SIU-SDM HAWAIIAN CRUISE

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SIU-SDM HAWAIIAN CRUISE
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SIU-SDM HAWAIIAN CRUISE
CONE BEAM C T IS IT FOR THE GENERALISTS OFFICE?
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DEBRA DIXON, DMD

• SDM GRADUATE 1993
• SDM AEGD 1995
• SDM IMPLANT FELLOW 1996
• THE UNIVERSITY OF LONDON MSc DENTAL
  RADIOLOGY 2002
• SDM DIRECTOR OF RADIOLOGY

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FUR
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OUR AGENDA

• History
• Radiology
• Digital Radiology
• CT
• Cone Beam CT
• What it is and What it can do for me

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HISTORY

• Nov 8, 1895 Wilhelm RÖntgen discovers the X-Ray
• Digital radiography is more than 25 years old
• 11 to 30 of dentists have converted to digital
• Financial investment
• Complexity of computers
• Software
• Hardware
• Simply reluctant to switchif everything is
  running smoothly, why change it?

Van der Stelt 2008
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BASICS OF DIGITAL IMAGING

• Composed of pixels (picture elements) which are
  characterized by 3 numbers
• These numbers are stored in an image file in the
  computer
• Image processing is possible
• Brightness/Darkness
• Contrast
• Zoomlimited by the resolution of the system

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BASICS OF DIGITAL IMAGING

• Image Analysis
• Measurement of root length for Endo
• Digital subtraction radiography

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BASICS OF DIGITAL IMAGING

• Advantages
• Immediate image with CCD sensor
• Ability to manipulate the image
• Integrated storage with software systems
• Security of backup and off-site archiving of
  images
• Ease of transfer by email
• Security of the original image
• DICOM (Digital Imaging and Communications in
  Medicine) format standards

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BASICS OF DIGITAL IMAGING

• Dose Reduction?
• Once promoted as a huge advantage to digital
  imaging
• Why the dose reduction is not as large as often
  suggested
• Dose per exposure
• Reduction of 0 to 50 as compared with F speed
  film
• Increase in the number of radiographs made
• Increase in the number of retakes due to the ease
  of exposing additional images
• 
  

Van der Stelt 2008
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SALLY
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C TCOMPUTED TOMOGRAPHY
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C T

• History
• Basics of Tomography
• Generations of Scanners
• 1st Generation
• 2nd Generation
• 3rd Generation
• 4th Generation
• 5th Generation
• Conventional data gathering versus Spiral
  geometry

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C T

• History
• The word Tomography can be traced to the 1920s
• Tomography section, from the Greek tomos
• Dr. Godfrey Hounsfield
• Born 1919 in Nottinghamshire, England
• The inventor of clinical computed tomography
• First patient scanned in 1972
• Demonstrated a suspected brain lesion
• Dr. Allan Cormack
• Born 1924 in Johannesburg, South Africa
• Developed solutions for the mathematical problems
  in CT

Seeram, Computed Tomography, 2001
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C T

• History
• Dr. Robert Ledley
• 1948 Doctorate in Dental Surgery, New York
  University
• 1949 Masters in theoretical physics, Columbia
  University
• Developed the first whole-body CT scanner

Seeram, Computed Tomography, 2001
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C T

• History
• Tomography
• X-ray tube and film move simultaneously and in
  opposite directions
• This keeps the object of interest in focus while
  blurring out the structures around it
• Panoramic technique

Seeram, Computed Tomography, 2001
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C T

• History
• A
• 1st Generation
• B
• 2nd Generation
• C
• 3rd Generation
• D
• 4th Generation

Seeram, Computed Tomography, 2001
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C T

• History
• 1st Generation
• Minimum 4.5 to 5.5 minute whole body scan
• Parallel beam, Translate Rotate
• After 1 translation, the tube and detector rotate
  by 1 and translate again, repeated for 180
  around the patient

Seeram, Computed Tomography, 2001
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C T

• History
• 2nd Generation
• Scan time 20 sec to 3.5 minutes
• Fan beam, Translate Rotate
• Fan beam 30 detectors coupled to the x-ray
  tube and multiple pencil beams
• Process is repeated for 180

Seeram, Computed Tomography, 2001
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C T

• History
• 3rd Generation
• Scan time of a few seconds
• Fan beam geometry that rotates continuously
  around the patient for 360

Seeram, Computed Tomography, 2001
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C T

• History
• 4th Generation
• Scan time is very short, varies by manufacturer
• A rotating fan beam within a stationary ring of
  detectors

