Deriving Hounsfield units using grey levels in cone beam CT: a clinical application.

OBJECTIVE: To present a clinical study demonstrating a method to derive Hounsfield units from grey levels in cone beam CT (CBCT). METHODS: An acrylic intraoral reference object with aluminium, outer bone equivalent material (cortical bone), inner bone equivalent material (trabecular bone), polymethlymethacrylate and water equivalent material was used. Patients were asked if they would be willing to have an acrylic bite plate with the reference object placed in their mouth during a routine CBCT scan. There were 31 scans taken on the Asahi Alphard 3030 (Belmont Takara, Kyoto, Japan) and 30 scans taken on the Planmeca ProMax 3D (Planmeca, Helsinki, Finland) CBCT. Linear regression between the grey levels of the reference materials and their linear attenuation coefficients was performed for various photon energies. The energy with the highest regression coefficient was chosen as the effective energy. The attenuation coefficients for the five materials at the effective energy were scaled as Hounsfield units using the standard Hounsfield units equation and compared to those derived from the measured grey levels of the materials using the regression equation. RESULTS: In general, there was a satisfactory linear relation between the grey levels and the attenuation coefficients. This made it possible to calculate Hounsfield units from the measured grey levels. Uncertainty in determining effective energies resulted in unrealistic effective energies and significant variability of calculated CT numbers. Linear regression from grey levels directly to Hounsfield units at specified energies resulted in greater consistency. CONCLUSIONS: The clinical application of a method for deriving Hounsfield units from grey levels in CBCT was demonstrated.

Characterization and correction of cupping effect artefacts in cone beam CT.

OBJECTIVE: The purpose of this study was to demonstrate and correct the cupping effect artefact that occurs owing to the presence of beam hardening and scatter radiation during image acquisition in cone beam CT (CBCT). METHODS: A uniform aluminium cylinder (6061) was used to demonstrate the cupping effect artefact on the Planmeca Promax 3D CBCT unit (Planmeca OY, Helsinki, Finland). The cupping effect was studied using a line profile plot of the grey level values using ImageJ software (National Institutes of Health, Bethesda, MD). A hardware-based correction method using copper pre-filtration was used to address this artefact caused by beam hardening and a software-based subtraction algorithm was used to address scatter contamination. RESULTS: The hardware-based correction used to address the effects of beam hardening suppressed the cupping effect artefact but did not eliminate it. The software-based correction used to address the effects of scatter resulted in elimination of the cupping effect artefact. CONCLUSION: Compensating for the presence of beam hardening and scatter radiation improves grey level uniformity in CBCT.

Pre-clinical evaluation of a new dental panoramic radiographic system based on tomosynthesis method.

OBJECTIVES: The purpose of the study was to compare the image generated by a classic panoramic machine equipped with a cadmium telluride sensor capable of digital tomosynthesis and special software with images produced by other popular panoramic X-ray machines using a charge-coupled device and native software for image capture. METHODS: Panoramic images were made using a phantom of a human skull on Planmeca ProMax, Planmeca EC Proline, Kodak 8000 and PC-1000. With the last machine we used the PanoACT® software to adjust the entire arch and to adjust the image in selected regions of interest (ROIs). Ten viewers evaluated the images and provided the viewer data. ANOVA for repeated measures was used to compare the means by pairwise comparisons of means. RESULTS: The image of the entire arch adjusted by the PanoACT® software was statistically superior to the images produced by other machines. The images generated and individually adjusted by PanoACT® were statistically superior to all other images. CONCLUSIONS: The image generated by the cadmium telluride sensor has great potential and can be processed to create superior images to those taken with other machines. Furthermore, the ROI individual images enhanced by the PanoACT® were superior to the entire arch adjusted by the same software.

Deriving Hounsfield units using grey levels in cone beam computed tomography.

