Position Statements on the use of CBCT

Recommendations for Performing & Interpreting CBCT Scans

The American Academy of Oral and Maxillofacial Radiology (AAOMR) issued an Executive Opinion “addressing the principles of application of CBCT as it relates to Acquisition and Interpretation of Maxillofacial Imaging in Dental Practice” summarized below:

CBCT utilization
  • Operated by licensed practitioner / certified radiologic worker
  • Only for valid diagnostic or treatment reasons and with the minimum exposure necessary for adequate image quality (ALADA)
Practitioner responsibilities
  • Must hold a valid dental license

  • Held to same standards as board-certified Oral & Maxillofacial Radiologists OMRs
    • Must systematically examine entire volume for diseases
    • Requires thorough knowledge of CT anatomy / abnormalities
    • Must interpret the findings of the examination and write a report
    • OMRs can diagnostically assist when practitioners need a second opinion / assistance reviewing the whole exposed tissue volume
  • Should have a thorough understanding of:
    • Indications and limitations of CBCT imaging
      • Use of alternative / complementary imaging and diagnostic procedures
    • Operational parameters and effects on image quality / radiation safety
      • Field of view, Positioning, Structures imaged, etc.
    • Calibration and quality control methods
Scan documentation
  • Pre-scan
    • Diagnostic / treatment need for CBCT imaging
    • Demographic, clinical, and case history information
    • Possible separate patient consent / education for CBCT imaging
  • Post-scan
    • Interpretation report of the imaging findings
    • Proper data storage format (DICOM) with suitable archival
Radiation safety and quality assurance
  • Dose optimization via specific policies / procedures / regulations
    • Patient body size, limit FOC to region of interest, and use protective devices
  • Quality control program minimizing radiation risk to patients (ALADA) and personnel (ALARA) while sustaining adequacy of the diagnostic information obtained
    • Quality control documentation
      • Calibration tests, dosimetry results, exposure parameters, etc.

Recommendations for use of CBCT for Dental Implants

The American Academy of Oral and Maxillofacial Radiology (AAOMR) issued a Position Statement for CBCT use regarding Dental Implants. After doing a literature based, consensus driven study with the goal of generating implant-related selection criteria, they specifically stated, “The AAOMR recommends that cross-sectional imaging be used for the assessment of all dental implant sites and that CBCT is the imaging method of choice for gaining this information.”

As always, ALARA (now ALADA) is the driving force in ensuring patient safety. Thus, when CBCT is used, ensure your machine is calibrated and utilizes (if capable) a pulsed beam with optimized mA/kV and/or dose reduction settings using the smallest field of view to cover the region of interest to ensure the diagnostic objective is achieved.

An abbreviated version of the 10-page guidelines is provided below for your reference noting your professional judgment guides the ultimate decision for Dental Implant Selection criteria.

Initial examination of possible dental implant patient
  • Panoramic radiography = image modality of choice
  • Intraoral periapical radiography to supplement
Preoperative site-specific planning
  • CBCT with cross-sectional imaging orthogonal to the site of interest
  • CBCT if clinical indications suggest site development needed due to:
    • Pneumatization of alveolar ridge (requiring sinus augmentation)
    • Alveolar ridge atrophy (requiring bone grafting)
      • Scan before and after (to verify integration)
    • Prior traumatic injury in area (requiring bone grafting)
    • Impacted teeth in close proximity (requiring extraction)
Postsurgical site-specific evaluation
  • Intraoral periapical radiography = imaging modality of choice
    • If in absence of clinical signs or symptoms
    • Includes periodic follow-ups
  • Panoramic radiography = imaging modality of choice
    • If many implants and lacking signs / symptoms
  • CBCT with cross-sectional imaging orthogonal to the site of interest
    • If immediate post-op mobility or altered sensation
    • If failing implant (retrieval anticipated)

Recommendations for use of CBCT for Endodontics

The American Associated of Endodontics (AAE) and American Academy of Oral and Maxillofacial Radiology (AAOMR) issued their Revised Joint Position Statement for CBCT use in Endodontics. They specifically stated, “The guidance in this statement is not intended to substitute for a clinician’s independent judgment in light of the conditions and needs of a specific patient.”

An abbreviated version of the 6-page guidelines is provided below for your reference noting your professional judgment guides the ultimate decision for use of limited field of view (FOV) CBCT scanning for Endodontics. Importantly, combined with clinical vitality testing, intraoral radiographs are the modality of choice to detect odontogenic pathoses during pre-op diagnosis as well as during post-op evaluation of surgical and non-surgical endodontic treatment.

