Advertisement

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

      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."
      • Baumrind S.
      • Miller D.
      • Molthen R.
      The reliability of head film measurements. 3. Tracing superimposition.
      • Moyers R.E.
      • Bookstein F.L.
      The inappropriateness of conventional cephalometrics.
      • Johnston Jr., L.E.
      A few comments on an elegant answer in search of useful questions.
      For instance, relapse of and unfavorable responses to orthodontic therapy remain poorly understood despite implications that considerations in the transverse plane are important factors in stability.
      • Little R.M.
      • Wallen T.R.
      • Riedel R.A.
      Stability and relapse of mandibular anterior alignment-first premolar extraction cases treated by traditional edgewise orthodontics.
      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),
      • National Council on Radiation Protection & Measurements
      Radiation Protection in Dentistry (Report No. 145).
      to CBCT imaging is supported by the American Dental Association.
      • 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.
      Justification of every radiographic exposure must be based primarily on the individual patient's presentation including considerations of the chief complaint, medical and dental history, and assessment of the physical status (as determined with a thorough clinical examination) and treatment goals.
      • 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.
      In 1987, a panel of representatives from general dentistry and various academic disciplines in the United States was convened by the Food and Drug Administration. This panel published broad selection recommendations for intraoral radiographic examinations.
      • Matteson S.R.
      • Joseph L.P.
      • Bottomley W.
      • et al.
      The selection of patients for X-ray examinations: dental radiographic examinations.
      These were updated in 2004.
      • U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration
      • American Dental Association, Council on Dental Benefit Programs, Council on Scientific Affairs
      The Selection of Patients for Dental Radiographic Examinations.
      • American Dental Association Council on Scientific Affairs
      The use of dental radiographs: update and recommendations.
      The guidelines suggest that for monitoring growth and development of children and adolescents, "clinical judgment be used in determining the need for, and type of radiographic images necessary for, evaluation and/or monitoring of dentofacial growth and development." In both the European Union
      • Janssens A.
      • Horner K.
      • Rushton V.
      • et al.
      Radiation Protection: European Guidelines on Radiation Protection in Dental Radiology-the Safe Use of Radiographs in Dental Practice.
      • SEDENTEXCT Project
      Chapter 4, Justification and referral criteria. The developing dentition.
      • European Commission
      Item 4.2 the Developing Dentition in Protection Radiation No. 172. Cone Beam CT for Dental and Maxillofacial Radiology (Evidence-based Guidelines).
      and the United Kingdom
      • Isaacson K.G.
      • Thom A.R.
      • Horner K.
      • Whaites E.
      Orthodontic Radiographs-Guidelines for the Use of Radiographs in Clinical Orthodontics.
      orthodontic imaging guidelines state that there is neither an indication for taking radiographs routinely before clinical examinations nor for taking a standard series of radiographic images for all orthodontic patients. The latter document provides clinical decision algorithms based on the ages of the patients (less than or over 9 years of age) and clinical presentation (delayed or ectopic eruption, crowding, or anteroposterior discrepancies such as overjet or overbite, etc.).

      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.
      • Müssig E.
      • Wörtche R.
      • Lux C.J.
      Indications for digital volume tomography in orthodontics.
      • Hechler S.L.
      Cone-beam CT: applications in orthodontics.
      • White S.C.
      • Pae E.K.
      Patient image selection criteria for cone beam computed tomography imaging.
      • Merrett S.J.
      • Drage N.A.
      • Durning P.
      Cone beam computed tomography: a useful tool in orthodontic diagnosis and treatment planning.
      • Mah J.K.
      • Huang J.C.
      • Choo H.
      Practical applications of cone-beam computed tomography in orthodontics.
      • Kapila S.
      • Conley R.S.
      • Harrell Jr., W.E.
      The current status of cone beam computed tomography imaging in orthodontics.
      • Nervina J.M.
      Cone beam computed tomography use in orthodontics.
      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.
      • Peck J.L.
      • Sameshima G.T.
      • Miller A.
      • Worth P.
      • Hatcher D.C.
      Mesiodistal root angulation using panoramic and cone beam CT.
      • Liu D.G.
      • Zhang W.L.
      • Zhang Z.Y.
      • Wu Y.T.
      • Ma X.C.
      Three-dimensional evaluations of supernumerary teeth using cone-beam computed tomography for 487 cases.
      • Treil J.
      • Braga J.
      • Loubes J.M.
      • et al.
      3D tooth modeling for orthodontic assessment.
      • Dudic A.
      • Giannopoulou C.
      • Leuzinger M.
      • Kiliaridis S.
      Detection of apical root resorption after orthodontic treatment by using panoramic radiography and cone-beam computed tomography of super-high resolution.
      • Liedke G.S.
      • Dias de Silveira H.E.
      • Dias de Silveira H.L.
      • Dutra V.
      • Poli de Figueiredo J.A.
      Influence of voxel size in the diagnostic ability of cone beam tomography to evaluate simulated external root resorption.
      • Sherrard J.F.
      • Rossouw P.E.
      • Benson B.W.
      • Carrillo R.
      • Buschang P.H.
      Accuracy and reliability of tooth and root lengths measured on cone-beam computed tomographs.
      • Katheria B.C.
      • Kau C.H.
      • Tate R.
      • Chen J.W.
      • English J.
      • Bouquot J.
      Effectiveness of impacted and supernumerary tooth diagnosis from traditional radiography versus cone beam computed tomography.
      • Leuzinger M.
      • Dudic A.
      • Giannopoulou C.
      • Killaridis S.
      Root-contact evaluation by panoramic radiography and cone-beam computed tomography of super-high resolution.
      • Lund H.
      • Grondahl K.
      • Grondahl H.G.
      Cone beam computed tomography for assessment of root length and marginal bone level during orthodontic treatment.
      • Van Elslande D.
      • Heo G.
      • Flores-Mir C.
      • Carey J.
      • Major P.W.
      Accuracy of mesiodistal root angulation projected by cone-beam computed tomographic panoramic-like images.
