Journal of the World Federation of Orthodontists 1 (2012) e3ee8

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Journal of the World Federation of Orthodontists

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Short Communication

Myths and facts of cone beam computed tomography in orthodontics

Ahmad Abdelkarim a, *
a

Care Planning and Restorative Sciences, University of Mississippi, School of Dentistry, Jackson, Mississippi

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 9 December 2011
Received in revised form
16 March 2012
Accepted 9 April 2012
Available online 11 May 2012

Cone beam computed tomography (CBCT) is a revolutionary imaging modality. It has changed numerous
aspects of dentistry and has added great value to its diagnostic phase as well as that of orthodontics.
Three-dimensional imaging CBCT has the potential to improve the diagnosis and treatment planning of
cases. However, there has been some confusion about CBCT and its implementation in orthodontics. This
could be due to overmarketing or limited understanding of the imaging technique itself. The purpose of
this article is to present 10 myths about CBCT in orthodontics and replace them with facts about this
imaging technique.
Published by Elsevier Inc.

Keywords:
Advanced imaging
Cone beam CT (CBCT) in orthodontics
Myths and facts of CBCT in orthodontics
Orthodontic cone beam CT

1. Introduction
Cone beam computed tomography (CBCT) is a revolutionary
imaging modality that has changed numerous aspects of dentistry
and has added great value to its diagnostic phase as well as that
of orthodontics. CBCT three-dimensional (3D) imaging has the
potential to improve the diagnosis and treatment planning.
With the desire to enhance treatment by incorporating the
highest technological advancements, CBCT has attracted signicant
attention. The potential applications in orthodontics have been
recognized and appreciated.
One of the most common selection criteria of CBCT in orthodontics is evaluation of impacted teeth [1e4]. It allows visualization
in three dimensions, and the relation to adjacent teeth. For example, visualization of an external resorption of a maxillary lateral
incisor due to impaction of a maxillary canine can be precisely
evaluated [5]. Additionally, CBCT can reveal the presence or absence
of the canine, size of the follicle, inclination of the long axis of the
tooth, relative buccal and palatal positions, amount of the bone
covering the tooth, local anatomic considerations, and overall stage
of dental development [6]. Supernumerary teeth can be evaluated
as well [7]. Additionally, CBCT examination is recommended in
patients with dentofacial deformities, including severe facial
asymmetry or facial disharmony [8], cleft palate [9], patients with

* Corresponding author: Care Planning and Restorative Sciences, University of

Mississippi, 2500 N. State Street, Jackson, MS 39216.
E-mail address: ahmadozbrain@yahoo.com.
2212-4438/$ e see front matter Published by Elsevier Inc.
doi:10.1016/j.ejwf.2012.04.002

obstructive sleep apnea, and when a patient has an airway study

[10e15]. The clear advantage of CBCT in these cases is evaluation of
3D structures through a 3D imaging modality. Additionally, the
nasopharyngeal and oropharyngeal airway can be assessed in
volume size and shape. Moreover, if temporary anchorage devices
are planned, CBCT can assist in initial site assessment [16e24], or
temporary anchorage device site status evaluation [25e27].
Therefore, CBCT applications in orthodontics are plentiful.
However, it is easy to be seduced by the sheer beauty of CBCT image
reconstructions. Following the ethical principle of nonmalecence,
practitioners in health care are supposed to minimize harm to
patients. A cornerstone of radiation protection is to keep radiation
As Low As Reasonably Achievable, the ALARA principle.
There has been some confusion about CBCT and its implementation in orthodontics. This could be due to overmarketing or
limited understanding of the imaging technique itself. The purpose
of this article is to present 10 myths about CBCT in orthodontics and
replace them with facts about this imaging technique.
The 10 myths of CBCT in orthodontics are (1) CBCT exposes
orthodontic patients to low radiation; (2) if daily background
radiation is 8 mSv, any CBCT acquisition would be justied because it
has the effect of only few days of background radiation; (3) we must
have totally new 3D CBCT cephalometric analyses that replace twodimensional (2D) standardized analyses; (4) CBCT can replace
impressions for orthodontics and be as accurate; (5) volume
rendering is sufcient to display external root resorption; (6) CBCT
changes the nal outcome of orthodontic treatment; (7) Boards of
Orthodontics will eventually adopt CBCT for all orthodontic records
and superimpositions; (8) CBCT is sufcient and the best imaging

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A. Abdelkarim / Journal of the World Federation of Orthodontists 1 (2012) e3ee8

Table 1
Effective doses of basic radiographic imaging versus CBCT and medical head CT
Imaging modality

Estimated range of effective dose (mSv)

