Segmentation of Trabecular Jaw Bone on Cone

Beam CT Datasets
Olivia Nackaerts, MSc, PhD;* Maarten Depypere, MSc, PhD;† Guozhi Zhang, MSc, PhD;‡
Bart Vandenberghe, DDS, MSc, PhD;§ Frederik Maes, MSc, PhD;¶ Reinhilde Jacobs, DDS, MSc, PhD;**
SEDENTEXCT Consortium

ABSTRACT
Background: The term bone quality is often used in a dentomaxillofacial context, for example in implant planning, as bone
density and bone structure have been linked to primary implant success.
Purpose: This research aimed to investigate the performance of adaptive thresholding of trabecular bone in cone beam CT
(CBCT) images. The segmentation quality was assessed for different imaging devices and upper and lower jaws.
Materials and Methods: Four jaws were scanned with eight CBCT scanners and one micro-CT device. Images of the jaws
were spatially aligned with the micro-CT images. Two volumes of interest for each jaw were manually delineated. Trabecular
bone in the volumes of interest in the micro-CT images was segmented so that the micro-CT images could serve as
high-resolution ground truth images. The volumes of interest in the CBCT images were segmented using both global and
adaptive thresholding.
Results: Segmentation was significantly better for the lower jaw than for the upper jaw. Differences in performance between
the scanners were significant for both jaws. Adaptive thresholding performed significantly better in segmenting the bone
structure out of CBCT images.
Conclusions: When assessing jaw bone structure, the observer should always choose adaptive thresholding. It remains a
challenge to identify the optimal threshold selection for the structural assessment of jaw bone.
KEY WORDS: bone density, CBCT imaging, micro-CT

INTRODUCTION application is bone quality assessment prior to implant

The term bone quality is often used in a dento-
maxillofacial context in the clinical evaluation of disease
processes affecting the jawbone. The most frequent
*Postdoctoral fellow, OMFS-IMPATH Research Group, Department
of Imaging & Pathology, KU Leuven, Leuven, Belgium; †postdoctoral
fellow, Medical Image Computing, Center for Processing Speech and
Images, Department of Electrical Engineering, KU Leuven, Leuven,
Belgium; ‡postdoctoral fellow, Leuven University Centre for Medical
Physics in Radiology, University Hospitals Leuven, Leuven, Belgium;
§
postdoctoral fellow, Department of Oral Health Sciences, KU
Leuven, Leuven, Belgium; ¶senior professor, Medical Image Comput-
ing, Center for Processing Speech and Images, Department of Elec-
trical Engineering & iMinds, KU Leuven, Leuven, Belgium; **senior
professor, OMFS-IMPATH Research Group, Department of Imaging
& Pathology, KU Leuven, Leuven, Belgium
Corresponding Author: Prof. Reinhilde Jacobs, OMFS-IMPATH
Research Group, Department of Imaging & Pathology, KU Leuven,
Kapucijnenvoer 7, Leuven 3000, Belgium; e-mail: reinhilde.jacobs
@med.kuleuven.be
© 2014 Wiley Periodicals, Inc.
DOI 10.1111/cid.12217
treatment, as bone density and bone structure have
been linked to primary implant success.1,2 Nevertheless,
the definition of jaw bone quality remains a matter of
debate.3 Bone quality can be assessed through X-ray-
based radiographic imaging, either by subjective evalu-
ation with or without reference images or by objective
quantification of jaw bone. Objective parameters of
bone quality typically relate to bone density as deduced
from the X-ray attenuation (gray values or Hounsfield
units) or to an image-based description of the bone
structure. The structure of trabecular jaw bone is indeed
of relevance, as it can provide information on bone
metabolism and biomechanical properties. Some well-
known parameters for describing the trabecular jaw
bone structure or morphology are bone volume per-
centage (bone volume/total volume, BV/TV), trabecular
thickness, trabecular number, and trabecular separation.
The reliable evaluation of these and other morpholo-
gical parameters from radiographic images strongly