      • Shemesh H.
      • Cristescu R.C.
      • Wesslink P.R.
      • Wu M.K.
      The use of cone-beam computed tomography and digital periapical radiographs to diagnose root perforations.
      • Makedonas D.
      • Lund H.
      • Grondahl K.
      • Hansen K.
      Root resorption diagnosed with cone beam computed tomography after 6 months of orthodontic treatment with fixed appliance and the relation to risk factors.
      • Chaushu S.
      • Chaushu G.
      • Becker A.
      The role of digital volume tomography in the imaging of impacted teeth.
      • Nakajima A.
      • Sameshima G.T.
      • Arai Y.
      • Homme Y.
      • Shimizu N.
      • Dougherty H.
      Two- and three-dimensional orthodontic imaging using limited cone beam-computed tomography.
      • Walker L.
      • Enciso R.
      • Mah J.
      Three-dimensional localization of maxillary canines with cone-beam computed tomography.
      • Kau C.H.
      • Richmond S.
      • Palomo J.M.
      • Hans M.G.
      Three-dimensional cone beam computerized tomography in orthodontics.
      • Bjerklin K.
      • Ericson S.
      How a computerized tomography examination changed the treatment plans of 80 children with retained and ectopically positioned maxillary canines.
      • Maverna R.
      • Gracco A.
      Different diagnostic tools for the localization of impacted maxillary canines: clinical considerations.
      • Liu D.
      • Zhang W.
      • Zhang Z.
      • Wu Y.
      • Ma X.
      Localization of impacted maxillary canines and observation of adjacent incisor resorption with cone-beam computed tomography.
      • Bedoya M.M.
      • Park J.H.
      A review of the diagnosis and management of impacted maxillary canines.
      • Gracco A.
      • Lombardo L.
      • Mancuso G.
      • Gravina V.
      • Siciliani G.
      Upper incisor position and bony support in untreated patients as seen on CBCT.
      • Kau C.H.
      • Pan P.
      • Gallerano R.L.
      • English J.D.
      A novel 3D classification system for canine impactions - the KPG index.
      • 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.
      • Tamimi D.
      • ElSaid K.
      Cone beam computed tomography in the assessment of dental impactions.
      • Becker A.
      • Chaushu C.
      • Casap-Caspi N.
      Cone-beam computed tomography and the orthosurgical management of impacted teeth.
      • Botticelli S.
      • Verna C.
      • Cattaneo P.M.
      • Heidmann J.
      • Melsen B.
      Two- versus three-dimensional imaging in subjects with unerupted maxillary canines.
      • Oberoi S.
      • Knueppel S.
      Three-dimensional assessment of impacted canines and root resorption using cone beam computed tomography.
      • Hofmann E.
      • Medelnik J.
      • Fink M.
      • Lell M.
      • Hirschfelder U.
      Three-dimensional volume tomographic study of the imaging accuracy of impacted teeth: MSCT and CBCT comparison - an in vitro study.
      • Guerrero M.E.
      • Shahbazian M.
      • Elsiena Bekkering G.
      • Nackaerts O.
      • Jacobs R.
      • Horner K.
      The diagnostic efficacy of cone beam CT for impacted teeth and associated features: a systematic review.
      • Nguyen E.
      • Boychuk D.
      • Orellana M.
      Accuracy of cone-beam computed tomography in predicting the diameter of unerupted teeth.
      • Rungcharassaeng K.
      • Caruso J.M.
      • Kan J.Y.
      • Kim J.
      • Taylor G.
      Factors affecting buccal bone changes of maxillary posterior teeth after rapid maxillary expansion.
      • Loubele M.
      • Van Assche N.
      • Carpentier K.
      • et al.
      Comparative localized linear accuracy of small-field cone-beam CT and multislice CT for alveolar bone measurements.
      • Leung C.C.
      • Palomo L.
      • Griffith R.
      • Hans M.G.
      Accuracy and reliability of cone-beam computed tomography for measuring alveolar bone height and detecting bony dehiscences and fenestrations.
      • Molen A.D.
      Considerations in the use of cone-beam computed tomography for buccal bone measurements.
      • Timock A.M.
      • Cook V.
      • McDonald T.
      • et al.
      Accuracy and reliability of buccal bone height and thickness measurements from cone-beam computed tomography imaging.
      • Yagci A.
      • Veli I.
      • Uysal T.
      • Ucar F.I.
      • Ozer T.
      • Enhos S.
      Dehiscence and fenestration in skeletal Class I, II, and III malocclusions assessed with cone-beam computed tomography.
      • Sievers M.M.
      • Larson B.E.
      • Gaillard P.R.
      • Wey A.
      Asymmetry assessment using cone beam CT. A Class I and Class II patient comparison.
      • AlHadidi A.
      • Cevidanes L.H.
      • Mol A.
      • Ludlow J.
      • Styner M.
      Comparison of two methods for quantitative assessment of mandibular asymmetry using cone beam computed tomography image volumes.
      • de Moraes M.E.
      • Hollender L.G.
      • Chen C.S.
      • Moraes L.C.
      • Balducci I.
      Evaluating craniofacial asymmetry with digital cephalometric images and cone-beam computed tomography.
      • Damstra J.
      • Fourie Z.
      • Ren Y.
      Evaluation and comparison of postero-anterior cephalograms and cone-beam computed tomography images for the detection of mandibular asymmetry.
      • Veli I.
      • Uysal T.
      • Ozer T.
      • Ucar F.I.
      • Eruz M.
      Mandibular asymmetry in unilateral and bilateral posterior crossbite patients using cone-beam computed tomography.
      • Kook Y.A.
      • Kim Y.
      Evaluation of facial asymmetry with three dimensional cone-beam computed tomography.
      • Cevidanes L.H.
      • Alhadidi A.
      • Paniagua B.
      • et al.
      Three-dimensional quantification of mandibular asymmetry through cone-beam computerized tomography.
      • Park J.U.
      • Kook Y.A.
      • Kim Y.
