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My Point of View on 3D's Field of View John Graham, DDS, MD

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In literature, “point of view” is a great determiner of many aspects of a good book. It can establish all of the necessary elements that can push it to the top of the bestseller list. In orthodontics, “field of view” is a determining factor and a valuable tool for an orthodontic practice. The 3D cone beam CT (CBCT) view helps me in diagnosis and treatment planning, and dramatically improves patient education. The full field of view provides complete and concise information in less time than conventional 2D methods.

Prior to investing in CBCT technology, my radiographic protocol was time consuming, inefficient and inaccurate. First, we took cephalometric and panoramic X-ray images at the initial diagnostic record exam. Then, a mid-treatment panoramic X-ray was obtained at an appointment that I call the “panoramic reset appointment.” From this, I evaluated root parallelism and other factors to determine if I needed to reposition brackets. At the final records exam, we would take a cephalometric X-ray and another panoramic X-ray. For “observation” patients, we needed an initial cephalometric and panoramic and annual follow- up panoramic radiographs; then, at the start of treatment, we would take a cephalometric and a panoramic radiograph and continue with the usual radiographic protocol until treatment completion. With my CBCT system, instead of “the many,” I’m down to “the one.” Every patient gets an initial full volume 3D scan, and if I need to get a progress panoramic X-ray at the panoramic reset appointment, I am most grateful that my cone beam system has the ability to take a 2D standard panoramic radiograph as well.

A full-field-of-view CBCT scan is invaluable. While CBCT units with a small field of view are currently available, it’s my opinion that for an orthodontic practice the large field of view provides greater benefits. Consider this: A view of craniofacial anatomical landmarks is needed for efficient orthodontic case planning, and the information obtained from complete facial structures and anatomical relationships is imperative for all types of orthodontic treatment, including facial reconstructive and orthognathic surgeries. With my full-field-of-view scanner, in about nine seconds I have the benefit of true orthogonal images, panoramic, lateral cephalometric, frontal cephalometric, paranasal sinuses, TMJ and airway views. With all of that data, even if I want to review a patient’s TMJ status two years later, I have the great benefit of having the initial full-volume scan. While I may not have considered the necessity of tomograms on that patient’s joints during the initial visit, now I have every conceivable view readily available. Just by virtue of telling my software exactly what it is I am looking for in the data cloud, I can reconstruct any view at any time. With the full-volume scans I obtain, I can even create 3D digital models.

CBCT scans truly facilitate patient education, which translates to more starts. If my younger patients have difficulty in understanding a particular problem or obstacle that I need to overcome for their orthodontic treatment, I can show them their 3D skeletal structure and the way their primary teeth are related to their permanent dentition, giving them a clearer picture of what I am attempting to diagnose and treat. With this tremendous educational tool, my younger patients and their parents understand what I am trying to do, why I am doing it, and why we need to start at a certain time.



So that parents do not worry about radiation exposure, I have effective dose comparison data that shows that my in-office CBCT emits 10 times less radiation than a medical CT scan of the same area. I explain to them as necessary, that the full field of view scan of their child gives me much more information than a traditional 2D X-ray. I feel comfortable and justified in my decision to use a CBCT scanner as my primary radiographic instrument.

Assistance and education are available to boost confidence in reading these scans responsibly. Since I was a surgeon before embracing orthodontics, I am very comfortable evaluating a CT scan. If I find an anomaly, I have a protocol in place for sending it out to an oral maxillofacial radiologist. For a simple e-mail and $75, he assesses the full-volume DICOM data and sends me a 2-page printed report. I follow up with a specialist, as necessary. Certainly not every scan needs a radiologists’ review. Learning about reading a CBCT scan can be compared to dental students looking at their first panoramic X-ray. Now, as educated orthodontists, we would chuckle if someone asked if we should send a pan out to a radiologist. That same concept applies to CBCT technology.

The cone beam’s clarity and detailed 3D images offer an element of reliability to diagnosis. For example, a few years ago a California jury determined that CBCT could have avoided a misplaced dental implant and subsequent facial pain. Dr. Donald Machen, a recognized authority on risk management in the orthodontic office (who is also a board certified orthodontist, physician, lawyer and a trial court judge) agrees that the learning curve for new technology can be successfully navigated. He says, “Accepting that each practitioner has dedicated their professional life to providing high quality treatment to patients, each will develop the skills needed to evaluate the technology used in their practice.” He adds, “Suspicious pathology should be promptly disclosed to the patient, and a diagnosis, treatment plan or informed consent given, or if the practitioner prefers, referral to another practitioner” or specialist in the field.

Education offers us new insight. Dr. Machen further advises, “Practitioners are well advised to receive some additional education and training on evaluation and interpretation, just as for any new technology that they intend to use.” Opportunities abound for learning – Webinars, seminars, symposiums and Congresses, such as those offered by the 3D Imaging Institute, provide instruction on a wide array of topics. Clinicians can learn how to fully take advantage of cone beam data, recognize deviations in anatomy, and how to integrate 3D scans with other 3D imaging and planning applications.

Cone beam technology is evolving into the standard of care in the orthodontic practice. This field of view has affected my point of view on imaging. The scans have helped me to achieve some novel orthodontic results and have had such a positive impact on my practice that I couldn’t imagine practicing without it.
Author’s Bio
Dr. John Graham, DDS, MD lectures worldwide to both doctors and orthodontic staff on the most advanced orthodontic treatment philosophies available. He received his Bachelor of Science degree from Brigham Young University, a dental degree from Baylor College of Dentistry in Dallas, Texas, and then a medical degree from the University of Texas Southwestern Medical School. After medical school, Dr. Graham completed an internship in general surgery at Parkland Memorial Hospital followed by training in oral and maxillofacial surgery. Following his surgical training, Dr. Graham received his certificate in orthodontics from the University of Rochester/Eastman Dental Center in Rochester, New York. He is a featured speaker at the 4th international Congress on 3D Dental Imaging in La Jolla, California.
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September 2025
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