3dx Accuitomo Clinical Report

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Thinking ahead. Focused to life.

3D Accuitomo FPD XYZ Slice View Tomography

Clinical Report


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3D Accuitomo system - a new imaging method or accurate

multidirectional slicing and graphic three-dimensional

presentation o dentomaxillary structures

Background and clinical evaluation

Erkki Tammisalo

Emeritus Proessor o Oral Radiology

Tomodent, Private Laboratory o Oral Diagnostic

Imaging

Turku, Finland

Due to continuing developments o treatment

methods and operative techniques, radiologists

are today required to provide their dental and

surgical colleagues with accurate and three-

dimensional imaging o oral anatomy and

pathology, allowing more precise diagnostics

and more detailed preoperative treatment and

surgical planning. Intraoral radiography does

permit viewing internal dental anatomy without

the superimposition o surrounding structures

and as well as panoramic radiography it provides

only a two-dimensional representation o the

oral bony structures in a single buccallingual

perspective. These methods are thereore or

limited value when analyzing complex anatomy

or when detecting and quantiying pathological

changes. Since the introduction o CT, digital

three-dimensional imaging has been more

and more used in medical radiology. With the

traditional CT methods, there is, however, a lack

o spatial resolution or demonstrating the subtle

dental structures or or detecting small apical

and alveolar lesions. Also the dose level is high

in conventional CT imaging. There has been no

validated practical method available or detailed

3D Accuitomo study o the dentition and the

surrounding structures in spite o the act that

the dental proession has badly needed more

sophisticated and eective imaging techniques to

solve existing and new coming diagnostic tasks

and problems.

The recent, tremendous advances in the

capability o personal computers to process

data and advances in detector technologies have

made it possible to use new technical solutions

or creating computed tomographic scans. By

applying new technology, J.Morita Mg. Corp.,

has developed a CT scanner based on the use

o a personal computer and a cone-shaped X-ray

beam. Now, with the advent o this advanced

CT scanner - called 3D Accuitomo dentistry

has or the ist time been exposed to the CT

technology specially designed or imaging o the

dento-maxillo-acial complex. Spatial resolution

o the 3D Accuitomo images is high enough to

accurately demonstrate all the nest hard tissue

structures, the x-ray dosage is low, it is easy to

use and comortable or the patient.

13D Accuitomo FPD XYZ Slice View Tomography Clinical Report


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the hard tissues. 3D Accuitomo is thereore,

the modality o choice when conventional oral

radiography is inadequate in detecting existing

subtle pathology. During the time we have used

the 3D Accuitomo imaging system, we havebeen able to help a large number o patients who

had been suering rom diagnostic problems

which had remained undetected in conventional

radiographs.

In summary, three years o clinical experience in

working with the 3D Accuitomo high resolution

and low dose 3D Accuitomo system has

established that this new imaging method hasrevolutionized oral radiology and opened a new

dimension or displaying complex structures and

establishing a diagnosis.

Finally, I would like to send my warmest regards

to all Japanese colleagues and oral radiologists.

We have been able to use the 3D Accuitomo

imaging system three years and since early 2005

the second generation o the 3D Accuitomo

scanner which has been urnished with a lat

panel detector. The range o contrast resolution othe FP detector is signicantly larger than that o

image intensier based detector when the spatial

resolution o both detectors is equally high. The

FP detector is equipped with a collimation system

that allows use o two dierent ield sizes. So,

when the FP detector is used, the eld size and

the dosage level can be selected according to

the diagnostic task. Through 3D Accuitomo's

sotware system, it is possible to generatetwo-dimensional reconstruction images at any

plane and in any direction. Slice reconstructions

in three dimensions provide a display o the

structures that is morphologically exact and

ree o superimposition. Multidimensional, ull-

perspective images can also be constructed

that permits appreciation o the anatomy and

pathological changes in an integrated and

comprehensive ormat.

