Vol. 116 No.

2 August 2013

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. (Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116:
238-257)

Malocclusions and craniofacial anomalies adversely SCOPE AND PURPOSE OF THE

affect quality of life. Orthodontics and dentofacial RECOMMENDATIONS AND CONCLUSIONS
orthopedic treatment address the correction of maloc- This position statement was developed by board-certified
clusions and facial disproportions due to dental/skeletal orthodontists and oral and maxillofacial radiologists
discrepancies to provide esthetic, psychosocial, and convened by the American Academy of Oral and
functional improvements. For almost a century, two- Maxillofacial Radiology (AAOMR). Their objectives
dimensional (2D) planar radiographic imaging and were to 1) review and evaluate critically the current
cephalometry have been used to assess the interrela- science, guidance and other resources available from
tionships of the dentition, maxillofacial skeleton, and professional organizations on the clinical benefits and
soft tissues in all phases of the management of ortho- potential limitations of the use of CBCT in orthodontics,
dontic patients, including diagnosis, treatment planning, and 2) develop consensus derived, orthodontic-specific
evaluation of growth and development, assessment clinical guidelines. Imaging selection recommendations,
of treatment progress and outcomes, and retention. optimization protocols and radiation-dose, risk-assess-
However, the limitations of 2D imaging have been ment strategies were developed to assist professional
realized for decades as many orthodontic and dentofacial clinical judgment on the use of CBCT in orthodontics. The
orthopedic problems involve the lateral or “third panel concluded that there is no clear evidence to support
dimension.”1-3 For instance, relapse of and unfavorable the routine use of ionizing radiation in standard ortho-
responses to orthodontic therapy remain poorly under- dontic diagnosis and treatment planning, including the use
stood despite implications that considerations in the of CBCT.
transverse plane are important factors in stability.4
For years, multiple radiographic projections were ob-
tained to attempt to display complex anatomic relation- BACKGROUND
ships and surrounding structures; however, interpreting Imaging considerations in orthodontic therapy
multiple-image inputs is challenging. With the increasing One purpose of radiographic imaging in orthodontics is
availability of multi-slice computed tomography (CT) to supplement clinical diagnosis in the pretreatment
and, more recently, cone beam computed tomography assessment of the orthodontic patient. Radiographic
(CBCT), visualization of these relationships in three imaging may also be performed during treatment to
dimensions is now feasible. 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
Received for publication Jun 1, 2013; accepted for publication Jun 3,
2013.
technique, 2) acquisition of appropriate images, and 3)
Ó 2013 Published by Elsevier Inc. interpretation of the images obtained. In some instances,
2212-4403/$ - see front matter these steps need to be repeated. Selection of the appro-
http://dx.doi.org/10.1016/j.oooo.2013.06.002 priate radiographic imaging technique (or techniques) is

238
OOOO ORIGINAL ARTICLE
Volume 116, Number 2 American Academy of Oral and Maxillofacial Radiology 239

based on the principle that practitioners who use imaging software techniques are readily available (e.g., maximum
with ionizing radiation have a professional responsibility intensity projection and surface or volumetric rendering)
of beneficencedthat imaging is performed to “serve the that provide three-dimensional visualization of the max-
patient’s best interests.” This requires that each radiation illofacial skeleton, airway space and soft tissue bound-
exposure is justified clinically and that procedures are aries such as the facial outline. The current diagnostic uses
applied that minimize patient radiation exposure while of CBCT are summarized in Appendix A.21-158
optimizing maximal diagnostic benefit. The extension of
this principle, referred to as the “as low as reasonably Evidence based assessments
achievable” (ALARA),5 to CBCT imaging is supported The potential for extracting additional diagnostic
by the American Dental Association.6 Justification of information from volumetric imaging and the technical
every radiographic exposure must be based primarily on ease of obtaining scans has led some clinicians and
the individual patient’s presentation including consid- manufacturers to advocate the replacement of current
erations of the chief complaint, medical and dental conventional imaging modalities with CBCT for stan-
history, and assessment of the physical status (as deter- dard orthodontic diagnosis and treatment.15,18,159,160
mined with a thorough clinical examination) and treat- Although CBCT imaging increases clinician confidence
ment goals.6 in orthodontic diagnosis161 and has demonstrated clin-
In 1987, a panel of representatives from general ical efficacy in altering treatment planning for impacted
dentistry and various academic disciplines in the United maxillary canines,37,43,161 unerupted teeth, severe root
States was convened by the Food and Drug Administra- resorption, and severe skeletal discrepancies,161 no
tion. This panel published broad selection recommenda- benefit has been demonstrated for patients specifically
tions for intraoral radiographic examinations.7 These referred for abnormalities of the temporomandibular
were updated in 2004.8,9 The guidelines suggest that for joint, airway assessment or dental crowding.161 Despite
monitoring growth and development of children and the number of publications on the use of CBCT for
adolescents, “clinical judgment be used in determining specific orthodontic applications, most are observa-
the need for, and type of radiographic images necessary tional studies of diagnostic performance and efficacy
for, evaluation and/or monitoring of dentofacial growth with wide ranging methodological soundness.162 Few
and development.” In both the European Union10-12 and authors have presented higher levels of evidence and
the United Kingdom13 orthodontic imaging guidelines measured the impact of CBCT on orthodontic diagnosis
state that there is neither an indication for taking radio- and treatment planning decisions.
graphs routinely before clinical examinations nor for Fundamentals to guideline development are system-
taking a standard series of radiographic images for all atic reviews of the published literature. Systematic
orthodontic patients. The latter document provides clin- reviews use well-defined and reproducible literature
ical decision algorithms based on the ages of the patients search strategies to identify evidence focused on
(less than or over 9 years of age) and clinical presentation a specific research question. Evidence is graded
(delayed or ectopic eruption, crowding, or anteroposterior according to its level of methodological rigor (or
discrepancies such as overjet or overbite, etc.). quality), relevance and strength. There is a lack of
CBCT-orthodontic systematic reviews. There is a need
CBCT imaging in orthodontics for rigorous investigation on the efficacy of CBCT
There has been a dramatic increase in the use of CBCT in imaging for all aspects of orthodontics related to its
dentistry over the last decade. This technology has found influence on therapy decisions and ultimately patient
particular applications in orthodontics for diagnosis outcome.163 Because of the lack of CBCT-orthodontic
and treatment planning for both adult and pediatric systematic reviews, the panel used consensus and pub-
patients.14-20 CBCT imaging provides two unique lished criteria.164-168 to develop three hierarchical
features for orthodontic practice. The first is that recommendations for CBCT imaging in orthodontics
numerous linear (e.g., lateral and posteroanterior cepha- (Table I). An important consideration in the use of
lometric images) or curved planar projections (e.g., CBCT is that ionizing radiation is a risk to patient health.
simulated panoramic images) currently used in ortho-
dontic diagnosis, cephalometric analysis, and treatment Radiation dose considerations in orthodontics
planning can be derived from a single CBCT scan. This There are two broad potential harmful effects of ionizing
provides for greater clinical efficiency. The second, and radiation in orthodontics. The first is deterministic
most important, is that CBCT data can be reconstructed to effects that cause the death of cells from high doses over
provide unique images previously unavailable in ortho- short periods of time and usually occur only after
dontic practice. Innately CBCT data are presented as thresholds are reached. Below these thresholds no clin-
inter-relational undistorted images in three orthogonal ical change has been reported. These levels are never
planes (i.e., axial, sagittal, and coronal); however, reached for a single exposure in the diagnostic range
ORAL AND MAXILLOFACIAL RADIOLOGY OOOO
240 American Academy of Oral and Maxillofacial Radiology August 2013

