The Cone Beam specialists - Henry Schein Halas

Introducing 

Body Logic 

The Cone Beam Specialists 

logic 

body 

Henry Schein Halas and Henry Schein Shalfoon are delighted to 

introduce Body Logic to its Australia/New Zealand customers. 

Read inside to discover how four of the world’s leading cone beam 

brands – iCat, Gendex, Morita, Planmeca – will come together under one 

umbrella, so that customers will experience unmatched sales expertise 

Case RepoR t 

and after-sales support from the most experienced and skilled specialist 

cone beam team in Australasia. 

Extractions Avoided by i-CAT ® 

“2-D“ view - only part of the story 3-D - precise locations of the impacted incisors 

This 8-year-old male was referred to my office by an oral surgeon. The surgeon was tasked with the removal 

of both the right lateral and central incisors following a previous orthodontic exam. The oral surgeon felt that 

through another orthodontic diagnosis and treatment plan utilizing an i-CAT 

www.henryschein.com.au orders: 1300 65 88 22 

® CBCT scan, both incisors could 

be saved. After taking the scan, I realized that the lateral incisor was oriented with the facial surface oriented 

buccally. The central incisor’s facial surface, on the other hand, was facing the midline of the palate. Both

ody logic 

Introducing Body Logic 

Body Logic was introduced to the Australian dental 

market in 1999 and since that time has established 

itself as the leading supplier of Cone Beam Imaging 

systems in Australasia. They have successfully 

established the iCAT as Australasia’s #1 choice for 

cone beam CT, with a large network of machines 

installed across both countries, in general dentistry, 

dental specialities and Radiology. 

This success has been built on a commitment to 

providing equipment of the highest imaging ® quality 

and reliability, as well as dedication to providing high 

quality continuing education seminars and hands-on 

courses to the dental community. These courses 

have utilized outstanding international speakers 

such as Prof Bill Scarfe and Dr Steve Olmos, and 

continually receive outstanding, positive feedback 

from attending practitioners. 

E REPORT i-CAT 

Lisa McAsey 

brought a copy of a standard two-dimensional panoramic radiograph from the previous consultation, which 

Lisa’s philosophy is simple: honesty, ethical integrity industry is testament to her ability to accept and 

demonstrated an un-erupted lower right first bicuspid. The 2-D panoramic image showed that the tooth was failing 

and prompt service. She measures her success by promote change and to lead the dental industry 

to her erupt; relationships however, with it was her difficult clients to and determine by exceeding exactly what in was innovation. preventing Her the relationships eruption, vital with information her clients necessary are 

before their expectations the proper diagnosis & satisfaction and treatment with quality plan services could be developed. invaluable An and i-CAT she endeavours to promote their 

and products. 

success at all times. 

Lisa’s approach is one that respects all aspects of Lisa is a problem solver, a lateral thinker and a 

the business process. She understands the absolute pioneer in the dental industry with a wonderful 

need for consistency in support and supply so that reputation, born of unyielding loyalty. Her family life is 

her clients can have the confidence to run their central to her beliefs and the motivation to fulfill her 

businesses as they choose. Her longevity in the potential and help others to achieve theirs. 

® 3-D cone beam scan clearly revealed 

the development of a supernumerary tooth with a full crown, inhibiting the eruption of the impacted bicuspid. 

With multiple views, sections, and renderings at my disposal, I had the good fortune of sharing my findings with the 

parents and the patient. The vividness of the views on my monitor during the consultation clearly left a favorable 

impression on both the parents and the patient. 

...Case continued on next page 

2 

Impacted bicuspid superimposed in 2-D 

We are now able to introduce Body Logic to a wider 

market, to leverage this expertise and commitment to 

a wider cone beam audience – which includes existing 

users of Gendex, Morita and Planmeca cone beam 

equipment, and, of course, to all prospective purchasers 

and anyone interested in finding our more about the 

benefits of Cone Beam Imaging for their patients and 

treatment planning. 

Existing iCat users will of course continue to receive the 

excellent after-sales support they are accustomed to 

and we will also be able to integrate and streamline the 

support that Henry Schein cone beam customers have 

received vi their own DI Support line. By creating a larger 

team of people who are specialized and totally dedicated 

to Cone Beam Imaging, we are indeed recognizing the 

importance of this area to dentistry, and ensuring that all 

our customers and prospective customers receive advice 

and support which is unparalleled. 

Unusual Impaction Revealed by i-CAT ® 

Supernumerary tooth with a full crown 

This following case involves a young teenage patient who presented to my office for a second opinion. This is a nice 

illustration General of Manager 

how even simple dental findings with the i-CAT ® can convert consultations into starts. The parents

Brett Butcher 

Sales and Marketing Manager 

Brett Butcher has held the position of Sales and 

Marketing Manager since 2005 and, in that time, he 

has guided the company to a position of market leader 

in the highly competitive field of 3D Dental Imaging. 

As well as exceptional sales and insightful marketing 

skills, Brett recognises his obligation and responsibility 

to our Health Care Professional clients and is 

committed to understanding their needs and supplying 

Laszlo Varkovi 

Sales Specialist 

Laszlo has developed an impressive career firstly with 

Halas Dental, then since 2005 with Henry Schein Halas. 

