Clin Oral Invest (2016) 20:10031010
DOI 10.1007/s00784-015-1592-3
ORIGINAL ARTICLE
Cone-beam computed tomography in pediatric dentistry,
a retrospective observational study
Jakob W. G. Van Acker 1 & Luc C. Martens 1 & Johan K. M. Aps 2
Received: 14 May 2015 / Accepted: 7 September 2015 / Published online: 16 September 2015
# Springer-Verlag Berlin Heidelberg 2015
Abstract
Objectives The aim of this study was to find the reasons for
referral and their correlation with age, gender, field of view,
and resolution for all patients under the age of 18 who
underwent a cone-beam computed tomography (CBCT) scan
between 1 May 2010 and 1 May 2012 in the dental out-patient
clinic of the University Hospital Ghent.
Material and methods From the local CBCT database, 79
pediatric patients gave their consent. Subsequently age, gen-
der, reason for referral, external or internal referral, field of
view (FOV), and resolution data were collected. Descriptive
and comparative statistical analysis was performed.
Results There seemed to be a correlation between orthodontic
referrals and female patients. The majority of patients referred
for trauma follow-up were 12 years and older. Fourteen per-
cent of referrals were for dento-alveolar trauma, 18 % for other
dento-alveolar reasons, 4 % for developing dentition-general-
ized, 36 % for developing dentition-localized, 10 % for end-
odontics, 1 % for periodontics, 16 % for surgical applications,
and 1 % was for the visualization of the TMJ.
Eighty percent of the CBCTs were taken at a FOV
5055 mm. Larger FOV was used for surgical planning or
follow-up reasons. The majority of the CBCTs was taken at a
resolution of 200 m, while a resolution of 150 m was used
* Jakob W. G. Van Acker
Jakob.VanAcker@UGent.be
1
Department Paediatric Dentistry PaeCoMedis Research, Ghent
University & University Hospital, De Pintelaan 185,
9000 Ghent, Belgium
2
School of Dentistry, University of Washington, Box 356370, 1959
NE Pacific Street, 98195 Seattle, WA, USA
for endodontic issues. From these results, a classification
system for referral was developed.
Conclusions From the present study, it can be concluded that
a referral pattern could be detected which was correlated with
gender, age group, FOV, and resolution. These results can help
practitioners make the decision to refer for CBCT when extra
three dimensional imaging is expected to have a benefit in
therapeutic value for a pediatric or adolescent patient.
Clinical relevance This study can guide dental professionals
referring pediatric and adolescent patients for CBCT.
Keywords Cone-beam computed tomography . Pediatric
dentistry . Radiodiagnostics . Indications . Radiographic
referral
Introduction
Cone-beam computed tomography (CBCT) was developed in
the late 90s by Arai et al. [1] in Japan and independently at the
same time by Mozzo et al. [2] in Italy. The device contains a
rotating gantry with both x-ray source and detector attached to
it (the C-arm) [3]. Contrary to multiple slice computerized
tomography (MSCT), the x-ray source can be a low energetic
fixed anode, comparable to those used for dental panoramic
tomography (DPT). In contrast to MSCT, not a fan-shaped but
a conical shaped radiation beam is sent through the region of
interest (ROI) and is subsequently received by a two dimen-
sional flat panel detector. These projections will be converted
into a three dimensional image (in axial, coronal, and sagittal
planes, respectively) by a modification of the original cone-
beam algorithm developed by Feldkamp et al. [4].
CBCT produces a three dimensional dataset of the ROI and
this in real-size data with isotropic voxel size. However, it
does not lose the potential to generate all two dimensional
1004
images if needed. Other advantages of this technique are the
production of high resolution images, reduced costs and energy
saving compared to MSCT, less disturbed images from metal
artifacts, easy accessibility, potential for vertical scanning im-
aging, and the possibility of in-office imaging with Digital Im-
aging and Communications in Medicine (DICOM) compatible
user-friendly viewing software [5]. There are also some disad-
vantages which need to be considered: CBCT can have a low
contrast range (depending on the type of X-ray detector) and
limited detector size causes limited field of view (FOV), a great
draw-back compared to MSCT is the limited inner soft tissue
information and the fact that CBCT cannot be used to produce
Hounsfield units (HU). Moreover, there is increased noise from
scatter radiation, concomitant loss of contrast resolution, and