      Assessment of asymmetry in a normal occlusion sample and asymmetric patients with three-dimensional cone beam computed tomography: a study for a transverse reference plane.
      • Orentlicher G.
      • Goldsmith D.
      • Horowitz A.
      Applications of 3-dimensional virtual computerized tomography technology in oral and maxillofacial surgery: current therapy.
      • Tucker S.
      • Cevidanes L.H.
      • Styner M.
      • et al.
      Comparison of actual surgical outcomes and 3-dimensional surgical simulations.
      • Lagravère M.O.
      • Carey J.
      • Heo G.
      • Toogood R.W.
      • Major P.W.
      Transverse, vertical, and anteroposterior changes from bone-anchored maxillary expansion vs traditional rapid maxillary expansion: a randomized clinical trial.
      • Cevidanes L.H.
      • Tucker S.
      • Styner M.
      • et al.
      Three-dimensional surgical simulation.
      • Heymann G.C.
      • Cevidanes L.
      • Cornelis M.
      • De Clerck H.J.
      • Tulloch J.F.
      Three-dimensional analysis of maxillary protraction with intermaxillary elastics to miniplates.
      • Almeida R.C.
      • Cevidanes L.H.
      • Carvalho F.A.
      • et al.
      Soft tissue response to mandibular advancement using 3D CBCT scanning.
      • Gateno J.
      • Xia J.J.
      • Teichgraeber J.F.
      New 3-dimensional cephalometric analysis for orthognathic surgery.
      • Kim Y.I.
      • Park S.B.
      • Son W.S.
      • Hwang D.S.
      Midfacial soft-tissue changes after advancement of maxilla with Le Fort I osteotomy and mandibular setback surgery: comparison of conventional and high Le Fort osteotomies by superimposition of cone-beam computed tomography volumes.
      • Lloyd T.E.
      • Drage N.A.
      • Cronin A.J.
      The role of cone beam computed tomography in the management of unfavourable fractures following sagittal split mandibular osteotomy.
      • Kim Y.I.
      • Choi Y.K.
      • Park S.B.
      • Son W.S.
      • Kim S.S.
      Three-dimensional analysis of dental decompensation for skeletal Class III malocclusion on the basis of vertical skeletal patterns obtained using cone-beam computed tomography.
      • King K.S.
      • Lam E.W.
      • Faulkner M.G.
      • Heo G.
      • Major P.W.
      Vertical bone volume in the paramedian palate of adolescents: a computed tomography study.
      • Miner R.M.
      • Al Qabandi S.
      • Rigali P.H.
      • Will L.A.
      Cone-beam computed tomography transverse analysis. Part I: normative data.
      • Hilgers M.L.
      • Scarfe W.C.
      • Scheetz J.P.
      • Farman A.G.
      Accuracy of linear temporomandibular joint measurements with cone beam computed tomography and digital cephalometric radiography.
      • Helenius L.M.
      • Hallikainen D.
      • Helenius I.
      • et al.
      Clinical and radiographic findings of the temporomandibular joint in patients with various rheumatic diseases: a case control study.
      • Bryndahl F.
      • Eriksson L.
      • Legrell P.E.
      • Isberg A.
      Bilateral TMJ disk displacement induces mandibular retrognathia.
      • Honey O.B.
      • Scarfe W.C.
      • Hilgers M.J.
      • et al.
      Accuracy of cone-beam computed tomography imaging of the temporomandibular joint: comparisons with panoramic radiology and linear tomography.
      • Koyama J.
      • Nishiyama H.
      • Hayashi T.
      Follow-up study of condylar bony changes using helical computed tomography in patients with temporomandibular disorder.
      • Ahmad M.
      • Hollender L.
      • Anderson Q.
      • et al.
      Research diagnostic criteria for temporomandibular disorders (RDC/TMD): development of image analysis criteria and examiner reliability for image analysis.
      • Alexiou K.
      • Stamatakis H.
      • Tsiklakis K.
      Evaluation of the severity of temporomandibular joint osteoarthritic changes related to age using cone beam computed tomography.
      • Schiffman E.L.
      • Ohrbach R.
      • Truelove E.L.
      • et al.
      The research diagnostic criteria for temporomandibular disorders. V: methods used to establish and validate revised Axis I diagnostic algorithms.
      • Schiffman E.L.
      • Truelove E.L.
      • Ohrbach R.
      • et al.
      The research diagnostic criteria for temporomandibular disorders. I: overview and methodology for assessment of validity.
      • Truelove E.
      • Pan W.
      • Look J.O.
      • et al.
      The research diagnostic criteria for temporomandibular disorders. III: validity of axis I diagnoses.
      • Alkhader M.
      • Kuribayashi A.
      • Ohbayashi N.
      • Nakamura S.
      • Kurabayashi T.
      Usefulness of cone beam computed tomography in temporomandibular joints with soft tissue pathology.
      • Tsiklakis K.
      Cone beam computed tomographic findings in temporomandibular joint disorders.
      • Cevidanes L.H.
      • Hajati A.K.
      • Paniagua B.
      • et al.
      Quantification of condylar resorption in temporomandibular joint osteoarthritis.
      • 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.
      • Nah K.S.
      Condylar bony changes in patients with temporomandibular disorders: a CBCT study.
      • Ferraz Jr., A.M.
      • Devito K.L.
      • Guimarães J.P.
      Temporomandibular disorder in patients with juvenile idiopathic arthritis: clinical evaluation and correlation with the findings of cone beam computed tomography.
      • Liu M.Q.
      • Chen H.M.
      • Yap A.U.
      • Fu K.Y.
      Condylar remodeling accompanying splint therapy: a cone-beam computerized tomography study of patients with temporomandibular joint disk displacement.
      • Barghan S.
      • Tetradis S.
      • Mallya S.
      Application of cone beam computed tomography for assessment of the temporomandibular joints.
      • Zain-Alabdeen E.H.
      • Alsadhan R.I.
      A comparative study of accuracy of detection of surface osseous changes in the temporomandibular joint using multidetector CT and cone beam CT.
