Use of CBCT in Orthodontics- A Review

Use of CBCT in Orthodontics- A Review ABSTRACT Lateral cephalometric radiographs are most commonly used as a diagnostic tool in orthognathic surgery as well as orthodontic treatment. But the limitation of lateral cephalograms is its 2 dimensional nature whereas the human body is 3 dimensional. Conventional 2D lateral cephalograms have numerous drawbacks in terms of investigating the changes in the alveolar bone and roots, particularly in the anterior region, as a consequence of the midsagittal projection. Additionally its accuracy is questionable as it has projection errors. The use of computed tomography in 3D imaging of human body is available in the field of medicine since last 30 years. CT scanning is the three dimensional imaging technique giving quantitative assessments of the buccal and lingual cortical bone plates and labiolingual width of alveolar bone with elevated accuracy and precision. But the use of computed tomography in dentistry is limited because the amount of radiation exposure with this technology is very high . Since the invention of Cone Beam Computed Tomography, the amount of radiation exposure in the patient is reduced. This enhances its use in obtaining the 3D images of the craniofacial structures. This technology helps in visualizing the hard and soft tissues of the craniofacial structures from various perspectives and helps in thorough diagnosis and treatment planning of orthognathic surgery and orthodontic patients. The principles of CBCT and its use in the field of orthodontics will be discussed in detail in this paper. KEYWORDS: Cone beam computed tomography, Surgical orthodontics. INTRODUCTION Orthodontics is a field, which places a significant amount of emphasis on the modification of abnormal craniofacial growth patterns, in addition to the correction of dental malrelationships. Successful orthodontic and surgical treatment of such anomalies naturally requires efficient and reliable imaging of the structures of the cranial complex. Ever since the advent ofÂÂ   the Bolton cephalometer in 1931 [1], orthodontists have consistently used lateral cephalograms in evaluation of treatment as well as in diagnosis and treatment planning. In addition, postero-anterior, panoramic, occlusal and peri-apical views of the skull and teeth have been used as and when required to aid in the diagnosis. All these additional radiographic views add up to a significant quantity of radiation exposure to the patient, which can and should be avoided if possible. Also, the 2 dimensional nature of these conventional radiographic views imposes further limitations such as overlap, leading to lack o f visualization of individual structures, errors due to projection, as well as the incapability to identify true skeletal asymmetries when present [2]. Thus, it has been recognized for some time now that three- dimensional imaging of the skull is the need of the hour in orthodontics. 3D Computed tomography in Orthodontics The use of computed tomography in 3D imaging of human body is available in the field of medicine since last 30 years. But the high radiation exposure and the prohibitive cost of this technology have till now precluded its use in orthodontics. However, recent advances in CT technology have seen a dramatic decrease in radiation as well as in cost, making it a viable and desirable alternative to traditional imaging. The newer CT machines can now perform a complete scan of the head in just a few seconds and provide the patient an effective dose of only 50 micro-Sieverts, compared with about 2000 from a conventional CT scan of the entire head [3]. This follows the ALARA principle (As low as reasonably acceptable) for radiation exposure, of the American Dental Association. Radiation exposures are further reduced when one believes that a single CT image can replace a number of conventional radiographs that are now considered essential for almost every orthodontic procedure. Thus, the routine use of CT scans for orthodontic diagnosis may not be very far away [4]. Cone Beam Computed Tomography (CBCT): Technique and Advantages Conventional CT machines acquire image data by using either a single narrow X-ray beam or a thin broad fan-shaped X-ray beam. These X-ray beams rotate around the patient in a circular or spiral path as the patient moves through the scanning machine or as the rotating beam passes over the patient. A series of detectors register the attenuation of these X rays, and from the data gathered, the machine reconstructs the internal structure of the patients body [5]. 