Advanced Applications of Cone Beam

Computed Tomography in Orthodontics

James K. Mah, Liu Yi, Reyes C. Huang, and HyeRan Choo

This article describes the advanced cone beam computed tomography

(CBCT) applications in orthodontic diagnosis and treatment planning. The
limitations of conventional 2-dimensional planar film are discussed, and
case examples are described that highlight the additional diagnostic infor-
mation and many benefits derived from 3-dimensional imaging. CBCT soft-
ware can manipulate the Digital Imaging and Communications in Medicine
(ie, DICOM) data to visualize anatomic structures and accurately display
relationships within the craniofacial complex. A combination of volumetric
reconstruction and multiplanar views can provide the orthodontic clinician
with skeletal hard tissue, soft tissue, dentition, and airway information.
Nonstandard orthodontic cases, such as impacted teeth, supernumerary
odontomas, or unexpected radiologic observations, such as pathologic le-
sions or incidental findings are best visualized with the 3-dimensinoal CBCT
scan. Advanced CBCT software applications also can be used to quantify
airway space (relevant for sleep apnea cases), perform superimpositions of
objects at different time points to semiquantitatively visualize changes (eg,
mandibular growth, temporomandibular joint, airway), and generate digital
dental models to streamline the workflow in the orthodontic clinic. (Semin
Orthod 2011;17:57-71.) © 2011 Elsevier Inc. All rights reserved.

he advent of 3-dimensional (3D) radio- ology in 1998 with the NewTom QR-DVT 9,000
T graphic imaging with cone beam computed
tomography (CBCT) has led to a multitude of
(NIM, s.r.l., Verona, Italy).1 After an initial pe-
riod of slow adoption and the emergence of
clinical applications across all dental disciplines. other CBCT manufacturers,2,3 this technology
CBCT, whose name reflects the type of imaging has become widely accepted in recent years, with
technique used, was introduced in dental radi- the number of CBCT units installed in the
United States almost doubling each year since
2005.
Associate Clinical Professor, Division of Craniofacial Sciences Many different names have been suggested
and Therapeutics, Herman Ostrow School of Dentistry, University of for this technology.4 Although functional no-
Southern California, Los Angeles, CA; Assistant Professor, Depart- menclature, such as digital volume tomography
ment of Orthodontics, Peking University School of Stomatology,
or cone beam volumetric tomography (or simply
Beijing, China; Assistant Professor of Clinical Dentistry, School of
Dentistry, University of Southern California, Los Angeles, CA; As- volumetric tomography or cone beam imaging),
sociate Clinical Professor and Vice-Chair, Division of Orthodontics, have been proposed in an effort to differentiate
Department of Orofacial Sciences, University of California, San it from its high-radiation, conventional medical
Francisco, CA; Attending Orthodontist, The Children’s Hospital of computed tomography (CT) counterpart, the
Philadelphia and Clinical Associate, University of Pennsylvania
School of Dental Medicine, Philadelphia, PA. original CBCT label seems to have been largely
Address correspondence to Dr James K. Mah, Herman Ostrow adopted by most users, albeit it is somewhat of a
School of Dentistry, University of Southern California, 925W, 34th misnomer.5
Street, DEN 312, Los Angeles, CA 90089-0641; E-mail: During a CBCT scan, many single 2D snap-
[email protected]
© 2011 Elsevier Inc. All rights reserved.
shot images are captured from predefined an-
1073-8746/11/1701-0$30.00/0 gles as the machine moves through a single iso-
doi:10.1053/j.sodo.2010.08.011 centric rotation of the x-ray source/sensor unit.

