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Tôi choáng ngợp và có phần khiêm tốn trước sự thành công ngoài mong đợi của ấn bản đầu tiên của tập bản đồ này. Tôi cũng biết ơn sâu sắc nhiều đồng nghiệp đã tiếp cận tôi tại các cuộc hội thảo để nói với tôi rằng họ giữ cuốn sách này bên cạnh khi họ kiểm tra khối lượng chùm tia hình nón của họ cũng như nhiều người khác đã yêu cầu tôi ký vào bản sao của Ấn bản đầu tiên. Rõ ràng, cuốn sách đã tạo ra một tác động trong kỷ nguyên mới đầy thú vị của ngành Xquang răng hàm mặt và răng miệng. Trong ấn bản thứ hai được cập nhật này, tôi đã sử dụng thuật ngữ chụp cắt lớp vi tính chùm tia hình nón (CBCT) thay vì hình ảnh thể tích chùm tia hình nón (CBVI). Tôi vẫn tin rằng thuật ngữ đúng hơn cho phương thức này là hình ảnh thể tích. Tuy nhiên, như hầu hết các đồng nghiệp X quang của tôi đã chỉ ra, thuật ngữ CBCT được đặt trong các tài liệu nha khoa và y tế, vì vậy tôi đã quyết định, hơi miễn cưỡng, tự mình chấp nhận thuật ngữ này. Ngoài thay đổi nhỏ về tiêu đề, tôi đã thêm các trường hợp mới vào hầu hết các chương, phát triển một phần mới đề cập đến giải phẫu trong tập nhỏ và thêm ba chương mới để thảo luận về các ứng dụng cho CBCT trong nội nha, các rủi ro và trách nhiệm của CBCT, và các trường hợp được chọn từ thực hành X quang của tôi. Tôi tin rằng những bổ sung và cập nhật này đã củng cố cuốn sách và làm cho cuốn sách trở nên hữu ích hơn. Tôi đủ thông minh để biết những hạn chế của mình, và trong ấn bản này, tôi đã mời người đóng góp đầu tiên của tôi, Tiến sĩ Thomas McClammy , một nhà nội nha giỏi và một người bạn tuyệt vời. Ông đã viết chương 16 về việc sử dụng CBCT trong chuyên ngành nội nha. Là một người đầu tiên chấp nhận, Tiến sĩ McClammy đã đánh giá kỹ lưỡng, đau đớn trước quyết định mua một máy CBCT, và sau đó lao vào. Anh ấy giống như một đứa trẻ trong cửa hàng kẹo có ngôn ngữ, và sự nhiệt tình của anh ấy về phương thức này xuất hiện khi anh ấy giải thích tiện ích đáng kinh ngạc của nó trong thực hành nội nha. Cuối cùng, một số độc giả có thể đặt câu hỏi về một bác sĩ X quang đang cố gắng giải quyết các vấn đề trách nhiệm pháp lý phát sinh từ việc sử dụng CBCT. Tuy nhiên, tôi rất cảm thấy rằng một số đồng nghiệp đang chuẩn bị cho hành động pháp lý bằng cách kiên trì xem xét khối lượng CBCT chỉ để xác định vị trí cấy ghép phù hợp và bằng cách bỏ qua việc kiểm tra phần còn lại của dữ liệu hoặc giới thiệu đến bác sĩ chuyên khoa. Đây là tiêu chuẩn chăm sóc của nghề nghiệp khi một nhiệm vụ hoặc chẩn đoán nằm ngoài khả năng của chúng tôi. Hầu hết những gì tôi nêu trong chương 17 là lẽ thường. Tuy nhiên, tôi đang tự chấp nhận rủi ro này bằng cách trực tiếp giải quyết mối lo ngại này. Tôi làm điều đó vì sự an tâm của bản thân và để giáo dục đồng nghiệp. Tôi biết người đọc ấn bản thứ hai này sẽ thấy những phát triển này trong nội dung cuốn sách vừa cần thiết vừa thú vị. Thưởng thức và cảm ơn một lần nữa vì đã hỗ trợ
www.ajlobby.com www.ajlobby.com Library of Congress Cataloging-in-Publication Data Miles, Dale A Atlas of cone beam imaging for dental applications / Dale A Miles — 2nd ed p ; cm Rev ed of: Color atlas of cone beam volumetric imaging for dental applications / Dale A Miles c2008 Includes bibliographical references and index ISBN 978-0-86715-565-5 (hardcover) eBook ISBN 978-0-86715-592-1 I Miles, Dale A Color atlas of cone beam volumetric imaging for dental applications II Title [DNLM: Stomatognathic Diseases radiography Atlases Cone-Beam Computed Tomography methods Atlases WN 17] 616.07’5722 dc23 2012036568 © 2013 Quintessence Publishing Co, Inc Quintessence Publishing Co, Inc 4350 Chandler Drive Hanover Park, IL 60133 www.quintpub.com 54321 All rights reserved This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher Editor: Bryn Grisham Design: Ted Pereda Production: Angelina Sanchez www.ajlobby.com Table of Contents Preface to Second Edition Preface to First Edition Acknowledgments CBCT in Clinical Practice Basic Principles of CBCT Anatomical Structures in Cone Beam Images Airway Analysis Dental Findings Impacted Teeth Implant Site Assessment Odontogenic Lesions Orthodontic Assessment 10 Orthognathic Surgery and Trauma Imaging 11 Paranasal Sinus Evaluation 12 Temporomandibular Joint Evaluation 13 Systemic Findings 14 Vertebral Body Evaluation 15 Selected Cases from Radiology Practice 16 Clinical Endodontics 17 Risk and Liability www.ajlobby.com Preface to the Second Edition I am overwhelmed and somewhat humbled by the unexpected success of the first edition