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INTRODUCTION
Intraoral and facial photographs, dental casts, and a
routine set of two-dimensional (2D) radiographs have
been obtained for orthodontic diagnosis and treatment
a
Postgraduate Student, Department of Orthodontics, National planning for decades.1 Recent studies suggested that
Engineering Laboratory for Digital and Material Technology of lateral cephalometric radiographs were dispensable for
Stomatology, Beijing Key Laboratory of Digital Stomatology,
Peking University School and Hospital of Stomatology, Beijing, most orthodontics treatment decisions.2 Noninvasive
China. imaging systems including laser scanners,3 stereo-
b
Professor, Department of Orthodontics, National Engineer- photogrammetry,4 and structured light imaging sys-
ing Laboratory for Digital and Material Technology of Stomatol- tems5 were developed for facial measurement. Several
ogy, Beijing Key Laboratory of Digital Stomatology, Peking
University School and Hospital of Stomatology, Beijing, China. studies have attempted to integrate digital dental
Corresponding author: Dr Yan Gu, Department of Orthodon- models into three-dimensional (3D) facial images to
tics, Peking University School and Hospital of Stomatology, No. simulate the anatomic dentofacial structure.6–8 Man-
22 Zhongguancun Avenue South, Haidian District, Beijing, osudprasit et al.9 evaluated the agreement between
100081, China
(e-mail: guyan96@126.com)
nonradiographic 3D dentofacial images and standard
orthodontic records for orthodontic diagnosis and
Accepted: November 2019. Submitted: July 2019.
Published Online: January 20, 2019 treatment planning. They found most diagnostic and
Ó 2020 by The EH Angle Education and Research Foundation, treatment decisions reached fair agreement between
Inc. the two records. Masoud et al.10 established male and
female reference values of 3D dentofacial photogram- age: 24.5 6 9.3 years) ready for pre-orthodontic
metry for orthodontic diagnosis. Castillo et al. 11 examinations in Peking University School and Hospital
investigated the correlation between nonradiographic of Stomatology were enrolled in the study from January
3D photogrammetry measurements and corresponding 2019 to March 2019. Inclusion criteria included: (1)
traditional cephalometric measurements, suggesting required CBCT examinations, (2) complete permanent
that 3D photography was a significant predictor of the dentition, and (3) no history of orthodontic treatment.
cephalometric measurements. Since some countries Subjects with crown restorations and history of
have already passed legislation to prohibit the use of maxillofacial trauma or maxillofacial surgery were
radiographs after orthodontic treatment,12 nonradio- excluded. A written informed consent was obtained
graphic dentofacial photography might serve as a from each participant.
suitable substitution.
Previous validation studies were limited to anterior Image Acquisition
teeth or the first premolar.6,7 However, some vital
anthropometric parameters of 3D dentofacial images, 3D facial photographs were acquired with the 3D
including molar position and cant of the occlusal plane, optical FaceSCAN3D system (3D-Shape, Erlangen,
have not been validated.13 In addition, validation Germany).5 Patients were instructed to sit in a natural
methods of previous studies were limited to root mean head position with eyes closed. Two facial images
square (RMS)6 or 2D linear measurements.7 3D were obtained: one at rest with teeth in occlusion
validation studies of dentofacial photography are (Figure 1A), and the other with exposure of anterior
generally unavailable. The aim of the present study teeth using cheek retractors (Figure 1B).6 All 3D facial
was to evaluate 3D accuracy and reliability of the photographs were filmed by a postgraduate student
nonradiographic dentofacial image compared with (ZX.X) (Figure 1C).