Seminars in Orthodontics, Vol 17, No 1 (March), 2011: pp 57-71 57

58 Mah et al

These raw images are then computationally cations since 2004. In a recent report, Hatcher
compiled into a 3D dataset with the use of spe- and Aboudara18 describe more comprehensive
cialized reconstruction algorithms. The volume and specific anatomic features related to orth-
is often referred to as the “3D image,” although odontic treatment, including a detailed review
technically this is still a misnomer because the of the craniofacial skeleton, dentition, soft tis-
views on the computer screen are in reality still sues of the face, the temporomandibular joints,
planar and not holographic projections. Never- sinuses, and airway space. Interstructural rela-
theless, the resultant overlap-free “3D image” tionships, such as condylar position relative to
still offers many advantages over standard 2D occlusion or the dentition support of the lips,
x-ray radiographs, such as: have also been identified. CBCT has a clear ad-
vantage over traditional 2D planar imaging by
● 3D representation of dental and craniofacial
revealing complex relationships with minimal
structures;
blurring of images caused by overlapping struc-
● custom image reformatting to provide optimal
tures, resulting in potentially clearer images for
visualization from different angles and per-
exclusion of pathologies. In addition, experi-
spectives;
enced users of CBCT imaging are using the data
● orthogonal images that do not contain mag-
to provide clinical therapy for selection and
nification errors or projection artifacts
planning of temporary anchorage device (TAD)
● management of superimpositions;
placement as well as for determining tooth po-
● interoperability in Digital Imaging and Com-
sitions for designing custom biomechanics using
munications in Medicine (DICOM) format;
conventional appliances as well as computer-as-
● generation of data that can be used in other
sisted tooth movement with wire-bending ro-
diagnostic, modeling, and manufacturing ap-
bots.19
plications; and
This article describes a comprehensive analy-
● radiation exposure within a similar range of
sis of the CBCT volume for orthodontic diagno-
other dental radiographic imaging devices,
sis and treatment planning, including the follow-
which is generally an order of magnitude
ing:
lower than that of medical CT devices.6-9
● lateral and frontal cephalometric views;
There are numerous CBCT systems currently on
● 3D skeletal views and 3D review of the denti-
the market, with an estimate of more than 30
tion;
CBCT device manufacturers worldwide as of
● alveolar ridge shape and volume;
early 2009. Configurations vary from system to
● temporomandibular joints;
system, with differences in: (1) patient position
● sinuses and airway;
during image acquisition (supine position similar
● facial analysis;
to medical CT devices, stand-up configurations
● cleft lip and palate; and
patterned after common panoramic machines,
● facial modeling and therapeutic applications.
seated units, or portable systems developed for
intraoperative examination and mobile scanning
centers), (2) image capture sensor type, (3) field
3D Cephalometry
of view (FOV), (4) x-ray generator, and (5) recon-
struction algorithm and visualization software. Cephalometric analysis in orthodontics is an es-
Many advantages can be gained by imaging sential diagnostic tool for evaluation of cranio-
craniofacial structures in 3 dimensions.10 Initial facial morphology. Its origins include assess-
publications in the dental literature predomi- ment from 2 perspectives. The Orientator was
nantly reported anomalies related to dentoalve- developed to provide simultaneous profile and
olar processes (impacted teeth, cysts),11,12 dental posterior-anterior perspectives.20 However, this
implant placement, or issues concerning maxillo- approach is very limited in providing all the
facial surgery (fractures, paranasal sinuses, osteo- perspectives required for realistic 3D visualiza-
myelitis).13-16 Three-dimensional imaging for diag- tion. Medical CT provides this ability and is used
nosis and treatment planning has also gained in the management of craniofacial anomalies21;
popularity in orthodontics,17 with a noticeable in- however, its cost, limited accessibility, and rela-
crease in orthodontically related imaging publi- tively high radiation dose preclude its use for
 Advanced Applications of CBCT in Orthodontics 59