      • Palconet G.
      • Ludlow J.B.
      • Tyndall D.A.
      • Lim P.F.
      Correlating cone beam CT results with temporomandibular joint pain of osteoarthritic origin.
      • Swennen G.R.
      • Mollemans W.
      • De Clercq C.
      • et al.
      A cone-beam computed tomography triple scan procedure to obtain a three-dimensional augmented virtual skull model appropriate for orthognathic surgery planning.
      • Schendel S.A.
      • Lane C.
      3D orthognathic surgery simulation using image fusion.
      • Ebner F.H.
      • Kürschner V.
      • Dietz K.
      • Bültmann E.
      • Nägele T.
      • Honegger J.
      Craniometric changes in patients with acromegaly from a surgical perspective.
      • Edwards S.P.
      Computer-assisted craniomaxillofacial surgery.
      • Jayaratne Y.S.
      • Zwahlen R.A.
      • Lo J.
      • Tam S.C.
      • Cheung L.K.
      Computer-aided maxillofacial surgery: an update.
      • Jayaratne Y.S.
      • Zwahllen R.A.
      • Lo J.
      • Cheung L.K.
      Three-dimensional color maps: a novel tool for assessing craniofacial changes.
      • Popat H.
      • Richmond S.
      New developments in: three-dimensional planning for orthognathic surgery.
      • Carvalho Fde A.
      • Cevidanes L.H.
      • da Motta A.T.
      • Almeida M.A.
      • Phillips C.
      Three-dimensional assessment of mandibular advancement 1 year after surgery.
      • da Motta A.T.
      • de Assis Ribeiro Carvalho F.
      • Oliveira A.E.
      • Cevidanes L.H.
      • de Oliveira Almeida M.A.
      Superimposition of 3D cone-beam CT models in orthognathic surgery.
      • Agarwal R.
      Anthropometric evaluation of complete unilateral cleft lip nose with cone beam CT in early childhood.
      • Behnia H.
      • Khojasteh A.
      • Soleimani M.
      • Tehranchi A.
      • Atashi A.
      Repair of alveolar cleft defect with mesenchymal stem cells and platelet derived growth factors: a preliminary report.
      • Dalessandri D.
      • Laffranchi L.
      • Tonni I.
      • et al.
      Advantages of cone beam computed tomography (CBCT) in the orthodontic treatment planning of cleidocranial dysplasia patients: a case report.
      • Abou-Elfetouh A.
      • Barakat A.
      • Abdel-Ghany K.
      Computed-guided rapid-prototyped templates for segmental mandibular osteotomies: a preliminary report.
      • Scolozzi P.
      • Terzic A.
      "Mirroring" computational planning, navigation guidance system, and intraoperative mobile C-arm cone-beam computed tomography with flat-panel detector.
      • Aboudara C.A.
      • Hatcher D.
      • Nielsen I.L.
      • Miller A.
      A three-dimensional evaluation of the upper airway in adolescents.
      • Sera T.
      • Fujioka H.
      • Yokota H.
      • et al.
      Three-dimensional visualization and morphometry of small airways from microfocal X-ray computed tomography.
      • Ogawa T.
      • Enciso R.
      • Memon A.
      • Mah J.K.
      • Clark G.T.
      Evaluation of 3D airway imaging of obstructive sleep apnea with cone-beam computed tomography.
      • Strauss R.A.
      • Burgoyne C.C.
      Diagnostic imaging and sleep medicine.
      • Osorio F.
      • Perilla M.
      • Doyle D.J.
      • Palomo J.M.
      Cone beam computed tomography: an innovative tool for airway assessment.
      • Tso H.H.
      • Lee J.S.
      • Huang J.C.
      • Maki K.
      • Hatcher D.
      • Miller A.J.
      Evaluation of the human airway using cone-beam computerized tomography.
      • Lenza M.G.
      • Lenza M.M.
      • Dalstra M.
      • Melsen B.
      • Cattaneo P.M.
      An analysis of different approaches to the assessment of upper airway morphology: a CBCT study.
      • El H.
      • Palomo J.M.
      Measuring the airway in 3 dimensions: a reliability and accuracy study.
      • Schendel S.A.
      • Hatcher D.
      Automated 3-dimensional airway analysis from cone-beam computed tomography data.
      • El A.S.
      • El H.
      • Palomo J.M.
      • Baur D.A.
      A 3-dimensional airway analysis of an obstructive sleep apnea surgical correction with cone beam computed tomography.
      • Oh K.M.
      • Hong J.S.
      • Kim Y.J.
      • Cevidanes L.S.
      • Park Y.H.
      Three-dimensional analysis of pharyngeal airway form in children with anteroposterior facial patterns.
      • Abramson Z.
      • Susarla S.M.
      • Lawler M.
      • Bouchard C.
      • Troulis M.
      • Kaban L.B.
      Three-dimensional computed tomographic airway analysis of patients with obstructive sleep apnea treated by maxillomandibular advancement.
      • Schendel S.
      • Powell N.
      • Jacobson R.
      Maxillary, mandibular, and chin advancement: treatment planning based on airway anatomy in obstructive sleep apnea.
      • Iwasaki T.
      • Saitoh I.
      • Takemoto Y.
      • et al.
      Evaluation of upper airway obstruction in Class II children with fluid-mechanical simulation.
      • Conley R.S.
      Evidence for dental and dental specialty treatment of obstructive sleep apnoea. Part 1: the adult OSA patient and Part 2: the paediatric and adolescent patient.
      • de Souza Carvalho A.C.
      • Magro Filho O.
      • Garcia Jr., I.R.
      • Araujo P.M.
      • Nogueira R.L.
      Cephalometric and three-dimensional assessment of superior posterior airway space after maxillomandibular advancement.
      • Lee Y.
      • Chun Y.S.
      • Kang N.
      • Kim M.
      Volumetric changes in the upper airway after bimaxillary surgery for skeletal Class III malocclusions: a case series study using 3-dimensional cone-beam computed tomography.
      • Farronato G.