Table I. Panel consensus recommendations for use of in children.174 It was found that children and young
CBCT imaging* adults who received radiation doses from the equivalent
Recommendation Consensus level Definition
of 2 or 3 medical CT scans of the head have almost
triple the risk of developing leukemia or brain cancer
Likely indicated I The use of CBCT imaging is
indicated in most later in life. Medical CT head scans may have an
circumstances for this effective dose of up to 2000 mSv175; however, for
clinical condition. There is CT examinations with dental protocols, substantial
an adequate body of reductions to less than 1000 mSv have been re-
evidence to indicate
ported.159,176-184 Most CBCT examinations impart
a favorable benefit from the
procedure relative to the a fraction of medical CT effective dose; however, doses
radiation risk in the vary considerably among CBCT units.90,137,159,176-196
majority of situations. Low-dose radiographic procedures (including maxil-
Possibly indicated II The use of CBCT imaging lofacial CBCT) are those that result in doses below
may be indicated in certain
about 1,00,000 mSv. The risk of cancer induction
circumstances for this
clinical condition. There is caused by low-dose radiographic procedures is difficult
a sufficient body of to assess. While there is lack of agreement among
evidence to indicate radiation epidemiologists and radiobiologists, there is
a possible favorable benefit consensus among the four authoritative agencies in the
from the procedure relative
United States responsible for developing public-health,
to the radiation risk in
many situations. radiation-safety directives that for stochastic risks, such
Likely not indicated III The use of CBCT imaging is as carcinogenesis, the risks should be considered to be
not indicated in the linearly related to doses, down to the lowest doses.197-200
majority of circumstances The assessment of risk is, however, confounded in that
for this clinical condition.
people are exposed to background radiation, including
There is an insufficient
body of evidence to cosmic radiation from airline flights and/or living at high
indicate a benefit from the altitudes. For this position statement, the panel reviewed
procedure relative to the information on the potential health effects of exposure to
radiation risk in most diagnostic ionizing radiation. There is neither convincing
situations.
evidence for carcinogenesis at the level of dental expo-
*In the future, if CBCT imaging radiation levels are equivalent to sures, nor the absence of evidence of such damage. This
conventional modalities, this table may be less relevant. 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
used in conventional oral and maxillofacial radiology. a risk exists. This implies that there is no safe limit or
They do, however, occur in dental patients who have “safety zone” for ionizing radiation exposure in diag-
cancer and undergo radiotherapy to the head and neck nostic imaging. Every exposure cumulatively increases
region. One example of this is radiation-induced oral the risk of cancer induction. Consequently, to be
mucositis. The second effect is a stochastic effect that cautious, the guidelines presented in this position state-
irreversibly alters the cells, usually by damaging cellular ment are focused on minimizing or eliminating unnec-
DNA. Such damage can result in cancer. The long-term essary radiation exposure in diagnostic imaging.
risk associated with diagnostic radiographic imaging is The overall biological effect of exposure to ionizing
radiation-induced carcinogenesis. Unlike deterministic radiation, expressed as the risk of cancer development
effects, stochastic effects can result from low levels of over a lifetime, is determined from absorbed radiation
radiation that are cumulative over time. dose to specific organs in combination with weighting
Assessment of the risks associated with the use of factors that account for differences in exposed-tissue
ionizing radiation for diagnostic imaging is an impor- sensitivity and patient susceptibility factors such as
tant public health issue. Recent reports have increased gender and age. For this position statement, the Inter-
concerns over the potential association between radia- national Commission on Radiological Protection
tion exposure and cancer. In one article, a relationship (ICRP)’s effective dose (E) method was used to estimate
was found between intracranial meningiomas and whole body dose and measure stochastic radiation risks
dental radiographic procedures169; however, numerous to patients based on evidence of biological effects
rebuttal articles have highlighted limitations in this currently available.201 Effective dose is calculated by
study.170-173 Most recently, the results of a retrospective multiplying organ doses by risk weighting factors (which
cohort study provide evidence of a link between are the organs’ relative radiosensitivities to developing
exposure to radiation from medical CT and cancer risk cancers). The sum of the products for all of the organs is
OOOO ORIGINAL ARTICLE
Volume 116, Number 2 American Academy of Oral and Maxillofacial Radiology 241