  • CBCT if contradictory / non-specific clinical signs/symptoms
First time treatment of a tooth
  • Pre-op
    • CBCT if extra canals / suspected complex morphology
  • Intra-op
    • CBCT if calcified canals (and CBCT has not already been taken)
Retreatment (surgical) being considered
  • CBCT to localize root apex / evaluate proximity of adjacent structures
Special conditions
  • CBCT if trauma – fractures of alveolar bone/roots; tooth luxation / displacement
  • CBCT if internal / external resorption
  • CBCT if placing implants

Recommendations for use of CBCT for Orthodontics

The American Academy of Oral and Maxillofacial Radiology (AAOMR) issued a Position Statement for CBCT use in Orthodontics with the aim to summarize potential benefits and risks of CBCT use in orthodontic diagnosis, treatment, and outcomes and to provide clinical guidance to dental practitioners. Development of the statement was done via consensus agreement of a panel convened by the AAOMR post-review of literature regarding clinical efficacy of and radiation dose concepts associated with CBCT in all aspects of orthodontic practice. The panel concluded use of CBCT in orthodontic treatment should be justified case-by-case based on individual clinical presentation.

This 20-page 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. An abbreviated version of the guidelines is provided below for your reference noting your professional judgment guides the ultimate decision.

Clinical condition (via patient history, exam, previous radiographs) dictates use of CBCT
  • Avoid CBCT if conventional imaging is adequate for diagnosis
  • Avoid CBCT if sole purpose is for virtual orthodontic study models
  • Avoid CBCT if sole purpose is to generate panoramic / lateral cephalometric images
  • Selection Criteria and FOV size (see Table III) based on:
    • Phase of Treatment
      • Pre-treatment, During treatment, or Post-treatment
    • Malocclusion Difficulty
      • Mild – CBCT usually not indicated (barring additional conditions)
        • Dental malocclusions including minimal anteroposterior, vertical, or transverse skeletal discrepancies
        • Conventional orthodontics (+/- extractions) is usual treatment
      • Moderate – CBCT usually indicated
        • Dental and skeletal discrepancies including bimaxillary proclination, open bite, and Class III malocclusion
        • Conventional orthodontics (+/- orthopedic) is usual treatment
      • Severe – CBCT + other advanced imaging may be indicated
        • Skeletal discrepancies including craniofacial anomalies (cleft lip and palate, craniofacial synostosis, etc.), sleep apnea, speech disorders, and post oncology / trauma / resection / pathology
        • Team-approach treatment including speech therapy, psychological, orthodontic, and surgical interventions
  • Dental and Skeletal Conditions (Appendix A)
    • Tooth anomalies
      • Atypical morphology (supernumeraries / gemination / fusion, root abnormalities), hypodontia, retained primary teeth, and external / internal resorption
    • Tooth position
      • Impactions, proximity to mandibular nerve canals and sinus floors, atypical eruption sequence, ectopic eruptions, and unerupted / impacted supernumerary teeth
    • Dento-alveolar boundary limitations
      • Diminished buccolingual alveolar width, compromised periodontal status, bimaxillary protrusion, and alveolar clefts
    • Craniofacial asymmetries
      • Mental protuberance / dental midline deviation, occlusal cants, and other dental and craniofacial asymmetries
    • Anteroposterior discrepancies
      • Skeletal Class II and Class III malocclusions
    • Vertical discrepancies
      • Vertical maxillary deficiency / excess (+/- anterior open bite / deep overbite)
    • Transverse discrepancies
      • Skeletal buccolingual crossbites (or without crossbites if excessive dental compensation via excessive inclination of posterior teeth)
    • TMJ signs / symptoms
      • Condylar changes (hyperplasia, or aplasia), arthritic degeneration, and bite changes (e.g., progressive open bite and limitation / deviation upon opening or closing)
Patient education of CBCT
  • Radiation risk: Document; highlight increased risk for pregnant / younger patients
  • Limitations: Artifacts, noise, and limited soft tissue visualization
Minimize patient exposure from CBCT while still meeting diagnostic purpose
  • FOV size: Smallest to capture the region of interest
  • Settings: Optimized mA & kV, fewest basis images, and lowest resolution
  • Calibration: Follow manufacturer and state regulations
  • Protective lead shielding: Torso coverage (and thyroid if maxillary-only scan)

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