Introduction to dental imaging

Sales training for new sales personnel

Joonas Sandholm
2.5.2010
Contents

Dental anatomy basics

Clinical needs and related imaging products

Related technologies: principles of x-ray imaging

Related technologies: digital x-ray imaging

Dental imaging market

2
Tooth anatomy

Crown

Root(s)

Source: www.studiodentaire.com
3
Basic anatomy of the jaws and teeth

Hard palate Condyle

Sinus
maxillary
Temporo-
mandibular
joint

Mandibular
canal

Premolars Incisors Premolars

Molars (3) Canine Canine Molars (3)

4
 Tooth numbering
International FDI system, US has their own ADA system

1 2

4 3

Note: deciduous (milk) teeth quadrants numbered similarly from 5 to 8 5

 Terms of orientation

Source: Kraus et al.; after Massler and Schour 1958 6

Contents

Dental anatomy basics

Clinical needs and related imaging products

Related technologies: principles of x-ray imaging

Related technologies: digital x-ray imaging

Dental imaging market

7
Why take x-ray images?

1. X-rays are used to complement visual and mechanical diagnostics

2. X-rays are only used when they provide a clear clinical benefit
8
Why take x-ray images?
What can be observed What is the information used for

Relationship of tooth to bone Preventive dentistry, especially caries

– Periodontal space
Diagnosis, identification of root causes for…
Anatomical structures – Pain
– Unerupted/impacted teeth – Swelling
– Roots: number, shape – Problems in general health
– Nerve canal
– Bone volume and quality Treatment planning and follow-up
– Temporomandibular joint – Orthodontics
– Surgery
Pathologies – Implant placement
– Caries
– Bone loss Intra-operative imaging, e.g.
– Anomalies – Root canal treatment
– Cysts

9
 Dental specialties and some typical imaging needs
USA example: dentists by specialty

Occlusion
Oral health status
Facial aesthetics
Caries diagnostics
Impacted teeth
Dental hygiene
Treatment planning
Infections

Third molars
Ortho Impacted teeth
General practitioners Missing teeth
Implant planning
Surgical planning
Surgery
Specialists
Perio Gingivitis
Connective tissues
Prostho Bone loss
Endo Implant planning

Other (pedo…)
Root&tip analysis
Infections
Root canal treatment
Treatment follow-up

Note: Images are examples – various image types are needed by each dental specialty and GPs 10
 Three general categories of dental x-ray products
Equipment perspective

3D imaging (CBCT)

60-200

2D
extraoral
Indicative
end user
system price 10-70
(kEUR)
Cephalometric
Intraoral Panoramic tomography

Cross-sectional
3-20 tomography

Periapical
Bitewing

Receptor Inside the mouth Outside the mouth Outside the mouth
Resolution High Medium Low
Imaging area Single to few teeth Dentition / jaws / skull Few teeth...skull
Dose Very low (single image), Low considering the Medium (proportional
medium for entire mouth large imaging area to field-of-view)
(1) Some regional exceptions like Japan 11
Intraoral imaging in a nutshell
Periapical
Bitewing

Intraoral = receptor is inside (intra) the mouth (oral)

Used for variety different tasks e.g. diagnosing caries, endodontic file location,
inflammations of the teeth etc.
Wide range of clinically relevant views: periapical, bitewing, Full Mouth Series,
occlusal

Merits: Demerits:
– Lowest equipment cost – Bigger risk for cross-contaminations
since the media (film/PSP/sensor) is
– Excellent contrast and spatial
in the mouth
resolution
– Slower image capture when
– Low radiation dose (excluding full comparing FMS to panoramic
mouth series) imaging

12
Panoramic imaging in a nutshell

Shows a curved layer of the jaws including TMJs

Used as an overview image of the jaws indicating overall condition. Starting point of
most treatments and imaging tasks
Wide range of clinical views e.g. PAN, Pediatric PAN, TMJs, segments, BW, etc.