1
2 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2014

depends on the segmentation of the trabecular bone in
the images. In turn, segmentation performance depends
on a range of factors, including hardware, patient posi-
tioning and imaging stability, reconstruction software,
postprocessing algorithms, and others.
For implant placement planning, clinicians often
opt for cone beam CT (CBCT) imaging.4,5 In previous
research, it has been shown that the intensity values of
CBCT images are not as uniform or reproducible as
those of multislice CT images,6,7 making mere densito-
metric analysis inappropriate for assessment of bone
quality with CBCT. When using segmentation-derived
morphometric measures, it is important that the post-
processing of CBCT images be adapted to this in-
consistency in intensity values. Adaptive thresholding
algorithms that allow the segmentation threshold to
vary in every pixel of the image can be expected to cope
reasonably well with the nonuniformity of intensity
values in CBCT images.8,9 A thorough evaluation of
global and adaptive thresholding of CBCT images is
therefore of interest. Both thresholding methods are
simple and fast, but they require manual selection of
appropriate threshold parameters. Comparing segmen-
tation methods that rely on user input can be delicate,
as it cannot be guaranteed that the user will select
optimal thresholds in practice. Moreover, different
CBCT devices or acquisition parameters may require
different threshold selections for optimal performance.
In fact, the entire imaging chain, including scanned
sample, CBCT device, and segmentation method,
should be evaluated, irrespective of the user input.
Receiver operating characteristic (ROC) curves
measure performance on classification tasks, provided
that the ground truth is known. While such curves are
often used in the medical imaging context to measure
the performance of a radiologist in detecting and clas-
sifying image patterns of disease, they can also serve as a
useful evaluation of image segmentation performance
through analysis of pixel classification accuracy. For
segmentation algorithms that require user input, every
possible parameter value generates a different point on
the ROC curve. When an algorithm is evaluated by its
ROC characteristics, all possible user-selected inputs are
considered.10 ROC curves can also be used to compare
the final segmentation accuracy of images obtained
by various imaging devices or the accuracy obtained
for different bone samples independently of the user-
selected parameters.
This research aims to investigate the performance
of adaptive thresholding of trabecular bone in images
of human jawbones acquired by CBCT. To account for
the varying user-selected thresholds in the segmentation
algorithms, ROC curves are used for evaluating the per-
formance of global and adaptive segmentation methods.
The ROC approach additionally enables assessment of
segmentation qualities for different imaging devices
and for upper and lower jaws. The impact of different
approaches for threshold selection on morphometric
indices is also investigated.
MATERIALS AND METHODS
This study received ethical approval from the medical
ethics committee of the University Hospitals Leuven
(number B32220083749). Table 1 shows an overview of
the steps that were followed in order to assess the per-
formance of adaptive thresholding of trabecular bone in
images of human jawbones acquired by CBCT. In the
paragraphs below, each step will be further clarified.

TABLE 1 Consecutive Steps in Assessing Segmentation Quality

Image analysis: Image analysis:
Scanning Image processing bone morphometry segmentation quality Statistical analysis

4 jaws Scan registration Percentage bone volume ROC curves One-way ANOVA:
8 CBCT scanners Scan normalisation Trabecular thickness Global thresholding versus scanner comparison
1 micro-CT Volume of interest (VOI) Trabecular number adaptive thresholding Paired t-test: thresholding
scanner selection Trabecular separation Manual thresholding versus method comparison,
Segmentation of trabecular thresholding based on upper versus lower jaw
bone, micro-CT sample properties versus
(ground truth) thresholding based on
Segmentation of trabecular optimal overlap
bone, CBCT
 Segmentation of Jaw Bone on CBCT Datasets 3