of this atlas I am also deeply grateful to the many colleagues who have approached me at seminars to tell me that they keep this book beside them when they are examining their cone beam volumes as well as to the many others who have asked me to sign their copy of the first edition Obviously, the book has made an impact in this exciting new era of oral and maxillofacial radiology In this updated second edition, I have used the term cone beam computed tomography (CBCT) instead of cone beam volumetric imaging (CBVI) I still believe that the more correct term for this modality is volumetric imaging However, as most of my radiology colleagues have pointed out, the term CBCT is ensconced in the dental and medical literature, so I have decided, somewhat reluctantly, to adopt the term myself In addition to the minor title change, I have added new cases to most chapters, developed a new section to address anatomy in the small volume, and added three new chapters to discuss applications for CBCT in endodontics, the risks and liabilities of CBCT, and selected cases from my radiology practice I believe that these additions and updates have strengthened the book and made it even more useful I am smart enough to know my limitations, and in this edition, I have invited my first contributor, Dr Thomas McClammy*, a great endodontist and a great friend He has written chapter 16 about the use of CBCT in the specialty of endodontics As an early adopter, Dr McClammy did his due diligence, agonized over the decision to purchase a CBCT machine, and then plunged in He has been like a kid in the proverbial candy store, and his enthusiasm about this modality comes through as he explains its incredible utility in his practice of endodontics Finally, some readers may question a radiologist attempting to address liability issues arising from the use of CBCT However, I feel very strongly that some colleagues are setting themselves up for legal action by persisting in looking at the CBCT volumes only to determine a suitable implant site, and by neglecting the examination of the rest of the data or its referral to a www.ajlobby.com specialist This is the profession’s standard of care when a task or diagnosis is beyond our capability Most of what I state in chapter 17 is common sense Nevertheless, I am taking this risk myself by addressing this concern directly I it for my own peace of mind and to educate my colleagues I know the reader of this second edition will see these developments in the book’s content as both necessary and exciting Enjoy, and thanks again for the support * Thomas V McClammy, DMD, MS Private Practice Scottsdale, Arizona www.ajlobby.com Preface to the First Edition Like any innovation in the dental profession, the availability of cone beam volumetric imaging (CBVI) has preceded the understanding of its use It happened with panoramic imaging as it did with digital radiographic imaging The cone beam images in this atlas will educate dental professionals on how to use CBVI technology to better visualize the diseases and disorders that they encounter with their patients One aim of this atlas is to refresh the reader’s memory of anatomy As dentists we never “worked” in the axial plane of section after our anatomy training; we have lived our lives in a world of plain films or digital images, all in the format of 2D grayscale panoramic, intraoral, or lateral cephalometric images CBVI allows us to visualize patient anatomy and pathology like never before CBVI helps to reveal bony changes caused by pathology In addition, the level of anatomic detail in the 3D image sets means that clinicians placing implants no longer have to experience anxiety about whether they are placed correctly CBVI allows us to determine the precise location of the inferior alveolar nerve in relation to impacted mandibular third molars, which improves preoperative planning and reduces patient morbidity as well as our liability At last, we can see out patients’ problems in a whole new manner—in 3D and color I hope this book will help you understand how CBVI can improve your clinical experiences and the management of your patients’ treatment www.ajlobby.com Acknowledgments I am deeply appreciative to CyberMed USA and CyberMed International for allowing me to continue to test their software product and to use it in my practice I happen to think that it is the premier software for examining cone beam computed tomography image data Mr Eusoon Han and the marketing team