the image can suffer from movement artifacts affecting the
whole dataset and from truncation artifacts, caused by the fact
that projections acquired with ROI selection do not contain the
entire object [5].
CBCT gives a lower radiation dose compared to MSCT but
a higher one compared to conventional dental radiography [6,
7]. It is evident that the three basic principles of radiation
protection (justification, optimization, and protection) should
always be respected [8]. As children are more susceptible to
the risks of ionizing radiation [9, 10], extra attention should be
paid to keep the radiation burden as low as possible, while
maintaining sufficient diagnostic yield.
Evidence-based guidelines for the use of CBCT have been
proposed by the SEDENTEXCT Guideline Development
Panel, but currently, there is little evidence for significant pa-
tient outcome efficacy in pediatric dentistry [11]. A recent
review of the literature relevant to CBCT in pediatric dentistry
concluded that the indications for the use of CBCT in pediatric
dentistry have not yet been properly addressed [12]. Still, this
review supported the use of CBCT in pediatric dentistry jus-
tified on a patient case individual basis, where benefits must
clearly outweigh the risk for the patient. Although there are
overall guidelines for the indications, to the best of the au-
thors knowledge, only three studies tried to research the cur-
rent reasons for referral used in pediatric dentistry [1315].
None of these did a comparative analysis between reason for
referral, resolution, and FOV of the CBCTs.
The first aim of the present study was to find the reasons for
referral, and the second aim was to find their correlation with
age, gender, FOV, and resolution for all patients under the age
of 18 years who underwent a CBCT scan between 1 May 2010
and 1 May 2012 in the dental out-patient clinic of the Univer-
sity Hospital Ghent.
Material and methods
One main investigator (JVA) made a hand search in the
Planmeca database (Romexis) for all patients under the
Clin Oral Invest (2016) 20:10031010
age of 18 years who underwent a CBCT scan between the
installation of the CBCT-unit in the hospital (1 May 2010)
for a period of 2 years (till 1 May 2012) in the dental out-
patient clinic of the University Hospital Ghent in Belgium. In
this period of time, the CBCT-unit was a Planmeca Promax
3D Max. All CBCTs were stored in the Romexis database in
the hospital during this time period, and there was no possi-
bility for missing/lost data. From the available CBCT data-
base, 135 patients could be retrieved. Informative letters for
parents of patients younger than 12 or for patients 12 years and
older and informed consents for the gathering of patient data
and the use of radiographic material according to the WHO
informed consent templates (14) were sent by mail to 135
patients. These contained the following information: aim of
the study, what happens when the patient gives no informed
consent, obligations of the researchers to report changes in
study setup, what was required of the subjects, method of data
processing, contact information in case of questions, costs for
participation, and a request to sign the informed consent.
There were two different types of informed consents, the for-
mer for parents of patients younger than 12 years and the latter
for patients between 12 and 18 years old. When no answer
was received, the main investigator tried to contact the patients
by telephone for a confirmation of the patients address. A
duplicate-copy of the informed consent was then sent to those
patients who did not reply the first time. In case still no re-
sponse was received, no further attempts were made to make
contact. Patients, residing outside Belgium at the time of the
research, were excluded from the study.
For those patients who provided their informed consent,
the following data were collected by the main investigator
from the Planmeca database and the electronic patient data-
base: age (y), gender, reason for referral, external or internal
referral, FOV (wh in mm), and resolution (m). All data
were collected by the main investigator (JVA) and checked
twice. In case of multiple CBCTs per patient, only the first
CBCT was included, and in case of a retake, the retake was
considered valid for evaluation only.
For statistical analysis, IBM SPSS 22 was used. Patients
were divided into three age groups (younger than 10 years,
between 10 and 12 years and 12 years and older) according to
the arbitrary age for dentition type (first and inter transitional