Imaging To facilitate comparison of the image datasets,

Four formalin-fixed human jaws, two upper and two
lower, including soft tissues, were scanned with eight
different CBCT devices at standard clinical settings
(Table 2) and with a micro-CT device (Skyscan 1173,
Skyscan, Kontich, Belgium; Table 2). The instructions
for patient positioning were followed for all CBCT
devices when the samples were placed. In the micro-CT
device, samples were firmly attached to the rotating
pin with polystyrene blocks and tape and were wrapped
in a humid paper towel in order to avoid dehydration
and subsequent movement of the jaws during the long
scanning time.
The CBCT devices tested were the following: Galileos
(Sirona Dental Systems, New York, NY, USA), i-CAT
(Imaging Sciences International, Hatfield, PA, USA),
Illuma (3M, St. Paul, MN, USA), Newtom (QR, Verona,
Italy), Picasso Trio (E-WOO, Yongin, Korea), Promax 3D
(Planmeca, Helsinki, Finland), 3D Scanora (Soredex,
Tuusula, Finland), and Skyview (MyRay, Imola, Italy).
For reporting the results, we have used codes, as the aim
was to focus on the postprocessing phase rather than the
absolute differences between the scanners.
Image Processing
After reconstruction of the images using vendor-
specific reconstruction software and parameter sett-
ings, further processing of the images was needed to
segment the bony structures of interest, that is, the
jawbone. This segmentation step can be performed
using commonly used image analysis tools such as
CT-Analyser (Skyscan).
all CBCT images were first spatially aligned to the
micro-CT scans by image registration using maximiza-
tion of mutual information,11 which is fully automated
and well suited for multimodal registration. Following
registration, the CBCT images of all scanners for each
sample were resampled by trilinear interpolation to an
identical voxel resolution of 0.2 × 0.2 × 0.2 mm, which
is assumed to be sufficient for comparative quality
evaluation. The intensity ranges of the images were sub-
sequently globally normalised by linear rescaling, such
that the average intensity within two selected regions in
soft tissue and cortical bone was identical in all datasets.
Next, in CT-Analyser, two volumes of interest (VOI)
for each jaw were manually delineated on the micro-CT
images. These volumes were selected to contain trabecu-
lar bone only and in a continuous way, thus avoiding
data distortion due to cortical bone areas in the VOI.
Due to the processing (i.e., registration and resampling
of all images), these regions were identical for all eight
CBCT scans.
Trabecular bone in the volumes of interest in
the micro-CT images was segmented using adaptive
thresholding. The threshold was visually determined by
an examiner. Prior to this manual process, the examiner
segmented four different but comparable VOIs in
micro-CT images of human jaw bone samples in con-
sensus with two researchers who regularly use bone
segmentation in their work. The research setup thus
provided a thorough training session for the examiner.
The resulting segmentations served as high-resolution
ground truth images. The volumes of interest in the
CBCT images were segmented using both global and

TABLE 2 CBCT Devices and Imaging Parameters

Field of view Voltage Current Scan Voxel size
Device Code (cm × cm) (kV) (mA) time (s) (mm)