Merits: Demerits:
– Fast way to obtain image of entire – Measurement prone to errors
dentition (compared to intra-oral) caused by difference in depth
compared to the sharp layer
– Low radiation dose (compared to
– Decreased resolution (and partly
size of anatomy covered) – same contrast) compared to intraoral
level as one day of background imaging
radiation – Sensitive to patient positioning

13
Cross-sectional imaging in a nutshell
Instrumentarium Dental VT
(Volumetric tomography) Traditional
tomography
Cross-sectional image of a detail with measurement capabilities (in 3D with VT)
Typically 3-4 consecutive slices are taken from the region of interest (256 with VT)
Minimum slice thickness of 1-2mm can be achieved (<1mm with VT)
Typical clinical imaging applications: implantology, 3rd molars, impacted teeth
Radiation burden typically similar to 4-6 pan images (3 pan images with VT)

Merits: Demerits:
– Cross-sectional view of anatomy – Traditional cross-sectional imaging
– Ability to do accurate measurements requires an additional sensor (not
– Cost effective compared to 3D VT)
imaging – Anatomical structures not always
– VT is patient movement tolerant due properly blurred
to fiducial markers

14
Cephalometric imaging in a nutshell
Lateral (LAT)
Posteroanterior (PA)

Offers projection images (Lateral, PA) of the skull

Long x-ray source–to–object distance to reduce magnification error
Typically used for planning orthodontic treatment utilizing landmarks from the image
Clinical applications: orthodontics, maxillofacial surgery (airways etc.)

Merits: Demerits:
– Large imaging area – Landmarks are in 3D but pinpointed
– Allows measurements of distance in 2D
and angle
– Soft tissues also well displayed
– Low dose, similar to 1 day’s
background radiation (critical as
patients are typically children)

15
Cone beam 3D imaging in a nutshell

3D volume of the region of interest (from 3x4cm to over 20x25cm)

Image can be sliced and viewed in arbitrary directions or angles after exposure
Multitude of clinical uses: implantology, maxillofacial surgery, orthodontics, etc.
Radiation burden to the patient depends on FOV but is on a level of 4-10+
panoramic images

Merits: Demerits:
– 1:1 representation of the human – Very sensitive to patient movement
anatomy
– Price of equipment
– Image can be viewed freely after
exposure – Relatively low spatial resolution
– No patient positioning errors, image – Radiation dose (big variation in
can be reoriented after exposure systems, relative to desired field-of-
– 1:1 volume allows 3D view)
measurements and CAD/CAM

16
Contents

Dental anatomy basics

Clinical needs and related imaging products

Related technologies: principles of x-ray imaging

Related technologies: digital x-ray imaging

Dental imaging market

17
What are X-rays?

…were discovered in Germany 1895 by Wilhelm Conrad Roentgen

…are electromagnetic radiation with a wavelength range of 1pm-1nm
…have penetrating abilities which are used in radiography

18
Basic characteristics of x-rays
X-rays move in a straight line like visible light

Radiation intensity diminishes with the square

of its distance from the source (see image)

X-rays interact with material

– Passes through air
– Partially blocked by human tissues
– Blocked by lead and other dense
materials

X-rays can be detected by materials sensitive

to radiation
– Film
– Imaging plates
– Solid state detectors

X-rays are ionizing radiation, harmful to living

tissue

19
How does x-ray imaging work in practice?
Image
receptor

Film
Film Light box
processor

Object

Imaging
Imaging
plate
plate
reader

Imaging
software

Sensor

20
 Image formed as tissues absorb radiation differently
Images displayed on screen as “negatives” of these original images

Crowns of teeth are

especially dense tissue and
don’t let much radiation
through.

X-rays easily
penetrate soft tissues
(skin, muscle, fat).

Bone, i.e. hard tissue,

absorbs more x-rays.