His experience was gained initially as a territory 

manager for consumables, and then in recent years 

as an equipment sales specialist. As a result of this 

grounding, he has developed a strong understanding 

of how dental practices tick, and a keen sense of 

what dentists require from their industry suppliers and 

representatives. 

Craig Cannons 

Technical & Training Manager 

Craig became part of our team in October 2007, having 

spent more than 20 years in the dental industry. His 

vast experience in product management and training 

and his technical prowess made him the perfect 

candidate to take on the role which we consider to be 

a priority, that of ensuring that all clients receive the 

highest level of support with limited downtime. 

With close to 60 machines under his care this is an 

extremely demanding role and one he performs to 

the highest standard. This level of support has helped 

forge Body Logic’s exceptional reputation for customer 

service and support. 

) Orders: 1300 65 88 22 8 www.henryschein.com.au 

products which will aid and support his clients and their 

patients. 

Brett also has a high degree of technical knowledge 

which puts him in the unique position of being able to 

offer support, clear communication and knowledgeable 

assistance. This, combined with his personal drive and 

commitment, places him in a class of his own. 

His success has been built around partnering with 

customers to help them achieve their ideal and unique 

surgery set-up, and guiding them through what can 

often be a difficult and drawn out process. 

He has a keen interest in dental imaging, and is now 

delighted to be joining the Body Logic team, to be able 

to continue to offer customers high levels of support in 

the specialized area of cone beam imaging. 

Craig also conducts all onsite customer training for new 

users and owners and, again, his attention to detail and 

his development of our comprehensive training ensures 

all users are competent and proficient in the operation 

of their iCAT, making the transition to 3D a smooth and 

successful one. 

Craig’s adept ability to resolve problems in a timely 

manner and delegate where needed ensures this 

department is cornerstone for Body Logic’s success 

in the 3D market. 

3

ody logic 

4 

Experience | Training | Education | Maintenance | Support | Expertise 

Australia’s #1 

Choice for 

Cone Beam CT

Experience the new 

GXCB-500 

the latest in cone beam 3-D 

imaging technology. 

• Standard Scan Mode - 8 cm by 8 cm 

• Extended Diameter Scan (EDS) Mode 

- 14 cm by 8 cm 

• Captures vital anatomical structures 

• Also easily switches to 2-D panoramic 

projections with the same sensor 

• Exceptional scan and reconstruction time 


5

ody logic 

CASE REPORT i-CAT 

CASE REPORT i-CAT 

6 



“2-D“ view - only part of the story 

“2-D“ view - only part of the story 

® 

® 

3-D - precise locations of the impacted incisors 

3-D - precise locations of the impacted incisors 

This 8-year-old male was referred to my office by an oral surgeon. The surgeon 

was tasked with the removal of both the right lateral and central incisors following a 

This 8-year-old male was referred to my office by an oral surgeon. The surgeon was tasked with the removal of both 

the right lateral and central incisors following a previous orthodontic exam. The oral surgeon felt that through another 

orthodontic diagnosis and treatment plan utilizing an i-CAT ® This 8-year-old male was referred to my office by an oral surgeon. The surgeon was tasked with the removal of both 

the right lateral and central incisors following a previous orthodontic CBCT scan, exam. both The incisors oral surgeon could be felt saved. that through After taking another the 

scan, orthodontic I realized diagnosis that the and lateral treatment incisor plan was utilizing oriented an with i-CAT the facial surface oriented buccally. The central incisor’s facial 

surface, on the other hand, was facing the midline of the palate. Both incisors were horizontally stacked with the 

central positioned above the lateral incisor. 

Determination of the orientations of the incisors is not possible with just a panoramic-type image, as illustrated by the 

reconstructed pan from the scan data (image on the left). However, the axial images from the CBCT scan demonstrate 

the orientation of both teeth. The cross-sectional views further demonstrate the horizontal “stacking” of both teeth 

(image on the right). 

A Phase I treatment plan was devised that included rapid maxillary expansion followed by upper fixed appliances. After 

expansion, along with leveling and aligning the arch, guided eruption techniques will be employed to bring both incisors 

into the arch form during Phase I treatment. 


® previous orthodontic exam. The oral surgeon felt that through another orthodontic 

diagnosis and treatment plan utilizing an i-CAT 

CBCT scan, both incisors could be saved. After taking the 

scan, I realized that the lateral incisor was oriented with the facial surface oriented buccally. The central incisor’s facial 

surface, on the other hand, was facing the midline of the palate. Both incisors were horizontally stacked with the 

central positioned above the lateral incisor. 

Determination of the orientations of the incisors is not possible with just a panoramic-type image, as illustrated by the 

reconstructed pan from the scan data (image on the left). However, the axial images from the CBCT scan demonstrate 

the orientation of both teeth. The cross-sectional views further demonstrate the horizontal “stacking” of both teeth 

(image on the right). 

A Phase I treatment plan was devised that included rapid maxillary expansion followed by upper fixed appliances. After 

expansion, along with leveling and aligning the arch, guided eruption techniques will be employed to bring both incisors 

into the arch form during Phase I treatment. 