period, second transitional period, and permanent dentition).
Descriptive and comparative statistics were performed. For
the comparative statistics, main categories were counted as 0
when no subcategory referral was given and 1 when one or
more subcategory referrals were found.
The level of significance was chosen at =0.05. For the
categorical variables, unpaired comparing statistics were done
by the Pearson chi-square test. Fishers exact tests were per-
formed when more than 20 % of cells had less than five
counts. When an association was found in tables greater than
22, binary logistic regression (=0.05) was considered
Clin Oral Invest (2016) 20:10031010
appropriate. If binary logistic regression was not possible be-
cause of a too small number of events, further 22 Fishers
exact tests were performed. Post-hoc Bonferroni corrections
were used to adjust the -levels for multiple testing.
This study was revised and approved by the Ethics Com-
mittee of the University Hospital Ghent, Belgian registration
number B670201214496.
Results
Descriptive statistics
Of the 135 retrieved patients, 79 gave their consent.
Thirty-five patients were female and 44 were male. Mean
age was 12.35 years (SD=2.75 years), the youngest pa-
tient was 7 years old, and the oldest was 17 years old.
Fourteen CBCT scans (18 %) were taken in children
younger than 10 years old, 29 (37 %) in children aged
between 10 and 12 years old and 36 (45 %) in children
aged 12 years and older.
The distribution for the FOVs was the following: 2 CBCTs
(2.5 %) had a FOVof 100130 mm, 6 (7.6 %) a FOVof 100
55 mm, 3 (3.8 %) a FOV of 10090 mm, 2 (2.5 %) a FOV of
13055 mm, 1 (1.3 %) a FOV of 13090 mm, 1 (1.3 %) a
FOVof 190150 mm, and 59 CBCTs (81 %) were taken with
a FOV of 5055 mm (Fig. 1).
Two CBCTs (2.5 %) were taken at a resolution of 100 m,
3 (3.8 %) at a resolution of 150 m, 68 (86.1 %) at a resolution
of 200 m, and 6 CBCTs (7.6 %) were taken at a resolution of
400 m (Fig. 2).
Thirty-eight patients (48.1 %) received treatment in the
local University Dental Out-Patient Hospital, while 39
(49.4 %) patients were external referrals. For 2 (2.5 %) pa-
tients, this information could not be retrieved.
A total of 107 reasons for referral were recorded, which
could subsequently be subdivided into 8 categories, based
on the represented cases (Fig. 3).
Of the 107 reasons for referral, 15 (14 %) were for dento-
alveolar trauma, 19 (18 %) for other dento-alveolar reasons, 5
(4 %) for developing dentition-generalized, 38 (36 %) for
developing dentition-localized, 11 (10 %) for endodontics, 1
(1 %) for periodontics, 17 (16 %) for surgical applications, and
one referral (1 %) was for the visualization of the temporo-
mandibular joint (TMJ).
Subsequently, main categories were divided into 32 subcat-
egories for all 107 reasons for referral (Fig. 4).
For the category Bdento-alveolar trauma^ (n=15), for
the total group, 9 referrals where for post-trauma com-
plications and 6 for a suspected root fracture. In the
group for Bdento-alveolar^ (n=19), 10 referrals were for
atypical tooth morphology and 9 for supernumerary
teeth. For the group Bdeveloping dentition-generalized^
1005
2
6 100x130mm
3 2
1 100x55mm
1 100x90mm
130x55mm
130x90mm
190x150mm
59 50x55mm
Fig. 1 Distribution of the FOVs by number (n=79)
(n = 5), 2 referrals were for a syndrome (Apert and
cherubism), and 3 were for reasons of tooth position
and localization. In the group Bdeveloping dentition-
localized^ (n=38), 3 were for cleft palate assessment, 3
for canine impaction, 12 for canine impaction with as-
sessment of possible external resorption of an adjacent
tooth, 2 for incisor impaction, 4 for molar impaction, 4
for premolar impaction, 1 for premolar impaction with
possible external resorption of an adjacent tooth, 7 for
tooth position and localization, and 2 for tooth position
and localization with assessment of possible external re-
sorption of an adjacent tooth. For the category
Bendodontics^ (n=11), 1 referral was for aiding manage-
ment of dens invaginatus and aberrant pulpal anatomy, 7
referrals were for evaluation of a concurrent resorption, 1
was for planning of initial endodontic treatment, and 2
were for endodontic retreatment. In the main category
Bsurgical application^ (n=17), 3 referrals accounted for
bony pathosis (complex odontome, dentigerous cyst, hyper-
ostosis), 1 for exodontia of a molar, 1 for exodontia of a pre-
molar, 3 for exodontia of a third molar, 1 for follow-up of an
6 2 3
68
Fig. 2 Distribution of the resolution by number (n=79)
1006 Clin Oral Invest (2016) 20:10031010

