Clinical recommendations regarding use of cone beam computed tomography in orthodontics. Position statement by the American Academy of Oral and Maxillofacial Radiology

doi:10.1016/j.oooo.2013.06.002

Oral and maxillofacial radiology| Volume 116, ISSUE 2, P238-257, August 2013

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Clinical recommendations regarding use of cone beam computed tomography in orthodontics. Position statement by the American Academy of Oral and Maxillofacial Radiology

American Academy of Oral and Maxillofacial Radiology
∗

Open AccessDOI:https://doi.org/10.1016/j.oooo.2013.06.002

Aims

To summarize the potential benefits and risks of maxillofacial cone beam computed tomography (CBCT) use in orthodontic diagnosis, treatment and outcomes and to provide clinical guidance to dental practitioners.

Methods

This statement was developed by consensus agreement of a panel convened by the American Academy of Oral and Maxillofacial Radiology (AAOMR). The literature on the clinical efficacy of and radiation dose concepts associated with CBCT in all aspects of orthodontic practice was reviewed.

Results

The panel concluded that the use of CBCT in orthodontic treatment should be justified on an individual basis, based on clinical presentation. This statement provides general recommendations, specific use selection recommendations, optimization protocols, and radiation-dose, risk-assessment strategies for CBCT imaging in orthodontic diagnosis, treatment and outcomes.

Conclusions

The AAOMR supports the safe use of CBCT in dentistry. This position statement is periodically revised to reflect new evidence and, without reapproval, becomes invalid after 5 years.

Malocclusions and craniofacial anomalies adversely affect quality of life. Orthodontics and dentofacial orthopedic treatment address the correction of malocclusions and facial disproportions due to dental/skeletal discrepancies to provide esthetic, psychosocial, and functional improvements. For almost a century, two-dimensional (2D) planar radiographic imaging and cephalometry have been used to assess the interrelationships of the dentition, maxillofacial skeleton, and soft tissues in all phases of the management of orthodontic patients, including diagnosis, treatment planning, evaluation of growth and development, assessment of treatment progress and outcomes, and retention. However, the limitations of 2D imaging have been realized for decades as many orthodontic and dentofacial orthopedic problems involve the lateral or "third dimension."

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For years, multiple radiographic projections were obtained to attempt to display complex anatomic relationships and surrounding structures; however, interpreting multiple-image inputs is challenging. With the increasing availability of multi-slice computed tomography (CT) and, more recently, cone beam computed tomography (CBCT), visualization of these relationships in three dimensions is now feasible.

Scope and Purpose of the Recommendations and Conclusions

This position statement was developed by board-certified orthodontists and oral and maxillofacial radiologists convened by the American Academy of Oral and Maxillofacial Radiology (AAOMR). Their objectives were to 1) review and evaluate critically the current science, guidance and other resources available from professional organizations on the clinical benefits and potential limitations of the use of CBCT in orthodontics, and 2) develop consensus derived, orthodontic-specific clinical guidelines. Imaging selection recommendations, optimization protocols and radiation-dose, risk-assessment strategies were developed to assist professional clinical judgment on the use of CBCT in orthodontics. The panel concluded that there is no clear evidence to support the routine use of ionizing radiation in standard orthodontic diagnosis and treatment planning, including the use of CBCT.

Background

Imaging considerations in orthodontic therapy

One purpose of radiographic imaging in orthodontics is to supplement clinical diagnosis in the pretreatment assessment of the orthodontic patient. Radiographic imaging may also be performed during treatment to assess the effects of therapy and posttreatment to monitor stability and outcome. Imaging for a specific orthodontic patient occurs in at least three 3 stages: 1) selection of the most appropriate radiographic imaging technique, 2) acquisition of appropriate images, and 3) interpretation of the images obtained. In some instances, these steps need to be repeated. Selection of the appropriate radiographic imaging technique (or techniques) is based on the principle that practitioners who use imaging with ionizing radiation have a professional responsibility of beneficence-that imaging is performed to "serve the patient's best interests." This requires that each radiation exposure is justified clinically and that procedures are applied that minimize patient radiation exposure while optimizing maximal diagnostic benefit. The extension of this principle, referred to as the "as low as reasonably achievable" (ALARA),

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CBCT imaging in orthodontics

There has been a dramatic increase in the use of CBCT in dentistry over the last decade. This technology has found particular applications in orthodontics for diagnosis and treatment planning for both adult and pediatric patients.

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CBCT imaging provides two unique features for orthodontic practice. The first is that numerous linear (e.g., lateral and posteroanterior cephalometric images) or curved planar projections (e.g., simulated panoramic images) currently used in orthodontic diagnosis, cephalometric analysis, and treatment planning can be derived from a single CBCT scan. This provides for greater clinical efficiency. The second, and most important, is that CBCT data can be reconstructed to provide unique images previously unavailable in orthodontic practice. Innately CBCT data are presented as inter-relational undistorted images in three orthogonal planes (i.e., axial, sagittal, and coronal); however, software techniques are readily available (e.g., maximum intensity projection and surface or volumetric rendering) that provide three-dimensional visualization of the maxillofacial skeleton, airway space and soft tissue boundaries such as the facial outline. The current diagnostic uses of CBCT are summarized in Appendix A.

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Palomo J.M.

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Schendel S.A.
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Oh K.M.
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Kim Y.J.
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Park Y.H.

Three-dimensional analysis of pharyngeal airway form in children with anteroposterior facial patterns.

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Abramson Z.
Susarla S.M.
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Farronato G.
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et al.

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Raffaini M.
Pisani C.

Clinical and cone-beam computed tomography evaluation of the three-dimensional increase in pharyngeal airway space following maxillo-mandibular rotation-advancement for Class II-correction in patients without sleep apnoea (OSA).

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Alsufyani N.A.
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Gracco A.
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Siciliani G.

Quantitative cone-beam computed tomography evaluation of palatal bone thickness for orthodontic miniscrew placement.

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Kim G.T.
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Choi Y.S.
et al.

Cone-beam computed tomography evaluation of orthodontic miniplate anchoring screws in the posterior maxilla.

^,

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Park J.
Cho H.J.

Three-dimensional evaluation of interradicular spaces and cortical bone thickness for the placement and initial stability of microimplants in adults.

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Kim S.H.
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Choi Y.S.
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Nelson G.

Evaluation of interdental space of the maxillary posterior area for orthodontic mini-implants with cone-beam computed tomography.

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Baumgaertel S.

Quantitative investigation of palatal bone depth and cortical bone thickness for mini-implant placement in adults.

^,

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Baumgaertel S.
Hans M.G.

Buccal cortical bone thickness for mini-implant placement.

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Baumgaertel S.
Hans M.G.

Assessment of infrazygomatic bone depth for mini-screw insertion.

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Kau C.H.
English J.D.
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Hamid H.
Ellis R.K.
Winklemann S.

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Park H.S.
Hwangbo E.S.
Kwon T.G.

Proper mesiodistal angles for microimplant placement assessed with 3-dimensional computed tomography images.

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Fayed M.M.
Pazera P.
Katsaros C.

Optimal sites for orthodontic mini-implant placement assessed by cone beam computed tomography.

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Morea C.
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Precise insertion of orthodontic miniscrews with a stereolithographic surgical guide based on cone beam computed tomography data: a pilot study.

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Qiu L.
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Accuracy of orthodontic miniscrew implantation guided by stereolithographic surgical stent based on cone-beam CT-derived 3D images.

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Garrett B.J.
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Christie K.F.
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Chung C.H.