the effective whole-body dose (effective dose).201 The Table II. Estimations of relative radiation level desig-
estimated risk weighting factors have recently been nations for children and adults for orthodontic imaging
revised, and a number of additional tissues found in the (with permission from ACR,* 2011)
head and neck region have been included (most impor- Effective dose estimate range (mSv)
tantly the salivary glands, lymphatic nodes, muscle, and
Relative radiation level Adult Childy
oral mucosa).197 These modifications have resulted in
0 0 0
substantial increases (ranging from 32% to 422%) in
<100 <30
effective doses for specific maxillofacial radiographic 100-1000 30-300
procedures.177 1000-10,000 300-3000
The effective dose for CBCT radiographic imaging 10,000-30,000 3,000-10,000
used for orthodontic records is of particular concern, *Some of the information in this document was provided with
especially as the modal age for initiating orthodontic permission from the American College of Radiology (ACR) and
treatment represents a pediatric population. The radiation taken from the ACR Appropriateness Criteria. The ACR is not
risk to ionizing radiation is greater for young children responsible for any deviations from original ACR Appropriateness
than for adolescents and adults because: 1) the rate of Criteria content.
y
Child is defined as any individual less than 18 years of age.
cellular growth and organ development (when radio-
sensitivity is highest) is greater in young children; 2)
children have longer life expectancies, so the cumulative GUIDELINES FOR CBCT IN ORTHODONTICS
effects of radiation exposures have longer time periods in The choice of modality used for imaging an orthodontic
which they can cause cancers; 3) with CBCT imaging, patient is based on a risk/benefit assessment (i.e., the risk
specific organ and effective doses, (particularly the to the patient attributable to radiation exposure in rela-
salivary glands) are, on average, 30% higher for young tionship to the benefit to the patient from imaging
children than for adolescents183; and 4) unless specific, procedure). Assessment of clinical benefit is primarily
pediatric, exposureereduction techniques are incorpo- patient and practitioner dependent but should be based
rated, the radiation doses for children (small patients) on the application of sound imaging selection principles.
may exceed typical adult radiation levels (with some As part of this position statement, the following guide-
currently available CBCT units, it is not possible to lines are suggested for the use of CBCT in orthodontics:
implement exposureereduction techniques). In sum, it is
1. Image appropriately according to clinical condition
estimated that children may be two to ten times or more
2. Assess the radiation dose risk
prone to radiation-induced carcinogenesis than mature
3. Minimize patient radiation exposure
adults.175,200-202 Because it is important to consider the
4. Maintain professional competency in performing and
increased risks associated with exposing children to
interpreting CBCT studies
ionizing radiation, the American College of Radiology
(ACR) has incorporated pediatric, effective-dose esti-
mates in relative radiation level (RRL) designations for 1. Image appropriately according to clinical
specific imaging procedures (Table II).203 In addition, condition
there are at least two national radiation safety initiatives Recently the American Dental Association Council on
to raise awareness of using lower radiation doses Scientific Affairs issued an advisory statement on the use
to image children: Image Gently204 and the National of CBCT in dentistry. The AAOMR contributed to the
Children’s Dose Registry.205 The AAOMR sought, statement,6 which is based on the ALARA principle and
and received, permission to adopt the ACR, relative- acknowledges the increased sensitivity of pediatric
radiation-level designations for several reasons: First, patients to ionizing radiation and recognizes that patients
this scheme provides a relative assessment of radiation present with varying degrees of orthodontic complexity.
dose risk based on the premise that with an exposure of The panel recommends the following general strategies
10,000 mSv, there is a risk of 1 in 1000 individuals for the use of CBCT in orthodontics:
developing cancer; second, the risk is related to diag- Recommendation 1.1. The decision to perform a
nostic imaging only (and is unrelated to considerations of CBCT examination is based on the patient’s history,
background radiation exposure); and three, risk assess- clinical examination, available radiographic imaging,
ment incorporates increased pediatric radiation sensi- and the presence of a clinical condition for which the
tivity considerations. benefits to the diagnosis and/or treatment plan outweigh
For all imaging procedures using ionizing radiation, the the potential risks of exposure to radiation, especially in
clinical benefits should be balanced against the potential the case of a child or young adult.
radiation risks, which are determined by the relative Recommendation 1.2. Use CBCT when the clinical
radiosensitivity of those being imaged and the abilities of question for which imaging is required cannot be
the operators to control radiation exposures. answered adequately by lower-dose conventional
ORAL AND MAXILLOFACIAL RADIOLOGY OOOO
242 American Academy of Oral and Maxillofacial Radiology August 2013

dental radiography or alternate non-ionizing imaging

and/or symptoms

CBCT, cone beam computed tomography; Field of View (FOV): FOVs ¼ Small FOV CBCT imaging; FOVm ¼ Medium FOV CBCT imaging; FOVl ¼ Large FOV CBCT imaging. Consensus Recom-
TMJ signs
modalities.

FOVs,m (III)
FOVm,l (II)
FOVm,l (II)
Presurgical FOVm,l (I) Presurgical FOVm,l (II) Presurgical FOVm,l (II) Presurgical FOVm,l (II) FOVm,l (II)
FOVm,l (II)
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 ortho-
dontic study models).
Recommendation 1.4. Use a CBCT protocol that

discrepancies
Transverse
restricts the field of view (FOV), minimizes exposure
(mA and kVp), the number of basis images, and reso-

FOVm,l (II)
FOVm,l (II)
FOVm,l (II)

FOVm,l (II)
lution 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 pano-
ramic view if the CBCT would result in higher radiation

discrepancies
Vertical
exposure than would conventional imaging.

FOVm,l (II)
FOVm,l (II)
FOVm,l (II)

FOVm,l (II)
Recommendation 1.6. Avoid taking conventional 2D
radiographs if the clinical examination indicates that

Table III. Imaging selection recommendations for the use of cone beam computed tomography in orthodontics
a CBCT study is indicated for proper diagnosis and/or

Dental and skeletal clinical conditions

treatment planning or if a recent CBCT study is
available.

Anteroposterior
discrepancies
To assist clinicians in defining the scope of ortho-
dontic conditions and the most appropriate CBCT

FOVm,l (II)
FOVm,l (II)
FOVm,l (II)

FOVm,l (II)
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
Asymmetry
additional skeletal and dental conditions. The table rows
list orthodontic phases of treatments and treatment
FOVm,l (II)
FOVm,l (II)
FOVm,l (II)

FOVm,l (II)
difficulty categories and columns list dental and skeletal
clinical conditions. Within each cell, the overall suit-
ability of the CBCT procedure (Table I) and most

mendations: I ¼ Likely Indicated; II ¼ Possibly Indicated; III ¼ Likely Not Indicated.

dento-alveolar
Anomalies in Compromised

appropriate FOV are provided. Table IV describes the

boundaries

(III)
(II)
(II)
(II)
(II)

three FOV ranges most commonly encountered in

FOVs,m
FOVs,m
FOVs,m
FOVs,m
FOVs,m

orthodontic imaging. The concerns in selecting a CBCT

FOV are the inclusion of the region of clinical impor-
tance and the collimation of the radiation beam to that
(III)
position

(II)
dental

specific region. The rational for orthodontic image

(I)
(I)
(I)
FOVS
FOVS
FOVS
FOVS
FOVS

selection recommendations is in Appendix B.