Digital panoramic radiography

Digital cephalometric radiography
CBCT
Head CT

2.7e23
1.7e3.4
20e1025
2000

3. Myth 2
If daily background radiation is 8 mSv, any CBCT acquisition
would be justied because it has the effect of only few days of
background radiation.
3.1. Fact

modality to examine the temporomandibular joints (TMJ); (9) if

CBCT is ordered, the orthodontist is at liability risk for any
pathology in the scan; and (10) CBCT is an orthodontic practice
builder.
2. Myth 1
CBCT exposes orthodontic patients to low radiation.
2.1. Fact
The effective dose of an imaging modality is a commonly used
term in radiation biology and presents a numeric value in microSieverts (mSv). It provides a mechanism for assessing the radiation
risk from partial body irradiations in terms of data derived from
whole body irradiations. It is calculated as the weighted average of
the mean absorbed dose to the various body organs and tissues,
where the weighting factor is the radiation risk for a given organ
(from a whole-body irradiation) as a fraction of the total radiation
detriment [28].
The effective dose of CBCT is quite exible and the range is much
wider than other imaging techniques used in dentistry. Table 1
describes that the effective dose of panoramic radiography is estimated to be 2.7 to 23 mSv [29e34]. Cephalometric radiography
effective dose is approximately 1.7 e 3.4 mSv [35].
On the other hand, effective dose range of CBCT is very large and
can be anywhere from 20 to 1000 mSv, depending on the machine,
eld of view, and selected technique factors [29,31,34,36e40]. Only
one CBCT machine with large eld of view exceeded 1000 mSv [36].
Each CBCT device uses different settings, which results in a wide
range of the effective dose. The latest ndings report that this wide
effective dose range of different CBCT devices is strongly related to
eld size [41]. Increasing the eld of view would increase the
effective dose [31]. Alternatively, reducing the volume size is
perhaps the best way to reduce radiation exposure for the patient.
For example, an impacted tooth does not require imaging of the
whole head. A smaller volume of 40  40 mm, for example, may be
appropriate. This has the potential benet of increased resolution of
the images because most CBCT machines that provide different scan
volume options usually use larger voxel size on large eld of view
scans and smaller voxels in smaller eld of views.
Fortunately, CBCT effective dose is comparatively smaller than
traditional medical CT imaging technique [42e48]. In other words,
CBCT effective dose is higher than conventional panoramic and
cephalometric radiography, but less than conventional CT.
No approach regarding CBCT radiation risk assessment in children in particular has been examined yet. However, a CT study
found that the smaller mass of children caused the corresponding
effective doses to be higher than those in adults undergoing similar
CT examinations [49].
Generally, thyroid shielding with a leaded thyroid shield
or collar is strongly recommended for children and pregnant
women d these patients are particularly sensitive to radiation [50].
This reduces the risk because lead shielding reduces the effective
dose [38].

There are certainly other sources of radiation from natural

sources and human activities besides diagnostic imaging. Natural
background radiation, terrestrial radiation, and long ights at high
altitudes constantly expose humans to radiation. The annual global
per capita effective dose due to natural background radiation
sources alone is estimated to be about 2400 mSv at sea level, and
may be of wide range between 1000 and 3000 mSv. Consequently,
the natural background radiation is estimated to be about 8 mSv
per day.
It is correct that a certain CBCT effective dose of 50 mSv is
equivalent in magnitude to 6 or 7 days of background radiation;
however, the effect is entirely different because the acute nature of
CBCT exposure of few a seconds is unlike the very low, continuous,
and chronic exposure of background radiation.
Radiation hormesis concept suggests that very low doses of
continuous and chronic ionizing radiation that are equivalent to
natural background levels are, in fact, benecial. This is because
they stimulate the activation of repair mechanisms that protect
against the disease process [51,52].
Therefore, it is better to adhere to the radiation protection
concept of ALARA [53], than comparing CBCT to background radiation, a source that cannot be controlled anyway. Ideally, CBCT
should be acquired in orthodontics when a 3D evaluation is
required. Otherwise, conventional 2D imaging might be sufcient.
For example, ordering a full head CBCT scan just to build cephalometric and panoramic radiographs is not justied, because these
two radiographs could have been ordered without exposing the
patient to the additional radiation. As previously mentioned, a full
head CBCT effective dose, in some machines and settings, can be
much higher the combined dosage of digital panoramic and cephalometric radiographs.
Consequently, ordering the higher radiation CBCT just to build
panoramic and cephalometric radiographs is not consistent with
the ALARA principle, and could not be justied if compared with the
myth of few days of background radiation. Additionally, it is
judicious to take advantage of the 3D capability of CBCT after
adopting this technology.
According to Buttke and Proft [54], only 15% of orthodontic
patients are adults. Therefore, because most orthodontic patients
are children, it is important to emphasize that the ALARA principle
applies even more critically in the majority of orthodontic patients
who are more sensitive to radiation and who have long years to live
whereby radiation risks may manifest in their lives [55,56].
4. Myth 3
We must have totally new 3D CBCT cephalometric analyses that
replace 2D standardized analyses.
4.1. Fact
Panoramic and cephalometric radiographs are standard orthodontic records. Introducing new CBCT cephalometric analyses
require some new landmarks, planes, and angles [57]. CBCT also
requires different analyses that may be difcult to memorize and
apply.