common orthodontic patients. With the intro-

duction of CBCT, 3D visualization is available
without the major limitations associated with
medical CT.
The current factors affecting CBCT 3D ceph-
alometry are the size of the scanning volume and
positional dependency of the image value of a
structure in view of the scanner.22 Large FOV
CBCT scanners have a scanned volume that is
sufficient for the establishment of a 3D cephalo-
metric reference system for hard- and soft-tissue
analyses without involving the entire calvarium.
Another major factor to consider is the visibility
of classic cephalometric landmarks, because the
CBCT x-ray energy is dramatically reduced com-
pared with medical CT, resulting in a correlative
decrease in detail of internal anatomical struc-
tures of the cranial base.
There are many different 3D cephalometric
approaches in the craniofacial literature,23-25
with most 3D cephalometric analyses based on a
transformation of a classical 2D topological
cephalometry. During this transitional period
between 2D and 3D cephalometric analysis,
many orthodontists who use CBCT are reformat-
ting the volumetric data to produce conven-
tional 2D views (lateral and frontal cephalo-
grams, panoramic radiograph), which can be Figure 1. CBCT -generated lateral cephalogram (A)
used for traditional analyses (Fig 1). and panoramic radiograph (B). Advantages include
Although the CBCT-generated lateral cepha- the ability to excise extraneous anatomical structures,
logram may appear similar to a conventional 2D thereby eliminating superimpositions. (Color version
lateral cephalometric image, CBCT has several of figure is available online.)
distinct advantages that can enhance visualiza-
tion. Conventional lateral cephalograms are de-
rived from a technique called perspective pro- onal image. When a standard of known length is
jection; the geometrical result is an inherent placed in view, the CBCT lateral cephalogram
magnification of the image depending on the can be calibrated to a true 1:1 representation of
distance from the structure to the film. For ex- the structure being imaged. Another obvious
ample, the difference between the left and right advantage is the ability to correct errors in head
mandibular bodies results in the double lower position using the 3-D manipulations. Moreover,
border of the mandible that is often seen in alignment of the cranial base between left and
conventional films. Ideal head positioning with right sides often reveals maxillomandibular
the patient’s left and right porions in correct asymmetries that would be otherwise difficult to
alignment and the patients head is in the opti- detect. Indeed, if a left and right side asymmetry
mal position, results in this double image due to exists, it is possible to generate a lateral cepha-
differential projection between left and right lometric view of each side for independent anal-
sides. It is impossible to determine whether the ysis. Further, visualization presets and manual
double structure is caused by a true skeletal adjustments allow for optimal visualization of
asymmetry or a radiographic artifact, on the re- soft and hard tissues. In the latter, this is a
sultant image. With CBCT, this projectional valuable feature as some osseous structures dif-
magnification is computationally corrected dur- fer considerably in their location and density.
ing primary reconstruction, creating an orthog- For example, visualization parameters for the
60 Mah et al

nasal bones are very different from that of the

internal cranial base structures.
Frontal cephalogram films have been limited
in their use for the examination of facial asym-
metry. The quality of posteroanterior cephalo-
grams are usually compromised because of su-
perimposition of the vertebral column and the
occiput causing limited visualization, and resul-
tant images are very subjective relative to head
position. The major advantages of CBCT-gener-
ated frontal cephalograms are 2-fold: (1) the
ability to perform volume operations for exci-
sion of extraneous portions of the cervical spine
and occipital bone thereby avoiding superimpo-
sition of irrelevant structures, and (2) the ability
to reposition the head into an ideal position in
all 3 planes of space before generation of a Figure 2. CBCT DICOM data volumetric reconstruc-
posterior-anterior cephalogram. As with the lat- tion of the maxillomandibular relationship relative to
eral CBCT view, the CBCT frontal cephalogram cranial base. (Color version of figure is available online.)
is orthogonal without projection effects and pro-
vides a remarkably clear image of pertinent max-
illofacial structures and thus creating a more lar structures relative to the cranial base (Fig 2).
accurate representation of cranial relationships. These images allow surface inspection of the
Conventional panoramic radiographs have osseous morphology of the jaws and external
been accepted as a relative indicator of root soft tissue while preserving the internal root po-
position during orthodontic treatment. How- sition, inferior alveolar nerve, and airway informa-
ever, the geometrics and physics of a film-based tion. A fundamental understanding of craniofacial
panoramic radiograph, and even digital pan- growth and development is very important to or-
oramic radiograph, provide skewed and dis- thodontists for predicting treatment outcomes
torted views of the dentition, depending on and stability. Much of this knowledge was devel-
which part of the dental arch a clinician is view- oped by the use of a longitudinal data based on 2D
ing. Studies on the accuracy of tooth tip uni- radiological film (eg, Bolton-Brush Growth Center
formly indicate that a panoramic image is highly Study Center, Burlington Growth Centre for
unreliable.26,27 Volumetric views of the dental Craniofacial Growth, Michigan Growth Study).
roots with enhanced 3-D software provide accu- CBCT offers unique research opportunities to re-
rate representation of individual dental root po- visit concepts of growth and development, espe-
sition, alveolar bone support, and relative ap- cially with the ever-increasing popularity of CBCT
proximation to adjacent crowns and roots. The use in orthodontic private practices. For example,
ability to digitally rotate and view an object in all a conventional lateral cephalogram may reveal re-
dimensions is very useful in determining the modeling changes on the anterior and posterior
relationship of mixed dentition, supernumerary surface of the vertical mandibular ramus but only
teeth, or impacted teeth. CBCT can show transverse changes using the same
Therefore, although CBCT software can rep- dataset without additional x-rays (Fig 3).
licate existing 2D planar images that most clini-
cians are accustomed to, clinicians are only just
3D Review of the Dentition
beginning to learn how to take advantage of the
full potential of 3D imaging using CBCT. CBCT offers a comprehensive view of the denti-
tion and is very useful for identifying missing
teeth, impacted teeth, supernumerary teeth,
Skeletal Views
stage of dental development and eruption se-
The volumetric 3D skeletal view is a new method quence, tooth size measurements, and root ab-
to visualize the relationships of maxillomandibu- normalities that could hinder or prevent tooth
 Advanced Applications of CBCT in Orthodontics 61

