Comparing Cone Beam Computed

Tomography Systems from an Orthodontic

Perspective
Aaron D. Molen
There are more than 40 cone beam computed tomography (CBCT) systems
currently available to consumers. Differentiating between the systems and
making fair comparisons can be difficult. The needs of orthodontists differ
from other dental specialists and require a different perspective when evaluating CBCT systems. In CBCT systems the characteristics of the reconstructed image are affected by the type of detector used, the features
available on the machine, and the software used to reconstruct the volume.
Understanding how each of these affects the resulting image will empower
the clinician to better compare various CBCT systems and find the right fit
for their practice. (Semin Orthod 2011;17:34-38.) 2011 Elsevier Inc. All
rights reserved.

he concept of 3-dimensional (3D) orthodontic diagnosis and treatment planning

existed long before the U.S. Federal Drug Administration approved the first cone beam computed tomography (CBCT) unit in 2001. In fact,
B. Holly Broadbent Sr recognized its need in
1925, just 30 years after the first radiograph was
taken by Wilhelm Rntgen. In that year Broadbent developed his first-generation Broadbent
cephalometer to rigidly position patients for the
simultaneous exposure of both a lateral and posteroanterior cephalogram.1 In the development
of the original cephalometer Broadbent recognized the need for a system with specific features
that could be adjusted by the practitioner to
improve the quality of the image. Similar to
Broadbents 3D cephalometer the 3D CBCT systems we use today also come with features that
play a large role in determining the quality of
the captured image.

Section of Orthodontics, Division of Associated Clinical Specialties, University of California, Los Angeles School of Dentistry, Los
Angeles, CA; Private Practice of Orthodontics, Auburn, WA.
Address correspondence to Aaron D. Molen, DDS, MS, Molen
Orthodontics, 1110 Harvey Road, Auburn, WA 98002-4218.
E-mail DrAaron@3DOrthodontist.com
2011 Elsevier Inc. All rights reserved.
1073-8746/11/1701-0$30.00/0
doi:10.1053/j.sodo.2010.08.007

34

As of last count, there were 43 CBCT systems

commercially available from 20 different companies.2 Each system in this crowded field attempts
to differentiate itself from its competitors by
providing numerous features. Each feature has
the potential to affect the quality of the reconstructed volume. It is important for the consumer, whether looking to buy or already using
a CBCT system, to understand these features
and be able to compare them between systems.
A common adage is that you cannot compare
apples to oranges. Unfortunately, this frequently
occurs when the features and capabilities of various CBCT systems are compared. This is partially because of a lack of standardization in how
certain features are measured and defined. This
is especially apparent by reviewing the promotional material available for various machines. It
is also important to realize that certain features
and characteristics important to a periodontist
may not be as important to an orthodontist
which can compound the challenge of comparing systems. By gaining a more thorough understanding of the features and capabilities of
CBCT systems the consumer should ultimately
be able to compare apples to apples.
In CBCT systems the quality and characteristics of the reconstructed volume are affected by
the type of detector used, the features available

Seminars in Orthodontics, Vol 17, No 1 (March), 2011: pp 34-38

CBCT Systems from an Orthodontic Perspective

on the machine, and the software used to reconstruct the volume. Most CBCT systems use either
a flat panel detector or an image intensifier.
Flat-panel detectors look similar to the photostimulable phosphor plates used in digital radiology, whereas image intensifier units are conical in shape with a convex detector surface at the
base. Flat-panel detectors result in cylindricalshaped volumes versus the spherical-shaped volumes of image intensifiers. When measuring the
dimensions of flat-panel generated volumes the
height and diameter of the volume are reported
in centimeters. In general, the diameter of the
volumes is fixed, whereas the height can be adjusted by the technician. Some systems allow the
flat panel to be rotated 45 degrees, thereby inverting the height and diameter. However, when
measuring the dimensions of image intensifier
generated volumes the diameter of the spherical
volume is reported in inches as a single number.
The shape of the volume can also affect the
amount of anatomy captured by the scan. For example, an image intensifier generated spherical volume with a diameter of 5 cm would have a volume of
65 cm3, whereas a flat panelgenerated cylindrical
volume with a height and width of 5 cm would have
a larger volume of 98 cm3. The increased volume
captured by cylindrical flat panel systems results from

Figure 1. Blue shading in the online version represents a cylindrical-shaped FOV and the red in the
online version represents a spherical-shaped FOV.
(Color version of figure is available online.)