A. Abdelkarim / Journal of the World Federation of Orthodontists 1 (2012) e3ee8

Realistically, few orthodontists perform tracing and full analyses

on all their patients. In fact, the availability of 2D analyses of
conventional lateral cephalometric radiograph may not make a
signicant difference to the treatment decisions [58].
Tracing the sagittal and frontal cephalometrics and analyzing
CBCT acquisitions are unquestionably recommended. However,
performing CBCT cephalometric analyses in three dimensions
(including new numeric and angle values that are not present in
conventional analyses such as Downs, Steiner, Ricketts, McNamara,
and Tweed) may not be necessary.
The 3D CBCT should benet clinicians in many different ways,
other than complicated 3D cephalometric analyses. This modality
offers three orthogonal images of oral and maxillofacial structures
(axial, sagittal, and coronal views), and any other at and curved
slices of variable thickness. Therefore, 3D superimpositions, assessment of treatment outcome, and growth change evaluation in
three dimensions can be performed [59e63]. Surgical outcomes can
be evaluated, and this can be of great value for the orthodontist and
the patient [64,65]. Lastly, soft tissue change can be visualized and
evaluated in the short- and long-term in cases of orthognathic
surgery [66,67].
Therefore, sophisticated 3D analyses may improve the diagnostic records in some cases, but they are questionable to be
valuable as a new standard.
5. Myth 4
CBCT can replace impressions for orthodontics and be as
accurate.
5.1. Fact
Even though CBCT digital models are sometimes accurate for
making linear measurements for overjet, overbite, and crowding
measurements [68], they are unlikely to be accurate for clear tray
and orthodontic wire fabrications as conventional impressions.
It takes only one amalgam restoration to create beam hardening artifact [69], which creates distortion. Beam hardening
occurs around dense objects such as metal brackets and bands [70].
Other CBCT image artifacts include cupping, dark bands, noise, and
scatter. Although CBCT acquisition during orthodontic treatment is
possible, the images would be distorted due to the beam hardening
and scatter around orthodontic appliances.
Another signicant limitation for these tasks is possible patient
movement, creating motion artifact during the relatively long
scans, especially in young orthodontic patients. All these limitations
of CBCT technique should be considered as they may reduce image
quality. In reality, image quality itself is not similar among different
CBCT machines. This was found in testing different CBCT machines
in detection of simulated canine impaction-induced external root
resorption in maxillary lateral incisors, a common application of
CBCT in orthodontics [71]. Those who are not familiar with CBCT
images may not be able to differentiate between different
machines, in regards to image quality.
These artifacts are not noted in digital or conventional impressions. One may argue, however, that CBCT will continue to improve
to where it will be as accurate and precise as impressions. But the
numerous CBCT machines already installed will not be replaced
with newer ones to replace these impressions.
6. Myth 5
Volume rendering is sufcient to display external root
resorption.

e5

6.1. Fact
Like any other volumetric imaging, CBCT interpretation requires
the use of computer software to provide multiplanar reformatted
images and supplementary 3D visual representations such as
volume rendering. The volume rendering, usually provided by the
software automatically, is similar to architectural exemplary
illustrations that provide the exterior layout but not the interior
details.
Three-dimensional volume rendering images can only be
utilized as an adjunctive aid where it can help the orthodontist, as
well as a great visual aid for the patient or parent to understand
the treatment plan. However, these attractive illustrations are
computer-generated and are created upon software algorithms that
may not be reliable. Selecting the volume rendering may obscure
normal anatomy or create artifacts that are not present.
Unfortunately, numerous presentations of CBCT images include
the volume rendering only. This rendering may produce falsenegatives or false-positives and is not sufcient to identify presence
or absence of mild external root resorption that may be present on
a maxillary lateral incisor, for example, due to impaction of
a maxillary canine.
Evaluation of multiple slices of the scan is necessary. Perhaps
some clinicians opt to present the volume rendering because
evaluating the axial, coronal, and sagittal views of the scan is more
technically demanding. Nevertheless, examination of the scan
through these views is generally required because this has higher
sensitivity and specicity.

7. Myth 6
CBCT changes the nal outcome of orthodontic treatment.

7.1. Fact
CBCT increases accuracy of orthodontic diagnosis. Increasing
diagnostic accuracy eliminates false-positive and false-negative
results. Also, the treatment plan becomes more appropriate for
specic cases. This may change the nal outcome in some cases, but
not always. Until now, there have not been randomized clinical
trials that examine whether there is a favorable difference between
orthodontic patients who were imaged by CBCT and those who
were not. The effects of information derived from these images in
altering diagnosis and treatment decisions have not been established in several types of cases [72].
This certainly does not mean that there is no benet of CBCT for
specic cases such as impacted and supernumerary teeth, temporary anchorage device site assessment, pharyngeal airway assessment, craniofacial deformities, cleft palate, identication of root
resorption, and orthognathic surgery planning [72].
Moreover, retrospective evaluation of existing CBCT data may, in
many cases, provide additional understanding of numerous aspects
of orthodontics. At this point, it is still arguable whether CBCT in
orthodontics always provides more diagnostic information than
panoramic and cephalometric radiographs, changing the nal
outcome, in order to justify its routine use in all orthodontic
patients. In fact, additional information or lack thereof cannot be
discovered unless comprehensive CBCT evaluation is performed. It
also should be remembered that incorporating CBCT routinely in
regular orthodontic practice increases the collective dose to
orthodontic patients as a whole, thereby increasing the probability
of deleterious effects of radiation in a group that is relatively
sensitive to radiation.

