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3D CBCT Imaging for Routine Use in Orthodontics Wm. Randol Womack, DDS Editorial Director, Orthotown Magazine

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Since its inception, cone beam computed tomography (CBCT) has been top of mind for orthodontic specialists (and even this publication). CBCT is potentially the most game-changing technology orthodontics has seen in a decade, and with every new iteration, it is becoming more of a reality for practices to integrate into their daily use. I spoke with Drs. Terry D. Carlyle, Ed Lin, Randall Moles, Dave Paquette and Ron Roncone to find out how they incorporated CBCT into their own practice.

When did you begin using CBCT routinely in your practice and what was your motivation to incorporate this technology?
Carlyle: We started with the Sirona Galileos CBCT unit in April 2007. I liked the idea of the software that was available as it was very easy to incorporate into the practice, however there were some initial integration issues with Dolphin but that was soon resolved. The Sirona unit had a mid-sized field of view, which for our purposes in 2007, served us well. I switched to the second generation i-CAT unit in December 2008 to allow us to work more effectively with our oral surgery colleagues as they liked the larger field of view.

Lin: I began using CBCT in September 2006. The motivation was primarily two-fold; 1. For superior 3D diagnostic imaging resulting in better treatment plans for my patients, and 2. I had been in discussion with Orametrix about the potential to incorporate the CBCT scan as a substitute for the SureSmile ora-scanner. We purchased the i-CAT knowing that we would be providing SureSmile with data for research to develop the integration of this technology.

Moles: I started using CBCT two-and-a-half years ago. My primary motivation was to integrate 3D imaging with SureSmile technology. This would reduce patient scan time from 15 minutes to 20 seconds. Moreover for the first time it would allow me to actually see and control true root movements during treatment. Of course I also wanted to provide our patients with the incredible diagnostics of CBCT.

Paquette: 2007. My goal was and is to eventually have an impressionless practice.

Roncone: I began using CBCT in my office about four years ago.

How did you decide on the type of scanner you purchased for your practice?
Carlyle: I chose Sirona first because of the software for ease of learning. At the time I purchased the Sirona, the other companies were working on technical and software changes and I felt the mid-sized field of view (FOV) would be adequate for our purposes. I did come to realize later, that for our larger patients, we could not adequately capture the facial soft tissues as well as the TMJ views at the same time. For orthodontic diagnosis and planning of treatment, the larger FOV machines work best.

Lin: I looked at the i-CAT, NewTom, and Iluma. These were the only CBCT scanners available at the time that provided us with the technology that was necessary for our needs with a 14-bit sensor and 20cm FOV. I was most impressed by i-CAT’s management team and felt confident that they would provide us with a high level of support and would continue to improve and develop their product.

Moles: I was part of the Beta team testing CBCT with SureSmile. The degree of accuracy needed for SureSmile is much greater than that needed merely for diagnostic viewing. Our team was working with two different manufactures at the time to get the units certified for accuracy. We tried for more than eight months to get our first unit to work. It could not deliver the needed accuracy. I switched to the i-CAT, which had achieved accuracy certification.

Paquette: I evaluated all of the CBCT scanners on the market at the AAO.

Roncone: I looked into most of the scanners that were available then and chose the Iluma. There was only one other in use at the time and usually I stay away from a product that has not been out for a while.

How did your initial scanner installation go and has technical support been satisfactory?
Carlyle: Yes. With both Sirona and i-CAT our local dental supply companies were knowledgeable about unit setups and the trainers they supplied for our team members were adequate. Retrospectively however, I wish that I would have had at least a half day for just doctor training.

Lin: It went very well. We had two days for the installation and training and we never really had any issues afterwards. Our i-CAT has gone down three times over the past three years. Imaging Sciences support has been excellent and they have had our machine up and running on all three occasions within 24 hours.

Moles: I am probably one of only a few orthodontists who has owned CBCT from two different manufactures. The installation of the i-CAT was without problems and the support has been very good.

Paquette: Installation was straightforward. Tech support has been erratic.

Roncone: Initially it was not smooth. A major component had to be replaced even before we took our first scan.

What issues or problems did you have to overcome to get the technology working satisfactorily in everyday practice?
Carlyle: None, really. Our IT support team was excellent in helping plan ahead for any real technology issues. We used Dolphin Imaging and the bridging software installation for both the Sirona and later the i-CAT, was relatively straightforward. Training and education of our staff was needed to explain the new direction we were going. We have been looking at airway issues for our younger patients and I developed training PowerPoints to educate our team and our patients. More training (three-to-six months) by the CBCT providers would be helpful. Also the doctors need anatomy reviews once they become more efficient in use of the images.