® CBCT scan, both incisors could be 

saved. After taking the scan, I realized that the lateral incisor was oriented with the 

facial surface oriented buccally. The central incisor’s facial surface, on the other 

hand, was facing the midline of the palate. Both incisors were horizontally stacked 

with the central positioned above the lateral incisor.Determination of the orientations 

of the incisors is not possible with just a panoramic-type image, as illustrated by the 

reconstructed pan from the scan data (image on the left). However, the axial images 

from the CBCT scan demonstrate the orientation of both teeth. The cross-sectional 

views further demonstrate the horizontal “stacking” of both teeth (image on the right). 

A Phase I treatment plan was devised that included rapid maxillary expansion followed 

by upper fixed appliances. After expansion, along with leveling and aligning the arch, 

guided eruption techniques will be employed to bring both incisors into the arch form 

during Phase I treatment. 

Bradford N. Edgren, DDS, MS 

Bradford N. Edgren, DDS, MS 

Dr. Bradford Edgren earned both his Doctorate of Dental Surgery, as Valedictorian, and 

Dr. Bradford Edgren earned both his Doctorate of Dental Surgery, as Valedictorian, and 

his Master of Science in Orthodontics from University of Iowa, College of Dentistry. He is 

his Master of Science in Orthodontics from University of Iowa, College of Dentistry. He is 

a Diplomate of the American Board of Orthodontics and an affiliate member of the SW 

a Diplomate of the American Board of Orthodontics and an affiliate member of the SW 

Angle Society. Dr. Edgren has presented to numerous groups on the value of CBCT and 

Angle Society. Dr. Edgren has presented to numerous groups on the value of CBCT and 

cephalometrics. His articles have been published in both the AJODO and American Journal 

cephalometrics. His articles have been published in both the AJODO and American Journal 

of Dentistry. Dr. Edgren currently has an active private practice in Greeley, CO. 

of Dentistry. Dr. Edgren currently has an active private practice in Greeley, CO.

Why 3-D, Why i-CAT ® 

i-CAT 

® 

i-CAT 

i-CAT 

The CBCT scanner scanner will will also also help help me follow me follow the eruption the eruption path of path of 

the maxillary right The right CBCT canine. scanner Guided Guided will eruption also eruption help techniques me techniques follow may the be eruption may be path of 

necessary with the this maxillary this tooth tooth in right the in canine. future the future as Guided treatment as eruption treatment progresses. techniques progresses. may be 

Currently, the 

the necessary lateral 

lateral 

incisor 

incisor with is this bonded 

is tooth bonded 

and in the being 

and future guided 

being as treatment into 

guided into progresses. 

occlusion. The Currently, central incisor the lateral is still incisor horizontally is bonded impacted, and being awaiting guided into 

occlusion. The central incisor is still horizontally impacted, awaiting 

future exposure occlusion. and bonding. The central The right incisor canine is still is erupting horizontally buccally impacted, awaiting 

future exposure and bonding. The right canine is erupting buccally 

to the lateral incisor. future exposure and bonding. The right canine is erupting buccally 

to the lateral to incisor. the lateral incisor. 

In the past, when addressing impacted teeth, the orthodontist has had to rely upon periapical, 

panoramic, and occlusal radiographs to determine the location of impacted teeth. Panoramic 

radiographs are suitable for a comprehensive and overall view of the jaws and teeth. 

However, panoramic radiographs possess inherent magnification and distortion errors that 

result in inconsistent information. Distortion errors with panoramic radiographs can vary from 

one part of the film to the next. All the anatomical elements that lie between the x-ray tube 

and the film are superimposed upon one another. Moreover, because of the nature of the 

focal trough of the panoramic radiograph, important anatomical features, undiagnosed 

pathologies, and/or teeth may lie outside the radiographic image. I have multiple cases where 

impacted teeth were missed on a standard 2-D image only to be diagnosed when a CBCT 

scan was made. One doesn’t realize how large the distortion errors are in standard 2-D 

panoramics until after looking at CBCT scans. 

CBCT completely eliminates the superimposition of images or structures outside the area 

of interest. Data from a single CBCT scan can be viewed as images in the axial, coronal, and 

sagittal planes. This is referred to as multiplanar reformatted imaging. CBCT scans can also 

provide cross-sectional images that are extremely useful in cases with impacted teeth. CBCT 

images do not possess magnification errors – true anatomic measurements are realizable. 

These true anatomic measurements improve surgical predictably as well as reduce surgical 

time. Since I have always taken pans plus lateral and frontal cephalograms on all my patients, 

the i-CAT ® Why 3-D, Why i-CAT 

machine with the EFOV makes it extremely easy to get these images all at once. 

I am now able to perform my 3-dimensional cephalometric analyses with a 3-dimensional 

machine. I also treat a number of patients with Temporomandibular Disorders. This machine 

is great for TMJ imaging. In the past I would take a submental vertex radiograph, calculate the 

angulations of the condyles for corrected tomographs, and then finally take the images of the 

condyles. This would take a considerable amount of time. Now, with a single scan, I can view 

images of the condyles within a matter of minutes. 