Fig. 3 Distribution of the main

Dento-alveolar trauma 15
categories for reason for referral
(n=107)
Dento-alveolar 19

Developing dentition-generalized 5

Developing dentition-localized 38

Endodontics 11

Periodontics 1

Surgical Application 17

TMJ 1

0 5 10 15 20 25 30 35 40

autotransplant, 4 for the planning of an autotransplant, 2 for referral was for Bperiodontal surgery planning,^ and another
implant planning, and 2 for orthognathic surgery. Only 1 was for assessment of the BTMJ.^

Fig. 4 The distribution of the 0 2 4 6 8 10 12

subcategories for reason for Suspected root-fracture 6

referral (n=107) Post-trauma complication 9

Supernumerary teeth 9

Atypical tooth morphology 10

Syndrome (Apert) 1

Syndrome (Cherubism) 1

Tooth position and localisation 3

Cleft palate assessment 3

Canine impaction 3

Canine impaction/ possible resorption adjacent tooth 12

Incisor impaction 2

Molar impaction 4

Premolar impaction 4

Premolar impaction/ possible resorption adjacent tooth 1

Tooth position and localization 7

Tooth position and localization/ possible resorption 2

Aiding management of dens invaginatus 1

Evaluation of a concurrent resorption 7

Planning 1

Planning of endodontic retreatment 2

Periodontal surgery planning 1

Bony pathosis (complex odontome) 1

Bony pathosis (dentigerous cyst) 1

Bony pathosis (hyperostosis) 1

Exodontia molar 1

Exodontia premolar 1

Exodontia third molar 3

Follow-up autotransplant 1

Planning autotransplant 4

Implant planning 2

Orthognatic surgery 2

TMJ 1
Clin Oral Invest (2016) 20:10031010
Comparative statistics
Fishers exact tests showed that by gender, FOV (p=0.374) as
well as the resolution (p=1), did not differ. There was no
correlation between age group and FOV (p=0.492, Fishers
exact test) and between age group and resolution (p=0.038,
Fishers exact test).
A significant correlation for gender with a higher odds for
females to be referred for the main category Bdeveloping den-
tition-localized^ was found (2 (1, N=79)=4.198, p=0.04,
OR=2.58).
For age group and main categories, a significant correlation
was found between age group and Bdento-alveolar^ (2 (1,
N=79)=6.315, p=0.043, Nagelkerke R2 =0.103) but further
binary logistic regression analysis with Bonferroni correction
found no significant differences in between age groups for this
indication. Also, significant correlation for age group with
Bdeveloping dentition-localized^ (2 (1, N=79)=15.411, p=
0.000, Nagelkerke R2 =0,263) was found. For the age group
younger than 10 years old, the odds to be referred for the
category Bdeveloping dentition-localized^ was about 29 times
lower compared to the odds for the age group between 10 and
12 years old (OR= 28,889, p=0.003, confidence interval
(CI)=3.363-1.113).
For age group and subcategories, significant correlations
were found for Bpost-trauma complication^ (p=0.022, Fish-
ers exact test) with a lower odds to be referred in the age
group between 10 and 12 years old compared to the group
12 years and older (OR =0.0667, p = 0.014, CI =0.0036
1.2212). There were also significant correlations between
age group and Bsupernumerary teeth^ (p=0.01, Fishers exact
test), Bcanine impaction with assessment of possible resorp-
tion of an adjacent tooth^ (p=0.044, Fishers exact test), and
Bdeveloping dentition-localized: tooth position and
localization^ (p=0.029, Fishers exact test). Further analysis
found no significant differences in between age groups for
these three last indications.
There was a significant association between FOV and the
main categories Bdeveloping dentition-generalized^
(p<0.001) and Bsurgical application^ (p<0.001). A 35 times
higher odds that a FOV of 10055 mm would be used in
comparison to a FOV of 5055 mm for surgical application
was found (OR=35, p=0.001, CI=3.6113339.2153, Fishers
exact test).
For FOV and subcategories, significant correlations
were found for Bsyndrome (cherubism)^ (p = 0.025),
Bdeveloping dentition-generalized: tooth position and
localization^ (p=0.022), Bdeveloping dentition-localized:
premolar impaction with possible external resorption of
a n a d j a c e n t t o o t h ^ ( p = 0 . 0 2 5 ) , Bp l a n n i n g o f a n
autotransplant^ (p = 0.022), and Borthognathic surgery^
(p =0.028). Further analysis found no significant differ-
ences in between FOVs.
1007
The main categories Bdento-alveolar trauma^ and
Bendodontics^ showed significant associations with the reso-
lution of the CBCT image. Further analysis showed an 81