Lin: The only real issue that we had in the beginning was in becoming proficient with getting the 2D slices out of the 3D volume in Dolphin 3D. Just like with anything else, hard work and practice pays off.

Moles: Installation was fairly simple and the integration of the I-Cat with Dolphin is easy. What the reader needs to understand about this technology is that beyond the cost of the 3D unit there can be considerable hidden costs. The file sizes are large which can require increased storage space. A separate program such as Dolphin 3D is highly recommended to get the greatest diagnostic capability. Beyond that, there may be the cost of upgrading computers and graphics cards if you want to manipulate and/or display these images throughout the office.

Paquette: Integration with our practice management system is still unavailable.

Roncone: The major problem was major! The scanner was not large enough for orthodontic use. The cephalometric landmarks of the skull could not all be seen. After a lot of back and forth and explanations of why, a larger screen was sent to me. Another problem was a relatively poor instruction manual.

How did you transition your orthodontic records from the “conventional” to cone beam scans?
Carlyle: At first we continued with our OrthoCad models and traditional mounted models. Later with the purchase of Anatomage software, we now have the capability of sending the DICOM images to Anatomage and they can produce a “digital 3D” model. We now take plaster models only on about 15 percent of our patients, those being adults, TMJ or surgery patients, severe Class II or III patients. To rely on your clinical examination, superb photographs and the 3D skeletal/dental relationships requires a disciplined approach to data gathering.

Lin: There really was no transition as we only use CBCT and still extrapolate the panorex and ceph. However, we can now get tomograms and any other 2D slices very quickly and efficiently.

Moles: We found the transition was seamless since our Dolphin imaging and management systems interface perfectly with the i-Cat. Training the staff to “pull” panoramic and tomographic views was easy.

Paquette: We were already 100 percent digital, so it was simple.

Roncone: The transition from our combination ceph/pano/ tomography machine was easy once the initial “basic” problems were solved. Any patient who was capable of remaining still without a problem was scanned. This eliminated some young patients and some older adults. We have completed about 1,800 scans to this point.

How much time do you devote to reviewing a scan in your treatment planning process?
Carlyle: More time is devoted to scanning as we look at TMJs, airways, sinuses, and bone levels. I do use the services of an OMFR on about 10 percent of our cases to get confirmation of our original diagnosis.

Lin: Depending on the case, I probably review each scan in both 2D and 3D anywhere from two-to-five minutes.

Moles: Reviewing the scans takes approximately five minutes.

Paquette: Three-to-five minutes.

Roncone: I have been fortunate to have a very experienced medical radiology technician to run our CBCT. She studies each scan and will alert me to any potential problem areas she detects. I then will spend about 20-25 minutes on the entire scan. We have a “basic” number of areas for each patient that I will always check ie, various views of the TMJ, airway, panoramic view, frontal and lateral cephalograms and any areas of particular interest to me based on the clinical examination. I then will look at the 3D view from various angles, scan up and down the airway, check areas of bone around suspect teeth, etc. I use all records simultaneously while going through a drastic checklist so that hopefully nothing is missed. (See Figure 1)

What benefits have you received from using CBCT scans over conventional radiographic records?
Carlyle: Patient education is much more efficient, and using the CBCT images along with other programs, such as Dolphin Aquarium, allows us to show relationships instantly at the initial examination. Our treatment coordinators are very highly trained and have the material ready for review before I enter the examination room. We can show airway issues, TMJ positional and remodeling issues. The location of supernumerary teeth and impactions (notably maxillary canines) is much easier to explain. With our younger patients we can have a much better predictive capability with the eruption of the maxillary canines and can provide better guidance and treatment where and when needed. It would be our goal to have no impacted canines to treat, if we can see the patients young enough.

Lin: I never knew what I was missing in the 2D world until I entered into the 3D world! My diagnosis and treatment has without a doubt significantly improved.

Moles: The integration with SureSmile has been a huge benefit. Besides significantly reducing scan times, the ability to see actual root movements in the treatment planning stage has made our treatment much more effective and efficient.

Paquette: I have treated several patients easily with ectopic eruption that I would not have attempted to treat before.

Roncone: The diagnostic benefits of using the cone beam have been dramatic. What is amazing to me is what I was not seeing in typical orthodontic diagnostic records. The clarity of the TMJ; airway from five different views; anomalies and pathology would never have been previously detected. Additionally, the various filters available make the tracing of the cephs much easier and more accurate than in the past. (See Figures 2-5).

Has the CBCT scanner been economically reasonable for you?
Carlyle: We charge a fee for our examination that includes a full series of photographs, our clinical examination and letter/report to the patient and referring doctor. If the patient proceeds with treatment, a diagnosis/records fee is also charged. Is it a “moneymaker” for us? No. We have similar fees for our diagnostic procedures as before.