Radiolucent: material that permits the passage of X-rays

Radiopaque: material that does not let X-rays through
21
Generation of X-rays

X-rays are produced when high energy electrons collide to the target material.
– 1% of the energy converts to X-rays, most to heat

Adjusting the temperature of the Adjusting the acceleration

filament controls the amount of potential (kV = kilovolts) between
radiation delivered by the tube the anode and cathode controls
the spectrum of the radiation, i.e.
(mA = milliampere) how penetrating the radiation is

22
AC vs. DC generators
All Instrumentarium Dental generators are DC type

AC generator
- soft spectrum
- high absorbed dose

DC generator (high frequency)

- constant voltage
- low absorbed dose

23
Core terminology in x-ray generation
On spec sheet of all x-ray generating products

kV = kilovoltage. Tube voltage (60-90kV) ~ X-ray penetration ability

mA =milliampere. Tube current(1-16mA) ~ amount of radiation per time unit
s = exposure time. (0.02 – 24 sec)
mAs = milliamperes * seconds = overall output of x-ray tube.

Focal spot = Size of area on x-ray tube target where the electron beam is
focused on. Focal spot sizes in dental x-ray units is typically 0.4…0.7mm.

DC = direct current. Generator maintain a constant voltage and a

correspondingly constant x-ray spectrum.
AC = alternating current. The voltage will rise and fall from peak to zero during
each cycle. The energy of the x-rays produced will rise and fall accordingly.

24
Example: Orthopantomograph® OP30 specification
Found in brochures, needed in tenders

25
 X-ray equipment are safe when used correctly
Incorporated in equipment design and applied at the office

In-office precautions according to

local regulations
X-ray generating – Staff training
parts shielded
– Equipment quality
assurance
– Dosimeters
– Radiation shielding
• Lead aprons for
patients for stray
X-rays targeted Shielding behind
radiation
only at the receptor the receptor • Shielded walls for
some equipment
– Safety distance even for
minor scattered radiation

26
 Relative radiation doses of x-ray examinations

Examination Effective dose (µSv)

Intraoral 1-4
Lateral cephalometric 5-7
Panoramic 3 - 10
Intraoral full mouth series 30-170
CBCT (3D) 40 – 135 depending on FOV
…
Chest x-ray 100
Implant study with Medical CT 40 – 600
Mammography 700
Brain study with Medical CT 700 - 4000

One panoramic exposure is equivalent to one day natural dose

or flying from Helsinki to Oulu (1 hour flight)

5. X-ray Imaging and Oral Healthcare by James Mah,DDS,MSc,MRCD,DMSc 27

 Dental radiology a minor source of radiation
Total annual dose of Finnish citizen ~4mSv

Note: natural radiation primarily originating from the bedrock and outer space 28
Contents

Dental anatomy basics

Clinical needs and related imaging products

Related technologies: principles of x-ray imaging

Related technologies: digital x-ray imaging

Dental imaging market

29
Concepts mostly the same as in digital photography
No mystique or black magic in underlying technology

Most people own a digital camera… …and use some kind of image handling software

30
What is a digital image? (1/4)

Film image

31
What is a digital image? (2/4)

Pixel

Image area split into rectangles of similar size, i.e. pixels (here 6 x 9 = 54 pixels)

32
What is a digital image? (3/4)

=0

=1

=2

=3

“Amount” of information (white) defined in each pixel (here with 4 shades of grey)

33
What is a digital image? (4/4)

=0

=1

=2

=3

Image stored digitally (pixel 1 value 0 etc.)

34
So what ?

Since the image is now represented as numbers, we can

– Show the image on monitor
– Send the image via internet
– Manipulate the image (i.e. image processing)
• Change gray values
• Decrease noise
• Extract interesting information
• Change size of the image
• Combine images (stitching)
• Make 3D model from number of images
– Analyze the data
– Store the images
– Rotate and mirror
– Etc…