cone-beam computed tomography (CBCT) based CBCT scans (i-CAT System, Imaging Sciences
standard references. International, Hatfield, PA, USA) were taken under
the following conditions: 120 kV; 5 mA; voxel size, 0.3
MATERIALS AND METHODS mm; and exposure time 3,708 ms. Patients were asked
This research was approved by the Institutional to sit in the same posture as in the 3D facial filming
Review Board of Peking University School and process (Figure 1D). CBCT scans were processed in
Hospital of Stomatology (PKUSSIRB-201839148). Materialise Mimics software (Materialise NV, Leuven,
Twenty healthy subjects (six males, 14 females; mean Belgium, version 17.0); skeletal and facial soft tissues
were segmented and exported as STL files (Figure canine to canine in most cases. Then, global registra-
1E). tion was performed. Step 2: the registration reference
Plaster casts were digitized with a 3D laser scanner areas were selected on the 3D facial image (at rest),
(R900, 3Shape, Copenhagen, Denmark). Each scan including the forehead, nasal root and zygoma
was exported as STL files and analyzed with Geo- regions.15 After global registration, the facial image
magic Studio software (ver. 2014; Geomagic Interna- (cheek retractor) was removed and a 3D dentofacial
tional, Morrisville, NC, USA). Five landmarks image was constructed (Figure 2F).
(mesioincisal edge of tooth 11, cusp tip of teeth 13
and 23, mesiobuccal cusp of teeth 16 and 26) were Construction of CBCT-Based Dentofacial Images
assigned to each dental model according to a previous as the Reference Standard
publication (Figure 1F).14
To eliminate the error of landmark identification, the
identical digital dental model (with landmarks) was
Construction of 3D Facial Image-Based Dentofacial
fused into the CBCT image (Figure 3, Step 3). The
Images
registration method and its accuracy were introduced
3D facial images and digital dental models were in previous studies.16,17 The gingival area and inter-
imported into Geomagic software. Two steps were proximal contact region were removed from the digital
necessary to integrate the dental model into the 3D dental model. After global registration, the skeletal
facial image (Figure 2).7 Step 1: to improve registration portion was removed. The CBCT-based image was
accuracy, only the dental crown and attached gingiva integrated into the 3D dentofacial image for unification
region on the dental model were isolated. The into the same coordinate system (Figure 3, Step 4).
registration reference area was selected on the facial The facial soft tissue surface was selected as the
image (cheek retractor). Because the canine is at the registration reference area on the 3D facial image,
corner of the dental arch, posterior teeth were blocked excluding the periorbital, nasolabial, and submandibu-
partially during filming, where the image of the teeth lar regions.15
became inaccurate for registration. Therefore, regis- Root mean square (RMS) between registration
tration reference areas could be selected at least from reference surfaces are presented in color-coded maps
(Figure 4). The RMS value was calculated with the intra- and interoperator reliability of the dentofacial
following equation: images and CBCT reference standards. Paired t-tests
rffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi between the dentofacial images and CBCT-based
1 2 reference standards were performed to evaluate the
RMS ¼ ðx þ x22 þ þ xn2 Þ
n 1 accuracy of the integration method. Analysis of
variance and Kruskal-Wallis analysis were performed
Construction and Unification of 3D Coordinate to assess the variance of method accuracy in different
System dimensions. Statistical significance were set at P ,
.05. Errors within 2 mm or 28 were considered as
A 3D coordinate system was generated with the clinically acceptable.
midpoint of the bilateral tragion (T) as the origin (0,0,0),
the line through bilateral tragion from right to left as the RESULTS
x-axis, and soft tissue Frankfort horizontal (FH) plane
as the x-z plane (Figure 4E). Soft tissue FH plane was Each registration step is shown separately in
introduced in a previous study.18 In this coordinate different color maps (Figure 4). Registration error of
system, positional differences between two sets of each step is presented in RMS values (Table 1). In four
dentofacial models in six dimensions (Figure 4E), three registration steps, mean RMS values between super-
translational directions (x, y, and z), and three imposition surfaces were ,0.36 mm, which were in
rotational orientations (pitch, yaw, roll) were measured accordance with previous research.6 Mean RMS error
between the integration method and reference stan-
through 3D coordinate values of the five dental
dard was 0.37 mm.
landmarks.