Seeram, Computed Tomography, 2001
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C T

• History
• 5th Generation
• High-speed CT scanners
• EBCT Electron Beam CT scanner
• DSR
• Dynamic Spatial Reconstructor
• Scan time of milliseconds

Seeram, Computed Tomography, 2001
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C T

• History
• A
• Conventional Slice by Slice data acquisition
• The x-ray tube stops between slices, the patient
  is repositioned for the next slice

Seeram, Computed Tomography, 2001
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C T

• History
• B
• Helical or spiral geometry
• The latest development in CT data acquisition (as
  of the writing of the text in 2001)
• Volume scanning
• Utilizes a narrowly collimated, fan shaped x-ray
  beam, projected through a limited thickness slice
  through the body
• Utilizes a linear array of detectors
• Patient has to be advanced through the gantry
  while the x-ray tube and detectors rotate around
  the patient

Seeram, Computed Tomography, 2001
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C T

• Spiral Scanners
• Provide improved multiplanar image
  reconstructions
• Reduced exam time
• 12 seconds versus 5 minutes for an incremental
  scan
• Reduced radiation dose
• Up to 75 of the dose delivered by an incremental
  scanner

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C T

• Image is recorded and displayed as matrix of
  individual blocks called voxels (volume elements)
• Voxel length (1 to 20 mm) is determined by the
  width of the x-ray beam
• Analogous to the tomographic layer in film
  tomography
• For image display, each pixel is assigned a CT
  number
• Represents density
• Also known as a Hounsfield unit
• Air -1000
• Water 0
• Dense bone 1000

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EM
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CONE BEAM C T
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C B C T

• Definition
• Indications
• Comparisons
• CBCT versus Panoramic
• CBCT versus Plain-film Tomography
• CBCT versus Medical CT
• Disadvantages
• Currently available units
• Specialized Uses
• Orthodontic Analysis
• Dolphin Imaging Software Program
• Interpretation

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C B C T

• Developed for Dental purposes to provide 3D
  volume images of the dental and craniofacial
  complex
• Available for craniofacial imaging
• Since 1999 in Europe
• Since 2001 in the U.S.
• Ideally suited for craniofacial imaging
• The compact size of the unit
• Relatively low radiation dose
• Becoming the Standard of Care for diagnosis of
  the craniofacial region
• Allows multiplanar viewing of the anatomical
  volume and overcomes the limitations of 2D
  radiography

www.conebeam.com
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C B C T

• Cone Beam
• Utilizes a cone shaped x-ray beam
• Round or rectangular
• Utilizes an area detector
• Acquires a full volume of images in a single
  rotation with no need for patient movement
• Rotates 360 around the head
• 360 projections
• Scan time typically lt 1 minute

www.conebeam.com
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C B C T

• End Result
• 3-D visualization of the oral and maxillofacial
  complex from any plane
• A stack of 360 images or exposures compiled into
  a volumetric dataset through a computer process
  known as primary reconstruction
• This data volume is then converted into a
  patient-study by accompanying software
• Can be visualized as
• 2D trans-axial, multi-planar reformatted
• 3D techniques such as surface reconstruction and
  volume rendering
• A combination of 2D and 3D techniques

www.conebeam.com
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C B C T

• Indications
• Evaluation of the jaw bones
• Implant placement and evaluation
• TMJ
• Pathology
• Bony Soft tissue lesions
• Periodontal assessment
• Endodontic assessment
• Alveolar ridge resorption
• Assessment of the IAN prior to extraction of
  impactions
• Orthodontic evaluation
• Airway assessment
• Need for 3D reconstructions

www.conebeam.com
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C B C T

• Evaluation of the jaw bones
• Implant placement and evaluation 12-13
• a) Panoramic line and cross-section line in the
  axial image of Maxilla identified
• b) Slices of the area in cross-section
• c) Reconstruction in a panoramic-like layout

Araki et al. Dentomaxillofac Radiol 31 (1)51,
Figure 9
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C B C T

• Evaluation of the jaw bones
• a) Slice as seen from a frontal view
• b) Slice as seen from the side
• c) Reconstructed maxilla and mandible

Dentomaxillofac Radiol (2004) 33, 285-290
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C B C T

• Evaluation of the jaw bones

www.ddsgadget.com
e-ssentialnetworks.com
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C B C T versusPANORAMIC

• PANORAMIC
• Provides a distorted (unequal magnification) and
  magnified image
• Image layer view only
• Structures are superimposed