      • Storti E.
      • Cuzzocrea M.L.
      • et al.
      Three-dimensional changes of the upper airway in patients with obstructive sleep apnea syndrome after a non-adjustable oral appliance treatment.
      • 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).
      • Kim M.A.
      • Kim B.R.
      • Choi J.Y.
      • Youn J.K.
      • Kim Y.J.
      • Park Y.H.
      Three-dimensional changes of the hyoid bone and airway volumes related to its relationship with horizontal anatomic planes after bimaxillary surgery in skeletal Class III patients.
      • Iwasaki T.
      • Saitoh I.
      • Takemoto Y.
      • et al.
      Tongue posture improvement and pharyngeal airway enlargement as secondary effects of rapid maxillary expansion: a cone-beam computed tomography study.
      • Weissheimer A.
      • Menezes L.M.
      • Sameshima G.T.
      • Enciso R.
      • Pham J.
      • Grauer D.
      Imaging software accuracy for 3-dimensional analysis of the upper airway.
      • Alsufyani N.A.
      • Flores-Mir C.
      • Major P.W.
      Three-dimensional segmentation of the upper airway using cone beam CT: a systematic review.
      • Poggio P.M.
      • Incorvati C.
      • Velo S.
      • Carano A.
      "Safe zones": a guide for miniscrew positioning in the maxillary and mandibular arch.
      • Gracco A.
      • Lombardo L.
      • Cozzani M.
      • Siciliani G.
      Quantitative evaluation with CBCT of palatal bone thickness in growing patients.
      • King K.S.
      • Lam E.W.
      • Faulkner M.G.
      • Heo G.
      • Major P.W.
      Predictive factors of vertical bone depth in the paramedian palate of adolescents.
      • Palomo L.
      • Palomo J.M.
      • Hans M.G.
      • Bissada N.
      Image guided placement of temporary anchorage devices for tooth movement.
      • Gracco A.
      • Luca L.
      • Cozzani M.
      • Siciliani G.
      Assessment of palatal bone thickness in adults with cone beam computerised tomography.
      • Ono A.
      • Motoyoshi M.
      • Shimizu N.
      Cortical bone thickness in the buccal posterior region for orthodontic mini-implants.
      • Gracco A.
      • Lombardo L.
      • Cozzani M.
      • Siciliani G.
      Quantitative cone-beam computed tomography evaluation of palatal bone thickness for orthodontic miniscrew placement.
      • Kim G.T.
      • Kim S.H.
      • Choi Y.S.
      • et al.
      Cone-beam computed tomography evaluation of orthodontic miniplate anchoring screws in the posterior maxilla.
      • 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.
      • Kim S.H.
      • Yoon H.G.
      • Choi Y.S.
      • Hwang E.H.
      • Kook Y.A.
      • Nelson G.
      Evaluation of interdental space of the maxillary posterior area for orthodontic mini-implants with cone-beam computed tomography.
      • Baumgaertel S.
      Quantitative investigation of palatal bone depth and cortical bone thickness for mini-implant placement in adults.
      • Baumgaertel S.
      • Hans M.G.
      Buccal cortical bone thickness for mini-implant placement.
      • Baumgaertel S.
      • Hans M.G.
      Assessment of infrazygomatic bone depth for mini-screw insertion.
      • Kau C.H.
      • English J.D.
      • Muller-Delgardo M.G.
      • Hamid H.
      • Ellis R.K.
      • Winklemann S.
      Retrospective cone-beam computed tomography evaluation of temporary anchorage devices.
      • Park H.S.
      • Hwangbo E.S.
      • Kwon T.G.
      Proper mesiodistal angles for microimplant placement assessed with 3-dimensional computed tomography images.
      • Fayed M.M.
      • Pazera P.
      • Katsaros C.
      Optimal sites for orthodontic mini-implant placement assessed by cone beam computed tomography.
      • Morea C.
      • Hayek J.E.
      • Oleskovicz C.
      • Dominguez G.C.
      • Chilvarquer I.
      Precise insertion of orthodontic miniscrews with a stereolithographic surgical guide based on cone beam computed tomography data: a pilot study.
      • Qiu L.
      • Haruyama N.
      • Suzuki S.
      • et al.
      Accuracy of orthodontic miniscrew implantation guided by stereolithographic surgical stent based on cone-beam CT-derived 3D images.
      • Garrett B.J.
      • Caruso J.M.
      • Rungcharassaeng K.
      • Farrage J.R.
      • Kim J.S.
      • Taylor G.D.
      Skeletal effects to the maxilla after rapid maxillary expansion assessed with cone-beam computed tomography.
      • Christie K.F.
      • Boucher N.
      • Chung C.H.
      Effects of bonded rapid palatal expansion on the transverse dimensions of the maxilla: a cone-beam computed tomography study.
      • 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.
      • Domann C.E.
      • Kau C.H.
      • English J.D.
      • Xia J.J.
      • Souccar N.M.
      • Lee R.P.
      Cone beam computed tomography analysis of dentoalveolar changes immediately after maxillary expansion.
      • Baratieri C.
      • Alves Jr., M.
      • Sant'anna E.F.
      • Nojima Mda C.
      • Nojima L.I.
      3D mandibular positioning after rapid maxillary expansion in Class II malocclusion.
      • Baysal A.
      • Karadede I.
      • Hekimoglu S.
      • et al.
      Evaluation of root resorption following rapid maxillary expansion using cone-beam computed tomography.
      • Tai K.
      • Park J.H.
      • Mishima K.
      • Shin J.W.
      3-Dimensional cone-beam computed tomography analysis of transverse changes with Schwarz appliances on both jaws.

      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.
      • Hechler S.L.
      Cone-beam CT: applications in orthodontics.
      • Mah J.K.
      • Huang J.C.
      • Choo H.
      Practical applications of cone-beam computed tomography in orthodontics.
      • 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.
      • 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
      • 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,
      • Bjerklin K.
      • Ericson S.
      How a computerized tomography examination changed the treatment plans of 80 children with retained and ectopically positioned maxillary canines.