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A. Abdelkarim / Journal of the World Federation of Orthodontists 1 (2012) e3ee8

8. Myth 7
Boards of Orthodontics will eventually adopt CBCT for all
orthodontic records and superimpositions.
8.1. Fact
As of today, these boards have not recommended CBCT for all
cases. It is, however, likely that 3D imaging will be required when it
provides useful information that meets the treatment needs.
For example, in 2000, a position paper by the American
Academy of Oral and Maxillofacial Radiology (AAOMR) recommended that some form of cross-sectional imaging be used for most
patients receiving implants [73]. Today, CBCT is the preferred
imaging modality for implantology. Fortunately, most elderly
patients receiving implants are less sensitive to radiation than most
orthodontic patients who are typically young. In another position
paper by the AAOMR and the American Association of Endodontists, CBCT was recommended for selected, but not all, cases in
endodontics [74]. It was recommended that CBCT must not be used
routinely for endodontic diagnosis or for screening purposes in the
absence of clinical signs and symptoms [74].
In orthodontics, the frequency of CBCT use is likely to be equal to
endodontics, unlike implant imaging, where CBCT is used more
frequently. Selection of CBCT in orthodontics is clearly case specic,
and wise clinical judgment should be used. In other words, CBCT is
justied in selected, but not all cases in orthodontics [75].
9. Myth 8
CBCT is sufcient and is the best imaging modality to examine
the temporomandibular joints (TMJ).
9.1. Fact
CBCT is excellent for imaging of the bony component of the
temporomandibular joints, especially if compared with panoramic
radiography. Therefore, it is a valuable diagnostic tool for TMJ
evaluation [76e78].
However, TMJ complex is composed of bony and soft tissue
structures. Unfortunately, CBCT does not map out the muscle
structures, and the articular disk cannot be visualized [79]. The
inability to visualize the articular disk and internal derangements
through CBCT imaging is a signicant disadvantage for TMJ imaging.
Although degenerative bone changes (which can be depicted by
CBCT) may be correlated with disk displacement without reduction
[80], there is actually a poor correlation between condylar changes
observed on CBCT images and pain, and with other clinical signs
and symptoms of TMJ of osteoarthritic origin [81].
Magnetic resonance imaging (MRI) is the imaging technique of
choice if an evaluation of the articular disk is required [82,83].
Although CBCT can provide valuable information about TMJ bony
changes, it is not the best imaging modality for TMJ evaluation. At
least, it is not sufcient to create a comprehensive radiographic
evaluation of the TMJ.
10. Myth 9
If CBCT is ordered, the orthodontist is at liability risk for any
pathology in the scan.
10.1. Fact
Lately, there has been considerable concern among dental
practitioners regarding the liability of reporting any pathology or

incidental nding present in the CBCT scan. Dentists are not typically trained on CBCT interpretation in dental schools, so a full
evaluation of CBCT scans can be a difcult task. Even though the
radiographic anatomy of CBCT is the basic structure of the skull,
differentiation between a patient with a normal anatomy and an
abnormality can be challenging. Until now, there have been mixed
opinions on this issue.
No denitive guidelines have been formed at this time. Turpin
[84] and Jerrold [85] advise that orthodontists, if ordering CBCT
imaging, are liable for the interpretation of the CBCT volume. But it
should be remembered that potential risks for the orthodontist
include unidentied pathology in traditional radiographs and
possibly photographs.
If examined by an oral and maxillofacial radiologist, liability
risks can be avoided. Afterwards, other risks in orthodontics may be
avoid as well, because CBCT contributes to accurate diagnosis and,
therefore, improved treatment plan [86].
Some argue that a legal document can eliminate the risk. The
patient can sign an informed consent that no interpretation of the
volume would be performed, and only the prescribed diagnostic
task would be evaluated. There is less discussion regarding the
moral consideration of fully evaluating the CBCT for the patients
benet.
Another way to reduce the risk is to use a smaller eld of view.
This actually has another benet of reduced effective dose.
11. Myth 10
CBCT is an orthodontic practice builder.
11.1. Fact
This is probably the most ironic and debatable myth. One may
claim that CBCT provides superior images that facilitate treatment
plan presentation. As previously said, some believe that CBCT has
the potential of replacing conventional impressions and intraoral
and extraoral photos, and subsequently, one CBCT scan can be
sufcient for initial orthodontic records. Furthermore, some believe
that patients are attracted to this technology.
However, this expensive technology that involves ionizing
radiation is unlikely to replace conventional impressions and be as
accurate and sufcient to create comprehensive diagnoses and
build wires and clear trays. Additionally, progress and nal photos
and radiographs cannot be compared with a single 3D radiographic
scan. For consistency, an initial CBCT scan would require an additional nal scan for comparison. In this case, the radiation dose is
doubled, assuming no acquisition retakes are performed.
Many parents are aware of ionizing radiation risks and are
unlikely to be interested in higher radiation for their children if
given the choice of whether or not to use CBCT.
Three-dimensional evaluations through CBCT should continue
to evolve in orthodontics. Unfortunately, this technology is not
ubiquitous yet. At this point, it is still signicantly more expensive
than other technologies in standard orthodontic practice. As
a result, CBCT may not be an orthodontic practice builder for
everybody.
12. Conclusions
CBCT is a valuable imaging modality in orthodontics. Its applications in this eld have been widely recognized. It is time to
reevaluate the validity of some erroneous ideas that are based on
blind faith and overmarketing, instead of scientic evidence and
common sense.