Figure 3. Segmentations of mandibular structure showing transverse dimensions. (A) Lateral, (B) oblique, and
(C) transverse. (Color version of figure is available online.)

movement. The best approach for evaluation of contra lateral side. In addition, there are no
the dentition is perhaps use of the volumetric projection artifacts, such as the burnout area
views and clipping operations which allow for often observed in the anterior region.
rapid review of the entire dentition and 3D lo- Left and right tooth pair views are used to
calization of individual teeth, especially those check for asymmetries and to verify the posi-
that are impacted (Fig 4). In the mixed denti- tions of the roots relative to the buccal and
tion, these projections effectively illustrate all lingual cortical plates of alveolar bone support
erupted, erupting, and developing teeth, their
(Fig 6). Some patients have alarmingly thin
relative positions, and the overall formation of
alveolar bone around the roots. Early identifi-
root structures in all 3 planes of space (Fig 5).
Thus, CBCT certainly improves the ability of the cation of this condition, which would not be
clinician to manage tooth eruption and to pro- noticed in traditional orthodontic records, al-
vide intervention as required. lows the orthodontist to make better treat-
The panoramic view of the dentition from ment decisions and to seek interdisciplinary
CBCT is similar to a traditional panoramic x-ray, collaboration if necessary. Volumetric analysis
but is remarkably clearer because there is no of a region of interest can also be used by oral
superimposition of the spinal column and the surgeon colleagues to assess cortical bone
62 Mah et al

thickness in planned areas of orthognathic

surgical cuts/splits (eg, bilateral sagittal split
osteotomy; Fig 7).
The frontal views of the dental arches enable
the clinician to assess vertical and transverse di-
mensions and volume, and to evaluate interarch
discrepancies and vertical limits of tooth move-
ment. The frontal view can be correlated with
temporomandibular joint (TMJ) views to show
the relationship of the TMJs to the intercuspal
positions. The occlusal views of the arches reveal

Figure 5. Dental morphology and development visu-

alization in a mixed dentition case. (Color version of
figure is available online.)

relative tooth positions and the shape of the

alveolar bone support.
Conventional radiological imaging, such as
pantomography and other dental films for vi-
sualizing root resorption, has severe limita-
tions.28-30 In contrast, root resorption is readily
observed in CBCT images, and the clarity of
images allows for classification by root resorp-

Figure 4. Volumetric views of impacted canines and

their positional relationship to adjacent teeth in both
maxillary and mandibular arches (A) Frontal and (B Figure 6. Left and right tooth-pair analysis to com-
and C) oblique views to better visualize the impacted pare root torque and symmetry of tooth inclination.
canine crown (B) and its root (C). (Color version of Note enostosis adjacent to the root apex of the left
figure is available online.) mandibular first molar.
 Advanced Applications of CBCT in Orthodontics 63

