Andreas Stratis

Ultralow dose dentomaxillofacial CT imaging and iterative reconstruction techniques: variability of Hounsfield units and contrast-to-noise ratio.

OBJECTIVE The aim of this study was to evaluate whether application of ultralow dose protocols and iterative reconstruction technology (IRT) influence quantitative Hounsfield units (HUs) and contrast-to-noise ratio (CNR) in dentomaxillofacial CT imaging. METHODS A phantom with inserts of five types of materials was scanned using protocols for (a) a clinical reference for navigated surgery (CT dose index volume 36.58 mGy), (b) low-dose sinus imaging (18.28 mGy) and (c) four ultralow dose imaging (4.14, 2.63, 0.99 and 0.53 mGy). All images were reconstructed using: (i) filtered back projection (FBP); (ii) IRT: adaptive statistical iterative reconstruction-50 (ASIR-50), ASIR-100 and model-based iterative reconstruction (MBIR); and (iii) standard (std) and bone kernel. Mean HU, CNR and average HU error after recalibration were determined. Each combination of protocols was compared using Friedman analysis of variance, followed by Dunns multiple comparison test. RESULTS Pearsons sample correlation coefficients were all >0.99. Ultralow dose protocols using FBP showed errors of up to 273 HU. Std kernels had less HU variability than bone kernels. MBIR reduced the error value for the lowest dose protocol to 138 HU and retained the highest relative CNR. ASIR could not demonstrate significant advantages over FBP. CONCLUSIONS Considering a potential dose reduction as low as 1.5% of a std protocol, ultralow dose protocols and IRT should be further tested for clinical dentomaxillofacial CT imaging. ADVANCES IN KNOWLEDGE HU as a surrogate for bone density may vary significantly in CT ultralow dose imaging. However, use of std kernels and MBIR technology reduce HU error values and may retain the highest CNR.

CUSTOMISATION OF A MONTE CARLO DOSIMETRY TOOL FOR DENTAL CONE-BEAM CT SYSTEMS

A versatile EGSnrc Monte Carlo (MC) framework, initially designed to explicitly simulate X-ray tubes and record the output data into phase space data files, was modified towards dental cone-beam computed tomography (CBCT) dosimetric applications by introducing equivalent sources. Half value layer (HVL) measurements were conducted to specify protocol-specific energy spectra. Air kerma measurements were carried out with an ionisation chamber positioned against the X-ray tube to obtain the total filtration attenuation characteristics. The framework is applicable to bowtie and non-bowtie inherent filtrations, and it accounts for the anode heel effect and the total filtration of the tube housing. The code was adjusted to the Promax 3D Max (Planmeca, Helsinki, Finland) dental CBCT scanner. For each clinical protocol, calibration factors were produced to allow absolute MC dose calculations. The framework was validated by comparing MC calculated doses and measured doses in a cylindrical water phantom. Validation results demonstrate the reliability of the framework for dental CBCT dosimetry purposes.

Two examples of indication specific radiation dose calculations in dental CBCT and Multidetector CT scanners

PURPOSE To calculate organ doses and estimate the effective dose for justification purposes in patients undergoing orthognathic treatment planning purposes and temporal bone imaging in dental cone beam CT (CBCT) and Multidetector CT (MDCT) scanners. METHODS The radiation dose to the ICRP reference male voxel phantom was calculated for dedicated orthognathic treatment planning acquisitions via Monte Carlo simulations in two dental CBCT scanners, Promax 3D Max (Planmeca, FI) and NewTom VGi evo (QR s.r.l, IT) and in Somatom Definition Flash (Siemens, DE) MDCT scanner. For temporal bone imaging, radiation doses were calculated via MC simulations for a CBCT protocol in NewTom 5G (QR s.r.l, IT) and with the use of a software tool (CT-expo) for Somatom Force (Siemens, DE). All procedures had been optimized at the acceptance tests of the devices. RESULTS For orthognathic protocols, dental CBCT scanners deliver lower doses compared to MDCT scanners. The estimated effective dose (ED) was 0.32mSv for a normal resolution operation mode in Promax 3D Max, 0.27mSv in VGi-evo and 1.18mSv in the Somatom Definition Flash. For temporal bone protocols, the Somatom Force resulted in an estimated ED of 0.28mSv while for NewTom 5G the ED was 0.31 and 0.22mSv for monolateral and bilateral imaging respectively. CONCLUSIONS Two clinical exams which are carried out with both a CBCT or a MDCT scanner were compared in terms of radiation dose. Dental CBCT scanners deliver lower doses for orthognathic patients whereas for temporal bone procedures the doses were similar.