® 




















the i-CAT 

Imaging Sciences International 

1910 North Penn Road 

Hatfield, PA 19440 

(800) 205-3570 

® Why 3-D, Why i-CAT 








® 




















the i-CAT 

Imaging Sciences International 



(800) 205-3570 

® Why 3-D, Why i-CAT 








® 



radiographs are suitable for a comprehensive and overall view of the jaws and teeth. However, 

panoramic radiographs possess inherent magnification and distortion errors that result in 

inconsistent information. Distortion errors with panoramic radiographs can vary from one part 

of the film to the next. All the anatomical elements that lie between the x-ray tube and the film 

are superimposed upon one another. Moreover, because of the nature of the focal trough of 

the panoramic radiograph, important anatomical features, undiagnosed pathologies, and/ 

or teeth may lie outside the radiographic image. I have multiple cases where impacted teeth 

were missed on a standard 2-D image only to be diagnosed when a CBCT scan was made. 

One doesn’t realize how large the distortion errors are in standard 2-D panoramics until 

after looking at CBCT scans.CBCT completely eliminates the superimposition of images 

or structures outside the area of interest. Data from a single CBCT scan can be viewed as 

images in the axial, coronal, and sagittal planes. This is referred to as multiplanar reformatted 

imaging. CBCT scans can also provide cross-sectional images that are extremely useful 

in cases with impacted teeth. CBCT images do not possess magnification errors – true 

anatomic measurements are realizable. These true anatomic measurements improve surgical 

predictably as well as reduce surgical time. Since I have always taken pans plus lateral 

and frontal cephalograms on all my patients, the i-CAT ® machine with the EFOV makes it 

extremely easy to get these images all at once. I am now able to perform my 3-dimensional 

cephalometric analyses with a 3-dimensional machine. I also treat a number of patients with 

Temporomandibular Disorders. This machine is great for TMJ imaging. In the past I would 

take a submental vertex radiograph, calculate the angulations of the condyles for corrected 

tomographs, and then finally take the images of the condyles. This would take a considerable 

amount of time. Now, with a single scan, I can view images of the condyles within a matter 

of minutes. 

g Sciences International 



(800) 205-3570 


® 

® 

CASE REPORT 

CASE REPORT 

CASE REPORT 

www.i-CAT.com 

www.i-CAT.com 

7

ody logic 

All volume sizes 

leading the way... 

Planmeca ProMax 3D 

Planmeca ProMax 3D is an intelligent and multipurpose 

X-ray unit series designed to obtain complete 

information on patient anatomy in the minutest detail. 

The units provide digital panoramic, cephalometric, 3D 

CBVT imaging, and 3D photo, as well as advanced 

imaging software tools to comply with every possible 

need in dental radiology. 

Planmeca ProMax 3Ds 

is ideal for imaging of small details Ø50 x 80 mm 

Planmeca ProMax 3D 

Covers the whole dentition area Ø80 x 80 mm 

Planmeca ProMax 3D Mid 

offers the widest selection volumes 

sizes Ø160 x 160 mm 

8 

Planmeca ProMax 3D Max 

enables imaging of the whole maxillofacial 

region Ø230 x 260 mm 

ProMax 3D ProFace 

produces 3D face photo in addition to traditional 

maxillofacial radiography. 

Full MAC 

Support

Morita 3De 

Veraviewepocs 3DE offers digital 3D, Panoramic & cephalometric 

(optional) imaging options with no cassette change required. This 

model features built-in sensors for all image types designed to save 

time and for ease of use. With 40x40 & 40x80mm 3D fields of view, 

3De is suitable for over 90% of all clinical cases. 

Features 

Veraviewepocs 3D 

• 3D, True panoramic (not reconstructed), pedo, TMJ, 

maxillary sinus images, 

bite wing & cephalometric capabilities 

• Easy positioning for 3D images – simply click the region 

of interest on the panoramic view 

• High resolution, contrast rich 3D images of both hard 

and soft tissue with minimal artifacts – and no distortion 

• Low dose and is only 1.8 times that of a Panoramic X-ray 

with film exposure. 

Also available... 

3DE with Ceph 

FOV 40 x 40 & 40 x 80 

3D Type A 

FOV 80 x 80 

3D Type B 

with Ceph FOV 80 x 80 

3D Accuitomo 80 

FOV 40 x 40, 60 x 60 & 80 x 80 

3D Accuitomo 170 

FOV 40 x 40, 60 x 60, 80 x 80, 

100 x 50, 100 x 100, 140 x 50, 

140 x 100, 170 x 50 & 170 x 120mm 

Thinking ahead. Focused on life. 


