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Diagnosis goes digital

David C. Hatcher, DDS, MSc, MRCD(c),a and Cameron L. Aboudara, DDS, MSb Sacramento and Moraga, Calif Accurate images of the craniofacial region are critical for the development of an orthodontic diagnosis and treatment plan. The NewTom QR 9000 Volume Scanner (QR s.r.l., Verona, Italy) represents a signicant advance in imaging capabilities for dentistry and orthodontics. This new-generation scanner uses computed tomography technology to provide a complete 3D view of the maxilla and mandible with relatively high resolution and low radiation exposure to patients. This article discusses some technical aspects of this new scanner and its possible orthodontic uses. (Am J Orthod Dentofacial Orthop 2004;125:512-5)

mages of the craniofacial region are an important part of the dental patient record. Ideally, the imaging process begins with the development of an imaging goal, or a clinically derived question that can be answered with imaging. Specic and detailed clinical questions require specic and detailed imaging solutions. Digital processes have improved the diagnostic capabilities of the imaging tools being used in dentistry and orthodontics.



A digital image is composed of picture elements (pixels) that are arranged in a 2-dimensional rectangular grid, with each pixel having a specic size, color, intensity value, and location within the image (ie, bitmapped or raster). A pixel is the smallest element of a digitized image. Radiographic images generally use gray color with an intensity value between 8 bits (28 or 256 shades of gray) and 12 bits (212 or 4096 shades of gray). Image resolution refers to the degree of sharpness of the image. Resolution is determined by the number of pixels per given length of an image (pixels/ mm), the number of gray levels per pixel (bits), and the management of the gray levels. Selected digital imaging devices can produce digital volumes or 3D images. The volume element (voxel) is the smallest element of a 3-dimensional (3D) image. A voxel volume can be thought of as a 3D array or stack of bitmapped images, with each voxel having height, width, and thickness.

Diagnostic Digital Imaging, Sacramento, Calif. Private practice, Moraga, Calif. Reprint requests to: Dr David C. Hatcher, Diagnostic Digital Imaging, 1 Scripps Dr, Suite 101, Sacramento, CA 95825; e-mail, Submitted, September 2003; revised and accepted, December 2003. 0889-5406/$30.00 Copyright 2004 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2003.12.009

New trends in dentistry include digital imaging and 3D imaging of the maxillofacial regions. The ultimate reward of the technologic imaging advancements is the digital representation of the patients anatomy as it exists in nature (anatomic truth). Multiplanar reformatting of the accurate digital 3D image data volume with software tools can provide clinically relevant diagnostic and spatial information. A digital imaging breakthrough, the NewTom QR 9000 Volume Scanner (QR s.r.l., Verona, Italy),1 is now available for clinical practice. Other medical volume scanners or computed tomography (CT) machines acquire image data by using either a single narrow x-ray beam or a thin, broad, fan-shaped x-ray beam. These beams rotate around the patient in a circular or spiral path as the patient moves through the scanning machine or as the rotating beam passes over the patient.2 The NewTom 900 scanner uses a cone-shaped x-ray beam that is large enough to encompass the region of interest. This type of beam uses the x-ray emissions very efciently, thus reducing the absorbed dose to the patient. This type of beam also allows for the acquisition of the image data in 1 revolution of the x-ray source and detector without the need for patient movement. These attributes make this system more efcient and mechanically simpler than others, and thus it can be designed for specic purposes, such as imaging the maxillofacial region. The NewTom QR 9000 volume imaging technique uses the principle of tomosynthesis or cone-beamed CT because of the shape of the x-ray beam. It received US Food and Drug Administration approval in April 2001. The NewTom QR 9000 has been designed specically to image the maxillofacial region (Fig 1). In a single scan, the x-ray source and a reciprocating x-ray sensor rotate around the patients head and acquire 360 pictures (1 image per degree of rotation) in 17 seconds of


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Fig 1. A, Patient just before entering scanner. B, Adjacent workstation. Courtesy of Diagnostic Digital Imaging, Sacramento, Calif ( ORTHODONTIC USES

Fig 2. Reformatted image in curve plane with buccolingual thickness of 10 mm.