times higher odds that a resolution of 150 m would be used
for the last reason compared to a resolution of 200 m (OR=
80.818, p=0.001, CI=3.68231773.7546, Fishers exact test).
Resolution showed significant correlations with the subcat-
egories Bsuspected root fracture^ (p=0.006), Bpost-trauma
complication^ (p=0.023), and Bevaluation of a concurrent
resorption^ (p<0.001). The odds were 131 times higher that
an evaluation of a concurrent resorption would happen with a
resolution of 150 m compared to a resolution of 200 m
(OR=131, p=0.000, CI=5.60073064.0905, Fishers exact
test).
No correlation was found between external or internal re-
ferral and the main- and subcategories for reason of referral.
Discussion
Half of the investigated group of patients was referred from
outside the University Hospital of Ghent. One could expect a
higher number of external referrals, as less CBCT devices are
available in a private setting than in a hospital environment. In
a hospital, one can be tempted to refer more often as the
machine is available and accessible at all times. The internal
and external referrals accounted each for about 50 %, which
illustrates well the fact that the departments of pediatric den-
tistry and orthodontics did not misuse the fact that they had
immediate and easy access to three dimensional imaging in
their patients. The latter is exactly what SEDENTEXCT ad-
vocates [11]. Besides the availability, economic aspects may
also be at play. To quote the SEDENTEXCT-files: BThe ben-
efits must outweigh the potential risks and CBCT should po-
tentially add new information to aid the patients management
at all times. No CBCT should be selected unless a history and
clinical examination have been performed. BRoutine^ or
Bscreening^ imaging is unacceptable^ [11].
Mean age was 12.35 years, with a peak in the oldest age
group, this is comparable with the age distribution in the study
by Hidalgo-Rivas et al. [14], but the study by Suzuki et al. [15]
showed a much lower mean age of 8.3 years. Possibly, this is
caused by differences in referral pattern and/or local regulato-
ry or cultural differences. For example, the present study as
well as the study by Hidalgo-Rivas et al. [14] found more
referrals for tooth localisation in the higher age groups, while
36 % in the present study was referred for the category
Bdeveloping dentition-localized^ which consists for the
greatest part out of orthodontic referrals, typically for second
transitional period and the permanent dentition. Especially, a
significant difference was found between the age group youn-
ger than 10 years old and the one from 10 till 12 years old in
the present study. Between age groups younger than 10 and
1008
12 years and older, no significant difference was found (p=
0.018>0.016). There was only one referral for this specific
category in the youngest age group. The study by Suzuki
et al. [15] showed an extremely high referral for supernumer-
ary teeth (51 %). The latter can geographically and ethnically
be explained by the fact that there is a higher prevalence of
supernumerary teeth in mongoloid groups [16]. However,
50 % is a high number. One can assume that patients with
supernumerary teeth are often earlier referred, and it is also
possible that there is a lower threshold in the Japanese hospital
in question to refer for CBCT at younger ages. It has to be
emphasized that the authors were not able to analyse the entire
publication, as only the abstract of the study by Suzuki et al.
[15] was available in English.
There were more males than females (44 %) in this sample,
in contrast to the study by Hidalgo-Rivas et al. [14] who found
a slightly higher percentage of female (53.1 %) subjects. The
odds to be referred for the category Bdeveloping dentition-
localized^ were significantly 2.58 times higher for females
than for males. No other correlation with subcategories could
be made, probably because of the small number of events in
each of the 9 subcategories.
The main category Bdeveloping dentition-localized^ (n=
35) is mainly an orthodontic category with referrals for spe-
cific local problems (impaction, tooth location, cleft palate).
Tooth impactions, especially canines (n=15) (whether or not
with the potential of concurrent incisor resorption), were the
most presented group in this category. These and some other
types of malocclusions are sometimes reported to be more
frequent in the female population [1726].