ICCs of CBCT reference standards for intra- and
Two postgraduate students (ZX.X and ZJ.L) per-
interobserver reliabilities are shown in Table 2, which
formed the registration procedures independently. The
were close to 1.000. Absolute mean error between two
registration process was repeated in a two-week
repeated reference standards were within 0.07 mm in
interval by ZX.X.
the five dental landmarks, indicating the CBCT
reference standard to be precise and reliable.
Statistical Analysis
The reliability and accuracy of the integration method
Statistical tests were performed with SPSS 21.0 are shown in Table 3. The results demonstrated a
(IBM Corporation, Armonk, NY, USA). Intraclass moderate to excellent method reliability, with ICC .
correlation coefficients (ICCs) were used to evaluate 0.998 in translation, ICC (intra-observer) . 0.905, and
ICC (interobserver) . 0.734 in rotation. In the which was larger than that of the corresponding RMS
dimension of translation, no significant difference was value with statistical significance (P , .05). In the
observed between the method and reference standard dimension of rotation, mean deviation of dentition
(P . .05). For full dentition in translation, mean rotation in pitch, yaw, and roll orientation were within
absolute deviations were within 0.42 mm in three 0.92 degree, which was clinically acceptable with no
directions, which was considered as clinically accept- significant difference compared with the CBCT refer-
ence standard (P . .05).
able. Mean absolute total error between the integration
The results of the variation analysis for accuracy of
method and the reference standard was 0.64 mm,
the method in different dimensions are shown in Figure
5. There was a significant difference between anterior
Table 1. Root Mean Square (RMS) Values Between Two Matched
Surfaces After Registration Procedurea and posterior teeth for mean absolute total errors of the
method in translation (P , .05), with the molar group
Registration Procedure RMS Value (mm)
greater than that of the incisor group and the premolar
Registration of digital dental model into 0.36 6 0.05 [0.28, 0.45]
group (Figure 5A). For translational errors of the full
3D facial image (cheek retractor)
Registration of 3D facial image (at rest) 0.30 6 0.04 [0.23, 0.41] dentition in three directions, mean absolute errors in
onto 3D facial image (cheek retractor) the x-direction were significantly greater than the other
Registration of laser-scanned dental 0.21 6 0.03 [0.17, 0.26] two directions (P , .05) (Figure 5B). For rotational
model into CBCT image errors in the full dentition, deviation in pitch orientation
Registration of CBCT image onto 3D 0.23 6 0.06 [0.17, 0.38]
facial image (at rest)
was significantly greater than that in yaw orientation (P
Difference between integration method 0.37 6 0.09 [0.19, 0.57] , .05) (Figure 5C).
and reference standard (CT0-T0)
a
RMS values are presented as mean 6 standard deviation DISCUSSION
[range]. CT0, reference standard images constructed by observer 1