Lin: Absolutely. It has made us much more efficient in the clinic and has saved us on overhead with reduced payroll expenses. We have also generated about $75,000 over the past three years from external referrals that have used our i-CAT machine.

Moles: It is difficult to put a hard number to the diagnostic advantage of using 3D CBCT. However, for those of us using SureSmile the saving of chair time is easy to calculate (Chair min. x Value of one minute of chair time = Savings). At 15-20 scans per month the CBCT is cost justified.

Paquette: Not really, but benefits outweigh expenses.

Roncone: While it was a large investment, I believe it was worth it. I began by planning to have other dentists and specialists use the CBCT and have it pay for itself. I find that there is no time for that. We are using the machine to its capacity. Additionally there are multiple X-ray laboratories in our area that do a terrific job with radiology records (including CBCT).

Do you offer CBCT scans to other professionals?
Carlyle: Yes, but we do not actively pursue this unless the referring doctor has access to image reading by an OMF radiologist. We will take images on conjoint patients for restorative, surgery and implants and forward the DICOM images for the patient as a courtesy to them. In the literature, there are discussions about liability issues for the image provider as well as the image reviewer (referring doctor or other professional). We also send DICOM images to patient’s medical doctors for their review, but most MDs are not trained to read images, only medical radiologist reports.

Lin: Yes. We have an online referral form on our web site. We manage all billing and insurance filings for all these patients. We will have a copy of the Dicom on CD and an oral radiology report provided to the referring doctor from Advanced Dental Board within five business days.

Moles: We have done so. However our success has been limited since there are commercial labs in our area that also provide 3D imaging.

Paquette: Yes.

What kind of additional training are you taking or plan to take regarding interpretation of the CBCT scans you take?
Carlyle: I have taken a number of CBCT image courses and am planning to spend some time with an OMF Radiologist as well.

Lin: I have taken several courses from Dr. David Hatcher and Dr. James Mah over the years. I have also attended all three International 3D Imaging Congress meetings over the past three years.

Moles: I would strongly recommend that anyone purchasing a CBCT take a course on how to read the images. Imaging Sciences has an excellent one-and-a-half day course.

Paquette: I have taken several interpretation courses.

Roncone: I have taken several classes on CBCT interpretation and will continue to do so.

What is your understanding of the “liability” issues with using CBCT and what is your risk
management policy?
Carlyle: In all Canadian provinces except Ontario, dental professionals can use CBCT imaging equipment. I have heard both sides of the discussion about liability of interpretation of images hence I use an OMFR for a percentage of cases. I feel that CBCT imaging should be an integral part of graduate orthodontic training. We use this in our teaching clinics at the University of Alberta Graduate Orthodontic program.

Lin: We have our patients sign a waiver form stating that they have been offered the opportunity to have their scan read by an OMFR for a fee. I personally feel that we need to be aware of our potential liabilities especially if we were to miss something on the scan.

Moles: This is certainly a gray area at the present time. However, as dentists we are not supposed to diagnose or treat outside of our area of expertise, which is the maxillae, mandible, joints and teeth. Having said that I believe that if you have CBCT you should take a course on how to read the 3D images then send anything out that looks suspicious for a radiologic read.

Paquette: My understanding is that unless dental boards change the definition of the practice of dentistry to include diagnosis of medical issues then it is no different then a pan or ceph. In other words, if we diagnose a non-dental issue then we are practicing medicine without a license.

Roncone: The liability issue is still vague. But most legal minds I know believe that if you “diagnose the scan” you are responsible for fully diagnosing the scan. I suppose it will take a future court case to finalize the true liability. At this point, I am comfortable with what we do for a majority of our cases. I have and will continue to use expert diagnosticians such as Dr. David Hatcher for any scans where there is any doubt at all.

What advice would you offer to our readers about this technology in terms of equipment selection and utilization in an orthodontic practice?
Carlyle: I think that CBCT imaging will have a profound effect on the dental profession as a whole and certainly in orthodontic diagnosis and planning treatment. The use of 3D imaging will reduce the need for models to use with aligner therapy, indirect bonding setups and the like, as DICOM images would be sent directly to appliance providers. Diagnosis of airway issues and treatment planning of complex cases requiring TADs or orthognathic surgery will become the norm. Two-dimensional imaging will have its place, but that place will become less important in the future. In addition, improvement in orthodontic research may occur as we will be able to look at treatment changes in new ways. Traditional orthodontic research has been hampered by 2D representation of what we are really dealing with – a 3D object. Orthodontic research can move to a new level of understanding.

