Combining virtual monoenergetic imaging and iterative metal artifact reduction in first-generation photon-counting computed tomography of patients with dental implants

Objectives While established for energy-integrating detector computed tomography (CT), the effect of virtual monoenergetic imaging (VMI) and iterative metal artifact reduction (iMAR) in photon-counting detector (PCD) CT lacks thorough investigation. This study evaluates VMI, iMAR, and combinations thereof in PCD-CT of patients with dental implants. Material and methods In 50 patients (25 women; mean age 62.0 ± 9.9 years), polychromatic 120 kVp imaging (T3D), VMI, T3D iMAR , and VMI iMAR were compared. VMIs were reconstructed at 40, 70, 110, 150, and 190 keV. Artifact reduction was assessed by attenuation and noise measurements in the most hyper- and hypodense artifacts, as well as in artifact-impaired soft tissue of the mouth floor. Three readers subjectively evaluated artifact extent and soft tissue interpretability. Furthermore, new artifacts through overcorrection were assessed. Results iMAR reduced hyper-/hypodense artifacts (T3D 1305.0/−1418.4 versus T3D iMAR 103.2/−46.9 HU), soft tissue impairment (106.7 versus 39.7 HU), and image noise (16.9 versus 5.2 HU) compared to non-iMAR datasets ( p ≤ 0.001). VMI iMAR ≥ 110 keV subjectively enhanced artifact reduction over T3D iMAR ( p ≤ 0.023). Without iMAR, VMI displayed no measurable artifact reduction ( p ≥ 0.186) and facilitated no significant denoising over T3D ( p ≥ 0.366). However, VMI ≥ 110 keV reduced soft tissue impairment ( p ≤ 0.009). VMI iMAR ≥ 110 keV resulted in less overcorrection than T3D iMAR ( p ≤ 0.001). Inter-reader reliability was moderate/good for hyperdense (0.707), hypodense (0.802), and soft tissue artifacts (0.804). Conclusion While VMI alone holds minimal metal artifact reduction potential, iMAR post-processing enabled substantial reduction of hyperdense and hypodense artifacts. The combination of VMI ≥ 110 keV and iMAR resulted in the least extensive metal artifacts. Clinical relevance Combining iMAR with VMI represents a potent tool for maxillofacial PCD-CT with dental implants achieving substantial artifact reduction and high image quality. Key Points • Post-processing of photon-counting CT scans with an iterative metal artifact reduction algorithm substantially reduces hyperdense and hypodense artifacts arising from dental implants. • Virtual monoenergetic images presented only minimal metal artifact reduction potential. • The combination of both provided a considerable benefit in subjective analysis compared to iterative metal artifact reduction alone.