• CBCT
• Provides an undistorted image
• Cross-sectional (bucco-lingual), axial, coronal,
  sagittal, and panoramic views
• Structures can be separated

www.conebeam.com
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C B C TversusPLAIN-FILM TOMOGRAPHY

• PLAIN-FILM TOMOGRAPHY
• Provides an undistorted image, but there is
  magnification
• Provides direct cross-sectional, sagittal, and
  coronal views
• Scan time may be short, but chair time can be
  lengthy

• CBCT
• Provides an undistorted, 11 image
• Provides reconstructed views
• Scan time
• 10-40 second range, dependent on the region being
  imaged and the desired quality
• Provides an indication of bone quality

www.conebeam.com
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C B C TversusMedical C T
www.osseonews.com

• Med CT
• Conventional linear fan beam
• Single row or a series (4, 8, 12, 32, 64) of
  solid state detectors
• Provides a set of consecutive slices of the
  patient

• CBCT
• Cone beam
• Square 2 dimensional array of detectors
• Provides a volume of data

www.conebeam.com
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C B C TversusMedical C T

• Med CT
• Greater contrast resolution
• More discrimination between different tissue
  types (i.e. bone, teeth, and soft tissue)

• CBCT
• Equipment
• Cost 3-5x less than MDCT
• Lighter Smaller
• No special electrical
• No floor strengthening
• No special cooling
• Ease of operation
• Dedicated to dental
• Patient sits or stands
• Both jaws can be imaged at the same time
• Lower radiation burden

www.conebeam.com
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C B C T

• Disadvantages
• Noise from radiation scatter
• Streak artifacts from metal restorations
• Algorithms and filters try to correct for noise
  artifacts
• Image degradation from patient movement
• Head stabilizing devices
• Cost
• Range from 150,000 to 300,000
• Training
• For maximum benefit
• For interpretation of the volume of data images
• Within the purview of the dentist
• Outside the purview of the dentist

Howerton et. al.
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C B C T

• Currently available units
• 3D Accuitomo FPD XYZ Slice View Tomograph
• J. Morita USA, Irvine, CA
• 3D X-ray CT Scanner Alphard Series
• Asahi, Kyoto, Japan
• Quolis Alphard Alphard-3030-Cone-Beam
• Belmont Equipment, Somerset, NJ
• CB MercuRay
• Hitachi Medical Systems America, Twinsburg, Ohio
• Galileos 3D
• Sirona Dental Systems, Charlotte, NC
• i-CAT
• Imaging Sciences International, Hatfield, PA

Howerton et. al.
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C B C T

• Currently available units
• Iluma Ultra Cone Beam CT Scanner
• Carestream, Rochester, NY
• NewTom 3G and VG
• AFP Imaging, Elmsford, NY
• Picasso
• E-woo Technology, Houston
• PreXion 3D
• TeraRecon, San Mateo, CA
• ProMax 3D
• Planmeca USA, Roselle, IL
• Scanora 3D
• Soredex, Tuusula, Finland

Howerton et. al.
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C B C T
i-CAT NewTom VG 3D Accuitomo
Position Seated Stand/Seated Seated
Scan time 5, 8.9, 26.9 sec 20 sec 18 sec
Scan Hgt 4,6,8,10,13 cm 9.84 inches 1.57-2.36 inches
kVp/mA 120/3-5 60-80/1-10
Rad Time 9 sec 5.4 sec Not listed
Scan thick 0.12-0.4 mm 0.1-0.5 mm .125-2.0 mm
Ceph Yes Yes No
Software Xoran Cat NewTom VG I-Dixel
Price 170,000 170,000 252,000
website imagingsciences.com newtomdental.com jmorita.com
Inside Dentistry 190-93, 2007, Dental Economics
August 2007, Dental Town August 2007
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C B C T

• All Cone Beam Units are not created equal!
• Volume Size
• Geometric resolution
• Contrast resolution
• Slice thickness
• Radiation dose
• Ease of use
• Image Capture

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C B C T
Effective dose (µSv) Dose in of Pans Dose in days Dose in Med CT
i-Cat 12 FOV 135 21 13 6.4
NewTom 3G 12 FOV 45 7 4 2.1
Panoramic 6 1 1 0.3
CT Maxilla Mandible 2,100 385 243 100
Farman AG, Levato CM, Scarfe WC. A primer on
cone beam CT. Inside Dentistry 190-93, 2007
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C B C T