2. Assess the radiation dose risk

(III)
(III)
anomalies
structure

(I)
(I)
(I)
Dental

Orthodontists must be knowledgeable of the radiation risk

FOVS
FOVS
FOVS
FOVS
FOVS

of performing CBCT and be able to communicate this risk

to their patients. Radiation risk has most often been esti-
Moderate FOVm,l (II)

mated by calculating the effective dose201 of a CBCT scan

FOVl (II)
None

and comparing this value to; 1) measurements obtained

III

III
III

from comparable imaging modalities (e.g., multiples of

Treatment

typical panoramic images or a multi-slice medical CT),

difficulty

Severe

2) background equivalent radiation time (e.g., days of

Mild

background), or 3) radiation detriment [e.g., probability of

Presentation

x cancers per million scans (stochastic-cancer rate)]. Often

During treatment
Posttreatment

the base unit of these comparisons (typical panoramic

Primary
Pretreatment

dose, background radiation, weighted probabilities of fatal

and nonfatal cancers) is variable and not absolute. This
means, for example, that depending on the panoramic
OOOO ORIGINAL ARTICLE
Volume 116, Number 2 American Academy of Oral and Maxillofacial Radiology 243

Table IV. Definition of cone beam computed tomog- the effective doses for specific orthodontic protocols and
raphy field of view (FOV) ranges for orthodontic various modalities. Appendix C provides an example of
imaging the calculation of RRL for Orthodontic Imaging.
FOV Abbreviation Definition
Recommendation 2.2. Because CBCT exposes
patients to ionizing radiation that may pose elevated
Small FOVs A region of radiation
exposure that is limited to risks to some patients (pregnant or younger patients),
a few teeth, a quadrant, and explain and disclosure to patients radiation exposure
up to two dental arches and risks, benefits and imaging modality alternatives and
that has a spherical volume document this in the patients’ records.
diameter or cylinder height
10 cm.
Medium FOVm A region of radiation
exposure that includes the 3. Minimize patient radiation exposure
dentition of at least one Depending on the equipment type and operator prefer-
arch up to both dental ences, operators can alter radiation doses to patients by
arches and that has
adjusting various exposure (e.g., milliamperage, kilo-
a spherical volume
diameter or cylinder height voltage), image-quality (e.g., number of basis images,
>10 cm and 15 cm. resolution, arc of trajectory) and beam-collimation (e.g.,
Large FOVl A region of radiation FOV) settings. CBCT units from different manufacturers
exposure that includes the vary in dose by as much as 10-fold for an equivalent
TMJ articulations and
FOV examination (Table V).184 In addition, adjustments
anatomic landmarks
necessary for quantitative of exposure factors to improve image quality are avail-
cephalometric and/or able in many CBCT units and can cause as much as
airway assessment and that 7-fold differences in patient doses (Table V).184 If CBCT
has a spherical volume imaging is warranted, appropriate selection of the FOV
diameter or cylinder height
to match the region of interest (ROI) may provide
>15 cm.
a substantial dose savings.
Based on these considerations, the following specific
image dose used for the comparison (e.g., equipment recommendations are made to minimize patient radia-
manufacturer and model, film vs. digital acquisition) the tion exposure for CBCT in orthodontics:
risk for CBCT may be reported either conservatively or Recommendation 3.1. Perform CBCT imaging with
liberally compared to panoramic radiography. acquisition parameters adjusted to the nominal settings
To standardize comparison of radiation dose risk consistent with providing appropriate images of task-
between various imaging procedures, this position specific diagnostic quality for the desired diagnostic
statement recommends the use of RRLs (Table II). information required: 1) Use a pulsed exposure mode of
The RRL for various imaging examinations used acquisition, 2) Optimize exposure settings (mA, kVp),
either as an isolated procedure or for a course of 3) Reduce the number of basis projection images, and
orthodontics can be determined for adults and 4) Employ dose reduction protocols (e.g., reduced
children using published effective dose calculations resolution) when possible.
(Table VI).90,159,176-196,206,207 Calculations of RRL Recommendation 3.2. When other factors remain the
levels in millisieverts (mSv; 1mSv ¼ 1000 mSv) were same, reduce the size of the FOV to match the ROI;
made with methods described elsewhere,197 and data however, selection of FOV may result in automatic or
from the 7th Biological Effects of Ionizing Radiation default changes in other technical factors (e.g., mAs)
report.208 The estimate in the report, and the basis for that should be considered because these concomitant
subsequent levels of radiation risk, is that approxi- changes can result in an increase in dose.
mately 1 in 1000 individuals develop cancer from an Recommendation 3.3. Use patient protective shield-
exposure of 10,000 mSv.197 RRL assignments are based ing (such as, lead torso aprons and consider the use of
on reviews of current literature. These assignments are thyroid shields) when possible (e.g., maxillary only
revised periodically, as practice evolves and further scan), to minimize exposure to radiosensitive organs
information becomes available. outside the FOV of the exposure.
Based on these considerations, the following recom- Recommendation 3.4. Ensure that all CBCT equip-
mendations are suggested for assessing patient radiation ment is properly installed, routinely calibrated and
dose risk for CBCT in orthodontics: updated, and meets all governmental requirements and
Recommendation 2.1. Consider the RRL (Table II) regulations.
when assessing the imaging risk for imaging procedures Appendix C provides an example of the calculation
over a course of orthodontic treatment. Table V contains of the RRL for both adults and children with and
 244
ORAL AND MAXILLOFACIAL RADIOLOGY
Table V. Selected published effective doses (EICRP, 2007) in microSieverts [mSv] 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

American Academy of Oral and Maxillofacial Radiology

Examination CBCT unit Scanning volume (cm2) Protocol E (mSv)Reference
Large FOV CBCT (>15 cm 3DeXAM 17  23 0.4 mm resolution 72196
height/diameter) 3D Accuitomo 170 17  12 Adolescent; 10 years old 216183; 282183
CB MercuRay 15  15 Maxillofacial/TMJ 436184; 569184; 680195;
511180/43690
20  20 SR/HR/TMJ 558177; 761195/1025177;
1073184/91690
Galileos 15  15 High/low dose 128184/70184
Galileos Comfort 15  15 Adult; adolescent; 10 years 84191; 71183; 70183
old
i-CAT Classic 16  22 Low/high resolution 65-69192; 193177; 82178;
206186; 110181/127-131192
i-CAT Next Generation 23  17 74 ; 78190
184

Iluma 19  19 Standard/ultra 98184/498184

Iluma Elite 21  14 368191
KODAK 9500 18  20 With; without filtration 136191; 166188/260188
NewTom 3G 15  15/20  20 57178/59177; 68184
NewTom 9000 15  15 56159; 95193; 52184
Newtom VGi 15  15 194191
Skyview 3D 17  17 Adult; adolescent; 10 years 87191; 90183; 105183
old
Medium FOV CBCT 3DeXAM 13  16 0.3 mm resolution 107196
(>10 cm and 15 cm height/ 3D Accuitomo 170 10  14 Adolescent; 10 years old 188183; 237183
diameter) CB Mercuray 10  10 Maxillofacial/TMJ imaging 283177; 407184; 603195/28390
i-CAT Classic 13  16 61159; 105177; 134186; 69184
i-CAT Next Generation 13  16 Adult; adolescent; 10 years 87184; 83191; 77190; 82183;
old 134183
NewTom VG 11  15 Adult; adolescent; 10 years 83191; 81183; 114183
old
Scanora 3D 13.5  14.5 Adult; adolescent; 10 years 68191; 74183; 85183
old
Small FOV CBCT (10 cm 3DeXAM 5  10 Man 111182
height/diameter)
8  16 0.25; 0.30 resolution 170196; 45196
4  16 Max 0.125 mm; 0.3 mm 68196; 33196/76196; 38196
resolution/man 0.125 mm;
0.3 mm resolution
88 0.125 mm; 0.3 mm resolution 122196; 62196

