"The watershed of dental digitalization is the emergence and use of CBCT equipment.

Oral CT equipment is an X-ray imaging system specially designed for the characteristics of oral and maxillofacial regions. With the help of CT, doctors have discovered and cured a variety of oral diseases and completed previously impossible operations. It can be said that oral CT equipment is a revolutionary tool for dentistry.

On the basis of traditional spiral CT, cone-beam CT (CBCT) has been upgraded in scanning and data acquisition methods. Its principle is that the X-ray generator makes a circular DR (digital projection) around the projector with a low amount of radiation (usually the current of the bulb is about 10 mA).

Then, around the projection body for many times (180 times - 360 times, depending on the product), the digital projection, the data obtained in the intersection are recombined in the computer to obtain the 3D image.

In 1995, the dynamic flat panel detector appeared for about two years, and the world's first CBCT was born. Since then, spiral CT and CBCT have been developed separately. The projection principle of CBCT data acquisition is different from that of traditional sector scan CT, but the algorithm principle of later computer reconstruction has similarities.

With the further precision of CBCT technology and related reconstruction algorithms, the advantages of traditional fan-scan CT will gradually expand.

The emergence of CBCT equipment has changed the panorama of dental radiology in the world, making it possible to digitize oral cavity. So, what is the situation of oral CBCT market, what are the mainstream players, and what is the market pattern? The arterial network was combed in detail.

1. Development process: the first dental CBCT NewTom 9000 came out in the 1990s

At the beginning, dentists can only use the dry skull to study hard tissues. The study of soft and hard tissues is separate.

Rontgen discovered X-ray in 1895, and this technology was quickly applied to the medical field. Specifically, for dentistry, he invented dental X-ray machine and panoramic camera.

In 1931, Broadbent and Hofrath proposed a new X-ray cephalometric measurement technology, invented a head locator, which made the head position of each X-ray film completely consistent, and standardized the size of each image.

This technology can make the research objects before and after treatment comparable. It plays an important role in clarifying the anatomical basis of dental deformities, diagnosing and analyzing the types of malocclusion, and predicting the growth and development of craniofacial. It also provides scientific basis for the formulation of clinical diagnosis and treatment standards and treatment plans in the later stage.

In the 1970s, cephalometric measurement began to develop from two-dimensional plane measurement to three-dimensional space and stereo photography. In the 1990s, the first CBCT machine NewTom 9000 for oral use came out, with accurate and clear three-dimensional images of the face, enabling doctors to obtain intuitive three-dimensional images of the patient's face and body surface.

The equipment entered the European market in 1996 and the American market in 2001. In 2013, Attilio Tacconi, Piero Mozzo, Daniele Godi and Giordano Ronca won the Conical CT Invention Award at the Festival della Scienza in Italy, rewarding the inventors of revolutionary technologies that have changed the world's dental radiology panorama.

Axial image obtained by the first conical beam 3D scanning

Because of the large dose of spiral CT, the high cost of procurement, and the lack of special post-processing software for oral cavity, oral medical institutions mainly purchase CBCT, and spiral CT is only used when large public oral medical institutions have the need for maxillofacial surgery.

For example, in orthodontic surgery, using the combination of three-dimensional reconstruction image technology and the parameters and application software used in orthodontics, CBCT equipment can build a three-dimensional image of the research object, which overcomes the shortcomings of unclear display of facial soft tissue in the X-ray cephalometric system, easy distortion of orthodontic parameter positioning, and doctors' insufficient understanding of the three-dimensional space of the patient's face, and is more conducive to the formulation of treatment plans for patients and the analysis of treatment results.

It can be said that without the application of CBCT in stomatology, digital orthodontics and dental implant cannot be applied as quickly as now.

An oral medical device manufacturer told the reporter: "The emergence of CBCT represents the evolution of medical imaging from two-dimensional to three-dimensional. CBCT improves the resolution of scanning to a height that spiral CT can not reach, and even appears MicroCT. At the same time, the radiation dose of CBCT has also decreased to a new level."

2. Comparison of advantages: CBCT makes digital orthodontics and implant possible

The biggest difference between CBCT and traditional CT is that CBCT uses 3D cone-beam X-ray scanning to obtain nearly 600 different images. After reconstruction, 3D images are directly obtained. The metal artifacts of the images are relatively light, while traditional CT uses 2D fan-beam scanning to form 2D image data after reconstruction, and the artifacts are relatively heavy. CBCT is widely used in maxillofacial surgery, dental pulp, orthodontic treatment and dental implant.

Specifically, the effective dose of CBCT is low, and the exposure dose of each projection is 19.0~464.0 μ Sv, about 1~30 times the dose of curved body slice, about 1/56-1/5 of the dose of spiral CT. Because the exposure time is short, it is easy for patients to locate, and there is less patient displacement resulting in image damage. High resolution, less metal artifacts, clear images, and stronger ability to analyze fine anatomical structures are conducive to doctors' diagnosis.