9

high tech | DENTISTRY 

body logic 


Obstructive sleep sleep 

apnea-hyponea apnea-hypopnea syndrome: syndrome: 

Obstructive Clinical sleep 

Clinical applications 

applications 

of cone beam 

of 

apnea-hypopnea CT 

cone beam CTsyndrome: 

Clinical applications of cone beam CT 

By Allison K. Lohse, BS 

William C. Scarfe, BDS, FRACDS, MS, Dipl. ABOMR 

Fidaa Shaib, MD, DABSM, CBSM and 

By Allison Allan G. K. Farman, Lohse, BS BDS, PhD, DSc, MBA, Dipl. ABOMR, Dipl. JBOMR 

William C. Scarfe, BDS, FRACDS, MS, Dipl. ABOMR 

Fidaa Shaib, MD, DABSM, CBSM and 

Allan G. Farman, BDS, PhD, DSc, MBA, Dipl. ABOMR, Dipl. JBOMR 

S 

S 

leep-Disordered Breathing (SDB) is a group cular diseases including high blood pressure, depres- 

of disorders characterized by disturbances in sion, irritability, learning and memory difficulties, 

the normal respiratory pattern during sleep. weight gain, impotence and headaches. In addition, 

Those are related to increased upper airway resistance 

and include snoring; upper airway resistance 

syndrome; and obstructive sleep apnea-hypopnea 

syndrome (OSAHS). OSAHS is the most common 

disorder and characterized by snoring, repetitive 

total or partial collapse of the pharyngeal airway 

during sleep terminated by oxygen desaturation or 

EEG arousal before ventilation resumes. Airway 

obstruction is manifested by a reduction in airflow, 

termed hypopnea, or a complete cessation of airflow, 

termed apnea, despite ongoing inspiratory 

effort. Hypopnea is defined in adults as a 10-second 

event where despite continued breathing, ventilation 

during sleep is reduced by at least 50% from 

baseline. Apnea is total cessation of airflow for at 

least 10 seconds. Apnea can be obstructive or due 

to failure in control centrally. 

The early effects of repeated disrupted sleep are 

waking somnolence, impaired mental function, 

delayed reaction time and difficulty maintaining 

concentration. Long term effects of recurrent sleep 

arousal in association with intermittent hypoxia and 

hypercapnia have been associated with cardiovas- 

there is evolving evidence that SDB may contribute to 

insulin resistance and other components of the metabolic 

syndrome. Population-based studies suggest 

that OSAHS is a relatively common disorder. In those 

aged 30 to 60 years, 24% of men and 9% of women 

are reported to have abnormal AHI indices. 

104 10 Australasian Dental Practice September/October 2009 

1 The 

prevalence of symptomatic OSAHS is conservatively 

estimated to be 1% to 2% in middle-aged men and 

approximately 0.5% to 1%, in middle-aged women. 2 

“CBCT has 

particular 

application in 

the diagnosis 

and assessment 

of therapy in 

OSAHS patients 

and has the 

potential 

to eliminate 

the need for 

additional 

static 

imaging...” 

leep-Disordered Breathing (SDB) is a group 

of disorders characterized by disturbances in 

the normal respiratory pattern during sleep. 

Those are related to increased upper airway resistance 

and include snoring; upper airway resistance 

syndrome; and obstructive sleep apnea-hypopnea 

syndrome (OSAHS). OSAHS is the most common 

disorder and characterized by snoring, repetitive 

total or partial collapse of the pharyngeal airway 

during sleep terminated by oxygen desaturation or 

EEG arousal before ventilation resumes. Airway 

obstruction is manifested by a reduction in airflow, 

termed hypopnea, or a complete cessation of airflow, 

termed apnea, despite ongoing inspiratory 

effort. Hypopnea is defined in adults as a 10-second 

event where despite continued breathing, ventilation 

during sleep is reduced by at least 50% from 

baseline. Apnea is total cessation of airflow for at 

least 10 seconds. Apnea can be obstructive or due 

to failure in control centrally. 

The early effects of repeated disrupted sleep are 

waking somnolence, impaired mental function, 

delayed reaction time and difficulty maintaining 

cular diseases including high blood pressure, depression, 

irritability, learning and memory difficulties, 

weight gain, impotence and headaches. In addition, 

there is evolving evidence that SDB may contribute to 

insulin resistance and other components of the metabolic 

syndrome. Population-based studies suggest 

that OSAHS is a relatively common disorder. In those 

aged 30 to 60 years, 24% of men and 9% of women 

are Sleep reported apnea to have is not abnormal always easily AHI indices. diagnosed as 

symptoms might not be evident, either to the 

patient or others. Factors contributing to the presence 

and severity of SDB are multifactorial and 

include reduced airway anatomy, nasal blockage, 

the presence and distribution of body fat and 

muscle tone. Being even moderately overweight is 

the most common risk factor, especially a body 

mass index or BMI (weight in kilograms divided by 

height in meters squared) greater than 28. Other 

risk factors include collar size of snoring patients 

(greater than 17 inches for men, 15 inches for 

women), physical nasal obstruction, underactive 

thyroid and excessive fat around the neck area. 

concentration. Long term effects of recurrent sleep 

arousal in association with intermittent hypoxia and 

hypercapnia have been associated with cardiovas- 

1 The 

prevalence of symptomatic OSAHS is conservatively 

estimated to be 1% to 2% in middle-aged men and 

approximately 0.5% to 1%, in middle-aged women. 2 

“CBCT has 

particular 

application in 

the diagnosis 

and assessment 

of therapy in 

OSAHS patients 

and has the 

potential 

to eliminate 

the need for 

additional 

static 

imaging...” 

Sleep apnea is not always easily diagnosed as 

symptoms might not be evident, either to the 

patient or others. Factors contributing to the presence 

and severity of SDB are multifactorial and 

include reduced airway anatomy, nasal blockage, 

the presence and distribution of body fat and 

muscle tone. Being even moderately overweight is 

the most common risk factor, especially a body 

mass index or BMI (weight in kilograms divided by 

height in meters squared) greater than 28. Other 

risk factors include collar size of snoring patients 

(greater than 17 inches for men, 15 inches for 

women), physical nasal obstruction, underactive 

thyroid and excessive fat around the neck area.

