Original Article

Assessment of thin bony structures using cone-beam computed

tomography
Camilla Lennholma; Anna Westerlundb; Henrik Lundc

ABSTRACT

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Objectives: To investigate the validity and reliability of marginal bone level measurements on
cone-beam computed tomography (CBCT) images of thin bony structures using various
reconstruction techniques, two image resolutions, and two viewing modes.
Materials and Methods: CBCT and histologic measurements of the buccal and lingual aspects of
16 anterior mandibular teeth from 6 human specimens were compared. Multiplanar (MPR) and
three-dimensional (3D) reconstructions, standard and high resolutions, and gray scale and inverted
gray scale viewing modes were assessed.
Results: Validity of radiologic and histologic comparisons were highest using the standard
protocol, MPR, and the inverted gray scale viewing mode (mean difference ¼ 0.02 mm) and lowest
using a high-resolution protocol and 3D-rendered images (mean difference ¼ 1.10 mm). Mean
differences were significant (P , .05) at the lingual surfaces for both reconstructions, viewing
modes (MPR windows), and resolutions.
Conclusions: Varying the reconstruction technique and viewing mode does not improve the
observer’s ability to visualize thin bony structures in the anterior mandibular region. The use of 3D-
reconstructed images should be avoided when thin cortical borders are suspected. The small
difference when using a high-resolution protocol is unjustified due to the higher radiation dose
required. Previous studies have focused on technical parameters; the present study explores the
next link in the imaging chain. (Angle Orthod. 2023;93:328–334.)
KEY WORDS: Cone-beam computed tomography; Histology; Marginal bone level; Window
settings; Reliability and validity; Orthodontics

INTRODUCTION the late 1990s. In orthodontics, it is an essential part of

studying the possible side effects of the marginal bone
Assessment of thin bony structures with cone-beam level due to treatment and retention.1,2 To achieve
computed tomography (CBCT) has attracted great accurate results, the technique must be properly used.
interest in various disciplines since its introduction in The vast majority of studies investigating the validity
and reliability of bone level measurements in relation to
a
PhD Student, Department of Oral and Maxillofacial Radiol- thin bony structures on CBCT images have focused on
ogy, Institute of Odontology, Sahlgrenska Academy, Gothenburg the inherent technical properties of the CBCT unit (eg,
University, Gothenburg, Sweden.
voxel size), field of view (FOV), and the exposure
b
Associate Professor, Department of Orthodontics, Institute of
Odontology, Sahlgrenska Academy, Gothenburg University, parameters (e.g., milliampere [mA], and kilovolt [kV]).3–5
Gothenburg, Sweden. Other parameters, such as spatial resolution and
c
Associate Professor, Department of Oral and Maxillofacial partial volume averaging, may also play an important
Radiology, Institute of Odontology, Sahlgrenska Academy,
role in the visualization of small or thin structures.
Gothenburg University, Gothenburg, Sweden.
Corresponding author: Camilla Lennholm, Department of Oral Crucial to achieving high validity and reliability,
and Maxillofacial Radiology, Institute of Odontology, Sahlgren- however, is that the raw radiologic data are recon-
ska Academy, Gothenburg University, PO Box 450, Göteborg structed in a way that optimizes visualization. Usually,
405 30, Sweden
(e-mail: [email protected])
this is done using multiplanar reconstruction (MPR),
which produces three image planes orthogonal to each
Accepted: January 2023. Submitted: September 2022.
Published Online: February 16, 2023 other (axial, sagittal, and coronal) to depict image
Ó 2023 by The EH Angle Education and Research Foundation, volume; this enables the observer to choose the best
Inc. view for the diagnostic task. Another option is to use

Angle Orthodontist, Vol 93, No 3, 2023 328 DOI: 10.2319/090922-633.1

CBCT IN THE ASSESSMENT OF THIN BONY STRUCTURES 329

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Figure 1. Multiplanar reconstruction (MPR) according to the long axis of the tooth and the metal ligature in the (a) axial, (b) coronal, and (c) sagittal
viewing planes.

