Cone Beam Computed Tomography: A Link

with the Past, a Promise for the Future

Mark G. Hans, Manish Valiathan, and J. Martin Palomo
During the last quarter of the 20th century, changes in clinical orthodontics
were largely driven by improvements in bracket design, attachment mechanisms, and arch wire materials. This focus on the mechanical aspects of
treatment led to decreased clinical interest in the underlying biology of facial
growth and, for a time, craniofacial practitioners often ignored the bio in
biomechanics. There was even more disappointment after the completion of
the Human Genome Project. Although this project promised exciting possibilities for biologically based manipulation of the growing face, the resulting
data were interesting but in most cases not clinically useful. In 2001, the
introduction of low-cost, low-radiation dose, high-resolution cone beam
computed tomography (CBCT) in clinical orthodontics created the potential
for new discoveries in craniofacial biology and facial growth. This technology provides researchers and clinicians with the tools needed to study
3-dimensional changes in craniofacial anatomy associated with the growth
process and clinical care. In the 20th century, radiographic cephalometry
was a pioneering advance that led to many fundamental insights into the
behavior of the face and neurocranium during growth. CBCT imaging promises similar advances in the 21st century. However, to take advantage of this
opportunity, clinicians will need to interpret 3D anatomic changes in the
context of the underlying growth process. This paper presents a short
history of imaging in orthodontics, reports on the current state of the art,
and suggests 3 ways CBCT imaging may influence the future of the
specialty. (Semin Orthod 2011;17:81-87.) 2011 Elsevier Inc. All rights reserved.

he history of radiographic imaging in orthodontics began in 1931 when B. Holly

Broadbent invented the cephalometer (Fig 1,
Table 1).1 The first cephalometers were installed
in the major teaching universities and growth
study centers in the United States and Europe.
Initially the technique was used to study normal
growth of the craniofacial skeleton, and several
major longitudinal growth studies were conducted between 1932 and 1970.2 Publications

Department of Orthodontics, Case Western Reserve University,

School of Dental Medicine, Cleveland, OH.
Address correspondence to Mark G. Hans, Case Western Reserve
University, School of Dental Medicine, 10900 Euclid Ave, Cleveland, OH 44106. E-mail: mark.hans@case.edu
2011 Elsevier Inc. All rights reserved.
1073-8746/11/1701-0$30.00/0
doi:10.1053/j.sodo.2010.08.006

were based on these longitudinal studies form

the bedrock of our current understanding of the
facial growth process. Before the invention of
the cephalometer, knowledge regarding the process of facial growth was based heavily on skeletal
material that was by its nature cross-sectional.
The strength of the cephalometric technique
was that it allowed the longitudinal study of
changes in the growing face. A comparison was
made by carefully tracing each radiograph, superimposing on relatively stable anatomic structures in the cranial base, and visualizing the
changes in the facial bones and teeth. In addition to studying normal facial growth, superimposition also provided a reliable method to evaluate the effects of orthodontic treatment on the
growing face. The knowledge gained from
cephalometrics changed the course of orth-

Seminars in Orthodontics, Vol 17, No 1 (March), 2011: pp 81-87

81

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Hans, Valiathan, and Palomo

Figure 1. Chart of imaging progress in orthodontics.

(Color version of figure is available online.)

odontic history. Although the impact of cephalometrics on orthodontics was substantial, the
projection of the 3D anatomy of the face and
skull onto a 2D film did have one disadvantage;
all parasagital information was either distorted
or lost.
Before the invention of cephalometrics, the
dental study casts and the clinical examination
(both 3D records) provided most diagnostic information on which orthodontic treatment decisions were based. Currently, most clinicians
regard cephalometric analysis as an integral part
of the diagnosis of orthodontic problems. However, the integration of cephalometrics into clinical practice took some time. If one examines
the timeline, it is noted that the specialty had to
wait until 1948 for the publication of the first
cephalometric analysis. So what began as a research tool finally found clinical application 15
years later! One reason for this delay is that it
takes time to generate longitudinal data, and it is
the longitudinal data that is most likely to generate new knowledge of facial growth and the
effects of orthodontic treatment. Therefore, it is
expected that there will be a similar lag in the
clinical application of 3D imaging to routine
clinical practice.
Since Downs first analysis, countless other
methods of cephalometric analysis have been
invented, but none has gained universal acceptance.3 Why, after 75 years, is there no consensus
on the best way to use the cephalogram for
diagnosis? In our opinion, the reason is that all
radiographic imaging answers clinical questions
and the questions asked when evaluating a
cephalogram can be answered by the use of a
wide variety of analyses. Importantly, there is
consensus on the questions. In clinical signifi-