      • 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.
      • 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,
      • 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.
      • 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.
      • 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.
      • 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.
      • National Health and Medical Research Council of Australia
      A Guide to the Development, Implementation and Evaluation of Clinical Practice Guidelines.
      • Cascade P.N.
      The American College of Radiology. ACR Appropriateness Criteria project.
      U.S. Preventive Services Task Force Ratings: Grade Definitions
      Guide to Clinical Preventive Services, Third Edition: Periodic Updates.

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

      • American College of Radiology
      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.
      RecommendationConsensus levelDefinition
      Likely indicatedIThe 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 indicatedIIThe 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 indicatedIIIThe 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.

      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
      • Claus E.B.
      • Calvocoressi L.
      • Bondy M.L.
      • Schildkraut J.M.
      • Wiemels J.L.
      • Wrensch M.
      Dental X-rays and risk of meningioma.
      ; however, numerous rebuttal articles have highlighted limitations in this study.
      • Jorgensen T.J.
      Dental X-rays and risk of meningioma.
      • Calnon W.R.
      Shortcomings of study on dental X-rays and risk of meningioma.
      • Tetradis S.
      • White S.C.
      • Service S.K.
      Dental x-rays and risk of meningioma; the jury is still out.
      • Dirksen D.
      • Runte C.
      • Berghoff L.
      • Scheutzel P.
      • Figgener L.
      Dental X-rays and risk of meningioma: anatomy of a case-control study.
      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.
      • 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
      • 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.
      • 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.
      • 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.
      • 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.
      • Loubele M.
      • Bogaerts R.
      • Van Dijck E.
      • et al.
      Comparison between effective radiation dose of CBCT and MSCT scanners for dentomaxillofacial applications.
      • 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.
      • Okano T.
      • Harata Y.
      • Sugihara Y.
      • et al.
      Absorbed and effective doses from cone beam volumetric imaging for implant planning.
      • Carrafiello G.
      • Dizonno M.
      • Colli V.
      • et al.
      Comparative study of jaws with multislice computed tomography and cone-beam computed tomography.
      • 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.
      • 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.
      • Ludlow J.B.
      • Ivanovic M.
      Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology.
      Most CBCT examinations impart a fraction of medical CT effective dose; however, doses vary considerably among CBCT units.
      • 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.
      • Palomo L.
      • Palomo J.M.
      • Hans M.G.
      • Bissada N.
      Image guided placement of temporary anchorage devices for tooth movement.
      • 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.
      • 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.
      • 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.
      • Loubele M.
      • Bogaerts R.
      • Van Dijck E.
      • et al.
      Comparison between effective radiation dose of CBCT and MSCT scanners for dentomaxillofacial applications.
      • 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.
      • Okano T.
      • Harata Y.
      • Sugihara Y.
      • et al.
      Absorbed and effective doses from cone beam volumetric imaging for implant planning.
      • Carrafiello G.
      • Dizonno M.
      • Colli V.
      • et al.
      Comparative study of jaws with multislice computed tomography and cone-beam computed tomography.
      • 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.
      • 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.
      • Ludlow J.B.
      • Ivanovic M.
      Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology.
      • 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.
      • Roberts J.A.
      • Drage N.A.
      • Davies J.
      • Thomas D.W.
      Effective dose from cone beam CT examinations in dentistry.
      • 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.
      • Ludlow J.B.
      A manufacturer's role in reducing the dose of cone beam computed tomography examinations: effect of beam filtration.
      • 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.
      • Davies J.
      • Johnson B.
      • Drage N.A.
      Effective doses from cone beam CT investigation of the jaws.
      • Pauwels R.
      • Beinsberger J.
      • Collaert B.
      • et al.
      The SEDENTEXCT Project Consortium
      Effective dose range for dental cone beam computed tomography scanners.
      • 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.
      • 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.
      • 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.
      • Palomo J.M.
      • Rao P.S.
      • Hans M.G.
      Influence of CBCT exposure conditions on radiation dose.
      • 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.
      • Valentin J.
      The 2007 recommendations of the International Commission on Radiological Protection. Publication 93.
      • Preston D.L.
      • Shimizu Y.
      • Pierce D.A.
      • Suyama A.
      • Mabuch K.
      Studies of mortality of atomic bomb survivors. Report 13: solid cancer and non-cancer disease mortality: 1950-1997.
      • United Nations Scientific Committee on the Effects of Atomic Radiation
      Effects of Ionizing Radiation: United Nations Scientific Committee on the Effects of Atomic Radiation - UNSCEAR 2006 Report, Volume 1-Report to the General Assembly, With Scientific Annexes A and B.
      • National Research Council (U.S.)
      • 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.
      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.
      • 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).
      • 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).
      • 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.
      • 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.
      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
      • 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.
      ; 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.
      • 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.
      • National Research Council (U.S.)
      • 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.
      • International Commission on Radiological Protection
      1990 recommendations of the International Commission on Radiological Protection, ICRP publication 60.
      • 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).
      • American College of Radiology
      ACR Appropriateness Criteria. Radiation Dose Assessment Introduction.
      In addition, there are at least two national radiation safety initiatives to raise awareness of using lower radiation doses to image children: Image Gently
      • The Alliance for Radiation Safety in Pediatric Imaging
      and the National Children's Dose Registry.
      • American College of Radiology
      The Quality Improvement Registry for CT Scans in Children.
      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 levelEffective dose estimate range (μSv)
      AdultChild
      Child is defined as any individual less than 18 years of age.
      000
      <100<30
      100-100030-300
      1000-10,000300-3000
      10,000-30,0003,000-10,000
      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.