Spatial and contrast resolution of ultralow dose dentomaxillofacial CT imaging using iterative reconstruction technology

OBJECTIVES The objective of this study was to determine how iterative reconstruction technology (IRT) influences contrast and spatial resolution in ultralow-dose dentomaxillofacial CT imaging. METHODS A polymethyl methacrylate phantom with various inserts was scanned using a reference protocol (RP) at CT dose index volume 36.56 mGy, a sinus protocol at 18.28 mGy and ultralow-dose protocols (LD) at 4.17 mGy, 2.36 mGy, 0.99 mGy and 0.53 mGy. All data sets were reconstructed using filtered back projection (FBP) and the following IRTs: adaptive statistical iterative reconstructions (ASIRs) (ASIR-50, ASIR-100) and model-based iterative reconstruction (MBIR). Inserts containing line-pair patterns and contrast detail patterns for three different materials were scored by three observers. Observer agreement was analyzed using Cohens kappa and difference in performance between the protocols and reconstruction was analyzed with Dunns test at α = 0.05. RESULTS Interobserver agreement was acceptable with a mean kappa value of 0.59. Compared with the RP using FBP, similar scores were achieved at 2.36 mGy using MBIR. MIBR reconstructions showed the highest noise suppression as well as good contrast even at the lowest doses. Overall, ASIR reconstructions did not outperform FBP. CONCLUSIONS LD and MBIR at a dose reduction of >90% may show no significant differences in spatial and contrast resolution compared with an RP and FBP. Ultralow-dose CT and IRT should be further explored in clinical studies.

As Low Dose as Sufficient Quality: Optimization of Cone-beam Computed Tomographic Scanning Protocol for Tooth Autotransplantation Planning and Follow-up in Children

Introduction: Tooth autotransplantation (TAT) offers a viable biological approach to tooth replacement in children. To enhance the outcome predictability of the TAT procedure, a cone‐beam computed tomographic (CBCT)‐based surgical planning and transfer technique has been developed. The aim of this study was to optimize the CBCT scanning protocol to achieve a dose as low as possible and to maintain sufficient image quality. Methods: A sectional head phantom (SK150; The Phantom Laboratory, Salem, NY) was scanned using 18 exposure protocols in 3 different CBCT machines: 3D Accuitomo 170 (Morita, Kyoto, Japan), ProMax 3D MAX (Planmeca, Helsinki, Finland), and NewTom VGI EVO (QR Verona, Verona, Italy). The effective dose (ED) was calculated using Monte Carlo simulation and pediatric voxel phantoms (5‐ and 8‐year‐old males and a 12‐year‐old female). Image quality was assessed by comparing segmented teeth volumes, evaluation of the visibility of the lamina dura, and morphologic surface analysis of 3‐dimensional models. A general linear mixed model was fit to combine image quality parameters and radiation effective dose for each protocol in order to rank and compare the protocols examined in the study. Results: The ED for the preoperative scan can be reduced to the range of 74.6–157.9 &mgr;Sv, with ProMax with ultra–low‐dose high‐definition reconstruction (Planmeca) 100 × 90 scoring the highest. The ED for the postoperative scan can be reduced to the range of 24.2–41.5 &mgr;Sv with ProMax with ultra–low‐dose normal‐dose reconstruction 50 × 55 and NewTom 50 × 50 with the standard mode scoring the highest. Conclusions: A considerable reduction in the pediatric ED can be achieved while maintaining sufficient image quality for tooth autotransplantation planning and follow‐up using the dose optimization protocols.

Rotating and translating anthropomorphic head voxel models to establish an horizontal Frankfort plane for dental CBCT Monte Carlo simulations: a dose comparison study

In order to carry out Monte Carlo (MC) dosimetry studies, voxel phantoms, modeling human anatomy, and organ-based segmentation of CT image data sets are applied to simulation frameworks. The resulting voxel phantoms preserve patient CT acquisition geometry; in the case of head voxel models built upon head CT images, the head support with which CT scanners are equipped introduces an inclination to the head, and hence to the head voxel model. In dental cone beam CT (CBCT) imaging, patients are always positioned in such a way that the Frankfort line is horizontal, implying that there is no head inclination. The orientation of the head is important, as it influences the distance of critical radiosensitive organs like the thyroid and the esophagus from the x-ray tube. This work aims to propose a procedure to adjust head voxel phantom orientation, and to investigate the impact of head inclination on organ doses in dental CBCT MC dosimetry studies. The female adult ICRP, and three in-house-built paediatric voxel phantoms were in this study. An EGSnrc MC framework was employed to simulate two commonly used protocols; a Morita Accuitomo 170 dental CBCT scanner (FOVs: 60  ×  60 mm2 and 80  ×  80 mm2, standard resolution), and a 3D Teeth protocol (FOV: 100  ×  90 mm2) in a Planmeca Promax 3D MAX scanner. Result analysis revealed large absorbed organ dose differences in radiosensitive organs between the original and the geometrically corrected voxel models of this study, ranging from  -45.6% to 39.3%. Therefore, accurate dental CBCT MC dose calculations require geometrical adjustments to be applied to head voxel models.