35

capturing the corners of the scan (Fig 1), which

spherical scans miss along the periphery.3
Detectors are available in various sizes that
dictate the size of the volume that can be captured. Most systems allow the technician to adjust the size of the volume being captured4; however, some systems allow only one or two preset
sizes to be used. The size of the volume is referred to as the field of view (FOV) and should
be large enough to capture the region of interest
(ROI) of the clinician. For orthodontists, the
ROI can vary from a small region containing an
impacted cuspid to a large region containing
enough craniofacial anatomy to perform cephalometric analyses. Orthodontists are unique,
with perhaps the exception of oral and maxillofacial surgeons, in their desire to capture most of
the head. Even though most orthodontists may
not use a large FOV on every patient it would be
beneficial to have the option to take one on
complicated craniofacial or orthognathic cases.
Most CBCT systems are directed at implant dentistry and therefore lack the ability to take a large
FOV scan (As defined by the author, a large FOV
scan has a minimum height of 16 cm). In addition to systems that can capture a native large
FOV volume there are also systems available that
can take two medium FOV volumes and using
software stitch them together to obtain a reconstructed large FOV. When comparing systems
for orthodontic use, clinicians may want to limit
their search to systems capable of capturing or
reconstructing large FOV volumes.
In addition to size and shape, the type of
detector used can also influence the quality of
the image. In general, flat panel detectors and
image intensifiers display similar sensitivity, but
flat panel detectors exhibit a larger dynamic
range and improved contrast.5 This difference
in image quality may not be diagnostically relevant when used for orthodontics. It is also difficult to tie the quality of the image simply to the
detector because it is extremely dependent
upon the quality and type of algorithms used by
the systems proprietary software to reconstruct
the raw image for viewing.
The characteristic most commonly associated
with the detector is the resolution of the scan.
However, this is a misnomer because the resolution of the reconstructed scan is influenced by
several variables. Resolution, more accurately
termed angular or spatial resolution, is the min-

36

Molen

imum distance between two distinguishable objects. Though often associated with voxel size,
they are not the same. The voxel size represents
the dimensions of the volume element into
which a volume is being subdivided and is usually measured in millimeters or microns. Each
voxel is assigned a value representing the density
of the object contained within its boundaries as
determined by the attenuation of the photons
passing through it. In a process called volume
averaging, if the objects contained within a single voxel differ in density then the average density of the voxels contents will be used. Therefore, it stands to reason that the use of smaller
voxel sizes will allow the visualization of smaller
variations in density. However, this does not
translate directly to spatial resolution. Noise
caused by scatter radiation,6 volume averaging,7
and artifacts can reduce a scans spatial resolution. In other words, a scan acquired with the
use of 0.3 mm voxels will not result in a spatial
resolution of 0.3 mm.8
Because voxel size does not equal spatial resolution, it is impossible to compare two CBCT
systems by voxel size alone with the reasoning
that the resolution is the same. Instead, the ideal
way to compare the spatial resolution of CBCT
systems is by the use of a line pair phantom (Fig
2). Line pair phantoms are imbedded with metallic strips set at ever decreasing distances from
each other. The point at which the user can no

Figure 2. An example of a line pair phantom used to

determine a scans spatial resolution. (Color version
of figure is available online.)

Figure 3. An example of a movement artifact. The

arrows denote the shadowing of the posterior border
of the mandibular ramus.