OBJECTIVES: an in vitro study was performed to investigate the relationship between grey levels in dental cone beam CT (CBCT) and Hounsfield units (HU) in CBCT scanners. METHODS: a phantom containing 8 different materials of known composition and density was imaged with 11 different dental CBCT scanners and 2 medical CT scanners. The phantom was scanned under three conditions: phantom alone and phantom in a small and large water container. The reconstructed data were exported as Digital Imaging and Communications in Medicine (DICOM) and analysed with On Demand 3D(R) by Cybermed, Seoul, Korea. The relationship between grey levels and linear attenuation coefficients was investigated. RESULTS: it was demonstrated that a linear relationship between the grey levels and the attenuation coefficients of each of the materials exists at some "effective" energy. From the linear regression equation of the reference materials, attenuation coefficients were obtained for each of the materials and CT numbers in HU were derived using the standard equation. CONCLUSIONS: HU can be derived from the grey levels in dental CBCT scanners using linear attenuation coefficients as an intermediate step.

Development of a new dental panoramic radiographic system based on a tomosynthesis method.

The objective of this study was to develop a new practical method to reconstruct a high-quality panoramic image in which radiographers would be free from the onerous task of correctly locating the patient's jaws within the image layer of the panoramic unit. In addition, dentists would be able to freely select any panoramic plane to be reconstructed after the acquisition of the raw scan data. A high-speed data acquisition device was used with a CdTe (cadmium telluride) semiconductor detector and a sophisticated digital signal-processing technique based on tomosynthesis was developed. The system processes many vertical strip images acquired with the detector and generates a high-resolution and high-contrast image. To apply the tomosynthesis technique to the acquired strip images correctly, the actual movement of the panoramic unit was measured, including the X-ray tube and detector, in a scan using a calibration phantom and the authors generated a shift amount table needed for the shift-and-add tomosynthesis operation. The results of the experiments with a PanoACT-1000 panoramic unit, which was a PC-1000 panoramic unit fitted with a high frame rate semiconductor detector SCAN-300FPC, demonstrated the capability of a tomosynthesis technique which, when applied to the strip images of a dry skull phantom, could change the location and inclination of an imaging plane. This system allowed the extraction of an optimum-quality panoramic image regardless of irregularities in patient positioning. Moreover, the authors could freely reconstruct a fine image of an arbitrary plane with different parameters from those used in the original data acquisition to study fine anatomical details in specific locations.

Transtomography: a new tomographic scanning technique.

OBJECTIVES: To introduce and test a new tomographic technique, namely transtomography, making it possible to expose tomographic images employing the narrow beam of an advanced panoramic machine. METHODS: The working principle of the new technique is described. It combines a translational movement with a pendular movement of the beam that creates motion unsharpness analogous to that of conventional tomography. In order to verify whether the new technique works and results in tomographic images, test radiographs were exposed on phantoms. RESULTS: The principle of transtomography works and give images with properties essentially equivalent to those of conventional tomography. With the transtomographic technique using a narrow beam, tomographic images may be exposed with an advanced panoramic machine. CONCLUSION: Transtomography may be employed to expose tomographic images basically on the same indications as for conventional tomography.

Comparison of the psychophysical properties of various intraoral film and digital systems by means of the perceptibility curve test.

OBJECTIVES: To compare psychophysical properties of two intraoral films and three digital systems using the perceptibility curve (PC) test. MATERIALS AND METHODS: A test object was used to determine the exposures and exposure differences between the total thickness of the test object and details consisting of holes of increasing depth. The PCs for the two intraoral films, UltraSpeed and EktaSpeed Plus, were constructed employing exposure and exposure differences from dose response functions. Integrals of the PCs were calculated to obtain the psychophysical properties of the two films. Psychophysical properties of the two films were compared with those of the three digital systems published previously (CDR, Dixel and Digora). RESULTS: The PC for the EktaSpeed Plus showed a slightly higher peak than that for the UltraSpeed. Available exposure ranges were comparable. The PC for the EktaSpeed Plus was shifted to the left of the exposure axis indicating its higher sensitivity as compared with UltraSpeed. All three digital systems had narrower but higher peaks compared with the films. The integrals for the digital systems were considerably larger than those for the two film types. CONCLUSIONS: All the three digital systems have superior psychophysical properties compared with the two tested films.