3D data of the patients anatomical structures is stored in the form of Voxels. These can be thought of as tiny cubes arranged next to each other. The brightness of each cube represents the density of the corresponding anatomic structure. Obtaining the final 3D object from the raw data requires a time consuming process called rendering, which is achieved using computer algorithms [6]. However, a new digital imaging breakthrough, the NewTom QR 9000 Volume Scanner (Verona, Italy) is now available for clinical practice. This CT scanner uses a cone-shaped X-ray beam that is large enough to encompass the region of interest. It produces a much focused beam, minimizing scatter, thus reducing the absorbed radiation dose to 45 microSieverts [7]. In contrast to conventional CT imaging the patient remains stationary throughout the procedure. In a single scan, the X-ray source and a reciprocating X-ray sensor rotate around the patients head and acquire 360 pictures (1 image per degree of rotation) in 17 seconds of exposure time. The 360 acquired images undergo a primary reconstruction to mathematically replicate the patients anatomy into a single 3 dimensional volume. Further, the software allows for reformatting and viewing the image data from any point of view in all 3 dimensions. Thus, from a single scan, frontal, lateral, panoramic and other views can be created. Addition ally, the anatomy can be peeled away layer by layer to locate the desired section. A major advantage of CBCT-generated cephalograms is the ability to excise unwanted structures such as the cervical spine and occiput, avoiding superimposition of irrelevant structures, and providing a remarkably clear image of pertinent maxillo-facial structures [8]. Uses of 3-dimensional computed tomography in Orthodontics Assessment of alveolar bone The alveolar bone height is particularly important in adults and periodontally compromised patients. Assessment of available bone is necessary prior to arch expansion or labial movement of incisors. Surface irregularities due to ectopic teeth, bone dehiscences, salivary gland invaginations and other abnormalities can also be visualized in three- dimensional images. A new resource for occlusal assessment is the lingual view-as if the clinician were looking from the back of the patients head into the oral cavity. Impacted tooth position Impaction (or failure of eruption) of teeth is a common orthodontic problem, which requires precise localization for the purpose of surgical exposure and guidance into the oral cavity. Conventional views such as the occlusal and periapical views cannot precisely locate such teeth. CT scans with 3 dimensional reconstructions provide an excellent means to accurately locate such teeth. In such a study done on a 21 year old girl, by Ravinder et al. [9], an impacted maxillary left canine was accurately localized, and revealed to be in a horizontal, palatal position. This was done, by obtaining various views, such as plain axial, sagittal CT slices, as well as superior, sagittal and superior- oblique views of the maxillary dentition. Walker, Enciso and Mah [10] have also reported the advantages of 3D imaging in the management of impacted canines. In addition, cysts of the jaws, supernumeraries and ectopic/buried teeth can also be visualized using this technique. Temporomandibular Joint Assessment Coronal, sagittal and axial views of the temporomandibular joint obtained from the CT scan can be correlated with the occlusal views. Functional shift of the joints can be occasionally detected as differences between the left and right TMJ views. In addition, 3D CT studies on patients who underwent orthognathic surgery, have allowed better evaluation of post surgical condylar resorption [11]. Surgical patients including syndromes and clefts Surgical planning for patients with jaw asymmetry, e.g. Hemifacial Microsomia can benefit from 3D imaging. This allows measurement of true jaw dimensions without the customary problems of magnification, superimposition and distortion, inherent in 2 D cephalograms. Use of virtual cutting tools and collision tools to plan out surgery on the 3D images, means that orthognathic surgery as well as distraction osteogenesis can be carried out with a far greater degree of precision, leading to more predictable results. [12] Facial Analysis A conventional photograph is a simple two- dimensional representation that is not correlated with the supporting skeleton. The 3D volume can provide any frontal, lateral or user-defined view of the face, and by altering the translucency of the image, one can determine the exact relationship