      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

      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,
      • 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
      PresentationDental and skeletal clinical conditions
      PrimaryTreatment difficultyNoneDental structure anomaliesAnomalies in dental positionCompromised dento-alveolar boundariesAsymmetryAnteroposterior discrepanciesVertical discrepanciesTransverse discrepanciesTMJ signs and/or symptoms
      PretreatmentMildIIIFOVS (I)FOVS (I)FOVs,m (II)FOVm,l (II)FOVm,l (II)FOVm,l (II)FOVm,l (II)FOVs,m (III)
      ModerateFOVm,l (II)FOVS (I)FOVS (I)FOVs,m (II)FOVm,l (II)FOVm,l (II)FOVm,l (II)FOVm,l (II)FOVm,l (II)
      SevereFOVl (II)FOVS (I)FOVS (I)FOVs,m (II)FOVm,l (II)FOVm,l (II)FOVm,l (II)FOVm,l (II)FOVm,l (II)
      During treatmentIIIFOVS (III)FOVS (II)FOVs,m (II)Presurgical FOVm,l (I)Presurgical FOVm,l (II)Presurgical FOVm,l (II)Presurgical FOVm,l (II)FOVm,l (II)
      PosttreatmentIIIFOVS (III)FOVS (III)FOVs,m (III)FOVm,l (II)FOVm,l (II)FOVm,l (II)FOVm,l (II)FOVm,l (II)
      CBCT, cone beam computed tomography; Field of View (FOV): FOVs = Small FOV CBCT imaging; FOVm = Medium FOV CBCT imaging; FOVl = Large FOV CBCT imaging. Consensus Recommendations: I = Likely Indicated; II = Possibly Indicated; III = Likely Not Indicated.
      Table IVDefinition of cone beam computed tomography field of view (FOV) ranges for orthodontic imaging
      FOVAbbreviationDefinition
      SmallFOVsA 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.
      MediumFOVmA 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.
      LargeFOVlA 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.

      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
      • 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).
      • 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.
      • 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.
      • 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.
      • 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.
      • Loubele M.
      • Bogaerts R.
      • Van Dijck E.
      • et al.
      Comparison between effective radiation dose of CBCT and MSCT scanners for dentomaxillofacial applications.
      • 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.
      • Okano T.
      • Harata Y.
      • Sugihara Y.
      • et al.
      Absorbed and effective doses from cone beam volumetric imaging for implant planning.
      • Carrafiello G.
      • Dizonno M.
      • Colli V.
      • et al.
      Comparative study of jaws with multislice computed tomography and cone-beam computed tomography.
      • 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.
      • 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.
      • Ludlow J.B.
      • Ivanovic M.
      Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology.
      • 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.
      • Roberts J.A.
      • Drage N.A.
      • Davies J.
      • Thomas D.W.
      Effective dose from cone beam CT examinations in dentistry.
      • 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.
      • Ludlow J.B.
      A manufacturer's role in reducing the dose of cone beam computed tomography examinations: effect of beam filtration.
      • 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.
      • Davies J.
      • Johnson B.
      • Drage N.A.
      Effective doses from cone beam CT investigation of the jaws.
      • Pauwels R.
      • Beinsberger J.
      • Collaert B.
      • et al.
      The SEDENTEXCT Project Consortium
      Effective dose range for dental cone beam computed tomography scanners.
      • 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.
      • 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.
      • 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.
      • Palomo J.M.
      • Rao P.S.
      • Hans M.G.
      Influence of CBCT exposure conditions on radiation dose.
      • Schilling R.
      • Geibel M.A.
      Assessment of the effective doses from two dental cone beam CT devices.
      • Kwong J.C.
      • Palomo J.M.
      • Landers M.A.
      • Figueroa A.
      • Hans M.G.
      Image quality produced by different CBCT settings.
      • 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,
      • 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.
      • 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.
      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.
      • 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 (EICRP, 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
      ExaminationCBCT unitScanning volume (cm2)ProtocolE (μSv)Reference
      Large FOV CBCT (>15 cm height/diameter)3DeXAM17 × 230.4 mm resolution72
      • Schilling R.
      • Geibel M.A.
      Assessment of the effective doses from two dental cone beam CT devices.
      3D Accuitomo 17017 × 12Adolescent; 10 years old216
      • 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.
      ; 282
      • 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.
      CB MercuRay15 × 15Maxillofacial/TMJ436
      • Ludlow J.B.
      • Ivanovic M.
      Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology.
      ; 569
      • Ludlow J.B.
      • Ivanovic M.
      Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology.
      ; 680
      • Palomo J.M.
      • Rao P.S.
      • Hans M.G.
      Influence of CBCT exposure conditions on radiation dose.
      ; 511
      • Okano T.
      • Harata Y.
      • Sugihara Y.
      • et al.
      Absorbed and effective doses from cone beam volumetric imaging for implant planning.
      /436
      • 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.
      20 × 20SR/HR/TMJ558
      • 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.
      ; 761
      • Palomo J.M.
      • Rao P.S.
      • Hans M.G.
      Influence of CBCT exposure conditions on radiation dose.
      /1025
      • 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.
      ; 1073
      • Ludlow J.B.
      • Ivanovic M.
      Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology.
      /916
      • 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.
      Galileos15 × 15High/low dose128
      • Ludlow J.B.
      • Ivanovic M.
      Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology.
      /70
      • Ludlow J.B.
      • Ivanovic M.
      Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology.
      Galileos Comfort15 × 15Adult; adolescent; 10 years old84
      • Pauwels R.
      • Beinsberger J.
      • Collaert B.
      • et al.
      The SEDENTEXCT Project Consortium
      Effective dose range for dental cone beam computed tomography scanners.
      ; 71
      • 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.
      ; 70
      • 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.
      i-CAT Classic16 × 22Low/high resolution65-69
      • 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
      • 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.
      ; 82
      • Loubele M.
      • Bogaerts R.
      • Van Dijck E.
      • et al.
      Comparison between effective radiation dose of CBCT and MSCT scanners for dentomaxillofacial applications.
      ; 206
      • Roberts J.A.
      • Drage N.A.
      • Davies J.
      • Thomas D.W.
      Effective dose from cone beam CT examinations in dentistry.
      ; 110
      • Carrafiello G.
      • Dizonno M.
      • Colli V.
      • et al.
      Comparative study of jaws with multislice computed tomography and cone-beam computed tomography.
