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The Future of Digital Imaging Wm. Randol Womack, DDS, Editorial Director, Orthotown Magazine

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by Wm. Randol Womack, DDS, Editorial Director, Orthotown Magazine

When I think of the movie Back to the Future and relate it to today's 3-D imaging machines, I get the feeling that the future is already here.

On May 10, 2001, a ribbon cutting ceremony was held at Loma Linda University for the NewTom OR-DVT-9000, the first dentomaxillofacial dedicated Cone Beam CT machine in the United States.1

Cut to a few years later: the August 2007 issue of Dentaltown Magazine featured the article "3D Images for 21st Century Dentistry," a comprehensive review of this new diagnostic tool and a comparison chart of 11 machines currently on the market that provide cone beam volumetric tomography (which we have updated and included in this feature). The pricing ranges above and below the $200,000 mark. Even though this is shocking to most orthodontists, it is valuable to understand the potential and the application of this type of information.

Virtually every orthodontist can benefit from this technology. In many metropolitan areas, imaging centers have made these scans available to all facets of the dental profession. The centers in my area use the i-CAT machine. The lab will scan the patient, manipulate the data with i-Vision proprietary software and provide you a viewable format of images. You can then scan through the images to see what is meaningful for your patient's problem. In other locations without imaging centers, there might be a specialist or group practice who has a machine and who would be willing to scan your patient for a fee.

There are stand-alone software packages that you can have on your office workstation that will enable you to create a full range of sophisticated views and even movies of a volumetric scan to evaluate areas of concern. These are beneficial in consultations to provide superior impact in demonstrating treatment problems to patients and parents. These programs are provided by Dolphin (www.dolphinimaging.com), In-Vivo Dental (www.anatomage.com) and V-works (www.cybermed.co.kr) just to list a few.
For this feature, we have updated the information chart on select manufacturers of cone beam CT machines for your review. Since this technology is so new, it is not unexpected to find changes, updates and even new machines on the market. As with most technology, high-tech items are always getting better and often, over time, less expensive. I am also including some user comments excerpted from the August 2007 Dentaltown article.  
Click Here to view the Cone Beam Comparison Chart
James Mah DDS, MSc, MRCD, DMSc, director of the Redmond Imaging Center at UCLA, commented about the option to have your own machine or use an imaging center. He emphasized the time commitment and skill of the operator in generating the best images from a cone beam CT scan. This is where imaging centers might have an advantage because they have highly trained technicians performing technical tasks repetitively, which provides consistent information. For an orthodontist thinking about buying his own machine there are several issues to be considered besides just cost alone: How many patients will be imaged each month? Where will the device be placed? Will leasehold improvements require lead shielding? What will be the real cost of ownership? Then there is the matter of staff training. Who will train the operator? What will it take to train the operator? How will data be transferred and archived? How will this device change the workflow of patient care? What are the checks and balances for quality?

Dr. Mah states that there will definitely be a "learning curve" with software utilization. In addition, software and the hardware itself, will continue to improve. What will be the cost to upgrade?

Dr. Mah suggests that you get educated first. Attend meetings, read articles, talk to cone beam CT owners about their experiences. Then you can talk to vendors with an educated view. According to a 2005 presentation by Dr. David A. Chenin (Anatomage.com) to the Southern Nevada Dental Society, some of the 3-D clinical applications for orthodontics are as follows:
  • Complete Dx and Tx Planning
  • Virtual patient
  • Soft tissue
  • Bone
  • Teeth
  • 3-D Modeling and Diagnostic Setups
  • Mini-screw ortho implants
  • Indirect bonding of brackets
  • Clear aligner fabrication
   CBCT Advantages
  • High resolution
  • Specifically designed for dentistry
  • Lower absorbed radiation dose
  • Rapid imaging
  • Lower cost
  • Easier access
  • Viewing software designed for dentistry
I have recently begun using CBCT scans for evaluating impacted teeth prior to treatment. Over the years, using a Pano (two-dimensional radiograph) to assess and treat impacted teeth has been my successful approach. Only in the past six months, in two separate patients, my treatment to reposition impacted upper cuspids resulted in discovering some degree of damage to the roots of lateral incisors after the upper cuspids had moved a few millimeters. In retrospect, a CBCT scan would have shown the exact relationship of the upper cuspid crown tip to the upper lateral incisor root tip and I would have definitely modified my force system and direction on the cuspid to avoid or at least minimize a collision with the lateral.

I currently have three new cases on my desk, two upper cuspid impactions and one upper lateral impaction. I have received CBCT scans from our imaging center and it is an eyeopening revelation to see exactly what we are dealing with in correcting these root positions. Even more remarkable is the impact that the scan images make on the parents and on our referring dentists.

There is a term in private aviation called "flying blind" (referring to flying in the clouds). I believe that term also applies to me in doing certain treatments prior to CBCT technology. To borrow from Dr. Mah once more, "Cone beam CT is a novel and disruptive technology in dentistry and for a fairly traditional profession, there is apprehension. Nevertheless, the future is indeed now. I believe cone beam CT in dentistry will parallel the imprint that medical CT had in medicine. Dentistry is following a parallel trend, albeit 30 years later. I believe that in the next 10 years, it will be the standard of care for most complex dental procedures much like CT imaging is in medicine."

Bibliography
1. Loma Linda University Autumn 2001 Newsletter (http://www.llu.edu/news/scope/aut01/nsconebeam.html)
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