at CyberMed USA work tirelessly to support the product and have helped me understand the incredible tools within the software Thanks to all Thanks once more to Prof C Young Kim, the CEO of CyberMed International for your product, your confidence, and your friendship This book would not be possible without your product and support A big thank you to Mr William Hartman of Quintessence for going the extra mile with my requests, and to Ms Lisa Bywaters and Ms Bryn Grisham for their editorial support Finally, love and special thanks to my wife, Kathryn, for her continued support, love, confidence, sacrifice, and patience www.ajlobby.com CBCT in Clinical Practice Nothing has captured the dental profession’s imagination in the past few years like the introduction of cone beam volumetric imaging (CBVI), which is now referred to by most clinicians and even in the literature as cone beam computed tomography (CBCT) I too now refer to the data volumes I receive from clients as CBCT volumes, despite my opinion that CBCT images bear no resemblance to traditional medical computed tomography (CT) scans except in the display of the final product The process of image acquisition for CBCT machines is unlike traditional medical CT scanners in that the patient is not usually supine, the image gathered is in a voxel (volume element) format, the x-ray dose absorbed by the patient is substantially lower, appointment availability is much easier, and it is less expensive In short, although this imaging modality produces signicant data volumes like medical CT, it is different and vastly superior to traditional CT data for specic dental applications Dentists and dental specialists continue to be amazed at the incredibly precise and profound information produced by CBCT scans, and they are realizing that the data they receive will influence their treatment decisions like no other imaging modality used in the profession in the past 100 years CBCT makes clinical decision making easier and more precise, patient treatment decisions more accurate, and visualization of the x-ray data more meaningful Dentistry is moving away from “radiographic interpretation” and into “disease visualization,” and it could not have come at a better time www.ajlobby.com complex (arrow) as well as some perforation defects encroaching on the lateral aspect of the mastoid process Fig 17-2d A sagittal slice near the medial pole of the right mandibular condyle of the TMJ Fig 17-2e A sagittal slice just medial to Fig 17-2d showing gross destruction of the posterior region of the mastoid process as well as radiopaque change in the inferior portion within the cells The faint outline of the mandibular condyle head can be seen within the fossa in this image (arrow) Fig 17-2f A 3D color reconstruction of the normal right mastoid process using the Cube tool (OnDemand 3D software, CyberMed International) Fig 17-2g A 3D reconstruction of the left mastoid process The superior portion reveals a perforation defect that has eroded through the bone (arrow) Case Presentation An 81-year-old white woman was referred to an endodontist in Mesa, Arizona, for evaluation of a radiographic radiolucency related to the mandibular right first premolar that had been treated endodontically In the data volume taken by a limited field of view CBCT machine, the endodontist also captured part of the mandibular right molar region The patient was asymptomatic Regardless, the data volume was sent for a second opinion The first finding was the radiolucency associated with the mandibular right first premolar (Figs 17-3a to 17-3d) The second was a pericoronal lesion around the mandibular right third molar (Figs 17-3e to 17-3k) Fig 17-3a Large radiolucency associated with the mandibular right first premolar Fig 17-3b Continuation of the lesion to the mesial aspect of the root of the mandibular right canine The margins of the lesion are welldefined and there are no internal calcifications Fig 17-3c The radiolucency associated with the mandibular right first premolar seen in cross section Fig 17-3d From the distal aspect of the mandibular right first premolar, the lesion shows thinning of the buccal cortex and small perforation defects on the lingual aspect (arrows) Fig 17-3e A pericoronal radiolucency associated with the mandibular right third molar seen in axial section Fig 17-3f The coronal section shows the displacement of the molar and thinning of the lingual cortical margin Fig 17-3g A sagittal view shows a thinning