• The i-CAT CT scanner
• Low dose settings for children
• Landscape View
• Full resolution and detail obtained for smaller
  fields of view
• Portrait View
• Captures Extended Field of View data
• Ceph data in 8.5 seconds

www.imagingsciences.com
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C B C T

• i-CAT
• Typical reconstruction time
• Less than 30 seconds

www.imagingsciences.com
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C B C T

• i-CAT
• Measurement
• Labeling
• Hounsfield units
• Density

www.imagingsciences.com
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C B C T

• NewTom VG
• Features a single 8"x10" Field Of View,
• Most utilized by implantologists and
  maxillo-facial surgeons.
• Small focal spot high quality images
• Volume of data captured kept to a minimum
• Short reconstruction times (3 minutes)
• Low dose
• up to 20 - 50 times less radiation than
  conventional CT
• Adjusts dose to size and age of patient
• Unique pulse system
• Activates the x-ray source only when
  neededdelivering less than 4 seconds of total
  exposure for a full scan.

www.afpimaging.com/newtom
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C B C T

• NewTom

www.afpimaging.com/newtom
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C B C T

• 3D Accuitomo
• J. Morita Manufacturing
• Imaging Areas 40x40 mm 60x60 mm
• High resolution for large imaging area
• Voxel size 0.125 mm, high resolution (2.0 line
  pair/mm)
• Low effective dose
• Wide dynamic range and expresive tone create
  brilliant images of both soft and hard tissue
  areas
• Enables the most accurate diagnosis for implants,
  apical lesions, temporomandibular joints,
  impactions, etc.

www.jmorita-mfg.com
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C B C TSPECIALIZED USES
ISLAND OF LANAI
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C B C T

• Specialized Uses
• Orthodontic Analysis
• Dolphin Imaging Software Program
• Oral Surgery
• Impactions
• Trauma
• Implants
• Endodontics
• Periodontics
• TMJ

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C B C T - ORTHO
Ortho Evaluation and Treatment Planning
www.dolphinimaging.com
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C B C T - ORTHO

• The Dolphin 3D software module
• A powerful tool that makes processing 3D data
  extremely easy, enabling dental specialists from
  a wide variety of disciplines to accurately
  diagnose and plan treatment.
• Dolphin 3D allows visualization and analysis of
  craniofacial anatomy from data produced by CBCT,
  MRI, medical CT and 3D facial camera systems.

www.dolphinimaging.com
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C B C T - ORTHO

• Dolphin Imaging Software
• Comprehensive cross sections with Multiple Planar
  View (MPV)
• 3D nerve marking
• TMJ analysis
• Create stunning, accurate cephalometric and
  panoramic radiographs
• Import from a variety of 3D files
• High-quality, fast 3D rendering
• Easily detect impacted teeth
• Analyze, visualize and measure airway
• Precise volume orientation
• Establish 3D/2D measurements
• Create movies
• Design automated image layouts
• Images export to other applications, including
  PowerPoint, Word, etc.
• Images easily saved into Dolphin patient file
• Export to standard file formats and Windows
  Clipboard
• Fully embedded in Dolphin Imagings SQL database

www.dolphinimaging.com
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C B C T - ORTHO

• Dolphin Imaging Software
• Object Orientation
• Comprehensive cross sections with Multiple Planar
  View
• Instant Ceph/Pan
• Ceph Tracing
• 3D Nerve Mapping
• TMJ analysis
• 3D Visualization

www.dolphinimaging.com
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C B C T - ORTHO

• Object Orientation
• To maximize the consistency of analysis of a 3D
  volume, it is crucial to establish a default
  orientation.
• Dolphin 3D provides comprehensive tools for
  defining the mid-sagittal, axial and coronal
  planes. You can also adjust the objects default
  yaw, pitch and roll.
• These operations can be performed on the CT soft
  tissue surface, CT hard tissue surface or 3D
  photo surface.

www.dolphinimaging.com
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C B C T - ORTHO

• Multiple Planar Views and Layouts
• Choose a layout that is best suited to your task
• 3D volume (just the 3D volume view)
• Volume3 planes (3D volume and 3 cross section
  planes on the side)
• 4-views (3D volume and the cross section planes
  in equal sized windows)
• Individual orthogonal projected slices sagittal,
  coronal and axial planes

www.dolphinimaging.com
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C B C T - ORTHO