Skyscan 1173 (micro-CT) — — — — — 0.04

Promax 3D A 8×8 84 14 18 0.16
Galileos Comfort B 15 × 15 85 7 4 0.3
Scanora 3D C 10 × 7.5 85 7 15 0.13
Newtom VGi D 12 × 8 110 4 18 0.3
Picasso Trio E 12 × 7 85 4 15 0.2
SkyView F 17 × 17 90 6.5 15 0.16
Illuma Elite G 14 × 21 120 3.8 30 0.2
i-CAT I 16 × 13 120 5 14.7 0.2
Next Generation
4 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2014
adaptive thresholding. In global thresholding, one single
intensity threshold value was selected to classify all
voxels as either background or bone. This method is
typically applied in CBCT data, as bone is bright in these
image sets. In adaptive thresholding, the average inten-
sity within a sphere around each voxel was calculated
and used as local threshold for that voxel. For the current
analysis, the radius of the sphere was kept constant at
3 voxels (i.e., 0.6 mm) based on an estimate of the tra-
becular thickness derived from micro-CT morphologi-
cal analysis. This approach implicitly assumes that each
sphere contains bone as well as soft tissue and defines
the threshold as the average of those two tissues. Adap-
tive thresholding enables the selection of a range of
intensity values outside of which voxels are excluded
from local thresholding. This range provides a correc-
tion for regions that contain no bone or only bone.
Through selection of a lower threshold, a minimum
average intensity is defined, under which none of the
voxels within the sphere are considered bone; through
selection of an upper threshold, a maximum average
intensity is defined, above which none of the pixels are
considered soft tissue. For the current analysis, no upper
threshold was selected, as no cortical bone was involved
in the analysis and therefore we did not expect to find
spheres with only bone. As a result, both segmentation
methods, global and adaptive, had a single parameter
that needed to be set manually.
Image Analysis: Bone Morphometry
Standard morphometric parameters were calculated
with CT-Analyser, including BV/TV, trabecular thick-
ness, trabecular number, and trabecular separation. For
precise definitions of these quantities and their inter-
pretation, please refer to Parfitt and colleagues.12
Image Analysis: Segmentation Quality
ROC Curves. To incorporate all the possible choices of
the threshold values, a ROC curve can be generated for
each combination of VOI and segmentation method.
Given the ground truth, every voxel within the VOI in
the segmented image can be categorised in one of four
possible classes. If the voxel is bone and it is segmented
as bone, it is classified as true positive; if it is segmented
as background it is classified as false negative. If the voxel
is background in the ground truth and segmented as
background, it is classified as true negative; if it is seg-
mented as bone it is classified as false positive. The false
positive rate (FPR) is then defined as the ratio of false
positives to the amount of background voxels in the
ground truth, while the true positive rate (TPR) is given
by the ratio of true positives to the amount of bone
voxels in the ground truth.
A point on the ROC curve plots the TPR versus the
FPR in the VOI of a segmented image. Figure 1 illus-
trates how global segmentations of the same VOI in the
same image with five different thresholds can result in a
ROC curve. The segmentation at the lower left has a
global threshold value higher than the highest intensity
in the image, resulting in no bone in the segmentation.
As no voxel is assigned to bone, there are no positives,
and both TPR and FPR are 0. Upon lowering of the
threshold, some voxels are segmented as bone, some
correctly and some incorrectly, leading to a specific com-
bination of TPR and FPR. The computation of a ROC
point for each threshold value results in a ROC curve. To
obtain an average ROC curve, such as the average of
ROC curves obtained for different images acquired with
the same CBCT device, these curves are averaged by
threshold averaging, that is, averaging the points on the
curve based on the thresholds that created the points.10
In general, a ROC curve that lies more northwest-
erly in a ROC graph provides higher accuracy, with
a high TPR and a low FPR. This feature can be
characterised by the area under the curve (AUC), which
will be larger for curves lying more northwesterly. Note
that for the adaptive thresholding scheme, not all voxels
can be segmented as bone, resulting in a curve that does
not reach the coordinate (1,1). Furthermore, the most
extreme threshold values are very unlikely to be chosen
by a user and are not of interest for our evaluation.
Therefore, we computed the partial area under the curve
(pAUC) as the AUC between an FPR of 0.1 and an FPR
of 0.4.
Manual Thresholding versus Thresholding
Based on Sample Properties or
Optimal Overlap
In clinical practice, a threshold is typically selected by
visual inspection by an examiner. Alternatively, some
information about the sample might be available, such
as the percentage bone volume (BV/TV), and a thresh-
old might then be chosen in a way that the segmented
volume has equivalent BV/TV values.
As stated before, the pAUC is based on the TPR and
FPR, which can be related to the overlap, defined as the

Figure 1 ROC curve construction. Each coordinate on the curve represents a threshold for segmentation. CBCT E: see Table 2.
proportion of correctly segmented pixels. In evaluating
and comparing segmentation methods using the pAUC,
we implicitly assumed that higher pAUC values resulted
in more accurate morphometric indices, meaning a
more accurate description of the bone microstructure.
To validate this assumption, the threshold value on the
ROC curve that resulted in the highest overlap of CBCT
bone segmentation with the micro-CT ground truth was
determined for both global and adaptive thresholding.
To proceed with the previously mentioned
assessments, we compared the morphometric indices
obtained with the different thresholds: the thres-
holds determined by an examiner (first), the thresholds
determined by optimal congruence with bone volume
fraction (second), and the thresholds determined
by maximal overlap (third). Results are reported as
percentage error from the ground truth value.
Statistical Analysis
Statistical tests were performed on the pAUCs obtained
on each VOI using Matlab (MathWorks, Natick, MA,
USA). Different CBCT scanners were compared by one-
way ANOVA, while global versus adaptive thresholding
and upper versus lower jaw performance were compared
with paired t-tests. Differences were considered signifi-
cant at p < .05.
Segmentation of Jaw Bone on CBCT Datasets 5
RESULTS
Table 3 summarizes the statistical test results. In the
following paragraphs, these results will be discussed in
more in detail with regard to significance values.
Figure 2 shows the average ROC curves for global
thresholding for the different CBCT scanners. In the
segmentation results, AUCs are significantly larger for
the lower jaw than for the upper jaw (p = .04). Differ-
ences in performance between the scanners were sig-
nificant for upper jaw segmentation (p = .005) and for
lower jaw segmentation (p < .001).
Figure 3 shows the ROC curves for adaptive
thresholding. There is a significant difference between
global and adaptive thresholding, where adaptive
thresholding performs better in segmenting the bone
structure out of CBCT images (p < .001). Figure 4
and Figure 5 show the difference between global (full
curves) and adaptive (dotted curves) thresholding for
four CBCT scanners as an example. All other scanners
showed a similar increase in AUC. The difference was
significant between the upper and lower jaws.
Based on the paired t-test, we identified a significant
difference between global and adaptive thresholding
for the procedures’ sensitivity to threshold changes
(p = .03), where segmentation based on adaptive thres-
holding was less sensitive to alternating thresholds.
6 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2014