Common treatments include biteplates to ex-

trude posterior teeth or intrusion arches to in-
trude the maxillary anterior teeth to reduce the
degree of overbite. However, clarity of a CBCT
cross-sectional view of the incisors reveals the
exact contours of the maxilla relative to the
incisor apices to the maxillary central incisors
and can reveal the limited available distance in
the vertical dimension for intrusion (Fig 10). In
these situations, extrusion of the posterior teeth
to address the deep bite would be a more appro-
priate treatment to avoid damage to the apices
of the central incisors compressing against the
dense bone of the nasal floor.

Alveolar Ridge Shape and Volume

In this category, CBCT offers enormous advan-
tages compared with conventional images for
the evaluation of dentoalveolar arch form, alve-
olar volume, lesions within the alveolus, and
Figure 7. Cross section of a mandible in the molar
cortical bone density. A recent study described
region to assess cortical bone thickness, which may be the use of CBCT occlusal images to select arch
especially useful in the prediction of favorable or wire forms (Wolff M, Mah J, manuscript in prep-
unfavorable splits during treatment planning for or- aration). Arch form tracings are typically made
thognathic surgery cases. (Color version of figure is at the height of the alveolus, but can be modi-
available online.)
fied according to the user’s preference. The
arch forms can then be superimposed to reveal
tion type (Fig 8). For multiroot teeth, resorption discrepancies or compatibility and can be
can be located to a specific root. printed at full size for selection and fabrication
The multidimensional nature of volumetric of arch wires. Other emerging uses of these im-
imaging allows for comprehensive visualization ages are for arch-length measurements and
of the dentition and recognition of some of the identifying tooth size discrepancies using the
limits of tooth movement. Many of these situa- Bolton analysis.
tions are not visualized with traditional orth-
odontic records. Enostosis, condensing osteitis,
dense bone island, and focal apical osteopetro-
sis31 are radiopaque lesions noted near the api-
ces of teeth and which appear to have no etio-
logic causative factors. Bsoul et al32 have noted a
very high predilection of these lesions being
noted in the mandible, that is, between 88% and
100%. These lesions may prevent tooth move-
ment but may not be readily visualized on a
panoramic radiograph (Fig 9). In these situa-
tions, space closure or establishment of proper
root tip or torque may not be possible and if
biomechanical forces are applied to move the
adjacent tooth against the dense lesion, external Figure 8. The use of 3D software to visualize specific
sites of root resorption: in this particular case, the
apical root resorption will likely result. compromised root of the upper left lateral incisor
A more common clinical orthodontic situa- during recovery of an adjacent impacted canine.
tion is a patient who presents with a deep bite. (Color version of figure is available online.)
64 Mah et al

Figure 9. Patient with enostosis in the interradicular area between the lower right second bicuspid and first
molar. Conventional 2D lateral cephalogram (A) and panoramic radiograph (B) do not show this radiographic
finding. The CBCT views of the same patient (C) make it possible to visualize the pathologic lesion in all 3 planes
(axial, sagittal, coronal) and in the volumetric reconstruction. White arrows in each panel identify the location
of the osseous lesion. (Color version of figure is available online.)

Traditional orthodontic records do not allow surface irregularities sometimes extend deep
assessment of bone volume. Evaluation of alveo- into the alveolus between the roots, their accu-
lar bone volume is important for all orthodontic rate identification is of great benefit to the or-
patients, especially in adults and periodontally thodontist in treatment planning. Of particular
compromised patients. Surface irregularities importance is the ability to assess bone width to
due to ectopic teeth, bone dehiscences, salivary determine adequate alveolar ridge width to al-
gland invaginations, and other abnormalities low for tooth movements. In some individuals
can be visualized on the 3D images. Misch et al33 the alveolus is exceedingly narrow, increasing
suggest that assessment of alveolar bone height the risk of complications during tooth move-
using CBCT imaging is superior to traditional ment, such as external apical root resorption
periodontal probing techniques. Because these and bone dehiscence.34
 Advanced Applications of CBCT in Orthodontics 65

