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Objectives: To assess patient movement characteristics in children and young adults and the impact on CBCT image quality., Methods: During 33 CBCT examinations, the patients (age: average, 14 years; range, 9-25 years) who had moved were identified by video observation [movement group (MG)]. The CBCT data sets were matched with those of 33 non-moving patients according to age, diagnostic task, examined region, field of view and voxel resolution [non-movement group (N-MG)]. Three observers scored the videos of MG, regarding motional state second by second (moving/non-moving), and movement characteristics: duration (in seconds), complexity (uniplanar or multiplanar) and distance (<3/≥3 ≤ 10/>10 mm). The observers blindly assessed axial sections of the 66 examinations individually, categorizing the image quality (appropriate/acceptable/inappropriate). Next, the observers blindly assessed axial sections of the matched-pairs images simultaneously, deciding which image in the pair had the highest image quality or if it was impossible to decide. The relationship between image quality and movement/movement characteristics was evaluated., Results: When the 66 CBCT images were evaluated individually, no relationship between image quality and movement was found. However, based on the matched-pairs assessment, accumulated number (≤2 vs ≥3, p = 0.039), duration (≤5 s vs ≥6 s, p = 0.024) and complexity (uniplanar vs multiplanar, p = 0.046) of movements had an impact on image quality; the more severe the movement, the more often the image quality was assessed lower in the MG., Conclusions: Axial CBCT images of young patients who moved during examination did not always present lower quality than images originating from non-moving patients. Image quality was, however, significantly lower in the moving patients when movement occurred several times, had a long duration or was multiplanar.

Objectives: Radiographic images suffer from varying amounts of noise. The most studied and discussed of these is random noise. However, recent research has shown that the projected anatomy contributes substantially to noise, especially when detecting low-contrast objects in the images. Our aim, therefore, was to evaluate the extent to which overprojected anatomical noise affects the detection of low-contrast objects in intra-oral images., Methods: Our study used four common sensor models. With each sensor, we took four series of images, three series with and one series without an anatomical phantom present. In each series, we exposed a low-contrast phantom at 18 different exposure times using a standardized method. 4 observers evaluated all 288 images., Results: The low-contrast characteristics differed substantially when imaging low contrast on a homogeneous background compared with imaging low contrast when an anatomical phantom was present. For three of the sensors, optimal exposure times for low-contrast imaging were found, while the fourth sensor displayed a completely different behaviour., Conclusions: Calibrating the low-contrast properties of an imaging system using low-contrast objects on a homogeneous background is not recommended. On an anatomical background, low-contrast properties are completely different, and these will mimic the clinical situation much more closely, directing the operator how to best use the system. There is a clear demand for further research on this subject.

Spatial resolution is one of the most important parameters objectively defining image quality, particularly in dental imaging, where fine details often have to be depicted. Here, we review the current status on assessment parameters for spatial resolution and on published data regarding spatial resolution in CBCT images. The current concepts of visual [line-pair (lp) measurements] and automated [modulation transfer function (MTF)] assessment of spatial resolution in CBCT images are summarized and reviewed. Published measurement data on spatial resolution in CBCT are evaluated and analysed. Effective (i.e. actual) spatial resolution available in CBCT images is being influenced by the two-dimensional detector, the three-dimensional reconstruction process, patient movement during the scan and various other parameters. In the literature, the values range between 0.6 and 2.8 lp mm(-1) (visual assessment; median, 1.7 lp mm(-1)) vs MTF (range, 0.5-2.3 cycles per mm; median, 2.1 lp mm(-1)). Spatial resolution of CBCT images is approximately one order of magnitude lower than that of intraoral radiographs. Considering movement, scatter effects and other influences in real-world scans of living patients, a realistic spatial resolution of just above 1 lp mm(-1) could be expected.

Objectives: To investigate whether standardizing commercial off-the-shelf (COTS) display devices to the digital imaging and communications in medicine part 14: greyscale standard display function (DICOM part 14: GSDF) would affect the presentation of dental images., Methods: Two COTS display devices from the radiology department of a dental teaching hospital and a laptop computer monitor for reference were calibrated to conform to DICOM part 14: GSDF. Four dental surgeons and two final-year students undertook a relative visual grading analysis of the two devices before and after calibration, under control of the viewing environment., Results: Calibrating COTS display devices to conform to the DICOM part 14: GSDF and viewing under reduced ambient light result in a consistent, perceived visual sensation for the presented radiological image. The area under the visual grading characteristics curve (AUCVGC) before calibration is 0.62 CI (0.56, 0.68) and AUCVGC after calibration is 0.51 CI (0.45, 0.57)., Conclusions: Standardizing COTS display devices to the DICOM part 14: GSDF can improve image presentation.