      /127-131
      • 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.
      i-CAT Next Generation23 × 1774
      • Ludlow J.B.
      • Ivanovic M.
      Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology.
      ; 78
      • Davies J.
      • Johnson B.
      • Drage N.A.
      Effective doses from cone beam CT investigation of the jaws.
      Iluma19 × 19Standard/ultra98
      • Ludlow J.B.
      • Ivanovic M.
      Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology.
      /498
      • Ludlow J.B.
      • Ivanovic M.
      Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology.
      Iluma Elite21 × 14368
      • Pauwels R.
      • Beinsberger J.
      • Collaert B.
      • et al.
      The SEDENTEXCT Project Consortium
      Effective dose range for dental cone beam computed tomography scanners.
      KODAK 950018 × 20With; without filtration136
      • Pauwels R.
      • Beinsberger J.
      • Collaert B.
      • et al.
      The SEDENTEXCT Project Consortium
      Effective dose range for dental cone beam computed tomography scanners.
      ; 166
      • Ludlow J.B.
      A manufacturer's role in reducing the dose of cone beam computed tomography examinations: effect of beam filtration.
      /260
      • Ludlow J.B.
      A manufacturer's role in reducing the dose of cone beam computed tomography examinations: effect of beam filtration.
      NewTom 3G15 × 15/20 × 2057
      • Loubele M.
      • Bogaerts R.
      • Van Dijck E.
      • et al.
      Comparison between effective radiation dose of CBCT and MSCT scanners for dentomaxillofacial applications.
      /59
      • 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.
      ; 68
      • Ludlow J.B.
      • Ivanovic M.
      Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology.
      NewTom 900015 × 1556
      • 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.
      ; 95
      • 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.
      ; 52
      • Ludlow J.B.
      • Ivanovic M.
      Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology.
      Newtom VGi15 × 15194
      • Pauwels R.
      • Beinsberger J.
      • Collaert B.
      • et al.
      The SEDENTEXCT Project Consortium
      Effective dose range for dental cone beam computed tomography scanners.
      Skyview 3D17 × 17Adult; adolescent; 10 years old87
      • Pauwels R.
      • Beinsberger J.
      • Collaert B.
      • et al.
      The SEDENTEXCT Project Consortium
      Effective dose range for dental cone beam computed tomography scanners.
      ; 90
      • 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.
      ; 105
      • 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.
      Medium FOV CBCT (>10 cm and ≤15 cm height/diameter)3DeXAM13 × 160.3 mm resolution107
      • Schilling R.
      • Geibel M.A.
      Assessment of the effective doses from two dental cone beam CT devices.
      3D Accuitomo 17010 × 14Adolescent; 10 years old188
      • 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.
      ; 237
      • 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.
      CB Mercuray10 × 10Maxillofacial/TMJ imaging283
      • 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.
      ; 407
      • Ludlow J.B.
      • Ivanovic M.
      Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology.
      ; 603
      • Palomo J.M.
      • Rao P.S.
      • Hans M.G.
      Influence of CBCT exposure conditions on radiation dose.
      /283
      • 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.
      i-CAT Classic13 × 1661
      • 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.
      ; 105
      • 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.
      ; 134
      • Roberts J.A.
      • Drage N.A.
      • Davies J.
      • Thomas D.W.
      Effective dose from cone beam CT examinations in dentistry.
      ; 69
      • Ludlow J.B.
      • Ivanovic M.
      Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology.
      i-CAT Next Generation13 × 16Adult; adolescent; 10 years old87
      • Ludlow J.B.
      • Ivanovic M.
      Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology.
      ; 83
      • Pauwels R.
      • Beinsberger J.
      • Collaert B.
      • et al.
      The SEDENTEXCT Project Consortium
      Effective dose range for dental cone beam computed tomography scanners.
      ; 77
      • Davies J.
      • Johnson B.
      • Drage N.A.
      Effective doses from cone beam CT investigation of the jaws.
      ; 82
      • 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.
      ; 134
      • 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.
      NewTom VG11 × 15Adult; adolescent; 10 years old83
      • Pauwels R.
      • Beinsberger J.
      • Collaert B.
      • et al.
      The SEDENTEXCT Project Consortium
      Effective dose range for dental cone beam computed tomography scanners.
      ; 81
      • 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.
      ; 114
      • 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.
      Scanora 3D13.5 × 14.5Adult; adolescent; 10 years old68
      • Pauwels R.
      • Beinsberger J.
      • Collaert B.
      • et al.
      The SEDENTEXCT Project Consortium
      Effective dose range for dental cone beam computed tomography scanners.
      ; 74
      • 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.
      ; 85
      • 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.
      Small FOV CBCT (≤10 cm height/diameter)3DeXAM5 × 10Man111
      • 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.
      8 × 160.25; 0.30 resolution170
      • Schilling R.
      • Geibel M.A.
      Assessment of the effective doses from two dental cone beam CT devices.
      ; 45
      • Schilling R.
      • Geibel M.A.
      Assessment of the effective doses from two dental cone beam CT devices.
      4 × 16Max 0.125 mm; 0.3 mm resolution/man 0.125 mm; 0.3 mm resolution68
      • Schilling R.
      • Geibel M.A.
      Assessment of the effective doses from two dental cone beam CT devices.
      ; 33
      • Schilling R.
      • Geibel M.A.
      Assessment of the effective doses from two dental cone beam CT devices.
      /76
      • Schilling R.
      • Geibel M.A.
      Assessment of the effective doses from two dental cone beam CT devices.
      ; 38
      • Schilling R.
      • Geibel M.A.
      Assessment of the effective doses from two dental cone beam CT devices.
      8 × 80.125 mm; 0.3 mm resolution122
      • Schilling R.
      • Geibel M.A.
      Assessment of the effective doses from two dental cone beam CT devices.
      ; 62
      • Schilling R.
      • Geibel M.A.
      Assessment of the effective doses from two dental cone beam CT devices.
      3D Accuitomo IID3 × 427
      • 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.