In addition, for doctors, the matching software operation is relatively simple, and 3D reconstruction is fast and rich. After training, ordinary technicians can operate it. For patients, the examination cost is relatively low and easy for patients to accept.

The current hardware of CBCT can basically meet the clinical requirements. Of course, there is still much room for improvement.

An orthodontist in the industry told the reporter: "With the orthodontic software such as 3shape and ExoCad, CBCT can enable doctors to pay more attention to the thickness, height and functional reconstruction of the lingual bone plate during the orthodontic process, which is very important for the completion of high-quality orthodontic cases and long-term stability after treatment, as well as periodontal health.

In addition, orthodontists now pay special attention to the temporomandibular joint. CBCT also plays an important role in observing the shape of the condyle and the joint space. "

With the support of further development of hardware, new software functions can be realized, such as the emergence of ultra-low dose CBCT, which enables orthodontic software to obtain real tooth information of patients, as well as occlusion information based on CBCT data.

This progress enables orthodontists to obtain more accurate data, so as to provide more professional orthodontic services for patients faster and better.

In dental implantation, before the operation, the bone and bone mass of the patient's jaw should be evaluated first, and the position of important tissues such as the mandibular nerve tube and nasal sinus should be grasped, and then the feasibility of the implant operation and the parameters such as the type, size, location, path and depth of the implant should be determined accordingly.

With the help of some implant software such as Simplant, Nobel clinician and 3shape, CBCT equipment can assist in the design of implant surgery, make implant guide plates, accurately control the position, direction, length, diameter, etc. of the implant, and ensure the success of surgery and later repair. Minimally invasive implant technology has also become a hot topic recently.

In addition, sensitivity, speed and accuracy have been verified in the analysis of impacted teeth, diagnosis of periodontal disease and diagnosis of temporomandibular joint disease.

After taking the image immediately after the oral scan, the dentist combined with CBCT to design the digital implant guide plate scheme, so as to complete the preoperative planning efficiently and conveniently. Of course, CBCT equipment also has some defects, such as the lack of standardized scaling system for reconstructing tooth values and the lack of bone mineral density evaluation.

CBCT commonly used in dentistry still needs to develop in the direction of higher spatial resolution, better soft tissue resolution and lower radiation dose.

"The function of panoramic camera is too limited. Now all orthodontic patients in my dental hospital are routinely photographed with CBCT," said the above orthodontic doctor.

3. Product selection: flat panel detector is the mainstream, and the supporting software still needs to be improved.

CBCT image detector determines the imaging quality. At present, there are amorphous silicon plate, CCD with image intensifier, CMOS plate, CSI plate, and amorphous silicon plate is relatively better. The exposure range size, exposure time, image reconstruction time and voxel size parameters are different. At present, the type of flat panel detector is still the mainstream.

According to the field of vision, the size of large-field CT detector is greater than 130mm × 150mm, the size of the mid-field detector is greater than 70mm × 80mm, less than 130mm × 150mm, small field detector size less than 70mm × 80mm。

In a word, too long or too short scanning time is not good. The shorter the reconstruction time is, the better. The smaller the spatial resolution value is, the higher the definition is, but the storage and transmission are more troublesome. In addition, in terms of volume and shape, the space required for the vertical and sitting type is smaller than that for the horizontal type, and the supporting software is also important, which determines the experience to a certain extent.

Ball tube is also very important, mainly divided into pulse type and continuous exposure type. To some extent, pulse type is superior to the latter, but the latter has a perfect cooling system, which is suitable for clinics with high frequency of use.

Ball tube rotating anode is superior to fixed anode, with obvious price difference. At present, the focus of the ball tube is between 0.3mm-0.7mm in the mainstream CBCT. The smaller the focus, the higher the definition. The degree of rotation also affects the definition.

From the perspective of the needs of users, small clinics can consider digitizing curved body X-ray machines. For implant-oriented or oral medicine, small and medium-sized field CBCT is sufficient. If orthodontics and orthognathic surgery are required, the large-view CBCT will be selected, and the large-view CBCT will be installed in professional general stomatological hospitals and large Class 3A general hospitals in public hospitals.

Finally, it should be noted that CBCT is a valuable precision instrument. Good after-sales service can ensure the normal use of the machine. It must also be considered whether there is a registration certificate.

As for CBCT, the hardware is relatively mature. A senior dentist said in an interview: "There is still room for improvement in the hardware mainly in the speed, resolution, clarity and low dose of scanning a circle. There is no problem with the hard tissue. The more difficult aspect is how to see the soft tissue clearly to cooperate with the doctor's diagnosis. In addition, the supporting guide plate software and correction software are constantly iterating, and there are many areas that can be developed and improved."