Objectives: Conventional panoramic radiography, a widely used radiographic examination tool in implant treatment planning, allows evaluation of the available bone height before inserting posterior mandibular implants. Image distortion and vertical magnification due to projection geometry is well described for rotational panoramic radiographs. To assess the accuracy of vertical height measurements on direct digital panoramic radiographs, implants and metal balls positioned in the posterior mandible were used as radio-opaque reference objects. The reproducibility of the measuring method was assessed by the inter- and intraobserver agreements., Methods: Direct digital panoramic radiographs, performed using a Kodak 8000C (Eastman Kodak Company, Rochester, NY), of 17 partially edentulous patients (10 females, 7 males, mean age 65 years) were selected from an X-ray database gathered during routine clinical evaluation of implant sites. Proprietary software and a mouse-driven calliper were used to measure the radiological length of 25 implants and 18 metal reference balls, positioned in mandibular posterior segments. The distortion ratio (DR) was calculated by dividing the radiological implant length by the implant's real length and the radiological ball height by the ball's real height., Results: Mean vertical DR was 0.99 for implants and 0.97 for balls, and was unrelated to mandibular sites, side, age, gender or observer. Inter- and intraobserver agreements were acceptable for both reference objects., Conclusions: Vertical measurements had acceptable accuracy and reproducibility when a software-based calibrated measurement tool was used, confirming that digital panoramic radiography can be reliably utilized to determine the pre-operative implant length in premolar and molar mandibular segments.

Objectives: The SEDENTEXCT Project proposed quality assurance (QA) methods and introduced a QA image quality phantom. A new prototype was recently introduced that may be improved according to previous reports. The purpose of this study is to evaluate image quality in various protocols of three cone beam CT (CBCT) machines using the proposed QA phantom., Methods: Using three CBCT machines, nine image quality parameters, including image homogeneity (noise), uniformity, geometrical distortion, pixel intensity value, contrast resolution, spatial resolution [line pair (LP) chart, point spread function (PSF) and modulation transfer function (MTF)] and metal artefacts, were evaluated using a QA phantom proposed by SEDENTEXCT. Exposure parameters, slice thickness and field of view position changed variously, and the number of total protocols was 22., Results: Many protocols showed a uniform gray value distribution except in the minimum slice thickness image acquired using 3D Accuitomo 80 (Morita, Kyoto, Japan) and Veraviewepocs 3Df (Morita). Noise levels differed among the protocols. There was no geometric distortion, and the pixel intensity values were correlated with the CT value. Low contrast resolution differed among the protocols, but high contrast resolution performed well in all. Many protocols showed that the maximum line pair was larger than 1 LP mm(-1) but smaller than 3 LP mm(-1). PSF and MTF did not correlate well with the pixel size. The measured metal artefact areas varied for each device., Conclusions: We studied the image quality of three CBCT machines using the SEDENTEXCT phantom. Image quality varied with exposure protocols and machines.

Patient artefacts in dental cone beam CT scans can happen for various reasons. These range from artefacts from metal restorations to movement. An audit was carried out in the Glasgow Dental Hospital analysing how many scans showed signs of "motion artefact", and then to assess if there was any correlation between patient age and movement artefacts. Specific age demographics were then analysed to see if these cohorts were at a higher risk of "movement artefacts".

Objective: The aim of this study was to assess the accuracy and reliability of cone beam CT (CBCT) images compared with multidetector CT (MDCT) images for the detection of surface osseous changes in temporomandibular joints (TMJs)., Methods: Naked-eye inspection of 110 sites in 10 TMJs from 5 dry human skulls provided the gold standard. Two radiologists interpreted the images. Sensitivity, specificity and kappa statistics were used for analysis., Results: The sensitivities of both modalities were low and comparable whereas the specificities were high and comparable. Intraobserver reliabilities for CBCT (p=0.0005) and for MDCT (p=0.0001) showed significant agreement. Interobserver reliability was higher for CBCT than for MDCT., Conclusion: CBCT and MDCT accuracy was comparable in detecting surface osseous changes with comparable intraobserver reliabilities. However, since CBCT requires less radiation exposure, it should be encouraged for imaging TMJ with suspected surface osseous changes.