(ZX.X) at T0; T0, 3D dentofacial images constructed by observer 1 Since nonradiographic dentofacial images have a
(ZX.X) at T0. potential use as 3D records for orthodontic diagnosis
and treatment planning, it is necessary to validate their standard and the tested method. The RMS values
accuracy and reliability in three dimensions. Rangel et were significantly smaller than the actual three-
Table 3. Accuracy and Reproducibility of the Integration Method in Translation and Rotationa
Paired-sample t-test ICC [95% CI]
Abs Mean Error (CT0–T0)
Translation (mm) (Mean 6 SD) Mean Error [95% CI] P Intra-observer (T0–T1) Interobserver (T0–T2)
I Total 0.63 6 0.22 0.15 [0.36, 0.05] .137 1.000 [1.000, 1.000] 1.000 [1.000, 1.000]
x 0.26 6 0.17 0.04 [0.11, 0.18] .622 0.999 [0.997, 1.000] 0.998 [0.996, 0.999]
y 0.22 6 0.22 0.00 [0.15, 0.14] .970 0.999 [0.998, 1.000] 1.000 [0.999, 1.000]
z 0.44 6 0.24 0.17 [0.40, 0.06] .143 1.000 [1.000, 1.000] 1.000 [1.000, 1.000]
PMR Total 0.68 6 0.20 0.22 [0.46, 0.02] .065 1.000 [1.000, 1.000] 1.000 [1.000, 1.000]
x 0.25 6 0.17 0.05 [0.10, 0.19] .487 0.999 [0.998, 1.000] 0.999 [0.998, 1.000]
y 0.31 6 0.22 0.08 [0.10, 0.26] .346 0.999 [0.997, 1.000] 0.999 [0.996, 0.999]
z 0.44 6 0.26 0.20 [0.43, 0.03] .085 1.000 [1.000, 1.000] 1.000 [1.000, 1.000]
PML Total 0.65 6 0.21 0.14 [0.34, 0.07] .179 1.000 [1.000, 1.000] 1.000 [1.000, 1.000]
x 0.27 6 0.17 0.05 [0.09, 0.20] .456 0.999 [0.999, 1.000] 0.999 [0.998, 1.000]
y 0.33 6 0.17 0.07 [0.10, 0.25] .398 0.999 [0.997, 1.000] 0.999 [0.998, 1.000]
z 0.41 6 0.26 0.13 [0.36, 0.09] .232 1.000 [1.000, 1.000] 1.000 [1.000, 1.000]
MR Total 0.86 6 0.29 0.28 [0.58, 0.01] .061 1.000 [0.999, 1.000] 1.000 [0.999, 1.000]
x 0.27 6 0.18 0.08 [0.07, 0.23] .274 0.999 [0.997, 1.000] 0.999 [0.997, 1.000]
y 0.55 6 0.39 0.19 [0.12, 0.49] .220 0.998 [0.995, 0.999] 0.998 [0.994, 0.999]
z 0.43 6 0.29 0.19 [0.42, 0.04] .096 1.000 [1.000, 1.000] 1.000 [1.000, 1.000]
ML Total 0.72 6 0.24 0.14 [0.37, 0.09] .226 1.000 [1.000, 1.000] 1.000 [1.000, 1.000]
x 0.27 6 0.18 0.09 [0.06, 0.24] .237 0.999 [0.998, 1.000] 0.999 [0.998, 1.000]
y 0.43 6 0.27 0.17 [0.05, 0.40] .126 0.998 [0.995, 0.999] 0.998 [0.994, 0.999]
z 0.40 6 0.25 0.10 [0.32, 0.12] .340 1.000 [1.000, 1.000] 1.000 [1.000, 1.000]
FD Total 0.64 6 0.17 0.19 [0.42, 0.04] .097 1.000 [1.000, 1.000] 1.000 [1.000, 1.000]
x 0.26 6 0.17 0.06 [0.08, 0.21] .383 0.999 [0.997, 0.999] 0.999 [0.997, 0.999]
y 0.28 6 0.19 0.10 [0.05, 0.25] .172 0.999 [0.998, 1.000] 0.999 [0.998, 1.000]
z 0.42 6 0.24 0.16 [0.38, 0.06] .146 1.000 [1.000, 1.000] 1.000 [1.000, 1.000]
RMS vs total translation 0.27 [0.21, 0.32] .001*
Rotation (8)
FD Pitch 0.92 6 0.70 0.35 [0.10, 0.82] .185 0.961 [0.905, 0.984] 0.920 [0.810, 0.968]
Yaw 0.25 6 0.23 0.09 [0.23, 0.05] .235 0.905 [0.779, 0.961] 0.734 [0.441, 0.885]
Roll 0.53 6 0.41 0.02 [0.31, 0.31] .915 0.928 [0.830, 0.971] 0.870 [0.702, 0.947]
* P , .05, according to paired-sample t-test between RMS and mean absolute total tooth deviation for accuracy evaluation.