Lin: I personally feel that CBCT is the future of orthodontics, if it has not already become the standard of care. There is no doubt that 3D imaging is a far superior technology when compared to 2D imaging. The radiation dose levels have come down significantly and I feel that the benefits far outweigh the risks when utilized appropriately. Be very careful when choosing the CBCT machine as you do not want to make a six-figure mistake. Not all of these scanners will be around in the future. My recommendation is to go with a company that has a long-standing history of product development and great customer support.

Moles: It’s important to know that all 3D imaging is not the same. If you are going to use it purely for viewing structure, most any unit will be sufficient. However, if you are eventually going to use the CBCT to as a treatment tool to create virtual models, the degree of accuracy needed is much higher. CBCT units with that degree of accuracy are few.

Accuracy is affected by patient motion, so a “sit down” unit helps to reduce this. In addition the head holder needs to be specially designed. At the present time, there are only two units certified accurate enough to use with SureSmile and I believe that is the litmus test. The best way to justify the cost of CBCT is to utilize it to the max. With that in mind it would be unfortunate to spend a substantial amount on 3D only to find that it will never be accurate enough to use for more than just diagnostic viewing.

Paquette: Go for it.

Roncone: There are many more manufacturers of CBCT machines now than there were when I purchased the Iluma. If I could give anyone advice about a potential purpose I guess it would be to be sure there is a “full screen” view not one, which only concentrates on areas for implants. Check on the reliability of the machine by asking multiple users. Check on support. Things will always go wrong from time to time, so how quickly does the company respond? After a bumpy start with our CBCT, the support for the Iluma has been superb. This technology is here to stay. It is especially helpful for those of us who lecture. It is taking some of the guesswork out of what is truly happening in our clinical treatment.
Respondent Bios
Dr. Terry Carlyle received his Degree in Dentistry from the University of Alberta in 1973. His passion for continuous learning and interest in orthodontics took him to the University of Manitoba Graduate Orthodontic Program and in 1977 he received his Master of Science in Oral Biology and earned his specialization in Orthodontics. Dr. Carlyle is a Clinical Associate Professor at the Graduate Orthodontic Program at the University of Alberta as well as Visiting Lecturer at the Orthodontic Graduate Program at the University of Manitoba.

Dr. Ed Lin is a full-time practicing orthodontist and partner at both Orthodontic Specialists of Green Bay (OSGB), in Green Bay, Wisconsin, and also Apple Creek Orthodontics (ACO) in Appleton, Wisconsin. Dr Lin received both his dental and orthodontic degrees from Northwestern University Dental School (‘95 - DDS and ‘99 - MS). OSGB and ACO are completely digital practices and have been at the forefront of the orthodontic profession in implementing technologies such as SureSmile, i-CAT, Dolphin and OrthoSesame. Their transition into a completely digital practice has led to more efficient systems in every aspect of their practice including scheduling, financials, digital records, and patient care. Dr Lin is an internationally recognized speaker and has taught at both Marquette University and the University of Minnesota Dental Schools. He was a featured speaker at the 3rd International Congress on 3D Dental Imaging in Chicago, Illinois, in June 2009.

Dr. Randall Moles graduated from Marquette University and practices in Milwaukee and Racine Wisconsin. He served in the US Coast Guard Division of the United States Public health Service and as an associate professor of Orthodontics at Marquette. Dr. Moles is board certified and for many years has been actively involved in research for a number of orthodontic companies, having three patents to his credit. He has written a book on TMD, numerous orthodontic articles and lectures both nationally and internationally on digital orthodontics, TMD and practice management.

Dr. David Paquette earned his DDS from the University of North Carolina at Chapel Hill and his masters in orthodontics from St. Louis University in 1990, receiving the Milo Hellman award from the American Association of Orthodontists that year for distinguished research in the field. He is a diplomate of the ABO, has served in several academic capacities, written numerous articles for peer-reviewed and other journals and lectured extensively nationally and internationally. Prior to entering orthodontics, Dr. Paquette was a consulting pediatric dentist for the U.S. Air Force and had earned many accolades in this field of dentistry, including becoming a diplomate to the American Board of Pediatric Dentistry. He is a past president and board member of the Charlotte Dental Society and the North Carolina Association of Orthodontists.

Dr. Ronald M. Roncone received his undergraduate degree at Marquette University and pursued graduate study in physiology and neuroanatomy at Marquette University School of Medicine, while simultaneously obtaining his dental degree at the same university. He obtained two postdoctoral certificates from Harvard School of Dental Medicine and the Forsythe Dental Center. Dr. Roncone practices orthodontics in San Diego County, California. He has specialized in adult treatment (aesthetics, surgical, and TMD) as well as “early” treatment for children. While teaching more than 500 seminars worldwide, he has been responsible for a large number of innovations in the practice of orthodontics.
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