Diagnosis of OSAHS is made through a sleep study that is generally 

performed at a sleep laboratory. Various physiologic 

functions related to sleep are recorded using a polysomnogram, a 

compilation of tests including an electroencephalogram, electrooculogram, 

nasal pressure and flow, abdominal and chest 

excursions, electromyogram and pulse oximetry. The severity of 

the OSAHS is indexed using the Apnea/Hypopnea Index (AHI) 

calculated by adding the total number of apneas and hypopneas and 

dividing by the number of hours of observed sleep. Another metric 

is the Respiratory Disturbance Index (RDI) which also includes 

other respiratory disturbances such as respiratory event related 

arousals. Severity of OSAHS is generally defined using AHI or 

RDI. An AHI or RDI of 5-15 is considered mild; 16-25 moderate 

and; greater than 26 severe. A second study is usually performed 

while using a continuous positive airway pressure (CPAP) ventilation 

machine as therapy to prevent obstructive events)(Figure 1). 

Therapies of OSAHS are primarily directed at pneumatically 

splinting the airway open or secondarily adjusting the airway in 

making it less apt to collapse. CPAP is the primary and most 

effective therapy initially offered for treatment of OSAHS. 3 It is 

usually provided in association with behavioral changes such as 

avoiding alcohol, smoking and medicines that cause sleepiness; 

and altered sleep posture or nutritional and dietary counseling to 

reduce weight. Unfortunately, CPAP is a cumbersome modality 

and hence approximately 25-50% of patients with OSAHS will 

either refuse the offer of CPAP therapy, or will not tolerate it. 4 

Secondary therapy for patients suffering from OSAHS who 

cannot tolerate CPAP is directed towards physically widening the 

pharyngeal airway. This can be performed reversibly by the use of 

removable oral appliances (OA) or permanently by surgery. OAs are 

categorized by the method used to improve the patency of the 

airway space. The most common OA appliances are mandibular 

advancement devices (MAD), which protrude the mandible anteriorly 

to pull the muscles of the oropharynx forward, and tongue 

retaining devices (TRD) that aim at holding the tongue in a protrusive 

position. These devices can be “titrated” to best fit the patient 

for comfort and efficiency (Figure 2). However, OA appliances are 

therapeutic only if selected appropriately for the specific site(s) of 

upper airway obstruction, which varies between individuals. 5,6 

For patients with severe AHI and co-morbidities (e.g. significant 

bradycardia, severe hypercarbia, cor pulmonale and extreme hypersomnolence) 

on whom CPAP is not a viable option, surgery is 

usually the most appropriate alternative. Surgery options include 

upper airway soft tissue correction to enlarge the pharyngeal space 

and prevent airway collapse (e.g. removal of tonsils or adenoids, 

radiofrequency ablation of the tongue or soft palate (somnoplasty), 

uvulopalatopharyngoplasty and laser-assisted uvulopalatopharyngoplasty, 

and reduction in tongue size or movement of the mandible 

anteriorly (e.g. genioglossal advancement with hypoid myotomy, 

bimaxillary advancement, or maxillomandibular advancement). 

Procedures to improve upper airway patency are successful in certain 

subsets of patients, but some do not achieve desired relief. 7 

If secondary treatments are necessary, the site of the oropharyngeal 

obstruction must be identified such that appropriate therapy 

can be applied. Numerous supplemental tests can be performed to 

determine the site of reduction in airway caliber including 

fiberoptic nasopharyngoscopy with the Müller maneuver, sleep 

endoscopy, fluoroscopy, rhinomanometry and diagnostic imaging 

studies. The specific role of diagnostic imaging is to evaluate the 


Figure 1. Example of CPAP device with patient wearing full face 

mask in sleep laboratory facility. 

Figure 2. Example of Herbst MAD device allowing titratable 

mandibular advancement using a bilateral piston system comprised 

of rods and sleeves from the anterior (a) and posterior (b) views. 

Figure 3. Patient seated in CBCT machine (iCAT Platinum edition, 

Imaging Sciences International). For OSAHS patients scan 

technique is modified such that the chin support is removed and 

the patient is allowed to adopt habitual head position. 

) 11 

Orders: 1300 65 88 22 8 www.henryschein.com.au 

September/October 2009 Australasian Dental Practice 105


body logic 

morphology of the upper airway, determine 

the site and degree of pharyngeal 

obstruction, identify potential causative 

conditions (Table 1) and anatomic characteristics 

that may be predictive of 

therapeutic efficacy. Lateral cephalometric 

radiography (LCR) has been long 

been used in clinical practice. Numerous 

authors have reported a variety of craniofacial 

anatomical abnormalities associated 

with OSAHS on LCR including reduced 

retroglossal airway linear dimensions, a 

long, bulky soft palate, an inferiorly 

placed hyoid bone and mandibular 

deficiency. 8-13 Computed tomography and 

magnetic resonance imaging have been 

used in the research environment to provide 

three-dimensional metrics of the naso-, 

oro- and hypo-pharyngeal regions such as 

minimal cross-sectional area, minimal 

antero-posterior/lateral dimensions and 

airway volumes. The results from these 

studies indicate that the upper airway is significantly 

narrowed among patients with 

OSA compared to controls, but that the site 

of narrowing varies among OSA patients. 