Evaluation of endodontic files in digital radiographs before and after employing three image processing algorithms.

OBJECTIVES: Two digital image processing algorithms, one aimed at correction for exponential attenuation and one at correction for visual response, have been developed. The aims of the present study were to test whether digital radiographs processed with these algorithms improve determination of the length of endodontic files and whether such processed radiographs are comparable with the radiographs processed with a default image processing method employed by one commercially available digital intraoral system. METHODS: A dried human skull embedded in an acrylic compound was used for exposing radiographs of the upper and lower premolars and molars with endodontic files (Kerr files size 10 and size 15) positioned to the full length of the roots or 1.5 mm short of it. Radiographs were then processed in three sets. In one set, the radiographs were processed to compensate for exponential attenuation and the response of the human visual system. In the second, the radiographs were processed with the same compensation but with an additional shift in grey levels so that the output luminance in dentin at root tips corresponds to the mean of the luminance range of a computer monitor. In the third, the radiographs were processed with the default processing method in the Sidexis program. Ten viewers evaluated all radiographs. Receiver operating characteristic (ROC) curves were obtained and areas under the curves were calculated. RESULTS: For file size 10, ROC curves for processed radiographs were higher than that for originals, while for file size 15, ROC curves for processed and original radiographs were close to each other. Significant differences were found between processed and original radiographs regarding areas under ROC curves for file size 10 but not between the differently processed radiographs. For file size 15, no significant differences were found. CONCLUSION: Radiographs processed to correct for attenuation and visual response may improve determination of the length of thin endodontic files. Such processed radiographs are comparable with the radiographs processed with the default processing method in the Sidexis program.

Determination of the resolution of a digital system for panoramic radiography based on CCD technology.

OBJECTIVES: To determine Line Spread Functions (LSFs) and Modulation Transfer Functions (MTFs) for a digital system for panoramic radiography: the Dimax I (Planmeca Oy, Helsinki, Finland) based on Charge-Coupled Device (CCD) technology. STUDY DESIGN: A test object was specially designed having a gold foil positioned vertically. Images of the gold foil created edge functions that were used to determine LSFs and MTFs. The design of the test object made it possible to move the gold foil forward and backward relative to the central plane of the image layer by means of a micrometer screw. The experiment was carried out for different object depths in 5 different regions: the anterior, the canine, the premolar, the molar, and the TMJ regions. LSFs and MTFs were calculated using specially designed software. RESULTS: The results are presented graphically. LSFs and MTFs for the central plane were essentially the same for all regions. The MTFs for different object depths in the 5 investigated regions exhibited typical characteristics of MTFs for panoramic radiography with the exception for the functions for the molar region. CONCLUSIONS: The present findings indicate that the resolution of the Dimax I CCD system is comparable to that of film-based panoramic radiography.

Perceptibility curves for the Digora system.

OBJECTIVES: To construct perceptibility curves (PCs) for given calibration settings in order to define psychophysical properties of the Digora storage phosphor system and to evaluate the effects of automatic exposure correction (AEC) on the PCs. METHODS: The Digora system was calibrated at two exposures, 80 microC kg(-1) (high calibration) and 40 microC kg(-1) (low calibration). Since the grey levels displayed in the radiographs are adjusted by AEC, dose-response functions at high calibration were obtained using AEC on and off modes. The dose-response function at low calibration was obtained with AEC off. The PC at each experimental setting was calculated using known physical parameters of the system and the performance of the average observer used in a previous study. In addition, PCs were also constructed using transmitted radiation flux behind the test object calculated from the attenuation coefficient in order to study observer and system performance. PCs obtained under these conditions were compared. RESULTS: The PC using calculated transmitted radiation flux behind the test object showed a wide plateau at the peak owing to AEC, while the PC obtained by a modified approach showed a higher but narrower peak. There were no differences between the two PCs using AEC on and off modes when the PCs were constructed using a modified approach. There were no differences between the two PCs obtained at high and low calibration settings or between the three PCs obtained with AEC on except for the position along the exposure axis. CONCLUSIONS: Psychophysical properties of the Digora system may be determined if we employ registered exposures from a dose-response function with AEC off under a given calibration setting. Under these circumstances the shape and height of the PCs will be unchanged irrespective of the AEC mode.