cance, all cephalometric analyses must answer 5

basic questions about facial morphology. What is
the position of the maxilla with respect to the
cranial base? What is the position of the mandible with respect to the cranial base? What is the
position of the upper incisors to the maxilla?
What is the position of the lower incisors within
the mandible? Finally, what is the vertical balance of the patient?
Once these 5 questions have been answered,
one may discard the pretreatment cephalogram
as far as diagnosis and treatment planning is
concerned. The reason we do not discard the
image after diagnosis is that the second, and the
probably more clinically applicable, use of the
cephalogram, is to allow comparison of subsequent images to the pretreatment image. This
comparison to baseline is an invaluable aid to
the clinician when attempting to understand the
response of the patient to orthodontic mechanotherapy. Although there is little agreement on
the best cephalometric analysis, there is nearuniversal agreement on the benefit of cephalometric superimposition techniques because the
unique value of radiographic imaging to orthodontic treatment is the ability to track progress
and make midcourse corrections. In the last 75
years clinicians have become adept at interpreting the effects of orthodontic treatment on midline structures. It would seem likely that the
addition of 3D information will have a similar
impact on our understanding of the effects of
orthodontic treatment on parasagital anatomic
structures.
Table 1. Important Dates in Orthodontic Imaging
History
1931B. Holly Broadbent invents the cephalometer
1948William Downs publishes the first cephalometric
analysis
1959First cephalometric workshop held at the Bolton
Study in Cleveland, Ohio
1960Second and final cephalometric workshop held at
the Bolton Study in Cleveland, Ohio
1970Bolton standards of facial growth published
1976Michigan standards of dentofacial development
published
1981David Sarver combines 2D digital imaging of the
face with digital cephalograms starting the 2D digital
age
2001NewTom introduces the first cone beam scanner for
dental use. Joe Caruso at Loma Linda installs the first
CBCT in the USA and 3D digital imaging begins
2008First meeting of the Joint Cephalometic Experts
Group held at the Bolton Brush Growth Study Center,
Cleveland, OH

CBCT: A Link with the Past, a Promise for the Future

It can be noted from the timeline in Figure 1

that by 1950 almost every orthodontist had a
cephalometer in their office, and by 1960 the
American Board of Orthodontics required before and after cephalograms on all cases.
Around 1982, 2D digital imaging was introduced
to the specialty by a few pioneers. David Sarver
(presentation and personal communication,
American Association of Dental Schools Meeting, Toward a Paperless OfficeThe Treatment
Records Minneapolis, MN, March 2, 1998), by
using commercially available software and hardware, designed a system that combined the digital lateral cephalogram with a digital image of
the facial profile into a composite image for
patient communication and treatment planning. This marked the beginning of a new era. It
took about 30 years for cephalometrics to be
used in almost every office. Although introduced
in 1980, 2-dimensional (2D) digital imaging has
yet to reach 50% market penetration. It is our
opinion that the reason is because 2D digital
imaging offered convenience and improved patient communication but did not really introduce any new information about the morphology of the patient.
Cone beam computed tomography (CBCT)
images are decidedly different. CBCT images
offer new information about patients. Since its
introduction in 2001, 3D cone beam imaging
has shown logarithmic growth. This growth has
been driven by 2 factors. First, 3D imaging provides a true-to-life representation of the patient.
The image contains information that is simply
not seen on a traditional cephalometric image.
As health care professionals, orthodontists naturally want to improve patient care. One way to
improve patient care is to have better information about the patients problem. There is already evidence that the treatment of some orthodontic conditions, such as supernumerary and
impacted teeth, benefit from 3D imaging.
Therefore, one of the reasons CBCT scanning is
gaining momentum in clinical practice is the
desire for excellence in patient care. A second
reason for the popularity of CBCT is perhaps
more draconian. In the competitive orthodontic
marketplace there is an economic advantage if
one is the first practitioner in ones area to have
this cutting edge technology. Patients tend to
think that a practitioner who uses the newest
technology provides the highest quality care.