TABLE 3 Summary of the Statistical Results

Investigated difference Test used Result p Value

AUC, global thresholding, upper versus lower jaw Paired t-test AUC lower > AUC upper .04
AUC, global thresholding, difference between scanners ANOVA (single-factor) Significant differences for .005
for upper jaw the upper jaw
AUC, global thresholding, difference between scanners ANOVA (single-factor) Significant differences for <.001
for lower jaw the lower jaw
AUC, global versus adaptive thresholding Paired t-test AUC adaptive > AUC global <.001
Sensitivity to threshold changes for global versus adaptive Paired t-test Sensitivity global > adaptive .03
thresholding

We can conclude from Table 4 that for all methods
of threshold selection, adaptive segmentation generally
produces smaller errors in morphometric indices than
global thresholding, which is translated into a smaller
mean absolute error over the morphometric indices.
Manual threshold selection results in smaller errors
for trabecular thickness than other threshold selection
methods, but other indices are estimated less accurately.
A threshold based on the ground truth bone volume
percentage (BV/TV as derived from segmented micro-
CT images) improves the results for this individual
morphometric index. When the threshold is based on
maximal overlap (aiming for maximal overlap with the
segmented micro-CT images), the result is a compro-
mise between all morphometric indices, as indicated by
the smaller mean error value for adaptive thresholding.
DISCUSSION
We have quantified the segmentation accuracy of
trabecular bone in CBCT images of the upper and
lower jaw obtained with eight different CBCT scanners
using global and adaptive thresholding, with micro-CT
imaging as the ground truth.
In the search for a robust method of bone quan-
tification, we found a clear benefit of using adaptive
instead of global thresholding for segmentation. Simi-
larly, Burghardt and colleagues13 found equivalent or
improved accuracy of trabecular bone quantification

Figure 2 ROC curves for global thresholding. a, Upper jaw. b, Lower jaw. For details on CBCTs A–I, see Table 2.
 Segmentation of Jaw Bone on CBCT Datasets 7

Figure 3 ROC curves for adaptive thresholding. a, Upper jaw. b, Lower jaw. For details on CBCTs A–I, see Table 2.

using a local thresholding scheme on high-resolution
peripheral quantitative computed tomography (HR-
pQCT) scans. As mentioned before, the intensity values
are not uniform through all CBCT scans.6,7 As adaptive
thresholding uses spheres for local thresholding, the
results of this procedure are less sensitive to density
fluctuations within the image. The problem of incon-
sistent intensity is less important in HR-pQCT, which
is why we could find an unequivocal improvement for
all indices in all scanners when adaptive thresholding
was used instead of global thresholding. Despite the
success of adaptive thresholding, segmentation accuracy
for a scanner with suboptimal hardware and software
performance cannot be brought to the same level as that
of other scanners.
Several authors have attempted to categorize CBCT
devices based on observers’ opinion on overall image
quality or image suitability for specific diagnostic
purposes.14–17 We summarize these results in Table 5,
including the assessment criteria used to classify differ-
ent devices. Not all studies included the same devices
or identical imaging parameters, so a full comparison is
not possible.
Based on the classification in Table 5, an average
ranking could be given to each scanner. As such, scan-
ners could be classified into 4 groups: {C,E} (mean rank

TABLE 4 Mean Percentage Error Compared with Micro-CT for Different Thresholding Methods
Mean percentage error (standard deviation)