longer distinguish between two pairs of metallic

strips is the point at which the spatial resolution
of the scan has been exceeded. Therefore, the
last set of distinguishable metallic strips represents the spatial resolution of the scan. Though
sometimes unpublished most CBCT manufactures can make their line pair test results available when asked. It should be borne in mind
that because spatial resolution is influenced by
voxel size, FOV size, and scan time (frame acquisition) one should only compare the line pair
results between scans with similar settings.
Beyond the detector each CBCT machine has
various characteristics that influence the outcome
of the scan. The most obvious is how the patient is
positioned for the scan. Systems allow the patients
to be seated, standing, or supine. Patient positioning is of paramount importance in CBCT imaging
because CBCT is very sensitive to any patient movement during the scan.9 Movement artifacts appear
as either a streak in the volume or as the shadowing of objects (Fig 3). Decreased risk of patient
movement artifacts can be achieved by placing the
patient in a stable position.
Creating a stable environment for the patient
usually requires them to be seated or supine,
because patients tend to sway or bend their legs
when standing. Another consideration is that
seated CBCT systems have a smaller footprint

CBCT Systems from an Orthodontic Perspective

and take up less office space than supine systems. It is also advisable to have the patient close
their eyes while performing the scan to help
them resist the urge to follow the rotating arm
with their eyes and head.
Another feature that allows for minimizing
the risk of patient movement is adjustable scan
times. Some systems allow adjustment of the
length of the scan from a short scan, less than 10
seconds, to scans longer than 30 seconds. The
advantage of longer scans is that more data, or
frames, are acquired by the scanner which results in better contrast and spatial resolution.
Inversely, shorter scans acquire fewer frames but
limit the amount of time in which the patient
may move. For orthodontic uses the image quality found in shorter scans is generally sufficient
for diagnosis and will reduce the risk of movement artifacts.
Image quality is also affected by the gray scale
bit depth of the CBCT system being used. Current CBCT systems range anywhere between 12
and 16-bit gray scale. Because the human eye
can only see up to 10-bit gray scale and computer monitors are only available in 8- or 10-bit
gray scale some would assume that it would be of
little worth to exceed these thresholds.10 However, this approach fails to take into account that
the reconstruction software uses the increased
bit depth to improve its primary and secondary
reconstructions, thereby resulting in a cleaner
and more defined volume. Most software also
allows the clinician to change the values of gray
scale displayed on the screen using a process referred to as window and leveling.11 By scrolling
through the various values of gray captured in the
scan the clinician can better visualize the volume.
In essence, the software allows use of the additional shades of gray captured by the scan despite
the limitations of the eyes and computer monitors.
Certain CBCT systems allow the clinician to
take conventional 2-dimensional (2D) digital radiographs in lieu of a full CBCT scan. CBCT
systems providing this feature can be divided
into two classes: single-detector and multipledetector. Single-detector systems use the same
detector to acquire either the CBCT scan or the
2D digital radiograph, but not both simultaneously. This configuration allows a more compact set-up with a smaller overall footprint. Multiple-detector systems use an additional detector
located on another arm to capture 2D radio-

37

graphs besides the main CBCT detector. Both

configurations give the clinician the option of
taking 2D radiographs for use in screenings or
recalls of patients; however, they should not be
confused with CBCT systems that simply allow
the reconstruction of a 2D image from the
CBCT volume. All CBCT systems, with a large
enough FOV, can be used to reconstruct traditional appearing panoramic and lateral cephalograms; but not all systems have true, low-dose,
2D capabilities.
Another feature to evaluate when comparing
CBCT systems is the control available to the
clinician to adjust the kVp and mA settings.
Some systems allow these settings to be adjusted
for each scan. In certain cases the clinician may
find that they can obtain the necessary diagnostic information with a lower radiation dose,
whereas other cases may require more detail.12
The radiation exposure associated with each
CBCT system is an often misunderstood, but
important consideration when comparing systems. The clinician must balance the improved
image quality associated with larger radiation
doses and the noise associated with lower doses.
To compare apples to apples, the absorbed dose
should be measured in microsieverts. The calculation of absorbed dose is based on the recommendations of the International Commission on
Radiological Protection (ICRP). In 2007, the
ICRP released new absorbed dose calculation
recommendations that superseded their 1990
recommendations.13 One change introduced in
the 2007 recommendations was the assignment
of calculation weight to the salivary glands which
had not been included in the 1990 recommendations. The result for all maxillofacial radiographs was an increase in calculated absorbed
dose. It is of critical importance when comparing the dosimetry of CBCT systems to only compare 1990 measurements with 1990 measurements
and 2007 measurements with 2007 measurements.
Otherwise, the 1990 calculated doses will always
appear lower than the 2007 calculated doses. To
further compare radiation doses fairly the scans
being compared should also be similar in FOV,
voxel size, and scan time.14
The final aspect that should be considered
when comparing CBCT systems are the capabilities of the software that is included. Each CBCT
systems associated software performs the reconstructions that produce the 3D volume used for