A. Abdelkarim / Journal of the World Federation of Orthodontists 1 (2012) e3ee8

The riskebenet ratio of CBCT is usually favorable. Due to

numerous overlapping carcinogenic factors in human life, it is
impossible to assess the long-term stochastic effects of radiographic examinations. For that reason, the concept of ALARA, suggesting that radiation should be kept As Low As Reasonably
Achievable, should be adhered to, rather than justifying CBCT
acquisitions by comparing their dose exposure to background
radiation. Replacing impressions with CBCT, ordering it for every
patient, and claiming that it would build the orthodontic practice
are tactics that should be debunked.
Once acquired, orthodontists are encouraged to evaluate the
scan thoroughly, primarily for the patients benet. Because
acquisition of CBCT is case specic, each patient may benet
differently, but some patients may not benet from the procedure.
In addition, CBCT usage will ultimately result in more validated
research being performed and will become an advantage of our
profession with secondary tangential benets to those undergoing
orthodontic therapy.
References
[1] Botticelli S, Verna C, Cattaneo PM, Heidmann J, Melsen B. Two- versus threedimensional imaging in subjects with unerupted maxillary canines. Eur J
Orthod 2011;33:344e9.
[2] Haney E, Gansky SA, Lee JS, et al. Comparative analysis of traditional radiographs and cone-beam computed tomography volumetric images in the
diagnosis and treatment planning of maxillary impacted canines. Am J Orthod
Dentofacial Orthop 2010;137:590e7.
[3] Liu DG, Zhang WL, Zhang ZY, Wu YT, Ma XC. Localization of impacted
maxillary canines and observation of adjacent incisor resorption with conebeam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2008;105:91e8.
[4] Maverna R, Gracco A. Different diagnostic tools for the localization of impacted
maxillary canines: clinical considerations. Prog Orthod 2007;8:28e44.
[5] Alqerban A, Jacobs R, Lambrechts P, Loozen G, Willems G. Root resorption of
the maxillary lateral incisor caused by impacted canine: a literature review.
Clin Oral Investig 2009;13:247e55.
[6] Walker L, Enciso R, Mah J. Three-dimensional localization of maxillary canines
with cone-beam computed tomography. Am J Orthod Dentofacial Orthop
2005;128:418e23.
[7] Liu DG, Zhang WL, Zhang ZY, Wu YT, Ma XC. Three-dimensional evaluations of
supernumerary teeth using cone-beam computed tomography for 487 cases.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:403e11.
[8] White S, Pae E. Patient image selection criteria for cone beam computed
tomography imaging. Semin Orthod 2009;15:19e28.
[9] Korbmacher H, Kahl-Nieke B, Schllchen M, Heiland M. Value of two conebeam computed tomography systems from an orthodontic point of view.
J Orofac Orthop 2007;68:278e89.
[10] El AS, El H, Palomo JM, Baur DA. A 3-dimensional airway analysis of an
obstructive sleep apnea surgical correction with cone beam computed
tomography. J Oral Maxillofac Surg 2011;69:2424e36.
[11] Schendel S, Powell N, Jacobson R. Maxillary, mandibular, and chin advancement: treatment planning based on airway anatomy in obstructive sleep
apnea. J Oral Maxillofac Surg 2011;69:663e76.
[12] Schendel SA, Hatcher D. Automated 3-dimensional airway analysis from
cone-beam computed tomography data. J Oral Maxillofac Surg 2010;68:
696e701.
[13] Enciso R, Nguyen M, Shigeta Y, Ogawa T, Clark GT. Comparison of cone-beam
CT parameters and sleep questionnaires in sleep apnea patients and control
subjects. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:285e93.
[14] Ogawa T, Enciso R, Memon A, Mah JK, Clark GT. Evaluation of 3D airway
imaging of obstructive sleep apnea with cone-beam computed tomography.
Stud Health Technol Inform 2005;111:365e8.
[15] Aboudara CA, Hatcher D, Nielsen IL, et al. A three-dimensional evaluation of
the upper airway in adolescents. Orthod Craniofac Res 2003;6(Suppl 1):
173e5.
[16] Farnsworth D, Rossouw PE, Ceen RF, Buschang PH. Cortical bone thickness at
common miniscrew implant placement sites. Am J Orthod Dentofacial Orthop
2011;139:495e503.
[17] Miyazawa K, Kawaguchi M, Tabuchi M, Goto S. Accurate pre-surgical determination for self-drilling miniscrew implant placement using surgical guides
and cone-beam computed tomography. Eur J Orthod 2010;32:735e40.
[18] Fayed MM, Pazera P, Katsaros C. Optimal sites for orthodontic mini-implant
placement assessed by cone beam computed tomography. Angle Orthod
2010;80:939e51.
[19] Heymann GC, Cevidanes L, Cornelis M, De Clerck HJ, Tulloch JF. Threedimensional analysis of maxillary protraction with intermaxillary elastics to
miniplates. Am J Orthod Dentofacial Orthop 2010;137:274e84.