Findings in referral patterns (Figs. 3 and 4) are different
from other studies, showing less referral for orthognathic sur-
gery in our study compared to Dobbyn et al. [13], less referral
for bony pathosis compared to Hidalgo-Rivas et al. [14] and
less referral for impacted supernumerary teeth and TMJ com-
pared to the study by Suzuki et al. [15]. From the above, it is
clear that there is a diversity in availability and access to
CBCT and that one should also take cultural and ethnical
consideration into account when assessing literature from dif-
ferent parts of the world.
Eighty one percent of the CBCTs were taken with a small
FOV (50 55 mm), this is favorable because the use of
LCBCT (limited CBCT or CBCT with a small FOV) is con-
sistent with the ALARA principle and is especially important
for pediatric patients who are extra sensitive to potential dam-
age from ionizing radiation [9, 10]. Our findings confirm
Hidalgo-Rivas et al. [14], who found 81.5 % of the CBCTs
to have a small FOV.
To cite the basic principles of CBCT, EAPD guidelines
2009 [27] BCBCT equipment should offer a choice of volume
sizes and examinations must use the smallest that is compat-
ible with the clinical situation if this provides less radiation
dose to the patient.^ Still, about 20 % had much larger FOVs,
Clin Oral Invest (2016) 20:10031010
most of them normally used for maxillofacial and cranial
CBCTs. The decision to do this is not to be taken lightly
because of the much higher radiation doses [2730], especial-
ly at high resolution. The latter (high resolution in large FOV)
was not the case in the present study group. FOV had a sig-
nificant correlation with main categories Bdeveloping denti-
tion-generalized^ and Bsurgical application.^ Possibly be-
cause of a too small sample, we could only find that signifi-
cantly more CBCTs where taken with FOV 10055mm for
surgical reasons, compared to the small FOV (5055mm).
However, in view of the indication, it makes complete sense
to have a larger FOV for surgical planning than for endodontic
issues for instance. Significant correlations with subcategories
for developing dentition-generalized were found, namely
cherubism and generalized tooth position and localization.
The sample was too small for further in between FOV differ-
ences to be found, but again, it seems logical that larger FOVs
are needed. For the main category Bsurgical application,^ a
significant correlation between FOV and Bplanning of an
autotransplant^ and Borthognathic surgery^ was found. Al-
though no significant differences in between FOVs could be
found, some autotransplant cases required a higher FOV be-
cause all premolars needed to be measured as it had to be
decided which premolar matched best in the receptor site.
The two referrals for orthognathic surgery were both taken
at a FOV of 100 55 mm (comparable to maxilla and
mandible).
Hidalgo-Rivas et al. [14] found that large FOVs consisted
mostly out of patients referred for facial trauma, TMJ, and
combined orthodontic/surgical management, although they
did not calculate for significant correlations. Only the
orthodontic/surgical management was consistent with our
results.
Finally, a significant correlation was found between FOV
and localized visualization of impaction of a premolar with
assessment of possible external resorption of adjacent teeth.
As this concerned only one case, no conclusions could be
drawn.
Dobbyn et al. [13] reported in a retrospective observational
study over 6-year orthodontic referrals for CBCT (n=290) a
proportion of 50.5 % of smaller FOVs (maximum 5 cm in
height), 20 % of large FOVs (22 cm in height), and 29.5 %
of sizes in between these. These are about 30 % more larger
FOVs compared to this study and the study by Hidalgo-Rivas
et al. [14]. Dobbyn et al. [13] did not give any correlations
between FOV and reason for referral, but they had a lot more
referrals for orthognathic surgery (25 % compared to 2 % in
this study), and their population also included patients older
than 18 years of age, which all can be held responsible for the
differences found between this and our study [31, 32].
Nevertheless it remains an interesting fact because a large
proportion of orthodontic patients consists of pediatric
patients [33, 34].
Clin Oral Invest (2016) 20:10031010
The choice for a certain FOV is also determined by the
CBCT-unit used. Compared to the Planmeca Promax 3D
Max, the i-CAT classic used in the study by Dobbyn et al.