As for the supporting software, the 3D post-processing software has matured and its functions fully meet the clinical needs. Although the current mainstream technology of the core image reconstruction algorithm software can basically meet the clinical requirements, it still needs to be further improved in reducing radiation dose, metal artifact removal, ultra-fast scanning, and expanding the effective field of vision.

An expert in oral digital software also told the reporter: "The open system is very easy to realize in technology, that is, using the common data format, namely Dicom and STL. Open is the trend, and now closed is that the competitive pressure of these manufacturers is not big enough, and they can earn money through consumables."

However, it is difficult to rely on the sale of consumables such as film and developer for profit because of the low price of general consumables and the gradual realization of digitalization.

The previous closed system is not competitive in the market. In order to obtain higher revenue, manufacturers also charge additional fees according to the number of scans in addition to selling equipment revenue, and even make additional money through exclusive supply of materials when connecting with 3D printing in the future.

He said that closure and openness are relative. During the development of a technology or product, it is bound to go through a cycle of closure and openness. Closure is conducive to focus and depth, and openness is conducive to application openness and popularization.

This depends on the business model selected by the manufacturer. If the equipment is sold directly, the open system can be used for one-time charging. If the service is sold or even for sharing economy, the closed system can be used for charging according to the number of scans.

For open systems, interface standards need to be established in hardware and data standards need to be established in software. To some extent, cloud and big data technology are more conducive to the establishment of open systems.

A closed system can theoretically provide more stable product quality. However, from the current market development, the advantages of closed systems are gradually losing. The advantages of open systems are lower price, better compatibility and more upgrade options.

With the development of the industry, the expansion of the industry scale and the increase of suppliers, the foreseeable future is that there will be global industry standards in industries such as home appliances and communications, which will reduce the R&D, reduce unnecessary duplication and waste in all links, improve the speed of the introduction of new technologies, reduce the production costs of new products, and avoid the waste caused by equipment incompatibility.

4. Market acceptance: training and data processing need to keep pace

Panorama machine, CT and CBCT exist in the market at the same time. What is the product acceptance? A study by Guotai Junan Securities Research Department shows that at present, the proportion of CBCT is still small, and the total of public and private ownership is less than 5%. At present, slightly better public hospitals are bound to use CBCT, and they are centralized procurement, rarely using spiral CT.

In the future, spiral CT is unlikely to be used in teaching, diagnosis and treatment, and clinical practice, because spiral CT is a large CT, requiring professional operation, and the resolution of the soft tissue of the main components in the mouth is very low, and the supporting dental diagnostic software needs to be improved. CBCT has a strong advantage in the oral market. Why is the penetration rate not high now?

First of all, not all private clinics will purchase CBCT. Small dental clinics will consider the initial investment costs. If the costs cannot be recovered within 1-3 years, the purchase intention is very low. Dentists who have purchased panoramic cameras are not willing to replace panoramic cameras with oral CBCT.

In the past, due to the high price of panoramic and CT machines, it is difficult to equip small and medium-sized clinics, and the oral cavity market is dominated by private small and medium-sized clinics, so the volume of oral CT has not increased. But now the price of domestic products has been suppressed by half or even one-third.

The panoramic camera can take two-dimensional images, but can't see clearly. Most dentists are not professional in viewing panoramic cameras. Even the most professional imaging experts can not see all the lesions through panoramic cameras.

However, CBCT 3D film can achieve accurate diagnosis and treatment, and has strong advantages. Therefore, oral CBCT is a development trend in the future, and its penetration rate will increase in the future.

In terms of price, the price of large view CBCT is between 1.5 million and 3.5 million, the price of medium view is between 600000 and 1.5 million, and the price of small view is between 400000 and 600000.

An oral clinic operator told the reporter: "CBCT is a supporting planting business. As long as planting is carried out, it must be equipped with CBCT. Developing new business will increase the profit points of clinics and hospitals, and we must accept it. It only depends on the brand, quality, cost-effectiveness and after-sales service. In addition, supporting software is also needed by the market, and it is not perfect now, or it is very expensive to do well. The software system will eventually be open, and there will be a strong platform."

In addition, digital equipment and technology are the demonstration and proof of the marketing gimmick and technical level of clinics and hospitals. Everyone is willing to invest in this aspect.

A person in charge of Borndent said: "The update cycle of CBCT depends on the technical breakthrough of the key component X-ray detector, which is about 5 years on average, and the supporting software is faster, which will be updated in about 2 years generally. Cost is one of the main reasons preventing small clinics from purchasing digital equipment and software."

The person in charge told the reporter that at present, doctors, clinics and hospitals have generally and fully accepted CBCT and supporting software. The 3D perspective and tissue density analysis function provided by CBCT make it easier and more confident for doctors to obtain diagnostic results. The first problem to be solved in the promotion is the purchase of funds, and the second is the training of software operation and imaging diagnosis and treatment technology.