FD indicates full dentition; CT0, reference standard images constructed by observer 1 (ZX.X) at T0; T0 and T1, 3D dentofacial images
a
constructed by observer 1 (ZX.X) at T0 and T1. T2, 3D dentofacial images constructed by observer 2 (ZJ.L).
integration method by comparing seven linear mea- absolute error was significantly greater in the molar
surements between virtual dentofacial reproduction group compared with the incisor and premolar group
and in direct measurement. Using manual anthropo- (Figure 5A, P , .05). For the full dentition, translational
metric measurements as the reference standard, the error in the z-direction was significantly greater than
majority of systematic errors probably were due to the other two directions (Figure 5B, P , .05). However,
landmark identification. Relevant research concluded the accuracy of the method was within 0.5 mm in all
that the reproducibility of either measurement through three directions, which was considered clinically
manual anthropometry or that on 3D photography was acceptable (Table 3). Bechtold et al.14 integrated the
unsatisfactory due to distortion of soft tissues and dentofacial images in a 10-step method assisted with a
illegibility of anatomical structures.19,20 In this study, in transfer device. Using the same FaceSCAN3D system
order to reduce errors in landmark identification, a as in the current study, they reported greater integra-
CBCT-based dentofacial image was chosen as refer- tion errors in both the vertical and sagittal dimensions.
ence standard.21 Five landmarks were digitized on the Therefore, it was hypothesized that the two-step
original digital dental model before the registration method in the present study could achieve higher
procedure. Subsequently, the original dental model precision without using an intricate transfer device.
was duplicated to the reference standard to avoid error
Additionally, rotational deviation in the pitch orientation
from landmark identification. Previous studies illustrat-
was significantly greater than that in the yaw orienta-
ed the accuracy of registration between the CBCT and
tion (Figure 5C, P , .05). Nevertheless, rotational
digital dental model,16 as well as that between the
errors in all three orientations were marginal, with
CBCT and 3D facial image.15 In this study, the mean
errors of tipping all , 18 (Table 3). In summary, the
absolute differences between repeated reference
accuracy of the method in translational and rotational
standard models were within 0.07 6 0.05 mm and
ICC values were close to 1.000 (Table 2), indicating orientations was clinically acceptable.
that the CBCT-based reference standard was accurate The current study had several limitations. According
and reliable. to Rosati et al.7 and Bechtold et al.,14 they conducted
Rangel et al.6 conducted measurements in the similar studies with a sample size of 11 and 19,
anterior tooth region. Rosati et al.7 extended measure- separately. In the current study, the sample size of 20
ment to the first premolars. With the lack of evaluation participants was acceptable; however, the predeter-
of the posterior part of the dentition, they were unable mined sample size requirement was not achieved. In
to measure the position of the molars and cant of the addition, although registrations were repeated by two
occlusal plane. In this study, measurements were operators, all facial scans were filmed by one operator
extended to the first molars. For both the five dental (ZX.X). Adding operators for repeated filming would
landmarks and the full dentition, there were no enhance the evaluation of the whole reproduction
significant differences between the reference standard procedure in a more comprehensive manner. Addition-
and integration method (Table 3, P . .05). In addition, ally, the lower dentition was not evaluated in the
the accuracy of the integration method between current study. With the virtual occlusal record,22 the
anterior and posterior teeth was compared. Total mean lower dentition could be transferred to the dentofacial
image, and adding this additional step should be tested 9. Manosudprasit A, Haghi A, Allareddy V, Masoud MI.
in a future study. Diagnosis and treatment planning of orthodontic patients
with 3-dimensional dentofacial records. Am J Orthod
Dentofacial Orthop. 2017;151:1083–1091.
CONCLUSIONS
10. Masoud MI, Bansal N, C. Castillo J, et al. 3D dentofacial
The 3D dentofacial image integrated with the two- photogrammetry reference values: a novel approach to
step method used is precise and acceptable for orthodontic diagnosis. Eur J Orthod. 2017;39:215–225.
clinical diagnostics and scientific purposes. 11. Castillo JC, Gianneschi G, Azer D, et al. The relationship
The integration errors were greater in the molar between 3D dentofacial photogrammetry measurements
and traditional cephalometric measurements. Angle Orthod.
region, in the z-orientation for translation, and in the
2019;89:275–283.
pitch orientation for rotation. 12. Turpin DL. British Orthodontic Society revises guidelines for