83

This gives the orthodontic office with a new

CBCT scanner an economic advantage over
competitors who might be using the old system. Whatever the reason, CBCT has gone from
0% to 50% market penetration in just 8 years. In
addition it is the authors opinion that within 5
years every orthodontist in the United States will
be using CBCT imaging for at least some patients.
Two paradigms for using CBCT have emerged. The first is the imaging center model. In
this scenario, one CBCT machine serves many
practitioners, with each practitioner having the
software necessary to manipulate the images.
The second is the individual office model. In this
scenario, CBCT scanners are part of every practitioners office. Although the imaging center
model held promise early in the evolution of 3D
imaging, it seems the individual office model is
gaining favor in the community. The main reason for the popularity of the individual office
model is that it fits the traditional way radiography has been used in dentistry. Except in California, the dentist has always had an x-ray machine in the office. Patients are just accustomed
to having radiographs taken at the same location
as another dental service. The in-office model
also benefits the manufacturers of CBCT scanners. The more scanners the better, so companies are trying hard to break the US$100,000
price barrier.
However, simply because one can afford to
buy a CBCT scanner does not mean one should.
In our opinion, given the current state of the art
and our knowledge of the benefits of 3D imaging to the average orthodontic patient, it is not
necessary to have a CBCT scanner in a private
orthodontic office to provide state-of-the-art
care. At this point practitioners should have access to a scanner for selected patients but need
not invest in a scanner for their own office. It will
likely be several years before there is sufficient
longitudinal data to know whether the average
orthodontic patient can benefit from 3D imaging.

The Present State of the Art

A Brief Report on the Joint Cephalometric
Experts Group Meeting of 2008
On November 21, 2008, the Joint Cephalometric
Experts Group (JCEG) met in Cleveland at the

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Hans, Valiathan, and Palomo

Table 2. Founding Members of JCEG

Sheldon Baumrind, Director, Craniofacial Research
Instrumentation Laboratory (CRIL), University of the
Pacific; sbaumrind@pacific.edu
Rolf G. Behrents, Saint Louis University; behrents@slu.edu
Barry Briss, ABO Technology Committee representative;
Barry.Briss@tufts.edu
B. Holly Broadbent Jr, CWRU, Curator Bolton Brush
Studies Collection. Only member present at both the
1959-1969 Cephalometic Workshops and the 2008 JCEG
meeting; b.broadbent@case.edu
Joseph Caruso, Associate Professor and Chair Department
of Orthodontics and Dentofacial Orthopedics, Loma
Linda University. First installation of a cone beam
scanner in the United States; jmcaruso2@mac.com
Jos Dibbets-Gronigen; jdibbets@planet.nl
Mark Hans, CWRU, Chairman and Professor Orthodontics
and Associate Dean Graduate Studies, School of Dental
Medicine; mark.hans@case.edu
William Harrel Jr, DMD, AAO Technology Committee
representative, Alexander City, AL; DrHarrell@aol.com
Lysle E. Johnston Jr, University of Michigan and SLU;
lejjr@umich.edu
Brent E. Larson, DDS, MS director, Orthodontics,
University of Minnesota; larso121@umn.edu
Juan Martin Palomo, CWRU Program Director,
Orthodontics and Director Craniofacial Imaging Center;
palomo@case.edu, Graduate Program Director,
Orthodontics
Manish Valiathan, CWRU; manish.valiathan@case.edu,
Assistant Professor, Orthodontics
Rick Walker, DDS, MSc, Orthodontist and Software
Developer; CEO, dentofacial Planner, Toronto, Canada;
dentofacial.support@gmail.com
Kuni Miyashita, Japan. Author of Radiographic
Cephalometric Anatomy, Tokyo, Japan;
miyashita92hiko@mac.com
JCEG, Joint Cephalometric Experts Group.

historic Bolton-Brush Growth Study Center for 2

days to discuss the state of the art in 3D CBCT
imaging. In attendance were international leaders in imaging and orthodontics (Table 2). The
stated purpose of the meeting was to map out a
plan for the transition from 2D cephalometrics
to 3D cone beam imaging for assessment of
orthodontic outcomes as well as diagnosis and
treatment planning. In other words, the focus
of the meeting was not on the use of CBCT
for radiographic examination of pathology but
rather on its unique application to the specialty
of orthodontics. Rather than produce answers,
this meeting generated a series of questions and
these questions must be addressed if 3D CBCT
imaging is to be widely accepted as a standard in
routine orthodontics.
Among the first issues that arise in assessing a
new imaging modality is the ability to compare
images of the same individual taken at 2 points.
Such longitudinal comparison was a major