August 2013
3D Accuitomo IID 34 27179
3D Accuitomo FPD 4  4/6  6 102180; 20185/43185; 50180;

OOOO
166179
Table V. Continued

Volume 116, Number 2

OOOO
Examination CBCT unit Scanning volume (cm2) Protocol E (mSv)Reference
3D Accuitomo 170 44 Man adult; adolescent; 43191
; 32183; 28183
10 year old
5  10 Max 54191
5  14 Max adolescent; 10 years old 70183; 214183
AZ3000CT 7.9  7.1 333182
i-CAT Classic 6  16 Man SR; HR/Mx SR; HR 96186; 189186/59186; 93186
i-CAT Next Generation 6  16 Man SR; HR/Max SR; HR 74184; 45191; 58190; 113190/
32190; 60190
6  16 Max adolescent; 10 year old/ 33183; 43183/49183; 63183
man adolescent; 10 year
old
Implagraphy 58 83182
KODAK 9500 5  15/9  15 Without; with filtration 93188; 76188/92191; 163188;
98188
KODAK 9000 3D 5  3.7 Max anterior adult; 10 years 19191; 16183/40191; 24183
old/man molar adult;
adolescent
Newtom VGi 8  12 265191
Pan eXam Plus 3D 4.1  6.1 Max 0.133 mm; 0.2 mm 79196; 40196/115196; 49196
resolution/man 0.133 mm;
0.2 mm resolution

American Academy of Oral and Maxillofacial Radiology 245

7.8  6.4 Max 0.2 mm; 0.3 mm 125196; 79196/184196; 110196
resolution/man 0.2 mm;
0.3 mm resolution
Picasso Trio 7  12 Low/high dose 81191/123191
PreXion 8.1  7.6 High/standard resolution 388184/189184
6  16 Max adolescent; 10 years old/ 33183; 43183/49183; 63183
man adolescent, 10 years
old
ProMax 3D 88 High/standard/low 674179; 652184; 122191;
306193/197193/488184;
30187; 28191
8 8 Adolescent; 10 years old 18183; 28183
Pax-Uni3D 5 5 Max anterior 44191
Scanora 3D 6 6 91179
7.5  10 Max/man/both 46191/47191/45191
 10

ORIGINAL ARTICLE
7.5 Adolescent; 10 year old 52183; 67183
Veraviewepocs 3D 4  4/4  8/6  6/8  8 31185/40185/40185/73191
(continued on next page)
Table V. Continued

246
ORAL AND MAXILLOFACIAL RADIOLOGY
Examination CBCT unit Scanning volume (cm2) Protocol E (mSv)Reference

American Academy of Oral and Maxillofacial Radiology

MSCT Siemens Somatom Lower jaw/head Head sensation 16; volume 474 ; 494178/995178;
178

zoom 4 1110178
Lower jaw Sensation 10; emotion 6 426182; 199182
10  12 Sensation 64 430159; 860-534177
20  12.8/11.7 Sensation 64 adolescent; 1047183; 605183
10 years old
Philips Mx8000IDT Lower jaw; head 541178; 1160178
GE 4 Slice CT 34.8 25 685179
GE 64 Slice CT 25  41.25 1410179
Toshiba Aquilion 64 94 990181
HiSpeed QX/I 7.7 15 769180
Panoramic Planmeca Promax N/A Film; CCD 26207; 24.3184
Planmeca PM Proline 2000 N/A High; low dose 38207; 12207
Veraviewepocs 15  10 Adolescent 6183
Sirona Orthophos DS 15  11; XGplus 23  15 10159; 50181
Instrumentarium OP100 30  15 21.5192
Cephalometric PSP N/A Lat ceph 5.6184
Orthophos DS 18  15 Lat ceph 10159
Instrumentarium OC 100 24  18 Lat ceph 4.5192
Veraviewepocs 2D 20  20 Lat ceph 2183
Planmeca Promax PA N/A PA 5.1184
CBCT, cone beam computed tomography; PSP, photo-stimulable phosphor; CCD, charged coupled device-based technology; Max, maxillary; Man, mandibular; TMJ, temporomandibular joint; MSCT, multi-
slice computed tomography; HR, high resolution; SR, standard resolution; Lat ceph, lateral cephalometric image; PA, posteroanterior cephalometric image; N/A, not available.
Product/Manufacturer details: 3DeXAM (KaVo Dental GmbH, Biberach/Rib, Germany); 3D Accuitomo 170 (J. Morita Mfg. Corp., Kyoto, Japan); CB Mercuray (Hitachi Medical Systems, Kyoto, Japan);
Galileos (Sirona Dental Systems GmbH, Bensheim Germany); Galileos Comfort (Sirona Dental Systems GmbH, Bensheim Germany); i-CAT Classic (Imaging Sciences International, Hatfield, PA); i-CAT
Next Generation (Imaging Sciences International, Hatfield, PA); Iluma (Imtec (3M), Ardmore, OK); Iluma Elite (Imtec (3M), Ardmore, OK); KODAK 9500 (Kodak Dental Systems, Carestream Health,
Rochester, NY); NewTom 3G (Quantitative Radiology, Verona, Italy); NewTom 9000 (Quantitative Radiology, Verona, Italy); Newtom VGi (Quantitative Radiology, Verona, Italy); Skyview 3D (MyRay,
Cefla Dental Group, Imola, Italy); 3DeXAM (KaVo Dental GmbH, Biberach/Rib, Germany); 3D Accuitomo 170 (J. Morita Mfg. Corp., Kyoto, Japan); CB Mercuray (Hitachi Medical Systems, Kyoto,
Japan); i-CAT Classic (Imaging Sciences International, Hatfield, PA); i-CAT Next Generation (Imaging Sciences International, Hatfield, PA); NewTom VG (Quantitative Radiology, Verona, Italy); Scanora
3D (Soredex, Tuusula, Finland); 3DeXAM (KaVo Dental GmbH, Biberach/Rib, Germany); 3D Accuitomo IID (J. Morita Mfg. Corp., Kyoto, Japan); 3D Accuitomo FPD (J. Morita Mfg. Corp., Kyoto,
Japan); 3D Accuitomo 170 (J. Morita Mfg. Corp., Kyoto, Japan); AZ3000CT (Asahi Roentgen, Kyoto, Japan); i-CAT Classic (Imaging Sciences International, Hatfield, PA); i-CAT Next Generation (Imaging
Sciences International, Hatfield, PA); Implagraphy (Vatech, E-WOO Technology Co, Ltd. Republic of Korea); KODAK 9500 (Kodak Dental Systems, Carestream Health, Rochester, NY); KODAK 9000 3D
(Kodak Dental Systems, Carestream Health, Rochester, NY); Newtom VGi (Quantitative Radiology, Verona, Italy); Pan eXam Plus 3D (PaloDEx Group Oy, Tuusula, Finland); Picasso Trio (Vatech, Co, Ltd.
Republic of Korea); PreXion 3D (PreXion Inc., San Mateo, CA); ProMax 3D (Planmeca OY, Helsinki, Finland); Pax-Uni3D (Vatech, Technology Co, Ltd. Republic of Korea); Scanora 3D (Soredex,
Tuusula, Finland); Veraview epocs 3D (J. Morita Mfg. Corp., Kyoto, Japan); Siemens Somatom (Siemens Medical Solutions USA, Malvern, PA); Philips Mx8000IDT (Philips Medical Systems, Best, the
Netherlands); GE 4 slice CT (GE Medical Systems, Little Chalfont, UK); GE 64 slice CT (GE Medical Systems, Little Chalfont, UK); Toshiba Aquilion 64 (Toshiba Medical Systems Corporation, Tochigi,
Japan); HiSpeed QX/I (GE Medical Systems, Little Chalfont, UK); Planmeca Promax (Planmeca, Helsinki, Finland); Planmeca PM Proline 2000 (Planmeca, Helsinki, Finland); Veraview epocs (J. Morita
Mfg. Corp., Kyoto, Japan); Sirona Orthophos (Sirona Dental Systems GmbH, Bensheim Germany); Instrumentarium OP100 (Instrumentarium Dental, Tuusula, Finland); Orthophos DS (Sirona Dental
Systems GmbH, Bensheim Germany); Instrumentarium OC 100 (Instrumentarium Dental, Tuusula, Finland); Veraview epocs 2D (J. Morita Mfg. Corp., Kyoto, Japan); Planmeca Promax PA (Planmeca OY,