of the soft tissues to the skeleton. This has major implications in the planning of tooth movements, orthodontic extractions, orthognathic surgery, and other therapies that could alter facial appearance. Tongue size and Posture Volume measurements of the tongue could provide a more objective assessment of size, to aid in the diagnosis of arch-width discrepancies and open bites. Airway assessment Volume measurements of the airway could evaluate patency, particularly in patients suspected of adenoid hypertrophy, mouth-breathing or obstructive sleep apnea. Turbinates and nasal morphology can also be evidently seen in CT scans. This would mark a significant improvement over the use of 2 dimensional lateral cephalograms. Root resorption 3D CT images can show areas of root resorption on central and lateral incisors adjacent to impacted canine teeth. Walker, Enciso and Mah [10] showed that incisor resorption adjacent to impacted canines is present in 66.7% of lateral incisors and 11.1 % of central incisors. A correlation was found between the proximity of impacted canines to the incisors and their resorption. Current CT machines may have too low resolution to detect early stages of root resorption as a result of orthodontic movement, but this may be possible in the future [6]. Planning for placement of dental implants Osseo-integrated implants may be used in orthodontics either for the prosthetic replacement of missing teeth, or as stationary anchorage to facilitate tooth movement. Optimal spacing as well as correct root angulations of adjacent teeth must be achieved in order to successfully place dental implants [13]. Cone beam CT scanning could be used to accurately assess space availability, root angulations, as well as the quality of alveolar bone at the implant site. This would replace the use of panoramic and peri-apical radiographs currently used for the purpose. Cephalometric Analysis Conventional 2D cephalometric measurements can also be carried out, by rendering a 2D projection of the 3 D data, resembling a radiograph. For bilateral cephalometric landmarks, the computer can calculate the midpoint between them. Certainly, new cephalometric landmarks and analyses based on 3D data shall be developed in the near future. Conclusion 3D computed tomography represents the cutting edge of orthodontic imaging and diagnostic capability. While mainstream orthodontists are still living and practicing in a 2D world, orthodontic residents in many universities are becoming 3D sense. The several distinct advantages of 3D CT imaging, with ever-decreasing radiation doses, mean that this is where the future of orthodontic imaging lies. References Broadbent B.H. A new technique and its application to Orthodontia. Angle Orthod 1931; 1: 45-66. Baumrind S. Integrated Three Dimensional Craniofacial Mapping: Background, Principles, andÂÂ   Perspectives. Semin Orthod 2001:7:223-232. Mah J.K, Danforth R.A, Bumann A, Hatcher D. Radiation absorbed in maxillofacial imaging with a new dental computed tomography device. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003; 96: 508-13. Hatcher D.C, Aboudara C.L. Diagnosis goes digital. Am J Orthod Dentofacial Orthop 2004; 125: 512-5. Carlsson C. Imaging modalities in x-ray computerized tomography and in selected volume tomography. Phys Med Biol 1999; 44: 23-56. Demetrios. J .Halazonetis. From 2-dimensional cephalograms to 3-dimensional computed tomography scans. Am J Orthod Dentofac Orthop 2005; 127:627-637. Kau C.H, Richmond S, Palomo J.M, M.G.Hans. Three-dimensional cone beam computerized tomography in orthodontics. Journal of Orthodontics 2005;32:282-293. Huang J.H, Bumann A, Mah J. Three-Dimensional radiographic analysis in orthodontics. J Clin Orthod 2005; 36; 7: 421-428. V. Ravinder, Nikhar Anand Verma, Ashima Valiathan. 3-Dimensional Computed Tomography- A new method for localization of Impacted Canines. J Ind Orthod Soc 2002; 35: 73-75. Walker L, Enciso R, Mah J. Three dimensional localization of maxillary canines with cone-beam computed tomography. Am J Orthod and Dentofacial Orthop 2005; 128: 418-423. Bailey LJ, Cevidanes LH, Proffit WR. Stability and predictability of orthognathic surgery. Am J Orthod Dentofac Orthop 2004; 126:273-7. Troulis M.J, Everett P, Seldin E.B, Kikinis R, Kaban L.B. Development of a three-dimensional planning system based on computed tomographic data. Int J Oral Maxillofac Surg 2002; 31:349-357 Ravinder V, James Sunny P, Mariette DSouza, Valiathan Ashima. Osseo-integrated implants for maxillary lateral incisors- Orthodontic considerations. Malaysian Dental Journal 2003; 24(1):79-86.