The 3D Accuitomo imaging system has shown

to be particularly useul in detection o subtle

pathological conditions that have been missed

with other imaging modalities and in studying

root canal morphology, in evaluating presurgical

tooth impactions, implant sites, mandibular canal

and maxillary sinus location. 3D Accuitomo is the

irst method o choice when analyzing complex

anatomical conditions or deining the extent

o cysts and tumors, and their relationship to

adjacent normal structures. It permits precise

planning o the surgical approach and reduces

intraoperative time and improves postoperative

outcome. In establishing a primary diagnosis o

dental lesions conventional imaging methods

remain the gold standard. With these methods,

there is an acknowledged lack o sensitivity

or detecting and quantiying small changes in

2 3D Accuitomo FPD XYZ Slice View Tomography Clinical Report


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Case 1 Large multilocular cyst in the let side o the lower jaw.

Cross-sectional slice through the retained third molar shows

the lingual position o the mandibular canal and the sagittal slice

demonstrates the anteroposterior extent o the cyst.

Case 2 The rontal alveolar process o the lower jaw has been

strengthend by a bone grat or implant surgery. The axial,coronal

and sagittal slices show the outcome o the operation. Bony 3D

reconstruction image demonstrates the bone grat and the place

rom which bone has been taken or the grat.

Case 3 Views in axial, tangential and cross-sectional directions o

the impacted multirooted third molar reveal that the mandibular

canal is running lingually to the mesial root and between the two

distal roots. The tips o the distal roots are bending distally and

embraced by cortical bone.

A short curriculum vitae of Emeritus Professor Erkki Tammisalo:

Dental degree, Helsinki University, 1957.

Assistant teacher in oral radiology, Helsinki University, 1958 1960.

Associate Proessor o Oral Radiology, Helsinki University, Finland,1961-1963.

Doctorate degree in oral diagnostic radiology, Helsinki University,

1963.

Proessor and Chairman o Oral Radiology, Turku University, Finland,

1964 1998.

Approximately 100 scientiic and review articles on radiographic

imaging physics, rotational panoramic radiography, diagnostic

accuracy o oral imaging techniques and oral X-ray pathology.

Written two Finnish textbooks on oral X-ray pathology and

diagnostics.

Honorary degree o Doctor o Dentistry, Medical Faculty, Gteborg

University, Sweden, 1997.

Special interest: improving panoramic imaging technique

and developing new imaging technologies and methods.

Cranex, Minray, Digora FMX, Digora PCT, Scanora multimodal

system,Cranex Tome and 3D Accuitomo.

Five worldwide patents on the area o imaging methods and

technology.



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Clinical Applications of 3D Accuitomo Cone Beam CT

Hans-Gran Grndahl

Proessor and head

Department o Oral and Maxilloacial Radiology,

Institute o Odontology,

The Sahlgrenska Academy

Gothenburg University, Gothenburg, Sweden.

In most clinical areas o dentistry, radiography

plays a pivotal role. The rather complex anatomical

conditions have required x-rays be taken rom

dierent angulations to permit a thorough

analysis o teeth and jaws. Nevertheless, there

has been a lack o a technique allowing the 3D

anatomy o teeth and jaws to be imaged in a

simple, aordable, dose-saving and yet high

qualitative way until the advent o a cone beam

CT technique designed or volumes o limited

size.

In the Department and Clinic o Oral and

Maxilloacial Radiology at the Sahlgrenska

Academy in Gothenburg, Sweden, we have used

3D Accuitomo (J. Morita MFG. Corp., Kyoto,

Japan) or about 4 years. We rst used the unit

equipped with an image intensiier and a CCD

or image capture and then switched to a CMOS

fat panel detector. This represented a signicant

step orward, not only because we could now

use two dierent volume sizes, but also because

we ound the image quality to be better.

The 3D Accuitomo unit is more and more

requently used as our clinical colleagues

begin to appreciate the value o 3D Accuitomo

inormat ion. Very ear l y on, i t s va lue in

endodontics and implant practice became

apparent and diagnostic issues related to those

two elds still belong to those most commonly

approached by means o 3D Accui tomo

examinations. A pie chart (Fig. 1) describes the

distribution o patient categories among the rst

500 patients examined at our clinic. By and large,

the distribution is still approximately the same

although larger cystic lesions and tumors as well

as dento-alveolar trauma are now more oten

examined with our 3D Accuitomo unit.



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In endodontics, lesions at the root apices can

be diicult to see in conventional radiographs

either because they are hidden behind dense

anatomical structures such as the roots o multi-

rooted teeth or because they are conned to the

cancellous bone only and thereore cause little

loss o bone mass.