August 2013
Helsinki, Finland).

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Volume 116, Number 2 American Academy of Oral and Maxillofacial Radiology 247

Table VI. Examples of the calculation of the RRL associated with specific imaging protocols used in orthodontics
Relative
Stage of treatment Dose (mSv) radiation level*
Initial
Protocol Modality diagnostic Mid-treatment Post-treatment Sub-total Total Child Adult
y
Conventional imaging Panoramic þ þ þ 36 47.2
Lateral cephalogramz þ  þ 11.2
Conventional þ small FOV Panoramicy þ þ þ 36 107.2
CBCT Lateral cephalogramz þ  þ 11.2
Small FOV CBCTx þ   60
Large FOV Panoramicy  þ þ 24 112.6
CBCT þ conventional Lateral cephalogramz   þ 5.6
imaging Large FOV CBCTk þ   83
Large FOV CBCT Large FOV CBCTk þ þ þ 249 249
CBCT, cone beam computed tomography; FOV, field of view; CCD, charged coupled device technology; Sub-total, product of the times when the
modality is used at each stage over a course of treatment by the average effective dose per modality exposure; Total, sum of subtotals for a particular
orthodontic imaging protocol.
*American College of Radiology relative radiation level203; , child (<30 mSv), adult (<100 mSv); , child (<30-300 mSv), adult (100-
1000 mSv).
y
Planmeca PM Proline 2000 (low dose) e charged coupled device (12 mSv).207
z
Photostimulable storage phosphor (5.6 mSv).177
x
i-CAT Next Generation e Maxilla 6 cm FOV height, high resolution (60 mSv).190
k
i-CAT Next Generation e 16  13 cm (83 mSv).191

without CBCT imaging for representative orthodontic Recommendation 4.2. Clinicians have legal respon-
imaging protocols (Table VI). sibilities when operating CBCT equipment and inter-
preting images and are expected to comply with all
governmental and third party payer (e.g., Medicare)
4. Maintain professional competency in
regulations.
performing and interpreting CBCT studies
Recommendation 4.3. It is important that patients/
Orthodontists must be able to exercise judgment by
guardians know about the limitations of CBCT with
applying professional standards to all aspects of CBCT.
regard to visualization of soft tissues, artifacts and
Any radiographic image prescribed and/or performed
noise.
by a dental practitioner may contain information that is
important to the management or general health of the
patient. Incidental findings in CBCT images of ortho- EMERGING DEVELOPMENTS
dontic patients are common,209-213 and some are critical CBCT acquisition technology continues to develop and
to patient health.214 Clinicians who order or perform a number of innovations are proposed to improve image
CBCT for orthodontic patients are responsible for quality, increase utility and reduce radiation output.
interpreting the entire image volumes, just as they are These include the use of automatic exposure control
responsible for interpreting all regions of other radio- with photon counting, added filtration, flat panel
graphic images that they order.215,216 detectors with greater photon sensitivity, customizable
Based on these considerations, the following reco- FOV collimation, variable exposure parameters (mA,
mmendations are related to performing and interpreting kVp) and image quality settings (e.g., scan trajectory
CBCT studies: options and number of basis images). The image quality
Recommendation 4.1. Clinicians have an obligation and dose reductions purported by such innovations
to attain and improve their professional skills through should be assessed critically and verified by indepen-
lifelong learning in regards to performing CBCT ex- dent published research.
aminations as well as interpreting the resultant images.
Clinicians need to attend continuing education courses SUMMARY
(such as those offered by the American Dental Associ- The recommendations provided for the use of CBCT in
ation Continuing Education Recognition Program) to orthodontics are neither rigid guidelines nor do they
maintain familiarity with the technical and operational represent or imply a standard of care. While it is the
aspects of CBCT and to maintain current knowledge of responsibility of each practitioner to make a decision,
scientific advances and health risks associated with the along with the patient/family, as to what imaging is
use of CBCT. considered to be in the patient’s best interest, this
ORAL AND MAXILLOFACIAL RADIOLOGY OOOO
248 American Academy of Oral and Maxillofacial Radiology August 2013