35
Benefits of digital vs. film imaging

Images instantly ready for use, no film processing needed

Images can be efficiently stored, retrieved and shared

Allows image processing and analysis after exposure, less under or overexposures

Lower radiation dose due to very sensitive detectors, less x-rays needed

Environmentally friendly, no development chemicals needed

Low operating cost, no disposable film or chemicals

Full daylight use, saved office space as no darkroom is needed

Enhanced communication with patients, colleagues and insurance companies

36
Key concepts: histogram
The count of each gray value in an image

37
 Histogram adjustment: add contrast

3
2
1
0
Original Image 0 1 2 3 New Image
0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0
0 0 0 3 3 3 0 0 0 0 => 0 0 0 0 3 3 3 0 0 0
0 0 0 2 2 2 1 1 0 0 0 0 3 3 3 0 0 0
2 1
1 => 0 3 0
0 0 0 2 2 0 0 0 0 0 3 3 0 0
0 0 0 2 2 2 1 0 0 2 => 3 0 0 0 3 3 3 0 0 0
0 0 0 0 0 0 0 0 0 3 => 3 0 0 0 0 0 0 0 0 0

38
Histogram adjustment: add brightness

3
2
1 000000011
003330
002221
00222000
0002221
00000000
00
00
10
3
2
1
OriginalImage 00 1 2 3 NewImage
0=>1 111112211
1=>2 111333111
10 2=>3 11113332
11333121
00 3=>3 11113332
21
11111111
11

0
Original Image 0 1 2 3 New Image
0 0 0 0 0 1 1 0 0 0 => 1 1 1 1 1 1 2 2 1 1
0 0 0 3 3 3 0 0 0 1 1 1 3 3 3 1 1 1
1 => 2
0 0 0 2 2 2 1 1 0 1 1 1 3 3 3 2 2 1
0 0 0 2 2 2 0 1 0 2 => 3 1 1 1 3 3 3 1 2 1
0 0 0 2 2 2 1 0 0 3 => 3 1 1 1 3 3 3 2 1 1
0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1

39
Key concepts: bit depth

Bit depth = how many different shades of grey

=0
are used to represent the image information
=1
Number of shades = 2bitdepth
=2

=3 1 bit = 21 = 2 shades (= black&white)

2 bits = 22 = 4 shades
8 bits = 28 =256 shades
16 bits = 216 = 65536 shades

Typical image formats are 8 and 16 bits

Dental x-ray images should be stored in 16

bits as these allow more image manipulation
without loss of information. Not all softwares
support 16 bits, CliniViewTM does

40
Two methods of digital X-ray imaging
Direct (with a sensor) and indirect (with imaging plates)

Image
receptor

Film
Film Light box
processor

Object

Imaging
Imaging
plate
plate
reader

Imaging Digital
software imaging

Sensor

41
 Imaging plate system concept (Express)

1 The imaging plate is exposed to X-rays during 1

which a latent image is formed into the plate 3

2 The plate is read out in the scanner unit

a) Laser beam scans through the plate
(point by point)
b) Light (energy) proportional to the
quantity of the absorbed X-rays is
released from the plate
c) The intensity of light is converted to
a corresponding amount of electrons
(charge) on a photomultiplier device 2
d) Charges of each point are digitized
and read to the computer

3 The plate is erased in the scanner with a

visible light and is ready for another cycle.

42
Direct digital sensor concept (digital OP, Snapshot)
High level overview

Digital image detector (CCD, CMOS,

ASi) is exposed to X-rays

Thin scintillator layer (Cesium iodide or

other) on top of the detector converts X-
rays to light, which the sensor is able to
“see”

Light entering the detector creates an

electronic charge in each pixel

Amount of electronic charge is converted

into grayscale values

43
 Many contributors to radiological image quality
We take this holistic view and that is why our products offer leading image quality

Viewing conditions
(display, lighting,
shuttering)

X-ray Image receptor

Imaging geometry Movement Image processing
characteristics (x-ray source, patient,
(Spatial resolution,
(calibration, technical,
(kV, mAs, spectrum, (SID, SOD, distortion) contrast resolution,
receptor) clinical)
focal spot) signal-to-noise)

Observer
Patient
(e.g. ability to detect
(anatomy, physiology,
differences in gray
positioning)
levels)

44
Image quality concepts: noise
Noise is information in the image that is not
caused by the object being imaged

Noise increases
– By decreasing the radiation dose
– By lowering the receptor sensitivity to x-
rays
– By decreasing pixel size