Conventional images in Fig. 2. are rom a patient

with severe pain in the upper molar region.

Although several radiographs were taken rom

dierent directions only small lesions were ound

at the apices o the upper right rst molar.

It is no exaggeration to say that the advent o

this technique and this particular unit represents

a major breakthrough and a paradigm shit in

dental diagnostics over the entire range o dental

problems.

Some examples may serve to illustrate the

versatility o the 3D Accuitomo unit while, at the

same time, demonstrating the shortcomings

o our commonly used x-ray techniques. Some

examinations were made with the image-

intensier/CCD-version, others with the fat panel

detector.

Fig. 2. Conventional radiographs in the upper rst quadrant o this patient in severe pain only demonstrated small lesions around the apices

o the rst molar.

Fig. 1. Distribution o patients among the rst 500 examined with 3D Accuitomo.

Endodontics: 22%

Implants: 38%

Orthodontics: 20%

Ears:3% Trauma:1%TMJ:5%

Impacted teeth:11%



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Examinat ion with the 3D Accuitomo unit

demonstrated a large lesion encompassing both

buccal roots. It expands the buccal bone and into

the lower part o the maxillary sinus where its

border is irregular and dense.

Fig. 3. A very dierent picture o the lesion at the rst upper molar rom that seen in the intraoral radiographs.



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need to access the oral cavity. In Fig.4. several

conventional intraoral radiographs are presented,

but only one o them clearly shows the presence

o a root racture.

In cases o suspected ractures o teeth and

alveolar bone the use o 3D Accuitomo is

particularly useul because o the large number

o directions rom which the teeth and jawbone

can be viewed rom just one exposure with no

Fig. 4. In several intraoral radiographs, taken rom dierent directions, only one clearly demonstrates the presence o a root racture.

Fig. 5. In the 3D Accuitomo images, one can clearly see the horizontal, oblique root racture, visible in one

o the intraoral radiographs. In addition, the 3D Accuitomo image set demonstrates a vertical oblique rootracture not displayed in any o the intraoral radiographs.



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appreciate the degree of dislocation of teeth and

bone. Fig. 6 shows such a case.

When many teeth have been involved in a trauma

that also includes the alveolar bone, it may be

of value to do a volume rendering to better

Fig. 6. Severe trauma to the upper frontal area causing fractures of the alveolar bone and dislocation of several teeth.

Fig. 7. Control radiographs after trauma treatment. Only an axial and a sagittal slice are shown. They show thatneither medial incisor has been optimally repositioned.

3D Accuitomo examinat ions can also be

performed to control the result of reposition and

root canal treatment after trauma (Fig.7).



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not the extent with which urcation areas are

involved (Fig.8).

The extent o periodontal marginal bone loss

is not always easy to determine and certainly

Fig. 9. In 3D Accuitomo images the marginal bone deect is easily seen and the degree o bone loss can beprecisely assessed. In the upper right corner is a 3D image based on the radiographic volume data.



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in whom implants were considered in both upper

lateral incisor regions. Images rom the right

upper lateral incisor region are shown.

3D Accuitomo images can play an important role

in implant planning and, in particular cases, also

or post-operative examinations. In Fig.10. 3D

Accuitomo images are presented rom a patient

Fig. 10. One exposure is sufcient to cover the entire rontal area making the examination very efcient. While the height o the alveolar

bone is sufcient, as well the horizontal distance between the cuspid and the medial incisor, its width is too small or conventional implant

treatment and may have to be augmented.



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aspect o the implants, but also on the buccal

and lingual sides. Fig. 11. shows an example o

such images, one rom the buccal and one rom

the lingual aspect.

We have used the 3D Accuitomo unit in animal

studies aimed at evaluating bone healing around

implants placed in dierent kind o tooth sockets.

With 3D Accuitomo images we are not restricted

to only evaluate bone on the mesial and distal

Fig.11. Implant images taken rom both the inside and outside.

From the inside

From the outside



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second upper molar upwards. In some places

there are no clear borders o the lesion and there

is a lack o a bony border both to the palatal and

buccal side. The lesion is a typical example o a

calciying odontogenic tumor. Particularly in thevolume rendering image, one can see that the

roots o the dislocated tooth are ound in the

lower part o the orbit.