Objectives: To evaluate the reliability of cone beam CT (CBCT) values and dimensional measurements of oropharyngeal air spaces as compared with those of multidetector row CT (MDCT)., Methods: A soft tissue equivalent phantom with different sized holes was used. The phantom was scanned using CBCT and MDCT. In addition, a volunteer was examined using both methods for clinical comparison. The CT data were retrieved to a personal computer and treated using image processing software for three-dimensional rendering and dimensional measurements. The CT values of air, water and soft tissues were measured experimentally and the CT values of air, fat and muscle were measured in a clinical case. The diameter of each hole drilled in the phantom was measured on CBCT and MDCT images using the software tool and digimatic callipers., Results: The CBCT values were quite different from the Hounsfield units obtained with a typical MDCT system. The standard deviations were almost ten times larger with CBCT. In vivo assessment showed that the CBCT values for fat had a wide range that partially overlapped the values for muscle. The measurement of distances greater than 4 mm was consistent for all methods. The difference for holes was less than 0.2 mm., Conclusions: The phantom study showed that CBCT provides limited quantitative CT values for each pixel on sliced images for differentiating air, water and soft tissues. However, the measurement of air spaces with CBCT was quite accurate.

Objectives: To compare the diagnostic quality of multiplanar reformations generated by a newly developed cone beam device with the diagnostic quality of multiplanar reformations obtained using a state of the art multidetector row CT scanner., Methods: Digital volume tomograms (DVTs) were obtained with the prototype of GALILEOS (Sirona Dental Systems Inc., Bensheim, Germany), a newly developed compact-sized cone beam machine with a scan volume of 15 x 15 x 15 cm. CT scans were performed for comparison with two 16-detector row CT scanners. The study included 30 image pairs obtained from the same patients. The multiplanar reformations in axial, coronal and sagittal planes were subjectively assessed by 3 observers using a 1(excellent)-5(poor) scale on 35 weighted criteria including findings detection, image quality and visualization of several anatomical structures., Results: There was no statistically significant difference between DVT and CT in cumulative values expressing the diagnostic quality of the reformations (P = 0.071). The interobserver agreement was better with CT than with DVT. Findings detection and the visualization of the majority of anatomical structures within the mandibulomaxillary area were ranked at the same level for DVT as with CT., Conclusions: The diagnostic quality of multiplanar reformations can be considered the same in both devices. Although sharpness, noise level and contrast resolution do not reach the level of CT, DVT images proved statistically not inferior for the detection of lesions which may be adequately depicted by both imaging modes.

Objectives: The aim of the present study was to determine (1) the absorbed and the exit radiation doses for cephalometric exposures on a phantom head with various exposure settings and image receivers, and (2) the diagnostic image quality for various modalities assessed on cephalometric radiographs of patients., Methods: The dose measurements for lateral cephalometric radiographs were performed with a semiconductor detector, and also with thermoluminescent detectors and an Alderson phantom. Both the integral and the effective doses were determined. Two radiographs of each patient (n=119) were taken at two different times, one at a low tube potential setting, 75+/-5 kV, and one with a decreased dose. Film-screen systems with speed class 400 and one storage phosphor plate were used. Five observers assessed the radiographs for the visualization of six cephalometric reference points on a three-point scale with -1, 0 and 1. Twenty-seven image pairs were rescored to determine inter- and intrarater reliability. The statistical analysis was done using analysis of variance and Tukey's HSD (honestly significant difference) post hoc test., Results: Increasing the tube potential setting led to an average dose reduction to 83% (integral dose) or to 87% (effective dose). Instead of taking the radiograph at a low tube potential setting (75 kV), a dose reduction of about 15% was feasible at a high tube potential setting (90 kV). A significant difference in reference point visibility existed between film radiographs at low tube potential settings (mean score 0.984) and at high tube potential settings (90 kV, mean score 0.958). For the storage phosphor plates, there was no significant difference to the film-screen combinations at low tube potential and halved milliampere seconds settings. In the second assessment, there was a high degree of agreement (96.6%) compared with the first assessment (unadjusted for random agreement)., Conclusions: As there is only minimal dose reduction at increased tube potential settings, for a dose reduction, it seems to be more useful to use storage phosphor plates at unchanged tube potential and halved milliampere seconds settings compared with the film-screen combination.

Objective: To evaluate the degradation of storage phosphor images relative to scanning delay., Methods: A series of exposures of an aluminium step-wedge with five 2 mm incremental steps were made using blue Digora storage phosphor plates (SPPs). After the first exposure the plates were immediately scanned. After the second the plates were scanned after a half hour delay, after the third after a 1 h delay and so on until a final delay of 8 h. Mean grey values (MGVs) of each step of the wedge and its background were compared using repeated measures analysis of variance (ANOVA). Difference between group means was assessed using Bonferroni/Dunn multiple comparison test (P<0.05)., Results: MGVs increased with the increase in scan delay. Repeated measures ANOVA revealed that MGVs of the background and each step of the wedge were significantly different from each other for all scan delays (P<0.0001). Bonferroni/Dunn test showed that MGVs from plates scanned half an hour after exposure were not significantly different from those scanned immediately (P>0.05). Longer delays gave rise to significant differences in MGVs (P<0.05)., Conclusion: Digora SPPs show statistically significant degradation of grey level values and contrast in plates scanned half an hour or longer after exposure.