position statement is intended to assist the clinician in 6. American Dental Association Council on Scientific Affairs. The
the decision making process. use of cone-beam tomography in dentistry. An advisory state-
ment from the American Dental Association Council on Scien-
This position statement supports and affirms the tific Affairs. J Am Dent Assoc. 2012;143:899-902.
position of the American Dental Association Council 7. Matteson SR, Joseph LP, Bottomley W, et al. The selection
on Scientific Affairs in that the selection of CBCT of patients for X-ray examinations: dental radiographic
imaging should be based on initial clinical evaluation examinations. In: Center for Devices and Radiological
and must be justified based on individual need.6 The Health, ed. U.S. Department of Health and Human Services,
Public Health Service, Food and Drug Administration;
perceived or actual benefits to the patient must 1987.
outweigh the radiation risks. Exposure of patients to 8. U.S. Department of Health and Human Services, Public Health
ionizing radiation must never be considered “routine.” Service, Food and Drug Administration; and American Dental
It is important to perform a thorough clinical exami- Association, Council on Dental Benefit Programs, Council on
nation prior to performing or ordering any radiographic Scientific Affairs. The Selection of Patients for Dental Radio-
graphic Examinations. Rev. ed. 2004. Available at: www.ada.
study. This position statement provides four guidelines org/prof/resources/topics/radiography.asp. Accessed May 26,
for CBCT use in orthodontic practice: 1) Image 2012.
appropriately by applying imaging selection recom- 9. American Dental Association Council on Scientific Affairs. The
mendations, 2) Assess the radiation dose risk, 3) use of dental radiographs: update and recommendations. J Am
Minimize patient radiation exposure and, 4) Maintain Dent Assoc. 2006;137:1304-1312.
10. Janssens A, Horner K, Rushton V, et al. Radiation Protection:
professional competency in performing and interpret- European Guidelines on Radiation Protection in Dental Radi-
ing CBCT studies. ologydthe Safe Use of Radiographs in Dental Practice, 2003.
Available at: www.sefm.es/docs/otros/raddigUE.pdf. Accessed
April 20, 2012.
Some of the information in this document was provided with 11. SEDENTEXCT Project. Chapter 4, Justification and referral
permission from the ACR and taken from the ACR Appro- criteria. The developing dentition. In: Radiation Protection: Cone
priateness Criteria. The ACR is not responsible for any Beam CT for Dental and Maxillofacial Radiology. Evidence
deviations from original ACR Appropriateness Criteria Based Guidelines 2011(v2.0 Final). 2011:36-48. Available
content. The panel gratefully acknowledges the contributions at: http://www.eadmfr.info/sites/default/files/guidelines_final.pdf.
of Dr. Michael M. Bornstein, Department of Oral Surgery and Accessed January 14, 2013.
Stomatology, School of Dental Medicine, University of Bern, 12. European Commission. Item 4.2 the Developing Dentition in
Bern, Switzerland and Professor Reinhilde Jacobs, Oral Protection Radiation No. 172. Cone Beam CT for Dental and
Maxillofacial Radiology (Evidence-based Guidelines). 2011:45-
Imaging Center, Department of Oral Health Sciences, KU
56. Available at: http://ec.europa.eu/energy/nuclear/radiation_
Leuven & Dentistry, University Hospitals Leuven, Belgium
protection/doc/publication/172.pdf. Accessed January 14, 2013.
for assistance in the development of Table V. 13. Isaacson KG, Thom AR, Horner K, Whaites E. Orthodontic
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Radiation Dose Assessment Introduction; 2011. Available at:
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204. The Alliance for Radiation Safety in Pediatric Imaging. Image teeth in clefts).14,22,27,33-50
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https://nrdr.acr.org/Portal/QuIRCC/Main/page.aspx. Accessed to that which can be determined by clinical examination
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53040-7, 2006:424. asymmetries.57-64
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211. Pazera P, Bornstein MM, Pazera A, Sendi P, Katsaros C. Inci-
dental maxillary sinus findings in orthodontic patients: a radio- Vertical discrepancies
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(CBCT). Orthod Craniofac Res. 2011;14:17-24. ically may suggest skeletal discrepancies related to
212. Gracco A, Incerti Parenti S, Ioele C, Alessandri Bonetti G,
Stellini E. Prevalence of incidental maxillary sinus findings vertical maxillary deficiency or excess and may present
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213. Drage N, Rogers S, Greenall C, Playle R. Incidental findings on
Transverse discrepancies
cone beam computed tomography in orthodontic patients. These anomalies may be present as either skeletal
J Orthod. 2013;40:29-37. lingual or buccal crossbites or discrepancies without the
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Volume 116, Number 2 American Academy of Oral and Maxillofacial Radiology 255

presence of crossbites in which there is excessive dental tooth and facial morphology of hard and soft tissues.
compensation of the bucco-lingual inclination of Studies on the morphological basis for craniofacial
posterior teeth.67,75,76 growth and response to treatment can help elucidate
clinical questions on variability of outcomes of treat-
Temporomandibular joint (TMJ) signs and/or ment, as well as clarify treatment effects and areas of
symptoms bone remodeling and displacement.
TMJ pathoses that result in alterations in the size, form,
quality and spatial relationships of the osseous joint Orthodontic mini-implants used as temporary
components may lead to skeletal and dental discrep- anchorage devices
ancies in the three planes of space. In affected condyles, Numerous authors have identified CBCT imaging
perturbed resorption and/or apposition can lead to as being clinically useful in identifying optimal
progressive bite changes and compensations in the site location for placement of orthodontic mini-
maxilla. In addition, tooth position, occlusion and the implants.67,75,134-151
articular fossa of the non-affected side of the mandible
can become involved. The sequelae of these changes
are unpredictable orthodontic outcomes. Such TMJ Maxillary expanders
conditions include developmental disorders such as CBCT imaging of maxillary transverse deficiencies
condylar hyperplasia, hypoplasia, or aplasia, arthritic treated with fixed and removable expanders has been
degeneration, persistently symptomatic joints, and bite reported of benefit in characterizing appliance specific
changes including progressive bite opening and limi- skeletal displacement, associated dental effects and
tation or deviation upon opening or closing.77-96 quantifying changes in skeletal dimensions of the nasal
cavity and maxillary sinus volume.51,152-158
Dentofacial deformities and craniofacial anomalies
CBCT imaging can facilitate analysis of these condi- APPENDIX B: RATIONAL FOR ORTHODONTIC
tions and be used to simulate virtual treatments and plan IMAGE SELECTION RECOMMENDATIONS
orthopedic corrections and orthognathic surgeries. The recommendations in Table III are based upon the
Computer-aided jaw surgery is increasing in use clini- complexity of the orthodontic case. The following were
cally because virtual plans accurately represent surgical considered in developing the recommendations.
procedures in the operating room.65,66,68-73,97-109

