 shows such a case.

Fig. 6. Severe trauma to the upper frontal area causing fractures of the alveolar bone and dislocation of several teeth.

3 D Ac c u i t o m o ex a m i n a t i o n s c a n a l s o b e performed to control the result of reposition and root canal treatment after trauma (Fig.7).

Fig. 7. Control radiographs after trauma treatment. Only an axial and a sagittal slice are shown. They show that neither medial incisor has been optimally repositioned.

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3D Accuitomo FPD XYZ Slice View Tomography Clinical Report

The extent of periodontal marginal bone loss is not always easy to determine and certainly

not the extent with which furcation areas are involved (Fig.8).

Fig. 9. In 3D Accuitomo images the marginal bone defect is easily seen and the degree of bone loss can be precisely assessed. In the upper right corner is a 3D image based on the radiographic volume data.

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3D Accuitomo images can play an important role in implant planning and, in particular cases, also for post-operative examinations. In Fig.10. 3D Accuitomo images are presented from a patient

in whom implants were considered in both upper lateral incisor regions. Images from the right upper lateral incisor region are shown.

Fig. 10. One exposure is sufficient to cover the entire frontal area making the examination very efficient. While the height of the alveolar bone is sufficient, as well the horizontal distance between the cuspid and the medial incisor, its width is too small for conventional implant treatment and may have to be augmented.

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3D Accuitomo FPD XYZ Slice View Tomography Clinical Report

We have used the 3D Accuitomo unit in animal studies aimed at evaluating bone healing around implants placed in different kind of tooth sockets. With 3D Accuitomo images we are not restricted to only evaluate bone on the mesial and distal

aspect of the implants, but also on the buccal and lingual sides. Fig. 11. shows an example of such images, one from the buccal and one from the lingual aspect.

From the inside

From the outside

Fig.11. Implant images taken from both the inside and outside.

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3D Accuitomo images, both in terms of slices and volume rendering images, are very useful for the assessment of cystic lesions and tumors. In the case presented in Fig. 12., both types of images were used in connection with the evaluation of a cystic lesion. It can be seen that the lesion contains calcified structures and soft tissues and has displaced the

second upper molar upwards. In some places there are no clear borders of the lesion and there is a lack of a bony border both to the palatal and buccal side. The lesion is a typical example of a calcifying odontogenic tumor. Particularly in the volume rendering image, one can see that the roots of the dislocated tooth are found in the lower part of the orbit.

Fig. 12. One mm thick slices and a volume rendering image of a typical calcified odontogenic tumour.

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3D Accuitomo FPD XYZ Slice View Tomography Clinical Report

The temporomandibular joint can easily be seen in all its aspects as witnessed by the example in Fig. 13. Many years ago, the patient was subjected to a trauma and she now has pain in her left temporomandibular joint region and a feeling of asymmetry. The radiographs show a

condyle that is in a much more lateral position than normal and that there is extensive flattening of the lateral part of the condyle and of the tubercular eminence. Above the medial part of the condule, a crescent-shaped, low contrast shadow may be a medially dislocated disk.

Fig. 13. A laterally displaced temporomandibular condyle with extensive flattening of its lateral part and of the lateral part of the tubercular fossa and eminence. Note the low contrast, crescent-shaped structure above the medial part of the condyle probably the disk.

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In the orthodontic patient with ectopically erupting teeth, notably the upper cuspid, 3D Accuitomo images can be used to exactly determine the position of the impacted cuspid, its relation to neighboring structures and whether

there is root resorption on roots close to the cuspids crown. Fig.14. shows such an example both by the use of slice images in three planes perpendicular to each other and volume rendering images.

Fig. 14. By combining slice images with volume rendering images that can be seen from any direction a comprehensive understanding of a situation with unerupted teeth can be obtained.

There are many instances in orthodontic practice besides those of unerupted teeth that can benefit from a radiological examination that provides detailed 3D Accuitomo information. Obviously, the management of cleft palate patients must be one, not only to obtain a precise description of the extent of the cleft, but also to enable detailed images of the teeth often supernumerary, unerupted and malformed in the vicinity of the cleft.

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3D Accuitomo FPD XYZ Slice View Tomography Clinical Report

Fig. 15. A combination of slice images and volume rendering images provides an understanding of the conditions in cleft palate cases that has not been able before.

Fig. 15. shows radiographs of a patient with a bilateral cleft and a premaxilla that has not fused with the maxillae. Conventional intraoral radiographs provide reasonably good information about conditions in directions perpendicular to the x-ray beam even though all anatomic structures become "compressed into a single image plane. On the other hand, they provide very limited information about conditions in the direction of the x-ray beam, that is, on the outside and inside of the teeth. Therefore, the possibilities of getting thin slices perpendicular to the tangent of the alveolar bone, that is, in bucco-lingual directions of the teeth,

will provide information about tooth surfaces that are not visible in conventional radiographs.

