Head Tilt as a Technique to Reduce Contralateral Arch Artifacts in Small Field of View Cone Beam Computed Tomography Imaging

Background/Objectives: Cone beam computed tomography (CBCT) is vital in endodontics but suffers from beam-hardening artifacts caused by metallic restorations, which can obscure diagnostic details. This study evaluated a novel patient positioning protocol—a controlled head tilt—designed to mitigate these artifacts by moving contralateral metallic structures outside the primary X-ray path in small field of view (FoV) CBCTs. Methods: Using a skull phantom with metallic restorations CBCT scans were acquired in three positions: standard alignment, a 12° tilt toward the region of interest (ROI), and a 12° tilt to the opposite side. Fifty experienced dentists, blinded to the protocol, subjectively compared image quality and artifact severity between the tilted and reference images. Results: The tilt away from the ROI was rated as providing better image quality significantly more often than the tilt towards the side of the ROI (442 of 585 non-tied comparisons; p < 0.001). A complementary rater-clustered GEE analysis adjusted for slide confirmed higher odds of “better” ratings under head tilt away from the ROI for image quality (OR = 4.16, 95% CI 3.12–5.56) and artefacts (OR = 2.87, 95% CI 1.93–4.26). An individual head tilt significantly improves subjective small-FoV CBCT image quality, most evidently in the longitudinal plane, by reducing artifact interference from contralateral metals, and should be considered a practical strategy for clinical use, and may serve as a practical chairside strategy, pending clinical validation.