Effects of bonded rapid palatal expansion on the transverse dimensions of the maxilla: a cone-beam computed tomography study.

^,

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Tai K.
Park J.H.

Dental and skeletal changes in the upper and lower jaws after treatment with Schwarz appliances using cone-beam computed tomography.

^,

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Domann C.E.
Kau C.H.
English J.D.
Xia J.J.
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Lee R.P.

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Baratieri C.
Alves Jr., M.
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Baysal A.
Karadede I.
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Evidence based assessments

The potential for extracting additional diagnostic information from volumetric imaging and the technical ease of obtaining scans has led some clinicians and manufacturers to advocate the replacement of current conventional imaging modalities with CBCT for standard orthodontic diagnosis and treatment.

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Hechler S.L.

Cone-beam CT: applications in orthodontics.

^,

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Mah J.K.
Huang J.C.
Choo H.

Practical applications of cone-beam computed tomography in orthodontics.

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Silva M.A.
Wolf U.
Heinicke F.
Bumann A.
Visser H.
Hirsch E.

Cone-beam computed tomography for routine orthodontic treatment planning: a radiation dose evaluation.

^,

¹⁶⁰

Larson B.E.

Cone-beam computed tomography is the imaging technique of choice for comprehensive orthodontic assessment.

Although CBCT imaging increases clinician confidence in orthodontic diagnosis

¹⁶¹

Hodges R.J.
Atchison K.A.
White S.C.

Impact of cone-beam computed tomography on orthodontic diagnosis and treatment planning.

and has demonstrated clinical efficacy in altering treatment planning for impacted maxillary canines,

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Bjerklin K.
Ericson S.

How a computerized tomography examination changed the treatment plans of 80 children with retained and ectopically positioned maxillary canines.

^,

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Haney E.
Gansky S.A.
Lee J.S.
et al.

Comparative analysis of traditional radiographs and cone-beam computed tomography volumetric images in the diagnosis and treatment planning of maxillary impacted canines.

^,

¹⁶¹

Hodges R.J.
Atchison K.A.
White S.C.

Impact of cone-beam computed tomography on orthodontic diagnosis and treatment planning.

unerupted teeth, severe root resorption, and severe skeletal discrepancies,

¹⁶¹

Hodges R.J.
Atchison K.A.
White S.C.

Impact of cone-beam computed tomography on orthodontic diagnosis and treatment planning.

no benefit has been demonstrated for patients specifically referred for abnormalities of the temporomandibular joint, airway assessment or dental crowding.

¹⁶¹

Hodges R.J.
Atchison K.A.
White S.C.

Impact of cone-beam computed tomography on orthodontic diagnosis and treatment planning.

Despite the number of publications on the use of CBCT for specific orthodontic applications, most are observational studies of diagnostic performance and efficacy with wide ranging methodological soundness.

¹⁶²

van Vlijmen O.J.
Kuijpers M.A.
Bergé S.J.
et al.

Evidence supporting the use of cone-beam computed tomography in orthodontics.

Few authors have presented higher levels of evidence and measured the impact of CBCT on orthodontic diagnosis and treatment planning decisions.

Fundamentals to guideline development are systematic reviews of the published literature. Systematic reviews use well-defined and reproducible literature search strategies to identify evidence focused on a specific research question. Evidence is graded according to its level of methodological rigor (or quality), relevance and strength. There is a lack of CBCT-orthodontic systematic reviews. There is a need for rigorous investigation on the efficacy of CBCT imaging for all aspects of orthodontics related to its influence on therapy decisions and ultimately patient outcome.

¹⁶³

Fryback D.G.
Thornbury J.R.

The efficacy of diagnostic imaging.

Because of the lack of CBCT-orthodontic systematic reviews, the panel used consensus and published criteria.

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National Health and Medical Research Council of Australia

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Cascade P.N.

The American College of Radiology. ACR Appropriateness Criteria project.

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European Commission. Radiation Protection 136. European Guidelines on Radiation Protection in Dental Radiology. 2004:115. ISBN 92-894-5958-1

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American College of Radiology

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to develop three hierarchical recommendations for CBCT imaging in orthodontics (Table I). An important consideration in the use of CBCT is that ionizing radiation is a risk to patient health.

Table IPanel consensus recommendations for use of CBCT imaging

∗

In the future, if CBCT imaging radiation levels are equivalent to conventional modalities, this table may be less relevant.

Recommendation	Consensus level	Definition
Likely indicated	I	The use of CBCT imaging is indicated in most circumstances for this clinical condition. There is an adequate body of evidence to indicate a favorable benefit from the procedure relative to the radiation risk in the majority of situations.
Possibly indicated	II	The use of CBCT imaging may be indicated in certain circumstances for this clinical condition. There is a sufficient body of evidence to indicate a possible favorable benefit from the procedure relative to the radiation risk in many situations.
Likely not indicated	III	The use of CBCT imaging is not indicated in the majority of circumstances for this clinical condition. There is an insufficient body of evidence to indicate a benefit from the procedure relative to the radiation risk in most situations.

∗ In the future, if CBCT imaging radiation levels are equivalent to conventional modalities, this table may be less relevant.

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Radiation dose considerations in orthodontics

There are two broad potential harmful effects of ionizing radiation in orthodontics. The first is deterministic effects that cause the death of cells from high doses over short periods of time and usually occur only after thresholds are reached. Below these thresholds no clinical change has been reported. These levels are never reached for a single exposure in the diagnostic range used in conventional oral and maxillofacial radiology. They do, however, occur in dental patients who have cancer and undergo radiotherapy to the head and neck region. One example of this is radiation-induced oral mucositis. The second effect is a stochastic effect that irreversibly alters the cells, usually by damaging cellular DNA. Such damage can result in cancer. The long-term risk associated with diagnostic radiographic imaging is radiation-induced carcinogenesis. Unlike deterministic effects, stochastic effects can result from low levels of radiation that are cumulative over time.

Assessment of the risks associated with the use of ionizing radiation for diagnostic imaging is an important public health issue. Recent reports have increased concerns over the potential association between radiation exposure and cancer. In one article, a relationship was found between intracranial meningiomas and dental radiographic procedures

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Claus E.B.
Calvocoressi L.
Bondy M.L.
Schildkraut J.M.
Wiemels J.L.
Wrensch M.

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; however, numerous rebuttal articles have highlighted limitations in this study.

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Jorgensen T.J.

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Most recently, the results of a retrospective cohort study provide evidence of a link between exposure to radiation from medical CT and cancer risk in children.

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Pearce M.S.
Salotti J.A.
Little M.P.
et al.

Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study.

It was found that children and young adults who received radiation doses from the equivalent of 2 or 3 medical CT scans of the head have almost triple the risk of developing leukemia or brain cancer later in life. Medical CT head scans may have an effective dose of up to 2000 μSv

¹⁷⁵

Smith-Bindman R.
Lipson J.
Marcus R.
et al.

Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer.

; however, for CT examinations with dental protocols, substantial reductions to less than 1000 μSv have been reported.

¹⁵⁹

Silva M.A.
Wolf U.
Heinicke F.
Bumann A.
Visser H.
Hirsch E.

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Ludlow J.B.
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Dosimetry of 3 CBCT devices for oral and maxillofacial radiology: CB Mercuray, NewTom 3G and i-CAT.

^,

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Ludlow J.B.
Davies-Ludlow L.E.
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^,

¹⁷⁸

Loubele M.
Bogaerts R.
Van Dijck E.
et al.

Comparison between effective radiation dose of CBCT and MSCT scanners for dentomaxillofacial applications.