3D Accuitomo images, both in terms o slices

and volume rendering images, are very useul

or the assessment o cystic lesions and tumors.

In the case presented in Fig. 12., both types

o images were used in connection with theevaluation o a cystic lesion.

It can be seen that the lesion contains calcifed

structures and sot tissues and has displaced the

Fig. 12. One mm thick slices and a volume rendering image o a typical calcifed odontogenic tumour.



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Fig. 13. A laterally displaced temporomandibular condyle with extensive fattening o its lateral part and o the lateral part o the tubercular

ossa and eminence. Note the low contrast, crescent-shaped structure above the medial part o the condyle probably the disk.

condyle that is in a much more lateral position

than normal and that there is extensive fattening

o the lateral part o the condyle and o the

tubercular eminence. Above the medial part o

the condule, a crescent-shaped, low contrastshadow may be a medially dislocated disk.

The temporomandibular joint can easily be seen

in all its aspects as witnessed by the example

in Fig. 13. Many years ago, the patient was

subjected to a trauma and she now has pain in

her let temporomandibular joint region and aeeling o asymmetry. The radiographs show a



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there is root resorption on roots close to the

cuspids crown. Fig.14. shows such an example

both by the use o slice images in three planes

perpendicular to each other and volume rendering

images.

In the orthodontic patient with ectopically

erupting teeth, notably the upper cuspid, 3D

Accuitomo images can be used to exactly

determine the position o the impacted cuspid,

its relation to neighboring structures and whether

Fig. 14. By combining slice images with

volume rendering images that can be

seen rom any direction a comprehensive

understanding o a situation with unerupted

teeth can be obtained.

There are many instances in orthodontic practice

besides those o unerupted teeth that can benet

rom a radiological examination that provides

detailed 3D Accuitomo inormation.

Obviously, the management o clet palate

patients must be one, not only to obtain a

precise description o the extent o the clet, but

also to enable detailed images o the teeth

oten supernumerary, unerupted and malormed

in the vicinity o the clet.



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will provide inormation about tooth suraces that

are not visible in conventional radiographs.

This can be illustrated by means o radiographs

rom a pat ient in whom teeth had been

orthodontically moved in order to provide

suicient distances between neighboring teeth

or an implant to be placed. An examination was

made to ascertain whether the width o the bone

was sucient or implant placement (Fig. 16).

Fig. 15. shows radiographs o a patient with a

bilateral clet and a premaxilla that has not used

with the maxillae.

Conventional intraoral radiographs provide

reasonably good inormation about conditions

in directions perpendicular to the x-ray beam

even though all anatomic structures become

"compressed into a single image plane. On the

other hand, they provide very limited inormation

about conditions in the direction o the x-ray

beam, that is, on the outside and inside o the

teeth.

Thereore, the possibilities o getting thin slices

perpendicular to the tangent o the alveolar bone,

that is, in bucco-lingual directions o the teeth,

Fig. 15. A combination o slice images and volume rendering images provides an understanding o the conditions in clet palate cases that

has not been able beore.



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modalities.

With the advent o the 3D Accuitomo technique

dentistry has entered into a completely new

ase. In many areas it will never be what it used

to be. The uture is here.

To sum up, there can be no doubt that the

3D Accuitomo technique has opened up new

possibilities or more accurate diagnosis in

the oral and maxil loacial arena and, as a

consequence, better possibilities or choosing

the treatment option with the best long-term

prognosis. In clinical research, it provides hitherto

unknown means to monitor new treatment

Fig. 16. In this composite o dierent types

o images (intraoral radiograph in the middle

o the upper row, volume rendering image

in the upper right corner, and 3D slices)

it is easy to appreciate the importance o

the added inormation provided by the 3D

technique. The intraoral radiograph reveals

neither the lack o lingual bone nor the

resorptions in the lingual root surace o the

indicated tooth.