Perceptibility curve test for digital radiographs before and after correction for attenuation and correction for attenuation and visual response.

OBJECTIVE: Two digital image processing methods, correction for X-ray attenuation and correction for attenuation and visual response, have been developed. The aim of the present study was to compare digital radiographs before and after correction for attenuation and correction for attenuation and visual response by means of a perceptibility curve test. MATERIAL AND METHODS: Radiographs were exposed of an aluminium test object containing holes ranging from 0.03 mm to 0.30 mm with increments of 0.03 mm. Fourteen radiographs were exposed with the Dixi system (Planmeca Oy, Helsinki, Finland) and twelve radiographs were exposed with the F1 iOX system (Fimet Oy, Monninkylä, Finland) from low to high exposures covering the full exposure ranges of the systems. Radiographs obtained from the Dixi and F1 iOX systems were 12 bit and 8 bit images, respectively. Original radiographs were then processed for correction for attenuation and correction for attenuation and visual response. Thus, two series of radiographs were created. Ten viewers evaluated all the radiographs in the same random order under the same viewing conditions. The object detail having the lowest perceptible contrast was recorded for each observer. Perceptibility curves were plotted according to the mean of observer data. RESULTS: The perceptibility curves for processed radiographs obtained with the F1 iOX system are higher than those for originals in the exposure range up to the peak, where the curves are basically the same. For radiographs exposed with the Dixi system, perceptibility curves for processed radiographs are higher than those for originals for all exposures. Perceptibility curves show that for 8 bit radiographs obtained from the F1 iOX system, the contrast threshold was increased in processed radiographs up to the peak, while for 12 bit radiographs obtained with the Dixi system, the contrast threshold was increased in processed radiographs for all exposures. When comparisons were made between radiographs corrected for attenuation and corrected for attenuation and visual response, basically no differences were found. CONCLUSION: Radiographs processed for correction for attenuation and correction for attenuation and visual response may improve perception, especially for 12 bit originals.

Detection of approximal caries in digital radiographs before and after correction for attenuation and visual response. An in vitro study.

OBJECTIVE: To evaluate if digital compensation for exponential attenuation and the characteristics of the human visual system improves the diagnosis of approximal caries from digital radiographs. MATERIAL AND METHODS: Forty premolar teeth were mounted in plaster blocks. Radiographs of the teeth were exposed with the Dixi digital intraoral system employing a Prostyle Intra dental X-ray unit (Planmeca Oy, Helsinki, Finland). Thirteen radiographs were then processed to compensate for the exponential attenuation and for the characteristic of the human visual system using equations presented in the paper. Ten observers were asked to diagnose approximal caries in all radiographs. ROC analyses were performed. The teeth were subsequently sectioned for histological validation of the lesions. The areas under ROC curves of original and processed radiographs were compared and analysed using Wilcoxon's signed-ranks test. RESULTS: There were significant diagnostic differences between the two types of radiographs (all lesions P=0.005. enamel P=0.028, and dentine P=0.050). CONCLUSION: Digital radiographs processed to compensate for exponential attenuation and the characteristics of the human visual system significantly improves the diagnosis of approximal caries in vitro.

Correction for attenuation and visual response in digital radiography.

OBJECTIVES: To derive a method to correct for the exponential attenuation adding visual linearization for digital radiography and to perform an experimental test to study effects on observer performance. METHOD: A theoretical analysis was performed and expressions were derived to correct radiographic data for the attenuation. An experiment was performed exposing an aluminum step wedge with holes of increasing depths behind each step plus soft tissue simulation. Seven original images were created with a digital intraoral X-ray sensor and a further 14 transformed images produced. Ten observers examined the images in a randomized order reporting the number of holes seen per wedge step. The results were analysed by One Way ANOVA. RESULTS: It was possible to correct for attenuation and the response of the human visual system to light intensities from a computer monitor. Perception was significantly improved in all recalculated radiographs that took both attenuation and the response of the eye into account (P-values ranged from <0.0001 to <0.0286). CONCLUSIONS: The transforms may be useful for improved perception when viewing digital radiographs.