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Suomalainen A.
Kiljunen T.
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Peltola J.
Kortesniemi M.

Dosimetry and image quality of four dental cone beam computed tomography scanners compared with multislice computed tomography scanners.

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Okano T.
Harata Y.
Sugihara Y.
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Absorbed and effective doses from cone beam volumetric imaging for implant planning.

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Carrafiello G.
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Jeong D.K.
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Comparison of effective dose for imaging of mandible between multi-detector CT and cone-beam CT.

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SEDENTEXCT Project Consortium
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^,

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Ludlow J.B.
Ivanovic M.

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Most CBCT examinations impart a fraction of medical CT effective dose; however, doses vary considerably among CBCT units.

⁹⁰

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Mallya S.M.

Cone-beam computed tomography to detect erosions of the temporomandibular joint: effect of field of view and voxel size on diagnostic efficacy and effective dose.

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^,

¹⁷⁶

Ludlow J.B.
Davies-Ludlow L.E.
Brooks S.L.
Howerton W.B.

Dosimetry of 3 CBCT devices for oral and maxillofacial radiology: CB Mercuray, NewTom 3G and i-CAT.

^,

¹⁷⁷

Ludlow J.B.
Davies-Ludlow L.E.
White S.C.

Patient risk related to common dental radiographic examinations: the impact of 2007 International Commission on Radiological Protection recommendations regarding dose calculation.

^,

¹⁷⁸

Loubele M.
Bogaerts R.
Van Dijck E.
et al.

Comparison between effective radiation dose of CBCT and MSCT scanners for dentomaxillofacial applications.

^,

¹⁷⁹

Suomalainen A.
Kiljunen T.
Käser Y.
Peltola J.
Kortesniemi M.

Dosimetry and image quality of four dental cone beam computed tomography scanners compared with multislice computed tomography scanners.

^,

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Okano T.
Harata Y.
Sugihara Y.
et al.

Absorbed and effective doses from cone beam volumetric imaging for implant planning.

^,

¹⁸¹

Carrafiello G.
Dizonno M.
Colli V.
et al.

Comparative study of jaws with multislice computed tomography and cone-beam computed tomography.

^,

¹⁸²

Jeong D.K.
Lee S.C.
Huh K.H.
et al.

Comparison of effective dose for imaging of mandible between multi-detector CT and cone-beam CT.

^,

¹⁸³

Theodorakou C.
Walker A.
Horner K.
Pauwels R.
Bogaerts R.
Jacobs R.

SEDENTEXCT Project Consortium
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^,

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Ludlow J.B.
Ivanovic M.

Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology.

^,

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Hirsch E.
Wolf U.
Heinicke F.
Silva M.A.

Dosimetry of the cone beam computed tomography Veraviewepocs 3D compared with the 3D Accuitomo in different fields of view.

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Roberts J.A.
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Qu X.M.
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Ludlow J.B.

A manufacturer's role in reducing the dose of cone beam computed tomography examinations: effect of beam filtration.

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Evaluation of subjective image quality in relation to diagnostic task for cone beam computed tomography with different fields of view.

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Davies J.
Johnson B.
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Effective doses from cone beam CT investigation of the jaws.

^,

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Pauwels R.
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The SEDENTEXCT Project Consortium
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Grünheid T.
Kolbeck Schieck J.R.
Pliska B.T.
Ahmad M.
Larson B.E.

Dosimetry of a cone-beam computed tomography machine compared with a digital X-ray machine in orthodontic imaging.

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Qu X.M.
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Sanderink G.C.
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Koivisto J.
Kiljunen T.
Tapiovaara M.
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Kortesniemi M.

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^,

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Palomo J.M.
Rao P.S.
Hans M.G.

Influence of CBCT exposure conditions on radiation dose.

^,

¹⁹⁶

Schilling R.
Geibel M.A.

Assessment of the effective doses from two dental cone beam CT devices.

Low-dose radiographic procedures (including maxillofacial CBCT) are those that result in doses below about 1,00,000 μSv. The risk of cancer induction caused by low-dose radiographic procedures is difficult to assess. While there is lack of agreement among radiation epidemiologists and radiobiologists, there is consensus among the four authoritative agencies in the United States responsible for developing public-health, radiation-safety directives that for stochastic risks, such as carcinogenesis, the risks should be considered to be linearly related to doses, down to the lowest doses.

¹⁹⁷

Valentin J.

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^,

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Preston D.L.
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The assessment of risk is, however, confounded in that people are exposed to background radiation, including cosmic radiation from airline flights and/or living at high altitudes. For this position statement, the panel reviewed information on the potential health effects of exposure to diagnostic ionizing radiation. There is neither convincing evidence for carcinogenesis at the level of dental exposures, nor the absence of evidence of such damage. This situation is unlikely to change in the near future. In the absence of evidence of a threshold dose, it is prudent, from a patient-policy perspective, to assume that such a risk exists. This implies that there is no safe limit or "safety zone" for ionizing radiation exposure in diagnostic imaging. Every exposure cumulatively increases the risk of cancer induction. Consequently, to be cautious, the guidelines presented in this position statement are focused on minimizing or eliminating unnecessary radiation exposure in diagnostic imaging.

The overall biological effect of exposure to ionizing radiation, expressed as the risk of cancer development over a lifetime, is determined from absorbed radiation dose to specific organs in combination with weighting factors that account for differences in exposed-tissue sensitivity and patient susceptibility factors such as gender and age. For this position statement, the International Commission on Radiological Protection (ICRP)'s effective dose (E) method was used to estimate whole body dose and measure stochastic radiation risks to patients based on evidence of biological effects currently available.

²⁰¹

International Commission on Radiological Protection

1990 recommendations of the International Commission on Radiological Protection, ICRP publication 60.

Effective dose is calculated by multiplying organ doses by risk weighting factors (which are the organs' relative radiosensitivities to developing cancers). The sum of the products for all of the organs is the effective whole-body dose (effective dose).

²⁰¹

International Commission on Radiological Protection

1990 recommendations of the International Commission on Radiological Protection, ICRP publication 60.

The estimated risk weighting factors have recently been revised, and a number of additional tissues found in the head and neck region have been included (most importantly the salivary glands, lymphatic nodes, muscle, and oral mucosa).

¹⁹⁷

Valentin J.

The 2007 recommendations of the International Commission on Radiological Protection. Publication 93.

These modifications have resulted in substantial increases (ranging from 32% to 422%) in effective doses for specific maxillofacial radiographic procedures.

¹⁷⁷

Ludlow J.B.
Davies-Ludlow L.E.
White S.C.

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The effective dose for CBCT radiographic imaging used for orthodontic records is of particular concern, especially as the modal age for initiating orthodontic treatment represents a pediatric population. The radiation risk to ionizing radiation is greater for young children than for adolescents and adults because: 1) the rate of cellular growth and organ development (when radiosensitivity is highest) is greater in young children; 2) children have longer life expectancies, so the cumulative effects of radiation exposures have longer time periods in which they can cause cancers; 3) with CBCT imaging, specific organ and effective doses, (particularly the salivary glands) are, on average, 30% higher for young children than for adolescents

¹⁸³

Theodorakou C.
Walker A.
Horner K.
Pauwels R.
Bogaerts R.
Jacobs R.

SEDENTEXCT Project Consortium
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; and 4) unless specific, pediatric, exposure-reduction techniques are incorporated, the radiation doses for children (small patients) may exceed typical adult radiation levels (with some currently available CBCT units, it is not possible to implement exposure-reduction techniques). In sum, it is estimated that children may be two to ten times or more prone to radiation-induced carcinogenesis than mature adults.