three-dimensional (3D) volume rendering, which, in marker to ensure correct positioning during radiograph-
comparison with MPR, presents the radiological data ic measurements in relation to the histologic section.
as a 3D surface object. Besides these two reconstruc-
tion techniques, the observer can vary the viewing Radiographic Examination
mode for brightness, contrast, and pixel value (MPR)
Before radiographic examination, each specimen
and enhance or reduce the visualization of tissues with
was surrounded by a tissue-equivalent material,
different densities (3D).
The effects of various technical and exposure imitating soft tissue (Superflab, Eckert & Ziegler,
parameters on the visualization of thin bony structures, BEBIG GmbH, Berlin, Germany). The Accuitomo 170
expressed as the validity and reliability of marginal 3D CBCT unit (J. Morita Mfg. Corp, Kyoto, Japan) was
bone level measurements, have been thoroughly then used to image the tooth. Exposure parameters
investigated. However, the effects of various recon- were 75 kV, 5 mA, and an FOV of 60 3 60 mm. A full
struction techniques and viewing modes have gar- 3608 rotation was made during imaging. Each tooth
nered less interest. was fully imaged twice: once at standard resolution
In an attempt to optimize the assessment of thin (121 images) and once at high a resolution (481
bony structures on CBCT images, the present study images). All image data were exported in the Digital
evaluated the validity and reliability of marginal bone Imaging and Communications in Medicine (DICOM)
level measurements made on CBCT images produced format with a slice thickness of 0.5 mm (standard
using two reconstruction techniques, two viewing resolution) or 0.125 mm (high resolution) for later
modes, and two resolutions and compared them with import and viewing in OsiriX MD, a medical image
the gold standard of histologic measurements. viewer for viewing DICOM images (Pixmeo SARL,
Bernex, Switzerland).
MATERIALS AND METHODS
Radiographic Measurement Procedure
The material consisted of 16 anterior mandibular
teeth (incisors and canines) from six human speci- The first step in preparing the raw data for analysis
mens. The Ethics Review Committee at Uppsala was to make the MPRs in the axial, coronal, and
granted ethical approval (Daybook no. [Dnr]: 2019- sagittal viewing planes. The planes were oriented in
01582) for the study protocol. relation to the long axis of the tooth and the metal
Prior to the radiographic examination, each tooth ligature (Figure 1). Image reconstruction enables an
was assigned a unique identification code, and a metal optimized visualization of the tooth and surrounding
ligature was attached to the buccal aspect of the tooth marginal bone. Measurements were made between
crown along the long axis. The ligature served as a the cemento-enamel junction and the marginal bone

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330 LENNHOLM, WESTERLUND, LUND

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Figure 2. An example of measurements between the cemento-enamel junction (CEJ) and the marginal bone level (MBL) at the buccal aspect of
an incisor using (a) multiplanar reconstruction (MPR) in a gray scale viewing mode, (b) MPR in an inverted gray scale viewing mode, and (c) 3D
rendered; (d) the corresponding histologic view.