Is Elizabeth Bennet the ‘perfect heroine’? Essay

Jane Austen wrote in a letter that she found Elizabeth Bennet to be ‘as delightful a creature as ever appeared in print’. Is Elizabeth the ‘perfect heroine’? Look at her character and its development throughout the novel to account for her appeal. Elizabeth is the second of Mr. and Mrs. Bennet’s five daughters. She is her father’s â€Å"favorite child† because she has ‘something more of quickness than her sisters’. Despite this, in her mother’s eyes ‘she is not a bit better than the others†¦She is not half so handsome as Jane, nor so good humored as Lydia’. As the book is written mainly from Elizabeth’s point of view, we know little of her physical appearance. Darcy’s admiration of her fine eyes is a constant source of teasing for Caroline Bingley. â€Å"I am afraid†¦ that this adventure has rather affected your admiration of her fine eyes†. We are also told that ‘she was a reputed beauty’ in Hertfordshire and that Colonel Fitzwilliam admires Mrs. Collins’ ‘pretty young friend’. At the start of the book, Lizzy is described as having a ‘lively, playful disposition, which delighted in anything ridiculous’. She admits to finding diversion in ‘follies and nonsense, whims and inconsistencies’. Towards the end of the novel, she believes that: â€Å"by her ease and liveliness, his mind might have been softened† Her refusal to forgive Mr. Darcy after he has snubbed her at the ball shows her to be proud; â€Å"I could easily forgive his pride, if he had not mortified mine.† She is determined; â€Å"†. . Lizzy always speaks her mind, illustrating her ability to think for herself; â€Å"I am no longer surprised at your knowing only six accomplished women. I rather wonder now at you knowing any.† It this mixture of frankness, belief in her own opinions and playfulness; â€Å"Elizabeth’s spirits soon rising to playfulness again† that makes her such a real person and an independent young woman. She also knows how to use sarcasm; â€Å"Mr. Darcy is uncommonly kind to Mr. Bingley, and takes a prodigious deal of care of him.† Lizzy is very perceptive, having ‘quickness of observation’. When Darcy and Wickham first meet in Meryton, she notices ‘the countenance of both as they looked at each other’. This quickness also leads her to see through the attentions of the Bingley sisters; † they were in fact very fine ladies; not deficient in good humour when they were pleased, nor in the power of being agreeable when they chose it, but proud and conceited† Lizzy’s perceptiveness at the start of the book has a great bearing on the end because it sometimes leads her to judge too quickly and jump to conclusions. Her opinion of Wickham was ill founded and derived from this tendency; â€Å"His countenance, voice, and manner, had established him at once in the possession of every virtue.† Elizabeth’s opinion of Wickham was also influenced by her prejudice against Mr. Darcy. When Wickham fails to attend the ball at Netherfield, Elizabeth immediately attributes this to â€Å"his being purposely omitted for Mr. Darcy’s pleasure in the Bingley’s invitation†. On hearing a different reason for his absence, and at a suggestion from Denny; â€Å"It assured her that Darcy was not less answerable than if her first surmise had been just†. It isn’t until this ball scene that we see the full extent of Lizzy’s prejudice against Darcy. She declares that â€Å"Attention, forbearence, patience with Darcy was injury to Wickham†. In a conversation with Charlotte Lucas, Lizzy exclaims; â€Å"To find a man agreeable whom one is determined to hate!† This quote is very significant as it shows that no matter what Darcy did, Lizzy would be prejudiced against him. Evidently Lizzy’s prejudice has overcome her common sense. This is a highly uncommon characteristic for an author to bestow on her heroine, for it shows very clearly that this is a real girl and by no means a model young lady as most heroines are. While dancing with Darcy at Netherfield, Lizzy ventures to say; â€Å"It is particularly incumbent on those who never change their opinion, to be sure of judging properly at first† This later proves to be ironic, as it is she, not Darcy who had jumped to conclusions therefore, proving that she had judged incorrectly at first. Once Elizabeth has an opinion of a person, it takes a lot to change it. She only achieves this after receiving the letter from Darcy. Despite her faults, Lizzy is not afraid to admit them and own that she was wrong; â€Å"She grew absolutely ashamed of herself. Of neither Darcy nor Wickham could she think without feeling that she had been blind, partial, prejudiced, absurd.† As well as being able to admit her mistakes, Lizzy has great honesty of mind. She has great self-belief but doesn’t try and delude herself; â€Å"The justice of the charge struck her too forcibly for denial†. As well as being honest with her self, she is honest with other people; â€Å"You know enough of my frankness to believe me capable of that† Throughout most of the book, Lizzy is prejudiced. This is where the ‘prejudice’ in the title stems from; â€Å"with a strong prejudice against anything he might say† And â€Å"to find a man agreeable, who one is determined to hate†. It is not until she reads Darcy’s letter that Lizzy realises her error. She blames her prejudice on the fact that she was ‘offended by the neglect of the other’ (meaning Darcy). It is clear by the end of the book, that she has learnt her lesson and will think before forming opinions about people in the future; â€Å"We have both reason to think