This can be illustrated by means of radiographs from a patient in whom teeth had been orthodontically moved in order to provide sufficient distances between neighboring teeth for an implant to be placed. An examination was made to ascertain whether the width of the bone was sufficient for implant placement (Fig. 16).

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Fig. 16. In this composite of different types of images (intraoral radiograph in the middle of the upper row, volume rendering image in the upper right corner, and 3D slices) it is easy to appreciate the importance of the added information provided by the 3D technique. The intraoral radiograph reveals neither the lack of lingual bone nor the resorptions in the lingual root surface of the indicated tooth.

To sum up, there can be no doubt that the 3D Accuitomo technique has opened up new possibilities for more accurate diagnosis in the oral and maxillofacial arena and, as a consequence, better possibilities for choosing the treatment option with the best long-term prognosis. In clinical research, it provides hitherto unknown means to monitor new treatment

modalities. With the advent of the 3D Accuitomo technique dentistry has entered into a completely new fase. In many areas it will never be what it used to be. The future is here.

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3D Accuitomo FPD XYZ Slice View Tomography Clinical Report

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Clinical experiences and scientific investigations with the 3D Accuitomo

Dr. Edgar Hirsch University Leipzig Dept. of DentoMaxilloFacial Radiology Our experiences with the 3D Accuitomo last now more than 5 years of clinical use, at first with the basic version and for 1,5 years with the 3D Accuitomo FPD. First of all, Ill report about the indications for this highly sophisticated X-ray machine.

Indications of the 3D Accuitomo FPD: DentoMaxillo-Facial- Surgery impacted , displaced teeth (wisdom teeth, canines, supernumerary teeth) apical periodontitis, cysts of the jaw pre- and postoperative for imaging of important anatomical landmarks and structures implant-planning and recall cleft-palate- patients trauma cases (fractures of bones and teeth) Periodontics marginal bone-contouring 3D imaging of deep pockets and furcations in bone Endodontics configuration of root-canals, root canal measurements additional canals, anatomical variations Orthodontics configuration of the roots anatomical situation, relation of the teeth between periodontal ligament (ankylosis) resorptions One special case of implant-planning shows as an example clearly the benefit of the 3D Accuitomo, and if there is a need for high resolution 3D X-ray imaging. The first image shows a panoramic view of a patient, who requested implant treatment (image1). As you can see, the mandibular nerve canal isnt visible, especially in the prospective implant region (marked with steel balls). To determine the upper border of the nerve canal, we performed a 3D Accuitomo FPD-scan. The sagittal view shows the nerve canal clearly, but not perfect in all areas (image 2). So if you take a look on the cross-sectional slices, you will see the anatomical situation perfect at all (image 3). No other X-ray machine gives a similar performance at this time. One of the main advantages of the 3D Accuitomo FPD is its very high resolution, resulting from a voxel-size of 0.125 mm3. Bearing in mind, that some of the structures we want to see, are smaller than 0.2 mm, we must have this high resolution.

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3D Accuitomo FPD XYZ Slice View Tomography Clinical Report

Image 1

Image 2

Image 3

There is a growing need for highly precise diagnostics in all fields of dentistry because of quality reasons. The patients want the best treatment options and accurate diagnostics is an important tool to deliver such a treatment. In

our opinion, the diagnostic accuracy of the 3D Accuitomo FPD can give support to made right decisions regarding diseases, treatment options and treatment planning in all fields of dentistry.

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Scientific investigations regarding the 3D Accuitomo and 3D Accuitomo FPD We performed the following experimental studies: 1. Dosimetric measurements A new radiation protection law was introduced in 2002 by the German Government. It is mandatory, to keep the radiation doses always as low as possible, especially with younger persons. The 3D Accuitomo seems to be a low dose 3D examination in dentistry. The aim of our dosimetric study was to compare the effective doses by the newly developed c o n e - b e a m - t o m o g r a p hy X - r ay d ev i c e 3 D Accuitomo FPD (J. Morita MFG. Corp., Kyoto, Japan) in relation to the NewTom DVT 9000 (Q.R. Italia, Verona, Italy) and the spiral-CT Somatom Emotion (Siemens, Erlangen , Germany). The dose measurements were carried out on an antropomorphic phantom (image 4), developed especially for dental radiography (Visser 1997). The absorbed doses in the head and neck region were measured with thermoluminescence detectors (TLD 100H, Harshaw/Bicron) at 16 different sites on the surface as well as inside the phantom. The effective doses were calculated based on the absorbed doses.