level. On MPR images, measurements were made at days on a randomized selection comprising 38% (one
the buccal and lingual aspects of each tooth with two tooth/histological specimen) by two specialists in
viewing modes: gray scale and inverted gray scale. On dentomaxillofacial radiology (Ms Lennholm, Dr Lund).
the 3D-rendered images, measurements were made The intraclass correlation coefficient (ICC) and
after the image had been optimized for visualizing bone descriptive statistics (mean, standard deviation) were
(Figure 2). A specialist in dentomaxillofacial radiology used to calculate the inter- and intraobserver reliability.
made all measurements. Mean differences between radiologic (CBCT) and
histologic measurements were used to calculate
Histologic Preparation and Analyses validity. Bland-Altman plots were used to depict
agreement. Wilcoxon signed rank tests were used to
The teeth were preinfiltrated with a mixture of
ethanol and Technovitt 7200 VLC (glycol methacry- compare paired samples. The level of statistical
late, 2-hydroxyethyl methacrylate) in decreasing (eth- significance was set at P , .05. The Statistical
anol) and increasing (Technovit) concentrations in Package for the Social Sciences (IBM SPSS, version
three steps (70/30, 50/50, and 30/70) followed by 2 27.0; IBM Inc, Chicago, Ill) or GraphPad Prism (version
weeks of infiltration in pure Technovit 7200 that was 8.3.1; GraphPad Software, San Diego, Calif) were
changed at halftime. The Technovit was cured in used for all statistical analyses.
ultraviolet and white light overnight to achieve poly-
merization. The teeth were then prepared according to RESULTS
Donath6: they were cut along the long axis using a Reliability
metal wire as a guide before grinding to a thickness of
about 100 lm. No further staining was done. A light Histology. The ICC was 0.99 (95% confidence
microscope (Nikon SMZ 800, Nikon, Tokyo, Japan) interval [CI]: 0.98–1.00) for buccal and lingual
connected to a Nikon DS-Fi1 camera and a computer measurements. The mean difference between
with NIS-Elements Documentation software from Ni- intraobserver measurements 1 and 2 was 0.04 mm
kon were used to photograph tooth slices; measure- (95% CI: 0.11 to 0.19 mm) for buccal measurements
ments were made with a 0.53 lens (1–6.43) and a and 0.03 mm (95% CI: 0.08 to 0.14 mm) for lingual
magnification of 103 (0.5 3 1 3 10). measurements.
One histological section (one tooth) was excluded Radiology. Intraobserver variation was assessed for
due to displacement from the alveolus during histologic the standard-resolution and high-resolution images
preparation; thus, the final sample comprised 15 teeth.
using the two viewing modes (MPR) and 3D
The histomorphometric evaluations were made by
rendering. The measurements of observer 1 varied
one observer (Dr Westerlund).
between ICCs of 0.94 and 1.00 (95% CI: 0.63–1.00)
except for one outlier (standard resolution, 3D
Statistical Analyses
rendering, buccal aspect; ICC 0.50 [95% CI: 1.19 to
Histomorphometric evaluations were repeated at 0.92]). The measurements of observer 2 varied
intervals of at least 10 days in order to measure between ICCs of 0.86 and 1.00 (95% CI: 0.43–1.00).
intraobserver reliability. To measure inter- and intra- The interobserver variation between observers 1 and
observer reliability of radiographic evaluations, mea- 2 varied between ICCs of 0.74 and 0.97 (95% CI: 0.12–
surements were repeated at intervals of at least 10 0.99).

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CBCT IN THE ASSESSMENT OF THIN BONY STRUCTURES 331

Table 1. Intra- and Interobserver Variation for Observer 1 and 2, for Standard (STD) and High-Resolution (HI) Protocols and Different
Reconstruction Techniques and Viewing Modes, Respectively (Mean Difference and Standard Deviation)
Observer 1 Observer 2 Interobserver
STD HI STD HI STD HI
MPR
Buccal 0.07 (0.63) 0.14 (0.25) 0.12 (0.61) 0.39 (0.70) 0.05 (0.73) 0.12 (0.47)
Lingual 0.04 (0.36) 0.23 (0.47) 0.04 (0.28) 0.50 (0.45) 0.54 (0.57) 0.22 (0.62)
Inverted gray scale
Buccal 0.11 (0.58) 0.12 (0.09) 0.23 (0.34) 0.53 (0.26) 0.64 (0.92) 0.37 (0.66)
Lingual 0.08 (0.31) 0.02 (0.40) 0.53 (0.50) 0.35 (0.22) 0.15 (0.63) 0.37 (0.64)
3D

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Buccal 0.80 (1.38) 0.06 (0.57) 0.15 (0.57) 0.25 (0.62) 0.39 (1.26) 0.03 (0.76)
Lingual 0.01 (0.78) 0.31 (0.97) 0.23 (1.34) 0.34 (0.44) 0.08 (1.02) 0.27 (0.90)