e7

[20] Baumgaertel S. Quantitative investigation of palatal bone depth and cortical

bone thickness for mini-implant placement in adults. Am J Orthod Dentofacial
Orthop 2009;136:104e8.
[21] Baumgaertel S, Hans MG. Buccal cortical bone thickness for mini-implant
placement. Am J Orthod Dentofacial Orthop 2009;136:230e5.
[22] Gracco A, Lombardo L, Cozzani M, Siciliani G. Quantitative cone-beam
computed tomography evaluation of palatal bone thickness for orthodontic
miniscrew placement. Am J Orthod Dentofacial Orthop 2008;134:361e9.
[23] Kim SH, Kang JM, Choi B, Nelson G. Clinical application of a stereolithographic
surgical guide for simple positioning of orthodontic mini-implants. World J
Orthod 2008;9:371e82.
[24] Kim SH, Choi YS, Hwang EH, Chung KR, Kook YA, Nelson G. Surgical positioning of orthodontic mini-implants with guides fabricated on models
replicated with cone-beam computed tomography. Am J Orthod Dentofacial
Orthop 2007;131(4 Suppl):S82e9.
[25] Alves Jr M, Baratieri C, Nojima LI. Assessment of mini-implant displacement
using cone beam computed tomography. Clin Oral Implants Res 2011;22:
1151e6.
[26] Hong C, Truong P, Song HN, Wu BM, Moon W. Mechanical stability assessment
of novel orthodontic mini-implant designs: Part 2. Angle Orthod 2011;81:
1001e9.
[27] Kau CH, English JD, Muller-Delgardo MG, Hamid H, Ellis RK, Winklemann S.
Retrospective cone-beam computed tomography evaluation of temporary
anchorage devices. Am J Orthod Dentofacial Orthop 2010;137:166.e1e5.
discussion 166e7.
[28] McCollough CH, Schueler BA. Calculation of effective dose. Med Phys 2000;27:
828e37.
[29] Okano T, Harata Y, Sugihara Y, et al. Absorbed and effective doses from cone
beam volumetric imaging for implant planning. Dentomaxillofac Radiol 2009;
38:79e85.
[30] Garcia Silva MA, Wolf U, Heinicke F, Grndler K, Visser H, Hirsch E. Effective
dosages for recording Veraviewepocs dental panoramic images: analog lm,
digital, and panoramic scout for CBCT. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2008;106:571e7.
[31] Ludlow JB, Davies-Ludlow LE, Brooks SL, Howerton WB. Dosimetry of 3 CBCT
devices for oral and maxillofacial radiology: CB Mercuray, NewTom 3G and
i-CAT. Dentomaxillofac Radiol 2006;35:219e26.
[32] Gijbels F, Jacobs R, Bogaerts R, Debaveye D, Verlinden S, Sanderink G.
Dosimetry of digital panoramic imaging. Part I: patient exposure. Dentomaxillofac Radiol 2005;34:145e9.
[33] Lecomber AR, Yoneyama Y, Lovelock DJ, Hosoi T, Adams AM. Comparison of
patient dose from imaging protocols for dental implant planning using
conventional radiography and computed tomography. Dentomaxillofac Radiol
2001;30:255e9.
[34] White S, Pharoah M. Oral radiology: principles and interpretation. 6th ed. St
Louis: Mosby; 2009. 35.
[35] Gijbels F, Sanderink G, Wyatt J, Van Dam J, Nowak B, Jacobs R. Radiation doses
of indirect and direct digital cephalometric radiography. Br Dent J 2004;197:
149e52.
[36] Ludlow JB, Ivanovic M. Comparative dosimetry of dental CBCT devices and 64slice CT for oral and maxillofacial radiology. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2008;106:106e14.
[37] Ludlow JB, Davies-Ludlow LE, Brooks SL. Dosimetry of two extraoral direct
digital imaging devices: NewTom cone beam CT and Orthophos Plus DS
panoramic unit. Dentomaxillofacial Radiol 2003;32:229e34.
[38] Roberts JA, Drage NA, Davies J, Thomas DW. Effective dose from cone beam CT
examinations in dentistry. Br J Radiol 2009;82:35e40.
[39] Tsiklakis K, Donta C, Gavala S, Karayianni K, Kamenopoulou V, Hourdakis CJ.
Dose reduction in maxillofacial imaging using low dose Cone Beam CT. Eur J
Radiol 2005;56:413e7.
[40] Danforth RA, Dus I, Mah J. 3-D volume imaging for dentistry: a new dimension. J Calif Dent Assoc 2003;31:817e23.
[41] Pauwels R, Beinsberger J, Collaert B, et al. SEDENTEXCT Project Consortium.
Effective dose range for dental cone beam computed tomography scanners.
Eur J Radiol 2012;81:267e71.
[42] Brooks S. CBCT dosimetry: orthodontic considerations. Semin Orthod 2009;
15:14e8.
[43] Silva MA, Wolf U, Heinicke F, Bumann A, Visser H, Hirsch E. Cone-beam
computed tomography for routine orthodontic treatment planning:
a radiation dose evaluation. Am J Orthod Dentofacial Orthop 2008;133:
640.e1e5.
[44] Bianchi S, Anglesio S, Castellano S, Rizzi L, Ragona R. Absorbed doses and risk
in implant planning: comparison between spiral CT and cone-beam CT.
Dentomaxillofac Radiol 2003;30:S28.
[45] Danforth RA, Peck J, Hall P. Cone beam volume tomography: an imaging
option for diagnosis of complex mandibular third molar anatomical relationships. J Calif Dent Assoc 2003;31:847e52.
[46] Sukovic P. Cone beam computed tomography in craniofacial imaging. Orthod
Craniofac Res 2003;6(suppl 1):31e6. 179e82.
[47] Mah JK, Danforth RA, Bumann A, Hatcher D. Radiation absorbed in maxillofacial imaging with a new dental computed tomography device. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2003;96:508e13.
[48] Mozzo P, Procacci C, Tacconi A, Martini PT, Andreis IA. A new volumetric CT
machine for dental imaging based on the cone-beam technique: preliminary
results. Eur Radiol 1998;8:1558e64.