Image 4: Dosimetry-phantom

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3D Accuitomo FPD XYZ Slice View Tomography Clinical Report

The X-ray devices under investigation were deployed using the following exposure conditions: 1. 3D Accuitomo FPD: single scan, cylindrical scan area 60 mm diameter and 60 mm height, 70 kV, 3mA, 17s scan time 2. NewTom DVT 9000: scan of the mandible, 110 kV, auto exposure (1-10 mA), 72 s scan time (36 s exposure) 3. Somatom Emotion: 130 kV, 90 mAs,1,5 s rotation time 1,0 mm slice thickness,1,5 mm/s pitch, (30 slices) Results:

Investigation procedure: 1. Loading the TLDs into the phantom 2.Positioning of the phantom in the X-ray machine (2 pre-scans) 3. Exposure: CBT 10 scans/ ROI CT 1scan, 30 mm 4. Reading of the TLDs/ data-capturing 5. Calculation of the effective doses

Table 1 Effective dose in Sv

The table above shows the very low doses caused by an examination with the 3D Accuitomo. For example, the value for one scan of the anterior maxilla is only 4Sv which means, the radiation dose is equivalent to approximately one day of natural background

radiation (in Germany). If you take a look on the 3D Accuitomo FPD, one scan of the maxilla causes approximately 24Sv that is equivalent to two conventional panoramic radiographs. In comparison to the NewTom DVT 9000 and the spiral-CT Somatom Emotion, the radiation burden

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is far low. From a radiation protection point of view, the use of the 3D Accuitomo FPD for high resolution 3D images of the jaws can be strongly recommended. Especially for younger patients, for example with cleft palate and orthodontic malformations, is there a great benefit, if one can use the 3D Accuitomo instead of a spiral-CT, keeping in mind, that these patients often have a requirement for 3D X-ray imaging. 2. Image quality We p e r fo r m e d a n ex p e r i m e n t a l s tu d y t o investigate the image qualit y of different 3D-imaging modalities. Five human cadaver heads were investigated using the cone-beam3D Accuitomo

CT machines 3D Accuitomo (J.Morita MFG. Corp., Kyoto, Japan) in relation to the NewTom DVT 9000 (Q.R. Italia, Verona, Italy) and the spiral-CT Somatom Emotion (Siemens, Erlangen, Germany). 14 anatomical landmarks were selected. The examination was carried out by 14 investigators using a five-point-rating scale. The 3D images were rated all good to excellent, whereas the images from the NewTom DVT 9000, as well the images from the Somatom Emotion, were mostly rated acceptable. The image below shows you as an example of the TMJ region in lateral, as well as frontal slices. As you can clearly see, the image quality of the 3D Accuitomo is far superior in comparison to the other modalities (image 5). Somatom Emotion

NewTom DVT 9000

Image 5: Comparison of the image quality

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3D Accuitomo FPD XYZ Slice View Tomography Clinical Report

3. Measurement accuracy The measurement accuracy of 3D X-ray-equipment is important for diagnosis and treatment planning as well as for image-guided surgery of the maxillo-facial region. The aim of this study was to evaluate the accuracy of the linear measurements in images obtained from the CBCT-device (3D Accuitomo FPD). A human dry skull was marked at 10 different sites using endo-instruments (image 6). The imaging was carried out at 70kV and 2mA. The distances between in each case two of the endoinstruments were detected.

Image 6: skull with metallic markers in the 3D Accuitomo

Linear distances were taken in three different axes of the volume data. The measurements from the CBCT images were obtained using the measuring tools of the 3D Accuitomo software. The real distances were taken using an electronic

calliper (image 7). The obtained data were statistically evaluated by Students t-test. There are no significant differences between both measurement results.

Image 7: Measurements by software and calliper

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The CBCT-device 3D Accuitomo FPD is a reliable tool for preoperative measurements of e.g. implant sites. It is possible to use the data obtained from 3D Accuitomo FPD for guided surgery, for example in connection with the Nobel Guide-system or other implant planning software. The data can be exported as DICOM 3 files. These files are running without any problems in different programs.

In summary, one can say, the introduction of high resolution cone-beam-CT in dentistry by the J. Morita MFG. Corp., is a milestone in dental diagnostics.

Thinking ahead. Focused on life. In 1916, Junichi Morita started to import products of the leading dental equipment manufacturers into Japan, where demands for modern dentistry were growing. His venturesome attempts of supplying selected products for oral healthcare has grown steadily by receiving valuable support and guidance from the dental profession. His enterprising spirit lives through the decades, and all Morita Group Companies join in continuing to pursue marketing, distribution and services, as well as R&D and manufacturing, in collaboration with world leaders in healthcare products and research organizations.

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