The mean differences and standard deviations for Although at the lingual surfaces, the limits of agree-
intra- and interobserver assessments are shown in ment were wider and thus the variation larger than at
Table 1. the buccal surfaces despite protocol, reconstruction,
and viewing mode used. Technical properties and
Validity exposure parameters, such as the resolution used in
image acquisition, are probably more important.
Comparisons between the CBCT and histological
In comparisons with the histologic reference, 3D-
measurements were made at the buccal and lingual
rendered images had somewhat lower validity at the
surfaces, on standard- and high-resolution protocols,
lingual surfaces than when MPR images were pre-
using MPRs with two viewing modes and 3D-rendered
sented in the gray scale or inverted gray scale viewing
images.
mode. These findings agreed with those of Fernandes
Comparisons of radiologic (CBCT) and histologic
et al.,7 in that measurements on the MPR images with
measurements yielded the highest validity at the
commonly used gray scale settings were more
buccal surfaces using the standard protocol, MPR,
accurate than measurements on 3D-reconstructed
and the inverted gray scale viewing mode (mean
images. CBCT, in contrast to conventional computed
difference ¼ 0.02 mm). The lowest validity occurred at
tomography (CT), does not use calibrated Hounsfield
the lingual surfaces using the high-resolution protocol
units. Thus, the ability to distinguish between tissues of
and 3D-rendered images (mean difference ¼ 1.10 mm).
differing densities is more difficult on CBCT than on CT
Bland-Altman plots (Figure 3a,b) depict the agreement
images; therefore, when trying to optimize a 3D-
between the two MPR viewing modes (gray scale [gs],
rendered image by varying screen settings, alterations
inverted [inv]), 3D rendering, and histology. At the
may occur in the visualization of the outer surface and,
lingual surfaces, the mean differences with both
as a consequence, of the remaining amount of bone.
resolutions were significant (P , .05) for both viewing
Bone tends to be thinner on the lingual surfaces of the
modes (MPR) and 3D rendering. At the buccal
alveolar process, which affects the reliability of the
surfaces, the mean differences were significant (P ,
assessment; thus, the greater the variation in radio-
.05) when using high-resolution and 3D rendering.
logic measurements, the greater the difference in the
histological reference and, consequently, the lower the
DISCUSSION
validity. In the present study, this was evident not only
The assessment of thin bony structures is an on the 3D-rendered images but also for MPR images
essential component of radiologic diagnosis and has visualized using a gray scale and inverted gray scale
gained widespread interest in various disciplines, viewing mode. Results for these three situations were
including orthodontics. Previous research, however, similar, with differences being significantly higher at the
has focused mainly on technical properties and lingual aspects.
exposure parameters. The present study strove to Reliability of bone level measurements at the buccal
assess the next link in the imaging chain, namely, the aspects of the teeth were higher than at the lingual
effect of a reconstruction technique and of two viewing aspects, as was validity, where differences between
modes on the observer’s ability to detect thin bony radiologic measurements on the CBCT images and of
structures. the histologic reference were lower. Neither recon-
In general, the present study found that 3D rendering struction technique (3D or MPR) nor any MPR viewing
and two viewing modes with MPR images had little mode (gray scale or inverted gray scale) showed
influence on visualization of thin bony structures. improved bone level measurements of clinical rele-

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Figure 3. Bland-Altman plots of marginal bone level measurements at the buccal and lingual aspects of 15 human specimen teeth on (a) standard
resolution and (b) high-resolution acquired images. The images were visualized using two reconstruction techniques (multiplanar reconstruction
[MPR] and 3D rendering) with two viewing modes for the MPR images (gray scale [gs] and inverted gray scale [inv]).

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CBCT IN THE ASSESSMENT OF THIN BONY STRUCTURES 333

vance compared with the histologic reference. Mea- tion dose delivered by the higher-resolution protocol is
surement reliability and thus validity at the buccal considered unjustifiable.11
aspects of the teeth on 3D-rendered images was better The results of the present study were comparable
than on MPR images presented in the gray scale or the with previous studies investigating the validity of CBCT
inverted gray scale viewing mode; the narrower limit of for assessing marginal bone level with a focus on the
agreement in the Bland-Altman plot illustrates this. A technical properties of the system and exposure
probable explanation is that, in the 3D-rendered parameters.12–14 However, as Thönissen et al.15 stated,
images, the outer surface of the bone and thus the CBCT imaging is unreliable for visualizing thin bony
remaining amount of bone, may be altered and structures less than 0.5 mm in width even if high
‘‘smoother,’’ yielding less variation in visualization of resolution is used. Apart from the various technical