Selection of clinical conditions for indications of

Conditions that affect airway morphology CBCT use
A number of authors have used CBCT imaging to measure The most common clinical dental and skeletal condi-
airway dimensions and reported changes over time with tions in the orthodontic patient are presented as column
specific therapies including orthognathic surgery and headings in Table III.
particularly obstructive sleep apnea.18,111-131 There are
challenges in the use of CBCT clinically as the validity of
such measurements may vary.132,133 The boundaries of Definition of orthodontic treatment difficulty
the nasopharynx with the maxillary/paranasal sinuses and criteria
of the oropharynx with the oral cavity are often not The panel acknowledges the uniqueness of the facial
consistent among subjects and image acquisitions, and form of each patient and the inherent difficulty in
airway shapes and volumes vary markedly with dynamic attempting to assess the severity of malocclusion and
processes such as breathing and head postures. quantifying and categorizing orthodontic treatment
In addition, CBCT has been reported useful in need. For patients with severe malocclusions, there are,
preoperative assessment and/or postoperative evalua- however, more choices with regard to appropriate
tion of treatment outcomes for specific research appli- orthodontic treatments, and there is an increased need
cations including: for radiographic diagnostic input. For Table III,
malocclusion severity was categorized and anticipated
appropriateness of CBCT imaging was listed according
Specific surgical procedures to three levels of patient presentation:
Research in the areas of craniofacial growth and Mild. Patients present with dental malocclusions,
development as well as assessments of the short- and with or without minimal anteroposterior, vertical, or
long-term outcomes of various treatment regimens has transverse skeletal discrepancies. These patients are
the potential to benefit from CBCT assessments of treated usually with conventional biomechanics (with
longitudinal changes and diagnostic characterization of or without extraction). CBCT imaging is likely
ORAL AND MAXILLOFACIAL RADIOLOGY OOOO
256 American Academy of Oral and Maxillofacial Radiology August 2013

inappropriate for these patients unless they present with Age considerations
the additional clinical conditions noted. The choice of radiographic imaging method of a patient
Moderate. Patients present with dental and skeletal with clinically determined dental and/or skeletal
discrepancies that are treated orthodontically and/or modifying factors is dependent on the stage of growth
orthopedically only. These discrepancies include of the individual and age-related presentation of the
bimaxillary proclination, open bite, and compensated condition; therefore, recommendations for CBCT for
Class III malocclusion. CBCT imaging is possibly some dental/skeletal conditions are age dependent.
indicated for many of these patients as indicated. These conditions include:
Severe. Patients present with skeletal conditions Tooth structural anomalies. A CBCT examination
including, but not limited to complicated skeletal may be indicated when other diagnostic modalities
discrepancies, craniofacial anomalies (e.g., cleft lip and indicate a problem with root morphology or resorption
palate, craniofacial synostosis, etc.), sleep apnea, in the mixed and permanent dentitions.
speech disorders, and post oncology/trauma/resection/ Tooth positional or eruption anomalies. A possible
pathology. For patients in this group, a team approach indication for a CBCT examination (in addition to
for treatment is used including speech therapy, clinical periapical, occlusal and/or panoramic images) exists
psychology, orthodontic and surgical interventions. when interceptive orthodontic treatment is being
Advanced imaging, including CBCT, may be indicated considered for children between the ages of 5-11. In
for many of these patients. such cases, a small FOV should be used. Another
possible indication for a CBCT examination (usually
Selection of FOV restricted or small FOV) is for children more than
There is limited published research on the many and 11 years of age if surgical exposure is being considered
varied technical issues associated with CBCT imaging as a treatment option and the location of the crown
in orthodontics including optimal fields of view (image cannot be determined clinically or with conventional
sizes) for specific diagnostic tasks, optimal exposure 2D images (e.g., panoramic, occlusal and/or periapical
settings (some tasks may require lower exposures than images).
others), and variations in the levels of ionizing radiation Craniofacial anomalies. An additional possible
used (for similar tasks) with various CBCT systems. indication for CBCT is in children (0-4 years) prior to
More specific and additional issues and controversies mandibular distraction or other craniofacial surgical
related to CBCT use include: 1) the necessary diag- treatments if the children can remain motionless during
nostic quality of images205; 2) imperfect superimposi- the scans. For children between 5 and 11 years of age,
tion of CBCT and surface-scan data; 3) differing levels CBCT is useful for locating developing teeth prior to
of exposure needed to determine root and bone alveolar bone grafting and Phase I orthodontic treat-
morphology related to appliance construction or for the ment for children with oral clefts. For these cases,
diagnosis of pathology; 4) indications for use of limited fields of views may suffice. For patients older
multiple CBCT scans; 5) lack of and utility of 3D than 11 and comprehensive orthodontic treatments are
norms; 6) impact of CBCT for the assessment of required in preparation for craniofacial surgical proce-
treatment outcome; 7) responsibility for the identifica- dures, CBCT may provide a benefit at the diagnostic
tion of clinically significant incidental pathology; and stage of orthodontic treatment as well as immediately
8) responsibility for calibration and maintenance of the before the surgical procedures. Such decisions are case
equipment.203 specific.

Assessment of progress and treatment outcomes APPENDIX C: CALCULATION OF RRL FOR

In complex cases, follow-up CBCT acquisitions for ORTHODONTIC IMAGING
growth observation, assessment of treatment progress, Table VI provides four orthodontic imaging protocols
and posttreatment analysis may be helpful. Any and provides RRLs168,203 and published effective doses.
imaging protocol for the longitudinal quantitative For example, if a typical imaging protocol incorporates
assessment of the craniofacial complex requires three digital (Planmeca PM Proline 2000 [low dose])
methods to: 1) minimize the radiation dose from panoramic images (initial- diagnostic-, mid- and post-
sequential multiple CBCT exposures; 2) construct treatment; 12 mSv207 for each exposure ¼ 36 mSv) and
accurate three-dimensional surface models; 3) reliably two digital (photo-stimulable storage phosphor) lateral
image registration (non-rigid, elastic and deformable; or cephalometric images (initial- and post-treatment;
rigid registration) using stable structures of reference 5.6 mSv177 for each exposure ¼ 11.2 mSv) the total
for cranial base or regional superimpositions; and 4) equivalent dose for the orthodontic series is 47.2 mSv.
quantify changes over time. For an adult this represents an RRL of whereas for
OOOO ORIGINAL ARTICLE
Volume 116, Number 2 American Academy of Oral and Maxillofacial Radiology 257

a child this represents an RRL of . This can be adult and child is the same ( ), this protocol provides
compared to orthodontic imaging series incorporating over twice the absolute dose than the conventional
a large FOV CBCT (i-CAT Next Generation imaging series and elevates the risk of the adult into
[16  13 cm]) image (initial; 83 mSv191), two digital a higher category.
(Planmeca PM Proline 2000 [low dose]206) panoramic
images (mid- and post-treatment; 12 mSv207 for each
Reprint requests:
exposure ¼ 24 mSv) and one digital (photo-stimulable
William C. Scarfe, BDS, MS, FRACDS
storage phosphor) lateral cephalometric image (post-
Department of Surgical and Hospital Dentistry
treatment; 5.6 mSv177). The equivalent dose for this School of Dentistry, University of Louisville
orthodontic imaging series is 112.6 mSv. While radiation Louisville, KY 40292, USA
risk (RRL) using CBCT in this example is for both the william.scarfe@louisville.edu; wcscar01@louisville.edu