Objectives: To compare the image quality of panoramic radiographs obtained with storage phosphor plate and screen-film systems., Methods: Panoramic radiographs were taken in 60 patients both with film and with a storage phosphor plate system (30 with DenOptix (Dentsply/Gendex) and 30 with Digora PCT). The images were obtained with either the Cranex Tome or the Scanora multimodal X-ray unit. The screen-film combination was Lanex medium/Curix Ortho HT-G. The digital images were displayed as 8-bit images with a 300 dpi resolution on a 19" monitor and the film images were placed on a light box adjacent to the screen. Ten observers evaluated diagnostic image quality by means of visual grading analysis of different anatomical structures. The structures were scored as being visualized much better (5), better (4), equal (3), worse (2) or much worse (1) in the digital images than in the film images. The mean number of patients receiving the different scores was calculated. Statistical methods used were Wilcoxon sign rank test and Mann-Whitney test., Results: On average, visualization was equal in 19 of the 30 patients imaged using Digora PCT; in 10 it was worse. The corresponding values for DenOptix were 20 and 9. The difference between the film-based and the digital images was small but statistically significant (P<0.0001). The difference between the two image plate systems was not statistically significant (P>/=0.17)., Conclusions: It was concluded that digital panoramic radiographs are equivalent to film-based images for most purposes.

Objectives: Because of methodology-induced structural differences in dental radiographs, determination of change has always depended upon expert interpretation. However, new methods should be able to considerably reduce structured error in digitized subtracted images. Once true change in density is obscured only by random variation in pixel density, statistical methods may be brought to bear on the problem of detecting change. The most appropriate statistic is not obvious, however, since density change can be quantified with respect to both magnitude and dimensional extent. Whereas mean density loss is often intuitively defined as the average density of those pixels losing density (to preclude gaining pixels from offsetting losing pixels), the extent of change may be defined in a variety of ways. In this study, extent was defined as either (a) the total number of pixels losing density, or (b) the size of the largest cluster of losing pixels. The object was to evaluate the comparative statistical power of three possible statistics (based on mean density, number of losing pixels, and size of largest losing cluster) for detecting change., Methods: In a series of simulations of comparative clinical trials, density was reduced in the centre of 1600-pixel square regions of interest by either one or 10 grey-scale units, and t-tests, based on the three statistics, were then compared for their ability to detect differences., Results: Each of the three statistics was shown to exhibit superior relative power under particular conditions of loss magnitude, loss distribution, and pixel threshold for change., Conclusion: Selection of the appropriate statistic for identifying change between radiographs will require further information about the anticipated distribution of density changes for the different disease processes under investigation.

A number of factors may determine the diagnostic accuracy of digitized intraoral radiographs. Conventional film radiographs were digitized with three different digitizers, a laser-scanner, a drum-scanner and a TV camera. Digital images, varying in pixel size, grey level and image processing, were displayed on three different video-monitors and assessed by 10 dentists. The detectability of incipient proximal surface caries was used as an index of the diagnostic accuracy and the effect of the different factors compared by means of receiver operating characteristic (ROC) analysis. Images digitized by the drum-scanner were found to have the best diagnostic accuracy. Sufficient diagnostic accuracy could be attained on the low-cost video monitor of a personal computer. Digital images with a pixel size of 100 microns and 32 grey levels were found to be acceptable for intraoral radiographs for diagnostic purposes. These results provide a practical guide for establishing a digital image acquiring system for any intraoral radiographs, reducing demands on data storage to a minimum.

This study evaluated dentists' perception of the quality of digitally captured radiographs. Thirty radiographs were taken with the Visualix digital video radiographic system, 10 periapicals for tooth and bone anatomy, 10 periapicals for bone disease and 10 bitewings for dental caries. Three numeric copies were made of each image and treated with three different filters: 'optimize', 'enhance' and 'enhance + smooth', respectively. Four images of the same case were displayed simultaneously in a random sequence on the monitor. Twenty dentists ranked each set of four images on a scale from 1 to 4. In general, most dentists preferred a treated image to the original. The optimized and enhanced images were selected most frequently as first or second choice from the tooth and bone anatomy and bone disease groups. The original image was ranked lowest in more than half (55%) of the series. For the bitewings, the smoothed images were ranked significantly higher. In conclusion, image treatment possibilities should be offered in digital radiography as the majority of dentists preferred a treated image to the original version. The image treatment chosen seemed to be task dependent; less treatment was required to delineate the more subtle tissue differences.