e8

A. Abdelkarim / Journal of the World Federation of Orthodontists 1 (2012) e3ee8

[49] Huda W, Atherton JV, Ware DE, Cumming WA. An approach for the estimation
of effective radiation dose at CT in pediatric patients. Radiology 1997;203:
417e22.
[50] American Dental Association Council on Scientic Affairs. The use of dental
radiographs: update and recommendations. J Am Dent Assoc 2006;137:
1304e12.
[51] Gori T, Mnzel T. Biological effects of low-dose radiation: of harm and
hormesis. Eur Heart J 2012;33:292e5.
[52] Kaiser J. Hormesis. Sipping from a poisoned chalice. Science 2003;302:376e9.
[53] Farman AG, Scarfe WC. Development of imaging selection criteria and
procedures should precede cephalometric assessment with cone-beam
computed tomography. Am J Orthod Dentofacial Orthop 2006;130:257e65.
[54] Buttke T, Proft W. Referring adult patients for orthodontic treatment. J Am
Dent Assoc 1999;130:73e9.
[55] Farman AG. ALARA still applies. Oral Surg Oral Med Oral Pathol Oral Radiol
Endo 2005;100:395e7.
[56] Lin EC. Radiation risk from medical imaging. Mayo Clin Proc 2010;85:1142e6.
[57] Cho HJ. A three-dimensional cephalometric analysis. J Clin Orthod 2009;43:
235e52.
[58] Devereux L, Moles D, Cunningham SJ, McKnight M. How important are lateral
cephalometric radiographs in orthodontic treatment planning? Am J Orthod
Dentofacial Orthop 2011;139:e175e81.
[59] Nguyen T, Cevidanes L, Cornelis MA, Heymann G, de Paula LK, De Clerck H.
Three-dimensional assessment of maxillary changes associated with bone
anchored maxillary protraction. Am J Orthod Dentofacial Orthop 2011;140:
790e8.
[60] Cevidanes LH, Oliveira AE, Grauer D, Styner M, Proft WR. Clinical application
of 3D imaging for assessment of treatment outcomes. Semin Orthod 2011;17:
72e80.
[61] Cevidanes LH, Alhadidi A, Paniagua B, et al. Three-dimensional quantication
of mandibular asymmetry through cone-beam computerized tomography.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111:757e70.
[62] Cevidanes L, Heymann G, Cornelis M, DeClerck H, Tulloch J. Superimposition of
3-dimensional cone-beam computed tomography models of growing patients.
Am J Orthod Dentofacial Orthop 2009;136:94e9.
[63] Cevidanes LH, Styner MA, Proft WR. Image analysis and superimposition of
3-dimensional cone-beam computed tomography models. Am J Orthod Dentofacial Orthop 2006;129:611e8.
[64] Tucker S, Cevidanes LH, Styner M, et al. Comparison of actual surgical
outcomes and 3-dimensional surgical simulations. J Oral Maxillofac Surg
2010;68:2412e21.
[65] Cevidanes LH, Bailey LJ, Tucker Jr GR, et al. Superimposition of 3D cone-beam
CT models of orthognathic surgery patients. Dentomaxillofac Radiol 2005;34:
369e75.
[66] Cevidanes LH, Motta A, Proft WR, Ackerman JL, Styner M. Cranial base
superimposition for 3-dimensional evaluation of soft-tissue changes. Am J
Orthod Dentofacial Orthop 2010;137(4 Suppl):S120e9.
[67] da Motta AT, de Assis Ribeiro Carvalho F, Oliveira AE, Cevidanes LH, de Oliveira
Almeida MA. Superimposition of 3D cone-beam CT models in orthognathic
surgery. Dental Press J Orthod 2010;15:39e41.
[68] Kau CH, Littleeld J, Rainy N, Nguyen JT, Creed B. Evaluation of CBCT digital
models and traditional models using the Littles Index. Angle Orthod 2010;80:
435e9.