Visual linearization of the display of digital radiographs.

OBJECTIVES: To derive and test a method to linearize the visual response of the display of digital radiographs so that equal steps in gray levels will be perceived as equal steps in brightness. METHOD: A mathematical analysis was performed and expressions for visual linearization were derived. Twenty-four test images were computer generated to confirm that visual linearization may be achieved. Each image had three groups of square areas of different size placed in three rows. The left and right squares in each row were given different gray levels to simulate various contrast levels. The middle squares were initially given the same gray level value as one of the outer squares. The images were examined by ten observers who could change the gray levels of the middle squares so that the step in brightness between the middle square and the outer squares become subjectively equal. The test was performed three times employing two different monitors. RESULTS: The experimental test confirmed that visual linearization could be achieved. Linear regression analyses gave determination coefficients of 0.9926 amd 0.9942 for monitors with gamma-values of 1.93 and 2.50. respectively. The mean data from the ten observers perfectly fitted those theoretically calculated. CONCLUSION: Visual linearization of gray levels can be achieved but further clinical research is needed to determine if this improves diagnosis.

Conventional and predicted perceptibility curves for contrast-enhanced direct digital intraoral radiographs.

OBJECTIVES: To construct Perceptibility Curves (PCs) for contrast-enhanced digital intraoral radiographs. METHODS: Radiographs of a test object having holes of increasing depths were exposed using three digital systems, the CDR (Schick Technologies, Long Island, NY, USA), the Dixel (J Morita MFG, Kyoto, Japan) and the Sens-A-Ray (Regam Medical Systems, Sundsvall, Sweden). The radiographs were contrast-enhanced and PCs constructed in the conventional way using 10 observers. Predicted PCs were calculated and compared with observer data. RESULTS: The PCs showed that contrast enhancement is effective for the perception of small contrast details, especially in the low exposure range. Predicted PCs demonstrated excellent agreement with observer data. CONCLUSIONS: Contrast enhancement should be advantageous in digital radiography. The effects of contrast enhancement on PCs may be predicted without previous knowledge of observer performance.

Comparison of five methods for the derivation of spectra for a constant potential dental X-ray unit.

OBJECTIVES: To compare the diagnostic X-ray spectra derived by different methods for a constant potential dental X-ray unit. MATERIALS AND METHODS: Five methods of deriving X-ray spectra for a constant potential dental X-ray unit were compared: measurement by spectrometer using cadmium-zinc-telluride (CZT) detector, calculation by Monte Carlo simulation, calculation by two different, semi-empirical methods and estimation from transmission data. The dental X-ray set was a Heliodent MD unit (Sirona, Charlotte, NC, USA) operable at 60 or 70 kV. A semiconductor detector was used in the spectrometer measurements and an ionization chamber dosimeter in the transmission measurements. From the five methods, photon-fluence spectra were derived. Based on the photon-fluence spectra, average energies and transmission curves in aluminum were calculated. RESULTS: For all five methods, the average energies were within 2.4% of one another. Comparison of the transmission curves showed an average difference in the range of 1 to 6%. CONCLUSION: All of the five methods of deriving spectra are in extremely good agreement with each other.

Measurement and validation of benchmark-quality thick-target tungsten X-ray spectra below 150 kVp.