Percentage bone Trabecular Trabecular Trabecular All

Threshold selection method volume thickness number separation indices*

Global threshold, manual −30.7 (26.9) 89.8 (48.6) −62.3 (16.4) 92.1 (53.6) 68.7
Adaptive threshold, manual −20.9 (25.4) 51.3 (22.8) −46.5 (18.8) 79.5 (52.6) 49.5
Global threshold based on micro-CT BV/TV 3.2 (2.2) 115.5 (47.8) −49.9 (10.7) 68.5 (34.5) 59.3
Adaptive threshold based on micro-CT BV/TV 3.2 (3.9) 55.2 (21.6) −32.4 (8.9) 57.3 (31.5) 37.0
Global threshold based on overlap −12.1 (82.6) 111.4 (110.7) −63.2 (22.1) 92.4 (71.9) 69.7
Adaptive threshold based on overlap 24.5 (54.1) 55.7 (24.6) −20.5 (31.5) 41.5 (38.2) 35.6

*Mean of the absolute errors of all morphometric indices.

8 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2014

quality. Vandenberghe and colleagues17 investigated

surface models of jaws and concluded that CBCT expo-
sure protocols influenced the model accuracy only to a
minor extent. The aforementioned studies seem to indi-
cate that development of objective criteria for assess-
ment of diagnostic image quality of CBCT is feasible
but challenging.
AUC values were significantly higher for lower jaws
than for upper jaws. Other authors have mentioned that
a lower tube potential resulted in higher segmentation
accuracy17 or diagnostic accuracy (Lofthag-Hansen and
colleagues,19 specifically for implant planning) only for
upper jaws. These differences are most probably due
to the different anatomical properties of the jaws: the
upper jaw has a very thin cortical shell, whereas the
lower jaw is covered in a rather dense cortical layer,

Figure 4 Examples of global (full curve) versus adaptive

(dotted curve) thresholding for four devices. For details on
CBCTs, see Table 2.

<2), {D,I} (mean rank 3 to 4), {A,B,G} (mean rank 5),

and {F} (mean rank 7). Performance of the scanners is
similar within each group, and differences in perfor-
mance classifications between the groups are consistent.
The classification of the scanners based on the perceived
image quality in subjective observer studies was largely
similar to the one presented here based on objective
ROC analysis. A major advantage of our approach is that
the use of image registration and computer-aided seg-
mentation, which provided better results than manual
threshold selection (Table 4), largely eliminates the need
for exertion of effort and time by examiners and the
bias they may introduce. It might therefore be recom-
mended to evaluate CBCT devices with anthropomor-
phic material with known ground truth. There have
been other studies on the comparison of CBCT devices
that used not observers but objective characteristics
such as contrast-to-noise ratio18 and jawbone model
accuracy.17 As the technical quality of CBCT images can
be expressed in many ways and is dependent on many
factors, it falls outside the scope of the current study
to compare the segmentation performance in human
trabecular jaw bone with the technical quality of the
respective devices. It is worth mentioning, though,
that Pauwels and colleagues18 concluded that there was
a fair correlation between X-ray exposure (mAs) and
observers’ opinion on diagnostic image quality, whereas Figure 5 Examples of binary images after global or adaptive
this correlation was less clear-cut for technical image thresholding for four devices. For details on CBCTs, see Table 2.
 Segmentation of Jaw Bone on CBCT Datasets 9

TABLE 5 Classification of Scanners Based on Different Assessment Criteria

Study Assessment criterion Scanner ranking*

Liang and colleagues, 201014 Subjective image quality CIDB

Liang and colleagues, 201014 Trabecular bone visibility CIDB
Alqerban and colleagues, 201115 Subjective image quality ECBA
Pauwels and colleagues, 201216 Technical image quality: line visibility ECDIABF
Pauwels and colleagues, 201216 Technical image quality: rod visibility EDCABIF
Vandenberghe and colleagues, 201217 Segmentation accuracy for jaw bone surface CEAG
Current study Segmentation accuracy for trabecular jaw bone CEDIBGFA

*Ranking based on assessment outcome, ignoring significance of differences in ranking.