Cone beam computed tomography 

(CBCT) scanners have been available for 

craniofacial imaging since 2001 in the 

United States (Figure 3). The CBCT has a 

cone- or pyramidal shaped beam originating 

from a low-energy fixed anode tube that is 

projected through the subject to an attached 

single solid-state or amorphous silicon 2D 

panel detector that rotates with the beam. In 

a single, rapid (5-20 sec) rotation, precise, 

accurate high resolution volumetric data is 

acquired. Reconstruction and subsequent 

viewing of the digital data is accomplished 

on a personal computer. Standard viewing 

layouts include the display of coronal, 

sagittal and axial data sets concurrently. A 

main advantage of using CBCT to image the 

oropharynx is the low dosage of radiation 

relative to conventional spiral computed 

tomography. Ludlow, et al reported largefield 

of view CBCT effective dose (E 2007) 

varied from 68 to 1,073µSv with most 

in the 100-200µSv range as compared to 

multi detector CT (range; 534-860µSv). 14 

Although soft tissue is not clearly delineated 

from other soft tissue on CBCT, it clearly 

shows high contrast between bone, teeth, 

empty space and soft tissue in general. It is 

ideal to show the patency of the airway 

related to the position of the hard tissue structures 

of the skull. The spatial resolution is also 

much greater than conventional CT, with a 

voxel resolution between 0.076 and 0.4 mm. 

Figure 4. Reorientation of volumetric data to adjust patient head position during scan 

to anthropomorphic standard reference planes. Lateral (a) and frontal (b) volume rendering 

show that the patient was originally scanned with the head raised and tilted towards 

the right. Comparable lateral (c) and frontal (d) volumetric rendering with 

adjusted data to position Frankfort horizontal (FH) parallel to floor and mid-sagittal 

plane perpendicular to FH. 

Table 1. Anatomic Abnormalities associated with OSAHS 

Region Structure Condition 

Nasal Cavity Turbinate Hypertrophy, polyps, mucosal 

thickening, hyper-secretion 

Septae Deviated 

Maxillofacial/Skeletal Mandible Relative hypoplasia, deficiency, cross-bite, 

mandibular tori 

Maxilla Relative hypoplasia, deficiency, cross-bite 

Hyoid Caudal displacement relative of the cervical 

spine and mandible 

Upper Airway Soft palate Excessive length, low lying position 

Tongue Macroglossia, short length, loss of 

muscle tone 

Nasopharynx Hypertrophic adenoids, fatty lumen 

Oropharynx Hypertrophic tonsils, lumen thickening, 

fat pad accumulation 

Hypopharynx Lumen thickening 

Larynx Abnormal vocal cord anatomy, paralysis 

of vocal cords 

106 12 Australasian Dental Practice September/October 2009


CBCT has particular application in the diagnosis 

and assessment of therapy in OSAHS 

patients and has the potential to eliminate the 

need for additional static imaging. The resulting 

volume of digital data can be manipulated to 

allow the clinician three-dimensional images that 

can be re-oriented in all three axes to correspond 

to anthropometric reference planes (Figure 4) and 

can be selectively contrasted, emphasized 

or reduced to visualize certain anatomical structures 

such as the craniofacial skeleton or airway 

(Figure 5). Data can exported as a DICOM (Digital 

Imaging and Communications in Medicine) 

format data set and imported into proprietary 

orthodontic image and analysis programs (e.g. 

InVivoDental by Anatomage or Dolphin 3D) 

which have specific modules capable of demonstrating 

and recording the airway and its 

surrounding structures. These programs offer 

practitioners opportunities to interact with the 

data and allow visualization of both untreated 

obstruction tendencies and potentially of changes 

in the airway by treatment modality. In this way, 

it may help identify those subsets of patients who 

may or may not benefit from a choice of treatment 

modalities. CBCT has been applied to 

describe significant differences in total airway 

volume and the antero-posterior dimension of the 

oropharyngeal airway between OSA and gendermatched 

controls, differences in airway shape 

between OSA (concave or elliptical) and non- 

OSA (concave, round, or square). 15,16 Recent 

research in the authors’ clinic applied CBCT 

imaging to patients with and without OSA to 

determine a quantifiable relationship between 

airway patency and mandibular advancement 

using OA. 17 It was determined that custom 

titrated MAD devices repositioned the mandible 

on average horizontally 4mm and vertically 8mm 

and resulted in an average oropharyngeal volume 

increase of ~2800mm 3 . It was possible to predict 

the airway volume gained, the amount of crosssectional 

area gained at the narrowest cross 

section; the cross-sectional area gained at C2; and 

the lateral linear dimension gained at this level 

from the distance the mandible is advanced. 