¹⁷⁵

Smith-Bindman R.
Lipson J.
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^,

²⁰²

Brenner D.J.
Elliston C.D.
Hall E.J.
Berdon W.E.

Estimated risks of radiation-induced fatal cancer from pediatric CT.

Because it is important to consider the increased risks associated with exposing children to ionizing radiation, the American College of Radiology (ACR) has incorporated pediatric, effective-dose estimates in relative radiation level (RRL) designations for specific imaging procedures (Table II).

²⁰³

American College of Radiology

ACR Appropriateness Criteria. Radiation Dose Assessment Introduction.

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In addition, there are at least two national radiation safety initiatives to raise awareness of using lower radiation doses to image children: Image Gently

²⁰⁴

The Alliance for Radiation Safety in Pediatric Imaging

Image Gently.

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and the National Children's Dose Registry.

²⁰⁵

American College of Radiology

The Quality Improvement Registry for CT Scans in Children.

Google Scholar

The AAOMR sought, and received, permission to adopt the ACR, relative-radiation-level designations for several reasons: First, this scheme provides a relative assessment of radiation dose risk based on the premise that with an exposure of 10,000 μSv, there is a risk of 1 in 1000 individuals developing cancer; second, the risk is related to diagnostic imaging only (and is unrelated to considerations of background radiation exposure); and three, risk assessment incorporates increased pediatric radiation sensitivity considerations.

Table IIEstimations of relative radiation level designations for children and adults for orthodontic imaging (with permission from ACR,

∗

Some of the information in this document was provided with permission from the American College of Radiology (ACR) and taken from the ACR Appropriateness Criteria. The ACR is not responsible for any deviations from original ACR Appropriateness Criteria content.

2011)

Relative radiation level	Effective dose estimate range (μSv)
Relative radiation level	Adult	Child ^† Child is defined as any individual less than 18 years of age.
0	0	0
	<100	<30
	100-1000	30-300
	1000-10,000	300-3000
	10,000-30,000	3,000-10,000

∗ Some of the information in this document was provided with permission from the American College of Radiology (ACR) and taken from the ACR Appropriateness Criteria. The ACR is not responsible for any deviations from original ACR Appropriateness Criteria content.

† Child is defined as any individual less than 18 years of age.

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For all imaging procedures using ionizing radiation, the clinical benefits should be balanced against the potential radiation risks, which are determined by the relative radiosensitivity of those being imaged and the abilities of the operators to control radiation exposures.

Guidelines for CBCT in Orthodontics

The choice of modality used for imaging an orthodontic patient is based on a risk/benefit assessment (i.e., the risk to the patient attributable to radiation exposure in relationship to the benefit to the patient from imaging procedure). Assessment of clinical benefit is primarily patient and practitioner dependent but should be based on the application of sound imaging selection principles. As part of this position statement, the following guidelines are suggested for the use of CBCT in orthodontics:

1.
Image appropriately according to clinical condition
2.
Assess the radiation dose risk
3.
Minimize patient radiation exposure
4.
Maintain professional competency in performing and interpreting CBCT studies

1 Image appropriately according to clinical condition

Recently the American Dental Association Council on Scientific Affairs issued an advisory statement on the use of CBCT in dentistry. The AAOMR contributed to the statement,

⁶

American Dental Association Council on Scientific Affairs

The use of cone-beam tomography in dentistry. An advisory statement from the American Dental Association Council on Scientific Affairs.

which is based on the ALARA principle and acknowledges the increased sensitivity of pediatric patients to ionizing radiation and recognizes that patients present with varying degrees of orthodontic complexity. The panel recommends the following general strategies for the use of CBCT in orthodontics:

Recommendation 1.1

The decision to perform a CBCT examination is based on the patient's history, clinical examination, available radiographic imaging, and the presence of a clinical condition for which the benefits to the diagnosis and/or treatment plan outweigh the potential risks of exposure to radiation, especially in the case of a child or young adult.

Recommendation 1.2

Use CBCT when the clinical question for which imaging is required cannot be answered adequately by lower-dose conventional dental radiography or alternate non-ionizing imaging modalities.

Recommendation 1.3

Avoid using CBCT on patients to obtain data that can be provided by alternate non-ionizing modalities (e.g., to produce virtual orthodontic study models).

Recommendation 1.4

Use a CBCT protocol that restricts the field of view (FOV), minimizes exposure (mA and kVp), the number of basis images, and resolution yet permits adequate visualization of the region of interest.

Recommendation 1.5

Avoid taking a CBCT scan solely to produce a lateral cephalogram and/or panoramic view if the CBCT would result in higher radiation exposure than would conventional imaging.

Recommendation 1.6

Avoid taking conventional 2D radiographs if the clinical examination indicates that a CBCT study is indicated for proper diagnosis and/or treatment planning or if a recent CBCT study is available.

To assist clinicians in defining the scope of orthodontic conditions and the most appropriate CBCT imaging in each circumstance, specific imaging selection recommendations for the use of CBCT in orthodontics are given in Table III. The proposed recommendations include the phase of treatment (pre-, during-, or post-treatment), the treatment difficulty and the presence of additional skeletal and dental conditions. The table rows list orthodontic phases of treatments and treatment difficulty categories and columns list dental and skeletal clinical conditions. Within each cell, the overall suitability of the CBCT procedure (Table I) and most appropriate FOV are provided. Table IV describes the three FOV ranges most commonly encountered in orthodontic imaging. The concerns in selecting a CBCT FOV are the inclusion of the region of clinical importance and the collimation of the radiation beam to that specific region. The rational for orthodontic image selection recommendations is in Appendix B.

Table IIIImaging selection recommendations for the use of cone beam computed tomography in orthodontics

Presentation		Dental and skeletal clinical conditions
Primary	Treatment difficulty	None	Dental structure anomalies	Anomalies in dental position	Compromised dento-alveolar boundaries	Asymmetry	Anteroposterior discrepancies	Vertical discrepancies	Transverse discrepancies	TMJ signs and/or symptoms
Pretreatment	Mild	III	FOV_S (I)	FOV_S (I)	FOV_s,m (II)	FOV_m,l (II)	FOV_m,l (II)	FOV_m,l (II)	FOV_m,l (II)	FOV_s,m (III)
	Moderate	FOV_m,l (II)	FOV_S (I)	FOV_S (I)	FOV_s,m (II)	FOV_m,l (II)	FOV_m,l (II)	FOV_m,l (II)	FOV_m,l (II)	FOV_m,l (II)
	Severe	FOV_l (II)	FOV_S (I)	FOV_S (I)	FOV_s,m (II)	FOV_m,l (II)	FOV_m,l (II)	FOV_m,l (II)	FOV_m,l (II)	FOV_m,l (II)
During treatment		III	FOV_S (III)	FOV_S (II)	FOV_s,m (II)	Presurgical FOV_m,l (I)	Presurgical FOV_m,l (II)	Presurgical FOV_m,l (II)	Presurgical FOV_m,l (II)	FOV_m,l (II)
Posttreatment		III	FOV_S (III)	FOV_S (III)	FOV_s,m (III)	FOV_m,l (II)	FOV_m,l (II)	FOV_m,l (II)	FOV_m,l (II)	FOV_m,l (II)

CBCT, cone beam computed tomography; Field of View (FOV): FOV_s = Small FOV CBCT imaging; FOV_m = Medium FOV CBCT imaging; FOV_l = Large FOV CBCT imaging. Consensus Recommendations: I = Likely Indicated; II = Possibly Indicated; III = Likely Not Indicated.