types of biomechanics, such as torquing or pro-

traction or retraction of teeth through the af-
fected area. Caution is required when this type
of lesion is encountered in a 3D evaluation. In a
case report, Marques-Silva et al39 described an
idiopathic osteosclerotic lesion which resulted in
significant root resorption during tooth move-
ment. The lesion indirectly caused resorption of
the molar root by deflecting the eruption path
of the premolar directly into the molar.
For placement of TADs, CBCT allows for vi-
sualization of the interproximal root space, pal-
atal cortical bone thickness, sinus morphology,
and other critical structures for proper selection
Figure 10. CBCT sagittal cross-sectional view of a pa- of TAD length. In addition, assessment of bone
tient with a deep overbite. Unlike conventional lateral density is possible from the volumetric data
cephalograms where the maxillary incisor apices are which allows selection of an ideal site for place-
difficult to discern, the CBCT images provide clear
ment of TADs.
anatomical relationships. Here, the maxillary incisor
apex is approximating the dense maxillary cortical
bone and any attempts for intrusion would signifi-
cantly increase the risk of root resorption. Temporomandibular Joints
CBCT is particularly useful for evaluation of the
CBCT allows for visualization within the alve- temporomandibular joints.40-42 The joints may
olar bone volume for sclerotic phenomenon be visualized in volumetric views as well as sec-
that produce local intra-alveolar bone densities tional views (Fig 12). Within the latter, the TMJ
which vary in size from a diameter of 2 to 3 mm images can be obtained in planes parallel or
to 1 to 2 cm35,36 (Fig 11). A very high proportion perpendicular to the long axis of the condyle in
of the lesions, between 88% and 100%, are addition to the conventional coronal and sagittal
found in the mandible.37 Within the mandible, planes. This provides comparability of TMJ im-
most of the lesions are noted in the premolar ages of the bony components on all planes. De-
and molar region.34,38 An orthodontist may use velopmental and pathologic changes can be de-
this valuable information to preclude certain tected using the lateral views. The central lateral

Figure 11. Identification of sclerotic phenomenon that produce local intra-alveolar bone densities on the left
side and right side of the mandible, visible using nonoverlapping independent visualization properties of 3-D
software. Note the extent of osseous sclerosis is much more pronounced adjacent and below the molars on the
patient’s left side (B).
66 Mah et al

Figure 12. A TMJ report series generated with user-defined directional axial and coronal tomographic slices of
the condyle and glenoid fossa. (Color version of figure is available online.)

view defines the true position of the condyle in offered a diagnostic specificity of 0.95 ⫾ 0.05
the fossa, which often reveals possible displace- compared with conventional panoramic radiog-
ment of the disk in the joint. Coronal views of raphy (0.64 ⫾ 0.11), TMJ-specific panoramic ra-
TMJ are difficult to obtain precisely and clearly diography (0.55 ⫾ 0.11) and tomograms (0.58 ⫾
with conventional techniques. High resolution 0.15).43
and unobscured coronal views of the joints are
available with CBCT. Volume rendered views
provide general overview of the TMJ, which is of
Sinuses and Airway Evaluation
value in patients with trauma, severe morpho-
logic abnormalities or for surgical planning. The Use of CBCT for the assessment of the sinuses
large field of view CBCT devices allow for visu- and airway is emerging as a major application for
alization of adjacent structures, such as the sty- the technology44 (Fig 13). This information is
lohyoid ligaments, cervical spine and other ana- particularly relevant to the orthodontist because
tomic regions that may be responsible for mouth breathing and consequent airway ob-
referred pain to the TMJ. Functional shifts can struction is considered an etiology of malocclu-
occasionally be detected because views can be sion. Unfortunately, the traditional orthodontic
correlated with the occlusal views differences records do not allow for comprehensive evalua-
between the left and right TMJ as they are all tion of the airways. Indeed, a review of 500 pa-
generated from the same dataset. The diagnostic tients imaged by CBCT showed that approxi-
specificity of CBCT for the evaluation of the TMJ mately 25% have significant airway findings.11
has been studied and it seems to be a significant Detailed views of the sinuses and the maxillary
improvement over conventional means. CBCT osteum are readily available.
 Advanced Applications of CBCT in Orthodontics 67

Figure 13. A virtual representation of a complete airway passage (nasopharynx, oropharynx, and hypopharynx)
segmented from a CBCT DICOM dataset. (Color version of figure is available online.)