Accurate centroid determination for evaluating the modulation transfer function with a circular edge in CT images

The in-plane modulation transfer function (MTF) for multi-slice computed tomography (CT) can be found by scanning a phantom with cylindrical contrast inserts and making use of the circular edges presented in reconstructed axial images. Pixel data across the edge are used to establish an edge spread function, which is then used to obtain the line spread function and finally the MTF. A crucial step in this approach is to accurately locate the centroid of the circular region. Since the ESF is usually established in subpixel scale, slight deviation of the centroid may result in large errors. It has been a common practice to apply a preset threshold and calculate the center of mass in the binary output on each individual slice. It has also been suggested to locate the centroid on each slice by maximizing the sum of pixel values lying under a predefined template. In this paper, we propose a new algorithm based on registering the entire cylindrical object in 3D space. In a test on a high-noise low-contrast edge, both the threshold and the maximization algorithm showed scattered distribution of centroids across consecutive slices, resulting in underestimation of the MTF up to 10% at intermediate frequencies. In comparison, the method based on 3D registration has been found more robust to noise and the centroid locations are more consistent in the longitudinal direction. It is therefore recommended to use the proposed algorithm for centroid determination in evaluating the MTF with a circular edge in CT images.

Development of a paediatric head voxel model database for dosimetric applications

OBJECTIVE To develop a database of paediatric head voxel models intended for Monte Carlo (MC) dosimetric applications. METHODS Seventeen head and neck CT image data sets were retrieved from the picture archiving and communicating system of our hospital and were reformed into voxel models. 22 organs were segmented at each data set. The segmented organ masses were compared to the respective age- and gender-specific ICRP reference mass value. Adjustments were made such that segmented and reference mass values coincide within a tolerance of 10%. A dental cone beam CT cleft palate simulation study was set up to demonstrate the applicability of our database to MC frameworks and to investigate the need for age- and gender-specific paediatric models. RESULTS The designed database covers the age range from 2 months to 14 years old. Each model represents a reference head voxel phantom for its corresponding age and gender category. The simulation study revealed absorbed organ dose differences larger than 50% among the 5, 8 and 12 years old models when exposed to identical conditions. CONCLUSION Children cannot be represented by one average phantom covering the entire age range like adults due to the fact that their organs change rapidly in size and shape. A database of paediatric head voxel models was designed to enable dose calculations via MC simulations. Advances in knowledge: The application of each model of the database to MC frameworks provides age- and gender-specific organ dose estimations from medical exposures in the head and neck region.

A Monte Carlo study on the effect of the orbital bone to the radiation dose delivered to the eye lens

The aim of this work was to investigate the influence of backscatter radiation from the orbital bone and the intraorbital fat on the eye lens dose in the dental CBCT energy range. To this end we conducted three different yet interrelated studies; A preliminary simulation study was conducted to examine the impact of a bony layer situated underneath a soft tissue layer on the amount of backscatter radiation. We compared the Percentage Depth Dose (PDD) curves in soft tissue with and without the bone layer and we estimated the depth in tissue where the decrease in backscatter caused by the presence of the bone is noticeable. In a supplementary study, an eye voxel phantom was designed with the DOSxyznrc code. Simulations were performed exposing the phantom at different x-ray energies sequentially in air, in fat tissue and in realistic anatomy with the incident beam perpendicular to the phantom. Finally, a virtual head phantom was implemented into a validated hybrid Monte Carlo (MC) framework to simulate a large Field of View protocol of a real CBCT scanner and examine the influence of scattered dose to the eye lens during the whole rotation of the paired tube-detector system. The results indicated an increase in the dose to the lens due to the fatty tissue in the surrounding anatomy. There is a noticeable dose reduction close to the bone-tissue interface which weakens with increasing distance from the interface, such that the impact of the orbital bone in the eye lens dose becomes small.