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Table IVDefinition of cone beam computed tomography field of view (FOV) ranges for orthodontic imaging

FOV	Abbreviation	Definition
Small	FOV_s	A region of radiation exposure that is limited to a few teeth, a quadrant, and up to two dental arches and that has a spherical volume diameter or cylinder height ≤10 cm.
Medium	FOV_m	A region of radiation exposure that includes the dentition of at least one arch up to both dental arches and that has a spherical volume diameter or cylinder height >10 cm and ≤15 cm.
Large	FOV_l	A region of radiation exposure that includes the TMJ articulations and anatomic landmarks necessary for quantitative cephalometric and/or airway assessment and that has a spherical volume diameter or cylinder height >15 cm.

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2 Assess the radiation dose risk

Orthodontists must be knowledgeable of the radiation risk of performing CBCT and be able to communicate this risk to their patients. Radiation risk has most often been estimated by calculating the effective dose

²⁰¹

International Commission on Radiological Protection

1990 recommendations of the International Commission on Radiological Protection, ICRP publication 60.

of a CBCT scan and comparing this value to; 1) measurements obtained from comparable imaging modalities (e.g., multiples of typical panoramic images or a multi-slice medical CT), 2) background equivalent radiation time (e.g., days of background), or 3) radiation detriment [e.g., probability of x cancers per million scans (stochastic-cancer rate)]. Often the base unit of these comparisons (typical panoramic dose, background radiation, weighted probabilities of fatal and nonfatal cancers) is variable and not absolute. This means, for example, that depending on the panoramic image dose used for the comparison (e.g., equipment manufacturer and model, film vs. digital acquisition) the risk for CBCT may be reported either conservatively or liberally compared to panoramic radiography.

To standardize comparison of radiation dose risk between various imaging procedures, this position statement recommends the use of RRLs (Table II). The RRL for various imaging examinations used either as an isolated procedure or for a course of orthodontics can be determined for adults and children using published effective dose calculations (Table VI).

⁹⁰

Librizzi Z.T.
Tadinada A.S.
Valiyaparambil J.V.
Lurie A.G.
Mallya S.M.

Cone-beam computed tomography to detect erosions of the temporomandibular joint: effect of field of view and voxel size on diagnostic efficacy and effective dose.

^,

¹⁵⁹

Silva M.A.
Wolf U.
Heinicke F.
Bumann A.
Visser H.
Hirsch E.

Cone-beam computed tomography for routine orthodontic treatment planning: a radiation dose evaluation.

^,

¹⁷⁶

Ludlow J.B.
Davies-Ludlow L.E.
Brooks S.L.
Howerton W.B.

Dosimetry of 3 CBCT devices for oral and maxillofacial radiology: CB Mercuray, NewTom 3G and i-CAT.

^,

¹⁷⁷

Ludlow J.B.
Davies-Ludlow L.E.
White S.C.

Patient risk related to common dental radiographic examinations: the impact of 2007 International Commission on Radiological Protection recommendations regarding dose calculation.

^,

¹⁷⁸

Loubele M.
Bogaerts R.
Van Dijck E.
et al.

Comparison between effective radiation dose of CBCT and MSCT scanners for dentomaxillofacial applications.

^,

¹⁷⁹

Suomalainen A.
Kiljunen T.
Käser Y.
Peltola J.
Kortesniemi M.

Dosimetry and image quality of four dental cone beam computed tomography scanners compared with multislice computed tomography scanners.

^,

¹⁸⁰

Okano T.
Harata Y.
Sugihara Y.
et al.

Absorbed and effective doses from cone beam volumetric imaging for implant planning.

^,

¹⁸¹

Carrafiello G.
Dizonno M.
Colli V.
et al.

Comparative study of jaws with multislice computed tomography and cone-beam computed tomography.

^,

¹⁸²

Jeong D.K.
Lee S.C.
Huh K.H.
et al.

Comparison of effective dose for imaging of mandible between multi-detector CT and cone-beam CT.

^,

¹⁸³

Theodorakou C.
Walker A.
Horner K.
Pauwels R.
Bogaerts R.
Jacobs R.

SEDENTEXCT Project Consortium
Estimation of paediatric organ and effective doses from dental cone beam CT using anthropomorphic phantoms.

^,

¹⁸⁴

Ludlow J.B.
Ivanovic M.

Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology.

^,

¹⁸⁵

Hirsch E.
Wolf U.
Heinicke F.
Silva M.A.

Dosimetry of the cone beam computed tomography Veraviewepocs 3D compared with the 3D Accuitomo in different fields of view.

^,

¹⁸⁶

Roberts J.A.
Drage N.A.
Davies J.
Thomas D.W.

Effective dose from cone beam CT examinations in dentistry.

^,

¹⁸⁷

Qu X.M.
Li G.
Ludlow J.B.
Zhang Z.Y.
Ma X.C.

Effective radiation dose of ProMax 3D cone-beam computerized tomography scanner with different dental protocols.

^,

¹⁸⁸

Ludlow J.B.

A manufacturer's role in reducing the dose of cone beam computed tomography examinations: effect of beam filtration.

^,

¹⁸⁹

Lofthag-Hansen S.
Thilander-Klang A.
Gröndahl K.

Evaluation of subjective image quality in relation to diagnostic task for cone beam computed tomography with different fields of view.

^,

¹⁹⁰

Davies J.
Johnson B.
Drage N.A.

Effective doses from cone beam CT investigation of the jaws.

^,

¹⁹¹

Pauwels R.
Beinsberger J.
Collaert B.
et al.

The SEDENTEXCT Project Consortium
Effective dose range for dental cone beam computed tomography scanners.

^,

¹⁹²

Grünheid T.
Kolbeck Schieck J.R.
Pliska B.T.
Ahmad M.
Larson B.E.

Dosimetry of a cone-beam computed tomography machine compared with a digital X-ray machine in orthodontic imaging.

^,

¹⁹³

Qu X.M.
Li G.
Sanderink G.C.
Zhang Z.Y.
Ma X.C.

Dose reduction of cone beam CT scanning for the entire oral and maxillofacial regions with thyroid collars.

^,

¹⁹⁴

Koivisto J.
Kiljunen T.
Tapiovaara M.
Wolff J.
Kortesniemi M.

Assessment of radiation exposure in dental cone-beam computerized tomography with the use of metal-oxide semiconductor field-effect transistor (MOSFET) dosimeters and Monte Carlo simulations.

^,

¹⁹⁵

Palomo J.M.
Rao P.S.
Hans M.G.

Influence of CBCT exposure conditions on radiation dose.

^,

¹⁹⁶

Schilling R.
Geibel M.A.

Assessment of the effective doses from two dental cone beam CT devices.

^,

²⁰⁶

Kwong J.C.
Palomo J.M.
Landers M.A.
Figueroa A.
Hans M.G.

Image quality produced by different CBCT settings.

^,

²⁰⁷

Gavala S.
Donta C.
Tsiklakis K.
Boziari A.
Kamenopoulou V.
Stamatakis H.C.

Radiation dose reduction in direct digital panoramic radiography.

Calculations of RRL levels in millisieverts (mSv; 1mSv = 1000 μSv) were made with methods described elsewhere,

¹⁹⁷

Valentin J.

The 2007 recommendations of the International Commission on Radiological Protection. Publication 93.

and data from the 7th Biological Effects of Ionizing Radiation report.