strength of the cephalometric technique and

must be included in any new method of imaging
patients in orthodontics. To date, the comparison of longitudinal 3D scans has relied on 2D
superimposition methods. The most common
process is to create a 2D cephalogram from the
3D data are to print out the digital data on
acetate or plain paper, then trace the printouts
and compare the 2D generated cephalograms
using traditional cephalometric superimposition
techniques. This process is both cumbersome and
inefficient. However, it is the only reliable way that
currently exists to compare 2 CBCT images.
Therefore, members of the JCEG identified
the need for biologically stable and relevant features for superimposition of 3D volumes as one of
the highest priorities. In particular the group recommended that biology, rather than the ease of
identification of the structure, should drive the
selection of anatomic structures. A task force led
by Dr J. Martin Palomo and Dr Lysle Johnston will
publish a trial set of landmarks to be tested by
comparison of serial superimposition methods.
Features that can be used for superimposition are
needed in the area of the cranial base, the maxilla
and the mandible. Registration should allow affine
transformation for comparison of changes in
cross-sectional and longitudinal datasets. Stability
and utility of these features should be tested using
existing 3D volumes from 3 imaging centers that
currently have before and after CBCT data. Institutions that will be involved include Case Western
Reserve University, Loma Linda University, and
the University of Minnesota.
A second issue that was identified was the lack
of consistency in the use of CBCT terms. To
ensure that information is transferred among
practitioners in an accurate and professional
manner, a subcommittee was tasked with defining the relevant terms that can be used to describe 3D volume data and orthodontic procedures. This lexicon of terms will also be used to
describe and characterize subjects included in
the 3D volume database. In addition to orthodontic terms, a lexicon of terms that are
needed to communicate 3D volume data and to
describe the methodology used to obtain the
data set is also needed. Terms, such as voxel,
pixel, jpeg, need to have accepted definitions in
relationship to orthodontic imaging.
In addition to standardizing terms there is
also a need for standards for hardware, software

CBCT: A Link with the Past, a Promise for the Future

and image parameters. To compare among available scanners there is a need for a set of hardware
phantoms that can be used to measure the resolution of each machine. Resolution can be a difficult
term to define because it depends on several
factors. For example, the ability to resolve 2 features that are anatomically different yet vary little
in their density, such as cementum and bone, is
much different from the ability to resolve 2 anatomic features that are both anatomically different
and of radically different density, such as mucosa
and air. As a second example, the resolution may
approach the size of a single voxel compared with
the first example where the resolution is directly
linked to radiation physics rather than digital technology. After the image is captured the image data
must also be stored such that it can be exchanged
among practitioners.
Closely related to the standardization of images files and orthodontic terms is the need to
develop and implement a database of 3D images
for craniofacial research. With funding from the
American Association of Orthodontists Foundation, a model for a cephalometric database has
been developed by Baumrind for the Legacy
Collections.4 A similar database of CBCT images
would store image acquisition information such
as brand of machine, milliamperage, kilovolt,
exposure time, and field of view, as well as images in the standard JCEG format. In addition to
image information, a useful research database
must also store patient information, such as gender, age, ethnicity, date of image acquisition,
and the degree and type of craniofacial treatment rendered. This is where the lexicon of
terms to describe treatment procedures becomes invaluable in constructing such a database. The final product would allow all craniofacial practitioners who take CBCT images
before and after treatment to participate and
contribute images to the project. This would
dramatically increase the number of treated
cases available for scientific study.
The final area identified was the need for
morphologic standards for orthodontic diagnosis and treatment planning. Rather than create
3D standards a priori a subgroup was charged
with preparing a draft of the methodology that
can be used to develop 3D standards. Ideas presented at the meeting included the concept of a
dynamic standard that can change as more data
are added to the data set. Also, the use of the

85

Bolton Standards in 3D to generate the longitudinal changes typically associated with facial
growth was proposed. Several methods were suggested as ways to generate standards. First was
the use of averaged images of selected individuals. Because of radiation concerns these averages
would have to be done using cross sectional
data. An example of this approach was Downs
use of 20 beautiful faces to establish norms for
his cephalometric analysis. The general goal of
standards should be to produce an easy way for
clinicians to use CBCT in daily practice. The
model for such an approach can be found in
Cecil Steiners classic article Cephalometrics
for You and Me.5 Readers interested in the
JCEG project should contact the author at
mark.hans@case.edu.