Pulse-height distributions of two constant potential X-ray tubes with fixed anode tungsten targets were measured and unfolded. The measurements employed quantitative alignment of the beam, the use of two different semiconductor detectors (high-purity germanium and cadmium-zinc-telluride), two different ion chamber systems with beam-specific calibration factors, and various filter and tube potential combinations. Monte Carlo response matrices were generated for each detector for unfolding the pulse-height distributions into spectra incident on the detectors. These response matrices were validated for the low error bars assigned to the data. A significant aspect of the validation of spectra, and a detailed characterization of the X-ray tubes, involved measuring filtered and unfiltered beams at multiple tube potentials (30-150 kVp). Full corrections to ion chamber readings were employed to convert normalized fluence spectra into absolute fluence spectra. The characterization of fixed anode pitting and its dominance over exit window plating and/or detector dead layer was determined. An Appendix of tabulated benchmark spectra with assigned error ranges was developed for future reference.

Using measured 30-150 kVp polychromatic tungsten x-ray spectra to determine ion chamber calibration factors, Nx (Gy C(-1)).

Two methods for determining ion chamber calibration factors (Nx) are presented for polychromatic tungsten x-ray beams whose spectra differ from beams with known Nx. Both methods take advantage of known x-ray fluence and kerma spectral distributions. In the first method, the x-ray tube potential is unchanged and spectra of differing filtration are measured. A primary standard ion chamber with known Nx for one beam is used to calculate the x-ray fluence spectrum of a second beam. Accurate air energy absorption coefficients are applied to the x-ray fluence spectra of the second beam to calculate actual air kerma and Nx. In the second method, two beams of differing tube potential and filtration with known Nx are used to bracket a beam of unknown Nx. A heuristically derived Nx interpolation scheme based on spectral characteristics of all three beams is described. Both methods are validated. Both methods improve accuracy over the current half value layer Nx estimating technique.

Analysis of sensitivity and specificity of a new digital subtraction system: an in vitro study.

OBJECTIVE: The purpose of this study was to compare a new digital subtraction system with conventional radiograph images for the detection of periapical and periodontal bone lesions. STUDY DESIGN: Periapical and periodontal bone lesions were simulated with cortical bone chips of varying sizes placed on a human dry mandible. Radiographic film images were acquired from varying projections and were subsequently digitized, registered, and subtracted. Four clinicians evaluated the subtracted images, and sensitivity and specificity were calculated. RESULTS: The mean sensitivity and specificity of the Diagnostic Subtraction Radiography system for detecting bone lesions of all sizes with varying projection geometry were 87.90% and 85.23%, respectively. The corresponding results for conventional radiograph images were 47.54% and 97.38%. The difference in sensitivity was statistically significant, whereas the difference in specificity was not. CONCLUSIONS: These results indicate that, even when radiographs are taken from disparate projection geometries, the Diagnostic Subtraction Radiography system is capable of excellent discrimination between healthy and disease states in this in vitro model.

Physical properties of a photostimulable phosphor system for intra-oral radiography.

OBJECTIVES: To determine physical properties of the Digora digital intra-oral radiographic system (Soredex Orion Corporation, Helsinki, Finland) for different calibration settings and beam energies. METHODS: The line spread function (LSF) and the modulation transfer function (MTF) were determined from radiographs of a slit. Noise power spectra (NPS) were determined from radiographs exposed to homogeneous radiation fields at 10, 50 and 100% of the calibration exposure for three tube potentials. All calculations were performed using relative values of exposure comprised of gray level, the signal at the photomultiplier tube and the amplified signal in order to confirm agreement between these different approaches. Noise equivalent quanta (NEQ) were calculated from the one-dimensional NPSs and the MTF. Detective quantum efficiencies (DQE) were determined from the NEQs and representative values of the photon fluence. Signal-to-noise ratios (SNR) were calculated for different signal contrasts applying the NEQs. RESULTS: The MTF of the system exhibited typical characteristics and falls to a value close to zero at the Nyquist frequency of about 7 cycles/mm. Noise as expressed by the NPS was found to be relatively low, i.e. about 10(-5) to 10(-6) mm2 depending on exposure and frequency. There was no significant difference between data obtained at different beam energies. The NEQ and hence the DQE were relatively high. DQE decreased with increased exposure. For exposures in the clinical range of the DQE reached a peak value of about 25%. SNRs are favorable. CONCLUSION: The physical properties of the Digora intra-oral system indicate that it is suitable for digital intra-oral radiography.