allowing more variation in exposure protocols without
changes in the study results. Moreover, trabecular bone
is sparse under the maxillary sinus, and a minor thresh-
old shift is capable of changing segmentation accuracy
to a great extent. All jaws were fixed in formaldehyde,
which has a high pH and therefore is known to affect the
chemical consistency of bone.20 This is obviously more
significant for thin structures. In the upper jaw, trabecu-
lar bone is densely vascularized, while the lower jaw
has a more centralized blood supply that flows through
channels. The formaldehyde might have been more
destructive in the upper jaw, causing the already sparse
trabeculation to become even thinner and thus more
sensitive to threshold changes during segmentation.20
Hence, differences in quality between scanners might be
best assessed based on their performance in upper jaw
scanning accuracy.
The ROC analysis evaluates segmentation quality by
true and false positive rates. In clinical practice, one is
typically more interested in morphometric indices such
as bone volume fraction and trabecular thickness. Such
morphometric indices are average values for the entire
volume that is analyzed and do not guarantee good
local congruence with the ground truth. This encum-
bers evaluation of segmentation quality, as all relevant
indices should be tested for a comprehensive result.
We hypothesize that individual morphometric indices
improve when more voxels are segmented correctly. To
test this hypothesis, we use the TPR and FPR, which are
a measure of overlap on a voxel-by-voxel basis. The
results in Table 3 indicate that the hypothesis has merit,
as thresholds based on overlap lead to a smaller mean
error for adaptive thresholding. For global threshold-
ing, however, the overlap threshold selection does not
provide a lower mean error. This can be attributed to the
lower FPR and TPR values for global thresholding,
hence a lower number of correctly selected voxels with
global thresholding. It seems that our assumption is only
valid when enough voxels are correctly segmented, such
that the morphometric index estimates are near their
nominal values. Manual threshold selection provides
lower errors for trabecular thickness than the automatic
methods, suggesting an observer bias resulting from
mentally trying to match thicknesses when selecting a
threshold.
Although the differences between adaptive and
global thresholding appear limited in the ROC graphs,
Table 3 shows that adaptive thresholding provides much
smaller errors on morphometric indices, irrespective of
the threshold selection method. However, as can be seen
from the ROC graphs, a good choice of scanning equip-
ment and scan settings influences the final segmentation
quality more than the segmentation method. Changing
the segmentation method influences the individual
pAUC, but it does not change the classification of the
scanners based on pAUC.
Some clinical advantages of adaptive thresholding are
obvious: Implant placement procedures can be planned
better and performed more safely with precise knowledge
of the supporting bone structures. Adaptive threshold-
ing indeed provides better visual inspection of the bone
pattern. The ability to increase segmentation accuracy can
also provide a better differentiation between bone and
nerves in osteoporotic bone. In the next research stage, we
intend to relate the results of the current study to clinical
results, such as in the optimization of implant surgery. We
are in need of systematic comparisons of segmentation
results with observers’ opinions on image quality as well as
objective technical quality parameters of CBCT scanners.
This requires the analysis of a large amount of data from
different CBCT equipment, but also a variation of expo-
sure and reconstruction settings for each device. Ideally
10 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2014
this type of investigation should be approached in a
simulation context.
CONCLUSIONS
When assessing jaw bone structure, for example in
implant planning, the observer should always choose
adaptive thresholding. Although it clearly provides better
structural assessment of jaw bone, it is not yet common
practice among scientists in dentomaxillofacial radiology
to use adaptive thresholding in image analysis. It remains
a challenging research focus to identify the optimal
threshold selection for meaningful jawbone structural