• Instant Ceph/Pan
• Create two-dimensional radiographic images from
  3D volume dataset in the lateral, panoramic
  (OPG), frontal and SMV views.
• 11 projection
• no distortion
• no magnification

www.dolphinimaging.com
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C B C T - ORTHOCeph Tracing
www.dolphinimaging.com
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C B C T - ORTHO Nerve Mapping
www.dolphinimaging.com
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C B C T - ORTHO

• TMJ View
• Choose an area of interest set center point and
  axis direction, designed specifically for
  analyzing the temporomandibular joint
• Choose desired slice thickness, width, number and
  direction (coronal, sagittal, or patent-pending
  circular)
• View key cross-sections at the chosen axes

www.dolphinimaging.com
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C B C T - ORTHO

• 3D Visualization
• Dolphin gives you the power to freely visualize
  the volume in 3D. In addition to switching from
  hard tissue and soft tissue views, you can also
  activate the see-thru hard tissue renderings.
  Adjust the factor of translucency and intensity
  to reveal the structure you desire.Clipping
  tools are also very useful for quickly
  visualizing hidden structures, or to simply
  eliminate portions of the contents that are not
  relevant.

www.dolphinimaging.com
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C B C T

• Interpretation of the Volume of Images
• Data collected within the Region of Interest
  (ROI)
• Within the purview of general dentists and
  specialists
• Data collected outside of the Region of Interest
• A large volume of information exists that is
  outside of a dentists purview
• Comprehensive Care of the Patient
• Documented interpretation of all the data in the
  volume
• 2007 Chairman of the AAOMS advised that all
  volumes be read by a radiologist

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C B C T

• Interpretation of the Volume of Images
• AAO Council on Scientific Affairs
• Survey of Radiologists
• All scans should be read by a qualified person.
• Panoramic can be read by the diagnostician
  (dentist)
• Cone Beam volume by an Oral Maxillofacial
  Radiologist or an MD Radiologist
• The interpretation fee can be either included in
  the scan fee, or be billed separately
• The entire volume of data requires
  interpretation. The patient cannot deny
  interpretation of non-dental data
• As in medicine, a written report is the standard

Am J Orthod Dentofacial Orthop 2007131697
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TIGGER
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CONE BEAM C T IS IT FOR THE GENERALISTS OFFICE?
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• THE BOTTOM LINE
• Is it worth your time and effort?
• Physical Space in your office
• Training
• Computer memory to work with images
• Storage of images

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• THE BOTTOM LINE
• Is it worth your time and effort?
• Physical Space in your office
• Training
• Computer memory to work with images
• Storage of images
• Will it be profitable?
• Costof the equipment
• Time involved
• Number of patient scans x 250-600/scan
• Types of images available Pan, Ceph, Bitewings,
  Periapicals

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MAHALO
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CONE BEAM C T

• References
• Araki et al. Dentomaxillofac Radiol 31 (1)51,
  Figure 9
• Am J Orthod Dentofacial Orthop 2007131697
• Turpin D., Editor-in-Chief. Befriend your oral
  and maxillofacial radiologist
• Danforth RA, Miles D. Cone Beam Computed
  Tomography for Dentistry (Journal unknown)
• Dental Economics August 2007
• Feuerstein P. Cone Beam Technology.
• Guttenberg S, Emery R. Profit in 3 dimensions
• R Baba, K Ueda and M Okabe. Using a flat-panel
  detector in high resolution cone beam CT for
  dental imaging. Dentomaxillofacial Radiology
  2004 33, 285-290
• DentalTown August 2007
• Giacobbi T. 3D Images for 21st Century Dentistry

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CONE BEAM C T

• References
• Inside Dentistry 190-93, 2007
• Farman AG, Levato CM, Scarfe WC. A primer on
  cone beam CT.
• JADA supplement June 2008, Vol. 139, Digital
  Imaging
• A. Ruprecht. Oral and Maxillofacial Radiology
  Then and Now
• P.F. van der Stelt. Better Imaging The
  Advantages of Digital Radiography
• A.G. Farman, et al. In Practice how Going
  Digital Will Affect the Dental Office
• W.B. Howerton Jr, M.A. Mora. Advancements in
  Digital Imaging What Is New and on the Horizon?
• Seeram, Euclid. Computed tomography physical
  principles, clinical applications, and quality
  control, 2nd edition, 2001, Saunders.

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CONE BEAM C T

• References
• www.afpimaging.com
• www.conebeam.com
• www.cile.co.nr
• www.ddsgadget.com
• www.dolphinimaging.com
• www.e-ssentialnetworks.com
• www.imagingsciences.com
• www.jmorita-mfg.com
• www.osseonews.com