of the posterior portion of the mandible Fig 17-3h A sagittal view from a more medial aspect showing expansion of the lesion Fig 17-3i A 3D color reconstructed sagittal view, showing destruction of the external oblique ridge Fig 17-3j A 3D color reconstructed sagittal view, showing destruction of the external oblique ridge Fig 17-3k A 3D color reconstructed view attempting to show the soft tissue of the cyst It is unlikely that these two radiolucent lesions are unrelated The presence of a pericoronal lesion around the mandibular right third molar would give rise to the following differential diagnosis: dentigerous cyst, odontogenic keratocyst, ameloblastoma, and, although more rare, a mucoepidermoid carcinoma or even a squamous cell carcinoma The presence of another large lesion that has thinned or eroded the buccal or lingual cortices and caused perforation defects suggests an odontogenic cyst or ameloblastoma Since the lesions could be related, it is more probable that these are odontogenic keratocysts such as those seen in the nevoid basal cell carcinoma syndrome Even if these two lesions are separate, they are significant After description of these lesions is completed and the differential diagnosis is established, the patient has to be imaged again using a CBCT machine with a larger field of view In addition, confirmation of nevoid basal cell carcinoma syndrome would require imaging of the chest and cranium to search for indication of bifid ribs and calcified falx cerebri, respectively What is significant about this case from an imaging standpoint is that both lesions were found in a data set taken by a CBCT unit with a small field of vision Even in a CBCT data set with a small field of view, there are often significant findings for which the clinician is responsible, if not for diagnosis, at least for follow-up In this case, the patient was referred to an oral and maxillofacial surgeon as well as to her primary care provider and a geneticist for further evaluation The clinician was responsible for locating and describing the lesion and referring the patient for further evaluation The endodontist did not have to make the diagnosis of nevoid basal cell carcinoma syndrome but was required to follow the standard of care of referral Parting Comments Dentistry has a new tool that will help clinicians to define the diseases and disorders that they encounter with our patients The CBCT technology available to clinicians can improve presurgical planning and reduce the patient’s morbidity and our liability Clinicians can visualize the bony changes caused by the pathology, capture sufficient presurgical anatomy in such detail that they no longer have to fear placing implants, and determine the precise location of the inferior alveolar nerve in relation to impacted mandibular third molars Now, at last, clinicians can visualize our patient anatomy in a whole new manner—in three dimensions and in color References Carter L, Farman AG, Geist J, et al American Academy of Oral and Maxillofacial Radiology executive opinion statement on performing and interpreting diagnostic cone beam computed tomography Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:561–562 Turpin DL Befriend your oral and maxillofacial radiologist Am J Orthod Dentofacial Orthop 2007;131:697 Holmes SM iCAT scanning in the dental office Fortress Guardian 2007;9:2 Friedland B Medicolegal issues related to cone beam CT Semin Orthod 2009;15:77–84 Breckenridge PJ (ed) Book of Accepted Jury Instructions, ed St Paul: West Group, 1995 Curley A CBCT: Controversies in the Legal Standard of Care Presented at the 3rd International 3D Dental Imaging Congress, Chicago, 20 June 2009 American Dental Association Principles of Ethics and Codes of Professional Conduct Chicago: American Dental Association, 2011 Learn more about Quintessence Publishing Co www.QuintPub.com ... Library of Congress Cataloging-in-Publication Data Miles, Dale A Atlas of cone beam imaging for dental applications / Dale A Miles — 2nd ed p ; cm Rev ed of: Color atlas of cone beam volumetric imaging. .. Clinical Applications of CBCT The applications for CBCT encompass most of the procedures clinicians perform in their office Some applications for CBCT are listed in Box 1-1; examples of many of these... second edition, I have used the term cone beam computed tomography (CBCT) instead of cone beam volumetric imaging (CBVI) I still believe that the more correct term for this modality is volumetric imaging