38

Molen

treatment planning and diagnosis. The software

uses complex mathematical algorithms to reconstruct the raw data into a usable format. The quality of the reconstructed volume is influenced by
the algorithms abilities to remove noise, artifacts,
and delineate the outline and position of objects
of various densities.15 The same CBCT scan, when
processed by two different software using different
algorithms, will produce volumes of differing quality and resolution. This fact also allows the quality
of the reconstructed volumes to improve with subsequent software updates.
Although all systems provide software on the
primary workstation for reconstruction of the volumes, not all systems allow installation of the software on other office computers. Some companies
will allow installation of the software on any computer at no charge, while some charge a per computer licensing fee. Another unique feature of
certain systems is the ability to create CD-ROMs
of a patients scan for distribution to other professionals whom the patient may consult that
includes a basic 3D viewing program. These systems permit one to dispense an unlimited number of basic 3D viewing programs, either at no
charge or with a per program fee.
The process of comparing CBCT systems can be
daunting, but for the informed consumer should
not be overwhelming. By better understanding the
aforementioned characteristics and features of
CBCT systems the clinician can make appropriate
comparisons that they can be confident with. Without question it can be challenging to stay abreast of
the latest technologies, but in the words of Dr G. V.
Black, The professional man has no right to be
other than a continuous student.

References
1. Broadbent BH Sr, Broadbent BH Jr, Golden WH: Bolton
Standards of Dentofacial Developmental Growth. Saint
Louis, Mosby, 1975

2. The 3D orthodontist: the Modern orthodontists source

for information of 3D technologies [Internet]. Lake
Tapps, WA, Aaron Molen, Web master. Available from:
http://www.3DOrthodontist.com/. Accessed December
16, 2009
3. Scarfe WC, Farman AG: What is cone-beam CT and
how does it work? Dent Clin North Am 52:707-730,
2008
4. Farman AG, Scarfe WC: The basics of maxillofacial cone
beam computed tomography. Semin Orthod 15:2-13,
2009
5. Baba R, Ueda K, Okabe M: Using a flat-panel detector in
high resolution cone beam CT for dental imaging. Dentomaxillofac Radiol 5:285-290, 2004
6. Endo M, Tsunoo T, Nakamori N, et al: Effect of scattered radiation on image noise in cone beam CT. Med
Phys 28:469-474, 2001
7. Chakeres DW: Clinical significance of partial volume
averaging of the temporal Bone. AJNR Am J Neuroradiol
5:297-302, 1984
8. Ballrick JW, Palomo JM, Ruch E, et al: Image distortion
and spatial resolution of a commercially available conebeam computed tomography machine. Am J Orthod
Dentofac Orthop 134:573-582, 2008
9. Holberg C, Steinhuser S, Geis P, et al: Cone-beam
computed tomography in orthodontics: benefits and
limitations. J Orofac Orthop 6:434-444, 2005
10. Kimke T, Tuytschaever T: Increasing the number of gray
shades in medical display systems how much is
enough? J Digit Imaging 20:422, 2006
11. Buzug TM: Computed Tomography: from Photon Statistics to Modern Cone-Beam CT. Berlin, Springer,
2008
12. Kwong JC, Palomo JM, Landers MA: Image quality produced by different cone-beam computed tomography
settings. Am J Orthod Dentofac Orthop 133:317-327,
2008
13. The 2007 Recommendations of the International Commission on Radiological Protection. ICRP Publishing
Group 103. Ann ICRP 37:137-246, 2007
14. Silva MAG, Wolf U, Heinicke F, et al: Cone-beam computed tomography for routine orthodontic treatment
planning: A radiation dose evaluation. Am J Orthod
Dentofac Orthop 133:e1640.e5, 2008
15. Ning R, Tang X, Conover D: X-Ray scatter correction
algorithm for cone beam CT imaging. Med Phys 31:
1195-1202, 2004