[69] Hsieh J, Molthen RC, Dawson CA, Johnson RH. An iterative approach to the
beam hardening correction in cone beam CT. Med Phys 2000;27:23e9.
[70] Endo M, Tsunoo T, Nakamori N, Yoshida K. Effect of scattered radiation on
image noise in cone beam CT. Med Phys 2001;28:469e74.
[71] Alqerban A, Jacobs R, Fieuws S, Nackaerts O, Willems G. SEDENTEXCT Project
Consortium. Comparison of 6 cone-beam computed tomography systems for
image quality and detection of simulated canine impaction-induced external
root resorption in maxillary lateral incisors. Am J Orthod Dentofacial Orthop
2011;140:e129e39.
[72] Kapila S, Conley RS, Harrell Jr WE. The current status of cone beam computed
tomography imaging in orthodontics. Dentomaxillofac Radiol 2011;40:24e34.
[73] Tyndall DA, Brooks SL. Selection criteria for dental implant site imaging:
a position paper of the American Academy of Oral and Maxillofacial radiology.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:630e7.
[74] American Association of Endodontists; American Academy of Oral and
Maxillofacial Radiology. Use of cone-beam computed tomography in
endodontics Joint Position Statement of the American Association of
Endodontists and the American Academy of Oral and Maxillofacial Radiology.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111:234e7.
[75] Merrett SJ, Drage NA, Durning P. Cone beam computed tomography: a useful
tool in orthodontic diagnosis and treatment planning. J Orthod 2009;36:
202e10.
[76] Hilgers ML, Scarfe WC, Scheetz JP, Farman AG. Accuracy of linear temporomandibular joint measurements with one beam computed tomography and
digital cephalometric radiography. Am J Orthod Dentofacial Orthop 2005;128:
803e11.
[77] Honda K, Arai Y, Kashima M, et al. Evaluation of the usefulness of the limited
cone-beam CT (3DX) in the assessment of the thickness of the roof of the
glenoid fossa of the temporomandibular joint. Dentomaxillofac Radiol 2004;
33:391e5.
[78] Tsiklakis K, Syriopoulos K, Stamatakis HC. Radiographic examination of the
temporomandibular joint using cone beam computed tomography. Dentomaxillofac Radiol 2004;33:196e201.
[79] Kau CH, Richmond S, Palomo JM, Hans MG. Three-dimensional cone beam
computerized tomography in orthodontics. J Orthod 2005;32:282e93.
[80] Sylvester DC, Exss E, Marholz C, Millas R, Moncada G. Association between
disk position and degenerative bone changes of the temporomandibular
joints: an imaging study in subjects with TMD. Cranio 2011;29:117e26.
[81] Palconet G, Ludlow J, Tyndall D, Lim PF. Correlating cone beam CT results with
temporomandibular joint pain of osteoarthritic origin. Dentomaxillofac Radiol
2012;41:126e30.
[82] Bertram S, Rudisch A, Innerhofer K, Pumpel E, Grubwieser G, Emshoff R.
Magnetic resonance imaging to diagnose temporomandibular joint internal
derangement and osteoarthrosis. J Am Dent Assoc 2001;66:75e7.
[83] Chirani RA, Jacq JJ, Meriot P, Roux C. Temporomandibular joint: a methodology of magnetic resonance imaging 3D reconstruction. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2004;97:756e61.
[84] Turpin DL. Befriend your oral and maxillofacial radiologist. Am J Orthod
Dentofacial Orthop 2007;131:697.
[85] Jerrold L. Litigation, legislation, and ethics: liability regarding computerized
axial tomography scans. Am J Orthod Dentofacial Orthop 2007;132:122e4.
[86] Curley A, Hatcher DC. Cone beam CT e anatomic assessment and legal issues:
the new standards of care. J Calif Dent Assoc 2009;37:653e62.