CBCT and the Future of Orthodontic

Treatment
Enlow and Hans6 characterized the growth fields
of the human face by using dry skull material. By
sectioning each skull and preparing microscopic
ground sections, they were able to create a topographic map showing areas of bone formation
(deposition) and bone reduction (resorption;
Fig 2). Their work was, by its very nature, crosssectional. However, to the extent possible these
growth fields have been confirmed by longitudi-

Figure 2. Top, mandibular remodeling. Resorptive

surfaces are dark shaded, and depository surfaces are
unshaded. Bottom, maxillary remodeling. (Reprinted
with permission from Enlow and Hans.6)

86

Hans, Valiathan, and Palomo

nal studies of the growing face using cephalometric radiography. For example, Enlow and
Hans characterized the anterior border of the
mandible as resorptive and the posterior border
as depository. Serial cephalometric radiographic
studies have confirmed this general pattern of
ramus remodeling. However, Bjrks implant
studies suggest that variations in this general
pattern exist.7 CBCT images can show density
variations on the surface of bones. Because deposition and resorption are surface phenomena,
it should also be possible to identify variations in
depository and resorptive activity if they exist.
Because the ramus is a bilateral structure, 3D
images will allow comparison of the right and
left sides to determine if remodeling occurs at
the same time on both sides. These are but 2 of
the many questions regarding bone remodeling
that can be addressed with CBCT imaging.
Orthodontists are interested in the movement of teeth within bones. Tooth movement in
the vertical and horizontal planes has been
extensively studied with current cephalometric
techniques. However, the movement of teeth in
the coronal plane has not been characterized.
Currently, the degree to which lateral tooth
movement stimulates new bone formation is still
a matter of debate. Some clinicians claim that
expansion of the dental arches stimulates bone
formation. Others claim that expansion of the
dental arches is not desirable because lateral
movement of teeth does not generate new bone.
Some clinicians have gone so far as to claim that
it is the make and style of the bracket or perhaps
the metallic composition of the archwire that
stimulates bone formation. Although it would
seem highly unlikely that a biological process
would differentiate among clinicians or manufacturers, it is possible that tooth movement
could trigger bone formation. CBCT imaging
should allow clinicians and researchers to begin
to answer this important clinical question.
Respiratory function and craniofacial anatomy are historically and anatomically linked in
orthodontics. Unfortunately, the 2D projection
of the airway seen in a cephalometric radiograph has never been shown to have clinical
relevance. Despite numerous attempts to measure airway size and shape, it seems that the
complex morphology of the airway cannot be
captured on a cephalometric film. In contrast,
the density difference between air and soft tissue

makes the visualization of the airway on CBCT a

relatively simple task. These 3D airway images
have taken on new importance with the realization that a serious health hazard, obstructive
sleep apnea, is caused by collapse of the pharyngeal airway during sleep. Although the respiratory physiology of apnea is complex, narrowing
of the airway passage, increased lumen pressure
during inspiration, and increased airway length
seem to be some of the anatomic risk factors for
obstructive apnea. In the future, it may be possible, by the use of CBCT images to identify
individuals at risk for obstructive sleep apnea
syndrome and to use this new knowledge of
airway anatomy to design optimal treatments.
Stability has been an elusive goal in orthodontics. In his introductory remarks, Baumrind
reminded the JCEG group that one goal of
orthodontics is to change one stable system
(malocclusion) into another stable system (normal occlusion). Although it would be unrealistic to think that orthodontically alignment of
teeth would be more stable than naturally occurring alignment, the goal should be to try to
equal the stability found in nature. If clinicians
give up on the idea of stability as a goal of
treatment and accept lifetime retention as a legitimate answer then we do not have a specialty.
Therefore, in the interest of preserving the specialty of orthodontics as a learned science, CBCT
studies must seek the underlying keys to stability
in the craniofacial system. The idea that expansion is never stable is as flawed as the idea that
expansion of the arches always works. The ability
to create a database to document treatment in
all 3 dimensions will allow researchers to combine the results of not 30 or 100 treated cases but
100,000 or 1 million. Sample sizes of this magnitude should allow the study of orthodontic
treatment results in a new and exciting way.

References
1. Broadbent BH: A new x-ray technique and its application
to orthodontia. Angle Orthod 1:45-66, 1931
2. Hunter WS, Baumrind S, Moyers RE: An inventory of
United States and Canadian growth record sets: preliminary
report. Am J Orthod Dentofac Orthop 103:545-555, 1993
3. Downs WB: Variation in facial relationships: their significance in treatment and prognosis. Am J Orthod 34:812840, 1948

CBCT: A Link with the Past, a Promise for the Future

4. American Association of Orthodontists. AAOF Craniofacial Growth Legacy Collection. Available at: http://www.
cril.org/aaof/aaof_home.asp. Accessed July 21, 2009
5. Steiner CC: Cephalometrics for you and me. Am J Orthod
39:729-755, 1953

87

6. Enlow DH, Hans MG: Essentials of Facial Growth. Ann

Arbor, MI, Needham Press, 2008
7. Bjrk A: Variations in the growth pattern of the human
mandible: longitudinal radiographic study by the implant
method. J Dent Res 42:400-411, 1963