²⁰⁸

National Research Council of the National Academies
Committee to Assess Health Risks from Exposure to Low Levels of Ionizing Radiation

Health Risks From Exposure to Low Levels of Ionizing Radiation: BEIR VII - Phase 2.

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The estimate in the report, and the basis for subsequent levels of radiation risk, is that approximately 1 in 1000 individuals develop cancer from an exposure of 10,000 μSv.

¹⁹⁷

Valentin J.

The 2007 recommendations of the International Commission on Radiological Protection. Publication 93.

RRL assignments are based on reviews of current literature. These assignments are revised periodically, as practice evolves and further information becomes available.

Table VSelected published effective doses (E_{ICRP, 2007)} in microSieverts [μSv] for various field of view (FOV) cone beam computed tomography devices used in orthodontics in comparison with multi-slice computed tomography (MSCT), rotational panoramic and cephalometric radiography

Examination	CBCT unit	Scanning volume (cm²)	Protocol	E (μSv)^Reference
Large FOV CBCT (>15 cm height/diameter)	3DeXAM	17 × 23	0.4 mm resolution	72 ¹⁹⁶ Schilling R. Geibel M.A. Assessment of the effective doses from two dental cone beam CT devices. Dentomaxillofac Radiol. 2013; 42: 20120273 Crossref PubMed Google Scholar
	3D Accuitomo 170	17 × 12	Adolescent; 10 years old	216 ¹⁸³ Theodorakou C. Walker A. Horner K. Pauwels R. Bogaerts R. Jacobs R. SEDENTEXCT Project Consortium Estimation of paediatric organ and effective doses from dental cone beam CT using anthropomorphic phantoms. Br J Radiol. 2012; 85: 153-160 Crossref PubMed Scopus (32) Google Scholar ; 282 ¹⁸³ Theodorakou C. Walker A. Horner K. Pauwels R. Bogaerts R. Jacobs R. SEDENTEXCT Project Consortium Estimation of paediatric organ and effective doses from dental cone beam CT using anthropomorphic phantoms. Br J Radiol. 2012; 85: 153-160 Crossref PubMed Scopus (32) Google Scholar
	CB MercuRay	15 × 15	Maxillofacial/TMJ	436 ¹⁸⁴ Ludlow J.B. Ivanovic M. Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 106: 106-114 Abstract Full Text Full Text PDF PubMed Scopus (278) Google Scholar ; 569 ¹⁸⁴ Ludlow J.B. Ivanovic M. Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 106: 106-114 Abstract Full Text Full Text PDF PubMed Scopus (278) Google Scholar ; 680 ¹⁹⁵ Palomo J.M. Rao P.S. Hans M.G. Influence of CBCT exposure conditions on radiation dose. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 105: 773-782 Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar ; 511 ¹⁸⁰ Okano T. Harata Y. Sugihara Y. et al. Absorbed and effective doses from cone beam volumetric imaging for implant planning. Dentomaxillofac Radiol. 2009; 38: 79-85 Crossref PubMed Scopus (53) Google Scholar /436 ⁹⁰ Librizzi Z.T. Tadinada A.S. Valiyaparambil J.V. Lurie A.G. Mallya S.M. Cone-beam computed tomography to detect erosions of the temporomandibular joint: effect of field of view and voxel size on diagnostic efficacy and effective dose. Am J Orthod Dentofacial Orthop. 2011; 140: e25-e30 Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar
	CB MercuRay	20 × 20	SR/HR/TMJ	558 ¹⁷⁷ Ludlow J.B. Davies-Ludlow L.E. White S.C. Patient risk related to common dental radiographic examinations: the impact of 2007 International Commission on Radiological Protection recommendations regarding dose calculation. J Am Dent Assoc. 2008; 139: 1237-1243 Abstract Full Text Full Text PDF PubMed Google Scholar ; 761 ¹⁹⁵ Palomo J.M. Rao P.S. Hans M.G. Influence of CBCT exposure conditions on radiation dose. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 105: 773-782 Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar /1025 ¹⁷⁷ Ludlow J.B. Davies-Ludlow L.E. White S.C. Patient risk related to common dental radiographic examinations: the impact of 2007 International Commission on Radiological Protection recommendations regarding dose calculation. J Am Dent Assoc. 2008; 139: 1237-1243 Abstract Full Text Full Text PDF PubMed Google Scholar ; 1073 ¹⁸⁴ Ludlow J.B. Ivanovic M. Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 106: 106-114 Abstract Full Text Full Text PDF PubMed Scopus (278) Google Scholar /916 ⁹⁰ Librizzi Z.T. Tadinada A.S. Valiyaparambil J.V. Lurie A.G. Mallya S.M. Cone-beam computed tomography to detect erosions of the temporomandibular joint: effect of field of view and voxel size on diagnostic efficacy and effective dose. Am J Orthod Dentofacial Orthop. 2011; 140: e25-e30 Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar
	Galileos	15 × 15	High/low dose	128 ¹⁸⁴ Ludlow J.B. Ivanovic M. Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 106: 106-114 Abstract Full Text Full Text PDF PubMed Scopus (278) Google Scholar /70 ¹⁸⁴ Ludlow J.B. Ivanovic M. Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 106: 106-114 Abstract Full Text Full Text PDF PubMed Scopus (278) Google Scholar
	Galileos Comfort	15 × 15	Adult; adolescent; 10 years old	84 ¹⁹¹ Pauwels R. Beinsberger J. Collaert B. et al. The SEDENTEXCT Project Consortium Effective dose range for dental cone beam computed tomography scanners. Eur J Radiol. 2012; 81: 267-271 Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar ; 71 ¹⁸³ Theodorakou C. Walker A. Horner K. Pauwels R. Bogaerts R. Jacobs R. SEDENTEXCT Project Consortium Estimation of paediatric organ and effective doses from dental cone beam CT using anthropomorphic phantoms. Br J Radiol. 2012; 85: 153-160 Crossref PubMed Scopus (32) Google Scholar ; 70 ¹⁸³ Theodorakou C. Walker A. Horner K. Pauwels R. Bogaerts R. Jacobs R. SEDENTEXCT Project Consortium Estimation of paediatric organ and effective doses from dental cone beam CT using anthropomorphic phantoms. Br J Radiol. 2012; 85: 153-160 Crossref PubMed Scopus (32) Google Scholar