In collaboration with colleagues of the University 

of Louisville Multidisciplinary Sleep 

Team, a specific CBCT imaging protocol has 

been developed that has proven particularly 

useful in the assessment of soft and hard tissue 

contributors to mechanical obstruction in 

patients with OSAHS. This involves: 

a. Sequential axial and coronal images (1mm 

thickness/3mm interval). These conventional 

orthogonal images enable visualization of 

potential nasal obstructions (Figure 6) and 

anatomic anomalies, palatal and mandibular 

structures and provide an overview of the max- 

Figure 5. 3D volumetric image of the right side of an OSA patient demonstrating 

airway only (a) and with maxillofacial skeleton overlay (b). This is performed by 

selective segmentation procedures (Images created using Dolphin 3D V.11). 

Figure 6. Reference sagittal orthogonal image at 0.4mm (a) of pediatric OSAHS 

patient demonstrating of coronal scans at progressively posterior locations. Note 

the generalized mucosal thickening of the turbinates of the right nasal fossa and 

marked reduction and partial occlusion in nasal cavity space. 

Figure 7. Reference sagittal CBCT image (a) and corresponding 0.4 mm axial cross sectional 

images of the upper (b) and lower retro-palatal (c), and retroglossal (d) airway. 

) 13 


108 Australasian Dental Practice September/October 2009


body logic 

imum and minimal (Figure 7) caliber of 

the airway space. Because of the relatively 

poor contrast resolution of CBCT 

imaging, potential specific soft tissue factors 

(e.g. muscular hypertrophy, redundant 

fat pads) are unable to be visualized. 

b. Ray-sum and maximum intensity projection 

simulated panoramic, lateral 

cephalometric, postero-anterio and submentovertex 

images. Specific volumetric 

rendering of the CBCT data can be 

performed to produce conventional craniofacial 

skull images. These projections 

demonstrate global deficiencies of the maxillofacial 

skeleton in all three orthogonal 

planes that may contribute to the obstruction 

(e.g. retrognathia, maxillary cross-bite, 

mandibular asymmetry, palatal soft tissue) 

and allow visualization and measurement of 

parameters that have been reported to be 

associated with OSAHS (Figure 8). 

c. Regionally corrected temporomandibular 

joint images. Visualization of the TMJ 

articulation provides information of the 

relative stability of morphology of this 

determinant of mandibular position. 

Active degenerative joint disease either 

osteoarthritic, autoimmune or idiopathic 

in nature can reduce mandibular ramal 

length resulting in an anterior open bite 

and produce substantial inferior and posterior 

positional changes in the location of 

the associated soft tissue (Figure 9). 

d. Three dimensional analysis of upper 

airway anatomy. Concomitant segmentation 

of hard tissue maxillofacial skeleton, 

airway space and facial soft tissue surfaces 

from 3D CBCT data provides dynamic 

visualization of the interrelationship of 

these structures on airway obstruction. 

This facilitates identification and classification 

of the level of the obstruction (Table 

2) and quantitative analysis of linear, area 

and volumetric parameters (Figures 10 and 

11). Images also provide superior visualization 

of airway shape and caliber as well 

as soft tissue elements such as the 

epiglottis and soft palate. 18 

e. Comparison of pre- and post-therapy 

effects. Volumetric superimposition of CBCT 

datasets can be performed to produce 

colour-contrasted blended views of the 

mechanical and resultant airway changes 

as a result of specific therapies (Figure 12). 

In addition to the imaging protocol presented 

above, it is possible to generate 

video frame of reference “fly through” 

reconstructions (e.g. Osiris imaging Software. 

V3.1, University Hospital of 

Figure 8. Ray sum simulated lateral cephalometric images demonstrating tracing of 

soft (a) and hard tissue (b) measurements using specific orthodontic analysis software 

(Images created using Dolphin 3D V.11). 

Figure 9. Temporomandibular image protocol demonstrating ray sum reformatted 

panoramic (b), 5mm thick sagittal (a and b) and sequential 1mm cross-sectional right 

(d) and left (e) images. Note the marked osteoarthritic degenerative joint disease of the 

right TMJ articulation in this OSAHS patient contributing to reduction in mandibular 

ramal length and asymmetry of the mandible. 

Table 2. Classification of Velohypopharyneal Airway Obstruction 18 

Type Sub-Type Description 

I Retropalatal or velopharyngeal 

II Combined retropalatal and hypopharyngeal/retroglossal (base of tongue) 

IIa Predominantly retropalatal 

IIb Predominantly retroglossal 

III Isolated retroglossal or hypopharyngeal (base of tongue) 

14 



Geneva, Switzerland and OnDemand3D, 

CyberMed Inc., Seoul, Korea). While 

images produced by this technique demonstrate 

the static airway, this non-invasive 

approach serves as a potential method to 

create virtual fiberoptic nasopharyngoscopy 

visualizations (Figure 13). 

OSAHS is an important public health 

concern because of under diagnosis and 

associated cardiovascular consequences. 

As upper airway constriction is an important 

contributing factor, CBCT technology 

provides a rapid low dose 3D imaging 

modality capable of providing simultaneous 

hard and soft tissue images 

facilitating visualization of upper airway 

characteristics. This, together with clinical 

information, may provide a valuable 

assessment tool of patients with OSAHS 

and assist in treatment modality choice 

based on predictable outcomes. 

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) 15 



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