The decline in costs will certainly greatly promote the demand for digital equipment and software in small clinics. At the same time, the technical promotion of digital equipment and software is also an important factor, which is as important as easy access and easy use.

A medical device manufacturer expressed his views on the CBCT industry to the reporter: "It is only more than ten years since the CBCT equipment was launched. At present, most of the updates seen are caused by the lack of vision. In the future, some brands may have product updates due to the lack of consideration of scalability in the design process. The cycle may be related to the efforts of CBCT manufacturers to promote new technologies and the supervision of regulatory authorities on some undetected problems."

The reporter learned from many interviewers that the problems generally reflected are the lack of good training and after-sales service, and how to handle the data brought by digitalization, where to send it, and who can provide digital supporting services.

5. Market space: private dental clinics may become the largest market increment

According to the research of Guotai Junan Securities Research Department, the estimated sales volume of CBCT in the whole industry was about 2000 in 2016. An unnamed investor disclosed to the reporter that the installed volume of oral CT market of various specifications in the domestic market exceeded 230

Sorting of CBCT enterprises on the market

Meiya Optoelectronics began to enter the field of oral medicine in 2009. In 2012, oral CBCT was successfully launched into the market, and Meiya Optoelectronics became the first enterprise with the development and production capacity of medical CBCT in China, filling the domestic gap in this field.

In addition to the all-digital three-in-one medium-view CBCT, Meiya Optoelectronics released the super-view CBCT product during the Shanghai CDS International Dental Exhibition in September 2014. The product uses the latest technology of super-large flat panel detector, which can present the whole skull 3D image in one scan, with an effective field of vision of 23x19cm, and has obtained the CFDA registration certification.

Meiya Optoelectronics sold 600 CBCT machines in 2016, a substantial increase of nearly three times over the same period of last year, which shows that the market is indeed booming. According to its annual report for the first half of 2017, oral X-ray CT diagnostic machines accounted for 23.82% of the total revenue, with a gross profit rate of 56.97%. The gross profit of such products is relatively high, basically maintaining between 50% and 60%.

What about the foreign market? According to the FMI Analysis data, the global dental imaging equipment market size in 2015 is estimated to be 208 million US dollars, of which 18% is CBCT, and the flat panel detector accounts for 88.3% of the dental CBCT market.

Sorting of CBCT enterprises on the market

Meiya Optoelectronics began to enter the field of oral medicine in 2009. In 2012, oral CBCT was successfully launched into the market, and Meiya Optoelectronics became the first enterprise with the development and production capacity of medical CBCT in China, filling the domestic gap in this field.

In addition to the all-digital three-in-one medium-view CBCT, Meiya Optoelectronics released the super-view CBCT product during the Shanghai CDS International Dental Exhibition in September 2014. The product uses the latest technology of super-large flat panel detector, which can present the whole skull 3D image in one scan, with an effective field of vision of 23x19cm, and has obtained the CFDA registration certification.

Meiya Optoelectronics sold 600 CBCT machines in 2016, a substantial increase of nearly three times over the same period of last year, which shows that the market is indeed booming. According to its annual report for the first half of 2017, oral X-ray CT diagnostic machines accounted for 23.82% of the total revenue, with a gross profit rate of 56.97%. The gross profit of such products is relatively high, basically maintaining between 50% and 60%.

What about the foreign market? According to the FMI Analysis data, the global dental imaging equipment market size in 2015 is estimated to be 208 million US dollars, of which 18% is CBCT, and the flat panel detector accounts for 88.3% of the dental CBCT market.

In 2015, the type of intraoral X-ray system accounted for most of the global market share, followed by extraoral X-ray system and cone-beam computed tomography. During the period from 2016 to 2024, it is estimated that the CAGR will be 7.5%, and CBCT will become the third largest product category in the global dental imaging equipment market.

According to the data of a research report of CSCI. There are more than 6000 private clinics in Taiwan with a population of 23.5 million, and 205000 in China with a population of 790 million in cities and towns, that is, at least 120000 private clinics are needed. The penetration rate is calculated by 30%, and 36000 oral CT machines are needed. The market has a large space for growth, and it will also be a ten-billion market in the future.

Compared with other departments, stomatology is the industry that is easiest to be privatized and realize remote replication. At present, there are about 80000 private dental clinics in China, which is the main growth point of CBCT.

Although CBCT enterprises have strong competition barriers, and the market pattern has changed significantly in the short term, with little expectation, the trend of oral digitization and system openness is basically irreversible, and the device manufacturers also need to change from "equipment manufacturers" to "equipment solution providers".

In addition, we are optimistic about the domestic substitution of panoramic camera and oral CT. In the context of aging and consumption upgrading in China, as well as the low prevalence of planting and orthodontics, the CBCT market will maintain rapid growth.