In addition, adult patients presenting for airway and its lateral dimension were signifi-
orthodontic treatment may be suffering from cantly smaller in sleep apnea cases. When mul-
snoring and sleep apnea. Evaluation of airway tivariate logistic regression analyses were used,
patency or obstruction is often a factor in decid- they found that patients older than 57 years of
ing between orthodontic and orthognathic ther- age, male patients, those with a high-risk score
apies. The most commonly skeletal abnormalities on the Berlin Questionnaire, and those with
in obstructive sleep apnea patients according to narrow upper airway lateral dimension (⬍17
Schwab45 are (1) mandibular and maxillary defi- mm) were identified having as significant risk
ciency, (2) reduced dimension of the posterior factors for obstructive sleep apnea.47,48
airway space (measured at the base of the tongue),
(3) enlarged tongue, (4) enlarged soft palate, and
Facial Analysis
a (5) caudally displaced hyoid. CBCT allows the
clinician to obtain anteroposterior and lateral A conventional facial photograph is a simple 2D
views of these parameters encompassing the up- representation that is not correlated with the
per airway, soft palate, tongue, and hypopharyn- supporting skeleton. New software features now
geal anatomical structures. Researchers who enable facial photos (either 2D or 3D) to be
used specialized software found sleep apnea pa- morphed onto a DICOM dataset using nodal
tients had a smaller anterioposterior dimension mapping algorithms, and the 3D volume can
(mm) of the minimum cross section segment generate a simulated 3D projection of the face
and smaller minimum cross section area posi- in any frontal, lateral, or user-defined view of the
tioned always retropalatal, compared with con- face. By changing the translucency of the image,
trol patients. There were no significant differ- one can determine the specific relationship of
ences in upper airway volume between the 2 the soft tissues to the skeleton (Fig 14). This has
groups.46 In a recent study by the same authors, significant implications in the planning of tooth
the minimum cross-sectional area of the upper movements, orthognathic surgery, or other
68 Mah et al

3D Superimposition
An interesting and useful function of 3D soft-
ware rendering is the ability to superimpose 2
volumes using operator-defined landmarks or
mapping cranial structures (e.g., entire surface
of the cranial base or along the anterior cranial
fossae).49 Traditional 2D superimposition in-
volves use of a combination of landmarks, ana-
tomic contours, and planes to achieve optimal
results. Software tools have been developed to
optimally align 3D CBCT datasets at different
time points with subvoxel accuracy after identi-
fication of the cranial base structures. The com-
puted registration is then applied to the seg-
mented structures to measure changes with time
or treatment procedures. Surface distance calcu-
lations can be applied to accurately quantify dis-
placement with growth or treatment. Semiquan-
titative color mapping can show surface area
distance differences of the 2 3D objects (Fig 15).
The visualization of 3D model superimposition
and the surface distance calculations can be
used to identify treatment outcomes and post-
treatment stability.

Cleft Lip and Palate (CLP)

CBCT offers many unique advantages for imag-
ing of patients with CLP. The rapid acquisition
time ranging from 5.7 to 40 seconds is a tremen-
dous advantage for young patients and for pa-
tients who have difficulty remaining stationary.
The much lower radiation dose for the patient is
Figure 14. Facial photos superimposed onto a 3D
volumetric skeletal rendering. Nodal mapping and
stereophotogrammetry morphing enable the photos
to be visualized and be manipulated in 3D. (Color
version of figure is available online.)

craniofacial therapies that could alter facial ap-

pearance.
In this regard, one must be aware that the
appearance of soft tissue may vary slightly de-
pending on the architecture of the CBCT device
(ie, image capture of the patient in a supine
position compared with units that have the pa-
tient seated or standing up). In addition, use of
certain head-stabilizing devices, such as a forehead
Figure 15. Superimposition of 2 structures and quan-
rest or chin cup may distort soft tissues of the face. titative color-mapping enables the comparison of 3D
Deep recessed head rests and circumferential objects at different time points to assess longitudinal
head straps seem to work well in orthodontics. growth. (Color version of figure is available online.)
 Advanced Applications of CBCT in Orthodontics 69