[13] has a smaller range in FOVs and stitched images are not
possible for the i-CAT classic. The NewTom VG has only
a large FOV (150150 mm), the i-CAT Next Generation is
only very versatile in FOV height and cannot reduce the vol-
ume below 8080 mm but can acquire very large FOVs
(230170mm), and the 3D Accuitomo 170 offers a range
of FOVs between 4040 mm and 170120 mm. The latter
was the machine used by Hivalgo-Rivas et al. [14]. Many
more CBCT-units are available nowadays, making compari-
sons between studies difficult.
The majority of the CBCTs was taken at a resolution of
200 m. The latter is also the standard resolution for small
FOV in this particular CBCT machine. The radiation dose is
proportionate to the resolution [35], but one has to be realistic
that a too low resolution will not always allow to distinguish
the pathology one is after [36]. It is not always necessary to
take the smallest resolution, to quote the basic principles of
CBCT, EAPD guidelines 2009 [27] Bwhere CBCT equipment
offers a choice of resolution, the resolution compatible with
adequate diagnosis and the lowest achievable dose should be
used.^
Resolution was correlated significantly with main catego-
ries dento-alveolar trauma and endodontics. Only for end-
odontics, significant difference was found for a resolution of
150 m compared to 200 m. Subsequently, it was found that
specific subcategories for these main categories (dento-alveo-
lar trauma: post-trauma complication, dento-alveolar trauma:
suspected root fracture and endodontics: evaluation of a con-
current resorption) were also correlated with the resolution.
For Bendodontics: evaluation of a concurrent resorption^ we
found a significant different resolution comparing 150 m to
200 m. It seems quite logical that for evaluation of small
resorptions and/or suspicion of root fracture, higher resolu-
tions are used. Melo et al. [37] recommended a resolution
higher than 0.3 mm for the detection of vertical root fractures
in vitro, while zer S.Y. [38] recommended 0.2 mm for non-
root filled teeth in vitro, and da Silveira et al. [39] recommend-
ed 0.3 mm for non-root filled and 0.2 mm for teeth with filled
root and/or metallic post.
Shortcomings of this study were a rather small sample size
with greater variability. Also, the authors chose for a rather
strict statistical method to adjust for multiple testing, being the
Bonferroni correction. This could lead to exclusion of some
borderline but potential correlations. On the other hand, it
highly supports the final significant results. Power calculation
for sample size was not done. At the time of research, no
statistical characteristics were known yet about the possible
proportion of reasons for referral for CBCT in pediatric den-
tistry. Also, the primary goal of the study was descriptive;
correlative statistics were done as a secondary goal on all
1009
available eligible patients who gave an informed consent.
These study results give an overview of the current reasons
for referral for CBCT of pediatric patients in and to the Ghent
University Dental Out-Patient Hospital, Belgium, as well as
the exposure settings used in this particular patient population.
It needs to be emphasized that these results are mainly
dictated by the type of CBCT machine that was used. In this
case, a Planmeca Promax 3D Max was available, and there-
fore, other centers may find other results because they use
another CBCT machine with its manufacturer-specific expo-
sure settings and FOVs. The latter makes comparisons of ra-
diation doses extremely difficult; however, the main goal to
keep the radiation dose as low as reasonably achievable re-
mains paramount.
Conclusion
From the present study, it can be concluded that a referral
pattern could be detected which was correlated with gender,
age group, FOV, and resolution. These results can help prac-
titioners make the decision to refer for CBCT when extra three
dimensional imaging is expected to have a benefit in thera-
peutic value for a pediatric or adolescent patient.
Acknowledgments The authors would like to acknowledge the depart-
ment for Paediatric and Special care Dentistry and the unit for Oral and
Maxillofacial Imaging, Ghent University hospital, for their support in the
development and realization of the present study.
Conflict of interest The authors declare that they have no competing
interests.
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