assessment. Lastly, it needs to be said that the present
study has been performed with CBCT image data of
existing scanners. Yet, considering the rapid develop-
ments in CBCT hardware and software, the differential
scanner results shown in the present study may not
necessarily be extrapolated to new generation devices.
ACKNOWLEDGMENTS
The research leading to these results has received fund-
ing from the European Atomic Energy Community’s
Seventh Framework Programme FP7/2007–2011 under
grant agreement no. 212246 (SEDENTEXCT: Safety and
Efficacy of a New and Emerging Dental X-ray Modality;
http://www.sedentexct.eu) and from the KU Leuven
Research Fund (Bijzonder Onderzoeksfonds OT/08/057).
REFERENCES
1. Ikumi N, Tsutsumi S. Assessment of correlation between
computerized tomography values of the bone and cutting
torque values at implant placement: a clinical study. Int J
Oral Maxillofac Impl 2005; 20:253–260.
2. Merheb J, Van Assche N, Coucke W, Jacobs R, Naert I,
Quirynen M. Relationship between cortical bone thickness
or computerized tomography-derived bone density values
and implant stability. Clin Oral Impl Res 2010; 21:612–617.
3. Ribeiro-Rotta RF, Lindh C, Pereira AC, Rohlin M. Ambiguity
in bone tissue characteristics as presented in studies on
dental implant planning and placement: a systematic review.
Clin Oral Impl Res 2011; 22:798–801.
4. Vandenberghe B, Jacobs R, Bosmans H. Modern dental imag-
ing: a review of the current technology and clinical applica-
tions in dental practice. Eur Radiol 2010; 20:2637–2655.
5. Jacobs R. Dental cone beam computed tomography and its
justified use in oral health care. JBR-BTR 2011; 94:254–265.
6. Nackaerts O, Maes F, Yan H, Couto Souza P, Pauwels R,
Jacobs R. Analysis of intensity variability in multislice and
cone beam computed tomography. Clin Oral Impl Res 2011;
22:873–879.
7. Pauwels R, Nackaerts O, Bellaiche N, et al. Variability of
dental cone beam computed tomography grey values for
density estimations. Br J Radiol 2013; 86. Doi: 20120135
8. Kuhn JL, Goldstein SA, Feldkamp LA, Goulet RW, Jesion G.
Evaluation of a microcomputed tomography system to
study trabecular bone structure. J Orthop Res 1990; 8:833–
842.
9. Waarsing JH, Day JS, Weinans H. An improved segmentation
method for in vivo microCT imaging. J Bone Min Res 2004;
19:1640–1650.
10. Fawcett T. An introduction to ROC analysis. Patt Rec Letters
2006; 27:861–874.
11. Maes F, Collignon A, Vandermeulen D, Marchal G,
Suetens P. Multimodality image registration by maximiza-
tion of mutual information. IEEE Med Im 1997; 16:187–198.
12. Parfitt AM, Drezner MK, Glorieux FH, et al. Bone histo-
morphometry: standardization of nomenclature, symbols
and units. J Bone Min Res 1987; 2:595–610.
13. Burghardt AJ, Kazakia GJ, Majumdar S. A local adaptive
threshold strategy for high resolution peripheral quantita-
tive computed tomography of trabecular bone. Annals
Biomed Eng 2007; 35:1678–1686.
14. Liang X, Jacobs R, Hassan B, et al. A comparative evaluation
of cone beam computed tomography and multislice CT.
Part I. On subjective image quality. Eur J Radiol 2010;
75:265–269.
15. Alqerban A, Jacobs R, Fieuws S, Nackaerts O, SEDENTEXCT
Project Consortium, Willems G. Comparison of 6 cone
beam computed tomography systems for image quality and
detection of simulated canine impaction-induced external
root resorption in maxillary lateral incisors. Am J Orthod
Dentofac Orthop 2011; 140:e129–e139.
16. Pauwels R, Beinsberger J, Stamatakis H, et al. Comparison of
spatial and contrast resolution for cone beam computed
tomography scanners. Oral Surg Oral Med Oral Path Oral
Radiol 2012; 114:127–135.
17. Vandenberghe B, Luchsinger S, Hostens J, Dhoore E,
Jacobs R, SEDENTEXCT Project Consortium. The influence
of exposure parameters on jaw bone model accuracy using
cone beam computed tomography and multislice CT.
Dentomaxillofac Radiol 2012; 41:466–474.
18. Pauwels R, Stamatakis H, Manousaridis G, et al. Develop-
ment and applicability of a quality control phantom for
dental cone beam computed tomography. J App Clin Med
Phys 2011; 12(4):245–260.
19. Lofthag-Hansen S, Thilander-Klang A, Gröndahl K. Evalua-
tion of subjective image quality in relation to diagnostic task
for cone beam computed tomography with different fields of
view. Eur J Radiol 2011; 80:483–488.
20. Fonseca AA, Cherubini K, Veeck EB, Ladeira RS,
Carapeto LP. Effect of 10% formalin on radiographic optical
density of bone specimens. Dentomaxillofac Radiol 2008;
37:137–141.