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the marginal bone. parameters of the system, other factors may play an
To discern the influence of technical properties and important role in the visualization of small or thin
exposure parameters on CBCT visualization, the structures, such as spatial resolution and partial
present study investigated two reconstruction tech- volume averaging. Spatial resolution is the minimum
niques, two viewing modes, and two acquisition distance needed between two objects to distinguish
resolutions. Other parameters such as FOV, kV, and between them. Partial volume averaging is the result of
mA were kept constant at exposure. This was done to densities between adjacent voxels being combined,
compare the day-to-day clinical setup with a proposed since each voxel can display only one grey level at a
optimal setup. Sun et al.3 investigated the accuracy of time; thus, for example, when thin cortical bones
adjacent to air share a voxel, the voxel displays a
alveolar bone-height measurements on CBCT (I-Cat)
median density. So, the gray scale bit depth of the
images using different technical parameters (voxel
system also plays an important role in assessment.
sizes) and specimens with varying bone thicknesses;
Today, most CBCT systems use a bit depth between
they found that measurement accuracy increased with
12 and 16, corresponding to 4096 (212) and 65,536 (216)
smaller voxel size. The present study used a CBCT
shades of gray, respectively.16
unit with a voxel size of 0.125 mm. A previous study
The present study used human specimens from the
investigating the influence of different exposure pa-
anterior mandibular region of the mouth, as this area in
rameters, such as varying FOVs, mAs, and kVs, and
general has a smaller buccolingual width, and thus, the
with and without a copper filter, concluded that the teeth are covered with thinner bone that may be further
presence or absence of a filter and variations in kV affected if the teeth move closer to the buccal or lingual
settings did not affect overall image quality, although plate, for example, during orthodontic treatment.17,18
the higher mA setting was always preferred.4 Better The rationale for using human specimens was to
image quality is associated with more photons per achieve a situation as close as possible to the clinical
voxel, and the mA settings determine the amount of situation. However, compared with an in vivo study, the
photons. Other studies, such as Dillenseger et al.,5 setting is not prone to image artifacts due to movement
presented contrasting results concerning the influence nor artifacts from metallic materials, which could occur
of different FOVs; they found that the quality of images in clinical conditions, influencing assessment.
made using a small FOV was similar to the quality of
those made with a large FOV. Molen, however, found CONCLUSIONS
that images made with larger FOVs had greater noise
from scatter and worse spatial resolution.8 Images When evaluating thin bony structures and marginal
made with smaller FOVs do have lower scatter noise, bone level in orthodontics:
but spatial resolution is poorer due to a higher  3D rendering and MPR images with an inverted gray
sensitivity to noise. This is because, given the same scale viewing mode do not improve the observer’s
exposure parameters, voxel size is smaller with smaller ability to visualize thin bony structures in the anterior
FOVs; hence, to achieve a similar level of noise, mandibular region.
exposure parameters need to change accordingly.  The use of 3D-reconstructed CBCT images to
Concerning the effect of imaging protocol on image assess thin bony structures should be avoided when
quality, the present study could not confirm previous thin cortical borders, such as in the anterior mandib-
findings that the validity of high-resolution protocols for ular region, are suspected.
detecting marginal bone level was higher than of lower-  The small difference between imaging protocols
resolution protocols.9,10 In agreement with Ruetters et (standard and high-resolution) in visualization of thin
al.,10 the difference between the two protocols in the bony structures does not justify the use of the higher
present study was small and of limited clinical radiation dose required using the high-resolution
relevance. Thus, the approximately 40% higher radia- protocol; thus, no changes in current, clinically used

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334 LENNHOLM, WESTERLUND, LUND

protocols (standard resolution) are recommended at J Orthod Dentofacial Orthop. 2010;137(4 suppl):S130–
this time. S135. doi:10.1016/j.ajodo.2010.01.015
9. Patcas R, Müller L, Ullrich O, Peltomäki T. Accuracy of cone-
beam computed tomography at different resolutions as-
ACKNOWLEDGMENTS sessed on the bony covering of the mandibular anterior
teeth. Am J Orthod Dentofacial Orthop. 2012;141:41–50. doi:
The authors want to express their sincere gratitude to Petra H. 10.1016/j.ajodo.2011.06.034
Johansson, Department of Prosthodontics/Dental Material 10. Ruetters M, Gehrig H, Kronsteiner D, et al. Ex-vivo imaging
Science, Institute of Odontology, Sahlgrenska Academy, of buccal and oral periodontal bone with low-dose CBCT in
Gothenburg University, Gothenburg, Sweden, for excellent porcine jaws. Dentomaxillofac Radiol. 2022;51:20210233.
histologic preparation of the specimens. doi:10.1259/dmfr.20210233
11. Feragalli B, Rampado O, Abate C, et al. Cone beam

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