Sources of noise
– X-ray quantum noise
– Dark current: thermally induced to
sensor
– Image read-out noise

Noise reduction filters exist in CliniView TM

Typical metric: signal-to-noise ratio

45
Digital image quality concepts: spatial resolution
Often casually referred to as “resolution” or “line pair resolution”

Spatial resolution ~ smallest detectable details that can be

depicted

Affected by e.g. focal spot size, magnification, detector

pixel size, scintillator and movement inaccuracies

Typical metric: line pairs / mm

Spatial resolution (and pixel size) is often mistakenly taken

as the metric of image quality as it is easy to measure
– True resolutions of >15 lp / mm don’t add
clinical value in dentistry
– The smaller the pixel, the noisier the image
(assuming same dose)

Theoretical lp / mm is NOT = true lp / mm

– For example Dürr advertises 40 lp/mm and the
truth is between 10-15 lp/mm

46
Digital image quality concepts: contrast resolution
Contrast on the image defines how well a given
structure on the object can be distinguished from
its immediate background

Imaging system contrast is affected by e.g.

– Imaging method
– Noise vs. dose
– Artefacts

Typical metric: Contrast transfer function (CTF)

47
Let the images speak for themselves
Demo database available – important tool for sales conversion

48
Contents

Dental anatomy basics

Clinical needs and related imaging products

Related technologies: principles of x-ray imaging

Related technologies: digital x-ray imaging

Dental imaging market

49
Global dental market ~15B EUR and growing

Market Growth drivers

• ~15B EUR market • Aging population
• 5+% medium term growth rate • Standard of living, cosmetic dentistry
• Over 1 million dentists world wide • In-depth diagnosis, advanced applications
• New technology
• Need for increased productivity

50
 Dental imaging market size 1+B EUR
One of the fastest growing areas even within dental

Imaging 1+B EUR Equipment ~5B EUR Consumables ~9B EUR

rate
Growth
7-8% te
Growth rate Growth ra
~5% 5-7%

film
ut
th o
Wi %
~10
• Metal alloys and ceramics
• Intraoral and extraoral X-ray • Treatment units and
• Filling and impressing
Products

systems instruments
materials
• 2D and 3D • Practice furniture
• Implants and orthodontic
• Digital and film based • CAD/CAM systems
materials
• Software • Sterilizers and lab equipment
• Hand instruments
• Handpieces

• 3D imaging applications • CAD/CAM • Implants

Growth
drivers

• Digitalization • Integrated treatment units • Treatment efficiency and

• Connectivity • Digital impression taking clinical efficacy
• Chairside solutions

51
 X-rays can be found in most dental practices
3D imaging (CBCT)

In <5% of offices
Typically one per office
60-200
Typically in separate
room

2D
Indicative extraoral In 20-50% of offices
end user Typically one per office
system price 10-70 Often separate room
or corner
(kEUR)
Cephalometric
Intraoral
Panoramic tomography
In most offices
3-20 Multiple units at
the same clinic
Periapical
Chairside imaging(1)
Bitewing

1’000 10’000 100’000

Order of magnitude market size (# of systems per year)

(1) Some regional exceptions like Japan 52

Total market size 1+ billion Euro

2008 market size

Market
(MEUR)
1000
3D + combo

800

600 2D extraoral

400 Imaging plate

systems
Intraoral
200 sensors
Intraoral
x-rays
0
2008

53
Main international competitors
Presence and market positions vary per country

Large dental
Dental imaging equipment company
“High performance Schick sensors
imaging solutions”
Dental imaging
Dental units
Distribution (Nordic)

Dental imaging
“Digital imaging made
easy”

Dental imaging
Challenger from Korea
Player mostly in 3D
Dental imaging
“Performance and Dental imaging
value” Practice mgmt SW
Film

54
Main trends

Continued digitalization

Increasing role of software and connectivity

3D imaging and related products and applications

Further heightened awareness of radiation safety

Insourcing of imaging procedures and operations by private practices

Increasing technological and clinical know-how requirements for sales people

55