my opinions not entirely unalterable†. Elizabeth has a reality about her, which is strong enough to make you believe that this person could have actually lived. She is not perfect and makes the same mistakes that anyone could, but learns from them at the same time. I think it is this and that she is such a model for the feminists of today that makes her such a charmingly different romantic heroine. It is that she is so unlike the majority of romantic heroines that must be held accountable for her appeal. It is the fact that she isn’t a perfect person, she is only the second prettiest in the Bennet family, which makes her so different from many of the stereotypical heroines, who are calm, passive, quiet, peaceful and vulnerable. She has survived time and, although set in the early eighteenth century, she gives you the feeling that as a person, Elizabeth Bennet would be just as at home in the year 2000. She is full of energy, witty, confident and independently minded, making her an ideal for modern femininity. â€Å"we have both reason to think my opinions not entirely unalterably†. â€Å"that I had not been so weak and vain and nonsensical as I knew I had!†. This again illustrates her hypocrisy as she had teased Mr. Darcy at the start of the book for having ‘vanity and pride’; here she admitted that she herself had been vain This quote also illustrates her devotion to ‘a most beloved sister’, Jane

Why Do Teens Suffer From Eating Disorders - 1596 Words

Lory Gonzalez Mr. Bishop English 132.010 October 20, 2015 Why Do Teens Suffer from Eating Disorders: Annotated Bib It is no new discovery that teenagers in America tend to have a conflict with eating disorders. This problematic issue tend to affect many young teens just as the people that surround them, those who care for them. People might stop to think why teens struggle so much with eating disorders or how can this issue be wiped out. The thing is people need to be well aware of eating disorders and there definition and try to find a way to help decrease the amount of teens that suffer by having them. Here are a six articles that might help people have a better understanding in regards to teens and eating disorders. POPA, Teodora. Eating Disorders In A Hyper-Consumerist And Post-Feminist Context. Scientific Journal Of Humanistic Studies 4.7 (2012): 162-166. Academic Search Complete. Web. 20 Oct. 2015. This article focuses on eating disorders, but most importantly on the top ones that society are more familiar with which are anorexia and bulimia. It addresses cultural aspects that help influence these two eating disorders. The article defines the disorders so people can have an actual intellectual definition, instead of what people most commonly think they are. Also it talks about eating disorders in relation with the consumerist society and the standards that are being established with body-management (POPA 162). This article will help in really definingShow MoreRelatedPromotion Of Eating Disorders And Social Medi Research Prospectus1110 Words   |  5 PagesPromotion of Eating Disorders in Social Media: Research Prospectus Background Eating disorders are defined as any range of psychological disorders, characterized by abnormal or disturbed eating habits. And in today’s society these disorders are fairly common. 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Dialectic Neocapitalist Theory In The Works Of Tarantino

Dialectic neocapitalist theory in the works of Tarantino 1. Tarantino and Derridaist reading In the works of Tarantino, a predominant concept is the concept of dialectic truth. However, Baudrillard promotes the use of modernism to read and modify class. Many desituationisms concerning the role of the participant as poet exist. If one examines prematerial Marxism, one is faced with a choice: either accept modernism or conclude that the task of the participant is deconstruction, given that prematerial Marxism is invalid. Therefore, the premise of dialectic neocapitalist theory implies that academe is intrinsically a legal fiction. The primary theme of Geoffreys[1] essay on prematerial Marxism is a capitalist whole. The characteristic†¦show more content†¦The subject is interpolated into a dialectic neocapitalist theory that includes narrativity as a reality. Therefore, Dahmus[5] holds that the works of Spelling are not postmodern. The primary theme of the works of Spelling is the role of the writer as participant. It could be said that the premise of Sontagist camp implies that language is used to entrench the status quo. The characteristic theme of Scuglias[6] model of prematerial Marxism is not dematerialism, but predematerialism. 2. Subdialectic discourse and Marxist capitalism If one examines modernism, one is faced with a choice: either reject Marxist capitalism or conclude that the significance of the artist is significant form, but only if narrativity is interchangeable with culture; otherwise, sexuality is capable of intentionality. Therefore, Sartre uses the term dialectic neocapitalist theory to denote the role of the participant as poet. Marxs essay on capitalist materialism suggests that society has intrinsic meaning, given that the premise of Marxist capitalism is valid. quot;Sexual identity is responsible for sexism,quot; says Sontag; however, according to Drucker[7] , it is not so much sexual identity that is responsible for sexism, but rather the failure, and thus the meaninglessness, of sexual identity. However, the primary theme of the works of Spelling is a conceptual totality. If dialectic