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Clinical experiences and scientifc investigations with the 3D Accuitomo

Dr. Edgar Hirsch

University Leipzig

Dept. o DentoMaxilloFacial Radiology

Indications o the 3D Accuitomo FPD:

DentoMaxillo-Facial- Surgery

impacted , displaced teeth (wisdom teeth,

canines, supernumerary teeth)

apical periodontitis, cysts o the jaw

pre- and postoperative or imaging o

important anatomical landmarks and

structures

implant-planning and recall

clet-palate- patients

trauma cases (ractures o bones and teeth)

Periodontics

marginal bone-contouring

3D imaging o deep pockets and urcations in

bone

Endodontics

confguration o root-canals,

root canal measurements

additional canals, anatomical variations

Orthodontics

confguration o the roots

anatomical situation, relation o the teeth

between

periodontal ligament (ankylosis)

resorptions

One special case o implant-planning shows as an

example clearly the beneft o the 3D Accuitomo,

and i there is a need or high resolution 3D X-ray

imaging.

The irst image shows a panoramic view o

a patient, who requested implant treatment

(image1). As you can see, the mandibular nerve

canal isnt visible, especially in the prospective

implant region (marked with steel balls). To

determine the upper border o the nerve canal,

we perormed a 3D Accuitomo FPD-scan. The

sagittal view shows the nerve canal clearly,

but not perect in all areas (image 2). So i you

take a look on the cross-sectional slices, you

will see the anatomical situation perect at all

(image 3). No other X-ray machine gives a similar

perormance at this time. One o the main

advantages o the 3D Accuitomo FPD is its very

high resolution, resulting rom a voxel-size o

0.125 mm3. Bearing in mind, that some o the

structures we want to see, are smaller than 0.2

mm, we must have this high resolution.

Our experiences with the 3D Accuitomo last now more than 5 years o clinical use, at frst with the

basic version and or 1,5 years with the 3D Accuitomo FPD. First o all, Ill report about the indications

or this highly sophisticated X-ray machine.



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our opinion, the diagnostic accuracy o the 3D

Accuitomo FPD can give support to made right

decisions regarding diseases, treatment options

and treatment planning in all elds o dentistry.

There is a growing need or highly precise

diagnostics in all ields o dentistry because

o quality reasons. The patients want the best

treatment options and accurate diagnostics is

an important tool to deliver such a treatment. In

Image 1

Image 2 Image 3



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Emotion (Siemens, Erlangen , Germany).

The dose measurements were carried out on an

antropomorphic phantom (image 4), developed

especially or dental radiography (Visser 1997).

The absorbed doses in the head and neck region

were measured with thermoluminescencedetectors (TLD 100H, Harshaw/Bicron) at 16

dierent sites on the surace as well as inside the

phantom. The eective doses were calculated

based on the absorbed doses.

Scientifc investigations regarding

the 3D Accuitomo and 3D Accuitomo FPD

We perormed the ollowing experimental

studies:

1. Dosimetric measurements

A new radiation protection law was introduced in

2002 by the German Government.

It is mandatory, to keep the radiation doses

always as low as possible, especially with

younger persons. The 3D Accuitomo seems to be

a low dose 3D examination in dentistry.The aim o our dosimetric study was to compare

the eective doses by the newly developed

cone-beam-tomography X-ray device 3D

Accuitomo FPD (J. Morita MFG. Corp., Kyoto,

Japan) in relation to the NewTom DVT 9000 (Q.R.

Italia, Verona, Italy) and the spiral-CT Somatom

Image 4: Dosimetry-phantom



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Investigation procedure:

1. Loading the TLDs into the phantom

2.Positioning o the phantom in the X-raymachine (2 pre-scans)

3. Exposure: CBT 10 scans/ ROI

CT 1scan, 30 mm

4. Reading o the TLDs/ data-capturing

5. Calculation o the eective doses

The X-ray devices under investigation were

deployed us ing the o l lowing exposure

conditions:

1. 3D Accuitomo FPD: single scan, cylindrical

scan area 60 mm diameter and 60 mm height,70 kV, 3mA, 17s scan time

2. NewTom DVT 9000: scan o the mandible,

110 kV, auto exposure (1-10 mA), 72 s scan

time (36 s exposure)

3. Somatom Emotion: 130 kV, 90 mAs,1,5 s

rotation time 1,0 mm slice thickness,1,5 mm/s

pitch, (30 slices)

radiation (in Germany). I you take a look on

the 3D Accuitomo FPD, one scan o the maxilla

causes approximately 24Sv that is equivalent

to two conventional panoramic radiographs. In

comparison to the NewTom DVT 9000 and the

spiral-CT Somatom Emotion, the radiation burden

The table above shows the very low doses

caused by an examinat ion wi th the 3D

Accuitomo. For example, the value or one

scan o the anterior maxilla is only 4Sv which

means, the radiation dose is equivalent to

approximately one day o natural background

Results:

Table 1 Eective dose in Sv



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is ar low. From a radiation protection point o

view, the use o the 3D Accuitomo FPD or high

resolution 3D images o the jaws can be strongly

recommended. Especially or younger patients,

or example with clet palate and orthodonticmalormations, is there a great beneit, i one

can use the 3D Accuitomo instead o a spiral-CT,

keeping in mind, that these patients oten have a

requirement or 3D X-ray imaging.

2. Image quality

We perormed an experimental study to

investigate the image qual ity o dierent3D-imaging modalities. Five human cadaver

heads were investigated using the cone-beam-

CT machines 3D Accuitomo (J.Morita MFG.

Corp., Kyoto, Japan) in relation to the NewTom

DVT 9000 (Q.R. Italia, Verona, Italy) and the

spiral-CT Somatom Emotion (Siemens, Erlangen,

Germany). 14 anatomical landmarks wereselected. The examination was carried out by 14

investigators using a fve-point-rating scale.

The 3D images were rated all good to excellent,

whereas the images rom the NewTom DVT

9000, as well the images rom the Somatom

Emotion, were mostly rated acceptable. The

image below shows you as an example o the

TMJ region in lateral, as well as rontal slices. As

you can clearly see, the image quality o the 3DAccuitomo is ar superior in comparison to the

other modalities (image 5).

Image 5: Comparison o the image quality

3D Accuitomo NewTom DVT 9000 Somatom Emotion



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FPD).

A human dry skull was marked at 10 dierent

sites using endo-instruments (image 6). Theimaging was carried out at 70kV and 2mA. The

distances between in each case two o the endo-

instruments were detected.

3. Measurement accuracy

The measurement accuracy of 3D X-ray-equipment

is important or diagnosis and treatment planning

as well as or image-guided surgery o themaxillo-acial region.

The aim o this study was to evaluate the

accuracy o the linear measurements in images

obtained rom the CBCT-device (3D Accuitomo

Image 6: skull with metallic markers in the 3D Accuitomo

calliper (image 7).

The obtained data were statistically evaluated

by Students t-test. There are no signiicant

dierences between both measurement results.

Linear distances were taken in three dierent

axes o the volume data. The measurements

rom the CBCT images were obtained using the

measuring tools o the 3D Accuitomo sotware.

The real distances were taken using an electronic

Image 7: Measurements by sotware and calliper



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In summary, one can say, the introduction of

high resolution cone-beam-CT in dentistry by the

J. Morita MFG. Corp., is a milestone in dental

diagnostics.

The CBCT-device 3D Accuitomo FPD is a reliable

tool for preoperative measurements of e.g.

implant sites.

It is possible to use the data obtained from 3DAccuitomo FPD for guided surgery, for example

in connection with the Nobel Guide-system

or other implant planning software. The data

can be exported as DICOM 3 files. These files

are running without any problems in different

programs.



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Thinking ahead. Focused on lie.

In 1916, Junichi Morita started to

import products o the leading

dental equipment manuacturers

into Japan, where demands or

modern dentistry were growing.

His venturesome attempts o

supplying selected products or

oral healthcare has grown steadily

by receiving valuable support and

guidance rom the dental proession.

His enterprising spirit lives through

the decades, and all Morita Group

Companies join in continuing to

pursue marketing, distribution and

services, as well as R&D and

manuacturing, in collaboration with

world leaders in healthcare products

and research organizations.

Diagnostic/Imaging Equipment

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Developed and Manuactured by

J. MORITA Mg. Corp.

680 Higashihama Minami-cho, Fushimi-ku, Kyoto,

612-8533 Japan

Tel: +81-75-611-2141, Fax: +81-75-622-4595,

Distributed by

J. MORITA CORPORATION

33-18, 3-Chome, Tarumi-cho Suita City, Osaka, 564-8650 Japan

Tel: +81-6-6380-2525, Fax: +81-6-6380-0585,

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3dx Accuitomo Clinical Report