	i-CAT Classic	16 × 22	Low/high resolution	65-69 ¹⁹² Grünheid T. Kolbeck Schieck J.R. Pliska B.T. Ahmad M. Larson B.E. Dosimetry of a cone-beam computed tomography machine compared with a digital X-ray machine in orthodontic imaging. Am J Orthod Dentofacial Orthop. 2012; 141: 436-443 Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar ; 193 ¹⁷⁷ Ludlow J.B. Davies-Ludlow L.E. White S.C. Patient risk related to common dental radiographic examinations: the impact of 2007 International Commission on Radiological Protection recommendations regarding dose calculation. J Am Dent Assoc. 2008; 139: 1237-1243 Abstract Full Text Full Text PDF PubMed Google Scholar ; 82 ¹⁷⁸ Loubele M. Bogaerts R. Van Dijck E. et al. Comparison between effective radiation dose of CBCT and MSCT scanners for dentomaxillofacial applications. Eur J Radiol. 2009; 71: 461-468 Abstract Full Text Full Text PDF PubMed Scopus (157) Google Scholar ; 206 ¹⁸⁶ Roberts J.A. Drage N.A. Davies J. Thomas D.W. Effective dose from cone beam CT examinations in dentistry. Br J Radiol. 2009; 82: 35-40 Crossref PubMed Scopus (134) Google Scholar ; 110 ¹⁸¹ Carrafiello G. Dizonno M. Colli V. et al. Comparative study of jaws with multislice computed tomography and cone-beam computed tomography. Radiol Med. 2010; 115: 600-611 Crossref PubMed Scopus (32) Google Scholar /127-131 ¹⁹² Grünheid T. Kolbeck Schieck J.R. Pliska B.T. Ahmad M. Larson B.E. Dosimetry of a cone-beam computed tomography machine compared with a digital X-ray machine in orthodontic imaging. Am J Orthod Dentofacial Orthop. 2012; 141: 436-443 Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar
	i-CAT Next Generation	23 × 17		74 ¹⁸⁴ Ludlow J.B. Ivanovic M. Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 106: 106-114 Abstract Full Text Full Text PDF PubMed Scopus (278) Google Scholar ; 78 ¹⁹⁰ Davies J. Johnson B. Drage N.A. Effective doses from cone beam CT investigation of the jaws. Dentomaxillofac Radiol. 2012; 41: 30-36 Crossref PubMed Scopus (21) Google Scholar
	Iluma	19 × 19	Standard/ultra	98 ¹⁸⁴ Ludlow J.B. Ivanovic M. Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 106: 106-114 Abstract Full Text Full Text PDF PubMed Scopus (278) Google Scholar /498 ¹⁸⁴ Ludlow J.B. Ivanovic M. Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 106: 106-114 Abstract Full Text Full Text PDF PubMed Scopus (278) Google Scholar
	Iluma Elite	21 × 14		368 ¹⁹¹ Pauwels R. Beinsberger J. Collaert B. et al. The SEDENTEXCT Project Consortium Effective dose range for dental cone beam computed tomography scanners. Eur J Radiol. 2012; 81: 267-271 Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar
	KODAK 9500	18 × 20	With; without filtration	136 ¹⁹¹ Pauwels R. Beinsberger J. Collaert B. et al. The SEDENTEXCT Project Consortium Effective dose range for dental cone beam computed tomography scanners. Eur J Radiol. 2012; 81: 267-271 Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar ; 166 ¹⁸⁸ Ludlow J.B. A manufacturer's role in reducing the dose of cone beam computed tomography examinations: effect of beam filtration. Dentomaxillofac Radiol. 2011; 40: 115-122 Crossref PubMed Google Scholar /260 ¹⁸⁸ Ludlow J.B. A manufacturer's role in reducing the dose of cone beam computed tomography examinations: effect of beam filtration. Dentomaxillofac Radiol. 2011; 40: 115-122 Crossref PubMed Google Scholar
	NewTom 3G	15 × 15/20 × 20		57 ¹⁷⁸ Loubele M. Bogaerts R. Van Dijck E. et al. Comparison between effective radiation dose of CBCT and MSCT scanners for dentomaxillofacial applications. Eur J Radiol. 2009; 71: 461-468 Abstract Full Text Full Text PDF PubMed Scopus (157) Google Scholar /59 ¹⁷⁷ Ludlow J.B. Davies-Ludlow L.E. White S.C. Patient risk related to common dental radiographic examinations: the impact of 2007 International Commission on Radiological Protection recommendations regarding dose calculation. J Am Dent Assoc. 2008; 139: 1237-1243 Abstract Full Text Full Text PDF PubMed Google Scholar ; 68 ¹⁸⁴ Ludlow J.B. Ivanovic M. Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 106: 106-114 Abstract Full Text Full Text PDF PubMed Scopus (278) Google Scholar
	NewTom 9000	15 × 15		56 ¹⁵⁹ Silva M.A. 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.e1-640.e5 Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar ; 95 ¹⁹³ Qu X.M. Li G. Sanderink G.C. Zhang Z.Y. Ma X.C. Dose reduction of cone beam CT scanning for the entire oral and maxillofacial regions with thyroid collars. Dentomaxillofac Radiol. 2012; 41: 373-378 Crossref PubMed Scopus (9) Google Scholar ; 52 ¹⁸⁴ Ludlow J.B. Ivanovic M. Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 106: 106-114 Abstract Full Text Full Text PDF PubMed Scopus (278) Google Scholar
	Newtom VGi	15 × 15		194 ¹⁹¹ Pauwels R. Beinsberger J. Collaert B. et al. The SEDENTEXCT Project Consortium Effective dose range for dental cone beam computed tomography scanners. Eur J Radiol. 2012; 81: 267-271 Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar
	Skyview 3D	17 × 17	Adult; adolescent; 10 years old	87 ¹⁹¹ Pauwels R. Beinsberger J. Collaert B. et al. The SEDENTEXCT Project Consortium Effective dose range for dental cone beam computed tomography scanners. Eur J Radiol. 2012; 81: 267-271 Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar ; 90 ¹⁸³ Theodorakou C. Walker A. Horner K. Pauwels R. Bogaerts R. Jacobs R. SEDENTEXCT Project Consortium Estimation of paediatric organ and effective doses from dental cone beam CT using anthropomorphic phantoms. Br J Radiol. 2012; 85: 153-160 Crossref PubMed Scopus (32) Google Scholar ; 105 ¹⁸³ Theodorakou C. Walker A. Horner K. Pauwels R. Bogaerts R. Jacobs R. SEDENTEXCT Project Consortium Estimation of paediatric organ and effective doses from dental cone beam CT using anthropomorphic phantoms. Br J Radiol. 2012; 85: 153-160 Crossref PubMed Scopus (32) Google Scholar
Medium FOV CBCT (>10 cm and ≤15 cm height/diameter)	3DeXAM	13 × 16	0.3 mm resolution	107 ¹⁹⁶ Schilling R. Geibel M.A. Assessment of the effective doses from two dental cone beam CT devices. Dentomaxillofac Radiol. 2013; 42: 20120273 Crossref PubMed Google Scholar
	3D Accuitomo 170	10 × 14	Adolescent; 10 years old	188 ¹⁸³ Theodorakou C. Walker A. Horner K. Pauwels R. Bogaerts R. Jacobs R. SEDENTEXCT Project Consortium Estimation of paediatric organ and effective doses from dental cone beam CT using anthropomorphic phantoms. Br J Radiol. 2012; 85: 153-160 Crossref PubMed Scopus (32) Google Scholar ; 237 ¹⁸³ Theodorakou C. Walker A. Horner K. Pauwels R. Bogaerts R. Jacobs R. SEDENTEXCT Project Consortium Estimation of paediatric organ and effective doses from dental cone beam CT using anthropomorphic phantoms. Br J Radiol. 2012; 85: 153-160 Crossref PubMed Scopus (32) Google Scholar
	CB Mercuray	10 × 10	Maxillofacial/TMJ imaging	283 ¹⁷⁷ Ludlow J.B. Davies-Ludlow L.E. White S.C. Patient risk related to common dental radiographic examinations: the impact of 2007 International Commission on Radiological Protection recommendations regarding dose calculation. J Am Dent Assoc. 2008; 139: 1237-1243 Abstract Full Text Full Text PDF PubMed Google Scholar ; 407 ¹⁸⁴ Ludlow J.B. Ivanovic M. Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 106: 106-114 Abstract Full Text Full Text PDF PubMed Scopus (278) Google Scholar ; 603 ¹⁹⁵ Palomo J.M. Rao P.S. Hans M.G. Influence of CBCT exposure conditions on radiation dose. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 105: 773-782 Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar /283 ⁹⁰ Librizzi Z.T. Tadinada A.S. Valiyaparambil J.V. Lurie A.G. Mallya S.M. Cone-beam computed tomography to detect erosions of the temporomandibular joint: effect of field of view and voxel size on diagnostic efficacy and effective dose. Am J Orthod Dentofacial Orthop. 2011; 140: e25-e30 Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar
	i-CAT Classic	13 × 16		61 ¹⁵⁹ Silva M.A. 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.e1-640.e5 Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar ; 105 ¹⁷⁷ Ludlow J.B. Davies-Ludlow L.E. White S.C. Patient risk related to common dental radiographic examinations: the impact of 2007 International Commission on Radiological Protection recommendations regarding dose calculation. J Am Dent Assoc. 2008; 139: 1237-1243 Abstract Full Text Full Text PDF PubMed Google Scholar ; 134 ¹⁸⁶ Roberts J.A. Drage N.A. Davies J. Thomas D.W. Effective dose from cone beam CT examinations in dentistry. Br J Radiol. 2009; 82: 35-40 Crossref PubMed Scopus (134) Google Scholar ; 69 ¹⁸⁴ Ludlow J.B. Ivanovic M. Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 106: 106-114 Abstract Full Text Full Text PDF PubMed Scopus (278) Google Scholar
	i-CAT Next Generation	13 × 16	Adult; adolescent; 10 years old	87 ¹⁸⁴ Ludlow J.B. Ivanovic M. Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 106: 106-114 Abstract Full Text Full Text PDF PubMed Scopus (278) Google Scholar ; 83 ¹⁹¹ Pauwels R. Beinsberger J. Collaert B. et al. The SEDENTEXCT Project Consortium Effective dose range for dental cone beam computed tomography scanners. Eur J Radiol. 2012; 81: 267-271 Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar ; 77 ¹⁹⁰ Davies J. Johnson B. Drage N.A. Effective doses from cone beam CT investigation of the jaws. Dentomaxillofac Radiol. 2012; 41: 30-36 Crossref PubMed Scopus (21) Google Scholar ; 82 ¹⁸³ Theodorakou C. Walker A. Horner K. Pauwels R. Bogaerts R. Jacobs R. SEDENTEXCT Project Consortium Estimation of paediatric organ and effective doses from dental cone beam CT using anthropomorphic phantoms. Br J Radiol. 2012; 85: 153-160 Crossref PubMed Scopus (32) Google Scholar ; 134 ¹⁸³ Theodorakou C. Walker A. Horner K. Pauwels R. Bogaerts R. Jacobs R. SEDENTEXCT Project Consortium Estimation of paediatric organ and effective doses from dental cone beam CT using anthropomorphic phantoms. Br J Radiol. 2012; 85: 153-160 Crossref PubMed Scopus (32) Google Scholar
	NewTom VG	11 × 15	Adult; adolescent; 10 years old	83 ¹⁹¹ Pauwels R. Beinsberger J. Collaert B. et al. The SEDENTEXCT Project Consortium Effective dose range for dental cone beam computed tomography scanners. Eur J Radiol. 2012; 81: 267-271 Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar ; 81 ¹⁸³ Theodorakou C. Walker A. Horner K. Pauwels R. Bogaerts R. Jacobs R. SEDENTEXCT Project Consortium Estimation of paediatric organ and effective doses from dental cone beam CT using anthropomorphic phantoms. Br J Radiol. 2012; 85: 153-160 Crossref PubMed Scopus (32) Google Scholar ; 114 ¹⁸³ Theodorakou C. Walker A. Horner K. Pauwels R. Bogaerts R. Jacobs R. SEDENTEXCT Project Consortium Estimation of paediatric organ and effective doses from dental cone beam CT using anthropomorphic phantoms. Br J Radiol. 2012; 85: 153-160 Crossref PubMed Scopus (32) Google Scholar
	Scanora 3D	13.5 × 14.5	Adult; adolescent; 10 years old	68 ¹⁹¹ Pauwels R. Beinsberger J. Collaert B. et al. The SEDENTEXCT Project Consortium Effective dose range for dental cone beam computed tomography scanners. Eur J Radiol. 2012; 81: 267-271 Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar ; 74 ¹⁸³ Theodorakou C. Walker A. Horner K. Pauwels R. Bogaerts R. Jacobs R. SEDENTEXCT Project Consortium Estimation of paediatric organ and effective doses from dental cone beam CT using anthropomorphic phantoms. Br J Radiol. 2012; 85: 153-160 Crossref PubMed Scopus (32) Google Scholar ; 85 ¹⁸³ Theodorakou C. Walker A. Horner K. Pauwels R. Bogaerts R. Jacobs R. SEDENTEXCT Project Consortium Estimation of paediatric organ and effective doses from dental cone beam CT using anthropomorphic phantoms. Br J Radiol. 2012; 85: 153-160 Crossref PubMed Scopus (32) Google Scholar
Small FOV CBCT (≤10 cm height/diameter)	3DeXAM	5 × 10	Man	111 ¹⁸² Jeong D.K. Lee S.C. Huh K.H. et al. Comparison of effective dose for imaging of mandible between multi-detector CT and cone-beam CT. Imaging Sci Dent. 2012; 42: 65-70 Crossref PubMed Google Scholar
		8 × 16	0.25; 0.30 resolution	170 ¹⁹⁶ Schilling R. Geibel M.A. Assessment of the effective doses from two dental cone beam CT devices. Dentomaxillofac Radiol. 2013; 42: 20120273 Crossref PubMed Google Scholar ; 45 ¹⁹⁶ Schilling R. Geibel M.A. Assessment of the effective doses from two dental cone beam CT devices. Dentomaxillofac Radiol. 2013; 42: 20120273 Crossref PubMed Google Scholar
		4 × 16	Max 0.125 mm; 0.3 mm resolution/man 0.125 mm; 0.3 mm resolution	68 ¹⁹⁶ Schilling R. Geibel M.A. Assessment of the effective doses from two dental cone beam CT devices. Dentomaxillofac Radiol. 2013; 42: 20120273 Crossref PubMed Google Scholar ; 33 ¹⁹⁶ Schilling R. Geibel M.A. Assessment of the effective doses from two dental cone beam CT devices. Dentomaxillofac Radiol. 2013; 42: 20120273 Crossref PubMed Google Scholar /76 ¹⁹⁶ Schilling R. Geibel M.A. Assessment of the effective doses from two dental cone beam CT devices. Dentomaxillofac Radiol. 2013; 42: 20120273 Crossref PubMed Google Scholar ; 38 ¹⁹⁶ Schilling R. Geibel M.A. Assessment of the effective doses from two dental cone beam CT devices. Dentomaxillofac Radiol. 2013; 42: 20120273 Crossref PubMed Google Scholar
		8 × 8	0.125 mm; 0.3 mm resolution	122 ¹⁹⁶ Schilling R. Geibel M.A. Assessment of the effective doses from two dental cone beam CT devices. Dentomaxillofac Radiol. 2013; 42: 20120273 Crossref PubMed Google Scholar ; 62 ¹⁹⁶ Schilling R. Geibel M.A. Assessment of the effective doses from two dental cone beam CT devices. Dentomaxillofac Radiol. 2013; 42: 20120273 Crossref PubMed Google Scholar
	3D Accuitomo IID	3 × 4		27 ¹⁷⁹ Suomalainen A. Kiljunen T. Käser Y. Peltola J. Kortesniemi M. Dosimetry and image quality of four dental cone beam computed tomography scanners compared with multislice computed tomography scanners. Dentomaxillofac Radiol. 2009; 38: 367-378 Crossref PubMed Scopus (98)

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