accumulated exposure time. The entire maxillofacial volume (13-cm-diameter eld of view) is imaged, and the patient receives an absorbed dose similar to a periapical survey of the dentition. The 360 acquired images undergo a primary reconstruction to mathematically replicate the patients anatomy into a single 3D volume that comprises voxels similar to those of a Rubiks cube. Each voxel is small (0.29 mm for each of the cube faces), thus the image has a relatively high resolution. The NewTom software allows for reformatting and viewing the image data from any point of view in straight or curbed planes and in 3 dimensions (Figs 2-4). With these software tools, the anatomy can be peeled away layer by layer to locate the desired section. The NewTom 9000 scanner ranks extremely high when the balance between high diagnostic yield, low cost, and low risk is considered. The image data can be organized into a mounting template and viewed on the computer screen, copied to a oppy or a compact digital disk (CD), or printed in diagnostic-quality glossy paper or transparency formats. This is similar to the way that digital extraoral and intraoral photographs are mounted. In addition, the entire data volume can be exported to a CD in DICOM format and transferred to any computer to be reconstructed and viewed as shown in Figs 2-4 with software tools that are available to the dental community.

The NewTom 9000 Volume scan has been extremely valuable for investigating impacted teeth, temporomandibular joints, implant planning, and pathology. Figures 2 through 4 give excellent examples of how the various reconstructions provide detailed information on the location of an impacted canine, thus facilitating treatment decisions regarding adjacent root resorption, surgical exposure planning, and mechanics design. With traditional orthodontic imaging techniques, some areas of anatomy are poorly visualized. Threedimensional scans can give valuable information about other areas of the dentition, such as the position of the maxillary incisor roots relative to the lingual cortical border of the palate to plan retraction, the amount of bone in the posterior maxilla available for distalization, the amount of bone lateral to the maxillary buccal segments available for dental rather than skeletal expansion, airway information on the pharynx and nasal passages, maxillary root proximity to the maxillary sinus, the 3D extent of an atrophied alveolar ridge, and the position of the mandibular incisor roots in bone. These scans also allow 3D visualization of bony defects and supernumerary teeth in patients with cleft lips or palates. Additionally, axially corrected tomograms of the temporomandibular joints can be obtained from the same scan. The ability to visualize an axially corrected view of the temporomandibular joints with the teeth in occlusion on the same reconstructed section is a significant advantage of the volume scan. Therefore, there are substantial value added imaging benets to these scans for complicated orthodontic patients. At this time, the NewTom 9000 volume scans occasionally needs to be supplemented with panoramic or periapical projections. According to its manufacturer, lateral views, including the cranial base, will be reconstructed and exported with the updated larger vertical sensor due to be released soon. Linear mea-

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Fig 3. Image collage shows multiplanar reformation of NewTom 9000 volume data of facial anatomy and impacted tooth. Top row, left to right: maxillary anatomy in axial plane; anatomy in curved plane similar to panoramic projection. Middle row, left to right: sagittal sections of head near midline; coupling of anterior teeth, hard and soft palate, tongue, and pharyngeal air space. Bottom row, left to right: coronal section through molars, maxillary sinuses, nasal fossa, and mandible; axially corrected view of right temporomandibular joint while teeth are in occlusion.

Fig 4. Image collage showing impacted tooth 6 in axial plane (upper right and middle left sections) and in 3 dimensions. This type of visualization can be used to determine location of impacted tooth relative to roots of adjacent teeth.

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surement tools are available in the current software. Software tools to facilitate accurate landmark identication for quantitative measurements and software to facilitate segmentation of regions of interest in individual slice sections for volumetric measures are currently in development.

the patient in the form of voxel volumes. Interactive software tools allow the clinician to peel away the tissue layers and see the hidden anatomy, which can be invaluable in orthodontic diagnosis and treatment planning.

Computer-assisted imaging is now allowing the dental profession to better visualize and study craniofacial anatomy. New imaging tools like the NewTom 9000 allow for accurate 3D replication and display of

1. Mozzo P, Procacci C, Tacconi A, Martini PT, Andreis IA. A new volumetric CT machine for dental imaging based on the conebeam technique: preliminary results. Eur Radiol 1998;8:1558-64. 2. Carlsson C. Imaging modalities in x-ray computerized tomography and in selected volume tomography. Phys Med Biol 1999;44: R23-56.