Figure 16. Digital dental models can be extracted from a DICOM dataset to simulate orthodontic study models.
Computer simulation can also determine points of occlusal contact, as well as simulation of jaw motion and
articulating movement. (Color version of figure is available online.)

favorable for subsequent imaging sessions and Modeling and Therapeutic Applications
decreases the total cumulative radiation dose
Digital Study Models
compared with serial medical CT scans. Medical
CT has been used for visualization of cleft pal- 3D study models of the dentition now can be
ates28 and other anomalies but there is concern obtained by intra- and extraoral imaging tech-
for single and cumulative exposure to young nologies. Intraoral scanning devices can accen-
patients.50 Recent improvements in CBCT fea- tuate detailed crown anatomy but is limited re-
tures of resolution, soft-tissue contrast, and spe- garding the location or relationship of the roots
cialized reconstruction algorithms for the head of the teeth and their relationships with other
and neck region, along with a significantly re- anatomic structures. CBCT imaging offers study
duced radiation exposure, make it a preferred models that display individual crowns and roots,
imaging modality of choice for CLP patients. In although the accuracy of the crowns can vary
depending on various factors, such as imaging
addition, the image quality is generally superior
device, patient movement and metallic artifacts
to that of medical CT allowing for detailed visu-
(Fig 16).
alization of the cleft region. CLP patients often
Future developments to produce 3D dynamic
have supernumerary teeth and malformed teeth
models51 can be used to analyze and predict the
in the anterior maxilla. This region is very diffi- interaction between structure and function. Cus-
cult to image with traditional dental films. For tomized patient representation using dynamic
osteoplasties, CBCT provides valuable informa- 3D modeling of motion will become a valuable
tion on the morphology of the bone defect, the tool in advanced dental applications.
proximity of adjacent teeth, and assessment of
the size and volume of the bony defect, allowing
clinicians to estimate the amount of bone re- Conclusions
quired to repair the defect. This aspect can play A comprehensive review of orthodontic analysis
a decisive role in surgical treatment planning, with CBCT imaging has been described, and this
especially in cleft patients requiring autologous article is not intended to be limited or dogmatic.
bone graft and other surgical procedures. Rather, the goal is to introduce clinicians to the
70 Mah et al

vast potential for 3D imaging and to stimulate 12. Walker L, Enciso R, Mah J: Three-dimensional localization of
their interest in enhancing an understanding of maxillary canines with cone-beam computed tomography.
Am J Orthod Dentofacial Orthop 128:418-423, 2005.
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directive is to extract pertinent details from the opment of a compact computed tomographic apparatus
image volume and to provide the orthodontist for dental use. Dentomaxillofac Radiol 4:245-248, 1999
with clinical applications using this information. 14. Guerrero ME, Jacobs R, Loubele M, et al: State-of-the-art
on cone beam CT imaging for preoperative planning of
Because of lower radiation exposure compared
implant placement. Clin Oral Invest 10:1-7, 2006
with CT imaging and the ease with which it can 15. Heiland M, Schulze D, Blake F, et al: Intraoperative imaging
be manipulated intraoperatively, CBCT imaging of zygomaticomaxillary complex fractures using a 3D C-arm
will find increasing acceptance and application system. Int J Oral Maxilllofac Surg 34:369-375, 2005
in the diagnosis and treatment, with a subse- 16. Holberg C, Steinhauser S, Geis P, et al: Cone-beam
computed tomography in orthodontics: benefits and
quent phasing out of conventional radiographs.
limitations. J Orofac Orthop 66:434-444, 2005
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to enhance the precision and effectiveness of volume tomography in orthodontics. J Orofac Orthop
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18. Hatcher DC, Aboudara CL: Diagnosis goes digital. Am J
Orthod Dentofac Orthop 125:512-515, 2004
19. Mah J, Sachdeva R: Computer-assisted orthodontic treat-
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